Professional Documents
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Ahdb 07 386
Ahdb 07 386
CLINICAL
ORIGINAL RESEARCH
BACKGROUND: Given the various profiles (eg, oral vs intravenous administration, risk of hot flashes vs
Stakeholder Perspective, fatigue) of treatment options (eg, endocrine therapy, chemotherapy) for metastatic breast cancer (mBC),
page 396 how patients value these attributes of their medications has implications on making treatment decisions
and on adherence.
OBJECTIVES: To understand how patients trade off medication side effects with improved effectiveness
and/or quality of life, to provide estimates of nonadherence among women with mBC, and to quantify the
association of medication nonadherence with health outcomes.
METHODS: The study was a cross-sectional, Internet-based survey of 181 women diagnosed with mBC
who were recruited from cancer-specific online panels (response rate, 7%). Treatment information, demo-
graphics, nonadherent behaviors, and quality of life assessed by the Functional Assessment of Cancer
Therapy-Breast (FACT-B) were collected in the survey, and each respondent completed a choice-based
conjoint exercise to assess patient preferences. The patients’ preferences were analyzed using hierarchi-
cal Bayesian logistic regression models, and the association between the number of nonadherent behav-
iors and the health outcomes was analyzed using general linear models.
RESULTS: The mean age of the patient sample was 52.2 years (standard deviation, ±9.1), with 93.9%
of participants being non-Hispanic white. Results from the conjoint model indicated that effectiveness
(overall survival) was of primary importance to patients, followed by side effects—notably alopecia, fatigue,
neutropenia, motor neuropathy, and nausea/vomiting—and finally, dosing regimen. In all, 34.8% of survey
respondents either discontinued their treatment or were nonadherent to their treatment regimen. Among
those who have ever used oral chemotherapy (N = 95; 52.5%) and those currently using oral chemother-
apy (N = 44; 24.3%), the number of nonadherent behaviors was significantly associated with a decrease
in functional well-being (b [unstandardized regression coefficient] = –2.01 for patients who had ever used
a targeted therapy and b = –3.14 for current users of a targeted therapy), FACT-General total score (b =
Am Health Drug Benefits.
2014;7(7):386-396 –4.30 and b = –7.37, respectively), FACT-B total score (b = –3.93 and b = –6.11, respectively), and FACT
www.AHDBonline.com trial outcome index (b = –5.22 and b = –8.63, respectively; all P <.05).
CONCLUSIONS: Patients were willing to accept substantial additional risks from side effects for gains in
Received July 7, 2014 overall survival. Approximately 33% of women with mBC reported engaging in nonadherent behaviors.
Accepted in final form September 16, 2014 Because forgetfulness and adverse events were among the most frequent reasons for nonadherence,
these results suggest that less complex treatment regimens, as well as regimens with less toxic profiles,
Disclosures are at end of text may be associated with improvements in adherence and, subsequently, could correspond to perceptible
patient benefits.
B
reast cancer is the most common cancer diagnosed also the second most deadly cancer, accounting for nearly
among women in the United States, with an esti- 40,000 deaths annually.1 The 5-year survival rates for
mated 232,000 new cases diagnosed annually.1 It is early-stage breast cancer is between 84% for regional
disease (ie, contained within the breast and lymph nodes)
Dr DiBonaventura is Vice President, Health Outcomes, and 99% for localized disease (ie, contained within the
Health Outcomes Practice, Kantar Health, New York, NY; breast); the survival rate drops to 24% in more advanced
Dr Copher is Associate Director, Health Economics and stages of the disease.2 Metastatic breast cancer (mBC) is
Outcomes Research, Eisai Inc, Woodcliff Lake, NJ; Mr defined as breast cancer that has spread to other parts of
Basurto is Senior Associate Methodologist, Kantar Health, the body. Whereas less than 10% of women are initially
New York, NY; Dr Faria is Director, Health Economics and diagnosed with mBC, approximately 33% of women who
Outcomes Research, Eisai Inc, Woodcliff Lake, NJ; and Ms are treated for early-stage disease will progress to mBC.2,3
Lorenzo is Senior Director of Research, Kantar Health, New The majority of breast cancer metastases affect the lymph
York, NY. nodes, followed by bone, liver, and lung.4,5
386 l American Health & Drug Benefits l www.AHDBonline.com October 2014 l Vol 7, No 7
Patient Preferences in Metastatic Breast Cancer
Vol 7, No 7 l October 2014 www.AHDBonline.com l American Health & Drug Benefits l 387
CLINICAL
Table 1 Abbreviated Example of the Choice Task screening questions to determine eligibility; 28 respon-
dents were ineligible: 21 because they had never received
Q: Which treatment are you most likely to choose to treat a taxane and 7 because of unknown reasons or for having
your metastatic breast cancer?
Medicaid insurance coverage.
Measurement Treatment A Treatment B All participants who completed the survey were com-
Regimen 21-day cycle; 2- to 28-day cycle; 6- to pensated with a $100 donation made in their name to a
5-minute infusion 10-minute infusion nonprofit charitable organization of their choice. For
on days 1 and 8 on days 1, 8, and 15 both the qualitative interview and the participant sur-
Alopecia 48% chance of losing 94% chance of losing vey, all respondents provided informed consent and had
most or all of your most or all of your their responses kept confidential. The protocol was ap-
hair, thinning of hair, thinning of proved by an Institutional Review Board (Essex IRB;
eyebrows/eyelashes; eyebrows/eyelashes;
starts to grow back starts to grow back Lebanon, NJ).
within 2-3 months within 2-3 months
after receiving after receiving Survey Measures
chemotherapy chemotherapy Demographics and health characteristics. All partic-
Effectiveness Has shown an Has shown an ipants provided information about their age, race/ethnici-
additional survival additional survival ty, marital status, college education, annual household
benefit of 1 month benefit of 3 months income, employment, insurance type, and out-of-pocket
Quality of life Difficulty performing Difficulty performing (OOP) costs. Health-related information was also provid-
work or other activi- work or other activi- ed, such as height and weight, which was then converted
ties none of the time ties all of the time to a body mass index category of underweight (<18.5 kg/
m2), normal weight (18.5 to <25 kg/m2), overweight (25
agnosed with mBC. Patients were invited to participate to <30 kg/m2), obese (≥30 kg/m2), or missing (for those
through cancer-specific online panels (eg, the Find A participants who chose not to provide their weight). A
Cure Panel), which recruit members from cancer-orient- family history of breast cancer, years diagnosed, specialty
ed nonprofit Internet communities for the purpose of of diagnosing physician, stage at diagnosis, and months in
participating in research projects. metastatic stage were also reported.
To be eligible to participate in the study, women had Treatment history and adherence. The participants’
to report that they met the criteria, including being diag- treatment modality experience was defined by surgery,
nosed with mBC, aged ≥18 years, and be proficient in the intravenous chemotherapy, oral chemotherapy, radia-
English language. Patients who never received treatment tion therapy, hormone therapy, clinical trial medication,
with a taxane (eg, paclitaxel, docetaxel) or who did not and palliative care. The participants reported their expe-
have health insurance, were covered by Medicaid, or rience in terms of previous treatment and current treat-
who did not know their form of health insurance were ment. All women were asked whether they had been
excluded. These latter criteria were included to ensure nonadherent to or had discontinued any of their previ-
sufficient treatment experience to put our hypothetical ous treatments. For the participants who responded
treatments into context. For research questions that were affirmatively for nonadherence, specific reasons for non-
unrelated to the current study, the study focused on pa- adherence or discontinuation were provided, and re-
tients with private insurance types. Interviews lasted spondents were asked to indicate whether they engaged
approximately 30 minutes and focused on the patient’s in the behavior.
experience with previous treatments, as well as the fre- Quality of life. The Functional Assessment of Cancer
quency, severity, and tolerability of side effects. Therapy-Breast (FACT-B) was also included as a
Participant survey. The present study was a cross- health-related QOL (HR-QOL) measurement instru-
sectional, Internet-based survey of 181 women who were ment.19 The FACT-B includes the 7 subscales from the
diagnosed with mBC. The inclusion and exclusion crite- Functional Assessment of Cancer Therapy-General
ria of the women surveyed were identical to the qualita- (FACT-G)—physical well-being, social well-being,
tive participants. Potential participants were also invited family well-being, relationship with doctor, emotional
from cancer-specific online panels, the same source used well-being, functional well-being, trial outcome index—
in the qualitative research. A total of 2500 panelists were and the total score for the FACT-G. The FACT-B also
e-mailed invitations to participate in the current study includes a separate breast cancer subscale and a total
(response rate, 7%); those who clicked the invitation score (FACT-B total score) that combines all of the
link were directed to the statement of informed consent, subscales. For all of the subscales and total scores, higher
and, if consent was given, they were then directed to values reflect better HR-QOL.
388 l American Health & Drug Benefits l www.AHDBonline.com October 2014 l Vol 7, No 7
Patient Preferences in Metastatic Breast Cancer
each level of that attribute were squared and were Overweight, N (%) 61 (33.7)
summed together. The resulting sums of squares were Obese, N (%) 42 (23.2)
divided by the attribute-specific degrees of freedom to
Decline to provide weight, N (%) 6 (3.3)
generate a mean sum of squares (MSS) for each attri-
bute. The relative importance of each attribute was Information not available.
a
calculated by dividing the MSS for that attribute by the SD indicates standard deviation.
sum of all MSS values for all attributes. The attributes
with higher relative importance have a disproportion- ducted using Sawtooth’s CBC/HB v4.6.4 (Sawtooth
ately larger MSS than other attributes, which is a result Software; Orem, UT).
of large coefficients of the individual levels. The indi- Because they were significantly related to adher-
vidual-level hierarchical Bayesian modeling was con- ence and associated with QOL, general linear models
Vol 7, No 7 l October 2014 www.AHDBonline.com l American Health & Drug Benefits l 389
CLINICAL
Race
White 170 (93.92) 309.57 (± 806.86) 96.53 (± 145.67) 26.90 (± 52.08) 11.55 (± 27.53)
Non-Hispanic white 11 (6.08) 200.45 (± 261.55) 275.91 (± 574.32) 29.55 (± 27.88) 17.91 (± 22.34)
Education
College graduate 130 (71.82) 322.12 (± 842.74) 103.77 (± 210.08) 26.22 (± 50.8) 14.55 (± 31.09)
Less than college graduate 51 (28.18) 254.04 (± 617.15) 116.76 (± 174.2) 29.22 (± 51.58) 5.27 (± 10.59)
Salary
<$25,000 11 (6.08) 120 (± 241.59) 144.09 (± 229.41) 20.18 (± 59.77) 0 (± 0)
$25,000 to <$50,000 31 (17.13) 172.52 (± 255.24) 122.58 (± 187.31) 28.55 (± 39.82) 9.03 (± 17.48)
$50,000 to <$75,000 28 (15.47) 385.96 (± 977.93) 110 (± 154.87) 23 (± 49.39) 9.29 (± 21.33)
≥$75,000 86 (47.51) 389.01 (± 963.77) 100.35 (± 231.35) 29.67 (± 56.51) 16.41 (± 33.78)
Decline to answer 25 (13.81) 156.08 (± 228.67) 94 (± 130.69) 23.8 (± 42.73) 8.40 (± 21.4)
Northeast 37 (20.44) 198.27 (± 309.54) 83.11 (± 114.98) 43.51 (± 76.27) 15.41 (± 43.67)
South 48 (26.52) 189.96 (± 361.34) 116.77 (± 298.61) 19.94 (± 39.64) 12.54 (± 18.91)
West 44 (24.31) 190.98 (± 290.85) 77.27 (± 89.94) 29.82 (± 40.43) 14.41 (± 26.06)
Intravenous 76 (41.99) 501.8 (± 1099.4) 108.16 (± 156.14) 27.16 (± 53.41) 12.75 (± 30.23)
NOTE: All costs are independent of one another (eg, costs of breast cancer and costs not related to breast cancer do not
overlap).
OOP indicates out-of-pocket; SD, standard deviation.
390 l American Health & Drug Benefits l www.AHDBonline.com October 2014 l Vol 7, No 7
Patient Preferences in Metastatic Breast Cancer
breast cancer and approximately $107 (SD, $200) for Table 4 Stated Importance of Various Treatment Attributes
physician visits related to breast cancer (Table 3).
The OOP costs, particularly for the treatment of Importance for all
patients (N = 181),
breast cancer, were higher among patients who were Treatment attribute mean (± SD)
non-Hispanic white, were college educated, had a higher
household income, and were not enrolled in a patient How well the treatment helps in slowing 1.19 (± 0.44)
down the progression of the cancer
assistance program. Women in the Midwest United
States (28.18%) reported the highest cancer-related How these treatments can help in 1.22 (± 0.49)
extending my life
OOP costs (ie, $586.96).
The patients had extensive previous treatment expe- How effective the treatment is compared 1.41 (± 0.67)
rience across treatment modalities (100% intravenous with other treatments
chemotherapy, 82.3% surgery, 77.4% hormone therapy, The impact of the treatment on my 1.43 (± 0.59)
71.3% radiation therapy, and 52.5% oral chemothera- overall quality of life
py). The majority of participants (90.6%) were currently Appropriateness for the stage of my 1.51 (± 0.74)
receiving treatment, with the most common treatment breast cancer
modalities being hormone therapy (47.5%), intravenous The severity of the treatment side effects 1.57 (± 0.72)
chemotherapy (42%), and oral chemotherapy (24.3%).
The impact of the treatment on my ability 1.57 (± 0.68)
Patient Preferences to perform daily activities
When asked directly, the most important attributes of Ways to manage/cope with treatment 1.62 (± 0.70)
treatments for participants were related to effectiveness, side effects
followed by side effects. Cost-related attributes were the Potential side effects 1.79 (± 0.82)
least important (Table 4).
Potential safety risks 1.82 (± 0.80)
Results from the conjoint model reaffirmed the prima-
ry importance of effectiveness, as indicated by overall Long-term safety of the treatment 1.90 (± 0.91)
survival, followed by side effects (the most notable of
How the treatment actually works 1.95 (± 0.94)
which were alopecia, fatigue, neutropenia, motor neu-
ropathy, and nausea/vomiting), and, finally, dosing regi- The importance of following the 1.96 (± 1.05)
men (Table 5, Figure). For example, the logit column in prescribed dosing regimen
Table 5 represents the strength (and direction) of the The impact of the treatment on my 1.97 (± 0.87)
relationship between the presence of an attribute and mental health/emotional well-being
selecting that treatment. Survival of 3 months (5.24), How the treatment is administered/what 2.27 (± 1.07)
alopecia of 0% (1.70), and fatigue of 0% (1.19) had the the procedure involves
highest positive logits, suggesting the strongest relation- How long I would have to stay on the 2.27 (± 1.11)
ship with the probability of selection. treatment
Post-hoc analyses investigated whether these prefer-
Other patients’ experiences with the 2.51 (± 0.94)
ences would vary by treatment experience (ie, rounds of treatments
chemotherapy). Our findings suggest that patient prefer-
ence was remarkably consistent and did not vary by How long the treatment has been 2.78 (± 1.11)
available
treatment experience. In our analyses, all attributes were
rank ordered identically, and relative importance values Ways to help cover treatment 3.15 (± 1.37)
of any given subgroup were within 2% to 3% of any costs provided by the
pharmaceutical manufacturer
other subgroup. For example, the relative importance of
effectiveness attribute was highest for having received Cost of the treatment 3.24 (± 1.22)
more than 6 rounds of chemotherapy (34.51%) and low- Patient support programs provided by 3.42 (± 1.21)
est for having received less than 2 rounds of chemother- the manufacturer
apy (32.45%). Financial assistance for breast cancer 3.43 (± 1.31)
treatment from a charity or research
Adherence organization
A total of 63 (34.8%) survey participants either dis-
continued their treatment or were nonadherent to their NOTE: Rating scale was from 1 (extremely important) to 5 (not at
all important).
treatment regimen. Patients who had ever received hor- SD indicates standard deviation.
mone therapy (37.9%) reported the greatest level of
Vol 7, No 7 l October 2014 www.AHDBonline.com l American Health & Drug Benefits l 391
CLINICAL
Regimen 21-day cycle; oral tablets taken twice daily 0.30 0.01 <.001
for first 2 weeks
21-day cycle; 2- to 5-minute infusion 0.16 0.01 <.001
on days 1 and 8
21-day cycle; 3-hour infusion on day 1 0.05 0.01 <.001
392 l American Health & Drug Benefits l www.AHDBonline.com October 2014 l Vol 7, No 7
Patient Preferences in Metastatic Breast Cancer
nonadherence, followed by patients who had ever re- Figure Relative Importance of Each Attribute
ceived an oral chemotherapy agent (36.8%). Across all
treatment modalities, forgetfulness (41.3%) and intoler-
Effectiveness 33.49%
ance of side effects (36.5%) were the most common
reasons for nonadherence among patients who reported Alopecia 21.32%
their nonadherence or discontinuation (Table 6). Fatigue 12.46%
Among the patients who had ever received an oral Neutropenia 10.37%
chemotherapy agent (N = 95), the number of nonadher-
Quality of life 7.69%
ent behaviors (mean, 1.57) was used to predict HR-QOL
(Table 7). Analogous models were also conducted Motor neuropathy 6.36%
among patients who were currently receiving a chemo- Nausea/vomiting 6.18%
therapy agent (N = 44). The number of nonadherent Diarrhea 1.08%
behaviors was significantly associated with a decrease in Myalgia/arthralgia 0.48%
functional well-being (b = –2.01 for patients who had
ever used a targeted therapy and b = –3.14 for current Mucositis/stomatitis 0.43%
users of a targeted therapy), FACT-G total score (b = Dosing regimen 0.14%
–4.30 and b = –7.37, respectively), FACT-B total score 0% 5% 10% 15% 20% 25% 30% 35% 40%
(b = –3.93 and b = –6.11, respectively), and FACT trial
Relative importance
outcome index (b = –5.22 and b = –8.63, respectively; all
P <.05).
Table 6 Reasons for Patient Nonadherence
Discussion
Patients who
The primary objective of this study was to assess pa- discontinued/were
tient preferences for the treatment of mBC, because most nonadherent,
of the existing literature focused on preferences among Reason stated N (%)
women with early-stage breast cancer. Although our re- Forgot to take medicines and/or keep 26 (41.3)
sults were generally comparable with the results of pa- treatment appointments
tients with early-stage disease,7,8 we found that treatment
I could not tolerate the side effects 23 (36.5)
effectiveness was rated as the most important attribute
among women with mBC, nearly twice as much as alo- Other a 19 (30.2)
pecia, and more than 3 times more important than other Had family obligations/an event to attend 10 (15.9)
side effects. The rank order of important attributes for a Side effects impacted my ability to perform 8 (12.7)
treatment is similar to the findings by Beusterien and daily activities
colleagues8; however, the current study estimated a
I was unable to enjoy everyday experiences 5 (7.9)
greater preference for treatment effectiveness and the
avoidance of alopecia, and a lower preference for regi- I could no longer afford the treatment 4 (6.4)
men and diarrhea. These findings help clarify the patient Treatment schedule was difficult to follow 3 (4.8)
perspective of treatments for mBC, which, if aligned I did not trust the medicine as it was still in 1 (1.6)
with prescribing patterns, may maximize treatment satis- clinical trials
faction and adherence.
I had to travel too far to get the treatment 0 (0)
A secondary objective of this study was to assess the
level of nonadherence for women with mBC who are Lack of support from family members/friend 0 (0)
receiving an oral chemotherapy agent and to establish I did not have someone to drive me to my 0 (0)
the relationship between nonadherence and QOL. Ap- treatment
proximately 33% of women with mBC reported engag- a
Additional information not available.
ing in medication nonadherent behavior. This rate is
consistent with previous reviews of treatment adherence apy agent were associated with significant decrements in
in patients with breast cancer.21 However, given the health status.
fairly affluent and engaged patient population, it can be Forgetfulness and adverse events were among the
hypothesized that adherence levels in the overall popu- most common reasons for nonadherence, and these re-
lation with mBC are even lower. Of note, even after sults suggest that a less complex treatment regimen and
adjusting for established predictors of QOL, the nonad- regimens with less toxic profiles may be associated with
herent behaviors of women receiving an oral chemother- improvements in adherence, and subsequently could
Vol 7, No 7 l October 2014 www.AHDBonline.com l American Health & Drug Benefits l 393
CLINICAL
Table 7 A
ssociation between the Number of Nonadherent Behaviors and FACT-B Scores Among Patients Who Ever
Received or Currently Receive an Oral Chemotherapy Agent
Social/ Breast Trial
Physical family Emotional Functional FACT-G cancer FACT-B outcome
well-being well-being well-being well-being total score subscale total score index
b b b b b b b b
Ever received an oral chemotherapy agent (N = 95)
Number of –1.00 (95% –0.90 (95% –0.39 (95% –2.01a (95% –4.30a (95% –0.92 (95% –3.93a (95% –5.22a (95%
nonadherent CI, –2.39 CI, –2.05 CI, –1.56 CI, –3.27 CI, –8.12 CI, –2.16 CI, –7.12 CI, –9.86
behaviors to 0.4) to 0.25) to 0.79) to –0.75) to –0.48) to 0.32) to –0.73) to –0.57)
correspond to perceptible patient benefits. Other poten- A literature search did not uncover any epidemiology
tial interventions may include greater education about study that could be useful to compare the general US
potential side effects (which could mitigate the influence population of patients receiving treatment for mBC
of side effects on nonadherence) and memory aids (eg, against the sample in this current study.
reminder systems). Further research is necessary to un-
derstand these potential interventions and their effec- Limitations
tiveness in this patient population. The results of the current study should be examined
Targeted therapies have become increasingly impor- within the context of its limitations. All data, including
tant in the treatment of many cancers, including breast treatments and adherence information, were self-report-
cancer.21 Such therapeutic agents are often taken orally ed and could have been subject to recall biases and other
and can often have less severe side effects than tradition- self-presentation effects. The conjoint task is a simplify-
al chemotherapy regimens, which can improve patient ing hypothetical exercise to estimate how patients value
outcomes.22 Although these advantages can increase certain attributes of treatments, and may differ with the
adherence—because patients prefer oral therapies to inclusion of other relevant attributes or levels. For exam-
those administered intravenously—medication adher- ple, in actual decision-making, the true benefit or risks
ence is complex. The complexity of adherence can be that will be experienced (eg, there is a probability of
influenced by a multitude of patient- and care-based certain survival outcomes, but not a guaranteed 3-month
factors, including the prohibitive costs of targeted treat- survival) cannot be known with certainty. In addition,
ments for some patients.21 differences in analytical methods and attributes can also
Research examining adherence to targeted oral medi- make it difficult to directly compare preference results
cations in the context of breast cancer has shown that from one study to another.
approximately 20% of patients are nonadherent, de- Of note, the relationship between nonadherence and
pending on the way in which adherence was mea- QOL was presented in a single direction as nonadher-
sured.22-24 Furthermore, in a study of adherence to lapati- ence predicting QOL. It is possible that the relationship
nib, Kartashov and colleagues reported that nonadherence could be bidirectional (eg, QOL influencing adherence)
is associated with increased provider visits and suggested or that there could be additional third variables that are
an increase in the cost of care.23 not included in the current study that could explain the
Further research is needed to enhance our understand- relationships observed here. In addition, detailed infor-
ing of the factors influencing adherence rates in the treat- mation on disease progression, treatment chronology,
ment of breast cancer, and to develop effective interven- side effects experienced, and dosing adjustments was
tions in line with advances in the pharmaceutical industry. unavailable, so the context for the results on adherence
394 l American Health & Drug Benefits l www.AHDBonline.com October 2014 l Vol 7, No 7
Patient Preferences in Metastatic Breast Cancer
Vol 7, No 7 l October 2014 www.AHDBonline.com l American Health & Drug Benefits l 395
CLINICAL
STAKEHOLDER PERSPECTIVE
In the well-known quip that has been attributed to high probability events (eg, side effects from medical treat-
individuals as diverse as the quantum physicist Niels ment) while overvaluing the likelihood of lower probabil-
Bohr and the extraordinary baseball manager Casey ity events (eg, cure in overall survival). This may also ex-
Stengel, both men are purported to have said, “I never plain some of the findings encountered in the current
make predictions, especially about the future.” Predic- study by DiBonaventura and colleagues.
tions, especially when they come to the ability and/or PAYERS: Payers understand these findings all too
desire to adhere to a medical regimen of care, are highly well. In addition to being a HEDIS (Healthcare Effec-
dependent on a number of factors. tiveness Data and Information Set) measure, medication
And so it is in the article by DiBonaventura and col- adherence is an area of great interest, because of its over-
leagues in this issue of American Health and Drug Bene- all impact on cost and outcomes. It is well-documented
fits.1 Not long ago, the paternalistic aspect of medical that nonadherence to treatment, whether pharmacolog-
care consisted of the physician prescribing a course of ic or otherwise, results in increased costs and worsened
medical care that was incumbent on the patient to fol- health. Many payers have thus developed specialty ana-
low. Societal norms stipulated such behavior as a func- lytic units to study and address the conundrum why pa-
tion of the asymmetric knowledge relationship between tients are nonadherent to therapy.
a physician and a patient. As patients became more PATIENTS: People often make decisions without
empowered, they demanded a greater role in determin- fully understanding the subconscious reasons why they
ing their own care, and we saw the genesis of the era of have chosen to act as they do. If individual patients
“shared decision-making.” As Mazur discusses in his perhaps had more time or more inclination to truly
book on shared decision-making, clarifying the notion of share their real perspectives, it is very possible that
this type of decision-making includes, among other there would be more adherence to treatment, or that
things, taking into account the risk preferences of pa- more appropriate therapy decisions would be made in a
tients.2 It is relatively easy for physicians and patients to shared manner in the first place. Of course, the key to
believe that they can and will conform to certain thera- this occurring is to study why it is not currently hap-
pies when they expect a relatively easy trade-off of pening. As DiBonaventura and colleagues note, per-
side-effect tolerance versus gains in survival time. How- haps a decrease in the complexity of therapy may help
ever, experience does not always mirror expectation. in that endeavor.1
One reason for this lack of congruence between plan Although we can certainly all hope for more under-
and result may lie in behavioral economics. In their semi- standing of patients’ preferences and their role in success-
nal article on prospect theory, Kahneman and Tversky ful care outcomes, what we cannot do, however, is predict
posited and demonstrated that people make decisions that this will actually happen. ■
based on the potential value of losses and gains rather than
on the final outcome.3 In the article by DiBonaventura 1. DiBonaventura MdC, Copher R, Basurto E, et al. Patient preferences and treat-
ment adherence among women diagnosed with metastatic breast cancer. Am Health
and colleagues, women with metastatic breast cancer were Drug Benefits. 2014;7:386-396.
willing to trade increases in side effects for increases in life 2. Mazur DJ. Shared Decision Making in the Physician-Patient Relationship. Tampa, FL:
American College of Physician Executives; 2001:103.
expectancy.1 Of course, one could also argue that prospect 3. Kahneman D, Tversky A. Prospect theory: an analysis of decision under risk.
theory notes how people underweight the likelihood of Econometrica. 1979;47:263-291.
396 l American Health & Drug Benefits l www.AHDBonline.com October 2014 l Vol 7, No 7