Original article
Do Patient Preferences Influence Decisions on Treatment for Patients With Steroid-Refractory Ulcerative Colitis?

https://doi.org/10.1016/j.cgh.2006.05.003Get rights and content

Background & Aims: Patients with steroid-refractory ulcerative colitis face a difficult treatment decision between colectomy and therapy with infliximab or cyclosporine. The aim of this study was to understand how individual patient preferences for the various treatment outcomes influence the optimal treatment decision for a given patient. Methods: A Markov model was used to simulate treatment with total colectomy with an ileo pouch–anal anastomosis (TC/IPAA), cyclosporine (CSA), infliximab (INFLX), and infliximab followed by cyclosporine for treatment failures (INFLX→CSA). Utility weights for treatment outcomes were elicited from 48 patients using both time trade-off and visual rating scale methods. Preference sets were applied to the model to identify the therapy that maximized quality-adjusted life years (QALYs) for each patient. Sensitivity analyses were performed to assess model robustness. Results: Optimal treatment was highly variable among patients (INFLX→CSA = 42%, 20/48; TC/IPAA = 37%, 18/48; CSA = 21%, 10/48; INFLX = 0%, 0/48). However, when average preference weights from our sample were applied to the model, medical treatments were superior to TC (CSA = .26 QALYs gained vs TC/IPAA; INFLX→CSA = .25 QALYs gained vs TC/IPAA). Conclusions: Patient preferences have a clear impact on the optimal treatment for steroid-refractory ulcerative colitis. Although averaged preferences support the use of medical interventions, a third of individual patients may benefit most from proceeding directly to colectomy. Failure to fully assess individual preferences may result in suboptimal treatment for these patients.

Section snippets

Markov Model

A Markov model was created to simulate the decision for patients with steroid-refractory ulcerative colitis to undergo one of the following treatments: (1) total colectomy with an ileo pouch–anal anastomosis (TC/IPAA); (2) continuous cyclosporine infusion (8 mg/kg/hr), with colectomy for treatment failures or disease relapse (CSA); (3) infliximab infusion (5 mg/kg), with colectomy for treatment failures and reinfusion for disease relapse (INFLX); or (4) infliximab (5 mg/kg) with cyclosporine

Individual Cases

Utility weights were obtained from 48 patients with ulcerative colitis treated at the University of Virginia Health System and Duke University Medical Center (Table 1). In this group, the mean Inflammatory Bowel Disease Questionnaire score was 170, and the mean utility score for current health status was .77. When individual utility sets were applied to the model, optimal treatment choices were highly variable (Figure 2). Infliximab with cyclosporine for treatment failures and disease relapse

Discussion

The present study demonstrates that “optimal” treatment choices for steroid-refractory ulcerative colitis (defined as the treatment strategy that maximizes a patient’s quality-adjusted life expectancy) vary among individual patients and are dependent on each patient’s personal preference for the possible treatment outcomes. Within our sample of ulcerative colitis patients, 63% maximized their QALYs through medical treatment with infliximab and/or cyclosporine, whereas 37% benefited most from

References (62)

  • A. Gafni et al.

    The physician–patient encounter: the physician as a perfect agent for the patient versus the informed treatment decision-making model

    Soc Sci Med

    (1998)
  • A.M. O’Connor et al.

    A decision aid for women considering hormone therapy after menopause: decision support framework and evaluation

    Patient Educ Couns

    (1998)
  • S.B. Hanauer et al.

    Maintenance infliximab for Crohn’s disease: the ACCENT I randomised trial

    Lancet

    (2002)
  • R.D. Hurst et al.

    Prospective analysis of perioperative morbidity in one hundred consecutive colectomies for ulcerative colitis

    Surgery

    (1995)
  • S. Lichtiger et al.

    Cyclosporine in severe ulcerative colitis refractory to steroid therapy

    N Engl J Med

    (1994)
  • O. Shibolet et al.

    Cyclosporine A for induction of remission in severe ulcerative colitis

    Cochrane Database Syst Rev

    (2005)
  • W.A. Stack et al.

    Short- and long-term outcome of patients treated with cyclosporin for severe acute ulcerative colitis

    Aliment Pharmacol Ther

    (1998)
  • F. Carbonnel et al.

    Intravenous cyclosporine in attacks of ulcerative colitis: short-term and long-term responses

    Dig Dis Sci

    (1996)
  • J. Santos et al.

    Efficacy of intravenous cyclosporine for steroid-refractory attacks of ulcerative colitis

    J Clin Gastroenterol

    (1995)
  • G. McCormack et al.

    Cyclosporin therapy in severe ulcerative colitis: is it worth the effort?

    Dis Colon Rectum

    (2002)
  • H.H. Wenzl et al.

    Short-term efficacy and long-term outcome of cyclosporine treatment in patients with severe ulcerative colitis

    Z Gastroenterol

    (1998)
  • A. Kornbluth et al.

    Cyclosporin for severe ulcerative colitis: a user’s guide

    Am J Gastroenterol

    (1997)
  • P. Rutgeerts et al.

    Infliximab for induction and maintenance therapy for ulcerative colitis

    N Engl J Med

    (2005)
  • S. Senn

    Some controversies in planning and analysing multi-centre trials

    Stat Med

    (1998)
  • F.A. Sonnenberg et al.

    Markov models in medical decision making

    Med Decis Making

    (1993)
  • B.A. Rosner
  • C.S. Probert et al.

    Infliximab in moderately severe glucocorticoid resistant ulcerative colitis: a randomised controlled trial

    Gut

    (2003)
  • A. Kohn et al.

    Infliximab in the treatment of severe ulcerative colitis: a follow-up study

    Eur Rev Med Pharmacol Sci

    (2004)
  • J.M. Gornet et al.

    Infliximab for refractory ulcerative colitis or indeterminate colitis: an open-label multicentre study

    Aliment Pharmacol Ther

    (2003)
  • J.C. Gohligher et al.
  • C.J. Devroede et al.

    Cancer risk and life expectancy of children with ulcerative colitis

    N Engl J Med

    (1971)
  • Cited by (54)

    View all citing articles on Scopus

    Supported by a Senior Research Award from the Crohn’s and Colitis Foundation of America.

    View full text