PERGAMON Social Science & Medicine 48 (1999) 535±546

Using conjoint analysis to take account of patient

preferences and go beyond health outcomes: an application
to in vitro fertilisation
Mandy Ryan *
Health Economics Research Unit, Department of Public Health, University of Aberdeen Medical School, Foresterhill, Aberdeen AB25
2ZD, UK

Abstract

There has been an assumption in the health economics literature that health outcomes are all that need to be
considered when attempting to measure the bene®ts from health care interventions. This is most evident in the
development of the quality adjusted life year (QALY) approach to bene®t assessment. This paper challenges this
view and considers the technique of conjoint analysis (CA) as a methodology for both taking account of patient
preferences and considering attributes beyond health outcomes. The technique is applied to in vitro fertilisation. CA
is shown to be sensitive to considering health outcomes, nonhealth outcomes and process attributes. It is also shown
to be internally consistent and internally valid. The paper demonstrates the application of CA to estimating
willingness to pay indirectly. It is argued that bene®t assessment within health economics should extend beyond
health outcomes and future research should investigate more thoroughly the potential application of CA in this
area. However, methodological issues need addressing before the instrument becomes an established evaluative
instrument. # 1998 Elsevier Science Ltd. All rights reserved.

Keywords: Health economics; Patient preferences; Conjoint analysis; Willingness to pay; In vitro fertilisation

1. Introduction comes in the provision of health care. This is done

Health economists have devoted much attention to
valuing the bene®ts of health care interventions, using
quality adjusted life years (QALYs) and, more
recently, healthy year equivalents (HYEs) (Williams,
1985; Kind, 1988; Mehrez and Gafni, 1989; Mehrez and
Gafni, 1991, 1993; Gafni et al., 1993; Buckingham,
1993). While de®nitions of the bene®ts of health care
interventions have been enhanced in recent years, the
emphasis has remained on health outcomes (Cadman
et al., 1986; Boyle et al., 1991; Torrance et al., 1992;
Feeny et al., 1994). One aim of this paper is to con-
sider the importance of attributes beyond health out-
* Tel.: +44-1224-681-818 ext. 54965; fax: +44-1224-662-
994; e-mail: m.ryan@abdn.ac.uk.
using the example of the provision of in vitro fertilisa-
tion (IVF). Economic evaluations of IVF have im-
plicitly assumed that the only factor of importance to
users is whether they leave the service with a child.
Analysts have estimated a cost `per live birth', `per
maternity' or per some other narrow medical de®nition
of success (Bartels, 1987; Batman, 1988; Wagner and
St Clair, 1989; Page, 1989; Webb and Holman, 1990;
Haan, 1991; Neumann et al., 1994). The usual applied
welfare economics framework requires bene®t assess-
ments to consider all e€ects of treatment on well-
being, both positive and negative, including, in this
case, the experiences of the majority of users who leave
the service childless.
A second aim of this paper is to demonstrate how
the application of a technique known as conjoint
analysis (CA) can take account of patient preferences

0277-9536/98/$ - see front matter # 1998 Elsevier Science Ltd. All rights reserved.
PII: S 0 2 7 7 - 9 5 3 6 ( 9 8 ) 0 0 3 7 4 - 8
536 M. Ryan / Social Science & Medicine 48 (1999) 535±546
within the delivery of health care. Whilst the technique
is applied speci®cally to the area of IVF, its appli-
cation in health service research more generally is also
discussed. With respect to IVF, it is shown how CA
can be used to establish whether a given attribute of
the service is important, the relative importance of the
various attributes of the service, the trade-o€s individ-
uals make between attributes and how willingness to
pay (WTP) (the monetary value of any given attribute)
can be estimated indirectly.
In Section 2 background information is provided on
CA. Following this, the methods and results from an
application of CA to IVF are outlined (Section 3).
Attention is given to whether attributes beyond the
narrow outcome of `having a child' are important.
Consideration is also given to some methodological
issues in the application of CA, namely internal con-
sistency, internal validity and estimation of willingness
to pay indirectly (Section 4). The results are presented
in Section 5. Finally issues of design and methodology
are discussed (Section 6).
2. Conjoint analysis
2.1. What is conjoint analysis?
Conjoint analysis is a technique for establishing the
relative importance of di€erent attributes in the pro-
vision of a good or a service. It can also be used to
estimate how individuals trade between these attributes
i.e. the rate at which they are willing to give up one
unit of an attribute for an increase in another attri-
bute. This is known as the marginal rate of substi-
tution (MRS). If cost is included as an attribute then
this MRS represents WTP1.
CA has its origin in market research, where it has
been used to identify factors in¯uencing the demand
for commodities (Cattin and Wittink, 1982). It has
also been used widely in transport economics
(Wardman, 1988) and environmental economics (Rae,
1981a,b; Desvouges et al., 1983; Magat et al., 1988;
Swallow et al., 1992; Opaluch et al., 1993) and was rec-
ommended to the UK Treasury as a method for evalu-
ation of quality in the provision of public services
(Cave et al., 1993).
1
WTP is based on the premise that the maximum amount
of money an individual is willing to pay for a commodity is
an indicator of the utility or satisfaction to her of that com-
modity. WTP is thus a monetary measure of the value or ben-
e®t of a given health care intervention. Traditionally studies
have directly asked individuals their WTP, using either the
open-ended, payment card or closed ended approach (Ryan et
al., 1997).
In the United States CA has been used by noneco-
nomists within the area of health care to examine fac-
tors important to patients in the provision of health
care systems (McClain and Rao, 1974; Parker and
Srinivasan, 1976; Wind and Spitz, 1976; Chakraborty
et al., 1993, 1994). In the UK it has been used to esti-
mate: the monetary value of reducing time spent on
waiting lists (Propper, 1990, 1995), the trade-o€s indi-
viduals make between the location of clinic and wait-
ing time in the provision of orthodontic services (Ryan
and Farrar, 1995); women's preferences for surgical
versus medical management of miscarriage (Ryan and
Hughes, 1997), preferences for magnetic resonance
imaging (MRI) in the investigation of knee injuries
(Bryan et al., 1998), women's preferences for the treat-
ment of menorraghia (San Miguel et al., 1997), patient
preferences in the doctor±patient relationship (Vick
and Scott, 1998) and patient preferences for blood
transfusion support (Van der Pol and Cairns, 1998).
2.2. Theoretical background to CA
In a typical CA study individuals are presented with
hypothetical scenarios involving di€erent levels of attri-
butes which have been identi®ed as important in the
provision of a good or service and asked to rank the
services, rate them or make pairwise choices. Within
market research ranking and rating exercises have
proved the most popular. Transport economists devel-
oped the pairwise comparison approach from the econ-
omic theory of random utility (McFadden, 1973). It
may be argued that individuals are used to making
such choices since it is the type of exercise in which
they engage on a daily basis. In contrast, individuals
seldom carry out ranking and rating type exercises for
decisions made every day. For these (related) reasons
the `choice' approach is developed and applied in this
paper.
The decision making process within the pairwise
choice framework can be seen as a comparison of two
indirect utility (or bene®t or satisfaction) functions.
The respondent is asked to make a series of pairwise
choices. For each comparison s/he chooses (or prefers)
the alternative that leads to the higher level of utility.
Thus, the individual chooses health care intervention B
over A if
U AB , Y, Z† > U AA , Y, Z†: 1†
U(.) represents the individual's indirect utility (or ben-
e®t) function, AB are the attributes of health care inter-
vention B, AA are the attributes of health care
intervention A, Y is the individual's income and Z rep-
resents the socio-economic characteristics of the indi-
vidual that in¯uence their utility. It is assumed that
individuals compare health care interventions on the
 M. Ryan / Social Science & Medicine 48 (1999) 535±546
basis of health outcomes (HO), nonhealth outcomes
(NHO) and process attributes (P). Further, whilst the
individual knows the nature of their utility function,
the researcher will not. This introduces the concept of
random utility, where an error term is included in the
utility function to re¯ect the unobservable factors in
the individual's utility function. Thus, within this
framework, the individual will choose B over A if
V HOB , NHOB , PB , Y, Z† ‡ eB
> V HOA , NHOA , PA , Y, Z† ‡ eA : 2†
V(.) is the measurable component of utility estimated
empirically, HOj, NHOj and Pj are, respectively, the
health outcomes, nonhealth outcomes and process
attributes of the health care intervention being con-
sidered (j = A, B) and ej re¯ects the unobservable fac-
tors in the individual's utility function. Assuming a
linear utility function V(.), the utility to be estimated
in moving from A to B is
X X
DV ˆ fbB ‡ biB HOiB ‡ bjB NHOjB
X and process type attributes (see Table 1).
‡ bkB PkB ‡ Y ‡ Z ‡ eB g ÿ fbA
X X
‡ biA HOiA ‡ bjA NHOjA
X A number of issues were raised when de®ning the
‡ bkA PkA ‡ Y ‡ Z ‡ eA g, 3†
which can be simpli®ed as
X X X ®ne qualitative levels. Obviously levels should be realis-
DV ˆ ac ‡ ai HOi ‡ aj NHOj ‡ ak Pk ‡ e: 4†
ac, ai, aj and ak (i = 1, n, j = n + 1, m and
k = m + 1, l) represent the parameters of the model
to be estimated. Parameter ac is the constant term for
the model and re¯ects preferences for one type of
Table 1
Attributes and levels included in the CA study
Attribute
Process attributes
Attitudes of sta€ toward you
Continuity of contact with same sta€
Time on waiting list for IVF attempt (months)
Cost to you of IVF attempt (£)
Health outcome
Chance of taking home a baby (%)
Nonhealth outcomes
Follow-up support
537
treatment over another when all attributes included in
the model are the same (Ryan and Hughes, 1997).
Parameters ai, aj and ak indicate whether the relevant
attribute is important (as indicated by its signi®cance
level) as well as how important (as indicated by its
relative size). The ratio of any two parameters is the
MRS between these attributes. If cost is included as an
attribute then the monetary value of each attribute can
be estimated. Finally, unobservable factors in the indi-
vidual's utility function are represented by e.
3. Methods
3.1. Establishing the attributes
In a previous study (Ryan, 1995) six attributes were
identi®ed as signi®cant predictors of utility from
undergoing IVF. These were: chance of taking home a
baby, follow-up support, time on the waiting list, con-
tinuity of sta€, cost and attitudes of sta€. These attri-
butes included health outcomes, nonhealth outcomes
3.2. Levels of attributes
levels, including identi®cation of the appropriate range
for levels, what the intervals should be and how to de-
tic. There would be no point in o€ering individuals a
100% chance of leaving the service with a child since
this is not a realistic option. Levels of attributes also
need to be set such that individuals are willing to trade
between them, i.e. if the levels for cost or chance of
leaving the service with a child were set with too broad
Levels and de®nition
`bad' Ð uncaring and unsympathetic
`good' Ð caring and sympathetic
`no' Ð you see many di€erent sta€
`yes' Ð you see the same sta€ on all visits
1, 3, 6, 18, 36
0, 750, 1500, 2500, 3000
5, 10, 15, 25, 35
`no' Ð no support
`yes' Ð you get support
538 M. Ryan / Social Science & Medicine 48 (1999) 535±546

Table 2
Di€erence between choices in CA study: clinic B minus clinic A di€erences

Type 1 Type 2

Choice Attitudes Chance Continuity Time on Cost to Follow-up Attitudes Chance Continuity Time on Cost to Follow-
of sta€a of taking of contact waiting you of supportb of sta€1 of taking of contact waiting you of up
home a with same list IVF home a with same list for IVF supportb
baby sta€b for IVF attempt baby sta€b IVF attempt
(%) (months) (£) (%) (months) (£)

1 0 ÿ20 1 ÿ15 0 1 0 ÿ5 ÿ1 ÿ5 ÿ1000 0

2 ÿ1 10 0 ÿ12 0 1 0 ÿ5 0 ÿ3 ÿ500 0
3c ÿ1 ÿ20 0 18 1000 0 0 ÿ10 ÿ1 30 500 1
4d ÿ1 10 1 0 1500 0 0 10 0 ÿ5 ÿ1750 0
5 ÿ1 0 0 ÿ15 1000 1 1 ÿ5 0 30 ÿ2500 1
6 0 10 1 ÿ17 1000 1 0 ÿ10 0 12 ÿ1750 1
7c 0 0 1 ÿ12 ÿ1500 0 0 0 0 30 ÿ1000 0
8 ÿ1 ÿ20 0 ÿ17 ÿ1500 0 0 20 ÿ1 ÿ3 ÿ2500 0
9c 0 ÿ15 0 0 1000 0 1 10 ÿ1 12 ÿ1000 0
10 ÿ1 ÿ10 0 0 ÿ1500 1 1 ÿ10 ÿ1 0 500 0
11 0 10 0 18 ÿ750 0 1 0 ÿ1 ÿ3 1750 0
12 ÿ1 ÿ15 0 ÿ12 ÿ750 1 1 0 ÿ1 ÿ5 500 1

a
Taking on a value of zero for bad and unity for good.bTaking on a value of zero for no and unity for yes.cChoice that allows
check of consistency in type 1 questionnaire.dChoice that allows check of consistency in type 2 questionnaire.

intervals then individuals may not be willing to trade.
This refusal to trade may be the result of a poor ques-
tionnaire design, rather than an unwillingness to trade
per se. Levels of cost must extend beyond the cost that
is currently being paid for the service since the actual
cost may not represent an individual's maximum
WTP. Levels for time on the waiting list, cost and
chance of leaving the service with a child were chosen
to be representative of the situation at the time in
Scotland (Ryan, 1995). De®ning levels for `quantitat-
ive' attributes is generally easier than for `qualitative'
attributes. Table 1 summarises the attributes and levels
included in the CA study.
3.3. Presentation of questions
The attributes and levels presented in Table 1 give
rise to 1000 possible scenarios (5323=1000). The
SPSS procedure Orthoplan (SPSS, 1989) was used to
reduce these to a `manageable level' whilst still being
able to infer utilities for all possible scenarios. The
technique results in an orthogonal main e€ects design
and gave rise to 26 scenarios from the original 1000.
Evidence from the transport literature suggests that in-
dividuals can manage between 9 and 16 pairwise com-
parisons before they become tired or bored (Pearmain
et al., 1991). The 26 scenarios were therefore randomly
split into two equal groups. Within each group, one
scenario was randomly chosen, and each of the

Fig. 1. Example of pairwise choice question in conjoint analysis questionnaire.

 M. Ryan / Social Science & Medicine 48 (1999) 535±546
remaining 12 scenarios were compared to this scenario.
These two groups formed the basis of two separate CA
questionnaires (type 1 and type 2) consisting of 12
pairwise choices (see Table 2). Subjects were randomly
allocated between these two questionnaires. An
example of one of the pairwise choices is shown in
Fig. 1.
The study sample comprised individuals attending
the Assisted Reproductive Unit (ARU) in Aberdeen,
U.K. In a previous study, a satisfaction questionnaire
was mailed to all 1164 individuals who had attended
the ARU since it opened in 1989 (Ryan, 1995). Among
these were individuals who were on the waiting list for
IVF, individuals who had had a `failed' attempt at
IVF and were still trying, as well as users who had left
the service both with a child and childless.
Questionnaires were mailed separately to men and
women. The 466 individuals who responded to this
`satisfaction' questionnaire were selected for the CA
study. A pilot questionnaire was mailed to a random
sample of 52 of these individuals to test whether indi-
viduals would complete the CA questionnaire, and to
see if trading was taking place among the chosen levels
of the attributes. The main questionnaire was mailed
to the remaining 414 individuals. Information had pre-
viously been collected on respondents age, sex, whether
or not they had had a child from IVF, whether they
were currently undergoing treatment and how many
additional IVF attempts they were willing to have.
Respondents were asked to return a slip if they did not
want to take part in the study. Two follow-up letters
were sent to individuals before they were considered
nonrespondents.
3.4. Analysis of data
The LIMDEP random e€ects probit procedure was
used to analyse the data (Greene, 1991; Propper,
1995). The function to be estimated was of the form
DV ˆ a1 staff ‡ a2 cont ‡ a3 wait ‡ a4 cost
‡ a5 chance ‡ a6 follow ‡ e ‡ u:
DV is the change in utility in moving from one IVF
clinic A to another B, sta€ is the di€erence in the sta€
attitudes between clinic A and B, cont is the di€erence
in continuity of sta€ contact, wait is the di€erence in
waiting time, cost is the di€erence in the cost of an
attempt at IVF, chance is the di€erence in the chance
of taking home a baby and follow is the di€erence in
follow up support and is the nonhealth outcome. The
unobservable error terms are represented by e and u,
where e is the error term due to di€erences amongst
observations and u is the error term due to di€erences
amongst respondents (Ryan and Hughes, 1997). The
relative importance of the di€erent attributes, and the
539
ratio of the parameters (i.e. the trade-o€s between
them) are given aj with aj/a4 ( j = 1, 2, 3, 5, 6) being
an estimate of WTP for levels of the individual attri-
butes.
The initial utility functions had a constant term
which re¯ects the importance of attributes not included
in the model. This was `suppressed' in the study by
asking subjects to assume that all aspects of the ser-
vice, other than those speci®ed in the questionnaire,
were identical. Thus, from Eqs. (3) and (4), ac=0 (or
bBÿbA=0) when there is no di€erence in the clinics
other than those speci®ed for the six attributes
included in the model.
To allow for nonrandom variation in coecients,
segmentation analysis was carried out. Interaction
terms were created between cost and income category,
time and an age category and time and income cat-
egory. This allowed a demonstration of how such
analysis can be conducted, as well as a testing of the
theoretical validity of the model (see below). The ®nal
function to be estimated was
DV ˆ a1 `staffatts' ‡ a2 `continuity' ‡ a31 `waitinc1'
‡ a32 `waitinc2' ‡ a33 `waitinc3'
‡ a34 `waitage1' ‡ a35 `waitage2'
‡ a36 `waitage3' ‡ a41 `costinc1'
‡ a42 `costinc2' ‡ a43 `costinc3' ‡ a5 `chance'
‡ a6 `follow ÿ up' ‡ e ‡ u, 6†
where `waitinc1', `waitinc2' and `waitinc1' represent the
waiting time attribute segmented by income groups 1,
2 and 3, respectively, `waitage1', `waitage2' and `wait-
age 3' represent the wait attribute segmented by age
groups 1, 2 and 3, respectively and `costinc1', `costinc2'
and `costinc3' represent the cost attribute segmented
by income groups 1, 2 and 3, respectively. All other
variables are as de®ned above. Mean WTP was esti-
mated for all attributes within each income and age
5† group and the Z statistic used to test whether these
mean WTP estimates were statistically signi®cantly
di€erent from one another (Bland, 1995).
4. Methodological issues addressed
When using CA it is important to include tests of
whether individuals appear to understand the tech-
nique and are taking it seriously. This study tested for
internal (theoretical) validity and consistency.
The results from the regression analysis were used to
test the internal validity of CA i.e. the extent to which
results are consistent with a priori expectations. Given
540 M. Ryan / Social Science & Medicine 48 (1999) 535±546

that lower levels of time on the waiting list and cost
are to be preferred, we would expect these attributes to
have a negative sign in the regression equation.
Similarly, given that higher levels of chance of taking
home a baby are to be preferred, and assuming conti-
nuity of care and good sta€ attitudes are preferred, we
would expect these attributes to have a positive sign in
the regression equation. No a priori assumptions were
made about the provision of follow-up support.
Assuming that higher socio-economic groups have a
higher marginal valuation of time, we would expect a
priori the coecient on waiting time segmented by
income to be higher for higher income groups a priori.
Assuming diminishing marginal utility of income, we
would expect higher income groups to have a lower
marginal valuation of cost and, therefore, the coe-
cient on cost to be lower for higher income groups.
Assuming older people place a higher value on redu-
cing waiting time, a priori we would expect the coe-
cient on waiting time segmented by age to increase
with age.
Internal consistency was checked by testing the
rationality of the choices made, i.e. if one scenario is
considered to be `better' than another, individuals are
expected to choose that scenario. Assuming that
patients prefer good attitudes of sta€ to bad, a higher
chance of taking home a baby, continuity of contact
with the same sta€, less time on the waiting list, a
lower cost to a higher cost and again making no a
priori assumption about follow-up support, the orthog-
onal plan resulted in four choices that, on any rational
choice process, should be preferred to others (see
Table 2). In the type 1 questionnaire it would be
expected that all individuals would prefer clinic A in
choice 3, clinic B in choice 7 and clinic A in choice 9.
In the type 2 questionnaire all individuals would be
expected to prefer clinic B in choice 4. Individuals who
answered inconsistently were assumed either to have
misunderstood the questionnaire or to not be taking it
seriously, and were dropped from the analysis.
CA assumes that individuals have continuous prefer-
ences such that there is always some improvement in
one attribute that can compensate for a deterioration
in the level of another attribute. In the context of this
study this implies that respondents would be willing to
trade lower levels of probability of leaving the service
with a child for improvements in levels of the other
attributes. This was tested for by establishing if there
was any individual who always chose the scenario with
the highest chance of leaving the service with a child.
5. Results
Of the 414 questionnaire mailed, 10 were returned
because they were sent to the wrong address, 14 were
returned by individuals who did not want to take part
in the study, 331 questionnaires were returned com-
pleted and there were 59 nonresponses. Of the 331
respondents, 149 were male and 182 female. Forty had
a child from IVF, 55 were currently undergoing treat-
ment and 121 were willing to have an additional
attempt.
There was evidence that individuals understood the
questions and answered them consistently. For the
type 1 questionnaire all 170 respondents answered
choice 3 consistently, only 3 answered choice 7 incon-
sistently and only 1 answered choice 9 inconsistently.

Table 3
Test for chance of leaving the service with a child being a dominant attribute in the choice process

Type 1 Type 2

Di€erence in chance of Prefer Prefer Di€erence in chance of Prefer Prefer

taking home a baby Clinic B Clinic A taking home a baby Clinic B Clinic A
(Clinic B ÿ Clinic A) (Clinic B ÿ Clinic A)

Choice 1 ÿ20% 32 137 ÿ5% 64 96

Choice 2 10% 117 53 ÿ5% 18 142
Choice 3 ÿ20% 170 0 ÿ10% 47 113
Choice 4 10% 40 130 10% 153 6
Choice 5 0 41 127 ÿ5% 57 103
Choice 6 10% 132 38 ÿ10% 13 146
Choice 7 0 167 3 0 36 124
Choice 8 ÿ20% 35 135 20% 155 5
Choice 9 ÿ15% 1 169 10% 123 36
Choice 10 ÿ10% 47 123 ÿ10% 6 154
Choice 11 10% 68 102 0 141 19
Choice 12 ÿ15% 34 136 0 104 57
 M. Ryan / Social Science & Medicine 48 (1999) 535±546 541

In the type 2 questionnaire only 6 respondents
answered inconsistently. Individuals providing incon-
sistent responses were dropped from all subsequent
analysis. Because there were so few inconsistent re-
sponses it was not possible to carry out statistical tests
to see if these were answered inconsistently by a par-
ticular group or population.
No individual always chose the scenario with the
highest chance of leaving the service with a child,
suggesting individuals were willing to make trade-o€s
between the level of probability of leaving the service
with a child and other attributes (see Table 3). These
results suggest that the level of probability of having a
child is not a dominant attribute. This ®nding chal-
lenges current economic evaluations of the service
which are based purely on the cost per live birth, or
some other medical de®nition of `success'.
5.1. Statistical signi®cance of attributes
All coecients have the expected sign and are sig-
ni®cant at the 1% level (see Table 4). This suggests
that all the chosen attributes are important in the pro-
vision of IVF services. The positive signs on attitudes
of sta€, continuity of care and chance of taking home
a baby indicate that the higher these attributes are in
clinic B relative to A, the more likely the individual is
to choose clinic B. Similarly, negative signs on cost,
time on waiting list and follow-up support indicate
that the lower these attributes are in clinic B relative
to clinic A, the more likely the individual is to choose
clinic B. The negative sign on follow-up support
suggests that having this is a disbene®t. Individuals not
wanting to discuss their infertility problems may
explain this. The coecients on the cost attribute indi-
cate that respondents with a higher income had a
lower marginal valuation of cost, re¯ecting diminishing
marginal utility of income. As expected, older respon-
dents valued a reduction in waiting time more highly
than younger respondents. These results support the
theoretical validity of CA.
5.2. Size of e€ect and trade-o€ between attributes
A 1% increase in the chance of having a child
results in more bene®t than a one month fall in waiting

Table 4
Results from random-e€ect probit model

Variable Random e€ects Standard errora

probit model (SE)
coecients

Sta€ attitudes 0.526** 0.040

Continuity of care 0.180** 0.048
Follow-up ÿ0.123** 0.045
Chance 0.080** 0.002
Cost  income1 ÿ0.0006** 0.00005
Cost  income2 ÿ0.0005** 0.00003
Cost  income3 ÿ0.0003** 0.00004
Waiting  income1 0.003 0.007
Waiting  income2 ÿ0.001 0.006
Waiting  income3 ÿ0.012* 0.006
Waiting  age1 ÿ0.031** 0.006
Waiting  age2 ÿ0.047** 0.006
Waiting  age3 ÿ0.044** 0.007
r 0.097

n 3953
Log likelihood ÿ1821
w2 27.36 (0.001)
Correct predictions 79%

**
Signi®cant at 1% level, *signi®cant at 5% level.
Income1 < £15,000, income2 = £15,001±30,000; income3 = £31001 + . Age1 is 25±35 years,
age2 36±42 years and age 3 42 + years.
a
Standard errors estimated from the Taylor series approximation to the variance of a random
variable: Var(WTP) = 1/bj 2[var(bi) ÿ 2WTP cov(bj, bi) + WTP2var(bj)], where bj=coecient for
cost variable and bi=coecient for the ith variable (i = sta€ attitudes, chance, continuity of
care, follow-up and waiting time).
542 M. Ryan / Social Science & Medicine 48 (1999) 535±546

time or a reduction of one pound in the cost of treat-
ment for all three income groups (as indicated by the
size of the respective coecients). Good sta€ attitudes
are more important than a 6% increase in the chance
of taking home a baby (i.e. 0.526>(0.080  6)), and
continuity of care is slightly more important than a
2% increase in the chance of taking home a baby
(0.180>(0.080  2)).
The ratio of the coecients shows how much of one
attribute an individual would be willing to give up to
get more of another attribute. For example, an individ-
ual would be willing to have a reduction in their
chance of leaving the service with a child of 6%
(0.526/0.080) to have good sta€ attitudes.
5.3. Estimating WTP
For all attributes WTP is lower for the lower income
groups than the higher income groups (Table 5). Those
in income group 3 are willing to pay signi®cantly more
for good sta€ attitudes than income group 1
(Z = 3.46; p < 0.001) and 2 (Z = 2.73; p < 0.001).
They are also willing to pay signi®cantly more to
increase their chance of having a child than income
group 1 (Z = 3.94; p < 0.001) and 2 (Z = 3.16;
p < 0.001).
WTP to reduce waiting time is related to both age
and income. For example, younger individuals on a
low income are willing to pay £52 for a month's re-

Table 5
Willingness to pay estimated indirectly from random e€ects probit model

Attribute Random e€ects Z

probit model (i, j indicates
WTP (SEa) comparing income
(£) groups i and j)

Attitudes of sta€ towards you

Income 1 877 (98) 3.46 (1, 3)**
Income 2 1052 (105) 1.21 (2, 1)
Income 3 1753 (233) 2.73 (3, 2) **

Continuity of contact with same sta€

Income 1 300 (86) 1.43 (1, 3)
Income 2 360 (105) 0.44 (2, 1)
Income 3 600 (191) 1.10 (3, 2)

Follow-up support
Income 1 205 (77) 1.17 (1, 3)
Income 2 246 (92) 0.34 (2, 1)
Income 3 410 (157) 0.90 (3, 2)

Chance of having a child (% increase)

Income 1 133 (12) 3.94 (1, 3)**
Income 2 160 (12) 1.62 (2, 1)
Income 3 267 (31) 3.16 (3, 2)**

Time on waiting list (per month)

Age1 and income 1 52 (10) 2.11 (1, 3)*
Age 1 and income 2 62 (11) 0.64 (2, 1)
Age 1 and income 3 103 (21) 1.64 (3, 2)*
Age2 and income 1 78 (11) 2.77 (1, 3)**
Age 2 and income 2 94 (10) 1.08 (2, 1)
Age 2 and income 3 157 (26) 2.26 (3, 2) *
Age3 and income 1 73 (12) 2.45 (1, 3) **
Age 3 and income 2 88 (15) 0.78 (2, 1)
Age 3 and income 3 147 (28) 1.87 (3, 2) *

**
P < 0.01; *P < 0.05.aStandard errors estimated from the Taylor series approximation to
the variance of a random variable: Var(WTP) = 1/bj 2[var(bi) ÿ 2WTP cov(bj,
bi) + WTP2var(bj)], where bj=coecient for cost variable and bi=coecient for the ith variable
(i = sta€ attitudes, chance, continuity of care, follow-up and waiting time).
 M. Ryan / Social Science & Medicine 48 (1999) 535±546
duction in waiting time, other things equal, compared
to £62 for the middle income group of the same age
and £103 for the higher income group of the same age.
A similar relationship is observed for the middle and
older age groups. These results all provide support for
the theoretical validity of the technique.
6. Discussion and conclusion
Evidence has been presented that, within the context
of IVF, users are concerned with more than whether
they leave the service with a child. Individuals are will-
ing to trade changes in the probability of leaving the
service with a child with other attributes. The paper
clearly provides evidence that there is utility beyond
health outcome. This should come as no surprise since
the health services satisfaction literature has been
reporting such ®ndings for many years. It is unlikely
that these results are speci®c to IVF. This suggests
that, assuming the goal of health care interventions is
to maximise utility, account should be taken of factors
beyond health outcomes when valuing bene®ts from
health care interventions. However, those adopting an
`extra welfarist' approach to valuing health care may
challenge this conclusion (Culyer, 1989, 1990).
Results from a CA study are potentially very useful
to policy makers. Many of the factors identi®ed as
nonhealth outcomes and process attributes are capable
of being directly in¯uenced by policy makers. Within
the context of this study, the results could be used to
help in the design of a given infertility clinic with given
resources, and to help decide how to spend additional
money to improve a clinic. The monetary measure of
bene®ts can be directly compared with costs within the
framework of a cost±bene®t analysis (CBA).
A number of interesting issues were raised.
Regarding de®ning levels for attributes, the researcher
would be encouraged to use quantitative rather than
qualitative levels. For example, `continuity of care'
may have been better de®ned as `you see one member
of sta€ throughout', `you see two±four', or `you see
®ve or more'. Where this is not possible a clear de®-
nition of the qualitative levels should be provided such
that all respondents are interpreting them in the same
way. When the researcher is faced with numerous
qualitative levels, interviews, interactive computer soft-
ware (Pearmain et al., 1991) and visual aids may be a
better method to collect data, although this is ulti-
mately an empirical question. The literature on patient
decision-making may be helpful here (Levine et al.,
1992; Elit et al., 1996).
Including cost as an attribute to estimate WTP
raises questions concerning the range of levels and the
de®nition of cost in a collectively funded health care
system. In establishing levels for the cost attribute,
543
future applications of CA should include pilot work to
establish the range of monetary valuations (San
Miguel et al., 1997). The issues raised here are similar
to those raised in devising the bid vector in a closed
ended WTP study (Ryan et al., 1997).
Since IVF is not freely available on the UK
National Health Service, the cost attribute was de®ned
as `cost to you per IVF per attempt'. However, this
may not be realistic when the health care intervention
being valued is collectively funded. Much can be learnt
from attempts to apply the direct WTP technique to
value collectively-funded health care interventions.
Here there has been a movement away from asking
patients WTP at the point of consumption to the use
of ex ante insurance based or taxation based questions
(O'Brien and Gafni, 1996; Olsen and Donaldson,
1998). Future applications of CA to collectively-funded
health care interventions should explore this approach.
In this study individuals were presented with 12
choices, and, for each of them, asked whether they pre-
ferred clinic A or clinic B (see Fig. 1) i.e. individuals
were forced to make a choice between A and B.
Future application of CA should consider giving indi-
viduals the option of indicating indi€erence or not
choosing. If such an approach were taken, alternative
statistical techniques, such as ordered probit, would be
appropriate (McKelvey and Zavoina, 1975; Ryan and
Farrar, 1995; Van der Pol and Ryan, 1996).
An important question in economic evaluations is
whether to elicit values from users or the community.
In this study the value of users were considered. This
had the advantage that respondents had experience of
the IVF clinic and, therefore, had relatively informed
preferences across the attributes. Gafni (1991) has
argued that within the context of a publicly provided
health care system it is the views of the community
that are relevant. A problem with the community
approach is that the community is unlikely to have
good knowledge of health care interventions. The
results of a CA study critically depend on the way in
which subjects are informed about the hypothetical
choices they are asked to make. When community pre-
ferences are being elicited it may be more important to
use interviews, interactive computer software and
visual aids. This is again ultimately an empirical ques-
tion. Again, literature on patient decision-making may
be helpful here in o€ering advice on ways of presenting
information to the general community (Levine et al.,
1992; Elit et al., 1996).
CA is potentially a very useful tool for bene®t
assessment in health economics. However, methodo-
logical work is needed before CA becomes an estab-
lished evaluative instrument (Ryan et al., 1996). This
study achieved a relatively high response rate, as well
as high levels of internal consistency and internal val-
idity. These results are consistent with ®ndings from
544 M. Ryan / Social Science & Medicine 48 (1999) 535±546
other studies (Ryan and Farrar, 1995; Ryan and
Hughes, 1997; San Miguel et al., 1997; Bryan et al.,
1998; Vick and Scott, 1998; Van der Pol and Cairns,
1998). The study also highlighted the need for meth-
odological work concerning how the data should be
collected and the sensitivity of the results to the range
and levels of attributes chosen. Further issues that
need addressing include testing the reliability and
external validity of the technique and issues around
the functional form of the utility function. Stated pre-
ference techniques have long been criticised for the
hypothetical nature of the questions posed and doubts
expressed as to whether individuals behave as stated in
such surveys (Mitchell and Carson, 1989). Whilst a
limited amount of work has established the reliability
and validity of CA within the areas of market research
and transport economics (Ryan, 1995), it is not clear
how applicable this work is to health economics, and
work is clearly needed in this area. Regarding the func-
tional form of the model, the application of CA in this
study is based on the premise that the objective of
health care resources is to maximise utility. It is also
the case that the utility function estimated in this study
was highly constrained i.e. a linear function based on
six attributes. Future work using CA should ensure
that the utility function is correctly speci®ed, both in
terms of the attributes included, and the functional
form estimated.
In conclusion, evidence has been provided of the im-
portance of factors beyond having a child in the infer-
tile person's utility function. This ®nding has
important implications for future economic evaluations
of IVF. There is no reason to believe this treatment is
the only health care intervention where utility bearing
arguments extend beyond health outcomes. Future
economic evaluations should take this into account.
CA was promoted as a tool for taking account of the
trade-o€s between health, nonhealth and process attri-
butes. It was shown to be internally consistent and
theoretically valid, as well as capable of estimating
WTP indirectly. However, further methodological
work is needed before the instrument becomes an
established evaluative instrument.
Acknowledgements
I am grateful to all respondents who completed
questionnaires and to Gavin Mooney, Cam
Donaldson, Emma McIntosh, Phil Shackley and anon-
ymous referees for comments on earlier drafts of this
paper. Financial support from the Medical Research
Council (MRC) and Chief Scientist Oce of the
Scottish Oce Department of Health (SODH) are
acknowledged. The views expressed in the paper are
those of the author.
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