A note on the expected biases in conventional iterative health state valuation protocols

Background: Typical health state valuation exercises use trade off methods, such as the Time Trade Off or the Standard Gamble, involving a series of iterated questions so that a value for each health state by each individual respondent is elicited. This iterative process is a source of potential biases, but this has not received much attention in the health state valuation literature. The issue has been researched widely in the contingent valuation (CV) literature which elicits the monetary value of hypothetical outcomes. Methods: The lessons learnt in the CV literature are revisited in the context of the design and administration of health state valuations. The paper introduces the main known biases in the CV literature, and then examines how each might affect conventional iterative health state valuations. Results: Of the eight main types of biases, starting point bias, range bias, and incentive incompatibility bias are found to be potentially relevant. Furthermore, the magnitude and direction of the bases are unlikely to be uniform, and depend on the range of the value (e.g. between 0 and 0.5). Limitation: this is an overview paper and the conclusions drawn need to be tested empirically. Conclusions: health state valuation studies, like CV studies, are susceptible to a number of possible biases that affect the resulting values. Their magnitude and direction are unlikely to be uniform, and thus empirical studies are needed to diagnose the problem and if necessary to address it

Using shared goal setting to improve access and equity: a mixed methods study of the Good Goals intervention

Background: Access and equity in children’s therapy services may be improved by directing clinicians’ use of resources toward specific goals that are important to patients. A practice-change intervention (titled ‘Good Goals’) was designed to achieve this. This study investigated uptake, adoption, and possible effects of that intervention in children’s occupational therapy services. Methods: Mixed methods case studies (n = 3 services, including 46 therapists and 558 children) were conducted. The intervention was delivered over 25 weeks through face-to-face training, team workbooks, and ‘tools for change’. Data were collected before, during, and after the intervention on a range of factors using interviews, a focus group, case note analysis, routine data, document analysis, and researchers’ observations. Results: Factors related to uptake and adoptions were: mode of intervention delivery, competing demands on therapists’ time, and leadership by service manager. Service managers and therapists reported that the intervention: helped therapists establish a shared rationale for clinical decisions; increased clarity in service provision; and improved interactions with families and schools. During the study period, therapists’ behaviours changed: identifying goals, odds ratio 2.4 (95% CI 1.5 to 3.8); agreeing goals, 3.5 (2.4 to 5.1); evaluating progress, 2.0 (1.1 to 3.5). Children’s LoT decreased by two months [95% CI −8 to +4 months] across the services. Cost per therapist trained ranged from £1,003 to £1,277, depending upon service size and therapists’ salary bands. Conclusions: Good Goals is a promising quality improvement intervention that can be delivered and adopted in practice and may have benefits. Further research is required to evaluate its: (i) impact on patient outcomes, effectiveness, cost-effectiveness, and (ii) transferability to other clinical contexts

Heparin-stabilised iron oxide for MR applications : a relaxometric study

Superparamagnetic nanoparticles have strong potential in biomedicine and have seen application as clinical magnetic resonance imaging (MRI) contrast agents, though their popularity has plummeted in recent years, due to low efficacy and safety concerns, including haemagglutination. Using an in situ procedure, we have prepared colloids of magnetite nanoparticles, exploiting the clinically approved anti-coagulant, heparin, as a templating stabiliser. These colloids, stable over several days, produce exceptionally strong MRI contrast capabilities particularly at low fields, as demonstrated by relaxometric investigations using nuclear magnetic resonance dispersion (NMRD) techniques and single field r1 and r2 relaxation measurements. This behaviour is due to interparticle interactions, enhanced by the templating effect of heparin, resulting in strong magnetic anisotropic behaviour which closely maps particle size. The nanocomposites have also reliably prevented protein-adsorption triggered thrombosis typical of non-stabilised nanoparticles, showing great potential for in vivo MRI diagnostics

Acceptability of Financial Incentives for Health Behaviours: A Discrete Choice Experiment.

BACKGROUND: Healthy behaviours are important determinants of health and disease, but many people find it difficult to perform these behaviours. Systematic reviews support the use of personal financial incentives to encourage healthy behaviours. There is concern that financial incentives may be unacceptable to the public, those delivering services and policymakers, but this has been poorly studied. Without widespread acceptability, financial incentives are unlikely to be widely implemented. We sought to answer two questions: what are the relative preferences of UK adults for attributes of financial incentives for healthy behaviours? Do preferences vary according to the respondents' socio-demographic characteristics? METHODS: We conducted an online discrete choice experiment. Participants were adult members of a market research panel living in the UK selected using quota sampling. Preferences were examined for financial incentives for: smoking cessation, regular physical activity, attendance for vaccination, and attendance for screening. Attributes of interest (and their levels) were: type of incentive (none, cash, shopping vouchers or lottery tickets); value of incentive (a continuous variable); schedule of incentive (same value each week, or value increases as behaviour change is sustained); other information provided (none, written information, face-to-face discussion, or both); and recipients (all eligible individuals, people living in low-income households, or pregnant women). RESULTS: Cash or shopping voucher incentives were preferred as much as, or more than, no incentive in all cases. Lower value incentives and those offered to all eligible individuals were preferred. Preferences for additional information provided alongside incentives varied between behaviours. Younger participants and men were more likely to prefer incentives. There were no clear differences in preference according to educational attainment. CONCLUSIONS: Cash or shopping voucher-type financial incentives for healthy behaviours are not necessarily less acceptable than no incentives to UK adults.This work is produced under the terms of a Career Development Fellowship research training fellowship issued by the National Institute of Health Research to JA (grant number NIHR-CDF-2011-04-17; http://www.nihr.ac.uk/funding/fellowship-programme.htm). The views expressed are those of the authors and not necessarily those of the NHS, The National Institute for Health Research or the Department of Health. JA is currently funded in full by the Centre for Diet & Activity Research (CEDAR), and the FFS is funded in full by Fuse: the Centre for Translational Research in Public Health. CEDAR and Fuse are UKCRC Public Health Research Centres of Excellence (http://www.ukcrc.org/research-coordination/joint-funding-initiatives/public-health-research/). Funding for CEDAR (grant number MR/K023187/1) and Fuse (grant number MR/K02325X/1) from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged.This is the final version of the article. It first appeared from PLOS via http://dx.doi.org/10.1371/journal.pone.015740

Heparin-stabilised iron oxide for MR applications: a relaxometric study

Superparamagnetic nanoparticles have strong potential in biomedicine and have seen application as clinical magnetic resonance imaging (MRI) contrast agents, though their popularity has plummeted in recent years, due to low efficacy and safety concerns, including haemagglutination. Using an in situ procedure, we have prepared colloids of magnetite nanoparticles, exploiting the clinically approved anti-coagulant, heparin, as a templating stabiliser. These colloids, stable over several days, produce exceptionally strong MRI contrast capabilities particularly at low fields, as demonstrated by relaxometric investigations using nuclear magnetic resonance dispersion (NMRD) techniques and single field r1 and r2 relaxation measurements. This behaviour is due to interparticle interactions, enhanced by the templating effect of heparin, resulting in strong magnetic anisotropic behaviour which closely maps particle size. The nanocomposites have also reliably prevented protein-adsorption triggered thrombosis typical of non-stabilised nanoparticles, showing great potential for in vivo MRI diagnostics

Parental preferences for the organisation of preschool vaccination programmes including financial incentives: a discrete choice experiment

Objective: To establish preferences of parents and guardians of preschool children for the organization of preschool vaccination services, including financial incentives. Design: An online discrete choice experiment. Participants: Parents and guardians of preschool children (up to age 5 years) who were (n = 259) and were not (n = 262) classified as at high risk of incompletely vaccinating their children. High risk of incomplete vaccination was defined as any of the following: aged less than 20 years, single parents, living in one of the 20% most deprived areas in England, had a preschool child with a disability, or had more than three children. Main Outcome Measures: Participant preferences expressed as positive (utility) or negative (disutility) on eight attributes and levels describing the organization of preschool vaccination programs. Results: There was no difference in preference for parental financial incentives compared to no incentive in parents “not at high risk” of incomplete vaccination. Parents who were “at high risk” expressed utility for cash incentives. Parents “at high risk” of incomplete vaccination expressed utility for information on the risks and benefits of vaccinations to be provided as numbers rather than charts or pictures. Both groups preferred universally available, rather than targeted, incentives. Utility was identified for shorter waiting times, and there were variable preferences for who delivered vaccinations. Conclusions: Cash incentives for preschool vaccinations in England would be welcomed by parents who are “at high risk” of incompletely vaccinating their children. Further work is required on the optimal mode and form of presenting probabilistic information on vaccination to parents/guardians, including preferences on mandatory vaccination schemes

Effect of Demographic and Health Dynamics on Cognitive Status in Mexico between 2001 and 2015: Evidence from the Mexican Health and Aging Study

Sources of health disparities such as educational attainment, cardiovascular risk factors, and access to health care affect cognitive impairment among older adults. To examine the extent to which these counteracting changes affect cognitive aging over time among Mexican older adults, we examine how sociodemographic factors, cardiovascular diseases, and their treatment relate to changes in cognitive function of Mexican adults aged 60 and older between 2001 and 2015. Self and proxy respondents were classified as dementia, cognitive impairment no dementia (CIND), and normal cognition. We use logistic regression models to examine the trends in dementia and CIND for men and women aged 60 years or older using pooled national samples of 6822 individuals in 2001 and 10,219 in 2015, and sociodemographic and health variables as covariates. We found higher likelihood of dementia and a lower risk of CIND in 2015 compared to 2001. These results remain after adjusting for sociodemographic factors, cardiovascular diseases, and their treatment. The improvements in educational attainment, treatment of diabetes and hypertension, and better access to health care in 2015 compared to 2001 may not have been enough to counteract the combined effects of aging, rural residence disadvantage, and higher risks of cardiovascular disease among older Mexican adults

Comparing how patients value and respond to information on risk given in three different forms during dental check-ups: the PREFER randomised controlled trial

Background: This study aims to compare patient preference for, and subsequent change in, oral health behaviour for three forms of risk information given at dental check-ups (verbal advice compared to verbal advice accompanied by a traffic light (TL) risk card; or compared to verbal advice with a quantitative light fluorescence (QLF) photograph of the patient's mouth). Methods: A multi-centre, parallel-group, patient-randomised clinical trial was undertaken between August 2015 and September 2016. Computer-generated random numbers using block stratification allocated patients to three arms. The setting was four English NHS dental practices. Participants were 412 dentate adults at medium/high risk of poor oral health. Patients rated preference and willingness to pay (WTP) for the three types of information. The primary outcome was WTP. After receiving their check-up, patients received the type of information according to their group allocation. Follow-up was by telephone/e-mail at 6 and 12 months. Mean and median WTP for the three arms were compared using Wilcoxon signed-rank tests. Tobit regression models were used to investigate factors affecting WTP and preference for information type. Secondary outcomes included self-rated oral health and change in oral health behaviours (tooth-brushing, sugar consumption and smoking) and were investigated using multivariate generalised linear mixed models. Results: A total of 412 patients were randomised (138 to verbal, 134 to TL and 140 to QLF); 391 revisited their WTP scores after the check-up (23 withdrew). Follow-up data were obtained for 185 (46%) participants at 6 months and 153 (38%) participants at 12 months. Verbal advice was the first preference for 51% (209 participants), QLF for 35% (145 participants) and TL for 14% (58 participants). TL information was valued lower than either verbal or QLF information (p Conclusions: Although a new NHS dental contract based on TL risk stratification is being tested, patients prefer the usual verbal advice. There was also a practice effect which will needs to be considered for successful implementation of this government policy

Robot-assisted training compared with an enhanced upper limb therapy programme and with usual care for upper limb functional limitation after stroke: the RATULS three-group RCT

Background Loss of arm function is common after stroke. Robot-assisted training may improve arm outcomes. Objective The objectives were to determine the clinical effectiveness and cost-effectiveness of robot-assisted training, compared with an enhanced upper limb therapy programme and with usual care. Design This was a pragmatic, observer-blind, multicentre randomised controlled trial with embedded health economic and process evaluations. Setting The trial was set in four NHS trial centres. Participants Patients with moderate or severe upper limb functional limitation, between 1 week and 5 years following first stroke, were recruited. Interventions Robot-assisted training using the Massachusetts Institute of Technology-Manus robotic gym system (InMotion commercial version, Interactive Motion Technologies, Inc., Watertown, MA, USA), an enhanced upper limb therapy programme comprising repetitive functional task practice, and usual care. Main outcome measures The primary outcome was upper limb functional recovery ‘success’ (assessed using the Action Research Arm Test) at 3 months. Secondary outcomes at 3 and 6 months were the Action Research Arm Test results, upper limb impairment (measured using the Fugl-Meyer Assessment), activities of daily living (measured using the Barthel Activities of Daily Living Index), quality of life (measured using the Stroke Impact Scale), resource use costs and quality-adjusted life-years. Results A total of 770 participants were randomised (robot-assisted training, n = 257; enhanced upper limb therapy, n = 259; usual care, n = 254). Upper limb functional recovery ‘success’ was achieved in the robot-assisted training [103/232 (44%)], enhanced upper limb therapy [118/234 (50%)] and usual care groups [85/203 (42%)]. These differences were not statistically significant; the adjusted odds ratios were as follows: robot-assisted training versus usual care, 1.2 (98.33% confidence interval 0.7 to 2.0); enhanced upper limb therapy versus usual care, 1.5 (98.33% confidence interval 0.9 to 2.5); and robot-assisted training versus enhanced upper limb therapy, 0.8 (98.33% confidence interval 0.5 to 1.3). The robot-assisted training group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale) than the usual care group at 3 and 6 months. The enhanced upper limb therapy group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale), better mobility (as measured by the Stroke Impact Scale mobility domain) and better performance in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the usual care group, at 3 months. The robot-assisted training group performed less well in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the enhanced upper limb therapy group at 3 months. No other differences were clinically important and statistically significant. Participants found the robot-assisted training and the enhanced upper limb therapy group programmes acceptable. Neither intervention, as provided in this trial, was cost-effective at current National Institute for Health and Care Excellence willingness-to-pay thresholds for a quality-adjusted life-year. Conclusions Robot-assisted training did not improve upper limb function compared with usual care. Although robot-assisted training improved upper limb impairment, this did not translate into improvements in other outcomes. Enhanced upper limb therapy resulted in potentially important improvements on upper limb impairment, in performance of activities of daily living, and in mobility. Neither intervention was cost-effective. Future work Further research is needed to find ways to translate the improvements in upper limb impairment seen with robot-assisted training into improvements in upper limb function and activities of daily living. Innovations to make rehabilitation programmes more cost-effective are required. Limitations Pragmatic inclusion criteria led to the recruitment of some participants with little prospect of recovery. The attrition rate was higher in the usual care group than in the robot-assisted training or enhanced upper limb therapy groups, and differential attrition is a potential source of bias. Obtaining accurate information about the usual care that participants were receiving was a challenge. Trial registration Current Controlled Trials ISRCTN69371850. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 54. See the NIHR Journals Library website for further project information