Evaluating migraineurs' preferences for migraine treatment outcomes using a choice experiment

Temporal analysis of remote electric neuromodulation for the prevention of migraine

Aim: To evaluate the onset, magnitude and persistence of efficacy of remote electrical neuromodulation (REN) compared with placebo for the preventive treatment of migraine. Materials & methods: Analysis was conducted on data from a prospective, double-blind, placebo-controlled clinical trial, which assessed the efficacy of REN for the prevention of migraine. The number of monthly migraine days (MMD) per group was calculated in 2-week intervals and compared between the groups. Results: Differences between the active (N = 95) and placebo (N = 84) groups reached significance at 2 weeks: therapeutic gain 0.84 MMD; p = 0.036. 4 weeks gain 1.59 MMD; p = 0.025, 6 weeks gain 2.27 MMD; p < 0.001, 8 weeks gain 2.68 MMD; p < 0.001. Conclusion: REN provides rapid and consistent efficacy in preventive treatment of migraine.

How Much Better is Faster? Value Adjustments for Health-Improvement Sequences

While the quality-adjusted life-year construct has advantages of simplicity and consistency, simplicity requires strong assumptions. In particular, standard assumptions result in health-state utility functions that are unrealistically linear and separable in risk and duration. Consequently, sequencing of a series of health improvements has no effect on the total value of the sequence because each increment is assessed independently of previous increments. Utility functions in nearly all other areas of applied economics are assumed to be nonlinear with diminishing marginal utility so it matters where an improvement occurs in a sequence. We construct a conceptual framework that that demonstrates how diminishing marginal utility for health improvements could affect preferences for different sequence patterns. Using this framework, we derive conditions for which the sum of conventional health-state utilities understates, overstates, or approximates the sequence-sensitive value of health improvements. These patterns suggest the direction and magnitude of possible adjustments to conventional value calculations. We provide numerical examples and identify recent studies whose results are consistent with the conceptual model.

Patient preference for early onset of efficacy of preventive migraine treatments

Objective

The objective of this study was to ascertain to what extent adults with migraine value an early onset of efficacy for preventive migraine treatments.

Background

In placebo‐controlled clinical trials, treatment with eptinezumab resulted in a lower proportion of adults with migraine on the first day following infusion (day 1; 14% point‐reduction for chronic migraine [CM] in PROMISE‐2 and 8% point‐reduction for episodic migraine [EM] in PROMISE‐1).

Methods

Adults with migraine completed an online preference‐elicitation thresholding exercise to ascertain to what extent they value not having a migraine on day 1 postdosing relative to a clinically relevant reduction in number of migraine days during the first month postdosing (≥2 migraine‐free days for CM and ≥1 migraine‐free days for EM).

Results

One hundred and one participants (mean age, 50.6 ± 12.4 years; 81 [80%] women) were included. In participants with CM, 29 of 50 (58%) considered the eptinezumab‐generated reduction in the likelihood of migraine on day 1 postdosing to be at least as important as a clinically relevant reduction in number of migraine days the first month postdosing, whereas 37 of 50 (74%) considered a clinically relevant reduction of migraine days the first month postdosing to have a value equivalent to the eptinezumab‐generated reduction in the likelihood of migraine on day 1 postdosing. In participants with EM, 18 of 35 (51%) considered the eptinezumab‐generated reduction in the likelihood of migraine on day 1 postdosing to be at least as important as a clinically relevant reduction in migraine days the first month postdosing, whereas 24 of 35 (69%) considered a clinically relevant reduction of migraine days the first month postdosing to have a value equivalent to the eptinezumab‐generated reduction in the likelihood of migraine on day 1 postdosing.

Conclusion

Most participants considered the reduction in the likelihood of migraine offered by eptinezumab on day 1 postdosing to be at least as important as a clinically relevant reduction in migraine days the first month postdosing.

Disability and Economic Loss Caused by Headache among Information Technology Workers in Korea

Background and Purpose

Headache disorders are a leading cause of disability globally. However, there is inadequate information available about these disorders and the related economic loss in the workplace in Asian countries. Information technology (IT) jobs are intellectually and cognitively challenging, and hence IT workers are a suitable population for assessing headache disorders and related economic loss.

Methods

We sent invitation emails to all employees of selected IT companies. A comprehensive Web-based questionnaire regarding headache characteristics, disability, quality of life, and economic loss was completed by 522 participants from 8 companies.

Results

The participants included 450 (86.2%) who had experienced headache more than once during the previous year. The frequencies of migraine, probable migraine (PM), and tension-type headache (TTH) were 18.2%, 21.1%, and 37.0%, respectively. The Migraine Disability Assessment score was higher for participants with migraine [median and interquartile range, 3.0 (0.0–6.0)] than for those with PM [0.0 (0.0–2.0), p<0.001] and TTH [0.0 (0.0–1.0), p<0.001]. The estimated annual economic losses caused by migraine per person associated with absenteeism and presenteeism were USD 197.5±686.1 and USD 837.7±22.04 (mean±standard deviation), respectively. The total annual economic loss per person caused by migraine (USD 1,023.3±1,972.7) was higher than those caused by PM (USD 424.8±1,209.1, p<0.001) and TTH (USD 197.6±636.4, p<0.001).

Conclusions

Migraine, PM, and TTH were found to be prevalent among IT workers in Korea. Disability and economic loss were significantly greater in participants with migraine than in those with PM or TTH.

Patient Preferences and Values in Decision Making for Migraines: A Systematic Literature Review

Objective

To comprehensively summarize the evidence on the preferences and values of migraine patients.

Methods

We searched PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Sino-Med, Chongqing VIP, and Wanfang Data for studies on the preferences and values of migraine patients. A qualitative review was performed, but no quantitative synthesis.

Results

Twenty‐one studies were finally included, involving a total of 8701 participants. Patients expected a cure, to be symptom-free, a reduction in frequency of headaches, a reduction in severity of headaches, and an improved quality of life from their preventive treatment. Patients expected rapid pain relief, complete pain relief, return to normal activities, no recurrence, and no adverse events from their acute symptomatic treatment.

Conclusion

Efficacy is the primary consideration in the treatment of migraine. Specifically, the most important embodiment of patient preferences and values is the reduced frequency of attacks with preventive treatment as well as prompt analgesia with acute symptomatic treatment.

European position paper on the management of patients with patent foramen ovale. Part II - Decompression sickness, migraine, arterial deoxygenation syndromes and select high-risk clinical conditions

Patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions but to date only one official position paper related to left circulation thromboembolism has been published. This interdisciplinary paper, prepared with the involvement of eight European scientific societies, reviews the available evidence and proposes a rationale for decision making for other PFO-related clinical conditions. In order to guarantee a strict evidence-based process, we used a modified grading of recommendations, assessment, development, and evaluation (GRADE) methodology. A critical qualitative and quantitative evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk/benefit ratio. The level of evidence and the strength of the position statements were weighed and graded according to predefined scales. Despite being based on limited and observational or low-certainty randomised data, a number of position statements were made to frame PFO management in different clinical settings, along with suggestions for new research avenues. This interdisciplinary position paper, recognising the low or very low certainty of existing evidence, provides the first approach to several PFO-related clinical scenarios beyond left circulation thromboembolism and strongly stresses the need for fresh high-quality evidence on these topics.

Investigating Patients' Preferences to Inform Drug Development Decisions: Novel Insights from a Discrete Choice Experiment in Migraine

There is limited evidence on the scope and overall benefit of patient-centred drug development decisions. The present study assessed patients’ preferences for the characteristics of an ideal migraine treatment through a discrete choice experiment in order to inform decision-making and drug development processes. We investigated the preferences according to five treatment attributes identified from a systematic literature review and two focus group elicitations. The heterogeneity of preferences was also investigated. Overall, the respondents considered the presence of adverse events, duration of treatment effect, reduction of symptom intensity, speed of effect and cost born by the patient as the most relevant treatment features. As expected, the patients preferred treatments with lower levels of adverse events and costs and treatments with greater speed, duration of treatment effect and effectiveness in reducing symptom intensity. There was significant preference heterogeneity only for the presence of adverse events. Compared to men, women had significantly higher preferences for quicker treatment effect and limited adverse events and reported higher preferences for costly treatments. The results of our survey help address research and development strategies in the pharmaceutical industry and public policy regarding treatments that are clinically effective and responsive to the needs expressed by patients.

A reanalysis of a randomized trial on meditation for migraine headaches: Distraction is not enough but meditation takes time

OBJECTIVE

Migraine headaches affect about approximately 15% of the population and some notable efforts have been made to develop meditation interventions to address pain and mood among this population. However, key active ingredients and the necessary duration of meditation interventions to produce an effect are still unknown. The purpose of this study is to assess key meditation ingredients that positively impact mood and headache factors across different meditation techniques and to establish an initial time or" dose" needed to reach proactive treatment efficacy.

METHOD

In this longitudinal study, three active management forms of meditation were compared to a cognitive distraction meditation to assess the effects on migraine headaches and emotions over a 30 day period when practiced 20 min per day.

RESULTS

The active group showed significant decreases in anger (p = .005) and migraine pain (p = .002) over time. Further analysis showed that the bulk of the change for the active management group occurred in the final 10 days, after 20 days of practice of the technique (p < .05).

CONCLUSION

This suggests that cognitively active forms of meditation are more effective in reducing migraine headache pain and negative mood than distraction techniques. However, individuals engaging in these strategies need to consistently practice these techniques for approximately 20 days to proactively reduce migraine headache pain and negative mood.

Attribute level overlap (and color coding) can reduce task complexity, improve choice consistency, and decrease the dropout rate in discrete choice experiments

A randomized controlled discrete choice experiment (DCE) with 3,320 participating respondents was used to investigate the individual and combined impact of level overlap and color coding on task complexity, choice consistency, survey satisfaction scores, and dropout rates. The systematic differences between the study arms allowed for a direct comparison of dropout rates and cognitive debriefing scores and accommodated the quantitative comparison of respondents' choice consistency using a heteroskedastic mixed logit model. Our results indicate that the introduction of level overlap made it significantly easier for respondents to identify the differences and choose between the choice options. As a stand-alone design strategy, attribute level overlap reduced the dropout rate by 30%, increased the level of choice consistency by 30%, and avoided learning effects in the initial choice tasks of the DCE. The combination of level overlap and color coding was even more effective: It reduced the dropout rate by 40% to 50% and increased the level of choice consistency by more than 60%. Hence, we can recommend attribute level overlap, with color coding to amplify its impact, as a standard design strategy in DCEs.

Discrete Choice Experiments in Health Economics: Past, Present and Future

OBJECTIVES

Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges.

METHODS

A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated.

RESULTS

Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels.

CONCLUSIONS

The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.

Effect of Level Overlap and Color Coding on Attribute Non-Attendance in Discrete Choice Experiments

OBJECTIVE

The aim of this study was to test the hypothesis that level overlap and color coding can mitigate or even preclude the occurrence of attribute nonattendance in discrete choice experiments.

METHODS

A randomized controlled experiment with five experimental study arms was designed to investigate the independent and combined impact of level overlap and color coding on respondents' attribute nonattendance. The systematic differences between the study arms allowed for a direct comparison of observed dropout rates and estimates of the average number of attributes attended to by respondents, which were obtained by using augmented mixed logit models that explicitly incorporated attribute non-attendance.

RESULTS

In the base-case study arm without level overlap or color coding, the observed dropout rate was 14%, and respondents attended, on average, only two out of five attributes. The independent introduction of both level overlap and color coding reduced the dropout rate to 10% and increased attribute attendance to three attributes. The combination of level overlap and color coding, however, was most effective: it reduced the dropout rate to 8% and improved attribute attendance to four out of five attributes. The latter essentially removes the need to explicitly accommodate for attribute non-attendance when analyzing the choice data.

CONCLUSIONS

On the basis of the presented results, the use of level overlap and color coding are recommendable strategies to reduce the dropout rate and improve attribute attendance in discrete choice experiments.

Patients' preferences for headache acute and preventive treatment

Background

We aimed to explore patients’ preferences for headache treatments with a self-administered questionnaire including the Q-No questionnaire for nocebo.

Methods

Questionnaires from 514 outpatients naïve to neurostimulation and monoclonal antibodies were collected.

Results

Patients assessed that the efficacy of a treatment is more important than safety or route of administration. They preferred to use an external neurostimulation device for both acute (67.1%) and preventive treatment (62.8%). Most patients preferred to take a pill (86%) than any other drug given parenterally for symptomatic pharmaceutical treatment. For preventive pharmaceutical treatment, most patients preferred to take a pill once per day (52%) compared to an injection either subcutaneously or intravenously each month (9% and 4%), or three months (15% and 11%). 56.6% of all participants scored more than 15 in Q-No questionnaire indicating potential nocebo behaviors that contributed significantly in their choices.

Conclusion

These patient preferences along with efficacy and safety data may help physicians better choose the right treatment for the right person.

Comparing preferences for outcomes of psoriasis treatments among patients and dermatologists in the U.K.: results from a discrete-choice experiment

BACKGROUND

Plaque psoriasis can have a significant negative effect on patients' quality of life, and treatments can result in serious toxicities. Although there have been several studies of patients' and physicians' relative preferences for the benefits and risks of psoriasis treatments, it is unclear how and whether patients' and physicians' preferences for the outcomes of psoriasis treatments differ.

OBJECTIVES

To quantify patient and dermatologist preferences for improvements in psoriasis symptoms and for increases in the risk of treatment-related serious adverse events.

METHODS

Members of the U.K. Psoriasis Association and U.K. dermatologists with experience prescribing biologics completed a web-enabled discrete-choice experiment survey in which they evaluated efficacy and safety features of biological treatments for psoriasis. Choices between hypothetical treatment options were used to estimate preference weights indicating respondents' relative trade-off preferences among treatment outcomes. These outcomes included improvements in the severity and coverage of psoriatic plaques and treatment-related risks of tuberculosis, serious infections and lymphoma. Preference estimates were used to derive the maximum level of side-effect risks that respondents would accept for improvements in psoriasis symptoms.

RESULTS

Respondents' tolerance for side-effect risks varied with side-effect severity and location of plaques, and risk tolerance for serious side-effects was greater for patients than for dermatologists.

CONCLUSIONS

Estimates of patients' risk tolerance for serious side-effects indicate that patients valued psoriasis symptom control highly and suggest that psoriasis symptoms have a significant effect on patients' quality of life. In light of research showing increased treatment satisfaction and improved treatment adherence among patients who receive therapies that are consistent with their preferences, our findings suggest that greater communication between dermatologists and patients about risk tolerance could help improve patient care.

Statistical Methods for the Analysis of Discrete Choice Experiments: A Report of the ISPOR Conjoint Analysis Good Research Practices Task Force

Conjoint analysis is a stated-preference survey method that can be used to elicit responses that reveal preferences, priorities, and the relative importance of individual features associated with health care interventions or services. Conjoint analysis methods, particularly discrete choice experiments (DCEs), have been increasingly used to quantify preferences of patients, caregivers, physicians, and other stakeholders. Recent consensus-based guidance on good research practices, including two recent task force reports from the International Society for Pharmacoeconomics and Outcomes Research, has aided in improving the quality of conjoint analyses and DCEs in outcomes research. Nevertheless, uncertainty regarding good research practices for the statistical analysis of data from DCEs persists. There are multiple methods for analyzing DCE data. Understanding the characteristics and appropriate use of different analysis methods is critical to conducting a well-designed DCE study. This report will assist researchers in evaluating and selecting among alternative approaches to conducting statistical analysis of DCE data. We first present a simplistic DCE example and a simple method for using the resulting data. We then present a pedagogical example of a DCE and one of the most common approaches to analyzing data from such a question format-conditional logit. We then describe some common alternative methods for analyzing these data and the strengths and weaknesses of each alternative. We present the ESTIMATE checklist, which includes a list of questions to consider when justifying the choice of analysis method, describing the analysis, and interpreting the results.

Caregiver Preferences for the Treatment of Males with Fragile X Syndrome

OBJECTIVE

Fragile X syndrome (FXS) is the most common inherited form of intellectual disability. The objective of this study was to determine the relative importance that caregivers place on improving different phenotypic traits observed in males with FXS to better understand the greatest medical needs for developing and evaluating FXS treatments.

METHOD

Fragile X syndrome caregivers (n = 614) compared hypothetical treatments in a discrete-choice experiment. The treatments varied in their effects on 6 outcomes associated with FXS: learning and applying new skills, explaining needs, controlling behavior, taking part in new social activities, caring for oneself, and paying attention. The relative importance was calculated for improving severe or moderate levels of disability and transformed to a 10-point scale. Relative importance was also quantified by patient age group (child, adolescent, and adult).

RESULTS

Most important to caregivers were controlling behavior (10.0) and caring for oneself (9.9). Least important was taking part in new social activities (4.2). A partial improvement in controlling behavior or self-care was more important than full resolution of the least important disabilities. This was consistent across age groups. Improvements from severe to moderate disability were more important than from moderate to no disability.

CONCLUSION

Caregivers expressed strong preferences for improvement in self-care and behavioral control, independent of the age of the individual with FXS. These data may be helpful when designing studies to test the efficacy of FXS treatments because small treatment effects on very important outcomes may be valued more than large treatment effects on less valued outcomes.