Knowledge |
Doubt about scientific background of guidelines for older age Absence of exact figures of benefit and risk specific for older age Changes in guidelines over time Specified guidelines for older patients (would facilitate) Risk charts with recurrence risks and expected benefit of medication (would facilitate)
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Skills |
Difficulty communicating risk in the absence of specific risk estimates Difficulty to start statins when cholesterol level is low Communicating risk in patients with low socioeconomic status Shared decision making Motivational interviewing
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Social/professional role and identity |
Problems with fixed treatment goals set by insurance companies Feel responsible for investigation of specific characteristics of the patients and explaining the benefits and risks for this specific patient (individualised care) Applying shared decision making: doctor is coach, but patient decides Sometimes problems when patients want the doctor to decide
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Beliefs about capabilities |
Not feeling free to change medication that was started by the specialist (in the case of side-effects, (especially GP trainees) GP feeling better qualified regarding secondary prevention than specialist because of knowledge of comorbidities and environmental context of the patient
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Optimism |
Not optimistic because of concern about possible side-effects Optimistic about positive effect of lifestyle changes and medication, especially if blood pressure and/or cholesterol are very high
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Beliefs about consequences |
Not knowing if this patient will have enough (life) time left to benefit Being reluctant to medicalise older patients Being reluctant to facilitate ageing and create ‘ready with life’ situations (Expected) side-effects Anticipated regret (fear of development of event, especially stroke, after stopping preventive medications) Expecting improvement in quality of life Believing in positive influence on quality of life Believing in more gain of medication in diabetes mellitus patients Prevention of heart failure
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Reinforcement |
Lack of evidence with regard to cost-effectiveness (this hinders) Observing beneficial effects of lifestyle change or medication in patients Getting support and financial stimulation from insurance companies Working with transmural protocols with GP as chief clinician Experiencing the benefits of systematic registration of kidney function
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Intention |
Presence of dementia or terminal cancer attenuates intentions to start or continue secondary preventive treatment Less intention to treat frail or multimorbid patients Less intention to treat if the cardiovascular event was long ago Fear of medicalisation, or introduction of side-effects reducing intentions to actively start treatment and follow-up Vital patients enhance active treatment and follow-up Prevention of symptoms (for example, heart failure) Prevention of recurrent events (especially stroke after transient ischaemic attack)
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Goals |
Side-effects, multimorbidity and polypharmacy attenuate treatment goals Different goals set by patient: do not want lifestyle changes or treatment but want improvement in quality of life Improvement of quality of life Also embarking on lifestyle goals when they directly lead to improvement of quality of life Analysing patient-specific benefits and risks together with the patient enhances goal setting
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Memory, attention, and decision process |
Concurrent preventive programmes for frail older people sometimes intervene Uncertainty as to whether patient is still under specialist care Cardiovascular event long ago reduces attention ICPC coding of cardiovascular disease for identification of patients needing secondary prevention Protocol for yearly check-up for secondary prevention Creating an action rule in the electronic medical record when the specialist letter states that specialist care has stopped helps to prevent the gap between primary and secondary care
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Environmental context and resources |
Patients lost in the gap between secondary and primary care Patients having to pay for yearly routine laboratory tests within the secondary preventive protocol (would hinder) Lacking public health activities for healthy lifestyle promotion in older people Insurance companies demanding whole standard cardiovascular risk management protocol yearly, without specific protocol and targets for older people Having no structured financial support Practice nurse necessary to organise the care Getting financial incentives from insurance companies for the organisation of yearly secondary preventive check-ups in older people (would facilitate) Having specified guidelines with targets for older people (would facilitate) Volunteers helping with preventive activities, sports etcetera, in the neighbourhood (would facilitate)
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Social influences |
Patient not wanting follow-up Reluctant patients not wanting to start medication Newspapers advocating stopping with statins Having active colleagues in GP group with regard to secondary cardiovascular prevention (would facilitate) Negotiating with insurance companies for specific targets for the older people (would facilitate) Patients having high esteem of their GP facilitates implementation Family sometimes demanding treatment for the patient
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Emotion |
Being uncertain about scientific background of guidelines for older people Feeling reluctant to medicalise older patients Fearing start of medication and introducing side-effects Doubting the necessity of lifestyle change in older age Fearing that patients might develop recurrent cardiovascular disease after stopping or reducing medication Feeling good when secondary preventive care for older patients in the GP practice is well organised
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Behavioural regulation |
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