Using Discrete Choice Experiments to Go Beyond Clinical Outcomes when Evaluating Clinical Practice

Until the 1990s benefit assessment in health economics was dominated by an assumption that health was the only important outcome from health care. This is evidenced by the large amount of research devoted to valuing health outcomes using quality-adjusted life years (QALYs) (Williams, 1985; Dolan, 1997). The 1990s saw a challenge to this assumption, arguing that concentration on health outcome fails to allow for the possibility that individuals derive benefit from other sources – nonhealth outcomes and process attributes – (Ryan and Shackley, 1995; Ryan and Hughes, 1997; Diener et al., 1998; Donaldson et al., 1998;Ryan, 1999; Donaldson and Shackley, 2003). Non-health outcomes refer to sources of benefit such as the provision of information, reassurance, autonomy and dignity in the provision of care. Process attributes include such aspects of care as waiting time, time in consultation, location of treatment and continuity of care and staff attitudes. While it should be recognised that some of these will have direct effects on health outcomes, they also have what can be regarded as pure non-health benefits. The debate about going beyond health outcomes led to the question of how such attributes can be valued. It became clear that QALYs would not be appropriate for valuing non-health outcome and process attributes. For example, it would not be realistic to ask individuals how many years at the end of their life they would be willing to give up to have waiting time reduced by 3 months; as would be required using the time–trade-off method.