Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States and worldwide. According to CDC statistics, one in every four Americans suffers from the effects of heart disease and stroke. Heart disease and stroke account for nearly six million hospitalizations each year. Current figures indicate that CVD costs the United States $300 billion each year in health expenditures and lost productivity. The burden of CVD morbidity and mortality worldwide is expected to increase as populations age and lifestyles are adapted to industrialized economies.
The majority of CVD in the United States is linked to preventable health-related behaviors, such as smoking, diet, and sedentary lifestyle. Two recent studies reviewing the presence of traditional risk factors (smoking, diabetes mellitus, hypertension, and hypercholesterolemia) in patients with coronary heart disease (CHD) showed that 80-90% of patients who had CHD and greater than 90% of patients who experienced a fatal CHD event had one or more major risk factors. These data contradict earlier assumptions that up to half of CHD patients did not have risk factors and provides further evidence that CVD is an epidemic related to modifiable risk factors. Approximately 23% of the U.S. population smokes, and over 60% of adults do not achieve the daily recommended amount of physical activity. Recent data show that 64.5% of U.S. adults are overweight and that 30.5% are obese. These figures are significantly higher than the targets set for the nation in Healthy People 2010.
Recent guidelines from the National Cholesterol Education Program and the American Heart Association highlight the need for primary prevention of CVD through identification and reduction of risk factors. Primary care providers may be uniquely situated to provide this care. As the majority of middle-aged patients visit their primary care physician several times each year, these visits provide many opportunities for preventive counseling. Yet most physicians do not counsel patients aggressively about CVD risk factors. Data from large, national surveys reveal that fewer than half of obese patients are counseled by their physicians to lose weight. Another review found that only 34% of all patients who had seen a physician in the previous year were counseled to exercise. A study that reviewed charts of family practice residents within an eight-site family medicine network found that only 45% of smokers and 20% of patients with hypercholesterolemia were counseled for those risk factors. A study of the directly observed behavior of 138 community family physicians found that delivery of at least one preventive service occurred during only 33% of all illness visits. In that study, physicians counseled infrequently on smoking (42%), exercise (42%), and diet (13%). Even diabetic patients, despite being at greater risk for CVD, receive low rates of CVD preventive services during office visits, and, in some cases, their rates of receiving counseling do not differ from nondiabetic patients.
Our study was conducted to assess the attitudes and practices of internal medicine residents and attending physicians in a teaching hospital with regard to CVD prevention counseling. Based on prior literature, we hypothesized that counseling rates for modifiable CVD risk factors among physicians would be low. However, we were interested if significant differences in counseling practices and attitudes between attending and resident physicians would exist and whether rates of counseling would vary for different risk factors. We also examined whether attitudinal and system barriers would contribute to low levels of preventive counseling within an inner-city teaching program.