Do Non-participants at Screening have a Different Threshold for an Acceptable Benefit–Harm Ratio than Participants? Results of a Discrete Choice Experiment
The objective of the study was to investigate non-participants’ preferences for cardiovascular disease screening programme characteristics and whether non-participation can be rationally explained by differences in preferences, decision-making styles and informational needs between non-participants and participants.
We conducted a discrete choice experiment at three screening sites between June and December 2017 among 371 male non-participants and 830 male participants who were asked to trade different levels of five key programme characteristics (chance of health benefit, risk of overtreatment, risk of later regret, screening duration and screening location). Data were analysed using a multinomial mixed-logit model. Health benefit was used as a payment vehicle for estimation of marginal substitution rates.
Non-participants were willing to accept that 0.127 (95% confidence interval 0.103–0.154) fewer lives would be saved to avoid overtreatment of one individual, whilst participants were willing to accept 0.085 (95% confidence interval 0.077–0.094) fewer lives saved. This translates into non-participants valuing health benefits 7.9 times higher than overtreatment. The corresponding value of participants is 11.8. Similarly, non-participants had higher requirements than participants for advanced technology and a quicker screening duration. With regard to their participation decision, 64% of the non-participants felt certain about their choice compared with 89% among participants.
This study shows that non-participants have different preferences than participants at screening as they express relatively more concern about overtreatment and have higher requirements for a high-tech screening programme. Non-participants also report to be more uncertain about their participation decision and more often seek additional information to the standard information provided in the invitation letter. Further studies on informational needs and effective communication strategies are warranted to ensure that non-participation is a fully informed choice.
The authors thank the screening invitees who responded to the questionnaire and the staff for the distribution of the survey at the screening sites.
TBH and RS conceived the idea for the study. All authors contributed to the design and planning of the study. TBH and RS performed the statistical analyses. TBH wrote the first draft of the manuscript. All authors have revised the manuscript critically. All authors have given their final approval of the version to be published. TBH and RS are responsible for the overall content.
Compliance with Ethical Standards
The randomised trial from which the respondents in the current study were recruited received financial support from the South Region of Denmark, the Danish Research Council, the Danish Heart Foundation, the Helse Foundation, Odense University Hospital and the Elitary Research Centre of Individualised Medicine in Arterial Disease. For the discrete choice experiment study, financial support has been granted by the Region Zealand (RSSF2017000614).
Conflict of interest
Tina Birgitte Hansen, Jes Sanddal Lindholt, Axel Diederichsen and Rikke Søgaard have no conflicts of interest that are directly relevant to the content of this article.
The study was approved by the Danish Data Protection Agency (REG-003-2017) and complies with the Declaration of Helsinki.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
- 18.ChoiceMetrics. Ngene 1.1.2 user manual and reference guide. 2014. http://www.choice-metrics.com/download.html#manual.
- 19.Bliemer MCJ, Rose JM. Efficiency and sample size requirements for stated choice studies. Working paper: ITLS-WP-05-08. 2005Google Scholar
- 21.) Wittrup-Jensen KU, Lauridsen JT, Gudex C, Brooks R, Pedersen KM. Estimating Danish EQ-5D tariffs using TTO and VAS. In: Norinder A, Pedersen K, Roos P, editors. Proceedings of the 18th plenary meeting of the EuroQol Group. IHE, The Swedish Institute for Health Economics; 2002: pp. 257–92.Google Scholar
- 35.General Medical Council. Seeking patients’ consent: the ethical considerations. London: GMC; 1999.Google Scholar
- 38.Edwards AG, Naik G, Ahmed H, Elwyn GJ, Pickles T, Hood K, et al. Personalised risk communication for informed decision making about taking screening tests. Cochrane Database Syst Rev. 2013;2:CD001865.Google Scholar
- 39.Stacey D, Légaré F, Lewis K, Barry MJ, Bennett CL, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017;4:CD001431.Google Scholar