Dawn R. Witt, Gretchen Benson, Michael Miedema, Jackie L. Boucher, Sharonne N. Hayes, Shannon Laughlin-Tommaso, Safa Gamam, Susan White, and Ruth Lindquist(2018) Cardiovascular Disease Screening Practices Among Obstetrics and Gynecology Providers in Minnesota. Journal of the Minneapolis Heart Institute Foundation: Spring/Summer 2018, Vol. 2, No. 1, pp. 32-37.
Dawn R. Witt, PhD, MPH
Gretchen Benson, BA
Michael Miedema, MD, MPH
Jackie L. Boucher, MS
Sharonne N. Hayes, MD
Shannon Laughlin-Tommaso, MD, MPH
Safa Gamam, BS
Susan White, BSRuth Lindquist, PhD
Minneapolis Heart Institute Foundation, Minneapolis, MN; Minneapolis Heart Institute Foundation, Minneapolis, MN; Children’s HeartLink, Minneapolis, MN; Mayo Clinic, Minneapolis, MN; University of Minnesota, Minneapolis, MN
Address for correspondence:
Dawn R. Witt, PhD, MPH
Minneapolis Heart Institute Foundation
920 East 28th Street, Suite 100
Minneapolis, MN 55407
Many reproductive-aged women, particularly low-income and minority women, rely solely on obstetrics and gynecology (OBGYN) providers for primary care. As such, visits to an OBGYN may be the best or only opportunity for a young to middle-aged woman to be screened for cardiovascular disease (CVD) and CVD risks, uniquely positioning these providers to address the gap in CVD prevention. However, CVD screening practices, barriers to screening, and knowledge gaps in CVD screening and treatment are largely unknown. A statewide survey was conducted to fill this gap in our understanding of the CVD-related needs and practices of OBGYN practitioners. We conducted an online survey of OBGYN-certified physicians and advanced practice nurses who provide care in Minnesota. A 25-item questionnaire about provider practices, needs, barriers, and knowledge gaps regarding CVD screening and treatment was sent to 794 providers. Ninety-seven (12%) respondents completed the survey; 26.8% (n = 26) of providers reported that ≥50% of patients considered them their primary care provider. Among respondents, 43.2% and 40.7% reported following general guidelines for lipid and glucose screening, respectively. A majority (70.6%) reported treating postpartum patients with preeclampsia themselves; however, only 10.1% reported prescribing antihypertensive medications outside of pregnancy. Lifestyle counseling was common in half or more of their patients: 97.8% of respondents reported counseling for tobacco cessation, 84.8% for physical activity, 59.8% on nutrition, and 40% on stress management. Barriers to CVD screening included limited time (50.6%), lack of confidence in managing CVD risk factors (43.6%), and having inadequate resources (55.7%). In a Minnesota-based survey of OBGYN providers, a majority of providers routinely discuss lifestyle modifications with their patients; however, opportunities exist to increase rates of CVD screening and management of CVD risk factors, as well as lifestyle counseling to improve CVD outcomes and reduce CVD risks in reproductive-aged women. We propose (1) targeted efforts to provide ongoing education and updates to OBGYN providers on CVD screening, counseling, and risk management, and referral; (2) incorporating screening for CVD and CVD risks and lifestyle counseling efficiently into the flow and fabric of routine care delivered in OBGYN clinics; and (3) enhancing CVD screening and counseling resources available to OBGYN providers.
Keywords: women, obstetrics and gynecology, knowledge survey research, cardiovascular disease risk screening
Over the past four decades, the incidence of coronary heart disease (CHD) and mortality rates have seen a marked downward trend; however, mortality rates among women <55 years are stagnant.1 This disparity in mortality rates highlights the need for focused prevention efforts in this age group of women. Screening for and management of cardiovascular disease (CVD) and CVD risks have traditionally been conducted by primary care providers (PCP). However, studies indicate that over two-thirds of women, particularly young and minority women, do not see a PCP and rely solely on their obstetrics and gynecology (OBGYN) provider for their care.2–5
Most women receiving care from OBGYNs do so during pregnancy, a critical time in a woman’s life in terms of future disease burden.6 Many pregnancy-related complications—such as gestational diabetes, preeclampsia, and pregnancy-induced hypertension—significantly increase a woman’s risk for developing CVD.6–12 As such, visits to an OBGYN provider may be the only opportunity a young woman has to be screened for CVD, uniquely positioning these providers to address the gap in CVD prevention.4,6,13,14 Indeed, efforts to address the gap in CVD risk screening, management, and prevention should target providers in settings where young women receive the majority of their care.
The objective of our study was to evaluate the state of CVD screening provided by OBGYN physicians, certified nurse midwives (CNM), certified nurse practitioners (CNP), and advanced practice nurses (APRNs) who care for women in the State of Minnesota.
The current study examined provider roles, practices, needs, barriers and knowledge gaps regarding CVD screening and primary prevention services for women.
Subjects and Setting
Targeted providers in our study included OBGYN physicians and APRNs specializing in OBGYN care in Minnesota. A sample of 794 providers was obtained, including a roster of 522 physicians from the Minnesota Department of Health and 272 APRNs from Medical Marketing Service Inc., a medical industry marketing database. Eight identified providers had incomplete contact data, reducing the targeted sample to 786 providers.
The primary methods of contact were mail (n = 444) and e-mail (n = 342). Providers without an identified e-mail address were mailed an invitation letter. The invitation letter included a URL link to the survey and an individual identification number/access code for the survey. The letter also included an alternative option to call in and complete the survey over the phone or to request a paper copy of the survey. A web survey system (Acuity) automatically tracked who did or did not complete the survey to enable the generation of follow-up reminders: After 1 week, a reminder postcard or e-mail was sent to providers who had not responded. After an additional 2 weeks, a final invitation letter or e-mail was mailed to individuals who had not participated. One reminder phone call was placed to 48 providers who had not completed the survey and for whom we had phone numbers. The reminder calls did not generate additional responses, so after the first round of calls, we chose to discontinue calling. The research study was conducted between October and December 2014. This study was approved as exempt by the Institutional Review Board serving the Minneapolis Heart Institute Foundation: Schulman and Associates, IRB, Inc.Survey Content/Measures
A 25-item questionnaire was developed to assess items related to provider roles, practices, needs, barriers, and knowledge gaps regarding CVD screening, risk factor identification and treatment for women. The questionnaire was pilot-tested with 3 OBGYN providers and did not result in any changes.Statistical Analyses
Overall frequencies and descriptive statistics were examined for all survey items. In some cases, to simplify or clarify analysis and interpretation of results, survey item categories were combined. For example, a 5-point scale ranging from “strongly agree” to “strongly disagree” with a midpoint of neutral was collapsed into a 3-point scale of “agree,” “neutral,” and “disagree.” This helped minimize the number of sparse cells in the cross-tabulations. The SPSS Exact Tests module was used, which accounts for expected cell counts of less than 5. Surveys were analyzed using SPSS Statistics (version 21; IBM, New York, NY).ResultsProvider characteristics.
A total of 97 providers completed the survey—71 physicians, 21 CNMs, and 4 CNP/APRNs—for an overall response rate of 12% (Table 1). Of the sample with e-mail addresses (n = 342), 19% completed the survey compared to 7% for those with only mailing addresses (n = 444), which were primarily clinic/work addresses. The majority of respondents were female (67%), and most were practicing in a metropolitan area (73.2%). A majority were working in a medium (10–49 providers; 32.3%) or large practice setting (≥50 providers; 43.5%), and 26.8% of respondents indicated that ≥50% of their patients consider them to be their primary care provider.
Characteristics of OBGYN providers in Minnesota, 97 respondents.
CVD treatment and screening.
Forty-one percent reported checking patients’ lipids every 5 years, and 43.2% indicated that they check glucose every 3 years per national guidelines.15 Most (70.6%) reported treating postpartum patients with a history of preeclampsia in pregnancy, but only 10.1% reported prescribing antihypertensive medications for those who had diagnosed hypertension outside of pregnancy. Of note, a sensitivity analysis was conducted to compare those who reported that ≥50% of their patients considered them their PCP to those who didn’t. No significant differences between these groups as it related to CVD screening and treatment were found. CVD screening and treatment responses are listed in Table 2.
Frequency of routine patient CVD screening and treatment.
Lifestyle and behavioral counseling.
When asked about counseling on lifestyle, virtually all (97.8%) reported providing counseling for tobacco cessation, 84.8% provided counseling on physical activity, and 85% on weight management for more than half their patients (Table 3). Counseling rates were lower for nutrition and stress management, with only 59.8% reporting to have provided for nutrition counseling and 40% for stress counseling for more than half their patients.
Prevalence of CVD behavior and lifestyle counseling among OBGYNs.
Screening attitudes and self-efficacy.
Just more than half (55.7%) reported that they have the tools and resources to provide preventive services, yet their reported confidence in managing CVD risk factors was only 43.6% (Table 4). Limited time was cited as a major barrier for 50.6% of providers to implementing CVD screening, and 39.1% cited it as a minor barrier. When asked if not being up-to-date on current screening guidelines was a barrier to providing CVD screening services to their patients, 46.3% reported this as a minor barrier, and 19.5% reported this as a major barrier. Fear of liability was less frequently reported as a barrier (minor in 11.8% and major in 3.5%). The majority of respondents reported that there was no barrier in finding referral practices for further CVD management.
CVD screening attitudes and self-efficacy.
CVD educational tools and resources.
When asked what resources would be helpful in enhancing their ability to provide CVD preventive services and treatment, respondents ranked cardiovascular screening tools (82.1%) and CVD educational materials (80.9%) the highest. CVD provider education (71.6%) was also identified by respondents as “very important” or “important” (Table 5).
Tools and resources to educate patients.
For women who see an OBGYN as their sole provider, risk factor identification, along with continued monitoring and management, are critical to CVD prevention. OBGYN providers are truly the front line of care for many women and serve an important role in helping women establish healthful lifestyles to prevent disease onset. Both early identification and risk factor modification have been shown to significantly reduce CVD.16 OBGYN providers may have a distinct advantage in the identification of risk factors related to pregnancy-induced conditions that increase future CVD risk, including preterm delivery, preeclampsia, pregnancy-induced hypertension, and gestational diabetes.
OBGYN providers in our Minnesota-based survey reported providing comprehensive care for lifestyle counseling, with the majority of providers routinely discussing nutrition, physical activity, weight management, and tobacco cessation with the majority of their patients. Research emphasizes the importance of early lifestyle habits—such as not smoking, maintaining a healthy body weight, being physically active, and healthy eating—on improving the future risk of developing coronary CHD.17 Previous studies have demonstrated that young women who implement health-promoting lifestyle behaviors can significantly lower their risk for developing CVD risk factors and reduce their lifetime risk of CHD.11,17,18 However, as demonstrated in other national surveys,5,19,20our results identified a significant gap in screening, identification, and management of CVD risk factors during visits to an OBGYN.
Many women who see an OBGYN have increased risk factors (eg, polycystic ovarian syndrome, history of GDM, or baby weighing more than 9 pounds) in addition to the general risk factors of obesity, physical inactivity and family history that impact risk screening for both blood glucose and lipids. Our findings suggest that only 43.2% of providers are screening their patients for blood glucose15 only 10% reported prescribing antihypertensive medications for those with diagnosed hypertension outside of pregnancy, consistent with other studies.21 A survey of OBGYN and family practice providers in Oregon revealed low rates of postpartum screening for gestational diabetes (GDM). Hunsberger and colleagues suggest that these low rates may be due to priorities in day-to-day practice as well as current practice patterns.22 In our study, the top reported barrier to practicing appropriate CVD prevention was limited time, but a quarter of respondents also felt that they lacked the tools to provide screening or did not feel confident managing CVD risk factors. In a recent survey of over 2,000 patients, women who utilized an OBGYN as their sole care provider were less likely to be aware of their cardiovascular risk factors than were women who had a primary care provider.10
Lack of CVD awareness is also particularly high among women ages 25 to 34 and is more pronounced in African-American and Latina women compared to white women.23In a study of 498 women, young women of color reported they saw their OBGYN more than any other type of provider; however, most women reported their OBGYN did not discuss heart health issues.24 This is critically important given CVD prevalence in these populations: 48.3% of African-American and 32.4% of Hispanic women have CVD.23 The lack of CVD awareness and progress in reducing CVD mortality among young women highlights the breadth and depth of the opportunity to raise awareness and increase CVD primary prevention.
Several studies have reported that the majority of women view their OBGYN as their sole provider;2,4,25 however, 70% of the providers surveyed here reported being the sole provider for less than half their patients. These discordant views may be one of the reasons for the gap in CVD prevention: If providers are unaware that they are acting as a primary care provider for their patients, a substantial number of women may not be receiving the full scope of recommended preventive services—including CVD education, screening, and prevention.Study Limitations
The data presented here are based on a small sample of providers and may not fully represent the actual practice patterns of OBGYN providers practicing in Minnesota or be representative of OBGYN providers practicing in other parts of the United States. As with any survey, respondents may be more interested in or knowledgeable of the survey content and may overestimate their actual practice rates.Implications for Practice
This study provides provocative information regarding CVD screening practices among Minnesota OBGYN providers that can be used to fuel and guide future efforts aimed at optimizing CVD prevention within OBGYN practices. Our findings underscore potential opportunities to increase CVD screenings during women’s routine visits to their OBGYN providers. We found that OBGYN providers generally recognize their potential key role in CVD prevention efforts, yet appropriate screening rates were suboptimal. OBGYN providers are frequently a woman’s sole health care provider, but providers cite barriers to delivering these preventive services, including a need for additional provider education and provision of resources such as patient education materials and screening tools. Our results identify a unique opportunity for OBGYN providers to recognize and enlarge their important role in CVD prevention among young reproductive-aged women. Programs aimed at developing efficient, evidence-based approaches to CVD prevention that OBGYN providers can realistically implement may substantially impact rates of CVD screening and risk factor control in young women.
|1.||Wilmot KA. O’Flaherty M. Capewell S. Ford ES. Vaccarino V.Coronary heart disease mortality declines in the United States from 1979 through 2011: evidence for stagnation in young adults, especially women. Circulation. 2015;132(11):997–1002. [Crossref][Google Scholar]|
|2.||Coleman VH. Laube DW. Hale RW. Williams SB. Power ML. Schulkin J.Obstetrician–gynecologists and primary care: training during obstetrics–gynecology residency and current practice patterns. Acad Med. 2007; 82(6):602–607. [Crossref] [Google Scholar]|
|3.||Mazzoni S. Brewer S. Durfee J.et al. Patient perspectives of obstetrician-gynecologists as primary care providers. J Reprod Med. 2017;62(1-2):3–8. [Google Scholar]|
|4.||Lewis BG. Halm EA. Marcus SM. Korenstein D. Federman AD.Preventive services use among women seen by gynecologists, general medical physicians, or both. Obstet Gynecol. 2008;111(4):945–952. [Crossref] [Google Scholar]|
|5.||Scholle S.H. Kelleher K.Assessing primary care performance in an obstetrics/gynecology clinic. Women Health. 2003;37(1):15–30. [Crossref] [Google Scholar]|
|6.||Yu J. Johnson JA. Theodoropoulos K.et al. Pregnancy-induced disorders identify high-risk women who benefit from cardiovascular screening: results from the women’s heart health initiative, an OB/GYN screening pilot program. Circulation. 2012;126:A19161. [Google Scholar]|
|7.||Bonamy A-KE. Parikh NI. Cnattingius S. Ludvigsson JF. Ingelsson E.Birth characteristics and subsequent risks of maternal cardiovascular disease clinical perspective: effects of gestational age and fetal growth. Circulation. 2011;124(25):2839–2846. [Crossref] [Google Scholar]|
|8.||Drost JT. Arpaci G. Ottervanger JP.et al Cardiovascular risk factors in women 10 years post early preeclampsia: the Preeclampsia Risk EValuation in FEMales study (PREVFEM). Eur J Prev Cardiol. 2012;19(5):1138–1144. [Crossref] [Google Scholar]|
|9.||Hastie CE. Smith GC. Mackay DF. Pell JP.Maternal risk of ischaemic heart disease following elective and spontaneous pre-term delivery: retrospective cohort study of 750 350 singleton pregnancies. Int J Epidemiol. 2011;40(4):914–919. [Crossref] [Google Scholar]|
|10.||Hermes W. Franx A. van Pampus MG.et al. Cardiovascular risk factors in women who had hypertensive disorders late in pregnancy: a cohort study. Am J Obstet Gynecol. 2013;208(6):474.e1–8. [Crossref] [Google Scholar]|
|11.||Lin Y-S. Tang CH. Yang CY.et al. Effect of pre-eclampsia–eclampsia on major cardiovascular events among peripartum women in Taiwan. Am J Cardiol. 2011;107(2):325–330. [Crossref] [Google Scholar]|
|12.||Wang I-K. Tsai IJ. Chen PC.et al. Hypertensive disorders in pregnancy and subsequent diabetes mellitus: a retrospective cohort study. Am J Med. 2012; 125(3):251–257. [Crossref] [Google Scholar]|
|13.||Barnhart J. Lewis V. Houghton JL. Charney P.Physician knowledge levels and barriers to coronary risk prevention in women: survey results from the Women and Heart Disease Physician Education Initiative. Women’s Health Issues. 2007;17(2):93–100. [Crossref] [Google Scholar]|
|14.||McSweeney JC. Pettey CM. Souder E. Rhoads S.Disparities in women’s cardiovascular health. J Obstet Gynecol Neonatal Nurs. 2011;40(3):362–371. [Crossref] [Google Scholar]|
|15.||American Diabetes Association. Glycemic targets: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl 1):S55–S64. [Crossref] [Google Scholar]|
|16.||Yusuf, S. Hawken S. Ounpuu S.et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937–952. [Crossref] [Google Scholar]|
|17.||Chomistek AK. Chiuve SE. Eliassen AH. Mukamal KJ. Willett WC. Rimm EB.Healthy lifestyle in the primordial prevention of cardiovascular disease among young women. J Am Coll Cardiol. 2015;65(1):43–51. [Crossref] [Google Scholar]|
|18.||Miedema MD. Petrone A. Shikany JM.et al. The association of fruit and vegetable consumption during early adulthood with the prevalence of coronary artery calcium after 20 years of follow-up: the CARDIA study. Circulation. 2015;132(21):1990–1998. [Crossref] [Google Scholar]|
|19.||Cohen D. Voco A.Do physicians address other medical problems during preventive gynecologic visits?J Am Board Fam Med. 2014;27(1):13–18. [Crossref] [Google Scholar]|
|20.||Morgan MA. Lawrence H III, Schulkin J.Obstetrician–gynecologists’ approach to well-woman care. Obstet Gynecol. 2010;116(3):715–722. [Crossref] [Google Scholar]|
|21.||Schmittdiel J. Selby JV. Swain B.et al. Missed opportunities in cardiovascular disease prevention?: low rates of hypertension recognition for women at medicine and obstetrics-gynecology clinics. Hypertension. 2011;57(4):717–722. [Crossref] [Google Scholar]|
|22.||Hunsberger ML. Donatelle RJ. Lindsay K. Rosenberg KD.Physician care patterns and adherence to postpartum glucose testing after gestational diabetes mellitus in Oregon. PLoS One. 2012;7(10):e47052. [Crossref] [Google Scholar]|
|23.||Mosca L. Hammond G. Mochari-Greenberger H.et al; American Heart Association Cardiovascular Disease and Stroke in Women, Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular Nursing, Council on High Blood Pressure Research, and Council on Nutrition, Physical Activity and Metabolism. Fifteen-year trends in awareness of heart disease in women: results of a 2012 American Heart Association national survey. Circulation. 2013;127(11):1254–1263. [Google Scholar]|
|24.||Rosser ML. Brusati AJ.An opportunity for obstetrician-gynecologists to affect the epidemic of cardiovascular disease in women. Gynecol Obstet. 2014;123:187S. [Crossref] [Google Scholar]|
|25.||Ehrenthal DB. Catov JM.Importance of engaging obstetrician/gynecologists in cardiovascular disease prevention. Curr Opin Cardiol. 2013;28(5):547. [Crossref] [Google Scholar]|
|Print ISSN: ||2475-0190|