Examining the attitudes and preferences of health care decision-makers in relation to access, equity and cost-effectiveness: a discrete choice experiment.

OBJECTIVES To describe the views of health care decision-makers and providers operating in the UK National Health Service (NHS) concerning the concepts of cost-effectiveness, equity and access through a series of attitudinal questions; to evaluate the preferences of health care providers in relation to each of these concepts using a discrete choice experiment (DCE); to assess the impact of prior completion of an attitude questionnaire on preferences elicited through a DCE. METHOD Three versions of a DCE questionnaire were developed with and without a series of attitudinal questions and randomly distributed to 1456 health care decision-makers and providers. The questionnaire sought to elicit their preferences between the competing objectives of cost-effectiveness, equity and access within the context of different hypothetical, specialist treatment programmes for cardiovascular disease. RESULTS The response rate was 26%. Female respondents exhibited a stronger preference than males for reducing health inequalities by targeting the worst off (Wald test, P<0.001). Primary Care Trusts (PCTs), Strategic Health Authorities (SHA) or Department of Health (DoH) staff were also more likely than hospital managers to favour programmes that targeted the worst off (Wald test, P<0.001 in each case). Those who were clinically trained and currently in a clinical post had a stronger preference for programmes with shorter waiting times compared to those in a managerial or non-clinical posts, who exhibited stronger preferences for equity. Completion of a series of attitudinal questions prior to completing the DCE task resulted in a lower proportion of dominant responses and an increased willingness to make trade-offs between attributes.