Readers Comments

Below are some of the comments and feedback we received from our readers regarding Therapeutics Letter 62.

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I'm not a member of the medical profession, just a consumer. But isn't it amazing that such a common-sense approach to health care delivery should be posed as a tentative suggestion to practitioners. Radical. Will we one day look back on our one-size fits all pharmaceutical company designed healthcare with disbelief that medicine delivery could have been so primitive. Oy vey.
SS [consumer, Canada]

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This is an excellent example of the sort of dilemma I feel strongly about and enjoy teaching. I use several similar examples for both hypertension and dyslipidaemia. I have been conducting some research on how well doctors appreciate the quantitative benefits (and risks) of preventive cardiovascular treatment using an audience response system. Their knowledge is somewhat vague, especially on absolute risk reduction. To be fair most patients do not ask the question spontaneously and it is a complex area to explain. Much of our collective aggressive approach to BP and cholesterol reduction has been built on our perception of group effects while the risk/benefit equation for the individual patient may be unimpressive (the Rose paradox). At a seminar, I once suggested to a leading Australian lipidologist that we should quote absolute risks for a patient with and without medication before writing the prescription; he looked at me in horror and said "We can't do that, nobody would take the medication!". It disturbs me that British GPs now get performance pay based on their prescription rates in admittedly generally higher risk groups. There are, of course residual uncertainties and concerns. What intermediate asymptomatic pathology might be prevented over the next 5 years that would otherwise have increased risk in the following five years? (Equally, what adverse effects might longer term medication have?).
SM [Assoc Professor of Cardiovascular Medicine, New Zealand]

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This is a clinically important topic and well analyzed. A couple of general comments: - I have more often lost patients from practice for providing evidence based medicine than any other cause since so many of my specialist colleagues scorn evidence based medicine in practice and when my patients see them my care is often criticized as being out-of-date for using older meds or the cause of the patients stroke or MI because I wasn't aggressive enough in treatment. - this case illustrates how much thinking and analysis is needed for a condition as "simple" as mild hypertension. Most of my colleagues are unwilling to spend the time on this kind of research and discussion, so do the simplest: mindlessly prescribe an antihypertensive. Keep up the encouragement to practice better medicine.
DE [MD, British Columbia, Canada]

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I am a 4th year pharmacy student and as part of my curriculum I have been taught critical appraisal. I am currently doing my 4th year clerkship at a community pharmacy and as my project I am going to try to help he pharmacists at this store become more evidence based in their practice. I was thrilled with this newsletter. It was so well laid out and really showed what you need to think about when using studies to answer a clinical question. I will be forwarding this on to all of the pharmacists that I work with!
KC [Pharmacy student, Nova Scotia, Canada]

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Wonderful! Thank you, as always! Comments: I would love to get better at doing this "real time" in face-to-face encounters with patients. Will have to get better at accessing the sites/tools that allow me to present good numbers to interested patients.
MM [MD, LaCrosse, WI, USA]

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First, I would like to make a general comment about the TI letters. I find them extremely helpful in my practice and I frequently refer to them or discuss them when teaching family medicine residents. This most recent letter is a clear and concise consideration of evaluating and presenting evidence about drug therapy to patients. Although it does take more time than the "usual" approach, I have been discussing clinical evidence about drug therapies in just such a fashion for several years now. My patients appreciate my attention to detail and enjoy the discussion. Most like to be involved in the decision making in this fashion. My continuing frustration, however, is that most published studies of drug therapies continue to present results as relative risk reductions, rather than ARRs or NNTs. It adds a layer of work to the whole process. Keep up the excellent work!
NP [Family Physician, Ontario, Canada]

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