Patients Preferences Regarding The Process and Outcomes of Lifesaving Technology

International Journal of Technology Assessment in Health Care, 15:2 (1999), 340351.
Copyright 1999 Cambridge University Press. Printed in the U.S.A.
PATIENTS PREFERENCES
REGARDING THE PROCESS
AND OUTCOMES OF LIFE-SAVING
TECHNOLOGY
An Application of Conjoint Analysis to Liver
Transplantation
Julie Ratcliffe
Martin Buxton
Brunel University
Abstract
The economic technique of conjoint analysis was used to assess the relative importance of health
outcome versus several process attributes (e.g., waiting time, continuity of contact with the same
medical staff) in determining patients preferences for liver transplantation services. The attributes
were established by reference to the literature and through initial qualitative interviews with liver
transplant recipients (n 5 12). Following a pilot study of 40 patients, a sample of patients (n 5 213)
who have received a liver transplant at the Queen Elizabeth Hospital in Birmingham were surveyed.
The technique of conjoint analysis was used to ascertain the relative importance of the attributes
included in the exercise and to estimate the marginal rates of substitution (MRS) between different
attributes. A useable response rate of 89% was achieved. Although a small proportion of respondents
(15%) exhibited dominant preferences for the chance of success attribute, the majority of respondents
indicated that they would be prepared to exchange a reduction in health outcome for an improvement
in the process characteristics of the liver transplantation service. The results of this study have
potentially important implications for the assessment of the benefits of medical technologies since
they suggest that, even in the extreme case of life-saving interventions, the preferences of respondents
may not be dependent solely upon health outcomes but may also be determined by attributes associ-
ated with the process of care.
Keywords: Conjoint Analysis, Liver Transplantation, Health Outcomes, Process
Traditionally, utility assessment within the economic evaluation of medical technol-

ogies has focused upon health outcomes. However, several commentators have
suggested that utility assessment should extend beyond health outcomes and that
there are other characteristics of the commodity health care (in addition to good
The authors would like to thank Dr. James Neuberger from the Queen Elizabeth Hospital in Birmingham
for his help in questionnaire design and administration of the study. We are also grateful to Mandy
Ryan, Martin Cave, Stirling Bryan, and Tony Scott for comments received on questionnaire design and
analysis and to Kathy Johnston for comments received on an earlier version of this paper. This work
was supported by a program grant to the Health Economics Research Group from the U.K. Department
of Health. The views expressed, however, are those of the authors alone.
340
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Patients preferences for liver transplantation services
health) that yield utility or disutility for the consumer and which should be included
in the utility function (14;29;30;37;38). Such characteristics may include factors
relating to the process of care such as continuity of staff, waiting time, location,
etc. It has also been suggested that the relative importance of such factors may
vary according to the technology under consideration (29). This paper reports the
methods and results of a conjoint analysis study that was designed to establish
whether liver transplant recipients derive utility from factors other than the chance
of a successful transplant and if so, the relative weights that are attached to
these factors.
BACKGROUND
In 1980 fewer than 50 liver transplants were performed throughout Europe (31).
However, in 1996 more than 600 liver transplants were performed in England and
Wales alone (22). Within the National Health Service (NHS) liver transplantation is
currently provided by seven Department of Health designated liver transplantation
centers. Although liver transplantation has never been the subject of a randomized
controlled trial, it has become an accepted intervention for the treatment of a
number of end-stage liver diseases. There is a growing body of evidence to suggest
that it is an effective intervention that can significantly improve survival and quality
of life for the individual patient (4;8;21;25). Previous evaluative studies of liver
transplantation have reflected this context, estimating the benefits of the procedure
in terms of the utility derived from an improvement in health outcome for a given
cohort of patients (5;23). Remarkably little research has been undertaken to elicit
patients preferences for factors associated with the process of treatment or their
relative importance in relation to health outcome.
Conjoint Analysis
Stated preference refers to a number of techniques for determining individual prefer-
ences in hypothetical controlled experimental conditions, as contrasted with revealed
preference techniques, which are based on observations of individual behavior in
reality. To date, within the health care sector, stated preference techniques (in-
cluding standard gamble [1], time trade-off [9], rating scale [16;17], magnitude
estimation [34], and equivalence of numbers [32]), have been used mainly to obtain
relative values for health states. More recently, stated preference techniques have
also been used to ascertain the relative importance of non-health outcomes and/
or factors associated with the process of health care through the application of
conjoint analysis and willingness-to-pay methodologies (13;37;38).
Conjoint analysis (CA) is a stated preference technique designed to establish
the impact of individual attributes in the overall utility of a good or service (12).
It involves the presentation to individuals of hypothetical scenarios. Respondents
use ranking, rating, or discrete choice exercises to represent their preferences for
these hypothetical scenarios. Their respective utility functions can then be estimated.
The scenarios are based upon the establishment of experimental design constructs
that represent each alternative in terms of specified levels across a set of attributes.
The CA technique has been widely used in the transport economics literature
and in the environmental economics literature (2;23;26;27;4547). Within health
care, its use has been limited, although an increasing number of studies have been
undertaken in recent years (7;10;33;35;36;37;43;44). Within a U.K. context, the
technique has not previously been applied to medical technologies that are perceived
to be life saving, although several life-enhancing procedures have been the subject
INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 15:2, 1999 341

Ratcliffe and Buxton
Table 1. Attributes and Levels Included in the Study
Attributes Levels
Chance of successful liver transplant 80%, 85%a, 90%

Time spent on the waiting list 2, 4a, 6 months
Continuity of contact with same medical staff Higha, Low
Amount of information received about the transplant Lots, Somea, Little
Follow-up support received Lots, Somea, Little
Distance of the transplantation center from your home 50, 100a, 200 miles
a
Indicates the levels of the attributes that most closely resembled the existing liver transplantation
service offered at the Queen Elizabeth Hospital.
of conjoint analysis studies, including magnetic resonance imaging for the investiga-
tion of knee injuries (7) and the provision of assisted reproduction services (35).
METHODS
In order to assess the relative value placed by patients on the process of treatment
vis-a-vis health outcome in the provision of liver transplantation services, a CA
exercise was performed. There are five main stages to a CA exercise (37); a)
identifying the attributes to include in the study; b) assigning levels to each of the
attributes included; c) presenting hypothetical scenarios involving different levels
of the attributes to individuals; d) obtaining preferences for these scenarios; and
e) analyzing the responses.
The Generation of the Attributes
First, it was necessary to identify the relevant attributes of the service to be included
in the exercise. A review of the literature identified a small number of qualitative
studies undertaken in North America and Europe concerning the preferences of
liver transplant patients for transplantation services (20;4042). These studies have
revealed that, in addition to the chance of surviving the operation, patients identified
the length of the waiting period and the amount and type of follow-up support
received as important factors in the provision of the service. Given the absence of
information obtained in a U.K. setting, a number of individual interviews were
undertaken to ascertain the key factors that patients considered to be important
in contributing to their overall satisfaction. A small sample of patients (n 5 12)
recently undergoing transplantation at the Queen Elizabeth Hospital (QEH) in
Birmingham were interviewed about their experience with the transplantation pro-
cess and the factors that they considered to be of importance in determining their
overall satisfaction. As expected, one of the key factors was the chance of a successful
transplant. The other factors mentioned most frequently were the time spent on
the waiting list, continuity of contact with the same medical staff, the amount of
information received about the risks and benefits of the transplantation process,
the amount of follow-up support received, and the distance of the transplantation
center from the individuals home.
Assignment of Levels to Attributes
The literature suggests that the chosen attribute levels should have the characteris-
tics of being realistic and sensible to respondents, and capable of being traded off
(12). The attribute descriptions and the levels that were chosen for the main study
are detailed in Table 1.
342 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 15:2, 1999

For the purposes of the CA exercise, the chance of success attribute was defined
in terms of the probability of surviving the operation and living for a minimum
period of 5 years afterwards (the alternative being a situation in which the recipient
would die as a result of liver failure within the 5-year period). The CA exercise
was administered to a group of patients with the same primary indication for liver
transplantation, primary biliary cirrhosis (PBC). This group was chosen on the
basis that it represents a fairly homogeneous group of patients with, on average, a
relatively high chance of surviving the transplantation process. The levels for the
chance of success attribute were based around the current actual mean 5-year
survival rates for patients with primary biliary cirrhosis at QEH. The levels for the
waiting time attribute were based upon QEH data and reflect the current expected
waiting times for the majority of patients with primary biliary cirrhosis. The levels
for the remaining attributes were developed in consultation with clinical colleagues
at QEH.
The Presentation of Hypothetical Scenarios

The attributes and levels selected gave rise to a very large number of possible
scenarios. These were reduced to a manageable number for the purposes of a postal
survey using the computer software package SPEED version 2.1 (6). This software
produces a fractional factorial design that ensures the absence of multicollinearity.
Establishing Respondents Preferences for Hypothetical Scenarios

Following Ethics Committee approval to administer the questionnaire, a pilot dis-
crete-choice questionnaire was given to a convenience sample of patients who had
undergone liver transplantation (n 5 40). The pilot study results indicated that
individuals understood the questions and that, with the chosen levels for the attri-
butes, trading between attributes was taking place. The questionnaire used the
discrete-choice approach, in which individuals are asked to make several pairwise
comparisons of alternative scenarios and indicate which would be their preferred
option. This approach has the advantage over the alternatives of ranking or rating,
in that it is easier for respondents to complete and it is firmly rooted in economic
theory. In addition, choice responses are directly translated into predictions through
the application of discrete-choice statistical models, whereas rank order and ratings
data need to be transformed in order to obtain useful predictive outputs (19).
The 18 scenarios chosen by the SPEED software were randomly split into two
groups of nine, and two versions of the CA questionnaire were produced. These
two versions were randomly allocated to all patients with PBC who had undergone
liver transplantation at QEH during the period between January 1987 and December
1996 and who were, in the opinion of a clinical research nurse based at the center,
well enough to complete the questionnaire (n 5 213).
There were two main reasons for choosing patients who had received a trans-
plant rather than those awaiting transplant. First, prospective patients may have
difficulty determining the relative importance of attributes relating to a service
that they have not yet experienced. Individuals who have experienced the liver
transplantation service are more familiar with the attributes presented and are thus
more likely to have informed preferences. Second, there was concern about possible
patient sensitivity and subsequent anxiety arising from the questions relating to the
length of the waiting period and chance of success attributes.
In both versions of the questionnaire, all scenarios were compared with the
levels of the attributes that most closely resembled the existing liver transplantation

service offered at QEH at the time that the study was undertaken. In responding
to the questions presented, individuals were instructed to think back to the time
prior to their transplant when they were first told that liver transplantation was an
option for them. They were asked to imagine that, at this time point, they had been
given a choice of two centers, A or B, at which to receive their liver transplant.
The centers differed according to several key factors or attributes. They were then
told that they had to choose between Center A and Center B for each of the
pairwise comparisons offered to them. The questionnaire was sent by post to the
patients home address and included a cover letter by a physician from the hospital
who had been involved in their care. One reminder was sent to nonrespondents
after approximately 3 weeks.
Respondents Characteristics
Respondents were asked their age, sex, the number of liver transplants they had
ever received, educational background, general state of health, the time they had
spent on the waiting list for their last transplant, how stressful they found the
waiting period, and the distance of the transplantation center from their home.
These questions were included to examine the extent to which preferences were
influenced by these factors. Several prior hypotheses were developed concerning
the possible effects of these characteristics upon individual preferences. These were
based upon a priori expectations about how the characteristics of the respondent
might influence their preferences. It was hypothesized that older people might find
the provision of information to be less important than younger people, since they
might not want to actively participate in making decisions about their treatment.
Similarly, information about the transplantation process might be relatively more
important to the better educated. Evidence exists from the noneconomics literature
to support these hypotheses (3;11). Given that older people are less mobile and
tend to have poorer health in general, it was hypothesized that they might exhibit
preferences for high levels of follow-up support, continuity of contact with the same
medical staff, and a shorter distance between the transplantation center and their
home. The level of follow-up support offered might be less important to those
individuals who report themselves in good health, because these individuals perceive
that they have less need for follow-up support and aftercare relative to those
individuals who report themselves in worse health. Individuals who found the time
spent on the waiting list for transplantation a stressful experience might attach
more importance to shorter waiting periods on the basis that the stressful period
is reduced. Finally, it was hypothesized that those individuals who lived longer
distances from the transplantation center at the time of their last transplant might
have experienced more difficulties and inconveniences in attending the transplanta-
tion center than those who lived nearby, and hence might attach relatively more
importance to the distance of the transplantation center from the patients home.
Analysis of the Data
According to economic theory, a pairwise comparison can be viewed as a comparison
of two indirect utility functions, and hence the data from a discrete choice CA
exercise can be analyzed within the framework of random utility theory (18;28).
For each comparison, the respondent chooses the alternative that leads to the higher
level of utility. Hence, the respondent will choose Center B over Center A (the
base alternative) if:
U(AB, s) . U(AA, s) (1)

Table 2. Interaction Terms to Test for the Effect of Respondents Characteristics on Pref-
erences
Interaction Expected
term sign Hypothesis
AGECONT 1 Continuity of contact with same medical staff is more

important to older people.
AGEINFO 2 Information is less important to older people.
AGEFOLL 1 Follow-up support is more important to older people.
AGEDIST 1 Distance of the transplantation center from the patients
home is more important for older people.
EDUCINFO 1 Information about the transplantation process is more
important to educated people.
HEAFOLL 2 Follow-up support is less important to those who report
themselves in good health.
SREWAIT 1 The time spent waiting is more important for those who
found the waiting period stressful.
DSTMIL 1 The distance of the center from home is more important
to those who live further away.
where U () represents the indirect utility function of the individual, AA represents

the attributes of Center A, AB represents the attributes of Center B, and s represents
the socio-economic characteristics of the individual that influence utility. The proba-
bility that an individual chooses Center B {PB} is a function of the difference in
utility between the two scenarios [U(AA, s) 2 U(AB, s)]. An error term should also
be included in the utility function to reflect the unobservable factors in the individ-
uals utility function.
Assuming a linear additive utility function, the utility to be estimated in moving
from Center A to Center B is:
U 5 1Wait 1 2Cont 1 3Success 1 4Inform 1 5Follow 1 6Distance 1 u (2)
where U is the change in utility in moving from Center A to Center B and 16 are
the parameters of the model to be estimated. Wait is the difference in waiting
time, Cont is the difference in continuity of care experienced, Success is the
difference in the chance of success, Inform is the difference in the amount of
information received about the transplantation process, Follow is the difference
in follow-up care received, Distance is the difference in the distance between the
hospital center and the patients home, and u is the error term. The marginal rate
of substitution (MRS) between any pair of attributes can be estimated by the
ratio of the relevant parameters, e.g., the MRS between the level of waiting time
experienced and continuity of care is equal to 1/2.
The data were analyzed using the random effects probit model. This regression
technique is more appropriate to use within this context than simple probit or
logit models because it takes account of the potential for correlation between
observations from any one individual. The data analysis included the six main
attributes as independent variables. In order to test the hypotheses about the effect
of respondents characteristics on preferences, an interaction term between each
respondent characteristic and the relevant attribute was also included in the model.
A list of the interaction terms included, the hypotheses underlying them, and the
direction of the effect expected is detailed in Table 2.

Methodological Issues Addressed

For every respondent, tests were carried out to see if any of the attributes were
dominant and, further, whether a strict lexicographic order could be established
(15;39;46). A dominant attribute implies that the scenario with the higher level of
this attribute is always chosen, irrespective of the levels of the remaining attributes.
A situation of dominance can be distinguished from a strict lexicographic ordering
in that it places no restriction on the ordering or extent of trading for other attributes.
A lexicographic ordering implies that there is an absolute order of preferences and
there is no degree of substitution between any of the attributes in the CA exercise.
It was hypothesized in advance that the chance of success attribute would
be dominant for some respondents. This would be a significant finding in itself,
because it would provide evidence that the current emphasis on expected health
outcome in valuing the benefits of medical technologies is not misplaced. Dominant
preferences are inconsistent with the underlying assumptions of a CA exercise,
which assumes that individuals will trade among the levels of the attributes pre-
sented. As such, it is recommended in the transport economics literature that such
individuals be removed from the data analysis or that the data collection exercise
be rerun, omitting the chance of success attribute from the pairwise comparisons
(46). However, it has also been argued that, from a public policy perspective, such
respondents should be included in the analysis, since the study objective is to provide
information that represents a statement of preferences for the sample as a whole (7).
The study also tested for internal consistency, assuming that patients prefer a
shorter waiting time, more continuity of contact with the same medical staff, a
greater chance of a successful liver transplant, more information about the trans-
plant, more follow-up support, and a shorter distance between the transplantation
center and the patients home. The fractional factorial design produced four choice
scenarios (two in each questionnaire), where one alternative was clearly superior
to the other scenario and hence should rationally be the chosen alternative.
The results from the random effects probit model were used to test the theoret-
ical validity of CA, i.e., the extent to which results are consistent with prior expecta-
tions. It was expected that individuals would prefer lower waiting times and shorter
distances between the transplantation center and the patients home, and hence it
was expected that these attributes would have a negative sign in the regression
equation. Conversely, it was anticipated that individuals would prefer a larger
chance of success, more continuity of contact, more information, and more follow-
up support, and hence these attributes would have a positive sign.
In order to check the ease of completion of the discrete choice CA questions,
respondents were also asked how difficult/easy they found the questionnaire to
complete and the amount of time that they spent filling in the questionnaire. Possible
responses to the former question were coded on a scale from 1 to 4, where 1
represents not difficult and 4 represents very difficult.
RESULTS
A useable response rate of 89% was achieved: 189 usable questionnaires were
returned, plus six additional questionnaires where the CA choice questions were
not completed and hence were excluded from the main data analysis. Respondents
were mostly female (90%) with a mean age of 57 years. 70.5% of respondents were
qualified to OGrade/GCSE or below.

Table 3. Respondents Views Concerning the Importance of Attributes in the Provision of

the Liver Transplantation Service
Very Quite Little Not

important important importance important
Attribute (n) (%) (n) (%) (n) (%) (n) (%)
Time spent on the waiting list 134 72.0 44 23.7 8 4.3 0 0.0
Continuity of contact with 150 79.8 36 19.1 2 1.1 0 0.0
same medical staff
Chance of successful liver 171 91.4 15 8.0 1 0.5 0 0.0
transplant
Amount of information re- 144 77.4 42 22.6 0 0.0 0 0.0
ceived about your transplant
Amount of follow-up support 159 85.5 26 14.0 0.5 0 0 0.0
received
Distance of the transplantation 60 32.1 61 32.6 36 19.3 30 16.0
center from your home
The majority of respondents indicated that the six attributes included in the
study were either important or very important to them (Table 3). Respondents
appeared to find the questionnaire not too difficult to complete, with 111 respon-
dents (59%) indicating that the questionnaire was not difficult to complete and 48
(26%) indicating that the questionnaire was slightly difficult to complete. However,
the tests of internal consistency revealed that a small number of respondents (17
[9%]) answered inconsistently. Of the 189 questionnaires, 29 respondents (15%)
exhibited a dominant preference for the chance of success attribute: they consistently
chose the center with the higher chance of success regardless of the levels of the
other attributes. However, none of these individuals exhibited a strict lexicographic
ordering for the attributes presented. The mean time taken to complete the question-
naire was 16 minutes, with an overall range of 1060 minutes.
The results from the random effects probit model are given in Table 4. The
results are presented excluding individuals exhibiting dominant preferences and
those with inconsistent preferences. A further analysis (not reported here) was also
conducted including individuals exhibiting dominant preferences, and the results
were very similar. The results indicate that all of the attributes included in the CA
exercise were highly significant in determining the choice of center. The results
also provide support for the models theoretical validity, since the sign of the
coefficient for each of the attributes is in the expected direction. The marginal rates
of substitution between attributes are calculated by dividing the coefficients of
the attributes of interest. For example, the marginal rate of substitution between
continuity and waiting time (2.59) is estimated by dividing the coefficient of conti-
nuity (0.4150) by the coefficient of waiting time (20.1603). The estimate indicates
that nondominant respondents were prepared to exchange an increase in waiting
time of 2.59 months to achieve a high level of continuity in the care received.
Similarly, the marginal rate of substitution between waiting time and chance of
success (1.26) is estimated by dividing the coefficient of waiting time (20.1603) by
the coefficient of chance of success (0.1273). The estimate indicates that nondomi-
nant respondents were prepared to exchange an increase in waiting time of 1.26
months for an increase in the probability of a successful transplant of 1%.

Table 4. Random Effects Probit Model Incorporating Interaction Termsa
Attributes Coefficient p 95% CI
WAIT 20.1603 ,.001b 20.2118 to 20.0955

CONT 0.4150 ,.001b 0.2281 to 0.6018
SUCCESS 0.1273 ,.001b 0.1071 to 0.1474
INFORM 0.5255 ,.001b 0.4189 to 0.6321
FOLLOW 0.5817 ,.001b 0.4748 to 0.6887
DISTANCE 20.0050 ,.001b 20.0064 to 20.0036
AGECONT 0.0053 .014b 0.0011 to 0.0995
AGEINFO 20.0053 .025b 20.0006 to 20.0099
AGEFOLL 0.0010 .602 20.0049 to 0.0029
AGEDIST 20.0013 .202 20.0032 to 0.0007
EDUCINFO 0.0167 .330 20.0169 to 0.0503
HEAFOLL 20.0580 .056 20.1176 to 20.0015
SREWAIT 20.0127 .330 20.0383 to 0.0129
DISTMIL 0.0003 .065 20.000 to 0.0007
a
Excluding subjects revealing dominant preferences and inconsistent responders. Number of observa-
tions 5 1,238. Number of groups 5 141. Observations per group (min/avg/max) 5 1/8.7/9. Chi2 5 379.3
(p 5 .000).
b
Significant at 5% level.
The interaction term of age with continuity (AGECONT) was found to be

significant in the model, with the positive sign on the coefficient indicating that, in
general, older people value continuity of care more highly. Similarly, the interaction
term of age with information (AGEINFO) is significant, with the negative sign on
this coefficient indicating that older people prefer to receive less information about
their condition and the risks and benefits of the transplantation process than do
younger people. None of the remaining interaction terms was found to be statisti-
cally significant.
DISCUSSION
This study used the technique of CA to determine the relative importance of several
key attributes in the provision of a liver transplantation service and to illustrate
how the marginal rates of substitution between different attributes can be estimated.
The response rate achieved in this study is higher than has previously been achieved
in postal CA surveys and may have been facilitated by the cover letter, sent with
the questionnaire, from the consultant who was involved in the care of a large
number of the patients in the sample. It was found that the use of CA produced
meaningful results. Although a small number of respondents exhibited a dominant
preference for the chance of success attribute, the results of the study indicated
that the majority of respondents were prepared to exchange a reduction in health
outcome for an improvement in the process characteristics of the liver transplanta-
tion service.
These results have potentially important implications for the assessment of the
benefits of medical technologies, since they suggest that process attributes are
valued by respondents in addition to health outcomes. This finding is supported
by several previous studies that have used CA in a health care context to ascertain
the value of process characteristics via-a-vis health outcomes (7;35). However, it
can be argued that the results of this study are more striking, given that liver

transplantation is perceived as a life-saving intervention. The results must be inter-

preted with caution, however, since the study was undertaken on a sample of liver
transplant recipients who had successfully survived the liver transplantation process.
Although the questionnaire instructed respondents to think back to the time before
their liver transplant took place in answering the questions, it is still possible that
such respondents would not attach as much importance to the chance of success
attribute as respondents who are waiting to receive their liver transplant. It would
be interesting to repeat the study on a sample of patients who are waiting to receive
a liver transplant to see whether their responses are different.
The differences in the levels for the chance of success attribute included in this
study reflect clinical opinion of a plausible range for possible differences between
centers. Although the available evidence is scarce and not well quantified, several
published studies have suggested that larger centers with more experience in per-
forming transplant operations have higher patient survival rates than smaller, less-
experienced centers. However, accurate data on the magnitude of this variability
for PBC patients in a U.K. context is currently not available. If the range for this
attribute were found to be higher in reality than that estimated in this study, it
can be postulated that potentially larger numbers of respondents might exhibit a
dominant preference for the chance of success attribute.
CA assumes that the utility function attributable to the consumer is additive
and preferences for attributes are independent. However, preferences for attributes
may not be independent in all cases. In the context of this study, for example, it is
possible that the combined influence of a relatively long waiting time and a relatively
low chance of success, when valued together, may be considered worse than the
sum of each of these attributes in isolation. As such, the separate effects of the
attributes on the overall preference of the respondent would be difficult to estimate.
The addition of interaction terms can be helpful in this respect, although their
addition complicates the design of the study, since more scenarios are required to
be presented.
CONCLUSION
This paper has highlighted an application of the technique of CA to measuring
patients preferences for characteristics of a liver transplantation service. It has
illustrated how the technique can be used to quantitatively examine patients prefer-
ences between health outcomes and process. Evidence for the theoretical validity,
ease of completion, and internal consistency of the CA technique have been pre-
sented. The results of the study suggest that, even in the extreme case of a life-saving
intervention, patients preferences are determined by the process characteristics of
the service provided in addition to health outcomes, and many patients will trade.
If similar results were found in other such studies, it would have major implications
for the evaluation of health care interventions and organizations, and would suggest
that evaluation based only on health outcomes may not adequately reflect pa-
tients preferences.
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International Journal of Technology Assessment in Health Care, 15:2 (1999), 340351.

Copyright 1999 Cambridge University Press. Printed in the U.S.A.

Keywords: Conjoint Analysis, Liver Transplantation, Health Outcomes, Process

Traditionally, utility assessment within the economic evaluation of medical technol-

INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 15:2, 1999 341

Table 1. Attributes and Levels Included in the Study

Chance of successful liver transplant 80%, 85%a, 90%

342 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 15:2, 1999

The Presentation of Hypothetical Scenarios

Establishing Respondents Preferences for Hypothetical Scenarios

INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 15:2, 1999 343

344 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 15:2, 1999

AGECONT 1 Continuity of contact with same medical staff is more

where U () represents the indirect utility function of the individual, AA represents

INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 15:2, 1999 345

Methodological Issues Addressed

346 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 15:2, 1999

Table 3. Respondents Views Concerning the Importance of Attributes in the Provision of

Very Quite Little Not

Attribute (n) (%) (n) (%) (n) (%) (n) (%)

INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 15:2, 1999 347

Table 4. Random Effects Probit Model Incorporating Interaction Termsa

Attributes Coefficient p 95% CI

WAIT 20.1603 ,.001b 20.2118 to 20.0955

The interaction term of age with continuity (AGECONT) was found to be

348 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 15:2, 1999

transplantation is perceived as a life-saving intervention. The results must be inter-

INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 15:2, 1999 349

350 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 15:2, 1999

INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 15:2, 1999 351

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