Therapy options for mesalamine-refractory ulcerative colitis (UC) include immunosuppressive medications or surgery. Chronic immunosuppressive therapy increases risks of infection and cancer, whereas surgery produces a permanent change in bowel function. We sought to quantify the willingness of patients with UC to accept the risks of chronic immunosuppression to avoid colectomy.
We conducted a state-of-the-art discrete-choice experiment among 293 patients with UC who were offered a choice of medication or surgical treatments with different features. Random parameters logit was used to estimate patients' willingness to accept trade-offs among treatment features in selecting surgery versus medical treatment.
A desire to avoid surgery and the surgery type (ostomy versus J-pouch) influenced patients' choices more than a specified range of 10-year mortality risks from lymphoma or infection, or disease activity (mild versus remission). To avoid an ostomy, patients were willing to accept a >5% 10-year risk of dying from lymphoma or infection from medical therapy, regardless of medication efficacy. However, data on patients' stated choice indicated perceived equivalence between J-pouch surgery and incompletely effective medical therapy. Patient characteristics and disease history influenced patients' preferences regarding surgery versus medical therapy.
Patients with UC are willing to accept relatively high risks of fatal complications from medical therapy to avoid a permanent ostomy and to achieve durable clinical remission. However, patients view J-pouch surgery, but not permanent ileostomy, as an acceptable therapy for refractory UC in which medical therapy is unable to induce a durable remission.
Article first published online 25 November 2013
*Department of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania;
†Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania;
‡RTI-HS, Research Triangle Institute, Research Triangle Park, North Carolina; and
§Inflammatory Bowel Disease Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Reprints: Meenakshi Bewtra, MD, MPH, Department of Gastroenterology, University of Pennsylvania, 423 Guardian Drive, 724 Blockley Hall, Philadelphia, PA 03164 (e-mail: firstname.lastname@example.org).
This study was funded in part from a research Grant from Centocor, and from NIH K08 grant K08 DK084347-01 and K24 DK078228. This study was funded in part from a research Grant from Centocor, who had no role in the collection, analysis and interpretation of data.
M. Bewtra: Grant support from Janssen. C. Siegel: consultant to Abbott, Elan, Janssen and UCB; CME lectures for Abbott and Janssen; Grant support from Abbott, Janssen, Salix and Warner-Chilcott. J. Lewis: Consultant to Abbott, Pfizer, Amgen, and Millennium Pharmaceuticals; Grant support from Takeda, Shire, Janssen, AstraZeneca, and Merck. The remaining authors have no conflicts of interest to disclose.
Received September 27, 2013
Accepted October 15, 2013