Self-reported cognitive and emotional effects and lifestyle changes shortly after preventive cardiovascular

consultations in general practice

Dea Kehler

Department of General Practice Research Unit for General Practice

U N I V E R S I T Y OF A A R H U S

Outline Background Aim Design Material Method Results Strenghts and weaknesses Conclusion Perspectives Future research

Background

It is evidence based that lifestyle interventions is effectfull in prevention of CVD

It is a fact that many patients with high risk of CVD do not obtain the treatment goals in daily clinic

The adherence to lifestyle counselling and medication is not optimal either from the GP or patient perspective

Background

In Denmark and many other countries, prevention of disease has become a priority area in recent years

Prevention of CVD has been a focus area in general practice in Denmark since 1999

Background

In 2006, a scheduled preventive consultation for people at increased risk of CVD was introduced together with a set of clinical guidelines, published by the Danish College of General Practitioners.

Clinical guidelines

To estimate the total cardiovascular risk from fatal CVD within 10 years by using the score system and use the recommendations addressing the specific risk

To identify components of risk that are to be modified and patients’ own perception of the issue

To use motivational interviewing and adopted risk handling strategies based on shared decision making

To schedule a follow-up consultation

0

200000

400000

600000

800000

1000000

1200000

2002 2005 2008

Prev CVD consultations Prev consultations in all

Number of preventive cardiovascular consultations (1999-2006) and preventive consultations in all (2006-2008) in DK

Aims

To explore og analyse GPs and patients experiences with:

1.1 Communication about motivation in relation to lifestylechanges through a mixed approach

1.2. The doctor-patient relationship in relation to lifestyle changesthrough a mixed approach

1.3. Risk commmuncation through a mixed approach

1.4 To quantify and analyse patients evaluations of preventive consultations through a questionnaire study

Questionnaire aim

To describe patients’ evaluation of the contents of preventive

cardiovascular consultations and to analyse whether their

evaluation is shaped by self-reported cognitive and emotional

effects and lifestyle change two to six weeks after the consultations

Questionnaire material

The health insurance register provided data on 2450 people, who had a preventive cardiovascular consultation in february 2007

1714 filled out a consultation evaluation questionnaire 2 to 6 weeks after their preventive consultation with their GP (70%)

Among these, 1226 fulfilled the inclusion criteria, which were:

Participation in a scheduled preventive consultation with focus on primary prevention of CVD and an individual risk assessment

To be at 5% or higher risk of fatal (death) CVD within 10 years by using the Score system without earlier identified CVD

Questionnaire sections Section 1Questions related to patient, GP and consultation characteristicsand demographic information validated by DIKE and SF12

Section 2Questions related to the consultation content and effectsdeveloped from qualitative consultation and interview studieswith patients at cardiovascular risk and their GPs

Section 3Comprised two items from COMRADE, a validated patientquestionnaire to evaluate risk communication and decisionmaking effectiveness in general practice.

The analysis

The exposure and outcome variables were dichotomized in order to analyse the data and create sum scores

Data cleaning and variabel modification

Generation of frequency analysis and histograms

Regression analysisCrude odds ratiosAdjusted odds ratios (confounder adjusted)

Effect modification analysis (Wald test)

Results

Slightly more men than women

Mean age 61 years (range 22-89)

Most patients were married

70.2 % short-term education

1-2 risk factors: 36%3-4 risk factors: 41%4-5 risk factors: 23%

Results

Patients reported cognitive effects 2-6 weeks after

participation in a preventive consultation in the form of:

Increased knowledge about health (79%)

Increased focus on health and CVD (61%)

Better overview in relation to own health (63%)

Increased ability to see how lifestyle influence on health (58%).

Results

Patients reported changes in lifestyle habits 2 to 6 weeks

after participation in a preventive consultation:

Eating habits (57%) Physical activity habits (48%) Smoking habits (22%)

Results

Patients reported emotional effects 2 to 6 weeks after

participation in a preventive consultation in the form of:

Relief (80%) Consultation satisfaction (97%) Concerns (23%)

Results

Patients, who communicated with their GP about:

Cardiovascular risk Daily living and lifestyle habits Knowledge about CVD Perception of cardiovascular risk Own preventive possibilities

reported significant more frequent 3 or 4 cognitive benefits, one or several changes in lifestyle habits and were more frequent satisfied after participation in a preventive cardiovascular consultation (OR range 1.74-4.27)

Results

Patients reporting being informed about risk of disease or that

lifestyle habits had been addressed during the consultation were

significantly less frequently relieved, than patients who rapported

that these issues had not been raised (OR 0.3-0.7)

Results

Patients, who reported that issues as:

Daily living Own perception of risk Knowledge about CVD Own preventive possibilities

had been raised in the consultation, were significantlymore often relieved (OR range 1.61–2.50) thanpatients, where the issues had not being raised

Results

Patients reported that issues as:

Information about riskDaily living and lifestyle habitsOwn perception of cardiovascular riskKnowledge about CVDOwn preventive possibilities

were significantly more often satisfied with theconsultation than those, who had not. (OR range 2.2-8.3)

Results

In all, there was no significant difference between crude and

adjusted ORs and introduction of interactions in the regression

models did not significantly change any of the ORs.

Questionnaire weaknesses

Cross-sectional study – no conclusions about causalities

No long-term effects of the preventive consultation

No statistical or psychometric validation of the deveoloped questionnaire during factor or correlation analysis

The study may be hampered by recall bias, selections bias and confouding

Questionnaire strenghts

The response rate was 70%

Quite narrow confidence intervals

High face and content validity

Good generalisability national related to the non-restrictive inclusion and the construction of the questionnaire

GP independent inclusion of patients

Conclusion

Cardiovascular risk patients reported cognitive and emotional

effects and healthy lifestyle changes 2-6 weeks after a preventive

consultation and increase in the effects and their consultation

satisfaction, if the following issues were raised during the consultation:

Cardiovascular risk Patients daily living and lifestyle habits Knowledge about health and cardiovascular disease Own perception of cardiovascular risk Own preventive possibilities

Perspectives

The questionnaire study has shown that the preventive

consultation has a development potential, which can be

used in medical education programmes based on

professional, communicative and lifestyle changing

competence elements in the future

Perspectives

When the education program is developed, it could be interesting

to investigate, whether patients have more benefits of the

preventive consultations on the long run than by participating

in the actual preventive consultation in general practice

Perspectives

The results can be used in the future development and political

debate about primary prevention and preventive consultations in

general practice

The results underline that the consultation and its content is

important in succesfull primary prevention of CVD

Future research

To investigate whether patiens reported cognitive and emotional effects andhealthy changes in life habits rest over time

To investigate and identify the consultation elements, which have the mostsignificant impact on patient reported effects of preventive consultations

To investigate how many and which type of patients, who need preventiveconsultations to change and maintain healthy lifestyle changes

To investigate whether motivational interviewing and adopted risk handlingstrategies based on shared decision making could help the GPs and thepatients to verbalise and solve the existing ambivalence in preventiveconsultations

Acknowledgements

Participating GPs and patients

The health insurance registers

The Danish Agency of science

Communicating Risks- illusion or truth?

BMJ

British Medical Journalthemed issue27th Sept 2003