Student: Talia Wise
Supervisors: Dr Ruth Savage and Pip Mason
Sponsor: Partnership Health Canterbury
Introduction
Cardiovascular disease (CVD) is defined as a class of diseases affecting the heart and the blood vessels, which includes heart attacks, angina and strokes. In many cases cardiovascular disease can be prevented yet in New Zealand 40% of deaths annually are from CVD and quality of life can also be affected. Risk factors that can be changed include poor eating habits, lack of exercise, being overweight cigarette smoking and high alcohol intake. Risk factors that can not be changed include a family history, ethnicity and gender.
Cardiovascular disease risk assessment (CVD risk assessment) is a tool to help general practitioners (GPs) and practice nurses determine a person's chance of having a cardiovascular event such as a heart attack, or stroke within the next 5 years. CVD risk assessment is encouraged for all adults in New Zealand from 45 years for men and 55 years for women (or 10 years earlier for individuals with various pre- existing risk factors). CVD is, to some extent preventable, so effective management of risk factors will help reduce the possibility of a cardiovascular event occurring. Management can include lifestyle changes, and or medications.
Variations (reported in previous studies) occur between how GPs and practice nurses assess CVD risk and their attitudes towards recording risk, yet the reasons for these variations are not well understood. In order to have a systematic approach to CVD screening it is important to understand the variations and make changes to ensure effective screening tools are used throughout general practice. This study aimed to compare the behaviours and attitudes of GPs and practice nurses towards performing and recording CVD risk assessments.
Method
Structured interviews were conducted with GPs and practice nurses currently working in general practices in Christchurch. All GPs within the Partnership Health Canterbury were invited to take part in this study. A total of 12 GPs and their practice nurses agreed to take part. These GPs were also identified as either high CVD risk recorders or low CVD risk recorders. Topics considered within the interviews included; health practitioner's beliefs about the value of doing CVD risk assessments, current systems and processes in place for measuring and recording CVD risk, tools used for performing CVD risk assessment, barriers and enablers to assessing and recording, and support needed to ensure health professionals can effectively assess and record CVD risk. The interview included eight open ended questions facilitating conversation.
Interviews were recorded, transcribed and the results prepared, and thematically analysed, in order to identify common themes, Overall themes were identified within the data, and further analysis showed the similarities and differences between GPs and practice nurses and the reasons for the differences.
Results
The following main themes were identified: “Limitations of the opportunity to perform screening, time, appropriate IT tools, funding and education in how to assess for CVD risk. Differences between behaviours and attitudes of GPs and practice nurses were found within these 5 themes. All GPs believed they conducted CVD risk assessments where appropriate but due to limited opportunities many indicated that the assessments were not routinely undertaken as often as recommended.. Some were also not convinced of the clinical merit of performing assessments. Seven of twelve practice nurses either did not attempt or did not conduct full CVD risk assessments as they believed GPs conducted them, or that is was not their role.
Twenty-two of twenty-four practitioners believed time was a limitation to completing CVD risk assessment, due to the difficulty of adding CVD risk assessment into a consultation that was for other issues. GPs stated they are too busy, and practice nurses stated that because they do them infrequently they took a lot of time.
Education that focuses on how to effectively conduct CVD risk assessment was requested by 10/12 practice nurses. One nurse revealed she had never been fully informed about how to conduct CVD risk assessments. And another stated that “Education was probably the big thing for her.” In contrast only one GP requested education related to CVD risk assessments.
Funding was requested by 15/24 practitioners. The majority of GPs believed that CVD risk assessment would become more important if there was a financial incentive. Practice nurses believed that funding was needed to subsidise the patient visit for the assessment. One nurse explained how she thought access to health care was a big issue in NZ, and people who really need to access health care often don't because of cost. Another nurse believed that if funding for the patient was provided she would be more likely to make an appointment.
Current IT system limitations meant GPs wanted a pre- populating tool (an IT tool that draws in all the relevant information from the data in the patient's file and then formulates a result without results having to be entered manually) and believed changes needed to be made to the MedTech system for recording. Several GPs experienced problems and expressed frustration when recording CVD risk assessment results in MedTech. CVD risk assessment results give a range eg 5-10% risk of a CVD event in the next 5 years, yet the MedTech tool only allows for a single number to be entered. Other GPs also asked for a more user friendly tool for both assessing and recording. In contrast practice nurses found the MedTech tool used to record CVD risk assessments beneficial and that limitations for them were more related to their IT skills.
Conclusion
This study explored the behaviours and attitudes of GPs and practice nurses towards assessing and recording CVD risk and identified the variations between the two groups. There was particular variations between GPs and practice nurses education requirements.
It is recommended that the themes discussed in this report are considered in order to enable GPs and practice nurses to perform consistent and effective CVD risk assessments.