Evidence-based Medicine On the Same Page™

The EBM Information Quest: Is it true? Is it useful? Is it usable?™

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05/05/2014
American College of Cardiology/American Heart Association Guidelines: Numbers-Needed-to-Treat (NNTs) for Statin Treatment in Primary Prevention of Cardiovascular Disease (CVD)

About PMID Numbers:
We frequently utilize a PMID number in place of a citation. Where PMID numbers are available, enter that number into the PubMed search box to retrieve that citation and listing.

 

Evidence-based Information & Decision Aid Examples for Health Care Professionals & Patients—Putting Everyone on the Same Page

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Important
Not all clinical recommendations from other sources have been reviewed for validity and ours may or may not be uptodate, so selections below should be viewed as representing examples of approaches and formats for communications, etc. Feel free to contact us for details. Read our Health Care Information Source Cautions at Notices.

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American College of Cardiology/American Heart Association Guidelines: Numbers-Needed-to-Treat (NNTs) for Statin Treatment in Primary Prevention of Cardiovascular Disease (CVD)
05/05/2014

Following publication of the November 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline [1], concern was expressed that, in the area of primary prevention for CVD, the 10 year guideline estimates of risk were overestimated [2]. Furthermore, the ACC/AHA criteria could result in more than 45 million middle-aged Americans without cardiovascular disease being recommended for consideration of statin therapy.

While the amount of risk overestimation is still being debated, Alper and Drabkin of DynaMed, have created very nice decision-support based on their evaluation of the most current and reliable systematic reviews available for estimating the effects of statins in individuals with various 10 year risks [3].

The risk estimates below will prove quite useful for individual decision-making providing the NNTs over 5 years for the use of statins by individual risk. More detailed information regarding the evidence of statins in preventing CVD events on is available on the DynaMed website [4].

For a person with an estimated 7.5% 10-year risk, the 5-year NNT was 108 for CVD events, 186 for MI, and 606 for stroke. At 15% 10-year risk, 5-year NNTs were 54 for CVD events, 94 for MI, 204 for stroke, and 334 for overall mortality. At 20% 10-year risk, 5-year NNTs were 40 for CVD events, 70 for MI, 228 for stroke, and 250 for overall mortality. 

References
1. Stone NJ, Robinson J, Lichtenstein AH et al. 2013 ACC/AHA Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013. [Epub ahead of print] [PMID: 24239923]

2. Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet. 2013 Nov 30;382(9907):1762-5. doi: 10.1016/S0140-6736(13)62388-0. Epub 2013 Nov 20. PubMed PMID: 24268611.

3. Click on the Comments Tab here: http://annals.org/article.aspx?articleid=1817258

4. Search "statins" at the link below:" http://archive.constantcontact.com/fs132/1102736301344/
archive/1116074054121.html

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Delfini Patient Information and Decision Aid for Menopause (sample only — not complete or up-to-date)
If you are a subscriber, look at BestTreatments as well for information on more treatment options and other information!

Here's a link to an example of a Patient Decision-Aid we created to illustrate how one might communicate around menopause issues — be patient for loading (or you might want to just print it out)— this is a big one:

Decision Aid — Menopause [PDF]

Read Patient Decision Aids: Potential value of patient decision aids.

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Drug Facts Boxes: Examples
05/27/09

In a recent study published in the Annals of Internal Medicine, authors Schwartz et al., conducted two randomized, controlled trials between October 2006 and April 2007 with the objective of determining whether providing consumers with a drug facts box—a table quantifying outcomes with and without the drug— improves knowledge and affects judgments about prescription medications.[1]

There are limitations in these trials, including a response rate of less than 50 percent, and like most literature in the area of patient communications, the strength of the evidence is weak.

We think it is useful, however, to see their format for providing information to patients as it is our opinion that this kind of format and information may be effective with patients, helping them to make decisions based on their own values and preferences.

The full text of the article can be accessed here by copying the following into an internet search engine: http://www.annals.org/cgi/content/full/150/8/516
Article includes appendices of the test cases, examples of the fact sheets and the patient surveys.
To access, copy the following into an internet search engine: http://www.annals.org/cgi/content/full/0000605-200904210-00106/DC1

Specifically, the authors recommend information in the following areas:

  • What is this drug for?
  • Who might consider taking it?
  • Who should NOT take it?
  • Recommended testing
  • Other things to consider doing

They also provide a Study Findings Box that provides nicely quantified information in easy to understand terms.

Lastly, they provide information about how long the drug has been in use with approval dates and a caution that, “Studies show that most serious side effects or recalls of new drugs happen during their first 5 years of approval.”

The authors have done a very nice job. Our main recommendation would be to add references to the fact sheet itself for full transparency.

A reminder that Delfini has some examples for providing evidence-based information to clinicians and patients at http://www.delfini.org/page_SamePage_RxMessagingScripts.htm

[1] Schwartz LM, Woloshin S, Welch HG. Using a drug facts box to communicate drug benefits and harms: two randomized trials.
Ann Intern Med. 2009 Apr 21;150(8):516-27. Epub 2009 Feb 16. PMID: 19221371

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Acute Bronchitis
Here's a link to an example of how to display Patient Information that we like (see the Campaign Posterat the bottom of the link):

Example from:
Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults

Gonzales R, Steiner JF, Lum A, Barrett PH Jr. Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA. 1999 Apr 28;281(16):1512-9. PubMed PMID: 10227321.

UPDATE: LINK TO THE DECISION SUPPORT EXAMPLES IS NO LONGER AVAILABLE (WE ARE TRYING TO GET A REPLACEMENT), BUT THE ARTICLE IS NOW FREELY AVAILABLE AT JAMA.

http://jama.ama-assn.org/cgi/content/full/281/16/1512

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AHRQ Breast Cancer: Medications for Primary Prevention
Posted 09/10/2011

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Cardiovascular Risk Calculators
Tools that can provide instant evidence-based answers are very much needed by clinicians. Tools that can provide customized information to patients are more likely to be used by patients.

Here's an example of an electronic risk calculator done by our friends of the New Zealand Guidelines Group in the New Zealand Health Ministry.

http://www.nzgg.org.nz/guidelines/0035/CVD_Risk_Chart.pdf

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Delfini Review of Oregon Evidence-based Practice Center Consumer Drug Reviews:
About NSAIDS and Cox2 Inhibitors (as of 8/2002)
General Information for Consumers: Evidence-based Medicine & Oregon Evidence-based Practice Center Drug Reviews

We reviewed consumer drug information developed by the Oregon Evidence-based practice center. This patient-centered piece is an example of evidence-based writing for consumers. Note: the information in this piece is based on Cox2 Inhibitors as a drug class. New Cox 2 Inhibitors may become available after the time of this writing (8/2002) which may be categorically different.

Decision Aid - About NSAIDS and Cox2 Inhibitors [PDF]

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