The smallest worthwhile effect on pain intensity of exercise therapy for people with chronic low back pain: a discrete choice experiment study.

OBJECTIVE: To identify the smallest worthwhile effect (SWE) of exercise therapy for people with non-specific chronic low back pain (CLBP). DESIGN: Discrete choice experiment. METHODS: The SWE was estimated as the lowest reduction in pain that participants would consider exercising worthwhile, compared to not exercising i.e., effects due to natural history and other components (e.g., regression to the mean). We recruited English-speaking adults in Australia with non-specific CLBP to our online survey via email obtained from a registry of previous participants and advertisements on social media. We used discrete choice experiment to estimate the SWE of exercise compared to no exercise for pain intensity. We analysed the discrete choice experiment using a mixed logit model, and mitigated hypothetical bias through certainty calibration, with sensitivity analyses performed with different certainty calibration thresholds. RESULTS: Two-hundred and thirteen participants completed the survey. The mean age (±SD) was 50.7±16.5, median (IQR) pain duration 10 years (5-20), and mean pain intensity (±SD) was 5.8±2.3 on a 0-10 numerical rating scale. For people with CLBP the SWE of exercise was a between-group reduction in pain of 20%, compared to no exercise. In the sensitivity analyses, the SWE varied with different levels of certainty calibration; from 0% without certainty calibration to 60% with more extreme certainty calibration. CONCLUSION: This patient-informed threshold of clinical importance could guide the interpretation of findings from randomised trials and meta-analyses of exercise therapy compared to no exercise.

Extending the theory of planned behaviour to investigate the issue of microplastics in the marine environment.

The attention to microplastics and the consequences of its presence in the marine environment is increasing in scientific fields as well as on common media channels. In the absence of regulation in many countries, manufacturers are not required to exclude microplastic from their products, however consumers could force the production in a more sustainable direction with their choices. This study demonstrates the utility of the Theory of Planned Behaviour (TPB) in understanding the publics' intention to avoid buying products which contain microplastics. All three TPB antecedents of intentions are important. The study, based on a sample of respondents in NSW (Australia), also reveals respondents' habitual behaviour of avoiding buying products containing microplastics strongly predicts their intended future behaviour. Last, modelling reveals direct and indirect means through which intentions to avoid buying microplastics can be increased, via increased environmental concerns and public knowledge and health concerns about microplastics.

Preferences for a COVID-19 vaccine in Australia.

In absence of a COVID-19 vaccine, testing, contact tracing and social restrictions are among the most powerful strategies adopted around the world to slow down the spread of the pandemic. Citizens of most countries are suffering major physical, psychological and economic distress. At this stage, a safe and effective COVID-19 vaccine is the most sustainable option to manage the current pandemic. However, vaccine hesitancy by even a small subset of the population can undermine the success of this strategy. The objective of this research is to investigate the vaccine characteristics that matter the most to Australian citizens and to explore the potential uptake of a COVID-19 vaccine in Australia. Through a stated preference experiment, preferences towards a COVID-19 vaccine of 2136 residents of the Australian states and territories were collected and analysed via a latent class model. Results show that preferences for mild adverse cases, mode of administration, location of administration, price and effectiveness are heterogeneous. Conversely, preferences for immediacy and severe reactions are homogeneous, with respondents preferring a shorter period until vaccine is available and lower instances of severe side effects. The expected uptake of the vaccine is estimated under three different scenarios, with the value of 86% obtained for an average scenario. By calculating individual preferences, the willingness to pay is estimated for immediacy, effectiveness, mild and severe side effects.

Are Healthcare Choices Predictable? The Impact of Discrete Choice Experiment Designs and Models.

BACKGROUND: Lack of evidence about the external validity of discrete choice experiments (DCEs) is one of the barriers that inhibit greater use of DCEs in healthcare decision making. OBJECTIVES: To determine whether the number of alternatives in a DCE choice task should reflect the actual decision context, and how complex the choice model needs to be to be able to predict real-world healthcare choices. METHODS: Six DCEs were used, which varied in (1) medical condition (involving choices for influenza vaccination or colorectal cancer screening) and (2) the number of alternatives per choice task. For each medical condition, 1200 respondents were randomized to one of the DCE formats. The data were analyzed in a systematic way using random-utility-maximization choice processes. RESULTS: Irrespective of the number of alternatives per choice task, the choice for influenza vaccination and colorectal cancer screening was correctly predicted by DCE at an aggregate level, if scale and preference heterogeneity were taken into account. At an individual level, 3 alternatives per choice task and the use of a heteroskedastic error component model plus observed preference heterogeneity seemed to be most promising (correctly predicting >93% of choices). CONCLUSIONS: Our study shows that DCEs are able to predict choices-mimicking real-world decisions-if at least scale and preference heterogeneity are taken into account. Patient characteristics (eg, numeracy, decision-making style, and general attitude for and experience with the health intervention) seem to play a crucial role. Further research is needed to determine whether this result remains in other contexts.

Capacity Building for and Implementation of Policy, Systems, and Environmental Change: Results from a Survey of the National Comprehensive Cancer Control Program.

Policy, systems, and environmental (PSE) approaches are commonly used to improve population health. Cancer-related examples include providing data and education to stakeholders about policies that support healthy living, or health systems changes such as universal reminders about recommended cancer screening. The National Comprehensive Cancer Control Program (NCCCP) funds health departments to form cancer coalitions that develop and implement cancer plans. NCCCP initiated a demonstration program in 13 of 65 funded grantees to determine whether skilled, dedicated staffing and using a strategic process to examine data, form a workgroup, and develop an agenda would enhance their capacity to implement PSE approaches, recruit new partners, and provide data and education to stakeholders. The objective of this study was to compare demonstration program grantees to other NCCCP grantees on their ability to develop and implement PSE strategies, and the short-term results that were achieved. Program directors (PDs) from each NCCCP-funded jurisdiction completed web surveys at 2 time points during implementation to assess changes in their capacity for PSE approaches, identify implementation activities, and document short-term outcomes. Responses from demonstration program PDs and other PDs at both time points were compared in a descriptive analysis. Demonstration program grantees experienced greater increases in skills and capacity to address PSE approaches, engaged in necessary implementation activities more often, and achieved greater improvements in stakeholder and decision maker awareness and support for PSE strategies, compared to nonparticipating NCCCP grantees. These findings support continued implementation of PSE approaches for sustainable cancer prevention and control.

Preferences for Policy Options for Deceased Organ Donation for Transplantation: A Discrete Choice Experiment.

BACKGROUND: Despite broad public support for organ donation, there is a chronic shortage of deceased donor organs. We sought to identify community preferences for features of organ donation policies. METHODS: A discrete choice study was conducted using an online panel of Australian community respondents older than 18 years. Respondents were presented with scenarios comparing a "new" policy to the current policy. Tradeoffs between 8 policy aspects were quantified using mixed logit and latent class models: registration system, extent of donor family involvement, ease of registration, frequency of confirmation of intent, direct payment, and funeral expense reimbursement, priority for donor's family, and formal recognition of donation. RESULTS: There were 2005 respondents (mean, 44.6 years). We found a strong preference for a new policy. Overall, respondents favored a policy that included: some involvement of the donor's family in the final decision, simple registration processes, less frequent reconfirmation of donation intent, direct payment or funeral expense reimbursement, and formal recognition of donation. However, there was significant preference heterogeneity across respondents, with various respondent groups valuing policy mechanisms differently. Respondents who viewed policy change negatively were also those who would be unlikely to be organ donors anyway, because they tended to hold negative views toward organ donation. CONCLUSIONS: Our results suggest that the Australian community are open to alternative organ donation policies including changes to: registration systems, family involvement, and financial and nonfinancial mechanisms. Future policy discussions should not be limited by preconceived notions of what is acceptable to the community, rather informed by actual community values and preferences.

Comprehensive Cancer Control Partners' Use of and Attitudes About Evidence-Based Practices.

INTRODUCTION: National Comprehensive Cancer Control Program (NCCCP) awardees are encouraged to work with partners (eg, nonprofit organizations) to develop and implement plans to reduce the cancer burden in their jurisdictions using evidence-based practices (EBPs). However, the extent of EBP use among awardees and their partners is not well understood. METHODS: From March through July 2012, we conducted a web-based survey of program partners referred by NCCCP program directors who were involved in implementation of cancer control plans. RESULTS: Approximately 53% of referred partners (n = 83) completed surveys, 91.6% of whom represented organizations. Most partners reported involvement in helping to identify (80.5%), adapt (81.7%), implement (90.4%), and evaluate (81.9%) EBPs. The factors rated most frequently as very important when selecting EBPs were "consistent with our organization's mission" (89.2%) and "cost-effective" (81.9%). Although most respondents said that their organizations understood the importance of using EBPs (84.3%) and had adequate access to cancer registry data (74.7%), few reported having sufficient financial resources to develop new EBPs (7.9%). The most frequently mentioned benefit of using EBPs was that they are proven to work. Resource limitations and difficulty adapting EBPs for specific populations and settings were challenges. CONCLUSIONS: Our findings help indicate how NCCCP partners are involved in using EBPs and can guide ongoing efforts to encourage the use of EBPs for cancer control. The challenges of using EBPs that partners identified highlight the need to improve strategies to translate cancer prevention and control research into practice in real-world settings and for diverse populations.

Community preferences for the allocation of donor organs for transplantation: a discrete choice study.

BACKGROUND: Demand for organs for transplant exceeds supply. There is an ongoing debate about the relative weighting that should be given to different allocation criteria. Little is known about the relative weight the community places on various allocation criteria. This study aims to determine community preferences for organ allocation. METHODS: Community respondents recruited from a web-based panel chose which patient received a transplant in 30 scenarios presenting two hypothetical patients. Patients were described in age, sex, previous transplants, whether they or family were registered donors, had caring responsibilities, adherence, time on waiting list, estimated survival and quality of life (QOL) with and without transplant, comorbidities, and lifestyle factors, such as smoking. Analyses were conducted in NLOGIT 5.0, using a mixed-logit model. RESULTS: Two thousand fifty-one respondents aged 18 to 83 years completed the survey. All attributes significantly influenced recipient choice except sex and having diabetes. Younger patients were preferred over older patients. Family member donor registration, having caring responsibilities, and longer time on waiting list increased priority. Pretransplant life expectancy was valued more highly than posttransplant life expectancy; 1 year less of pretransplant life expectancy required an increase of 1.49 years in posttransplant life expectancy to compensate. Posttransplant QOL was valued more highly than pretransplant QOL. CONCLUSION: Lower pretransplant life expectancy (need) was more important than higher posttransplant life expectancy (utility). Although current allocation algorithms are consistent with community preferences for prioritizing children and time on the waiting list, favoring patients with high predicted posttransplant survival as potential recipients may not be aligned with community preferences.

Use of Evidence-Based Practices and Resources Among Comprehensive Cancer Control Programs.

CONTEXT: While efforts to promote use of evidence-based practices (EBPs) for cancer control have increased, questions remain whether this will result in widespread adoption of EBPs (eg, Guide to Community Preventive Services interventions) by comprehensive cancer control (CCC) programs. OBJECTIVE: To examine use of EBPs among CCC programs to develop cancer control plans and select interventions. DESIGN: Conducted Web-based surveys of and telephone interviews with CCC program staff between March and July 2012. SETTING: CCC programs funded by the Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program (NCCCP). PARTICIPANTS: Sixty-one CCC program directors. MAIN OUTCOME MEASURES: 1) Use of and knowledge/attitudes about EBPs and related resources and 2) EBP-related technical assistance needs. RESULTS: Seventy-five percent of eligible program directors reported use of EBPs to a moderate or great extent to address program objectives. Benefits of using EBPS included their effectiveness has been proven, they are an efficient use of resources, and they lend credibility to an intervention. Challenges to using EBPs included resource limitations, lack of culturally appropriate interventions, and limited skills adapting EBPs for local use. Most respondents had heard of and used Web sites for The Guide to Community Preventive Services (95% and 91%, respectively) and Cancer Control P.L.A.N.E.T. (98% and 75%, respectively). Training needs included how to adapt an EBP and its materials for cultural appropriateness (state 78%, tribe 86%, territory 80%) and how to maintain the fidelity of an EBP (state 75%, tribe 86%, territory 60%). CONCLUSIONS: While awareness, knowledge, and use of EBPs and related resources are high, respondents identified numerous challenges and training needs. The findings from this study may be used to enhance technical assistance provided to NCCCP grantees related to selecting and implementing EBPs.

Stated Choice design comparison in a developing country: recall and attribute nonattendance.

BACKGROUND: Experimental designs constitute a vital component of all Stated Choice (aka discrete choice experiment) studies. However, there exists limited empirical evaluation of the statistical benefits of Stated Choice (SC) experimental designs that employ non-zero prior estimates in constructing non-orthogonal constrained designs. This paper statistically compares the performance of contrasting SC experimental designs. In so doing, the effect of respondent literacy on patterns of Attribute non-Attendance (ANA) across fractional factorial orthogonal and efficient designs is also evaluated. The study uses a 'real' SC design to model consumer choice of primary health care providers in rural north India. A total of 623 respondents were sampled across four villages in Uttar Pradesh, India. METHODS: Comparison of orthogonal and efficient SC experimental designs is based on several measures. Appropriate comparison of each design's respective efficiency measure is made using D-error results. Standardised Akaike Information Criteria are compared between designs and across recall periods. Comparisons control for stated and inferred ANA. Coefficient and standard error estimates are also compared. RESULTS: The added complexity of the efficient SC design, theorised elsewhere, is reflected in higher estimated amounts of ANA among illiterate respondents. However, controlling for ANA using stated and inferred methods consistently shows that the efficient design performs statistically better. Modelling SC data from the orthogonal and efficient design shows that model-fit of the efficient design outperform the orthogonal design when using a 14-day recall period. The performance of the orthogonal design, with respect to standardised AIC model-fit, is better when longer recall periods of 30-days, 6-months and 12-months are used. CONCLUSIONS: The effect of the efficient design's cognitive demand is apparent among literate and illiterate respondents, although, more pronounced among illiterate respondents. This study empirically confirms that relaxing the orthogonality constraint of SC experimental designs increases the information collected in choice tasks, subject to the accuracy of the non-zero priors in the design and the correct specification of a 'real' SC recall period.

A discrete choice experiment to obtain a tariff for valuing informal care situations measured with the CarerQol instrument.

BACKGROUND / OBJECTIVE: Economic evaluations adopting a societal perspective need to include informal care whenever relevant. However, in practice, informal care is often neglected, because there are few validated instruments to measure and value informal care for inclusion in economic evaluations. The CarerQol, which is such an instrument, measures the impact of informal care on 7 important burden dimensions (CarerQol-7D) and values this in terms of general quality of life (CarerQol-VAS). The objective of the study was to calculate utility scores based on relative utility weights for the CarerQol-7D. These tariffs will facilitate inclusion of informal care in economic evaluations. METHODS: The CarerQol-7D tariff was derived with a discrete choice experiment conducted as an Internet survey among the general adult population in the Netherlands (N = 992). The choice set contained 2 unlabeled alternatives described in terms of the 7 CarerQol-7D dimensions (level range: "no,""some," and "a lot"). An efficient experimental design with priors obtained from a pilot study (N = 104) was used. Data were analyzed with a panel mixed multinomial parameter model including main and interaction effects of the attributes. RESULTS: The utility attached to informal care situations was significantly higher when this situation was more attractive in terms of fewer problems and more fulfillment or support. The interaction term between the CarerQol-7D dimensions physical health and mental health problems also significantly explained this utility. The tariff was constructed by adding up the relative utility weights per category of all CarerQol-7D dimensions and the interaction term. CONCLUSIONS: We obtained a tariff providing standard utility scores for caring situations described with the CarerQol-7D. This facilitates the inclusion of informal care in economic evaluations.

A closer look at decision and analyst error by including nonlinearities in discrete choice models: implications on willingness-to-pay estimates derived from discrete choice data in healthcare.

BACKGROUND: Most researchers in health economics cite random utility theory (RUT) when analysing discrete choice experiments (DCEs). Under RUT, the error term is associated with the analyst's inability to properly capture the true choice processes of the respondent as well as the inconsistency or mistakes arising from the respondent themselves. Under such assumptions, it stands to reason that analysts should explore more complex nonlinear indirect utility functions, than currently used in healthcare, to strive for better estimates of preferences in healthcare. OBJECTIVE: To test whether complex indirect utility functions decrease error variance for models that either implicitly (i.e. the multinomial logit (MNL) model) or explicitly (i.e. entropy multinomial logit (EMNL) model) account for error variance in health(care)-related DCEs; and to determine the impact of complex indirect utility functions on willingness-to-pay (WTP) measures. METHODS: Using data from DCEs aimed at healthcare-related decisions, we empirically compared (1) complex and simple indirect utility specifications in terms of goodness of fit, (2) their impact on WTP measures, including confidence intervals (CIs) based on the Delta method, the Krinsky and Robb-procedure, and Bootstrapping, and (3) MNL and EMNL model results. RESULTS: Complex indirect utility functions had a better model fit than simple specifications (p < 0.05). WTP estimates were quite similar across alternative specifications. The Delta method produced the most narrow CIs. The EMNL model showed that respondents apply simplifying strategies when answering DCE questions. CONCLUSION: Complex indirect utility functions reduce error arisen from researchers, which can have important implications for measures in healthcare such as the WTP, whereas EMNL provides insights into the behaviour of respondents when answering DCEs. Understanding how respondents answer DCE questions may allow researchers to construct DCEs that minimise scale differences, so that the decision error made across respondents is more homogeneous and therefore taken out as additional noise in the data. Hence, better estimates of preferences in healthcare can be provided.

Patient preferences for community pharmacy asthma services: a discrete choice experiment.

BACKGROUND: Specialized community pharmacy services, involving the provision of disease state management and care by pharmacists, have been developed and trialled and have demonstrated very good health outcomes. Most of these services have been developed from a healthcare professional perspective. However, for the future uptake and long-term sustainability of these services as well as for better and sustained health outcomes for patients, it is vital to gain an understanding of patients' preferences. We can then structure healthcare services to match these preferences and needs rather than around clinical viewpoints alone. OBJECTIVE: The aim of this study was to elicit patient preferences for pharmacy-based specialized asthma services using a discrete choice experiment and to explore the value/importance that patients place on the different attributes of the asthma service. The existence of preference heterogeneity in the population was also investigated. METHODS: The study was conducted with asthma patients who had recently experienced a specialized asthma management service at their pharmacy in New South Wales, Australia. Pharmacists delivering the asthma service mailed out the discrete choice questionnaires to participating patients at the end of 6 months of service provision. A latent class (LC) model was used to investigate each patient's strength of preference and preference heterogeneity for several key attributes related to asthma service provision: frequency of visits, access to pharmacist, interaction with pharmacy staff, availability of a private area for consultation, provision of lung function testing, type and depth of advice provision, number of days with asthma symptoms and cost of service. RESULTS: Eighty useable questionnaires (of 170 questionnaires sent out) were received (response rate 47.1%). The study identified various key elements of asthma services important to patients. Further, the LC analysis revealed three classes with differing patient preferences for levels of asthma service provision. Patients in the Minimalistic Model class valued provision of lung function testing and preferred more frequent service visits. Cost of service had a negative effect on service preference for patients in this class. Patients in the Partial Model class mainly derived utility from the provision of lung function testing and comprehensive advice at the pharmacy and also wanted more frequent service visits. The Holistic Model class patients considered all attributes of the service to be important when making a choice. While the majority of the service attributes had a positive effect on preference for patients in this class, cost of service and days with symptoms of asthma had a negative effect on service preference. These patients also preferred fewer service visits. CONCLUSION: The study identified various key attributes that are important to patients with respect to community pharmacy-based asthma services. The results also demonstrate the existence of preference heterogeneity in the population. Asthma service providers need to take these findings into consideration in the design and development of future service models so as to increase their uptake and ensure their long-term sustainability.

Allocation decisions and patient preferences in emergency medicine.

Allocation decisions in emergency medicine must occur when demand for emergency services exceeds supply. In many circumstances, strong clinical or cost evidence upon which to base allocation decisions is lacking. In these circumstances, patient or community preference may be used to inform decisions. If preference is to be incorporated into allocation decision-making, scientifically rigorous quantitative methods should be chosen for measuring preference. This article describes the theoretical background, advantages, risks and applications of discrete choice experiments for measuring patient preference in emergency medicine.

Towards a more comprehensive understanding of cancer burden in North Carolina: priorities for intervention.

OBJECTIVE: To apply 4 measures of population burden in examining cancer burden in North Carolina and to identify priorities for intervention. METHODS: Four measures were used: incidence, mortality, prevalence, and years of potential life lost (YPLL). The North Carolina Central Cancer Registry provided summary data on incidence and mortality and record-level data that were examined using SEER*Stat software to calculate prevalence. North Carolina vital statistics (mortality) data and life expectancy estimates stratified by age, race, and sex were used to calculate YPLL. Each cancer site was ranked according to burden for each of the 4 individual burden measures and summarized into an overall rank. Burden was examined overall and by sex and race. PRINCIPAL FINDINGS: Four cancers--lung/bronchus, female breast, prostate, and colon/rectum--accounted for approximately 57% of the total cancer incidence, prevalence, mortality, and YPLL in North Carolina. Patterns of burden in gender and race subgroups were similar, although non-whites often had higher mortality rates than did whites despite similar incidence rates. An estimated 207,583 people were living with cancer in 2004 Breast and prostate cancer accounted for 42% of these survivors. Lung/bronchus cancer was the most severe cancer, accounting for more deaths and years of life lost than any other 5 cancers combined. CONCLUSIONS: Each of the 4 measures provides unique insight and guidance for cancer coordination and control efforts. Lung/bronchus, female breast, prostate, and colon/rectum cancers accounted for the majority of North Carolina's cancer burden and should be priorities for intervention.