To the best of our knowledge, this is the first study examining patient and physician preferences for prophylaxis of variceal hemorrhage in patients with cirrhosis. In direct contrast to current clinical practice and guidelines, we found that 64% of patients with cirrhosis requiring primary prophylaxis for variceal hemorrhage and 57% of prescribing physicians prefer EVL over beta-blockers. Of note, our results also demonstrated that treatment preferences vary significantly, indicating that this choice is value-based, and emphasizing the importance of incorporating individual patient preferences into the treatment planning process.
Shortness of breath or low blood pressure was perceived as the most important factor by both patients and physicians. However, patients were more influenced by the risk of fatigue and much less influenced by the risk of rare procedure-related complications compared to physicians. This finding is consistent with other studies demonstrating differences between physician and patient preferences. (23
Physicians may be more strongly influenced by the rare, but serious risks of perforation and bleeding in part due to the availability heuristic. The availability heuristic or bias refers to the observation that the frequency of events that are easier to remember or imagine are falsely believed to be more frequent than events which are less easy to imagine or remember. This bias predicts that physicians who may have caused or heard about as a single catastrophic adverse event would be more strongly influenced by this risk than patients.
Despite recruiting patients from seven different centers from across Connecticut, none of the patients enrolled received EVL as primary prophylaxis for variceal hemorrhage. This pattern of practice is consistent with consensus guidelines (7
), but may be questionable given the variability in patient preferences noted in this study.
The strengths of this study lie in the methods used to evaluate preferences as well as the successful recruitment of a substantial number of patients at the time of their clinical decision to start primary prophylaxis for variceal hemorrhage. ACA measures preferences based on how subjects evaluate specific risks and benefits. Subjects do not evaluate treatment alternatives directly. Values are computed based on how each respondent makes trade-offs between competing risks and benefits related to the treatment options under consideration. These values are then used to predict which option most closely suits each patient’s individual priorities.
There are also several important limitations that must be considered. We assumed that the efficacy of EVL and beta-blockers were equivalent. In reality, it may be that for an individual patient, EVL would be more effective due to the endoscopic characteristics of their varices, the severity of their liver disease, or adherence. On the other hand, additional beneficial effects of beta-blockers in preventing other complications of cirrhosis such as ascites were not presented, neither was the option of switching from beta-blockers to EVL proposed. Also, additional evidence supporting that bleeding from EVL ulcers can be fatal was not available at the time of the preparation of the ACA task and was therefore not included (27
). Given the difficulty of recruiting patients with incident disease we were limited in terms of the total number of patients enrolled. In terms of data collection for physicians, data exploring the difference between preference and prescribing practice were only collected on approximately half the physicians, limiting our interpretation of this discordance. Lastly, cost was not considered in this study.
In summary, we found significant heterogeneity among physicians and patients regarding preferences for primary prophylaxis for variceal hemorrhage. These results suggest that physicians’ recommendations for primary prophylaxis of variceal hemorrhage should be based on explicit elicitation of individual patient preferences.