A majority of
middle-aged men and women eligible to take aspirin to prevent heart attack and
stroke do not recall their doctors ever telling them to do so, according to a
University of Rochester study of a national sample of more than 3,000 patients.
Published online
by the Journal of General Internal
Medicine, the finding illustrates a common disconnect between public health
guidelines and what occurs in clinical practice. The UR study is consistent
with other research showing that physicians often do not recommend aspirin as
prevention therapy to the general population, despite established guidelines by
the U.S. Preventative Services Task Force. Several reasons might explain
the reluctance, such as competing demands and limited time to properly assess a
patient's eligibility for aspirin, according to lead author Kevin A. Fiscella,
M.D., M.P.H., professor of Family Medicine at the UR School of Medicine and
Dentistry. Uncertainty about the benefits of aspirin therapy versus
potential harms like bleeding in the digestive track, also hinder physicians'
decisions, the study said.
For the JGIM
study, Fiscella's group analyzed data from 3,439 patients included in the
2011-'12 National Health and Nutrition Examination Survey (NHANES). None of the
patients had cardiovascular disease, but all qualified for aspirin therapy
based on their 10-year risk score for factors such as diabetes, high blood
pressure, obesity, smoking, and use of cholesterol-lowering medications.
Of the sample, 87 percent of men and 16 percent of women were eligible to
take aspirin as a preventive measure. But when they were asked the question --
"Doctors and other health care providers sometimes recommend that you take
a low-dose aspirin each day to prevent heart attack, strokes, or cancer. Have
you ever been told to do this?" -- a low rate of 34 percent of the men and
42 percent of the women said yes.
Co-author John
Bisognano, M.D., Ph.D., director of outpatient cardiology services at UR
Medicine, said most physicians can agree on approaches to medical care in
immediately life-threatening situations, but have less enthusiasm to quickly
embrace preventive guidelines, particularly when they involve wide-ranging
interventions for a large segment of the population. New studies that
present conflicting data or re-interpret older data also complicate the issue
and can be confusing for patients, he said. Despite the USPSTF guidelines for
aspirin being published in 2009, for example, the FDA declined to approve the
same recommendations as recently as last spring.
"Patients
often view changes as an illustration that folks in the medical field can't
really make up their minds," said Bisognano, professor of Medicine.
"Changes can undermine a practitioner's or patient's enthusiasm to
immediately endorse new guidelines because they wonder if it will change again
in three years." But science and medical practice is fluid, he said,
and the only way to move the field forward is to continually understand and
look for ways to apply the new data and avoid assumptions of the past.
The study also
noted that using expanded primary care teams of nurses, medical assistants, and
health educators may help to reduce the volume of decisions that rest solely
with the physician at the office visit. Sharing care can improve agreement
between published guidelines, the use of risk models, and actual practice, the
study said.
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