A systematic review of discrete choice experiments in stroke rehabilitation

OBJECTIVES

Existing research qualitatively explores consumer preferences for stroke rehabilitation interventions. However, it remains unclear which intervention characteristics are most important to consumers, and how these preferences may influence uptake and participation. Discrete choice experiments (DCE) provide a unique way to quantitatively measure preferences for health and health care. This study aims to explore how DCEs have been used in stroke rehabilitation and to identify reported consumer preferences for rehabilitation interventions.

MATERIAL AND METHODS

A systematic review of published stroke rehabilitation DCEs was completed (PROSPERO registration: CRD42021282578). Six databases (including CINAHL, MEDLINE, EconLIT) were searched from January 2000-March 2023. Data extracted included topic area, sample size, aim, attributes, design process, and preference outcomes. Descriptive and thematic analyses were conducted, and two methodological checklists applied to review quality.

RESULTS

Of 2,446 studies screened, five were eligible. Studies focused on exercise preference (n = 3), the structure and delivery of community services (n = 1), and self-management programs (n = 1). All had small sample sizes (range 50-146) and were of moderate quality (average score of 77%). Results indicated people have strong preferences for one-to-one therapy (over group-based), light-moderate intensity of exercise, and delivery by qualified therapists (over volunteers).

CONCLUSIONS

Few DCEs have been conducted in stroke rehabilitation, suggesting consumer preferences could be more rigorously explored. Included studies were narrow in the scope of attributes included, limiting their application to practice and policy. Further research is needed to assess the impact of differing service delivery models on uptake and participation.

The Current Update of Conventional and Innovative Treatment Strategies for Central Nervous System Injury

This review explores the complex challenges and advancements in the treatment of traumatic brain injury (TBI) and spinal cord injury (SCI). Traumatic injuries to the central nervous system (CNS) trigger intricate pathophysiological responses, frequently leading to profound and enduring disabilities. This article delves into the dual phases of injury-primary impacts and the subsequent secondary biochemical cascades-that worsen initial damage. Conventional treatments have traditionally prioritized immediate stabilization, surgical interventions, and supportive medical care to manage both the primary and secondary damage associated with central nervous system injuries. We explore current surgical and medical management strategies, emphasizing the crucial role of rehabilitation and the promising potential of stem cell therapies and immune modulation. Advances in stem cell therapy, gene editing, and neuroprosthetics are revolutionizing treatment approaches, providing opportunities not just for recovery but also for the regeneration of impaired neural tissues. This review aims to emphasize emerging therapeutic strategies that hold promise for enhancing outcomes and improving the quality of life for affected individuals worldwide.

Exploring the valued outcomes of school-based speech-language therapy services: a sequential iterative design

Background

Achieving outcomes that community members value is essential to high-quality, family-centred care. These valued outcomes should inform the production and interpretation of research evidence. To date, outcomes included in studies of service delivery models for speech-language services in schools have been narrowly defined, and do not match the outcomes suggested as important by families, teachers, and children. The most important outcomes of school-based, speech-languages services have not been directly and systematically investigated. We aimed to address this gap by asking school community members what outcomes were most relevant to evaluating and improving the delivery of speech-language services in schools.

Methods

A sequential, iterative mixed-method study was conducted using interviews with 14 family members, educators, and speech-language therapists that asked what outcomes or impacts of school-based services they considered most important or valuable. Summative content analysis was used to analyse the data. Structural topic modelling between rounds of qualitative analysis was used to describe both the quality and the quantity of the interview content. School community members' perspectives were compared through estimation of topic proportions within interviews from each member group and through qualitative comparison.

Results

Structural topic modelling diagnostics and qualitative interpretation of topic output suggested a six-topic solution. This solution was estimated successfully and yielded the following topics: (1) meeting all needs appropriately, (2) teamwork and collaboration, (3) building capacities, (4) supporting individual student needs in context, (5) coordinating care, and finally (6) supporting core educational goals. Families focused on school-based services meeting all needs appropriately and coordinating care, while educators highlighted supporting individual student needs in context. By contrast, speech-language therapists emphasized building capacities and supporting core educational goals. All school community members agreed that current assessment tools and outcome measures were inadequate to capture the most important impacts of school-based services.

Conclusions

Outcomes identified by school community members as important or valuable were broad, and included individual student outcomes, interpersonal outcomes, and systems-level outcomes. Although these outcomes were discussed by all member groups, each group focused on different outcomes in the interviews, suggesting differences in the prioritization of outcomes. We recommend building consensus regarding the most important outcomes for school-based speech-language services, as well as the prioritization of outcomes for measure development.

Adult experiences of constraint-induced movement therapy programmes: a qualitative study using the Theoretical Domains Framework and Capability, Opportunity, Motivation - Behaviour system

AIM

To explore the experiences of adults who completed a constraint-induced movement therapy (CIMT) programme, and the barriers and enablers to their participation.

METHODS

Qualitative design using semi-structured interviews. Stroke and brain injury survivors (n = 45) who had completed CIMT as part of their usual rehabilitation were interviewed 1 month post-CIMT. Interviews were audio-recorded, transcribed and imported into Nvivo for analysis. Inductive coding was used to identify initial themes. Themes were then deductively mapped to the Capability, Opportunity, Motivation - Behaviour system, a behaviour change model, to identify barriers and enablers to CIMT programme adherence and engagement.

RESULTS

Enablers influencing participation included being provided with education about the programme (Capability - psychological), seeing improvements in arm function (Motivation - reflective), being committed to the programme (Motivation - reflective) and having strong social support from staff, family and allied health students (Opportunity - social). The structured programme was a motivator and offered a way to fill the time, particularly during inpatient rehabilitation (Opportunity - physical). Barriers to participation included experiencing physical and mental fatigue (Capability - physical) and frustration early in the CIMT programme (Motivation - automatic), and finding exercises boring and repetitive (Motivation - automatic).

CONCLUSION

Therapist provision of educational supports for CIMT participants and their families is important to maximise CIMT programme uptake. During CIMT delivery, we recommend the provision of positive feedback and coaching in alignment with CIMT principles, and the inclusion of social supports such as group-based programmes to enhance participant adherence.

Stroke survivors' perspectives on decision-making about rehabilitation and the prospect of taking recovery-promoting drugs: A qualitative study

Objectives

To investigate factors which influence stroke survivors' decision-making about their rehabilitation and the prospect of taking recovery-promoting drugs, to enhance their recovery.

Methods

Seventeen stroke survivors who had undertaken stroke rehabilitation, and three spouses, participated in focus groups and individual interviews in northern Queensland, Australia. Inductive thematic analysis of the interview data was conducted in accordance with Braun and Clarke's six-phase process.

Results

Two specific, pivotal decision points during participants' stroke recovery process were identified: 1) overall, when deciding what rehabilitation they would undertake and hypothetically what recovery-promoting drugs they would take, and 2) on a daily basis, when deciding whether to participate in rehabilitation and take recovery-promoting drugs on any given day. Six themes which described factors influencing their decision-making were: 'My options for rehabilitation and recovery-promoting drugs'; 'The costs of rehabilitation and recovery-promoting drugs'; 'My recovery goals'; 'What I can deal with today'; 'The people my rehabilitation and recovery-promoting drugs affect'; and 'Fitting rehabilitation and recovery-promoting drugs into my life.' These themes were applicable at either one or both of the identified decision points.

Conclusion

Factors that influence stroke survivors' decision-making, overall and on a day-to-day basis, need to be considered to ensure they can make the best decisions for themselves to achieve their full recovery potential. Understanding the conditions under which a stroke survivor would take a recovery-promoting drug will contribute to the development of dosing protocols to which stroke survivors could adhere.

Preferences for Rehabilitation in Persons with a History of Stroke: A Discrete Choice Experiment

Objective

To investigate the preferences of persons with a history of stroke for various attributes of rehabilitation using a discrete choice experiment (DCE).

Design

Cross-sectional study.

Setting

A web-based survey.

Participants

A total of 600 adults with a history of stroke who were not asked whether or not they had participated in previous rehabilitation.

Intervention

None.

Main Outcome Measures

Preference weights by attribute ie, treatment time (30 minutes, one hour, one and a half hours), treatment content (walking exercises, activities of daily living; ADL exercises), priority treatment of paralyzed limbs (upper extremity, lower upper extremity), treatment location (hospital visit, home visit), therapist gender, and out-of-pocket costs for stroke rehabilitation using discrete choice experiment.

Results

The most common self-reported diagnosis was cerebral infarction (408 patients, 68%). The mean age was 62.0 ± 9.8 years, and 515 (85.8%) were male. Of the five attributes, excluding out-of-pocket costs, the highest relative importance score was treatment location (0.331), followed by treatment time (0.304). Among the rehabilitation programs, the statistically significant coefficients calculated were one hour of therapy (0.173, 95% CI = 0.088-0.258), hospital visits (0.241, 95% CI = 0.180-0.303), and female therapists (0.186, 95% CI = 0.125-0. 247). No significant differences were obtained regarding the treatment contents or the paralyzed limb to be treated.

Conclusion

A discrete choice experiment revealed that persons with a history of stroke prefer a one-hour hospital rehabilitation program with a female therapist, with cost being a major consideration for rehabilitation. The results of this study may provide useful information for rehabilitation professionals.

Supporting rehabilitation stakeholders in making service delivery decisions: a rapid review of multi-criteria decision analysis methods

PURPOSE

This review aimed to synthesize knowledge about multi-criteria decision analysis methods for supporting rehabilitation service design and delivery decisions, including: (1) describing the use of these methods within rehabilitation, (2) identifying decision types that can be supported by these methods, (3) describing client and family involvement, and (4) identifying implementation considerations.

METHODS

We conducted a rapid review in collaboration with a knowledge partner, searching four databases for peer-reviewed articles reporting primary research. We extracted relevant data from included studies and synthesized it descriptively and with conventional content analysis.

RESULTS

We identified 717 records, of which 54 met inclusion criteria. Multi-criteria decision analysis methods were primarily used to understand the strength of clients' and clinicians' preferences (n = 44), and five focused on supporting decision making. Shared decision making with stakeholders was evident in only two studies. Clients and families were mostly engaged in data collection and sometimes in selecting the relevant criteria. Good practices for supporting external validity were inconsistently reported. Implementation considerations included managing cognitive complexity and offering authentic choices.

CONCLUSIONS

Multi-criteria decision analysis methods are promising for better understanding client and family preferences and priorities across rehabilitation professions, contexts, and caseloads. Further work is required to use these methods in shared decision making, for which increased use of qualitative methods and stakeholder engagement is recommended. IMPLICATIONS FOR REHABILITATIONMulti-criteria decision analysis methods are promising for evidence-based, shared decision making for rehabilitation.However, most studies to date have focused on estimating stakeholder preferences, not supporting shared decision making.Cognitive complexity and modelling authentic and realistic decision choices are major barriers to implementation.Stakeholder-engagement and qualitative methods are recommended to address these barriers.

Client preferences and perceptions regarding a written home exercise program or video self-modeling: A cross-sectional study

STUDY DESIGN

This was a cross-sectional study.

INTRODUCTION

Home exercise programs (HEPs) are frequently prescribed to maximize a patient's recovery and ensure maintenance of therapeutic gains produced during supervised treatment. Improved understanding of patient preferences and incorporation of simple mobile health technologies may be beneficial strategies for improving patient HEP adherence.

PURPOSE

The purpose of this study was to determine client's preferred mode of home exercise program delivery when offered a choice between a cellular video and paper handout.

METHODS

A convenience sample was recruited from clients receiving services at an upper extremity rehabilitation facility. Participants were provided a paper handout with written instructions and an audiovisual recording of themselves performing the exercises. A questionnaire was developed to compare clients' preferences and perceptions. Quantitative data regarding patient preference were gathered and analyzed with descriptive statistics. Collected qualitative data were themed to determine the characteristics of home exercise programs (HEPs) perceived by patients.

RESULTS

A total of 30 patients participated in the study. Of the 29 responses regarding patient preference of HEP mode, 20 (69%) patients preferred a video, 4 (14%) patients preferred a paper handout, and 5 (17%) patients preferred both paper and video HEP. Patients with preference to a paper HEP reported the handout was helpful to be accessed in a simple manner and could be displayed as a visual reminder to perform the exercises. Those who preferred the cellular video reported increased understanding and confidence with accurate performance of exercises using audiovisual instructions.

DISCUSSION

HEP adherence enhancement techniques include improved understanding of patient preferences in order to facilitate customized client-centered treatment.

CONCLUSION

The majority of participants in this study preferred a mobile-based video HEP. Participants perceived the video as visually appealing and a more effective mode of instruction than paper handouts.

Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury

BACKGROUND

Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses.

METHODS

A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit.

RESULTS

Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality-based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality-based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight-supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance.

DISCUSSION

The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient's engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy.

LIMITATIONS

As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance.

SUMMARY

The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury.

DISCLAIMER

These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.

Barriers, Facilitators and Interventions to Support Virtual Reality Implementation in Rehabilitation: A Scoping Review

Virtual reality and active video games (VR/AVGs) are promising rehabilitation tools because of their potential to facilitate abundant, motivating, and feedback-rich practice. However, clinical adoption remains low despite a growing evidence base and the recent development of clinically accessible and rehabilitation-specific VR/AVG systems. Given clinicians' eagerness for resources to support VR/AVG use, a critical need exists for knowledge translation (KT) interventions to facilitate VR/AVG integration into clinical practice. KT interventions have the potential to support adoption by targeting known barriers to, and facilitators of, change. This scoping review of the VR/AVG literature uses the Theoretical Domains Framework (TDF) to (1) structure an overview of known barriers and facilitators to clinical uptake of VR/AVGs for rehabilitation; (2) identify KT strategies to target these factors to facilitate adoption; and (3) report the results of these strategies. Barriers/facilitators and evaluated or proposed KT interventions spanned all but 1 and 2 TDF domains, respectively. Most frequently cited barriers/facilitators were found in the TDF domains of Knowledge, Skills, Beliefs About Capabilities, Beliefs About Consequences, Intentions, Goals, Environmental Context and Resources, and Social Influences. Few studies empirically evaluated KT interventions to support adoption; measured change in VR/AVG use did not accompany improvements in self-reported skills, attitudes, and knowledge. Recommendations to target frequently identified barriers include technology development to meet end-user needs more effectively, competency development for end-users, and facilitated VR/AVG implementation in clinical settings. Subsequent research can address knowledge gaps in both clinical and VR/AVG implementation research, including on KT intervention effectiveness and unexamined TDF domain barriers. LEVEL OF EVIDENCE: IV.

Discrete Choice Experiments in Health Economics: Past, Present and Future

OBJECTIVES

Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges.

METHODS

A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated.

RESULTS

Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels.

CONCLUSIONS

The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.

Developing a multidisciplinary rehabilitation package following hip fracture and testing in a randomised feasibility study: Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR)

BACKGROUND

Proximal femoral fracture is a major health problem in old age, with annual UK health and social care costs of £2.3B. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of clinical effectiveness and cost-effectiveness is lacking.

OBJECTIVES

To develop an enhanced community-based rehabilitation package following surgical treatment for proximal femoral fracture and to assess acceptability and feasibility for a future definitive randomised controlled trial (RCT) and economic evaluation.

DESIGN

Phase I - realist review, survey and focus groups to develop the rehabilitation package. Phase II - parallel-group, randomised (using a dynamic adaptive algorithm) feasibility study with focus groups and an anonymised cohort study.

SETTING

Recruitment was from orthopaedic wards of three acute hospitals in the Betsi Cadwaladr University Health Board, North Wales. The intervention was delivered in the community following hospital discharge.

PARTICIPANTS

Older adults (aged ≥ 65 years) who had received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by the clinical team) and received rehabilitation in the North Wales area.

INTERVENTIONS

Participants received usual care (control) or usual care plus an enhanced rehabilitation package (intervention). Usual care was variable and consisted of multidisciplinary rehabilitation delivered by the acute hospital, community hospital and community services depending on need and availability. The intervention was designed to enhance rehabilitation by improving patients' self-efficacy and increasing the amount and quality of patients' practice of physical exercise and activities of daily living. It consisted of a patient-held information workbook, a goal-setting diary and six additional therapy sessions.

MAIN OUTCOME MEASURES

The primary outcome measure was the Barthel Activities of Daily Living (BADL) index. The secondary outcome measures included the Nottingham Extended Activities of Daily Living (NEADL) scale, EuroQol-5 Dimensions, ICEpop CAPability measure for Older people, General Self-Efficacy Scale, Falls Efficacy Scale - International (FES-I), Self-Efficacy for Exercise scale, Hospital Anxiety and Depression Scale (HADS) and service use measures. Outcome measures were assessed at baseline and at 3-month follow-up by blinded researchers.

RESULTS

Sixty-two participants were recruited (23% of those who were eligible), 61 were randomised (control, n = 32; intervention, n = 29) and 49 (79%) were followed up at 3 months. Compared with the cohort study, a younger, healthier subpopulation was recruited. There were minimal differences in most outcomes between the two groups, including the BADL index, with an adjusted mean difference of 0.5 (Cohen's d = 0.29). The intervention group showed a medium-sized improvement on the NEADL scale relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d = 0.63). There was a trend for greater improvement in FES-I and HADS in the intervention group, but with small effect sizes, with an adjusted mean difference of 4.2 (Cohen's d = 0.31) and 1.3 (Cohen's d = 0.20), respectively. The cost of delivering the intervention was £231 per patient. There was a possible small relative increase in quality-adjusted life-years in the intervention group. No serious adverse events relating to the intervention were reported.

CONCLUSIONS

Trial methods were feasible in terms of eligibility, recruitment and retention, although recruitment was challenging. The NEADL scale was more responsive than the BADL index, suggesting that the intervention could enable participants to regain better levels of independence compared with usual care. This should be tested in a definitive Phase III RCT. There were two main limitations of the study: the feasibility study lacked power to test for differences between the groups and a ceiling effect was observed in the primary measure.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22464643.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 44. See the NIHR Journals Library for further project information.

Patient and therapist experiences of using affordable feedback-based technology in rehabilitation: a qualitative study nested in a randomized controlled trial

Objective:

To explore how technologies are used and experienced in rehabilitation.

Design:

A qualitative study using a grounded theory approach within a randomized controlled trial investigating the effectiveness of tailored, affordable technologies to improve mobility and physical activity.

Settings:

Aged care and neurological rehabilitation wards with community follow-up.

Participants:

Twenty patients undergoing rehabilitation and randomized to the experimental arm of a trial (mean age 64 years (SD 23)) were recruited for interviews, plus 11 physiotherapists involved in technology prescription as part of the trial.

Method:

Two interviews per patient (one in hospital, one post-discharge) and four focus groups with physiotherapists were conducted. Transcribed data were coded and synthesized. Memo-writing and constant comparison methods guided data analysis.

Results:

A process of patient engagement with technology involving two stages: (1) initial patient engagement and (2) maintaining patient engagement was identified. Therapists used a series of steps and strategies to gain and maintain patient engagement. A positive first experience and continued input into patient programmes was needed. The level of patient engagement was not consistent across the duration of the trial, increasing or decreasing due to changes in the technologies prescribed or setting of use. Two conditions were key to optimizing patient engagement: sufficient support and perceived benefit from using technology.

Conclusions:

Patients can engage with technology during rehabilitation when prescription is tailored by a therapist. Perceiving benefit from using technology, in addition to receiving the right support to enable use appears to influence the level of patient engagement.

Differences in Waiting List Prioritization Preferences of Occupational Therapists, Elderly People, and Persons With Disabilities: A Discrete Choice Experiment

OBJECTIVE

To compare the preferences of occupational therapists, elderly people, and adults with disabilities regarding prioritization criteria for occupational therapy waiting lists in home care.

DESIGN

Discrete choice experiment survey.

SETTING

Survey mailed to occupational therapists working in home care and community-dwelling elderly or disabled persons.

PARTICIPANTS

A sample (N=714) of home-based occupational therapists (n=241), elderly persons from a bank of research participants (n=226), and adults with physical disabilities recruited through community organizations (n=247).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The dependent variable was whether the referral scenario was prioritized or not in each question. The results were analyzed through logistic regression using conditional logit models.

RESULTS

Prioritization preferences differed between groups (P<.001). Occupational therapists most strongly prioritized people who had a few falls (odds ratio vs no falls, 48.7), whereas elderly people and adults with disabilities most strongly prioritized people who were unable to enter and exit the home (odds ratio vs no difficulty entering and exiting the home, 30.8 for elderly people and 16.8 for persons with disabilities.) CONCLUSIONS: Our results highlight the gap between the priorities of home-based occupational therapists and their target clientele. Although further inquiry is needed to inform priority setting, the findings emphasize the importance of public or patient involvement in decisions on waiting list prioritization.

Do patients and health care providers have discordant preferences about which aspects of treatments matter most? Evidence from a systematic review of discrete choice experiments

OBJECTIVES

To review studies eliciting patient and healthcare provider preferences for healthcare interventions using discrete choice experiments (DCEs) to (1) review the methodology to evaluate similarities, differences, rigour of designs and whether comparisons are made at the aggregate level or account for individual heterogeneity; and (2) quantify the extent to which they demonstrate concordance of patient and healthcare provider preferences.

METHODS

A systematic review searching Medline, EMBASE, Econlit, PsycINFO and Web of Science for DCEs using patient and healthcare providers.

INCLUSION CRITERIA

peer-reviewed; complete empiric text in English from 1995 to 31July 2015; discussing a healthcare-related topic; DCE methodology; comparing patients and healthcare providers.

DESIGN

Systematic review.

RESULTS

We identified 38 papers exploring 16 interventions in 26 diseases/indications. Methods to analyse results, determine concordance between patient and physician values, and explore heterogeneity varied considerably between studies. The majority of studies we reviewed found more evidence of mixed concordance and discordance (n=28) or discordance of patient and healthcare provider preferences (n=12) than of concordant preferences (n=4). A synthesis of concordance suggested that healthcare providers rank structure and outcome attributes more highly than patients, while patients rank process attributes more highly than healthcare providers.

CONCLUSIONS

Discordant patient and healthcare provider preferences for different attributes of healthcare interventions are common. Concordance varies according to whether attributes are processes, structures or outcomes, and therefore determining preference concordance should consider all aspects jointly and not a binary outcome. DCE studies provide excellent opportunities to assess value concordance between patients and providers, but assessment of concordance was limited by a lack of consistency in the approaches used and consideration of heterogeneity of preferences. Future DCEs assessing concordance should fully report the framing of the questions and investigate the heterogeneity of preferences within groups and how these compare.

Implementation of a home-based interactive training system for fall prevention: requirements and challenges

A critical need exists for rehabilitation for improving older adults' physical abilities, especially in the field of fall prevention. Although virtual reality and ambient-assistive technology-based approaches are promising, they are cost intensive and frequently face significant obstacles during the developmental process. The authors of the current article developed a motivational interactive training system for fall prevention and stroke rehabilitation and planned a pilot study to measure its usability, user acceptance, and effect on physical abilities and quality of life. Usability results from a field trial are presented. The purpose of the current article is to describe the technological and organizational problems during the development process and field trial. Recommendations for overcoming these barriers are described. These experiences should be taken into account when planning further field trials with assistive technology and older adults.