Community IntraVenous Antibiotic Study (CIVAS): protocol for an evaluation of patient preferences for and cost-effectiveness of community intravenous antibiotic services

Introduction: Outpatient parenteral antimicrobial therapy (OPAT) is used to treat a wide range of infections, and is common practice in countries such as the USA and Australia. In the UK, national guidelines (standards of care) for OPAT services have been developed to act as a benchmark for clinical monitoring and quality. However, the availability of OPAT services in the UK is still patchy and until quite recently was available only in specialist centres. Over time, National Health Service (NHS) Trusts have developed OPAT services in response to local needs, which has resulted in different service configurations and models of care. However, there has been no robust examination comparing the cost-effectiveness of each service type, or any systematic examination of patient preferences for services on which to base any business case decision. Methods and analysis: The study will use a mixed methods approach, to evaluate patient preferences for and the cost-effectiveness of OPAT service models. The study includes seven NHS Trusts located in four counties. There are five inter-related work packages: a systematic review of the published research on the safety, efficacy and cost-effectiveness of intravenous antibiotic delivery services; a qualitative study to explore existing OPAT services and perceived barriers to future development; an economic model to estimate the comparative value of four different community intravenous antibiotic services; a discrete choice experiment to assess patient preferences for services, and an expert panel to agree which service models may constitute the optimal service model(s) of community intravenous antibiotics delivery. Ethics and dissemination: The study has been approved by the NRES Committee, South West—Frenchay using the Proportionate Review Service (ref 13/SW/0060). The results of the study will be disseminated at national and international conferences, and in international journals

The Community IntraVenous Antibiotic Study (CIVAS): a mixed methods evaluation of patient preferences for and cost effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy

Background: Outpatient parenteral antimicrobial therapy (OPAT) is widely used in most developed countries, providing considerable opportunities for improved cost savings. However, it is implemented only partially in the UK, using a variety of service models. Objectives: The aims of this research were to (1) establish the extent of OPAT service models in England and identify their development; (2) evaluate patients’ preferences for different OPAT service delivery models; (3) assess the cost-effectiveness of different OPAT service delivery models; and (4) convene a consensus panel to consider our evidence and make recommendations. Methods: This mixed-methods study included seven centres providing OPAT using four main service models: (1) hospital outpatient (HO) attendance; (2) specialist nurse (SN) visiting at home; (3) general nurse (GN) visiting at home; and (4) self-administration (SA) or carer administration. Health-care providers were surveyed and interviewed to explore the implementation of OPAT services in England. OPAT patients were interviewed to determine key service attributes to develop a discrete choice experiment (DCE). This was used to perform a quantitative analysis of their preferences and attitudes. Anonymised OPAT case data were used to model cost-effectiveness with both Markov and simulation modelling methods. An expert panel reviewed the evidence and made recommendations for future service provision and further research. Results: The systematic review revealed limited robust literature but suggested that HO is least effective and SN is most effective. Qualitative study participants felt that different models of care were suited to different types of patient and they also identified key service attributes. The DCE indicated that type of service was the most important factor, with SN being strongly preferred to HO and SA. Preferences were influenced by attitudes to health care. The results from both Markov and simulation models suggest that a SN model is the optimal service for short treatment courses (up to 7 days). Net monetary benefit (NMB) values for HO, GN and SN services were £2493, £2547 and £2655, respectively. For longer treatment, SA appears to be optimal, although SNs provide slightly higher benefits at increased cost. NMB values for HO, GN, SN and SA services were £8240, £9550, £10,388 and £10,644, respectively. The simulation model provided useful information for planning OPAT services. The expert panel requested more guidance for service providers and commissioners. Overall, they agreed that mixed service models were preferable. Limitations: Recruitment to the qualitative study was suboptimal in the very elderly and ethnic minorities, so the preferences of patients from these groups might not be represented. The study recruited from Yorkshire, so the findings may not be applicable nationally. Conclusions: The quantitative preference analysis and economic modelling favoured a SN model, although there are differences between sociodemographic groups. SA provides cost savings for long-term treatment but is not appropriate for all. Future work: Further research is necessary to replicate our results in other regions and populations and to evaluate mixed service models. The simulation modelling and DCE methods used here may be applicable in other health-care settings. Funding: The National Institute for Health Research Health Service and Delivery Research programme

Interactive stated choice surveys: a study of air travel behaviour

Stated preference (SP) experiments are becoming an increasingly popular survey methodology for investigating travel behaviour. Nevertheless, some evidence suggests that SP experiments do not mirror decisions in real markets. With an increasing number of real world decisions made using the internet, an opportunity exists to improve the realism of the SP counterparts of such choices by aligning the choice environment with such online portals. In this paper, we illustrate the benefits of such an approach in the context of air travel surveys. Our survey is modelled on the interface and functionality of an online travel agent (OTA). As with a real OTA, many ticket options are presented. Sort tools allow the options to be reordered, search tools allow options to be removed from consideration, and a further tool allows attributes to be hidden and shown. Extensive use of these tools is made by the 462 respondents. A traditional SP component was also completed by the respondents. Our exploratory analysis as well as random utility model estimation results confirm not only that respondents seem to engage more actively with the interactive survey, but also that the resulting data allows for better performance in model estimation compared to a more conventional SP experiment. These results have implications for the study of other complex travel choices where interactive surveys may similarly be preferable to standard approaches

Antenatal care for first time mothers: a discrete choice experiment of women's views on alternative packages of care

Objective: To investigate the views of women in relation to the provision of antenatal care. Methods: A discrete choice experiment using a sample of 100 women who were nulliparous (pregnant for the first time) and attending for routine ultrasound scan in the 20th week of their pregnancy. Results: Women preferred antenatal care visits to be provided by a community midwife at a local clinic and to have 10 visits rather than 7. In addition they favoured the provision of education/preparation for birth, the use of uterine artery Doppler screening, and the provision of a telephone advice line. The results show that women were prepared to trade-off fewer antenatal care visits to ensure access to their packages of antenatal care that reflected their preferences. Conclusions: Whilst the number of antenatal care visits is important to women they may accept fewer visits if antenatal care is provided by midwives and they receive enhanced service provision such as a telephone advice line and uterine artery Doppler screening

Preferences for rehabilitation service delivery: A comparison of the views of patients, occupational therapists and other rehabilitation clinicians using a discrete choice experiment

BACKGROUND/AIM Understanding the differences in preferences of patients and occupational therapists for the way in which rehabilitation services are provided is important. In particular, it is unknown whether new approaches to rehabilitation such as high intensity therapy and virtual reality programs are more or less acceptable than traditional approaches. METHODS A discrete choice experiment was conducted to assess and compare the acceptability of these new approaches, relative to other characteristics of the rehabilitation program. The study included patients participating in a stroke or medical rehabilitation program (n = 100), occupational therapists (n = 23) and other clinicians (n = 91) working in rehabilitation settings at three hospitals in South Australia. Data were analysed using a conditional (fixed-effects) logistic regression model. RESULTS The model coefficient attached to very high intensity therapy programs (defined as six hours per day) was negative and highly statistically significant for both patients and therapists indicating aversion for this option. In addition, other rehabilitation clinicians and patients were strongly averse to the use of virtual reality programs (as evidenced by the negative and highly statistically significant coefficient attached to this attribute for both groups) relative to occupational therapists. CONCLUSION The comparison of the views of patients, occupational therapists and other rehabilitation clinicians revealed some differences. All participants (patients and clinicians) showed an inclination for programs that resulted in the best recovery. However, patients expressed stronger preferences than clinicians for traditional therapy approaches. As a group, occupational therapists were most likely to accept approaches such as virtual reality suggesting changes away from traditional delivery methods will be more readily integrated into practice.Kate Laver, Julie Ratcliffe, Stacey George, Laurence Lester and Maria Crott