Helen Salisbury: Evidence and experienceBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1772 (Published 16 April 2019) Cite this as: BMJ 2019;365:l1772
All rapid responses
I find it quite ironical that doctors in one field of medicine do not perceive or practice the same medicine as other even when dealing with the same evidence based.
I find it even more inconsistent that the doctors who have a problem with prescribing statin for a perceived risk of 10% CVD complications but the same group of professional would probably not think twice about prescribing anticoagulants, particularly NOACs for stroke prevention when for CHA2DS2–VASc =2 or more.
Just because someone decided that an annual risk ischaemic stroke from AF of 1 to 2% should be the threshold for treatment (ref 1).
Even those that there are plenty of evidence the relationship between stroke point scores by CHA2DS2–VASc and annual stroke rates may vary substantially across populations and real-world experience of the actual stroke rate is very much incompatible with predicted rate (ref 2)
Why the inequity in hesitancy in CVD treatment? Are so many doctors won over by the misleading reports of safety profile of NOACs whereas the statins doesn't merit the same good will from the whispers of big pharma conspiracy theorists?
It is important to re-examine the evidence in statins and reassess its risk-benefit profile, but to limit the concerns to this group of CVD drugs whilst the NOACs appear to still have a free pass without reservation, simply invites criticism of cherry picking from other health care professionals like myself
Competing interests: I have previously written about the overly enthusiastic uptake of NOACs
The tension highlighted in the article is one which resonates with all of anticipatory medicine, an area where success (i.e. a non-event) cannot be verified at the individual level. Rather than substituting one's own preconceptions, however, the clinician should realize that the way the data are communicated may affect perception (1) and make an effort to represent harm and benefit in a way which is more understandable. It is well known, for example, that reporting the data only as relative risk reduction will raise expectations behind the real benefit provided by the intervention (1,2). In a study of 307 patients, translating the same benefit from relative to absolute risk reduction led to only 27% of the participants accepting to take a drug offering «just» 5% absolute risk reduction over 5 years (a benefit superior to that provided by many current pharmacological interventions) (3). Empowering patients to make decisions more consistent with their own values, rather than population values, requires better communication of benefit and harm (4).
(1) Covey J. A meta-analysis of the effects of presenting treatment benefits in different formats. Med Decis Making 2007; 27 : 638-54
(2) Gigerenzer G, Wegwarth O, peufel M. Misleading communication of risk. BMJ 2010; 341 : c4830
(3) Trewby PN, Reddy AV, Trewby CS et al. Are preventive drugs preventive enough ? A study of patients'expectations of benefit from preventive drugs. Clin Med JRCPL 2002; 2 : 527-33
(4) Fagerlin A, Zikmund-Fisher BJ, Ubel PA. Helping patients decide : ten steps to better risk communication. J Natl Cancer Inst 2011; 103 : 1436-43.
Competing interests: No competing interests