Demography, years of life lost and statins Bendix Carstensen Steno Diabetes Center Gentofte, Denmark http://BendixCarstensen.com SDC 16 May 2016 http://BendixCarstensen.com/DMreg/demoYLL.pdf 1/ 1
Expected life time ◮ Take, say 200, persons ◮ follow till all are dead ◮ compute the mean age at death (life time) ◮ — that is the life expectancy (at birth) ◮ . . . so let’s do it and see how it works 2/ 1
Expected life time ◮ Take, say 200, persons ◮ follow till all are dead ◮ compute the mean age at death (life time) ◮ — that is the life expectancy (at birth) ◮ . . . so let’s do it and see how it works 2/ 1
Expected life time ◮ Take, say 200, persons ◮ follow till all are dead ◮ compute the mean age at death (life time) ◮ — that is the life expectancy (at birth) ◮ . . . so let’s do it and see how it works 2/ 1
Expected life time ◮ Take, say 200, persons ◮ follow till all are dead ◮ compute the mean age at death (life time) ◮ — that is the life expectancy (at birth) ◮ . . . so let’s do it and see how it works 2/ 1
Expected life time ◮ Take, say 200, persons ◮ follow till all are dead ◮ compute the mean age at death (life time) ◮ — that is the life expectancy (at birth) ◮ . . . so let’s do it and see how it works 2/ 1
0 20 40 60 80 100 Age 3/ 1
0 20 40 60 80 100 Age 4/ 1
Expected life time and years lost ◮ ERL ( E xpected R esidual L ifetime): Area under the survival curve ◮ YLL ( Y ears of L ife L ost) (to diabetes): ERL pop − ERL DM ◮ difference between areas under the survival curves ◮ ⇒ area between the curves ◮ . . . all the way till all are dead 5/ 1
Expected life time and years lost ◮ ERL ( E xpected R esidual L ifetime): Area under the survival curve ◮ YLL ( Y ears of L ife L ost) (to diabetes): ERL pop − ERL DM ◮ difference between areas under the survival curves ◮ ⇒ area between the curves ◮ . . . all the way till all are dead 5/ 1
Expected life time and years lost ◮ ERL ( E xpected R esidual L ifetime): Area under the survival curve ◮ YLL ( Y ears of L ife L ost) (to diabetes): ERL pop − ERL DM ◮ difference between areas under the survival curves ◮ ⇒ area between the curves ◮ . . . all the way till all are dead 5/ 1
Expected life time and years lost ◮ ERL ( E xpected R esidual L ifetime): Area under the survival curve ◮ YLL ( Y ears of L ife L ost) (to diabetes): ERL pop − ERL DM ◮ difference between areas under the survival curves ◮ ⇒ area between the curves ◮ . . . all the way till all are dead 5/ 1
Expected life time and years lost ◮ ERL ( E xpected R esidual L ifetime): Area under the survival curve ◮ YLL ( Y ears of L ife L ost) (to diabetes): ERL pop − ERL DM ◮ difference between areas under the survival curves ◮ ⇒ area between the curves ◮ . . . all the way till all are dead 5/ 1
Expected life time and years lost to DM ◮ Survival curves for persons with/without DM at age 50 in 2012 ◮ Compute difference in area under curve ◮ Repeat for all ages, both sexes, all years 1995 – 2012 6/ 1
Expected life time and years lost to DM ◮ Survival curves for persons with/without DM at age 50 in 2012 ◮ Compute difference in area under curve ◮ Repeat for all ages, both sexes, all years 1995 – 2012 6/ 1
Expected life time and years lost to DM ◮ Survival curves for persons with/without DM at age 50 in 2012 ◮ Compute difference in area under curve ◮ Repeat for all ages, both sexes, all years 1995 – 2012 6/ 1
Years lost to diabetes in DK 12 12 1995 1995 Men Women 10 10 Years lost to DM 8 Years lost to DM 8 2012 2012 6 6 4 4 2 2 0 0 30 40 50 60 70 80 90 100 30 40 50 60 70 80 90 100 Age Age 7/ 1
12 Years lost to diabetes in DK 10 8 Years lost to DM 6 4 2 0 30 40 50 60 70 80 90 100 Age 8/ 1
The effect of statins on average survival in randomised trials, an analysis of end point postponement Malene Lopez Kristensen, 1 Palle Mark Christensen, 1 Jesper Hallas 1,2 To cite: Kristensen ML, ABSTRACT Strengths and limitations of this study Christensen PM, Hallas J. Objective: To estimate the average postponement of The effect of statins on death in statin trials. ▪ This is the first study ever to systematically average survival in Setting: A systematic literature review of all statin evaluate statin trials using average postponement randomised trials, an analysis trials that presented all-cause survival curves for of death as the primary outcome. of end point postponement. treated and untreated. ▪ We have only estimated the survival gain BMJ Open 2015; 5 :e007118. doi:10.1136/bmjopen-2014- Intervention: Statin treatment compared to placebo. achieved within the trials ’ running time, whereas 007118 Primary outcome measures: The average in real life, treatment is often continued much postponement of death as represented by the area longer. ▪ We have only focused on all-cause mortality. ▸ Prepublication history and between the survival curves. Other outcomes may also be relevant, for additional material is Results: 6 studies for primary prevention and 5 for available. To view please visit example, non-fatal cardiovascular end points. secondary prevention with a follow-up between 2.0 and the journal (http://dx.doi.org/ 6.1 years were identified. Death was postponed 9/ 1 10.1136/bmjopen-2014- between − 5 and 19 days in primary prevention trials to take or to prescribe the drug are largely 007118).
of death as the primary outcome. of end point postponement. treated and untreated. ▪ We have only estimated the survival gain BMJ Open 2015; 5 :e007118. Intervention: Statin treatment compared to placebo. doi:10.1136/bmjopen-2014- achieved within the trials ’ running time, whereas 007118 Primary outcome measures: The average in real life, treatment is often continued much postponement of death as represented by the area longer. between the survival curves. ▪ We have only focused on all-cause mortality. ▸ Prepublication history and Other outcomes may also be relevant, for additional material is Results: 6 studies for primary prevention and 5 for available. To view please visit example, non-fatal cardiovascular end points. secondary prevention with a follow-up between 2.0 and the journal (http://dx.doi.org/ 6.1 years were identified. Death was postponed 10.1136/bmjopen-2014- between − 5 and 19 days in primary prevention trials to take or to prescribe the drug are largely 007118). and between − 10 and 27 days in secondary prevention unaffected by the NNT values given. Also, trials. The median postponement of death for primary Received 21 November 2014 NNT may be criticised for not conveying a and secondary prevention trials were 3.2 and 4.1 days, Revised 29 April 2015 plausible model for how the bene fi t of statins respectively. Accepted 7 May 2015 is distributed. 10 The thinking behind NNT sug- Conclusions: Statin treatment results in a surprisingly gests a lottery-like model, where, for example, small average gain in overall survival within the trials ’ 1 patient in 40 receives full bene fi t from the running time. For patients whose life expectancy is drug, while in the remaining 39 patients, it has limited or who have adverse effects of treatment, no effect. It is more plausible that statins will withholding statin therapy should be considered. delay atherosclerotic progression in all those treated, to an extent where 1 in 40 patients will have his or her end point postponed until INTRODUCTION HMG-CoA reductase inhibitors — or after the outcome is measured. The remaining 39 patients will also have their end points post- ‘ statins ’— are important drugs for the preven- tion of atherosclerotic conditions such as poned, but none to an extent where they cross stroke, myocardial infarction or limb ischae- this timeline. As an alternative to the NNT , it mia. 1 Current guidelines indicate that statins has been suggested that the drug bene fi t may 10/ 1 should be prescribed to all patients manifest- be conveyed by an estimate of the average post-
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