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Background/aims: To elicit the preferences and calculate the willingness to pay (WTP) of patients with ocular hypertension (OHT) for eye monitoring services in the UK., Methods: Patients with OHT aged at least 18 years recruited from four NHS ophthalmology departments were included in the study. Patients' preferences and WTP for an OHT monitoring service in the National Health Service were elicited using a discrete choice experiment (DCE) within a postal survey based on six attributes: (1) how OHT monitoring is organised, (2) monitoring frequency, (3) travel time from home, (4) use of a risk calculator for conversion to glaucoma, (5) risk of developing glaucoma in the next 10 years and (6) cost of monitoring. We used a sequential mixed-methods approach to design the survey., Results: 360 patients diagnosed with OHT were recruited with a mean age of 69 years. In the DCE, reducing the risk of conversion to glaucoma was the most important factor influencing respondents' choice of monitoring service. Respondents preferred hospital-based monitoring services to community optometrist monitoring, and annual monitoring compared with more frequent (every 6 months) and less frequent (every 18 or 24 months) monitoring. These results can be monetised using WTP. Results of heterogeneity analysis suggest that patients with prior experience in community optometrist monitoring preferred this to hospital-based monitoring., Conclusions: Although hospital-based monitoring is generally preferred, patients with prior experience in community services have a different opinion, suggesting that patients who are unfamiliar with community optometry services may need additional support to accept monitoring in this setting., Competing Interests: Competing interests: GG: Consulting: Alcon, Allergan, Belkin, Elios, Equinox, Genentech/Roche, Glaukos, Ivantis, McKinsey, Rayner, Reichert, Ripple Therapeutics, Santen, Sight Sciences, Thea, Vialase, Visufarma, Zeiss; Grants: Thea, Santen; Honoraria: Alcon, Allergan, Belkin, Glaukos, Ivantis, Lumibird, McKinsey, Reichert, Sight Sciences, Thea; Travel: Ivantis, Thea; Board membership: Glaucoma UK, UK & Ireland Glaucoma Society. AK: Advisory Board: Thea & Abbvie. DPC: Consulting: Apellis; Financial Support: Apellis, Santen; Recipient: Allergan/Abbvie, Janssen, Santen, Thea. YT: Grants: National Institute of Health Research. VW: Chief Scientist Office, Scotland; National Institute for Health Research; Economic and Social Research Council; Economic and Social Research Council and Global Challenges Research Fund; Imperial College London; The Urology Foundation. RH: Grants: Chief Scientist Office, Scotland; National Institute of Health Research., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background/aims: To assess the cost-effectiveness of making treatment decisions for patients with ocular hypertension (OHT) based on a risk prediction (RP) tool in the United Kingdom., Methods: A discrete event simulation model was constructed to compare the cost-effectiveness of an alternative care pathway in which the treatment decision was guided by a validated RP tool in secondary care against decision-making based on the standard care (SC). Individual patient sampling was used. Patients diagnosed with OHT and with an intraocular pressure of 24 mm Hg or over entered the model with a set of predefined individual characteristics related to their risk of conversion to glaucoma. These characteristics were retrieved from electronic medical records (n=5740). Different stages of glaucoma were modelled following conversion to glaucoma., Results: Almost all (99%) patients were treated using the RP strategy, and less than half (47%) of the patients were treated using the SC strategy. The RP strategy produced higher cost but also higher quality-adjusted life years (QALYs) than the SC strategy. The RP strategy was cost-effective compared with the SC strategy in the base-case analysis, with an incremental cost-effectiveness ratio value of £11 522. The RP strategy had a 96% probability of being cost-effective under a £20 000 per QALY threshold., Conclusions: The use of an RP tool for the management of patients with OHT is likely to be cost-effective. However, the generalisability of the result might be limited due to the high-risk nature of this cohort and the specific RP threshold used in the study., Competing Interests: Competing interests: GG – Consulting: Alcon, Allergan, Belkin, Elios, Equinox, Genentech/Roche, Glaukos, Ivantis, McKinsey, Rayner, Reichert, Ripple Therapeutics, Santen, Sight Sciences, Thea, Vialase, Visufarma, Zeiss; Grants: Thea, Santen; Honoraria: Alcon, Allergan, Belkin, Glaukos, Ivantis, Lumibird, McKinsey, Reichert, Sight Sciences, Thea; Travel: Ivantis, Thea; Board membership: Glaucoma UK, UK & Ireland Glaucoma Society. AK – Advisory Board: Thea & Abbvie. DC - Consulting: Apellis; Financial Support: Apellis, Santen; Recipient: Allergan/Abbvie, Janssen, Santen, Thea. YT – Grants: National Institute of Health Research. VW: Chief Scientist Office, Scotland; National Institute for Health Research; Economic and Social Research Council; Economic and Social Research Council and Global Challenges Research Fund; Imperial College London; The Urology Foundation. RH – Grants: National Institute of Health Research., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Willingness-to-pay (WTP) estimates are useful to policy makers only if they are generalizable beyond the moment when they are collected. To understand the "shelf life" of preference estimates, preference stability needs be tested over substantial periods of time., Methods: We tested the stability of WTP for preventative dental care (scale and polish) using a payment-card contingent valuation question administered to 909 randomized controlled trial participants at 4 time points: baseline (prerandomization) and at annual intervals for 3 years. Trial participants were regular attenders at National Health Service dental practices. Participants were randomly offered different frequencies (intensities) of scale polish (no scale and polish, 1 scale and polish per year, 2 scale and polishes per year). We also examined whether treatment allocation to these different treatment intensities influenced the stability of WTP. Interval regression methods were used to test for changes in WTP over time while controlling for changes in 2 determinants of WTP. Individual-level changes were also examined as well as the WTP function over time., Results: We found that at the aggregate level, mean WTP values were stable over time. The results were similar by trial arm. Individuals allocated to the arm with the highest scale and polish intensity (2 per year) had a slight increase in WTP toward the latter part of the trial. There was considerable variation at the individual level. The WTP function was stable over time., Conclusions: The payment-card contingent valuation method can produce stable WTP values in health over time. Future research should explore the generalizability of these results in other populations, for less familiar health care services, and using alternative elicitation methods., Highlights: Stated preferences are commonly used to value health care.Willingness-to-pay (WTP) estimates are useful only if they have a "shelf life."Little is known about the stability of WTP for health care.We test the stability of WTP for dental care over 3 y.Our results show that the contingent valuation method can produce stable WTP values., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support for the iQuaD study was provided by the UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme (project No. 09/01/45). The Health Economics Research Unit is funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Department of Health or the funders that provide institutional support for the authors. This work was presented at the European Health Economics Association, Oslo, Norway, 2022.

Introduction: Climate change poses a major threat to our health, livelihoods and the planet. In 2020, the UK National Health Service (NHS) committed to reducing its Scope 1, 2 and 3 emissions to reach net zero by 2045. Although a net zero NHS would help to limit the consequences of climate change, little is known about the UK general public's values and preferences for the proposed service changes needed to reach net zero., Methods: This study will elicit the public's preferences for actions to help achieve net zero NHS in England and Scotland using a discrete choice experiment (DCE). The DCE attributes and levels describe actions that can be taken by the NHS across key areas: buildings and estates, outdoor space, travel and transport, provision of care, goods and services and food and catering. The survey was designed using online think-aloud interviews with 17 members of the public. Two versions of the survey will be administered to a sample of up to 2200 respondents. One will include a payment vehicle as income tax increases. We will estimate the relative importance of each attribute and, for the former survey, the monetary trade-offs which individuals are willing to make between attributes. Where possible, we will match both samples to gauge preference robustness with the inclusion of the monetary payment. We will test whether respondents' preferences differ based on their socioeconomic circumstances and attitudes toward the NHS and climate change., Ethics and Dissemination: The University of Aberdeen's School of Medicine, Medical Sciences and Nutrition Ethics Research Board has approved the study (reference: SERB/690090). All participants will provide informed consent. Results will be submitted to peer-reviewed publications and presented at relevant conferences and seminars. A lay summary of the research will be published on the Health Economics Research Unit website., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The COVID-19 pandemic accelerated the trend towards teleworking. Many predicted that this would shift housing demand to the suburbs and homes with the potential for high quality office space. We examine these predictions using a survey of the working age population who live in the private housing sector. The majority in the sector are happy with their current home, but new teleworkers who plan to continue to do so - accounting for one fifth of the population - are characterised by a higher intention to move. Consistent with predictions, these teleworkers value a high quality home office more than others and are prepared to live further away from the centre to find it., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Background: The views of mothers are important in shaping policy and practice regarding options for intrapartum care. Mothers in rural and remote areas face unique challenges accessing services, and these need to be well understood. Therefore, our aim was to understand the compromises that women who live in remote and rural settings, more than 1 h from a maternity unit, face regarding intrapartum care., Methods: Qualitative semi-structured telephone interviews (n = 14) were undertaken in rural Scotland with 13 women who had young children and one who was pregnant. Interviews were transcribed and thematically analysed by two researchers., Results: Key themes identified were women's perceptions about risk and the safety of different pathways of maternity care and birth locations; the actual and perceived distance between home and the place of birth, and the type of maternity care available at a place of birth. Mothers in rural and remote areas face particular challenges in choosing where to have their babies. In addition to clinical decisions about 'place of birth' agreed with healthcare professionals, they have to mentally juggle the implications of giving birth when at a distance from family support and away from familiar surroundings. It was clear that many women from rural communities have a strong sense of 'place' and that giving birth in a geographical location, community and culture that feels familiar is important to many of them., Conclusions: Health care staff need to appreciate the impact of non-clinical factors that are important to mothers in remote and rural areas and acknowledge these, even when they cannot be accommodated. Local and national policy also needs to reflect and respond to the practical challenges faced by rurality., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Antimicrobial resistance is a threat to human health. We need to strive for a rational use of antibiotics to reduce the selection of resistant bacteria. Most antibiotics are prescribed in general practice, but little is known about factors influencing general practitioners' (GPs) decision-making when prescribing antibiotics., Aim: To 1) assess the importance of factors that influence decisions by GPs to prescribe antibiotics for acute respiratory tract infections (RTIs) and 2) identify segments of GPs influenced differently when deciding to prescribe antibiotics., Methods: A questionnaire survey including a discrete choice experiment was conducted. Danish GPs were asked to indicate whether they would prescribe antibiotics in six hypothetical choice sets with six variables: whether the GP is behind schedule, patient's temperature, patient's general condition, lung auscultation findings, C-reactive protein (CRP) level, and whether the patient expects antibiotics. Error component and latent class models were estimated and the probabilities of prescribing in different scenarios were calculated., Results: The questionnaire was distributed to every Danish GP (n = 3,336); 1,152 (35%) responded. Results showed that GPs were influenced by (in prioritised order): CRP level (Relative importance (RI) 0.54), patient's general condition (RI 0.20), crackles at auscultation (RI 0.15), and fever (RI 0.10). Being behind schedule and patient expectations had no significant impact on antibiotic prescription at the aggregate level. The latent class analysis identified five classes of GPs: generalists, CRP-guided, general condition-guided, reluctant prescribers, and stethoscopy-guided. For all classes, CRP was the most important driver, while GPs were heterogeneously affected by other drivers., Conclusion: The most important factor affecting Danish GPs' decision to prescribe antibiotics at the aggregate level, in subgroups of GPs, and across latent classes was the CRP value. Hence, the use of CRP testing is an important factor to consider in order to promote rational antibiotic use in the battle against antimicrobial resistance., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Context: Advances in systemic agents have increased overall survival for men diagnosed with metastatic prostate cancer. Additional cytoreductive prostate treatments and metastasis-directed therapies are under evaluation. These confer toxicity but may offer incremental survival benefits. Thus, an understanding of patients' values and treatment preferences is important for counselling, decision-making, and guideline development., Objective: To perform a systematic review of patients' values, preferences, and expectations regarding treatment of metastatic prostate cancer., Evidence Acquisition: The MEDLINE, Embase, and CINAHL databases were systematically searched for qualitative and preference elucidation studies reporting on patients' preferences for treatment of metastatic prostate cancer. Certainty of evidence was assessed using Grading of Recommendation, Assessment, Development and Evaluation (GRADE) or GRADE Confidence in the Evidence from Reviews of Qualitative Research (CERQual). The protocol was registered on PROSPERO as CRD42020201420., Evidence Synthesis: A total of 1491 participants from 15 studies met the prespecified eligibility for inclusion. The study designs included were discrete choice experiments ( n = 5), mixed methods ( n = 3), and qualitative methods ( n = 7). Disease states reported per study were: metastatic castration-resistant prostate cancer in nine studies (60.0%), metastatic hormone-sensitive prostate cancer in two studies (13.3%), and a mixed cohort in four studies (26.6%). In quantitative preference elicitation studies, patients consistently valued treatment effectiveness and delay in time to symptoms as the two top-ranked treatment attributes (low or very low certainty). Patients were willing to trade off treatment-related toxicity for potential oncological benefits (low certainty). In qualitative studies, thematic analysis revealed cancer progression and/or survival, pain, and fatigue as key components in treatment decisions (low or very low certainty). Patients continue to value oncological benefits in making decisions on treatments under qualitative assessment., Conclusions: There is limited understanding of how patients make treatment and trade-off decisions following a diagnosis of metastatic prostate cancer. For appropriate investment in emerging cytoreductive local tumour and metastasis-directed therapies, we should seek to better understand how this cohort weighs the oncological benefits against the risks., Patient Summary: We looked at how men with advanced (metastatic) prostate cancer make treatment decisions. We found that little is known about patients' preferences for current and proposed new treatments. Further studies are required to understand how patients make decisions to help guide the integration of new treatments into the standard of care., (© 2021 The Author(s).)

It can be assumed that higher SARS-CoV-2 infection risk is associated with higher COVID-19 vaccination intentions, although evidence is scarce. In this large and representative survey of 6007 adults aged 18-64 years and residing in France, 8.1% (95% CI, 7.5-8.8) reported a prior SARS-CoV-2 infection in December 2020, with regional variations according to an East-West gradient ( p < 0.0001). In participants without prior SARS-CoV-2 infection, COVID-19 vaccine hesitancy was substantial, including 41.3% (95% CI, 39.8-42.8) outright refusal of COVID-19 vaccination. Taking into account five characteristics of the first approved vaccines (efficacy, duration of immunity, safety, country of the vaccine manufacturer, and place of administration) as well as the initial setting of the mass vaccination campaign in France, COVID-19 vaccine acceptance would reach 43.6% (95% CI, 43.0-44.1) at best among working-age adults without prior SARS-CoV-2 infection. COVID-19 vaccine acceptance was primarily driven by vaccine characteristics, sociodemographic and attitudinal factors. Considering the region of residency as a proxy of the likelihood of getting infected, our study findings do not support the assumption that SARS-CoV-2 infection risk is associated with COVID-19 vaccine acceptance.

Background: Opinion polls on vaccination intentions suggest that COVID-19 vaccine hesitancy is increasing worldwide; however, the usefulness of opinion polls to prepare mass vaccination campaigns for specific new vaccines and to estimate acceptance in a country's population is limited. We therefore aimed to assess the effects of vaccine characteristics, information on herd immunity, and general practitioner (GP) recommendation on vaccine hesitancy in a representative working-age population in France., Methods: In this survey experiment, adults aged 18-64 years residing in France, with no history of SARS-CoV-2 infection, were randomly selected from an online survey research panel in July, 2020, stratified by gender, age, education, household size, and region and area of residence to be representative of the French population. Participants completed an online questionnaire on their background and vaccination behaviour-related variables (including past vaccine compliance, risk factors for severe COVID-19, and COVID-19 perceptions and experience), and were then randomly assigned according to a full factorial design to one of three groups to receive differing information on herd immunity (>50% of adults aged 18-64 years must be immunised [either by vaccination or infection]; >50% of adults must be immunised [either by vaccination or infection]; or no information on herd immunity) and to one of two groups regarding GP recommendation of vaccination (GP recommends vaccination or expresses no opinion). Participants then completed a series of eight discrete choice tasks designed to assess vaccine acceptance or refusal based on hypothetical vaccine characteristics (efficacy [50%, 80%, 90%, or 100%], risk of serious side-effects [1 in 10 000 or 1 in 100 000], location of manufacture [EU, USA, or China], and place of administration [GP practice, local pharmacy, or mass vaccination centre]). Responses were analysed with a two-part model to disentangle outright vaccine refusal (irrespective of vaccine characteristics, defined as opting for no vaccination in all eight tasks) from vaccine hesitancy (acceptance depending on vaccine characteristics)., Findings: Survey responses were collected from 1942 working-age adults, of whom 560 (28·8%) opted for no vaccination in all eight tasks (outright vaccine refusal) and 1382 (71·2%) did not. In our model, outright vaccine refusal and vaccine hesitancy were both significantly associated with female gender, age (with an inverted U-shaped relationship), lower educational level, poor compliance with recommended vaccinations in the past, and no report of specified chronic conditions (ie, no hypertension [for vaccine hesitancy] or no chronic conditions other than hypertension [for outright vaccine refusal]). Outright vaccine refusal was also associated with a lower perceived severity of COVID-19, whereas vaccine hesitancy was lower when herd immunity benefits were communicated and in working versus non-working individuals, and those with experience of COVID-19 (had symptoms or knew someone with COVID-19). For a mass vaccination campaign involving mass vaccination centres and communication of herd immunity benefits, our model predicted outright vaccine refusal in 29·4% (95% CI 28·6-30·2) of the French working-age population. Predicted hesitancy was highest for vaccines manufactured in China with 50% efficacy and a 1 in 10 000 risk of serious side-effects (vaccine acceptance 27·4% [26·8-28·0]), and lowest for a vaccine manufactured in the EU with 90% efficacy and a 1 in 100 000 risk of serious side-effects (vaccine acceptance 61·3% [60·5-62·1])., Interpretation: COVID-19 vaccine acceptance depends on the characteristics of new vaccines and the national vaccination strategy, among various other factors, in the working-age population in France., Funding: French Public Health Agency (Santé Publique France)., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Despite the recognised importance of participant understanding for valid and reliable discrete choice experiment (DCE) results, there has been limited assessment of whether, and how, people understand DCEs, and how 'understanding' is conceptualised in DCEs applied to a health context., Objectives: Our aim was to identify how participant understanding is conceptualised in the DCE literature in a health context. Our research questions addressed how participant understanding is defined, measured, and used., Methods: Searches were conducted (June 2019) in the MEDLINE, EMBASE, PsychINFO and Econlit databases, as well as hand searching. Search terms were based on previous DCE systematic reviews, with additional understanding keywords used in a proximity-based search strategy. Eligible studies were peer-reviewed journal articles in the field of health, related to DCE or best-worst scaling type 3 (BWS3) studies, and reporting some consideration or assessment of participant understanding. A descriptive analytical approach was used to chart relevant data from each study, including publication year, country, clinical area, subject group, sample size, study design, numbers of attributes, levels and choice sets, definition of understanding, how understanding was tested, results of the understanding tests, and how the information about understanding was used. Each study was categorised based on how understanding was conceptualised and used within the study., Results: Of 306 potentially eligible articles identified, 31 were excluded based on titles and abstracts, and 200 were excluded on full-text review, resulting in 75 included studies. Three categories of study were identified: applied DCEs (n = 52), pretesting studies (n = 7) and studies of understanding (n = 16). Typically, understanding was defined in relation to either the choice context, such as attribute terminology, or the concept of choosing. Very few studies considered respondents' engagement as a component of understanding. Understanding was measured primarily through qualitative pretesting, rationality or validity tests included in the survey, and participant self-report, however reporting and use of the results of these methods was inconsistent., Conclusions: Those conducting or using health DCEs should carefully select, justify, and report the measurement and potential impact of participant understanding in their specific choice context. There remains scope for research into the different components of participant understanding, particularly related to engagement, the impact of participant understanding on DCE validity and reliability, the best measures of understanding, and methods to maximise participant understanding.