Development of a disease-specific health utility score for chronic obstructive pulmonary disease from a discrete choice experiment patient preference study.

OBJECTIVES: While patient input to health technology assessment (HTA) has traditionally been of a qualitative nature, there is increasing interest to integrate quantitative evidence from patient preference studies into HTA decision making. Preference data can be used to generate disease-specific health utility data. We generated a health utility score for patients with chronic obstructive pulmonary disease (COPD) and consider its use within HTAs. METHODS: Based on qualitative research, six symptoms were identified as important to COPD patients: shortness of breath, exacerbations, chronic cough, mucus secretion, sleep disturbance, and urinary incontinence. We employed a discrete choice experiment (DCE) and the random parameter logistic regression technique to estimate utility scores for all COPD health states. The relationship between patients' COPD health utility scores, self-perceived COPD severity, and EQ-5D-3L utility scores was analyzed, with data stratified according to disease severity and comorbidity subgroups. RESULTS: The COPD health utility score had face validity, with utility scores negatively correlated with patients' self-perceived COPD severity. The correlation between the COPD health utility scores and EQ-5D-3L values was only moderate. While patient EQ-5D-3L scores were impacted by comorbidities, the COPD health utility score was less impacted by comorbid conditions. CONCLUSIONS: Our COPD utility measure, derived from a DCE, provides a patient-centered health utility score and is more sensitive to the COPD health of the individual and less sensitive to other comorbidities. This disease-specific instrument should be considered alongside generic health-related quality of life instruments when valuing new COPD therapies in submissions to licensing and reimbursement agencies.

Keeping an eye on cost: What can eye tracking tell us about attention to cost information in discrete choice experiments?

Concern has been expressed about including a cost attribute within discrete choice experiments (DCEs) when individuals do not have to pay at the point of consumption. We use eye tracking to investigate attention to cost when valuing publicly financed health care. One-hundred and four individuals completed a DCE concerned with preferences for UK general practitioner appointments: 51 responded to a DCE with cost included and 53 to the same DCE without cost. Eye-movements were tracked whilst respondents completed the DCE. We assessed if respondents pay attention to cost. We then compare fixation time (FT) on attributes, eye movement patterns and mental effort across the experimental groups. Results are encouraging for the inclusion of cost in DCEs valuing publicly provided healthcare. Most respondents gave visual attention to the cost attribute most of the time. Average FT on multi-attribute tasks increased by 44% in the cost DCE, with attention to non-monetary attributes increasing by 22%. Including cost led to more structured decision-making and did not increase mental effort. Acceptability of the cost attribute and difficulty of choice tasks were predictors of cost information processing, highlighting the importance of both motivating the cost attribute and considering difficulty of the tasks when developing DCEs.

The Baby Box scheme in Scotland: A study of public attitudes and social value.

BACKGROUND: The Scottish Government introduced a free Baby Box scheme for all new parents in 2017, modelled on the Finnish scheme, to give every baby 'an equal start in life'. There is little evidence that it results in better health outcomes, but there has been limited research into different perspectives and discourses on such schemes. METHODS: Four focus groups were conducted with 21 parents in North-East Scotland. Recordings were transcribed verbatim, anonymized and analysed thematically with NVivo 12 software. Our thematic analysis was both inductive and deductive-remaining open to themes identified by participants themselves but also informed by the social policy literature on universalism and social cohesion. RESULTS: Across all the focus groups, we found a high degree of positivity about the principle of the Baby Box scheme, and for the most part the practical value of the contents. This was remarkably consistent across different communities and backgrounds. There was little evidence of the strongly polarized views present in media reporting. Parents seemed considerably less focused than the media on safety and health outcomes, and more focused on practical, material and social impacts. They reported little in the way of feeling patronized or monitored by the government. CONCLUSION: Our findings have important implications for future economic evaluations of the baby box. Such evaluations should broaden the valuation space beyond health outcomes to allow for the value of feelings of inclusion, solidarity and being part of a community. PATIENT OR PUBLIC CONTRIBUTION: This small project was designed in response to parent views already collected in the early roll-out of the Baby Box scheme in Scotland, about their priorities and responses to the scheme. Additional views were sought on the topic guide for the focus groups, and local community groups advised us on recruitment and the best timing and location for the focus groups to be held. The focus groups themselves were conducted as research, but with the intent of ensuring parent views featured more prominently in a debate that has been largely dominated by clinical and public health perspectives.

Weighting or aggregating? Investigating information processing in multi-attribute choices.

Multi-attribute choices are commonly analyzed in economics to value goods and services. Analysis assumes individuals consider all attributes, making trade-offs between them. Such decision-making is cognitively demanding, often triggering alternative decision rules. We develop a new model where individuals aggregate multi-attribute information into meta-attributes. Applying our model to a choice experiment (CE) dataset, accounting for attribute aggregation (AA) improves model fit. The probability of adopting AA is greater for: homogenous attribute information; participants who had shorter response time and failed the dominance test; and for later located choices. Accounting for AA has implications for welfare estimates. Our results underline the importance of accounting for information processing rules when modelling multi-attribute choices.

Survey modes comparison in contingent valuation: Internet panels and mail surveys.

Stated preferences methods are extensively applied in health economics to elicit preferences. Although mailed surveys were commonly used to collect data, internet panel (IP) surveys are being increasingly used. This raises questions about the validity of responses and estimated willingness-to-pay (WTP) values generated from IP surveys. We conduct the first study in health to compare a contingent valuation IP survey with a mailed survey using the electoral roll. Our IP has a higher response rate and lower item missing response rate. The difference is reduced but remains when restricting comparisons with valid WTPs. Sample characteristics differ, with significant differences between modes for gender, age, income, and attitudes and knowledge. Although difference in WTP values exist, with the IP resulting in higher values, we find limited evidence that such differences are statistically significant. The mail survey has lower initial cost per response; however, once restricting samples to valid WTP responses with nonmissing respondent information, the cost per response across modes is similar. Our results, suggesting that IPs generate valid and cost-effective values, are encouraging as researchers move increasingly to IPs to collect preference data.

U.K. Intensivists' Preferences for Patient Admission to ICU: Evidence From a Choice Experiment.

OBJECTIVES: Deciding whether to admit a patient to the ICU requires considering several clinical and nonclinical factors. Studies have investigated factors associated with the decision but have not explored the relative importance of different factors, nor the interaction between factors on decision-making. We examined how ICU consultants prioritize specific factors when deciding whether to admit a patient to ICU. DESIGN: Informed by a literature review and data from observation and interviews with ICU clinicians, we designed a choice experiment. Senior intensive care doctors (consultants) were presented with pairs of patient profiles and asked to prioritize one of the patients in each task for admission to ICU. A multinomial logit and a latent class logit model was used for the data analyses. SETTING: Online survey across U.K. intensive care. SUBJECTS: Intensive care consultants working in NHS hospitals. MEASUREMENTS AND MAIN RESULTS: Of the factors investigated, patient's age had the largest impact at admission followed by the views of their family, and severity of their main comorbidity. Physiologic measures indicating severity of illness had less impact than the gestalt assessment by the ICU registrar. We identified four distinct decision-making patterns, defined by the relative importance given to different factors. CONCLUSIONS: ICU consultants vary in the importance they give to different factors in deciding who to prioritize for ICU admission. Transparency regarding which factors have been considered in the decision-making process could reduce variability and potential inequity for patients.

For better or worse? Investigating the validity of best-worst discrete choice experiments in health.

Discrete choice experiments (DCEs) are frequently used in health economics to measure preferences for nonmarket goods. Best-worst discrete choice experiment (BWDCE) has been proposed as a variant of the traditional "pick the best" approach. BWDCE, where participants choose the best and worst options, is argued to generate more precise preference estimates because of the additional information collected. However, the validity of the approach relies on two necessary conditions: (a) best and worst decisions provide similar information about preferences and (b) asking individuals to answer more than one choice question per task does not reduce data quality. Whether these conditions hold in empirical applications remains under researched. This is the first study to compare participants' choices across three experimental conditions: (a) BEST choices only, (b) WORST choices only, and (c) BEST and WORST choices (BWDCE). We find responses to worst choices are noisier. Implied preferences from the best only and worst only choices are qualitatively different, leading to different WTP values. Responses to BWDCE tasks have lower consistency, and respondents are more likely to use simplifying decision heuristics. We urge caution in using BWDCE as an alternative to the traditional "pick the best" DCE.

For more than money: willingness of health professionals to stay in remote Senegal.

BACKGROUND: Poor distribution of already inadequate numbers of health professionals seriously constrains equitable access to health services in low- and middle-income countries. The Senegalese Government is currently developing policy to encourage health professionals to remain in areas defined as 'difficult'. Understanding health professional's preferences is crucial for this policy development. METHODS: Working with the Senegalese Government, a choice experiment (CE) was developed to elicit the job preferences of physicians and non-physicians. Attributes were defined using a novel mixed-methods approach, combining interviews and best-worst scaling (Case 1). Six attributes were categorised as 'individual (extrinsic) incentive' attributes ('type of contract', 'provision of training opportunities', 'provision of an allowance' and 'provision of accommodation') or 'functioning health system' attributes ('availability of basic equipment in health facilities' and 'provision of supportive supervision by health administrators'). Using face-to-face interviews, the CE was administered to 55 physicians (3909 observations) and 246 non-physicians (17 961 observations) randomly selected from those working in eight 'difficult' regions in Senegal. Conditional logit was used to analyse responses. This is the first CE to both explore the impact of contract type on rural retention and to estimate value of attributes in terms of willingness to stay (WTS) in current rural post. RESULTS: For both physicians and non-physicians, a permanent contract is the most important determinant of rural job retention, followed by availability of equipment and provision of training opportunities. Retention probabilities suggest that policy reform affecting only a single attribute is unlikely to encourage health professionals to remain in 'difficult' regions. The relative importance of an allowance is low; however, the level of such financial incentives requires further investigation. CONCLUSION: Contract type is a key factor impacting on retention. This has led the Senegalese Health Ministry to introduce a new rural assignment policy that recruits permanent staff from the pool of annually contracted healthcare professionals on the condition that they take up rural posts. While this is a useful policy development, further efforts to retain rural health workers, considering both personal incentives and the functioning of health systems, are necessary to ensure health worker numbers are adequate to meet the needs of rural communities.

The eyes have it: Using eye tracking to inform information processing strategies in multi-attributes choices.

Although choice experiments (CEs) are widely applied in economics to study choice behaviour, understanding of how individuals process attribute information remains limited. We show how eye-tracking methods can provide insight into how decisions are made. Participants completed a CE, while their eye movements were recorded. Results show that although the information presented guided participants' decisions, there were also several processing biases at work. Evidence was found of (a) top-to-bottom, (b) left-to-right, and (c) first-to-last order biases. Experimental factors-whether attributes are defined as "best" or "worst," choice task complexity, and attribute ordering-also influence information processing. How individuals visually process attribute information was shown to be related to their choices. Implications for the design and analysis of CEs and future research are discussed.

Decision heuristic or preference? Attribute non-attendance in discrete choice problems.

This paper investigates if respondents' choice to not consider all characteristics of a multiattribute health service may represent preferences. Over the last decade, an increasing number of studies account for attribute non-attendance (ANA) when using discrete choice experiments to elicit individuals' preferences. Most studies assume such behaviour is a heuristic and therefore uninformative. This assumption may result in misleading welfare estimates if ANA reflects preferences. This is the first paper to assess if ANA is a heuristic or genuine preference without relying on respondents' self-stated motivation and the first study to explore this question within a health context. Based on findings from cognitive psychology, we expect that familiar respondents are less likely to use a decision heuristic to simplify choices than unfamiliar respondents. We employ a latent class model of discrete choice experiment data concerned with National Health Service managers' preferences for support services that assist with performance concerns. We present quantitative and qualitative evidence that in our study ANA mostly represents preferences. We also show that wrong assumptions about ANA result in inadequate welfare measures that can result in suboptimal policy advice. Future research should proceed with caution when assuming that ANA is a heuristic.

Is Best-Worst Scaling Suitable for Health State Valuation? A Comparison with Discrete Choice Experiments.

Health utility indices (HUIs) are widely used in economic evaluation. The best-worst scaling (BWS) method is being used to value dimensions of HUIs. However, little is known about the properties of this method. This paper investigates the validity of the BWS method to develop HUI, comparing it to another ordinal valuation method, the discrete choice experiment (DCE). Using a parametric approach, we find a low level of concordance between the two methods, with evidence of preference reversals. BWS responses are subject to decision biases, with significant effects on individuals' preferences. Non parametric tests indicate that BWS data has lower stability, monotonicity and continuity compared to DCE data, suggesting that the BWS provides lower quality data. As a consequence, for both theoretical and technical reasons, practitioners should be cautious both about using the BWS method to measure health-related preferences, and using HUI based on BWS data. Given existing evidence, it seems that the DCE method is a better method, at least because its limitations (and measurement properties) have been extensively researched. Copyright © 2016 John Wiley & Sons, Ltd.

External Validity of Contingent Valuation: Comparing Hypothetical and Actual Payments.

Whilst contingent valuation is increasingly used in economics to value benefits, questions remain concerning its external validity that is do hypothetical responses match actual responses? We present results from the first within sample field test. Whilst Hypothetical No is always an Actual No, Hypothetical Yes exceed Actual Yes responses. A constant rate of response reversals across bids/prices could suggest theoretically consistent option value responses. Certainty calibrations (verbal and numerical response scales) minimise hypothetical-actual discrepancies offering a useful solution. Helping respondents resolve uncertainty may reduce the discrepancy between hypothetical and actual payments and thus lead to more accurate policy recommendations. Copyright © 2016 John Wiley & Sons, Ltd.

Determining cancer survivors' preferences to inform new models of follow-up care.

BACKGROUND: Specialist-led cancer follow-up is becoming increasingly expensive and is failing to meet many survivors' needs. Alternative models informed by survivors' preferences are urgently needed. It is unknown if follow-up preferences differ by cancer type. We conducted the first study to assess British cancer survivors' follow-up preferences, and the first anywhere to compare the preferences of survivors from different cancers. METHODS: A discrete choice experiment questionnaire was mailed to 1201 adults in Northeast Scotland surviving melanoma, breast, prostate or colorectal cancer. Preferences and trade-offs for attributes of cancer follow-up were explored, overall and by cancer site. RESULTS: 668 (56.6%) recipients (132 melanoma, 213 breast, 158 prostate, 165 colorectal) responded. Cancer survivors had a strong preference to see a consultant during a face-to-face appointment when receiving cancer follow-up. However, cancer survivors appeared willing to accept follow-up from specialist nurses, registrars or GPs provided that they are compensated by increased continuity of care, dietary advice and one-to-one counselling. Longer appointments were also valued. Telephone and web-based follow-up and group counselling, were not considered desirable. Survivors of colorectal cancer and melanoma would see any alternative provider for greater continuity, whereas breast cancer survivors wished to see a registrar or specialist nurse, and prostate cancer survivors, a general practitioner. CONCLUSIONS: Cancer survivors may accept non-consultant follow-up if compensated with changes elsewhere. Care continuity was sufficient compensation for most cancers. Given practicalities, costs and the potential to develop continuous care, specialist nurse-led cancer follow-up may be attractive.

The intended and unintended consequences of quality improvement interventions for small practices in a community-based electronic health record implementation project.

BACKGROUND: Despite the rapid rise in the implementation of electronic health records (EHR), commensurate improvements in health care quality have not been consistently observed. OBJECTIVES: To evaluate whether the implementation of EHRs and complementary interventions-including clinical decision support, technical assistance, and financial incentives-improved quality of care. RESEARCH DESIGN: The study included 143 practices that implemented EHRs as part of the Primary Care Information Project-a long-standing community-based EHR implementation initiative. A total of 71 practices were randomized to receive financial incentives and quality feedback and 72 were randomized to feedback alone. All practices received technical assistance and had clinical decision support in their EHR. Using data from 2009 to 2011, we estimated measure-level fixed effects models to evaluate the association between exposure to clinical decision support, technical assistance, financial incentives, and quality of care. Associations were estimated separately for 4 cardiovascular measures that were rewarded by the financial incentive program and 4 measures that were not rewarded by incentives. RESULTS: Financial incentives for quality were consistently associated with higher performance for the incentivized measures [+10.1 percentage points at 18 mo of exposure (approximately +22%), P<0.05] and lower performance for the unincentivized measures [-8.3 percentage points at 12 mo of exposure (approximately -20%), P<0.05]. Technical assistance was associated with higher quality for the unincentivized measures, but not for the incentivized measures. CONCLUSIONS: Technical assistance and financial incentives-alongside EHR implementation-can improve quality of care. Financial incentives for quality may not result in similar improvements for incentivized and unincentivized measures.

Does it get easier to use an EHR? Report from an urban regional extension center.

BACKGROUND: Little is known about whether more experience with an electronic health record (EHR) makes it easier for providers to meaningfully use EHRs. OBJECTIVE: To assess whether the length of time that small practice providers have been using the EHR is associated with greater ease in performing meaningful use-related tasks and fewer EHR-related concerns. DESIGN/PARTICIPANTS: We administered a web-based survey to 400 small practice providers in medically underserved communities in New York City participating in an EHR implementation and technical assistance project. We used logistic regression to estimate the association between the length of time a provider had been using the EHR (i.e., "live") and the ease of performing meaningful use-related tasks and EHR-related concerns, controlling for provider and practice characteristics. KEY RESULTS: Compared to providers who had been live 6 to 12 months, providers who had been live 2 years or longer had 2.02 times greater odds of reporting it was easy to e-prescribe new prescriptions (p < 0.05), 2.12 times greater odds of reporting it was easy to e-prescribe renewal prescriptions (p < 0.05), 2.02 times greater odds of reporting that quality measures were easy to report (p < 0.05), 2.64 times greater odds of reporting it was easy to incorporate lab results as structured data (p < 0.001), and 2.00 times greater odds of reporting it was easy to generate patient lists by condition (p < 0.05). Providers who had been live 2 years or longer had 0.40 times lower odds of reporting financial costs were a concern (p < 0.001), 0.46 times lower odds of reporting that productivity loss was a concern (p < 0.05), 0.54 times lower odds of reporting that EHR unreliability was a concern (p < 0.05), and 0.50 times lower odds of reporting that privacy/security was a concern (p < 0.05). CONCLUSIONS: Providers can successfully adjust to the EHR and over time are better able to meaningfully use the EHR.

Specification of the utility function in discrete choice experiments.

BACKGROUND: The specification of the utility function has received limited attention within the discrete choice experiment (DCE) literature. This lack of investigation is surprising given that evidence from the contingent valuation literature suggests that welfare estimates are sensitive to different specifications of the utility function. OBJECTIVE: This study investigates the effect of different specifications of the utility function on results within a DCE. METHODS: The DCE elicited the public's preferences for waiting time for hip and knee replacement and estimated willingness to wait (WTW). RESULTS: The results showed that the WTW for the different patient profiles varied considerably across the three different specifications of the utility function. Assuming a linear utility function led to much higher estimates of marginal rates of substitution (WTWs) than with nonlinear specifications. The goodness-of-fit measures indicated that nonlinear specifications were superior.

Trade-offs between overall survival and side effects in the treatment of metastatic breast cancer: eliciting preferences of patients with primary and metastatic breast cancer using a discrete choice experiment.

OBJECTIVES: There has been a recent proliferation in treatment options for patients with metastatic breast cancer. Such treatments often involve trade-offs between overall survival and side effects. Our study aims to estimate the trade-offs that could be used to inform decision-making at the individual and policy level. DESIGN: We designed a discrete choice experiment (DCE) to look at preferences for avoiding severity levels of side effects when choosing treatment for metastatic breast cancer. Treatment attributes were: fatigue, nausea, diarrhoea, other side effects (peripheral neuropathy, hand-foot syndrome and mucositis) and urgent hospital admission and overall survival. Responses were analysed using an error component logit model. We estimated the relative importance of attributes and minimum acceptable survival for improvements in side effects. SETTING: The DCE was completed online by UK residents with self-reported diagnoses of breast cancer. PARTICIPANTS: 105 respondents participated, of which 72 patients had metastatic breast cancer and 33 patients had primary breast cancer. RESULTS: Overall survival had the largest relative importance, followed by other side effects, diarrhoea, nausea and fatigue. The risk of urgent hospital admission was not significant. While overall survival was the most important attribute, respondents were willing to forgo some absolute probability of overall survival for reductions in all Grade 2 side effects (12.02% for hand-foot syndrome, 11.01% for mucositis, 10.42% for peripheral neuropathy, 6.33% for diarrhoea and 3.62% for nausea). Grade 1 side effects were not significant, suggesting respondents have a general tolerance for them. CONCLUSIONS: Patients are willing to forgo overall survival to avoid particular severity levels of side effects. Our results have implications for data collected in research studies and can help inform person-centred care and shared decision-making.

Public preferences and willingness to pay for a net zero NHS: a protocol for a discrete choice experiment in England and Scotland.

INTRODUCTION: Climate change poses a major threat to our health, livelihoods and the planet. In 2020, the UK National Health Service (NHS) committed to reducing its Scope 1, 2 and 3 emissions to reach net zero by 2045. Although a net zero NHS would help to limit the consequences of climate change, little is known about the UK general public's values and preferences for the proposed service changes needed to reach net zero. METHODS: This study will elicit the public's preferences for actions to help achieve net zero NHS in England and Scotland using a discrete choice experiment (DCE). The DCE attributes and levels describe actions that can be taken by the NHS across key areas: buildings and estates, outdoor space, travel and transport, provision of care, goods and services and food and catering. The survey was designed using online think-aloud interviews with 17 members of the public. Two versions of the survey will be administered to a sample of up to 2200 respondents. One will include a payment vehicle as income tax increases. We will estimate the relative importance of each attribute and, for the former survey, the monetary trade-offs which individuals are willing to make between attributes. Where possible, we will match both samples to gauge preference robustness with the inclusion of the monetary payment. We will test whether respondents' preferences differ based on their socioeconomic circumstances and attitudes toward the NHS and climate change. ETHICS AND DISSEMINATION: The University of Aberdeen's School of Medicine, Medical Sciences and Nutrition Ethics Research Board has approved the study (reference: SERB/690090). All participants will provide informed consent. Results will be submitted to peer-reviewed publications and presented at relevant conferences and seminars. A lay summary of the research will be published on the Health Economics Research Unit website.

Should Scotland provide genome-wide sequencing for the diagnosis of rare developmental disorders? A cost-effectiveness analysis.

AIMS: This study aims to evaluate the cost effectiveness of genetic and genomic testing strategies for the diagnosis of rare developmental disorders in NHS Scotland. METHODS: Six genetic and genomic testing strategies were evaluated using a decision tree model. First-line, second-line and last-resort trio genome sequencing (GS), and second-line and last-resort trio exome sequencing (ES) were compared with standard genetic testing. The cost effectiveness of each strategy was expressed in terms of incremental cost per additional diagnosis. The impact of uncertainty on cost-effectiveness results was explored using deterministic and probabilistic sensitivity analysis. RESULTS: 2nd-line ES was a cost-saving option, increasing diagnostic yield by 13.9% and decreasing cost by £1027 per trio compared to standard genetic testing. Compared to ES, strategies involving GS increased costs significantly, with only a moderate or zero improvement in diagnostic yield. Sensitivity analysis indicated that significant reductions in cost or improvements in diagnostic yield are required before 1st-line GS becomes cost effective. CONCLUSION: 2nd-line ES (after chromosomal microarray; replacing gene panel testing) for the diagnosis of developmental disorders is a cost-saving option for the Scottish NHS. Ongoing economic evaluation is required to monitor the evolving cost and diagnostic yield of GS and ES over time.

Patient-centered medical home among small urban practices serving low-income and disadvantaged patients.

PURPOSE: Research on the patient-centered medical home (PCMH) model and practice redesign has not focused on the unique challenges and strengths of very small primary care practices serving disadvantaged patient populations. We analyzed the practice characteristics, prior experiences, and dimensions of the PCMH model that exist in such practices participating in the Primary Care Information Project (PCIP) of the New York City Department of Mental Health and Hygiene. METHODS: We obtained descriptive data, focusing on PCMH, for 94 primary care practices with 5 or fewer clinicians serving high volumes of Medicaid and minority patient populations in New York City. Data included information extracted from PCIP administrative data and survey data collected specifically for this study. RESULTS: Survey results indicated substantial implementation of key aspects of the PCMH among small practices serving disadvantaged patient populations, despite considerable potential challenges to achieving PCMH implementation. Practices tended to use few formal mechanisms, such as formal care teams and designated care or case managers, but there was considerable evidence of use of informal team-based care and care coordination nonetheless. It appears that many of these practices achieved the spirit, if not the letter, of the law in terms of key dimensions of PCMH. CONCLUSIONS: Small practices can achieve important aspects of the PCMH model of primary care, often with informal rather than formal mechanisms and strategies. The use of flexible, less formal strategies is important to keep in mind when considering implementation and assessment of PCMH-like initiatives in small practices.