The realities of primary prevention of cardiovascular disease in general practice: A qualitative study using reflective diary and focus group methods.

Problem

NICE lipid modification guidelines (2014) recommend prescribing statins for primary prevention to patients with cardiovascular disease (CVD) risk scores above 10% 10-year risk. Quantitative research suggests, of those at-risk, less than 50% are prescribed a statin. Why?

Despite growing evidence, contention exists about prescribing statins for primary prevention, especially at lower risk. The debate has made the medical and popular press. Inadequately prescribing treatments for primary prevention has been labelled a public health crisis. Consequently, the GP and patient are left grappling with difficult decisions about the acceptability of preventative treatments. This study looks at the reality of consulting about primary prevention and identifies factors that influence outcome, achievability and success of consultations.

Approach

Novel qualitative methodology was used to gain contemporaneous insight into GP’s experiences of primary prevention consultations. Twelve GPs (7 female, 5 male) representing diverse location and employment backgrounds, reflected on cases typical of their experiences of consulting about primary prevention of CVD. Two cases were selected where they discussed prevention; a third where the patient had a qualifying CVD risk, but discussion was decided against. GPs audio-recorded their reflections within three days of the consultation, reflecting on factors felt to influence outcome. The data was triangulated with participants at a focus group to allow deeper analysis and clarification.

Findings

NICE recommend systematic screening of practice databases to identify patients with an estimated QRISK2 score above 10%. Only 3 of 34 cases presented in this way. Ad-hoc discussions in crowded consultations with multi-morbid patients was common. GPs saw primary prevention as important, but other clinical priorities and limited time in the consultation negatively impacted. GPs reflected on battling patient preconceptions influenced by the media or fear of side effects. Some highlighted mistrust of the applicability of guidelines to individuals. Reasons to not consult were lack of time, other clinical priorities or a fear of over-burdening patients; particularly mental health patients. Although attempts were made to employ shared-decision making techniques, satisfactory outcome was often cited if the patient’s wishes were respected; regardless of CVD risk.

Consequences

The realities of general practice are impacting on the achievability of implementing NICE guidance. Ad-hoc consultations about CVD risk is a deviation from the guidance and may result in inadequate identification of at-risk patients.

Consultations dedicated to primary prevention were deemed more successful. The realities of time-limited, complex general practice consultations on a background of negative media influence, is affecting the success of consultations. GPs value the importance of primary prevention and shared-decision making (SDM) when deciding about prescribing statins. Incentivisation via QoF for prescribing statins for primary prevention may be undesirable. Reaching shared decisions about treatments was deemed more appropriate. Consultations, may however, need adapting if full SDM is to be fully achieved.