An in-office linguistic study was conducted to assess physician–patient discussions of mixed dyslipidemia. Naturally occurring interactions among 12 cardiologists, 12 primary care physicians, and 45 of their patients diagnosed with low levels of high-density lipoprotein cholesterol and being treated with prescription niacin extended-release were recorded. The participants were interviewed separately after the visit. The transcripts were analyzed using sociolinguistic techniques. Determined from the time at talk and the number of questions asked, the patients were moderately engaged in the visit conversations; however, most communication was physician-driven. Only 6% of the average visit was dedicated to disease education. Conversations about dyslipidemia were characterized by numerous laboratory values but rarely contained clear benchmarking or goal setting. In the postvisit interviews, the patients demonstrated a lack of understanding about their lipid levels and the next steps they should take. Both “HDL” [high-density lipoprotein] and “good cholesterol” were the most frequently mentioned aspects of dyslipidemia in these conversations; however, most physicians did not contextualize these components such that the patients were able to understand and retain the information after the visit. Although the conversations about treatment with niacin extended-release contained detailed information about how to manage the side effect of flushing, they lacked a clear description of this side effect. Also, missing from the dialogue was a balanced discussion of risks and benefits. Communication gaps were observed in the discussions regarding mixed dyslipidemia and its treatment with niacin extended-release. In conclusion, additional research is warranted to assess the efficacy of communication strategies to educate both physicians and patients about this condition and its treatment.
Cardiovascular disease (CVD) is the leading cause of mortality worldwide; however, patients’ understanding regarding CVD prevention has been shown to be insufficient. In addition, patients’ knowledge of individual risk status has been shown to be poor. Studies have also shown an inverse relation between high-density lipoprotein (HDL) cholesterol and the risk of developing CVD; research on the exact role of HDL cholesterol continues to progress. Niacin extended-release (NER) has been shown to be effective in increasing low HDL cholesterol levels, and strategies exist to manage its side effects. However, NER might be underused in community practice because of a perception of side effects that are more severe and less manageable than clinical data would suggest. To evaluate the discussions of HDL cholesterol and its treatment, an observational study was conducted using sociolinguistic methods. The present study was designed to capture naturally occurring conversations among cardiologists, primary care physicians (PCPs), and patients with dyslipidemia. Of particular interest was patient understanding of the risks and benefits associated with treatment of low HDL cholesterol level with NER.
Methods
The Independent Investigational Review Board, Inc., approved the observational study in November 2007, and the study began in December 2007-January 2008. Invitations were mailed to 1,600 community-based cardiologists and PCPs from a list of high prescribers of NER. Of these physicians, 91 responded to the mailing. Of these 91, the first 30 who met the eligibility criteria ( Table 1 ), were available during the appropriate period, and agreed to participate were enrolled in the present study.
| Cardiologist or primary care physician |
| Board certified |
| In practice 2–30 years |
| Spent ≥80% of time in direct patient care (vs administrative, research) |
| Has not participated in market research regarding dyslipidemia in past month |
| Not affiliated with |
|
On previously agreed-on days, field researchers were sent to physicians’ offices. The office staff approached all patients who had a regularly scheduled appointment and met the eligibility criteria ( Table 2 ) and invited them to take part in a study of physician–patient communication. All research participants were compensated for their participation; however, none was aware of the study sponsor. Informed written consent was obtained from all physicians and patients, after which the office visit was recorded on videotape and audiotape, without the researcher present in the examination room.
| English-speaking adults who had received a diagnosis of low high-density lipoprotein cholesterol |
| Patients being treated with Niaspan (brand name) ≤6 months |
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Immediately after the visit, the patients participated in interviews with the researcher that were recorded on video- and audiotape. At the end of the day, the physicians were similarly interviewed regarding all patients who had participated that day. Medical records were brought into the interview to aid physicians with recall, but the records were not shared with the researcher. These postvisit interviews revealed the relative match or mismatch of the participants’ perceptions regarding the issues discussed at the visit, including diagnoses, medication regimens, side effects, and level of treatment satisfaction. The interview questions were designed to uncover what providers meant to convey and what the patients had understood.
A sample size of 45 patients was chosen as a robust sample for in-depth analysis, supported by published work in the area of physician–patient communications. Of the 30 practices, 24 yielded ≥1 patient for the final sample ( Table 3 ). None contributed >3 patients, and the average per practice yield was 1.8 patients. A total of 64 interactions were recorded. A total of 12 patients were excluded from the final study sample for the reasons listed in Table 4 . The remaining 52 patients, whose visits included relatively robust discussions of HDL cholesterol and/or treatment with NER, were enrolled until the desired sample size of 45 had been obtained ( Table 5 ).
| Variable | Value |
|---|---|
| Total physicians (n) | 24 |
| Primary care physicians | 12 |
| Cardiologists | 12 |
| Average practice time (years) | 18 |
| Primary care physicians | 17 |
| Cardiologists | 19 |
| Average age (years) | 56.9 |
| Men (%) | 83% |
| Reason for Exclusion | Patients (n) |
|---|---|
| Patient was prerecruited by physician | 5 |
| Patient taking extended-release niacin >6 months | 4 |
| No high-density lipoprotein or extended-release niacin discussion | 2 |
| Patient appeared mentally altered/incapacitated | 1 |
| Total | 12 |
| Variable | Value |
|---|---|
| Patients (n) | 45 |
| Men (%) | 76% |
| Average age (years) | 55 |
| Average co-morbidities reported | 3.5 |
|
|
| Previous heart attack, per physician report (n) | 8/45 |
| Taking average of 1 prescription medication for non-cholesterol cardiovascular condition (n) | 45 |
| Health insurance (%) | 98% |
| Prescription drug coverage (%) | 92% |
All physician–patient interactions and postvisit interviews were transcribed using audio recordings. Videotapes provided a method for transcript quality control and facilitated the addition of nonverbal cues that facilitated the flow of dialogue (e.g., nodding, shrugging of shoulders). Body language and the tone of voice were not evaluated in the present study. The transcripts were analyzed using techniques from the field of interactional sociolinguistics. Specific linguistic analyses included, but were not limited to, quantification of the topics discussed and the time spent on each; quantification and a description of the questions asked and answered; analyses of the key lexical items (i.e. vocabulary or word choices); and “open door/close door” of topics put forth or blocked in conversation. Descriptive statistics were calculated.
Results
First, despite a moderate level of patient engagement, most dialogue was physician-driven. A minority of the visit time was devoted to disease education.
The typical visit consisted of nearly 10 minutes of talk time. Visits with cardiologists were longer than those with PCPs (11 minutes, 27 seconds vs 9 minutes, 23 seconds). Patients demonstrated a moderate level of engagement by speaking 24% of the words in the dialogue. In addition, 36 (80%) of 45 patients asked questions regarding their lipids, an average of 4.4 questions per visit. More than ½ of the visit time was spent discussing lipid-related topics, including medications, side effects, and test results. Medication-related conversation comprised 18% of the average dialogue ( Figure 1 ). Disease education consisted of only 6% of the visits.
Second, the current dyslipidemia dialogue contained many “numbers” without clear benchmarking or goal setting, resulting in apparent patient confusion and a lack of an action plan.
Although physicians provided many lipid values in these visits, HDL cholesterol was discussed most often. The HDL cholesterol numbers were also most often recalled by the patients after their visit. Importantly, 45% of patients were already taking a statin to control their low-density lipoprotein (LDL) cholesterol.
When sharing the test results, the physicians often did not focus on context. They rarely benchmarked the patients’ current test results against previous laboratory values, and they did not explicitly benchmark the patients’ results against the National Cholesterol Education Program guidelines or discuss clear goals. Most patients could not recall their specific laboratory values when asked after the visit; instead, they said things such as “too high” or “a little low.”
During the postvisit interviews, the patients rated the importance of knowing their lipid values an average of “8” on a 1 to 10 scale, with 10 “very important.” However, some patients indicated that they relied on their physicians to indicate when they needed to be concerned or to take action about their lipids or cardiovascular health. Patients were unaware of the discrepancy between the importance they placed on their laboratory values and that they could not recall them.
Third, although “HDL” and “good cholesterol” were the most frequently mentioned aspects of dyslipidemia during the office visits, most physicians did not successfully communicate its role to their patients.
Both HDL and LDL cholesterol were discussed in detail during these 45 visits. In several instances, physicians described the link between the mechanism of action of HDL cholesterol on LDL cholesterol using metaphors focused on trucks. Three physicians in 4 visits likened HDL cholesterol to a truck carrying LDL cholesterol away. Two characterized HDL cholesterol as a “garbage” or “trash” truck, such as in the following example between a 53-year-old male patient and his PCP.
Doctor: and finally we did get an improvement in the good cholesterol—the HDL cholesterol. For men we like to be over 40—in the 40s. The last time you were 32 and this time 36. So, we’re still on the low side with the good cholesterol.
Patient: Mm-hmm.
Doctor: It’s good and protective, because it goes into the arteries, it pulls the fat out of the arteries. So, anything that’s deposited by bad cholesterol, the LDL, is reversed by the good cholesterol. It goes in and acts like a trash truck. It removes the trash out of the arteries. Okay?
In other cases, physicians intimated a relation in measured blood levels, such as in the following example in which a cardiologist, in a discussion with a 59-year-old female patient, described HDL cholesterol and LDL cholesterol as 2 sides of a “teeter-totter.”
Doctor: The good cholesterol, you’re at the cutoff. The goal is over 40 and remember the issue is this—is that good cholesterol and bad cholesterol work kind of like—a teeter-totter is the way I always tell people. As the good goes up, the bad comes down. And the good cholesterol—the reason they call it that is it binds to the bad cholesterol and takes it to your liver and your liver gets rid of it. So, the stuff that plugs up your arteries, you can help get rid of, not just by getting—taking more medicine, but by elevating your good cholesterol.
Triglyceride levels of >200 mg/dl affected 17 patients (38%); however, only 7 of these patients’ visits contained a discussion of triglyceride levels. Triglycerides were discussed in visits with 11 of 27 patients with normal triglyceride levels. In addition, although current National Cholesterol Education Program guidelines stress the importance of non-HDL cholesterol in lipid management, only 2 visits contained mentions of “non-HDL cholesterol.” These both occurred appropriately in visits with patients whose triglyceride levels were >200 mg/dl.
Fourth, communication about NER was often limited, lacking a balanced risk/benefit discussion.
Overall, the visits did not contain discussions of specific health-related benefits associated with NER, such as a reduced risk of CVD or the regression of plaque in the arteries. Only 1 cardiologist stated in 1 visit that NER “… will improve your HDL and therefore protect you from having any heart blockages or development of plaque in the arteries.” After the visit, however, physicians reported having described numerous cardiovascular-related benefits of NER ( Table 6 ).
