Early rehabilitation management after stroke: What do stroke patients prefer?

A systematic review of discrete choice experiments in stroke rehabilitation

OBJECTIVES

Existing research qualitatively explores consumer preferences for stroke rehabilitation interventions. However, it remains unclear which intervention characteristics are most important to consumers, and how these preferences may influence uptake and participation. Discrete choice experiments (DCE) provide a unique way to quantitatively measure preferences for health and health care. This study aims to explore how DCEs have been used in stroke rehabilitation and to identify reported consumer preferences for rehabilitation interventions.

MATERIAL AND METHODS

A systematic review of published stroke rehabilitation DCEs was completed (PROSPERO registration: CRD42021282578). Six databases (including CINAHL, MEDLINE, EconLIT) were searched from January 2000-March 2023. Data extracted included topic area, sample size, aim, attributes, design process, and preference outcomes. Descriptive and thematic analyses were conducted, and two methodological checklists applied to review quality.

RESULTS

Of 2,446 studies screened, five were eligible. Studies focused on exercise preference (n = 3), the structure and delivery of community services (n = 1), and self-management programs (n = 1). All had small sample sizes (range 50-146) and were of moderate quality (average score of 77%). Results indicated people have strong preferences for one-to-one therapy (over group-based), light-moderate intensity of exercise, and delivery by qualified therapists (over volunteers).

CONCLUSIONS

Few DCEs have been conducted in stroke rehabilitation, suggesting consumer preferences could be more rigorously explored. Included studies were narrow in the scope of attributes included, limiting their application to practice and policy. Further research is needed to assess the impact of differing service delivery models on uptake and participation.

Stroke survivors' perspectives on decision-making about rehabilitation and the prospect of taking recovery-promoting drugs: A qualitative study

Objectives

To investigate factors which influence stroke survivors' decision-making about their rehabilitation and the prospect of taking recovery-promoting drugs, to enhance their recovery.

Methods

Seventeen stroke survivors who had undertaken stroke rehabilitation, and three spouses, participated in focus groups and individual interviews in northern Queensland, Australia. Inductive thematic analysis of the interview data was conducted in accordance with Braun and Clarke's six-phase process.

Results

Two specific, pivotal decision points during participants' stroke recovery process were identified: 1) overall, when deciding what rehabilitation they would undertake and hypothetically what recovery-promoting drugs they would take, and 2) on a daily basis, when deciding whether to participate in rehabilitation and take recovery-promoting drugs on any given day. Six themes which described factors influencing their decision-making were: 'My options for rehabilitation and recovery-promoting drugs'; 'The costs of rehabilitation and recovery-promoting drugs'; 'My recovery goals'; 'What I can deal with today'; 'The people my rehabilitation and recovery-promoting drugs affect'; and 'Fitting rehabilitation and recovery-promoting drugs into my life.' These themes were applicable at either one or both of the identified decision points.

Conclusion

Factors that influence stroke survivors' decision-making, overall and on a day-to-day basis, need to be considered to ensure they can make the best decisions for themselves to achieve their full recovery potential. Understanding the conditions under which a stroke survivor would take a recovery-promoting drug will contribute to the development of dosing protocols to which stroke survivors could adhere.

Effectiveness of Rehabilitation Exercise in Improving Physical Function of Stroke Patients: A Systematic Review

Rehabilitation is a crucial part of recovery for stroke survivors, and numerous studies have examined various exercises and treatments of stroke. In addition, it is very important for patients to choose the timing of rehabilitation and what kind of rehabilitation they will proceed with. The purpose of the current study is to examine research investigating the effects of rehabilitation exercise programs in recovery of physical function in patients with stroke, based on aspects of their physical function, physical strength, and daily activities, and systematically examine their effects. Therefore, through systematic review, we have investigated the effects of interventions in rehabilitation exercise programs for recovery of physical function in patients with stroke. We collected relevant publications through the databases MEDLINE/PubMed and Google scholar. Twenty-one articles were ultimately selected for the analysis. We classified the rehabilitation programs and identified the trends of treatment for stroke survivors. Our review indicated that task-oriented therapy is still dominant, but various types of combined rehabilitations have been attempted. In addition, it was identified that physical and active rehabilitation were required rather than unconditional rest, even at an early stage. Home-based treatment was used for rapid recovery and adaptation to daily life during the mid-term period.

Supporting rehabilitation stakeholders in making service delivery decisions: a rapid review of multi-criteria decision analysis methods

PURPOSE

This review aimed to synthesize knowledge about multi-criteria decision analysis methods for supporting rehabilitation service design and delivery decisions, including: (1) describing the use of these methods within rehabilitation, (2) identifying decision types that can be supported by these methods, (3) describing client and family involvement, and (4) identifying implementation considerations.

METHODS

We conducted a rapid review in collaboration with a knowledge partner, searching four databases for peer-reviewed articles reporting primary research. We extracted relevant data from included studies and synthesized it descriptively and with conventional content analysis.

RESULTS

We identified 717 records, of which 54 met inclusion criteria. Multi-criteria decision analysis methods were primarily used to understand the strength of clients' and clinicians' preferences (n = 44), and five focused on supporting decision making. Shared decision making with stakeholders was evident in only two studies. Clients and families were mostly engaged in data collection and sometimes in selecting the relevant criteria. Good practices for supporting external validity were inconsistently reported. Implementation considerations included managing cognitive complexity and offering authentic choices.

CONCLUSIONS

Multi-criteria decision analysis methods are promising for better understanding client and family preferences and priorities across rehabilitation professions, contexts, and caseloads. Further work is required to use these methods in shared decision making, for which increased use of qualitative methods and stakeholder engagement is recommended. IMPLICATIONS FOR REHABILITATIONMulti-criteria decision analysis methods are promising for evidence-based, shared decision making for rehabilitation.However, most studies to date have focused on estimating stakeholder preferences, not supporting shared decision making.Cognitive complexity and modelling authentic and realistic decision choices are major barriers to implementation.Stakeholder-engagement and qualitative methods are recommended to address these barriers.

Preference of caregivers on residential care homes for older persons with versus without communication problems: a discrete choice experiment

Background

A residential care service voucher scheme has been introduced to expand the capacity and enhance choice of public-funded long-term care (LTC) in Hong Kong, enabling users to have greater choices over the types of LTC facilities. Older persons with communication problems have difficulties in understanding the care options available to them and expressing their preferences to care homes and daily service delivery, therefore hindering their ability to exercise control and choice. Thus, they may have different needs and preferences for the facilities than others due to their conditions. This study therefore aimed to investigate their preference for care homes in comparison with those without communication problems.

Methods

A discrete choice experiment was conducted to elicit preference for six attributes derived from prior studies. The family caregivers of a random sample of older voucher holders were invited to undertake face-to-face interview. Willingness-to-pay (WTP) for the attributes was estimated for those with or without communication problems separately.

Results

Two hundred eighty-three caregivers provided valid responses (74% response rate). Caregivers of those with communication problem preferred facilities operated by non-governmental organizations (WTP=HK$1777.4) and shorter travelling time (WTP=HK$1502.5 for <=0.5 hours), while those without the problem had greater preference for fewer roommates (WTP=HK$3048.1 for single room) and extra healthcare professionals (WTP=HK$1765.5). Heterogenous WTPs were identified from those with different income, marital status and caregivers’ age.

Conclusions

The reputation, greater space and staff, and proximity/familiarity of the facilities were important for those with communication problems. To help meet these preferences, the facilities could establish collaborations with local community-based service providers and build their own outreach team to familiarize themselves with older persons. Additionally, household income and informal support availability should be considered for care planning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03073-9.

Preference of Older Adults for Flexibility in Service and Providers in Community-Based Social Care: A Discrete Choice Experiment

Empowerment of control and choice of the service users in health and social care has been incorporated into service provision in various countries. This study aimed to elicit the preference of community-based long-term care (LTC) service users on levels of flexibility in service provision. A discrete choice experiment was performed among older community care service users to measure their preference for attributes of LTC services identified from a prior qualitative study. Each participant was asked to make choices in six choice tasks with two alternatives of hypothetical LTC services that were generated from the attributes. A generalized multinomial logistic model was applied to determine the relative importance and willingness to pay for the attributes. It found that the participants preferred multiple flexible providers, determining services by themselves, meeting case managers every month and social workers as sources of information on service provision. Significant preference heterogeneity was found for flexibility in providers and flexibility in services between those with and without activity of daily living impairment. The findings highlighted the preference of older adults for greater flexibility in LTC, while they rely heavily on social workers in decision making. The enhancement of flexibility in LTC should be supported by policies that allow the older service users to make decisions based on their own preferences or communication with social workers instead of determining the services and providers for them. Options should be offered to users to decide their preferred level of flexibility to better reflect their divided preferences.

Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury

BACKGROUND

Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses.

METHODS

A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit.

RESULTS

Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality-based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality-based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight-supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance.

DISCUSSION

The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient's engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy.

LIMITATIONS

As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance.

SUMMARY

The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury.

DISCLAIMER

These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.

Developing a new quality of life instrument with older people for economic evaluation in aged care: study protocol

INTRODUCTION

The ageing of the population represents a significant challenge for aged care in Australia and in many other countries internationally. In an environment of increasing resource constraints, new methods, techniques and evaluative frameworks are needed to support resource allocation decisions that maximise the quality of life and well-being of older people. Economic evaluation offers a rigorous, systematical and transparent framework for measuring quality and efficiency, but there is currently no composite mechanism for incorporating older people's values into the measurement and valuation of quality of life for quality assessment and economic evaluation. In addition, to date relatively few economic evaluations have been conducted in aged care despite the large potential benefits associated with their application in this sector. This study will generate a new preference based older person-specific quality of life instrument designed for application in economic evaluation and co-created from its inception with older people.

METHODS AND ANALYSIS

A candidate descriptive system for the new instrument will be developed by synthesising the findings from a series of in-depth qualitative interviews with 40 older people currently in receipt of aged care services about the salient factors which make up their quality of life. The candidate descriptive system will be tested for construct validity, practicality and reliability with a new independent sample of older people (n=100). Quality of life state valuation tasks using best worst scaling (a form of discrete choice experiment) will then be undertaken with a representative sample of older people currently receiving aged care services across five Australian states (n=500). A multinomial (conditional) logistical framework will be used to analyse responses and generate a scoring algorithm for the new preference-based instrument.

ETHICS AND DISSEMINATION

The new quality of life instrument will have wide potential applicability in assessing the cost effectiveness of new service innovations and for quality assessment across the spectrum of ageing and aged care. Results will be disseminated in ageing, quality of life research and health economics journals and through professional conferences and policy forums. This study has been reviewed by the Human Research Ethics Committee of the University of South Australia and has ethics approval (Application ID: 201644).

Physiotherapists' and Physiotherapy Students' Perspectives on the Use of Mobile or Wearable Technology in Their Practice

Purpose: Although extensive research has been carried out on the determinants of mobile or wearable health care technology (mHealth), as well as on its acceptance by patients and other health care providers, very little research has been done on physiotherapists' perspectives on the use of mHealth in their current or future practice. The aims of this study were to (1) explore the attitudes of physiotherapists toward mHealth using a modified technology acceptance model questionnaire, (2) understand the applications and delivery paradigms that are most desirable, and (3) assess the content validity of the questionnaire. Method: The questionnaire was administered online. Participants (n=76) were recruited using snowball and convenience sampling. Data were analyzed using factor analysis and partial least-squares path modelling. Results: Results indicate that perceived usefulness and perceived ease of use were related to early adoptive behaviour among participants. We found no evidence that age, gender, experience, or practice setting influenced early adoptive behaviour. Participants demonstrated favourable attitudes toward mHealth tools in clinical practice. Conclusions: This article provides initial insights into factors that are likely to be significant determinants of adoption of mHealth among physiotherapists. Further work, including qualitative research, will help to identify personal and institutional factors that will improve the acceptance of mHealth.

A novel design process for selection of attributes for inclusion in discrete choice experiments: case study exploring variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke

BACKGROUND

A discrete choice experiment (DCE) is a method used to elicit participants' preferences and the relative importance of different attributes and levels within a decision-making process. DCEs have become popular in healthcare; however, approaches to identify the attributes/levels influencing a decision of interest and to selection methods for their inclusion in a DCE are under-reported. Our objectives were: to explore the development process used to select/present attributes/levels from the identified range that may be influential; to describe a systematic and rigorous development process for design of a DCE in the context of thrombolytic therapy for acute stroke; and, to discuss the advantages of our five-stage approach to enhance current guidance for developing DCEs.

METHODS

A five-stage DCE development process was undertaken. Methods employed included literature review, qualitative analysis of interview and ethnographic data, expert panel discussions, a quantitative structured prioritisation (ranking) exercise and pilot testing of the DCE using a 'think aloud' approach.

RESULTS

The five-stage process reported helped to reduce the list of 22 initial patient-related factors to a final set of nine variable factors and six fixed factors for inclusion in a testable DCE using a vignette model of presentation.

CONCLUSIONS

In order for the data and conclusions generated by DCEs to be deemed valid, it is crucial that the methods of design and development are documented and reported. This paper has detailed a rigorous and systematic approach to DCE development which may be useful to researchers seeking to establish methods for reducing and prioritising attributes for inclusion in future DCEs.

Measuring stroke patients' exercise preferences using a discrete choice experiment

Physical activity post stroke improves health, yet physical inactivity is highly prevalent. Tailored exercise programs considering physical activity preferences are a promising approach to promote physical activity. Therefore, this study seeks to measure exercise preferences of stroke survivors. Stroke survivors conducted a discrete choice experiment (DCE). DCE was presented in a face-to-face interview where patients had to choose eight times between two different exercise programs. Exercise programs differed by characteristics, with the six attributes under consideration being social situation, location, type of exercise, intensity, frequency, and duration. Utilities of the exercise attributes were estimated with a logit choice model. Stroke survivors (n=103, mean age: 67, SD=13.0; 60% male) show significant differences in the rated utilities of the exercise attributes (P<0.001). Participants had strong preferences for light and moderate intense physical activity and favored shorter exercise sessions. Stroke survivors have remarkable exercise preferences especially for intensity and duration of exercise. Results contribute to the tailoring of physical activity programs after stroke thereby facilitating maintenance of physical activity.

Priorities for Closing the Evidence-Practice Gaps in Poststroke Aphasia Rehabilitation: A Scoping Review

OBJECTIVE

To identify implementation priorities for poststroke aphasia management relevant to the Australian health care context.

DATA SOURCES

Using systematized searches of databases (CINAHL and MEDLINE), guideline and stroke websites, and other sources, evidence was identified and extracted for 7 implementation criteria for 13 topic areas relevant to aphasia management. These 7 priority-setting criteria were identified in the implementation literature: strength of the evidence, current evidence-practice gap, clinician preference, patient preference, modifiability, measurability, and health effect.

STUDY SELECTION

Articles were included if they were in English, related to a specific recommendation requiring implementation, and contained information pertaining to any of the 7 prioritization criteria.

DATA EXTRACTION

The scoping review methodology was chosen to address the broad nature of the topic. Evidence was extracted and placed in an evidence matrix. After this, evidence was summarized and then aphasia rehabilitation topics were prioritized using an approach developed by the research team.

DATA SYNTHESIS

Evidence from 100 documents was extracted and summarized. Four topic areas were identified as implementation priorities for aphasia: timing, amount, and intensity of therapy; goal setting; information, education, and aphasia-friendly information; and constraint-induced language therapy.

CONCLUSIONS

Closing the evidence-practice gaps in the 4 priority areas identified may deliver the greatest gains in outcomes for Australian stroke survivors with aphasia. Our approach to developing implementation priorities may be useful for identifying priorities for implementation in other health care areas.

Factors that influence clinicians' decisions to offer intravenous alteplase in acute ischemic stroke patients with uncertain treatment indication: Results of a discrete choice experiment

Background Treatment with intravenous alteplase for eligible patients with acute ischemic stroke is underused, with variation in treatment rates across the UK. This study sought to elucidate factors influencing variation in clinicians' decision-making about this thrombolytic treatment. Methods A discrete choice experiment using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted with UK-based clinicians. Mixed logit regression analyses were conducted on the data. Results A total of 138 clinicians completed the discrete choice experiment. Seven patient factors were individually predictive of increased likelihood of immediately offering IV alteplase (compared to reference levels in brackets): stroke onset time 2 h 30 min [50 min]; pre-stroke dependency mRS 3 [mRS 4]; systolic blood pressure 185 mm/Hg [140 mm/Hg]; stroke severity scores of NIHSS 5 without aphasia, NIHSS 14 and NIHSS 23 [NIHSS 2 without aphasia]; age 85 [68]; Afro-Caribbean [white]. Factors predictive of withholding treatment with IV alteplase were: age 95 [68]; stroke onset time of 4 h 15 min [50 min]; severe dementia [no memory problems]; SBP 200 mm/Hg [140 mm/Hg]. Three clinician-related factors were predictive of an increased likelihood of offering IV alteplase (perceived robustness of the evidence for IV alteplase; thrombolyzing more patients in the past 12 months; and high discomfort with uncertainty) and one with a decreased likelihood (high clinician comfort with treating patients outside the licensing criteria). Conclusions Both patient- and clinician-related factors have a major influence on the use of alteplase to treat patients with acute ischemic stroke. Clinicians' views of the evidence, comfort with uncertainty and treating patients outside the license criteria are important factors to address in programs that seek to reduce variation in care quality regarding treatment with IV alteplase. Further research is needed to further understand the differences in clinical decision-making about treating patients with acute ischemic stroke with IV alteplase.

Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment

Background

Intravenous thrombolysis for patients with acute ischaemic stroke is underused (only 80% of eligible patients receive it) and there is variation in its use across the UK. Previously, variation might have been explained by structural differences; however, continuing variation may reflect differences in clinical decision-making regarding the eligibility of patients for treatment. This variation in decision-making could lead to the underuse, or result in inappropriate use, of thrombolysis.

Objectives

To identify the factors which contribute to variation in, and influence, clinicians’ decision-making about treating ischaemic stroke patients with intravenous thrombolysis.

Methods

A discrete choice experiment (DCE) using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted to better understand the influence of patient-related and clinician-related factors on clinical decision-making. An online DCE was developed following an iterative five-stage design process. UK-based clinicians involved in final decision-making about thrombolysis were invited to take part via national professional bodies of relevant medical specialties. Mixed-logit regression analyses were conducted.

Results

A total of 138 clinicians responded and opted to offer thrombolysis in 31.4% of cases. Seven patient factors were individually predictive of the increased likelihood of offering thrombolysis (compared with reference levels in brackets): stroke onset time of 2 hours 30 minutes (50 minutes); pre-stroke dependency modified Rankin Scale score (mRS) of 3 (mRS4); systolic blood pressure (SBP) of 185 mmHg (140 mmHg); stroke severity scores of National Institutes of Health Stroke Scale (NIHSS) 5 without aphasia, NIHSS 14 and NIHSS 23 (NIHSS 2 without aphasia); age 85 years (65 years); and Afro-Caribbean (white). Factors predictive of not offering thrombolysis were age 95 years; stroke onset time of 4 hours 15 minutes; severe dementia (no memory problems); and SBP of 200 mmHg. Three clinician-related factors were predictive of an increased likelihood of offering thrombolysis (perceived robustness of the evidence for thrombolysis; thrombolysing more patients in the past 12 months; and high discomfort with uncertainty) and one factor was predictive of a decreased likelihood of offering treatment (clinicians’ being comfortable treating patients outside the licensing criteria).

Limitations

We anticipated a sample size of 150–200. Nonetheless, the final sample of 138 is good considering that the total population of eligible UK clinicians is relatively small. Furthermore, data from the Royal College of Physicians suggest that our sample is representative of clinicians involved in decision-making about thrombolysis.

Conclusions

There was considerable heterogeneity among respondents in thrombolysis decision-making, indicating that clinicians differ in their thresholds for treatment across a number of patient-related factors. Respondents were significantly more likely to treat 85-year-old patients than patients aged 68 years and this probably reflects acceptance of data from Third International Stroke Trial that report benefit for patients aged > 80 years. That respondents were more likely to offer thrombolysis to patients with severe stroke than to patients with mild stroke may indicate uncertainty/concern about the risk/benefit balance in treatment of minor stroke. Findings will be disseminated via peer-review publication and presentation at national/international conferences, and will be linked to training/continuing professional development (CPD) programmes.

Future work

The nature of DCE design means that only a subset of potentially influential factors could be explored. Factors not explored in this study warrant future research. Training/CPD should address the impact of non-medical influences on decision-making using evidence-based strategies.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Stroke survivors' perspectives on two novel models of inpatient rehabilitation: seven-day a week individual therapy or five-day a week circuit class therapy

PURPOSE

To explore stroke survivors' perspectives of two novel models of inpatient physiotherapy, which provide an increased amount of therapy: five days a week circuit class therapy and seven days a week individual therapy.

METHOD

This is a qualitative descriptive study using semi-structured interviews and thematic analysis. The participants were 10 purposively sampled stroke survivors in the post-acute phase of recovery, who had experienced seven days a week individual therapy or five days a week circuit group therapy during inpatient rehabilitation.

RESULTS

Three main themes emerged from the data: Too much, too little or just right; My experience - alone and together; and Meeting my needs. Findings revealed considerable variety in participants' beliefs, priorities and preferences regarding how intensely they could work; their experience of success and challenge individually and collectively; and their need to have their own unique individual needs met. Lack of choice seemed to be a linking concept between the themes.

CONCLUSION

In order to provide patient-centred services, novel methods of increased therapy must take into consideration the individual needs and preferences of the people accessing them. One model may not meet all these needs, hence a "menu" of options for therapy sessions (different timing, frequency, duration, content, rest and supervision) may be required to accommodate the diversity of patient needs, preferences and capacities. Implications for Rehabilitation People with stroke have diverse needs and preferences regarding the modes of delivering more therapy during rehabilitation. These diverse needs may not be met by one rigid service model. Therapists and service providers could engage their clients in a dialogue about the need for more therapy and how it can be delivered. This dialogue could include options of the various ways to increase their therapy. Therapists need to provide clear reasons and education around therapy components, including rest time and practice schedules.

Discrete choice experiments in health economics: a review of the literature

BACKGROUND

Discrete choice experiments (DCEs) are increasingly used in health economics to address a wide range of health policy-related concerns.

OBJECTIVE

Broadly adopting the methodology of an earlier systematic review of health-related DCEs, which covered the period 2001-2008, we report whether earlier trends continued during 2009-2012.

METHODS

This paper systematically reviews health-related DCEs published between 2009 and 2012, using the same database as the earlier published review (PubMed) to obtain citations, and the same range of search terms.

RESULTS

A total of 179 health-related DCEs for 2009-2012 met the inclusion criteria for the review. We found a continuing trend towards conducting DCEs across a broader range of countries. However, the trend towards including fewer attributes was reversed, whilst the trend towards interview-based DCEs reversed because of increased computer administration. The trend towards using more flexible econometric models, including mixed logit and latent class, has also continued. Reporting of monetary values has fallen compared with earlier periods, but the proportion of studies estimating trade-offs between health outcomes and experience factors, or valuing outcomes in terms of utility scores, has increased, although use of odds ratios and probabilities has declined. The reassuring trend towards the use of more flexible and appropriate DCE designs and econometric methods has been reinforced by the increased use of qualitative methods to inform DCE processes and results. However, qualitative research methods are being used less often to inform attribute selection, which may make DCEs more susceptible to omitted variable bias if the decision framework is not known prior to the research project.

CONCLUSIONS

The use of DCEs in healthcare continues to grow dramatically, as does the scope of applications across an expanding range of countries. There is increasing evidence that more sophisticated approaches to DCE design and analytical techniques are improving the quality of final outputs. That said, recent evidence that the use of qualitative methods to inform attribute selection has declined is of concern.

Understanding clinicians' decisions to offer intravenous thrombolytic treatment to patients with acute ischaemic stroke: a protocol for a discrete choice experiment

BACKGROUND

Intravenous thrombolysis is an effective emergency treatment for acute ischaemic stroke for patients meeting specific criteria. Approximately 12% of eligible patients in England, Wales and Northern Ireland received thrombolysis in the first quarter of 2013, yet as many as 15% are eligible to receive treatment. Suboptimal use of thrombolysis may have been largely attributable to structural factors; however, with the widespread implementation of 24/7 hyper acute stroke services, continuing variation is likely to reflect differences in clinical decision-making, in particular the influence of ambiguous areas within the guidelines, licensing criteria and research evidence. Clinicians' perceptions about thrombolysis may now exert a greater influence on treatment rates than structural/service factors. This research seeks to elucidate factors influencing thrombolysis decision-making by using patient vignettes to identify (1) patient-related and clinician-related factors that may help to explain variation in treatment and (2) associated trade-offs in decision-making based on the interplay of critical factors.

METHODS/ANALYSIS

A discrete choice experiment (DCE) will be conducted to better understand how clinicians make decisions about whether or not to offer thrombolysis to patients with acute ischaemic stroke. To inform the design, exploratory work will be undertaken to ensure that (1) all potentially influential factors are considered for inclusion; and (2) to gain insights into the 'grey areas' of patient factors. A fractional factorial design will be used to combine levels of patient factors in vignettes, which will be presented to clinicians to allow estimation of the variable effects on decisions to offer thrombolysis.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the Newcastle University Research Ethics Committee. The results will be disseminated in peer review publications and at national conferences. Findings will be translated into continuing professional development activities and will support implementation of a computerised decision aid for thrombolysis (COMPASS) in acute stroke care.

Cognitive overload? An exploration of the potential impact of cognitive functioning in discrete choice experiments with older people in health care

OBJECTIVES

This exploratory study sought to investigate the effect of cognitive functioning on the consistency of individual responses to a discrete choice experiment (DCE) study conducted exclusively with older people.

METHODS

A DCE to investigate preferences for multidisciplinary rehabilitation was administered to a consenting sample of older patients (aged 65 years and older) after surgery to repair a fractured hip (N = 84). Conditional logit, mixed logit, heteroscedastic conditional logit, and generalized multinomial logit regression models were used to analyze the DCE data and to explore the relationship between the level of cognitive functioning (specifically the absence or presence of mild cognitive impairment as assessed by the Mini-Mental State Examination) and preference and scale heterogeneity.

RESULTS

Both the heteroscedastic conditional logit and generalized multinomial logit models indicated that the presence of mild cognitive impairment did not have a significant effect on the consistency of responses to the DCE.

CONCLUSIONS

This study provides important preliminary evidence relating to the effect of mild cognitive impairment on DCE responses for older people. It is important that further research be conducted in larger samples and more diverse populations to further substantiate the findings from this exploratory study and to assess the practicality and validity of the DCE approach with populations of older people.

Investigating preferences for support with life after stroke: a discrete choice experiment

Background

There is little evidence of service user preferences to guide the commissioning and improvement of services that support life after stroke. We report the first investigation of patients’ and family carers’ preferences for community services after stroke using a discrete choice experiment (DCE).

Methods

Two workshops with patients and family carers (n = 8) explored stroke experiences, identifying attributes important in shaping views about service design, and piloted data collection strategies. Attributes were group versus individual support; service provider; additional support for social and leisure activities; and the total time required to access services. Patients and family carers were recruited six months post stroke-onset (mean 331 days) from four stroke services, and invited to participate in the DCE. Patients’ general health (EQ5D) and functional dependence (Barthel Index) were also assessed. Of 474 eligible patients, 144 (30%) expressed an interest in the study, and 80 (56%) of these completed the survey questionnaire. 34 of 74 (46%) family carers recruited through patients completed the DCE.

Results

All four attributes were significant in shaping patients preferences for stroke support service delivery (p < 0.05), confirming the interpretation of workshop findings. Patients prefer help and support for emotional needs, communication problems and physical difficulties to be provided on an individual basis; and to be offered additional social and leisure activities that they are able to attend on their own. Patients would appear to prefer that voluntary organisations do not provide these services, although this may be linked to lack of experience of these services. Family carers would prefer help and support in their caring role on a one-to-one basis. Whilst health related quality of life is associated with preference for format of service, results were relatively consistent across sub-groups, with the exception of time since stroke, where social and leisure activities had a greater impact on preferences of established service users.

Conclusions

The data provide unique insights into how preferences for community services that support life after stroke are shaped. This information can be used to inform both service re-design, and barriers to implementation that will need to be accounted for in policy shifts towards a more mixed economy of service provision.

What factors influence older people in the decision to relinquish their driver's licence? A discrete choice experiment

PURPOSE

To investigate the relative importance of a number of key factors that influence older people in the decision to relinquish their driver's licence.

METHOD

A discrete choice experiment (DCE) was administered as an online survey to Australian adults, 65 years plus (N=114) who drive, recruited from an online panel. The survey was composed of three main sections. (A) The Adelaide Driving Self Efficacy Scale to assess confidence in driving. The scale is generated from individual's responses about confidence in their driving ability in various situations. (B) The DCE in which respondents were presented with a series of hypothetical binary choice situations and asked to indicate in which situation they would be more likely to relinquish their driving licence. (C) Socio-demographic and health status questions. A conditional logit regression model was adopted to analyse the DCE data.

RESULTS

Older people would be more likely to relinquish their driver's licence due to advanced age, low confidence in driving ability and in situations where their local doctor advises them to cease driving. Other transport options availability and the cost of public transport were not found to be influential to this decision.

CONCLUSIONS

Factors pertaining to the individual themselves including advanced old age and low confidence in driving ability may be more influential than environmental factors such as availability of other transport options and the cost of public transport in an older person's decision to relinquish their driving licence.