Family Practice Vol. 19, No. 6, 596-604
© Oxford University Press 2002
Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey
a Division of Primary Care, Public and Occupational Health, Department of Primary Care and General Practice, University of Birmingham, Edgbaston, Birmingham, UK and
b Cardiology Research Unit, University of Lund, Malmö University Hospital, Malmö, Sweden.
Correspondence to FDR Hobbs. E-mail: hobbs{at}bham.ac.uk
Hobbs FDR, Erhardt L. Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey. Family Practice 2002; 19: 596–604.
Received 17 January 2002; Revised 7 May 2002; Accepted 16 July 2002.
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Abstract |
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Background. Although primary care is the major target of coronary heart disease (CHD) clinical recommendations, little is known of how community physicians view guidelines and their implementation. The REACT survey was designed to assess the views, and perceived implementation, of CHD and lipid treatment guidelines among primary care physicians.
Methods. Semi-structured validated telephone interviews were conducted, in the relevant native tongue, with 754 randomly selected primary care physicians (GPs and family doctors) in five European countries (France, Germany, Italy, Sweden and the UK).
Results. Most physicians (89%) agreed with the content of current guidelines and reported use of them (81%). However, only 18% of physicians believed that guidelines were being implemented to a major extent. Key barriers to greater implementation of guidelines were seen as lack of time (38% of all physicians), prescription costs (30%), and patient compliance (17%). Suggestions for ways to improve implementation centred on more education, both for physicians themselves (29%) and patients (25%); promoting, publicizing or increasing guideline availability (23%); simplifying the guidelines (17%); and making them clearer (12%). Physicians perceived diabetes to be the most important risk factor for CHD, followed by hypertension and raised LDL-C. Most physicians (92%) believe their patients do associate high cholesterol levels with CHD. After establishing that a patient is ‘at risk’ of CHD, physicians reported spending an average of 16.5 minutes discussing risk factors and lifestyle changes or treatment that is required. Factors preventing this included insufficient time (42%), having too many other patients to see (27%) and feeling that patients did not listen or understand anyway (21%).
Conclusions. Primary care physicians need more information and support on the implementation of CHD and cholesterol guideline recommendations. This need is recognized by clinicians.
Keywords. Cholesterol, coronary heart disease, guidelines, risk factors.
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Introduction |
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The most common lethal outcome of hypercholesterolaemia, hypertension, smoking and diabetes is coronary heart disease (CHD), now the leading cause of death worldwide.1 Up to 25% of first myocardial infarctions are fatal,2 and the outcome for survivors is also serious, with a 10 year mortality rate of 37% for those with angina and 55% for those suffering a myocardial infarction.3 In addition, approximately one-third of myocardial infarctions go unrecognized, but have a prognosis almost as severe as individuals surviving symptomatic infarctions.4 The need for CHD prevention strategies aimed at treating the underlying disease process has never been so paramount.5 However, there are also seemingly healthy individuals whose risk for CHD may be as high as those who already have clinically manifest disease. These individuals can be targeted by estimating absolute risk (the risk of developing CHD, either a non-fatal event or coronary death, over the next 10 years) by taking into account all the major risk factors.5,6
High quality and repeated scientific evidence has demonstrated that lifestyle interventions—diet, smoking, exercise—and the use of cholesterol-lowering therapies in patients with CHD and in individuals at high absolute risk can reduce cardiovascular morbidity and mortality.6 Benefit has been shown in patients with,7–9 and without prior coronary disease,10,11 and in at-risk patient groups with both elevated and average low-density lipoprotein cholesterol (LDL-C) levels. However, despite these well publicized results from the mid-1990s, and the wide dissemination of guidelines, studies document that the management of risk factors, especially hypercholesterolemia, in high-risk individuals is sub-optimal.12–15
For example, the first EUROASPIRE survey in nine European countries of CHD patients 6 months after discharge into the community showed that 19% were still smoking, 25% were overweight, 53% were hypertensive and 86% had a total cholesterol level of 5.5 mmol/L or greater.13 One study in a UK primary care setting revealed that only 17% of CHD patients had their lipid levels controlled.16 A second hospital discharge survey (EUROASPIRE II), undertaken in 1999–2000 in the same countries and almost identical centres, to see whether preventive cardiology had improved,14 showed disappointing changes: smoking prevalence remained almost unchanged at 21%; the prevalence of obesity increased substantially from 25% to 33%; and the proportion with high blood pressure was virtually the same at 55%. Although the prevalence of high total cholesterol concentrations decreased from 86% to 59%, many individuals are still not achieving the cholesterol goal of <5mmol/L.
Poor implementation is also observed in the USA. A survey of 4888 patients from five regions of the USA found that 47% had two or more risk factors and no evidence of CHD (high-risk group) and 30% had established CHD.15 Success rates for patients achieving US National Cholesterol Education Program (NCEP) LDL-C targets were 37% among high-risk patients and only 18% among patients with CHD.4 These findings are consistent with those from the Third National Health and Nutrition Examination Survey (NHANES III),17 conducted on a nation-wide probability sample of 33 994 persons and covered the period 1988–1994. Both studies found that over 80% of patients with existing CHD (those at highest risk for a further cardiovascular event) do not achieve target cholesterol levels.
To explore this gap between evidence and practice in the prevention and management of CHD, the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey was conducted. The two major objectives of the survey were to assess acceptance and/or implementation of treatment guidelines for high cholesterol and CHD among physicians, and attitudes and behaviours towards cholesterol as a risk factor for CHD among the general public. This paper reports on the physician data.
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Methods |
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Study population and questionnaire
The REACT survey was conducted in France, Germany, the UK, Italy and Sweden by the NOP Healthcare Group. NOP Healthcare is a long-established marketing research agency, with a centralized telephone interviewing facility based in London, using a specially trained team of interviewers to recruit and conduct medical market research among healthcare professionals. The interviews in all countries, with the exception of Italy, were conducted from the London telephone facility.
Primary care physicians (defined as GPs or family doctors working in the community) were randomly recruited using telephone and hospital directories for each of the countries concerned. The sample for each country was obtained by selecting every fourth telephone number from the directory for each region. Regional quotas were imposed on the sample, in line with the size of the general public population in each of the regions. If a physician declined to be interviewed, random sampling continued until the required sample size was achieved. Physicians were screened to ensure that: they had been in practice for between 2 and 30 years; they were not working as a locum at the time of interview; they had not participated in a market research survey on the subject of CHD within the last month; and they did not work on a consultancy basis for a pharmaceutical company.
Physicians were surveyed by 15 minute telephone calls, as this offered the greatest flexibility for the scheduling of interviews to fit in with the physician’s workload. Physicians were reimbursed an amount equivalent to £15 sterling for their time in completing the survey. Interviews were conducted in the relevant language by trained interviewers. Interviews comprised a pre-determined sequence of semi-structured questions, with ‘prompts’ for extra information in some areas. Both qualitative and quantitative questions were asked. The latter involved obvious numerical information (e.g. how often do you . . . ?) or conversion to a numerical format by the use of rating scales (e.g. how useful on a scale of 1 to 10 do you find . . . ?).
The questionnaire covered a range of areas including perceived need, use and usefulness of CHD guidelines, extent and barriers to implementation of guidelines and the importance of risk factors assumed in practice. To establish how physicians determine whether a patient is at risk of CHD, respondents were asked how they would rate the relative importance of the major cardiovascular risk factors for CHD on a scale from 1 (not at all important) to 10 (very important). Further questions exposed what tests would be performed to assess CHD risk and how frequently testing would be repeated. The final scores of questions related to physician/patient communication on CHD prevention, the use of medication, and patient targets. Fieldwork was carried out during July and August 1999 by NOP Research.
Statistical analysis
A purposive, random sample of 150 physicians interviewed in each of the five countries was estimated to capture the likely range of practice and opinion across physicians in each country. Quotas for the number of interviews to be conducted in each region within the five countries were imposed, according to the percentage of the national population residing in each region, to ensure a generalizable spread of geographical locations.
Data are given as percentage response rates. Mean values derived from rating scales are quoted ± standard error. The significance of the difference between pairs of means was established using Student’s t-tests. Comparison between more than two mean values used chi-squared tests or analysis of variance (two-sided). Significance testing was performed at the 95% confidence interval (5% risk level). Significance testing between countries was performed on multi-country tabulations, with the percentage derived from responses in each country tested against the total percentage and against each other individual country percentage.
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Results |
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A total of 754 physicians were interviewed. Refusal rates were 83%, 72%, 66% and 47% for the UK, France, Germany and Sweden, respectively, with consecutive random sampling continuing until the target number in each country had accepted interview. In Italy the number of physicians who declined to be interviewed was not recorded. Demographic characteristics for physicians are given in Table 1
. Across the five European countries, the physicians had, on average, been in practice for 17 years (range 14 years in Germany to 19 in the UK). On average, respondents saw 462 patients (with any problem) per month. Estimated monthly consultation rates varied considerably, from just 260 in Sweden to 650 in the UK.
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Views on CHD guidelines
Across all countries, 87% of physicians believed that formal guidelines on the prevention of CHD were needed either to a major extent (43%) or moderate extent (44%). Most physicians (89%) also said that they agreed with the content of common guidelines relating to the management of high cholesterol. Of these, approximately one-third (29%) agreed completely and two-thirds (60%) agreed somewhat. The level of agreement with the content of guidelines for cholesterol was broadly similar in all countries except the UK, where only 17% of physicians agreed completely with their content.
Overall, 81% of physicians claimed to be using some kind of guideline, most frequently national guidelines (59%) and physician’s own practice guidelines (56%), followed by local hospital guidelines (43%) (Table 2). Despite the wide dissemination of the revised European Joint Societies Task Force guidelines, only 15% of physicians reported their use.
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Almost one fifth (19%) of the physicians claimed, spontaneously, not to use any guidelines for the prevention and management of CHD, while 12% answered ‘don’t know’. Use of any guidelines decreased with increasing number of patient consultations, with 27% of high consulting physicians (600 patients per month) spontaneously reporting no use.
Usefulness of guidelines in practice
Ninety-one per cent of physicians stated that the guidelines were either ‘very useful’ (32%) or ‘fairly useful’ (59%), versus only 8% who said either ‘not very’ or ‘not at all useful’. Italian physicians were more likely to consider guidelines useful (99%) than colleagues in France (90%), Germany (90%) and the UK (85%). Guidelines for diabetes, hypertension and cholesterol were seen as useful by over 80% of physicians with mean ratings of 3.1 (±0.03) for cholesterol, 3.4 (±0.03), for diabetes, and 3.3 (±0.03) for hypertension out of 4.
Overall, 8% of physicians said they found guidelines either ‘not very’ or ‘not at all useful’ in their practice, but this figure was higher among UK physicians (16%). Reasons stated for this perceived lack of usefulness were that they preferred to rely on their own experience and knowledge (28%); guidelines were too difficult to implement in practice (23%); there were too many guidelines (23%); and guidelines were irrelevant in clinical practice (23%).
Implementation of CHD and cholesterol guidelines
Eighteen per cent of physicians believed that CHD prevention and management guidelines were being implemented to a major extent and 60% to a moderate extent. Key barriers to greater implementation of CHD guidelines were seen as lack of time (38% of all physicians), followed by prescription costs (30%), and patient compliance (17%) (Table 3). There was country variation, with lack of time the greatest barrier in Sweden (65%) and Italy (42%), whereas in the UK, lack of time and prescription costs were held equally responsible (57%). Prescribing cost was the greatest single barrier in Germany (53%), but in France, patient compliance was rated highest (34%).
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Unprompted suggestions for ways to improve the implementation of CHD guidelines centred on more education, both for physicians themselves (29%) and patients (25%). Promoting or publicizing the guidelines or increasing their availability was suggested by 23%, while others felt that simplifying guidelines (17%) or making them clearer (12%) would be solutions.
Risk factors for CHD and use of risk calculators
Mean ratings show that diabetes was perceived to be the most important risk factor (mean 8.8), followed by hypertension (8.4) and raised LDL-C (8.2) (Table 4). Low high-density lipoprotein cholesterol (HDL-C) was viewed as the least important risk factor (6.8). Those respondents who believed that guidelines for cholesterol were useful gave raised LDL-C a higher importance rating than those who did not find them useful.
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The most frequently used test to initially assess a patient’s risk of CHD was cholesterol, mentioned by over three-quarters (78%) of all physicians. Blood pressure (69%), blood glucose (63%) and lifestyle (56%) were all noted by a majority of physicians, while family history (46%), weight (33%) and ECG (with exercise) (31%) were also reported (Table 5
).
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Forty-three per cent of physicians said that they rarely or never use any risk calculator charts that may accompany guidelines. A further 43% said that they sometimes referred to them, but only 13% said that this was always the case. Usage was particularly low among French physicians, where 55% said they never or rarely used risk charts, and much higher among Italian physicians, where 90% stated that they always or sometimes use the risk charts.
Physician–patient communication and management of CHD
Most physicians (92%) believed their patients associate high cholesterol levels with CHD, with the exception of France, where fewer physicians (86%) believed this to be the case. After establishing that a patient is ‘at risk’ of CHD, 65% of all physicians said that they spend 15 minutes or less discussing risk factors and lifestyle changes or treatment that is required (Table 6), 12% of physicians reported 5 minutes or less in discussion with patients and 24% spending 6–10 minutes. There were three main factors volunteered that influenced discussion with patients at risk of CHD: insufficient time (42%), having (too many) other patients to see (27%), and feeling that patients did not listen or understand anyway (21%).
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Most physicians (94%) stated that they advised patients what their target cholesterol numbers should be. This proportion was higher than average in Germany (98%) and Italy (99%), but lower than the overall average in Sweden (87%). Physicians who found guidelines for cholesterol useful were more likely to report discussing target cholesterol levels with their patients.
The most common group for whom physicians spontaneously reported prescribing lipid-lowering drug therapy were patients with high lipid levels (mentioned by 59% of physicians), patients with existing heart disease (53% of the physicians), and diabetic patients (cited by 46%) (Fig. 1). Swedish and UK physicians were most likely to cite existing heart disease patients as routine recipients of lipid-lowering drug therapy (65% and 66%, respectively).
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For existing CHD patients, 80% of physicians thought that cholesterol was managed either ‘fairly’ or ‘very’ well and 19% felt that it was managed ‘fairly’ or ‘very’ badly. Perceived management of at-risk groups was less positive, with two-thirds of all physicians (68%) believing that cholesterol tends to be managed fairly or very well and almost a third (30%) stating that it is managed badly. National differences in opinion were marked, with German and UK physicians less likely to feel that cholesterol management in both at-risk and existing CHD patients is performed well. For example, 41% of UK physicians felt that patients who were at risk of developing CHD tended to be managed badly compared with only 10% in France. Physicians were more positive about their ability to achieve blood pressure targets (75% of physicians) than those for cholesterol (63%).
When physicians were asked without prompting how they thought cholesterol management could be improved, the most frequent suggestion was by improving patient education (Fig. 2). Other suggestions included the provision of better physician education (18%), better patient co-operation (15%), more money/funding (14%) and dietary control/advice (13%).
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Discussion |
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As with most surveys, this study’s main limitations relate to the reliability and generalizabilty of the physician responses. The varied response rates of physicians in different countries (the UK and France being the lowest) might have resulted in more interested or aware practitioners responding. There is also no mechanism to validate the physician responses, although how doctors say they practice might not be how they actually practice. Despite such limitations, the sample of doctors was selected randomly, a good number of responses were collected across five different countries, and the findings are important and relevant even if they are not entirely generalizable.
Successful implementation of CHD prevention relies heavily on the primary care physician providing risk factor evaluation, intervention and patient education.18 The results of the REACT survey show that the majority of primary care physicians appear to support the concept of preventive cardiology. Most of those interviewed believed there was a need for formal guidelines (87%), agreed with their content (89%), and reported use of them (81%). However, these results do not appear to reflect what is happening in current practice.
The results of practice performance surveys are particularly discouraging because there is widespread agreement on the value of aggressive lipid lowering in secondary prevention. As the majority of physicians interviewed were in agreement with current guidelines, it appears that the problem lies not with the concept of guidelines but with their understanding or their implementation.
Under-identification of at-risk patients
To implement preventive strategies it is first necessary to identify those individuals at risk of, or with, established CHD. Evidence from several large randomized clinical trials indicates that aggressive management of risk factors has a significant positive impact on the natural history of atherosclerotic cardiovascular disease.7–11
The most appropriate mechanism used to determine who has most to benefit from primary prevention is an estimate of an individual’s absolute risk, determined by multiple factors including age, sex, smoking status, cholesterol levels, blood pressure and presence of diabetes. To assist physicians in calculating absolute risk for primary prevention, coronary risk charts have been developed, all based on the Framingham equation. Intervention is recommended in those individuals for whom the 10-year risk of a coronary event is greater than 20% or would be greater than 20% if projected to age 60 years. In some countries, including the UK, recommendations for treating patients are higher (on cost grounds) at 30% or greater than 10 years risk. The REACT survey found that 43% of physicians reported rarely or never using risk charts that may accompany guidelines.
Many obstacles to preventive care have been highlighted in past literature but are confirmed as still prevalent by the results of the REACT survey. Time constraints were identified as the largest single barrier to preventive cardiology, particularly in the UK, where physicians had the highest monthly consultation rates.
Many primary care physicians manage the majority of patients visiting their practice without referral elsewhere and require information to help manage difficult or complex decisions.19 However, physicians may also be overwhelmed by the amount of literature they receive. A recent survey of 22 general practices in the UK found 855 different guidelines—a pile 68 cm high and weighing 28 kg. This mass of paper represents a large amount of information, but is in an unmanageable form that does little to aid decision making.20
In terms of secondary prevention, communication between primary and secondary care is also a major issue. The cardiologist may wrongly assume that the primary care physician will manage the follow-up of risk factors such as blood pressure and cholesterol. It has been postulated that the primary care physician may perceive this lack of a treatment plan to mean that the cardiologist does not believe a risk-lowering strategy is important.21 Communication between physicians and patients is also an important element of any prevention plan and one of the first to suffer when physicians have limited time.
Strategies for improving preventive care
The REACT survey revealed that the majority of physicians agreed with the content of current guidelines and reported use of them. However, existence of guidelines is not enough to ensure that physicians consistently apply the messages they contain. Three key components of a useful clinical guideline are: the identification of key decisions and their consequences; a review of the relevant, valid evidence on the benefits, risks, and costs of alternative decisions; and the presentation of the evidence required to make key decisions in a simple, accessible format.22
In the REACT survey, improved education for both patients and physicians was reported as the best way of improving cholesterol management. For physicians, this would focus on the benefits of using evidence-based guidelines (including how to implement the evidence into routine consultations), establishing priorities for prevention, diagnostic thresholds, the importance of risk charts for assessing an individual’s level of risk, and the benefits of statin therapy for achieving cholesterol reductions.
It is possible that the dramatic results achieved in large, randomized, secondary prevention trials may not be achievable with the resources currently available to most health care providers. The patients who participate in these trials receive regular follow-ups through a system of organized medical care. Such an approach could be the key to future risk-reduction efforts, for example, through greater involvement by nurses and other health care professionals, both in hospitals and in the primary care setting.23,24,25 One UK study of 1173 patients with CHD showed secondary prevention clinics run by nurses in general practice26 improved patients’ health and reduced hospital admissions. In the USA, a nurse-managed approach produced marked improvement in the use of risk-reduction therapies among post-MI patients. The impact was significant although the nurses only spent an average of 9 hours per year with each patient.27
The challenge now is to motivate and support more physicians to routinely practice preventive cardiology. Passive dissemination of information in isolation is generally ineffective and, at best, results in only small changes in practice. However, these passive approaches represent the most common approaches adopted by health care organizations.28 In a UK survey of 100 physicians (50 consultants and 50 primary care physicians) who worked in a range of medical fields, the three most frequently cited reasons for change in consensus of opinion and new physician prescribing practices were hospital and practice organization factors (18%), education (17%) and contact with professionals (13%).29
Equally important is the need to provide training and structural support for such clinical practice, including personal and financial incentives. Physicians should not be financially penalized for practising preventive cardiology. The REACT survey provides qualitative data on some of the factors that primary care physicians perceive are related to their practice in cardiovascular prevention.
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Acknowledgments |
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The costs of the survey, in terms of sampling, interviews, and physician reimbursement, were met by an unrestricted research grant from Pfizer Inc.
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