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The number needed to treat (NNT) is an epidemiological measure used in assessing the effectiveness of a health-care intervention, typically a treatment with medication. The NNT is the number of patients who need to be treated in order to prevent one additional bad outcome (i.e. to reduce the expected number of cases of a defined endpoint by one). It is defined as the inverse of the absolute risk reduction. It was described in 1988.[1]
Contents |
Derivation
In general, NNT is computed with respect to two treatments A and B, with A typically a drug and B a placebo (e.g., A might be a 5-year treatment with a drug, while B is no treatment). A defined endpoint has to be specified (e.g., the appearance of colon cancer in a five-year period). If the probabilities pA and pB of this endpoint under treatments A and B, respectively, are known, then the NNT is computed as 1/(pB – pA).
Relevance
The NNT is an important measure in pharmacoeconomics. If a clinical endpoint is devastating enough (e.g. death, heart attack), drugs with a high NNT may still be indicated in particular situations. If the endpoint is minor, health insurers may decline to reimburse drugs with a high NNT.
Example: statins for primary prevention
For example, the ASCOT-LLA manufacturer-sponsored study addressed the benefit of atorvastatin 10 mg (a cholesterol-lowering drug) in patients with hypertension (high blood pressure) but no previous cardiovascular disease (primary prevention). The trial ran for 3.3 years, and during this period the relative risk of a "primary event" (heart attack) was reduced by 36%. The absolute risk reduction (ARR), however, was much smaller, because the study group did not have a very high rate of cardiovascular events over the study period: 2.67% in the control group, compared to 1.65% in the treatment group.[2] Taking atorvastatin for 3.3 years, therefore, would lead to an ARR of only 1.02% (2.67% minus 1.65%). The number needed to treat to prevent one cardiovascular event would then be 99.7 for 3.3 years.[3] [4]
Worked example
| Abbreviation | Variable | Equation | Value |
| - | subjects in control group | - | 250 |
| - | subjects in experimental group | - | 150 |
| - | events in control group | - | 100 |
| - | events in experimental group | - | 15 |
| CER | control event rate | = events / subjects in control group | 0.4, or 40% |
| EER | experimental event rate | = events / subjects in experimental group | 0.1, or 10% |
| ARR | absolute risk reduction (or increase) | = CER - EER | 0.3, or 30% |
| RRR | relative risk reduction (or increase) | = (CER - EER) / CER | 0.75 |
| NNT | number needed to treat/number needed to harm | = 1 / ARR | 3.33 |
| OR, RR | odds ratio, relative risk (not really identical, but similar -- see articles for details) | = CER / EER | 4 |
The relative risk (odds ratio) is .25 in the example above. It is always 1-relative risk reduction, or vice versa.
See also
- Number needed to harm - the converse for side-effects
References
- ^ Laupacis A, Sackett DL, Roberts RS (1988). "An assessment of clinically useful measures of the consequences of treatment". N. Engl. J. Med. 318 (26): 1728–33. PMID 3374545.
- ^ Sever PS, Dahlöf B, Poulter NR, et al (2003). "Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial--Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial". Lancet 361 (9364): 1149–58. doi:. PMID 12686036.
- ^ "Bandolier - Statin effectiveness: ASCOT update". Retrieved on 2008-03-31.
- ^ "Do Cholesterol Drugs Do Any Good?", Business Week. Retrieved on 2008-03-31. "'That means in a large clinical study, 3% of patients taking a sugar pill or placebo had a heart attack compared to 2% of patients taking Lipitor.' ... The numbers in that sentence mean that for every 100 people in the trial, which lasted 3 1/3 years, three people on placebos and two people on Lipitor had heart attacks.... One fewer heart attack per 100 people. So to spare one person a heart attack, 100 people had to take Lipitor for more than three years. The other 99 got no measurable benefit. Or to put it in terms of a little-known but useful statistic, the number needed to treat (or NNT) for one person to benefit is 100."
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- This page was last modified on 21 September 2008, at 04:25.
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