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

Perceptions and misperceptions of overdetection of breast cancer.

Editorial piece commenting on: Pappadis MR, Volk RJ, Krishnan S, et al. Perceptions of overdetection of breast cancer among women 70 years of age and older in the USA: a mixed-methods analysis. BMJ Open 2018;8:e022138

Interventions for improving health literacy in people with chronic kidney disease

This is the protocol for a review and there is no abstract. The objectives are as follows: This review aims to look at the benefits and harms of interventions for improving health literacy in patients with CKD

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

Discussing cost and value in patient decision aids and shared decision making: A call to action

Direct and indirect costs of care influence patients\u27 health choices and the ability to implement those choices. Despite the significant impact of care costs on patients\u27 health and daily lives, patient decision aid (PtDA) and shared decision-making (SDM) guidelines almost never mention a discussion of costs of treatment options as part of minimum standards or quality criteria. Given the growing study of the impact of costs in health decisions and the rising costs of care more broadly, in fall 2021 we organized a symposium at the Society for Medical Decision Making\u27s annual meeting. The focus was on the role of cost information in PtDAs and SDM. Panelists gave an overview of work in this space at this virtual meeting, and attendees engaged in rich discussion with the panelists about the state of the problem as well as ideas and challenges in incorporating cost-related issues into routine care. This article summarizes and extends our discussion based on the literature in this area and calls for action. We recommend that PtDA and SDM guidelines routinely include a discussion of direct and indirect care costs and that researchers measure the frequency, quality, and response to this information

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

The Patient Typology about deprescribing and medication-related decisions: A quantitative exploration.

This study aimed to test the adequacy of a quantitative measure of our qualitatively-developed Patient Typology - categories of older adults' attitudes towards medicines and medicine decision-making - and identify characteristics associated with each Typology. We conducted secondary data analyses of a subset of survey item measures of adults (≥65 years) who were members of online survey panels in Australia, the UK, the US, and the Netherlands (n=4,688). Multinomial logistic regression analyses assessed associations between demographic, psychosocial, and medication-related measures. Mean age was 71.5 (5) and 47.5% of participants were female. Factors associated with an increased likelihood of identifying with Typology 1 'Attached to medicines' over Typology 2 'Open to deprescribing' were higher positive attitude towards polypharmacy (RRR=1.12, p =<.001) and higher need for certainty (RRR=1.11, p=.039). Factors associated with an increased likelihood of identifying with Typology 3 'Defers (medication decision-making) to others' over Typology 2 were older age (RRR=1.47 per 10-year age increase, p=<.001) and a decreased likelihood of prior deprescribing experience (RRR=0.73, p=.033). This study provides validation of the Typology with large samples from four countries, with the quantitatively-measured typologies generally aligning with the qualitatively-derived categories. Our Patient Typology measure provides a succinct way researchers can assess attitudes towards deprescribing