Table 2.

Key concerns about adopting a risk prediction-based approach to CVD treatment and prevention

Key Concerns	Representative Quote
Quantified medicine vs Whole person approach	“a person is a person, you cannot formulize and say, one and one is two… one plus one doesn’t always add up to two. There’s so many other factors that are there that changes the way you think…so the comorbidities and…medications that will interact with it, all these things has to be factored in in order to see whether you can really get to that goal or not.” (10011CA) “Motivation levels, access to care, ability to meet dietary goals based on a lot of different factors that play into a person making the necessary changes to be healthy. And when you say realistic goals, well, you can tell a person to not eat fast food, but if that’s what they can afford, they won’t change. (10023EA) “…medication burden and how that negatively influences adherence I think is something to take in…like adherence vs. medication burden and if it’s worth a whole other agent to get like 1% reduction. Um, and then also like fall risk, risk of adverse reactions for them.” (10016EA – clinical pharmacist)
Validity of Risk Model	“I mean what does this really mean, so break it down...show me the studies.” (10021EA, 299–302) “If somebody says, ‘Do you want to get it down to [the reasonable goal],’ I would say, ‘I need to know how you calculated It.’” (10029EA) “Which population did you do in your study, you know what focus was studied, are they applicable to the other populations?” (10031NA)
Impact on Workflow	“…perhaps if there was, like in a little box, you know like on the kind of the main page of the patient where it would say you know, what these numbers are so that it could be something we could reference without having to “answer to” such and such a reminder” (10036EA) “No, it needs to be maybe a little side note somewhere, even in their office or somewhere that the providers can look at, but we do not need another task (taps table with each syllable for emphasis). We can’t, no.” (10001NA) “I have to plug the numbers in, okay yeah, so I’ve got another 10 min to sit in front of you and say, ‘Let me see, oh your blood pressure is this, oh, that’s a + 2. Let me see what your cholesterol, oh, + 5. Oh, here’s your magic number, oh, now your risk factor is 12.8%, how can I make that better?’ I had to do all the work, well I’ve already got a lot of work to do. Now if you could do the work for me and you’re going to say here’s your magic numbers, Dr. X., I’m all right with that.” (10028EA)
Does risk prediction add value?	Adds value: By Identifying High-risk Patients “I wouldn’t have the same like blood pressure goals for everybody, so the hard part is some people that let’s say they have diabetes and micro albuminuria or macro albuminuria, they really should be less than 130/80 for their blood pressure, but if you look in like I think it’s our SAL or our HEDIS or whatever it is, when you pull it up, those patients wouldn’t be identified and they really should be on… an ace inhibitor for their risk but it doesn’t necessarily show that, so it’s like those people kind of get lost in the shuffle…So I think it’d be better to try to move to you know a system that shows like 10 year risk and who to target the most.” (10016EA) By Improving Communication with Patients “I would use it as a tool to show the patient that didn’t want to take medication…and say, “Well, you’ve got a 30% chance now, a 10-year chance of a heart attack or stroke with no medication,”…that might help to sway them to take medication.” (10000CA) “… it’s a visual for them and I think visuals really tend to you know, be a good thing in practice…if they see numbers, maybe cut in half that’s pretty impressive, even with just you know smoking cessation, how significantly the numbers drop or even weight loss, 5% you know with a reduction in your blood pressure…I think it gives them incentive you know to strive to be healthier.” (10002EA) “‘Your risk is 13% without no medication, if we put you on, optimize your medications, we can get your risk down to 6%,’ I mean most people even if they don’t have a good health literacy can understand that 6 is less than 13” (10015EA) May not add value: “…you could say that everybody has to be within 2% of the realistic goal, and have 30 people that are 2.1% [within] the realistic goal. Is it worth bringing them in, beating them over the head and say, ‘I’m going to give you a fourth blood pressure medicine because if I just got back down, my numbers would now be at two and I will get bonus, but if not, my poor grandkids won’t go to Disneyland,’ so we’re still playing that silly little game of numbers. But I think it’d be easier rather than doing different areas and trying to chase your tail all the time. You know this week it’s hypertension, next week I’ll get yelled at for diabetics, the weekend after that it’s cholesterol, the weekend after that it’s you doing up mammograms I mean it just we’re always chasing your…If all my patients are 0.2 away from their realistic goal, are 35 years old, it would be more concerning. If all of my patients that were 2.2 away from their goal are 85, those are two different people, two different populations at two different levels in their life to be worried about 0.2.” (10028EA) “Yeah, so some risks are modifiable and some are not, like if there is family with hyperlipidemia, you can’t, but if you modify the hyperlipidemia and get to at goal, this may not be at goal for a person oh you know who has a family history of premature coronary artery disease, you want it lower the better, things like that. So you go from the person’s risk, history and based on the smoking, smoke cessation is what you can alter, blood pressure number is what you can alter, which is what we are talking about…so that kind of stuff, and weight.” (10012CA) “It’s not like I’m saying “No you can’t do this,” but will this current goal pressure on the physician help that? I don’t think so.” (10012CA)