The impact of health vs. non-health goals on individuals' lifestyle program choices: a discrete choice experiment approach.

BACKGROUND: Goals play an important role in the choices that individuals make. Yet, there is no clear approach of how to incorporate goals in discrete choice experiments. In this paper, we present such an approach and illustrate it in the context of lifestyle programs. Furthermore, we investigate how non-health vs. health goals affect individuals' choices via non-goal attributes. METHODS: We used an unlabeled discrete choice experiment about lifestyle programs based on two experimental conditions in which either a non-health goal (i.e., looking better) or a health goal (i.e., increasing life expectancy) was presented to respondents as a fixed attribute level for the goal attribute. Respondents were randomly distributed over the experimental conditions. Eventually, we used data from 407 Dutch adults who reported to be overweight (n = 212 for the non-health goal, and n = 195 for the health goal). RESULTS: Random parameter logit model estimates show that the type of goal significantly (p < 0.05) moderates the effect that the attribute diet has on lifestyle program choice, but that this is not the case for the attributes exercise per week and expected weight loss. CONCLUSIONS: A flexible diet is more important for individuals with a non-health goal than for individuals with a health goal. Therefore, we advise policy makers to use information on goal interactions for developing new policies and communication strategies to target population segments that have different goals. Furthermore, we recommend researchers to consider the impact of goals when designing discrete choice experiments.

The effect of presenting information about invasive follow-up testing on individuals' noninvasive colorectal cancer screening participation decision: results from a discrete choice experiment.

OBJECTIVES: Many national colorectal cancer screening campaigns have a similar structure. First, individuals are invited to take a noninvasive screening test, and, second, in the case of a positive screening test result, they are advised to undergo a more invasive follow-up test. The objective of this study was to investigate how much individuals' participation decision in noninvasive screening is affected by the presence or absence of detailed information about invasive follow-up testing and how this effect varies over screening tests. METHODS: We used a labeled discrete choice experiment of three noninvasive colorectal cancer screening types with two versions that did or did not present respondents with detailed information about the possible invasive follow-up test (i.e., colonoscopy) and its procedure. We used data from 631 Dutch respondents aged 55 to 75 years. Each respondent received only one of the two versions (N = 310 for the invasive follow-up test information specification version, and N = 321 for the no-information specification version). RESULTS: Mixed logit model results show that detailed information about the invasive follow-up test negatively affects screening participation decisions. This effect can be explained mainly by a decrease in choice shares for the most preferred screening test (a combined stool and blood sample test). Choice share simulations based on the discrete choice experiment indicated that presenting invasive follow-up test information decreases screening participation by 4.79%. CONCLUSIONS: Detailed information about the invasive follow-up test has a negative effect on individuals' screening participation decisions in noninvasive colorectal cancer screening campaigns. This result poses new challenges for policymakers who aim not only to increase uptake but also to provide full disclosure to potential screening participants.

Preferences for potential innovations in non-invasive colorectal cancer screening: A labeled discrete choice experiment for a Dutch screening campaign.

BACKGROUND: The introduction of innovative non-invasive screening tests (e.g. tests based on stool and blood samples or both) may be a solution to increase colorectal cancer (CRC) screening uptake. However, preferences for these non-invasive screening tests have not been investigated in great detail yet. The purpose of this article therefore is to elicit individuals' preferences for different non-invasive screening tests in a Dutch screening campaign context. MATERIAL AND METHODS: We investigate preferences by means of a labeled discrete choice experiment. Data of 815 individuals, aged 55-75 years, are used in the analysis. RESULTS: Multinomial logit model analysis showed that the combi-test is generally preferred over the blood-test and the (currently available) stool-test. Furthermore, besides the large effect of screening test type, there are significant differences in preference depending on participants' socio-demographic background. Finally, the analysis showed a significant positive effect on screening test choice for the attributes sensitivity, risk reduction, and level of evidence and a non-significant effect for the attribute unnecessary follow-up test. CONCLUSION: Introducing new non-invasive screening tests that are based on a combination of stool and blood samples (or blood sample only) has the potential to increase CRC screening participation compared to the current standard stool-based test.

Consumer preferences for health and nonhealth outcomes of health promotion: results from a discrete choice experiment.

OBJECTIVE: Health promotion (HP) interventions have outcomes that go beyond health. Such broader nonhealth outcomes are usually neglected in economic evaluation studies. To allow for their consideration, insights are needed into the types of nonhealth outcomes that HP interventions produce and their relative importance compared with health outcomes. This study explored consumer preferences for health and nonhealth outcomes of HP in the context of lifestyle behavior change. METHODS: A discrete choice experiment was conducted among participants in a lifestyle intervention (n = 132) and controls (n = 141). Respondents made 16 binary choices between situations that can be experienced after lifestyle behavior change. The situations were described by 10 attributes: future health state value, start point of future health state, life expectancy, clothing size above ideal, days with sufficient relaxation, endurance, experienced control over lifestyle choices, lifestyle improvement of partner and/or children, monetary cost per month, and time cost per week. RESULTS: With the exception of "time cost per week" and "start point of future health state," all attributes significantly determined consumer choices. Thus, both health and nonhealth outcomes affected consumer choice. Marginal rates of substitution between the price attribute and the other attributes revealed that the attributes "endurance," "days with sufficient relaxation," and "future health state value" had the greatest impact on consumer choices. The "life expectancy" attribute had a relatively low impact and for increases of less than 3 years, respondents were not willing to trade. CONCLUSIONS: Health outcomes and nonhealth outcomes of lifestyle behavior change were both important to consumers in this study. Decision makers should respond to consumer preferences and consider nonhealth outcomes when deciding about HP interventions.

Consumers' intention to use health recommendation systems to receive personalized nutrition advice.

BACKGROUND: Sophisticated recommendation systems are used more and more in the health sector to assist consumers in healthy decision making. In this study we investigate consumers' evaluation of hypothetical health recommendation systems that provide personalized nutrition advice. We examine consumers' intention to use such a health recommendation system as a function of options related to the underlying system (e.g. the type of company that generates the advice) as well as intermediaries (e.g. general practitioner) that might assist in using the system. We further explore if the effect of both the system and intermediaries on intention to use a health recommendation system are mediated by consumers' perceived effort, privacy risk, usefulness and enjoyment. METHODS: 204 respondents from a consumer panel in the Netherlands participated. The data were collected by means of a questionnaire. Each respondent evaluated three hypothetical health recommendation systems on validated multi-scale measures of effort, privacy risk, usefulness, enjoyment and intention to use the system. To test the hypothesized relationships we used regression analyses. RESULTS: We find evidence that the options related to the underlying system as well as the intermediaries involved influence consumers' intention to use such a health recommendation system and that these effects are mediated by perceptions of effort, privacy risk, usefulness and enjoyment. Also, we find that consumers value usefulness of a system more and enjoyment less when a general practitioner advices them to use a health recommendation system than if they use it out of their own curiosity. CONCLUSIONS: We developed and tested a model of consumers' intention to use a health recommendation system. We found that intermediaries play an important role in how consumers evaluate such a system over and above options of the underlying system that is used to generate the recommendation. Also, health-related information services seem to rely on endorsement by the medical sector. This has considerable implications for the distribution as well as the communication channels of health recommendation systems which may be quite difficult to put into practice outside traditional health service channels.

Combining individual-level discrete choice experiment estimates and costs to inform health care management decisions about customized care: the case of follow-up strategies after breast cancer treatment.

OBJECTIVE: Customized care can be beneficial for patients when preferences for health care programs are heterogeneous. Yet, there is little guidance on how individual-specific preferences and cost data can be combined to inform health care decisions about customized care. Therefore, we propose a discrete choice experiment-based approach that illustrates how to analyze the cost-effectiveness of customized (and noncustomized) care programs to provide information for hospital managers. METHODS: We exploit the fact that choice models make it possible to determine whether preference heterogeneity exists and to obtain individual-specific parameter estimates. We present an approach of how to combine these individual-specific parameter estimates from a random parameter model (mixed logit model) with cost data to analyze the cost-effectiveness of customized care and demonstrate our method in the case of follow-up after breast cancer treatment. RESULTS: We found that there is significant preference heterogeneity for all except two attributes of breast cancer treatment follow-up and that the fully customized care program leads to higher utility and lower costs than the current standardized program. Compared with the single alternative program, the fully customized care program has increased benefits and higher costs. Thus, it is necessary for health care decision makers to judge whether the use of resources for customized care is cost-effective. CONCLUSIONS: Decision makers should consider using the results obtained from our methodological approach when they consider implementing customized health care programs, because it may help to find ways to save costs and increase patient satisfaction.

Follow-up after treatment for breast cancer: one strategy fits all? An investigation of patient preferences using a discrete choice experiment.

Clinical guidelines for the follow-up after breast cancer recommend frequent outpatient clinic visits to be examined for a possible recurrence or a second primary breast tumour, and to receive information and psychosocial support. However, needs and preferences for follow-up may differ between patients, raising the question whether the current 'one size fits all' approach is appropriate. This study explored patients' preferences for follow-up. Patients and methods. A discrete choice experiment survey with 16 choice tasks was filled out by 331 breast cancer patients. Each choice task consisted of two hypothetical follow-up scenarios for the first year after treatment, described by levels of the following characteristics; attendance at an educational group programme, frequency of visits, waiting time, contact mode, and type of healthcare provider. Results. The healthcare provider and contact mode were the most important characteristics of follow-up to patients. The medical specialist was the most preferred to perform the follow-up, but a combination of the medical specialist and breast care nurse alternating was also acceptable to patients. Face-to-face contact was strongly preferred to telephone contact. Follow-up visits every three months were preferred over visits every four, six, or 12 months. Heterogeneity in preference between patients was strong, especially for the healthcare provider and attendance at an educational group programme. Age, education, and previous experience with follow-up characteristics influenced preferences, but treatment modality did not. Conclusion. The results of this study show that overall patient satisfaction would not differ significantly if patients have follow-up by medical specialist and breast care nurse alternating compared to follow-up by a medical specialist only. Furthermore, we found heterogeneity in preferences for most attributes, indicating that one strategy does not fit all. Individualised follow-up seems to offer the potential for significant increases in patient satisfaction.

Discrete choice experiments for complex health-care decisions: does hierarchical information integration offer a solution?

This paper describes an application of hierarchical information integration (HII) discrete choice experiments. We assessed theoretical and construct validity, as well as internal consistency, to investigate whether HII can be used to investigate complex multi-faceted health-care decisions (objective 1). In addition, we incorporated recent advances in mixed logit modelling (objective 2). Finally, we determined the response rate and predictive ability to study the feasibility of HII to support health-care management (objective 3). The clinical subject was the implementation of the guideline for breast cancer surgery in day care, which is a complex process that involves changes at the organizational and management levels, as well as the level of health-care professionals and that of patients.We found good theoretical and construct validity and satisfactory internal consistency. The proposed mixed logit model, which included repeated measures corrections and subexperiment error scale variations, also performed well. We found a poor response, but the model had satisfactory predictive ability. Therefore, we conclude that HII can be used successfully to study complex multi-faceted health-care decisions (objectives 1 and 2), but that the feasibility of HII to support health-care management, in particular in challenging implementation projects, seems less favourable (objective 3).

Paying more for faster care? Individuals' attitude toward price-based priority access in health care.

Increased competition in the health care sector has led hospitals and other health care institutions to experiment with new access allocation policies that move away from traditional expert based allocation of care to price-based priority access (i.e., the option to pay more for faster care). To date, little is known about individuals' attitude toward price-based priority access and the evaluation process underlying this attitude. This paper addresses the role of individuals' evaluations of collective health outcomes as an important driver of their attitude toward (price-based) allocation policies in health care. The authors investigate how individuals evaluate price-based priority access by means of scenario-based survey data collected in a representative sample from the Dutch population (N = 1464). They find that (a) offering individuals the opportunity to pay for faster care negatively affects their evaluations of both the total and distributional collective health outcome achieved, (b) however, when health care supply is not restricted (i.e., when treatment can be offered outside versus within the regular working hours of the hospital) offering price-based priority access affects total collective health outcome evaluations positively instead of negatively, but it does not change distributional collective health outcome evaluations. Furthermore, (c) the type of health care treatment (i.e., life saving liver transplantation treatment vs. life improving cosmetic ear correction treatment - priced at the same level to the individual) moderates the effect of collective health outcome evaluations on individuals' attitude toward allocation policies. For policy makers and hospital managers the results presented in this article are helpful because they provide a better understanding of what drives individuals' preferences for health care allocation policies. In particular, the results show that policies based on the "paying more for faster care" principle are more attractive to the general public when treatment takes place outside the regular working hours of a hospital.

Investigating the complementary value of discrete choice experiments for the evaluation of barriers and facilitators in implementation research: a questionnaire survey.

BACKGROUND: The potential barriers and facilitators to change should guide the choice of implementation strategy. Implementation researchers believe that existing methods for the evaluation of potential barriers and facilitators are not satisfactory. Discrete choice experiments (DCE) are relatively new in the health care sector to investigate preferences, and may be of value in the field of implementation research. The objective of our study was to investigate the complementary value of DCE for the evaluation of barriers and facilitators in implementation research. METHODS: Clinical subject was the implementation of the guideline for breast cancer surgery in day care. We identified 17 potential barriers and facilitators to the implementation of this guideline. We used a traditional questionnaire that was made up of statements about the potential barriers and facilitators. Respondents answered 17 statements on a five-point scale ranging from one (fully disagree) to five (fully agree). The potential barriers and facilitators were included in the DCE as decision attributes. Data were gathered among anaesthesiologists, surgical oncologists, and breast care nurses by means of a paper-and-pencil questionnaire. RESULTS: The overall response was 10%. The most striking finding was that the responses to the traditional questionnaire hardly differentiated between barriers. Forty-seven percent of the respondents thought that DCE is an inappropriate method. These respondents considered DCE too difficult and too time-consuming. Unlike the traditional questionnaire, the results of a DCE provide implementation researchers and clinicians with a relative attribute importance ranking that can be used to prioritize potential barriers and facilitators to change, and hence to better fine-tune the implementation strategies to the specific problems and challenges of a particular implementation process. CONCLUSION: The results of our DCE and traditional questionnaire would probably lead to different implementation strategies. Although there is no 'gold standard' for prioritising potential barriers and facilitators to the implementation of change, theoretically, DCE would be the method of choice. However, the feasibility of using DCE was less favourable. Further empirical applications should investigate whether DCE can really make a valuable contribution to the implementation science.