 |
|
Exploring the Treatment-Risk Paradox in Coronary Disease
Finlay A. McAlister, MSc, MD;
Antigone Oreopoulos, MSc;
Colleen M. Norris, PhD;
Michelle M. Graham, MD;
Ross T. Tsuyuki, MSc, PharmD;
Merril Knudtson, MD;
William A. Ghali, MD, MPH; for the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators
Arch Intern Med. 2007;167(10):1019-1025.
Background The cause of the "treatment-risk paradox" reported for patients with coronary disease is unknown; however, determining the factors that contribute to this paradox is essential to properly design quality improvement interventions.
Methods Prospective cohort study enrolling consecutive patients with angiographically proved coronary disease between February 1, 2004, and November 30, 2005, in Alberta.
Results One month after an angiogram, statins were being taken by 2436 (62.9%) of 3871 patients (mean age, 64 years). High-risk patients were less likely to be taking statins than lower-risk patients (55.8% vs 63.5%; crude odds ratio [OR], 0.72 [95% confidence interval {CI}, 0.57-0.92]; risk ratio [RR], 0.88 [95% CI, 0.79-0.97]), but this treatment-risk paradox was completely attenuated by adjusting for exertional capacity and depressive symptoms (OR, 0.98 [95% CI, 0.75-1.28]; RR, 0.99 [95% CI, 0.89-1.09]). These results were robust across drug classes: while high-risk patients were less likely to be taking angiotensin-converting enzyme inhibitors, aspirin, and statins (25.8% vs 32.3%; crude OR, 0.73 [95% CI, 0.56-0.95]; RR, 0.80 [95% CI, 0.65-0.97]), this association did not persist in the adjusted model (OR, 0.98 [95% CI, 0.72-1.33] [P = .87]; RR, 0.99 [95% CI, 0.79-1.20]).
Conclusions The treatment-risk paradox reported in administrative database analyses is attributable to clinical factors not typically captured in these databases (such as functional capacity and depressive symptoms). Interventions to address the treatment-risk paradox should recognize that patients with reduced functional capacity, depression, or both are at higher risk for underuse of these beneficial therapies and should target physicians and patients.
Author Affiliations: Divisions of General Internal Medicine (Dr McAlister), Cardiothoracic Surgery (Ms Oreopoulos), and Cardiology (Drs Graham and Tsuyuki), and the Faculty of Nursing (Dr Norris), University of Alberta, Edmonton; and the Divisions of Cardiology (Dr Knudtson) and General Internal Medicine (Dr Ghali), University of Calgary, Calgary, Alberta.
RELATED ARTICLES
Management Patterns in Relation to Risk Stratification Among Patients With Non–ST Elevation Acute Coronary Syndromes
Andrew T. Yan, Raymond T. Yan, Mary Tan, Anthony Fung, Eric A. Cohen, David H. Fitchett, Anatoly Langer, Shaun G. Goodman, and for the Canadian Acute Coronary Syndromes 1 and 2 Registry Investigators
Arch Intern Med. 2007;167(10):1009-1016.
ABSTRACT
| FULL TEXT
Translating Evidence Into Practice: Are We Neglecting the Neediest?
John A. Spertus and Mark I. Furman
Arch Intern Med. 2007;167(10):987-988.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
The Treatment-Risk Paradox: More Complex Than We Think
JWatch Emergency Med. 2007;2007:5-5.
FULL TEXT
The Treatment-Risk Paradox in Cardiology
Journal Watch Cardiology 2007;2007:4-4.
FULL TEXT
Translating Evidence Into Practice: Are We Neglecting the Neediest?
Spertus and Furman
Arch Intern Med 2007;167:987-988.
FULL TEXT
|
