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Objective To compare the clinical effectiveness and cost benefit of different frequencies of scale and polish (S&P) treatments in combination with different types of oral hygiene advice (OHA). Design Multi-centre, multi-level cluster randomised factorial open trial with blinded outcome evaluation. UK dental practices were cluster randomised to deliver OHA as usual or personalised. In a separate randomisation, patients were allocated to receive S&P 6-monthly, 12-monthly or never. Setting UK primary dental care. Participants Practices providing NHS care and adults who had received regular dental check-ups. Main outcome measures The percent of sites with bleeding on probing, patient confidence in self-care, incremental net benefits (INB) over three years. Results Sixty-three practices and 1,877 adult patients were randomised and 1,327 analysed (clinical outcome). There was no statistically significant or clinically important difference in gingival bleeding between the three S&P groups (for example, six-monthly versus none: difference 0.87% sites, 95% CI: 1.6 to 3.3, p = 0.48) or between personalised or usual OHA groups (difference -2.5% sites, -95%CI: -8.3 to 3.3, p = 0.39), or oral hygiene self-efficacy (cognitive impact) between either group (for example, six-monthly versus none: difference -0.028, 95% CI -0.119 to 0.063, p = 0.543). The general population place a high value on, and are willing to pay for, S&P services. However, from a dental health perspective, none of the interventions were cost-effective. Conclusion Results suggest S&P treatments and delivering brief personalised OHA provide no clinical benefit and are therefore an inefficient approach to improving dental health (38% of sites were bleeding whatever intervention was received). However, the general population value both interventions. Zusatzmaterial online: Zu diesem Beitrag sind unter 10.1038/s41415-021-2662-3 für autorisierte Leser zusätzliche Dateien abrufbar., Key points Describes the process of successfully delivering a multi-centre, cluster randomised factorial open trial in general dental practice in the NHS, for the most frequently provided dental treatment, scale and polish (S&P), and oral hygiene advice.Highlights the clinical, economic and patient-centred outcomes from providing S&P at different time intervals alongside personalised or routine oral hygiene advice to over 2,000 participants for three years.Evidence from IQuaD concludes that there was no difference in gingival bleeding across trial arms at three years; however, the general population are willing to pay for and place a high value on both S&P and personalised oral hygiene advice. Zusatzmaterial online: Zu diesem Beitrag sind unter 10.1038/s41415-021-2662-3 für autorisierte Leser zusätzliche Dateien abrufbar.

Objective To compare the clinical effectiveness of different frequencies of dental recall over a four-year period. Design A multi-centre, parallel-group, randomised controlled trial with blinded clinical outcome assessment. Participants were randomised to receive a dental check-up at six-monthly, 24-monthly or risk-based recall intervals. A two-strata trial design was used, with participants randomised within the 24-month stratum if the recruiting dentist considered them clinically suitable. Participants ineligible for 24-month recall were randomised to a risk-based or six-month recall interval. Setting UK primary dental care. Participants Practices providing NHS care and adults who had received regular dental check-ups. Main outcome measures The percentage of sites with gingival bleeding on probing, oral health-related quality of life (OHRQoL), cost-effectiveness. Results In total, 2,372 participants were recruited from 51 dental practices. Of those, 648 were eligible for the 24-month recall stratum and 1,724 participants were ineligible. There was no evidence of a significant difference in the mean percentage of sites with gingival bleeding on probing between intervention arms in any comparison. For those eligible for 24-month recall stratum: the 24-month versus six-month group had an adjusted mean difference of -0.91%, 95% CI (-5.02%, 3.20%); the 24-month group versus risk-based group had an adjusted mean difference of 0.07%, 95% CI (-3.99%, 4.12%). For the overall sample, the risk-based versus six-month adjusted mean difference was 0.78%, 95% CI (-1.17%, 2.72%). There was no evidence of a difference in OHRQoL (0-56 scale, higher score for poorer OHRQoL) between intervention arms in any comparison. For the overall sample, the risk-based versus six-month effect size was -0.35, 95% CI (-1.02, 0.32). There was no evidence of a clinically meaningful difference between the groups in any comparison in either eligibility stratum for any of the secondary clinical or patient-reported outcomes. Conclusion Over a four-year period, we found no evidence of a difference in oral health for participants allocated to a six-month or a risk-based recall interval, nor between a 24-month, six-month or risk-based recall interval for participants eligible for a 24-month recall. However, patients greatly value and are willing to pay for frequent dental check-ups. Zusatzmaterial online: Zu diesem Beitrag sind unter 10.1038/s41415-021-2612-0 für autorisierte Leser zusätzliche Dateien abrufbar., Key points This is the first national, multi-centre, pragmatic RCT in a primary care setting to evaluate the clinical, patient-centred and cost benefit of different recall intervals.Traditional practice of scheduling six-monthly recall appointments for patients, regardless of their risk of developing dental disease, does not improve oral health. A variable risk-based recall interval is appropriate, is not detrimental to oral health, and is acceptable to patients and dentists.Considering the impact of the COVID-19 pandemic limiting access to dental care, this study provides reassurance that, for appropriate patients, intervals between check-ups can be extended, based on an individual's risk, without detriment to oral health. Zusatzmaterial online: Zu diesem Beitrag sind unter 10.1038/s41415-021-2612-0 für autorisierte Leser zusätzliche Dateien abrufbar.

Background Progression of dental caries can result in irreversible pulpal damage. Partial irreversible pulpitis is the initial stage of this damage, confined to the coronal pulp whilst the radicular pulp shows little or no sign of infection. Preserving the pulp with sustained vitality and developing minimally invasive biologically based therapies are key themes within contemporary clinical practice. However, root canal treatment involving complete removal of the pulp is often the only option (other than extraction) given to patients with irreversible pulpitis, with substantial NHS and patient incurred costs. The European Society of Endodontology’s (ESE 2019) recent consensus statement recommends full pulpotomy, where the inflamed coronal pulp is removed with the goal of keeping the radicular pulp vital, as a more minimally invasive technique, potentially avoiding complex root canal treatment. Although this technique may be provided in secondary care, it has not been routinely implemented or evaluated in UK General Dental Practice. Method This feasibility study aims to identify and assess in a primary care setting the training needs of general dental practitioners and clinical fidelity of the full pulpotomy intervention, estimate likely eligible patient pool and develop recruitment materials ahead of the main randomised controlled trial comparing the clinical and cost-effectiveness of full pulpotomy compared to root canal treatment in pre/molar teeth of adults 16 years and older showing signs indicative of irreversible pulpitis. The feasibility study will recruit and train 10 primary care dentists in the full pulpotomy technique. Dentists will recruit and provide full pulpotomy to 40 participants (four per practice) with indications of partial irreversible pulpitis. Discussion The Pulpotomy for the Management of Irreversible Pulpitis in Mature Teeth (PIP) study will address the lack of high-quality evidence in the treatment of irreversible pulpitis, to aid dental practitioners, patients and policymakers in their decision-making. The PIP feasibility study will inform the main study on the practicality of providing both training and provision of the full pulpotomy technique in general dental practice. Trial registration ISRCTN Registry, ISRCTN17973604. Registered on 28 January 2021. Protocol version Protocol version: 1; date: 03.02.2021

Aim It is commonly observed that individuals transition into and out of physical activity behaviours over time. A better understanding of the determinants of these transitions is important in order to develop effective interventions. Our focus is on examining the role of time preference and present bias (how present or future oriented individuals are) in the decision to start, quit and maintain physical activity over time. Subject and methods We examine changes in different types of physical activity participation over time, allowing us to distinguish between physical activity initiation versus maintenance. We use data from the National Longitudinal Survey of Youth 1979 (NLSY79). Results We show that present bias impacts maintenance but not initiation of physical activity behaviour. The time preference rate impacts maintenance of strengthening exercise in men only. Conclusion The results of our study suggest that interventions aimed at overcoming present bias, such as commitment devices in the form of deposit contracts, may be effective in maintaining physical activity but not initiating physical activity.

Non-adherence to treatments is prevalent. The aim of this paper is to model how doctors should adapt their medical treatment decisions if non-adherence is due to present-bias in the patient population, and to test the predictions of this model in a lab experiment. Under certain conditions, a rational doctor should adapt to non-adherence by choosing a treatment all patients complete (though less effective) when the probability of a patient being present-biased is sufficiently large. This is explored in a lab experiment where we test whether students in the doctor role adapt their behaviour as they learn about the distribution of non-adherence (due to present bias) in the patient population over the rounds of the experiment. We test the model prediction when we align individual incentives with the goal of maximising overall patient welfare. The results show that, on average, participants adapt to non-adherence as they learn about the probability of non-adherence (due to present-bias). However, a proportion of participants do not adapt to the optimal choice. The rate of adaptation was similar for the first 5 rounds under both individual incentives and salary. However, participants continued to adapt after round 5 under individual incentives whilst adaptation plateaued under salary. The adaptation to non-adherence may indicate that adherence can be improved by providing doctors with information about the probability of non-adherence (due to present-bias) in their patients.

Little is known about the drivers of migration of GPs. Risk attitude may play an important role as migration is fundamentally a risky decision that balances the risks of staying with the risks associated with leaving. This paper examines the association between risk attitudes and the migration of UK GPs to Australia.GPs who qualified in the UK but work in Australia and who responded to the Medicine in Australia: Balancing Employment and Life (MABEL) national longitudinal survey of doctors, were compared with GPs based in Scotland who responded to a survey. Risk attitudes were elicited for financial risks, career and professional risks and clinical risks on a scale from 1 to 5.GPs in Scotland and UK trained GPs in Australia have similar risk attitudes for financial risk. However, UK trained GPs in Australia are less willing to take clinical and career risks.GPs who migrated to Australia after qualifying in the UK were more risk averse about their career and clinical risks. This may suggest that more risk averse GPs migrate to Australia due to pull factors such as less uncertainty around career and clinical outcomes in Australia. The uncertain NHS climate may push more risk averse doctors away from the UK.

Background Ascertaining the acceptability of healthcare provision to service users is an important factor in promoting service uptake, especially for populations who are reluctant to access care. This study identified the attributes of a Hepatitis C (HCV) testing service for people prescribed Opioid Substitution Therapy (OST) and used their expressed preferences to guide design of a service, using an applied health economics approach. Materials and methods Preferences of OST users were elicited using a discrete choice experiment. Important attributes for HCV testing were partly pre-determined by the research question and also identified using literature review and focus groups. Predetermined attributes included choice of provider and financial incentives. Other important attributes were place of testing; travel distance; attitudes and staff undertaking testing; waiting time for test results and incentive payment. The relative importance of defined attributes was assessed in 103 OST users attending 6 pharmacies from Dundee. Results OST users preferred testing at their “own pharmacy”, by their drug worker, followed by their general practitioner (GP). Use of another pharmacy was the least preferred option. Being treated with dignity and respect was valued most highly, with waiting time for test results and travel distance also important. Financial incentives were not considered important. Conclusions This study provides evidence that OST users prefer testing at their own pharmacy. The addition of a pharmacy to the providers offering HCV testing may increase uptake and support policies to eliminate HCV from our communities. Being treated with dignity and respect was highly valued and this suggests that testing uptake can be increased by developing positive relationships between OST users and test providers. Financial incentives were not found to be important.

Objectives Understanding the value the general population place on dentistry services is important for policymakers to aide service planning. Willingness to pay (WTP) is an economic method used to elicit the value of a good or service. The aim of this study is to estimate United Kingdom (UK) general population WTP for commonly provided scale and polish, and detailed and personalized oral hygiene advice (OHA), and to investigate what factors influence WTP. Methods Participants completed an online hypothetical WTP survey for scale and polish and detailed and personalized oral hygiene advice. The estimation sample consisted of 1405 participants, nationally representative of the UK general population in terms of age and sex. Regression analysis was used to estimate WTP and determine what factors are associated with WTP. Analyses were conducted including and excluding protest answers. Results The mean (SD) WTP for a scale and polish is £26.77 (£21.91) excluding protest answers and £24.80 (£22.71) for the full sample. The mean (SD) WTP for detailed and personalized OHA is £16.56 (£19.75) excluding protest answers and £12.77 (£22.28) for the full sample. Participants on higher incomes, private attenders and those who stated that maintaining clean and healthy gums was important had higher WTP for both services. Participants in Scotland and Northern Ireland were WTP less than their English counterparts, reflecting the different regional specific payment systems. Conclusion The general UK population value scale and polish, and detailed and personalized OHA. This study provides estimates of WTP for these services which can be used to inform resource allocation decisions.

BackgroundIn 2016, 26% of UK men were estimated to be obese. Systematic reviews suggest that few men engage in formal weight loss interventions that support weight reduction and improve health.ObjectiveTo co-produce, with patient and public involvement, an acceptable and feasible randomised controlled trial design to test a men-only weight management intervention.DesignThis was a two-phase feasibility study. Phase 1 was the development of intervention components, study procedures and materials including a discrete choice experiment with survey questions. Phase 2 was an individually randomised three-arm feasibility trial over 12 months. Qualitative interviews were conducted at 3 and 12 months.SettingThe setting was two sites in Scotland that had disadvantaged urban and rural areas and differed in employment levels and ethnic groups.ParticipantsIn phase 1, 1045 men with obesity were recruited by Ipsos MORI (London, UK;www.ipsos.com/ipsos-mori/en-uk) to represent the UK population. In phase 2, 105 men with obesity were recruited in the community or through general practice obesity registers. Qualitative interviews were conducted with 50 men at 3 months and with 33 men at 12 months.InterventionsThe trial arms were narrative short message service (SMS) for 12 months (SMS only), financial endowment incentive informed by loss aversion and linked to achievement of weight loss targets plus narrative SMS for 12 months (SMS + I), and waiting list control group for 12 months followed by 3 months of an alternative SMS style developed based on feedback from men who had received the narrative SMS (control).Main outcome measuresThe main outcome measures were acceptability and feasibility of recruitment, retention, engagement, intervention components and trial procedures. Outcomes were assessed by examining procedural, quantitative and qualitative data at 3, 6 and 12 months.ResultsThe most acceptable incentive strategy, based on the discrete choice experiment results, was to verify weight loss of 5% at 3 months, verify weight loss of 10% at 6 months and maintain weight loss of 10% at 12 months. Overall, 105 men with obesity from across the socioeconomic spectrum were successfully recruited to target, 59% of whom lived in more disadvantaged areas. Retention at 12 months was acceptable (74%) and was higher among individuals from disadvantaged areas. Narrative SMS were acceptable to many men, with a minority reporting negative reactions. Incentives were acceptable but were not the primary motivation for behaviour change. Twelve men in the incentive arm (33%) secured at least some money and three (8%) secured the full amount. Both intervention arms lost some weight, with greater weight loss in the arm that received SMS and incentives. The alternative SMS based on men’s feedback received no strong negative reactions.LimitationsFewer participants from the SMS + I arm (64%) completed the study at 12 months than did those in the SMS-only (79%) and control (83%) arms. The reasons for this difference were complex.ConclusionsThe men-only weight management intervention consisting of narrative SMS and financial incentives was acceptable and feasible, meeting the progression criteria for a full trial. Tailoring of SMS may improve acceptability and retention.Future workMinor refinements to the intervention components based on the study findings will be made prior to testing in a multisite definitive randomised controlled trial.Trial registrationClinicalTrials.gov NCT03040518.FundingThis project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 8, No. 11. See the NIHR Journals Library website for further project information.

ObjectivesTo examine the acceptability and feasibility of narrative text messages with or without financial incentives to support weight loss for men.DesignIndividually randomised three-arm feasibility trial with 12 months’ follow-up.SettingTwo sites in Scotland with high levels of disadvantage according to Scottish Index for Multiple Deprivation (SIMD).ParticipantsMen with obesity (n=105) recruited through community outreach and general practitioner registers.InterventionsParticipants randomised to: (A) narrative text messages plus financial incentive for 12 months (short message service (SMS)+I), (B) narrative text messages for 12 months (SMS only), or (C) waiting list control.OutcomesAcceptability and feasibility of recruitment, retention, intervention components and trial procedures assessed by analysing quantitative and qualitative data at 3, 6 and 12 months.Results105 men were recruited, 60% from more disadvantaged areas (SIMD quintiles 1 or 2). Retention at 12 months was 74%. Fewer SMS+I participants (64%) completed 12-month assessments compared with SMS only (79%) and control (83%). Narrative texts were acceptable to many men, but some reported negative reactions. No evidence emerged that level of disadvantage was related to acceptability of narrative texts. Eleven SMS+I participants (31%) successfully met or partially met weight loss targets. The cost of the incentive per participant was £81.94 (95% CI £34.59 to £129.30). Incentives were acceptable, but improving health was reported as the key motivator for weight loss. All groups lost weight (SMS+I: −2.51 kg (SD=4.94); SMS only: −1.29 kg (SD=5.03); control: −0.86 kg (SD=5.64) at 12 months).ConclusionsThis three-arm weight management feasibility trial recruited and retained men from across the socioeconomic spectrum, with the majority from areas of disadvantage, was broadly acceptable to most participants and feasible to deliver.Trial registration numberNCT03040518.

Background Periodontal disease is preventable but remains the most common oral disease worldwide, with major health and economic implications. Stakeholders lack reliable evidence of the relative clinical effectiveness and cost-effectiveness of different types of oral hygiene advice (OHA) and the optimal frequency of periodontal instrumentation (PI). Objectives To test clinical effectiveness and assess the economic value of the following strategies: personalised OHA versus routine OHA, 12-monthly PI (scale and polish) compared with 6-monthly PI, and no PI compared with 6-monthly PI. Design Multicentre, pragmatic split-plot, randomised open trial with a cluster factorial design and blinded outcome evaluation with 3 years’ follow-up and a within-trial cost–benefit analysis. NHS and participant costs were combined with benefits [willingness to pay (WTP)] estimated from a discrete choice experiment (DCE). Setting UK dental practices. Participants Adult dentate NHS patients, regular attenders, with Basic Periodontal Examination (BPE) scores of 0, 1, 2 or 3. Intervention Practices were randomised to provide routine or personalised OHA. Within each practice, participants were randomised to the following groups: no PI, 12-monthly PI or 6-monthly PI (current practice). Main outcome measures Clinical – gingival inflammation/bleeding on probing at the gingival margin (3 years). Patient – oral hygiene self-efficacy (3 years). Economic – net benefits (mean WTP minus mean costs). Results A total of 63 dental practices and 1877 participants were recruited. The mean number of teeth and percentage of bleeding sites was 24 and 33%, respectively. Two-thirds of participants had BPE scores of ≤ 2. Under intention-to-treat analysis, there was no evidence of a difference in gingival inflammation/bleeding between the 6-monthly PI group and the no-PI group [difference 0.87%, 95% confidence interval (CI) –1.6% to 3.3%; p = 0.481] or between the 6-monthly PI group and the 12-monthly PI group (difference 0.11%, 95% CI –2.3% to 2.5%; p = 0.929). There was also no evidence of a difference between personalised and routine OHA (difference –2.5%, 95% CI –8.3% to 3.3%; p = 0.393). There was no evidence of a difference in self-efficacy between the 6-monthly PI group and the no-PI group (difference –0.028, 95% CI –0.119 to 0.063; p = 0.543) and no evidence of a clinically important difference between the 6-monthly PI group and the 12-monthly PI group (difference –0.097, 95% CI –0.188 to –0.006; p = 0.037). Compared with standard care, no PI with personalised OHA had the greatest cost savings: NHS perspective –£15 (95% CI –£34 to £4) and participant perspective –£64 (95% CI –£112 to –£16). The DCE shows that the general population value these services greatly. Personalised OHA with 6-monthly PI had the greatest incremental net benefit [£48 (95% CI £22 to £74)]. Sensitivity analyses did not change conclusions. Limitations Being a pragmatic trial, we did not deny PIs to the no-PI group; there was clear separation in the mean number of PIs between groups. Conclusions There was no additional benefit from scheduling 6-monthly or 12-monthly PIs over not providing this treatment unless desired or recommended, and no difference between OHA delivery for gingival inflammation/bleeding and patient-centred outcomes. However, participants valued, and were willing to pay for, both interventions, with greater financial value placed on PI than on OHA. Future work Assess the clinical effectiveness and cost-effectiveness of providing multifaceted periodontal care packages in primary dental care for those with periodontitis. Trial registration Current Controlled Trials ISRCTN56465715. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 38. See the NIHR Journals Library website for further project information.

Background Hospital admissions for Ambulatory Care Sensitive Conditions (ACSC) are those that could potentially be prevented by timely and effective disease management within primary care. ACSC admissions are increasingly used as performance indicators. However, key questions remain about the validity of these measures. The evidence to date has been inconclusive and limited to specific conditions. The aim of this study was to test the robustness of ACSC admissions as indicators of the quality of primary care. It is the first study to examine a wide range of ACSCs using longitudinal data which enables us to control for unmeasured characteristics which differ by practice but which are constant over time. Methods Using longitudinal data at the practice level, from 907 Scottish practices for the time period 1/4/2005 to 31/32012, we explored the relationships between the quality of primary care, and hospital admissions for multiple ACSCs controlling for a wide range of covariates including characteristics of GP practices, characteristics of the practice population, hospital effects and year effects. We examined the impact of two dimensions of quality of care: clinical quality of and access to daytime general practice. Generalised Estimating Equations taking the form of Negative Binomial regression models with the practice population included as the exposure term were estimated. Results We found that higher achievement on some clinical quality measures of primary care was associated with reduced ACSC emergency admissions. We also show that access to primary care was associated with ACSC emergency admissions. However, the effects were small and inconsistent and ACSC emergency admissions were associated with several confounding factors such as deprivation, rurality and distance to the hospital. Conclusions The results suggest caution in the use of crude ACSC admission rates as a performance indicator of quality of primary care. Electronic supplementary material The online version of this article (10.1186/s12875-019-0921-z) contains supplementary material, which is available to authorized users.

Changing physical activity and dietary behavior in chronic disease patients is associated with significant health benefits but is difficult to achieve. An often-used strategy is for the physician or other health professional to encourage behavior changes by providing advice on the health consequences of such behaviors. However, adherence to advice on health behavior change varies across individuals. This paper uses data from a population-based cross-sectional survey of 1849 individuals with chronic disease to explore whether differences in individuals' time and risk preferences can help explain differences in adherence. Health behaviors are viewed as investments in health capital within the Grossman model. Physician advice plays a role in the model in that it improves the understanding of the future health consequences of investments. It can be hypothesized that the effect of advice on health behavior will depend on an individuals' time and risk preference. Within the survey, which measured a variety of health-related behaviors and outcomes, including receipt and compliance with advice on dietary and physical activity changes, time preferences were measured using financial planning horizon, and risk preferences were measured through a commonly used question which asked respondents to indicate their willingness to take risks on a ten-point scale. Results suggest that time preferences play a role in adherence to physical activity advice. While time preferences also play a role in adherence to dietary advice, this effect is only apparent for males. Risk preferences do not seem to be associated with adherence. The results suggest that increasing the salience of more immediate benefits of health behavior change may improve adherence.

The interest in eliciting time preferences for health has increased rapidly since the early 1990s. It has two main sources: a concern over the appropriate methods for taking timing into account in economics evaluations, and a desire to obtain a better understanding of individual health and healthcare behaviors. The literature on empirical time preferences for health has developed innovative elicitation methods in response to specific challenges that are due to the special nature of health. The health domain has also shown a willingness to explore a wider range of underlying models compared to the monetary domain. Consideration of time preferences for health raises a number of questions. Are time preferences for health similar to those for money? What are the additional challenges when measuring time preferences for health? How do individuals in time preference for health experiments make decisions? Is it possible or necessary to incentivize time preference for health experiments?

In a perfect agency relationship, doctors consider all information and select the patient's ‘utility maximising’ option given the patient's preferences. The patient's time preferences are important as treatments vary in the timing and length of their benefits. However, doctors often do not have full information on patients' preferences and may apply their own preferences. This has generated empirical interest in estimating doctors' time preferences. However, these studies generally elicit doctors' private preferences (preferences for their own health) rather than professional preferences (preferences for the patient). We hypothesise that private and professional preferences may differ. Professional time preferences may be ‘taught’ in medical school or learned through repeated interactions with patients. If preferences differ then estimates of doctors' private preferences are less informative for medical decision-making. This study compares private and professional time preferences for health in a national sample of General Practitioners, using a between sample design. Time discounting is explored using exponential and quasi-hyperbolic models. We elicit time preferences using multiple price lists. We find no significant difference between the time preference for the self or the patient. This result holds for axiomatic discounting classification and maximum likelihood estimates. We do not find evidence of present-bias. There are a high proportion of increasingly impatient GPs, potentially implying a maximum ‘willingness to wait’ for treatment benefits. GPs value the health state differently between themselves or for a patient. These results suggest that we can use estimates of private preferences from doctors to inform medical decision-making.

Time and risk preferences are known to vary considerably across individuals but less is known about the determinants of these individual differences. This paper examines whether preferences vary by geographical location. The motivation for examining geographic heterogeneity is the higher level of mortality experienced in Glasgow over and above that explained by deprivation, sometimes referred to as the 'Glasgow effect'. Data were collected from 3702 individuals across Glasgow, Manchester and Liverpool between July and November 2011. The results show evidence of geographic preference heterogeneity. Contrary to our hypothesis, individuals in Glasgow have a lower rather than higher time preference rate. Individuals in Glasgow are on average more risk seeking compared to Liverpool and more likely to be at the tail end of the distribution (very risk seeking) compared to Manchester. Differences in risk preferences may help explain some of the differences in mortality associated with risky health behaviours such as drug and alcohol use. However, individuals in Glasgow were also more future oriented suggesting that they are less likely to engage in risky healthy behaviours. As the differences in time and risk preferences work in opposite directions in terms of health investments it less likely that these differences can help explain excess mortality in Glasgow.

Highlights • Explores correlation in offspring and parent time and risk preference using Australian panel data. • We examine correlations across the preference distribution and by gender. • Evidence of correlation in offspring risk and time preferences was found. • Largest correlation in time preference was found for the longest planning horizons. • Gender differences in the preference correlations were found., There is a growing interest in individual time and risk preferences. Little is known about how these preferences are formed. It is hypothesised that parents may transmit their preferences to their offspring. This paper examines the correlation in offspring and parental time and risk preferences using data from an annual household survey in Australia (the HILDA survey). Both time and risk preferences are examined and we explored whether the correlation in time and risk preferences varies across the distribution of preferences and across the across the four parent–child dyads (mother/daughter, mother/son, father/daughter, father/son). The results show that there is a significant relationship between parents and their young adult offspring risk and time preference measures. The correlation varies across the distribution of time preferences. The correlation was largest for longer planning horizons. Risk averse parents are more likely to have risk averse children. Except for the father/daughter dyad risk seeking parents are more likely to have risk seeking offspring. Some gender differences were found. The association in parental and offspring time preference was larger for mothers than fathers. Daughters are more likely to be influenced by their mother’s risk preferences, however, sons are equally influenced by both parents. The results of this study suggest that the transmission in preferences is more nuanced than previously thought and parental gender may be important.

We compared the costs and cost-effectiveness of telemonitoring vs usual care for patients with chronic obstructive pulmonary disease (COPD). A total of 256 patients were randomised to either telemonitoring or usual care. In the telemonitoring arm, the touch-screen telemonitoring equipment transmitted data to clinical teams monitoring the patients. Total healthcare costs were estimated over a 12-month period from a National Health Service perspective and quality adjusted life year (QALYs) were estimated by the EQ-5D tool. Telemonitoring was not significantly more costly than usual care (mean difference per patient £2065.90 ( P

Evidence suggests that maternal and offspring smoking behaviour is correlated. Little is known about the mechanisms through which this intergenerational transfer occurs. This paper explores the role of time preferences. Although time preference is likely to be heritable and correlated with health investments, its role in the intergenerational transmission of smoking has not been explored previously. This is the first paper to empirically test this. Data (2002, 2003, 2004, 2006 and 2008) from the Household, Income and Labour Dynamics in Australia are used. Estimates by using a pooled probit model show that there is not a direct effect of maternal time preference, measured in terms of financial planning horizon, on the likelihood that their offspring is a smoker. However, there is an indirect effect of maternal time preference. Sons of mothers that are smokers and have a shorter planning horizon are 6% more likely to smoke than if their mother had a longer planning horizon, and daughters of mothers that smoke with a shorter planning horizon are 7% more likely to smoke themselves than if their mother had a longer planning horizon.

Background Despite being a core component of self-management, goal setting is rarely used in routine care. We piloted a primary care, nurse-led intervention called Achieving Good Outcomes for Asthma Living (GOAL) for adults with asthma. Patients were invited to identify and prioritise their goals in preparation for discussing and negotiating an action/coping plan with the nurse at a routine asthma review. Methods The 18-month mixed methods feasibility cluster pilot trial stratified and then randomised practices to deliver usual care (UC) or a goal-setting intervention (GOAL). Practice asthma nurses and adult patients with active asthma were invited to participate. The primary outcome was asthma-specific quality of life. Semi-structured interviews with a purposive patient sample (n = 14) and 10 participating nurses explored GOAL perception. The constructs of normalisation process theory (NPT) were used to analyse and interpret data. Results Ten practices participated (five in each arm), exceeding our target of eight. However, only 48 patients (target 80) were recruited (18 in GOAL practices). At 6 months post-intervention, the difference in mean asthma-related quality of life (mAQLQ) between intervention and control was 0.1 (GOAL 6.20: SD 0.76 (CI 5.76–6.65) versus UC 6.1: SD 0.81 (CI 5.63–6.57)), less than the minimal clinically important difference (MCID) of 0.5. However, change from baseline was stronger in the intervention group: at 6 months the change in the emotions sub-score was 0.8 for intervention versus 0.2 for control. Costs were higher in the intervention group by £22.17. Routine review with goal setting was considered more holistic, enhancing rapport and enabling patients to become active rather than passive participants in healthcare. However, time was a major barrier for nurses, who admitted to screening out patient goals they believed were unrelated to asthma. Conclusions The difference in AQLQ score from baseline is larger in the intervention arm than the control, indicating the intervention may have impact if appropriately strengthened. The GOAL intervention changed the review dynamic and was well received by patients, but necessitated additional time, which was problematic in the confines of the traditional nurse appointment. Modification to recruitment methods and further development of the intervention are needed before proceeding to a definitive cluster randomised controlled trial. Trial registration ISRCTN18912042. Registered on 26 June 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1684-7) contains supplementary material, which is available to authorized users.

Individuals' risk attitude is an important concept within the health domain. A previous study showed that risk attitude varied across health outcomes, life years and quality of life. The aim of this article is to improve the elicitation methods used in that study and to provide further evidence of whether risk attitude varies within the health domain. The elicitation method was improved by using the probability equivalent method rather than the certainty equivalent method, by using face-to-face interviews rather than web-based questionnaires and by omitting financial incentives which may be more attractive to individuals who are risk seeking. In line with the previous study, this article shows that risk attitude varies across the health domain. However, in the current study, risk attitude for the two life years gambles were very similar and the majority of the participants were risk averse. In the previous study, risk attitude varied across these two gambles with the majority of individuals being risk ave...

Intertemporal preferences for health are an important concept when modelling health-affecting behaviour and with respect to informing discounting practice in economic evaluation. The aim of this paper is to test robustly stationarity, the key axiom of the Discounted Utility model, and to test whether the quasi-hyperbolic or generalised hyperbolic model provides a better description of individual time preferences for health outcomes when stationarity is violated. Very little is known about the descriptive validity of the quasi-hyperbolic model. The different models can lead to different predictions and it is therefore crucial to test which functional form is more descriptively valid. An axiomatic approach is used. Intertemporal preferences were elicited from 203 university students. The results showed that stationarity is violated. Individuals discounted both initial delay and further delays between outcomes at a decreasing rate. This suggests that the quasi-hyperbolic model may not be appropriate to use in intertemporal analyses of health behaviour.

Education has been shown to be the most important correlate of health. However, the mechanism through which education influences health has been largely unexplained. Grossman argued that education improves health production efficiency. In contrast, Fuchs argued that the association between health and education is not primarily causal but reflects unobserved causes of both outcomes. Instead of education causing better health, some 'third' variables may be related to both education and health. The 'third' variable most frequently mentioned is time preference. The aim of this paper is to investigate the role of time preference in the relationship between education and health. The role of risk attitude is also investigated. The paper exploits a unique data set of households that incorporated stated preference questions eliciting individuals' time preferences. The results show that the effect of education reduces but does not disappear when controlling for individuals' time preferences.

Objective To demonstrate how a discrete choice experiment (DCE) can be used to elicit individuals’ preferences for health care and how these preferences can be incorporated into a cost–benefit analysis. Methods A DCE which elicited preferences for three perinatal services: specialist nurse appointments; home visits from a trained lay visitor; and home-help. Cost was included to obtain a monetary measure of the value that individuals place on the services. In total, 292 women who had previously participated in a randomized trial of alternative forms of pre-natal care were interviewed. Results The most preferred service configuration consisted of three nurse appointments and two home visits before birth and 4 h of home-help per week for the first 4 weeks after birth. On average, women are willing to pay $371 for this package. A package that excluded home-help was valued at $122 whilst provision of three nurse appointments only was valued at $97. The predicted uptake of the services ranged from 37% to 93% depending on the woman’s experience with the service, whether or not it was her first child and her level of education. Conclusion The willingness to pay values were much higher than the costs for nurse appointments, suggesting this service produces a net social benefit. The willingness to pay for the package including both the nurse appointments and home visits only just exceeded the costs of the package, suggesting there is a relatively high chance that this package produces a net social loss.

We have conducted a feasibility study to establish whether ENT tele-endoscopy would be a suitable method of service delivery for patients who live in the Shetland Islands. Ten clinics were conducted over a period of 17 months using ISDN-based videoconferencing at a bandwidth of 384 kbit/s. A total of 42 patients were seen in Aberdeen via videoconferencing for a head and neck cancer assessment. Feasibility was confirmed after the first 20 patients, following positive feedback from all concerned and the absence of any significant clinical or technical problems. A total of 42 journeys was avoided, each journey saving 123 kg CO2 per person. A preliminary cost analysis showed that the threshold at which tele-ENT became cheaper than travel was a workload of 35 patients/year. The actual workload during the pilot study was 29 patients/year. A national telemedicine service for the initial assessment of potential malignancy has the potential to reduce unnecessary transfers to specialist centres, with accompanying reductions in carbon emissions.

The aim of this study is to examine whether individuals' risk attitude for life years differ from their risk attitude for quality of life. The study also investigates two different framing effects, an order and sequence effect, and the interaction between risk attitude and time preferences. The results showed that individuals tended to be risk averse with respect to the gamble involving risk of immediate death and risk seeking with respect to the other health gambles. Varying the order of the questions or the sequence of full health and ill-health did not seem to systematically bias the estimates.

Many theories have been proposed to explain the high levels of 'excess' mortality (i.e. higher mortality over and above that explained by differences in socio-economic circumstances) shown in Scotland-and, especially, in its largest city, Glasgow-compared with elsewhere in the UK. One such proposal relates to differences in optimism, given previously reported evidence of the health benefits of an optimistic outlook.A representative survey of Glasgow, Liverpool and Manchester was undertaken in 2011. Optimism was measured by the Life Orientation Test (Revised) (LOT-R), and compared between the cities by means of multiple linear regression models, adjusting for any differences in sample characteristics.Unadjusted analyses showed LOT-R scores to be similar in Glasgow and Liverpool (mean score (SD): 14.7 (4.0) for both), but lower in Manchester (13.9 (3.8)). This was consistent in analyses by age, gender and social class. Multiple regression confirmed the city results: compared with Glasgow, optimism was either similar (Liverpool: adjusted difference in mean score: -0.16 (95% CI -0.45 to 0.13)) or lower (Manchester: -0.85 (-1.14 to -0.56)).The reasons for high levels of Scottish 'excess' mortality remain unclear. However, differences in psychological outlook such as optimism appear to be an unlikely explanation.

We conduct a framed field experiment among patients and doctors to test whether the two groups have similar risk and time preferences. We elicit risk and time preferences using multiple price list tests and their adaptations to the healthcare context. Risk and time preferences are compared in terms of switching points in the tests and the structurally estimated behavioural parameters. We find that doctors and patients significantly differ in their time preferences: doctors discount future outcomes less heavily than patients. We find no evidence that doctors and patients systematically differ in their risk preferences in the healthcare domain.

The aim of this paper is to predict attendance if the age range for routine invitation to breast screening were to be extended. The response to the most recent screening invitation is modelled for women eligible for screening if the age range were extended. The independent variables include (i) the woman's characteristics: her screening history; the deprivation score of the area she lives in and (ii) the characteristics of the screening: whether the screening took place in a mobile van or at a static site; and time of the year. The predictive ability of the regression model is tested by goodness of fit measures and by predicting attendance for a holdout sample of the data and for women who participated in a demonstration project. The modelling of attendance is quite successful in that most hypothesised variables have the expected sign. Moreover, the predictive ability of the model is satisfactory in terms of goodness of fit statistics and in terms of accuracy of predictions for a holdout sample. The model predicts less well for the demonstration project possibly because it is less representative of usual screening practice.

Whilst there is substantial evidence that hyperbolic discounting models describe intertemporal preferences for monetary outcomes better than the discounted utility (DU) model, there is only very limited evidence in the context of health outcomes. This study elicits private and social intertemporal preferences for non-fatal changes in health. Specific functional forms of the DU model and three hyperbolic models are fitted. The results show that the stationarity axiom is violated, and that the hyperbolic models fit the data better than the DU model. Intertemporal preferences for private and social decisions are found to be very similar.

It has been suggested that individuals employ simple decision heuristics when answering stated preference questions. Evidence from discrete choice experiments of individuals failing to trade may indicate that they employ simple decision making heuristics. However, individuals might not trade because their preferences are not captured by the range of trade-offs they are offered. This is explored by offering a series of choices where the trade-offs implied by subsequent choices depend on the subject's responses to previous choices. The results suggest that individuals answer discrete choices without recourse to simplifying heuristics, and that information is generated on their preferences rather than on how they make such choices.

BACKGROUND: Getting lost outside is stressful for people with dementia and their caregivers and a leading cause of long-term institutionalisation. Although Global Positional Satellite (GPS) location has been promoted to facilitate safe walking, reduce caregivers' anxiety and enable people with dementia to remain at home, there is little high quality evidence about its acceptability, effectiveness or cost-effectiveness. This observational study explored the feasibility of recruiting and retaining participants, and the acceptability of outcome measures, to inform decisions about the feasibility of a randomised controlled trial (RCT).METHODS: People with dementia who had been provided with GPS devices by local social-care services and their caregivers were invited to participate in this study. We undertook interviews with people with dementia, caregivers and professionals to explore the perceived utility and challenges of GPS location, and assessed quality of life (QoL) and mental health. We piloted three methods of calculating resource use: caregiver diary; bi-monthly telephone questionnaires; and interrogation of health and social care records. We asked caregivers to estimate the time spent searching if participants became lost before and whilst using GPS.RESULTS: Twenty people were offered GPS locations services by social-care services during the 8-month recruitment period. Of these, 14 agreed to be referred to the research team, 12 of these participated and provided data. Eight people with dementia and 12 caregivers were interviewed. Most participants and professionals were very positive about using GPS. Only one person completed a diary. Resource use, anxiety and depression and QoL questionnaires were considered difficult and were therefore declined by some on follow-up. Social care records were time consuming to search and contained many omissions. Caregivers estimated that GPS reduced searching time although the accuracy of this was not objectively verified.CONCLUSIONS: Our data suggest that a RCT will face challenges not least that widespread enthusiasm for GPS among social-care staff may challenge recruitment and its ready availability may risk contamination of controls. Potential primary outcomes of a RCT should not rely on caregivers' recall or questionnaire completion. Time spent searching (if this could be accurately captured) and days until long-term admission are potentially suitable outcomes.

This study is the first to use discrete choice experiments to elicit inter-temporal preferences for health. Inter-temporal preferences with respect to one's own future health are compared with inter-temporal preferences with respect to others' future health. Discrete choice experiments are used to measure the relative importance of the duration of ill-health and how far in the future the ill-health occurs. Data were collected by postal questionnaire in the UK. The median implied rates of discount range from 0.055 to 0.091 for own health, depending on the period of delay, and from 0.078 to 0.147 for others' health. The implied discount rate varies with respect to age, self-rated health, and version of the questionnaire. The implied discount rates are broadly comparable with other published estimates using closed-ended methods. One concern is the large percentage of respondents with dominant preferences. This issue needs to be explored before adopting the approach of discrete choice experiments to elicit inter-temporal preferences.

It is standard practice in economic evaluation and in any economic analysis of future events to assume the discounted utility model on the part of economic agents. This paper compares the discounted utility model with three hyperbolic discounting models with respect to private and social financial benefits. The discounting models are fitted using non-linear regression techniques to data collected from the general public. Regression analysis is then used to test the theoretical validity of the models. The main test is whether the period of years for which the benefit is to be delayed is a statistically significant predictor of the respective values of the discounted utility model and the three hyperbolic discounting models. This tests whether these discounting models are satisfactory representations of the individuals’ intertemporal preferences. The results show that there is evidence in favour of hyperbolic discounting models over the discounted utility model. There were not any statistically significant differences in the discounting models fitted for the private and social financial benefits. The regression results were very similar for the private and social financial benefits.

The assumption of positive time preference is seldom challenged in analyses of intertemporal choices, despite considerable evidence of zero and negative discount rates. In this study, the majority of respondents have positive discount rates, but a substantial number have negative or zero discount rates. Using probit regression, the perception of the severity of the health-state, gender, education and perception of the questions in terms of difficulty are shown to influence whether individuals have positive discount rates.

The purpose of this study was to investigate whether time preferences for own health are the same as time preferences for others' health. A random sample of the general public was sent a postal questionnaire containing six choices between ill health in the near future and ill health in the further future. They were asked to indicate the maximum duration of more distant ill health they would be willing to accept in return for a specified delay in the onset of the period of ill health. For half of the sample the questions were set in the context of their own health and for the other half in terms of others' health. The median implied discount rates were not statistically different, 0.061 for own health and 0.062 for others' health. A multilevel analysis of the determinants of these implied discount rates provided additional evidence of the similarity of time preferences for own health and others' health. Key words: intertemporal preferences; own versus other's health. (Med Decis Making 1999; 19:466-472)

This paper models the costs of collecting whole blood in the north of Scotland in order to investigate strategies whereby the annual collection target can be met at lower cost. Data on the costs of the individual sessions held in 1993–1995 are analyzed using multilevel analysis. A new technique, namely the conditioned iterative generalized least squares (CIGLS) estimator is applied. Then the feasibility of collecting increased volumes from particular panels and areas is assessed by examining which factors determine the number of blood donors at a session. Results show that fixed cost and marginal cost vary across panels but marginal cost does not vary by volume. This implies that the cost-minimizing policy is to equalize marginal costs and collect higher volume at fewer panels (those with lower fixed costs). The level of donations can be increased by increasing the number of opportunities to donate and/or increasing the average length of a session. The latter policy is shown to be more cost-effective. Multilevel analysis proves not only to be appropriate but also particularly useful. © 1998 John Wiley & Sons, Ltd.