Thursday, 27 July 2017

What do you prefer

BACKGROUND:Treatment adherence in patients with multiple sclerosis (MS) is essential to reduce the rate of acute neurological attacks, severity of relapses, and hospitalizations and to slow its progression. Adherence rates in MS patients have been shown to be affected by multiple factors, including physical or cognitive difficulties, perceived lack of treatment efficacy, treatment-related adverse events, injection anxiety, and frequency of administration.
OBJECTIVE:To elicit the preferences of MS patients for noneconomic and economic attributes of current disease-modifying therapies (DMTs).
METHODS:We used conjoint analysis to estimate preferences from a convenience sample through a web-based online survey. 

Patients were invited to participate in the study using web portals and newsletters for MS patients. The conjoint survey included the following 6 attributes: 
(1) overall efficacy based on autoimmune disease progression stabilization; 
(2) acute increase in disease activity (flare-up); 
(3) rate of respiratory tract infections; 
(4) rate of serious respiratory tract infections (leading to hospitalization); 
(5) medication use; 
and (6) patient monthly out-of-pocket medication costs.

 Using a fractional factorial design, 24 product profiles were created. Each respondent reviewed a random selection of 8 profiles. With each profile, subjects were asked to indicate their likelihood to try the hypothetical products on a scale from 0 to 100. Random effects linear regression was used to elicit preferences.
RESULTS:After exclusion of respondents with incomplete information, data from 129 subjects were included in the analysis. The overall relative importance of each attribute for the ranges presented were 
(1) 38.4% for monthly out-of-pocket cost; 
(2) 21.5% for route and frequency of administration; 
(3) 15.9% for risk of hospitalization by infection; 
(4) 11.9% for risk of respiratory tract infection; 
(5) 7.4% for risk of flare-ups; and 
(6) 5.0% for disease progression stabilization. 

Preference weights indicated that subjects favored: 
subcutaneous (beta coefficient [β] = -2.26, 95% CI = -4.22 to -0.22) and oral administration (β = 7.93, 95% CI = 5.95 to 10.2) over intramuscular (β = -5.67, 95% CI = -8.67 to -3.56), but no significant differences were found between subcutaneous over intramuscular administration. 

Monthly out-of-pocket cost was the most influential attribute, with an overall relative importance of 38%. The most preferred level was $75 (β = 12.85, 95% CI = 10.64 to 15.06) followed by $150 (β = 3.41, 95% CI = 0.98 to 5.84) when compared between $75, $150, $300, and $450 a month.

CONCLUSIONS:Conjoint analysis proved to be a convenient tool to quantify respondents' relative preferences for DMT characteristics. Respondents gave higher weight to DMT monthly out-of-pocket costs and mode of administration than to adverse effects or efficacy. These findings may assist in the development of DMT cost-sharing strategies and shared decision making at the point of care

What do you prefer? My guess would have been lack of side effects as top of your tree. Otherwise how do you explain that glatiramer acetate is number one best seller. Maybe Lazy-assed Neuros influence things as this does not require much monitoring. 
This survey confirms that efficacy is not high on the requirements, but cost is. Now if we had a low cost alternative maybe that would fly with pwMS, not so sure neuros are so happy....oh I forgot we do have this.


  1. Efficacy and lack of side effects should be at the top of the tree.

    I wonder if these people really understand the difference between DMTs and the value of their health over time. How many do the essential calculation: how much salary will I be able to continue to get if I (partially) pay now for this drug..

    Sure lazy neuros (including laziness in clearly informing patients), pressure from insurances, and overall cost are part of the equation.

    This means it is a growing gap between well informed, well treated patients and all others. It is more and more true almost everywhere for most disease and it is sad.

    1. I wasn't Tony Blair's biggest fan, but his mantra of 'Education, education, education' is so very true.

  2. Your group has been advocating inj. cladribine for about 2 years. It's got so much going for it - efficacy, safety, tolerability, cost, low monitoring requirements, brain penetration, easy dosing (max of 12 injections over 2 years) and resets the T- & B-cell profile. How come more people aren't opting for this option over the more popular, expensive and harder to tolerate drugs? Does the neurologist have to recommend? Does the patient have to see advertising to persuade? Does it require a critical mass of social media commenting, like for HSCT or CSSVI? In other words, are MS patients sheep, or are they well able to judge exactly what is in their best interest?

  3. Efficacy Efficacy Efficacy!

    Your have to prise tysabri from my cold dead hands, hopefully not literally

  4. Oral cladribine pills will be available in Europe soon. You could ask your neurologist to try the injectable variant, however your neurologist has to be willing to use this. We have a cohort of about 100 people and we get a number of referrals from other neuros who are less comfortable. As use of the oral variant increases neuros will be be more at at ease with this drug.

    The big question is how many courses will oral variant be approved for, if it is just two and you break through with disease what do you do switch to other drug or try the more sensible apporach and add another course of the generic version

  5. Replies
    1. What would you like references aboyt

    2. Wonders why you are awake ? 1.14 am

  6. If you wanted to know what aspect of a DMD was deemed important, wouldn't you just consult (a) the people who had stopped taking one why they stopped taking it and (b) the people who had persevered why they persevered and what it had cost them to do so? Why bother with theoretical, made-up stuff like the quoted study when there is real live (i.e. not theoretical) information out there just waiting to be gathered?

  7. I think the simple question to pose is: how much brain damage are you happy to accrue? I'd guess most people would say none. My own theory is the risks of DMTs are put out there really clearly whereas the risks of MS are more drip fed over time.


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