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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 |
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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 |
|
Page Navigation |
 Attributes
of Good Scripts
Quantifying
Information
Template
for Scripting
Samples:
Latest update — Statins
Download
tool and template here [Word]
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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
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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 TM 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]
Example
of a script for use with a patient directly
• Statins and Lipids
»
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| Sample |
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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 DelfiniGroup,
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 |
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
|
Prepared
by DelfiniGroup,
LLC, 1/1/04, Updated 4/3/07
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 DelfiniGroup,
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 DelfiniGroup,
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 DelfiniGroup,
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. |
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 DelfiniGroup,
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.
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| Prepared
by Delfini
Group, LLC, 2/18/04, Updated 4/3/07 |
|
Download
the tool and template [Word]
|
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