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Larson AN, Marks MC, Gonzalez Sepulveda JM, Newton PO, Devlin VJ, Peat R, Tarver ME, Babalola O, Chen AL, Gebben D, Cahill P, Shah S, Samdani A, Bachmann K, Lonner B. Non-Fusion Versus Fusion Surgery in Pediatric Idiopathic Scoliosis: What Trade-Offs in Outcomes Are Acceptable for the Patient and Family? J Bone Joint Surg Am 2024; 106:2-9. [PMID: 37943944 DOI: 10.2106/jbjs.23.00503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
BACKGROUND Vertebral body tethering and other non-fusion techniques for the treatment of pediatric idiopathic scoliosis are increasing in popularity. There is limited physician consensus on this topic as the result of a paucity of published data regarding which patients most benefit from non-fusion strategies. Thus, much of the decision-making is left to patients and parents, who must select a treatment based on their goals and values and the information available from health-care providers, the internet, and social media. We sought to understand patient and family preferences regarding the attributes of fusion versus non-fusion surgery that drive these choices. METHODS Patients and families were recruited from 7 pediatric spine centers and were asked to complete a survey-based choice experiment that had been jointly developed with the U.S. Food and Drug Administration (FDA) to evaluate patient preferences. Choices between experimentally designed alternatives were analyzed to estimate the relative importance of outcomes and requirements associated with the choice options (attributes). The attributes included appearance, confidence in the planned correction, spinal motion, device failure, reoperation, and recovery period. The inclusion criteria were (1) an age of 10 to 21 years and (2) a diagnosis of adolescent idiopathic scoliosis in patients who were considering, or who had already undergone, treatment with fusion or non-fusion surgery. Preference weights were estimated from the expected changes in choice given changes in the attributes. RESULTS A total of 344 respondents (124 patients, 92 parents, and 128 parent/patient dyads) completed the survey. One hundred and seventy-three patients were enrolled prior to surgery, and 171 were enrolled after surgery. Appearance and motion were found to be the most important drivers of choice. For the entire cohort, fusion was preferred over non-fusion. For patients who were considering surgery, the most important attributes were preservation of spinal motion and appearance. CONCLUSIONS Patients and families seeking treatment for idiopathic scoliosis value appearance and preservation of spinal motion and, to a lesser extent, reoperation rates when considering fusion versus non-fusion surgery.
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Affiliation(s)
- A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Peter O Newton
- Setting Scoliosis Straight Foundation, El Cajon, California
- Division of Orthopedics, Rady Children's Hospital, San Diego, California
| | - Vincent J Devlin
- Office of Product Evaluation and Quality, Office of Health Technology-6: Orthopedic Devices, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland
| | - Raquel Peat
- Office of Product Evaluation and Quality, Office of Health Technology-6: Orthopedic Devices, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland
| | - Michelle E Tarver
- Office of Strategic Partnerships and Technology Innovation, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland
| | - Olufemi Babalola
- Office of Strategic Partnerships and Technology Innovation, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland
| | - Allen L Chen
- Office of Strategic Partnerships and Technology Innovation, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland
| | - David Gebben
- Office of Strategic Partnerships and Technology Innovation, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland
| | - Patrick Cahill
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Suken Shah
- Department of Orthopaedic Surgery, Nemours Children's Hospital, Wilmington, Delaware
| | - Amer Samdani
- Department of Pediatric Orthopedic Surgery, Shriners Children's Philadelphia, Philadelphia, Pennsylvania
| | - Keith Bachmann
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Baron Lonner
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
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Babalola O, Gebben D, Tarver ME, Sangha R, Roberts J, Price V. Patient Preferences Regarding Surgical Treatment Methods for Symptomatic Uterine Fibroids. Ther Innov Regul Sci 2023:10.1007/s43441-023-00525-1. [PMID: 37210440 PMCID: PMC10400705 DOI: 10.1007/s43441-023-00525-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 04/14/2023] [Indexed: 05/22/2023]
Abstract
STUDY OBJECTIVE The purpose of this study is to rank the factors that are most and least important to patients with symptomatic uterine fibroids when considering surgical treatment options. MATERIALS AND METHODS Using a best worst scaling (BWS) preference elicitation approach, participants completed an online survey to rank factors associated with fibroid surgical treatments. Survey content was based on a literature review and included the following factors: symptom relief; surgical complications; repeat treatment; recovery time; cosmetic effects; risk of spreading undiagnosed cancer; sexual outcomes; maintenance of child-bearing; continuation of menses; unpredictable menses; and location of procedure. Participants completed 11 BWS tasks. For each task, we presented participants with a subset of 5 factors from the possible 11, and participants chose the most important and least important factor. Participants' responses were analyzed using conditional logistic regression to determine the relative importance of factors. Patient priorities were further explored via age and race. RESULTS 285 respondents with symptomatic uterine fibroids (69 physician-confirmed and 216 self-reported) who had not undergone prior surgical treatment completed the survey. Respondents were enrolled from two clinical sites (clinical site cohort) and an online consumer panel (panel cohort). Both cohorts identified symptom relief, cancer risk, repeat treatment and complications as the most important factors in selecting surgical treatment options and location of procedure, return to normal activities after surgery, and cosmetic effects like presence of a scar after the surgical treatment as the least important factors. Of note, younger women (≤ 40) placed greater importance on the ability to have children after the procedure. CONCLUSION Information regarding the factors most and least important to patients with symptomatic uterine fibroids might inform development and regulatory evaluation of new technologies and procedures. Study results may be useful in efforts to develop a set of outcomes to include in future fibroids clinical studies.
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Affiliation(s)
- Olufemi Babalola
- Patient Science & Engagement, Office of Strategic Partnerships and Technology Innovation, Center for Devices and Radiological Health, U.S. Food and Drug Administration, White Oak, Bldg. 66, Room 5574, Silver Spring, MD, 20993, USA.
| | - David Gebben
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Michelle E Tarver
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Roopina Sangha
- Department of Obstetrics and Gynecology, JPS Health Network, Fort Worth, TX, USA
| | - Jason Roberts
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Veronica Price
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, USA
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Chaudhuri SE, Adamson P, Bruhn-Ding D, Ben Chaouch Z, Gebben D, Rincon-Gonzalez L, Liden B, Reed SD, Saha A, Schaber D, Stein K, Tarver ME, Lo AW. Patient-Centered Clinical Trial Design for Heart Failure Devices via Bayesian Decision Analysis. Patient 2023:10.1007/s40271-023-00623-0. [PMID: 37076697 DOI: 10.1007/s40271-023-00623-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND The statistical significance of clinical trial outcomes is generally interpreted quantitatively according to the same threshold of 2.5% (in one-sided tests) to control the false-positive rate or type I error, regardless of the burden of disease or patient preferences. The clinical significance of trial outcomes-including patient preferences-are also considered, but through qualitative means that may be challenging to reconcile with the statistical evidence. OBJECTIVE We aimed to apply Bayesian decision analysis to heart failure device studies to choose an optimal significance threshold that maximizes the expected utility to patients across both the null and alternative hypotheses, thereby allowing clinical significance to be incorporated into statistical decisions either in the trial design stage or in the post-trial interpretation stage. In this context, utility is a measure of how much well-being the approval decision for the treatment provides to the patient. METHODS We use the results from a discrete-choice experiment study focusing on heart failure patients' preferences, questioning respondents about their willingness to accept therapeutic risks in exchange for quantifiable benefits with alternative hypothetical medical device performance characteristics. These benefit-risk trade-off data allow us to estimate the loss in utility-from the patient perspective-of a false-positive or false-negative pivotal trial result. We compute the Bayesian decision analysis-optimal statistical significance threshold that maximizes the expected utility to heart failure patients for a hypothetical two-arm, fixed-sample, randomized controlled trial. An interactive Excel-based tool is provided that illustrates how the optimal statistical significance threshold changes as a function of patients' preferences for varying rates of false positives and false negatives, and as a function of assumed key parameters. RESULTS In our baseline analysis, the Bayesian decision analysis-optimal significance threshold for a hypothetical two-arm randomized controlled trial with a fixed sample size of 600 patients per arm was 3.2%, with a statistical power of 83.2%. This result reflects the willingness of heart failure patients to bear additional risks of the investigational device in exchange for its probable benefits. However, for increased device-associated risks and for risk-averse subclasses of heart failure patients, Bayesian decision analysis-optimal significance thresholds may be smaller than 2.5%. CONCLUSIONS A Bayesian decision analysis is a systematic, transparent, and repeatable process for combining clinical and statistical significance, explicitly incorporating burden of disease and patient preferences into the regulatory decision-making process.
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Affiliation(s)
| | | | | | - Zied Ben Chaouch
- MIT Laboratory for Financial Engineering, Cambridge, MA, USA
- MIT Department of Electrical Engineering and Computer Science, Cambridge, MA, USA
| | - David Gebben
- FDA Center for Devices and Radiological Health, Silver Spring, MD, USA
| | | | | | - Shelby D Reed
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Anindita Saha
- FDA Center for Devices and Radiological Health, Silver Spring, MD, USA
| | | | | | - Michelle E Tarver
- FDA Center for Devices and Radiological Health, Silver Spring, MD, USA
| | - Andrew W Lo
- QLS Advisors, Cambridge, MA, USA.
- MIT Laboratory for Financial Engineering, Cambridge, MA, USA.
- MIT Sloan School of Management, Cambridge, MA, USA.
- Santa Fe Institute, Santa Fe, NM, USA.
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Hauber B, Penrod JR, Gebben D, Musallam L. The Value of Hope: Patients' and Physicians' Preferences for Survival in Advanced Non-Small Cell Lung Cancer. Patient Prefer Adherence 2020; 14:2093-2104. [PMID: 33154633 PMCID: PMC7608144 DOI: 10.2147/ppa.s248295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 09/19/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Immuno-oncology treatments offer patients with advanced non-small cell lung cancer (NSCLC) treatment options with greater probability of durable survival and a different toxicity profile compared with traditional chemotherapy. The objective of this study was to explore the importance of increases in the probability of long-term survival versus changes in expected (median) survival and treatment toxicities among patients with advanced NSCLC and physicians. PATIENTS AND METHODS In a discrete-choice experiment, oncologists and patients diagnosed with NSCLC chose between profiles of treatments for advanced NSCLC offering different combinations of benefits (expected, best-case, and worst-case survival) and risks. We analyzed preference data from each sample using a random-parameters logit model that controls for preference heterogeneity and the panel nature of the data. RESULTS Both patients and physicians expressed a strong preference for improving the probability of best-case survival; however, patients viewed increases in the probability of long-term survival as more important than increases in expected survival, while the opposite was true for physicians. Both patients and physicians weighted survival to be more important than toxicities. CONCLUSION This study identified a potentially important divergence between physician and patient perspectives on survival statistics. Physicians placed more importance on increases in expected survival than did patients with NSCLC. The importance patients placed on long-term survival reinforce previous research identifying the primacy of hope as a value among seriously ill patients. The findings underscore the importance of considering patients' priorities and in shared decision-making when choosing treatment.
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Affiliation(s)
- Brett Hauber
- RTI Health Solutions, Research Triangle Park, NC, USA
- Correspondence: Brett Hauber Email
| | | | - David Gebben
- RTI Health Solutions, Research Triangle Park, NC, USA
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Mansfield C, Thomas N, Gebben D, Lucas M, Hauber AB. Preferences for Multiple Sclerosis Treatments: Using a Discrete-Choice Experiment to Examine Differences Across Subgroups of US Patients. Int J MS Care 2017; 19:172-183. [PMID: 28835741 DOI: 10.7224/1537-2073.2016-039] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The growing number of treatments for relapsing multiple sclerosis (MS) provides opportunities to consider patient preferences in treatment decisions. METHODS We designed a Web-based, discrete-choice experiment survey to analyze treatment preferences in patients with relapsing-remitting MS (RRMS). The survey presented hypothetical MS treatments defined by six attributes: risk of MS progression, time between relapses, risk of serious infection, treatment-related flu-like symptoms and gastrointestinal symptoms, and route and frequency of administration. Preference weights estimated with random-parameters logit were used to calculate importance scores and preference shares among three pairs of subsamples. RESULTS Patients with a self-reported physician diagnosis of RRMS (N = 301) completed the survey: 56% rated their disability level as normal or mild; 43% currently used a self-injectable treatment. Respondents with normal or mild disability levels placed greater weight on avoiding injections with flu-like symptoms and risk of progression, whereas patients with worse disability placed greater weight on reducing risk of progression and risk of serious infection. Patients taking injectables placed the most weight on risk of progression and risk of serious infection, whereas respondents not taking injectables placed the most weight on route and frequency of administration. Differences in preferences between subgroups were significant (P < .05). The presence of common adverse events associated with daily pills and injectables altered predicted preferences for route of administration. CONCLUSIONS Preferences of patients with RRMS varied depending on current treatment and disability level, especially regarding mode of administration. Considering patient preferences for treatment features may lead to higher treatment satisfaction and adherence.
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