The results of this study provide an insight into how GPs use absolute risk within broader communication strategies about CVD risk, and how this may influence the use of absolute risk assessment. Using a ‘positive’ or ‘scare tactic’ strategy could facilitate the use of absolute risk assessment for communication purposes, while an ‘indirect’ strategy discouraged both the assessment and communication of absolute risk. However, some GPs found it helpful to use non-quantitative absolute risk formats within an ‘indirect’ strategy. A challenge for the implementation of absolute risk guidelines is finding a way to make absolute risk assessment useful regardless of the communication strategy being used.
GPs in this study adapted their communication approach based on their perception of the patient’s risk, motivation and anxiety. Absolute risk could reinforce a ‘positive’ strategy for lower risk and motivated patients, or a ‘scare tactic’ strategy for higher risk and unmotivated patients. However, it was seen as inappropriate for less educated patients, and lower risk patients with high anxiety or low motivation, resulting in an ‘indirect’ strategy. As identified in previous research, the concept of absolute risk was sometimes considered difficult to explain [8, 9]. However, some GPs demonstrated how alternative absolute risk formats could be used in these situations, such as the use of colour-coded charts and graphs, and guideline-based qualitative descriptions of the risk level as low, moderate or high. Best practice guidelines for risk communication suggest that alternative risk formats may be beneficial for patient understanding, including verbal and visual formats, but their benefit may depend on patient characteristics [13, 24]. In line with this, a recent qualitative paper on alternative absolute CVD risk formats found that patients preference for and understanding of equivalent verbal, numerical and visual formats was very variable . Our finding that male patients were perceived by GPs to be more interested in the evidence, prompting communication of quantitative absolute risk, provides an explanation for a previous study’s finding that qualitative formats were used more for female patients , but further quantitative research is needed to identify the best risk formats for different patient groups .
Although shared decision making is increasingly accepted as an ideal approach , discussions of CVD risk that do not provide information in ‘optimal’ quantitative risk formats may instead be focusing on one of the other functions of medical communication. These include fostering the relationship, gathering information, providing information, decision making, enabling disease and treatment related behaviour, and responding to emotions . A ‘positive’ strategy might be more focused on fostering the relationship than providing information, a ‘scare tactic’ strategy may be required to enable disease and treatment related behaviour, and an ‘indirect’ strategy may involve gathering information about competing concerns and responding to negative emotions regarding CVD risk.
More broadly, this study sheds light on how GPs reconcile the sometimes conflicting aims of evidence-based guidelines and patient-centred care, by adapting their communication approach based on psychosocial factors. Our findings suggest that GPs’ perceptions of patients’ risk, motivation and anxiety determine whether GPs use a shared decision making approach, rather than a general tendency to use shared decision making versus paternalistic styles across all patients. This is in line with another qualitative study that found GPs ‘decide who decides’ depending on the level of risk and anxiety of the patient . If the patient was judged to be lower risk, the GP was more likely to actively involve them in treatment decision making, unless they were perceived as being too anxious to decide. However, GP and patient perceptions of CVD-related risk and anxiety may differ considerably , and GP judgments of overall CVD risk are not necessarily consistent with calculated absolute risk . The shared decision making approach also requires a distinct point at which the need for a decision is identified, after which quantified risks and benefits can be considered before choosing one of several options [12, 13]. This may not always be applicable to the management of CVD risk, since the benefits and harms of lifestyle versus medication approaches for a particular patient change over time, as individual risk factors increase or decrease.
Future research could investigate education approaches that equip GPs with a range of ways they can describe and explain absolute risk, including quantitative, qualitative and visual approaches that are consistent with the guidelines. The New Zealand Heart Foundation has implemented such a tool, which includes percentage risk, an equivalent ‘heart age’ format, a graph showing how risk will increase with age, and colour-coded risk levels, but its efficacy has not been formally assessed [29, 30]. Taping real consultations to more objectively analyse the communication strategies identified in this study, as well as the impact of alternative absolute risk formats, would also be beneficial.
The strengths of this study include a heterogeneous sample and rigorous analysis process. The findings are limited by the reliance on self report, as GPs’ descriptions of their communication approaches may not match what they actually do in practice. Taping consultations could address this issue. Our method did however allow GPs to reflect on a wide range of patient situations they had encountered, and explain why their communication strategies and use of absolute risk may differ across patients.