Designing Discrete Choice Experiments for Health Care

Musculoskeletal patients' preferences for care from physiotherapists or support workers: a discrete choice experiment

BACKGROUND

Delegation of clinical tasks from physiotherapists to physiotherapy support workers is common yet varies considerably in musculoskeletal outpatient physiotherapy services, leading to variation in patient care. This study aimed to explore patients' preferences and estimate specific trade-offs patients are willing to make in treatment choices when treated in musculoskeletal outpatient physiotherapy services.

METHODS

A discrete choice experiment was conducted using an efficient design with 16 choice scenarios, divided into two blocks. Adult patients with musculoskeletal conditions recruited from a physiotherapy service completed a cross-sectional, online questionnaire. Choice data analyses were conducted using a multinomial logit model. The marginal rate of substitution for waiting time to first follow-up physiotherapy appointment and distance from the physiotherapy clinic was calculated and a probability model was built to estimate the probability of choosing between two distinct physiotherapy service options under different scenarios.

RESULTS

382 patient questionnaires were completed; 302 participants were treated by physiotherapists and 80 by physiotherapists and support workers. There was a significant preference to be seen by a physiotherapist, have more follow-up treatments, to wait less time for the first follow-up appointment, to be seen one-to-one, to see the same clinician, to travel a shorter distance to get to the clinic and to go to clinics with ample parking. Participants treated by support workers did not have a significant preference to be seen by a physiotherapist and it was more likely that they would choose to be seen by a support worker for clinic scenarios where the characteristics of the physiotherapy service were as good or better.

CONCLUSIONS

Findings highlight that patients treated by support workers are likely to choose to be treated by support workers again if the other service characteristics are as good or better compared to a service where treatment is provided only by physiotherapists. Findings have implications for the design of physiotherapy services to enhance patient experience when patients are treated by support workers. The findings will contribute to the development of "best practice" recommendations to guide physiotherapists in delegating clinical work to physiotherapy support workers for patients with musculoskeletal conditions.

Improving Uptake of Non-Communicable Disease Screening in Sri Lanka: Eliciting Peoples' Preferences using a Discrete Choice Experiment

A national programme to universally screen the population between 35 - 65 years for non-communicable diseases was established at 'Healthy Lifestyle Centres (HLCs)' in 2011 in Sri Lanka. Despite several efforts by policy makers, the uptake of screening remained below 10% of the target population and with disparities in uptake across districts and among men and women. Considering service beneficiaries as a vital stakeholder, a discrete choice experiment was carried out to estimate people's preference for a NCD screening service delivery model in rural, urban and estate sectors in a district in Sri Lanka. The choice design and the general survey questionnaire was developed through focus group discussions, literature reviews and stakeholder consultations. Data was collected by stratified random sampling, with 187 participants from the urban sector, 253 from the rural sector and 152 from the estate/plantation sector. Peoples' preference was assessed as utility estimates derived using multinomial logistic regression. Reliability was assessed within test among all study participants and with test-retest among 40 participants showed 80% precision. Urban and rural sectors gave the highest priority to workplace screening over screening at HLCs. The estates attributed the highest priority for cost free screening. If cost free screening is offered with having to spend 1-2 hours at the most preferred opening times for each sector with warm and friendly staff, the uptake of screening can predicted to be increased by 65, 29 and 21 times respectively in urban, rural and estate sectors relative to having to attend HLCs from 8am - 4 pm, spending more than 2 hours and Rs. 1000 with unfriendly staff. Thus, peoples' preferences on service delivery aspects seemed to have differed from government priorities. Preferences when ill and apparently healthy differed, as they preferred to spend less time and money when healthy than when ill.

Does Energy Poverty Affect Energy Efficiency Investment Decisions? First Evidence from a Stated Choice Experiment

Energy poverty is a multidimensional and continuously growing societal problem, with political roots. In pursuit of mitigating the problem, the European Commission has adopted a bundle of policies, such as consumer protection measures, short-term financial interventions, motivations for energy efficiency (e.g., energy retrofits and replacement of old household appliance) and information campaigns, among others. There is no doubt, however, that increasing the income of vulnerable households would be the most preferred and effective option. Focusing on energy efficiency, a measure typically incorporated in the National Energy and Climate Plans (NECPs) of many Member States as a means to fight energy poverty, this paper aims to shed light on the need to gradually move towards more localized—not to say personalized—actions. In this direction, a labeled choice-based experiment is used, which involves a hypothetical selection between three alternative energy interventions, i.e., house retrofit, upgrading of heating system and upgrading of household electrical appliances. The research aims to integrate the preferences of households from the choice experiment with indicators of energy poverty and establish a connection between energy poverty and energy efficiency investment decisions. The results demonstrate that households’ preferences are affected by qualitative and quantitative aspects of energy vulnerability and sociodemographic characteristics. Furthermore, vulnerable households seem to be more prone to the so-called “discounting gap”, as previous studies also suggest. These findings are worrisome because, without tailor-made support, these households may never escape the vicious circle of energy poverty. To this end, the survey could provide useful information to policy-makers towards developing more robust policies of energy poverty alleviation.

Patient preferences for topical treatment of actinic keratoses: a discrete-choice experiment

BACKGROUND

The treatment of actinic keratosis (AK) is a potentially effective strategy for the prevention of cutaneous squamous cell carcinoma (cSCC). However, the patient perspective on potential benefits of AK treatment in terms of skin cancer reduction has received little attention to date.

OBJECTIVES

(i) To investigate patient preferences for topical treatments for AK using a discrete-choice experiment (DCE); (ii) to evaluate patient willingness to trade between clinical benefit and medical burden.

METHODS

The DCE was conducted as part of a study to establish the feasibility of a phase III randomized controlled trial evaluating the prevention of cSCC using currently available topical interventions. Preferences were elicited by asking patients to make a series of choices between treatment alternatives with different hypothetical combinations of attribute levels. Willingness to trade between treatment attributes was estimated using a flexible-choice model that allows for the heterogeneity of patient preferences.

RESULTS

A total of 109 patients with AK completed the DCE. The majority of patients who expressed valid preferences were willing to accept some reduction in both prophylactic and cosmetic efficacy to reduce the burden of the treatment regimen, the severity of skin reaction and other adverse effects. Patients may reject treatment if the perceived therapeutic benefit is outweighed by the subjective burden of treatment.

CONCLUSIONS

Evidence of significant variation in the perceived utility of treatments across patients highlights the importance of taking individual patient preferences into account to improve AK treatment acceptability and adherence.

Perspectives of patients, first-degree relatives and rheumatologists on preventive treatments for rheumatoid arthritis: a qualitative analysis

Background

There is growing evidence that it may be possible to identify people at high risk of developing rheumatoid arthritis (RA). Assuming that effective interventions were available, this could mean that treatments introduced in the pre-symptomatic phase could prevent or delay the onset of the disease. Our study aimed to identify the potential attributes involved in decision-making around whether or not to take preventive treatment for RA, in order to inform the development of a discrete choice experiment (DCE) to ascertain consumer preferences for a preventive treatment program for RA.

Methods

We conducted a focus group study to develop conceptual attributes, refine their meaning, and develop levels. Participants included RA patients, first-degree relatives of RA patients, and rheumatologists who were 18 years of age and over, could read and speak English, and could provide informed consent. Candidate attributes were refined through iterative rounds of data collection and analysis. All focus groups were audio-recorded and transcribed, and then analyzed using the Framework Method to identify, compare, and contrast key conceptual attributes.

Results

Attributes identified from analysis included: accuracy of the test, certainty in estimates, method of administration, risk of RA and risk of reduction with treatment, risk and seriousness of side effects, person recommending the test, and opinion of the health care professional. Patients with RA, first-degree relatives of patients, and rheumatologists all valued the accuracy of testing due to concerns about false positives, and valued certainty in estimates of the test and preventive treatment. Patients and first-degree relatives desired this evidence from a range of sources, including discussions with people with the disease and health care professionals, and their preferences were modified by the strength of recommendation from their health care professional.

Conclusions

The role of the person who recommends a test and the opinion of a health care professional are novel potential attributes involved in decisions around whether or not to take preventive treatment for RA, that have not been included in previous DCEs.

Gynaecologists' and general surgeons' preference for the features of integrated theatres: a discrete choice experiment

Background

Laparoscopic surgery is progressing rapidly is becoming the normal route for many abdominal operations, even for major complex surgery. The integrated laparoscopic theatre is a state-of-the-art system in which the laparoscopic equipment and multiple flat-screen monitors are permanently installed to be operational on demand inside the theatre. These expensive systems are being widely adopted, however very little research has been published regarding which features of these systems are desired by the surgeons who use them.

The study objective was to assess the strength of preference for key attributes of integrated laparoscopic theatres and to compare these preferences between Gynaecologists and General surgeons.

Methods

This was an electronically distributed discrete choice experiment survey of British practicing Laparoscopic Gynaecologists and General Surgeons (Through The British Society of Gynaecology Endoscopy and The Association of Laparoscopic Surgeons of Great Britain and Ireland).

An electronic survey was designed and pre-tested. This was then sent to practicing British Laparoscopic Gynaecologists and General-Surgeons. There were structured questions regarding the seven key attributes of integrated laparoscopic theatres in the standard form for a discrete choice experiment.

Results

Questionnaires from 167 respondents were analysed. One hundred three were gynaecologists and 64 were general-surgeons. Adjustable screens for height and position was the most favoured attribute and it is 4.7 times more desirable than the next most desirable attribute, which was a wire free floor. The least desirable features were piped CO2, ceiling-mounted-screens and external-transmission-of-images.

Conclusion

Both groups favour adjustable screens for position and height above all the other features. These findings are in contrast with previous research, which showed that when asked to rank the attributes in order, gynaecologists chose ceiling mounted screens first and adjustable screens fourth. When asked to “trade off” attributes in the discrete choice experiment the adjustability of the screens became much more important than how the screens were mounted. With new wireless technology the benefits of a fully integrated theatre could be delivered with floor mounted systems at a considerably reduced cost. This information is important to manufacturers and purchasers of these systems in order to design cost effective ergonomic theatres that are fit for purpose.

Electronic supplementary material

The online version of this article (10.1186/s12905-018-0576-2) contains supplementary material, which is available to authorized users.

Factors influencing job preferences of health workers providing obstetric care: results from discrete choice experiments in Malawi, Mozambique and Tanzania

BACKGROUND

Task shifting from established health professionals to mid-level providers (MLPs) (professionals who undergo shorter training in specific procedures) is one key strategy for reducing maternal and neonatal deaths. This has resulted in a growth in cadre types providing obstetric care in low and middle-income countries. Little is known about the relative importance of the different factors in determining motivation and retention amongst these cadres.

METHODS

This paper presents findings from large sample (1972 respondents) discrete choice experiments to examine the employment preferences of obstetric care workers across three east African countries.

RESULTS

The strongest predictors of job choice were access to continuing professional development and the presence of functioning human resources management (transparent, accountable and consistent systems for staff support, supervision and appraisal). Consistent with similar works we find pay and allowances significantly positively related to utility, but financial rewards are not as fundamental a factor underlying employment preferences as many may have previously believed. Location (urban vs rural) had the smallest average effect on utility for job choice in all three countries.

CONCLUSIONS

These findings are important in the context where efforts to address the human resources crisis have focused primarily on increasing salaries and incentives, as well as providing allowances to work in rural areas.

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

Discrete choice experiments (DCEs) have become a commonly used instrument in health economics. This paper updates a review of published papers between 1990 and 2000 for the years 2001-2008. Based on this previous review, and a number of other key review papers, focus is given to three issues: experimental design; estimation procedures; and validity of responses. Consideration is also given to how DCEs are applied and reported. We identified 114 DCEs, covering a wide range of policy questions. Applications took place in a broader range of health-care systems, and there has been a move to incorporating fewer attributes, more choices and interview-based surveys. There has also been a shift towards statistically more efficient designs and flexible econometric models. The reporting of monetary values continues to be popular, the use of utility scores has not gained popularity, and there has been an increasing use of odds ratios and probabilities. The latter are likely to be useful at the policy level to investigate take-up and acceptability of new interventions. Incorporation of interactions terms in the design and analysis of DCEs, explanations of risk, tests of external validity and incorporation of DCE results into a decision-making framework remain important areas for future research.