General Practitioners’ Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study

Abstract

BackgroundPrimary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more susceptible to treatment harms. Moreover the potential benefits and harms of preventive medication for older people are uncertain. We explored GPs’ decision making about primary CVD prevention in patients aged 75 years and older.Method25 GPs participated in semi-structured interviews in New South Wales, Australia. Transcribed audio-recordings were thematically coded and Framework Analysis was used.ResultsAnalysis identified factors that are likely to contribute to variation in the management of CVD risk in older people. Some GPs based CVD prevention on guidelines regardless of patient age. Others tailored management based on factors such as perceptions of prevention in older age, knowledge of limited evidence, comorbidities, polypharmacy, frailty, and life expectancy. GPs were more confident about: 1) medication and lifestyle change for fit/healthy older patients, and 2) stopping or avoiding medication for frail/nursing home patients. Decision making for older patients outside of these categories was less clear.ConclusionOlder patients receive different care depending on their GP’s perceptions of ageing and CVD prevention, and their knowledge of available evidence. GPs consider CVD prevention for older patients challenging and would welcome more guidance in this area.

A cardiovascular risk prediction model for older people: Development and validation in a primary care population

“…Polypharmacy as a predictor is consistent with a previous study with 1196 older people (aged ≥ 65 years) where “number of medications” was identified as an additional predictor for fatal CVD . Polypharmacy is a complex product of patient characteristics, physician management, and patient preferences . However, it is easy to ascertain and can therefore easily be implemented in risk prediction.…”

“…29 Polypharmacy is a complex product of patient characteristics, physician management, and patient preferences. 14 In previous studies, circulating concentrations of apolipoproteins (ApoA1 [protective factor] and ApoB [risk factor]) as well as apolipoprotein E gene variants have been associated with incident CVD in populations including older persons. 9,10 In our study, they did not have incremental predictive value.…”

“…While traditionally models predict a ten‐year risk of CVD mortality, older persons and their GPs favor models assessing risk of developing any major atherosclerotic event within a shorter time span . Hence, GPs pragmatically and intuitively weigh additional factors including frailty, multimorbidity, quality of life, and life expectancy in their decision whether or not to start preventive treatment . Furthermore, while risk of death from non‐cardiovascular causes competes with CVD events, most existing models in older persons do not account for this, and so fueling overestimation of CVD risks …”

“…13 Hence, GPs pragmatically and intuitively weigh additional factors including frailty, multimorbidity, quality of life, and life expectancy in their decision whether or not to start preventive treatment. 14 Furthermore, while risk of death from non-cardiovascular causes competes with CVD events, most existing models in older persons do not account for this, 2,4 and so fueling overestimation of CVD risks. 5,15 The aim of this paper was therefore to develop and internally validate a risk prediction model for fatal and non-fatal CVD, for people aged 70 years and over, by (re)evaluating the predictive value of traditional factors, exploring additional factors and taking competing risks of non-cardiovascular death into account.…”

‘It's difficult, I think it's complicated’: Health care professionals’ barriers and enablers to providing opportunistic behaviour change interventions during routine medical consultations

“…Health risk communication strategies may depend on how health care professionals perceive patient risk and patient motivation to take preventive action (Bonner et al ., ; Jansen et al ., ). Our findings suggest that health care professionals often consciously decided which patients to engage with in conversations about their health, depending on whether they would respond positively.…”