Controlling Symptoms versus Minimizing Negative Treatment Impact: A Grounded Theory Study of Heterogeneity in Patient...

Patients vary in preferences for health outcomes, risks, and treatments. However, heterogeneity in patient preferences is not typically considered in health technology assessment (HTA) decision-making. Using plaque psoriasis as a case study, we aimed to provide an in-depth understanding of how preferences are shaped and explore real-world preference heterogeneity subgroups for psoriasis treatments.

In this grounded theory study, 38 Canadians with moderate-to-severe psoriasis engaged in one-to-one, semi-structured interviews between October 2023 and December 2024. Theoretical sampling was guided by treatment history, and data collection and analysis occurred in parallel. Data were coded in NVIVO using the constant comparison technique. Themes were developed iteratively, and a conceptual model was developed to illustrate how treatment priorities, personal and contextual factors shape preferences for specific psoriasis therapeutic modalities.

Participant ages ranged from 25 to 66 years; 24 were female, 19 were currently experiencing moderate-to-severe symptoms and 16 had received injectable biologics. We identified that treatment priorities could be grouped under two headings: control of psoriasis symptoms and minimization of negative treatment impact. All participants valued treatment effectiveness, while preferences for other treatment aspects varied. Prioritizing symptom control was also driven by social and emotional factors (such as avoiding stigma and embarrassment, or impact on daily activities) and the need to control multiple comorbid conditions. Those prioritizing the minimization of negative treatment impact often valued treatments that were convenient or easy to take, avoiding "unnecessary" medical treatment, and avoiding adverse events and dependence. Similar underlying preference drivers could result in different reported preferences. While wanting a "convenient" treatment was common, some considered a daily pill ideal and others a monthly injection; according to what fitted best into their current lifestyle. While acceptance of their chronic health condition was a commonly discussed theme, some operationalized this as preferences for more intensive treatments (minimizing psoriasis impact), versus less intensive regimens (minimizing treatment burden). Some participants reported being unable to afford co-payments for treatments they would prefer to take. Preferences varied according to age, psoriasis severity, life stage and treatment experience.

Heterogeneity in patient preferences for aspects of psoriasis impact and treatment translate into a range of different preferences for specific psoriasis therapies. These findings support considering preference heterogeneity in expanding decision-making frameworks to ensure patient voices are considered within HTA.