Communicating the risk reduction achieved by cholesterol reducing drugs
BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7149.1956 (Published 27 June 1998) Cite this as: BMJ 1998;316:1956
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Dear Sir,
The paper by Skolbekken offers yet another form of words or a 'salesman's patter' to help clinicians communicate difficult or complex concepts to patients. Every clinician uses such a salesman's patter when talking with patients. Our patter reflects our own understanding of what we are trying to communicate together with what we think the patient needs to hear. I have often learnt what to say and how to say it (and what not to say and how not to say it) from overhearing colleagues talking to their patients.
A recent paper (2) outlined the problems and challenges clinicians face when applying the results of clinical trials to patients in general practice. The quantity and quality of information combined by the author in his worked example (acute sinusitis)has been described as a parody (3) by a correspondent. Clinicians working in the swamp (4) need help.
Could the BMJ run a 'patter' competition for the Christmas issue or establish a 'patter-bank' so that we can all learn from one another?
Yours sincerely,
Jonathan Richards
References
1. Skolbekken JA Communicating the risk reduction achieved by cholesterol reducing drugs BMJ 1998; 316: 1956-1958
2. Fahey T. Applying the results of clinical trials to patients in general practice: percieved problems, strengths and assumptions and challenges for the future. BR. J. Gen. Pract.1998;48:1173-1177
3. Kernick D. From theory to reality. (letter) Br. J. Gen. Pract. 1998;48;1433
4. Schon DA The Reflective Practitioner. How professionals think in action. Aldershot: Avebury. 1991:42-43
Competing interests: No competing interests
Dear Sir,
Re: Skolbekken JA. Communicating the risk reduction achieved by cholesterol reducing drugs. British Medical Journal 1998;316:1956-8.
Skolbekken has highlighted several important and general risk communication issues(1), but which require further elaboration. One concern is drawing a distinction between risk communication to professionals who deliver health care and risk communication with patients. Another concern is whether it is "best" to present data in relative or absolute risk format.
The responses of professionals and patients to risk information are likely to differ. In both groups most people do not have specific training and have difficulty with statistical information, but it is more likely that professionals have a grounding from which their understanding of probabilistic information can be developed. In general this is likely to be more challenging with patient groups. Different strategies to improve risk communication will be necessary for these two groups of consumers. Standardising the "language of risk"(2) may be helpful to professionals but not for patients, for whom the contextual variations are great and flexibility is required to tailor information to specific needs(3).
Concerning the presentation of risk information, Skolbekken cites many studies demonstrating the persuasive effects of relative risk information. Incidentally most of these concern presentation of information to professionals rather than patients though the effects appear similar. It is worth noting that currently preferred formats for presentation of trial data in journals are in terms of odds ratios which are also relative comparators of outcomes. The absolute risk or probability of key outcomes are often not given the same headline prominence (as for example in the studies of a potential association between neonatal vitamin K administration and childhood leukaemia(4,5)). The real impact in terms of health gain is derived from absolute risk reductions (or as expressed as numbers needed to treat), but it would be re-dressing the balance too far to say that this format should now be the only way of presenting results.
Risk information may be useful in clinical practice but a further decision making step then follows. This may be doctor- or patient-led or shared between them, but in all situations individual preferences and values ("utilities") contribute. In making decisions both professionals and patients often find relative risk information, and comparison with everyday "familiar" risks helpful(3). We suggest therefore that researchers should present results with both relative and absolute risk estimates and not present either in isolation which may be misleading or insufficiently helpful for arriving at a decision. Such methods are nearer to the "whole truth".
Yours faithfully,
Adrian Edwards Glyn Elwyn Nigel Stott
Lecturer Senior Lecturer Professor
Word Count 399
References
1. Skolbekken JA. Communicating the risk reduction achieved by cholesterol reducing drugs. British Medical Journal 1998;316:1956-8.
2. Calman KC. Cancer: science and society and the communication of risk. British Medical Journal 1996;313:799-802.
3. Edwards A, Matthews E, Pill RM, and Bloor M. Communication about risk: the responses of primary care professionals to a standardised "language of risk". Family Practice 1998; 15 (4) in press
4. McKinney PA, Juszczak E, Findlay E, and Smith K. Case-control study of childhood leukaemia and cancer in Scotland: findings for neo-natal intramuscular vitamin K. British Medical Journal 1998;316:173-7.
5. Passmore SJ, Draper G, Brownbill P, and Kroll M. Case-control studies of relation between childhood cancer and neonatal vitamin K administration. British Medical Journal 1998;316:178-84.
Competing interests: No competing interests
EDITOR-Dr. Skolbekken 1 has rightly pointed out some of the pitfalls
of reading drug advertisements naively and not taking into account
the natural tendency to put the most favourable interpretation on the
effects of their product- that is the aim of advertisements . As he
points out the basic facts may be correct; but they can be interpreted
in several different ways (i.e. by substituting relative for absolute
risks). Practising physicians are well aware of the `spin' that is
put on such data and take it into account when assimilating their
message. Physicians do also obtain information about the effects of
drugs from other sources e.g. from journals such as the BMJ.
However the author himself falls into the same error by selecting for
consideration a single example of gross hyperbole from the American
Journal of Cardiology 2 to the effect that statins are ` miracle
drugs', and from this he concludes that there is an `overconfidence in
scientific knowledge'. Whatever advertisements may claim, the Drug
Industry is to be congratulated for developing and bringing to
fruition this new and extremely useful class of drugs to treat
hypercholesterolaemia. In no way are they `miracle drugs'- their
mechanism of action is clearly understood. Their effects result mainly
from a powerful inhibition of the enzyme HMG CoA reductase central to
cholesterol synthesis. Dr. Skolbekken does not appear to appreciate
that they will cause an almost invariable fall in plasma cholesterol
in hypercholesterolaemic patients, but because coronary heart disease
is multifactorial will not have a similar impact on reducing the
incidence of arterial disease. This is equivalent to demanding that
hypoglycaemic drugs when used in diabetics to lower the blood glucose
will have a similar impact on reducing coronary artery disease.
Dr. Skolbekken is right to be concerned about the hazards of
miscommunication in any field, but should not fall into the same
errors that he is attacking by only presenting half the picture.
D J Galton. Chairman British Hyperlipidaemia Association and
Professor, Department of Metabolism and Genetics, St. Bartholomew's
Hospital London EC1A 7BE. Fax: 0171 982 6064
M Seed. Secretary of the British Hyperlipidaemia Association and
Senior Lecturer, Honorary Consultant Physician, Imperial College
School of Medicine at Charing Cross Hospital , London.
1. Skolbekken J-A. Communicating the risk reduction achieved by
cholesterol lowering drugs. BMJ. 1998;316:1956-58.
2. Roberts WC. The underused miracle drugs: the statin drugs are to
atherosclerosis what penicillin was to infectious disease. Am. J.
Cardiol. 1996;78:377-8.
Competing interests: No competing interests
Modifying risk is different to treating illness
EDITOR - Skolbekken reviews the important issue of how the perceptions of risk reduction from cholesterol lowering drugs are strongly influenced by the way data are presented(1). His comparison of the effectiveness of statins with penicillin deserves further attention. It is hard to think of a situation where an antibiotic would be much use if its effectiveness was based on treating hundreds of patients daily for half a decade to cure the infection in one of them. Why then are statins considered to be a major therapeutic advance?
The answer perhaps lies in the difference between an illness, such as an infection, and an asymptomatic risk factor such as moderately raised cholesterol. Managing a risk factor is about dealing with probabilities applied to populations rather than treating an illness. This seems to make a much lower likelihood of individual benefit acceptable. Because raised cholesterol is common, widespread treatment is likely to bring large benefits to the community despite offering little to each participating individual. Rose called this the prevention paradox, before statins were available(2).
The distinction between treating an illness and modifying a risk factor has implications for both doctor and patient. For the doctor, there is a danger that modifying the risk factor can become an end in itself, obscuring the real goal of preventing future morbidity and mortality. Galton may have succumbed to this when he appears to suggest that a fall in plasma cholesterol is important even if it does not have a similar impact on arterial disease(3). For the patient, their individual perspective on the risk factor becomes more important. Risk is relative, and can mean different things to different people, and so the patient needs to be involved in putting a value on potential future benefits(4). However, Skolbekken points out that a patient's choice may not always be what a doctor would like it to be. Presenting patients with information about the risks and benefits of cholesterol treatment may mean they do not accept treatment(5). This difference of opinion is about an individual's attitude to risk rather than a medical matter.
I suggest that patients should be told clearly that the aim of cholesterol reduction is to modify risk, rather than to treat an illness. Only then, with knowledge about the individual patient's attitude to risk, can doctor and patient assess information about relative or absolute risk reduction.
References.
1. Skolbekken JA. Communicating the risk reduction achieved by cholesterol reducing drugs. BMJ 1998;316:1956-8.
2. Rose G. Strategy of prevention: lessons from cardiovascular disease. BMJ 1981;282:1847-1851.
3. Galton DJ and Seed M. (letter) Communicating the risk reduction achieved by cholesterol reducing drugs. eBMJ 1998; http://www.bmj.com/cgi/eletters/316/7149/1956. Electronic Citation
4. Brett AS. Ethical issues in risk factor intervention. Am J Med 1984;76:557-561.
5. Reed WW, Herbers JE Jr, Noel GL. Cholesterol-lowering therapy: what patients expect in return. J Gen Intern Med 1993;8:591-596.
Competing interests: No competing interests