Clinicians' preferences for managing aneurysmal subarachnoid hemorrhage using endothelin receptor antagonists

Background

The endothelin receptor antagonist (ERA) clazosentan is being investigated for the medical prevention of cerebral vasospasm and associated complications, such as delayed cerebral ischemia (DCI), after aneurysmal subarachnoid hemorrhage (aSAH). This study quantified how clinicians weigh the benefits and risks of ERAs for DCI prevention to better understand their treatment needs and expectations.

Methods

An online choice experiment was conducted to elicit preferences of neurologists, intensivists, and neurosurgeons treating aSAH in the US and UK for the use of ERAs. The design of the choice experiment was informed by a feasibility assessment (N = 100), one-on-one interviews with clinicians (N = 10), a qualitative pilot (N = 13), and a quantitative pilot (N = 50). Selected treatment attributes included in the choice experiment were: one benefit (likelihood of DCI); and three risks (lung complications, hypotension, and anemia). In the choice experiment, clinicians repeatedly chose best and worst treatment options based on a scenario of a patient being treated in the ICU after aneurism repair. A correlated mixed logit model determined the relative attribute importance (RAI) and associated highest density interval (HDI) as well as acceptable benefit-risk trade-offs.

Results

The final choice experiment was completed by 350 clinicians (116 neurologists, 129 intensivists/intensive care clinicians, and 105 neurosurgeons; mean age, 47.4 years). Reducing the likelihood of DCI (RAI = 56.5% [HDI, 53.6-59.5%]) had the largest impact on clinicians' treatment choices, followed by avoiding the risks of lung complications (RAI = 29.6% [HDI, 27.1-32.3%]), hypotension (RAI = 9.2% [HDI, 7.5-10.8%]), and anemia (RAI = 4.7% [HDI, 3.7-5.8%]). Clinicians expected the likelihood of DCI to decrease by ≥8.1% for a 20% increase in the risk of lung complications, ≥2.4% for a 20% increase in the risk of hypotension, and ≥1.2% for a 20% increase in the risk of anemia.

Conclusions

Clinicians were willing to accept certain increased risks of adverse events for a reduced risk of DCI after aSAH. The likelihood of DCI occurring after aSAH can therefore be considered a clinically relevant endpoint in aSAH treatment development. Thus, evaluations of ERAs might focus on whether improvements (i.e., reductions) in the likelihood of DCI justify the risks of adverse events.

Does in vitro fertilization (IVF) treatment provide good value for money? A cost-benefit analysis

Background

Using traditional health technology assessment (HTA) outcome metrics, such as quality-adjusted life-years, to assess fertility treatments raises considerable methodological challenges because the objective of fertility treatments is to create new life rather than extend, save, or improve health-related quality of life.

Objective

The aim of this study was to develop a novel cost-benefit framework to assess value for money of publicly funded IVF treatment; to determine the number of cost-beneficial treatment cycles for women of different ages; and to perform an incremental cost-benefit analysis from a taxpayer perspective.

Methods

We developed a Markov model to determine the net monetary benefit (NMB) of IVF treatment by female age and number of cycles performed. IVF treatment outcomes were monetized using taxpayers' willingness-to-pay values derived from a discrete choice experiment (DCE). Using the current funding environment as the comparator, we performed an incremental analysis of only funding cost-beneficial cycles. Similar outputs to cost-effectiveness analyses were generated, including net-benefit acceptability curves and cost-benefit planes. We created an interactive online app to provide a detailed and transparent presentation of the results.

Results

The results suggest that at least five publicly funded IVF cycles are cost-beneficial in women aged <42 years. Cost-benefit planes suggest a strong taxpayer preference for restricting funding to cost-beneficial cycles over current funding arrangements in Australia from an economic perspective.

Conclusions

The provision of fertility treatment is valued highly by taxpayers. This novel cost-benefit method overcomes several challenges of conventional cost-effectiveness methods and provides an exemplar for incorporating DCE results into HTA. The results offer new evidence to inform discussions about treatment funding arrangements.

Physician preferences for attributes of pediatric combination vaccines in the United States

OBJECTIVE

To understand physician preferences for various attributes of pediatric combination vaccines.

METHODS

An online survey was completed by 400 US physicians (pediatricians and family physicians) who routinely administer vaccines to infants aged 1-12 months in outpatient settings. Respondents completed a discrete choice experiment (DCE) by selecting their preferred options from different hypothetical vaccine profiles with systematic variation in the levels of five attributes: vaccine presentation, number of injections administered at a single visit, completion rates, timeliness rates (within 30 days of recommended age), and years of availability for routine use, assuming similar cost, safety, and efficacy. Odds ratios and relative attribute importance scores were estimated using a random parameters logit model.

RESULTS

Physicians (mean age 50.4 years, 52.5% women) preferred combination vaccines that reduced the number of injections administered at a single visit, facilitated higher completion and timeliness rates for the primary DTaP series, were available as a pre-filled syringe rather than a vial needing reconstitution and had been available for routine use for more than 1 year. All odds ratios were statistically significant. Physicians were twice as likely to prefer administering three injections in a single visit instead of four. The most important attribute was the number of injections administered at a single visit (relative importance 38%), followed by timeliness, completion rates, and vaccine presentation; years a vaccine has been available was the least important attribute.

CONCLUSION

US physicians prefer pediatric combination vaccines that enable fewer injections to be administered at a single visit, facilitate higher completion and timeliness rates, are offered as a pre-filled syringe, and have been available for routine use for more than 1 year. The most important attribute of pediatric combination vaccines was a reduction in the number of injections administered at a single visit.

Patient Preferences for Longer or More Frequent In-Center Hemodialysis Regimens: A Multicenter Discrete Choice Study

RATIONALE & OBJECTIVE

Longer and more frequent hemodialysis sessions are associated with both benefits and harms. However, their relative importance to patients and how they influence acceptability for patients have not been quantified.

STUDY DESIGN

Discrete-choice experiment in which a scenario followed by 12 treatment choice sets were presented to patients in conjunction with varying information about the clinical impact of the treatments offered.

SETTING & PARTICIPANTS

Patients with kidney failure treated with maintenance dialysis for≥1 year in 5 UK kidney centers.

PREDICTORS

Length and frequency of hemodialysis sessions and their prior reported associations with survival, quality of life, need for fluid restriction, hospitalization, and vascular access complications.

OUTCOME

Selection of longer (4.5 hours) or more frequent (4 sessions per week) hemodialysis regimens versus remaining on 3 sessions per week with session lengths of 4 hours.

ANALYTICAL APPROACH

Multinomial mixed effects logistic regression estimating the relative influence of different levels of the predictors on the selection of longer and more frequent dialysis, controlling for patient demographic characteristics.

RESULTS

Among 183 prevalent in-center hemodialysis patients (mean age of 63.7 years, mean dialysis vintage of 4.7 years), 38.3% (70 of 183) always chose to remain on regimens of 3 sessions per week with session duration of 4 hours. Depicted associations of increasing survival and quality of life, reduced need for fluid restriction, and avoiding additional access complications were all significantly associated with choosing longer or more frequent treatment regimens. Younger age, fatigue, previous experience of vascular access complications, absence of heart failure, and shorter travel time to dialysis centers were associated with preference for 4 sessions per week. Patients expressed willingness to trade up to 2 years of life to avoid regimens of 4 sessions per week or access complications. After applying estimated treatment benefits and harms from existing literature, the fully adjusted model revealed that 27.1% would choose longer regimens delivered 3 times per week and 34.3% would choose 4 hours 4 times per week. Analogous estimates for younger fatigued patients living near their unit were 23.5% and 62.5%, respectively.

LIMITATIONS

Estimates were based on stated preferences rather than observed behaviors. Predicted acceptance of regimens was derived from data on treatment benefits and harms largely sourced from observational studies.

CONCLUSIONS

Predicted acceptance of longer and more frequent hemodialysis regimens substantially exceeds their use in current clinical practice. These findings underscore the need for robust data on clinical effectiveness of these more intensive regimens and more extensive consideration of patient choice in the selection of dialysis regimens.

Preferences for HIV Testing Services and HIV Self-Testing Distribution Among Migrant Gay, Bisexual, and Other Men Who Have Sex With Men in Australia

Background

In Australia, undiagnosed HIV rates are much higher among migrant gay, bisexual, or other men who have sex with men (GBMSM) than Australian-born GBMSM. HIV self-testing is a promising tool to overcome barriers to HIV testing and improve HIV testing uptake among migrant GBMSM. We compared the preferences for HIV testing services, including HIV self-testing, among migrant and Australian-born GBMSM.

Methods

Preferences were assessed via two discrete choice experiments (DCEs). Participants were recruited between December 2017 and January 2018 using online and offline advertising and randomly assigned to complete one of two online DCE surveys. Migrant GBMSM were classified as being born in a country with a reciprocal healthcare agreement (RHCA) with Australia (providing free or subsided health care) or not. Latent class analysis and mixed logit models were used to explore heterogeneity in preferences.

Findings

We recruited 1,606 GBMSM, including 583 migrant men of whom 419 (72%) were born in non-RHCA countries. Most participants preferred a free or cheap oral test with higher accuracy and a shorter window period to facilitate early detection of infections. Cost was more important for men born in non-RHCA countries than for men from RHCA countries or Australia. All groups preferred accessing kits through online distributers or off the shelf purchasing from pharmacies. Men born in RHCA countries least preferred accessing HIV self-testing kits from a medical clinic, while more than half of men from non-RHCA countries most preferred sourcing kits from a clinic. Sex-on-premises venues were the least preferred location to access test kits among all groups. In addition, two latent class analyses explored heterogeneity in preferences among men from non-RHCA countries and we found four latent classes for HIV testing services and two latent classes for HIVST distribution.

Interpretation

Our findings emphasise the need for high-performing and low-cost HIV self-testing kits that are accessible from a variety of distribution points as a component of Australia's HIV response, especially for those who do not have access to free or subsidised health care in Australia.

Consumer Preferences and Willingness to Pay for Mud Crabs in Southeast Asian Countries: A Discrete Choice Experiment

The mud crab (Scylla serrata) is an economically important species found in the mangroves and estuaries of tropical countries and is a popular seafood product in the coastal areas of Southeast Asian markets. The aim of this study is to identify factors affecting consumer preference of mud crabs, and to understand consumers’ willingness to pay (WTP) for these factors in a Singapore market where imported mud crabs from other Asian countries are sold. The results showed that the country of origin matters to participants, affecting purchasing decisions, and consumers were willing to pay approximately 16.48 SGD (11.49 USD, the average price of four shops: 35.55 USD/kg for one mud crab) more if the mud crabs were from Sri Lanka if compared with Indonesian or Cambodian mud crabs. Moreover, consumers were willing to pay 25.08 SGD (17.48 USD) more if the mud crabs were alive and 13.40 SGD (9.34 USD) less if the mud crabs were frozen compared with fresh, but not alive, mud crabs. Furthermore, consumers’ preference in mud crab was associated with the consumers’ religion. Some groups of consumers preferred female mud crabs with eggs over male mud crabs, while other groups preferred male crabs. The results identified diverse consumer preference of mud crabs and, therefore, could provide new insights that are useful for sustainable consumption of mud crabs in the region.

European Consumers' Willingness to Pay for Red Meat Labelling Attributes

Simple Summary

Given the decrease in red meat consumption in the last decade, it is crucial for red meat producers to understand consumer preferences. This international study analyses the European consumer preferences for red meat (beef, lamb and goat) in seven countries: Finland, France, Greece, Italy, Spain, Turkey and the United Kingdom. Through a survey with hypothetical choice situations (choice experiment), 2900 responses were collected. Advanced econometric models were estimated to identify the diversity of preferences among consumers at the country level. The results indicate substantial differences between the most relevant attributes for the average consumer in each country. Nevertheless, national origin and organic labels were highly valued in most countries.

Abstract

Food consumption in Europe is changing. Red meat consumption has been steadily decreasing in the past decades. The rising interest of consumers for healthier and more sustainable meat products provides red meat producers with the opportunity to differentiate their offers by ecolabels, origin and health claims. This international study analyses the European consumer preferences for red meat (beef, lamb and goat) in seven countries: Finland, France, Greece, Italy, Spain, Turkey and the United Kingdom. Through a choice experiment, 2900 responses were collected. Mixed multinomial logit models were estimated to identify heterogeneous preferences among consumers at the country level. The results indicate substantial differences between the most relevant attributes for the average consumer, as well as their willingness to pay for them in each country. Nevertheless, national origin and organic labels were highly valued in most countries.

Treatment Preferences of Patients with Chronic Obstructive Pulmonary Disease: Results from Qualitative Interviews and Focus Groups in the United Kingdom, United States, and Germany

BACKGROUND

A wide range of therapeutic regimens, including single-inhaler triple therapies (SITTs), are now available for the maintenance treatment of chronic obstructive pulmonary disease (COPD). Thus, an improved understanding of patient preferences may be valuable to inform physician prescribing decisions. This study was performed to assess the factors considered by patients when making decisions about their COPD treatments using qualitative techniques.

METHODS

In the United Kingdom, United States and Germany, individual qualitative interviews (n=10 per country) and focus groups (1 per country; [United Kingdom, n=4; United States, n=6; Germany, n=6 participants]) were conducted. Interviews and focus groups were semi‑structured, lasting approximately 60 minutes, and focused on treatment preferences. Data were analyzed according to emerging themes identified from the interviews; qualitative thematic analysis of the data was performed using specialist software.

RESULTS

In interviews and focus groups, efficacy, ease of use, and lower frequency of use were favored attributes for current treatment, while side effects, medication taste, and more complex administration techniques were key dislikes. In interviews, most participants would consider a switch in medication, mainly for improved efficacy, but also to reduce medication frequency or following physician advice. Overall, efficacy and ease of use were the 2 most important attributes reported in interviews in all 3 countries.

CONCLUSION

Patients with COPD have preferences for certain attributes of medication, highlighting the multi-faceted nature of treatment effectiveness and the importance of the delivery device.These results were subsequently used to inform the design of a discrete choice experiment.

Choosing Video Instead of In-Clinic Consultations in Primary Care in Israel: Discrete Choice Experiment Among Key Stakeholders-Patients, Primary Care Physicians, and Policy Makers

BACKGROUND

Despite its innovative benefits, the adoption of video consultations (VCs) in primary care settings is complex and slow.

OBJECTIVES

To quantify the preferences of key stakeholders in Israel's primary care-patients, primary care practitioners, and policy makers-regarding VCs compared with traditional in-clinic consultations (ICC) in nonurgent conditions.

METHODS

Discrete choice experiment surveys were completed by 508 patients, 311 physicians, and 141 policy makers. These consisted of 12 choice tasks of 2 labeled alternatives (VC or ICC), with the 4 attributes most relevant to each stakeholder group. A random effects logit model analysis was used to estimate stakeholders' preferences.

RESULTS

All 4 experiments' attributes were significantly important in choosing VC versus ICC for the patient group and the physician group. Three out of 4 attributes were significantly important to policy makers. Differences and similarities between stakeholders were identified in attribute rank order, trade-offs, and VC uptake probabilities. Policy makers' VC uptake rate was 86%. Patients' preferences suggested that 68% of ICCs could be replaced by VCs. Physicians' VC uptake was 30% in cases in which the consultation purpose was to diagnose and provide treatment and 48% in cases in which the consultation purpose was follow-up.

CONCLUSIONS

Our findings show key stakeholders' preferences about VC integration, to be considered when these systems are introduced into primary care and optimize the implementation process. Although there is a stronger preference for ICC among physicians and patients, alternative combinations of attribute levels might be used to compensate and reconfigure a more preferred VC service.

What do community health workers want? Findings of a discrete choice experiment among Accredited Social Health Activists (ASHAs) in India

Introduction

A number of factors contribute to the performance and motivation of India’s Accredited Social Health Activists (ASHAs). This study aims to identify the key motivational factors (and their relative importance) that may help retain ASHAs in service.

Methods

A discrete choice experiment (DCE) survey presented ASHAs with eight unlabelled choice sets, each describing two hypothetical jobs that varied based on five attributes, specifically salary, workload, travel allowance, supervision and other job benefits. Multinomial logit and latent class (LC) models were used to estimate stated preferences for the attributes.

Result

We invited 318 ASHAs from 53 primary health centres of Guntur, a district in south India. The DCE was completed by 299 ASHAs using Android tablets. ASHAs were found to exhibit a strong preference for jobs that incorporated training leading to promotion, a fixed salary and free family healthcare. ASHAs were willing to sacrifice 2530 Indian rupee (INR) from their monthly salary, for a job offering training leading to promotion opportunity and 879 INR for a free family health-check. However, there was significant heterogeneity in preferences across the respondents. The LC model identified three distinct groups (comprising 51%, 35% and 13% of our cohort, respectively). Group 1 and 2 preferences were dominated by the training and salary attributes with group 2 having higher preference for free family health-check while group 3 preferences were dominated by workload. Relative to group 3, ASHAs in groups 1 and 2 were more likely to have a higher level of education and less likely to be the main income earners for their families.

Conclusion

ASHAs are motivated by both non-financial and financial factors and there is significant heterogeneity between workers. Policy decisions aimed at overcoming workforce attrition should target those areas that are most valued by ASHAs to maximise the value of investments into these workers.

Trial registration number

CTRI/2018/03/012425.

First and Foremost Battle the Virus: Eliciting Patient Preferences in Antiviral Therapy for Hepatitis C Using a Discrete Choice Experiment

BACKGROUND

There has been tremendous progress regarding treatment options for hepatitis C virus (HCV) infection. Several interferon-free regimens are awaiting regulatory approval. These innovations promise substantial reductions in the burden of disease and side effects as well as a decrease in treatment duration.

OBJECTIVES

The aim of this quantitaitive study was to elicit patient preferences for attributes of innovative antiviral therapies for hepatitis C.

METHODS

A systematic literature search and 14 semi-structured interviews were performed, resulting in eight patient-relevant characteristics. For the discrete choice experiment, an experimental design (3×3 + 5×6) was generated using Ngene software. The survey was conducted in August 2014 through computer-assisted personal interviews. The data were effects-coded in a random parameter logit estimation.

RESULTS

Participants were patients with HCV (N = 561; 58.1% men) in different treatment states. The analysis revealed a predominance of the attribute "reaching sustained virological response." When considering confidence intervals, the results showed three different preference ranks. At first place was "sustained virological response" (level difference [LD] 3.98), second was "anemia" (LD 1.10), followed by "number of interferon injections" (LD 0.92), "rash" (LD 0.82), "nausea and/or diarrhea" (LD 0.79), and "duration of antiviral therapy" (LD 0.78). The last position was occupied by both "tiredness/fatigue" (LD 0.31) and "headache" (LD 0.34).

CONCLUSIONS

From the patients' point of view, sustained virological response is the most essential criterion for choosing an HCV therapy. It was ranked at the highest, dominating all side effects and modes of administration. Furthermore, this study proved that patients consider both the probability of occurrence and the severity of treatment-induced side effects. Results clearly point to valuation of probabilities that is separate from that of severity.

Comparison of Value Set Based on DCE and/or TTO Data: Scoring for EQ-5D-5L Health States in Japan

BACKGROUND

The valuation study of the five-level version of the EuroQol five-dimensional questionnaire (EQ-5D-5L) involved composite time trade-off (cTTO) and a discrete choice experiment (DCE). The DCE scores must be anchored to the quality-of-life scale from 0 (death) to 1 (full health). Nevertheless, the characteristics of the statistical methods used for converting the EQ-5D-5L DCE results by using TTO information are not yet clearly known.

OBJECTIVES

To present the Japanese DCE value set of the EQ-5D-5L and compare three methods for converting latent DCE values.

METHODS

The survey sampled the general population at five locations in Japan. 1098 respondents were stratified by age and sex. To obtain and compare the value sets of the EQ-5D-5L, the cTTO and DCE data were analyzed by a linear mixed model and conditional logit, respectively. The DCE scores were converted to the quality-of-life scale by anchoring to the worst state using cTTO, mapping DCE onto cTTO, and a hybrid model.

RESULTS

The data from 1026 respondents were analyzed. All the coefficients in the cTTO and DCE value sets were consistent throughout all the analyses. Compared with the cTTO algorithm, the mapping and hybrid methods yielded very similar scoring coefficients. The hybrid model results, however, produced a lower root mean square error and fewer health states with errors exceeding 0.05 than did the other models. The DCE anchored to the worst state overestimated the cTTO scores of almost all the health states.

CONCLUSIONS

Japanese value sets based on DCE were demonstrated. On comparing the observed cTTO scores, we found that the hybrid model was slightly superior to the simpler methods, including the TTO model.

Eliciting willingness to pay in obstetrics: comparing a direct and an indirect valuation method for complex health outcomes

OBJECTIVE

To compare direct and indirect willingness to pay (WTP) elicitation methods in terms of feasibility, reliability, and comparability. The application is obstetrics, where always both a mother's and a child's health are at stake.

METHODS

An open-ended contingent valuation method (CVM) as a direct WTP elicitation method, and the discrete choice experiment (DCE) as an indirect WTP elicitation method. Vignettes to be valued were based on clinical patient data. Participants were 88 laypersons who received their questionnaires by postal mail.

RESULTS

The DCE task was completed faster (p=0.006) and was regarded easier (p<0.001) than the CVM task. Test-retest for CVM was substantial (ICC=0.76), and for DCE moderate (k=0.49). Female sex (p<0.001), age≥50 years (p=0.013), higher income (p<0.001), and higher education (p<0.001) were associated with higher WTP. Correlation between CVM and DCE was 0.79 (Kendall's Tau-b; p<0.001). The implied WTP as derived with DCE was between 2.3 and 10.2 times higher than with CVM. The relationship between the WTPs was linear.

CONCLUSION

It is yet unclear what lies behind the numbers of DCE. DCE has no methodological benefits over the conventional CVM when eliciting WTP for complex health outcomes in obstetrics.

A discrete choice experiment evaluation of patients' preferences for different risk, benefit, and delivery attributes of insulin therapy for diabetes management

OBJECTIVE

To evaluate patients' preferences for various attributes of insulin treatment, including route of insulin delivery.

METHODS

We used a discrete choice experiment (DCE) to quantify patients' preferences. The attributes (and levels) included in the DCE questionnaire were: glucose control, frequency of hypoglycemic events, weight gain, route of administration for the long-acting and the short-acting insulin, and out-of-pocket cost. Data were analyzed using conditional logit regression and segmented models were also developed to evaluate differences in preferences between subgroups.

RESULTS

Two hundred and seventy-four questionnaires were completed. The mean age (SD) of participants was 56.7 (12.9) years. Forty-nine percent of participants were insulin users, and 17% had type 1 diabetes. Overall, patients' ideal insulin treatment would provide better glucose control, result in fewer adverse reactions, have the lowest cost, and be administered orally. Overall, there was a strong positive preference for better glucose control relative to the other attributes. Segmented analyses by insulin use and type of diabetes suggest that there may be an important psychosocial barrier to initiating insulin therapy but that patients tend to adjust to subcutaneous administration once they initiate therapy.

CONCLUSIONS

This study illustrates the importance that patients with diabetes place on glucose control and how preferences for insulin therapy differ between subgroups. Specifically, efforts need to be made to overcome the psychosocial barriers to initiating insulin therapy which may lead to improved control through improved treatment acceptance and ultimately improve patients' quality of life and reduce the economic burden of the disease.