A descriptive review on methods to prioritize outcomes in a health care context

Outcomes and Attributes Patients Value When Choosing Glucose-Lowering Medications: A Mixed-Methods Study

This mixed-methods study sought to identify pharmacotherapy preferences among 40 noninsulin-treated adults with type 2 diabetes receiving care at two U.S. health care systems. Participants ranked by relative importance various health outcomes and medication attributes and then contextualized their rankings. Most participants ranked blindness (63%), death (60%), heart attack (48%), and heart failure (48%) as the most important health outcomes and glucose-lowering efficacy (68%) as the most important medication attribute, followed by oral administration (45%) and lack of gastrointestinal side effects (38%).

Der Einfluss des Behandlungsvolumens psychiatrischer Kliniken auf das Risiko der Anwendung besonderer Sicherungsmaßnahmen

Ziel Bestimmen des Einflusses des Behandlungsvolumens auf die Häufigkeit und Dauer der Anwendung von Besonderen Sicherungsmaßnahmen (bSm) wie Fixierung und Isolierung.

Methode Datenbasis sind krankenhausbezogene Registerdaten aus Niedersachsen der Halbjahre 2/2019 bis 1/2021 zu Fällen, die nach dem Niedersächsischen Gesetz für Psychisch Kranke (NPsychKG) untergebracht sind, zum Anteil der Fälle, die eine bSm erhielten sowie zur Anzahl und kumulativen Dauer von bSm/Fall. Es wurden einfache lineare Regressionsmodelle gerechnet.

Ergebnis und Diskussion Mit Zunahme des Behandlungsvolumens von nach NPsychKG untergebrachten Fällen sinkt der Anteil der Fälle, die bSm erhalten. Dieses Ergebnis bleibt bestehen auch wenn statistische Ausreißer aus den Berechnungen herausgelassen werden.

Schlussfolgerung Angesichts von Hinweisen, dass auch in der psychiatrischen Versorgung das Behandlungsvolumen mit dem gewünschten Behandlungsziel assoziiert ist, sollte das Spannungsfeld wohnortnahe vollstationäre Versorgung in kleinen Kliniken versus Konzentration von Expertise in Zentren diskutiert werden.

Use of a risk communication survey to prioritize family-valued outcomes and communication preferences for children undergoing outpatient surgical procedures

BACKGROUND

Effective shared decision-making in pediatric surgery requires clarity regarding which surgical outcomes are most important to patients and their families, and how they prefer to receive the information. Despite how essential this is for effective risk communication, little is known about the communication needs and preferences of patients and their families in elective pediatric surgery.

METHODS

We administered a mailed and online cross-sectional survey in English and French to 548 families before or after surgery for hernia/hydrocele repair or tonsillectomy/adenoidectomy between July 2019 and February 2021. The survey consisted of 22 questions eliciting most valued patient-reported outcomes (PROs) across 4 domains: health-related quality of life (5), functional status (5), symptoms and symptom burden (5), health behaviours and patient experience (7), as well as overall impressions (3), surgical risks (5), communication preferences (4), and demographic questions (16).

RESULTS

The survey was completed by 368 patient families (60 preoperative, 308 postoperative, response rate 67.2%). Most respondents (72%) indicated a significant desire to be informed on all listed PROs alongside surgical complications, and highly valued all functional and quality of life outcomes (92.9% & 89.8%, respectively). Preoperatively, patient families preferred to receive information in the form of pamphlets and websites, whereas postoperatively they preferred direct communication.

CONCLUSION

Families value functional and quality of life PROs as much as clinical outcomes, and increasingly seek more contemporary (electronic) means of risk communication than we currently offer. This data will inform the development of mobile tools for personalized communication in pediatric surgery.

A Protocol for Developing a Discrete Choice Experiment to Elicit Preferences of General Practitioners for the Choice of Specialty

OBJECTIVES

Discrete choice experiment (DCE) has been increasingly used in studies investigating preferences of the health workforce. This pilot study aimed to provide a comprehensive protocol for design and quality assessment of a DCE to elicit preferences of general practitioners for the choice of specialty.

METHODS

We conducted 3 rigorous qualitative studies, including a review of literature, qualitative interviews, and focus group discussion to develop attributes and levels of the DCE. Then a D-efficient fractional factorial design was applied to generate choice tasks and to block them into 4 equal versions using SAS software. Two hundred and forty general practitioners participated in a pilot study conducted to evaluate the quality of the instrument using 7 tests.

RESULTS

The qualitative studies resulted in the development of 8 attributes and 24 levels. Experimental design led to the generation of 36 choice tasks divided into 4 blocks. The pilot study revealed that the instrument has validity and reliability and also indicated that the design is comprehensible and feasible.

CONCLUSIONS

This study provided an integrated, comprehensive framework for development and quality assessment of a DCE that could be used in other studies. The pilot study indicated that the instrument is of sufficient quality because it was developed using rigorous qualitative studies and accurate experimental design method.

Decision Model for Allocation of Intensive Care Unit Beds for Suspected COVID-19 Patients under Scarce Resources

This paper puts forward a decision model for allocation of intensive care unit (ICU) beds under scarce resources in healthcare systems during the COVID-19 pandemic. The model is built upon a portfolio selection approach under the concepts of the Utility Theory. A binary integer optimization model is developed in order to find the best allocation for ICU beds, considering candidate patients with suspected/confirmed COVID-19. Experts' subjective knowledge and prior probabilities are considered to estimate the input data for the proposed model, considering the particular aspects of the decision problem. Since the chances of survival of patients in several scenarios may not be precisely defined due to the inherent subjectivity of such kinds of information, the proposed model works based on imprecise information provided by users. A Monte-Carlo simulation is performed to build a recommendation, and a robustness index is computed for each alternative according to its performance as evidenced by the results of the simulation.

What are the Relevant Outcomes of the Periodic Health Examination? A Comparison of Citizens' and Experts' Ratings

PURPOSE

Despite evidence from clinical guideline development that physicians and patients show discordance in what they consider important in outcome selection and prioritization, it is unclear to what extent outcome preferences are concordant between experts and citizens when it comes to the context of primary prevention. Therefore, the objective of this study was to assess whether expert judgments about the importance of beneficial and harmful outcomes differ from citizen preferences when considering intervention options for a periodic health examination (PHE) program.

PARTICIPANTS AND METHODS

We conducted an online survey using a modified Delphi approach. The target population for the survey consisted of citizens who had attended the PHE (n=18) and experts who made evidence-based recommendations (n=11). Citizens and experts assigned a score on a 9-point Likert scale for each outcome of 14 interventions. We analyzed the intragroup agreement based on Krippendorff's alpha and the intergroup agreement using the cube root product measure (CRPm). We further tested for significant differences between the groups using the Mann U-test.

RESULTS

Agreements within the groups of citizens and experts varied across the interventions and tended to be poor (α ≤0 to 0.20) or fair (α = 0.21 to 0.40), with three exceptions showing moderate agreement (α = 0.44 to 0.55). The agreements between the citizens and experts across the interventions was fair (CRPm = 0.28) during the first Delphi rating round. The mean differences between the citizens and experts on the Likert scale ranged from 0.0 to 3.8 during the first rating round and from 0.0 to 3.3 during the second. Across interventions, the citizens rated the outcomes as more important than the experts did (p<0.01). Individual participants' ratings varied substantially.

CONCLUSION

Because experts generally underestimated the outcomes' importance to citizens, the involvement of citizens in guideline panels for preventive services is important.

Comparing the Preferences of Patients and the General Public for Treatment Outcomes in Type 2 Diabetes Mellitus

BACKGROUND

Healthcare treatments and interventions are traditionally evaluated from the societal perspective, but a more patient-centric perspective has been proposed in recent years. We sought to compare preferences of patients and the general public for treatment outcomes of type 2 diabetes using both best-worst scaling (BWS) and rating approaches.

METHODS

A survey evaluating the treatment priorities for type 2 diabetes was conducted in the United States. Members of the general public and patients with type 2 diabetes were recruited from a nationally sampled panel. Participants indicated the importance of seven potential treatment outcomes (hypoglycemic events, glycated hemoglobin [A1c], weight loss, mental health, functioning, glycemic stability, and cardiovascular health) using (1) BWS case 1 and (2) a rating task. Preference differences from BWS prioritizations were explored using mixed logistic regression (BWS preference weights were probability re-scaled so that the weightings of the seven items collectively summed to 100). The consistency of scale between samples was explored using heteroskedastic conditional logistic regression of BWS data. Spearman rank correlation was used to compare standardized BWS preference weights and rating scores for each group. Both groups evaluated the BWS and rating activities using debriefing questions.

RESULTS

The public and patient samples included 314 and 313 respondents, respectively. The public was on average 16 years younger than patients (48 vs 64 years, P < 0.001). In BWS, patients and the public both ranked A1c, glycemic stability, and cardiovascular health within their top three outcomes. Patients valued the outcome A1c most highly and found it twice as important as did the public (41.0 vs 20.2, P < 0.001). The public valued cardiovascular health most highly, and found it to be twice as important than did patients (31.3 vs 17.4, P < 0.001). Patients were more consistent in their preferences than the public (λ = 1.66, P = 0.01). Preferences elicited using BWS and rating approaches were highly correlated for both patients (ρ = 0.96) and the public (ρ = 0.92). Patients were more likely than the public to endorse the BWS as easy to answer (P < 0.001), easy to understand (P < 0.001), consistent with preferences (P < 0.001), and relevant (P < 0.001). Both patients and the public found the rating activity easier to answer and understand, and more consistent with their preferences, than the BWS (P < 0.001).

CONCLUSIONS

We provide some of the first evidence demonstrating a difference in patient and public treatment priorities for diabetes. That patients were more consistent in their preferences than the public and found the BWS and Likert rating instruments more relevant suggests that patient priorities may be more appropriate than those of the general public in some medical decision-making contexts.

Hybrid Methodology to Improve Health Status Utility Values Derivation Using EQ-5D-5L and Advanced Multi-Criteria Techniques

This paper presented a new approach to the calculation of quality-adjusted life years (QALY) based on multi-criteria decision-making (MCDM) methods and using the EQ-5D-5L questionnaire. The health status utility values were calculated through a hybrid methodology. We combined the analytic hierarchy process (AHP), the AHP with a D-number extended fuzzy preference relation (D-AHP), the fuzzy analytic hierarchy process (F-AHP), and the technique for order preference by similarity to the ideal solution (TOPSIS) to obtain individual and aggregated utility values. The preference data were elicited using a sample of individuals from a Colombian university. In all tested methods, the ordinal preferences were consistent, and the weights were compared using the Euclidean distance criterion (EDC). We identified F-AHP-TOPSIS as the optimal method; its benefits were associated with modeling the response options of the EQ-5D in linguistic terms, it gave the best approximation to the initial preferences according to EDC, and it could be used as an alternative to the known prioritization method. This hybrid methodology was particularly useful in certain medical decisions concerned with understanding how a specific person values his or her current health or possible health outcomes from different interventions in small population samples and studies carried out in low- and middle-low-income countries.

Health Outcome Prioritization in Alzheimer's Disease: Understanding the Ethical Landscape

BACKGROUND

Dementia has been described as the greatest global health challenge in the 21st Century on account of longevity gains increasing its incidence, escalating health and social care pressures. These pressures highlight ethical, social, and political challenges about healthcare resource allocation, what health improvements matter to patients, and how they are measured. This study highlights the complexity of the ethical landscape, relating particularly to the balances that need to be struck when allocating resources; when measuring and prioritizing outcomes; and when individual preferences are sought.

OBJECTIVE

Health outcome prioritization is the ranking in order of desirability or importance of a set of disease-related objectives and their associated cost or risk. We analyze the complex ethical landscape in which this takes place in the most common dementia, Alzheimer's disease.

METHODS

Narrative review of literature published since 2007, incorporating snowball sampling where necessary. We identified, thematized, and discussed key issues of ethical salience.

RESULTS

Eight areas of ethical salience for outcome prioritization emerged: 1) Public health and distributive justice, 2) Scarcity of resources, 3) Heterogeneity and changing circumstances, 4) Knowledge of treatment, 5) Values and circumstances, 6) Conflicting priorities, 7) Communication, autonomy and caregiver issues, and 8) Disclosure of risk.

CONCLUSION

These areas highlight the difficult balance to be struck when allocating resources, when measuring and prioritizing outcomes, and when individual preferences are sought. We conclude by reflecting on how tools in social sciences and ethics can help address challenges posed by resource allocation, measuring and prioritizing outcomes, and eliciting stakeholder preferences.

A patient and community-centered approach selecting endpoints for a randomized trial of a novel advance care planning tool

BACKGROUND

Despite a movement toward patient-centered outcomes, best practices on how to gather and refine patients' perspectives on research endpoints are limited. Advanced care planning (ACP) is inherently patient centered and would benefit from patient prioritization of endpoints for ACP-related tools and studies.

OBJECTIVE

This investigation sought to prioritize patient-centered endpoints for the content and evaluation of an ACP video being developed for patients undergoing major surgery. We also sought to highlight an approach using complementary engagement and research strategies to document priorities and preferences of patients and other stakeholders.

MATERIALS AND METHODS

Endpoints identified from a previously published environmental scan were operationalized following rating by a caregiver co-investigator, refinement by a patient co-investigator, review by a stakeholder committee, and validation by patients and family members. Finalized endpoints were taken to a state fair where members of the public who indicated that they or a loved one had undergone major surgery prioritized their most relevant endpoints and provided comments.

RESULTS

Of the initial 50 ACP endpoints identified from the review, 12 endpoints were selected for public prioritization. At the state fair, 359 individuals prioritized the endpoints, the highest ranking of which was having a meaningful conversation with a physician before surgery (57%).

CONCLUSION

Using a novel combination of engagement and research techniques provided the opportunity to understand which endpoints were most important to patients and families and fostered framework development clarifying the differential contributions of engagement and research. Results from this study ultimately changed the content and evaluation of the ACP video.

Conducting a Discrete-Choice Experiment Study Following Recommendations for Good Research Practices: An Application for Eliciting Patient Preferences for Diabetes Treatments

OBJECTIVES

To consolidate and illustrate good research practices in health care to the application and reporting of a study measuring patient preferences for type 2 diabetes mellitus medications, given recent methodological advances in stated-preference methods.

METHODS

The International Society for Pharmacoeconomics and Outcomes Research good research practices and other recommendations were used to conduct a discrete-choice experiment. Members of a US online panel with type 2 diabetes mellitus completed a Web-enabled, self-administered survey that elicited choices between treatment pairs with six attributes at three possible levels each. A D-efficient experimental design blocked 48 choice tasks into three 16-task surveys. Preference estimates were obtained using mixed logit estimation and were used to calculate choice probabilities.

RESULTS

A total of 552 participants (51% males) completed the survey. Avoiding 90 minutes of nausea was valued the highest (mean -10.00; 95% confidence interval [CI] -10.53 to -9.47). Participants wanted to avoid low blood glucose during the day and/or night (mean -3.87; 95% CI -4.32 to -3.42) or one pill and one injection per day (mean -7.04; 95% CI -7.63 to -6.45). Participants preferred stable blood glucose 6 d/wk (mean 4.63; 95% CI 4.15 to 5.12) and a 1% decrease in glycated hemoglobin (mean 5.74; 95% CI 5.22 to 6.25). If cost increased by $1, the probability that a treatment profile would be chosen decreased by 1%.

CONCLUSIONS

These results are consistent with the idea that people have strong preferences for immediate consequences of medication. Despite efforts to produce recommendations, ambiguity surrounding good practices remains and various judgments need to be made when conducting stated-preference studies. To ensure transparency, these judgments should be described and justified.

Patients' preferences in periodontal disease treatment elicited alongside an IQWiG benefit assessment: a feasibility study

BACKGROUND AND PURPOSE

The German Institute for Quality and Efficiency in Health Care (IQWiG) previously tested two preference elicitation methods in pilot projects and regarded them as generally feasible for prioritizing outcome-specific results of benefit assessment. The present study aimed to investigate the feasibility of completing a discrete choice experiment (DCE) within 3 months and to determine the relative importance of attributes of periodontal disease and its treatment.

PATIENTS AND METHODS

This preference elicitation was conducted alongside the IQWiG benefit assessment of systematic treatments of periodontal diseases. Attributes were defined based on the benefit assessment, literature review, and patients' and periodontologists' interviews. The DCE survey was completed by patients with a history of periodontal disease. Preferences were elicited for the attributes "tooth loss within next 10 years", "own costs for treatment, follow-up visits, re-treatment", "complaints and symptoms", and "frequency of follow-up visits". Patients completed a self-administered questionnaire including 12 choice tasks. Data were analyzed using a random parameters logit model. The relative attribute importance was calculated based on level ranges.

RESULTS

Within 3 months, survey development, data collection among 267 patients, data analysis, and provision of a study report could be completed. The analysis showed that tooth loss (score 0.73) was the most important attribute in patients' decisions, followed by complaints and symptoms (0.22), frequency of follow-up visits (0.02), and costs (0.03) (relative importance scores summing up to 1).

CONCLUSION

A preference analysis performing a DCE can be generally feasible within 3 months; however, a good research infrastructure and access to patients is required. Outcomes used in benefit assessments might need to be adapted to be used in preference analyses.

TAKING PATIENT HETEROGENEITY AND PREFERENCES INTO ACCOUNT IN HEALTH TECHNOLOGY ASSESSMENTS

OBJECTIVES

The INTEGRATE-HTA project provided methodology to evaluate complex technologies. This study provides guidance on how to retrieve and critically appraise available evidence on moderators and predictors of treatment effects and on patient preferences for treatment outcomes as a source of complexity.

METHODS

Search filters for PubMed were developed by hand-searching a large volume of articles reporting on relevant aspects. Search terms were retrieved from selected papers and algorithmically combined to find the optimal combination of search terms. For the development of the appraisal checklists literature was searched in PubMed and Google Scholar together with citation chasing. For the CHecklist for the Appraisal of Moderators and Predictors (CHAMP) a Delphi procedure was used to value a set of eligible appraisal criteria retrieved from the literature.

RESULTS

Search filters were developed optimized for different accuracy measures. The final version of CHAMP consists of a seventeen questions covering the design, analysis, results and transferability of results of moderator and predictor analysis. The final checklist for appraisal of literature on patient preferences for treatment outcomes consist of six questions meant to help the user to identify relevant quality issues together with a guidance toward existing tools concerning the appraisal of specific preference elicitation methods.

CONCLUSIONS

Incorporating knowledge on subgroups for whom a specific treatment will produce more benefit holds the promise of better targeting and, ultimately, enhancing overall effectiveness and efficiency of healthcare technology. Finally, incorporating information on preferences for treatment outcomes will foster health technology assessment that addresses outcomes that are important to patients.

Importance of hemodialysis-related outcomes: comparison of ratings by a self-help group, clinicians, and health technology assessment authors with those by a large reference group of patients

BACKGROUND

The selection of important outcomes is a crucial decision for clinical research and health technology assessment (HTA), and there is ongoing debate about which stakeholders should be involved. Hemodialysis is a complex treatment for chronic kidney disease (CKD) and affects many outcomes. Apart from obvious outcomes, such as mortality, morbidity and health-related quality of life (HRQoL), others such as, concerning daily living or health care provision, may also be important. The aim of our study was to analyze to what extent the preferences for patient-relevant outcomes differed between various stakeholders. We compared preferences of stakeholders normally or occasionally involved in outcome prioritization (patients from a self-help group, clinicians and HTA authors) with those of a large reference group of patients.

PARTICIPANTS AND METHODS

The reference group consisted of 4,518 CKD patients investigated previously. We additionally recruited CKD patients via a regional self-help group, nephrologists via an online search and HTA authors via an expert database or personal contacts. All groups assessed the relative importance of the 23 outcomes by means of a discrete visual analog scale. We used descriptive statistics to rank outcomes and compare the results between groups.

RESULTS

We received completed questionnaires from 49 self-help group patients, 19 nephrologists and 18 HTA authors. Only the following 3 outcomes were ranked within the top 7 outcomes by all 4 groups: safety, HRQoL and emotional state. The ratings by the self-help group were generally more concordant with the reference group ratings than those by nephrologists, while HTA authors showed the least concordance.

CONCLUSION

Preferences of CKD patients from a self-help group, nephrologists and HTA authors differ to a varying extent from those of a large reference group of patients with CKD. The preferences of all stakeholders should form the basis of a transparent approach so as to generate a valid list of important outcomes.

Preferences of patients undergoing hemodialysis - results from a questionnaire-based study with 4,518 patients

BACKGROUND

Chronic kidney disease is an increasing health problem worldwide and in its final stage (stage V) can only be treated by renal replacement therapy, mostly hemodialysis. Hemodialysis has a major influence on the everyday life of patients and many patients report dissatisfaction with treatment. Little is known about which aspects of treatment are considered important by hemodialysis patients. The objective of this study was to rate the relative importance of different outcomes for hemodialysis patients and to analyze whether the relative importance differed among subgroups of patients.

PATIENTS AND METHODS

Within the framework of a yearly questionnaire which is distributed among patients receiving hemodialysis by the largest hemodialysis provider in Germany, we assessed the relative importance of 23 outcomes as rated on a discrete visual analog scale. Descriptive statistics were used to rank the outcomes. Subgroup analyses were performed using Mann-Whitney U or Kruskal-Wallis tests.

RESULTS

Questionnaires of 4,518 hemodialysis patients were included in the analysis. The three most important outcomes were safety of treatment, health-related quality of life, and satisfaction with care. Further important outcomes were hospital stays, accompanying symptoms, hemodialysis duration, and the improvement or preservation of a good emotional state. Age, profession, and education had the strongest influence on relevant differences of preferences for outcomes; no relevant influence of sex or comorbidity was observed.

CONCLUSION

Outcomes concerning the delivery or provision of care and aspects influencing quality of life are rated by patients to be at least as important as clinical outcomes. Many of the outcomes judged to be important by the patients are not regularly considered in research, evaluation studies, or quality programs.