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Delfini
Rx
Messaging Scripts ™
are scripts for
scripts.
Messaging scripts
are targeted treatment messaging & decision support tools
for specific clinical topics. This tool, and accompanying template,
can help you construct your own. This tool can also be used
in conjunction with the Delfini
Patient
Information & Decision Aid Tool for greater depth
of script or aid development. |
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Messaging
scripts can be used for a variety of purposes – some examples:
1. Information and decision aids for clinicians, pharmacists and
nurses
2. Scripts for academic detailing
3. Customized chart-based advisements from pharmacists to clinicians
4. Information, decision & action aids for patients |
|
Legal Information & Disclaimers |
Use
of this website implies your agreement to our Notices.
Terms
of Use: Please include a credit statement acknowledging this
work, such as this one –
• Consulted
Delfini
Rx Messaging Scripts
™
Template — www.delfini.org |
| |
|
| Attributes
of Good Scripts
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A
good messaging script is —
- Concise, text
table-based
- Patient-centered
and customizable to individual patient, caretaker or clinician
- Evidence-based
with short evidence statements plus key references
- Informative
and quantitative
- Presents
quantified information on baseline risk, benefits and
harms in natural language and in ways research suggests
may be most easily understood
- Informs about
the benefits and harms of relevant choices, including no
treatment
- Flexible –
can add dosing info, cost info, patient preferences, value
considerations, action steps, etc. to customize to topic and
need
- Utility oriented
- Helps prepare
for academic detailing and for preparation of information,
decision and action aids
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Communicating
Results to Physicians and Patients
Quantified information
is important to convey likelihood of benefit or harm. Physician
and patients’ selection of interventions varies dramatically
depending upon how study results are communicated.
Four primary methods
are –
1. Risk with and
without intervention Recommended
Two-by-two table information.
Example: Out of 100 people, 10% died without treatment and 5%
of people died with treatment within 5 years.
2. Absolute risk reduction (ARR) Recommended
The actual percent risk.
From above example: 5% ARR (5 yrs), meaning “Five percent
of people benefited from using treatment x within 5 years.”
Effect out of 100
*Highly Recommended*
ARR can also be expressed as benefit or risk out of 100.
Example: “For every 100 people who used treatment x, 5
people benefited within 5 years.”
3. Number-needed-to-treat
(NNT) Recommended
The reciprocal of ARR.
(1/ARR).
Easy conversion tip: ARR # goes into 100 how many times?
From above example: NNT 20 (5 yrs)
NNT is always expressed in terms of 1 person benefiting. For
example NNT 20 (5yrs) is expressed as, “For every 20 people
treated, 1 person will benefit from treatment x within 5 years.”
4. Relative Risk
Reduction (RRR) NOT Recommended without one or more
from above
The relative percent difference in the proportion of the outcomes.
(Comparison group outcomes - Intervention group outcomes) /
Comparison group outcomes
RRR can overstate results size.
From the above example: RRR 50% (5 yrs).
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Template for
Scripting
(more
available by downloading the tool)
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This
patient is a good candidate for [INTERVENTION]
Baseline
Risk: The best available valid and useful evidence
indicates that [population description summarized from
study inclusion, exclusions and baseline characteristics
including ages and other meaningful prognostic characteristics
such as with a history of…] have a [x percent] %
risk of developing [condition] within [time period].
Medical
Intervention Benefits and Risks: The best available
valid and useful evidence indicates that [population description
from above] have a [x percent] risk of developing [condition]
within [time period] if treated with [study comparator,
e.g., placebo] within [study period]. However, the risk
drops to [x percent] within [study period] for those treated
with [intervention]. This is a [ARR] % decrease in risk.
Out of 100 patients, [ARR without % symbol] will benefit.
[List below quantified information for benefits, harms
and risks.]
For
lay users: You may wish to substitute “risk”
for “harms” unless harms are 100% known.
- Consider
what matters to patients: morbidity, mortality, symptom
relief, functioning, health-related quality of life,
satisfaction, costs, uncertainties and alternatives.
- Consider
patient preferences, value considerations and action
steps, etc.
- Customize
and personalize as you can.
|
|
+ |
[ARR
#] people |
[Benefit
in what way? Language to convey – will avoid / be
prevented from developing / will receive a mortality benefit
/ will have overall improvement / will recover / will show
significant improvement, etc.] |
|
- |
[ARR
#] people |
[Be
harmed in what way? Language to convey
risks and harms – will experience / discontinue due
to / will develop / will stop taking, etc.] |
| Dosing
Information: ---------------- |
| Other
Information: ---------------- |
Evidence:
[brief statement]
[references] |
| [documentation:
date prepared & by whom] |
|
Consulted
Delfini
Rx Messaging
Scripts ™
Template — www.delfini.org |
Additional
Notes
- Harms: When
expressing evidence about harms, we advocate describing potential
harms observed from weaker data, but we also advocate caution
in not making the evidence sounding stronger than it is. See
the Delfini Evidence Grading Tool for more information and
advice.
- Grade U (Uncertain
validity and/or clinical usefulness): When describing Grade
U evidence, we recommend including a statement to the effect
that, “Grade U evidence does not disprove the potential
benefit of a treatment. Valid evidence is needed to disprove
benefit, which would require evidence that is Grade A, B or
BU.”
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| Samples
only for ideas – complete and verify for accuracy and
currency
Below
• Ace
Inhibitors
• Alendronate
•
Antidepressants
•
Beta Blocker
• Blood
Pressure Treatment (personalized example)
• Diabetic
Retinopathy
• Hormone
Replacement Therapy
• Statins
(personalized example)
Available
as PDF
•
Low-back
Pain — Sciatica [PDF]
•
Prevention
of Venous Thromboemobolism (VTE) in Total Hip and Total Knee
Replacement
[PDF]
Also read about the VTE
Project and access the clinical practice guideline and the clinician
1-pager. Plus from the Agency for Healthcare Research &
Quality, general
information for patients about blood thinners.
Example
of a script for use with a patient directly
• Statins and
Lipids
|
| Sample |
|
ACE
Inhibitors
|
This
patient is a good candidate for… |
| ACE
Inhibitors due to this patient’s high risk for developing
heart failure |
| The
best available valid and useful evidence indicates that
men and women at least 55 years of age with a history
of coronary artery disease, stroke, peripheral (legs)
vascular disease, or diabetes plus one other risk factor
(elevated blood pressure, elevated total cholesterol,
low HDL cholesterol, cigarette smoking or protein in their
urine) have a 15% risk of developing heart failure within
5 years. Howver, the risk drops to 9% within 5 years for
those treated with an ACE inhibitor. This is a 6% decrease
in risk. Out of 100 patients, 6 will benefit.
Summary:
Out of 100 of these people treated for 5 years with an
ACEI, as compared to usual care, during that time period
— |
+ |
6
people |
will
avoid developing heart failure |
- |
6
people |
will
discontinue the ACEI because of cough |
Dosing
Information:
Before prescribing any medication, review full prescribing
information such as from the Physicians Desk Reference,
DrugStore.Com or other source. |
Drug
Information for Patients:
Detailed information is available at MEDLINEPlus. www.nlm.nih.gov/medlineplus/druginformation.html |
Evidence:
Risk of heart failure (5 yrs) – Usual Care 15%,
Placebo 11.5%, ACEI 9%
The Heart
Outcome Prevention Evaluation Study Investigators. Effects
of an angiotensin-converting-enzyme inhibitor, ramipril,
on cardiovascular events in high-risk patients. N Engl
J Med 2000;342:145–153. |
Prepared
by Delfini
Group, LLC, 1/1/04, Updated 4/3/07
Consulted Delfini
Rx Messaging Scripts TM Template
– www.delfini.org |
|
| Sample |
Hormone Replacement
Therapy
(see
also our Decision Aid for Menopause) |
You
may wish to review this patient’s need for … |
| Hormone
Replacement Therapy |
| The
best available valid and useful evidence indicates there
are benefits (+) and risks (–) of taking estrogen
and progestin. Compared to placebo, within the treatment
period below, out of 400 women, the following
is expected: |
| +
Benefit or
– Risk |
Number
of Women |
Treatment
Years |
Outcome |
| + |
133 |
3 |
will
avoid hot flashes |
| + |
1 |
5 |
will
be prevented from having a hip fracture |
| + |
~9 |
5 |
will
be prevented from having any fracture |
| + |
1 |
5 |
will
be prevented from having colon cancer |
| — |
~1-2* |
5 |
will
have a heart attack |
| — |
~1-2* |
5 |
will
have a stroke |
| — |
~1-2* |
5 |
will
have invasive breast cancer |
| — |
~1-2 |
5 |
will
have a pulmonary embolism |
| — |
~1-2 |
5 |
will
have a deep venous thrombosis in the leg |
| — |
3-4 |
4 |
will
develop dementia |
— |
~36 |
1 |
will
develop urinary incontinence |
| *Note:
Some risks may be lower in younger postmenopausal
women. Important mortality data was obtained by pooling
data from the 2 large Women's Health Initiative (WHI) trials
[4]. The two trials included 8,832 women aged 50 to 59 years.
There were some methodological limitations (grade B-U evidence)
but the evidence is suggestive that women < 60 years
of age who use HRT for the first time in early menopause
for around 10 years may not be at increased risk for breast
cancer, heart attack, or stroke. According to this data
for women with no history of cardiovascular disease, approximately
1 death per 1,000 women per year would be prevented by taking
HRT |
Dosing
Information:
Before prescribing any medication, review full prescribing
information such as from the Physicians Desk Reference,
DrugStore.Com or other source. |
| Evidence:
1. The Cochrane Database of Systematic Reviews
The Cochrane Collaboration Volume (1), 2003. PMID 15213207
2. Risks and benefits of estrogen plus progestin in healthy
postmenopausal women. Authors: Writing Group for the Women's
Health Initiative Journal: JAMA 2002;288:321–333.
PMID 15467059
3. Risks and benefits of estrogen plus progestin in healthy
postmenopausal women. Authors: Writing Group for the Women's
Health Initiative Journal: JAMA 2002-2005. PMID 15657326
4.
Rossouw JE, Prentice RL, Manson JE, et al. Postmenopausal
hormone therapy and risk of cardiovascular disease and
years since menopause. JAMA. 2007; 297(13):1465-1477.
PMID 17405972
|
Prepared
by Delfini
Group, LLC, 11/02, Updated 01/10
Consulted Delfini
Rx Messaging Scripts TM Template
– www.delfini.org |
|
| Sample |
Blood
Pressure Treatment
(Personalized Example)
|
This
patient is a good candidate for… |
| Blood
Pressure Treatment |
| This
70 year old patient has a BP of 195/90. With
this blood pressure, he has a 28% mortality risk
over the next 5 years. The best available valid and useful
evidence indicates that if 25 people with
systolic hypertension, who are similar in age, are treated
for their elevated blood pressure for 5 years,
during that time period, as compared to placebo –
|
1
person |
may
avoid dealth due to cardiovascular disease |
24
people |
will
not receive a mortality benefit from blood pressure Rx,
but may avoid a CV event and are very unlikely to experience
adverse drug effects |
Dosing
Information:
Before prescribing any medication, review full prescribing
information such as from the Physicians Desk Reference,
DrugStore.Com or other source. |
Evidence:
A well-done
systematic review of patients > age 60 with systolic
hypertension (systolic BP >160) – Active treatment
reduced total mortality (RR 0.87, 95% CI 0.78 to 0.98;
P = 0.02).
Staessen
JA, Gasowski J, Wang JG, et al. Risks of untreated and
treated isolated systolic hypertension in the elderly:
meta-analysis of outcome trials. Lancet 2000;355:865–872.
|
Prepared
by Delfini
Group,
LLC, 1/1/04, Updated 4/3/07
Consulted Delfini
Rx Messaging Scripts TM Template
– www.delfini.org |
|
| Sample |
Statins
(Personalized Example)
|
This
patient is a good candidate for treatment with a… |
| Statin |
| This
70 year old patient has a history of myocardial
infarction. The best available valid and useful evidence
(Grade B-U) indicates that if 28 people
with coronary artery disease are treated with a statin for
5 years, during that time period, compared
to placebo – |
1
person |
will
avoid dying.
Other
benefits include decreased risk of cardiac death, non-fatal
MI and revascularization. |
4
people |
will
not benefit from the statin, but are very unlikely to experience
serious adverse drug effects. |
Dosing
Information:
Before prescribing any medication, review full prescribing
information such as from the Physicians Desk Reference,
DrugStore.Com or other source. |
| Evidence:
Afilalo J, Duque G, Steele R, J. Jukema W, de
Craen AJ, Eisenberg MJ. Statins for Secondary Prevention
in Elderly Patients: A Hierarchical Bayesian Meta-Analysis..Journal
of the American College of Cardiology 2008; 51: 37-45.
|
Prepared
by Delfini
Group,
LLC, 1/1/04, Updated 02/14/08
Consulted Delfini
Rx Messaging Scripts TM Template
– www.delfini.org |
|
| Sample |
Antidepressant Therapy
|
This
patient is a good candidate for… |
| Antidepressant
Therapy |
| For
patients who have mild to severe depression, the best available
valid and useful evidence indicates that out of 20
people who are treated for 50 days,
as compared to placebo, within 26 to 49 days… |
5
people on a TCA
|
will
recover from depression |
2.5
people on an SSRI |
will
recover from depression |
Discontinuation
Rates:
Not significantly different from placebo for TCAs or SSRIs |
| Harms:
Caution — Deaths have been reported in otherwise healthy
people while taking antidepressants. Also review adverse
effects in MedLinePlus (link below). |
Dosing
Information:
Before prescribing any medication, review full prescribing
information such as from the Physicians Desk Reference,
DrugStore.Com or other source. |
| Evidence:
A well-done systematic review of 17 RCTs, 1326 people
aged > 55 years with mild to moderate or severe
depression comparing antidepressants versus placebo
Wilson K,
Mottram P, Sivanranthan A, et al. Antidepressant versus
placebo for the depressed elderly. In: The Cochrane Library,
Issue 2, 2002. Oxford |
Prepared
by Delfini
Group, LLC, 1/1/04, Updated 4/3/07
Consulted Delfini
Rx Messaging Scripts TM Template
– www.delfini.org |
|
| Sample |
Beta
Blocker
|
This
patient is a good candidate for a… |
|
Beta
Blocker |
| For
patients who have had a recent MI, the best available valid
and useful evidence indicates that out of 100 people
treated with a beta blocker for at least 2 years,
as compared to placebo, during that time period – |
2.5
people |
will
be prevented from dying |
1
person |
will
be prevented from having another MI |
|
Exclusions:
Exclusions should be determined by a physician. Caution
is advised in numerous patients, for example, those with
impaired renal function, severely impaired myocardial
contractility, bronchospastic disease, and in patients
taking some calcium channel blockers. |
Dosing
Information:
Before prescribing any medication, review full prescribing
information such as from the Physicians Desk Reference,
DrugStore.Com or other source. |
| Evidence:
ß blockers versus placebo significantly reduced
mortality over 6 months to 4 years in patients with previous
MI. No significant difference in effectiveness was found
between different types of ß blocker
Freemantle
N, Cleland J, Young P, et al. Beta blockade after myocardial
infarction: systematic review and meta regression analysis.
BMJ 1999;318:1730–1737.
|
| Prepared
by Delfini
Group,
LLC, 1/1/04, Updated 4/3/07
Consulted Delfini
Rx Messaging Scripts TM Template
– www.delfini.org |
|
| Sample |
Alendronate
|
This
patient is a good candidate for… |
| Alendronate |
| Valid
and useful evidence demonstrates that alendronate reduces
vertebral and non-vertebral fractures as compared with placebo.
Out of 100 women who are treated with alendronate
for 3 years, during that time period –
|
5
women with a T score < -2.0 |
will
avoid a vertebral or non-vertebral fracture |
2.5
women with a previous vertebral fracture |
will
avoid a vertebral or non-vertebral fracture |
| Harms
(in pre-marketing studies) |
No
significant difference in discontinuation rates between
alendronate and placebo groups. 15%-18% of subjects receiving
alendronate and placebo reported adverse esophageal effects. |
Dosing
Information:
Before prescribing any medication, review full prescribing
information such as from the Physicians Desk Reference,
DrugStore.Com or other source. |
Evidence:
Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE,
Nevitt MC, et al. Randomised trial of effect of alendronate
on risk of fracture in women with existing vertebral fractures.
Lancet 1996;348:1535-41. PMID 8950879 |
Prepared
by DelfiniGroup,
LLC, 1/1/04, Updated 4/3/07
Consulted Delfini
Rx Messaging Scripts TM Template
– www.delfini.org |
|
| Sample |
Diabetic
Retinopathy |
This patient
is a good candidate for… |
Retinopathy
Screening |
| This
patient is a good candidate for retinopathy screening every
two years. If screening is positive for diabetic retinopathy,
the ophthalmologist is likely to adjust the screening frequency.
The best available valid and useful evidence indicates that
type I diabetics ages 10 and older who have had diabetes for
5 years, type II diabetics, and diabetic women who become pregnant
have a significant risk of developing retinopathy.
Out of 100 people with advanced retinopathy
treated for 5 years with photocoagulation as
compared to no treatment during that time period –
|
| 14
people |
will
avoid visual loss. |
| Harms:
There have been case reports of bleeding and macular or choroidal
detachment following photocoagulation, but these adverse events
have not been shown to be caused by treatment. |
| Evidence:
Well-done systematic reviews of randomized controlled trials
provide sufficient evidence for concluding benefit from photocoagulation
in patients with diabetic retinopathy.
1. Bachmann M O,
Nelson S J, Impact of diabetic retinopathy screening on a British
district population: case detection and blindness prevention
in an evidence-based model. Journal of Epidemiology and Community
Health 1998;52:45-52.
2. Singer DE, Nathan DM, Fogel HA, Schachat AP. Screening for
diabetic retinopathy. Ann Intern Med. 1992 Apr 15;116:660-71.
3. Clinical Evidence, June 2003. Issue 9.
|
Prepared
by Delfini
Group, LLC, 1/7/04, Updated 4/3/07
Consulted Delfini
Rx Messaging Scripts TM Template
– www.delfini.org
|
| Sample |
Example
of a Script for Use with Patients Directly
Statins
& Lipids
[PDF] |
Information
about your elevated cholesterol level… |
| Your
Risk |
The
best available valid and useful scientific evidence indicates
that you have a risk of approximately 23% for experiencing
a heart attack or stroke within 5 years. This means that
almost 1 in 4 people like you will have a heart attack or
stroke in the next 5 years if you have no treatment for
your cholesterol.
Your risk can be decreased by taking a statin medication
to lower your cholesterol and your risk.
|
| Benefits
for Reduced Risk of Heart Attack or Stroke
High quality research studies
tell us that out of 100 patients like you —
|
| 23
people will have a heart attack or stroke if they choose
no treatment. |
| 16
people will have a heart attack or stroke if they choose
to take a statin drug. This means that 7 people will be
prevented from having a heart attack. |
| Risks
and Harms |
- Do not
take a statin medication if you are pregnant, nursing
or if you might get pregnant while taking the drug because
statins may interfere with normal development of a fetus.
- If you
notice muscle weakness, stop the statin medication and
notify you doctor— statins can, on rare occasion,
cause muscle injury.
|
Dosing
Information:
Before prescribing any medication, review full prescribing
information such as from the Physicians Desk Reference,
DrugStore.Com or other source. |
References:
1. Randomized Trial of cholesterol lowering in 4444 patients
with coronary heart disease. The Scandinavian Simvastatin
Survival Study. Lancet 1994; 344:1383-89
2. LaRosa JC, He J, Vupputuri S. Effect of statins on risk
of coronary disease: a meta-analysis of randomized controlled
trials. JAMA 1999;282:2340–2346.
|
| Prepared
by Delfini
Group, LLC, 2/18/04, Updated 4/3/07 |
|
Download
the tool and template
[Word]
|
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