Skip Navigation

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Request Permissions
Google Scholar
Right arrow Articles by Erhardt, L. R.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Erhardt, L. R.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Managing cardiovascular risk: reality vs. perception

Leif R. Erhardt*

Department of Cardiology, University of Lund, Malmö University Hospital, Malmö, Sweden

* Corresponding author. E-mail address: leif.erhardt{at}med.lu.se


   Abstract
Top
 Abstract
Risk assessment
 Patient perception of...
 The way forward
 Conclusions
 Key points
 References
 
Clinical practice guidelines attempt to bridge the gap between the generation of scientific evidence and its application. For cardiovascular risk reduction, the implementation of knowledge into practice, both with respect to lifestyle change and pharmacological treatment, has been shown to be poor. There are several reasons for this ‘guidelines gap’, with physician factors including insufficient time and underestimation of a patient's cardiovascular risk and patient factors including lack of adherence to lifestyle modification and lack of awareness about cardiovascular risk. Survey data indicate that physicians believe that they are implementing guidelines, but the majority of patients remains undertreated. There is a need for better physician and patient education and also for simplified guidelines to encourage their use by physicians. Cardiologists should work with primary care physicians to adapt national guidelines to ensure local acceptance.

Key Words: Barriers • Cardiovascular risk • Guidelines gap • Obesity • Practice guidelines

The management of patients with coronary heart disease involves lifestyle change and pharmacological treatment of various risk factors. The importance of treatment of risk factors is increasingly recognized, and the recent joint European guidelines on cardiovascular disease prevention1 emphasize the need to assess overall cardiovascular risk in the context of primary prevention, taking into account of all the major risk factors. Global risk has become the target for treatment rather than focusing on the modification of single risk factors.

However, despite the wide dissemination of practice guidelines, the implementation of knowledge into clinical practice, both with respect to lifestyle change and pharmacological treatment, has been shown to be poor. This has been called the ‘guidelines gap’ or the ‘knowing/doing gap’. Barriers to successful implementation of clinical practice guidelines centre on the healthcare system, physicians, and patients.2,3 This article will address physician and patient barriers, which include the following:

Physician barriers:

  • lack of awareness, familiarity, and agreement;
  • low motivation and/or outcome expectancy;
  • inability to reconcile guidelines with patient preferences;
  • insufficient time and/or resource.

Patient barriers:

  • lack of awareness and understanding;
  • limited access to care;
  • low level of compliance; reluctance to take life-long medication;
  • lack of adherence to lifestyle modifications.

The REACT (Reassessing European Attitudes about Cardiovascular Treatment) survey was conducted to explore the gap between evidence and practice in the prevention and management of coronary heart disease. In this survey, 754 primary care physicians in five European countries (France, Germany, Italy, Sweden, and the UK) were interviewed to assess their views and perceived implementation of coronary heart disease and lipid treatment guidelines.4 Key barriers to greater implementation of guidelines were identified by physicians as lack of time (38% of all interviewees), prescription costs (30%), and patient compliance (17%). Ten per cent of doctors believed that there were too many guidelines, and 10% said that they were not fully aware of the guidelines. The overall picture that emerged is that clinicians wrongly believe that they are implementing guidelines. They blame their patients or the healthcare system (e.g. lack of time during consultations) rather than focusing on their own motivation as a barrier to guideline implementation.

It is important to understand physicians' and patients' perceptions about risk and risk management. Studies have shown sub-optimal management of risk factors. For example, the EUROASPIRE surveys5 showed a high prevalence of risk factors in European patients with coronary heart disease. Two surveys were carried out, in 1995–96 and in 1999–2000, the second survey being designed to assess whether preventive cardiology had improved since the first survey. For EUROASPIRE I, 3569 patients were interviewed, and for EUROASPIRE II, 3379 patients were interviewed, with interviews taking place at least 6 months after hospitalization for an acute coronary event or procedure. The results were disappointing: in the second survey, the prevalence of smoking was almost unchanged from the first survey (19.4 vs. 20.8%); the prevalence of high total-cholesterol concentrations (≥5 mmol/L) had decreased from 86.2 to 58.8%, but the proportion of patients with high blood pressure (≥140/90 mmHg) was virtually the same (55.4 vs. 53.9%) and the prevalence of obesity (body mass index ≥30 kg/m2) had increased from 25.3 to 32.8%. Even in secondary prevention, therefore, the treatment goals of preventive cardiology are not being achieved.

What doctors say that they do in relation to implementation of guidelines does not appear to reflect what is happening in clinical practice.6–8 Using data from several studies, Figure 1 shows that only ~50% of patients are reaching cholesterol goals, although market research data show that in most cases, prescribers believe that their practice is consistent with guideline recommendations. Hence, despite physicians reporting that they follow clinical guidelines, the majority of patients remain undertreated. This demonstrates that there is a clear gap between perception and reality.



View larger version (23K):
[in this window]
[in a new window]
  		Figure 1 Discrepancy between perception and reality. Physicians' views on their adherence to guideline recommendations and patient treatment. The bars show physicians' self-reported implementation of guidelines (market research data), and the line indicates the proportion of patients meeting cholesterol treatment goals in clinical studies.6–8

 
The situation is similar in the USA. The third National Health and Nutrition Examination Survey (NHANES III) showed that physicians are treating patients, but not achieving goals. For example, only 22% of patients with hypertension were controlled to target levels, whereas 54% were on blood pressure lowering medication. For dyslipidaemia, 7% were controlled, whereas 16% were on lipid lowering medication. Of greater concern, given the current emphasis on global risk management, fewer than 3.6% of patients with both hypertension and dyslipidaemia were at both therapeutic goals. More recent surveys indicate that these figures have improved, but multiple risk management targets are being achieved only in a very low proportion of patients.

Physicians' knowledge and attitudes are instrumental in determining behaviour in terms of guideline implementation3 (Figure 2). One reason why physicians may fail to achieve optimal pharmacological treatment is that they believe that clinical trial data cannot be generalized to their patients, for example, that their patients are older, of different gender, or more likely to have concomitant disease than the patients included in clinical trials. This might be scientifically correct, but should not be used as an excuse not to treat patients.



View larger version (17K):
[in this window]
[in a new window]
  		Figure 2 Physician barriers to guideline implementation (adapted from Cabana et al.3).

 

   Risk assessment
Top
 Abstract
 Risk assessment
Patient perception of...
 The way forward
 Conclusions
 Key points
 References
 
Physicians often underestimate their patients' cardiovascular risk. In a study in Sweden comparing actual vs. perceived risk, 80 primary care physicians were shown case histories and asked to estimate the patients' risk of having a cardiovascular event over the next 10 years.9 All of the physicians underestimated the actual risk, as calculated by the Framingham algorithm. One example was the case of a woman aged 66 with diabetes, an LDL-cholesterol concentration of 4.6 mmol/L (178 mg/dL), and a total-cholesterol concentration of 6.9 mmol/L (267 mg/dL). The Framingham calculated risk was 27%, but the clinicians perceived a 10% risk for the patient. Another example was a male smoker, aged 61, with an LDL-cholesterol concentration of 6.3 mmol/L (244 mg/dL) and a total-cholesterol concentration of 8.2 mmol/L (317 mg/dL), in whom the Framingham calculated risk was 33% and the doctors' perception of risk was 10%. For a woman aged 51 who smoked and had an LDL-cholesterol concentration of 4.1 mmol/L (166 mg/dL) and a total-cholesterol concentration of 6.5 mmol/L (255 mg/dL), the Framingham calculated risk was 14% and the physicians' perception of risk was 5%.

These data highlight the importance of using some type of risk assessment system to calculate cardiovascular risk. This is not the case currently: in the REACT survey,4 only 13% of primary care physicians said that they always used a risk chart to assess a patient's risk of developing coronary heart disease. Forty-three per cent said that they sometimes used them and another 43% said that they rarely or never used them.

In REACT, 81% of physicians said that they were using some kind of coronary heart disease guideline, most frequently the physician's own practice guidelines (59%) or national guidelines (56%). Only 15% of physicians were using the Joint European Societies guideline. Use of a practice guideline is not optimal; rather than doctors relying on their own beliefs to decide practice goals, it is preferable to follow an official guideline.

Further evidence of the difference between perception and reality was apparent from questioning on how well guidelines were being implemented. Seventy-eight per cent of physicians believed that guidelines were being implemented to a ‘major’ or ‘moderate’ extent. Only one in five of the doctors suggested that guidelines were only being implemented to a ‘minor’ extent.4


   Patient perception of cardiovascular risk
Top
 Abstract
 Risk assessment
 Patient perception of...
The way forward
 Conclusions
 Key points
 References
 
The REACT survey also included an assessment of public perception of cardiovascular risk. Interviews were carried out with 5104 members of the public in the same five European countries as for the physician survey.10 Only one-third of members of the public correctly identified heart disease as the leading cause of death worldwide. In each country, people were more likely to identify cancer as the leading cause of death. In terms of perception of risk, 13% reported that they were at high or very high risk of heart disease and 32% identified their risk as low or very low. However, 37% of the interviewees had two or more risk factors, putting them at high risk. The discrepancy between reality and perception, therefore, applies to patients as well as to physicians.

It should not be assumed that patients know about cardiovascular risk factors (Figure 3). For example, in the REACT survey, only 51% of the public knew that high cholesterol was a risk factor.10 In contrast, 92% of physicians believed that their patients knew that cholesterol was associated with CHD.4 Sixty-two per cent of the members of the public who were interviewed were aware that being overweight or obese was a health risk. However, this does not necessarily indicate that they identified overweight as a cardiovascular risk, because it is possible that they were referring to other problems associated with overweight, such as joint pain. In terms of awareness of target levels, members of the public were twice as likely to be aware of their ideal blood pressure than aware of their target cholesterol level (69 vs. 33%).



View larger version (12K):
[in this window]
[in a new window]
  		Figure 3 Patients' perception and awareness of coronary heart disease risk factors in the REACT survey (adapted from Erhardt and Hobbs11).

 
The survey data thus demonstrate the need to educate the public and patients about the risk of cardiovascular disease and the lifestyle changes that can be made to modify risk.

Where do patients currently obtain their information about cardiovascular risk factors? A growing proportion will collect information from the Internet, but in the REACT study, the physician was identified by patients as their most common source of information, followed by television and other media.10 Clearly, the physician has a pivotal role in the provision of health information and must start the information-giving process, although the patient might then be referred elsewhere, for example, to the nurse, or perhaps to the Internet, for further advice. Our experience in Sweden is that nurses are very effective in providing information to patients.

One major problem, however, is that increases in knowledge may not be sufficient to produce changes in behaviour or lifestyle.11 In addition, in routine clinical practice, information-giving procedures are often inadequate, inconsistent, and inaccurate.12–14 There is certainly room for improvement in the provision of patient education.


   The way forward
Top
 Abstract
 Risk assessment
 Patient perception of...
 The way forward
Conclusions
 Key points
 References
 
Asked about ways of improving implementation of coronary heart disease guidelines, doctors in the REACT survey acknowledged that the key priorities should be better physician and patient education.4 They also identified a need for promotion of clinical practice guidelines and for simplification and clarification of the guidelines.

Rather than having guidelines for each specific disease (e.g. blood pressure, lipids, and glucose control), it is preferable to merge the guidelines and to consider a holistic approach to care. This is the approach taken in the joint European guidelines; however, these guidelines are bulky and need to be simplified to encourage their use by physicians.

Steps can be taken to improve the success of patient intervention. Haynes et al.15 reviewed trials of interventions to help patients to follow prescriptions for medications and to improve adherence. Common aspects of successful interventions included:

  • more instruction for patients (written, verbal, programmed learning);
  • improve the convenience of care (simplified dose frequency, cost, provision at the worksite);
  • involve patients in their care (self-monitoring, tailoring doses);
  • use of reminder [refills (phone, mail), dose (pill dispensers)];
  • re-inforcement or rewards for improved adherence and treatment response (e.g. reduced visit frequency, payment for blood pressure monitoring equipment).

Use of reminders is easy and has been tested in various diseases, including heart failure, diabetes, and asthma, and the need to give re-inforcement, to praise our patients, and to show empathy should not be forgotten.

It is also important that global guidelines are adapted to ensure local acceptance; this, in turn, should lead to better implementation (Figure 4). Guidelines such as those issued by the Joint European Societies have the advantages of being evidence-based and endorsed by leading authorities in the field. However, international guidelines do not always address regional, cultural, social, and economic factors or the way in which local medical practice is organized.2 Physicians understandably prefer to take an active role in the creation of any guidelines that they use, enabling them to involve other healthcare professionals such as nurses, health visitors, pharmacists, and dieticians to create a sense of ‘ownership’.16 Cardiologists should work with primary care physicians to create a programme that they want to offer to their patients.



View larger version (48K):
[in this window]
[in a new window]
  		Figure 4 Global guidelines need adaptation to ensure local acceptance and better implementation (adapted from Erhardt et al.2).

 

   Conclusions
Top
 Abstract
 Risk assessment
 Patient perception of...
 The way forward
 Conclusions
Key points
 References
 
Practice guidelines on the prevention of cardiovascular disease have been widely disseminated, but their implementation has been shown to be poor. Several reasons for this ‘guidelines gap’ have been identified. Physicians' and patients' perceptions of cardiovascular risk factors are highly deficient and physicians need a better understanding of the needs of their patients. Compliance programmes should therefore be multidimensional, involving both the patients' and doctors' perspectives. More time needs to be set aside for preventive work, which can be carried out in collaboration with nurses and other healthcare professionals.


   Key points
Top
 Abstract
 Risk assessment
 Patient perception of...
 The way forward
 Conclusions
 Key points
References
 

  • There has been a failure to put into practice the key developments in preventive cardiology, with barriers to successful implementation of cardiovascular guidelines relating to both physician and patient factors.
  • Studies indicate that physicians are treating cardiovascular risk factors, but are not achieving therapeutic goals.
  • Cardiologists should work with primary care physicians to develop local programmes for prevention of cardiovascular disease. These programmes should be carried out in collaboration with nurses and other healthcare professionals.
  • Improved tools are needed to help patients to understand their cardiovascular risk and how to reduce risk by lifestyle modification.

Conflict of interest: The author has lectured at Abbott-sponsored symposia.


   References
Top
 Abstract
 Risk assessment
 Patient perception of...
 The way forward
 Conclusions
 Key points
 References
 

  1. De Backer G, Ambrosioni E, Borch-Johnsen K et al.; European Society of Cardiology Committee for Practice Guidelines. European guidelines on cardiovascular disease prevention in clinical practice: third joint task force of European and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of eight societies and by invited experts). Eur J Cardiovasc Prev Rehabil 2003;10(Suppl. 1);S1–S78.[CrossRef][ISI][Medline]
  2. Erhardt L, Pearson TA, Bruckert E et al. Guidelines and their implementation: a discussion document focused on the best approaches to drive improvement. Vasc Dis Prev 2004;1:167–174.[CrossRef]
  3. Cabana MD, Rand CS, Powe NR et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458–1465.[Abstract/Free Full Text]
  4. Hobbs FD, Erhardt L. Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) Survey. Fam Pract 2002;19:596–604.[Abstract/Free Full Text]
  5. EUROASPIRE I and II Group. European action on secondary prevention by intervention to reduce events. Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries. Lancet 2001;357:995–1001.[CrossRef][ISI][Medline]
  6. Pearson TA, Laurora I, Chu H et al. The lipid treatment assessment project (L-TAP): a multicenter survey to evaluate the percentages of dyslipidemic patients receiving lipid-lowering therapy and achieving low-density lipoprotein cholesterol goals. Arch Intern Med 2000;160:459–467.[Abstract/Free Full Text]
  7. EUROASPIRE II Study Group. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries; principal results from EUROASPIRE II. Eur Heart J 2001;22:554–572.[Abstract/Free Full Text]
  8. Vale MJ, Jelinek MV, Best JD; COACH Study Group. Coaching patients on achieving cardiovascular health. How many patients with coronary heart disease are not achieving their risk-factor targets? Experience in Victoria 1996–1998 versus 1999–2000. Med J Aust 2002;176:211–215.[ISI][Medline]
  9. Backlund L, Bring J, Strender L-E. How accurately do general practitioners and students estimate coronary risk in hypercholesterolaemic patients? Prim Health Care Res Dev 2004;5:145–152.[CrossRef]
  10. Erhardt L, Hobbs FD. Public perceptions of cardiovascular risk in five European countries: the react survey. Int J Clin Pract 2002;56:638–644.[ISI][Medline]
  11. Duryee R. The efficacy of inpatient education after myocardial infarction. Heart Lung 1992;21:217–225.[ISI][Medline]
  12. Murray PJ. Rehabilitation information and health beliefs in the post-coronary patient: do we meet their information needs? J Adv Nurs 1989;14:686–693.[Medline]
  13. Wynn A. Unwarranted emotional distress in men with ischaemic heart disease (IHD). Med J Aust 1967;2:847–851.[Medline]
  14. Newens AJ, McColl E, Lewin R et al. Cardiac misconceptions and knowledge in nurses caring for myocardial infarction patients. Coronary Health Care 1997;1:83–89.
  15. Haynes RB, McKibbon KA, Kanani R. Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications. Lancet 1996;348:383–386.[CrossRef][ISI][Medline]
  16. Thomson R, Lavender M, Madhok R. How to ensure that guidelines are effective. BMJ 1995;311:237–242.[Abstract/Free Full Text]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Request Permissions
Google Scholar
Right arrow Articles by Erhardt, L. R.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Erhardt, L. R.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?