Assessing quality of care in nursing homes using discrete choice experiments: How does the level of cognitive functioning impact upon older people's preferences?

A pilot study on preferences from surgeons to deal with an innovative customized and connected knee prosthesis - A discret choice experiment

Background

To address the increasing global demand for Total Knee Arthroplasty and reduce the need for revisions, several technologies combining 3D planning and artificial intelligence have emerged. These innovations aim to enhance customization, improve component positioning accuracy and precision. The integration of these advancements paves the way for the development of personalized and connected knee implant.

Questions/purposes

These groundbreaking advancements may necessitate changes in surgical practices. Hence, it is important to comprehend surgeons' intentions in integrating these technologies into their routine procedures. Our study aims to assess how surgeons' preferences will affect the acceptability of using this new implant and associated technologies within the entire care chain.

Methods

We employed a Discrete Choice Experiment, a predictive technique mirroring real-world healthcare decisions, to assess surgeons' trade-off evaluations and preferences.

Results

A total of 90 experienced surgeons, performing a significant number of procedures annually (mostly over 51) answered. Analysis indicates an affinity for technology but limited interest in integrating digital advancements like preoperative software and robotics. However, they are receptive to practice improvements and considering the adoption of future sensors.

Conclusions

In conclusion, surgeons prefer customized prostheses via augmented reality, accepting extra cost. Embedded sensor technology is deemed premature by them.

Valuing the Quality-of-Life Aged Care Consumers (QOL-ACC) Instrument for Quality Assessment and Economic Evaluation

OBJECTIVE

This paper reports on the valuation of the classification system for the Quality-of-Life Aged Care Consumers (QOL-ACC) instrument using a discrete choice experiment (DCE) with duration with a large sample of older people receiving aged care services.

METHODS

A DCE with 160 choice sets of two quality-of-life state-survival duration combinations blocked into 20 survey versions, with eight choice sets in each version, was designed and administered through an on-line survey to older Australians receiving aged care services in home and via interviewer facilitation with older people in residential aged care settings. Model specifications investigating preferences with respect to survival duration and interactions between QOL-ACC dimension levels were estimated. Utility weights were developed, with estimated coefficients transformed to the 0 (being dead) to 1 (full health) scale to generate a value set suitable for application in quality assessment and for the calculation of quality-adjusted life-years for use in economic evaluation.

RESULTS

In total, 953 older people completed the choice experiment with valid responses. The estimation results from econometric model specifications indicated that utility increased with survival duration and decreased according to quality-of-life impairment levels. An Australian value set (range - 0.56 to 1.00) was generated for the calculation of utilities for all QOL-ACC states.

CONCLUSION

The QOL-ACC is unique in its focus on measuring and valuing quality of life from the perspective of older people themselves, thereby ensuring that the preferences of aged care service users are the primary focus for quality assessment and economic evaluation.

Using discrete choice experiments to elicit the service preferences of people with mild intellectual disability: An exploratory study

The National Disability Insurance Scheme (NDIS) in Australia and other similar international movements towards consumer direction have highlighted the importance of including consumers to ensure their service preferences are operationalised. Discrete Choice Experiments (DCEs) are an established method to quantify consumer preferences. The feasibility of using DCEs with people with intellectual disability is largely untested. Consenting participants eligible for disability support services (n = 18) participated in the mixed methods exploratory study. The DCE comprised a series of choices between two hypothetical service providers offering a combination of services relating to social and economic participation (e.g. support with finding and keeping a job), with four levels of service (no service, online support, group support, one to one support). Pictographs and simplified English were used to represent the hypothetical services and levels and a 'think aloud' protocol adopted. Most participants (N = 16, 89%) completed the DCE task. The findings from the think aloud task indicated that some participants were weighing up the options and making decisions based on their goals and personal preferences. However, other participants did not focus on all presented attributes and levels when making a decision; a common 'short-cut' heuristic also observed in DCE tasks with general population participants. Further research including investigating other DCE techniques, such as best-worst scaling, would be beneficial to identify how preference-elicitation tasks can be developed and applied with people with intellectual disabilities to ensure that future service innovations are designed and administered in ways which best meet their needs and preferences.

What Constitutes Preferred Long-Term Care Provided in Residential Aged Care Facilities? An Empirical Comparison of the Preferences of the General Population, Residents, and Family Members

OBJECTIVES

Relatively few studies to date have examined the preferences of members of the general population as potential future consumers of long-term aged care services. This study aimed to use discrete choice experiment methodology to compare the preferences of 3 groups: the general population, residents, and family members of people living in long-term aged care.

METHODS

A total of 6 salient attributes describing the physical and psychosocial care in long-term residential aged care were drawn from qualitative research with people with a lived experience of aged care and were used to develop the discrete choice experiment questionnaire. The 6 attributes included: the level of time care staff spent with residents, homeliness of shared spaces, the homeliness of their own rooms, access to outside and gardens, frequency of meaningful activities, and flexibility with care routines. The questionnaire was administered to 1243 respondents including consumers (residents [n = 126], family member carers [n = 416]), and members of the general population (n = 701).

RESULTS

For both the general population and resident samples, having their own room feeling "home-like" exhibited the largest impact upon overall preferences. For the family member sample, care staff being able to spend enough time exhibited the largest impact. Tests of poolability indicated that the resident and general population samples estimates could be pooled. The null hypothesis of equal parameters between the groups was rejected for the family members, indicating significant differences in preferences relative to the resident and the general population samples.

CONCLUSIONS

This study illustrates that preferences for residential aged care delivery may vary depending upon perspective and experience.

Using Eye-Tracking Technology with Older People in Memory Clinics to Investigate the Impact of Mild Cognitive Impairment on Choices for EQ-5D-5L Health States Preferences

BACKGROUND

Population ageing is a phenomenon taking place in almost every global region. Current estimates indicate that 10-20% of older people in developed countries have mild cognitive impairment (MCI), with these percentages predicted to rise markedly by 2050.

OBJECTIVE

Our objective was to apply eye-tracking technology to investigate the information processes adopted by older people with and without MCI in determining preferences for health states in the five-level EuroQol-5 Dimensions (EQ-5D-5L) instrument.

METHODS

Older people (aged ≥ 65 years; including both patients and family carers) attending outpatient memory clinics in Southern Adelaide between July 2017 and June 2018, competent to read and converse in English and with a Mini-Mental State Examination (MMSE) cognition score of ≥ 19 were invited to participate. In total, 52 people met the inclusion criteria, of whom 20 (38%) provided informed consent and fully participated. Participants were categorised into two subgroups (each n = 10) for comparison based upon established MMSE cognition thresholds (19-23, lower MMSE indicative of MCI; ≥ 24, higher MMSE indicative of good cognition). A discrete-choice experiment (DCE) comprising a series of pairwise choices between alternative EQ-5D-5L health states of varying survival duration with differential levels of task complexity (approximated by the degree of attribute level overlap in each choice), was administered as a face-to-face interview with the participant wearing an eye-tracking device.

RESULTS

Attribute non-attendance (ANA) was higher for the lower MMSE subgroup than for the higher MMSE subgroup, although these differences were generally not statistically significant. ANA remained relatively low and consistent for participants with good cognition regardless of task complexity. In contrast, ANA increased notably in participants exhibiting MCI, increasing from 10% on average per participant in the lower MMSE subgroup with five attribute level overlap to 23% on average per participant in the lower MMSE subgroup with zero attribute level overlap.

CONCLUSIONS

This exploratory study provided important insights into the information processes adopted by older people with varying levels of cognitive functioning when choosing between alternative EQ-5D-5L health states of varying survival duration and specifically the relationships between cognitive capacity, task complexity and the extent of ANA. Recent advances in econometric modelling of health state valuation data have demonstrated the added value of capturing ANA information as this can be accounted for in the DCE data analysis, thereby improving the precision of model estimates. Eye-tracking technology can usefully inform the design, conduct and econometric modelling of DCEs, driving the inclusion of this rapidly growing population traditionally excluded from preference-elicitation studies of this nature.

The Feasibility of Connecting Conversations: A Narrative Method to Assess Experienced Quality of Care in Nursing Homes from the Resident's Perspective

Currently, residents living in nursing homes and their caring relationships are being placed more centrally in the care experience. Experienced quality of care is influenced by the interactions between residents, family and caregivers, who each have their own experiences and needs. Connecting Conversations is a narrative method aimed at assessing experienced quality of care in nursing homes from the resident's perspective by having separate conversations with residents, family and caregivers (triads), adopting an appreciative inquiry approach. This study presents how to use Connecting Conversations and its feasibility. Feasibility was assessed as performance completeness, protocol adherence and interviewers' experiences. Conversations were conducted by trained nursing home staff (n = 35) who performed 275 Connecting Conversations in another nursing home than where they were employed (learning network). Findings show it is feasible to perform separate appreciative conversations with resident-family-caregiver triads by an interviewer employed in another nursing home; however, protocol adherence was sometimes challenging in conversations with residents. Interviewers valued the appreciative approach, the learning network and the depth of the separate conversations. Challenges were experienced with scheduling conversations and receiving time and support to perform the conversations. Stakeholders should continue collaboration to embed Connecting Conversations into daily practice in nursing homes.

The Validity of Connecting Conversations: A Narrative Method to Assess Experienced Quality of Care in Nursing Homes from the Resident's Perspective

It is important to assess experienced quality of care in nursing homes, as this portrays what is important to residents and helps identify what quality improvements should focus on. Connecting Conversations is a narrative method that assesses experienced quality of care from the resident’s perspective in nursing homes by having separate conversations with residents, family, and professional caregivers (triads) within a learning network. This study assessed the validity of performing the narrative method, Connecting Conversations. Trained nursing home staff (interviewers) performed the conversations in another nursing home than where they were employed. In total, 149 conversations were performed in 10 nursing homes. Findings show that experts deemed the narrative assessment method appropriate and complete to assess experienced quality of care (face validity). The questions asked appeared to capture the full construct of experienced quality of care (content validity). Additionally, there was a range in how positive conversations were and first results indicated that a nursing home scoring higher on satisfaction had more positive conversations (construct validity). More data are needed to perform additional construct validity analyses. In conclusion, Connecting Conversations shows promising results for its use as a valid narrative method to assess experienced quality of care.