Physicians slow to intervene with high-risk patients

Cholesterol screening done only half the time

No medical professional would dispute the voluminously documented benefits of exercise, improved diet, smoking cessation, and cholesterol screening for millions of Americans with coronary heart disease.

Yet a recent study published in Circulation, the journal of the American Heart Association, shows physicians are woefully deficient when it comes to assessing patients for risk of heart disease and showing them ways to save their own lives. The same is true for physicians treating patients in heart failure, say specialists in that field.

Five years after the National Cholesterol Education Program guidelines recommended widespread screening for cardiovascular risk factors and treatment of high cholesterol, a study led by Joseph Frolkis, MD, PhD, of the Cleveland Clinic Foundation showed physicians do cholesterol screening only half the time, even in high-risk patients, and counsel patients in preventive measures even less frequently.

Frolkis’ team reviewed the charts of 225 patients in the coronary care unit of a major teaching hospital during the first half of 1996 and found that, of eight possible risk factors listed in the 1993 NCEP guidelines, medical professionals screened, on the average, for 2.4 of them.

Nancy Albert, MSN, RN, CCRN, CNA, clinical nurse specialist for heart failure and transplantation at the Cleveland Clinic Foundation was not connected with the Frolkis study, but she says the conclusions translate well to patients in congestive heart failure.

"From a heart failure and noncompliance standpoint, there are a lot of physicians out there who aren’t good about following the [two sets of] guidelines that have been set out for heart failure," Albert says.

Many physicians are "miscommunicating activity expectations" for CHF patients and still telling them to rest, take naps, and lie around in bed. "We get patients all the time who tell us their doctors tell them not to exercise. We encourage exercise.

"From a diet standpoint," Albert adds, "a low-sodium diet is expected for heart failure patients, but they aren’t referred to a dietician for counseling, so patients are forced to figure it out on their own. And physicians aren’t very good about getting very specific."

Sidney C. Smith Jr., MD, past president of the American Heart Association and professor and chief of cardiology at the University of North Carolina at Chapel Hill, says studies on patients with congestive heart failure "show a similar lack of utilization of newer therapies such as ace inhibitors which could significantly improve outcome for these patients."

In addition, heart failure patients, like patients with heart disease, often benefit from lowering cholesterol, dietary changes and smoking cessation. The results of Frolkis’ study complement what needs to be done with CHF patients as well, experts say.

Why are physicians failing to do the recommended screenings?

The Frolkis study points the finger at three "powerful negative incentives" for doctors:

• increasingly limited amount of time a physician is permitted to spend with a patient;

• a lack of reimbursement by insurers;

• lack of training during medical school.

Frolkis told Reuters News Agency, "The data is there that prevention works. By and large, physicians are very bright and very caring and they still don’t do it — that’s what’s so peculiar."

Physicians treating patients with congestive heart failure are similarly remiss, Albert says. And with rapid developments in the field, particularly since the advent of ace inhibitors and beta blockers in the past decade, some physicians simply haven’t kept up.

"Physicians who don’t do heart failure for their livelihoods are perhaps too conservative with drugs, so they don’t use the therapies to their maximum," Albert says. "Most do a good job of starting ace inhibitors, for example, but they do a bad job of getting it up to the target dose. The symptoms go away, but the heart failure is really worsening."

Beta blockers critically underused

The situation is even more serious with beta blockers, she says. For some physicians, it is easier not to start the beta blockers than to do the intensive in-office monitoring necessary. And that is quite clearly costing lives, Albert says: "Beta blockers, carvedilol especially, can cause a 67% reduction in heart failure mortality when added to the other three big drugs we use on just about everybody."

To one of the Frolkis study’s authors, Pamela S. Suhan, RN, MBA, CCRC, clinical research coordinator at Cleveland Clinic, the time pressure doctors find themselves under is driving the noncompliance with the NCEP guidelines.

"They are so limited by the time. I don’t know how much time docs have, depending on the practice. One cardiologist I know is supposed to see a patient every six minutes. How can you even do a follow-up in that time?"

A high percentage of the coronary care unit patients in the Frolkis study were never screened for major coronary risk factors:

• One-quarter were not screened for previous heart disease.

• One-third were not tested for high blood pressure.

• More than 40% did not have cholesterol levels checked.

Of other heart risk factors, physicians screened even fewer:

• Only 37% were screened for diabetes.

• Eleven percent were screened for hormone replacement therapy.

• One percent were screened for premature menopause.

Exacerbating the problem, only an infinitesimal number were counseled to eliminate behavioral risk factors:

• Four percent were counseled to stop smoking;

• Fourteen percent were sent to a dietician for assistance in diet modification.

• Only 1% were encouraged to exercise.

By way of contrast, interns at the teaching hospital did relatively well in screening, but even they inquired about only two risk factors, (a history of heart disease and smoking) 70% of the time.

Why? To Suhan, it’s a chain of events from bottom to top.

Suhan says interns take histories and sometimes do counseling, then a resident and finally the cardiologist look at the notes and think the counseling has been done.

"Everybody thinks someone else is doing it" when in the end, often no one is, Suhan says.

Strike while the iron’s hot

Suhan says another factor is patient noncompliance or lack of education. In those cases, she says, she is an advocate of what she calls the "fear factor."

"We need to hit them while they’re in the hospital," she says. "If you get somebody when they have had an event and say, Listen, you had this event because your cholesterol is high. We need to get it down and this is how we’re going to get it down,’ you’ve made an impact and it is indelible because you’ve got them when the fear is high."

If doctors followed the guidelines religiously, experts agree than a significant number of the half million deaths of Americans each year from CHD could be prevented, not to speak of the $100 million in medical costs that might be saved.

"At a time when cardiovascular disease is the leading cause of death and disability for our society, and at a time when there are so many new promising medications which could alter this toll, it is extremely important that we examine our health care delivery systems, our educational systems and practice patterns to ensure that preventive therapies and medical therapies with patients having significant disease are provided," Smith says.

Suhan, herself an RN, favors a team approach with nurses and other health professionals performing most of the screening and counseling. She says nurses performed even better than interns in many cases in following the NCEP guidelines, and nurses are expected to move into increasingly responsible roles in the management of clinics and practices under physician supervision.

"The nurses have a care plan, a database they follow through. Nurses have a standard set of questions. They have to ask about medications, certain history questions. Doctors don’t use a checklist, they just file progress notes," Suhan says.

She also suggests nurses may be doing more counseling than records reflect. "When I talked to the nurses, they say they always counsel patients on smoking. I said, If you always do, why, in a six-month period, only one person was documented?’" The reply? "We must not be charting it."

"If it’s not charted, it’s not done," Suhan says. "It was a shame."

To rectify a bad situation, Smith favors massive education at all levels — and high-level pressure on managed care companies.

"The American Heart Association has initiated a major campaign to make physicians and patients more aware of the benefit of these therapies. Public education is very important. We are also working with managed care at a national level to see that funding is made available," he concludes.