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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Do promotions of healthier or more sustainable foods increase sales? Findings from three natural experiments in UK supermarkets
Background: Dietary changes are necessary to improve population health and meet environmental sustainability targets. Here we analyse the impact of promotional activities implemented in UK supermarkets on purchases of healthier and more sustainable foods. Methods: Three natural experiments examined the impact of promotional activities on sales of a) no-added-sugar (NAS) plant-based milk (in 199 stores), b) products promoted during ‘Veganuary’ (in 96 stores), and c) seasonal fruit (in 100 non-randomised intervention and 100 matched control stores). Data were provided on store-level product sales, in units sold and monetary value (£), aggregated weekly. Predominant socioeconomic position (SEP) of the store population was provided by the retailer. Analyses used interrupted time series and multivariable hierarchical mixed-effects models. Results: Sales of both promoted and total NAS plant-based milks increased significantly during the promotional period (Promoted:+126 units, 95%CI: 105–148; Overall:+307 units, 95%CI: 264–349). The increase was greater in stores with predominately low SEP shoppers. During Veganuary, sales increased significantly for plant-based foods on promotion (+60 units, 95%CI: 37–84), but not for sales of plant-based foods overall (dairy alternatives: -1131 units, 95%CI: -5821–3559; meat alternatives: 1403 units, 95%CI: -749–3554). There was no evidence of a change in weekly sales of promoted seasonal fruit products (assessed via ratio change in units sold: 0.01, 95%CI: 0.00–0.02), and overall fruit category sales slightly decreased in intervention stores relative to control (ratio change in units sold: -0.01, 95%CI: -0.01–0.00). Conclusion: During promotional campaigns there was evidence that sales of plant-based products increased, but not seasonal fruits. There was no evidence for any sustained change beyond the intervention period.
Do calorie labels change energy purchased in a simulated online food delivery platform? A multi-arm randomised controlled trial
Background: As rates of obesity and overweight continue to increase in the UK, calorie labels have been introduced on menus as a policy option to provide information to consumers on the energy content of foods and to enable informed choices. This study tested whether the addition of calorie labels to items in a simulated food delivery platform may reduce the energy content of items selected. Methods: UK adults (n = 8,780) who used food delivery platforms were asked to use the simulated platform as they would in real life to order a meal for themselves. Participants were randomly allocated to a control condition (no calorie labels) or to one of seven intervention groups: (1) large size calorie labels adjacent to the price (LP), (2) large size label adjacent to the product name (LN), (3) small label adjacent to price (SP), (4) small label adjacent to product name (SN), (5) LP with a calorie label switch-off filter (LP + Off), (6) LP with a switch-on filter (LP + On), or, (7) LP with a summary label of the total basket energy content (LP + Sum). Regression analysis assessed the impact of calorie labels on energy content of foods selected compared to the control condition. Results: The mean energy selected in the control condition was 1408 kcal (95%CI: 93, 2719). There was a statistically significant reduction in mean energy selected in five of the seven intervention trial arms (LN labels (-60 kcal, 95%CI: -111, -6), SN (-73, 95%CI: -125, -19), LP + Off (-110, 95%CI: -161, -57), LP + On (-109, 95%CI: -159, -57), LP + Sum (-85 kcal, 95%CI: -137, -30). There was no evidence the other two conditions (LP (-33, 95%CI: -88, 24) and SP (-52, 95%CI: -105, 2)) differed from control. There was no evidence of an effect of any intervention when the analysis was restricted to participants who were overweight or obese. Conclusion: Adding calorie labels to food items in a simulated online food delivery platform reduced the energy content of foods selected in five out of seven labelling scenarios. This study provides useful information to inform the implementation of these labels in a food delivery platform context.
The impact of the English calorie labelling policy on the energy content of food offered and purchased in worksite cafeterias: a natural experiment
Background: On 6 April 2022, legislation came into effect in England requiring calorie labels to be applied to food items on menus of larger food businesses. This study aimed to assess the impact of calorie labelling on (a) food purchased and (b) energy content of menu options in worksite cafeterias. Methods: Product-level sales data and energy content of available items was obtained from 142 worksite cafeterias from January 2022-October 2022. Interrupted-time-series (ITS) analysis with level and slope change evaluated daily energy (kcal) purchased per item, and ITS with level change assessed mean energy per option available on menus before and after calorie labelling. Each analysis was conducted 6 weeks and 6 months from implementation. A post-hoc ITS examined weekly energy purchased per item over a longer period (March 2021-October 2022; 135 sites). Results: There was no evidence calorie labelling changed the energy content of foods purchased (6-week: + 0.60 cal/product, 95%CI:-2.54, + 3.75; 6-month: + 1.59 cal/product, 95%CI:-0.96, + 4.16). Post-hoc analyses suggested calorie labels were associated with a reduction in mean energy of items purchased over time (-0.65 kcal/week, 95%CI:-0.81,-0.49), but a significant increase (+ 3 kcal, 95%CI: + 0.43, + 5.60) at the point of implementation. There was a reduction in the mean energy content of menu options at each seasonal menu change (April 2022:-1.79 kcal, 95%CI:-3.42,-0.15; July 2022:-4.18 kcal, 95% CI:-7.65,-0.73). Conclusion: This large observational study in worksite cafeterias found no evidence to indicate the introduction of calorie labelling led to any immediate reduction in energy purchased by customers. There was some evidence of increasing impact over time, possibly associated with changes in menu offerings, but this effect was small and cannot be directly attributed to calorie labelling.
The impact of altering restaurant and menu option position on food selected from an experimental food delivery platform: a randomised controlled trial
Background: Overconsumption is one of the most serious public health challenges in the UK and has been linked to increased consumption of food ordered through delivery platforms. This study tested whether repositioning foods and/or restaurant options in a simulated food delivery platform could help to reduce the energy content of users’ shopping basket. Methods: UK adult food delivery platform users (N = 9,003) selected a meal in a simulated platform. Participants were randomly allocated to a control condition (choices listed randomly) or to one of four intervention groups, (1) food options listed in ascending order of energy content, (2) restaurant options listed in ascending order of average energy content per main meal, (3) interventions 1 and 2 combined (4) interventions 1 and 2 combined, but food and restaurant options repositioned based on a kcal/price index to display options lower in energy but higher in price at the top. Gamma regressions assessed the impact of interventions on total energy content of baskets at checkout. Results: The energy content of participants’ baskets in the control condition was 1382 kcals. All interventions significantly reduced energy content of baskets: Compared to control, repositioning both foods and restaurants purely based on energy content of options resulted in the greatest effect (-209kcal; 95%CIs: -248,-168), followed by repositioning restaurants (-161kcal; 95%CIs: -201,-121), repositioning restaurants and foods based on a kcal/price index (-117kcals; 95%CI: -158,-74) and repositioning foods based on energy content (-88kcals; 95%CI: -130,-45). All interventions reduced the basket price compared to the control, except for the intervention repositioning restaurants and foods based on a kcal/price index, which increased the basket price. Conclusions: This proof-of-concept study suggests repositioning lower-energy options more prominently may encourage lower energy food choices in online delivery platforms and can be implemented in a sustainable business model.
The impact of price promotions on confectionery and snacks on the energy content of shopping baskets: A randomised controlled trial in an experimental online supermarket
Overconsumption of foods high in fat, sugars, and salt (HFSS) poses a significant risk to health. The government in England has passed legislation that would limit some price promotions of HFSS foods within supermarkets, but evidence regarding likely impacts of these policies, especially in online settings, is limited. This study aimed to determine whether there were any differences in the energy and nutrient content of shopping baskets after removing promotions on HFSS foods in an online experimental supermarket. UK adults (n = 511) were asked to select food from four categories with a £10 budget in an online experimental supermarket: confectionery; biscuits and crackers; crisps, nuts and snacking fruit; cakes and tarts. They were randomly allocated to one of two trial arms: (1) promotions present (matched to promotion frequency seen in a major UK retailer) (n = 257), or (2) all promotions removed from all products within the target food categories (n = 254). The primary outcome analysis used linear regression to compare total energy (kcal) of items placed in shopping baskets when promotions were present vs. absent, while secondary analyses investigated differences in nutrients and energy purchased from individual food categories. Mean energy in food selected without promotions was 5156 kcal per basket (SD 1620), compared to 5536 kcal (SD 1819) with promotions, a difference of −552kcal (95%CIs: −866, −238), equivalent to 10%. There were no significant differences in energy purchased for any individual category between groups. No evidence was found of other changes in nutritional composition of baskets or of significant interactions between the impact of promotions and participant characteristics (gender, age, ethnicity) on energy purchased. Removing promotions on HFSS foods resulted in significantly less total energy selected in an online experimental supermarket study.
Changing the availability and positioning of more vs. less environmentally sustainable products: A randomised controlled trial in an online experimental supermarket
Food purchasing behaviours are shaped by the choices available to shoppers and the way they are offered for sale. This study tested whether prominent positioning of more sustainable food items online and increasing their relative availability might reduce the environmental impact of foods selected in a 2x2 (availability x position) factorial randomised controlled trial. Participants (n = 1179) selected items in a shopping task in an experimental online supermarket. The availability intervention added lower-impact products to the regular range. The positioning intervention biased product order to give prominence to lower-impact products. The primary outcome was the environmental impact score (ranging from 1 “least impact” to 5 “most impact”, of each item in shopping baskets) analysed using Welch's ANOVA. Secondary outcomes included interactions (analysed via linear regression) by gender, age group, education, income and meat consumption and we assessed intervention acceptability (using different frames) in a post-experiment questionnaire. Compared to control (mean = 21.6), mean eco quintile score was significantly reduced when availability & order was altered (−2.30; 95%CI: 3.04; −1.56) and when order only was changed (−1.67; 95%CI: 2.42; −0.92). No significant difference between availability only (−0.02; 95%CI: 0.73; 0.69) and control was found. There were no significant interactions between interventions or by demographic characteristics. Both interventions were acceptable under certain frames (positioning emphasising lower-impact products: 70.3% support; increasing lower-impact items: 74.3% support). Prominent positioning of more sustainable products may be an effective strategy to encourage more sustainable food purchasing. Increasing availability of more sustainable products alone did not significantly alter the environment impact of products selected.
Preferences for multi-cancer tests (MCTs) in primary care: discrete choice experiments of general practitioners and the general public in England
Background: Multi-Cancer tests (MCTs) hold potential to detect cancer across multiple sites and some predict the origin of the cancer signal. Understanding stakeholder preferences for MCTs could help to develop appealing MCTs, encouraging their adoption. Methods: Discrete Choice Experiments (DCEs) conducted online in England. Results: GPs (n = 251) and the general public (n = 1005) preferred MCTs that maximised negative predictive value, positive predictive value, and could test for a larger number of cancer sites. A reduction of the NPV of 4.0% was balanced by a 12.5% increase in the PPV for people and a 32.5% increase in PPV for GPs. People from ethnic minority backgrounds placed less importance on whether MCTs can detect multiple cancers. People with more knowledge and experience of cancer placed substantial importance on the MCT being able to detect cancer at an early stage. Both GPs and members of the public preferred the MCT reported in the SYMPLIFY study to FIT, PSA, and CA125, and preferred the SYMPLIFY MCT to 91% (GPs) and 95% (people) of 2048 simulated MCTs. Conclusions: These findings provide a basis for designing clinical implementation strategies for MCTs, according to their performance characteristics.
Is “nature” a policy solution to mental health in schools?
The UK faces a growing youth mental health crisis (NHS, 2023; RCPsych 2025). Schools may play a key role in preventing these difficulties from worsening. The integration of nature-based programs (NbPs) into school settings has been proposed as a policy solution to address such mental health challenges but robust evidence is lacking (Lomax et al., 2024), particularly at the secondary school level. This Sprint utilised an implementation science framework to co-produce evidence on NbPs in secondary schools with stakeholders including policymakers from the Government’s Department for Education (DfE), young people, and educators. Using a range of methodologies we are evaluating effectiveness, amplifying stakeholder voices, and creating actionable, evidence-based education policy insights.
Variation in duration of repeat prescriptions: a primary care cohort study in England
Background Many patients receive repeat prescriptions for routine medications used to treat chronic conditions. Doctors typically issue repeat prescriptions with durations ranging from 28 to 84 days. There is currently no national guidance in England for the optimal prescription duration for routine medications. Aim To evaluate current prescription durations for five common routine medications in England; explore and visualise geographical variation; and identify practice factors that are associated with shorter prescribing duration to inform policy making. Design and setting A retrospective cohort study of NHS primary care prescribing data in England from December 2018 to November 2019. Method The prescription duration was analysed for five common routine medications in England; ramipril, atorvastatin, simvastatin, levothyroxine, and amlodipine. Variation was assessed between regional clinical commissioning groups (CCGs), and practice factors associated with different durations were identified. Results Of the common medications included, 28-day prescriptions accounted for 48.5% (2.5 billion) tablets/ capsules issued, while 43.6% were issued for 56 days. There was very wide regional variation (7.2%–95.0%) in the proportion of 28-day prescriptions issued by CCGs. Practice dispensing status was the most likely predictor of prescription duration; dispensing practices had a higher 28-day prescribing proportion than non-dispensing practices. The proportion of patients with chronic conditions and the electronic health record system used by a practice were also associated with prescription duration. Conclusion This analysis of OpenPrescribing data showed that repeat prescriptions of 28 days are common for patients taking routine medications for chronic conditions, particularly in dispensing practices. This provides data to inform the policy debate on current practice. Configuration of electronic health record systems offer an opportunity to implement and evaluate new policies on repeat prescription duration in England.
Cost-effectiveness of a novel AI technology to quantify coronary inflammation and cardiovascular risk in patients undergoing routine coronary computed tomography angiography
AIMS: Coronary computed tomography angiography (CCTA) is a first-line investigation for chest pain in patients with suspected obstructive coronary artery disease (CAD). However, many acute cardiac events occur in the absence of obstructive CAD. We assessed the lifetime cost-effectiveness of integrating a novel artificial intelligence-enhanced image analysis algorithm (AI-Risk) that stratifies the risk of cardiac events by quantifying coronary inflammation, combined with the extent of coronary artery plaque and clinical risk factors, by analysing images from routine CCTA. METHODS AND RESULTS: A hybrid decision-tree with population cohort Markov model was developed from 3393 consecutive patients who underwent routine CCTA for suspected obstructive CAD and followed up for major adverse cardiac events over a median (interquartile range) of 7.7(6.4-9.1) years. In a prospective real-world evaluation survey of 744 consecutive patients undergoing CCTA for chest pain investigation, the availability of AI-Risk assessment led to treatment initiation or intensification in 45% of patients. In a further prospective study of 1214 consecutive patients with extensive guidelines recommended cardiovascular risk profiling, AI-Risk stratification led to treatment initiation or intensification in 39% of patients beyond the current clinical guideline recommendations. Treatment guided by AI-Risk modelled over a lifetime horizon could lead to fewer cardiac events (relative reductions of 11%, 4%, 4%, and 12% for myocardial infarction, ischaemic stroke, heart failure, and cardiac death, respectively). Implementing AI-Risk Classification in routine interpretation of CCTA is highly likely to be cost-effective (incremental cost-effectiveness ratio £1371-3244), both in scenarios of current guideline compliance, or when applied only to patients without obstructive CAD. CONCLUSIONS: Compared with standard care, the addition of AI-Risk assessment in routine CCTA interpretation is cost-effective, by refining risk-guided medical management.
Risk of bias in routine mental health outcome data: The case of Health of the Nation Outcome Scales
Background Routine outcome data in secondary mental health services have significant potential for service planning, evaluation and research. Expanding the collection and use of these data is an ongoing priority in the National Health Service (NHS), but inconsistent use threatens their validity and utility. If recording is more likely among certain patient groups or at specific stages of treatment, measured outcomes may be biased and unreliable. Objective The objective is to assess the scale, determinants and implications of incomplete routine outcome measurement in a secondary mental health provider, using the example of the widely collected Health of the Nation Outcome Scores (HoNOS). Methods A retrospective cohort study was conducted using routine HoNOS assessments and episodes of care for patients receiving secondary mental healthcare from an NHS Trust in Southeast England between 2016 and 2022 (n=30 341). Associations among demographic, clinical and service factors, and rates and timings of HoNOS assessments were explored with logistic regressions. Relationships between total HoNOS scores and related mental health outcomes (costs, relapse and improvement between assessments) were estimated after adjusting for the likelihood of assessment. Findings 66% of patients (n=22 288) had a recorded HoNOS assessment. Of the distinct episodes of care for these patients (n=65 439), 43% (n=28 170) were linked to any assessment, 25% (n=16 131) were linked to an initial baseline assessment, while 4.7% (n=3 094) were linked to multiple HoNOS assessments, allowing for evaluation of clinical progress. Likelihood and timing of assessment were significantly associated with a range of factors, including service type, diagnosis, ethnicity, age and gender. After adjusting for observed factors determining the likelihood of assessment, the strength of association between HoNOS scores and overall costs was significantly reduced. Conclusion Most of the activity observed in this study cannot be evaluated with HoNOS. HoNOS assessments are highly unlikely to be missing at random. Without approaches to correct for substantial gaps in routine outcome data, evaluations based on these may be systematically biased, limiting their usefulness for service-level decision-making. Clinical implications Routine outcome collection must increase significantly to successfully implement proposed strategies for outcome assessment in community mental healthcare without inconsistent records undermining the use of resulting data.
Long-term outcomes after stress echocardiography in real-world practice: a 5-year follow-up of the UK EVAREST study
Aims Stress echocardiography is widely used to assess patients with chest pain. The clinical value of a positive or negative test result to inform on likely longer-term outcomes when applied in real-world practice across a healthcare system has not been previously reported. Methods Five thousand five hundred and three patients recruited across 32 UK NHS hospitals between 2018 and 2022, participating and results in the EVAREST/BSE-NSTEP prospective cohort study, with data on medical outcomes up to 2023 available from NHS England were included in the analysis. Stress echocardiography results were related to outcomes, including death, procedures, hospital admissions, and relevant cardiovascular diagnoses, based on Kaplan–Meier analysis and Cox proportional hazard ratios (HRs). Median follow-up was 829 days (interquartile range 224–1434). A positive stress echocardiogram was associated with a greater risk of myocardial infarction [HR 2.71, 95% confidence interval (CI) 1.73–4.24, P < 0.001] and a composite endpoint of cardiac-related mortality and myocardial infarction (HR 2.03, 95% CI 1.41–2.93, P < 0.001). Hazard ratios increased with ischaemic burden. A negative stress echocardiogram identified an event-free ‘warranty period’ of at least 5 years in patients with no prior history of coronary artery disease and 4 years for those with disease. Conclusion In real-world practice, the degree of myocardial ischaemia recorded by clinicians at stress echocardiography correctly categorizes risk of future events over the next 5 years. Reporting a stress echocardiogram as negative correctly identifies patients with no greater than a background risk of cardiovascular events over a similar time period.
Critical components of 'Early Intervention in Psychosis': National retrospective cohort study
Background Psychotic disorders are severe mental health conditions frequently associated with long-term disability, reduced quality of life and premature mortality. Early Intervention in Psychosis (EIP) services aim to provide timely, comprehensive packages of care for people with psychotic disorders. However, it is not clear which components of EIP services contribute most to the improved outcomes they achieve. Aims We aimed to identify associations between specific components of EIP care and clinically significant outcomes for individuals treated for early psychosis in England. Method This national retrospective cohort study of 14 874 EIP individuals examined associations between 12 components of EIP care and outcomes over a 3-year follow-up period, by linking data from the National Clinical Audit of Psychosis (NCAP) to routine health outcome data held by NHS England. The primary outcome was time to relapse, defined as psychiatric inpatient admission or referral to a crisis resolution (home treatment) team. Secondary outcomes included duration of admissions, detention under the Mental Health Act, emergency department and general hospital attendances and mortality. We conducted multilevel regression analyses incorporating demographic and service-level covariates. Results Smaller care coordinator case-loads and the use of clozapine for eligible people were associated with reduced relapse risk. Physical health interventions were associated with reductions in mortality risk. Other components, such as cognitive-behavioural therapy for psychosis (CBTp), showed associations with improvements in secondary outcomes. Conclusions Smaller case-loads should be prioritised and protected in EIP service design and delivery. Initiatives to improve the uptake of clozapine should be integrated into EIP care. Other components, such as CBTp and physical health interventions, may have specific benefits for those eligible. These findings highlight impactful components of care and should guide resource allocation to optimise EIP service delivery.
Value-Based Commissioning of Mental Health Services in England: A Feasibility Study Using Multicriteria Decision Analysis
Objectives: Improving mental health services through value-based investment is high priority in healthcare systems globally. However, there is lack of comprehensive and robust evidence on the value for money of these services that incorporates several value elements and public preferences. This study aims to demonstrate the application of multicriteria decision analysis (MCDA) in the assessment of 2 early intervention in psychosis (EIP) services in England. Methods: An MCDA-based evaluation using patient records was conducted to evaluate the value-for-money of 2 EIP services in South-East England: Oxfordshire (EIP-Oxf) and Buckinghamshire (EIP-Bucks). The assessment considered 5 value elements: years of life, quality of life (time to relapse), patient experience (disengagement rates), health inequality (time-to-relapse disparity), and average annual cost. Performance on each value element was estimated using generalized linear models and propensity score matching on electronic health records of 1127 patients. Total MCDA scores integrated standardized predicted means with relative weights that were derived in a previous study. Robustness was assessed using probabilistic sensitivity analysis and service affordability was illustrated in conditional multiattribute acceptability curves. Results: EIP-Oxf outperformed EIP-Bucks in overall scores (0.563 vs 0.552) and offered higher value per pound spend according to cost-per-value ratios (£10 438 per unit of value vs £12 655). Results were driven by lower annual cost per patient and health inequality in EIP-Oxf. Conclusions: MCDA can facilitate value-for-money assessments of mental health services, addressing gaps in comprehensive rationing frameworks. This approach provides a systematic, evidence-driven method for local decision making, with potential for broader healthcare applications.
Challenges and solutions to system-wide use of precision oncology as the standard of care paradigm.
The personalised oncology paradigm remains challenging to deliver despite technological advances in genomics-based identification of actionable variants combined with the increasing focus of drug development on these specific targets. To ensure we continue to build concerted momentum to improve outcomes across all cancer types, financial, technological and operational barriers need to be addressed. For example, complete integration and certification of the 'molecular tumour board' into 'standard of care' ensures a unified clinical decision pathway that both counteracts fragmentation and is the cornerstone of evidence-based delivery inside and outside of a research setting. Generally, integrated delivery has been restricted to specific (common) cancer types either within major cancer centres or small regional networks. Here, we focus on solutions in real-world integration of genomics, pathology, surgery, oncological treatments, data from clinical source systems and analysis of whole-body imaging as digital data that can facilitate cost-effectiveness analysis, clinical trial recruitment, and outcome assessment. This urgent imperative for cancer also extends across the early diagnosis and adjuvant treatment interventions, individualised cancer vaccines, immune cell therapies, personalised synthetic lethal therapeutics and cancer screening and prevention. Oncology care systems worldwide require proactive step-changes in solutions that include inter-operative digital working that can solve patient centred challenges to ensure inclusive, quality, sustainable, fair and cost-effective adoption and efficient delivery. Here we highlight workforce, technical, clinical, regulatory and economic challenges that prevent the implementation of precision oncology at scale, and offer a systematic roadmap of integrated solutions for standard of care based on minimal essential digital tools. These include unified decision support tools, quality control, data flows within an ethical and legal data framework, training and certification, monitoring and feedback. Bridging the technical, operational, regulatory and economic gaps demands the joint actions from public and industry stakeholders across national and global boundaries.
Incorporating Complexity and System Dynamics into Economic Modelling for Mental Health Policy and Planning
Care as usual has failed to stem the tide of mental health challenges in children and young people. Transformed models of care and prevention are required, including targeting the social determinants of mental health. Robust economic evidence is crucial to guide investment towards prioritised interventions that are effective and cost-effective to optimise health outcomes and ensure value for money. Mental healthcare and prevention exhibit the characteristics of complex dynamic systems, yet dynamic simulation modelling has to date only rarely been used to conduct economic evaluation in this area. This article proposes an integrated decision-making and planning framework for mental health that includes system dynamics modelling, cost-effectiveness analysis, and participatory model-building methods, in a circular process that is constantly reviewed and updated in a ‘living model’ ecosystem. We describe a case study of this approach for mental health system policy and planning that synergises the unique attributes of a system dynamics approach within the context of economic evaluation. This kind of approach can help decision makers make the most of precious, limited resources in healthcare. The application of modelling to organise and enable better responses to the youth mental health crisis offers positive benefits for individuals and their families, as well as for taxpayers.
Unravelling Elements of Value of Healthcare and Assessing their Importance Using Evidence from Two Discrete-Choice Experiments in England
Background: Health systems are moving towards value-based care, implementing new care models that allegedly aim beyond patient outcomes. Therefore, a policy and academic debate is underway regarding the definition of value in healthcare, the inclusion of costs in value metrics, and the importance of each value element. This study aimed to define healthcare value elements and assess their relative importance (RI) to the public in England. Method: Using data from 26 semi-structured interviews and a literature review, and applying decision-theory axioms, we selected a comprehensive and applicable set of value-based elements. Their RI was determined using two discrete choice experiments (DCEs) based on Bayesian D-efficient DCE designs, with one DCE incorporating healthcare costs expressed as income tax rise. Respondent preferences were analysed using mixed logit models. Results: Six value elements were identified: additional life-years, health-related quality of life, patient experience, target population size, equity, and cost. The DCE surveys were completed by 402 participants. All utility coefficients had the expected signs and were statistically significant (p < 0.05). Additional life-years (25.3%; 95% confidence interval [CI] 22.5–28.6%) and patient experience (25.2%; 95% CI 21.6–28.9%) received the highest RI, followed by target population size (22.4%; 95% CI 19.1–25.6%) and quality of life (17.6%; 95% CI 15.0–20.3%). Equity had the lowest RI (9.6%; 95% CI 6.4–12.1%), decreasing by 8.8 percentage points with cost inclusion. A similar reduction was observed in the RI of quality of life when cost was included. Conclusion: The public prioritizes value elements not captured by conventional metrics, such as quality-adjusted life-years. Although cost inclusion did not alter the preference ranking, its inclusion in the value metric warrants careful consideration.