title: Evaluating Health Workers' Potential Resistance to New Interventions: A Role for Discrete Choice Experiments Discrete Choice Experiment to Evaluate Factors That Influence Preferences for Antibiotic Prophylaxis in Pediatric Oncology In the Eye of the Beholder: Preferences of Patients, Family Physicians, and Surgeons for Lumbar Spinal Surgery Citizen Participation in Patient Prioritization Policy Decisions: An Empirical and Experimental Study on Patients' Characteristics Patient and parent preferences for immunoglobulin treatments: a conjoint analysis Patient preferences for reducing toxicities of treatments for gastrointestinal stromal tumor (GIST) Patient preferences for osteoporosis in Spain: a discrete choice experiment Eliciting Population Preferences for Mass Colorectal Cancer Screening Organization What determines patient preferences for treating low risk basal cell carcinoma when comparing surgery vs imiquimod? A discrete choice experiment survey from the SINS trial Using discrete choice experiments to inform randomised controlled trials: an application to chronic low back pain management in primary care. A comparison of two experimental design approaches in applying conjoint analysis in patient-centered outcomes research: a randomized trial. Physicians’ stated trade-off preferences for chronic hepatitis B treatment outcomes in Germany, France, Spain, Turkey, and Italy Patients rank toxicity against progression free survival in second-line treatment of advanced renal cell carcinoma Hypothetical bias, cheap talk, and stated willingness to pay for health care. An empirical comparison of methods for analyzing correlated data from a discrete choice survey to elicit patient preference for colorectal cancer screening Designing Family-Centered Male Circumcision Services Using qualitative methods for attribute development for discrete choice experiments: issues and recommendations. Patients’ view of retail clinics as a source of primary care: Boon for nurse practitioners? Using discrete choice experiment to elicit doctors' preferences for the report card design of diabetes care in Taiwan - a pilot study. Public preferences for establishing nephrology facilities in Greenland: estimating willingness-to-pay using a discrete choice experiment GP preferences for information systems: conjoint analysis of speed, reliability, access and users. 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 Patients', physicians', and pharmacists' preferences towards coagulation factor concentrates to treat haemophilia with inhibitors: results from the COHIBA Study. How Do Physicians Weigh Benefits and Risks Associated with Treatments in Patients with Osteoarthritis in the United Kingdom? Dialysis modality preference of patients with CKD and family caregivers: a discrete-choice study. The effect of information on preferences stated in a choice-based conjoint analysis. Patient and parent preferences for haemophilia A treatments. General practitioners' preferences for the organisation of primary care: a discrete choice experiment. Random Regret-Based Discrete-Choice Modelling: An Application to Healthcare Feasibility of Using Modified Adaptive Conjoint Analysis Importance Questions Patients' Preferences for Scoliosis Brace Treatment: A Discrete Choice Experiment Does the Inclusion of a Cost Attribute Result in Different Preferences for the Surgical Treatment of Primary Basal Cell Carcinoma? Deleting 'irrational' responses from discrete choice experiments: a case of investigating or imposing preferences? Understanding the impact of economic evidence on clinical decision making: a discrete choice experiment in cardiology. Does attribute framing in discrete choice experiments influence willingness to pay? Results from a discrete choice experiment in screening for colorectal cancer. Eliciting public preference for health-care resource allocation in South Korea. Willingness to pay for improvements in chronic long-acting insulin therapy in individuals with type 1 or type 2 diabetes mellitus.
abstract: Background The currently recommended approach for preventing malaria in pregnancy ( MiP ) , intermittent preventive treatment with sulphadoxine-pyrimethamine ( SP-IPT ) , has been question ed due to the spread of resistance to SP . Whilst trials are underway to test the efficacy of future alternative approaches , it is important to start exploring the feasibility of their implementation . Methods and Findings This study uses a discrete choice experiment ( DCE ) method to assess the potential resistance of health workers to changing strategies for control of MiP. In Ashanti region in Ghana , 133 antenatal clinic health workers were presented with 16 choice sets of two alternative policy options , each consisting of a bundle of six attributes representing certain clinical guidelines for controlling MiP ( type of approach and drug used ) , possible associated maternal and neo-natal outcomes , workload and financial incentives . The data were analysed using a r and om effects logit model . Overall , staff showed a preference for a curative approach with pregnant women tested for malaria parasites and treated only if positive , compared to a preventive approach ( OR 1.6 ; p = 0.001 ) . Increasing the incidence of low birth weight or severe anaemia by 1 % would reduce the odds of preferring an approach by 18 % and 10 % respectively . Midwives were more resistant to potential changes to current guidelines than lower-level cadres . Conclusions In Ashanti Region , resistance to change by antenatal clinic workers from a policy of SP-IPT to IST would generally be low , and it would disappear amongst midwives if health outcomes for the mother and baby were improved by the new strategy . DCEs are a promising approach to identifying factors that will increase the likelihood of effective implementation of new interventions immediately after their efficacy has been proven Background Bacterial and fungal infections in pediatric oncology patients cause morbidity and mortality . The clinical utility of antimicrobial prophylaxis  in children is uncertain and the personal utility of these agents is disputed . Objectives were to use a discrete choice experiment to : ( 1 ) describe the importance of attributes to parents and healthcare providers when deciding between use and non-use of antibacterial and antifungal prophylaxis ; and ( 2 ) estimate willingness-to-pay for prophylactic strategies . Methods Attributes were chances of infection , death and side effects , route of administration and cost of pharmacotherapy . Respondents were r and omized to a discrete choice experiment outlining hypothetical treatment options to prevent antibacterial or antifungal infections . Each respondent was presented 16 choice tasks and was asked to choose between two unlabeled treatment options and an opt-out alternative ( no prophylaxis ) . Results 102 parents and 60 healthcare providers participated . For the antibacterial discrete choice experiment , frequency of administration was significantly associated with utility for parents but not for healthcare providers . Increasing chances of infection , death , side effects and cost were all significantly associated with decreased utility for parents and healthcare providers in both the antibacterial and antifungal discrete choice experiment . Parental willingness-to-pay was higher than healthcare providers for both strategies . Conclusion Chances of infection , death , side effects and costs were all significantly associated with utility . Parents have higher willingness-to-pay for these strategies compared with healthcare providers . This knowledge can help to develop prophylaxis programs Study Design . Survey to all orthopedic and neurosurgeons , a r and om sample of family physicians ( FPs ) and patients in Ontario , Canada . Objective . To identify the dominant clinical factors influencing patient and physician preferences for lumbar spinal surgery .  Summary of Background Data . Surgery on the degenerative lumbar spine offers significant benefit for patients with moderate-severe symptoms failing nonoperative treatment . Referring FPs have little appreciation of factors that identify the ideal surgical c and i date . Differences in preferences may lead to wide variation in referrals and impedes the shared decision-making process . Methods . We used conjoint analysis , a rigorous method for eliciting preferences , to determine the importance that respondents place on decisions for lumbar spinal surgery . We identified 6 clinical factors ( walking tolerance , pain duration , severity , neurologic symptoms , typical onset , and dominant location of pain ) and presented hypothetical vignettes to participants who rated their preference for surgery . Data were analyzed using r and om-effects ordered probit regression models and the importance of each clinical factor relative to the others was determined . Results . We obtained responses from 131 surgeons , 202 FPs , and 164 patients . We found that FPs had the highest overall preferences for surgery and surgeons had the lowest . Surgeons placed the highest importance on the location of pain . FPs considered neurologic symptoms , walking tolerance , and severity to be of similar importance . Pain severity , walking tolerance , and duration of pain were the most important factors for patients in deciding for surgery . Orthopedic ( over neurosurgical ) surgeons had a lower preference for surgery ( P < 0.05 ) . Older patients ( P < 0.03 ) and previous surgical consultation ( P < 0.03 ) had greater patient preferences for surgery . Conclusion . Different preferences for surgery exist between surgeons , FPs , and patients . FPs may reduce over- and under-referrals by appreciating surgeons ' importance on location of pain ( leg vs. back ) . Surgeons and FPs may improve the shared decision-making process by underst and ing that patients place high importance on quality of life symptoms Health systems worldwide are grappling with the need to control costs to maintain system viability . With the combination of worsening economic conditions , an aging population and reductions in tax revenues , the pressures to make structural changes are expected to continue growing . Common cost control mechanisms , e.g. curtailment of patient access and treatment prioritization , are likely to be adversely viewed by citizens . It seems therefore wise to include them in the decision making processes that lead up to policy changes . In the context of a multilevel iterative mixed- method design a quantitative survey representative of the German population ( N = 2031 ) was conducted to probe the acceptance of priority setting in medicine and to explore the practicability of direct public involvement . Here we focus on preferences for patients ' characteristics ( medical aspects , lifestyle and socio-economic status ) as possible criteria for prioritizing medical services . A question naire with closed response options was fielded to gain insight into attitudes toward broad prioritization criteria of patient groups . Furthermore , a discrete choice experiment was used as a rigorous approach to investigate citizens ' preferences toward specific criteria level in context of other criteria . Both the question naire and the discrete choice experiment were performed with the same sample . The citizens ' own health and social situation are included as explanatory variables . Data were evaluated using corresponding analysis , contingency analysis , logistic regression and a multinomial exploded logit model . The results show that some medical criteria are highly accepted for prioritizing patients whereas socio-economic criteria are rejected Abstract Objectives : The purpose was to quantify patient and parent preferences for administration attributes of  immunoglobulin ( IG ) treatments ; and determine which administration attributes were most important to users of IG treatment and whether patients and parents have similar preferences for administration attributes . Methods : US adult patients and parents of children with a self-reported physician diagnosis of a primary immunodeficiency disorder completed a best- practice web-enabled choice-format conjoint survey that presented a series of 12 choice questions , each including a pair of hypothetical IG-treatment profiles . After review ing current therapies , each profile was defined by mode of administration , frequency , location , number of needle sticks , and treatment duration . Before answering the choice questions , respondents were told to assume all treatments worked equally well . Choice questions were based on a D-efficient experimental design . Preference weights for attribute levels were estimated using r and om-parameters logit for each sample ( adult patients and parents ) . Tests were performed to determine potential interactions among the administration attributes . All respondents provided online informed consent . Results : In total , 252 patients and 66 parents completed the choice questions appropriately . Overall , both groups preferred a home setting , monthly frequency , fewer needle sticks , and shorter treatment duration s of IG treatment relative to alternative choices ( p < 0.05 ) . Mode of administration was the least important attribute to both sample s ; however , parents strongly preferred  self-administration  to an appointment with a healthcare professional ( p < 0.05 ) , whereas patients slightly preferred self-administration but were indifferent to the two modes . Limitations : Respondents evaluate hypothetical treatments and differences can arise between stated and actual choices . Conclusions : Considering the hypothetical treatments evaluated , IG treatments that provide the option of a home setting , monthly frequency , fewer needle sticks , and shorter treatment duration s may address the needs of both patients and parents . Patients and parents have different preferences for administration attributes of IG treatments Purpose : To quantify gastrointestinal stromal tumor ( GIST ) patients ’ preferences for reducing treatment toxicities and the likely effect of toxicities on patients ’ stated adherence . Methods : English-speaking members of the Life Raft Group , a GIST patient advocacy and research organization , aged 18 years and older , completed a web-enabled survey including a series of treatment-choice questions , each presenting a pair of hypothetical GIST medication toxicity profiles . Each profile was defined by common or concerning toxicities verified via pretest interviews including : severity of edema , diarrhea , nausea , fatigue , rash , h and -foot syndrome , and heart failure ; and risk of serious infection . Each subject answered 13 choice-format questions based on a predetermined experimental design with known statistical properties . Subjects were asked to rate the likelihood that they would miss or skip doses of medications with different toxicity profiles . R and om-parameters logit was used to estimate a relative preference weight for each level of toxicity . Results : 173 subjects completed the survey . Over the ranges of toxicity levels included in the study , heart failure was the most important toxicity . Edema was the least important . For all toxicities , reducing severity from severe to moderate was more important to subjects than reducing severity from moderate to mild . Reducing heart failure from moderate to mild and diarrhea from severe to moderate had the largest effects on subjects ’ evaluation of adherence . Conclusions : All toxicities included in the study are important to patients . Treating or reducing severe toxicities is much more important to patients than treating or reducing moderate toxicities . Focused reductions of certain toxicities may improve treatment adherence Summary In Spain , various treatments are available to prevent osteoporotic fractures . A discrete choice experiment ( DCE ) was used to investigate the importance of different treatment aspects and its influence on patients ’ preferences . All attributes included as type and place of drug administration as well as costs showed to be significant predictors of choice . Spanish osteoporosis patients have well-defined preferences and accept trade-offs among attributes . Introduction This study was design ed to identify patient preferences for different aspects of osteoporosis treatments in Spain . Methods Main attributes of severe osteoporosis treatments were determined by literature review and consultations with nurses . The discrete choice experiment included three attributes : type of drug administration , place of administration , plus a cost attribute in order to estimate willingness to pay for improvements in attribute levels . A pilot study with 50 patients was performed to identify the areas of misunderst and ing . One hundred sixty-six patients with a diagnosis of osteoporosis and severe osteoporosis were presented with pairs of hypothetical treatment profiles with different type of administration levels , places of administration and costs . Questions to collect socio-demographic and disease-related treatment data were also included . Data were analysed using a r and om effects probit model . Results All attributes had the expected polarity and were significant predictors of choice . Patients were willing to pay 183 € /month to have a subcutaneous injection once per day rather than an intravenous injection once per year . Patients with osteoporosis were willing to pay 121 € /month to have medical support when administering the drug treatment at home rather than being admitted several hours to a hospital for drug administration . ConclusionS panish osteoporosis patients have well-defined preferences among treatment attributes and are willing to accept trade-offs among attributes . Participants indicated that they are willing to accept self medication with medical support rather than being hospitalised for several hours . The perspective of the patients should be taken into account when making treatment decisions Introduction . The implementation of mass colorectal cancer ( CRC ) screening is a public health priority . Population participation is fundamental for the success of CRC screening as for any cancer screening program . The preferences of the population may influence their likelihood of participation . Objectives . The authors sought to elicit population preferences for CRC screening test characteristics to improve the design of CRC screening campaigns . Methods . A discrete choice experiment was used . Question naires were compiled with a set of pairs of hypothetical CRC screening scenarios . The survey was conducted by mail from June 2006 to October 2006 on a representative sample of 2000 inhabitants , aged 50 to 74 years from the northwest of France , who were r and omly selected from electoral lists . Question naires were sent to 2000 individuals , each of whom made 3 or 4 discrete choices between hypothetical tests that differed in 7 attributes : how screening is offered , process , sensitivity , rate of unnecessary colonoscopy , expected mortality reduction , method of screening test result transmission , and cost . Results . Complete responses were received from 656 individuals ( 32.8 % ) . The attributes that influenced population preferences included expected mortality reduction , sensitivity , cost , and process . Participants from high social classes were particularly influenced by sensitivity . Conclusions . The results demonstrate that the discrete choice experiment provides information on patient preferences for CRC screening : improving screening program effectiveness , for instance , by improving test sensitivity ( the most valued attribute ) would increase satisfaction among the general population with regard to CRC screening programs . Additional studies are required to study how patient preferences actually affect adherence to regular screening programs Background The SINS trial ( Controlled Clinical Trials IS RCT N48755084 ; Eudract No. 2004 - 004506 - 24 ) is a r and omised controlled trial evaluating long term success of excisional surgery vs. imiquimod 5 % cream for low risk nodular and superficial basal cell carcinoma ( BCC ) . The trial included a discrete choice experiment question naire to explore patient preferences of a cream versus surgery for the treatment of their skin cancer . Methods The self-completed question naire was administered at baseline to 183 participants , measuring patients ’ strength of preferences  when choosing either alternative ‘ surgery ’ or ‘ imiquimod cream ’ instead of a fixed ‘ current situation ’ option ( of surgical excision as st and ard practice in UK ) . The treatments were described according to : cost , chance of complete clearance , side effects and appearance . Participants had to choose between various scenarios . Analysis was performed using a mixed logit model , which took into account the impact of previous BCC treatment and sample preference variability . Results The analysis showed that respondents preferred ‘ imiquimod cream ’ to their ‘ current situation ’ or ‘ surgery ’ , regardless of previous experience of BCC symptoms and treatment . Respondents were more likely to be worried about their cosmetic outcomes and side effects they might experience over and above their chance of clearance and cost . Those with no experience of surgery ( compared with experience ) valued more the choice of  ‘ imiquimod cream ’ ( £ 1013 vs £ 781 ) . All treatment characteristics were significant determinants of treatment choice , and there was significant variability in the population preferences for all of them . Conclusions Patients with BCC valued more ‘ imiquimod cream ’ than alternative ‘ surgery ’ options , and all treatment characteristics were important for their choice of care . Underst and ing how people with a BCC value alternative interventions may better inform the development of health care interventions Pain Management Programmes ( PMPs ) are a multi-disciplinary approach to the management of chronic low back pain ( CLBP ) . Notwithst and ing evidence of effectiveness , successful take-up of programmes requires acceptability to patients . We used a discrete choice experiment to investigate patient preferences for alternative PMPs for managing CLBP in primary care . Specifically , we estimated the probability of uptake of alternative configurations of PMPs . Potential attributes and associated levels influencing take-up were identified through a systematic literature review , survey of current PMPs , expert consultation , and focus groups . Five attributes were included : content ; provider ; schedule ; group size ; and travel time to clinic . Four hundred and fourteen question naires were mailed to patients attending clinics and 124 question naires were returned suitable for analysis . Method of delivery influenced probability of take-up , with small group sizes and low intensity programmes over a prolonged period increasing the probabilities . Travel time was also important . However , providers and contents of PMPs were not main drivers of preferences , though those with more severe pain did prefer PMPs provided by more specialists . Probability of take-up increases when PMPs better reflect patient preferences . Given preferences , re source constraints , and evidence on clinical outcomes of alternative configurations it is suggested more re source -intensive PMPs be reserved for those with the most severe and disabling pain and less intensive programmes delivered over a longer time period in smaller groups for those with less severe pain . These findings can inform future r and omised trials to evaluate acceptable PMPs in primary care BACKGROUND While the application of conjoint analysis and discrete-choice experiments in health are now widely accepted , a healthy debate exists around competing approaches to experimental design . There remains , however , a paucity of experimental evidence comparing competing design approaches and their impact on the application of these methods in patient-centered outcomes research . OBJECTIVES Our objectives were to directly compare the choice-model parameters and predictions of an orthogonal and a D-efficient experimental design using a r and omized trial ( i.e. , an experiment on experiments ) within an application of conjoint analysis study ing patient-centered outcomes among out patients diagnosed with schizophrenia in Germany . METHODS Out patients diagnosed with schizophrenia were surveyed and r and omized to receive choice tasks developed using either an orthogonal or a D-efficient experimental design . The choice tasks elicited judgments from the respondents as to which of two patient profiles ( varying across seven outcomes and process attributes ) was preferable from their own perspective . The results from the two survey design s were analyzed using the multinomial logit model , and the result ing parameter estimates and their robust st and ard errors were compared across the two arms of the study ( i.e. , the orthogonal and D-efficient design s ) . The predictive performances of the two result ing models were also compared by computing their percentage of survey responses classified correctly , and the potential for variation in scale between the two design s of the experiments was tested statistically and explored graphically . RESULTS The results of the two models were statistically identical . No difference was found using an overall chi-squared test of e quality for the seven parameters ( p = 0.69 ) or via uncorrected pairwise comparisons of the parameter estimates ( p-values ranged from 0.30 to 0.98 ) . The D-efficient design result ed in directionally smaller st and ard errors for six of the seven parameters , of which only two were statistically significant , and no differences were found in the observed D-efficiencies of their st and ard errors ( p = 0.62 ) . The D-efficient design result ed in poorer predictive performance , but this was not significant ( p = 0.73 ) ; there was some evidence that the parameters of the D-efficient design were biased marginally towards the null . While no statistical difference in scale was detected between the two design s ( p = 0.74 ) , the D-efficient design had a higher relative scale ( 1.06 ) . This could be observed when the parameters were explored graphically , as the D-efficient parameters were lower . CONCLUSIONS Our results indicate that orthogonal and D-efficient experimental design s have produced results that are statistically equivalent . This said , we have identified several qualitative findings that speak to the potential differences in these results that may have been statistically identified in a larger sample . While more comparative studies focused on the statistical efficiency of competing design strategies are needed , a more pressing research problem is to document the impact the experimental design has on respondent efficiency Objective To quantify physicians ’ preferences among possible outcomes associated with chronic hepatitis B treatments and to determine which outcomes are most important to physicians in making treatment decisions . Methods Physicians in five countries who treat chronic hepatitis B patients completed a web-enabled  ,  choice-format , conjoint- analysis survey . The survey presented physicians with four treatment-choice questions for three different patient types . Each treatment-choice question included a pair of hypothetical medication profiles . Medication outcomes included how long the medication has been studied ( weight of evidence ) ; the probability that a patient ’s viral load remains undetectable for 5 years , with a possible histological improvement or reversal of disease progression ( long-term efficacy ) ; the 5-year treatment-related risk of fracture ; the 5-year treatment-related risk of renal dysfunction ; and patient cost . Treatment-choice questions were derived from a predetermined experimental design with known statistical properties . For each country , the r and om-parameters logit was used to estimate preference weights for all outcome levels and the mean relative importance of each outcome . Results Long-term efficacy and risk of renal dysfunction were the most important outcomes for the 788 physicians completing the survey , whereas weight of evidence was the least important . However , physicians perceived significant differences in weight of evidence timeframes . Physicians in Germany and France ranked efficacy above side-effect risk , whereas physicians in Spain , Italy , and Turkey ranked side-effect risk above efficacy in importance . Conclusion Physician preferences among treatment profiles indicate systematic differences in the relative importance of treatment outcomes . Physicians require higher efficacy for treatments with higher side-effect risk but somewhat less efficacy for treatments with longer evidence Abstract Background : The aims of this study were to quantify and contrast patient preferences between second-line advanced renal cell carcinoma ( RCC ) medication profiles and their associated benefits and toxicities , and to help frame the doctor – patient discussion about selecting appropriate RCC therapies . Research design and methods : Adult residents of the US with a diagnosis of RCC completed a Web-enabled choice-format conjoint survey consisting of a series of 10 treatment-choice questions , each of which included a pair of hypothetical RCC medication profiles . Each profile was described by various medication attributes ( features or outcomes ) with varying levels . The attributes included efficacy ( progression-free survival [ PFS ] ) , tolerability ( fatigue , stomach problems , mucositis or stomatitis , h and –foot syndrome [ HFS ] ) , serious but rare adverse events ( pneumonitis , hepatic impairment ) , and mode of administration . Treatment-choice questions were based on an experimental design with known statistical properties . R and om-parameters logit regression was used to estimate relative preference weights for each attribute level . Benefit equivalent measures ( additional months of PFS in exchange for toxicities ) were also calculated . Results : Of the 272 patients who completed the survey , the majority were female ( 53 % ) , white ( 92 % ) , and had at least a college degree ( 66 % ) . The mean age was 57 years ( st and ard deviation : 10 years ) . Over the range of attributes and attribute levels included in the survey , PFS was the most important attribute , followed by fatigue , stomach problems , hepatic impairment , mucositis or stomatitis , HFS , pneumonitis , and mode of administration . To reduce severe fatigue to mild-to-moderate fatigue , patients on average would be willing to forego 4.4 months of PFS . To reduce hepatic impairment risk from 0.5 % to 0.0 % , patients on average would be willing to forego 1.0 month of PFS . The main study limitation was that patients answered hypothetical treatment-choice questions . Conclusions : This study provides information to physicians about patient priorities when review ing and selecting RCC therapies with patients Subjects with rheumatoid arthritis ( RA ) enrolled in an online panel were asked to evaluate pairs of treatment alternatives with different attributes . Half of the sample saw a cheap-talk text . Preference parameters were estimated using r and om-parameters logit models to account for unobserved taste heterogeneity . The models also were estimated in willingness-to-pay ( WTP ) space instead of conventional utility space . Cheap talk not only affected the coefficient on the cost attribute , but also preferences for other attributes . WTP estimates were generally lower in cheap talk sample , except for the most important attribute and a 2-level attribute . Subjects who were presented with cheap talk discriminated between the adjoning attribute levels better than the subjects in the control sample Background A discrete choice experiment ( DCE ) is a preference survey which asks participants to make a choice among product portfolios comparing the key product characteristics by performing several choice tasks . Analyzing DCE data needs to account for within-participant correlation because choices from the same participant are likely to be similar . In this study , we empirically compared some commonly-used statistical methods for analyzing DCE data while accounting for within-participant correlation based on a survey of patient preference for colorectal cancer ( CRC ) screening tests conducted in Hamilton , Ontario , Canada in 2002 . Methods A two-stage DCE design was used to investigate the impact of six attributes on participants ' preferences for CRC screening test  and willingness to undertake the test . We compared six models for clustered binary outcomes ( logistic and probit regressions using cluster-robust st and ard error ( SE ) , r and om-effects and generalized estimating equation approaches ) and three models for clustered nominal outcomes ( multinomial logistic and probit regressions with cluster-robust SE and r and om-effects multinomial logistic model ) . We also fitted a bivariate probit model with cluster-robust SE treating the choices from two stages as two correlated binary outcomes . The rank of relative importance between attributes and the estimates of βcoefficient within attributes were used to assess the model robustness . Results In total 468 participants with each completing 10 choices were analyzed . Similar results were reported for the rank of relative importance and βcoefficients across models for stage-one data on evaluating participants ' preferences for the test . The six attributes ranked from high to low as follows : cost , specificity , process , sensitivity , preparation and pain . However , the results differed across models for stage-two data on evaluating participants ' willingness to undertake the tests . Little within-patient correlation ( ICC ≈ 0 ) was found in stage-one data , but substantial within-patient correlation existed ( ICC = 0.659 ) in stage-two data . Conclusions When small clustering effect presented in DCE data , results remained robust across statistical models . However , results varied when larger clustering effect presented . Therefore , it is important to assess the robustness of the estimates via sensitivity analysis using different models for analyzing clustered data from DCE studies Abstract Background : Male circumcision ( MC ) has become an important weapon in the fight against HIV/AIDS in many Sub-Saharan African countries . The successful implementation of a national MC program requires the design of circumcision services that are attractive to young men of various ages . For many potential clients , mothers and /or fathers will play an important role in the decision to be circumcised , and hence services will need to be design ed with the preferences of mothers , fathers , and sons in mind . Objective : Our objective was to value multiple design characteristics of potential community-based MC services from the perspectives of mothers , fathers , and sons in Johannesburg , South Africa , and to test for concordance between their values for the design characteristics . Methods : Potential design characteristics of MC services were identified through open-ended interviews with key informants ( n=25 ) . Preferences were estimated using conjoint analysis implemented as part of a cluster r and omized household survey . Each participant was r and omized to receive one of two possible blocks of conjoint analysis , each consisting of six forced-choice tasks comparing two possible MC services varying on 11 design characteristics . With only two levels for each attribute , our experimental design utilized a main effects orthogonal array . Data were analyzed using linear probability models , with tests of concordance of values using Wald tests generated from stratified estimates calculated using restricted least square estimation . Results : A racially and geographically diverse sample consisting of 204 fathers , 204 mothers , and 237 sons completed the survey . In aggregate , requiring a follow-up visit was the most valued design factor ( p < 0.001 ) , followed by having a lower infection rate ( p < 0.001 ) , having less pain ( p = 0.001 ) , and a private waiting room ( p = 0.001 ) . Based on stratified analysis , sons also valued having the risks and benefits of MC explained  ( p = 0.01 ) and mothers valued requiring an HIV test as part of the procedure . Requiring an HIV test was the most significant difference between the respondents ( p = 0.03 ) , with sons finding it somewhat repulsive ( p = 0.30 ) . Conclusion : Our findings suggest that valuation of aspects of MC clinic design can diverge by decision maker . To better ensure utilization of services , these variations should be taken into account to prior to implementation of a national strategy in South Africa Attribute generation for  discrete choice experiments ( DCEs ) is often poorly reported , and it is unclear whether this element of research is conducted rigorously . This paper explores issues associated with developing attributes for DCEs  and contrasts different qualitative approaches . The paper draws on eight studies , four developed attributes for measures , and four developed attributes  for more ad hoc policy questions . Issues that have become apparent through these studies include the following : the theoretical framework for r and om utility theory and the need for attributes that are neither too close to the latent construct nor too intrinsic to people 's personality ; the need to think about attribute development as a two-stage process involving conceptual development followed by refinement of language to convey the intended meaning ; and the difficulty in resolving tensions inherent in the reductiveness of condensing complex and nuanced qualitative findings into precise terms . The comparison of alternative qualitative approaches suggests that the nature of data collection will depend both on the characteristics of the question ( its sensitivity , for example ) and the availability of existing qualitative information . An iterative , constant comparative approach to analysis is recommended . Finally , the paper provides a series of recommendations for improving the reporting of this element of DCE studies Purpose : To estimate consumer utilities associated with major attributes of retail clinics ( RCs ) . Data sources : A discrete choice experiment ( DCE ) with 383 adult residents of the metropolitan statistical areas in Georgia conducted via R and om Digit Dial survey of households . The DCE had two levels each of four attributes : price ( $ 59 ; $ 75 ) , appointment wait time ( same day ; 1 day or more ) , care setting ‐provider combination  ( nurse practitioner  [NP]‐RC ; physician‐private office ) , and acute illness ( urinary tract infection ; influenza ) , result ing in 16 choice scenarios . The respondents indicated whether they would seek care under each scenario . Conclusions : Cost savings and convenience offered by RCs are attractive to urban patients , and given sufficient cost savings they are likely to seek care there . All else equal , one would require cost savings of at least $ 30.21 to seek care from an NP at RC rather than a physician at private office , and $ 83.20 to wait one day or more . Implication s for practice : Appointment wait time is a major determinant of careseeking decisions for minor illnesses . The size of the consumer utility associated with the convenience feature of RCs indicates that there is likely to be further growth and employment opportunities for NPs in these clinics OBJECTIVES Little is known about doctors ' preferences regarding public report card design .  Taiwan just announced the first diabetes report card on April 2008 . The aim of this study was to investigate the Diabetes Mellitus ( DM ) providers ' preferences towards four report card attributes : up date frequency , risk adjustment , content information and display format . METHODS A discrete choice question naire  was mailed to hospital and primary care doctors in the northern part of Taiwan , with 221 study targets . The response rate was 29 % . RESULTS Using r and om effect logistic regression , doctors ' preference attribute rankings were risk adjustment for patients ( 44.7 % ) , content information ( 25.2 % ) , display format ( 18.3 % ) and up date frequency ( 11.8 % ) . One-year up date frequency , risk adjustment , detailed scores of technical quality and interpersonal quality and bar chart display were the most important items noted in our survey . CONCLUSIONS This is the first study to investigate provider 's preferences for a diabetes report card . It enables the policy maker to clearly see the implication of trade-offs between different choices when design ing a report card that doctors will like . Our findings suggest that doctors do not favour the ' less is more ' principle , or the higher frequency of up date s that patients may prefer . Rather , our findings suggest that risk adjustment and more information content are the most important factors for doctors . Future studies should use discrete choice experiment on different aspects of report card design , such as vulnerable patients or health care administrations At present there are no nephrology facilities in Greenl and . Greenl and ic patients with renal failure needing dialysis thus have to travel to Denmark to obtain treatment . For patients in haemodialysis this necessitates a permanent residence in Denmark . Our study was aim ed at examining Greenl and ers ’ preferences for  establishing nephrology facilities in Greenl and at Queen Ingrid ’s Hospital in Nuuk , and to estimate the associated change in welfare . Preferences were elicited using a discrete choice experiment ( DCE ) . A r and om sample of 500 individuals of the general population was sent a postal question naire in which they were asked to consider the trade-offs of establishing nephrology facilities in Greenl and as opposed to the current situation . This involved trading off the benefits of having such facilities in their home country against the costs of the intervention . Besides including a payment attribute described in terms of incremental tax payment , the DCE included two interventions attributes related to ( 1 ) the organisation of labour , and ( 2 ) the physical setting s of the patients . Respondents succeeded in answering the DCE despite cultural and linguistic disparity . We found that all the included attributes had a significant effect on respondents ’ choices , and that respondents ’ answers to the DCE were in keeping with their values as stated in the question naire . DCE data was analyzed using a r and om parameter logit model reparametrized in willingness-to-pay space . The results showed that establishing facilities in Greenl and were preferred to the current treatment in Denmark . The welfare estimate from the DCE , at DKK 18.74 million , exceeds the estimated annual costs of establishing treatment facilities for patients with chronic renal failure . Given the estimated confidence interval this result seems robust . Establishing facilities in Greenl and therefore would appear to be welfare-improving , deriving positive net benefits . Despite the relatively narrow policy focus , we believe that our findings provide some insight into individuals ’ preferences for de central ization of public services and on citizens ’ views of ‘ self-governance ’ that go beyond the case of Greenl and . More generally , this paper illustrates how DCE can be applied successfully to developing countries with culturally , demographically , and geographically distinct features RATIONALE , AIMS AND OBJECTIVE To elicit the preferences and trade-offs of UK general practitioners about key features of health information systems , to help inform the design of such systems in future . METHODS A stated choice study to uncover implicit preferences based on a binary choice between scenarios presented in r and om order . PARTICIPANTS were all 303 general practice members of the UK Internet service provider , Medix who were approached by email to participate . The main outcome measure was the number of seconds delay in system response that general practitioners were willing to trade off for each key system feature : the reliability of the system , the sites from which the system could be accessed and which staff are able to view patient data . RESULTS Doctors valued speed of response most in information systems but would be prepared to wait 28 seconds to access a system in exchange for improved reliability from 95 % to 99 % , a further 2 seconds for an improvement to 99.9 % and 27 seconds for access to data from anywhere including their own home compared with one place in a single health care premises . However , they would require a system that was 14 seconds faster to compensate for allowing social care as well as National Health Service staff to read patient data . CONCLUSIONS These results provide important new evidence about which system characteristics doctors value highly , and hence which characteristics design ers need to focus on when large scale health information systems are planned Background Most research ers in health economics cite r and om 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 st and s 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 aim ed 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 research ers , which can have important implication s for measures in healthcare such as the WTP , whereas EMNL provides insights into the behaviour of respondents when answering DCEs . Underst and ing how respondents answer DCE questions may allow research ers 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 Despite modern highly efficacious technologies , there is still a lack of consensus on how to optimally treat haemophilia patients with inhibitors . The aim of the study was to evaluate preferences towards the characteristics of different coagulation factor concentrates for haemophilia inhibitors patients , from the perspective of patients or their caregivers , haematologists and pharmacists . A discrete choice study was conducted . Potential products were described with eight selected characteristics : perceived viral safety , risk of anamnestic response , possibility of undergoing major surgery , frequency of infusions in prophylaxis , number of infusions to stop bleeding , time to stop bleeding , time to pain recovery and cost . Participants received 16 pairs of potential products and chose from each pair the option they considered better . Data were analysed with a r and om-effects conditional logistic model . Totally 1614 observations were obtained from 37 patients /caregivers , 39 physicians and 25 pharmacists from Italy . Cost was the most important characteristic to every group . For patients /caregivers , the next most important factors were : risk of anamnestic response , possibility of undergoing major surgery and perceived viral safety . For physicians , the next most important characteristics were : risk of anamnestic response , number of infusions to stop bleeding and possibility of undergoing major surgery . For pharmacists , the next most important factors were : time to stop bleeding , time to pain recovery and possibility of undergoing major surgery . Decisions on treatments must take into account patients clinical needs ; however , preferences can also play an important role in the choice and success of treatments . The results of this study could , therefore , help decision-makers to optimize the overall benefits of treatments Objective . To quantify the relative importance that UK physicians attach to the benefits and risks of current drugs when making treatment decisions for patients with osteoarthritis ( OA ) . Methods . Physicians treating at least 10 patients with OA per month completed an online discrete-choice experiment survey and answered 12 treatment-choice questions comparing medication profiles . Medication profiles were defined by 4 benefits ( reduction in ambulatory pain , resting pain , stiffness , and difficulty doing daily activities ) and 3 treatment-related risks [ bleeding ulcer , stroke , and myocardial infa rct ion ( MI ) ] . Each physician made medication choices for 3 of 9 hypothetical patients ( varied by age , history of MI , hypertension , and history of gastrointestinal bleeding ) . Importance weights were estimated using a r and om-parameters logit model . Treatment-related risks physicians were willing to accept in exchange for various reductions in ambulatory and resting pain also were calculated . Results . The final sample was 475 . A reduction in ambulatory pain from 75 mm to 25 mm ( 1.6 units ) was 1.1 times as important as an increase in MI risk from 0 % to 1.5 % ( 1.5 units ) . The greatest importance was for eliminating a 3 % treatment-related risk of MI or stroke . On average , physicians were willing to accept an increase in bleeding ulcer risk of 0.7 % ( 95 % CI 0.4%–1.7 % ) for a reduction in ambulatory pain of 75 mm to 50 mm . Conclusion . When presented with well-known benefits and risks of OA treatments , physicians placed greater importance on the risks than on the analgesic properties of the drug . This has implication s for the reporting of the results of clinical research to physicians BACKGROUND Dialysis modality preferences of patients with chronic kidney disease ( CKD ) and family caregivers are important , yet rarely quantified . STUDY DESIGN Prospect i ve , unlabeled , discrete-choice experiment with r and om-parameter logit analysis . SETTING & PARTICIPANTS Adults with stages 3 - 5 CKD and caregivers educated about dialysis treatment options from 8 Australian renal clinics . PREDICTORS Preferences for and trade-offs between the dialysis treatment attributes of life expectancy , number of hospital visits per week , ability to travel , hours per treatment , treatment time of day , subsidized transport service , and flexibility of treatment schedule . OUTCOMES & MEASUREMENTS Results presented as ORs for preferring home-based or in-center dialysis to conservative care . RESULTS 105 predialysis patients and 73 family caregivers completed the study . Median patient age was 63 years , and mean estimated glomerular filtration rate was 18.1 ( range , 6 - 34 ) mL/min/1.73 m(2 ) . Median caregiver age was 61 years .  Home-based dialysis ( either peritoneal or home hemodialysis ) was chosen by patients in 65 % of choice sets ; in-center dialysis , in 35 % ; and conservative care , in 10 % . For caregivers , this was 72 % , 25 % , and 3 % , respectively . Both patients and caregivers preferred longer rather than shorter hours of dialysis  ( ORs of 2.02 [ 95 % CI , 1.51 - 2.70 ] and 2.67 [ 95 % CI , 1.85 - 3.85 ] for patients and caregivers , respectively ) , but were less likely to choose nocturnal than daytime dialysis ( ORs of 0.07 [ 95 % CI , 0.01 - 0.75 ] and 0.03 [ 95 % CI , 0.01 - 0.20 ] ) . Patients were willing to forgo 23 ( 95 % CI , 19 - 27 ) months of life expectancy with home-based dialysis to decrease their travel restrictions . For caregivers , this was 17 ( 95 % CI , 16 - 18 ) patient-months . LIMITATIONS Data were limited to stated preferences rather than actual choice of dialysis modality . CONCLUSIONS Our study suggests that it is rare for caregivers to prefer conservative nondialytic care for family members with CKD . Home-based dialysis modalities that enable patients and their family members to travel with minimal restriction would be strongly aligned with the preferences of both parties OBJECTIVE The objective of the study was to investigate the effect of a priori information on preferences for treatment elicited in a discrete choice experiment . METHODS A convenience sample of 100 subjects was r and omly split into two groups . The groups received minimal or extensive information on the treatment  of ankle and foot impairment in stroke . Then , they participated in a discrete choice experiment . Possible treatment was described using eight decision criteria with two to four levels each . Part-worth utility coefficients for the criteria levels , criteria importance and overall treatment preference were estimated . It was tested whether the amount of information that was received influenced the outcome of the discrete choice experiment . RESULTS In the extensively informed group fewer reversals in the expected order of part-worth utilities were found . Criteria importance for four of the eight criteria and criteria importance ranking between the minimally and extensively informed subject groups were significantly different . The difference in part-worth utility of the levels had a minor effect on the predicted utility of the available treatments . CONCLUSION The lower number of level rank reversals in the extensively informed subjects indicates a better underst and ing of outcome desirability and thus a better underst and ing of the decision task . The effect of more extensive information on predicted treatment preference was minimal . PRACTICE IMPLICATION S While interpreting the results of a discrete choice experiment , the effect of prior knowledge on the decision problem has to be taken into account . Although information seems to increase the underst and ing of the decision task , outcomes valuation can also be directed by information and more extensive information increases the cognitive burden which is placed on the subjects . Future research should focus on the exact nature and size of the effects and the results of this study should be clinical ly vali date Little is known about the relative importance of factor VIII ( FVIII ) treatment attributes to haemophilia A patients and their willingness to accept trade-offs among these attributes . To quantify patient and parent preferences for FVIII treatments and compare the relative importance of treatment attributes . Adult patients and parents of children with severe haemophilia A in the US completed a web-enabled , choice-format conjoint survey that presented a series of 12 trade-off questions , each including a pair of hypothetical treatment profiles . Each profile was defined by percent of bleeds stopped with one or two infusions , chance of developing an inhibitor , risk of viral infection , preparation volume , dosage strengths available , and history of supply shortage . Trade-off questions were based on a D-optimal experimental design . Preference weights for attribute levels were estimated using r and om-parameters logit . One hundred and forty seven subjects completed the survey . Over the ranges of attribute levels included in the study , risk of viral infection was the most important attribute . Remaining attributes were ranked in decreasing order of importance as follows : chance of developing an inhibitor , dosage strengths available , percent of bleeds stopped with one or two infusions , history of supply shortage , and preparation volume . Risk of viral infection was 6.0 times as important as percent of bleeds stopped with one or two infusions and 2.7 times as important as the chance of developing an inhibitor . While risk of viral infection was the most important attribute , this research demonstrates that many FVIII treatment attributes are important in the decision-making process OBJECTIVES To examine GPs ' preferences for organisational characteristics in general practice with focus on aspects that can potentially mitigate problems with GP shortages . METHODS A simple r and om sample of 1823 GPs ( corresponding to half of all GPs in Denmark ) was drawn at the beginning of 2010 , and a response rate of 68 % was obtained . A discrete choice experiment ( DCE ) is applied , and attributes included are :  practice type ( solo/shared ) , number of GPs in general practice , collaboration with other practice s ( yes/no ) , change in weekly working hours ( administrative versus patient related ) and change in yearly surplus . Multinomial logit analyses ( with and without interaction variables ) are used , and marginal rates of substitution are calculated . RESULTS GPs working in solo practice s have different preferences for the organisational attributes compared to GPs in shared practice s. The compensation needed for GPs to re-organise from solo to shared practice is associated with the size of the practice . GP characteristics such as age , working hours and surplus affect their willingness to undergo organisational changes . CONCLUSIONS Our results are of relevance to decision makers in design ing policies aim ed at influencing GPs ' organisation in order to overcome problems related to shortages Background A new modelling approach for analysing data from discrete-choice experiments ( DCEs ) has been recently developed in transport economics based on the notion of regret minimization-driven choice behaviour . This so-called R and om Regret Minimization ( RRM ) approach forms an alternative to the dominant R and om Utility Maximization ( RUM ) approach . The RRM approach is able to model semi-compensatory choice behaviour and compromise effects , while being as parsimonious and formally tractable as the RUM approach . Objectives Our objectives were to introduce the RRM modelling approach to healthcare-related decisions , and to investigate its usefulness in this domain . Methods Using data from DCEs aim ed at determining valuations of attributes of osteoporosis drug treatments and human papillomavirus ( HPV ) vaccinations , we empirically compared RRM models , RUM models and Hybrid RUM – RRM models in terms of goodness of fit , parameter ratios and predicted choice probabilities . Results In terms of model fit , the RRM model did not outperform the RUM model significantly in the case of the osteoporosis DCE data ( p = 0.21 ) , whereas in the case of the HPV DCE data , the Hybrid RUM – RRM model outperformed the RUM model ( p < 0.05 ) . Differences in predicted choice probabilities between RUM models and ( Hybrid RUM- ) RRM models were small . Derived parameter ratios did not differ significantly between model types , but trade-offs between attributes implied by the two models can vary substantially . Conclusion Differences in model fit between RUM , RRM and Hybrid RUM – RRM were found to be small . Although our study did not show significant differences in parameter ratios , the RRM and Hybrid RUM – RRM models did feature considerable differences in terms of the trade-offs implied by these ratios . In combination , our results suggest that RRM and Hybrid RUM – RRM modelling approach hold the potential of offering new and policy-relevant insights for health research ers and policy makers Background : Prior practical experience in conducting adaptive conjoint analysis ( ACA ) surveys has demonstrated that many subjects have difficulty underst and ing the ‘ importance ’ questions . Objective : To develop a modified version of ACA importance questions . Methods : Modified ACA importance questions composed of two tasks were developed and tested in a pilot study of patients with knee pain . In the first , respondents were presented with the list of attributes and asked to choose which they considered the most important . In the second , they were asked to rate the importance of the remaining attributes relative to the most important one on an 11-point numeric rating scale . Consecutive patients with knee pain , followed at a hospital-based Bone and Joint Clinic , were r and omized to complete the  original or modified version of the ACA survey . The two versions were identical except for the importance questions . The ACA survey included six attributes :  pain , energy , route of administration , stomach upset , bleeding ulcer and cost . Each attribute contained three levels , all of which had a natural order except for route of administration . As this was a pilot study , we present descriptive statistics only . Results : A total of 49 patients were recruited ; 24 completed the original version and 25 completed the modified version . Subjects felt that bar graphs illustrating the relative importance were more accurate for the modified version of ACA . The proportion of subjects for which the most important attribute chosen on a card-sorting task matched that generated by ACA was greater for the modified than for the original version ( 48 % vs 29 % ) . The proportion of subjects for which the treatment option chosen on a card-sorting task matched that predicted by ACA was also greater for the modified than for the original version ( 80 % vs 75 % ) . Subjects used a greater number of points to rate the importance of attributes on the modified version of ACA ( mean±SD = 3.4±0.9 ) than on the original version ( mean±SD = 2.7±1.0 ) . Conclusions : The modified version of the ACA importance questions appears to perform as well as or better than the original version . Use of a simplified set of ACA importance questions is a reasonable alternative for investigators interested in using ACA as a decision-support tool in clinical practice Study Design . Discrete choice experiment . Objective . To investigate the reduction in the risk of surgery that scoliosis patients would require in order to consider brace treatment as acceptable , and to elicit the trade-offs individuals make between characteristics of brace treatment . Summary of Background Data . The effectiveness of brace treatment in idiopathic scoliosis patients has not been established in r and omized controlled trials ( RCTs ) . Treatment with a brace can be quite bothersome . Patients ' preferences for brace treatment are unknown . Insight into patients ' preferences for ( characteristics of ) brace treatment will be useful for future trials and for the development of braces that may optimize compliance with brace treatment . Methods . A total of 197 patients who had completed treatment ( brace and /or surgery ) for scoliosis were approached for the study , of which 135 gave informed consent . A discrete choice experiment was design ed in which patients had to choose between hypothetical brace treatment profiles that differed in following 4 treatment attributes : effectiveness , visibility , discomfort , and treatment duration . A multinomial logit model was used to analyze the relative importance of these attributes . Subgroup analyses were conducted for brace-only , brace-surgery , and surgery-only patients . Results . The response rate was 86 % ( 116/135 ) . All treatment attributes proved to be important for patients ' choices . All subgroups were prepared to initiate treatment with a Boston brace if the brace would reduce the need for surgery by 53 % . Risk reductions in a range of 32 % to 74 % were required for acceptance of a treatment duration of 3 years . Conclusion . Scoliosis patients stated to be prepared to undergo brace treatment only if it provides sizeable reduction of the risk of surgery . Effectiveness and discomfort in wearing a brace were the most important determinants of the choices . These results are important if RCTs would conclusively establish that bracing is effective , and show directions for the further technical development of braces to increase the compliance with brace treatment Background : Nowadays , an increasing number of discrete-choice experiments ( DCEs ) incorporate cost as an attribute . However , the inclusion of a cost attribute , particularly within collectively funded healthcare systems , can be challenging because health services or goods are generally not traded in a market situation and individuals are not used to paying for a service or a good at the point of consumption . Objective : To examine whether the inclusion of a cost attribute in a DCE results in different preferences regarding a surgical treatment  for primary basal cell carcinoma ( BCC ) compared with a DCE without a cost attribute . Methods : A r and omized study was performed in which the impact of a cost attribute on the general public ’s preferences for a surgical treatment ( Mohs micrographic surgery [ MMS ] or st and ard excision [ SE ] ) to remove BCC was examined . This was done by comparing the outcomes of two DCEs , one with a cost attribute ( DCE_cost ) and one without ( DCE_nocost ) . Six attributes ( recurrence , re-excision , travel time , surgical time , waiting time for surgical results , costs ) and their levels were selected , based on results of a clinical trial , a cost-effectiveness study , a review and a focus group of patients who had recently received treatment for BCC . Outcomes of both DCEs were compared in terms of theoretical validity , relative importance of the attributes and the rank order of preferences . Results : A total of 615 respondents ( n = 303 for DCE_nocost ; n = 312 for DCE_cost ) were interviewed by telephone . This gave an overall response rate of 38%.Respondents in DCE_nocost preferred a surgical treatment with a lower probability of recurrence , lower surgery time , lower waiting time and no risk for a re-excision . Respondents in DCE_cost showed the same preferences , but also preferred a treatment with less travel time and lower costs . Overall , respondents in both DCEs showed the same preference for a surgical treatment : MMS  was preferred over SE . Conclusion : Results suggest that , in this population , the inclusion of a cost attribute in a DCE leads to the same preference regarding a surgical treatment to remove BCC as a DCE without a cost attribute . However , further research in different setting s is needed to confirm these findings Investigation of the ' rationality ' of responses to discrete choice experiments ( DCEs ) has been a theme of research in health economics . Responses have been deleted from DCEs where they have been deemed by research ers to ( a ) be ' irrational ' , defined by such studies as failing tests for non-satiation , or ( b ) represent lexicographic preferences . This paper outlines a number of reasons why deleting responses from DCEs may be inappropriate after first review ing the theory underpinning rationality , highlighting that the importance placed on rationality depends on the approach to consumer theory to which one ascribes . The aim of this paper is not to suggest that all preferences elicited via DCEs are rational . Instead , it is to suggest a number of reasons why it may not be the case that all preferences labelled as ' irrational ' are indeed so . Hence , deleting responses may result in the removal of valid preferences ; induce sample selection bias ; and reduce the statistical efficiency and power of the estimated choice models . Further , evidence suggests r and om utility theory may be able to cope with such preferences . Finally , we discuss a number of implication s for the design , implementation and interpretation of DCEs and recommend caution regarding the deletion of preferences from stated preference experiments The present study aims to evaluate the impact of  cost-effectiveness information  on clinical decision making using discrete choice experiment ( DCE ) methodology . Data were collected through a self-completed question naire  administered to Italian cardiologists in June 2007 ( n = 129 respondents , 1143 observations ) . The question naire asked clinicians to make choices between paired scenarios , across which three key dimensions were identified and varied : ( 1 ) quality of clinical evidence , ( 2 ) size of health gain ( reduction of relative and absolute risk ) , and ( 3 ) economic impact ( incremental cost-effectiveness ratio ) . A r and om effects probit model was used to estimate clinicians ' preferences for the different dimensions , while the heterogeneity of preferences was tested in a model with interaction terms . Dominance tests were used to assess the consistency of responses . The results indicate that Italian cardiologists regard economic impact ( cost-effectiveness ) as an important factor in their decision making . Economic evidence is valued more highly among clinicians with a higher self-assessed level of knowledge regarding economic evaluation techniques , as well as among younger professionals ( age<45 ) . While relevant study limitations should be acknowledged , our results suggest that DCEs can be used to elicit clinicians ' decision-making criteria and to inform the allocation of re sources for future research in a logical manner . Italian cardiologists appear to take  cost-effectiveness information into account when deciding whether to use new treatments OBJECTIVE Recent review s of discrete choice methodology identified method ological issues warranting further exploration , including the issue of " framing . " The objective of this study was to conduct a method ological exploration of the effect of attribute framing on marginal rates of substitution ( MRS ) , including willingness to pay ( WTP ) from a discrete choice experiment ( DCE ) , within the context of colorectal cancer screening preferences . METHODS The survey , a fractional factorial design of a two-alternative , unlabeled experiment , was mailed to a sample of 1920 subjects in NSW , Australia . Participants were r and omized to one of four alternative " frames " of information . Attributes included : accuracy of the test for finding cancers , accuracy of the test for finding large polyps , how good the test is at saying you do n't have cancer , cost , dietary and medication restrictions and sample collection . A mixed logit model was used to estimate preferences ; MRS between attributes , including WTP , was calculated . RESULTS A total of 1157 surveys from 1920 ( 60.2 % ) were returned . Accuracy of the test for finding cancer was most likely to influence choice of test , followed by accuracy of the test for finding large polyps . Under some circumstances , framing of the attributes ( e.g. , cancers found vs. cancers missed ) influenced the relative importance of attributes . Attribute framing significantly influenced estimates of WTP , and benefit : harm trade-offs that were calculated from MRS . CONCLUSIONS Attribute framing can influence willingness to pay and benefit : harm trade-offs from DCEs . Appropriate design and analysis methods should be explored to further characterize the influence and extent of framing in discrete choice studies OBJECTIVES To identify the principles the public considers important and the trade-offs between different values in health-care re source allocation practice s. METHODS This study approached the issue in both qualitative and quantitative ways . In a qualitative study , two focus groups discussed the issues of re source allocation in health care . To facilitate the discussion , a simple ranking task and a series of pairwise choice practice s were implemented . A discrete choice experiment survey question naire was also administered to a sample of the general population . Attributes and levels were determined through literature review s and the results from the focus group interview . We used a r and om-effect probit model to assess the effects of each attribute . RESULTS Through the focus group interviews , we found strong public support for the principle of equal opportunity . The participants thought that the severity of disease was the most important criterion when setting priorities . The majority supported the idea that the most disadvantaged should have the highest priority even when their health gains are less than those of others . The discrete choice experiment results showed that the severity of disease , health gains , and patients ' socioeconomic status significantly influence their choices , with each parameter having an expected sign . CONCLUSION The results showed that Koreans support not only health maximization but also equal opportunity , fair re source allocation , and e quality BACKGROUND Long-acting insulin treatments with varying clinical benefits are currently available for patients with type 1 diabetes mellitus ( T1DM ) and type 2 diabetes mellitus ( T2DM ) . The current evidence base demonstrates the efficacy of treatments , but it is critical also to underst and patient preferences regarding treatments and how they are determined . OBJECTIVE This study aim ed to measure the willingness to pay ( WTP ) of individuals with diabetes in the United Kingdom for different attributes of long-acting insulin therapy . METHODS A survey based on discrete choice experiment methodology was developed to elicit the preferences and values of adults with T1DM or insulin-dependent T2DM regarding different aspects of their therapy . Participants were presented with a series of 27 paired choices and asked which they preferred . WTP values were calculated for relevant attribute levels . RESULTS A total of 252 participants completed the question naire ( 52 % response rate ) ; 143 had T1DM and 109 had insulin-treated T2DM . The highest WTP values in participants with T1DM were avoiding 2-kg or 4-kg weight gain ( £ 29 and £ 58 , respectively ) , avoiding major difficulties with the injection device ( £ 49 ) , increasing the number of days per week when blood glucose levels are in the target range from 2 to 6 ( £ 40 ) , reducing the number of daily injections from 3 to 1 ( £ 39 ) , and avoiding nighttime hypoglycemia ( £ 33 ) . In participants with T2DM , similar factors had the highest WTP . CONCLUSIONS This is the first study to assess WTP  for long-acting insulin therapy and could have implication s for future guidelines on diabetes management , however some limitations , notably in sample selection , could affect generalizability of the results . In both T1DM and T2DM , the highest WTP values were for avoidance of weight gain , and reduction in the number of injections and hypoglycemia
target: We found a continuing trend towards conducting DCEs across a broader range of countries .
  However , the trend towards including fewer attributes was reversed , whilst the trend towards interview-based DCEs reversed because of increased computer administration .
  The trend towards using more flexible econometric models , including mixed logit and latent class , has also continued .
  Reporting of monetary values has fallen compared with earlier periods , but the proportion of studies estimating trade-offs between health outcomes and experience factors , or valuing outcomes in terms of utility scores , has increased , although use of odds ratios and probabilities has declined .
  The reassuring trend towards the use of more flexible and appropriate DCE design s and econometric methods has been reinforced by the increased use of qualitative methods to inform DCE processes and results .
  However , qualitative research methods are being used less often to inform attribute selection , which may make DCEs more susceptible to omitted variable bias if the decision framework is not known prior to the research project .
background: Background Discrete choice experiments ( DCEs ) are increasingly used in health economics to address a wide range of health policy-related concerns .
  Objective Broadly adopting the methodology of an earlier systematic review of health-related DCEs , which covered the period 2001–2008 , we report whether earlier trends continued during 2009–2012 .