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Primary Prevention Drug Therapy: Can It Meet Patients’ Requirements for Reduced Risk?

Center for the Evaluative Clinical Sciences, Department of Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire, Clinical Epidemiology Unit, Institute for Clinical Evaluative Sciences, Sunnybrook & Women’s College Health Science Centre, Toronto, Ontario, Canada

J. Michael Paterson, MSc

Institute for Clinical Evaluative Sciences, Sunnybrook & Women’s College Health Science Centre, Toronto, Ontario, Canada

Judy A. Carter, BScPharm

Institute for Clinical Evaluative Sciences, Sunnybrook & Women’s College Health Science Centre, Toronto, Ontario, Canada

Antoni Basinski, MD, PhD

Clinical Epidemiology Unit, Institute for Clinical Evaluative Sciences, Sunnybrook & Women’s College Health Science Centre, Toronto, Ontario, Canada, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada

Martin G. Myers, MD

Department of Medicine, University of Toronto, Toronto, Ontario, Canada

Gordon D. Hardacre, MD

Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada

Earl V. Dunn, MD

Clinical Epidemiology Unit, Sunnybrook & Women’s College Health Science Centre, Toronto, Ontario, Canada, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada

Ralph B. D’Agostino, PhD

Department of Mathematics, Boston University, Boston, Massachusetts

Philip A. Wolf, MD

Departments of Neurology and Medicine, Boston University, Boston, Massachusetts

C. David Naylor, MD, DPhil

Clinical Epidemiology Unit, Institute for Clinical Evaluative Sciences, Sunnybrook & Women’s College Health Science Centre, Toronto, Ontario, Canada, Department of Medicine, University of Toronto, Toronto, Ontario, Canada

The objective was to identify, in primary prevention, patients whose "required risk reduction" (ReqRR) is greater than the "achievable risk reduction" (ARR) that cholesterol-lowering or antihypertensive medication could provide. Individualized estimates of 10-year coronary heart disease or stroke risk were derived for 66 hypercholesterolemic (HC) and 64 hypertensive (HT) patients without symptomatic cardiovascular disease. These estimates were used in trade-off tasks identifying each individual’s ReqRR. Then individual ARRs were estimated (in HC patients by assuming total cholesterol/high density lipoprotein ratio reductions to 5.0; in HT patients by assuming systolic blood pressure reductions to 120 mmHg). 12 (18%) HC and 12 (19%) HT subjects would refuse medication regardless of the risk reduction offered. Of the remaining patients, 15/54 (28%; 95% C.I.: 16-40%) HC and 19/52 (37%; 95% C.I.: 24-51%) HT subjects were "over-requirers," in that their ReqRR/ARR ratio was 1.5. There may be a notable proportion of patients whose ReqRR is considerably greater than what is achievable, implying that decision aids may help individuals clarify preferences about accepting/refusing medication for the primary prevention of cardiovascular disease.

Key Words: treatment preferences • hypertension • hypercholesterolemia • primary prevention • patients’ decision aids • trade-off technique

Medical Decision Making, Vol. 22, No. 4, 326-339 (2002)
DOI: 10.1177/0272989X0202200411


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