Patient-Accessible Tool for Shared Decision Making in Cardiovascular Primary Prevention: Balancing Longevity Benefits Against Medication Disutility
Background—Primary prevention guidelines focus on risk, often assuming negligible aversion to medication. Yet most subjects discontinue primary prevention statins within 3 years. We quantify real-world distribution of medication disutility, and separately calculate average utilities for a range of risk strata.
Method and Results—We randomly sampled 360 members of the general public in London. Medication aversion was quantified as the gain in lifespan required by each individual to offset the inconvenience (disutility) of taking an idealised daily preventative tablet. In parallel, we constructed tables of expected gain in lifespan (utility) from initiating statin therapy for each age group, sex and cardiovascular risk profile in the population. This allowed comparison of the widths of the distributions of medication disutility and of group-average expectation of longevity gain. Observed medication disutility ranged from 1 day to >10 years of life being required by subjects (median 6 months, inter-quartile range 1 to 36 months) to make daily preventative therapy worthwhile. Average expected longevity benefit from statins at ages ≥50 years ranges from 3.6 months (low-risk women) to 24.3 months (high-risk men).
Conclusions—We can no longer assume that medication disutility is almost zero. Over a quarter of subjects had disutility exceeding the group-average longevity gain from statins expected even for the highest-risk (i.e. highest-gain) group. Future primary prevention studies might explore medication disutility in larger populations. Patients may differ more in disutility than in prospectively-definable utility (which provides only group-average estimates). Consultations could be enriched by assessing disutility, and exploring its reasons.
- Received November 24, 2013.
- Revision received February 23, 2014.
- Accepted March 19, 2014.