Treatment choices by seriously ill patients: the Health Stock Risk Adjustment model

Economic Evaluation for the UK of Systemic Chemotherapies as First-Line Treatment of Metastatic Pancreatic Cancer

BACKGROUND

Gemcitabine (GEM), oxaliplatin plus GEM (OX + GEM), cisplatin plus GEM (CIS + GEM), capecitabine plus GEM (CAP + GEM), FOLFIRINOX (FFX), and nab-paclitaxel plus GEM (NAB-P + GEM) are the most commonly used regimens as first-line treatment of metastatic pancreatic cancer (MPC) in the UK. Independent economic evaluation of these regimens simultaneously has not been conducted for the UK.

OBJECTIVE

Using data from a network meta-analysis as efficacy measures, we estimated the cost effectiveness and cost utility of these regimens for the UK.

METHODS

A three-state Markov model (progression-free, progressed-disease, and death) simulating the total costs and health outcomes (quality-adjusted life-years [QALYs] gained and life-years [LYs]) was developed to estimate the incremental cost-utility (ICUR) and incremental cost-effectiveness ratios (ICER) for patients with MPC, from the payer perspective. The model was specified to calculate total costs in 2017 British pounds (GBP, £). All values were discounted at 3.5% per year over a full lifetime horizon. One-way sensitivity and probabilistic sensitivity analyses were conducted to assess the impact of parameter uncertainty on the results.

RESULTS

FFX was the most effective regimen, NAB-P + GEM was the most costly regimen, and GEM was the least costly and least effective regimen. OX + GEM, CIS + GEM, and NAB-P + GEM were dominated by CAP + GEM and FFX. Compared with GEM, the ICUR for CAP + GEM and FFX was £28,066 and £33,020/QALY gained, respectively; compared with GEM, the ICER for CAP + GEM and FFX was £17,437 and £22,291/LY gained, respectively; and compared with CAP + GEM, the ICUR and ICER for FFX were £34,947/QALY gained and 24,414/LY gained, respectively.

CONCLUSIONS

At a threshold value of £30,000/QALY, CAP + GEM was found to be the only cost-effective regimen in the management of MPC in the UK.

Do Risk Attitudes Differ across Domains and Respondent Types?

Objective . To evaluate differences in risk attitude across the domains of health and money for 2 types of respondents, patients and community members. Methods . Two groups of respondents, patients with multiple sclerosis (n = 56) and members of the general community (n = 57), completed a survey that collected information on risk attitudes and socioeconomic and clinical variables (e.g., disability level). Risk attitude was measured using 2 standard-gamble questions on money and 1 standard-gamble question on health outcomes. Multivariate regression was used to evaluate the relationship between risk attitude and respondent type (patient v. community), adjusting for covariates that could affect risk attitude. Results . The median certainty equivalents for money gambles were significantly different from and less than the expected value of the gamble for both types of respondents. Median certainty equivalents for the health gamble were not significantly different from the expected value for either group of respondents. For all 3 gambles, there was no difference in median certainty equivalents between the 2 types of respondents in both unadjusted and adjusted analyses. Conclusions . Risk attitude varied across domains but not by respondent type. Patients and community members were predominantly risk neutral with respect to health outcomes and risk averse with respect to money. Research on risk preferences on money outcomes may not be an appropriate proxy for risk preferences regarding health outcomes. Risk preferences may depend more on characteristics of the choice than on respondent type.

An Exploration of Relative Health Stock in Advanced Cancer Patients

Objective. The authors sought to empirically test whether relative health stock, a measure of patients’ sense of loss in their health due to illness, influences the treatment decisions of patients facing life-threatening conditions. Specifically, they estimated the effect of relative health stock on advanced cancer patients’ decisions to participate in phase I clinical trials. Method. A multicenter study was conducted to survey 328 advanced cancer patients who were offered the opportunity to participate in phase I trials. The authors asked patients to estimate the probabilities of therapeutic benefits and toxicity, their relative health stock, risk preference, and the importance of quality of life. Results. Controlling for health-related quality of life, an increase in relative health stock by 10 percentage points reduced the odds of choosing to participate in a phase I trial by 16% (odds ratio = 0.84, 95% confidence interval = 0.72, 0.97). Conclusion. Relative health stock affects advanced cancer patients’ treatment decisions.

Decision-Making Process Related to Participation in Phase I Clinical Trials: A Nonsystematic Review of the Existing Evidence

Due to the lack of other treatment options, patient candidates for participation in phase I clinical trials are considered the most vulnerable, and many ethical concerns have emerged regarding the informed consent process used in the experimental design of such trials. Starting with these considerations, this nonsystematic review is aimed at analyzing the decision-making processes underlying patients' decision about whether to participate (or not) in phase I trials in order to clarify the cognitive and emotional aspects most strongly implicated in this decision. Considering that there is no uniform decision calculus and that many different variables other than the patient-physician relationship (including demographic, clinical, and personal characteristics) may influence patients' preferences for and processing of information, we conclude that patients' informed decision-making can be facilitated by creating a rigorously developed, calibrated, and validated computer tool modeled on each single patient's knowledge, values, and emotional and cognitive decisional skills. Such a tool will also help oncologists to provide tailored medical information that is useful to improve the shared decision-making process, thereby possibly increasing patient participation in clinical trials.

"Nudge" in the clinical consultation--an acceptable form of medical paternalism?

Background

Libertarian paternalism is a concept derived from cognitive psychology and behavioural science. It is behind policies that frame information in such a way as to encourage individuals to make choices which are in their best interests, while maintaining their freedom of choice. Clinicians may view their clinical consultations as far removed from the realms of cognitive psychology but on closer examination there are a number of striking similarities.

Discussion

Evidence has shown that decision making is prone to bias and not necessarily rational or logical, particularly during ill health. Clinicians will usually have an opinion about what course of action represents the patient’s best interests and thus may “frame” information in a way which “nudges” patients into making choices which are considered likely to maximise their welfare. This may be viewed as interfering with patient autonomy and constitute medical paternalism and appear in direct opposition to the tenets of modern practice. However, we argue that clinicians have a responsibility to try and correct “reasoning failure” in patients. Some compromise between patient autonomy and medical paternalism is justified on these grounds and transparency of how these techniques may be used should be promoted.

Summary

Overall the extremes of autonomy and paternalism are not compatible in a responsive, responsible and moral health care environment, and thus some compromise of these values is unavoidable. Nudge techniques are widely used in policy making and we demonstrate how they can be applied in shared medical decision making. Whether or not this is ethically sound is a matter of continued debate but health care professionals cannot avoid the fact they are likely to be using nudge within clinical consultations. Acknowledgment of this will lead to greater self-awareness, reflection and provide further avenues for debate on the art and science of clinical communication.

A Web-based communication aid for patients with cancer: the CONNECT Study

BACKGROUND

Cancer patients and their oncologists often report differing perceptions of consultation discussions and discordant expectations regarding treatment outcomes. CONNECT, a computer-based communication aid, was developed to improve communication between patients and oncologists.

METHODS

CONNECT includes assessment of patient values, goals, and communication preferences; patient communication skills training; and a preconsultation physician summary report. CONNECT was tested in a 3-arm, prospective, randomized clinical trial. Prior to the initial medical oncology consultation, adult patients with advanced cancer were randomized to the following arms: 1) control; 2) CONNECT with physician summary; or 3) CONNECT without physician summary. Outcomes were assessed with postconsultation surveys.

RESULTS

Of 743 patients randomized, 629 completed postconsultation surveys. Patients in the intervention arms (versus control) felt that the CONNECT program made treatment decisions easier to reach (P = .003) and helped them to be more satisfied with these decisions (P < .001). In addition, patients in the intervention arms reported higher levels of satisfaction with physician communication format (P = .026) and discussion regarding support services (P = .029) and quality of life concerns (P = .042). The physician summary did not impact outcomes. Patients with higher levels of education and poorer physical functioning experienced greater benefit from CONNECT.

CONCLUSIONS

This prospective randomized clinical trial demonstrates that computer-based communication skills training can positively affect patient satisfaction with communication and decision-making. Measurable patient characteristics may be used to identify subgroups most likely to benefit from an intervention such as CONNECT.

Cost implications of new treatments for advanced colorectal cancer

BACKGROUND

Since 1996, 6 new drugs have been introduced for the treatment of metastatic colorectal cancer. Although they are promising, these drugs frequently are given in the palliative and are much more expensive than older treatments. The objective of the current study was to measure the cost implications of treatment with sequential regimens that include chemotherapy and/or monoclonal antibodies.

METHODS

A Markov model was used to evaluate a hypothetical cohort of 1000 patients with newly diagnosed, metastatic colorectal cancer. Patients supposedly received up to 3 lines of treatment before supportive care and subsequent death. Data were obtained from published, multicenter phase 2 and randomized phase 3 clinical trials. Sensitivity analyses were conducted on the efficacy, toxicity, and cost.

RESULTS

Using drug costs alone, treatment that included new chemotherapeutic agents increased survival at an incremental cost-effectiveness ratio (ICER) of $100,000 per discounted life-year (DLY). The addition of monoclonal antibodies improved survival at an ICER of >$170,000 per DLY. The results were most sensitive to changes in the initial regimen. Even with significant improvements in clinical characteristics (efficacy and toxicity), treatment with the most effective regimens still had very high ICERs.

CONCLUSIONS

Treatment of metastatic colorectal cancer with the most effective regimens came at very high incremental costs. The authors concluded that cost-effectiveness analyses should be a routine component of the drug-development process, so that physicians and patients are informed appropriately regarding the value of new innovations.

Cancer patients' awareness of clinical trials, perceptions on the benefit and willingness to participate: Korean perspectives

To understand patients' perceptions of clinical trials (CTs) is the principal step in the enrolment of patients to CTs. However, these perceptions in eastern countries are very rare. From 12 February 2007 to 13 April 2007, we consecutively distributed the questionnaire to 842 cancer patients who initiated a first cycle of chemotherapy regardless of each treatment step in the Seoul National University Hospital. Younger age, higher educational degree, higher economic status, and possession of private cancer insurance were related with significantly higher awareness of CTs (P=0.001, P=0.006, P=0.002, and P=0.009, respectively). However, unlike awareness, perceptions on benefits of CTs were not changed according to age, educational degree, and economic status (P=0.709, P=0.920, and P=0.847, respectively). Willingness was also not changed according to age, educational degree, economic status, and private cancer insurance (P=0.381, P=0.775, P=0.887, and P=0.392, respectively). Instead, males and heavily treated patients had more positive perceptions on benefits (P=0.002 and P=0.001, respectively) and more willingness to participate in CTs (OR=1.17, 1.14–2.75: OR=1.59, 1.01–2.51, respectively). In summary, cancer patients' awareness of CTs, perceptions on the benefit in CTs, and willingness to participate are differently influenced by diverse medical and social conditions. This information would be very helpful for investigators to properly conduct CTs in eastern cancer patients.

Cost of cancer care: issues and implications

Medical technology is increasingly costly in most fields of clinical medicine. Oncology has not been spared from issues related to cost, in part resulting from the tremendous scientific progress that has lead to new tools for diagnosis, treatment, and follow-up of our patients. The increasing cost of health care in general (and cancer care in particular) raises complex questions related to its effects on our economy and the citizens of our society. This article reviews the macroeconomic principles and individual behaviors that govern medical spending, and examines how cost disproportionately affects various populations. Our overall goal is to frame debate about health policy concerns that influence the clinical practice of oncology.

Value of High-Cost Cancer Care: A Behavioral Science Perspective

Concerns about the high costs of cancer care have led to a renewed interest in understanding how patients value the outcomes of care. Psychologists, economists, and others have highlighted some of the ways in which patients and caregivers perceive and make treatment decisions. Prospect theory is the predominant framework for understanding decisions made in situations where the outcomes of each choice are uncertain. Prospect theory assumes that a patient values the outcomes of care not in absolute terms, such as years of life saved, but as deviations from the patient's point of reference. This article discusses some of the implications of this notion, along with discussing differences among people in their reference points. These and other considerations from the psychology of decision making help to clarify why some patients might be inclined to seek expensive or risky treatments in the hopes of achieving benefits that others might consider not worthwhile. An appreciation of these psychological issues might improve the quality of debates concerning the rising costs of cancer care.

An Internet method to assess cancer patient information needs and enhance doctor-patient communication: a pilot study

BACKGROUND

We previously reported that doctor-patient communication in the cancer context may be suboptimal. We therefore developed measures to assess patient communication preferences and established feasibility of an Internet-based intervention to improve communication.

METHODS

Cancer patients completed an Internet-based survey about communication preferences, with a summary provided to the physician before the consultation. Patients completed a follow-up survey to assess consultation content and satisfaction.

RESULTS

Study procedures were feasible, measures exhibited strong internal consistency, and patients expressed satisfaction with the intervention.

CONCLUSION

The Internet offers an opportunity to assess patient preferences and prompt physicians about individual patient informational needs prior to the clinical encounter.

Understanding of an aggregate probability statement by patients who are offered participation in Phase I clinical trials

BACKGROUND

There is concern that patients with poor numeracy may have difficulty understanding the information necessary to make informed treatment decisions. The authors sought to characterize a special form of numeracy among patients with advanced cancer who were offered participation in Phase I oncology clinical trials.

METHODS

Surveys were administered to 328 cancer patients who were considering Phase I trials. Their frequency-type numeracy was assessed using a multiple-choice question involving a hypothetical scenario in which a physician stated that an experimental treatment would control cancer in "40% of cases like yours." In univariate and multivariable analyses, patient characteristics that were associated with better numeracy were identified.

RESULTS

The correct frequency-type interpretation was selected by 72% of respondents. Fourteen percent of respondents incorrectly selected a belief-type answer, "The doctor is 40% confident that the treatment will control my cancer." In a multivariable model, patients who answered incorrectly tended to have less formal education and less experience with experimental therapies.

CONCLUSIONS

Because the misunderstandings some patients demonstrated may influence their treatment decision making adversely, it is critical to identify such patients and to give them special consideration when communicating information about potential risks and benefits of treatment.

Perceptions of patients and physicians regarding phase I cancer clinical trials: implications for physician-patient communication

PURPOSE

To describe and compare the perceptions of cancer patients and their physicians regarding phase I clinical trials.

METHODS

Eligible patients had been offered phase I trial participation and had decided to participate but had not yet begun treatment. Each patient's physician also served as a study subject. Patients and physicians completed questionnaires with domains including perceptions of potential benefit and harm from treatment (experimental and standard), relative value of quality and length of life, and perceived content of patient-physician consultations.

RESULTS

Three hundred twenty-eight patients and 48 physicians completed surveys. Patients had high expectations regarding treatment outcomes (eg, median 60% benefit from experimental therapy), with those choosing to participate in a phase I trial being more optimistic than those declining phase I participation. Patients predicted a higher likelihood of both benefit and adverse reactions from treatment (experimental and standard) than their physicians (P <.0001 for all comparisons). Although 95% of patients reported that quality of life was at least as important as length of life, only 28% reported that changes in quality of life with treatment were discussed with their physicians. In contrast, 73% of physicians reported that this topic was discussed (P <.0001).

CONCLUSION

Cancer patients offered phase I trial participation have expectations for treatment benefit that exceed those of their physicians. The discordant perceptions of patients and physicians may possibly be explained by patient optimism and confidence; however, the discrepancies in reports of consultation content, particularly given patients' stated values regarding quality of life, raise the possibility that communication in this context is suboptimal.

The correlation between patient characteristics and expectations of benefit from Phase I clinical trials

BACKGROUND

Patients in Phase I clinical trials sometimes report high expectations regarding the benefit of treatment. The authors examined a range of patient characteristics to determine which factors were associated with greater expectations of benefit from Phase I trials.

METHODS

Participants were adult patients with cancer who had been offered participation in Phase I studies and had decided to participate. Patients completed interviewer-administered surveys before initiation of treatment. Physicians assessed Eastern Cooperative Oncology Group performance status for each patient. Statistical analyses (Pearson product moment correlation and t tests) used multiple imputation to account for missing data.

RESULTS

Overall, 593 patients who were offered participation in Phase I trials were contacted, and 328 patients agreed to participate in a study of decision making by cancer patients. Of these, 260 patients (79%) enrolled in a Phase I trial. Patients' expectations regarding the chance that their disease would be controlled with experimental therapy were unrelated to age, gender, living situation, education level, or functional status. Expectations were correlated positively with beliefs about the benefit of standard therapy and the maximum benefit patients may experience from experimental therapy. Greater expectations of benefit were associated with better health-related quality of life, stronger religious faith, optimism, relative health stock, monetary risk seeking, and poorer numeracy.

CONCLUSIONS

Expectations expressed as beliefs in personal outcomes may be related more to quality of life and personality variables than to patients' knowledge or functional status. Whether such expectations are accurate reflections of knowledge has important implications for evaluating the informed consent process.

Outcomes research in oncology: improving patients' experiences with cancer treatment

Outcomes research in oncology is a relatively young field, but its potential for expanding our understanding of patients' experiences with cancer gives it increasing relevance to clinical oncology research. We provide a brief overview of the growing prevalence of oncology outcomes research, and we discuss some of the key areas of inquiry currently engaging outcomes researchers. In doing so, we introduce the articles in this supplemental section, which address some of the unique concerns of outcomes researchers and outline the most important challenges confronting this research community.

Economic analysis of conventional-dose chemotherapy compared with high-dose chemotherapy plus autologous hematopoietic stem-cell transplantation for metastatic breast cancer

We performed an economic analysis of data from 180 women in a clinical trial of conventional-dose chemotherapy vs high-dose chemotherapy plus stem-cell transplantation for metastatic breast cancer responding to first-line chemotherapy. Data on resource use, including hospitalizations, medical procedures, medications, and diagnostic tests, were abstracted from subjects' clinical trial records. Resources were valued using the Medicare Fee Schedule for inpatient costs at one academic medical center and average wholesale prices for medications. Monthly costs were calculated and stratified by treatment group and clinical phase. Mean follow-up was 690 days in the transplantation group and 758 days in the conventional-dose chemotherapy group. Subjects in the transplantation group were hospitalized for more days (28.6 vs 17.8, P=0.0041) and incurred higher costs (US dollars 84055 vs US dollars 28169) than subjects receiving conventional-dose chemotherapy, with a mean difference of US dollars 55886 (95% CI, US dollars 47298-US dollars 63666). Sensitivity analyses resulted in cost differences between the treatment groups from US dollars 36528 to US dollars 75531. High-dose chemotherapy plus stem-cell transplantation resulted in substantial additional morbidity and costs at no improvement in survival. Neither the survival results nor the economic findings support the use of this procedure outside of the clinical trial setting.

Outcomes research related to patient decision making in oncology

For outcomes research, what are the implications of seeing the patient as a decision maker? In the current medical environment, greater emphasis is placed on the role played by the patient in clinical decision making. In the past 2 decades, considerable work has been done to identify and measure decision-related outcomes, including knowledge about the treatment options (risks and benefits), satisfaction, anxiety, decisional conflict, and involvement in the decision process. Attempts to improve these decision-related outcomes involve patient decision aids, which convey patient-specific information and sometimes help patients proceed through an explicit decision-making process. These interventions have produced positive results, especially with respect to improving patient knowledge. Future research is needed to understand which aspects of the interventions work and for what types of patients. Research is also needed to better understand the decision making process of patients who do not use decision aids.

What is known about the economics of end-of-life care for medicare beneficiaries?

PURPOSE

This article reviews the state of science on the economics of end-of-life care for Medicare beneficiaries and outlines the research needed to fill gaps in that literature.

DESIGNS AND METHODS

Searches of the medical, health services, and economics literature were conducted. Key topics examined were studies of spending on end-of-life care and financial, organizational, and nonfinancial barriers to high-quality end-of-life care.

RESULTS

Studies have documented poor quality of care, dissatisfaction with care, and limitations in the coverage of end-of-life care for Medicare beneficiaries. However, critical gaps in our knowledge about how to design a better end-of-life care system for Medicare beneficiaries remain.

IMPLICATIONS

Further research on how treatment decisions at the end of life are made and prospective studies of costs, satisfaction, and outcomes are needed.

Impact of quality of life on patient expectations regarding phase I clinical trials

PURPOSE

Quality of life (QOL) is increasingly recognized as a critical cancer-treatment outcome measure, but little is known about the impact of QOL on the patient decision-making process. A pilot study was conducted in an effort to (1) measure the expectations of patients, physicians, and research nurses regarding the potential benefits and toxicities from experimental and standard therapies, and (2) determine the relationship of QOL to patient perceptions regarding treatment options.

METHODS

Thirty cancer patients enrolling in phase I clinical trials, their physicians, and their research nurses were administered questionnaires that assessed demographics, QOL, and treatment expectations.

RESULTS

Compared with their physicians, patients overestimated potential benefits and toxicities from experimental therapy (mean expected benefit, 59.8% v 23.8%, P <.01; mean expected toxicity, 29.8% v 16.0%, P <.01). Patients estimated a greater potential for benefit (59.8% v 36.8%, P <.01) and less potential for toxicity (29.8% v 45.6%, P =.01) for experimental therapy, compared with standard therapy. Short Form-36 general health perception correlated with patient perception of potential benefit from experimental therapy (r =.48, P =.01).

CONCLUSION

Participants in phase I clinical trial have high expectations regarding the success of experimental therapy and discount potential toxicity. Patient QOL may affect the expectation of benefit from experimental therapy and, ultimately, treatment choice. Understanding the interactions between QOL and patient expectations may guide the development of improved strategies to present appropriate information to patients considering early-phase clinical trials.