Variation in minimum desired cardiovascular disease-free longevity benefit from statin and antihypertensive medications: a cross-sectional study of patient and primary care physician perspectives

Abstract

Objective: Expressing therapy benefit from a lifetime perspective, instead of only a 10-year perspective, is both more intuitive and of growing importance in doctor-patient communication. In cardiovascular disease (CVD) prevention, lifetime estimates are increasingly accessible via online decision tools. However, it is unclear what gain in life expectancy is considered meaningful by those who would use the estimates in clinical practice. We therefore quantified lifetime and 10-year benefit thresholds at which physicians and patients perceive statin and antihypertensive therapy as meaningful, and compared the thresholds with clinically attainable benefit.

Design: Cross-sectional study.

Settings: (1) continuing medical education conference in December 2016 for primary care physicians;(2) information session in April 2017 for patients.

Participants: 400 primary care physicians and 523 patients in the Netherlands.

Outcome: Months gain of CVD-free life expectancy at which lifelong statin therapy is perceived as meaningful, and months gain at which 10 years of statin and antihypertensive therapy is perceived as meaningful. Physicians were framed as users for lifelong and prescribers for 10-year therapy.

Results: Meaningful benefit was reported as median (IQR). Meaningful lifetime statin benefit was 24 months (IQR 23-36) in physicians (as users) and 42 months (IQR 12-42) in patients willing to consider therapy. Meaningful 10-year statin benefit was 12 months (IQR 10-12) for prescribing (physicians) and 14 months (IQR 10-14) for using (patients). Meaningful 10-year antihypertensive benefit was 12 months (IQR 8-12) for prescribing (physicians) and 14 months (IQR 10-14) for using (patients). Women desired greater benefit than men. Age, CVD status and co-medication had minimal effects on outcomes.

Conclusion: Both physicians and patients report a large variation in meaningful longevity benefit. Desired benefit differs between physicians and patients and exceeds what is clinically attainable. Clinicians should recognise these discrepancies when prescribing therapy and implement individualised medicine and shared decision-making. Decision tools could provide information on realistic therapy benefit.

Keywords: doctor-patient communication; individualized prevention; preventive medicine; primary care; shared decision making; vascular medicine.

Figure 1

Months gain in CVD-free life expectancy above which physicians (as users) and patients perceive lifelong statin therapy as meaningful. Missing responses was seen in 5 physicians (1.3%) and 23 patients (4.4%). CVD, cardiovascular disease.

Figure 2

Months gain in CVD-free life expectancy above which physicians (as prescribers) and patients (as users) consider (A) statin and (B) antihypertensive therapy meaningful. Missing responses was seen in 9 physicians (2.3%) and 27 patients (5.2%) for statin medication and 8 physicians (2.0%) and 28 patients (5.4%) for antihypertensive medication. CVD, cardiovascular disease.

Figure 3

Numbers represent total gain (in months) of CVD-free life expectancy to be attained from lifelong therapy with simvastatin 40 mg for the specific combination of age, sex, lipid-profile, blood pressure and smoking status calculated with the JBS3 risk score. Colours represent the (non)-concordance between ESC guideline recommendations and participant views of meaningful therapy. CVD, cardiovascular disease; ESC, European Society of Cardiology.

Figure 4

Numbers represent total gain (in months) of CVD-free life expectancy to be attained from lifelong therapy with a single blood-pressure-lowering medication for the specific combination of age, sex, lipid profile, blood pressure and smoking status calculated with the JBS3 risk score. Colours represent the (non)-concordance between ESC guideline recommendations and participant views of meaningful therapy. CVD, cardiovascular disease; ESC, European Society of Cardiology.