Transcript pan European market research - Cardiovascular Round Table (CRT)

Factors Impeding the Practical Implementation
of Cardiovascular Prevention
An international market research project in 6 countries:
Germany, France, Italy, Spain, the United Kingdom and Poland
This study was commissioned by
European Society of Cardiology (ESC)
Cardiovascular Round Table (CRT)
Task Force 4
Sponsors: AVENTIS / BAYER / BOSTON SCIENTIFIC /
GLAXOSMITHKLINE / NOVARTIS / MERCK-SCHERING PLOUGH / PFIZER
The study was carried out by
Psyma International:
Alexander Rummel
Monica Bach
Dr. Britta Meyer-Lutz
Psyma International Medical
Marketing Research GmbH
Gartenweg 2
90607 Rückersdorf/Nürnberg
Germany
phone: +49-911-95 785-0
fax:
+49-911-95 785-33
e-mail: [email protected]
website: www.psyma-international.com
Cardiovascular Round Table Taskforce 4
Study No: 41057021
December 2002
Main Objectives
To understand the practical hurdles of CV risk prevention in daily practice.

Identify how physicians assess and manage risk

Obtain baseline data on guideline usage

Reveal barriers why guidelines are not applied

Determine what changes can be made to make them more readily
adopted
Cardiovascular Round Table Taskforce 4
Methodology Sampling
F2F in-depth interviews
Focus groups
EE
UK
PL
50
30
30
30
35
35
21
21
21
154
15
15
9
9
9
66
2
1*
1*
6
-
7
9
10
-
7
D
D
FF
II
Total n =
30
50
PCPs
21
Cards
9
Total n =
2
PCPs
9
-
Cards
7
-
220
* PCPs only
Cardiovascular Round Table Taskforce 4
Screening Criteria
 Work in outpatient care
 < 60 years of age
 Practicing as a PCP or cardiologist > 3 years
 Must initiate drug treatments for patients presenting or at risk of CV disease
 Work full-time (i.e. > 6 hrs per day)
 Not participating in clinical trials on CV disease
 Not working as a CV consultant for the pharmaceutical industry
GPs only
 Must see and treat patients in at least 4 different indication areas
Cardiovascular Round Table Taskforce 4
Assessing Patients for CHD/ CV
Risk
All physicians ...

simple questioning + examining lifestyle (e.g. smoking, drinking, exercise)

measure BP

cholesterol tests

weight
PLUS
UK
E E
D
D
PL

medical history

medical history

personal experience

patient's appearance

high blood sugar/
diabetes

HDL

age

age

LDL

dyslipidemia

lipids

triglycerides


urine tests

glycemia
occasional use of scores
(Card)

Framingham guidelines

gender (Card)
Q. 13./15. Discussion Guide - Focus Groups
Cardiovascular Round Table Taskforce 4
Patient Types Perceived at Greater
Risk of a CHD/ CV Event
54%
Diabetics
42%
Smokers
Hypertension
26%
Dyslipidemia
26%
Combined
Combinedrisk
risk factors
factors
25%
Family history
Patient's cardiac history
UK: 71%
PL: 20%
34%
Overweight
M iddle-aged/ elderly
UK: 73%
UK: 13%
PL: 10%
F: 62%
20%
16%
10%
Q. 5.c (o); Base: n = 220 physicians in 6 countries; responses < 8% not included
Cardiovascular Round Table Taskforce 4
E Card: 44%
E: 13%
UK: 10%
PL: 3%
"Total" or "Global" Risk on CHD/ CV
Risk Prevention
What do these terms mean to physicians?
PL: 67%
Sum of several
risk factors
48%
Risk of a future
CV event
Global and
total risk differ
Severity of risk
factors
UK: 20%
19%
PL PCPs: 32%
12%
7%
"Patients already suffering from coronary diseases" (E Cards)
n.a./ d.k.
25%
Q. 5.d (o); Base: n = 220 physicians in 6 countries
Cardiovascular Round Table Taskforce 4
D: 43%
UK: 50%
I: 2%
"Total" or "Global" Risk
 25% of target sample don't know or can't explain terms
 D
UK
43%
50%
EDUCATIONAL NEED
Cardiovascular Round Table Taskforce 4
"Total" or "Global" Risk on CHD/ CV
Risk Prevention
VERBATIMS
SUM OF RISK FACTORS
"... it's a group of factors which is important and not each factor taken individually ..."
"... it's ignoring the value of individual risk factors and using a table or calculator estimating the effect of
interactions of the various risks ..."
"... means the possibility to become ill as a result of an accumulation of risk factors ..."
RISK OF FUTURE CV EVENT
"... total means an individual risk of major cardiac events over 10 years ..."
"... risk of an CV event within 5 years ..."
SEVERITY OF RISK FACTORS
"... we don't use these terms - we use high, moderate or low risk ..."
"... risk > 20% of developing CV events ..."
Q. 5.d (o); Base: n = 220 physicians in 6 countries
Cardiovascular Round Table Taskforce 4
Assessment of CV Risk
85% physicians base assessment on all the risk factors (D Card: 44%)
Why?
Accumulation of risks/
synergetic effect
38%
Global approach
In certain combinations
34%
24%
Individual assessment of each
factor
14%
According to guidelines
13%
To individualize therapy
13%
Q. 6.a (c), 6.b (o), 8. (o); Base: n = 220 physicians in 6 countries; responses < 8% not included
Cardiovascular Round Table Taskforce 4
E Card: 56%
E PCPs: 33%
UK PCPs: 38%
Risk Factors Considered when
Assessing CV Risk
Spontaneous - Unprompted
86%
Hypertension
Dyslipidemia
84%
Smoking
84%
Diabetes
84%
UK: 100%
UK: 100%
66%
Family history
E: 47%
58%
Overweight
44%
Age
Sedentary lifestyle
31%
Gender
30%
PL Cards: 75%
PL Cards: 63%
Q. 7.a (c); Base: n = 220 physicians in 6 countries; responses < 15% not included
Cardiovascular Round Table Taskforce 4
Risk Factors Considered when
Assessing CV Risk
Recall increases when prompted
Prompted
100%
Smoking
99%
Hypertension
Diabetes
97%
Dyslipidemia
97%
93% (66%)
Family history
88% (58%)
Overweight
81%
Age
69% (31%)
Sedentary lifestyle
66% (30%)
Gender
54% (15%)
Stress level
Alcohol use
(44%)
38%
(8%)
Q. 7.b (c); Base: n = 220 physicians in 6 countries; responses < 15% not included
Cardiovascular Round Table Taskforce 4
Why Special Attention is Required with
Specific Risk Factor Combinations
Hypertension + diabetes (n=28)
Smoking + hypertension + diabetes (n=20)
Smoking + hypertension + dyslipidemia (n=19)
 They are the worst combination
 Development of arteriosclerotic/ vessel damage
 "Diabetes" in a combination is an important risk factor
 Statistical data
 Interactions/ synergistic effect
Q. 9.c (c); Base: n = 220 physicians in 6 countries
Cardiovascular Round Table Taskforce 4
Treatment Goals for Persons at High
Risk of a CV Event (Overview)
Hypertension
65% Values below 140/90
Dyslipidemia
39%
31% BP stabilization in general
8%
BP values in diabetics lower
than in other patients
32%
8%
weight reduction/ diet
14%
Reduction of LDL values as
recommended
Weight Management
45% Weight normalization
37% BMI < = 25
Reduction of total cholesterol 10% BMI - value higher than
- values as recommended
recommended
Normalizing lipid levels (in
10% Balance diet
general)
11%
Increase of HDL - values as
recommended
10%
Reduction of LDL (in general)
Q. 13. (o); Base: n = 220 physicians in 6 countries; responses < 9% not included
Cardiovascular Round Table Taskforce 4
Factors Perceived Most Important/
Concerning in CV Risk Assessment
Prompted list of 11 Factors:
82%
Diabetes
77%
Hypertension
69%
Dyslipidemia
F: 88%
E: 93%
36%
Family history
33%
Overweight
Gender
PL: 7%
70%
Smoking
Age
PL: 40%
21%
18%
Q. 17.a (c); Base: n = 220 physicians in 6 countries; responses < 15% not included
Cardiovascular Round Table Taskforce 4
UK: 43%
PL: 27%
Preferred Method for Total Risk
Assessment
Subjective assessment of factors
Specific guidelines/ risk calculators
88%
77%
73%
68%
Int'l
Avera
ge
62%
77% 77%
72%
58%
43%
Int'l
Avera
ge
43%
Other:
34%
33%
30%
43%
33%
22%
20%
D
D
F
F
II
EE
UK
PL
PCPs
Cards
7%
-
6%
3%
3%
3%
4%
4%
Q. 18. (c); Base: n = 220 physicians in 6 countries
Cardiovascular Round Table Taskforce 4
2.
Awareness/ Usage of
Guidelines
Cardiovascular Round Table Taskforce 4
Awareness of CV Risk Prevention
Guidelines
National cardiologic guidelines
52%
26%
Scoring systems/ scales
National guidelines on metabolic
disturbances
WHO guidelines
E PCPs: 71%
UK PCPs: 67%
14%
10%
I PCPs: 43%
6% of physicians mention ESC guidelines (D Cards: 22%; E Cards: 22%)
None
10%
D PCPs: 33%
Q. 19.a (o); Base: n = 220 physicians in 6 countries; responses < 9% not included
Cardiovascular Round Table Taskforce 4
Where did physicians find out about these
guidelines?
National cardiologic guidelines
n = 93
Scoring system/ scales
n = 47
National guidelines on metabolic
disturbances
n = 26
32% Literature/ magazines/
books
37%
Literature/ magazines/
books
35%
Literature/ magazines/
books
17% Sent/ published directly
21%
Pharmaceutical
companies/ sales reps
10%
Sent/ published directly
10%
Congresses
11%
Internet
8%
Lectures/ training
11%
Lectures/ training
9%
Sent/ published directly
13%
don't know/ n.a.
39%
don't know/ n.a.
11% Congresses
8%
Internet
40% don't know/ n.a.
Q. 19.b (o); Base: n = 220 physicians in 6 countries; responses < 6% not included
Cardiovascular Round Table Taskforce 4
Physicians Viewpoints on Guidelines
(country-specific)
EE
UK

All say the same thing

Very aware of guidelines on CHD prevention

NSF is the official document

Strong users

New Zealand tables are strong favorites
PL
D
D

Doctors follow different guidelines

They provide a general basis for treatment

Too many specific guidelines - should include
treatment of more conditions in one

Names of guidelines & publishers unimportant
(PCP)

Cards have easier access to guidelines

Scores generally not used, viewed as pseudoscientific (PCPs)
Q. 18.a - 20. Discussion Guide - Focus Groups
Cardiovascular Round Table Taskforce 4
Guidelines Currently Used
Usage corresponds with awareness
National cardiologic guidelines
45%
Scoring systems/ scales
21%
National guidelines on metabolic
disturbances
E PCPs: 67%
UK PCPs: 57%
14%
"Unspecific" guidelines on metabolic
disturbances
9%
WHO guidelines
8%
I PCPs: 37%
4% of physicians use ESC guidelines (D, Cards: 22%)
None
19%
D PCPs: 52%
F PCPs: 46%
Q. 19.c (o); Base: n = 220 physicians in 6 countries; responses < 5% not included
Cardiovascular Round Table Taskforce 4
Usage of Guidelines when Assessing CV
Risk
Physicians ...
... use a combination of guidelines with
personal experience
... use individual guidelines with
modifications
41%
I: 70%
21%
... use guidelines as specified
19%
E: 43%
NEVER USE
18%
D PCPs; 48%
F PCPs: 43%
59% of physicians use routinely/ 20% only on occasion
Q. 24., 25. (c); Base: n = 220 physicians in 6 countries
Cardiovascular Round Table Taskforce 4
D: 10%
Reasons for Not Using CV Risk
Prevention Guidelines
19% of physicians indicate not using CV risk prevention guidelines

Doesn't fit to my patients

Decide according to my own experience

Difficult to use/ values often change

Don't trust them

Not used by colleagues

Used guidelines in the past
Q. 19.c, 22. (o); Base: only physicians not using guidelines (n=34)
Cardiovascular Round Table Taskforce 4
Obstacles Preventing Usage and
Implementation
UK
EE

Lack of resources

Too much information

Lack of government support

Not well distributed

Preventive medicine & education is dull

Gap between guide & reality

Bad influence of advertising & media

Transparency of guideline source lacking (who
sends them out?)
PL
D
D

Patient compliance lacking

Gap between guide & reality

Too much information

Economics

Clarity lacking

Health system

Medical progress not reflected in guidelines

Most results of clinical trials are sponsored by the
pharmaceutical industry
TIME & COST OF PREVENTIVE MEDICINE
Q. 20./21. Discussion Guide - Focus Groups
Cardiovascular Round Table Taskforce 4
Improving Guidelines to Increase
Future Use
 Easy to understand & easy to use
 Include back-up data of latest scientific studies
 Regular updates
 Short
 Realistic - possible to implement
 Clear objectives - quick to implement
 Solve gap between prevention (doctors) and lack of awareness (population)
 Universal
 Source must be credible & trustworthy
Q. 25./26./27. Discussion Guide - Focus Groups
Cardiovascular Round Table Taskforce 4
Improving Guidelines to Increase Future Use
(country-specific)
UK









Gov't initiatives, i.e. encourage more sports, tax
junk food, increase tax on cigarettes
Accurate
Validated
Approved by NICE nationally
Approved by PCT locally
Provide cost effective treatment/ advice
Appealing
Provide expiry date
IT compatible
EE

Adapted to Spanish-mediterraneen patients

Schematic therapy schemes
PL
D
D

Patient education

Show potential for cost reduction

Inexpensive

Wide use possible

Studies based on local population

Define risk levels

Recommendations on optimal therapy

Recommendations on expensive medications

Access via Internet
Q. 25./26./27. Discussion Guide - Focus Groups
Cardiovascular Round Table Taskforce 4
Barriers Preventing Physicians from
Implementing CV Guidelines (unprompted)
36%
Patient compliance
No time
23%
E: 50%
Too theoretical - individual treatment
necessary
21%
UK Card: 44%
Financial barriers
20%
D Card: 44%
PL: 67%
Complicated to use
15%
UK Card: 44%
E Card: 33%
Q. 30. (o), 16.b (o); Base: n = 220 physicians in 6 countries; responses < 8% not included
Cardiovascular Round Table Taskforce 4
Most Important Barriers in the Implementation
of CHD Prevention Guidelines
Scale: 1 "small/ unimportant" - 10 "large/ very important"
Top Box 8 - 10
[19 prompted statements]
Government health strategy does not
help in prevention
40%
There is little or no financial reward for
prevention
36%
30%
Budget constraints prevent me ...
Don't have time with each patient ...
Hospital/ local policies do not help
Patients not motivated
27%
23%
20%
Q. 31.a (c); Base: n = 220 physicians in 6 countries; responses < 19% not included
Cardiovascular Round Table Taskforce 4
PL: 77%
F: 16%
PL: 93%
D: 57%
D: 60%
PL: 67%
PL: 70%
F: 8%
E: 10%
Barriers Preventing Proper Assessment
of CV Risk
In all countries TIME LIMITATIONS is the main barrier
also ...
 Consultations not rewarded sufficiently
 Lack of resources
 Discrepancy between goals and reality
 Depends on patients (emotional/ social aspects)
 Patients non-compliant in changing lifestyle (unmotivated)
 Situation difficult in rural areas (PL)
 Financially weak patients (cost) (PL)
 Public healthcare patient does not stay with one doctor (PL)
 Insufficient availability of tests (PL/ D)
"Working time must be paid" (D)
"Secondary prevention is easier because there are obvious conditions to treat" (PL)
Q. 12./12.a Discussion Guide - Focus Groups
Cardiovascular Round Table Taskforce 4
Barriers are Important because ....
There is little or no financial reward for prevention as opposed to
treatment in my healthcare system
 No extra payments for prevention
 Not enough money in the healthcare system
 Lack of incentives/ campaigns to support patients in prevention
Budget constraints prevent me from implementing guidelines for all
patients
 Budget problems with prescribing drug
"... if one wanted to comply to the guidelines we would run into big problems
in regards to the budget ..."
 Treatment only at high risk
 Impossible to implement prevention for all patients
 Lack of money for screening examinations
Q. 31.b (c); Base: n = 220 physicians in 6 countries
Cardiovascular Round Table Taskforce 4
Barriers are Important because ....
I don't have time with each patient to undertake practical prevention
 Prevention is time intensive
 Too many patients
 Need time to motivate patients
"... it is difficult to find time for patients if there is a crowd of patients in the
waiting room ..."
"... I have too many patients, therefore I focus on the ones with the most important risk
factors ..."
Hospital/ local policies do not help me to develop prevention
 No cooperation between docs & hospital
 No prevention in hospitals/ only treatment of urgent cases
 Rising costs are limiting
"... Patients always have to become really sick before anything happens and
then things become really expensive ..."
"... local policy means reduction of examination costs ..."
"... they are not interested because they are more involved in treating acute events ..."
Q. 31.b (c); Base: n = 220 physicians in 6 countries
Cardiovascular Round Table Taskforce 4
Most Important Aspects in Making
Practical Prevention Easier
Scale: 1 "would not make it easier at all" - 10 "would make it a lot easier" [12 prompted statements]
Top Box 8 - 10
Simpler guidelines
46%
M ore nursing staff trained in prevention
46%
E Card: 89%
UK: 73%
PL: 87%
M ore medical colleagues trained in
prevention
46%
PL: 93%
Shorter guidelines
45%
Developoment of shared care prorams
between GPs & consultants
44%
E: 70%
Regular newsletters or updates
43%
PL: 80%
Workshops to help develop skills &
prevention strategy
41%
Q. 33. (c); Base: n = 220 physicians in 6 countries; responses < 37% not included
Cardiovascular Round Table Taskforce 4
PL: 90%
F: 8%
Most Important Aspects in Making Practical
Prevention Easier (2)
Scale: 1 "would not make it easier at all" - 10 "would make it a lot easier" [12 prompted statements]
Top Box 8 - 10
Wider availability of paper-based risk charts
& guidelines
37%
Risk calculators
37%
Computer based risk charts
32%
Computer based risk charts with interactivity
to lead into management recommendations
Other aspects, i.e.
29%
11%
more time needed
see less patients
Spanish risk charts, protocols and guides
Simpler, shorter, more training
Q. 33. (c); Base: n = 220 physicians in 6 countries
Cardiovascular Round Table Taskforce 4
PL Card: 63%
UK Card: 67%
UK: 60%
E PCP: 48%
Most Influential Sources on (New)
Guidelines (prompted)
Medical journals/
studies
82%
Medical conferences
70%
Sales reps
34%
Medical societies
29%
Colleagues/ opinion
leaders
29%
Internet
Newspapers
21%
11%
Q. 36. (c); Base: n = 220 physicians in 6 countries; multiple choice; responses < 5% not included
Cardiovascular Round Table Taskforce 4
UK: 57%
E: 40%
SUMMARY
CHD ASSESSMENT
• Awareness that global risk approach is necessary to assess risk, yet
physicians don’t fully understand the principle and they revert back to
individual risk factor assessments
GUIDELINES
• National guidelines are the predominant reference for recommendations
• Uniform recognition of guidelines seem linked to a clearer source and
consistency of guidance
• Current use & understanding of guidelines does not necessarily translate
into an understanding of the principles of global risk
• Scoring systems seem to convey global risk more directly
Many BARRIERS TO IMPLEMENTATION
FUTURE AREAS OF FOCUS
• Different countries may require focus on slightly different areas of
implementation
• Improving implementation goes beyond just developing a new set of
guidelines
Cardiovascular Round Table Taskforce 4