PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before due due. ' DATEDDE DATE DUE DATE DUE VM'IMI ll SLR. 3" v. : 3:9 “'2 S @513? Vii? W usu Is An Ammulvo ActiorVEquel Opportunity Institution cmpns-pd CKRDWOVASCUIARJRISKrASSESSMENT'0F PERIMENOPEUSAILWUMEN: .AJDESCRIPTIVE STUDY LynM.Behnke A.THESIS smtudtted.to Michigan State university in partial fulfillment of the requizments for the degree of MBSTERAOF’SCIENCE INWNURSING College of Nursing 1990 Am QRDIOVASCIILARRISKASSESSDWI’OF WWW: AII‘SCRIPI'IVESTUDY By IynM.Behrflce Caxdicvasailardjseaseiscmeoftheleadingcausesofdeathin older wunen. Certain risk factors have been identified that cmtrihrte tothedevelopnerrtofcazdiovasmlardisease. Adescriptivesuflywas mutedtoidentifthprimxycampxcvidersscreenperimernpausal wanenforcardicvaswlardisease. Datawereoollectedbymeansofa self-administeredqwstimimfrm93advamedpracticemusesinfl1e state of Michigan, and70 physicians inGenesee, Lapeer, andShiawassee camtiesinuidzigan. Aquestimirewasdevelopedandbasedmthe recannsndatims oftheUnited States Preverrtive'raskForce (1989). Data wereanalyzed using descriptive statistics. 'merearedifferencesin thetypeoffactozsscreenedbyprimzycareproviders. These differences relate to screening forpsydaosocial issues, behavioral factors, and laboratory tests associated with cardiovascular risk. Wreseardzmedstobemderwmtoecplammuenyirgcausesfor fliesedifferences. Why mmmm 1990 'nfisthesisisdedicated tomymentorardfrierxi SusanWentlardHoward,M.D. iv Asimeretharflcymisextendedtomythesiscxaizpersm, Marilyn Rathert, BLD. I‘mldliketoreccgnizetheamtmfleffortofhye Anattinttnprochctimofthisthesis. Ivmldalsolibtotlnnkmyfimilyfortheirpatiernearfl Wing, Sally J’dmsm, EILD. forhersugport, SusanWentlarrl Howard, 14.0. forrm'wpportandemmraganmt,myclasmates for apatheticears, PattyPeek, M.S.N. forherexpertclinical guidance, andmyanimlsfortheirmmditiaxal love. MECFGNIENI'S F5 HSTOFMES..........................Viii StatementofProblem..... . . 5 Impose........... ..... 6 OverviavofProposedReeeardm..................13 damn-mm Weeoeeeeeeeeeeoeoeeeeeeeeeeeee 15 Principlesofthe'meory..................... 17 WW........ ....... ........18 mm-mormm Overviavmmm... 22 'meoriesoffiealthPranDtim...................22 IrdividtaalRiskFactorszs Year2000Hea1thObjectives........... ..... 43 SmaryofAvailableIiterabn'e.................46 mm-mmmmm Overviav 47 'meSuzvey 48 vi 48 52 mentimal Definitions . . . . 53 matim O O O I O O O O O O O O O O O O O O O O O O O O O O O O 54 ReliabilityaniValidity..................... 55 56 mm mllmm O O O O O O O O O O O O O O O O O O O O O O O O 0 ma WIFE O O O O O C O O O O O O O O O O O O I O O O O O I 0 mm C I O O O O O O O O O O O O O O O O O O O O O O O O 56 NYSE Of mu. 0 O O O O O O O O O O O O O O O O O O O O 57 ProtectimofI-nmanRights 58 59 6O mv-mmmmmsxs 62 63 DescriptimofFirxiingsoftheSttxiy............... 64 65 67 mm mm. I O O O I O O O O O O O O O O O O O O O O O O 68 69 StmmaryofFirflings emu-mm, W106, ANDRECIIMENDATIQIS 70 7O RsviadofPreviousmapters 72 Stmnaryandnmerpretatimofr‘irdirgs.............. 76 ImitatiGBOftl‘lesuflYDDDDDDeeeoeeeeeeeeeee 76 Inplicatiomformrsing 77 ImplicatimsforMJrsingPractice............. 84 85 88 InplicatimsforNursirgEdlmtim......... RecanneniatimsforFumreReseazdxHW 9O 92 94 96 mun-MWWCOCOIOOOOOOOOOOOI Amo-mmmm.............. APPENDDKC- APPENDDKA-CDVERWMMJRSESANDH'IYSICIANS. . . . . . . 97 vii HSTOFMEB SmotScreenimBelnviorsofAdvamedPracticeNurses SmmryofScreexfingBehaviomofAdvamedPracticeNurses foer-supportedFactors. Smmary of Screening Behaviors of Physicians for Supported viii 65 66 67 68 LISTOF FIGURES Figure l W Framedork .................... 2 Summary Figure for Study. ................. GIAPIERI mow mm cardiovasmlardiseasewvmisthemstcmcauseofdeathin bothmandwcneninthemitedStates. (NationalCerrterforI-Iealth StatisticleBG). Pastreseardzhasshownthatthecvndeathratefor waistviceflzatofmatanygivenageo-Iazzard,l986),however, theriskformissignificant. In1983,CVDwasthecauseof52%of alldeathsinwunen. (film, 1987). Omestrokeisrawvedfzunthe definitimofCVD,rnartdisease(C3D),wasthethizdleadingcauseof deathinm35to39years,secaflinwunsnbetween40arfl44yeazs, ardtheleadimcauseofdeathinméSyearsarflolder. Although the figures for CED/CVO are inpressive, preventative efforts in terms of Gm/Qbriskfactorminghavebeenfowsedprimrflymmmaker, 'man, Castelli, 1988). matoanotuusmaaumpmjectism ascribetheecreaflxgprasticamedhyprimryaremdmto WmethareatriskfarfiD/GD. 29m Holmn,}bsill, andStralg (1960) denominated thatthe atherogeniclesimslmcwntocauseambegintodevelopasearlyasthe secmdardthirddecadesoflife. Atherosclerosisisagradualprocess ofdnolesterol depositimthatdisrtptstheirmerliningoftlmarterial wall. Asthisdisruptimocans,thecellsoftheintimalliningare exposedtolipids, becmemaghened, diszuptplatelets, andeventuallya clctisformed. Asmisclotbecaneshardened,theprocessrepeats itselfmwtilthearteryeventuallyisclosedoraclotfonscverthe narrowedlumen. ‘meendproductofthisprocessmaybestroke, myocardialinfamtimorinfamtimoftheothervitalozgansflolman,et al., (1960). Ornetluspmcesswasidentified,severalsmdiesmmdertaken toidentifythepotentialfactozsthatmaypredisposeametothe develqment ofCVD(Framingtm,l948thm1ghl989,'meBostmNurses smdylsss,meWa1threeksmdy1968, 1978). 'Ihefollcwing risk factors, identifiedthruaghtheselmgiuflinal studies, cartributeto thedevelopnentofCVDinbothsexes: l. Familyhistotryofpremaunedeaflufrancmmriortoagesm 2. Diabetesmellims 3. Smoking 4. Diet 5. Hypertensim 6. mesity 7. Sederrtarylifestyle 8. Malegerfler 9. 'I'ypeAbdxavior lo. Elevateddiolesterollevels 'meriskpmfilewasdevelopedasaresultofmnysmdies. Although initially developed for men, this risk profile has been applied towunen. (Perlmn, Wolf, Ray, and Lieberlmed‘xt, 1988). 'Iheir findings suggesttlutalflnaghthemmybesanediffemnesinflxeinportameof flieriskfactorsinm,screeningfortlwseriskfactorsatanear1y agemyfacilitatethegrachaldeclireinprammredeathofvmenfran CVD. CVDriskfactorscreeningcanbedescribedasbothprimaryand secaflazyfommofprevmtimfordisease. If,afterthormgh screaflm,amnisfotmdtobefreeofCVDriskfactors,ttma healthcareprcvidermayinstibxtecotmselingandeducatimto facilitatefllemintenameoffl‘xisstate (Perrier, 1987). Forthis study, mmisisplacedmtheprimarypreventiveroleofpravidezsin screeningforcnrdiwaswlardisease. . ‘meSLngeaaceneral(l978),inthedeveloprentoftheaDjectives Fbr'meNatimforl99o,tazgstedbehavioralriskfactorsasanareafor mumbyhealthcareproviders. mummusas) of theseobjectivesdmwstratedthatevaluatimofprogressmthese objectiveshasbeentrmrtedbyalackofbaselinedata. ‘Ihelackof dataindicatesthatl)screerfingisbeingda1e,hrtthedataisrnt available,or2)thatscreeningismtbeingdane. 4 'IhedraftoftheYear 2000 National Health Objectives is characterized by, "an increase of musis m pramtim of disability andmrbidity, greater attentionto improve thehealth status of definablegzulps athighest risk of prmture death, disease, and disability, and inclusion of more screening irrtezventiais to detect asynptmntic diseases and conditims early ernigh to prevent early death orchrcznic illness." (His, 1989, pg. 1). Qirrentliteraunestillhasmtreporteddatamgardingscreening practices. 'mecauseofthislackofdataismflmn. Isitaproblan inreportingscremingactivity? Isecreeningnctbeirgdonedueto tinecmstraints,lackofreimhnsanent,ladcofm1edgemthepart oftheprovider,orotherfactors? Stardardsforassessmentofcardiovaswlarriskhavebeen developedbythemiitedstatesPrsvermiveTaskarceu989). Inthe TaskrbmeReport,oonsideratimmsgiventoboththeprevalence (proportimofthepqmlatimaffected)anitheimiderce(mmberofnav casesperyear)ofthecmditim. Cmditimsthatwereornecmxmt havebecomerarebecaueeof effective preventive interventims (e.g., policnyelitis)wereim1udedinthereview(pg.xiX). 'Ihereportalso includedmlythosecafiitiasthatcmldbealteredbyapreventative intervention. Foreadztargstcmditim,ftmtherdelineatiaismre nude. First, mly preventative servicesmiedoutmasynptamtic iJflivichJalsmca'lsiderad. 'meseca‘dcaflitimmarflatedthatthe preventiveeffortmstbecarriedaxtintheclinicalsettim. ‘Ihe fowsofthisshflyrelatestoperimxpausalmpresexrtingfor 5 "routine health mintenance 'visit" , and not visits specifically related tosynptansofcardicvasailardisease. ‘Ihisreportisexcitinginthatparticipantswerefrunall specialties,ardtherewasspecificrepresentatimfranthemmsing calamity. 'Ihisisalsothefirstdoamm‘rtinthemiitedstatesthat cmbirasrecannematimsfzmallorganizatims,ardrntthosemlated solelytomdicine. 'niedoamEJ‘rtcmbinestheresear'di,cost/benefit analysis, and efficacy reports to clearly identify what screening paramtersslmldbemxdertalmatvarimspomtsinthelifecycle. Howsver,cnecmcernranim. Inrelatimtocardicvascularrisk factors,mstofu1ereseaxd1hasbeencadictedinrelatimshiptom. Insevemlsunies,theresultswerethme)¢rapolatedtoinchflewmen. mgmm Cardiovasmlardiseaseaffectswmenaswellasmen. 'Ihe cardioprotective effect of estrogen is lessened in perimermausal marten duetodecreasingprommimofestrogen mutehead, 1988). Previous researdieffortstoidentifyacazdiovaswlarriskpmfilehasfowsed mmenarxitheresultshavebeengeneralizedtoimludem. Itis mtlcmhowortomteaaentpruvidersassessmrdicvasmlarriskin perimmmausalm. 'nms,thequestimbeingaddressedis: m mmmmammmm mammammmmsanmmmmmm WWW m,mmmmasssssm? 6 842%me 'meproposedsuflywillattalpttodescribemmrtifiedm Practitiaiersthruiglmtthestateofuidiiganwhocarefor perimenopausalmscmenthesemforriskfactorsforthe develomentofcoraiaryarterydisease. mysicianprcvidersinthe'lri- camtyareaofGenesee,I.apeer,ardShiawasseecomtieswillbe included. 'me physician pqaulatim will include all Family Physicians, Internists, andaastetrician/Gymcologists inthe'rri-camty area. 'memaindojectiveofthisreseardiistoacguireanacan'ate descriptimofhavpsriwrpausalvmenarescreenedforcardicvasaflar riskfactorsbycertifiedmnsepractitimersinthestateofuidiigan. ‘mepiysicisngmupisselectedasapopulatimtofacilitatethe descriptimofpracticepattemsbecausethereisapmicityofmrse practitiaaersintheimediateareaofthereseardier. DescriptimsofpracticepattemscanbecmparedtouieNatimal 'I‘askForcerecannendatimswhidiwillbedescribedindetail- Sucha omparism may facilitate the generatim of nav standards targeted specificallyarcmdm. Mluatimofpracticeisaninportantpointinthemrsirg process. mereareessentiallytwolevelsofevaluatiminthemrsing process: 1) evaluaticn oftheclierrtandZ) evaluatim of practice. Evaluatim of practice allows for the critical enaminatim of previous practices. Mambatiminunnmaygiveinsighttootherareasfor aseesmxt,p1amingandinterventiminrelatimtothepracticeof missing. 7 Advancedmrsingpracticeispredimtedmhealthardwellness issuesratherthantreatmentofdisease. 'Ihisdescriptivestudyismt afizststepinthedevelopnentofmedlanimswherebymsimczn facilitatemllmssbymlpirgperimmausalmdevelopahealflly lifestyle. mm Mgzgm: Inthissudy,aproviderisdefinedasa licersedhealthcareprofessimal thataclientmayamroadltotake careoftheirhealthneeds. 'meprovidermaybeanAdvancedPractice Nursemirsepractitimer)pmvidirgprimrycareforperiwiopausal moraMedicalDoctorom)withclinicnlspecialtiesinFamily Practice, Internal Medicine, or Obstetrics/Why. mmm: mirsePractitimersandplysicians providirgprimrycaresharethecamimleofassesmm. Focus (:1 practice in a specific area will facilitate recognition of practioepattemsinrelatimtotheassessmentofperimenopausal mforcardiovaswlarriskfactors. Amajorfocusformnsesinadvancedpractioerelatesto health pramtim, wellness issues, health educatim, and interventimstoprmotethehealthofirdividualsintheir practice. Altlnlghitisrecognizedfrantheoutsetthattheremlts frunthe'Iri-camtyareamymtbegeneralizable,and pooling ofall results is nctpossible, adescription of 8 practice differences between rhysicians and advanced nurses may be possible. Evaltntim of caupliance with the National TaskForcerecamnerfiatimswillalsobepossible. Mam: Astrategytoidentifyfactore(eitherby questiming the patient/client or per-fouling diagnostic testing) to iderrtifyvmefllerormtafactorlsmntooartrihrtetofliedevelqment omeispresent. Wm: McKem (1987) inherarticleonDispelling MempmlseMyths,states"Cmtaiporarythimdrgviavsmenopauseasa mlphysiologiceventmfiadlangeindirectim. 'Iheperimenopausal tremitim—timlOtoZOyearssurmndirgtheacmalprocess—isseen asanaturalprocessarxiatimeofdevelqmentanddlange" (pg. 29). Utian (1987) indicates that the climacteric madrune fulfills the postulates ofanendocrinopathy; for sample, removal ofthecvaries beforethewlopausecausestissuesrespmsivetospecificovarian mummamesremltiminspecificwnpausalsynptms. Caversely,replacaientofthewarianhormesmereesflesesynptms. Sandelowski (1981) reviews several works related to synptanatology ofwunentmdergoingmempmise: "mule,mtheonehand,weare presentedwithapicuzreofthenermmisalmnasadepressed, amdcus,ardgenerallymstable persan,wearealsoofferednead's observatimthattheyarezestfulandeagerforlifearrithenav challenges that emit them" (pg. 58). AccordirgtotheNatimalCenterforHealthStatisticsthereare over40millia1wunenintheUnitedStates50yearsoldorolder. 'Ihe 9 averageageofmulralnenopauseisfléyearswiththemngebeingages 40-55 (National Center for Health Statistics, 1986). 'nlerearemnydefinitimsassociatedwithmenopause. Forthe plrposeofthissmdy,theperinempmlsalmnisdefimdasbeingin theagerangeof40-55. Atthisstageoflife,therearemanynamral processesocwrring. ‘nlereisalsothepcterrtialfordlangeand develqlnent. Waneninthisagegrmphavemdergcnetranerdmsdlangesintheir lifestyles. Sincethel960'stherehasbeenatrmrendmsmsurgeinthe mndaerofsingleardmrriedworldmmthers. mtranceirrtothe workforce creates mltiple rolestressandstrainWertngge, (1982), Sorenson, Pirie, Folsan, Inepker, Jacobs, Gillum (1985)]. Sorensmetal,(l985)assessedattheinpactofworkimmthe healthofmardoucludedtlntentranceintotheworkforeehadm effectmhealth. Researd11nthisareahas2majordrawbacks:l)mt takingintoaccamtoulerrelestlntworkingwmenhaveandmnct loddxgathealthdlangeslalgitudimllytotakeintoaccamtdlangesin workforceparticipatimduringthepastdecade. Giordano (1988) indicates that parents of "baby boaters" or those Whornbstweenn30arfll950arethe"caught" generaticm. 'Ihese individmlsareinthemidstofcareersandmaritalrespasibflitiesarfl mstcopewithmtmlyparentdmissaes,h1talsowifl1agingparents. Insmmry,theperimempausalwunanisfacihgmanynewreles,has amltiuldeofstressorsrelatedtomtaflydiargingroles,bltalsoin copirg with the naturally occurring physiologic changes associated with menopause. 10 Wmmswmsmm: The literature has identified that perimenopmlsal wanen are at risk for cardiovasallarevents. Cuwersely,perimenopm:sa1vnnenaretheleast synptanaticinrelatimtocardicvasculardisease. 'Iheraticnalefor usirgperimerupausalwunenisrelatedtotherelativepmlcityof informtim availabletoclinicians. Internsofthisstudy, itis asstmedflntcardiwasallarriskassessmm'rtofperimenopausalwmen allowstineforthedevelognentofstrategiestoreducethe cardiwasallarriskstamsinsteadofwaitingforaperiodoftimem theymaybeatgreaterriskorslmdevelqnentofdisease. WMM: Belmriml.psydwlogical. and/or geneticfactorethatarelcmntoccxrtrihltetothedevelopnentof coronaryarterydisease. 1) Familyhistoryofpranatllredeathfranmdiseasemriorto 89350) 2) Diabetesmllitlls 3) Sinking 4) Diet 5) Hypertensim 6) Cbesity 7) Sedentarylifestyle 8) ‘IypeABehaviorssmhashostilityandaggressimtochanges inlife 9) Elevateddlolesterollevels Simethestniyisdirectedatwmemmalegerflerisremovedfm the definition of risk factors . ll mmmmz Fortheplnposesofflfisstlfiy. arartinehealfllmihtmancevisitisthattinevmenamnpresents foranm-aarte,rm—obstetricalvisit. 'Ihefumztionofthisvisitmay beayearlyphysical, "paparflpelvic",orayearly"d1eck—up". 'Ihis maybeaninitialvisit,hrtthepurposeisforhealthmaintenanoemri isnotrelatedtocardiavascularsymptcms. 131mm: Anyproactiveirrtmmtim.themrposeof midliseithertomintainorinproveanindividual'shealthas cartrastedtothetreatlmrrtofdisease. mm: Fender (1987) presentsdefinition of health prmotim as consisting of activities directed toward increasing the level of well-being and actmalizirg the healthpatehtial of individuals, families, mities, andsociety. 'Ihissmdyprovidesadescription of how providers identify behaviors that are "risky" or capable of dininifllilyfllelevelofmllness. Emmy-2.1.: m(1937)8180pmsemsnisease Preventimasomsistingofthreelevels: 1)PrimryPreventim mists of activities directed toward decreasing the prcbability of specificillnessesordysfimctiminindividuals, families, and caunmities, including active protectimagaimtmmecessarystressors; 2)SecadaryPreventimenrhasizesear1ydiagnosisandprmpt interverrticmtohaltthepathological process, therebyshortenirg its amatimardseverityardemblirgtheirflividualtoregainmrmal function attheearliest possible point; andB) 'DertiaryPreverrticm intoplaywhena defectordisability is fixed, stabilized, or irreversible. Rehabilitatim, the goal of tertiary prevention, is more 12 thanInltihgtmdiseaseprocessitself—itisrestorirgtheirdividual to’ancptimllevelotmctimihg. Forthisstmdy,thedefinitimofPrimaryPreventimisofmajor inportance. Altlnlgh the efficacy of health pranoticn activities is not camletelydoamentedforwunen, itisreasonabletoassumethat preventimofthediseaseismreefficacimsinrednirgnortalityarfl morbiditythanctherforms of preventimasdefined. W l) I-Iealthmintenancevisitsarepatient generated. That is, thepatierm/clieutseeksaccesstocarebasedmabeliefthatscremirg fordiseaseorflleladtflmofisvaluable. 2) AdvamedPracticemrsesandmysiciansprovideasimilar levelofcareinrelatimtoassesanentofhealthardillness. 'Ihe differencebehreenmedicalandmmsingcareliesinflleplmmingard interventicnalplasesoftheermmter. 3) PrimryCareProviders,aswellasperinerwausalwmen, haveoptionsinchoosing available healthcareoptias. 4) PrimaryCareProvider-swillacmratelyreporttheir practice. _ 5) Altlnlghthelo'umriskfactorsforcardiovaswlardisease hmrebemdevelopedflimlghsmdiesrelatingtonen,theseriskfactors also apply to wunen. 13 Wimm Itisrealizedfrmflleimtimofthisstudythatthereare severallimitatims: 1) ‘Iherealltsfranplysiciarswillbelilnitedtothe'rri- camtyareaofGenesee, IapeerarriShiawasseecomtiesandmaymtbe generalizable. 2) missmdyislimitedtotheassessnmtofperimenopausal wunerimly. 3) 'misisavolmtarystudywl‘iidlprovidesfor self-selection versusrandanassigrment. 4) 'Ihesbxiydesigndoesnotidentifyfactorswhichmayaffect providerscreeningbehavior. 5) Sincethisstuiyasksaboutscreeningduringa"rwtine healthmintenanoevisit”, thereisapopllatimofperimnpzmsalm thatwillmtbescreened. 'nnls,wunenthatarebeingscreenedmy representapopdlatimmtatriskforcardiovasallardimbyvirme ofpriorhealthmaintenameactivities. mgmm InChapterI, theihtroductim, backgroimd, statenentofthe problan, purpose of the project, emcepmal definitions, asstmprticms, andlimitatims ofthereseardlhavebeenpresented. 14 clapterIIpresentsthetheoreticalbasisforthereseardl. 'Ihe omceptualframrork,mjorcaceptsoftheshady,ardfl1erelatimships bsmeentheframeworkanithestiflywillbediscussed. ClapterIIIenminesthemrrentreseamhinrelatimtothe specificsofdeteminirgcardiovascllarriskforperimernpausalm. Healfllprmotiniseaseprarentimaspectsofprimrycarewillalsobe discussed. dwterIVprovidesthenethodologytobeusedinthestudy. Imludedihthissectimwillbeadescriptimofthereseardidesign, data oollecticn procedures, subject selection, and querational definitions of the variables. Means of data scoring, reliability and validity, analysis of data, and protectim of human rights will be described. Clapteerrwidesastmmaryoftheproject. 'Iheresultsand analysisoftheseresfltswillbepresented. Tableswillbeusedto illustrateresultsofthedata. anterVIoutlinestheoartributia'eofthiss‘udy. Implications forfuuneresear'dl,advancsdnnei1gpractioe,primrycareedimtim andprimrycarewillbediswssed. 'Iherelatimshipofthenodeltothestudywillalsobepresented. G-IAPI'ERII 919211114 'meperimelwmlsalmnhasbeendescribedconceptuallyas zestful,eagerforliferardtheperimenopausalyearsareseenasatine ofdevelopnerrtanddlange. 'misprocessofdevelognentarrlchangecan beinterpretedasaprocessofbecaning,oran"irwariantore—waytrerd" (Rogers, 1979, pg. 55). Viewingperimeropausalwcuenasintheprocessofbecanimisthe foundation ofthisstudy. MarthaRogers' (l979)theoryofUnitarymman Beingsprovidestlnccrcephnlbasisforthesmdyofperimenopausal wuneninrelatimtocardicvascllarriskfactore. Rogers(l979)describesNursirgasbothaSciencearrianArt(pg. 121). "mescienceofmlrsingisabodyofabstzactlcmledgearrived at by scientific research and logical analysis. It is this body of lmowledge that encmpasses nursing's descriptive, explanatory, and predictive principles indispensable to professional practice in mlrsing. 'nleprecticeofmrsihgencmpassestheartofmlrsihgandisthe utilization of mlrsim'sbodyofabstractlmowledgeinservicetomnnan beings. Newdimensiaeofartistryareadlievedasthescienoeof mlrsirggrowsardisincorporatedintopractioe" (pg. 121-122). Rogers l6 alsosays that N'ursingexiststoservepeople. Nursing's responsibility is to society, andhas nodependent functiors, ally collaborative ones. Forthiss’a.1dy,theroleofassessoristakenfrunthedescriptive cmpment of Roger's definition of nursing. 'Ihedescriptive canponerrt (asssment) provides thebasis to explainandpossibly predict plenum-la. Intemsofthesb1dy,assessmen‘tofcardiovaswlarrisk factorsprcvidesthebasistofomalateinterventicms. Aswillbe shown, the guiding principles of synchrmy, unidirectialality, and resamwcyfacilitatetheassessnentprocess. Rogersdefinesrnmnbeihgsasatmifiedvmolepossessinghisom integrityarximanifestingcharacteristicsthataremorethanand differentfrcmtheamofhispartsmg. 47). 'melifeprocessofI-mman Beings isdlaracterizedbywholeness, openness, midirectimality, patternanior'ganizatim, sentienceardtlnlght. I-nmanbeingscarmctbeseparatedfrmtheirenvirament. 'Ihe erergyfieldsofmnnansarritheirmwiramentareinastateofcmstant interchange. "Itisthisirrtercharqethatpcrtelfisthecreativityof life" (pg. 54). Ehdiperimenqoausalmnisinteractingwithher elwiraunentraIfithatenvimmerrtisdlangingcmstantly. Causeguently, themrseseestheperinernpausalmnatapointinspacetineand assessestheinteractimbshreenthewunanandhererwirament. this mirumentermpassasnotmlyflleintenaLhrtmlenvimment. 17 ‘Erirsislgsfusm 'Iheprincipalofsyruirulyisstated, "mangeinthehimenfield deperdsmlyupmthestateofthetnmanfieldanithesimltanems state oftheenviromnental field atanygiven point inspacetime" (pg. 98). misindimtes thatmsirgleeventmaybeviewedinisolation, arrlthat interactia'usaremtstatic. Events, situations, reactionsare cmtinnllydianging. W: ”'nlelifeprocessisabeccming. 'Ihe evoluticn of life exhibits an invariant ale-way trerd" (pg. 55). In ctherwords,tineisalwayspassimarflcarmotberepeated. m: 'meprihcipleofresonanceposbdlatesthatdlangein pattern an! organizatim of the Inmn field and the envirmmental field ispropagatedbywaves. 'meIifeProcessinlnmanbeingsisasymiony of rhythmical vibrations oscillating at various frequencies (pg. 107) . 'niismeansthatirrteractiasbemeentheerergyfieldsofmmansard theirerwirumentsmaybeharmmiws,ormybeprobl.ticresultingin discordance, andmyvary in intensityarricarpleldty. mm: memmsnandmvimmtalrieldsazeemtimally interactingwithoneamther. mismansthatmmanbeingsandtheir enviromnentscamlotbetakenseparately. Bothoftheseenergyfields aredynamicinmune,ttmsdnrgesineadlareocwrringsimlltanewsly which resultsindifferent actionsandreactions. 'nms, thedynamic interactimbebdeenmnnananitheirenvirorments. Inrelatimtothisstudy,theprincipleofsyrdlrmyalertsthe musetlnttheassessmentphaseismlyapartofthetotalpicmre. 18 'meriskfactoretlntareapparentmmgtheihitialinterviavmaymt beapparentatalaterencom'rter. 'Ihisisthebasisfortheneedfor cartiruirgassessnm'rtofriskfactorsatrepeatedvisits. Unidirectionalityprovidesqporumityforinterventim. 'Ihetrendis towardahealthierlifestyle. Riskassessnentprcvidesthedatabasefor effective interventim that can facilitate an upward spiral of the life process. Resalamegivesdirectimtotheassessmentfilase. Assessment can effectively determine probl‘tic interaction with the environment that may result in discordance (cardiovascular event). Reciprocity allows positive charge, e.g., mokilgcessaticn createsabeneficial dnrgeinerwirament,vmidlinumnproducespositivednngesinthe interrulmvimnnerrtmdiasrednedvasospamoffllecoranryarteries. Weightlossreducesdumfimthemyocardimresultingindecreased bloodpresame,reafltillgindecreasedriskofcardiovascllareverits, andsom. Inammary,theguidimprinciplesofmgerstheoryofmitary mnnanBeihgsguidesthisstudyofperimenopmlsalwunen. 'lheassessment wdescriptiveflmctimofmnsingprovidesthebasisforinterventim. mgerelooksatlnmnbeingsinaprocessofbecaning. Shealso indicatesthatmrseslookatapersmatapointinspaoetime. 'Ihe foolsofthissmdyismetherormtprovidersarelookirgat perinernpausalvmenatapointinspacetimethatwmldallwforrisk factor reductim and facilitate the process of beaming. mm (Figurelwctpage) 20 AscanbeseeninFigurel,them1rseandthepatient/clierrthave tointeractwiththeirenvirorments. misisdmlstratedbythe arrows. 'nlebmndariescreatedbythesearrwsaremlysdmatic representations of interactims. Energy fields without boundaries are notcmducivetoca'cretegrafilic interpretatim. 'meinteractilgrolesoftheAdvamedPracticemlrsearealso dynamicinrespa'setotheerwimment. Envflleinteractimsirrtertwine dependsonrepatternixg. (‘hangingcalrrentpattenlsinrespmsetoa stimlusoccursmthepartofthemrsingandthepatient. Energy fieldsareeadlangedbybothparticipantsintheinterview. 'Ihepatient gives informationthat alertsthemrsetothepatient'slmman- envirormmtinteractimthatisoccnringatapointinspacetime. 'niisthenalertsthemneetovmichroleisappropriateardsetsthe rctatimalaldsinmotim. 'Ihepatient reactimtoanurses's specific roleisassessed,arrirepatternirgbythemrseismdertalm. 'nlemlrseisalsoaproductofaninteractimbetweenmmanand enviramentalenergyfields. Partoftheenvira‘mentoftheprovideris theproductofaninteractimwithpeers,merrtors,andcolleagues. In thissmdy,theinteractimofotherprovidere(mneesarrl;hysicians) playsanillportantrole. Practicepattermsofthemrsearedevelcped asareactimtothepatterrsofothers. mlowledgeoflwwothersreact totheirenvirammtallowsthemrsetbevaluateherreactimstoher envimmentsandfacilitatesherprocessofbecaning. Becaninginthis sensecanbedescribedasgrowinginher/hisroleasclinician. Researdlhasdaulstratedthatoertainbehavioralreactionsto intennlanieamlmvirmrtscanbedismptivetoulemmsnmergy 21 fieldresultirgindiscordance,orinthissense, cardiovascular disease. 'meroleoftheadvancedpracticemrseistoreoognizethese pctamialbdlaviorstlntarelcnwntocausediscordame,othemiselmwn asprimarypreventimofdisease. Itishopedthatthisdacriptivestiflywillfacilitatethe processofbecaningforbothperimermausalwmenarrimrsing. CHAPI‘ERIII mania ‘Ihisdiapterisdedicatedtoarevievofthepertinentliterature relatedtoprwiderecreenirgofperinelnpausalvmenforcardimscular riskfactors. 'mereison'rentlyadedicatedpancityofliteramrerelatedto screenihgpracticesofhealthcareproviders. Manynonenpirical articles are dedicated to review of current recamneridatims frun various agenciesaboutwhoshouldbescreenedforvarialsprobl; however, descriptimofacmalpractioeintermsofscreenirgbdlaviorsdoesmt exist. Mfimm Screeningisamedlanianofhealthpranctim. Ifscreeningis dale, thentheeffimcy of changing client behaviorsispcterrtially einmedaeooxdingtehsuipender(1987),aedcerandnaimn(1985). Perrier (1987) givesseveraltheoriesalfltypesof health prmntion behavior. She identifies a ”nodal" for health pranotim. Emmet, the modelisverysimilartoaedcerarfimimn'sfiealthaelieflbdela985). 22 23 Efficacy of Perder'smodelismtyetompletely documented. The researchdescribedinthehealthpranctimliterahmeislargely descriptivearridoesmtleniinfemtimtothisstudyotherthanthe theoreticalbelieftlntifscreeningisdcme,thedlarneofcharging client behaviorisenhanced. ciaxgimhehaviorwmldheaecmplishedby assistirgtheirriividualtodlangetheirhealth beliefsinrelationto cardiovascularrisk. Inviavofthelackofdataregardirgscreeningpractices, literamre fran: 1) 'IhePreverrtive ServicesTaskForce, 2) Literature relatedtothespecificriskfactors, and3)‘1hedraftoftheYear2000 dajectives fortheNaticnwillbediscussed. mmmm 2mm 'IheU.S. PreverrtiveServices'l‘askForcewascawenedinl984under themspices oftheU.S. PublicI-Iealth Service. 'Ihefocus ofthenon- Federalbodyofexpertswastoanalyzetrendsrelatedtoincreased interestinprarentiveservicesfrmbothplblicardprivatesectors. ‘memkeupofthelaskrorceihcluiedexpertsfranmreingand medicihe,aswellasothers. ‘me'I‘askForoenetutimesbstweenJuly, 1984andFebruary, 1988. ‘meoverallgoalofthe'raskforoewasto reviavandammarizeevidencerelatedtoscreenirqparametersforw target cafiitims (me of whichwas cardiovascular disease) affecting 24 patientsfraninfancytooldage- mwmmm mummofflntextensiveeffort. mmmfiewlminatimofcverfmyearsofliteraulre review, debate, and synthesis of critiml mm franedcpert revieders. Itoffersflle'raskFcroenmbers'bestjulgau'tt,basedm evidence, of the clinical preventive services that prudent clinicians shuddprcvidetheirpatientsintheoamseofroutiheclinicalcare" (immense, 1989, pg. iii). mmemmmumm facilitatethalghtfuldecisimmldngmthepartoftheclinician. ‘Ihe introductimisanoverviavoftheprocessandraticnaleusedfor producticnofthedoament. Sevencriticalfindingsdevelopedasa resultofthereviswofevidenoefamdinthereportofthe'laskforce: (Pg.xv-xiv). l) 'medatasuggestthatmgthemsteffectiveinterventions availabletocliniciansforreducimtheincidernemrlseverityof leadingcausesofdiseasearridisabilityinthev.s.arethosethat addressthe perealalhealthpracticesofpatients. Primrypreventim asitrelatestosudlriskfactorsassnddhg,physicalimctivity,poor mrtritim,anialcdlolandotherdngablseholdsgenerallygreater prmiseforinprovirgoverallhealththanmysecmdarypreventive measures. 2) 'meproperselectimofscreeningtestsrequirescareful cmsideratimoftheage,sex,ardotherindividualriskfactorsofule patientiftheclinicianistomirdmizetheriskofadvereeeffectsand mecessaryexpendimreswetoscreenihg. 25 3) (lamentimal clinical activities (e.g., diagnostic testing) maybeoflessvaluetopatientsthanactivitiesmceoa'sideredaltside thetraditicnal role oftheclinician (e.g., coin-iselingandpatient educatim). 4) ‘Ihe shifting responsibility of clinicians also inplies a chargingroleforpatients. 'meirrzreasihgevidenceoftheinportame ofperemalhealthbehaviorsardprimryprsventimmeansthatthe patiem'smstassmegreaterrespmsibilityfortheirownhealth. 5) preventive services need not be delivered exclusively during visitsdevotedentirelytopreventim. 6) Formsttopicsexamihedinthismort,thelaskForce fundilmequateevidencetoevalmte effectivenessortodeterminethe cptimlfrequencyofapreventiveservice. 7) 'metedmiquesthathavebeendevelcpedbytheU.S.Task Forceforthestarxiardizedreviavofevidenceardfordeveloping clinicalpractioerecamendatiaabasedmdocmenteddecisimmlesare equally applicabletomanyotherpractices. Ashasbeenstm,m1rsiryhasbeenimtnnmrtalinthe develcpm'ltoffllesetrelfls. Nineimhastraditiaiallybaenirrterested inindividualhealthpractioesardbdlaviors. 'nletraditional diagnosticdmainhasmtbeenaftmctimofmrsirg. ‘Iherefore, enuresis on behavior, educatim, perscnalized interventim, and advocacy fortheiniividualhavebeenapartoftheroleofthemrse. Itisfor tlflsveryreasmthatmnseswereinstnmentaltothedevelqmentofthe TaskForoereport. 26 Inrelatimtothisstudy,mofthecriticalfindingshasnajor inplicatims. 'Ihe Task Force cites inadequate evidence to evaluate screwingpractices. 'Ihisirdimtedthatevaluatimof provider/clinicianscremingpracticesisladdng. Withoutknowing baselinescremixgbetuvior,itisinpossibletoeva1uatewietherormt thescreenirgiseffective. 'niismettndologysectimofflleggggdelineatesthemethodof systanatic evaluation of the effectiveness of clinical Wive services. Criteria fordeterminingeffectiveness ofaparticular interventim, efficacy of screening tests, reliability, and several otherfactoreutilizedbythe'l‘askForoeareoutlimdindetail. ‘nms, theclinicianmyreviewthisinfomatimardmaloejuhmentsabartthe informtimrelevanttohis/herpractice. 'nleggiggservesasabasis forthisthesis. Mespecificdlartsareavailableinthemulatdetailmt screamingparametersdmldbemdertakenatmidlagegroup. 'Ihe durtsareorganizedtoincluieascremirg,canselingardimmizatim section. Wtiasformigh-riskgroup"isbasedmthe traditimalcmprel'iensivepatienthistory. Certain principles gleaned frcm alpirical evidence are presented tofamiliarizethecliniciantowaysofdlangimclientbehavior. 'Ihis daapterisaimedatpiysiciamtoincreasephysicianawarenessof primiplesofbehaviordlange. Aspreviouslydiscussed,thisisa"new role" for-medicine. Nursingexperienceinthisrolecanserveasa positivemodel. 27 Wtiasofthe'l‘askForceappearfirstineadidiapter. Eadldlapterisdedicatedtoadifferentproblenardincludehlrdenof suffering, efficacy of screening tests, effectiveness of early detectim, Weatimsofethers,adiswssim,ardeniswiththe clinical interventim. 'Ihe raticnale for imluding this information is alceagaintoallwthecliniciantousehis/heromjudgmentsasto whid'iparameterstouse. WAofthegndestmrizestherecmnendatimsfor scremunginterventims, almgwithqualityofevidenceardstrengthof reconnendations. Witness! 'mefollmirgitansareextrapolated, andwillbeusedas guidelinesforscreeningintheslnveyusedforthisreseardi. ‘Ihe scremirrgpractimrelatedtocormaryarterydiseaseare: l) W: Dietary intake, physical activity , tobaccouse. 2) mm: heightandmight, blood pressure. 3) cholesterol, fasting glucose for markedly obese, persons withafamilyhistoryofdiabetes, orwcnenwithahistory ofgestaticnaldiabetes. Beformenwmohaveriskfactors formyoczrdialinfarctim. Altlnlghfamilyhistoryofcormaryheartdiseaseismt specificallystatedinthetable,theinportanoeofacmprehensive historyhasalreadybeenimluied. “memedforevaluatingrisk 28 factorsmflerscoresatimernloredprimipleofompletemedical history...".(pg.XV) 'niegngggivesthepracticingclinicianacmprehensivereviwof literauuearrlrecmmendatiasthatmaybeinstiurtedintheclinical stetting. AcriticismoftheMiscertainlymtthefaultoftheTask Fbroeeffort. Studiesofcardiavascularriskfactorshavebeen ca'lductedprimarilymmen. Asaresult,falseasstmptimsthatwum domtalfferfrunCVDmybegenerated. AncthercmcerminrelatiashiptotheMisthemtablelack ofguidelirasrewrdingdevelqmerrtalarrlpsydlosocialcanpaaentsof riskforcardiovasoalardisease. Althoughitmaybearguedthata cmprehensivehistoryvmldentailstdlissuesasdevelopnental milestales, stressars, behavior types, etc., theclinician may feel that sudlissuesareasimportanttoale'soverallhealthasmorecamete diagnostictesting. 'mislackofrecamendatimforscreenirgstress- related issues creates difficulty for the researd'ler attaipting to describepractioepatternsarrievaluatetlmagairetastandard. 'lheranairxierofthisdlapterisdedicatedtoliterahlre associatedwiththeirriividualriskfactors. Adiort,pertinerrtreview ofthedraftoftheYear 2000 wjectives fortheNatim (PBS, 1989) will canpletetheliteraturereviavforthisstudy. 'mereseardiidentifyingthecardicvasallarriskstatusis extensivearxiwell-supported. Cardiovasallarriskstatusisdefinedasfllepresenceofafamily historyofcormaryheartdisease, elevated cholesterol levels, diabetes 29 mllitus, m, diet, hypertensim, daesity, sedentary lifestyle, male sex, andstress. Sinoethis stildyproposestoworkwithwanen, male sex is not valid. Specific definitions of variables related to thesecmceptswillappearattheendofthedefinitimsectimforeadl ccncept. 'Ii'leriskprofileisbasedmtheAuericanHeartAssociatim declaration of risk factors for cardiavasmlar disease (am, 1986) . W: maimgfmm Dealer and miterovid‘i (1988) attanprt to define this variable on thebasisofaneadlaustiveaooovmtingofpastreseardi. ‘Ihe doamentatimofcase-omtmlretrospectivesuldiespointstothefact thatthereisarelatiashipbetweenafmnflyhistoryofooraaryartery diseasearriheredity (RissanenaniNincila, 1977, Rissanen, 1979, Nora, Lortscher, and Spengler, 1980). nlreeprospectivesunies,1heWesternCDllaborativeGroupsmdy, 'mehaminghamfieartsufly,ardthefiarvardNursessmdy,have doamentedafairlyoasistentriskrargeofztines, l.5timesand2.8 timesrespectively, forthedevelopnentofcvmthisriskocwrewhen theparentorsiblingdevelopedacardiwasaflareventpriortotheage of60yearsold. Familyhistoryasariskfactorhasnotbeenoonsistentlydefined. Inordertoattelpttoidentifyaomsistentdefinitimofthisrisk factor, I-hn'tt, Williams, 8111 Barlow (1986) applied several differed: definiticrs of ”family history" of CVD to predict the relative risk of CVDofadultrelativesofBZOOhighsdloolstudents. Familieswichor mrerelativeswithCVDhadriskofthreetosixtimesthatofthe 30 general pwulatim. Those with we relative encountered a relative risk of 1.4. Miriam Forthepurposesofthisstudy, thedefinitimoffamilyhistory of CVD is: at least a first-degree relative(s) . (e.g., mother, father, brother, sister, son, daughter) withahistoryofmrdiovasallarevent prior to age 60. Wmmmm 'misriskfactorwillbeidentifiedbythequestim, "Misha perimenopausalwunan (age 40-55) presentstoyouroffice foraroutine healfllmintemnoevisitdoyouorqustaffrurtinelyinquireasto the causeof death of family manbers?". CINCEPI': mm; 'Ihenextca‘nepttobediscussedistheeffectofd‘lolesterolin temofcardiovascularrisk. Inthereportoftheexpertpanelmmetectim,mraluatim,and Treatmm‘ltoffiighBloodclolesterolinAdults" coordimtedbythe Natianlfieart,1m1g,ardaloodmstiuitein1988providescmprehersive datatosumorttherole‘oflcwnensityiipoproteins (IDL) inCorrmary Heartnm (Crib). Severalstudiesanalyzedbythepanelpointtothe steadyircreaseindevelopnmtofcminmenmdmstratedhighsermn dnlesterollevelsoversixyears. 31 'nieisSLleofvtletherormtlcweringtheIDLwollldhavea cardioprortective effectwas the focus of ten randanized clinical trials. 'mesetrialsimludedplaceboversusdiolestyramineandotherlipid lowerirgdrugs,anddiettherapy. Followupbyargiografiiyproduceda statistially significant reduction in athercma femtim as well as redxtimofcoruarya‘ulerosclerosisinmenwiulcorunrybypassgrafts whoincluleddiettherapyinthetreatmentregime. (Blankenhorn,Nessm, Jainism, Sanmarco, Azen, W1, 1987, LipidReseardl Clinics Prograns, 1984, Delong, Delong,Wood, Limel, and Rifkind, 1986, Castelli, 1986). Inspiteofthelackofwuneninthestudies,thereailtshave bemgeneralizedtoallirflividdalsintemsofscreeninggtfidelims, evaluation, and ‘treatlnent of high blood cholesterol. Saneoftherecmnendatiaisoftheeocpertpanelirclude: l) 'Ihetotalcholesterolahmldbemasureinalladnltszo yearsofageandoveratleastmceeveryfiveyears. 2) Patients with desirable blood dlolesterol (<200 Wdl) stmldbegivmadviceardedmatianlmterialsmthedietrecamerfled forthegeneralpopnatimandadvisedtornveanothersenmdwlesterol testwithinfiveyears. (ReportofthebpertPanelanetectim, Evaluatim, and Treatment of High Blood Cholesterol in Adults, 1988). 'misreportthendetailsothermethodsofanalysisandtreatnent inthepersmwithhighblooddaolesterol. aneagain,womenwerenot cmsideredinthetreamentcdlortsorrardanclinicaltrials. ‘nlelackoftestingthehypothesisofircreasedriskof aniiovasculardiseaseduetohighbloodcholestemlinwanenis 32 disturbing. 'meresear'dlindicatesthatthismaymlybeaproblanin nenduetothewerahnriameofinfomtimutilizingmmassubjects andthepaucity of info-atimregardirgwmen. 'Ihismay falsely lead fliepractitiaertobelievetlntdnlesterolscreeningismtinportant in wunen, especially perimencpausal wanen. Wefttsm Screeningfordlolesterollevelsisdefinedasarqrtine evaluatim for serum cholesterol . mmemm 'misriskfactorwillbeidentifiedbytheqmstim, "Ma perimempausalwanan (age40—55) presentstoyourofficeforarwtine healthmaintenancevisitdoymoryourstaffroutinelyorderaserim cholesterol?" W: mm Diabetesmellitusisacmfamdingfactorintheanalysisof cardiovascllarriskfactorsforthedevelqnentofcvn. 'Ihereeeuto bethreemjorareasinmidldiabetescanomtrihrtetocoruuryartery disease. ‘mefirst,asdisamsedbyYamg,Iopez,ardmra(l988), relatestotheabsorptimofdietarydiolesterolanidlolesterol synthesizedinthesmallintestineofdiabeticrats. Diabetesmellitlls mycartributetomryaxtezydiseasebyhypemngiabmehtmby the insufficient metabolism or "starvatim effect” of diabetes mellitus. 33 niesecmdhypotresisrelatestotheerfectorctmiicdiabetosm myocardial oellmetabolismand insulin sensitivity. Barrett, Schwartz, Yamg,arr1Jacws(l988)smdieddogsinrespecttothefreefattyacid cartent ofthemyomrdiumafter infusions of insulin, fatty acids, and nonnalsaline. mesmdyfomithatcaidiacmscleismarkedly resistant to stimlatim of glucose uptake by physiologic canartrations ofirsulin,arflthisresistancecarmctbeaccamtedforsolelybyhigher levels of anbient fatty acids. 'nlerefore,withtherealltantirurease infreefattyacidsfomflinthediabeticpatients,theheartwill suffer an increase in fat proliferation of the myocardium. 'Ihis is an animalstlldy,thetrueresultsinmmansaremtlcmcanlusively. 'Ihethirdhypothesisrelatestoenharmitofplatelet aggregatim by low density lipcproteins in patients with m (Watanabe, Wd'iltman, Klein, Cblmll, arr! Icpes-Virella, 1988). Inzreased platelet aggregatimhasbemstmnindiabeticpatientsevmvmentheirplama lipid levelsarenorml. 'nms,althou;hplasnalipoprotein levelsmay playamleinerhancirgplateletaggregatimindiabetics,theremybe otherfactorsaswell. Matthews. Diabeteshasbeenehowninanimalarfilnmanstudiestooontrihrte totheriskprofileforthedevelopnentofcoronaryarterydisease. misoatributimmybeinthefomofalteredfatmetabolism, Woffliemyocardimdletoahwrmalnetabolism, and/orincreased platelet aggregatim. Basic screening for diabetes mellitus is the evaluation of the fasting blood sugar m a yearly basis. 34 MMQMQEM 'mequestimusedtoidentifyifscreeningisdonsfordiabetes reads, ”Maperimenopausalmn (age 40-55) presentstoyouroffioe forarartinehealthmintenamevisitdoyouoryourstaffrurtinely order a fasting glucose level?." W: m amidngisamajorriskfactorforcardiovaswlardisease. Nicotinemycmtrihrtetothemgniufleamthefrequemyofreversible myocardialisdianiaincormaryarterydiseasemermitz, 1986). anolcingacigaretteoraninfusimofnicotineactivatesthe synpatheticnervwssystan(¢ryer,l~layna1d,$antiago,&8hah, 1976). In healthypeople,thisresultsinanin:reaseinheartrateaniblood pressure,cardiacstrokevolmeandartput,andoormarybloodflow (Nicod, Rent, Winniford, oanpbell, Firth, & Hillis, 1984). Other diangesinthevascdlarsystemimluieaxtarmlsvasocnlstrictim, associatedwithadecreaseinsldntaiperature,systenic venocmstrictim, and increasedmiscle blood flow (Fremcl andWard, 1960). Circulating free fatty acids, glyoerol, andlactate mumsmcrease (Benowitz, 1986), cmtributimtotheatherana fomation. 'nms,thefactorsrelatingtosmo}dngarricardicvasculardisease seantoberelatedtoincreasedirritabilityoftheanteriorwalls, increasedbloodflow,aswellasanircreaseinriskofatheruna fomtim. 35 Wfimm Althoughthestudiesciteddealprimrilywithmen, itcannortbe assmedthatwunenareimmtotheeffectsofnicctine,aswellasthe pllmmaryeffects of smoking. therefore, cigarette smoking, regardless oftheammtofcigarettesperday, iscmsideredariskfactor. WMQWM: 'nlequestim'Wmaperimempmlsalvman(age4o-55)presentsto yumofficeforamrtinehealthmaintenancevisitdoyaioryourstaff rwtirelydotainaamldnghistory?"wfllmeasmescremhgforanoking behavior. CINCEPI': mg; 'Ihe ratia'iale and cardiovascular inplimtims for reducing cholesterol inthediethasbeenpreviouslyestablished. 'IheExpert Panel on the Detectim, Evaluation, and 'I‘reatnent of High Blood Cholesterol in Adults (1988) identifies three dietary habits that cartribute greatly to the develcpnent of elevated plasm cholesterol. Firstisthehighintakeofsaulratedfattyacids. 'Iheaverageintaloe is 13-15% oftotal calories, butmnyAnericanscmstme 15-20% oftheir calories as saturated fatty acids (pg. 29) . 'Ihe second "bad habit" is a relatively high intake of dnlesterol . Many patients with high-risk iDL cholesterol levels exceed the current average intake of about 350-450 liq/day. 'Ihirdly, acaloricintakethatexcesdsthebody'sdanandcauses fat storage. cholesterol intake should be less than zoo mg/day. 36 madam Altlnlghthedoannentatimismtreported, thisstudywill imludeahighfatdietasariskfactorforcormaryheartdisease. mmmmm 'Ihequestion: "Maperinenopausalwunan(ages40-45)presents toyourofficeforaroutinehealthmaintenancevisitdcymoryour staffmrtinelyobtainadiethistory?"willevaluateifscreeningis beirgdone. W: Wise 'mecmpletepattngeresismdtreatmentofhypertensimisbeyafl thescopeofthisstudy. miever,abriefmrlerstandingofthe pathophysiology of hypertensim in relatim to myocardial ischania is essential. Brush, Cannm, Schenke, Bmcw, Ieon, Maren, andEpstein (1988), studied a group of 12 hypertensive patients with clinical cmplaints of chestpain. 'nlehypertensivegralpwithanginahadsignificantlyhigher meanarterialpressmeandsystanicvasollarresistameirdextlnnthe normortensiveccntrolgroup. 'nlereseardiersconcludedthatanginal diestpainmaybeduetomyocardialisdlaniainhypertensivepatierrts, tintthenedunimrespmsibleforisdlaniaardrestntingangimappears tobeanah'nmallyelevatedresistametocormarybloodflowarxithat theincreasedresistanceocansinthecormarymicrocirwlatim. 37 Aproblenwiththisstudyisthat 50% ofthestudygroupwasmale, andéo% ofthecartrolgroupwasalsomale. lidlenstein, Steels, Hoehn, Bilpitt, and Coles, (1989), analyzed datafruntheBritidlDeparUnentofHealthandSocialServioes HypertensimCareCalprtiJngjecttosbxiydeterminantsofvisit frequencyinhypertersimmnaganent. 'Ihestudyresults indicatethat physicians are attaipting to control hypertension, especially when the diastolicpressureis>104. 'merearemnytechnicnltroubleswiththis suldyinterneofabilitytoexplainvariances, what lmgerorshorter intervalsreallymean, etc. Itdoessuggest, however, thatincreased mitorin; activity istakingplace. 'Ihe risk of cardiovascular calplicatiors related to hypertension increases cultinnlsly with increasilg levels of both systolic blood presalre and diastolic blood pressure (the Joint Natimal Committee on Detectim, Ewaluatim, and Treatment of High Blood Pressure, 1988). WQSM Itiswelldoannentedthathypertensimisamjorriskfactorfor thedevelopnentofcardiovasculardisease. Bothoverandmldertreaunerrt cartroversieseldstandarebeyadthescopeofthispaper. Screening inthefomofmeamingthebloodpresanewithasplygnmenaneteram steuwsccpeisinperative,ashasbeendoamented:tlms,theratiomle fortheinclusimofthisriskfactorinthesmdy. 38 mmmmm 'Ihequesticn, "Mapuiuempausalwunan (age40-55) presentsto ymrofficeforarartinehealthmaintenarcevisitdoymorywrstaff rcutinelymeasure blood pressure?" will evaluate screenim for hypertensial. W: my mequestimofobesityor"cverweight"isnctvmetherornotthe extrafatcreateshardshipsforthecardiovascllarsystan—itis finding a siuple definition of obesity or overweight. Obesity refers to aneucessive accumlation ofbodyfat. Inmost individuals, thesebdo calceptsarerelated;hmever,definimthepointatvmid1ircreased weight er body fat is labeled "overweight” or "obese" is at best ternlous. ‘IheNatiaialertitlrteofHealthCa‘lsensusPanelmluied flntzzotwerweightimreasestheriskfordiabetes,hypertensim, lipiddisorders,arricardicvasculardisease. 'nlerminimquestimiswhatmtimtesnomlbodyweight? 'Ihe Metropolitan Life Weight Tables of 1983 have been criticized by sane duetothelackofca'rtrolinnethcdsdeterminimvmatthe"ideal"may be. 'Ihemtropolitan'rablesaremtcorrectedforage,ardrepresent ally specific populations (airman, 1988) . Sane other difficulties includeamomrtofclothimmrnbysubjects,differencesintimeofday ofneasuranents,andinequalitiesbetweennenandwmen. Saneauthors suggestthatperhapsneasuemerrtofbodynessmaybemoreacalrate; Inlever,alceagain,thebodymassmeasmentsthatpredictdisease remainurflmown (NIH, 1985). m (13% the we 39 Worm Althoughadefinitim of obesitydoesnorttruly exist, forthe pnposesoffliissuriy,neasmelentofmightirdicatesanmrenessm thepartoftheproviderfllatincreasirgwimtposesathreatforthe develqnentofcardiovasallardisease. mwemm 5F 'Ihequestim, "Ml-maperinenopausalwmen (ages40-55) presents toyun'officedoyuloryourstaffmighthepatient?"mllindicate thescreenimbehavior. omcspr: germ 'Iheroleofexerciseinthepreventimofheartdiseaseismt cmpletelymderstoodrhcwever,thereu.tobeafewprevailim theories. Vbod(1988)cmtendsthate>aeroisecausesalossofbody weight,anicasequentlytheremybeadecreaseinplasmalipoproteins. W(l988)tookagrwpofsedentarynenanienrolledthemina diet-oartrolledeorerciseprogram. 'nledietcmtrolwasintroducedin attmttoseparatevmethertheexerciseorthedietcausedanincrease inthemLompment. Hisresultsshowedthatintense,prolalged exercise (statimary bicyclirg five times aweek for onehcur at 80% of fliepredeterminedmximmheartrateoverathreemmthperiod)causeda 13%averageincreaseinI-Im... Abbott, levy, Kemel, Castelli, Wilscm, Garrism, arriStokes (1989) evaluated CardiovascularRiskFactors inI-Iealthy Adults aspart l5? fa: i3? 4O oftheFraminghamdata. ‘lheyfound, asvellasdidtheooronaryprimary Prevertia'l'lrm (1983), that cholesterol levelswere lowered, blood pressure was lowered, and insulin sensitivity was increased with exercise. nearbjecteofthef‘ramirghamsmdyweremtexercisedas rigorouslyasthosein'nmpsm'ssuldy. 'Iheenerciseconsistedof treadmillwalkimwithgradualincreasesingradearrlspeedofthe treadmill. MsKeag (1983) recanmends anexeroise prescription that includes a frequencyof 3-5timeeperweek, intesiveernlghtoallwthepatient toachieve 60-90% oftheirmaldnnnpulserate, 50-80% ofthemaximm aerobic capacity, and duratim of 15-60 minutes (ca-minions) to achieve fitness. mam 'Ihe relatimship between exercise and the lowering of cholesterol levels iswell dchmIented. 'lheories of enhancement of well-being, weightless,aswellasmsclestremthenimalsoeidstbutareharder toquantify. Forthepurposesofthisstuiy, lackofexaroisemeans failure to engage in aerobic activity (walking, swiming, ruming, cycling) fortwentymimrtesatleastthreetimesperweek. Wilflmmm 'Ihequestion, 'thaperimexopausalwunan (age40-55) preeentsto youroffice forarurtinehealthmaintermlcevisitdoymorymrstaff routimlyaskmeulerornotthepatiertperfornsaerobicactivityma 41 regularbasis?"willmeasurevmetherormtscreeiimisocalrrimfor exercise. OWCEPI': MAM Streseasacalceptisdiffiallttomeaalre,quantify,anidefine. 'Ihe focus will be the definitim and inclusim of definitiam of Type A behavior. 'me'IypeAbehaviorpatternhasbeeiexteIsivelyreeeardiedard reportedintheliterature. 'meomponentsofthisbehaviorpattern include the entrees of carpetitive striving for achievement, hostility, time urgency, aggressiveness, vigorous voice, and denonstrative psydnnetermannerisms (Mathews, Glass, Roseman, Bortner, 1977). 'menaninghansmdy (Haynes, Feinleib, andKannel, 1980). dmmetratedarelatimehipbeweelflleimidemedprevaleneofthe IypeABehaviorPereeialityardtheincidelceardprevaleiceofcorelary heartdisease. AllenarriSdleidt(l988)reportedmthecartrovereyofwhether 'IypeAbeiaviorisariskfactorincardiovasallardisease. Raglandard Brard(1988)slnoedalowermrtalityrateammgthelypeApersm deustratimamerardhostilitywmomparedtothenoreagreeable, calmer Type B personality in a follow-up to the West Collaborative Study. 'mecmtroversystensformmnytedmical difficultiesinthe researchofRaglandaniBrand. Saneoftheseproblenscamotbe overoaneinviewoftheretrospectivenatlreofthecriticisn. 42 'meissueofiypeApersaalityisatbestomplex,arfidimensims oftheoanept,a:d1asaggressiveness,rnstility,andtimepresmre ameartohavedifferentoamotatimstodifferentreseardm. 'IbaddmmimtoflxebodyoflmwledgeomoenfinglypeA betmviorarxioormazyartaydisease,ameta-analysisof833t1flies relatirgtlnseomoeptswasWtedbyBooth-Kewleyandftiedman (1987). Notaxlywas'lypeAbehaviorlinkedtoanirmeaeeinrisk,hxt depressimaleoameazstoixmeasethatdaanoeofoora'azyheart disease. 'nxereameeveralquestiamimsandintetviavtedmiqmsdesigned tohringcut'rypeAbehaviora. 'mestmcturedintezviavisazommrte interviavrequiringahighlyakilledintexviewertoobtainthe W infomatim (WES, 1960). ‘Ihe Jeanns Activity Survey, developeddurirvgtheomreeofmwasdevelopedasaneasybto- administerpencflarfipapertesttoassessfor'lypeamaavior. However, ashllanandexeidt (1988) point mt,thephysioal attributes andmanoeedaaracteristicoftypeAbehavioroannotbemeamned. 'Ihe Emingtmstudymamel,l980)usedalsitemquestimiretomeam Wm. Asoanbeseenbythisbriefdiswssim,themed1animfor assemltoftypeAbehaviorisextzmelydifflmltardeeamtousea nfltidieciplinary as well as mlti-instnmerrt approach. mam Inmzy, forthisetudy, theasamptimismdethatdmxging life events camse different reactims in different people. Negative 43 reactimsintemofhostilityormgerpredisposeflwseirdividualsto arelativeriskofooruaazyarterydisease. 'mefrequmcyofthese reactimsmayberelatedtotheriskofcvn. 'Ihatis,themore explosivethe irdividual, thematrisktheindivicmal. MMQMM 'meclinician'sawarenessfluat charging lifeeventsandstrong reactiautothosedmagesmaybeomsideredariskfactorforcvnwill bedmastratedbyanaffirmativeanswertotheqnstims: "Whena perimenopausalwunan (age 40-55) presentstoyouroffioe foramrtine healthmaintmamevisitdoymorymrstaffrartinelyaskabartmajor life changes (new job, loss of job, charge injob, additimorloss of childrenand ...) Doyouimrestigate attitudestowarddmage?" WWW: MRZOOOOBJECI'IVESFW'H'IENATIW (Dr-aftforPublicReviewardcmment-HB, 1989) Since 1987, the mblic Health Service (FEB) hasbeen interaively hmlvedintheoversiglrtanddevelopnentofobjectives forthenation inrelatimtopreventingdiseaseandprunotirghealth. 'Ihedrai‘t, available since 1989, is aoaupilation ofexpert input andreview of over7,000individualsardgru1ps. 'metargetedpriorityareasexparfl ardrwisethelQQOobjects. "Inadditim, them'aftobjectivesaredlaracterizedbyan ircreased amnesia m preventim of disability and morbidity, greater atterrtim to inpmvarerrts in the health status of definable pqmlation gramsathighestriskof pramture death, disease, disability, and 44 inclusimofmrescreexfinginterveutiazstodetectasynptmatic diseasesarflcaflitiaaearlyemnlghtopmeventearlydeathordnmic illness" (ll-15139.1). 'lb facilitate evaluatim of these objectives, each priority area isorganizedirrtofiveparts: 1) Healthstatus-targetstorflxcedeaflndiseasmmfi disability. 2) Riskreductim-targetstoreducetheprevalenceor imidentsofriskstobealthortoirmeasebehaviorshnwntczemwe stashrisks. 3) mblicwareness-targetstoixcreasepsblicawamxess abatthealthrisksard/orammpriatepreventiveinterventions. 4) Professianleducatimandawareness-targetstoimase themmbersofprofessianlsawareof,trainedtoprovide,aminscne casesprovidingapprcpriateirrterventias. 5) Servicesandprctectim-targetstoixm'ease cmprehensiveness, accessibility, and/or quality of preventive services ardprctectiveirrterverrtims. Of thesewjectives, professimal educatimaniamreness are criticaltothisstudy. Eadxobjectiveattalptstoprovidebaselim datatogiveabasisforneamranentofmccessinmeetimthe objective. Ashasbemstated,manyofthesedojectivesdomthave baselinedataatthistim. Saneexanplesare: 0811.18 ImreasetoatleastSOpercenttheproportimofprinery careprovidersmoprovidemtritionalccm'selingard/or 033 15.21 CRT 17. 18 OBI 19.15 45 referral to qualified mtritimists and/or dieticians. (Baseline unavailable) pg. 1-20. Measetoatleast75percenttheprcportimofprimry careproviderswhoinitiatedietand/ordmgtherapyat levels of blood cholesterol that accord with current treatment recannendatims. (Camarable baseline date unavailable) pg. 15-5. IrmeasetoatleastSOpercenttheproportimofprimary careprcviderswboreceiveperiodictrainingorcartiming medical educatim in current cmcepts of diabetes care and management. (Baseline data unavailable) pg. 17-6 IrmeasetoatleastSOpercenttheprcportimofpecpleage 18andoldervmoarequestimedroutine1ybyprimarycare providers about their mental and mticnal health, imludjng scurcesofstressandcopingskills. (Baselinedata unavailable) pg. 19-5. Smedajectivesdchaveatleastsanebaselinedata: OBI 3.8 Increasetoatleast75percenttheprcportimofall primrycareprcviderswhomxtirelyadvisecessatimof snokingandpmvideassistanceandfollw—upforallof theirtobaccousirg patients. (Baseline: About 52 percent ofintemistsmortedccmselimmorethan75percentof theirpatients about sucking cessation in 1986) pg. 3-4. 46 misstudywillattenpttoexaminehowadvancedpracticemnses evaluate periwwausalvmenforriskfactors zelatedtocazdicvaswlar disease. AphysiciangzuzpinGenesee,Lapeer,andShiawasseecamties arealsoincludedtodescribelocalpracticepatterns. Itishcpedthat thissmdywillbegintopmovidesane'baselimdata"bywhichto evaluate the objectives of the natim. mxmwm Inmry,theliteramrepertainingtothissmdyisquite variedinrelatimtovmetrerperinerqamsalmarebeingscreenirg forcardicvaswlarriskfactotm. Ashasbeeneham,doam1tatimendstsinrelatimtnwhata perimenopausalstateis. merearemmermsreasmsforscreenirg. Riskfactorsforcardicvasculardiseasearefairlywelldocmrted. One oftheinlwrentdiffiwltiesforthePrimaryCareminiciancanbe deducedfrantheeodmastiveamamtofliteraumefamdmgardingrisk factorsandscreeningpractices. Matisclinicallyrespomible? For thenrposesofflziss‘bximtherecmneniatiasofthemitedStates WiveSezvicesTaskForceaswellasthepreviwslyreviewed literaumeinrelatimtoscremimforcardicvasmlardisemsewillbe usedtoidentifymetherperimencpausalmarebeirqscreened. QIAPI'ERIV mmmm mas: misdxapterpresentsthereseardidesignandmethodsusedto guidethesmdy. 'Ihedata collectim procedure, operational definitims, scoring, reliability and validity, analysis of data, and protectimoflnmnrightsaredescribed. 'misdescriptivestuiyexaminedtheextenttommprimrycare providersassessperinerxpausalminrelatimtothemn's cardiovascular risk profiledmingthemltimhealthmintenancevisit. Criteriaforscmeningpncticesmascertainedttmlghareviavof theliterauueardtheuseofthe”GuidetovaentiveServices"(ms 1989). 'megoalofthissuadywastodescribethepracticepattemsof advancedpracticemrsesacrosstheStateofMidiigan,aswellas, medicaldoctorsintheTri-cctmtyareaofsenesee,lepeer,arfl Shiamsseecamties. Alfinaghthereseardiquestimsrelatetoprimry careprcviders,thedecisimwasmadetoreportrespmsesasseparate groups; and, if possible, identify any differences and similarities betweenthegroups. 47 48 W Aself-administeredslmreymsdevelqzedforthissuadymidi incluied forced-dwice, closed-ended, and an open-ended item. Before darelopirgtheinitialqmstimire,recamendatiaafzmflxegiggg W m, (FEB 1989) ani the literahn'ewere synthesized. Questimsweredevelcpedfzmobservatimofacwalpnctice. 'Ihus,the questiasforthesmveycanistedoftnogruxpsoffactormthosethat aresugaortedby‘uieliteram,ardttnsethatarerntsu;portedbythe literahxremtmaybeusedinpractice. Finally,theopen-ended questimwasutilizedtoprcvidearidierdescriptimofacmal practice. 'mesequestiasweredesignedtoansmrtheoverallquestims addressedinthisstudy: mmmycareprovidersperfmarisk Muimperimalm(m4o-55)fcrardiavascflar riskfactcrsdn'irqtheruxtixahealthnintamnevisit? matarethe facbazsassessed? Screening for cardiovascular risk is operatimalized by specific questicns m the imtrument (Appendix B). ‘Ihese cperatimal definitions oftheiniividualriskfactorsmpportedbytheliteramewere identified by specific questions as follows: SUPP SUFEX offic offic affim 49 WW: mmgwm 'Ihequesticm: "Maperimenopausalwunan(ages4o-55)presents toymrofficeforarmtimhealthmaintenancevisitdoymorymr staffrwtinelyinquimastothecwseofdeathoffamilynanbers?" representsthefamilyhistoryriskfactor. Apositiverespa'neon questimZindicatedthatflaeparticipantmrtimlyaskedabmtfamily history. WW: mm Mquestionsrelatetoscreeningfordiabetes. 'Iheseinclude: 1) “maperinmmmalmn(ages40-55)pmesentstoymr officeforarwtinehealthmaintenamevisitdoymorymrstaff my weigh the patient? (question 1) 2) Maperimencpausalmn(ages40-55)presentstoymr officeforamrtimhealthmintenamevisitdoymorycurstaff routinely order a fasting glucose? (question 11) Affirmative answers m these questims indicate that screenirg is beingda'ue. WW: m Screeningfcrsmoldngisindicatedbyanaffirmativem relatedtoobtainirgasmcldnghistory. 'Ihisisrepresentedmthe smeyasquestima. WW: Meier; Qaestimllrelatedtoneamrementofbloodpressme. An affinetiveanswertothisquestimirdicatedsczeerfingtnsocan'red. 50 WW: mm 'mequestim:"m1enaperinmnpwsalwunan(ages4O-55)preserrts toyun'officeforarmtinehealthmaintenancevisitdoyworyar staff routinely weigh the patient?" represented the variable of obesity. Affirmtiveanswerstofliisquestimirdicatedttntthisscreeninghas beendcme. Wm: mmm Questim7relatedtoe0m'cise. Apositiveanswerihdicatedthat flaeparticipantmxtinelyscremsperinempausalwunenforasedemary lifestyle. Wm: Ems Screeningforstressandreactimstostresswasrepresentedbyz questicns. 'mefirstquestim(7)askedabcuthetherormtthe participarrtrcutinelyaskedabartmjorlifedzanges. 'lhesecmd questimaskedifflaeclinicianimestigatedthemn'sattiufletcward change(8). Affimtiveanmersmthesequestions ixflicatescreening forstress. quortedFactor: mm Questiml4mlatedtomornotthecliniciancrdersasenm cholesterol . An affirmative answer irdicated screening for this risk factor. Nm-amtedmtms: Severalotherquestimsmreaskedtoinvestigatemtother factorsaclinicianmayusetoscreenaperimencpausalvmnfor cardiavaswlardisease. the] Mme ..ue. m. We 51 Altlnaghthesefactorsmaymtbesumortedbytheliterature, cliniciansmyusetlmduetocawenienceorecamicreasms. Affinnativeanswersmthesequestims (5, 9, 12, 13, 15, and16) was listedasbeimdme,b.rtismtrecognizedasascreenimfactor Whyttnliterature. 'nieopen-endedquestimwasalsousedfor thepzrposeofprovidiryaridxerdescriptimofacmalpractice. W: Mybeusedtolockforvaswlarquessuggestiveof hypertensicn, arddiabetesmellitus. W: mybemedforlocldrgforventrimlarsizesecmdarytodarmic hypertensim, andpatientexpectatim. W: Maybeusedforscxeeningfordiabetesmellimsdneto availability ofthepatient, i.e., fearthatthepatientmymtreturn forfastirgwork. Best-MM: Maybeusedforscreeningfordimnellimssothatthe patientwclfldmthavetoreurmforfas'tingmrk. WMMM= Maybeusedtoscreenforhyperdaolesterolaniaforecamic reasms, i.e., maybeecoxmicaltoperfom "batch" testing, ratherthan individualtests. a. E- fill 52 mm Apilctsuflywascariuctedutilizingsmersofthepotential stuiygrtmp. AClinicaISpecialistinCardiovascilarNursirgwasalso utilizedfcrheraqzertiseinrelatimtocardiovasmlarriskfactors. Eadipilotsuadyparticipantmspersmallycontactedardreqmstedto fillqrtthepilotsurvey(seeAppe1flifoorsurvey). 'merespondent wasalsoaskedtoevaluatelengthoftimerequiredtocmpletethe anvey,useofcolorforthesurvey,cmstructim,andccntent. ‘Ihese respadentsdidmtparticipateinthefull-scalesmdy. Afterthepilotsbadywascmpleted,thequestiamairewasrevised toincorporatemggesticmamcannentsobtained. memestothesurvey included wording, clarification of questicns, minorchanges inthe cover letter,arridemografixicsectimofthesurvey. ‘mepapermwhid1the sunveywasprintedmsligrrtlaverder,ardallagreedthatthis facilitates identificatim ofthesurveycmabusyclinician's desk. 'naeccverletterwasrevisedtoixcludeasectimthatallandthe participanttorequestresultsofthestudy. ‘menursesletterwas diargedtorequestdenngramicdatammnseswhodonotparticipatein thecareofperinenopausalm. 'mecpen-endedquestimpertainingto otherfactors (tmserntsugportedbytheliterature) cliniciansmayuse toassessperimempausalmwasfocasedtocardiwaswlarriskfactor assessment. 'melastquestimrelatimtomnmerofperinencpausal mamintheofficewasdmarqedtospecifyfiormrtimhealth maintenance." 53 'mefimlchraftofthesurveywascmpletedafteramrcvalfrm malbersofthethesiscanmittee. ‘mestudywastheninplanented. azaleas; napcpalatimutilizedinthissuflyccnsistedofcertifiedmrse practitimersintheStateofuidiigan,ardnedialdoctors, Walking in interval nedicine, family practice and cbstetrics/ gynecologyinGenesee,Iapeer,andShiawasseechmties (11-577). 'Ihe unsesinthestudywereselectedfranlistsofcertifiedmrse practitiaxersdrtainedfrantheuidliganNursesAssociatimandthe StateBoardofNursirgforMidiigan. 'melistingsfruntheseagencies mlyidentifiedthatthemrsesareinadvamedpractice. 'Iheareaof specialtywasnotavailable. 'Jherefore,allcertifiedrn1rse practitiaxerswerecmsideredpotmtialparticipantsardsentflaeccver letterandsmveym-Bel). flheflxysicianswereselectedfrunthelSBQteleghcnedirectories specifictotheccunty. Directorylistirgbyspecialtywasusedto develcpthemailinglist (11-196). niefi1ysiciansweretlmsentcover lettersandthesurvey. Familypracticeandintemalmedicine fixysiciansarecmsideredprimarycareprcviders. Obstetrician/ gyrecologistswreutilizedbecnusemfreqmrtlyuseflmasprimry careproviders. ‘nieintentinselectimthiqunlatimwastofacilitate identificatimofpracticepattemsbymnsesinthestate,m:ever, sincethe(n)ccu1dnctbe accurately predicted, thephysiciangrcupwas 54 selectedtoallowidentificatimofpracticepatternsinthe researdier'sgeographiclocatim. Self-selectimbiaseadstsinthisstudy. Nurseswere specificallyaskedtoself-selectbyfillirqoutthedanographic section ofthesmveymlyiftheirpracticedidmtimludeperiwrpausal m1. Welenentofself-selectimmaybepresentinthesmdy. mysiciansarrimrsesthatrespomedmayhaveanactiveinterestin cardiovasculardisease, ardmynctreflectthetruepracticeofthe population. megfmm 'mevalidityofaninstnmentwasdefinedbymlitandmmgler (1987)asfl1e"degreetomid1aninstrmentmeasuresmatitis axpposedtobemeasm'irg“ (p. 323). Inthiss‘tudy,cmtentvalidityis themstinportantsimethedesignofthesmveywastodescribe lowledgeinaspecificcmtentarea; cardiovaswlarriskfactors. Catterrtvaliditywascmcemedwiththesanplingadequacyofthe cartentareabeingmeamredwclitardmmgler, 1987). Sincethereare no ijectivemethods formeasuring cartentvalidity (Polit andHngler, 1987),ca:ta1tvaliditymfldthereforeneedtobejuhedbyexmnining themethodsusedtodsvelmthequestimsusedinthesurvey. Inthis sundy,eaq:ertsinthecmtaxtarea,aswellas,cliniciansineveryday practicewereaskedtoidentifyvmeuierorncttheitansmthemey adequatelyaddressedtheissues. 'medevelopnentofthequestionsmre 5’. did 55 basedmathoraaghliteramrereviewandvalidatedbythepanelcf experts. Facevalidityiscunemedwithuhetherormtaninstnmrtlooks lflceitisneamringmaatitpuportstomeasm'e. 'Ibsbady professimals,thisisinportanttoobtainparticipantcocperatim. 'Ihe surveymsdesignedbasedinpracticeguidelihesardpractical experience, andpilct testedto assure credibility. 'mereliabilityofaninstrumentisthedegreeofca'sistencywith midiismeasurestheattrimteitismpposedtobemeaming(Polit arrlnurgler, 1987, pg. 316). the KR-zo forthe 10 screeningbehaviors exportedbytheliteratmewasfié. Allpractiticnersassessed mdcirrg,bloodpressure,ardmight,causingmvariabflityduetothe dichotmaschoiceswesorm). Variabilitycmldhavebeenircreased bytheuseofamlcertdtypescale. mm fixesurveydatainthisstudywasobtaihedusingbcthforced- choice, close-eldedquestims,andancpen-endedqmstim. 'Ihepurpose oftheforced-dnicewastoammagetheparticipanttomakeadecisim regardingher/his"mrtim"practice. 'mecpen-endedquestimmsused toprcvidearidier,mredescriptivebasefranwhid1todescribe practicesnifacilitatedevelcpnentofissuesnctaddressedbythe closed-endedquestims. Severaltedmiqusswereutilizedtodecreaseerrorsrelatedtc instrulmatfomat. 'meseincludeduseofacolorfortheinsmment ‘5’ fa 1214 a: 56 thatwaildnctbecmmmlyencamteredintheparticipantsumal practice, i.e., energencyroanreports, labresults, historyform, etc. Mostquatimswereclose-ended. 'Iheopen-endedquestimwasusedfor descriptivepnpoeesafly- 'Ihesurvey,coverletter, (printedmlightlavenderpaper) anda self-addressed, stanpedenvelcpewereneiledtothepotential participants. (neweeklater, armindermte,writtenmthesame lightlavenderpaper,wasmailedtoallpctentialparticipants. ereceived,cmpletedsmveysweretrmseparatedaccordingto thesub-sectimofthepcpulatim. N'urseswhoixflicatedtlnttheydid mtparticipateinthecareofperinempmsalmwerecodedmtoa separatepredesignedcodingsheet. Nlmseswhocaredfcrperimencpausal mumsortedandcodedinthesmnemmer. Resporsesthat indicatedtheparticipantmsafixysicianvaresortedardcodedmtoa thirdpredesignedcodingsheet. (noeallofthequestiamireswere sortedanicoded,theresu1tswerefl1enenteredimoapersanlcmp1ter utilizixgthemmblicnmeinwordprocessingsystan. 32% m: Eadusub-groupingofthepopilatimwascodedinaspecific fashion and placed in separate files. the first three digits identified the particular questimire. The identification codes do not represent a particular provider. fa @mmmm memwmwm Q m 57 Screeningfactorsthataresupportedbytheliteramre (supported factors) (1,2, 3,4, 6, 7, 8, 10, 11,14)weregivennonimlvalues of 1 if answered affirmatively, 3 if answered negatively. Factors not supportedbythisliterature (run-supported) factors (5, 9, 12, 13, 15, 16)weregivenananinalvalueof2. 'mefunctimofseparatingthe rum-supported and supported factors was to facilitate the identification ofotherscreeningfactorsthatmaybeusedinthedescriptimof practice. 'meanswerstotheopen-afiedquesticnswereemmeratedas designatedbytheresparlertt. Fbraanple,ifarespaderrtwrotein cm,thencmwasgivenarminalvalueofleverytimeitamearedma survey. Ifaresparlentwrotestress—test,tlmstress-testwasgivena valueonead‘xtinestress-tes'tamearedmaamrey. Noattanptwas madebytheresearcl'sertointerpretthewrittmcmments. Denngraphicdatawascodedutilizingancmimlvaluesystan appropriatetotheparticilarsub-groxp. Ftreoanple,mrseswho providecareforperimopmsalmfflledartthedemgraphicdata andwassorecordedman. 'Ihemrsesmmodonotprovidecarefor perimenopausalwmmwerecodedinasimilarfashimandplacedinthe ategory (NR2). 'Ihepaysiciangrmpingwascodedagainutilizing noninalvaluestorepresentdanographicinformtim. Waiters: Severalstatisticaltedmiqueswereusedtoanalyzethedata: freqiemy distributions, means, stardard deviations, chi-squares, variances, apooled T-test, andpercentages. Statisticalprocedures 58 usedmthedanogramicdataircludedfreguencydistributims, peroentagesandmeans. 'mefowsofthisstudywastodescribenhatfactorsprimarycare providersusedtoscreenperinenopausalvmmforcardiovaswlar disease. And, sirnethissuadydescribesactualpractice,versus idealizedconditimsrecessaryforresearda, itispredictedtlntthere willbeadiscrepancybetweentheprimrycareprovidersuseofthe supportedfactorsanima—suppcrtedfactcrs. Forthisreascn,useof 50%ofa1ppcrtedfactorsiscmsideredscremingforcardiovaswlar disease. Mmefmnm 'merightsoftherespa'rientswereprotectedinseveralways: 1) Adherernetotheestablishedstarflardcriteriadsvelmedby themiversitycmmitteemneseardinwolvingflieUseofmmanSubjects (UCRIIB). Wofthel‘nmnriglrtsproteotimprocedureswas WbymmOZMDSO. 2) Wityforthesubjectswasguaranteedbythelackof iderrtifyimfeamresmthesurvey. 'meladcofidentifyirgdataforoed thereseardaertoneiltheminderstoallpotentialparticipants. 3) Abriefexplanatimofthereseardistuiyarridajective, voluntary participatim, time involved in participatim, imtructims, ardassurarcesofamiymitymreprovidedinthecoverletter. 4) 'n'xoseparticipantsmterestedinremltswereaskedtoserd therequestpprtimofthecoverlettermderaseparatecover. fol 59 WWQQM Inadditicntothe limitations admledged 111(1an 1, the following limitatims have been identified which may have affected the resultsofthissmdy: 1) Msstlxiyaskedclinicianstoreoordtheir”m1tim" practice. the professims of nursing and medicine are predicated on judgment. 'merefore,thedatamaynotrepresentpracticeman individualbasis. 'matis,mtallwcmenmaybescreenedinthemamer describedbecanseofcertainhistoricalchtails. Forexample,ifa mnprovidesafamflyhistoryofcardiovaswlardiseaseinallfirst degreerelatives,screeningmybemorerigoro1sthanscreeningda\e withawunanwittnrtastrargfamflyhistoryofcardiovasctflardisease. 2) The study provides for self-report of "routine" practice. Variatimbetweenperoeivedarriactualpracticemyhaveocwrred. 3) Empirical evidence of screening behaviors would necessitate rardmizatim of the population, possible chart audit, arri starriardizatimoflaboratoryproceduresrelatedtodaarges. Patients mldhavetopresentformly”rmtinehealthmintermce"ardmtfor anyotherproblu. 'nms,thisstudyismerelydescriptiveardm absoluteca'clusicrsmybedrawn. 4) Respmsestotheopen-erriedquestimsveretamlatedasthe infomatimwas received. Further investigation to these screening parameters, i.e.,uayused,wasmtavailabletothereseard1er. m Pfil rig. 198: Pa: 60 5) Adisadwntageofutilizatimofamailedmrveyforthe shriywasinaninabilitytoclarifyquestiomcnthepartofthe researdxerandtheparticipant. 6) Self—selection of the mrsirg pcpilation occurred in regards totheirpractice. Cuneivably, onlythoserespmdents (bothmrsesand physicians) withaninterestincardimrasculardiseasemayhave reapcnded- 7) Separatim of the pcpulation into three separate data files resulted in difficulty in data handling. Omsequently, many of the statistical tests had.to bejperformed.by hand. 8) Use of a convenience pqlulaticn resulted in a small sample size that failed to damnstrate significant differences within and betweengroups. m 'niereseardidesignhasbeendescn'ibed. 'niedatagainedbythis study will facilitate the develoment of standards of practice for primrycareprovidersinrelatimtotheassessmentofcardiovascilar riskfactorsinperimenopausalwmen. Basedonthequalityof infonnatimobtained,thisstudymyserveasapartialbasisfor evaluation of the Year 2000 Health (bjwtives for the Nation (PBS, 1989). 'Ihedatagainedalsowillhelpthegrowthprocessfortheadvanced practicenurse. 'mefirststeptoassessnentisgatherirgthebaseline dat of 61 data. 'menextstep,mtaddressedinthisstudy, shouldbetoacplain themflerlyingcmlsesforproviderdeficitsinscreening. Remlts will be presented in clapter v, followed by implications ofthesunyresultsarrirecamerdatimsforfmtherreseardlas proposedinclapterVI. m ri: murmmkhmm. fimmm CHAPMV glands-2 'mepurposeofthiss‘mdywastoeaamimtheextenttcmidl primarycareprwidersscreenperinenopausalvmenforcardiwascllar riskfactors. Inthischapter,datawlidldescribethesmdy pcpflatimsaniaddressthereseardiquestimarepresented. Additional descriptive data, altlnghrntdirectly relatedtothes‘uxiyvariables, arepresentedtcbroadenthedescriptimofthesample. Datapertaining totheresearchquesticnsznoPrimrymreProviarsPErfomhRisk WW1thPerinamaaleax(m40—55)nlrimmm:tim BealthhintamneVisit,amvhatArefileFactcrsW,are preserttedandtheresultsdescribed. 'mestatisticelted'miquesusedtoanalyzethedataincluded frequencies, means, standarddeviations, apooled m, variances, and percentages. 'Ihedataarepresentedasfollows: first, descriptive data relatedtothesanpleofmmsesprovidirgcareforperinerrpausalvmen andseccnd, descriptive data forthephysician group. 'Ihefinal data presentatimwillbeadescriptimofpracticeortlihedbythe participants. 62 63 Ofthe577surveys,theoverallretumrateforthesimveywas 52.3%. 'nlereturnrate,forallrnlrsesms6o%(n=228),andthe physician return ratewas 39% (II-76). Of the 304 surveys received, 163 (54%)werefranprimrycareprovidersvmoparticipateinthecereof perimenopausalvmen. Ofthese163,93werefrcmrnlrsesand70were frunphysicians. 'medatafronthe93mrsesurveysandthe7o physiciansurveysmreusedtoanswerthereseardlquestim. mmxmm wmmmmmz Adiswssim ofthesociodalographic variableswillbelimitedtothepopulaticns thatprovidecareforperimencpausalwunen. 'Ihenurseswhoprovidecare forperinempwealwunenintheirpracticereportedameanageof43.38 years, witharangefron27to65years,arriterriedtobeclusteredin large mucpolitan counties such as Wayne (14.4%), Washtenaw (15,6%), Kent (10%), and Irgham (8.9%). the majority of the mlrses had Master's Degrees (46.6%), and functioned in settings other than private practice (62.4%), such as clinics, university settings, and hospitals. The nurses were primarily fenale (96.8%), and primrily specialized in dastetrics/Gynecology (31.5%), Family Practice (23.9%), Maternal/Child (14.1%), or Adult Nursim (15.2%) . Elbe nurses terfied to be aperierloed in practice, with 11.9 mean years of practice. Characteristics of this population are cmsistent with those rqaortedby 'I‘alaczyk (1988). Sixty threepercatoftlamnsesreportedseeinglo-wperimempausalvmen per week for routine health maintenance. A small percent (23.1%) (12 gr WMfimh®mmmum aflmmmh 64 reportedeeeinglessthanlOwunenperweek, ardanevensnellerpercent (12.3%) rmted more than 31 per week. Sociodemografilic diaracteristics of the physician population are glitedifferentfrmthoseofthemlrses. firemanageofthe physicianswas51.43witharangeof 30to67. 'merespcxrientswere primarily male (94.3%) 21.24 mean years in practice. The educational level ofthephysicianswaslnnogenems; allwerenedical Doctors. ‘Ihe geographic location of practice for the physicians was Genesee, Lapeer, and Shiwassee counties. 'Jhe majority of respondents (57.1%) reported Family Practice as their specialty, followed by Internists (20%) and Obstetricians/Gynecologists (10%). The majority of physicians (70.6%) indicated that they saw 10-30 perimenopausal wonen in their office per weekforroutinehealthmaintenarne, mile4%sawfaoerthanlo, and 19.1%see31-51wunen, and6% smmrethanszperimermansalwunenfor routine health maintenance per week. ammmm A description of practice in relatim to cardiovascular risk assessnentwasobtaihedfronthepcpulatimstudied. Descriptionof practice supported by the literature was obtained by affirmative respcreesonlOkeyquestions. Findingswillbeorganizedamrithe researdlquestims. 'medatapertainingtoadvancedpracticemrsesin ttnStateofMidliganwillbepresentedfirst,fonwedbythemysician dataforGenesee,I.apeer,arriShimcotmties. fa: den fa: E((mmmmiD|L INK 65 mm: W: DoPrimaryCareProvidersperfomariskassessment with perimenopausal wmen (ages 40—55) for cardiovascular risk factors duringtheroitinehealthmaintenancevisit? 'n'iernlrserespaflentsreportedscreeningameanof7.5risk factorsartofapossiblelo,witharangeof4tolo. 'Ihestandard deviaticnwas 1.65. 'n'ms"riskassessmentfor cardiovascularrisk factors”isbein;dmesixcethismetthecriteriaestablishedof50%of screening behaviors. 13.21.11- SimaryofScreeningBehaviorsofAdvancedPracticeNursesfor SupportedFactors. VARIABIE FREUJENCY PERCENT WEIGH‘ 89 96 (ObesitY) (Diabetes) FAMIIM HISICRY 01“ mm DISEASE 86 92 W OF some 93 100 BLOOD PRESSURE 93 100 (Hypertersion) EXERCISE W 59 63 (Sedentary life style) LIFE CHANGES 71 76 (Stress) mm mom mamas 43 46 (Stress) DIET 1119102! 58 62 (Diet risk) ras'rms H.000 GIUCDSE 36 39 (Diabetes) SERUM CIDWL 76 82 (Hypercholesterolemia) MISSING 31 3 Note: mtawereconsideredmissingifrespa'dentwrotein'maybe" or "sanetimes" mtheiralrvey. Q FER \W. \ Qflmmfifimmmmmmmmfl * .2 * 66 Mm: matarethefactorsassessed? 'Ihiswasansweredbya conbinaticn of supported factors (Table 1) and non-supported factors (Table2). Nm-amcrtedfactorsusedinscreenimarethosethatmay heused,kmever,aremteqportedhytheliteraune. Therm- supportedtedmiqueswererepresentedbyquestimsinthesurveyas cutlinedinclapterlv. Affimativeanswerstotheclosed—erded questicns indicated that respondents used that factor, negative mamasMflmthtquomtmemfipuflwhrflaw.Tm cpen-endedquestimalsoprovideddatamotherfactorsusedfor screenim. Ahighpercentageofthesemrsesusedtriglycerides(57%)and highdensity lipoproteins(53.3%)toscreenperimencpausalvnnenfor cardiovaswlar disease. Tablez illustratesrm-smportedfactors that maybeusedbythesemrsesinassessmentofperinempausalmfor cardiovascularrisk. MWofSGreenimBehaviorsofAdvamedPracticeMrsesfor rm-SurportedFactors. \mmmr fimmmm; *mmmmm cmifi ME$TBTH GmflXfiM** mmwm N EEENLEWB** EUWGMLGMNUMWEGE** mmmmmcmm “thUHHH HG B IWMMGflnE 17 20 NEWMMMLGHHE 8 9 mmmmmmr & fl EMHEEHWHEHMEM w 53 * Peroartagesvarymetomissimrespcnsesarrimltiplechoiceof factors. ** Indicates factors iderrtifiedbyrespondentsbycpen—exriedqmstims. E a E REEMHWMMEM kw 67 Harlem: 'nlenexteectimpresentsthephysician'srespa‘isestothe glestim: ”Doprimrycareprovidersperfomariskassesatentwith perinenopanmal wunen (ages 40-55) forcardiovascularrisk factors during fllemrtinehealthmaintenancevisit?" 'nlemanmmberofriskfactorsassesseddm'ingfllemtinehealth mintenamevisitbypuysiciamwas7.7,witharangeof3tolo. 'Ihe standarddeviatimwas 1.73. 'Ihus, screenimfor cardiovascular riskis beimperfornedsincetheestablishedcriteriamssm. mm: SlmaryofScreenimBehaviors of Physicians forSupported 11 Factors. VARIABLE W *PERCENEGE man (Obesity) 70 100.0 (Diabetes) Fm RISK!!! OF mm DISEASE 66 94 HIS'IIRY 0F SIDKDG 69 99 moon PRESSURE (Hypertensim) 68 97 ECERCISE msm (Sedentary life style) 37 53 IIIFE cm (Stress) 55 79 A'I'I'I'IUDES m m (Stress) 32 46 DIET msm (Diet risk) 46 66 mm BLOOD GIIJCIEE (Diabetes) 37 53 8mm cnrrsmaor. (Hyperdmlesterolenia) 62 89 MISSIM; 61 9 Note: Datawerecmsideredmissimifresparientswrotein'mybe"or "santimes"mtheirsurvey. Mg}: 'nlesecondreseardlquestimasked:matarethe factorsassessed? 'mequestimisansweredbyacmbinatimof supportedfactors(Table3),arrirax-stqportedfactors(Table4). Non- exportedfactorsusedinscremingareflwseflntmybeused,rnwever, aremtsupportedbytheliteramre. 'merm-stzpportedtedmiqueswere. 1) trig perm £3.th m &m\v\ mammmmrmm Gm PULL mm * h D as 68 representedbyclosed-erriedquestia'isinthesurvey. Affimative uflwerstcflleclosed-erfledquestimirdicatedtlntrespaflmrtsusetlnt factor, negativerespaeesindicate thattheydonotusethat particular factor. 'nieopexr-eniedquestimalsowasusedtodescribeothermr- aipportedfactors. Ahighpercentageoftl'iefixysicianpcpulatimalsoused triglyceride lsvelsandhighdensity lipcproteinsinscreening ’___ perimempmisalhnnen. 0ver50%ofthep1ysiciansalsousedfmdoscopic mandanelectrocardiogram. '1‘able4illustratesncn—supported factorstrntmybeusedbyrhysiciansinassessnentofperinetmausal wmlenforcardiovascularrisk. WSWofScreeningBehaviorsofmysicians form-Supported Factors VARIABLE NUMBER OF W* W csc ** 1 1 GE! HDFIIE ** 4 6 GEST X-RAY ** 3 4 T4 ** 1 1 ES'IRDDIAL IEVEIS ** 1 1 WC EXAM 38 58 Em 35 54 RAM GIUCIBE 23 38 EST PRANDIAL 611m 13 22 'IRIGLY“ 57 85 HIE! mm IIPOPMIEINS 51 76 * Peroentagesvaryduetomissimreqamsesandmltipledioiceof parameters. ** Indicates factors identifiedbyrespmdentsbycpen-endedquestims. Midi: Although cmparism of two highly different populations is questicnable, apoclethwasdaxetoattaxpttodetemimifttnre 69 is a statistically significant difference in the mean response (supported factors) ofthez groups (mrsesandphysicians), arrimim'mal differencesinthevariamesofmmbersofscreenimfactorsperfomed. Another rationale for looking at a difference between the populations was related to relatively close sizes (n-70, 11:93) . The 'I' value was not significant at the 0.5 level indicatim no differences in the pcpulatim. mam Inmry,thereseard1questia'is:"DoPrimaryCarePrcviders performariskassessmentwithperinenopausalwunen(ages40-55) for cardiovascllarriskfactorsmmingthemrtiremintenancevisit? What are the factors assessed?" were answered affinnatively in relaticm to bothpopulatims. Meanscreeningfactorsassessedbyadvancedpractice mrsesardfilysiciamwere7.5and7.7 respectively. 'IL-testper-formed mthe‘hmpqnlatiasrevealedmdifferercesbetweenthesegmlpsm screenimbehavior. flieseccrdquestim'mtarethefactorsassessed?"msanswered byboththesupportedandrm-sqportedfactors. Furtherdiswssion willbepresentedinclapterVI,alongwithinterpretatimofthe findings, inplicatims for nursing practice, nursim education, and futureresearoh. WW W, DEMOS, AND W018 mas: Aetmryarriinterpretatimofthefiniixgsforthesmdyare presentedina'iapterVI. 'niisstmmaryardinterpretatimimludesa diswssialofthesociodamgraphicvariablesinthesuldyardhmthey myhaveinpactedtheortcaneofthesmdy. Firdingsoftheresearoh gustimarediscussedrelatedtotheliteraulreanithefmrk. mmmm Cardiovasculardisease(CVD) isthemostcmcauseofdeathin bothmardminthetmi‘tedstates (NaticmalOenterforI-lealth Statistics, 1986). In1983, heartdiseasewasthethirdleadim cause ofdeathinwonen35-39, secmdleadimwlseofdeathinwunenbetween ages4o-44,arrltheleadimcauseofdeathinwmen65yearsardo1der (mm, 1986). Riskfactorslmowntoca'rtrihxtetothedevelopnentof cardiovasallardiseasehavebeendevelopedtluolghextemivesmdies 7O 71 utilizing male subjects. 'nleresultshavebeenextrapolatedtoinclude wmnen. Perimencpalnsalhmnenarethetopicofdloiceforthissundyas thistimeof life isa‘neof change, zest, andgrowth, McKea'n (1988), Sardelowski (1981). Screenimahmanwhoisintheagerangeofm-ss allowstineforbehaviordnangesthatwilldecreaseherriskof eaqneriencimacatastrofiniccardiwascdlarevent. Researdnincerdiovaswlarriskassessmsntisvaried, confusing, andsfienflve. mltiplerecomendatia'nshavecanefranavarietyof sourcesasoutlihedincnapterm. ‘Ihemostconciseguideforthe mummmmmmmmmrmw theU.S. Preventive Services Task Force (19889). lbs drawbackof the guideisthepmlcityofinfcnnatimrelatedtopsydnosocialriskfactors forcardiovasculardisease. Evaluatimoftheguide,aswellas,theygrmm Wmmmmflmrtedbyaladcofdescriptimofacmal practice. Ashasbeenshow,thereareseveralsh1diestoindicatewhat, shmldbe dale, l‘ncwever, there is a paucity of infomatim describim whatisactuallydmebycliniciansinrelatimtoscreenim periwwausalmforczrdicvasallardisease. 'nnegoalofthisshndywastoprovideadescriptimofpractice pattennsofAdvancedPracticeNnnsesarriasmallmmberofphysiciansin relatim to their "routine" practice for evaluating wunen for cardiovaswlardisease. 'Ihiss'undymsplrelydescriptivereseardnand tlmswasnotintendedtoexplainmnycertainparanetersareorarenot usedforscreeningpurposes. 'Ihepredictedmmberofscreenim 72 paraneterswasSO%,tuuever,theactualmmberasdescribedbythis popllatimofprimarycareproviderswasfit mmmxm WWfiQEMW: 'Ihe sociodamgrarhicvariablesofthehealthcareprwidersvmorewmdedto tlneamreymayhaveaffectedtheoutcane. 'Ihemrsepcpilaticmtended tobeclusteredinlargemeu'cpolitanareasofnidligan. 'Ihese metropolitanareasterritohavethemajor universities forthestate. 'nnerefore,theacmalpracticeforadvancedpracticemmsesinthestate mybeskaedmeto"prmressiveness",oraccesstoinformtimthat providesguidesforscreening. 'nnemnrseswereprimarilyfanale,ard thephysicians,primarilymale. mls,a'nemigntexpect,fronafaninist perspective, thatthemrsesmaybescreenimwonenmorecloselythan thepredanimtelymalefilysicianpqnlatim. 'Bliswasnotfan‘dtobe trnleasmeanscreehimbemviorswerecanparableforboflnpnysiciansard mm: Inthisstudy, lOspecificvariableswereusedtoirdicate screenimbehaviorsthatrepresentriskfactors forcardiovascular disease. 'nneriskfactorsweredevelopedfronathomlghliterature review, and operationalized by specific questicm on the survey. Affimtiveanswerstothespecificqmstiaswredeened"screemm" behaviors. 73 mag: 'nnemeannmberofscreeningbehaviorsperfomedbythemrseswas 7.5. 'BnesnmportedscreeningfactorsrwortedbygreaterthanSMof advancedpracticemrsesimludeweigtrhfamilyhistoryof cardiovasallardisease, smoking, blood pressure, exercise history, life dnanges,diethistoryarrlsermncholesterol. Factorsnotsugncrtedby theliteraulrehrtusedbytheadvancedpracticemlrsesincllfle triglycerides, andhighdensity lipanotein levels. Non-sumorted factorsusedbylesstmnsmoftheadvancedpractioemrsesincluied: cac, stress test, dnestx—ray, hemocult, estradiol levels, historyof cartraceptive use, funduscopic a, ekg, randannarripost-prandial glucose levels. Although the efficacy of these nm-sugnorted factors hasnotbeendanls‘tratedintheliteratne,fmtherreseardimay inflicatethatthesefactorsshalldbelookedatwhenscreening perinerrpmsalwunenforcardiovasculardisease. 'lherelativelylowrnmberofrespandentsthatreportedusim fastirggluooselevelsmyberelatedtothefactthatmanyofthe mlrsesarenotinaprivatepracticesettim,andfastimglucoselevels wouldrequirearsvisitbythepatient. 'nnemoetiuportanttimingorthieetudywasthelackotscreming forpsydnosocialissues. mmgmmmamm doesnotincludethisasanissueinscreenim. Ashasbeenshamin cmpterIII,isa.lessudlasstress,dnmrgimlifeevents,ardreactions tothesediangesareverydifficallttoquantifyarrievaluate. 'Ihisarea isalsooa'rtr'oversial,ardthereseard1hasbeenmixedastothe relaticxshipofthesefactorsarricardiovasculardisease. Quickand 74 efficientmthods of evaluatim ofthese factorsdonotexist. ‘Bnerefore,thec1inicianmayavoidsnx31issuesduetotimeardecamic restraints. ItisreasmabletoassmnethatI-DI/‘Iriglyceridelevelsaredrawn almgwithsenmdioleeterolleveleaietomnytineeuhatohutestingie moreecamicalthanirdividualtests(thismyvaryfronlaboratoryto laboratory). Electrocardiogram are clearly not indicated for screening. The finctimofthemisdiagmsticardforuseinsynptmeticpatimts. However, patient expectaticnmay cause the clinician to performthis test. Inammary,theconstructofcardiovascilarriskassesanentin perinernpausalwonenasmtlimdbytheliteraunewasupheldinthis study. lheareasmnerescreenihgwasweakestmspsydnosocialissnns arrifastingglucoselevels. minicimnsmywelluseother'm- supported"factorstolookatthewcman'sriskprofileduetotime caustraints,accessissuesandlasrebnnvisits,settimsinmidnuney practice,theacwsstoalrrentlcmledge,anilmowledgeabwt intmafimto change recalcitrant behaviors (smoking, eatim, stress related life style) once assessed. 'missmdydidmtaddresswhatinterventicxsweremndertakenasa resultofscreenim,m'ditisinportanttlntprovidersrecognizethat screenirrgalaiewillnotreducetheriskprofile. 75 mm: 'Ihemannmberofscreenimfactorsassessedbythephysiciars was7.7. 'nnesugportedfactorsreportedbygreaterthansmcfthe physicians inclucle: weight, familyhistoryof cardiovascular disease, historyof snaking, blood pressure, exercise, life changes, diet history, fastim glucose levels, ardeerumcholesterol. Attitudes towarddnarqesinlifewastheleastcamnlyusedfactor. 'nnenm- suppcrted factors usedmst frequently included triglycerides, high density lipoproteins, furriuscopic exam, andekg. Iberian-supported factorsusedbylesstlnnSfiimlnfledrarflmmfipost—prendialglucose levels, (30, chenistryprofile, chest x-ray, T4 levels, and estradiol levels. Orneagaimpsydncsocialissuesseentonotenterintotherisk profileasexpressedbythephysiciangroup. ‘Ihelackofscreeningfor psydnosocialissuesiscmparabletothemrses. Possibleexplanatims forthisincludealackoftimeintheofficesettim,lackofquickand efficientmethodsforassessment,arrllackoflcwledgeofhowto effectivelyinterveneinmchissuss. Alttnlghthefastimglucoselevelisthescreeningtoolmst calmly referredto intheliterature, it is canceivable thatthe physiciangrolpusesthemnimarflpost-praroialglucoselevelsbecause ofthefearthatthepatientmaynotreturnforthisevaluatian. In snmmary, the rhysician and nurse popllaticn utilized in this sundydoscreenperimelmusalvmenforcardiovasanlarriskfactors, arritendtouseavarietyoffactors,notjustthosesupportedbythe literature. 'nnelackofscreenimforpsydlosocialissuesis 76 disturbing, but not surprisim due to a lack of efficient mans for assessimthis factor. message: InadditiantothelimitatiensaclmowledgedinclapterIaniIv, the followim limitatia'ns have been identified whid'n may have affected theresultsofthissundy: l) Amajordisadvantageof usingtheforced choice formatwas reductien ofthereliability ofthequetionnaire. mismdetherisk assesanent profile less reliable. 2) Reasensfor choice of specific factorstouseforscreening werenotidentifiedinthissuriy. 3) 'Bneissueofwhatisda'newithdatadatainedbyscreeningis notaddressed. Providersmydoaneccellentjobscreening,b.rtnotdo anythingtofacilitatednangimthe"risky“ behaviors. Inelmmry,thelimitatiensdiscussedinthisardprevious sectiasdescribethosefactorsthatneedtobecesiderednmen developingamethodologyforftmlrereseardnedmyalsoinfluelcehcw realltscanbeinterpreted. maximize Inthissectien, theinplications ofthisstudyfor nursing practice, mrsimeducatien, andfuunremlrsingreseardiwillbe 77 presumed. 'meseinplicatia'swfllbediswssedwithintbeooncepwal frameworkdesigned fortbissuxiy (see Figure 1, pg. 19). WMWW= Nlnsixugisdescribedasbothasciaxoeardanart,ardmmsim's descriptiveompment(assessment)pmovidesthebasisformnsim practice. Nursirgdoes mthavedepenient functions, only collaborative ales. 'nms, thissbxlyisareaflt of collaborative consultation betwemtlwreseardnrardmnsemarfibebdeenthereseardaerand physicians. Eaduparticipanthastheiromrationale for selection of specificscreeningbehaviors,andtheftmctimofthesuflymsto describemidascremingfactozswereselected. Perimenopausalwmm wereselectedasatopicforscremimforcardiovaswlarriskfacbom becausemseardzhasslmthatflxesemamprimtaxgetsformt Roger'sdefimsasrepatterningmmmuSBB). Aoornernofthe researdxeristlntprwidemaretmdixqtoigmmaniuportantportim oftheperimenopwsalwmen'serwimmerrt. Sinoetheperimerwausal mnisseenasbednginseparatefranherirrtennlarflexteml enviroment, psychosocial issues wristbaoverlooloed. Consequently, themdelcollapsesinrelatimtoflieperiwmausalmn. Although wecanmlyspecilatereasmsfortheladcofflwestigatimintothese ism,nnsesamcmsistentwiththeparticularpaysiciangru1pin flzisstniy. Musinganimedicalliteraturelnsnotdauwstratedwlut screenirgparaneters arebeixgutilized. ‘merefore, it ispossible that physiciamaxflmnsesinaoollaborativeprimrycamsettingmaywork '78 witheadicthertoidentify‘screermxgprotocolsfortheirpartiwlar practice. 'mefomsofthestuiywastofacilitatetheprocessofgrowthfor perimupausalmafimmsing. 'meremfltofthes’axiyprcvides directim for nepatteming of nursing practice that will facilitate the gruethprocessforperimwausalwunen. Howthismyoccurwillbe presentedintennsofeducatim,policyismee,practiceisaesarfl further-m. the Clinical Nurse Specialist (CNS) can facilitate this process of "beccnim" for perimenopausal wanen. Selectim of one of the multiple rolesoftheQISisbasedmtheassessmentdatagleanedintbe interview. ItisinportantforthemStorealizethatthepatierrtis atapartiailarpointinspacetine. 'Ihepatierrtreactiontothe assesanentpmcesswilldiangeinrespmsetothevaricusmlesofthe CNS. Mora,iftlieQISismtset‘Bitivetotheismesbruaghtfortli bythepatient, themrsing role is ineffective. FigueZprovidesaamaryoftherelatiaxshipofthemodelto thestudy. 'meroleofassessor,canbinedkncwledgeofthe cardiovaswlarriskprofileandhcwotherprwidemscmenfortrnse riskfactorsprcvidesthebasisfortheclinicalhrterviw. Howthe patientzespaxistofliescmeningdictatesthemrse'sselectimofme properroletofacilitatethepmcessofbecanirg(orgrowth)forthe perimmopausalm. (See Figure 2 m following page) 80 Cardiovaswlardiseaseandwunenareinthemassmedia. 'Ihe generalpqnlatimiscmcemedabmtissuessudiasdnlesterol,blood pressure,andexercise. 'Ihisirrteresthasspawmdseveralhuickfim" sudnas'batbran", health equipnent, autmtedbloodpressure equimm'rt, the"perfect" athletic shoe, etc. axeof nursing's functions iseducaticn. Musingmstimrestintheechmtimofmtohelpthe mtoma]aewise,infoneddxoicesabaxthcwtomnaged1angeintheir lifestyle. NUrses mst educate wunen as to what the "right choiws" are inrelatimtocardiovaswlarrisk. Altl'nagh‘thetanprtatimtoixmlge mafia"quidcfixes"isreal,issuesaldiasweightleductim,m cessatim, stress reduction, exercise, andmanaganerrt of multiple roles mastheaddressedbythecls. 'meselifestylediarqesarediffiailtto achieve, especiallysincethepresertthealthcaresystanplacesmre msismdiagmsisardphamcologicaltmamentofdiseasemanm mlhiessissues. Professional educatimprogrmarebeixqpresented. LifgLilg WWWWatiwtmmme inpactofcardiovasmlardiseaseardm. Musingmstprcvideimxt totheseprograms. Asirdirectlyshowninthegggetgm m,mrtilrecerrtly,medicinehasmtbeentrainedinissuesof behaviordxarqearfloamselirq. Belmiordiargearfieducatimhavebeen the respmsibility of musing. Not onlymst mrsitg educate the public, mnsingmstalsohelpeducatephysiciamabwthowto facilitatebehaviordaarqeardfocasmwellnessinsteadofdisease. 'nieminicalNLn'seSpecialistmstplayaroleinpolicymking decisicrs regarding screening practices. Reimmrsanent for this 81 activityisseverelylimited. 'mereasmsforthelackofreimbursement arennltiple. misshflyfmctimsasamilot"stmdyinidentifying unattypesofscreenirgambeingperformedinacmalpractice. 'Ihisis thebasis fordeterminirgefficacyofscreenimbehavior. Nursingcan, ardshaildcartinietoevalmtemenimbehavior,whetheritbe cardiwasculardisease,cervicalcancer,breastcamer,remiratory dim,substameabuse,mentalhealthissues,etc. 'IhedlScamand doespravidealargedatabasefiunherpractice. DefiJfiJQefficacyof screenirqbehaviorsisafirststepintheintervmtimprocess. Methodsofirtterverrtimanidoamrtatimoftheefficacyofthese nethodswillhelpprovidedoamentatimforreimmsanent. Policyissuesstxhaspreventimof"scamclnes"fordiseaseare withintherealmofmmsing. Mmsirqadvocacyfacilitatesthe develommxtofinfomdcammers,mid1flmresultsininprovmmin thelevelofhealthcare. mimzesear'diwillprovideimighttothe mastouiataresafehealthpractices. Nimsimresearchwill also provide infonnaticn for health policy makers by identification of s‘tarxiardsofpr'actice (inrelatimtoassesamlt)slmldbeutilizedarfi midiintervartiaaaremsteffectiveinmdmingcardicvasmlarrisk. Mushgisaprofessimpracticedbyprimarilyvnnen. Wm's issuesaremrsing issues. Nursirg professionalsmstrecognize that their behaviors impact an policies related to m. Activism, advocacy, recognitimofemwiramentalissuesusdefinedbylbgers), willallhaveapositiveinpactmnmen. Socialissuessuchas niltiplemlesanddiildcazenistbeinvestigatedbymmsim. 'Ihese dnmes,arxithereactimstothesedungescancausedisruptiminflie 82 mn'sintemalanienctennlmvimmerrts. Nursingnustbeonthe forefraitofevaluatihgorassessingtheinpactsofthesedzangesm m1. Nursirgnustbeinshxmantalindevelqmantofamdmnimwhereby issmsadmasstmss,tnstility,arfllifed1angeisaiescanbeassessed quicklyarxiefficientlyintheprimrycaresettim. Perhaps,a meetiamaimtlntisfflledwtpriortothehealthmintemncevisit myhelpindecreasmgtineaniimeasirgscreeningbehaviors. 'Ihis formmybefilledqminthewaitirgroan,ormailedtothepatient priortothevisit. Sanevmlen'shealthcareclinicsareamttly usingsudifonns,rmrever,literaumeismtamrentlyavaflableasto theeffectivenessofaldxmsthodsinmlatimtoscreeningfor cardiovascular-disease. Becausethemnprovidestheinformtim, doesn'tmeanthattheprcvideradmledgesorintervenes. 'meprcvider nust, once again, utilize the informticnto intervene apprcpriately. anstasinportantasfillingoutfom,orperfomirgtheinitial assesm'xtisthedevelqnentofarelatimshipthatprcvides cartimity,aswellas,follwi:gthepatientalaxgpointsintime versusmevisitperyear. Asstwinthemdel,mehealthmintenance visitiscnlycnepointintine. Medianimsthatarecosteffective, efficient, acceptabletothepatient in relatimtoherexwironnentnay imludefollowuptelepiniecalls,aletterthmetosixnarthsafter the visit or provision of "group meetings" coverirg topics know to be ofinteresttotheparticilarpatierrt. Nursesmstbeeducatedthat healthoutcmesaretherespmsibilityofhealthcare. Screening 83 behmior does not cause or facilitate behavior mange. Specific strategizingmthepartofthemnseardpatientcreatesartcanes. Instmry,thissuidyhasmltipleinplicatiasformrses. 'meserangefrunmleinplanerrtatimtosocialpolicyissues,“ practiceissues. Nursingnnstca‘xtirmetoevaluatepracticepattems. Nursirgmstcmtimietoeducate,notmlythepjblic,hrtmrselves, arriqmcolleaguesinmedicineinrelatimtothemrsingrole. Nursing mstrecognizetlntm'sisaiesaremnsixgiswes,andviceversa. UtilizingRogersbasicpranisethatdnrqeintheiniividualenergy fieldswillwasediangeinenvimmentalenergyfields,andtlntm mmnislessthanthesmofher/hispartswillhelpindevelopingcost efficient, efficacious, cmpassimate are. Perinampausal «men benefit franniltidisciplinary fmctioning, especiallyintheprimarycaresetting. Interflisciplimrycollaborative practice can mly cane about by interdisciplinary, collaborative educatim. 'mequalityofcareforperimerwausalmisaffectedby tlieftmticriirlgoftrleirlterdisciplinaryteam. 'IheroleoftheQBmust beclearlydefinedforthepatimtandnmbersofthehealthteam. 'Ihe 08mleisa1eofrm-medicalinterventimarfifoamedtowardhealth. 'matis,ifproperscreeninginiicatesthatpresenceofdiw, amropriate referrals thatarwebeyaritherealnof nursing, i.e., thallium stress-testim,angiografi1y,etc.,slnildbemde. 'Ihisismt tosaythatthepatientslmldbeW-over”toamysician specialist. 'Ihe crucial point is the collaborative relatimship. 'Ihe memstcartinietherelatiaishipwiththepatienttoordiestrate continuity of care. Interventions designed withthepatient in relation 84 to smoking cessation, weight reduction, exercise prescription, dietary marge, etc., stmldbecartirmedbythemneeintheprimaxycare setting. Furtherinterventimsfrmthemedicalaspectmstalsobe incorporatedtoprwidecmprehensivecare. M £21: Nursing Mm: Nursing fawlty, respmsible for the ednmtim of graduate mrsihg shflerrtsinprimrycare,mstincludeinthewrricalatheskills neededformrsestomeetrmdmrdsasaresultoftedmologyam dmxgesinfocusofhealthcare. Ihecurriwlainmneingecmcatimmstfomsmtherolemodeling andleadershiprolethataOSinprimrycarecanplay. Itistimefor mingtotaherespmsibilityforlookingatthemmanasamified whole, inseparatefrmher/hismmnflims. Inthiseraofcost cartairmentarrica'mmeramremss,thereismtmforloddmata patientasanarsansystem- mmmmmmam placetostart. 'meMpresentsscreenirgismesacrossthelifetine ofirdividuals,lnnever,itismtthefinaldoamrt. Psychosocial issuesnzstbeincludedinming,andallprimarycareproviders mstmreeffectivelyintervenemcescreeningisdme. 'Ihe educatimal preparaticn of licersednursesvaries, ashasbeen denstratedbythestudypopulatim. 'miscmfusion,alongwithlack of specificity of titles creates difficulties for the cmsmer, as well as,cthermrses. 'mewrricilaformrsesinprimrycareslmldbe gerrericernghtoprovideamfrmrk,yetallwspecializatim tomitdanamsofthemrketardthemrse. Sincecardicvasazlar 85 diseaseisanissuethatbegixsearlyinlife,screenimforpcterrtial riskfactorsslmldbeginearlyinlife. Althmrghthissmdyfowsedm perinempmlsalm,severalsocialardbeluvioraldnrgesmstocwr inasycmgasthepediatricpqnlatimtocartiniethedeclineof cardimrasaalardeathsinthemi‘tedStates. 'niesechangesimluie mopermtritim,useofexerciseasamsthodofstressreductim, cessatimofmkirq,andsocializatimofd1fldrmtoreducethehnden of nultiple roles of m. Instmnary,mrsingedncatimhasbeendiswssedinrelatimto screenimperinenopausalwmen,theCNSroleinprimrycare,and interdisciplimryftmtionirg. mirsesinadvancedpractioemst caxtirmetoevalmtetheirpractice. Researchrelatingtoactual practiceisaneiwellenttoolfordevelopnentofstardardsofpractice. Wmmm: Wfimm. 'Ihesurveyusedinthisstudyisthe firststepinthedevelopnentofamrerefimdirstrmxtforfumre replicatim. The following suggestims are rare for revisim of the questiomaireforfutureuse. SeeAmemixcmmreferenceismadeto specificquestimsinthequestimire. 'metem"mrtinehealfl1mintenancevisit"isatermthatcmised sanediffimltyforrespmdents. Itismggestedthatadifferentterm such as ”rmtine yearly physical" mybemre descriptive, and facilitatetheparticipants'mrierstarflirq. 'Ihe forced-choice opticn caused cmsiderable difficulty for sane zesparients. Sincemrsirganimedicineareafimjudgalmltbased 86 professicns, perhapsaninstnmentdesignedtoallw for judgement would bemoredescriptiveofacmalpractice. Anexanpleofsmhan instrtmrtwmldbecasescernriosvmidxpresentpatimtswiflivarying levelsofrisk. 'mequestimastomatfactorsinfluemeaprovider droosesaparticalarscreeningfactormybeaddressedinsudiasufly. 'nxedifficiltywithMadesign,however,isthatthesmveyvmld becmennhmretimcmsminmammaytlmsdecreasethereunnrate. 'mequestimrelatedtolifedmrgesardattiuflestowarddaanges \memtdiffiailtfortheparticipantsinthepilotstuly. Sane negativeanswerswerereceived,hcwever,theparticipantshadm difficulty interpreting the meaning. A ratimale for not asking about theseisaiesmayberelatedtolackoftime,energy,ardmeasurable outcanes. misstudyalsodidmtaskwhyormiymtinrelatimto screeningbehaviors. 'nms, reasons for deficienciescannotbedefined. Funnereseardxsrnfldfoamnotmlymdescribingbehaviors,butalso, reasonsfordeficiencies. 'mesbxiyalsodidmtaskabaitvmatinterventimswere mdertalmasaresultofscreenh'g. auceagaimacasesmdytypeof meymyprcvidedeeperinsighttothisquestim. Wdoammitatimofpracticepatternswillhelprefinethe instrmnent. Reliabilityofthewrveywmldbeenhancedbytheuseofa Likert type scale to increase the variability, and thus facilitate the developnerrtofthecmstructofcardicvascilarriskassessmentof perimenopausal wunen. 87 'meuseofamailedquestimirehaslimitaticrsarflbenefits. The major difficulty, as discussed previously, is the limitation of the interd'xangebeunenthereseardaerardtheparticipant. I-Icwever,this meywaseffectiveinprovidimalargemmtofdataprecisely bemzseitmsshort,tothepoirrtanddidmtallwforjudgalmt calls. ‘mehxsyclinicianhaslimitedtimforpatierrtcare. Alengthy, difficilt to answer questicrmaire takes low priority. Persmal interviav,sd:eduledasapatierrtvisit,thatutilizesacasesmdycan vastlyinprurethisreseardx. Inmry,thissmdymstbereplicated. 'Ihemethodsof replicatimmzsttakeintoaccamttimaniecamicfactoremthepart ofnotmlythereseardaer,hrtalso,theparticipant. ‘Iheirstnmerrt mastberefined,anduseofadecisim-basedquestimirenistbe entertained. laplicatim and validaticm of the study will facilitate mmmumofmmmmmmmmmm 2999. Fuhrereseardiinrelatimtoperimempausalmam cardiovasailardiseasemytakemltipleavemes. First, investigation astohowstress—relatedissuesaddtocardicvascularriskmmtbe definedandtestedforefficacy. Issuessuchashcwadecreasein availableestrogenaffectswminrelatimtocardicvaswlarrisk needstobeadiressed. Aretheretrade-offsnecessaryaswm‘lgrw older? Forexanple,doesanirx:reaseinbodyfathaveabeneficial effectmflreriskpmfilebyincreasingesfiogmlevels? Doeshormnal replacmitflaerapyreducecardicvasaflarriskinmmlsalwmen? 88 Otherreseardimstfoaismdarnstratingtheefficacyof interventimsinrelatimtoscreening. Justbecmiseprcvidersscreen, doesthismeanthatinterventimsareurflertakentoreduce car'dimrascularrisk? Ifso,whatinterventimsaremdertaluen? Arethern'a-azpportedfactoreidentifiedinthissmdyeffective? Foreample,isutilizirgarandanorpost-prandialglucosejustas effectiveasafastingglmoseinscremjrgfordiabetes? Isit inportanttommetherormtamnhasusedoralcartraceptives? Doesuseoforalcmtraceptivecartrihltetothedevelopnentof cardiovascilardiminlaterlife? Warehrtafewoftheissuesneedingtobeaddressedinthe areaofcardiovaswlardiseasearriwunen. Qnr'entreseardihasbem focusedmmen. Isaiesspecificallyrelatedtowunenmmtbeaddressed. m IndiapterVI,astmryarriinterpretatimoffiJflingswere presented. Limitatims of the study were cited arr! inplicatims for mirsirgpractice,educatim,andftm1rereseard1presented. Rogers theoryoftmitarymmanneingswasusedasthecanepmalframworkfor thissuflyarriincludedinthediswssimformrsirgpractice. 'Ihe firdingsofthestudyirrlicatethatprovidereareperfominga cardiovasmlarriskassesmmtofperimerrpausalwunen. Providerstend touseacmbinatimofsumortedanirarapportedfactorstoassess flaecardicvaswlarriskprofile. However,psydiosocialissuesterrinot tobeincludedinscreenirg. Entherreseard'xneedstobemdertalm 89 to: refinethe instmment, replicatethe study, address issues specific tomaidiasestrogenlevels, lag-termeffectsoforal Wm, ardgobeymdscreeningtointerventimsthatassist mtodm'gebehaviorthatleadstocardiovaswlardisease. mastigatimsastovmycertainfactorsareselectedraflierthanothers reedtobemdertaken. Fixnlly, researdumchargingbehaviortodecreasethe cardiovasailarriskprofile ofperimenopausalwunenmayfacilitatea decreaseinpranatm'edeathfrmcardicvaswlareventsforvmen. APPENDIX A Cover Letters For Nurses and Physicians 90 14 March 1990 Dear Nursing Colleague. As a graduate student in the College of Nursing at Michigan State University, I am gathering data for my thesis. My interest is in the assessment of perimenopausal women (ages 40-55) in relation to their cardiovascular risk status. The purpose of this research is to . describe practice patterns related to screening perimenopausal women for cardiovascular disease. The study is of a descriptive nature, and your input is essential to this research. Your name was selected from the list of Certified Nurse Practitioners from MNA and the State Board of Nursing. This listing provides only your address and that you are certified. there is no information on your area of specialty. Therefore, if you do not care for perimenopausal women in your practice, thank you for taking the time to read thus far. Please proceed to the end of the questionnaire and fill out section II. I; ygg g9 cape fig; perimenopausal wome , please pg assured that there lg pg risk pg ygg py participating in this study. mpg only identifying featuges ingluded 1p this study app ppg gpestions related pg demographic data including: your specialty, your age, sex, whether you are certified, geographic location of your practice, educational preparation, and years in practice. All data will be reported in the aggregate, (i.e. as a whole group), and individuals will remain anonymous. There is no mechanism for me to identify your name, so you will receive a reminder notice after you have already completed the questionnaire. Again, this is done only to assure anonymity. You indicate your voluntary agreement to participate by completing and returning this survey. I know that your time is valuable. However, I do sincerely appreciate the 10 minutes required to fill out this survey, and the prompt return of the survey in the self-addressed, stamped envelope. Thank you in advance for your participation. Sincerely, Lyn Behnke, RN, MSN Candidate Michigan State University College of Nursing IF YOU WOULD LIKE A COPY OF THE RESEARCH FINDINGS, TEAR OFF THIS PORTION AND MAIL WITH YOUR NAME AND ADDRESS UNDER A SEPARATE COVER. Name Mail to: Address Lyn Behnke, RN xxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx ‘‘‘‘‘ 91 19 March 1990 Dear Doctor. As a graduate student in the College of Nursing at Michigan State University, I am gathering data for my thesis. My interest is in the assessment of perimenopausal women (ages 40-55) in relation to their cardiovascular risk status. The purpose of this research is to identify practice patterns in relation to cardiovascular risk assessment in the Tri-county area of Genesee, Lapeer, and Shiawassee Counties. The study is of a descriptive nature, and your input is essential to this research. Your name was selected from the yellow pages of the telephone book listing your specialty. Please be assured that there is no risk to you by participating in this study. The only identifying features included in this study are the questions relating to demographic information, including: your specialty, your age, sex, whether you are board certified, number of perimenopausal women seen in your practice per week and years in practice. All data will be reported only in the aggregate, (i.e. as a whole group), and individuals will remain anonymous. There is no mechanism for me to identify your name, so you will receive a reminder notice after you have already completed the questionnaire. Again, this is done only to assure anonymity. You indicate your voluntary agreement to participate by completing and returning this questionnaire. I know that your time is valuable. However, I do sincerely appreciate the 10 minutes it will take to fill out this survey. A self-addressed stamped envelope is included for your convenience. Thank you in advance for your participation. Sincerely, Lyn Behnke RN, MSN Candidate Michigan State University College of Nursing IF YOU WOULD LIKE A COPY OF THE RESEARCH FINDINGS, TEAR OFF THIS PORTION AND MAIL WITH YOUR NAME AND ADDRESS UNDER A SEPARATE COVER. Name Mail to: Address Lyn Behnke RN xxxxxxxxxxxxxxxxxxxxxxxx XXXXXXXXXXXXXXXXXXXX APPENDIX B Pilot Study Survey 92 Uhen a perieenOpausal uoaan Iage ao-ss: presents to your oitice tor a ROUTINE NEALTN MAINTENANCE VISIT do you or your start ROUTINELY: __vs 9.9 i. Ueigh the patient? 2. Inquire as to the cause oi death oi iaaily aesbers? 3. Ask tor a smoking history? a. Measure Blood Pressure? Pertore fundoscopic eras? 5. Ask whether the patient perforas aerobic activity Iualking. running. cycling. swiaeingl for 20 einutes at least 3 tiaes per week? 8. Ask about aajor lire changes Ineu job. loss or job. loss or spouse change in Job. children, etc.) Do you investigate attitudes toward change? 7. Periore a 12 lead EKG? 6. Ask for a diet history? 5. Order a fasting glucose? A randos glucose? A post-prandial glucose? 10.0rder a serua cholesterol? triglycerides? HDL/LDL levels? Any other parameters that you use? i 93 Please coeplete a few deaographios~for descriptive purposes only. It will not be possible to identify you free this inforaation. PHYSICIANSI Uhat is your specialty? Faaily Practitioner Internist Obstetrician-Gynecologist_____ Board Certified? NURSES: Nurse Practitioner Clinical Nurse Specialist Uhat is your specialty? a. Faeily? Certified? b. Maternal-Child? Certified? c. Geriatric? Certified? d. fled/surg? Certified? e. Oncology? Certified? Other Iplease list) Certified? Private Practice? Yes No If no, where? 110. clinic. ' hospital,etc.l ALL PARTICIPANTS: 1o. Years in Practice? 15. Male or Fesale? la. Nuaber of periaenopausal wosen seen in your office per year: 25-50 51-75 76-100 101-150 ‘ 151-200 201-300 over 300 Thank You for your ties and effort. Please disregard any further. reainders that you say receive. ' APPENDIX C Instrument 94 Uhen a periaenopausal woean Iago eO-SSI presents to your office for a ROUTINE HEALTH MAINTENANCE VISIT do you 0' YOU? Cit?! ROUTINELT! YES pg 1. Ueigh the patient? 2. Inquire as to the cause of death of faaily aeabers? 3. Obtain a sacking history? A. Measure Blood Pressure? 5. Perfora fundoscopic esae? 6. Ask whether the patient perfores aerobic activity on a routine basis? 7. Ask about eaior life changes Inew Job. loss of job. loss of spouse change in job, children, etc.) 6. Do you investigate attitudes toward change? 9. Perfors a 12 lead EKG? iO. Obtain a diet history? 11. Order a fasting glucose? 12. Order a randoe glucose? 13. Order a post-prandial glucose? 14. Order a serua cholesterol? 15. Order triglycerides? 16. Order NDLILDL levels? ______ Any other paraseters that you use to screen periaenopausal woaen Iages so to $5) for cardiovascuIar disease? Inest page. please) 95 Please complete a few demographics for descriptive Purposes OOIY- It will not be possible to identify you from this information. I. PHYSICIANS (ONLY): ‘Uhat is your specialty? Family Practitioner Internist Obstetrician-Gynecologist Board Certified? 60 TO SECTION III. II. NURSES (ONLY): Nurse Practitioner Clinical Nurse Specialist Highest Degree in Nursing? AD with NP certificate Dipl. with NP certificate BSN with NP certificate HSN PHD Uhat is your specialty? a. Family? Certified? b. Maternal-Child? Certified? c. Geriatric? Certified? d. Ned/surg? Certified? e. Oncology? Certified? Other (please list: Certified? Ill llll Private Practice? Yes No If no. where? tie. clinic. hospital,etc.l Geographic location Icounty: 0f practice GO TO SECTION III. III. ALL PARTICIPANTS: Years in Practice? AGE Hale or Female? Number of perimenopausal women seen in your orfice for routine health maintenance per week: 10-50 31-51 52-72 73-93 over 93 Thank You for your time and effort. Please disregard any further reminders that you may receive. APPENDIX D Approval Letter From UCRIHS 96 MICHIGAN STATE UNIVERSITY UNIVERSITY COMMITTEE ON USMC-I INVOLVING LAST LANSING 0 MICHIGAN ‘ «IN-III! HUMAN SUBJECTS (DOM) 3“ my “All (917) 333-973. March 2, I99) IRB# 90-080 Lyn Behnke, RN. 6-3095 Stockbridge Ave. Flint, MI 48506 Dear Ms. Behnke: RE: 'CARDIOVASCULAR RISKASSESSMENT OF PERIMENOPAUSALWOMEN: A DESCRIPTIVE STUDY IRB# 90-080" The above project is exempt from full UCRIHS review. The proposed research protocol has been reviewed by another committee member. The rights and welfare of human subjects appear to be protected and you have approval to conduct the research. You are reminded that UCRIHS approval is valid for one calendar year. If you plan to continue this project beyond one year, please make provisions for obtaining appropriate UCRIHS approval one month prior to March 2, I99l. Any changes in procedures involving human subjects must be reviewed by UCRIHS prior to initiation of the change. UCRIHS must also be notified promptly of any problems (unexpected side effects, oommaints, etc.) involving human subjects during the course of the work Thank you for bringing this project to my attention. If I an be of any future help, please do not hesitate to let me know. Sincerely. Job; K. Htlldzik, PhD. Chair, UCRIHS JKH/sar cc: M. Rothert MSU r. on 41/5me Adios/Equal Opportunity lurid-nee REFERENCES Bofaranoaa Abbott, R. D., Levy, D., Kannel, W. B., Castelli, W.P., Wilson, P. W. F., Garrison, R. I., & Stokes, J. (1989). Cardiovascular risk factors and graded treadmill exercise endurance in healthy adults: The Framingham offSPring study- The American lonnnal.of Cardiology. §;(5), 342-346. Allan, R., & Scheidt, S. 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