探讨不孕症患者治疗决策的影响因素！

BACKGROUND

背景

ART differs in effectiveness, side-effects, administration,and costs. To improve the decision-making process, we need to understand what factors patients consider to be most important.

ART在有效性、副作用、给药方式和费用方面存在差异。为了改善决策过程，我们需要了解患者认为最重要的因素是什么。

OBJECTIVE AND RATIONALE

目的和理由

We conducted this systematic review to assess which aspects of ART treatment (effectiveness, safety, burden, costs, patient-centeredness, and genetic parenthood) are most important in the decision-making of patients with an unfulfilled wish to have a child.

我们进行了这项系统回顾，以评估对于有生育愿望但尚未实现的患者来说，辅助生殖技术治疗的哪些方面（疗效、安全性、负担、费用、以患者为中心的关怀和遗传亲子关系）在决策过程中最为重要。

SEARCH METHODS

检索方法

We searched studies indexed in Embase, PubMed, PsycINFO, and CINAHL prior to November 2023. Discrete choice experiments (DCEs), surveys, interviews, and conjoint analyses (CAs) about ART were included. Studies were included if they described two or more of the following attributes: effectiveness, safety, burden, costs, patient-centeredness, and genetic parenthood.Participants were men and women with an unfulfilled wish to have a child. From each DCE/CA study, we extracted the betacoefficients and calculated the relative importance of treatment attributes or, in case of survey studies, extracted results. We assessed the risk of bias using the rating developed by the Grading of Recommendations Assessment, Development and Evaluation working group. Attributes were classified into effectiveness, safety, burden, costs, patient-centeredness, genetic parenthood,and others.

我们检索了2023年11月之前Embase、PubMed、PsycINFO和CINAHL中索引的研究。包括关于ART治疗的离散选择实验（DCE）、调查、访谈和联合分析（CAs）。如果研究描述了以下两个或两个以上的属性：有效性、安全性、负担、成本、以患者为中心和遗传亲子关系。参与者是那些未能实现愿望的男性和女性。我们从每项 DCE/CA研究中抽取了 beta 系数，并计算了治疗属性的相对重要性，或者在调查研究中抽取了结果。我们采用由“建议评估、制定和评价”工作组制定的评级来评估偏倚风险。属性分为有效性、安全性、负担、成本、以患者为中心、遗传亲子关系等。

OUTCOMES

结果

The search identified 938 studies of which 20 were included: 13 DCEs, three survey studies, three interview studies, and one conjoint analysis, with a total of 12 452 patients. Per study, 47-100% of the participants were women. Studies were assessed as having moderate to high risk of bias (critical: six studies, serious: four studies, moderate: nine studies, low: one study). The main limitation was the heterogeneity in the questionnaires and methodology utilized. Studies varied in the number and types of assessed attributes. Patients’treatment decision-making was mostly driven by effectiveness, followed by safety, burden, costs, and patientcenteredness. Effectiveness was rated as the first or second most important factor in 10 of the 12 DCE studies (83%) and the relative importance of effectiveness varied between 17% and 63%, with a median of 34% (moderate certainty of evidence). Of eight studies evaluating safety, five studies valued safety as the first or second most important factor (63%), and the relative importance ranged from 8% to 35% (median 23%) (moderate certainty of evidence). Cost was rated as first or second most important in five of 10 studies, and the importance relative to the other attributes varied between 5% and 47% (median 23%) (moderate certainty of evidence). Burden was rated as first or second by three of 10 studies (30%) and the relative importance varied between 1% and 43% (median 13%) (low certainty of evidence). Patient-centeredness was second most important in one of five studies (20%) and had a relative importance between 7% and 24% (median 14%) (low certainty of evidence). Results suggest that patients are prepared to trade-off some effectiveness for more safety, or less burden and patient-centeredness. When safety was evaluated, the safety of the child was considered more important than the mother’s safety. Greater burden (cycle cancellations, number of injections, number of hospital visits, time) was more likely to be accepted by patients if they gained effectiveness, safety, or lower costs. Concerning patient-centeredness, information provision and physician attitude were considered most important, followed by involvement in decision-making, and treatment continuity by the same medical professional. Non-genetic parenthood did not have a clear impact on decision-making.

检索确定了938项研究，其中20项被纳入：13项DCE研究，3项调查研究，3项访谈研究和1项联合分析，共12 452例患者。根据研究结果显示，参与者中有47%-100%是女性。对这些研究进行评估发现，存在中度到高度的偏倚风险（其中关键性风险的研究有六个，严重性风险的研究有四个，中度风险的研究有九个，低风险的研究有一个）。主要的局限性是调查问卷和方法的异质性。研究中评估属性的数量和类型各不相同。患者的治疗决策主要是由有效性驱动的，其次是安全性、负担、成本和以患者为中心。在12项DCE研究中，有10项（83%）被评为第一或第二重要因素，有效性的相对重要性在17%到63%之间，中位数为34%（中等确定性证据）。在8项评估安全性的研究中，有5项研究将安全性视为第一或第二最重要的因素（63%），相对重要性从8%到35%（中位数23%）（确定性证据中等）。在 10 项研究中的 5 项中，成本被评为第一或第二重要因素，相对于其他属性的重要性在 5%-47% 之间（中位数为23%）（证据确定性中等）。在 10 项研究中的 3 项（30%）中，负担被评为第一或第二重要因素，相对重要性在 1%-43% 之间（中位数为 13%）（证据确定性低）。在5项研究中的1项（20%）是以患者为中心评为第二重要，相对重要性在7%-24% 之间（中位数为 14%）（证据确定性低）。结果表明，患者愿意牺牲一些有效性来换取更多的安全性，或者更少的负担和以患者为中心。在评估安全性时，孩子的安全被认为比母亲的安全更重要。如果患者获得有效性、安全性或更低的成本，更大的负担（周期取消、注射次数、就诊次数、时间）更有可能被患者接受。关于以患者为中心，信息提供和医生态度被认为是最重要的，其次是参与决策和由同一医疗专业人员进行连续治疗。非遗传父母身份对决策没有明显影响。

WIDER IMPLICATIONS

更广泛的影响

The findings of this review can be used in future preference studies and can help healthcare professionals in guiding patients’ decision-making and enable a more patient-centered approach.

本综述的发现可用于未来的偏好研究，并可以帮助医疗保健专业人员指导患者的决策，并实现更加以患者为中心的治疗方法。

参考文献：

Felicia von Estorff, Monique H Mochtar, Vicky Lehmann, Madelon van Wely, Driving factors in treatment decision-making of patients seeking medical assistance for infertility: a systematic review, Human Reproduction Update, Volume 30, Issue 3, May-June 2024, Pages 341–354, https://doi.org/10.1093/humupd/dmae001