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Ascher SB, Kravitz RL, Scherzer R, Berry JD, de Lemos JA, Estrella MM, Tancredi DJ, Killeen AA, Ix JH, Shlipak MG. Incorporating Individual-Level Treatment Effects and Outcome Preferences Into Personalized Blood Pressure Target Recommendations. J Am Heart Assoc 2024; 13:e033995. [PMID: 39136305 DOI: 10.1161/jaha.124.033995] [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: 01/05/2024] [Accepted: 05/13/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND There are no shared decision-making frameworks for selecting blood pressure (BP) targets for individuals with hypertension. This study addressed whether results from the SPRINT (Systolic Blood Pressure Intervention Trial) could be tailored to individuals using predicted risks and simulated preferences. METHODS AND RESULTS Among 8202 SPRINT participants, Cox models were developed and internally validated to predict each individual's absolute difference in risk from intensive versus standard BP lowering for cardiovascular events, cognitive impairment, death, and serious adverse events (AEs). Individual treatment effects were combined using simulated preference weights into a net benefit, which represents a weighted sum of risk differences across outcomes. Net benefits were compared among those above versus below the median AE risk. In simulations for which cardiovascular, cognitive, and death events had much greater weight than the AEs of BP lowering, the median net benefit was 3.3 percentage points (interquartile range [IQR], 2.0-5.7), and 100% of participants had a net benefit favoring intensive BP lowering. When simulating benefits and harms to have similar weights, the median net benefit was 0.8 percentage points (IQR, 0.2-2.2), and 87% had a positive net benefit. Compared with participants at lower risk of AEs from BP lowering, those at higher risk had a greater net benefit from intensive BP lowering despite experiencing more AEs (P<0.001 in both simulations). CONCLUSIONS Most SPRINT participants had a predicted net benefit that favored intensive BP lowering, but the degree of net benefit varied considerably. Tailoring BP targets using each patient's risks and preferences may provide more refined BP target recommendations.
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Affiliation(s)
- Simon B Ascher
- Department of Internal Medicine, Kidney Health Research Collaborative San Francisco Veterans Affairs Health Care System and University of California San Francisco San Francisco CA
- Department of Internal Medicine University of California Davis Sacramento CA
| | - Richard L Kravitz
- Department of Internal Medicine University of California Davis Sacramento CA
| | - Rebecca Scherzer
- Department of Internal Medicine, Kidney Health Research Collaborative San Francisco Veterans Affairs Health Care System and University of California San Francisco San Francisco CA
| | - Jarett D Berry
- Department of Internal Medicine University of Texas at Tyler Health Science Center Tyler TX
| | - James A de Lemos
- Division of Cardiology, Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Michelle M Estrella
- Department of Internal Medicine, Kidney Health Research Collaborative San Francisco Veterans Affairs Health Care System and University of California San Francisco San Francisco CA
| | - Daniel J Tancredi
- Department of Pediatrics University of California Davis Sacramento CA
| | - Anthony A Killeen
- Department of Laboratory Medicine and Pathology University of Minnesota Minneapolis MN
| | - Joachim H Ix
- Division of Nephrology-Hypertension University of California San Diego La Jolla CA
- Nephrology Section, Veterans Affairs San Diego Healthcare System San Diego CA
| | - Michael G Shlipak
- Department of Internal Medicine, Kidney Health Research Collaborative San Francisco Veterans Affairs Health Care System and University of California San Francisco San Francisco CA
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Moll H, Frey E, Gerber P, Geidl B, Kaufmann M, Braun J, Beuschlein F, Puhan MA, Yebyo HG. GLP-1 receptor agonists for weight reduction in people living with obesity but without diabetes: a living benefit-harm modelling study. EClinicalMedicine 2024; 73:102661. [PMID: 38846069 PMCID: PMC11154119 DOI: 10.1016/j.eclinm.2024.102661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 06/09/2024] Open
Abstract
Background The benefit of Glucagon-like Peptide-1 (GLP-1) receptor agonists (RAs) in weight reduction against potential harms remains unclear. This study aimed at evaluating the benefit-harm balance of initiating GLP-1 RAs versus placebo for weight loss in people living with overweight and obesity but without diabetes. Methods We performed benefit-harm balance modelling, which will be updated as new evidence emerges. We searched for randomised controlled trials (RCTs) in PubMed, controlled trials registry, drug approval and regulatory documents, and outcome preference weights as of April 10, 2024. We synthesize data using pairwise meta-analysis to estimate the effect of GLP-1 RAs to inform the benefit-harm balance modelling. We predicted the absolute effects of the positive and negative outcomes over 1 and 2 years of treatment using exponential models. We applied preference weights to the outcomes, ranging from 0 for least concerning to 1.0 for most concerning. We then calculated whether the benefit of achieving 5% and 10% weight loss outweighed the harms on a common scale. The analyses accounted for the statistical uncertainties of treatment effects, preference weights, and outcome risks. Findings We included 8 RCTs involving 8847 participants. The pooled average age was 46.7 years, with the majority being women (74%) and people living with obesity (96%). Of 1000 persons treated with GLP-1 RAs for 2 years, 375 (95% confidence interval 352 to 399) achieved a 10% weight loss, and 318 (296 to 339) achieved a 5% weight loss compared to those treated with placebo. Several harm outcomes were more frequent in the GLP-1 RA group, including 41 abdominal pain events per 1000 persons over 2 years (19 to 69), cholelithiasis (8, 1 to 21), constipation (118, 78 to 164), diarrhoea (100, 42 to 173), alopecia (57, 10 to 176), hypoglycaemia (17, 1 to 68), injection site reactions (4, -3 to 19), and vomiting (110, 80 to 145) among others. Achieving a 10% weight loss with GLP-1 RA therapy outweighed the cumulative harms, with a net benefit probability of 0.97 at year 1 and 0.91 at year 2. The absolute net benefit was equivalent to 104 (100 to 112) per 1000 persons achieving a 10% weight loss over 2 years without experiencing any worrisome harm. A 5% weight loss did not show a net benefit, with probabilities of 0.13 and 0.01 at year 1 and year 2, respectively. However, these benefits were sensitive to preference weights, suggesting that even a 5% weight loss could be net beneficial for individuals with less concern about harm outcomes. The net benefit for a 10% weight loss was highest for semaglutide, followed by liraglutide and tirzepatide, with 2-year probabilities of 0.96, 0.72, and 0.60, respectively. Interpretation The benefit of GLP-1 RAs exceeded the harms for weight loss in the first 2 years of treatment, yet the net benefit was dependent on individual' treatment goals (10% or 5% weight loss) and willingness to accept harms in pursuit of weight loss. This implies that treatment decisions have to be personalized to individuals to optimize benefits and reduce harms and overuse of treatments. Due to varying evidence, especially regarding harm outcomes across studies, it is necessary to continuously update and monitor the benefit-harm balance of GLP-1 RAs. Funding SNSF and LOOP Zurich.
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Affiliation(s)
- Hannah Moll
- Department of Epidemiology, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Eliane Frey
- Department of Chemistry and Applied Biosciences, Institute of Pharmaceutical Sciences, ETH, Zurich, Switzerland
| | - Philipp Gerber
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Bettina Geidl
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Marco Kaufmann
- Department of Epidemiology, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Julia Braun
- Department of Epidemiology, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität, Munich, Germany
- The LOOP Zurich - Medical Research Center, Zurich, Switzerland
| | - Milo A. Puhan
- Department of Epidemiology, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Henock G. Yebyo
- Department of Epidemiology, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
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Totton N, Waddingham E, Owen R, Julious S, Hughes D, Cook J. A proposal for using benefit-risk methods to improve the prominence of adverse event results when reporting trials. Trials 2024; 25:409. [PMID: 38909232 PMCID: PMC11193225 DOI: 10.1186/s13063-024-08228-0] [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] [Received: 12/01/2023] [Accepted: 06/03/2024] [Indexed: 06/24/2024] Open
Abstract
Adverse events suffer from poor reporting within randomised controlled trials, despite them being crucial to the evaluation of a treatment. A recent update to the CONSORT harms checklist aims to improve reporting by providing structure and consistency to the information presented. We propose an extension wherein harms would be reported in conjunction with effectiveness outcome(s) rather than in silo to provide a more complete picture of the evidence acquired within a trial. Benefit-risk methods are designed to simultaneously consider both benefits and risks, and therefore, we believe these methods could be implemented to improve the prominence of adverse events when reporting trials. The aim of this article is to use case studies to demonstrate the practical utility of benefit-risk methods to present adverse events results alongside effectiveness results. Two randomised controlled trials have been selected as case studies, the Option-DM trial and the SANAD II trial. Using a previous review, a shortlist of 17 benefit-risk methods which could potentially be used for reporting RCTs was created. From this shortlist, three benefit-risk methods are applied across the two case studies. We selected these methods for their usefulness to achieve the aim of this paper and which are commonly used in the literature. The methods selected were the Benefit-Risk Action Team (BRAT) Framework, net clinical benefit (NCB), and the Outcome Measures in Rheumatology (OMERACT) 3 × 3 table. Results using the benefit-risk method added further context and detail to the clinical summaries made from the trials. In the case of the SANAD II trial, the clinicians concluded that despite the primary outcome being improved by the treatment, the increase in adverse events negated the improvement and the treatment was therefore not recommended. The benefit-risk methods applied to this case study outlined the data that this decision was based on in a clear and transparent way. Using benefit-risk methods to report the results of trials can increase the prominence of adverse event results by presenting them alongside the primary efficacy/effectiveness outcomes. This ensures that all the factors which would be used to determine whether a treatment would be recommended are transparent to the reader.
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Affiliation(s)
- Nikki Totton
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Ed Waddingham
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Ruth Owen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Steven Julious
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Jonathan Cook
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Pluymen LPM, Yebyo HG, Stegeman I, Fransen MP, Dekker E, Brabers AEM, Leeflang MMG. Perceived Importance of the Benefits and Harms of Colorectal Cancer Screening: A Best-Worst Scaling Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:918-924. [PMID: 36646279 DOI: 10.1016/j.jval.2022.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 12/16/2022] [Accepted: 12/30/2022] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To elicit the relative importance of the benefits and harms of colorectal cancer (CRC) screening among potential screening participants in the Dutch population. METHODS In a consensus meeting with 11 experts, risk reduction of CRC and CRC deaths (benefits) and complications from colonoscopy, stress of receiving positive fecal immunological test (FIT) results, as well as false-positive and false-negative FIT results (harms) were selected as determinant end points to consider during decision making. We conducted an online best-worst scaling survey among adults aged 55 to 75 years from the Dutch Health Care Consumer Panel of The Netherlands Institute for Health Services Research to elicit preference values for these outcomes. The preference values were estimated using conditional logit regression. RESULTS Of 265 participants, 234 (89%) had ever participated in CRC screening. Compared with the stress of receiving a positive FIT result, the outcome perceived most important was the risk of CRC death (odds ratio [OR] 4.5; 95% confidence interval [CI] 3.9-5.1), followed by risk of CRC (OR 4.1; 95% CI 3.6-4.7), a false-negative FIT result (OR 3.1; 95% CI 2.7-3.5), colonoscopy complications (OR 1.6; 95% CI 1.4-1.8), and a false-positive FIT result (OR 1.4; 95% CI 1.3-1.6). The magnitude of these differences in perceived importance varied according to age, educational level, ethnic background, and whether the individual had previously participated in CRC screening. CONCLUSION Dutch men and women eligible for FIT-based CRC screening perceive the benefits of screening to be more important than the harms.
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Affiliation(s)
- Linda P M Pluymen
- Epidemiology and Data Science, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health, Methodology, Amsterdam, The Netherlands.
| | - Henock G Yebyo
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Inge Stegeman
- Epidemiology and Data Science, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Mirjam P Fransen
- Public and Occupational Health, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Quality of Care, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Evelien Dekker
- Gastroenterology and Hepatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Anne E M Brabers
- Nivel, The Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Mariska M G Leeflang
- Epidemiology and Data Science, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
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Biccler J, Bollaerts K, Vora P, Sole E, Rodriguez LAG, Lanas A, Langley RE, Gabarró MS. Public health impact of low-dose aspirin on colorectal cancer, cardiovascular disease and safety in the UK - Results from micro-simulation model. IJC HEART & VASCULATURE 2021; 36:100851. [PMID: 34401469 PMCID: PMC8350404 DOI: 10.1016/j.ijcha.2021.100851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/26/2021] [Indexed: 12/29/2022]
Abstract
Background Low-dose aspirin therapy reduces the risk of cardiovascular disease and may have a positive effect on the prevention of colorectal cancer. We evaluated the population-level expected effect of regular low-dose aspirin use on cardiovascular disease (CVD), colorectal cancer (CRC), gastrointestinal bleeding, symptomatic peptic ulcers, and intracranial hemorrhage, using a microsimulation study design. Methods We used individual-level state transition modeling to assess the impact of aspirin in populations aged 50–59 or 60–69 years old indicated for low-dose aspirin usage for primary or secondary CVD prevention. Model parameters were based on data from governmental agencies from the UK or recent publications. Results In the 50–59 years cohort, a decrease in incidence rates (IRs per 100 000 person years) of non-fatal CVD (-203 and −794) and fatal CVD (-97 and-381) was reported in the primary and secondary CVD prevention setting, respectively. The IR reduction of CRC (-96 and −93) was similar for primary and secondary CVD prevention. The IR increase of non-fatal (116 and 119) and fatal safety events (6 and 6) was similar for primary and secondary CVD prevention. Similar results were obtained for the 60–69 years cohort. Conclusions The decrease in fatal CVD and CRC events was larger than the increase in fatal safety events and this difference was more pronounced when low-dose aspirin was used for secondary compared to primary CVD prevention. These results provide a comprehensive image of the expected effect of regular low-dose aspirin therapy in a UK population indicated to use aspirin for CVD prevention.
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Affiliation(s)
- Jorne Biccler
- P95 Epidemiology and Pharmacovigilance, Leuven, Belgium
| | | | - Pareen Vora
- Bayer AG, Epidemiology, Integrated Evidence Generation, Berlin, Germany
| | - Elodie Sole
- P95 Epidemiology and Pharmacovigilance, Leuven, Belgium
| | | | - Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico, University of Zaragoza, Zaragoza, Spain.,CIBERehd. IIS Aragón, Zaragoza, Spain
| | - Ruth E Langley
- MRC Clinical Trials Unit, University College London, London, United Kingdom
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Garg T, Polenick CA, Schoenborn N, Jih J, Hajduk A, Wei MY, Hughes J. Innovative Strategies to Facilitate Patient-Centered Research in Multiple Chronic Conditions. J Clin Med 2021; 10:jcm10102112. [PMID: 34068839 PMCID: PMC8153595 DOI: 10.3390/jcm10102112] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 12/20/2022] Open
Abstract
Multiple chronic conditions (MCC) are one of today’s most pressing healthcare concerns, affecting 25% of all Americans and 75% of older Americans. Clinical care for individuals with MCC is often complex, condition-centric, and poorly coordinated across multiple specialties and healthcare services. There is an urgent need for innovative patient-centered research and intervention development to address the unique needs of the growing population of individuals with MCC. In this commentary, we describe innovative methods and strategies to conduct patient-centered MCC research guided by the goals and objectives in the Department of Health and Human Services MCC Strategic Framework. We describe methods to (1) increase the external validity of trials for individuals with MCC; (2) study MCC epidemiology; (3) engage clinicians, communities, and patients into MCC research; and (4) address health equity to eliminate disparities.
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Affiliation(s)
- Tullika Garg
- Department of Urology, Department of Population Health Sciences, Geisinger, Danville, PA 17822, USA
- Correspondence: ; Tel.: +1-570-271-6328
| | - Courtney A. Polenick
- Geriatric Psychiatry Program, Department of Psychiatry, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Nancy Schoenborn
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Jane Jih
- Division of General Internal Medicine and Multiethnic Health Equity Research Center, University of California San Francisco, San Francisco, CA 94143, USA;
| | - Alexandra Hajduk
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, USA;
| | - Melissa Y. Wei
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA;
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
| | - Jaime Hughes
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27705, USA;
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Tervonen T, Vora P, Seo J, Krucien N, Marsh K, De Caterina R, Wissinger U, Soriano Gabarró M. Patient Preferences of Low-Dose Aspirin for Cardiovascular Disease and Colorectal Cancer Prevention in Italy: A Latent Class Analysis. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 14:661-672. [PMID: 33829397 PMCID: PMC8357711 DOI: 10.1007/s40271-021-00506-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/28/2021] [Indexed: 12/02/2022]
Abstract
Background Patients taking low-dose aspirin to prevent cardiovascular disease (CVD) may also benefit from a reduced risk of colorectal cancer (CRC). Objective The aim was to examine the preferences of people eligible for preventive treatment with low-dose aspirin and the trade-offs they are willing to make between CVD prevention, CRC prevention, and treatment risks. Methods A cross-sectional study using a discrete choice experiment (DCE) survey was conducted in Italy in 2019 to elicit preferences for three benefit attributes (prevention of ischemic stroke, myocardial infarction, and CRC) and four risk attributes (intracranial and gastrointestinal bleeding, peptic ulcer, and severe allergic reaction) associated with use of low-dose aspirin. Latent class logit models were used to evaluate variation in treatment preferences. Results The DCE survey was completed by 1005 participants eligible for use of low-dose aspirin. A four-class model had the best fit for the primary CVD prevention group (n = 491), and a three-class model had the best fit for the secondary CVD prevention group (n = 514). For the primary CVD prevention group, where classes differed on age, education level, type 2 diabetes, exercise, and low-dose aspirin use, the most important attributes were intracranial bleeding (two classes), myocardial infarction (one class), and CRC (one class). For the secondary CVD prevention group, where classes differed on various comorbidities, self-reported health, exercise, and CVD medication use, the most important attributes were intracranial bleeding (two classes), myocardial infarction (one class), and gastrointestinal bleeding (one class). Conclusion Patient preferences for the benefits and risks of low-dose aspirin differ significantly among people eligible for treatment as primary or secondary CVD prevention. Supplementary Information The online version contains supplementary material available at 10.1007/s40271-021-00506-2.
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Affiliation(s)
- Tommi Tervonen
- Patient-Centered Research, Evidera, London, UK. .,Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | | | - Jaein Seo
- Patient-Centered Research, Evidera, Bethesda, MD, USA
| | | | - Kevin Marsh
- Patient-Centered Research, Evidera, London, UK
| | - Raffaele De Caterina
- Cardiology Division, University of Pisa, Pisa University Hospital, Pisa, Italy.,Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy
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Zeng L, Helsingen LM, Kenji Nampo F, Wang Y, Yao L, Siemieniuk RA, Bretthauer M, Guyatt GH. How do cancer screening guidelines trade off benefits versus harms and burdens of screening? A systematic survey. BMJ Open 2020; 10:e038322. [PMID: 33268404 PMCID: PMC7713181 DOI: 10.1136/bmjopen-2020-038322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 09/29/2020] [Accepted: 10/05/2020] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES Cancer screening guidelines differ in their recommendations for or against screening. To be able to provide explicit recommendations, guidelines need to specify thresholds for the magnitude of benefits of screening, given its harms and burdens. We evaluated how current cancer screening guidelines address the relative importance of benefits versus harms and burdens of screening. DATA SOURCE We searched the Guidelines International Network, International Guideline Library, ECRI Institute and Medline. Two pairs of reviewers independently performed guideline selection and data abstraction. ELIGIBILITY CRITERIA We included all cancer screening guidelines published in English between January 2014 and April 2019. RESULTS Of 68 eligible guidelines, 25 included a statement regarding the trade-off between screening benefits versus harms and burdens (14 guidelines), or a statement of direction of the net effect (defined as benefits minus harms or burdens) (13 guidelines). None of these 25 guidelines defined how large a screening benefit should be to recommend screening, given its harms and burdens. 11 guidelines performed an economic evaluation of screening. Of these, six identified a key benefit outcome; two specified a cost-effectiveness threshold for recommending a screening option. Eight guidelines commented on people's values and preferences regarding the trade-off between benefits versus harms and burdens. CONCLUSIONS Current cancer screening guidelines fail to specify the values and preferences underlying their recommendations. No guidelines provide a threshold at which they believe the benefits of screening outweigh its harms and burdens. PROSPERO REGISTRATION NUMBER CRD42019138590.
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Affiliation(s)
- Linan Zeng
- Pharmacy Department/Evidence-based Pharmacy Center, West China Second University Hospital, Sichuan University; Key Laboratory of Birth Defects and Related Disease of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lise Mørkved Helsingen
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, and Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Fernando Kenji Nampo
- Latin-American Institute of Life and Nature Sciences/Evidence-Based Public Health Research Group, Federal University of Latin-American Integration, Foz do Iguacu, Paraná, Brazil
| | - Yuting Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Reed Alexander Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, and Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Yebyo HG, Zappacosta S, Aschmann HE, Haile SR, Puhan MA. Global variation of risk thresholds for initiating statins for primary prevention of cardiovascular disease: a benefit-harm balance modelling study. BMC Cardiovasc Disord 2020; 20:418. [PMID: 32942999 PMCID: PMC7495829 DOI: 10.1186/s12872-020-01697-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/31/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND We previously showed that the 10-year cardiovascular disease (CVD) risk threshold to initiate statins for primary prevention depends on the baseline CVD risk, age, sex, and the incidence of statin-related harm outcome and competing risk for non-CVD death. As these factors appear to vary across countries, we aimed in this study to determine country-specific thresholds and provide guidelines a quantitative benefit-harm assessment method for local adaptation. METHODS For each of the 186 countries included, we replicated the benefit-harm balance analysis using an exponential model to determine the thresholds to initiate statin use for populations aged 40 to 75 years, with no history of CVD. The analyses took data inputs from a priori studies, including statin effect estimates (network meta-analysis), patient preferences (survey), and baseline incidence of harm outcomes and competing risk for non-CVD (global burden of disease study). We estimated the risk thresholds above which the benefits of statins were more likely to outweigh the harms using a stochastic approach to account for statistical uncertainty of the input parameters. RESULTS The 5th and 95th percentiles of the 10-year risk thresholds above which the benefits of statins outweigh the harms across 186 countries ranged between 14 and 20% in men and 19-24% in women, depending on age (i.e., 90% of the country-specific thresholds were in the ranges stated). The median risk thresholds varied from 14 to 18.5% in men and 19 to 22% in women. The between-country variability of the thresholds was slightly attenuated when further adjusted for age resulting, for example, in a 5th and 95th percentiles of 14-16% for ages 40-44 years and 17-21% for ages 70-74 years in men. Some countries, especially the islands of the Western Pacific Region, had higher thresholds to achieve net benefit of statins at 25-36% 10-year CVD risks. CONCLUSIONS This extensive benefit-harm analysis modeling shows that a single CVD risk threshold, irrespective of age, sex and country, is not appropriate to initiate statin use globally. Instead, countries need to carefully determine thresholds, considering the national or subnational contexts, to optimize benefits of statins while minimizing related harms and economic burden.
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Affiliation(s)
- Henock G Yebyo
- Department of Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland.
| | - Sofia Zappacosta
- School of Public Health, Mekelle University, Ayder, Mekelle, Ethiopia
- Institute of Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig Maximilians Universität, Marchioninistrasse 15, 81377, Munich, Germany
| | - Hélène E Aschmann
- Department of Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland
| | - Sarah R Haile
- Department of Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland
| | - Milo A Puhan
- Department of Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland
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Aschmann HE, Boyd CM, Robbins CW, Chan WV, Mularski RA, Bennett WL, Sheehan OC, Wilson RF, Bayliss EA, Leff B, Armacost K, Glover C, Maslow K, Mintz S, Puhan MA. Informing Patient-Centered Care Through Stakeholder Engagement and Highly Stratified Quantitative Benefit-Harm Assessments. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:616-624. [PMID: 32389227 DOI: 10.1016/j.jval.2019.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 11/01/2019] [Accepted: 11/16/2019] [Indexed: 06/11/2023]
Abstract
OBJECTIVES In a previous project aimed at informing patient-centered care for people with multiple chronic conditions, we performed highly stratified quantitative benefit-harm assessments for 2 top priority questions. In this current work, our goal was to describe the process and approaches we developed and to qualitatively glean important elements from it that address patient-centered care. METHODS We engaged patients, caregivers, clinicians, and guideline developers as stakeholder representatives throughout the process of the quantitative benefit-harm assessment and investigated whether the benefit-harm balance differed based on patient preferences and characteristics (stratification). We refined strategies to select the most applicable, valid, and precise evidence. RESULTS Two processes were important when assessing the balance of benefits and harms of interventions: (1) engaging stakeholders and (2) stratification by patient preferences and characteristics. Engaging patients and caregivers through focus groups, preference surveys, and as co-investigators provided value in prioritizing research questions, identifying relevant clinical outcomes, and clarifying the relative importance of these outcomes. Our strategies to select evidence for stratified benefit-harm assessments considered consistency across outcomes and subgroups. By quantitatively estimating the range in the benefit-harm balance resulting from true variation in preferences, we clarified whether the benefit-harm balance is preference sensitive. CONCLUSIONS Our approaches for engaging patients and caregivers at all phases of the stratified quantitative benefit-harm assessments were feasible and revealed how sensitive the benefit-harm balance is to patient characteristics and individual preferences. Accordingly, this sensitivity can suggest to guideline developers when to tailor recommendations for specific patient subgroups or when to explicitly leave decision making to individual patients and their providers.
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Affiliation(s)
- Hélène E Aschmann
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Craig W Robbins
- Center for Clinical Information Services, Kaiser Permanente Care Management Institute, Oakland, CA, USA; Kaiser Permanente National Guideline Program, Oakland, CA, USA; Colorado Permanente Medical Group, Denver, CO, USA; Guidelines International Network, Board of Trustees, Denver, CO, USA; Permanente Federation, Clinical Education MOC Portfolio, Oakland, CA, USA
| | - Wiley V Chan
- Kaiser Permanente Northwest National Guideline Program, Portland, OR, USA
| | - Richard A Mularski
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA; Department of Pulmonary & Critical Care Medicine, Northwest Permanente, Portland, OR, USA; Oregon Health & Science University, Portland, OR, USA
| | - Wendy L Bennett
- Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Renée F Wilson
- Department of Health Policy and Management, The Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Elizabeth A Bayliss
- Institute for Research Health, Kaiser Permanente, Denver, CO, USA; University of Colorado School of Medicine, Aurora, CO, USA
| | - Bruce Leff
- Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Armacost
- Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carol Glover
- Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katie Maslow
- Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Gerontological Society of America, Washington, DC, USA
| | - Suzanne Mintz
- Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Family Caregiver Advocacy, Kensington, MD, USA
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
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Schoenborn NL, Massare J, Park R, Pollack CE, Choi Y, Boyd CM. Clinician Perspectives on Overscreening for Cancer in Older Adults With Limited Life Expectancy. J Am Geriatr Soc 2020; 68:1462-1468. [PMID: 32232838 DOI: 10.1111/jgs.16415] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND/OBJECTIVES Guidelines recommend against routine screening for breast, colorectal, and prostate cancers in older adults with less than 10 years of life expectancy. However, clinicians often continue to recommend cancer screening for these patients. We examined primary care clinicians' perspectives regarding overscreening, as defined by limited life expectancy. DESIGN Semistructured, in-depth individual interviews. SETTING Twenty-one academic and nonacademic primary care clinics in Maryland. PARTICIPANTS Thirty primary care clinicians from internal medicine, family medicine, medicine/pediatrics, and geriatric medicine. MEASUREMENTS Interviews explored whether the clinicians believed that overscreening for breast, colorectal, or prostate cancers existed in older adults and their views on using life expectancy to decide on stopping routine screening. Audio recordings of the interviews were transcribed verbatim. Two investigators independently coded all transcripts using qualitative content analysis. RESULTS Most clinicians were physicians (24/30) and women (16/30). Content analysis generated three major themes. (1) Many, but not all, clinicians perceived overscreening in older adults as a problem. (2) There was controversy around using limited life expectancy to define overscreening due to concerns that the guidelines did not capture potential nonmortality benefits of screening; that population-based screening data could not be easily applied to individuals; that this approach failed to account for patient choice; and that life expectancy predictions were inaccurate. (3) Some clinicians worried that using life expectancy to define overscreening may inadvertently introduce bias and lead to unintended harms. CONCLUSIONS Several clinicians disagreed with guideline frameworks of using limited life expectancy to guide cancer screening cessation. Some disagreement stems from inadequate knowledge about the benefits and harms of cancer screening and indicates a need for education or decision support. Other reasons for disagreement highlight the need to refine the current recommended cancer screening approaches and identify strategies to avoid unintended consequences, such as introducing bias or exacerbating existing disparities. J Am Geriatr Soc 68:1462-1468, 2020.
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Affiliation(s)
- Nancy L Schoenborn
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jacqueline Massare
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Reuben Park
- The Johns Hopkins University, Baltimore, Maryland, USA
| | - Craig E Pollack
- Department of Healthy Policy and Management, The Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
| | - Youngjee Choi
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cynthia M Boyd
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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12
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Aschmann HE, Puhan MA, Robbins CW, Bayliss EA, Chan WV, Mularski RA, Wilson RF, Bennett WL, Sheehan OC, Yu T, Yebyo HG, Leff B, Tabano H, Armacost K, Glover C, Maslow K, Mintz S, Boyd CM. Outcome preferences of older people with multiple chronic conditions and hypertension: a cross-sectional survey using best-worst scaling. Health Qual Life Outcomes 2019; 17:186. [PMID: 31856842 PMCID: PMC6924040 DOI: 10.1186/s12955-019-1250-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 11/25/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Older people with hypertension and multiple chronic conditions (MCC) receive complex treatments and face challenging trade-offs. Patients' preferences for different health outcomes can impact multiple treatment decisions. Since evidence about outcome preferences is especially scarce among people with MCC our aim was to elicit preferences of people with MCC for outcomes related to hypertension, and to determine how these outcomes should be weighed when benefits and harms are assessed for patient-centered clinical practice guidelines and health economic assessments. METHODS We sent a best-worst scaling preference survey to a random sample identified from a primary care network of Kaiser Permanente (Colorado, USA). The sample included individuals age 60 or greater with hypertension and at least two other chronic conditions. We assessed average ranking of patient-important outcomes using conditional logit regression (stroke, heart attack, heart failure, dialysis, cognitive impairment, chronic kidney disease, acute kidney injury, fainting, injurious falls, low blood pressure with dizziness, treatment burden) and studied variation across individuals. RESULTS Of 450 invited participants, 217 (48%) completed the survey, and we excluded 10 respondents who had more than two missing choices, resulting in a final sample of 207 respondents. Participants ranked stroke as the most worrisome outcome and treatment burden as the least worrisome outcome (conditional logit parameters: 3.19 (standard error 0.09) for stroke, 0 for treatment burden). None of the outcomes were always chosen as the most or least worrisome by more than 25% of respondents, indicating that all outcomes were somewhat worrisome to respondents. Predefined subgroup analyses according to age, self-reported life-expectancy, degree of comorbidity, number of medications and antihypertensive treatment did not reveal meaningful differences. CONCLUSIONS Although some outcomes were more worrisome to patients than others, our results indicate that none of the outcomes should be disregarded for clinical practice guidelines and health economic assessments.
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Affiliation(s)
- Hélène E. Aschmann
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Milo A. Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Craig W. Robbins
- Center for Clinical Information Services, Kaiser Permanente Care Management Institute, Oakland, CA USA
- Kaiser Permanente National Guideline Program, Oakland, CA USA
- Guidelines International Network, Board of Trustees, Denver, CO USA
- Family Medicine, Colorado Permanente Medical Group, Denver, CO USA
- Clinical Education MOC Portfolio, The Permanente Federation, Oakland, CA USA
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente, Denver, CO USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO USA
| | - Wiley V. Chan
- Kaiser Permanente Northwest, National Guideline Program, Portland, OR USA
| | - Richard A. Mularski
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
- Department of Pulmonary & Critical Care Medicine, Northwest Permanente, Portland, OR USA
- Oregon Health & Science University, Portland, OR USA
| | - Renée F. Wilson
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD USA
| | - Wendy L. Bennett
- Division of General Internal Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD USA
| | - Orla C. Sheehan
- Division of Geriatrics and Gerontology, Johns Hopkins University, School of Medicine, Baltimore, MD USA
| | - Tsung Yu
- Department of Public Health College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Henock G. Yebyo
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Bruce Leff
- Division of Geriatrics and Gerontology, Johns Hopkins University, School of Medicine, Baltimore, MD USA
| | - Heather Tabano
- Institute for Health Research, Kaiser Permanente, Denver, CO USA
| | - Karen Armacost
- Division of Geriatrics and Gerontology, Patient and Caregiver Partner Group, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Carol Glover
- Division of Geriatrics and Gerontology, Patient and Caregiver Partner Group, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Katie Maslow
- Division of Geriatrics and Gerontology, Patient and Caregiver Partner Group, Johns Hopkins University School of Medicine, Baltimore, MD USA
- Gerontological Society of America, Washington, District of Columbia, USA
| | - Suzanne Mintz
- Division of Geriatrics and Gerontology, Patient and Caregiver Partner Group, Johns Hopkins University School of Medicine, Baltimore, MD USA
- Family Caregiver Advocacy, Kensington, MD USA
| | - Cynthia M. Boyd
- Division of Geriatrics and Gerontology, Johns Hopkins University, School of Medicine, Baltimore, MD USA
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Selak V, Jackson R, Poppe K, Wu B, Harwood M, Grey C, Pylypchuk R, Mehta S, Choi YH, Kerr A, Wells S. Personalized Prediction of Cardiovascular Benefits and Bleeding Harms From Aspirin for Primary Prevention: A Benefit-Harm Analysis. Ann Intern Med 2019; 171:529-539. [PMID: 31525775 DOI: 10.7326/m19-1132] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Whether the benefits of aspirin for the primary prevention of cardiovascular disease (CVD) outweigh its bleeding harms in some patients is unclear. OBJECTIVE To identify persons without CVD for whom aspirin would probably result in a net benefit. DESIGN Individualized benefit-harm analysis based on sex-specific risk scores and estimates of the proportional effect of aspirin on CVD and major bleeding from a 2019 meta-analysis. SETTING New Zealand primary care. PARTICIPANTS 245 028 persons (43.6% women) aged 30 to 79 years without established CVD who had their CVD risk assessed between 2012 and 2016. MEASUREMENTS The net effect of aspirin was calculated for each participant by subtracting the number of CVD events likely to be prevented (CVD risk score × proportional effect of aspirin on CVD risk) from the number of major bleeds likely to be caused (major bleed risk score × proportional effect of aspirin on major bleeding risk) over 5 years. RESULTS 2.5% of women and 12.1% of men were likely to have a net benefit from aspirin treatment for 5 years if 1 CVD event was assumed to be equivalent in severity to 1 major bleed, increasing to 21.4% of women and 40.7% of men if 1 CVD event was assumed to be equivalent to 2 major bleeds. Net benefit subgroups had higher baseline CVD risk, higher levels of most established CVD risk factors, and lower levels of bleeding-specific risk factors than net harm subgroups. LIMITATIONS Risk scores and effect estimates were uncertain. Effects of aspirin on cancer outcomes were not considered. Applicability to non-New Zealand populations was not assessed. CONCLUSION For some persons without CVD, aspirin is likely to result in net benefit. PRIMARY FUNDING SOURCE Health Research Council of New Zealand.
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Affiliation(s)
- Vanessa Selak
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., Y.C., S.W.)
| | - Rod Jackson
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., Y.C., S.W.)
| | - Katrina Poppe
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., Y.C., S.W.)
| | - Billy Wu
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., Y.C., S.W.)
| | - Matire Harwood
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., Y.C., S.W.)
| | - Corina Grey
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., Y.C., S.W.)
| | - Romana Pylypchuk
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., Y.C., S.W.)
| | - Suneela Mehta
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., Y.C., S.W.)
| | - Yeun-Hyang Choi
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., Y.C., S.W.)
| | - Andrew Kerr
- University of Auckland and Middlemore Hospital, Auckland, New Zealand (A.K.)
| | - Sue Wells
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., Y.C., S.W.)
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14
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Aschmann HE, Boyd CM, Robbins CW, Mularski RA, Chan WV, Sheehan OC, Wilson RF, Bennett WL, Bayliss EA, Yu T, Leff B, Armacost K, Glover C, Maslow K, Mintz S, Puhan MA. Balance of benefits and harms of different blood pressure targets in people with multiple chronic conditions: a quantitative benefit-harm assessment. BMJ Open 2019; 9:e028438. [PMID: 31471435 PMCID: PMC6720326 DOI: 10.1136/bmjopen-2018-028438] [Citation(s) in RCA: 5] [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] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Recent studies suggest that a systolic blood pressure (SBP) target of 120 mm Hg is appropriate for people with hypertension, but this is debated particularly in people with multiple chronic conditions (MCC). We aimed to quantitatively determine whether benefits of a lower SBP target justify increased risks of harm in people with MCC, considering patient-valued outcomes and their relative importance. DESIGN Highly stratified quantitative benefit-harm assessment based on various input data identified as the most valid and applicable from a systematic review of evidence and based on weights from a patient preference survey. SETTING Outpatient care. PARTICIPANTS Hypertensive patients, grouped by age, gender, prior history of stroke, chronic heart failure, chronic kidney disease and type 2 diabetes mellitus. INTERVENTIONS SBP target of 120 versus 140 mm Hg for patients without history of stroke. PRIMARY AND SECONDARY OUTCOME MEASURES Probability that the benefits of a SBP target of 120 mm Hg outweigh the harms compared with 140 mm Hg over 5 years (primary) with thresholds >0.6 (120 mm Hg better), <0.4 (140 mm Hg better) and 0.4 to 0.6 (unclear), number of prevented clinical events (secondary), calculated with the Gail/National Cancer Institute approach. RESULTS Considering individual patient preferences had a substantial impact on the benefit-harm balance. With average preferences, 120 mm Hg was the better target compared with 140 mm Hg for many subgroups of patients without prior stroke, especially in patients over 75. For women below 65 with chronic kidney disease and without diabetes and prior stroke, 140 mm Hg was better. The analyses did not include mild adverse effects, and apply only to patients who tolerate antihypertensive treatment. CONCLUSIONS For most patients, a lower SBP target was beneficial, but this depended also on individual preferences, implying individual decision-making is important. Our modelling allows for individualised treatment targets based on patient preferences, age, gender and co-morbidities.
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Affiliation(s)
- Hélène E Aschmann
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Craig W Robbins
- Center for Clinical Information Services, Kaiser Permanente Care Management Institute, Oakland, California, USA
- Kaiser Permanente National Guideline Program, Oakland, California, USA
- Guidelines International Network, Board of Trustees, Denver, Colorado, USA
- Family Medicine, Colorado Permanente Medical Group, Denver, Colorado, USA
- Clinical Education MOC Portfolio, The Permanente Federation, Oakland, California, USA
| | - Richard A Mularski
- The Center for Health Research, Kaiser Permanente Northwest, Northwest Permanente Research and Evaluation, Portland, Oregon, USA
- Department of Pulmonary & Critical Care Medicine, Northwest Permanente, Portland, Oregon, USA
- Oregon Health & Science University, Portland, Oregon, USA
| | - Wiley V Chan
- Kaiser Permanente Northwest, National Guideline Program, Portland, Oregon, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Center on Aging and Health, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Renée F Wilson
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Wendy L Bennett
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente, Denver, Colorado, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tsung Yu
- Department of Public Health College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Bruce Leff
- Division of Geriatric Medicine and Gerontology, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen Armacost
- Division of Geriatric Medicine and Gerontology, Patient and Caregiver Partner Group, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carol Glover
- Division of Geriatric Medicine and Gerontology, Patient and Caregiver Partner Group, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Katie Maslow
- Division of Geriatric Medicine and Gerontology, Patient and Caregiver Partner Group, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Gerontological Society of America, Washington, District of Columbia, USA
| | - Suzanne Mintz
- Division of Geriatric Medicine and Gerontology, Patient and Caregiver Partner Group, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Family Caregiver Advocacy, Kensington, Maryland, USA
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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15
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Bennett WL, Aschmann HE, Puhan MA, Robbins CW, Bayliss EA, Wilson R, Mularski RA, Chan WV, Leff B, Sheehan O, Glover C, Maslow K, Armacost K, Mintz S, Boyd CM. A benefit-harm analysis of adding basal insulin vs. sulfonylurea to metformin to manage type II diabetes mellitus in people with multiple chronic conditions. J Clin Epidemiol 2019; 113:92-100. [PMID: 31059802 DOI: 10.1016/j.jclinepi.2019.03.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 02/12/2019] [Accepted: 03/30/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The benefits and harms of diabetes treatments need to be carefully weighed in people with type II diabetes mellitus (DM) and multiple chronic conditions (MCCs). Our objective was to quantitatively assess the benefits and harms of the addition of basal insulin (insulin) vs. sulfonylurea (SU) to metformin in people with DM and MCCs. STUDY DESIGN AND SETTING Data inputs into the benefit-harms analysis included (1) baseline risks of patient-centered outcomes (death, myocardial infarction, stroke, severe hypoglycemia, diarrhea, nausea) from cohorts and trials; (2) treatment effects for the addition of insulin vs. SU from a network meta-analysis; and (3) patient preference survey for outcome weights. Statistical analysis calculated the probability that adding insulin has greater benefits than harms, when compared with an SU, overall and by prespecified subgroups. RESULTS Including the six outcomes, the probability of net benefit for insulin compared with SU was similar, across subgroups by age and diabetes duration (probability range, using conditional logit weights: 0.44-0.56). Adding patient preferences for treatment burden associated with insulin injections shifted the probability to favor SU over insulin (probability range, using conditional logit weights: 0.01-0.12). CONCLUSION In people with DM and MCCs, we demonstrated incomplete evidence to conclude if basal insulin or SU should be added in people with DM and MCCs on metformin alone. The benefit-harm balance was sensitive to treatment preferences, that is., perceived treatment burden, indicating the importance of shared-decision making in caring for people with MCCs who are at high risk for experiencing harms associated with diabetes management.
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Affiliation(s)
- Wendy L Bennett
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Epidemiology, The Johns Hopkins University School of Public Health, Baltimore, MD, USA.
| | - Hélène E Aschmann
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Craig W Robbins
- Kaiser Permanente Center for Health Research, Portland, OR, USA; Kaiser Permanente, Institute for Health Research, Denver, CO, USA
| | | | - Renee Wilson
- Department of Epidemiology, The Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Richard A Mularski
- Kaiser Permanente Center for Health Research, Portland, OR, USA; Department of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Wiley V Chan
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Bruce Leff
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Orla Sheehan
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carol Glover
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Informing Patient-Centered Care for People with Multiple Chronic Conditions Patient and Caregiver Partners, Baltimore, MD, USA
| | - Katie Maslow
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Informing Patient-Centered Care for People with Multiple Chronic Conditions Patient and Caregiver Partners, Baltimore, MD, USA; Gerontological Society of America, Washington, DC, USA
| | - Karen Armacost
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Informing Patient-Centered Care for People with Multiple Chronic Conditions Patient and Caregiver Partners, Baltimore, MD, USA
| | - Suzanne Mintz
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Informing Patient-Centered Care for People with Multiple Chronic Conditions Patient and Caregiver Partners, Baltimore, MD, USA
| | - Cynthia M Boyd
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Tervonen T, Angelis A, Hockley K, Pignatti F, Phillips LD. Quantifying Preferences in Drug Benefit-Risk Decisions. Clin Pharmacol Ther 2019; 106:955-959. [PMID: 30929257 DOI: 10.1002/cpt.1447] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/21/2019] [Indexed: 01/13/2023]
Abstract
Benefit-risk assessment is used in various phases along the drug lifecycle, such as marketing authorization and surveillance, health technology assessment (HTA), and clinical decisions, to understand whether, and for which patients, a drug has a favorable or more valuable profile with reference to one or more comparators. Such assessments are inherently preference-based as several clinical and nonclinical outcomes of varying importance might act as evaluation criteria, and decision makers must establish acceptable trade-offs between these outcomes. Different healthcare stakeholder perspectives, such as those from patients and healthcare professionals, are key for informing benefit-risk trade-offs. However, the degree to which such preferences inform the decision is often unclear as formal preference-based evaluation frameworks are generally not used for regulatory decisions, and, if used, rarely communicated in HTA decisions. We argue that for better decisions, as well as for reasons of transparency, preferences in benefit-risk decisions should more often be quantified and communicated explicitly.
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Affiliation(s)
| | - Aris Angelis
- Department of Health Policy and LSE Health, London School of Economics and Political Science, London, UK
| | | | | | - Lawrence D Phillips
- Department of Management, London School of Economics and Political Science, London, UK
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Yebyo HG, Aschmann HE, Puhan MA. Finding the Balance Between Benefits and Harms When Using Statins for Primary Prevention of Cardiovascular Disease: A Modeling Study. Ann Intern Med 2019; 170:1-10. [PMID: 30508425 DOI: 10.7326/m18-1279] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many guidelines use expected risk for cardiovascular disease (CVD) during the next 10 years as a basis for recommendations on use of statins for primary prevention of CVD. However, how harms were considered and weighed against benefits is often unclear. OBJECTIVE To identify the expected risk above which statins provide net benefit. DESIGN Quantitative benefit-harm balance modeling study. DATA SOURCES Network meta-analysis of primary prevention trials, a preference survey, and selected observational studies. TARGET POPULATION Persons aged 40 to 75 years with no history of CVD. TIME HORIZON 10 years. PERSPECTIVE Clinicians and guideline developers. INTERVENTION Low- or moderate-dose statin versus no statin. OUTCOME MEASURES The 10-year risk for CVD at which statins provide at least a 60% probability of net benefit, with baseline risk, frequencies of and preferences for statin benefits and harms, and competing risk for non-CVD death taken into account. RESULTS OF BASE-CASE ANALYSIS Younger men had net benefit at a lower 10-year risk for CVD than older men (14% for ages 40 to 44 years vs. 21% for ages 70 to 75 years). In women, the risk required for net benefit was higher (17% for ages 40 to 44 years vs. 22% for ages 70 to 75 years). Atorvastatin and rosuvastatin provided net benefit at lower 10-year risks than simvastatin and pravastatin. RESULTS OF SENSITIVITY ANALYSIS Most alternative assumptions led to similar findings. LIMITATION Age-specific data for some harms were not available. CONCLUSION Statins provide net benefits at higher 10-year risks for CVD than are reflected in most current guidelines. In addition, the level of risk at which net benefit occurs varies considerably by age, sex, and statin type. PRIMARY FUNDING SOURCE Swiss Government Excellence Scholarship Office, Béatrice Ederer-Weber Foundation, and North-South Cooperation at the University of Zurich.
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Affiliation(s)
- Henock G Yebyo
- University of Zurich, Zurich, Switzerland (H.G.Y., H.E.A., M.A.P.)
| | | | - Milo A Puhan
- University of Zurich, Zurich, Switzerland (H.G.Y., H.E.A., M.A.P.)
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18
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Scott J, Owen-Smith A, Tonkin-Crine S, Rayner H, Roderick P, Okamoto I, Leydon G, Caskey F, Methven S. Decision-making for people with dementia and advanced kidney disease: a secondary qualitative analysis of interviews from the Conservative Kidney Management Assessment of Practice Patterns Study. BMJ Open 2018; 8:e022385. [PMID: 30420346 PMCID: PMC6252646 DOI: 10.1136/bmjopen-2018-022385] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To explore dialysis decision-making for adults who lack capacity due to cognitive impairment, a common and under-recognised condition in those with advanced chronic kidney disease (CKD). DESIGN Secondary analysis of qualitative data collected during the Conservative Kidney Management Assessment of Practice Patterns Study programme of research was performed. Sixty semistructured interviews were conducted with multiprofessional team members from UK renal centres. Staff were asked about local facilities, the value of conservative kidney management (CKM), when and with whom CKM was discussed and how CKM could be improved. Thematic analysis was employed to identify, characterise and report on themes that emerged from the data, focused on the specific issues experienced by people with dementia. SETTING A purposive sample of nine UK renal centres differing in the scale of their CKM programmes. PARTICIPANTS Clinical directors of renal centres identified staff involved in CKM. Staff were asked to participate if they had experience of low clearance clinics or of caring for patients with advanced CKD (estimated glomerular filtration rate <20mL/min/1.732 or >65 years with end-stage kidney disease). RESULTS Two overarching themes were identified: factors taken into consideration during decision-making, and the process of decision-making itself. Comorbidity, social support, quality of life and the feasibility of dialysis were reported as factors pertinent to clinicians' decisions regarding suitability. The majority of renal centres practised multidisciplinary 'best interests' decision-making for those without capacity. Attitudes to advance care planning were divided. CONCLUSIONS In view of the prevalence of cognitive impairment among those with advanced CKD, we suggest consideration of routine assessment of cognition and capacity. In the UK, dialysis is initiated and continued for individuals with dementia and services should be adapted to meet the needs of this population.
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Affiliation(s)
- Jemima Scott
- Richard Bright Renal Unit, Southmead Hospital, Bristol, UK
- Department of Social & Community Medicine, University of Bristol, Bristol, UK
| | - Amanda Owen-Smith
- Department of Social & Community Medicine, University of Bristol, Bristol, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Bristol, UK
| | - Hugh Rayner
- Department of Renal Medicine, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Paul Roderick
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Ikumi Okamoto
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Geraldine Leydon
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Fergus Caskey
- Richard Bright Renal Unit, Southmead Hospital, Bristol, UK
- Department of Social & Community Medicine, University of Bristol, Bristol, UK
- UK Renal Registry, Bristol, UK
| | - Shona Methven
- UK Renal Registry, Bristol, UK
- Department of Renal Medicine, Aberdeen Royal Infirmary, Aberdeen, UK
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19
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Yebyo HG, Aschmann HE, Yu T, Puhan MA. Should statin guidelines consider patient preferences? Eliciting preferences of benefit and harm outcomes of statins for primary prevention of cardiovascular disease in the sub-Saharan African and European contexts. BMC Cardiovasc Disord 2018; 18:97. [PMID: 29776337 PMCID: PMC5960214 DOI: 10.1186/s12872-018-0838-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 05/10/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Patient preferences are key parameters to evaluate benefit-harm balance of statins for primary prevention but they are not readily available to guideline developers and decision makers. Our study aimed to elicit patient preferences for benefit and harm outcomes related to use of statins for primary cardiovascular disease prevention and to examine how the preferences differ across economically and socio-culturally different environments. METHODS We conducted preference-eliciting surveys using best-worst scaling designed with a balanced incomplete-block design (BIBD) on 13 statins-related outcomes on 220 people in Ethiopia and Switzerland. The participants made tradeoff decisions and selected the most and least worrisome outcomes concurrently from each scenario generated using the BIBD. The design yielded 34,320 implied paired-comparisons and 2860 paired-responses as unit of analysis for eliciting the preferences that were analyzed using a conditional-logit model on a relative scale and surface under the cumulative ranking curve from multivariate random-effects meta-analysis model on a scale of 0 to 1. RESULTS There was high internal consistency of responses and minimal amount of measurement error in both surveys. Severe stroke was the most worrisome outcome with a ceiling preference of 1 (on 0 to 1 scale) followed by severe myocardial infarction, 0.913 (95% CI, 0.889-0.943), and cancer, 0.846 (0.829-0.855); while treatment discontinuation, 0.090 (0.023-0.123), and nausea/headache, 0.060 (0.034-0.094) were the least worrisome outcomes. Preferences were similar between Ethiopia and Switzerland with overlapping uncertainty intervals and concordance correlation of 0.97 (0.90-0.99). CONCLUSIONS Our study provides much needed empirical evidence on preferences that help clinical guidelines consider for weighing the benefit and harm outcomes when recommending for or against statins for primary prevention of cardiovascular disease. The preferences are consistent across the disparate settings; however, we recommend inclusion of more countries in future studies to ensure the generalizability of the preferences to all environments.
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Affiliation(s)
- Henock G Yebyo
- Department of Epidemiology, Biostatistics & Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland.,School of Public Health, College of Health Sciences, Mekelle University, Ayder, Mekelle, Ethiopia
| | - Hélène E Aschmann
- Department of Epidemiology, Biostatistics & Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland
| | - Tsung Yu
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Milo A Puhan
- Department of Epidemiology, Biostatistics & Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland.
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20
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Slob EMA, Vijverberg SJH, Pijnenburg MW, Koppelman GH, Maitland-van der Zee AH. What do we need to transfer pharmacogenetics findings into the clinic? Pharmacogenomics 2018; 19:589-592. [PMID: 29701121 DOI: 10.2217/pgs-2018-0026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Elise M A Slob
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, P.O. Box 22700, NL-1100 DE Amsterdam, The Netherlands
| | - Susanne J H Vijverberg
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, P.O. Box 22700, NL-1100 DE Amsterdam, The Netherlands
| | - Mariëlle W Pijnenburg
- Department of Paediatrics, Paediatric Pulmonology & Allergology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Gerard H Koppelman
- Department of Paediatric Pulmonology & Paediatric Allergology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands.,Groningen Research Institute for Asthma & COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anke-Hilse Maitland-van der Zee
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, P.O. Box 22700, NL-1100 DE Amsterdam, The Netherlands
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21
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Olsen M, Sharp MK, Bossuyt PM. From the theoretical to the practical: how to evaluate the ethical and scientific justifications of randomized clinical trials. J Clin Epidemiol 2018; 99:170-171. [PMID: 29596973 DOI: 10.1016/j.jclinepi.2018.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/20/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Maria Olsen
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; INSERM, U1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Methods of Therapeutic Evaluation of Chronic Diseases Team (METHODS), Paris F-75014 France; Paris Descartes University, Sorbonne Paris Cité, France
| | - Melissa K Sharp
- INSERM, U1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Methods of Therapeutic Evaluation of Chronic Diseases Team (METHODS), Paris F-75014 France; Paris Descartes University, Sorbonne Paris Cité, France; Department of Psychology, Faculty of Humanities and Social Sciences, University of Split, Poljicka cesta 35, Split 2100, Croatia.
| | - Patrick M Bossuyt
- Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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22
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Guerra B, Haile SR, Lamprecht B, Ramírez AS, Martinez-Camblor P, Kaiser B, Alfageme I, Almagro P, Casanova C, Esteban-González C, Soler-Cataluña JJ, de-Torres JP, Miravitlles M, Celli BR, Marin JM, ter Riet G, Sobradillo P, Lange P, Garcia-Aymerich J, Antó JM, Turner AM, Han MK, Langhammer A, Leivseth L, Bakke P, Johannessen A, Oga T, Cosio B, Ancochea-Bermúdez J, Echazarreta A, Roche N, Burgel PR, Sin DD, Soriano JB, Puhan MA. Large-scale external validation and comparison of prognostic models: an application to chronic obstructive pulmonary disease. BMC Med 2018; 16:33. [PMID: 29495970 PMCID: PMC5833113 DOI: 10.1186/s12916-018-1013-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 01/26/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND External validations and comparisons of prognostic models or scores are a prerequisite for their use in routine clinical care but are lacking in most medical fields including chronic obstructive pulmonary disease (COPD). Our aim was to externally validate and concurrently compare prognostic scores for 3-year all-cause mortality in mostly multimorbid patients with COPD. METHODS We relied on 24 cohort studies of the COPD Cohorts Collaborative International Assessment consortium, corresponding to primary, secondary, and tertiary care in Europe, the Americas, and Japan. These studies include globally 15,762 patients with COPD (1871 deaths and 42,203 person years of follow-up). We used network meta-analysis adapted to multiple score comparison (MSC), following a frequentist two-stage approach; thus, we were able to compare all scores in a single analytical framework accounting for correlations among scores within cohorts. We assessed transitivity, heterogeneity, and inconsistency and provided a performance ranking of the prognostic scores. RESULTS Depending on data availability, between two and nine prognostic scores could be calculated for each cohort. The BODE score (body mass index, airflow obstruction, dyspnea, and exercise capacity) had a median area under the curve (AUC) of 0.679 [1st quartile-3rd quartile = 0.655-0.733] across cohorts. The ADO score (age, dyspnea, and airflow obstruction) showed the best performance for predicting mortality (difference AUCADO - AUCBODE = 0.015 [95% confidence interval (CI) = -0.002 to 0.032]; p = 0.08) followed by the updated BODE (AUCBODE updated - AUCBODE = 0.008 [95% CI = -0.005 to +0.022]; p = 0.23). The assumption of transitivity was not violated. Heterogeneity across direct comparisons was small, and we did not identify any local or global inconsistency. CONCLUSIONS Our analyses showed best discriminatory performance for the ADO and updated BODE scores in patients with COPD. A limitation to be addressed in future studies is the extension of MSC network meta-analysis to measures of calibration. MSC network meta-analysis can be applied to prognostic scores in any medical field to identify the best scores, possibly paving the way for stratified medicine, public health, and research.
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Affiliation(s)
- Beniamino Guerra
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Sarah R. Haile
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Bernd Lamprecht
- Department of Pulmonary Medicine, Kepler Universitatsklinikum GmbH, Linz, Austria
- Faculty of Medicine, Johannes Kepler Universitat Linz, Linz, Austria
| | - Ana S. Ramírez
- Facultad de Medicina UASLP, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | | | - Bernhard Kaiser
- Department of Pulmonary Medicine, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria
| | | | - Pere Almagro
- Internal Medicine, Hospital Universitario Mutua de Terrassa, Terrassa, Spain
| | - Ciro Casanova
- Pulmonary Department and Research Unit, Hospital Universitario NS La Candelaria, Tenerife, Spain
| | | | | | - Juan P. de-Torres
- Pulmonary Department, Clinica Universidad de Navarra, Pamplona, Spain
| | - Marc Miravitlles
- European Respiratory Society (ERS) Guidelines Director, Barcelona, Spain
| | - Bartolome R. Celli
- Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Jose M. Marin
- IISAragón and CIBERES, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Gerben ter Riet
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Peter Lange
- Department of Public Health, Section of Social Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Judith Garcia-Aymerich
- ISGlobal, CIBER Epidemiología y Salud Pública (CIBERESP), Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Josep M. Antó
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), IMIM (Hospital del Mar Medical Research Institute, Universitat Pompeu Fabra (UPF), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Alice M. Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Meilan K. Han
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
| | - Arnulf Langhammer
- Department of Public Health and Nursing, Norvegian University of Science and Technology, Trondheim, Norway
| | - Linda Leivseth
- Centre for Clinical Documentation and Evaluation, Northern Norway Regional Health Authority, Bodø, Norway
| | - Per Bakke
- University of Bergen, Haukeland University Hospital, Bergen, Norway
| | - Ane Johannessen
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Toru Oga
- Department of Respiratory Care and Sleep Control Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Borja Cosio
- Department of Respiratory Medicine, Hospital Son Espases-IdISBa-CIBERES, Palma de Mallorca, Spain
| | - Julio Ancochea-Bermúdez
- Instituto de Investigación Sanitaria Princesa (IISP)-Servicio de Neumología- Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Andres Echazarreta
- Universidad Nacional de la Plata, Hospital San Juan de Dios de La Plata, Buenos Aires, Argentina
| | - Nicolas Roche
- Hopitaux Universitaires Paris Centre, Service de Pneumologie AP-HP, Paris, France
| | | | - Don D. Sin
- University of British Columbia, James Hogg Research Centre, Vancouver, Canada
| | - Joan B. Soriano
- Instituto de Investigación del Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Servicio de Neumología, Madrid, Spain
- Scientific and Methodological Consultant of SEPAR www.separ.es, Barcelona, Spain
| | - Milo A. Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, Room HRS G29, CH -8001 Zurich, Switzerland
- Epidemiology & Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - for the 3CIA collaboration
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
- Department of Pulmonary Medicine, Kepler Universitatsklinikum GmbH, Linz, Austria
- Faculty of Medicine, Johannes Kepler Universitat Linz, Linz, Austria
- Facultad de Medicina UASLP, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
- Dartmouth College Geisel School of Medicine, Dartmouth, NH USA
- Department of Pulmonary Medicine, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria
- Hospital Universitario de Valme, Sevilla, Spain
- Internal Medicine, Hospital Universitario Mutua de Terrassa, Terrassa, Spain
- Pulmonary Department and Research Unit, Hospital Universitario NS La Candelaria, Tenerife, Spain
- Network and Health Services Research Chronic Diseases (REDISSEC), Hospital Galdakao, Bizkaia, Spain
- Servicio de Neumología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
- Pulmonary Department, Clinica Universidad de Navarra, Pamplona, Spain
- European Respiratory Society (ERS) Guidelines Director, Barcelona, Spain
- Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA USA
- IISAragón and CIBERES, Hospital Universitario Miguel Servet, Zaragoza, Spain
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Hospital Univarsitario de Cruces, Barakaldo, Vizcaya Spain
- Department of Public Health, Section of Social Medicine, University of Copenhagen, Copenhagen, Denmark
- ISGlobal, CIBER Epidemiología y Salud Pública (CIBERESP), Universitat Pompeu Fabra (UPF), Barcelona, Spain
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), IMIM (Hospital del Mar Medical Research Institute, Universitat Pompeu Fabra (UPF), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
- Department of Public Health and Nursing, Norvegian University of Science and Technology, Trondheim, Norway
- Centre for Clinical Documentation and Evaluation, Northern Norway Regional Health Authority, Bodø, Norway
- University of Bergen, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Respiratory Care and Sleep Control Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Respiratory Medicine, Hospital Son Espases-IdISBa-CIBERES, Palma de Mallorca, Spain
- Instituto de Investigación Sanitaria Princesa (IISP)-Servicio de Neumología- Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain
- Universidad Nacional de la Plata, Hospital San Juan de Dios de La Plata, Buenos Aires, Argentina
- Hopitaux Universitaires Paris Centre, Service de Pneumologie AP-HP, Paris, France
- Hopital Cochin; Universite Paris Descartes, Paris, France
- University of British Columbia, James Hogg Research Centre, Vancouver, Canada
- Instituto de Investigación del Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Servicio de Neumología, Madrid, Spain
- Scientific and Methodological Consultant of SEPAR www.separ.es, Barcelona, Spain
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, Room HRS G29, CH -8001 Zurich, Switzerland
- Epidemiology & Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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23
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Girardat-Rotar L, Braun J, Puhan MA, Abraham AG, Serra AL. Temporal and geographical external validation study and extension of the Mayo Clinic prediction model to predict eGFR in the younger population of Swiss ADPKD patients. BMC Nephrol 2017; 18:241. [PMID: 28716055 PMCID: PMC5513403 DOI: 10.1186/s12882-017-0654-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 07/03/2017] [Indexed: 12/16/2022] Open
Abstract
Background Prediction models in autosomal dominant polycystic kidney disease (ADPKD) are useful in clinical settings to identify patients with greater risk of a rapid disease progression in whom a treatment may have more benefits than harms. Mayo Clinic investigators developed a risk prediction tool for ADPKD patients using a single kidney value. Our aim was to perform an independent geographical and temporal external validation as well as evaluate the potential for improving the predictive performance by including additional information on total kidney volume. Methods We used data from the on-going Swiss ADPKD study from 2006 to 2016. The main analysis included a sample size of 214 patients with Typical ADPKD (Class 1). We evaluated the Mayo Clinic model performance calibration and discrimination in our external sample and assessed whether predictive performance could be improved through the addition of subsequent kidney volume measurements beyond the baseline assessment. Results The calibration of both versions of the Mayo Clinic prediction model using continuous Height adjusted total kidney volume (HtTKV) and using risk subclasses was good, with R2 of 78% and 70%, respectively. Accuracy was also good with 91.5% and 88.7% of the predicted within 30% of the observed, respectively. Additional information regarding kidney volume did not substantially improve the model performance. Conclusion The Mayo Clinic prediction models are generalizable to other clinical settings and provide an accurate tool based on available predictors to identify patients at high risk for rapid disease progression.
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Affiliation(s)
- Laura Girardat-Rotar
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland
| | - Julia Braun
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland
| | - Alison G Abraham
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andreas L Serra
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland. .,Medizinisches Kompetenzzentrum für ADPKD, Suisse ADPKD, Department of Internal Medicine and Nephrology, Hirslanden, Witellikerstrasse 40, CH-8032, Zurich, Switzerland.
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24
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Frouws MA, van Herk-Sukel MPP, Maas HA, Van de Velde CJH, Portielje JEA, Liefers GJ, Bastiaannet E. The mortality reducing effect of aspirin in colorectal cancer patients: Interpreting the evidence. Cancer Treat Rev 2017; 55:120-127. [PMID: 28359968 DOI: 10.1016/j.ctrv.2016.12.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 12/20/2016] [Accepted: 12/21/2016] [Indexed: 12/16/2022]
Abstract
In 1971 the first study appeared that suggested a relationship between aspirin and cancer. Currently publications on the subject of aspirin and cancer are numerous, with both a beneficial effect of aspirin on cancer incidence and a beneficial effect on cancer survival. This review focusses on the relation between the use of aspirin and improved survival in colorectal cancer patients. Various study designs have been used, with the main part being observational studies and post hoc meta-analyses of cancer outcomes in cardiovascular prevention trials. The results of these studies are unambiguously pointing towards an effect of aspirin on colorectal cancer survival, and several randomised controlled trials are currently ongoing. Some clinicians feel that the current evidence is conclusive and that the time has come for aspirin to be prescribed as adjuvant therapy. However, until this review, not much attention has been paid to the specific types of bias associated with these studies. One of these biases is confounding by indication, because aspirin is indicated for patients as secondary prevention for cardiovascular disease. This review aims to provide perspective on these biases and provide tools for the interpretation of the current evidence. Albeit promising, the current evidence is not sufficient to already prescribe aspirin as adjuvant therapy for colorectal cancer.
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Affiliation(s)
- Martine A Frouws
- Department of Surgical Oncology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, The Netherlands.
| | - Myrthe P P van Herk-Sukel
- PHARMO Institute for Drug Outcomes Research, Van Deventerlaan 30/40, 3528 AE Utrecht, The Netherlands
| | - Huub A Maas
- Department of Geriatric Medicine, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Cornelis J H Van de Velde
- Department of Surgical Oncology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, The Netherlands
| | - Johanneke E A Portielje
- Department of Medical Oncology, Haga Hospital, Leyweg 275, 2545 CH The Hague, The Netherlands
| | - Gerrit-Jan Liefers
- Department of Surgical Oncology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, The Netherlands
| | - Esther Bastiaannet
- Department of Surgical Oncology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, The Netherlands
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25
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Agapova M, Bresnahan BB, Higashi M, Kessler L, Garrison LP, Devine B. A proposed approach for quantitative benefit-risk assessment in diagnostic radiology guideline development: the American College of Radiology Appropriateness Criteria Example. J Eval Clin Pract 2017; 23:128-138. [PMID: 27762080 DOI: 10.1111/jep.12635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 07/24/2016] [Accepted: 07/26/2016] [Indexed: 12/20/2022]
Abstract
The American College of Radiology develops evidence-based practice guidelines to aid appropriate utilization of radiological procedures. Panel members use expert opinion to weight trade-offs and consensus methods to rate appropriateness of imaging tests. These ratings include an equivocal range, assigned when there is disagreement about a technology's appropriateness and the evidence base is weak or for special circumstances. It is not clear how expert consensus merges with the evidence base to arrive at an equivocal rating. Quantitative benefit-risk assessment (QBRA) methods may assist decision makers in this capacity. However, many methods exist and it is not clear which methods are best suited for this application. We perform a critical appraisal of QBRA methods and propose several steps that may aid in making transparent areas of weak evidence and barriers to consensus in guideline development. We identify QBRA methods with potential to facilitate decision making in guideline development and build a decision aid for selecting among these methods. This study identified 2 families of QBRA methods suited to guideline development when expert opinion is expected to contribute substantially to decision making. Key steps to deciding among QBRA methods involve identifying specific benefit-risk criteria and developing a state-of-evidence matrix. For equivocal ratings assigned for reasons other than disagreement or weak evidence base, QBRA may not be needed. In the presence of disagreement but the absence of a weak evidence base, multicriteria decision analysis approaches are recommended; and in the presence of weak evidence base and the absence of disagreement, incremental net health benefit alone or combined with multicriteria decision analysis is recommended. Our critical appraisal further extends investigation of the strengths and limitations of select QBRA methods in facilitating diagnostic radiology clinical guideline development. The process of using the decision aid exposes and makes transparent areas of weak evidence and barriers to consensus.
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Affiliation(s)
- Maria Agapova
- Pharmaceutical Outcomes Research and Policy Program, University of Washington, Seattle, Washington, USA
| | - Brian B Bresnahan
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | | | - Larry Kessler
- Department of Health Services, University of Washington, Seattle, Washington, USA
| | - Louis P Garrison
- Pharmaceutical Outcomes Research and Policy Program, University of Washington, Seattle, Washington, USA
| | - Beth Devine
- Pharmaceutical Outcomes Research and Policy Program, University of Washington, Seattle, Washington, USA.,Department of Health Services, University of Washington, Seattle, Washington, USA
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Emilsson L, Holme Ø, Bretthauer M, Cook NR, Buring JE, Løberg M, Adami HO, Sesso HD, Gaziano MJ, Kalager M. Systematic review with meta-analysis: the comparative effectiveness of aspirin vs. screening for colorectal cancer prevention. Aliment Pharmacol Ther 2017; 45:193-204. [PMID: 27859394 DOI: 10.1111/apt.13857] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 09/29/2016] [Accepted: 10/17/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Both aspirin use and screening with flexible sigmoidoscopy or guaiac faecal occult blood testing (FOBT) may reduce mortality from colorectal cancer, but comparative effectiveness of these interventions is unknown. AIM To compare aspirin to guaiac FOBT screening with regard to incidence and mortality of colorectal cancer in a network meta-analysis. METHODS We searched Medline, EMBASE and the COCHRANE central register (CENTRAL) for relevant randomised trials identified until 31 October 2015. Randomised trials in average-risk populations that reported colorectal cancer mortality, colorectal cancer incidence, or both, with a minimum follow-up of 2 years, and more than 100 randomised individuals were included. Three investigators independently extracted data. We calculated relative risks [RR with 95% predictive intervals (PrIs)] for the comparison of the interventions by frequentist network meta-analyses. RESULTS The effect of aspirin on colorectal cancer mortality was similar to FOBT (RR 1.03; 95% PrI 0.76-1.39) and flexible sigmoidoscopy (RR 1.16; 95% PrI 0.84-1.60). Aspirin was more effective than FOBT (RR 0.36; 95% PrI 0.22-0.59) and flexible sigmoidoscopy (RR 0.37; 95% PrI 0.22-0.62) in preventing death from or cancer in the proximal colon. Aspirin was equally effective as screening in reducing colorectal cancer incidence, while flexible sigmoidoscopy was superior to FOBT (RR 0.84; 95% PrI 0.72-0.97). CONCLUSIONS Low-dose aspirin seems to be equally effective as flexible sigmoidoscopy or guaiac FOBT screening to reduce colorectal cancer incidence and mortality, and more effective for cancers in the proximal colon. A randomised comparative effectiveness trial of aspirin vs. screening is warranted.
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Affiliation(s)
- L Emilsson
- Institute of Health and Society, University of Oslo, Oslo, Norway.,Primary Care Research Unit, Vårdcentralen Värmlands Nysäter, Värmland, Sweden.,Department of Transplantation Medicine, K. G. Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Ø Holme
- Institute of Health and Society, University of Oslo, Oslo, Norway.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - M Bretthauer
- Institute of Health and Society, University of Oslo, Oslo, Norway.,Department of Medicine, Sørlandet Hospital, Kristiansand, Norway.,Department of Transplantation Medicine, K. G. Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway
| | - N R Cook
- Department of Transplantation Medicine, K. G. Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway.,Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - J E Buring
- Department of Transplantation Medicine, K. G. Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway.,Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - M Løberg
- Institute of Health and Society, University of Oslo, Oslo, Norway.,Department of Medicine, Sørlandet Hospital, Kristiansand, Norway
| | - H-O Adami
- Department of Transplantation Medicine, K. G. Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - H D Sesso
- Department of Transplantation Medicine, K. G. Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway.,Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - M J Gaziano
- Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - M Kalager
- Institute of Health and Society, University of Oslo, Oslo, Norway.,Department of Transplantation Medicine, K. G. Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway.,Telemark Hospital, Skien, Norway
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Thorat MA. Individualised benefit-harm balance of aspirin as primary prevention measure - a good proof-of-concept, but could have been better…. BMC Med 2016; 14:101. [PMID: 27383519 PMCID: PMC4936221 DOI: 10.1186/s12916-016-0648-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 06/23/2016] [Indexed: 12/11/2022] Open
Abstract
Guidelines from different organisations regarding the use of aspirin for primary prevention vary despite being based on similar evidence. Translating these in practice presents a further major challenge. The benefit-harm balance tool developed by Puhan et al. (BMC Med 13:250, 2015) for aspirin can overcome some of these difficulties and is therefore an important step towards personalised medicine. Although a good proof-of-concept, this tool has some important limitations that presently preclude its use in practice or for further research. One of the major benefits of aspirin that has become apparent in the last decade or so is its effect in preventing cancer and cancer-related deaths. However, this benefit is clear and consistent in randomised as well as observational evidence only for specific cancers. Additionally, it has long lag-time and carry-over periods. These nuances of aspirin's effects demand a specific and a more sophisticated model such as a time-varying model. Further refinement of this tool with respect to these aspects is merited to make it ready for evaluation in qualitative and quantitative studies with the goal of clinical utility.Please see related article: http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0493-2.
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Affiliation(s)
- Mangesh A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK. .,Breast Services, Division of Surgery and Interventional Science, Whittington Hospital, Magdala Avenue, London, N19 5NF, UK.
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Bembenek JP, Niewada M, Karlinski M, Czlonkowska A. Effect of prestroke antiplatelets use on first-ever ischaemic stroke severity and early outcome. Int J Clin Pract 2016; 70:477-81. [PMID: 27040605 DOI: 10.1111/ijcp.12804] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES We aimed to investigate whether prior use of antiplatelet agents (AP) may be associated with lower severity and improved short-term outcome of the first-ever acute ischaemic stroke. METHODS This was a retrospective, case-control study based on a prospective hospital stroke registry covering consecutive acute stroke patients admitted to a single stroke centre in highly urbanised area (Warsaw, Poland) between 1995 and 2013. Patients receiving oral anticoagulants were excluded from the analysis. Statistical analysis included multiple regression and logistic regression adjusted for age, sex, hypertension, atrial fibrillation, congestive heart failure, diabetes, coronary heart disease and history of myocardial infarction. RESULTS During the study period, there were 3036 eligible patients, of whom 879 (29%) received AP before stroke onset. Patients from the AP group were older and more often burdened with stroke risk factors. There were no differences in baseline stroke severity, hospital mortality and proportion of patients alive and independent at discharge. However, AP turned out to be independently associated with lower NIHSS score on admission (β = -0.045, p = 0.008) and increased odds for being alive and independent at discharge (odds ratio 1.36, 95% CI: 1.13-1.67) and decreased odds for in-hospital mortality (odds ratio 0.77, 95% CI: 0.59-0.99). CONCLUSIONS Our findings provide further evidence supporting modest benefit of AP therapy on the course and outcome of first-ever ischaemic stroke. Further large studies are needed to confirm this effect.
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Affiliation(s)
- J P Bembenek
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - M Niewada
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | - M Karlinski
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - A Czlonkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
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Evidence selection for a prescription drug's benefit-harm assessment: challenges and recommendations. J Clin Epidemiol 2016; 74:151-7. [PMID: 26939932 DOI: 10.1016/j.jclinepi.2016.02.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 01/07/2016] [Accepted: 02/03/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To describe challenges and make recommendations for researchers in how they select evidence to quantitatively assess a prescription drug's benefits and harms. STUDY DESIGN AND SETTING These challenges and recommendations are based on our recent experience conducting a benefit-harm assessment for the prescription drug roflumilast. We considered the selection of evidence to quantify (1) the drug's treatment effects in patients, (2) the patient population's baseline risks for beneficial and harmful outcomes without treatment, and (3) the patient population's preferences for these beneficial effects and harms. These are fundamental steps for most benefit-harm assessment methods. RESULTS We identify critical issues in selecting evidence for each of these steps. We justify in particular the need to incorporate (1) clinical trials for the drug's specific treatment effect; (2) observational studies with the most valid, precise, and applicable effect estimates for the baseline risk; and (3) flexible weighting approaches for balancing the drug benefits and harms. CONCLUSION We identify challenges and make recommendations for selecting evidence at the critical steps in a prescription drug's benefit-harm assessment. Our findings should assist other researchers conducting these assessments for prescription drugs, which could help regulators, medical professionals, and patients make better decisions about prescription drug use.
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DeCensi A, Thorat MA, Bonanni B, Smith SG, Cuzick J. Barriers to preventive therapy for breast and other major cancers and strategies to improve uptake. Ecancermedicalscience 2015; 9:595. [PMID: 26635899 PMCID: PMC4664508 DOI: 10.3332/ecancer.2015.595] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Indexed: 12/31/2022] Open
Abstract
The global cancer burden continues to rise and the war on cancer can only be won if improvements in treatment go hand in hand with therapeutic cancer prevention. Despite the availability of several efficacious agents, utilisation of preventive therapy has been poor due to various barriers, such as the lack of physician and patient awareness, fear of side effects, and licensing and indemnity issues. In this review, we discuss these barriers in detail and propose strategies to overcome them. These strategies include improving physician awareness and countering prejudices by highlighting the important differences between preventive therapy and cancer treatment. The importance of the agent-biomarker-cohort (ABC) paradigm to improve effectiveness of preventive therapy cannot be overemphasised. Future research to improve therapeutic cancer prevention needs to include improvements in the prediction of benefits and harms, and improvements in the safety profile of existing agents by experimentation with dose. We also highlight the role of drug repurposing for providing new agents as well as to address the current imbalance between therapeutic and preventive research. In order to move the field of therapeutic cancer prevention forwards, engagement with policymakers to correct research imbalance as well as to remove practical obstacles to implementation is also urgently needed.
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Affiliation(s)
- Andrea DeCensi
- Division of Medical Oncology, E.O. Ospedali Galliera, Mura delle Cappuccine 14, Genoa 16128, Italy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
| | - Mangesh A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
- Breast Services, Division of Surgery and Interventional Science, Whittington Hospital, Magdala Avenue, London N19 5NF, UK
| | - Bernardo Bonanni
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Via Ripamonti 435, Milan 20141, Italy
| | - Samuel G Smith
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
- Health Behaviour Research Centre, University College London, London WC1E 7HB, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
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