Clinicians Commonly Miss Opportunities to Prevent Cardiovascular Disease
By Nancy A. Melville
Medscape Medical News
February 23, 2010 (Crystal City, Virginia) — Clinicians commonly fail to use effective strategies to prevent cardiovascular disease, even when treating patients with the highest risk factors, according to a chart review of North Carolina patients presented here at Preventive Medicine 2010: the Annual Meeting of the American College of Preventive Medicine.
Although 1 of 3 people in the United States die from cardiovascular disease, the country has made significant improvement in the past 2 decades in decreasing mortality rates. Part of the credit goes to advances in technology, treatment, and systems of care for a cardiovascular event, but preventive measures have also played a role, said Annette DuBard, MD, MPH, director of informatics, quality, and evaluation at the North Carolina Department of Health and Human Services in Chapel Hill, and a coauthor of the study.
"There have been big successes on the prevention end, including decreases in smoking and better blood pressure control, but it's clear that there's a lot of untapped opportunity for improvement," Dr. DuBard said.
The study's goal was to identify opportunities for better management of cardiovascular risk in the primary care setting. The researchers conducted a retrospective chart review looking at 3742 Medicaid recipients with diagnosed hypertension managed in a primary care setting in North Carolina.
The findings showed that most of the patients had been with a single primary care provider for at least 3 years and had 5 or more office visits during the previous year. Although most had been screened for diabetes (95%), cholesterol (81.2%), and tobacco use (72.9%), 96% of the patients had at least 1 modifiable risk factor, including obesity.
Blood pressure and cholesterol levels were above desired goals in 52.9% and 37.2% of patients, respectively, yet only 43.9% of those with uncontrolled blood pressure were prescribed 3 or more antihypertensive drug classes, and only 44.3% had had therapy intensified in the previous year.
Only 73% of patients had been screened for tobacco use; among the 45% who were current smokers, only 47% had any documented advice to quit and just 7% had been prescribed a smoking cessation agent.
For patients with documented low-density-lipoprotein (LDL) cholesterol elevations, 37% were above treatment goal, and only half of those had been prescribed any lipid-lowering medication. Documentation of provider response to the lab results for LDL cholesterol levels that were above goal was only seen in a third of cases.
Obesity screening using body mass index or waist circumference showed a rate of 23%. On the basis of extracted height and weight information, 52% of the population was obese.
In the subgroup of 1000 patients with known cardiovascular disease or a greater than 10% risk on the Framingham scale, only 38% had been treated to their blood pressure goal and 50% had LDL cholesterol treatment to below goal. Only 35% of the patients had any notation of a recommendation for aspirin use in the chart.
The researchers checked to see if physicians were perhaps failing to respond when blood pressure levels were only slightly above normal, but they found surprisingly low responses even when rates were high.
"Even at high levels of blood pressure that were more than 40 points systolic or 20 points diastolic above their goal, we still saw medication intervention less than half of the time," Dr. DuBard told Medscape Public Health Prevention.
She theorized that several factors could be behind the shortfalls in preventive care, including clinician inertia and uncertainty about what they're truly dealing with.
"From the literature and my own clinical instincts, I think we know that clinicians are often feeling uncertain about what a patient's true blood pressure is in the office setting," Dr. DuBard said.
"There's also clinician uncertainty about adherence to the regimen that has already been prescribed. We know that about a third of patients have a less than 80% adherence to blood pressure prescriptions, so clinicians are hesitant to increase the dose if they're not sure whether the existing drug regimen is being taken."
Another issue is the multiple comorbidities that patients with high blood pressure tend to have, including mental illness, substance abuse, and chronic pain, which can complicate care.
Another factor could be complacency on the part of clinicians when blood pressure and cholesterol levels are not quite at their goal but almost there, she added.
But the biggest culprit of all is likely the simple issue of time — the limitations of 15-minute visits, Dr. DuBard said.
"I really think the biggest issue is the demand of the 15-minute visit, especially in this kind of patient population, where there are usually a lot of issues to be addressed. The issues that are of lesser urgency are going to fall through the cracks."
"The bottom line is that access to care is clearly only part of the healthcare solution," she added. "These Medicaid patients had excellent access to care and regular visits with their primary care providers. What they didn't have, in many cases, was adequate preventive care for cardiovascular disease."
"The usual care being received by patients in the current system is clearly not good enough and it's unlikely we'll be able to meet our goals of cardiovascular risk reduction if we don't change the way we deliver care," Dr. DuBard said.
She suggested some solutions for improvement: moving beyond approaches that only focus on a single disease and instead considering multiple morbidity models, and using team-based approaches that involve nurses, pharmacies, and between-visit care, she suggested.
Even the simplest of measures — such as prescribing aspirin therapy — can make a big difference, Dr. DuBard said. "The use of aspirin therapy alone (among patients with existing or a risk of heart disease) could be expected to avert between 600 and 1800 cardiovascular events within 5 years," she said.
Although the study's findings offer a discouraging picture of the state of care in cardiovascular disease prevention, they are not, unfortunately, all that surprising, said Michael LeFevre, MD, professor and associate chair of family and community medicine at the University of Missouri Health Care in Columbia.
"I find nothing particularly surprising about the data," he said. "There is irony in the fact that many preventive services that have been shown to be effective are significantly underutilized, and many others with less science to support them are used more frequently."
"The fact that the study is a chart review represents a limitation, but its results are not unexpected," he told Medscape Public Health Prevention.
"There are problems with chart review as a sole means for measurement, and there may be other methodologic issues that are not apparent in the abstract, but the findings are certainly consistent with what we know about the delivery of preventive services," Dr. LeFevre asserted.
The study was conducted by the North Carolina Division of Medical Assistance and did not receive any external funding. Dr. DuBard and Dr. LeFevre have disclosed no relevant financial relationships.
Preventive Medicine 2010: the Annual Meeting of the American College of Preventive Medicine (ACPM): Abstract?212702. Presented February?19, 2010.