Measuring Patient Preferences for Colorectal Cancer Screening Using a Choice-Format Survey

OBJECTIVE: Colorectal cancer (CRC) screening uptake remains poor. Until we understand patient motivation and preferences for undertaking screening, it is unlikely the uptake will be optimal. Our objective is to examine patient preferences for CRC screening modalities and uptake rates using utility-based methods. METHODS: The preference survey was mailed to a random sample of Canadian subjects aged 40 to 60 years from a primary care network. A fractional factorial experimental design maximized D-efficiency and included four blocks with 12 choice tasks in a conditional two-step design, two-alternative discrete choice format with five screening attributes (process, pain, preparation, sensitivity, and specificity). Bivariate probit regression analysis was used to estimate patient preferences for attributes, choice probabilities for alternative modalities and expected rates of uptake. RESULTS: Five hundred forty-seven of 1047 surveys were returned. Almost 30% of respondents preferred no screening. The most preferred test attribute levels were noninvasive process (e.g., CT), no preparation, no pain, 100% specificity, and 90% sensitivity. Accuracy-related attributes were more important than test process-related attributes. Virtual colonoscopy was the most preferred, followed by colonoscopy, barium enema, sigmoidoscopy, and fecal DNA testing, based on simulated choice probability estimates. Fecal occult blood testing (FOBT) was least preferred. Adjusted screening uptake rate estimates showed the greatest impact (42% increase) would be achieved if all CRC screening modalities were available rather than FOBT alone. CONCLUSIONS: Our findings emphasize the important role of patient preferences for no screening and in selecting alternative CRC screening modalities. CRC screening implementation in Canada should consider patient preferences to optimize uptake.     

Estimating the Danish Populations' Preferences for Pharmacogenetic Testing Using a Discrete Choice Experiment. The Case of Treating Depression

Objective:  The objective is to estimate willingness-to-pay (WTP) for pharmacogenetic testing in the treatment of depression.
Methods:  In a web-based discrete choice questionnaire, four attributes were included: 1) number of changes in antidepressants before symptom relief; 2) time with dosage adjustments due to adverse side effects and/or lack of effects; 3) cost of pharmacogenetic testing; 4) probability of benefits from pharmacogenetic testing. Respondents were asked to choose between two scenarios; 1) pharmacogenetic testing; and 2) an opt-out option reflecting a scenario without pharmacogenetic testing. The indirect utility model was assumed to be multiplicative in probability of benefits and reduced time with dosage adjustments as well as reduced number of antidepressant changes.
Results:  Most coefficients had the expected signs and were statistically significant. WTP for avoidance of one change in antidepressant medication is 1571 Danish Krone (DKK), whereas WTP for reducing the period with dosage-adjustments by 1 month is DKK604. Both were statistically significantly different from zero.
Conclusion:  If diagnosed with depression, peoples' WTP for pharmacogenetic testing appears to exceed its price as long as there is a reasonable probability for improvements in treatment (in the present case 10%). Utility is associated with outcomes only. Hence, other modes of provision of similar improvements in treatment may be valued equally highly. WTP estimates and the associated policy implications appear to be robust because they were unaffected by estimation model.     

Heterogeneous Patient Preferences for Modern Antiretroviral Therapy: Results of a Discrete Choice Experiment

ObjectiveLimited data describe patient preferences for the growing number of antiretroviral therapies (ARTs). We quantified preferences for key characteristics of modern ART deemed relevant to shared decision making.MethodsA discrete choice experiment survey elicited preferences for ART characteristics, including dosing (frequency and number of pills), administration characteristics (pill size and meal requirement), most bothersome side effect (from diarrhea, sleep disturbance, headaches, dizziness/difficulty thinking, depression, or jaundice), and most bothersome long-term effect (from increased risk of heart attacks, bone fractures, renal dysfunction, hypercholesterolemia, or hyperglycemia). Between March and August 2017, the discrete choice experiment was fielded to 403 treatment-experienced persons living with human immunodeficiency virus (HIV), enrolled from 2 infectious diseases clinics in the southern United States and a national online panel. Participants completed 16 choice tasks, each comparing 3 treatment options. Preferences were analyzed using mixed and latent class logit models.ResultsMost participants were male (68%) and older (interquartile range: 42-58 years), and had substantial treatment experience (interquartile range: 7-21 years). In mixed logit analyses, all attributes were associated with preferences. Side and long-term effects were most important, with evidence of substantial preference heterogeneity. Latent class analysis identified 5 preference classes. For classes 1 (40%), 2 (24%), and 3 (21%), side effects were most important, followed by long-term effects. For class 4 (10%), dosing was most important. Class 5 (4%) was largely indifferent to ART characteristics.ConclusionOverall, treatment-experienced persons living with HIV valued minimizing side effects and long-term toxicities over dosing and administration characteristics. Preferences varied widely, highlighting the need to elicit individual patient preferences in models of shared antiretroviral decision making.     

Patient Preferences for Medications in Managing Type 2 Diabetes Mellitus: A Discrete Choice Experiment

ObjectivesTo quantify patients’ maximum acceptable risk (MAR) of urinary and genital tract infections (UGTI) in exchange for benefits associated with treatments for managing type 2 diabetes mellitus (T2DM).MethodsIn a discrete choice experiment, adult patients with T2DM and currently on metformin and/or sulphonylurea (first-line treatments) were asked to choose between 2 hypothetical medications defined by 6 attributes: years of medication effectiveness in controlling blood glucose, weight reduction, UGTI risk, risk of hospitalization from heart failure, all-cause mortality risk, and out-of-pocket medication cost. We used latent class logistic regression parameters to estimate the conditional relative importance of treatment attributes and MAR of UGTI for various treatment benefits.ResultsA 2-class latent class model was identified as the best fit for the responses from 147 patients. The first class (49% of sample), termed as “survival-conscious,” stated that they were willing to accept 46% (95% confidence interval [CI]: 2%-90%) UGTI risk in exchange for a reduction from 6% to 1% in all-cause mortality risk. The second class (51% of sample), termed as “UGTI/cost-conscious” were willing to accept significantly lower (6%; CI: 2%-11%, and 5%; CI: 2%-8%) UGTI risk in exchange for the same reduction in all-cause mortality and hospitalization risks, respectively.ConclusionsOn average, patients were willing to trade higher UGTI risk for a more effective medication. Our findings suggest that physicians should present the benefits and potential side effects of all available treatments and consider patient preferences in their treatment recommendations.     

Preferences for Depression Advice Among Low-Income Women

Maternal and Child Health Journal - Objectives: Because patient reluctance to discuss depression may influence the success of depression interventions, we assessed preferences for the source of...     

Heterogeneous Preferences for Colorectal Cancer Screening in Germany: Results of a Discrete Choice Experiment

ObjectivesColorectal cancer (CRC) screening tests differ in benefits, harms, and processes, making individual informed decisions preference based. The objective was to analyze the preferences of insurees in Germany for characteristics of CRC screening modalities.MethodsA generic discrete choice experiment with 2-alternative choice sets and 6 attributes (CRC mortality, CRC incidence, complications, preparation, need for transportation, and follow-up; 3 levels each) depicting characteristics of fecal testing, sigmoidoscopy, and colonoscopy was generated. Participants completed 8 choice tasks. Internal validity was tested using a within-set dominated pair. Between June and October 2020, written questionnaires were sent to a stratified random sample (n = 5000) of 50-, 55-, and 60-year-old insurees of the AOK (Allgemeine Ortskrankenkasse) Lower Saxony, who had previously received an invitation to participate in the organized screening program including evidence-based information. Preferences were analyzed using conditional logit, mixed logit, and latent-class model.ResultsFrom 1282 questionnaires received (26% [1282 of 4945]), 1142 were included in the analysis. Approximately 42% of the respondents chose the dominated alternative in the internal validity test. Three heterogeneous preference classes were identified. Most important attributes were preparation (class 1; n = 505, 44%), CRC mortality (class 2; n = 347, 30%), and CRC incidence (class 3; n = 290, 25%). Contrary to a priori expectations, a higher effort was preferred for bowel cleansing (class 1) and accompaniment home (classes 1 and 2).ConclusionInternal validity issues of choice data need further research and warrant attention in future discrete choice experiment surveys. The observed preference heterogeneity suggests different informational needs, although the underlying reasons remained unclear.     

Current Health State Affected Patient Preferences More Than Disease Status: A Discrete Choice Experiment in Multiple Myeloma

ObjectivesTo examine how disease status and current health state influence treatment preferences of patients with multiple myeloma (MM).MethodsParticipants with MM from France, Germany, and the United Kingdom completed a web-based survey that included a discrete choice experiment (DCE) and EQ-5D assessment. The DCE elicited preferences for 8 attributes: increased life expectancy, increased time to relapse, pain, fatigue, risk of infection, administration (route and duration), frequency of administration, and monitoring. Multinomial logit models were used to analyze DCE preference data and to calculate life expectancy trade-offs.ResultsThree hundred participants with MM (newly diagnosed, transplant eligible, n = 108; newly diagnosed, transplant ineligible, n = 105; relapsed-refractory, n = 87) completed the survey. The most valued attributes were pain, fatigue, and increased life expectancy. Participants would want an additional 2.7 years of life expectancy (95% confidence interval [CI] 2.4-3.1 years) to tolerate extreme pain and an additional 2.0 years of life expectancy (95% CI 1.6-2.3 years) to tolerate constant fatigue. Participants in a better health state (third EQ-5D score quartile [0.897]) required less additional life expectancy than participants with a worse health state (first EQ-5D score quartile [0.662]) to tolerate extreme pain (2.3 years [95% CI 1.9-2.6 years] vs 3.0 years [95% CI 2.6-3.4 years]; P = .007). There was little difference in treatment preferences between newly diagnosed and relapsed-refractory patients for pain, fatigue, and increased life expectancy.ConclusionsCurrent health state influenced treatment preferences of patients with MM more than disease status and should be considered when making treatment decisions.     

Preferences for e-Mental Health Interventions in Germany: A Discrete Choice Experiment

ObjectivesRecent evidence suggests that e-mental health interventions can be effective at improving mental health but that there is still a notable hesitation among patients to use them. Previous research has revealed that they are perceived by patients as being less helpful than face-to-face psychotherapy. The reasons for this unfavorable perception are, however, not yet well understood. The aim of our study was to address this question by eliciting preferences for individual components of e-mental health interventions in a discrete choice experiment.MethodsUsing a stepwise qualitative approach, we developed the following 5 attributes of eMHIs: introductory training, human contact, peer support, proven effectiveness, content delivery, and price. Additionally, we asked questions about respondents’ demographics, attitudes, and previous experience of traditional psychotherapy, as well as their distress level.ResultsA total of 1984 respondents completed the survey. Using mixed logit models, we found that personal contact with a psychotherapist in blended care, proven effectiveness, and low price were highly valued by participants. Participants were indifferent toward the mode of content delivery but showed a slight preference for introductory training via phone, as well as for peer support via online forum alongside coach-led group meetings on site.DiscussionOur results suggest a clear preference for blended care that includes face-to-face contact with a psychotherapist. This preference remained stable irrespective of sociodemographics, previous experience of psychotherapy, distress level, and the 2 context scenarios used in our discrete choice experiment. Further investigations looking at the potential benefits and risks of blended care are needed.     

Reporting Quality of Marginal Rates of Substitution in Discrete Choice Experiments That Elicit Patient Preferences

BackgroundDiscrete choice experiments (DCEs) are commonly used to elicit patient preferences as marginal rates of substitution (MRSs) between treatment or health service attributes. Because these studies are increasing in importance, it is vital that uncertainty around MRS estimates is reported.ObjectiveTo review recently published DCE studies that elicit patient preferences in relation to MRS reporting and to explore the accuracy of using other reported information to estimate the uncertainty of the MRSs.MethodsA systematic literature review of DCEs conducted with patients between 2014 and July 2019 was performed. The number of studies reporting coefficients, MRSs, standard errors (SEs), and confidence intervals was recorded. If all information was reported, studies were included in an analysis to determine the impact of estimating the SEs of MRSs using coefficients and assuming zero covariance, to determine the impact of this assumption.ResultsTwo hundred and thirty-two patient DCEs were identified in the review; 34.1% (n = 79) reported 1 or more MRS and, of these, only 62.0% (n = 49) provided an estimate of the uncertainty. Of these studies, 16 contained enough information for inclusion in the analysis, providing 116 datapoints. Actual SEs were smaller than estimated SEs in 75.0% of cases (n = 87), and estimated SEs were within 25% of the actual SE in 59.5% of cases (n = 69).ConclusionUncertainty of MRS estimates is unreported in a substantial proportion of recently published DCE studies. Estimating the SE of a MRS by solely using the SEs of the utility coefficients is likely to lead to biased estimates of the precision of patient trade-offs.     

A Discrete Choice Experiment to Elicit General Population Preferences Around the Factors Influencing the Choice to Make Clinical Negligence Claims

ObjectivesThis article determines public stated preferences around different factors that influence the choice to make clinical negligence claims against a national healthcare system.MethodsA large online survey was conducted using a discrete choice experiment (DCE) with the UK general population (N = 1013). DCE tasks involved a single profile and participants chose whether to make a claim for compensation (yes/no) after one of 3 randomly allocated patient safety incident (PSI) “scenarios” of different severities (mild, moderate, severe). DCE attributes described the actions of the healthcare system after a PSI and characteristics of the clinical negligence claims process. The data were modeled separately for each scenario (mild, moderate, severe) using logistic regression. Marginal effects and the probability of making a claim in a baseline case were estimated.ResultsProbability of choosing to claim was reduced by receipt of an apology, investigation and prevention of recurrence of the PSI, and longer time until claim decision and increased by an easy and straightforward claims process and high chance of compensation and for the mild scenario higher compensation amounts. Marginal effects and baseline case probabilities differed by scenario severity.ConclusionsThe results suggest the actions of the healthcare system after a PSI and characteristics of the claims process have a larger impact on the probability of making a claim for milder PSIs. For more severe PSIs, a larger probability of making a claim was observed, and the choice was less influenced by the actions of the healthcare system after the PSI and characteristics of the claims process.     

Measuring Preferences for a Diabetes Pay-for-Performance for Patient (P4P4P) Program using a Discrete Choice Experiment

ObjectiveTo elicit a patient’s willingness to participate in a diabetes pay-for-performance for patient (P4P4P) program using a discrete choice experiment method.MethodsThe survey was conducted in March 2013. Our sample was drawn from patients with diabetes at five hospitals in Taiwan (International Classification of Diseases, Ninth Revision, Clinical Modification code 250). The sample size was 838 patients. The discrete choice experiment questionnaire included the attributes monthly cash rewards, exercise time, diet control, and program duration. We estimated a bivariate probit model to derive willingness-to-accept levels after accounting for the characteristics (e.g., severity and comorbidity) of patients with diabetes.ResultsThe preferred program was a 3-year program involving 30 minutes of exercise per day and flexible diet control. Offering an incentive of approximately US $67 in cash per month appears to increase the likelihood that patients with diabetes will participate in the preferred P4P4P program by approximately 50%.ConclusionsPatients with more disadvantageous characteristics (e.g., elderly, low income, greater comorbidity, and severity) could have less to gain from participating in the program and thus require a higher monetary incentive to compensate for the disutility caused by participating in the program’s activities. Our result demonstrates that a modest financial incentive could increase the likelihood of program participation after accounting for the attributes of the P4P4P program and patients’ characteristics.     

Societal Preferences for Funding Orphan Drugs in the United Kingdom: An Application of Person Trade-Off and Discrete Choice Experiment Methods

Background

It is unclear whether UK National Health Service (NHS) policies for orphan drugs, which permit funding of non–cost-effective treatments, reflect societal preferences.

The Internal Validity of Discrete Choice Experiment Data: A Testing Tool for Quantitative Assessments

Objectives

To develop a tool for testing internal validity of discrete choice experiment (DCE) data, deploy the program, and collect summary test results from a sample of active health researchers to demonstrate the practical utility of the tool in a wide range of health applications.

Conducting a Discrete-Choice Experiment Study Following Recommendations for Good Research Practices: An Application for Eliciting Patient Preferences for Diabetes Treatments

Objectives

To consolidate and illustrate good research practices in health care to the application and reporting of a study measuring patient preferences for type 2 diabetes mellitus medications, given recent methodological advances in stated-preference methods.

Preferences for Attributes of Initial COVID-19 Diagnosis in the United States and China During the Pandemic: Discrete Choice Experiment With Propensity Score Matching

BackgroundChina and the United States play critical leading roles in the global effort to contain the COVID-19 virus. Therefore, their population’s preferences for initial diagnosis were compared to provide policy and clinical insights.ObjectiveWe aim to quantify and compare the public’s preferences for medical management of fever and the attributes of initial diagnosis in the case of presenting symptoms during the COVID-19 pandemic in China and the United States.MethodsWe conducted a cross-sectional study from January to March 2021 in China and the United States using an online discrete choice experiment (DCE) questionnaire distributed through Amazon Mechanical Turk (MTurk; in the United States) and recruited volunteers (in China). Propensity score matching (PSM) was used to match the 2 groups of respondents from China and the United States to minimize confounding effects. In addition, the respondents’ preferences for different diagnosis options were evaluated using a mixed logit model (MXL) and latent class models (LCMs). Moreover, demographic data were collected and compared using the chi-square test, Fisher test, and Mann-Whitney U test.ResultsA total of 9112 respondents (5411, 59.4%, from China and 3701, 40.6%, from the United States) who completed our survey were included in our analysis. After PSM, 1240 (22.9%) respondents from China and 1240 (33.5%) from the United States were matched for sex, age, educational level, occupation, and annual salary levels. The segmented sizes of 3 classes of respondents from China were 870 (70.2%), 270 (21.8%), and 100 (8.0%), respectively. Meanwhile, the US respondents’ segmented sizes were 269 (21.7%), 139 (11.2%), and 832 (67.1%), respectively. Respondents from China attached the greatest importance to the type of medical institution (weighted importance=40.0%), while those from the United States valued the waiting time (weighted importance=31.5%) the most. Respondents from China preferred the emergency department (coefficient=0.973, reference level: online consultation) and fever clinic (a special clinic for the treatment of fever patients for the prevention and control of acute infectious diseases in China; coefficient=0.974, reference level: online consultation), while those from the United States preferred private clinics (general practices; coefficient=0.543, reference level: online consultation). Additionally, shorter waiting times, COVID-19 nucleic acid testing arrangements, higher reimbursement rates, and lower costs were always preferred.ConclusionsImprovements in the availability of COVID-19 testing and medical professional skills and increased designated health care facilities may help boost potential health care seeking during COVID-19 and prevent unrecognized community spreading of SARS-CoV-2 in China and the United States. Moreover, to better prevent future waves of pandemics, identify undiagnosed patients, and encourage those undiagnosed to seek health care services to curb the pandemic, the hierarchical diagnosis and treatment system needs improvement in China, and the United States should focus on reducing diagnosis costs and raising the reimbursement rate of medical insurance.     

Patient Preferences for Minimally Invasive and Open Locoregional Treatment for Early-Stage Breast Cancer

Background

Noninvasive or minimally invasive treatments are being developed as alternatives to surgery for patients with early-stage breast cancer. Patients’ preferences with regard to these new treatments have not been investigated.

Public Preferences for Policies to Promote COVID-19 Vaccination Uptake: A Discrete Choice Experiment in The Netherlands

ObjectivesThe COVID-19 pandemic forms an unprecedented public health, economic, and social crisis. Uptake of vaccination is critical for controlling the pandemic. Nevertheless, vaccination hesitancy is considerable, requiring policies to promote uptake. We investigate Dutch citizens’ preferences for policies that aim to promote vaccination through facilitating choice of vaccination, profiling it as the norm, making vaccination more attractive through rewards, or punishing people who reject vaccination.MethodsWe conducted a discrete choice experiment in which 747 respondents were asked to choose between policies to promote vaccination uptake and their impacts on the number of deaths, people with permanent health problems, households with income loss, and a tax increase.ResultsRespondents generally had a negative preference for policies that promote vaccination. They particularly disliked policies that punish those who reject the vaccine and were more favorable toward policies that reward vaccination, such as awarding additional rights to vaccinated individuals through vaccination passports. Respondents who reject vaccination were in general much more negative about the policy options than respondents who consider accepting the vaccine. Nevertheless, vaccination passports are supported by both respondents who accept the vaccine, those who reject vaccination, and those who are unsure about vaccination.ConclusionsThis study provides concrete directions for governments attempting to increase the vaccination uptake in ways that are supported by the public. Our results could encourage policy makers to focus on policy options that make vaccination easier and reward people who take the vaccine, as especially the implementation of vaccination passports was supported.     

Mimicking Real-Life Decision Making in Health: Allowing Respondents Time to Think in a Discrete Choice Experiment

ObjectiveTo empirically test the impact of allowing respondents time to think (TTT) about their choice options on the outcomes of a discrete choice experiments (DCE).MethodsIn total, 613 participants of the Swedish CArdioPulmonary bioImage Study (SCAPIS) completed a DCE questionnaire that measured their preferences for receiving secondary findings of a genetic test. A Bayesian D-efficient design with 60 choice tasks divided over 4 questionnaires was used. Each choice task contained 2 scenarios with 4 attributes: type of disease, disease penetrance probability, preventive opportunities, and effectiveness of prevention. Respondents were randomly allocated to the TTT or no TTT (NTTT) sample. Latent class models (LCMs) were estimated to determine attribute-level values and their relative importance. In addition, choice certainty, attribute-level interpretation, choice consistency, and potential uptake rates were compared between samples.ResultsIn the TTT sample, 92% of the respondents (245 of 267) indicated they used the TTT period to (1) read the information they received (72%) and (2) discuss with their family (24%). In both samples, respondents were very certain about their choices. A 3-class LCM was fitted for both samples. Preference reversals were found for 3 of the 4 attributes in one class in the NTTT sample (34% class-membership probability). Relative importance scores of the attributes differed between the 2 samples, and significant scale effects indicating higher choice consistency in TTT sample were found.ConclusionsOffering respondents TTT influences decision making and preferences. Developers of future DCEs regarding complex health-related decisions are advised to consider this approach to enhance the validity of the elicited preferences.     

Public Attitudes on Lung Cancer Screening and Radiation Risk: A Best-Worst Experiment

ObjectivesTo measure Australian population preferences for lung cancer screening and to explore whether these preferences are related to respondent characteristics and lung cancer risk.MethodsAn online ranking task was administered to a sample of 521 Australians between the ages of 50 and 80 with a history of cigarette smoking. Choice sets contained 2 alternative lungs screens and an opt-out, and respondents were asked to rank the 3 options. Both conditional logit and mixed logit analyses were conducted exploring both the forced choice between the 2 screens and identifying the types of respondent most likely to opt out of any screening. For this, respondent 6-year lung cancer risk was estimated and used as a covariate.ResultsRespondents valued tests that involved breath or blood tests in addition to computerized tomography (CT), locations that were close to home, receiving results quickly, and minimizing radiation from the CT scan. Willingness to pay differed between relatively higher and lower risk individuals; higher risk individuals placed greater emphasis on convenience, result timeliness, and radiation. Respondent characteristics that predicted opting out of any screening included being male, fewer years of smoking, and not having a previous cancer diagnosis. Lung cancer risk did not influence the likelihood of opting out.ConclusionsUptake of lung cancer screening is likely to be changeable if different modalities of screening are provided, with effects likely differing across population subgroups.