https://orcid.org/0000-0003-4274-9258
The patient’s perspective is becoming increasingly important in clinical and policy decisions. There has therefore been an increasing interest in evaluating patients’ preferences for healthcare treatments. In particular, the use of stated-preference studies has markedly increased in recent yearsCitation1. Discrete-choice experiments (DCE), a stated-preference method, are gaining more popularity in healthcare nowadays and have been widely used to elicit and analyse preferencesCitation2. DCE, with origin in marketing, break down a healthcare intervention into attributes (such as effectiveness, side-effects, accessibility and costs) suggesting the utility a patient derives from the treatment is a combination of these attributes. By asking respondents to repeatedly choose between two or more hypothetical treatments that differ according to attributes of interest, DCEs can quantify the relative importance of the various attributes that characterize a treatment by quantifying the trade-offs that respondents make from their choices.
As the case in many other disease areas, stated-preference studies can be attractive and have been used to elicit preferences for HIV antiretroviral therapy (ART). A few DCEs have been conducted to assess preferences for HIV testing or careCitation3, but relatively few for HIV treatmentCitation4. Previous studies have suggested that HIV patients are willing to trade off between treatment characteristics including treatment efficacy, side-effects, delivery form and dosing frequency. However, literature provides little guidance and information regarding treatment preferences in developing countries such as Colombia, and especially in its rural population since most of the previous DCEs assessed developed countries and/or urban settingsCitation1. Overall, the rural and urban populations differ in several aspects, e.g. rural populations being lower educatedCitation5 and economically disadvantagedCitation6 compared to urban populations. Therefore, it is important to be cognizant of potential differences regards patient preferences in different areas, and don’t assume transferability of preference studies in urban areas to rural areasCitation7.
In this issue of the Journal of Medical Economics (August 2020), Goossens et al.Citation8 and Sijstermans et al.Citation9 reported on DCEs conducted to assess patients’ preferences for HIV treatment in rural and urban Colombia. Five attributes were derived from literature review and a focus group with patients: “effect on life expectancy,” “effect on physical activity,” “risk of moderate side effects,” “accessibility to clinic” and “economic cost to access controls”. The same DCE was then conducted in the rural and urban population of Colombia. In both populations, all five attributes were shown to be important, suggesting that patients are willing to trade-off between treatment outcomes, side-effects, cost and accessibility. Interestingly, in the rural population, accessibility was associated with a higher conditional relative importance, revealing the importance to provide access to care in rural population. Yet, “economic cost to access controls” was shown to be less important for the rural population.
Other studies have also revealed differences in preferences between rural and urban populations. For instance, Yu et al.Citation10 revealed that urban or rural dwelling patients with different income level shave different preferences for healthcare providers and this partially mediated the outcome of care. In another study, Shi et al.Citation11 revealed that proximity to care home facilities and higher income from urban population are associated with an increase in the willingness to live in a care home in urban China. Using a DCE, Eshun-WilsonCitation12 also revealed some differences between rural and urban participants regarding location of ART collection accounted. These differences reveal that the needs of rural and urban patients may differ, and effective health communication and policy interventions therefore needs a targeted approach. In order to optimise adoption and sustained use of any intervention such as ART, it is important to match the treatment as well as broader interventions (e.g. health communication) to patient needsCitation13. From a behaviour change perspective, preference differences between rural and urban patients may also reflect differences in the underlying mechanism to adoption and adherence to ART. The important socio-cognitive beliefs that relate to treatment use and adherence are therefore different. For instance, when beliefs regard the perceived advantages and disadvantages of specific treatment characteristics (which may reflect attitude) are different, e.g. access costs, the intervention design needs to be mapped differentlyCitation13. Access to care in rural population (especially in low and middle-income countries) remain a challenging task, but seem of utmost importance for patients. Next to enhancing actual access, perhaps efforts could also be taken to boost the patient’s self-efficacy to access care. Researchers and decision-makers should thus be aware of potential variations in preferences between urban and rural population. Assessing the location of respondents, and investigating potential differences between urban and rural population could thus be an important consideration in future preference studies and in intervention design.
Next to rural versus urban differences, it is important to consider the different modes of administration of ART, which could be delivered orally as well as via injection. The studies of Goossens et al.Citation8 and Sijstermans et al.Citation9 did not include mode of administration, which means that more research is needed to identify potential differences in preferences between modes of administration. Recently, in the Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) and Assessment of ibrutinib plus rituximab in front-line CLL (FLAIR) trials, monthly ART injection was shown to be noninferior to continuing current daily three-drug oral ARTCitation14. Both studies also revealed a higher treatment satisfaction and preference for the injectable versus the daily oral therapy. Monthly or every-2-month injections could therefore represent a new effective and potentially more convenient treatment for HIV patients. Information on patients’ preferences for mode (injection or oral), frequency (daily) and number of tablets per administration would be extremely useful for health professionals and decision-makers in the future. A recent study already suggested that young women from Kenya stated preferences for an injection every 2–3 months compared to daily oral tabletCitation4, but more work will be needed to assess preferences of HIV patients for different modes of administration and to identify characteristics of patients preferring long-acting ART injection.
Transparency
Declaration of funding
No funding was received for this study.
Declaration of financial/other relationships
MH and KLC have no conflict of interest relevant to the content of this study. JME peer reviewers on this manuscript have no relevant financial or other relationships to disclose.
Acknowledgements
None reported.
References
- Clark MD, Determann D, Petrou S, et al. Discrete choice experiments in health economics: a review of the literature. Pharmacoeconomics. 2014;32(9):883–902.
- Whitty JA, de Bekker-Grob EW, Cook NS, et al. Patient preferences in the medical product lifecycle. Patient. 2020;13(1):7–10.
- Zanolini A, Sikombe K, Sikazwe I, et al. Understanding preferences for HIV care and treatment in Zambia: evidence from a discrete choice experiment among patients who have been lost to follow-up. PLoS Med. 2018;15(8):e1002636.
- Minnis AM, Browne EN, Boeri M, et al. Young women’s stated preferences for biomedical HIV prevention: results of a discrete choice experiment in Kenya and South Africa. J Acquir Immune Defic Syndr. 2019;80(4):394–403.
- Nieto S, Ramos R, Duque JC, editors. Rural-urban differences in educational outcomes: evidence for Colombia using PISA microdata. ERSA conference papers, European Regional Science Association; 2012 Aug 21–25; Bratislava, Slovakia.
- Schultz TP. Rural-urban migration in Colombia. Rev Econ Stat. 1971;53(2):157–163.
- Goeree R, He J, O’Reilly D, et al. Transferability of health technology assessments and economic evaluations: a systematic review of approaches for assessment and application. CEOR. 2011;3:89.
- Goossens AJ, Cheung KL, Sijstermans E, et al. A discrete choice experiment to assess patients’ preferences for HIV treatment in the rural population in Colombia. J Med Econ. 2020;1–9. DOI:10.1080/13696998.2020.1735398
- Sijstermans E, Cheung KL, Goossens AJ, et al. A discrete choice experiment to assess patients’ preferences for HIV treatment in the urban population in Colombia. J Med Econ. 2020;1–7. DOI:10.1080/13696998.2020.1735399
- Yu T-H, Chung K-P, Wei C-J, et al. Do the preferences of healthcare provider selection vary among rural and urban patients with different income and cause different outcome? PloS One. 2016;11(4):e0152776.
- Shi C, Hu B. Preferences for formal social care in rural and urban China: evidence from a national survey. J Gerontol Soc Work. 2020;63(1–2):19–40.
- Eshun-Wilson I, Mukumbwa-Mwenechanya M, Kim H-Y, et al. Differentiated care preferences of stable patients on antiretroviral therapy in Zambia: a discrete choice experiment. J Acquir Immune Defic Syndr. 2019;81(5):540–546.
- Eldredge LKB, Markham CM, Ruiter RA, et al. Planning health promotion programs: an intervention mapping approach. San Francisco, CA: John Wiley & Sons; 2016.
- Swindells S, Andrade-Villanueva J, Richmond G, et al., editors. Long-acting cabotegravir + rilpivirine as maintenance therapy: ATLAS week 48 results. Conference on Retroviruses and Opportunistic Infections; 2019 Mar 4–7; Seattle, WA.