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Ben: Again - not sure why guidelines need to define a treatment threshold. Why not have the guideline provide tools to estimate risks and show how treatment changes that risk. In other words they give tools for shared-decision making not treatment thresholds (regardless of how these could be developed)
James
On Dec 3, 2018, at 7:52 PM, Djulbegovic, Benjamin <[log in to unmask]> wrote:
James, indeed the guidelines panel may define the threshold but that does not mean that they defined it correctly (as I said in my first reply to your message , the METHOD for determining the threshold is crucial but this is completely different issue )Ben
Sent from my iPhone(Please excuse typos & brevity)Thanks Ben - one totally needs info on harm - my example was strictly limited to the discussion of the risks and benefits. I think maybe we are talking at cross purposes??
When I say treatment thresholds I mean guidelines that say if your risk is >10% then you should treat - is that what you mean by thresholds or something else?
James
On Dec 3, 2018, at 7:40 PM, Djulbegovic, Benjamin <[log in to unmask]> wrote:
Yes, you do - you need not only benefit information ( risk goes down to 15%) but information on harms...Also, even in your example you implicitly defined the threshold at 15% ( but, as I just said, determination of more precise threshold will require information on harms and if harms are higher than benefits, the threshold will exceed 100% ie normatively no one should be treated despite benefits )Ben
Sent from my iPhone(Please excuse typos & brevity)Hope people find this interesting - an example of what could be said
Your risk of a clinical fracture in the next 10 years is ~20% (based on clinical features etc) - if you take treatment your risk goes down to ~15%
What further information would you need around risk and benefits? Still don't need a treatment threshold.
James
On Dec 3, 2018, at 6:27 PM, Djulbegovic, Benjamin <[log in to unmask]> wrote:
But, how do you anchor/frame discussion without (first) determining the thresholds? Theoretically, risk can range from 0 to 1 - where do you start?This is another important discussion that you have started James, and I would love to hear what other folks think. I should also add this is linked to the fundamental insights that all our policy decisions ( including guidelines) have to work within framework of “irreducible uncertainty, inevitable errors, unavoidable injustice”( Paul Ash and I had a piece along these lines a number of years ago:Ben
Sent from my iPhone(Please excuse typos & brevity)HI Ben - then what is the point of the threshold. Just present the risks and then potential benefits - do shared decision-making and leave it at that.
James
On Dec 3, 2018, at 6:07 PM, Djulbegovic, Benjamin <[log in to unmask]> wrote:
Hi James,My own view is that once you determine the thresholds , say by using decision -analytic methods, you elicit patient’s V&P to adjust the threshold , up or down ...ThanksBen
Sent from my iPhone(Please excuse typos & brevity)Hi Ben - if you have treatment thresholds (instead of discussion thresholds) how do you incorporate patient values and preferences.
James
On Dec 3, 2018, at 5:57 PM, Djulbegovic, Benjamin <[log in to unmask]> wrote:
I think it is a mistake to get away from action (treatment) thresholds; (decision analytic) threshold helps link the quality evidence (which exist on the continuum of credibility) with the decision-making (which is a categorical exercise).
Without threshold, there is no way to help people make decisions ( NB a completely separate issue is how and which model we should use to determine threshold, but determination of the threshold is of fundamental importance for any decision-making under risk/uncertainty)
Ben
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Hi Guylene - really love your approach - we did this with our lipid guideline http://www.cfp.ca/content/61/10/857 where we had absolute risks (determined by using the cvdcalculator.org) that defined when we would have treatment discussions - in other words there were NO treatment thresholds just discussion thresholds. This ideology, if you will, changes the entire focus of a guideline.
You are correct that there is no such thing as overdiagnosis or false positive/false negative when it comes to risk reduction.
The only concept of overdiagnosis would be if you have a person on a treatment for risk (BP, statin, bisphosphonate) yet if they knew or had been given the absolute benefit they wouldn’t have chosen to take the treatment given the benefits and harms.
Hope that makes sense.
James
HI all,
I need your help
I am on the Canadian Task Force and we are looking at doing a guideline on screening to prevent fragility fractureWe wish to get away from a treatment threshold in our recommandations. If we use a threshold if would be for shared decision making not for treatment.We also wish to get away from a disease label (osteoporosis) and use the risk level (% risk) as the outcome to determine actions following screening.We encounter diverging views on certain definitions.
What would these be in that context? Our real question is the last one about overdiagnosis.
False positive and false negative: For us there cannot be a false positive or false positive.If you are labeled at higher risk (example 30% risk of a fracture) there cannot be a false positive because not having a fracture is a possible issue included in the risk.
If you are labeled at lower risk (example 5% risk of fracture) there cannot be a false negative because having a fracture is a possible issue included in the risk.
But what is overdiagnosis in that context? Can we even talk about overdiagnosis?Considering that osteoporosis even if it has a name (diagnostic name) is essentially a risk assessment.
I am eager for your thoughts
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