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Research Article Preferences for rehabilitation service delivery: A comparison of the views of patients, occupational therapists and other rehabilitation clinicians using a discrete choice experiment Kate Laver, 1 Julie Ratcliffe, 1 Stacey George, 1 Laurence Lester 2 and Maria Crotty 1 1 Department of Rehabilitation and Aged Care, Flinders University, and 2 Adelaide University Centre for Housing, Urban and Regional, Adelaide, South Australia, Australia Background/aim: Understanding the differences in prefer- ences of patients and occupational therapists for the way in which rehabilitation services are provided is important. In par- ticular, 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 rehabili- tation 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 hospi- tals in South Australia. Data were analysed using a con- ditional (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 sig- nificant 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 suggest- ing changes away from traditional delivery methods will be more readily integrated into practice. KEY WORDS attitude of health personnel, patient pref- erence, questionnaires. Introduction There is increasing recognition that health-care services should be designed to reflect the needs and preferences of health-care recipients (National Health Service, 2010; National Health & Hospitals Reform Commission, 2009). Previous studies have shown that health-care interventions that are acceptable to patients are likely to be more highly accessed, result in improved patient sat- isfaction and ultimately result in improved health out- comes (Crawford et al., 2002). Clinical rehabilitation programs are changing as new technologies emerge and research demonstrates which techniques are most effective. Recent approaches used by occupational therapists in rehabilitation include the use of virtual reality programs (Rand, Weiss & Katz, 2009) and therapies that are designed to be delivered at a higher dose than traditional approaches (for example constraint-induced movement therapy) (Hayner, Gibson & Giles, 2010; Walker & Pink, 2009). Although these approaches are well supported by the literature, wide- spread integration into clinical practice has not occurred (Laver, George, Thomas, Deutsch & Crotty, 2011; Wolf et al., 2006). It is possible that this lack of integration is Kate Laver MClinRehab; Occupational Therapist and PhD Student. Julie Ratcliffe PhD; Professor in Health Econom- ics. Stacey George PhD; Senior Lecturer and Course Coor- dinator. Laurence Lester PhD; Research Fellow. Maria Crotty FAFRM; Professor and Director of Rehabilitation. Correspondence: Kate Laver, Flinders University Depart- ment of Rehabilitation and Aged Care, Repatriation Gen- eral Hospital, Daws Rd, Daw Park, SA 5401, Australia. Email: [email protected] Accepted for publication 14 October 2012. © 2012 The Authors Australian Occupational Therapy Journal © 2012 Occupational Therapy Australia Australian Occupational Therapy Journal (2013) 60, 93–100 doi: 10.1111/1440-1630.12018

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Page 1: Preferences for rehabilitation service delivery: A comparison of the views of patients, occupational therapists and other rehabilitation clinicians using a discrete choice experiment

Research Article

Preferences for rehabilitation service delivery: Acomparison of the views of patients, occupationaltherapists and other rehabilitation clinicians using adiscrete choice experiment

Kate Laver,1 Julie Ratcliffe,1 Stacey George,1 Laurence Lester2 and Maria Crotty1

1Department of Rehabilitation and Aged Care, Flinders University, and 2Adelaide University Centre for Housing, Urbanand Regional, Adelaide, South Australia, Australia

Background/aim: Understanding the differences in prefer-ences of patients and occupational therapists for the way inwhich rehabilitation services are provided is important. In par-ticular, it is unknown whether new approaches to rehabilitationsuch as high intensity therapy and virtual reality programsare more or less acceptable than traditional approaches.Methods: A discrete choice experiment was conducted toassess and compare the acceptability of these newapproaches, relative to other characteristics of the rehabili-tation program. The study included patients participatingin a stroke or medical rehabilitation program (n = 100),occupational therapists (n = 23) and other clinicians(n = 91) working in rehabilitation settings at three hospi-tals in South Australia. Data were analysed using a con-ditional (fixed-effects) logistic regression model.Results: The model coefficient attached to very highintensity therapy programs (defined as six hours per day)was negative and highly statistically significant for bothpatients and therapists indicating aversion for this option.In addition, other rehabilitation clinicians and patientswere strongly averse to the use of virtual reality programs(as evidenced by the negative and highly statistically sig-nificant coefficient attached to this attribute for bothgroups) relative to occupational therapists.

Conclusion: The comparison of the views of patients,occupational therapists and other rehabilitation cliniciansrevealed some differences. All participants (patients andclinicians) showed an inclination for programs thatresulted in the best recovery. However, patients expressedstronger preferences than clinicians for traditional therapyapproaches. As a group, occupational therapists were mostlikely to accept approaches such as virtual reality suggest-ing changes away from traditional delivery methods willbe more readily integrated into practice.

KEY WORDS attitude of health personnel, patient pref-erence, questionnaires.

Introduction

There is increasing recognition that health-care services

should be designed to reflect the needs and preferences

of health-care recipients (National Health Service, 2010;

National Health & Hospitals Reform Commission,

2009). Previous studies have shown that health-care

interventions that are acceptable to patients are likely to

be more highly accessed, result in improved patient sat-

isfaction and ultimately result in improved health out-

comes (Crawford et al., 2002).Clinical rehabilitation programs are changing as new

technologies emerge and research demonstrates which

techniques are most effective. Recent approaches used

by occupational therapists in rehabilitation include the

use of virtual reality programs (Rand, Weiss & Katz,

2009) and therapies that are designed to be delivered at

a higher dose than traditional approaches (for example

constraint-induced movement therapy) (Hayner, Gibson

& Giles, 2010; Walker & Pink, 2009). Although these

approaches are well supported by the literature, wide-

spread integration into clinical practice has not occurred

(Laver, George, Thomas, Deutsch & Crotty, 2011; Wolf

et al., 2006). It is possible that this lack of integration is

Kate Laver MClinRehab; Occupational Therapist and PhDStudent. Julie Ratcliffe PhD; Professor in Health Econom-ics. Stacey George PhD; Senior Lecturer and Course Coor-dinator. Laurence Lester PhD; Research Fellow. MariaCrotty FAFRM; Professor and Director of Rehabilitation.

Correspondence: Kate Laver, Flinders University Depart-ment of Rehabilitation and Aged Care, Repatriation Gen-eral Hospital, Daws Rd, Daw Park, SA 5401, Australia.Email: [email protected]

Accepted for publication 14 October 2012.

© 2012 TheAuthorsAustralianOccupational Therapy Journal© 2012OccupationalTherapyAustralia

Australian Occupational Therapy Journal (2013) 60, 93–100 doi: 10.1111/1440-1630.12018

Page 2: Preferences for rehabilitation service delivery: A comparison of the views of patients, occupational therapists and other rehabilitation clinicians using a discrete choice experiment

due to patients and clinicians preferences for more

familiar and traditional therapy approaches.

Traditional measures for evaluating the acceptability

of interventions include questionnaires, interviews and

focus groups. Although these methods provide useful

data and identify areas of satisfaction and dissatisfac-

tion, there are also disadvantages to using these

approaches (Ryan et al., 2001). One of the key problems

with these approaches is that they do not usually pro-

vide information about patients’ priorities in a context

of limited resources. For example, patients may report

that they would like more highly trained staff, more

intensive therapy input and higher quality facilities.

However, this information does not provide policy

makers with information about the relative priorities for

expenditure from the patients’ perspective within the

limited funds allocated to rehabilitation services.

Discrete choice experiments (DCEs) are an increas-

ingly popular method for determining patient prefer-

ences regarding the acceptability of health-care

programs and their optimal configuration (Ryan, 2004).

Discrete choice experiments are based on the assump-

tion that health-care programs can be described in terms

of their attributes (for example; cost, personnel

involved, length of program). It is also assumed that an

individual’s valuation of the service depends on the lev-

els of these attributes (for example; low cost vs. high

cost, short program vs. long program) (Ratcliffe et al.,2010). One of the main objectives of the application of

DCEs in this context is to determine which attributes of

programs are most and least preferred by respondents

to facilitate decisions about the configuration of services

and the relative priorities for expenditure. DCEs are

typically administered via a questionnaire in which the

respondent is presented with a series of hypothetical

choices between health programs and asked to choose

the program that they would prefer. The alternative

programs are described in terms of their attributes and

associated levels. Analysis of the choices made reveals

which ‘levels’ of the health-care program were favoured

and which ‘levels’ respondents avoided. Thus, informa-

tion is provided regarding the acceptability of different

attributes of programs and the relative importance of

each of these attributes to respondents (Ryan, Gerard &

Amaya-Amaya, 2008). Although there has been an

increase in the development and application of DCE

methods in the health-care sector in recent years (Ryan

et al.) this is one of the first applications of the DCE

approach to our knowledge in the area of clinical reha-

bilitation and the first to specifically compare the views

and preferences of occupational therapists, other reha-

bilitation clinicians and patients (Ratcliffe et al.).The objective of this study was to identify the prefer-

ences, using a DCE method, of patients, occupational

therapists and other rehabilitation clinicians for the way

in which rehabilitation programs are delivered. Of par-

ticular interest was the acceptability of new approaches

(virtual reality and high intensity therapy) relative to

more traditional approaches.

Methods

The process of applying DCEs in health care involves (i)

establishing the key attributes of the health-care pro-

grams; (ii) specifying realistic levels of these attributes;

and (iii) assessing the relative importance of the attri-

butes and their associated levels (usually via a question-

naire) (Lanscar & Louviere, 2008).

Establishing the attributes and their levels

The attributes and levels within the DCE were estab-

lished based on a review of the literature and qualita-

tive data involving interviews with patients

participating in rehabilitation (n = 10) as recommended

by experts in this field (Coast & Horrocks, 2007). The

characteristics identified from the literature review and

interviews were then developed into four attributes

with three levels for each attribute. ‘Cost’ was included

as a fifth attribute to enable the estimation of monetary

value or willingness to pay for alternative levels of each

of the characteristics presented. The final selection of

attributes comprised: mode of therapy, dose of therapy,

type of staff providing the therapy, the cost to the

patient of the therapy program and a health outcome

attribute (the degree of recovery). The chosen attributes

and their associated levels are presented in Table 1. The

levels of group therapy, 30 minutes of therapy, commu-

nity-based treating team, no cost and 70% recovery

were treated as the base case to which the other attri-

butes would be compared.

Producing scenarios

The five chosen attributes with three levels for each

attribute resulted in 243 possible scenarios (or hypothet-

ical choices). As it was not practical for participants to

respond to this number of scenarios, a technique (frac-

tional factorial design) was employed to reduce the

number of scenarios in each questionnaire to six while

maintaining optimal statistical efficiency (Burgess &

Street, 2005). An example of a choice question is pre-

sented in Table 2.

Administering the questionnaire

The study was approved by the associated institu-

tional review boards of the participating sites. Patients

were recruited from inpatient rehabilitation wards at

three hospitals in Adelaide, South Australia: Griffiths

Rehabilitation Hospital (GRH) (a private hospital), and

the Repatriation General Hospital (RGH) and St Mar-

garet’s Rehabilitation Hospital (SMRH) (both public

hospitals). The patient sample was sequential; all

rehabilitation inpatients admitted between October

2009 and January 2010 meeting the inclusion criteria

were referred to the research team by a key contact

© 2012 The AuthorsAustralian Occupational Therapy Journal © 2012 Occupational Therapy Australia

94 K. LAVER ET AL.

Page 3: Preferences for rehabilitation service delivery: A comparison of the views of patients, occupational therapists and other rehabilitation clinicians using a discrete choice experiment

staff member at each hospital. Inclusion criteria were

diagnosis of stroke or any other medical condition for

which rehabilitation was required, adequate communi-

cation skills to complete the questionnaire as deter-

mined in consultation with the treating team

(including a speech pathologist) and absence of cogni-

tive impairment (participants needed a Mini Mental

State Examination (MMSE) (Folstein, Folstein &

McHugh, 1975) score of � 24/30). Eligible patients

were approached approximately two weeks into their

rehabilitation program and were provided with verbal

and written information about the study. Patients who

consented to participate took part in a face to face

interview with the research therapist (KL) who

administered the questionnaire in an interview style

format. The questionnaire was presented in three sec-

tions. The first section consisted of a series of attitudi-

nal statements which were related to the attributes of

the discrete choice experiment. For example, partici-

pants were asked to what extent they agreed or dis-

agreed that rehabilitation programs should use the

latest technologies. The second section consisted of

the discrete choice experiment in which the partici-

pant was presented with six scenarios (as per the

example scenario in Table 2) and asked to identify

their preferred rehabilitation program. The third sec-

tion comprised socio-demographic details, including

age, gender, living situation, country of birth, level of

educational attainment and income.

TABLE 1: Attributes and levels of the discrete choice experiment

Attribute Levels Explanation

Mode of therapy Group therapy The therapist sees you with a small group

of other patients

Individual therapy The therapist sees you one-to-one

Computer therapy The therapist will provide you with life-like

computer games designed to be therapeutic.

The therapist will support you in using

the programs and be present at all times

Dose of therapy 30 minutes per day

Three hours per day

Six hours per day

Team providing therapy Community-based doctor

and physiotherapist visiting

You will have a doctor and therapist visiting

you in hospital from their practices in the

community. They will have skills and experience

to treat people with a mix of different needs, but

do not specialise in people with your condition

Same specialist therapy team

from admission to discharge

You will have the same therapy team from

admission to discharge with skills and experience

in treating people with your needs

Different specialist team

for each phase

You will have three different therapy teams over

the course of your recovery. They will have skills

and experience in treating people with your needs

Amount of recovery made 70% recovery

80% recovery

90% recovery

Cost of therapy program No cost

$50 per week

$100 per week

TABLE 2: Example of discrete choice question included in the

questionnaire “Which rehabilitation program would you choose?”

Program 1 Program 2

Individual therapy Group therapy

30 minutes per day Six hours per day

$100 per week No cost

Same specialist team

from admission to discharge

Different specialist teams

for each phase

80% recovery 90% recovery

© 2012 The AuthorsAustralian Occupational Therapy Journal © 2012 Occupational Therapy Australia

DISCRETE CHOICE EXPERIMENT 95

Page 4: Preferences for rehabilitation service delivery: A comparison of the views of patients, occupational therapists and other rehabilitation clinicians using a discrete choice experiment

Occupational therapists and rehabilitation clinicians

who were currently or had recently worked with reha-

bilitation clients were selected from the three hospitals.

There were no additional inclusion or exclusion criteria

for clinicians. Two approaches were used to obtain

responses. First, occupational therapists and rehabilita-

tion clinicians at one of the hospitals (RGH) were noti-

fied about the study via an email inviting them to

complete a questionnaire. Spot visits were also made to

wards. All allied health staff at the other hospitals were

invited to participate by self-completing a questionnaire

following a team meeting. Clinicians were asked to

choose between the rehabilitation programs based on

what they would recommend for one of their ‘typical

rehabilitation clients’.

Data analysis

Data were analysed in STATA version 11 (StataCorp,

College Station, TX, USA) using conditional (fixed-

effects) logistic regression to account for correlation

between the multiple responses (due to each person

responding to six choice sets). Effects coding was used

to enter the data in preparation for analysis (Ryan,

Gerard & Amaya-Amaya, 2008). The size and statistical

significance of the coefficients indicate the importance of

that attribute in determining overall value of the rehabili-

tation program to respondents. Coefficients with positive

signs indicate that the level of attribute was favoured by

respondents and coefficients with negative signs indicate

that respondents were averse to that particular level. The

marginal rates of substitution (MRS) between the value

attribute “cost” and the remaining attribute levels

provides an estimate of the amount that respondents are

willing to pay (WTP) for an improvement in one attri-

bute. WTP is determined, for example, by dividing the

coefficient for dose of therapy (three hours) by the

coefficient for cost. Estimation of willingness to pay is a

technique frequently used in health economics to deter-

mine the worth of goods or services, expressed as the

amount that a person would be willing to pay for that

good or service (Hole, 2007). Results in this study are

expressed as the amount that participants would be

willing to pay per week for the rehabilitation program.

Results

Characteristics of respondents

A total of 137 patients participating in multidisciplinary

rehabilitation were referred to the researchers within

the study period. Twenty-four were excluded due to

dysphasia (n = 8), MMSE score < 24/30 (n = 11), insuf-

ficient English (n = 4) or poor vision which impacted on

their ability to see and understand the DCE (n = 1).

Seven patients did not consent. Six patients were unable

to understand the concept of the DCE and were unable

or unwilling to complete the DCE and were therefore

excluded. Therefore, the questionnaire was completed

by 100 rehabilitation patients. The mean age of partici-

pants was 75 (SD 13) years, and the majority were

female (67%). Half the participants were receiving reha-

bilitation following stroke (50%). Other participants

were receiving rehabilitation following falls (15%) or

another neurological condition (3%). The remaining par-

ticipants were receiving rehabilitation to reverse the

effects of ‘deconditioning’ post hospital stay for a range

of medical conditions such as pneumonia. Participants

from the private rehabilitation hospital made up 54%

(n = 54) of the respondents and the remaining 46%

(n = 46) were from the public rehabilitation hospitals.

The majority of participants lived (59%) alone and were

born in Australia (79%). The reported annual household

income of participants ranged from less than AU$40,000

per year (80%) up to more than AU$100,000 per year

(3%). Thirty-seven percent of participants reported

completing further education (for example, TAFE or

University following secondary school). Twenty-three

occupational therapists were recruited, and the majority

(91%) were female. Occupational therapists reported an

average age of 32 (SD 8) years and had an average of 8

(SD 6) years experience. The group of other rehabilita-

tion clinicians was made up of nurses (n = 30), doctors

(n = 16), physiotherapists (n = 20), speech pathologists

(n = 4), social workers (n = 6) and other staff, including

therapy aids and program managers (n = 15). The reha-

bilitation clinicians were also mostly female (69%) with

an average age of 40 (SD 11) years and an average of 12

(SD 11) years experience.

Responses to the attitudinal statements are presented

in Table 3. The majority of patients and clinicians

agreed that participating in rehabilitation results in

recovery, that rest was an important part of a rehabilita-

tion program and that rehabilitation services should use

the latest technologies. Both patients and clinicians had

mixed feelings as to whether it was important to have

the same therapy team from admission to discharge.

Discrete choice experiment model estimation

The results of the conditional logit model for the

patient, occupational therapist and other clinician sam-

ples are presented in Table 4. Attributes highlighted as

statistically significant were assessed as influential in

determining patient preference. The relative size of the

coefficient indicates that health outcome (90% recovery)

was the most important characteristic to patients.

Patients also significantly preferred individual therapy

and continuity of care (same therapy team from admis-

sion to discharge) compared with the base case of com-

munity-based care. In contrast, patients’ least preferred

characteristics were therapy delivered using a computer

and very high dose therapy (six hours). Subgroup anal-

ysis showed that participants from both the private and

public rehabilitation hospitals had similar aversions to

high therapy cost ($100 per week). The model results

© 2012 The AuthorsAustralian Occupational Therapy Journal © 2012 Occupational Therapy Australia

96 K. LAVER ET AL.

Page 5: Preferences for rehabilitation service delivery: A comparison of the views of patients, occupational therapists and other rehabilitation clinicians using a discrete choice experiment

show that both occupational therapists and other reha-

bilitation clinicians had stronger preferences towards

the therapy program that would result in the best out-

come (90% recovery) and continuity of care (same

therapy team). Consistent with patients’ responses,

occupational therapists and other rehabilitation

TABLE 4: Results of the discrete choice experiment for patients (n = 100), occupational therapists (n = 23) and other rehabilitation

clinicians (n = 91) indicating preferred (with positive coefficient) and non-preferred (with negative coefficient) characteristics

Characteristic

Patients Occupational therapists Other clinicians

Coefficient 95% CI Coefficient 95% CI Coefficient 95% CI

Group therapy Base case Base case Base case

Individual therapy 0.349* 0.176, 0.522 0.124 �0.316, 0.563 0.035 �0.170, 0.240

Computer therapy �0.741* �0.914, �0.567 0.002 �0.404, 0.409 �0.250* �0.445, �0.056

30 minutes per day Base case Base case Base case

Hours per day (3) 0.168 �0.002, 0.338 0.309 �0.114, 0.732 0.340* 0.143, 0.537

Hours per day (6) �0.474* �0.648, �0.299 �0.601* �1.009, �0.195 �0.371* �0.569, �0.174

Community-based doctor

and physiotherapist visiting

Base case Base case Base case

Same therapy team 0.182* 0.012, 0.351 0.438* 0.025, 0.851 0.295* 0.010, 0.491

Different team �0.082 �0.254, 0.091 0.358 �0.058, 0.773 0.069 �0.128, 0.266

Recovery 70% Base case Base case Base case

Recovery 80% �0.015 �0.184, 0.155 0.142 �0.245, 0.529 �0.039 �0.227, 0.149

Recovery 90% 0.668* 0.490, 0.846 1.269* 0.815, 1.722 1.407* 1.191, 1.622

No cost Base case Base case Base case

Cost $50 per week 0.022 �0.148, 0.192 �0.023 �0.453, 0.408 �0.091 �0.290, 0.107

Cost $100 per week �0.571* �0.743, �0.399 �0.842* �1.294, �0.390 �0.693* �0.892, �0.494

*P < 0.05.

TABLE 3: Responses to attitudinal statements – n (%)

Strongly

agree Agree

Some-what

agree

Some-what

disagree Disagree

Strongly

disagree Total

Participating in rehabilitation always results in recovery

Patients 20 (20) 37 (38) 20 (20) 6 (6) 14 (14) 1 (1) 98 (100)

OTs 3 (13) 9 (39) 6 (26) 4 (17) 1 (4) 0 (0) 23 (100)

Other clinicians 8 (9) 18 (20) 37 (41) 11 (12) 14 (15) 3 (3) 91 (100)

Rest is an important part of a rehabilitation program

Patients 32 (32) 61 (61) 3 (3) 2 (2) 1 (1) 0 (0) 99 (100)

OTs 5 (22) 15 (65) 3 (13) 0 (0) 0 (0) 0 (0) 23 (100)

Other clinicians 31 (34) 34 (38) 19 (21) 6 (7) 0 (0) 0 (0) 90 (100)

Rehabilitation services should use the latest technologies

Patients 28 (28) 62 (62) 9 (9) 1 (1) 0 (0) 0 (0) 100 (100)

OTs 7 (30) 4 (17) 12 (52) 0 (0) 0 (0) 0 (0) 23 (100)

Other clinicians 29 (32) 34 (37) 23 (25) 5 (5) 0 (0) 0 (0) 91 (100)

It doesn’t matter whether you have the same therapy team from admission to discharge

Patients 7 (7) 47 (47) 12 (12) 11 (11) 22 (22) 0 (0) 99 (100)

OTs 0 (0) 3 (13) 4 (17) 11 (48) 5 (22) 0 (0) 23 (100)

Other clinicians 1 (1) 18 (20) 14 (15) 29 (32) 22 (24) 7 (8) 91 (100)

OT, Occupational Therapist.

Percentages may not add up to 100% due to rounding of figures.

© 2012 The AuthorsAustralian Occupational Therapy Journal © 2012 Occupational Therapy Australia

DISCRETE CHOICE EXPERIMENT 97

Page 6: Preferences for rehabilitation service delivery: A comparison of the views of patients, occupational therapists and other rehabilitation clinicians using a discrete choice experiment

clinicians were also averse to programs that were very

high in intensity or very costly ($100 per week) com-

pared with the base cases of 30 minutes per day and

programs at no cost. Although other rehabilitation clini-

cians showed a significant aversion to the use of com-

puters in therapy, it appears that occupational

therapists were more accepting of this approach as this

attribute did not play a statistically significant role in

their choice of therapy program.

Figure 1 summarises the estimated willingness to pay

values for attribute levels and further enables compari-

sons across the different participant groups. All partici-

pant groups on average were willing to pay most for a

90% recovery, nevertheless, it can be seen that patients

were willing to pay the least ($59) and other rehabilita-

tion clinicians willing to pay the most ($95). All partici-

pant groups had negative willingness to pay values for

very high intensity programs (six hours per day) imply-

ing they required to be paid to accept high intensity

programs with patients reporting the strongest negative

values (�$42) for this attribute. When compared with

other participant groups, occupational therapists placed

the highest value on different specialist therapy teams

($21) and placed more value on individual therapy ses-

sions ($7) than other rehabilitation clinicians ($2). As

reported above, although patients were relatively averse

to computer-based therapy (�$66) and the group of

other rehabilitation clinicians also had negative attitudes

to this approach (�$15), occupational therapists were

the more accepting of the use of this approach ($0.40).

Discussion

In this study, we found that although recovery was

highly valued by all groups, both patient and clinicians

felt that the process of rehabilitation, not just the out-

come, was important and indicated that they were not

prepared to strive for recovery ‘at any cost’.

Furthermore, all groups were averse to very high

doses of therapy (six hours per day). This could be

explained by rehabilitation patients not typically having

access to patient-friendly information about the types of

therapy approaches that are most likely to result in

improved outcome. However, it is interesting that occu-

pational therapists and other rehabilitation clinicians also

reported preferences for lower doses of therapy, given

that recent literature shows that higher intensity therapy

programs are more effective (Kwakkel, 2006; Wolf et al.,2006). However, it has been acknowledged that transla-

tion of higher intensity therapy approaches into clinical

practice is lacking (Kwakkel). This has frequently been

attributed to lack of resources (staffing); yet, the findings

of this study raise questions about whether staff prefer-

ences may also play a part or whether clinicians feel that

patients cannot cope with high intensity therapies. Fur-

ther research is required to understand the reasons

behind these preferences and the application of qualita-

tive techniques (for example the use of ‘think aloud’

techniques in which the respondent is asked to verbalise

their thoughts while completing the DCE) may help in

this regard in understanding the reasons for underlying

preferences (Cheraghi-Sohi et al., 2007; Ryan, Watson &

Entwistle, 2009). In addition, these results suggest that

although six hours of therapy per day is too much, three

hours per day is an acceptable amount to both patients

and clinicians. Evidence and information from this study

regarding patient preferences therefore suggests that

rehabilitation services providing less than three hours

per day could explore ways of increasing therapy dose

(Kwakkel; Wolf et al.).

$100.00

$120.00

$40.00

$60.00

$80.00

–$20.00

$0.00

$20.00

Aus

tral

ian

dolla

rs

–$80.00

–$60.00

–$40.00

Pa ent

OT

Other

Individualtherapy

Computertherapy

Hours per day(3)

Hours per day(6)

Same therapyteam

Differentteam

80%Recovery

90%Recovery

31.2 –66.22 15.13 –42.37 16.21 –7.26 –1.25 59.72

7.2 0.42 17.61 –34.93 25.73 21.02 8.18 74.34

1.8 –15.96 22.31 –24.52 19.8 5 –2.49 95.1

FIGURE 1: Comparison of patient, occupational therapist and other rehabilitation clinician willingness to pay per week for different

attributes of the rehabilitation program (AUD$) *Note that estimated amounts ($) are to assist in the interpretation of the DCE data and

demonstrate which aspects of rehabilitation programs were most and least preferred. As patients do not currently pay for rehabilitation

services these may not represent ‘real-world’ amounts.

© 2012 The AuthorsAustralian Occupational Therapy Journal © 2012 Occupational Therapy Australia

98 K. LAVER ET AL.

Page 7: Preferences for rehabilitation service delivery: A comparison of the views of patients, occupational therapists and other rehabilitation clinicians using a discrete choice experiment

The findings of this study also have clinical implica-

tions for the introduction of computer technologies such

as robotics and virtual reality into rehabilitation settings.

Despite previous studies suggesting that occupational

therapists are ‘traditionalists’ (Gustafsson & Yates, 2009;

Koh, Hoffmann, Bennett & McKenna, 2009; Walker,

Drummond, Gatt & Sackley, 2000), this study found that

as a group, occupational therapists are more willing to

embrace new technologies as part of rehabilitation than

other disciplines if the technologies are shown to be

effective. Although more studies are required, current

research suggests that these approaches show promise

(Laver, George, Thomas, Deutsch & Crotty, 2011; Mehr-

holz, Platz, Kugler & Pohl, 2008). Occupational therapists

appear ready to apply these technologies in clinical set-

tings and should take a lead role in further research and

development of these approaches to maximise their

clinical utility. As more conclusive evidence becomes

available, other barriers to integration of these technolo-

gies will need to be overcome, for example, patient accep-

tance which is currently low. It appears that occupational

therapists will need to develop strategies to convince

patients (and perhaps colleagues) of the usefulness of

technologies as a rehabilitation approach. Furthermore,

although occupational therapists may be accepting of

new technologies, implementation into clinical practice

will also depend on the development of skills in using

associated devices and changes in established routines

(Grol, Wensing & Eccles, 2005).

Discrete choice experiments are relatively complex for

respondents to complete, yet, of the 106 patients who

attempted the DCE, only six struggled with the com-

plexity of the task and were therefore unable or unwill-

ing to complete the task. This suggests that although this

method appears to be complex, it offers a promising

approach for examining subtle preferences in clinical pop-

ulations which may be important for ensuring engage-

ment with complex treatments. Results from other studies

conducted in similar populations confirm that preferences

of older people for programs can be elicited and included

in health service planning (Milte et al., 2012). In this

study, the exclusion of patients with significant cogni-

tive impairment (MMSE < 24/30) and the utilisation of

an interview mode of administration may have pro-

moted participant understanding and completion rates.

There are several limitations to this study. First, the

presentation of a cost attribute within the DCE (while

providing a useful indicator for researchers of the relative

strength of preference for individual attribute levels

expressed in monetary terms), may appear somewhat

unusual to respondents as there is currently no cost to

individuals for participation in rehabilitation services in

South Australia. This attribute may have therefore lacked

credibility with some respondents. Nonetheless, the

ability of DCE to ‘price’ non-market goods may make

this information particularly useful for private service

providers. It should be noted that the estimation of these

costs was dependent on the initial levels presented to

respondents within the DCE (no cost, $50 per week and

$100 per week). These levels were determined based on

interviews and piloting of the DCE to determine levels

that were both realistic and would result in participants

being willing to trade. Thus, they are presented for the

purpose of comparison rather than the intention of pro-

viding precise ‘real-world’ amounts. Second, there is some

previous evidence from DCEs undertaken in a health-care

setting that people tend to prefer what they know (Sal-

keld, Ryan & Short, 2000). This may explain the strong

preferences of both patients and other rehabilitation clini-

cians for more traditional therapy approaches. This

behaviour is consistent with the underlying utility theory

and the tendency of individuals, on average, to be risk-

averse (Samuelson & Zeckhauser, 1988). Further research

of both a quantitative and qualitative nature is required to

determine the relationship between familiarity with tradi-

tional services and innovations in service delivery in the

determination of preferences in this population. Finally, a

larger number of occupational Therapy respondents and

individuals from a number of different settings would

have allowed subgroup analysis to determine whether

particular characteristics of therapists (for example age, or

years of experience) were associated with preferences for

particular attributes of rehabilitation programs.

Conclusion

In summary, although participant groups had broadly

similar preferences overall, differences were apparent.

Clinicians placed a stronger emphasis on achieving the

best recovery for the patient and were more accepting

of newer rehabilitation approaches such as higher inten-

sity therapies and the use of computers, whereas

patients strongly valued more traditional approaches.

Successful therapy usually requires shared therapist

and patient expectations to work towards common

goals, but our work suggests that differences in prefer-

ences exist. It seems likely that investing time exploring

and reconciling these differences early in the implemen-

tation process will be helpful.

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