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Women's values and preferences for thromboprophylaxis during pregnancy: a comparison of direct-choice and decision analysis using patient specific utilities.

ABSTRACT: BACKGROUND:Women with a history of venous thromboembolism (VTE) have an increased recurrence risk during pregnancy. Low molecular weight heparin (LMWH) reduces this risk, but is costly, burdensome, and may increase risk of bleeding. The decision to start thromboprophylaxis during pregnancy is sensitive to women's values and preferences. Our objective was to compare women's choices using a holistic approach in which they were presented all of the relevant information (direct-choice) versus a personalized decision analysis in which a mathematical model incorporated their preferences and VTE risk to make a treatment recommendation. METHODS:Multicenter, international study. Structured interviews were on women with a history of VTE who were pregnant, planning, or considering pregnancy. Women indicated their willingness to receive thromboprophylaxis based on scenarios using personalized estimates of VTE recurrence and bleeding risks. We also obtained women's values for health outcomes using a visual analog scale. We performed individualized decision analyses for each participant and compared model recommendations to decisions made when presented with the direct-choice exercise. RESULTS:Of the 123 women in the study, the decision model recommended LMWH for 51 women and recommended against LMWH for 72 women. 12% (6/51) of women for whom the decision model recommended thromboprophylaxis chose not to take LMWH; 72% (52/72) of women for whom the decision model recommended against thromboprophylaxis chose LMWH. CONCLUSIONS:We observed a high degree of discordance between decisions in the direct-choice exercise and decision model recommendations. Although which approach best captures individuals' true values remains uncertain, personalized decision support tools presenting results based on personalized risks and values may improve decision making.

SUBMITTER: Eckman MH

PROVIDER: S-EPMC4880369 | biostudies-literature | 2015 Aug

REPOSITORIES: biostudies-literature

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Women's values and preferences for thromboprophylaxis during pregnancy: a comparison of direct-choice and decision analysis using patient specific utilities.

Eckman Mark H MH Alonso-Coello Pablo P Guyatt Gordon H GH Ebrahim Shanil S Tikkinen Kari A O KA Lopes Luciane Cruz LC Neumann Ignacio I McDonald Sarah D SD Zhang Yuqing Y Zhou Qi Q Akl Elie A EA Jacobsen Ann Flem AF Santamaría Amparo A Annichino-Bizzacchi Joyce Maria JM Bitar Wael W Sandset Per Morten PM Bates Shannon M SM

Thrombosis research 20150522 2

<h4>Background</h4>Women with a history of venous thromboembolism (VTE) have an increased recurrence risk during pregnancy. Low molecular weight heparin (LMWH) reduces this risk, but is costly, burdensome, and may increase risk of bleeding. The decision to start thromboprophylaxis during pregnancy is sensitive to women's values and preferences. Our objective was to compare women's choices using a holistic approach in which they were presented all of the relevant information (direct-choice) versu ...[more]

PMID: 26033397

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Project description:BackgroundPregnant women with prior venous thromboembolism (VTE) are at risk of recurrence. Low molecular weight heparin (LWMH) reduces the risk of pregnancy-related VTE. LMWH prophylaxis is, however, inconvenient, uncomfortable, costly, medicalizes pregnancy, and may be associated with increased risks of obstetrical bleeding. Further, there is uncertainty in the estimates of both the baseline risk of pregnancy-related recurrent VTE and the effects of antepartum LMWH prophylaxis. The values and treatment preferences of pregnant women, crucial when making recommendations for prophylaxis, are currently unknown. The objective of this study is to address this gap in knowledge.MethodsWe will perform a multi-center cross-sectional interview study in Canada, USA, Norway and Finland. The study population will consist of 100 women with a history of lower extremity deep vein thrombosis (DVT) or pulmonary embolism (PE), and who are either pregnant, planning pregnancy, or may in the future consider pregnancy (women between 18 and 45 years). We will exclude individuals who are on full dose anticoagulation or thromboprophylaxis, who have undergone surgical sterilization, or whose partners have undergone vasectomy. We will determine each participant's willingness to receive LMWH prophylaxis during pregnancy through direct choice exercises based on real life and hypothetical scenarios, preference-elicitation using a visual analog scale ("feeling thermometer"), and a probability trade-off exercise. The primary outcome will be the minimum reduction (threshold) in VTE risk at which women change from declining to accepting LMWH prophylaxis. We will explore possible determinants of this choice, including educational attainment, the characteristics of the women's prior VTE, and prior experience with LMWH. We will determine the utilities that women place on the burden of LMWH prophylaxis, pregnancy-related DVT, pregnancy-related PE and pregnancy-related hemorrhage. We will generate a "personalized decision analysis" using participants' utilities and their personalized risk of recurrent VTE as inputs to a decision analytic model. We will compare the personalized decision analysis to the participant's stated choice.DiscussionThe preferences of pregnant women at risk of VTE with respect to the use of antithrombotic therapy remain unexplored. This research will provide explicit, quantitative expressions of women's valuations of health states related to recurrent VTE and its prevention with LMWH. This information will be crucial for both guideline developers and for clinicians.

Project description:BackgroundWomen can choose from a range of contraceptive methods that differ in important ways. Inadequate decision support may lead them to select a method that poorly fits their circumstances, leading to dissatisfaction, misuse, or nonuse. Decision support interventions, such as decision aids, may help women choose a method of contraception that best fits their personal circumstances. To guide future decision aid development, we aim to summarize the attributes of contraceptive methods included in available decision aids as well as surveys and interviews of women actively choosing a contraceptive method.MethodsWe conducted a systematic review to identify attributes of contraceptive methods that may be important to women when engaging in this decision making process. We performed a database search of MEDLINE/PubMed, Ovid EMBASE, OVID CENTRAL, Ovid PsycInfo, EBSCO CINAHL, Popline, and Scopus from 1985 until 2013 to identify decision aids, structured interviews and questionnaires reporting attributes of contraceptive options that are of importance to women. A free-text internet search was also performed to identify additional decision support tools. All articles and tools were reviewed in duplicate for inclusion, and a summary list of attributes was compiled.ResultsWe included 20 surveys, 1 semistructured interview report and 19 decision aids, reporting 32 unique attributes. While some attributes were consistently included in surveys/interviews and decision aids, several were included more often in decision aids as opposed to surveys/interviews (e.g., STI prevention, noncontraceptive benefits, how the method is used, requirement of a healthcare provider), and vice versa (e.g., a woman's vicarious experience with contraceptive methods). Key attributes mentioned in both surveys/interviews and decision aids include efficacy (29 total mentioned) and side effects/health risks (28 total mentioned). While a limited number of decision support tools were formally evaluated, many were not rigorously studied.ConclusionsMany attributes were identified as potentially important to women choosing a method of contraception, but these were inconsistently included in the reviewed resources. Formal evaluation of decision support tools for contraceptive choice and involvement of users in the development process may lead to more user-centered design and implementation.

Project description:ObjectiveTo investigate women's values and preferences regarding antiretroviral therapy (ART) during pregnancy to inform a BMJ Rapid Recommendation.SettingPrimary studies reporting patient-reported outcomes relevant to decision-making regarding ART in any clinical and geographical setting.ParticipantsWomen living with HIV who are pregnant, postpartum or considering pregnancy.Outcome measuresQuantitative measurements and qualitative descriptions of values and preferences in relation to ART during pregnancy. We also included studies on women's reported barriers and facilitators to adherence. We excluded studies correlating objective measures (eg, CD4 count) with adherence, or reporting only outcomes which are not expected to differ between ART alternatives (eg, access to services, knowledge about ART).ResultsWe included 15 qualitative studies reporting values and preferences about ART in the peripartum period; no study directly studied choice of ART therapy during pregnancy. Six themes emerged: a desire to reduce vertical transmission (nine studies), desire for child to be healthy (five studies), concern about side effects to the child (eight studies), desire for oneself to be healthy (five studies), distress about side effect to oneself (10 studies) and pill burden (two studies). None of the studies weighed the relative importance of these outcomes directly, but pill burden/medication complexity appears to be a lower priority for most women compared with other factors. Overall, the body of evidence was at low risk of bias, with minor limitations.ConclusionsWomen who are or may become pregnant and who are considering ART appear to place a high value on both their own and their children's health. Evidence on the relative importance between these values when choosing between ART regimens is uncertain. There is variability in individual values and preferences among women. This highlights the importance of an individualised women-centred approach, such as shared decision-making when choosing between ART alternatives.Trial registration numberInternational Prospective Register of Systematic Reviews:CRD42017057157.

Project description:Increasing breastfeeding rates have been associated with reductions in disease in babies and mothers as well as in related costs. 'Nourishing Start for Health (NoSH)', a financial incentive scheme has been proposed as a potentially effective way to increase both the number of mothers breastfeeding and duration of breastfeeding.To establish women's relative preferences for different aspects of a financial incentive scheme for breastfeeding and to identify importance of scheme characteristics on probability on participation in an incentive scheme.A discrete choice experiment (DCE) obtained information on alternative specifications of the NoSH scheme designed to promote continued breastfeeding duration until at least 6 weeks after birth. Four attributes framed alternative scheme designs: value of the incentive; minimum breastfeeding duration required to receive incentive; method of verifying breastfeeding; type of incentive. Three versions of the DCE questionnaire, each containing 8 different choice sets, provided 24 choice sets for analysis. The questionnaire was mailed to 2,531 women in the South Yorkshire Cohort (SYC) aged 16-45 years in IMD quintiles 3-5. The analytic approach considered conditional and mixed effects logistic models to account for preference heterogeneity that may be associated with a variation in effects mediated by respondents' characteristics.564 women completed the questionnaire and a response rate of 22% was achieved. Most of the included attributes were found to affect utility and therefore the probability to participate in the incentive scheme. Higher rewards were preferred, although the type of incentive significantly affected women's preferences on average. We found evidence for preference heterogeneity based on individual characteristics that mediated preferences for an incentive scheme.Conclusions Although participants' opinion in our sample was mixed, financial incentives for breastfeeding may be an acceptable and effective instrument to change behaviour. However, individual characteristics could mediate the effect and should therefore be considered when developing and targeting future interventions.

Project description:IntroductionDecision analysis is a quantitative approach to decision making that could bridge the gap between decisions based solely on evidence and the unique values and preferences of individual patients, a feature especially important when existing evidence cannot support clear recommendations and there is a close balance between harms and benefits for the treatments options under consideration. Low molecular weight heparin (LMWH) for the prevention of venous thromboembolism (VTE) during pregnancy represents one such situation. The objective of this paper is to describe the rationale and methodology of a pilot study that will explore the application of decision analysis to a shared decision-making process involving prophylactic LMWH for pregnant women or those considering pregnancy who have experienced a VTE.Methods and analysisWe will conduct an international, mixed methods, explanatory, sequential study, including quantitative data collection and analysis followed by qualitative data collection and analysis. In step I, we will ask women who are pregnant or considering pregnancy and have experienced VTE to participate in a shared decision-making intervention for prophylactic LMWH. The intervention consists of three components: a direct choice exercise, a values elicitation exercise and a personalised decision analysis. After administration of the intervention, we will ask women to make a treatment decision and measure decisional conflict, self-efficacy and satisfaction. In step II, which follows the analysis of quantitative data, we will use the results to inform the qualitative interview. Step III will be a qualitative descriptive study that explores participants' experiences and perceptions of the intervention. In step IV, we will integrate findings from the qualitative and quantitative analyses to obtain meta-inferences.Ethics and disseminationSite-specific ethics boards have approved the study. All participants will provide informed consent. The research team will take an integrated approach to knowledge translation.

Dataset Information

Women's values and preferences for thromboprophylaxis during pregnancy: a comparison of direct-choice and decision analysis using patient specific utilities.

Publications

Women's values and preferences for thromboprophylaxis during pregnancy: a comparison of direct-choice and decision analysis using patient specific utilities.

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