Preferences of GPs and patients for preventive osteoporosis drug treatment: a discrete-choice experiment

Determining patient preferences for the medical management of osteoporosis using conjoint analysis

We used conjoint analysis-a method that assesses complex decision making-to quantify patients' choices when selecting an osteoporosis therapy. While 60% of people prioritized medication efficacy when deciding among treatments, the remaining 40% highly valued factors other than efficacy, suggesting the need for personalized shared decision-making tools.

INTRODUCTION

In this study, we aimed to examine patient decision-making surrounding osteoporosis medications using conjoint analysis.

METHODS

We enrolled osteoporosis patients at an academic medical center to complete an online conjoint exercise which calculated each patient's relative importance score of 6 osteoporosis medication attributes (higher = greater relative importance in decision-making). We used latent class analysis to identify distinct segments of patients with similar choice patterns and then used logistic regression to determine if demographics and osteoporosis disease features were associated with latent class assignment.

RESULTS

Overall, 304 participants completed the survey. The rank order of medication attributes by importance score was the following: efficacy at preventing hip fractures (accounted for 31.0% of decision making), mode of administration (17.5%); risk of serious side effects (16.6%); dose frequency (13.9%); efficacy at preventing spine fractures (12.5%); risk of non-serious side effects (8.4%). We found that 60.9% of the cohort prioritized medication efficacy as their top factor when selecting among the therapies. Being a college graduate, having stronger beliefs on the necessity of using medications for osteoporosis, and never having used osteoporosis medicines were the only factors associated with prioritizing medication efficacy for fracture prevention over the other factors in the decision-making process.

CONCLUSIONS

While about 60% of patients prioritized efficacy when selecting an osteoporosis therapy, the remaining 40% valued other factors more highly. Furthermore, individual patient characteristics and clinical factors did not reliably predict patient decision making, suggesting that development and implementation of shared decision-making tools is warranted.

Preferences for active surveillance or standard oesophagectomy: discrete-choice experiment

Over one-quarter of patients would choose not to undergo standard oesophagectomy again, at least 1 year after they underwent neoadjuvant chemoradiotherapy and standard oesophagectomy. These patients had worse short- and long-term health-related quality of life (HRQoL) than patients who chose standard oesophagectomy. Considering both treatments, 5-year survival and long-term HRQoL were considered most important factors by individual patients.

Health state utilities associated with treatment process for oral and injectable GLP-1 receptor agonists for type 2 diabetes

Purpose

Previous research suggests that treatment process can have an influence on patient preference and health state utilities. This study examined preferences and estimated utilities for treatment processes of two daily oral treatment regimens and two weekly injectable regimens for treatment of type 2 diabetes (T2D).

Methods

Participants with T2D in the UK reported preferences and valued four health state vignettes in time trade-off utility interviews. The vignettes had identical descriptions of T2D but differed in treatment process: (1) daily simple oral treatment (tablets without administration requirements), (2) daily oral semaglutide (with administration requirements per product label), (3) weekly dulaglutide injection, (4) weekly semaglutide injection.

Results

Interviews were completed by 201 participants (52.7% male; mean age = 58.7). Preferences between treatment processes varied widely. Mean utilities were 0.890 for simple oral, 0.880 for oral semaglutide, 0.878 for dulaglutide injection, and 0.859 for semaglutide injection (with higher scores indicating greater preference). All pairwise comparisons found statistically significant differences between utilities (p < 0.01), except the comparison between oral semaglutide and the dulaglutide injection (p = 0.49).

Conclusions

Results suggest that routes of administration cannot be compared using only the simplest descriptions (e.g., oral versus injectable). Dose frequency and specific details of the treatment process administration had an impact on patient preference and health state utilities. The utilities estimated in this study may be useful in cost-utility models comparing these treatments for T2D. Results also suggest that it may be helpful to consider patient preferences for treatment process when selecting medications for patients in clinical settings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-02808-2.

Preferences, satisfaction and decision-making processes in osteoporosis treatment: a systematic review of the literature

Aim: To synthesize information available in the literature on patients' preferences and satisfaction with osteoporosis treatment and their unmet needs on the treatment decision-making process. Materials & methods: Systematic literature review consulting international database and grey literature of articles published between January 1, 2009 and January 1, 2019. Results: Nineteen publications were reviewed, 79% of them focused on evaluating the importance that patients attached to the mode and frequency of administration, adverse events and treatment efficacy. 21% of them provided information about treatment satisfaction and 26% regarding unmet needs on treatment-decision making process. Conclusion: Aligning treatment with patients' preferences, promoting physician-patient communication and identifying patients' concerns with treatment may contribute to improve treatment satisfaction and adherence and ultimately achieve the treatment goal.

What are patients' preferences for revision surgery after periprosthetic joint infection? A discrete choice experiment

OBJECTIVES

Understanding patients' preferences for treatment is crucial to provision of good care and shared decisions, especially when more than one treatment option exists for a given condition. One such condition is infection of the area around the prosthesis after hip replacement, which affects between 0.4% and 3% of patients. There is more than one treatment option for this major complication, and our study aimed to assess the value that patients place on aspects of revision surgery for periprosthetic hip infection.

DESIGN

We identified four attributes of revision surgery for periprosthetic hip infection. Using a discrete choice experiment (DCE), we measured the value placed on each attribute by 57 people who had undergone either one-stage or two-stage revision surgery for infection.

SETTING

The DCE was conducted with participants from nine National Health Service hospitals in the UK.

PARTICIPANTS

Adults who had undergone revision surgery for periprosthetic hip infection (N=57).

RESULTS

Overall, the strongest preference was for a surgical option that resulted in no restrictions on engaging in valued activities after a new hip is fitted (β=0.7). Less valued but still important attributes included a shorter time taken from the start of treatment to return to normal activities (6 months; β=0.3), few or no side effects from antibiotics (β=0.2), and having only one operation (β=0.2).

CONCLUSIONS

The results highlight that people who have had revision surgery for periprosthetic hip infection most value aspects of care that affect their ability to engage in normal everyday activities. These were the most important characteristics in decisions about revision surgery.

What attributes should be included in a discrete choice experiment related to health technologies? A systematic literature review

Discrete choice experiments (DCEs) are a way to assess priority-setting in health care provision. This approach allows for the evaluation of individuals’ preferences as a means of adding criteria to traditional quality-adjusted life year analysis. The aim of this systematic literature review was to identify attributes for designing a DCE in order to then develop and validate a framework that supports decision-making on health technologies. Our systematic literature review replicated the methods and search terms used by de Bekker-Grob et al. 2012 and Clark et al. 2014. The Medline database was searched for articles dated between 2008 and 2015. The search was limited to studies in English that reflected general preferences and were choice-based, published as full-text articles and related to health technologies. This study included 72 papers, 52% of which focused on DCEs on drug treatments. The average number of attributes used in all included DCE studies was 5.74 (SD 1.98). The most frequently used attributes in these DCEs were improvements in health (78%), side effects (57%) and cost of treatment (53%). Other, less frequently used attributes included waiting time for treatment or duration of treatment (25%), severity of disease (7%) and value for money (4%). The attributes identified might inform future DCE surveys designed to study societal preferences regarding health technologies in order to better inform decisions in health technology assessment.

Women's Values and Preferences Regarding Osteoporosis Treatments: A Systematic Review

BACKGROUND

Several treatments are available to reduce the risk of fragility fractures associated with osteoporosis. The choice of treatment requires knowledge of patients' values and preferences. The aim of the present study was to summarize what is known about the values and preferences relevant to the management of osteoporosis in women.

METHODS

We conducted a comprehensive search of several databases for studies reported in any language that had included women who had already started or were about to start any pharmacological therapy for osteoporosis. Pairs of reviewers independently selected the studies and extracted the data. The results were synthesized narratively.

RESULTS

We included 26 studies reporting on 15,348 women (mean age, 66 years). The women considered the effectiveness and adverse events equally, followed by the convenience of taking the drug and its effect on daily routine (less frequent dosing was preferred, the oral route was preferred, and the injectable route was preferred over oral if given less frequently). The treatment cost and duration were less important factors for decision making. Fear of breast cancer and fear of resuming uterine bleeding were common reasons for not choosing estrogen therapy. Calcium and vitamin D were viewed as safe and natural. Across the studies, the preferences were not affected by age, previous drug exposure, or employment status.

CONCLUSIONS

Women starting osteoporosis medications value effectiveness and side effects equally and prefer medications given less frequently. Injectable drugs appear acceptable if given less frequently. More research on patient values and preferences is needed to guide decision making in osteoporosis.

Patients' preferences for treatment after neoadjuvant chemoradiotherapy for oesophageal cancer

Background

After neoadjuvant chemoradiotherapy (nCRT) plus surgery for oesophageal cancer, 29 per cent of patients have a pathologically complete response in the resection specimen. Active surveillance after nCRT (instead of standard oesophagectomy) may improve health-related quality of life (HRQoL), but patients need to undergo frequent diagnostic tests and it is unknown whether survival is worse than that after standard oesophagectomy. Factors that influence patients' preferences, and trade-offs that patients are willing to make in their choice between surgery and active surveillance were investigated here.

Methods

A prospective discrete-choice experiment was conducted. Patients with oesophageal cancer completed questionnaires 4–6 weeks after nCRT, before surgery. Patients' preferences were quantified using scenarios based on five aspects: 5-year overall survival, short-term HRQoL, long-term HRQoL, the risk that oesophagectomy is still necessary, and the frequency of clinical examinations using endoscopy and PET–CT. Panel latent class analysis was used.

Results

Some 100 of 104 patients (96·2 per cent) responded. All aspects, except the frequency of clinical examinations, influenced patients' preferences. Five-year overall survival, the chance that oesophagectomy is still necessary and long-term HRQoL were the most important attributes. On average, based on calculation of the indifference point between standard surgery and active surveillance, patients were willing to trade off 16 per cent 5-year overall survival to reduce the risk that oesophagectomy is necessary from 100 per cent (standard surgery) to 35 per cent (active surveillance).

Conclusion

Patients are willing to trade off substantial 5-year survival to achieve a reduction in the risk that oesophagectomy is necessary.

Comparison of preferences of healthcare professionals and MS patients for attributes of disease-modifying drugs: A best-worst scaling

Background

The choice between disease‐modifying drugs (DMDs) for the treatment of multiple sclerosis (MS) becomes more often a shared decision between the patient and the neurologist and MS nurse. This study aimed to assess which DMD attributes are most important for the healthcare professionals in selecting a DMD for a patient. Subsequently, within this perspective, the neurologists’ and nurses’ perspectives were compared. Lastly, the healthcare professionals’ perspective was compared with the patients’ perspective to detect any differences that may need attention in the communication about DMDs.

Design

A best‐worst scaling (BWS) was conducted among 27 neurologists and 33 MS nurses treating patients with MS to determine the importance of 27 DMD attributes. These attributes were identified through three focus groups with MS patients in a previous study (N=19). Relative importance scores (RISs) were estimated for each attribute. Multivariable linear regression analyses were used to compare the different perspectives.

Results

According to the neurologists and nurses, safety of the DMD was the most important DMD attribute in the treatment decision, closely followed by effect on disability progression, quality of life and relapse rate. Patients with MS agreed with the importance of the last three attributes, but valued safety significantly lower (b=−2.59, P<.001).

Conclusions

This study suggests that, overall, neurologists and nurses regard the same DMD attributes as important as MS patients with the notable exception of safety. This study provides valuable information for the development of interventions to support shared decision making and highlights which attributes of DMDs may need additional attention.

Do patients and health care providers have discordant preferences about which aspects of treatments matter most? Evidence from a systematic review of discrete choice experiments

OBJECTIVES

To review studies eliciting patient and healthcare provider preferences for healthcare interventions using discrete choice experiments (DCEs) to (1) review the methodology to evaluate similarities, differences, rigour of designs and whether comparisons are made at the aggregate level or account for individual heterogeneity; and (2) quantify the extent to which they demonstrate concordance of patient and healthcare provider preferences.

METHODS

A systematic review searching Medline, EMBASE, Econlit, PsycINFO and Web of Science for DCEs using patient and healthcare providers.

INCLUSION CRITERIA

peer-reviewed; complete empiric text in English from 1995 to 31July 2015; discussing a healthcare-related topic; DCE methodology; comparing patients and healthcare providers.

DESIGN

Systematic review.

RESULTS

We identified 38 papers exploring 16 interventions in 26 diseases/indications. Methods to analyse results, determine concordance between patient and physician values, and explore heterogeneity varied considerably between studies. The majority of studies we reviewed found more evidence of mixed concordance and discordance (n=28) or discordance of patient and healthcare provider preferences (n=12) than of concordant preferences (n=4). A synthesis of concordance suggested that healthcare providers rank structure and outcome attributes more highly than patients, while patients rank process attributes more highly than healthcare providers.

CONCLUSIONS

Discordant patient and healthcare provider preferences for different attributes of healthcare interventions are common. Concordance varies according to whether attributes are processes, structures or outcomes, and therefore determining preference concordance should consider all aspects jointly and not a binary outcome. DCE studies provide excellent opportunities to assess value concordance between patients and providers, but assessment of concordance was limited by a lack of consistency in the approaches used and consideration of heterogeneity of preferences. Future DCEs assessing concordance should fully report the framing of the questions and investigate the heterogeneity of preferences within groups and how these compare.

Weighing Clinical Evidence Using Patient Preferences: An Application of Probabilistic Multi-Criteria Decision Analysis

The need for patient engagement has been recognized by regulatory agencies, but there is no consensus about how to operationalize this. One approach is the formal elicitation and use of patient preferences for weighing clinical outcomes. The aim of this study was to demonstrate how patient preferences can be used to weigh clinical outcomes when both preferences and clinical outcomes are uncertain by applying a probabilistic value-based multi-criteria decision analysis (MCDA) method. Probability distributions were used to model random variation and parameter uncertainty in preferences, and parameter uncertainty in clinical outcomes. The posterior value distributions and rank probabilities for each treatment were obtained using Monte-Carlo simulations. The probability of achieving the first rank is the probability that a treatment represents the highest value to patients. We illustrated our methodology for a simplified case on six HIV treatments. Preferences were modeled with normal distributions and clinical outcomes were modeled with beta distributions. The treatment value distributions showed the rank order of treatments according to patients and illustrate the remaining decision uncertainty. This study demonstrated how patient preference data can be used to weigh clinical evidence using MCDA. The model takes into account uncertainty in preferences and clinical outcomes. The model can support decision makers during the aggregation step of the MCDA process and provides a first step toward preference-based personalized medicine, yet requires further testing regarding its appropriate use in real-world settings.

How important is mode of administration in treatments for rheumatic diseases and related conditions?

Many new drugs do not offer clinical benefits over existing treatments but provide potentially more convenient modes of administration. These include how frequently a treatment is given, how it is delivered, who gives the treatment, and whether there are any associated local adverse reactions. We reviewed studies in rheumatology that ask patients and society the value they assign to these aspects of treatment in comparison to the benefits and side effects and costs. We find that mode of administration is generally valued by both patients and society, but the extent depends on the context of the disease and the study participants. Respondents with a more severe disease seem to assign less value to mode and frequency of administration, and prioritize improvement in pain and function. However, patients with chronic, but less severe, disease seem to place greater value on mode of administration. Furthermore, respondents with experience of the treatments perceived to be more inconvenient assigned lower value to more convenient treatments. Unfortunately, we found few examples of studies that reported values in a format that could easily be incorporated into resource allocation decisions by payers.

Preference for pharmaceutical formulation and treatment process attributes

PURPOSE

Pharmaceutical formulation and treatment process attributes, such as dose frequency and route of administration, can have an impact on quality of life, treatment adherence, and disease outcomes. The aim of this literature review was to examine studies on preferences for pharmaceutical treatment process attributes, focusing on research in diabetes, oncology, osteoporosis, and autoimmune disorders.

METHODS

The literature search focused on identifying studies reporting preferences for attributes of the pharmaceutical treatment process. Studies were required to use formal quantitative preference assessment methods, such as utility valuation, conjoint analysis, or contingent valuation. Searches were conducted using Medline, EMBASE, Cochrane Library, Health Economic Evaluation Database, and National Health Service Economic Evaluation Database (January 1993-October 2013).

RESULTS

A total of 42 studies met inclusion criteria: 19 diabetes, nine oncology, five osteoporosis, and nine autoimmune. Across these conditions, treatments associated with shorter treatment duration, less frequent administration, greater flexibility, and less invasive routes of administration were preferred over more burdensome or complex treatments. While efficacy and safety often had greater relative importance than treatment process, treatment process also had a quantifiable impact on preference. In some instances, particularly in diabetes and autoimmune disorders, treatment process attributes had greater relative importance than some or all efficacy and safety attributes. Some studies suggested that relative importance of treatment process depends on disease (eg, acute vs chronic) and patient (eg, injection experience) characteristics.

CONCLUSION

Despite heterogeneity in study methods and design, some general patterns of preference clearly emerged. Overall, the results of this review suggest that treatment process has a quantifiable impact on preference and willingness to pay for treatment, even in many situations where safety and efficacy were the primary concerns. Patient preferences for treatment process attributes can inform drug development decisions to better meet the needs of patients and deliver improved outcomes.

Applying discrete choice modelling in a priority setting: an investigation of public preferences for primary care models

OBJECTIVES

The shift toward more innovative and sustainable primary care models in Italy leads policy makers and clinicians to face difficult decisions between options that are all regarded as potentially beneficial. In this study, patient preferences for different primary care models in the Tuscany region of Italy were elicited. The relative importance of different attributes to the surveyed respondents was then examined, as well as the rate at which individuals trade between attributes and the relative value of different service configurations.

METHODS

A discrete choice experiment survey explored the following attributes in a stratified random sample of 6,970 adults: primary care provider, diagnostic facilities and waiting time for the visit.

RESULTS

Respondents (3,263) were likely to prefer a consultation by their own general practitioner (GP) and a practice with many diagnostic facilities. The predicted utilities of different service configurations have shown that a "primary care centre" with many diagnostic facilities was preferable to a "solo GP" model or a "group general practice".

CONCLUSIONS

The study demonstrated how a patient choice model could be used by decision makers for developing successful policies that takes into account different healthcare needs, balancing responsiveness with care continuity, equity and appropriateness. Considering that a primary care centre would perform better than a "solo GP", especially for younger respondents and for those with minor healthcare needs, for a more rapid diffusion of this model policymakers and managers could direct the care of primary care centres towards these targeted subgroups, at least in the first phase.

Discrete choice experiments in health economics: a review of the literature

BACKGROUND

Discrete choice experiments (DCEs) are increasingly used in health economics to address a wide range of health policy-related concerns.

OBJECTIVE

Broadly adopting the methodology of an earlier systematic review of health-related DCEs, which covered the period 2001-2008, we report whether earlier trends continued during 2009-2012.

METHODS

This paper systematically reviews health-related DCEs published between 2009 and 2012, using the same database as the earlier published review (PubMed) to obtain citations, and the same range of search terms.

RESULTS

A total of 179 health-related DCEs for 2009-2012 met the inclusion criteria for the review. We found a continuing trend towards conducting DCEs across a broader range of countries. However, the trend towards including fewer attributes was reversed, whilst the trend towards interview-based DCEs reversed because of increased computer administration. The trend towards using more flexible econometric models, including mixed logit and latent class, has also continued. Reporting of monetary values has fallen compared with earlier periods, but the proportion of studies estimating trade-offs between health outcomes and experience factors, or valuing outcomes in terms of utility scores, has increased, although use of odds ratios and probabilities has declined. The reassuring trend towards the use of more flexible and appropriate DCE designs and econometric methods has been reinforced by the increased use of qualitative methods to inform DCE processes and results. However, qualitative research methods are being used less often to inform attribute selection, which may make DCEs more susceptible to omitted variable bias if the decision framework is not known prior to the research project.

CONCLUSIONS

The use of DCEs in healthcare continues to grow dramatically, as does the scope of applications across an expanding range of countries. There is increasing evidence that more sophisticated approaches to DCE design and analytical techniques are improving the quality of final outputs. That said, recent evidence that the use of qualitative methods to inform attribute selection has declined is of concern.

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

BACKGROUND

Evidence synthesis has seen major methodological advances in reducing uncertainty and estimating the sizes of the effects. Much less is known about how to assess the relative value of different outcomes.

OBJECTIVE

To identify studies that assessed preferences for outcomes in health conditions.

METHODS

SEARCH STRATEGY

we searched MEDLINE, EMBASE, PsycINFO and the Cochrane Library in February 2014.

INCLUSION CRITERIA

eligible studies investigated preferences of patients, family members, the general population or healthcare professionals for health outcomes. The intention of this review was to include studies which focus on theoretical alternatives; studies which assessed preferences for distinct treatments were excluded.

DATA EXTRACTION

study characteristics as study objective, health condition, participants, elicitation method, and outcomes assessed in the study were extracted.

MAIN RESULTS

One hundred and twenty-four studies were identified and categorized into four groups: (1) multi criteria decision analysis (MCDA) (n = 71), (2) rating or ranking (n = 25), (3) utility eliciting (n = 5) and (4) studies comparing different methods (n = 23). The number of outcomes assessed by method group varied. The comparison of different methods or subgroups within one study often resulted in different hierarchies of outcomes.

CONCLUSIONS

A dominant method most suitable for application in evidence syntheses was not identified. As preferences of patients differ from those of other stakeholders (especially medical professionals), the choice of the group to be questioned is consequential. Further research needs to focus on validity and applicability of the identified methods.

A closer look at decision and analyst error by including nonlinearities in discrete choice models: implications on willingness-to-pay estimates derived from discrete choice data in healthcare

BACKGROUND

Most researchers in health economics cite random utility theory (RUT) when analysing discrete choice experiments (DCEs). Under RUT, the error term is associated with the analyst's inability to properly capture the true choice processes of the respondent as well as the inconsistency or mistakes arising from the respondent themselves. Under such assumptions, it stands to reason that analysts should explore more complex nonlinear indirect utility functions, than currently used in healthcare, to strive for better estimates of preferences in healthcare.

OBJECTIVE

To test whether complex indirect utility functions decrease error variance for models that either implicitly (i.e. the multinomial logit (MNL) model) or explicitly (i.e. entropy multinomial logit (EMNL) model) account for error variance in health(care)-related DCEs; and to determine the impact of complex indirect utility functions on willingness-to-pay (WTP) measures.

METHODS

Using data from DCEs aimed at healthcare-related decisions, we empirically compared (1) complex and simple indirect utility specifications in terms of goodness of fit, (2) their impact on WTP measures, including confidence intervals (CIs) based on the Delta method, the Krinsky and Robb-procedure, and Bootstrapping, and (3) MNL and EMNL model results.

RESULTS

Complex indirect utility functions had a better model fit than simple specifications (p < 0.05). WTP estimates were quite similar across alternative specifications. The Delta method produced the most narrow CIs. The EMNL model showed that respondents apply simplifying strategies when answering DCE questions.

CONCLUSION

Complex indirect utility functions reduce error arisen from researchers, which can have important implications for measures in healthcare such as the WTP, whereas EMNL provides insights into the behaviour of respondents when answering DCEs. Understanding how respondents answer DCE questions may allow researchers to construct DCEs that minimise scale differences, so that the decision error made across respondents is more homogeneous and therefore taken out as additional noise in the data. Hence, better estimates of preferences in healthcare can be provided.

Patients' and urologists' preferences for prostate cancer treatment: a discrete choice experiment

Background:

Patients' preferences are important for shared decision making. Therefore, we investigated patients' and urologists' preferences for treatment alternatives for early prostate cancer (PC).

Methods:

A discrete choice experiment was conducted among 150 patients who were waiting for their biopsy results, and 150 urologists. Regression analysis was used to determine patients' and urologists' stated preferences using scenarios based on PC treatment modality (radiotherapy, surgery, and active surveillance (AS)), and risks of urinary incontinence and erectile dysfunction.

Results:

The response rate was 110 out of 150 (73%) for patients and 50 out of 150 (33%) for urologists. Risk of urinary incontinence was an important determinant of both patients' and urologists' stated preferences for PC treatment (P<0.05). Treatment modality also influenced patients' stated preferences (P<0.05), whereas the risk of erectile dysfunction due to radiotherapy was mainly important to urologists (P<0.05). Both patients and urologists preferred AS to radical treatment, with the exception of patients with anxious/depressed feelings who preferred radical treatment to AS.

Conclusion:

Although patients and urologists generally may prefer similar treatments for PC, they showed different trade-offs between various specific treatment aspects. This implies that urologists need to be aware of potential differences compared with the patient's perspective on treatment decisions in shared decision making on PC treatment.

Random regret-based discrete-choice modelling: an application to healthcare

BACKGROUND

A new modelling approach for analysing data from discrete-choice experiments (DCEs) has been recently developed in transport economics based on the notion of regret minimization-driven choice behaviour. This so-called Random Regret Minimization (RRM) approach forms an alternative to the dominant Random Utility Maximization (RUM) approach. The RRM approach is able to model semi-compensatory choice behaviour and compromise effects, while being as parsimonious and formally tractable as the RUM approach.

OBJECTIVES

Our objectives were to introduce the RRM modelling approach to healthcare-related decisions, and to investigate its usefulness in this domain.

METHODS

Using data from DCEs aimed at determining valuations of attributes of osteoporosis drug treatments and human papillomavirus (HPV) vaccinations, we empirically compared RRM models, RUM models and Hybrid RUM-RRM models in terms of goodness of fit, parameter ratios and predicted choice probabilities.

RESULTS

In terms of model fit, the RRM model did not outperform the RUM model significantly in the case of the osteoporosis DCE data (p = 0.21), whereas in the case of the HPV DCE data, the Hybrid RUM-RRM model outperformed the RUM model (p < 0.05). Differences in predicted choice probabilities between RUM models and (Hybrid RUM-) RRM models were small. Derived parameter ratios did not differ significantly between model types, but trade-offs between attributes implied by the two models can vary substantially.

CONCLUSION

Differences in model fit between RUM, RRM and Hybrid RUM-RRM were found to be small. Although our study did not show significant differences in parameter ratios, the RRM and Hybrid RUM-RRM models did feature considerable differences in terms of the trade-offs implied by these ratios. In combination, our results suggest that RRM and Hybrid RUM-RRM modelling approach hold the potential of offering new and policy-relevant insights for health researchers and policy makers.

Patient weighting of osteoporosis medication attributes across racial and ethnic groups: a study of osteoporosis medication preferences using conjoint analysis

We studied the ranking of osteoporosis (OP) medication attributes in a convenience sample of four different racial/ethnic groups in the United States. Our study showed that postmenopausal women differ in the ranking of OP medication attributes based on age, educational level, income, and prior fracture history.

INTRODUCTION

Decision making about OP medication-related behavior relies heavily on patient preferences about specific medication attributes. Patients may decide to initiate, change, or stop therapies based on ranking of perceived attributes of the therapy and their personal attitudes toward those attributes. We used MaxDiff, a form of conjoint analysis (Ryan and Farrar 2000), to explore patient weighting of attributes across four racial/ethnic groups at two sites in the United States and defined four critical attributes that influence such decisions (safety, efficacy, cost, and convenience) from qualitative interviews.

METHODS

We recruited a sample of 367 Postmenopausal (PM) women at risk of OP fractures from four racial/ethnic groups: Caucasian (n = 100), African American (n = 100), Asian American (n = 82), and Hispanic American (n = 85). Respondents completed a laptop-based questionnaire that included demographic items, several short scales on medical care preference and OP patient perceptions, and a MaxDiff procedure that determines comparative ranking of attributes either as least important or most important to their decisions.

RESULTS

MaxDiff analyses were done to evaluate the relative weight of specific statements for each participant and to determine whether racial/ethnic groups differed across dimensions. Overall, participants in all four groups rated efficacy > safety > cost > convenience.

CONCLUSIONS

Although there were no significant differences among the racial/ethnic groups on overall ranking of attributes, subgroup analyses revealed significant impact of age, education, income, and prior fracture on these decisions. The findings from this study suggest that postmenopausal women differ in their ranking of OP medication attributes, and healthcare providers must account for personal preferences in their communication about and selection of OP medications.

Patient preferences versus physicians' judgement: does it make a difference in healthcare decision making?

Clinicians and public health experts make evidence-based decisions for individual patients, patient groups and even whole populations. In addition to the principles of internal and external validity (evidence), patient preferences must also influence decision making. Great Britain, Australia and Germany are currently discussing methods and procedures for valuing patient preferences in regulatory (authorization and pricing) and in health policy decision making. However, many questions remain on how to best balance patient and public preferences with physicians' judgement in healthcare and health policy decision making. For example, how to define evaluation criteria regarding the perceived value from a patient's perspective? How do physicians' fact-based opinions also reflect patients' preferences based on personal values? Can empirically grounded theories explain differences between patients and experts-and, if so, how? This article aims to identify and compare studies that used different preference elicitation methods and to highlight differences between patient and physician preferences. Therefore, studies comparing patient preferences and physician judgements were analysed in a review. This review shows a limited amount of literature analysing and comparing patient and physician preferences for healthcare interventions and outcomes. Moreover, it shows that methodology used to compare preferences is diverse. A total of 46 studies used the following methods-discrete-choice experiments, conjoint analyses, standard gamble, time trade-offs and paired comparisons-to compare patient preferences with doctor judgements. All studies were published between 1985 and 2011. Most studies reveal a disparity between the preferences of actual patients and those of physicians. For most conditions, physicians underestimated the impact of intervention characteristics on patients' decision making. Differentiated perceptions may reflect ineffective communication between the provider and the patient. This in turn may keep physicians from fully appreciating the impact of certain medical conditions on patient preferences. Because differences exist between physicians' judgement and patient preferences, it is important to incorporate the needs and wants of the patient into treatment decisions.

Glucocorticoid-induced osteoporosis: an update on current pharmacotherapy and future directions

INTRODUCTION

Glucocorticoid-induced osteoporosis (GIOP) is one of the most devastating side-effects of glucocorticoid (GC) use, as it is associated with an increased fracture risk. The importance of GIOP as a health problem is underlined by the frequent use of GC treatment in patients with various chronic diseases and by the high rates of osteoporosis found in these patient groups.

AREAS COVERED

Recent studies on bone metabolism and the influence of GCs have contributed to a better understanding of the pathogenesis of GIOP. Furthermore, new intervention trials have reported beneficial effects of antiresorptive and anabolic agents on GIOP. This article reviews the epidemiology and pathophysiology of osteoporosis and fractures in GC-treated patients and discusses current pharmacotherapy and possible future treatment options.

EXPERT OPINION

Several guidelines for the management of GIOP have been published, using different criteria for bone mineral density (BMD) thresholds and for GC dosages above which anti-osteoporotic therapy should be started. Although alendronate and risedronate are currently first choice, the anabolic agent teriparatide seems to be superior and might be considered as a potential first-line therapy for patients with low BMD on long-term GC treatment. Adherence to anti-osteoporotic drugs is limited, particularly in GIOP patients, due to several factors.

What's good and bad about contraceptive products?: a best-worst attribute experiment comparing the values of women consumers and GPs

BACKGROUND

In the past decade, the range of contraceptives available has increased dramatically. There are limited data on the factors that determine women's choices on contraceptive alternatives or what factors providers consider most important when recommending contraceptive products to women.

OBJECTIVES

Our objectives were to compare women's (consumers') preferences and GPs' (providers') views in relation to existing and new contraceptive methods, and particularly to examine what factors increase the acceptability of different contraceptive products.

METHODS

A best-worst attribute stated-choice experiment was completed online. Participants (Australian women of reproductive age and Australian GPs) completed questions on 16 contraceptive profiles. 200 women of reproductive age were recruited through a commercial panel. GPs from all states of Australia were randomly sampled and approached by phone; 162 GPs agreed to participate. Participants chose the best and worst attribute levels of hypothetical but realistic prescribed contraceptive products. Best and worst choices were modelled using multinomial logit and product features were ranked from best to worst according to the size of model coefficients.

RESULTS

The most attractive feature of the contraceptive products for both GPs and women consumers were an administration frequency of longer than 1 year and light or no bleeding. Women indicated that the hormonal vaginal ring was the least attractive mode of administration.

CONCLUSIONS

Women and GPs agree that longer-acting methods with less bleeding are important features in preferred methods of contraception; however, women are also attracted to products involving less invasive modes of administration. While the vaginal ring may fill the niche in Australia for a relatively non-invasive, moderately long-acting and effective contraceptive, the results of this study indicate that GPs will need to promote the benefits of the vaginal ring to overcome negative perceptions about this method among women who may benefit from using it.

Discrete choice experiments in pharmacy: a review of the literature

Objective

Discrete choice experiments (DCEs) have been widely used to elicit patient preferences for various healthcare services and interventions. The aim of our study was to conduct an in-depth scoping review of the literature and provide a current overview of the progressive application of DCEs within the field of pharmacy.

Methods

Electronic databases (MEDLINE, EMBASE, SCOPUS, ECONLIT) were searched (January 1990–August 2011) to identify published English language studies using DCEs within the pharmacy context. Data were abstracted with respect to DCE methodology and application to pharmacy.

Key findings

Our search identified 12 studies. The DCE methodology was utilised to elicit preferences for different aspects of pharmacy products, therapy or services. Preferences were elicited from either patients or pharmacists, with just two studies incorporating the views of both. Most reviewed studies examined preferences for process-related or provider-related aspects with a lesser focus on health outcomes. Monetary attributes were considered to be important by most patients and pharmacists in the studies reviewed. Logit, probit or multinomial logit models were most commonly employed for estimation.

Conclusion

Our study showed that the pharmacy profession has adopted the DCE methodology consistent with the general health DCEs although the number of studies is quite limited. Future studies need to examine preferences of both patients and providers for particular products or disease-state management services. Incorporation of health outcome attributes in the design, testing for external validity and the incorporation of DCE results in economic evaluation framework to inform pharmacy policy remain important areas for future research.

A comparison of preferences of targeted therapy for metastatic renal cell carcinoma between the patient group and health care professional group in South Korea

OBJECTIVES

To evaluate the preferences of health care professional groups and patient groups with respect to efficacy, adverse events, and administration method for targeted agents of metastatic renal cell carcinoma.

METHODS

A total of 485 respondents including cancer patients and health care professionals (medical oncologists, nurses, and pharmacists) were surveyed by using a discrete choice experiment in South Korea. Through a literature review and expert consultation, six attributes--progression-free survival, four adverse events (bone marrow suppression, hand-foot skin reaction, gastrointestinal perforation, and bleeding), and administration--were selected. This study employed the conditional logit regression model.

RESULTS

The six attributes are statistically significant for the patient group and health care professional group. The two groups, however, present differences in progression-free survival, hand-foot skin reaction, gastrointestinal perforation, and administration. The relative importance of adverse events is greater for the patient group, while that of efficacy and administration is greater for the health professional group. For doctors, the relative importance of efficacy is as high as 31%, compared with 7% for the patient group. If progression-free survival is prolonged by 1 month, the acceptable level of bone marrow suppression is 1.3% for the patient group and 9.6% for doctors and that of hand-foot skin reaction is 1.0% and 11.8%, respectively, for the patient group and doctors.

CONCLUSIONS

This study demonstrates substantial differences in the preference for a targeted drug between the patient group and the health care professional group. Doctors prefer effective and orally administered drugs while patients show more reluctant attitudes about adverse events than do health care professionals.

Patient preferences for osteoporosis in Spain: a discrete choice experiment

In Spain, various treatments are available to prevent osteoporotic fractures. A discrete choice experiment (DCE) was used to investigate the importance of different treatment aspects and its influence on patients' preferences. All attributes included as type and place of drug administration as well as costs showed to be significant predictors of choice. Spanish osteoporosis patients have well-defined preferences and accept trade-offs among attributes.

INTRODUCTION

This study was designed to identify patient preferences for different aspects of osteoporosis treatments in Spain.

METHODS

Main attributes of severe osteoporosis treatments were determined by literature review and consultations with nurses. The discrete choice experiment included three attributes: type of drug administration, place of administration, plus a cost attribute in order to estimate willingness to pay for improvements in attribute levels. A pilot study with 50 patients was performed to identify the areas of misunderstanding. One hundred sixty-six patients with a diagnosis of osteoporosis and severe osteoporosis were presented with pairs of hypothetical treatment profiles with different type of administration levels, places of administration and costs. Questions to collect socio-demographic and disease-related treatment data were also included. Data were analysed using a random effects probit model.

RESULTS

All attributes had the expected polarity and were significant predictors of choice. Patients were willing to pay 183 euro/month to have a subcutaneous injection once per day rather than an intravenous injection once per year. Patients with osteoporosis were willing to pay 121 euro/month to have medical support when administering the drug treatment at home rather than being admitted several hours to a hospital for drug administration.

CONCLUSION

Spanish osteoporosis patients have well-defined preferences among treatment attributes and are willing to accept trade-offs among attributes. Participants indicated that they are willing to accept self medication with medical support rather than being hospitalised for several hours. The perspective of the patients should be taken into account when making treatment decisions.

Advances in glucocorticoid-induced osteoporosis

Glucocorticoid-induced osteoporosis (GIOP) is one of the most important side effects of glucocorticoid use, as it leads to an increased risk of fractures. Recently, many published studies have focused on the cellular and molecular mechanisms of bone metabolism, the pathophysiology of GIOP, and the intervention options to prevent GIOP. In this review, recent advances in GIOP are summarized, particularly recent progress in our understanding of the mechanisms of GIOP resulting in improved insight that might result in the development of new treatment options in the near future.

Labeled versus unlabeled discrete choice experiments in health economics: an application to colorectal cancer screening

OBJECTIVES

Discrete choice experiments (DCEs) in health economics commonly present choice sets in an unlabeled form. Labeled choice sets are less abstract and may increase the validity of the results. We empirically compared the feasibility, respondents' trading behavior, and convergent validity between a labeled and an unlabeled DCE for colorectal cancer (CRC) screening programs in The Netherlands.

METHODS

A labeled DCE version presented CRC screening test alternatives as "fecal occult blood test,""sigmoidoscopy," and "colonoscopy," whereas the unlabeled DCE version presented them as "screening test A" and "screening test B." Questionnaires were sent to participants and nonparticipants in CRC screening.

RESULTS

Total response rate was 276 (39%) out of 712 and 1033 (46%) out of 2267 for unlabeled and labeled DCEs, respectively (P<0.001). The labels played a significant role in individual choices; approximately 22% of subjects had dominant preferences for screening test labels. The convergent validity was modest to low (participants in CRC screening: r=0.54; P=0.01; nonparticipants: r=0.17; P=0.45) largely because of different preferences for screening frequency.

CONCLUSION

This study provides important insights in the feasibility and difference in results from labeled and unlabeled DCEs. The inclusion of labels appeared to play a significant role in individual choices but reduced the attention respondents give to the attributes. As a result, unlabeled DCEs may be more suitable to investigate trade-offs between attributes and for respondents who do not have familiarity with the alternative labels, whereas labeled DCEs may be more suitable to explain real-life choices such as uptake of cancer screening.