title: Patient-accessible tool for shared decision making in cardiovascular primary prevention: balancing longevity benefits against medication disutility.
abstract: BACKGROUND
  Primary prevention guidelines focus on risk, often assuming negligible aversion to medication, yet most patients discontinue primary prevention statins within 3 years. We quantify real-world distribution of medication disutility and separately calculate the average utilities for a range of risk strata.
  
  
  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 idealized 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; interquartile range, 1-36 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 one-quarter of subjects had disutility exceeding the group-average longevity gain from statins expected even for the highest-risk (ie, 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.
authors.affiliation: International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK.
authors.forename: Marianna
authors.initials: M
authors.lastname: Fontana
authors.affiliation: International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK.
authors.forename: Perviz
authors.initials: P
authors.lastname: Asaria
authors.affiliation: International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK.
authors.forename: Michela
authors.initials: M
authors.lastname: Moraldo
authors.affiliation: International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK.
authors.forename: Judith
authors.initials: J
authors.lastname: Finegold
authors.affiliation: International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK.
authors.forename: Khalil
authors.initials: K
authors.lastname: Hassanally
authors.affiliation: International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK.
authors.forename: Charlotte H
authors.initials: CH
authors.lastname: Manisty
authors.affiliation: International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK.
authors.forename: Darrel P
authors.initials: DP
authors.lastname: Francis
mesh_terms: D000328:Adult; D001794:Blood Pressure; D002318:Cardiovascular Diseases / Q000188:drug therapy* / Q000453:epidemiology / Q000517:prevention & control*; D002784:Cholesterol / Q000097:blood; D003657:Decision Making; D005260:Female; D006306:Health Surveys; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000008:administration & dosage*; D008131:London / Q000453:epidemiology; D008136:Longevity; D008297:Male; D008875:Middle Aged; D010358:Patient Participation / Q000706:statistics & numerical data*; D015995:Prevalence; D011322:Primary Prevention / Q000706:statistics & numerical data; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D012907:Smoking / Q000453:epidemiology; D011795:Surveys and Questionnaires; D055815:Young Adult; D016903:Drug Monitoring
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D002784:Cholesterol
keywords: compliance; hydroxymethylglutaryl-CoA reductase inhibitors; primary prevention
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