Page 116 - 2018_12-Haematologica-web

Haematologica 2018 Volume 103(12):2040-2048
Ferrata Storti Foundation
Acute Myeloid Leukemia
Physician uncertainty aversion impacts medical decision making for older patients with acute myeloid leukemia: results
of a national survey
Pierre Bories,1,2 Sébastien Lamy,3,4 Célestine Simand,5 Sarah Bertoli,2
Cyrille Delpierre,3 Sandra Malak,6 Luc Fornecker,5 Stéphane Moreau,7 Christian Récher2 and Antoine Nebout8
1Regional Cancer Network Onco-Occitanie, Toulouse University Institute of Cancer- Oncopole; 2Department of Hematology, Toulouse University Institute of Cancer- Oncopole; 3INSERM Unit 1027, Faculty of Medicine, Toulouse; 4Department of Clinical Pharmacology, Toulouse University Hospital; 5Department of Hematology, Strasbourg University Hospital; 6Department of Hematology, Rene Huguenin Hospital, Curie Institute, Saint-Cloud; 7Department of Hematology, Limoges University Hospital and 8INRA, UR 1303 ALISS, Ivry-sur-Seine, France
ABSTRACT
Elderly patients with acute myeloid leukemia can be treated with intensive chemotherapy, low-intensity therapy such as low-dose aracytine or hypomethylating agents, or best supportive care. The choice between these treatments is a function of many patient-related and disease-related factors. We investigated how physicians’ behavioral characteristics affect medical decision-making between intensive and non-intensive therapy in this setting. A nationwide cross-sectional online survey of hematologists collected data on medical decision-mak- ing for 6 clinical vignettes involving older acute myeloid leukemia patients that were representative of routine practice. Questionnaires elicited physicians’ demographic and occupational characteristics along with their individual behavioral characteristics according to a decision theory framework. From the pattern of responses to the vignettes, a K- means clustering algorithm was used to distinguish those who were like- ly to prescribe more intensive therapy and those who were likely to pre- scribe less intensive or no therapy. Multivariate analyses were used to identify physician’s characteristics predictive of medical decision-mak- ing. We obtained 230 assessable answers, which represented an adjusted response rate of 45.4%. A multivariate model (n=210) revealed that physicians averse to uncertainty recommend significantly more inten- sive chemotherapy: Odds Ratio (OR) [95% Confidence Interval (CI)]: 1.15 [1.01;1.30]; P=0.039. Male physicians who do not conform to the expected utility model (assumed as economically irrational) recommend more intensive chemotherapy [OR (95% CI) = 3.45 (1.34; 8.85); P=0.01]. Patient volume per physician also correlated with therapy intensity [OR (95% CI)=0.98 (0.96; 0.99); P=0.032]. The physicians’ medical decision- making was not affected by their age, years of experience, or hospital facility. The significant association between medical decision and indi- vidual behavioral characteristics of the physician identifies a novel non- biological factor that may affect acute myeloid leukemia patients’ out- comes and explain variations in clinical practice. It should also encourage the use of validated predictive models and the description of novel bio- markers to best select patients for intensive chemotherapy or low-inten- sity therapy.
Correspondence:
pierre.bories@onco-occitanie.fr
Received: March 2, 2018. Accepted: July 12, 2018. Pre-published: July 13, 2018.
doi:10.3324/haematol.2018.192468
Check the online version for the most updated information on this article, online supplements, and information on authorship & disclosures: www.haematologica.org/content/103/12/2040
©2018 Ferrata Storti Foundation
Material published in Haematologica is covered by copyright. All rights are reserved to the Ferrata Storti Foundation. Use of published material is allowed under the following terms and conditions: https://creativecommons.org/licenses/by-nc/4.0/legalcode. Copies of published material are allowed for personal or inter- nal use. Sharing published material for non-commercial pur- poses is subject to the following conditions: https://creativecommons.org/licenses/by-nc/4.0/legalcode, sect. 3. Reproducing and sharing published material for com- mercial purposes is not allowed without permission in writing from the publisher.
2040
haematologica | 2018; 103(12)
ARTICLE