Patient-Accessible Tool for Shared Decision Making in Cardiovascular Primary Prevention

Abstract

T he initiation of lifelong primary prevention therapy for cardiovascular disease in a high-risk patient should be based on a shared decision-making process between patient and doctor following the clear presentation of appropriate information, including the quantification of the risks and benefits expected from treatment and the cost and inconvenience (disutility) to the patient. This ideal scenario is almost never achieved. Editorial see p 2500 Clinical Perspective on p 2546Currently, primary prevention practice focuses on risk stratification by using population-based statistical estimates to determine which individuals would have most to gain from preventative therapy.1 Doctors are documented to view risks differently from patients, and both have difficulty in evaluating, perceiving, and conveying risks and benefits in an easily understood manner.2-5 The benefits of primary prevention are thus often presented to the patient without formal quantification of the cost, harms, or inconvenience they might incur. However, patients do understand risks and trade-offs 3 and trust doctors more when presented with numeric information than when given vague interpretations of risk. 6Previous interventions, aimed at improving adherence, have used new methods to convey cardiovascular risk rather than tackling the underlying reasons why people stop medication. The focus has been on individual counseling, and on quantitative and graphical displays, or the use of imaging techniques such as coronary CT scans to improve risk perception. [7][8][9] These are based on the principle that better risk perception will lead to higher adherence and persistence with primary prevention therapy. 10-12Patient inconvenience, or medication disutility, has rarely been taken into consideration when initiating therapy. Knowing one's risk to be high does not necessarily mean that one will, must, or even should take a preventive step. Taking action depends on many factors, and a large part of a patient's resistance to treatment involves the reluctance to embark on a Background-Primary prevention guidelines focus on risk, often assuming negligible aversion to medication, yet most patients discontinue primary prevention statins within 3 years. We quantify real-world distribution of medication disutility and separately calculate the average utilities for a range of risk strata. Method and Results-We randomly sampled 360 members of the general public in London. Medication aversion was quantified as the gain in lifespan required by each individual to offset the inconvenience (disutility) of taking an idealized daily preventative tablet. In parallel, we constructed tables of expected gain in lifespan (utility) from initiating statin therapy for each age group, sex, and cardiovascular risk profile in the population. This allowed comparison of the widths of the distributions of medication disutility and of group-average expectation of longevity gain. Observed medication disutility ranged from 1 day to >10 years of life being required by subjects (median, 6...

Aspirin for Primary Prevention: What’s a Clinician to Do?

“…This discussion should ideally take into account patient preferences and values and the growing appreciation of the disutility associated with medication use for some people. 10 However, given time constraints and the complex tradeoffs involved, we agree with Fiscella et al that better tools to help busy clinicians assess the balance of benefit and risk would be helpful. Hopefully, ongoing trials will illuminate the situation further.…”

Quantifying the Utility of Taking Pills for Cardiovascular Prevention

“…A recent study performed in London, UK, attempted to determine the utility of taking a pill daily by interviewing 360 people in public streets in North West London. 16 In that study, participants answered a questionnaire to determine the amount of life they would need to gain to take a preventive pill for the rest of their life. The median increase required was 6 months, with an interquartile range from 1 to 36 months; 12% had extreme disutility (requiring more than a 10-year increase in life expectancy), whereas 34% required less than a month increase.…”

Do Pills Have No Ills? Capturing the Impact of Direct Treatment Disutility

“…Taking statins would generally be considered to be non-invasive in the traditional sense and is believed to have low day-to-day treatment burden on patients. However, with a relatively small absolute benefit from treatment which accrues over very long periods, patient preferences regarding use of the medicine over a life-time could be important in determining patients' take-up of the intervention [5,6] as well as its cost-effectiveness.…”

“…Three published empirical studies that relate to the concept of DTD were identified through the search strategy [6,8,9]; and one was found via reference list searching [10]. Gage et al find a disutility directly associated with taking warfarin of 0.003 and no disutility associated with taking aspirin when using a time-trade off method in patients (n=70) with atrial fibrillation [10].…”