Medicine and Health Sciences Commons^™

Patient Preferences For Cardiovascular Preventive Medication: A Systematic Review, Loai Albarqouni, Jenny Doust, Paul Glasziou

Jenny Doust

OBJECTIVE:

To systematically review current evidence regarding the minimum acceptable risk reduction of a cardiovascular event that patients feel would justify daily intake of a preventive medication.

METHODS:

We used the Web of Science to track the forward and backward citations of a set of five key articles until 15 November 2016. Studies were eligible if they quantitatively assessed the minimum acceptable benefit-in absolute values-of a cardiovascular disease preventive medication among a sample of the general population and required participants to choose if they would consider taking the medication.

RESULTS:

Of 341 studies screened, we included 22, involving a total …

General Practitioners' Decision Making About Primary Prevention Of Cardiovascular Disease In Older Adults: A Qualitative Study, Jesse Jansen, Shannon Mckinn, Carissa Bonner, Les Irwig, Jenny Doust, Paul Glasziou, Katy Bell, Vasi Naganathan, Kirsten Mccaffery

Jenny Doust

BACKGROUND:

Primary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more susceptible to treatment harms. Moreover the potential benefits and harms of preventive medication for older people are uncertain. We explored GPs' decision making about primary CVD prevention in patients aged 75 years and older.

METHOD:

25 GPs participated in semi-structured interviews in New South Wales, Australia. Transcribed audio-recordings were thematically coded and Framework Analysis was used.

RESULTS:

Analysis identified factors that are likely to contribute to variation in the management of CVD risk …

Ten-Year Legacy Effects Of Baseline Blood Pressure ‘Treatment Naivety’ In The Second Australian National Blood Pressure Study, Mark Nelson, Enayet Chowdhury, Jenny Doust, Christopher Reid, Lindon Wing

Jenny Doust

Objectives: Current blood pressure (BP) management guidelines recommend that treatment thresholds for BP be based on absolute cardiovascular disease (CVD) risk rather than on elevated BP levels alone. Clinicians are concerned that delayed pharmacotherapy in individuals with high BP, but low CVD risk, may increase long-term CVD events. To investigate this, we examined differences in CVD events within the Second Australian National BP study (ANBP2) for those previously on pharmacotherapy and those who were not, as well as fatal events in the 6-year post-trial period. Methods: Population consisted of ANBP2 participants without a prior CVD event. Adjusted Cox-regression hazard models …

"What Should Happen Before Asymptomatic Men Decide Whether Or Not To Have A Psa Test?"A Report On Three Community Juries, Chris Degeling, Lucie Rychetnik, Kristen Pickles, Rae Thomas, Jennifer Doust, Robert Gardiner, Paul Glasziou, Ainsley Newson, Stacy Carter

Jenny Doust

OBJECTIVES: To elicit the views of well informed community members on the ethical obligations of general practitioners regarding prostate-specific antigen (PSA) testing, and what should be required before a man undergoes a PSA test. DESIGN AND SETTING: Three community juries held at the University of Sydney over 6 months in 2014. PARTICIPANTS: Forty participants from New South Wales, of diverse social and cultural backgrounds and with no experience of prostate cancer, recruited through public advertising: two juries of mixed gender and ages; one all-male jury of PSA screening age. RESULTS: In contrast to Royal Australian College of General Practitioners guidelines, …

Systematic Review Of Clinical Practice Guidelines Recommendations About Primary Cardiovascular Disease Prevention For Older Adults, Jesse Jansen, Shannon Mckinn, Carissa Bonner, Les Irwig, Jenny Doust, Paul Glasziou, Brooke Nickel, Barbara Van Munster, Kirsten Mccaffery

Jenny Doust

Background: Clinical care for older adults is complex and represents a growing problem. They are a diverse patient group with varying needs, frequent presence of multiple comorbidities, and are more susceptible to treatment harms. Thus Clinical Practice Guidelines (CPGs) need to carefully consider older adults in order to guide clinicians. We reviewed CPG recommendations for primary cardiovascular disease (CVD) prevention and examined the extent to which CPGs address issues important for older people identified in the literature.

Is The 'Heart Age' Concept Helpful Or Harmful Compared To Absolute Cardiovascular Disease Risk? An Experimental Study, Carissa Bonner, Jesse Jansen, Ben Newell, Les Irwig, Armando Teixeira-Pinto, Paul Glasziou, Jenny Doust, Shannon Mckinn, Kirsten Mccaffery

Jenny Doust

Background Cardiovascular disease (CVD) prevention guidelines are generally based on the absolute risk of a CVD event, but there is increasing interest in using ‘heart age’ to motivate lifestyle change when absolute risk is low. Previous studies have not compared heart age to 5-year absolute risk, or investigated the impact of younger heart age, graphical format, and numeracy. Objective Compare heart age versus 5-year absolute risk on psychological and behavioral outcomes. Design 2 (heart age, absolute risk) 3 3 (text only, bar graph, line graph) experiment. Setting. Online. Participants 570 Australians aged 45–64 years, not taking CVD-related medication. Intervention CVD …

Simplification Of A Scoring System Maintained Overall Accuracy But Decreased The Proportion Classified As Low Risk, S. Sanders, Dylan Flaws, Martin Than, John Pickering, Jenny Doust, Paul Glasziou

Jenny Doust

Objectives: Scoring systems are developed to assist clinicians in making a diagnosis. However, their uptake is often limited because they are cumbersome to use, requiring information on many predictors, or complicated calculations. We examined whether, and how, simplifications affected the performance of a validated score for identifying adults with chest pain in an emergency department who have low risk of major adverse cardiac events.

What Do You Think Overdiagnosis Means? A Qualitave Analysis Of Responses From A National Community Survey Of Australians?, Ray Moynihan, Brooke Nickel, Jolyn Hersch, Jenny Doust, Alexandra Barratt, Elaine Beller, Kirsten Mccaffery

Jenny Doust

Objective: Overdiagnosis occurs when someone is diagnosed with a disease that will not harm them. Against a backdrop of growing evidence and concern about the risk of overdiagnosis associated with certain screening activities, and recognition of the need to better inform the public about it, we aimed to ask what the Australian community understood overdiagnosis to mean. Design, setting and participants: Content analysis of verbatim responses from a randomly sampled community telephone survey of 500 Australian adults, between January and February 2014. Data were analysed independently by two researchers. Main outcome measures: Analysis of themes arising from community responses to …

A Systematic Review Of Studies Comparing Diagnostic Clinical Prediction Rules With Clinical Judgement, Sharon Sanders, Jenny A. Doust, Paul Glasziou

Jenny Doust

Diagnostic clinical prediction rules (CPRs) are developed to improve diagnosis or decrease diagnostic testing. Whether, and in what situations diagnostic CPRs improve upon clinical judgment is unclear. We searched MEDLINE, Embase and CINAHL, with supplementary citation and reference checking for studies comparing CPRs and clinical judgment against a current objective reference standard. We report 1) the proportion of study participants classified as not having disease who hence may avoid further testing and or treatment and 2) the proportion, among those classified as not having disease, who do (missed diagnoses) by both approaches. 31 studies of 13 medical conditions were included, …

The Challenge Of Of Overdiagnosis Begins With Its Definition, S Carter, W Rogers, I Heath, C Degeling, Jenny Doust, Alexandra Barratt

Jenny Doust

Overdiagnosis means different things to different people. S M Carter and colleagues argue that we should use a broad term such as too much medicine for advocacy and develop precise, case by case definitions of overdiagnosis for research and clinical purposes.

A Multifaceted Quality Improvement Intervention For Cvd Risk Management In Australian Primary Healthcare: A Protocol For A Prcoess Evaluation, Bindu Patel, Anushka Patel, Stephen Jan, Tim Usherwood, Mark F. Harris, Katie Panaretto, Nick Zwar, Julie Redfern, Jesse Jansen, Jenny A. Doust, David Peiris

Jenny Doust

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. Despite the widespread availability of evidence-based clinical guidelines and validated risk predication equations for prevention and management of CVD, their translation into routine practice is limited. We developed a multifaceted quality improvement intervention for CVD risk management which incorporates electronic decision support, patient risk communication tools, computerised audit and feedback tools, and monthly, peer-ranked performance feedback via a web portal. The intervention was implemented in a cluster randomised controlled trial in 60 primary healthcare services in Australia. Overall, there were improvements in risk factor recording and in prescribing …

Identified Health Concerns And Changes In Management Resulting From The Healthy Kids Check In Two Queensland Practices, Rae Thomas, Jenny Doust, Kartik Vasan, Bianca Rajapakse, Leanne Mcgregor, Evan Ackermann, Chris Del Mar

Jenny Doust

Objectives: To determine how many children had health problems identified by the Healthy Kids Check (HKC) and whether this resulted in changes to clinical management. Design, setting and participants: A medical records audit from two Queensland general practices, identifying 557 files of children who undertook an HKC between January 2010 and May 2013. Main outcome measures: Child health problems identified in the medical records before, during and after the HKC. Results: Most children in our sample had no problems detected in their medical record (56%), 21% had problems detected during the HKC assessment, 19% had problems detected before, and 4% …

How Do General Practitioners And Patients Make Decisions About Cardiovascular Disease Risk?, Carissa Bonner, Jesse Jansen, Shannon Mckinn, Jenny Doust, Paul Glasziou, Kirsten Mccaffery

Jenny Doust

Objective: Although current guidelines around the world recommend using absolute risk (AR) thresholds to decide whether cardiovascular disease (CVD) risk should be managed with lifestyle or medication, the use of AR in clinical practice is limited. The aim of this study was to explore the factors that influence general practitioner (GP) and patient decision making about CVD risk management, including the role of risk perception. Methods: Qualitative descriptive study involving semi-structured interviews with 25 GPs and 38 patients in Australia in 2011-2012. Transcribed audio-recordings were thematically coded and a Framework Analysis method was used. Results: GPs rarely mentioned AR thresholds …

Prevalence Of Attention-Deficit/ Hyperactivity Disorder: A Systematic Review And Meta-Analysis, Rae Thomas, Sharon Sanders, Jenny Doust, Elaine Beller, Paul Glasziou

Jenny Doust

Overdiagnosis and underdiagnosis of attention-deficit/hyperactivity abstract disorder (ADHD) are widely debated, fueled by variations in prevalence estimates across countries, time, and broadening diagnostic criteria. We conducted a meta-analysis to: establish a benchmark pooled prevalence for ADHD; examine whether estimates have increased with publication of different editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM); and explore the effect of study features on prevalence. METHODS: Medline, PsycINFO, CINAHL, Embase, and Web of Science were searched for studies with point prevalence estimates of ADHD. We included studies of children that used the diagnostic criteria from DSM-III, DSM-III-R and DSM-IV in …

Primary Prevention Of Cardiovascular Disease: New Guidelines, Technologies And Therapies, Mark Nelson, Jenny Doust

Jenny Doust

A trend in primary prevention of cardiovascular disease (CVD) has been a move away from managing isolated risk factors, such as hypertension and dyslipidaemia, towards assessment and management of absolute CVD risk. In Australian guidelines, absolute CVD risk is calculated as the probability of a stroke, transient ischaemic attack, myocardial infarction, angina, peripheral arterial disease or heart failure occurring within the next 5 years. Absolute CVD risk should be regularly assessed in patients aged 45 years or older (35 years or older in Aboriginal and Torres Strait Islander people) using the Australian absolute CVD risk calculator (http://www.cvdcheck.org.au). For …

Clinical Decision-Making Tools: How Effective Are They In Improving The Quality Of Health Care?, Lyndal Trevana, Kirsten Mccaffery, Glenn Salkeld, Paul Glasziou, Chris Del Mar, Jenny A. Doust, Tammy Hoffmann

Jenny Doust

Exec Summary Clinical decision-making tools can be considered in two broad categories – those designed to be used by clinicians and those designed to promote shared decision making with the clinician and patient together. The potential effect of computerised clinical decision support systems (CDSS) on variations in practice is not well understood, and CDSS are currently not a recommended means of improving evidence-based practice, or patient outcomes, since the mechanisms of success and failure are not well defined and the potential impact on workflows and adverse events are poorly evaluated. Despite numerous randomised controlled trials, there is poor quality evidence …

Political Drive To Screen For Pre-Dementia: Not Evidence Based And Ignores The Harms Of Diagnosis, David Le Couteur, Jenny A. Doust, Helen Creasey, Carol Brayne

Jenny Doust

Current policy in many countries is aimed at increasing the rates of diagnosis of dementia and cognitive impairment.1 2 3 This policy drive has been accompanied by research into early detection of dementia, including preclinical identification of underlying neurobiology that might later be associated with dementia.4 Although the clinical features of people with established dementia are unmistakable,5 6 the ability of these preclinical features to predict future disease is less clear. Nevertheless, the belief that there is value in screening for “pre-dementia” or mild cognitive impairment is creeping into clinical practice, with the resulting overdiagnosis having potential adverse consequences for …

Is There Sufficient Evidence For Tuning Fork Tests In Diagnosing Fractures?, Kayalvili Mungunthan, Jenny Doust, Bodo Kurz, Paul Glasziou

Jenny Doust

Objective: To determine the diagnostic accuracy of tuning fork tests for detecting fractures. Design: Systematic review of primary studies evaluating the diagnostic accuracy of tuning fork tests for the presence of fracture. Data source: We searched MEDLINE, CINAHL, AMED, EMBASE, Sports Discus, CAB Abstracts and Web of Science from commencement to November 2012. We manually searched the reference lists of any review papers and any identified relevant studies. Study selection and data extraction: Two reviewers independently reviewed the list of potentially eligible studies and rated the studies for quality using the QUADAS-2 tool. Data were extracted to form 2x2 contingency …

Communicating Cardiovascular Disease Risk: An Interview Study Of General Practitioners' Use Of Absolute Risk Within Tailored Communication Strategies, Carissa Bonner, Jesse Jansen, Shannon Mckinn, Les Irwig, J. Doust, Paul Glasziou, Kirsten Mccaffery

Jenny Doust

Background: Cardiovascular disease (CVD) prevention guidelines encourage assessment of absolute CVD risk - the probability of a CVD event within a fixed time period, based on the most predictive risk factors. However, few General Practitioners (GPs) use absolute CVD risk consistently, and communication difficulties have been identified as a barrier to changing practice. This study aimed to explore GPs' descriptions of their CVD risk communication strategies, including the role of absolute risk. Methods. Semi-structured interviews were conducted with a purposive sample of 25 GPs in New South Wales, Australia. Transcribed audio-recordings were thematically coded, using the Framework Analysis method to …

I Don't Believe It, But I'D Better Do Something About It: Patient Experiences Of Online Heart Age Risk Calculators, Carissa Bonner, Jesse Jansen, Ben Newell, Les Irwig, Paul Glasziou, Jenny Doust, Haryana, Kirsten Mccaffery

Jenny Doust

Background: Health risk calculators are widely available on the Internet, including cardiovascular disease (CVD) risk calculators that estimate the probability of a heart attack, stroke, or death over a 5- or 10-year period. Some calculators convert this probability to "heart age", where a heart age older than current age indicates modifiable risk factors. These calculators may impact patient decision making about CVD risk management with or without clinician involvement, but little is known about how patients use them. Previous studies have not investigated patient understanding of heart age compared to 5-year percentage risk, or the best way to present heart …

Development And Validation Of The Emergency Department Assessment Of Chest Pain Score And 2h Accelerated Diagnostic Protocol, Martin Than, Dylan Flaws, Sharon Sanders, Jenny Doust, Paul Glasziou, Jeffrey Kline, Sally Aldous, Richard Troughton, Christopher Reid, William Parsonage, Christopher Frampton, Jaimi Greenslade, Joanne Deely, Erik Hess, Amr Sadiq, Rose Singleton, Rosie Shopland, Laura Vercoe, Morgana Woolhouse-Williams, Michael Ardagh, P. Bossuyt, Laura Bannister, Louise Cullen

Jenny Doust

Objective: Risk scores and accelerated diagnostic protocols can identify chest pain patients with low risk of major adverse cardiac event who could be discharged early from the ED, saving time and costs. We aimed to derive and validate a chest pain score and accelerated diagnostic protocol (ADP) that could safely increase the proportion of patients suitable for early discharge. Methods: Logistic regression identified statistical predictors for major adverse cardiac events in a derivation cohort. Statistical coefficients were converted to whole numbers to create a score. Clinician feedback was used to improve the clinical plausibility and the usability of the final …

General Practitioners' Use Of Different Cardiovascular Risk Assessment Strategies: A Qualitative Study, Carissa Bonner, Jesse Jansen, Shannon Mckinn, Les Irwig, J. Doust, Paul Glasziou, Andrew Hayen, Kirsten Mccaffery

Jenny Doust

Objectives: To identify factors that influence the extent to which general practitioners use absolute risk (AR) assessment in cardiovascular disease (CVD) risk assessment. Design, setting and participants: Semi-structured interviews with 25 currently practising GPs from eight Divisions of General Practice in New South Wales, Australia, between October 2011 and May 2012. Data were analysed using framework analysis. Results: The study identified five strategies that GPs use with patients in different situations, defined in terms of the extent to which AR was used and the reasons given for this: the AR-focused strategy, used when AR assessment was considered useful for the …

Monitoring In Clinical Biochemistry, Jenny Doust, Paul Glasziou

Jenny Doust

Monitoring tests form an increasing proportion of the workload in clinical biochemistry and biochemists can help by providing clinicians with information about the variability and precision of tests, the time frame for pharmacodynamic stabilisation after a treatment change, and the frequency of testing. This paper outlines the phases of monitoring, and how to decide if monitoring is beneficial, which test to use for monitoring, when a change in the test result indicates a need for the change in treatment and the length of testing intervals. We conclude with some recommendations for biochemists for future areas of research and advice that …

A Community Jury On Psa Screening: What Do Well-Informed Men Want The Government To Do About Prostate Cancer Screening - A Qualitative Analysis, Lucie Rychetnik, Jenny Doust, Rae Thomas, Robert A. Gardiner, Geraldine Mackenzie, Paul Glasziou

Jenny Doust

Objective: Cancer screening policies and programmes should take account of public values and concerns. This study sought to determine the priorities, values and concerns of men who were 'fully informed' about the benefits and harms of prostate-specific antigen (PSA) screening; and empirically examine the value of a community jury in eliciting public values on PSA screening. Setting: Community jury was convened on the Gold Coast, Queensland (Australia) to consider PSA screening benefits and harms, and whether government campaigns on PSA screening should be conducted. Participants: 27 men (volunteers) aged 50-70 with no personal history of prostate cancer and willing to …

General Practitioners' Use Of Absolute Risk Versus Individual Risk Factors In Cardiovascular Disease Prevention: An Experimental Study, Jesse Jansen, Carissa Bonner, Shannon Mckinn, Les Irwig, Paul Glasziou, Jenny Doust, Armando Teixeira-Pinto, Andrew Hayen, Robin Turner, Kirsten Mccaffery

Jenny Doust

Objective: To understand general practitioners' (GPs) use of individual risk factors (blood pressure and cholesterol levels) versus absolute risk in cardiovascular disease (CVD) risk management decision-making. Design: Randomised experiment. Absolute risk, systolic blood pressure (SBP), cholesterol ratio (total cholesterol/high-density lipoprotein (TC/HDL)) and age were systematically varied in hypothetical cases. High absolute risk was defined as 5-year risk of a cardiovascular event >15%, high blood pressure levels varied between SBP 147 and 179 mm Hg and high cholesterol (TC/HDL ratio) between 6.5 and 7.2 mmol/L. Setting: 4 GP conferences in Australia. Participants: 144 Australian GPs. Outcomes: GPs indicated whether they would …

The Chronic Kidney Disease Controversy: How Expanding Definitions Care Unnecessarily Labelling Many People As Diseased, Ray Moynihan, Richard Glassock, Jenny A. Doust

Jenny Doust

Extract: In 2002 the United States Kidney Foundation launched a novel framework for defining and classifying chronic kidney disease. The framework was widely embraced because it imposed order in a chaotic landscape characterised by a variety of names, including renal insufficiency, renal impairment, and renal failure. It has had an appreciable effect on clinical care worldwide through guidelines, pay for performance measures, and sparked debate on the merits of screening programmes. However, it has also generated considerable controversy. We examine the rationale for the framework, the varying responses and controversies it has provoked, and provide advice for clinicians who are …

Expanding Disease Definitions In Guidelines And Expert Panel Ties To Industry: A Cross-Sectional Study Of Common Conditions In The United State, Ray Moynihan, Georga Cooke, Jenny Doust, Lisa Bero, Suzanne Hill, Paul Glasziou

Jenny Doust

Financial ties between health professionals and industry may unduly influence professional judgments and some researchers have suggested that widening disease definitions may be one driver of over-diagnosis, bringing potentially unnecessary labeling and harm. We aimed to identify guidelines in which disease definitions were changed, to assess whether any proposed changes would increase the numbers of individuals considered to have the disease, whether potential harms of expanding disease definitions were investigated, and the extent of members' industry ties.

Preventing Overdiagnosis: How To Stop Harming The Healthy, Ray Moynihan, Jenny Doust, David Henry

Jenny Doust

Medicine’s much hailed ability to help the sick is fast being challenged by its propensity to harm the healthy. A burgeoning scientific literature is fuelling public concerns that too many people are being overdosed, overtreated, and overdiagnosed. Screening programmes are detecting early cancers that will never cause symptoms or death, sensitive diagnostic technologies identify “abnormalities” so tiny they will remain benign, while widening disease definitions mean people at ever lower risks receive permanent medical labels and lifelong treatments that will fail to benefit many of them. With estimates that more than $200bn (£128bn; €160bn) may be wasted on unnecessary treatment …

Prioritising Cvd Prevention Therapy - Absolute Risk Versus Individual Risk Factors, Jenny Doust, Sharon Sanders, Jonathon Shaw, Paul Glasziou

Jenny Doust

Background: Previous studies suggest that a high proportion of persons at high risk of cardiovascular disease in Australia are not receiving adequate disease prevention with blood pressure and lipid lowering therapy. However, it is not clear how a move to an absolute risk factor approach will affect the proportion of the population that is treated with blood pressure and lipid lowering therapy versus treatment based on individual risk factors. Methods: We classified participants in the AusDiab follow up cohort study who had no previous history of cardiovascular disease and who were not taking blood pressure or lipid lowering medication currently …

Aloe Vera For Treating Acute And Chronic Wounds, Anthony D. Dat, Flora Poon, Kim Bt Pham, Jenny Doust

Jenny Doust

Background: Aloe vera is a cactus-like perennial succulent belonging to the Liliaceae Family that is commonly grown in tropical climates. Animal studies have suggested that Aloe vera may help accelerate the wound healing process.

Objectives: To determine the effects of Aloe vera-derived products (for example dressings and topical gels) on the healing of acute wounds (for example lacerations, surgical incisions and burns) and chronic wounds (for example infected wounds, arterial and venous ulcers).

Search methods: We searched the Cochrane Wounds Group Specialised Register (9 September 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), …