Comparison of benefit-risk preferences of patients and physicians regarding cyclooxygenase-2 inhibitors using discrete choice experiments

Patient preferences in the treatment of chronic musculoskeletal pain: a systematic review of discrete choice experiments

ABSTRACT

Chronic musculoskeletal pain (CMP) is a preference-sensitive condition for which numerous treatment options are available, each with benefits and risks. Thus, patient preferences play a critical role in decision making. This study summarized evidence from discrete choice experiments (DCEs) to quantify patient preferences for CMP treatment and identified important treatment attributes. A systematic review of DCEs on patient preferences for CMP treatment was conducted. Studies were included if they used DCE to determine patient preferences for CMP. A previously described methodological assessment tool was used to assess the risk of bias. The treatment attributes were summarized and sorted according to the frequency of citation and relative weight. Subgroup analyses were conducted to explore the intervention-specific attributes. A total of 15 eligible studies with 4065 participants were included. We identified "capacity to realize daily life activities," "risk of adverse events," "effectiveness in pain reduction," and "out-of-pocket cost" as important attributes. Although "treatment frequency" and "onset of treatment efficacy" were less frequently mentioned, they were also important attributes. The attribute of "risk of adverse events" was especially important for drug treatment. The "out-of-pocket cost" and "treatment location and mode" were important attributes of exercise therapy. The attributes identified in this review will inform the design of future DCE studies, facilitate the translation of measurement-based care to value-based care, and provide the rationale to promote shared decision making and patient-centered care.

Preferences for Renal Cell Carcinoma Pharmacological Treatment: A Discrete Choice Experiment in Patients and Oncologists

Introduction

The purpose of this investigation was to explore patients’ and oncologists’ preferences for the characteristics of a pharmacological regimen for patients with advanced renal cell carcinoma (aRCC).

Material and Methods

Cross-sectional observational study based on a discrete choice experiment (DCE) conducted in Spain. A literature review, a focus group with oncologists and interviews with patients informed the DCE design. Five attributes were included: progression survival gain, risk of serious adverse events (SAEs), health-related quality of life (HRQoL), administration mode, and treatment cost. Preferences were analyzed using a mixed-logit model to estimate relative importance (RI) of attributes (importance of an attribute in relation to all others), which was compared between aRCC patients and oncologists treating aRCC. Willingness to pay (WTP, payer: health system) for a benefit in survival or in risk reduction and maximum acceptable risk (MAR) in SAEs for improving survival were estimated from the DCE. Subgroup analyses were performed to identify factors that influence preference.

Results

A total of 105 patients with aRCC (77.1% male, mean age 65.9 years [SD: 10.4], mean time since RCC diagnosis 6.3 years [SD: 6.1]) and 67 oncologists (52.2% male, mean age 41.9 years [SD: 8.4], mean duration of experience in RCC 10.2 years [SD: 7.5]) participated in the study. The most important attribute for patients and oncologists was survival gain (RI: 43.6% vs. 54.7% respectively, p<0.05), followed by HRQoL (RI: 35.5% vs. 18.0%, respectively, p<0.05). MAR for SAEs was higher among oncologists than patients, while WTP (for the health system) was higher for patients. Differences in preferences were found according to time since diagnosis and education level (patients) or length of professional experience (oncologists).

Conclusion

Patients’ and oncologists’ preferences for aRCC treatment are determined mainly by the efficacy (survival gain) but also by the HRQoL provided. The results of the study can help to inform decision-making in the selection of appropriate aRCC treatment.

Personalized diabetes management: what do patients with diabetes mellitus prefer? A discrete choice experiment

BACKGROUND

There are unresolved procedural and medical problems in the care of diabetes, which cause high costs for health systems. These include the inadequate glycemic adjustment, care gaps, therapeutic inertia, and a lack of motivation. Personalized diabetes management can be seen as a kind of "standard process" that provides both physicians and patients with a framework. The aim of this empirical survey is the evaluation of patient preferences regarding personalized diabetes management. The purpose of this experiment is to demonstrate the properties of the programs that are relevant for the choice of insulin-based therapy regimens for patients with type II diabetes mellitus.

METHODS

A discrete choice experiment (DCE) was applied to identify preferences for a personalized diabetes management in patients with type II diabetes mellitus. Six attributes were included. The DCE was conducted in June 2017 using a fractional factorial design, and the statistical data analysis used random effect logit models.

RESULTS

N = 227 patients (66.1% male) were included. The preference analysis showed dominance for the attribute "occurrence of severe hypoglycemias per year" [level difference (LD) 2765]. Preference analysis also showed that participants weight the "risk of myocardial infarction (over 10 years)" (LD 1.854) highest among the side effects. Within the effectiveness criterion of "change in the long-term blood glucose level (HbA1c)" a change at an initial value of 9.5% (LD 1.146) is weighted slightly higher than changes at 7.5% (LD 1.141). Within the random parameter logit estimation, all coefficients proved to be significantly different from zero at the level p ≤ 0.01. The latent class analysis shows three heterogeneous classes, each showing clearly different weights of the therapeutic properties. This results in a clear three-folding: for 1/3 of the respondents the change of the long-term blood sugar (HbA1c value) is the top objective. Another third is solely interested in the short-term effectiveness of the therapy in the sense of the occurrence of severe hypoglycemias per year. The last third of the interviewees finally focuses on the follow-up regarding cardiovascular events. Overall, there were five structural and personality traits which have an influence on the respective probability of the class membership.

DISCUSSION/CONCLUSION

This study identifies and weights the key decision-making criteria for optimal management of diabetes from the perspective of patients. It was shown that the effectiveness of a care program is the most important from the perspective of the patient and avoiding severe a hypoglycemia has the greatest influence on the choice. The risk of myocardial infarction as a follow-up disease and the long-term adjustment of the blood glucose follow the importance. In the analysis of possible subgroup differences by means of latent class analysis, it was found that three preference patterns exist within the sample. The generated preference data can be used for the design of personalized management approaches. It remains open to the extent to which expert opinions and patient preferences diverge.

Patients' Preferences Regarding Osteoarthritis Medications: An Adaptive Choice-Based Conjoint Analysis Study

BACKGROUND AND OBJECTIVE

Osteoarthritis (OA) patients consider ranges of harms and benefits offered by alternative pharmaceutical treatments. Choice-based experiments provide a mechanism to value outcomes, but they can pose a significant burden on respondents. Thus, the number of attributes studied is typically artificially restricted. We used an adaptive choice-based conjoint (ACBC) method that allows the inclusion of more attributes affecting patients' preferences regarding non-invasive pharmaceutical treatment for OA than traditional choice-based technique to better understand the trade-offs that OA patients consider, without increasing respondents' burden.

METHODS

After consulting with OA patients and public involvement (PPI) group, we constructed an online ACBC survey consisting of 9 attributes and a total of 31 levels (two benefits, four harms and three concerning the availability and modality of treatment). A cohort of patients with a diagnosis of OA and reporting joint pain within the last 12 months were recruited.

RESULTS

Our study (n 43) showed that the most important factor in choosing OA medication was the risk of heart attacks and strokes (19.5%), followed by the risk of addiction (18.4%), risk of kidney and liver side effects (17.5%), risk stomach side effects (14.6%), availability (11.6%), frequency of use (5.3%), pain reduction (5%), way of taking medication (4.6%) and mobility improvement (3.5%).

CONCLUSION

ACBC provides a mechanism for understanding patient preferences that address the limitations of traditional choice-based experiments. For OA patients, avoidance of the risk of side effects were the most affecting medication choices, and reductions in pain and mobility were the least. Clinicians discussing options for medication with OA patients should discuss the potential trade-offs in terms of risks and benefits.

Defined Daily Dose and Appropriateness of Clinical Application: The Coxibs and Traditional Nonsteroidal Anti-Inflammatory Drugs for Postoperative Orthopaedics Pain Control in a Private Hospital in Malaysia

Introduction: Drug utilization of analgesics in a private healthcare setting is useful to examine their prescribing patterns, especially the newer injectable cyclooxygenase (COX)-2 inhibitors (coxibs). Objectives: To evaluate the utilization of coxibs and traditional nonsteroidal anti-inflammatory drugs (tNSAIDs) indicated for postoperative orthopaedic pain control using defined daily dose (DDD) and ratio of use density to use rate (UD/UR). Method: A retrospective drug utilization review (DUR) of nonsteroidal anti-inflammatory drugs (NSAIDs) at an inpatient department of a private teaching hospital in Seremban, Malaysia was conducted. Patients’ demographic characteristics, medications prescribed, clinical lab results, visual analogue scale (VAS) pain scores and length of hospital stay were documented. Orthopaedic surgeries, namely arthroscopy, reconstructive, and fracture fixation, were included. Stratified random sampling was used to select patients. Data were collected through patients’ medical records. The DDD per 100 admissions and the indicator UD/UR were calculated with the World Health Organization’s DDD as a benchmark. The inclusion criteria were patients undergoing orthopaedic surgery prescribed with coxibs (celecoxib capsules, etoricoxib tablets, parecoxib injections) and tNSAIDs (dexketoprofen injections, diclofenac sodium tablets). Data were analysed descriptively. This research was approved by the academic institution and the hospital research ethics committee. Result: A total of 195 records of patients who received NSAIDs were randomly selected among 1169 cases. In term of the types of orthopaedic surgery, the ratio of included records for arthroscopy:fracture fixation:reconstructive surgery was 55.4:35.9:8.7. Most of the inpatients had low rates of common comorbidities such as cardiovascular disease as supported by their baseline parameters. The majority were not prescribed with other concomitant prescriptions that could cause drug interaction (74.9%), or gastroprotective agents (77.4%). Overall, DDDs per 100 admissions for all NSAIDs were less than 100, except for parecoxib injections (389.23). The UD/UR for all NSAIDs were less than 100, except for etoricoxib tablets (105.75) and parecoxib injections (108.00). Discussion: As per guidelines, the majority (96.9%) received other analgesics to ensure a multimodal approach was carried out to control pain. From the UD/UR results, the arthroscopy surgery was probably the most appropriate in terms of NSAID utilization. Conclusion: The prescribing pattern of NSAIDs except parecoxib was appropriate based on adverse effect and concurrent medication profile. The findings of this DUR provide insight for a low-risk patient population at a private specialized teaching hospital on the recommended use of NSAIDs for postoperative orthopaedic pain control.

Respondent Understanding in Discrete Choice Experiments: A Scoping Review

Introduction

Despite the recognised importance of participant understanding for valid and reliable discrete choice experiment (DCE) results, there has been limited assessment of whether, and how, people understand DCEs, and how ‘understanding’ is conceptualised in DCEs applied to a health context.

Objectives

Our aim was to identify how participant understanding is conceptualised in the DCE literature in a health context. Our research questions addressed how participant understanding is defined, measured, and used.

Methods

Searches were conducted (June 2019) in the MEDLINE, EMBASE, PsychINFO and Econlit databases, as well as hand searching. Search terms were based on previous DCE systematic reviews, with additional understanding keywords used in a proximity-based search strategy. Eligible studies were peer-reviewed journal articles in the field of health, related to DCE or best-worst scaling type 3 (BWS3) studies, and reporting some consideration or assessment of participant understanding. A descriptive analytical approach was used to chart relevant data from each study, including publication year, country, clinical area, subject group, sample size, study design, numbers of attributes, levels and choice sets, definition of understanding, how understanding was tested, results of the understanding tests, and how the information about understanding was used. Each study was categorised based on how understanding was conceptualised and used within the study.

Results

Of 306 potentially eligible articles identified, 31 were excluded based on titles and abstracts, and 200 were excluded on full-text review, resulting in 75 included studies. Three categories of study were identified: applied DCEs (n = 52), pretesting studies (n = 7) and studies of understanding (n = 16). Typically, understanding was defined in relation to either the choice context, such as attribute terminology, or the concept of choosing. Very few studies considered respondents’ engagement as a component of understanding. Understanding was measured primarily through qualitative pretesting, rationality or validity tests included in the survey, and participant self-report, however reporting and use of the results of these methods was inconsistent.

Conclusions

Those conducting or using health DCEs should carefully select, justify, and report the measurement and potential impact of participant understanding in their specific choice context. There remains scope for research into the different components of participant understanding, particularly related to engagement, the impact of participant understanding on DCE validity and reliability, the best measures of understanding, and methods to maximise participant understanding.

Electronic supplementary material

The online version of this article (10.1007/s40271-020-00467-y) contains supplementary material, which is available to authorized users.