Patient Preference

The development of new devices has generated a number of studies in which preference is assessed. 

Most studies do not provide relevant information on patient preference and patient compliance, as study periods rarely exceed 7 weeks (16-19). 

Although it is reasonable to assume that preference for one or another device may affect patient compliance, the clinical significance of this phenomenon remains difficult to value. Furthermore, studies looking at patient s preference that are sponsored by the pharmaceutical industry often tend to have a biased questionnaire in favor of their own products, and new products tend to be preferred 

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LAAM usually has been prescribed in doses of 20—140 mg (Ling et al. 1978 Tennant et al. 1986). The typical Monday-Wednesday-Friday dosing schedule is 100 mg—100 mg—140 mg. The maximum recommended doses are 140 mg—140 mg—140 mg or 130 mg—130 mg—180 mg (thrice-weekly schedule) or 140 mg every other day. For some patients LAAM holds better than methadone. There is evidence that LAAM may be particularly helpful for patients who do not respond to high-dose methadone because of low plasma levels (Tennant 1988). Others patients prefer LAAM to methadone because they can attend the clinic less often (Tennant et al. 1986 Trueblood et al. 1978). However, a few experience nervousness and stimulation while taking this drug. 

Patel SG, Collie DA, Wardlaw JM, Lewis SC, Wright AR, Gibson RJ, Sellar RJ. Outcome, observer reliability, and patient preferences if CTA, MRA, or Doppler ultrasound were used, individually or together, instead of digital subtraction angiography before carotid endarterectomy. J Neurol Neurosurg Psychiatry 2002 73(l) 21-28. 

Because all inhaled corticosteroids are equally effective if given in equipotent doses, product selection should be individualized based on the available dosage form, delivery device, and patient preference. In infants, administration may require the use of a nebulizer or spacer/holding chamber with a facemask. Caregivers should use a soft, damp cloth to wipe the face of infants receiving an inhaled corticosteroid via a facemask to prevent topical candidiasis.18... 

If performed appropriately airway clearance techniques provide similar clearance results, so choice should be based on patient preference and compliance. Airway clearance therapy is typically performed once or twice daily for maintenance care and is increased to three or four times per day for acute exacerbations. Inhaled medications are usually given with the therapies and will be discussed in a later section. 

Obtain serum drug levels for aminoglycosides and/or vancomycin and perform pharmacokinetic analysis. Adjust the dose, if needed, according to the parameters in Table 13-2. Obtain follow-up trough levels at weekly intervals or sooner if renal function is unstable. Follow serum creatinine levels if renal function is unstable. Hearing tests may be scheduled yearly or per patient preference. 

Insulin pump therapy consists of a programmable infusion device that allows for basal infusion of insulin 24 hours daily, as well as bolus administration following meals. As seen in Fig. 40-3, an insulin pump consists of a programmable infusion device with an insulin reservoir. This pump is attached to an infusion set with a small needle that is inserted in subcutaneous tissue in the patient s abdomen, thigh, or arm. Most patients prefer insertion in abdominal tissue because this site provides optimal insulin absorption. Patients should avoid insertion sites along belt lines or in other areas where clothing may cause undue irritation. Infusion sets should be changed every 2 to 3 days to reduce the possibility of infection. 

Initiate GH replacement therapy based on patient preference. Make sure that the child does not have any contraindications to GH therapy. 

Given the role of prostaglandins in the pathophysiology of I dysmenorrhea, NSAIDs are the treatment of choice. There does not appear to be a difference between agents in efficacy. Choice of one agent over another may be based on cost, convenience, and patient preference.17 The most commonly used agents are naproxen and ibuprofen. 

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be initiated if acetaminophen therapy fails. At equipotent doses, all NSAIDs elicit similar analgesic and anti-inflammatory responses. Selection is based on patient preference, dosing frequency, tolerability, and cost. 

Assess patient preference for systemic (oral) or local (topical) therapy. Would frequent application of topical medications be possible Would the patient accept topical medications with a medicinal odor ... 

Currently, the choice of therapy is based on the size, site, and morphology of lesions, as well as patient preference, treatment costs, convenience, adverse effects, and patient experience. Assuming that the diagnosis is correct, switching to alternate therapy is appropriate if there has been no response observed after three treatment cycles. A comparison of adverse effects related to treatment options maybe found in Table 77-2. 

Selection of antifungal agents to treat uncomplicated vulvovaginal candidiasis is influenced by patient preference,... 

Due to the numerous treatment options available, a vari-ety of factors can influence product selection, with patient preference playing a significant role. To improve adherence with therapy, the practitioner should discuss with the patient what options are available and what her preferences are. 

Selection of an NSAID depends on prescriber experience, medication cost, patient preference, toxicities, and adherence issues. An individual patient should be given a trial of one drug that is adequate in time (2 to 3 weeks) and dose. If the first NSAID fails, another agent in the same or another chemical class can be tried this process may be repeated until an effective drug is found. Combining two NSAIDs increases adverse effects without providing additional benefit. 

The treatment of choice depends on the type of epilepsy (Table 52-2) and on drug-specific adverse effects and patient preferences. Fig. 52-1 is a suggested algorithm for treatment of epilepsy. 

Historically, the choice of an endocrine therapy was based primarily on toxicity and patient preference but study results have led to changes in MBC treatment (Table 61-2). 

Selection of an adjuvant regimen (Table 62-1) is based on patient specific factors including performance status, comorbid conditions, and patient preference based on lifestyle factors. 

Appropriate therapy for NHL depends on many factors including patient age, histologic type, stage and site of disease, presence of adverse prognostic factors, and patient preference. 

Factors that influence the choice of antidepressant include the patient s history of response, history of familial response, concurrent medical conditions, presenting symptoms, potential for drug-drug interactions, comparative side-effect profiles of various drugs, patient preference, and drug cost. 

Table 12.1 summarizes five major types of pharmacoeconomic evaluations cost-consequence, cost-benefit, cost-effectiveness, cost-minimization, and cost-utility (Drummond et al., 1997 Kielhorn and Graf von der Schulenburg, 2000). In a cost-consequence analysis, a comprehensive list of relevant costs and outcomes (consequences) of alternative therapeutic approaches are presented in tabular form. Costs and outcomes are typically organized according to their relationship to cost (direct and indirect), quality of life, patient preferences, and clinical outcomes (see taxonomy below). No attempt is made to combine the costs and outcomes into an economic ratio, and the interpretation of the analysis is left in large part to the reader. 

In a cost-benefit analysis, both costs and consequences are valued in dollars and the ratio of cost to benefit (or more commonly benefit to cost) is computed. Cost-benefit analysis has been used for many years to assess the value of investing in a number of different opportunities, including investments (or expenditure) for health care services. Cost-effectiveness analysis attempts to overcome (or avoid) the difficulties in cost-benefit analysis of valuing health outcomes in dollars by using nonmonetary outcomes such as life-years saved or percentage change in biomarkers like serum cholesterol levels. Cost-minimization analysis is a special case of cost-effectiveness analysis in which the outcomes are considered to be identical or clinically equivalent. In this case, the analysis defaults to selecting the lowest-cost treatment alternative. Cost-utility analysis is another special case of cost-effectiveness analysis in which the value of the outcome is adjusted for differences in patients preferences (utilities) for the outcomes. Cost-utility analyses are most appropriate when quality of life is a very important consideration in the therapeutic decision. 

The hrst-line treatments for panic disorder are (1) cognitive-behavioral therapy (CBT), (2) benzodiazepines, and (3) SSRIs/SNRls. Each of these three treatment modalities can be nsed independently or in combination. The selection of the primary treatment depends on several factors inclnding severity and frequency of the panic attacks, comorbid illnesses, and patient preference. 

When treating mild-to-moderate panic disorder, we recommend avoiding benzodiazepines in favor of CBT or antidepressants. Because CBT and antidepressants are both effective for panic disorder and major depression (commonly comorbid with panic disorder), the choice between the two largely rests on patient preference. Antidepressants are preferred for those who are pessimistic regarding the potential benefit of CBT, cannot afford CBT, or are unable (or unwilling) to invest the time necessary to complete a course of CBT. In our experience, some patients may accrue significant beneht from the combined treatment, particularly those with more moderate symptoms who struggle with the exposure aspects of therapy. 

First-line GAD treatments include (1) cognitive-behavioral therapy (CBT), (2) antidepressants, (3) buspirone, and (4) benzodiazepines. Treatment selection is determined by the severity of the illness, the presence of any comorbid illnesses, previous patient treatment responses, and patient preference. When treating mild GAD, we recommend eschewing psychotropic medication altogether in favor of CBT. Moderate-to-severe GAD usually requires pharmacotherapy, though combined CBT-pharmacotherapy is highly encouraged. 

AII recommendations are subject to modification by individual characteristics, including patient preference, age, comorbidity, and likelihood of recurrence. 

The size required of the sample to identify a meaningful economic difference is frequently problematic. Often those setting up clinical trials focus on the primary clinical question when developing sample-size estimates. They fail to consider the fact that the sample required to address the economic questions posed in the trial may differ from that needed for the primary clinical question. In some cases the sample size required for the economic analysis is smaller than that required to address the clinical question. More often, however, the opposite is true, in that the variances in cost and patient preference data are larger than those for clinical data. Then one needs to confront the question of whether it is either ethical... 

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