Integrating patients' views into health technology assessment: Analytic hierarchy process (AHP) as a method to elicit patient preferences

Background: Patient involvement is widely acknowledged to be a valuable component in health technology assessment (HTA) and healthcare decision making. However, quantitative approaches to ascertain patients' preferences for treatment endpoints are not yet established. The objective of this study is to introduce the analytic hierarchy process (AHP) as a preference elicitation method in HTA. Based on a systematic literature review on the use of AHP in health care in 2009, the German Institute for Quality and Efficiency in Health Care (IQWiG) initiated an AHP study related to its HTA work in 2010. - \ud Methods: The AHP study included two AHP workshops, one with twelve patients and one with seven healthcare professionals. In these workshops, both patients and professionals rated their preferences with respect to the importance of different endpoints of antidepressant treatment by a pairwise comparison of individual endpoints. These comparisons were performed and evaluated by the AHP method and relative weights were generated for each endpoint. - \ud Results: The AHP study indicates that AHP is a well-structured technique whose cognitive demands were well handled by patients and professionals. The two groups rated some of the included endpoints of antidepressant treatment differently. For both groups, however, the same six of the eleven endpoints analyzed accounted for more than 80 percent of the total weight. - \ud Conclusions: AHP can be used in HTA to give a quantitative dimension to patients' preferences for treatment endpoints. Preference elicitation could provide important information at various stages of HTA and challenge opinions on the importance of endpoints

Trends in incidence, treatment, survival and subsequent breast cancer in lobular carcinoma in situ in the Netherlands:A population-based analysis

Purpose: We analysed incidence, treatment, survival, occurrence of ductal carcinoma in situ (DCIS) and invasive breast cancer (IBC) after lobular carcinoma in situ (LCIS) in the Netherlands. Methods: All women diagnosed with classic LCIS between 1989 and 2017 were identified from the Netherlands Cancer Registry. We calculated overall (OS), relative survival (RS) and cumulative incidence functions (CIF, accounting for competing risks) of mortality, DCIS and IBC. For IBC, standardised incidence ratios (SIR) of IBC were calculated. Analyses were stratified for surgical treatment. Results: We included 1890 patients. Median age was 51 years. Median follow-up was 8.5 years. In 1989–2017, LCIS incidence increased from 41 to 124, surgical treatment decreased from 100% to 41.1 % – mostly BCS. 10-year OS and 20-year RS exceeded 90 % in all subgroups. Overall, 48 (2.5 %) and 270 (14.3 %) patients were diagnosed with DCIS and IBC. IBCs were mostly early-stage. After mastectomy, 13 of 14 IBCs presented contralaterally. In the other groups, 64.8–70.9 % of IBCs presented ipsilaterally, 34.5–53.9 % of these were lobular. The SIR of ipsilateral IBC was highest after no surgery (6.9, 95%CI:4.9–9.4), lowest after mastectomy (0.2, 95%CI:0.4–0.8). Conclusion: LCIS incidence increased, surgical treatment decreased. The low mortality risks support consideration of active surveillance. However, the increased IBC incidence suggests careful monitoring

Time trends in psychotropic drug prescriptions in Dutch nursing home residents with dementia between 2003 and 2018

Objective: Several European studies investigated the trends in psychotropic drug prescriptions (PDPs) among nursing home (NH) residents and reported a decline in antipsychotics prescriptions. Since the Dutch long-term care system differs from other European systems (e.g. higher threshold for NH admission and trained elderly care physicians), this study explores the trends in PDPs in Dutch NH residents with dementia. Methods: The study used data from nine studies, comprising two cross-sectional studies, one cohort study, and six cluster-randomized controlled trials, collected in Dutch NHs between 2003 and 2018. With multilevel logistic regression analysis, NHs as a random effect, we estimated the trends in PDPs overall and for five specific psychotropic drug groups (antipsychotics, antidepressants, anxiolytics, hypnotics, and anti-dementia drugs), adjusting for confounders: age, gender, severity of dementia, severity of neuropsychiatric symptoms, and length of stay in NHs. Results: The absolute prescription rate of antipsychotics was 37.5% in 2003 and decreased (OR = 0.947, 95% CI [0.926, 0.970]) every year. The absolute prescription rate of anti-dementia drugs was 0.8% in 2003 and increased (OR = 1.162, 95% CI [1.105, 1.223]) per year. The absolute rate of overall PDPs declined from 62.7% in 2003 to 40.4% in 2018. Conclusions: Among Dutch NH residents with dementia, the odds of antipsychotics prescriptions decreased by 5.3% per year while the odds of anti-dementia drug prescriptions increased by 16.2%. There were no distinct trends in antidepressants, anxiolytics, and hypnotics prescriptions. However, overall PDPs were still high. The PDPs in NH residents remain an issue of concern

ACE I/D polymorphism is associated with mortality in a cohort study of patients starting with dialysis

ACE I/D polymorphism is associated with mortality in a cohort study of patients starting with dialysis.BackgroundIn dialysis patients, only a few follow-up studies have addressed the relationship between the insertion/deletion (I/D) polymorphism in the angiotensin-converting enzyme (ACE) gene and mortality, but the available data are contradictory.MethodsA cohort of 453 consecutive patients starting dialysis between January 1999 and January 2002 and participating in a Dutch multicenter prospective study was examined. Patients who died within 3 months after the start of dialysis were excluded. Patients were followed until date of death or censoring in November 2003.ResultsThe ACE II, ID, and DD genotype frequencies were 24.3% (N = 110), 50.1% (N = 227), and 25.6% (N = 116). Besides a slightly higher number of Caucasians in the DD group, all other patient characteristics of the 3 ACE groups were similar at the start of dialysis. After adjustment for age, comorbidity, and ethnic background, patients with the ID and DD genotype showed an increased hazard ratio (HR) for all-cause mortality of 1.55 (95% CI 1.00-2.42) and 2.30 (95% CI 1.41-3.75), compared to patients with the II genotype. Slightly lower HRs were found for cardiovascular mortality. All groups of primary kidney disease showed a 2- to 3-fold increased adjusted HR for DD.ConclusionThe DD genotype identifies dialysis patients at an increased risk for mortality

Catalan Renal Registry (RMRC), Catalan Transplant Organisation, Catalan Health Service, Autonomous Government of Catalonia

Abstract Background. This study compared the prevalence of co-morbidity in patients starting renal replacement therapy (RRT) between European countries and further examined how co-morbidity affects access to transplantation. Methods. In this ERA-EDTA registry special study, 17907 patients from Austria, Catalonia (Spain), Lombardy (Italy), Norway, and the UK (England/ Wales) were included (1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001). Co-morbidity was recorded at the start of RRT. Results. The prevalence of co-morbidity was: diabetes mellitus (DM) (primary renal disease and co-morbidity) 28%, ischaemic heart disease (IHD) 23%, peripheral vascular disease (PVD) 24%, cerebrovascular disease (CVD) 14% and malignancy 11%. With exception of malignancy, the prevalence of co-morbidity was highest in Austria, but differences were small among other countries. With exception of DM, males suffered more often from co-morbidity than females. In general, the percentage of haemodialysis was higher in patients with co-morbidity, but treatment modality differed substantially between countries. Using a Cox regression with adjustment for demographics, country, year of start and other co-morbidities, the presence of each of the co-morbid conditions made it less likely [RR; 95%CI] 86 [3.36-4.45] for Norway (Austria ¼ reference). These international differences existed for patients with and without co-morbidity. Conclusions. The prevalence of co-morbidity was highest in Austria but differences were small among other countries. The access to a renal graft was most affected by the presence of malignancy and least affected by the presence of DM. International differences in access to transplantation were only partly due to co-morbid variability

Changes in medicine prescription following a medication review in older high-risk patients with polypharmacy

Background The more (inappropriate) drugs a patient uses, the higher the risk of drug related problems. To reduce these risks, medication reviews can be performed. Objective To report changes in the prescribed number of (potentially inappropriate) drugs before and after performing a medication review in high-risk polypharmacy patients. A secondary objective was to study reasons for continuing potentially inappropriate drugs (PIDs). Setting Dutch community pharmacy and general medical practice. Methods A retrospective longitudinal intervention study with a pre-test/post-test design and follow-up of 1 week and 3 months was performed. The study population consisted of 126 patients with polypharmacy and with additional risk for drug related problems that underwent a medication review in five community pharmacies. The medication review was performed by the pharmacist in close cooperation with the general practitioner of each corresponding patient. Main outcome measure Number of (potentially inappropriate) drugs, and appropriateness of prescribed medicines. Results The average number of drugs a patient used 1 day before the review was 8.7 (SD = 2.9), which decreased (p < 0.05) to 8.3 (SD = 2.7) 1 week after the review, and to 8.4 (SD = 2.6) 3 months after the review. The average number of PIDs was initially 0.6 (SD = 0.8) per patient and decreased to 0.4 (SD = 0.6, p < 0.05). Twenty-two of the 241 initial drug changes (9%) were deprescribed during follow-up. Registered reasons for continuing PIDs are clinical or patients’ preferences. Conclusions Performing medication reviews in polypharmacy patients seems useful to continue at least in high-risk patients in The Netherlands. The time-consuming reviews could be limited to patients who are willing to change their medication

When to start dialysis treatment:Where do we stand?

Background: Since the publication of opinion-based guidelines regarding the timing of dialysis treatment, there has been a trend toward earlier initiation.Objective. In this review, the existing guidelines and the currently published studies that evaluate them are discussed.Results: These studies could not demonstrate a clear benefit on survival or quality of life for patients who started with relatively higher renal function.Conclusion: Early start of dialysis treatment should not be confused with early referral to the nephrologist. It is concluded that initiation of dialysis should not depend on a predefined magnitude of renal function, but should be tailored to the individual patient.</p

When to start dialysis treatment:Where do we stand?

Background: Since the publication of opinion-based guidelines regarding the timing of dialysis treatment, there has been a trend toward earlier initiation.Objective. In this review, the existing guidelines and the currently published studies that evaluate them are discussed.Results: These studies could not demonstrate a clear benefit on survival or quality of life for patients who started with relatively higher renal function.Conclusion: Early start of dialysis treatment should not be confused with early referral to the nephrologist. It is concluded that initiation of dialysis should not depend on a predefined magnitude of renal function, but should be tailored to the individual patient.</p