Why Physicians Prescribe Prophylactic Seizure Medications after Intracerebral Hemorrhage: An Adaptive Conjoint Analysis.

BACKGROUND: Seizures are a morbid complication of intracerebral hemorrhage (ICH) and increase the risk for herniation, status epilepticus, and worse patient outcomes. Prophylactic levetiracetam is administered to approximately 40% of patients with ICH. It is unclear which patients are consciously selected for treatment by physicians. We sought to determine how patients are selected for treatment with prophylactic levetiracetam after ICH. METHODS: We administered an adaptive conjoint analysis using decision making software to an NIH Stroke Trials Network Working Group. The adaptive conjoint analysis determines the most influential attributes for making a decision in an iterative, algorithm-driven process. We asked respondents which would most influence a decision to administer prophylactic levetiracetam. The attributes and their levels were taken from published phenotypes associated with prophylactic seizure medications and the likelihood of seizures after ICH: hematoma location (lobar or basal ganglia), hematoma volume (<=10 mL or >10 mL), level of consciousness (Glasgow Coma Scale 5-12 or Glasgow Coma Scale 13-15), age (<65 or ≥65 years), and race (White or Caucasian or Black/African American). The algorithm terminated when the attributes were ranked from most to least influential. RESULTS: The study sample included 27 respondents who completed the adaptive conjoint analysis out of 42 who responded to the survey with a mean age of 43.4 ± 9.4 years. The attribute with the greatest weight was hematoma location (30%), followed by reduced level of consciousness (24%), hematoma volume (19%), race (14%), and age (13%). Ranks of attributes were different (P < .001). CONCLUSIONS: The decision to administer prophylactic levetiracetam to patients with ICH is driven by lobar hematoma location and depressed level of consciousness. Future research on prophylactic seizure medication could focus on patients most likely to receive it.

A new approach and insights on modelling the impact of production diseases on dairy cow welfare.

Animal welfare is becoming an important consideration in animal health-related decision-making. Integrating considerations of animal welfare into the decision-making process of farmers involves recognising the significance of health disorder impacts in relation to animal welfare. Yet little research quantifies the impact, making it difficult to include animal welfare in the animal health decision-making process. Quantifying the impact of health disorders on animal welfare is incredibly challenging due to empirical animal-based data collection constraints. An approach to circumvent these constraints is to rely on expert knowledge whereby perceived welfare impairment weights are indicative of the negative welfare effect. In this research, we propose an expertise-based method to quantify the perceived impact of sub-optimal mobility (SOM) on the welfare of dairy cows, because of its welfare importance. We first quantified perceived welfare impairment weights of SOM by eliciting expert knowledge using adaptive conjoint analysis (ACA). Second, using the perceived welfare impairment weights, we derived the perceived welfare disutility (i.e., perceived negative welfare effect) of mobility scores 1-5 (1 = optimal mobility, 5 = severely impaired mobility). Third, using the perceived welfare disutility per mobility score, we quantified the perceived welfare impact at case- and herd-level of SOM for different SOM severity. Results showed that perceived welfare disutility increased with each increase in mobility score. However, the perceived welfare impact of SOM cases with lower mobility scores was higher compared to SOM cases with higher mobility scores. This was because of the longer-lasting duration of the SOM cases with lower mobility scores. Moreover, the perceived herd-level welfare impact was largely due to SOM cases with lower mobility scores because of the longer duration and more frequent incidence compared to the SOM cases with higher mobility scores. These results entail that better welfare of dairy cows with respect to SOM can be achieved if lower mobility scores are detected and treated sooner. Our research demonstrates a novel approach that quantifies the perceived impact of health disorders on animal welfare when empirical evidence is limited.

Hazard perception of Dutch farmers and veterinarians related to dairy young stock rearing.

A group of 110 dairy farmers and 26 bovine veterinarians participated in a web-based questionnaire using the adaptive conjoint analysis technique to rank their perception regarding several hazards during 6 subsequent periods of the process of dairy young stock rearing. The method applied only involved selected respondents with a high consistency in their answering (correlation >30%). For the ranking, answers were first transformed into a utility score (US) for each hazard. The final ranking for each of the 6 periods was based on the US per hazard separately for farmers and veterinarians. Besides the ranking, the absolute values and the US itself were also compared between farmers and veterinarians to determine any statistically significant differences between the levels of the score despite the ranking. The overall conclusion is that, for almost every designated period, the ranking of the hazards differed between farmers and veterinarians. Only 1 period was observed (period IV, Pregnancy period until 4 weeks before calving) where veterinarians and farmers had the same top 3 ranking of the hazards, namely "Mastitis," "Abortion," and "Poor growth rate of the pregnant heifer." Major differences between farmers and veterinarians were seen during period II (feeding milk until weaning) for the hazard "Diarrhea in older calf," which was considered less important by farmers compared to veterinarians, and period number III (weaning until insemination) for "Over-condition," which, again, was seen as the most important hazard by veterinarians, but only ranked as number 5 by farmers. Besides the ranking, significant differences in absolute US values between veterinarians and farmers were seen in "Infection with Johne's disease" (14.5 vs. 7.8), "Diarrhea in newborn calf" (18.2 vs. 12.2), and "Insufficient feed intake" (16.2 vs. 8.4) in period I (colostrum until transition to milk replacer). Lameness represented the most important significant difference in absolute values in period III (weaning until insemination; 6.3 vs. 14.3), which was again significant in period V (4 wks before calving until calving; 7.4 vs. 12.1). The outcome of this study shows that hazard perception of veterinarians and farmers differs for most rearing periods (in ranking and absolute values). The outcome of this study can be used for 2 purposes: first, to improve communication between farmers and their consulting veterinarian about hazards and hazard perception in young stock rearing; and second, the US scores can be used to select top priority hazards which should at least be integrated into management advisory programs to improve dairy young stock rearing.

Identification of Thoroughbred Racehorse Welfare Issues by Industry Stakeholders.

Identifying key welfare issues for thoroughbred racehorses could lead to an improvement in standards. A lack of scientific information on the relative importance of key issues was addressed by soliciting the views of, first, welfare experts in the industry and, second, a broader group of stakeholders, who selected the best welfare options by adaptive conjoint analysis. The experts represented racehorse breeders, veterinarians, trainers, owners, government officials, salespeople, farriers, transporters, and horse re-trainers for post-racing activities. In a focus group meeting, the experts identified fourteen key welfare issues, each with two to four levels that related to common husbandry practices. Then, in an internet survey, 224 stakeholders ranked the issues using adaptive conjoint analysis, in declining importance, as: horsemanship > health and disease > education of the horse > track design and surface > ventilation > stabling > weaning > transport > nutrition > wastage > heat and humidity > whips > environment > gear. Relatively uniform responses to the survey by the different stakeholder groups suggested that there was a common view on what had the biggest impact on welfare. An exception was a greater rating given by women than men to the importance of correct horse nutrition. The rating of importance for welfare of different levels of provision of each issue mostly conformed to the scientific evidence, with the exception of weaning. This understanding of the importance of welfare issues for thoroughbred racehorses could be used to target interventions to the most serious problems.

Efficacy of a Preference-Based Decision Tool on Treatment Decisions for a First-Time Anterior Shoulder Dislocation: A Randomized Controlled Trial of At-Risk Patients.

BACKGROUND: First-time anterior shoulder dislocations (FTASD) provide an opportunity to examine the value of integrating stated-preference data with decision modeling to differentiate between patients whose preferred management strategy involves operative or nonoperative treatment. The objective of this study was to evaluate the efficacy of a FTASD decision tool intervention with individual preference measurement compared with a text-based control in a randomized controlled trial. METHODS: Two hundred respondents between 18 and 35 years of age at risk for experiencing an FTASD were enrolled from the orthopedic clinics and randomized to receive either an interactive decision tool intervention capable of eliciting patient preferences for treatment of an FTASD or a text-based control on shoulder dislocations and treatments. The primary outcome was preference for operative or nonoperative treatment choice. Secondary outcomes included the decisional conflict scale (DCS), stage of decision making, patient activation and engagement, awareness of preference sensitive decisions, knowledge retention, and instrument acceptability. RESULTS: One hundred respondents were randomized to the intervention and 100 to the control. A total of 154 men and 46 women with an average age of 23.6 years completed the survey. Participants in the intervention group made treatment decisions that aligned more closely with evidence-based recommendations than those in the control group ( P = 0.016). Secondary outcomes showed no difference between intervention and control, excluding several DCS subscales. DISCUSSION: An interactive, preference-based decision tool for treatment of FTASD affects patient decision making by guiding respondents toward treatment decisions that align more closely with evidence-based recommendations in the absence of a consultation with an orthopedic provider compared with a standard-of-care control tool. Additional study is needed to evaluate the long-term effects of this tool on treatment outcomes, patient adherence, and satisfaction. LEVEL OF EVIDENCE: 2.

Patient-Centered Approach to Develop the Patient's Preferences for Prostate Cancer Care (PreProCare) Tool.

Objectives. To describe the development of our Patient Preferences for Prostate Cancer Care (PreProCare) tool to aid patient-centered treatment decision among localized prostate cancer patients. Methods. We incorporated patient and provider experiences to develop a patient preference elicitation tool using adaptive conjoint analysis. Our patient-centered approach used systematic literature review, semistructured patient interviews, and provider focus groups to determine the treatment attributes most important for decision making. The resulting computer-based PreProCare tool was pilot tested in a clinical setting. Results. A systematic review of 56 articles published between 1995 and 2015 yielded survival, cancer recurrence, side effects, and complications as attributes of treatment options. We conducted one-on-one interviews with 50 prostate cancer survivors and 5 focus groups of providers. Patients reported anxiety, depression, treatment specifics, and caregiver burden as important for decision making. Providers identified clinical characteristics as important attribute. Input from stakeholders' advisory group, physicians, and researchers helped finalize 15 attributes for our PreProCare preference assessment tool. Conclusion. The PreProCare tool was developed using a patient-centered approach and may be a feasible and acceptable preference clarification intervention for localized prostate cancer patients. The PreProCare tool may translate into higher participant engagement and self-efficacy, consistent with patients' personal values.

Individual Value Clarification Methods Based on Conjoint Analysis: A Systematic Review of Common Practice in Task Design, Statistical Analysis, and Presentation of Results.

BACKGROUND: There is an increased practice of using value clarification exercises in decision aids that aim to improve shared decision making. Our objective was to systematically review to which extent conjoint analysis (CA) is used to elicit individual preferences for clinical decision support. We aimed to identify the common practices in the selection of attributes and levels, the design of choice tasks, and the instrument used to clarify values. METHODS: We searched Scopus, PubMed, PsycINFO, and Web of Science to identify studies that developed a CA exercise to elicit individual patients' preferences related to medical decisions. We extracted data on the above-mentioned items. RESULTS: Eight studies were identified. Studies included a fixed set of 4-8 attributes, which were predetermined by interviews, focus groups, or literature review. All studies used adaptive conjoint analysis (ACA) for their choice task design. Furthermore, all studies provided patients with their preference results in real time, although the type of outcome that was presented to patients differed (attribute importance or treatment scores). Among studies, patients were positive about the ACA exercise, whereas time and effort needed from clinicians to facilitate the ACA exercise were identified as the main barriers to implementation. DISCUSSION: There is only limited published use of CA exercises in shared decision making. Most studies resembled each other in design choices made, but patients received different feedback among studies. Further research should focus on the feedback patients want to receive and how the CA results fit within the patient-physician dialogue.

Patient preferences for diabetes treatment attributes and drug classes.

OBJECTIVE: To identify which treatment attributes are most influential in determining patient preferences for diabetes treatments and explore patient preferences for diabetes drug classes. RESEARCH DESIGN AND METHODS: US adults with type 1 or type 2 diabetes completed an online adaptive conjoint analysis survey. The survey examined 14 attributes, including efficacy, regimen, and risk of common side effects and rare but serious adverse events. Respondents selected between hypothetical treatments with different attributes. Sawtooth Software, ordinary least-squares regression, and hierarchical Bayes regression were used to calculate utilities (i.e. preference weights), importance ratings, and shares of preference across 13 diabetes drug classes or combination products. RESULTS: A total of 167 adults (mean age 58 years; 55% female) with type 1 or type 2 diabetes completed the survey. Based on importance ratings, the most influential attributes driving preferences were regimen, risk of diarrhea, weight change, risk of hypoglycemia, and efficacy. Sodium-glucose co-transporter-2 inhibitors (SGLT-2is) were highly preferred in direct comparison to each of the other classes (range: 84.2-99.9%), with the exception of dipeptidyl peptidase-4 inhibitors (DPP-4is); DPP-4is (52.9%) were preferred over SGLT-2is (47.1%). CONCLUSIONS: Although preferences varied across participants, attributes with the greatest likelihood of affecting daily life and routine were generally more influential in determining patient preferences. DPP-4is and SGLT-2is were overwhelmingly preferred over other drug classes, primarily due to favorable regimen and side effect profiles. Understanding patient preferences can help optimize patient-centered treatment and may lead to improved patient satisfaction, adherence, and outcomes. LIMITATIONS: The primary limitations of this study are that a small sample size of type 1 diabetes patients were included, which may reduce the reliability of the preference estimates, and patients were recruited from a patient panel and may not be representative of patients with diabetes in the US.

European organic dairy farmers' preference for animal health management within the farm management system.

The expertise and knowledge of veterinary advisors on improving animal health management is key towards a better herd health status. However, veterinary advisors are not always aware of the goals and priorities of dairy farmers. To dairy farmers animal health is only one aspect of farm management and resources may be allocated to other more preferred areas. Veterinary advisors may experience this as non-compliant with their advice. To explore the preferences of European Union (EU) organic dairy farmers for improved animal health management relative to other farm management areas an adaptive conjoint analysis (ACA) was performed. A total of 215 farmers participated originating from organic dairy farms in France (n = 70), Germany (n = 60), Spain (n = 28) and Sweden (n = 57). The management areas udder health and claw health represented animal health management whereas barn, calf and pasture management represented potential conflicting management areas. Results indicate that EU organic dairy farmers differ in their preferences for improved animal health management within the farming system. In general, improved calf management was the most preferred area and improved claw health management was found to be least preferred, the remaining areas were of intermediate interest. Cluster analyses on claw health measures and udder health measures resulted in respectively seven and nine distinct preference profiles. The results indicate a high degree of variation in farmers' preference, which cannot be explained by the typical herd characteristics. With the individual preferences revealed by ACA, a veterinary advisor can now find out whether his intended advice is directed at a favourable or unfavourable management area of the farmer. If the latter is the case the veterinarian should first create awareness of the problem to the farmer. Insights in individual farmers preferences will allow veterinary advisors to better understand why farmers were incompliant with their advice and improve their advice by showing, for example, the potential benefits of their advice.

Preferences for Attention-Deficit/Hyperactivity Disorder (ADHD) Non-Stimulant Treatment Characteristics Among Children and Adolescents With ADHD and Their Caregivers.

Background: Understanding patient and caregiver preferences for treatment is important for optimizing treatment decisions. Non-stimulant therapies are an alternative treatment option to stimulant therapy for attention-deficit/hyperactivity disorder (ADHD). Guanfacine extended release (GXR) and atomoxetine (ATX) are two non-stimulant medications approved in the United States for the treatment of ADHD. Objective: To identify non-stimulant ADHD medication attributes important to caregivers/patients. Methods: US caregivers of ADHD patients (6-17 years) and child/adolescent patients (10-17 years) completed an adaptive conjoint analysis survey. Respondents selected between hypothetical treatments with different attributes. Ordinary least-squares and hierarchical Bayes regression using Sawtooth Software were used to calculate utilities, importance ratings, and preferences. Results: 483 caregivers (mean age: 41.9 years, standard deviation [SD]: 8.7; 75% female) and 211 children/adolescents (mean age: 14.5 years, SD: 2.2; 70% male) completed the survey. Based on importance ratings, the most influential attributes for both caregivers and children/adolescents were chance of somnolence, efficacy, and for caregivers, effect on oppositionality and black box warning. Most caregivers (95.3%) and children/adolescents (93.8%) preferred GXR over ATX. In several sensitivity analyses in which attribute levels varied, GXR remained the preferred medication with the exception of one scenario. Conclusions: Children/adolescents and caregivers demonstrated in this study that they can clearly express their preferences for treatment attributes and treatment choices; in this case they preferred GXR to ATX. Patients and caregiver preferences could be useful inputs to the treatment selection decision-making process.