A systematic review of stated preference studies reporting public preferences for healthcare priority setting

Research outcomes informing the selection of public health interventions and strategies to implement them: A cross-sectional survey of Australian policy-maker and practitioner preferences

BACKGROUND

A key role of public health policy-makers and practitioners is to ensure beneficial interventions are implemented effectively enough to yield improvements in public health. The use of evidence to guide public health decision-making to achieve this is recommended. However, few studies have examined the relative value, as reported by policy-makers and practitioners, of different broad research outcomes (that is, measures of cost, acceptability, and effectiveness). To guide the conduct of research and better inform public health policy and practice, this study aimed at describing the research outcomes that Australian policy-makers and practitioners consider important for their decision-making when selecting: (a) public health interventions; (b) strategies to support their implementation; and (c) to assess the differences in research outcome preferences between policy-makers and practitioners.

METHOD

An online value-weighting survey was conducted with Australian public health policy-makers and practitioners working in the field of non-communicable disease prevention. Participants were presented with a list of research outcomes and were asked to select up to five they considered most critical to their decision-making. They then allocated 100 points across these - allocating more points to outcomes perceived as more important. Outcome lists were derived from a review and consolidation of evaluation and outcome frameworks in the fields of public health knowledge translation and implementation. We used descriptive statistics to report relative preferences overall and for policy-makers and practitioners separately.

RESULTS

Of the 186 participants; 90 primarily identified as policy-makers and 96 as public health prevention practitioners. Overall, research outcomes of effectiveness, equity, feasibility, and sustainability were identified as the four most important outcomes when considering either interventions or strategies to implement them. Scores were similar for most outcomes between policy-makers and practitioners.

CONCLUSION

For Australian policy-makers and practitioners working in the field of non-communicable disease prevention, outcomes related to effectiveness, equity, feasibility, and sustainability appear particularly important to their decisions about the interventions they select and the strategies they employ to implement them. The findings suggest researchers should seek to meet these information needs and prioritize the inclusion of such outcomes in their research and dissemination activities. The extent to which these outcomes are critical to informing the decision of policy-makers and practitioners working in other jurisdictions or contexts warrants further investigation.

Participatory Value Evaluation (PVE): A New Preference-Elicitation Method for Decision Making in Healthcare

Participatory value evaluation (PVE) has recently been introduced in the field of health as a new method to elicit stated preferences for public policies. PVE is a method in which respondents in a choice experiment are presented with various policy options and their attributes, and are asked to compose their portfolio of preference given a public-resource constraint. This paper aims to illustrate PVE's potential for informing healthcare decision making and to position it relative to established preference-elicitation methods. We first describe PVE and its theoretical background. Next, by means of a narrative review of the eight existing PVE applications within and outside the health domain, we illustrate the different implementations of the main features of the method. We then compare PVE to several established preference-elicitation methods in terms of the structure and nature of the choice tasks presented to respondents. The portfolio-based choice task in a PVE requires respondents to consider a set of policy alternatives in relation to each other and to make trade-offs subject to one or more constraints, which more closely resembles decision making by policymakers. When using a flexible budget constraint, respondents can trade-off their private income with public expenditures. Relative to other methods, a PVE may be cognitively more demanding and is less efficient; however, it seems a promising complementary method for the preference-based assessment of health policies. Further research into the feasibility and validity of the method is required before researchers and policymakers can fully appreciate the advantages and disadvantages of the PVE as a preference-elicitation method.

Justification of principles for healthcare priority setting: the relevance and roles of empirical studies exploring public values

How should scarce healthcare resources be distributed? This is a contentious issue that became especially pressing during the pandemic. It is often emphasised that studies exploring public views about this question provide valuable input to the issue of healthcare priority setting. While there has been a vast number of such studies it is rarely articulated, more specifically, what the results from these studies would mean for the justification of principles for priority setting. On the one hand, it seems unreasonable that public values would straightforwardly decide the ethical question of how resources should be distributed. On the other hand, in a democratic society, it seems equally unreasonable that they would be considered irrelevant for this question. In this paper we draw on the notion of reflective equilibrium and discuss the relevance and roles that empirical studies may plausibly have for justification in priority setting ethics. We develop a framework for analysing how different kinds of empirical results may have different kinds of implications for justification.

Public preferences for the allocation of societal resources over different healthcare purposes

OBJECTIVE

Increasing healthcare expenditures require governments to make difficult prioritization decisions. Considering public preferences can help raise citizens' support. Previous research has predominantly elicited preferences for the allocation of public resources towards specific treatments or patient groups and principles for resource allocation. This study contributes by examining public preferences for budget allocation over various healthcare purposes in the Netherlands.

METHODS

We conducted a Participatory Value Evaluation (PVE) choice experiment in which 1408 respondents were asked to allocate a hypothetical budget over eight healthcare purposes: general practice and other easily accessible healthcare, hospital care, elderly care, disability care, mental healthcare, preventive care by encouragement, preventive care by discouragement, and new and better medicines. A default expenditure was set for each healthcare purpose, based on current expenditures. Respondents could adjust these default expenditures using sliders and were presented with the implications of their adjustments on health and well-being outcomes, the economy, and the healthcare premium. As a constraint, the maximum increase in the mandatory healthcare premium for adult citizens was €600 per year. The data were analysed using descriptive statistics and a Latent Class Cluster Analysis (LCCA).

RESULTS

On average, respondents preferred to increase total expenditures on all healthcare purposes, but especially on elderly care, new and better medicines, and mental healthcare. Three preference clusters were identified. The largest cluster preferred modest increases in expenditures, the second a much higher increase of expenditures, and the smallest favouring a substantial reduction of the healthcare premium by decreasing the expenditure on all healthcare purposes. The analyses also demonstrated substantial preference heterogeneity between clusters for budget allocation over different healthcare purposes.

CONCLUSIONS

The results of this choice experiment show that most citizens in the Netherlands support increasing healthcare expenditures. However, substantial heterogeneity was identified in preferences for healthcare purposes to prioritize. Considering these preferences may increase public support for prioritization decisions.

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.

Donor versus recipient preferences for aid allocation: A systematic review of stated-preference studies

As Official Development Assistance (ODA) tops 180 billion USD per year, there is a need to understand the mechanisms underlying aid effectiveness. Over the past decade we have seen some low- and middle-income countries become developed nations with record economic growth. Others remain in development purgatory, unable to provide their citizens with access to essential services. In an effort to improve aid effectiveness, the prescriptive nature of aid, where (typically) Western countries allocate funds based on perceived need or the strategic priorities of donors is being reconsidered in favour of locally-led development, whereby recipient governments and sometimes citizens are involved in the allocation and delivery of development aid. Meeting the preferences of donors (both governments and citizens) has been a longstanding priority for international development organisations and democratically governed societies. Understanding how these donor preferences relate to recipient preferences is a more recent consideration. This systematic review analysed 58 stated preference studies to summarise the evidence around donor and recipient preferences for aid and, to the extent possible, draw conclusions on where donor and recipient preferences diverge. While the different approaches, methods, and attributes specified by included studies led to difficulties drawing comparisons, we found that donors had a stronger preference than recipients for aid to the health sector, and that aid effectiveness could be more important to donors than recipients when deciding how to allocate aid. Importantly, our review identifies a paucity of literature assessing recipient perspectives for aid using stated preference methods. The dearth of studies conducted from the recipient perspective is perplexing after more than 30 years of 'alignment with recipient preferences', 'local ownership of aid', 'locally-led development' and 'decolonisation of aid'. Our work points to a need for further research describing preferences for aid across a consistent set of attributes in both donor and recipient populations.

Comparison of Rare and Common Diseases in the Setting of Healthcare Priorities: Evidence of Social Preferences Based on a Systematic Review

Background

In light of the limited availability of healthcare resources, providing universal access to healthcare is a challenging task. As a result, prioritizing healthcare services has emerged as a crucial issue. This study aims to explore the preferences of the public regarding healthcare prioritization for rare and common diseases. By examining public attitudes, this study seeks to inform government decisions concerning resource allocation and distribution within healthcare.

Methods

"Social preference" and "rare disease" were searched as MeSH terms in the electronic databases of Ovid Medline, Web of Science, Embase, and Econlit for articles published since their establishment, and the information on the characteristics of the articles and the results of social preferences for rare diseases were analyzed and summarized.

Results

The public held predominantly neutral views on the setting of healthcare priorities for rare and common diseases. The results of the included studies showed that with all else being equal, no social preference for rarity was found, but when the public considered the proportional advantage of rare diseases or when the respondents were young, a social preference for rarity existed. In addition, the public weighed attributes such as the health benefits of treatments, the effectiveness of treatment options, the safety of treatment, equity, unmet needs, and disease severity in the process of setting of treatment priorities for rare diseases. Furthermore, in consideration of equity, the public showed a willingness to pay for rare diseases in spite of the high medical costs.

Conclusion

International studies on social preferences provide some evidence for the setting of healthcare priorities for rare diseases, and health policymakers should consider social preferences in an integrated manner in order to set healthcare priorities appropriately.

Impact of information and deliberation on the consistency of preferences for prioritization in health care - evidence from discrete choice experiments undertaken alongside citizens' juries

BACKGROUND

Public preferences are an important consideration for priority-setting. Critics suggest preferences of the public who are potentially naïve to the issue under consideration may lead to sub-optimal decisions. We assessed the impact of information and deliberation via a Citizens' Jury (CJ) or preference elicitation methods (Discrete Choice Experiment, DCE) on preferences for prioritizing access to bariatric surgery.

METHODS

Preferences for seven prioritization criteria (e.g. obesity level, obesity-related comorbidities) were elicited from three groups who completed a DCE: (i) participants from two CJs (n = 28); (ii) controls who did not participate in the jury (n = 21); (iii) population sample (n = 1,994). Participants in the jury and control groups completed the DCE pre- and post-jury. DCE data were analyzed using multinomial logit models to derive "priority weights" for criteria for access to surgery. The rank order of criteria was compared across groups, time points and CJ recommendations.

RESULTS

The extent to which the criteria were considered important were broadly consistent across groups and were similar to jury recommendations but with variation in the rank order. Preferences of jurors but not controls were more differentiated (that is, criteria were assigned a greater range of priority weights) after than before the jury. Juror preferences pre-jury were similar to that of the public but appeared to change during the course of the jury with greater priority given to a person with comorbidity. Conversely, controls appeared to give a lower priority to those with comorbidity and higher priority to treating very severe obesity after than before the jury.

CONCLUSION

Being informed and undertaking deliberation had little impact on the criteria that were considered to be relevant for prioritizing access to bariatric surgery but may have a small impact on the relative importance of criteria. CJs may clarify underlying rationale but may not provide substantially different prioritization recommendations compared to a DCE.

Public voices on tie-breaking criteria and underlying values in COVID-19 triage protocols to access critical care: a scoping review

Background

To reduce the arbitrariness in the allocation of rare resources in intensive care units (ICU) in the context of the pandemic, tiebreakers were considered in some COVID-19 triage algorithms. They were also contemplated to facilitate the tragic decisions of healthcare workers when faced with two patients with similar prognosis and only one ICU bed available. Little is known about the public's perspective on tiebreakers.

Objectives

To consolidate the available scientific literature on public consultations, particularly on tiebreakers and their underlying values. Also, to obtain an overview of the key arguments presented by the participating public and to identify potential gaps related to this topic.

Methods

The steps described by Arksey and O'Malley was the preferred method to our approach. Seven electronic databases were searched from January 2020 to April 2022, using keywords for each database: PubMed, Medline, EMBASE, Web of Science, PsycINFO, EBM reviews, CINAHL complete. We also searched in Google and Google Scholar, and in the references of the articles found. Our analysis was mainly qualitative. A thematic analysis was performed to consider the public's perspectives on tiebreakers and their underlying values, according to these studies.

Results

Of 477 publications found, 20 were selected. They carried out public consultations through various methods: surveys (80%), interviews (20%), deliberative processes (15%) and others (5%) in various countries: Australia, Brazil, Canada, China, France, Germany, India, Iran, Italy, Japan, Korea, Netherlands, Portugal, Spain, Switzerland, Thailand, United Kingdom, and United States. Five themes emerged from our analysis. The public favored the life cycle (50%) and absolute age (45%) as a tiebreaker. Other values considered important were reciprocity, solidarity, equality, instrumental value, patient merit, efficiency, and stewardship. Among the new findings were a preference for patient nationality and those affected by COVID-19.

Conclusions

There is a preference for favoring younger patients over older patients when there is a tie between similar patients, with a slight tendency to favor intergenerational equity. Variability was found in the public's perspectives on tiebreakers and their values. This variability was related to socio-cultural and religious factors. More studies are needed to understand the public's perspective on tiebreakers.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44250-023-00027-9.

Moral and Social Values in Evidence-Informed Deliberative Processes for Health Benefit Package Design Comment on "Evidence-Informed Deliberative Processes for Health Benefit Package Design - Part II: A Practical Guide"

An evidence-informed deliberative process (EDP) is defined as "a practical and stepwise approach for health technology assessment (HTA) bodies to enhance legitimate health benefit package design based on deliberation between stakeholders to identify, reflect and learn about the meaning and importance of values, informed by evidence on these values." In this commentary, I discuss some considerations for EDPs that arise from acknowledging the difference between social and moral values. First, the best practices for implementing EDPs may differ depending on whether the approach is grounded in moral versus social values. Second, the goals of deliberation may differ when focused on moral versus social values. I conclude by offering some considerations for future research to support the use of EDPs in practice, including the need to assess how different approaches to appraisal (eg, more quantitative versus qualitative) impact perceptions of the value of deliberation itself.

Societal preferences for funding orphan drugs in China: An application of the discrete choice experiment method

Objectives

To explore whether a societal preference for orphan drugs exists in Chinese general public and to quantitatively measure the personal trade-off between essential attributes of orphan drugs through a discrete choice experiment.

Methods

A labeled discrete choice experiment was employed to measure public preference. Six attributes (impact of diseases on life-years, impact of diseases on quality of life, availability of alternative drug treatments, annual cost per patient paid by medical insurance, expected increases in life-expectancy, and improvements to the quality of life) were identified through a literature review, experts' suggestions, and stakeholders' semi-structured interviews, then refined through a pre-survey. The current study used a D-efficient design to yield 27 choice sets divided into three blocks with nine questions containing the labeled treatment (either orphan drugs or common drugs). Information on sociodemographic characteristics and individual preferences was collected through a web-based questionnaire using convenience sampling. A mixed logit model was used to test societal preferences for orphan drugs over common drugs, while a binary logit model was used to measure the relative importance of each attribute in orphan drug access for the National Reimbursement Drug List and its willingness to pay.

Results

A total of 323 persons participated in this study. Respondents largely had indifferent attitudes toward orphan drugs and common drugs. The binary logit model results showed that 5 of the 6 attributes were significant, except for the availability of alternative drug treatments. The most impacted factor was the annual cost per patient paid by medical insurance (β = -1.734, odds ratio [OR] = 0.177). Among non-economic attributes, the impact of diseases on life-years-with no treatment, the patient will die in the prime of life (β = 0.523, OR = 1.688, willingness to pay = 301,895)-was most concerning, followed by significant improvements to the quality of life (β = 0.516, OR = 1.676, willingness to pay = 297,773).

Conclusion

The general public in China does not value rarity as a sufficient reason to justify special consideration in funding orphan drugs. When making orphan drug coverage decisions, the public prioritized the annual cost, disease severity, and drug effects.

Quantifying public preferences for healthcare priorities in Taiwan through an integrated citizens jury and discrete choice experiment

Priority setting is a critical process for national healthcare systems that need to allocate limited resources across unlimited healthcare demands. In recent decades, health policymakers have identified the need to combine technical dimensions of priority setting with political dimensions relating to community values. A range of methods for engaging the public in priority setting has been developed, yet there is no consensus around the most effective methodology. A 2014 paper proposed the integration of two methods currently used for soliciting public preferences around health care services: i) an individual survey instrument, Discrete Choice Experiments (DCEs) and ii) Citizen Juries (CJs), a group-based model that incorporates education and deliberative dialogue. This pilot study is among the first to empirically test this integrated method to assess its value across two domains: does the CJ process alter participant preferences and are the consensus values of the CJ captured by the individualistic DCE? The two-part, mixed methods study was administered in Taipei, Taiwan in August of 2016. Twenty-seven participants completed a DCE as a baseline pre-test, ranking a set of attributes in terms of importance for future resource allocation under Taiwan's National Health Insurance System. Twenty of the participants next took part in the integrated CJ-DCE method, which consisted of education and facilitated dialogue through a CJ, followed by retaking the DCE survey. Participant preferences changed after undergoing the CJ process and these new, group-based preferences were reflected in the second DCE, meaning participants did not revert to their original individualistic preferences. The results of this study demonstrate that the integrated CJ-DCE method adds value in allowing an ethically communitarian set of values to be developed and captured via an individualistic methodology. Further testing is needed to investigate the reliability of our findings and how it may be implemented to maximize public acceptance.

Methods to Summarize Discrete-Choice Experiments in a Systematic Review: A Scoping Review

BACKGROUND AND OBJECTIVE

Systematic reviews of discrete-choice experiments (DCEs) are being increasingly conducted. The objective of this scoping review was to identify and describe the methodologies that have been used to summarize results across DCEs.

METHODS

We searched the electronic databases MEDLINE and EMBASE from inception to March 18, 2021, to identify English-language systematic reviews of patient preferences that included at least two DCEs and extracted data on attribute importance. The methods used to summarize results across DCEs were classified into narrative, semi-quantitative, and quantitative (meta-analytic) approaches and compared. Approaches to characterize the extent of preference heterogeneity were also described.

RESULTS

From 7362 unique records, we identified 54 eligible reviews from 2010 to Mar 2021, across a broad range of health conditions. Most (83%) used a narrative approach to summarize findings of DCEs, often citing differences in studies as the reason for not formally pooling findings. Semi-quantitative approaches included summarizing the frequency of the most important attributes, the frequency of attribute statistical significance, or tabulated comparisons of attribute importance for each pair of attributes. One review conducted a meta-analysis using the maximum acceptable risk. While reviews often commented on the heterogeneity of patient preferences, few (6%) addressed this systematically across studies.

CONCLUSION

While not commonly used, several semi-quantitative and one quantitative approach for synthesizing results of DCEs were identified, which may be useful for generating summary estimates across DCEs when appropriate. Further work is needed to assess the validity and usefulness of these approaches.

If you were a policymaker, which treatment would you disinvest? A participatory value evaluation on public preferences for active disinvestment of health care interventions in the Netherlands

INTRODUCTION

Currently, it is not known what attributes of health care interventions citizens consider important in disinvestment decision-making (i.e. decisions to discontinue reimbursement). Therefore, this study aims to investigate the preferences of citizens of the Netherlands toward the relative importance of attributes of health care interventions in the context of disinvestment.

METHODS

A participatory value evaluation (PVE) was conducted in April and May 2020. In this PVE, 1143 Dutch citizens were asked to save at least €100 million by selecting health care interventions for disinvestment from a list of eight unlabeled health care interventions, described solely with attributes. A portfolio choice model was used to analyze participants' choices.

RESULTS

Participants preferred to disinvest health care interventions resulting in smaller gains in quality of life and life expectancy that are provided to older patient groups. Portfolios (i.e. combinations of health care interventions) resulting in smaller savings were preferred for disinvestment over portfolios with larger savings.

CONCLUSION

The disinvestment of health care interventions resulting in smaller health gains and that are targeted at older patient groups is likely to receive most public support. By incorporating this information in the selection of candidate interventions for disinvestment and the communication on disinvestment decisions, policymakers may increase public support for disinvestment.

Willingness-to-pay for cancer treatment and outcome: a systematic review

BACKGROUND

Understanding patient preferences in cancer management is essential for shared decision-making. Patient or societal willingness-to-pay (WTP) for desired outcomes in cancer management represents their preferences and values of these outcomes.

OBJECTIVE

The aim of this systematic review is to critically evaluate how current literature has addressed WTP in relation to cancer treatment and achievement of outcomes.

METHODS

Seven databases were searched from inception until 2 March 2021 to include studies with primary data of WTP values for cancer treatments or achievement of outcomes that were elicited using stated preference methods.

RESULTS

Fifty-four studies were included in this review. All studies were published after year 2000 and more than 90% of the studies were conducted in high-income countries. Sample size of the studies ranged from 35 to 2040, with patient being the most studied population. There was a near even distribution between studies using contingent valuation and discrete choice experiment. Based on the included studies, the highest WTP values were for a quality-adjusted life year (QALY) ($11,498-$589,822), followed by 1-year survival ($3-$198,576), quality of life (QoL) improvement ($5531-$139,499), and pain reduction ($79-$94,662). Current empirical evidence suggested that improvement in QoL and pain reduction had comparable weights to survival in cancer management.

CONCLUSION

This systematic review provides a summary on stated preference studies that elicited patient preferences via WTP and summarised their respective values. Respondents in this review had comparable WTP for 1-year survival and QoL, suggesting that improvement in QoL should be emphasised together with survival in cancer management.

Personal Responsibility for Health: Exploring Together with Lay Persons

Emerging parallel to long-standing, academic and policy inquiries on personal responsibility for health is the empirical assessment of lay persons' views. Yet, previous studies rarely explored personal responsibility for health among lay persons as dynamic societal values. We sought to explore lay persons' views on personal responsibility for health using the Fairness Dialogues, a method for lay persons to deliberate equity issues in health and health care through a small group dialogue using a hypothetical scenario. We conducted two 2-h Fairness Dialogues sessions (n = 15 in total) in Nova Scotia, Canada. We analyzed data using thematic analysis. Our analysis showed that personal choice played an important role in participants' thinking about health. Underlying the concept of personal choice was considerations of freedom and societal debt. In participants' minds, personal and social responsibilities co-existed and they were unwilling to determine health care priority based on personal responsibility. The Fairness Dialogues is a promising deliberative method to explore lay persons' views as dynamic values to be developed through group dialogues as opposed to static, already-formed values waiting to be elicited.

A Delphi study to explore clinician and lived experience perspectives on setting priorities in eating disorder services

Background

Due to scarce resources and high demand, priority setting in mental health services is necessary and inevitable. To date, no study has examined priority setting in eating disorder (ED) services specifically. Here, we evaluate the level of consensus and perceived relative importance of factors used to determine patient prioritisation in ED services, amongst clinicians and individuals with lived experience (LE) of an ED.

Methods

A three round Delphi study and a ranking task were used to determine the level of consensus and importance. Consensus was defined as > 80% agreement or disagreement. Items that reached consensus for agreement were ranked in order of importance from most to least important. Participants were 50 ED clinicians and 60 LE individuals. Participant retention across rounds 2, 3, and 4 were 92%, 85%, and 79%, respectively.

Results

Over three iterative rounds, a total of 87 statements about patient prioritisation were rated on a 5-point Likert-scale of agreement. Twenty-three items reached consensus in the clinician panel and 20 items reached consensus in the LE panel. The pattern of responding was broadly similar across the panels. The three most important items in both panels were medical risk, overall severity, and physical health deteriorating quickly. Clinicians tended to place greater emphasis on physical risk and early intervention whereas the LE panel focused more on mental health and quality of life.

Conclusions

Eating disorder services tend to prioritise patients based upon medical risk and severity, and then by the order in which patients are referred. Our findings align in some respects with what is observed in services, but diverge in others (e.g., prioritising on quality of life), providing important novel insights into clinician and LE opinions on waiting list prioritisation in EDs. More research is warranted to validate these findings using multi-criterion decision techniques and observational methods. We hope these findings provide a foundation for future research and encourage evidence-based conversations around priority setting in ED services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08170-4.

What public health interventions do people in Canada prefer to fund? A discrete choice experiment

Objective

To assess public support of tailored and targeted public health interventions for marginalized communities.

Methods

We conducted a discrete choice experiment using a web-based survey advertised to Facebook and Instagram users living in Canada, aged > 16. Participants were asked to choose between funding two hypothetical public health programs. Each program was described by its purpose; expected increase in life expectancy; and target audience. Demographically weighted generalized linear mixed-effects models were constructed to identify program factors associated with program selection.

Results

Participants completed up to 8 discrete choice comparison exercises each resulting in 23,889 exercises were completed by 3054 participants. Selected programs were less likely to focus on prevention (vs. treatment). For each 1-year increase in the marginal years of life gained, there was a 15% increase in the odds of a program being selected. Interventions tailored to marginalized communities or targeting stigmatized health conditions were less likely to be selected compared to interventions targeted to the general population or targeting chronic health conditions. Noteworthy exceptions included an increased preference for interventions aligning with the perceived needs or cultural expectations for marginalized communities.

Conclusions

Stigmatizing perceptions of health conditions and key populations likely influence public health programming preferences of Canadians.

Public health implications

Informational campaigns highlighting disparities experienced by marginalized populations may improve support for targeted and tailored interventions.

Should rare diseases get special treatment?

Orphan drug policy often gives 'special treatment' to rare diseases, by giving additional priority or making exceptions to specific drugs, based on the rarity of the conditions they aim to treat. This essay argues that the goal of orphan drug policy should be to make prevalence irrelevant to funding decisions. It aims to demonstrate that it is severity, not prevalence, which drives our judgments that important claims are being overlooked when treatments for severe rare diseases are not funded. It shows that prioritising severity avoids problems caused by prioritising rarity, and that it is compatible with a range of normative frameworks. The implications of a severity-based view for drug development are then derived. The severity-based view also accounts for what is wrong with how the current system of drug development unfairly neglects common diseases that burden the developing world. Lastly, the implications of a severity-based view for current orphan drug policies are discussed.

Willingness to Pay for Preventive Dental Care Amongst Older Adults

OBJECTIVE

The aims of this study were (1) to investigate willingness to pay (WTP) for preventive and curative dental care procedures and (2) to determine the factors that influence older adults' WTP for dental care.

METHODOLOGY

Older, independently living adults from Singapore aged 60 years and older and eligible for government-subsidised dental care were nonrandomly recruited for this study. Data were collected using questionnaires and a clinical examination which recorded details of caries experience, number and distribution of posterior occluding contacts, prosthodontic status, and periodontal status. Using a contingent valuation method, participants were asked to rate WTP in Singapore dollars [SGD$] for 4 aspects of care: dental fillings, dental scaling, dental extraction, and disease prevention advice. Negative binomial regression was used to assess the relationship between the predictor variables associated with WTP for dental fillings, scaling, extraction, and preventive advice.

RESULTS

The mean value of WTP for a dental filling was SGD$30.23 (SGD$31.05), for scaling was SGD$30.28 (SGD$29.46), for dental extraction was SGD$35.08 (SGD$58.54). In a multivariate model, factors associated with higher WTPfees were as follows: (1) dental filling: age (younger), level of education (higher), and frequency of dental visits (regular); (2) scaling: level of education (higher), agree that dental problems affect overall health, and frequency of dental visits (regular); (3) dental extractions: age (younger), level of education (higher), frequency of dental visits (regular), and prosthodontic status (not wearing); (4) preventive advice: age (younger), gender (male), ethnicity (Chinese), level of education (higher), marital status (married), self-perceived oral health (good), and dental visits (regular).

CONCLUSIONS

The findings of our study suggest that older adults are willing to pay most for extraction and least for preventive advice.

Clarifying Values: An Updated and Expanded Systematic Review and Meta-Analysis

Background

Patient decision aids should help people make evidence-informed decisions aligned with their values. There is limited guidance about how to achieve such alignment.

Purpose

To describe the range of values clarification methods available to patient decision aid developers, synthesize evidence regarding their relative merits, and foster collection of evidence by offering researchers a proposed set of outcomes to report when evaluating the effects of values clarification methods.

Data Sources

MEDLINE, EMBASE, PubMed, Web of Science, the Cochrane Library, and CINAHL.

Study Selection

We included articles that described randomized trials of 1 or more explicit values clarification methods. From 30,648 records screened, we identified 33 articles describing trials of 43 values clarification methods.

Data Extraction

Two independent reviewers extracted details about each values clarification method and its evaluation.

Data Synthesis

Compared to control conditions or to implicit values clarification methods, explicit values clarification methods decreased the frequency of values-incongruent choices (risk difference, –0.04; 95% confidence interval [CI], –0.06 to –0.02; P < 0.001) and decisional conflict (standardized mean difference, –0.20; 95% CI, –0.29 to –0.11; P < 0.001). Multicriteria decision analysis led to more values-congruent decisions than other values clarification methods (χ² = 9.25, P = 0.01). There were no differences between different values clarification methods regarding decisional conflict (χ² = 6.08, P = 0.05).

Limitations

Some meta-analyses had high heterogeneity. We grouped values clarification methods into broad categories.

Conclusions

Current evidence suggests patient decision aids should include an explicit values clarification method. Developers may wish to specifically consider multicriteria decision analysis. Future evaluations of values clarification methods should report their effects on decisional conflict, decisions made, values congruence, and decisional regret.

Citizens from 13 countries share similar preferences for COVID-19 vaccine allocation priorities

How does the public want a COVID-19 vaccine to be allocated? We conducted a conjoint experiment asking 15,536 adults in 13 countries to evaluate 248,576 profiles of potential vaccine recipients who varied randomly on five attributes. Our sample includes diverse countries from all continents. The results suggest that in addition to giving priority to health workers and to those at high risk, the public favors giving priority to a broad range of key workers and to those with lower income. These preferences are similar across respondents of different education levels, incomes, and political ideologies, as well as across most surveyed countries. The public favored COVID-19 vaccines being allocated solely via government programs but were highly polarized in some developed countries on whether taking a vaccine should be mandatory. There is a consensus among the public on many aspects of COVID-19 vaccination, which needs to be taken into account when developing and communicating rollout strategies.

Citizens from 13 countries share similar preferences for COVID-19 vaccine allocation priorities

How to allocate COVID-19 vaccines is one of the most important decisions currently facing governments. With limited supplies, what is most pressing is deciding who gets priority in the vaccine allocation rollout. Some governments are exploring allowing private purchases of COVID-19 vaccines. Many countries are debating whether COVID-19 vaccines should be mandated. There is little evidence on what policies are preferred by the global public. Our survey of 15,536 adults in 13 countries confirms that priority should be given to health workers and those at high risk but also, to a broad range of key workers and those with lower incomes. The public favors allocating COVID-19 vaccines solely via government programs but was polarized in some countries on mandatory vaccinations.

How does the public want a COVID-19 vaccine to be allocated? We conducted a conjoint experiment asking 15,536 adults in 13 countries to evaluate 248,576 profiles of potential vaccine recipients who varied randomly on five attributes. Our sample includes diverse countries from all continents. The results suggest that in addition to giving priority to health workers and to those at high risk, the public favors giving priority to a broad range of key workers and to those with lower income. These preferences are similar across respondents of different education levels, incomes, and political ideologies, as well as across most surveyed countries. The public favored COVID-19 vaccines being allocated solely via government programs but were highly polarized in some developed countries on whether taking a vaccine should be mandatory. There is a consensus among the public on many aspects of COVID-19 vaccination, which needs to be taken into account when developing and communicating rollout strategies.

Public and decision-maker stated preferences for pharmaceutical subsidy decisions in Iran: an application of the discrete choice experiment

Background

The argument about funding criteria poses challenges for health decision-makers in all countries. This study aimed to investigate the public and decision-maker preferences for pharmaceutical subsidy decisions in Iran.

Methods

A discrete choice experiment (DCE) was used for eliciting the preferences of the public and decision-makers. Four attributes including health gain after treatment, the severity of the disease, prevalence of the disease, and monthly out of pocket and relevant levels were designed in the form of hypothetical scenarios. The analysis was done by using conditional logit analysis.

Results

The results show all of four attributes are important for pharmaceutical subsidy decisions. But a medicine that improves health gain after treatment is more likely to be a choice in subsidy decisions (by relative importance of 28% for public and 42% for decision-makers). Out of pocket, severity, and prevalence of disease subsequently influence the preferences of the public and decision-makers, respectively. The greatest difference is observed in changing the health gain after treatment and out of pocket levels, between public and decision-makers.

Conclusion

This research reveals that the public is willing and able to provide preferences to inform policymakers for pharmaceutical decision-making; it also sets grounds for further studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40545-021-00365-0.

A systematic review of moral reasons on orphan drug reimbursement

BACKGROUND

The number of market approvals of orphan medicinal products (OMPs) has been increasing steadily in the last 3 decades. While OMPs can offer a unique chance for patients suffering from rare diseases, they are usually very expensive. The growing number of approved OMPs increases their budget impact despite their low prevalence, making it pressing to find solutions to ethical challenges on how to fairly allocate scarce healthcare resources under this context. One potential solution could be to grant OMPs special status when considering them for reimbursement, meaning that they are subject to different, and less stringent criteria than other drugs. This study aims to provide a systematic analysis of moral reasons for and against such a special status for the reimbursement of OMPs in publicly funded healthcare systems from a multidisciplinary perspective.

RESULTS

With a systematic review of reasons, we identified 39 reasons represented in 243 articles (scientific and grey literature) for and against special status for the reimbursement of OMPs, then categorized them into nine topics. Taking a multidisciplinary perspective, we found that most articles came from health policy (n = 103) and health economics (n = 49). More articles took the position for a special status of OMPs (n = 97) than those against it (n = 31) and there was a larger number of reasons identified in favour (29 reasons) than against (10 reasons) this special status.

CONCLUSION

Results suggest that OMP reimbursement issues should be assessed and analysed from a multidisciplinary perspective. Despite the higher occurrence of reasons and articles in favour of a special status, there is no clear-cut solution for this ethical challenge. The binary perspective of whether or not OMPs should be granted special status oversimplifies the issue: both OMPs and rare diseases are too heterogeneous in their characteristics for such a binary perspective. Thus, the scientific debate should focus less on the question of disease prevalence but rather on how the important variability of different OMPs concerning e.g. target population, cost-effectiveness, level of evidence or mechanism of action could be meaningfully addressed and implemented in Health Technology Assessments.

Systematic Review to Update 'Value of a Statistical Life' Estimates for Australia

The value of a statistical life (VSL) estimates individuals’ willingness to trade wealth for mortality risk reduction. This economic parameter is often a major component of the quantified benefits estimated in the evaluation of government policies related to health and safety. This study reviewed the literature to update the VSL recommended for Australian policy appraisals. A systematic literature review was conducted to capture Australian primary studies and international review papers reporting VSL estimates published from 2007 to January 2019. International estimates were adjusted for income differences and the median VSL estimate was extracted from each review study. VSL estimates were used to calculate the value of a statistical life year. Of the 18 studies that met the inclusion criteria, two studies were primary Australian studies with a weighted mean VSL of A$7.0 million in 2017 values. The median VSL in the review studies was A$7.3 million. For Australian public policy appraisals, we recommend the consideration of a base case VSL for people of all ages and across all risk contexts of A$7.0 million. Sensitivity analyses could use a high value of A$7.3 million and a low value that reflects the value (A$4.3 million) currently recommended by the Australian government.

A systematic review and meta-regression of studies eliciting willingness-to-pay per quality-adjusted life year in the general population

OBJECTIVES

From the demand-side perspective, the monetary value of one additional quality-adjusted life year (QALY) is estimated as willingness-to-pay per QALY (WTPQ). This study aims to summarize the methods and contexts of elicitation of willingness-to-pay per quality-adjusted life year (WTPQ) in the general population and to investigate the heterogeneity of WTPQ estimates.

METHODS

Meta-regression analysis was conducted using Comprehensive Meta-Analysis Software. Sensitivity analyses were undertaken by replacing the lowest and highest 5% and 2.5% of WTPQ by percentiles.

RESULTS

33 studies with 102 WTPQ estimates were included. The overall mean and median WTPQ estimates are $1,280,002 and $44,072, respectively. The meta-regressions demonstrated that types of health gain (quality of life or life length) and certainty of health outcomes are statistically significant factors. Furthermore, compared with online interviews, face-to-face interviews tend to yield lower WTPQ. Moreover, the declining trend of QALY gains and positive effect with statistical significance of the sample age were also noticed.

CONCLUSION

For valid and representative values of WTPQ, future researchers should therefore take into consideration various scenarios and investigate both health gain with certainty and uncertainty, health gain from both life length and quality of life, and different size of QALY gains.

Value judgment of new medical treatments: Societal and patient perspectives to inform priority setting in The Netherlands

BACKGROUND

In many countries, medical interventions are reimbursed on the basis of recommendations made by advisory boards and committees that apply multiple criteria in their assessment procedures. Given the diversity of these criteria, it is difficult to find common ground to determine what information is required for setting priorities.

OBJECTIVE

To investigate whether society and patients share the same interests and views concerning healthcare priorities.

METHODS

We applied a framework of discrete choice models in which respondents were presented with judgmental tasks to elicit their preferences. They were asked to choose between two hypothetical scenarios of patients receiving a new treatment. The scenarios graphically presented treatment outcomes and patient characteristics. Responses were collected through an online survey administered among respondents from the general population (N = 1,253) and patients (N = 1,389) and were analyzed using conditional logit and mixed logit models.

RESULTS

The respondents' preferences regarding new medical treatments revealed that they attached the most relative importance to additional survival years, age at treatment, initial health condition, and the cause of disease. Minor differences in the relative importance assigned to three criteria: age at treatment, initial health, and cause of disease were found between the general population and patient samples. Health scenarios in which patients had higher initial health-related quality of life (i.e., a lower burden of disease) were favored over those in which patients' initial health-related quality of life was lower.

CONCLUSIONS

Overall, respondents within the general population expressed preferences that were similar to those of the patients. Therefore, priority-setting studies that are based on the perspectives of the general population may be useful for informing decisions on reimbursement and other types of priority-setting processes in health care. Incorporating the preferences of the general population may simultaneously increase public acceptance of these decisions.

'There is no such thing as getting sick justly or unjustly' - a qualitative study of clinicians' beliefs on the relevance of personal responsibility as a basis for health prioritisation

BACKGROUND

Concerns have been raised regarding the reasonableness of using personal health responsibility as a principle or criterion for setting priorities in healthcare. While this debate continues, little is known about clinicians' views on the role of patient responsibility in clinical contexts. This paper contributes to the knowledge on the empirical relevance of personal responsibility for priority setting at the clinical level.

METHODS

A qualitative study of Norwegian clinicians (n = 15) was designed, using semi-structured interviews with vignettes to elicit beliefs on the relevance of personal responsibility as a basis for health prioritisation. Sampling was undertaken purposefully. The interviews were conducted in three hospital trusts in South-Eastern Norway between May 2018 and February 2019 and were analysed with conceptually driven thematic analysis.

RESULTS

The findings suggest that clinicians endorsed a general principle of personal health responsibility but were reluctant to introduce personal health responsibility as a formal priority setting criterion. Five main objections were cited, relating to avoidability, causality, harshness, intrusiveness, and inequity. Still, both retrospective and prospective attributions of personal responsibility were perceived as relevant in specific clinical settings. The most prominent argument in favour of personal health responsibility was grounded in the idea that holding patients responsible for their conduct would contribute to the efficient use of healthcare resources. Other arguments included fairness to others, desert and autonomy, but such standpoints were controversial and held only marginal relevance.

CONCLUSIONS

Our study provides important novel insights into the clinicians' beliefs about personal health responsibility improving the empirical knowledge concerning its fairness and potential applications to healthcare prioritisation. These findings suggest that although personal health responsibility would be difficult to implement as a steering criterion within the main priority setting framework, there might be clinical contexts where it could figure in prioritisation practices. Additional research on personal health responsibility would benefit from considering the multiple clinical encounters that shape doctor-patient relationships and that create the information basis for eligibility and prioritisation for treatment.

[Equity in the health economic evaluation of public health: An overview]

AIM

Starting from the claim that public health interventions should aim to improve health equity, the article examines which methodological approaches of health economic evaluation exist to support the analysis of equity-related outcomes of different interventions.

METHOD

Critical review of the relevant literature.

RESULTS

Against the background of the normative foundations of health economic evaluation, three methodological approaches and three practical methods are presented that allow for considering health equity concerns in health economic evaluations. Implications of the different approaches and references to the German context are discussed.

CONCLUSION

The use of the instruments presented offers good potential to improve transparency with respect to distributive effects of different allocation decisions. This appears to be necessary in order to meet demands for health equity improving public health interventions - especially in the context of the German Prevention Act.

Methods for measuring patient preferences: an update and future directions

PURPOSE OF REVIEW

The current review highlights the growing number of available methods used to measure patient preferences and discusses how this impacts preference research in rheumatology. Spurred by the growing role of preferences in regulatory decisions and drug development, researchers have begun applying preference methods to study questions beyond the clinical context. We explore these trends, provide case studies highlighting changes in measuring patient preferences, compare strengths and weaknesses of common stated-preference methods, and discuss considerations for the future use of these methods.

RECENT FINDINGS

Early literature on patient preferences often mimicked clinical practice, asking whether treatment A is better or worse than treatment B for a patient. Early applications of patient preference methods in rheumatology aimed to value different attributes of treatments, but remained focused on informing clinical questions. Spurred by interest in preferences by regulatory agencies and patient-centeredness throughout the product lifecycle, there are now a wide array of methods available to measure preference.

SUMMARY

Although these different preference methods have strengths and weaknesses, they serve to highlight the broad number of questions that could help rheumatology beyond the clinical context. Researchers in rheumatology now have the opportunity to better serve diverse stakeholders by considering how these methods could aid in clinical trial design, regulatory policy, and other elements of the medical product life cycle.

Empirical Investigation of Ranking vs Best-Worst Scaling Generated Preferences for Attributes of Quality of Life: One and the Same or Differentiable?

OBJECTIVES

The objective of this study was to investigate the degree of inconsistency in quality-of-life attribute preference orderings generated via successive best-worst scaling (a form of ranking whereby the respondent chooses the best and worst attributes from a choice set, these attributes are then eliminated and the best and worst attributes from the reduced choice set are then chosen and this process is continued until all presented attributes are eliminated) and conventional ranking methods (whereby the respondent chooses the best, second best and third best from a choice set until all presented attributes are eliminated).

METHODS

An on-line survey was developed for administration to two general population samples comprising younger people (aged 18-64 years) and older people (aged 65 years and above). Data were analysed in STATA through an empirical examination of the relative level of choice inconsistency (randomness in responses or the variability in choice outcomes not explained by attributes and their associated preference weights) for successive best-worst in comparison with the conventional ranking method for the younger and older person samples.

RESULTS

For the younger person sample, both methods were found to be similarly consistent. In contrast, for the older person sample, ranking performed relatively worse than best-worst scaling with more inconsistent responses (tau = 0.515, p < 0.01).

CONCLUSIONS

These findings lend some support to the hypothesis initially propagated by the developers of best-worst scaling that it is a comparatively easier choice task for respondents to undertake than a traditional ranking task.

What Does Society Value About Cancer Medicines? A Discrete Choice Experiment in the Belgian Population

BACKGROUND

Debate on pricing and reimbursement of cancer medicines highlights the need to establish the value of cancer medicines.

OBJECTIVE

This study aims to elicit the trade-offs in cancer medicine characteristics that the Belgian population is willing to make.

METHODS

A discrete choice experiment used six attributes with three levels each, based on literature and focus group discussions. The survey was sent to a random sample of 3500 Belgian citizens. Based on the choice of 961 respondents, individual parameters were estimated with a mixed logit model.

RESULTS

Societal value of cancer medicines was positively affected by a higher number of patients eligible for treatment, a high initial life expectancy and quality of life of patients, a high gain in quality of life and life expectancy due to treatment, and a low treatment cost. The value of 1-year gain in life expectancy was independent from the initial life expectancy of the patient. However, the value of one-point gain in quality of life was higher for patients with a low initial quality of life than for patients with a high initial quality of life.

CONCLUSIONS

This study has shown that gain in quality of life with cancer medicines is valued higher by Belgian society for patients who have lower initial quality of life before the start of treatment.

What attributes should be included in a discrete choice experiment related to health technologies? A systematic literature review

Discrete choice experiments (DCEs) are a way to assess priority-setting in health care provision. This approach allows for the evaluation of individuals’ preferences as a means of adding criteria to traditional quality-adjusted life year analysis. The aim of this systematic literature review was to identify attributes for designing a DCE in order to then develop and validate a framework that supports decision-making on health technologies. Our systematic literature review replicated the methods and search terms used by de Bekker-Grob et al. 2012 and Clark et al. 2014. The Medline database was searched for articles dated between 2008 and 2015. The search was limited to studies in English that reflected general preferences and were choice-based, published as full-text articles and related to health technologies. This study included 72 papers, 52% of which focused on DCEs on drug treatments. The average number of attributes used in all included DCE studies was 5.74 (SD 1.98). The most frequently used attributes in these DCEs were improvements in health (78%), side effects (57%) and cost of treatment (53%). Other, less frequently used attributes included waiting time for treatment or duration of treatment (25%), severity of disease (7%) and value for money (4%). The attributes identified might inform future DCE surveys designed to study societal preferences regarding health technologies in order to better inform decisions in health technology assessment.

Being Healthy, Being Sick, Being Responsible: Attitudes towards Responsibility for Health in a Public Healthcare System

Lifestyle-induced diseases are becoming a burden on healthcare, actualizing the discussion on health responsibilities. Using data from the National Association for Heart and Lung Diseases (LHL)’s 2015 Health Survey (N = 2689), this study examined the public’s attitudes towards personal and social health responsibility in a Norwegian population. The questionnaires covered self-reported health and lifestyle, attitudes towards personal responsibility and the authorities’ responsibility for promoting health, resource-prioritisation and socio-demographic characteristics. Block-wise multiple linear regression assessed the association between attitudes towards health responsibilities and individual lifestyle, political orientation and health condition. We found a moderate support for social responsibility across political views. Respondents reporting unhealthier eating habits, smokers and physically inactive were less supportive of health promotion policies (including information, health incentives, prevention and regulations). The idea that individuals are responsible for taking care of their health was widely accepted as an abstract ideal. Yet, only a third of the respondents agreed with introducing higher co-payments for treatment of ‘self-inflicted’ conditions and levels of support were patterned by health-related behaviour and left-right political orientation. Our study suggests that a significant support for social responsibility does not exclude a strong support for personal health responsibility. However, conditional access to healthcare based on personal lifestyle is still controversial.

Combining Health and Outcomes Beyond Health in Complex Evaluations of Complex Interventions: Suggestions for Economic Evaluation

In this journal there has been considerable discussion regarding the development of tools for valuing the multiple attributes that arise from complex interventions with benefits beyond health. Nevertheless, unlike the rigorous underpinnings of cost-utility analysis, much of this work has been taking place in fragmented research communities and without theoretical underpinnings, leading to a call for better and more comprehensive frameworks. We discuss the challenges faced by economic evaluation using as our example a "social prescribing" intervention, a novel health intervention based on the social model of health. We suggest a mixed-methods approach to uncover important attributes and then combine tools from health economics and economics to provide measures of benefit in a common money numeraire. This approach provides the theoretical underpinnings necessary for deliberate, transparent, and structured decision-making processes. It also enables the correct allocation of costs within complex payment systems. We suggest that, because of the complexities of randomized controlled trials, interventions should be introduced in a way that allows the application of causal analysis for evaluation. In the short term, such evaluations may be challenging and expensive. Nevertheless, as has happened with health economics evaluation and the quality-adjusted life-year, when a common set of attributes is agreed upon, the expense will fall and these methods can become embedded in interventions with diffuse outcomes.

Willingness to pay for medical treatments in chronic diseases: a multicountry survey of patients and physicians

AIM

The objective was to investigate factors influencing patients' willingness to pay (WTP) and physician's views on the cost of therapy for two contrasted chronic diseases, chronic heart failure and psoriasis.

METHODS

A cross-sectional survey was conducted in ten developing countries, using a stated WTP contingent valuation method. Multivariate analyses were performed by linear regression.

RESULTS

Independent factors influencing patient WTP were income (+0.04 $PPP [purchasing power parity] in WTP per $PPP in monthly income; p < 0.001) and purchase of branded treatment for chronic heart failure therapy, and income, out-of-pocket treatment costs but also education level higher than secondary school (+115 $PPP in WTP comparatively to patients with none/primary school level; p = 0.008) for psoriasis therapy, suggesting the influence of sociopsychological factors in this disease.

CONCLUSION

Disease-specific factors may affect WTP for treatment that should be accounted for to support effective public health programs in developing countries.

A Systematic Review Comparing the Acceptability, Validity and Concordance of Discrete Choice Experiments and Best-Worst Scaling for Eliciting Preferences in Healthcare

OBJECTIVE

The aim of this study was to compare the acceptability, validity and concordance of discrete choice experiment (DCE) and best-worst scaling (BWS) stated preference approaches in health.

METHODS

A systematic search of EMBASE, Medline, AMED, PubMed, CINAHL, Cochrane Library and EconLit databases was undertaken in October to December 2016 without date restriction. Studies were included if they were published in English, presented empirical data related to the administration or findings of traditional format DCE and object-, profile- or multiprofile-case BWS, and were related to health. Study quality was assessed using the PREFS checklist.

RESULTS

Fourteen articles describing 12 studies were included, comparing DCE with profile-case BWS (9 studies), DCE and multiprofile-case BWS (1 study), and profile- and multiprofile-case BWS (2 studies). Although limited and inconsistent, the balance of evidence suggests that preferences derived from DCE and profile-case BWS may not be concordant, regardless of the decision context. Preferences estimated from DCE and multiprofile-case BWS may be concordant (single study). Profile- and multiprofile-case BWS appear more statistically efficient than DCE, but no evidence is available to suggest they have a greater response efficiency. Little evidence suggests superior validity for one format over another. Participant acceptability may favour DCE, which had a lower self-reported task difficulty and was preferred over profile-case BWS in a priority setting but not necessarily in other decision contexts.

CONCLUSION

DCE and profile-case BWS may be of equal validity but give different preference estimates regardless of the health context; thus, they may be measuring different constructs. Therefore, choice between methods is likely to be based on normative considerations related to coherence with theoretical frameworks and on pragmatic considerations related to ease of data collection.

Sharing and the Provision of "Cost-Ineffective" Life-Extending Services to Less Severely Ill Patients

BACKGROUND

Cost-utility analysis prioritizes services using cost, life-years, and the health state utility of the life-years. Nevertheless, a significant body of evidence suggests that the public would prefer more variables to be considered in decision making and at least some sharing of the budget with services for severe conditions that are not cost-effective because of their high cost.

OBJECTIVES

To examine whether this preference for sharing persists for less severe conditions when both cost effectiveness and illness severity would indicate that resources should be allocated to other services.

METHODS

Survey respondents were asked to divide a budget between two patients facing life-threatening illnesses. The severity of the illnesses differed and the price of treatment was varied.

RESULTS

Sharing occurred in all scenarios including scenarios in which the illness was less severe and services were not cost-effective. Results are consistent with behavior commonly observed in other contexts.

CONCLUSIONS

Results suggest that sharing per se is important and that the public would support some funding of cost-ineffective services for less severe health problems.

Inference Procedures to Quantify the Efficiency-Equality Trade-Off in Health from Stated Preferences: A Case Study in Portugal

OBJECTIVES

This article develops two inference procedures to calculate the inequality aversion and alpha parameters of a health-related social welfare function with constant elasticity (CES-HRSWF) using stated preferences. Based on the relative concept of inequality, a range of values were proposed for the trade-offs between improving total population health and reducing health inequalities.

METHODS

A self-administered questionnaire was used to collect data from a sample of 422 college students in Portugal. Respondents faced three hypothetical allocation scenarios where they needed to decide between two health programmes that assign different health gains to two anonymous sub-groups of the population and to two sub-groups identified by socioeconomic class. Combinations of the median response to these three questions were used to estimate the parameters of the CES-HRSWF.

RESULTS

Findings suggest that the quantification of the efficiency-equality trade-off is not independent of the inference procedure used. Plausible values for the inequality aversion and for the alpha parameters were obtained ranging from 2.24 to 4.85 and from 0.5 to 0.58, respectively.

CONCLUSIONS

Respondents revealed some aversion to health inequality. However, the extent of this aversion seems to be sensitive to (1) the identification of the groups by occupation status, (2) the size of the health gain, and (3) the inference procedure used.

Does a patient's health potential affect the social valuation of health services?

Background

Patients with a permanent impairment may be unable to reach full health. Consequently health services which cure illnesses which are unrelated to the impairment may increase health less than services for patients with no impairment. While it has been argued that this should not lead to discrimination against impaired patients there is little evidence to determine whether this equity-efficiency trade-off is consistent with social values.

Objectives

To measure the effect of permanent impairment upon the social valuation of services for unrelated illnesses.

Methods

Social valuations of services for illnesses associated with mobility, depression or pain were assessed and compared for patients with and without a permanent impairment using the Relative Social Willingness to Pay (RS-WTP) instrument. The maximum valuation of services for impaired patients was also compared with the maximum utility which could be gained when utility was measured using three multi attribute utility instruments.

Results

Curing the illness of impaired patients was valued 8–11 percent less than the cure of patients with no impairment. Discrimination decreased as the severity of the illness increased. Valuation of health states using the utility instruments implied significantly greater discrimination than the social valuations using the RS-WTP instrument.

Conclusions

Health services are valued less highly when a patient’s health potential is impaired. However discrimination is significantly less than would occur if the value of the services were limited to the value of the health state causing the impairment. The argument for disregarding a patient’s limited health potential when resources are allocated therefore receives some support from social valuations but the case for completely equal treatment depends upon additional ethical arguments.

Application of Discrete-Choice Experiment Methods in Tobacco Control: A Systematic Review

BACKGROUND

Economic evidence relating to tobacco control is generally derived from the cost effectiveness of smoking-cessation programs or the economic impact of tobacco-induced disease, based on revealed-preference data. However, empirical estimates from stated-preference data on tobacco users' preferences, smoking behaviour and smoking cessation aids using analytical techniques such as discrete-choice experiments (DCEs) could be important for policy decision making in tobacco control.

OBJECTIVES

Our objective was to review the practice and utility of DCE methodology across nicotine- and tobacco-related issues, particularly smoking and smoking-cessation behaviour, anti-smoking policies and preferences for smoking-cessation aids.

METHODS

We searched the PubMed, MEDLINE and ECONLIT databases for full-text original research articles on tobacco-related issues published between January 2000 and April 2016 that used a DCE method. We summarised the evidence and methodological characteristics of DCEs according to Lancsar and Louviere, 2008.

RESULTS

Our review of the 12 eligible studies showed that DCE methodology was used to elicit smoker preferences and to evaluate tobacco-control policies. The majority of the studies were published in the last 5 years. The areas of application were smoking cessation, smoking behaviour, electronic cigarette use, water-pipe smoking and tobacco packaging. Monetary attributes were the most influential attributes in all studies. The design of the DCEs varied.

CONCLUSION

DCE studies of tobacco-related issues were methodologically consistent with guidelines proposed for conducting health-related DCEs.

Integrating social justice concerns into economic evaluation for healthcare and public health: A systematic review

Social justice is the moral imperative to avoid and remediate unfair distributions of societal disadvantage. In priority setting in healthcare and public health, social justice reaches beyond fairness in the distribution of health outcomes and economic impacts to encompass fairness in the distribution of policy impacts upon other dimensions of well-being. There is an emerging awareness of the need for economic evaluation to integrate all such concerns. We performed a systematic review (1) to describe methodological solutions suitable for integrating social justice concerns into economic evaluation, and (2) to describe the challenges that those solutions face. To be included, publications must have captured fairness considerations that (a) involve cross-dimensional subjective personal life experience and (b) can be manifested at the level of subpopulations. We identified relevant publications using an electronic search in EMBASE, PubMed, EconLit, PsycInfo, Philosopher's Index, and Scopus, including publications available in English in the past 20 years. Two reviewers independently appraised candidate publications, extracted data, and synthesized findings in narrative form. Out of 2388 publications reviewed, 26 were included. Solutions sought either to incorporate relevant fairness considerations directly into economic evaluation or to report them alongside cost-effectiveness measures. The majority of reviewed solutions, if adapted to integrate social justice concerns, would require their explicit quantification. Four broad challenges related to the implementation of these solutions were identified: clarifying the normative basis; measuring and determining the relative importance of criteria representing that basis; combining the criteria; and evaluating trade-offs. All included solutions must grapple with an inherent tension: they must either face the normative and operational challenges of quantifying social justice concerns or accede to offering incomplete policy guidance. Interdisciplinary research and broader collaborations are crucial to address these challenges and to support due attention to social justice in priority setting.

The importance of population differences: Influence of individual characteristics on the Australian public's preferences for emergency care

A better understanding of the public's preferences and what factors influence them is required if they are to be used to drive decision-making in health. This is particularly the case for service areas undergoing continual reform such as emergency and primary care. Accordingly, this study sought to determine if attitudes, socio-demographic characteristics and healthcare experiences influence the public's intentions to access care and their preferences for hypothetical emergency care alternatives. A discrete choice experiment was used to elicit the preferences of Australian adults (n=1529). Mixed logit regression analyses revealed the influence of a range of individual characteristics on preferences and service uptake choices across three different presenting scenarios. Age was associated with service uptake choices in all contexts, whilst the impact of other sociodemographics, health experience and attitudinal factors varied by context. The improvements in explanatory power observed from including these factors in the models highlight the need to further clarify their influence with larger populations and other presenting contexts, and to identify other determinants of preference heterogeneity. The results suggest social marketing programs undertaken as part of demand management efforts need to be better targeted if decision-makers are seeking to increase community acceptance of emerging service models and alternatives. Other implications for health policy, service planning and research, including for workforce planning and the possible introduction of a system of co-payments are discussed.