Analyzing the determinants of willingness-to-pay values for testing the validity of the contingent valuation method. Application to home care compared to hospital care

The contingent valuation (CV) method is an attractive approach for comparing home care to hospital care in which the only difference is patients' well-being during the treatment process and not health outcomes. We considered the empirical situation of blood transfusion (BT) in cancer patients and collected willingness to pay (WTP) values among BT users. Our main objective was to test the validity of the CV method, namely its ability to elicit true preferences. Firstly, possible determinants of WTP values and their expected influences were identified, from both economic and non economic literature and from the findings of a pilot study. Secondly, they were compared to predicted influences resulting from appropriate econometric analysis of WTP values elicited by a bidding process. From the health economics literature it appeared that the double-hurdle model is the most appropriate approach to account for zero values and protest responses. However, because the number of protest responses was too small, we used a truncated regression model. None of the 7 hypothesized influences was invalidated by econometric results. The anchoring bias hypothesis was confirmed. The WTP for home BT compared to hospital BT increased with household income, with previous experience of home care, with living far from the hospital and with low quality of life. Conversely, it was lower for advanced-stage (palliative or terminal) than for early-stage (curative) patients. We conclude that the CV approach is acceptable to severely ill patients. Moreover, WTP values demonstrate good validity given that influences predicted by our model are consistent with expected determinants.contingent valuation ; validity ; protest responses ; censored data ; home care

Organisation de la transfusion Sanguine Thérapeutique : Etude des modalités alternatives de la transfusion sanguine hérapeutique organisable en ambulatoire

233pCe rapport présente les résultats d'une recherche pilote sur l'organisation d'un soin de santé, la transfusion sanguine thérapeutique. Majoritairement organisée au sein des services hospitalier, elle peut être assurer dans des conditions de sécurité satisfaisante dans des centres de santé ou à domicile avec des équipes mobile. Pourtant, les grands centres hospitaliers sont majoritaires dans sa prise en charge, malgré des demandes répétées, notamment de l'Etablissement Français du Sang, pour en développer la réalisation en dehors de l'hôpital. Nous examinons dans ce rapport les raisons de cette situation à partie d'une investigation en région Rhône Alpes

The information content of the WTP-WTA gap : An empirical analysis among severely ill patients

Large disparities between willingness to pay (WTP) and willingness-to-accept (WTA) are commonly encountered in empirical studies and raise some important controversies. Nevertheless, the relationships between WTA and WTP can help understand not only how a service is valued but also how it can be substituted or how its loss can be resisted. The purpose of this study was to examine cancer patients' preferences for blood transfusion setting from the perspective of WTA and WTP. A contingent valuation (CV) survey was administered to 139 patients receiving transfusions either at home or in the hospital. While few patients (6%) gave WTP protest responses, the WTA approach generated more protest responses (18%). The WTA-WTP discrepancy was confirmed. One in four of the patients reported that no amount was deemed sufficient to compensate for the renunciation of their home BT management. The main determinants of WTP were significantly different from WTA predictors. Our results suggest that individuals' strategies towards constructing WTP and WTA differ in terms of determinants, reasoning, use of information and economic rationality. They give empirical evidence on the usefulness to elicit both WTP and WTA responses in healthsurveys to help understand the economic evaluation of health technology assessment and care organization

Analyzing the Determinants of Willingness-to-Pay Values for Testing the Validity of the Contingent Valuation Method: Application to Home Care Compared to Hospital Care

In the small animal obstetrical practice, the elective sterilization is still the safest and most effective method of population control. This surgical procedure consists of the removal of ovaries, oviducts and uterus in the case of females and the removal of testis in males. Frequently the orchiectomy is performed for modify or eliminate undesirable behavior patterns as, for example, the aggressiveness. Objective: to monitor the postoperative period of castrated animals through an university extension project. Method: the present study evaluated 262 felines (171 females and 91 males); 58 dogs (43 females and 15 males). The 320 animals were castrated by an University Extension Project “Sterilization in Dogs and Cats” by students of the 4th year of the Veterinary Medicine Course, UNESP, Araçatuba, considering especially the low-income community. Approximately one year after the surgery, the owners of these animals were contacted by telephone and interviewed using a structured interview protocol considering the postoperative period. Results: of evaluated felines 66.4% (174/262) gained weight, 66.4% (174/262) decreased activity, 23.3% (61/262) changed the hair coat and 40.1% (105/262) were less aggressive with other animals and people. It was verified that there were no significant difference of these parameters between the sexes (p> 0,05). In relation to the behavior modifications, 39.6% (36/91) of the male cats still rambled, but 72.2% (26/36) of these animals showed less roaming behavior and 12.1% (11 cats) still manifested mating behavior. Considering the females, 8.2% (14/171) continued presenting estrus signs and 12.9% (22/171) still attracted males. In the dogs 77.6% (45/58) gained weight and 32,8% (19/58) decreased activities, 13.8% (8/58) showed modified hair coat and 32.8% (19/58) increased appetite, there were no significant difference between the sexes. Considering the male dogs, 60% (9/13) still tried to mate females and 60% (9/13) demonstrated less aggressiveness. In relation to the dogs, 7% (3/43) showed estrus behavior and 11.6% (5/43) still attracted males. In both species occurred a correlation between less activity and weight gain; and between the increased food intake and the weight gain. Our study revealed that the percentage of surgical procedure in adult animals (82.1% dogs and 83.1% in cats) were higher, nevertheless the procedure is considered safe in younger animals. The elective sterilization represents an effective aid in population control, reduces unwanted behavior patterns and does not cause any harm to the patients.En la clínica obstétrica de pequeños animales, la esterilización es tenida como el método de control de la población elegida, comprobadamente más efectivo y seguro. Este procedimiento de cirugía consiste en la retirada de los ovarios, trompas y útero en las hembras y en la extirpación de los testículos en los machos. Muchas veces la “gonadectomia” también es ejecutada con el intuito de corregir comportamientos indeseables, como, por ejemplo, la agresividad. Objetivo: monitorear el periodo pos-operatorio de animales castrados en proyectos de extensión universitaria. Método: el presente estudio evaluó 262 felinos (171 hembras y 91 machos); 58 canes (43 hembras y 15 machos). Los 320 animales fueron operados a través del proyecto de Extensión Universitaria “Esterilización de canes y gatos” por alumnos del 4° año del curso de Medicina Veterinaria, UNESP, Campus de Araçatuba, atendiendo especialmente a la población carente. Aproximadamente, un año después de la cirugía, los dueños de estos animales fueron contactados por teléfono y entrevistados conforme un cuestionario pre-establecido sobre el periodo pos-operatorio. Resultados: de los felinos evaluados 66.4% (174/262) engordaron, 66.4% (174/262) se mostraron más sedentarios, 23.3% (61/262) tuvieron cambio de pelo y 40.1% (105/262) se mostraron más dóciles (con otros animales y personas). Se verificó que no había diferencia significativa de estos parámetros entre los sexos (p>0.05). En relación a la alteración del comportamiento, 39.6% (36/91) de los gatos machos todavía deambulaban, pero 72.2% (26/36) de estos animales salían de casa con menor frecuencia y 12.1% (11 gatos) todavía intentaban aparejar las hembras. Ya entre las hembras, 8.2% (14/171) continuaron presentando señales de celo y 12.9% (22/171) todavía atraían a los machos. En los canes se observó que 77.6% (45/58) aumentaron de peso, 32.8% (19/58) se volvieron más sedentarios, 13.8% (8/58) tuvieron cambios de pelo, no habiendo diferencia significativa entre sexos. Considerando los canes machos, 60% (9/15) todavía intentaron se aparejar con las hembras y 60% (9/15) demostraron menor agresividad. En relación a las perras, 7% (3/430) presentaban señales de “estro” y 11.6% (5/43) atrajeron los machos. Ocurrió, en ambas especies, correlación entre el sedentarismo y el aumento de peso; y entre el aumento de la ingestión alimentar y el aumento de peso. Nuestro estudio reveló que la operación de animales adultos todavía presenta mayor ocurrencia (82.1% entre caninos y 83.1% en felinos) a pesar que las misma pueda ser realizada en animales jóvenes. La esterilización además de representar un método efectivo de control de la población, reduce comportamientos indeseables y no causa cualquier daño a los pacientes.Na clínica obstétrica de pequenos animais, a esterilização é tida como o método de controle populacional de eleição, comprovadamente mais efetivo e seguro. Este procedimento cirúrgico consiste na retirada dos ovários, trompas e útero no caso das fêmeas e na extirpação dos testículos, em machos. Muitas vezes a gonadectomia também é executada com o intuito de corrigir comportamentos indesejáveis, como, por exemplo, a agressividade. Objetivo: monitorar o período pós-operatório de animais castrados em projeto de extensão universitária. Método: o presente estudo avaliou 262 felinos (171 fêmeas e 91 machos); 58 cães (43 fêmeas e 15 machos). Os 320 animais foram operados pelo projeto de Extensão Universitária “Esterilização em Cães e Gatos” por alunos do 4º ano do curso de Medicina Veterinária, UNESP, Campus Araçatuba, atendendo especialmente a população carente. Aproximadamente um ano após a cirurgia, os donos destes animais foram contatados por telefone e entrevistados conforme um questionário préestabelecido sobre o período pós-operatório. Resultados: dos felinos avaliados 66,4% (174/262) engordaram, 66,4% (174/262) mostraram-se mais sedentários, 23,3% (61/262) tiveram mudança na pelagem e 40,1% (105/262) mostraram-se mais dóceis (com outros animais e pessoas). Verificou-se que não havia diferença significativa destes parâmetros entre os sexos (p> 0,05). Em relação à alteração de comportamento, 39,6% (36/91) dos gatos machos ainda perambulavam, mas 72,2% (26/36) destes animais saiam de casa com menor freqüência e 12,1% (11 gatos) ainda tentavam cobrir fêmeas. Já entre as fêmeas, 8,2% (14/171) continuaram apresentando sinais de cio e 12,9% (22/171) ainda atraíam machos. Nos cães observou-se que 77,6% (45/58) aumentaram de peso, 32,8 % (19/58) tornaram-se mais sedentários, 13,8% (8/58) tiveram mudança na pelagem, não havendo diferença significativa entre os sexos. Considerando os cães machos, 60% (9/15) ainda tentavam cobrir fêmeas e 60% (9/15) demonstraram menor agressividade. Em relação às cadelas, 7% (3/43) apresentavam sinais de estro e 11,6% (5/43) atraíam machos. Ocorreu, em ambas as espécies, correlação entre o sedentarismo e o ganho de peso; e entre o aumento na ingesta alimentar e o ganho de peso. O nosso estudo revelou que a operação de animais adultos ainda apresenta maior ocorrência (82,1% entre caninos e 83,1% em felinos) embora a mesma possa ser realizada com segurança também em animais jovens. A esterilização além de representar um método efetivo de controle populacional, reduz comportamentos indesejáveis e não causa quaisquer danos aos pacientes

Analyzing the determinants of willingness-to-pay values for testing the validity of the contingent valuation method. Application to home care compared to hospital care

Working paper GATE 08-20The contingent valuation (CV) method is an attractive approach for comparing home care to hospital care in which the only difference is patients' well-being during the treatment process and not health outcomes. We considered the empirical situation of blood transfusion (BT) in cancer patients and collected willingness to pay (WTP) values among BT users. Our main objective was to test the validity of the CV method, namely its ability to elicit true preferences. Firstly, possible determinants of WTP values and their expected influences were identified, from both economic and non economic literature and from the findings of a pilot study. Secondly, they were compared to predicted influences resulting from appropriate econometric analysis of WTP values elicited by a bidding process. From the health economics literature it appeared that the double-hurdle model is the most appropriate approach to account for zero values and protest responses. However, because the number of protest responses was too small, we used a truncated regression model. None of the 7 hypothesized influences was invalidated by econometric results. The anchoring bias hypothesis was confirmed. The WTP for home BT compared to hospital BT increased with household income, with previous experience of home care, with living far from the hospital and with low quality of life. Conversely, it was lower for advanced-stage (palliative or terminal) than for early-stage (curative) patients. We conclude that the CV approach is acceptable to severely ill patients. Moreover, WTP values demonstrate good validity given that influences predicted by our model are consistent with expected determinants

Administration des transfusions sanguines à l'hôpital ou à domicile ? Le choix des patients atteints de cancer

National audienceLa réalisation de transfusions sanguines est fréquente au cours du traitement des pathologies cancéreuses. Une anémie et/ou une thrombopénie surviennent habituellement après une chimiothérapie et/ou un envahissement médullaire et caractérisent le plus souvent un stade avancé de la maladie cancéreuse où le pronostic vital peut être engagé à court terme. La grande majorité de ces transfusions sanguines ont lieu à l'hôpital, en hospitalisation de jour principalement. Néanmoins, certains établissements de transfusion sanguine disposent de centres de soins ou d'équipes mobiles pouvant pratiquer la transfusion sanguine à domicile (TAD). Par exemple, en collaboration avec l'établissement régional de transfusion sanguine Rhône-Alpes, le Centre de Lutte Contre le Cancer de Lyon - Léon Bérard (CLB) organise depuis plusieurs années une partie des transfusions sanguines de ses patients au domicile. Ces transfusions ont été développées dans le cadre plus global d'un réseau de soins à domicile et d'une structure d'hospitalisation à domicile coordonnés par l'hôpital, et qui prennent en charge une part importante des traitements anticancéreux (chimiothérapies, alimentation parentérale, antibiothérapie, contrôle de la douleur...). Le site transfusionnel de Lyon, appartenant à l'Etablissement Français du Sang (EFS) réalise près de 800 transfusions à domicile chaque année, et deux médecins transfuseurs participent à cette activité. En pratique, les modalités d'administration de la TAD sont les suivantes : pour les patients suivis par la coordination des soins à domicile du centre, le médecin coordinateur des soins à domicile décide, sur la base des numérations sanguines, de la nécessité d'une transfusion et la prescription est alors transmise à l'antenne transfusionnelle de l'EFS. Pour certains patients transfusés fréquemment, la décision peut être prise directement par le médecin transfuseur en concertation avec la coordination.Le médecin transfuseur de l'EFS prend alors rendez-vous avec le patient. Il apporte les produits sanguins au domicile, met en place la perfusion et reste pendant tout le temps d'administration le jour de la transfusion. S'il est indépendant du centre, le médecin transfuseur est donc identifié par les patients comme un professionnel de santé avec des compétences particulières dans la transfusion, travaillant en étroite collaboration avec la coordination des soins à domicile et avec lequel ils pourront être en rapports répétés

Administration des transfusions sanguines à l'hôpital ou à domicile ? Le choix des patients atteints de cancer

La réalisation de transfusions sanguines est fréquente au cours du traitement des pathologies cancéreuses. Une anémie et/ou une thrombopénie surviennent habituellement après une chimiothérapie et/ou un envahissement médullaire et caractérisent le plus souvent un stade avancé de la maladie cancéreuse où le pronostic vital peut être engagé à court terme. La grande majorité de ces transfusions sanguines ont lieu à l'hôpital, en hospitalisation de jour principalement. Néanmoins, certains établissements de transfusion sanguine disposent de centres de soins ou d'équipes mobiles pouvant pratiquer la transfusion sanguine à domicile (TAD). Par exemple, en collaboration avec l'établissement régional de transfusion sanguine Rhône-Alpes, le Centre de Lutte Contre le Cancer de Lyon - Léon Bérard (CLB) organise depuis plusieurs années une partie des transfusions sanguines de ses patients au domicile. Ces transfusions ont été développées dans le cadre plus global d'un réseau de soins à domicile et d'une structure d'hospitalisation à domicile coordonnés par l'hôpital, et qui prennent en charge une part importante des traitements anticancéreux (chimiothérapies, alimentation parentérale, antibiothérapie, contrôle de la douleur...). Le site transfusionnel de Lyon, appartenant à l'Etablissement Français du Sang (EFS) réalise près de 800 transfusions à domicile chaque année, et deux médecins transfuseurs participent à cette activité. En pratique, les modalités d'administration de la TAD sont les suivantes : pour les patients suivis par la coordination des soins à domicile du centre, le médecin coordinateur des soins à domicile décide, sur la base des numérations sanguines, de la nécessité d'une transfusion et la prescription est alors transmise à l'antenne transfusionnelle de l'EFS. Pour certains patients transfusés fréquemment, la décision peut être prise directement par le médecin transfuseur en concertation avec la coordination.Le médecin transfuseur de l'EFS prend alors rendez-vous avec le patient. Il apporte les produits sanguins au domicile, met en place la perfusion et reste pendant tout le temps d'administration le jour de la transfusion. S'il est indépendant du centre, le médecin transfuseur est donc identifié par les patients comme un professionnel de santé avec des compétences particulières dans la transfusion, travaillant en étroite collaboration avec la coordination des soins à domicile et avec lequel ils pourront être en rapports répétés.transfusion sanguine ; choix des patients

Randomised trials comparing different healthcare settings : an exploratory review of the impact of pre-trial preferences on participation, and discussion of other methodological challenges

BACKGROUND: We recently published a systematic review of different healthcare settings (such as outpatient, community or home) for administering intravenous chemotherapy, and concluded that performing conventionally designed randomised trials was difficult. The main problems were achieving adequate trial accrual rates and recruiting a study population which adequately represented the target population of interest. These issues stemmed from the fact that potential participants may have had pre-trial perceptions about the trial settings they may be allocated; such preferences will sometimes be strong enough for patients to decline an invitation to participate in a trial. A patient preference trial design (in which patients can choose, or be randomised to, an intervention) may have obviated these recruitment issues, although none of the trials used such a design. METHODS: In order to gain a better understanding of the broader prevalence and extent of these preference issues (and any other methodological challenges), we undertook an exploratory review of settings trials in any area of healthcare treatment research. We searched The Cochrane Library and Google Scholar and used snowballing methods to identify trials comparing different healthcare settings. RESULTS: Trial accrual was affected by patient preferences for a setting in 15 of the 16 identified studies; birth setting trials were the most markedly affected, with between 68 % and 85 % of eligible women declining to participate specifically because of preference for a particular healthcare setting. Recruitment into substance abuse and chemotherapy setting studies was also notably affected by preferences. Only four trials used a preference design: the proportion of eligible patients choosing to participate via a preference group ranged from between 33 % and 67 %. CONCLUSIONS: In trials of healthcare settings, accrual may be seriously affected by patient preferences. The use of trial designs which incorporate a preference component should therefore strongly be considered. When designing such trials, investigators should consider settings to be complex interventions, which are likely to have linked components which may be difficult to control for. Careful thought is also needed regarding the choice of comparator settings and the most appropriate outcome measures to be used

Analysis of Tp53 Codon 72 Polymorphisms, Tp53 Mutations, and HPV Infection in Cutaneous Squamous Cell Carcinomas

Non-melanoma skin cancers are one of the most common human malignancies accounting for 2-3% of tumors in the US and represent a significant health burden. Epidemiology studies have implicated Tp53 mutations triggered by UV exposure, and human papilloma virus (HPV) infection to be significant causes of non-melanoma skin cancer. However, the relationship between Tp53 and cutaneous HPV infection is not well understood in skin cancers. In this study we assessed the association of HPV infection and Tp53 polymorphisms and mutations in lesional specimens with squamous cell carcinomas.We studied 55 cases of histologically confirmed cutaneous squamous cell carcinoma and 41 controls for the presence of HPV infection and Tp53 genotype (mutations and polymorphism).We found an increased number of Tp53 mutations in the squamous cell carcinoma samples compared with perilesional or control samples. There was increased frequency of homozygous Tp53-72R polymorphism in cases with squamous cell carcinomas, while the Tp53-72P allele (Tp53-72R/P and Tp53-72P/P) was more frequent in normal control samples. Carcinoma samples positive for HPV showed a decreased frequency of Tp53 mutations compared to those without HPV infection. In addition, carcinoma samples with a Tp53-72P allele showed an increased incidence of Tp53 mutations in comparison carcinomas samples homozygous for Tp53-72R.These studies suggest there are two separate pathways (HPV infection and Tp53 mutation) leading to cutaneous squamous cell carcinomas stratified by the Tp53 codon-72 polymorphism. The presence of a Tp53-72P allele is protective against cutaneous squamous cell carcinoma, and carcinoma specimens with Tp53-72P are more likely to have Tp53 mutations. In contrast Tp53-72R is a significant risk factor for cutaneous squamous cell carcinoma and is frequently associated with HPV infection instead of Tp53 mutations. Heterozygosity for Tp53-72R/P is protective against squamous cell carcinomas, possibly reflecting a requirement for both HPV infection and Tp53 mutations