Aims. To explore general practitioners’ (GPs’) descriptions of their thoughts and action when prescribing cardiovascular preventive drugs. Methods. Qualitative content analysis of transcribed group interviews with 14 participants from two primary health care centres in the southeast of Sweden. Results. GPs’ prescribing of cardiovascular preventive drugs, from their own descriptions, involved “the patient as calculated” and “the inclination to prescribe,” which were negotiated in the interaction with “the patient in front of me.” In situations with high cardiovascular risk, the GPs reported a tendency to adopt a directive consultation style. In situations with low cardiovascular risk and great uncertainty about the net benefit of preventive drugs, the GPs described a preference for an informed patient choice. Conclusions. Our findings suggest that GPs mainly involve patients at low and uncertain risk of cardiovascular disease in treatment decisions, whereas patient involvement tends to decrease when GPs judge the cardiovascular risk as high. Our findings may serve as a memento for clinicians, and we suggest them to be considered in training in communication skills. 1. Introduction General practitioners are heavily involved in considering and prescribing cardiovascular preventive drugs and maintaining their increasing use [1]. Numerous trials have shown indisputable effects of cardiovascular preventive drugs [2]. How to apply these findings in clinical medicine remains an issue of controversy. Proponents of increased drug use calculate on reduced cardiovascular mortality whereas sceptics fear a threat to public health and to the sustainability of health care by introducing preventive drug treatment to large proportions of healthy populations [3, 4]. A Swedish survey showed that between 1980 and 2000, the number of people who stated that they had a chronic disease almost doubled. This was parallel to an increase in preventive drug utilisation, inferring that people comprehend the preventive medication as a treatment for disease [5]. There is a movement towards increased patient participation in health-care decisions in practice and in the legislation of many countries including Sweden [6]. Governments, health-care organisations and insurance companies have a common interest in public health and costeffectiveness in prescribing. Guidelines aim to implement evidence-based prescribing [7] and rational drug use [8] but are supported by drug trials largely sponsored by the pharmaceutical industry [9]. Demands on GPs’ prescribing are thus numerous,
References
[1]
J. L. G. Nilsson and A. Melander, “Increased introduction, advertising, and sales of preventive drugs during 1986–2002 in Sweden,” Journal of Ambulatory Care Management, vol. 29, no. 3, pp. 238–249, 2006.
[2]
B. S. Ferket, E. B. Colkesen, J. J. Visser et al., “Systematic review of guidelines on cardiovascular risk assessment: which recommendations should clinicians follow for a cardiovascular health check?” Archives of Internal Medicine, vol. 170, no. 1, pp. 27–40, 2010.
[3]
N. J. Wald and M. R. Law, “A strategy to reduce cardiovascular disease by more than 80%,” British Medical Journal, vol. 326, no. 7404, pp. 1419–1423, 2003.
[4]
L. Getz, A. L. Kirkengen, I. Hetlevik, S. Romundstad, and J. A. Sigurdsson, “Ethical dilemmas arising from implementation of the European guidelines on cardiovascular disease prevention in clinical practice: a descriptive epidemiological study,” Scandinavian Journal of Primary Health Care, vol. 22, no. 4, pp. 202–208, 2004.
[5]
B. Hagstrom, B. Mattsson, A. Wimo, and R. K. Gunnarsson, “More illness and less disease? A 20-year perspective on chronic disease and medication,” Scandinavian Journal of Public Health, vol. 34, no. 6, pp. 584–588, 2006.
[6]
H？lso-och sjukv？rdslagen (Health and Medical Service Act), 1982.
[7]
D. L. Sackett, W. M. C. Rosenberg, J. A. M. Gray, R. B. Haynes, and W. S. Richardson, “Evidence based medicine: what it is and what it isn't. It's about integrating individual clinical expertise and the best external evidence,” British Medical Journal, vol. 312, no. 7023, pp. 71–72, 1996.
[8]
“The rational use of drugs: report of the Conference of Experts,” in Conference of Experts on the Rational Use of Drugs, World Health Organization, November 1985.
[9]
F. Taylor, K. Ward, T. H. Moore et al., “Statins for the primary prevention of cardiovascular disease,” Cochrane Database of Systematic Reviews, vol. 1, p. CD004816, 2011.
[10]
I. Skoglund, K. Segesten, and C. Bj？rkelund, “GPs' thoughts on prescribing medication and evidence-based knowledge: the benefit aspect is a strong motivator,” Scandinavian Journal of Primary Health Care, vol. 25, no. 2, pp. 98–104, 2007.
[11]
P. B. Rahmner, L. I. Gustafsson, J. Larsson, U. Rosenqvist, G. Tomson, and I. Holmstr？m, “Variations in understanding the drug-prescribing process: a qualitative study among Swedish GPs,” Family Practice, vol. 26, no. 2, pp. 121–127, 2009.
[12]
W. S. M. Summerskill and C. Pope, “‘I saw the panic rise in her eyes, and evidence-based medicine went out of the door’. An exploratory qualitative study of the barriers to secondary prevention in the management of coronary heart disease,” Family Practice, vol. 19, no. 6, pp. 605–610, 2002.
[13]
E. Fh？rm, O. Rolandsson, and E. E. Johansson, “‘Aiming for the stars—GPs’ dilemmas in the prevention of cardiovascular disease in type 2 diabetes patients: focus group interviews,” Family Practice, vol. 26, no. 2, pp. 109–114, 2009.
[14]
U. H. Graneheim and B. Lundman, “Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness,” Nurse Education Today, vol. 24, no. 2, pp. 105–112, 2004.
[15]
B. G. Glaser and A. L. Strauss, The Discovery of Grounded Theory, Strategies for Qualitative Research, Aldine, Chicago, Ill, USA, 1967.
[16]
C. Charles, T. Whelan, and A. Gafni, “What do we mean by partnership in making decisions about treatment?” British Medical Journal, vol. 319, no. 7212, pp. 780–782, 1999.
[17]
L. Silwer, R. Wahlstr？m, and C. S. Lundborg, “Views on primary prevention of cardiovascular disease-an interview study with Swedish GPs,” BMC Family Practice, vol. 11, article 44, 2010.
[18]
M. A. Stewart, “What is a successful doctor-patient interview? A study of interactions and outcomes,” Social Science and Medicine, vol. 19, no. 2, pp. 167–175, 1984.
[19]
M. Klein Buller and D. B. Buller, “Physicians' communication style and patient satisfaction,” Journal of Health and Social Behavior, vol. 28, no. 4, pp. 375–388, 1987.
[20]
M. Marinker, From Compliance to Concordance: Achieving Shared Goals in Medicine Taking, Royal Pharmaceutical Society, in partnership with Merck Sharp & Dohme, London, UK, 1997.
[21]
V. Wirtz, A. Cribb, and N. Barber, “Patient-doctor decision-making about treatment within the consultation - A critical analysis of models,” Social Science and Medicine, vol. 62, no. 1, pp. 116–124, 2006.
[22]
L. M. Ong, et al., “Doctor-patient communication: a review of the literature,” Social Science & Medicine, vol. 40, no. 7, pp. 903–918, 1995.
[23]
L. S. Phillips, W. T. Branch, C. B. Cook et al., “Clinical inertia,” Annals of Internal Medicine, vol. 135, no. 9, pp. 825–834, 2001.
[24]
P. Midl？v, R. Ekesbo, L. Johansson et al., “Barriers to adherence to hypertension guidelines among GPs in southern Sweden: a survey,” Scandinavian Journal of Primary Health Care, vol. 26, no. 3, pp. 154–159, 2008.
[25]
M. M. Safford, R. Shewchuk, H. Qu et al., “Reasons for not intensifying medications: differentiating “clinical inertia” from appropriate care,” Journal of General Internal Medicine, vol. 22, no. 12, pp. 1648–1655, 2007.
[26]
P. Brindle, A. Beswick, T. Fahey, and S. Ebrahim, “Accuracy and impact of risk assessment in the primary prevention of cardiovascular disease: a systematic review,” Heart, vol. 92, no. 12, pp. 1752–1759, 2006.
[27]
M. S. Blois, Information and Medicine : the Nature of Medical Descriptions, University of California Press, Berkeley, Calif, USA, 1984.
[28]
S. Svensson, P. Linell, and K. I. Kjellgren, “Making sense of blood pressure values in follow-up appointments for hypertension,” International Journal of Cardiology, vol. 123, no. 2, pp. 108–116, 2008.
[29]
J. Gabbay and A. Le May, “Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care,” British Medical Journal, vol. 329, no. 7473, pp. 1013–1016, 2004.
[30]
L. Coar and J. Sim, “Interviewing one's peers: methodological issues in a study of health professionals,” Scandinavian Journal of Primary Health Care, vol. 24, no. 4, pp. 251–256, 2006.
