Purpose: Endoscopic variceal ligation (EVL) and non-selective beta-blockers are both effective for primary prophylaxis of variceal hemorrhage in patients with cirrhosis and medium/large-sized esophageal varices. However, the modes of administration and side effects of these treatments are distinct; therefore decision-making should be guided by patient preferences.

Methods: Untreated patients with newly diagnosed esophageal varices underwent a standardized educational session after which their preferences for treatment were evaluated using an Adaptive Conjoint Analysis (ACA) task. Patients with contraindications to either treatment were excluded. Attributes were based on randomized controlled trial data and included: route of administration, risk of fatigue, sexual dysfunction, dysphagia, shortness of breath and/or hypotension, procedure-related bleeding and perforation. All attributes were presented using lay terminology and risk communication was facilitated using natural frequencies and pictographs. Preference data are presented in terms of shares of preference where strength of preference for both options sum to 100. Subjects were telephoned one month after performing the ACA task to determine which treatment they received.

Results: 49 subjects have been enrolled to date; 78% male, mean age = 54 (range 24-76); 52% college educated; 94% Caucasian; mean desire for information = 18 (maximum = 20); 84% preferred an active or collaborative role in decision-making. The risk of shortness of breath and/or hypotension was most important to patients whereas the risk of dysphagia and perforation were least important. 92% of participants felt that the ACA task correctly predicted the relative importance they attached to each attribute. Overall, respondents preferred EVL over beta-blockers (61% versus 39%). In bivariate analyses, older patients (p=0.007) as well as those generally preferring medications over procedures were more likely to prefer beta–blockers (p=0.0003). In contrast, having a college education (p=0.03) and higher annual income (p=0.007) were positively associated with preference for EVL. In a linear regression model only age and preference for medication over procedures remained significantly associated with treatment preference. Despite stronger preferences for EVL, almost all subjects (N = 44) were prescribed beta-blockers.

Conclusion: Although patient preferences for prophylaxis of variceal bleed are variable, many patients prefer EVL over beta-blockers, and many do not receive treatment concordant with their values. Given patients' desire for an active role in shared decision-making, both EVL and beta-blockers should be discussed with patients requiring primary prophylaxis.