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

Total synthesis of noricumazole B establishes D-arabinose as glycan unit

The total synthesis of noricumazole B, a secondary metabolite from myxobacteria, was achieved. It established the glycan moiety to be D-α-arabinoside. © The Royal Society of Chemistry 2012

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

Objective classification of residents based on their psychomotor laparoscopic skills

Background - From the clinical point of view, it is important to recognize residents’ level of expertise with regard to basic psychomotor skills. For that reason, surgeons and surgical organizations (e.g., Acreditation Council for Graduate Medical Education, ACGME) are calling for assessment tools that credential residents as technically competent. Currently, no method is universally accepted or recommended for classifying residents as ‘‘experienced,’’ ‘‘intermediates,’’ or ‘‘novices’’ according to their technical abilities. This study introduces a classification method for recognizing residents’ level of experience in laparoscopic surgery based on psychomotor laparoscopic skills alone. Methods - For this study, 10 experienced residents (>100 laparoscopic procedures performed), 10 intermediates (10– 100 procedures performed), and 11 novices (no experience) performed four tasks in a box trainer. The movements of the laparoscopic instruments were recorded with the TrEndo tracking system and analyzed using six motion analysis parameters (MAPs). The MAPs of all participants were submitted to principal component analysis (PCA), a data reduction technique. The scores of the first principal components were used to perform linear discriminant analysis (LDA), a classification method. Performance of the LDA was examined using a leave-one-out crossvalidation. Results - Of 31 participants, 23 were classified correctly with the proposed method, with 7 categorized as experienced, 7 as intermediates, and 9 as novices. Conclusions - The proposed method provides a means to classify residents objectively as experienced, intermediate, or novice surgeons according to their basic laparoscopic skills. Due to the simplicity and generalizability of the introduced classification method, it is easy to implement in existing trainers.Biomechanical EngineeringMechanical, Maritime and Materials Engineerin

Visual force feedback in laparoscopic training

Background - To improve endoscopic surgical skills, an increasing number of surgical residents practice on box or virtual reality (VR) trainers. Current training is focused mainly on hand–eye coordination. Training methods that focus on applying the right amount of force are not yet available. Methods - The aim of this project is to develop a low-cost training system that measures the interaction force between tissue and instruments and displays a visual representation of the applied forces inside the camera image. This visual representation continuously informs the subject about the magnitude and the direction of applied forces. To show the potential of the developed training system, a pilot study was conducted in which six novices performed a needledriving task in a box trainer with visual feedback of the force, and six novices performed the same task without visual feedback of the force. All subjects performed the training task five times and were subsequently tested in a post-test without visual feedback. Results - The subjects who received visual feedback during training exerted on average 1.3 N (STD 0.6 N) to drive the needle through the tissue during the post-test. This value was considerably higher for the group that received no feedback (2.6 N, STD 0.9 N). The maximum interaction force during the post-test was noticeably lower for the feedback group (4.1 N, STD 1.1 N) compared with that of the control group (8.0 N, STD 3.3 N). Conclusions - The force-sensing training system provides us with the unique possibility to objectively assess tissuehandling skills in a laboratory setting. The real-time visualization of applied forces during training may facilitate acquisition of tissue-handling skills in complex laparoscopic tasks and could stimulate proficiency gain curves of trainees. However, larger randomized trials that also include other tasks are necessary to determine whether training with visual feedback about forces reduces the interaction force during laparoscopic surgery.Biomechanical EngineeringMechanical, Maritime and Materials Engineerin

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

Impact of a diagnosis of polycystic ovary syndrome on diet, physical activity and contraceptive use in young women: findings from the Australian Longitudinal Study of Women's Health

Study question: Do diet, physical activity and contraceptive use change after receiving a diagnosis of polycystic ovary syndrome (PCOS)? Summary answer: Using longitudinal data 12\ua0months apart, young women newly diagnosed with PCOS were more likely to stop using contraception but did not change their physical activity or vegetable intake. What is known already: Diagnostic criteria for PCOS have widened to capture more women, despite limited evidence of the benefits and harms. Possible benefits of a PCOS diagnosis are that it may help women with family planning and motivate them to implement healthy lifestyle changes to reduce the reproductive, metabolic and cardiovascular risks associated with PCOS. However, there are no empirical studies investigating how women respond to a diagnosis of PCOS with respect to their health behaviour, and longitudinal population-based studies are lacking. Study design, size, duration: This is a longitudinal analysis of two waves of data collected 12\ua0months apart from the cohort born 1989-1995 in the Australian Longitudinal Survey on Women's Health, a population-based cohort study. Women in this cohort were first surveyed in 2012-2013, aged 18-23 years. Participants/materials, setting, methods: Women who responded to the 2014 survey (aged 19-24, n\ua0= 11 344) and 2015 survey (aged 20-25, n\ua0= 8961) were included. Using logistic regression, multinomial logistic regression and linear regression, change in vegetable intake, physical activity and contraceptive use were compared for women newly diagnosed with PCOS to women not reporting a diagnosis of PCOS. Changes in psychological distress and BMI were also examined. Main results and the role of chance: Young women reporting a new diagnosis of PCOS were no more likely to increase their vegetable intake or physical activity than women not reporting a PCOS diagnosis. Women newly diagnosed with PCOS were 3.4 times more likely to stop using contraception during the 12-month study period than women without PCOS (14% versus 4%, 95% CI = 2.3 to 5.1, P\ua

Systematic review of clinical practice guidelines recommendations about primary cardiovascular disease prevention for older adults

Background: Clinical care for older adults is complex and represents a growing problem. They are a diverse patient group with varying needs, frequent presence of multiple comorbidities, and are more susceptible to treatment harms. Thus Clinical Practice Guidelines (CPGs) need to carefully consider older adults in order to guide clinicians. We reviewed CPG recommendations for primary cardiovascular disease (CVD) prevention and examined the extent to which CPGs address issues important for older people identified in the literature. Methods: We searched: 1) two systematic reviews on CPGs for CVD prevention and 2) the National CPG Clearinghouse, G-I-N International CPG Library and Trip databases for CPGs for CVD prevention, hypertension and cholesterol. We conducted our search between April and December 2013. We excluded CPGs for diabetes, chronic kidney disease, HIV, lifestyle, general screening/prevention, and pregnant or pediatric populations. Three authors independently screened citations for inclusion and extracted data. The primary outcomes were presence and extent of recommendations for older people including discussion of: (1) available evidence, (2) barriers to implementation of the CPG, and (3) tailoring management for this group. Results: We found 47 eligible CPGs. There was no mention of older people in 4 (9 %) of the CPGs. Benefits were discussed more frequently than harms. Twenty-three CPGs (49 %) discussed evidence about potential benefits and 18 (38 %) discussed potential harms of CVD prevention in older people. Most CPGs addressed one or more barriers to implementation, often as a short statement. Although 27 CPGs (58 %) mentioned tailoring management to the older patient context (e.g. comorbidities), concrete guidance was rare. Conclusion: Although most CVD prevention CPGs mention the older population to some extent, the information provided is vague and very limited. Older adults represent a growing proportion of the population. Guideline developers must ensure they consider older patients’ needs and provide appropriate advice to clinicians in order to support high quality care for this group. CPGs should at a minimum address the available evidence about CVD prevention for older people, and acknowledge the importance of patient involvement.NHMR