Examining the influence of treatment preferences on attrition, adherence and outcomes: a protocol for a two-stage partially randomized trial

The Impact on Survival of Neoadjuvant Treatment Interruptions in Locally Advanced Rectal Cancer Patients

The standard oncologic treatment of locally advanced rectal cancer is long-course radio-chemotherapy followed by surgery and adjuvant chemotherapy. This can result in a lengthy total treatment duration, sometimes up to one year from the diagnosis. Interruptions to neoadjuvant treatment can occur for a variety of reasons, forced or unforced. The main purpose of this study is to analyze the survival data of locally advanced rectal cancer patients who received neoadjuvant treatment and to find a cut-off point showing exactly how many days of interruption of neoadjuvant treatment the risk of death or disease relapse increases. We conducted a retrospective study on 299 patients with locally advanced rectal cancer using survival analysis (Kaplan-Meier curve and Cox regression) to determine survival probabilities for overall survival, local control, and disease-free survival. Patients with 0 to 3 days of neoadjuvant therapy interruption had a higher overall survival probability compared to patients with 4 or more days (90.2% compared to 57.9%, p-value < 0.001), hazard ratio 5.89 (p < 0.001). Local control and disease-free survival had a higher probability in patients with 0-2 days of interruption compared to people with 3 or more days (94% vs. 75.4%, and 82.2% vs. 50.5%, respectively, both p-values < 0.001). Patients with tumoral or nodal downstaging experienced fewer days of interruption than patients with no downstage. These findings reinforce the need for radiation oncologists to be well-organized when starting neoadjuvant treatment for rectal cancer, in order to anticipate and prevent potential treatment interruptions and achieve the best therapeutic results.

Factors associated with choice of behavioural weight loss program by adults with obesity

We assessed the preference for two behavioural weight loss programs, Diabetes Prevention Program (DPP) and Healthy Weight for Living (HWL) in adults with obesity. A cross-sectional survey was fielded on the Amazon Mechanical Turk. Eligibility criteria included reporting BMI ≥30 and at least two chronic health conditions. Participants read about the programs, selected their preferred program, and answered follow-up questions. The estimated probability of choosing either program was not significantly different from .5 (N = 1005, 50.8% DPP and 49.2% HWL, p = .61). Participants' expectations about adherence, weight loss magnitude, and dropout likelihood were associated with their choice (p < .0001). Non-White participants (p = .040) and those with monthly income greater than $4999 (p = .002) were less likely to choose DPP. Participants who had postgraduate education (p = .007), did not report high serum cholesterol (p = .028), and reported not having tried losing weight before (p = .025) were more likely to choose DPP. Those who chose HWL were marginally more likely to report that being offered two different programs rather than one would likely affect their decision to enrol in one of the two (p = .052). The enrolment into DPP and HWL was balanced, but race, educational attainment, income, previous attempt to lose weight, and serum cholesterol levels had significant associations with the choice of weight loss program.

The IMAGINE Intervention: Impacting Physical Activity, Body Fat, Body Mass Index, and Dietary Inflammatory Index

Background

Many behavior-change interventions focused on nutrition and physical activity (PA) have been implemented to prevent disease and promote optimal health.

Purpose

This study examined changes in PA with Energy-adjusted Dietary Inflammatory Index (E-DII™) and chronic disease risk factors in participants of a multicomponent intervention.

Methods

Data from the Inflammation Management Intervention (IMAGINE) were used. Participants self-selected into the intervention or control group. At baseline and 12 weeks (post-intervention), participants completed three unannounced 24-hour dietary recalls (24HR), anthropometric measures (height, weight), and a dual x-ray absorptiometry scan. PA was measured using Sensewear^® armbands. E-DII scores were calculated from the 24HR. Descriptive statistics and t-tests summarized variables and multiple regression assessed relationships between PA and body mass index (BMI), total body fat percent, and E-DII scores.

Results

Intervention participants increased moderate-to-vigorous PA (MVPA) and lowered BMI, total body fat, and E-DII scores compared to controls. Every 10-minute increase in post-intervention MVPA was associated with 1.6 kg/m² lower BMI (p<0.01) and 2.4% lower body fat percent (p<0.01) among control participants, after adjusting for covariates. Every 10-minute increase in post-intervention MVPA was associated with 0.3 lower (i.e., less inflammatory) post-intervention E-DII (p=0.01) scores among intervention participants, after adjusting for covariates.

Conclusion

Participants who changed dietary intake changed PA. While changes were in expected directions, this intervention's emphasis on dietary behaviors compared to PA may have attenuated the relationship between PA and study outcomes.

Impact of a Theory-based Intervention to Promote Medication Adherence in Patients With a History of Myocardial Infarction

BACKGROUND

Patient discontinuation of cardioprotective medications after a cardiac ischemic event commonly occurs early after hospital discharge. Theory-based interventions could be effective in promoting better patient self-regulation of health-related behaviors and positive intentions to adhere to the recommended medical regimen.

OBJECTIVE

The aim of this study was to evaluate the potential efficacy and feasibility of a theory-based intervention to promote adherence to cardioprotective medications.

METHODS

In this mixed-methods quasi-experimental study with 3 time points, we recruited 45 participants with a positive intention to adhere and a history of myocardial infarction. They were recruited in primary care units in Brazil. Data collection occurred in 2 waves (Tb and T60). The intervention consisted of developing action and coping plans, delivered in a 30-minute face-to-face session, with face-to-face reinforcement at a 30-day interval. Quantitative data were submitted to descriptive, Wilcoxon, and McNemar analyses; qualitative data were submitted to content analysis.

RESULTS

An increase in the proportion of patients adhering to medications at the end of follow-up was found (T60 - Tb, +60.0%; P < .001). In addition, a significant reduction was found for blood pressure (T60 - Tb, -8.6 mm Hg; P < .001), heart rate (T60 - Tb, -6.6 bpm; P < .001), and low-density lipoprotein (T60 - Tb, -6.2 mg/dL; P < .05). Qualitative results revealed that the intervention was feasible, with an attrition rate of zero. The intervention was found to be easy to apply to patients' daily lives, and there was adequate time for implementation.

CONCLUSIONS

Our data confirm the potential efficacy of a theory-based intervention on the promotion of adherence to cardioprotective medications and on the related clinical end points, as well as its feasibility in the clinical context (Universal Trial Number: U1111-1189-9967).

Feasibility and acceptability of conducting a partially randomised controlled trial examining interventions to improve psychological health after discharge from the intensive care unit

BACKGROUND

Interventions to support psychological recovery after critical illness, including information provision via an intensive care unit (ICU) diary or discharge summary, have been widely adopted in some regions, albeit without strong empirical evidence.

OBJECTIVE

The objective of this study was to examine the feasibility and acceptability, for patients, family members, and clinicians, of information provision via an ICU diary or discharge summary to support psychological recovery for critical illness survivors.

METHODS

This was a pilot, partially randomised patient preference study in a mixed ICU in a tertiary hospital in Australia. Eligible patients were those in the ICU for >24 h and who were able to converse in English. Interventions were ICU diary or discharge summary compared with usual care. Feasibility was assessed throughout the study process, and acceptability assessed 3 and 6 months after hospital discharge, with data analysed descriptively and thematically.

RESULTS

Sixty-one patients were recruited; 45 completed 3-month follow-up (74%), and 37 (61%), 6-month follow-up. Participants were medical (39%), surgical (30%), and trauma (31%) patients; aged 55 [interquartile range (IQR): 36-67] years; and stayed in the ICU for 7 [IQR: 3-13] days and hospital for 23 [IQR: 14-32] days. Within the partially randomised framework, 34 patients chose their intervention - four chose usual care, 10 ICU diary, and 20 discharge summary. The remaining 27 patients were randomised - nine usual care, 10 ICU diary, and seven discharge summary. The majority (>90%) considered each intervention helpful during recovery; however, a significant proportion of patients reported distress associated with reading the ICU diary (42%) or discharge summary (15%). Clinicians reported they were hesitant to make diary entries.

CONCLUSIONS

When given a choice, more patients chose a discharge summary over the ICU diary or usual care. Participants considered both interventions acceptable. Given the reports of distress associated with information provision, clear empirical evidence is required to determine effectiveness, optimal timing, support needed, and for whom they should be used.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12615001079538.

Preference option randomized design (PORD) for comparative effectiveness research: Statistical power for testing comparative effect, preference effect, selection effect, intent-to-treat effect, and overall effect

Comparative effectiveness research trials in real-world settings may require participants to choose between preferred intervention options. A randomized clinical trial with parallel experimental and control arms is straightforward and regarded as a gold standard design, but by design it forces and anticipates the participants to comply with a randomly assigned intervention regardless of their preference. Therefore, the randomized clinical trial may impose impractical limitations when planning comparative effectiveness research trials. To accommodate participants' preference if they are expressed, and to maintain randomization, we propose an alternative design that allows participants' preference after randomization, which we call a "preference option randomized design (PORD)". In contrast to other preference designs, which ask whether or not participants consent to the assigned intervention after randomization, the crucial feature of preference option randomized design is its unique informed consent process before randomization. Specifically, the preference option randomized design consent process informs participants that they can opt out and switch to the other intervention only if after randomization they actively express the desire to do so. Participants who do not independently express explicit alternate preference or assent to the randomly assigned intervention are considered to not have an alternate preference. In sum, preference option randomized design intends to maximize retention, minimize possibility of forced assignment for any participants, and to maintain randomization by allowing participants with no or equal preference to represent random assignments. This design scheme enables to define five effects that are interconnected with each other through common design parameters-comparative, preference, selection, intent-to-treat, and overall/as-treated-to collectively guide decision making between interventions. Statistical power functions for testing all these effects are derived, and simulations verified the validity of the power functions under normal and binomial distributions.

Nurses' Perception of a Tailored Web-Based Intervention for the Self-Management of Pain After Cardiac Surgery

Background

Cardiac surgeries rank among the most frequent surgical procedures and present a risk of chronic postsurgical pain (CPSP). A continuum approach is required to prevent the development of CPSP. As a first step, a tailored web-based intervention was developed and successfully tested to tackle pain management during hospitalization. Before proceeding to further development, preliminary acceptability of the intervention including the postdischarge phase must be evaluated.

Purpose

The purpose of this study was to examine nurses’ perception of a tailored Web-based intervention for pain management in the early recovery phase. The objectives were to evaluate intervention’s acceptability and to identify ways to enhance its acceptability.

Methods

A parallel mixed methods approach was used to assess the acceptability of the intervention in the early recovery phase (first month after surgery).

Results

In total, 249 participants completed the online survey and 10 participants were individually interviewed. Overall, the intervention was rated as acceptable. No difference was found in acceptability ratings by demographics. The intervention was rated as appropriate to very much appropriate by 79% of participants. Although nurses seemingly would recommend it to their patients, they did not perceive that their patients would be as highly willing to use it. Interviews highlighted several strengths of the intervention, such as postoperative pain awareness, customization of content, and flexible dosage and schedule. However, the main weakness was related to patient adherence. Opting for a hybrid format and integrating individual preferences could enhance the coaching experience.

Conclusion

The innovative intervention was judged as acceptable for pain management in the early recovery phase. Considering that the intervention has demonstrated positive effects on the pain experience in the first week after cardiac surgery, it seems logical to explore its potential impact after discharge on the transition to CPSP.

A Cross-Sectional Study Assessing Treatment Preference of People With Chronic Low Back Pain

OBJECTIVE

To assess treatment preference and attributes of 2 exercise-based treatments for people with chronic low back pain (LBP).

DESIGN

Cross-sectional study.

SETTING

Academic research setting.

PARTICIPANTS

Individuals (N=154) with chronic LBP.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants completed a treatment preference assessment (TPA) measure that described 2 treatments for chronic LBP (strength and flexibility [SF] and motor skill training [MST]). Participants rated each treatment on 4 attributes: effectiveness, acceptability/logicality, suitability/appropriateness, and convenience. An overall score for each treatment was calculated as the mean of the 4 attribute ratings. The participants indicated either (1) no treatment preference or (2) preference for SF or MST.

RESULTS

One hundred four participants (67.5%) had a treatment preference; of those, 95 (91.3%) preferred SF and 9 (8.7%) preferred MST. The SF preference group rated SF higher than MST overall and on all attributes (all Ps <.01, ds ranged from .48-1.07). The MST preference group did not rate the treatments differently overall or on any of the attributes (all Ps >.05, ds ranged from .43-.66). Convenience of SF (P=.05, d=.79) and effectiveness (d=1.20), acceptability/logicality (d=1.27), and suitability/appropriateness (d=1.52) of MST (all Ps <.01) were rated differently between the 2 preference groups.

CONCLUSIONS

When presented with 2 treatment options, a majority of patients preferred SF over MST. Convenience was a particularly important attribute affecting preference. Assessing treatment preference and attributes prior to treatment initiation allows the clinician to identify factors that may need to be addressed to enhance adherence to, and outcomes of, treatment.