Valuing patients' experiences of healthcare processes: towards broader applications of existing methods

Unravelling Elements of Value of Healthcare and Assessing their Importance Using Evidence from Two Discrete-Choice Experiments in England

BACKGROUND

Health systems are moving towards value-based care, implementing new care models that allegedly aim beyond patient outcomes. Therefore, a policy and academic debate is underway regarding the definition of value in healthcare, the inclusion of costs in value metrics, and the importance of each value element. This study aimed to define healthcare value elements and assess their relative importance (RI) to the public in England.

METHOD

Using data from 26 semi-structured interviews and a literature review, and applying decision-theory axioms, we selected a comprehensive and applicable set of value-based elements. Their RI was determined using two discrete choice experiments (DCEs) based on Bayesian D-efficient DCE designs, with one DCE incorporating healthcare costs expressed as income tax rise. Respondent preferences were analysed using mixed logit models.

RESULTS

Six value elements were identified: additional life-years, health-related quality of life, patient experience, target population size, equity, and cost. The DCE surveys were completed by 402 participants. All utility coefficients had the expected signs and were statistically significant (p < 0.05). Additional life-years (25.3%; 95% confidence interval [CI] 22.5-28.6%) and patient experience (25.2%; 95% CI 21.6-28.9%) received the highest RI, followed by target population size (22.4%; 95% CI 19.1-25.6%) and quality of life (17.6%; 95% CI 15.0-20.3%). Equity had the lowest RI (9.6%; 95% CI 6.4-12.1%), decreasing by 8.8 percentage points with cost inclusion. A similar reduction was observed in the RI of quality of life when cost was included.

CONCLUSION

The public prioritizes value elements not captured by conventional metrics, such as quality-adjusted life-years. Although cost inclusion did not alter the preference ranking, its inclusion in the value metric warrants careful consideration.

Valuing Outpatients' Perspective on Primary Health Care Services in Greece: A Cross-Sectional Survey on Satisfaction and Personal-Centered Care

INTRODUCTION

The aims of the study were to identify and analyze the determinants associated with outpatient satisfaction in Greek primary care. This is because there is a general consensus that primary care is the linchpin of effective person-centered care delivery.

METHODS

A cross-sectional survey was conducted with 1012 patients' exit interviews; sociodemographic variables were included in the questionnaire to obtain data on the satisfaction of primary care users with 20 public primary healthcare centers in Athens between June 2019 and April 2021. Statistical analysis was applied to 55 items and eight dimensions of patient satisfaction, namely, arrival and admission, waiting before the appointment, cleanliness of toilets, medical examination and behavior of physician, behavior of nursing staff, laboratories, departure, and contribution of the PHCs. Descriptive analyses and multiple linear regression were used to analyze the factors influencing patient satisfaction through coefficients (β) with 95% confidence intervals and associated tests of statistical significance.

RESULTS

Τwo-thirds (74.21%) of this survey's participants ranged from 45 to 74 years of age. More than half of the participants were women (62.15%). The most common reasons for visits were pathological (26.48%), followed by cardiological conditions (9.78%), orthopedics (9.49%), gynecologic conditions (8.70%), and ophthalmologic problems (7.31%). In the center of satisfaction with primary care was the medical care and the behavior of the physician (β = 0.427; p < 0.01), followed by the time during appointment (β = 0.390; p < 0.01). Dimensions like "accessibility and availability, 2.19/5"; "waiting times, 2.89/5"; "infrastructure of facilities (2.04/5) and cleanliness of them, (2/5)"; "laboratories, 2.99/5" and "bureaucracy in the departure, 2.29/5" were crucial for the trust and satisfaction of patients. Overall satisfaction was rated at a moderate level (2.62 ± 0.18) while person-centered care was rated as weak (2.49 ± 0.28).

CONCLUSIONS

Greece is recommended to increase the sensitivity of the use of the primary health care system by patients as a first contact, continuous, comprehensive, and effective patient- and family-focused care.

Benefits and harms of antenatal and newborn screening programmes in health economic assessments: the VALENTIA systematic review and qualitative investigation

Background

Health economic assessments are used to determine whether the resources needed to generate net benefit from an antenatal or newborn screening programme, driven by multiple benefits and harms, are justifiable. It is not known what benefits and harms have been adopted by economic evaluations assessing these programmes and whether they omit benefits and harms considered important to relevant stakeholders.

Objectives

(1) To identify the benefits and harms adopted by health economic assessments in this area, and to assess how they have been measured and valued; (2) to identify attributes or relevance to stakeholders that ought to be considered in future economic assessments; and (3) to make recommendations about the benefits and harms that should be considered by these studies.

Design

Mixed methods combining systematic review and qualitative work.

Systematic review methods

We searched the published and grey literature from January 2000 to January 2021 using all major electronic databases. Economic evaluations of an antenatal or newborn screening programme in one or more Organisation for Economic Co-operation and Development countries were considered eligible. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist. We identified benefits and harms using an integrative descriptive analysis and constructed a thematic framework.

Qualitative methods

We conducted a meta-ethnography of the existing literature on newborn screening experiences, a secondary analysis of existing individual interviews related to antenatal or newborn screening or living with screened-for conditions, and a thematic analysis of primary data collected with stakeholders about their experiences with screening.

Results

The literature searches identified 52,244 articles and reports, and 336 unique studies were included. Thematic framework resulted in seven themes: (1) diagnosis of screened for condition, (2) life-years and health status adjustments, (3) treatment, (4) long-term costs, (5) overdiagnosis, (6) pregnancy loss and (7) spillover effects on family members. Diagnosis of screened-for condition (115, 47.5%), life-years and health status adjustments (90, 37.2%) and treatment (88, 36.4%) accounted for most of the benefits and harms evaluating antenatal screening. The same themes accounted for most of the benefits and harms included in studies assessing newborn screening. Long-term costs, overdiagnosis and spillover effects tended to be ignored. The wide-reaching family implications of screening were considered important to stakeholders. We observed good overlap between the thematic framework and the qualitative evidence.

Limitations

Dual data extraction within the systematic literature review was not feasible due to the large number of studies included. It was difficult to recruit healthcare professionals in the stakeholder's interviews.

Conclusions

There is no consistency in the selection of benefits and harms used in health economic assessments in this area, suggesting that additional methods guidance is needed. Our proposed thematic framework can be used to guide the development of future health economic assessments evaluating antenatal and newborn screening programmes.

Study registration

This study is registered as PROSPERO CRD42020165236.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127489) and is published in full in Health Technology Assessment; Vol. 28, No. 25. See the NIHR Funding and Awards website for further award information.

Development of a minimum dataset for subacute rehabilitation: a three-round e-Delphi consensus study

OBJECTIVES

To develop a minimum dataset to be routinely collected across a heterogenous population within a subacute rehabilitation service to guide best care and outcomes for patients, and value for the health service.

DESIGN

Three-round e-Delphi exercise, followed by consensus meetings.

SETTING

Multicentre study in Brisbane, Australia.

PARTICIPANTS

Rehabilitation decision-makers, researchers and clinicians were invited to participate in the e-Delphi exercise. A multidisciplinary project steering committee (rehabilitation decision makers, researchers, clinicians and consumers) participated in consensus meetings.

METHODS

In round 1 of the e-Delphi, participants responded to an open-ended question, generating data and outcomes that should be routinely collected in rehabilitation. In rounds 2 and 3, participants rated the importance of collecting each item on a nine-point scale. Consensus was defined a priori, as items rated as 'essential' by at least 70%, and of 'limited importance' by less than 15%, of respondents. Consensus meetings were held to further refine and define the dataset for implementation.

RESULTS

In total, 38 participants completed round 1 of the e-Delphi. Qualitative content analysis of their responses generated 1072 codes, which were condensed into 39 categories and 209 subcategories. Following two rounds of rating (round 2: n=32 participants; round 3: n=28 participants), consensus was reached for 124 items. Four consensus meetings (n=14 participants) resulted in the final dataset which included 42 items across six domains: (1) patient demographics, (2) premorbid health and psychosocial information, (3) admission information, (4) service delivery and interventions, (5) outcomes and (6) caregiver information and outcomes.

CONCLUSIONS

We identified 42 items that reflect the values and experiences of rehabilitation stakeholders. Items unique to this dataset include caregiver information and outcomes, and detailed service delivery and intervention data. Future research will establish the feasibility of collection in practice.

Conceptualising 'Benefits Beyond Health' in the Context of the Quality-Adjusted Life-Year: A Critical Interpretive Synthesis

There is growing interest in extending the evaluative space of the quality-adjusted life-year framework beyond health. Using a critical interpretive synthesis approach, the objective was to review peer-reviewed literature that has discussed non-health outcomes within the context of quality-adjusted life-years and synthesise information into a thematic framework. Papers were identified through searches conducted in Web of Science, using forward citation searching. A critical interpretive synthesis allows for the development of interpretations (synthetic constructs) that go beyond those offered in the original sources. The final output of a critical interpretive synthesis is the synthesising argument, which integrates evidence from across studies into a coherent thematic framework. A concept map was developed to show the relationships between different types of non-health benefits. The critical interpretive synthesis was based on 99 papers. The thematic framework was constructed around four themes: (1) benefits affecting well-being (subjective well-being, psychological well-being, capability and empowerment); (2) benefits derived from the process of healthcare delivery; (3) benefits beyond the recipient of care (spillover effects, externalities, option value and distributional benefits); and (4) benefits beyond the healthcare sector. There is a wealth of research concerning non-health benefits and the evaluative space of the quality-adjusted life-year. Further dialogue and debate are necessary to address conceptual and normative challenges, to explore the societal willingness to sacrifice health for benefits beyond health and to consider the equity implications of different courses of action.

Disentangling the welfarism/extra-welfarism distinction: Towards a more fine-grained categorization

In health economics, the distinction between welfarism and extra-welfarism has been employed to discuss various epistemological and normative differences between health evaluation approaches. However, a clear consensus on the definition of either welfarism, extra-welfarism, or the differences between the two sets of approaches has not emerged. I propose an alternative set of distinctions that allows for a more fine-grained categorization of health evaluation approaches. This categorization focuses on five dimensions: (1) the maximand of an evaluation approach, (2) its sensitivity toward normative concerns that defy compensation, (3) its position on which groups of individuals or collective entities act as sources of values, (4) its sensitivity to changes of mind, and (5) the inclusion of process-external values.

An economic valuation technique identified different inpatient care experience as priorities for older Canadians than a traditional approach

OBJECTIVES

To (1) estimate the relative value of older adults' healthcare experiences based on the Canadian Patient Experience Survey for Inpatient Care (CPES-IC) using an economic valuation technique, and (2) compare the results with those of a conventional key-driver analysis of healthcare experiences based on bivariate correlations.

STUDY DESIGN AND SETTING

An online survey of 1,074 Canadians aged 60 and older who had been hospitalized within five years. Participants completed the CPES-IC and a best-worst scaling (BWS) valuation task. BWS data were analyzed using a conditional logit model. These results were compared to a conventional key-driver analysis that estimates importance through Spearman's correlations between experiences and a global rating of overall experience.

RESULTS

The valuation approach found that the three experiences most valued by patients were: that staff seemed informed and up-to-date about their hospital care, doctors explained things in a way that they could understand, and that they got all the information they needed about their care and treatment. Three of the top five most valued experiences from the valuation approach were among the top five in the key driver analysis. However, there were noteworthy differences in rank order.

CONCLUSION

The results of the valuation exercise can inform local and/or system level quality improvement efforts by identifying priorities from an economic evaluation point of view, which are different than those based on a conventional key-driver analysis. Given the degree of uncertainty in estimates both the rank order and confidence intervals should be used to guide decision-making.

The Social Construction of Incompetency: Moving Beyond Embedded Paternalism Toward the Practice of Respect

This article illustrates the less-acknowledged social construction of the concept of 'incompetency' and draws attention to the moral concerns it raises in health care encounters in the south Indian city of Chennai. Based on data drawn from qualitative research, this study suggests that surgeons subjectively construct the idea of incompetency through their understanding of the perceived circumstantial characteristics of the patients and family members they serve. The findings indicate that surgeons often underestimate patients and family members' capacity based on constructed assessments, which leads to paternalistic practice. In this article, I illustrate how these assessments influence the surgeons' practices and provide the moral and practical justifications for their actions. The constructed knowledge becomes a source for drawing normative justification for surgeons' actions and, in conjunction with socially enforced power relationships, results in patients and family members to be on the receiving end of disrespectful attitudes. Based on the data analysis and by drawing on philosophical analysis, I emphasize the need to focus on 'respect for persons,' to rethink the framework of 'capacity,' and to practice respect in hospital settings.

Exploring young people's preferences for STI screening in the UK: A qualitative study and discrete choice experiment

INTRODUCTION

Stigma remains a key issue for many health screening interventions such as screening for sexually transmitted infections (STIs). Young people continue to experience the greatest burden of STI infection. In order to increase uptake, screening services need to be more patient-focused. This study sought to examine young people's preferences for sexual health screening to understand how scarce public health resources can optimise screening uptake.

METHODS

This study involved both qualitative and quantitative components. Focus groups and individual interviews were undertaken with young people aged 16-24 recruited from community settings and a specialist clinic. Themes which emerged from the focus groups were used to inform the design of a discrete choice experiment (DCE). A questionnaire survey (incorporating the DCE) was conducted with members of an internet panel, with over-sampling of black, Asian and minority ethnic groups.

RESULTS

Overall, 41 participants took part in eight focus groups and two in individual interviews. Six major themes emerged as important when making decisions about STI screening - stigma and embarrassment; knowledge about STIs and risk; where to get tested; how staff would treat them; what STIs to be tested for; and convenience (waiting times). Overall, 1946 participants took part in the survey. The DCE results revealed that the most important factors for young people are that all STIs are tested for, and that staff attitude is non-judgemental. The results also suggest that there is a preference for screening in specialist clinics and for full appointments over limited ones. Although respondents preferred shorter time periods for appointments and results, other 'process' factors were also important.

CONCLUSION

This study demonstrates that by combining qualitative and quantitative methods, a richer understanding of STI screening preferences is possible. The findings show that comprehensive testing and a perceived 'non-judgemental' attitude are particularly important to young people, as well as convenience.

Experiences With Health Care Services in Switzerland Among Immigrant Women With Chronic Illnesses

Introduction: Descriptive data indicate a high burden of chronic illness among immigrant women in Switzerland. Little is known about how immigrant women with chronic illnesses experience healthcare services. This paper presents a methodological approach theoretically informed by Sen's capability approach and Levesque's framework of access to healthcare to study patient-reported experiences (PREs) of Swiss healthcare services among immigrant women with chronic conditions. Methods: We conducted 48 semi-structured qualitative interviews in Bern and Geneva with Turkish (n = 12), Portuguese (n = 12), German (n = 12), and Swiss (n = 12) women. Participants were heterogenous in age, length of stay, SES, and educational attainment, illness types and history. We also conducted semi-structured interviews with healthcare and social service providers (n = 12). Interviewed women participated in two focus group discussions (n = 15). Interviews were transcribed verbatim and analyzed using Atlas.ti software, based on Gale et al.'s framework approach. Findings informed three stakeholder dialogues in which women as well as healthcare providers and policymakers from various territorial levels participated. Results: Our methodological approach succeeded in integrating women's perspectives-from initial data collection in interviews to identify issues, focus group discussions to increase rigor, and stakeholder dialogues to develop tailored recommendations based on PREs. Discussion: This is one of the first studies in Switzerland that used PREs to research healthcare services and healthcare needs among immigrant women with chronic illnesses. This paper provides new insights on how to better understand existing challenges and potentially improve access to and quality of care.

A customer journey perspective on service delivery system design: insights from healthcare

Purpose

The purpose of this paper is to provide novel theoretical insight into service delivery system (SDS) design. To do so, this paper adopts a customer journey perspective, using it as a frame to explore dimensions of experience quality that inform design requirements.

Design/methodology/approach

This study utilises UK Patient Opinion data to analyse the stories of 200 cancer patients. Using a critical incident technique, 1,207 attributes of experience quality are generated and classified into 17 quality dimensions across five stages of the customer (patient) journey.

Findings

Analysis reveals both similarity and difference in dimensions of experience quality across the patient journey: seven dimensions are common to all five journey stages, from receiving diagnosis to end of life care; ten dimensions were found to vary, present in one or several of the stages but not in all.

Research limitations/implications

Limitations include a lack of representativity of the story sample and the impossibility to verify the factual occurrence of the stories.

Practical implications

Adopting a patient journey perspective can improve the practitioner understanding of the design requirements of SDS in healthcare. The results of the study can be applied by managers to configure SDS that achieve a higher quality of patient care throughout the patient journey.

Originality/value

This paper extends existing literature on SDS design by adopting a customer journey perspective, revealing heterogeneity in experience quality across the customer journey currently unaccounted for in SDS design frameworks. Specifically, the findings challenge homogeneity in extant SDS design frameworks, evidencing the need for multiple, stage-specific SDS design requirements.

The patient experience in community mental health services for older people: a concept mapping approach to support the development of a new quality measure

Background

The patient experience is a crucial part of the measurement of service quality. However, instruments to evaluate experiential quality in the community mental health care of older adults are lacking. Before designing a new instrument, clarity is needed about what is to be measured, and how care experiences are articulated by patients. The study aimed to construct a framework to describe older patients’ experience of community mental health and social care.

Methods

Concept mapping blends structured qualitative data collection with quantitative analysis in a mixed method approach. Five activities were undertaken. Patients first identified sentences describing the care experience; a card-sort exercise then grouped these thematically; multidimensional analysis portrayed these data in a map of clusters; interpretation was by patient advisers; finally a new questionnaire was designed. The research involved 22 older people with mental health problems and 29 mental health practitioners, from one region of England.

Results

Sixty-seven statements were identified that described the care experience. Analysis of card sort data revealed seven clusters, which were interpreted by patient advisers to the study as: personal qualities and relationships; communication problems; feeling powerless; in-and-out care; bureaucracy; focus on life, not just mental health; and continuity of care. These themes and the component statements were used as a foundation for later work, developing a new measure of the care experience in mental health services for older people.

Conclusions

Concept mapping has many strengths as an empirical and participant-driven means for underpinning new measurement instruments. A group of older people identified 67 candidate statements that could act as questionnaire items grouped within seven themes. Future research will establish the psychometric properties of the new measure.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3231-6) contains supplementary material, which is available to authorized users.

Qualitative process study to explore the perceived burdens and benefits of a digital intervention for self-managing high blood pressure in Primary Care in the UK

OBJECTIVES

Digital interventions can change patients' experiences of managing their health, either creating additional burden or improving their experience of healthcare. This qualitative study aimed to explore perceived burdens and benefits for patients using a digital self-management intervention for reducing high blood pressure. A secondary aim was to further our understanding of how best to capture burdens and benefits when evaluating health interventions.

DESIGN

Inductive qualitative process study nested in a randomised controlled trial.

SETTING

Primary Care in the UK.

PARTICIPANTS

35 participants taking antihypertensive medication and with uncontrolled blood pressure at baseline participated in semistructured telephone interviews.

INTERVENTION

Digital self-management intervention to support blood pressure self-monitoring and medication change when recommended by the healthcare professional.

ANALYSIS

Data were analysed using inductive thematic analysis with techniques from grounded theory.

RESULTS

Seven themes were developed which reflected perceived burdens and benefits of using the intervention, including worry about health, uncertainty about self-monitoring and reassurance. The analysis showed how beliefs about their condition and treatment appeared to influence participants' appraisal of the value of the intervention. This suggested that considering illness and treatment perceptions in Burden of Treatment theory could further our understanding of how individuals appraise the personal costs and benefits of self-managing their health.

CONCLUSIONS

Patients' appraisal of the burden or benefit of using a complex self-management intervention seemed to be influenced by experiences within the intervention (such as perceived availability of support) and beliefs about their condition and treatment (such as perceived control and risk of side effects). Developing our ability to adequately capture these salient burdens and benefits for patients could help enhance evaluation of self-management interventions in the future. Many participants perceived important benefits from using the intervention, highlighting the need for theory to recognise that engaging in self-management can include positive as well as negative aspects.

TRIAL REGISTRATION NUMBER

ISRCTN13790648; Pre-results.

Emerging Use of Early Health Technology Assessment in Medical Product Development: A Scoping Review of the Literature

Early health technology assessment is increasingly being used to support health economic evidence development during early stages of clinical research. Such early models can be used to inform research and development about the design and management of new medical technologies to mitigate the risks, perceived by industry and the public sector, associated with market access and reimbursement. Over the past 25 years it has been suggested that health economic evaluation in the early stages may benefit the development and diffusion of medical products. Early health technology assessment has been suggested in the context of iterative economic evaluation alongside phase I and II clinical research to inform clinical trial design, market access, and pricing. In addition, performing early health technology assessment was also proposed at an even earlier stage for managing technology portfolios. This scoping review suggests a generally accepted definition of early health technology assessment to be "all methods used to inform industry and other stakeholders about the potential value of new medical products in development, including methods to quantify and manage uncertainty". The present review also aimed to identify recent published empirical studies employing an early-stage assessment of a medical product. With most included studies carried out to support a market launch, the dominant methodology was early health economic modeling. Further methodological development is required, in particular, by combining systems engineering and health economics to manage uncertainty in medical product portfolios.

The value of different aspects of person-centred care: a series of discrete choice experiments in people with long-term conditions

OBJECTIVE

To measure the value the patients place on different aspects of person-centred care.

DESIGN

We systematically identified four attributes of person-centred care. We then measured their value to 923 people with either chronic pain or chronic lung disease over three discrete choice experiments (DCEs) about services to support self-management. We calculated the value of each attribute for all respondents and identified groups of people with similar preferences using latent class modelling.

SETTING

DCEs conducted online via a commercial survey company.

PARTICIPANTS

Adults with either chronic pain (two DCEs, n=517 and 206, respectively) or breathlessness due to chronic respiratory disease (n=200).

RESULTS

Participants were more likely to choose services with higher level person-centred attributes. They most valued services that took account of a person's current situation likelihood of selection increased by 16.9% (95% CI=15.4 to 18.3) and worked with the person on what they wanted to get from life (15.8%; 14.5 to 17.1). More personally relevant information was valued less than these (12.3%; 11.0 to 13.6). A friendly and personal communicative style was valued least (3.8%; 2.7 to 4.8). Latent class models indicated that a substantial minority of participants valued personally relevant information over the other attributes.

CONCLUSION

This is the first study to measure the value patients place on different aspects of person-centred care. Professional training needs to emphasise the substance of clinical communication-working responsively with individuals on what matters to them-as well as the style of its delivery.

Involving Patients in Weighting Benefits and Harms of Treatment in Parkinson's Disease

Introduction

Little is known about how patients weigh benefits and harms of available treatments for Parkinson’s Disease (oral medication, deep brain stimulation, infusion therapy). In this study we have (1) elicited patient preferences for benefits, side effects and process characteristics of treatments and (2) measured patients’ preferred and perceived involvement in decision-making about treatment.

Methods

Preferences were elicited using a best-worst scaling case 2 experiment. Attributes were selected based on 18 patient-interviews: treatment modality, tremor, slowness of movement, posture and balance problems, drowsiness, dizziness, and dyskinesia. Subsequently, a questionnaire was distributed in which patients were asked to indicate the most and least desirable attribute in nine possible treatment scenarios. Conditional logistic analysis and latent class analysis were used to estimate preference weights and identify subgroups. Patients also indicated their preferred and perceived degree of involvement in treatment decision-making (ranging from active to collaborative to passive).

Results

Two preference patterns were found in the patient sample (N = 192). One class of patients focused largely on optimising the process of care, while the other class focused more on controlling motor-symptoms. Patients who had experienced advanced treatments, had a shorter disease duration, or were still employed were more likely to belong to the latter class. For both classes, the benefits of treatment were more influential than the described side effects. Furthermore, many patients (45%) preferred to take the lead in treatment decisions, however 10.8% perceived a more passive or collaborative role instead.

Discussion

Patients weighted the benefits and side effects of treatment differently, indicating there is no “one-size-fits-all” approach to choosing treatments. Moreover, many patients preferred an active role in decision-making about treatment. Both results stress the need for physicians to know what is important to patients and to share treatment decisions to ensure that patients receive the treatment that aligns with their preferences.

Managing Minor Ailments; The Public's Preferences for Attributes of Community Pharmacies. A Discrete Choice Experiment

BACKGROUND

Demand for health services continues to rise. Greater use of community pharmacy services instead of medical services for minor ailments could help relieve pressure on healthcare providers in high-cost settings. Community pharmacies are recognised sources of treatment and advice for people wishing to manage these ailments. However, increasing the public's use of pharmacy services may depend on attributes of pharmacies and their staff. This study aimed to determine the general public's relative preferences for community pharmacy attributes using a discrete choice experiment (DCE).

METHOD

A UK-wide DCE survey of the general public was conducted using face-to-face computer-assisted personal interviews. Attributes and levels for the DCE were informed by a literature review and a cohort study of community pharmacy customers. The context for the experiment was a minor ailment scenario describing flu-like symptoms. The DCE choice sets described two hypothetical community pharmacy services; respondents were asked to choose which (if either) of the two pharmacies they would prefer to help them manage symptoms. Data from 1,049 interviews were analysed using an error components logit model. Willingness to pay (WTP), a monetary measure of benefit, was estimated for the different attribute levels.

RESULTS

When seeking help or treatment for flu-like symptoms, respondents most valued a pharmacy service that would improve their understanding and management of symptoms (WTP = £6.28), provided by staff who are trained (WTP (pharmacist) = £2.63: WTP(trained assistant) = £3.22), friendly and approachable (WTP = £3.38). Waiting time, pharmacy location and availability of parking also contributed to respondents' preferences. WTP for a service comprising the best possible combination of attributes and levels was calculated as £55.43.

CONCLUSION

Attributes of a community pharmacy and its staff may influence people's decisions about which pharmacy they would visit to access treatment and advice for minor ailments. In line with the public's preferences, offering community pharmacy services that help people to better understand and manage symptoms, are provided promptly by trained staff who are friendly and approachable, and in a local setting with easy access to parking, has the potential to increase uptake amongst those seeking help to manage minor ailments. In this way it may be possible to shift demand away from high-cost health services and make more efficient use of scarce public resources.

Valuing Treatments for Parkinson Disease Incorporating Process Utility: Performance of Best-Worst Scaling, Time Trade-Off, and Visual Analogue Scales

OBJECTIVE

The objective of this study was to compare treatment profiles including both health outcomes and process characteristics in Parkinson disease using best-worst scaling (BWS), time trade-off (TTO), and visual analogue scales (VAS).

METHODS

From the model comprising of seven attributes with three levels, six unique profiles were selected representing process-related factors and health outcomes in Parkinson disease. A Web-based survey (N = 613) was conducted in a general population to estimate process-related utilities using profile-based BWS (case 2), multiprofile-based BWS (case 3), TTO, and VAS. The rank order of the six profiles was compared, convergent validity among methods was assessed, and individual analysis focused on the differentiation between pairs of profiles with methods used.

RESULTS

The aggregated health-state utilities for the six treatment profiles were highly comparable for all methods and no rank reversals were identified. On the individual level, the convergent validity between all methods was strong; however, respondents differentiated less in the utility of closely related treatment profiles with a VAS or TTO than with BWS. For TTO and VAS, this resulted in nonsignificant differences in mean utilities for closely related treatment profiles.

CONCLUSIONS

This study suggests that all methods are equally able to measure process-related utility when the aim is to estimate the overall value of treatments. On an individual level, such as in shared decision making, BWS allows for better prioritization of treatment alternatives, especially if they are closely related. The decision-making problem and the need for explicit trade-off between attributes should determine the choice for a method.

Importance of hemodialysis-related outcomes: comparison of ratings by a self-help group, clinicians, and health technology assessment authors with those by a large reference group of patients

BACKGROUND

The selection of important outcomes is a crucial decision for clinical research and health technology assessment (HTA), and there is ongoing debate about which stakeholders should be involved. Hemodialysis is a complex treatment for chronic kidney disease (CKD) and affects many outcomes. Apart from obvious outcomes, such as mortality, morbidity and health-related quality of life (HRQoL), others such as, concerning daily living or health care provision, may also be important. The aim of our study was to analyze to what extent the preferences for patient-relevant outcomes differed between various stakeholders. We compared preferences of stakeholders normally or occasionally involved in outcome prioritization (patients from a self-help group, clinicians and HTA authors) with those of a large reference group of patients.

PARTICIPANTS AND METHODS

The reference group consisted of 4,518 CKD patients investigated previously. We additionally recruited CKD patients via a regional self-help group, nephrologists via an online search and HTA authors via an expert database or personal contacts. All groups assessed the relative importance of the 23 outcomes by means of a discrete visual analog scale. We used descriptive statistics to rank outcomes and compare the results between groups.

RESULTS

We received completed questionnaires from 49 self-help group patients, 19 nephrologists and 18 HTA authors. Only the following 3 outcomes were ranked within the top 7 outcomes by all 4 groups: safety, HRQoL and emotional state. The ratings by the self-help group were generally more concordant with the reference group ratings than those by nephrologists, while HTA authors showed the least concordance.

CONCLUSION

Preferences of CKD patients from a self-help group, nephrologists and HTA authors differ to a varying extent from those of a large reference group of patients with CKD. The preferences of all stakeholders should form the basis of a transparent approach so as to generate a valid list of important outcomes.

Making sense of the shadows: priorities for creating a learning healthcare system based on routinely collected data

Socrates described a group of people chained up inside a cave, who mistook shadows of objects on a wall for reality. This allegory comes to mind when considering 'routinely collected data'-the massive data sets, generated as part of the routine operation of the modern healthcare service. There is keen interest in routine data and the seemingly comprehensive view of healthcare they offer, and we outline a number of examples in which they were used successfully, including the Birmingham OwnHealth study, in which routine data were used with matched control groups to assess the effect of telephone health coaching on hospital utilisation.Routine data differ from data collected primarily for the purposes of research, and this means that analysts cannot assume that they provide the full or accurate clinical picture, let alone a full description of the health of the population. We show that major methodological challenges in using routine data arise from the difficulty of understanding the gap between patient and their 'data shadow'. Strategies to overcome this challenge include more extensive data linkage, developing analytical methods and collecting more data on a routine basis, including from the patient while away from the clinic. In addition, creating a learning health system will require greater alignment between the analysis and the decisions that will be taken; between analysts and people interested in quality improvement; and between the analysis undertaken and public attitudes regarding appropriate use of data.

Community Priority Index: Utility, Applicability and Validation for Priority Setting in Community-Based Participatory Research

Background

Providing practitioners with an intuitive measure for priority setting that can be combined with diverse data collection methods is a necessary step to foster accountability of the decision-making process in community settings. Yet, there is a lack of easy-to-use, but methodologically robust measures, that can be feasibly implemented for reliable decision-making in community settings. To address this important gap in community based participatory research (CBPR), the purpose of this study was to demonstrate the utility, applicability, and validation of a community priority index in a community-based participatory research setting.

Design and Methods

Mixed-method study that combined focus groups findings, nominal group technique with six key informants, and the generation of a Community Priority Index (CPI) that integrated community importance, changeability, and target populations. Bootstrapping and simulation were performed for validation.

Results

For pregnant mothers, the top three highly important and highly changeable priorities were: stress (CPI=0.85; 95%CI: 0.70, 1.00), lack of affection (CPI=0.87; 95%CI: 0.69, 1.00), and nutritional issues (CPI=0.78; 95%CI: 0.48, 1.00). For non-pregnant women, top priorities were: low health literacy (CPI=0.87; 95%CI: 0.69, 1.00), low educational attainment (CPI=0.78; 95%CI: 0.48, 1.00), and lack of self-esteem (CPI=0.72; 95%CI: 0.44, 1.00). For children and adolescents, the top three priorities were: obesity (CPI=0.88; 95%CI: 0.69, 1.00), low self-esteem (CPI=0.81; 95%CI: 0.69, 0.94), and negative attitudes toward education (CPI=0.75; 95%CI: 0.50, 0.94).

Conclusions

This study demonstrates the applicability of the CPI as a simple and intuitive measure for priority setting in CBPR.

What matters to patients? A systematic review of preferences for medication-associated outcomes in mental disorders

OBJECTIVE

To investigate patients' preferences for outcomes associated with psychoactive medications.

SETTING/DESIGN

Systematic review of stated preference studies. No settings restrictions were applied.

PARTICIPANTS/ELIGIBILITY CRITERIA

We included studies containing quantitative data regarding the relative value adults with mental disorders place on treatment outcomes. Studies with high risk of bias were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

We restricted the scope of our review to preferences for outcomes, including the consequences from, attributes of, and health states associated with particular medications or medication classes, and process outcomes.

RESULTS

After reviewing 11 215 citations, 16 studies were included in the systematic review. These studies reported the stated preferences from patients with schizophrenia (n=9), depression (n=4), bipolar disorder (n=2) and attention deficit hyperactive disorder (n=1). The median sample size was 81. Side effects and symptom outcomes outnumbered functioning and process outcomes. Severe disease and hospitalisation were reported to be least desirable. Patients with schizophrenia tended to value disease states as higher and side effects as lower, compared to other stakeholder groups. In depression, the ability to cope with activities was found to be more important than a depressed mood, per se. Patient preferences could not consistently be predicted from demographic or disease variables. Only a limited number of potentially important outcomes had been investigated. Benefits to patients were not part of the purpose in 9 of the 16 studies, and in 10 studies patients were not involved when the outcomes to present were selected.

CONCLUSIONS

Insufficient evidence exists on the relative value patients with mental disorders place on medication-associated outcomes. To increase patient-centredness in decisions involving psychoactive drugs, further research-with outcomes elicited from patients, and for a larger number of conditions-should be undertaken.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42013005685.

Community-based decision making and priority setting using the R software: the community priority index

This paper outlines how to compute community priority indices in the context of multicriteria decision making in community settings. A simple R function was developed and validated with community needs assessment data. Particularly, the first part of this paper briefly overviews the existing methods for priority setting and reviews the utility of a multicriteria decision-making approach for community-based prioritization. The second part illustrates how community priority indices can be calculated using the freely available R program to handle community data by showing the computational and mathematical steps of CPI (Community Priority Index) with bootstrapped 95% confidence intervals.

A descriptive review on methods to prioritize outcomes in a health care context

BACKGROUND

Evidence synthesis has seen major methodological advances in reducing uncertainty and estimating the sizes of the effects. Much less is known about how to assess the relative value of different outcomes.

OBJECTIVE

To identify studies that assessed preferences for outcomes in health conditions.

METHODS

SEARCH STRATEGY

we searched MEDLINE, EMBASE, PsycINFO and the Cochrane Library in February 2014.

INCLUSION CRITERIA

eligible studies investigated preferences of patients, family members, the general population or healthcare professionals for health outcomes. The intention of this review was to include studies which focus on theoretical alternatives; studies which assessed preferences for distinct treatments were excluded.

DATA EXTRACTION

study characteristics as study objective, health condition, participants, elicitation method, and outcomes assessed in the study were extracted.

MAIN RESULTS

One hundred and twenty-four studies were identified and categorized into four groups: (1) multi criteria decision analysis (MCDA) (n = 71), (2) rating or ranking (n = 25), (3) utility eliciting (n = 5) and (4) studies comparing different methods (n = 23). The number of outcomes assessed by method group varied. The comparison of different methods or subgroups within one study often resulted in different hierarchies of outcomes.

CONCLUSIONS

A dominant method most suitable for application in evidence syntheses was not identified. As preferences of patients differ from those of other stakeholders (especially medical professionals), the choice of the group to be questioned is consequential. Further research needs to focus on validity and applicability of the identified methods.

Inclusiveness in the health economic evaluation space

This paper presents an overview of Gavin Mooney's contributions to broadening the evaluative space in health economics. It outlines how Mooney's ideas have encouraged many, including ourselves, to expand the conventional QALYs/health gain approach and look more broadly at what it is that is of value from health services. We reflect on Mooney's contributions to debates around cost-effectiveness analysis, Quality Adjusted Life Years (QALYs) and cost-utility analysis as well as his contribution to the development and application of contingent valuation and discrete choice experiments in health economics. We conclude by suggesting important avenues for future research to take forward Mooney's work.