RISK-Identification to Prevent Cardiovascular Disease – How do official versions of preventative care align with the everyday experiences of front-line clinicians and patients?

Problem

Screening to identify individuals who are at risk of cardiovascular disease is an increasingly prominent public health strategy, achieved through the NHS Health Check and opportunistically in routine primary care consultations. Clinical guidelines hinge around assessing the risk that an individual will experience a heart attack or stroke, with the aim of triggering them to alter their lifestyle or take medication to modify their risk. Although a wealth of evidence has demonstrated the impact of treatment interventions on surrogate markers of risk (such as cholesterol or blood pressure), other evidence points to tensions between the intentions of clinical guidelines and front-line experiences of clinicians and patients. For example: engagement with screening and risk modification interventions is patchy; population based interventions may have relatively small benefits, or even harms, to individuals; and guideline recommendations may fail to convey the uncertainty which is inherent to both risk, and to associated interventions. Additionally, individualised risk management pays limited attention to the socioeconomic factors which play an important, if poorly understood, role in the risk status. Critics of screening for risk argue that it may contribute to, rather than address, inequalities.Few studies have looked at differences between official versions of prevention and what actually happens in practice

Approach

This study is an institutional ethnography of cardiovascular risk assessment and management. In the first phase, I observe in general practice, and conduct interviews with patients and clinicians. In the second phase, I interview other informants and collect key texts in order to show how the work of prevention is accomplished across multiple sites, and the tensions that arise in the practices of clinicians and patients.

Findings

Findings will make visible the links between everyday practices of clinicians and patients, official representations of preventative care in guidelines and policy, and other discursive and textual practices which organise what happens in general practice. This will help show where current policies may help or hinder patients in caring for themselves.

Consequences

Ethnography is increasingly recognised as an important approach to identify problems in healthcare, for reflexive learning, and for studying the context of quality improvement. This study is designed to show the realities of cardiovascular disease prevention in practice, and to reveal opportunities for improving preventative care. I will also reflect on how ethnographic approaches may help researchers to look ‘through the patient’s eyes’, in order to support improvements in complex healthcare policies.