181 General discussion 7 guideline recommendations are followed. Therefore, surveys should address current research gaps in secondary prevention and health determinants, so their results can inform clinical guidelines effectively. BRINGING IT TOGETHER: HOW CAN SURVEYS DO BETTER? Surveys in secondary prevention of CHD should be informative, representative, of excellent quality, and useful for practice, policy and research. To do so, they should collect data on topics relevant to secondary prevention and adequate to investigate specific research questions, including data availability, risk factor and treatment levels, guideline adherence and patient’s characteristics and outcomes. Representativeness or surveys should be improved by having a broader geographical coverage, include centers of different complexity, use pre-existing data and participation of local actors. Regular quality checks, periodicity and evaluation and dissemination of results promote quality and impact of surveys. The ideal survey: pragmatic or in depth? Can we have it all? Comprehensive patient information as well as representative samples are necessary to improve research in secondary prevention. Simplified, easy-to-perform surveys facilitate implementation in a wide, more representative set of health centers, but they can capture less information. Pragmatic surveys can be useful to collect the basic, most relevant data, and use it to identify challenges and generate research questions, especially in centers where the application of an extensive survey can be challenging. On the other hand, surveys with extensive data collection are demanding in terms of resources, which has a negative impact on their representativeness. The comprehensive information derived from these surveys provides a more complete picture of the patient and can be used to explore research questions in depth, such as (social) determinants of risk factor control, risk factor awareness, medication doses and adherence. These two approaches, far from opposite, are complementary and can work optimally if integrated. The ideal survey in secondary prevention of CHD would have two components, one pragmatic and one extensive. The first would provide an overall, representative picture risk factors and treatment levels, allowing the participation of low resource areas and centers. The extensive component of the survey would collect in depth-information in a sample the patients from this study can then undergo in-depth interviews and measurements. Current surveys in secondary prevention have adopted either a pragmatic or extensive approach, however, a nested or combined strategy as described above has not been put in practice. Collaborative efforts between existing surveys with complementary approaches could serve as a pilot for a combined strategy, providing both representative and in-depth data. CONCLUSION This thesis investigated secondary prevention of CHD by use of an international perspective. The findings of this thesis show low levels of risk factor target attainment and participation
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