Abstract
Objective
To examine patient’s perceived quality of care and reported receipt of information on diet and exercise related to cardiovascular prevention.
Main Outcome Measures
Patients admitted with acute coronary syndromes or elective catheterization were eligible for enrollment. Baseline medical information was collected through medical record review. Patients completed surveys at the time of hospitalization which included items on perceived quality of care and whether they received information on diet and exercise as related to their heart from a healthcare provider. Perceived quality of care was grouped into 3 levels; poor to fair, good and very good to excellent.
Results
Among the 182 cardiac patients who completed the survey, those who reported poor to fair quality of care were more likely to report that they received no advice regarding diet as compared to those who perceived their quality of care as good or very good to excellent (61%, 59% and 26%, respectively, p < 0.0001). A similar pattern was observed for exercise (71%, 74% and 36%, respectively, p < 0.0001).
Conclusions
Patients with low perceived quality of care were less likely to have discussed diet and exercise habits with healthcare providers. Improving receipt of lifestyle counseling warranted given the central role diet and exercise has in secondary prevention.
Keywords: Heart disease, cardiovascular prevention, education
INTRODUCTION
An estimated 16.8 million American adults carry a diagnosis of coronary heart disease, with almost 8 million having experienced a myocardial infarction.1 A critical component of secondary prevention is lifestyle modification to improve diet and increase physical activity. Major guidelines for risk factor modification and treatment of cardiac disease, all recommend that healthcare providers advice patients regarding lifestyle modifications.2, 3 Medical societies such as the American Heart Association have recently begun several programs aimed at patients and their families which provide medical knowledge, including recommendations for dietary and physical activity goals.4, 5 In order to evaluate such educational initiatives, an understanding of current sources of information used by cardiac patients and information on factors which may affect how and why patients seek medical information is needed. Patient satisfaction with their healthcare may be one such factor.
Using data from an observational study of recently hospitalized cardiac patients, we examined self-reported patient satisfaction for medical care in relationship to patient-reported receipt of advice on diet and physical activity. We hypothesized that patients who reported higher levels of satisfaction were more likely to report having received advice on diet and exercise.
METHODS
Data Source
Patients admitted to the University of Massachusetts Health Center’s University Hospital, between September 2004 and October 2008, with diagnosis of acute coronary syndrome (ACS) or elective coronary angiogram were eligible for study inclusion. Patients admitted for elective coronary angiography were excluded if they had no prior history of coronary artery disease (CAD) or no significant CAD was found at the time of the angiogram (defined as the presence of a coronary stenosis (defined as ≥ 50% stenosis in ≥ 1 vessels). ACS was defined as unstable angina (UA), ST-segment elevation myocardial infarction (STEMI), or non-ST-segment elevation myocardial infarction (NSTEMI) using standard definitions.6 The diagnosis of ACS was documented by the presence of symptoms consistent with acute coronary insufficiency, increases in cardiac enzymes (CK-MB > 2x upper limit of the hospital’s normal range and/or positive troponin I), and/or positive acute electrocardiographic changes including: 1) transient ST-segment elevations of ≥ 1 mm in 2 or more contiguous leads, 2) ST-segment depressions of ≥ 1 mm, 3) new T-wave inversions of ≥ 1 mm, and 4) new left bundle branch block. ACS type and other eligibility criteria were based on review of medical records. Information on co-morbidities including history of angina, myocardial infarction (MI,) hyperlipidemia, peripheral vascular disease [PVD], diabetes mellitus [DM], hypertension, and prior stroke were also obtained through review of medical records. Patients were excluded if they lived outside of the Worcester metropolitan area, were unable to complete the baseline surveys, were nursing home residents or had a life expectancy less than six months, or whose cardiac events were the result of trauma or bleeding.
Baseline demographic information including age, gender, and race/ethnicity were collected from patients during the index hospital information. Patients were also asked to complete questions regarding cardiac risk factors knowledge, satisfaction of care and sources of medical knowledge during the index hospitalization. Information on cardiac risk factor knowledge included questions on perceived impact of specific behaviors including diet and physical activity on a patient’s risk for heart disease. The survey included questions asking whether anyone had spoken with the patient regarding foods which may lower his/her risk for heart disease (yes, no) and if yes who provided such information. Predefined responses included family members, friends, physicians (cardiologists, primary care physicians), nurses or nurse practitioners, dieticians, and cardiac rehabilitation staff. Similar items were administered regarding weight and exercise habits. The participants were asked to rate their interest and confidence for improving their diet, weight, and physical activity. Lastly the participants were asked about additional sources of medical information including family members, friends, magazines, internet, and books. Patient reported satisfaction for their cardiac care was assessed through 2 questions,7 which asked patients to rate their overall quality of care and the outcome of their care, on a Likert scale ranging from poor to excellent. Patients were divided into 3 groups according to their responses to questions asking them to rate their perceived quality of care (poor to fair, good, and very good to excellent).
The study personnel were trained to administer surveys and review medical records in a standardized format. Data were collected on standardized forms and then forwarded to a database service for data entry after review for face validity. Data not within the set limit ranges, inconsistencies, and/or unrecorded fields were flagged and then returned for clarification and correction. All aspects of this study were approved by the Institutional Review Boards from University of Massachusetts Medical School and the University of Michigan Health System. Informed consent was obtained from all patients.
Summary statistics are presented as frequencies and percentages or as means and standard deviations. Student’s t-tests and chi-square tests were used to compare differences in the baseline physical and clinical characteristics between levels of patients’ satisfaction for their care. Reported patient satisfaction was grouped into 3 levels ranging from poor to fair, and good to very good to excellent. Analysis of variance was used to evaluate the differences between groups in reported sources of information on diet, and/or exercise. Similar comparisons were made for patient reported confidence in their ability to change diet and/or physical activity, and for reported sources of medical information. All analyses were performed using SASR v 9.1
RESULTS
A total of 182 participants (mean age 59.9 years), who completed the baseline surveys were included in this study. Of these, 68.1% (n=124) were men and 87.9% (n=160) were white (Table 1). The majority of respondents had graduated high school and 25% reported completing college. Cardiovascular risk factors were common with over 40% of the subjects having a prior history of hypertension and/or hyperlipidemia. Diabetic patients comprised 19.3% of the study population. Approximately 30% of patients reported a prior history of heart disease. ST elevation myocardial infarction (STEMI) was the primary diagnosis for 32.2% of the study population, with a further 37.4% of patients admitted for a non-ST elevation myocardial infarction (NSTEMI), and the remainder admitted for elective angiography.
Table 1.
Baseline Characteristics
| Characteristics | Participants N = 182 |
|---|---|
| Age, y, mean (SD) | 59.9 ± 12.3 |
| Male, n (%) | 124 (68.1) |
| White ethnicity, n (%) | 160 (87.9) |
| Education, n (%) | |
| No High School diploma | 29 (15.9) |
| High School diploma and/or some college | 107 (58.8) |
| College diploma and/or Graduate Degree | 46 (25.3) |
| Clinical Factors | |
| Pre-existing heart disease | 59 (32.6) |
| Diabetes mellitus | 35 (19.3) |
| Hypertension | 79 (43.7) |
| Hyperlipidemia | 79 (43.7) |
| Admission type | |
| STEMI | 56 (32.2) |
| NSTEMI or UA | 65 (37.4) |
| Elective angiography | 53 (30.5) |
SD = standard deviation
STEMI = ST elevation myocardial infarction; NSTEMI = non-ST elevation myocardial infarction; UA = unstable angina
Baseline characteristics were then examined in relation to patient self-reported perceived quality of care. (Table 2) Age, gender, ethnicity, education level and pre-existing co-morbidities did not differ for patients who reported poor to fair quality of care, good quality of care or very good to excellent quality of care. Patients who were admitted for an elective coronary angiography were more likely to report good or very good to excellent quality of care.
Table 2.
Baseline characteristics by perceived quality of Care
| Perceived Quality of Care | ||||
|---|---|---|---|---|
| Characteristics | Poor to Fair N = 28 | Good N = 58 | Very Good to Excellent N = 89 | P value |
| Age, y, mean (SD) | 55.1 ± 12.7 | 60.1 ± 12.9 | 60.9±12.1 | 0.10 |
| Male, n (%) | 21 (75) | 43 (74) | 56 (63) | 0.26 |
| White ethnicity, n (%) | 25 (89) | 52 (90) | 77 (87) | 0.83 |
| Education, n (%) | ||||
| Low (less than high school) | 5 (18) | 12 (21) | 12 (21) | 0.51 |
| Intermediate (any postsecondary) | 11 (39) | 16 (39) | 31 (28) | 0.50 |
| High (university or college) | 12 (43) | 28 (48) | 46 (52) | 0.71 |
| Clinical Factors | ||||
| Pre-existing heart disease | 9 (32) | 18 (31) | 29 (33) | 0.98 |
| Diabetes mellitus | 5 (18) | 13 (22) | 17 (22) | 0.85 |
| Hypertension | 8 (29) | 22 (38) | 45 (51) | 0.08 |
| Hyperlipidemia | 7 (25) | 24 (41) | 42 (47) | 0.12 |
| Admission type | ||||
| STEMI | 5 (18) | 17 (29) | 21 (24) | 0.49 |
| NSTEMI or UA | 8 (29) | 23 (40) | 31 (35) | 0.59 |
| Elective angiography | 3 (11) | 11 (19) | 36 (19) | 0.001 |
SD = standard deviation
STEMI = ST elevation myocardial infarction; NSTEMI = non-ST elevation myocardial infarction; UA = unstable angina
Few patients reported receiving advice on diet (40%) or exercise (30%) from their providers (Table 3). Overall, 41% of patients reported having no discussion on diet with anyone including healthcare providers (doctors, nurses and nurse practitioners) or family and friends. Approximately half of all patients reported having a discussion about exercise, most often with their physician. Patients who reported receiving advice from a healthcare provider regarding lifestyle (diet or physical activity) had similar baseline characteristics to those who reported not receiving such advice, with 2 exceptions. Patients with a history of hyperlipidemia or who were admitted for elective angiography were more likely to report having received lifestyle counseling from a provider.
Table 3.
Sources of medical advice by perceived quality of Care
| Perceived Quality of Care | ||||
|---|---|---|---|---|
| Sources, n (%) | Poor to Fair N = 28 | Good N = 58 | Very Good to Excellent N = 89 | P value |
| Discussed diet and heart disease | ||||
| Family member | 2 (7) | 6 (10) | 27 (30) | 0.004 |
| Friends | 2 (7) | 2 (3) | 16 (18) | 0.03 |
| Doctors | 7 (25) | 16 (28) | 50 (56) | < 0.0001 |
| Nurses (or Nurse Practitioner) | 4 (14) | 4 (7) | 30 (34) | < 0.0001 |
| No discussion | 17 (61) | 34 (59) | 23 (26) | <0.0001 |
| Discussed exercise and heart disease | ||||
| Family member | 1 (4) | 2 (3) | 20 (22) | <0.0001 |
| Friends | 1 (4) | 0 (0) | 14 (16) | 0.003 |
| Doctors | 2 (7) | 10 (17) | 44 (49) | <0.0001 |
| Nurses (or Nurse Practitioner) | 1 (4) | 1 (2) | 19 (21) | <0.0001 |
| No discussion | 20 (71) | 43 (74) | 32 (36) | <0.0001 |
Patients who perceived their quality of care as poor to fair were more likely to report having no discussion on diet (related to heart disease) as compared to patients who reported very good to excellent care (61% vs. 26%, p < 0.0001). Patients, who were satisfied with their care, reported having discussed diet and heart disease more often with family members and friends as well as with doctors and nurses. A similar pattern was observed between perceived quality of care and patients’ who reported having discussed their exercise habits with a healthcare professional. Those who reported higher levels of quality of care were more likely to report having such discussions with healthcare providers, and family and friends. In contrast, over 71% of those who reported poor to fair or good quality of care, reported having no discussion about exercise and heart disease, while only 36% of those who reported very good to excellent quality care reported no discussion on exercise.
We also asked patients to rate their confidence in making lifestyle modifications related to diet and physical activity. Overall, those who reported good, or very good to excellent quality of care had higher levels of confidence in their ability to modify their diet. Even in the group who reported poor to fair quality of care, the majority of respondents (57%) reported a high level of confidence for making dietary changes. A similar pattern was observed for patients’ confidence in improving their physical activity.
In terms of specific sources of information, the majority of patients reported their doctors as being a primary source of medical information (Table 5). However many patients reported magazines and newspapers as sources of information, and 25% of patients reported using the internet as a source of medical information. Overall, patients who reported poor to fair quality of care were less likely to use any of these resources, which included healthcare providers, family or friends and medial sources such as newspapers, internet or books.
Table 5.
Sources of medical information which patients feel comfortable using and perceived quality of care
| Perceived Quality of Care | ||||
|---|---|---|---|---|
| Sources, n (%) | Poor to Fair N = 28 | Good N = 58 | Very Good to Excellent N = 89 | P value |
| Doctors | 24 (86) | 54 (93) | 87 (98) | 0.01 |
| Nurses | 3 (11) | 9 (16) | 35 (39) | <0.0001 |
| Nurse Practitioners | 12 (43) | 32 (55) | 53 (60) | 0.05 |
| Family members | 13 (46) | 21 (36) | 27 (30) | 0.02 |
| Friends | 4 (14) | 7 (12) | 13 (15) | 0.08 |
| Magazines or newspapers | 10 (36) | 20 (34) | 40 (45) | 0.55 |
| Internet | 7 (25) | 19 (33) | 18 (20) | 0.02 |
| Books | 0 (0) | 4 (7) | 7 (8) | 0.04 |
DISCUSSION
Using a survey of cardiac patients admitted to a major teaching hospital, we observed that the majority of patients reported not receiving diet or exercise advice from their physicians. Patients who perceived their quality of care as poor to fair were more likely to report not having discussed lifestyle modification as compared to patients who were satisfied with their care.
Diet and physical activity recommendations are included in many cardiac guidelines and are a well known component of secondary prevention.2, 3 We rely on healthcare providers to promote these guideline recommendations by educating their patients about a cardiac healthy lifestyle. Provider counseling is associated with smoking cessation, weight loss and exercise, all of which are components of secondary prevention.8–12 However, few providers counsel their patients on diet and exercise.13–17 Barriers to such counseling include time limitations, reimbursement, and providers’ confidence in their counseling ability and providers' perception of the patients to make lifestyle changes.12, 18, 19 An examination of all these factors is beyond the scope of this current study. However our findings do suggest the patients’ perceived quality of care relates to their reported receipt of lifestyle counseling. These data suggest the need to better understand factors which influence patients’ perceived or real receipt of information on health. Ongoing evaluations of such factors should be a key component of interventions which modify lifestyle behaviors among cardiac patients.
Several limitations exist for the current study. As a cross-sectional examination of cardiac patients at one institution, our results may not directly apply to other patients or hospitals. Potential biases, including selection bias, may exist, which further limit generalizability of our findings. Given the relatively small sample size, we were limited from examining specific groups of patients, or groups of factors which could influence either patient satisfaction and/or receipt of information on lifestyle.
Conclusions
Improving the numbers of patients who report having discussed lifestyle as it relates to secondary cardiac prevention is a critical component of cardiac care. Perceived quality of care appears to be one factor related to patients’ receipt of counseling on diet and exercise. Interventions to reduce barriers to lifestyle counseling such as incorporation of such counseling into current measures of quality need to be considered to optimize current non-pharmacologic prevention efforts.
Table 4.
Reported confidence in ability to make lifestyle modifications and perceived quality of care
| Perceived Quality of Care | ||||
|---|---|---|---|---|
| Lifestyle Factors, n (%) | Poor to Fair N = 28 | Good N = 58 | Very Good to Excellent N = 89 | P value |
| Improving diet | ||||
| Low (1–2) | 2 (7) | 9 (16) | 4 (16) | <0.01 |
| Intermediate (3) | 8 (29) | 10 (17) | 14 (17) | 0.30 |
| High (4–5) | 16 (57) | 38 (66) | 70 (66) | 0.05 |
| Improving physical activity | ||||
| Low (1–2) | 6 (21) | 14 (24) | 7 (24) | 0.02 |
| Intermediate (3) | 6 (21) | 15 (26) | 15 (26) | 0.42 |
| High (4–5) | 13 (46) | 28 (48) | 65 (48) | <0.01 |
Acknowledgments
Dr. Jackson receives support from the NHLBI (K23 HL073310-01).
References
- 1.Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation. 2010 Feb 23;121(7):e46–e215. doi: 10.1161/CIRCULATIONAHA.109.192667. [DOI] [PubMed] [Google Scholar]
- 2.Lichtenstein AH, Appel LJ, Brands M, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation. 2006 Jul 4;114(1):82–96. doi: 10.1161/CIRCULATIONAHA.106.176158. [DOI] [PubMed] [Google Scholar]
- 3.Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. 2007 Aug 28;116(9):1081–1093. doi: 10.1161/CIRCULATIONAHA.107.185649. [DOI] [PubMed] [Google Scholar]
- 4.Jones DW, Peterson ED, Bonow RO, et al. Partnering to reduce risks and improve cardiovascular outcomes: American Heart Association initiatives in action for consumers and patients. Circulation. 2009 Jan 20;119(2):340–350. doi: 10.1161/CIRCULATIONAHA.108.191328. [DOI] [PubMed] [Google Scholar]
- 5.Jones DW, Peterson ED, Bonow RO, et al. Translating research into practice for healthcare providers: the American Heart Association's strategy for building healthier lives, free of cardiovascular diseases and stroke. Circulation. 2008 Aug 5;118(6):687–696. doi: 10.1161/CIRCULATIONAHA.108.189934. [DOI] [PubMed] [Google Scholar]
- 6.Latchamsetty R, Fang J, Kline-Rogers E, et al. Prognostic value of transient and sustained increase in in-hospital creatinine on outcomes of patients admitted with acute coronary syndrome. Am J Cardiol. 2007 Apr 1;99(7):939–942. doi: 10.1016/j.amjcard.2006.10.058. [DOI] [PubMed] [Google Scholar]
- 7.Ross CK, Steward CA, Sinacore JM. A comparative study of seven measures of patient satisfaction. Med Care. 1995 Apr;33(4):392–406. doi: 10.1097/00005650-199504000-00006. [DOI] [PubMed] [Google Scholar]
- 8.Cohen SJ, Stookey GK, Katz BP, Drook CA, Smith DM. Encouraging primary care physicians to help smokers quit. A randomized, controlled trial. Ann Intern Med. 1989 Apr 15;110(8):648–652. doi: 10.7326/0003-4819-110-8-648. [DOI] [PubMed] [Google Scholar]
- 9.Wilson DM, Taylor DW, Gilbert JR, et al. A randomized trial of a family physician intervention for smoking cessation. JAMA. 1988 Sep 16;260(11):1570–1574. [PubMed] [Google Scholar]
- 10.Hash RB, Munna RK, Vogel RL, Bason JJ. Does physician weight affect perception of health advice? Prev Med. 2003 Jan;36(1):41–44. doi: 10.1006/pmed.2002.1124. [DOI] [PubMed] [Google Scholar]
- 11.Abramson S, Stein J, Schaufele M, Frates E, Rogan S. Personal exercise habits and counseling practices of primary care physicians: a national survey. Clin J Sport Med. 2000 Jan;10(1):40–48. doi: 10.1097/00042752-200001000-00008. [DOI] [PubMed] [Google Scholar]
- 12.Rogers LQ, Bailey JE, Gutin B, et al. Teaching resident physicians to provide exercise counseling: a needs assessment. Acad Med. 2002 Aug;77(8):841–844. doi: 10.1097/00001888-200208000-00019. [DOI] [PubMed] [Google Scholar]
- 13.Walsh JM, Swangard DM, Davis T, McPhee SJ. Exercise counseling by primary care physicians in the era of managed care. American journal of preventive medicine. 1999 May;16(4):307–313. doi: 10.1016/s0749-3797(99)00021-5. [DOI] [PubMed] [Google Scholar]
- 14.Anis NA, Lee RE, Ellerbeck EF, Nazir N, Greiner KA, Ahluwalia JS. Direct observation of physician counseling on dietary habits and exercise: patient, physician, and office correlates. Preventive medicine. 2004 Feb;38(2):198–202. doi: 10.1016/j.ypmed.2003.09.046. [DOI] [PubMed] [Google Scholar]
- 15.Halm J, Amoako E. Physical activity recommendation for hypertension management: does healthcare provider advice make a difference? Ethnicity & disease. 2008 Summer;18(3):278–282. [PubMed] [Google Scholar]
- 16.Petrella RJ, Lattanzio CN, Overend TJ. Physical activity counseling and prescription among canadian primary care physicians. Archives of internal medicine. 2007 Sep 10;167(16):1774–1781. doi: 10.1001/archinte.167.16.1774. [DOI] [PubMed] [Google Scholar]
- 17.Tsui JI, Dodson K, Jacobson TA. Cardiovascular disease prevention counseling in residency: resident and attending physician attitudes and practices. Journal of the National Medical Association. 2004 Aug;96(8):1080–1083. 1088–1091. [PMC free article] [PubMed] [Google Scholar]
- 18.Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005 Feb 1;111(4):499–510. doi: 10.1161/01.CIR.0000154568.43333.82. [DOI] [PubMed] [Google Scholar]
- 19.Rogers LQ, Gutin B, Humphries MC, et al. Evaluation of internal medicine residents as exercise role models and associations with self–reported counseling behavior, confidence, and perceived success. Teaching and learning in medicine. 2006 Summer;18(3):215–221. doi: 10.1207/s15328015tlm1803_5. [DOI] [PubMed] [Google Scholar]