The use of a decision board to elicit Brazilian patients' and physicians' preferences for treatment: the case of lupus nephritis.

OBJECTIVES: To find preferences for treatment expressed by lupus patients and physicians (who were asked to assume they have lupus) and to explore if certain variables explain these preferences. METHODS: One hundred seventy-two patients and 202 physicians were interviewed using a lupus nephritis decision board that describes the treatment options and their potential benefits and risks. Clinical and sociodemographic variables were collected. Participants were asked to indicate their preferred treatment and provide justification for their choice. Descriptive statistics, t tests, and Pearson's chi-square tests were used to determine the significance of differences in the decisions made by the two groups. A logistic regression model determined which factors contributed to treatment decisions. RESULTS: The average age of study participants was 34 ± 8 years for patients and 31 ± 7 years for physicians. Sixty-eight percent of patients and 96% of physicians (P < 0.001) selected the oral option. Patients and physicians justified their choice of treatment using different arguments (P < 0.001 in each case). Logistic regression showed that risk potential (P < 0.001) and a history of joint involvement (P = 0.011) were the arguments used most often to explain a patient's decision and the risk of side effects was most relevant among physicians (P < 0.001). CONCLUSIONS: Using a decision board, patients and physicians were found to have different preferences for treatment when faced with the same treatment options. Further, the variables that influence their preferences are different.

Relation between fractures and mortality: results from the Canadian Multicentre Osteoporosis Study.

BACKGROUND: Fractures have largely been assessed by their impact on quality of life or health care costs. We conducted this study to evaluate the relation between fractures and mortality. METHODS: A total of 7753 randomly selected people (2187 men and 5566 women) aged 50 years and older from across Canada participated in a 5-year observational cohort study. Incident fractures were identified on the basis of validated self-report and were classified by type (vertebral, pelvic, forearm or wrist, rib, hip and "other"). We subdivided fracture groups by the year in which the fracture occurred during follow-up; those occurring in the fourth and fifth years were grouped together. We examined the relation between the time of the incident fracture and death. RESULTS: Compared with participants who had no fracture during follow-up, those who had a vertebral fracture in the second year were at increased risk of death (adjusted hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.1-6.6); also at risk were those who had a hip fracture during the first year (adjusted HR 3.2, 95% CI 1.4-7.4). Among women, the risk of death was increased for those with a vertebral fracture during the first year (adjusted HR 3.7, 95% CI 1.1-12.8) or the second year of follow-up (adjusted HR 3.2, 95% CI 1.2-8.1). The risk of death was also increased among women with hip fracture during the first year of follow-up (adjusted HR 3.0, 95% CI 1.0-8.7). INTERPRETATION: Vertebral and hip fractures are associated with an increased risk of death. Interventions that reduce the incidence of these fractures need to be implemented to improve survival.

Economic evaluation of HIV screening in pregnant women attending antenatal clinics in India.

OBJECTIVE: With prevalence of HIV rising in pregnant women in India, pediatric HIV/AIDS is emerging as a public health problem. We evaluated the additional costs to the health care system and the additional health outcomes of introducing a voluntary primary care HIV screening program for pregnant women in India. METHODS: The analysis was conducted from the government perspective. We analyzed two scenarios: a programme of universal screening nation-wide and a programme of screening restricted to high prevalence states. Health benefits were measured by the number of perinatal HIV cases prevented and the reduction in the potential years of life lost (PYLL). FINDINGS: Nation-wide screening would cost the government Rs. 254.78 million and would prevent 9880 cases of perinatal HIV resulting in savings of 131,700 life years (average cost per HIV case prevented Rs. 25,787; per year reduction in PYLLs Rs. 1935). Implementing the program in only the high prevalence states would achieve 45% of these reductions in cases and life years lost at only 20% of this cost, at an average of Rs. 12,091 per HIV case prevented or Rs. 907 per year reduction in PYLLs (44 Indian rupees = 1 US dollar). In sensitivity analysis, the cost of the program was influenced mainly by antenatal coverage, the cost of the HIV test, the lifetime costs of treatment of a HIV infected child and the overhead costs. CONCLUSIONS: We provide an estimate of the additional costs and health effects of two approaches to introducing HIV screening among pregnant women in India. Decision-makers would have to demonstrate that the resources used for its implementation would result in more health benefits than from the alternative uses of those resources.

Development and testing of a decision board to help clinicians present treatment options to lupus nephritis patients in Brazil.

OBJECTIVE: Decision boards (DBs) help clinicians present options and include patients in the decision-making process. Our objective was to describe the steps to develop a DB to support shared decision making and assess reliability and construct validity. METHODS: Systemic lupus erythematosus (SLE) scenarios were designed with the support of experts for disease severity, potential side effects, and outcomes. The DB comprised clinical information, 2 different treatment options (oral and intravenous), a description of the potential to control SLE within 5 years, and a list of potential side effects. Patients selected what they thought would be the 3 worst side effects and were informed of the probability that these would occur. We presented the DB to 172 patients who were asked to select and justify 1 treatment option. Reliability was assessed by kappa statistics. Construct validity was tested by an a priori hypothesis, analyzing the correlation between treatment decision and side effects selected, self-assessment score, educational level, and clinical aspects. RESULTS: Patients favored oral medication, and side effects most often listed were iatrogenic cancer (44.2%), hair loss (21.6%), and severe infection (19.1%). Justifications were risk (48.9%), practicality (36.6%), effectiveness (12.2%), and risk-benefit tradeoff (2.3%). Reliability was similar to that found in the test phase (kappa = 0.689, P < 0.001). Validity was tested by prediction of treatment decision based on the undesirable side effects selected (P = 0.047). DB content was clear and easy for all patients to understand (P = 0.05). Immunosuppressive drugs influenced patient decisions (P = 0.006). CONCLUSION: DB is a reliable and valid instrument to assess SLE patient preference.

Adjunctive human papillomavirus testing in the 2-year follow-up of women with low-grade cervical cytologic abnormalities: a randomized trial and economic evaluation.

CONTEXT: Although human papillomavirus (HPV) testing may aid in managing low-grade abnormality on screening cervical cytology, patient compliance with repeat testing programs requires consideration. OBJECTIVES: To determine effectiveness and costs of repeated Papanicolaou (Pap) test and oncogenic HPV testing for detecting cervical intraepithelial neoplasia 2 or 3. DESIGN: We conducted a randomized controlled trial of combined Pap test and cervical HPV testing by Hybrid Capture 1 test compared with Pap test alone; tests were performed every 6 months for up to 2 years. The study end point was colposcopic examination performed on all women at 2 years, or earlier if an HPV test was positive or if a Pap test showed high-grade squamous intraepithelial lesion. SETTING: Sixty-six community family practices. PARTICIPANTS: Two hundred fifty-seven women with atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion on screening cervical cytology. MAIN OUTCOME MEASURES: Detection of histologically confirmed cervical intraepithelial neoplasia 2 or 3, fully allocated costs, and loss to follow-up. RESULTS: Combined Pap test and HPV testing detected 11 (100%) of 11 cases of cervical intraepithelial neoplasia 2/3, whereas Pap test alone detected 7 (63.6%) of these 11 cases (P =.14); corresponding specificities were 39 (46.4%) of 84 and 45 (71.4%) of 63 (P =.005). The cost-effectiveness ratio was Can $4456 per additional case of high-grade cervical intraepithelial neoplasia. Sixty-nine (26.8%) of the 257 women (24.6% combined group vs 29.1% Pap test only group, P =.41) defaulted from testing or from colposcopy when referred with an abnormal result. CONCLUSIONS: Combined testing was more costly but may detect more cases of cervical intraepithelial neoplasia 2/3 than Pap test alone. However, poor adherence limits usefulness of a management strategy that requires repeated follow-up.