The direct and spillover effects of diabetes diagnosis on lifestyle behaviours

Using blood sample data we exploit an arbitrary cut-off of diabetes risk and through a fuzzy regression kink design we estimate the effect of a diabetes diagnosis on own and partner health-related behaviours. Diabetes diagnosis increases the probability of exercising, both for those diagnosed with diabetes and their partner. We also conduct mediation analysis which suggests that joint household participation is the channel behind this effect. Our results have significant implications for the understanding of the channels that induce behavioural change, and household decision making, as well as, for the evaluation of diabetes related policies

Exploring Different Assumptions about Outcome-Related Risk Perceptions in Discrete Choice Experiments

Environmental outcomes are often affected by the stochastic nature of the environment and ecosystem, as well as the effectiveness of governmental policy in combination with human activities. Incorporating information about risk in discrete choice experiments has been suggested to enhance survey credibility. Although some studies have incorporated risk in the design and treated it as either the weights of the corresponding environmental outcomes or as a stand-alone factor, little research has discussed the implications of those behavioural assumptions under risk and explored individuals’ outcome-related risk perceptions in a context where environmental outcomes can be either described as improvement or deterioration. This paper investigates outcome-related risk perceptions for environmental outcomes in the gain and loss domains together and examines differences in choices about air quality changes in China using a discrete choice experiment. Results suggest that respondents consider the information of risk in both domains, and their elicited behavioural patterns are best described by direct risk aversion, which states that individuals obtain disutility directly from the increasing risk regardless of the associated environmental outcomes. We discuss the implication of our results and provide recommendations on the choice of model specification when incorporating risk

Cigarette packaging, warnings, prices, and contraband: A discrete choice experiment among smokers in Ontario, Canada

In Canada, despite substantial decline, tobacco use remains the leading risk factor responsible for mortality and morbidity. There is overwhelming evidence that higher tobacco taxes reduce tobacco use, even if high taxes create an incentive to avoid or evade tobacco taxes. Recently, in addition to taxes, plain and standardized packaging and printing a warning on each cigarette have been lauded to reduce tobacco use. In November 2019, Canada became the country with the most comprehensive cigarette packaging regulations; and in June 2022, Canada proposed to print health warnings on individual cigarettes, the first jurisdiction to ever do so. The regulations came into force on August 1, 2023, and are being implemented through a stepwise approach. Our objective was to examine the effects of plain and standardized packaging, warning on cigarettes, price, and the availability of illicit cigarettes on intention to purchase and risk perceptions. We conducted a discrete choice experiment, and examined heterogeneity in preferences using latent class models among smokers in Ontario, Canada. We found that using latent class analyses was essential in quantifying preferences for attributes of cigarettes and cigarette packs. First, nearly half of smokers stated a preference for cheaper illicit cigarettes in a branded pack without any health warnings, regardless of the licit cigarette alternatives. For about 20% of respondents, plain packaging and especially warning on cigarette sticks decreased the probability of stating a purchasing preference for these alternatives. Third, about a third of respondents chose competing alternatives with mostly one attribute in mind, price. Lastly, none of the products and attributes seem to have significantly influenced risk perception. Our findings attest to the importance of prices and taxes, to the potential of warnings on cigarette sticks to control tobacco use, and indicate that efforts to restrict the availability of illicit cigarettes may yield substantial benefits

Automated analysis of free-text comments and dashboard representations in patient experience surveys: a multimethod co-design study

BACKGROUND: Patient experience surveys (PESs) often include informative free-text comments, but with no way of systematically, efficiently and usefully analysing and reporting these. The National Cancer Patient Experience Survey (CPES), used to model the approach reported here, generates > 70,000 free-text comments annually. MAIN AIM: To improve the use and usefulness of PES free-text comments in driving health service changes that improve the patient experience. SECONDARY AIMS: (1) To structure CPES free-text comments using rule-based information retrieval (IR) (‘text engineering’), drawing on health-care domain-specific gazetteers of terms, with in-built transferability to other surveys and conditions; (2) to display the results usefully for health-care professionals, in a digital toolkit dashboard display that drills down to the original free text; (3) to explore the usefulness of interdisciplinary mixed stakeholder co-design and consensus-forming approaches in technology development, ensuring that outputs have meaning for all; and (4) to explore the usefulness of Normalisation Process Theory (NPT) in structuring outputs for implementation and sustainability. DESIGN: A scoping review, rapid review and surveys with stakeholders in health care (patients, carers, health-care providers, commissioners, policy-makers and charities) explored clinical dashboard design/patient experience themes. The findings informed the rules for the draft rule-based IR [developed using half of the 2013 Wales CPES (WCPES) data set] and prototype toolkit dashboards summarising PES data. These were refined following mixed stakeholder, concept-mapping workshops and interviews, which were structured to enable consensus-forming ‘co-design’ work. IR validation used the second half of the WCPES, with comparison against its manual analysis; transferability was tested using further health-care data sets. A discrete choice experiment (DCE) explored which toolkit features were preferred by health-care professionals, with a simple cost–benefit analysis. Structured walk-throughs with NHS managers in Wessex, London and Leeds explored usability and general implementation into practice. KEY OUTCOMES: A taxonomy of ranked PES themes, a checklist of key features recommended for digital clinical toolkits, rule-based IR validation and transferability scores, usability, and goal-oriented, cost–benefit and marketability results. The secondary outputs were a survey, scoping and rapid review findings, and concordance and discordance between stakeholders and methods. RESULTS: (1) The surveys, rapid review and workshops showed that stakeholders differed in their understandings of the patient experience and priorities for change, but that they reached consensus on a shortlist of 19 themes; six were considered to be core; (2) the scoping review and one survey explored the clinical toolkit design, emphasising that such toolkits should be quick and easy to use, and embedded in workflows; the workshop discussions, the DCE and the walk-throughs confirmed this and foregrounded other features to form the toolkit design checklist; and (3) the rule-based IR, developed using noun and verb phrases and lookup gazetteers, was 86% accurate on the WCPES, but needs modification to improve this and to be accurate with other data sets. The DCE and the walk-through suggest that the toolkit would be well accepted, with a favourable cost–benefit ratio, if implemented into practice with appropriate infrastructure support. LIMITATIONS: Small participant numbers and sampling bias across component studies. The scoping review studies mostly used top-down approaches and focused on professional dashboards. The rapid review of themes had limited scope, with no second reviewer. The IR needs further refinement, especially for transferability. New governance restrictions further limit immediate use. CONCLUSIONS: Using a multidisciplinary, mixed stakeholder, use of co-design, proof of concept was shown for an automated display of patient experience free-text comments in a way that could drive health-care improvements in real time. The approach is easily modified for transferable application. FUTURE WORK: Further exploration is needed of implementation into practice, transferable uses and technology development co-design approaches. FUNDING: The National Institute for Health Research Health Services and Delivery Research programme

The economic and health impact of rare diseases: A meta-analysis

Objective: Lack of medical and scientific knowledge on rare diseases (RD) often translates into limited research on them and a subsequent lack of understanding of their economic impact. This meta-analysis aims to fill this gap by evaluating the economic impact of RDs and exploring potential factors associated with the societal burden of RD. Methods: Studies published between January 2010 and February 2017 were identified by searches in the PubMed platform. Thirty eligible studies were identified for inclusion, and nineteen studies were included in the meta-analysis and outcomes were explored. The cost categories include direct healthcare costs, direct non-healthcare formal costs, and direct non-healthcare informal costs. The patients’ health-related quality of life (QoL) dimensions examined include EQ-5D scores, VAS scores and Barthel index, and the carers’ utility outcomes include EQ-5d scores, VAS scores and Zarit scale. Random effects meta-regression models were used for modelling the impact of study and societal characteristics on cost. Results: Across all RDs, mean direct healthcare (DH) costs ($16,513) account for the majority of direct costs (mainly driven by drug costs), followed by mean direct healthcare informal (€15,557) and mean direct healthcare formal (€4,579) costs. Body system affected by the RD, Gross Domestic Product (GDP) per capita and public health expenditure in country of study were the most significant determinants in predicting cost. In regards to QoL outcomes, patients with musculoskeletal diseases seem to have the lowest quality of life across EQ-5D scores, VAS scores and Barthel index. The burden on caregivers seemed to be associated with Autoimmune, followed by Musculoskeletal and Respiratory conditions. Conclusions: This meta-analysis highlights the significant burden of RDs on the health care system and explicitly provides evidence for the magnitude of this impact. Such estimates are necessary to further the debate on priority setting around RDs and their comparison with other chronic diseases. Nevertheless, the large degree of cost variability across RDs might suggest that the use of umbrella terms to raise awareness around RDs’ societal impact might not be warranted

Discrete choice experiment exploring women's preferences in a novel device designed to monitor the womb environment and improve our understanding of reproductive disorders

Objectives: The study aims to determine the relative importance of key attributes of a novel intrauterine device. The device monitors uterine oxygen, pH and temperature in real time with the aim of improving our understanding and treatment of reproductive disorders. Design: A discrete choice experiment was used to elicit preferences in this novel investigative tool. The attributes and levels used in the choice scenarios were length of time using the device (7, 14 or 28 days), information obtained to guide treatment (limited, majority or all cases), risk of complications (1% or 10%) and discreteness (completely discrete, moderately discrete or indiscrete). Setting: Secondary care hospital in Hampshire, UK. Participants: 361 women of reproductive age. Primary and secondary outcome measures: Conditional logit and latent class logit regression models to determine the preference for each attribute. Results: Conditional logit coefficients allow comparison between attributes; women placed most importance on obtaining information to guide treatment in all cases (2.771), followed by having a completely discrete device (1.104), reducing risk of complications by 1% (0.184) and decreased length of time by 1 day (0.0150). All coefficients p<0.01. Latent class conditional logit assigns participants to two classes with 27.4% in class 1 who are less likely to have higher education or qualify for National Health Service-funded in vitro fertilisation compared with class 2. Those in class 2 placed 1.7 times more importance on a device whose information guided treatment in all cases and a 1% decrease in complications risk was nearly 15 times more attractive. Conclusions: Women placed most importance on having a device that obtains information to guide treatment and are willing to use the device for a longer, have a device with higher risk of complications and an indiscrete device if it is able to provide answers and direction for treatment of their reproductive disorder

Priority setting in the German healthcare system: results from a discrete choice experiment

Worldwide, social healthcare systems must face the challenges of a growing scarcity of resources and of its inevitable distributional effects. Explicit criteria are needed to define the boundaries of public reimbursement decisions. As Germany stands at the beginning of such a discussion, more formalised priority setting procedures seem in order. Recent research identified multi-criteria decision analysis (MCDA) as a promising approach to inform and to guide decision-making in healthcare systems. In that regard, this paper aims to analyse the relative weight assigned to various criteria in setting priority interventions in Germany. A discrete choice experiment (DCE) was employed in 2015 to elicit equity and efficiency preferences of 263 decision makers, through six attributes. The experiment allowed us to rate different policy interventions based on their features in a composite league table (CLT). As number of potential beneficiaries, severity of disease, individual health benefits and cost-effectiveness are the most relevant criteria for German decision makers within the sample population, the results display an overall higher preference towards efficiency criteria. Specific high priority interventions are mental disorders and cardiovascular diseases

Adjusting the risk-adjustment: accounting for variation between organisations in the responsiveness of their expenditure to need

There is concern that basing healthcare budgets on risk adjustment estimates derived from historical utilisation data may reinforce patterns of unmet need. We propose a method to avoid this, based on a measure of how closely local health organisations align resources to the needs of their populations. We refer to this measure as the ‘responsiveness of expenditure to need’ and estimate it using national person-level data on use of acute hospital and secondary mental health services in England. We find large variation in responsiveness in both services and show that higher expenditure responsiveness in mental health is associated with fewer suicides. We then re-estimate the national risk-adjustment model removing the data from the organisations with the lowest expenditure responsiveness to need. As expected, higher need individuals are estimated to have higher expenditure needs when less responsive organisations are removed from the estimation of the risk-adjustment. Removal of organisations with below-average responsiveness results in the neediest deciles of individuals having an extra £163 (7%) annual need for acute hospital care and an additional £79 (27%) annual need for mental health services. The application of this approach to risk adjustment would result in more resources being directed towards organisations serving higher-need populations

Patient preferences and willingness-to-pay for a home or clinic based program of chronic heart failure management: findings from the which? trial

BACKGROUND Beyond examining their overall cost-effectiveness and mechanisms of effect, it is important to understand patient preferences for the delivery of different modes of chronic heart failure management programs (CHF-MPs). We elicited patient preferences around the characteristics and willingness-to-pay (WTP) for a clinic or home-based CHF-MP. METHODOLOGY/PRINCIPAL FINDINGS A Discrete Choice Experiment was completed by a sub-set of patients (n = 91) enrolled in the WHICH? trial comparing home versus clinic-based CHF-MP. Participants provided 5 choices between hypothetical clinic and home-based programs varying by frequency of nurse consultations, nurse continuity, patient costs, and availability of telephone or education support. Participants (aged 71±13 yrs, 72.5% male, 25.3% NYHA class III/IV) displayed two distinct preference classes. A latent class model of the choice data indicated 56% of participants preferred clinic delivery, access to group CHF education classes, and lower cost programs (p<0.05). The remainder preferred home-based CHF-MPs, monthly rather than weekly visits, and access to a phone advice service (p<0.05). Continuity of nurse contact was consistently important. No significant association was observed between program preference and participant allocation in the parent trial. WTP was estimated from the model and a dichotomous bidding technique. For those preferring clinic, estimated WTP was ≈AU$9-20 per visit; however for those preferring home-based programs, WTP varied widely (AU$15-105). CONCLUSIONS/SIGNIFICANCE Patient preferences for CHF-MPs were dichotomised between a home-based model which is more likely to suit older patients, those who live alone, and those with a lower household income; and a clinic-based model which is more likely to suit those who are more socially active and wealthier. To optimise the delivery of CHF-MPs, health care services should consider their patients’ preferences when designing CHF-MPs.Jennifer A. Whitty, Simon Stewart, Melinda J. Carrington, Alicia Calderone, Thomas Marwick, John D. Horowitz, Henry Krum, Patricia M. Davidson, Peter S. Macdonald, Christopher Reid, Paul A. Scuffha

Exploring the feasibility of Conjoint Analysis as a tool for prioritizing innovations for implementation

Background: In an era of scarce and competing priorities for implementation, choosing what to implement is a key decision point for many behavioural change projects. The values and attitudes of the professionals and managers involved inevitably impact the priority attached to decision options. Reliably capturing such values is challenging. Methods: This paper presents an approach for capturing and incorporating professional values into the prioritization of healthcare innovations being considered for adoption. Conjoint Analysis (CA) was used in a single UK Primary Care Trust to measure the priorities of healthcare professionals working with women with postnatal depression. Rating-based CA data was gathered using a questionnaire and then mapped onto 12 interventions being considered as a means of improving the management of postnatal depression. Results: The ‘impact on patient care’ and the ‘quality of supporting evidence’ associated with the potential innovations were the most influential in shaping priorities. Professionals were least influenced by whether an innovation was an existing national or local priority, or whether current practice in the Trust was meeting minimum standards. Ranking the 12 innovations by the preferences of potential adopters revealed ‘guided self help’ was the top priority for implementation and ‘screening questions for post natal depression’ the least. When other factors were considered (such as the presence of routine data or planned implementation activity elsewhere in the Trust), the project team chose to combine the eight related treatments and implement these as a single innovation referred to as ‘psychological therapies’. Conclusions: Using Conjoint Analysis to prioritise potential innovation implementation options is a feasible means of capturing the utility of stakeholders and thus increasing the chances of an innovation being adopted. There are some practical barriers to overcome such as increasing response rates to conjoint surveys before routine and unevaluated use of this technique should be considered