Decisions on statin therapy by patients' opinions about survival gains: cross sectional survey of general practitioners

Prolongation of disease-free life: When is the benefit sufficient to warrant the effort of taking a preventive medicine?

The prolongation of disease-free life (PODL) required by people to be willing to accept an offer of a preventive treatment is unknown. Quantifying the required benefits could guide information and discussions about preventive treatment. In this study, we investigated how large the benefit in prolongation of a disease-free life (PODL) should be for individuals aged 50-80 years to accept a preventive treatment offer. We used a cross-sectional survey design based on a representative sample of 6847 Danish citizens aged 50-80 years. Data were collected in 2019 through a web-based standardized questionnaire administered by Statistics Denmark, and socio-demographic data were added from a national registry. We analyzed the data with chi-square tests and stepwise multinomial logistic regression. The results indicate that the required minimum benefit from the preventive treatment varied widely between individuals (1-week PODL = 14.8%, ≥4 years PODL = 39.2%), and that the majority of individuals (51.1%) required a PODL of ≥2 years. The multivariable analysis indicate that education and income were independently and negatively associated with requested minimum benefit, while age and smoking were independently and positively associated with requested minimum benefit to accept the preventive treatment. Most individuals aged 50-80 years required larger health benefits than most preventive medications on average can offer. The data support the need for educating patients and health care professionals on how to use average benefits when discussing treatment benefits, especially for primary prevention.

Predicting difference in mean survival time from cause-specific hazard ratios for women diagnosed with breast cancer

BACKGROUND

Relative reduction in breast cancer mortality is the preferred outcome measure for evaluation of mammography screening. However, mean survival time has been advocated as a better and more intuitive outcome for risk communication. We have previously introduced a method to predict difference in mean survival time from empirical hazard ratios for all-cause mortality. In this article, we aim to investigate the association between hazard ratios for breast cancer mortality and the difference in mean survival time for women diagnosed with breast cancer.

METHODS

We retrieved data on all women diagnosed with first-time invasive breast cancer in Norway from 1960 through 2004. Women were followed until emigration or end of follow-up on 31 December 2015, whichever came first. Observed differences in mean survival times and hazard ratios for both breast cancer death and death from causes other than breast cancer were obtained for neighbouring time periods defined by women's age and year of diagnosis. Based on previously developed methods, we fitted a linear relationship between observed differences in mean survival and logarithmic hazard ratios.

RESULTS

A linear association was found between breast cancer-specific hazard ratios and difference in mean survival time for women diagnosed with breast cancer. This association was also estimated with adjustment for other causes of death than breast cancer.

CONCLUSIONS

The change in mean survival time could be predicted from an estimated reduction in breast cancer mortality. This outcome measure can contribute to better and more understandable risk information about the effect of mammography screening programmes.

Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles

BACKGROUND

Shared decision making requires evidence to be conveyed to the patient in a way they can easily understand and compare. Patient decision aids facilitate this process. This article reviews the current evidence for how to present numerical probabilities within patient decision aids.

METHODS

Following the 2013 review method, we assembled a group of 9 international experts on risk communication across Australia, Germany, the Netherlands, the United Kingdom, and the United States. We expanded the topics covered in the first review to reflect emerging areas of research. Groups of 2 to 3 authors reviewed the relevant literature based on their expertise and wrote each section before review by the full authorship team.

RESULTS

Of 10 topics identified, we present 5 fundamental issues in this article. Although some topics resulted in clear guidance (presenting the chance an event will occur, addressing numerical skills), other topics (context/evaluative labels, conveying uncertainty, risk over time) continue to have evolving knowledge bases. We recommend presenting numbers over a set time period with a clear denominator, using consistent formats between outcomes and interventions to enable unbiased comparisons, and interpreting the numbers for the reader to meet the needs of varying numeracy.

DISCUSSION

Understanding how different numerical formats can bias risk perception will help decision aid developers communicate risks in a balanced, comprehensible manner and avoid accidental "nudging" toward a particular option. Decisions between probability formats need to consider the available evidence and user skills. The review may be useful for other areas of science communication in which unbiased presentation of probabilities is important.

Postponement of Death by Pharmacological Heart Failure Treatment: A Meta-Analysis of Randomized Clinical Trials

BACKGROUND

Outcome postponement has been proposed as an effect measure for preventive drug treatment. It describes the average delay of the investigated unwanted clinical event, achieved by taking medication. The objective was to estimate postponement of death for the following heart failure medications compared to placebo: beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), ARB added to ACE inhibitors, aldosterone antagonists, ivabradine, and renin antagonists.

METHODS

We searched Medline and Embase from inception of databases until October 2017. Eligibility criteria were randomized placebo-controlled heart failure trials, including at least 1000 participants, with survival as a prespecified outcome and a minimum trial duration of 1 year. We calculated the outcome postponement by modeling the area between survival curves. This area was modeled on the basis of the hazard ratio or relative risk, the rate of mortality in the placebo group, and the trial duration. All results were standardized to a 3-year trial duration to ensure comparability between treatments.

RESULTS

We identified 14 eligible trials, with a total of 52,014 patients. The results in terms of postponement of all-cause mortality was: beta-blockers 43.7 days (95% confidence interval [95% CI], 20.8-66.5), ACE inhibitors 41.0 days (95% CI, 18.8-63.3), and aldosterone-antagonists 41.3 days (95% CI, 14.3,68.4).

CONCLUSION

The modeled outcome postponement estimates reiterate beta-blockers, ACE inhibitors, and aldosterone antagonists as the mainstay of heart failure treatment. Furthermore, ivabradine or ARBs added to ACE inhibitors results in no statistically significant gain in survival.

Postponement of Death by Statin Use: a Systematic Review and Meta-analysis of Randomized Clinical Trials

BACKGROUND

The average postponement of the outcome (gain in time to event) has been proposed as a measure to convey the effect of preventive medications. Among its advantages over number needed to treat and relative risk reduction is a better intuitive understanding among lay persons.

OBJECTIVES

To develop a novel approach for modeling outcome postponement achieved within a trial's duration, based on published trial data and to present a formalized meta-analysis of modeled outcome postponement for all-cause mortality in statin trials.

METHODS

The outcome postponement was modeled on the basis of the hazard ratio or relative risk, the mortality rate in the placebo group and the trial's duration. Outcome postponement was subjected to a meta-analysis. We also estimated the average outcome postponement as the area between Kaplan-Meier curves. Statin trials were identified through a systematic review.

RESULTS

The median modeled outcome postponement was 10.0 days (interquartile range, 2.9-19.5 days). Meta-analysis of 16 trials provided a summary estimate of outcome postponement for all-cause mortality of 12.6 days, with a 95% postponement interval (PI) of 7.1-18.0. For primary, secondary, and mixed prevention trials, respectively, outcome postponements were 10.2 days (PI, 4.0-16.3), 17.4 days (PI, 6.0-28.8), and 8.5 days (PI, 1.9-15.0).

CONCLUSIONS

The modeled outcome postponement is amenable to meta-analysis and may be a useful approach for presenting the benefits of preventive interventions. Statin treatment results in a small increase of average survival within the duration of a trial.

SYSTEMATIC REVIEW REGISTRATION

The systematic review was registered in PROSPERO [CRD42016037507] .

Variation in minimum desired cardiovascular disease-free longevity benefit from statin and antihypertensive medications: a cross-sectional study of patient and primary care physician perspectives

OBJECTIVE

Expressing therapy benefit from a lifetime perspective, instead of only a 10-year perspective, is both more intuitive and of growing importance in doctor-patient communication. In cardiovascular disease (CVD) prevention, lifetime estimates are increasingly accessible via online decision tools. However, it is unclear what gain in life expectancy is considered meaningful by those who would use the estimates in clinical practice. We therefore quantified lifetime and 10-year benefit thresholds at which physicians and patients perceive statin and antihypertensive therapy as meaningful, and compared the thresholds with clinically attainable benefit.

DESIGN

Cross-sectional study.

SETTINGS

(1) continuing medical education conference in December 2016 for primary care physicians;(2) information session in April 2017 for patients.

PARTICIPANTS

400 primary care physicians and 523 patients in the Netherlands.

OUTCOME

Months gain of CVD-free life expectancy at which lifelong statin therapy is perceived as meaningful, and months gain at which 10 years of statin and antihypertensive therapy is perceived as meaningful. Physicians were framed as users for lifelong and prescribers for 10-year therapy.

RESULTS

Meaningful benefit was reported as median (IQR). Meaningful lifetime statin benefit was 24 months (IQR 23-36) in physicians (as users) and 42 months (IQR 12-42) in patients willing to consider therapy. Meaningful 10-year statin benefit was 12 months (IQR 10-12) for prescribing (physicians) and 14 months (IQR 10-14) for using (patients). Meaningful 10-year antihypertensive benefit was 12 months (IQR 8-12) for prescribing (physicians) and 14 months (IQR 10-14) for using (patients). Women desired greater benefit than men. Age, CVD status and co-medication had minimal effects on outcomes.

CONCLUSION

Both physicians and patients report a large variation in meaningful longevity benefit. Desired benefit differs between physicians and patients and exceeds what is clinically attainable. Clinicians should recognise these discrepancies when prescribing therapy and implement individualised medicine and shared decision-making. Decision tools could provide information on realistic therapy benefit.

Can we trust what parents tell us? A systematic review

Taking a history is a key diagnostic instrument in paediatric consultations. Numerous issues potentially reduce the history's reliability. Therefore, paediatricians have always expressed ambivalence regarding history taking from parents, both valuing and distrusting it. In this review, we describe how parents build and present a description of their child's health issues in the conceptual framework of self-regulation theory. We performed a systematic review on the literature on the reliability of history taking. No studies examined the reliability of history taking from parents, but there is a considerable body of evidence on the issue of mutual trust in relationships between health care professionals and patients. Because trust is a dynamic relational phenomenon, taking a patient centred approach in consultations is likely to increase the patients' and parents' trust in the health care professional, and their willingness to follow the health care professional's treatment proposals. We provide evidence based recommendations on how to build and maintain trust in paediatric consultations by taking a patient centred approach in such consultations.

Associations between patients' adherence and GPs' attitudes towards risk, statin therapy and management of non-adherence--a survey and register-based study

BACKGROUND

Previous studies suggest that doctors' personal lifestyle, risk taking personality and beliefs about risk reducing therapies may affect their clinical decision-making. Whether such factors are further associated with patients' adherence with medication is largely unknown.

OBJECTIVE

To estimate associations between GPs' attitudes towards risk, statin therapy and management of non-adherence and their patients' adherence, and to identify subgroups of GPs with poor patient adherence.

METHODS

All Danish GPs were invited to participate in an online survey. We asked whether they regarded statin treatment as important, how they managed non-adherence and whether non-adherence annoyed them. The Jackson Personality Inventory-revised was used to measure risk attitude. The GPs' responses were linked to register data on their patients' redeemed statin prescriptions. Mixed effect logistic regression was used to estimate associations between patient adherence and GPs' attitudes. Adherence was estimated by the proportion of days covered in a 1-year period using an 80% cut-off.

RESULTS

We received responses from 1398 GPs (42.2%) who initiated statin therapy in 12 192 patients during the study period. In total 6590 (54.1%) of these patients were adherent. Patients who had GPs rarely assessing their treatment adherence were less likely to be adherent than those who had GPs assessing their patients' treatment adherence now and then, odds ratio (OR) 0.86 [confidence interval (CI) 0.77-0.96]. No other associations were found between patients' adherence and GPs' attitudes.

CONCLUSIONS

Our findings suggest that GPs' attitudes to risk, statin therapy or management of non-adherence are not significantly associated with their patients' adherence.