Barriers to cardiovascular risk prevention and management in Germany – an analysis of the EURIKA study

Figures & data

Table 1 Physician demographics

	Germany physicians (%)	Rest of Europe physicians (%)
Physicians (total)	66	740
Sex
Male	48 (72.7)	463 (62.6)
Female	18 (27.3)	277 (37.4)
Mean age (years ± SD)	51.7 ± 8.4	47.0 ± 9.7
Specialty
Primary care	34 (51.5)	480 (64.9)
Cardiology	7 (10.6)	87 (11.8)
Internal medicine	21 (31.8)	126 (17.0)
Diabetes or endocrinology	1 (1.5)	23 (3.1)
Other	3 (4.5)	24 (3.2)
Main work setting
Urban	48 (72.7)	477 (64.5)
Suburban	7 (10.6)	114 (15.4)
Rural	11 (16.7)	148 (20.0)
Did not specify	0 (0.0)	1 (0.1)
Number of patients treated per week
<50	1 (1.5)	124 (16.8)
50–99	12 (18.2)	266 (35.9)
100–199	28 (42.4)	228 (30.8)
>199	25 (37.9)	122 (16.5)
Number of physicians in working environment
<5	45 (68.2)	329 (44.5)
5–9	8 (12.1)	134 (18.1)
10–19	6 (9.1)	121 (16.4)
>19	7 (10.6)	155 (20.9)
Did not specify	0 (0.0)	1 (0.1)

Figure 1 Physicians’ use of guidelines for the management of cardiovascular risk factors.

Notes: ESC CVD Prevention, European Society of Cardiology (ESC) Guideline on Cardiovascular Disease Prevention in Clinical Practice; ESC/ESH Hypertension, ESC Guideline for the Management of Arterial Hypertension; ATP III, Adult Treatment Panel III; JNC VII, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.^1–3,45 Other guidelines not specified.

Table 2 Physicians’ reasons for not using clinical guidelines and global risk assessment tools, and beliefs about the limitations of risk assessment tools

	Germany physicians N (%)	Rest of Europe physicians N (%)
Reasons for not using clinical guidelines	n = 8	n = 93
There are too many guidelines	5 (62.5)	43 (46.2)
Time constraints	3 (37.5)	31 (33.3)
Do not know them	1 (12.5)	27 (29.0)
Guidelines were unrealistic	6 (75.0)	18 (19.4)
Poor acceptance by the patient	3 (37.5)	11 (11.8)
Guidelines are confusing	2 (25.0)	9 (9.7)
Do not agree with recommendations	3 (37.5)	2 (2.2)
Reasons for not using global risk assessment tools	n = 29	n = 211
Time constraints	19 (65.5)	127 (60.2)
Risk assessment tools are of little use	9 (31.0)	44 (20.9)
Do not know how to use	2 (6.9)	46 (21.8)
Do not know how to proceed after risk assessment	0 (0.0)	10 (4.7)
Other	6 (20.7)	25 (11.8)
Believe risk assessment tools have limitations	n = 64	n = 725
Yes	51 (79.7)	520 (71.7)
No	13 (20.3)	205 (28.3)
Limitations of risk assessment tools*	n = 47	n = 510
Miss important risk factors	39 (83.0)	474 (92.9)
Do not allow calculation of risk in the elderly	36 (80.0)	344 (67.5)
Assess risk over too long a time period	23 (52.3)	244 (47.8)
Overestimate risk	21 (45.7)	176 (34.5)

Note:

* Missing responses were considered negative.

Figure 2 Physicians’ use of global risk assessment tools (of those using these tools).

Notes: ESC Score; ESC/ESH Hypertension, ESC Guideline for the Management of Arterial Hypertension; Framingham study; Framingham Coronary Risk Score.^2,6,7,38 *Locally calibrated version of the Framingham study score. Other guidelines not specified.

Table 3 Sociodemographic and clinical patient characteristics

	Germany patients (%) n = 678	Rest of Europe patients (%) n = 6963
Sex
Male	333 (49.1)	3363 (48.3)
Female	345 (50.9)	3600 (51.7)
Age (years ± SD)
Mean	65.3 ± 8.9	63.0 ± 8.9
<65 years	309 (45.6)	4210 (60.5)
≥65 years	369 (54.4)	2753 (39.5)
Blood pressure (mm Hg ± SD)
SBP (mean)	135.4 ± 17.1	135.0 ± 16.5
DBP (mean)	80.7 ± 9.5	80.0 ± 10.0
Alcohol
U/week ± SD	6.4 ± 11.8	5.6 ± 11.3
Smoking (%)	325 (47.9)	3373 (48.4)
Current (%)	112 (16.5)	1516 (21.8)
Former (%)	212 (31.3)	1859 (26.7)
Hypertension (%)	549 (81.0)	5006 (71.9)
Dyslipidemia (%)	404 (59.6)	4005 (57.5)
Diabetes mellitus (%)	256 (37.8)	1792 (25.7)
Obesity (%)	332 (49.0)	2992 (43.0)
Physical inactivity (%)	82 (12.1)	1431 (20.6)
Living alone (%)	146 (21.6)	1313 (18.9)
High CV risk* (score ≥5%) (%)	87 (57.1)	2677 (38.4)

Note:

* High CV risk (SCORE ≥5%) – calculation of SCORE risk was based on the following data: age, sex, systolic blood pressure, and total cholesterol values at the study visit, and smoking status.

Abbreviations: SBP, systolic blood pressure; DBP, diastolic blood pressure.

Figure 3 Control of treated hypertension (<140/90 mm Hg), dyslipidemia (total cholesterol < 5 and LDL-c < 3 mmol/L),* type 2 diabetes (HbA_1c < 6.5%), and obesity (BMI < 30 kg/m²) in special countries versus the average control rate in all countries.

Notes: *Patients with diabetes: <130/80 mm Hg; <4.5 mmol/L, and <2.5 mmol/L (100 mg/dL).
Abbreviations: BEL, Belgium; FRA, France; GER, Germany; GRE, Greece; UK, United Kingdom; DL, dyslipidemia; DM, diabetes mellitus; HT, hypertension; OBES, obesity.

Table 4 Communication tips usually used for the management of behavioral risk factors (physicians)

	Germany physicians (%) n = 66	Rest of Europe physicians (%) n = 729
Physician-centered tips
Spend enough time with patient	55 (83.3)	540 (74.1)
Speak to patient with his/her own language	47 (71.2)	565 (77.5)
Develop a sympathetic alliance with the patient	55 (83.3)	518 (71.1)
Involve the family in the treatment	37 (56.1)	325 (44.6)
Patient-centered tips
Listen carefully, recognize strength and weakness in the patient’s attitude to illness and lifestyle	50 (75.8)	504 (69.1)
Ensure that the patient understands the relationship between lifestyle and disease	58 (87.9)	609 (83.5)
Offer specific courses to patient	28 (42.4)	157 (21.5)
Accept the patient’s view of his/her disease, allow expression of worries	45 (68.2)	471 (64.6)
Acknowledge that changing life-long habits can be difficult, and gradual change that is sustained is often more useful	53 (80.3)	550 (75.4)
Gain commitment to lifestyle change	28 (42.4)	329 (45.1)
Involve patient in identifying the barriers to change	34 (51.5)	334 (45.8)
Involvement of others
Involve other health care staff (nurse)	14 (21.2)	242 (33.2)
Involve other health care staff (dietician, social worker, psychologist)	21 (31.8)	299 (41.0)

GrahamIAtarDBorch-JohnsenKEuropean Society of Cardiology (ESC); European Association for Cardiovascular Prevention and Rehabilitation (EACPR); Council on Cardiovascular Nursing; European Association for Study of Diabetes (EASD); International Diabetes Federation Europe (IDF-Europe); European Stroke Initiative (EUSI); Society of Behavioural Medicine (ISBM); European Society of Hypertension (ESH); WONCA Europe (European Society of General Practice/Family Medicine); European Heart Network (EHN); European Atherosclerosis Society (EAS)European guidelines on cardiovascular disease prevention in clinical practice: full text. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts)Eur J Cardiovasc Prev Rehabil.200714Suppl 2S111317726407

 PubMed Web of Science ®Google Scholar

National Cholesterol Education Program (NCEP), Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final reportCirculation2002106253143342112485966

 PubMed Web of Science ®Google Scholar

ChobanianAVBakrisGLBlackHRNational Heart, Lung, and Blood Insitute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, National High Blood Pressure Education Program Coordinating CommitteeThe Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 ReportJAMA2003289192560257212748199

 PubMed Web of Science ®Google Scholar

ManciaGDe BackerGDominiczakAThe Task Force for the Management of Arterial Hypertension of the European Society of Hypertension, The Task Force for the Management of Arterial Hypertension of the European Society of Cardiology2007 Guidelines for the management of arterial hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)Eur Heart J200728121462153617562668

 PubMed Web of Science ®Google Scholar

De BackerGAmbrosioniEBorch-JohnsenKThird Joint Task Force of the European and Other Societies on Cardiovascular Disease Prevention in Clinical PracticeEuropean guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical PracticeEur Heart J200324171601161012964575

 PubMed Web of Science ®Google Scholar

ConroyRMPyoralaKFitzgeraldAPSCORE Project GroupEstimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE projectEur Heart J20032411987100312788299

 PubMed Web of Science ®Google Scholar

BrindlePEmbersonJLampeFPredictive accuracy of the Framingham coronary risk score in British men: prospective cohort studyBMJ20033277426126714644971

 PubMed Web of Science ®Google Scholar