A recent article by Lee and Kim highlights a pragmatic approach to individualize prevention for older adults. While individualizing prevention may seem like an intuitive concept, historically many specialty society guidelines (including within cardiology) have taken a population-level approach with blanket recommendations. Anyone in practice for a few years realizes that this “one size fits all” approach falls well short in older adults, particularly when considering treatments in the setting of limited trial evidence, comorbid medical conditions, and the potential for harm.
In this context, Lee and Kim propose a simple framework to implement, based on life expectancy (LE) versus time to benefit (TTB). In their model, the intervention should be encouraged if LE > TTB, should be avoided if LE < TTB, and if LE = TTB then they advise that “the individual’s values and preferences should be the major determinant of the decision.” As a concrete example within cardiology, many trials of statins for primary prevention (the topic of a prior blog post here) have shown at least 2 years until TTB, and statins would therefore be avoided in a patient with LE < 1 year.
While predicting LE can be notoriously difficult, several risk calculators have been developed. Lee and Kim propose using ePrognosis.com, which includes risk estimates based on site of care (e.g. living at home, admitted to the hospital, living in a nursing home) and a wide range of comorbid medical conditions.
A major limitation of LE and TTB is that they are not always clear. TTB, for example, may vary widely in different clinical trials based on factors including population studied, medication adherence rates (with drug trials), and competing risks. Lee and Kim acknowledge the importance of communicating this uncertainty, as well as incorporating individual patient preferences into the treatment plan. I still find this framework incredibly useful and anticipate that risk calculators, as well as visual aids to facilitate communication with patients, will continue to be developed and improved.
By: John Dodson, MD, MPH