BackgroundPrimary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more susceptible to treatment harms. Moreover the potential benefits and harms of preventive medication for older people are uncertain. We explored GPs’ decision making about primary CVD prevention in patients aged 75 years and older.Method25 GPs participated in semi-structured interviews in New South Wales, Australia. Transcribed audio-recordings were thematically coded and Framework Analysis was used.ResultsAnalysis identified factors that are likely to contribute to variation in the management of CVD risk in older people. Some GPs based CVD prevention on guidelines regardless of patient age. Others tailored management based on factors such as perceptions of prevention in older age, knowledge of limited evidence, comorbidities, polypharmacy, frailty, and life expectancy. GPs were more confident about: 1) medication and lifestyle change for fit/healthy older patients, and 2) stopping or avoiding medication for frail/nursing home patients. Decision making for older patients outside of these categories was less clear.ConclusionOlder patients receive different care depending on their GP’s perceptions of ageing and CVD prevention, and their knowledge of available evidence. GPs consider CVD prevention for older patients challenging and would welcome more guidance in this area.

BackgroundCardiovascular disease (CVD) prevention guidelines encourage assessment of absolute CVD risk - the probability of a CVD event within a fixed time period, based on the most predictive risk factors. However, few General Practitioners (GPs) use absolute CVD risk consistently, and communication difficulties have been identified as a barrier to changing practice. This study aimed to explore GPs’ descriptions of their CVD risk communication strategies, including the role of absolute risk.MethodsSemi-structured interviews were conducted with a purposive sample of 25 GPs in New South Wales, Australia. Transcribed audio-recordings were thematically coded, using the Framework Analysis method to ensure rigour.ResultsGPs used absolute CVD risk within three different communication strategies: ‘positive’, ‘scare tactic’, and ‘indirect’. A ‘positive’ strategy, which aimed to reassure and motivate, was used for patients with low risk, determination to change lifestyle, and some concern about CVD risk. Absolute risk was used to show how they could reduce risk. A ‘scare tactic’ strategy was used for patients with high risk, lack of motivation, and a dismissive attitude. Absolute risk was used to ‘scare’ them into taking action. An ‘indirect’ strategy, where CVD risk was not the main focus, was used for patients with low risk but some lifestyle risk factors, high anxiety, high resistance to change, or difficulty understanding probabilities. Non-quantitative absolute risk formats were found to be helpful in these situations.ConclusionsThis study demonstrated how GPs use three different communication strategies to address the issue of CVD risk, depending on their perception of patient risk, motivation and anxiety. Absolute risk played a different role within each strategy. Providing GPs with alternative ways of explaining absolute risk, in order to achieve different communication aims, may improve their use of absolute CVD risk assessment in practice.

Research urrent guidelines for cardiovascular disease (CVD) prevention advocate the use of absolute risk (AR) assessment to guide the use of preventive medication, rather than treating blood pressure and cholesterol separately. 2-5 Age, sex, smoking, diabetes, systolic blood pressure and cholesterol ratio are used to estimate the risk of a cardiovascular event in the next 5 years. Preventive medication is recommended if AR is higher than 15%, or 10%-15% with other risk factors. 2,3 Reviews suggest that the AR approach may improve the clinical management of CVD without harm to patients. 6,7 Basing treatment decisions on high AR rather than high individual risk factors may prevent overtreatment of patients with isolated risk factors but low to moderate overall risk, and undertreatment of patients with high overall risk. 8,9 However, international 10-13 and Australian 14-18 research suggests that CVD risk management is not consistently based on AR. Possible barriers to general practitioners using AR assessment include lack of time, accessibility, knowledge and trust; conflicting guidelines; difficulty understanding and explaining AR; and focusing on individual risk factors that may not be included in AR models.10-18 According to the "behaviour change wheel" framework, these factors may act as barriers to the use of AR assessment through three determinants of behaviour: opportunity (eg, access), capability (eg, knowledge) and motivation (eg, trust). 19Little is known about how and why GPs do use AR in CVD risk assessment, and the alternative strategies employed when AR is not the focus of assessment. We aimed to investigate GPs' views and experiences of CVD risk assessment to identify factors that influence the extent to which Australian AR assessment guidelines are used. MethodsWe used purposive sampling to recruit participants, aiming for maximum variation among a set of characteristics known to influence CVD risk management (Box 1). [20][21][22] Invitation letters were posted to all 3743 members of eight Divisions of General Practice in metropolitan New South Wales. Of 55 GPs who returned expression of interest forms, we allocated 25 to this study. GPs signed a consent form before participating in person (two participants) or via telephone (23 participants). They received $100 for their time. Preliminary analysis suggested saturation of key themes related to the range of CVD risk assessment strategies described by GPs, so no further recruitment was conducted.23 Ethics approval was obtained through the Sydney Local Health District Human Research Ethics Committee.A semi-structured interview schedule covering CVD risk assessment and management was developed (Appendix 1; online at mja.com.au), piloted with two GPs, and clarified. Interviews lasted between 22 and 55 minutes, and de-identified audiorecordings were transcribed verbatim. Between October 2011 and May 2012, interviews were conducted by two of us (C B, S M) who have qualifications in public health.We used a framework analysis method 24 and summarised data w...

BackgroundClinical care for older adults is complex and represents a growing problem. They are a diverse patient group with varying needs, frequent presence of multiple comorbidities, and are more susceptible to treatment harms. Thus Clinical Practice Guidelines (CPGs) need to carefully consider older adults in order to guide clinicians. We reviewed CPG recommendations for primary cardiovascular disease (CVD) prevention and examined the extent to which CPGs address issues important for older people identified in the literature.MethodsWe searched: 1) two systematic reviews on CPGs for CVD prevention and 2) the National CPG Clearinghouse, G-I-N International CPG Library and Trip databases for CPGs for CVD prevention, hypertension and cholesterol. We conducted our search between April and December 2013. We excluded CPGs for diabetes, chronic kidney disease, HIV, lifestyle, general screening/prevention, and pregnant or pediatric populations. Three authors independently screened citations for inclusion and extracted data. The primary outcomes were presence and extent of recommendations for older people including discussion of: (1) available evidence, (2) barriers to implementation of the CPG, and (3) tailoring management for this group.ResultsWe found 47 eligible CPGs. There was no mention of older people in 4 (9 %) of the CPGs. Benefits were discussed more frequently than harms. Twenty-three CPGs (49 %) discussed evidence about potential benefits and 18 (38 %) discussed potential harms of CVD prevention in older people. Most CPGs addressed one or more barriers to implementation, often as a short statement. Although 27 CPGs (58 %) mentioned tailoring management to the older patient context (e.g. comorbidities), concrete guidance was rare.ConclusionAlthough most CVD prevention CPGs mention the older population to some extent, the information provided is vague and very limited. Older adults represent a growing proportion of the population. Guideline developers must ensure they consider older patients’ needs and provide appropriate advice to clinicians in order to support high quality care for this group. CPGs should at a minimum address the available evidence about CVD prevention for older people, and acknowledge the importance of patient involvement.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0310-1) contains supplementary material, which is available to authorized users.

Background: Cardiovascular disease (CVD) prevention guidelines are generally based on the absolute