Cardiovascular Disease Control Efforts Among Primary-Care Physicians Missouri, 1990

Nearly half (43%) of all deaths in the United States each year are related to cardiovascular diseases (CVD), including coronary heart disease and cerebrovascular disease (1). CVD is linked to certain risk factors and behaviors, including high blood pressure, elevated total serum cholesterol, cigarette smoking, and physical inactivity (2). Because approximately 70% of the population has at least one contact with a physician each year (3), primary-care physicians are central to health promotion and disease-prevention efforts and early detection of CVD. In May and August 1990, the Missouri Department of Health (MDH) conducted a survey of practicing Missouri physicians to characterize their efforts to identify and control CVD risk factors among their patients.

MDH mailed a questionnaire to a random sample of 400 physicians drawn from 3345 family practitioners, internal medicine specialists, and obstetricians/gynecologists; 295 (74%) responded. Questions included demographic information, physician knowledge of CVD risk factors, current activity levels in CVD detection and prevention, possible barriers or constraints in CVD control, and preferred types of patient-education materials and counseling. Physicians were also asked about their own smoking status, serum cholesterol and blood pressure levels, and physical-activity patterns. Questionnaire items were standardized using previous physician surveys (i.e., statewide surveys in cancer control [4] and National Heart, Lung, and Blood Institute instruments [5]).

When asked to rate 10 diseases according to their impact (i.e., morbidity and mortality) on the population, physicians considered diseases of the heart and blood vessels (79%), cancer (56%), and diabetes (37%) to be of very high importance.

Respondents were also asked to indicate the level of effect (i.e., large, moderate, or little effect) of eight risk factors (i.e., cigarette smoking, hypertension, diabetes, high-fat diet, overweight, elevated blood cholesterol, sedentary lifestyle, and Type A behavior/stress) on CVD risk (Table 1). Of the eight risk factors, 89% and 19% of physicians rated cigarette smoking and Type A behavior/stress, respectively, as risk factors with a large effect on CVD. Sedentary lifestyle ranked seventh among the eight CVD risk factors, despite 82% of physicians indicating that physical activity substantially lowers blood pressure among persons who are hypertensive.

The most frequently performed CVD-prevention activity was patient blood pressure screening (Table 2): 81% of physicians reported always measuring blood pressure on adult patients at each visit. The second and third most often performed prevention activities were physical examinations and tobacco education, respectively. Physicians' beliefs about the contribution of tobacco to CVD incidence were correlated with the prevalence of tobacco-cessation education efforts or counseling and taking smoking histories for patients at each visit. Sixty-three percent reported always taking patients' smoking

histories.

Nearly all (98%) physicians reported knowing their own "usual" blood pressure reading. Nearly 42% of physicians reported a predominantly sedentary lifestyle (defined as not participating in regular physical activity for at least 20 minutes 3 or more days a week). Few (8%) physicians were current smokers, and 34% were former smokers.

Respondents reported that more time was required than was available in their offices to conduct adequate tobacco-cessation counseling (36%), dietary counseling (31%), and physical-activity counseling (15%). In addition, 22% of respondents agreed strongly with the statement "The lack of financial reimbursement for tobacco-cessation, dietary, and physical-activity counseling reduces the likelihood of conducting these activities in the primary-care office"; 29% of the physicians agreed "somewhat" with the statement.

Reported by: NE Jorge, MPH, RC Brownson, PhD, CA Smith, MSPH, S Dabney, MPH, Div of Chronic Disease Prevention and Health Promotion, Missouri Dept of Health. Health Intervention and Translation Br, Div of Chronic Disease Control and Community Intervention; National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report suggest that primary-care physicians in Missouri are generally aware of the importance of CVD risk factors; however, some physicians may miss opportunities for CVD-prevention and early detection activities, such as conducting nutritional and physical-activity education or counseling. Even though a recent survey of primary-care physicians in another state (North Carolina) indicated that most (96%) agreed that primary-care physicians should assist asymptomatic patients in reducing behavioral risk factors (6), the MDH survey identified important barriers to CVD-prevention activities, including lack of time for counseling and inadequate reimbursement.

Primary-care physicians have cost-effectively provided prevention activities, such as smoking-cessation counseling (7). This survey did not assess the effectiveness and cost-effectiveness of primary-care physicians in providing CVD-prevention activities; however, if primary-care physicians are to play a role in prevention activities, barriers to their involvement must be addressed. For example, increased emphasis on prevention education in medical schools, residency programs, and continuing medical-education training may enhance their skills in identifying behavioral risk factors and conducting counseling. In addition, efficacious and time-efficient interventions targeting CVD-risk behaviors must be developed.

National health objectives for the year 2000 target coronary heart disease and stroke as priorities for preventive services (2). Specific objectives include reducing coronary heart disease deaths to less than 100 per 100,000 persons * and reducing deaths from strokes to less than 20 per 100,000 persons ** (objectives 15.1 and 15.2, respectively). Preventive services targeted include increasing physician assessment and counseling for CVD risk factors (e.g., physical inactivity, cigarette smoking, and nutrition) and increasing the proportion of adults who have their blood pressure and blood cholesterol checked (objectives 15.13 and 15.14, respectively). However, to meet these objectives, primary-care physicians must continue to play a role in identifying patients with risk factors, counseling patients on changing these behaviors, and referring patients to appropriate health-education and counseling sources, such as hospital or community cardiovascular health programs (8). In addition, public health agencies and other community organizations must coordinate their efforts more closely with primary-care physicians to provide and reinforce patient CVD health education messages (8).

The MDH is using these survey findings in programs such as the American Stop Smoking Intervention Study and the Missouri Diabetes Control Program to reduce missed opportunities for health-promotion activities during patient contacts with primary-care physicians.

References

1. NCHS. Annual summary of births, marriages, divorces, and deaths: United States, 1990. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1991. (Monthly vital statistics report; vol 39, no. 13).

2. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

3. Wilensky GR, Bernstein A. Contacts with physicians in ambulatory settings: rates of use, expenditures, and source of payments. Washington, DC: US Department of Health and Human Services, 1983; DHHS publication no. (PHS)83-361.

4. Brownson RC, Davis JR, Simms SG, Kern TG, Harmon RG. Cancer control knowledge and priorities among primary care physicians. J Cancer Educ (in press).

5. Schucker B, Wittes JT, Cutler JA, et al. Change in physician perspective on cholesterol and heart disease. JAMA 1987;258:3521-6.

6. CDC. Counseling practices of primary-care physicians -- North Carolina, 1991. MMWR 1992; 41:565-8.

7. Cummings SR, Rubin SM, Oster G. The cost-effectiveness of counseling smokers to quit. JAMA 1989;261:75-9.

8. Maheux B, Pineault R, Lambert J, Beland F, Berthiaume M. Factors influencing physicians' preventive practices. Am J Prev Med 1989;5:201-6.

• Age-adjusted baseline: 135 per 100,000 population in 1987. ** Age-adjusted baseline: 30.3 per 100,000 population in 1987.

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