A multiple stakeholder multicriteria decision analysis in diabetic macular edema management: the MULTIDEX‑EMD study

Background The clinical and economic management of retinal diseases has become more complex following the introduction of new intravitreal treatments. Multicriteria decision analysis (MCDA) ofers the potential to overcome the challenges associated with traditional decision-making tools. Objectives A MCDA to determine the most relevant criteria to decision-making in the management of diabetic macular edema (DME) based on the perspectives of multiple stakeholders in Spain was developed. This MCDA was termed the MULTIDEX-EMD study. Methods Nineteen stakeholders (7 physicians, 4 pharmacists, 5 health authorities and health management experts, 1 psychologist, and 2 patient representatives) participated in this three-phase project. In phase A, an advisory board defned all of the criteria that could infuence DME treatment decision-making. These criteria were then screened using a discrete choice experiment (DCE) (phase B). Next, a multinomial logit model was ftted by applying the backward elimination algorithm (relevant criteria: p value<0.05). Finally, the results were discussed in a deliberative process (phase C). Results Thirty-one criteria were initially defned (phase A) and grouped into 5 categories: efcacy/efectiveness, safety, organizational and economic impact, patient-reported outcomes, and other therapeutic features. The DCE results (phase B) showed that 10 criteria were relevant to the decision-making process for a 50- to 65-year-old DME patient: mean change in best corrected visual acuity (p value<0.001), percentage of patients with an improvement of ≥15 letters (p value<0.001), efect duration per administration (p value=0.008), retinal detachment (p value<0.001), endophthalmitis (p value=0.012), myocardial infarction (p value<0.001), intravitreal hemorrhage (p value=0.021), annual treatment cost per patient (p value=0.001), health-related quality of life (HRQoL) (p value=0.004), and disability level (p value=0.021). Conclusions From a multi-stakeholder perspective, the selection of an appropriate treatment for DME patients should guarantee patient safety and maximize the visual acuity improvement and treatment efect duration. It should also contribute to system sustainability by being afordable, it should have a positive impact on HRQoL, and it should prevent disability

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Background. An increase of cardiovascular disease (CVD) risk in the younger population has been reported in Spain. Adolescents have changed their dietary habits and increased the risk of metabolic syndrome (MS). The Longitudinal study in the area of Toledo aims to evaluate food intake and nutritional habits and their relationship with early development of CVD and insulin resistance/sensitivity biomarkers. Methods. A cross-sectional study was performed on 53 adolescents aged 16-17 years belonging to the Area of Toledo. Energy, macronutrient and micronutrient intakes and diet quality were assessed, as well as the prevalence to being overweight, the presence of CVD risk factors and parameters related to glucose homeostasis to identify candidates for MS. Results. Adolescents consumed monotonous diets, with low Mediterranean diet Adherence (MDA) and Health Eating Index (HEI) scores and with elevated energy contribution of saturated fatty acids and low carbohydrates. Being overweight but not obese was moderately prevalent in volunteers. However, a low percentage of them showed dyslipemia or insulin resistance. No significant differences between male and female adolescents were found for any dietary parameter tested. HEI and MDA scores appear inversely related to insulin resistance markers in boys and to fat mass in girls, respectively. Conclusions. The high similitude of diet in both male and female subjects suggests a general adherence to potentially negative dietary habits in this population. Paradoxically, dietary components and altered lipoprotein factors were not related. The overweight prevalence and, the association between diet quality and MS-markers found demands a follow-up study to ascertain the importance of present results later in life