National Study of Physician Awareness and Adherence to Cardiovascular Disease Prevention Guidelines
http://www.100md.com
循环学杂志 2005年第2期
Columbia University College of Physicians and Surgeons, New York, NY (L.M., A.H.L.)
Boston University School of Medicine, Boston, Mass (E.J.B.)
Stanford University School of Nursing, Palo Alto, Calif (K.B.)
Mayo Clinic College of Medicine, Rochester, Minn (S.N.H.)
Brigham and Women’s Hospital, Boston, Mass (B.W.W.)
American Heart Association, Dallas, Tex (R.P.F.)
Segmentation Company, a Division of Yankelovich, Chapel Hill, NC (J.K., T.M., S.L.S.).
Abstract
Background— Few data have evaluated physician adherence to cardiovascular disease (CVD) prevention guidelines according to physician specialty or patient characteristics, particularly gender.
Methods and Results— An online study of 500 randomly selected physicians (300 primary care physicians, 100 obstetricians/gynecologists, and 100 cardiologists) used a standardized questionnaire to assess awareness of, adoption of, and barriers to national CVD prevention guidelines by specialty. An experimental case study design tested physician accuracy and determinants of CVD risk level assignment and application of guidelines among high-, intermediate-, or low-risk patients. Intermediate-risk women, as assessed by the Framingham risk score, were significantly more likely to be assigned to a lower-risk category by primary care physicians than men with identical risk profiles (P<0.0001), and trends were similar for obstetricians/gynecologists and cardiologists. Assignment of risk level significantly predicted recommendations for lifestyle and preventive pharmacotherapy. After adjustment for risk assignment, the impact of patient gender on preventive care was not significant except for less aspirin (P<0.01) and more weight management recommended (P<0.04) for intermediate-risk women. Physicians did not rate themselves as very effective in their ability to help patients prevent CVD. Fewer than 1 in 5 physicians knew that more women than men die each year from CVD.
Conclusions— Perception of risk was the primary factor associated with CVD preventive recommendations. Gender disparities in recommendations for preventive therapy were explained largely by the lower perceived risk despite similar calculated risk for women versus men. Educational interventions for physicians are needed to improve the quality of CVD preventive care and lower morbidity and mortality from CVD for men and women.
Key Words: cardiovascular diseases ; guidelines ; prevention ; risk assessment ; women
Introduction
Cardiovascular disease (CVD) is the leading killer of both men and women in the United States.1 Sex disparities in CVD outcomes in women have been widely documented, yet the mechanisms remain unclear.2 In numerous studies, women have been shown to receive suboptimal CVD preventive care, which may contribute to worse outcomes compared with men.3–8 To address this important public health issue, the American Heart Association (AHA) released "Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women" in February 2004 to assist healthcare providers in determining appropriate preventive care based on a woman’s future risk of coronary heart disease (CHD).9
Successful adoption of practice guidelines has been shown to be related to physician awareness/agreement, self-efficacy, outcome expectancy, and practice habits/routines, in addition to patient- and system-related factors.10 Few data have systematically assessed physicians’ reasons for nonadherence and barriers to adoption of guidelines specific to CVD prevention. Moreover, most disparities research has not used a controlled or experimental design to evaluate possible gender-based differences in preventive practice patterns. An understanding of the barriers may potentially isolate factors related to differential treatment that could be targeted for improving quality of care.
The primary purpose of the present study was to determine whether CVD preventive care varied by patient gender among a random sample of US physicians using an experimental case-studies design. We also sought to examine whether awareness of and barriers to adoption of CVD prevention guidelines varied by physician specialty (primary care physicians [PCPs], obstetricians/gynecologists [OBGyns], and cardiologists [CARDs]).
Methods
Design
An online cross-sectional survey was administered to 500 physicians in November 2004 that included standardized questions about awareness of and barriers to CVD prevention guidelines. In addition, physicians were asked to choose preventive therapies that they recommend for patients at high, intermediate, and lower risk of CHD from a standard list. They were then given experimental case studies to test their knowledge of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III Framingham risk categories (high risk, 10-year absolute CHD risk >20%, established CVD, or CHD risk equivalent; intermediate risk, 10-year absolute CHD risk of 10% to 20%; or low risk, 10-year absolute risk <10%). The case studies subsequently tested the physicians’ application of AHA evidence-based guidelines for women and the equivalent guidelines in men based on NCEP ATP III, the Joint National Committee on the Prevention, Detection, and Treatment of High Blood Pressure (JNC) 7, and AHA primary and secondary prevention recommendations.9,11–14 Once physicians completed a survey question, they were not allowed to return to a previous question.
Physician CVD preventive practice patterns were assessed using a factorial case study design in which certain patient characteristics were varied and several others were held constant (Appendix 1). For purposes of this study, we tested specific hypotheses related to treatment variation by age, gender, race/ethnicity, LDL cholesterol, HDL cholesterol, and diabetes as a CHD risk equivalent because they were important new recommendations or were highlighted in the AHA evidence-based guidelines for women.9 This approach allowed an evaluation of whether a factor such as gender drove treatment decisions when risk profiles were otherwise similar. Physicians were asked to assign a risk level (high, intermediate, low) to each case and then to recommend preventive therapies specific to that case. Because calculated risk could be compared with perceived risk, we were also able to assess determinants of assigning risk levels among the experimental cases.
Sample
The study was conducted among a stratified random sample of 500 physicians (300 PCPs, 100 OBGyns, and 100 CARDs) drawn from the J. Reckner Associates national database of >300 000 healthcare professionals. The research panel participants have been compiled over the years by multiple mechanisms (eg, random dialing, purchased samples, referrals) and are unbiased with respect to an artificially high concentration of Internet users. Regional samples for large population specialties are drawn by use of a "rolling over blocks" method to ensure that there is no overuse of samples within specialty.
A total of 8550 invitations were sent to physicians asking them to participate in an online study of treatment and prevention of CVD, and a small monetary incentive ($60 for PCPs, $75 for OBGyns and CARDs) was offered to qualified respondents who submitted completed surveys. The log in response rate was 13%, 10%, and 15% among PCPs, OBGyns, and CARDs, respectively, typical of a single mailing response rate for an epidemiological survey. In lieu of repeated mailings to the same physicians to improve the response, invitations were sent until the prespecified number of physician participants was attained by specialty category. Among the respondents, 74% of PCPs, 34% of OBGyns, and 61% of CARDs met eligibility criteria.
To qualify for the research study, physicians had to be board certified or board eligible in their respective specialties and be in full-time clinical practice for 3 to 30 years after residency. Each physician completed a standardized questionnaire that included demographic information, practice type and setting, and characteristics of patients in their practice. For purposes of this survey, PCPs had to spend 70% of their time in clinical practice, see 100 patients in a typical month, and treat 25% of their patients for hypertension or other CVD-related condition. OBGyns had to spend 50% of their time in clinical practice (with 30% in nonobstetric care), see 75 patients per month, treat 10% of patients for hypertension or other CVD-related conditions, and serve as the primary care provider for 30% of their patients. CARDs were eligible if they spent 50% of their time in clinical practice (with <50% of time doing interventional procedures), saw 75 patients in a typical month, and treated 50% of their patients for hypertension or other CVD-related conditions.
Experimental Cases
Each physician was presented 10 patient cases with information about age, sex, ethnicity/race, smoking status, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, blood pressure, treatment for hypertension, body mass index (BMI), family history of CHD, and personal history of CHD or diabetes mellitus. Once physicians assigned a level of risk to each of the 10 cases, they were asked to specify their preventive treatment recommendations from a prespecified list of possible interventions.
Of the 10 cases, 2 were designed to be patients at low risk that differed only with regard to sex. In addition, there were 4 intermediate-risk and 4 high-risk cases with information about patient attributes that were generated from a balanced orthogonal design yielding 32 possible patient profiles. To reduce respondent fatigue, a subset of 16 patient profiles was selected for this study. The experimental design was developed with the SAS macro MktEx (SAS version 9.1.3). The profiles selected yielded a D-efficiency score of 100%. Each respondent was randomly selected to view 1 block of 4 intermediate-risk patient profiles and 1 block of 4 high-risk patient profiles, in addition to the 2 low-risk profiles, in random order. The factors varied and held constant within each risk category are presented in appendix 1.
The intermediate-risk factors that varied in the experimental design were age (42 versus 65 years), sex (male versus female), ethnicity (white versus black), LDL cholesterol (90 versus 162 mg/dL), and blood pressure (160/110 versus 118/78 mm Hg). Factors held constant in the intermediate-risk cases were nonsmoking status, HDL cholesterol of 56 mg/dL, triglycerides of 120 mg/dL, ;-blocker antihypertensive treatment, BMI of 27 kg/m2, positive family history of premature CHD, and no personal history of CVD. Among the high-risk cases, factors that were varied included age (50 versus 76 years), sex (male versus female), LDL cholesterol (90 versus 130 mg/dL), HDL cholesterol (42 versus 62 mg/dL), and personal history (CHD versus diabetes). Factors held constant in the high-risk cases were white race, nonsmoking, triglycerides of 100 mg/dL, blood pressure of 140/95 mm Hg, ;-blocker therapy, BMI of 27 kg/m2, and no family history of premature CHD.
Statistical Methods
Descriptive statistics of physician practices and preventive recommendations are presented as proportions and mean±SD. Differences in the percent of physicians making each type of preventive therapy recommendation by specialty were evaluated with t tests of proportion. We used 2 tests to assess concordance between NCEP ATP III calculated risk and physicians’ assessed risk level.11 Agreement with statements about physician effectiveness and prevention barriers/perceptions was evaluated by use of a 4-point (very effective versus others) and 10-point (strongly agree/agree versus others) Likert scale, respectively.
Cumulative, ordered logit models were used to evaluate the impact of experimentally designed patient factors on risk assessment. SAS PROC LOGISTIC (SAS version 9.1.3) was used to fit this model with physician risk assessment (low, intermediate, high) as the response variable and patient factors (age, gender, race/ethnicity, cholesterol level, blood pressure, patient history) as explanatory variables.
A step-wise (2 steps only) logistic regression model was used to investigate the effects of patient factors on physicians’ therapy choices independently of assessment of risk. SPSS (version 12.0.1) logistic regression was used to fit this model with therapy choice (physical activity, cardiac rehabilitation, dietary counseling, weight reduction, dietary supplements, blood pressure medication, lipid-lowering medication, aspirin therapy) as the response variable (selected or not selected for 1 patient case in a risk group) and patient factors (age, gender, race/ethnicity, LDL cholesterol levels, blood pressure, patient history) as explanatory variables. Statistical significance was set at P<0.05.
Results
Physician/Practice Characteristics
Awareness/Incorporation of CVD Prevention Guidelines
Lifestyle, Supplement, and Aspirin Recommendations
OBGyns were more likely to recommend supplements to prevent CVD than PCPs or CARDs, although the AHA women’s guidelines do not strongly recommend this strategy and suggest that antioxidant supplements should not be used for CVD prevention (Appendix 2). Each physician group recommended supplements more frequently among intermediate-risk and high-risk patients than low-risk patients. The 3 most common supplements that physicians recommended were multivitamin/mineral, omega-3 fatty acids, and folic acid. Consistent with AHA women’s guidelines, recommendations for aspirin therapy varied by risk level, with patients at high risk more likely to receive a recommendation (90% PCPs, 84% OBGyns, 86% CARDs) and about one third of physician recommending aspirin therapy for low-risk patients (Appendix 2).9 The most frequently recommended dose was 81 mg. However, one third of PCPs and CARDs recommended 325 mg for the high-risk patient, despite guidelines suggesting a dose range of 75 to 162 mg daily.
Lipid, Diabetes, and Blood Pressure Management
Most PCPs (92%) and CARDs (90%) recommended further antihypertensive drug therapy for high-risk patients who were already on ;-blocker therapy and had a blood pressure of 140/95 mm Hg (Table 5); OBGyns were less likely to do so compared with either PCPs or CARDs (69%, P<0.01). Similar trends were observed for intermediate-risk cases. The most frequently recommended medication to manage hypertension was ACE inhibitors or angiotensin receptor blockers, followed by diuretics, although national guidelines suggest that diuretics should be part of the antihypertensive drug regimen for most patients unless contraindicated. Calcium channel blockers were more commonly recommended as antihypertensive therapy in the intermediate- compared with the high-risk group.
Framingham/ATP III Risk Versus Perceived Risk
Physicians’ perceptions of patients’ risk levels were compared with calculated risk category based on ATP III Framingham risk scores, stratified by patient gender and physician specialty.11 Among PCPs, 34% correctly categorized low-risk male patients, 47% correctly categorized intermediate-risk male patients, and 59% correctly identified high-risk male patients. A similar trend was seen for PCPs’ evaluation of female patients (43%, 47%, and 55%, respectively).
Among OBGyns, 19% correctly identified male patient’s risk as low, 41% correctly categorized intermediate-risk patients, and 43% correctly categorized high-risk patients. In their assessment of female patients’ risk, OBGyns’ accuracy rates were 17%, 38%, and 37%, respectively. CARDs correctly categorized low-risk male patients 29% of the time, 51% correctly categorized intermediate-risk male patients, and 58% correctly identified high-risk male patients. A similar trend was seen for CARDs’ evaluation of female patients’ risk level (36%, 53%, and 56%, respectively).
Data on determinants of physicians assigning increasing risk levels among patients calculated to be at intermediate and high risk as defined by NCEP ATP III reveal a significant influence of patient gender on assignment of risk category (Table 6). Intermediate-risk women were significantly less likely to be assigned to a higher-risk category than men with similar risk profiles (OR, 0.62; 95% CI, 0.49 to 0.78) by PCPs, with similar but nonsignificant trends for OBGyns and CARDs. For example, PCPs assigned 20% of women compared with 13% of men to the low-risk category with the same risk profile (65 years of age, nonsmoking, LDL cholesterol of 162 mg/dL, HDL cholesterol of 56 mg/dL, BMI of 27 kg/m2, blood pressure of 118/78 mm Hg, positive family history of premature CHD, and no personal history of CVD).
Guideline Adherence by Patient Risk Level
Physicians’ assessment of the patient as intermediate or high risk significantly predicted recommendations for preventive interventions (physical activity, cardiac rehabilitation, dietary therapy, weight reduction, blood pressure control, lipid management, and aspirin therapy) in the experimental case studies among all specialties combined. After assignment of risk by physician was taken into consideration, older high-risk patients were less likely to receive recommendations for dietary counseling (P=0.03) and weight reduction (P<0.01) and were more likely to receive a recommendation for aspirin therapy (P=0.05) than younger patients. As expected, high-risk patients with elevated LDL cholesterol levels were more likely to receive a recommendation for lipid pharmacotherapy (P<0.01) and dietary counseling (P=0.02). Diabetics were more likely to be recommended dietary therapy (P<0.01) and less likely to receive a recommendation for cardiac rehabilitation than patients with CHD (P<0.01). HDL cholesterol levels were not associated with preventive recommendations among the high-risk cases.
Among intermediate-risk cases, increased age was predictive of a physician recommendation for aspirin therapy (P<0.01). As expected, intermediate-risk cases with elevated LDL cholesterol levels were more likely to be recommended dietary counseling (P=0.01) and lipid pharmacotherapy (P<0.01). Similarly, antihypertensive drug therapy was more frequently recommended among cases with elevated blood pressure (P<0.01). After adjustment for physician assignment of risk level, women calculated to be at intermediate risk by NCEP ATP III received significantly more recommendations for weight reduction (P=0.04) and less frequent recommendations for aspirin therapy (P<0.01), suggesting that factors beyond perceived risk may also contribute to gender differences in some therapeutic choices.
Among the low-risk cases in which only gender varied, sex was not a significant predictor of recommendations for CVD preventive therapy.
Physician Effectiveness and Barriers to Adherence
Physicians in this study did not rate themselves as very effective in their ability to help patients prevent CVD and manage risk factors (Table 7). In particular, OBGyns did not rate themselves as very effective in helping patients achieve lifestyle change such as weight management, smoking cessation, and physical activity and felt less effective in managing lipids, controlling blood pressure, and preventing heart disease in their patients compared with PCPs and CARDs.
Twenty-six percent of PCPs, 11% of OBGyns, and 28% of CARDs reported having a system in place to track patient adherence to prescription regimens, with OBGyns being less likely to have such a system (P<0.05). Of those who reported having a system to track patient’s medication adherence, most cited a standard query at the patient’s visit as the method used.
Many physicians reported that they are willing to seek additional training that will allow them to better engage in preventive health treatment for CVD in women, with the greatest enthusiasm among OBGyns. Despite documentation that more women die of CVD each year than men, surprisingly few physicians (<1 in 5) from any of the specialties strongly agreed or agreed with that fact.
Discussion
Two main findings from this national study were that recommendations for CVD prevention were driven by risk level assignment and that women were more likely than men to be assigned a lower-risk category despite a similar calculated risk. These data are concordant with a study by Shulman et al,16 which found that gender independently influenced how physicians managed chest pain. In that study, PCPs were given a computerized survey instrument incorporating taped interviews of actors portraying patients and asked to assess risk and to make recommendations about further care. Physician estimates of the probability of CHD were lower for women, and despite adjustment for estimate of probability of disease, level of coronary risk, and presenting symptoms, women were less likely to be referred for diagnostic cardiac catheterization. Both studies suggest that improving physician assessment of CHD risk may be an important educational target to reduce sex-based disparities in care.
Our study also showed that awareness and incorporation of CVD prevention guidelines differed by type of physician. OBGyns were substantially less aware of national guidelines for cholesterol and blood pressure management than PCPs, consistent with a lower reported rate of incorporation into their practice and lower self-reported effectiveness in managing major CHD risk factors and preventing heart disease. Because OBGyns in our study reported that they provided primary care to 67% of their patients, they can play a vital role in assessing and managing CVD risk among women. It was encouraging that most OBGyns in our study were willing to adopt guidelines published by professionals outside their specialty. The American College of Obstetrics and Gynecology was a major cosponsor of the AHA evidence-based guidelines for CVD prevention in women, and our data show that OBGyns were more aware of these guidelines than JNC 7, suggesting that partnerships to develop and disseminate female-specific guidelines may be an effective strategy to improve the quality of preventive care.
According to our study, fewer than two thirds of physicians recommended physical activity to low-risk patients, and only about half advised dietary counseling. This finding is similar to that of the National Ambulatory Medial Care Survey, which found low rates of lifestyle counseling in practice that was worse for women than men.8 An educational opportunity exists for all physicians to encourage lifestyle strategies to prevent the development of risk factors that may require more intensive therapy later. We also observed significant prospects to improve adherence to national guidelines for lipid management, especially among the high-risk patients who are most likely to benefit. Recently, statin therapy has been recommended for high-risk patients regardless of LDL cholesterol level,9,11 yet only about half of OBGyns recommended such therapy when treating high-risk patients. Similarly, the AHA women’s guidelines recommended niacin or fibrate therapy when HDL-cholesterol was low or non–HDL-cholesterol was elevated among high-risk women, and only one third of OBGyns recommended such therapy. Our data also suggest that more education is needed with regard to optimal glucose and blood pressure management.
Barriers to CVD preventive care in our study (lack of time and reimbursement) were similar to other data and suggest that policy makers and insurers need to address systems constraints to better serve public health.10 Although many physicians suggested that the patient was an important barrier to the prevention of heart disease, this may reflect the perceived difficulty in adherence to lifestyle factors that are within the control of the patient and crucial for preventing CVD. A potential sex-specific barrier cited by a large percent of physicians was that results of clinical research conducted in men may not generalize to women, emphasizing the importance of including women in CVD prevention studies to increase adoption of evidence-based guidelines. Finally, a striking finding in our study was a very low level of recognition (8% PCPs, 13% OBGyns, and 17% CARDs) that heart disease kills more women every year than men. According to AHA statistics, nearly 500 000 women die of CVD each year, exceeding the number of men.1 These physician data underscore the need for awareness campaigns about women and heart disease among healthcare providers, especially because awareness of risk is a critical first step in taking action to reduce it.
Our study has limitations. The results may not be generalizable to all physicians because our response rate was low and we did not survey every specialty. However, our data may represent a best-case scenario among full-time practitioners because survey respondents may be more likely to be aware of and adhere to guidelines as a result of selection bias. Our power to evaluate recommendations among low-risk cases was reduced as a result of the limited number of low-risk profiles by design because of cost constraints. The additive effects of risk assignment and independent risk factors on therapy choice were not evaluated in the present analysis. We also lacked the power to examine whether awareness of, adoption of, and barriers to treatment varied by age, gender, or race/ethnicity of the physician. In addition, we conducted multiple analyses without adjusting for statistical testing. Our results will need to be validated in other cohorts and by other study designs.
In conclusion, interventions to raise awareness and adoption of CVD prevention guidelines among healthcare providers are needed. Educational efforts should be targeted to assisting physicians in CHD risk assessment, which may help reduce sex-based disparities in preventive care. Further research into effective strategies to improve physician and patient adherence to CVD prevention guidelines is merited.
Appendix 1
APPENDIX 1. Experimental Patient Cases
Appendix 2
APPENDIX 2. Clinical Recommendations
APPENDIX 2. Continued
Acknowledgments
This research was partially funded by an unrestricted educational grant to the American Heart Association from KOS Pharmaceuticals.
References
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Mosca L, Manson JE, Sutherland SE, Langer RD, Manolio T, Barrett-Connor E. Cardiovascular disease in women: a statement for healthcare professionals from the American Heart Association Writing Group. Circulation. 1997; 96: 2468–2482.
Kim C, Hofer TP, Kerr EA. Review of evidence and explanations for suboptimal screening and treatment of dyslipidemia in women: a conceptual model. J Gen Intern Med. 2003; 18: 854–863.
Sueta CA, Chowdhury M, Boccuzzi SJ, Smith SC Jr, Alexander CM, Londhe A, Lulla A, Simpson RJ Jr. Analysis of the degree of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease. Am J Cardiol. 1999; 83: 1303–1307.
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Ford ES, Mokdad AH, Giles WH, Mensah GA. Serum total cholesterol concentrations and awareness, treatment, and control of hypercholesterolemia among US adults: findings from the National Health and Nutrition Examination Survey, 1999 to 2000. Circulation. 2003; 107: 2185–2189.
Jha A, Varosy PD, Kanaya AM, Hunninghake DB, Hlatky MA, Waters DD, Furberg CD, Shlipak MG. Differences in medical care and disease outcomes among black and white women with heart disease. Circulation. 2003; 108: 1089–1094.
Missed opportunities in preventive counseling for cardiovascular disease–United States 1995. MMWR Morb Mortal Wkly Rep. 1998; 47: 91–95.
Mosca L, Appel LJ, Benjamin EJ, Berra K, Chandra-Strobos N, Fabunmi RP, Grady D, Haan CK, Hayes SN, Judelson DR, Keenan NL, McBride P, Oparil S, Ouyang P, Oz MC, Mendelsohn ME, Pasternak RC, Pinn VW, Robertson RM, Schenck-Gustafsson K, Sila CA, Smith SC, Sopko G, Taylor AL, Walsh BW, Wenger NK, Williams CL. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation. 2004; 109: 672–693.
Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don’t physicians follow clinical practice guidelines; JAMA. 1999; 282: 1458–1465.
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): final report. Circulation. 2002; 106: 3143–3421.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ, for the National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee On Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003; 289: 2560–2572.
Pearson TA, Blair SN, Daniels SR, Eckel RH, Fair JM, Fortmann SP, Franklin BA, Goldstein LB, Greenland P, Grundy SM, Hong Y, Miller NH, Lauer RM, Ockene IS, Sacco RL, Sallis JF Jr, Smith SC Jr, Stone NJ, Taubert KA. AHA Guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases: American Heart Association Science Advisory and Coordinating Committee. Circulation. 2002; 106: 388–391.
Smith S, Blair S, Bonow R, Brass LM, Cerqueira MD, Dracup K, Fuster V, Gotto A, Grundy SM, Miller NH, Jacobs A, Jones D, Krauss RM, Mosca L, Ockene I, Pasternak RC, Pearson T, Pfeffer MA, Starke RD, Taubert KA. American Heart Association/American College of Cardiology Scientific Statement: AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: a 2001 update: a statement for health care professionals from the American Heart Association and the American College of Cardiology. Circulation. 2001; 104: 1577–1579.
Grundy SM, Cleeman JI, Bairey Merz CN, Brewer HB, Clark LT, Hunninghake NB, Pasternak RC, Smith SC, Stone NJ. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation. 2004; 110: 227–239.
Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, Dube R, Taleghani CK, Burke JE, Williams S, Eisenberg JM, Escarce JJ, Ayers W. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1999; 340: 618–626.(Lori Mosca, MD, MPH, PhD;)
Boston University School of Medicine, Boston, Mass (E.J.B.)
Stanford University School of Nursing, Palo Alto, Calif (K.B.)
Mayo Clinic College of Medicine, Rochester, Minn (S.N.H.)
Brigham and Women’s Hospital, Boston, Mass (B.W.W.)
American Heart Association, Dallas, Tex (R.P.F.)
Segmentation Company, a Division of Yankelovich, Chapel Hill, NC (J.K., T.M., S.L.S.).
Abstract
Background— Few data have evaluated physician adherence to cardiovascular disease (CVD) prevention guidelines according to physician specialty or patient characteristics, particularly gender.
Methods and Results— An online study of 500 randomly selected physicians (300 primary care physicians, 100 obstetricians/gynecologists, and 100 cardiologists) used a standardized questionnaire to assess awareness of, adoption of, and barriers to national CVD prevention guidelines by specialty. An experimental case study design tested physician accuracy and determinants of CVD risk level assignment and application of guidelines among high-, intermediate-, or low-risk patients. Intermediate-risk women, as assessed by the Framingham risk score, were significantly more likely to be assigned to a lower-risk category by primary care physicians than men with identical risk profiles (P<0.0001), and trends were similar for obstetricians/gynecologists and cardiologists. Assignment of risk level significantly predicted recommendations for lifestyle and preventive pharmacotherapy. After adjustment for risk assignment, the impact of patient gender on preventive care was not significant except for less aspirin (P<0.01) and more weight management recommended (P<0.04) for intermediate-risk women. Physicians did not rate themselves as very effective in their ability to help patients prevent CVD. Fewer than 1 in 5 physicians knew that more women than men die each year from CVD.
Conclusions— Perception of risk was the primary factor associated with CVD preventive recommendations. Gender disparities in recommendations for preventive therapy were explained largely by the lower perceived risk despite similar calculated risk for women versus men. Educational interventions for physicians are needed to improve the quality of CVD preventive care and lower morbidity and mortality from CVD for men and women.
Key Words: cardiovascular diseases ; guidelines ; prevention ; risk assessment ; women
Introduction
Cardiovascular disease (CVD) is the leading killer of both men and women in the United States.1 Sex disparities in CVD outcomes in women have been widely documented, yet the mechanisms remain unclear.2 In numerous studies, women have been shown to receive suboptimal CVD preventive care, which may contribute to worse outcomes compared with men.3–8 To address this important public health issue, the American Heart Association (AHA) released "Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women" in February 2004 to assist healthcare providers in determining appropriate preventive care based on a woman’s future risk of coronary heart disease (CHD).9
Successful adoption of practice guidelines has been shown to be related to physician awareness/agreement, self-efficacy, outcome expectancy, and practice habits/routines, in addition to patient- and system-related factors.10 Few data have systematically assessed physicians’ reasons for nonadherence and barriers to adoption of guidelines specific to CVD prevention. Moreover, most disparities research has not used a controlled or experimental design to evaluate possible gender-based differences in preventive practice patterns. An understanding of the barriers may potentially isolate factors related to differential treatment that could be targeted for improving quality of care.
The primary purpose of the present study was to determine whether CVD preventive care varied by patient gender among a random sample of US physicians using an experimental case-studies design. We also sought to examine whether awareness of and barriers to adoption of CVD prevention guidelines varied by physician specialty (primary care physicians [PCPs], obstetricians/gynecologists [OBGyns], and cardiologists [CARDs]).
Methods
Design
An online cross-sectional survey was administered to 500 physicians in November 2004 that included standardized questions about awareness of and barriers to CVD prevention guidelines. In addition, physicians were asked to choose preventive therapies that they recommend for patients at high, intermediate, and lower risk of CHD from a standard list. They were then given experimental case studies to test their knowledge of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III Framingham risk categories (high risk, 10-year absolute CHD risk >20%, established CVD, or CHD risk equivalent; intermediate risk, 10-year absolute CHD risk of 10% to 20%; or low risk, 10-year absolute risk <10%). The case studies subsequently tested the physicians’ application of AHA evidence-based guidelines for women and the equivalent guidelines in men based on NCEP ATP III, the Joint National Committee on the Prevention, Detection, and Treatment of High Blood Pressure (JNC) 7, and AHA primary and secondary prevention recommendations.9,11–14 Once physicians completed a survey question, they were not allowed to return to a previous question.
Physician CVD preventive practice patterns were assessed using a factorial case study design in which certain patient characteristics were varied and several others were held constant (Appendix 1). For purposes of this study, we tested specific hypotheses related to treatment variation by age, gender, race/ethnicity, LDL cholesterol, HDL cholesterol, and diabetes as a CHD risk equivalent because they were important new recommendations or were highlighted in the AHA evidence-based guidelines for women.9 This approach allowed an evaluation of whether a factor such as gender drove treatment decisions when risk profiles were otherwise similar. Physicians were asked to assign a risk level (high, intermediate, low) to each case and then to recommend preventive therapies specific to that case. Because calculated risk could be compared with perceived risk, we were also able to assess determinants of assigning risk levels among the experimental cases.
Sample
The study was conducted among a stratified random sample of 500 physicians (300 PCPs, 100 OBGyns, and 100 CARDs) drawn from the J. Reckner Associates national database of >300 000 healthcare professionals. The research panel participants have been compiled over the years by multiple mechanisms (eg, random dialing, purchased samples, referrals) and are unbiased with respect to an artificially high concentration of Internet users. Regional samples for large population specialties are drawn by use of a "rolling over blocks" method to ensure that there is no overuse of samples within specialty.
A total of 8550 invitations were sent to physicians asking them to participate in an online study of treatment and prevention of CVD, and a small monetary incentive ($60 for PCPs, $75 for OBGyns and CARDs) was offered to qualified respondents who submitted completed surveys. The log in response rate was 13%, 10%, and 15% among PCPs, OBGyns, and CARDs, respectively, typical of a single mailing response rate for an epidemiological survey. In lieu of repeated mailings to the same physicians to improve the response, invitations were sent until the prespecified number of physician participants was attained by specialty category. Among the respondents, 74% of PCPs, 34% of OBGyns, and 61% of CARDs met eligibility criteria.
To qualify for the research study, physicians had to be board certified or board eligible in their respective specialties and be in full-time clinical practice for 3 to 30 years after residency. Each physician completed a standardized questionnaire that included demographic information, practice type and setting, and characteristics of patients in their practice. For purposes of this survey, PCPs had to spend 70% of their time in clinical practice, see 100 patients in a typical month, and treat 25% of their patients for hypertension or other CVD-related condition. OBGyns had to spend 50% of their time in clinical practice (with 30% in nonobstetric care), see 75 patients per month, treat 10% of patients for hypertension or other CVD-related conditions, and serve as the primary care provider for 30% of their patients. CARDs were eligible if they spent 50% of their time in clinical practice (with <50% of time doing interventional procedures), saw 75 patients in a typical month, and treated 50% of their patients for hypertension or other CVD-related conditions.
Experimental Cases
Each physician was presented 10 patient cases with information about age, sex, ethnicity/race, smoking status, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, blood pressure, treatment for hypertension, body mass index (BMI), family history of CHD, and personal history of CHD or diabetes mellitus. Once physicians assigned a level of risk to each of the 10 cases, they were asked to specify their preventive treatment recommendations from a prespecified list of possible interventions.
Of the 10 cases, 2 were designed to be patients at low risk that differed only with regard to sex. In addition, there were 4 intermediate-risk and 4 high-risk cases with information about patient attributes that were generated from a balanced orthogonal design yielding 32 possible patient profiles. To reduce respondent fatigue, a subset of 16 patient profiles was selected for this study. The experimental design was developed with the SAS macro MktEx (SAS version 9.1.3). The profiles selected yielded a D-efficiency score of 100%. Each respondent was randomly selected to view 1 block of 4 intermediate-risk patient profiles and 1 block of 4 high-risk patient profiles, in addition to the 2 low-risk profiles, in random order. The factors varied and held constant within each risk category are presented in appendix 1.
The intermediate-risk factors that varied in the experimental design were age (42 versus 65 years), sex (male versus female), ethnicity (white versus black), LDL cholesterol (90 versus 162 mg/dL), and blood pressure (160/110 versus 118/78 mm Hg). Factors held constant in the intermediate-risk cases were nonsmoking status, HDL cholesterol of 56 mg/dL, triglycerides of 120 mg/dL, ;-blocker antihypertensive treatment, BMI of 27 kg/m2, positive family history of premature CHD, and no personal history of CVD. Among the high-risk cases, factors that were varied included age (50 versus 76 years), sex (male versus female), LDL cholesterol (90 versus 130 mg/dL), HDL cholesterol (42 versus 62 mg/dL), and personal history (CHD versus diabetes). Factors held constant in the high-risk cases were white race, nonsmoking, triglycerides of 100 mg/dL, blood pressure of 140/95 mm Hg, ;-blocker therapy, BMI of 27 kg/m2, and no family history of premature CHD.
Statistical Methods
Descriptive statistics of physician practices and preventive recommendations are presented as proportions and mean±SD. Differences in the percent of physicians making each type of preventive therapy recommendation by specialty were evaluated with t tests of proportion. We used 2 tests to assess concordance between NCEP ATP III calculated risk and physicians’ assessed risk level.11 Agreement with statements about physician effectiveness and prevention barriers/perceptions was evaluated by use of a 4-point (very effective versus others) and 10-point (strongly agree/agree versus others) Likert scale, respectively.
Cumulative, ordered logit models were used to evaluate the impact of experimentally designed patient factors on risk assessment. SAS PROC LOGISTIC (SAS version 9.1.3) was used to fit this model with physician risk assessment (low, intermediate, high) as the response variable and patient factors (age, gender, race/ethnicity, cholesterol level, blood pressure, patient history) as explanatory variables.
A step-wise (2 steps only) logistic regression model was used to investigate the effects of patient factors on physicians’ therapy choices independently of assessment of risk. SPSS (version 12.0.1) logistic regression was used to fit this model with therapy choice (physical activity, cardiac rehabilitation, dietary counseling, weight reduction, dietary supplements, blood pressure medication, lipid-lowering medication, aspirin therapy) as the response variable (selected or not selected for 1 patient case in a risk group) and patient factors (age, gender, race/ethnicity, LDL cholesterol levels, blood pressure, patient history) as explanatory variables. Statistical significance was set at P<0.05.
Results
Physician/Practice Characteristics
Awareness/Incorporation of CVD Prevention Guidelines
Lifestyle, Supplement, and Aspirin Recommendations
OBGyns were more likely to recommend supplements to prevent CVD than PCPs or CARDs, although the AHA women’s guidelines do not strongly recommend this strategy and suggest that antioxidant supplements should not be used for CVD prevention (Appendix 2). Each physician group recommended supplements more frequently among intermediate-risk and high-risk patients than low-risk patients. The 3 most common supplements that physicians recommended were multivitamin/mineral, omega-3 fatty acids, and folic acid. Consistent with AHA women’s guidelines, recommendations for aspirin therapy varied by risk level, with patients at high risk more likely to receive a recommendation (90% PCPs, 84% OBGyns, 86% CARDs) and about one third of physician recommending aspirin therapy for low-risk patients (Appendix 2).9 The most frequently recommended dose was 81 mg. However, one third of PCPs and CARDs recommended 325 mg for the high-risk patient, despite guidelines suggesting a dose range of 75 to 162 mg daily.
Lipid, Diabetes, and Blood Pressure Management
Most PCPs (92%) and CARDs (90%) recommended further antihypertensive drug therapy for high-risk patients who were already on ;-blocker therapy and had a blood pressure of 140/95 mm Hg (Table 5); OBGyns were less likely to do so compared with either PCPs or CARDs (69%, P<0.01). Similar trends were observed for intermediate-risk cases. The most frequently recommended medication to manage hypertension was ACE inhibitors or angiotensin receptor blockers, followed by diuretics, although national guidelines suggest that diuretics should be part of the antihypertensive drug regimen for most patients unless contraindicated. Calcium channel blockers were more commonly recommended as antihypertensive therapy in the intermediate- compared with the high-risk group.
Framingham/ATP III Risk Versus Perceived Risk
Physicians’ perceptions of patients’ risk levels were compared with calculated risk category based on ATP III Framingham risk scores, stratified by patient gender and physician specialty.11 Among PCPs, 34% correctly categorized low-risk male patients, 47% correctly categorized intermediate-risk male patients, and 59% correctly identified high-risk male patients. A similar trend was seen for PCPs’ evaluation of female patients (43%, 47%, and 55%, respectively).
Among OBGyns, 19% correctly identified male patient’s risk as low, 41% correctly categorized intermediate-risk patients, and 43% correctly categorized high-risk patients. In their assessment of female patients’ risk, OBGyns’ accuracy rates were 17%, 38%, and 37%, respectively. CARDs correctly categorized low-risk male patients 29% of the time, 51% correctly categorized intermediate-risk male patients, and 58% correctly identified high-risk male patients. A similar trend was seen for CARDs’ evaluation of female patients’ risk level (36%, 53%, and 56%, respectively).
Data on determinants of physicians assigning increasing risk levels among patients calculated to be at intermediate and high risk as defined by NCEP ATP III reveal a significant influence of patient gender on assignment of risk category (Table 6). Intermediate-risk women were significantly less likely to be assigned to a higher-risk category than men with similar risk profiles (OR, 0.62; 95% CI, 0.49 to 0.78) by PCPs, with similar but nonsignificant trends for OBGyns and CARDs. For example, PCPs assigned 20% of women compared with 13% of men to the low-risk category with the same risk profile (65 years of age, nonsmoking, LDL cholesterol of 162 mg/dL, HDL cholesterol of 56 mg/dL, BMI of 27 kg/m2, blood pressure of 118/78 mm Hg, positive family history of premature CHD, and no personal history of CVD).
Guideline Adherence by Patient Risk Level
Physicians’ assessment of the patient as intermediate or high risk significantly predicted recommendations for preventive interventions (physical activity, cardiac rehabilitation, dietary therapy, weight reduction, blood pressure control, lipid management, and aspirin therapy) in the experimental case studies among all specialties combined. After assignment of risk by physician was taken into consideration, older high-risk patients were less likely to receive recommendations for dietary counseling (P=0.03) and weight reduction (P<0.01) and were more likely to receive a recommendation for aspirin therapy (P=0.05) than younger patients. As expected, high-risk patients with elevated LDL cholesterol levels were more likely to receive a recommendation for lipid pharmacotherapy (P<0.01) and dietary counseling (P=0.02). Diabetics were more likely to be recommended dietary therapy (P<0.01) and less likely to receive a recommendation for cardiac rehabilitation than patients with CHD (P<0.01). HDL cholesterol levels were not associated with preventive recommendations among the high-risk cases.
Among intermediate-risk cases, increased age was predictive of a physician recommendation for aspirin therapy (P<0.01). As expected, intermediate-risk cases with elevated LDL cholesterol levels were more likely to be recommended dietary counseling (P=0.01) and lipid pharmacotherapy (P<0.01). Similarly, antihypertensive drug therapy was more frequently recommended among cases with elevated blood pressure (P<0.01). After adjustment for physician assignment of risk level, women calculated to be at intermediate risk by NCEP ATP III received significantly more recommendations for weight reduction (P=0.04) and less frequent recommendations for aspirin therapy (P<0.01), suggesting that factors beyond perceived risk may also contribute to gender differences in some therapeutic choices.
Among the low-risk cases in which only gender varied, sex was not a significant predictor of recommendations for CVD preventive therapy.
Physician Effectiveness and Barriers to Adherence
Physicians in this study did not rate themselves as very effective in their ability to help patients prevent CVD and manage risk factors (Table 7). In particular, OBGyns did not rate themselves as very effective in helping patients achieve lifestyle change such as weight management, smoking cessation, and physical activity and felt less effective in managing lipids, controlling blood pressure, and preventing heart disease in their patients compared with PCPs and CARDs.
Twenty-six percent of PCPs, 11% of OBGyns, and 28% of CARDs reported having a system in place to track patient adherence to prescription regimens, with OBGyns being less likely to have such a system (P<0.05). Of those who reported having a system to track patient’s medication adherence, most cited a standard query at the patient’s visit as the method used.
Many physicians reported that they are willing to seek additional training that will allow them to better engage in preventive health treatment for CVD in women, with the greatest enthusiasm among OBGyns. Despite documentation that more women die of CVD each year than men, surprisingly few physicians (<1 in 5) from any of the specialties strongly agreed or agreed with that fact.
Discussion
Two main findings from this national study were that recommendations for CVD prevention were driven by risk level assignment and that women were more likely than men to be assigned a lower-risk category despite a similar calculated risk. These data are concordant with a study by Shulman et al,16 which found that gender independently influenced how physicians managed chest pain. In that study, PCPs were given a computerized survey instrument incorporating taped interviews of actors portraying patients and asked to assess risk and to make recommendations about further care. Physician estimates of the probability of CHD were lower for women, and despite adjustment for estimate of probability of disease, level of coronary risk, and presenting symptoms, women were less likely to be referred for diagnostic cardiac catheterization. Both studies suggest that improving physician assessment of CHD risk may be an important educational target to reduce sex-based disparities in care.
Our study also showed that awareness and incorporation of CVD prevention guidelines differed by type of physician. OBGyns were substantially less aware of national guidelines for cholesterol and blood pressure management than PCPs, consistent with a lower reported rate of incorporation into their practice and lower self-reported effectiveness in managing major CHD risk factors and preventing heart disease. Because OBGyns in our study reported that they provided primary care to 67% of their patients, they can play a vital role in assessing and managing CVD risk among women. It was encouraging that most OBGyns in our study were willing to adopt guidelines published by professionals outside their specialty. The American College of Obstetrics and Gynecology was a major cosponsor of the AHA evidence-based guidelines for CVD prevention in women, and our data show that OBGyns were more aware of these guidelines than JNC 7, suggesting that partnerships to develop and disseminate female-specific guidelines may be an effective strategy to improve the quality of preventive care.
According to our study, fewer than two thirds of physicians recommended physical activity to low-risk patients, and only about half advised dietary counseling. This finding is similar to that of the National Ambulatory Medial Care Survey, which found low rates of lifestyle counseling in practice that was worse for women than men.8 An educational opportunity exists for all physicians to encourage lifestyle strategies to prevent the development of risk factors that may require more intensive therapy later. We also observed significant prospects to improve adherence to national guidelines for lipid management, especially among the high-risk patients who are most likely to benefit. Recently, statin therapy has been recommended for high-risk patients regardless of LDL cholesterol level,9,11 yet only about half of OBGyns recommended such therapy when treating high-risk patients. Similarly, the AHA women’s guidelines recommended niacin or fibrate therapy when HDL-cholesterol was low or non–HDL-cholesterol was elevated among high-risk women, and only one third of OBGyns recommended such therapy. Our data also suggest that more education is needed with regard to optimal glucose and blood pressure management.
Barriers to CVD preventive care in our study (lack of time and reimbursement) were similar to other data and suggest that policy makers and insurers need to address systems constraints to better serve public health.10 Although many physicians suggested that the patient was an important barrier to the prevention of heart disease, this may reflect the perceived difficulty in adherence to lifestyle factors that are within the control of the patient and crucial for preventing CVD. A potential sex-specific barrier cited by a large percent of physicians was that results of clinical research conducted in men may not generalize to women, emphasizing the importance of including women in CVD prevention studies to increase adoption of evidence-based guidelines. Finally, a striking finding in our study was a very low level of recognition (8% PCPs, 13% OBGyns, and 17% CARDs) that heart disease kills more women every year than men. According to AHA statistics, nearly 500 000 women die of CVD each year, exceeding the number of men.1 These physician data underscore the need for awareness campaigns about women and heart disease among healthcare providers, especially because awareness of risk is a critical first step in taking action to reduce it.
Our study has limitations. The results may not be generalizable to all physicians because our response rate was low and we did not survey every specialty. However, our data may represent a best-case scenario among full-time practitioners because survey respondents may be more likely to be aware of and adhere to guidelines as a result of selection bias. Our power to evaluate recommendations among low-risk cases was reduced as a result of the limited number of low-risk profiles by design because of cost constraints. The additive effects of risk assignment and independent risk factors on therapy choice were not evaluated in the present analysis. We also lacked the power to examine whether awareness of, adoption of, and barriers to treatment varied by age, gender, or race/ethnicity of the physician. In addition, we conducted multiple analyses without adjusting for statistical testing. Our results will need to be validated in other cohorts and by other study designs.
In conclusion, interventions to raise awareness and adoption of CVD prevention guidelines among healthcare providers are needed. Educational efforts should be targeted to assisting physicians in CHD risk assessment, which may help reduce sex-based disparities in preventive care. Further research into effective strategies to improve physician and patient adherence to CVD prevention guidelines is merited.
Appendix 1
APPENDIX 1. Experimental Patient Cases
Appendix 2
APPENDIX 2. Clinical Recommendations
APPENDIX 2. Continued
Acknowledgments
This research was partially funded by an unrestricted educational grant to the American Heart Association from KOS Pharmaceuticals.
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