Individualized Cost-Effectiveness Analysis

John Ioannidis and Alan Garber discuss how to use incremental cost-effectiveness ratios (ICER) and related metrics so they can be useful for decision-making at the individual level, whether used by clinicians or individual patients

Addressing preference heterogeneity in public health policy by combining Cluster Analysis and Multi-Criteria Decision Analysis: Proof of Method.

The use of subgroups based on biological-clinical and socio-demographic variables to deal with population heterogeneity is well-established in public policy. The use of subgroups based on preferences is rare, except when religion based, and controversial. If it were decided to treat subgroup preferences as valid determinants of public policy, a transparent analytical procedure is needed. In this proof of method study we show how public preferences could be incorporated into policy decisions in a way that respects both the multi-criterial nature of those decisions, and the heterogeneity of the population in relation to the importance assigned to relevant criteria. It involves combining Cluster Analysis (CA), to generate the subgroup sets of preferences, with Multi-Criteria Decision Analysis (MCDA), to provide the policy framework into which the clustered preferences are entered. We employ three techniques of CA to demonstrate that not only do different techniques produce different clusters, but that choosing among techniques (as well as developing the MCDA structure) is an important task to be undertaken in implementing the approach outlined in any specific policy context. Data for the illustrative, not substantive, application are from a Randomized Controlled Trial of online decision aids for Australian men aged 40-69 years considering Prostate-specific Antigen testing for prostate cancer. We show that such analyses can provide policy-makers with insights into the criterion-specific needs of different subgroups. Implementing CA and MCDA in combination to assist in the development of policies on important health and community issues such as drug coverage, reimbursement, and screening programs, poses major challenges -conceptual, methodological, ethical-political, and practical - but most are exposed by the techniques, not created by them

Osteoarthritis and functional disability: results of a cross sectional study among primary care patients in Germany

Contains fulltext : 52359.pdf ( ) (Open Access)BACKGROUND: The aim of the study was to determine factors associated with functional disability in patients with OA. METHODS: 1250 questionnaires were distributed to OA outpatients from 75 general practices; 1021 (81.6%) were returned. Questionnaires included sociodemographic data, the short form of the Arthritis Impact Measurement Scale (AIMS2-SF), and the Patient Health Questionnaire (PHQ-9) to assess concomitant depression. A hierarchical stepwise multiple regression analysis with the AIMS2-SF dimension "lower body" as dependent was performed. RESULTS: Main factors associated with functional disability were depression symptoms, as reflected in a high score of the PHQ-9 (beta = 0.446; p < 0.0009), pain as reflected in the AIMS2-SF symptom scale (beta = 0.412; p = 0.001), and few social contacts (beta = 0.201; p < 0.042). A high body mass index was associated with lower functional ability (beta = 0.332; p = 0.005) whereas a higher educational level (beta = -0.279; p = 0.029) predicted less impairment. Increased age was a weak predictor (beta = 0.178; p = 0.001) of disability. With a p of 0.062 the radiological severity according to the grading of Kellgren and Lawrence slightly surpassed the required significance level for remaining in the final regression model. CONCLUSION: The results emphasize that psychological as well as physical factors need to be addressed similarly to improve functional ability of patients suffering from OA. More research with multifaceted and tailored interventions is needed to determine how these factors can be targeted appropriately

How to integrate individual patient values and preferences in clinical practice guidelines? A research protocol

Background Clinical practice guidelines are largely conceived as tools that will inform health professionals' decisions rather than foster patient involvement in decision making. The time now seems right to adapt clinical practice guidelines in such a way that both the professional's perspective as care provider and the patients' preferences and characteristics are being weighed equally in the decision-making process. We hypothesise that clinical practice guidelines can be adapted to facilitate the integration of individual patients' preferences in clinical decision making. This research protocol asks two questions: How should clinical practice guidelines be adapted to elicit patient preferences and to support shared decision making? What type of clinical decisions are perceived as most requiring consideration of individual patients' preferences rather than promoting a single best choice? Methods Stakeholders' opinions and ideas will be explored through an 18-month qualitative study. Data will be collected from in-depth individual interviews. A purposive sample of 20 to 25 key-informants will be selected among three groups of stakeholders: health professionals using guidelines (e.g., physicians, nurses); experts at the macro- and meso-level, including guideline and decision aids developers, policy makers, and researchers; and patient representatives. Ideas and recommendations expressed by stakeholders will be prioritized by nominal group technique in expert meetings. Discussion One-for-all guidelines do not account for differences in patients' characteristics and for their preferences for medical interventions and health outcomes, suggesting a need for flexible guidelines that facilitate patient involvement in clinical decision making. The question is how this can be achieved. This study is not about patient participation in guideline development, a closely related and important issue that does not however substitute for, or guarantee individual patient involvement in clinical decisions. The study results will provide the needed background for recommendations about potential effective and feasible strategies to ensure greater responsiveness of clinical practice guidelines to individual patient's preferences in clinical decision-making

Patient and Physician Roles in End-of-Life Decision Making

This study is a cross-sectional descriptive survey of randomly selected primary care patients and physicians regarding patient, physician, and family roles in end-of-life decision making. The subjects included 329 adult outpatients and 272 practicing physicians. Physicians were more likely than patients to believe the patient alone was responsible for making end-of-life decisions. Patients were more likely than physicians to believe the physician should provide a recommendation in addition to facts to help the patient make end-of-life decisions. We conclude that patients prefer a more active role for physicians in both decision making and discussion of end-of-life care than do physicians themselves

Preferences for shared decision making in chronic pain patients compared with patients during a premedication visit.

Contains fulltext : 49583.pdf (publisher's version ) (Closed access)BACKGROUND: There is some evidence that patients' outcomes improve if they are involved in shared decision making (SDM). A chronic pain clinic or premedication visit could be adequate settings for the implementation of SDM. So far, the patients' preference for involvement in decision making and their desire for information have not been tested in anesthesiological settings. METHODS: A group of chronic pain patients was compared with a group of patients in the premedication visit with respect to SDM, the desire for information and perceived involvement in care. The autonomy preference index (API, measuring preference for involvement and desire for information) and the perceived involvement in care scale (PICS, measuring patients' perception of easier involvement by doctors and information exchange) were administered. RESULTS: In total, 190 chronic pain patients and 151 patients of premedication were included in this study. Patient of the premedication visit had significantly higher SDM scores. Desire for information was high, but there were no differences between groups. Younger patients [B (estimate) =- 0.3; 95% CI (-0.4) - (-0.1)], women (B = 10.9; 95% CI 6.3-15.4) and patients with higher educational level (B = 10.1; 95% CI 5.6-14.6) had more desire for SDM. PICS scores were basically influenced by groups: chronic pain patients felt more facilitated by doctors [B =- 0.185; 95% CI (-0.4) - (-0.1)] and had more information exchange [B =- 19.5; 95% CI (-15.8) - (-2.4)] than patients in the premedication visit. CONCLUSION: In both anesthesiological settings, the desire for information was high, but patients in the premedication visit had higher SDM scores, especially young female patients with higher educational level. Real patient-physician interaction showed that premedication patients felt less involved by doctors and had less information exchange compared with the chronic pain patients. Therefore, premedication visits should be focussed more on adequate information exchange and involvement of the patient in the shared decision making process