BMJ  2003;327:841 (11 October), doi:10.1136/bmj.327.7419.841

Primary care

Factors involved in deciding to start preventive treatment: qualitative study of clinicians' and lay people's attitudes

¹ Department of Public Health, Central Liverpool Primary Care Trust, Hamilton House, Liverpool L3 6AL, ² Health and Community Care Research Unit, Thompson Yates Building, University of Liverpool, Liverpool L69 3GB

Objectives To explore the views of clinicians and lay people about the minimum benefit needed to justify drug treatment to prevent heart attacks, and to explore the rationale behind treatment decisions.

Design Qualitative study using semi-structured interviews.

Participants 4 general practitioners, 4 practice nurses, and 18 lay people.

Setting 8 general practices and 6 community settings across Liverpool.

Results Participants varied widely in the minimum acceptable benefits chosen. Most people found the concepts difficult initially, and few appreciated that increased length of treatment should increase absolute benefits. Lay people usually wanted to make decisions for themselves, and clinicians supported this. Participants wanted to consider adverse effects and costs of treatment. Dislike of drug taking was common, and many people preferred lifestyle change to an imperfect treatment. Quality of life and personal views were more important than an individual's age.

Conclusions Evidence based guidelines make assumptions about people's preferences, and, by using 10 year estimates of risk, inflate the apparent benefits of treatment. It is unlikely that guidelines could incorporate the wide range of people's preferences, and true dialogue is necessary between clinicians and patients before starting long term preventive treatment.

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