Ordinal preference elicitation methods in health economics and health services research: using discrete choice experiments and ranking methods

Using stated preference methods to facilitate knowledge translation in implementation science

Enhancing the arsenal of methods available to shape implementation strategies and bolster knowledge translation is imperative. Stated preference methods, including discrete choice experiments (DCE) and best-worst scaling (BWS), rooted in economics, emerge as robust, theory-driven tools for understanding and influencing the behaviors of both recipients and providers of innovation. This commentary outlines the wide-ranging application of stated preference methods across the implementation continuum, ushering in effective knowledge translation. The prospects for utilizing these methods within implementation science encompass (1) refining and tailoring intervention and implementation strategies, (2) exploring the relative importance of implementation determinants, (3) identifying critical outcomes for key decision-makers, and 4) informing policy prioritization. Operationalizing findings from stated preference research holds the potential to precisely align health products and services with the requisites of patients, providers, communities, and policymakers, thereby realizing equitable impact.

Robot-assisted surgery and artificial intelligence-based tumour diagnostics: social preferences with a representative cross-sectional survey

BACKGROUND

The aim of this study was to assess social preferences for two different advanced digital health technologies and investigate the contextual dependency of the preferences.

METHODS

A cross-sectional online survey was performed among the general population of Hungary aged 40 years and over. Participants were asked to imagine that they needed a total hip replacement surgery and to indicate whether they would prefer a traditional or a robot-assisted (RA) hip surgery. To better understand preferences for the chosen method, the willingness to pay (WTP) method was used. The same assessment was conducted for preferences between a radiologist's and AI-based image analysis in establishing the radiological diagnosis of a suspected tumour. Respondents' electronic health literacy was assessed with the eHEALS questionnaire. Descriptive methods were used to assess sample characteristics and differences between subgroups. Associations were investigated with correlation analysis and multiple linear regressions.

RESULTS

Altogether, 1400 individuals (53.7% female) with a mean age of 58.3 (SD = 11.1) years filled in the survey. RA hip surgery was chosen by 762 (54.4%) respondents, but only 470 (33.6%) chose AI-based medical image evaluation. Those who opted for the digital technology had significantly higher educational levels and electronic health literacy (eHEALS). The majority of respondents were willing to pay to secure their preferred surgical (surgeon 67.2%, robot-assisted: 68.8%) and image assessment (radiologist: 70.9%; AI: 77.4%) methods, reporting similar average amounts in the first (p = 0.677), and a significantly higher average amount for radiologist vs. AI in the second task (p = 0.001). The regression showed a significant association between WTP and income, and in the hip surgery task, it also revealed an association with the type of intervention chosen.

CONCLUSIONS

Individuals with higher education levels seem to accept the advanced digital medical technologies more. However, the greater openness for RA surgery than for AI image assessment highlights that social preferences may depend considerably on the medical situation and the type of advanced digital technology. WTP results suggest rather firm preferences in the great majority of the cases. Determinants of preferences and real-world choices of affected patients should be further investigated in future studies.

A Novel Approach to Computing Preference Estimates for Different Treatment Pathways: An Application in Oncology

BACKGROUND

Patients with cancer may progress through multiple treatments with differing adverse effect profiles. Moreover, pathways may be fixed or flexible in allowing for escalation or de-escalation of treatment depending on interim outcomes. We sought to develop a methodology capable of estimating preferences for the entirety of a pathway involving a sequence of different treatments.

METHODS

Patients with early breast cancer completed an online discrete choice experiment to assess preferences for eight key early breast cancer attributes. Hierarchical Bayesian modeling was used to calculate attribute-level preference weights. Preference weights for hypothetical pathways were estimated by summing the respective weights for efficacy, flexible or fixed pathway, duration, administration regimen, and adverse event risk, the last two of which were time-adjusted by multiplying each weight by the proportion of time spent on a selected treatment.

RESULTS

Increases in the risk of a serious adverse event were most influential in treatment pathway preferences, followed by increases in efficacy and decreases in overall pathway duration. Patients preferred a flexible pathway versus a fixed pathway. Pathway preference estimates fluctuated in a logically consistent manner. Switching from a flexible to a fixed pathway yielded a significantly lower pathway preference. For this same pathway, when adjuvant treatment was replaced with a treatment with a more favorable toxicity profile and shorter duration, it offset the negative impact of the more toxic neoadjuvant chemotherapy.

CONCLUSIONS

This novel methodology accounts for patient preference throughout a sequence of treatments, allowing for comparison of preferences across complex treatment pathways.

Measuring Quality of Life in Diabetic Retinal Disease: A Narrative Review of Available Patient-Reported Outcome Measures

Topic

Several patient-reported outcome measures (PROMs) are available to measure health-related quality of life (HRQoL) in patients with late-stage clinical diabetic retinal diseases (DRDs). However, an understanding of the psychometric properties of PROMs is needed to assess how they could relate to severity levels of a revised DRD grading system. This narrative review assessed the available generic-, vision-, and DRD-related PROMs used in DRD research and highlights areas for improvement.

Clinical Relevance

Diabetic retinal disease is a common complication of diabetes and can lead to sight-threatening complications with a devastating effect on HRQoL.

Methods

The Quality of Life working group is one of 6 working groups organized for the DRD Staging System Update Effort, a project of the Juvenile Diabetes Research Foundation Mary Tyler Moore Vision Initiative. PubMed, Cochrane Library, Embase, and Google Scholar databases were searched using core keywords to retrieve ophthalmology-related review articles, randomized clinical trials, and prospective, observational, and cross-sectional studies in the English language. A detailed review of 12 PROMs (4 QoL questionnaires and 8 utilities) that met a minimum level of evidence (LOE) was conducted. The relevance of each PROM to DRD disease stage and Biomarker Qualification guidelines (Biomarkers, EndpointS, and other Tools) categories was also defined.

Results

The National Eye Institute 25-item Visual Function Questionnaire (NEI VFQ-25), Impact of vision impairment-computerized adaptive testing, and Diabetic Retinopathy and Macular Edema Computerized Adaptive Testing System had a LOE of II in detecting change due to late-stage DRD (diabetic macular edema), although several areas for improvement (e.g., psychometrics and generalizability) were identified. Other PROMs, particularly the utilities, had a LOE of III due to cross-sectional evidence in late-stage clinical DRD. Although the NEI VFQ-25 has been the most widely used PROM in late-stage DRD, more work is required to improve its multidimensional structure and other psychometric limitations. No PROM was deemed relevant for subclinical or early/mid-DRD.

Conclusion

This narrative review found that the most commonly used PROM is NEI VFQ-25, but none meets the ideal psychometric, responsiveness, and clinical setting digital administration requirements that could be included in an updated DRD staging system for diagnosis and monitoring of DRD progression.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A systematic review on the direct approach to elicit the demand-side cost-effectiveness threshold: Implications for low- and middle-income countries

Several literature review studies have been conducted on cost-effectiveness threshold values. However, only a few are systematic literature reviews, and most did not investigate the different methods, especially in-depth reviews of directly eliciting WTP per QALY. Our study aimed to 1) describe the different direct approach methods to elicit WTP/QALY; 2) investigate factors that contribute the most to the level of WTP/QALY value; and 3) investigate the relation between the value of WTP/QALY and GDP per capita and give some recommendations on feasible methods for eliciting WTP/QALY in low- and middle-income countries (LMICs). A systematic review concerning select studies estimating WTP/QALY from a direct approach was carried out in seven databases, with a cut off date of 03/2022. The conversion of monetary values into 2021 international dollars (i$) was performed via CPI and PPP indexes. The influential factors were evaluated with Bayesian model averaging. Criteria for recommendation for feasible methods in LMICs are made based on empirical evidence from the systematic review and given the resource limitation in LMICs. A total of 12,196 records were identified; 64 articles were included for full-text review. The WTP/QALY method and values varied widely across countries with a median WTP/QALY value of i$16,647.6 and WTP/QALY per GDP per capita of 0.53. A total of 11 factors were most influential, in which the discrete-choice experiment method had a posterior probability of 100%. Methods for deriving WTP/QALY vary largely across studies. Eleven influential factors contribute most to the level of values of WTP/QALY, in which the discrete-choice experiment method was the greatest affected. We also found that in most countries, values for WTP/QALY were below 1 x GDP per capita. Some important principles are addressed related to what LMICs may be concerned with when conducting studies to estimate WTP/QALY.

Is it fun or is it hard? Studying physician-related attributes of shared decision-making by ranking case vignettes

Objective

This study investigated provider-related attributes of shared decision-making (SDM). It studied how physicians rank SDM cases compared to other cases, taking 'job satisfaction' and 'complexity' as ranking criteria.

Methods

Ten vignettes representing three cases of SDM, three cases dealing with patients' emotions and four with technical problems were designed to conduct a modified ordinal preference elicitation study. Gynaecologists and trainees ranked the vignettes for 'job satisfaction' or 'complexity'. Results were analysed by comparing the top three and down three ranked cases for each type of case using exact p-values obtained with custom-made randomisation tests.

Results

Participants experienced more satisfaction significantly from performing technical cases than cases dealing with emotions or SDM. Moreover, technical cases were perceived as less complex than those dealing with emotions. However, results were inconclusive about whether gynaecologists find SDM complex.

Conclusion

Findings suggest gynaecologists experience lower satisfaction with SDM tasks, possibly due to them falling outside their comfort zone. Integrating SDM into daily routines and promoting culture change favouring dealing with non-technical problems might help mitigate issues in SDM implementation.

Innovation

Our novel study assesses SDM in the context of task appraisal, illuminating the psychology of health professionals and providing valuable insights for implementation science.

Older adult patient preferences for the content and format of prescription medication labels - A best-worst scaling and discrete choice experiment study

BACKGROUND

Patient preferences for the content and format of prescription medication labels (PMLs, i.e., sticker labels placed on medication bottles/packets at dispensing) have been extensively studied. However, accommodating all preferences on PMLs is impractical due to space limitations. Understanding how patients prioritise the content and format attributes of PMLs can inform improvements while working within PML space constraints.

OBJECTIVES

We aimed to (1) identify a ranking of medication-related content attributes to be prioritised on PMLs using best-worst scaling (BWS), and (2) determine the relative importance of format attributes when incorporated onto PMLs using discrete choice experiment (DCE), from the perspective of older adult patients in Singapore.

METHODS

Attributes were informed by our prior qualitative study and PML best practice guidelines. For the BWS component, the assessed content attributes were indication, precautions, interaction or paired medicines, food instructions, side effects, expiry date, and missed dose action, all of which are currently not legally mandated on PMLs in Singapore. A BWS object case was used to rank the content attributes. For the DCE component, in a series of questions, participants were asked to choose between two PML options each time, that varied in the presentation of dosage-frequency instructions, font size, presentation of dosage, presentation of precautions, and font colour of precautions. A mixed logit model estimated the relative utilities of format attribute levels, enabling the calculation of importance scores of the format attributes.

RESULTS

The study recruited 280 participants (mean age: 68.8 ± 5.4 years). The three most-preferred content attributes were indication, precautions and interaction or paired medicines. The top three format preferences were tabular style presentation of dosage-frequency instructions, large font size and precautions in red colour.

CONCLUSIONS

Healthcare institutions should consider improving their PMLs based on the leading content and format preferences voiced by older adult patients. The methodology adopted in the study can also be used for aligning the content and format of other patient education materials with patient preferences.

User-Centered Evaluation and Design Recommendations for an Internal Medicine Resident Competency Assessment Dashboard

OBJECTIVES

Clinical Competency Committee (CCC) members employ varied approaches to the review process. This makes the design of a competency assessment dashboard that fits the needs of all members difficult. This work details a user-centered evaluation of a dashboard currently utilized by the Internal Medicine Clinical Competency Committee (IM CCC) at the University of Cincinnati College of Medicine and generated design recommendations.

METHODS

Eleven members of the IM CCC participated in semistructured interviews with the research team. These interviews were recorded and transcribed for analysis. The three design research methods used in this study included process mapping (workflow diagrams), affinity diagramming, and a ranking experiment.

RESULTS

Through affinity diagramming, the research team identified and organized opportunities for improvement about the current system expressed by study participants. These areas include a time-consuming preprocessing step, lack of integration of data from multiple sources, and different workflows for each step in the review process. Finally, the research team categorized nine dashboard components based on rankings provided by the participants.

CONCLUSION

We successfully conducted user-centered evaluation of an IM CCC dashboard and generated four recommendations. Programs should integrate quantitative and qualitative feedback, create multiple views to display these data based on user roles, work with designers to create a usable, interpretable dashboard, and develop a strong informatics pipeline to manage the system. To our knowledge, this type of user-centered evaluation has rarely been attempted in the medical education domain. Therefore, this study provides best practices for other residency programs to evaluate current competency assessment tools and to develop new ones.

Valuing the Dental Caries Utility Index in Australia

INTRODUCTION

The Dental Caries Utility Index (DCUI) is a new oral health-specific health state classification system for adolescents, consisting of 5 domains: pain/discomfort, difficulty eating food/drinking, worried, ability to participate in activities, and appearance. Each domain has 4 response levels. This study aims to generate an Australian-specific utility algorithm for the DCUI.

METHODS

An online survey was conducted using a representative sample of the adult Australian general population. The discrete choice experiment (DCE) was used to elicit the preferences on 5 domains. Then, the latent utilities were anchored onto the full health-dead scale using the visual analogue scale (VAS). DCE data were modeled using conditional logit, and 2 anchoring procedures were considered: anchor based on the worst health state and a mapping approach. The optimal anchoring procedure was selected based on the model parsimony and the mean absolute error (MAE).

RESULTS

A total of 995 adults from the Australian general population completed the survey. The conditional logit estimates on 5 dimensions and levels were monotonic and statistically significant, except for the second level of the "worried" and "appearance" domains. The mapping approach was selected based on a smaller MAE between the 2 anchoring procedures. The Australian-specific tariff of DCUI ranges from 0.1681 to 1.

CONCLUSION

This study developed a utility algorithm for the DCUI. This value set will facilitate utility value calculations from the participants' responses for DCUI in economic evaluations of dental caries interventions targeted for adolescents.

HIGHLIGHTS

Preference-based quality-of-life measures (PBMs), which consist of a health state classification system and a set of utility values (a scoring algorithm), are used to generate utility weights for economic evaluations.This study is the first to develop an Australian utility value set for the Dental Caries Utility Index (DCUI), a new oral health-specific classification system for adolescents.The availability of a utility value set will enable using DCUI in economic evaluations of oral health interventions targeted for adolescents and may ultimately lead to more effective and efficient planning of oral health care services.

Stakeholder validation of a Sepedi core vocabulary list as a resource for augmentative and alternative communication

PURPOSE

The development of culturally and linguistically appropriate resources to support communication interventions for underserved communities is an urgent necessity. The purpose of the study was to obtain stakeholder feedback on vocabulary items from a Sepedi core vocabulary list developed as a resource for vocabulary selection for augmentative and alternative communication (AAC) systems, and to expand the list based on stakeholders' vocabulary recommendations.

METHOD

A questionnaire was used to obtain the ratings of 57 stakeholders regarding the importance of including 155 Sepedi words from the Sepedi core vocabulary list on an AAC system for a child with receptive language skills at the level of a 4-year-old or higher. Stakeholders also suggested additional words to include on the system.

RESULT

All words were rated as important or very important. However, there was a statistically significant inverse relationship between the average frequency of occurrence of words belonging to a specific category and the average importance rating that stakeholders assigned to words in that category. A total of 48 words were additionally suggested by three or more stakeholders.

CONCLUSION

Stakeholder ratings validated the list as relevant to consult in vocabulary selection for Sepedi AAC systems for children. Stakeholder-suggested words may be a useful supplement to this list.

Comparison of Preferences and Data Quality between Discrete Choice Experiments Conducted in Online and Face-to-Face Respondents

INTRODUCTION

Discrete choice experiments (DCE) are increasingly being conducted using online panels. However, the comparability of such DCE-based preferences to traditional modes of data collection (e.g., in-person) is not well established. In this study, supervised, face-to-face DCE was compared with its unsupervised, online facsimile on face validity, respondent behavior, and modeled preferences.

METHODS

Data from face-to-face and online EQ-5D-5L health state valuation studies were compared, in which each used the same experimental design and quota sampling procedure. Respondents completed 7 binary DCE tasks comparing 2 EQ-5D-5L health states presented side by side (health states A and B). Data face validity was assessed by comparing preference patterns as a function of the severity difference between 2 health states within a task. The prevalence of potentially suspicious choice patterns (i.e., all As, all Bs, and alternating As/Bs) was compared between studies. Preference data were modeled using multinomial logit regression and compared based on dimensional contribution to overall scale and importance ranking of dimension-levels.

RESULTS

One thousand five Online respondents and 1,099 face-to-face screened (F2FS) respondents were included in the main comparison of DCE tasks. Online respondents reported more problems on all EQ-5D dimensions except for Mobility. The face validity of the data was similar between comparators. Online respondents had a greater prevalence of potentially suspicious DCE choice patterns ([Online]: 5.3% [F2FS] 2.9%, P = 0.005). When modeled, the relative contribution of each EQ-5D dimension differed between modes of administration. Online respondents weighed Mobility more importantly and Anxiety/Depression less importantly.

DISCUSSION

Although assessments of face validity were similar between Online and F2FS, modeled preferences differed. Future analyses are needed to clarify whether differences are attributable to preference or data quality variation between modes of data collection.

Updating Korean Disability Weights for Causes of Disease: Adopting an Add-on Study Method

OBJECTIVES

Disability weights require regular updates, as they are influenced by both diseases and societal perceptions. Consequently, it is necessary to develop an up-to-date list of the causes of diseases and establish a survey panel for estimating disability weights. Accordingly, this study was conducted to calculate, assess, modify, and validate disability weights suitable for Korea, accounting for its cultural and social characteristics.

METHODS

The 380 causes of disease used in the survey were derived from the 2019 Global Burden of Disease Collaborative Network and from 2019 and 2020 Korean studies on disability weights for causes of disease. Disability weights were reanalyzed by integrating the findings of an earlier survey on disability weights in Korea with those of the additional survey conducted in this study. The responses were transformed into paired comparisons and analyzed using probit regression analysis. Coefficients for the causes of disease were converted into predicted probabilities, and disability weights in 2 models (model 1 and 2) were rescaled using a normal distribution and the natural logarithm, respectively.

RESULTS

The mean values for the 380 causes of disease in models 1 and 2 were 0.488 and 0.369, respectively. Both models exhibited the same order of disability weights. The disability weights for the 300 causes of disease present in both the current and 2019 studies demonstrated a Pearson correlation coefficient of 0.994 (p=0.001 for both models). This study presents a detailed add-on approach for calculating disability weights.

CONCLUSIONS

This method can be employed in other countries to obtain timely disability weight estimations.

Context matters for disability and priority setting for musculoskeletal diseases: revisiting the egalitarian approach to disability weights and disability-adjusted life-years

Health metrics have evolved with increasing sophistication. The disability-adjusted life-year (DALY) has emerged as a widely used metric. While DALYs vary between countries, the global disability weights (DWs) that are integral to the DALY ignore the potential impact of local factors on the burden of disease. Developmental dysplasia of the hip (DDH), a spectrum of hip pathologies, typically develops during early childhood and is a leading cause of early hip osteoarthritis. This paper explores the variability in the DW for DDH in relation to to local health environments using select health system indicators.The DW for DDH increases with decreasing income level of countries. The Human Development Index and the Gross Domestic Product per capita are both negatively correlated with (p<0.05) the DW for DDH per country. For the indicators surgical workforce, surgical procedures and hospital beds per 1000 population, there is a significant negative correlation in countries not meeting the minimum standard of that indicator (p<0.05), while for countries meeting that minimum standard, the correlation between DW for DDH and the respective indicator is not significantly different from zero.Consideration should be given to re-establishing the DWs for health entities in countries that do not meet the minimum standards of a functional health system. This would more accurately reflect the burden of disease from a functional perspective in LMICs, and perhaps allow for more informed priority setting within LMICs and for donors. The establishment of these DWs should not start from scratch; our data suggest that the variability in DWs due to context can most likely be modelled using health system and financial protection indicators already in use today.

A Comparison of Ordered Categorical versus Discrete Choices within a Stated Preference Survey of Whole-Blood Donors

HIGHLIGHTS

This article compares the relative preferences from stated preference (SP) questions requiring ordered categorical versus discrete choice responses. The approaches were contrasted for blood donation service characteristics that offer opportunities to donate blood.The estimates of relative preferences for alternative blood donation service characteristics were similar between the 2 forms of SP approach.This study illustrates how SP survey questions can be formulated to provide responses on an ordered categorical scale and to estimate marginal rates of substitution between different attributes, which can be compared with those derived from discrete choice experiment (DCE) choices.The article highlights the potential value of considering alternative choice framings rather than relying solely on DCEs.

Use of Stated Preference Methods in HIV Treatment and Prevention Research in the United States: A Systematic Review

Stated preference (SP) methods are increasingly being applied to HIV-related research and continuously provide researchers with health utility scores of select healthcare products or services that populations consider important. Following PRISMA guidelines, we sought to understand how SP methods have been applied in HIV-related research. We conducted a systematic review to identify studies meeting the following criteria: SP method is clearly stated, conducted in the United States, was published between 01/01/2012 and 02/12/2022, and included adults aged 18 and over. Study design and SP method application were also examined. We identified six SP methods (e.g., Conjoint Analysis, Discrete Choice Experiment) across 18 studies, which were categorized into one of two groups: HIV prevention and HIV treatment-care. Categories of attributes used in SP methods largely focused on: administration, physical/health effects, financial, location, access, and external influences. SP methods are innovative tools capable of informing researchers on what populations consider most beneficial when deciding on treatment, care, or prevention options for HIV.

Surgeon preference for treatment allocation in older people facing major gastrointestinal surgery: an application of the discrete choice experiment methodology

AIM

Variation in major gastrointestinal surgery rates in the older population suggests heterogeneity in surgical management. A higher prevalence of comorbidities, frailty and cognitive impairments in the older population may account for some variation. The aim of this study was to determine surgeon preference for major surgery versus conservative management in hypothetical patient scenarios based on key attributes.

METHOD

A survey was designed according to the discrete choice methodology guided by a separate qualitative study. Questions were designed to test for associations between key attributes (age, comorbidity, urgency of presentation, pathology, functional and cognitive status) and treatment preference for major gastrointestinal surgery versus conservative management. The survey consisting of 18 hypothetical scenarios was disseminated electronically to UK gastrointestinal surgeons. Binomial logistic regression was used to identify associations between the attributes and treatment preference.

RESULTS

In total, 103 responses were received after 256 visits to the questionnaire site (response rate 40.2%). Participants answered 1847 out of the 1854 scenarios (99.6%). There was a preference for major surgery in 1112/1847 (60.2%) of all scenarios. Severe comorbidities (OR 0.001, 95% CI 0.000-0.030; P = 0.000), severe cognitive impairment (OR 0.001, 95% CI 0.000-0.033; P = 0.000) and age 85 years and above (OR 0.028, 95% CI 0.005-0.168; P = 0.000) were all significant in the decision not to offer major gastrointestinal surgery.

CONCLUSION

This study has demonstrated variation in surgical treatment preference according to key attributes in hypothetical scenarios. The development of fitness-stratified guidelines may help to reduce variation in surgical practice in the older population.

Test-Retest Reliability of EQ-5D-Y-3L Best-Worst Scaling Choices of Adolescents and Adults

BACKGROUND

There is an increasing interest to obtain adolescents' own health state valuation preferences and to understand how these differ from adult preferences for the same health state. An important question in health state valuation is whether adolescents can report preferences reliably, yet research remains limited.

OBJECTIVE

This study aims to investigate the test-retest reliability of best-worst scaling (BWS) to elicit adolescent preferences compared with adults.

METHODS

Identical BWS tasks designed to value 3-level version of EQ-5D-Y health states were administered online in samples of 1000 adolescents (aged 11-17 years) and 1006 adults in Spain. The valuation survey was repeated approximately 3 days later. We calculated (1) simple percentage agreement and (2) kappa statistic as measures of test-retest reliability. We also compared BWS marginal frequencies and relative attribute importance between baseline and follow-up to explore similarities in the obtained preferences.

RESULTS

We found that both adolescents and adults were able to report their preferences with moderate reliability (kappa: 0.46 for adolescents, 0.46 for adults) for best choices and fair to moderate reliability (kappa: 0.39 for adolescents, 0.41 for adults) for worst choices. No notable difference was observed across years of child age. Higher consistency was observed for best choices than worst in some dimensions for both populations. No significant differences were found in the relative attribute importance between baseline and follow-up in both populations.

CONCLUSION

Our results suggest that BWS is a reliable elicitation technique to value 3-level version of EQ-5D-Y health states in both adolescents and adults.

Student COVID-19 vaccination preferences in China: A discrete choice experiment

Objective

This study uses a discrete choice experiment (DCE) questionnaire to investigate student vaccination preferences for both intrinsic and extrinsic attributes.

Methods

A two-part DCE questionnaire was distributed to 1,138 students through face-to-face interviews at vaccination centers in Qingdao, China. Conditional logit models were used to understand student preference trade-offs. Mixed logit models (MLM) and sub-group analysis were conducted to understanding student preference heterogeneity.

Results

We found that students preferred vaccines with fewer side effects (β = 0.845; 95% CI, 0.779-0.911), administered through third level health facilities (β = 0.170; 95% CI, 0.110-0.230), and had at least 1 year duration of protection (β = 0.396; 95% CI, 0.332-0.461. Higher perception of COVID-19 risks (β = 0.492; 95% CI, 0.432-0.552) increased the likelihood of student vaccination uptake. Surprisingly, vaccine effectiveness (60%) and percentages of acquaintances vaccinated (60%) reduced vaccination utility, which points to free-rider problems. In addition, we find that student study majors did not contribute to preference heterogeneity, and the main disparities in preferences were attributed to student risk tolerances.

Conclusion

Both intrinsic and extrinsic attributes were influential factors shaping student preferences for COVID-19 vaccines. Our results inform universities and local governments across China on targeting their vaccination programs.

Public Preferences and Willingness to Pay for a COVID-19 Vaccine in Iran: A Discrete Choice Experiment

BACKGROUND AND OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic is a major international threat and vaccination is the most robust strategy to terminate this crisis. It is helpful for policymakers to be aware of community preferences about vaccines. The present study aims to investigate the public's preferences and willingness to pay for the COVID-19 vaccine in Iran.

METHODS

This research is a cross-sectional study performed using a discrete choice experiment for a sample of the public population of several provinces of Iran in 2021. The samples were divided into two groups: one group expressed their preferences regarding the vaccine's attributes, and another group expressed their preferences regarding prioritizing individuals to get the vaccine. The discrete choice experiment design included five attributes including effectiveness, risk of severe complications, price, location of vaccine production, and duration of protection related to preferences for vaccine selection and six attributes including age, underlying diseases, employment in the healthcare sector, the rate of virus spread, the necessary job, and cost to the community related to preferences for prioritizing individuals to get the vaccine. A total of 715 individuals completed the questionnaire. The conditional logit regression model was used to analyze the discrete choice experiment data. Willingness to pay for each attribute was also calculated.

RESULTS

The willingness to pay for the COVID-19 vaccine with 90% (70%) efficacy, the risk of severe complications for 1 (5) person per one million people, imported (domestic) vaccine, and 24-month (12-month) duration of protection attributes was about US$71 (US$37). The preference for vaccination for respondents was enhanced by increasing the efficacy and the duration of vaccine protection and decreasing complications and costs. The likelihood of prioritizing individuals to get a vaccination was increased for a person with an underlying disease, employment in the healthcare sector, the necessary job for the community, the high potential for virus spread in the community, and the high cost of death to the community. The age variable was not statistically significant for prioritizing individuals to get the vaccine.

CONCLUSIONS

In the setting of the COVID-19 vaccination program, the public's preferences identified in this study should be considered. The obtained results provide useful information for policymakers to identify individual and social values for an appropriate vaccination strategy.

The critical role of mixed methods research in developing valid and reliable patient-reported outcome measures

Randomised controlled clinical trials provide the gold standard for evidence underpinning clinical guidelines and patient centred care. However, this is only true when they are robustly designed, conducted and reported and then only if they include outcomes that are important to patients and clinicians. Important outcomes include those that measure impact on patient experience, quality of life, overall well-being, and physical, social, cognitive and emotional functioning, all of which require patient reported outcome measures (PROMs). Patient centred care must be underpinned by objective evidence of the effect of interventions on outcomes that are important to patients. Evidence for patient reported outcomes must be supported by valid and reliable PROMs. Importantly the PROM must reflect patient experience of the impact of the intervention on the outcome and enable quantitative evaluation of that impact. The purpose of this paper is to highlight the critical role of mixed methods research in developing PROMs that are valid (measure what they purport to measure), acceptable to those reporting the outcome and able to reliably detect meaningful differences between individuals with different conditions or severity and with time. This can only be achieved through a structured mixed methods program combining qualitative and quantitative research techniques.

What do Iranian physicians value most when choosing a specialty? Evidence from a discrete choice experiment

BACKGROUND

Choosing a specialty by physicians is fundamentally linked to the performance of health systems and public health outcomes. Identifying the determinants of specialty selection is important to health policy for targeting resources and planning the development of services. This study examined preferences of Iranian physicians for medical specialty using a discrete choice experiment (DCE) method.

METHODS

In this study, the attributes of the DCE were determined using rigorous qualitative approach. Then we applied D-efficiency criteria to design the DCE and validated it at a pilot study. In the final survey, we recruited participants from six Iranian provinces and analyzed data using conditional logit model. We estimated willingness to pay (WTP) for non-monetary attributes.

RESULTS

The WTP analysis revealed that the most important non-monetary attributes in the selection of a specialty were job burnout, opportunity for procedural activities, and job prestige. The results imply that the attributes that were related to the quality of personal life was more important only for physicians who preferred to choose non-surgical specialties.

CONCLUSIONS

The findings demonstrate that traditional gender patterns of specialty selection are changing and quality of personal life characteristics might be the most important factor when developing policies to recruit physicians into non-surgical specialties.

One Fraction Size Does Not Fit All: Patient Preferences for Hypofractionated Radiation Therapy From a Discrete Choice Experiment

PURPOSE

Hypofractionated external beam radiation therapy (EBRT) is a standard of care option for localized prostate cancer. To inform clinical practice we quantified patients' preferences for convenience, efficacy, and toxicity risks, of conventional, moderate hypofractionation, and stereotactic radiation therapy regimens.

METHODS AND MATERIALS

We used a discrete choice experiment with a voluntary sample consisting of patients treated with EBRT for localized prostate cancer at our academic cancer center. In 2019, 58 participants, mean (SD) age of 72.9 (7.1) years, agreed to complete an in-person 1:1 discrete choice experiment. Each participant made 12 choices between 2 unique EBRT scenarios, each described by 5 attributes: (1) treatment time; (2) fiducial markers; and risk of (3) prostate specific antigen recurrence; (4) acute and (5) late GI or GU toxicity. Patient preferences were estimated using mixed multinomial logistic regression, and prespecified subgroups with conditional logistic regression.

RESULTS

All attributes were statistically significant, thus influenced participants' choices. Risks of prostate specific antigen recurrence (β = -2.581), late (β = -1.854), and acute (β = -1.005) toxicity were most important to participants (P < .001 for each), followed by EBRT length (β = -0.728; P = .017) and fiducial marker implantation (β = -0.563; P = .004). Older (β = -0.063; 95% confidence interval, -0.12, -0.01) and rural (β = -0.083; 95% CI -0.14, -0.02) participants significantly preferred shorter EBRT and were less willing-to-extend treatment to reduce toxicity risk.

CONCLUSIONS

Patients with prostate cancer place importance on EBRT attributes, and some are willing to trade-off increased risk of toxicity for improved convenience. Our findings promote shared clinical decision-making because patients are interested in learning about the trade-offs involved.

Conceptualising 'Benefits Beyond Health' in the Context of the Quality-Adjusted Life-Year: A Critical Interpretive Synthesis

There is growing interest in extending the evaluative space of the quality-adjusted life-year framework beyond health. Using a critical interpretive synthesis approach, the objective was to review peer-reviewed literature that has discussed non-health outcomes within the context of quality-adjusted life-years and synthesise information into a thematic framework. Papers were identified through searches conducted in Web of Science, using forward citation searching. A critical interpretive synthesis allows for the development of interpretations (synthetic constructs) that go beyond those offered in the original sources. The final output of a critical interpretive synthesis is the synthesising argument, which integrates evidence from across studies into a coherent thematic framework. A concept map was developed to show the relationships between different types of non-health benefits. The critical interpretive synthesis was based on 99 papers. The thematic framework was constructed around four themes: (1) benefits affecting well-being (subjective well-being, psychological well-being, capability and empowerment); (2) benefits derived from the process of healthcare delivery; (3) benefits beyond the recipient of care (spillover effects, externalities, option value and distributional benefits); and (4) benefits beyond the healthcare sector. There is a wealth of research concerning non-health benefits and the evaluative space of the quality-adjusted life-year. Further dialogue and debate are necessary to address conceptual and normative challenges, to explore the societal willingness to sacrifice health for benefits beyond health and to consider the equity implications of different courses of action.

A Comparison of Generic and Condition-Specific Preference-Based Measures Using Data From Nivolumab Trials: EQ-5D-3L, Mapping to the EQ-5D-5L, and European Organisation for Research and Treatment of Cancer Quality of Life Utility Measure-Core 10 Dimensions

OBJECTIVES

There is growing interest in condition-specific preference measures, including the European Organisation for Research and Treatment of Cancer Quality of Life Utility Measure-Core 10 Dimensions (QLU-C10D). This research assessed the implications of using utility indices on the basis of the EQ-5D-3L, a mapping of EQ-5D-3L to the EQ-5D-5L, and the QLU-C10D, and compared their psychometric properties.

METHODS

Data were taken from 8 phase 3 randomized controlled trials of nivolumab with or without ipilimumab for the treatment of solid tumors. Utilities for progression-related states were calculated using the UK and English value sets and incremental quality-adjusted life-years (QALYs) derived from established UK cost-effectiveness models. The psychometric properties of the utility indices were assessed using pooled trial data.

RESULTS

Compared with the EQ-5D-3L index, the mapped EQ-5D-5L index yielded an average of 6% more and the QLU-C10D index an average of 2% fewer incremental QALYs for nivolumab versus comparators. All indices could differentiate between groups defined by performance status, cancer stage, or self-reported health status at baseline and detect meaningful changes in performance status, tumor response, health status, and quality of life over approximately 12 weeks of treatment.

CONCLUSIONS

The lower QALY yield of the QLU-C10D was balanced by evidence of greater validity and responsiveness. Benefits gained from using the QLU-C10D may be apparent when treatments affect targeted symptoms and functional aspects, including sleep, bowel function, appetite, nausea, and fatigue. The observed differences in QALYs may not be sufficiently large to affect health technology assessment decisions.

Attributes Used for Cancer Screening Discrete Choice Experiments: A Systematic Review

BACKGROUND

Evidence from discrete choice experiments can be used to enrich understanding of preferences, inform the (re)design of screening programmes and/or improve communication within public campaigns about the benefits and harms of screening. However, reviews of screening discrete choice experiments highlight significant discrepancies between stated choices and real choices, particularly regarding willingness to undergo cancer screening. The identification and selection of attributes and associated levels is a fundamental component of designing a discrete choice experiment. Misspecification or misinterpretation of attributes may lead to non-compensatory behaviours, attribute non-attendance and responses that lack external validity.

OBJECTIVES

We aimed to synthesise evidence on attribute development, alongside an in-depth review of included attributes and methodological challenges, to provide a resource for researchers undertaking future studies in cancer screening.

METHODS

A systematic review was conducted to identify discrete choice experiments estimating preferences towards cancer screening, dated between 1990 and December 2020. Data were synthesised narratively. In-depth analysis of attributes led to classification into four categories: test specific, service delivery, outcomes and monetary. Attribute significance and relative importance were also analysed. The International Society for Pharmacoeconomics and Outcomes Research conjoint analysis checklist was used to assess the quality of reporting.

RESULTS

Forty-nine studies were included at full text. They covered a range of cancer sites: over half (26/49) examined colorectal screening. Most studies elicited general public preferences (34/49). In total, 280 attributes were included, 90% (252/280) of which were significant. Overall, test sensitivity and mortality reduction were most frequently found to be the most important to respondents.

CONCLUSIONS

Improvements in reporting the identification, selection and construction of attributes used within cancer screening discrete choice experiments are needed. This review also highlights the importance of considering the complexity of choice tasks when considering risk information or compound attributes. Patient and public involvement and stakeholder engagement are recommended to optimise understanding of unavoidably complex choice tasks throughout the design process. To ensure quality and maximise comparability across studies, further research is needed to develop a risk-of-bias measure for discrete choice experiments.

Clarifying Values: An Updated and Expanded Systematic Review and Meta-Analysis

Background

Patient decision aids should help people make evidence-informed decisions aligned with their values. There is limited guidance about how to achieve such alignment.

Purpose

To describe the range of values clarification methods available to patient decision aid developers, synthesize evidence regarding their relative merits, and foster collection of evidence by offering researchers a proposed set of outcomes to report when evaluating the effects of values clarification methods.

Data Sources

MEDLINE, EMBASE, PubMed, Web of Science, the Cochrane Library, and CINAHL.

Study Selection

We included articles that described randomized trials of 1 or more explicit values clarification methods. From 30,648 records screened, we identified 33 articles describing trials of 43 values clarification methods.

Data Extraction

Two independent reviewers extracted details about each values clarification method and its evaluation.

Data Synthesis

Compared to control conditions or to implicit values clarification methods, explicit values clarification methods decreased the frequency of values-incongruent choices (risk difference, –0.04; 95% confidence interval [CI], –0.06 to –0.02; P < 0.001) and decisional conflict (standardized mean difference, –0.20; 95% CI, –0.29 to –0.11; P < 0.001). Multicriteria decision analysis led to more values-congruent decisions than other values clarification methods (χ² = 9.25, P = 0.01). There were no differences between different values clarification methods regarding decisional conflict (χ² = 6.08, P = 0.05).

Limitations

Some meta-analyses had high heterogeneity. We grouped values clarification methods into broad categories.

Conclusions

Current evidence suggests patient decision aids should include an explicit values clarification method. Developers may wish to specifically consider multicriteria decision analysis. Future evaluations of values clarification methods should report their effects on decisional conflict, decisions made, values congruence, and decisional regret.

Application of Discrete Choice Experiment in Health Care: A Bibliometric Analysis

Background: Discrete choice experiment (DCE) as a tool that can measure medical stakeholders' preferences especially patients recently has been increasingly applied in health care.

Objective: The aim of this study was to examine the hotspots and trends of the application of DCE in health care and to provide reference and direction for further development of DCE in the future.

Method: A bibliometric method was implemented using the Web of Science (WoS) Core Collection for the period from the database established to December 8, 2020. The data files are imported into CiteSpace and Excel to analyze and visualize the annual volume of productive, authors, countries, cited journals, cited articles, and keywords.

Results: A total of 1,811 articles were retrieved, then we read the abstract of each paper one by one, and 1,562 articles were included after screening, with an exponential increase in publication volume. John F. P. Bridges contributed to 40 publications and ranked first, followed by F. Reed Johnson (n = 37), Julie Ratcliffe (n = 36). The majority of the papers were conducted in the United States (n = 513) and the United Kingdom (n = 433). The top three cited journals were “Health Economics” (n = 981), “Value in Health” (n = 893), and “Pharmaceutical Economics” (n = 774), and the top three articles were “Constructing experimental designs for discrete-choice experiments: report of the ISPOR Conjoint Analysis Experimental Design Good Research Practices Task Force,” “Conjoint analysis applications in health-a checklist: a report of the ISPOR Good Research Practices for Conjoint Analysis Task Force,” and “Discrete choice experiments in health economics: a review of the literature.” The research hotspots and trends included “health technology assessment,” “survival,” “preference based measure,” and “health state valuation.”

Conclusion: The size of the literature about DCE studies in health care showed a noticeable increase in the past decade. The application of DCE in health care remains in an early growth phase, and “health technology assessment,” “survival,” “preference based measure,” and “health state valuation” reflected the latest research hotpots and future trends.

A Protocol for Developing a Discrete Choice Experiment to Elicit Preferences of General Practitioners for the Choice of Specialty

OBJECTIVES

Discrete choice experiment (DCE) has been increasingly used in studies investigating preferences of the health workforce. This pilot study aimed to provide a comprehensive protocol for design and quality assessment of a DCE to elicit preferences of general practitioners for the choice of specialty.

METHODS

We conducted 3 rigorous qualitative studies, including a review of literature, qualitative interviews, and focus group discussion to develop attributes and levels of the DCE. Then a D-efficient fractional factorial design was applied to generate choice tasks and to block them into 4 equal versions using SAS software. Two hundred and forty general practitioners participated in a pilot study conducted to evaluate the quality of the instrument using 7 tests.

RESULTS

The qualitative studies resulted in the development of 8 attributes and 24 levels. Experimental design led to the generation of 36 choice tasks divided into 4 blocks. The pilot study revealed that the instrument has validity and reliability and also indicated that the design is comprehensible and feasible.

CONCLUSIONS

This study provided an integrated, comprehensive framework for development and quality assessment of a DCE that could be used in other studies. The pilot study indicated that the instrument is of sufficient quality because it was developed using rigorous qualitative studies and accurate experimental design method.

Perspectives of rehabilitation professionals on assistive technology provision to young children in South Africa: a national survey

PURPOSE

Various factors influence the selection of assistive technology for young children within a context with limited resources, such as South Africa. Rehabilitation professionals are required to weigh up different factors as part of their professional reasoning process when making assistive technology (AT) selections. Insight into the perceived influence of different factors may assist in understanding how professionals make decisions about AT in this context.

MATERIALS AND METHODS

An online survey with questions designed using best-worst scaling was distributed to rehabilitation professionals throughout South Africa. Factors influencing assistive technology selection included in the best-worst survey were identified in previous phases of a larger project. A total of n = 451 rehabilitation professionals completed the survey by selecting the factors that were most and least influential on their assistive technology provision.

RESULTS

Results of the survey were obtained by calculating the number of times each factor was selected as most influential across the entire sample, and across all questions, enabling the researchers to sort the items in terms of the frequency of selection.

CONCLUSIONS

Even though the rehabilitation professionals that participated in the study provide services in a context with limited resources, assessment and factors pertaining to the assistive technology itself were generally perceived to be of greater influence than environmental factors. It is recommended that these factors be reflected in frameworks and models of AT selection.IMPLICATIONS FOR REHABILITATIONThe family's ability to support the implementation of AT is an important resource that is perceived to influence the selection of AT by an RP.Insight into the mind-set of professionals that are used to selecting AT within settings with limited resources may provide RPs in well-resourced contexts with guidance on how to do more, with less.RPs should aim to determine child preference and attitude towards AT during the AT selection process.RPs should be aware of their own influence on AT selection. Existing AT Selection models should be adapted to clearly reflect the influence of the recommending professional.

Detecting Heterogeneity of Intervention Effects in Comparative Judgments

Comparative measures such as paired comparisons and rankings are frequently used to evaluate health states and quality of life. The present article introduces log-linear Bradley-Terry (LLBT) models to evaluate intervention effectiveness when outcomes are measured as paired comparisons or rankings and presents a combination of the LLBT model and model-based recursive partitioning (MOB) to detect treatment effect heterogeneity. The MOB LLBT approach enables researchers to identify subgroups that differ in the preference order and in the effect an intervention has on choice behavior. Applicability of MOB LLBT models is demonstrated using an artificial data example with known data-generating mechanism and a real-world data example focusing on drug-harm perception among music festival visitors. In the artificial data example, the MOB LLBT model is able to adequately recover the "true" (population) model. In the real-world data example, the standard LLBT model confirms the existence of a situational willingness among festival visitors to trivialize drug harm when peer consumption behavior is made cognitively accessible. In addition, MOB LLBT results suggest that this trivialization effect is highly context-dependent and most pronounced for participants with low-to-moderate alcohol intoxication who also proactively contacted a substance counselor at the festival venue. Both data examples suggest that MOB LLBT models allow for more nuanced statements about the effectiveness of interventions. We provide R code examples to implement MOB LLBT models for paired comparisons, rankings, and rating (Likert-type) data.

Application of discrete choice experiments to estimate value of life: a national study protocol in Iran

Background

Global concerns regarding the significant burden of non-communicable diseases and injuries (NCDIs) exist from both public health and economic perspectives. Our research focuses on the reduction of fatal risks due to NCDIs and the citizens’ preferences about health programs and intervention to reduce premature death due to NCDIs. Governments and health authorities need reliable evidence and information to prioritize the interests of their citizens. One crucial piece of evidence to justify the resources spent on NCDIs is the value derived from the interventions on prevention and NCDIs control. This concept is usually called “Value of Statistical Life” (VSL), meaning the monetary value that individuals place on changes in the risk levels of life- threatening events. To the best of our knowledge, for the first time, our study will estimate the statistical value of life for selected interventions for the prevention and control of NCDIs at both national and sub-national levels in the context of Iran. This paper reports the development of a national protocol through Discrete Choice Experiments (DCEs) method.

Methods and designs

Our study comprises several stages: (a) a literature review to identify the attributes and levels of the prevention programs and Willingness to Pay (WTP) for reducing the NCDI’s fatal risks; (b) experimental design to assessing, prioritizing, and finalizing the identified attributes and levels; (c) instrumental design to conduct face-to-face structured survey interviews of 3180 respondents aged 18–69 across the entire country; (d) statistical analysis to estimate the results through the Mixed Multinomial logit (MMNL) model.

Discussion

We anticipate that our findings will help build a stronger empirical basis for monetizing the value of small changes in selected fatality risks. It paves the way for other national or vast VSL estimates for NCDIs, as well as other major causes of morbidity and mortality in the context of Iran, and perhaps other low and middle-income countries (LMICs).

Iranian general populations' and health care providers' preferences for benefits and harms of statin therapy for primary prevention of cardiovascular disease

BACKGROUND

The use of statins for primary prevention of cardiovascular diseases is associated with different benefit and harm outcomes. The aime of this study is how important these outcomes are for people and what people's preferences are.

METHODS

We conducted a preference-eliciting survey incorporating a best-worst scaling (BWS) instrument in Iran from June to November 2019. The relative importance of 13 statins-related outcomes was assessed on a sample of 1085 participants, including 913 general population (486 women) and 172 healthcare providers from the population covered by urban and rural primary health care centers. The participants made trade-off decisions and selected the most and least worrisome outcomes concurrently from 13 choice sets; each contains four outcomes generated using the balanced incomplete block design.

RESULTS

According to the mean (SD) BWS scores, which can be (+ 4) in maximum and (- 4) in minimum, in the general population, the most worrisome outcomes were severe stroke (3.37 (0.8)), severe myocardial infarction (2.71(0.7)), and cancer (2.69 (1.33)). While myopathy (- 3. 03 (1.03)), nausea/headache (- 2.69 (0.94)), and treatment discontinuation due to side effects (- 2.24 (1.14)) were the least worrisome outcomes. Preferences were similar between rural and urban areas and among health care providers and the general population with overlapping uncertainty intervals.

CONCLUSION

The rank of health outcomes may be similar in various socio-cultural contexts. The preferences for benefits and harms of statin therapy are essential to assess benefit-harm balance when recommending statins for primary prevention of cardiovascular diseases.

Valuation study for a preference-based quality of life measure for dental caries (Dental Caries Utility Index - DCUI) among Australian adolescents - study protocol

INTRODUCTION

A new health state classification system has been developed for dental caries - Dental Caries Utility Index (DCUI) to facilitate the assessment of oral health interventions in the cost-utility analysis (CUA). This paper reports the protocol for a valuation study, which aims to generate a preference-based algorithm for the classification system for the DCUI.

METHODS AND ANALYSIS

Discrete choice experiments (DCEs) will be conducted to value health states generated by the DCUI classification system and preferences for these health states will be modelled to develop a utility algorithm. DCEs produce utility values on a latent scale and these values will be anchored into the full health-dead scale to calculate the quality-adjusted life years in CUA. There is no previous evidence for the most suitable anchoring method for dental caries health state valuation. Hence, we will first conduct pilot studies with two anchoring approaches; DCE including duration attribute and DCE anchoring to worst heath state in Visual Analogue Scale. Based on the pilot studies, the most suitable anchoring method among two approaches will be used in the main valuation survey, which will be conducted as an online survey among a representative sample of 2000 adults from the Australian general population. Participants will be asked to complete a set of DCE choice tasks along with anchoring tasks, basic social-demographic questions, DCUI, a generic preference-based measure and oral health quality of life instrument.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the Human Research Ethics Committee, Griffith University (reference number HREC/2019/550). The generated algorithm will facilitate the use of the new dental caries preference-based measure in economic evaluations of oral health interventions. The results will be disseminated through journal articles and professional conferences.

Standard Gamble to Derive Utility Health States for Limbal Stem Cell Deficiency

Purpose

To generate UK health-related quality-of-life (HRQoL) data for adult patients with moderate-to-severe limbal stem cell deficiency (LSCD), unilateral or bilateral, due to physical or chemical ocular burns to help inform economic evaluations of treatments.

Patients and Methods

EQ-5D-3L with vision bolt-on scores was prospectively measured for one of five clinical scenarios of LSCD described in vignettes in a demographically representative population of 520 UK adults. These were converted to health state utilities using three different UK value sets. A standard gamble (SG) was then undertaken using 12 SG scenarios to examine the component drivers of health utility for the treatment of LSCD.

Results

For the EQ-5D-3L scenarios, the mean disutility for LSCD with poor visual acuity, pain and disfigurement in both eyes compared to one eye was −0.084 (range=−0.156 to −0.045 across the value sets). The mean disutility of bilateral LSCD with pain, disfigurement, and poor visual acuity compared to unilateral LSCD with only poor visual acuity in one eye was −0.104 (range=−0.151 to −0.078). Similarly, where one eye was affected, pain and disfigurement in combination were associated with a greater mean disutility than improvements in visual acuity alone: −0.011 (range=−0.04 to 0.005). Mean SG utilities were within a narrow range (0.682–0.765). Where one eye was affected, the main driver was disfigurement: mean utility was 0.731 (0.709–0.753) compared to 0.682 (0.659–0.704) when disfigurement was removed compared to vision restored to normal. For bilateral LSCD, mean utilities were 0.693 (0.672–0.715) for normal vision and 0.75 (0.73–0.771) when disfigurement and pain were removed.

Conclusion

Improvements in pain and disfigurement appeared to be the main factors driving differences in health utilities associated with symptom profiles in LSCD, with improvements in visual acuity having lesser impact.

Discrete choice experiments to generate utility values for multi-attribute utility instruments: a systematic review of methods

OBJECTIVES

In recent years, discrete choice experiments (DCEs) have become frequently used to generate utility values, but there are a diverse range of approaches to do this. The primary focus of this systematic review is to summarise the methods used for the design and analysis of DCEs when estimating utility values in both generic and condition-specific preference-based measures.

METHODS

Published literature using DCEs to estimate utility values from preference-based instruments were identified from MEDLINE, Embase, Cochrane Library and CINAHL using PRISMA guidelines. To assess the different DCE methods, standardised information was extracted from the articles including the DCE design method, the number of choice sets, the number of DCE pairs per person, randomisation of questions, analysis method, logical consistency tests and techniques for anchoring utilities. The CREATE checklist was used to assess the quality of the studies.

RESULTS

A total of 38 studies with samples from the general population, students and patients were included. Values for health states described using generic multi attribute instruments (MAUIs) (especially the EQ-5D) were the most commonly explored using DCEs. The studies showed considerable methodology and design diversity (number of alternatives, attributes, sample size, choice task presentation and analysis). Despite these differences, the quality of articles reporting the methods used for the DCE was generally high.

CONCLUSION

DCEs are an important approach to measure utility values for both generic and condition-specific instruments. However, a gold standard method cannot yet be recommended.

Preferences of Medical Sciences Students for Work Contracts in Deprived Areas of Iran: A Discrete Choice Experiment Analysis

Background

An unequal distribution of human resources affects access to health-care services. This study aimed to elicit the preferences of medical, dentistry, and pharmacy students about attributes of work contracts in deprived areas of Iran; this is a primary important step to decrease inequity.

Methods

Two-hundred and one students were entered into the study through proportional sample size estimation from Kermanshah University of Medical Sciences in the west of Iran in 2018. The attributes of work contracts were determined using the discrete choice experiment (DCE) method, then possible dual scenarios of work contracts were designed through the D-efficiency method of SAS software and the data were collected using a questionnaire designed by the researchers. The conditional logistic model was used to analyze the data.

Results

Salary, workplace, side facilities, scholarship, and workload were considered as important factors for working in the deprived areas (p<0.001). There were differences between the students’ preferences regarding their residential areas, majors, and state or tuition-paying education (p<0.001). Higher payments, side facilities, and availability of quota after working in the deprived areas were considered as creators of higher utility, and working in deprived areas and high workload were considered as creators of lower utility (p<0.001).

Conclusion

This study provides new evidence about the preferences of medical sciences students for work contracts in deprived areas of Iran. According to the findings, money is not the only factor that affects the decisions of medical sciences students related to working contracts in deprived areas of Iran. Designing work contracts that are matched with preferences of the workforce can lead to an improvement in equity, access, and utilization of health-care services.

Health Preference Research in Europe: A Review of Its Use in Marketing Authorization, Reimbursement, and Pricing Decisions-Report of the ISPOR Stated Preference Research Special Interest Group

OBJECTIVE

This study examines European decision makers' consideration and use of quantitative preference data.

METHODS

The study reviewed quantitative preference data usage in 31 European countries to support marketing authorization, reimbursement, or pricing decisions. Use was defined as: agency guidance on preference data use, sponsor submission of preference data, or decision-maker collection of preference data. The data could be collected from any stakeholder using any method that generated quantitative estimates of preferences. Data were collected through: (1) documentary evidence identified through a literature and regulatory websites review, and via key opinion leader outreach; and (2) a survey of staff working for agencies that support or make healthcare technology decisions.

RESULTS

Preference data utilization was identified in 22 countries and at a European level. The most prevalent use (19 countries) was citizen preferences, collected using time-trade off or standard gamble methods to inform health state utility estimation. Preference data was also used to: (1) value other impact on patients, (2) incorporate non-health factors into reimbursement decisions, and (3) estimate opportunity cost. Pilot projects were identified (6 countries and at a European level), with a focus on multi-criteria decision analysis methods and choice-based methods to elicit patient preferences.

CONCLUSION

While quantitative preference data support reimbursement and pricing decisions in most European countries, there was no utilization evidence in European-level marketing authorization decisions. While there are commonalities, a diversity of usage was identified between jurisdictions. Pilots suggest the potential for greater use of preference data, and for alignment between decision makers.

Improving Patient Preference Elicitation by Applying Concepts From the Consumer Research Field: Narrative Literature Review

BACKGROUND

Although preference research finds its origins in consumer research, preference elicitation methods have increasingly attracted attention in different decision-making contexts in health care. Simulating real-life decision making is believed to be important during consumer preference elicitation.

OBJECTIVE

The aims of this study were to compare the process of decision making between patients and consumers and to identify methods from the consumer research field that could be applied in patient preference elicitation.

METHODS

A narrative literature review was performed to identify preference elicitation concepts from a consumer context that could offer improvements in health care.

RESULTS

The process of decision making between patients and consumers was highly comparable. The following five concepts from the consumer research field that could effectively simulate a real-life decision-making process for applications in health care were identified: simulating alternatives, self-reflection, feedback-driven exploration, separated (adaptive) dual response, and arranging profiles in blocks.

CONCLUSIONS

Owing to similarities in the decision-making process, patients could be considered as a subgroup of consumers, suggesting that preference elicitation concepts from the consumer field may be relevant in health care. Five concepts that help to simulate real-life decision making have the potential to improve patient preference elicitation. However, the extent to which real decision-making contexts can be mimicked in health care remains unknown.

Eliciting Life Priorities of Older Adults Living in Permanent Supportive Housing

BACKGROUND AND OBJECTIVES

Adults who have experienced chronic homelessness are considered to be "old" by age 50 due to accelerated aging. While permanent supportive housing (PSH) has been found effective for these individuals, there is limited focus on the needs of adults "aging in place" in PSH. This study examined (1) how older adults in PSH identify and rank their life priorities, (2) how they describe these priorities in their own words, and (3) how life course adversity deepens an understanding of these priorities.

RESEARCH DESIGN AND METHODS

A convergent parallel mixed methods design was used in which qualitative case study analyses informed by a life course perspective provided a deeper understanding of how 14 older residents of PSH viewed their life priorities using quantitative card-sort rankings of 12 life domains.

RESULTS

Housing, family, mental health, physical health, and partner were the most frequently endorsed life priorities. Four themes emerged from the cross-case analyses: "aging in, aging out," "carefully restoring relationships," "life goes on," and "housing is fundamental." Convergent findings indicated that life adversity-social losses and interrupted lives-influenced both the high- and low-ranked card-sort priorities.

DISCUSSION AND IMPLICATIONS

This study demonstrated that participants were aware of their advancing years yet they sought to overcome adversity and losses through maintaining mental health and sobriety, improving physical health, and cautiously rebuilding relationships. As the numbers of older homeless rise, the inclusion of age-related services will be an important component of PSH services for residents as they age.

Preferences of Iranian average risk population for colorectal cancer screening tests

PURPOSE

The purpose of this paper is to explore the preferences of the average risk Iranian population for colorectal cancer (CRC) screening tests.

DESIGN/METHODOLOGY/APPROACH

A standard stated-preferences method with discrete choice models was used to identify the preferences. Data about socio-demographic status, health status and preferences for CRC screening tests were collected by a structured questionnaire that was completed by 500 people aged 50-75 years. Mixed logit model was used to analyze the preferences.

FINDINGS

The regression model showed that the test process, pain, place, frequency, preparation, sensitivity, complication risk, mortality rate and cost were the final attributes; that had a statistically significant correlation with the preferences of the people in choosing CRC screening tests. The socio-demographic and health status of participants had no significant correlation with the individuals' preferences.

PRACTICAL IMPLICATIONS

This study provides insight into how different characteristics of a CRC screening test might influence the preferences of individuals about that test.

ORIGINALITY/VALUE

This was the first study of this type in Iran to elicit the preferences of the average risk population for CRC screening tests using a discrete choice model.

Preferences for centralised emergency medical services: discrete choice experiment

OBJECTIVES

It is desirable that public preferences are established and incorporated in emergency healthcare reforms. The aim of this study was to investigate preferences for local versus centralised provision of all emergency medical services (EMS) and explore what individuals think are important considerations for EMS delivery.

DESIGN

A discrete choice experiment was conducted. The attributes used in the choice scenarios were: travel time to the hospital, waiting time to be seen, length of stay in the hospital, risks of dying, readmission and opportunity for outpatient care after emergency treatment at a local hospital.

SETTING

North East England.

PARTICIPANTS

Participants were a randomly sampled general population, aged 16 years or above recruited from Healthwatch Northumberland network database of lay members and from clinical contact with Northumbria Healthcare National Health Service Foundation Trust via Patient Experience Team.

PRIMARY AND SECONDARY OUTCOME MEASURES

Analysis used logistic regression modelling techniques to determine the preference of each attribute. Marginal rates of substitution between attributes were estimated to understand the trade-offs individuals were willing to make.

RESULTS

Responses were obtained from 148 people (62 completed a web and 86 a postal version). Respondents preferred shorter travel time to hospital, shorter waiting time, fewer number of days in hospital, low risk of death, low risk of readmission and outpatient follow-up care in their local hospital. However, individuals were willing to trade off increased travel time and waiting time for high-quality centralised care. Individuals were willing to travel 9 min more for a 1-day reduction in length of stay in the hospital, 38 min for a 1% reduction in risk of death and 112 min for having outpatient follow-up care at their local hospital.

CONCLUSIONS

People value centralised EMS if it provides higher quality care and are willing to travel further and wait longer.

Attribute development and level selection for a discrete choice experiment to elicit the preferences of health care providers for capitation payment mechanism in Kenya

BACKGROUND

Stated preference elicitation methods such as discrete choice experiments (DCEs) are now widely used in the health domain. However, the "quality" of health-related DCEs has come under criticism due to the lack of rigour in conducting and reporting some aspects of the design process such as attribute and level development. Superficially selecting attributes and levels and vaguely reporting the process might result in misspecification of attributes which may, in turn, bias the study and misinform policy. To address these concerns, we meticulously conducted and report our systematic attribute development and level selection process for a DCE to elicit the preferences of health care providers for the attributes of a capitation payment mechanism in Kenya.

METHODOLOGY

We used a four-stage process proposed by Helter and Boehler to conduct and report the attribute development and level selection process. The process entailed raw data collection, data reduction, removing inappropriate attributes, and wording of attributes. Raw data was collected through a literature review and a qualitative study. Data was reduced to a long list of attributes which were then screened for appropriateness by a panel of experts. The resulting attributes and levels were worded and pretested in a pilot study. Revisions were made and a final list of attributes and levels decided.

RESULTS

The literature review unearthed seven attributes of provider payment mechanisms while the qualitative study uncovered 10 capitation attributes. Then, inappropriate attributes were removed using criteria such as salience, correlation, plausibility, and capability of being traded. The resulting five attributes were worded appropriately and pretested in a pilot study with 31 respondents. The pilot study results were used to make revisions. Finally, four attributes were established for the DCE, namely, payment schedule, timeliness of payments, capitation rate per individual per year, and services to be paid by the capitation rate.

CONCLUSION

By rigorously conducting and reporting the process of attribute development and level selection of our DCE,we improved transparency and helped researchers judge the quality.

Developing a cerebral palsy-specific preference-based measure for a six-dimensional classification system (CP-6D): protocol for a valuation study

INTRODUCTION

Cerebral palsy (CP) is a lifelong condition. The CP quality of life (CPQOL) instrument is a frequently used disease-specific instrument to assess health-related quality of life (HRQoL) in people with CP, but it cannot be used to generate quality-adjusted life years (QALY) which are the basis of cost utility analysis (CUA). Generic utility instruments (such as the EQ-5D or SF-6D) that are used to value HRQOL may be insensitive to small but important health changes in children with CP. This study aims to generate a preference-based scoring algorithm for the CP six dimensions (CP-6D), a classification system developed from the CPQOL.

METHODS AND ANALYSIS

A discrete choice experiment with duration (DCEtto) will be administrated to value health states described by the CP-6D classification system. These health states will be presented to members of Australian general population and parents of children with CP via an online survey. Conditional logit regression will be used to produce the utility algorithm for CP-6D.

ETHICS AND DISSEMINATION

The Griffith University Human Research Ethics Committee approved for the study (reference HREC/number 2018/913). The developed algorithm can be applied to previous and future economic evaluation of interventions and treatments targeting people with CP which have used either the CPQOL or CP-6D.

Discrete choice experiment to evaluate preferences of patients with cystic fibrosis among alternative treatment-related health outcomes: a protocol

INTRODUCTION

Clinical decision-making is a complex process. Patient preference information regarding desirable health states should inform treatment and is critical to agreeing on goals of therapy. Cystic fibrosis (CF) is a common, inheritable multisystem disorder for which the major manifestation is progressive, chronic lung disease. Intermittent pulmonary exacerbations are a hallmark of disease and these drive lung damage that results in premature death. We suspect that clinicians make assumptions, most likely implicit assumptions, about outcomes that are desired by patients who are treated for pulmonary exacerbations. The aim of this study is to identify and quantify the preferences of patients with cystic fibrosis regarding treatment outcomes.

METHODS AND ANALYSIS

We will develop a discrete choice experiment (DCE) in collaboration with people with CF and their carers, and evaluate how patients make trade-offs between different aspects of health-related status when considering treatment options.

ETHICS AND DISSEMINATION

Ethics approval for all aspects of this study was granted by the Western Australia Child and Adolescent Health Service Human Research Ethics Committee [RGS903]. Weighted preference information from the DCE will be used to develop a multiattribute utility instrument as a measure of treatment success in the upcoming Bayesian Evidence-Adaptive Trial to optimise management of CF. Dissemination of results will also occur through peer-reviewed publications and presentations to relevant stakeholders and research networks.

Disutility associated with cancer screening programs: A systematic review

Objectives

Disutility allows to identify how much population values intervention-related harms contributing to knowledge on the benefits/harms ratio of cancer screening programs. This systematic review evaluates disutility related to cancer screening applying a utility theory framework.

Methods

Using a predefined protocol, Embase, Medline Ovid, Web of Science, Cochrane, Google scholar and supplementary sources were systematically searched. The framework grouped disutilities associated with breast, cervical, lung, colorectal, and prostate cancer screening programs into the screening, diagnostic work up, and treatment phases. We assessed the quality of included studies according to the relevance to target population, risk of bias, appropriateness of measure and the time frame.

Results

Out of 2840 hits, we included 38 studies, of which 27 measured (and others estimated) disutilities. Around 70% of studies had medium to high-level quality. Measured disutilities and Quality Adjusted Life Years loss were 0–0.03 and 0–0.0013 respectively in screening phases. Both disutilities and Quality Adjusted Life Years loss had similar ranges in diagnostic work up (0–0.26), and treatment (0.09–0.27) phases. We found no measured disutilities available for lung cancer screening and—little evidence for disutilities in treatment phase. Almost 40% of the estimated disutility values were above the range of measured ones.

Conclusions

Cancer screening programs led to low disutities related to screening phase, and low to moderate disutilities related to diagnostic work up and treatment phases. These disutility values varied by the measurement instrument applied, and were higher in studies with lower quality. The estimated disutility values comparing to the measured ones tended to overestimate the harms.

Valuing health states: is the MACBETH approach useful for valuing EQ-5D-3L health states?

BACKGROUND

Quality Adjusted Life Years (QALYs) are a key outcome measure widely used within health technology assessment and health service research studies. QALYs combine quantity and quality of life, with quality of life calculations relying on the value of distinct health states. Such health states' values capture the preferences of a population and have been typically built through numerical elicitation methods. Evidence points to these value scores being influenced by methods in use and individuals reporting cognitive difficulties in eliciting their preferences. Evidence from other areas has further suggested that individuals may prefer using distinct elicitation techniques and that this preference can be influenced by their numeracy. In this study we explore the use of the MACBETH (Measuring Attractiveness by a Categorical Based Evaluation Technique) non-numerical preference elicitation approach for health states' evaluation.

METHODS

A new protocol for preference elicitation based on MACBETH (only requiring qualitative judgments) was developed and tested within a web survey format. A sample of the Portuguese general population (n=243) valued 25 EQ-5D-3L health states with the MACBETH protocol and with a variant of the time trade-off (TTO) protocol, for comparison purposes and for understanding respondents' preference for distinct protocols and differences in inconsistent evaluations. Respondents answered to a short numeracy test, and basic socio-economic information collected.

RESULTS

Results show that the mean values derived from MACBETH and the TTO variant are strongly correlated; however, there are substantial differences for several health states' values. Large and similar numbers of logical inconsistencies were found in respondents' answers with both methods. Participants with higher levels of numeracy according to the test preferred expressing value judgments with MACBETH, while participants with lower levels were mostly indifferent to both methods. Higher correlations between MACBETH and TTO variant evaluations were observed for individuals with higher numeracy.

CONCLUSION

Results suggest that it is worth researching the use of non-numerical preference elicitation methods. Numeracy tests more appropriate for preference elicitation when no explicit considerations of uncertainty are made need to be explored and used. Further behavioural research is needed to fully understand the potential for using these methods in distinct settings (e.g. in different evaluation contexts and in face-to-face and non-face-to-face environments), as well as to explore the effect of literacy on assessments and on respondents' preferences.

Symptoms and feelings valued by patients after a percutaneous coronary intervention: a discrete-choice experiment to inform development of a new patient-reported outcome

OBJECTIVE

To inform the development of a patient-reported outcome measure, the aim of this study was to identify which symptoms and feelings following percutaneous coronary intervention (PCI) are most important to patients.

DESIGN

Discrete-choice experiment consisting of two hypothetical scenarios of 10 symptoms and feelings (pain or discomfort; shortness of breath; concern/worry about heart problems; tiredness; confidence to do usual activities; ability to do usual activities; happiness; sleep disturbance; dizziness or light-headedness and bruising) experienced after PCI, described by three levels (never, some of the time, most of the time). Preference weights were estimated using a conditional logit model.

SETTING

Four Australian public hospitals that contribute to the Victorian Cardiac Outcomes Registry (VCOR) and a private insurer's claim database.

PARTICIPANTS

138 people aged >18 years who had undergone a PCI in the previous 6 months.

MAIN OUTCOME MEASURES

Patient preferences via trade-offs between 10 feelings and symptoms.

RESULTS

Of the 138 individuals recruited, 129 (93%) completed all 16 choice sets. Conditional logit parameter estimates were mostly monotonic (eg, moving to worse levels for each individual symptom and feeling made the option less attractive). When comparing the magnitude of the coefficients (based on the coefficient of the worst level relative to best level in each item), feeling unhappy was the symptom or feeling that most influenced perception of a least-preferred PCI outcome (OR 0.42, 95% CI 0.34 to 0.51, p<0.0001) and the least influential was bruising (OR 0.81, 95% CI 0.67 to 0.99, p=0.04).

CONCLUSION

This study provides new insights into how patients value symptoms and feelings they experience following a PCI.

Stated preferences for long-term care: a literature review

Person-centred provision of long-term care (LTC) requires information on how individuals value respective LTC services. The literature on LTC preferences has not been comprehensively reviewed, existing summaries are contradictory. An explorative, scoping review was conducted to provide a thorough methodological description and results synthesis of studies that empirically investigated LTC preference outcomes based on respondents’ statements. A wide search strategy, with 18 key terms relating to ‘LTC’ and 31 to ‘preferences’, was developed. Database searches in PubMed, Ovid and ScienceDirect were conducted in February 2016. The 59 studies meeting the inclusion criteria were grouped and methodically described based on preference elicitation techniques and methods. Despite substantial methodological heterogeneity between studies, certain findings consistently emerged for the investigated LTC preference outcomes. The large majority of respondents preferred to receive LTC in their known physical and social environment when care needs were moderate, but residential care when care needs were extensive. Preferences were found to depend on a variety of personal, environmental, social and cultural aspects. Dependent individuals aspired to preserve their personal and social identity, self-image, independence, autonomy, control and dignity, which suggests that LTC preferences are a function of the perceived ability of a specific LTC arrangement to satisfy peoples’ basic physiological and mental/social needs. Research on LTC preferences would greatly profit from a standardisation of respective concepts and methods.

Developing a dementia-specific preference--based quality of life measure (AD-5D) in Australia: a valuation study protocol

INTRODUCTION

Generic instruments for assessing health-related quality of life may lack the sensitivity to detect changes in health specific to certain conditions, such as dementia. The Quality of Life in Alzheimer's Disease (QOL-AD) is a widely used and well-validated condition-specific instrument for assessing health-related quality of life for people living with dementia, but it does not enable the calculation of quality-adjusted life years, the basis of cost utility analysis. This study will generate a preference-based scoring algorithm for a health state classification system -the Alzheimer's Disease Five Dimensions (AD-5D) derived from the QOL-AD.

METHODS AND ANALYSIS

Discrete choice experiments with duration (DCE_TTO) and best-worst scaling health state valuation tasks will be administered to a representative sample of 2000 members of the Australian general population via an online survey and to 250 dementia dyads (250 people with dementia and their carers) via face-to-face interview. A multinomial (conditional) logistic framework will be used to analyse responses and produce the utility algorithm for the AD-5D.

ETHICS AND DISSEMINATION

The algorithms developed will enable prospective and retrospective economic evaluation of any treatment or intervention targeting people with dementia where the QOL-AD has been administered and will be available online. Results will be disseminated through journals that publish health economics articles and through professional conferences. This study has ethical approval.