Factors involved in deciding to start preventive treatment: qualitative study of clinicians' and lay people's attitudes

"I think taking herbal medicine first can help prevent. If it doesn't work, then can take start taking the medication given by the doctors." Patients' perceptions towards hypertension in Fiji

BACKGROUND

Hypertension remains a public health challenge worldwide however, the prevention, detection, treatment and management of this condition are not highly prioritized. Health knowledge has an important impact on individual's health. The ability to actively participate in screening, diagnosis and management of hypertension are influenced by patient's knowledge of hypertension. To understand why hypertension is so difficult to control, it may be of benefit to gain an understanding of the patient's perspective. Hence, the aim of the study is to explore the perceptions of patients on prevention and diagnosis of hypertension in Fiji.

METHODS

The study used a qualitative method approach. The study was conducted at the four purposively selected health centers in the Lautoka/ Yasawa medical subdivision. A purposive sampling was used which included all the patients who attended the SOPD, age more than 18 years and above, diagnosed with hypertension for 6 months or more and attended clinic at one of the 4 selected health centers. Semi-structured open-ended interview guide were used to collect data among patients through in-depth interviews. Thematic analysis was used manually to analyze the data using four steps that is immersion in the data, coding the data, creating categories and identifying themes / subthemes.

RESULTS

Twenty-five SOPD patients took part in the in-depth interview and the responses were grouped into two themes. The themes emerged included hypertension knowledge and diagnosis of hypertension in a closed family and self. Subthemes derived from the hypertension knowledge were measures of awareness, hypertension aetiology, risk perception, origin of information and concept of prevention. Sub themes derived from the diagnosis of hypertension in a closed family were perception when first diagnosed, hypertension in relation and hypertension impact. Patients' knowledge on etiologies and risk factors of hypertension were generally poor. Majority of the participants learnt about hypertension in hospitals and few over radios and television. Diagnosis in a closed family triggered worrisome, fear and fright on some patients.

CONCLUSION

Majority of the patients have less knowledge about various risk factors of hypertension. Worrisome, fearful, frightful, frustration and sadness were some of the reactions and emotions highlighted by the patients. It is important to design culturally tailored interventions that address the psychological and behavioral needs of the patients. Recommendation to conduct further studies to understand the perception of hypertension among the general public.

Integrating patient values and preferences in healthcare: a systematic review of qualitative evidence

OBJECTIVES

To identify and thematically analyse how healthcare professionals (HCPs) integrate patient values and preferences ('values integration') in primary care for adults with non-communicable diseases (NCDs).

DESIGN

Systematic review and meta-aggregation methods were used for extraction, synthesis and analysis of qualitative evidence.

DATA SOURCES

Relevant records were sourced using keywords to search 12 databases (ASSIA, CINAHL, DARE, EMBASE, ERIC, Google Scholar, GreyLit, Ovid-MEDLINE, PsycINFO, PubMed-MEDLINE, Scopus and Web of Science).

ELIGIBILITY CRITERIA

Records needed to be published between 2000 and 2020 and report qualitative methods and findings in English involving HCP participants regarding primary care for adult patients.

DATA EXTRACTION AND SYNTHESIS

Relevant data including participant quotations, authors' observations, interpretations and conclusions were extracted, synthesised and analysed in a phased approach using a modified version of the Joanna Briggs Institute (JBI) Data Extraction Tool, as well as EPPI Reviewer and NVivo software. The JBI Critical Appraisal Checklist for Qualitative Research was used to assess methodological quality of included records.

RESULTS

Thirty-one records involving >1032 HCP participants and 1823 HCP-patient encounters were reviewed. Findings included 143 approaches to values integration in clinical care, thematically analysed and synthesised into four themes: (1) approaches of concern; (2) approaches of competence; (3) approaches of communication and (4) approaches of congruence. Confidence in the quality of included records was deemed high.

CONCLUSIONS

HCPs incorporate patient values and preferences in healthcare through a variety of approaches including showing concern for the patient as a person, demonstrating competence at managing diseases, communicating with patients as partners and tailoring, adjusting and balancing overall care. Themes in this review provide a novel framework for understanding and addressing values integration in clinical care and provide useful insights for policymakers, educators and practitioners.

PROSPERO REGISTRATION NUMBER

CRD42020166002.

Professionals’ Treatment Preferences in the Prodromal Phase of Parkinson’s Disease: A Discrete Choice Experiment

Background:

In Parkinson’s disease (PD), several disease-modifying treatments are being tested in (pre-)clinical trials. To successfully implement such treatments, it is important to have insight into factors influencing the professionals’ decision to start disease-modifying treatments in persons who are in the prodromal stage of PD.

Objective:

We aim to identify factors that professionals deem important in deciding to a start disease-modifying treatment in the prodromal stage of PD.

Methods:

We used a discrete choice experiment (DCE) to elicit preferences of neurologists and last-year neurology residents regarding treatment in the prodromal phase of PD. The DCE contained 16 hypothetical choice sets in which participants were asked to choose between two treatment options. The presented attributes included treatment effect, risk of severe side-effects, risk of mild side-effects, route of administration, and annual costs.

Results:

We included 64 neurologists and 18 last year neurology residents. Participants attached most importance to treatment effect and to the risk of severe side-effects. Participants indicated that they would discuss one of the presented treatments in daily practice more often in persons with a high risk of being in the prodromal phase compared to those with a moderate risk. Other important factors for deciding to start treatment included the amount of evidence supporting the putative treatment effect, the preferences of the person in the prodromal phase, and the life expectancy.

Conclusion:

This study provides important insights in factors that influence decision making by professionals about starting treatment in the prodromal phase of PD.

Consensus-Based Development of an Assessment Tool: A Methodology for Patient Engagement in Primary Care and CPD Research

With cardiovascular disease (CVD) posing a significant disease burden in Canada and more broadly, preventative efforts which incorporate best evidence, patient preference, and physician expertise must continue to take place. Primary care providers play a pivotal role in this effort, and a greater understanding of patient perspectives is needed to guide management and inform training. We used a validated consensus method, the nominal group technique (NGT), to identify patient-reported experience measures (PREM) related to CVD prevention deemed most important by both patients and providers. The NGT was used by using structured discussions between patients and providers to bring ideas about PREM CVD outcomes to a consensus. Four patient partners and four primary care providers were selected to participate in an NGT session. Each participant wrote down items/questions they believed important in CVD preventative care. After discussions, all items underwent anonymous ranking on a 5-point scale. Items were included/excluded based on 75% agreement a priori. The panel produced 10 items from a total of 26 after 2 rounds of ranking. The top two items were as follows: "Is your treatment plan tailored to you" and "Was your physician good at giving information about your risk factors?" These results are significantly different compared with existing quality measures because they highlight aspects of patient experience and therapeutic relationship. A questionnaire consisting of prioritized PREM items is valuable in quality improvement and continuous professional development (CPD).

Exploring education preferences of Australian women regarding long-term health after hypertensive disorders of pregnancy: a qualitative perspective

BACKGROUND

Hypertensive disorders of pregnancy (HDP) affect 5-10% of pregnant women. Long-term health issues for these women include 2-3 times the risk of heart attacks, stroke and diabetes, starting within 10 years after pregnancy, making long-term health after HDP of major public health importance. Recent studies suggest this knowledge is not being transferred sufficiently to women and how best to transmit this information is not known. This study explored women's preferred content, format and access to education regarding long-term health after HDP.

METHODS

This was a qualitative study and framework analysis was undertaken. Women with a history of HDP who had participated in a survey on long-term health after HDP were invited to participate in this study. During telephone interviews women were asked about preferences and priorities concerning knowledge acquisition around long-term health after HDP.

RESULTS

Thirteen women were interviewed. They indicated that they wanted more detailed information about long-term and modifiable risk factors. Their preference was to receive risk counselling from their healthcare provider (HCP) early after giving birth along with evidence-based, print or web-based information to take home. All women suggested more structured postnatal follow-up, with automated reminders for key appointments. Automated reminders should detail rationale for follow-up, recommended tests and discussion topics to be addressed at the appointment.

CONCLUSION

Our findings show that most participants wanted information soon after birth with all women wanting information within 12 months post birth, complemented with detailed take-home evidence. Participants indicated preference for structured follow-up via their HCP with automated alerts about the appointment and recommended tests. This evidence can be used to guide the development of education programs for women on health after HDP which may enhance knowledge, preventive health management and more generally improve women's health trajectories.

Sex Differences in Subsequent Falls and Falls Risk: A Prospective Cohort Study in Older Adults

BACKGROUND

Sex differences for subsequent falls and falls risk factors in community-dwelling older adults who have fallen are unknown. Our aim was to: (1) compare the number of falls between sexes, (2) identify modifiable falls risk factors, and (3) explore the interaction of sex on falls risk factors in older adults who fall.

METHODS

Four hundred sixty-two community dwellers seeking medical attention after an index fall were recruited from the Vancouver Falls Prevention Clinic and participated in this 12-month prospective cohort study. Ninety-six participants were part of a randomized controlled trial of exercise. Falls were tracked with monthly falls calendars. Demographics, falls risk measures, and the number of subsequent falls were compared between sexes. A principal component analysis (PCA) was employed to reduce the falls risk measures to a smaller set of factors. The PCA factors were used in negative binomial regression models to predict the number of subsequent falls. Age, exposure time (i.e., number of falls monitoring days), and prescribed exercise (yes/no) were used as covariates, and sex (male/female) and PCA factors were used as main effects. The interaction of sex by PCA factor was then included.

RESULTS

Males fell more over 12 months (males: 2.80 ± 6.86 falls; females: 1.25 ± 2.63 falls) than females, and poorer executive function predicted falls in males. Four PCA factors were defined - impaired cognition and mobility, low mood and self-efficacy, mobility resilience, and perceived poor health - each predicted the number of falls. The sex by mobility resilience interaction suggested that mobility resilience was less protective of falls in males.

CONCLUSION

Modifiable risk factors related to cognition, physical function, psychological wellbeing, and health status predicted subsequent falls. In males, better mobility was not as protective of falls compared with females. This may be due to males' poorer executive function, contributing to decreased judgement or slowed decision-making during mobility. These results may inform efficacious sex-specific falls prevention strategies.

Shared decision making in peri-operative medicine: Miles to go in Indian scenario

Shared Decision Making (SDM) in peri-operative medicine is increasingly encouraged as an ideal model of treatment decision making in the medical encounter. Moreover, it has the potential to improve the quality of the decision-making process for patients and ultimately, patient outcomes. This review focuses on several published literature on SDM in peri-operative medicine, its Implementation, barriers faced by Patient and the Provider, Myths regarding SDM and current scenario of SDM in India. Within the anesthetic community, patient consent is vigorously guided. However, this community suffers from lack of advancements in implementing the patient-focused rather than doctor-focused characteristics of SDM. Out of the several barriers, the most common barrier towards the implementation of SDM is the lack of time from the provider community. Within the anesthesia domain, the consultations discussed directly preceding the surgery do not pursue the customary and highly organized stages of typical outpatient consultations. Under these backgrounds and to be successfully implemented, it becomes imperative to begin the process of SDM pre-operative assessment clinic targeting both the high- and low-risk patients. It is critical to summarise that SDM does not end at the time of anesthesia for the peri-operative healthcare professional, but it gets to carry forward until patient discharge. Therefore, it is carried as the Pinnacle of Patient-Centred Care.

Patients' Experiences of Cardiovascular Health Education and Risk Communication: A Qualitative Synthesis

Coronary heart disease (CHD) has no cure, and patients with myocardial infarction are at high risk for further cardiac events. Health education is a key driver for patients' understanding and motivation for lifestyle change, but little is known about patients' experience of such education. In this review, we aimed to explore how patients with CHD experience health education and in particular risk communication. A total of 2,221 articles were identified through a systematic search in five databases. 40 articles were included and synthesized using thematic analysis. Findings show that both "what" was communicated, and "the way" it was communicated, had the potential to influence patients' engagement with lifestyle changes. Communication about the potential of lifestyle change to reduce future risk was largely missing causing uncertainty, anxiety, and, for some, disengagement with lifestyle change. Recommendations for ways to improve health education and risk communication are discussed to inform international practice.

General practitioners' perspectives on the prevention of cardiovascular disease: systematic review and thematic synthesis of qualitative studies

OBJECTIVE

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality globally, and prevention of CVD is a public health priority. This paper aims to describe the perspectives of general practitioners (GPs) on the prevention of CVD across different contexts.

DESIGN

Systematic review and thematic synthesis of qualitative studies using the Enhancing Transparency of Reporting the Synthesis of Qualitative research (ENTREQ) framework.

DATA SOURCES

MEDLINE, Embase, PsycINFO and CINAHL from database inception to April 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included qualitative studies on the perspectives of GPs on CVD prevention.

DATA EXTRACTION AND SYNTHESIS

We used HyperRESEARCH to code the primary papers and identified themes.

RESULTS

We selected 34 studies involving 1223 participants across nine countries. We identified six themes: defining own primary role (duty to prescribe medication, refraining from risking patients' lives, mediating between patients and specialists, delegating responsibility to patients, providing holistic care); trusting external expertise (depending on credible evidence and opinion, entrusting care to other health professionals, integrating into patient context); motivating behavioural change for prevention (highlighting tangible improvements, negotiating patient acceptance, enabling autonomy and empowerment, harnessing the power of fear, disappointment with futility of advice); recognising and accepting patient capacities (ascertaining patient's drive for lifestyle change, conceding to ingrained habits, prioritising urgent comorbidities, tailoring to patient environment and literacy); avoiding overmedicalisation (averting long-term dependence on medications, preventing a false sense of security, minimising stress of sickness) and minimising economic burdens (avoiding unjustified costs to patients, delivering practice within budget, alleviating healthcare expenses).

CONCLUSIONS

GPs sought to empower patients to prevent CVD, but consideration of patients' individual factors was challenging. Community-based strategies for assessing CVD risk involving other health professionals, and decision aids that address the individuality of the patient's health and environment, may support GPs in their decisions regarding CVD prevention.

Risk perception of cardiovascular diseases among individuals with hypertension in rural Malaysia

Objective

Despite various efforts, hypertension remains poorly controlled, thus allowing cardiovascular disease (CVD) to impact the health burden worldwide. Patients' perception of risk may contribute to this scenario. The present study aims to assess the level of risk perception among individuals with hypertension in rural Malaysia.

Methods

This is a community-based study conducted among adults between 2010 and 2011 among a rural population in Raub, Pahang, Malaysia. Blood pressure was measured after 5 min of rest. Measurement was done twice and the average was recorded. Cardiovascular risk perception score (CvRPS) was derived using the Modified Risk and Health Behavior Questionnaire. Higher CvRPS indicates the respondent perceives a poorer prognostic outlook.

Results

A total of 383 respondents who have hypertension participated in this study. The mean age of respondents was 62±10.6 years; men 63.1±9.6 years, women 61.2±11.1 years (p>0.05). Among hypertensives, those who were not on medication had significantly lower CvRPS compared with those who were on medications (115.9±22.1vs 120.9±23.5, p=0.036); those who were not aware of their hypertensive status had significantly lower CvRPS compared with respondents who were aware about their hypertension (116.7±22.5vs 121.7±21.3, p=0.029) and those with uncontrolled hypertension had significantly lower CvRPS compared with those whose blood pressure was controlled (118.2±22.2vs 128.8±25.8, p=0.009).

Conclusions

Our study shows that respondents who were not on medications, unaware of their hypertension status and those who had uncontrolled hypertension tended to underestimate (lower CvRPS) their risk for CVD. Improving their CvPRS through a concerted health education may lead to better therapeutic behaviour and outcomes.

Interventions to improve adherence to lipid-lowering medication

BACKGROUND

Lipid-lowering drugs are widely underused, despite strong evidence indicating they improve cardiovascular end points. Poor patient adherence to a medication regimen can affect the success of lipid-lowering treatment.

OBJECTIVES

To assess the effects of interventions aimed at improving adherence to lipid-lowering drugs, focusing on measures of adherence and clinical outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO and CINAHL up to 3 February 2016, and clinical trials registers (ANZCTR and ClinicalTrials.gov) up to 27 July 2016. We applied no language restrictions.

SELECTION CRITERIA

We evaluated randomised controlled trials of adherence-enhancing interventions for lipid-lowering medication in adults in an ambulatory setting with a variety of measurable outcomes, such as adherence to treatment and changes to serum lipid levels. Two teams of review authors independently selected the studies.

DATA COLLECTION AND ANALYSIS

Three review authors extracted and assessed data, following criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions. We assessed the quality of the evidence using GRADEPro.

MAIN RESULTS

For this updated review, we added 24 new studies meeting the eligibility criteria to the 11 studies from prior updates. We have therefore included 35 studies, randomising 925,171 participants. Seven studies including 11,204 individuals compared adherence rates of those in an intensification of a patient care intervention (e.g. electronic reminders, pharmacist-led interventions, healthcare professional education of patients) versus usual care over the short term (six months or less), and were pooled in a meta-analysis. Participants in the intervention group had better adherence than those receiving usual care (odds ratio (OR) 1.93, 95% confidence interval (CI) 1.29 to 2.88; 7 studies; 11,204 participants; moderate-quality evidence). A separate analysis also showed improvements in long-term adherence rates (more than six months) using intensification of care (OR 2.87, 95% CI 1.91 to 4.29; 3 studies; 663 participants; high-quality evidence). Analyses of the effect on total cholesterol and LDL-cholesterol levels also showed a positive effect of intensified interventions over both short- and long-term follow-up. Over the short term, total cholesterol decreased by a mean of 17.15 mg/dL (95% CI 1.17 to 33.14; 4 studies; 430 participants; low-quality evidence) and LDL-cholesterol decreased by a mean of 19.51 mg/dL (95% CI 8.51 to 30.51; 3 studies; 333 participants; moderate-quality evidence). Over the long term (more than six months) total cholesterol decreased by a mean of 17.57 mg/dL (95% CI 14.95 to 20.19; 2 studies; 127 participants; high-quality evidence). Included studies did not report usable data for health outcome indications, adverse effects or costs/resource use, so we could not pool these outcomes. We assessed each included study for bias using methods described in the Cochrane Handbook for Systematic Reviews of Interventions. In general, the risk of bias assessment revealed a low risk of selection bias, attrition bias, and reporting bias. There was unclear risk of bias relating to blinding for most studies.

AUTHORS' CONCLUSIONS

The evidence in our review demonstrates that intensification of patient care interventions improves short- and long-term medication adherence, as well as total cholesterol and LDL-cholesterol levels. Healthcare systems which can implement team-based intensification of patient care interventions may be successful in improving patient adherence rates to lipid-lowering medicines.

Using quantitative risk information in decisions about statins: a qualitative study in a community setting

Background

A large literature informs guidance for GPs about communicating quantitative risk information so as to facilitate shared decision making. However, relatively little has been written about how patients utilise such information in practice.

Aim

To understand the role of quantitative risk information in patients’ accounts of decisions about taking statins.

Design and setting

This was a qualitative study, with participants recruited and interviewed in community settings.

Method

Semi-structured interviews were conducted with 34 participants aged >50 years, all of whom had been offered statins. Data were analysed thematically, using elements of the constant comparative method.

Results

Interviewees drew frequently on numerical test results to explain their decisions about preventive medication. In contrast, they seldom mentioned quantitative risk information, and never offered it as a rationale for action. Test results were spoken of as objects of concern despite an often-explicit absence of understanding, so lack of understanding seems unlikely to explain the non-use of risk estimates. Preventive medication was seen as ‘necessary’ either to treat test results, or because of personalised, unequivocal advice from a doctor.

Conclusion

This study’s findings call into question the assumption that people will heed and use numerical risk information once they understand it; these data highlight the need to consider the ways in which different kinds of knowledge are used in practice in everyday contexts. There was little evidence from this study that understanding probabilistic risk information was a necessary or valued condition for making decisions about statin use.

Prevention of cardiovascular disease in rural Australian primary care: an exploratory study of the perspectives of clinicians and high-risk men

Rural primary care services have the potential to play a major role in reducing the gap in cardiovascular disease (CVD) outcomes between rural and metropolitan Australians, particularly in men at high risk of CVD. The aim of this study was to explore the self-reported behaviours and satisfaction with their general practice/practitioner of men at high risk of CVD, and attitudes of rural primary care clinicians regarding the role of primary care in CVD prevention. This observational research was addressed through survey questionnaires with rural men at high risk of CVD and semi-structured interviews with rural primary care clinicians. Fourteen rural primary care practices from towns with populations less than 25000 participated. One hundred and fifty-eight high-risk men completed the questionnaire. Their responses demonstrated poorly controlled risk factors despite a willingness to change. Alternatively, rural primary care clinicians (n=20) reported that patients were unlikely to change and that illness-based funding models inhibited cardiovascular preventive activities. Australians living in rural areas have worse CVD outcomes. In addition, there is a disparity in the assumptions of health providers and male patients at high risk of CVD in rural areas. This necessitates innovative rural primary care models that include a blended payment system that incentivises or funds preventive care alongside an emphasis on lifestyle advice, as well as an explicit strategy to influence clinician and patient behaviour to help address the disparity.

A clinico-ethical framework for multidisciplinary review of medication in nursing homes

Residents in care homes are more likely to be prescribed multiple medicines yet often have little involvement in these prescribing decisions. Reviewing and stopping inappropriate medicines is not currently adopted across the health economy. This Health Foundation funded Shine project developed a pragmatic approach to optimising medicines in care homes while involving all residents in decision making.

The pharmacist undertook a detailed medication review using primary care records. The results were discussed at a multidisciplinary team (MDT) meeting involving the care home nurse and the resident's general practitioner (GP), with input from the local psychiatry of old age service (POAS) where appropriate.

Suggestions for medicines which should be stopped, changed or started, and other interventions (eg monitoring) were discussed with the resident and/or their family.

Over 12 months 422 residents were reviewed, and 1346 interventions were made in 91% of residents reviewed with 15 different types of interventions. The most common intervention (52.3%) was to stop medicines; 704 medicines stopped in 298 residents (70.6%). On average, 1.7 medicines were stopped for every resident reviewed (range zero to nine medicines; SD=1.7), with a 17.4% reduction in medicines prescribed (3602 medicines prescribed before and 2975 after review). The main reasons for stopping medicines were: no current indication (401 medicines; 57%), resident not wanting medicine after risks and benefits were explained (120 medicines; 17%), and safety concerns (42 medicines; 6%).

The net annualised savings against the medicines budget were £77,703 or £184 per person reviewed. The cost of delivering the intervention was £32,670 (pharmacist, GP, POAS consultant, and care home nurse time) for 422 residents; for every £1 invested, £2.38 could be released from the medicines budget.

This project demonstrated that a multidisciplinary medication review with a pharmacist, doctor, and care home nurse can safely reduce inappropriate medication in elderly care home residents.

Relationship between universal health outcome priorities and willingness to take medication for primary prevention of myocardial infarction

OBJECTIVES

To determine how well universal health outcome priorities represent individuals' preferences in specific clinical situations.

DESIGN

Observational cohort study.

SETTING

Community.

PARTICIPANTS

Community-dwelling adults aged 65 and older (N = 357).

MEASUREMENTS

Participants used three tools assessing universal health outcome priorities related to two common trade-offs: quality versus quantity of life and future health versus present inconveniences and burdens of treatment. The tools' ability to identify participants who were unwilling to take a medication that reduced the risk of myocardial infarction but caused dizziness and fatigue was analyzed.

RESULTS

There were consistent and significant associations between unwillingness to take the medication and prioritizing quality of life or future health for all three tools in the expected direction (P < .05). Despite these associations, the positive (PPV) and negative predictive values for the tools were generally modest (0.49-0.83). The tool with the most specific statements resembling the medication scenario had the best specificity (0.97) and PPV (0.83).

CONCLUSION

Universal health outcome priorities only modestly identified older persons who would be unwilling to take a medication for primary prevention of myocardial infarction that causes adverse effects. Although tools that are the most general in their assessment of priorities have the benefit of being applicable across the widest range of scenarios, tools with greater specificity may be necessary to inform individual treatment decisions.

Adherence to antidepressant treatment

Depression is a common disorder with painful symptoms and, frequently, social impairment and decreased quality of life. The disorder has a tendency to be long lasting, often with frequent recurrence of symptoms. The risk of relapse and the severity of the symptoms may be reduced by correct antidepressant medication. However, the medication is often insufficient, both in respect to dosage and length of time. The reasons for incorrect medication are many, with lack of adherence to treatment being the most important. Although some patients taking antidepressant medication experience side effects, this may not be the most frequent reason for immature discontinuation of treatment. Other reasons for decreased adherence have been investigated in recent years. The patient's beliefs about the disorder and beliefs about antidepressants, including lack of conviction that the medication is needed and fear of dependence of antidepressant medicine, have a great influence on adherence to treatment.

The perspectives of Iranian physicians and patients towards patient decision aids: a qualitative study

BACKGROUND

Patient preference is one of the main components of clinical decision making, therefore leading to the development of patient decision aids. The goal of this study was to describe physicians' and patients' viewpoints on the barriers and limitations of using patient decision aids in Iran, their proposed solutions, and, the benefits of using these tools.

METHODS

This qualitative study was conducted in 2011 in Iran by holding in-depth interviews with 14 physicians and 8 arthritis patient. Interviewees were selected through purposeful and maximum variation sampling. As an example, a patient decision aid on the treatment of knee arthritis was developed upon literature reviews and gathering expert opinion, and was presented at the time of interview. Thematic analysis was conducted to analyze the data by using the OpenCode software.

RESULTS

The results were summarized into three categories and ten codes. The extracted categories were the perceived benefits of using the tools, as well as the patient-related and physician-related barriers in using decision aids. The following barriers in using patient decision aids were identified in this study: lack of patients and physicians' trainings in shared decision making, lack of specialist per capita, low treatment tariffs and lack of an exact evaluation system for patient participation in decision making.

CONCLUSIONS

No doubt these barriers demand the health authorities' special attention. Hence, despite patients and physicians' inclination toward using patient decision aids, these problems have hindered the practical usage of these tools in Iran--as a developing country.

Starting and staying on preventive medication for cardiovascular disease

PURPOSE OF REVIEW

To synthesize the qualitative research literature regarding medication use to prevent cardiovascular disease in order to explain the variation in healthcare professional (HCP) and patient behaviours, and to evaluate the implications for practice.

RECENT FINDINGS

The decision to start preventive medication is affected by the patient-HCP relationship and by the design of the service. Both HCPs and patients are influenced by their understanding of the evidence regarding the value of preventive interventions; their values and preferences; and their sociopolitical context and the organizational structure of their practice environment. The design of their service affects uptake as a consequence of its impact on clinical communication and the extent to which the service is tailored to the needs of the local community. Continuing to take prescribed medication is affected by both contextual and practical factors. Recommendations for practice can be split into those with a clinical focus and those with a patient or community focus. More sophisticated analyses have moved beyond recommendations for patient and HCP education, and address constraints in the organization of clinical services and the social context of evidence translation.

SUMMARY

Qualitative health research provides important insights into the experience of and context for decision making about medication prescription and adherence that can help efforts to prevent cardiovascular disease.

Comparison of prescribing and adherence patterns of anti-osteoporotic medications post-admission for fragility type fracture in an urban teaching hospital and a rural teaching hospital in Ireland between 2005 and 2008

INTRODUCTION

Poor adherence reduces the potential benefits of osteoporosis therapy, lowering gains in bone mineral density resulting in increased risk of fractures.

AIM

To compare prescribing and adherence patterns of anti-osteoporotic medications in patients admitted to an urban teaching hospital in Ireland with a fragility type fracture to patients admitted to a rural hospital in the North Western region.

METHODOLOGY

We identified all patients >55 years admitted to Sligo General Hospital between 2005 and 2008 with a fragility fracture (N = 744) using the hospital in-patient enquiry system (HIPE). The medical card number of those patients eligible for the primary care reimbursement services scheme (PCRS) facilitated the linkage of the HSE-PCRS scheme database to the HIPE database which enabled a study to identify persistence rates of patients prescribed osteoporosis therapy after discharge. The results were compared to the findings of a similar study carried out in St. James's Hospital, Dublin.

RESULTS

The 12 months post-fracture prescribing increased from 11.0 % (95 % CI 9.6, 12.4) in 2005 to 47 % (95 % CI 43.6, 50.3) in 2008 in the urban setting and from 25 % (95 % CI 21.5, 28.9) to 39 % (95 % CI 34.5, 42.7) in the rural setting. Adherence levels to osteoporosis medications at 12 months post-initiation of therapy was <50 % in both study groups. Patients on less frequent dosing regimes were better adherers.

CONCLUSION

The proportion of patients being discharged on anti-osteoporosis medications post-fragility fracture increased between 2005 and 2008 in both patient groups. Sub-optimal adherence levels to osteoporosis medications continue to be a major concern.

Women's perception of future risk following pregnancies complicated by preeclampsia

OBJECTIVE

To elicit women's personal understanding of future cardiovascular risk, following a pregnancy complicated by preeclampsia, and to identify the postnatal needs of these women.

METHODS

Semi-structured interviews with 12 women with a recent history of preeclampsia who had attended a postnatal follow-up clinic.

RESULTS

The interviews were held at a median of 47 weeks postpartum (range 24-62 weeks). Family history of cardiovascular disease was associated with a greater awareness of future cardiovascular risk. Women without traditional risk factors found it hard to envisage themselves as being at risk and may not see the relevance of such information. It may take several months after delivery for a woman to be able to fully consider her own health as well as the baby's; a reminder of risk and health information is needed.

CONCLUSIONS

Although receptive to follow-up, the situational factors of being a new mother need to be taken into account to engage successfully with this patient group. Further research is needed to help clarify the extent to which a history of preeclampsia is an independent factor for future cardiovascular disease to provide a solid foundation for effective risk communication.

Reasons for non-use of proven pharmacotherapeutic interventions: systematic review and framework development

RATIONALE, AIMS AND OBJECTIVES

The quality of patient care and safety is dependent on addressing both errors of commission (e.g. overuse of medications) and errors of omission (e.g. patients receiving too little care). Despite guidelines recommending the use of certain proven pharmacotherapeutic interventions, a large gap exists between the patients that have an indication for, and those that actually receive such interventions. To address how the rate of implementation of proven interventions can be improved is dependent on a comprehensive knowledge of the factors contributing to their underuse. The aim of the review is to create an evidence-based framework of reasons why eligible patients do not receive proven pharmacotherapeutic interventions.

METHODS

A systemic review of the published reasons for non-use based on the Cochrane methodology.

RESULTS

The systematic review identified 67 articles meeting the inclusion criteria. The reasons for non-use were extracted from the studies and a framework was created from the results.

CONCLUSIONS

The factors associated with lack of implementation of proven pharmacotherapeutic interventions are complex and heterogeneous but can be understood from the perspectives of clinicians, patients and health care delivery systems. Efforts to increase the utilization of proven interventions should focus on disease/intervention-specific programmes that take into account the identified modifiable clinician, patient and system factors.

Effect of bariatric surgery on cardiovascular risk profile

Obesity is associated with increased risk for cardiovascular (CV) disease (CVD) and CV mortality. Bariatric surgery has been shown to resolve or improve CVD risk factors, to varying degrees. The objective of this systematic review was to determine the impact of bariatric surgery on CV risk factors and mortality. A systematic review of the published research was performed to evaluate evidence regarding CV outcomes in morbidly obese bariatric patients. Two major databases (PubMed and the Cochrane Library) were searched. The review included all original reports reporting outcomes after bariatric surgery, published in English, from January 1950 to July 2010. In total, 637 studies were identified from the initial screen. After applying inclusion and exclusion criteria, 52 studies involving 16,867 patients were included (mean age 42 years, 78% women). The baseline prevalence of hypertension, diabetes, and dyslipidemia was 49%, 28%, and 46%, respectively. Mean follow-up was 34 months (range 3 to 155), and the average excess weight loss was 52% (range 16% to 87%). Most studies reported significant decreases postoperatively in the prevalence of CV risk factors, including hypertension, diabetes, and dyslipidemia. Mean systolic pressure reduced from to 139 to 124 mm Hg and diastolic pressure from 87 to 77 mm Hg. C-reactive protein decreased, endothelial function improved, and a 40% relative risk reduction for 10-year coronary heart disease risk was observed, as determined by the Framingham risk score. In conclusion, this review highlights the benefits of bariatric surgery in reducing or eliminating risk factors for CVD. It provides further evidence to support surgical treatment of obesity to achieve CVD risk reduction.

When tight blood pressure control is not for everyone: a new model for performance measurement in hypertension

BACKGROUND

Many patients with hypertension have legitimate reasons to forego standard blood pressure targets yet are nonetheless included in performance measurement systems. An approach to performance measurement incorporating clinical reasoning was developed to determine which patients to include in a performance measure.

DESIGN

A 10-member multispecialty advisory panel refined a taxonomy of situations in which the balance of benefits and harms of anti-hypertensive treatment does not clearly favor tight blood pressure control (< 140/90 mm Hg).

FINDINGS

The panel identified several broad categories of reasons for exempting a patient from performance measurement for blood pressure control. These included (1) patients who have suffered adverse effects from multiple classes of antihypertensive medications; (2) patients already taking four or more antihypertensive medications; (3) patients with terminal disease, moderate to severe dementia, or other conditions that overwhelmingly dominate the patient's clinical status; and (4) other patient factors, including comfort care orientation and poor medication adherence despite attempts to remedy adherence difficulties. Several general principles also emerged. Performance measurement should focus on patients for whom the benefits of treatment clearly outweigh the harms and should incorporate a longitudinal approach. In addition, the criteria for exempting a patient from performance measurement should be more strict in patients at higher risk of adverse health outcomes from hypertension and more lenient for patients at lower risk.

CONCLUSIONS

Incorporating "real world" clinical principles and judgment into performance measurement systems may improve targeting of care and, by accounting for patient case mix, allow for better comparison of performance between institutions.

Interventions to improve adherence to lipid lowering medication

BACKGROUND

Lipid lowering drugs are still widely underused, despite compelling evidence about their effectiveness in the treatment and prevention of cardiovascular disease. Poor patient adherence to a medication regimen is a major factor in the lack of success in treating hyperlipidaemia. In this updated review we focus on interventions which encourage patients at risk of heart disease or stroke to take lipid lowering medication regularly.

OBJECTIVES

To assess the effects of interventions aimed at improved adherence to lipid lowering drugs, focusing on measures of adherence and clinical outcomes.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE, EMBASE, PsycINFO and CINAHL (March 2008). No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials of adherence-enhancing interventions for lipid lowering medication in adults for both primary and secondary prevention of cardiovascular disease in an ambulatory setting looking at adherence, serum lipid levels, adverse effects and health outcomes. Studies were selected independently by two review authors.

DATA COLLECTION AND ANALYSIS

Data were extracted and assessed by two review authors following criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Three additional studies were found in the update and, in total, 11 studies were included in this review. The studies included interventions that caused a change in adherence ranging from -3% to 25% (decrease in adherence by 3% to increase in adherence by 25%). Patient re-enforcement and reminding was the most promising category of interventions, investigated in six trials of which four showed improved adherent behaviour of statistical significance (absolute increase: 24%, 9%, 8% and 6%). Other interventions associated with increased adherence were simplification of the drug regimen (absolute increase 11%) and patient information and education (absolute increase 13%). The methodological and analytical quality of some studies was low and results have to be considered with caution.

AUTHORS' CONCLUSIONS

At this stage, reminding patients seems the most promising intervention to increase adherence to lipid lowering drugs. The lack of a gold standard method of measuring adherence is one major barrier in adherence research. More reliable data might be achieved by newer methods of measurement, more consistency in adherence assessment and longer duration of follow up. More recent studies have started using more reliable methods for data collection but follow-up periods remain too short. Increased patient-centredness with emphasis on the patient's perspective and shared decision-making might lead to more conclusive answers when searching for tools to encourage patients to take lipid lowering medication.

Are consumer surveys valuable as a service improvement tool in health services? A critical appraisal

PURPOSE

In the recent climate of consumerism and consumer focused care, health and social care needs to be more responsive than ever before. Consumer needs and preferences can be elicited with accepted validity and reliability only by strict methodological control, customerisation of the questionnaire and skilled interpretation. To construct, conduct, interpret and implement improved service provision, requires a trained work force and infrastructure. This article aims to appraise various aspects of consumer surveys and to assess their value as effective service improvement tools.

DESIGN/METHODOLOGY/APPROACH

The customer is the sole reason organisations exist. Consumer surveys are used worldwide as service and quality of care improvement tools by all types of service providers including health service providers. The article critically appraises the value of consumer surveys as service improvement tools in health services tool and its future applications.

FINDINGS

No one type of survey is the best or ideal. The key is the selection of the correct survey methodology, unique and customised for the particular type/aspect of care being evaluated. The method used should reflect the importance of the information required.

RESEARCH LIMITATIONS/IMPLICATIONS

Methodological rigor is essential for the effectiveness of consumer surveys as service improvement tools. Unfortunately so far there is no universal consensus on superiority of one particular methodology over another or any benefit of one specific methodology in a given situation. More training and some dedicated resource allocation is required to develop consumer surveys. More research is needed to develop specific survey methodology and evaluation techniques for improved validity and reliability of the surveys as service improvement tools. Measurement of consumer preferences/priorities, evaluation of services and key performance scores, is not easy.

PRACTICAL IMPLICATIONS

Consumer surveys seem impressive tools as they provide the customer a voice for change or modification. However, from a scientific point-of-view their credibility in service improvement in terms of reproducibility, reliability and validity, has remained debatable.

ORIGINALITY/VALUE

This artcile is a critical appraisal of the value of consumer surveys as a service improvement tool in health services--a lesson which needs to be learnt.

Individuals' responses to global CHD risk: a focus group study

OBJECTIVE

To explore how individuals respond to global coronary heart disease (CHD) risk and use it in combination with treatment information to make decisions to initiate and maintain risk reducing strategies.

METHODS

We conducted four focus groups of individuals at risk for CHD (n=29), purposively sampling individuals with each of several risk factors. Two reviewers coded verbatim transcripts and arbitrated differences, using ATLAS.ti 5.2 to facilitate analysis.

RESULTS

Participants generally regarded the concept of global CHD risk as useful and motivating, although had questions about its precision and comprehensiveness. They identified several additional influential factors in decision-making (e.g. achievable risk, the quickness and self-evidence of results) and generally preferred lifestyle changes to medications (although most would accept medications under certain circumstances). They also noted the importance of participating in decision-making.

CONCLUSION

Our results underscore the motivating potential of global CHD risk and the importance of patient participation in decision-making.

PRACTICE IMPLICATIONS

Global CHD risk is a useful adjunct to CHD prevention and can be presented in ways, and with information, that might improve CHD outcomes.

Nurses' perceptions of factors influencing patient decision support for place of care at the end of life

Although patients have more choices about where to receive care as death approaches, they often need help with decision making. This study identified factors that influence nurses' provision of decision support. A total of 22 nurses, from 3 health networks, participated in semistructured interviews. Overall, nurses held favorable attitudes toward providing decision support for place of care at end of life. Overlap between other professionals' roles and nurses' clinical experience affected nurses' decision support behaviors. Although nurses considered decision support to be part of patient-centered care, they report a lack of skills, confidence, and tools to help them provide it. These findings confirm the need to develop practical postlicensure education strategies and ways to embed patient decision support tools into systems of care.

Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions

OBJECTIVE

To update a systematic review on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals.

METHODS

From March to December 2006, PubMed, Embase, CINHAL, PsycINFO, and Dissertation Abstracts were searched. Studies were included if they reported on health professionals' perceived barriers and facilitators to implementing shared decision-making in practice. Quality of the included studies was assessed. Content analysis was performed with a pre-established taxonomy.

RESULTS

Out of 1130 titles, 10 new eligible studies were identified for a total of 38 included studies compared to 28 in the previous version. The vast majority of participants (n=3231) were physicians (89%). The three most often reported barriers were: time constraints (22/38) and lack of applicability due to patient characteristics (18/38) and the clinical situation (16/38). The three most often reported facilitators were: provider motivation (23/38) and positive impact on the clinical process (16/38) and patient outcomes (16/38).

CONCLUSION

This systematic review update confirms the results of the original review.

PRACTICE IMPLICATIONS

Interventions to foster implementation of shared decision-making in clinical practice will need to address a range of factors.

Understanding the concept of medical risk reduction: a comparison between the UK and Germany

OBJECTIVE

To explore the views of German general practitioners, healthcare assistants, and laypeople about the minimum absolute risk reduction needed to justify drug treatment to prevent heart attacks, and to compare these views with those found in the UK.

METHOD

Qualitative content analysis study using the same clinical risk scenario and semi-structured interview schedule concerning a "pill" reducing cardiovascular risk as a recent UK study. The similarly recruited participants included six general practitioners (GPs), four healthcare assistants, and 12 laypeople, interviewed in 10 GP surgeries, two community settings, and five private homes.

RESULTS

In both countries, most participants, health professionals as well as laypeople, used risk numbers inconsistently in preventive treatment decisions. In Germany, some people explicitly rejected the probabilistic risk concept as a basis for such decisions. In the UK, people were generally more aware of cost for society than in Germany. Other factors were similar in both countries.

CONCLUSION

In both countries, preventive risk information is not well understood. Our results suggest that this is not only a technical communication problem.

Medication management in older adults: a critique of concordance

This article shows that the terms compliance, adherence and concordance are used interchangeably in the medication management literature. As such, it is argued that nurses should focus on those interventions that are demonstrably effective in enhancing medication management for the older adult rather than attempt to make sense of a meaningless ideal. In this article the concepts of concordance, compliance and adherence are first critiqued and it is then argued that all the terms remain valid for practical purposes. That is, a literature search of all the terms is required to comprehensively discuss medication management. Focus then switches to factors that have been shown to be beneficial as well as detrimental to medication management in older adults. While many factors appear to correlate with good and bad management of medication the conclusion is that individual, tailored approaches are most effective. For the purpose of this article, the term 'older adult' refers to those over 65 years where not otherwise specified.

Improving patient adherence to lifestyle advice (IMPALA): a cluster-randomised controlled trial on the implementation of a nurse-led intervention for cardiovascular risk management in primary care (protocol)

BACKGROUND

Many patients at high risk of cardiovascular diseases are managed and monitored in general practice. Recommendations for cardiovascular risk management, including lifestyle change, are clearly described in the Dutch national guideline. Although lifestyle interventions, such as advice on diet, physical exercise, smoking and alcohol, have moderate, but potentially relevant effects in these patients, adherence to lifestyle advice in general practice is not optimal. The IMPALA study intends to improve adherence to lifestyle advice by involving patients in decision making on cardiovascular prevention by nurse-led clinics. The aim of this paper is to describe the design and methods of a study to evaluate an intervention aimed at involving patients in cardiovascular risk management.

METHODS

A cluster-randomised controlled trial in 20 general practices, 10 practices in the intervention arm and 10 in the control arm, starting on October 2005. A total of 720 patients without existing cardiovascular diseases but eligible for cardiovascular risk assessment will be recruited. In both arms, the general practitioners and nurses will be trained to apply the national guideline for cardiovascular risk management. Nurses in the intervention arm will receive an extended training in risk assessment, risk communication, the use of a decision aid and adapted motivational interviewing. This communication technique will be used to support the shared decision-making process about risk reduction. The intervention comprises 2 consultations and 1 follow-up telephone call. The nurses in the control arm will give usual care after the risk estimation, according to the national guideline. Primary outcome measures are self-reported adherence to lifestyle advice and drug treatment. Secondary outcome measures are the patients' perception of risk and their motivation to change their behaviour. The measurements will take place at baseline and after 12 and 52 weeks. Clinical endpoints will not be measured, but the absolute 10-year risk of cardiovascular events will be estimated for each patient from medical records at baseline and after 1 year.

DISCUSSION

The combined use of risk communication, a decision aid and motivational interviewing to enhance patient involvement in decision making is an innovative aspect of the intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN51556722.

Association between antihypertensive medication use and non-cardiovascular outcomes in older men

BACKGROUND

Antihypertensive drugs are prescribed commonly in older adults for their beneficial cardiovascular and cerebrovascular effects, but few studies have assessed antihypertensive drugs' adverse effects on non-cardiovascular outcomes in routine clinical practice.

OBJECTIVE

To evaluate, among older adults, the association between antihypertensive medication use and physical performance, cognition, and mood.

DESIGN AND SETTING

Prospective cohort study in a Veterans Affairs primary care clinic, with patients enrolled in 2000-2001 and assessed for medication use, comorbidities, health behaviors, and other characteristics; and followed-up 1 year later.

PARTICIPANTS

544 community-dwelling hypertensive men over age 65 years.

MEASUREMENTS

Timed chair stands; Trail Making Test part B; and Centers for Epidemiologic Studies Depression (CES-D) scores.

RESULTS

Participants had a mean age of 74.4 +/- 5.2 years and took a mean of 2.3 +/- 1.2 antihypertensive medications at baseline. After adjustment for age, comorbidities, level of blood pressure, and other confounders, each 1-unit increase in antihypertensive medication "intensity" was associated with a 0.11-second (95% confidence interval, 0.05-0.16) increase in the time required to complete the timed chair stands. No significant relationship was found between antihypertensive medication intensity and outcomes for Trail Making B or CES-D scores.

CONCLUSIONS

A higher cumulative exposure to antihypertensive medications in community-living older men was associated with adverse effects on physical performance, but not on the cognitive or depression measures available in this study. Clinicians should consider non-cardiovascular related adverse effects when treating older males taking multiple antihypertensive medications.

Primary Prevention of Cardiovascular Diseases in General Practice: Mismatch between Cardiovascular Risk and Patients' Risk Perceptions

Objective. Guidelines on primary prevention of cardiovascular disease (CVD) emphasize identifying high-risk patients for more intensive management, but patients' misconceptions of risk hamper implementation. Insight is needed into the type of patients that general practitioners (GPs) encounter in their cardiovascular prevention activities. How appropriate are the risk perceptions and worries of patients with whom GPs discuss CVD risks? What determines inappropriate risk perception? Method. Cross-sectional study in 34 general practices. The study included patients aged 40 to 70 years with whom CVD risk was discussed during consultation. After the consultation, the GPs completed a registration form, and patients completed a questionnaire. Correlations between patients' actual CVD risk and risk perceptions were analyzed. Results. In total, 490 patients were included. In 17% of the consultations, patients were actually at high risk. Risk was perceived inappropriately by nearly 4 in 5 high-risk patients (incorrect optimism) and by 1 in 5 low-risk patients (incorrect pessimism). Smoking, hypertension, and obesity were determinants of perceiving CVD risk as high, whereas surprisingly, diabetic patients did not report any anxiety about their CVD risk. Men were more likely to perceive their CVD risk inappropriately than women. Conclusion. In communicating CVD risk, GPs must be aware that they mostly encounter low-risk patients and that the perceived risk and worry do not necessarily correspond with the actual risk. Incorrect perceptions of CVD risk among men and patients with diabetes were striking.

Adding "value" to clinical practice guidelines

OBJECTIVE

To determine the degree to which current Canadian clinical practice guidelines (CPGs) for common chronic conditions (ie, diabetes, dyslipidemias, hypertension, and osteoporosis) discuss the importance of patients' values and preferences in therapeutic decision making, and provide quantitative information that would allow for comprehensive shared informed decision making.

DESIGN

Retrospective, observational review.

MAIN OUTCOME MEASURES

The presence or absence of specific mentions of the importance of incorporating patients' values and preferences into therapeutic decision making; the number and type (relative or absolute) of quantitative descriptions of benefit or harm; the number of interventions for which a means of quantitatively determining the probability that an individual patient will experience an end point without and with implementation of the therapeutic intervention; and the number of descriptions of specific or comparative costs of treatment.

RESULTS

Three of 5 CPGs mentioned that patients' values or preferences should influence treatment decisions. None of the CPGs recommended that benefits and harms of therapies be discussed with patients. Of the 63 quantitative mentions of therapeutic effects of interventions, 81%were presented using relative terms and 19% met our criteria for applicability to decision making for individual patients. Two of the 5 CPGs did not enumerate any harms. Three of the 5 CPGs made no mention of cost.

CONCLUSION

Five prominent Canadian CPGs paid little attention to the issue of patients' values and preferences in therapeutic decision making, even though these issues are fundamental tenets of evidence-based practice. These 5 CPGs provided limited quantitative information on benefits and harms and therefore could not be used by clinicians to truly involve patients in informed decision making.

Improving cardiovascular risk management: a randomized, controlled trial on the effect of a decision support tool for patients and physicians

BACKGROUND

There is nonoptimal adherence of general practitioners (GPs) and patients to cardiovascular risk reducing interventions. GPs find it difficult to assimilate multiple risk factors into an accurate assessment of cardiovascular risk. In addition, communicating cardiovascular risk to patients has proved to be difficult.

AIMS

Improving primary prevention of cardiovascular disease (CVD) in primary care by enhancing patient involvement in the use of a decision support tool.

DESIGN

Cluster randomized trial.

METHODS

Thirty-four GPs included patients (40-75 years old) without CVD. In an interactive, small group training session lasting 4 h, the GPs in the intervention group were trained to use the guidelines on cardiovascular risk and a decision support tool. The control group received educational materials about the guidelines on paper. GPs' clinical performance and patients' risk perception and self-reported lifestyles were measured at baseline and after 6 months.

RESULTS

Thirty-four GPs recorded 490 consultations, 276 in the intervention and 214 in the control group. After 6 months, no significant effect of the intervention on the GPs' performance or the patients' risk perception was found. There was only an effect on self-reported lifestyle, in that more men in the intervention group than in the control group increased their physical activity (odds ratio 3.8, 95% confidence interval 1.7-8.7).

CONCLUSION

The 4-h interactive, small group training did not guarantee correct application of the decision support tool and as such failed to improve GPs' performance or correct patients' risk perception. The positive effect on physical activity justifies further research on patient involvement.

The journey to concordance for patients with hypertension: a qualitative study in primary care

OBJECTIVE

We aimed to explore, using qualitative methods, the perspectives of patients with hypertension on issues relating to concordance in prescribing.

METHOD

This study took place in NHS general practices in Northern Ireland. A purposeful sample of patients who had been prescribed anti-hypertensive medication for at least one year were invited to participate in focus groups or semi-structured interviews; data were analysed using constant comparison.

MAIN OUTCOME MEASURES

The perspectives of patients with hypertension on issues relating to concordance in prescribing.

RESULTS

Twenty-five individuals participated in five focus groups; two participated in semi-structured interviews. Participants felt they could make valuable contributions to consultations regarding their management. They were prepared to negotiate with GPs regarding their medication, but most deferred to their doctor's advice, perceiving doctors' attitudes and time constraints as barriers to their greater involvement in concordant decision-making. They had concerns about taking anti-hypertensive drugs, were aware of lifestyle influences on hypertension and reported using personal strategies to facilitate adherence and reduce the need to take medication.

CONCLUSIONS

Participants indicated a willingness to be involved in concordance in prescribing anti- hypertensive medication but needed health professionals to address their concerns and confusion about the nature of hypertension. These findings suggest that there is a need for doctors and other healthcare professionals with responsibility for prescribing to develop skills specifically to explore the beliefs and views underlying an individual's medication use. Such skills may need to be developed through specific training programmes at both undergraduate and postgraduate level.

Patients' preferences shed light on the murky world of guideline-based medicine

Concordance--that is, shared decision-making between doctors and patients--is nowadays accepted as an integral part of good clinical practice. It is of particular importance in the case of treatments with only marginal benefits such as those recommended in guidelines for the management of common, chronic diseases. However, the implementation of guideline-based medicine conflicts with that of concordance. Studies indicate that patients are not adequately informed about their treatment. Clinical guidelines for conditions such as cardiovascular disease are based on large-scale randomized trials and the complex nature of the data limits effective communication especially in an environment characterized by time constraints. But other factors may be more relevant, notably pressures to comply with guidelines and financial rewards for meeting targets: it is simply not in the interests of doctors to disclose accurate information. Studies show that patients are far from impressed by the small benefits derived from large scale trials. Indeed, faced with absolute risk reductions, patients decline treatment promoted by guidelines. To participate in clinical decisions, patients require unbiased information concerning outcomes with and without treatment, and the absolute risk reduction; they should be told that most patients receiving long-term medication obtain no benefit despite being exposed to adverse drug reactions; furthermore, they should be made aware of the questionable validity of large-scale trials and that these studies may be influenced by those with a vested interest. Genuine concordance will inevitably lead to many patients rejecting the recommendations of guidelines and encourage a more critical approach to clinical research and guideline-based medicine.

Medicines for hypertension: changes to the UK NICE guidelines

New NICE guidance on the use of medicines for hypertension, published in June 2006, will prompt a major review of treatment for those already receiving medication and also sets out a new treatment pathway for the newly diagnosed. The major change in the guidelines is in the status of beta blockers, which are no longer to be used as a routine treatment for hypertension. The guidelines provide a consensus on treatment, and nurses and their patients now have a clear and straightforward algorithm to follow. It is envisaged that these changes to the way medicines are prescribed for hypertension will have a significant impact on the number of people reaching their target blood pressure, and therefore the number of cardiovascular events occurring each year.

Primary health care professionals' views on barriers and facilitators to the implementation of the Ottawa Decision Support Framework in practice

OBJECTIVE

To describe primary health care professionals' views on barriers and facilitators for implementing the Ottawa Decision Support Framework (ODSF) in their practice.

METHODS

Thirteen focus groups with 118 primary health care professionals were performed. A taxonomy of barriers and facilitators to implementing clinical practice guidelines was used to content-analyse the following sources: reports from each workshop, field notes from the principal investigator and written materials collected from the participants.

RESULTS

Applicability of the ODSF to the practice population, process outcome expectation, asking patients about their preferred role in decision making, perception that the ODSF was modifiable, time issues, familiarity with the ODSF and its practicability were the most frequently identified both as barriers as well as facilitators. Forgetting about the ODSF, interpretation of evidence, challenge to autonomy and total lack of agreement with using the ODSF in general were identified only as barriers. Asking about values, health professional's outcome expectation, compatibility with the patient-centered approach or the evidence-based approach, ease of understanding and implementation, and ease of communicating the ODSF were identified only as facilitators.

CONCLUSION

These results provide insight on the type of interventions that could be developed in order to implement the ODSF in academic primary care practice.

PRACTICE IMPLICATIONS

Interventions to implement the ODSF in primary care practice will need to address a broad range of factors at the levels of the health professionals, the patients and the health care system.

Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals' perceptions

BACKGROUND

Shared decision-making is advocated because of its potential to improve the quality of the decision-making process for patients and ultimately, patient outcomes. However, current evidence suggests that shared decision-making has not yet been widely adopted by health professionals. Therefore, a systematic review was performed on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals.

METHODS

Covering the period from 1990 to March 2006, PubMed, Embase, CINHAL, PsycINFO, and Dissertation Abstracts were searched for studies in English or French. The references from included studies also were consulted. Studies were included if they reported on health professionals' perceived barriers and facilitators to implementing shared decision-making in their practices. Shared decision-making was defined as a joint process of decision making between health professionals and patients, or as decision support interventions including decision aids, or as the active participation of patients in decision making. No study design was excluded. Quality of the studies included was assessed independently by two of the authors. Using a pre-established taxonomy of barriers and facilitators to implementing clinical practice guidelines in practice, content analysis was performed.

RESULTS

Thirty-one publications covering 28 unique studies were included. Eleven studies were from the UK, eight from the USA, four from Canada, two from The Netherlands, and one from each of the following countries: France, Mexico, and Australia. Most of the studies used qualitative methods exclusively (18/28). Overall, the vast majority of participants (n = 2784) were physicians (89%). The three most often reported barriers were: time constraints (18/28), lack of applicability due to patient characteristics (12/28), and lack of applicability due to the clinical situation (12/28). The three most often reported facilitators were: provider motivation (15/28), positive impact on the clinical process (11/28), and positive impact on patient outcomes (10/28).

CONCLUSION

This systematic review reveals that interventions to foster implementation of shared decision-making in clinical practice will need to address a broad range of factors. It also reveals that on this subject there is very little known about any health professionals others than physicians. Future studies about implementation of shared decision-making should target a more diverse group of health professionals.

Acceptance survey of a fast dissolving tablet pharmaceutical formulation in allergic patients. Satisfaction and expectancies

BACKGROUND

One of the factors affecting compliance is the pharmaceutical formulation used. Many patients find it difficult to swallow tablets or capsules. The fast dissolving tablet (FDT) formulation could help to enhance patient compliance, because of its ease of administration and because no liquid is required to help intake.

MATERIAL AND METHODS

A survey was conducted in patients diagnosed with allergic rhinitis or dermatitis (positive skin tests and/or specific IgE) and urticaria to asses the degree of acceptance of and preference for an FDT formulation.

RESULTS

Of the 7,686 patients who participated in the survey, 90 % considered the initial flavor and 83 % considered the aftertaste to be very or quite satisfactory, 95 % were very satisfied with the disintegration time, 79 % were very satisfied with the form, 82 % with the size, 72 % with the packaging and 78 % with the instructions for use. Ninety-three percent considered that being able to take the drug at any time or place was very important or fairly important. Ninety-four percent considered the ease of use to be much better or better. If given the choice, 93 % would choose an FDT formulation. Eighty-eight percent of the patients would like to change their current antihistaminic drug for a new allergy drug in an FDT formulation.

CONCLUSIONS

Most of the patients were highly satisfied with the characteristics of the FDT formulation and would choose it for the treatment of their allergies.

Views of older adults on patient participation in medication-related decision making

BACKGROUND

Medication decision making is complex, particularly for older patients with multiple conditions for whom benefits may be uncertain and health priorities may be variable. While patient input would seem important in the face of this uncertainty and variability, little is known about older patients' views of involvement in medication decision making.

OBJECTIVE

To explore the views of older adults regarding participation in medication decision making.

DESIGN

Qualitative study.

PARTICIPANTS

Fifty-one persons at least 65 years old who consumed at least one medication were recruited from 3 senior centers and 4 physicians' offices.

APPROACH

One-on-one interviews were conducted to uncover participants' perceptions of medication-related decision making through semistructured, open-ended questions. Themes were compared according to the constant comparative method of analysis.

RESULTS

The predominant theme that emerged was the variability in perceptions concerning whether it was possible or desirable for patients to participate in prescribing decisions. For some participants, involvement was limited to sharing information. Physician and system factors that were felt to facilitate or impede patient participation included communication skills, the expanding number of medications available, multiple physicians prescribing for the same patient, and a focus on treating numbers. Perceived lack of knowledge, low self-efficacy, and fear were the patient factors mentioned. Both the presence and absence of trust in the prescribing physician were seen as alternatively impeding and enhancing patient participation. Only 1 participant explicitly mentioned patient preference, a cornerstone of shared decision making.

CONCLUSIONS

While evolution to greater patient involvement in medication decision making may be possible, and desirable to some older patients, findings suggest that the transition will be challenging.

Fifteen-year risk of major coronary events predicted by Holter ST-monitoring in asymptomatic middle-aged men

BACKGROUND

Ambulatory electrocardiogram monitoring (Holter) with ST-analysis as a measure of myocardial ischemia has in populations with coronary heart disease been shown to predict major coronary events: death, myocardial infarction or coronary revascularization. There has, however, been conflicting evidence regarding the usefulness of this technique in identification of healthy subjects with increased risk for coronary heart disease. The aim of this study was to assess if Holter monitoring with ST-analysis could be used to predict future major coronary events in asymptomatic middle-aged men with a defined aggregation of traditional risk factors for coronary heart disease.

METHODS

One hundred and fifty-five asymptomatic participants from the city of Malmö, Sweden, with known levels of conventional cardiovascular risk factors underwent Holter monitoring for analysis of transient ST-segment depression at the age of 55 years. Fifteen years after the Holter monitoring, hospital records, diagnosis and death registries were revisited for major coronary events.

RESULTS

An ST-segment depression of 1 mm or greater (0.1 mV) was considered significant for myocardial ischemia and was found in 54 of the 155 men. There were no significant differences in risk factors in the two groups at baseline. The 15-year incidence of a first major coronary event was significantly higher in men with ST-segment depression (39%) than in men without ST-segment depression (20%) (P<0.015). A Holter electrocardiogram could predict future major coronary events with a positive and negative predictive value of 35 and 80%, respectively.

CONCLUSIONS

Holter monitoring can be used as a complement to conventional risk factor evaluation in deciding whether or not to treat risk factors for CHD in asymptomatic subjects.

Factors influencing clinicians' decisions to prescribe medication to prevent coronary heart disease

BACKGROUND AND OBJECTIVE

There are variations between individual clinicians as to the thresholds at which preventive treatment for coronary heart disease (CHD) should commence. Patients' decisions may be influenced by clinicians' recommendations. Free text comments added by respondents to closed questionnaires may identify areas which are of real concern to them about the topic being studied. The study aimed to identify issues voluntarily raised by clinicians surrounding the decision to prescribe preventive treatment for CHD.

METHODS

An analysis was undertaken of the free text comments made by cardiologists, general practitioners and practice nurses who responded to a closed question postal questionnaire in which they were asked to identify at which level of pretreatment risk they would offer treatment.

RESULTS AND DISCUSSION

A similar percentage of respondents in each professional group provided free text comments. Clinicians' concerns centred on five main themes around prescribing decisions: the risks and benefits of treatment, the patient's role in treatment decisions, patient characteristics, costs to patients, and costs to the health services. Different issues may be of more concern to some professional groups than others.

CONCLUSION

In addition to the use of risk assessment tools and guidelines, clinicians' actual prescribing behaviour may be influenced by more subjective factors. Patients at similar risk may receive different advice depending on the individual clinician they consult.

Will nanotechnology make the world a better place?

Nanotechnology could produce a revolutionary wave of innovation in society. The form that such a revolution might take will depend upon many things but certainly upon the context, content and purposes of research projects and agendas decided by existing political and corporate institutions. Lessons from the genetically modified organism debate indicate that the behaviour of these institutions is at least as important as the 'risk' in informing public acceptability. This article argues that current research priorities need to shift in favour of environmental and health protection to engender public support and/or an ongoing need to remain sensitive to emerging societal preferences.