Andre's story
A Gap between Evidence and Practice
How is it done now, and what are the faults?
How can it be done better?
Where and by whom?
Why now?
What we need to do - assignments
What resources do we need?
About samapproach.com

Andre's story

Andre came to the clinic on a hot May morning, nervous and in a bad mood.
He planted his stout figure in the doorway and explained with bristling agitation, that being the only Rumanian-speaking doctor in town, I was his last resort.
He needed to see a doctor urgently because his blood pressure, which had always been perfect, not a bit of trouble, had gone up and was making him feel bad.
Had it not been for his son, he would have stayed in Rumania among his friends at the railway and all this trouble would never have happened in the first place.
My lessons in Rumanian ended when my grandmother was relieved of taking care of me at the age of five, and although I am somehow able to understand, actually speaking the language is beyond me.
Andre was not deterred.
He assured me that all I had to do was fix his blood pressure and he trusted me to do a perfectly good job.
Recruiting his son to translate, I learned that Andre was a seventy-three year old retired locomotive driver, married to Natasha for more than forty years, and father to Michael, a young bachelor engineer. The parents joined the son a few years ago.
He declared himself healthy and fit, except for "this blood pressure business".
He smoked a bit "but only for pleasure", did not drink and had never taken any medications. His blood pressure was 180/95. The physical examination was otherwise unremarkable. An ECG revealed signs consistent with an old inferior wall myocardial infarction. When pressed Andre confessed to "some minor heart trouble" for which he had been hospitalized 15 years ago, a long forgotten episode.
Therapy with a thiazide-diuretic lowered his blood pressure to 140/80 in the course of two weeks. His LDL cholesterol was 95 mg/dl and his serum glucose a 100 mg/dl.
He did not want a cardiologic consultation, and refused aspirin because he had heard it caused stomach problems.
He was quite happy and felt his old self again.
Three weeks later my car-phone rang. Michael was worried about his father. Since the morning he had not got out of bed, seemed sleepy, and could not move his left hand. At the hospital a large right cerebral infarction was diagnosed.
Andre’s hospital course was prolonged, and complicated by a myocardial infarction. He recovered slowly and partially. He was discharged with aspirin and a beta-blocker.
A spastic left hemi-paresis had set in and he walked stiffly with a tripod cane, his natural stubbornness aiding him in the activities of daily living. I felt bad for him. I asked myself if the stroke could have been prevented. Had there been more time to get to know him, I thought, then perhaps he would have agreed to further tests or accepted a low dose of aspirin?
Then I asked myself how many more patients of mine were heading for this scenario?
How many patients were at risk for adverse cardiovascular events? Did I know who they were? Was I aware of their individual risk?
Come to think of it, how long was it since I had seen Mrs. Gold and spoke to her about her cholesterol? Surely, less than a month ago. No. The last time- it was her joint pain that we dealt with. I should check her last lipid profile. Her husband still smoked. Did the last dose adjustment normalize his blood pressure? A long time has passed since I have thought of those two. In fact I was suddenly not so confident that my patients were receiving all that I could timely offer them by way of cardiovascular risk reduction. Could this be? I considered myself well rehearsed in the subject. I made a point of keeping abreast with the relevant clinical-practice guidelines. How big was the difference between knowing what should be done and actually doing it efficiently in day-to-day practice?

A Gap between Evidence and Practice

On may 9th 1998 the BMJ published an article dealing with secondary prevention of coronary artery disease in primary care. The files of 1921 patients under 80 years of age with coronary heart disease were reviewed for treatment with aspirin, blockers, angiotensin-converting-enzyme inhibitors, and management of lipid concentrations and hypertension according to local guidelines. Dietary habits, physical activity, smoking status, and body mass index were noted. Results showed that: " ...63% patients took aspirin. Of patients with recent myocardial infarction, only 32% took blockers, and of those with heart failure, only 40% took angiotensin-converting-enzyme inhibitors. Blood pressure was managed according to current guidelines for 82% of patients but lipid concentrations for only 17%. 51% took little or no exercise, 18% were current smokers, 64% were overweight, and 52% ate more fat than recommended." The conclusions of this study: "..in terms of secondary prevention , half of patients had at least two aspects of their medical management that were sub-optimal and nearly two thirds had at least two aspects of their health behavior that would benefit from change. There seems to be considerable potential to increase secondary prevention of coronary heart disease in general practice." (1)
Three years later the BMJ published the results of a primary care survey dealing with the same issue. Major modifiable risk factors and prescription of secondary preventive drug treatment were assessed in 24 431 patients with a diagnosis of coronary disease. The results showed that: "..almost a quarter of the total study population still smoked. About two thirds of the overall study population had blood pressure below 160/90 mm Hg. However, blood pressure is less well managed among diabetic patients. Lipids were much less well managed than blood pressure. Most patients were hypercholesterolaemic or had never been tested. Only a few were taking statins, despite evidence that these drugs are effective. It is also disappointing that so few patients with a previous myocardial infarction were receiving blockers, drugs that are proved to reduce ventricular tachycardia and sudden death after a heart attack. It is encouraging that about half of the patients with heart failure in this study were prescribed angiotensin converting enzyme inhibitors." (2)
Similar studies published in leading medical journals produced similar results. A gap indeed exists between clinical knowledge and clinical practice.
I decided to review the practical approach to cardiovascular risk reduction in primary care. How are we doing it now, and what are the faults? How can it be done better? Where and by whom?

How is it done now, and what are the faults?

Currently the field of cardiovascular risk reduction suffers from two major inadequacies:

1. Sub-optimal use of relevant clinical information
   This is due to several factors, among them a staggering amount of information presented in a plethora of available guidelines, a lack of knowledge of guideline content and a misunderstanding of the way guidelines should be used.
2. Lack of a systematic approach to implementation
   • Most primary care physicians detect patients with cardiovascular risk factors through case-finding rather than screening. Many times this is done when a patient comes to the clinic with an unrelated concern. A serious and effective approach to risk factor detection and monitoring cannot be carried out as a side issue of the clinical encounter. Time is too short, and neither party is adequately focused.
   • Every physician treating patients with cardiovascular risk factors tries constantly, almost automatically, to gauge individual risk. Experience, knowledge and intuition are used. Usually, there is no attempt at quantifying cardiovascular risk, and therefore no consistent link between the risk level and the intervention plan.
   • There is still a tendency to manage the disease rather than the patient, sometimes in specialized diabetes, lipid or blood pressure clinics. This division into disciplines is often illogical and cumbersome, although important in certain severe cases. The synergistic effects of the various risk factors, and the implications regarding the setting of treatment goals are still underestimated.
   • When risk factors are detected, follow up is usually based on recommendations from visit to visit and not on a regular pre-set basis.
   • Finally, modification of cardiovascular risk factors begins too often after the onset of the cardiovascular disease.

How can it be done better?

These inadequacies can be overcome by:

1. Optimal use of relevant clinical information
   For the busy practitioner, swift access must be offered to information relevant to the task of cardiovascular risk reduction. This information should be available both in full-text high quality clinical-practice guidelines and in summarized, quick-reference format.
2. A systematic approach to implementation
   • Screening for cardiovascular risk factors should augment case finding. A well-accepted paradigm is that a disease that is prevalent and serious on the one hand, while preventable on the other, calls for an appropriate screening program. Since cardiovascular disease is prevalent, serious and preventable, screening is more than justified.
   • An individual risk assessment should be made for each patient, and a consistent link established between risk level and intervention plan.
   • The therapeutic focus should be on the patient, with a holistic view of his/hers cardiovascular risk factors. An emphasis should be placed on early and ongoing interventions.
   • Patients with cardiovascular risk factors should be monitored on a regular pre-set basis.

Where and by whom?

The primary care setting is the right place and the primary care physician the right person for implementing such an approach. The primary care clinic supervises a relatively stable and familiar patient population over long periods of time. Many of the patients start visiting the clinic at a young age, when detection of cardiovascular risk factors can lead to early intervention.
The clinics population is concentrated mainly within its geographical vicinity and has access to it. The primary care clinic also represents the lowest cost to the health care system to which it belongs. Today’s primary care physician, having completed an internal medicine or a family practice residency, is well oriented toward prevention and treatment of cardiovascular disease. An ongoing and stable doctor-patient relationship, as is common in many primary care settings, encourages compliance with long-term follow up and treatment.
This same physician has modern technology working for him in several areas. An electronic medical record helps to maintain patient-files and retrieve data from them. Availability of modern ambulatory facilities in the way of laboratory examinations, imaging tests, and specialist consultations facilitates clinical work.
Immediate access, via the internet, to high quality medical sources provides clinical information, which includes consensus statements and clinical-practice guidelines, relevant to every day work.

Why now?

A systematic approach to cardiovascular risk reduction is a task of the hour.
Several processes have evolved to make this so.

1. The international pooling of data concerning the epidemiology of cardiovascular disease, shows that it is the leading cause of death in the developed world and is claiming a heavy toll in developing countries as well. (3) (4) (5) It spans gender and race and poses a heavy burden on patients and their families, on national health care systems and on society as a whole.
2. The increasing economic burden of treating CVD, especially in the tertiary setting.
   With advances in modern cardiovascular medicine, especially in the field of invasive vascular medicine, interventions of increasing complexity and cost are being offered to patients, giving new hope, but also adding an enormous logistic and economic burden to systems already operating on the brink.
3. The growing body of knowledge regarding the different cardiovascular risk factors. This knowledge is based on the results of large population-based longitudinal studies. Major cardiovascular risk factors have been (and are being) defined, along with conditional and predisposing risk factors, and important steps have been made toward a better understanding of their individual and synergistic impacts.
4. The development of proven effective interventions for risk factor modification.
   Multi-centered randomized controlled trials have tested the efficacy of various non-pharmacological and pharmacological interventions. Some of these interventions reduce cardiovascular morbidity and mortality significantly. Combining them systematically may lead to superior results.

What we need to do - assignments

1. Devise a swift access to clinical information relevant to the task of cardiovascular risk reduction, both in full-text clinical-practice guidelines and in summarized, quick-reference format.
2. In order to systematically detect and monitor patients with cardiovascular risk factors, we must take on four assignments:
   • Screen our patient population at reasonable intervals in order to detect patients with cardiovascular risk factors, yet unrecognized.
   • Assess each patient’s individual cardiovascular risk.
   • Monitor patients with cardiovascular risk factors on a regular basis.
   • Provide the best intervention plan available for each patient according to his/her cardiovascular risk profile.
   We must do all this in a time efficient manner, as part of the work routine.

What resources do we need?

We need three types of resources in order to fulfill these four assignments.

1. Human resources- the primary care clinician.
   (In large practices a major part of the work can be done by other medical personnel)
2. Scientific resources- evidence-based, clinical-practice guidelines and consensus statements.
3. One technological resource- the software you use for your patient’s medical records. (This is the simplest part!)

About samapproach.com

This site will assist in the organization of an integrated medical-practice work environment, involving the primary care clinician (skills, experience and knowledge), clinical information regarding cardiovascular risk-reduction and the Electronic Medical Records (EMR) software.
Direct access to cardiovascular risk-assessment and modification strategies is available.
For every major modifiable cardiovascular risk factor, a link is provided to a clinical-practice-guideline, as well as a “flash-summary” of this guideline (see Clinical Information).
Familiarity with three of the basic features on the EMR software used within the practice, will enable the screening and monitoring of patients with cardio-vascular risk factors (see Implementation).
This combination of access to relevant, high quality clinical information and the clinician’s own risk population may result in more effective CVD prevention.

It is recommended that the practical section of this site be read in full. The scientific section may be approached as and when required.
New content on epidemiological and clinical data surface constantly, so bookmark the site in your browser Favorites and visit often.

Israel Rabinowitz MD

1. Neil C Campbell, Joan Thain, H George Deans, Lewis D Ritchie, And John M Rawles. Secondary Prevention In Coronary Heart Disease: Baseline Survey Of Provision In General Practice
BMJ 1998; 316: 1430-1434
2. A J B Brady, M A Oliver, And J B Pittard. Secondary Prevention In 24 431 Patients With Coronary Heart Disease: Survey In Primary Care. BMJ 2001; 322: 1463.
3.Heart Disease. National Vital Statistics Reports, Vol. 49. No. 8
http://www.cdc.gov/nchs/fastats/heart.htm
4. Stroke. National Vital Statistics Reports, Vol. 49. No. 12
http://www.cdc.gov/nchs/fastats/stroke.htm
5. World Health Report 1997 -Executive Summary.http://www.who.int/whr/1997/exsum97e.htm