Abstract
Introduction
Cardiovascular disease (CVD) is not only the most widespread chronic illness in the United States, but it is also the leading cause of morbidity and mortality, accounting for 33% of all deaths. 1 It has caused a significant burden on the health care system and, thus, has become an increasingly important issue to address in order to reduce costs and improve quality of life. CVD risk reduction has a strong behavioral component, which emphasizes the adoption of healthy lifestyle behaviors. 2 Therefore, patients at increased risk for CVD benefit not only from standard pharmacotherapy but also from physician counseling regarding lifestyle behavioral changes such as nutrition, weight loss, and exercise. With recent technological and medical advancements, identification of those at risk has become easier. Previous studies in the late 1990s showed a lack of awareness on the part of the medical community to identify and counsel those at highest risk.3,4 Recent evidence has shown that risk reduction is the result of excellent medical and pharmacological management, but just as importantly, due to lifestyle changes initiated and supported by physicians. 2 This study examined the frequency of nutrition and exercise counseling among a high risk population, as well as the patient factors that influenced physicians’ provision of counseling to improve cardiovascular risk.
Methods
Patient Selection
Subjects included 388 inner city and rural individuals at increased risk for CVD who participated in a study to evaluate 2 methods of CVD risk surveillance and communication regarding risk improvement. The study was conducted at Temple University Hospital, which serves an inner city, predominantly African American population, and at Geisinger Medical Center, which serves a rural, predominantly white population. Subjects were recruited from outpatient populations of both institutions, as well as through flyers and presentations at local churches and community centers. Individuals were classified by race/ethnicity by survey, with the options being defined by the investigators.
Subjects were between 18 and 85 years of age, with a 10% or greater Framingham 10-year risk of CVD (This study was conducted prior to the release of ATP 4). All subjects were able to read and had access to a telephone. Exclusion criteria included overt coronary artery disease, class 3 or 4 heart failure, and angina, as the study was designed to detect the counseling, or lack thereof, provided to patients at risk for these conditions. We also excluded patients with significant cognitive deficits from stroke or dementia, end-stage renal disease on dialysis, subjects living in nursing homes or boarding homes, and pregnancy. All subjects were instructed on the nature of the study and signed an informed consent. The original trial was approved by the institutional review boards at Temple University Medical School and the Geisinger Medical Center.
Baseline Assessment
The subjects had an initial medical history, physical examination, and electrocardiogram performed. Baseline assessments included weight, height, waist circumference, and blood pressure. The laboratory evaluation included fasting blood glucose, A1c, and lipid profile that included total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides. All subjects underwent a formal assessment of CVD risk using the Framingham risk assessment model, which incorporates nonmodifiable (age, sex) and modifiable (blood pressure, cholesterol, HDL, smoking status, and diabetes) risk factors to determine the subject’s 10-year risk of CVD. Subjects were followed for 1 year and were seen for quarterly assessments, where they completed questionnaires regarding recommendations made by their primary physicians regarding lifestyle behaviors, specifically diet, weight loss, and exercise (see Supplementary Material available at http://jpc.sagepub.com/content/by/supplemental-data). Details of the specific counseling provided by patients’ primary care physicians were not available for our study, as we only collected qualitative data via questionnaire. Out of the 388 subjects who completed the study, 371 (95.6%) completed the questionnaire. The characteristics of the group with missing survey data was similar compared with those who completed the survey.
Results
Data from 388 patients (84%) who completed the study are included in the analysis. The demographics of the patients recruited into the study are reflective of the urban population of Philadelphia and the rural population of central Pennsylvania (Table 1). This cohort was retrospectively analyzed to determine the impact of individual patient risk factors (weight, body mass index [BMI], blood pressure, lipid levels, and glucose status) on physician provision of lifestyle counseling. The average age of patients was 61 years with a mean BMI of 32 m/kg2. Fifty-four percent of the subjects were males, one-fourth of the patients smoked cigarettes and almost one-half (46%) carried a diagnosis of diabetes mellitus. Mean blood pressure was 146/82 mm Hg, and mean LDL was 121 mg/dL. The average Framingham risk score was 17.6% (Table 2). Forty-three percent of the subjects earned less than $25 000 annually, while 45% earned between $25 000 and $55 000. One-half of the subjects had some college education, while 8.5% did not complete high school.
Patient Demographics.
Patient Baseline Measurements.
Abbreviations: HDL, high-density lipoprotein; LDL, low-density lipoprotein.
The distribution of BMI measurements of all patients participating in the study reflects the prevalence of obesity in our population (Figure 1). Most subjects (85%) were at least overweight, with a significant proportion being obese and morbidly obese (55%). The frequencies of nutritional and exercise counseling offered by primary care physicians were recorded (Figures 2 and 3). In general, both types of counseling were provided with similar frequency, with about one-third of subjects reporting they rarely or never received counseling and less than 40% of subjects recalled being counseled either often or on every visit.
Body mass index (BMI) distribution in 388 subjects.
Frequency of nutritional counseling obtained by questionnaire in 388 subjects.
Frequency of exercise counseling obtained by questionnaire in 388 subjects.
We analyzed the clinical factors that affected physician counseling regarding diet and exercise using a binary logistic regression model. BMI (P < .025, odds ratio [OR] = 1.073, CI = 1.02-1.13) was the only clinical factor that prompted physicians to provide nutritional counseling. Other clinical factors such as systolic blood pressure, LDL cholesterol, A1c, or Framingham risk score showed no correlation (Table 3). There was no correlation observed with any of the mentioned markers of CVD with respect to exercise counseling.
Binary Logistic Regression Coefficients for Patient Factors as Predictors of Physicians Providing Exercise Counseling.
Discussion
With the high prevalence of CVD in the United States, the importance of CVD risk factor modification cannot be understated. In fact, at the turn of the past decade, 34% of deaths attributable to CVD occurred before the age of 75 years, which is well before the average life expectancy of 78.5 years in 2009. 1 While cardiovascular risk is attributable to several nonmodifiable risk factors such as age, family history, and gender, altering modifiable risk factors such as physical activity, hypertension, cigarette smoking, hyperlipidemia, and diabetes can produce significant reduction in cardiovascular risk. 5 We undertook a retrospective analysis to examine which patient characteristics and risk factors affected clinicians’ provision of counseling. Our cohort of patients represented an intermediate and high risk group of patients without overt CVD. We found that only patients’ BMI had a statistically and clinically significant correlation with physician counseling, even though virtually all of the modifiable risk factors were substantially elevated in these subjects. Thus, only the visual cue of obesity, even in the face of overtly abnormal blood pressures, lipid panels, and fasting blood sugars, resulted in physicians providing nutrition and weight loss counseling. Kreuter and colleagues 6 also made a similar observation in their questionnaire-based study, finding that having a high BMI was the strongest predictor of receiving counseling (OR = 1.6, 95% CI = 1.2-2.0). Their cohort of 915 patients from a community-based Missouri population also included a significant proportion of patients with diabetes, hypertension, hyperlipidemia, and obesity. They concluded that physicians’ advising may be guided by “quick but fallible heuristics that systematically exclude patients whose needs are not easily visible.” 6 Fifteen years later, we are unfortunately drawing the same conclusions.
There are countless landmark studies indicating that medical therapy for risk factor modification results in significant survival benefit.7-12 More recently, Ford et al 2 applied the IMPACT statistical model13,14 to calculate the age-adjusted rate of death from coronary artery disease between the years 1980 and 2000. The death rate for coronary heart disease fell from 542.9 to 266.8 deaths per 100 000 men and from 263.3 to 134.4 deaths per 100 000 among women, resulting in 341 745 fewer deaths from coronary heart disease in 2000. Surprisingly, medical therapy accounted for 47% of improved CVD mortality, while lifestyle changes attributed to 44% of the CVD mortality benefit. 2 This pattern has also been validated in similar studies from other industrialized countries.13-17 Despite the reductions in deaths from coronary artery disease due to risk factor modification, two risk factors have contributed an increase in CVD mortality. The prevalence of diabetes and obesity has led to an additional 60 000 deaths over this time period. Indeed, in every year since 1995, the prevalence of diagnosed diabetes has increased, with a 25% increase since 2005, 18 with about 20 million Americans carrying a diagnosis of diabetes mellitus in 2010 and an estimated 8.2 million remaining undiagnosed.1,18 It is more important than ever to use both the medical resources at our disposal and counseling to combat these epidemics.
However, there remains a gap between the identification of those at highest risk and the introduction of lifestyle counseling to promote risk factor modification. In fact, McGlynn et al 19 in 2003 demonstrated that patients actually receive about half of the recommended care for chronic medical conditions, including overt CVD. This gap in both primary and secondary prevention continues to exist, despite initiatives by both the federal government and private health care delivery systems to improve care. Ratanawongsa and colleagues 20 looked at patient-physician communication and its effect on various outcomes in a cross-sectional analysis of 9377 diabetic patients in northern California. Using the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) score, they found that with each 10-point decrease in the survey score (range 0-100), poor patient medication refill adherence increased by 1.6% (P < .001). Even after adjusting for confounders, prevalence of noncompliance increased by 0.9% (P = .01). Compared with patients offering higher ratings, patients who gave lower ratings for health care providers’ involving patients in decisions, understanding patients’ problems with treatment, and eliciting confidence and trust were more likely to have poor adherence. It appears that patient perceptions of poor communication with their health care providers was modestly predictive of inadequate adherence, in this case medication compliance, and thus a worsening in their cardiovascular risk. This is consistent with prior studies that have observed the same relationship.21-24 Calfas et al 25 evaluated the efficacy of physician-based counseling to increase physical activity in sedentary patients in a nonrandomized study. A total of 255 apparently healthy patients that lived sedentary lifestyles were recruited from 17 physician offices. Those patients selected to be in the interventional group received 3 to 5 minutes of structured counseling regarding physical activity during a well visit. In addition, a health educator made a “booster phone call” to the patients in the interventional group 2 weeks after receiving the counseling. Self-reported physical activity was collected at baseline and 4- to 6-week follow-up. They found that the intervention patients had increased walking compared with the control patients (+37 vs +7 min/wk). In addition, they reported that the intervention patients demonstrated a greater increase in readiness to adopt activity compared with the control patients.
Clearly, physicians must augment their arsenal of pharmacotherapy with appropriate counseling and communication. To this point, the ACC/AHA jointly released guidelines, which were endorsed by numerous associations, to help guide physicians in reducing cardiovascular risk. 26 Unfortunately, even though these tools are available, physicians are not taking advantage of them. Patient-centered communication behaviors, on the other hand, include core strategies by which clinicians can engender patient trust, which enhances patients’ adherence by promoting self-efficacy.20,27,28 Perhaps more importantly, this would allow clinicians to include and engage patients in self management through collaborative goal setting and action planning, thus fostering shared decision making. Applying these principles to all patients at risk, prior to the onset of overt cardiovascular disease, is paramount.
Conclusion
In an aging population with a high incidence of chronic medical conditions that affect cardiovascular mortality, physicians need to be more adept in preventing and modifying these risk factors for CVD. The traditional mantra of secondary prevention strategies and prescription therapy is only half of the battle. Our data suggest that the patient-physician relationship is limited by the physician’s own bias and/or perception of the patient. The patient’s weight was found to be the major factor associated with the provision of patient counseling by physicians. We are missing important opportunities to influence behavior and reduce cardiovascular risk factors in patients at high risk for CVD by limiting our focus only to obese subjects. Instead, the focus must be placed on patient-centered communication and lifestyle counseling to every patient at risk for cardiovascular disease.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.