Pilot study of a hierarchical Bayes method for utility estimation in a choice-based conjoint analysis of prescription benefit plans including medication therapy management services

Patient preferences and cost-benefit of hypertension and hyperlipidemia collaborative management model between pharmacies and primary care in Portugal: A discrete choice experiment alongside a trial (USFarmácia®)

BACKGROUND

Little is known about patient preferences and the value of pharmacy-collaborative disease management with primary care using technology-driven interprofessional communication under real-world conditions. Discrete Choice Experiments (DCEs) are useful for quantifying preferences for non-market services.

OBJECTIVES

1) To explore variation in patient preferences and estimate willingness-to-accept annual cost to the National Health Service (NHS) for attributes of a collaborative intervention trial between pharmacies and primary care using a trial exit DCE interview; 2) to incorporate a DCE into an economic evaluation using cost-benefit analysis (CBA).

METHODS

We performed a DCE telephone interview with a sample of hypertension and hyperlipidemia trial patients 12 months after trial onset. We used five attributes (levels): waiting time to get urgent/not urgent medical appointment (7 days/45 days; 48 hrs./30 days; same day/15 days), model of pharmacy intervention (5-min. counter basic check; 15-min. office every 3 months for BP and medication review of selected medicines; 30-min. office every 6 months for comprehensive measurements and medication review of all medicines), integration with primary care (weak; partial; full), chance of having a stroke in 5 years (same; slightly lower; much lower), and annual cost to the NHS (0€; 30€; 51€; 76€). We used an experimental orthogonal fractional factorial design. Data were analyzed using conditional logit. We subtracted the estimated annual incremental trial costs from the mean WTA (Net Benefit) for CBA.

RESULTS

A total of 122 patients completed the survey. Waiting time to get medical appointment-on the same day (urgent) and within 15 days (non-urgent)-was the most important attribute, followed by 30-minute pharmacy intervention in private office every 6 months for point-of-care measurements and medication review of all medicines, and full integration with primary care. The cost attribute was not significant. Intervention patients were willing to accept the NHS annual cost of €877 for their preferred scenario. The annual net benefit per patient is €788.20 and represents the monetary value of patients' welfare surplus for this model.

CONCLUSIONS

This study is the first conducted in Portugal alongside a pharmacy collaborative trial, incorporating DCE into CBA. The findings can be used to guide the design of pharmacy collaborative interventions with primary care with the potential for reimbursement for uncontrolled or at-risk chronic disease patients informed by patient preferences. Future DCE studies conducted in community pharmacy may provide additional contributions.

TRIAL REGISTRATION

Current Controlled Trials (ISRCTN): ISRCTN13410498, retrospectively registered on 12 December 2018.

Preferences for policy measures to regulate urban vehicle access for climate change mitigation

In cognisance of the urgent need to decarbonise the transport sector to limit its impact on climate change and to internalise other negative transport externalities, regulating vehicle access in urban areas is essential. However, urban areas often struggle to implement these regulations due to concerns relating to social acceptability, heterogeneity of citizen preferences, lack of information on preferred measure attributes, and other factors that can boost the acceptance of urban vehicle access regulations. This study explores the acceptability and willingness to support Urban Vehicle Access Regulations (UVAR) in Budapest, Hungary to reduce transportation emissions and promote sustainable urban mobility. Using a structured questionnaire, which includes a choice-based conjoint exercise, the study finds that 42% of respondents were willing to support a car-free policy measure. Results were analysed to elicit preferences for specific UVAR measure attributes, identify population subgroups, and assess factors influencing willingness to support UVAR implementation. Access fee and proportion of revenue earmarked for transport development were the most important attributes to respondents. The study also identified three distinct subgroups of respondents with differing preferences, which could be characterised based on access to passenger cars, age, and employment status. The findings suggest that for effective UVAR, access fees for non-compliant vehicles should be excluded from measure designs, and the attribute preference approach highlights the importance of considering the heterogeneity of residents' preferences in UVAR measure planning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12302-023-00745-0.

Patient and Public Preferences for Coordinated Care in Switzerland: Development of a Discrete Choice Experiment

Objective

Our objective was to develop and test a discrete choice experiment (DCE) eliciting public and patient preferences for better-coordinated care in Switzerland.

Methods

We applied a multistage mixed-methods procedure using qualitative and quantitative approaches. First, to identify attributes, we performed a review of the DCE literature in healthcare with a focus on chronic care. Next, attribute selection involved stakeholders (N = 7) from various healthcare sectors to select the most relevant and actionable attributes, followed by three organized focus groups involving the general public and patients (N = 21) to verify the selection and the clarity of the DCE tasks and explanations. Finally, we conducted an online pilot in the target population to test the survey and obtain priors for a final six tested attributes to refine the final design of the experiment.

Results

After identifying an initial 33 attributes, a final list of six attributes was selected following stakeholder involvement and the three focus groups involving the target population. At the online pilot-testing stage with 301 participants, the majority of respondents found the DCE choice tasks socially relevant for Switzerland but challenging. The quality of the answers was relatively high. Most attributes had signs matching those in the literature and focus group discussions.

Conclusion

This article will be useful to researchers designing DCEs from a broad health policy perspective. The multistage approach involving a range of stakeholders was essential for the development of a DCE that is relevant for policy makers and well-accepted by the general public and patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-021-00568-2.

Implementation of a Medicare Plan Selection Assistance Program Through a Community Partnership

Objective. To describe the implementation and outcomes of a sustainable Medicare Plan Selection Assistance Program conducted through a partnership between Auburn University Harrison School of Pharmacy (AU) and the Alabama State Health Insurance and Assistance Program (SHIP) since 2013. Methods. The program's goal is to assist Medicare beneficiaries in Medicare Part D plan selection. Reported outcomes included Medicare beneficiaries' plan cost savings and satisfaction, and pharmacy students' self-reported changes in knowledge and attitudes. Results. Each year, more than 80 pharmacy students assist more than 120 beneficiaries; at least 10 events are held covering 6-10 Alabama counties. On average, Medicare beneficiaries had a projected savings of $278.71 (2013), $1,081.66 (2014), $842.84 (2015), and $1,382.90 (2016) after enrolling in a new plan, and most students reported perceived increased ability to help beneficiaries select the most appropriate Medicare Part D plan. Conclusion. The program produced positive outcomes for both beneficiaries and students. Other pharmacy schools may consider partnering with their State Health Insurance and Assistance Program to deliver a similar program to benefit their students and Medicare beneficiaries.

Patient versus neurologist preferences: A discrete choice experiment for antiepileptic drug therapies

OBJECTIVE

This assessment was conducted to quantify and compare patient and neurologist preferences regarding antiepileptic drug (AED) attributes for treating epilepsy.

METHODS

Patients with epilepsy (≥18years, treated with AEDs) and neurologists were recruited from nationally representative US panels to complete an online survey that included a discrete choice experiment (DCE). Participants chose between two hypothetical AEDs, characterized by six attributes in the DCE, which included 1) level of seizure control/reduction; 2) dosing frequency, 3) diminished coordination and balance, 4) psychiatric issues, 5) diminished energy level, and 6) dietary restrictions. The Sawtooth Software Choice-Based Conjoint (CBC) System for CBC Analysis was used to estimate treatment attribute ranking and weighting.

RESULTS

Of the 720 respondents (518 patients and 202 neurologists), both patients and neurologists ranked seizure control as the most important attribute (rank 1) and dietary restrictions as the least important attribute (rank 6). However, seizure control had a significantly greater weighting in neurologists' decision-making than among patients (45% vs 32%, p<0.005). On the other hand, patients considered the risks of psychiatric adverse effects (19% vs 15%), diminished coordination and balance (16% vs 10%), and fatigue or diminished energy (13% vs 11%) as significantly more important (p<0.05) than did neurologists.

CONCLUSION

Patients and neurologists had similar preference ranking order, with seizure reduction being ranked the most important attribute. However, neurologist treatment preferences were significantly more influenced by seizure reduction while patient preferences were significantly more influenced by adverse effects that may impact their quality of life. Understanding how patient and neurologist perspectives differ should encourage dialog to communicate the potential risks and benefits of AED therapy and assist in the shared decision-making process.

Discrete choice experiments of pharmacy services: a systematic review

Background Two previous systematic reviews have summarised the application of discrete choice experiments to value preferences for pharmacy services. These reviews identified a total of twelve studies and described how discrete choice experiments have been used to value pharmacy services but did not describe or discuss the application of methods used in the design or analysis. Aims (1) To update the most recent systematic review and critically appraise current discrete choice experiments of pharmacy services in line with published reporting criteria and; (2) To provide an overview of key methodological developments in the design and analysis of discrete choice experiments. Methods The review used a comprehensive strategy to identify eligible studies (published between 1990 and 2015) by searching electronic databases for key terms related to discrete choice and best-worst scaling (BWS) experiments. All healthcare choice experiments were then hand-searched for key terms relating to pharmacy. Data were extracted using a published checklist. Results A total of 17 discrete choice experiments eliciting preferences for pharmacy services were identified for inclusion in the review. No BWS studies were identified. The studies elicited preferences from a variety of populations (pharmacists, patients, students) for a range of pharmacy services. Most studies were from a United Kingdom setting, although examples from Europe, Australia and North America were also identified. Discrete choice experiments for pharmacy services tended to include more attributes than non-pharmacy choice experiments. Few studies reported the use of qualitative research methods in the design and interpretation of the experiments (n = 9) or use of new methods of analysis to identify and quantify preference and scale heterogeneity (n = 4). No studies reported the use of Bayesian methods in their experimental design. Conclusion Incorporating more sophisticated methods in the design of pharmacy-related discrete choice experiments could help researchers produce more efficient experiments which are better suited to valuing complex pharmacy services. Pharmacy-related discrete choice experiments could also benefit from more sophisticated analytical techniques such as investigations into scale and preference heterogeneity. Employing these sophisticated methods for both design and analysis could extend the usefulness of discrete choice experiments to inform health and pharmacy policy.

Developing attributes and attribute-levels for a discrete choice experiment on micro health insurance in rural Malawi

Background

Discrete choice experiments (DCEs) are attribute-driven experimental techniques used to elicit stakeholders’ preferences to support the design and implementation of policy interventions. The validity of a DCE, therefore, depends on the appropriate specification of the attributes and their levels. There have been recent calls for greater rigor in implementing and reporting on the processes of developing attributes and attribute-levels for discrete choice experiments (DCEs). This paper responds to such calls by carefully reporting a systematic process of developing micro health insurance attributes and attribute-levels for the design of a DCE in rural Malawi.

Methods

Conceptual attributes and attribute-levels were initially derived from a literature review which informed the design of qualitative data collection tools to identify context specific attributes and attribute-levels. Qualitative data was collected in August-September 2012 from 12 focus group discussions with community residents and 8 in-depth interviews with health workers. All participants were selected according to stratified purposive sampling. The material was tape-recorded, fully transcribed, and coded by three researchers to identify context-specific attributes and attribute-levels. Expert opinion was used to scale down the attributes and levels. A pilot study confirmed the appropriateness of the selected attributes and levels for a DCE.

Results

First, a consensus, emerging from an individual level analysis of the qualitative transcripts, identified 10 candidate attributes. Levels were assigned to all attributes based on data from transcripts and knowledge of the Malawian context, derived from literature. Second, through further discussions with experts, four attributes were discarded based on multiple criteria. The 6 remaining attributes were: premium level, unit of enrollment, management structure, health service benefit package, transportation coverage and copayment levels. A final step of revision and piloting confirmed that the retained attributes satisfied the credibility criteria of DCE attributes.

Conclusion

This detailed description makes our attribute development process transparent, and provides the reader with a basis to assess the rigor of this stage of constructing the DCE. This paper contributes empirical evidence to the limited methodological literature on attributes and levels development for DCE, thereby providing further empirical guidance on the matter, specifically within rural communities of low- and middle-income countries.

A novel clinical pharmacy management system in improving the rational drug use in department of general surgery

Hospital information system is widely used to improve work efficiency of hospitals in China. However, it is lack of the function providing pharmaceutical information service for clinical pharmacists. A novel clinical pharmacy management system developed by our hospital was introduced to improve the work efficiency of clinical pharmacists in our hospital and to carry out large sample statistical analyzes by providing pharmacy information services and promoting rational drug use. Clinical pharmacy management system was developed according to the actual situation. Taking prescription review in the department of general surgery as the example, work efficiency of clinical pharmacists, quality and qualified rates of prescriptions before and after utilizing clinical pharmacy management system were compared. Statistics of 48,562 outpatient and 5776 inpatient prescriptions of the general surgical department were analyzed. Qualified rates of both the inpatient and outpatient prescriptions of the general surgery department increased, and the use of antibiotics decreased. This system apparently improved work efficiency, standardized the level and accuracy of drug use, which will improve the rational drug use and pharmacy information service in our hospital. Meanwhile, utilization of prophylactic antibiotics for the aseptic operations also reduced.

Discrete choice experiments in pharmacy: a review of the literature

Objective

Discrete choice experiments (DCEs) have been widely used to elicit patient preferences for various healthcare services and interventions. The aim of our study was to conduct an in-depth scoping review of the literature and provide a current overview of the progressive application of DCEs within the field of pharmacy.

Methods

Electronic databases (MEDLINE, EMBASE, SCOPUS, ECONLIT) were searched (January 1990–August 2011) to identify published English language studies using DCEs within the pharmacy context. Data were abstracted with respect to DCE methodology and application to pharmacy.

Key findings

Our search identified 12 studies. The DCE methodology was utilised to elicit preferences for different aspects of pharmacy products, therapy or services. Preferences were elicited from either patients or pharmacists, with just two studies incorporating the views of both. Most reviewed studies examined preferences for process-related or provider-related aspects with a lesser focus on health outcomes. Monetary attributes were considered to be important by most patients and pharmacists in the studies reviewed. Logit, probit or multinomial logit models were most commonly employed for estimation.

Conclusion

Our study showed that the pharmacy profession has adopted the DCE methodology consistent with the general health DCEs although the number of studies is quite limited. Future studies need to examine preferences of both patients and providers for particular products or disease-state management services. Incorporation of health outcome attributes in the design, testing for external validity and the incorporation of DCE results in economic evaluation framework to inform pharmacy policy remain important areas for future research.

Choosing between Hospitals

Objective. Publicly available information on hospital performance is increasing, with the aim to support consumers when choosing a hospital. Besides general hospital information and information on outcomes of care, there is increasing availability of systematically collected information on experiences of other patients. The aim of this study was to assess the influence of previous patients’ experiences relative to other information when choosing a hospital for surgical treatment. Methods. Three hundred thirty-seven patient volunteers and 280 healthy volunteers (response rate of 52.4% and 93.3%, respectively) filled out an Internet-based questionnaire that included an adaptive choice-based conjoint analysis. They were asked to select hospital characteristics they would use for future hospital choice, compare hospitals, and choose the overall best hospital. Based on the respondents’ choices, the relative importance (RI) of each hospital characteristic for each respondent was estimated using hierarchical Bayes estimation. Results. Information based on previous patients’ experience was considered at least as important as information provided by hospitals. “Report card regarding physician’s expertise” had the highest RI (16.83 [15.37–18.30]) followed by “waiting time for outpatient clinic appointment” (14.88 [13.42–16.34]) and “waiting time for surgery” (7.95 [7.12–8.78]). Patient and healthy volunteers considered the same hospital attributes to be important, except that patient volunteers assigned greater importance to “positive judgment about physician communication” (7.65 v. 5.80, P < 0.05) and lower importance to “complications” (2.56 v. 4.22, P < 0.05). Conclusion. Consumers consider patient experience–based information at least as important as hospital-based information. They rely most on information regarding physicians’ expertise, waiting time, and physicians’ communication when choosing a hospital.

Conjoint analysis of patient preferences on Medicare medication therapy management

OBJECTIVES

To identify attributes of medication therapy management (MTM) valued by Medicare beneficiaries and to determine patient preferences and willingness to pay for MTM attributes.

DESIGN

Cross-sectional contingency valuation study.

SETTING

Six senior centers in Memphis, TN, from September 2007 through August 2008.

PARTICIPANTS

355 Medicare beneficiaries.

INTERVENTION

A discrete choice experiment was used, in which each study participant was asked to choose from two different hypothetical MTM services defined by seven attributes (service setting, provider type, number of drug therapy problems, provider experience in overall practice, provider experience in geriatrics, time spent, and cost of MTM service) and associated levels.

MAIN OUTCOME MEASURES

Patient preferences for different attributes of MTM services and patients' estimated marginal willingness to pay for each attribute level.

RESULTS

Study participants viewed cost (relative importance 32.2%) as the most important attribute of MTM, followed by service setting (24.2%), provider experience in overall practice (19.5%), and provider experience in geriatrics (16.6%). Community pharmacies (β = 0.146, P = 0.007) were the most preferred environment for MTM services, followed by clinics, whereas telephone consultation was the least preferred environment (β = -0.349, P < 0.001). Study participants were willing to spend as much as $31.76 (95% CI 19.84-45.27) to trade telephone MTM for clinic-based MTM. They also were willing to pay $13.31 more (3.60-23.65) for MTM service at a community pharmacy compared with clinic-based MTM.

CONCLUSION

Health plans should consider developing community pharmacy-based MTM options, at least for Medicare beneficiaries without mobility limitations.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly.