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Sheppard JP, Benetos A, Bogaerts J, Gnjidic D, McManus RJ. Strategies for Identifying Patients for Deprescribing of Blood Pressure Medications in Routine Practice: An Evidence Review. Curr Hypertens Rep 2024; 26:225-236. [PMID: 38305846 PMCID: PMC11153298 DOI: 10.1007/s11906-024-01293-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 02/03/2024]
Abstract
PURPOSE OF REVIEW To summarise the evidence regarding which patients might benefit from deprescribing antihypertensive medications. RECENT FINDINGS Older patients with frailty, multi-morbidity and subsequent polypharmacy are at higher risk of adverse events from antihypertensive treatment, and therefore may benefit from antihypertensive deprescribing. It is possible to examine an individual's risk of these adverse events, and use this to identify those people where the benefits of treatment may be outweighed by the harms. While such patients might be considered for deprescribing, the long-term effects of this treatment strategy remain unclear. Evidence now exists to support identification of those who are at risk of adverse events from antihypertensive treatment. These patients could be targeted for deprescribing interventions, although the long-term benefits and harms of this approach are unclear. PERSPECTIVES Randomised controlled trials are still needed to examine the long-term effects of deprescribing in high-risk patients with frailty and multi-morbidity.
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Affiliation(s)
- James P Sheppard
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK.
| | - Athanase Benetos
- CHRU-Nancy, Pôle "Maladies du Vieillissement, Gérontologie Et Soins Palliatifs", and Inserm DCAC u1116, Université de Lorraine, 54000, Nancy, France
| | - Jonathan Bogaerts
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, the Netherlands
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
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Finnikin S, Finney B, Khatib R, McCormack J. Statins, risk, and personalised care. BMJ 2024; 384:e076774. [PMID: 38499292 DOI: 10.1136/bmj-2023-076774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Affiliation(s)
- Sam Finnikin
- Institute of Applied Health Research, Murray Learning Centre, University of Birmingham, Birmingham, UK
| | | | - Rani Khatib
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | - James McCormack
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
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Kuss O, Akbulut C, Schlesinger S, Georgiev A, Kelm M, Roden M, Wolff G. Absolute treatment effects for the primary outcome and all-cause mortality in the cardiovascular outcome trials of new antidiabetic drugs: a meta-analysis of digitalized individual patient data. Acta Diabetol 2022; 59:1349-1359. [PMID: 35879478 PMCID: PMC9402762 DOI: 10.1007/s00592-022-01917-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 06/05/2022] [Indexed: 11/19/2022]
Abstract
AIMS Treatment effects from the large cardiovascular outcome trials (CVOTs) of new antidiabetic drugs are almost exclusively communicated as hazard ratios, although reporting guidelines recommend to report treatment effects also on an absolute scale, e.g. as numbers needed to treat (NNT). We aimed to analyse NNTs in CVOTs comparing dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, or sodium-glucose cotransporter-2 (SGLT2) inhibitors to placebo. METHODS We digitalized individual time-to-event information for the primary outcome and all-cause mortality from 19 CVOTs that compared DPP-4 inhibitors, GLP-1 receptor agonists, or SGLT2 inhibitors to placebo. We estimated Weibull models for each trial and outcome and derived monthly NNTs. NNTs were summarized across all trials and within drug classes by random effects meta-analysis methods. RESULTS Treatment effects in the CVOTs appear smaller if they are reported as NNTs: Overall, 100 (95%-CI: 60, 303) patients have to be treated for 29 months (the median follow-up time across all trials) to avoid a single event of the primary outcome, and 128 (95%-CI: 85, 265) patients have to be treated for 39 months to avoid a single death. NNT time courses are very similar for GLP-1 receptor agonists and SGLT2 inhibitors, whereas treatment effects with DPP-4 inhibitors are smaller. CONCLUSIONS We found that the respective treatment effects look less impressive when communicated on an absolute scale, as numbers needed to treat. For a valid overall picture of the benefit of new antidiabetic drugs, trial authors should also report treatment effects on an absolute scale.
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Affiliation(s)
- Oliver Kuss
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
- Centre for Health and Society, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany.
- Deutsches Diabetes-Zentrum, Institut für Biometrie und Epidemiologie, Auf'm Hennekamp 65, 40225, Düsseldorf, Germany.
| | - Cihan Akbulut
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
| | - Sabrina Schlesinger
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
| | - Asen Georgiev
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Michael Roden
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Drapkina OM, Kontsevaya AV, Kalinina AM, Avdeev SM, Agaltsov MV, Alexandrova LM, Antsiferova AA, Aronov DM, Akhmedzhanov NM, Balanova YA, Balakhonova TV, Berns SA, Bochkarev MV, Bochkareva EV, Bubnova MV, Budnevsky AV, Gambaryan MG, Gorbunov VM, Gorny BE, Gorshkov AY, Gumanova NG, Dadaeva VA, Drozdova LY, Egorov VA, Eliashevich SO, Ershova AI, Ivanova ES, Imaeva AE, Ipatov PV, Kaprin AD, Karamnova NS, Kobalava ZD, Konradi AO, Kopylova OV, Korostovtseva LS, Kotova MB, Kulikova MS, Lavrenova EA, Lischenko OV, Lopatina MV, Lukina YV, Lukyanov MM, Mayev IV, Mamedov MN, Markelova SV, Martsevich SY, Metelskaya VA, Meshkov AN, Milushkina OY, Mukaneeva DK, Myrzamatova AO, Nebieridze DV, Orlov DO, Poddubskaya EA, Popovich MV, Popovkina OE, Potievskaya VI, Prozorova GG, Rakovskaya YS, Rotar OP, Rybakov IA, Sviryaev YV, Skripnikova IA, Skoblina NA, Smirnova MI, Starinsky VV, Tolpygina SN, Usova EV, Khailova ZV, Shalnova SA, Shepel RN, Shishkova VN, Yavelov IS. 2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-3235] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Nielsen JB, Kristiansen IS, Thapa S. Prolongation of disease-free life: When is the benefit sufficient to warrant the effort of taking a preventive medicine? Prev Med 2022; 154:106867. [PMID: 34740678 DOI: 10.1016/j.ypmed.2021.106867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 10/21/2021] [Accepted: 10/30/2021] [Indexed: 11/18/2022]
Abstract
The prolongation of disease-free life (PODL) required by people to be willing to accept an offer of a preventive treatment is unknown. Quantifying the required benefits could guide information and discussions about preventive treatment. In this study, we investigated how large the benefit in prolongation of a disease-free life (PODL) should be for individuals aged 50-80 years to accept a preventive treatment offer. We used a cross-sectional survey design based on a representative sample of 6847 Danish citizens aged 50-80 years. Data were collected in 2019 through a web-based standardized questionnaire administered by Statistics Denmark, and socio-demographic data were added from a national registry. We analyzed the data with chi-square tests and stepwise multinomial logistic regression. The results indicate that the required minimum benefit from the preventive treatment varied widely between individuals (1-week PODL = 14.8%, ≥4 years PODL = 39.2%), and that the majority of individuals (51.1%) required a PODL of ≥2 years. The multivariable analysis indicate that education and income were independently and negatively associated with requested minimum benefit, while age and smoking were independently and positively associated with requested minimum benefit to accept the preventive treatment. Most individuals aged 50-80 years required larger health benefits than most preventive medications on average can offer. The data support the need for educating patients and health care professionals on how to use average benefits when discussing treatment benefits, especially for primary prevention.
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Affiliation(s)
- Jesper B Nielsen
- Research Unit of General Practice, University of Southern Denmark, J.B. Winsløws Vej 9, 5000 Odense, Denmark.
| | - Ivar S Kristiansen
- Research Unit of General Practice, University of Southern Denmark, J.B. Winsløws Vej 9, 5000 Odense, Denmark; Department of Health Management and Health Economics, University of Oslo, Norway.
| | - Subash Thapa
- Research Unit of General Practice, University of Southern Denmark, J.B. Winsløws Vej 9, 5000 Odense, Denmark.
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Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FDR, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur J Prev Cardiol 2021; 29:5-115. [PMID: 34558602 DOI: 10.1093/eurjpc/zwab154] [Citation(s) in RCA: 208] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Alessandro Biffi
- European Federation of Sports Medicine Association (EFSMA).,International Federation of Sport Medicine (FIMS)
| | | | | | | | | | | | | | | | | | | | - F D Richard Hobbs
- World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) - Europe
| | | | | | | | | | | | | | | | | | | | | | - Christoph Wanner
- European Renal Association - European Dialysis and Transplant Association (ERA-EDTA)
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Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FDR, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021; 42:3227-3337. [PMID: 34458905 DOI: 10.1093/eurheartj/ehab484] [Citation(s) in RCA: 2180] [Impact Index Per Article: 726.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Alessandro Biffi
- European Federation of Sports Medicine Association (EFSMA)
- International Federation of Sport Medicine (FIMS)
| | | | | | | | | | | | | | | | | | | | - F D Richard Hobbs
- World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) - Europe
| | | | | | | | | | | | | | | | | | | | | | - Christoph Wanner
- European Renal Association - European Dialysis and Transplant Association (ERA-EDTA)
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Bonner C, Trevena LJ, Gaissmaier W, Han PKJ, Okan Y, Ozanne E, Peters E, Timmermans D, Zikmund-Fisher BJ. Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles. Med Decis Making 2021; 41:821-833. [PMID: 33660551 DOI: 10.1177/0272989x21996328] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Shared decision making requires evidence to be conveyed to the patient in a way they can easily understand and compare. Patient decision aids facilitate this process. This article reviews the current evidence for how to present numerical probabilities within patient decision aids. METHODS Following the 2013 review method, we assembled a group of 9 international experts on risk communication across Australia, Germany, the Netherlands, the United Kingdom, and the United States. We expanded the topics covered in the first review to reflect emerging areas of research. Groups of 2 to 3 authors reviewed the relevant literature based on their expertise and wrote each section before review by the full authorship team. RESULTS Of 10 topics identified, we present 5 fundamental issues in this article. Although some topics resulted in clear guidance (presenting the chance an event will occur, addressing numerical skills), other topics (context/evaluative labels, conveying uncertainty, risk over time) continue to have evolving knowledge bases. We recommend presenting numbers over a set time period with a clear denominator, using consistent formats between outcomes and interventions to enable unbiased comparisons, and interpreting the numbers for the reader to meet the needs of varying numeracy. DISCUSSION Understanding how different numerical formats can bias risk perception will help decision aid developers communicate risks in a balanced, comprehensible manner and avoid accidental "nudging" toward a particular option. Decisions between probability formats need to consider the available evidence and user skills. The review may be useful for other areas of science communication in which unbiased presentation of probabilities is important.
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Affiliation(s)
- Carissa Bonner
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia.,ASK-GP NHMRC Centre of Research Excellence, The University of Sydney, Australia
| | - Lyndal J Trevena
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia.,ASK-GP NHMRC Centre of Research Excellence, The University of Sydney, Australia
| | | | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA.,School of Medicine, Tufts University, USA
| | - Yasmina Okan
- Centre for Decision Research, University of Leeds, Leeds, UK
| | | | - Ellen Peters
- Center for Science Communication Research, University of Oregon, Eugene, OR, USA
| | - Daniëlle Timmermans
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, North Holland, The Netherlands
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10
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Bell K, Doust J, McGeechan K, Horvath AR, Barratt A, Hayen A, Semsarian C, Irwig L. The potential for overdiagnosis and underdiagnosis because of blood pressure variability: a comparison of the 2017 ACC/AHA, 2018 ESC/ESH and 2019 NICE hypertension guidelines. J Hypertens 2021; 39:236-242. [PMID: 32773652 PMCID: PMC7810411 DOI: 10.1097/hjh.0000000000002614] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 07/02/2020] [Accepted: 07/12/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate the extent that BP measurement variability may drive over- and underdiagnosis of 'hypertension' when measurements are made according to current guidelines. METHODS Using data from the National Health and Nutrition Examination Survey and empirical estimates of within-person variability, we simulated annual SBP measurement sets for 1 000 000 patients over 5 years. For each measurement set, we used an average of multiple readings, as recommended by guidelines. RESULTS The mean true SBP for the simulated population was 118.8 mmHg with a standard deviation of 17.5 mmHg. The proportion overdiagnosed with 'hypertension' after five sets of office or nonoffice measurements using the 2017 American College of Cardiology guideline was 3-5% for people with a true SBP less than 120 mmHg, and 65-72% for people with a true SBP 120-130 mmHg. These proportions were less than 1% and 14-33% using the 2018 European Society of Hypertension and 2019 National Institute for Health and Care Excellence guidelines (true SBP <120 and 120-130 mmHg, respectively). The proportion underdiagnosed with 'hypertension' was less than 3% for people with true SBP at least 140 mmHg after one set of office or nonoffice measurements using the 2017 American College of Cardiology guideline, and less than 18% using the other two guidelines. CONCLUSION More people are at risk of overdiagnosis under the 2017 American College of Cardiology guideline than the other two guidelines, even if nonoffice measurements are used. Making clinical decisions about cardiovascular prediction based primarily on absolute risk, minimizes the impact of blood pressure variability on overdiagnosis.
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Affiliation(s)
- Katy Bell
- School of Public Health, Faculty of Medicine and Health, The University of Sydney
| | - Jenny Doust
- New South Wales Health Pathology, Department of Clinical Chemistry and Endocrinology
| | - Kevin McGeechan
- School of Public Health, Faculty of Medicine and Health, The University of Sydney
| | | | - Alexandra Barratt
- School of Public Health, Faculty of Medicine and Health, The University of Sydney
| | - Andrew Hayen
- Australian Centre for Public and Population Health Research, University of Technology Sydney (UTS)
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Les Irwig
- School of Public Health, Faculty of Medicine and Health, The University of Sydney
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12
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Franco JVA, Arancibia M, Meza N, Madrid E, Kopitowski K. Clinical practice guidelines: Concepts, limitations and challenges. Medwave 2020; 20:e7887. [PMID: 32428925 DOI: 10.5867/medwave.2020.03.7887] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/20/2020] [Indexed: 11/27/2022] Open
Abstract
Clinical practice guidelines are the most important documents for the incorporation of scientific evidence in health decision making through the formulation of recommendations. There is a variable terminology used to refer to the documents that guide health professionals in decision making. When clinical practice guidelines are of high quality, they appraise contextual aspects such as the use of resources, applicability, and patients values and preferences. Even so, they are not recipe books, since they may have limitations. In this review, we propose to clarify the different denominations across the various types of documents available to guide the health professional when making clinical decisions. We discuss the main characteristics of clinical practice guidelines, quality assessment, challenges, and limitations.
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Affiliation(s)
- Juan Víctor Ariel Franco
- Centro Cochrane Asociado, Departamento de Investigación, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina. ORCID: 0000-0003-0411-899X
| | - Marcelo Arancibia
- Centro Interdisciplinario de Estudios en Salud (CIESAL), Escuela de Medicina, Universidad de Valparaíso, Viña del Mar, Chile. . ORCID: 0000-0003-2239-6248
| | - Nicolás Meza
- Centro Interdisciplinario de Estudios en Salud (CIESAL), Escuela de Medicina, Universidad de Valparaíso, Viña del Mar, Chile. ORCID: 0000-0001-9505-0358
| | - Eva Madrid
- Centro Interdisciplinario de Estudios en Salud (CIESAL), Escuela de Medicina, Universidad de Valparaíso, Viña del Mar, Chile. ORCID: 0000-0002-8095-5549
| | - Karin Kopitowski
- Departamento de Investigación, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina. ORCID: 0000-0003-0939-0263
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De Smedt D, De Backer T, Petrovic M, De Backer G, Wood D, Kotseva K, De Bacquer D. Chronic medication intake in patients with stable coronary heart disease across Europe: Evidence from the daily clinical practice. Results from the ESC EORP European Survey of Cardiovascular Disease Prevention and Diabetes (EUROASPIRE IV) Registry. Int J Cardiol 2020; 300:7-13. [PMID: 31744720 DOI: 10.1016/j.ijcard.2019.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 08/21/2019] [Accepted: 09/05/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND As advised by the European guidelines on cardiovascular prevention, medication intake is a major component of secondary prevention. The aim of this study is to provide an in-depth overview of the medication intake in stable European coronary heart disease (CHD) patients. METHODS Analyses are based on the EUROASPIRE IV survey, including CHD patients (18 to 80 years) who were hospitalized for a coronary event. These patients were interviewed and examined 6 months to 3 years after their hospitalization. Information on cardiovascular medication intake is available for 7953 patients. RESULTS About 99.2% of patients were on any kind of cardiovascular medication and 67.6% of patients were taking at least 5 different cardiovascular drugs. Overall, even when patients are taking the recommended drug combination as advised by the European guidelines - accounting for their disease profile - a large proportion of patients is still not on blood pressure, LDL-C or HbA1c target. In addition, huge variations were seen in medication dose intake across countries. Comparing the dose intake to the defined daily dose (DDD as published by the WHO) indicated a substantial deviation from the DDDs for a large proportion of patients. CONCLUSION This study provides a unique overview of the cardiovascular medication intake in CHD patients. Overall, even when patients are taking the advised drug combination, a large proportion of patients is still not on risk factor target. Physicians should seek for a balance in medication intake and appropriate dose, accounting both for the benefits and risks of chronic drug intake.
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Affiliation(s)
- Delphine De Smedt
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Tine De Backer
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Ghent University Hospital, Ghent, Belgium
| | - Mirko Petrovic
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Ghent University Hospital, Ghent, Belgium
| | - Guy De Backer
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - David Wood
- National Heart & Lung Institute, Imperial College London, London, UK; National Institute for Prevention and Cardiovascular Health, National University of Ireland, Galway, Ireland
| | - Kornelia Kotseva
- National Institute for Prevention and Cardiovascular Health, National University of Ireland, Galway, Ireland; Imperial College Healthcare NHS Trust, London, UK
| | - Dirk De Bacquer
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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Translating clinical trial results into personalized recommendations by considering multiple outcomes and subjective views. NPJ Digit Med 2019; 2:81. [PMID: 31453376 PMCID: PMC6704144 DOI: 10.1038/s41746-019-0156-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 07/03/2019] [Indexed: 12/05/2022] Open
Abstract
Currently, clinicians rely mostly on population-level treatment effects from RCTs, usually considering the treatment's benefits. This study proposes a process, focused on practical usability, for translating RCT data into personalized treatment recommendations that weighs benefits against harms and integrates subjective perceptions of relative severity. Intensive blood pressure treatment (IBPT) was selected as the test case to demonstrate the suggested process, which was divided into three phases: (1) Prediction models were developed using the Systolic Blood-Pressure Intervention Trial (SPRINT) data for benefits and adverse events of IBPT. The models were externally validated using retrospective Clalit Health Services (CHS) data; (2) Predicted risk reductions and increases from these models were used to create a yes/no IBPT recommendation by calculating a severity-weighted benefit-to-harm ratio; (3) Analysis outputs were summarized in a decision support tool. Based on the individual benefit-to-harm ratios, 62 and 84% of the SPRINT and CHS populations, respectively, would theoretically be recommended IBPT. The original SPRINT trial results of significant decrease in cardiovascular outcomes following IBPT persisted only in the group that received a “yes-treatment” recommendation by the suggested process, while the rate of serious adverse events was slightly higher in the "no-treatment" recommendation group. This process can be used to translate RCT data into individualized recommendations by identifying patients for whom the treatment’s benefits outweigh the harms, while considering subjective views of perceived severity of the different outcomes. The proposed approach emphasizes clinical practicality by mimicking physicians’ clinical decision-making process and integrating all recommendation outputs into a usable decision support tool.
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Hansen TB, Lindholt JS, Diederichsen A, Søgaard R. Do Non-participants at Screening have a Different Threshold for an Acceptable Benefit-Harm Ratio than Participants? Results of a Discrete Choice Experiment. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2019; 12:491-501. [PMID: 31165400 DOI: 10.1007/s40271-019-00364-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The objective of the study was to investigate non-participants' preferences for cardiovascular disease screening programme characteristics and whether non-participation can be rationally explained by differences in preferences, decision-making styles and informational needs between non-participants and participants. METHODS We conducted a discrete choice experiment at three screening sites between June and December 2017 among 371 male non-participants and 830 male participants who were asked to trade different levels of five key programme characteristics (chance of health benefit, risk of overtreatment, risk of later regret, screening duration and screening location). Data were analysed using a multinomial mixed-logit model. Health benefit was used as a payment vehicle for estimation of marginal substitution rates. RESULTS Non-participants were willing to accept that 0.127 (95% confidence interval 0.103-0.154) fewer lives would be saved to avoid overtreatment of one individual, whilst participants were willing to accept 0.085 (95% confidence interval 0.077-0.094) fewer lives saved. This translates into non-participants valuing health benefits 7.9 times higher than overtreatment. The corresponding value of participants is 11.8. Similarly, non-participants had higher requirements than participants for advanced technology and a quicker screening duration. With regard to their participation decision, 64% of the non-participants felt certain about their choice compared with 89% among participants. CONCLUSIONS This study shows that non-participants have different preferences than participants at screening as they express relatively more concern about overtreatment and have higher requirements for a high-tech screening programme. Non-participants also report to be more uncertain about their participation decision and more often seek additional information to the standard information provided in the invitation letter. Further studies on informational needs and effective communication strategies are warranted to ensure that non-participation is a fully informed choice.
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Affiliation(s)
- Tina Birgitte Hansen
- Department of Cardiology, Zealand University Hospital, Sygehusvej 10, 4000, Roskilde, Denmark. .,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Jes Sanddal Lindholt
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark.,Elitary Research Unit of Personalized Medicine in Arterial Disease (CIMA), Odense University Hospital, Odense, Denmark
| | - Axel Diederichsen
- Elitary Research Unit of Personalized Medicine in Arterial Disease (CIMA), Odense University Hospital, Odense, Denmark.,Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Rikke Søgaard
- Department of Public Health, Aarhus University, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Statins for primary prevention of cardiovascular disease: modelling guidelines and patient preferences based on an Irish cohort. Br J Gen Pract 2019; 69:e373-e380. [PMID: 31015226 DOI: 10.3399/bjgp19x702701] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 12/14/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Changes in clinical guidelines for primary prevention of cardiovascular disease (CVD) have widened eligibility for statin therapy. AIM To illustrate the potential impacts of changes in clinical guidelines. DESIGN AND SETTING Modelling the impacts of seven consecutive European guidelines based on a cohort of people aged ≥50 years from the Irish Longitudinal Study on Ageing. METHOD The eligibility for statin therapy of a sample of people without a history of CVD was established, according to changing guideline recommendations and modelled associated potential costs. The authors calculated the numbers needed to treat (NNT) to prevent one major vascular event in patients at the lowest baseline risk for which each of the seven guidelines recommended treatment, and for those at low, medium, high, and very-high risk according to 2016 guidelines. These were compared with the NNT that patients reported as required to justify taking a daily medicine. RESULTS The proportion of patients eligible for statins increased from approximately 8% in 1987 to 61% in 2016; associated costs rose from €13.9 million to €107.1 million per annum. The NNT for those at the lowest risk for which each guideline recommended treatment rose from 40 to 400. By 2016, the NNT for low-risk patients was 400 compared to ≤25 very-high risk patients. The proportion of patients eligible for statins achieving NNT levels that patients regarded as justified to taking a daily medicine fell as guidelines changed over time. CONCLUSION Increased eligibility for statin therapy impacts large proportions of the present population and healthcare budgets. Decisions to take and reimburse statins should be considered on the basis of expected cost-effectiveness and acceptability to patients.
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Byrne P, Cullinan J, Smith A, Smith SM. Statins for the primary prevention of cardiovascular disease: an overview of systematic reviews. BMJ Open 2019; 9:e023085. [PMID: 31015265 PMCID: PMC6500096 DOI: 10.1136/bmjopen-2018-023085] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To synthesise evidence from exclusively primary prevention data on the effectiveness of statins for prevention of cardiovascular disease (CVD), including stroke, and outcomes stratified by baseline risk and gender. DESIGN Overview of systematic reviews (SRs) using Revised-AMSTAR approach to assess quality. DATA SOURCES Cochrane Database of Systematic Reviews, MEDLINE, Embase, PubMed, Scopus and PROSPERO to June 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES SRs of randomised control trials (RCTs) or individual patient data (IPD) from RCTs, examining the effectiveness of statins versus placebo or no treatment on all-cause mortality, coronary heart disease, CVD (including stroke) and composite endpoints, with stratification by baseline risk and gender. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed methodological quality. A narrative synthesis was conducted. RESULTS Three SRs were included. Quality of included SRs was mixed, and none reported on the risk of bias of included trials.We found trends towards reduced all-cause mortality in all SRs (RR 0.91 [95% CI 0.85 to 0.97]), (RR 0.91 [95% CI 0.83 to 1.01]) and (RR 0.78 [95% CI 0.53 to 1.15]) though it was not statistically significant in two SRs. When stratified by baseline risk, the effect on all-cause mortality was no longer statistically significant except in one medium risk category. One review reported significant reductions (RR 0.85 [95% CI 0.77 to 0.95]) in vascular deaths and non-significant reductions in non-vascular deaths (RR 0.97 [95% CI 0.88 to 1.07]). There were significant reductions in composite outcomes overall, but mixed results were reported in these when stratified by baseline risk. These reviews included studies with participants considered risk equivalent to those with established CVD. CONCLUSIONS There is limited evidence on the effectiveness of statins for primary prevention with mixed findings from studies including participants with widely ranging baseline risks. Decision making for the use of statins should consider individual baseline risk, absolute risk reduction and whether risk reduction justifies potential harms and taking a daily medicine for life. TRIAL REGISTRATION NUMBER CRD42017064761.
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Affiliation(s)
- Paula Byrne
- J.E. Cairnes School of Business and Economics, National University of Ireland Galway, Galway, Ireland
| | - John Cullinan
- J.E. Cairnes School of Business and Economics, National University of Ireland Galway, Galway, Ireland
| | - Amelia Smith
- Department of Pharmacology and Therapeutics, University of Dublin Trinity College, Dublin, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research and Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
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Albarqouni L, Doust JA, Magliano D, Barr ELM, Shaw JE, Glasziou PP. External validation and comparison of four cardiovascular risk prediction models with data from the Australian Diabetes, Obesity and Lifestyle study. Med J Aust 2019; 210:161-167. [DOI: 10.5694/mja2.12061] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 11/13/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Loai Albarqouni
- Centre for Research in Evidence‐Based PracticeBond University Gold Coast QLD
| | - Jennifer A Doust
- Centre for Research in Evidence‐Based PracticeBond University Gold Coast QLD
| | | | - Elizabeth LM Barr
- Baker IDI Heart and Diabetes Institute Melbourne VIC
- Menzies School of Health Research Darwin NT
| | | | - Paul P Glasziou
- Centre for Research in Evidence‐Based PracticeBond University Gold Coast QLD
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Individual preferences on the balancing of good and harm of cardiovascular disease screening. Heart 2019; 105:761-767. [DOI: 10.1136/heartjnl-2018-314103] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 12/04/2018] [Accepted: 12/10/2018] [Indexed: 01/19/2023] Open
Abstract
ObjectiveTransition towards value-based healthcare requires insight into what makes value to the individual. The aim was to elicit individual preferences for cardiovascular disease screening with respect to the difficult balancing of good and harm as well as mode of delivery.MethodsA discrete choice experiment was conducted as a cross-sectional survey among 1231 male screening participants at three Danish hospitals between June and December 2017. Participants chose between hypothetical screening programmes characterised by varying levels of mortality risk reduction, avoidance of overtreatment, avoidance of regretting participation, screening duration and location. A multinomial mixed logit model was used to model the preferences and the willingness to trade mortality risk reduction for improvements on other characteristics.ResultsRespondents expressed preferences for improvements on all programme characteristics. They were willing to give up 0.09 (95% CI 0.08 to 0.09) lives saved per 1000 screened to avoid one individual being over treated. Similarly, respondents were willing to give up 1.22 (95% CI 0.90 to 1.55) or 5.21 (95% CI 4.78 to 5.67) lives saved per 1000 screened to upgrade the location from general practice to a hospital or to a high-tech hospital, respectively. Subgroup analysis revealed important preference heterogeneity with respect to smoking status, level of health literacy and self-perceived risk of cardiovascular disease.ConclusionsIndividuals are able to express clear preferences about what makes value to them. Not only health benefit but also time with health professionals and access to specialised facilities were important. This information could guide the optimal programme design in search of value-based healthcare.
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Ho CLB, Chowdhury EK, Breslin M, Doust J, Reid CM, Wing LMH, Nelson MR. Short- and long-term association of lipid-lowering drug treatment and cardiovascular disease by estimated absolute risk in the Second Australian National Blood Pressure study. J Clin Lipidol 2018; 13:148-155. [PMID: 30293937 DOI: 10.1016/j.jacl.2018.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/30/2018] [Accepted: 08/31/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is currently insufficient evidence to support the use of lipid-lowering drug treatment (LLT) for primary prevention of cardiovascular disease (CVD) in the elderly. OBJECTIVES We examined the relationship of early initiation of LLT with short- and long-term all-cause and CVD mortality in persons older than 65 years in this post hoc study from the Second Australian National Blood Pressure study (ANBP2). METHODS This was an in- and post-trial observational study. About 4257 hypertensive participants aged 65 to 84 years within Australian family practices were randomized to an angiotensin-converting enzyme inhibitor or a diuretic treatment group. After excluding participants with a prior history of CVD, the cohort was stratified into "LLT" and "no LLT" subgroups based on LLT status at randomization. RESULTS At randomization, the participants had a mean age of 72 years, average blood pressure of 168/91 mm Hg and estimated 5-year CVD risk of 18.7 ± 8.3%. In the overall study population, the association of LLT with long-term (11-years) all-cause and non-CVD mortality was significant (hazard ratio [HR] 0.78 [95% confidence interval {CI} 0.66-0.92, P = .003] and HR 0.70 [95% CI 0.54-0.90, P = .006], respectively). Magnitudes of the association of LLT with long-term mortality and the association with short-term mortality were similar; however, no statistically significant association with short-term mortality was observed. In the subgroup analysis by baseline 5-year CVD risk, LLT participants in the highest risk tertile had a substantially lower relative risk for short-term all-cause mortality (HR 0.31, 95% CI 0.13-0.71, P for interaction .02) compared to those with lower estimated CVD risk. All analyses were adjusted for baseline and in-trial characteristics. CONCLUSION Our study showed a strong association between LLT and reduced long-term all-cause mortality. Thus, our findings support recommendations of the use of LLT in patients over 65 years, particularly those with high CVD risk who were more likely to obtain additional benefits in the short term. The findings also suggested that mortality benefits of LLT for the elderly may take longer to become evident.
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Affiliation(s)
- Chau L B Ho
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
| | - Enayet K Chowdhury
- CCRE Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; School of Public Health, Curtin University, Perth, Australia
| | - Monique Breslin
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Jenny Doust
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Christopher M Reid
- CCRE Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; School of Public Health, Curtin University, Perth, Australia
| | - Lindon M H Wing
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; CCRE Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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22
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McCartney D, McManus RJ. Intensive versus standard blood pressure treatment improves cardiovascular outcomes without any difference in patient-reported outcomes. BMJ Evid Based Med 2018; 23:114-115. [PMID: 29789320 DOI: 10.1136/bmjebm-2017-110879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2018] [Indexed: 11/03/2022]
Affiliation(s)
- David McCartney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Bell KJL, Doust J, Glasziou P. Incremental Benefits and Harms of the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline. JAMA Intern Med 2018; 178:755-757. [PMID: 29710197 DOI: 10.1001/jamainternmed.2018.0310] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Katy J L Bell
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jenny Doust
- Centre for Research in Evidence Based Practice, Bond University, Gold Coast, Queensland, Australia
| | - Paul Glasziou
- Centre for Research in Evidence Based Practice, Bond University, Gold Coast, Queensland, Australia
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Jaspers NEM, Visseren FLJ, Numans ME, Smulders YM, van Loenen Martinet FA, van der Graaf Y, Dorresteijn JAN. Variation in minimum desired cardiovascular disease-free longevity benefit from statin and antihypertensive medications: a cross-sectional study of patient and primary care physician perspectives. BMJ Open 2018; 8:e021309. [PMID: 29804065 PMCID: PMC5988148 DOI: 10.1136/bmjopen-2017-021309] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/27/2018] [Accepted: 03/29/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE Expressing therapy benefit from a lifetime perspective, instead of only a 10-year perspective, is both more intuitive and of growing importance in doctor-patient communication. In cardiovascular disease (CVD) prevention, lifetime estimates are increasingly accessible via online decision tools. However, it is unclear what gain in life expectancy is considered meaningful by those who would use the estimates in clinical practice. We therefore quantified lifetime and 10-year benefit thresholds at which physicians and patients perceive statin and antihypertensive therapy as meaningful, and compared the thresholds with clinically attainable benefit. DESIGN Cross-sectional study. SETTINGS (1) continuing medical education conference in December 2016 for primary care physicians;(2) information session in April 2017 for patients. PARTICIPANTS 400 primary care physicians and 523 patients in the Netherlands. OUTCOME Months gain of CVD-free life expectancy at which lifelong statin therapy is perceived as meaningful, and months gain at which 10 years of statin and antihypertensive therapy is perceived as meaningful. Physicians were framed as users for lifelong and prescribers for 10-year therapy. RESULTS Meaningful benefit was reported as median (IQR). Meaningful lifetime statin benefit was 24 months (IQR 23-36) in physicians (as users) and 42 months (IQR 12-42) in patients willing to consider therapy. Meaningful 10-year statin benefit was 12 months (IQR 10-12) for prescribing (physicians) and 14 months (IQR 10-14) for using (patients). Meaningful 10-year antihypertensive benefit was 12 months (IQR 8-12) for prescribing (physicians) and 14 months (IQR 10-14) for using (patients). Women desired greater benefit than men. Age, CVD status and co-medication had minimal effects on outcomes. CONCLUSION Both physicians and patients report a large variation in meaningful longevity benefit. Desired benefit differs between physicians and patients and exceeds what is clinically attainable. Clinicians should recognise these discrepancies when prescribing therapy and implement individualised medicine and shared decision-making. Decision tools could provide information on realistic therapy benefit.
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Affiliation(s)
- Nicole E M Jaspers
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mattijs E Numans
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Yvo M Smulders
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Yolanda van der Graaf
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
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