We found that 39% of the patients who visited physicians' offices in 2005 through 2006 who did not already have CVD were at risk for CVD, and 49% of those at risk for CVD had more than 1 of 4 risk factors. As might be expected, more clinical preventive services were provided to at-risk patients compared with patients not at risk for CVD.
At-risk patients were treated differently according to demographic and patient characteristics. Physicians were more likely to report prescribing or recommending the continuation of aspirin therapy to patients who were men and were aged 65 years or older. In 2002, USPSTF recommended that clinicians discuss aspirin therapy with adults who are at risk for coronary heart disease (CHD). Further, they suggested that the balance of benefits and risks was most favorable in patients at high risk for CHD (those with a 5-year risk ≥3%) (15
). USPSTF recently revised its recommendations on aspirin use for prevention of CVD, limiting the ages to men aged 45 to 79 years and to women aged 55 to 79 years and taking both age and 10-year risk into consideration, balancing cardiovascular benefit with risk for gastrointestinal hemorrhage (16
). Although the update to this recommendation was not published until 2009, providers in our study reported prescribing aspirin more frequently for men, which is more consistent with the new recommendation than with the recommendation that was current at the time of data collection.
Guidelines for when screening should start, frequency of screening, and special considerations for people at high risk for diabetes, lipid disorders, and hypertension vary according to age (17
). Women in our study were less likely than men to receive cholesterol screening. This finding may be partly attributable to clinicians following the USPSTF guideline for lipid screening, which recommends routine screening for men from age 35 but only recommends screening for women aged 20 to 45 years who are at increased risk for CHD (19
). Another guideline, the National Cholesterol Education Program Adult Treatment Expert Panel III, recommends routine blood cholesterol screening of all adults aged 20 years or older every 5 years (20
). Patients with Medicare/Medicaid or with no insurance were also less likely to receive cholesterol screening than were patients with private insurance. Out-of-pocket cost to patients or differences in covered services by public-sector payers, or both, may be among the reasons for these differences. Patients younger than 35 years received blood pressure screening at their visits less often than did patients aged 35 to 44 years. USPSTF recommends that clinicians screen all adults aged 18 years or older for hypertension but does not recommend a specific screening interval (21
). Many professional organizations, including the American Academy of Pediatrics and the American Heart Association, recommend that everyone aged 3 years or older have their blood pressure measured during every health care visit (24
). Given that hypertension in youth is being diagnosed with increasing frequency (25
) and that controlling blood pressure is one of the most cost-effective methods of reducing premature CVD (26
), blood pressure screening for people of all ages should be routine.
We found lower rates of educational services for older adults (aged ≥65 y) for all 3 lifestyle interventions, although the weight-reduction counseling was the only one that was significant. Patients younger than 20 years received significantly more diet/nutrition, weight-reduction, and exercise education than did patients aged 35 to 44 years. Recommendations for lifestyle education or counseling in the clinical setting do not vary by age, although many guidelines recommend that sedentary middle-aged or older adults consult a physician before starting a new exercise program (21
). The age discrepancy in weight-reduction education may indicate that providers believe older adults are not as willing to change behavior or are less likely to succeed at changing behavior. Older adults may also have been less likely than younger adults to be overweight or to have had more serious health problems for clinicians to address during the visit. We also found that Hispanic and other race/ethnicity groups were more likely to receive diet or nutrition education than were non-Hispanic whites and that men were less likely than women to receive weight-reduction and exercise education. Other large surveys have found that women received exercise counseling more frequently than did men (27
). The most recent BRFSS data show that men are more likely than women to report meeting Healthy People 2010
physical activity guidelines (52% vs 48%, respectively) (29
). If men are already exercising more than women, it could account for the differences seen in exercise counseling in our study. Despite national guidelines for lifestyle counseling in the primary care setting, barriers limit its use, such as time, skills, reimbursement, coverage of services by insurance companies, and perceived effectiveness of lifestyle counseling (30
). Another challenge is the multiplicity of independent guidelines from different organizations for physicians to follow. To overcome some of these barriers, health care providers can refer patients to community programs, such as wellness classes, fitness facilities, and programs offered by health plans, employers, or public health departments, for more intensive counseling (6
This study has several limitations. First, as noted above, the data were collected per visit, not per patient. It was not possible to determine whether patients were eligible for screening tests at the visit, and most tests are not recommended at every visit. Diabetes screening, for example, is recommended only every 2 years for people at increased risk (17
). Another limitation was the cross-sectional study design, which did not allow us to determine when the risk for CVD began. Additionally, the encounter form used to collect the data had little detail about the specific services provided, such as the type and intensity of the educational sessions. Lastly, since the data were reported by providers themselves or obtained from the providers' notes in the medical record, there may be some bias toward overreporting, because of either expectations or reimbursement concerns.
This study suggests that physicians are accounting for CVD risk factors and that they are providing some preventive services to most at-risk patients. However, it also identifies disparities between some subgroups in the populations of at-risk patients who are not receiving the same level of preventive care. It may be necessary to clarify practice guidelines and to specify that lifestyle interventions are appropriate and effective for all ages. Physicians also may require more education and support for effective lifestyle counseling. And finally, since the impetus for this study was A Purchaser's Guide to Clinical Preventive Services: Moving Science Into Coverage
), it would be beneficial to know whether the guide is having an effect on the provision of services or on coverage for these services.