Appropriately incorporating individual patient preferences poses a challenge for developers of clinical practice guidelines. Sometimes, the best treatment depends not only on the likely harms and benefits of the treatment alternatives but also on how patients trade off the those harms and benefits. In the setting of the management of mild hypertension, some patients may have strong concerns about the possibility of stroke, while others may have a strong dislike for the side effects associated with medical therapy or changes in lifestyle. When variations in patient preferences exist, guidelines that make generic treatment recommendations may be inappropriate. The long-term goal of the proposed study is the development of a formal approach for determining whether individual patient preferences should be incorporated into practice guidelines.
The specific aim of this project is to apply one such approach in the setting of mild hypertension. To achieve this aim, the study investigators will estimate the cost-effectiveness, relative to the use of a preference-fixed guideline, of individualizing treatment recommendations to account for each patient's preferences. To support the estimation of the cost-effectiveness of individualized utility assessment, study investigators will assess the utilities of 200 mild hypertension patients. Utilities are formal, quantitative measures of the desirability of potential medical outcomes. Utilities will be assessed using an existing automated assessment tool, U-titer. The utilities will then be incorporated into an existing decision model to determine the impact of the variation in patient preferences on the health benefit offered by medical treatment relative to monitoring. The cost-effectiveness ratio of individualized utility assessment is the cost of utility assessment divided by the health benefit derived from utility assessment. The cost-effectiveness ratio of individualized utility assessment will be compared to other health interventions accepted by the medical community. The determination that individualized utility assessment is cost-effective would suggest that future guidelines for the management of mild hypertension incorporate sufficient flexibility to accommodate variations in patient preferences. In addition to providing insight into the degree of flexibility required by guidelines for the management of mild hypertension, this project is designed to meet the need of the Agency for Health Care Policy and Research (AHCPR) to improve the effectiveness of the techniques it uses to develop practice guidelines. While the proposed study involves an application to the specific problem of mild hypertension, the methodology developed as part of this effort can be used to improve the health benefit offered by all AHCPR -sponsored guidelines.
