A circulation education for the primary care physician

This article is part of the Medical Economics Business of Health: Circulatory Disorders resource center.

Diseases of the circulatory system are not just the domain of specialists. The 2010 National Ambulatory Medical Care Survey found that family physicians have more visits for circulatory problems (35% of visits) than cardiologists (19%) in the United States.

Circulatory system diseases accounted for about 7,500 office visits a year out of a little more than 1 million in the survey, which is a nationally representative sample survey of visits to nonfederal office-based patient-care physicians, excluding anesthesiologists, radiologists, and pathologists.

Circulatory system disorders such as heart disease and stroke have been the leading causes of death and major causes of disability in the United States for almost a century, even as mortality rates decline. They account for more than $200 billion in annual costs in the healthcare system and are the cause of more than one-third of the deaths in those aged at least 65 years. Also, circulatory disorders often signal other health problems.

Many circulatory problems can be improved with better lifestyle choices, however. As the U.S. healthcare system moves from volume-based to value-based incentives, primary care physicians (PCPs) and others have the opportunity to make major improvements in their patient outcomes by redoubling efforts to counsel patients to adopt good health habits at any age.

Your top ally: The patient

According to the American Heart Association, a physician’s most valuable ally in stroke treatment and prevention is the patient.

Harlan M. Krumholz, MD, an internationally recognized heart disease specialist, believes that PCPs have a pivotal role in providing front-line care that can help patients lower their risk factors for circulatory system diseases, with smoking at the top of the list.

Krumholz is the Harold H. Hines Jr. Professor of Medicine (cardiology) and professor of investigative medicine and of public health (health policy) at the Yale University School of Medicine. He is also director of Yale-New Haven Hospital Center for Outcomes Research and Evaluation. He has authored more than 250 journal articles and chapters on cardiovascular care and serves on many national committees focused on improving the care of patients with heart disease.

“Every appointment needs to be seen as an opportunity to encourage and educate patients to stop smoking,” he says. “Too often, this gets pushed aside by fancy risk assessments or lipid tests, but nothing beats making education a priority.”

Education should not be limited to smoking cessation, however. Patients need to be informed about the importance of physical activity, meal portion control, blood pressure management, and more, he says.

“You need to let them know what they can do for themselves to improve their health without medications,” he says. “Anything they can do to avoid having to take medication is worth it. Pills seem like a simple and easy answer, but all have risks and costs associated with them, for the patient and for society.”

Helping a patient make significant lifestyle changes is powerful, he stresses. It offers the possibility of a cure that has no side effects and the opportunity to avoid many other problems, such as hypertension or osteoarthritis. “We just don’t have enough respect for the power of lifestyle interventions,” he says.

Time constraints

With PCPs being pressed to see more patients than ever, taking the time to deliver lifestyle coaching can seem impossible. Krumholz suggests, however, that physicians use whatever time they do have in each visit to push the message. Even 20 seconds is worth it, he says.

“Patients hear you, even if it doesn’t seem like it,” he says. “Offer positive reinforcement of the benefits, and one day they will be ready to make changes.”

Having a practice that is a medical home has helped Yul Ejnes, MD, immediate past chairman of the American College of Physicians Board of Regents and a practicing internist in Cranston, Rhode Island, reach out to patients with high-risk factors.

“Part of the solution is to use the clinical staff more efficiently,” Ejnes says. “It does not all have to be on the doctor. There is not enough time in the exam room. At least some screening can be done by the staff, and the physician can train them to deliver a consistent message about these issues.” The heart association, the American Stroke Association, and many other organizations also offer a wide range of patient information, tools, and resources online.

Although his office has a nurse care manager who can work closely with patients to schedule follow-up appointments for things such as a smoking cessation regimen, he says that even medical assistants can ask about smoking status, note excess weight or blood pressure readings, and give relevant printed materials to patients to take home and think about.

“Sometimes the best thing doctors can do is get out of the way and let the staff help,” Ejnes says. “It’s not something that only we can do.”

Although some insurers now reimburse practices for the time spent on lifestyle education, even practices that are not compensated for it can make it at least somewhat profitable by identifying patients who could benefit from such services-possibly through an electronic health record system-and contacting them later to see how they are doing and encourage them to come back for a followup.

“Sometimes it is useful to uncouple some activities from a visit. Normally, if the patient doesn’t come back in, nothing happens,” he says.

The extra visits generated by such follow-up can be profitable, and they can help improve your scores on performance measures, which will be increasingly valuable in the future.

Persistence pays off

Both experts agree that although PCPs already know the value of counseling patients to help them make healthier choices, it is essential that they do not get discouraged if patients do not respond right away to their encouragement to stop smoking or take other steps.

“Many won’t act on your advice, but there are enough success stories to show us that repetitive messaging is effective,” Krumholz says. “Patients hear you, and your work really does pay off in the end.”

Don’t view patients’ unsuccessful attempts at change as failures, Ejnes adds. Stay positive and open-minded.

“Reassure patients that many people do not succeed on their first attempt and that we can learn from what didn’t work and change our approach next time,” he says. “Scolding them is not terribly effective. Be positive and productive.”

Another potential benefit of continuously repeating the message about healthier choices is that if you can change one patient’s lifestyle choices, it can have a ripple effect on their social networks. Some of their friends will be influenced to make changes, a trend that is beneficial to the community far beyond your actual patient base, Krumholz says.

“New behaviors become normative and spread like healthy virus among a person’s friends,” he says. “We don’t have to change everyone, but if we can prevail on some, it spreads.

“This type of work is not flashy, but it is worth it,” he concludes. “Even if you just get one person to respond, it is a huge win.”

Working with specialists

Another aspect of improving circulatory health and the costs associated with it is not only your ability to know when to refer to a specialist but also how to manage that referral for maximum outcomes.

“Care coordination is something we need to do better,” Ejnes says. “If a patient is seeing a [PCP] and a cardiologist, who is checking their lipids and managing their cholesterol?”

When you do refer a patient to a specialist, make communication a priority so that your patient’s efforts at improving his or her health are maximized.

AAFP programs

The American Academy of Family Physicians (AAFP) offers several programs to help physicians encourage wellness in the realm of circulatory disorders:

“Ask and Act”

The AAFP’s tobacco cessation program “Ask and Act” encourages family physicians to ask all patients about tobacco use, then to act to help them quit.

According to the AAFP, strong evidence exists that advice from a healthcare professional can more than double smoking cessation success rates and that patients are more satisfied with their healthcare if their primary care provider offers smoking cessation interventions-even if a patient is not ready to quit.

Resources on the AAFP Web site (www.aafp.org/online/en/home/clinical/publichealth/tobacco.html) are designed to make your interventions with your tobacco-using patients more effective. Information on maximizing billing for preventive services also is included, as well as many links to additional resources.

Materials to encourage patients to quit smoking, including posters, brochures, and pins encouraging them to ask for help, are offered for purchase. One example is packets of “prescription” pads that contain brief, specific patient tips on what to do before, during, and after their quit dates, so patients know exactly what steps to take as they go through their smoking cessation.

Americans In Motion–Healthy Interventions

Americans In Motion–Healthy Interventions (AIM-HI) is an AAFP initiative designed to improve the health of patients through a multifaceted fitness program addressing physical activity, nutrition, and emotional well-being in the individual, family, and community.

AIM-HI goals include encouraging family physicians to be fitness role models, improving family physicians’ ability to positively affect the fitness of their patients, and enhancing awareness of the family physicians’ unique ability to promote fitness within their communities.

AIM-HI presents fitness-physical activity, nutrition, and emotional well-being-as “the treatment of choice” for prevention and management of many chronic conditions. AIM-HI helps family medicine practices create a fitness focus through implementation of these critical strategies:

• raising awareness among clinicians and office staff regarding their own personal fitness,

• creating an office environment that is conducive to integrating AIM-HI concepts into everyday office routines, and

• using the AIM-HI philosophy and tools to help patients improve their fitness.

Circulatory disease demographics

The 2011 National Health Interview Survey, a multipurpose health survey conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics, provides insight into which patients are most likely to present with circulatory problems.

It found that 11% of adults aged at least 18 years had ever been told by a doctor or other health professional that they had heart disease, 6% had never been told they had coronary heart disease, 24% had been told on two or more visits that they had hypertension, and 3% had ever been told they had experienced a stroke.

Men were more likely than women to have ever been told they had coronary heart disease, but the prevalence of stroke in men and women was similar.

The survey found a positive relationship between age and the presence of heart disease (including coronary heart disease), hypertension, and stroke: As age increased, the percentages of adults with these conditions also increased.

Being educated mattered, but so did poverty. As educational levels increased, the percentages of adults with coronary heart disease, hypertension, and stroke decreased. Adults in families that were poor or near poor were more likely to have ever been told they had these types of conditions than were adults in families that were not poor.

The motivational interview

The American Heart Association recommends physicians use the following script of five Rs when interacting with patients who are not ready to quit smoking:

Relevance
Personalize why quitting to relevant to them, such as the health benefits they will gain.

Risks
Ask the patient to identify the negative consequences of tobacco use, such as stroke, heart attack, or shortness of breath.

Rewards
Ask the patient to identify the rewards of stopping smoking, such as saving money or setting a good example for their children.

Roadblocks
Ask the patient what are his or her barriers to quitting. Is the patient afraid of weight gain? Depression? Withdrawal symptoms?

Repetition
Repeat these steps at each appointment. Remember that nearly half of all smokers try to quit each year, and most will make several attempts before they succeed.

Preventing death and disability from cardiovascular disease

Cardiovascular disease (CVD) is the number one and most costly killer in the United States and a major cause of disability. It cost the United States a projected $503 billion in medical expenses (direct costs) and lost productivity (indirect costs) in 2010.

According to the Centers for Disease Control and Prevention Heart Disease and Stroke Prevention Program, the past 50 years have seen significant progress in the battle against heart disease, stroke, and other forms of CVD.

According to the National Institutes of Health, 1.6 million lives have been saved since 1977 that otherwise would have been lost to heart disease and stroke. An estimated 44% of the decrease in heart disease deaths from 1980 to 2000 was a result of prevention through the reduction of risk factors. 

According to the American Heart Association, avoiding key risk factors and receiving early diagnosis and correct treatment are essential to combating heart disease and stroke. Not smoking, maintaining a healthy weight, and controlling blood sugar, blood pressure, and cholesterol may add 10 years of life.

Other facts:

• An estimated 47% of U.S. adults at least 20 years have total cholesterol levels of 200 mg/dL or higher. A 10% decrease in these levels population-wide may result in about a 30% cut in the incidence of coronary heart disease.

• One in three U.S. adults has high blood pressure. About 69% of people who have a first heart attack, 77% who have a first stroke, and 74% with congestive heart failure have blood pressure above 140/90 mm Hg.

• Only 27% of respondents in a 2005 study knew heart attack signs and symptoms and would call 911 first if someone were having a heart attack or stroke.

• People free of risk factors have lower healthcare costs and are far less likely to develop CVD.

After 2 decades of progress, however, the percentage of Americans without major heart disease risk factors is dropping and now stands at less than 10%.