Consumer preferences for telehealth in Australia: A discrete choice experiment

Feby Savira; Suzanne Robinson; Kaylie Toll; Lauren Spark; Elizabeth Thomas; Julia Nesbitt; Isobel Frean; Richard Norman

doi:10.1371/journal.pone.0283821

Peer Review History

Original SubmissionOctober 24, 2022
19 Dec 2022 Decision Letter - Francesca Ferrè, Editor PONE-D-22-29056Consumer preferences for telehealth in Australia: a discrete choice experimentPLOS ONE Dear Dr. Savira, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The contribution merits to be considered for publication but as indicated by the reviewers it needs to address some aspects related to the implementation of the research design. Specifically, there is a need to clary aspects related to data collection using semi-structured focus group, the process of theme identification for DCE survey, sampling strategy and possible biases, presentation of choice sets. Please submit your revised manuscript by Feb 02 2023 11:59PM. 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If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments: The contribution provides an empirical analysis about population preferences around telehealth services in Australia. The topic presented and the quantitative analysis and evidence are important to inform current debate about the implementation and use at large scale of telehealth solutions, thus I believe the contribution fits the purpose of the journal. I have few concerns about the research design applied, specifically authors should: I) provide additional information about the composition and numbers of semi-structured focus group(s) discussion done to identify main themes for the DCE; II) clarify the process for the identification of sub-set of themes: what analytical approach has been followed (eg thematic analysis or similar?); III) discuss in the limitations the possible distortion/bias of respondent to the DCE since it is said survey respondents were given a pay. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The paper aims to elicit the patients’ preferences on telehealth and face-to-face consultations in Australia. The authors intend to understand which are the potential barriers and facilitators that could discourage or encourage patients to prefer remote visits than in-person visits, respectively. To address this question, the authors implement a Discrete Choice Experiment, where respondents identify their preferred option between two alternative medical consultations, which differ with respect to some characteristics (attributes). I think this work represents an innovative contribution in the medical literature on telehealth. The research question is highly interesting, because, although during the COVID-19 pandemic the potential benefits of using telehealth (together with all the other remote services) clearly emerged, the actual usage of these services is still limited, and their effective diffusion has not been quantified yet. The DCE experiment is well planned, and results are highly interesting from the policy making perspective. In addition, I find it very useful to differentiate the analysis among the different reason that motivate people to seek healthcare services. However, some aspects that could still be improved by the authors. First, the process for identifying the attributes and levels to be used in the DCE is not extensively discussed, in my opinion. As far as I understand, the authors combined the qualitative information that results from a focus group discussion, and some other clinical input. I would personally like to know more details on the focus group discussion: how many participants were involved? how were the participants chosen? which were their characteristics (age, gender, professional experience)? which were the elements that emerged from the discussion? How did the authors identify the exact subset of attributes (and levels) to be employed in the DCE? Second, the sampling strategy to deliver the web survey does not follow a probabilistic rule (the survey has been delivered to a panel of participants who declared to be willing to participate to the survey for small remuneration). I would more extensively discuss this limitation in the paper, while advancing the policy implications of the study. Third, it is not clear to me how do you account for the different motivations that can push patients to seek healthcare services (needing a repeat prescription, having a new physical symptom, and requiring surgical follow-up). Does the experiment “assign” each respondent to one of these frames so that the 15 choice sets that the given respondent faces are all related to the frame he/she is actually assigned to? I strongly suggest clarifying this issue in the manuscript. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? 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Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0283821.r001
Revision 1
1 Mar 2023 Author Response Additional Editor Comments: The contribution provides an empirical analysis about population preferences around telehealth services in Australia. The topic presented and the quantitative analysis and evidence are important to inform current debate about the implementation and use at large scale of telehealth solutions, thus I believe the contribution fits the purpose of the journal. I have few concerns about the research design applied, specifically authors should: I) provide additional information about the composition and numbers of semi-structured focus group(s) discussion done to identify main themes for the DCE; • Response: The focus group discussions were conducted by 10 community members, each hosting a group of up to 10 participants. A total of 90 participants took part from across Australia, and 70% reported using telehealth in the past. We have added this information in the Methods section (page 5-6). Please also see our response to Reviewer to the first set of questions below as it is related to the Editor’s question. II) clarify the process for the identification of sub-set of themes: what analytical approach has been followed (eg thematic analysis or similar?); • Response: The sub-set of themes were identified through expert panel discussion with the team. The identified dimensions and constituent levels we identified as being of broad importance across the focus group discussion. However, the interview data was analysed using qualitative methods. See below for the updated Methods section (page 5-6) and refer to our previous publication for more details (PLoS One. 2022; 17(8): e0273935). “The analysis of the interview data employed a combination of inductive (generating new knowledge) and deductive (testing theories) techniques. Data were analysed sequentially according to the steps of thematic analysis detailed by Braun and Clarke. The focus group discussions yielded a range of key themes regarding consumer attitudes towards telehealth, including convenience, access, fit-for-purpose, communication, existing consumer-clinician relationship, wait time, connectivity, and cost. We identified a subset of these themes to implement into the choice tasks based on relative importance.” III) discuss in the limitations the possible distortion/bias of respondent to the DCE since it is said survey respondents were given a pay. • Response: We thank the Editor for the feedback. Please refer to our response to Reviewer’s second question below. Reviewers’ comments: Reviewer #1: The paper aims to elicit the patients’ preferences on telehealth and face-to-face consultations in Australia. The authors intend to understand which are the potential barriers and facilitators that could discourage or encourage patients to prefer remote visits than in-person visits, respectively. To address this question, the authors implement a Discrete Choice Experiment, where respondents identify their preferred option between two alternative medical consultations, which differ with respect to some characteristics (attributes). I think this work represents an innovative contribution in the medical literature on telehealth. The research question is highly interesting, because, although during the COVID-19 pandemic the potential benefits of using telehealth (together with all the other remote services) clearly emerged, the actual usage of these services is still limited, and their effective diffusion has not been quantified yet. The DCE experiment is well planned, and results are highly interesting from the policy making perspective. In addition, I find it very useful to differentiate the analysis among the different reason that motivate people to seek healthcare services. However, some aspects that could still be improved by the authors. First, the process for identifying the attributes and levels to be used in the DCE is not extensively discussed, in my opinion. As far as I understand, the authors combined the qualitative information that results from a focus group discussion, and some other clinical input. I would personally like to know more details on the focus group discussion: how many participants were involved? How were the participants chosen? Which were their characteristics (age, gender, professional experience)? Which were the elements that emerged from the discussion? How did the authors identify the exact subset of attributes (and levels) to be employed in the DCE? • Response: We have now added more information to the Methods section to clarify these details. “In brief, the qualitative work involved semi-structured focus group discussion regarding consumer attitudes and experiences with telehealth [21]. These focus groups were conducted by 10 trained facilitators with strong community networks. Participants were recruited by the trained facilitator through non-probability convenience sampling with each facilitator inviting up to 10 community members within their local community. This allowed health consumers, carers and community members who do not ordinarily participate in healthcare consultation to have their voice heard in a supportive and safe environment. A total of 90 participants from all across Australia contributed to the focus group discussions. Majority of the participants were female (79%) and aged between 35 to 54 (42%) or 55 to 74 (32%). Most participants were currently living in major cities, although a significant proportion lived in inner and outer regional areas of Australia, or had experience living in rural, regional or remote areas. Approximately half were living with a chronic health condition (47%). Seventy per cent of participants have used telehealth in the past.” (Methods, page 5-6). Regarding subset of attributes, this has been answered in response to the Editor’s question (II). Second, the sampling strategy to deliver the web survey does not follow a probabilistic rule (the survey has been delivered to a panel of participants who declared to be willing to participate to the survey for small remuneration). I would more extensively discuss this limitation in the paper, while advancing the policy implications of the study. • Response: We have added this point to the Limitations section. Note that we had age- and gender- sampling frames imposed (now added in Methods, page 8, and already discussed under Table 2, page 12-13), thus we believe the sampling strategy is probabilistic in those dimensions. “Finally, the DCE survey was delivered to a panel of participants for a small remuneration, leading to the possibility of bias. Nonetheless, this paper provides important insights into the community preferences of telehealth in Australia, which has important policy implications. It would be important to expand the research to include the voice of those less likely to opt into panels of survey respondents, such as those who are digitally limited, those with lower education levels, culturally and linguistically diverse and other disadvantaged population groups. Future studies should also consider conducting the survey using different recruitment strategies, for example through face-to-face means in the community. (Limitations section, page 23). Third, it is not clear to me how do you account for the different motivations that can push patients to seek healthcare services (needing a repeat prescription, having a new physical symptom, and requiring surgical follow-up). Does the experiment “assign” each respondent to one of these frames so that the 15 choice sets that the given respondent faces are all related to the frame he/she is actually assigned to? I strongly suggest clarifying this issue in the manuscript. • Response: This is a very important point, and the prior qualitative point suggested this to be the case here. The three frames (motivations) for seeking healthcare ie., needing a repeat prescription, having a new physical symptom, and requiring surgical follow-up, were all embedded into the 15 choice sets, with each participant completing 5 tasks related to each of the three frames. This information has now been added to the Methods section, page 8. Interestingly, the frames did not demonstrate a very strong pattern of difference between frames, which was one of the few areas where the qualitative and quantitative results did not align. We do not have a hypothesis for such a difference which can be tested using current data, but it is certainly worthy of follow-up in future work. Attachments Attachment Submitted filename: Response to Editor and Reviewer - PLOS ONE.docx https://doi.org/10.1371/journal.pone.0283821.r002
20 Mar 2023 Decision Letter - Francesca Ferrè, Editor Consumer preferences for telehealth in Australia: a discrete choice experiment PONE-D-22-29056R1 Dear Dr. Savira, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Francesca Ferrè Academic Editor PLOS ONE Additional Editor Comments (optional): We thanks the authors for reviewing the manuscript. With their revision, the authors have taken into account all the comments, which has led to an improved manuscript that can now be coinsedered for publication. Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: I think the authors adequately addressed all my comments. The limitations of the project have been outlined in the Discussion, and additional information on focus groups is also provided ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No ******** https://doi.org/10.1371/journal.pone.0283821.r003
Formally Accepted
22 Mar 2023 Acceptance Letter - Francesca Ferrè, Editor PONE-D-22-29056R1 Consumer preferences for telehealth in Australia: a discrete choice experiment Dear Dr. Savira: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Francesca Ferrè Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0283821.r004

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