178 Chapter 7 prevention do not achieve global coverage, and countries with a high burden of disease are often not participating in large research studies. It is necessary to improve geographical representation, with a focus on regions and countries with a high burden of disease and risk factors, to provide a broader picture of secondary prevention and obtain relevant risk factor and treatment data from regions in which it is most necessary. Strategies that can improve geographical coverage relate to simplicity and the use of existing data, and will be discussed later in this section. Representativeness within countries Achieving global geographical coverage is important, but risk factor burden and management can vary greatly within countries and according to center characteristics (56–59). The inclusion of centers from various regions, located in urban and rural areas, and with public and private organization, improves the representativeness of survey results within countries. A common limitation of extensive surveys in clinical settings is that the centers participating in them consist mostly large academic hospitals (11). Therefore, patients attending local or regional centers of lower complexity are largely missed in surveys. It is possible that these patients present specific characteristics, for example not being able to travel to a facility of higher complexity, and potentially a better risk factor profile or a longer time since index event. The limited representativeness of current surveys has a negative impact on the generalizability of their results, because the sample of centers does not fully reflect the patient population to which guideline recommendations assessed in surveys are applied to. Improved survey representativeness will provide a more complete and less biased reflection of the patient population targeted by guidelines, and will allow development of efficient preventive strategies based on a more realistic sample of patients. How can we improve representativeness? Surveys in secondary prevention, despite their efforts, fall short on representativeness at global level and within countries. It is important to promote inclusion of centers with a wide geographical coverage globally and regionally, and to facilitate the participation of centers of different complexity, to obtain more representative and realistic results on secondary prevention of CHD. In addition, participation of small centers in large, international research studies allows their professionals to access a community of cardiologists around the world, promoting the development of more representative research in the long term. Potential strategies to improve representativeness relate to simplicity of the surveys themselves, the use of pre-existing data, and the collaboration with international and local partners. Small, regional centers might not have enough staff to interview patients in depth and might not be able to include the required number of eligible participants within a limited study timeframe. Surveys that are simplified require less time per patient to collect the information, and therefore less resources and staff is needed to run them. Simplicity, together with wide and flexible data collection timelines, allows centers with limited resources to take part in research, providing results from settings that would otherwise not
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