Preference Phenotypes in Thyroid Nodule Management: A Patient Segmentation Approach

OBJECTIVE

Patient preferences regarding thyroid nodules are poorly understood. Our objective is to (1) employ a discrete choice experiment (DCE) to explore risk tradeoffs in thyroid nodule management, and (2) segment respondents into preference phenotypes.

STUDY DESIGN

DCE.

SETTING

Thyroid surgery clinic, online survey.

METHODS

A DCE including 5 attributes (cancer risk, voice concerns, incision/scar, medication requirement, follow-up frequency) was refined with qualitative patient and physician input. A final DCE including 8 choice tasks, demographics, history, and risk tolerance was administered to participants with and without thyroid disease. Analysis was performed with multinomial logit modeling and latent class analysis (LCA) for preference phenotyping.

RESULTS

A total of 1026 respondents were included; 480 had thyroid disease. Risk aversion was associated with increasing age (P < .001), female gender (P < .001), and limited education (P = .038), but not previous thyroid disease. Cancer risk most significantly impacted decision-making. Of the total possible utility change from thyroid nodule decision-making, 47.8% was attributable to variations in cancer risk; 20.0% from medication management; 14.9% from voice changes; 12.7% from incision/scar; and 4.6% from follow-up concerns. LCA demonstrated 3 classes with distinct preference phenotypes: the largest group (64.2%) made decisions primarily based on cancer risk; another group (18.2%) chose based on aversion to medication; the smallest group (17.7%) factored in medication and cancer risk evenly.

CONCLUSION

Cancer risk and the need to take medication after thyroid surgery factor into patient decision-making most heavily when treating thyroid nodules. Distinct preference phenotypes were demonstrated, reinforcing the need for individual preference assessment before the treatment of thyroid disorders.

Impact of animal origin of milk, processing technology, type of product, and price on the Boursin cheese choice process: Insights of a discrete choice experiment and eye tracking

Boursin is a versatile semisoft cheese that can be made with different types of milk. While widely distributed in the European and North American markets, Boursin is produced to a limited extent in Brazil despite its commercial potential. This scenario encourages consumer-oriented product development studies by facilitating data collection with less bias and fewer product preconceptions, thus favoring the investigation of technological aspects of commercial interest. This study evaluates Brazilians' perceptions regarding different versions of Boursin cheese, with the aim of gaining a better understanding of the factors related to choosing cheese. Four attributes related to cheese production were evaluated at three different levels using two discrete choice experiments: one with eye tracking (n = 20) and another without (n = 312). These attributes included "type of processing" (evaluating pasteurization, ohmic heating, and preparation with raw milk), "animal origin of milk" (cow, goat, or buffalo milk), "type of product" (traditional, light, and lactose-free versions), and "price" (10.99, 13.99, and 16.99 BRL). Information regarding processing with ohmic heating did not affect the probability of Boursin being chosen, suggesting that consumers are open to using this emerging technology in Boursin cheese. However, information on being made with goat, buffalo, and raw milk negatively impacted the probability of choice, along with the price of 16.99 BRL. The frequency of cheese consumption and the level of health concerns also affected the probability of choosing the product. PRACTICAL APPLICATION: Identifying the relationship between extrinsic attributes presented on the Boursin cheese label and the consumer's choice process can aid the communication process with the target audience and reveal how some technological issues of interest to manufacturers are perceived. This study indicates how information regarding the animal origin of the milk (cow, goat, and buffalo), the type of processing (pasteurization, ohmic heating, and raw milk), the version of the product (traditional, light, and lactose-free), and the price affect the consumer choice process. The results provide insights that can be applied to product processing and designing labels.

A Longitudinal Evaluation of the Preferences of Patients With Advanced Cancer for Quality of Life and Survival in Malaysia: A Discrete Choice Experiment

OBJECTIVES

This study aims to quantify the preferences of patients with advanced cancer for quality of life (QoL) outcomes versus survival extension in Malaysia. The secondary aim of this study is to explore the change in preferences over time.

METHODS

A discrete choice experiment was developed to include 7 attributes valued in cancer management: physical, psychological and social functioning, pain control, survival, place of death, and cost. Patients were recruited via convenience sampling from 2 Malaysian public hospitals. The survey questionnaire was administered to patients within 6 months of their cancer diagnosis with a follow-up 3 months later. Conditional logit regression was used to estimate the preference weight, relative attribute importance, and willingness to pay.

RESULTS

One hundred valid responses were collected at baseline and 45 at follow-up. Respondents placed higher values on QoL improvements from severe to moderate or mild levels and to achieve home death over survival extension from 6 to 18 months. However, additional improvements (from moderate to mild) in some of the QoL outcomes were not valued as highly as life extension from 12 to 18 months, showing that it was vital for patients to avoid being in "severe" health dysfunction. Improving physical dysfunction from severe to mild yielded 3 times as much value as additional 1-year survival. After 3 months, the respondents' preferences changed significantly, with increased relative attribute importance of physical functioning, pain control, and cost.

CONCLUSIONS

As QoL outcomes are valued more than survival, palliative care should be introduced as early as possible to alleviate suffering related to advanced cancer.

Exploring preferences of older adults for dental services: A pilot multi-national discrete choice experiment

OBJECTIVES

To pilot an exploration of older adults' future preferences using discrete choice experiments to understand who should provide dental examinations and treatment, where these services should be provided, and participants' willingness to pay and willingness to travel.

BACKGROUND

The proportion of older adults in the general population is increasing and is recognised as a pressing public health challenge.

MATERIALS AND METHODS

Older people aged 65 years and over were recruited into this study from the UK, Switzerland and Greece. Drawing on earlier stakeholder engagement, a set of choice experiments are developed to explore the future preferences of older people for dental examinations and dental treatment, as they anticipated losing their independence. These were presented to the participants using a range of platforms, because of the COVID pandemic. Data were analysed in STATA using a random-effects logit model.

RESULTS

Two hundred and forty-six participants (median age 70 years) completed the pilot study. There was a strong preference across all countries for a dentist to undertake a dental examination (Greece: β = 0.944, Switzerland: β = 0.260, UK β = 0.791), rather than a medical doctor (Greece: β = -0.556, Switzerland: β = -0.4690, UK: β = -0.468). Participants in Switzerland and the UK preferred these examinations to be undertaken in a dental practice (Switzerland: β = 0.220, UK: β = 0.580) while participants in Greece preferred the dental examination to be undertaken in their homes (β = 1.172). Greek participants preferred dental treatment to be undertaken by a specialist (β = 0.365) in their home (β = 0.862), while participants from the UK and Switzerland preferred to avoid any dental treatment at home (Switzerland: β = -0.387; UK: β = -0.444). Willingness to pay analyses highlighted that participants in Switzerland and the UK were willing to pay more to ensure the continuity of future service provision at a family dental practice (Switzerland: β = 0.454, UK: β = 0.695).

CONCLUSION

Discrete choice experiments are valuable for exploring older people's preferences for dental service provision in different countries. Future larger studies should be conducted to further explore the potential of this approach, given the pressing need to design services that are fit for purpose for older people. Continuity of dental service provision is considered as important by most older people, as they anticipate losing their dependence.

Identifying the Determinants of Anticipated Post-Pandemic Mode Choices in the Greater Toronto Area: A Stated Preference Study

The COVID-19 pandemic had a significant impact on travel mode choices in cities across the world. Driven by perceptions of risk and the fear of infection, the pandemic resulted in an increased preference for private vehicles and active modes and a reduced preference for public transit and ride-sourcing. As travel behavior and modal preferences evolve, a key question is whether the pandemic will result in long-term changes to travel mode choices. This study uses data from a web-based survey to examine the factors influencing mode choices for non-commuting trips in the post-pandemic era. Specifically, it uses stated preference data to develop a random parameter mixed logit model, which is used to compare the elasticity of key variables across different income and age groups. The results of the study highlight the influence of sociodemographic attributes and pre-pandemic travel habits on anticipated post-pandemic mode choices. Additionally, the results suggest that frequent users of private vehicles, public transit, and active modes are likely to continue to use these modes post-pandemic. Furthermore, the results highlight the potential for the perception of shared modes to influence post-pandemic mode choice decisions. The results of the study offer insights into policy measures that could be applied to address the increased use of private vehicles and reduced use of transit during the pandemic, while also emphasizing the need to ensure that certain segments of the population can maintain a sufficient level of mobility and access to transport.

Estimating biotic integrity to capture existence value of freshwater ecosystems

The US Environmental Protection Agency (EPA) uses a water quality index (WQI) to estimate benefits of proposed Clean Water Act regulations. The WQI is relevant to human use value, such as recreation, but may not fully capture aspects of nonuse value, such as existence value. Here, we identify an index of biological integrity to supplement the WQI in a forthcoming national stated preference survey that seeks to capture existence value of streams and lakes more accurately within the conterminous United States (CONUS). We used literature and focus group research to evaluate aquatic indices regularly reported by the EPA's National Aquatic Resource Surveys. We chose an index that quantifies loss in biodiversity as the observed-to-expected (O/E) ratio of taxonomic composition because focus group participants easily understood its meaning and the environmental changes that would result in incremental improvements. However, available datasets of this index do not provide the spatial coverage to account for how conditions near survey respondents affect their willingness to pay for its improvement. Therefore, we modeled and interpolated the values of this index from sampled sites to 1.1 million stream segments and 297,071 lakes across the CONUS to provide the required coverage. The models explained 13 to 36% of the variation in O/E scores and demonstrate how modeling can provide data at the required density for benefits estimation. We close by discussing future work to improve performance of the models and to link biological condition with water quality and habitat models that will allow us to forecast changes resulting from regulatory options.

Estimating the benefits of stream water quality improvements in urbanizing watersheds: An ecological production function approach

Streams in urbanizing watersheds are threatened by economic development that can lead to excessive sediment erosion and surface runoff. These anthropogenic stressors diminish valuable ecosystem services and result in pervasive degradation commonly referred to as "urban stream syndrome." Understanding how the public perceives and values improvements in stream conditions is necessary to support efforts to quantify the economic benefits of water quality improvements. We develop an ecological production framework that translates measurable indicators of stream water quality into ecological endpoints. Our interdisciplinary approach integrates a predictive hierarchical water quality model that is well suited for sparse data environments, an expert elicitation that translates measurable water quality indicators into ecological endpoints that focus group participants identified as most relevant, and a stated preference survey that elicits the public's willingness to pay for changes in these endpoints. To illustrate our methods, we develop an application to the Upper Neuse River Watershed located in the rapidly developing Triangle region of North Carolina (the United States). Our results suggest, for example, that residents are willing to pay roughly $127 per household and $54 million per year in aggregate (2021 US$) for water quality improvements resulting from a stylized intervention that increases stream bank canopy cover by 25% and decreases runoff from impervious surfaces, leading to improvements in water quality and ecological endpoints for local streams. Although the three components of our analysis are conducted with data from North Carolina, we discuss how our findings are generalizable to urban and urbanizing areas across the larger Piedmont ecoregion of the Eastern United States.

Perspectives on valuing water quality improvements using stated preference methods

Improvements to the quality of freshwater rivers and lakes can generate a wide array of benefits, from "use values" such as recreational boating, fishing, and swimming to "nonuse values" such as improved outcomes for aquatic biodiversity. Bringing these nonmarket values into decision-making is crucial to determining appropriate levels of investment in water quality improvements. However, progress in the economic valuation of water quality benefits has lagged similar efforts to value air quality benefits, with implications for water policy. New data sources, modeling techniques, and innovation in stated preference survey methods offer notable improvements to estimates of use and nonuse benefits of improved water quality. Here, we provide a perspective on how recent applications of stated preference techniques to the valuation of the nonmarket benefits of water quality improvements have advanced the field of environmental valuation. This overview is structured around four key questions: i) What is it about water quality that we seek to value? ii) How should we design and implement the surveys which elicit individuals' stated preferences? iii) How do we assess the validity of the findings provided by such studies? and iv) What are the contributions of these valuation exercises to public policy? In answering these questions, we make reference to the contributions provided by the papers in this Symposium.

Economic Valuation of Balkan Chamois Conservation

The Balkan chamois (Rupicapra rupicapra balcanica) is a caprine of the rocky mountain slopes, threatened in Greece by illegal hunting and population isolation. We used a contingent valuation method to assess the willingness to pay (WTP) for chamois conservation of 500 residents of the region of Eastern Macedonia and Thrace. Most of the participants (61.6%) were WTP a mean of EUR 41.6 for chamois conservation, totaling EUR 6.03 million for the target population. Attitudes toward and knowledge about chamois, moralistic worldviews (spiritual reverence and ethical concern for nature and wildlife), participation in wildlife-related consumptive outdoor activities (i.e., hunting and fishing), intention to participate in conservation actions for the species, and encounters with the species in the wild were positively associated with WTP for its conservation. Dominionistic worldviews (humans have mastery, physical control, and dominance of wildlife) were negatively associated with WTP, while highly educated females with high income were more WTP for implementing relevant conservation actions. Factors involving previous knowledge of the chamois positively influenced the WTP, thus, confirming the construct's bias toward charismatic species. The findings show that Greek residents highly value the chamois and its conservation and would be useful for advising this process and achieving its conservation management.

A world of choices: preference elicitation methods for improving the delivery and uptake of HIV prevention and treatment

PURPOSE OF REVIEW

Despite the growing availability of effective HIV prevention and treatment interventions, there are large gaps in their uptake and sustained use across settings. It is crucial to elicit and apply patients' and stakeholders' preferences to maximize the impact of existing and future interventions. This review summarizes quantitative preference elicitation methods (PEM) and how they can be applied to improve the delivery and uptake of HIV prevention and treatment interventions.

RECENT FINDINGS

PEM are increasingly applied in HIV implementation research; however, discrete choice experiments (DCEs) have predominated. Beyond DCEs, there are other underutilized PEM that may improve the reach and effectiveness of HIV prevention and treatment interventions among individuals by prioritizing their barriers to engagement and determining which attributes of interventions and delivery strategies are most valued. PEM can also enhance the adoption and sustained implementation of strategies to deliver HIV prevention and treatment interventions by assessing which attributes are the most acceptable and appropriate to key stakeholders.

SUMMARY

Greater attention to and incorporation of patient's and stakeholders' preferences for HIV prevention and treatment interventions and their delivery has the potential to increase the number of persons accessing and retained in HIV prevention and treatment services.

A Qualitative Study to Assess US Patient Preferences between new Transdermal System and Injectable Anabolic Therapies for Osteoporosis Treatment

US patients with osteoporosis included in three focus groups identified efficacy, safety, cost, and convenience as important attributes of treatment when choosing between anabolic therapies with high stated preference for the solid Microstructured Transdermal System.

OBJECTIVE

The current study evaluated patient perspective and relative importance of treatment attributes of in-home daily self-administration of abaloparatide-solid Microstructured Transdermal System (sMTS) compared with other anabolic agents (i.e. in-home daily subcutaneous self-injections, and monthly subcutaneous injections at doctor office) among a group of US patients with osteoporosis.

METHODS

The current study included systematic literature reviews, experts' consultation and three online patients focus groups (n=27), including patients ≥50 years of age at high risk for fracture. Nominal Group Technique was used by asking patients to (1) Individually identify characteristics that would be important for them when choosing between anabolic treatments, (2) Share ideas and discuss perspectives with other patients, (3) Review additional attributes generated from a systematic literature review, (4) Select and rank individually the 7 most important characteristics from the list and (5) Report their acceptability and stated preference ranking between the three treatment options.

RESULTS

Twenty women and 7 men with a mean age of 65 (range 51-85 years) participated in the focus groups. Twenty-four treatment characteristics were identified through focus groups and literature review. Efficacy, safety, out-of-pocket costs, strength of evidence and the option to self-administer were ranked as the most important attributes. The majority of patients stated preference for a daily sMTS if prescribed by their doctor.

CONCLUSIONS

This study revealed that efficacy, safety, costs, and convenience are important attributes of osteoporosis treatment for US patients at high risk for fractures when choosing between anabolic therapies, with a high stated preference for sMTS.

Stated job preferences of three health worker cadres in Ethiopia: a discrete choice experiment

Attracting, training and retaining high-quality health workers are critical for a health system to function well, and it is important to know what health workers value in their roles. Many studies eliciting the labour market preferences of health workers have interviewed doctors or medical students, and there has been little research on the job preferences of lower-skilled cadres such as community health workers, mid-skilled clinical care staff such as nurses and midwives, or non-patient facing staff who manage health facilities. This study estimated the job preferences of public health sector community health extension workers (HEWs), care providers including nurses and midwives, and non-patient-facing administrative and managerial staff in Ethiopia. We used a discrete choice experiment to estimate which aspects of a job are most influential to health worker choices. A multinomial logistic regression model estimated the importance of six attributes to respondents: salary, training, workload, facility quality, management and opportunities to improve patient outcomes. We found that non-financial factors were important to respondents from all three cadres: e.g., supportive management [odds ratio (OR) = 2.96, P-value = 0.001] was the only attribute that influenced the job choices of non-patient-facing administrative and managerial staff. Training opportunities (OR = 3.45, P-value < 0.001), supportive management (OR = 3.26, P-value < 0.001) and good facility quality (OR = 2.42, P-value < 0.001) were valued the most amongst HEWs. Similarly, supportive management (OR = 3.22, P-value < 0.001), good facility quality (OR = 2.69, P-value < 0.001) and training opportunities (OR = 2.67, P-value < 0.001) influenced the job choices of care providers the most. Earning an average salary also influenced the jobs choices of HEWs (OR = 1.43, P-value = 0.02) and care providers (OR = 2.00, P-value < 0.001), which shows that a combination of financial and non-financial incentives should be considered to motivate health workers in Ethiopia.

How Much Is a Human Life Worth? A Systematic Review

OBJECTIVES

To systematically review studies eliciting monetary value of a statistical life (VSL) estimates within, and across, different sectors and other contexts; compare the reported estimates; and critically review the elicitation methods used.

METHODS

In June 2019, we searched the following databases to identify methodological and empirical studies: Cochrane Library, Compendex, Embase, Environment Complete, Informit, ProQuest, PubMed, Scopus, and Web of Science. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for reporting and a modified Consolidated Health Economic Evaluation Reporting Standards checklist to assess the quality of included studies.

RESULTS

We identified 1455 studies, of which we included 120 in the systematic review. A stated-preference approach was used in 76 articles, with 51%, 41%, and 8% being contingent valuation studies, discrete-choice experiments, or both, respectively. A revealed-preference approach was used in 43 articles, of which 74% were based on compensating-wage differentials. The human capital approach was used in only 1 article. We assessed most publications (87%) as being of high quality. Estimates for VSL varied substantially by context (sector, developed/developing country, socio-economic status, etc), with the median of midpoint purchasing power parity-adjusted estimates of 2019 US$5.7 million ($6.8 million, $8.7 million, and $5.3 million for health, labor market, and transportation safety sectors, respectively).

CONCLUSIONS

The large variation observed in published VSLs depends mainly on the context rather than the method used. We found higher median values for labor markets and developed countries. It is important that health economists and policymakers use context-specific VSL estimates. Methodological innovation and standardization are needed to maximize comparability of VSL estimates within, and across, sectors and methods.

Sample restrictions and the elicitation of a constant willingness to pay per quality adjusted life year

It is well established that the underlying theoretical assumptions needed to obtain a constant proportional trade-off between a quality adjusted life year (QALY) and willingness to pay (WTP) are restrictive and often empirically violated. In this paper, we set out to investigate whether the proportionality conditions (in terms of scope insensitivity and severity independence) can be satisfied when data is restricted to include only respondents who pass certain consistency criteria. We hypothesize that the more we restrict the data, the better the compliance with the requirement of constant proportional trade-off between WTP and QALY. We revisit the Danish data from the European Value of a QALY survey eliciting individual WTP for a QALY (WTP-Q). Using a "chained approach" respondents were first asked to value a specified health state using the standard gamble (SG) or the time-trade-off (TTO) approach and subsequently asked their WTP for QALY gains of 0.05 and 0.1 (tailored according to the respondent's SG/TTO valuation). Analyzing the impact of the different exclusion criteria on the two proportionality conditions, we find strong evidence against a constant WTP-Q. Restricting our data to include only respondents who pass the most stringent consistency criteria does not impact on the performance of the proportionality conditions for WTP-Q.

How Patients Choose a Laryngologist: A Pilot Stated Preference Study

Objective

Patients consider many factors when deciding how to receive medical care. This study used best-worst scaling (BWS), a technique novel to otolaryngology, to quantitatively examine preferences among patients choosing a laryngologist. Our objective was to quantify in a pilot cohort the relative importance patients place on a variety of attributes when seeking a laryngologist.

Study Design

BWS survey.

Setting

Academic voice clinic.

Methods

New patients were recruited to take a computerized BWS survey developed using attributes derived from patient input, expert opinion, and literature review. Attributes were grouped into 4 categories: physician reputation, physician qualifications, hospital-related factors, and other nonclinical factors. Responses were analyzed using multinomial logit regression to determine importance scores and associations with other variables.

Results

Eighty-seven of 93 patients recruited participated (93.5% response rate). Physician qualifications were the most important attributes to patients, with specialty laryngology training receiving the highest importance score (20.8; 95% CI, 20.2 to 21.5; P < .0001). Recommendations from referring physicians (15.6; 95% CI, 14.3 to 16.9) and use of cutting-edge technology (11.9; 95% CI, 10.7 to 13.1) were the second and third most important, respectively. Least important were nonclinical factors, including wait time to get an appointment (4.3; 95% CI, 2.8 to 5.8) and convenience of office location (1.5; 95% CI, 0.9 to 2.1). Just over half of patients (51.2%) reported willingness to wait 4 weeks for an appointment with a laryngologist. Older patients were less concerned with convenience-related factors.

Conclusion

Nonclinical factors were less important to patients than clinical factors, and laryngology-specific training was paramount. Stated preference methodologies can elucidate underlying preferences and help providers make care more patient centered.

The Value of Preventative Dental Care: A Discrete-Choice Experiment

Scale and polish (SP) and oral hygiene advice (OHA) are commonly provided in primary care dental practice to help prevent periodontal disease. These services are widely consumed by service users, incurring substantial cost, without any clear evidence of clinical benefit. This article aims to elicit general population preferences and willingness to pay (WTP) for preventative dental care services and outcomes. An online discrete-choice experiment (DCE) was completed by a nationally representative sample of the UK general population. Respondents each answered 10 choice tasks that varied in terms of service attributes (SP, OHA, and provider of care), outcomes (bleeding gums and aesthetics), and cost. Choice tasks were selected using a pivoted segmented experimental design to improve task realism. An error components panel logit model was used to analyze the data. Marginal WTP (mWTP) for each attribute and level was calculated. In total, 667 respondents completed the DCE. Respondents valued more frequent SP, care provided by a dentist, and personalized OHA. Respondents were willing to pay for dental packages that generated less frequent ("never" or "hardly ever") bleeding on brushing and teeth that look and feel at least "moderately clean." Respondents were willing to pay more (+£145/y) for improvements in an aesthetic outcome from "very unclean" (-£85/y) to "very clean" (+£60/y) than they were for reduced bleeding frequency (+£100/y) from "very often" (-£54/y) to "never" (+£36/y). The general population value routinely provided SP, even in the absence of reductions in bleeding on brushing. Dental care service providers must consider service user preferences, including preferences for both health and nonhealth outcomes, as a key factor in any service redesign. Furthermore, the results provide mWTP estimates that can be used in cost-benefit analysis of these dental care services.

Willingness to Accept Trade-Offs Among COVID-19 Cases, Social-Distancing Restrictions, and Economic Impact: A Nationwide US Study

OBJECTIVE

To conduct a discrete-choice experiment to quantify Americans' acceptance of severe acute respiratory syndrome coronavirus 2 infection risks for earlier lifting of social-distancing restrictions and diminishing the pandemic's economic impact.

METHODS

We designed a discrete-choice experiment to administer 10 choice questions to each respondent representing experimentally controlled pairs of scenarios defined by when nonessential businesses could reopen (May, July, or October 2020), cumulative percentage of Americans contracting coronavirus disease 2019 (COVID-19) through 2020 (2% to 20%), time for economic recovery (2 to 5 years), and the percentage of US households falling below the poverty threshold (16% to 25%). Respondents were recruited by SurveyHealthcareGlobus.

RESULTS

A total of 5953 adults across all 50 states completed the survey between May 8 and 20, 2020. Latent-class analysis supported a 4-class model. The largest class (36%) represented COVID-19 risk-minimizers, reluctant to accept any increases in COVID-19 risks. About 26% were waiters, strongly preferring to delay reopening nonessential businesses, independent of COVID-19 risk levels. Another 25% represented recovery-supporters, primarily concerned about time required for economic recovery. This group would accept COVID-19 risks as high as 16% (95% CI: 13%-19%) to shorten economic recovery from 3 to 2 years. The final openers class prioritized lifting social distancing restrictions, accepting of COVID-19 risks greater than 20% to open in May rather than July or October. Political affiliation, race, household income, and employment status were all associated with class membership (P<.01).

CONCLUSION

Americans have diverse preferences pertaining to social-distancing restrictions, infection risks, and economic outcomes. These findings can assist elected and public-health officials in making difficult policy decisions related to the pandemic.

The Value of a Statistical Life-Year in Sub-Saharan Africa: Evidence From a Large Population-Based Survey in Tanzania

BACKGROUND

The value of a statistical life-year (VSLY) is the central number for the economic allocation of health resources. Nevertheless, empirical data on VSLY are lacking for most low- and middle- income countries. In the absence of empirically established VSLY, researchers typically use an arbitrary 3-times multiple of per-capita gross domestic product or per-capita income per life-year saved to establish cost-effectiveness.

OBJECTIVE

In this study, we establish an empirical VSLY for the first time for a community in sub-Saharan Africa.

METHODS

To empirically establish VSLY, we randomly selected 4000 individuals in the Ukonga community of Tanzania and employed a contingent valuation survey to measure VSLY. Using the contingent valuation methodology, we elicited willingness to pay for a 2% mortality risk reduction and had individuals convert this into an annualized payment to be paid each year over their expected remaining life.

RESULTS

We compared our elicited value to per-capita income and found that mean VSLY is $9340 (95% CI $6206-$12 373). The mean annual income in our sample was $2069, resulting in a VSLY that is equivalent to 4.5 times per-capita income.

CONCLUSION

Our results provide empirical evidence to support moving away from using the World Health Organization cost-effectiveness thresholds in practice because they will likely result in inefficient underinvestment in cost-effective interventions, even in relatively poor samples.

United States Valuation of EQ-5D-5L Health States Using an International Protocol

OBJECTIVE

To derive a US-based value set for the EQ-5D-5L questionnaire using an international, standardized protocol developed by the EuroQol Group.

METHODS

Respondents from the US adult population were quota-sampled on the basis of age, sex, ethnicity, and race. Trained interviewers guided participants in completing composite time trade-off (cTTO) and discrete choice experiment (DCE) tasks using the EuroQol Valuation Technology software and routine quality control measures. Data were modeled using a Tobit model for cTTO data, a mixed logit model for DCE data, and a hybrid model that combined cTTO and DCE data. Model performance was compared on the basis of logical ordering of coefficients, statistical significance, parsimony, and theoretical considerations.

RESULTS

Of 1134 respondents, 1062, 1099, and 1102 respondents provided useable cTTO, DCE, and cTTO or DCE responses, respectively, on the basis of quality control criteria and interviewer judgment. Respondent demographic characteristics and health status were similar to the 2015 US Census. The Tobit model was selected as the preferred model to generate the value set. Values ranged from -0.573 (55 555) to 1 (11 111), with 20% of all predicted health states scores less than 0 (ie, worse than dead).

CONCLUSIONS

A societal value set for the EQ-5D-5L was developed that can be used for economic evaluations and decision making in US health systems. The internationally established, standardized protocol used to develop this US-based value set was recommended by the EuroQol Group and can facilitate cross-country comparisons.

An Exploratory Application of Eye-Tracking Methods in a Discrete Choice Experiment

Background. Discrete choice experiments (DCEs) are increasingly used to elicit preferences for benefit-risk tradeoffs. The primary aim of this study was to explore how eye-tracking methods can be used to understand DCE respondents’ decision-making strategies. A secondary aim was to explore if the presentation and communication of risk affected respondents’ choices. Method. Two versions of a DCE were designed to understand the preferences of female members of the public for breast screening that varied in how risk attributes were presented. Risk was communicated as either 1) percentages or 2) icon arrays and percentages. Eye-tracking equipment recorded eye movements 1000 times a second. A debriefing survey collected sociodemographics and self-reported attribute nonattendance (ANA) data. A heteroskedastic conditional logit model analyzed DCE data. Eye-tracking data on pupil size, direction of motion, and total visual attention (dwell time) to predefined areas of interest were analyzed using ordinary least squares regressions. Results. Forty women completed the DCE with eye-tracking. There was no statistically significant difference in attention (fixations) to attributes between the risk communication formats. Respondents completing either version of the DCE with the alternatives presented in columns made more horizontal (left-right) saccades than vertical (up-down). Eye-tracking data confirmed self-reported ANA to the risk attributes with a 40% reduction in mean dwell time to the “probability of detecting a cancer” (P = 0.001) and a 25% reduction to the “risk of unnecessary follow-up” (P = 0.008). Conclusion. This study is one of the first to show how eye-tracking can be used to understand responses to a health care DCE and highlighted the potential impact of risk communication on respondents’ decision-making strategies. The results suggested self-reported ANA to cost attributes may not be reliable.

Comparing the Noncomparable: The Need for Equivalence Measures That Make Sense in Health-Economic Evaluations

BACKGROUND

The popularity of quality-adjusted life years (QALYs) has been resistant to concerns about validity and reliability. Utility-theoretic outcome equivalents are widely used in other areas of applied economics. Equivalence values can be derived for time, money, risk, and other metrics. These equivalence measures preserve all available information about individual preferences and are valid measures of individual welfare changes.

OBJECTIVE

The objective of this study was to derive alternative generalized equivalence measures from first principles and illustrate their application in an empirical comparative-effectiveness example.

METHODS

We specify a general-equilibrium model incorporating neoclassical utility functions, health production function, severity-duration preferences, and labor-market tradeoff function. The empirical implementation takes advantage of discrete-choice experiment methods that are widely accepted in other areas of applied economics and increasingly in health economics. We illustrate the practical significance of restrictive QALY assumptions using comparative-effectiveness results based on both QALYs and estimates of welfare-theoretic time-equivalent values for anti-tumor necrosis factor and prolonged corticosteroid treatments for Crohn's disease in three distinct preference classes.

RESULTS

The QALY difference between the two treatments is 0.2 months, while time-equivalent values range between 0.5 and 1.3 months for aggregate and class-specific differences. Thus, the QALY-based analysis understates welfare-theoretic values by 60%-85%.

CONCLUSION

These results suggest that using disease-specific equivalence values offer a meaningful alternative to QALYs to compare global outcomes across treatments. The equivalence values approach is consistent with principles of welfare economics and offers several features not represented in QALYs, including accounting for preference nonlinearities in disease severity and duration, inclusion of preference-relevant nonclinical healthcare factors, representing preferences of clinically-relevant patient subpopulations, and including utility losses related to risk aversion.

Three gaps and what they may mean for risk preference

Risk preference is one of the most important building blocks of choice theories in the behavioural sciences. In economics, it is often conceptualized as preferences concerning the variance of monetary payoffs, whereas in psychology, risk preference is often thought to capture the propensity to engage in behaviour with the potential for loss or harm. Both concepts are associated with distinct measurement traditions: economics has traditionally relied on behavioural measures, while psychology has often relied on self-reports. We review three important gaps that have emerged from work stemming from these two measurement traditions: first, a description-experience gap which suggests that behavioural measures do not speak with one voice and can give very different views on an individual's appetite for risk; second, a behaviour-self-report gap which suggests that different self-report measures, but not behavioural measures, show a high degree of convergent validity; and, third, a temporal stability gap which suggests that self-reports, but not behavioural measures, show considerable temporal stability across periods of years. Risk preference, when measured through self-reports-but not behavioural tests-appears as a moderately stable psychological trait with both general and domain-specific components. We argue that future work needs to address the gaps that have emerged from the two measurement traditions and test their differential predictive validity for important economic, health and well-being outcomes. This article is part of the theme issue 'Risk taking and impulsive behaviour: fundamental discoveries, theoretical perspectives and clinical implications'.

What's important in AAC decision making for children? Evidence from a best-worst scaling survey

The choice of which AAC device to provide for a child can have long lasting consequences, but little is known about the decision-making of AAC professionals who make recommendations in this context. A survey was conducted with AAC professionals using best-worst scaling methodology examining what characteristics of children and attributes of AAC devices are considered most important in decision-making. A total of 19 child characteristics and 18 device attributes were selected by the authors from lists generated from literature reviews and from focus groups with AAC professionals, people who use AAC, and other stakeholders. The characteristics and attributes were used to develop two best-worst scaling surveys that were administered to 93 AAC professionals based in the UK. The relative importance of characteristics/attributes was estimated using statistical modelling. Child characteristics related to language and communication, cognitive and learning abilities, and personality traits were generally found to be more important than physical features. Communication, language, and interface-related AAC device attributes were generally more important than hardware and physical attributes. Respondent demographics (e.g., experience, professional background) did not seem to influence the importance assigned to device characteristics or attributes. Findings may inform both future quantitative research into decision-making and efforts to improve decision-making in practice.

PREFERENCES OF PATIENTS WITH MULTIPLE SCLEROSIS FOR ATTRIBUTES OF INJECTABLE MULTIPLE SCLEROSIS TREATMENTS IN THE UNITED KINGDOM AND FRANCE

Objectives:

Adherence to injectable disease-modifying treatments in patients with multiple sclerosis (MS) impacts outcomes and can be influenced by perceptions of treatment efficacy, side effects, injection frequency, and the duration of injection. This study aimed to quantify preferences for selected attributes of injectable treatments among individuals with MS in the United Kingdom and France.

Methods:

Respondents with a self-reported diagnosis of MS completed an online discrete-choice-experiment survey, consisting of a series of treatment-choice questions. Each choice question presented two hypothetical treatments, each with six attributes (years until disability progression, relapses in the next 4 years, injection time, injection frequency, flu-like symptoms (FLS), and injection-site reactions), each with various levels. Mixed-logit regression analysis was used to estimate preference weights for attribute levels and to calculate the relative importance of changes in treatment attributes (vertical distance between preference weights). Minimum acceptable efficacy estimates indicate improvement in efficacy that respondents would require in exchange for worsening injection frequency and FLS.

Results:

In both countries, 100 respondents completed the survey. In the United Kingdom and France, respectively, improving the time until disability progression from 2 to 4 years, reducing injection frequency from “daily” to “every 2 weeks”, and reducing FLS from 3 days after every injection to none had a relative importance of 2.9 and 2.6, 3.0 and 3.5, and 2.5 and 3.1. Given the ranges included in the study, changes in these attributes were more important than most changes in other attributes assessed.

Conclusions:

Reductions in the injection frequency of MS treatments and FLS can be as important to patients as improvements in treatment efficacy.

Using Nominal Group Technique to Identify Key Attributes of Oncology Treatments for a Discrete Choice Experiment

Background. Responding to rising oncology therapy costs, multiple value frameworks are emerging. However, input from economists in their design and conceptualization has been limited, and no existing framework has been developed using preference weightings as legitimate indicators of value. This article outlines use of the nominal group technique to identify valued treatment attributes (such as treatment inconvenience) and contextual considerations (such as current life expectancy) to inform the design of a discrete choice experiment to develop a preference weighted value framework for future decision makers. Methods. Three focus groups were conducted in 2017 with cancer patients, oncology physicians, and nurses. Using the nominal group technique, participants identified and prioritized cancer therapy treatment and delivery attributes as well as contextual issues considered when choosing treatment options. Results. Focus groups with patients (n = 8), physicians (n = 6), and nurses (n = 10) identified 30 treatment attributes and contextual considerations. Therapy health gains was the first priority across all groups. Treatment burden/inconvenience to patients and their families and quality of evidence were prioritized treatment attributes alongside preferences for resource use and cost (to patients and society) attributes. The groups also demonstrated that contextual considerations when choosing treatment varied across the stakeholders. Patients prioritized existence of alternative treatments and oncologist/center reputation while nurses focused on administration harms, communication, and treatment innovation. The physicians did not prioritize any contextual issues in their top rankings. Conclusions. The study demonstrates that beyond health gains, there are treatment attributes and contextual considerations that are highly prioritized across stakeholder groups. These represent important candidates for inclusion in a discrete choice experiment seeking to provide weighted preferences for a value framework for oncology treatment that goes beyond health outcomes.

Using bayesian model to estimate the cost of traffic injuries in Iran in 2013

Background and Aim:

A significant social and economic burden inflicts by road traffic injuries (RTIs). We aimed to use Bayesian model, to present the precise method, and to estimate the cost of RTIs in Iran in 2013.

Materials and Methods:

In a cross-sectional study on costs resulting from traffic injuries, 846 people per road user were randomly selected and investigated during 3 months (1^st September–1^st December) in 2013. The research questionnaire was prepared based on the standard for willingness to pay (WTP) method considering perceived risks, especially in Iran. Data were collected along with four scenarios for occupants, pedestrians, vehicle drivers, and motorcyclists. Inclusion criterion was having at least high school education and being in the age range of 18–65 years old; risk perception was an important factor to the study and measured by visual tool. Samples who did not have risk perception were excluded from the study. Main outcome measure was cost estimation of traffic injuries using WTP method.

Results:

Mean WTP was 2,612,050 internal rate of return (IRR) among these road users. Statistical value of life was estimated according to 20,408 death cases 402,314,106,073,648 IRR, equivalent to 13,410,470,202$ based on the dollar free market rate of 30,000 IRR (purchase power parity). In sum, injury and death cases came to 1,171,450,232,238,648 IRR equivalents to 39,048,341,074$. Moreover, in 2013, costs of traffic accident constituted 6.46% of gross national income, which was 604,300,000,000$. WTP had a significant relationship with age, middle and high income, daily payment to injury reduction, more payment to time reduction, trip mileage, private cars drivers, bus, minibus vehicles, and occupants (P < 0.01).

Conclusion:

Costs of traffic injuries included noticeable portion of gross national income. If policy-making and resource allocation are made based on the scientific pieces of evidence, an enormous amount of capital can be saved through reducing death and injury rates.

Valuing Ecological Improvements in the Chesapeake Bay and the Importance of Ancillary Benefits

Reducing the excess nutrient and sediment pollution that is damaging habitat and diminishing recreational experiences in coastal estuaries requires actions by people and communities that are within the boundaries of the watershed but may be far from the resource itself, thus complicating efforts to understand tradeoffs associated with pollution control measures. Such is the case with the Chesapeake Bay, one of the most iconic water resources in the United States. All seven states containing part of the Chesapeake Bay Watershed were required under the Clean Water Act to submit detailed plans to achieve nutrient and sediment pollution reductions. The implementation plans provide information on the location and type of management practices making it possible to project not only water quality improvements in the Chesapeake Bay but also improvements in freshwater lakes throughout the watershed, which provide important ancillary benefits to people bearing the cost of reducing pollution to the Bay but unlikely to benefit directly. This paper reports the results of a benefits study that links the forecasted water quality improvements to ecological endpoints and administers a stated preference survey to estimate use and nonuse value for aesthetic and ecological improvements in the Chesapeake Bay and watershed lakes. Our results show that ancillary benefits and nonuse values account for a substantial proportion of total willingness to pay and would have a significant impact on the net benefits of pollution reduction programs.

Comparing Increments in Utility of Health: An Individual-based Approach

BACKGROUND

Many economic evaluations of health care changes rely on quality-adjusted life year (QALY) estimates. Notably, though, the QALY approach values health states rather than changes in health states. Hence, a gain in utility of health is only indirectly valued through an ex ante preference elicitation of health states and the subsequent subtraction of health state values from one another, rather than being valued directly. There is therefore an underlying assumption that individuals, from an ex ante perspective ceteris paribus, would be indifferent between equal utility increments from health states with different baseline utilities.

OBJECTIVE

The aim of this paper is to develop a method that would allow us to measure individual-based preferences over utility increments from different baselines. We elicit our data using face-to-face interviews on a sample of UK individuals.

RESULTS

Overall, we find that gains of "equal" utility increments from different baselines are not found to be equally preferable by the individual.

CONCLUSIONS

The results indicate that the subtraction approach could lead to sub-optimal resource allocations and suggest that a new approach which values health changes directly would better reflect individual preferences. This paper provides the foundations for a method to achieve this.

Prescriber preferences for behavioural economics interventions to improve treatment of acute respiratory infections: a discrete choice experiment

OBJECTIVE

To elicit prescribers' preferences for behavioural economics interventions designed to reduce inappropriate antibiotic prescribing, and compare these to actual behaviour.

DESIGN

Discrete choice experiment (DCE).

SETTING

47 primary care centres in Boston and Los Angeles.

PARTICIPANTS

234 primary care providers, with an average 20 years of practice.

MAIN OUTCOMES AND MEASURES

Results of a behavioural economic intervention trial were compared to prescribers' stated preferences for the same interventions relative to monetary and time rewards for improved prescribing outcomes. In the randomised controlled trial (RCT) component, the 3 computerised prescription order entry-triggered interventions studied included: Suggested Alternatives (SA), an alert that populated non-antibiotic treatment options if an inappropriate antibiotic was prescribed; Accountable Justifications (JA), which prompted the prescriber to enter a justification for an inappropriately prescribed antibiotic that would then be documented in the patient's chart; and Peer Comparison (PC), an email periodically sent to each prescriber comparing his/her antibiotic prescribing rate with those who had the lowest rates of inappropriate antibiotic prescribing. A DCE study component was administered to determine whether prescribers felt SA, JA, PC, pay-for-performance or additional clinic time would most effectively reduce their inappropriate antibiotic prescribing. Willingness-to-pay (WTP) was calculated for each intervention.

RESULTS

In the RCT, PC and JA were found to be the most effective interventions to reduce inappropriate antibiotic prescribing, whereas SA was not significantly different from controls. In the DCE however, regardless of treatment intervention received during the RCT, prescribers overwhelmingly preferred SA, followed by PC, then JA. WTP estimates indicated that each intervention would be significantly cheaper to implement than pay-for-performance incentives of $200/month.

CONCLUSIONS

Prescribing behaviour and stated preferences are not concordant, suggesting that relying on stated preferences alone to inform intervention design may eliminate effective interventions.

TRIAL REGISTRATION NUMBER

NCT01454947; Results.

What influences persistence with medicines? A multinational discrete choice experiment of 2549 patients

AIM

The aim was to examine patients' stated preferences to persist with medicines and to explore the influence of psychosocial and sociocognitive factors.

METHODS

Community-dwelling, hypertensive patients recruited from nine European countries were invited to complete a discrete choice experiment (DCE) with attributes for treatment benefits, mild yet common adverse drug reactions (ADRs), rare but potentially life-threatening ADRs and dosing frequency. Patients responded to the binary choice of which medicine would they be most likely to continue taking. Data were analyzed using a random effects logit model.

RESULTS

Two thousand five hundred and forty-nine patients from Austria (n = 321), Belgium (n = 175), England (n = 315), Germany (n = 266), Greece (n = 288), Hungary (n = 322), the Netherlands (n = 231), Poland (n = 312) and Wales (n = 319) completed the DCE. All attributes significantly influenced patients' stated preference to persist with medications (P < 0.05). Patients were willing to accept decreases in treatment benefits of 50.6 percentage points (95% CI 46.1, 57.9) for a very rare (as opposed to rare) risk of severe ADR, 28.3 percentage points (95% CI 25.2, 33.1) for a once daily instead of twice daily dosing and 0.74 percentage points (95% CI 0.67, 0.85) for a 1% point reduction in mild ADRs. Models accounting for psychosocial and sociocognitive characteristics were significantly different from the base case.

CONCLUSION

Patients' intention to persist with treatment was associated with their willingness to trade potential benefits, harms and dosing frequency. Psychosocial and sociocognitive factors influenced the extent of trading. The utility model may have value in assessing patients' likelihood of persisting with medicines and to tailor treatment to maximize persistence.

Public preferences for electronic health data storage, access, and sharing - evidence from a pan-European survey

Objective To assess the public’s preferences regarding potential privacy threats from devices or services storing health-related personal data.

Materials and Methods A pan-European survey based on a stated-preference experiment for assessing preferences for electronic health data storage, access, and sharing.

Results We obtained 20 882 survey responses (94 606 preferences) from 27 EU member countries. Respondents recognized the benefits of storing electronic health information, with 75.5%, 63.9%, and 58.9% agreeing that storage was important for improving treatment quality, preventing epidemics, and reducing delays, respectively. Concerns about different levels of access by third parties were expressed by 48.9% to 60.6% of respondents.

On average, compared to devices or systems that only store basic health status information, respondents preferred devices that also store identification data (coefficient/relative preference 95% CI = 0.04 [0.00-0.08], P = 0.034) and information on lifelong health conditions (coefficient = 0.13 [0.08 to 0.18], P < 0.001), but there was no evidence of this for devices with information on sensitive health conditions such as mental and sexual health and addictions (coefficient = −0.03 [−0.09 to 0.02], P = 0.24). Respondents were averse to their immediate family (coefficient = −0.05 [−0.05 to −0.01], P = 0.011) and home care nurses (coefficient = −0.06 [−0.11 to −0.02], P = 0.004) viewing this data, and strongly averse to health insurance companies (coefficient = −0.43 [−0.52 to 0.34], P < 0.001), private sector pharmaceutical companies (coefficient = −0.82 [−0.99 to −0.64], P < 0.001), and academic researchers (coefficient = −0.53 [−0.66 to −0.40], P < 0.001) viewing the data.

Conclusions Storing more detailed electronic health data was generally preferred, but respondents were averse to wider access to and sharing of this information. When developing frameworks for the use of electronic health data, policy makers should consider approaches that both highlight the benefits to the individual and minimize the perception of privacy risks.

A discrete-choice experiment to determine patient preferences for injectable multiple sclerosis treatments in Germany

OBJECTIVES

The aim of this study was to assess the relative importance of features of a hypothetical injectable disease-modifying treatment for patients with multiple sclerosis using a discrete-choice experiment.

METHODS

German residents at least 18 years of age with a self-reported physician diagnosis of multiple sclerosis completed a 25-30 minute online discrete-choice experiment. Patients were asked to choose one of two hypothetical injectable treatments for multiple sclerosis, defined by different levels of six attributes (disability progression, the number of relapses in the next 4 years, injection time, frequency of injections, presence of flu-like symptoms, and presence of injection-site reactions). The data were analyzed using a random-parameters logit model.

RESULTS

Of 202 adults who completed the survey, results from 189 were used in the analysis. Approximately 50% of all patients reported a diagnosis of relapsing-remitting multiple sclerosis, and 31% reported secondary progressive multiple sclerosis. Approximately 71% of patients had current or prior experience with injectable multiple sclerosis medication. Approximately 53% had experienced flu-like symptoms caused by their medication, and 47% had experienced mild injection-site reactions. At least one significant difference was seen between levels in all attributes, except injection time. The greatest change in relative importance between levels of an attribute was years until symptoms get worse from 1 to 4 years. The magnitude of this difference was about twice that of relapses in the next 4 years, frequency of injections, and flu-like symptoms.

CONCLUSIONS

Most attributes examined in this experiment had an influence on patient preference. Patients placed a significant value on improvements in the frequency of dosing and disability progression. Results suggest that changes in injection frequency can be as important as changes in efficacy and safety attributes. Understanding which attributes of injectable therapies influence patient preference could potentially improve outcomes and adherence in patients with multiple sclerosis.

An Empirical Study of Two Alternative Comparators for Use in Time Trade-Off Studies

BACKGROUND

Studies to produce value sets for preference-based measures of health require definition of a full health upper anchor if the values are to be used to calculate quality-adjusted life years. Recent value sets derived for the EQ-5D-5L instrument have described the upper anchor as "full health," whereas older valuation studies for the EQ-5D used "best health state" in the descriptive system (11111). It is unclear whether this change could have led to differences in the values obtained. The objective of this study was to assess differences in time trade-off (TTO) valuations using two different comparators (full health and 11111).

METHODS

Preferences for EQ-5D-5L health states were elicited from a broadly representative sample of the UK general public. TTO data were collected by using computer-assisted personal interviews. Respondents were randomly allocated to one of two arms, each using a different comparator health state. Respondents completed 10 or 11 TTO valuations and a series of follow-up questions examining their interpretations of the term "full health."

RESULTS

Interviews with 443 respondents were completed in 2014. The differences in mean values across arms are mostly small and nonsignificant. The two arms produced data of similar quality. There is evidence of interviewer effects. Health state 11111 was given a value of 1 by 98.2% of the respondents who valued it.

CONCLUSIONS

EQ-5D-5L values elicited by using the composite TTO approach are not greatly affected by the use of full health or 11111 as the comparator health state.

Willingness to pay per quality-adjusted life year for life-saving treatments in Thailand

OBJECTIVE

To estimate the willingness to pay (WTP) per quality-adjusted life year (QALY) value for life-saving treatments and to determine factors affecting the WTP per QALY value.

DESIGN

A cross-sectional survey with multistage sampling and face-to-face interviews.

SETTING

General population in the southern part of Thailand.

PARTICIPANTS

A total of 600 individuals were included in the study. Only 554 (92.3%) responses were usable for data analyses.

OUTCOME MEASURE

Participants were asked for the maximum amount of WTP value for life-saving treatments by an open-ended question. EQ-5D-3L and visual analogue scale (VAS) were used to estimate additional QALY.

RESULTS

The amount of WTP values varied from 0 to 720,000 Baht/year (approximately 32 Baht=US$1). The averages of additional QALY obtained from VAS and EQ-5D-3L were only slightly different (0.872 and 0.853, respectively). The averages of WTP per QALY obtained from VAS and EQ-5D-3L were 244,720 and 243,120 Baht/QALY, respectively. As compared to male participants, female participants were more likely to pay less for an additional QALY (p=0.007). In addition, participants with higher household incomes tended to have higher WTP per QALY values (p<0.001).

CONCLUSIONS

Our study added another WTP per QALY value specifically for life-saving treatments, which would complement the current cost-effectiveness threshold used in Thailand and optimise patient access to innovative treatments or technologies.

An Investigation of the Feasibility and Cultural Appropriateness of Stated Preference Methods to Generate Health State Values in the United Arab Emirates

BACKGROUND

No five-level EuroQol five-dimensional questionnaire (EQ-5D-5L) value sets are currently available in the Middle East to inform decision making in the region's health care systems.

OBJECTIVES

To test the feasibility of eliciting EQ-5D-5L values from a general public sample in the United Arab Emirates (UAE) using the EuroQol Group's standardized valuation protocol.

METHODS

Values were elicited in face-to-face computer-assisted personal interviews. Adult Emiratis were recruited in public places. Respondents completed 10 time trade-off tasks and 7 discrete choice experiment tasks, followed by debriefing questions about their experience of completing the valuation tasks. Descriptive analyses were used to assess the face validity of the data.

RESULTS

Two hundred respondents were interviewed in December 2013. The face validity of the data appears to be reasonably high. Mean time trade-off values ranged from 0.81 for the mildest health state (21111) to 0.19 for the worst health state in the EQ-5D-5L descriptive system (55555). Health states were rarely valued as being worse than dead (6.2% of all observations; 10% of all valuations of 55555). In a rationality check discrete choice experiment task whereby a health state (55554) was compared with another that logically dominated it (55211), 99.5% of the respondents chose the dominant option. Most of the respondents stated that their religious beliefs influenced their responses to the valuation tasks.

CONCLUSIONS

Our results suggest that it is feasible to generate meaningful health-state values in the UAE, though some adaptation of the methods may be required to improve their acceptability in the UAE (and other countries with predominantly Arab and/or Muslim populations).

Eliciting road traffic injuries cost among Iranian drivers' public vehicles using willingness to pay method

Background and Aim:

To allocate resources at the national level and ensure the safety level of roads with the aim of economic efficiency, cost calculation can help determine the size of the problem and demonstrate the economic benefits resulting from preventing such injuries. This study was carried out to elicit the cost of traffic injuries among Iranian drivers of public vehicles.

Materials and Methods:

In a cross-sectional study, 410 drivers of public vehicles were randomly selected from all the drivers in city of Tehran, Iran. The research questionnaire was prepared based on the standard for willingness to pay (WTP) method (stated preference (SP), contingent value (CV), and revealed preference (RP) model). Data were collected along with a scenario for vehicle drivers. Inclusion criteria were having at least high school education and being in the age range of 18 to 65 years old. Final analysis of willingness to pay was carried out using Weibull model.

Results:

Mean WTP was 3,337,130 IRR among drivers of public vehicles. Statistical value of life was estimated 118,222,552,601,648 IRR, for according to 4,694 dead drivers, which was equivalent to 3,940,751,753 $ based on the dollar free market rate of 30,000 IRR (purchase power parity). Injury cost was 108,376,366,437,500 IRR, equivalent to 3,612,545,548 $. In sum, injury and death cases came to 226,606,472,346,449 IRR, equivalent to 7,553,549,078 $. Moreover in 2013, cost of traffic injuries among the drivers of public vehicles constituted 1.25% of gross national income, which was 604,300,000,000$. WTP had a significant relationship with gender, daily payment, more payment for time reduction, more pay to less traffic, and minibus drivers.

Conclusion:

Cost of traffic injuries among drivers of public vehicles included 1.25% of gross national income, which was noticeable; minibus drivers had less perception of risk reduction than others.

Can property values capture changes in environmental health risks? Evidence from a stated preference study in Italy and the United Kingdom

Hedonic models are a common nonmarket valuation technique, but, in practice, results can be affected by omitted variables and whether homebuyers respond to the assumed environmental measure. We undertake an alternative stated preference approach that circumvents these issues. We examine how homeowners in the United Kingdom and Italy value mortality risk reductions by asking them to choose among hypothetical variants of their home that differ in terms of mortality risks from air pollution and price. We find that Italian homeowners hold a value of a statistical life (VSL) of €6.4 million, but U.K. homeowners hold a much lower VSL (€2.1 million). This may be because respondents in the United Kingdom do not perceive air pollution where they live to be as threatening, and actually live in cities with relatively low air pollution. Italian homeowners value a reduction in the risk of dying from cancer more than from other causes, but U.K. respondents do not hold such a premium. Lastly, respondents who face higher baseline risks, due to greater air pollution where they live, hold a higher VSL, particularly in the United Kingdom. In both countries, the VSL is twice as large among individuals who perceive air pollution where they live as high.

Species-specific preferences of German recreational anglers for freshwater fishing experiences, with emphasis on the intrinsic utilities of fish stocking and wild fishes

To answer the question, whether anglers have an intrinsic preference for stocking or a preference for catch outcomes (e.g. catch rates) believed to be maintained by stocking, a discrete choice experiment was conducted among a sample of anglers (n = 1335) in Lower Saxony, Germany. After controlling for catch aspects of the fishing experience, no significant influence of two stocking attributes (stocking frequency and composition of the catch in terms of wild v. hatchery fishes) on the utility gained from fishing was found for any of the freshwater species that were studied. It was concluded that the previously documented large appreciation of fish stocking by anglers may be indicative of an underlying preference for sufficiently high catches rather than reflect an intrinsic preference for stocking or the catching of wild fishes per se.

Beyond Happiness and Satisfaction: Toward Well-Being Indices Based on Stated Preference

This paper proposes foundations and a methodology for survey-based tracking of well-being. First, we develop a theory in which utility depends on "fundamental aspects" of well-being, measurable with surveys. Second, drawing from psychologists, philosophers, and economists, we compile a comprehensive list of such aspects. Third, we demonstrate our proposed method for estimating the aspects' relative marginal utilities-a necessary input for constructing an individual-level well-being index-by asking ~4,600 U.S. survey respondents to state their preference between pairs of aspect bundles. We estimate high relative marginal utilities for aspects related to family, health, security, values, freedom, happiness, and life satisfaction.

Quantifying preferences for the natural world using monetary and nonmonetary assessments of value

Given that funds for biodiversity conservation are limited, there is a need to understand people's preferences for its different components. To date, such preferences have largely been measured in monetary terms. However, how people value biodiversity may differ from economic theory, and there is little consensus over whether monetary metrics are always appropriate or the degree to which other methods offer alternative and complementary perspectives on value. We used a choice experiment to compare monetary amounts recreational visitors to urban green spaces were willing to pay for biodiversity enhancement (increases in species richness for birds, plants, and aquatic macroinvertebrates) with self-reported psychological gains in well-being derived from visiting the same sites. Willingness-to-pay (WTP) estimates were significant and positive, and respondents reported high gains in well-being across 3 axes derived from environmental psychology theories (reflection, attachment, continuity with past). The 2 metrics were broadly congruent. Participants with above-median self-reported well-being scores were willing to pay significantly higher amounts for enhancing species richness than those with below-median scores, regardless of taxon. The socio-economic and demographic background of participants played little role in determining either their well-being or the probability of choosing a paying option within the choice experiment. Site-level environmental characteristics were only somewhat related to WTP, but showed strong associations with self-reported well-being. Both approaches are likely to reflect a combination of the environmental properties of a site and unobserved individual preference heterogeneity for the natural world. Our results suggest that either metric will deliver mutually consistent results in an assessment of environmental preferences, although which approach is preferable depends on why one wishes to measure values for the natural world.

Assessing whether there is a cancer premium for the value of a statistical life

This article estimates whether there is a cancer risk premium for the value of a statistical life using stated preference valuations of cancer risks for a large, nationally representative US sample. The present value of an expected cancer case that occurs after a one decade latency period is $10.85m, consistent with a cancer premium that is 21% greater than the median value of a statistical life estimates for acute fatalities. This cancer premium is smaller than the premium proposed for policy analyses in the UK and the USA. There is also a greater premium for policies that reduce cancer risks to zero and for risk reductions affecting those who perceive themselves to have a greater than average probability of having cancer.

Where would you go for your next hospitalization?

We examine the effects of diverse dimensions of hospital quality - including consumers' perceptions of unobserved attributes - on future hospital choice. We utilize consumers' stated preference weights to obtain hospital-specific estimates of perceptions about unmeasured attributes such as reputation. We report three findings. First, consumers' perceptions of reputation and medical services contribute substantially to utility for a hospital choice. Second, consumers tend to select hospitals with high clinical quality scores even before the scores are publicized. However, the effect of clinical quality on hospital choice is relatively small. Third, satisfaction with a prior hospital admission has a large impact on future hospital choice. Our findings suggest that including measures of consumers' experience in report cards may increase their responsiveness to publicized information, but other strategies are needed to overcome the large effects of consumers' beliefs about other quality attributes.

Survey mode effects on valuation of environmental goods

This article evaluates the effect of the choice of survey recruitment mode on the value of water quality in lakes, rivers, and streams. Four different modes are compared: bringing respondents to one central location after phone recruitment, mall intercepts in two states, national phone-mail survey, and an Internet survey with a national, probability-based panel. The modes differ in terms of the representativeness of the samples, non-response rates, sample selection effects, and consistency of responses. The article also shows that the estimated value of water quality can differ substantially depending on the survey mode. The national Internet panel has the most desirable properties with respect to performance on the four important survey dimensions of interest.