Relative importance of benefits and risks associated with antithrombotic therapies for acute coronary syndrome: patient and physician perspectives

Abstract

Background:

In acute coronary syndrome (ACS), antithrombotic therapies prevent thrombotic events, but also increase bleeding risk. Knowledge is limited about how patients and physicians balance these benefits and risks.

Objective:

To quantify US patient and physician preferences for outcomes associated with antithrombotic therapies in ACS.

Methods:

Two independent web-based surveys were conducted using best–worst scaling in board-certified cardiologists and adult patients hospitalized within the last 5 years due to heart attack and who used aspirin or prescription antithrombotic therapies. Participants selected best and worst of three possible outcomes across a series of questions. Outcomes included death, various levels of stroke, myocardial infarction (MI), and bleeding. Data were analyzed using a maximum difference model employing random-parameters logit. Relative importance of each outcome was estimated relative to death.

Findings:

Patients (n = 206) and physicians (n = 273) who met face validity requirements, viewed death and nonfatal major disabling stroke as nearly equivalent and most important outcomes to avoid. Relative to death and disabling stroke, physicians considered nondisabling stroke, all nonfatal bleeding, and mild MI all as least important to avoid, while patients considered all bleeds, except major bleeding requiring transfusion, as least important to avoid. Physicians considered severe MI equivalent to 0.92 (0.02 SE) deaths. Patients (∼0.35 [0.04] deaths) and physicians (∼0.64 [0.05] deaths) had different views for nonfatal moderate stroke. Patients viewed nonfatal major bleeding requiring transfusion ∼0.13 (0.02) deaths, and nonfatal heart attack ∼0.09 (0.02) deaths.

Conclusion:

US patients and physicians agree on the relative importance of avoiding death, disabling stroke and bleeding without transfusions. Differing perspectives on bleeding requiring transfusions, MI, and moderately disabling stroke suggest that patients and physicians may have different benefit–risk preferences. Transparent discussion between physicians and patients in ACS treatment shared decision-making seems warranted, although limitations of survey methodology and cultural differences compared with US participants should be considered.

Keywords::

• Acute coronary syndrome
• Antithrombotic therapy
• Best
• worst scaling
• Conjoint analysis
• Myocardial infarction
• Stated preferences
• Stroke

Transparency

Declaration of funding

This study was funded by Janssen Research & Development LLC, USA. The sponsor also provided a formal review of the manuscript.

Author contributions: C.P. and A.B.H. served as subject matter experts and contributed to the development and conduct of the study, as well as the analyses and study report. Z.Y. and B.L. contributed to the development and design of the study. P.B. and J.A.B. contributed to the conceptual discussion of the study. All authors contributed to the interpretation of the study results, writing/reviewing/editing, and final approval of the manuscript. All authors met ICMJE criteria and all those who fulfilled those criteria are listed as authors. All authors had access to the study data and made the final decision about where to publish these data and approved submission to this journal.

Declaration of financial/other relationships

Z.Y., B.L., and P.B. have disclosed that they are employees of Janssen Research & Development LLC and own stocks in Johnson & Johnson, the parent company of Janssen. J.A.B. has disclosed that he is an employee of, and stockholder in, Johnson & Johnson. B.L. has disclosed that he is a stockholder in Johnson & Johnson, Baxter International Inc., Pharmaceutical Holders Trust, and Zimmer Holdings Inc. C.P. and A.B.H. have disclosed that they are employees of RTI Health Solutions, USA, an independent scientific research organization. The study that is the subject of this manuscript was conducted by RTI Health Solutions and funded by Janssen.

CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

Raju Gautam PhD (SIRO Clinpharm Pvt Ltd) provided writing assistance and Wendy P. Battisti PhD (Janssen Research & Development LLC) provided additional editorial support for this manuscript. The authors also thank Mr. Vikram Kilambi and Mr. Juan Macros Gonzalez (RTI Health Solutions, USA) who were involved in the analysis of the data.

Previous presentation: Some of these data were previously presented as a poster at International Society for Pharmacoeconomics and Outcomes Research, May 2013, New Orleans, LA, USA.