Prostate cancer patients' utilities for health states: how it looks depends on where you stand

Patient preferences in chronic immune-mediated inflammatory diseases potentially treated with biological drugs: discrete choice analysis using real-world data analysis

OBJECTIVES

Immune-mediated inflammatory diseases (IMIDs) represent a high burden due to their chronicity, high prevalence, and associated comorbidities. Chronic patients' preferences must be considered in IMIDs treatment and follow-up. The objective of this study was to further understand patient's preferences in private settings.

METHODS

A literature review was performed to choose the most relevant criteria for patients. A D-efficient discrete choice experiment was designed to elicit preferences of adult patients with IMIDs and potential biological treatment prescription. Participants were collected from private practices (rheumatology, dermatology, and gastroenterology) from February to May 2022. Patients chose between option pairs, characterized by six health-care attributes, as well as monthly out-of-pocket drug price. Responses were analyzed through a conditional logit model.

RESULTS

Eighty-seven patients answered the questionnaire. The most frequent pathologies were Rheumatoid Arthritis (31%) and Psoriatic Arthritis (26%). The most relevant criteria were choosing the preferred physician (OR 2.25 [SD0.26]); reducing time until visit with specialist (OR 1.79 [SD0.20]), access through primary care (OR 1.60 [SD0.08]), and an increase in monthly out-of-pocket price from 100€ to 300€ (OR 0.55 [SD0.06]) and to 600€ (OR 0.08 [SD0.02]).

CONCLUSIONS

Chronic IMIDs patients showed a preference toward a faster, personalized service, even with a trade-off in terms of out-of-pocket price.

Norm-based comparison of the quality-of-life impact of ravulizumab and eculizumab in paroxysmal nocturnal hemoglobinuria

Aims

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare and life-threatening intravascular hematologic disorder with significant morbidity and premature mortality. Clinical trials (NCT02946463 and NCT03056040) comparing ravulizumab with eculizumab for PNH have supported the non-inferiority of the former and similar safety and tolerability. This secondary analysis compared PNH trial participants after 26 weeks on either treatment (n = 438) to a general-population sample (GenPop) (n = 15,386) and investigated response-shift effects.

Methods

Multivariate analysis of covariance (MANCOVA) investigated function and symptom scores on the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 of people with PNH as compared to GenPop, after covariate adjustment. Risk-factor groups were created based on clinical indicators known to be associated with worse PNH outcomes, and separate MANCOVAs were computed for lower- and higher-risk-factor groups. Differential item functioning (DIF) analyses examined whether item response varied systematically (1) by treatment, (2) compared to GenPop, and (3) over time, the latter two suggesting and reflecting response-shift effects, respectively. DIF analyses examined 24 items from scales with at least two items. Recalibration response shift was operationalized as uniform DIF over time, reflecting the idea that, for a given group, the difficulty of endorsing an item changes over time, after adjusting for the total subscale score. Reprioritization response shift was operationalized as non-uniform DIF over time, i.e., the relative difficulty of endorsing an item over time changes across the total domain score.

Results

Across PNH risk-factor levels, people who had been on either treatment for 26 weeks reported better-than-expected functioning and lower symptom burden compared to GenPop. Ravulizumab generally showed larger effect sizes. Results were similar for lower and higher PNH risk factors, with slightly stronger effects in the former. DIF analyses revealed no treatment DIF, but did uncover group DIF (9 items with uniform DIF, and 11 with non-uniform) and DIF over time (7 items with uniform DIF, and 3 with non-uniform).

Conclusions

This study revealed that people with PNH on ravulizumab or eculizumab for 26 weeks reported QOL levels better than those of the general population. Significant effects of DIF by group and DIF over time support recalibration and reprioritization response-shift effects. These findings suggest that the treatments enabled adaptive changes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-02016-8.

A Review and Meta-Analysis of Prostate Cancer Utilities

Background. Health-related quality of life is a key issue in prostate cancer (PC) management. The authors summarized published utilities for common health-related quality of life outcomes of PC and determined how methodological factors affect them. Methods. In their systematic review, the authors identified 23 articles in English, providing 173 unique utilities for PC health states, each obtained from 2 to 422 respondents. Data were pooled using linear mixed-effects modeling with utilities clustered within the study, weighted by the number of respondents divided by the variance of each utility. Results. In the base model, the estimated utility of the reference case (scenario of a metastatic PC patient with severe sexual symptoms, rated by non-PC patients using time tradeoff) was 0.76. Disease stage, symptom type and severity, source of utility, and scaling method were associated with utility differences of 0.10 to 0.32 (P < 0.05). Utilities from PC patients rating their own health were 0.14 higher than those from the reference case, but utilities from PC patients rating scenarios were lowest. Time tradeoff yielded the highest utilities. Computer administration yielded lower utilities than personal interview (P = 0.02). Neither the scale's high anchor nor study purpose had significant effects on utilities. Conclusions. This study provides pooled utility estimates for common PC health states and describes how clinical and methodological factors can significantly affect these values. When possible, utility estimates for a modeling application should be derived similarly. Formal data synthesis methods might be useful to researchers integrating utility data from heterogeneous sources. Further exploration of these methods for this purpose is warranted.

Effect of Assessment Method on the Discrepancy between Judgments of Health Disorders People have and do not have: A Web Study

Three experiments on the World Wide Web asked subjects to rate the severity of common health disorders such as acne or arthritis. People who had a disorder (“Haves”) tended to rate it as less severe than people who did not have it (“Not-haves”). Two explanations of this Have versus Not-have discrepancy were rejected. By one account, people change their reference point when they rate a disorder that they have. More precise reference points would, on this account, reduce the discrepancy, but, if anything, the discrepancy was larger. By another account, people who do not have the disorder focus on attributes that are most affected by it, and the discrepancy should decrease when people make ratings on several attributes. Again, if anything, the discrepancy increased when ratings were on separate attributes (combined by a weighted average). The discrepancy varied in size and direction across disorders. Subjects also thought that they would be less affected than others.

Preference Assessment Method Affects Decision-Analytic Recommendations: A Prostate Cancer Treatment Example

Purpose. To evaluate the effect of preference assessment method on treatment recommended by an individualized decision-analytic model for early prostate cancer. Methods. Health state preferences were elicited by time tradeoff, rating scale, and a power transformation of the rating scale from 63 men ages 55 to 75. The authors used these values in a Markov model to determine whether radical prostatectomy or watchful waiting yielded the greater quality-adjusted life expectancy. Results. Time tradeoff and transformed rating scale recommendations differed widely. Time tradeoff and transformed rating scale utilities differed in their treatment recommendation for 21% to 52% of men, and the mean difference in quality-adjusted life years varied from less than 0.5 to greater than 1.0. Conclusions. Treatment recommendations from the prostate cancer decision model were sensitive to the method of preference assessment. If decision analysis is used to counsel individual patients, careful considerationmust be given to the method of preference elicitation.

Method variation in the impact of missing data on response shift detection

PURPOSE

Missing data due to attrition or item non-response can result in biased estimates and loss of power in longitudinal quality-of-life (QOL) research. The impact of missing data on response shift (RS) detection is relatively unknown. This overview article synthesizes the findings of three methods tested in this special section regarding the impact of missing data patterns on RS detection in incomplete longitudinal data.

METHODS

The RS detection methods investigated include: (1) Relative importance analysis to detect reprioritization RS in stroke caregivers; (2) Oort's structural equation modeling (SEM) to detect recalibration, reprioritization, and reconceptualization RS in cancer patients; and (3) Rasch-based item-response theory-based (IRT) models as compared to SEM models to detect recalibration and reprioritization RS in hospitalized chronic disease patients. Each method dealt with missing data differently, either with imputation (1), attrition-based multi-group analysis (2), or probabilistic analysis that is robust to missingness due to the specific objectivity property (3).

RESULTS

Relative importance analyses were sensitive to the type and amount of missing data and imputation method, with multiple imputation showing the largest RS effects. The attrition-based multi-group SEM revealed differential effects of both the changes in health-related QOL and the occurrence of response shift by attrition stratum, and enabled a more complete interpretation of findings. The IRT RS algorithm found evidence of small recalibration and reprioritization effects in General Health, whereas SEM mostly evidenced small recalibration effects. These differences may be due to differences between the two methods in handling of missing data.

CONCLUSIONS

Missing data imputation techniques result in different conclusions about the presence of reprioritization RS using the relative importance method, while the attrition-based SEM approach highlighted different recalibration and reprioritization RS effects by attrition group. The IRT analyses detected more recalibration and reprioritization RS effects than SEM, presumably due to IRT's robustness to missing data. Future research should apply simulation techniques in order to make conclusive statements about the impacts of missing data according to the type and amount of RS.

Fluctuations in appraisal over time in the context of stable versus non-stable health

PURPOSE

This study seeks to estimate clinically significant change in quality of life (QOL) appraisal by comparing changes in appraisal over 6 months of follow-up in people with multiple sclerosis who experienced no change in symptoms versus those with worsening symptoms. This estimation is important for enabling valid interpretation of longitudinal change, both in terms of ensuring the comparison of scores and for response shift estimation.

METHODS

This is a secondary analysis of longitudinal data (N = 859) of participants in the North American Research Committee on Multiple Sclerosis registry. Patient groupings were characterized on the basis of self-reported symptom change over 1 year of follow-up and compared in terms of their responses to the QOL Appraisal Profile. Bonferroni adjustments reduced the type I error rate, and interpretation was restricted to those comparisons with small or larger effect sizes using Cohen's criteria.

RESULTS

The Symptoms Unchanged group evidenced more change in Frame of Reference goal delineation themes and Combinatory Algorithm, whereas the Symptoms Worse group evidenced more change in Sampling of Experience and Standards of Comparison items. The group differences were, however, not large or statistically significant in most cases, likely due to being under-powered to detect interaction effects.

CONCLUSIONS

Many aspects of appraisal are relatively constant in the context of unchanging and changing symptom experience, but symptom changes led patients to make substantial shifts in what experiences they sample when thinking about their health-related QOL. These underlying cognitive processes may help people to maintain homeostasis in their perceived QOL.

Survival gains needed to offset persistent adverse treatment effects in localised prostate cancer

Background:

Men diagnosed with localised prostate cancer (LPC) face difficult choices between treatment options that can cause persistent problems with sexual, urinary and bowel function. Controlled trial evidence about the survival benefits of the full range of treatment alternatives is limited, and patients' views on the survival gains that might justify these problems have not been quantified.

Methods:

A discrete choice experiment (DCE) was administered in a random subsample (n=357, stratified by treatment) of a population-based sample (n=1381) of men, recurrence-free 3 years after diagnosis of LPC, and 65 age-matched controls (without prostate cancer). Survival gains needed to justify persistent problems were estimated by substituting side effect and survival parameters from the DCE into an equation for compensating variation (adapted from welfare economics).

Results:

Median (2.5, 97.5 centiles) survival benefits needed to justify severe erectile dysfunction and severe loss of libido were 4.0 (3.4, 4.6) and 5.0 (4.9, 5.2) months. These problems were common, particularly after androgen deprivation therapy (ADT): 40 and 41% overall (n=1381) and 88 and 78% in the ADT group (n=33). Urinary leakage (most prevalent after radical prostatectomy (n=839, mild 41%, severe 18%)) needed 4.2 (4.1, 4.3) and 27.7 (26.9, 28.5) months survival benefit, respectively. Mild bowel problems (most prevalent (30%) after external beam radiotherapy (n=106)) needed 6.2 (6.1, 6.4) months survival benefit.

Conclusion:

Emerging evidence about survival benefits can be assessed against these patient-based benchmarks. Considerable variation in trade-offs among individuals underlines the need to inform patients of long-term consequences and incorporate patient preferences into treatment decisions.

An economic analysis of outcomes and complications of treating distal radius fractures in the elderly

PURPOSE

There is a lack of scientific data regarding which treatment provides the best outcome for distal radius fractures (DRFs) in the elderly. Currently, casting is used to treat the majority of these fractures, although open reduction and internal fixation (ORIF) has been used increasingly in recent years. Given the recent emphasis on the wise use of medical resources, we conducted a cost-utility analysis to assess which of 4 common DRF treatments (casting, wire fixation, external fixation, or ORIF) optimizes the cost-to-patient preference ratio.

METHODS

We created a decision tree to model the process of choosing a DRF treatment and experiencing a final outcome. Fifty adults aged 65 and older were surveyed in a time trade-off, one-on-one interview to obtain utilities for DRF treatments and possible complications. We gathered Medicare reimbursement rates and calculated the incremental cost-utility ratio for each treatment.

RESULTS

Participants rated DRF treatment relatively high, assigning utility values close to perfect health to all treatments. The ORIF was the most preferred treatment (utility, 0.96), followed by casting (utility, 0.94), wire fixation (utility, 0.94), and external fixation (utility, 0.93). The ORIF was the most expensive treatment (reimbursement, $3,516), whereas casting was the least expensive (reimbursement, $564). The incremental cost-utility ratio for ORIF, when compared to casting, was $15,330 per quality-adjusted life years, which is less than $50,000 per quality-adjusted life year, thereby indicating that, from the societal perspective, ORIF is considered a worthwhile alternative to casting.

CONCLUSIONS

There is a slight preference for the faster return to minimally restricted activity provided by ORIF. Overall, patients show little preference for one DRF treatment over another. Because Medicare patients pay similar out-of-pocket costs regardless of procedure, they are not particularly concerned with procedure costs. Considering the similar long-term outcomes, this study adds to the uncertainty surrounding the choice of DRF treatment in the elderly, further indicating the need for a high-powered, randomized trial.

Response shift in patients with multiple sclerosis: an application of three statistical techniques

OBJECTIVE

With the evolution of theory and methods for detecting recalibration, reprioritization, and reconceptualization response shifts, the time has come to evaluate and compare the current statistical detection techniques. This manuscript presents an overview of a cross-method validation done on the same patient sample.

METHODS

Three statistical techniques were used: Structural Equation Modeling, Latent Trajectory Analysis, and Recursive Partitioning and Regression Tree modeling. The study sample (n = 3,008) was drawn from the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry to represent patients soon after diagnosis, classified as having either a self-reported relapsing, progressive, or stable disease trajectory. Patient-reported outcomes included the disease-specific Performance Scales and the Patient-Derived Disease Steps, and the generic SF-12v2 measure.

RESULTS

Small response shift effect sizes were detected by all of the methods. Recalibration response shift was detected by Structural Equation Modeling, Recursive Partitioning Regression Tree demonstrated patterns consistent with all three types of response shift, and Latent Trajectory Analysis, although unable to distinguish types of response shift, did detect response shift in less than 1% of the sample.

CONCLUSION

The methods and their findings were discussed for operationalization, interpretability, assumptions, ability to use all data points from the study sample, limitations, and strengths. Directions for future research are discussed.

Robotic radical prostatectomy: a critical analysis of surgical quality

PURPOSE OF REVIEW

To review the ways in which the quality of radical prostatectomy and robot-assisted radical prostatectomy have been assessed, including quality-of-life (QoL) assessment, combined outcomes reporting, and patient utilities.

RECENT FINDINGS

Superlative survival expectations following radical prostatectomy have shifted the paradigm of assessing surgical quality toward the prospective evaluation of QoL outcomes and combined outcomes reporting. Several high quality multi-institutional studies have compared QoL outcomes between the common treatment modalities for prostate cancer. Single-institution combined outcomes 'Trifecta' studies provide a convenient presentation of outcomes most important to the surgeon but have many associated limitations. The assessment of patient preferences for treatment outcomes is an underexplored area within the urologic literature and can provide an insight into a patient's perception of surgical quality as seen in a pilot study performed at our institution.

SUMMARY

Advances in the use of validated QoL instruments allow patients and clinicians to select treatment based on the perceived risk of adverse QoL impact but do not provide an insight into what the individual patient considers important. Combined outcomes reports also fail to address key patient concerns. A phenomenologic assessment of robot-assisted radical prostatectomy surgical quality does not exist, but will be necessary to properly evaluate surgical quality.

Going home better not worse: older adults' views on physical function during hospitalization

Functional decline is a common complication for hospitalized older adults. Illuminating the factors that influence the physical function of hospitalized older adults is critical in order to develop effective interventions to prevent avoidable loss of function. Twenty-four older adults in three senior centres located in metropolitan New York City, who had recent experience with hospitalization, participated in focus groups to discover these factors. An exploratory qualitative design was used. Participants defined physical function as the ability to be mobile and resume the enactment of their roles, routines and relationships. Participants also believed that hospitalization should improve physical function. They described staff and system supports of, as well as the challenges to physical function in the hospital setting. The findings provide evidence for developing education programmes as well as new models of nursing care aimed at preventing functional decline.

A prospective cohort study defining utilities using time trade-offs and the Euroqol-5D to assess the impact of cancer-related lymphedema

BACKGROUND

The devastating impact of lymphedema on cancer survivors' quality of life has prompted consideration of several changes in medical and surgical care. Unfortunately, our understanding of the benefits gained from these approaches relative to their cost remains limited. This study was designed to estimate utilities for lymphedema and characterize how utilities differ between subgroups defined by lymphedema etiology and distribution.

METHODS

A consecutive sample of 236 subjects with lymphedema seen at a lymphedema clinic completed both a time trade-off (TTO) exercise and the Euroqol 5D. Responses were adjusted in multivariate regression models for demographic factors, comorbidities, and lymphedema severity/location.

RESULTS

Most participants (167 of 236, 71%) had lymphedema as a consequence of cancer treatment; 123 with breast cancer and upper extremity involvement. Mean TTO utility estimates were consistently higher than Euroqol 5D estimates. Unadjusted TTO (0.85; standard deviation [SD], 0.21) and Euroqol 5D (0.76; SD, 0.18) scores diminished with increasing lymphedema stage and patient body mass index (BMI). Adjusted utility scores were lowest in patients with cancer-related lower extremity lymphedema (TTO=0.82; SD, 0.04 and Euroqol 5D=0.80; SD, 0.03). Breast cancer patients also had lower adjusted Euroqol 5D scores (0.80; SD, 0.02).

CONCLUSIONS

Lymphedema-associated utilities are in the range of 0.80. Lower utilities are observed for patients with higher lymphedema stages, elevated BMI, and cancer-related lymphedema. Greater expenditures for the prevention and treatment of cancer-related lymphedema are warranted.

Role of positron emission tomography in the treatment of occult disease in head-and-neck cancer: a modeling approach

PURPOSE

To determine under what conditions positron emission tomography (PET) imaging will be useful in decisions regarding the use of radiotherapy for the treatment of clinically occult lymph node metastases in head-and-neck cancer.

METHODS AND MATERIALS

A decision model of PET imaging and its downstream effects on radiotherapy outcomes was constructed using an influence diagram. This model included the sensitivity and specificity of PET, as well as the type and stage of the primary tumor. These parameters were varied to determine the optimal strategy for imaging and therapy for different clinical situations. Maximum expected utility was the metric by which different actions were ranked.

RESULTS

For primary tumors with a low probability of lymph node metastases, the sensitivity of PET should be maximized, and 50 Gy should be delivered if PET is positive and 0 Gy if negative. As the probability for lymph node metastases increases, PET imaging becomes unnecessary in some situations, and the optimal dose to the lymph nodes increases. The model needed to include the causes of certain health states to predict current clinical practice.

CONCLUSION

The model demonstrated the ability to reproduce expected outcomes for a range of tumors and provided recommendations for different clinical situations. The differences between the optimal policies and current clinical practice are likely due to a disparity between stated clinical decision processes and actual decision making by clinicians.

Understanding inconsistencies in patient-reported outcomes after spine treatment: response shift phenomena

BACKGROUND CONTEXT

Not uncommonly, spine surgeons and physiatrists note a mismatch between patient-reported outcome measures, where one measure might indicate a good outcome and another indicates an inferior outcome after spine treatment. This may be the result of patient characteristics that lead to changes in internal standards, values, and conceptualization of their own health-related quality of life. This can result in a "moving goal post" when a self-report outcome measure is used for prepost comparisons. These "response shifts" may obfuscate relevant changes of interest to clinicians and are meaningful and worthy of study in and of themselves.

PURPOSE

To provide a background on response shift with an emphasis on distinctions relevant to spinal interventions, both surgical and nonsurgical. To describe current methods for detecting and investigating response shift phenomena, and to propose specific hypotheses that can be tested in collaborative research.

METHODS AND RESULTS

Two types of methods will be briefly described: methods that require new data collection; and methods that use recent statistical and technical advances to implement secondary analysis of existing data. Two specific testable hypotheses for spinal disorders are suggested along with suggested methods for testing these hypotheses.

CONCLUSIONS

A response shift will cause the patient to use the same functional outcome report measure differently pre- and posttreatment. Response shift phenomena are likely to affect the measurement properties of standard spine outcome measures and to obfuscate differences between treatments in clinical trials and cost-effectiveness studies. They point to a need for developing strategies in clinical practice to manage response shifts so that they enhance patient well-being.

The influence of subjective life expectancy on health state valuations using a 10 year TTO

AIM

To investigate if subjective life expectancy (SLE) impacts the willingness to trade-off (WTT) and the number of years traded-off in a 10-years time trade-off (TTO) exercise to obtain health state valuations.

METHODS

An Internet-based questionnaire was administered in a sample representative for the Dutch general public. Next to basic demographic characteristics and SLE, respondents were asked to perform three TTO exercises. The following EQ-5D health states were included 21211 (TTO1), 22221 (TTO2) and 33312 (TTO3). The WTT was studied using a probit regression model. The number of years traded-off was investigated using a generalized negative binomial regression model. The independent variables used in both models were age, gender, quality of life, education, the difference between age and expected age of death (SLE), and a variable indicating whether the SLE was less than 10 years (SLE<10).

RESULTS

Three hundred and thirty nine respondents completed the questionnaire. The mean utility scores were 0.96 (TTO1), 0.94 (TTO2) and 0.79 (TTO3). The probit model showed that SLE was the only variable with a significant influence on WTT. The gnbreg showed that the number of years traded-off was also significantly influenced by SLE. In addition, age and education significantly influenced the number of years traded-off.

CONCLUSION

The WTT years and the number of years traded-off were both influenced by SLE in 10-years TTO exercises. Reducing remaining life expectancy to 10 years in a TTO may thus increase loss aversion and, especially in respondents losing relatively many expected life years, diminish WTT and the amount of time traded off.

Health state utilities: a framework for studying the gap between the imagined and the real

OBJECTIVES

Health state utilities play an important role in decision analysis and cost-utility analysis. The question whose utilities to use at various levels of health-care decision-making has been subject of considerable debate. The observation that patients often value their own health, but also other health states, higher than members of the general public raises the question what underlies such differences? Is it an artifact of the valuation methods? Is it adaptation versus poor anticipated adaptation? This article describes a framework for the understanding and study of potential mechanisms that play a role in health state valuation. It aims at connecting research from within different fields so that cross-fertilization of ideas may occur.

METHODS

The framework is based on stimulus response models from social judgment theory. For each phase, from stimulus, through information interpretation and integration, to judgment, and, finally, to response, we provide evidence of factors and processes that may lead to different utilities in patients and healthy subjects.

RESULTS

Examples of factors and processes described are the lack of scope of scenarios in the stimulus phase, and appraisal processes and framing effects in the information interpretation phase. Factors that play a role in the judgment phase are, for example, heuristics and biases, adaptation, and comparison processes. Some mechanisms related to the response phase are end aversion bias, probability distortion, and noncompensatory decision-making.

CONCLUSIONS

The framework serves to explain many of the differences in valuations between respondent groups. We discuss some of the findings as they relate to the field of response shift research. We propose issues for discussion in the field, and suggestions for improvement of the process of utility assessment.

Why people refuse to make tradeoffs in person tradeoff elicitations: a matter of perspective?

OBJECTIVE

Person tradeoff (PTO) elicitations assess people's values for health states by asking them to compare the value of treatment programs. For example, people might be asked how many patients need to be cured of health condition X to equal the benefit of curing 100 people of condition Y. However, when faced with PTO elicitations, people frequently refuse to make quantifiable tradeoffs, exhibiting 2 kinds of refusals: 1) They say that 2 treatment programs have equal value, that curing 100 of X is just as good as curing 100 of Y, even if X is a less serious condition than Y, or 2) they say that the 2 programs are incomparable, that millions of people need to be cured of X to be as good as curing 100 of Y. The authors explore whether people would be more willing to make tradeoffs if the focus was changed from trading off groups of patients to choosing the best decision or evaluating treatment benefits.

DESIGN

. Two randomized trials used diverse samples (N=2400) via the Internet to test for the effect of perspective on refusal rates. The authors predicted that perspectives that removed people from decision-making roles would increase their willingness make tradeoffs.

RESULTS

Contrary to expectations, refusal rates increased when people were removed from decision-making roles. In fact, the more pressure put on people to make a decision, the less likely they were to refuse to make tradeoffs.

CONCLUSION

To reduce PTO refusals, it is best to adopt a decision-maker perspective.

Side-effects of treatment for localized prostate cancer: are they valued differently by patients and healthy controls?

OBJECTIVES

To determine how men treated for localized prostate cancer and who had permanent side-effects, and healthy controls, would value five descriptions of health states associated with side-effects of treatment for localized prostate cancer, hypothesising that patients would value the health states as less detrimental than men with no prostate cancer.

PATIENTS, SUBJECTS AND METHODS

In previous research, patients with prostate cancer reported high generic quality-of-life scores after primary treatment, despite side-effects; it was suggested that these patients accepted the side-effects, i.e. urinary, bowel and sexual dysfunction, as 'part of the bargain' because they felt they were saved from a life-threatening disease. Thus, we asked 54 men who had been treated for localized prostate cancer and had permanent side-effects, and 53 healthy controls, to value five descriptions of health states. All respondents valued all descriptions using two valuation methods, a visual analogue scale (VAS, range 0-100) and time trade-off (TTO, range 0-1). The respondent functioning was assessed using the EuroQol-5D, completed with items on urinary, bowel and sexual function.

RESULTS

Patients and healthy controls had similar valuations for nine of the 10 comparisons (five health states by two methods). Valuations in both groups resulted in the same ranking order of states on the TTO and one exchange in rank order on the VAS.

CONCLUSIONS

When asked to value five health states associated with side-effects of treatment for localized prostate cancer, there was no difference in the valuation of erectile, urinary and bowel dysfunction between patients with permanent side-effects after treatment and healthy controls. More likely explanations for the high generic quality-of-life scores after primary treatment for prostate cancer are a response shift and insensitivity of generic health-related quality-of-life measures.

Being there is important, but getting there matters too: the role of path in the valuation process

PURPOSE

Traditional decision-analytic models presume that utilities are invariant to context. The influence of 2 types of context on patients' utility assessments was examined here the path by which one reaches a health state and personal experience with a health state.

METHODS

Three groups of patients were interviewed: men older than age 49 years with prostate cancer but no diabetes (CaP), diabetes but no prostate cancer (DM), and neither disease (ND). The utility of erectile dysfunction (ED) was assessed using a standard gamble (SG). Each subject completed 2 SGs: 1) a no-context version that gave no explanation for the cause of ED and 2) a contextualized version in which prostate cancer treatment, the failure to manage diabetes, or the natural course of aging was said to be the cause.

RESULTS

Patients with disease assigned higher utilities to ED in a matching context than in discrepant contexts. Regression models found that the valuation process was also sensitive to the match between disease path in the utility assessment and patients' personal experiences.

CONCLUSIONS

These findings lend insight into why acontextual utility assessments typically used in decision analyses have not been able to predict patient behavior as well as expected. The valuation process appears to change systematically when context is specified, suggesting that unspecified contexts rather than random error may lead to fluctuations in the values assigned to identical health states.

Primer: using decision analysis to improve clinical decision making in urology

Many clinical decisions in urology involve uncertainty about the course of disease or the effectiveness of treatment. Many decisions also involve trade-offs; for example, an improvement in patient survival at the cost of an increased risk of treatment-related adverse effects. Decision analysis is a formal, quantitative method for systematically comparing the benefits and harms of alternative clinical strategies under circumstances of uncertainty. The basic steps in performing a decision analysis are to define the clinical scenario or problem, identify the clinical strategies to be considered in the decision, enumerate all of the important sequelae of each strategy and their associated probabilities, define the outcome of interest, and assign a value to each possible outcome. Health outcomes can be defined in a number of ways, including quality-adjusted survival. A key aspect of decision analysis is allowing the values of particular health outcomes to vary from patient to patient, depending on individual preferences. Decision analysis has already been used to assess a variety of prevention, screening and treatment decisions in urology, and there is much potential for its future application. Greater incorporation of decision-analytic techniques into urology research and clinical practice might improve decision making, and thereby improve patient outcomes.

Age-related macular degeneration: economic burden and value-based medicine analysis

It can be estimated that 17,100 new cases of neovascular (wet) AMD and 180,000 new cases of geographic-atrophy (dry) AMD occur in Canada annually. In addition to having a devastating effect on patients' lives, the condition causes significant adverse consequences for the economy. The deleterious effect of AMD on quality of life is markedly underestimated by ophthalmologists who treat patients with AMD, by non-ophthalmic physicians and by the public. In fact, patients with different degrees of severity of AMD have a perceived impairment of their quality of life that is 96% to 750% greater than the impairment estimated by treating ophthalmologists. Mild AMD causes a 17% decrease in the quality of life of the average patient, a decrease similar to that encountered with symptomatic human immunodeficiency virus infection or moderate cardiac angina. Moderate AMD produces a 40% decrease in quality of life, a decrease similar to that associated with permanent renal dialysis or severe cardiac angina. Very severe AMD causes a 63% decrement in quality of life, a decrease similar to that encountered with advanced prostatic cancer with uncontrollable pain or a severe stroke that leaves a person bedridden, incontinent and requiring constant nursing care. The adverse economic consequences of AMD include an annual $2.6 billion negative impact on Canada's gross domestic product. The return on investment is high for both current AMD therapies and research into new treatment modalities.

Estimating the risk of long-term erectile, urinary and bowel symptoms resulting from prostate cancer treatment

Reports on long-term complications resulting from treatment for localized prostate cancer are very inconsistent. In order to estimate the risks of long-term erectile dysfunction, urine symptoms and bowel symptoms following prostatectomy (RP), external conventional or conformal beam radiation (ERT or CRT) and brachytherapy (BRT), 98 papers from the PubMed and Cochrane Clinical Trial databases were selected, reviewed and critically evaluated. The majority of papers were institution-based retrospective and prospective follow-up studies; only two of these studies measured the risk of developing more than one treatment complication. Due to differences in study designs and populations, it is difficult to directly compare studies and not meaningful to calculate summary estimates. In addition to focusing on randomized clinical trials and well-designed population based studies, future research should adopt standardized methodologies and should measure the risk of developing more than one treatment complication.

Trading people versus trading time: what is the difference?

Background

Person trade-off (PTO) elicitations yield different values than standard utility measures, such as time trade-off (TTO) elicitations. Some people believe this difference arises because the PTO captures the importance of distributive principles other than maximizing treatment benefits. We conducted a qualitative study to determine whether people mention considerations related to distributive principles other than QALY-maximization more often in PTO elicitations than in TTO elicitations and whether this could account for the empirical differences.

Methods

64 members of the general public were randomized to one of three different face-to-face interviews, thinking aloud as they responded to TTO and PTO elicitations. Participants responded to a TTO followed by a PTO elicitation within contexts that compared either: 1) two life-saving treatments; 2) two cure treatments; or 3) a life-saving treatment versus a cure treatment.

Results

When people were asked to choose between life-saving treatments, non-maximizing principles were more common with the PTO than the TTO task. Only 5% of participants considered non-maximizing principles as they responded to the TTO elicitation compared to 68% of participants who did so when responding to the PTO elicitation. Non-maximizing principles that emerged included importance of equality of life and a desire to avoid discrimination. However, these principles were less common in the other two contexts. Regardless of context, though, participants were significantly more likely to respond from a societal perspective with the PTO compared to the TTO elicitation.

Conclusion

When lives are at stake, within the context of a PTO elicitation, people are more likely to consider non-maximizing principles, including the importance of equal access to a life-saving treatment, avoiding prejudice or discrimination, and in rare cases giving treatment priority based purely on the position of being worse-off.

Patient Preferences in Prostate Cancer: A Clinician's Guide to Understanding Health Utilities

Prostate cancer treatments have positive and negative outcomes that must be taken into account when deciding how to proceed with a patient's care. One way to quickly determine a patient's preferences in this situation is to ascertain their health utilities for various health states. Health utilities are underutilized but powerful tools in aiding shared decision making between patients and physicians. This review is intended to inform physicians about the different techniques available, help the physician choose among them, and aid initial development of utilities for use in the clinic by way of the tables' references. A brief history, summary of applications and current directions of health utilities, and collection of references are provided to increase the reader's overall knowledge of health utilities and encourage their use in the clinic. Ultimately, the use and choice of one of these direct preference-based measures depends on the needs of the physician.

Measuring utilities by the time trade-off method in Tunisian rheumatoid arthritis patients

The objective of this study was to determine the feasibility, reliability and validity of the time trade-off (TTO) in Tunisian rheumatoid arthritis (RA) patients. The TTO was used to measure the utility in 122 RA patients with increasing difficulty in performing activities of daily living. The 1-week test-retest reproducibility was studied in 57 patients using the intraclass correlation coefficient (ICC). Validity was evaluated by comparison with other outcome measures: utility rating scale (RS), quality of life (QOL) [arthritis impact measurement scale 2 (AIMS2), rheumatoid arthritis quality of life (RAQOL)], functional status [health assessment questionnaire (HAQ), Lee index] and disease activity score (DAS). Eight patients (6.6%) did not complete the TTO. The median value of the TTO score was 0.655 (0.019-1.000). The ICC for reliability of the TTO was 0.89 (p<0.001). The TTO showed poor to moderate correlation (Spearman's correlation coefficients between 0.2 and 0.409, p<0.01) with AIMS2, RAQOL, HAQ and Lee index. We did not find any correlation between TTO and DAS. Multiple regression analysis showed that only 32% of TTO scores could be explained. The TTO method appeared to be reliable in a group of Tunisian RA patients, but TTO values were poorly to moderately related to measures of QOL, functional ability, and disease activity. We think that TTO and RS are not feasible for use in RA patients.

Patients' values and clinical substituted judgments: The case of localized prostate cancer

The authors examined agreement between patients' utilities and importance rankings and clinicians' judgments of these assessments using a multiattribute model representing 6 aspects of health states potentially associated with localized prostate cancer. Patients were interviewed individually shortly after diagnosis and at a follow-up visit to obtain time-tradeoff utilities for 4 health states, including current health, and importance ranks of the 6 attributes. Their clinicians independently provided views of what utilities and importance ranks would be in the patient's best interest. Using patient-clinician pairs as the unit of analysis, the authors discovered that only about 50% of the correlations across 4 health states were high enough (.80) to be acceptable for clinical use for substituted judgment. Their conclusion: Clinicians should recognize that their judgments of the utility of health states associated with localized prostate cancer may not correspond closely with those of the patient.

Assessment of health state utilities and quality of life in patients with malignant esophageal Dysphagia

OBJECTIVES

Palliation of terminal conditions such as malignant dysphagia must take into account individual preferences for aggressive or nonaggressive care, with a focus on quality of life. Despite this, there are very few data on patients' preferences for palliative therapy. This study is designed to quantitatively determine individual preferences for palliation of malignant dysphagia using health state utilities (HSU).

METHODS

HSU were measured using three methods: time trade-off (TTO), visual analog scale (VAS), and the EQ-5D. Patients with esophageal cancer were asked to rate their own state of health and of three standardized scenarios of local, regional, and metastatic disease.

RESULTS

Fifty patients with esophageal cancer were enrolled. Using the TTO method, the utilities of their own health state were 0.80 (95% CI 0.59-0.99) for localized, 0.54 (0.37-0.70) for regional, and 0.52 (0.32-0.71) for metastatic cancer showing no significant difference in mean utility scores for the three staging groups. VAS and EQ5D gave statistically similar values to TTO. Patients consistently rated their own utility better than the utility of standardized scenarios with similar stage and prognosis. Independent of their staging, patients with high dysphagia scores rated their utility worse than patients with low dysphagia scores.

CONCLUSIONS

These results confirm the perceived poor state of health of patients with esophageal cancer and are substantially lower than previous estimates in operated patients. Cost-effectiveness models must take into account significant differences between patients' assessment of their own state of health, and that of a "societal" perspective of others with a similar disease. All three methods provided similar estimates. Given the ease of use of VAS and EQ-5D, these methods may be preferable to TTO.

Ethnic variation in localized prostate cancer: a pilot study of preferences, optimism, and quality of life among black and white veterans

Ethnic variations that may influence the preferences and outcomes associated with prostate cancer treatment are not well delineated. Our objective was to evaluate prospectively preferences, optimism, involvement in care, and quality of life (QOL) in black and white veterans newly diagnosed with localized prostate cancer. A total of 95 men who identified themselves as black/African-American or white who had newly diagnosed, localized prostate cancer completed a "time trade-off" task to assess utilities for current health and mild, moderate, and severe functional impairment; importance rankings for attributes associated with prostate cancer (eg, urinary function); and baseline and follow-up measures of optimism, involvement in care, and QOL. Interviews were scheduled before treatment, and at 3 and 12 months after treatment. At baseline, both blacks and whites ranked pain, bowel, and bladder function as their most important concerns. Optimism, involvement in care, and QOL were similar. Utilities for mild impairment were lower for blacks than whites, but were similar for moderate and severe problems. Decline in QOL at 3 and 12 months compared to baseline occurred for both groups. However, even with adjustment for marital status, education level, and treatment, blacks had less increase in nausea and vomiting and more increase in difficulty with sexual interest and weight gain compared with whites. Black and white veterans entered localized prostate cancer treatment with similar priorities, optimism, and involvement in care. Quality-of-life declines were common to both groups during the first year after diagnosis, but ethnic variation occurred with respect to nausea and vomiting, sexual interest, and weight gain.

Agreement between prostate cancer patients and their clinicians about utilities and attribute importance

PURPOSE

To examine the agreement between prostate cancer patients' utilities for selected health states and their rankings of the importance of six attributes of the health states and the clinicians' judgements of what would be in the patients' best interests.

METHOD

Patients with newly diagnosed localized prostate cancer individually completed a time trade-off utility assessment shortly after being diagnosed. The health states evaluated were constructed from a multi-attribute utility model that incorporated six aspects of living with the disease and outcomes of treatment. Each patient assessed his current health state and three hypothetical states that might occur in the future, and provided rankings of the importance of the six attributes. The clinicians caring for each patient independently provided their views of what utilities and importance rankings would be in the patient's best interest.

RESULTS

The across-participant correlations between patients' and clinicians' utilities were very low and not statistically significant. Across-participant correlations between patient and clinician importance rankings for the six attributes were also low. Across-health state and across-attribute correlations between utilities or importance rankings were highly variable across patient-clinician pairs.

CONCLUSION

In the clinical settings studied, there is not a strong relationship between valuations of current and possible future health states by patients with newly diagnosed prostate cancer and their clinicians. Implications of these results for substituted judgement, when clinicians advise their patients or recommend a treatment strategy, are discussed.

Predictors of preferences and utilities in men treated with 3D-CRT for prostate cancer

PURPOSE

To assess the preferences and utilities for prostate cancer health state scenarios of men treated with three-dimensional conformal radiotherapy and the predictors of treatment preferences.

METHODS AND MATERIALS

The preferences and utilities for probabilistic health states of impotence and incontinence associated with prostate cancer therapies were elicited from prostate cancer registry participants using a modified time trade-off interview. Sociodemographic, disease, and treatment characteristics, as well as quality-of-life scores, were assessed to determine the predictors of preferences.

RESULTS

Fifty-seven men treated with three-dimensional conformal radiotherapy completed the time trade-off interview. Of these men, 83% had Stage T1-T2 and 30% were receiving hormonal therapy. The utilities followed a linear trend with declining scores for increasing risk of poorer health states. Men showed an increased preference for health states associated with radiotherapy compared with surgery or hormonal therapy. Univariate predictors of preference included income and marital status. Multivariate predictors of preferences included more aggressive therapy and better prognostic indicators. Current quality-of-life scores in terms of global, sexual, or urinary function were poor predictors of preferences.

CONCLUSION

Preference elicitation can assist in decision-making, and understanding the predictors of patient preferences can assist in identifying factors that may increase patient perceptions of poorer outcomes.

A randomized study comparing epirubicin in a 4-weekly versus a weekly intravenous regimen in patients with metastatic, hormone resistant, prostatic carcinoma: effects on health related quality of life

The treatment of hormone resistant prostate cancer) with epirubicin 25 mg/m(2)(Epi25) on a weekly intravenous regimen may be better in terms of health related quality of life (HRQOL) than with 100 mg/m(2)(Epi100) on a 4-weekly regimen. A total of 79 patients who filled out the EORTC-QLQ-C30 questionnaire for the assessment of HRQOL could be evaluated. Compared with the baseline, no changes in HRQOL function scales or significant changes in the following HRQOL symptom scales were found. The Epi25 group reported less pain during the first 3 months and the Epi100 group more dyspnoea after 4 weeks and less pain and less insomnia but more loss of appetite after 8 weeks. In both groups, toxicity was comparable, except for World Health Organisation grade II-III alopecia occurring in 82% in the Epi100 versus 31% in the Epi25 group. There were no significant differences between groups in response rates and survival. In this study, HRQOL was not improved which is in line with other studies using only epirubicine. Epirubicin as single agent therapy should not be used in future treatment of patients with HRPC.

The impact of androgen deprivation therapy on health related quality of life in asymptomatic men with lymph node positive prostate cancer

PURPOSE

To evaluate the impact of androgen deprivation on health related quality of life (HRQOL) in patients with asymptomatic lymph node positive prostatic carcinoma (LPPC).

MATERIALS AND METHODS

HRQOL domains were measured, using standard instruments in 91 patients with histologically proven LPPC. Most patients were randomized for immediate or deferred hormonal treatment until progression was observed. For analyses concerning the time to progression and survival the Kaplan-Meier method was used.

RESULTS

Patients treated with androgen deprivation showed a significantly worse sexual, emotional, and physical function, experienced more hot flushes and a worse overall HRQOL, compared with patients receiving no therapy. Time to progression was significantly shorter in the deferred treated patients in comparison with the immediately treated patients (33 vs. 62 months, p<0.001). No significant differences were found with respect to the duration of survival.

CONCLUSION

Hormonally treated patients with asymptomatic LPPC have a worse HRQOL compared with patients receiving no therapy. The duration of survival was similar, whether patients received immediate or deferred hormonal treatment. Nowadays, with patients' preferences playing an increasingly important role in therapeutic decision making, physicians should be aware of this negative impact and ought to inform the patients on this.

Natural history of change in physical function among long-stay nursing home residents

BACKGROUND

Few longitudinal studies exist to guide clinicians or administrators on what functional outcomes can be expected among nursing home residents with different levels of cognitive impairment. Extrapolating from cross-sectional studies or from longitudinal studies of community-dwelling residents may provide misleading estimates of prognosis, hindering efforts to target preventive care.

OBJECTIVE

To describe patterns of change in physical function on a quarterly basis over 1 year among long-stay nursing home residents grouped according to their level of cognitive impairment on admission.

METHOD

Retrospective analysis of activities of daily living dependence ratings were based on quarterly MDS+ assessments from 76,016 long-stay residents admitted to nursing homes during calendar years 1993 through 1996 in five states participating in the National Case Mix and Quality and Demonstration Project. Residents were stratified by level of cognitive impairment on admission using a 7-level Cognitive Performance Scale. The activities of daily living dependence was measured by a 20 point scale. Mean activities of daily living scores on admission to the hospital and at four quarterly intervals following admission were compared across cognitive impairment levels and by state of residence.

RESULTS

A change in activities of daily living dependence over 1 year in most groups averaged 1 point or less. Three patterns of activities of daily living dependence were identified consistently across five states. Those with mild cognitive impairment on admission showed an initial reduction in dependence followed by slow increase; those with moderately severe impairment showed slow linear increased dependence; and those with severe cognitive impairment showed an initial improvement in dependence, followed by stability.

CONCLUSION

More complex statistical models that take into account comorbid conditions at baseline, in addition to cognitive performance, might identify subgroups of nursing home residents who are at risk for rapid decline. Ways to better characterize declines in function are needed, otherwise relatively large samples will be required for intervention trials.

Toward improved methods for measurement of utility: automated repair of errors in elicitations

This study examines the effects of use of an automated computer protocol to correct a common error in utility elicitations--namely, scoring of a health state with a greater impairment as being more desirable than one with lesser impairment. The authors studied the protocol in a sample of 563 members of the Internet-using public. Results revealed that errors were common (17% of ratings) but were typically successfully repaired (individuals who made only 1 or 2 errors had a 75% chance of repairing them). The values of individuals who repaired errors were similar to those without apparent error. In contrast, individuals who refused to repair errors had lower scores for the best health state in the series and higher ones for the worst health state. Results suggest that the repair procedures were successful and that inclusion of utility scores from individuals who fail to repair illogically ordered ratings may bias estimates of mean utilities.

A review of measurement of patient preferences for treatment outcomes after prostate cancer

The diagnosis of early-stage prostate cancer cases creates dilemmas for many men diagnosed with the disease each year. Treatment interventions are all associated with significant treatment morbidity, including impotence and incontinence. The basic concept behind patient preferences, or utilities, is to ask patients to make judgments about the value of particular health outcomes. Several preference-based instruments are available, including the visual analog rating scale, the time trade-off utility assessment, and the standard gamble. These assessments result in scores or weights assigned to different health states. From the perspective of the patient with prostate cancer, the treatment that produces optimal outcomes will depend on the relative importance of several domains, which may include pain, urinary functioning, sexual functioning, and general physical health. Patients with similar diagnoses and overlapping clinical characteristics may have markedly different preferences for treatment outcomes.

Pilot Study of a Utilities-Based Treatment Decision Intervention for Prostate Cancer Patients

This pilot study evaluates a shared decision-making approach to individual decision making in localized prostate cancer care. The approach is based on a decision analytic model that incorporates patient utilities, ie, patient preferences among possible health states that might occur with prostate cancer treatments. Data on comorbidities, histologic grade of the biopsy, and age were obtained for 13 patients with newly diagnosed localized prostate cancer who received care in a Veterans Administration medical center. Using a standard gamble technique, interviewers obtained patient utilities for 5 distinct health states related to prostate cancer treatment. Utilities and patient clinical and pathologic characteristics were incorporated into the decision analytic model, and the derived quality-adjusted life expectancies were shared with the treating urologist before the first patient-physician discussion about treatment options. The results of the pilot study raised 2 major concerns. First, 4 patients had utility scores of 1.0 for all of the possible health states, and 7 patients had inconsistent utilities in which they rated both impotence and incontinence as a better health state than having just one of these problems. Second, the model recommended radiation therapy to individuals with a broad range of clinical characteristics, pathologic findings, and utility scores. Many of the patients who were recommended radiation therapy by the model received discordant recommendations from the treating urologist. Future refinements of both the utility assessment exercise and decision analytic model may be needed before the feasibility of the model in the clinical setting can be determined.

Prostate cancer and health-related quality of life: a review of the literature

With the established effectiveness of diverse treatments for prostate cancer, identification of the physical and psychosocial consequences of the disease and various treatments becomes critical. We review the literature on the effects of prostate cancer and its treatment on health-related quality of life (HRQoL). Studies show that prostate cancer and its treatment affect both disease-specific HRQoL (i.e. urinary, sexual, and bowel function) as well as general HRQoL (i.e. energy/vitality, performance in physical and social roles). Yet, these effects appear to differ across stage of disease and type of treatment. We outline evidence from three sources: (1) studies that compare men with the disease with an age-matched sample of men without the disease, (2) studies that assess men with the disease across time, and (3) cross-sectional studies that highlight predictors of HRQoL. Future research directions are discussed.

A comparison of three measures

We investigated the correlation between descriptive and valuational measures of health-related quality of life (HRQL) and assessed determinants affecting these measures. Our suspicion was that there is little similarity in the content of descriptive and valuational measures of HRQL. We thus conducted a cross-sectional observational study of 56 hemodialysis patients. All underwent structured interviews. Dependent variables were patients utilities [time trade-off (TTO)], global rating of HRQL and generic HRQL (SF-36). Independent variables were socioeconomic details, disease severity, comorbidity, symptoms, depression, social support, and laboratory data. The correlation between TTO and global HRQL was -0.33 (P = .0178) and between TTO and the SF-36 physical and mental summary scores -0.16 (P = .2383) and -0.20 (P = .1443), respectively. The regression models for the SF-36 physical and mental summary scores explained 75% and 64% of the variance, and for global HRQL 29% of the variance. The independent variables had no effect on the TTO. This confirmed our suspicion that a qualitative difference exists between TTO and descriptive quality of life tools. The TTO content could not be explained by the variables that entail the content of HRQL instruments.

Clinical conduct and nursing quality of life in prostate cancer

Recent advances in cancer therapy and supportive care have increased patient survival and improved quality of life. These advances have led to an increase in the responsibilities of nurses caring for these patients. Knowledge of new drugs, mode of action, expected side effects, and benefits, including effects on QOL, are essential. Nurses are vital to the safety and the quality of life that patients may experience while participating in clinical trials.

Preference for fractures and other glucocorticoid-associated adverse effects among rheumatoid arthritis patients

OBJECTIVE

The objective of this study was to determine rheumatoid arthritis (RA) patients' preferences for validated health state scenarios depicting glucocorticoid adverse events, predictors of these preferences, and psychometric properties of different preference techniques in this population.

METHODS

Preferences were elicited by rating scale and time trade-off methods. Time trade-offs included trading current health for either time spent alive in an adverse health state for chronic conditions (time trade-off) or time spent in a sleeplike state for acute conditions (sleep trade-off).

RESULTS

A total of 107 subjects with long-standing RA participated in the preference interviews. Mean preference values (rating scale/trade-off) were lowest for serious fracture adverse events, including hip fracture requiring a nursing home stay (0.55+/-0.22/0.76+/-0.36) and vertebral fracture with chronic pain (0.59+/-0.23/0.67+/-0.35), and highest for cataracts (0.84 + 0.17/0.96 0.09) and wrist fracture (0.82+/-0.18/0.81+/-0.29). Rating scales had a stronger correlation (r= 0.88) with physician ranking of scenarios than trade-off methods (r = 0.31). All methods were feasible and demonstrated good reliability, while rating scale method showed better construct validity than trade-off techniques.

CONCLUSION

Relative to their current health, RA patients assigned low preference values to many glucocorticoid adverse events, particularly those associated with chronic fracture outcomes. Results varied with the preference measure used, indicating that methodological attributes of preference determinations must be considered in clinical decision making.

Living with treatment decisions: regrets and quality of life among men treated for metastatic prostate cancer

PURPOSE

To examine variation in men's long-term regret of treatment decisions, ie, surgical versus chemical castration, for metastatic prostate cancer and its associations with quality of life.

METHODS

Survey of previously treated patients to assess treatment decisions and quality of life, supplemented with focus groups. Two items addressing whether a patient wished he could change his mind and the belief that he would have been better off with the treatment not chosen were combined in classifying survey respondents as either satisfied or regretful. Chi(2) and t tests were used to test associations between regret and treatment history, complications, and quality of life.

RESULTS

Survey respondents included 201 men aged 45 to 93 years (median, 71 years), who had begun treatment (71% chemical castration, 29% orchiectomy) a median of 2 years previously. Most reported complications: hot flashes (70%), nausea (34%), and erectile dysfunction (81%). Most were satisfied with the treatment decision, but 23% expressed regret. Regretful men more frequently reported surgical (43%) versus chemical (36%) castration (P: = .030) and nausea in the past week (54% v 32%; P: = .010) but less frequently reported erectile dysfunction (56% v 72%; P: = .048). Regretful men indicated poorer scores on every measure of generic and prostate cancer-related quality of life. Qualitative analyses revealed substantial uncertainty about the progress of their disease and the quality of the decisions in which patients participated.

CONCLUSION

Regret was substantial and associated with treatment choice and quality of life. It may derive from underlying psychosocial distress and problematic communication with physicians when decisions are being reached and over subsequent years.

Value of the time trade off method for measuring utilities in patients with rheumatoid arthritis

OBJECTIVE

To assess the feasibility, reliability, and validity of the time trade off (TTO) in patients with rheumatoid arthritis (RA).

METHODS

The TTO was applied in 194 patients with RA with increasing difficulty in performing activities of daily living. The test-retest reliability was determined in 35 of these patients and was calculated by the intraclass correlation coefficient (ICC). Construct validity was evaluated with the following sets of variables: measures of utility (rating scale), quality of life (RAND 36 item Health Status Survey (RAND-36) and RAQoL), functional status (Health Assessment Questionnaire, grip strength, and walk test), and disease activity (doctor's global assessment, disease activity score, pain, and morning stiffness).

RESULTS

Ten patients (5%) did not complete the TTO. The median value of the TTO was 0.77 (range 0.03-1. 0). The test-retest ICC of the TTO was 0.85 (p<0.001). Construct validity testing of the TTO showed poor to moderate correlations (Spearman's r(s) between 0.19 and 0.36, p<0.01) with all outcome measures except for the subscale role limitation (physical problem) of the RAND-36, the walk test, the doctor's global assessment of disease activity, and morning stiffness. Multiple regression analysis showed that only 17% of the variance of the TTO scores could be explained.

CONCLUSIONS

The TTO method appeared to be feasible and reliable in patients with RA. The poor to moderate correlations of the TTO with measures of quality of life, functional ability, and disease activity suggest that the TTO considers additional attributes of health status. This may have implications for the application of the TTO in clinical trials in patients with RA.

Validity and interpretation of preference-based measures of health-related quality of life

Utilities are numeric measurements that reflect an individual's beliefs about the desirableness of a health condition, willingness to take risks to gain health benefits, and preferences for time. This report discusses the approaches to assess and compare the validity of methods used to assign utilities for cost-utility analysis. Threats to validity include construct underrepresentation and construct-irrelevant variance. Construct underrepresentation occurs when a stimulus presented to a judge fails to fully represent the depth and complexity of information required in actual judgments. Construct-irrelevant variation occurs when factors irrelevant to preferences influence measurements of utilities. Among several factors that cause construct-irrelevant variation are cognitive abilities, numeracy skills, emotions and prejudices, and the elicitation procedure. Commonly used elicitation methods (visual-analog scales, time tradeoff, and standard gamble) capture different facets of utilities (desirableness of states, time preferences, and risk attitude) to different degrees. The validity of an elicitation protocol depends (1) on the degree to which its scaling method captures the relevant facets of utility and (2) on the degree to which measurements are influenced by construct-irrelevant variation. Discrete-state health index models provide an alternative to direct elicitation of utilities and work by attaching fixed preference weights to observable health states. The creation of discrete-state models with current technologies requires the adoption of strong assumptions about the scaling properties of utilities. Future research must refine methods of eliciting utilities and identify sources of construct-irrelevant variability that reduce the validity of utility assessments. Because of the impact of variation in techniques on measurements, we do not recommend the combination of utilities elicited with different protocols in cost-utility analysis and do not recommend the display of cost-utility ratios from different studies in comparison or "league" tables.

Rethinking fundamental assumptions: SUPPORT's implications for future reform. Study to Understand Prognoses and Preferences and Risks of Treatment

BACKGROUND

The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in changing communication, decision-making, and treatment patterns despite evidence that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention design probably did not explain the lack of substantial effects.

OBJECTIVE

To explore the possibility that improved individual, patient-level decision-making is not the most effective strategy for improving end-of-life care and that improving routine practices may be more effective.

DESIGN

This paper reflects our efforts to synthesize findings from SUPPORT and other sources in order to explore our conceptual models, their consistency with the data, and their leverage for change.

RESULTS

Many of the assumptions underlying the model of improved decision-making are problematic. Furthermore, the results of SUPPORT suggest that implementing an effective intervention based on a normative model of shared decision-making can be quite difficult. Practice patterns and social expectations may be strong influences in shaping patients' courses of care. Innovations in system function, such as quality improvement or changing the financing incentives, may offer more powerful avenues for reform.

CONCLUSIONS

SUPPORT's intervention may have failed to have an impact because strong psychological and social forces underlie present practices. System-level innovation and quality improvement in routine care may offer more powerful opportunities for improvement.