Clinical Gaze in Risk-Factor Haze: Swedish GPs' Perceptions of Prescribing Cardiovascular Preventive Drugs

Åby Health Care Centre, County Council of Östergötland, Department of Medical and Health Sciences, General Practice, Faculty of Health Sciences, Linköping University, 581 85 Linköping, Sweden.
International journal of family medicine 11/2012; 2012(3):612572. DOI: 10.1155/2012/612572
Source: PubMed


Aims. To explore general practitioners' (GPs') descriptions of their thoughts and action when prescribing cardiovascular preventive drugs. Methods. Qualitative content analysis of transcribed group interviews with 14 participants from two primary health care centres in the southeast of Sweden. Results. GPs' prescribing of cardiovascular preventive drugs, from their own descriptions, involved "the patient as calculated" and "the inclination to prescribe," which were negotiated in the interaction with "the patient in front of me." In situations with high cardiovascular risk, the GPs reported a tendency to adopt a directive consultation style. In situations with low cardiovascular risk and great uncertainty about the net benefit of preventive drugs, the GPs described a preference for an informed patient choice. Conclusions. Our findings suggest that GPs mainly involve patients at low and uncertain risk of cardiovascular disease in treatment decisions, whereas patient involvement tends to decrease when GPs judge the cardiovascular risk as high. Our findings may serve as a memento for clinicians, and we suggest them to be considered in training in communication skills.

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Available from: Josabeth Hultberg, Nov 11, 2014
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    • "Our findings suggest that GPs’ perceptions of patients’ risk, motivation and anxiety determine whether GPs use a shared decision making approach, rather than a general tendency to use shared decision making versus paternalistic styles across all patients. This is in line with another qualitative study that found GPs ‘decide who decides’ depending on the level of risk and anxiety of the patient [27]. If the patient was judged to be lower risk, the GP was more likely to actively involve them in treatment decision making, unless they were perceived as being too anxious to decide. "
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    ABSTRACT: Background: Cardiovascular disease (CVD) prevention guidelines encourage assessment of absolute CVD risk - the probability of a CVD event within a fixed time period, based on the most predictive risk factors. However, few general practitioners (GPs) use absolute CVD risk consistently, and communication difficulties have been identified as a barrier to changing practice. This study aimed to explore GPs' descriptions of their CVD risk communication strategies, including the role of absolute risk. Methods: Semi-structured interviews were conducted with a purposive sample of 25 GPs in New South Wales, Australia. Transcribed audio-recordings were thematically coded, using the Framework Analysis method to ensure rigour. Results: GPs used absolute CVD risk within three different communication strategies: 'positive', 'scare tactic', and 'indirect'. A 'positive' strategy, which aimed to reassure and motivate, was used for patients with low risk, determination to change lifestyle, and some concern about CVD risk. Absolute risk was used to show how they could reduce risk. A 'scare tactic' strategy was used for patients with high risk, lack of motivation, and a dismissive attitude. Absolute risk was used to 'scare' them into taking action. An 'indirect' strategy, where CVD risk was not the main focus, was used for patients with low risk but some lifestyle risk factors, high anxiety, high resistance to change, or difficulty understanding probabilities. Non-quantitative absolute risk formats were found to be helpful in these situations. Conclusions: This study demonstrated how GPs use three different communication strategies to address the issue of CVD risk, depending on their perception of patient risk, motivation and anxiety. Absolute risk played a different role within each strategy. Providing GPs with alternative ways of explaining absolute risk, in order to achieve different communication aims, may improve their use of absolute CVD risk assessment in practice.
    Full-text · Article · May 2014 · BMC Family Practice

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