Current conditions or future risks: certainty and uncertainty in decisions about statins

The Disparate Approaches of General Practitioners to the Pharmaceuticalisation of Cardiovascular Disease Prevention

In the context of current clinical practice guidance, this paper will analyse the role of GPs in decision-making about the primary prevention of cardiovascular disease (CVD) using the concept of pharmaceuticalisation. Drawing on thematic analysis of semi-structured interviews with 20 GPs, the paper argues that the way GPs approach CVD pharmaceuticalisation is shaped by their understandings of and use of guidelines (and the knowledge they embody), existing treatment perspectives and the moral qualities of preventative treatment, and professional evaluations of 'relevant' information. The analysis indicates that there exist disparate and distinct approaches to and understandings of CVD pharmaceuticalisation amongst GPs. Depending on how knowledge, treatment perspectives and values variously combine, GPs sit somewhere on a spectrum of how pharmaceuticalised they are in terms of the approaches to and understandings of the prevention of CVD.

Factors predicting statin prescribing for primary prevention: a historical cohort study

Background

Initiation of statins for the primary prevention of cardiovascular disease (CVD) should be based on CVD risk estimates, but their use is suboptimal.

Aim

To investigate the factors influencing statin prescribing when clinicians code and do not code estimated CVD risk (QRISK2).

Design and setting

A historical cohort of patients who had lipid tests in a database (IQVIA Medical Research Data) of UK primary care records.

Method

The cohort comprised 686 560 entries (lipid test results) between 2012 and 2016 from 383 416 statin-naive patients without previous CVD. Coded QRISK2 scores were extracted, with variables used in calculating QRISK2 and factors that might influence statin prescribing. If a QRISK2 score was not coded, it was calculated post hoc. The outcome was initiation of a statin within 60 days of the lipid test result.

Results

Of the entries, 146 693 (21.4%) had a coded QRISK2 score. Statins were initiated in 6.6% (95% confidence interval [CI] = 6.4% to 6.7%) of those with coded and 4.1% (95% CI = 4.0% to 4.1%) of uncoded QRISK2 (P<0.001). Statin initiations were consistent with National Institute for Health and Care Excellence guideline recommendations in 85.0% (95% CI = 84.2% to 85.8%) of coded and 44.2% (95% CI = 43.5% to 44.9%) of uncoded QRISK2 groups (P<0.001). When coded, QRISK2 score was the main predictor of statin initiation, but total cholesterol was the main predictor when a QRISK2 score was not coded.

Conclusion

When a QRISK2 score is coded, prescribing is more consistent with guidelines. With no QRISK2 score, prescribing is mainly based on total cholesterol. Using QRISK2 is associated with statin prescribing that is more likely to benefit patients. Promoting the routine CVD risk estimation is essential to optimise decision making.

Overruling uncertainty about preventative medications: the social organisation of healthcare professionals' knowledge and practices

In this article, we draw on an institutional ethnographic (IE) study of cardiovascular disease prevention in general practice, exploring the work of healthcare professionals who introduce a discussion of risk and preventative medications into consultations with patients. Our aim is to explicate, using IE's theoretical ontology and analytical tools, how troubling patient experiences in this clinical context are coordinated institutionally. We focus our attention on the social organisation of healthcare professionals' knowledge and front-line practices, highlighting the textual processes through which they overrule patients' concerns and uncertainties about taking preventative medication, such that some patients feel unable to openly discuss their health needs in preventative consultations. We show how healthcare professionals activate knowledge of 'evidence-based risk reduction' to frame patients' queries as 'barriers' to be overcome. Our analysis points not to deficiencies of healthcare professionals who lack the expertise or inclination to adequately 'share decisions' with patients, but to the ways in which their work is institutionally orientated towards performance measures which will demonstrate to local and national policymakers that they are tackling the 'burden of (cardiovascular) disease'.

A qualitative exploration of the prescribing and use of statins in asymptomatic people in Ireland: A case of medicalisation, biomedicalisation and pharmaceuticalisation

There has been a notable increase in the use of statins in people without cardiovascular disease but who may be at risk in the future. The majority of statin users now fall into this category but little research has focused exclusively on this group. Debate has ensued regarding medicating asymptomatic people, and processes described variously as medicalisation, biomedicalisation and pharmaceuticalisation are used to explain how this happens. These overlapping and interrelated processes require issues to be 'problemised' as medical problems requiring medical solutions given the prevailing understandings of health, risk and disease. However, current understandings of risk and disease are not simply the result of technological and scientific advances, they are also socially constructed. We interviewed members of the public, GPs and others, and found that rather than high cholesterol being seen as one of several risk factors that contributes to heart disease, it tended to be promoted simplistically to the status of a disease needing treatment of itself. Statins were justified by those taking them as different to 'unnecessary medicines'. However, some participants demonstrated resistance to statins, worried about over-medicalisation and deviated from accepted practices, indicating a complex 'muddling through' in the face of uncertainty.

Rethinking decision-making in the context of preventive medication: How taking statins becomes "the right thing to do"

To understand decision-making in the context of longterm preventive medication, we explore the way "deciding" articulates with household medication practices and other everyday routines. Taking statins as a case study, we use qualitative data from interviews with 34 participants in the UK who had all been offered statins; 19 were currently taking them. Although all participants reference similar information about statins, the way they assemble and use their knowledge varies: there is a marked asymmetry between participants taking statins and those not taking them. Deliberation is a prominent feature of accounts of deciding not to take statins, but seldom visible within accounts of those taking them. Statin-takers emphasise that they have "no choice" about taking them, while non-takers stress the need to "think about it"; statin-takers' accounts prioritise biomedical tests over experiential knowledge, whereas non-takers sometimes prioritise experiential knowledge. All participants reference similar theoretical and experiential knowledge about side-effects, but whereas non-takers often use this knowledge to explain their decision to decline statins, those taking statins downplay both their own experiences and the likelihood that these are due to statins. To account for these asymmetries, we propose a model of decision-making in which deciding upon a course of action entails constructing a narrative presentation of medication use that frames it as "the right thing to do". This model helps us examine the two-way interactions between decision-making and the material practices through which regular medication gets taken, interactions often elided from accounts both of decision-making and of medication practice. In the context of longterm medication, the boundaries between "deciding" and "doing" are blurred; decision-making is situated within a web of collaborative, discursively-informed practices.

Do Words Matter? Health Care Providers' Use of the Term Prediabetes

Communication of risk is not solely the transfer of information; it is an interaction and exchange of ideas between concerned individuals. Health care provider communication about type 2 diabetes risk status may influence individual participation in behaviours that prevent or delay the disease, which is concerning from a public health perspective. The term prediabetes is used to convey risk status and little is known about how health care providers view or use the term. In this article, we describe health care provider use and perceptions of the term prediabetes drawing on data from a survey conducted between August and November 2011 of 15 health care providers practicing in Southeast Wyoming and Northern Colorado USA. We used a grounded theory research design to guide data collection and analysis and in the interviews invited providers to describe their use and perception of the term prediabetes. We found that providers use of the term 'prediabetes' depended on their view of the term's meaning (such as, whether patients were likely to understand or be confused by it) and impact (in terms of motivating patients to mitigate risk). We found there were differences in providers' perceptions of the negative and positive associations of the term and this influenced whether or not they used it. These findings are not surprising given the lack of consensus over definitions and diagnosis criteria for prediabetes. Given this this lack of agreement, there are difficulties about the use of the term prediabetes and its use should take place within effective risk communication. Health care providers must consider essential aspects of risk communication in order to enable individuals at risk of type 2 diabetes to mitigate the risk and by doing so reduce incidence and prevalence rates of the disease.

What is wrong with 'being a pill-taker'? The special case of statins

In an interview study of decision-making about statins, many participants said they took pills regularly, yet described themselves as 'not really pill-takers'. This paper explores this paradox and its implications. The practice of pill-taking itself can constitute a challenge to the presentation of moral adequacy, beyond the potential for rendering stigmatised illnesses visible. Meeting this challenge involves a complex process of calibrating often-conflicting moral imperatives: to be concerned, but not too concerned, over one's health; to be informed, but not over-informed; and deferential but not over-deferential to medical expertise. This calibration reflects a broader tension between rival tropes: embracing medical progress and resisting medicalisation. Participants who take statins present them as unquestionably necessary; 'needing' pills, as opposed to choosing to take them, serves as a defence against the devalued identity of being a pill-taker. However, needing to take statins offers an additional threat to identity, because taking statins is widely perceived to be an alternative strategy to 'choosing a healthy lifestyle'. This perception underpins a responsibilising health promotion discourse that shapes and complicates the work participants do to avoid presenting themselves as 'pill-takers'. The salience of this discourse should be acknowledged where discussions of medicalisation use statins as an example.