Implementing cardiovascular disease prevention guidelines to translate evidence-based medicine and shared decision making into general practice: theory-based intervention development, qualitative piloting and quantitative feasibility

Background: The use of cardiovascular disease (CVD) prevention guidelines based on absolute risk assessment is poor around the world, including Australia. Behavioural barriers amongst GPs and patients include capability (e.g. difficulty communicating/understanding risk) and motivation (e.g. attitudes towards guidelines/medication). This paper outlines the theory-based development of a website for GP guidelines, and piloting of a new risk calculator/decision aid. Methods: Stage 1 involved identifying evidence-based solutions using the Behaviour Change Wheel (BCW) framework, informed by previous research involving 400 GPs and 600 patients/consumers. Stage 2 co-developed website content with GPs. Stage 3 piloted a prototype website at a national GP conference. Stage 4 iteratively improved the website based on "think aloud" interviews with GPs and patients. Stage 5 was a feasibility study to evaluate potential efficacy (guidelines-based recommendations for each risk category), acceptability (intended use) and demand (actual use over 1 month) amongst GPs (n = 98). Results: Stage 1 identified GPs as the target for behaviour change; the need for a new risk calculator/decision aid linked to existing audit and feedback training; and online guidelines as a delivery format. Stage 2-4 iteratively improved content and format based on qualitative feedback from GP and patient user testing over three rounds of website development. Stage 5 suggested potential efficacy with improved identification of hypothetical high risk patients (from 26 to 76%) and recommended medication (from 57 to 86%) after viewing the website (n = 42), but prescribing to low risk patients remained similar (from 19 to 22%; n = 37). Most GPs (89%) indicated they would use the website in the next month, and 72% reported using it again after one month (n = 98). Open feedback identified implementation barriers including a need for integration with medical software, low health literacy resources and pre-consultation assessment. Conclusions: Following a theory-based development process and user co-design, the resulting intervention was acceptable to GPs with high intentions for use, improved identification of patient risk categories and more guidelines-based prescribing intentions for high risk but not low risk patients. The effectiveness of linking the intervention to clinical practice more closely to address implementation barriers will be evaluated in future research

Shared decision-making about cardiovascular disease medication in older people: A qualitative study of patient experiences in general practice

Objectives To explore older people's perspectives and experiences with shared decision-making (SDM) about medication for cardiovascular disease (CVD) prevention. Design, setting and participants Semi-structured interviews with 30 general practice patients aged 75 years and older in New South Wales, Australia, who had elevated CVD risk factors (blood pressure, cholesterol) or had received CVD-related lifestyle advice. Data were analysed by multiple researchers using Framework analysis. Results Twenty eight participants out of 30 were on CVD prevention medication, half with established CVD. We outlined patient experiences using the four steps of the SDM process, identifying key barriers and challenges: Step 1. Choice awareness: taking medication for CVD prevention was generally not recognised as a decision requiring patient input; Step 2. Discuss benefits/harms options: CVD prevention poorly understood with emphasis on benefits; Step 3. Explore preferences: goals, values and preferences (eg, length of life vs quality of life, reducing disease burden vs risk reduction) varied widely but generally not discussed with the general practitioner; Step 4. Making the decision: overall preference for directive approach, but some patients wanted more active involvement. Themes were similar across primary and secondary CVD prevention, different levels of self-reported health and people on and off medication. Conclusions Results demonstrate how older participants vary widely in their health goals and preferences for treatment outcomes, suggesting that CVD prevention decisions are preference sensitive. Combined with the fact that the vast majority of participants were taking medications, and few understood the aims and potential benefits and harms of CVD prevention, it seems that older patients are not always making an informed decision. Our findings highlight potentially modifiable barriers to greater participation of older people in SDM about CVD prevention medication and prevention in general

Heuristics and biases in cardiovascular disease prevention:How can we improve communication about risk, benefits and harms?

Objective Cardiovascular disease (CVD) prevention guidelines recommend medication based on the probability of a heart attack/stroke in the next 5–10 years. However, heuristics and biases make risk communication challenging for doctors. This study explored how patients interpret personalised CVD risk results presented in varying formats and timeframes. Methods GPs recruited 25 patients with CVD risk factors and varying medication history. Participants were asked to ‘think aloud’ while using two CVD risk calculators that present probabilistic risk in different ways, within a semi-structured interview. Transcribed audio-recordings were coded using Framework Analysis. Results Key themes were: 1) numbers lack meaning without a reference point; 2) risk results need to be both credible and novel; 3) selective attention to intervention effects. Risk categories (low/moderate/high) provided meaningful context, but short-term risk results were not credible if they didn’t match expectations. Colour-coded icon arrays showing the effect of age and interventions were seen as novel and motivating. Those on medication focused on benefits, while others focused on harms. Conclusion CVD risk formats need to be tailored to patient expectations and experiences in order to counteract heuristics and biases. Practice implications Doctors need access to multiple CVD risk formats to communicate effectively about CVD prevention

Recruiting general practitioners as participants for qualitative and experimental primary care studies in Australia

Recruiting general practitioners (GPs) for participation in primary care research is vitally important, but it can be very difficult for researchers to engage time-poor GPs. This paper describes six different strategies used by a research team recruiting Australian GPs for three qualitative interview studies and one experimental study, and reports the response rates and costs incurred. Strategies included: (1) mailed invitations via Divisions of General Practice; (2) electronic newsletters; (3) combining mailed invitations and newsletter; (4) in-person recruitment at GP conferences; (5) conference satchel inserts; and (6) combining in-person recruitment and satchel inserts. Response rates ranged from 0 (newsletter) to 30% (in-person recruitment). Recruitment costs per participant ranged from A$83 (in-person recruitment) to A$232 (satchel inserts). Mailed invitations can be viable for qualitative studies, especially when free/low-cost mailing lists are used, if the response rate is less important. In-person recruitment at GP conferences can be effective for short quantitative studies, where a higher response rate is important. Newsletters and conference satchel inserts were expensive and ineffective

Medicines Conversation Guide

A Medicines Conversation Guide was developed for pharmacists to use in the context of a Home Medicines Review. The Guide aims to increase patient involvement and support discussions about: general health understanding, decision-making and information preferences, health priorities related to medicines, patient goals and fears, views on important activities and trade-offs

Effect of two behavioural 'nudging' interventions on management decisions for low back pain: A randomised vignette-based study in general practitioners

Objective €Nudges' are subtle cognitive cues thought to influence behaviour. We investigated whether embedding nudges in a general practitioner (GP) clinical decision support display can reduce low-value management decisions. Methods Australian GPs completed four clinical vignettes of patients with low back pain. Participants chose from three guideline-concordant and three guideline-discordant (low-value) management options for each vignette, on a computer screen. A 2×2 factorial design randomised participants to two possible nudge interventions: €partition display' nudge (low-value options presented horizontally, high-value options listed vertically) or €default option' nudge (high-value options presented as the default, low-value options presented only after clicking for more). The primary outcome was the proportion of scenarios where practitioners chose at least one of the low-value care options. Results 120 GPs (72% male, 28% female) completed the trial (n=480 vignettes). Participants using a conventional menu display without nudges chose at least one low-value care option in 42% of scenarios. Participants exposed to the default option nudge were 44% less likely to choose at least one low-value care option (OR 0.56, 95%CI 0.37 to 0.85; p=0.006) compared with those not exposed. The partition display nudge had no effect on choice of low-value care (OR 1.08, 95%CI 0.72 to 1.64; p=0.7). There was no interaction between the nudges (OR 0.94, 95% CI 0.41 to 2.15; p=0.89). Interpretation A default option nudge reduced the odds of choosing low-value options for low back pain in clinical vignettes. Embedding high value options as defaults in clinical decision support tools could improve quality of care. More research is needed into how nudges impact clinical decision-making in different contexts

Communicating cardiovascular disease risk: an interview study of General Practitioners’ use of absolute risk within tailored communication strategies

Background: Cardiovascular disease (CVD) prevention guidelines encourage assessment of absolute CVD risk - the probability of a CVD event within a fixed time period, based on the most predictive risk factors. However, few General Practitioners (GPs) use absolute CVD risk consistently, and communication difficulties have been identified as a barrier to changing practice. This study aimed to explore GPs’ descriptions of their CVD risk communication strategies, including the role of absolute risk. Methods: Semi-structured interviews were conducted with a purposive sample of 25 GPs in New South Wales, Australia. Transcribed audio-recordings were thematically coded, using the Framework Analysis method to ensure rigour. Results: GPs used absolute CVD risk within three different communication strategies: ‘positive’, ‘scare tactic’, and ‘indirect’. A ‘positive’ strategy, which aimed to reassure and motivate, was used for patients with low risk, determination to change lifestyle, and some concern about CVD risk. Absolute risk was used to show how they could reduce risk. A ‘scare tactic’ strategy was used for patients with high risk, lack of motivation, and a dismissive attitude. Absolute risk was used to ‘scare’ them into taking action. An ‘indirect’ strategy, where CVD risk was not the main focus, was used for patients with low risk but some lifestyle risk factors, high anxiety, high resistance to change, or difficulty understanding probabilities. Non-quantitative absolute risk formats were found to be helpful in these situations. Conclusions: This study demonstrated how GPs use three different communication strategies to address the issue of CVD risk, depending on their perception of patient risk, motivation and anxiety. Absolute risk played a different role within each strategy. Providing GPs with alternative ways of explaining absolute risk, in order to achieve different communication aims, may improve their use of absolute CVD risk assessment in practice.NHMR

I don't believe it, but I'd better do something about it: patient experiences of online 'heart age' risk calculators

Background: Health risk calculators are widely available on the internet, including cardiovascular disease (CVD) risk calculators that estimate the probability of a heart attack, stroke or death over a 5 or 10 year period. Some calculators convert this probability to 'heart age', where older heart age than current age indicates modifiable risk factors. These calculators may impact patient decision making about CVD risk management with or without clinician involvement, but little is known about how patients use them. Objectives: This study aimed to investigate patient experiences and understanding of online heart age calculators based on the Framingham Risk Equation used in clinical guidelines around the world. Methods: General Practitioners in New South Wales, Australia recruited 26 patients with CVD/lifestyle risk factors who were not taking cholesterol or blood pressure-lowering medication in 2012. Participants were asked to ‘think aloud’ while using two heart age calculators in random order, with semi-structured interviews before and after. Transcribed audio-recordings were coded and a Framework Analysis method was used. Results: Risk factor questions were often misinterpreted, reducing the accuracy of the calculators. Participants perceived older heart age as confronting, and younger heart age as positive but unrealistic. Unexpected or contradictory results (e.g. low percentage risk but older heart age) led participants to question the credibility of the calculators. Reasons to discredit the results included the absence of relevant lifestyle questions and impact of corporate sponsorship. However, the calculators prompted participants to consider lifestyle changes irrespective of whether they received younger, same or older heart age results. Conclusions: Online heart age calculators can be misunderstood and disregarded if they produce unexpected or contradictory results, but they may motivate lifestyle change anyway. Future research should investigate both the benefits and harms of communicating risk in this way, and how to increase the reliability and credibility of online health risk calculators.NHMR

Factors influencing general practitioners’ decisions about cardiovascular disease risk reassessment: findings from experimental and interview studies

Background: Guidelines on cardiovascular disease (CVD) risk reassessment intervals are unclear, potentially leading to detrimental practice variation: too frequent can result in overtreatment and greater strain on the healthcare system; too infrequent could result in the neglect of high risk patients who require medication. This study aimed to understand the different factors that general practitioners (GPs) consider when deciding on the reassessment interval for patients previously assessed for primary CVD risk. Methods: This paper combines quantitative and qualitative data regarding reassessment intervals from two separate studies of CVD risk management. Experimental study: 144 Australian GPs viewed a random selection of hypothetical cases via a paper-based questionnaire, in which blood pressure, cholesterol and 5-year absolute risk (AR) were systematically varied to appear lower or higher. GPs were asked how they would manage each case, including an open-ended response for when they would reassess the patient. Interview study: Semi-structured interviews were conducted with a purposive sample of 25 Australian GPs, recruited separately from the GPs in the experimental study. Transcribed audio-recordings were thematically coded, using the Framework Analysis method. Results: Experiment: GPs stated that they would reassess the majority of patients across all absolute risk categories in 6 months or less (low AR = 52 % [CI = 47-57 %], moderate AR = 82 % [CI = 76-86 %], high AR = 87 % [CI = 82-90 %], total = 71 % [CI = 67-75 %]), with 48 % (CI = 43-53 %) of patients reassessed in under 3 months. The majority (75 % [CI = 70-79 %]) of patients with low-moderate AR (≤15 %) and an elevated risk factor would be reassessed in under 6 months. Interviews: GPs identified different functions for reassessment and risk factor monitoring, which affected recommended intervals. These included perceived psychosocial benefits to patients, preparing the patient for medication, and identifying barriers to lifestyle change and medication adherence. Reassessment and monitoring intervals were driven by patient motivation to change lifestyle, patient demand, individual risk factors, and GP attitudes. Conclusions: There is substantial variation in reassessment intervals for patients with the same risk profile. This suggests that GPs are not following reassessment recommendations in the Australian guidelines. The use of shorter intervals for low-moderate AR contradicts research on optimal monitoring intervals, and may result in unnecessary costs and over-treatment