Do doctors and patients agree on cardiovascular-risk management recommendations post-consultation? The INTERMEDE study

Study design

The design and methods of the INTERMEDE study's quantitative phase (Figure 1) have been described in detail elsewhere.7

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Figure 1

Diagram of quantitative data-collection procedure.

Briefly, answers to questions on management of cardiovascular risk factors (obesity, arterial hypertension, sedentary lifestyle, poor diet, alcohol and tobacco consumption) were collected from ‘mirrored questionnaires’, whereby patients and their GPs were asked the same questions respectively and independently after the consultation, in a sample of volunteer GPs and their patients (Appendix 1). Physicians were not advised to enquire about cardiovascular risk factors.

Educational level was used to measure socioeconomic status in three categories: A-level+ (≥12 years' education); up to GCSE (general certificate of secondary education; 6–11 years' education); and no qualification (<6 years' education).

Statistical analysis

Agreement between patients and GPs about what happened during consultations was analysed using the kappa statistic κ.8 The cluster effect of several patients sharing the same physician was taken into account by carrying out a multilevel logistic regression analysis, adjusting for age and sex.9 Analyses were conducted using Stata 10 statistical software.

Ethics

All data were anonymised, and the study received approval from the French Data Protection Authority (CNIL).

Quantitative sample

The sample consisted of 585 eligible patients and 27 GPs (Figure 2). Patient characteristics are described in Table 1. No difference was observed in educational level between the sexes; however, there was an association between age and education, where 48.7% of patients without any diploma were aged over 65 years. GP characteristics are described in Table 2.

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Figure 2

Diagram of quantitative patients' sample.

Agreement between physicians and patients

Overall, concordance varied widely by topic (Appendix 2). Physician non-response to questions about the assessment of patients' physical activity level, and patients' cigarette and alcohol consumption were high (18.7%, 14.4%, and 39.7% respectively).

Agreement between physicians and patients and patients' educational levels

The bivariate analyses (Appendix 2) showed that as patients' level of education decreased, there was a significant decrease in agreement between patients and their GPs about information given by the GP during the consultation (blood pressure, glycaemia, weight). A similar gradient was observed for whether advice was given on nutrition, weight loss, and physical activity, with the poorest agreement for patients without any qualification. Among the discordant pairs, physicians were likely to declare having advised their patients on nutrition (67%), when the patients claimed the opposite (33%).

Associations with education level disappeared with the introduction of patients' age into the model (Table 3). No interaction term was statistically significant, and the multilevel analysis revealed no significant physician-level effect.

Summary of main findings

The research aim was to explore facets of the patient–physician interaction, which may generate health disparities, notably concerning the management of cardiovascular risk factors in the context of primary care. The agreement between patients and their GPs was better for tangible aspects of the consultation, such as measurements and physical examinations undertaken (auscultation, measuring blood pressure and weight) and information given, compared to more abstract dimensions, such as counselling and assessing patients' physical activity and alcohol intake.

Discordances between patients and physicians were most salient for facets of the consultation relating to physical activity and nutrition, while, in contrast, there was a good level of concordance on whether advice was given on alcohol and cigarette consumption. Thus, the management of hypertension, and alcohol and cigarette consumption were discussed more readily and understood by both parties during a typical consultation, in contrast to issues of nutrition and physical activity. This highlights that some facets of the management of cardiovascular risk factors appear to be dealt with more comfortably by both patients and GPs, whereas others are characterised by lack of clarity and misunderstanding.

Patients' age played a significant role in the concordance between physicians and patients, and was closely related to the level of education, with older patients having the lowest level of education. Although adjusting for age in the multivariate model deleted a statistical association between education and agreement/disagreement between patients and GPs, a trend across educational categories still remained. It is likely, therefore, that both age and educational level play a role in determining concordance between patients and GPs, whereby mutual comprehension may be affected when the patient is older and/or has a low education level. This could potentially lead to misunderstandings between patients and GPs and, consequently, to the quality of care being compromised.

Strengths and limitations of the study

To the authors' knowledge, this study is original in its design and contributes to understanding what goes on during a consultation between patients and GPs.

Potential bias and limitations of study design have been described and discussed in detail elsewhere.7 While κ is the most commonly used statistic for measuring the agreement between two or more observers, the limitations of this statistic are well known,10 explaining why a multiple regression was carried out in the second step of the analyses.

Comparison with existing literature

This study brings to light misunderstandings between patients and GPs in the content of the consultation, especially with regard to prevention. A study of three general practices in England revealed how patients' and doctors' perceptions of the content of the consultation differed according to the patients' social class.11 Doctors perceived that they listened, examined, and gave advice less often to patients in the lowest social class compared to those in the upper social classes, and gave explanations more often to males than females. Taira et al showed that physicians were more likely to discuss diet and exercise with high-income patients than those from a low-income group; however, they were more likely to discuss smoking with low-income patients.12

A rich international literature highlights that a patient's inclination to participate in medical decision making, notably on cardiovascular disease management, varies by characteristics, such as age and education, but also by sex, coping style, and severity of condition.13–18 This emphasises the importance of a shared identity between patients and physicians that improves patients' trust, satisfaction, and observance, facilitating more positive healthcare interactions.19,20 Likewise, the way in which a physician perceives a patient (for example, intelligent, compliant) affects how they treat them during the consultation.21–25 If, as evidence suggests, the patient–physician relationship does affect a patient's healthcare trajectory, how they are treated, and their compliance with treatments could, in turn, lead to health disparities that will permeate across the healthcare system.

Implications for clinical practice and future research

Taking age and educational level into account during a consultation in general practice could improve the mutual comprehension between physicians and their patients, and therefore the quality of care, notably in relation to management of cardiovascular risk factors. Future research on how best to advise patients on nutrition and exercise could be a first step.