Do the benefits of statins outweigh their drawbacks? Assessing patients' trade-off preferences with conjoint analysis

Adolescent-Preferred financial incentives to promote type 1 diabetes Self-Care: A discrete choice experiment

AIMS

This study aimed to quantify preferences for the characteristics of a financial incentives program that would motivate adolescent engagement in type 1 diabetes (T1D) self-care.

METHOD

We performed a discrete choice experiment with 12-18 year-olds with T1D from two pediatric hospital endocrinology clinics (n = 317). We identified key attributes of incentives: (1) monthly value of the reward, (2) payment structure, and (3) difficulty of incentivized behaviors. In twelve choice questions, adolescents chose the incentive option from a pair of profiles that was more likely to motivate them to increase adherence to recommended self-care. Options presented were tailored to adolescents' T1D technology use and perceived difficulty of completing each behavior. We analyzed data using a conditional logit model.

RESULTS

The value of the reward accounted for 60.8% of preferences. Adolescents were willing to accept lower value rewards when incentive payments used positive vs. negative reinforcement (-$10.88 (95% CI: -$12.60, -9.24)) and preferred higher incentives for performing hard vs. easier behaviors (+$14.92 (95% CI: +$12.66, +$17.28)).

CONCLUSIONS

Stated preferences can inform intervention design. Future research will evaluate the external validity of the discrete choice experiment-informed intervention design by assessing adolescent health and behavioral outcomes in a randomized controlled trial.

At Odds About the Odds: Women's Choices to Accept Osteoporosis Medications Do Not Closely Agree with Physician-Set Treatment Thresholds

BACKGROUND

Osteoporosis guidelines recommend pharmacologic therapy based on 10-year risk of major osteoporotic fracture (MOF) and hip fracture, which may fail to account for patient-specific experiences and values.

OBJECTIVE

We aimed to determine whether patient decisions to initiate osteoporosis medication agree with guideline-recommended intervention thresholds.

DESIGN AND PARTICIPANTS

This prospective cohort study included women aged ≥ 45 with age-associated osteoporosis who attended a group osteoporosis self-management consultation at a tertiary osteoporosis center.

INTERVENTION

A group osteoporosis self-management consultation, during which participants received osteoporosis education and then calculated¹ their 10-year MOF and hip fracture risk using FRAX and² their predicted absolute fracture risk with therapy (assuming 40% relative reduction). Participants then made autonomous decisions regarding treatment initiation.

MAIN MEASURES

We evaluated agreement between treatment decisions and physician-set intervention thresholds (10-year MOF risk ≥ 20%, hip fracture risk ≥ 3%).

KEY RESULTS

Among 85 women (median [IQR] age 62 [58-67]), 27% accepted treatment (median [IQR] MOF risk, 15.1% [9.9-22.0]; hip fracture risk, 3.3% [1.3-5.3]), 46% declined (MOF risk, 9.5% [6.5-11.6]; hip fracture risk, 1.8% [0.6-2.3]), and 27% remained undecided (MOF risk, 14.0% [9.8-20.2]; hip fracture risk, 4.4% [1.7-4.9]). There was wide overlap in fracture risk between treatment acceptors and non-acceptors. Odds of accepting treatment were higher in women with prior fragility fracture (50% accepted; OR, 5.3; 95% CI, 1.9-15.2; p = 0.0015) and with hip fracture risk ≥ 3% (32% accepted; OR, 3.6; 95% CI, 1.4-9.2; p = 0.012), but not MOF risk ≥ 20% (47% accepted; OR, 3.0; 95% CI, 1.0-8.5; p = 0.105).

CONCLUSIONS

Informed decisions to start osteoporosis treatment are highly personal and not easily predicted using fracture risk. Guideline-recommended intervention thresholds may not permit sufficient consideration of patient preferences.

Patient-centered Treatment Decisions for Urethral Stricture: Conjoint Analysis Improves Surgical Decision-making

OBJECTIVE

To determine whether the use of a choice-based conjoint analysis (CA) exercise decreased patients' decisional conflict about treatment preferences for surgical management of urethral stricture disease. Understanding patient preferences for treatment decisions assists in shared decision-making and emphasizes patient-centered outcomes. CA offers a method to understand what risks patients are willing to take for what gains.

METHODS

The CA methodology was used by providing participants with case-based choices to elucidate the relative importance that individuals place on various treatment aspects. Patients' decisional conflict regarding surgery for urethral stricture was assessed before and after the CA exercise to assess the impact the exercise had on their decisional conflict.

RESULTS

Completion of the CA exercise resulted in a significant decrease in decisional conflict (P < .001). The majority (59.5%) of participants with decisional conflict before the CA exercise experienced a decrease in decisional conflict afterwards, with only a minority (16.5%) experiencing new decisional conflict after the exercise. Participants felt the choice-based CA exercise was helpful in deciding what was important in making treatment decisions (70%) and in expressing their priorities and treatment preferences (82%). The number needed to counsel to achieve a decrease in decisional conflict was 1.69 and to achieve no decisional conflict was 3.65.

CONCLUSION

Choice-based CA improves patients' ability to express their treatment preferences and decreases decisional conflict. CA may be a new tool that physicians and patients can use to aid in shared decision-making with a focus on patient-centered outcomes.

Parents' preferences for enhanced access in the pediatric medical home: a discrete choice experiment

IMPORTANCE

Efforts to transform primary care through the medical home model may have limited effectiveness if they do not incorporate families' preferences for different primary care services.

OBJECTIVE

To assess parents' relative preferences for different categories of enhanced access services in primary care.

DESIGN, SETTING, AND PARTICIPANTS

Internet-based survey that took place with a national online panel from December 8, 2011, to December 22, 2011. Participants included 820 parents of children aged 0 to 17 years. Hispanic and black non-Hispanic parents were each oversampled to 20% of the sample. The survey included a discrete choice experiment with questions that asked parents to choose between hypothetical primary care practices with different levels of enhanced access and other primary care services.

MAIN OUTCOMES AND MEASURES

We estimated parents' relative preferences for different enhanced access services using travel time to the practice as a trade-off and parents' marginal willingness to travel in minutes for practices with different levels of services.

RESULTS

The response rate of parents who participated in the study was 41.2%. Parents were most likely to choose primary care offices that guaranteed same-day sick visits (coefficient, 0.57 [SE, 0.05]; P < .001) followed by those with higher professional continuity (coefficient, 0.36 [SE, 0.03]; P < .001). Parents were also significantly more likely to choose practices with 24-hour telephone advice plus nonurgent email advice (0.08 [0.04]; P < .05), evening hours 4 or more times a week (0.14 [0.04]; P < .001), and at least some hours on weekends. Parents were significantly less likely to choose practices that were closed during some weekday daytime hours or had wait times longer than 4 weeks for preventive care visits. There was very little variation in preferences among parents with different sociodemographic characteristics. Parents' marginal willingness to travel was 14 minutes (95% CI, 11-16 minutes) for guaranteed same-day sick visits and 44 minutes (95% CI, 37-51 minutes) for an office with idealized levels of all services.

CONCLUSIONS AND RELEVANCE

As primary care practices for children implement aspects of the medical home model, those that emphasize same-day sick care and professional continuity are more likely to meet parents' preferences for enhanced access. Practices should seek to engage families in prioritizing changes in practice services as part of medical home implementation.