Primary care physicians and coronary heart disease prevention: a practice model1

Patient Education and Counseling 32 (1997) 207–217

Primary care physicians and coronary heart disease prevention: a practice model 1 Lydia Makrides*, Paula L. Veinot, Josie Richard, Michael J. Allen Cardiac Prevention and Rehabilitation Research Centre, Dalhousie University, Camp Hill Medical Centre, Abbie J. Lane Building, 9 th Floor, 1763 Robie St., Halifax, Nova Scotia, B3 H 3 G2 Canada Received 23 April 1996; received in revised form 25 March 1997; accepted 25 March 1997

Abstract Primary care physicians have an important role in coronary heart disease prevention. This paper discusses the results of a qualitative study conducted with Nova Scotian physicians to explore the following: physicians’ expectations about their role in prevention; obstacles to providing preventive care; and, mechanisms by which preventive care occurs. The second part of the paper presents a practice model which is intended as a framework by which physicians may more effectively educate and counsel their patients about health issues, such as coronary heart disease.  1997 Elsevier Science Ireland Ltd. Keywords: Coronary heart disease; Counselling; Physician; Prevention

1. Introduction Cardiovascular disease (CVD), including coronary heart disease (CHD), is the major cause of death and disability in Canadian adults. In 1990, 39% of deaths in Canada were attributed to CVD [1]. Disease prevention efforts such as making healthy lifestyle choices can help decrease morbidity and mortality from CHD [2]. In a review of literature, Goldman and Cook [3] estimated that over half the decline in

*Corresponding author. Tel.: (902) 473 8622; fax: (902) 473 4571. 1 A collaborative project supported by the Cardiac Prevention and Rehabilitation Research Centre, Dalhousie University and the Nova Scotia Department of Health.

ischemic heart disease mortality in the United States between 1968 and 1976 was related to changes in lifestyle and modification of risk factors such as hyperlipidemia and smoking. Physicians have the potential to make an impact on the major risk factors for CHD. For example, studies examining the effects of physicians’ counselling against smoking, as part of everyday practice, have shown an increase in smoking cessation resulting from simple anti-smoking advice [4–8]. Primary care physicians have an important role in the prevention of CHD because they have repeated contact and long-term relationships with the majority of the population. In Nova Scotia, 91% of the population sees a family physician at least once a year [9], and patients expect physicians to know about prevention and be involved in it [10]. Al-

0738-3991 / 97 / $17.00  1997 Elsevier Science Ireland Ltd. All rights reserved. PII S0738-3991( 97 )00031-1

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though physicians are willing to adopt prevention into practice [11–13], studies of the extent to which preventive activities have been integrated into clinical practice in Canada [11,12,14–17] and in the United States [18–24] show that implementation falls short of recommendations. This may be related to the fact that not all physicians are comfortable with or knowledgeable about counselling for lifestyle issues [11,25,26]. Physicians feel uncertain about their responsibilities because health reform emphasizes home care, pre-hospital care, wellness and prevention, and multidisciplinary health care teams [27]. Many view health reform as a guise for health cuts. Physicians fees and hospital costs have been a major focus of cuts to Nova Scotia’s health care budget. The resulting insecurity has led to some physicians to leave Nova Scotia for the United States. The Medical Society of Nova Scotia is now working with government to define physicians’ roles in the new regionalised health system [28]. In light of this uncertainty, a qualitative study was conducted with Nova Scotian physicians to explore their expectations about their role in prevention, the obstacles they experience, and the mechanisms by which preventive care occurs. A discussion of the results of this study forms the first part of this paper. Although these results may not necessarily be generalized to all Nova Scotia physicians, they do provide valuable information to assist in the development of a physician’s practice model for CHD prevention. In the process of qualitative research, we are not concerned with generalizability to the extent that we assume findings apply for all physicians. Carey [29] points out that when saturation is reached (i.e., no new information is discovered) one can cautiously infer that results are generalizable to similar groups. However, qualitative research emphasizes the action, process, perspective and knowledge as they influence a social phenomenon. It focuses on understanding and description, and not on prediction [30]. It does not attempt to quantify how strongly opinions are held [31]. The physician’s practice model is presented in the second part of the paper. This model is intended as a framework by which physicians may more effectively educate and counsel their patients about health issues. CHD is used as an example.

2. Physicians’ preventive care behaviours

2.1. Methods Four focus groups, 16 participants in total, and 15 one-on-one interviews were conducted with primary care physicians in Nova Scotia. Participants were CCFP-certified physicians and general practitioners, males and females, and salaried and fee-for-service. They were from solo and group practices, including community health clinics, and from urban and rural practices. Practice experience of participants ranged from 3 to 32 years. A list of potential participants was delineated from all physicians in Nova Scotia. Physicians were sampled randomly within the categories described above to ensure representation from various groups, including both MDs and CCFP-certified physicians. Potential focus group participants across the province were approached by letter to introduce the project. These individuals were then contacted by telephone to confirm interview arrangements. The researchers had confirmed eight to nine participants for each group (n 5 33). However, due to physician time constraints and poor weather, in one instance, actual participation was limited to lower numbers. Participants for the one-on-one interviews were selected by snowball sampling, a technique in which a knowledgeable person(s) is asked, ‘‘Who knows a lot about ?’’. In this case, a physician affiliated ]]]]] with the Cardiac Prevention Research Centre provided assistance in locating initial contacts. The snowball grows as the interviewer asks the participants to recommend other individuals to interview [32]. Interview guides were used for focus groups and interviews to improve internal validity [32]. However, the researcher had enough flexibility to ‘‘probe’’ participants’ responses for clarification. All focus group participants were asked questions specifically related to CHD prevention. At the end of the sessions, which lasted one to two hours, a general discussion took place. The face-to-face open-ended interviews lasted 45 to 60 min. They addressed general prevention issues. All sessions were audiotaped and transcribed for analysis. Recurring themes were identified using content analysis. Patterns in the

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data were identified, coded and then categorized into themes by reading verbatim transcripts line by line.

2.2. Results Three main topics were discussed: roles and responsibilities of physicians in prevention; obstacles to prevention; and prevention strategies.

2.2.1. Roles and responsibilities ( Table 1) All participants stated that primary care physicians have a responsibility to carry out preventive activities. Specific responsibilities include learning and implementing current screening guidelines (e.g., monitoring blood pressure, assessing smoking status), counselling patients to help them make healthy lifestyle choices and being part of a multidisciplinary health care team. Participants stated that the physician’s role in CHD prevention extends beyond the office into the community. Physicians serve on committees, provide Table 1 Roles and responsibilities Roles and responsibilities • Screening activities • Lifestyle counselling • Being part of a multidisciplinary health care team • Community participation

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presentations to community groups and schools, participate in the development of community prevention programs and initiate and support healthy public policy. The community role of physicians is strong for rural physicians, who may be the only health resource in the community.

2.2.2. Obstacles to effective prevention ( Table 2) Physicians identified a number of obstacles to their preventive care behaviour which can be classified as structural, behavioural and personal. Structural obstacles are broad factors, beyond the physician’s immediate control. One prominent structural obstacle is funding. Participants reported that the fee-for-service system is seen to reward those who provide less preventive care because prevention takes more time, and physicians are pressured into booking shorter appointments to cover overhead costs. Physicians on salary do not experience time pressures in this same way. Some physicians have tried to solve the problem by ‘‘creative billing’’ (i.e., billing for symptoms unrelated to the problem). Others suggest that a salaried system and a specific billing code for preventive services are a solution. Time is another major obstacle to providing adequate lifestyle counselling. To provide more indepth counselling, the physician has to follow through on preventive care during the present visit, thus delaying visits with other patients, or the patient has to be brought back for a follow-up visit. Particip-

Table 2 Obstacles to preventive care Obstacles to physician success

Obstacles to patient success

Personal • negative attitude toward prevention • lack of motivation • inadequate counselling skills • poor memory Organizational • inadequate space • organization of practice around medical model • negative staff attitude toward prevention Structural • inadequate / lack of remuneration • lack of time • patients’ expectations • sparse community resources

Individual • current lifestyle behaviours • patient’s perceived discomfort with making healthy lifestyle choices • patient’s negative attitude toward prevention • patient’s lack of motivation Socioenvironmental • lack of social support • inadequate financial resources • culture and family traditions

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ants stated that a nurse or another health professional is not always available for referral. Particularly in rural communities, there is lack of community resources to support physicians in their prevention efforts There is also a need for more hands-on cardiovascular programming for patients, including pre- and post-cardiac lifestyle programs that provide instruction in food selection, cooking and exercise. Another structural obstacle to preventive care discussed by participants is patients’ expectations. Although patients think physicians should do prevention [10], their primary concern is for an acute problem. Therefore, it is necessary for the physician to set the agenda early in the visit to include CHD and other disease prevention issues. Participants also discussed organizational obstacles or factors within the office environment that impede a physician’s prevention efforts. The physician has a greater ability to change these than the structural obstacles. Participants identified such things as inadequate space, organization of the office around the traditional treatment-oriented medical model, and poor practice management. Support staff who do not have a positive attitude toward prevention can also undermine a physician’s CHD prevention efforts. However, having a more flexible booking system that allows for preventive visits, improving staff attitudes towards prevention and having office policy that supports prevention efforts (e.g., a policy prohibiting smoking by staff and others inside or outside the building) were cited by the physicians interviewed as ways to overcome organizational obstacles. Finally, personal obstacles are barriers within the physician. The physician has the most control in modifying these obstacles. For example, participants stated they do not always remember to initiate CHD prevention. This personal obstacle may be overcome by computerized and manual reminders. Physicians themselves may have a negative attitude toward prevention and lack the motivation to practice prevention. Furthermore, participants stated that physicians often do not have adequate skills to successfully counsel people about reducing their risk for CHD. Medical school does not emphasize lifestyle modelling as an important skill, and continuing medical education (CME) workshops are expensive. Consequently, physicians tend to share prevention ideas

with colleagues. They also use patient educational materials such as written handouts and videos to assist them in their counselling. Providing more local learning opportunities through CME and medical school for lifestyle modelling were offered as broader solutions to these personal obstacles. Physicians interviewed also described various obstacles patients experience when making and maintaining a healthy choice. These obstacles have an indirect impact on a physician’s prevention efforts by negatively reinforcing physicians’ preventive care behaviour. Physicians may perceive their efforts as ineffective. These factors can affect a physician’s perceived ability to influence patients’ health choices and add to the frustration they feel about a patient’s lack of success. Some of these obstacles are socioenvironmental in nature, and beyond the individual’s control. They are related to the way our society is structured and include lack of social support, inadequate financial resources, and culture and family traditions. Other patient obstacles identified by physicians are more individual and within the patient’s control to modify. They include current lifestyle behaviours, perceived discomfort associated with change, negative attitude toward prevention, the commitment required for a healthy choice, lack of motivation to make more healthy choices, and inadequate knowledge and skills. Given time constraints, physicians stated that they tend to focus on the individual factors, as the systemic socioenvironmental factors are more difficult to address.

2.2.3. Prevention strategies ( Table 3) Physicians interviewed identified a variety of prevention strategies to overcome patients’ individual obstacles. Participants stated that every visit should be considered an opportunity for prevention. However, physicians pointed out that it is not practical to target their entire practice and often choose to focus on identifiable risk factors (secondary and tertiary prevention). Consequently, opportunities for primary prevention are often missed. Providing one-on-one counselling was cited by physicians interviewed as the most effective strategy for prevention. It was said to be more effective and easier to do than group counselling because of the traditional one-on-one physician–patient relationship, but they saw value in group counselling. A

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Table 3 Prevention strategies Prevention strategies • Viewing all visits as an opportunity for prevention • Targeting risk factors • Providing one-on-one counselling • Providing group counselling • Providing simple educational materials • Offering clear and consistent advice • Ensuring adequate follow-up • Referring to other health professionals and community resources • Enlisting the help of family and friends • Identifying / addressing patient’s personal obstacles • Identifying / addressing socioenvironmental obstacles

frustration with the lack of motivation to modify negative health choices in some patients, despite repeated counselling, was widely expressed. To overcome this frustration, physicians emphasized that the physician must form a partnership with the patient as the final decision for making a healthy choice resides with the individual. In instilling a sense of responsibility in the patient, the physician must be non-judgemental because a paternalistic or authoritarian attitude undermines the patient’s trust and can be counterproductive. Other useful prevention strategies for working with patients include providing simple educational materials, being clear and consistent in offering advice, ensuring adequate monitoring and follow-up, referring to other health professionals and community programs and enlisting the help of family and friends. Acknowledging and addressing the socioenvironmental context in which patients make their health choices, as well as the personal factors affecting the patient’s heart health choices, was also identified as necessary when assisting patients with their choices.

physician and patient behaviours. Predisposing factors are internal characteristics which motivate a behaviour before it occurs. They include knowledge, attitudes, beliefs and self-efficacy. Enabling factors are external characteristics that facilitate action and any skill or resource required to attain a specific behaviour. Reinforcing factors are rewards or punishment that follow or are anticipated as a result of a behaviour, including feedback from others [33]. As described by the physicians interviewed, elements of a successful practice model must address such factors as lack of time, forgetfulness and an office organized around the medical model approach that emphasizes acute care. The proposed model (Fig. 2) consists of five components: (1) an educational workshop to improve physicians’ lifestyle counselling skills; (2) a heart health assessment questionnaire completed by patients; (3) a negotiated lifestyle ‘‘prescription’’ or wellness contract; (4) a lifestyle program in which the physician provides one-on-one counselling in a designated patient visit or group counselling sessions; and (5) patient education materials to supplement counselling efforts.

3. Prevention practice model for physicians

3.1. Educational workshop for physicians

The last part of this paper discusses a prevention practice model for physicians which has been developed based on the qualitative study reported and related literature. The PRECEDE–PROCEED model ([33], Fig. 1) is a useful tool to understand the various factors identified in the research and to explain how the prevention practice model will affect

The first component is a workshop for physicians to address the personal and organizational obstacles to preventive practice. The purpose of the workshop is to help physicians learn how to best assist their patients to make heart healthy lifestyle choices and to discuss ways to organize their practice to facilitate prevention efforts. As physicians underestimate their

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Fig. 1. Primary care physicians and counselling for coronary heart disease prevention conceptual model (based on PRECEDE–PROCEED model [33]).

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Fig. 2. Components of the prevention model

ability to influence patients’ health behaviours [25,34,35], the workshop will help increase physicians’ self-efficacy in helping patients make healthy lifestyle choices. Self-efficacy is the confidence that an individual feels about performing a specific behaviour [36]. It is an important prerequisite for behaviour change and affects how much effort is invested in a given task [37,38]. Inadequate counselling skills can contribute to low self-efficacy. Therefore, physicians will require knowledge and practical skills about lifestyle counselling. For example, Mann and Putnam [11] found that physicians perceived themselves as having inadequate skills in enhancing patient compliance and achieving behaviour change. In this workshop, physicians should be instructed in effective communication skills, the negotiation of lifestyle plans, and family participation in patient ‘‘care’’. Physicians must have the opportunity to practice these newly learned skills in a supportive environment [39]. Physicians also need to learn about effective CHD prevention interventions and the determinants of such negative health choices as

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smoking, physical inactivity and eating unhealthy foods. Physicians must know how to elicit these causes from individual patients, keeping in mind individual and socioenvironmental obstacles. Patients may have inadequate knowledge, lack the skills to perform a particular task or lack the self-efficacy or belief in themselves to make the heart healthy choice. Still others may not have the social or financial support. It is crucial that the physician be able to identify these factors, as they will help define the most appropriate and effective educational strategy. These factors can be assessed by asking the patient questions throughout the encounter. Physicians should also learn how to assess a patient’s readiness to adopt a heart healthy choice. Patients are at various stages in willingness to change and interventions will have to be tailored to that stage. Prochaska [40] proposes that a model of change based on stages has greater potential to assess the dynamics of change. Prochaska states that individuals progress through five stages of behaviour change—precontemplation, contemplation, preparation, action, and maintenance. Some people progress linearly through contemplation to maintenance, while others relapse. It is important for physicians to assess patients’ willingness or readiness to make heart healthy choices. Using a staged approach is one way to do this.

3.2. Heart health lifestyle assessment The lifestyle assessment component may be either a pen and paper questionnaire or a computerized version. This assessment assists the physician to identify the specific CHD risk factors for which the patient should receive counselling. Ockene and Ockene [41] have referred to this stage as diagnosis or assessment of health risks using the medical interview, questionnaires and laboratory tests. Assessment tools are intended to be a screening mechanism upon which to base patient education and counselling and appropriate clinical interventions. The questionnaire can be completed by the patient in the waiting area prior to seeing the physician. Depending on whether a manual or computerized questionnaire are used, the receptionist will give the patient the questionnaire upon entry or direct the patient to a computer with on-screen prompts about

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how to complete the questionnaire. The questionnaire then serves as a cue for the physician to advise the patient on making healthy choices. Various studies have documented the effectiveness of manual [42,43] and computer-generated [44–46] reminders in helping to increase physicians’ attention to preventive health screening recommendations. For example, Harris et al. [45] found that prompting physicians at the time of the visit, either manually or by a computer system, increased physician performance.

3.3. Negotiated lifestyle ‘‘ prescription’’ or wellness contract The negotiated lifestyle prescription or wellness contract is planned together by the physician and the patient. Based on the results of the lifestyle assessment, the patient prioritizes the healthy lifestyle choices to be made. The physician and patient together must decide on a mutually acceptable plan on how to achieve the agreed upon lifestyle goals and what the time line for achievement will be. The agreement is written out on a ‘‘prescription’’ pad in the form of a contract for the patient. For example, the patient may decide to quit smoking gradually by reducing the amount smoked daily. Involving the individual as an active participant in his or her own learning is more likely to facilitate behaviour change. [47,48] At this stage the patient may wish to involve his or her family. It is reported that involving families in making the healthy choices enhances the patient’s success [49].

3.4. Lifestyle counselling program The lifestyle counselling program is the fourth component of the prevention model. In the same way that the educational workshop for physicians should be premised on adult learning principles, so should these principles be incorporated into the lifestyle counselling program. Making healthy lifestyle choices takes time and patience. People learn what they want to learn, and they will incorporate into practice those concepts and ideas which have personal meaning and relevance [50]. The patient already has extensive experience and will need to be able to connect what they are learning with what they

already know and have experienced. Therefore, it is necessary to create an atmosphere that encourages people to be active participants in learning, emphasizes the personal and subjective nature of learning, encourages openness, permits confrontation and lets people feel they are respected [50]. This allows the learner to safely practice new behaviours, guided by a qualified professional [47]. The physician should provide one-on-one counselling to the patient to assist him or her in making and maintaining the heart healthy lifestyle choice. Group counselling sessions may also be appropriate. Childers and Guyton [51] state that groups can be more economical than individual counselling because more clients can receive services at one time. They also report that group work can help move the focus from treatment (historically the role of health professionals) to prevention. Groups also provide an opportunity to share experiences and develop a kind of support which may not be provided by health professionals [52]. Group work helps to enhance self-awareness and competence through peer feedback [47]. Counselling must be tailored to meet the needs of the individual and the goals he or she has identified. Appropriate follow-up, either in-person or by telephone, is necessary. Various researchers discuss the importance of follow-up [41,53]. For example, Orleans et al. [54], in a study on the effects of smoking self-help materials, social support instructions and telephone counselling, found that telephone counselling increased adherence to the quitting protocol and quit rates. Perri et al. [55] addressed strategies for components of a successful weight loss program and found that continued professional contact is important for weight loss maintenance. In addition, patients should be referred to appropriate community resources as required or to groups which address the specific CHD risk factors. Upon achieving the goal in the negotiated lifestyle prescription, the physician must schedule a follow-up visit to discuss maintenance of the healthy lifestyle choice.

3.5. Educational materials Print and audiovisual resources are useful tools to assist physicians in counselling patients. However, such resources are not sufficient to guide people to

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heart healthy choices [41]. Print educational materials are less effective if used on their own rather than as a teaching tool and must be used in conjunction with appropriate patient-centred counselling. To maximize learning, reading materials must be at the level of the patient and content guided by the individual’s interests and concerns [56,57].

4. Conclusion The research findings discussed in the first half of this paper indicate that the primary care physicians interviewed have an interest in prevention and consider it an important part of their work. However, their efforts are constrained primarily by the obstacles discussed such as lack of time, inadequate remuneration and inadequate counselling skills. The literature indicates that, to date, most of physicians’ preventive care has focused on screening activities, such as checking blood pressure [48]. Mann and Putnam [11] found that this was the activity which physicians perceived themselves to be most effective at addressing. Neighbor and colleagues [23] suggest that high rates of assessment and counselling for hypertension may relate to a higher perceived self-efficacy. These research findings have guided the development of a preventive care practice model for physicians, which is presented in the last part of the paper. There have been other models of preventive cardiology. For example, Green [53] addresses the concept of self-care and how a physician can organize his / her practice to relinquish responsibility to the patient so that the patient can have a larger role in self-care. He argues that physicians are in an ideal position to offer patients positive reinforcement, and a medical rationale for healthy lifestyle choices. They also have a familiarity with patient history. Self-care education in secondary prevention has the potential for large cost savings such as reduced emergency room visits and decreased disability and premature death [53]. Cohen and associates [58] suggest using an office system approach with motivational strategies that focuses not only on physicians but also staff and patients. This is similar to the approach we have outlined in this paper. However, Cohen’s model does not address physicians’ lack of skills in counselling

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for healthy lifestyle choices. Without addressing this inadequacy, it will be difficult to guarantee much success on other levels. Walsh and McPhee [59] review a systems model of clinical preventive care. They report that an ideal model must take into account the physician, the patient and the factors influencing each. These factors are described as predisposing, reinforcing and enabling, as developed by Green and Kreuter [33]. Although this model provides a theoretical base for doing preventive care, it does not pose a specific plan to increase physicians’ preventive care behaviours or how to overcome the barriers identified. In light of health reform, it is becoming necessary for physicians to define a role for themselves in a new health system that emphasizes health promotion, disease prevention and community-based care. The model presented in this paper is a comprehensive one and can assist physicians to better incorporate preventive care into their practice. The next phase will be to implement and evaluate the model.

Acknowledgements This project has been supported by the Cardiac Prevention and Rehabilitation Research Centre, Dalhousie University and the Nova Scotia Department of Health. Appreciation also goes to the physicians who offered their time and shared their experiences.

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