Issues in the Design of Discrete Choice Experiments

Examining alignment of community health teams' preferences for health, equity, and spending with state all-payer waiver priorities: A discrete choice experiment

OBJECTIVE

The state of Vermont has a statewide waiver from the centers for medicare and medicaid services to allow all-payer Accountable Care Organizations (ACOs). The Vermont all-payer model (VAPM) waiver is layered upon previous reforms establishing regional community health teams (CHTs) and medical homes. The waiver is intended to incentivize healthcare value and quality and create alignment between health system payers, providers, and CHTs. The objective of this study was to examine CHT's trade-offs and preferences for health, equity, and spending and the alignment with VAPM priorities.

DATA SOURCES/STUDY SETTING

Data were gathered from a survey and discrete choice experiment among CHT leadership and CHT team members of the 13 CHTs in Vermont.

STUDY DESIGN

We used conditional logit models to model the choice as a function of its characteristics (attributes) and mixed logit models to analyze whether preferences for programs varied by persons and roles within CHTs.

DATA COLLECTION/EXTRACTION METHODS

There were 60 respondents who completed the survey online with 14 choice tasks, with three program options in each task, for a total sample size of 2520.

PRINCIPAL FINDINGS

We found that CHTs prioritized programs in the community health plan and those with quantitative evidence of effectiveness. They were less likely to choose either programs targeting racial and ethnic minorities or programs having a small effect on a large population. Preferences did not vary across individual or community attributes. Program priorities of the VAPM, especially healthcare spending, were not prioritized.

CONCLUSIONS

The results suggest that the new VAPM does not automatically create system alignment: CHTs tended to prioritize local needs and voices. The statewide priorities are less important to CHTs, which have excellent internal alignment. This creates potential disconnection between state and community health goals. However, CHTs and the VAPM prioritize similar populations, indicating an opportunity to increase alignment by allowing flexible programs tailored to local needs. CHTs also prioritized programs with a strong evidence base, suggesting another potential avenue to create system alignment.

What Physician Assistants Prefer in a Postprofessional Doctorate Program: A Cross-Sectional Rating and Rankings Study

PURPOSE

The physician assistant (PA) literature has focused on the implications of creating an entry-level doctoral degree; however, there is scant primary literature on postprofessional doctorates, which are becoming more popular as the number of institutions offering them increases. The purposes of this project were to: (1) describe interest and motivation of currently practicing PAs to enroll in a postprofessional doctorate program and (2) identify the most- and least-preferred attributes of a postprofessional doctorate program.

METHODS

This was a quantitative cross-sectional survey of recent alumni from one institution. Measures included interest in obtaining a postprofessional doctorate, a nonrandomized Best-Worst Scaling (BWS) exercise, and motivators for enrolling in a postprofessional doctorate. The main outcome of interest was the BWS standardized score for each attribute.

RESULTS

The research team received 172 eligible responses (n = 172, response rate = 25.83%). Results indicate that 47.67% of respondents (n = 82) expressed interest in a postprofessional doctorate. The most preferred doctorate program attribute was a clinically based program, ending with a residency, conferring a Doctor of Medical Science (DMSc) degree, with a hybrid course delivery.

DISCUSSION

This sample included various interests, motivations, and preferred program attributes. Understanding these factors may help inform the design and redesign of doctoral programs.

Do preferences differ based on respondent experience of a health issue and its treatment? A case study using a public health intervention

OBJECTIVES

Preference information is increasingly being elicited to support decision-making. Although discrete choice experiments (DCEs) are commonly used, little is known about how respondents' relative experience of a health issue, and its treatment, might impact the results of preference studies. The aim of this study was to explore how preferences differ between groups of individuals with varying levels of experience of a health issue and its treatment, using a weight loss maintenance (WLM) programme as a case study.

METHODS

An online DCE survey was provided to four groups, each differing in their level of experience with weight loss and WLM programmes. One group was recruited from a randomised controlled trial of a WLM programme (ISRCTN14657176) and the other three from an online panel. Choice data were analysed using mixed logit models. Relative attribute importance scores and willingness-to-pay (WTP) estimates were estimated to enable comparisons between groups.

RESULTS

Preferences differed between the groups across different attributes. The largest differences related to the outcome (weight re-gain) and cost attributes, resulting in WTP estimates that were statistically significantly different. The most experienced group was willing to pay £0.35 (95% CI: £0.28, £0.42) to avoid a percentage point increase in weight re-gain, compared with £0.12 (95% CI: £0.08, £0.16) for the least experienced group.

CONCLUSION

This study provides evidence in a public health setting to suggest that preferences differ based on respondent experience of the health issue and its treatment. Health preference researchers should therefore carefully consider the appropriate composition of their study samples.

Women's preference to apply shared decision-making in breast cancer screening: a discrete choice experiment

OBJECTIVE

To analyse women's stated preferences for establishing the relative importance of each attribute of shared decision-making (SDM) and their willingness to pay (WTP) for more participatory care in breast cancer screening programmes (BCSP).

DESIGN

A discrete choice experiment was designed with 12 questions (choice tasks). It included three attributes: 'How the information is obtained', regarding benefits and harms; whether there is a 'Dialogue for scheduled mammography' between the healthcare professional and the woman; and, 'Who makes the decision', regarding participation in BCSP. Data were obtained using a survey that included 12 choice tasks, 1 question on WTP and 7 socioeconomic-related questions. The analysis was performed using conditional mixed-effect logit regression and stratification according to WTP.

SETTING

Data collection related to BCSP was conducted between June and November 2021 in Catalonia, Spain.

PARTICIPANTS

Sixty-five women aged between 50 and 60.

MAIN OUTCOME MEASURES

Women's perceived utility of each attribute, trade-off on these attributes and WTP for SDM in BCSP.

RESULT

The only significant attribute was 'Who makes the decision'. The decision made alone (coefficient=2.879; 95% CI=2.297 to 3.461) and the decision made together with a healthcare professional (2.375; 95% CI=1.573 to 3.177) were the options preferred by women. The former contributes 21% more utility than the latter. Moreover, 52.3% of the women stated a WTP of €10 or more for SDM. Women's preferences regarding attributes did not influence their WTP.

CONCLUSIONS

The participant women refused a current paternalistic model and preferred either SDM or informed decision-making in BCSP.

Self-esteem in patients with venous thromboembolism predicts time trade-off values for own health

Background

The time trade-off (TTO) is a commonly used preference based method to assess health related values used in health economic analyses. Surprisingly little is known about the factors influencing the TTO. Since self-esteem is a predictor for health status measurements, and health status affects the TTO, we studied the relation between self-esteem and TTO values.

Methods

Data of 128 patients treated with vitamin K antagonists for venous thromboembolism on Short Form-36 (SF-36), Rosenberg self-esteem and patient characteristics were collected. TTO values were obtained for ‘current health’ and three chronic health states related to thrombosis, in face-to-face interviews with patients. Regression analyses were performed with the TTO as dependent variable. Analyses were performed in two groups; the complete sample, and traders only. Selected predictors were entered in four blocks: socio-demographic factors, medical-clinical factors, health status, and self-esteem.

Results

In the complete sample (N = 128), bivariate regression analysis showed that self-esteem explained 14% of the variance in TTO values for current health (p < .000, N = 117). In traders, multivariate regression analysis showed a significant relationship between self-esteem and TTO values for current health. Self-esteem increased the variance explained (R²) by 8.8%, from 28.1 to 36.9%, (p = 0.01; N = 57). For hypothetical health states, the effect of self-esteem was weaker and mostly absent after controlling for selected variables.

Conclusions

In patients willing to trade-off time, higher self-esteem was associated with higher TTO values for own current health. Self-esteem explained an appreciable proportion of the variance in TTO values in traders. For hypothetical health states such associations were weak or absent.