Knowledge and attitudes of primary care physicians in the management of patients at risk for cardiovascular events

Hamidreza Doroodchi, Maziar Abdolrasulnia, Jill A Foster, Elyse Foster, Mintu P Turakhia, Kimberly A Skelding, Kiran Sagar, Linda L Casebeer, Hamidreza Doroodchi, Maziar Abdolrasulnia, Jill A Foster, Elyse Foster, Mintu P Turakhia, Kimberly A Skelding, Kiran Sagar, Linda L Casebeer

Abstract

Background: Adherence to clinical practice guidelines for management of cardiovascular disease (CVD) is suboptimal. The purposes of this study were to identify practice patterns and barriers among U.S. general internists and family physicians in regard to cardiovascular risk management, and examine the association between physician characteristics and cardiovascular risk management.

Methods: A case vignette survey focused on cardiovascular disease risk management was distributed to a random sample of 12,000 U.S. family physicians and general internists between November and December 2006.

Results: Responses from a total of 888 practicing primary care physicians who see 60 patients per week were used for analysis. In an asymptomatic patient at low risk for cardiovascular event, 28% of family physicians and 37% of general internists made guideline-based preventive choices for no antiplatelet therapy (p < .01). In a patient at high risk for cardiovascular event, 59% of family physicians and 56% of general internists identified the guideline-based goal for serum fasting LDL level (< 100 mg/dl). Guideline adherence was inversely related to years in practice and volume of patients seen. Cost of medications (87.7%), adherence to medications (74.1%), adequate time for counseling (55.7%), patient education tools (47.1%), knowledge and skills to recommend dietary changes (47.8%) and facilitate patient adherence (52.0%) were cited as significant barriers to CVD risk management.

Conclusion: Despite the benefits demonstrated for managing cardiovascular risks, gaps remain in primary care practitioners' management of risks according to guideline recommendations. Innovative educational approaches that address barriers may facilitate the implementation of guideline-based recommendations in CVD risk management.

References

    1. American Heart Association/American College of Cardiology Guidelines. American Heart Association and American College of Cardiology Websites . Accessed November 30, 2007.
    1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jr, Jones DW, Materson BJ, Oparil S, Wright JT, Jr, Roccella EJ, National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, National High Blood Pressure Education Program Coordinating Committee The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560–2572. doi: 10.1001/jama.289.19.2560.
    1. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): Final Report. Circulation. 2002;106:3143–3421.
    1. Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn EA. Who is at greatest risk for receiving poor-quality healthcare? N Engl J Med. 2006;354:1147–1156. doi: 10.1056/NEJMsa044464.
    1. Davidson MH, Maki KC, Pearson TA, Pasternak RC, Deedwania PC, McKenney JM, Fonarow GC, Maron DJ, Ansell BJ, Clark LT, Ballantyne CM. Results of the National Cholesterol Education Program Evaluation Project utilizing novel E-technology (NEPTUNE) II survey and implications for treatment under the recent NCEP Writing Group recommendations. Am J Cardiol. 2005;96:556–563. doi: 10.1016/j.amjcard.2005.04.019.
    1. Ma J, Sehgal NL, Ayanian JZ, Stafford RS. National trends in statin use by coronary heart disease risk category. PLoS Med. 2005;2:e123. doi: 10.1371/journal.pmed.0020123.
    1. Mosca L, Linfante AH, Benjamin EJ, Berra K, Hayes SN, Walsh BW, Fabunnmi RP, Kwan J, Mills T, Simpson SL. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499–510. doi: 10.1161/01.CIR.0000154568.43333.82.
    1. Muntner P, He J, Roccella EJ, Whelton PK. The impact of JNC-VI guidelines on treatment recommendations in the US population. Hypertension. 2002;39:897–902. doi: 10.1161/01.HYP.0000013862.13962.1D.
    1. Rosamond W, Flegal K, Friday G, Furie K, Go A, Greenlund K, Haase N, Ho M, Howard V, Kissela B, Kittner S, Lloyd-Jones D, McDermott M, Meigs J, Moy C, Nichol G, O'Donnell CJ, Roger V, Rumsfeld J, Sorlie P, Steinberger J, Thom T, Wasserthiel-Smoller S, Hong Y, American Heart Association Statistics Committee and Stroke Statistics Subcommittee Heart Disease and Stroke Statistics–2007 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:69–171. doi: 10.1161/CIRCULATIONAHA.106.179918.
    1. Assmann G. Calculating global risk: the key to intervention. Eur Heart J Suppl. 2005;7:F9–F14. doi: 10.1093/eurheartj/sui037.
    1. Christian AH, Mills T, Simpson SL, Mosca L. Quality of cardiovascular disease preventive care and physician/practice characteristics. J Gen Intern Med. 2006;21:231–237. doi: 10.1111/j.1525-1497.2006.00331.x.
    1. Correa-de-Araujo R, Stevens B, Moy E, Nilasena D, Chesley F, McDermott K. Gender differences across racial and ethnic groups in the quality of care for acute myocardial infarction and heart failure associated with comorbidities. Womens Health Issues. 2006;16:44–45. doi: 10.1016/j.whi.2005.04.003.
    1. Goff DC, Bertoni AG, Kramer H, Bonds D, Blumenthal RS, Tsai MY, Psaty BM. Dyslipidemia prevalence, treatment, and control in the Multi-Ethnic Study of Atherosclerosis (MESA): gender, ethnicity, and coronary artery calcium. Circulation. 2006;113:647–656. doi: 10.1161/CIRCULATIONAHA.105.552737.
    1. Hajjar I, Miller K, Hirth V. Age-related bias in the management of hypertension: a national survey of physicians' opinions on hypertension in elderly adults. J Gerontol A Biol Sci Med Sci. 2002;57:M487–491.
    1. Henderson SO, Bretsky P, DeQuattro V, Henderson BE. Treatment of hypertension in African Americans and Latinos: the effect of JNC VI on urban prescribing practices. J Clin Hypertens (Greenwich) 2003;5:107–112. doi: 10.1111/j.1524-6175.2003.01486.x.
    1. Massing MW, Foley KA, Carter-Edwards L, Sueta CA, Alexander CM, Simpson RJ., Jr Disparities in lipid management for African Americans and Caucasians with coronary artery disease: a national cross-sectional study. BMC Cardiovasc Disord. 2004;4:15. doi: 10.1186/1471-2261-4-15.
    1. Mehta SS, Wilcox CS, Schulman KA. Treatment of hypertension in patients with comorbidities: results from the study of hypertensive prescribing practices (SHyPP) Am J Hypertens. 1999;12:333–340.
    1. Oparil S, Miller AP. Gender and blood pressure. J Clin Hypertens (Greenwich) 2005;7:300–309. doi: 10.1111/j.1524-6175.2005.04087.x.
    1. Raji MA, Kuo YF, Salazar JA, Satish S, Goodwin JS. Ethnic differences in antihypertensive medication use in the elderly. Ann Pharmacother. 2004;38:209–214.
    1. Sonel AF, Good CB, Mulgund J, Roe MT, Gibler WB, Smith SC, Jr, Cohen MG, Pollack CV, Jr, Ohman EM, Peterson ED, CRUSADE Investigators Racial Variations in Treatment and Outcomes of Black and White Patients With High-Risk Non-ST-Elevation Acute Coronary Syndromes: Insights From CRUSADE. Circulation. 2005;111:1225–1232. doi: 10.1161/01.CIR.0000157732.03358.64.
    1. Hyman DJ, Pavlik VN. Self-reported hypertension treatment practices among primary care physicians: blood pressure thresholds, drug choices, and the role of guidelines and evidence-based medicine. Arch Intern Med. 2000;160:2281–2286. doi: 10.1001/archinte.160.15.2281.
    1. World Hypertension League calls for urgent action to get more hypertensive patients to goal. Hypertension News. May 12, 2006.
    1. Borzecki AM, Oliveria SA, Berlowitz DR. Barriers to hypertension control. Am Heart J. 2005;149:785–794. doi: 10.1016/j.ahj.2005.01.047.
    1. Phillips LS, Branch WT, Jr, Cook CB, Doyle JP, El-Kebbi IM, Gallina DL, Miller CD, Ziemer DC, Barnes CS. Clinical Inertia. Ann Intern Med. 2001;135:825–834.
    1. Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M. Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality. JAMA. 2000;283:1715–1722. doi: 10.1001/jama.283.13.1715.
    1. Peabody JW, Luck J, Glassman P, Jain S, Hansen J, Spell M, Lee M. Measuring the quality of physician practice by using clinical vignettes: a prospective validation study. Ann Intern Med. 2004;141:771–780.
    1. Luck J, Peabody JW, Lewis BL. An automated scoring algorithm for computerized clinical vignettes: evaluating physician performance against explicit quality criteria. Int J Med Inform. 2006;75:701–707. doi: 10.1016/j.ijmedinf.2005.10.005.
    1. Veloski , Jon , Tai Stephen, Evans AdamS, Nash DavidB. Clinical vignette-based surveys: a tool for assessing physician practice variation. Am J Med Qual. 2005;20:151–157. doi: 10.1177/1062860605274520.
    1. Grundy SM, Cleeman JI, Merz CN, Brewer HB, Jr, Clark LT, Hunninghake DB, Pasternack RC, Smith SC, Jr, Stone NJ, National Heart, Lung, and Blood Institute, American College of Cardiology Foundation, American Heart Association Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227–239. doi: 10.1161/01.CIR.0000133317.49796.0E.
    1. Abookire SA, Karson AS, Fiskio J, Bates DW. Use and monitoring of "statin" lipid-lowering drugs compared with guidelines. Arch Intern Med. 2001;161:53–58. doi: 10.1001/archinte.161.1.53.
    1. Heart Protection Study Collaborative Group MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomized placebo-controlled trial. Lancet. 2002;360:7–22. doi: 10.1016/S0140-6736(02)09327-3.
    1. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142:260–273.
    1. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458–1465. doi: 10.1001/jama.282.15.1458.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner