Choosing vs. allocating: discrete choice experiments and constant-sum paired comparisons for the elicitation of societal preferences.

BACKGROUND: There is growing evidence of a reluctance to allocate health care solely on the basis of maximizing quality-adjusted life years (QALYs). Stated preference methods can be used to elicit preferences for efficiency vs. equity in the allocation of health-care resources. OBJECTIVE: To compare discrete choice experiment (DCE) and constant-sum paired comparison (CSPC) methods for eliciting societal preferences. METHODS: Over a series of choice pairs, DCE respondents allocated a fixed budget to one preferred group and CSPC respondents allocated budget percentages between the groups. Questionnaires were compared in terms of completion rates, preference consistency, dominant preferences and derived attribute importance. RESULTS: There was no significant difference in the proportions that rated the questionnaires somewhat or extremely difficult, but a significantly greater proportion completed the DCE compared to the CSPC. Preference consistency was also higher in the DCE. The incidence of dominant preferences, including for aggregate QALYs, was low and not significantly different between questionnaires. Similarly, no CSCP respondents equalized budgets or outcomes in every task. Final health state was the most important attribute in both questionnaires, but the rankings diverged for the other attributes. Notably, the total patients' treated attribute was important in the CSPC but insignificant in the DCE, perhaps reflecting a 'prominence effect'. CONCLUSIONS: Despite lower completion rates and preference consistency, CSPC may offer advantages over DCE in eliciting preferences over the distribution of resources and/or outcomes as well as attribute levels, avoiding extreme 'all-or-nothing' distributions and possibly aligning respondent attention more closely with a societal perspective.

Use of physician profiles to influence prescribing of topical corticosteroids.

BACKGROUND: Physician profiling is a tool used to attempt to affect changes in prescribing. The Drug Evaluation Alliance of Nova Scotia (DEANS) decided to implement a physician profiling project to determine if prescribing of topical corticosteroids could be altered. OBJECTIVES: To evaluate a DEANS initiative utilizing physician prescribing profiles to shift prescribing of topical corticosteroids from higher to lower potency agents in beneficiaries of the Nova Scotia Seniors' Pharmacare Program. METHODS: Administrative claims from the Nova Scotia Seniors' Pharmacare program were used to identify prescriptions for topical corticosteroids. Prescriptions were summarized at the individual physician level, and aggregated by Anatomical Therapeutic Classification into weak, moderately potent, potent and very potent products. The number of prescriptions for topical corticosteroids was compared for the twelve-month period before and after mailing of the profiles. Overall results were aggregated by utilization and expenditures. RESULTS: The number of prescriptions for topical corticosteroids per physician profiled was 44.0 in 2000/2001 and 42.8 in 2001/2002 (p = NS) and the expenditures per physician profiled were 838.94 dollars in 2000/2001 and 826.81 dollars in 2001/2002 (p = NS). There was a small decrease in prescriptions dispensed for potent topical products over the profiling period (52.4% of prescriptions in 2000/2001 versus 51.5% of prescriptions in 2001/2002, p=0.03). Otherwise, changes in utilization or expenditures for topical corticosteroids were not statistically different between the profiling periods. CONCLUSIONS: This project showed that mailing unsolicited individual-level profiles did not alter prescribing or expenditures for topical corticosteroids over a two-year period. Further work is needed to determine physician attitudes towards such projects.

Topical corticosteroid prescribing patterns following changes in drug benefit status.

OBJECTIVE: To examine changes in prescribing patterns for topical corticosteroid products dispensed to elderly patients in Nova Scotia, Canada, after all but 2 combination topical corticosteroid products were removed from the Nova Scotia Seniors' Pharmacare Program benefit list. METHODS: Administrative prescription claims from the Nova Scotia Seniors' Pharmacare Program were used to identify the number and costs of topical corticosteroid, antifungal, antibiotic, and combination corticosteroid products dispensed. Time-series analysis was used to compare the periods before (April 1, 1999-March 31, 2000) and after (April 1, 2000-March 31, 2001) the delisting. RESULTS: In 1999-2000, 26,031 of 103 400 eligible elderly patients (25%) and in 2000-2001, 22,837 of 95,550 eligible elderly (24%) received a prescription for a defined topical product. Nova Scotia Seniors' Pharmacare Program expenditures for all topical products decreased from 11.88 to 10.60 Canadian dollars per beneficiary per year (11%) after the policy revision. Topical combination products decreased from 18% of all topical products dispensed to 14%, while the percentage of potent corticosteroid products dispensed increased from 24% to 27% over the study period. Pre- and post-policy time-trend analysis showed statistically significant increasing trends in cost per beneficiary for all topical products and potent corticosteroid products. Combination corticosteroid products showed no change in trends for costs per beneficiary before, and a slight increasing trend after, the policy revision. CONCLUSIONS: Prescribing of topical corticosteroid combination products in Nova Scotia decreased following the formulary revision. There was an increase in potent topical corticosteroid prescribing. Future study involving evaluation of patient outcomes would be useful.