Making Treatment Choices Research Articles

P0688 Decisional conflict among patients with fistulizing perianal disease phenotype of Crohn’s disease at diagnosis

Abstract Background Crohn’s Disease peri-anal fistula (CD-pAF) is a disabling form of the disease affecting work, social and sexual function. Despite Current improvements in medical and surgical management, pCD remains a difficult entity to treat. Decisions about optimal treatment in CD perianal fistula is frequently associated with decisional conflict. We aimed to assess what levels of decisional conflict (DC) do patients with CD-pAF experience after discussing treatment option(s) while making treatment choices at baseline. Methods We used the 16 point decision conflict scale to evaluate patients’ understanding and approval of treatment decision at baseline defined as within 6 months of fistula diagnosis. Results 67 patients with newly diagnosed CD-PAF provided a response to Decision Conflict Scale questionnaire. The median age at fistula diagnosis was 37(31, 48). 39/67 (58%) were females. Notably, 20-30% of patients reported as "unsure" across most of the questions. 32/67(48%) chose biologics to be their preferred treatment option while 9/67(13%) chose surgery. 64% of patients reported to have made an informed choice regarding their treatment. Only 54% reported they have enough information about their treatment options. (Figure1) Conclusion Due to persisting uncertainties in the optimal management of CD- pAF, making informed choices on treatment approaches remain a challenge for patients. Decisional conflict can be lowered with decision supporting interventions. This does not only involve offering better therapeutic choices but also improvement in information, education and shared decision making strategies

Association between Rheumatoid Arthritis Disease Activity and Comorbidities

Background and objectives: Rheumatoid arthritis is an autoimmune condition marked by chronic joint inflammation, frequently resulting in substantial impairment and diminished quality of life. However, rheumatoid arthritis rarely occurs in isolation, as individuals with this condition frequently present with comorbidities, such as cardiovascular disease, diabetes, and osteoporosis. Understanding the role of comorbidities in Rheumatoid Arthritis is critical for comprehensive patient care. The aim of this study was to investigate the impact of various comorbidities on disease activity of rheumatoid arthritis. Methods: Patient data for this cross-sectional study was collected at rheumatology outpatient of Rizgary teaching hospital in Erbil city of Kurdistan-Iraq from August 2022 August 2023. Study participants included patients with rheumatoid arthritis with (n=60) and without (n=60) comorbidities and they were matched for age and sex. Results: Our findings revealed that among patients with rheumatoid arthritis, hypertension is the most frequent comorbidity, affecting 27 patients (45%) of them. This is followed by the coexistence of hypertension and diabetes mellitus in 9 (15%) of cases, and hypothyroidism in 8 (13.3%) of cases. Furthermore, the study establishes a strong and statistically significant link between patient age and the presence of comorbidities (p<0.001). Additionally, it demonstrates a significant correlation between the high activity of RA disease and comorbidities (p=0.03). Conclusions: This research is providing insights into the ways in which these accompanying medical conditions affect the activity of rheumatoid arthritis. The results of this current study have important implications for making treatment choices, assessing risks, and crafting customized approaches to managing this disease.

Factors Influencing Treatment Preference in Patients with Diabetic Macular Edema: A Study Using Conjoint Analysis.

Despite the wide range of treatment options available for diabetic macular edema (DME), adherence to treatment remains a barrier. Therefore, this study used conjoint analysis to examine the factors that patients with DME prioritize when choosing a course of treatment and investigated differences in quality of life and levels of disease self-management in patients with or without experience of anti-vascular endothelial growth factor (VEGF) treatment. A cross-sectional study was conducted through an online survey in Japan between May 31, 2022, and June 30, 2022. Questionnaires were sent to 27,236 individuals registered in the diabetes panels, with experience of treatment for DME within the last 10years. Conjoint analysis was employed to calculate the relative importance, i.e., degree of influence on patients' treatment choices, considering the trade-offs among five factors: cost per treatment, frequency of visits, anticipated post-treatment visual acuity, physician's explanation about disease and treatment, and frequency of treatment-related side effects. A total of 237 responses were used to assess the relative importance of cost per treatment, frequency of visits, anticipated post-treatment visual acuity, physician's explanation about the disease, treatment, and frequency of treatment-related side effects using conjoint analysis. The importance of each factor was anticipated post-treatment visual acuity at 30.0, frequency of treatment-related side effects at 25.5, treatment frequency at 17.7, cost per treatment at 16.5, and physician explanation about the disease and treatment at 10.4. The average EuroQoL 5 dimension 5 level index value in patients with and without anti-VEGF treatment experience was 0.785 and 0.825, respectively, with no major difference. Anticipated post-treatment visual acuity was identified as the most important factor in selecting a treatment regardless of the anti-vascular endothelial growth factor treatment experience demonstrating when patients with DME make treatment choices, anticipated post-treatment visual acuity is prioritized over treatment frequency and cost.

Understanding Global Access to Topical Onychomycosis Therapy: A Systematic Review and Meta-Analysis.

Equal access to medicines is crucial to ensuring public health, but access is difficult to measure, especially for infections where changes in infective species make treatment choices highly dynamic. This study investigated if the combination of infection prevalence with medicine efficacy and regulatory availability could access medicines access of topical onychomycosis medicines. Two databases, PubMed and Web of Science, were used to identify relevant information published between 1990 and 2019. For the meta-analysis, human onychomycosis investigations using PCR analysis were included. Reviewers independently selected eligible articles, extracted data and assessed the study quality. A random-effects meta-analysis model with a Freeman-Tukey transformation was employed to the PCR data. For the meta-analysis, the global infection trends and regional differences in the infective organisms were determined. Of the 26 studies analysed, the PCR analysis in 18 studies confirmed onychomycosis in about half of the visually suspected cases (55%, CI 43%-67%). Across all 26 studies dermatophytes were the most prevalent infective organism (57%, CI 37%-76%), but a sub-group analysis showed yeasts predominated in females (31%, CI 0%-84%) (p < 0.0001), in fingernail infections (42%, CI 21%-65%) (p < 0.0001) and in arid countries (p < 0.0001). Combining these results with medicine efficacy data showed that residents from 83 of the 92 countries assessed (90%) could not access the most efficacious topical product, and 22% could not access any broad-spectrum agents. Countries in Africa had the poorest access to topical onychomycosis medicines. This study identified that access to effective topical products for onychomycosis is a global problem. This issue appeared to be due to under-representation of candida infections in pivotal clinical studies of topical onychomycosis products. A head-to-head multicentre study for topical efinaconazole or a novel broad spectrum topical agent is needed to help resolve these access problems. PROSPERO-CRD42023464744.

Development and validation of accelerated failure time model for cause-specific survival and prognostication of oral squamous cell carcinoma: SEER data analysis.

Oral Squamous Cell Carcinoma is the most prevalent malignancies affecting the oral cavity. Despite progress in studies and treatment options its outlook remains grim with survival prospects greatly affected by demographic and clinical factors. Precisely predicting survival rates and prognosis plays a role in making treatment choices for the best achievable overall health outcomes. To develop and validate an accelerated failure time model as a predictive model for cause-specific survival and prognosis of Oral Squamous Cell Carcinoma patients and compare its results to the traditional Cox proportional hazard model. We screened Oral cancer patients diagnosed with Squamous Cell Carcinoma from the Surveillance Epidemiology and End Results (SEER) database between 2010 and 2020. An accelerated failure time model using the Type I generalized half logistic distribution was used to determine independent prognostic factors affecting the survival time of patients with oral squamous carcinoma. In addition, accelerated factors were estimated to assess how some variables influence the survival times of the patients. We used the Akaike Information Criterion, Bayesian Information Criterion to evaluate the model fit, the area under the curve for discriminability, Concordance Index (C-index) and Root Mean Square Error and calibration curve for predictability, to compare the type I generalized half logistic survival model to other common classical survival models. All tests are conducted at a 0.05 level of significance. The accelerated failure time models demonstrated superior effectiveness in modeling (fit and predictive accuracy) the cause-specific survival (CSS) of oral squamous cell carcinoma compared to the Cox model. Among the accelerated failure time models considered, the Type I generalized half logistic distribution exhibited the most robust model fit, as evidenced by the lowest Akaike Information Criterion (AIC = 27370) and Bayesian Information Criterion (BIC = 27415) values. This outperformed other parametric models and the Cox Model (AIC = 47019, BIC = 47177). The TIGHLD displayed an AUC of 0.642 for discrimination, surpassing the Cox model (AUC = 0.544). In terms of predictive accuracy, the model achieved the highest concordance index (C-index = 0.780) and the lowest root mean square error (RMSE = 1.209), a notable performance over the Cox model (C-index = 0.336, RMSE = 6.482). All variables under consideration in this study demonstrated significance at the 0.05 level for CSS, except for race and the time span from diagnosis to treatment, in the TIGHLD AFT model. However, differences emerged regarding the significant variations in survival times among subgroups. Finally, the results derived from the model revealed that all significant variables except chemotherapy, all TNM stages and patients with Grade II and III tumor presentations contributed to the deceleration of time to cause-specific deaths. The accelerated failure time model provides a relatively accurate method to predict the prognosis of oral squamous cell carcinoma patients and is recommended over the Cox PH model for its superior predictive capabilities. This study also underscores the importance of using advanced statistical models to improve survival predictions and outcomes for cancer patients.

Decision-making preferences and regret in rectal cancer patients undergoing restorative proctectomy: A prospective cohort study

BackgroundHow patients make treatment choices in rectal cancer is poorly understood and may affect long-term regret and satisfaction. The objective of this study is to characterize decision-making preferences and their effect on decisional regret in patients undergoing restorative proctectomy for rectal cancer. MethodsA prospective cohort study was conducted in a single academic specialist rectal cancer center from October 2018 to June 2022. Adult patients who underwent restorative proctectomy at least one year prior were recruited. Health literacy was assessed using the BRIEF instrument. Decision-making preferences regarding cancer treatment were assessed using the Control Preferences Scale. Decisional regret regarding their choice of restorative proctectomy was assessed using the Decision Regret Score. Bowel dysfunction was measured using the low anterior resection syndrome score. ResultsOverall, 123 patients were included. Health literacy was categorized as adequate in 63%, marginal in 25%, and limited in 12%. Patients with adequate health literacy were more likely to prefer a collaborative decision-making role compared with those with low health literacy (86% vs 65%, P = .016). Patients with incongruence between preferred and actual decision-making roles were more likely to report high regret (56% vs 25%, P = .003). Patients with major low anterior resection syndrome were also more likely to experience high regret compared with patients with no/minor low anterior resection syndrome (44% vs 25%, P = .036). ConclusionA significant proportion of patients with rectal cancer undergoing restorative proctectomy do not have a decision-making role that is congruent with their preferences, and these patients experience a high degree of regret.

Surgery compared to fibrinolytic therapy for symptomatic left-sided prosthetic heart valve thrombosis (SAFE-PVT): Rationale and design of a randomized controlled trial

BackgroundLeft-sided mechanical prosthetic heart valve thrombosis (PVT) occurs because of suboptimal anticoagulation and is common in low-resource settings. Urgent surgery and fibrinolytic therapy (FT) are the two treatment options available for this condition. Urgent surgery is a high-risk procedure but results in successful restoration of valve function more often and is the treatment of choice in developed countries. In low-resource countries, FT is used as the default treatment strategy, though it is associated with lower success rates and a higher rate of bleeding and embolic complications. There are no randomized trials comparing the two modalities. MethodsWe performed a single center randomized controlled trial comparing urgent surgery (valve replacement or thrombectomy) with FT (low-dose, slow infusion tissue plasminogen activator, tPA) in patients with symptomatic left-sided PVT. The primary outcome was the occurrence of a complete clinical response, defined as discharge from hospital with completely restored valve function, in the absence of stroke, major bleeding or non-CNS systemic embolism. Outcome assessment was done by investigators blinded to treatment allocation. The principal safety outcome was the occurrence of a composite of in-hospital death, non-fatal stroke, non-fatal major bleed or non-CNS systemic embolism. Outcomes will be assessed both in the intention-to-treat, and in the as-treated population. We will also report outcomes at one year of follow-up. The trial has completed recruitment. ConclusionThis is the first randomized trial to compare urgent surgery with FT for the treatment of left-sided PVT. The results will provide evidence to help clinicians make treatment choices for these patients.(Clinical trial registration: CTRI/2017/10/010159).

Personal legacy and treatment choices for serious illness: a scoping review

BackgroundLegacy—how one hopes to be remembered after death—is an unexplored and important dimension of decision-making for people facing serious illness.ObjectivesWe conducted a scoping review to answer the following research questions:...

The development of a decision aid for patients with operable oropharyngeal carcinoma in the Netherlands – A mixed methods study

ObjectiveThe aim of this project is to create an interactive online patient decision aid (PDA) for oropharyngeal cancer (OPSCC) patients, eligible for transoral (robotic) surgery with an ultimate goal to assist both physicians and patients in making treatment choices. Materials and methodsFollowing the International Patient Decision Aid Standards, a mixed-methods approach was employed. The study involved semi-structured in-depth interviews with patients and physicians, thinking-out-loud sessions, and study-specific questionnaires. Thematic coding and analysis were conducted on verbatim transcriptions of audio-recorded interviews. ResultsThe PDA drafts were evaluated by twenty OPSCC survivors and twenty multidisciplinary specialists. Significant revisions were made after phase 1 to enhance readability and reduce text, whilst incorporating videos and graphics. Following all phases, both patients and specialists rated the PDA as comprehensible, feasible, and a valuable addition to regular counseling. ConclusionThis study showcases the development of a PDA for early stage oropharyngeal cancer patients considering surgery and radiotherapy options. The decision aid emphasizes the disparities in short- and long-term side effects between the two treatments. Patients and physicians found the decision aid to be understandable, user-friendly, and helpful for future patients. The PDA is available on https://beslissamen.nl/.

“Bad memories and a big debt—not a legacy I want to leave.” Patient perspectives on cancer treatment choices, cost of care, and legacy goals.

283 Background: Legacy—how one hopes to be remembered and how one impacts others after death—is an unexplored and important dimension of care decision-making for people facing serious illness. This study examined 1) how people with cancer facing serious illness conceive of legacy, 2) the types of treatment choices people make with legacy in mind and 3) if and how patients want to discuss their legacy goals with their care team. Methods: We conducted a scoping literature review to characterize the legacy construct and identify legacy-related treatment choices. We conducted semi-structured telephone interviews with cancer patients at an integrated health system who had received at least 1 palliative care consult in the past year. Interview topics included patient definitions of legacy, the importance of legacy over time, and what mattered most as they made treatment choices. We used Atlas.ti to thematically analyze interview transcripts. Results: In the scoping review, we identified three major intersecting legacy goals that influence patients’ care choices: being remembered as an individual, being remembered for one’s social role, and impacting others' well-being. Financial legacy—the material artifacts related to one’s estate—cut across all three legacy domains and emerged as a substantial factor at the intersection of care decision-making and legacy planning. In qualitative interviews, many people worried that the cost of care and necessary medications would negatively impact the legacy they were able to leave behind. Examples included choosing less expensive or forgoing treatment to preserve their financial legacy (e.g. not wanting to lose their house because of medical costs); feeling shame at experiencing financial hardship due to cancer care costs (“I don’t want to be remembered begging people for gas money to get to my appointments”); and death planning with cost in mind (“I don’t want to leave a horrible mess behind.”). Few people had discussed their legacy goals with their health care team, but many wanted support to do so, especially as these goals were threatened by high out of pocket costs. Conclusions: People with cancer consider their legacy goals, and in particular their financial legacy, as they make treatment choices. Further work is needed to identify how and for whom legacy goals should be addressed as part of patient-centered care, including for whom legacy and financial legacy is most important.

Study of radiochemotherapy decision-making for young high-risk low-grade glioma patients using a macroscopic and microscopic combined radiomics model.

As a few types of glioma, young high-risk low-grade gliomas (HRLGGs) have higher requirements for postoperative quality of life. Although adjuvant chemotherapy with delayed radiotherapy is the first treatment strategy for HRLGGs, not all HRLGGs benefit from it. Accurate assessment of chemosensitivity in HRLGGs is vital for making treatment choices. This study developed a multimodal fusion radiomics (MFR) model to support radiochemotherapy decision-making for HRLGGs. A MFR model combining macroscopic MRI and microscopic pathological images was proposed. Multiscale features including macroscopic tumor structure and microscopic histological layer and nuclear information were grabbed by unique paradigm, respectively. Then, these features were adaptively incorporated into the MFR model through attention mechanism to predict the chemosensitivity of temozolomide (TMZ) by means of objective response rate and progression free survival (PFS). Macroscopic tumor texture complexity and microscopic nuclear size showed significant statistical differences (p < 0.001) between sensitivity and insensitivity groups. The MFR model achieved stable prediction results, with an area under the curve of 0.950 (95% CI: 0.942-0.958), sensitivity of 0.833 (95% CI: 0.780-0.848), specificity of 0.929 (95% CI: 0.914-0.936), positive predictive value of 0.833 (95% CI: 0.811-0.860), and negative predictive value of 0.929 (95% CI: 0.914-0.934). The predictive efficacy of MFR was significantly higher than that of the reported molecular markers (p < 0.001). MFR was also demonstrated to be a predictor of PFS. A MFR model including radiomics and pathological features predicts accurately the response postoperative TMZ treatment. Our MFR model could identify young high-risk low-grade glioma patients who can have the most benefit from postoperative upfront temozolomide (TMZ) treatment. • Multimodal radiomics is proposed to support the radiochemotherapy of glioma. • Some macro and micro image markers related to tumor chemotherapy sensitivity are revealed. • The proposed model surpasses reported molecular markers, with a promising area under the curve (AUC) of 0.95.

Shared decision making and associated factors among patients with psychotic disorders: a cross-sectional study

BackgroundShared decision making is a process where patients and clinicians collaborate to make treatment choices based on the patients’ preferences and best available evidence. The implementation of shared decision making remains limited for patients with psychotic disorders despite being recommended at policy level, being advocated as ethical right and wanted by the patient’s. A barrier to implementation that is often mentioned is reduced decision-making capacity among patients. The challenges of implementing shared decision making highlights a need for more knowledge on shared decision making for these patients. Moreover, the association between patient-related characteristics and shared decision making is unclear, and further research have been suggested. More knowledge of factors associated with involvement in shared decision making can enhance understanding and help to empower patients in the decision-making process. The current study examined the extent of reported shared decision making among patients with a psychotic disorder in mental health care and factors associated with shared decision making.MethodsThis study included 305 participants with a psychotic disorder from 39 clinical inpatient and outpatient sites across Norway. Shared decision making was assessed using the CollaboRATE survey. A linear mixed model was estimated to assess characteristics associated with shared decision making scores.ResultsThe CollaboRATE mean score was 6.3 (ranging from 0 to 9), the top score was 14.1% and increased global satisfaction with services was significantly associated with a higher level of shared decision making (regression coefficient 0.27, 95% confidence interval (0.23; 0.32), p < 0.001).ConclusionsThe low top score shows that few patients felt that they received the highest possible quality of shared decision making, indicating that many patients found room for improvement. This suggests that services for patients with psychotic disorders should be designed to give them a greater role in decision making. Shared decision making might play a key role in mental health care, ensuring that patients with psychotic disorders are satisfied with the services provided.Trial registrationNCT03271242, date of registration: 5 Sept. 2017.

Actual situation of decision-making support from medical staff when cancer patients make treatment choices

Background: We investigated factors involved in decision-making support provided by physicians, nurses, pharmacists and medical and psychiatric social workers involved in cancer care. Materials &amp; methods: A questionnaire survey on decision-making support was conducted. The level of clinician support was classified as ‘supporting patients’ ‘decision-making process regarding cancer treatment’, ‘no support for patients’ ‘decision-making process regarding cancer treatment’ or ‘team-based support for patients’ ‘decision-making process regarding cancer treatment’. Results: Physicians estimated that 83.7% of patients made a cancer treatment decision within 1 week, but 45.4% of patients had difficulty making a decision. Conclusion: Medical personnel should support patients who have difficulty making decisions, establish a screening method to identify those needing support and develop a system providing decision-making support through interprofessional work.

Clinicians’ views of prescribing oral and intravenous bisphosphonates for osteoporosis: a qualitative study

BackgroundBisphosphonate medications, including alendronate, ibandronate and risedronate administered orally and zoledronate, administered intravenously, are commonly prescribed for the treatment of osteoporosis based on evidence that, correctly taken, bisphosphonates can improve bone strength and lead to a reduction in the risk of fragility fractures. However, it is currently unclear how decisions to select between bisphosphonate regimens, including intravenous regimen, are made in practice and how clinicians support patients with different treatments.MethodsThis was an interpretivist qualitative study. 23 semi-structured telephone interviews were conducted with a sample of general practitioners (GPs), secondary care clinicians, specialist experts as well as those providing and leading novel treatments including participants from a community intravenous (IV) zoledronate service. Data analysis was undertaken through a process of iterative categorisation.ResultsThe results report clinicians varying experiences of making treatment choices, as well as wider aspects of osteoporosis care. Secondary care and specialist clinicians conveyed some confidence in making treatment choices including on selecting IV treatment. This was aided by access to diagnostic testing and medication expertise. In contrast GPs reported a number of challenges in prescribing bisphosphonate medications for osteoporosis and uncertainty about treatment choice. Results also highlight how administering IV zoledronate was seen as an opportunity to engage in broader care practices.ConclusionApproaches to making treatment decisions and supporting patients when prescribing bisphosphonates for osteoporosis vary in practice. This study points to the need to co-ordinate osteoporosis treatment and care across different care providers.

Treatment patterns, health care resource utilization, and costs associated with use of atypical antipsychotics as first vs subsequent adjunctive treatment in major depressive disorder.

BACKGROUND: Major depressive disorder (MDD) is a highly prevalent mental health condition associated with substantial economic burden. Inadequate response to first-line antidepressant monotherapy is common, with most patients requiring 1 or more changes in their treatment regimen. Adjunctive treatment with atypical antipsychotics (AAs) is a guideline-recommended treatment option in patients with inadequate response. However, patients often cycle through multiple treatments before receiving adjunctive AAs, and the economic impact of this delay is unknown. OBJECTIVE: To describe adjunctive treatment patterns among patients with MDD and compare health care resource utilization (HCRU) and costs between patients whose first adjunctive therapy included an AA and those who received an AA after other adjunctive treatments. METHODS: The Merative MarketScan Commercial Database (January 1, 2014, to June 30, 2019) was used to identify patients with administrative claims meeting the following inclusion criteria: adults with newly diagnosed MDD (first observed MDD diagnosis = index diagnosis date); continuous health insurance for at least 6 months pre-index and at least 3 months post-index; and initiation of MDD treatment within 60 days post-index. Lines of therapy (LOTs), HCRU, and costs were analyzed in patients who received AA adjunctive therapy, including those who initiated AAs as the first adjunctive treatment and those who initiated AAs as subsequent adjunctive treatment. RESULTS: Of 508,830 patients meeting inclusion criteria, 121,060 (24%) received adjunctive treatment and 20,797 (4%) received an AA as adjunctive therapy. Mean time to adjunctive therapy initiation was approximately 7.3 months for AA adjunctive therapy. Patients who initiated an AA as their first adjunctive therapy compared with patients who initiated an AA as their subsequent adjunctive therapy had fewer LOTs on average (0.9 LOTs vs 3.9 LOTs) and shorter time between index diagnosis date and initiation of an AA (5 months vs 12 months). Subsequent AA initiators had significantly greater HCRU than first AA initiators (driven primarily by outpatient visits) and incurred significantly higher total health care costs, with mean all-cause and mental health-related health care cost differences per patient per year of $2,441 and $1,762, respectively (both P < 0.05). CONCLUSIONS: Less than 5% of patients in this study received an adjunctive AA as part of their MDD treatment regimen, suggesting underutilization of this recommended therapeutic approach. Patients who received an AA as their first adjunctive treatment regimen had lower HCRU and health care costs than subsequent AA initiators. Along with published evidence of clinical benefits, this potential impact on economic burden should be considered when making treatment choices for patients with inadequate response to antidepressants.

Understanding Treatment Preferences Among People Living with HIV in Australia: A Discrete Choice Experiment.

To better understand what is most important to people living with human immunodeficiency virus (PLWH) when choosing their treatment. We assessed how PLWH trade off the potential risks and benefits of oral and long acting injectable (LAI) treatments. Firstly, in-depth interviews were conducted with 11 PLWH to develop a holistic understanding of experiences and determine attributes that contribute to treatment decision-making. Secondly, a discrete choice experiment (DCE) was used to understand the treatment preferences for PLWH with n = 99 PLWH aged 18 years or over with a diagnosis of human immunodeficiency virus (HIV) and who were currently using anti-retroviral therapy (ART). Study participants were presented with 12 scenarios and asked to select their preferred treatment among two hypothetical injectable treatment alternatives, "injection 1" and "injection 2" and their current oral ART treatment. The DCE data were modelled using a latent class model (LCM). The model revealed significant heterogeneity in preferences for treatment attributes among study participants. Two segments/classes of PLWH were identified. The first segment expressed a strong preference for their current oral treatment; the second segment showed strong preference for the injection treatment and for it to be administered in a GP clinic. Overall, out-of-pocket cost was the most important attribute for participants. One-third of PLWH were willing to switch to an LAI. Not all PLWH valued the same treatment attributes equally. Overall, out-of-pocket costs for treatments were considered by respondents as the most determining factor in making treatment choices. Results have important implications for healthcare policy and will serve to better inform patients and stakeholders involved in the treatment decision-making process about the treatment preferences of PLWH. Clinicians are encouraged to consider shared decision-making to establish the treatment course that best aligns with PLWH's treatment goals.

Design of a Non-Interventional Study to Assess Neurologists' Perspectives and Pharmacological Treatment Decisions in Early Alzheimer's Disease.

The current therapeutic landscape of Alzheimer's disease (AD) is evolving rapidly. Our treatment options include new anti-amyloid-β protein disease-modifying therapies (DMTs) that decrease cognitive decline in patients with early AD (prodromal and mild AD dementia). Despite these advances, we have limited information on how neurologists would apply the results of recent DMT trials to make treatment decisions. Our goal is to identify factors associated with the use of new AD DMTs among neurologists applying concepts from behavioral economics. This non-interventional, cross-sectional, web-based study will assess 400 neurologists with expertise in AD from across Spain. Participants will start by completing demographic information, practice settings, and a behavioral battery to address their tolerance to uncertainty and risk preferences. Participants will then be presented with 10 simulated case scenarios or vignettes of common encounters in patients with early AD to evaluate treatment initiation with anti-amyloid-β DMTs (e.g., aducanumab, lecanemab, etc.). The primary outcomes will be therapeutic inertia and suboptimal decisions. Discrete choice experiments will be used to determine the weight of factors influencing treatment choices. The results of this study will provide new insights into a better understanding of the most relevant factors associated with therapeutic decisions on the use of DMTs, assessing how neurologists handle uncertainty when making treatment choices, and identifying the prevalence of therapeutic inertia in the management of early AD.

Effect of Presenting Survival Information as Text or Pictograph During Periviable Birth Counseling: A Randomized, Controlled Trial

To examine whether presenting a 30% or a 60% chance of survival in different survival information formats would influence hypothetical periviable birth treatment choice and whether treatment choice would be associated with participants' recall or their intuitive beliefs about the chances of survival. An internet sample of women (N = 1,052) were randomized to view a vignette with either a 30% or 60% chance of survival with intensive care during the periviable period. Participants were randomized to survival information presented as text-only, in a static pictograph, or in an iterative pictograph. Participants chose intensive care or palliative care and reported their recall of the chance of survival and their intuitive beliefs about their infant's chance of survival. There was no difference in treatment choice by presentation with a 30% vs. 60% chance of survival (p=0.48), by survival information format (p=0.80), or their interaction (p=0.18). However, participants' intuitive beliefs about chance of survival significantly predicted treatment choice (p<0.001) and had the most explanatory power of any participant characteristic. Intuitive beliefs were optimistic and did not differ by presentation of a 30% or 60% chance of survival (p=0.65), even among those with accurate recall of the chance of survival (p=0.09). Physicians should recognize that parents may use more than outcome data to make treatment choices and in forming their own, often optimistic, intuitive beliefs about their infant's chance of survival.

Trans-diagnostic determinants of psychotherapeutic treatment response: The pressing need and new opportunities for a more systematic way of selecting psychotherapeutic treatment in the age of virtual service delivery.

Numerous forms of psychotherapy have demonstrated effectiveness for individuals with specific mental disorders. It is, therefore, the task of the clinician to choose the most appropriate therapeutic approach for any given client to maximize effectiveness. This can prove to be a difficult task due to at least three considerations: (1) there is no treatment approach, method or model that works well on all patients, even within a particular diagnostic class; (2) several treatments are equally efficacious (i.e., more likely to be effective than no treatment at all) when considered only in terms of the patient's diagnosis; and (3) effectiveness in the real-world therapeutic setting is determined by a host of non-diagnostic factors. Typically, consideration of these latter, trans-diagnostic factors is unmethodical or altogether excluded from treatment planning - often resulting in suboptimal patient care, inappropriate clinic resource utilization, patient dissatisfaction with care, patient demoralization/hopelessness, and treatment failure. In this perspective article, we argue that a more systematic research on and clinical consideration of trans-diagnostic factors determining psychotherapeutic treatment outcome (i.e., treatment moderators) would be beneficial and - with the seismic shift toward online service delivery - is more feasible than it used to be. Such a transition toward more client-centered care - systematically considering variables such as sociodemographic characteristics, patient motivation for change, self-efficacy, illness acuity, character pathology, trauma history when making treatment choices - would result in not only decreased symptom burden and improved quality of life but also better resource utilization in mental health care and improved staff morale reducing staff burnout and turnover.

Conceptions of Legacy Among People Making Treatment Choices for Serious Illness: Protocol for a Scoping Review.

Legacy-what one leaves behind and how one hopes to be remembered after death-is an unexplored and important dimension of decision-making for people facing serious illnesses. A preliminary literature review suggests that patients facing serious illness consider legacy when making medical decisions, for example, forgoing expensive treatment with limited or unknown clinical benefit to preserve one's inheritance for their children. To date, very little is known about the conceptual foundations of legacy. No conceptual frameworks exist that provide a comprehensive understanding of how legacy considerations relate to patient choices about their medical care. The objective of this scoping review is to understand the extent and type of research addressing the concept of legacy by people facing serious illness to inform a conceptual framework of legacy and patient treatment choices. This protocol follows the guidelines put forth by Levac et al, which expands the framework introduced by Arksey and O'Malley, as well as the Joanna Briggs Institute Reviewer's manual. This scoping review will explore several electronic databases including PubMed, Medline, CINAHL, Cochrane Library, PsycINFO, and others and will include legacy-specific gray literature, including dissertation research available via ProQuest. An initial search will be conducted in English-language literature from 1990 to the present with selected keywords to identify relevant articles and refine the search strategy. After the search strategy has been finalized, 2 independent reviewers will undertake a 2-part study selection process. In the first step, reviewers will screen article titles and abstracts to identify the eligibility of each article based on predetermined exclusion or inclusion criteria. A third senior reviewer will arbitrate discrepancies regarding inclusions or exclusions. During the second step, the full texts will be screened by 2 reviewers, and only relevant articles will be kept. Relevant study data will be extracted, collated, and charted to summarize the key findings related to the construct of legacy. This study will identify how people facing serious illness define legacy, and how their thinking about legacy impacts the choices they make about their medical treatments. We will note gaps in the literature base. The findings of this study will inform a conceptual model that outlines how ideas about legacy impact the patient's treatment choices. The results of this study will be submitted to an indexed journal. Very little is known about the role of legacy in the treatment decisions of patients across the continuum of serious illness. In particular, no comprehensive conceptual model exists that would provide an understanding of how legacy is considered by people making decisions about their care during serious illness. This study will be among the first to construct a conceptual model detailing how considerations of legacy impact medical decision-making for people facing or living with serious illnesses. DERR1-10.2196/40791.