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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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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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Hedberg B, Malm D, Karlsson JE, Årestedt K, Broström A. Factors associated with confidence in decision making and satisfaction with risk communication among patients with atrial fibrillation. Eur J Cardiovasc Nurs 2017; 17:446-455. [DOI: 10.1177/1474515117741891] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Atrial fibrillation is a prevalent cardiac arrhythmia. Effective communication of risks (e.g. stroke risk) and benefits of treatment (e.g. oral anticoagulants) is crucial for the process of shared decision making. Aim: The aim of this study was to explore factors associated with confidence in decision making and satisfaction with risk communication after a follow-up visit among patients who three months earlier had visited an emergency room for atrial fibrillation related symptoms. Methods: A cross-sectional design was used and 322 patients (34% women), mean age 66.1 years (SD 10.5 years) with atrial fibrillation were included in the south of Sweden. Clinical examinations were done post an atrial fibrillation episode. Self-rating scales for communication (Combined Outcome Measure for Risk Communication and Treatment Decision Making Effectiveness), uncertainty in illness (Mishel Uncertainty in Illness Scale–Community), mastery of daily life (Mastery Scale), depressive symptoms (Hospital Anxiety and Depression Scale) and vitality, physical health and mental health (36-item Short Form Health Survey) were used to collect data. Results: Decreased vitality and mastery of daily life, as well as increased uncertainty in illness, were independently associated with lower confidence in decision making. Absence of hypertension and increased uncertainty in illness were independently associated with lower satisfaction with risk communication. Clinical atrial fibrillation variables or depressive symptoms were not associated with satisfaction with confidence in decision making or satisfaction with risk communication. The final models explained 29.1% and 29.5% of the variance in confidence in decision making and satisfaction with risk communication. Conclusion: Confidence in decision making is associated with decreased vitality and mastery of daily life, as well as increased uncertainty in illness, while absence of hypertension and increased uncertainty in illness are associated with risk communication satisfaction.
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Affiliation(s)
- Berith Hedberg
- Jönköping Academy for Health and Welfare, Jönköping University, Sweden
- Region Jönköpings län, Futurum, Jönköping, Sweden
| | - Dan Malm
- Department of Nursing Science, School of Health Sciences, Jönköping University, Sweden
- Ryhov County Hospital, Region Jönköpings län Jönköping, Sweden
| | - Jan-Erik Karlsson
- Jönköping Academy for Health and Welfare, Jönköping University, Sweden
- Department of Internal Medicine, Department of Medical and Health Sciences, Linköping University, Sweden
| | - Kristofer Årestedt
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
- Department of Medicine and Health Sciences, Linköping University, Sweden
| | - Anders Broström
- Department of Nursing Science, School of Health Sciences, Jönköping University, Sweden
- Department of Clinical Neurophysiology, Linköping University Hospital, Sweden
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Nielsen JB, Leppin A, Gyrd-Hansen DE, Jarbøl DE, Søndergaard J, Larsen PV. Barriers to lifestyle changes for prevention of cardiovascular disease - a survey among 40-60-year old Danes. BMC Cardiovasc Disord 2017; 17:245. [PMID: 28899356 PMCID: PMC5596487 DOI: 10.1186/s12872-017-0677-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 09/04/2017] [Indexed: 11/10/2022] Open
Abstract
Background Elimination of modifiable risk factors including unhealthy lifestyle has the potential for prevention of 80% of cardiovascular disease cases. The present study focuses on disclosing barriers for maintaining specific lifestyle changes by exploring associations between perceiving these barriers and various sociodemographic and health-related characteristics. Methods Data were collected through a web-based questionnaire survey and included 962 respondents who initially accepted treatment for a hypothetical cardiovascular risk, and who subsequently stated that they preferred lifestyle changes to medication. Logistic regression was used to analyse associations between barriers to lifestyle changes and relevant covariates. Results A total of 45% of respondents were identified with at least one barrier to introducing 30 min extra exercise daily, 30% of respondents reported at least one barrier to dietary change, and among smokers at least one barrier to smoking cessation was reported by 62% of the respondents. The perception of specific barriers to lifestyle change depended on sociodemographic and health-related characteristics. Conclusion We observed a considerable heterogeneity between different social groups in the population regarding a number of barriers to lifestyle change. Our study demonstrates that social inequality exists in the ability to take appropriate preventive measures through lifestyle changes to stay healthy. This finding underlines the challenge of social inequality even in populations with equal and cost-free access to health care. Our study suggests supplementing traditional public campaigns to counter cardiovascular disease by using individualized and targeted initiatives.
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Affiliation(s)
- Jesper Bo Nielsen
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, J.B.Winsløwvej 9, DK-5000, Odense, Denmark.
| | - Anja Leppin
- Unit for Health Promotion Research, Department of Public Health, University of Southern Denmark, Niels Bohrs Vej 9, DK-6700, Esbjerg, Denmark
| | - Dort E Gyrd-Hansen
- COHERE, Department of Public Health, University of Southern Denmark, J.B.Winsløwvej 9, DK-5000, Odense, Denmark
| | - Dorte Ejg Jarbøl
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, J.B.Winsløwvej 9, DK-5000, Odense, Denmark
| | - Jens Søndergaard
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, J.B.Winsløwvej 9, DK-5000, Odense, Denmark
| | - Pia Veldt Larsen
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, J.B.Winsløwvej 9, DK-5000, Odense, Denmark
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Albarqouni L, Doust J, Glasziou P. Patient preferences for cardiovascular preventive medication: a systematic review. Heart 2017; 103:1578-1586. [PMID: 28501795 DOI: 10.1136/heartjnl-2017-311244] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/11/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To systematically review current evidence regarding the minimum acceptable risk reduction of a cardiovascular event that patients feel would justify daily intake of a preventive medication. METHODS We used the Web of Science to track the forward and backward citations of a set of five key articles until 15 November 2016. Studies were eligible if they quantitatively assessed the minimum acceptable benefit-in absolute values-of a cardiovascular disease preventive medication among a sample of the general population and required participants to choose if they would consider taking the medication. RESULTS Of 341 studies screened, we included 22, involving a total of 17 751 participants: 6 studied prolongation of life (POL), 12 studied absolute risk reduction (ARR) and 14 studied number needed to treat (NNT) as measures of risk reduction communicated to the patients. In studies framed using POL, 39%-54% (average: 48%) of participants would consider taking a medication if it prolonged life by <8 months and 56%-73% (average: 64%) if it prolonged life by ≥8 months. In studies framed using ARR, 42%-72% (average: 54%) of participants would consider taking a medication that reduces their 5-year cardiovascular disease (CVD) risk by <3% and 50%-89% (average: 77%) would consider taking a medication that reduces their 5-year CVD risk by ≥3%. In studies framed using 5-year NNT, 31%-81% (average: 60%) of participants would consider taking a medication with an NNT of >30 and 46%-87% (average: 71%) with an NNT of ≤30. CONCLUSIONS Many patients require a substantial risk reduction before they consider taking a daily medication worthwhile, even when the medication is described as being side effect free and costless.
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Affiliation(s)
- Loai Albarqouni
- Centre for Research in Evidence-Based Practice (CREBP), Bond University, Gold Coast, Australia
| | - Jenny Doust
- Centre for Research in Evidence-Based Practice (CREBP), Bond University, Gold Coast, Australia
| | - Paul Glasziou
- Centre for Research in Evidence-Based Practice (CREBP), Bond University, Gold Coast, Australia
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Guthrie B, Thompson A, Dumbreck S, Flynn A, Alderson P, Nairn M, Treweek S, Payne K. Better guidelines for better care: accounting for multimorbidity in clinical guidelines – structured examination of exemplar guidelines and health economic modelling. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05160] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BackgroundMultimorbidity is common but most clinical guidelines focus on single diseases.AimTo test the feasibility of new approaches to developing single-disease guidelines to better account for multimorbidity.DesignLiterature-based and economic modelling project focused on areas where multimorbidity makes guideline application problematic.Methods(1) Examination of accounting for multimorbidity in three exemplar National Institute for Health and Care Excellence guidelines (type 2 diabetes, depression, heart failure); (2) examination of the applicability of evidence in multimorbidity for the exemplar conditions; (3) exploration of methods for comparing absolute benefit of treatment; (4) incorporation of treatment pay-off time and competing risk of death in an exemplar economic model for long-term preventative treatments with slowly accruing benefit; and (5) development of a discrete event simulation model-based cost-effectiveness analysis for people with both depression and coronary heart disease.Results(1) Comorbidity was rarely accounted for in the clinical research questions that framed the development of the exemplar guidelines, and was rarely accounted for in treatment recommendations. Drug–disease interactions were common only for comorbid chronic kidney disease, but potentially serious drug–drug interactions between recommended drugs were common and rarely accounted for in guidelines. (2) For all three conditions, the trials underpinning treatment recommendations largely excluded older, more comorbid and more coprescribed patients. The implications of low applicability varied by condition, with type 2 diabetes having large differences in comorbidity, whereas potentially serious drug–drug interactions were more important for depression. (3) Comparing absolute benefit of treatments for different conditions was shown to be technically feasible, but only if guideline developers are willing to make a number of significant assumptions. (4) The lifetime absolute benefit of statins for primary prevention is highly sensitive to the presence of both the direct treatment disutility of taking a daily tablet and competing risk of death. (5) It was feasible to use a discrete event simulation-based model to represent the relevant care pathways to estimate the relative cost-effectiveness of pharmacological treatments of major depressive disorder in primary care for patients who are also likely to go on and receive treatment for coronary heart disease but the analysis was reliant on eliciting some parameter values from experts, which increases the inherent uncertainty in the results. The key limitation was that real-life use in guideline development was not examined.ConclusionsGuideline developers could feasibly (1) use epidemiological data characterising the guideline population to inform consideration of applicability and interactions; (2) systematically compare the absolute benefit of long-term preventative treatments to inform decision-making in people with multimorbidity and high treatment burden; and (3) modify the output from economic models used in guideline development to examine time to benefit in terms of the pay-off time and varying competing risk of death from other conditions.Future workFurther research is needed to optimise presentation of comparative absolute benefit information to clinicians and patients, to evaluate the use of epidemiological and time-to-benefit data in guideline development, to better quantify direct treatment disutility and to better quantify benefit and harm in people with multimorbidity.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Bruce Guthrie
- Population Health Sciences Division, University of Dundee, Dundee, UK
| | - Alexander Thompson
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Siobhan Dumbreck
- Population Health Sciences Division, University of Dundee, Dundee, UK
| | - Angela Flynn
- Population Health Sciences Division, University of Dundee, Dundee, UK
| | - Phil Alderson
- Centre for Clinical Practice, National Institute for Health and Care Excellence, Manchester, UK
| | - Moray Nairn
- Scottish Intercollegiate Guidelines Network, Edinburgh, UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
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Berglund E, Westerling R, Sundström J, Lytsy P. Treatment effect expressed as the novel Delay of Event measure is associated with high willingness to initiate preventive treatment - A randomized survey experiment comparing effect measures. PATIENT EDUCATION AND COUNSELING 2016; 99:2005-2011. [PMID: 27499030 DOI: 10.1016/j.pec.2016.07.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES This study aimed to investigate patients' willingness to initiate a preventive treatment and compared two established effect measures to the newly developed Delay of Events (DoE) measure that expresses treatment effect as a gain in event-free time. METHODS In this cross-sectional, randomized survey experiment in the general Swedish population,1079 respondents (response rate 60.9%) were asked to consider a preventive cardiovascular treatment. Respondents were randomly allocated to one of three effect descriptions: DoE, relative risk reduction (RRR), or absolute risk reduction (ARR). Univariate and multivariate analyses were performed investigating willingness to initiate treatment, views on treatment benefit, motivation and importance to adhere and willingness to pay for treatment. RESULTS Eighty-one percent were willing to take the medication when the effect was described as DoE, 83.0% when it was described as RRR and 62.8% when it was described as ARR. DoE and RRR was further associated with positive views on treatment benefit, motivation, importance to adhere and WTP. CONCLUSIONS Presenting treatment effect as DoE or RRR was associated with a high willingness to initiate treatment. PRACTICE IMPLICATIONS An approach based on the novel time-based measure DoE may be of value in clinical communication and shared decision making.
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Affiliation(s)
- Erik Berglund
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
| | - Ragnar Westerling
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Per Lytsy
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
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Communicating risk using absolute risk reduction or prolongation of life formats: cluster-randomised trial in general practice. Br J Gen Pract 2015; 64:e199-207. [PMID: 24686884 DOI: 10.3399/bjgp14x677824] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND It is important that patients are well-informed about risks and benefits of therapies to help them decide whether to accept medical therapy. Different numerical formats can be used in risk communication but It remains unclear how the different formats affect decisions made by real-life patients. AIM To compare the impact of using Prolongation Of Life (POL) and Absolute Risk Reduction (ARR) information formats to express effectiveness of cholesterol-lowering therapy on patients' redemptions of statin prescriptions, and on patients' confidence in their decision and satisfaction with the risk communication. DESIGN AND SETTING Cluster-randomised clinical trial in general practices. Thirty-four Danish GPs from 23 practices participated in a primary care-based clinical trial concerning use of quantitative effectiveness formats for risk communication in health prevention consultations. METHOD GPs were cluster-randomised (treating practices as clusters) to inform patients about cardiovascular mortality risk and the effectiveness of statin treatment using either POL or ARR formats. Patients' redemptions of statin prescriptions were obtained from a regional prescription database. The COMRADE questionnaire was used to measure patients' confidence in their decision and satisfaction with the risk communication. RESULTS Of the 240 patients included for analyses, 112 were allocated to POL information and 128 to ARR. Patients redeeming a statin prescription totalled six (5.4%) when informed using POL, and 32 (25.0%) when using ARR. The level of confidence in decision and satisfaction with risk communication did not differ between the risk formats. CONCLUSION Patients redeemed statin prescriptions less often when their GP communicated treatment effectiveness using POL compared with ARR.
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Bo NJ, Ejg JD, Dorte GH, Lind BBM, Veldt LP. Determinants for acceptance of preventive treatment against heart disease - a web-based population survey. BMC Public Health 2014; 14:783. [PMID: 25086654 PMCID: PMC4137069 DOI: 10.1186/1471-2458-14-783] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/22/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients' perception of risk and their lifestyle choices are of major importance in the treatment of common chronic diseases. This study reveals determinants for and knowledge about why people accept or reject preventive medical interventions against heart disease. METHODS A representative sample of 40-60-year-old Danish inhabitants was invited to participate in a web-based survey. The respondents were presented with a hypothetical scenario and asked to imagine that they were at an increased risk of heart disease, and subsequently presented with an offer of a preventive medical intervention. The aim was to elicit preference structures when potential patients are presented with different treatment conditions. RESULTS About one third of the respondents were willing to accept preventive medical treatment. Respondents with personal experience with heart disease were more likely to accept treatment than respondents with family members with heart disease or no prior experience with heart disease. The willingness to accept treatment was similar for both genders, and when adjusting for experience with heart disease, age was not associated with willingness to accept treatment. Socioeconomic status in terms of lower education was positively associated with acceptance. The price of treatment reduced willingness to accept for the lower income groups, whereas it had no effect in the highest income group. Some 57% of respondents who were willing to accept treatment changed their decision following information on potential side effects. CONCLUSIONS In accordance with our pre-study hypothesis, individuals with low income were more sensitive to price than individuals with high income. Thus, if the price of preventive medication increases above certain limits, a substantial proportion of the population may refrain from treatment. More than half of the respondents who were initially willing to accept treatment changed their decision when informed about the presence of potential side effects. This is an important observation in relation to risk communication, since most side effects occur very seldom, and a skewed assessment of treatment efficacy compared to risk of side effects may refrain some patients from treatment. Thus, more research is needed to better allow patients to compare treatment efficacy with risk of side effects in quantitative terms.
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Affiliation(s)
- Nielsen Jesper Bo
- />Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B.Winsløws Vej 9, DK-5000 Odense C, Denmark
| | - Jarbøl Dorte Ejg
- />Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B.Winsløws Vej 9, DK-5000 Odense C, Denmark
| | - Gyrd-Hansen Dorte
- />COHERE, Institute of Public Health, University of Southern Denmark, J.B.Winsløws Vej 9, DK-5000 Odense C, Denmark
| | - Barfoed Benedicte Marie Lind
- />Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B.Winsløws Vej 9, DK-5000 Odense C, Denmark
| | - Larsen Pia Veldt
- />Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B.Winsløws Vej 9, DK-5000 Odense C, Denmark
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Harmsen CG, Jarbøl DE, Nexøe J, Støvring H, Gyrd-Hansen D, Nielsen JB, Edwards A, Kristiansen IS. Impact of effectiveness information format on patient choice of therapy and satisfaction with decisions about chronic disease medication: the "Influence of intervention Methodologies on Patient Choice of Therapy (IMPACT)" cluster-randomised trial in general practice. BMC Health Serv Res 2013; 13:76. [PMID: 23442351 PMCID: PMC3599428 DOI: 10.1186/1472-6963-13-76] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 02/14/2013] [Indexed: 01/22/2023] Open
Abstract
Background Risk communication is an integral part of shared decision-making in health care. In the context of interventions for chronic diseases it represents a particular challenge for all health practitioners. By using two different quantitative formats to communicate risk level and effectiveness of a cholesterol-lowering drug, we posed the research question: how does the format of risk information influence patients’ decisions concerning therapy, patients’ satisfaction with the communication as well as confidence in the decision. We hypothesise that patients are less prone to accept therapy when the benefits of long-term intervention are presented in terms of prolongation of life (POL) in months compared to the absolute risk reduction (ARR). We hypothesise that patients presented with POL will be more satisfied with the communication and confident in their decision, suggesting understanding of the time-related term. Methods/Design In 2009 a sample of 328 general practitioners (GPs) in the Region of Southern Denmark was invited to participate in a primary care-based clinical trial among patients making real-life clinical decisions together with their GP. Interested GPs were cluster-randomised to inform patients about cardiovascular disease (CVD) risk and the effectiveness of statin therapy using either POL or ARR. The GPs attended a training session before informing their patients. Before training and after the trial period they received a questionnaire about their attitudes to risk communication and the use of numerical information. Patients’ redemptions of statin prescriptions will be registered in a regional prescription database to evaluate a possible association between redemption rates and effectiveness format. The Combined Outcome Measure for Risk Communication And Treatment Decision Making Effectiveness (COMRADE) questionnaire will be used to measure patients’ confidence and satisfaction with the risk communication immediately after the conversation with their GPs. Discussion This randomised clinical trial compares the impact of two effectiveness formats on real-life risk communication between patients and GPs, including affective patient outcomes and actual choices about acceptance of therapy. Though we found difficulties in recruiting GPs, according to the study protocol we have succeeded in engaging sufficient GPs for the trial, enabling us to perform the planned analyses. Trial registration ClinicalTrials.gov Protocol Registration System
http://ww.clinicaltrials.gov/NCT01414751
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Affiliation(s)
- Charlotte Gry Harmsen
- Research Unit of General Practice, University of Southern Denmark, Southern Denmark, Denmark.
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Harmsen CG, Støvring H, Jarbøl DE, Nexøe J, Gyrd-Hansen D, Nielsen JB, Edwards A, Kristiansen IS. Medication effectiveness may not be the major reason for accepting cardiovascular preventive medication: a population-based survey. BMC Med Inform Decis Mak 2012; 12:89. [PMID: 22873796 PMCID: PMC3465182 DOI: 10.1186/1472-6947-12-89] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 08/02/2012] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Shared decision-making and patients' choice of interventions are areas of increasing importance, not least seen in the light of the fact that chronic conditions are increasing, interventions considered important for public health, and still non-acceptance of especially risk-reducing treatments of cardiovascular diseases (CVD) is prevalent. A better understanding of patients' medication-taking behavior is needed and may be reached by studying the reasons why people accept or decline medication recommendations. The aim of this paper was to identify factors that may influence people's decisions and reasoning for accepting or declining a cardiovascular preventive medication offer. METHODS From a random sample of 4,000 people aged 40-59 years in a Danish population, 1,169 participants were asked to imagine being at increased risk of cardiovascular disease and being offered a preventive medication. After receiving 'complete' information about effectiveness of the medication they were asked whether they would accept medication. Finally, they were asked about reasons for the decision. RESULTS A total of 725 (67%) of 1,082 participants accepted the medication offer. Even quite large effects of medication (up to 8 percentage points absolute risk reduction) had a smaller impact on acceptance to medication than personal experience with cardiovascular disease. Furthermore, increasing age of the participant and living with a partner were significantly associated with acceptance. Some 45% of the respondents accepting justified their choice as being for health reasons, and they were more likely to be women, live alone, have higher income and higher education levels. Among those who did not accept the medication offer, 56% indicated that they would rather prefer to change lifestyle. CONCLUSIONS Medication effectiveness seems to have a moderate influence on people's decisions to accept preventive medication, while factors such as personal experience with cardiovascular disease may have an equally strong or stronger influence, indicating that practitioners could do well to carefully identify the reasons for their patients' treatment decisions.
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Affiliation(s)
| | - Henrik Støvring
- Department of Public Health, Biostatistics, Aarhus University, Aarhus, Denmark
| | - Dorte Ejg Jarbøl
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Jørgen Nexøe
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Dorte Gyrd-Hansen
- Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Bo Nielsen
- Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Adrian Edwards
- Department of Primary Care & Public Health, School of Medicine, Cardiff University, Wales, UK
| | - Ivar Sønbø Kristiansen
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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Perneger TV, Agoritsas T. Doctors and patients' susceptibility to framing bias: a randomized trial. J Gen Intern Med 2011; 26:1411-7. [PMID: 21792695 PMCID: PMC3235613 DOI: 10.1007/s11606-011-1810-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 06/23/2011] [Accepted: 07/06/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Framing of risk influences the perceptions of treatment benefit. OBJECTIVE To determine which risk framing format corresponds best to comprehensive multi-faceted information, and to compare framing bias in doctors and in patients. DESIGN Randomized mail surveys. PARTICIPANTS One thousand four hundred and thirty-one doctors (56% response rate) and 1121 recently hospitalized patients (65% response rate). INTERVENTION Respondents were asked to interpret the results of a hypothetical clinical trial comparing an old and a new drug. They were randomly assigned to the following framing formats: absolute survival (new drug: 96% versus old drug: 94%), absolute mortality (4% versus 6%), relative mortality reduction (reduction by a third) or all three (fully informed condition). The new drug was reported to cause more side-effects. MAIN MEASURE Rating of the new drug as more effective than the old drug. RESULTS The proportions of doctors who rated the new drug as more effective varied by risk presentation format (abolute survival 51.8%, absolute mortality 68.3%, relative mortality reduction 93.8%, and fully informed condition 69.8%, p < 0.001). In patients these proportions were similar (abolute survival 51.7%, absolute mortality 66.8%, relative mortality reduction 89.3%, and fully informed condition 71.2%, p < 0.001). In both doctors (p = 0.72) and patients (p = 0.23) the fully informed condition was similar to the absolute risk format, but it differed significantly from the other conditions (all p < 0.01). None of the differences between doctors and patients were significant (all p > 0.1). In comparison to the fully informed condition, the odds ratio of greater perceived effectiveness was 0.45 for absolute survival (p < 0.001), 0.89 for absolute mortality (p = 0.29), and 4.40 for relative mortality reduction (p < 0.001). CONCLUSIONS Framing bias affects doctors and patients similarly. Describing clinical trial results as absolute risks is the least biased format, for both doctors and patients. Presenting several risk formats (on both absolute and relative scales) should be encouraged.
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Affiliation(s)
- Thomas V Perneger
- Division of clinical epidemiology, University Hospitals of Geneva, 4 rue Gabrielle-Perret-Gentil, CH-1211, Geneva, Switzerland.
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Gyrd-Hansen D, Halvorsen P, Nexøe J, Nielsen J, Støvring H, Kristiansen I. Joint and Separate Evaluation of Risk Reduction. Med Decis Making 2010; 31:E1-10. [PMID: 21173438 DOI: 10.1177/0272989x10391268] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. When people make choices, they may have multiple options presented simultaneously or, alternatively, have options presented 1 at a time. It has been shown that if decision makers have little experience with or difficulties in understanding certain attributes, these attributes will have greater impact in joint evaluations than in separate evaluations. The authors investigated the impact of separate versus joint evaluations in a health care context in which laypeople were presented with the possibility of participating in risk-reducing drug therapies. Methods. In a randomized study comprising 895 subjects aged 40 to 59 y in Odense, Denmark, subjects were randomized to receive information in terms of absolute risk reduction (ARR), relative risk reduction (RRR), number needed to treat (NNT), or prolongation of life (POL), all with respect to heart attack, and they were asked whether they would be willing to receive a specified treatment. Respondents were randomly allocated to valuing the interventions separately (either great effect or small effect) or jointly (small effect and large effect). Results. Joint evaluation reduced the propensity to accept the intervention that offered the smallest effect. Respondents were more sensitive to scale when faced with a joint evaluation for information formats ARR, RRR, and POL but not for NNT. Evaluability bias appeared to be most pronounced for POL and ARR. Conclusion. Risk information appears to be prone to evaluability bias. This suggests that numeric information on health gains is difficult to evaluate in isolation. Consequently, such information may bear too little weight in separate evaluations of risk-reducing interventions.
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Affiliation(s)
- Dorte Gyrd-Hansen
- University of Southern Denmark, Institute of Public Health, Odense, Denmark (DG-H, J. Nielsen, HS)
- Health Economics Unit, Danish Institute for Health Services Research, Dampfaergvej, Denmark (DG-H)
- University of Tromsø, Institute of Community Medicine, Tromsø, Norway (PH)
- University of Southern Denmark, Research Unit for General Practice, Odense, Denmark (J. Nexøe)
- University of Oslo, Institute of Health Management and Health Economics, Oslo, Norway (IK)
| | - Peder Halvorsen
- University of Southern Denmark, Institute of Public Health, Odense, Denmark (DG-H, J. Nielsen, HS)
- Health Economics Unit, Danish Institute for Health Services Research, Dampfaergvej, Denmark (DG-H)
- University of Tromsø, Institute of Community Medicine, Tromsø, Norway (PH)
- University of Southern Denmark, Research Unit for General Practice, Odense, Denmark (J. Nexøe)
- University of Oslo, Institute of Health Management and Health Economics, Oslo, Norway (IK)
| | - Jørgen Nexøe
- University of Southern Denmark, Institute of Public Health, Odense, Denmark (DG-H, J. Nielsen, HS)
- Health Economics Unit, Danish Institute for Health Services Research, Dampfaergvej, Denmark (DG-H)
- University of Tromsø, Institute of Community Medicine, Tromsø, Norway (PH)
- University of Southern Denmark, Research Unit for General Practice, Odense, Denmark (J. Nexøe)
- University of Oslo, Institute of Health Management and Health Economics, Oslo, Norway (IK)
| | - Jesper Nielsen
- University of Southern Denmark, Institute of Public Health, Odense, Denmark (DG-H, J. Nielsen, HS)
- Health Economics Unit, Danish Institute for Health Services Research, Dampfaergvej, Denmark (DG-H)
- University of Tromsø, Institute of Community Medicine, Tromsø, Norway (PH)
- University of Southern Denmark, Research Unit for General Practice, Odense, Denmark (J. Nexøe)
- University of Oslo, Institute of Health Management and Health Economics, Oslo, Norway (IK)
| | - Henrik Støvring
- University of Southern Denmark, Institute of Public Health, Odense, Denmark (DG-H, J. Nielsen, HS)
- Health Economics Unit, Danish Institute for Health Services Research, Dampfaergvej, Denmark (DG-H)
- University of Tromsø, Institute of Community Medicine, Tromsø, Norway (PH)
- University of Southern Denmark, Research Unit for General Practice, Odense, Denmark (J. Nexøe)
- University of Oslo, Institute of Health Management and Health Economics, Oslo, Norway (IK)
| | - Ivar Kristiansen
- University of Southern Denmark, Institute of Public Health, Odense, Denmark (DG-H, J. Nielsen, HS)
- Health Economics Unit, Danish Institute for Health Services Research, Dampfaergvej, Denmark (DG-H)
- University of Tromsø, Institute of Community Medicine, Tromsø, Norway (PH)
- University of Southern Denmark, Research Unit for General Practice, Odense, Denmark (J. Nexøe)
- University of Oslo, Institute of Health Management and Health Economics, Oslo, Norway (IK)
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