1. Self-reported cognitive and emotional effects and lifestyle changes shortly after preventive cardiovascular consultations in general practice Dea Kehler Department of General PracticeResearch Unit for General Practice U N I V E R S I T Y OF A A R H U S

2. Outline  Background  Aim  Design  Material  Method  Results  Strenghts and weaknesses  Conclusion  Perspectives  Future research

3. Background  It is evidence based that lifestyle interventions is effectfull in prevention of CVD  It is a fact that many patients with high risk of CVD do not obtain the treatment goals in daily clinic  The adherence to lifestyle counselling and medication is not optimal either from the GP or patient perspective

4. Background  In Denmark and many other countries, prevention of disease has become a priority area in recent years  Prevention of CVD has been a focus area in general practice in Denmark since 1999

5. Background In 2006, a scheduled preventive consultation for people at increased risk of CVD was introduced together with a set of clinical guidelines, published by the Danish College of General Practitioners.

6. Clinical guidelines  To estimate the total cardiovascular risk from fatal CVD within 10 years by using the score system and use the recommendations addressing the specific risk  To identify components of risk that are to be modified and patients’ own perception of the issue  To use motivational interviewing and adopted risk handling strategies based on shared decision making  To schedule a follow-up consultation

7. Number of preventive cardiovascular consultations (1999-2006) and preventive consultations in all (2006-2008) in DK

8. Aims To explore og analyse GPs and patients experiences with: 1.1 Communication about motivation in relation to lifestyle changes through a mixed approach 1.2. The doctor-patient relationship in relation to lifestyle changes through a mixed approach 1.3. Risk commmuncation through a mixed approach 1.4 To quantify and analyse patients evaluations of preventive consultations through a questionnaire study

9. Questionnaire aim To describe patients’ evaluation of the contents of preventive cardiovascular consultations and to analyse whether their evaluation is shaped by self-reported cognitive and emotional effects and lifestyle change two to six weeks after the consultations

10. Questionnaire material The health insurance register provided data on 2450 people, who had a preventive cardiovascular consultation in february 2007 1714 filled out a consultation evaluation questionnaire 2 to 6 weeks after their preventive consultation with their GP (70%) Among these, 1226 fulfilled the inclusion criteria, which were:  Participation in a scheduled preventive consultation with focus on primary prevention of CVD and an individual risk assessment  To be at 5% or higher risk of fatal (death) CVD within 10 years by using the Score system without earlier identified CVD

11. Questionnaire sections  Section 1 Questions related to patient, GP and consultation characteristics and demographic information validated by DIKE and SF12  Section 2 Questions related to the consultation content and effects developed from qualitative consultation and interview studies with patients at cardiovascular risk and their GPs  Section 3 Comprised two items from COMRADE, a validated patient questionnaire to evaluate risk communication and decision making effectiveness in general practice.

12. The analysis  The exposure and outcome variables were dichotomized in order to analyse the data and create sum scores  Data cleaning and variabel modification  Generation of frequency analysis and histograms  Regression analysis Crude odds ratios Adjusted odds ratios (confounder adjusted)  Effect modification analysis (Wald test)

13. Results Slightly more men than women Mean age 61 years (range 22-89) Most patients were married 70.2 % short-term education 1-2 risk factors: 36% 3-4 risk factors: 41% 4-5 risk factors: 23%

14. Results Patients reported cognitive effects 2-6 weeks after participation in a preventive consultation in the form of:  Increased knowledge about health (79%)  Increased focus on health and CVD (61%)  Better overview in relation to own health (63%)  Increased ability to see how lifestyle influence on health (58%).

15. Results Patients reported changes in lifestyle habits 2 to 6 weeks after participation in a preventive consultation:  Eating habits (57%)  Physical activity habits (48%)  Smoking habits (22%)

16. Results Patients reported emotional effects 2 to 6 weeks after participation in a preventive consultation in the form of:  Relief (80%)  Consultation satisfaction (97%)  Concerns (23%)

17. R esults Patients, who communicated with their GP about:  Cardiovascular risk  Daily living and lifestyle habits  Knowledge about CVD  Perception of cardiovascular risk  Own preventive possibilities reported significant more frequent 3 or 4 cognitive benefits, one or several changes in lifestyle habits and were more frequent satisfied after participation in a preventive cardiovascular consultation (OR range 1.74-4.27)

18. Results Patients reporting being informed about risk of disease or that lifestyle habits had been addressed during the consultation were significantly less frequently relieved, than patients who rapported that these issues had not been raised (OR 0.3-0.7)

19. Results Patients, who reported that issues as:  Daily living  Own perception of risk  Knowledge about CVD  Own preventive possibilities had been raised in the consultation, were significantly more often relieved (OR range 1.61–2.50) than patients, where the issues had not being raised

20. Results Patients reported that issues as: Information about risk Daily living and lifestyle habits Own perception of cardiovascular risk Knowledge about CVD Own preventive possibilities were significantly more often satisfied with the consultation than those, who had not. (OR range 2.2-8.3)

21. Results In all, there was no significant difference between crude and adjusted ORs and introduction of interactions in the regression models did not significantly change any of the ORs.

22. Questionnaire weaknesses  Cross-sectional study – no conclusions about causalities  No long-term effects of the preventive consultation  No statistical or psychometric validation of the deveoloped questionnaire during factor or correlation analysis  The study may be hampered by recall bias, selections bias and confouding

23. Questionnaire strenghts  The response rate was 70%  Quite narrow confidence intervals  High face and content validity  Good generalisability national related to the non- restrictive inclusion and the construction of the questionnaire  GP independent inclusion of patients

24. Conclusion Cardiovascular risk patients reported cognitive and emotional effects and healthy lifestyle changes 2-6 weeks after a preventive consultation and increase in the effects and their consultation satisfaction, if the following issues were raised during the consultation:  Cardiovascular risk  Patients daily living and lifestyle habits  Knowledge about health and cardiovascular disease  Own perception of cardiovascular risk  Own preventive possibilities

25. Perspectives The questionnaire study has shown that the preventive consultation has a development potential, which can be used in medical education programmes based on professional, communicative and lifestyle changing competence elements in the future

26. Perspectives When the education program is developed, it could be interesting to investigate, whether patients have more benefits of the preventive consultations on the long run than by participating in the actual preventive consultation in general practice

27. Perspectives The results can be used in the future development and political debate about primary prevention and preventive consultations in general practice The results underline that the consultation and its content is important in succesfull primary prevention of CVD

28. Future research To investigate whether patiens reported cognitive and emotional effects and healthy changes in life habits rest over time To investigate and identify the consultation elements, which have the most significant impact on patient reported effects of preventive consultations To investigate how many and which type of patients, who need preventive consultations to change and maintain healthy lifestyle changes To investigate whether motivational interviewing and adopted risk handling strategies based on shared decision making could help the GPs and the patients to verbalise and solve the existing ambivalence in preventive consultations

29. Acknowledgements  Participating GPs and patients  The health insurance registers  The Danish Agency of science