Background: 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.
Methods: 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.
Results: 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.
Conclusions: 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