1. health and fitness
2. disease
3. heart disease

Beyond Scare Tactics: Effective Risk
Communication Strategies
Lola Coke, PhD, ACNS-BC, CNS, FAHA, FPCNA
Associate Professor
Cardiovascular Clinical Nurse Specialist
Disclosure Statement of Financial Interest
I have no disclosures
Presentation Objectives
• At the end of this presentation the participant will:
1. Understand the importance of risk assessment in
patients with cardiovascular disease.
2. Apply risk communication strategies with
patients to increase understanding of level of risk.
3. Develop a strategy to effectively communicate
risk using a case-study approach.
Audience Response Question 1
Assessing risk in cardiovascular patients is
important because it:
*1. can be used to motivate the patient to
change behavior.
2. give the provider information to threaten
the patient.
3. is the best tool to teach patients about
their family history of cardiovascular disease.
4. All of the above.
Lifetime vs 10-Year CVD Risk Estimates
Individuals (millions)
Women
CVD risk levels
High short term (>10% 10-yr)
Low short term/high lifetime (<10% 10-yr/>39% lifetime)
Low short term/low lifetime (<10% 10-yr/<39% lifetime)
20-29
30-39
40-49
50-59
Age (yr)
Marma et al: Circ Cardiovasc Qual Outcomes, 2010 NHANES
60-79
Global risk score predictor variables
Sex
Framingham
Risk Score
Reynolds
Risk Score
(M or F)
Age
Race (WH or AA)
Total cholesterol
HDL-C
Systolic BP
Rx of BP (Y or N)
Diabetes (Y or N)
Smoker
(Y or N)
CRP and family hx
ASCVD
Risk
Calculator
(ASCVD) Risk Calculator
Understanding Cardiovascular Risk
• The 10-year calculated ASCVD risk is a
quantitative estimation of absolute risk based
upon data from representative population
samples.
• The 10-year risk estimate for "optimal risk
factors" is: Total cholesterol of 170 mg/dL,
HDL-cholesterol of 50 mg/dL, untreated
systolic blood pressure of 110 mm Hg, no
diabetes history, and not a current smoker.
.
Understanding Cardiovascular Risk
• The lifetime calculated ASCVD risk represents
a quantitative estimation of absolute risk for a
50 year old man or woman with the same risk
profile.
• This estimation of risk is based on the
grouping of risk factor levels into 5 strata.
– All risk factors are optimal
– ≥1 risk factors are not optimal
– ≥1 risk factors are elevated
– 1 major risk factor
– ≥2 major risk factors
Nurses Health Study II: Risk for Coronary Heart
Disease based on Optimal Lifestyle Behaviors
JACC 2015;65(1):43-51.
Optimal Lifestyle Behaviors Lowered Risk of Heart Disease
and Risk Factor Development
• Nonsmoking, Healthy BMI, Exercise, and Healthy Diet were independently and
significantly associated with lower CHD risk.
• Compared with Women with No Healthy Lifestyle Factors, the risk for CHD for
women with 6 lifestyle factors was 0.08
• 73% of CHD cases were attributable to poor adherence to a healthy lifestyle
• 46% of clinical CVD risk factor cases were attributed to a poor lifestyle
Chomistek AK, et al. J Am Coll Cardiol. 2015;65:43-51
Sitting for Too Long Can Kill You, Even if You Exercise
• Pooled data from 41 international studies
• The amount of time a person sits during the day is
associated with a higher risk of heart disease,
diabetes, cancer and death, regardless of regular
exercise
• Despite the health-enhancing benefits of physical activity,
this alone may not be enough to reduce the risk for
disease
• Prolonged sedentary behavior was associated with a 1520% higher risk of death from any cause; a 15-20%
higher risk of heart disease, death from heart disease,
cancer, death from cancer; and as much as a 90%
increased risk of developing diabetes
• Sitting is the ‘NEW’ Smoking
Biswas et al. Ann Intern Med. 2015;162(2):123-132
Risk Communication using a Life
Span Approach
IOM Ecological Model
Heart Disease is a process over time that needs multiple strategies as risk factors change.
Communicating Risk
Assessments
Risk Communication Terms
Tavena, et.al (2013) BMC Med Inform Decis Mak. 13 Suppl2:57
Influences on Risk Communication
• Absolute Risk is rarely mentioned by Primary
Care providers
• Providers were influenced by:
– Subjective perception of patient risk and
motivation
– Attitudes toward prevention including side effects
and efficacy of lifestyle change
– High Risk patients were more likely to be
prescribed medication
Influences on Risk Communication
• Patients were influenced by:
– # of risk factors
– Motivation to change
– Attitudes about taking medication
• Negative unless medication worked better than lifestyle
change
– Higher risk resulted in > motivation to change
lifestyle especially if not willing to take medication
Bonner, et. al. (2015) Health Psychology. 34(3): 253-61
Communicating Risk Factor Assessments
• Risk calculations are done later when risk
factors are present
• Relative vs. Absolute risk
• The range in age and number of risk factors
impact the discussion
• Meta-analysis of 15 studies examined
strategies to discuss risk factor calculations
• Using multiple strategies showed increase in
understanding
Communicating Risk Factor Assessments
Graphical Formats: lead to increased understanding
of risk and can reduce negative emotions
– bar and pie charts (patients like pie charts)
Presentation of Comparative Risk vs. Personal risk
– affected risk perception and emotions
• Dependent on level of personal risk: > personal risk =
more negative emotions and < behavior change
•
Waldron, et.al. (2011) Pt Ed & Counsel: 169-181
Communicating Risk Factor Assessments
• Timeframe manipulation
– Shorter time frame or percentage led to more accurate
risk perceptions and increased intention to change
behaviors
– Net present value vs. future value
– Biological age reduction vs. increased lifespan if risks
are addressed
Communicating Risk Factor Assessments
• Framing of risk information
– Negative versus positive framing of risk
information
• Morbidity/mortality/side effects vs. survival data, free
of disease
– Gain frame vs. loss frame ( i.e. benefit vs. cost)
• Doing nothing vs. doing something
• Short or long term gain or loss
• Younger participants didn’t perceive susceptibility
Communicating Risk Factor Assessments
• Verbal vs. Numerical Communication
– Better outcomes with verbal as part of the
discussion but can also increase anxiety
• More data points vs. fewer data points
– More cautious with more data
– More scary with more data
Communication Strategies
EUROACTION TRIAL
• Nurse coordinated, multidisciplinary familybased cardiovascular disease prevention
program for CAD and at-risk patients
– Matched-paired RCT with 12 general hospitals and
12 general practice centers in 6 different European
countries > 1000 patients in each arm
– Endpoints measured at one year--were familybased lifestyle change; management of blood
pressure, lipids, and blood glucose to target
concentrations; and prescriptions of
cardioprotective drugs.
–
Wood, et.al, Lancet (2008). 371:1999-2012
EUROACTION TRIAL
Findings of Intervention group vs. usual care
– 58% vs. 47% did not smoke
– 55% vs. 40 % reduction in fats
– 72% vs. 35% increase in fruits and vegetables
– 65% vs.55% to B/P goal of 140/90
– Drugs were more readily prescribed
Family intervention and multidisciplinary approach was
successful
– each family was assessed individually, attended
sessions together
Nurse-Based Multidisciplinary Models for Risk Reduction
• Preventive care should be implemented according to evidence-based
guidelines that improve quality, reduce re-hospitalizations and support
health provider reimbursement.
• Preventive efforts should target those at high-risk of developing disease
and family members of these patients; groups with highest prevalence of
CVD risk factors
• Focus should be on promoting lifestyle habits to address total risk
• Effective mechanism for prescribing and adhering to medication
• Develop and disseminate new and expanded models to serve
disadvantaged populations
• Focus on empowerment toward self-care and literacy level
Berra K, Houston Miller N, Jennings C. Eur J Cardiovasc Nurs 2011 S42-50.
Importance of Patient Perception
• Survey research of 701 patients from 6
primary health centers in Netherlands.
– Age, educational level and gender were
significantly associated with perceived experience
– Smokers were less likely to want to work with a
nurse: awkward, getting my “knuckles rapped”,
rather see the primary provider less often
– More educated felt they needed less contact
– Felt more understood and listened to by the nurse
– Men less interested in talking about “ups and
downs” in health
Voogdt-Pruis, et.al. Intl Jnl Nsg Studies (2010) 1237-44.
Patient Perception (continued)
• Communication skills need to include motivational
interviewing/coaching/counseling
• More attention to appropriate timing of consultations in order
for patients to make changes in their behavior
• Nurses are more communicative during consultations and
patients felt more at ease
• Nurses provided more information than doctors
• Design specific consultation strategies for certain patient
groups according to the type of risk factor to be treated to
minimize patient non-attendance in the long term
Voogdt-Pruis, et.al. Intl Jnl Nsg Studies (2010) 1237-44.
Tailoring Risk based on Perception
Bonner et al. BMC Family Practice. (2014). 15:106
STRATEGIES FOR CVD COMMUNICATION
• Cognitive-behavioral strategies: Class 1A
―
―
―
―
Design interventions with specific goals
Provide feedback on progress toward goals
Provide strategies for self-monitoring
Establish frequency/duration of follow-up contacts in
accordance with individual needs
― Utilize motivational interviewing
― diminish ambivalence and resistance
Artinian NT, et al. Circulation 2010; 122: 406-441
STRATEGIES FOR CVD COMMUNICATION
• Cognitive-behavioral strategies: Class 1A
― Provide direct or peer-based long-term support and followup to offset declining adherence
― Incorporate strategies to build self-efficacy
― Use a combination of > 2 strategies (e.g. goal setting,
feedback, self-monitoring, follow-up, motivational
interviewing, self-efficacy) in an intervention
Artinian NT, et al. Circulation 2010; 122: 406-441.
.
COMMUNICATING HEALTH BEHAVIORS
• 90 million Americans have difficulty with literacy; 50% leave an office
perplexed about what to do
• Educate by:
― 1-3 minute messages
― Using the repeat back method to clarify
― Summarizing at the end of a visit
― Writing down ALL important instructions
― Offering 2 methods of information
A 1-3 MINUTE MESSAGE
“Mr. Jones, giving up smoking is the single most important thing
you can do for your health.
Directive/Persuasive Statement
Smoking decreases the amount of oxygen that is carried in the
blood to your heart. Your angina is caused by a lack of blood flow
to your heart muscle. Continuing to smoke is likely to cause you
more chest discomfort.
Tailored and Personalized Statement
I would like to work with you to help you to stop smoking for good.
Are you willing to make an attempt to quit smoking?
 Warm/Empathy and Clear Question
COMMUNICATING HEALTHY BEHAVIORS
― Drafting educational materials that are culturally sensitive
― Ethnicity
― Work environments
― Drafting educational materials focusing on health literacy
― 2 syllable words
― Photos, clip art
― White space
Community Based Interventions
• Assess the needs and priorities of the community
• Efforts should be focused on underserved and vulnerable
populations.
• Mobilize key leaders and agencies from various sectors of the
community to promote healthy lifestyles among large
proportions of the population;
• Use multiple individual level intervention strategies, including
mass media, self-help programs, screenings, contests, and
competitions;
• Implement cost-effective interventions in multiple community
settings, including neighborhoods, schools, churches,
worksites, restaurants, health care facilities, voluntary
agencies, and other organizations to ensure adequate dose
•
Parker & Assaf (2005) Prim Care Clin Office Prac. 32:865-881
Community-Based Interventions
• Mobilize communities to help achieve program goals and using
volunteers from the community to help administer these programs;
• Develop intervention strategies for promoting environmental
changes, including supermarket shelf labeling for healthy foods,
restaurant menu labeling;
• Develop policy initiatives (i.e., restriction of tobacco use in the
workplace)
• Develop a reliable monitoring and evaluation system: monitor the
change process and conduct summary evaluations.
• Disseminate results to ensure that the benefits from the community
program reach all communities.
Case Study
• Sally S. is a 55 year old woman.
• Family history of heart disease and diabetes
(mother became diabetic at 68 and father had
a first heart attack at 65).
• Blood pressure is 130/88.
• Cholesterol is 200 and her HDL is 70. She
takes simvastatin 20 mg daily at night.
• Non smoker. She drinks 2 glasses of red wine
3 days a week.
Case Study
• Sally is a administrative assistant and works four 10 hour
days. She works with datasets to determine marketing
strategies for the company.
• BMI is 31.
• Fasting glucose is 95. Creatinine is .8. CRP is 3
• Seasonal allergies and takes Zyrtec as needed.
• Sally states she is too young to worry about heart disease or
diabetes because her parents got the diseases at a much older
age.
Case Study: Audience Response 2
The best risk assessment tool to use for Sally is:
1.
2.
3.
4.
Framingham Risk Assessment
Reynolds Risk Assessment
ASCVD Risk Assessment
Chads2 Risk Assessment
Case Study: Information
• Your message: Prolonged sedentary
behavior is associated with a 15-20%
higher risk of death from any cause; a 1520% higher risk of heart disease, death
from heart disease, cancer, death from
cancer; and as much as a 90% increased
risk of developing diabetes
Case Study: Group Work
1. Discuss the Reynolds Risk Assessment and
ASCVD Assessment results in your group.
2. Based on the Risk Assessment data and the
information you have about Sally, develop a
plan for how you would discuss her risk.
Thank you for your attention!