Rationalizing Prescribing for Older Patients with Multimorbidity: Considering Time to Benefit
Rationalizing Prescribing for Older Patients with Multimorbidity: Considering Time to Benefit
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DOI：
10.1007/s40266-013-0095-7
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发表时间：
2013-09-01
期刊：
影响因子：
2.8
通讯作者：
Boyd, Cynthia M.
中科院分区：
文献类型：
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作者：
Holmes, Holly M.;Min, Lillian C.;Boyd, Cynthia M.
鉴于越来越多的患有多种疾病的老年人需要服用多种药物，临床医生需要优先考虑哪些药物最有可能使患者受益且最不可能伤害个体患者。除了药物有效性的其他衡量标准之外，受益时间 (TTB) 的概念也得到了越来越多的讨论，以便了解治疗对个体患者的益处和危害并对其进行背景分析。然而，如何从现有证据中收集这些信息尚不明确。临床医生缺乏此类信息凸显了临床试验设计和报告的迫切需要，以提供与患有多种疾病的老年人的决策最相关的信息。我们将 TTB 定义为在接受治疗的受试者与未接受治疗的对照组进行的试验中观察到统计学上显着的益处之前的时间。同样，伤害时间 (TTH) 是指在试验中治疗组与对照组相比出现统计上显着的不良反应之前的时间。为了确定 TTB 和 TTH，我们还必须明确定义所考虑的益处或危害，这一点至关重要。明确定义的益处或危害是患者期望（或回避）的具有临床意义、可测量的结果。在这篇概念性综述中，我们阐述了他汀类药物用于心血管疾病一级预防的随机对照试验 (RCT) 中的 TTB 概念。利用已发表的结果，我们估计了他汀类药物的可能 TTB，未来的目标是利用此类信息来改善个体患者的处方决策。了解与患者药物相关的相对 TTB 和 TTH 对于临床医生为患有多种疾病的老年患者做出决策非常有用。我们描述了定义和确定 TTB 和 TTH 的挑战，并讨论了分析和报告试验结果的可能方法，这些方法将为临床医生的证据基础添加有关药物有效性这方面的更多信息。
Given the growing number of older adults with multimorbidity who are prescribed multiple medications, clinicians need to prioritize which medications are most likely to benefit and least likely to harm an individual patient. The concept of time to benefit (TTB) is increasingly discussed in addition to other measures of drug effectiveness in order to understand and contextualize the benefits and harms of a therapy to an individual patient. However, how to glean this information from available evidence is not well established. The lack of such information for clinicians highlights a critical need in the design and reporting of clinical trials to provide information most relevant to decision making for older adults with multimorbidity. We define TTB as the time until a statistically significant benefit is observed in trials of people taking a therapy compared to a control group not taking the therapy. Similarly, time to harm (TTH) is the time until a statistically significant adverse effect is seen in a trial for the treatment group compared to the control group. To determine both TTB and TTH, it is critical that we also clearly define the benefit or harm under consideration. Well-defined benefits or harms are clinically meaningful, measurable outcomes that are desired (or shunned) by patients. In this conceptual review, we illustrate concepts of TTB in randomized controlled trials (RCTs) of statins for the primary prevention of cardiovascular disease. Using published results, we estimate probable TTB for statins with the future goal of using such information to improve prescribing decisions for individual patients. Knowing the relative TTBs and TTHs associated with a patient's medications could be immensely useful to a clinician in decision making for their older patients with multimorbidity. We describe the challenges in defining and determining TTB and TTH, and discuss possible ways of analyzing and reporting trial results that would add more information about this aspect of drug effectiveness to the clinician's evidence base.