12.5.2  More about the number needed to treat (NNT)

The number needed to treat (NNT) is defined as the expected number of people who need to receive the experimental rather than the comparator intervention for one additional person to either incur or avoid an event in a given time frame.  Thus, for example, an NNT of 10 can be interpreted as ‘it is expected that one additional (or less) person will incur an event for every 10 participants receiving the experimental intervention rather than control over a given time frame’.  It is important to be clear that:

  1. since the NNT is derived from the risk difference, it is still a comparative measure of effect (experimental versus a certain control) and not a general property of a single intervention; and

  2. the NNT gives an ‘expected value’. For example, NNT = 10 does not imply that one additional event will occur in each and every group of ten people.

 

NNTs can be computed for both beneficial and detrimental events, and for interventions that cause both improvements and deteriorations in outcomes. In all instances NNTs are expressed as positive whole numbers, all decimals being rounded up.  Some authors use the term ‘number needed to harm’ (NNH) when an intervention leads to a deterioration rather than improvement in outcome. However, this phrase is unpleasant, misleading and inaccurate (most notably, it can easily be read to imply the number of people who will experience a harmful outcome if given the intervention), and it is strongly recommended that ‘number needed to harm’ and ‘NNH’ are avoided. The preferred alternative is to use phrases such as ‘number needed to treat for an additional beneficial outcome’ (NNTB) and ‘number needed to treat for an additional harmful outcome’ (NNTH) to indicate direction of effect.

 

As NNTs refer to events, their interpretation needs to be worded carefully when the binary outcome is a dichotomization of a scale-based outcome.  For example, if the outcome is pain measured on a ‘none, mild, moderate or severe’ scale it may have been dichotomized as ‘none or mild’ versus ‘moderate or severe’.  It would be inappropriate for an NNT from these data to be referred to as an ‘NNT for pain’.  It is an ‘NNT for moderate or severe pain’.