Adjusting the risk-adjustment: Accounting for variation between organisations in the responsiveness of their expenditure to need.

There is concern that basing healthcare budgets on risk adjustment estimates derived from historical utilisation data may reinforce patterns of unmet need. We propose a method to avoid this, based on a measure of how closely local health organisations align resources to the needs of their populations. We refer to this measure as the 'responsiveness of expenditure to need' and estimate it using national person-level data on use of acute hospital and secondary mental health services in England. We find large variation in responsiveness in both services and show that higher expenditure responsiveness in mental health is associated with fewer suicides. We then re-estimate the national risk-adjustment model removing the data from the organisations with the lowest expenditure responsiveness to need. As expected, higher need individuals are estimated to have higher expenditure needs when less responsive organisations are removed from the estimation of the risk-adjustment. Removal of organisations with below-average responsiveness results in the neediest deciles of individuals having an extra £163 (7%) annual need for acute hospital care and an additional £79 (27%) annual need for mental health services. The application of this approach to risk adjustment would result in more resources being directed towards organisations serving higher-need populations.

Would plain packaging and health warning labels reduce smoking in the presence of informal markets? A choice experiment in Colombia.

BACKGROUND: Despite progress made by many countries on the adoption of plain tobacco packaging laws over the last years, low- and middle-income countries, with a large supply of loose cigarettes via informal vendors, remain far behind. AIM: To study the potential effectiveness of plain tobacco packaging and dissuasive cigarette sticks, via willingness-to-pay estimates, when illicit cigarette options are available. METHODS: We conducted a discrete choice experiment (DCE) in which respondents chose licit and illicit products with three attributes: packaging (standard vs. plain packaging), stick design (branded stick vs. stick with warning), and price level. The sample, collected on 12/2021, consisted of 1761 respondents from an internet panel involving smokers and nonsmokers. Conditional logit and latent class models were used to estimate the willingness-to-pay (WTP) to avoid restrictive packaging elements. RESULTS: Nonsmokers are willing to pay USD $5.63 for a pack of cigarettes to avoid plain packaging, which is higher than the actual commercial price of illicit cigarettes (USD $2.40). The WTP increases to USD $12.14 in the presence of illicit alternatives. Smokers are also willing to pay to avoid illicit options, which they also deem riskier, and the presence of such options increases the WTP to avoid plain packaging. However, nonsmokers do not perceive the illicit option as riskier. The dissuasive stick (stick with warning) does not affect perceptions of risk and plays a small role in terms of choice for both smokers and nonsmokers. CONCLUSIONS: Even in the presence of illicit tobacco alternatives, plain packaging seems to be as effective in reducing the attractiveness of tobacco products in Colombia as in other countries that have already adopted it. Given conflicting results on the case for dissuasive sticks, there is a need for more research.

The direct and spillover effects of diabetes diagnosis on lifestyle behaviours.

Using blood sample data we exploit an arbitrary cut-off of diabetes risk and through a fuzzy regression kink design we estimate the effect of a diabetes diagnosis on own and partner health-related behaviours. Diabetes diagnosis increases the probability of exercising, both for those diagnosed with diabetes and their partner. We also conduct mediation analysis which suggests that joint household participation is the channel behind this effect. Our results have significant implications for the understanding of the channels that induce behavioural change, and household decision making, as well as, for the evaluation of diabetes related policies.

Cigarette packaging, warnings, prices, and contraband: A discrete choice experiment among smokers in Ontario, Canada.

In Canada, despite substantial decline, tobacco use remains the leading risk factor responsible for mortality and morbidity. There is overwhelming evidence that higher tobacco taxes reduce tobacco use, even if high taxes create an incentive to avoid or evade tobacco taxes. Recently, in addition to taxes, plain and standardized packaging and printing a warning on each cigarette have been lauded to reduce tobacco use. In November 2019, Canada became the country with the most comprehensive cigarette packaging regulations; and in June 2022, Canada proposed to print health warnings on individual cigarettes, the first jurisdiction to ever do so. The regulations came into force on August 1, 2023, and are being implemented through a stepwise approach. Our objective was to examine the effects of plain and standardized packaging, warning on cigarettes, price, and the availability of illicit cigarettes on intention to purchase and risk perceptions. We conducted a discrete choice experiment, and examined heterogeneity in preferences using latent class models among smokers in Ontario, Canada. We found that using latent class analyses was essential in quantifying preferences for attributes of cigarettes and cigarette packs. First, nearly half of smokers stated a preference for cheaper illicit cigarettes in a branded pack without any health warnings, regardless of the licit cigarette alternatives. For about 20% of respondents, plain packaging and especially warning on cigarette sticks decreased the probability of stating a purchasing preference for these alternatives. Third, about a third of respondents chose competing alternatives with mostly one attribute in mind, price. Lastly, none of the products and attributes seem to have significantly influenced risk perception. Our findings attest to the importance of prices and taxes, to the potential of warnings on cigarette sticks to control tobacco use, and indicate that efforts to restrict the availability of illicit cigarettes may yield substantial benefits.

Discrete choice experiment exploring women's preferences in a novel device designed to monitor the womb environment and improve our understanding of reproductive disorders.

OBJECTIVES: The study aims to determine the relative importance of key attributes of a novel intrauterine device. The device monitors uterine oxygen, pH and temperature in real time with the aim of improving our understanding and treatment of reproductive disorders. DESIGN: A discrete choice experiment was used to elicit preferences in this novel investigative tool. The attributes and levels used in the choice scenarios were length of time using the device (7, 14 or 28 days), information obtained to guide treatment (limited, majority or all cases), risk of complications (1% or 10%) and discreteness (completely discrete, moderately discrete or indiscrete). SETTING: Secondary care hospital in Hampshire, UK. PARTICIPANTS: 361 women of reproductive age. PRIMARY AND SECONDARY OUTCOME MEASURES: Conditional logit and latent class logit regression models to determine the preference for each attribute. RESULTS: Conditional logit coefficients allow comparison between attributes; women placed most importance on obtaining information to guide treatment in all cases (2.771), followed by having a completely discrete device (1.104), reducing risk of complications by 1% (0.184) and decreased length of time by 1 day (0.0150). All coefficients p<0.01. Latent class conditional logit assigns participants to two classes with 27.4% in class 1 who are less likely to have higher education or qualify for National Health Service-funded in vitro fertilisation compared with class 2. Those in class 2 placed 1.7 times more importance on a device whose information guided treatment in all cases and a 1% decrease in complications risk was nearly 15 times more attractive. CONCLUSIONS: Women placed most importance on having a device that obtains information to guide treatment and are willing to use the device for a longer, have a device with higher risk of complications and an indiscrete device if it is able to provide answers and direction for treatment of their reproductive disorder.

Patient preferences for use of virtual consultations in an orthopaedic rehabilitation setting: Results from a discrete choice experiment.

OBJECTIVE: Virtual Consultations may reduce the need for face-to-face outpatient appointments, thereby potentially reducing the cost and time involved in delivering health care. This study reports a discrete choice experiment (DCE) that identifies factors that influence patient preferences for virtual consultations in an orthopaedic rehabilitation setting. METHODS: Previous research from the CONNECT (Care in Orthopaedics, burdeN of treatmeNt and the Effect of Communication Technology) Project and best practice guidance informed the development of our DCE. An efficient fractional factorial design with 16 choice scenarios was created that identified all main effects and partial two-way interactions. The design was divided into two blocks of eight scenarios each, to reduce the impact of cognitive fatigue. Data analysis were conducted using binary logit regression models. RESULTS: Sixty-one paired response sets (122 subjects) were available for analysis. DCE factors (whether the therapist is known to the patient, duration of appointment, time of day) and demographic factors (patient qualifications, access to equipment, difficulty with activities, multiple health issues, travel costs) were significant predictors of preference. We estimate that a patient is less than 1% likely to prefer a virtual consultation if the patient has a degree, is without access to the equipment and software to undertake a virtual consultation, does not have difficulties with day-to-day activities, is undergoing rehabilitation for one problem area, has to pay less than £5 to travel, is having a consultation with a therapist not known to them, in 1 weeks' time, lasting 60 minutes, at 2 pm. We have developed a simple conceptual model to explain how these factors interact to inform preference, including patients' access to resources, context for the consultation and the requirements of the consultation. CONCLUSIONS: This conceptual model provides the framework to focus attention towards factors that might influence patient preference for virtual consultations. Our model can inform the development of future technologies, trials, and qualitative work to further explore the mechanisms that influence preference.

Price versus clinical guidelines in primary care statin prescribing: a retrospective cohort study and cost simulation model.

OBJECTIVE: To investigate the relative impact of generic entry and National Institute for Health and Care Excellence clinical guidelines on prescribing using statins as an exemplar. DESIGN: Retrospective analysis of statin prescribing in primary care and cost simulation model. SETTING: Royal College of General Practitioners Research and Surveillance Centre (RCGP R&SC) database and Prescription Cost Analysis (PCA) database. PARTICIPANTS: New patients prescribed statins for the first time between July 2003 and September 2018. MAIN OUTCOME MEASURES: Shares of new patients prescribed one of the five statins available in the British National Formulary, and cost of prescribing statins to new and existing patients in primary care in England. RESULTS: General trends of statin' prescriptions were largely driven by a decrease in acquisition costs triggered by patent expiration, preceding NICE guidelines which themselves did not seem to affect prescription trends. Significant heterogeneity is observed in the prescription of the most cost-effective statin acrossGPs. A cost simulation shows that, between 2004 and 2018, the NHS could have saved £2.8bn (around 40% of the £6.3bn spent on statins during this time) if all GP practices had prescribed only the most cost-effective treatment. CONCLUSIONS: There is potential for large savings for the NHS if new and, whenever possible, ongoing patients are promptly switched to the first medicine that becomes available as generic within a therapeutic class as long as it has similar efficacy to still-patented medicines.

Incidence and risk factors of cancer in individuals with cystic fibrosis in the UK; a case-control study.

To assess cancer incidence in the UK cystic fibrosis (CF) population and determine the associated risk factors, we undertook a nested case-control study of patients with CF, registered with the UK CF Registry. Each case with a first reported cancer between 1999 and 2017 was matched with up to 4 controls: by age (±2-years) and year of cancer diagnosis. Conditional logistic regressions were adjusted for sex, lung function (FEV1%), CF related diabetes (CFRD), F508del status, transplant status, DIOS, gastro-oesophageal reflux disease, meconium ileus, Pseudomonas aeruginosa infection, pancreatic insufficiency, proton pump inhibitor (PPI) use, IV antibiotic days and BMI. Results: From 12,886 registered patients, 146 (1.1%) cases of malignancy were identified with 14.3% of cases occurring post solid organ transplant. Site of primary cancer was available for 98 patients: 22% were gastro-intestinal in origin (77% lower, 23% upper GI), 13% skin, 13% breast and 11% lymphomas/leukaemia. In univariable analysis, transplantation increased the odds of reporting any cancer by 2.46 times (95%CI: 1.3-4.6). CFRD also increased the odds of reporting any cancer (OR 2.35; CI: 1.37-4.0) and PPI use (OR 2.0; CI 1.28-3.19). In the multivariable models significant associations with CFRD and transplant remained, while PA infection, PPI use and being overweight showed increased, but statistically insignificant risks. The incidence of GI cancer was strongly associated with CFRD (OR=4.04; 1.47-11.1). Conclusions: We observed a high incidence of lower GI cancers in our cohort which was significantly affected by the presence of CFRD. Screening for gastrointestinal cancers could benefit patients at higher risk.

Powered Respirators Are Effective, Sustainable, and Cost-Effective Personal Protective Equipment for SARS-CoV-2.

Objectives: The provision of high-quality personal protective equipment (PPE) has been a critical challenge during the COVID-19 pandemic. We evaluated an alternative strategy, mass deployment of a powered air-purifying respirator (PeRSo), in a large university hospital. Methods: We performed prospective user feedback via questionnaires sent to healthcare workers (HCWs) issued PeRSos, economic analysis, and evaluated the real-world impact. Results: Where paired responses were available, PeRSo was preferred over droplet precautions for comfort, patient response, overall experience, and subjective feeling of safety. For all responses, more participants reported the overall experience being rated "Very good" more frequently for PeRSo. The primary limitation identified was impairment of hearing. Economic simulation exercises revealed that the adoption of PeRSo within ICU is associated with net cost savings in the majority of scenarios and savings increased progressively with greater ITU occupancy. In evaluation during the second UK wave, over 3,600 respirators were deployed, all requested by staff, which were associated with a low staff absence relative to most comparator hospitals. Conclusions: Health services should consider a widespread implementation of powered reusable respirators as a safe and sustainable solution for the protection of HCWs as SARS-CoV-2 becomes an endemic viral illness.

A proof-of-concept framework for the preference elicitation and evaluation of health informatics technologies: the online PRESENT patient experience dashboard as a case example.

BACKGROUND: Constrained budgets within healthcare systems and the need to efficiently allocate resources often necessitate the valuation of healthcare interventions and services. However, when a technological product is developed for which no market exists it is a challenge to understand how to place the product and which specifications are the most sought after and important for end users. This was the case for a dashboard we developed, displaying analyses of patient experience survey free-text comments. METHOD: We describe a customisation and evaluation process for our online dashboard that addresses this challenge, using a Discrete Choice Experiment (DCE). We were not interested in the exact content of the dashboard, which was determined in previous stages of our larger study, but on the availability of features and customization options and how they affect individuals' purchasing behaviours. RESULTS: Our DCE completion rate was 33/152 (22%). Certain features were highly desirable - the search function, filtering, and upload own data - and would contribute significant added value to the dashboard. Purchasing behaviour was dependent on the dashboard features, going from a 10 to 90% probability to purchase when we moved from a baseline to a fully-featured dashboard. The purchasing behaviour elicited in this study assumes individuals already have buy-in to the online dashboard, so we assessed only how the various features of our dashboard influence the probability of purchasing the product. Results were used to inform development of a generic checklist of desirable healthcare dashboard features as well as to refine the dashboard itself. Our study suggests the development of the online dashboard and its roll-out in the market would result in a positive net benefit in terms of utilities. The cost-benefit analysis offers a lower bound estimate of the net benefit as it does not acknowledge or incorporate non-monetary benefits that would result from the use of the online dashboard, such as from improved healthcare management. CONCLUSION: DCEs can be successfully used to inform development of an online dashboard by determining preferences for particular features and customisation options and how this affects individuals' purchasing behaviours. The process should be transferable to the development of other technologies.

Inequality aversion in income, health, and income-related health.

Based on a survey of a sample of the general public, we estimate inequality aversion across income, health, and bivariate income-health. Inequality aversion is domain specific: mean inequality aversion is greater for income than for health, but the underlying distributions of aversion attitudes differ, with a highly bi-modal distribution of inequality-aversion values for health in which nearly half the participants display very low aversion and nearly half display very high aversion. Aversion to income-related health inequality is greater than that to income or health alone. Consistent with previous literature, we find only weak associations between aversion attitudes and individual characteristics. The magnitude of the estimates implies potentially large gains in welfare from reducing inequality in these domains.

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.

Protocol for the CONNECT project: a mixed methods study investigating patient preferences for communication technology use in orthopaedic rehabilitation consultations.

INTRODUCTION: Technology has been placed at the centre of global health policy and has been cited as having the potential to increase efficiency and remove geographical boundaries for patients to access care. Communication technology may support patients with orthopaedic problems, which is one of the leading causes of disability worldwide. There are several examples of technology being used in clinical research, although uptake in practice remains low. An understanding of patient preferences will support the design of a communication technology supported treatment pathway for patients undergoing orthopaedic rehabilitation. METHODS AND ANALYSIS: This mixed methods project will be conducted in four phases. In phase I, a systematic review of qualitative studies reporting communication technology use for orthopaedic rehabilitation will be conducted to devise a taxonomy of tasks patients' face when using these technologies to access their care. In phase II, qualitative interviews will investigate how the work of being a patient changes during face-to-face and communication technology consultations and how these changes influence preference. In phase III, a discrete choice experiment will investigate the factors that influence preferences for the use of communication technology for orthopaedic rehabilitation consultations. Phase IV will be a practical application of these results. We will design a 'minimally disruptive' communication technology supported pathway for patients undergoing orthopaedic rehabilitation. ETHICS AND DISSEMINATION: The design of a pathway and underpinning patient preference will assist in understanding factors that might influence technology implementation for clinical care. This study requires ethical approval for phases II, III and IV. Approvals have been received for phase II (approval received on 4 December 2016 from the South Central-Oxford C Research Ethics Committee (IRAS ID: 255172, REC Reference 18/SC/0663)) and phase III (approval received on 18 October 2019 from the London-Hampstead Research Ethics Committee (IRAS ID: 248064, REC Reference 19/LO/1586)) and will be sought for phase IV. All participants will provide informed written consent prior to being enrolled onto the study. PROSPERO REGISTRATION NUMBER: CRD42018100896.

Estimating Determinants of Attrition in Eating Disorder Communities on Twitter: An Instrumental Variables Approach.

BACKGROUND: The use of social media as a key health information source has increased steadily among people affected by eating disorders (EDs). Research has examined characteristics of individuals engaging in online communities, whereas little is known about discontinuation of engagement and the phenomenon of participants dropping out of these communities. OBJECTIVE: This study aimed to investigate the characteristics of dropout behaviors among eating disordered individuals on Twitter and to estimate the causal effects of personal emotions and social networks on dropout behaviors. METHODS: Using a snowball sampling method, we collected a set of individuals who self-identified with EDs in their Twitter profile descriptions, as well as their tweets and social networks, leading to 241,243,043 tweets from 208,063 users. Individuals' emotions are measured from their language use in tweets using an automatic sentiment analysis tool, and network centralities are measured from users' following networks. Dropout statuses of users are observed in a follow-up period 1.5 years later (from February 11, 2016 to August 17, 2017). Linear and survival regression instrumental variables models are used to estimate the effects of emotions and network centrality on dropout behaviors. The average levels of attributes among an individual's followees (ie, people who are followed by the individual) are used as instruments for the individual's attributes. RESULTS: Eating disordered users have relatively short periods of activity on Twitter with one half of our sample dropping out at 6 months after account creation. Active users show more negative emotions and higher network centralities than dropped-out users. Active users tend to connect to other active users, whereas dropped-out users tend to cluster together. Estimation results suggest that users' emotions and network centralities have causal effects on their dropout behaviors on Twitter. More specifically, users with positive emotions are more likely to drop out and have shorter lasting periods of activity online than users with negative emotions, whereas central users in a social network have longer lasting participation than peripheral users. Findings on users' tweeting interests further show that users who attempt to recover from EDs are more likely to drop out than those who promote EDs as a lifestyle choice. CONCLUSIONS: Presence in online communities is strongly determined by the individual's emotions and social networks, suggesting that studies analyzing and trying to draw condition and population characteristics through online health communities are likely to be biased. Future research needs to examine in more detail the links between individual characteristics and participation patterns if better understanding of the entire population is to be achieved. At the same time, such attrition dynamics need to be acknowledged and controlled when designing online interventions so as to accurately capture their intended populations.

Social interactions in online eating disorder communities: A network perspective.

Online health communities facilitate communication among people with health problems. Most prior studies focus on examining characteristics of these communities in sharing content, while limited work has explored social interactions between communities with different stances on a health problem. Here, we analyse a large communication network of individuals affected by eating disorders on Twitter and explore how communities of individuals with different stances on the disease interact online. Based on a large set of tweets posted by individuals who self-identify with eating disorders online, we establish the existence of two communities: a large community reinforcing disordered eating behaviours and a second, smaller community supporting efforts to recover from the disease. We find that individuals tend to mainly interact with others within the same community, with limited interactions across communities and inter-community interactions characterized by more negative emotions than intra-community interactions. Moreover, by studying the associations between individuals' behavioural characteristics and interpersonal connections in the communication network, we present the first large-scale investigation of social norms in online health communities, particularly on how a community approves of individuals' behaviours. Our findings shed new light on how people form online health communities and can have broad clinical implications on disease prevention and online intervention.

Body-weight and psychological well-being in the UK general population.

Background: While the consequences of body weight for physical health are well explored, the evidence for psychological well-being is less straightforward. An instrumental variable approach is used to address the endogenous relationship between body weight and well-being in the UK general population. Methods: Data from the Health Survey for England (2003, 2004 and 2006) are used to fit linear and ordered probit instrument variable models for a sample of 13 862 individuals, with frequent white meat consumption instrumenting for body-weight. Non-linearities in the relationship, robustness to weak instruments and relaxation of strict exogeneity assumption are further examined. Results: Accounting for endogeneity and conditional on health a protective effect on well-being is observed. A unit increase in body mass index (BMI) improves General Health Questionnaire (GHQ) by 0.17 (95% CI: 0.02-0.31) points and reduces the probability of reporting very low GHQ by 2.5% (95% CI: 0.01-0.05). Empirical testing showed that the instrument performs well, with increased meat consumption adding 0.58 points (95% CI: 0.42-0.74) to ones' BMI. Conclusions: We present support for the jolly-fat hypothesis, however, caution is recommended in drawing inferences. Further research needs to resolve the mixed findings in the literature.

Efficiency and equity considerations in the preferences of health policy-makers in Israel.

BACKGROUND: There is a traditional tension in public policy between the maximization of welfare from given resources (efficiency) and considerations related to the distribution of welfare among the population and to social justice (equity). The aim of this paper is to measure the relative weights of the efficiency- and equity-enhancing criteria in the preferences of health policy-makers in Israel, and to compare the Israeli results with those of other countries. METHODS: We used the criteria of efficiency and equity which were adopted in a previous international study, adapted to Israel. The equity criteria, as defined in the international study, are: severity of the disease, age (young vs. elderly), and the extent to which the poor are subsidized. Efficiency is represented by the criteria: the potential number of beneficiaries, the extent of the health benefits to the patient, and the results of economic assessments (cost per QALY gained). We contacted 147 policy-makers, 65 of whom completed the survey (a response rate of 44%). Using Discrete Choice Experiment (DCE) methodology by 1000Minds software, we estimated the relative weights of these seven criteria, and predicted the desirability of technologies characterized by profiles of the criteria. RESULTS: The overall weight attached to the four efficiency criteria was 46% and that of the three equity criteria was 54%. The most important criteria were "financing of the technology is required so that the poor will be able to receive it" and the level of individual benefit. "The technology is intended to be used by the elderly" criterion appeared as the least important, taking the seventh place. Policy-makers who had experience as members of the Basket Committee appear to prefer efficiency criteria more than those who had never participated in the Basket Committee deliberations. While the efficiency consideration gained preference in most countries studied, Israel is unique in its balance between the weights attached to equity and efficiency considerations by health policy-makers. DISCUSSION: The study explored the trade-off between efficiency and equity considerations in the preferences of health policy-makers in Israel. The way these declarative preferences have been expressed in actual policy decisions remains to be explored.

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.

Comparative analysis of decision maker preferences for equity/efficiency attributes in reimbursement decisions in three European countries.

BACKGROUND: In addition to cost-effectiveness, national guidelines often include other factors in reimbursement decisions. However, weights attached to these are rarely quantified, thus decisions can depend strongly on decision-maker preferences. OBJECTIVE: To explore the preferences of policymakers and healthcare professionals involved in the decision-making process for different efficiency and equity attributes of interventions and to analyse cross-country differences. METHOD: Discrete choice experiments (DCEs) were carried out in Austria, Hungary, and Norway with policymakers and other professionals working in the health industry (N = 153 respondents). Interventions were described in terms of different efficiency and equity attributes (severity of disease, target age of the population and willingness to subsidise others, potential number of beneficiaries, individual health benefit, and cost-effectiveness). Parameter estimates from the DCE were used to calculate the probability of choosing a healthcare intervention with different characteristics, and to rank different equity and efficiency attributes according to their importance. RESULTS: In all three countries, cost-effectiveness, individual health benefit and severity of the disease were significant and equally important determinants of decisions. All countries show preferences for interventions targeting young and middle aged populations compared to those targeting populations over 60. However, decision-makers in Austria and Hungary show preferences more oriented to efficiency than equity, while those in Norway show equal preferences for equity and efficiency attributes. CONCLUSION: We find that factors other than cost-effectiveness seem to play an equally important role in decision-making. We also find evidence of cross-country differences in the weight of efficiency and equity attributes.

Psychological Distress and Problem Drinking.

We examine the influence of harmful alcohol use on mental health using a flexible two-step instrumental variables approach and household survey data from nine countries of the former Soviet Union. Using alcohol advertisements to instrument for alcohol, we show that problem drinking has a large detrimental effect on psychological distress, with problem drinkers exhibiting a 42% increase in the number of mental health problems reported and a 15% higher chance of reporting very poor mental health. Ignoring endogeneity leads to an underestimation of the damaging effect of excessive drinking. Findings suggest that more effective alcohol policies and treatment services in the former Soviet Union may have added benefits in terms of reducing poor mental health.