Liana Fraenkel

Increased Risk of Fragility Fractures among HIV Infected Compared to Uninfected Male Veterans

Background HIV infection has been associated with an increased risk of fragility fracture. We explored whether or not this increased risk persisted in HIV infected and uninfected men when controlling for traditional fragility fracture risk factors. Methodology/Principal Findings Cox regression models were used to assess the association of HIV infection with the risk for incident hip, vertebral, or upper arm fracture in male Veterans enrolled in the Veterans Aging Cohort Study Virtual Cohort (VACS-VC). We calculated adjusted hazard ratios comparing HIV status and controlling for demographics and other established risk factors. The sample consisted of 119,318 men, 33% of whom were HIV infected (34% aged 50 years or older at baseline, and 55% black or Hispanic). Median body mass index (BMI) was lower in HIV infected compared with uninfected men (25 vs. 28 kg/m2; p<0.0001). Unadjusted risk for fracture was higher among HIV infected compared with uninfected men [HR: 1.32 (95% CI: 1.20, 1.47)]. After adjusting for demographics, comorbid disease, smoking and alcohol abuse, HIV infection remained associated with an increased fracture risk [HR: 1.24 (95% CI: 1.11, 1.39)]. However, adjusting for BMI attenuated this association [HR: 1.10 (95% CI: 0.97, 1.25)]. The only HIV-specific factor associated with fragility fracture was current protease inhibitor use [HR: 1.41 (95% CI: 1.16, 1.70)]. Conclusions/Significance HIV infection is associated with fragility fracture risk. This risk is attenuated by BMI.

Inconsistency Over Time in the Preferences of Older Persons with Advanced Illness for Life-Sustaining Treatment

OBJECTIVES: To determine whether preferences for future attempts at life‐sustaining treatment change over time in a consistent and predictable manner.

What are the Essential Elements to Enable Patient Participation in Medical Decision Making

BACKGROUNDPatient participation in shared decision making (SDM) results in increased patient knowledge, adherence, and improved outcomes. Despite the benefits of the SDM model, many patients do not attain the level of participation they desire.OBJECTIVETo gain a more complete understanding of the essential elements, or the prerequisites, critical to active patient participation in medical decision making from the patient’s perspective.DESIGNQualitative study.SETTINGIndividual, in-depth patient interviews were conducted until thematic saturation was reached. Two analysts independently read the transcripts and jointly developed a list of codes.PATIENTSTwenty-six consecutive subjects drawn from community dwelling subjects undergoing bone density measurements.MEASUREMENTSRespondents’ experiences and beliefs related to patient participation in SDM.RESULTSFive elements were repeatedly described by respondents as being essential to enable patient participation in medical decision making: (1) patient knowledge, (2) explicit encouragement of patient participation by physicians, (3) appreciation of the patient’s responsibility/rights to play an active role in decision making, (4) awareness of choice, and (5) time.LIMITATIONSThe generalizability of the results is limited by the homogeneity of the study sample.CONCLUSIONSOur findings have important clinical implications and suggest that several needs must be met before patients can become active participants in decisions related to their health care. These needs include ensuring that patients (1) appreciate that there is uncertainty in medicine and “buy in” to the importance of active patient participation in decisions related to their health care, (2) understand the trade-offs related to available options, and (3) have the opportunity to discuss these options with their physician to arrive at a decision concordant with their values.

Informing Patients: The Influence of Numeracy, Framing, and Format of Side Effect Information on Risk Perceptions

Background. Given the importance of effective patient communication, findings about influences on risk perception in nonmedical domains need replication in medical domains. Objective. To examine whether numeracy influences risk perceptions when different information frames and number formats are used to present medication risks. Methods. The authors manipulated the frame and number format of risk information in a 3 (frame: positive, negative, combined) × 2 (number format: frequency, percentage) design. Participants from an Internet sample (N = 298), randomly assigned to condition, responded to a single, hypothetical scenario. The main effects and interactions of numeracy, framing, and number format on risk perception were measured. Results. Participants given the positive frame perceived the medication as less risky than those given the negative frame. Mean risk perceptions for the combined frame fell between the positive and negative frames. Numeracy did not moderate these framing effects. Risk perceptions also varied by number format and numeracy, with less-numerate participants given risk information in a percentage format perceiving the medication as less risky than when given risk information in a frequency format; highly numerate participants perceived similar risks in both formats. The generalizability of the findings is limited due to the use of non-patients, presented a hypothetical scenario. Given the design, one cannot know whether observed differences would translate into clinically significant differences in patient behaviors. Conclusions. Frequency formats appear to increase risk perceptions over percentage formats for less-numerate respondents. Health communicators need to be aware that different formats generate different risk perceptions among patients varying in numeracy.

Patient preferences for treatment of rheumatoid arthritis.

Objective: To elicit treatment preferences of patients with rheumatoid arthritis (RA) for disease modifying antirheumatic drugs (DMARDs) with varying risk profiles. Methods: Patient values for 16 DMARD characteristics were ascertained using published data about side effects, effectiveness, and cost. Patient preferences were determined by Adaptive Conjoint Analysis, an interactive computer program that predicts preferences by asking patients to make trade-offs between specific treatment characteristics. Simulations were run to derive preferences for four drugs: methotrexate, gold, leflunomide, and etanercept, under different risk-benefit scenarios. Infliximab was not included because it is given with methotrexate, and we did not include preferences for combination therapy. Based on each patient’s expressed preferences, and the characteristics of the treatments available at the time of the study, the option that best fitted each patient’s perspective was identified. Results: 120 patients (mean age 70 years) were interviewed. For the base case scenario (which assumed the maximum benefits reported in the literature, a low probability of adverse effects, and low equal monthly “co-pays” (out of pocket costs)), 95% of the respondents preferred etanercept over the other treatment options. When all four options were described as being equally effective, 88% continued to prefer etanercept owing to its safer short term adverse effect profile. Increasing etanercept’s co-pay to

Health Outcome Priorities Among Competing Cardiovascular, Fall Injury, and Medication-Related Symptom Outcomes

30.00 decreased the percentage of patients preferring this option to 80%. Conclusions: In this study, older patients with RA, when asked to consider trade-offs between specific risk and benefits, preferred etanercept over other treatment options. Preference for etanercept is explained by older patients’ risk aversion for drug toxicity.

Understanding Patient Preferences for the Treatment of Lupus Nephritis With Adaptive Conjoint Analysis

OBJECTIVES: To determine the priority that older adults with coexisting hypertension and fall risk give to optimizing cardiovascular outcomes versus fall‐ and medication symptom‐related outcomes.

Understanding why rheumatoid arthritis patient treatment preferences differ by race

Background.Incorporation of patient preferences into treatment decisions is an essential component of medical care. Conjoint analysis is an established method of eliciting consumer preferences in market research and is being increasingly used to study patient preferences for health care. Objective.To examine the value of Adaptive Conjoint Analysis (ACA), a unique method of performing conjoint analysis, and to evaluate patient treatment preferences. Research Design. Interactive computer survey. Subjects.Consecutive women (n = 103) with lupus followed in three community rheumatology practices. Measures.ACA was used to assess patients’ relative preferences for specific cytotoxic medication characteristics, and to estimate the percentage of women preferring cyclophosphamide over azathioprine for different risk-benefit scenarios. Results.All participants were able to complete the conjoint task in 14 ±5 minutes. Of the nine medication characteristics studied, efficacy and risk for infection had the greatest impact on preference (each accounting for 20% of the variation in preferences), suggesting that patients consider differences in the risk for infection equally as important as differences in the probability of renal survival. Premenopausal women wanting more children were less likely to choose cyclophosphamide compared with their counterparts (56% vs. 80%, P = 0.04). Modest changes in the probability of renal survival or risk for major toxicity lowered the percentage of women preferring cyclophosphamide by more than 20%, irrespective of their desire for more children. Conclusions.ACA is a feasible method of assessing how patients consider specific medication characteristics and predicting treatment preferences under different risk-benefit scenarios. ACA may be a valuable tool to incorporate patient preferences into medical decision-making.

Decision tool to improve the quality of care in rheumatoid arthritis.

OBJECTIVE Rheumatoid arthritis (RA) patient preferences may account for some of the variability in treatment between racial groups. How and why treatment preferences differ by race is not well understood. We sought to determine whether African American and white RA patients differ in how they evaluate the specific risks and benefits related to medications. METHODS A total of 136 RA patients completed a conjoint analysis interactive computer survey to determine how they valued the specific risks and benefits related to treatment characteristics. The importance that respondents assigned to each characteristic and the ratio of the importance that patients attached to overall benefit versus overall risk were calculated. Subjects having a risk ratio <1 were classified as being risk averse. RESULTS The mean age of the study sample was 55 years (range 22-84). Forty-nine percent were African American and 51% were white. African American subjects assigned the greatest importance to the theoretical risk of cancer, whereas white subjects were most concerned with the likelihood of remission and halting radiographic progression. Fifty-two percent of African American subjects were found to be risk averse compared with 12% of the white subjects (P < 0.0001). Race remained strongly associated with risk aversion (adjusted odds ratio [95% confidence interval] 8.4 [3.1, -23.1]) after adjusting for relevant covariates. CONCLUSION African American patients attach greater importance to the risks of toxicity and less importance to the likelihood of benefit than their white counterparts. Effective risk communication and improved understanding of expected benefits may help decrease unwanted variability in health care.

The Association of Estrogen Replacement Therapy and the Raynaud Phenomenon in Postmenopausal Women

Despite the importance of achieving tight control, many patients with rheumatoid arthritis (RA) are not effectively treated with disease‐modifying antirheumatic drugs. The objective of this study was to develop a decision support tool to inform RA patients with ongoing active disease about the risks and benefits related to biologic therapy.