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Treat-to-target approach in managing modifiable risk factors of patients with coronary heart disease in primary care in Singapore: what are the issues?

Treat-to-target approach in managing modifiable risk factors of patients with coronary heart... Background: The key management strategy for established coronary heart disease (CHD) patients is to control the underlying risk factors. Further complications will be reduced when these risk factors are treated-to-target (TTT) as recommended by clinical practice guidelines. These targets include blood pressure (BP) lower than 130/80 mm Hg and LDL-cholesterol of less than 2.6 mmol/L and for those with type 2 diabetes mellitus (DM), HBA1c less than 7%. This article aimed to explore the issues affecting this approach from both the patients’ and primary care physicians’ (PCP) perspectives. Methods: The study involved triangulation of research methods to determine the findings. Part A: focus group discussions to collect qualitative data from patients with CHD and from PCPs who were managing them in primary care. Part B: A subsequent questionnaire survey to determine the extent of their awareness of treatment targets for modifiable risk factors. Results: CHD patients had variable awareness of the modifiable risk factors for CHD due to poor concordance between the PCPs’ approach in managing the CHD patients and the latter’s reception of information. 46% of participants knew their targets of BP control correctly; 11% of them were correct in stating their target for LDL-cholesterol control. Amongst these participants with DM (n = 146), 27% of them were correct in indicating their target of diabetic control. Conclusions: Communication and practice barriers exist which hinder the treat-to-target approach in mitigating the risk factors for CHD patients. Incorporating this approach in routine clinical practice by PCPs has greater potential to achieve treatment targets for patients. Keywords: Coronary Heart Disease, primary care, risk factor Background deaths from CHD has only declined marginally from Hypertension, dyslipidaemia and diabetes mellitus are 19.8% in 2007 to 19.2% in 2009 [3] Moreover, Ho KT et al prime risk factors for coronary heart disease (CHD). Glo- [4] reported that 70% of CHD patients in a cohort study of bal clinical practice guidelines recommend controlling CHD patients from the Singapore National Cardiac Regis- these risk factors as a management strategy to mitigate the try did not achieve a serum LDL-C target of < 100 mg/dL (2.6 mmol/L). 94% of the very high risk patients did not risk of recurrent CHD. Hence, physicians managing these patients should focus on treating these modifiable risk fac- achieve the stringent serum LDL-C target of < 70 mg/dL tors to evidence-based targets. However, most CHD (1.8 mmol/L). patients failed to reach these targets [1,2]. In Singapore, Locally, patients with CHD are often discharged to pri- mary care from cardiologists in tertiary institutions, once their conditions are stabilised after the acute cardiac * Correspondence: Tan.Ngiap.Chuan@singhealth.com.sg events. Due to the dual healthcare system in Singapore, SingHealth Polyclinics-Pasir Ris, 1, Pasir Ris Drive 4, #01-11, 519457, Singapore CHD patients can select their primary care physicians Full list of author information is available at the end of the article © 2011 Tan and Chih Wei; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Tan and Ho Asia Pacific Family Medicine 2011, 10:12 Page 2 of 6 http://www.apfmj.com/content/10/1/12 (PCP) based on their personal preference, either at the investigators carried out debrief after each FGD. Any public polyclinics or the private general practitioner new concepts and ideas were noted and included in the clinics. To reduce their CHD associated mortality and topic guide for discussion in the subsequent FGD. The morbidity risks, more effective disease management in study was terminated after saturation of ideas as primary care is urgently needed. Secondary prevention of assessed by the investigators. recurrent CHD by adopting “Treat-to-target” (TTT) The investigators used the software package NVivo7 approach towards their risk factors is being advocated a (QSR International Pty Ltd, Australia) to code the ver- batim transcripts and organised them into emergent cluster of polyclinics in Singapore. themes. This study aimed to determine the issues associated with this “TTT” approach in managing the health of Based on findings generated by qualitative content CHD patients in primary care in Singapore. analysis of the CAD study, themes considered to be important were included in the design of the question- Methods naire to be used in part two of the study. A mixed-method was used in this study. A qualitative study (CAD study) which aimed to explore the manage- Part 2: HEALTH (Heart patients’ Expectation of care, ment issues of PCP and their CHD patients was first Awareness of disease, Lifestyle modifications, Targets of carried out. This was followed by a cross-sectional treatment and Health-seeking behaviour) study quantitative study (HEALTH study) of a larger sampling This cross-sectional surveywas acollaborativestudy of CHD patients, whose aim was to substantiate and between SingHealth Polyclinics and Ngee Ann Polytech- complement the earlier qualitative data based on the nic School of Nursing. The investigators deliberated and same source population. This paper presents the results designed the HEALTH study questionnaire based on of this triangulation method from both a qualitative preliminary qualitative data from the CAD study. The study and quantitative survey. Both studies were surveys were carried out by the polytechnic student approved by SingHealth Polyclinics Institution Review nurses in the nine SingHealth Polyclinics from June 07 Board. to September 07. These interviewers received briefings from the investigators to clarify implementation issues Part 1: CAD (Coronary Artery Disease) study and to standardise the execution of the survey. They Focus group discussions (FGD), executed between were supervised by their polytechnic tutors. September 2005 and March 2007, were used to gather The participants satisfied the same inclusion and qualitative data from (a) patients and separately, from exclusion criteria of the CAD study. The questionnaire (b) PCPs [5,6]. These target participants were identified comprised thirty questions pertaining to CHD patients’ by the investigators based on a case-encounter basis at expectation of care, awareness of disease, lifestyle modi- the research sites. Snowball sampling method was also fications, targets of treatment and their health-seeking used to recruit potential participants. The latter were behaviours. The questionnaire content was derived from invited to take part in the FGD if they were able to issues raised during the CAD study to ensure internal understand and communicate in English. They were validity. No external validation was done due to absence also screened for eligibility using the following criteria: of local precedent studyand thesimpledesignofthe (a) The participants were adult CHD patients treated questions. with the following modalities: percutaneous, transluminal CHD participants were asked by the student nurses if coronary angioplasty (PTCA), coronary arterial bypass they were aware of their treatment targets for blood grafting (CABG) or non-invasive pharmacological treat- pressure, LDL-C (LDL-cholesterol) and glycated haemo- ment. They were diagnosed with CHD for at least one globin (where relevant), with “yes”, “no” and “don’t year, based on polyclinic medical records and confirmation know” answers. For affirmative answers, the participants based on referral documents from cardiologists. were expected to identify correctly the appropriate tar- (b) The PCPs included polyclinic doctors and general get range based on multiple choices. Blood pressure is practitioners from singleton and group practices, who targeted at lower than130 mm Hg (systolic) and lower were managing CHD patients in the community. than 80 mm Hg (diastolic), which is standardised for all Purposive selection of these participants from a variety CHD patients based on the investigators’ institution of demographic profiles was conducted to ensure multi- clinical practice guidelines. variate construct of the study population in both groups. Categorical variables were tabulated and analysed Investigators took turns to facilitate the FGDs based using Stata-10 software (StataCorp LP, USA). All inves- on semi-structured topic guide developed after mutual tigators deliberated the results in both segments of the deliberations. All FGDs were audio-taped for subsequent study. SingHealth Polyclinics institution review board transcription by independent transcribers. The approved the two studies. Tan and Ho Asia Pacific Family Medicine 2011, 10:12 Page 3 of 6 http://www.apfmj.com/content/10/1/12 Table 2 Demographic profile of 303 participants in Results HEALTH Study The demographic profiles of 44 participants (including 3 Age (years) No of patients (%) participants on follow up by private primary care clinics and 2 were managed at specialist clinics) in the CAD 41-60 79 (26.1) study are shown in Table 1 and that of 303 participants, 61-70 87 (28.7) of the HEALTH study are depicted in Table 2. The pro- 71-80 137 (45.2) files of the 18 PCPs from 3 FGDs are shown in Figure 1. Gender Male 182 (60.1) Female 121 (39.9) Theme 1: Gap in communication between PCPs and CHD Ethnic groups patients on specific goals of treatment, with differences Chinese 223 (73.6) in foci and expectation between the two parties during Malay 43 (14.2) the consultation Indian 31 (10.2) CHD participants were generally satisfied when their Others 6 (2.0) PCPs reported that their disease control was adequate. Education They did not expect to be told of their specific treat- Primary/Secondary 275 (90.8) ment targets. Junior college/diploma/tertiary 28 (9.2) When asked if the doctors discussed the treatment Duration of coronary heart disease (years) target of blood pressure (BP) control with patients, < 1 16 (5.3) polyclinic participant (aged 67 years, FGD3) replied: 1-5 101 (33.3) “No.Mydoctor, that Ilastsaw said: “Ok, your blood > 5 186 (61.4) pressure is good”, that’s all. I don’t know what is good, what is not good.” Similarly in FGD4, when asked about treatment target they’re smoking, check whether they would stop. If all are for cholesterol, polyclinic participant A: “Inever askthe okay, I would check their blood pressure. If the blood pres- doctor how much. Never say good or no good.” Polyclinic sure is quite under control, then I would ask them if they participant B in the same FGD: “They (doctors) say all are worried about anything else. Are they satisfied? Yes, my cholesterol is good.” everything is fine; I would just repeat the same medica- On the other hand, PCPs were preoccupied with clini- tion. But if for example, the panel test is not done within cal assessment of cardiac status to exclude any acute the last year, I would advise that they do another one, myocardial event in their consultation with CHD patients. Specifying treatment targets with their patients and from the panel test, I can follow up next visit and see was not mentioned in all three FGDs. There was lack of whether the cholesterol, and sugar etcetera are under con- discussion of mutually agreed goals of treatment trol, or it’s getting out of control.” between PCPs and their CHD patients. In this study, it appeared that acute presentation of chest PCP (FGD1): “I usually ask them whether they have any pain was a more common reason of consultation with new symptoms, like chest pain, breathlessness on walking. PCPs in private clinics. In the context of potential litiga- tion risk, their focus was to exclude potentially life-threa- If they say, well I’m, that’s okay. So the next thing I would tening acute cardiac event. PCPs were aware of the find out is whether they are compliant with their medica- common risk factors of CHD but they did not generally tions. If they’re a bit on the obese side, I ask them if they communicate the specific treatment targets of these risk are doing anything about diet control, and estimate their factors to their patients understanding of their weight, and some risk factors. If Table 1 Demographic profile of participants in CAD Study FGD* (n) Gender Age Race Highest educational Level attained Site of follow-up (years) Male Female ≤ 60 > 60 Chinese Malay Indian Others Secondary or below JC/Diploma/Tertiary Polyclinic GP/Specialist 1 (8) 6 2 5 3 7 0 1 0 6 2 8 0 2 (6) 5 1 2 4 3 1 1 1 4 2 6 0 3 (7) 6 1 4 3 4 1 2 0 7 0 6 1 4 (11) 10 1 5 6 7 0 2 2 8 3 8 3 5 (12) 10 2 7 5 7 1 3 1 10 2 11 1 Total (44) 37 7 23 21 28 3 9 4 35 9 39 5 *FGD: Focus Group Discussion (n: number of participants in the respective FGD) Tan and Ho Asia Pacific Family Medicine 2011, 10:12 Page 4 of 6 http://www.apfmj.com/content/10/1/12 11 11 11 7 7 7 Characteristics of doctors Figure 1 Profile of doctors who participated in CAD Study. in the clinic. For the new cases, if they come in with When asked about what took place in a consultation fairly new onset of angina symptoms, I think they deserve with CHD patients, PCP (FGD1): “Management of ischemic heart disease is primarily history taking (and) a more thorough cardiologist’sreview. By thetimethese risk assessment. In our practice, a lot of patients com- patients come to us, they have other risk factors to take plain of chest pain. If we end up referring all of them to into consideration, like smoking, cholesterol. So looking cardiologist, we are not exercising enough clinical judge- at these risk factors, they would have some degree of nar- ment. We are liable... if the history is typical of chest rowing of the coronary arteries. How severe (are the pain, I will refer immediately to A and E (Accident and arteries affected), it is beyond our assessment at the pri- Emergency). But if the history and the rest of risk factors mary care level. In a sense, we are still controlling symp- are not there, then I will do an ECG and do my own toms. Chronic cases would be treated like those in the assessment. But there’s still a small chance, but your risk polyclinic.” is low. So I always discuss options with the patient. Sometimes the atypical chest pain may still be angina, Theme 2: Difficulty in remembering the numerical or acute myocardial infarct. If I find that this patient is treatment targets amongst CHD patients very demanding, I may jeopardize my license, so I will Patient (FGD4): “Ican’t remember but I think LDL formally refer. In one month there are so many cases should be kept to within 60 (mg/dl) or what, I can’t with chest pain you cannot afford to refer all of them. remember the exact figure.” For those chronic cases, you realize that they are just CHD patients appeared to experience difficulty in musculoskeletal pain, you can just give painkiller.” remembering the treatment targets, with some incor- PCP (FGD1): “In the private sector, we see two types of rectly perceived it to be a variable target. ischemic heart disease patients. Those fresh cases, they’ve When asked about BP treatment target, Patient A never been worked up, they step into the consultation (FGD2): “120 (mmHg). More than 120... still on the high room and in the course of the consultation we realize side.” In the same FGD, Patient B indicated “130-140 that they may have underlying ischemic heart disease. (mmHg)” as the target BP control and polyclinic partici- The second group is the stable angina patient. They have pant 3 (aged 55 years): “Fluctuate lah. This kind of thing been worked up somewhere else and decide to follow up (treatment target) fluctuates.” Demog raph ic pro file 35 yrs & below Abo ve 35 years Male Female Chinese Malay Indian Basic medicaldegree Post grad qua lif ica tion Polyclinic practice Privatepractice No of participants Tan and Ho Asia Pacific Family Medicine 2011, 10:12 Page 5 of 6 http://www.apfmj.com/content/10/1/12 The lack of awareness of treatment targets is opportunities to recognise the various risk factors and expounded In the HEALTH study. 30% of CHD patients commence preventive interventions. This entails a were aware of the correct target BP control, 27% for paradigm shift from merely counselling and motivating correct HBA1c target level and 11% for the appropriate patients to embark on healthy lifestyles to empowering LDL-cholesterol level (Figure 2). the patients to recognise their respective treatment tar- gets. Discussion should focus on addressing the issues Theme 3: Inadequate understanding of the pertaining to lifestyle modifications [8] and negotiation glycated haemoglobin as the treatment target for on mutually agreed measures to achieve the treatment targets. CHD patients with diabetes mellitus In this study, 48% of the CHD patients in the HEALTH Whilst patient-dependent lifestyle modifications are study have type 2 diabetes mellitus. Amongst these dia- important, PCPs should mitigate their patients’ modifi- betic CHD patients, there was confusion between serum able risk factors such as blood pressure, LDL-cholesterol glucose level and glycated haemoglobin as the treatment and diabetic control by optimising physician-initiated target. Awareness of the treatment target for diabetes pharmaceutical interventions to reach evidence-based mellitus was also lacking amongst these patients. treatment targets. Physician-centred intervention alone Patient (FGD3): “For diabetes, the level should be six may be inadequate. To achieve these targets, they and below.” When probed by the moderator on the should communicate such goals to patients and negoti- reference blood test, the same patient replied: “It’s the ate for mutual agreement during the physician-patient one that they poke (with) the needle. I can’t remember consultation. The rationale and benefits behind this the name of the test.” treat-to-target approach should be explained to patients Patient (FGD2): “What I understand (HBA1c), it is the in lay language, such that the latter can understand and three months’ average. With the blood (glucose) test, you embrace as an essential component of their CHD can cheat: you don’t eat, your reading will be low. But management. with the three months’ average, whether you eat or don’t 45% of CHD patients in the HEALTH study were eat, it will show. I think it should be below ten; seven, above 70 years of age and 98% of them had, at most, eight, I think it’s acceptable.” secondary education. In view of age and educational status, educating these patients to remember their treat- Discussion ment targets would require innovative measures. These Effective prevention of recurrent CHD encompasses a include provision of aide-memoires, diaries and educa- comprehensive range of therapeutic interventions to tional literature detailing target values to patients and their caregivers, developing enhanced health education, manage the various risk factors, from lifestyle modifi- cations, weight management, smoking cessation to outreach programmes, quiz, games or other support medications [7]. This presents a challenge to the PCPs, group activities that focus on treatment targets. How- who face time and resource constraints in their prac- ever such multi-modal interventions need further tices and the imperatives of other immediate issues research evaluation to ascertain their cost-effectiveness. raised by the CHD patients during the consultation. Only 27% of diabetic CHD patients correctly identified However, PCPs have the unique advantage of mana- the glycated haemoglobin target for their diabetic ging these patients from a holistic perspective with control. Whilst it is uncertain if understanding the true nature of the test makes any impact in their diabetic control, simplifying the diabetic treatment target to a 100 single value may be easier for these patients to assimi- late the information. 46.2 64.4 In the local setting, the private primary care clinics are 84.2 % of CHD patients serviced by off-site commercial laboratory vendors. In 23.8 8.9 contrast, in-house laboratory service is provided within 4.6 26.7 the public polyclinics. These polyclinics are affiliated to 11.2 the respective regional public hospitals, which support BP target LDLͲ chol DM (%) target control their laboratory services. Laboratory reports for LDL-C (%) target in private clinics (in mg/L) and the public polyclinics (in (%) mmol/L) differ in terms of units of the assay. This may Correct indication of target Incorrect indication of target Don't know target further increase the difficulty of remembering the cho- Figure 2 Extent of awareness of treatment targets for BP, LDL- lesterol treatment target amongst the patients. Whilst cholesterol and HBA1c (for Diabetes mellitus) amongst CHD conversion tables are available, a standardised unit of patients (HEALTH study). measurement for LDL-C will facilitate the delivery of Tan and Ho Asia Pacific Family Medicine 2011, 10:12 Page 6 of 6 http://www.apfmj.com/content/10/1/12 disease and elevated coronary risk: results of the Hong Kong hospital CHD-related information to patients with cardiovascular audit study. Value Health 2008, 11(Suppl 1):S91-8. risk across the whole nation. Harmonisation of the 3. Ministry of Health, Health Facts, Singapore 2009: Principal Causes of Death laboratory reports is a potential solution and this will be and Top 10 Conditions of Hospitalisation. 2011, http://www.moh.gov.sg/ mohcorp/statistics.aspx?id=5526 Cited on 19 Aug. implemented when the national electronic health record 4. Ho KT, Chin KW, Ng KS, Alemao E, Rajagopalan S, Yin D: The A-SACT system rolls out in the near future. (Achievement in Singapore of Cholesterol Targets) study in patients While this study employed triangulation approach with coronary heart disease. Am J Cardiovasc Drugs 2006, 6(6):383-91. 5. Palton M: Qualitative evaluation and research methods. Sage Publications: towards combining both qualitative and quantitative Newbury Park, California; 1990. data, the subjects recruited were mainly CHD patients 6. Kitzinger J: Introduction to Focus group discussion. BMJ 1995, managed in public polyclinics and caution should be 311:299-302. 7. Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, Grundy SM, Hiratzka L, exercised in generalising the results to all CHD patients Jones D, Krumholz HM, Mosca L, Pasternak RC: AHA/ACC Guidelines for in Singapore. Most participants, who were recruited in secondary prevention for patients with coronary and other thequalitativeCAD studydueto transcriptioncon- atherosclerotic vascular disease: 2006 update. endorsed by the National Heart, Lung, and Blood Institute, Circulation. 2006, 113:2362-72. straints, spoke English during the FGD, which constitu- 8. Tan NC, Ho CWS, Cheah SL: Lifestyle modifications of patients with tes another limitation. The investigators did not include coronary heart disease on follow up in public primary care centres in the data pertaining to whether the CHD patients Singapore: assessment of perception and behaviour. SFP 2011, 37(1):67-72. achieved their treatment targets as such data are published in the official websites of the two clusters of doi:10.1186/1447-056X-10-12 polyclinics in Singapore. Cite this article as: Tan and Ho: Treat-to-target approach in managing modifiable risk factors of patients with coronary heart disease in primary care in Singapore: what are the issues? Asia Pacific Family Conclusion Medicine 2011 10:12. Treat-to-target approach in managing risk factors for CHD is hampered by a gap of communication between PCPs and patients on treatment targets, leading to low level of awareness of the latter. This may result in their failuretoappreciatethe relevanceofachieving treat- ment target in managing their chronic condition. Acknowledgements The investigators were grateful to Singapore Heart Foundation for grant sponsorship of the CAD study, NM Cheah Seng Lian for assisting in the study, Ms Yan Chau Chain and Dr Jason Tang for their coordinating roles and the Ngee Ann Polytechnic student nurses for data collection in the HEALTH study. Author details SingHealth Polyclinics-Pasir Ris, 1, Pasir Ris Drive 4, #01-11, 519457, Singapore. DUKE-NUS Graduate Medical School Singapore, 8, College Road, 169857, Singapore. NUS Yong Loo Lin School of Medicine, 21, Lower Kent Ridge Road, 119077, Singapore. Department of Education and Research, Singhealth Polyclinics, 167, Jalan Bukit Merah, #15-10, Connection One (Tower 5), 150167, Singapore. Authors’ contributions TNC designed and conceptualised the study, executed the study, analysed the qualitative and survey data and drafted the manuscript. SH facilitated and executed the FGD. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Submit your next manuscript to BioMed Central and take full advantage of: Received: 15 June 2011 Accepted: 22 September 2011 Published: 22 September 2011 • Convenient online submission • Thorough peer review References 1. Lewis SJ: An urgent matter-identifying your patients’ cardiovascular risk • No space constraints or color figure charges and improving their outcomes. Low-density lipoprotein cholesterol and • Immediate publication on acceptance coronary heart disease: the importance of reaching target goals with statin therapy. J Fam Pract 2009, 58(11 Suppl):S32-40. • Inclusion in PubMed, CAS, Scopus and Google Scholar 2. Lee KK, Lee VW, Chan WK, Lee BS, Chong AC, Wong JC, Yin D, Alemao E, • Research which is freely available for redistribution Tomlinson B: Cholesterol goal attainment in patients with coronary heart Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Treat-to-target approach in managing modifiable risk factors of patients with coronary heart disease in primary care in Singapore: what are the issues?

Asia Pacific Family Medicine , Volume 10 (1) – Sep 22, 2011

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Springer Journals
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Copyright © 2011 by Tan and Chih Wei; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/1447-056X-10-12
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21936960
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Abstract

Background: The key management strategy for established coronary heart disease (CHD) patients is to control the underlying risk factors. Further complications will be reduced when these risk factors are treated-to-target (TTT) as recommended by clinical practice guidelines. These targets include blood pressure (BP) lower than 130/80 mm Hg and LDL-cholesterol of less than 2.6 mmol/L and for those with type 2 diabetes mellitus (DM), HBA1c less than 7%. This article aimed to explore the issues affecting this approach from both the patients’ and primary care physicians’ (PCP) perspectives. Methods: The study involved triangulation of research methods to determine the findings. Part A: focus group discussions to collect qualitative data from patients with CHD and from PCPs who were managing them in primary care. Part B: A subsequent questionnaire survey to determine the extent of their awareness of treatment targets for modifiable risk factors. Results: CHD patients had variable awareness of the modifiable risk factors for CHD due to poor concordance between the PCPs’ approach in managing the CHD patients and the latter’s reception of information. 46% of participants knew their targets of BP control correctly; 11% of them were correct in stating their target for LDL-cholesterol control. Amongst these participants with DM (n = 146), 27% of them were correct in indicating their target of diabetic control. Conclusions: Communication and practice barriers exist which hinder the treat-to-target approach in mitigating the risk factors for CHD patients. Incorporating this approach in routine clinical practice by PCPs has greater potential to achieve treatment targets for patients. Keywords: Coronary Heart Disease, primary care, risk factor Background deaths from CHD has only declined marginally from Hypertension, dyslipidaemia and diabetes mellitus are 19.8% in 2007 to 19.2% in 2009 [3] Moreover, Ho KT et al prime risk factors for coronary heart disease (CHD). Glo- [4] reported that 70% of CHD patients in a cohort study of bal clinical practice guidelines recommend controlling CHD patients from the Singapore National Cardiac Regis- these risk factors as a management strategy to mitigate the try did not achieve a serum LDL-C target of < 100 mg/dL (2.6 mmol/L). 94% of the very high risk patients did not risk of recurrent CHD. Hence, physicians managing these patients should focus on treating these modifiable risk fac- achieve the stringent serum LDL-C target of < 70 mg/dL tors to evidence-based targets. However, most CHD (1.8 mmol/L). patients failed to reach these targets [1,2]. In Singapore, Locally, patients with CHD are often discharged to pri- mary care from cardiologists in tertiary institutions, once their conditions are stabilised after the acute cardiac * Correspondence: Tan.Ngiap.Chuan@singhealth.com.sg events. Due to the dual healthcare system in Singapore, SingHealth Polyclinics-Pasir Ris, 1, Pasir Ris Drive 4, #01-11, 519457, Singapore CHD patients can select their primary care physicians Full list of author information is available at the end of the article © 2011 Tan and Chih Wei; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Tan and Ho Asia Pacific Family Medicine 2011, 10:12 Page 2 of 6 http://www.apfmj.com/content/10/1/12 (PCP) based on their personal preference, either at the investigators carried out debrief after each FGD. Any public polyclinics or the private general practitioner new concepts and ideas were noted and included in the clinics. To reduce their CHD associated mortality and topic guide for discussion in the subsequent FGD. The morbidity risks, more effective disease management in study was terminated after saturation of ideas as primary care is urgently needed. Secondary prevention of assessed by the investigators. recurrent CHD by adopting “Treat-to-target” (TTT) The investigators used the software package NVivo7 approach towards their risk factors is being advocated a (QSR International Pty Ltd, Australia) to code the ver- batim transcripts and organised them into emergent cluster of polyclinics in Singapore. themes. This study aimed to determine the issues associated with this “TTT” approach in managing the health of Based on findings generated by qualitative content CHD patients in primary care in Singapore. analysis of the CAD study, themes considered to be important were included in the design of the question- Methods naire to be used in part two of the study. A mixed-method was used in this study. A qualitative study (CAD study) which aimed to explore the manage- Part 2: HEALTH (Heart patients’ Expectation of care, ment issues of PCP and their CHD patients was first Awareness of disease, Lifestyle modifications, Targets of carried out. This was followed by a cross-sectional treatment and Health-seeking behaviour) study quantitative study (HEALTH study) of a larger sampling This cross-sectional surveywas acollaborativestudy of CHD patients, whose aim was to substantiate and between SingHealth Polyclinics and Ngee Ann Polytech- complement the earlier qualitative data based on the nic School of Nursing. The investigators deliberated and same source population. This paper presents the results designed the HEALTH study questionnaire based on of this triangulation method from both a qualitative preliminary qualitative data from the CAD study. The study and quantitative survey. Both studies were surveys were carried out by the polytechnic student approved by SingHealth Polyclinics Institution Review nurses in the nine SingHealth Polyclinics from June 07 Board. to September 07. These interviewers received briefings from the investigators to clarify implementation issues Part 1: CAD (Coronary Artery Disease) study and to standardise the execution of the survey. They Focus group discussions (FGD), executed between were supervised by their polytechnic tutors. September 2005 and March 2007, were used to gather The participants satisfied the same inclusion and qualitative data from (a) patients and separately, from exclusion criteria of the CAD study. The questionnaire (b) PCPs [5,6]. These target participants were identified comprised thirty questions pertaining to CHD patients’ by the investigators based on a case-encounter basis at expectation of care, awareness of disease, lifestyle modi- the research sites. Snowball sampling method was also fications, targets of treatment and their health-seeking used to recruit potential participants. The latter were behaviours. The questionnaire content was derived from invited to take part in the FGD if they were able to issues raised during the CAD study to ensure internal understand and communicate in English. They were validity. No external validation was done due to absence also screened for eligibility using the following criteria: of local precedent studyand thesimpledesignofthe (a) The participants were adult CHD patients treated questions. with the following modalities: percutaneous, transluminal CHD participants were asked by the student nurses if coronary angioplasty (PTCA), coronary arterial bypass they were aware of their treatment targets for blood grafting (CABG) or non-invasive pharmacological treat- pressure, LDL-C (LDL-cholesterol) and glycated haemo- ment. They were diagnosed with CHD for at least one globin (where relevant), with “yes”, “no” and “don’t year, based on polyclinic medical records and confirmation know” answers. For affirmative answers, the participants based on referral documents from cardiologists. were expected to identify correctly the appropriate tar- (b) The PCPs included polyclinic doctors and general get range based on multiple choices. Blood pressure is practitioners from singleton and group practices, who targeted at lower than130 mm Hg (systolic) and lower were managing CHD patients in the community. than 80 mm Hg (diastolic), which is standardised for all Purposive selection of these participants from a variety CHD patients based on the investigators’ institution of demographic profiles was conducted to ensure multi- clinical practice guidelines. variate construct of the study population in both groups. Categorical variables were tabulated and analysed Investigators took turns to facilitate the FGDs based using Stata-10 software (StataCorp LP, USA). All inves- on semi-structured topic guide developed after mutual tigators deliberated the results in both segments of the deliberations. All FGDs were audio-taped for subsequent study. SingHealth Polyclinics institution review board transcription by independent transcribers. The approved the two studies. Tan and Ho Asia Pacific Family Medicine 2011, 10:12 Page 3 of 6 http://www.apfmj.com/content/10/1/12 Table 2 Demographic profile of 303 participants in Results HEALTH Study The demographic profiles of 44 participants (including 3 Age (years) No of patients (%) participants on follow up by private primary care clinics and 2 were managed at specialist clinics) in the CAD 41-60 79 (26.1) study are shown in Table 1 and that of 303 participants, 61-70 87 (28.7) of the HEALTH study are depicted in Table 2. The pro- 71-80 137 (45.2) files of the 18 PCPs from 3 FGDs are shown in Figure 1. Gender Male 182 (60.1) Female 121 (39.9) Theme 1: Gap in communication between PCPs and CHD Ethnic groups patients on specific goals of treatment, with differences Chinese 223 (73.6) in foci and expectation between the two parties during Malay 43 (14.2) the consultation Indian 31 (10.2) CHD participants were generally satisfied when their Others 6 (2.0) PCPs reported that their disease control was adequate. Education They did not expect to be told of their specific treat- Primary/Secondary 275 (90.8) ment targets. Junior college/diploma/tertiary 28 (9.2) When asked if the doctors discussed the treatment Duration of coronary heart disease (years) target of blood pressure (BP) control with patients, < 1 16 (5.3) polyclinic participant (aged 67 years, FGD3) replied: 1-5 101 (33.3) “No.Mydoctor, that Ilastsaw said: “Ok, your blood > 5 186 (61.4) pressure is good”, that’s all. I don’t know what is good, what is not good.” Similarly in FGD4, when asked about treatment target they’re smoking, check whether they would stop. If all are for cholesterol, polyclinic participant A: “Inever askthe okay, I would check their blood pressure. If the blood pres- doctor how much. Never say good or no good.” Polyclinic sure is quite under control, then I would ask them if they participant B in the same FGD: “They (doctors) say all are worried about anything else. Are they satisfied? Yes, my cholesterol is good.” everything is fine; I would just repeat the same medica- On the other hand, PCPs were preoccupied with clini- tion. But if for example, the panel test is not done within cal assessment of cardiac status to exclude any acute the last year, I would advise that they do another one, myocardial event in their consultation with CHD patients. Specifying treatment targets with their patients and from the panel test, I can follow up next visit and see was not mentioned in all three FGDs. There was lack of whether the cholesterol, and sugar etcetera are under con- discussion of mutually agreed goals of treatment trol, or it’s getting out of control.” between PCPs and their CHD patients. In this study, it appeared that acute presentation of chest PCP (FGD1): “I usually ask them whether they have any pain was a more common reason of consultation with new symptoms, like chest pain, breathlessness on walking. PCPs in private clinics. In the context of potential litiga- tion risk, their focus was to exclude potentially life-threa- If they say, well I’m, that’s okay. So the next thing I would tening acute cardiac event. PCPs were aware of the find out is whether they are compliant with their medica- common risk factors of CHD but they did not generally tions. If they’re a bit on the obese side, I ask them if they communicate the specific treatment targets of these risk are doing anything about diet control, and estimate their factors to their patients understanding of their weight, and some risk factors. If Table 1 Demographic profile of participants in CAD Study FGD* (n) Gender Age Race Highest educational Level attained Site of follow-up (years) Male Female ≤ 60 > 60 Chinese Malay Indian Others Secondary or below JC/Diploma/Tertiary Polyclinic GP/Specialist 1 (8) 6 2 5 3 7 0 1 0 6 2 8 0 2 (6) 5 1 2 4 3 1 1 1 4 2 6 0 3 (7) 6 1 4 3 4 1 2 0 7 0 6 1 4 (11) 10 1 5 6 7 0 2 2 8 3 8 3 5 (12) 10 2 7 5 7 1 3 1 10 2 11 1 Total (44) 37 7 23 21 28 3 9 4 35 9 39 5 *FGD: Focus Group Discussion (n: number of participants in the respective FGD) Tan and Ho Asia Pacific Family Medicine 2011, 10:12 Page 4 of 6 http://www.apfmj.com/content/10/1/12 11 11 11 7 7 7 Characteristics of doctors Figure 1 Profile of doctors who participated in CAD Study. in the clinic. For the new cases, if they come in with When asked about what took place in a consultation fairly new onset of angina symptoms, I think they deserve with CHD patients, PCP (FGD1): “Management of ischemic heart disease is primarily history taking (and) a more thorough cardiologist’sreview. By thetimethese risk assessment. In our practice, a lot of patients com- patients come to us, they have other risk factors to take plain of chest pain. If we end up referring all of them to into consideration, like smoking, cholesterol. So looking cardiologist, we are not exercising enough clinical judge- at these risk factors, they would have some degree of nar- ment. We are liable... if the history is typical of chest rowing of the coronary arteries. How severe (are the pain, I will refer immediately to A and E (Accident and arteries affected), it is beyond our assessment at the pri- Emergency). But if the history and the rest of risk factors mary care level. In a sense, we are still controlling symp- are not there, then I will do an ECG and do my own toms. Chronic cases would be treated like those in the assessment. But there’s still a small chance, but your risk polyclinic.” is low. So I always discuss options with the patient. Sometimes the atypical chest pain may still be angina, Theme 2: Difficulty in remembering the numerical or acute myocardial infarct. If I find that this patient is treatment targets amongst CHD patients very demanding, I may jeopardize my license, so I will Patient (FGD4): “Ican’t remember but I think LDL formally refer. In one month there are so many cases should be kept to within 60 (mg/dl) or what, I can’t with chest pain you cannot afford to refer all of them. remember the exact figure.” For those chronic cases, you realize that they are just CHD patients appeared to experience difficulty in musculoskeletal pain, you can just give painkiller.” remembering the treatment targets, with some incor- PCP (FGD1): “In the private sector, we see two types of rectly perceived it to be a variable target. ischemic heart disease patients. Those fresh cases, they’ve When asked about BP treatment target, Patient A never been worked up, they step into the consultation (FGD2): “120 (mmHg). More than 120... still on the high room and in the course of the consultation we realize side.” In the same FGD, Patient B indicated “130-140 that they may have underlying ischemic heart disease. (mmHg)” as the target BP control and polyclinic partici- The second group is the stable angina patient. They have pant 3 (aged 55 years): “Fluctuate lah. This kind of thing been worked up somewhere else and decide to follow up (treatment target) fluctuates.” Demog raph ic pro file 35 yrs & below Abo ve 35 years Male Female Chinese Malay Indian Basic medicaldegree Post grad qua lif ica tion Polyclinic practice Privatepractice No of participants Tan and Ho Asia Pacific Family Medicine 2011, 10:12 Page 5 of 6 http://www.apfmj.com/content/10/1/12 The lack of awareness of treatment targets is opportunities to recognise the various risk factors and expounded In the HEALTH study. 30% of CHD patients commence preventive interventions. This entails a were aware of the correct target BP control, 27% for paradigm shift from merely counselling and motivating correct HBA1c target level and 11% for the appropriate patients to embark on healthy lifestyles to empowering LDL-cholesterol level (Figure 2). the patients to recognise their respective treatment tar- gets. Discussion should focus on addressing the issues Theme 3: Inadequate understanding of the pertaining to lifestyle modifications [8] and negotiation glycated haemoglobin as the treatment target for on mutually agreed measures to achieve the treatment targets. CHD patients with diabetes mellitus In this study, 48% of the CHD patients in the HEALTH Whilst patient-dependent lifestyle modifications are study have type 2 diabetes mellitus. Amongst these dia- important, PCPs should mitigate their patients’ modifi- betic CHD patients, there was confusion between serum able risk factors such as blood pressure, LDL-cholesterol glucose level and glycated haemoglobin as the treatment and diabetic control by optimising physician-initiated target. Awareness of the treatment target for diabetes pharmaceutical interventions to reach evidence-based mellitus was also lacking amongst these patients. treatment targets. Physician-centred intervention alone Patient (FGD3): “For diabetes, the level should be six may be inadequate. To achieve these targets, they and below.” When probed by the moderator on the should communicate such goals to patients and negoti- reference blood test, the same patient replied: “It’s the ate for mutual agreement during the physician-patient one that they poke (with) the needle. I can’t remember consultation. The rationale and benefits behind this the name of the test.” treat-to-target approach should be explained to patients Patient (FGD2): “What I understand (HBA1c), it is the in lay language, such that the latter can understand and three months’ average. With the blood (glucose) test, you embrace as an essential component of their CHD can cheat: you don’t eat, your reading will be low. But management. with the three months’ average, whether you eat or don’t 45% of CHD patients in the HEALTH study were eat, it will show. I think it should be below ten; seven, above 70 years of age and 98% of them had, at most, eight, I think it’s acceptable.” secondary education. In view of age and educational status, educating these patients to remember their treat- Discussion ment targets would require innovative measures. These Effective prevention of recurrent CHD encompasses a include provision of aide-memoires, diaries and educa- comprehensive range of therapeutic interventions to tional literature detailing target values to patients and their caregivers, developing enhanced health education, manage the various risk factors, from lifestyle modifi- cations, weight management, smoking cessation to outreach programmes, quiz, games or other support medications [7]. This presents a challenge to the PCPs, group activities that focus on treatment targets. How- who face time and resource constraints in their prac- ever such multi-modal interventions need further tices and the imperatives of other immediate issues research evaluation to ascertain their cost-effectiveness. raised by the CHD patients during the consultation. Only 27% of diabetic CHD patients correctly identified However, PCPs have the unique advantage of mana- the glycated haemoglobin target for their diabetic ging these patients from a holistic perspective with control. Whilst it is uncertain if understanding the true nature of the test makes any impact in their diabetic control, simplifying the diabetic treatment target to a 100 single value may be easier for these patients to assimi- late the information. 46.2 64.4 In the local setting, the private primary care clinics are 84.2 % of CHD patients serviced by off-site commercial laboratory vendors. In 23.8 8.9 contrast, in-house laboratory service is provided within 4.6 26.7 the public polyclinics. These polyclinics are affiliated to 11.2 the respective regional public hospitals, which support BP target LDLͲ chol DM (%) target control their laboratory services. Laboratory reports for LDL-C (%) target in private clinics (in mg/L) and the public polyclinics (in (%) mmol/L) differ in terms of units of the assay. This may Correct indication of target Incorrect indication of target Don't know target further increase the difficulty of remembering the cho- Figure 2 Extent of awareness of treatment targets for BP, LDL- lesterol treatment target amongst the patients. Whilst cholesterol and HBA1c (for Diabetes mellitus) amongst CHD conversion tables are available, a standardised unit of patients (HEALTH study). measurement for LDL-C will facilitate the delivery of Tan and Ho Asia Pacific Family Medicine 2011, 10:12 Page 6 of 6 http://www.apfmj.com/content/10/1/12 disease and elevated coronary risk: results of the Hong Kong hospital CHD-related information to patients with cardiovascular audit study. Value Health 2008, 11(Suppl 1):S91-8. risk across the whole nation. Harmonisation of the 3. Ministry of Health, Health Facts, Singapore 2009: Principal Causes of Death laboratory reports is a potential solution and this will be and Top 10 Conditions of Hospitalisation. 2011, http://www.moh.gov.sg/ mohcorp/statistics.aspx?id=5526 Cited on 19 Aug. implemented when the national electronic health record 4. Ho KT, Chin KW, Ng KS, Alemao E, Rajagopalan S, Yin D: The A-SACT system rolls out in the near future. (Achievement in Singapore of Cholesterol Targets) study in patients While this study employed triangulation approach with coronary heart disease. Am J Cardiovasc Drugs 2006, 6(6):383-91. 5. Palton M: Qualitative evaluation and research methods. Sage Publications: towards combining both qualitative and quantitative Newbury Park, California; 1990. data, the subjects recruited were mainly CHD patients 6. Kitzinger J: Introduction to Focus group discussion. BMJ 1995, managed in public polyclinics and caution should be 311:299-302. 7. Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, Grundy SM, Hiratzka L, exercised in generalising the results to all CHD patients Jones D, Krumholz HM, Mosca L, Pasternak RC: AHA/ACC Guidelines for in Singapore. Most participants, who were recruited in secondary prevention for patients with coronary and other thequalitativeCAD studydueto transcriptioncon- atherosclerotic vascular disease: 2006 update. endorsed by the National Heart, Lung, and Blood Institute, Circulation. 2006, 113:2362-72. straints, spoke English during the FGD, which constitu- 8. Tan NC, Ho CWS, Cheah SL: Lifestyle modifications of patients with tes another limitation. The investigators did not include coronary heart disease on follow up in public primary care centres in the data pertaining to whether the CHD patients Singapore: assessment of perception and behaviour. SFP 2011, 37(1):67-72. achieved their treatment targets as such data are published in the official websites of the two clusters of doi:10.1186/1447-056X-10-12 polyclinics in Singapore. Cite this article as: Tan and Ho: Treat-to-target approach in managing modifiable risk factors of patients with coronary heart disease in primary care in Singapore: what are the issues? Asia Pacific Family Conclusion Medicine 2011 10:12. Treat-to-target approach in managing risk factors for CHD is hampered by a gap of communication between PCPs and patients on treatment targets, leading to low level of awareness of the latter. This may result in their failuretoappreciatethe relevanceofachieving treat- ment target in managing their chronic condition. Acknowledgements The investigators were grateful to Singapore Heart Foundation for grant sponsorship of the CAD study, NM Cheah Seng Lian for assisting in the study, Ms Yan Chau Chain and Dr Jason Tang for their coordinating roles and the Ngee Ann Polytechnic student nurses for data collection in the HEALTH study. Author details SingHealth Polyclinics-Pasir Ris, 1, Pasir Ris Drive 4, #01-11, 519457, Singapore. DUKE-NUS Graduate Medical School Singapore, 8, College Road, 169857, Singapore. NUS Yong Loo Lin School of Medicine, 21, Lower Kent Ridge Road, 119077, Singapore. Department of Education and Research, Singhealth Polyclinics, 167, Jalan Bukit Merah, #15-10, Connection One (Tower 5), 150167, Singapore. Authors’ contributions TNC designed and conceptualised the study, executed the study, analysed the qualitative and survey data and drafted the manuscript. SH facilitated and executed the FGD. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Submit your next manuscript to BioMed Central and take full advantage of: Received: 15 June 2011 Accepted: 22 September 2011 Published: 22 September 2011 • Convenient online submission • Thorough peer review References 1. Lewis SJ: An urgent matter-identifying your patients’ cardiovascular risk • No space constraints or color figure charges and improving their outcomes. Low-density lipoprotein cholesterol and • Immediate publication on acceptance coronary heart disease: the importance of reaching target goals with statin therapy. J Fam Pract 2009, 58(11 Suppl):S32-40. • Inclusion in PubMed, CAS, Scopus and Google Scholar 2. Lee KK, Lee VW, Chan WK, Lee BS, Chong AC, Wong JC, Yin D, Alemao E, • Research which is freely available for redistribution Tomlinson B: Cholesterol goal attainment in patients with coronary heart Submit your manuscript at www.biomedcentral.com/submit

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Asia Pacific Family MedicineSpringer Journals

Published: Sep 22, 2011

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