The impact of risk information on patients' willingness to pay for autologous blood donation

Cost-effectiveness of Fibrinogen Concentrate vs Cryoprecipitate for Treating Acquired Hypofibrinogenemia in Bleeding Adult Cardiac Surgical Patients

Importance

Excessive bleeding requiring fibrinogen replacement is a serious complication of cardiac surgery. However, the relative cost-effectiveness of the 2 available therapies-fibrinogen concentrate and cryoprecipitate-is unknown.

Objective

To determine cost-effectiveness of fibrinogen concentrate vs cryoprecipitate for managing active bleeding in adult patients who underwent cardiac surgery.

Design, Setting, and Participants

A within-trial economic evaluation of the Fibrinogen Replenishment in Surgery (FIBERS) randomized clinical trial (February 2017 to November 2018) that took place at 4 hospitals based in Ontario, Canada, hospitals examined all in-hospital resource utilization costs and allogeneic blood product (ABP) transfusion costs incurred within 28 days of surgery. Participants included a subset of 495 adult patients from the FIBERS trial who underwent cardiac surgery and developed active bleeding and acquired hypofibrinogenemia requiring fibrinogen replacement.

Interventions

Fibrinogen concentrate (4 g per dose) or cryoprecipitate (10 units per dose) randomized (1:1) up to 24 hours postcardiopulmonary bypass.

Main Outcomes and Measures

Effectiveness outcomes included number of ABPs administered within 24 hours and 7 days of cardiopulmonary bypass. ABP transfusion (7-day) and in-hospital resource utilization (28-day) costs were evaluated and a multivariable net benefit regression model built for the full sample and predefined subgroups.

Results

Patient level costs for 495 patients were evaluated (mean [SD] age 59.2 [15.4] years and 69.3% male.) Consistent with FIBERS, ABP transfusions and adverse events were similar in both treatment groups. Median (IQR) total 7-day ABP cost was CAD $2280 (US dollars [USD] $1697) (CAD $930 [USD $692]-CAD $4970 [USD $3701]) in the fibrinogen concentrate group and CAD $2770 (USD $1690) (IQR, CAD $1140 [USD $849]-CAD $5000 [USD $3723]) in the cryoprecipitate group. Median (interquartile range) total 28-day cost was CAD $38 180 (USD $28 431) $(IQR, CAD $26 350 [USD $19 622]-CAD $65 080 [USD $48 463]) in the fibrinogen concentrate group and CAD $38 790 (USD $28 886) (IQR, CAD $26 180 [USD $19 495]-CAD $70 380 [USD $52 409]) in the cryoprecipitate group. After exclusion of patients who were critically ill before surgery (11%) due to substantial variability in costs, the incremental net benefit of fibrinogen concentrate vs cryoprecipitate was positive (probability of being cost-effective 86% and 97% at $0 and CAD $2000 (USD $1489) willingness-to-pay, respectively). Net benefit was highly uncertain for nonelective and patients with critical illness.

Conclusions and Relevance

Fibrinogen concentrate is cost-effective when compared with cryoprecipitate in most bleeding adult patients who underwent cardiac surgery with acquired hypofibrinogenemia requiring fibrinogen replacement. The generalizability of these findings outside the Canadian health system needs to be verified.

Patients' and health care professionals' perceptions of blood transfusion: a systematic review

BACKGROUND

Blood transfusions are frequently prescribed for acute and chronic conditions; however, the extent to which patients' and health care professionals' (HCPs') perceptions of transfusion have been investigated is unclear. Patients' treatment perceptions influence how patients cope with illnesses or symptoms. HCPs' perceptions may influence treatment decision making.

STUDY DESIGN AND METHODS

This was a systematic review of studies post-1984 reporting adult patients' and HCPs' perceptions of blood transfusion. Seven databases were searched using a three-domain search strategy capturing synonyms relating to: 1) blood transfusion, 2) perceptions, and 3) participant group (patients or HCPs). Study and sample characteristics were extracted and narratively summarized. Reported perceptions were extracted and synthesized using inductive qualitative methods to identify key themes.

RESULTS

Thirty-two studies were included: 14 investigated patients' perceptions and 18 HCPs' perceptions. Surgical patients were the highest represented patient group. HCPs were from a wide range of professions. Transfusions were perceived by patients and HCPs as being of low-to-moderate risk. Risk and negative emotions were perceived to influence preference for alternatives. Five themes emerged from the synthesis, classified as Safety/risk, Negative emotions, Alternatives (e.g., autologous, monitoring), Health benefits, and Decision making. "Safety/risk" and "Negative emotions" were most frequently investigated over time, yet periods of research inactivity are apparent.

CONCLUSIONS

The literature has identified themes on how transfusions are perceived by patients and HCPs, which overlap with recognized discussion points for transfusion specialists. These themes may help HCPs when educating patients about transfusion or consenting patients. Theory-based qualitative methods may add an important dimension to this work.

Family Caregivers’ Willingness to Pay for Drugs Indicated for the Treatment of Alzheimer’s Disease

The aim of the present study was to examine the willingness of family members caring for patients with probable Alzheimer’s Disease (AD) to pay for drug treatment, using the contingent valuation technique and the theory of planned behavior. A sample of 220 family members (68.2% F, mean age = 62.3; 59.8% spouses and the rest children) were interviewed regarding their willingness to pay (WTP) for drug treatment, their attitudes, normative expectations of significant others and perceived behavioral control. The mean WTP for drug treatment was estimated at about 60–80% of the retail price of the drug at the time of the study. Participants were willing to pay a significantly higher price when provided with information regarding side effects. Including psychological determinants (especially regarding affordability and normative expectations of significant others) improved an economic model. The understanding of decision-making processes in the framework of dementia should be expanded to include economic and psychological determinants.

The impact of information on patient preferences in different delivery patterns: a contingent valuation study of prescription versus OTC drugs

OBJECTIVES

Our analysis assessed the impact of information on patients' preferences in prescription versus over-the-counter (OTC) delivery systems.

METHODS

A contingent valuation (CV) study was implemented, randomly assigning 534 lay people into the receipt of limited or extended information concerning new influenza drugs. In each information arm, people answered two questions: the first asked about willingness to pay (WTP) for the new prescription drug; the second asked about WTP for the same drug sold OTC.

RESULTS

We show that WTP is higher for the OTC scenario and that the level of information plays a significant role in the evaluation of the OTC scenario, with more information being associated with an increase in the WTP. In contrast, the level of information provided has no impact on WTP for prescription medicine. Thus, for the kind of drug considered here (i.e. safe, not requiring medical supervision), a switch to OTC status can be expected to be all the more beneficial, as the patient is provided with more information concerning the capability of the drug.

CONCLUSIONS

Our results shed light on one of the most challenging issues that health policy makers are currently faced with, namely the threat of a bird flu pandemic. Drug delivery is a critical component of pandemic influenza preparedness. Furthermore, the congruence of our results with the agency and demand theories provides an important test of the validity of using WTP based on CV methods.

A comparison between willingness to pay and willingness to give up time

We compared the willingness-to-pay and willingness to give up time methods to assess preferences for digital subtraction angiography (DSA), computed tomography angiography (CTA) and magnetic resonance angiography (MRA). Respondents were hypertensive patients suspected of having renal artery stenosis. Data were gathered using telephone interviews. Both the willingness-to-pay and willingness to give up time methods revealed that patients preferred CTA to MRA in order to avoid DSA. The agreement between willingness-to-pay and willingness to give up time responses was high (kappa 0.65-0.85). The willingness-to-pay method yielded relatively more protest answers (12%) as compared to willingness to give up time (2%). So, our results provided evidence for the comparability of willingness to pay and willingness to give up time. The high percentage of protest answers on the willingness-to-pay questions raises questions with respect to the application of the willingness-to-pay method in a broad decision-making context. On the other hand, the strength of willingness-to-pay is that the method directly arrives at a monetary measure well founded in economic theory, whereas the willingness to give up time method requires conversion to monetary units.

Measuring acceptable treatment failure rates for community-acquired pneumonia: potential for reducing duration of treatment and antimicrobial resistance

OBJECTIVE

This study was designed to establish the rates of treatment failure for community-acquired pneumonia that are acceptable to knowledgeable and experienced physicians, in order to facilitate the interpretation of existing studies and the design of new studies aimed at optimizing the duration of antibiotic therapy. Reducing the duration of antibiotic therapy is one strategy for reducing antibiotic exposure and thereby minimizing the potential for the emergence of antimicrobial resistance.

DESIGN

Survey soliciting the acceptable failure rate for treatment given to an adult patient with uncomplicated community-acquired pneumonia treated with standard-of-care therapy in the outpatient setting. Analysis was performed using a modification of established methods of contingent valuation analysis.

PARTICIPANTS

Six hundred eighty infectious diseases physicians in North America who were also members of the Emerging Infections Network of the Infectious Diseases Society of America.

RESULTS

Three hundred seventy-five (55.1%) of 680 physicians responded to the survey. The median acceptable failure rate for treatment was 13.5%. Five hundred ten respondents (75.0%) found a failure rate of 7.3% acceptable, and 170 respondents (25.0%) found a failure rate of 19.8% acceptable.

CONCLUSIONS

This study identified the failure rates for treatment of community-acquired pneumonia that were acceptable to infectious disease physicians. This range of acceptable treatment failure rates may facilitate the design of studies aimed at optimizing the duration of antimicrobial therapy for community-acquired pneumonia.

Demand for private health insurance in Chinese urban areas

Between 1993 and 2003, the proportion of urban residents without health insurance rose from 27 to 50%. The probability of outpatient visits in the previous 2 weeks dropped from 19.9 to 11.8% in urban areas between 1993 and 2003, and from 16.0 to 13.9% in rural areas. To improve risk-pooling and risk-sharing, private health insurance should play an important role in China's health insurance system. This paper estimates the demand for private health insurance in urban areas using contingent valuation methods. Individuals were asked about their willingness-to-pay (WTP) for major catastrophic disease insurance (MCDI), inpatient expenses insurance (IEI), and outpatient expenses insurance (OEI). The study was based on a household survey conducted in four small cities in China in 2004 and included 2671 respondents. More people would like to buy IEI and MCDI (48.5 and 43.0%, respectively) than OEI (24.5%). In addition, individuals would pay a higher premium for MCDI and IEI than for OEI. The price elasticities of demand for MCDI, IEI, and OEI were -0.27, -0.34, and -0.42, respectively. The determinants of enrollment in the three private health insurance programs were similar with employment status, age, education, and income.

Perception of Blood Transfusion Risk

Perceptions of risk ultimately drive the responses of individuals and society to risk issues, and transfusion risk is no exception. Surveys of lay people over the past decade indicate that public concern about transfusion safety has remained prevalent, dominated by the ongoing fear of contracting HIV infection. Such perceptions persist despite the acknowledgment that blood transfusion is safer now than in years past. Judgements by the lay public that may, at first glance, seem irrational can often be understood when the heuristics, biases, and models of human judgements of risk are considered. Risk perception research suggests that how lay people perceive risk has less to do with the unidimensional view of risk as a probabilistic expression and more to do with a complex multidimensional construct in which affect, reason, worldviews, trust, and other factors are intertwined. This review summarizes some of the principles of risk perception as applicable to transfusion medicine.

Testing the construct validity of willingness to pay valuations using objective information about risk and health benefit

This paper describes an experiment to test the construct validity of contingent valuation, by eliciting women's valuations for the NHS cervical cancer screening programme. It is known that, owing to low levels of knowledge of cancer and screening in the general population, women both over-estimate the risk of disease and the efficacy of screening. The study is constructed as a randomised experiment, in which one group is provided with accurate information about cervical cancer screening, whilst the other is not. The first hypothesis supporting construct validity, that controls who perceive greater benefits from screening will offer higher valuations, is substantiated. Both groups are then provided with objective information on an improvement to the screening programme, and are asked to value the improvement as an increment to their original valuations. The second hypothesis supporting construct validity, that controls who perceive the benefits of the programme to be high already will offer lower incremental valuations, is also substantiated.

Physicians' acceptable treatment failure rates in antibiotic therapy for coagulase-negative staphylococcal catheter-associated bacteremia: implications for reducing treatment duration

BACKGROUND

Decreasing the duration of antimicrobial therapy is an attractive strategy for delaying the emergence of antimicrobial resistance. Limited data regarding optimal treatment durations for most clinical infections hinder the adoption of this approach and impair optimal physician-patient communication under the shared decision-making model. We aimed to identify acceptable failure rates among infectious disease consultants (IDCs) for treatment of central venous catheter-associated bacteremia.

METHODS

A case scenario involving a representative patient who developed central venous catheter-associated bacteremia caused by coagulase-negative staphylococci and who received standard-of-care therapy was distributed to all nonpediatric IDC members of the Infectious Diseases Society of America's Emerging Infections Network in August 2003. Each member was suggested 1 of 10 treatment failure rates and asked whether he or she would accept or reject the given value. Logistic regression was used to evaluate the relationship between specific failure rates offered to respondents and their willingness to accept them using a methodology derived from contingent valuation.

RESULTS

Among the 374 respondents (response rate, 54%), the median acceptable failure rate was 6.8%. Thus, one-half of the IDCs would have found a failure rate of 6.8% to be acceptable. Seventy-five percent of IDCs would have found a failure rate of 1.6% to be acceptable, and 25% of IDCs would have found a failure rate as high as 11.9% to be acceptable.

CONCLUSIONS

The quantified acceptable failure rates, when used to interpret clinical trial or cohort study results, will help select optimal antimicrobial therapy durations for this specific condition. These findings are a critical step in the development of effective shared decision-making models.

Influences of the absence of random assignment of bids on estimating willingness to pay using a discrete-choice question

This study examined the influences of the interaction between a bid and the respondent's characteristics due to insufficient random assignment of bids on the estimation of willingness to pay (WTP) using data from a discrete-choice question. A contingent valuation survey of 152 examinees undergoing X-ray testing for gastric cancer screening was conducted, and the median and mean WTP for the serum pepsinogen test were estimated using a logistic regression model to which the interaction terms between the bid and the respondent's characteristics, which included gender, age, annual income, frequency of prior use of a gastric cancer screening program, and perceived health, were added. There were remarkable differences in the estimated WTP according to whether the interaction term of annual income, to which the bids had failed to be assigned randomly and which had been positively correlated with the bid, was added in the model. It is suggested that it may be necessary to check if the bids were randomly assigned to the respondent's characteristics and, when correlations with the bid are found, to adjust their interaction effects.

Blood transfusion and autologous donation: a survey of post-surgical patients, interest group members and the public

Before planned surgery, patients may choose autologous donation in order to avoid the small, but potential, risks of receiving an allogeneic blood transfusion. This study examined the perceived risks of allogeneic blood transfusions, preferences and willingness to pay for autologous donation and the desired role in the decision-making process in three populations: post-surgical patients, special interest group members and the general public. Quantitative and qualitative data were collected from 206 respondents with the help of computer-assisted semi-structured telephone interviews. Thirty-three per cent of the sample voiced concerns about receiving allogeneic blood transfusions. The risks of hepatitis C virus, human immunodeficiency virus, variant Creutzfeldt-Jakob disease and a haemolytic reaction were perceived as being low, but were rated as numerically higher than those of other life events that have equal probability. Autologous donation was perceived as removing all the risks associated with transfusion, and respondents were willing to pay a median $976 AUD ($664 US) to use this technique. Over 80% of respondents preferred to be involved in making the decision about whether to use autologous donation. Even though autologous donation is not 'risk-free' and the blood supply is very safe, people overestimate the associated risks and have a preference for their own blood. Decision aids presenting balanced information on the advantages and disadvantages of both allogeneic and autologous blood may be required.

Physicians' perceptions towards the impact of and willingness to pay for clinical computerization in Hong Kong

BACKGROUND AND OBJECTIVES

We evaluated factors associated with physicians' perceptions towards the effects of computers on health care and on current levels of computerization in their practice. We also performed a contingent valuation to quantify physicians' perceived benefits from computerization in a hypothetical ambulatory, solo clinic.

METHODS

We surveyed 949 representative physicians in Hong Kong by post. Factor analysis was performed to summarize similar items into categories. Multivariable log-linear regression models were employed to assess the relationships between different factor scores and the number of functions computerized. We elicited their willingness-to-pay (WTP) for three defined computer systems using contingent valuation techniques. WTP values were estimated using econometric modeling by both, parametric and geometric methods. Sociodemographic, attitudinal, and practice-related predictors of WTP were estimated through regression analyses.

RESULTS

Factor analysis revealed a three-factor solution which explained 53% of total variance. The overall mean score (mean = 3.51 +/- 0.45) showed a generally positive attitude towards the effects of computers on health care. Respondents with a higher level of computer knowledge had significantly higher mean overall (P = 0.002) and factor scores for all three factors (P < 0.01). Higher factor scores on the effects of computers on patient care and clinicians (P = 0.006) and on the health system (P = 0.032) were associated with a higher number of functions computerized. The parametric median WTP values for computerizing administrative, clinical, and both sets of functions were HK dollars 21205 (US dollars 2719), HK dollars 34231 (US dollars 4389), and HK dollars 45720 (US dollars 5862), respectively, which were lower than the estimates obtained from demand curves using the geometric method [HK dollars 43286 (US dollars 5549), HK dollars 59570 (US dollars 7637), and HK dollars 84623 (US dollars 10849), respectively]. Doctors with higher incomes were willing to pay more to computerize the clinic, with strong dose-response gradients demonstrated. Those who worked in corporate settings were also more likely to accept higher WTP values.

CONCLUSIONS

Our findings confirm that better knowledge about computers is contributory to a more positive attitude towards the effects of computers on health care, which is in turn significantly associated with higher levels of actual computerization in clinical practice. WTP values represent the likelihood, in monetary terms, of translating doctors' perceived benefits from computerization into investment action.

The impact of information on non-health attributes on willingness to pay for multiple health care programmes

Despite the acceptance that health gain is the most important attribute of health care, other aspects of health care may affect utility. The aim of this paper is to report an experiment to test the impact of providing different levels of information in the context of the EuroWill study, a joint contingent valuation (CV) of multiple health programmes. Three hundred and three respondents were simultaneously asked for their willingness-to-pay (WTP) for three health care programmes: more heart operations, a new breast cancer treatment and a helicopter ambulance service. To test for the impact of variation in information, three versions of one of the programmes (heart) were provided. Results show that WTP for all three programmes tended to be significantly higher for respondents who were provided additional positive information about the heart programme. Our results show that CV of health care programmes, which only take into account medical outcomes, may lead to the value of such programmes not being adequately estimated, and that the impact of information may even be more decisive in the context of joint evaluation of multiple, rather than single, programmes.

Acceptable rates of treatment failure in osteomyelitis involving the diabetic foot: a survey of infectious diseases consultants

Shortening the duration of antibiotic therapy is an attractive strategy for delaying the emergence of antimicrobial resistance. The paucity of data about optimal treatment durations hinders adoption of this approach. This study used contingent valuation analysis to identify failure rates for treatment of diabetic foot osteomyelitis acceptable to infectious diseases consultants (IDCs). The Infectious Diseases Society of America's Emerging Infections Network (EIN) provided members with the case scenario and 1 of 10 failure rates; members were asked, assuming delivery of standard therapy, if they would accept or reject the given failure rate. The relationship between specific failure rates and the willingness of IDCs to accept them was analyzed. The median acceptable failure rate for EIN members was 18.1%; 75% of IDCs found a failure rate of 7.8% to be acceptable, and 25% found a rate of 28.4% to be acceptable. The methodology used in this study may prove useful in delineating acceptable treatment failure thresholds, an initial step in shortening durations of antimicrobial therapy.

Should we use willingness to pay to elicit community preferences for health care? New evidence from using a 'marginal' approach

We describe a willingness to pay (WTP) survey in which values were elicited from the public for three disparate health care programmes. Previous applications of WTP in this context have revealed a high proportion of preference reversals between WTP values and ordinal ranking of the programmes. In view of the doubts these findings raise over the use of WTP in this context, our aim was to develop a method of eliciting WTP values which we considered would improve consistency between respondents' explicit ranking of the programmes and their WTP values. Compared to the standard approach, the structure of the new design (the marginal approach) reduced the number of possible preference reversals, thus encouraging a degree of consistency among respondents. Despite this, the marginal approach did not result in fewer preference reversal being observed in actuality, thus casting doubt on the application of WTP in this context.

The effect of an educational intervention on willingness to receive therapeutic touch

The purpose of this quasi-experimental study was to test the effect of an educational intervention on participants' willingness to receive Therapeutic Touch (TT). A sample of 108 participants was recruited from three area nursing programs and one professional business women's group. Participants completed questionnaires before and after a 10-minute talk on TT and a 5-minute demonstration of TT. Participants were asked to rank their willingness to experience a TT treatment and to explain the reasons for their rankings. The hypothesis that the intervention would increase participants' willingness to experience TT was supported; there was a significant difference in pre- and postintervention willingness to experience TT.

Does willingness to pay vary by race/ethnicity? An analysis using mammography among low-income women

As part of a population-based intervention to improve periodic mammogram screening, we examined WTP for mammography in five ethnic groups. Through random digit dialing, we contacted households in low-income census tracts of Alameda County, California (San Francisco Bay area). Women who met the ethnicity, age and cancer-free eligibility criteria were invited to participate. For the baseline assessment, women were surveyed over the phone in their preferred language. Of the 1465 surveyed women, 499 identified themselves as African-American, 199 were Chinese, 167 were Filipino, 300 were Latina, and 300 were non-Hispanic white. Bivariate and multivariate analysis showed that WTP varied significantly by ethnicity (P<0.05). We also found that when Filipino and Chinese women had a female relative with breast cancer, they were willing to pay less money for a mammogram. African-American, Latino, and non-Hispanic white women, however, were willing to pay more money for a mammogram if a female relative had had breast cancer. This ethnic difference, when there is a familial link to breast cancer, needs further study as it has implication for genetic testing. Nevertheless, WTP studies that do not account for ethnic differences may be overstating net benefits to society.

Utilization of technologies to reduce allogeneic blood transfusion in the United States

Concern over safety of the blood supply has led to the use of technologies to reduce allogeneic blood transfusion. The objective of this research was to determine the utilization of these technologies in the United States. We evaluated the following techniques: preoperative autologous donation (PAD), cell salvage (CS) and acute normovolemic haemodilution (ANH); and the following pharmaceuticals: aprotinin (APR), epsilon-aminocaproic acid (EACA), tranexamic acid (TXA), desmopressin (DDAVP) and recombinant human erythropoietin (EPO). In 1997, we conducted a cross-sectional mail survey of service chiefs at 1000 US hospitals randomly selected and stratified by status as a provider of open-heart surgery, geographical location and hospital bed size. Sixty-nine per cent (690) of hospitals responded to at least one of the four surveys sent to each hospital. Hospitals reported use of techniques more than pharmaceuticals (P < 0.001); PAD (83%, n = 206) and CS (82% n = 420) were used most frequently. Lack of familiarity was the most common reason cited for infrequent use of pharmaceuticals. Organizational characteristics (e.g. provision of open-heart surgery, size, geographical location, teaching status and type of hospital) were differentially associated with technology use. There is greater use of techniques than pharmaceuticals in US hospitals to reduce the need for allogeneic blood in the peri-operative setting. Providing open-heart surgery is strongly associated with the utilization of these technologies.