Perceived determinants of cardiovascular risk management in primary care: disconnections between patient behaviours, practice organisation and healthcare system

Abstract

BackgroundAlthough conditions for high quality cardiovascular risk management in primary care in the Netherlands are favourable, there still remains a gap between practice guideline recommendations and practice. The aim of the current study was to identify determinants of cardiovascular primary care in the Netherlands.MethodsWe performed a qualitative study, using semi-structured interviews with healthcare professionals and patients with established cardiovascular diseases or at high cardiovascular risk. A framework analysis was used to cluster the determinants into seven domains: 1) guideline factors, 2) individual healthcare professional factors, 3) patient factors, 4) professional interaction, 5) incentives and recourses, 6) mandate, authority and accountability, and 7) social, political and legal factors.ResultsTwelve healthcare professionals and 16 patients were interviewed. Healthcare professionals and patients mentioned a variety of factors concerning all seven domains. Determinants of practice according to the health care professionals were related to communication between healthcare professionals, patients’ lack of knowledge and self-management, time management, market mechanisms in the Dutch healthcare system and motivational interviewing skills of healthcare professionals. Patients mentioned determinants related to their knowledge of risk factors for cardiovascular diseases, medication adherence and self-management as key determinants. A key finding is the mismatch between healthcare professionals’ and patients’ views on patient’s knowledge and self-management.ConclusionsPerceived determinants of cardiovascular risk management were mainly related to patient behaviors and (but only for health professionals) to the healthcare system. Though health care professionals and patients agree upon the importance of patients’ knowledge and self-management, their judgment of the current state of knowledge and self-management is entirely different.

Current and future cardiovascular disease risk assessment in the European Union: an international comparative study

“…Consistent with the findings from this study, recent research from the Netherlands highlights the gap between positive policy intent and implementation of CVD risk assessment in practice, 21 with patient, organisation and health system factors all influencing implementation in primary care. A systematic review of breast cancer risk prediction models found that the model most widely implemented in practice was the one that was most widely available, rather than the model with the best predictive ability.…”

Control of cardiovascular risk factors and its determinants in the general population– findings from the STAAB cohort study

“…This would be in line with findings from the HYDRA study (Hypertension and Diabetes Risk Screening and Awareness Study), which reported on an insufficient BP control that seemed to be unnoticed by the treating physicians [ 9 ]. Another issue might be the mismatch of insufficient knowledge and compliance from patients´ side and the lack of time for a comprehensive evaluation of all guidelines applying for an individual patient combined with explanations and close guidance from physicians´ side [ 42 , 43 ].…”

Tailored implementation of cardiovascular risk management in general practice: a cluster randomized trial

“…A tailored implementation program was developed in a systematic, stepwise process. We have reported on the various steps in this developmental process before [ 6 – 8 , 12 ]. First, prevailing clinical guidelines [ 13 , 14 ] and clinical audit data were analyzed to define the following interrelated targets for improvement: systolic blood pressure (SBP) <140 mmHg in patients with established CVD or in patients at high risk for CVD; low-density lipoprotein (LDL) cholesterol <2.5 mmol/l in patients with established CVD or in patients at high risk for CVD; promote lifestyle changes in patients with (high risk for) CVD; create a risk profile for patients with chronic kidney disease.…”

“…Then, an interview study was done, involving physicians, nurses, and patients, which identified 139 plausibly important determinants of practice (“barriers or enablers of implementation”). Of this list, a set of 11 determinants was selected based on importance and changeability as judged by the research team and used for subsequent steps [ 8 , 12 ]. Subsequently, group interviews with different stakeholders and patients generated 181 suggested strategies for implementation, which were perceived to address the selected set of 11 most relevant determinants [ 6 ].…”

“…As part of a large, international study of tailored implementation, the Tailored Implementation for Chronic Diseases (TICD) project, we adopted these strategies to CVRM in the Netherlands. In an interview study, primary care professionals, patients, and other stakeholders emphasized the challenges of counselling patients on health-related lifestyles, medication adherence, and self-management [ 6 – 8 ]. We developed and evaluated a tailored implementation program to address these challenges, based on a comprehensive empirical analysis of determinants of delivering recommended CVRM and suggestions for interventions.…”