How well do discrete choice experiments predict health choices? A systematic review and meta-analysis of external validity

Preferences of US adolescents and parents for vaccination against invasive meningococcal disease

BACKGROUND

Percentage uptake of some meningococcal vaccines is low in the US. Understanding what drives vaccination preferences may help to increase vaccination rates.

OBJECTIVES

To determine how attributes of meningococcal vaccines and the availability of a pentavalent (MenABCWY) vaccine profile drive adolescents' and young people's (AYP's) willingness to be vaccinated and parents' and legal guardians' (PLG') willingness for their child to be vaccinated (WTV). To also explore how preferences for meningococcal vaccines vary by participant characteristics.

METHODS

Vaccine preferences were elicited in a discrete choice experiment (DCE) with AYP aged 16-23 years and PLG of adolescents aged 11-17 years. Participants chose between two hypothetical vaccine profiles that differed in level of protection, dosing, and risks of mild-to-moderate and severe side effects, and a no vaccination profile. Main outcome measures were relative attribute importance (RAI) and WTV. RAI measured the maximum contribution of an attribute to vaccination choice relative to other attributes. WTV compared predicted choice probabilities for the three vaccine profiles.

RESULTS

407 AYP and 394 PLG participated (50.9% male, 78.4% White/Caucasian). Irrespective of vaccine attributes, 59.5% always opted into vaccination and 3.6% always opted out of vaccination. The most important attributes were level of protection (RAI: 33.7%) and risk of mild-to-moderate side effects (RAI: 32.3%). Dosing was more important to PLG (RAI: 5.9%) than AYP (RAI: 2.0%; p < .01). Adding a pentavalent vaccine alternative increased WTV by 3.7 percentage points (PP) for PLG, 2.4 PP for AYP, 16.4 PP for vaccine-hesitant participants, 13.4 PP for participants without health insurance, and 9.6 PP for adults.

CONCLUSION

Level of protection and risk of mild-to-moderate side effects were the most important vaccine attributes. Adding a pentavalent vaccine alternative increased WTV particularly among adults, individuals who were vaccine-hesitant, and individuals without health insurance.

Patients' Preferences for Sphingosine-1-Phosphate Receptor Modulators in Multiple Sclerosis Based on Clinical Management Considerations: A Choice Experiment

BACKGROUND

Several sphingosine-1-phosphate receptor (S1PR) modulators are available in the US for treating relapsing forms of multiple sclerosis (RMS). Given that these S1PR modulators have similar efficacy and safety, patients may consider the clinical management characteristics of the S1PR modulators when deciding among treatments. However, none of the S1PR modulators is clearly superior in every aspect of clinical management, and for some treatments, clinical management varies based on a patient's comorbid health conditions (e.g., heart conditions [HC]).

OBJECTIVES

This study aimed to determine which S1PR modulator patients with relapsing-remitting multiple sclerosis (RRMS) would prefer based on clinical management considerations, and to estimate how different clinical management considerations might drive these preferences. Preferences were explored separately for patients with and without comorbid HC.

METHODS

A multicriteria decision analysis was conducted on S1PR modulators approved to treat RMS: fingolimod, ozanimod, siponimod, and ponesimod. Clinical management preferences of patients with RRMS were elicited in a discrete choice experiment (DCE) in which participants repeatedly chose between hypothetical S1PR modulator profiles based on their clinical management attributes. Attributes included first-dose observations, genotyping, liver function tests, eye examinations, drug-drug interactions, interactions with antidepressants, interactions with foods high in tyramine, and immune system recovery time. Preferences were estimated separately for patients with HC and without HC (noHC). Marginal utilities were calculated from the DCE data for each attribute and level using a mixed logit model. In the multicriteria decision analysis, partial value scores were created by applying the marginal utilities for each attribute and level to the real-world profiles of S1PR modulators. Partial value scores were summed to determine an overall clinical management value score for each S1PR modulator.

RESULTS

Four hundred patients with RRMS completed the DCE. Ponesimod had the highest overall value score for patients both without (n = 341) and with (n = 59) HC (noHC: 5.1; HC: 4.0), followed by siponimod (noHC: 4.9; HC: 3.3), fingolimod (noHC: 3.4; HC: 2.8), and ozanimod (noHC: 0.9; HC: 0.8). Overall, immune system recovery time contributed the highest partial value scores (noHC: up to 1.9 points; HC: up to 1.2 points), followed by the number of drug-drug interactions (noHC: up to 1.2 points; HC: up to 1.7 points).

CONCLUSIONS

When considering the clinical management of S1PR modulators, the average patient with RRMS is expected to choose a treatment with shorter immune system recovery time and fewer interactions with other drugs. Patients both with and without heart conditions are likely to prefer the clinical management profile of ponesimod over those of siponimod, fingolimod, and ozanimod. This information can help inform recommendations for treating RRMS and facilitate shared decision making between patients and their doctors.

Preferences for a Clostridioides difficile vaccine among adults in the United States

INTRODUCTION

Clostridioides difficile (C.diff) infection (CDI) causes significant morbidity and mortality among older adults. Vaccines to prevent CDI are in development; however, data on the target population's preferences are needed to inform vaccination recommendations in the United States (US). This study assessed US adults' willingness to receive a C.diff vaccine and examined how vaccine attributes influence their choices.

METHODS

A cross-sectional online survey with a discrete choice experiment (DCE) was conducted among US adults aged ≥50 years. DCE attributes included effectiveness, duration of protection, reduction in symptom severity, out-of-pocket (OOP) costs, number of doses, and side effects. The DCE included 11 choice tasks, each with two hypothetical vaccine profiles and an opt-out (i.e., no vaccine). Attribute-level preference weights were estimated using hierarchical Bayesian modeling. Attribute relative importance (RI) was compared between select subgroups.

RESULTS

Of 1216 adults in the analyses, 29.9% reported they knew either 'a little' (20.7%) or 'a lot' (9.2%) about C.diff before the study. A C.diff vaccine was chosen 58.0% of the time (vs. opt-out) across choice tasks. It was estimated that up to 75.0% would choose a vaccine when OOP was $0. Those who were immunocompromised/high-risk for CDI (vs. not) more frequently chose a C.diff vaccine. Decreases in OOP costs (RI = 56.1), improvements in vaccine effectiveness (RI = 17.7), and reduction in symptom severity (RI = 10.3) were most important to vaccine choice. The rank ordering of attributes by importance was consistent across subgroups.

CONCLUSION

OOP cost, improvements in vaccine effectiveness, and reduction in CDI severity were highly influential to vaccine selection. Most adults aged ≥50 years were receptive to a C.diff vaccine, especially with little-to-no OOP cost, suggesting that mandating insurance coverage of vaccination with no copayment may increase uptake. The limited awareness about C.diff among adults presents an opportunity for healthcare providers to educate their patients about CDI prevention.

Stated patient preferences for overnight at-home diagnostic assessment of sleep disorders

PURPOSE

The diagnostic workup for assessment of sleep disorders commonly involves overnight testing to assess sleep patterns and pathological events. So far, little is known about preferences for provision of home sleep tests to patients with sleep disorders. This study aims to close this gap by eliciting preferences for home sleep testing using a discrete choice experiment (DCE).

METHODS

A DCE with seven attributes of at-home sleep testing and three levels per attribute was developed using a fractional factorial design. Patients with and without previous sleep testing experience were recruited from two large sleep centers in Germany. Coefficients for attribute levels were calculated using a conditional logit model to estimate their influence on choice decisions and calculate the relative importance of each attribute.

RESULTS

305 patients (54.5 ± 13,1 years, 65.3% male) were enrolled, and 288 surveys with complete data included for analysis. Attributes with greatest relevance were Waiting time to discuss sleep study results; Waiting time to conduct sleep study, and Sleep quality during measurement. Of lowest importance was Diagnostic accuracy of sleep study, followed by Effort to apply sleep study device. Significant heterogeneity in choice behavior was found, including differences by gender, willingness-to-pay for sleep studies, and previous experience with sleep studies. Preferred location for conducting sleep testing was at-home in 50.7% and in-lab in 46.9%.

CONCLUSIONS

Preferences and relative importance of home sleep test attributes vary among different subgroups. Considering those preferences can be important for clinicians and policymakers when designing care pathways and planning of testing policies for sleep disorders.

Patient Factors Influencing Prescription of Antithrombotic Medication After Lower Limb Endovascular Intervention

OBJECTIVE

There is significant practice variation in the use of antithrombotic therapy after endovascular intervention for lower limb peripheral arterial disease, with differences in medication choice and duration. Prescriber decision making is complex, and patient factors have been shown to substantially contribute to prescribing variation. To determine the influence of patient factors on antithrombotic prescribing, a discrete choice experiment was distributed to vascular surgeons and trainees across Australia and Aotearoa New Zealand.

METHODS

After pilot testing, the discrete choice experiment questionnaire was distributed to 300 vascular surgeons and trainee members of the Australian and New Zealand Society for Vascular Surgery. Multinomial logistic regression models were used to analyse patient factors that had the most influence on decisions to prescribe a second antithrombotic agent, and the preferred choice of antithrombotic (clopidogrel 75 mg daily or rivaroxaban 2.5 mg twice daily) in addition to aspirin 100 mg daily. The odds ratio (OR) with 95% confidence interval (CI) reported preference strength.

RESULTS

A total of 44 questionnaires were completed between September and October 2023, reaching the 15% targeted response rate. Prescribing a second antithrombotic was more likely after femoropopliteal stenting compared with angioplasty (OR 1.89, 95% CI 1.20 - 2.13), and in chronic limb threatening ischaemia compared with intermittent claudication (OR 1.58, 95% CI 1.20 - 2.13). Most respondents preferred clopidogrel over rivaroxaban (62%), with over a third of respondents exclusively prescribing clopidogrel. Patients with stents (OR 1.77, 95% CI 1.32 - 2.37) or moderate bleeding risk (OR 1.38, 95% CI 0.97 - 1.84) were more likely to receive clopidogrel than rivaroxaban.

CONCLUSION

This study demonstrates that vascular surgeons primarily prioritise antithrombotic prescribing decisions by procedure type. Clopidogrel is more likely to be prescribed than rivaroxaban as a second agent in combination with aspirin, especially after stenting. Knowing these clinician preferences can target implementation strategies towards supporting decision making in subgroups of patients according to individual risk profiles.

Nurses' preferences for working in Uber-style 'Internet plus' nursing services: A discrete choice experiment

BACKGROUND

China's 'Internet Plus' nursing services, which are Uber-style home care services with an 'online application, offline service' approach, have been evolving over the past five years. Registered nurses' preference for these Uber-style Internet Plus nursing services are crucial for improving human resource management and service efficiency, yet research in this area remains scarce.

OBJECTIVE

This study aimed to explore registered nurses' preferences for Uber-style Internet Plus nursing services and provide optimization recommendations from a supply-side perspective.

DESIGN

A cross-sectional study utilising a discrete choice experiment.

SETTING(S)

Two public tertiary hospitals located in Tianjin, China, which have implemented Internet Plus nursing services.

PARTICIPANTS

211 registered nurses who participated in Internet Plus nursing services.

METHODS

The survey was conducted anonymously using an online survey platform. Respondents were presented with choices between two alternatives, based on five key attributes: income, safety and security, patient and family cooperation, commute time, and service type. Mixed logit models estimated the stated preferences for attributes. Relative importance scores, willingness-to-pay estimates, and simulations of service-type uptake rates were calculated. Subgroup analysis and seemingly unrelated regression estimation were performed to examine heterogeneity in preferences.

RESULTS

A total of 3202 choice observations were generated. When sorted by the strength of preference, the five attributes related to registered nurses' choice of Uber-style Internet Plus nursing services, measured by their relative importance scores, are as follows: safety and security (30.89 %), income (27.41 %), patient and family cooperation (18.47 %), service type (11.96 %), and commuting time (11.27 %). Elevating safety and security from low to high levels has the same utility as a 31.81 % increase in monthly income, equivalent to 2586.14 yuan. Subgroup analysis showed that senior nurses place more value on safety and security than junior nurses (β = 1.421 vs.β = 0.725; P = 0.011), and unmarried nurses had a stronger preference for family and caregiver cooperation (β = 1.105 vs.β = 0.314; P = 0.023).

CONCLUSIONS

The strength and heterogeneity of registered nurses' preferences should be highlighted in the dispatch algorithms model of Uber-style Internet Plus nursing services, thereby enhancing the efficiency and humanity of Uber-style Internet Plus nursing services.

TWEETABLE ABSTRACT

Registered nurses prioritise safety and security, acknowledging heterogeneous preferences in Uber-style Internet Plus nursing services.

Sources and processes of social influence on health-related choices: A systematic review based on a social-interdependent choice paradigm

BACKGROUND

Most choices in healthcare are not made in social isolation. However, current econometric models treat patients' preferences as the sole determinants of their choices. Through the lens of sociology and medical sociology theories, this paper presents a systematic literature review of identifiable social influences on patients' choices, serving as a first step in developing a social-interdependent choice paradigm.

METHODS

Following the PRISMA guideline and using nine databases, we identified the individual agents or groups involved in health-related choices, the functional content through which social relationships influence patients, and the choice constructs affected by these processes. From 9036 screened articles, we selected 208 to develop an analytical framework connecting social relationships with choice constructs.

RESULTS

Social influences predominantly come from family, friends, specialized physicians, and general practitioners. We decomposed the functional content of social relationships into functions and contents. Dyadic interactions and expert knowledge were prominent functions, followed by social control. Prescriptive and informational contents were prevalent, followed by instrumental and emotional ones. Expert knowledge and social norms aligned with prescriptive and informational signals, while dyadic interactions provide emotional and instrumental signals. Reference points for social norms included friends, coworkers, and patients. Social relationships primarily impact which alternatives are evaluated, followed by alternative evaluation strategies and goal selection. Distinctions between medical domains and dimensions emerged, highlighting how the medical area conditions the social influence process.

CONCLUSION

This systematic review presents a comprehensive framework that elucidates the social influence process in healthcare patient decision-making. By detailing the functional content of social relationships into functions and contents and linking these components to the elements of the choice process, we created a structured approach to understanding how social relationships impact patient choices. This will facilitate the systematic integration of social relationships into econometric models of patient choice.

Health impact, budget impact, and price threshold for cost-effectiveness of lenacapavir for HIV pre-exposure prophylaxis in eastern and southern Africa: a modelling analysis

BACKGROUND

Injectable lenacapavir administered every 6 months is a promising product for HIV pre-exposure prophylaxis (PrEP). We aimed to estimate the health and budget impacts and threshold price at which lenacapavir could be cost-effective in eastern and southern Africa.

METHODS

We adapted an agent-based network model, EMOD-HIV, to simulate lenacapavir scale-up in Zimbabwe, South Africa, and western Kenya from 2026 to 2035. Uptake assumptions were informed by a literature review of PrEP product preferences. In the main analysis, we varied lenacapavir coverage by subgroup: female sex workers (40% coverage); male clients of female sex workers (40%); adolescent girls and young women aged 15-24 years with more than one sexual partner (32%); women aged 25 years and older with more than one sexual partner (36%); and males with more than one sexual partner (32%). We also assessed a higher coverage scenario (64-76% across subgroups) and scenarios of expanding lenacapavir use, varying from concentrated among those at highest HIV risk to broader coverage including those at medium HIV risk. We estimated the maximum per-dose lenacapavir price that achieved cost-effectiveness (

FINDINGS

In the main analysis, lenacapavir was projected to achieve from 1·6% (95% uncertainty interval [UI] 1·5-1·8) to 4·0% (3·4-5·1) population coverage across settings and to avert from 12·3% (5·4-19·5) to 18·0% (11·0-22·9) of infections over 10 years. The maximum price per dose was highest in South Africa ($106·28 [95% UI 95·72-115·87]), followed by Zimbabwe ($21·15 [17·70-24·89]), and lowest in western Kenya ($16·58 [15·44-17·70]). The 5-year budget impact was US$507·25 million (95% UI 436·14-585·42) in South Africa, $16·80 million (13·95-22·64) in Zimbabwe, and $4·09 million (3·86-4·30) in western Kenya. In the higher coverage scenario, lenacapavir distribution was projected to reach from 3·2% (95% UI 2·9-3·6) to 8·1% (6·8-10·5) population coverage and to avert from 21·2% (95% UI 14·7-18·5) to 33·3% (28·5-36·9) of HIV infections across settings over 10 years. Price thresholds were lower than in the main analysis: $88·34 (95% UI 83·02-94·19) in South Africa, $17·71 (15·61-20·05) in Zimbabwe, and $14·78 (14·33-15·30) in western Kenya. The 5-year budget impact was higher than the main analysis: $835·29 million (95% UI 736·98-962·98) in South Africa, $29·50 million (24·62-39·52) in Zimbabwe, and $7·45 million (7·11-7·85) in western Kenya. Expanding lenacapavir coverage resulted in higher HIV infections averted but lower price thresholds than scenarios of concentrated use among those with highest HIV risk.

INTERPRETATION

Our findings suggest that lenacapavir could avert substantial HIV incidence and that price thresholds and budget impacts vary by setting and coverage. These results could inform policy deliberations regarding lenacapavir pricing and resource planning.

FUNDING

The Bill & Melinda Gates Foundation.

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Affiliation(s)

Linxuan Wu Department of Epidemiology, University of Washington, Seattle, WA, USA
David Kaftan Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
Rachel Wittenauer CHOICE Institute, University of Washington School of Pharmacy, Seattle, WA, USA
Cory Arrouzet Department of Epidemiology, University of Washington, Seattle, WA, USA
Nishali Patel Department of Global Health, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
Arden L Saravis Department of Epidemiology, University of Washington, Seattle, WA, USA
Brian Pfau Department of Epidemiology, University of Washington, Seattle, WA, USA
Edinah Mudimu Department of Decision Sciences, University of South Africa, Pretoria, South Africa
Anna Bershteyn Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
Monisha Sharma Department of Global Health, University of Washington, Seattle, WA, USA.

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Assessing the Deterrent Effects of Ignition Interlock Devices

INTRODUCTION

Ignition interlock devices installed after conviction for driving under the influence of alcohol (DUI) have been shown to reduce subsequent DUI arrests (specific deterrence). However, there is little evidence on how interlock-device penalties might affect general deterrence, that is, deterring people from driving after consuming alcohol prior to a DUI conviction.

METHODS

A discrete choice experiment was conducted and data were analyzed in 2023 with 583 U.S.-based adults who consume alcohol at least once in the past week to assess the deterrent effects of five different penalties (fine, jail time, interlock device, license suspension, alcohol treatment) for alcohol-impaired driving under randomized sequential scenarios of high (20% chance of being caught) and low (1%) police enforcement. Participants resided in 46 states.

RESULTS

Deterrent effects of an interlock penalty, operationalized as having to install an interlock device for 1 year, are large and on par with a 20-fold increase in police enforcement activity (from 1% chance of being caught to 20%), or a $2,000 increase in the DUI fine under the status quo enforcement regime. On average, a 1-year interlock penalty had the same deterrent effect as a 10-day increase in jail time.

CONCLUSIONS

Wider use of interlock devices as a DUI penalty could have large deterrent effects, independent of their ability to physically prevent the motor vehicle of an intoxicated driver from starting. The deterrent effect documented here adds to evidence on interlock devices' overall effectiveness as well as their potential to shift DUI penalties away from criminalization (jail time) and toward immobilization and rehabilitation.

Virtual Service Delivery in Mental Health and Substance Use Care: A Systematic Review of Preference Elicitation Studies

Mental health and substance use disorders affect the lives of many people worldwide. Prevention and treatment of these conditions is important for optimal health and wellbeing, yet service access barriers are common. Virtual models of care may help to reduce barriers to receiving care. However, to facilitate uptake and use of virtual services, they need to appeal to patients and clinicians. This systematic review aimed to synthesise preference elicitation studies to determine what features of virtual mental health and substance use care are preferred by service users and service providers. Following the PRISMA guidelines for systematic reviews, we searched PubMed, PsycINFO, EconLit, MEDLINE, CINAHL, Academic Search Ultimate, and ProQuest Central for all available studies from database inception until May 2023. The Mixed Methods Appraisal Tool was used to assess the methodological quality of included studies. Nineteen studies met the eligibility criteria. However, none examined preferences for elements of different models of virtual care. Across the included studies, we identified 41 unique features that mapped to four themes of mental health and substance use care ('service', 'treatment', 'clinician' and 'additional supports'). Participant preferences were for individual, in-person, effective, flexible, and low-cost treatment. These preferences varied based on demographic factors, such as culture, gender, and participant type (e.g., patients, clinicians, general population). A user-centred approach should be adopted when designing and implementing mental health and substance use services. While preferences for features of mental health and substance use services more broadly are known, preferences for different models of virtual care remain unexplored. Future research should examine what features of virtual services would lead to optimal uptake and use across different users and stakeholders.

Preferences for sexual health services among middle-aged and older adults in the UK: a discrete choice experiment

OBJECTIVES

Sexual health is an integral part of well-being. However, the sexual health needs and desires of middle-aged and older adults have been largely disregarded. Therefore, this study aimed to understand the sexual health service preferences of adults aged 45 and older to improve the accessibility of sexual health services in the UK.

METHODS

The formative stage of the discrete choice experiment (DCE) followed three steps: concept elicitation, refining and implementation. The attributes and levels were determined through 22 semistructured interviews during the concept elicitation, followed by pilot testing for refining the survey. Qualtrics XM, with conjoint project features, was implemented as the DCE survey platform. We used a random parameter logit model to estimate the relative importance (RI) of each attribute and preference for each attribute level. We also used a latent class model to explore groups of participants with similar preferences.

RESULTS

In total, 200 responses were included for analysis. The demographic breakdown included 62.5% females, 35.5% people with disabilities and 26.0% identifying as a sexual minority. The median age was 53. Preferences for using sexual health services were mainly influenced by the mode of delivery (RI 32%), location (RI 18%) and cost (RI 16%). Participants showed a preference for face-to-face interactions at sexual health clinics and displayed a willingness to pay for private services. Extra support and the consultation style played minor roles in their decision-making process. No differences in preferences were identified among disabled people. However, sexual minorities expressed their preferences for conventional messaging.

CONCLUSIONS

Our study revealed that middle-aged and older individuals prioritise sexual health services offering face-to-face consultations, emphasising a preference to attend sexual health clinics over cost. Aligning service delivery with these preferences has the potential to significantly improve the accessibility and uptake of sexual health services for adults aged 45 and older in the UK.

Financial Toxicity and Willingness-to-Pay for Cancer Treatment Among People With Multiple Myeloma

PURPOSE

This study used willingness-to-pay (WTP) exercises to explore the relationships between race, financial toxicity, and treatment decision making among people with cancer.

METHODS

A convenience sample of people with multiple myeloma who attended an academic medical center in 2022 was surveyed. Financial toxicity was assessed by the Comprehensive Score for financial Toxicity, with scores <26 indicating financial toxicity. WTP was assessed with (1) a discrete choice experiment (DCE), (2) fixed-choice tasks, and (3) a bidding game.

RESULTS

In total, 156 people were approached, and 130 completed the survey. The majority of the sample was White (n = 99), whereas 24% (n = 31) was African American or Black. Forty-six percent (n = 60) of the sample were experiencing financial toxicity. In the DCE, the relative importance of cost was twice as high for those with financial toxicity (30% compared with 14%; P < .001). In the fixed-choice tasks, they were twice as likely to accept a treatment with shorter progression-free survival but lower costs (adjusted odds ratio [aOR], 2.47; P = .049). In the bidding game, the median monthly WTP of those with financial toxicity was half that of those without ($100 in US dollars [USD] compared with $200 USD; P < .001). Only in the bidding game was race statistically associated with WTP; after controlling for financial toxicity, African American or Black participants were three times as likely (aOR, 3.06; P = .007) to report a lower WTP.

CONCLUSION

Across all three exercises, participants with financial toxicity reported lower WTP than those without. As financial toxicity disproportionally affects some segments of patients, it is possible that financial toxicity contributes to cancer disparities.

Clinicians' Preferences for Sphingosine-1-Phosphate Receptor Modulators in Multiple Sclerosis Based on Clinical Management Considerations: A Choice Experiment

BACKGROUND

Four sphingosine-1-phosphate receptor (S1PR) modulators are currently available in the USA for treating relapsing forms of multiple sclerosis (MS). These S1PR modulators have similar efficacy. Clinicians may therefore consider other factors, such as clinical management considerations, when distinguishing among treatments. This study estimated which S1PR modulator clinicians would choose on the basis of a treatment's clinical management and quantified how individual aspects of clinical management might drive this choice.

METHODS

A multi-criteria decision analysis (MCDA) was conducted on the basis of clinical management preferences elicited in a discrete choice experiment (DCE) and real-world clinical management profiles of the S1PR modulators currently available to treat relapsing forms of MS (fingolimod, ozanimod, ponesimod, siponimod). The DCE was completed by neurologists in the USA experienced in treating MS and included eight clinical management attributes: first-dose observations, genotyping, liver function tests, eye exams, drug-drug interactions, interactions with antidepressants, interactions with foods high in tyramine, and immune system recovery time. Attribute levels were selected on the basis of S1PR modulator product labels. In the MCDA, partial MCDA scores were created for each attribute and summed to produce an overall MCDA score for each S1PR modulator.

RESULTS

The DCE was completed by 200 neurologists. The overall MCDA score was highest for ponesimod (4.78 points), followed by siponimod (4.10 points), fingolimod (3.61 points), and ozanimod (2.38 points). Having fewer drug-drug interactions contributed most to the overall scores (up to 1.56 points), followed by having no first-dose observations (0.95 points), the shortest immune system recovery time (0.94 points), and not interacting with foods high in tyramine (0.86 points).

CONCLUSION

When considering clinical management convenience, the average US-based neurologist treating MS is likely to choose ponesimod over siponimod, fingolimod, or ozanimod. The strongest driver of preferences was the number of drug-drug interactions. This information can help inform recommendations for the treatment of MS and facilitate shared decision-making between clinicians and patients.

The effects of free prescriptions on community pharmacy selection: A discrete choice experiment

BACKGROUND

Little is known about preferences for community pharmacies, particularly the influence of prescription co-payments, and for New Zealand's priority populations, Māori and Pacific Peoples. Improving understanding of community pharmacy preferences will enable tailoring services to meet community needs.

OBJECTIVES

This study aims to investigate New Zealanders' preferences for community pharmacies when collecting prescriptions. Additionally, variations in preferences for community pharmacy attributes between different latent and demographic groups were examined.

METHODS

Focus group discussions with various community groups were thematically analyzed to develop six attributes: location, wait time, customer service, prescription co-payments, parking availability, and nearby businesses. Participants were asked to complete an online survey involving 12 choice tasks, where they had to choose their preferred option of 3 unlabeled pharmacies along with demographic questions. A mixed multinomial logit model and latent classes analysis were used to assess and compare the participant preferences.

RESULTS

The sample of 553 participants, representative of the New Zealand population, resulted in 19,908 observations for analysis. The most attractive pharmacy attribute was its proximity, being within a 10-min travel distance from home or work. The importance of prescription co-payments is evident, with free prescriptions being the second most attractive attribute level and $15 NZD prescription co-payments being the least appealing. Different classes placed importance on different attributes, the largest of which prioritized prescription co-payments. Including demographic characteristics did not improve model accuracy nor predict class membership.

CONCLUSIONS

Under current policy, the most effective way for pharmacies to attract business is by offering free prescriptions. However, the trend of adopting lower-cost models may reduce the quality of care they deliver. Policy decision-makers must decide if they are comfortable with this potential impact.

Understanding general practitioner and pharmacist preferences for pharmacogenetic testing in primary care: a discrete choice experiment

Pharmacogenetic testing in the United Kingdom's National Health Service (NHS) has historically been reactive in nature, undertaken in the context of single gene-drug relationships in specialist settings. Using a discrete choice experiment we aimed to identify healthcare professional preferences for development of a pharmacogenetic testing service in primary care in the NHS. Respondents, representing two professions groups (general practitioners or pharmacists), completed one of two survey versions, asking them to select their preferred pharmacogenetic testing service in the context of a presentation of low mood or joint pain. Responses from 235 individuals were included. All respondents preferred pharmacogenetic testing over no testing, though preference heterogeneity was identified. Both professional groups, but especially GPs, were highly sensitive to service design, with uptake varying depending on the service offered. This study demonstrates uptake of a pharmacogenetic testing service is impacted by service design and highlights key areas which should be prioritised within future initiatives.

Impact of eliminating retirement earnings test on labor supply and pension benefit claims

This study explores the hypothetical elimination of Japan's retirement earnings test (ET) for public pensions, focusing on its implications for older workers' labor supply and pension-claiming behaviors. The ET currently reduces public pension benefits for individuals aged 65 and older if their earnings exceed specified thresholds, potentially discouraging employment in this demographic. Notably, the Japanese ET influences both immediate and future pension benefits, thus diminishing current payouts for working pensioners and foregoing beneficial actuarial adjustments-adjustments based on actuarial calculations that would otherwise increase future benefits to account for delayed pension claims. This dual impact may discourage the labor supply and influence pension-claiming behavior among older workers. Through a survey-based experiment with male workers aged 40-59 years expected to face the ET upon retirement, we assess three reform scenarios as the first study in the literature: (1) eliminating future benefit reductions through actuarial adjustments, thereby enhancing the value of deferred pension claims; (2) removing immediate benefit suspensions to increase current pension payments directly; and (3) a comprehensive reform combining both approaches. Our findings reveal that eliminating reductions through actuarial adjustments increases the intensive margin (labor hours and income) and encourages delayed pension claims. Conversely, removing immediate benefit suspensions influences both the extensive margin (decision to work) and the intensive margin but leads to earlier pension claims. By highlighting the importance of differentiating between immediate and future benefit components in designing ET reforms, this study demonstrates their significant impact on labor supply and pension-claiming decisions.

Developing feasible person-centred care alternatives to emergency department responses for adults with epilepsy: a discrete choice analysis mixed-methods study

Background

Calls have been made for paramedics to have some form of care pathway that they could use to safely divert adults with epilepsy away from emergency departments and instigate ambulatory care improvements. Different configurations are possible. To know which to prioritise for implementation/evaluation, there is a need to determine which are acceptable to service users and likely National Health Service-feasible.

Objective(s)

(1) Identify configurations being considered, (2) understand service users' views of them and current provision, (3) identify what sort of care service users want and (4) determine which configuration(s) is considered to achieve optimal balance in meeting users' preference and being National Health Service-feasible.

Design

Service providers were surveyed to address objective 1. Interviews with service users addressed objective 2. Objective 3 was addressed by completing discrete choice experiments. These determined users' care preferences for different seizure scenarios. Objective 4 was addressed by completing 'knowledge exchange' workshops. At these, stakeholders considered the findings on users' stated preferences and judged different pathway configurations against Michie's 'acceptability, practicability, effectiveness, affordability, side-effects and equity' feasibility criteria.

Setting

This project took place in England. The survey recruited representatives from neurology and neuroscience centres and from urgent and emergency care providers. For the interviews, recruitment occurred via third-sector support groups. Recruitment for discrete choice experiments occurred via the North West Ambulance Service NHS Trust and public advert. Workshop participants were recruited from neurology and neuroscience centres, urgent and emergency care providers, support groups and commissioning networks.

Participants

Seventy-two services completed the survey. Interviews were conducted with 25 adults with epilepsy (and 5 relatives) who had emergency service contact in the prior 12 months. Discrete choice experiments were completed by 427 adults with epilepsy (and 167 relatives) who had ambulance service contact in the prior 12 months. Workshops were completed with 27 stakeholders.

Results

The survey identified a range of pathway configurations. They differed in where they would take the patient and their potential to instigate ambulatory care improvements. Users had been rarely consulted in designing them. The discrete choice experiments found that users want a configuration of care markedly different to that offered. Across the seizure scenarios, users wanted their paramedic to have access to their medical records; for an epilepsy specialist (e.g. an epilepsy nurse, neurologist) to be available to advise; for their general practitioner to receive a report; for the incident to generate an appointment with an epilepsy specialist; for the care episode to last < 6 hours; and there was a pattern of preference to avoid conveyance to emergency departments and stay where they were. Stakeholders judged this configuration to be National Health Service-feasible within 5-10 years, with some elements being immediately deployable.

Limitations

The discrete choice experiment sample was broadly representative, but those reporting recent contact with an epilepsy specialist were over-represented.

Conclusions

Users state they want a configuration of care that is markedly different to current provision. The configuration they prefer was, with support and investment, judged to likely be National Health Service-feasible. The preferred configuration should now be developed and evaluated to determine its actual deliverability and efficacy.

Study registration

The study is registered as researchregistry4723.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/62) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 24. See the NIHR Funding and Awards website for further award information.

Treatment preferences among people at risk of developing tuberculosis: A discrete choice experiment

Diagnosing and treating people with bacteriologically-negative but radiologically-apparent tuberculosis (TB) may contribute to more effective TB care and reduce transmission. However, optimal treatment approaches for this group are unknown. It is important to understand peoples' preferences of treatment options for effective programmatic implementation of people-centred treatment approaches. We designed and implemented a discrete choice experiment (DCE) to solicit treatment preferences among adults (≥18 years) with TB symptoms attending a primary health clinic in Blantyre, Malawi. Treatment attributes included in the DCE were as follows: duration of treatment; number of tablets per dose; reduction in the risk of being unwell with TB disease; likelihood of infecting others; adverse effects from the treatment; frequency of follow up; and the annual travel cost to access care. Quantitative choice modelling with multinomial logit models estimated through frequentist and Bayesian approaches investigated preferences for the management of bacteriologically-negative, but radiographically-apparent TB. 128 participants were recruited (57% male, 43.8% HIV-positive, 8.6% previously treated for TB). Participants preferred to take any treatment compared to not taking treatment (odds ratio [OR] 5.78; 95% confidence interval [CI]: 2.40, 13.90). Treatments that reduced the relative risk of developing TB disease by 80% were preferred (OR: 2.97; 95% CI: 2.09, 4.21) compared to treatments that lead to a lower reduction in risk of 50%. However, there was no evidence for treatments that are 95% effective being preferred over those that are 80% effective. Participants strongly favoured the treatments that could completely stop transmission (OR: 7.87, 95% CI: 5.71, 10.84), and prioritised avoiding side effects (OR: 0.19, 95% CI: 0.12, 0.29). There was no evidence of an interaction between perceived TB disease risk and treatment preferences. In summary, participants were primarily concerned with the effectiveness of TB treatments and strongly preferred treatments that removed the risk of onward transmission. Person-centred approaches of preferences for treatment should be considered when designing new treatment strategies. Understanding treatment preferences will ensure that any recommended treatment for probable early TB disease is well accepted and utilized by the public.

Patients' Preferences for Cytoreductive Treatments in Newly Diagnosed Metastatic Prostate Cancer: The IP5-MATTER Study

BACKGROUND AND OBJECTIVE

Cytoreductive treatments for patients diagnosed with de novo synchronous metastatic hormone-sensitive prostate cancer (mHSPC) confer incremental survival benefits over systemic therapy, but these may lead to added toxicity and morbidity. Our objective was to determine patients' preferences for, and trade-offs between, additional cytoreductive prostate and metastasis-directed interventions.

METHODS

A prospective multicentre discrete choice experiment trial was conducted at 30 hospitals in the UK between December 3, 2020 and January 25, 2023 (NCT04590976). The individuals were eligible for inclusion if they were diagnosed with de novo synchronous mHSPC within 4 mo of commencing androgen deprivation therapy and had performance status 0-2. A discrete choice experiment instrument was developed to elicit patients' preferences for cytoreductive prostate radiotherapy, prostatectomy, prostate ablation, and stereotactic ablative body radiotherapy to metastasis. Patients chose their preferred treatment based on seven attributes. An error-component conditional logit model was used to estimate the preferences for and trade-offs between treatment attributes.

KEY FINDINGS AND LIMITATIONS

A total of 352 patients were enrolled, of whom 303 completed the study. The median age was 70 yr (interquartile range [IQR] 64-76) and prostate-specific antigen was 94 ng/ml (IQR 28-370). Metastatic stages were M1a 10.9% (33/303), M1b 79.9% (242/303), and M1c 7.6% (23/303). Patients preferred treatments with longer survival and progression-free periods. Patients were less likely to favour cytoreductive prostatectomy with systemic therapy (Coef. -0.448; [95% confidence interval {CI} -0.60 to -0.29]; p < 0.001), unless combined with metastasis-directed therapy. Cytoreductive prostate radiotherapy or ablation with systemic therapy, number of hospital visits, use of a "day-case" procedure, or addition of stereotactic ablative body radiotherapy did not impact treatment choice. Patients were willing to accept an additional cytoreductive treatment with 10 percentage point increases in the risk of urinary incontinence and fatigue to gain 3.4 mo (95% CI 2.8-4.3) and 2.7 mo (95% CI 2.3-3.1) of overall survival, respectively.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Patients are accepting of additional cytoreductive treatments for survival benefit in mHSPC, prioritising preservation of urinary function and avoidance of fatigue.

PATIENT SUMMARY

We performed a large study to ascertain how patients diagnosed with advanced (metastatic) prostate cancer at their first diagnosis made decisions regarding additional available treatments for their prostate and cancer deposits (metastases). Treatments would not provide cure but may reduce cancer burden (cytoreduction), prolong life, and extend time without cancer progression. We reported that most patients were willing to accept additional treatments for survival benefits, in particular treatments that preserved urinary function and reduced fatigue.

Preference of treatment characteristics among people with haemophilia or their caregivers, and physicians in the Japanese healthcare environment

INTRODUCTION

Studies of treatment preferences in haemophilia have been conducted in many countries. This study is the first to examine treatment characteristic preferences among people with haemophilia (PWH) and their caregivers, and physicians in Japan.

AIM

To examine current treatment preferences of PWH and their caregivers, plus those of physicians at haemophilia treatment centres (HTCs) and non-HTCs for different treatment characteristics in Japan.

METHODS

Physicians listed on a survey panel were invited to participate in the survey and to refer PWH and caregivers to participate in the survey. Web-based surveys were conducted to examine physician and PWH/caregiver background, prophylaxis background, prophylaxis goals, understanding of haemophilia treatment products, important information sources, preferences while choosing prophylaxis products, understanding of the patient's condition, and potential product switching. A discrete choice experiment exercise was included in the survey.

RESULTS

A total of 107 physicians and 44 PWH/caregivers participated in the study. Key treatment goals of physicians included optimisation of haemophilia management. PWH/caregivers were focused on quality of life and reduced treatment burden. Consistent differences in haemophilia treatment strategies at HTCs and non-HTCs were observed for prescribed treatments, preferences in choosing prophylaxis products, understanding of patients' condition, and reasons for potential product switch.

CONCLUSION

Our study utilises real-world survey data and presents preferences for haemophilia treatment characteristics among physicians, PWH and their caregivers in Japan, which could encourage improvements in individualised treatment and disease management. Alignment between treatment approaches at HTCs and non-HTCs could facilitate improvements in the quality of care for PWH across Japan.

Women's preferences for HIV prevention service delivery in pharmacies during pregnancy in Western Kenya: a discrete choice experiment

INTRODUCTION

Pharmacy-delivered HIV prevention services might create more options for pregnant women to use HIV prevention tools earlier and more consistently during pregnancy. We quantified preferences for attributes of potential HIV prevention services among women of childbearing age in Western Kenya.

METHODS

From June to November 2023, we administered a face-to-face discrete choice experiment survey to women aged 15-44 in Kenya's Homa Bay, Kisumu and Siaya counties. The survey evaluated preferences for HIV prevention services, described by seven attributes: service location, travel time, type of HIV test, sexually transmitted infection (STI) testing, partner HIV testing, pre-exposure prophylaxis (PrEP) and service fee. Participants answered a series of 12-choice questions. Each question asked them to select one of two service options or no services-an opt-out option. We used hierarchical Bayesian modelling levels to estimate each attribute level's coefficient and understand how attributes influenced service choice.

RESULTS

Overall, 599 participants completed the survey, among whom the median age was 23 years (IQR: 18-27); 33% were married, 20% had a job and worked regularly, and 52% had been pregnant before. Participants, on average, strongly preferred having any HIV prevention service option over none (opt-out preference weight: -5.84 [95% CI: -5.97, -5.72]). The most important attributes were the availability of PrEP (relative importance 27.04% [95% CI: 25.98%, 28.11%]), followed by STI testing (relative importance 20.26% [95% CI: 19.52%, 21.01%]) and partner HIV testing (relative importance: 16.35% [95% CI: 15.79%, 16.90%]). While, on average, participants preferred obtaining services at the clinic more than pharmacies, women prioritized the availability of PrEP, STI testing and partner HIV testing more than the location or cost.

CONCLUSIONS

These findings suggest the importance of providing comprehensive HIV prevention services and ensuring PrEP, STI testing and partner HIV testing are available. If pharmacies can offer these services, women are likely to access those services at pharmacies even if they prefer clinics.

Willingness to pay for improved working conditions of nurses: Results from a factorial survey experiment in Germany

BACKGROUND

Many countries face substantial shortages of skilled nurses. With an aging population and global demographic changes, developing a skilled workforce of nurses has become one of the central challenges for public health care. The recent COVID-19 pandemic has exacerbated labor shortages, which pose a threat to the quality of publicly provided health care. Improving nurses' working conditions could be a means by which to address the global shortages of nurses. However, in countries with public health care, such improvements may come with additional costs in the form of higher taxes or social security contributions. Therefore, such improvements partly depend on people's willingness to pay (WTP) for them.

OBJECTIVE

In this paper, we investigate workers' willingness to pay for improvements in the working conditions of nurses.

DESIGN

This study is a factorial survey experiment included as part of an online survey.

SETTING(S)

The factorial survey experiment was implemented within the high-frequency online panel survey "Life and Employment in Times of Corona" (IAB-HOPP) conducted by the Institute for Employment Research (Germany).

PARTICIPANTS

We analyze data from N = 2128 survey participants; our main analysis consists of N = 6384 responses from those participants.

METHODS

Our research is based on a factorial survey experiment (vignette analysis) designed to quantitatively measure the willingness to pay for various improvements in the working conditions of nurses. We use random effect models and mixed models to estimate the individual-level willingness to pay for these improvements.

RESULTS

Our results show that the survey participants are generally willing to pay for particular policies aimed at improving the working conditions of nurses. However, the amount that respondents are willing to pay varies with the type of policy changes. Survey participants exhibit a high willingness to pay for increases in minimum wages for nurses and wage-related improvements in general. We find, however, a lower willingness to pay for the right to participate in training courses aimed at reducing work-related stress.

CONCLUSIONS

The broad support for improvements in the working conditions of nurses provides policymakers with some guidance in implementing policy measures that might address labor shortages in the nursing sector.

REGISTRATION

There was no preregistration.

TWEETABLE ABSTRACT

Many people are willing to pay extra to improve the working conditions of nurses. Wage-related increases for nurses show the highest willingness to pay.

Risk-Adapted Breast Screening for Women at Low Predicted Risk of Breast Cancer: An Online Discrete Choice Experiment

BACKGROUND

A risk-stratified breast screening program could offer low-risk women less screening than is currently offered by the National Health Service. The acceptability of this approach may be enhanced if it corresponds to UK women's screening preferences and values.

OBJECTIVES

To elicit and quantify preferences for low-risk screening options.

METHODS

Women aged 40 to 70 y with no history of breast cancer took part in an online discrete choice experiment. We generated 32 hypothetical low-risk screening programs defined by 5 attributes (start age, end age, screening interval, risk of dying from breast cancer, and risk of overdiagnosis), the levels of which were systematically varied between the programs. Respondents were presented with 8 choice sets and asked to choose between 2 screening alternatives or no screening. Preference data were analyzed using conditional logit regression models. The relative importance of attributes and the mean predicted probability of choosing each program were estimated.

RESULTS

Participants (N = 502) preferred all screening programs over no screening. An older starting age of screening, younger end age of screening, longer intervals between screening, and increased risk of dying had a negative impact on support for screening programs (P < 0.01). Although the risk of overdiagnosis was of low relative importance, a decreased risk of this harm had a small positive impact on screening choices. The mean predicted probabilities that risk-adapted screening programs would be supported relative to current guidelines were low (range, 0.18 to 0.52).

CONCLUSIONS

A deintensified screening pathway for women at low risk of breast cancer, especially one that recommends a later screening start age, would run counter to women's breast screening preferences. Further research is needed to enhance the acceptability of offering less screening to those at low risk of breast cancer.

HIGHLIGHTS

Risk-based breast screening may involve the deintensification of screening for women at low risk of breast cancer.Low-risk screening pathways run counter to women's screening preferences and values.Longer screening intervals may be preferable to a later start age.Work is needed to enhance the acceptability of a low-risk screening pathway.

Treatment Preferences for Acute Allergic Reactions: A Discrete Choice Experiment

Background: Timely treatment of acute allergic reactions (AARs) is important to minimize reaction severity. Corticosteroid tablets dissolved in water are commonly used in mainstay treatment. A new oral film that dissolves on the tongue provides a faster and less cumbersome alternative to tablets for corticosteroid administration during AARs. This study evaluated patients' preferences for attributes related to administration mode of corticosteroids in AARs. Methods: A web-based survey was sent to a sample from the adult Swedish population (≥18 years) with experience of corticosteroid treatment for AAR. We assessed the willingness to pay (WTP) for attributes related to corticosteroid treatment by applying a discrete choice experiment (DCE) approach. DCE attributes were administration mode, time to symptom relief, and price. The WTP for each attribute was derived using the attribute's coefficient in a logistic regression analysis. We specified a forced choice (FC) and an unforced choice (UC) model. In the FC model, the respondents chose between 2 hypothetical treatments and in the UC model, between any of 2 hypothetical treatments and their current treatment. Results: The final study population included 348 subjects, of which 80% were women. All the evaluated DCE attributes were significant predictors for the treatment choice (p<.001). In the FC model, the incremental WTP for an oral film compared with tablets was 409 Swedish kronor (SEK [≈€36.7]), with no other factors considered. In the UC model, the incremental WTP for the oral film compared with tablets was 574 SEK (≈€51.7). After considering the value of the respondents' current treatment, the WTP for the oral film decreased to 336 SEK (≈€30.3). The total WTP was reduced by 17 SEK (≈€1.5) per minute of shorter time to symptom relief. Subgroup analyses showed that people with circulatory symptoms and experience of swallowing difficulties related to allergy medication had higher WTP for the oral film than the average respondent. Conclusion: The findings show a substantial economic benefit of the oral film vs tablets for patients with AARs in Sweden. This result remained also after compensation for the full value of the patients' current treatment.

Healthcare Providers' and Pregnant People's Preferences for a Preventive to Protect Infants from Serious Illness Due to Respiratory Syncytial Virus

We assessed the impact of respiratory syncytial virus (RSV) preventive characteristics on the intentions of pregnant people and healthcare providers (HCPs) to protect infants with a maternal vaccine or monoclonal antibodies (mAbs). Pregnant people and HCPs who treated pregnant people and/or infants were recruited via convenience sample from a general research panel to complete a cross-sectional, web-based survey, including a discrete choice experiment (DCE) wherein respondents chose between hypothetical RSV preventive profiles varying on five attributes (effectiveness, preventive type [maternal vaccine vs. mAb], injection recipient/timing, type of medical visit required to receive the injection, and duration of protection during RSV season) and a no-preventive option. A best-worst scaling (BWS) exercise was included to explore the impact of additional attributes on preventive preferences. Data were collected between October and November 2022. Attribute-level preference weights and relative importance (RI) were estimated. Overall, 992 pregnant people and 310 HCPs participated. A preventive (vs. none) was chosen 89.2% (pregnant people) and 96.0% (HCPs) of the time (DCE). Effectiveness was most important to preventive choice for pregnant people (RI = 48.0%) and HCPs (RI = 41.7%); all else equal, pregnant people (RI = 5.5%) and HCPs (RI = 7.2%) preferred the maternal vaccine over mAbs, although preventive type had limited influence on choice. Longer protection, protection starting at birth or the beginning of RSV season, and use for both pre-term and full-term babies were ranked highest in importance (BWS). Pregnant people and HCPs strongly preferred a preventive to protect infants against RSV (vs. none), underscoring the need to incorporate RSV preventives into routine care.

Driving factors in treatment decision-making of patients seeking medical assistance for infertility: a systematic review

BACKGROUND

ART differs in effectiveness, side-effects, administration, and costs. To improve the decision-making process, we need to understand what factors patients consider to be most important.

OBJECTIVE AND RATIONALE

We conducted this systematic review to assess which aspects of ART treatment (effectiveness, safety, burden, costs, patient-centeredness, and genetic parenthood) are most important in the decision-making of patients with an unfulfilled wish to have a child.

SEARCH METHODS

We searched studies indexed in Embase, PubMed, PsycINFO, and CINAHL prior to November 2023. Discrete choice experiments (DCEs), surveys, interviews, and conjoint analyses (CAs) about ART were included. Studies were included if they described two or more of the following attributes: effectiveness, safety, burden, costs, patient-centeredness, and genetic parenthood.Participants were men and women with an unfulfilled wish to have a child. From each DCE/CA study, we extracted the beta-coefficients and calculated the relative importance of treatment attributes or, in case of survey studies, extracted results. We assessed the risk of bias using the rating developed by the Grading of Recommendations Assessment, Development and Evaluation working group. Attributes were classified into effectiveness, safety, burden, costs, patient-centeredness, genetic parenthood, and others.

OUTCOMES

The search identified 938 studies of which 20 were included: 13 DCEs, three survey studies, three interview studies, and one conjoint analysis, with a total of 12 452 patients. Per study, 47-100% of the participants were women. Studies were assessed as having moderate to high risk of bias (critical: six studies, serious: four studies, moderate: nine studies, low: one study). The main limitation was the heterogeneity in the questionnaires and methodology utilized. Studies varied in the number and types of assessed attributes. Patients' treatment decision-making was mostly driven by effectiveness, followed by safety, burden, costs, and patient-centeredness. Effectiveness was rated as the first or second most important factor in 10 of the 12 DCE studies (83%) and the relative importance of effectiveness varied between 17% and 63%, with a median of 34% (moderate certainty of evidence). Of eight studies evaluating safety, five studies valued safety as the first or second most important factor (63%), and the relative importance ranged from 8% to 35% (median 23%) (moderate certainty of evidence). Cost was rated as first or second most important in five of 10 studies, and the importance relative to the other attributes varied between 5% and 47% (median 23%) (moderate certainty of evidence). Burden was rated as first or second by three of 10 studies (30%) and the relative importance varied between 1% and 43% (median 13%) (low certainty of evidence). Patient-centeredness was second most important in one of five studies (20%) and had a relative importance between 7% and 24% (median 14%) (low certainty of evidence). Results suggest that patients are prepared to trade-off some effectiveness for more safety, or less burden and patient-centeredness. When safety was evaluated, the safety of the child was considered more important than the mother's safety. Greater burden (cycle cancellations, number of injections, number of hospital visits, time) was more likely to be accepted by patients if they gained effectiveness, safety, or lower costs. Concerning patient-centeredness, information provision and physician attitude were considered most important, followed by involvement in decision-making, and treatment continuity by the same medical professional. Non-genetic parenthood did not have a clear impact on decision-making.

WIDER IMPLICATIONS

The findings of this review can be used in future preference studies and can help healthcare professionals in guiding patients' decision-making and enable a more patient-centered approach.

Getting it right with discrete choice experiments: Are we hot or cold?

Discrete Choice Experiments (DCEs) are widely employed survey-based methods to assess preferences for healthcare services and products. While they offer an experimental way to represent health-related decisions, the stylized representation of scenarios in DCEs may overlook contextual factors that could influence decision-making. The aim of this paper was to evaluate the predictive validity of preferences elicited through a DCE in decisions likely influenced by a hot-cold empathy gap, and compare it to another commonly used method, a direct-elicitation question. We focused on preferences for pain-relief modalities, especially for an epidural during childbirth - a context where direct-elicitation questions have shown a preference for or intention to have a natural birth (representing the "cold" state), yet individuals often opt for an epidural during labor (representing the "hot" state). Leveraging a unique dataset collected from 248 individuals, we incorporated both the stated preferences collected through a survey administered upon hospital admission for childbirth and the actual pain-relief modality usage data documented in medical records. The DCE allowed for the evaluation of scenarios outside of those expected by respondents to simulate decision-making during childbirth. When we compared the predicted epidural use with the actual epidural use during labor, we observed a choice concordance of 71-60%, depending on the model specification. The concordance rate between the predicted and actual choices increased to 77-76% when accounting for the initial use of other ineffective modalities. In contrast, the direct-elicitation choices, relying solely on respondents' baseline expectations, yielded a lower concordance rate of 58% with actual epidural use. These findings highlight the flexibility of the DCE method in simulating complex decision contexts, including those involving hot-cold empathy gaps. The DCE proves valuable in assessing nuanced preferences, providing a more accurate representation of the decision-making processes in healthcare scenarios.

Understanding Australian pharmacy degree holders' job preferences through the lens of motivation-hygiene theory

Increasing the contribution of pharmacists to primary care has been long discussed, particularly in the context of health workforce shortages and the push to better integrate all providers across primary care. This study examines the employment preferences of Australian pharmacy degree holders (PDHs) elicited through a discrete choice experiment (DCE), to better understand the drivers of current labour force choices. A labelled DCE was developed incorporating the six employment sectors: hospital pharmacy, community pharmacy, primary healthcare settings, pharmaceutical industry, government/academia, and non-pharmacy-related sector. Each alternative was described by five attributes using Herzberg's Two Factor Theory as a conceptual framework. They include motivators - role and career opportunities, and hygiene factors-flexible work schedule, geographic location, and salary. Unforced choice data were analysed using conditional logit and mixed logit models. Based on a sample of 678 PDHs in Australia, our findings indicated pharmaceutical industry is the least preferred sector, followed by non-pharmacy-related sector. Motivators in the form of role and career opportunities are the most important attributes in hospital pharmacy while hygiene factors - geographic location and salary significantly drive the choice of community pharmacy and primary care settings. We provided evidence of a willingness to adopt expanded roles in community pharmacy. This unique interpretation of the key drivers of employment preference in light of motivators and hygiene factors provides policy makers with important information when designing policies to attract and retain PDHs across employment sectors.

Developing an alternative care pathway for emergency ambulance responses for adults with epilepsy: A Discrete Choice Experiment to understand which configuration service users prefer. Part of the COLLABORATE project

INTRODUCTION

To identify service users' preferences for an alternative care pathway for adults with epilepsy presenting to the ambulance service.

METHODS

Extensive formative work (qualitative, survey and knowledge exchange) informed the design of a stated preference discrete choice experiment (DCE). This hypothetical survey was hosted online and consisted of 12 binary choices of alternative care pathways described in terms of: the paramedic's access to medical records/ 'care plan', what happens next (described in terms of conveyance), time, availability of epilepsy specialists today, general practitioner (GP) notification and future contact with epilepsy specialists. DCE scenarios were described as: (i) typical seizure at home. (ii) typical seizure in public, (iii) atypical seizure. Respondents were recruited by a regional English ambulance service and by national public adverts. Participants were randomised to complete 2 of the 3 DCEs.

RESULTS

People with epilepsy (PWE; n = 427) and friends/family (n = 167) who completed the survey were representative of the target population. PWE preferred paramedics to have access to medical records, non-conveyance, to avoid lengthy episodes of care, availability of epilepsy specialists today, GP notification, and contact with epilepsy specialists within 2-3 weeks. Significant others (close family members or friends) preferred PWE experiencing an atypical seizure to be conveyed to an Urgent Treatment Centre and preferred shorter times. Optimal configuration of services from service users' perspective far out ranked current practice (rank 230/288 possible configurations).

DISCUSSION

Preferences differ to current practice but have minimal variation by seizure type or stakeholder. Further work on feasibility of these pathways in England, and potentially beyond, is required.

Old people's preference for nursing homes in East China: a discrete choice experiment

BACKGROUND

The aged people who live in nursing home are predicted to keep growing in the following decades. There are both quantitative imbalance and structural imbalance in the utilization of nursing homes in China. This study aimed to analyze old people's preference for nursing homes and help the government optimize resource allocation.

METHODS

A discrete choice experiment (DCE) was conducted and six attributes of nursing homes including monthly fee, distance from home, geographical location, medical facilities, environment of nursing homes and nursing staff were determined. Respondents were recruited from Nantong and Yangzhou city, China. In each city, two communities or villages were randomly selected. In each community/village, about 65 old people were randomly selected. Analysis was conducted using mixed logit regression models to determine preferences for potential attributes.

RESULTS

A total of 233 old people were included in the analysis. The findings indicated that all six attributes were statistically significant factors for participants. "Professional nursing staff" was the most important characteristic to participants, followed by "Medical facilities". Compared with female, the males preferred professional nursing staff (β = 2.939 vs. β = 2.643, P < 0.001), medical facilities (β = 1.890 vs. β = 1.498, P < 0.001), and the environment (β = 0.752, P < 0.01). For different age groups, participants aged 60-69 didn't pay attention to distance and location, while those aged 80 and above only paid attention to professional nursing staff and medical facilities.

CONCLUSIONS

The present study provides important insights into the characteristics of nursing home that are most preferred by old people. Authorities should take into account old people's preference in the planning, design and evaluation of nursing homes.

Messaging about very low nicotine cigarettes (VLNCs) to influence policy attitudes, harm perceptions and smoking motivations: a discrete choice experiment

BACKGROUND

To reduce smoking and the harms it causes, countries, including the USA, are considering policies to reduce nicotine in combustible tobacco to minimally addictive levels. Effective messages about very low nicotine cigarettes (VLNCs) and this policy are crucial in combating misperceptions threatening the policy's effectiveness.

DATA AND METHODS

A discrete choice experiment assessed messages about VLNCs. Participants were 590 adults who smoked exclusively, 379 adults who both smoked and used e-cigarettes, 443 adults who formerly smoked and 351 young adults who never smoked (total n=1763). Seven message attributes were varied systematically (source, harm, chemicals, nicotine, satisfaction, addictiveness and quitting efficacy). Outcomes were selection of messages that generated the most positive attitude towards reduced nicotine policy, the greatest perceived harmfulness of VLNCs, and most strongly motivated quitting and initiating behaviour for VLNCs.

RESULTS

Information about specific harms and chemicals of VLNCs had the largest effects on selection of messages as eliciting more negative attitudes towards VLNCs policy, increasing perceived VLNC harmfulness, increasing motivation to quit VLNCs and decreasing motivation to try VLNCs. Messages with information about quitting efficacy were selected as more motivating to quit among those who smoke, but also more motivating to try VLNCs among those who do not smoke.

CONCLUSION

Harm and chemical information can be prioritised to ensure VLNCs are not misperceived as less harmful than regular cigarettes. Messages about increased quitting efficacy and reduced addictiveness associated with VLNCs may backfire if presented to those who do not smoke.

The value of genomic testing in severe childhood speech disorders

With increasing gene discoveries for severe speech disorders, genomic testing can alter the diagnostic and clinical paradigms, enabling better life outcomes for children and their families. However, evidence on the value of the outcomes generated is lacking, impeding optimal translation into health care. This study aims to estimate the value and uptake of genomic testing for severe childhood speech disorders. A discrete choice experiment was undertaken to elicit preferences for genomic testing from the perspective of the Australian public (n = 951) and parents of children experiencing severe speech disorder (n = 56). Choice attributes associated with genomic testing were identified through focus groups. A Bayesian D-efficient design was used to develop choice scenarios and choice data were analyzed using a panel error component mixed logit model and a latent class model. Statistically significant preferences were identified across all seven attributes. The mean monetary value of the benefits of genomic testing relative to standard diagnostic care in Australia was estimated at AU$7489 (US$5021) and AU$4452 (US$2985) from the perspectives of the Australian public and families with lived experience of severe speech disorders, with a corresponding test uptake of 94.2% and 99.6%. To ensure fair prioritization of genomics, decision-makers need to consider the wide range of risks and benefits associated with genomic information.

Identifying Preferred Features of Weight Loss Programs for Adults With or at Risk of Type 2 Diabetes: A Discrete Choice Experiment With 3,960 Adults in the U.K

OBJECTIVE

To understand preferences for features of weight loss programs among adults with or at risk of type 2 diabetes in the U.K.

RESEARCH DESIGN AND METHODS

We conducted a discrete choice experiment with 3,960 U.K. adults living with overweight (n = 675 with type 2 diabetes). Preferences for seven characteristics of weight loss programs were analyzed. Simulations from choice models using the experimental data predicted uptake of available weight loss programs. Patient groups comprising those who have experience with weight loss programs, including from minority communities, informed the experimental design.

RESULTS

Preferences did not differ between individuals with and without type 2 diabetes. Preferences were strongest for type of diet. Healthy eating was most preferred relative to total diet replacement (odds ratio [OR] 2.24; 95% CI 2.04-2.44). Individual interventions were more popular than group interventions (OR 1.40; 95% CI 1.34-1.47). Participants preferred programs offering weight loss of 10-15 kg (OR 1.37; 95% CI 1.28-1.47) to those offering loss of 2-4 kg. Online content was preferred over in-person contact (OR 1.24; 95% CI 1.18-1.30). There were few differences in preferences by gender or ethnicity, although weight loss was more important to women than to men, and individuals from ethnic minority populations identified more with programs where others shared their characteristics. Modeling suggested that tailoring programs to individual preferences could increase participation by ∼17 percentage points (68% in relative terms).

CONCLUSIONS

Offering a range of weight loss programs targeting the preferred attributes of different patient groups could potentially encourage more people to participate in weight loss programs and support those living with overweight to reduce their weight.

Platelets, Puppies, and Payment: How Surveys can be Misleading in the Remuneration Debate

In a recent article ("The current state of the platelet supply in the US and proposed options to decrease the risk of critical shortages") published in Transfusion, Stubbs et al. have argued that platelet donors should be paid. Dodd et al. have argued against this proposal, supporting their response with survey data that shows that blood donors (and by extension platelet donors) and potential platelet donors are uninterested in receiving incentives to encourage them to donate. Instead, argue Dodd et al., prospective platelet donors are motivated more by the ease of donation than the prospect of payment. This article defends Stubbs et al. from the criticisms of Dodd et al. It first argues that the preferences that persons state they have in response to survey questions might not reflect the preferences that their actions would reveal they have in actual rather than hypothetical situations. This hypothetical bias is especially likely when persons respond to surveys that ask them about the performance of morally commendable actions (such as platelet donation). This article then argues that the survey that Dodd et al. rely on exhibits serious selection bias with respect to the set of persons it considers to be potential platelet donors.

Examining alignment of community health teams' preferences for health, equity, and spending with state all-payer waiver priorities: A discrete choice experiment

OBJECTIVE

The state of Vermont has a statewide waiver from the centers for medicare and medicaid services to allow all-payer Accountable Care Organizations (ACOs). The Vermont all-payer model (VAPM) waiver is layered upon previous reforms establishing regional community health teams (CHTs) and medical homes. The waiver is intended to incentivize healthcare value and quality and create alignment between health system payers, providers, and CHTs. The objective of this study was to examine CHT's trade-offs and preferences for health, equity, and spending and the alignment with VAPM priorities.

DATA SOURCES/STUDY SETTING

Data were gathered from a survey and discrete choice experiment among CHT leadership and CHT team members of the 13 CHTs in Vermont.

STUDY DESIGN

We used conditional logit models to model the choice as a function of its characteristics (attributes) and mixed logit models to analyze whether preferences for programs varied by persons and roles within CHTs.

DATA COLLECTION/EXTRACTION METHODS

There were 60 respondents who completed the survey online with 14 choice tasks, with three program options in each task, for a total sample size of 2520.

PRINCIPAL FINDINGS

We found that CHTs prioritized programs in the community health plan and those with quantitative evidence of effectiveness. They were less likely to choose either programs targeting racial and ethnic minorities or programs having a small effect on a large population. Preferences did not vary across individual or community attributes. Program priorities of the VAPM, especially healthcare spending, were not prioritized.

CONCLUSIONS

The results suggest that the new VAPM does not automatically create system alignment: CHTs tended to prioritize local needs and voices. The statewide priorities are less important to CHTs, which have excellent internal alignment. This creates potential disconnection between state and community health goals. However, CHTs and the VAPM prioritize similar populations, indicating an opportunity to increase alignment by allowing flexible programs tailored to local needs. CHTs also prioritized programs with a strong evidence base, suggesting another potential avenue to create system alignment.

Implementation preferences for the management of sexually transmitted infections in the South African health system: a discrete choice experiment

OBJECTIVES

Despite strengthening HIV prevention with the introduction of pre-exposure prophylaxis (PrEP), STI services have remained relatively unchanged and the standard of care remains syndromic management. We used a discrete choice experiment to investigate service users' preferences for the diagnosis and treatment of STIs in South Africa.

METHODS

Between 1 March 2021 and 20 April 2021, a cross-sectional online questionnaire hosted on REDCap was administered through access links sent to WhatsApp support groups for HIV PrEP users and attendees of two primary healthcare clinics and two mobile facilities in the Eastern Cape and Gauteng provinces aged between 18 and 49 years. Participants either self-completed the questionnaire or received support from a research assistant. We used a conditional logit model for the initial analysis and latent class model (LCM) to establish class memberships, with results displayed as ORs and probabilities.

RESULTS

We enrolled 496 individuals; the majority were female (69%) and <30 years (74%). The LCM showed two distinct groups. The first group, comprising 68% of the participants, showed a strong preference for self-sampling compared with no sampling (OR 2.16, 95% CI 1.62 to 2.88). A clinic follow-up appointment for treatment was less preferable to same-day treatment (OR 0.78, 95% CI 0.63 to 0.95). Contact slip from index patient (OR 0.86, 95% CI 0.76 to 0.96) and healthcare professional (HCP)-initiated partner notification (OR 0.63, 95% CI 0.55 to 0.73) were both less preferable than expedited partner treatment (EPT). The second group included 32% of participants with a lower preference for self-sampling compared with no sampling (OR 0.65, 95% CI 0.41 to 1.04). There was no treatment option that was significantly different from the others; however, there was a strong preference for HCP-initiated partner notification to EPT (OR 1.53, 95% CI 1.10 to 2.12).

CONCLUSIONS

Our results suggest that service users preferred STI testing prior to treatment, with the majority preferring self-taken samples and receiving aetiology-based treatment on the same day.

Understanding how they really feel: Lesson learned from four approaches to soliciting user preferences for new contraceptive products in development

Background

An expanded range of contraceptive methods could reduce unintended pregnancies. User preferences research is important for successful development of products people want to use. This paper describes four approaches to preferences research soliciting user input in different ways: 1) perspectives on contraceptive method characteristics, 2) reactions to products in development, 3) trade-offs between contraceptive method characteristics, and 4) "blue-sky" ideas on novel contraceptive technologies.

Methods

We conducted two mixed-method studies: one implemented in Burkina Faso and Uganda combining three of these approaches, and the other implemented in India and Nigeria using two approaches. We share observations on the strengths and weaknesses of each approach and draw on our experience to highlight lessons learned for future user preferences studies.

Results

Each approach contributes to product development in different ways, and the usefulness of each methodology depends on the product development stage and corresponding informational needs.

Conclusions

Recommendations for future research include combining different methods, angles, and perspectives; using sequential designs whenever possible; tailoring product descriptions to user understanding for optimal feedback; and acknowledging the value and limitations of both quantitative results for modeling demand and idiosyncratic ideas to inspire development of new products.

Patient Preference Trade-offs for Next-Generation Kidney Replacement Therapies

BACKGROUND

Next-generation implantable and wearable KRTs may revolutionize the lives of patients undergoing dialysis by providing more frequent and/or prolonged therapy along with greater mobility compared with in-center hemodialysis. Medical device innovators would benefit from patient input to inform product design and development. Our objective was to determine key risk/benefit considerations for patients with kidney failure and test how these trade-offs could drive patient treatment choices.

METHODS

We developed a choice-based conjoint discrete choice instrument and surveyed 498 patients with kidney failure. The choice-based conjoint instrument consisted of nine attributes of risk and benefit pertinent across KRT modalities. Attributes were derived from literature reviews, patient/clinician interviews, and pilot testing. The risk attributes were serious infection, death within 5 years, permanent device failure, surgical requirements, and follow-up requirements. The benefit attributes were fewer diet restrictions, improved mobility, pill burden, and fatigue. We created a random, full-profile, balanced overlap design with 14 choice pairs plus five fixed tasks to test validity. We used a mixed-effects regression model with attribute levels as independent predictor variables and choice decisions as dependent variables.

RESULTS

All variables were significantly important to patient choice preferences, except follow-up requirements. For each 1% higher risk of death within 5 years, preference utility was lower by 2.22 ( β =-2.22; 95% confidence interval [CI], -2.52 to -1.91), while for each 1% higher risk of serious infection, utility was lower by 1.38 ( β =-1.46; 95% CI, -1.77 to -1.00) according to comparisons of the β coefficients. Patients were willing to trade a 1% infection risk and 0.5% risk of death to gain complete mobility and freedom from in-center hemodialysis ( β =1.46; 95% CI, 1.27 to 1.64).

CONCLUSIONS

Despite an aversion to even a 1% higher risk of death within 5 years, serious infection, and permanent device rejection, patients with kidney failure suggested that they would trade these risks for the benefit of complete mobility.

Preferences for Living Arrangements in Dementia: A Discrete Choice Experiment

BACKGROUND

Dementia affects about 55 million people worldwide. Demographic change and shifting lifestyles challenge the organization of dementia care. A discrete choice experiment (DCE) was conducted to elicit preferences for living arrangements in dementia in urban and rural regions of Germany.

METHODS

Preliminary work included review of previous literature and focus groups. The DCE consists of seven attributes (group size, staff qualifications, organization of care, activities offered, support of religious practice, access to garden, consideration of food preferences) with three levels each. Individuals from the general population between the ages of 50 and 65 years were identified through population registration offices in three rural municipalities and one urban area, and 4390 individuals were approached via postal survey. A hierarchical Bayesian mixed logit model was estimated and interactions with sociodemographic characteristics were investigated.

RESULTS

A total of 428 and 412 questionnaires were returned by rural and urban respondents, respectively. Access to a garden was perceived as the most important attribute (average importance 36.0% in the rural sample and 33.4% in the urban sample), followed by consideration of food preferences (15.8%, 17.8%), staff qualification (14.6%, 15.3%), care organization (11.4%, 12.3%), group size (12.2%, 11.1%), and range of activities (8.0%, 10.1%). The attribute relating to religious practice was given the least importance (2.1%, 0%). Preferences vary according to gender, age, religious beliefs, experience as an informal caregiver, and migrant background.

CONCLUSION

Heterogeneous preferences for living arrangements for people with dementia were identified. The expansion of concepts with access to natural environments for persons with dementia might be a viable option for the formal care market in Germany. Further research is needed to meet the challenges of setting up and designing innovative living arrangements for people with dementia. Preferences vary by gender, age, religious beliefs, experience as an informal caregiver, and migrant background.

Preferences of pregnant women toward a future maternal Group B Streptococcus vaccine in China: A cross-sectional survey with a discrete choice experiment

Group B streptococcus (GBS) is a major cause of neonatal death worldwide. A GBS vaccine for pregnant women is under development and is expected to be available in the near future. The perceptions and preferences of pregnant women in China of GBS vaccines has not been investigated, and this study aimed to investigate pregnant women's awareness of GBS and their potential preferences for the GBS vaccine. A discrete choice experiment was conducted among pregnant women in hospitals from Shaanxi, Hunan, and Zhejiang provinces located in Western, Central, and Eastern China, respectively. A conditional logit model was used to analyze the data and calculate willingness to pay values and choice probabilities of different GBS vaccine programs. A total of 354 pregnant women were included in the final analysis, 45.8% of whom were willing to receive a GBS vaccine if it were licensed. Vaccine safety was the most important attribute of a future vaccine, while cost was the least important attribute. Compared with no vaccination, pregnant women had a strong preference for future GBS vaccination (ASC = 1.267, p < .001). Pregnant women's decisions were highly influenced by those of other pregnant women. Improving the safety, efficacy, and vaccination rate of the GBS vaccine in China is of great significance for future GBS vaccine development and vaccination. Compared to other variable options, the cost of a GBS vaccine was of the least importance among pregnant women in mainland China. These findings can inform public health policy decisions related to GBS vaccination in China.

Do You Like Your Voice? A Population-Based Survey of Voice Satisfaction and Voice Enhancement

OBJECTIVES

Voice enhancement for patients without obvious vocal pathology or loss of function is rarely discussed clinically or in academic research. Our objectives were to: (1) determine voice satisfaction on a population level, and (2) assess willingness to consider interventions to change one's voice.

METHODS

A standardized questionnaire was created to assess current and past voice disorders. Questions assessed demographics, health status, prevalence of voice disorders, and questions regarding satisfaction with voice. Iterative survey testing and piloting were performed. A cohort with age, gender, and geographic distribution of the general adult population was then queried in an online survey. Qualitative analysis and both descriptive and multivariate statistics were performed.

RESULTS

A total of 1522 respondents were included, with an age, gender, and regional distribution reflective of the US population. A minority (38.8%) of respondents reported that they did not like the sound of their own voice in normal conversation; when asked about listening to a recording of their own voice, a majority (57.5%) reported dissatisfaction with voice. Discontent with one's voice was associated with being middle age (p = 0.005), female gender (p < 0.0001), and white race (p < 0.0001). Approximately 50.6% of respondents without a history of dysphonia would consider interventions to change their voice. Of those who indicated they may elect to change their voice, qualities regarding clarity and pitch were paramount.

CONCLUSION

Dissatisfaction with one's speaking voice is common. A considerable percentage of the general population without a voice disorder would consider interventions to change their voice.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3455-3461, 2023.

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.

Placing the values and preferences of people most affected by TB at the center of screening and testing: an approach for reaching the unreached

To reach the millions of people with tuberculosis (TB) undiagnosed each year, there is an important need to provide people-centered screening and testing services. Despite people-centered care being a key pillar of the WHO END-TB Strategy, there have been few attempts to formally characterize and integrate the preferences of people most affected by TB - including those who have increased exposure to TB, limited access to services, and/or are at increased risk for TB - into new tools and strategies to improve screening and diagnosis. This perspective emphasizes the importance of preference research among people most affected by TB, provides an overview of qualitative preference exploration and quantitative preference elicitation research methods, and outlines how preferences can be applied to improve the acceptability, accessibility, and appropriateness of TB screening and testing services via four key opportunities. These include the following: (1) Defining the most preferred features of novel screening, triage, and diagnostic tools, (2) exploring and prioritizing setting-specific barriers and facilitators to screening and testing, (3) understanding what features of community- and facility-based strategies for improving TB detection and treatment are most valued, and (4) identifying the most relevant and resonant communication strategies to increase individual- and community-level awareness and demand. Preference research studies and translation of their findings into policy/guidance and operationalization have enormous potential to close the existing gaps in detection in high burden settings by enhancing the people-centeredness and reach of screening and diagnostic services to people most affected by TB who are currently being missed and left behind.

Public preference on sharing health data to inform research, health policy and clinical practice in Australia: A stated preference experiment

OBJECTIVE

To investigate public willingness to share sensitive health information for research, health policy and clinical practice.

METHODS

A total of 1,003 Australian respondents answered an online, attribute-driven, survey in which participants were asked to accept or reject hypothetical choice sets based on a willingness to share their health data for research and frontline-medical support as part of an integrated health system. The survey consisted of 5 attributes: Stakeholder access for analysis (Analysing group); Type of information collected; Purpose of data collection; Information governance; and Anticipated benefit; the results of which were analysed using logistic regression.

RESULTS

When asked about their preference for sharing their health data, respondents had no preference between data collection for the purposes of clinical practice, health policy or research, with a slight preference for having government organisations manage, govern and curate the integrated datasets from which the analysis was being conducted. The least preferred option was for personal health records to be integrated with insurance records or for their data collected by privately owned corporate organisations. Individuals preferred their data to be analysed by a public healthcare provider or government staff and expressed a dislike for any private company involvement.

CONCLUSIONS

The findings from this study suggest that Australian consumers prefer to share their health data when there is government oversight, and have concerns about sharing their anonymised health data for clinical practice, health policy or research purposes unless clarity is provided pertaining to its intended purpose, limitations of use and restrictions to access. Similar findings have been observed in the limited set of existing international studies utilising a stated preference approach. Evident from this study, and supported by national and international research, is that the establishment and preservation of a social license for data linkage in health research will require routine public engagement as a result of continuously evolving technological advancements and fluctuating risk tolerance. Without more work to understand and address stakeholder concerns, consumers risk being reluctant to participate in data-sharing and linkage programmes.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Maximum Acceptable Risk Estimation Based on a Discrete Choice Experiment and a Probabilistic Threshold Technique

OBJECTIVE

We aimed to empirically compare maximum acceptable risk results estimated using both a discrete choice experiment (DCE) and a probabilistic threshold technique (PTT).

METHODS

Members of the UK general public (n = 982) completed an online survey including a DCE and a PTT (in random order) measuring their preferences for preventative treatment for rheumatoid arthritis. For the DCE, a Bayesian D-efficient design consisting of four blocks of 15 choice tasks was constructed including six attributes with varying levels. The PTT used identical risk and benefit attributes. For the DCE, a panel mixed-logit model was conducted, both mean and individual estimates were used to calculate maximum acceptable risk. For the PTT, interval regression was used to calculate maximum acceptable risk. Perceived complexity of the choice tasks and preference heterogeneity were investigated for both methods.

RESULTS

Maximum acceptable risk confidence intervals of both methods overlapped for serious infection and serious side effects but not for mild side effects (maximum acceptable risk was 32.7 percent-points lower in the PTT). Although, both DCE and PTT tasks overall were considered easy or very easy to understand and answer, significantly more respondents rated the DCE choice tasks as easier to understand compared with those who rated the PTT as easier (7-percentage point difference; p < 0.05).

CONCLUSIONS

Maximum acceptable risk estimate confidence intervals based on a DCE and a PTT overlapped for two out of the three included risk attributes. More respondents rated the DCE as easier to understand. This may suggest that the DCE is better suited in studies estimating maximum acceptable risk for multiple risk attributes of differing severity, while the PTT may be better suited when measuring heterogeneity in maximum acceptable risk estimates or when investigating one or more serious adverse events.

Opportunities to Increase Access to HIV Prevention: Evaluating the Implementation of Pharmacist-Initiated Pre-exposure Prophylaxis in California

Background

Pharmacies are a promising setting through which to expand access to human immunodeficiency virus (HIV) prevention, including pre-exposure and post-exposure prophylaxis (PrEP and PEP, respectively). We aimed to evaluate and inform the implementation of California's Senate Bill 159 (2019), allowing pharmacists to independently prescribe PrEP and PEP.

Methods

From October through December 2022, we conducted a cross-sectional study of 919 California pharmacists and pharmacy students, primarily recruited via the email listservs of professional organizations. Participants completed an online survey assessing the implementation of pharmacist-initiated PrEP/PEP, including knowledge, attitudes, practices, perceived barriers, and implementation preferences elicited through a discrete choice experiment.

Results

Among 919 participants (84% practicing pharmacists, 43% in community pharmacies), 11% and 13% reported that pharmacists at their pharmacy initiate PrEP and PEP, respectively. Most believed that pharmacist-initiated PrEP/PEP is important (96%) and were willing to provide PrEP (81%); fewer (27%) had PrEP/PEP training. Common implementation barriers were lack of staff/time and payment for pharmacist services. Participants preferred PrEP implementation models with in-pharmacy rapid oral HIV testing and pharmacists specifically hired to provide PrEP services.

Conclusions

Despite pharmacists' supportive attitudes, Senate Bill 159 implementation in California pharmacies remains limited, in part due to policy-level and organizational-level barriers. Ensuring PrEP/PEP-related payment for services and sufficient workforce capacity is key to leveraging pharmacists' role in HIV prevention.

Preferences and willingness-to-pay for a blood pressure telemonitoring program using a discrete choice experiment

This study aimed to elicit the preferences and willingness-to-pay for blood pressure (BP) telemonitoring programs. This study also investigated the different factors or participant characteristics that could influence preferences and choice behaviors. Participants with hypertension were identified from an online survey panel demographically representative of Singapore's general population. Participants completed a discrete choice experiment (DCE) with 12 choice sets, selecting their preferred BP monitoring program differing on five attributes: mode of consultation, BP machine type (with Bluetooth or not), BP machine price, monthly fee, and program duration. The base reference population (male, married, higher income, more formal education years, full-time worker, aged 55 to <65 years, and digital skills score of 36) preferred teleconsultation over in-person consultation, Bluetooth feature, lower machine price, lower monthly fee, and shorter program duration. A subgroup of participants can be considered teleconsultation-resistant, and three demographic factors were associated with lower preference for teleconsultation: female, fewer formal education years, and lower income. Considering the reference population and Bluetooth attribute, participants were willing to pay 66 SGD (~49 USD) additional for the machine to obtain the Bluetooth feature. Considering the reference population and teleconsultation attribute, participants were willing to pay 6.80 SGD (~5.10 USD) extra monthly fee for a program using teleconsultation. Here we report that amongst participants with hypertension, there is strong preference for the use of teleconsultation and a BP machine with Bluetooth feature in a BP monitoring program. However, a subgroup of participants are teleconsultation-resistant and would prefer in-person consultation.

Preferences of people living with HIV for features of tuberculosis preventive treatment regimens - a discrete choice experiment

Background

Tuberculosis (TB) preventive treatment (TPT) is recommended for people living with HIV (PLHIV) in high TB burden settings. While 6 months of daily isoniazid remains widely used, shorter regimens are now available. However, little is known about preferences of PLHIV for key features of TPT regimens.

Methods

We conducted a discrete choice experiment among adult PLHIV engaged in care at an urban HIV clinic in Kampala, Uganda. In nine random choice tasks, participants chose between two hypothetical TPT regimens with different features (pills per dose, frequency, duration, need for adjusted antiretroviral therapy [ART] dosage and side effects). We analyzed preferences using hierarchical Bayesian estimation, latent class analysis, and willingness-to-trade simulations.

Results

Of 400 PLHIV, 392 (median age 44, 72% female, 91% TPT-experienced) had high quality choice task responses. Pills per dose was the most important attribute (relative importance 32.4%, 95% confidence interval [CI] 31.6 - 33.2), followed by frequency (20.5% [95% CI 19.7 - 21.3]), duration (19.5% [95% CI 18.6 - 20.5]), and need for ART dosage adjustment (18.2% [95% CI 17.2 - 19.2]). Latent class analysis identified three preference groups: one prioritized less frequent, weekly dosing (N=222; 57%); another was averse to ART dosage adjustment (N=107; 27%); and the last prioritized short and tolerable regimens (N=63; 16%). All groups highly valued fewer pills per dose. Participants were willing to accept a regimen of 2.8 months' additional duration [95% CI: 2.4 - 3.2] to reduce pills per dose from five to one, 3.6 [95% CI 2.4 - 4.8] months for weekly rather than daily dosing, and 2.2 [95% CI 1.3 - 3.0] months to avoid ART dosage adjustment.

Conclusions

To align with preferences of PLHIV, decision-makers should prioritize the development and implementation of TPT regimens with fewer pills, less frequent dosing, and no need for ART dosage adjustment, rather than focus primarily on duration of treatment.