Do patient preferences influence decisions on treatment for patients with steroid-refractory ulcerative colitis?
Do patient preferences influence decisions on treatment for patients with steroid-refractory ulcerative colitis?
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DOI：
10.1016/j.cgh.2006.05.003
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发表时间：
2006-09-01
影响因子：
12.6
通讯作者：
Cominelli, Fabio
中科院分区：
文献类型：
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作者：
Arseneau, Kristen O.;Sultan, Shahnaz;Cominelli, Fabio
背景和目的：类固醇难治性溃疡性结肠炎患者在结肠切除术和英夫利昔单抗或环孢素治疗之间面临着艰难的治疗决定。本研究的目的是了解患者对各种治疗结果的偏好如何影响特定患者的最佳治疗决策。方法：使用马尔可夫模型模拟全结肠切除加回肠贮袋肛管吻合术（TC/IPAA）、环孢素（CSA）、英夫利昔单抗（INFLX）以及英夫利昔单抗治疗失败后联合环孢素治疗（INFLX-->CSA）。使用时间权衡和视觉评定量表方法从 48 名患者中得出治疗结果的效用权重。将偏好集应用于模型，以确定使每位患者的质量调整生命年 (QALY) 最大化的治疗方法。进行敏感性分析以评估模型的稳健性。结果：患者之间的最佳治疗差异很大（INFLX-->CSA = 42%, 20/48；TC/IPAA = 37%, 18/48；CSA = 21%,10/48；INFLX = 0%, 0/48）。然而，当我们样本的平均偏好权重应用于模型时，药物治疗优于 TC（与 TC/IPAA 相比，CSA =.26 QALY 获得；INFLX-->CSA =.25 QALY 与 TC/IPAA 相比）。结论：患者偏好对类固醇难治性溃疡性结肠炎的最佳治疗有明显影响。尽管平均偏好支持使用医疗干预措施，但三分之一的患者可能从直接进行结肠切除术中获益最多。未能充分评估个人偏好可能会导致这些患者的治疗效果不佳。
Background & Aims: Patients with steroid-refractory ulcerative colitis face a difficult treatment decision between colectomy and therapy with infliximab or cyclosporine. The aim of this study was to understand how individual patient preferences for the various treatment outcomes influence the optimal treatment decision for a given patient. Methods: A Markov model was used to simulate treatment with total colectomy with an ileo pouch-anal anastomosis (TC/IPAA), cyclosporine (CSA), infliximab (INFLX), and infliximab followed by cyclosporine for treatment failures (INFLX-->CSA). Utility weights for treatment outcomes were elicited from 48 patients using both time trade-off and visual rating scale methods. Preference sets were applied to the model to identify the therapy that maximized quality-adjusted life years (QALYs) for each patient. Sensitivity analyses were performed to assess model robustness. Results: Optimal treatment was highly variable among patients (INFLX-->CSA = 42%, 20/48; TC/IPAA = 37%, 18/48; CSA = 21%,10/48; INFLX = 0%, 0/48). However, when average preference weights from our sample were applied to the model, medical treatments were superior to TC (CSA =.26 QALYs gained vs TC/IPAA; INFLX-->CSA =.25 QALYs gained vs TC/IPAA). Conclusions: Patient preferences have a clear impact on the optimal treatment for steroid-refractory ulcerative colitis. Although averaged preferences support the use of medical interventions, a third of individual patients may benefit most from proceeding directly to colectomy. Failure to fully assess individual preferences may result in suboptimal treatment for these patients.