| Domain | Subject area; indicator | ||||||
|---|---|---|---|---|---|---|---|
| Smoking | Obesity | Hypertension | Diabetes | Dyslipidemia | Atrial fibrillation | Access to primary care | |
| Prevalence | Prevalence of smoking | Prevalence of obesity | Prevalence of hypertension | Prevalence of diabetes | Prevalence of high lipid levels (e.g., total cholesterol ≥ 5.2 mmol/L) | Prevalence of atrial fibrillation | % of patients who have visited a primary care provider |
| Screening | NA | % of patients with height and weight measured | % of patients with blood pressure measured | % of patients aged ≥ 40 yr who have had full fasting blood glucose or HbA1c screening test in previous 36 mo | % of men aged ≥ 40 yr and women aged ≥ 50 yr who have had full lipid profile in previous 5 yr | NA | NA |
| Management | % of smokers who received smoking cessation counselling | NA | % of patients with hypertension taking ≥ 1 antihypertensive medication OR Mean number of antihypertensive medications taken among patients with treated hypertension | % of patients with diabetes taking antidiabetic medications % of patients with diabetes aged ≥ 55 yr taking ACE inhibitors/ARBs % of patients with diabetes aged ≥ 40 yr taking statins | % of primary prevention patients at high risk (e.g., LDL-C level > 5.0, high Framingham risk score, diabetic) taking statins | % of patients with atrial fibrillation taking warfarin or direct oral anticoagulants | Mean no. of primary care visits per yr (e.g., for hypertension, diabetes) |
| Intermediate outcomes | NA | NA | % of patients with hypertension with measured blood pressure control (< 140 mm Hg systolic and < 90 mm Hg diastolic)* OR Rate of emergency department visits for hypertension among patients with hypertension | % of patients with diabetes with HbA1c level controlled (≤ 7%)† | % of patients taking statins for primary prevention who have lipid levels controlled (LDL-C ≤ 2.0 mmol/L) | % of time in therapeutic range (INR 2-3) among patients with atrial fibrillation taking warfarin | NA |
Note: ACE = angiotensin-converting-enzyme inhibitor, ARB = angiotensin receptor blockers, HbA1c = hemoglobin A1c, INR = international normalized ratio, LDL-C = low-density lipoprotein cholesterol, NA = not applicable.
*Patients with diabetes should be treated to target blood pressures of < 130 mm Hg systolic and < 80 mm Hg diastolic.22
†A less stringent hemoglobin A1c target of 7.1%-8.5% may be used in certain patients with diabetes such as those with limited life expectancy and those with high levels of functional dependency.23