Outcome Preferences in Patients With Noninfectious Uveitis: Results of a Best-Worst Scaling Study

Psychosocial Well-Being and Quality of Life in Uveitis: A Review

PURPOSE

As a potentially sight-threatening disease with ocular, systemic, and treatment-related complications, uveitis diminishes quality of life (QOL) and affects psychosocial well-being. This review summarizes the existing tools for evaluating psychosocial well-being and/or QOL in patients with uveitis, explores the biological and non-biological factors affecting psychosocial well-being and/or QOL, and proposes future directions for incorporating these tools into clinical practice.

METHODS

A systematic search of the MEDLINE, Embase, and Cochrane databases from inception to June 8, 2022 was conducted, screening for articles focused on psychosocial well-being and/or QOL in patients with uveitis. Both quantitative and qualitative analyses were performed.

RESULTS

In uveitis research, the most frequently studied patient-reported outcome measures were vision-related QOL (e.g. Visual Function Questionnaire [VFQ-25]) and health-related QOL (e.g. Short Form Survey [SF-36]), followed by mental health indicators including depression and anxiety. Instruments have also been developed specific to the pediatric population (e.g. Effects of Youngsters' Eyesight on Quality of Life [EYE-Q]). Generally, studies report worse psychosocial outcomes and QOL in patients with uveitis compared to the general population. Contributory factors include both clinical (e.g. visual impairment, ocular comorbidities) and patient-related (e.g. older age, female sex) factors.

CONCLUSION

Given the heterogeneity of instruments used, it is worth considering standardization across large uveitis studies and trials. Beyond research, given the biopsychosocial effects on patients with uveitis, there are benefits to incorporating QOL and psychosocial assessments into clinical practice. Simplification of questionnaires into abridged forms, focusing on the most clinically relevant aspects of patient care, may be considered.

Perceived Importance of the Benefits and Harms of Colorectal Cancer Screening: A Best-Worst Scaling Study

OBJECTIVES

To elicit the relative importance of the benefits and harms of colorectal cancer (CRC) screening among potential screening participants in the Dutch population.

METHODS

In a consensus meeting with 11 experts, risk reduction of CRC and CRC deaths (benefits) and complications from colonoscopy, stress of receiving positive fecal immunological test (FIT) results, as well as false-positive and false-negative FIT results (harms) were selected as determinant end points to consider during decision making. We conducted an online best-worst scaling survey among adults aged 55 to 75 years from the Dutch Health Care Consumer Panel of The Netherlands Institute for Health Services Research to elicit preference values for these outcomes. The preference values were estimated using conditional logit regression.

RESULTS

Of 265 participants, 234 (89%) had ever participated in CRC screening. Compared with the stress of receiving a positive FIT result, the outcome perceived most important was the risk of CRC death (odds ratio [OR] 4.5; 95% confidence interval [CI] 3.9-5.1), followed by risk of CRC (OR 4.1; 95% CI 3.6-4.7), a false-negative FIT result (OR 3.1; 95% CI 2.7-3.5), colonoscopy complications (OR 1.6; 95% CI 1.4-1.8), and a false-positive FIT result (OR 1.4; 95% CI 1.3-1.6). The magnitude of these differences in perceived importance varied according to age, educational level, ethnic background, and whether the individual had previously participated in CRC screening.

CONCLUSION

Dutch men and women eligible for FIT-based CRC screening perceive the benefits of screening to be more important than the harms.

Fingolimod versus interferon beta 1-a: Benefit–harm assessment approach based on TRANSFORMS individual patient data

Background

Fingolimod is a disease-modifying drug approved for multiple sclerosis but its benefit–harm balance has never been assessed compared to other active treatments.

Objectives

Our aim was to compare the benefits and harms of fingolimod with interferon beta-1a using individual patient data from TRial Assessing injectable interferon versus FTY720 Oral in RRMS trial.

Methods

We modelled the health status of patients over time including Expanded Disability Status Scale measurements, relapses and any adverse events. We assessed the mean health status between arms and the proportion of patients whose health deteriorated or improved relatively to baseline, using a prespecified minimal important difference of 4.6. We performed sensitivity analyses to test our assumptions.

Results

Main and sensitivity analyses favoured fingolimod 0.5 mg over interferon beta-1a. The average health status difference was 1.01 (95% CI 0.93–1.08). Patients on fingolimod 0.5 mg were 0.47 (95% CI: 0.35–0.63, p < 0.001) times less likely to experience a relevant decline in health status compared to interferon beta-1a patients, with a number needed to treat of 7.10 [5.18, 11.23].

Conclusions

Fingolimod's net benefit over interferon beta-1a did not reach the clinical relevance over 1 year, but the decreased risk for health status deterioration may be more pronounced more long term and patients may prefer less treatment burden associated with fingolimod. [Formula: see text]

Best-Worst Scaling Study to Identify Complications Patients Want to Be Informed About Prior to Abdominal Aortic Aneurysm Surgery

Background

Surgeons must discuss the most severe surgical complications with their patients while making a treatment decision. However, it is unclear which complications patients deem most severe. This study aimed to have patients classify potential complications following abdominal aortic aneurysm surgery based on severity using best–worst scaling.

Methods

Dutch patients with an abdominal aortic aneurysm, either under surveillance or following surgery, received a survey with 33 potential surgical complications. The survey presented these complications in sets of three. Patients had to classify one of three complications as most severe and one as least severe. After all participants had completed the survey, the number of times a complication was classified as most severe was subtracted from the number of times that the complication was classified as least severe, thus resulting in a best–worse scaling score. Complications with the lowest scores were ranked as more severe.

Results

Fifty out of 79 participating patients completed the survey in full. Patients classified the following ten complications as most severe: Below-ankle amputation, aneurysm rupture, stroke, renal failure, type 1 endoleak, spinal cord ischaemia, peripheral bypass surgery, bowel lesion, myocardial infarction and heart failure. Haematoma was ranked as the least severe complication.

Conclusion

This best–worst scaling study enabled patients to classify complications following abdominal aortic aneurysm surgery based on severity. Vascular surgeons should discuss the ten complications deemed most severe with their patients and help their patients to effectively weigh the benefits of surgery against the harms patients themselves deem important, thereby improving shared decision making.

Electronic supplementary material

The online version of this article (10.1007/s40271-020-00438-3) contains supplementary material, which is available to authorized users.

Risks following surgery that are discussed with patients prior to surgery often differ per surgeon. By law, surgeons are required to discuss the most common and most severe complications that may occur following surgery with their patients. But what do patients actually consider to be the most severe complications? In this study, we have asked this question to 50 patients with a widened abdominal aorta. These patients were approached via the Dutch patient organisation for people with cardiovascular diseases (Harteraad) and the Amsterdam University Medical Centres. From previous research, we collected 33 complications that may occur following surgery of the abdominal aorta. Using a survey, participating patients were shown three complications at a time. Of these three complications, they had to indicate which complication they considered the most severe complication and which the least severe complication. After all participants had completed their survey, we looked at how often a complication was deemed most severe and least severe. The ten most severe complications according to the participating patients were forefoot amputation, rupture of the widened abdominal aorta, stroke, kidney failure, leakage of blood along the aortic prosthesis, not enough blood supply to the spinal cord or bowels, a narrowing of the arteries in the leg, a heart attack and heart failure. We recommend that vascular surgeons discuss these ten severe complications with their patient, when a decision must be made about whether or not that patient should undergo surgery for their widened abdominal aorta. This will allow patients to weigh the benefits of the surgery against the risks they themselves deem important.

Informing Patient-Centered Care Through Stakeholder Engagement and Highly Stratified Quantitative Benefit-Harm Assessments

OBJECTIVES

In a previous project aimed at informing patient-centered care for people with multiple chronic conditions, we performed highly stratified quantitative benefit-harm assessments for 2 top priority questions. In this current work, our goal was to describe the process and approaches we developed and to qualitatively glean important elements from it that address patient-centered care.

METHODS

We engaged patients, caregivers, clinicians, and guideline developers as stakeholder representatives throughout the process of the quantitative benefit-harm assessment and investigated whether the benefit-harm balance differed based on patient preferences and characteristics (stratification). We refined strategies to select the most applicable, valid, and precise evidence.

RESULTS

Two processes were important when assessing the balance of benefits and harms of interventions: (1) engaging stakeholders and (2) stratification by patient preferences and characteristics. Engaging patients and caregivers through focus groups, preference surveys, and as co-investigators provided value in prioritizing research questions, identifying relevant clinical outcomes, and clarifying the relative importance of these outcomes. Our strategies to select evidence for stratified benefit-harm assessments considered consistency across outcomes and subgroups. By quantitatively estimating the range in the benefit-harm balance resulting from true variation in preferences, we clarified whether the benefit-harm balance is preference sensitive.

CONCLUSIONS

Our approaches for engaging patients and caregivers at all phases of the stratified quantitative benefit-harm assessments were feasible and revealed how sensitive the benefit-harm balance is to patient characteristics and individual preferences. Accordingly, this sensitivity can suggest to guideline developers when to tailor recommendations for specific patient subgroups or when to explicitly leave decision making to individual patients and their providers.

Balance of benefits and harms of different blood pressure targets in people with multiple chronic conditions: a quantitative benefit-harm assessment

OBJECTIVE

Recent studies suggest that a systolic blood pressure (SBP) target of 120 mm Hg is appropriate for people with hypertension, but this is debated particularly in people with multiple chronic conditions (MCC). We aimed to quantitatively determine whether benefits of a lower SBP target justify increased risks of harm in people with MCC, considering patient-valued outcomes and their relative importance.

DESIGN

Highly stratified quantitative benefit-harm assessment based on various input data identified as the most valid and applicable from a systematic review of evidence and based on weights from a patient preference survey.

SETTING

Outpatient care.

PARTICIPANTS

Hypertensive patients, grouped by age, gender, prior history of stroke, chronic heart failure, chronic kidney disease and type 2 diabetes mellitus.

INTERVENTIONS

SBP target of 120 versus 140 mm Hg for patients without history of stroke.

PRIMARY AND SECONDARY OUTCOME MEASURES

Probability that the benefits of a SBP target of 120 mm Hg outweigh the harms compared with 140 mm Hg over 5 years (primary) with thresholds >0.6 (120 mm Hg better), <0.4 (140 mm Hg better) and 0.4 to 0.6 (unclear), number of prevented clinical events (secondary), calculated with the Gail/National Cancer Institute approach.

RESULTS

Considering individual patient preferences had a substantial impact on the benefit-harm balance. With average preferences, 120 mm Hg was the better target compared with 140 mm Hg for many subgroups of patients without prior stroke, especially in patients over 75. For women below 65 with chronic kidney disease and without diabetes and prior stroke, 140 mm Hg was better. The analyses did not include mild adverse effects, and apply only to patients who tolerate antihypertensive treatment.

CONCLUSIONS

For most patients, a lower SBP target was beneficial, but this depended also on individual preferences, implying individual decision-making is important. Our modelling allows for individualised treatment targets based on patient preferences, age, gender and co-morbidities.

Use of best-worst scaling to estimate the magnitude of stressful life events in older adults

AIM

The magnitude of stressful life events can be measured by using rating scales such as the Social Readjustment Rating Scale. This study aimed to estimate the magnitude of stressful life events by using a best-worst scaling approach in a sample of community-dwelling older persons in Taiwan.

METHODS

Participants aged 55 years or older were asked to rate the stressfulness of 11 life events on a scale from 0 to 10 and the best-worst scaling. We used the case one (object case) best-worst scaling design: each task on a list of events was presented to participants, and they were asked to indicate the events that they considered most and least stressful.

RESULTS

A total of 61 persons (66% women) provided valid responses for analysis; the mean age was 64.8 ± 8.6 years. For best-worst scaling, 'major illness of family member' (mean best-minus-worst score = 128) was rated the most stressful, and 'sexual difficulties' was rated the least stressful (mean best-minus-worst score = -153). For the rating scale, 'major personal illness' was rated the most stressful (mean rating = 6.95), and 'sexual difficulties' was again the least stressful (mean rating = 2.05). Rankings of events based on both methods were similar but were different from ratings based on the Social Readjustment Rating Scale.

CONCLUSION

The current study explored using BWS to estimate the magnitude of stressful life events. The magnitude of events estimated in our study was found to differ from the magnitude estimated previously by some common scales for assessing stressful life events.

The burden of non-infectious intraocular inflammatory eye diseases: a systematic literature review

OBJECTIVE

Non-infectious inflammatory eye diseases (IEDs), although rare, are complex and varied and may result in detrimental effects. A systematic literature review was conducted on the clinical outcome and economic burden of IED.

METHODS

The Ovid search platform (Wolters Kluwer) was used to access scientific literature databases, including MEDLINE, Embase, Cochrane libraries, Health Technology Assessment and the NHS Economic Evaluation database. The search strategy targeted clinical and economic outcomes research in 2009-2016. Titles and abstracts resulting from inclusion criteria were screened, and two reviewers independently extracted relevant information from the selected full-text articles.

RESULTS

Thirty-nine papers met the inclusion criteria - 21 clinical trials, 7 database analyses, 6 non-systematic literature reviews with expert commentary, 3 chart reviews, and 2 surveys - which assessed steroids, immunosuppressants, implants and biologics. Patients experienced considerable morbidity, much of which was associated with corticosteroid use. The average annual healthcare costs of patients with IED were $13,728 to $32,268 in 2009 US dollars, which amounted to 3.1 to 8.3 times that of patients without IED. Steroid-releasing intraocular implants were associated with higher up-front costs, close monitoring requirements, potential for implant removal and increased rates of adverse ocular events than systemic steroids.

CONCLUSIONS

IEDs are rare and complex conditions that threaten eyesight and impose considerable morbidity as well as a substantial economic burden. This review confirms that further research is needed to more fully explore the burden of IED and treatment-related adverse events, as well as appropriate means for clinicians to intensify treatment.

Guidance on Noncorticosteroid Systemic Immunomodulatory Therapy in Noninfectious Uveitis: Fundamentals Of Care for UveitiS (FOCUS) Initiative

TOPIC

An international, expert-led consensus initiative to develop systematic, evidence-based recommendations for the treatment of noninfectious uveitis in the era of biologics.

CLINICAL RELEVANCE

The availability of biologic agents for the treatment of human eye disease has altered practice patterns for the management of noninfectious uveitis. Current guidelines are insufficient to assure optimal use of noncorticosteroid systemic immunomodulatory agents.

METHODS

An international expert steering committee comprising 9 uveitis specialists (including both ophthalmologists and rheumatologists) identified clinical questions and, together with 6 bibliographic fellows trained in uveitis, conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol systematic review of the literature (English language studies from January 1996 through June 2016; Medline [OVID], the Central Cochrane library, EMBASE, CINAHL, SCOPUS, BIOSIS, and Web of Science). Publications included randomized controlled trials, prospective and retrospective studies with sufficient follow-up, case series with 15 cases or more, peer-reviewed articles, and hand-searched conference abstracts from key conferences. The proposed statements were circulated among 130 international uveitis experts for review. A total of 44 globally representative group members met in late 2016 to refine these guidelines using a modified Delphi technique and assigned Oxford levels of evidence.

RESULTS

In total, 10 questions were addressed resulting in 21 evidence-based guidance statements covering the following topics: when to start noncorticosteroid immunomodulatory therapy, including both biologic and nonbiologic agents; what data to collect before treatment; when to modify or withdraw treatment; how to select agents based on individual efficacy and safety profiles; and evidence in specific uveitic conditions. Shared decision-making, communication among providers and safety monitoring also were addressed as part of the recommendations. Pharmacoeconomic considerations were not addressed.

CONCLUSIONS

Consensus guidelines were developed based on published literature, expert opinion, and practical experience to bridge the gap between clinical needs and medical evidence to support the treatment of patients with noninfectious uveitis with noncorticosteroid immunomodulatory agents.

Using Best-Worst Scaling to Investigate Preferences in Health Care

INTRODUCTION

Best-worst scaling (BWS) is becoming increasingly popular to elicit preferences in health care. However, little is known about current practice and trends in the use of BWS in health care. This study aimed to identify, review and critically appraise BWS in health care, and to identify trends over time in key aspects of BWS.

METHODS

A systematic review was conducted, using Medline (via Pubmed) and EMBASE to identify all English-language BWS studies published up until April 2016. Using a predefined extraction form, two reviewers independently selected articles and critically appraised the study quality, using the Purpose, Respondents, Explanation, Findings, Significance (PREFS) checklist. Trends over time periods (≤2010, 2011, 2012, 2013, 2014 and 2015) were assessed further.

RESULTS

A total of 62 BWS studies were identified, of which 26 were BWS object case studies, 29 were BWS profile case studies and seven were BWS multi-profile case studies. About two thirds of the studies were performed in the last 2 years. Decreasing sample sizes and decreasing numbers of factors in BWS object case studies, as well as use of less complicated analytical methods, were observed in recent studies. The quality of the BWS studies was generally acceptable according to the PREFS checklist, except that most studies did not indicate whether the responders were similar to the non-responders.

CONCLUSION

Use of BWS object case and BWS profile case has drastically increased in health care, especially in the last 2 years. In contrast with previous discrete-choice experiment reviews, there is increasing use of less sophisticated analytical methods.

Using a patient-centered approach to benefit-harm assessment in treatment decision-making: a case study in uveitis

BACKGROUND

Synthesizing evidence from comparative effectiveness trials can be difficult because multiple outcomes of different importance are to be considered. The goal of this study was to demonstrate an approach to conducting quantitative benefit-harm assessment that considers patient preferences.

METHODS

We conducted a benefit-harm assessment using data from the Multicenter Uveitis Steroid Treatment Trial that compared corticosteroid implant versus systemic corticosteroids and immunosuppression in non-infectious intermediate, posterior, and panuveitis. We focused on clinical outcomes considered important to patients, including visual acuity, development of cataracts/glaucoma, need for eye surgery, prescription-requiring hypertension, hyperlipidemia, and infections. Patient preferences elicited in a recent survey were then incorporated into our assessment of the benefit-harm balance.

RESULTS

Benefit-harm metrics were calculated for each time point that summarized the numbers of outcomes, caused or prevented by implant therapy versus systemic therapy if 1000 patients were treated. The benefit-harm metric was -129 (95% confidence interval: -242 to -14), -317 (-436 to -196), -390 (-514 to -264), and -526 (-687 to -368) at 6, 12, 18, and 24 months follow up, respectively, suggesting that systemic therapy may have a better benefit-harm balance. However, measures of quality of life for patients treated with implant therapy were found to be better than patients treated with systemic therapy over the same time period.

CONCLUSIONS

Results of benefit-harm assessment were different from the prospectively collected quality of life data during trial follow up. Future studies should explore the reasons for such discrepancies and the strength and weakness of each method to assess treatment benefits and harms.