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Objectives: This study investigated the relationship between numeracy skills (NS) and choice consistency in discrete choice experiments (DCEs)., Methods: A DCE was conducted to explore patients' preferences for kidney transplantation in Italy. Patients completed the DCE and answered 3-item numeracy questions. A heteroskedastic multinomial logit model was used to investigate the effect of numeracy on choice consistency., Results: Higher NS were associated with greater choice consistency, increasing the scale to 1.63 (P < .001), 1.39 (P < .001), and 1.18 (P < .001) for patients answering 3 of 3, 2 of 3, and 1 of 3 questions correctly, respectively, compared with those with no correct answers. This corresponded to 63%, 39%, and 18% more consistent choices, respectively. Accounting for choice consistency resulted in varying willingness-to-wait (WTW) estimates for kidney transplant attributes. Patients with the lowest numeracy (0/3) were willing to wait approximately 42 months [95% CI: 29.37, 54.68] for standard infectious risk, compared with 33 months [95% CI: 28.48, 38.09] for 1 of 3, 28 months [95% CI: 25.13, 30.32] for 2 of 3, and 24 months [95% CI: 20.51, 27.25] for 3 of 3 correct answers. However, WTW differences for an additional year of graft survival and neoplastic risk were not statistically significant across numeracy levels. Supplementary analyses of 2 additional DCEs on COVID-19 vaccinations and rheumatoid arthritis, conducted online, supported these findings: higher NS were associated with more consistent choices across different disease contexts and survey formats., Conclusions: The findings suggested that combining patients with varying NS could bias WTW estimates, highlighting the need to consider numeracy in DCE data analysis and interpretation., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section., (Copyright © 2024. Published by Elsevier Inc.)

Concern has been expressed about including a cost attribute within discrete choice experiments (DCEs) when individuals do not have to pay at the point of consumption. We use eye tracking to investigate attention to cost when valuing publicly financed health care. One-hundred and four individuals completed a DCE concerned with preferences for UK general practitioner appointments: 51 responded to a DCE with cost included and 53 to the same DCE without cost. Eye-movements were tracked whilst respondents completed the DCE. We assessed if respondents pay attention to cost. We then compare fixation time (FT) on attributes, eye movement patterns and mental effort across the experimental groups. Results are encouraging for the inclusion of cost in DCEs valuing publicly provided healthcare. Most respondents gave visual attention to the cost attribute most of the time. Average FT on multi-attribute tasks increased by 44% in the cost DCE, with attention to non-monetary attributes increasing by 22%. Including cost led to more structured decision-making and did not increase mental effort. Acceptability of the cost attribute and difficulty of choice tasks were predictors of cost information processing, highlighting the importance of both motivating the cost attribute and considering difficulty of the tasks when developing DCEs., (© 2023 The Authors. Health Economics published by John Wiley & Sons Ltd.)

Objective: To understand how individuals trade off between features of non-pharmaceutical interventions (eg, lockdowns) to control a pandemic across the four nations of the UK., Design: A survey that included a discrete choice experiment. The survey design was informed using policy documents, social media analysis and input from remote think-aloud interviews with members of the public (n=23)., Setting: A nationwide survey across the four nations of the UK using an online panel between 29 October and 12 December 2020., Participants: Individuals who are over 18 years old. A total of 4120 adults completed the survey (1112 in England, 848 in Northern Ireland, 1143 in Scotland and 1098 in Wales)., Primary Outcome Measure: Adult's preferences for, and trade-offs between, type of lockdown restrictions, length of lockdown, postponement of routine healthcare, excess deaths, impact on the ability to buy things and unemployment., Results: The majority of adults are willing to accept higher excess deaths if this means lockdowns that are less strict, shorter and do not postpone routine healthcare. On average, respondents in England were willing to accept a higher increase in excess deaths to have less strict lockdown restrictions introduced compared with Scotland, Northern Ireland and Wales, respectively. In all four countries, one out of five respondents were willing to reduce excess deaths at all costs., Conclusions: The majority of the UK population is willing to accept the increase in excess deaths associated with introducing less strict lockdown restrictions. The acceptability of different restriction scenarios varies according to the features of the lockdown and across countries. Governments can use information about trade-off preferences to inform the introduction of different lockdown restriction levels and design compensation policies that maximise societal welfare., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In the past decade, researchers have shifted their interests to explore different ways to mitigate environmental degradation. In that context, the present study explores the role of solar energy and eco-innovation in reducing environmental degradation in China. The study utilized data for the period 1990-2018 and applied the latest available econometric technique, a quantile autoregressive distributed lag model, to determine the impacts of solar energy and eco-innovation on improving China's environmental quality. According to the empirical results, in the long term, solar energy is negatively and significantly associated with CO 2 emissions at higher quantiles. Eco-innovation has proven to be the most important channel to mitigate CO 2 emissions in China. Eco-innovation is exerting a negative and significant influence on CO 2 emissions at all quantiles in the long term. In addition, the population size is causing CO 2 emissions to surge significantly at lower quantiles. The empirical analysis reveals that per capita income (PI) is positively associated with CO 2 emissions at all quantiles, but it is significant only at higher quantiles in China. We found evidence of unidirectional causality for eco-innovation to CO 2 emissions and solar energy to CO 2 emissions. However, for population and CO 2 emissions, per capita income, and CO 2 emissions, we found bidirectional causality. As indicated by our empirical results, solar energy and eco-innovation are the two most effective channels to control CO 2 emissions in China. Therefore, policies based on the promotion of eco-innovation and the initiation of new solar energy projects can control emissions and improve environmental quality in China. Integr Environ Assess Manag 2022;18:555-571. © 2021 SETAC., (© 2021 SETAC.)

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).)

Introduction: Systemic therapy with androgen deprivation therapy (ADT) and intensification with agents such as docetaxel, abiraterone acetate and enzalutamide has resulted in improved overall survival in men with de novo synchronous metastatic hormone-sensitive prostate cancer (mHSPC). Novel local cytoreductive treatments and metastasis-directed therapy are now being evaluated. Such interventions may provide added survival benefit or delay the requirement for further systemic agents and associated toxicity but can confer additional harm. Understanding men's preferences for treatment options in this disease state is crucial for patients, clinicians, carers and future healthcare service providers., Methods: Using a prospective, multicentre discrete choice experiment (DCE), we aim to determine the attributes associated with treatment that are most important to men with mHSPC. Furthermore, we plan to determine men's preferences for, and trade-offs between, the attributes (survival and side effects) of different treatment options including systemic therapy, local cytoreductive approaches (external beam radiotherapy, cytoreductive radical prostatectomy or minimally invasive ablative therapy) and metastases-directed therapies (metastasectomy or stereotactic ablative body radiotherapy). All men with newly diagnosed mHSPC within 4 months of commencing ADT and WHO performance status 0-2 are eligible. Men who have previously consented to a cytoreductive treatment or have developed castrate-resistant disease will be excluded. This study includes a qualitative analysis component, with patients (n=15) and healthcare professionals (n=5), to identify and define the key attributes associated with treatment options that would warrant trade-off evaluation in a DCE. The main phase component planned recruitment is 300 patients over 1 year, commencing in January 2021, with planned study completion in March 2022., Ethics and Dissemination: Ethical approval was obtained from the Health Research Authority East of England, Cambridgeshire and Hertfordshire Research Ethics Committee (Reference: 20/EE/0194). Project information will be reported on the publicly available Imperial College London website and the Heath Economics Research Unit (HERU website including the HERU Blog). We will use the social media accounts of IP5-MATTER, Imperial Prostate London, HERU and the individual researchers to disseminate key findings following publication. Findings from the study will be presented at national/international conferences and peer-reviewed journals. Authorship policy will follow the recommendations of the International Committee of Medical Journal Editors., Trial Registration Number: NCT04590976., Competing Interests: Competing interests: HUA currently receives funding from the Wellcome Trust, Prostate Cancer UK, MRC (UK), Cancer Research UK, The Urology Foundation, BMA Foundation, Imperial Healthcare Charity, Sonacare, Trod Medical and Sophiris Biocorp for trials in prostate cancer. HUA was a paid medical consultant for Sophiris Biocorp, Sonacare and BTG in the past 3 years. He is currently a paid proctor for Sonacare and Boston., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Multi-attribute choices are commonly analyzed in economics to value goods and services. Analysis assumes individuals consider all attributes, making trade-offs between them. Such decision-making is cognitively demanding, often triggering alternative decision rules. We develop a new model where individuals aggregate multi-attribute information into meta-attributes. Applying our model to a choice experiment (CE) dataset, accounting for attribute aggregation (AA) improves model fit. The probability of adopting AA is greater for: homogenous attribute information; participants who had shorter response time and failed the dominance test; and for later located choices. Accounting for AA has implications for welfare estimates. Our results underline the importance of accounting for information processing rules when modelling multi-attribute choices., (© 2021 The Authors. Health Economics published by John Wiley & Sons Ltd.)

Discrete choice experiments (DCEs) commonly include a monetary attribute. This enables willingness to pay (WTP), a monetary measure of benefit, to be estimated for non-monetary attributes. There has been concern that the inclusion of a cost attribute challenges the credibility of the experiment when valuing publicly funded healthcare systems. However, very little research has explored this issue. Using a UK sample, we allocated participants across two versions of a DCE: one including a cost attribute and the other excluding a cost attribute. The DCE was identical in all other respects. We find no significant difference in response time across the two surveys, monotonicity was higher for the COST DCE and cost was stated as the most commonly ignored attribute in the COST DCE. Whilst the inclusion of a cost attribute did not alter the structure of preferences, it resulted in a lower level of choice consistency. Using an unrestricted latent class model, we find evidence of a credibility effect: respondents with experience of paying for health services and who perceive the choices as realistic are less likely to ignore cost. Further, respondents with a higher response time are less likely to be cost minimisers. Results are robust across different model specifications and choice formats. DCE practitioners should give due consideration to cost credibility when including a cost attribute, ensuring participants engage with the cost attribute. Ways to do this are suggested, including careful motivation of the cost attribute, consideration to the appropriate payment vehicle and careful consideration to the cost attribute when developing and piloting the survey. Failure to do this will result in an invalid willingness to pay estimates and thus policy recommendations., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Italy was the first Western country to experience a major coronavirus outbreak and consequently faced large-scale health and socio-economic challenges. The Italian government enforced a wide set of homogeneous interventions nationally, despite the differing incidences of the virus throughout the country., Objective: The paper aims to analyse the policies implemented by the government and their impact on health and non-health outcomes considering both scaling-up and scaling-down interventions., Methods: To categorise the policy interventions, we rely on the comparative and conceptual framework developed by Moy et al. (2020). We investigate the impact of policies on the daily reported number of deaths, case fatality rate, confirmation rate, intensive care unit saturation, and financial and job market indicators across the three major geographical areas of Italy (North, Centre, and South). Qualitative and quantitative data are gathered from mixed sources: Italian national and regional institutions, National Health Research and international organisations. Our analysis contributes to the literature on the COVID-19 pandemic by comparing policy interventions and their outcomes., Results: Our findings suggest that the strictness and timing of containment and prevention measures played a prominent role in tackling the pandemic, both from a health and economic perspective. Technological interventions played a marginal role due to the inadequacy of protocols and the delay of their implementation., Conclusions: Future government interventions should be informed by evidence-based decision making to balance, the benefits arising from the timing and stringency of the interventions against the adverse social and economic cost, both in the short and long term ., (© 2020 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.)

Introduction: Social distancing and lockdown measures are among the main government responses to the COVID-19 pandemic. These measures aim to limit the COVID-19 infection rate and reduce the mortality rate of COVID-19. Given we are likely to see local lockdowns until a treatment or vaccine for COVID-19 is available, and their effectiveness depends on public acceptability, it is important to understand public preference for government responses., Methods and Analysis: Using a discrete choice experiment (DCE), this study will investigate the public's preferences for pandemic responses in the UK. Attributes (and levels) are based on: (1) lockdown measures described in policy documents; (2) literature on preferences for lockdown measures and (3) a social media analysis. Attributes include: lockdown type; lockdown length; postponement of usual non-urgent medical care; number of excess deaths; number of infections; impact on household spending and job losses. We will prepilot the DCE using virtual think aloud interviews with respondents recruited via Facebook. We will collect preference data using an online survey of 4000 individuals from across the four UK countries (1000 per country). We will estimate the relative importance of the attributes, and the trade-offs individuals are willing to make between attributes. We will test if respondents' preferences differ based on moral attitudes (using the Moral Foundation Questionnaire), socioeconomic circumstances (age, education, economic insecurity, health status), country of residence and experience of COVID-19., Ethics and Dissemination: The University of Aberdeen's College Ethics Research Board (CERB) has approved the study (reference: CERB/2020/6/1974). We will seek CERB approval for major changes from the developmental and pilot work. Peer-reviewed papers will be submitted, and results will be presented at public health and health economic conferences nationally and internationally. A lay summary will be published on the Health Economics Research Unit blog., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

We elicit time and risk preferences for kidney transplantation from the entire population of patients of the largest Italian transplant centre using a discrete choice experiment (DCE). We measure patients' willingness-to-wait (WTW) for receiving a kidney with one-year longer expected graft survival, or a low risk of complication. Using a mixed logit in WTW-space model, we find heterogeneity in patients' preferences. Our model allows WTW to vary with patients' age and duration of dialysis. The results suggest that WTW correlates with age and duration of dialysis, and that accounting for patients' preferences in the design of kidney allocation protocols could increase their welfare. The implication for transplant practice is that eliciting patients' preferences could help in the allocation of "non-ideal" kidneys., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)