We investigated whether the risk estimates of General Practitioners (GPs) and their treatment decisions mutually influence each other and whether factors not related to the patient's risk, such as the gender and length in clinical practice, interact.

The quantitative assessment of the absolute risk of developing coronary heart disease (CHD) and the decision to start treatment with lipid-lowering drugs are crucial tasks in the primary prevention of CHD.

Nine clinical vignettes, four rated high-risk and five rated low-risk according to the Framingham equation, were mailed to three groups of 90 randomly selected GPs in Stockholm. One group (R) was asked to estimate the risk of CHD within 10 years on a visual analogue scale. A second group (R + D) was asked to estimate the risk and to specify whether they would recommend a pharmacological lipid-lowering treatment. A third group (D) only to indicate whether they would recommend treatment.

Response rate ranged from 42.2% to 45.6%. The median risk estimates were higher in the R group than in the R + D group (difference not statistically significant). R + D group showed higher proportions of correct decisions to start treatment compared with the R group (86.2% versus 77.5%, P = 0.19). More correct decisions were made by female doctors (OR 1.77, 95% CI 1.19–2.61, P = 0.004) and by less experienced doctors (OR 0.97, 95% CI 0.95–0.99, P = 0.016).

The task of making CHD risk estimates and the task of making decisions whether to start lipid-lowering treatment do not seem to influence each other. The gender of physicians and the length of clinical experience seem to affect treatment decisions. Female GPs and less experienced GPs are more likely to make correct decisions. However, the relatively low response rate to the questionnaires may limit the generalizability of these results.

To investigate whether general practitioners (GPs) in countries with different levels of cardiovascular risk would make different risk estimates and choices about lipid-lowering treatment when assessing the same patients.

Primary prevention of coronary heart disease should be based on the quantitative assessment of an individual’s absolute risk. Risk-scoring charts have been developed, but in clinical practice risk estimates are often made on a subjective basis.

Mail survey: Nine written case simulations of four cases rated by the Framingham equations as high risk, and five rated as low-risk were mailed to 90 randomly selected GPs in Stockholm, as a high-risk area, and 90 in Sicily as a low-risk area. GPs were asked to estimate the 10-year coronary risk and to decide whether to start a lipid-lowering drug treatment.

Overall risk estimate was lower in Stockholm than in Sicily for both high-risk cases (median 20.8; interquartile range (IQR) 13.5–30.0 versus 29.1; IQR 21.8–30.6; P = 0.033) and low-risk cases (6.4; IQR 2.2–9.6 versus 8.5; IQR 6.0–14.5; P = 0.006). Swedish GPs were less likely than Sicilian GPs to choose to treat when their estimate of risk was above the recommended cut-off limit for treatment, both for the entire group (means of GPs’ decision proportions: 0.64 (0.45) and 0.92 (0.24), respectively, P = 0.001) and for high-risk cases (0.65 (0.45) and 0.93 (0.23), P = 0.001).

The cardiovascular risk level in the general population influences GPs’ evaluations of risk and subsequent decisions to start treatment. GPs’ risk estimates seem to be inversely related to the general population risk level, and may lead to inappropriate over- or under-treatment of patients.