Family Practice Vol. 19, No. 6, 605-610
© Oxford University Press 2002
‘I saw the panic rise in her eyes, and evidence-based medicine went out of the door.’ An exploratory qualitative study of the barriers to secondary prevention in the management of coronary heart disease
a GP, Saintbridge Surgery, Askwith Road, Gloucester and
b Department of Social Medicine, University of Bristol, Bristol, UK.
Catherine Pope, Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK; E-mail: c.pope{at}bristol.ac.uk
Summerskill WSM and Pope C. ‘I saw the panic rise in her eyes, and evidence-based medicine went out of the door.’ An exploratory qualitative study of the barriers to secondary prevention in the management of coronary heart disease. Family Practice 2002; 19: 605–610.
Received 30 October 2001; Revised 29 April 2002; Accepted 16 July 2002.
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Abstract |
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Background. Coronary heart disease (CHD) is the leading cause of death in the UK, yet only 50% of CHD patients receive appropriate secondary prevention.
Objectives. To explore GP attitudes to evidence about CHD, and to identify factors influencing the implementation of secondary prevention in GP consultations.
Methods. Semi-structured interviews and focus groups exploring consultations with patients previously diagnosed as having CHD.
Results. Use of evidence is influenced by credibility. Lack of time was the greatest barrier to accessing evidence and to implementing secondary prevention. Patients were more likely to receive secondary prevention in a dedicated clinic. Patient characteristics including physical and mental co-morbidity mitigate against secondary prevention. GPs experienced difficulty balancing implementation of evidence with the demands of the doctor–patient relationship.
Conclusions. The doctor–patient relationship may act as a barrier to the delivery of secondary prevention in primary care. It may be time to re-evaluate models of these relationships and reconsider the strategies for implementing evidence.
Keywords. Doctor–patient relationship, evidence-based medicine, guidelines, qualitative research, secondary prevention of coronary heart disease.
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Introduction |
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Coronary heart disease (CHD) is the leading cause of death in the UK, and half of these deaths occur in individuals with known CHD1. Evidence supports various strategies to inhibit the pathological progression of CHD, including blood pressure control,2 anti-thrombotic therapies,3 cholesterol reduction,4 beta-blockers after myocardial infarction,5 and smoking cessation.6 These strategies are collectively termed ‘secondary prevention’.
Secondary prevention has been advocated by national guidelines,7 culminating in the National Service Framework (NSF) for CHD, a ten-year strategy to reduce CHD incidence and mortality in the UK.8 Nine of the 12 standards in the NSF refer directly to secondary prevention in primary care, but previous research has suggested that only 50% of patients with a diagnosis of CHD received appropriate secondary prevention from their GP.9 Various explanations have been offered, including credibility of evidence,10 patient factors,11 practitioner characteristics12 and practice or organizational features.13 Others argue that many GPs simply do not share the evidence paradigm.14
The study reported here was conducted to investigate why GPs do not follow guidelines about secondary prevention of CHD and to explore whether this was associated with the nature of evidence itself, or with problems linked to implementation. Qualitative methods were used to identify factors that influenced the use of secondary prevention, such as sources of evidence, GPs’ attitudes to evidence, and the application of evidence within consultations.
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Methods |
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Exploratory semi-structured interviews and focus groups15 involving 14 GPs working in 12 practices in Gloucestershire were undertaken between April and August 2000. The study was approved by the Gloucestershire Local Research Ethics Committee.
Gloucestershire has a population of 560 000, served by 339 GPs in 85 practices. All GPs were invited to participate (excluding WS). Those expressing interest in the study were sent a protocol to identify four consultations involving patients aged 18–74 with CHD (two in which secondary prevention had been implemented and two—without contraindications—in which it had not been implemented). GPs also received four stamped recruitment packs to send to patients whose consultations met the inclusion criteria. The pack explained the study to patients, and included a consent form and a stamped return envelope. Patients had to be competent to give consent, and to do so before inclusion in the study.
A topic guide for semi-structured interviews with these GPs was developed jointly by CP and WS, informed by the observations of Fairhurst and Huby10 and a local pilot study. The topic guide was modified as the study progressed to include new areas of relevance as additional issues emerged from analysis of earlier interviews. WS conducted the one-hour interviews which included a card-sorting exercise to prompt discussion about sources of evidence, and questions about recent CHD consultations selected by the GP.
The card-sorting exercise asked GPs to rank a list of ten potential sources of evidence in order of influence on their own management of CHD (Box 1
). The choice of potential sources reflected those considered to be influential (positively or negatively) in previous studies.16,17 One source was listed on each of ten 8.5 x 11.5 cm. cards. These were shuffled and presented to the GP to arrange in order of importance.18 Card sorting is an indirect technique to understand an individual’s hierarchy of evidence and minimize ‘socially desirable’ responses.19 Traditionally sorting is conducted in silence, but as so many GPs commented on their decisions during the ranking process, these data were included in the qualitative analysis.
| Box 1 Sources of evidence for card sorting Sources of evidence Clinical meetings Drug reps Editorials or review articles GP colleagues Health authority Hospital consultants Local guidelines National guidelines Original articles Primary care group
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Two focus groups were conducted, one facilitated by each author. All the participating GPs were invited to attend these focus groups which included a brief presentation of the preliminary interview data and emerging themes. Eight of the participating GPs took part in these groups. Their reactions to the presentation and discussion were used to verify the themes identified and to elicit further detail and comment.
The interviews and focus groups were audio-taped and transcribed verbatim. Each author examined the transcripts independently to identify thematic categories. Themes were organised with the assistance of NUD*IST Vivo (version 1.1).20 The authors met to compare and discuss categories and areas of interpretative disagreement. Despite differences in perspective (WS is a GP and CP a sociologist), the key themes identified were similar. Disagreement concerned subgroups within themes and further discussion with reference to the data enabled modifications to be made and consensus achieved.
Alongside this qualitative work, the Gloucestershire Primary Care Clinical Audit Group (PCCAG) was auditing the same five secondary prevention criteria in all practices within the county.21 Their sample of 7908 patients with CHD was calculated to predict management with 95% confidence in each practice population of CHD patients aged 18–74 years. In smaller practices this involved all CHD patients, in larger practices the sample was selected at random. The audit data allow comparison between the participants in this study and the wider county population.
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Results |
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Out of 338 GPs, 64 replied, of whom 23 agreed to join the study. Twelve GPs were able to recruit patients and were interviewed. Of the remaining 11 GPs who failed to recruit eligible patients, two responded to interview invitations where they discussed their attitudes to evidence and participated in the card-sorting exercise. While the self-selected 14 GPs comprise a relatively small qualitative sample,22 they do reflect the overall characteristics of GPs within the county (Tables 1 and 2
). Two were women and one was British-Asian. Their average age was 41 years (range 30–56 years), and mean length time in general practice was 14 years (range 2–29 years). Seven participants were GP trainers, which was a higher proportion than in the non-study population. Practice size and location reflect patterns of provision in Gloucestershire.
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Forty-two patients were invited to participate in the study. Of these, eight did not reply, four withheld consent and four were over 75 years of age and excluded by the protocol. In four consultations, the protocol criteria were not satisfied. This left a total of 22 consultations for analysis, 12 in which secondary prevention had been implemented and 10 in which it had been omitted. Patient characteristics were representative of individuals with CHD in the county (Table 3
). The average age of these patients was 64 years (range 48–74 years); all were Caucasian, three were female. The mean time since diagnosis of CHD was 7 years (range 1–15 years).
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Ranking sources of evidence
Often respondents suggested that there was a ‘correct’ ranking for the card-sorting exercise. Some believed that national guidelines were a ‘gold standard’, but then tempered this with comments that they were not always appropriate to everyday practice. Editorials in respected journals were deemed especially credible. At the other extreme, reservations were expressed about placing drug company representatives last:
"I don’t know whether I’m just being politically correct in putting them at the bottom. They often, sometimes, have useful information, [you] can get papers and things from them, but obviously they are often biased towards their own product." (GP138, interview)
A key feature of the interviewees’ assessments was ‘trustworthiness’. ‘Drug reps’ were typically sorted to the lowest level of the ranking as the least credible source of evidence, but not always:
"They come quite high on the list because to me they are a most useful source of information on drugs, and it is often on a weekly basis . . . I try not to let them influence me in what I actually use but, inevitably, if they are trying to sell their drug, and give some obvious advantages, or perhaps cost savings, one would consider that." (GP318, interview)
Primary care groups (PCGs) and the local health authority were viewed with caution. It was suggested that these sources might not have "the patient’s best interest at heart" (GP163, interview) or had other vested interests:
"It’s interesting that the PCG is so low down. I guess there’s a lot, maybe, of suspicion that PCG advice is primarily going to be weighted on sort of financial considerations." (GP186, focus group)"It’s presumably, hopefully, PCG guidance is derived from things like national guidelines, but there is a suspicion there, isn’t there?" (GP138, focus group)
Notions of trustworthiness came to the fore when discussing personal contacts as sources of evidence. Respondents ranked hospital consultants quite highly, although their confidence in them was often qualified by personal experience:
"I have always been respectful of most colleagues who are in consultant posts, with the obvious exception of people who are burnt out or useless. Cardiologists are obviously an important source of information and I do rely on them to be impartial and I do not expect them to be in the pockets of drug companies . . . If I got a letter from [a cardiologist] saying that ‘we really find drug Y is superior in this situation’ then that would influence me to use it." (GP31, interview)
Hospital consultants could influence GP attitudes to other sources of evidence, by discrediting it:
"Even the cardiologists don’t follow it. They don’t follow the guideline either!"(GP31, interview)
or showing how evidence could be translated into practice:
"[Consultants] do refine one’s practice, I think, in the woolier areas of the guidelines." (GP94, interview)
Barriers to obtaining and using evidence
Many GPs lack critical appraisal skills or the time to evaluate current evidence. Instead, they rely on secondary sources. Lack of knowledge led to difficulties in communicating evidence:
"I find weighing up the relative value of each intervention actually very difficult to convey to the patient." (GP94, interview)
This was compounded by changes in the evidence base:
"I am going to say to them [patients] that the current recommendation for cholesterol is this. It won’t be that next year. It wasn’t that ten years ago. We have lots of good evidence but that will all change, so be aware of that fact. I have this discussion everyday with people. That this is a moving target but the best I can do for you is try to interpret the stuff that is coming in my direction . . . I don’t always trust evidence entirely. We have all seen evidence come and go." (GP31, interview)
A key theme from the interviews was that evidence had to be balanced against other competing demands:
"I think [GPs] are used to looking at the way they practise medicine in the way of coping, and juggling several balls in the air. Evidence is one of them, but it isn’t necessarily the most important." (GP163, interview)"in every consultation you’ve got ‘x’ amount of time. How are you going to spend it? Are you going to spend it addressing the thing that happens to be at the top of the national guidelines for treating . . . cardiovascular disease, or is our time better spent giving somebody an explanation of what the illness is? Or talking to them about their lifestyle? Or discussing the implications of their work? Or have they discussed their problems with the family?" (GP186, focus group)
Comparing consultations in which these GPs had implemented or failed to implement secondary prevention, provided further clues about competing demands. The most striking of these concerned doctor–patient relationships. These relationships sometimes became barriers to the implementation of secondary prevention. GPs made judgements and decisions based on their understanding of personal circumstances and perceived ability to comply with or tolerate interventions:
"I know what he would want and I think that maybe influenced my judgement and I was perhaps less coldly clinical that I could have been." (GP163, interview)
There was an emotional dimension here, as respondents frequently contrasted ‘cold’ clinical evidence with the ‘warm’ (although sometimes challenging) relationships they had with individual patients. GPs recounted life events such as bereavements, or other personal circumstances that mitigated against secondary prevention at a particular consultation:
"as I saw the panic rise in her eyes, evidence-based medicine went out of the door and reassurance was what was needed, because there was very little one could do about her and I could see her husband pleading behind, ‘stop talking science and start talking something else’. So I patted her on the hand and told her all was well and it would get better in a little while." (GP92, interview)
Secondary prevention was considered inappropriate for some patients with co-morbidity, for example, anxious patients were less likely to receive interventions. A desire to avoid upsetting patients could prevent the implementation of secondary prevention particularly within time-limited consultations, as this quote illustrates:
"Somebody’s come in, floods of tears, their marriage has broken down. You know it may be difficult to get them to switch onto that [secondary prevention] subject and spend the next 5 minutes—"Forget about that problem you came in with, but actually I am more interested in your aspirin, cholesterol and things that are going to save your life"—and they are actually more interested in marital trauma . . . You can’t do it all."(GP31, focus group)
The desire to preserve a good relationship and to maintain compliance with other treatment regimens was sometimes more important than implementing secondary prevention:
"it’s far better, I feel, to keep him compliant with a smaller number of drugs than lose his confidence by trying to push something he doesn’t want onto him . . . it’s this fear of alienation as well. I don’t want to lose this patient." (GP94, interview)
Nineteen consultations were dedicated to CHD review. All 12 patients who received secondary prevention interventions, did so in this environment. None of the three patients seen opportunistically received secondary prevention. Interviewees recognized that some failures to implement secondary prevention, particularly in routine consultations, were simply missed opportunities —often as a result of fatigue and time pressures.
"you are sat in your surgery and you know you should be doing better with CHD, but you are damned pooped and tired. You’ve got sixteen people waiting, and I think what you do is tuck it in your mind and eventually it comes back as a sort of gremlin and says ‘you really ought to be doing better son’. You sit there and you think well I’ll do this one then, and then leave it for a while with your conscience assuaged." (GP163, interview)
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Discussion |
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This study complements existing research about why GPs’ compliance with guidelines on secondary prevention in CHD is inconsistent. The patients included in the study are comparable in disease characteristics and management to those found elsewhere in Gloucestershire. Although similar demographically and in CHD care to their colleagues within the county, the participating GPs represent a self-selected group and this may mean that they are more interested in research or have a particular interest in CHD management. Several of the participants were involved in training GP registrars and would therefore have particular experience in consultation analysis, patient behaviour and personal reflection; qualities that will have added depth to their narrative. The simultaneous PCCAG audit and NSF guidelines may have heightened these practitioners’ awareness of under-treated CHD, and accounted for the fact that many of the patients were seen in appointments dedicated to CHD review. If these GPs represent the practitioners most interested in CHD then the reported failure to implement secondary prevention is of even greater concern.
Card sorting within the interview served as a useful prompt for discussion of different sources of evidence. As GPs ranked sources of evidence, they explained why they favoured some rather than others. While interviewees were aware of an extrinsic hierarchy of evidence, many expressed doubts about the relevance of various sources of evidence in their daily practice. As in previous research,10 trustworthiness of evidence was paramount. Some sources, notably PCGs and health authorities, were tainted by their association with financial considerations and this finding suggests that the local implementation of guidelines by these bodies may be problematic.
A key, unanticipated, theme to emerge concerned the importance of doctor–patient relationships for GPs. Previous analyses have tended to focus on the patient perspective, exploring expectations, satisfaction, or communication within the consultation.23 Relationships with patients are nurtured over time and represent an important investment by GPs, yet their perspective has been overlooked. The respondents in this study expressed concern that relationships might be damaged by ‘gratuitous’ interventions or used the concept of ‘patient-centred care’ to justify not implementing secondary prevention. It is possible to view these accounts within a paternalistic model of primary care;24 indeed, one GP reflected that there was an element of complicity in arguing that a patient is too distressed to be offered potentially life-saving interventions. Nonetheless, it may be worth reconsidering the role of the doctor–patient relationship from the doctor’s perspective. This study suggests that GPs’ concerns about doctor–patient relationships can act as a barrier to secondary prevention.
The NSF and much of the literature in this area implies that GPs should be implementing secondary prevention, but perhaps this is inappropriate. Other research has shown that GPs readily find reasons for not applying evidence-based guidelines to their own patients,25 perhaps because they realise that doctor–patient relationships can be damaged by opportunistic health promotion.26 It may be that the imperative to implement secondary prevention runs counter to other demands on the doctor’s time and jeopardizes the relationships they have with patients. One possible alternative is to replace opportunistic and GP-led secondary prevention with nurse-led, protocol-driven clinics.27,28 This strategy would avoid forcing GPs to choose between ‘evidence’ and what they see as other important and valid aspects of patient care, such as responding to patient anxiety, or nurturing long-term professional relationships with their patients.
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Acknowledgments |
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We thank the participating GPs and patients who gave their time to this study. This research was sponsored by a grant from the Royal College of General Practitioners. There are no conflicts of interest. CP and WS act as guarantors for this work.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1 Gilder J, Moher M, Schofield T. Have general practitioners fulfilled the necessary requirements for the management of patients with coronary heart disease? Audit Trends 1996; 4: 95–97.
2 Collins R, Peto R, MacMahon S et al. Blood pressure, stroke, and coronary heart disease Part 2, short term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet 1990; 335: 827–838.[Web of Science][Medline]
3 Antiplatelet trialists collaboration. Collaborative overview of randomised trials of anti-platelet therapy I. Prevention of death, myocardial infarction and stroke by prolonged anti-platelet therapy in various categories of patients. Br Med J 1994; 308: 81–106.
4 Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study. Lancet 1994; 344: 1383–1389.[Web of Science][Medline]
5 Yusuf S, Peto R, Lewis J. Beta-blockade during and after myocardial infarction: an overview of the randomised trials. Prog Cardiovasc Dis 1983; 371: 335–371.
6 Daly LE, Mulcahy R, Graham IM. Long term effects on mortality of stopping smoking after unstable angina and myocardial infarction. Br Med J 1983; 287: 324–326.
7 British Cardiac Society, British Hyperlipidaemia Association, British Hypertension Society, British Diabetic Association. Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart 1998; 80 (Suppl. 2): S1–S29.
8 Department of Health. National Service Framework for Coronary Heart Disease. London: HMSO, 2000.
9 Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM. Secondary prevention in coronary heart disease: baseline survey of provision in general practice. Br Med J 1998; 316: 1430–1434.
10 Fairhurst K, Huby G. From trial data to practical knowledge: qualitative study of how general practitioners have accessed and used evidence about statin drugs in their management of hypercholesterolaemia. Br Med J 1998; 317: 1130–1134.
11 Tod AM, Read C, Lacey A, Abbott J. Barriers to uptake of services for coronary heart disease: qualitative study. Br Med J 2001; 323: 1522–1526.
12 Salisbury C, Bosanquet N, Wilkinson E, Bosanquet A, Hasler J. The implementation of evidence-based medicine in general practice prescribing. Br J Gen Pract 1998; 48: 1849–1852.[Web of Science][Medline]
13 Greenhalgh PM. Shared Care for Diabetes. A Systematic Review. London: RCGP (occasional paper 67), 1994.
14 Tomlin Z, Humphrey C, Rogers S. General Practitioners’ perceptions of effective health care. Br Med J 1999; 318: 1532–1535.
15 Pope C, Mays N. Qualitative research in health care (2nd edn). London: BMJ Books, 1999.
16 Ziegler MG, Lew P, Singer BC. The accuracy of drug information from pharmaceutical sales representatives. JAMA 1995; 16: 1296–1298.
17 Thomson MA, Oxman AD, Haynes RB, Davis DA, Freemantle N, Harvey EL. Local opinion leaders to improve health professional practice and health care outcomes. The Cochrane Library 1998.
18 Weller SC, Romney AK. Systematic Data Collection. Qualitative research methods series, Vol. 10. Newbury Park, California: Sage, 1988.
19 Stanton BF, Aronson R, Borgatti S, Galbraith J, Feigelman S, AIDS Youth Research Team. Urban adolescent high-risk sexual behaviour: corroboration of focus group discussions through pile-sorting. AIDS Educ and Prev 1993; 5: 162–173.
20 Qualitative Solutions and Research Pty. Ltd, Melbourne, Australia.
21 Gloucestershire Primary Care Clinical Audit Group. An audit on the secondary prevention of coronary heart disease in Gloucestershire 1999–2000. Gloucestershire PCCAG, Agriculture House, Sandhurst Lane, Gloucester.
22 Patton M. Qualitative evaluation and research methods. Newbury Park: Sage, 1990.
23 Williams S, Calnan M. Key determinants of consumer satisfaction with general practice. Fam Pract 1991; 8: 237–242.
24 Byrne PS, Long BL. Doctors Talking to Patients. London: HMSO, 1976.
25 Cranney M, Warren E, Barton S, Gardner K, Walley T. Why do GPs not implement evidence-based guidelines? A descriptive study. Fam Pract 2001; 18: 359–363.
26 Butler CC, Pill R, Stott, NCH. Qualitative study of patients’ perceptions of doctors; advice to quit smoking: implications for opportunistic health promotion. Br Med J 1998; 316: 1878–1881.
27 Campbell NC, Ritchie LD, Thain J, Deans HG, Rawles JM, Squair JL. Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care. Heart 1998; 80: 447–452.
28 Moher M, Yudkin P, Wright L et al. Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care. Br Med J 2001; 322: 1338–1342.
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