Institute of Management in Medicine and
Health Care Sciences, University of Bayreuth
Stakeholder preferences in
organ allocation
–
a conjoint measurement
approach
Thorsten Ahrend
Boston, April, 25th
Priorities 2010
1
AGENDA
Public discourse on setting priorities in the German health
care system
Exploration of stakeholder preferences in organ allocation
Measurement of preference orders in organ allocation with
conjoint analysis
2
AGENDA
Public discourse on setting priorities in the German
health care system
Exploration of stakeholder preferences in organ allocation
Measurement of preference orders in organ allocation with
conjoint analysis
3
Priorities in Health Care – the German discussion
Current discussion
May 2009
March 2010
Prof. Hoppe, President of the German Medical Association
addressed the problem of hidden rationing and stressed the
necessity of an open discussion on priorities in medical care.
He requested the implementation of a Health Care Council of
physicians, ethicians, lawyers, health care scientists,
theologians, social scientists and patient representatives to
develop recommendations to the politics for a just allocation
of scarce resources.
The German Health Minister argued against a discussion
on priorities in health care. For him prioritisation of health
care is not a task of the German Federal Parliament and is
also not in accordance with his ethical values as a
physician. He rather strives for a health care system which
works efficiently with the statutory insurance contributions.
4
Priorities in Health Care – the German discussion
Members of the Central Association of the statutory
health insurance system point out, the there is no legal
basis for rationing of health care in Germany as an
insured person has a legal title to all necessary in- and
out-patient services. They question whether the offered
health care services correspond to the medical
necessity and assume behind the discussion on
rationing and prioritization a competition for resources.
5
The research group FOR 655 - Focus
Prioritizing in Medicine:
A theoretical and empirical analysis in
consideration of the public health insurance
system
www.for655.de
• Funded by the German Research Foundation
• Members: 11 working groups from 15 German universities and
research institutions
6
The research group FOR 655 - Projects
Projects
Theoretical
projects
Focus on legal, philosophical and economic
aspects, frameworks and implications relating to
the process of setting priorities in the statutory
health insurance.
Empirical
projects
Analyse stakeholder preferences concerning
prioritization in medicine from a horizontal and
vertical point of view.
7
The research group FOR 655 – Project examples
Project B3: “Stakeholder preferences and
criteria in organ allocation - exemplified by heart,
liver and renal transplantation”
Project B5: Evidence based medicine (EbM)
and health related quality of life (hrQoL) –
potential criteria for prioritization exemplified by
the peripheral arterial occlusive disease (PAD)
8
AGENDA
Public discourse on setting priorities in the German health
care system
Exploration of stakeholder preferences in organ
allocation
Measurement of preference orders in organ allocation with
conjoint analysis
9
Exploration of preferences – background (1/2)
In Germany, the supply of donor organs does not
meet the demand of waiting list patients. Due to this
scarcity of resources, transplantation medicine is one
of the few health care sectors in Germany, in which
priority setting and rationing based on explicit
allocation criteria has already been established.
10
Exploration of preferences – background (2/2)
1
However, these allocation criteria are challenged by several
stakeholders and areas of research, e.g. ethics or theories of
democracy.
2
Utilitarian criteria (e.g. mismatch grade and –probability) are
questioned as they are contradictory to the principle of
indifference of the worth of life. On the other hand, waiting
time is seen as critical, since transplant life span reduces
with prior waiting time.
3
The conducted study aimed at the exploration and ranking of
preferred organ allocation criteria of those stakeholders who
are personally or professionally involved, but also included
unrelated individuals.
11
Exploration of preferences - methodology
• So far there is no comprehensive previous knowledge
about stakeholder preferences to potential
prioritization criteria in Germany.
• The study focused on the comprehension of
individual stakeholder preferences and aimed at the
analytical representativity of it’s research results, that
means the exploration of a preferably heterogeneous
set of prioritization criteria.
• The heterogeneity of the sample refers to the study’s
respondents who belong to different stakeholder
groups (qualitative content analysis according to
Mayring).
• The ranking of the prioritization criteria is examined in
a conjoint measurement study.
12
Exploration of preferences – stakeholder groups
Respondents are stratified as follows:
Physicians
Nurses
Patients
Relatives
Uninvolved
citizens
• Different specialisations
• In and out-patient
• Hospital-based or not
• Length of work experience
• Age
• Severity of disease
• Education
• Age
• Severity of disease
• education
• Age
• Education
13
Exploration of preferences – study procedure
•
Study procedure
•
•
•
•
•
•
•
Qualitative approach with 41 semi-structured
interviews
Interview duration between 40 - 80 minutes
Interviewees
12 transplanted and waiting list patients
(kidney, liver or heart transplantation)
9 relatives or close friends
9 citizens without significant insight into organ
transplantation
4 nurses from transplantation centres
7 physicians with and without professional
experience in organ transplantation
Interview transcription with f4-software
Qualitative content analysis
Interview coding with MAXQDA
Tests on objectivity, validity and reliability
Reliability tests: Intra- and inter-coder-reliability
14
Exploration of preferences – results (1/3)
As the central result of the study a set of categories with
three levels was derived.
The individual patient level refers to individual
characteristics of persons or patients.
The medical level is related to the core elements of
medical treatment.
The societal level aims at certain high-level views on the
structure and function of the organ allocation or healthcare
system from a societal point of view.
15
Exploration of preferences – results (2/3)
1
2
Patient Level
• Age (children, younger people in
general)
• Personal responsibility (high
therapy compliance, no self
inflicted diseases)
Medical level
• Medical prognosis (high transplant survival
rate in general, low co-morbidity, short
cold ischaemia, high histocompatibility,
inverse waiting time, age correspondence
between donor and recipient)
• Medical necessity (life-threatening
situation, long waiting time)
• Health-related quality of life (lowest
baseline life quality, highest outcome life
quality)
• Patients’ state of health (low degree of
(co-)morbidity)
3
Societal Level
• Commitment to society (higher job-related productivity, responsibility for children, potential
organ donors / club solution, posteriorisation of hardened criminals, high social status)
• Utility maximisation (optimization of donor organ utilization)
• Balancing histocompatibility-related allocation disadvantages (high mismatch probability)
• One chance (preference for a first-time transplantation)
16
Exploration of preferences – results (3/3)
Frequency analysis
• The medical level accounts for 81 codings (54,0%), the individual
patient level for 49 mentions (32,7%). The fewest codings with 20
codings (13,3%) fell upon the societal level.
• The most frequently mentioned criteria were life-threatening situation,
younger people in general, high transplant survival rate in general,
high therapy compliance, long waiting time and low co-morbidity.
• Patients and their relatives mentioned above average often criteria of
the individual patient level.
• Physicians stated disproportionately high frequently criteria at the
medical level.
• Nurses argued less from a medical-professional perspective, but
rather from a patient-related view.
• Uninvolved citizens contributed mainly criteria on the societal level.
17
AGENDA
Public discourse on setting priorities in the German health
care system
Exploration of stakeholder preferences in organ allocation
Measurement of preference orders in organ allocation
with conjoint analysis
18
Measurement of preference order – procedure
• The explored set of prioritization criteria in organ
transplantation is the basis for a subsequent
quantitative study.
• The aim of the quantitative study is to explore a
ranking of the prioritization criteria and to test for
preference differences of stakeholder groups.
• The qualitative study showed that the views of
relatives were much in line with patient views,
therefore they are not included as a separate
stakeholder group.
• The ranking of the prioritization criteria is examined
by applying a conjoint analysis approach.
19
Measurement of preference order – methods (1/2)
CONJOINT ANALYSIS - VARIANTS
•1 Traditional full-profile conjoint value analysis (CVA): alternatives which are composed
of levels of all attributes are brought into a ranking or rating order. The number of
attributes and attribute levels determines the amount of alternatives. Through partial
(fractioned) designs the number of alternatives can be reduced. With more than 6
attributes the ranking or rating tasks become too complex for respondents.
•2 Choice Based Conjoint (CBC) analysis generates preference evaluations by discreet
choice decisions among sets of objects. CBC is more realistic than traditional fullprofile conjoint analysis, but also gets too complex with more than 6 attributes.
•3 Adaptive Conjoint Analysis (ACA) is a hybrid method which combines directly
collected utility values of attributes with preference evaluations from pair-wise
comparisons of profiles.
•4 In 2006 a meta analysis of 135 conjoint studies was conducted to evaluate the
reliability and validity of different conjoint analysis methods.
20
Measurement of preference order – methods (2/2)
CONJOINT ANALYSIS - VARIANTS
•5 Choice Based Conjoint (CBC) methods achieved the best results as well for
individual predictions of preference evaluations as also on the level of aggregate
choice shares.
•6 Adaptive Conjoint Analysis (ACA) results in better validity criteria than traditional
CVA.
•7 In 2009 Sawtooth Software Inc. introduced Adaptive Choice Based Conjoint (ACBC),
a software tool which combines the advantages of adaptive and choice based
conjoint measurement methods.
•8 ACBC allows also for non-compensatory decision rules and is best used in instances
where there are 5 or more attributes.
21
Measurement of preference order – design
• After a pre-test with students of health care science to evaluate the
practicability of the study design a study with 240 respondents is planned.
• The matter of the study are the prioritization criteria and their attribute levels
which where explored in the foregoing qualitative study.
• The study includes 60 participants each from the following stakeholder groups:
- Physicians
- Nurses
- Patients
- Health care managers
22
Outlook
• Legitimacy is a crucial issue in the discussions on stakeholder
participation in decision processes in the health care system.
• The conjoint measurement study helps to reveal preference
orders with regard to different prioritization criteria of certain
stakeholder groups.
• The focus of the study so far is on vertical prioritising (organ
transplantation) but shall be extended to more general
horizontal prioritization criteria.
• The results of the study should be compared to other analyses
of prioritization settings in order to derive at a widely accepted
set of criteria for prioritising in the context of the German health
care system.
23
Acknowledgements
-
Birgitta Bayerl, M.A., M.P.H.
-
Kathrin Alber, M.A.
-
Eckhard Nagel, M.D., Ph.D.
-
Walter A. Wohlgemuth, M.D., Ph.D.
German Research Foundation
Comments/Questions:
Thorsten.Ahrend@kfh-dialyse.de
24
Institute of Management in Medicine and
Health Care Sciences, University of Bayreuth
Stakeholder preferences in
organ allocation
–
a conjoint measurement
approach
Thorsten Ahrend
Thank you for your attention!
25