Prioritizing the worries of AML patients: Quantifying patient experience using best-worst scaling

Patient Preferences for Treatment in Relapsed/Refractory Acute Leukemia in the United Kingdom: A Discrete Choice Experiment

Background

Acute leukemia is a cancer of the white blood cells which progresses rapidly and aggressively. There are two types: acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML). The latter has a rare subtype: acute promyelocytic leukemia (APL). For some patients, following first-line treatment, remission is not achieved ("refractory disease"), and for others the leukemia returns after achieving remission ("relapse"). For these individuals, outcomes are typically poor. It is, therefore, important to understand patients' treatment priorities in this context.

Methods

Building upon formative qualitative research, an online survey containing a discrete choice experiment (DCE) was designed to explore patients' treatment preferences in the relapsed/refractory setting. The DCE attributes were mode of administration; quality of life during treatment; chance of response; duration of response; and quality of life during response. Each respondent completed twelve scenarios containing two hypothetical treatments. Participants were eligible if they lived in the United Kingdom and had a diagnosis of acute leukemia. The data were analysed using a latent class model.

Results

A total of 95 patients completed the survey. The latent class analysis identified two classes. For both, chance of response was the most important attribute. For class 1, every attribute was important, whereas for class 2, the only important attributes were quality of life (during treatment and response) and chance of response. A greater proportion of respondents would fall into class 1 overall, and those with ALL or APL and those more recently diagnosed were more likely to be in class 2.

Conclusion

Our results indicate that patients are strongly concerned about the chance of response, as well as quality of life (to a lesser extent), when faced with different treatment options in the relapsed/refractory setting. However, there is significant preference heterogeneity within the patient population, and other treatment characteristics also matter to many.

Experiences of treatment decision-making among older newly diagnosed adults with acute myeloid leukemia: a qualitative descriptive study

PURPOSE

Treatment decision-making for older adults with acute myeloid leukemia (AML) is complex and preference-sensitive. We sought to understand the patient experience of treatment decision-making to identify specific challenges in shared decision-making to improve clinical care and to inform the development of directed interventions.

METHODS

We conducted in-depth interviews with newly diagnosed older (≥ 60 years) adults with AML and their caregivers following a semi-structured interview guide at a public safety net academic hospital. Interviews were digitally recorded, and qualitative thematic analysis was employed to synthesize findings.

RESULTS

Eighteen in-depth interviews were conducted. Age ranged from 62 to 78 years. Patients received intermediate- (50%) or high-intensity (44%) chemotherapy or best supportive care only (6%). Six themes of patient experiences emerged from the analysis: patients (1) felt overwhelmed and in shock at diagnosis, (2) felt powerless to make decisions, (3) felt rushed and unprepared to make a treatment decision, (4) desired to follow oncologist recommendations for treatment, (5) balanced multiple competing factors during treatment decision-making, and (6) desired for ongoing engagement into their care planning. Patients reported many treatment outcomes that were important in treatment decision-making.

CONCLUSIONS

Older adults with newly diagnosed AML feel devastated and in shock at their diagnosis which appears to contribute to a feeling of being overwhelmed, unprepared, and rushed into treatment decisions. Because no one factor dominated treatment decision-making for all patients, the use of strategies to elicit individual patient preferences is critical to inform treatment decisions. Interventions are needed to reduce distress and increase a sense of participation in treatment decision-making.

Telehealth serious illness care program for older adults with hematologic malignancies: a single-arm pilot study

ABSTRACT

Older patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) feel shocked and bewildered when diagnosed. Serious illness conversations (SICs) may increase disease understanding and preparations for the future. However, SICs often happen late, in part because of clinician-perceived patient discomfort. Telehealth may promote patient comfort by allowing SICs to take place at home. This study assesses the feasibility and usability of a telehealth-delivered Serious Illness Care Program (SICP) for older adults with AML and MDS. We conducted a single-arm pilot study including 20 older adults with AML and MDS. Feasibility was measured using retention rate, with >80% considered feasible. Usability was measured using telehealth usability questionnaire (TUQ; range, 1-7): >5 considered usable. We collected other outcomes including acceptability and disease understanding and conducted post-visit qualitative interviews to elicit feedback. Hypothesis testing was performed at α = 0.10 owing to the pilot nature and small sample size. Retention rate was 95% (19/20); mean TUQ scores were 5.9 (standard deviation [SD], 0.9) and 5.9 (SD, 1.1) for patients and caregivers, respectively. We found the SICP to be acceptable. The majority of patients found the SICP to be very or extremely worthwhile (88.2%; 15/17), and reported it increased closeness with their clinician (75.0%; 12/16). After their visit, patient estimates of curability, and overall life expectancy aligned more closely with those of their clinicians. In qualitative interviews, most patients said that they would recommend this program to others (89.5%, 17/19). This study demonstrated that delivery of the telehealth SICP to older patients with AML and MDS is feasible, usable, and acceptable. This trial is registered at www.clinicaltrials.gov as #NCT04745676.

Increasing Access to Buprenorphine for Opioid Use Disorder in Primary Care: an Assessment of Provider Incentives

BACKGROUND

Primary care providers (PCPs) are essential to increasing access to office-based buprenorphine medication treatment for opioid use disorder (B-MOUD). Barriers to B-MOUD prescribing are well-documented, but there is little information regarding incentives to overcome these barriers.

OBJECTIVE

To identify optimal incentives for PCPs to promote B-MOUD prescribing and compare incentive preferences across provider and practice characteristics.

DESIGN

We surveyed PCPs using best-worst scaling (BWS) to prioritize seven potential incentives for B-MOUD prescribing (monetary compensation, paid vacation, protected time, professional development, reduced workload, service recognition, clinical resources). We then used a direct elicitation approach to determine preferred incentive levels (e.g., monetary thresholds) and types (e.g., specific clinical resources).

PARTICIPANTS

Primary care physicians and advanced practice providers (APPs) at a large Department of Veterans Affairs healthcare system.

MAIN MEASURES

B-MOUD prescribing incentive preferences and relative preference levels using descriptive statistics and conditional logistic regression with relative importance scale transformation (coefficients sum to 100, higher coefficient=greater importance).

KEY RESULTS

Fifty-three PCPs responded (73% response), including 47% APPs and 36% from community-based clinics. Reduced workload (relative importance score=26.8), protected time (18.7), and clinical resources (16.8) were significantly more preferred (Ps < 0.001) than professional development (10.5), paid vacation (10.3), or service recognition (1.5). Relative importance of monetary compensation varied between physicians (12.6) and APPs (17.5) and between PCPs located at a medical center (11.4) versus community clinic (22.3). APPs were more responsive than physicians to compensation increases of $5000 and $12,000 but less responsive to $25,000; trends were similar for medical center versus community clinic PCPs. The most frequently requested clinical resource was on-demand consult access to an addiction specialist.

CONCLUSIONS

Interventions promoting workload reductions, protected time, and clinical resources could increase access to B-MOUD in primary care. Monetary incentives may be additionally needed to improve B-MOUD prescribing among APPs and within community clinics.

Patient preferences, regret, and health-related quality of life among older adults with acute myeloid leukemia: A pilot longitudinal study

INTRODUCTION

Acute myeloid leukemia (AML) is associated with poor outcomes and is generally incurable. Therefore, understanding preferences of older adults with AML is critical. We sought to assess whether best-worst scaling (BWS) can be used to capture attributes considered by older adults with AML when making initial treatment decisions and longitudinally, as well as assess changes in health-related quality of life (HRQoL) and decisional regret over time.

MATERIALS AND METHODS

In a longitudinal study for adults ≥60 years with newly diagnosed AML, we collected: (1) attributes of treatment most important to patients using BWS, (2) HRQoL using EQ-5D-5L, (3) decisional regret using the Decisional Regret Scale, and (4) treatment worthiness using the "Was it worth it?" questionnaire. Data was collected at baseline and over six months. A hierarchical Bayes model was used to allocate percentages out of 100%. Due to small sample size, hypothesis testing was performed at α = 0.10 (2-tailed). We analyzed how these measures differed by treatment choice (intensive vs. lower intensity treatment).

RESULTS

Mean age of patients was 76 years (n = 15). At baseline, the most important attributes of treatment to patients were response to treatment (i.e., chance that the cancer will respond to treatment; 20.9%). Compared to those who received lower intensity treatment (n = 7) or best supportive care (n = 2), those who received intensive treatment (n = 6) generally ranked "alive one year or more after treatment" (p = 0.03) with higher importance and ranked "daily activities" (p = 0.01) and "location of treatment" (p = 0.01) with less importance. Overall, HRQoL scores were high. Decisional regret was mild overall and lower for patients who chose intensive treatment (p = 0.06).

DISCUSSION

We demonstrated that BWS can be used to assess the importance of various treatment attributes considered by older adults with AML when making initial treatment decisions and longitudinally throughout treatment. Attributes of treatment important to older patients with AML differed between treatment groups and changed over time. Interventions are needed to re-assess patient priorities throughout treatment to ensure care aligns with patient preferences.

Patient-centered communication tool for older patients with acute myeloid leukemia, their caregivers, and oncologists: A single-arm pilot study

BACKGROUND

In a single-arm pilot study, we assessed the feasibility and usefulness of an innovative patient-centered communication tool (UR-GOAL tool) that addresses aging-related vulnerabilities, patient values, and prognostic awareness for use in treatment decision making between older adults with newly diagnosed acute myeloid leukemia (AML), their caregivers, and oncologists.

METHODS

Primary feasibility metric was retention rate; >50% was considered feasible. We collected recruitment rate, usefulness, and outcomes including AML knowledge (range 0-14) and perceived efficacy in communicating with oncologists (range 5-25). Due to the pilot nature and small sample size, hypothesis testing was performed at α = 0.10.

RESULTS

We included 15 patients (mean age 76 years, range 64-88), 12 caregivers, and 5 oncologists; enrollment and retention rates for patients were 84% and 73%, respectively. Patients agreed that the UR-GOAL tool helped them understand their AML diagnosis and treatment options, communicate with their oncologist, and make more informed decisions. From baseline to post-intervention, patients and caregivers scored numerically higher on AML knowledge (patients: +0.6, p = 0.22; caregivers: +1.1, p = 0.05) and perceived greater efficacy in communicating with their oncologists (patients: +1.5, p = 0.22; caregivers: +1.2, p = 0.06).

CONCLUSION

We demonstrated that it is feasible to incorporate the UR-GOAL tool into treatment decision making for older patients with AML, their caregivers, and oncologists.

A Systematic Review of Decision Aids in Hematologic Malignancies: What Are Currently Available and What Are We Missing?

BACKGROUND

Patient decision aids (PDAs) are tools designed to facilitate decision-making. In this systematic review, we summarized existing studies on the development and evaluation of PDAs for patients with hematologic malignancies.

PATIENTS AND METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched for articles in PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. We included studies, abstracts, and clinical trial protocols available in English involving PDAs for patients age ≥18 diagnosed with a hematologic malignancy and/or their caregivers. Data were summarized using descriptive statistics.

RESULTS

Of the 5281 titles/abstracts screened, 15 were included: 1 protocol, 7 abstracts, and 7 full-texts. Six were PDA developmental studies, 6 were pilot studies, and 3 were randomized trials. PDA formats included electronic with web content, videos, and/or audio, questionnaires, bedside instruments, and a combination of various formats. Average participant age ranged from 36.0 to 62.4 years. Patients and caregivers identified efficacy, adverse effects, cost, and quality of life as important decision-making factors. PDAs were associated with increased knowledge and patient satisfaction as well as decreased decisional conflict and attitudinal barriers. Research on PDAs for adult patients with hematologic malignancies and their caregivers is limited. Among the studies, PDAs appear to support patients in shared decision-making.

CONCLUSION

While current literature examining the use of PDAs for adults with hematologic malignancies is limited, the positive impact of PDAs on shared decision-making and patient outcomes warrants additional research in this field.

Women's priorities towards ovarian cancer testing: a best-worst scaling study

OBJECTIVE

To investigate the importance of key characteristics relating to diagnostic testing for ovarian cancer and to understand how previous test experience influences priorities.

DESIGN

Case 1 best-worst scaling embedded in an online survey.

SETTING

Primary care diagnostic testing in England and Wales.

PARTICIPANTS

150 women with ovaries over 40 years old living in England and Wales.

METHODS

We used best-worst scaling, a preference-based survey method, to elicit the relative importance of 25 characteristics relating to ovarian cancer testing following a systematic review. Responses were modelled using conditional logit regression. Subgroup analysis investigated variations based on testing history.

MAIN OUTCOME MEASURES

Relative importance scores.

RESULTS

'Chance of dying from ovarian cancer' (0.380, 95% CI 0.26 to 0.49) was the most important factor to respondents, closely followed by 'test sensitivity' (0.308, 95% CI 0.21 to 0.40). In contrast, 'time away from usual activities' (-0.244, 95% CI -0.33 to -0.15) and 'gender of healthcare provider' (-0.243, 95% CI -0.35 to -0.14) were least important to respondents overall. Women who had previously undergone testing placed higher importance on certain characteristics including 'openness of healthcare providers' and 'chance of diagnosing another condition' at the expense of reduced emphasis on characteristics such as 'pain and discomfort' and 'time away from usual activities'.

CONCLUSIONS

The results clearly demonstrated items at the extreme, which were most and least important to women considering ovarian cancer testing. Differences in priorities by testing history demonstrate an experience effect, whereby preferences adapt over time based on evidence and experience. Acknowledging these differences helps to identify underlying barriers and facilitators for women with no test experience as well as shortcomings of current service based on women with experience.

Development of a Patient-Centered Preference Tool for Patients With Hematologic Malignancies: Protocol for a Mixed Methods Study

BACKGROUND

The approval of novel therapies for patients diagnosed with hematologic malignancies have improved survival outcomes but increased the challenge of aligning chemotherapy choices with patient preferences. We previously developed paper versions of a discrete choice experiment (DCE) and a best-worst scaling (BWS) instrument to quantify the treatment outcome preferences of patients with hematologic malignancies to inform shared decision making.

OBJECTIVE

We aim to develop an electronic health care tool (EHT) to guide clinical decision making that uses either a BWS or DCE instrument to capture patient preferences. The primary objective of this study is to use both qualitative and quantitative methods to evaluate the perceived usability, cognitive workload (CWL), and performance of electronic prototypes that include the DCE and BWS instrument.

METHODS

This mixed methods study includes iterative co-design methods that will involve healthy volunteers, patient-caregiver pairs, and health care workers to evaluate the perceived usability, CWL, and performance of tasks within distinct prototypes. Think-aloud sessions and semistructured interviews will be conducted to collect qualitative data to develop an affinity diagram for thematic analysis. Validated assessments (Post-Study System Usability Questionnaire [PSSUQ] and the National Aeronautical and Space Administration's Task Load Index [NASA-TLX]) will be used to evaluate the usability and CWL required to complete tasks within the prototypes. Performance assessments of the DCE and BWS will include the evaluation of tasks using the Single Easy Questionnaire (SEQ), time to complete using the prototype, and the number of errors. Additional qualitative assessments will be conducted to gather participants' feedback on visualizations used in the Personalized Treatment Preferences Dashboard that provides a representation of user results after completing the choice tasks within the prototype.

RESULTS

Ethical approval was obtained in June 2021 from the Institutional Review Board of the University of North Carolina at Chapel Hill. The DCE and BWS instruments were developed and incorporated into the PRIME (Preference Reporting to Improve Management and Experience) prototype in early 2021 and prototypes were completed by June 2021. Heuristic evaluations were conducted in phase 1 and completed by July 2021. Recruitment of healthy volunteers began in August 2021 and concluded in September 2021. In December 2021, our findings from phase 2 were accepted for publication. Phase 3 recruitment began in January 2022 and is expected to conclude in September 2022. The data analysis from phase 3 is expected to be completed by November 2022.

CONCLUSIONS

Our findings will help differentiate the usability, CWL, and performance of the DCE and BWS within the prototypes. These findings will contribute to the optimization of the prototypes, leading to the development of an EHT that helps facilitate shared decision making. This evaluation will inform the development of EHTs to be used clinically with patients and health care workers.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/39586.

Patient, Family Member and Physician Perspectives and Experiences with AML Treatment Decision-Making

Introduction

Treatment decisions in older adults with acute myeloid leukemia (AML) are challenging, particularly for those who are not candidates for intensive chemotherapy (IC), and the trade-offs patients, their families and physicians consider when choosing a treatment option are not well understood. This qualitative research explored the value of extending survival and the treatment decision-making process from a multi-stakeholder perspective.

Methods

Overall, 28 patients with AML (≥ 65 years old, unsuitable for IC), 25 of their relatives and 10 independent physicians from the US, UK and Canada took part in one-on-one, 60-minute qualitative interviews.

Results

Across all stakeholders, improved health-related quality of life (HRQoL), extended survival and relief of AML symptoms were recognized as most important in AML treatment decision-making. However, extending survival in ‘good health’ was more important than extending survival alone, particularly because of the extra time it gives patients and their relatives together, and allows patients to achieve important goals. Patients’ limited understanding of available treatment options, paired with incorrect perceptions of treatment side effects, impacted their involvement in the treatment decision-making process. Patients and physicians perceived physicians to have the most influence in the decision-making process despite their priorities not always aligning.

Conclusion

These findings illustrate the importance of having structured discussions which explicitly assess patients’ goals and their understanding and expectations of treatments and also the need for patient friendly resources about the lived experience of AML and available treatment options. These measures will help to ensure that patients are fully involved in the shared decision-making process.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40487-022-00200-9.

Improving personalized treatment decision-making for older adults with cancer: The necessity of eliciting patient preferences

We have a fundamental responsibility as oncologists to deliver personalized care tailored to each individual. In addition to an unprecedented expansion of treatment options for patients, recent advances in molecular profiling and functional assessments have greatly improved our ability to predict risks, benefits, and outcomes for older patients with cancer.^1,2 Molecular profiling identifies genomic abnormalities and allows oncologists to predict response to cancer therapy. Functional assessment such as a geriatric assessment allows oncologists to predict risks of treatment-related morbidity and mortality. Ongoing efforts aim to further refine our ability to predict outcomes for individuals by identifying relevant clinically meaningful thresholds (e.g., cut-off values for variant allele frequency, fitness criteria for a specific disease). Complex risk prediction models are now routinely used to integrate these data and produce personalized estimates of survival and response to cancer therapies, helping oncologists to provide personalized, high-quality care. Assessments of the disease and function of the patient, however, are insufficient to guide personalized treatment recommendations—we must understand patient preferences for treatment outcomes in order to tailor treatment.