Sir, We are grateful to Dr Armstrong  for sharing his views and concerns about our recent paper that elicited patients’ preferences for osteoporosis drug treatment using a cross-European discrete-choice experiment (DCE) . First, the correspondent questioned the use of DCE in the area of osteoporosis therapy. Although the application of DCEs within healthcare is relatively new, DCEs are nowadays increasingly used to elicit preferences for various healthcare conditions and purposes. Previous DCEs were already conducted in osteoporosis , suggesting that respondents were able to discriminate between medication attributes and that a DCE could be suitable in the area of osteoporosis. Our study confirms this finding. External validity has, however, not yet been tested in the area of osteoporosis. As indicated in our paper, an inherent limitation of DCEs is that respondents are evaluating hypothetical medications. Therefore, what respondents declare they will do may potentially be different from what they would actually do if faced with the choice in real life. Some studies about the external validity of DCEs have already been conducted in health care, suggesting that predicted and actual treatment choices could differ at the individual level and that further work needs to be done to understand the reasons for these differences . So, it would definitely be interesting in the future to compare the results of a DCE in osteoporosis to actual real choices, which could help in validating the DCE findings. We further agree with the correspondent that every physician working in the field will have experienced a patient who swore absolute and conscientious compliance with medication, only for the truth to emerge of failure to take almost any treatment. A DCE does not aim to be used in a clinical setting but rather aims to reveal preferences at the group level. Our study reveals, however, that patients have preferences and suggests that incorporating patients’ preferences in decision making could help in improving medication adherence. A previous study showed an influence of patients’ perceptions and preferences for osteoporosis medications on adherence behaviour . Incorporating preferences into clinical decision making could lead to improved adherence. Second, the correspondent correctly pointed out as a limitation the failure to include osteonecrosis of the jaw or atypical femoral fracture as potential adverse events. We agree that rare and serious adverse events such as osteonecrosis of the jaw and atypical femoral fracture could also occur with osteoporosis medications, which could also influence patients’ preferences. In DCE tasks it is important to select the attributes and levels that are important to patients and policy relevant and to keep the choice task manageable. We had an extensive discussion on the inclusion of adverse events, which remains a challenging attribute for inclusion in a DCE. Several components of adverse events could be relevant including the frequency, timing (short vs long term), severity or type of side effects. Understanding how patients’ trade-off between all these dimensions would require a single DCE alone. Increasing the number of attributes in the choice tasks increases how complicated the choice task is to respondents. We selected the attributes included in our DCE using a rigorous approach, as recommended in good practice guideline . The results of the qualitative study among patients, which was part of this approach, have been reported elsewhere . Based on this qualitative research (conducted in 2012) and extensive discussion with experts, we focused on common side effects instead of rare complications. We concluded that rare adverse events will be as (in)frequent in all categories of anti-resorptive drugs . We agree with the correspondent that these adverse events have received more attention in recent years (also resulting from media discussion). It would certainly be interesting to investigate how the incorporation of less frequent serious adverse events could affect the preferences of patients. We further acknowledge that DCEs provide patients’ preferences for the best possible set of attributes/levels at the time of the analysis. New information such as adverse events or new therapies could further affect preferences. As an example, new anti-osteoporosis medications with different mode of administration are currently in development including abaloparatide and romozumab, and further assessment of patients’ preferences for new attributes or levels of attributes that these new drug options can bring will be interesting. Finally, we acknowledge that although preferences studies provide relevant insights into patients’ preferences, they cannot always capture all dimensions that play a role in clinical decision making. Our study suggests a substantial heterogeneity in patients’ preferences suggesting the importance of incorporating individual preferences into clinical decision making. Notwithstanding, despite potential limitations, our study was the first to use a rigorous approach to assess preferences of osteoporotic patients in a large sample from different countries, and revealed that patients are willing to trade-off drug efficacy or to pay for their preferred mode of administration. Funding: No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript. Disclosure statement: M.H. has received research grants from Amgen and Radius through institution, and paid advisory board from UCB. A.B. has received research grants to their department from Amgen, Merck and AbbVie and honoraria for board meetings or lectures from Janssen, Sandoz, Pfizer, Lilly and Novartis. The other authors have declared no conflicts of interest. References 1 Armstrong D. Comment on: Patients’ preferences for anti-osteoporosis drug treatment: a cross-European discrete choice experiment. Rheumatology 2018; 57: 583– 4. 2 Hiligsmann M, Dellaert BG, Dirksen CD et al. Patients' preferences for anti-osteoporosis drug treatment: a cross-European discrete choice experiment. Rheumatology 2017; 56: 1167– 76. http://dx.doi.org/10.1093/rheumatology/kex071 Google Scholar CrossRef Search ADS PubMed 3 Hiligsmann M, Dellaert BG, Dirksen CD et al. Patients' preferences for osteoporosis drug treatment: a discrete-choice experiment. Arthritis Res Therapy 2014; 16: R36. Google Scholar CrossRef Search ADS 4 Lancsar E, Swait J. Reconceptualising the external validity of discrete choice experiments. Pharmacoeconomics 2014; 32: 951– 65. http://dx.doi.org/10.1007/s40273-014-0181-7 Google Scholar CrossRef Search ADS PubMed 5 Kendler DL, Macarios D, Lillestol MJ et al. Influence of patient perceptions and preferences for osteoporosis medication on adherence behavior in the Denosumab Adherence Preference Satisfaction study. Menopause 2014; 21: 25– 32. http://dx.doi.org/10.1097/GME.0b013e31828f5e5d Google Scholar CrossRef Search ADS PubMed 6 Coast J, Al-Janabi H, Sutton EJ et al. Using qualitative methods for attribute development for discrete choice experiments: issues and recommendations. Health Econ 2012; 21: 730– 41. http://dx.doi.org/10.1002/hec.1739 Google Scholar CrossRef Search ADS PubMed 7 Hiligsmann M, van Durme C, Geusens P et al. Nominal group technique to select attributes for discrete choice experiments: an example for drug treatment choice in osteoporosis. Patient Prefer Adherence 2013; 7: 133– 9. Google Scholar CrossRef Search ADS PubMed 8 Rizzoli R, Reginster JY, Boonen S et al. Adverse reactions and drug-drug interactions in the management of women with postmenopausal osteoporosis. Calcified Tissue Int 2011; 89: 91– 104. http://dx.doi.org/10.1007/s00223-011-9499-8 Google Scholar CrossRef Search ADS © The Author 2017. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: email@example.com
Rheumatology – Oxford University Press
Published: Mar 1, 2018
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