Beyond Scare Tactics: Effective Risk Communication Strategies Lola Coke, PhD, ACNS-BC, CNS, FAHA, FPCNA Associate Professor Cardiovascular Clinical Nurse Specialist Disclosure Statement of Financial Interest I have no disclosures Presentation Objectives • At the end of this presentation the participant will: 1. Understand the importance of risk assessment in patients with cardiovascular disease. 2. Apply risk communication strategies with patients to increase understanding of level of risk. 3. Develop a strategy to effectively communicate risk using a case-study approach. Audience Response Question 1 Assessing risk in cardiovascular patients is important because it: *1. can be used to motivate the patient to change behavior. 2. give the provider information to threaten the patient. 3. is the best tool to teach patients about their family history of cardiovascular disease. 4. All of the above. Lifetime vs 10-Year CVD Risk Estimates Individuals (millions) Women CVD risk levels High short term (>10% 10-yr) Low short term/high lifetime (<10% 10-yr/>39% lifetime) Low short term/low lifetime (<10% 10-yr/<39% lifetime) 20-29 30-39 40-49 50-59 Age (yr) Marma et al: Circ Cardiovasc Qual Outcomes, 2010 NHANES 60-79 Global risk score predictor variables Sex Framingham Risk Score Reynolds Risk Score (M or F) Age Race (WH or AA) Total cholesterol HDL-C Systolic BP Rx of BP (Y or N) Diabetes (Y or N) Smoker (Y or N) CRP and family hx ASCVD Risk Calculator (ASCVD) Risk Calculator Understanding Cardiovascular Risk • The 10-year calculated ASCVD risk is a quantitative estimation of absolute risk based upon data from representative population samples. • The 10-year risk estimate for "optimal risk factors" is: Total cholesterol of 170 mg/dL, HDL-cholesterol of 50 mg/dL, untreated systolic blood pressure of 110 mm Hg, no diabetes history, and not a current smoker. . Understanding Cardiovascular Risk • The lifetime calculated ASCVD risk represents a quantitative estimation of absolute risk for a 50 year old man or woman with the same risk profile. • This estimation of risk is based on the grouping of risk factor levels into 5 strata. – All risk factors are optimal – ≥1 risk factors are not optimal – ≥1 risk factors are elevated – 1 major risk factor – ≥2 major risk factors Nurses Health Study II: Risk for Coronary Heart Disease based on Optimal Lifestyle Behaviors JACC 2015;65(1):43-51. Optimal Lifestyle Behaviors Lowered Risk of Heart Disease and Risk Factor Development • Nonsmoking, Healthy BMI, Exercise, and Healthy Diet were independently and significantly associated with lower CHD risk. • Compared with Women with No Healthy Lifestyle Factors, the risk for CHD for women with 6 lifestyle factors was 0.08 • 73% of CHD cases were attributable to poor adherence to a healthy lifestyle • 46% of clinical CVD risk factor cases were attributed to a poor lifestyle Chomistek AK, et al. J Am Coll Cardiol. 2015;65:43-51 Sitting for Too Long Can Kill You, Even if You Exercise • Pooled data from 41 international studies • The amount of time a person sits during the day is associated with a higher risk of heart disease, diabetes, cancer and death, regardless of regular exercise • Despite the health-enhancing benefits of physical activity, this alone may not be enough to reduce the risk for disease • Prolonged sedentary behavior was associated with a 1520% higher risk of death from any cause; a 15-20% higher risk of heart disease, death from heart disease, cancer, death from cancer; and as much as a 90% increased risk of developing diabetes • Sitting is the ‘NEW’ Smoking Biswas et al. Ann Intern Med. 2015;162(2):123-132 Risk Communication using a Life Span Approach IOM Ecological Model Heart Disease is a process over time that needs multiple strategies as risk factors change. Communicating Risk Assessments Risk Communication Terms Tavena, et.al (2013) BMC Med Inform Decis Mak. 13 Suppl2:57 Influences on Risk Communication • Absolute Risk is rarely mentioned by Primary Care providers • Providers were influenced by: – Subjective perception of patient risk and motivation – Attitudes toward prevention including side effects and efficacy of lifestyle change – High Risk patients were more likely to be prescribed medication Influences on Risk Communication • Patients were influenced by: – # of risk factors – Motivation to change – Attitudes about taking medication • Negative unless medication worked better than lifestyle change – Higher risk resulted in > motivation to change lifestyle especially if not willing to take medication Bonner, et. al. (2015) Health Psychology. 34(3): 253-61 Communicating Risk Factor Assessments • Risk calculations are done later when risk factors are present • Relative vs. Absolute risk • The range in age and number of risk factors impact the discussion • Meta-analysis of 15 studies examined strategies to discuss risk factor calculations • Using multiple strategies showed increase in understanding Communicating Risk Factor Assessments Graphical Formats: lead to increased understanding of risk and can reduce negative emotions – bar and pie charts (patients like pie charts) Presentation of Comparative Risk vs. Personal risk – affected risk perception and emotions • Dependent on level of personal risk: > personal risk = more negative emotions and < behavior change • Waldron, et.al. (2011) Pt Ed & Counsel: 169-181 Communicating Risk Factor Assessments • Timeframe manipulation – Shorter time frame or percentage led to more accurate risk perceptions and increased intention to change behaviors – Net present value vs. future value – Biological age reduction vs. increased lifespan if risks are addressed Communicating Risk Factor Assessments • Framing of risk information – Negative versus positive framing of risk information • Morbidity/mortality/side effects vs. survival data, free of disease – Gain frame vs. loss frame ( i.e. benefit vs. cost) • Doing nothing vs. doing something • Short or long term gain or loss • Younger participants didn’t perceive susceptibility Communicating Risk Factor Assessments • Verbal vs. Numerical Communication – Better outcomes with verbal as part of the discussion but can also increase anxiety • More data points vs. fewer data points – More cautious with more data – More scary with more data Communication Strategies EUROACTION TRIAL • Nurse coordinated, multidisciplinary familybased cardiovascular disease prevention program for CAD and at-risk patients – Matched-paired RCT with 12 general hospitals and 12 general practice centers in 6 different European countries > 1000 patients in each arm – Endpoints measured at one year--were familybased lifestyle change; management of blood pressure, lipids, and blood glucose to target concentrations; and prescriptions of cardioprotective drugs. – Wood, et.al, Lancet (2008). 371:1999-2012 EUROACTION TRIAL Findings of Intervention group vs. usual care – 58% vs. 47% did not smoke – 55% vs. 40 % reduction in fats – 72% vs. 35% increase in fruits and vegetables – 65% vs.55% to B/P goal of 140/90 – Drugs were more readily prescribed Family intervention and multidisciplinary approach was successful – each family was assessed individually, attended sessions together Nurse-Based Multidisciplinary Models for Risk Reduction • Preventive care should be implemented according to evidence-based guidelines that improve quality, reduce re-hospitalizations and support health provider reimbursement. • Preventive efforts should target those at high-risk of developing disease and family members of these patients; groups with highest prevalence of CVD risk factors • Focus should be on promoting lifestyle habits to address total risk • Effective mechanism for prescribing and adhering to medication • Develop and disseminate new and expanded models to serve disadvantaged populations • Focus on empowerment toward self-care and literacy level Berra K, Houston Miller N, Jennings C. Eur J Cardiovasc Nurs 2011 S42-50. Importance of Patient Perception • Survey research of 701 patients from 6 primary health centers in Netherlands. – Age, educational level and gender were significantly associated with perceived experience – Smokers were less likely to want to work with a nurse: awkward, getting my “knuckles rapped”, rather see the primary provider less often – More educated felt they needed less contact – Felt more understood and listened to by the nurse – Men less interested in talking about “ups and downs” in health Voogdt-Pruis, et.al. Intl Jnl Nsg Studies (2010) 1237-44. Patient Perception (continued) • Communication skills need to include motivational interviewing/coaching/counseling • More attention to appropriate timing of consultations in order for patients to make changes in their behavior • Nurses are more communicative during consultations and patients felt more at ease • Nurses provided more information than doctors • Design specific consultation strategies for certain patient groups according to the type of risk factor to be treated to minimize patient non-attendance in the long term Voogdt-Pruis, et.al. Intl Jnl Nsg Studies (2010) 1237-44. Tailoring Risk based on Perception Bonner et al. BMC Family Practice. (2014). 15:106 STRATEGIES FOR CVD COMMUNICATION • Cognitive-behavioral strategies: Class 1A ― ― ― ― Design interventions with specific goals Provide feedback on progress toward goals Provide strategies for self-monitoring Establish frequency/duration of follow-up contacts in accordance with individual needs ― Utilize motivational interviewing ― diminish ambivalence and resistance Artinian NT, et al. Circulation 2010; 122: 406-441 STRATEGIES FOR CVD COMMUNICATION • Cognitive-behavioral strategies: Class 1A ― Provide direct or peer-based long-term support and followup to offset declining adherence ― Incorporate strategies to build self-efficacy ― Use a combination of > 2 strategies (e.g. goal setting, feedback, self-monitoring, follow-up, motivational interviewing, self-efficacy) in an intervention Artinian NT, et al. Circulation 2010; 122: 406-441. . COMMUNICATING HEALTH BEHAVIORS • 90 million Americans have difficulty with literacy; 50% leave an office perplexed about what to do • Educate by: ― 1-3 minute messages ― Using the repeat back method to clarify ― Summarizing at the end of a visit ― Writing down ALL important instructions ― Offering 2 methods of information A 1-3 MINUTE MESSAGE “Mr. Jones, giving up smoking is the single most important thing you can do for your health. Directive/Persuasive Statement Smoking decreases the amount of oxygen that is carried in the blood to your heart. Your angina is caused by a lack of blood flow to your heart muscle. Continuing to smoke is likely to cause you more chest discomfort. Tailored and Personalized Statement I would like to work with you to help you to stop smoking for good. Are you willing to make an attempt to quit smoking? Warm/Empathy and Clear Question COMMUNICATING HEALTHY BEHAVIORS ― Drafting educational materials that are culturally sensitive ― Ethnicity ― Work environments ― Drafting educational materials focusing on health literacy ― 2 syllable words ― Photos, clip art ― White space Community Based Interventions • Assess the needs and priorities of the community • Efforts should be focused on underserved and vulnerable populations. • Mobilize key leaders and agencies from various sectors of the community to promote healthy lifestyles among large proportions of the population; • Use multiple individual level intervention strategies, including mass media, self-help programs, screenings, contests, and competitions; • Implement cost-effective interventions in multiple community settings, including neighborhoods, schools, churches, worksites, restaurants, health care facilities, voluntary agencies, and other organizations to ensure adequate dose • Parker & Assaf (2005) Prim Care Clin Office Prac. 32:865-881 Community-Based Interventions • Mobilize communities to help achieve program goals and using volunteers from the community to help administer these programs; • Develop intervention strategies for promoting environmental changes, including supermarket shelf labeling for healthy foods, restaurant menu labeling; • Develop policy initiatives (i.e., restriction of tobacco use in the workplace) • Develop a reliable monitoring and evaluation system: monitor the change process and conduct summary evaluations. • Disseminate results to ensure that the benefits from the community program reach all communities. Case Study • Sally S. is a 55 year old woman. • Family history of heart disease and diabetes (mother became diabetic at 68 and father had a first heart attack at 65). • Blood pressure is 130/88. • Cholesterol is 200 and her HDL is 70. She takes simvastatin 20 mg daily at night. • Non smoker. She drinks 2 glasses of red wine 3 days a week. Case Study • Sally is a administrative assistant and works four 10 hour days. She works with datasets to determine marketing strategies for the company. • BMI is 31. • Fasting glucose is 95. Creatinine is .8. CRP is 3 • Seasonal allergies and takes Zyrtec as needed. • Sally states she is too young to worry about heart disease or diabetes because her parents got the diseases at a much older age. Case Study: Audience Response 2 The best risk assessment tool to use for Sally is: 1. 2. 3. 4. Framingham Risk Assessment Reynolds Risk Assessment ASCVD Risk Assessment Chads2 Risk Assessment Case Study: Information • Your message: Prolonged sedentary behavior is associated with a 15-20% higher risk of death from any cause; a 1520% higher risk of heart disease, death from heart disease, cancer, death from cancer; and as much as a 90% increased risk of developing diabetes Case Study: Group Work 1. Discuss the Reynolds Risk Assessment and ASCVD Assessment results in your group. 2. Based on the Risk Assessment data and the information you have about Sally, develop a plan for how you would discuss her risk. Thank you for your attention!
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