Cardiovascular Round Table Taskforce 4 Factors Impeding the Practical Implementation of Cardiovascular Prevention An international market research project

Cardiovascular Round Table Taskforce 4Cardiovascular Round Table Taskforce 4

Factors Impeding the Practical Implementationof Cardiovascular Prevention

An international market research project in 6 countries:Germany, France, Italy, Spain, the United Kingdom and Poland

This study was commissioned byEuropean Society of Cardiology (ESC)

Cardiovascular Round Table (CRT)Task Force 4

Sponsors: AVENTIS / BAYER / BOSTON SCIENTIFIC /GLAXOSMITHKLINE / NOVARTIS / MERCK-SCHERING PLOUGH / PFIZER

The study was carried out by Psyma International:

Alexander RummelMonica Bach

Dr. Britta Meyer-Lutz

Study No: 41057021December 2002

Psyma International MedicalMarketing Research GmbH

Gartenweg 290607 Rückersdorf/Nürnberg

Germanyphone: +49-911-95 785-0fax: +49-911-95 785-33

e-mail: [email protected]: www.psyma-international.com


Main Objectives

To understand the practical hurdles of CV risk prevention in daily practice.

Identify how physicians assess and manage risk

Obtain baseline data on guideline usage

Reveal barriers why guidelines are not applied

Determine what changes can be made to make them more readily adopted


Methodology Sampling

D F I E UK PL

F2F in-depth interviews Total n = 30 50 50 30 30 30220

PCPs 21 35 35 21 21 21 154

Cards 9 15 15 9 9 9 66

Focus groups Total n = 2 2 1* 1* 6

PCPs 9 - - 7 9 10

Cards 7 - - 7

* PCPs only

ED F I


Screening Criteria

Work in outpatient care

< 60 years of age

Practicing as a PCP or cardiologist > 3 years

Must initiate drug treatments for patients presenting or at risk of CV disease

Work full-time (i.e. > 6 hrs per day)

Not participating in clinical trials on CV disease

Not working as a CV consultant for the pharmaceutical industry

GPs only

Must see and treat patients in at least 4 different indication areas


Assessing Patients for CHD/ CV Risk

Q. 13./15. Discussion Guide - Focus Groups

UK E D PL

medical history high blood sugar/

diabetes lipids urine tests Framingham guidelines

medical history HDL LDL triglycerides glycemia

personal experience age dyslipidemia occasional use of scores

(Card) gender (Card)

patient's appearance age

E D

All physicians ...

simple questioning + examining lifestyle (e.g. smoking, drinking, exercise)

measure BP

cholesterol tests

weight

PLUS


Patient Types Perceived at Greater Risk of a CHD/ CV Event

Q. 5.c (o); Base: n = 220 physicians in 6 countries; responses < 8% not included

54%

42%

34%

26%

26%

25%

20%

16%

10%

Diabetics

Smokers

Hypertension

Overweight

Dyslipidemia

Combined risk factors

Family history

Middle-aged/ elderly

Patient's cardiac history

UK: 73%

UK: 71% PL: 20%

UK: 13%PL: 10%

F: 62% E: 13%UK: 10%PL: 3%

E Card: 44%

Combined risk factors


"Total" or "Global" Risk on CHD/ CV Risk Prevention

Q. 5.d (o); Base: n = 220 physicians in 6 countries

What do these terms mean to physicians?

PL: 67% UK: 20%

PL PCPs: 32%

D: 43% I: 2%UK: 50%

48%

19%

12%

7%

25%

Sum of severalrisk factors

Risk of a futureCV event

Global andtotal risk differ

Severity of riskfactors

n.a./ d.k.

"Patients already suffering from coronary diseases" (E Cards)


"Total" or "Global" Risk

25% of target sample don't know or can't explain terms

D 43%

UK 50%

EDUCATIONAL NEED


"Total" or "Global" Risk on CHD/ CV Risk Prevention

Q. 5.d (o); Base: n = 220 physicians in 6 countries

VERBATIMS

SUM OF RISK FACTORS

"... it's a group of factors which is important and not each factor taken individually ..."

"... it's ignoring the value of individual risk factors and using a table or calculator estimating the effect of interactions of the various risks ..."

"... means the possibility to become ill as a result of an accumulation of risk factors ..."

RISK OF FUTURE CV EVENT

"... total means an individual risk of major cardiac events over 10 years ..."

"... risk of an CV event within 5 years ..."

SEVERITY OF RISK FACTORS

"... we don't use these terms - we use high, moderate or low risk ..."

"... risk > 20% of developing CV events ..."


Assessment of CV Risk

85% physicians base assessment on all the risk factors (D Card: 44%)

E Card: 56%

E PCPs: 33%UK PCPs: 38%

Why?

38%

34%

24%

14%

13%

13%

Accumulation of risks/synergetic effect

Global approach

In certain combinations

Individual assessment of eachfactor

According to guidelines

To individualize therapy

Q. 6.a (c), 6.b (o), 8. (o); Base: n = 220 physicians in 6 countries; responses < 8% not included


Risk Factors Considered when Assessing CV Risk

Q. 7.a (c); Base: n = 220 physicians in 6 countries; responses < 15% not included

Spontaneous - Unprompted

86%

84%

84%

84%

66%

58%

44%

31%

30%

Hypertension

Dyslipidemia

Smoking

Diabetes

Family history

Overweight

Age

Sedentary lifestyle

Gender

UK: 100%

UK: 100%

E: 47%

PL Cards: 75%

PL Cards: 63%


Recall increases when prompted

Risk Factors Considered when Assessing CV Risk

Q. 7.b (c); Base: n = 220 physicians in 6 countries; responses < 15% not included

Prompted 100%

99%

97%

97%

93%

88%

81%

69%

66%

54%

38%

Smoking

Hypertension

Diabetes

Dyslipidemia

Family history

Overweight

Age

Sedentary lifestyle

Gender

Stress level

Alcohol use

(66%)

(58%)

(44%)

(31%)

(30%)

(15%)

(8%)


Why Special Attention is Required with Specific Risk Factor Combinations

Q. 9.c (c); Base: n = 220 physicians in 6 countries

Hypertension + diabetes (n=28)

Smoking + hypertension + diabetes (n=20)

Smoking + hypertension + dyslipidemia (n=19)

They are the worst combination

Development of arteriosclerotic/ vessel damage

"Diabetes" in a combination is an important risk factor

Statistical data

Interactions/ synergistic effect


Treatment Goals for Persons at High Risk of a CV Event (Overview)

Q. 13. (o); Base: n = 220 physicians in 6 countries; responses < 9% not included

Hypertension Dyslipidemia Weight Management

65%

31%

8%

8%

Values below 140/90

BP stabilization in general

BP values in diabetics lowerthan in other patients

weight reduction/ diet

39%

32%

14%

11%

10%

Reduction of LDL values asrecommended

Reduction of total cholesterol- values as recommended

Normalizing lipid levels (ingeneral)

Increase of HDL - values asrecommended

Reduction of LDL (in general)

45%

37%

10%

10%

Weight normalization

BMI < = 25

BMI - value higher thanrecommended

Balance diet


Factors Perceived Most Important/ Concerning in CV Risk Assessment


Prompted list of 11 Factors:

82%

77%

70%

69%

36%

33%

21%

18%

Diabetes

Hypertension

Smoking

Dyslipidemia

Family history

Overweight

Age

Gender

PL: 40%

PL: 7%

F: 88% UK: 43%E: 93% PL: 27%


Preferred Method for Total Risk Assessment

Q. 18. (c); Base: n = 220 physicians in 6 countries

77%

88%

68%

30%

77%

58%

72%

33%

22%

34%

73%77%

20%

43% 43%

33%

D F I E UK PL PCPs Cards

Subjective assessment of factors Specific guidelines/ risk calculators

Int'lAvera

ge62%

ED F I

77%

88%

68%

30%

77%

58%

72%

33%

22%

34%

73%77%

20%

43% 43%

33%

D F I E UK PL PCPs Cards

Subjective assessment of factors Specific guidelines/ risk calculators

ED F I

Int'lAvera

ge43%

Other: 7% - 6% 3% 3% 3% 4% 4%


2.Awareness/ Usage of

Guidelines


Awareness of CV Risk Prevention Guidelines

Q. 19.a (o); Base: n = 220 physicians in 6 countries; responses < 9% not included

52%

26%

14%

10%

10%

National cardiologic guidelines

Scoring systems/ scales

National guidelines on metabolicdisturbances

WHO guidelines

None


I PCPs: 43%

D PCPs: 33%

6% of physicians mention ESC guidelines (D Cards: 22%; E Cards: 22%)


Where did physicians find out about these guidelines?

Q. 19.b (o); Base: n = 220 physicians in 6 countries; responses < 6% not included

National cardiologic guidelinesn = 93

Scoring system/ scalesn = 47


n = 26

32%

17%

11%

8%

Literature/ magazines/books

Sent/ published directly

Congresses

Internet

37%

21%

11%

11%

9%


Pharmaceuticalcompanies/ sales reps

Internet

Lectures/ training


35%

10%

10%

8%



Congresses

Lectures/ training

40% don't know/ n.a. 13% don't know/ n.a. 39% don't know/ n.a.


Physicians Viewpoints on Guidelines(country-specific)

Q. 18.a - 20. Discussion Guide - Focus Groups

UK E

All say the same thing NSF is the official document New Zealand tables are strong favorites

Very aware of guidelines on CHD prevention Strong users

PL D

Doctors follow different guidelines Too many specific guidelines - should include

treatment of more conditions in one

They provide a general basis for treatment Names of guidelines & publishers unimportant

(PCP) Cards have easier access to guidelines Scores generally not used, viewed as pseudo-

scientific (PCPs)

E

D


Guidelines Currently Used

Q. 19.c (o); Base: n = 220 physicians in 6 countries; responses < 5% not included

45%

21%

14%

9%

8%

19%

National cardiologic guidelines

Scoring systems/ scales


"Unspecific" guidelines on metabolicdisturbances

WHO guidelines

None


I PCPs: 37%

D PCPs: 52%F PCPs: 46%

4% of physicians use ESC guidelines (D, Cards: 22%)

Usage corresponds with awareness


Usage of Guidelines when Assessing CV Risk

Q. 24., 25. (c); Base: n = 220 physicians in 6 countries

41%

21%

19%

18%

... use a combination of guidelines withpersonal experience

... use individual guidelines withmodifications

... use guidelines as specified

NEVER USE

Physicians ...

59% of physicians use routinely/ 20% only on occasion

I: 70% D: 10%

E: 43%

D PCPs; 48%F PCPs: 43%


Reasons for Not Using CV Risk Prevention Guidelines

Q. 19.c, 22. (o); Base: only physicians not using guidelines (n=34)

19% of physicians indicate not using CV risk prevention guidelines

Doesn't fit to my patients

Decide according to my own experience

Difficult to use/ values often change

Don't trust them

Not used by colleagues

Used guidelines in the past


Obstacles Preventing Usage and Implementation

Q. 20./21. Discussion Guide - Focus Groups

UK E

Lack of resources Lack of government support Preventive medicine & education is dull Bad influence of advertising & media

Too much information Not well distributed Gap between guide & reality Transparency of guideline source lacking (who

sends them out?)

PL D

Patient compliance lacking Too much information Clarity lacking Medical progress not reflected in guidelines

Gap between guide & reality Economics Health system Most results of clinical trials are sponsored by the

pharmaceutical industry

E

D

TIME & COST OF PREVENTIVE MEDICINE


Improving Guidelines to Increase Future Use

Q. 25./26./27. Discussion Guide - Focus Groups

Easy to understand & easy to use

Include back-up data of latest scientific studies

Regular updates

Short

Realistic - possible to implement

Clear objectives - quick to implement

Solve gap between prevention (doctors) and lack of awareness (population)

Universal

Source must be credible & trustworthy


Improving Guidelines to Increase Future Use(country-specific)

Q. 25./26./27. Discussion Guide - Focus Groups

UK E

Gov't initiatives, i.e. encourage more sports, taxjunk food, increase tax on cigarettes

Accurate Validated Approved by NICE nationally Approved by PCT locally Provide cost effective treatment/ advice Appealing Provide expiry date IT compatible

Adapted to Spanish-mediterraneen patients Schematic therapy schemes

PL D

Patient education Inexpensive Studies based on local population

Show potential for cost reduction Wide use possible Define risk levels Recommendations on optimal therapy Recommendations on expensive medications Access via Internet

E

D


Barriers Preventing Physicians fromImplementing CV Guidelines (unprompted)

Q. 30. (o), 16.b (o); Base: n = 220 physicians in 6 countries; responses < 8% not included

36%

23%

21%

20%

15%

Patient compliance

No time

Too theoretical - individual treatmentnecessary

Financial barriers

Complicated to use

E: 50%

UK Card: 44%

D Card: 44%PL: 67%

UK Card: 44%E Card: 33%


Most Important Barriers in the Implementationof CHD Prevention Guidelines


Scale: 1 "small/ unimportant" - 10 "large/ very important"Top Box 8 - 10

[19 prompted statements]

40%

36%

30%

27%

23%

20%

Government health strategy does nothelp in prevention

There is little or no financial reward forprevention

Budget constraints prevent me ...

Don't have time with each patient ...

Hospital/ local policies do not help

Patients not motivated

PL: 77% F: 16%

PL: 93%D: 57%

D: 60% F: 8%PL: 67% E: 10%

PL: 70%


Barriers Preventing Proper Assessment of CV Risk

Q. 12./12.a Discussion Guide - Focus Groups

In all countries TIME LIMITATIONS is the main barrier

also ...

Consultations not rewarded sufficiently

Lack of resources

Discrepancy between goals and reality

Depends on patients (emotional/ social aspects)

Patients non-compliant in changing lifestyle (unmotivated)

Situation difficult in rural areas (PL)

Financially weak patients (cost) (PL)

Public healthcare patient does not stay with one doctor (PL)

Insufficient availability of tests (PL/ D)

"Working time must be paid" (D)"Secondary prevention is easier because there are obvious conditions to treat" (PL)


Barriers are Important because ....

Q. 31.b (c); Base: n = 220 physicians in 6 countries

There is little or no financial reward for prevention as opposed to treatment in my healthcare system

No extra payments for prevention Not enough money in the healthcare system Lack of incentives/ campaigns to support patients in prevention

Budget constraints prevent me from implementing guidelines for all patients

Budget problems with prescribing drug"... if one wanted to comply to the guidelines we would run into big problemsin regards to the budget ..."

Treatment only at high risk Impossible to implement prevention for all patients Lack of money for screening examinations


Barriers are Important because ....

Q. 31.b (c); Base: n = 220 physicians in 6 countries

I don't have time with each patient to undertake practical prevention Prevention is time intensive Too many patients Need time to motivate patients

"... it is difficult to find time for patients if there is a crowd of patients in thewaiting room ..."

"... I have too many patients, therefore I focus on the ones with the most important risk factors ..."

Hospital/ local policies do not help me to develop prevention No cooperation between docs & hospital No prevention in hospitals/ only treatment of urgent cases Rising costs are limiting

"... Patients always have to become really sick before anything happens andthen things become really expensive ..."

"... local policy means reduction of examination costs ...""... they are not interested because they are more involved in treating acute events ..."


Most Important Aspects in Making Practical Prevention Easier

Q. 33. (c); Base: n = 220 physicians in 6 countries; responses < 37% not included

Scale: 1 "would not make it easier at all" - 10 "would make it a lot easier"Top Box 8 - 10


46%

46%

46%

45%

44%

43%

41%

Simpler guidelines

More nursing staff trained in prevention

More medical colleagues trained inprevention

Shorter guidelines

Developoment of shared care proramsbetween GPs & consultants

Regular newsletters or updates

Workshops to help develop skills &prevention strategy

E Card: 89% F: 8%UK: 73%PL: 87%

PL: 93%

E: 70%

PL: 80%

PL: 90%


Most Important Aspects in Making PracticalPrevention Easier (2)

Q. 33. (c); Base: n = 220 physicians in 6 countries

Scale: 1 "would not make it easier at all" - 10 "would make it a lot easier"Top Box 8 - 10


37%

37%

32%

29%

11%

Wider availability of paper-based risk charts& guidelines

Risk calculators

Computer based risk charts

Computer based risk charts with interactivityto lead into management recommendations

Other aspects, i.e.

PL Card: 63%

UK Card: 67%

UK: 60%

E PCP: 48%

Simpler, shorter, more training

more time neededsee less patientsSpanish risk charts, protocols and guides


Most Influential Sources on (New) Guidelines (prompted)

Q. 36. (c); Base: n = 220 physicians in 6 countries; multiple choice; responses < 5% not included

82%

70%

34%

29%

29%

21%

11%

Medical journals/studies

Medical conferences

Sales reps

Medical societies

Colleagues/ opinionleaders

Internet

Newspapers

UK: 57%

E: 40%


SUMMARY

CHD ASSESSMENT• Awareness that global risk approach is necessary to assess risk, yet physicians don’t fully understand the principle and they revert back to individual risk factor assessments

GUIDELINES• National guidelines are the predominant reference for recommendations• Uniform recognition of guidelines seem linked to a clearer source and consistency of guidance• Current use & understanding of guidelines does not necessarily translate into an understanding of the principles of global risk• Scoring systems seem to convey global risk more directly

Many BARRIERS TO IMPLEMENTATION

FUTURE AREAS OF FOCUS• Different countries may require focus on slightly different areas of implementation• Improving implementation goes beyond just developing a new set of guidelines

Documents

Cardiovascular Round Table Taskforce 4 Factors Impeding the Practical Implementation of Cardiovascular Prevention An international market research project