Inaccurate risk perceptions contribute to treatment gaps in secondary prevention of cardiovascular disease J. Thakkar,1,2,3 E. L. Heeley,1,2 J. Chalmers1,2 and C. K. Chow1,2,3 1 The George Institute for Global Health, 2The University of Sydney, and 3Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
Key words risk perception, cardiovascular diseases, secondary prevention. Correspondence Jay Thakkar, Level 10, King George V Building, PO Box M 201, Missenden Road, Camperdown, NSW 2050, Australia. Email: [email protected] Received 28 August 2015; accepted 7 December 2015. doi:10.1111/imj.12982
Abstract Background: All patients with cardiovascular disease (CVD) are at high risk of recurrent events. Despite strong evidence, large treatment gaps exist in CVD secondary prevention. We hypothesise that patients’ self-perception and general practitioner’s (GP) assessment of future cardiovascular (CV) risk may influence secondary prevention behaviours. Aim: To examine in patients with known CVD the perceived risk of future CV events and its relationship with use of secondary prevention medications and risk factor control. Methods: We examined patient and practitioner’s perceived risk and its relationship with the uptake of secondary prevention recommendations in adults with CVD participating in the Australian Hypertension and Absolute Risk Study. Results: Among the 1453 participants, only 11% reported having a high absolute risk and 29% reported high relative risk of recurrent events. The GP categorised only 30% as having a 5-year risk ≥15%. After adjusting for covariates, hospitalisation within the preceding 12 months was the only significant predictor of patients’ accurate risk perception. Conventional CV risk factors were predictive of the GP’s risk estimates. Patients who accurately understood their risk reported higher smoking cessation rates (7 vs 3%, P = 0.003) and greater use of antiplatelet, blood pressure lowering therapy and statins (P ≤ 0.01). However, there was no relationship between GP’s risk perception and secondary prevention treatments. Conclusion: Both patients and GP have optimistic bias and underestimate the risk of future CV events. Patients’ accurate self-perception, but not GP risk perception, was associated with improved secondary preventative behaviours. This suggests that helping patients to understand their risk may influence their motivation towards secondary prevention. Providing support to GP or programmes to help patients better understand their risks could have potential benefit on secondary prevention behaviours.
Funding: The current manuscript has no funding or grant. The original data collection for the AusHEART study was supported by an unrestricted educational grant from Servier Australia. Conflict of interest: The AusHEART study was conducted as a collaborative project between The George Institute for Global Health and Servier Australia. Jay Thakkar is a PhD student with The School of Public Health at The University of Sydney and recipient of Australian Post Graduate Award Scholarship. Emma Heeley received a travel grant from Servier to present AusHEART findings at the European Stroke Conference. John Chalmers has received research grant from Servier for the Perindopril Protection Against Recurrent Stroke Study, The Action in Diabetes and Vascular Disease Preterax and Diamicron MR Controlled Evaluation and the AusHEART study, and has received lecture fees for speaking at scientific meetings from Servier. Clara Chow is a primary supervisor of Jay Thakkar’s PhD and is funded by a Career Development Fellowship cofunded by the National Health and Medical Research Council and National Heart Foundation of Australia (1033478) and Sydney Medical Foundation Chapman Fellowship.
© 2016 Royal Australasian College of Physicians
Introduction Cardiovascular disease (CVD) is the leading cause of death globally and affects approximately one in six Australians.1,2 CVD is the most expensive disease group in Australia in terms of direct healthcare expenditure and is a major driver of escalating healthcare costs.3 Patients who have had a prior cardiovascular (CV) event are at a very high risk for repeat events with an estimated risk that exceeds 20% over 5 years.4 Almost half of the CV events occur in those with prior CVD,5 yet many of these events may have been prevented with intensive secondary prevention therapy.6 Preventative efforts are most efficient when directed at those patients with highest risk. Despite the strong evidence that treatment with secondary prevention medications, lifestyle modification and risk factor control decrease the risk of
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repeat events, numerous studies have shown a gap in use of secondary prevention treatments.7,8 We have shown this in The Australian Hypertension and Absolute risk study (AusHEART).9 Several studies have suggested that patient and clinician attitudes towards their treatments may be a barrier to adherence,10 however, there is a little quantitative evidence that supports this. The general practitioners (GP) assessment of their patients’ overall CV risk could impact on the prevention treatments they advise. Patients’ perceptions of their own CV risk may influence their own secondary prevention behaviours. The aims of this research paper was to examine, in patients with known CVD recruited in the AusHEART study through general practice: (i) the perceived future risk of CV events as estimated by patients and their GP in absolute and relative terms and (ii) the relationship between these perceptions and the uptake of secondary preventive measures.
Methods Study design and population AusHEART was a nationally representative, clusterstratified, cross-sectional survey of CV risk management in patients aged 55 years or older presenting to primary healthcare centres that has been described previously.9,11 The study was approved by The Royal Australasian college of General Practitioners National Research and Evaluation Ethics Committee. All patients gave informed written consent for participation. Expression of interest letters was sent out to 21 074 GP registered to practise in Australia at the beginning of 2008. Of the 1416 GP who expressed interest in the study, 534 were randomly selected stratified by geographic location to ensure that distribution by state and rural–urban reflected the population distribution according to the data from 2004 census. GP were asked to recruit 15–20 consecutive adult patients (aged ≥55 years) presenting to their practices irrespective of the reasons for their consultation between April and June 2008. In total, 5293 patients were recruited to AusHEART, 1453 patients with history of CVD are the subjects of the current analysis.
Data collection The GP completed a one-page questionnaire for each recruited patient on CV risk factors, use of cardiac medications, checked blood pressure with an electronic monitor (Omron HEM-907 when available). If certain key CV risk factors, including fasting blood lipids, blood glucose, estimated glomerular filtration rate and urine 340
albumin–creatinine ratio, had not been measured within the National Heart Foundation of Australia guideline-recommended time frame, the GP were requested to repeat these tests and record the results, to allow a ‘forced capture’ of CV risk factor levels in all registered patients. GP were asked to estimate and record the patient’s absolute risk of a future CV event over the next 5 years. Each patient completed a questionnaire that included questions on socio-economic status and physical activity. Each patient was asked to estimate their future risk of a CV event in the next 5 years and report this in absolute and relative terms. Specifically each patient was asked firstly ‘What do you think your chances of having a heart attack or stroke in the next 5 years are?’ and given six response options to select from – no chance, low, mild, moderate, high and very high. Secondly, they were asked – ‘How do you think your chances of having a heart attack or stroke in the next 5 years compare to chances of an average person the same age and sex as you?’ and given a scale from 1 to 5 (where 1–2, lower chance; 3, same chance; 4–5, higher chance). Finally, they were requested to provide a numeric risk estimate (range 0–100%) of the risk of an average person the same age and sex, and their risk of having a heart attack or stroke in the next 5 years.
Definitions CVD was defined as patients with prior stroke, transient ischaemic attack (TIA), myocardial infarction (MI), angina or coronary revascularisation. Patients with established CVD are considered to be at high risk of a future CV event, that is, they are generally regarded to have a 5-year risk greater than 15%.12 We categorised GP’s risk estimates as an ‘accurate risk estimate’ if the GP reported the absolute CV risk of patients with CVD to be >15% over 5 years and otherwise an ‘underestimate of risk’.13 We categorised patients who indicated their future chances of heart attack or stroke was ‘high’ or ‘very high’ as ‘accurate high self-perception of risk’, whereas patients who indicated their risk as ‘no chance, low, mild or moderate’ were categorised into the ‘inaccurate low-moderate self-perception of risk’ group. We defined good risk factor control as achieving three or more of the following five parameters: (i) physical activity of >30 min for 5 or more days per week, (ii) non-smoking status, (iii) LDL
Key words risk perception, cardiovascular diseases, secondary prevention. Correspondence Jay Thakkar, Level 10, King George V Building, PO Box M 201, Missenden Road, Camperdown, NSW 2050, Australia. Email: [email protected] Received 28 August 2015; accepted 7 December 2015. doi:10.1111/imj.12982
Abstract Background: All patients with cardiovascular disease (CVD) are at high risk of recurrent events. Despite strong evidence, large treatment gaps exist in CVD secondary prevention. We hypothesise that patients’ self-perception and general practitioner’s (GP) assessment of future cardiovascular (CV) risk may influence secondary prevention behaviours. Aim: To examine in patients with known CVD the perceived risk of future CV events and its relationship with use of secondary prevention medications and risk factor control. Methods: We examined patient and practitioner’s perceived risk and its relationship with the uptake of secondary prevention recommendations in adults with CVD participating in the Australian Hypertension and Absolute Risk Study. Results: Among the 1453 participants, only 11% reported having a high absolute risk and 29% reported high relative risk of recurrent events. The GP categorised only 30% as having a 5-year risk ≥15%. After adjusting for covariates, hospitalisation within the preceding 12 months was the only significant predictor of patients’ accurate risk perception. Conventional CV risk factors were predictive of the GP’s risk estimates. Patients who accurately understood their risk reported higher smoking cessation rates (7 vs 3%, P = 0.003) and greater use of antiplatelet, blood pressure lowering therapy and statins (P ≤ 0.01). However, there was no relationship between GP’s risk perception and secondary prevention treatments. Conclusion: Both patients and GP have optimistic bias and underestimate the risk of future CV events. Patients’ accurate self-perception, but not GP risk perception, was associated with improved secondary preventative behaviours. This suggests that helping patients to understand their risk may influence their motivation towards secondary prevention. Providing support to GP or programmes to help patients better understand their risks could have potential benefit on secondary prevention behaviours.
Funding: The current manuscript has no funding or grant. The original data collection for the AusHEART study was supported by an unrestricted educational grant from Servier Australia. Conflict of interest: The AusHEART study was conducted as a collaborative project between The George Institute for Global Health and Servier Australia. Jay Thakkar is a PhD student with The School of Public Health at The University of Sydney and recipient of Australian Post Graduate Award Scholarship. Emma Heeley received a travel grant from Servier to present AusHEART findings at the European Stroke Conference. John Chalmers has received research grant from Servier for the Perindopril Protection Against Recurrent Stroke Study, The Action in Diabetes and Vascular Disease Preterax and Diamicron MR Controlled Evaluation and the AusHEART study, and has received lecture fees for speaking at scientific meetings from Servier. Clara Chow is a primary supervisor of Jay Thakkar’s PhD and is funded by a Career Development Fellowship cofunded by the National Health and Medical Research Council and National Heart Foundation of Australia (1033478) and Sydney Medical Foundation Chapman Fellowship.
© 2016 Royal Australasian College of Physicians
Introduction Cardiovascular disease (CVD) is the leading cause of death globally and affects approximately one in six Australians.1,2 CVD is the most expensive disease group in Australia in terms of direct healthcare expenditure and is a major driver of escalating healthcare costs.3 Patients who have had a prior cardiovascular (CV) event are at a very high risk for repeat events with an estimated risk that exceeds 20% over 5 years.4 Almost half of the CV events occur in those with prior CVD,5 yet many of these events may have been prevented with intensive secondary prevention therapy.6 Preventative efforts are most efficient when directed at those patients with highest risk. Despite the strong evidence that treatment with secondary prevention medications, lifestyle modification and risk factor control decrease the risk of
339
Thakkar et al.
repeat events, numerous studies have shown a gap in use of secondary prevention treatments.7,8 We have shown this in The Australian Hypertension and Absolute risk study (AusHEART).9 Several studies have suggested that patient and clinician attitudes towards their treatments may be a barrier to adherence,10 however, there is a little quantitative evidence that supports this. The general practitioners (GP) assessment of their patients’ overall CV risk could impact on the prevention treatments they advise. Patients’ perceptions of their own CV risk may influence their own secondary prevention behaviours. The aims of this research paper was to examine, in patients with known CVD recruited in the AusHEART study through general practice: (i) the perceived future risk of CV events as estimated by patients and their GP in absolute and relative terms and (ii) the relationship between these perceptions and the uptake of secondary preventive measures.
Methods Study design and population AusHEART was a nationally representative, clusterstratified, cross-sectional survey of CV risk management in patients aged 55 years or older presenting to primary healthcare centres that has been described previously.9,11 The study was approved by The Royal Australasian college of General Practitioners National Research and Evaluation Ethics Committee. All patients gave informed written consent for participation. Expression of interest letters was sent out to 21 074 GP registered to practise in Australia at the beginning of 2008. Of the 1416 GP who expressed interest in the study, 534 were randomly selected stratified by geographic location to ensure that distribution by state and rural–urban reflected the population distribution according to the data from 2004 census. GP were asked to recruit 15–20 consecutive adult patients (aged ≥55 years) presenting to their practices irrespective of the reasons for their consultation between April and June 2008. In total, 5293 patients were recruited to AusHEART, 1453 patients with history of CVD are the subjects of the current analysis.
Data collection The GP completed a one-page questionnaire for each recruited patient on CV risk factors, use of cardiac medications, checked blood pressure with an electronic monitor (Omron HEM-907 when available). If certain key CV risk factors, including fasting blood lipids, blood glucose, estimated glomerular filtration rate and urine 340
albumin–creatinine ratio, had not been measured within the National Heart Foundation of Australia guideline-recommended time frame, the GP were requested to repeat these tests and record the results, to allow a ‘forced capture’ of CV risk factor levels in all registered patients. GP were asked to estimate and record the patient’s absolute risk of a future CV event over the next 5 years. Each patient completed a questionnaire that included questions on socio-economic status and physical activity. Each patient was asked to estimate their future risk of a CV event in the next 5 years and report this in absolute and relative terms. Specifically each patient was asked firstly ‘What do you think your chances of having a heart attack or stroke in the next 5 years are?’ and given six response options to select from – no chance, low, mild, moderate, high and very high. Secondly, they were asked – ‘How do you think your chances of having a heart attack or stroke in the next 5 years compare to chances of an average person the same age and sex as you?’ and given a scale from 1 to 5 (where 1–2, lower chance; 3, same chance; 4–5, higher chance). Finally, they were requested to provide a numeric risk estimate (range 0–100%) of the risk of an average person the same age and sex, and their risk of having a heart attack or stroke in the next 5 years.
Definitions CVD was defined as patients with prior stroke, transient ischaemic attack (TIA), myocardial infarction (MI), angina or coronary revascularisation. Patients with established CVD are considered to be at high risk of a future CV event, that is, they are generally regarded to have a 5-year risk greater than 15%.12 We categorised GP’s risk estimates as an ‘accurate risk estimate’ if the GP reported the absolute CV risk of patients with CVD to be >15% over 5 years and otherwise an ‘underestimate of risk’.13 We categorised patients who indicated their future chances of heart attack or stroke was ‘high’ or ‘very high’ as ‘accurate high self-perception of risk’, whereas patients who indicated their risk as ‘no chance, low, mild or moderate’ were categorised into the ‘inaccurate low-moderate self-perception of risk’ group. We defined good risk factor control as achieving three or more of the following five parameters: (i) physical activity of >30 min for 5 or more days per week, (ii) non-smoking status, (iii) LDL
