Most everyone has had the experience of sitting across from a doctor, being offered a prescription and walking out the door. Most patients will accept the instructions — maybe ask a few questions — and move on. For some of those patients, the medications are more than a one-off; they are intended to be taken indefinitely.
One of the most common of these medications is a statin. Imagine you exercise four times per week, and do not smoke, have high blood pressure, or diabetes. At your annual physical, your doctor proclaims that you are a healthy 55-year-old man, but gives you a prescription for a statin because you have an elevated cholesterol level of 220 mg/dL (ideal level is less than 200 mg/dL). Should you take a statin for the rest of your life?
The answer is, “it depends.” You obviously do not want to have a heart attack, and a statin seems like it would achieve that goal. You ponder whom to ask about the benefits and risk of taking statins and if you should take a statin for the rest of your life? Since your doctor already decided to give you the prescription, you think about asking your family, friends, or an acquaintance.
According to recent guidelines from the American Heart Association (AHA), patients who are estimated to have a greater than 8 percent chance of having a heart attack or stroke within 10 years should be treated with a statin to reduce their risk of a heart attack. If these guidelines were followed exactly, more than 75 percent of people older than 60 — more than 1 billion people worldwide — would be taking statins, including the patient above. However, the reality is that approximately 10 percent will never fill the prescription or start taking statins and more than half of patients who start taking statins stop taking them on their own within two years of starting.
So how can patients make the right decision for themselves from that first conversation with a doctor?
A novel solution is now available: shared decision-making. Using this approach, patients and clinicians work together to learn, understand and identify what are the best ways of achieving a patient’s personal goals. This process can inform and individualize treatments to take into account both the best scientific evidence available and the patient’s personal values, preferences, and context (for example, will the cost of the pill be disruptive to their life, are there side effects, or could the patient achieve the same results through exercise or a change in diet instead of a pill?).
Central to this discussion is a clear understanding of what this medicine can — and can’t — do. It will not guarantee you do not have a heart attack; it will reduce the likelihood. For instance, the patient described earlier is 55 years old and has an 8 percent chance of having a heart attack within 10 years. Taking statins does not mean he will avoid a heart attack, and not taking a statin does not mean he is destined to have a heart attack. In fact, taking statins for a decade will lower his risk from 8 percent to 6 percent; it is not an all-or-none outcome.
In other words, that means that for every 100 patients like him with comparable risk who take statins for a decade, two patients will avoid a heart attack or stroke, six will still have a heart attack or stroke, and ninety-two will not have a heart attack or stroke (regardless of whether they took a statin or not).
If this risk and benefit profile were you, what would you choose to do?
This shared decision-making process is an opportunity for clinicians and patients to discuss the potential benefits, harms and burdens of statins in order to arrive at a choice that reflects the existing research and the values, preferences, and context of each patient. The goal of shared decision-making is not to convince a patient to take a statin or not to take a statin for the next decade. Rather, it is intended to empower a better and more informed choice that the patient understands and is more likely to adhere to.
Very few medical decisions about potential, alternative treatments are black or white, and many treatments require patient’s to act and adhere to the decision in order to realize any benefits (for example to take a medication every day for a decade), we advocate shared decision-making to drive better choices and patient preferences. The value of shared decision-making is to drive better conversations and communications between doctors and patients — leading to better decisions that the patients want and will stick to.
Henry H. Ting is the senior vice-president and chief quality officer, New York–Presbyterian Hospital, New York, NY and fellows ambassador, New York Academy of Medicine. Victor M. Montori is director, Mayo Clinic Knowledge and Evaluation Research Unit, Rochester, MN.
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