Older adult preferences regarding benefits and harms of statin and aspirin therapy for cardiovascular primary prevention

OBJECTIVE Personalizing preventive therapies for atherosclerotic cardiovascular disease (ASCVD) is particularly important for older adults, as they tend to have multiple chronic conditions, increased risk for medication adverse effects, and may have heterogenous preferences when weighing health outcomes. However, little is known about outcome preferences related to ASCVD preventive therapies in older adults. METHODS In May 2021, using an established online panel, KnowledgePanel, we surveyed older US adults aged 65-84 years without history of ASCVD on outcome preferences related to statin therapy (benefit outcomes to be reduced by the therapy: heart attack, stroke; adverse effects: diabetes, abnormal liver test, muscle pain) or aspirin therapy (benefit outcomes: heart attack, stroke; adverse effects: brain bleed, bowel bleed, stomach ulcer). We used standardized best-worst scores (range of -1 for "least worrisome" to +1 for "most worrisome") and conditional logistic regression to examine the relative importance of the outcomes. RESULTS In this study, 607 ASCVD-free participants (median age 74, 46% male, 81% White) were included; 304 and 303 completed the statin and aspirin versions of the survey, respectively. For statin-related outcomes, stroke and heart attack were most worrisome (score 0.55; 95% CI 0.51, 0.60) and (0.53; 0.48, 0.58), followed by potential harms of diabetes (-0.07; -0.10, -0.03), abnormal liver test (-0.25; -0.29, -0.20), and muscle pain (-0.77; -0.82, -0.73). For aspirin-related outcomes, stroke and heart attack were similarly most worrisome (0.48; 0.43, 0.52) and (0.43; 0.38, 0.48), followed by brain bleed (0.30; 0.25, 0.34), bowel bleed (-0.31; -0.33, -0.28), and stomach ulcer (-0.90; -0.92, -0.87). Conditional logistic regression and subgroup analyses by age, sex, and race yielded similar results. CONCLUSIONS Older adults generally consider outcomes related to benefits of ASCVD primary preventive therapies-stroke and heart attack-more important than their adverse effects. Integrating patient preferences with risk assessment is an important next step for personalizing ASCVD preventive therapies for older adults

Primary care clinicians’ perceptions of colorectal cancer screening tests for older adults

Colonoscopy is an effective screening test for colorectal cancer but is associated with significant risks and burdens, especially in older adults. Stool tests, which are more convenient, more accessible, and less invasive, can be important tools to improve screening. How clinicians make decisions about colonoscopy versus stool tests in older patients is not well-understood.We conducted semi-structured interviews with primary care clinicians throughout Maryland in 2018–2019 to examine how clinicians considered the use of stool tests for colorectal cancer screening in their older patients. Thirty clinicians from 21 clinics participated. The mean clinician age was 48.2 years. The majority were physicians (24/30) and women (16/30). Four major themes were identified using qualitative content analysis: (1) Stool test equivalency - although many clinicians still considered colonoscopy as the test of choice, some clinicians considered stool tests equivalent options for screening. (2) Reasons for recommending stool tests – clinicians reported preferentially using stool tests in sicker/older patients or patients who declined colonoscopy. (3) Stool test overuse – some clinicians reported recommending stool tests for patients for whom guidelines do not recommend any screening. (4) Barriers to use – perceived barriers to using stool tests included lack of familiarity, un-returned stool test kits, concern for accuracy, and concern about cost.In summary, clinicians reported preferentially using stool tests in sicker and older patients and mentioned examples of potential overuse. Additional studies are needed on how to better individualize the use of different colorectal screening tests in older patients

L'EU appelle à une réduction de 60% des soutiens distorsifs

Suite à la réunion 'mini-ministérielle' de Montréal, le Commissaire européen à l'agriculture, Franz Fischler a affirmé, le 30 juillet 2003, que l'UE était prête à engager une réduction importante de 60% de ses soutiens intérieurs distorsifs', à éliminer 'les subventions à l'exportation pour certains produits' et à les réduire pour les autres. Toutefois ceci est conditionné à la mise en oe uvre de mesures équivalentes pour d'autre formes de soutiens à l'exportation. Le Commissaire Fischler a également réaffirmé la volonté de l'UE de réduire les tarifs douaniers de 36% en moyenne et manifesté la volonté 'd'ouvrir ou d'étendre les quotas pour certains produits sensibles'. Il a aussi plaidé pour une meilleure protection des produits de qualité et pour plus de concession sur les questions non commerciales. Il a enfin réitéré l'appel à tous les pays développés pour qu'ils accordent un accès libre de droits et de quotas aux exportations provenant des pays les moins avancés. Comment: La volonté de l'UE de réduire de 60% les soutiens intérieurs distorsifs est en effet conditionnée par l'acceptation par l'OMC des systèmes de soutien de l'UE pour traiter les questions non commerciale, c'est à dire une acceptation internationale de la définition de l'UE des formes de soutien non distorsives. Une telle approbation conduira bien sur à un retrait de toute sanction pour ce type de soutien, qui se développe actuellement dans le cadre de la réforme de la PAC. Les projections de l'USDA sur l'impact budgétaire des propositions originales de l'UE pour la réforme de la PAC montrent une réduction de 55% des dépenses sur les mesures liées aux marchés. Si on y ajoute les autres réformes en attente, l'UE devrait pouvoir atteindre ses objectifs dans le cadre de la construction actuelle de la réforme de la PAC.Suite à la réunion 'mini-ministérielle' ..

Demographic, health, and attitudinal factors predictive of cancer screening decisions in older adults

Many older adults receive routine cancer screening even when it is no longer recommended. We sought to identify demographic, health-related, and attitudinal factors that are most predictive of continued breast, colorectal, and prostate cancer screening decisions in older adults under various scenarios. A sample of adults age 65+ (n = 1272) were recruited from a nationally representative panel in November 2016, of which 881 (69.3%) completed our survey. Participants were presented vignettes in which we experimentally varied a hypothetical patient's life expectancy, age, quality of life, and physician screening recommendation. The dependent variable was the choice to continue cancer screening in the vignette. Classification and regression tree (CART) analysis was used to identify characteristics most predictive of screening decisions; both the participants' characteristics and the hypothetical patient's characteristics in the vignettes were included in the analysis. CART analysis uses recursive partitioning to create a classification tree in which variables predictive of the outcome are included as hierarchical tree nodes. We used automated ten-fold cross-validation to select the tree with lowest misclassification and highest predictive accuracy. Participants' attitude towards cancer screening was most predictive of choosing screening. Among those who agreed with the statement “I plan to get screened for cancer for as long as I live” (n = 300, 31.9%), 73.2% chose screening and 57.2% would still choose screening if hypothetical patient had 1-year life expectancy. For this subset of older adults with enthusiasm towards screening even when presented with scenario involving limited life expectancy, efforts are needed to improve informed decision-making about screening. Keywords: Cancer screening, Life expectancy, Decision-making, CART analysi