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Willingness to pay to assess patient preferences for therapy in a Canadian setting Marra, Carlo A; Frighetto, Luciana; Goodfellow, Alan F; Wai, Amy O; Chase, MLynn; Nicol, Ruth E; Leong, Carole A; Tomlinson, Sally; Ferreira, Barbara M; Jewesson, Peter J Jun 7, 2005

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ralssBioMed CentBMC Health Services ResearchOpen AcceResearch articleWillingness to pay to assess patient preferences for therapy in a Canadian settingCarlo A Marra1,2, Luciana Frighetto1,2, Alan F Goodfellow1, Amy O Wai1,2, M Lynn Chase1, Ruth E Nicol1, Carole A Leong1, Sally Tomlinson1, Barbara M Ferreira1 and Peter J Jewesson*1,2Address: 1Pharmaceutical Sciences Clinical Service Unit, Vancouver Hospital and Health Sciences Centre, Vancouver British Columbia, Canada and 2Faculty of Pharmaceutical Sciences, Uniiversity of British Columbia, Vancouver, British Columbia, CanadaEmail: Carlo A Marra - cmarra@interchange.ubc.ca; Luciana Frighetto - luciana.frighetto@vch.ca; Alan F Goodfellow - pjj@interchange.ubc.ca; Amy O Wai - amy.wai@vch.ca; M Lynn Chase - lynn.chase@vch.ca; Ruth E Nicol - ruth.nicol@vch.ca; Carole A Leong - carole.leong@vch.ca; Sally Tomlinson - sally.tomlinson@vch.ca; Barbara M Ferreira - barb.ferreira@vch.ca; Peter J Jewesson* - pjj@interchange.ubc.ca* Corresponding author    willingness to payoutpatientintravenousantibioticsAbstractBackground: Adult outpatient parenteral antibiotic therapy (OPAT) programs have been reported in the literature for over20 years, however there are no published reports quantifying preference for treatment location of patients referred to an OPATprogram. The purpose of this study was to elicit treatment location preferences and willingness to pay (WTP) from patientsreferred to an OPAT program.Methods: A multidisciplinary, single centre, prospective study at a 1000-bed Canadian adult tertiary care teaching hospital. Thisstudy involved a WTP questionnaire that was administered over a 9-month study period. Eligible and consenting patientsreferred to the OPAT program were asked to state their preference for treatment location and WTP for a hypotheticaltreatment scenario involving intravenous antibiotic therapy. Multiple linear regression analysis was performed to determinepredictors of WTP.Results: Of 131 eligible patients, 91 completed the WTP questionnaire. The majority of participants were males, married, intheir sixth decade of life and had a secondary school education or greater. The majority of participants were retired or theywere employed with annual household incomes less than $60,000. Osteomyelitis was the most common type of infection forwhich parenteral therapy was required. Of those 87 patients who indicated a preference, 77 (89%) patients preferred treatmentat home, 10 (11%) patients preferred treatment in hospital. Seventy-one (82%) of these patients provided interpretable WTPresponses. Of these 71 patients, 64 preferred treatment at home with a median WTP of $490 CDN (mean $949, range $20 to$6250) and 7 preferred treatment in the hospital with a median WTP of $500 CDN (mean $1123, range $10 to $3000). Testsfor differences in means and medians revealed no differences between WTP values between the treatment locations. The totalWTP for the seven patients who preferred hospital treatment was $7,859 versus $60,712 for the 64 patients who preferredhome treatment. Income and treatment location preference were independent predictors of WTP.Conclusion: This study reveals that treatment at home is preferred by adult inpatients receiving intravenous antibiotic therapyPublished: 07 June 2005BMC Health Services Research 2005, 5:43 doi:10.1186/1472-6963-5-43Received: 29 December 2004Accepted: 07 June 2005This article is available from: http://www.biomedcentral.com/1472-6963/5/43© 2005 Marra et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 6(page number not for citation purposes)that are referred to our OPAT program. Income and treatment location appear to be independently associated with theirwillingness to pay.BMC Health Services Research 2005, 5:43 http://www.biomedcentral.com/1472-6963/5/43BackgroundAdult outpatient parenteral antibiotic therapy (OPAT)programs have been reported in the literature for over 20years [1]. These programs have now become an acceptedalternative to inpatient therapy for select patients andinfection types [2-4]. OPAT programs have been demon-strated to be a safe, effective and acceptable alternative tohospitalization [5-7]. Cost analysis of OPAT programs inthe U.S., Canadian and other settings have been reported[5,8-13].An adult OPAT program was implemented at our hospitalin 1995. A cost analysis performed at our institution from1995 to 1998 showed significant cost avoidance for boththe hospital and the Ministry of Health [14]. Informalpatient satisfaction surveys have shown that the programhas been well received by patients. However, there are nopublished reports quantifying preference for treatmentlocation of OPAT program patients. Willingness to pay(WTP) is a method of quantifying preference and thismethodology is gaining popularity in health care [15-19].WTP provides a measure of how much an individual val-ues a particular treatment preference.The objective of this study was to elicit hypothetical infec-tion treatment location preferences, and the willingness topay for this preferred treatment option from OPAT pro-gram referral patients.MethodsThis was conducted as a multidisciplinary, single centre,prospective study at a 1000-bed Canadian adult tertiarycare teaching hospital. Our OPAT program receives about250 patient referrals and provides approximately 3,000patient-days of outpatient parenteral therapy per year[20]. General characteristics of patients managed by thisservice are described elsewhere [14,20]. Adult patients areaccepted into the program if they had a proven or sus-pected infection requiring one or more parenteral antimi-crobials for an expected minimum duration of 5 days, aremedically stable, have an acceptable venous access, dem-onstrate a willingness and capability to perform the neces-sary self-management tasks and live in a suitable homeenvironment with access to a telephone. Once enrolled,the OPAT pharmacist and nurses provide patient teaching,insert the appropriate vascular device, liaise with commu-nity nursing personnel, coordinate delivery of drugs andsupplies and arranged appropriate patient follow up.These patients are treated in their home environment andreturn to the hospital periodically for follow-up purposesonly. Patients requiring short courses of parenteral antibi-otics are typically excluded from the program and aretreated as inpatients or managed in a hospital medicalThis study was approved by the University Ethics Com-mittee and the Hospital Research Committee.Patient enrollmentPatients referred to the OPAT program during the 9-month study (September 1999 – June 2000) were consid-ered eligible for the patient preference assessment. Forinclusion into the study, the questionnaire had to beadministered to the patient prior to assessment by theOPAT clinical staff for possible inclusion into the pro-gram. Only consenting patients were administered theWTP questionnaire. This precaution was taken to avoidthe possibility of biased responses from the participants inan attempt to obtain the treatment location of theirchoice.Willingness to payContingent valuation methodology (CVM) was used toquantitatively measure patient preference (i.e. WTP) forintravenous antibiotic treatment location [15-19]. CVM isa survey-based approach for eliciting a consumer's mone-tary valuations for program benefits for use in cost-benefitanalysis. The specific methodology employed was similarto that adopted by Donaldson et al [21]. The consumerutility being measured was compensating variation andthe survey measured WTP in the context of program avail-ability. Since the questionnaires were given to individualsundertaking the valuation who were already consumers ofthe treatment in question (i.e. were receiving parenteralantimicrobials when enrolled) and thus the primaryuncertainty at the time of the questionnaire was the prob-ability of treatment course outcomes, an ex-post perspec-tive was adopted [15,16].The WTP questionnaire consisted of two hypothetical sce-narios that were created based upon OPAT program datacollected during the period 1995–1998 (see AdditionalFile 1) [14]. Each hypothetical scenario involved an infec-tion that required a 23-day course of intravenous antibiot-ics (the average duration of therapy for patients enrolledin the OPAT program). The first scenario described a hos-pital treatment course, while the second scenariodescribed a similar treatment regimen that was adminis-tered in the home setting. Using these historic data, therisks associated with each treatment location were alsoprovided to the patient [14]. Patients were asked to specifytheir preference for treatment location based upon thesescenarios. Utilizing open-ended questions, patients wereasked to quantify their preference by stating how muchthey would be willing to pay to obtain treatment in theirpreferred location.The survey was initially designed and tested on tenPage 2 of 6(page number not for citation purposes)daycare setting. patients, four clinical nurse specialists and two infectiousdiseases specialists. We utilized comments from theseBMC Health Services Research 2005, 5:43 http://www.biomedcentral.com/1472-6963/5/43individuals to modify our survey in order to improvedreadability and understandability.Data collectionA single investigator coordinated all patient self-adminis-tered WTP questionnaires. Partial completion of the sur-veys was identified in four of the first eleven patients;thereafter, the investigator examined the questionnairesfor completeness at bedside and encouraged patients toprovide responses if necessary. If requested by the patient,the questionnaire was read aloud and the investigatorrecorded the patient's responses. In these cases, the com-pleted questionnaire was subsequently reviewed with thepatient to ensure accuracy. Demographic information,socioeconomic data, infection details and WTP for treat-ment location were collected for all patients.Data analysisMeans, medians and ranges for WTP by treatment prefer-ence location were determined. Differences in means andmedians were testing using t-tests and Mann-Whitney Utests, respectively. To estimate an overall monetary valua-tion, a total WTP was calculated for patients preferringhospital treatment and a total WTP was also calculated forthose preferring home treatment.A positive association between WTP and income wasassessed to determine the construct validity of our ques-tionnaire [22]. WTP was examined for normality usinghistograms to determine if a natural log transformationwas necessary to fit the assumptions of linear regression.Using WTP as the dependent variable, multiple linearregression was utilized. Univariate analyses were per-formed between each of the possible predictor variables(gender, marital status, level of education, employment,annual household income, infection type) and thedependent variable using ordinary least-squares linearregression.Variables associated with WTP with a p-value < = 0.10 inthe univariate analyses were considered in the multiplelinear regression models. Adjusted r2 was calculated forthe multivariable models to determine the amount of var-iance in the outcome variable explained by the predictorvariables in the final models. Among significant variables,two-way interactions were investigated. No adjustmentswere made to p-values to account for multiple compari-sons. Studentized residuals and Cook's distance wereexamined to determine if assumptions of multiple linearregression were violated. Two-sided P values are reportedfor all analyses. A p value of less than 0.05 was consideredto be statistically significant. All analyses were conductedby using SPSS, version 10.ResultsDuring the 9-month study period, 131 patients were con-sidered eligible for enrollment in the contingent valuationanalysis. Of these patients, 40 were excluded, as the inves-tigator was unavailable to conduct an interview prior tothe assessment by the OPAT team, informed consentcould not be obtained due to language barriers, decreasedcognitive status was evident or patients simply declined toparticipate. The remaining 91 patients completed the WTPquestionnaire.Patient demographics and socioeconomic status arereported in Table 1. Participants were typically marriedmales in their sixth decade of life with a secondary schooleducation or greater. The majority of participants wereretired or were employed with an annual householdTable 1: Patient demographicsParameter ValueNo. of Patients 91Mean age, years (range) 56 (25–81)GenderMale (%) 63 (69)Marital Status (%)Married 60 (66)Divorced 11 (12)Widowed 9 (10)Single 10 (12)Highest Level of Education (%)Elementary School 7 (8)Secondary School 29 (32)Trades/Technical College 34 (36)University Degree 16 (18)Post-graduate 5 (6)Employment (%)Retired 45 (49)Employed 29 (32)Unemployed 16 (18)Unknown 1 (1)Annual Household Income (%)< $20,000 22 (24)$20,000–39,999 20 (23)$40,000–59,999 22 (24)$60,000–79,999 9 (10)$80,000–99,999 3 (3)$100,000–149,000 7 (8)> $150,000 4 (4)Unknown 4 (4)Type of Infection (%)Osteomyelitis 39 (43)Infected pacemaker/wires 9 (10)Endocarditis 9 (10)Wound infection 7 (8)Abscess 6 (7)Bacteremia 4 (5)Other1 17 (17)1Page 3 of 6(page number not for citation purposes)Meningitis (3), pneumonia (4), infected graft of lower limb (2), line sepsis (2), septic arthritis (2), cellulites (1), pyelonephritis (1), CMV (1), discitis (1)BMC Health Services Research 2005, 5:43 http://www.biomedcentral.com/1472-6963/5/43income of less than $60,000. Osteomyelitis was the mostcommon type of infection for which parenteral therapywas required.Willingness to payOf the 91 patients who were enrolled in the study, 87(96%) indicated a treatment location preference while theremaining four participants had no preference. Of those87 patients who indicated a preference, 77 (89%) pre-ferred treatment at home while 10 (11%) preferred treat-ment in hospital. Seventy-one (82%) patients provided aninterpretable response regarding WTP for treatment intheir preferred location. Of those 16 patients (13 patientswith a preference for home therapy vs. 3 patient with apreference for hospital therapy) who did not provide aninterpretable response, one registered an astronomicallyhigh "protest" WTP far exceeding their ability to pay,while 15 indicated a treatment preference but provided nomonetary value.For those 71 patients who provided an interpretableresponse, 64 patients preferred treatment at home with amedian WTP of $490 CDN (mean $949, range $20 to$6250), and 7 patients preferred treatment in the hospitalwith a median WTP of $500 CDN (mean $1123, range$10 to $3000). Tests for differences in means and medi-ans revealed no statistically significant differencesbetween WTP values between the treatment locations atthe 5% level. The total WTP for the seven patients whopreferred hospital treatment was $7,859 versus $60,712for the 64 patients who preferred home treatment.The natural logarithm of WTP values approximated a nor-mal distribution, thus satisfying this assumption of linearregression (Figure 1). Only seventy-five patients (71patients with an interpretable response plus those 4patients with no treatment location preference) wereincluded in the regression analysis. Multiple linear regres-sion analysis revealed that income and treatment locationpreference were independent predictors of WTP (Table 2).There was a trend towards respondents with lowerincomes being willing to pay slightly less for their pre-ferred treatment location than those with the highestincomes (p = 0.067). In addition, people who stated pref-erences were willing to pay significantly more for thanthose who did not state a preference (p < 0.001). In themultiple linear regression model that included interactionterms (adjusted r2 = 0.543), there was also a significantinteraction between income and treatment location pref-erence such that patients with the lowest income werewilling to pay significantly more for hospital treatmentthan for home treatment (p < <0.0001). The fact that therewas a significant association between WTP and ability toDiscussionTo our knowledge, this is the first published report quan-tifying preference for treatment location in an adult OPATprogram patients using WTP.According to our WTP analysis, candidates for the pro-gram expressed an overwhelming preference for treatmentin the home setting. Our results also demonstrated thatthe WTP values were similar between those patients whopreferred to be treated at home and those who wished toremain in hospital. Accordingly, the total WTP value wasgreater (in fact, almost 8-fold greater) for those patientspreferring treatment at home. This reflects the overallmagnitude of societal preference for the management ofinfectious diseases that require intravenous therapy, butdoes not require institutionalization.There were several limitations to this study. We conductedthis trial in one adult acute care institution, thus cautionmust be exercised when attempting to generalize theresults to other health care settings involving differentpatient populations, and other infectious diseases whichwill require different treatment regimens. We relied on ahypothetical treatment scenario in our attempt to solicit apreference location and willingness to pay for this patientpopulation. As the scenario did not necessarily reflect thetreatment that they were about to receive, we must becareful in our extrapolation of the results. Although weacknowledge the potential problems with using such sce-narios in CVM, we believe that this effect was minimizedFigure 1Page 4 of 6(page number not for citation purposes)pay (i.e. higher income) validates the theoretical constructof our survey.by surveying patients who were currently experiencing aninfection that initiated a consult from the OPAT team (i.e.BMC Health Services Research 2005, 5:43 http://www.biomedcentral.com/1472-6963/5/43the ex-post perspective). We believe that most of theseindividuals would be able to realistically comprehend thehealth outcomes described in our scenarios.We also relied on open-ended technique rather than a bid-ding-game technique to solicit a WTP value. While thebidding game technique forces an upper and lower limitto the patient response and can be criticized for introduc-ing a starting point bias, the open-ended technique hasalso been questioned. As described by O'Brien and Vira-montes, patient naivety regarding health care costs due tothe Canadian universal health insurance environmentmay lead to an inability to quantify the value of anexpected health improvement [16]. The broad range ofWTP values provided by our participants may be a reflec-tion of this naivety. In addition, O'Brien and Gafni discussthat open-ended questions often elicit large numbers ofnon-responses or protest zero responses [21]. Indeed,some patients in our study expressed difficulty in placinga dollar value on their choice of treatment location. Insome cases, this appeared to be a protest against the inter-view question and reflected a concern that their responsewould be used to determine a future fee for their treat-ment preference. In other cases, this may have beenrelated to the fact that patients are not typically aware of,nor directly pay for, the costs of health care services in theCanadian health care system. Finally, WTP surveys meas-ure only what a patient claims they are willing to pay fora particular treatment. The magnitude of payment is notnecessarily an accurate reflection of what they would actu-ally be willing to pay if they were to encounter the actualscenario.As expected, ability to pay was associated with WTP andthis functioned as a confirmation of construct validity ofhealth programs and, thus, there is no "gold standard"against which one can compare WTP values [22]. It is,therefore, difficult to establish criterion validity in thiscontext.ConclusionThis study reveals that the majority, but not all, of adultinpatients receiving parenteral antibiotic therapy who arereferred to an outpatient parenteral antibiotic therapyprogram prefer to be treated at home. Income and treat-ment location appear to independently predict their will-ingness to pay.Competing interestsThis was an unfunded study. The authors declare that theyhave no competing interests.Authors' contributionsCM made substantial contributions to the conception,design, analysis and interpretation of the data; he wasinvolved in the drafting of the article and revising it criti-cally for intellectual content and has given final approvalfor the current version to be published. LF madesubstantial contributions to the conception, design, anal-ysis and interpretation of the data; she was involved in thedrafting of the article and revising it critically for intellec-tual content and has given final approval for the currentversion to be published. AG contributed to the studydesign, made substantial contributions to data collection,and assisted in the interpretation of the data; he wasinvolved in the drafting of the article, revising it, and hasgiven final approval for the current version to be pub-lished. AW contributed to the study conception, design,daily supervision of and participation in data collection,analysis and interpretation of the data; she was involvedTable 2: WTP regression analysis1,2Parameter β - coefficient p-value 95% Confidence IntervalLower UpperIntercept 0.75 0.35 -0.82 2.32Income, $ CAN 0.067≤ 20,000 -0.991 0.031 -1.89 -0.09321,000–79,000 -1.011 0.037 -1.96 -0.060≥ 80,000 ReferenceLocation preference <0.001Home 6.10 <0.001 4.58 7.54Hospital 6.13 <0.001 4.32 7.94None Reference1Dependent variable is the natural logarithm of WTP2Adjusted r2 = 0.478Page 5 of 6(page number not for citation purposes)our questionnaire. Unfortunately, as mentioned byDrummond et al, there is not an actual market for mostin the drafting of the article, revising it, and has given finalapproval for the current version to be published. LCPublish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central BMC Health Services Research 2005, 5:43 http://www.biomedcentral.com/1472-6963/5/43contributed to the study design, data collection and inter-pretation of the data; she was involved in the drafting ofthe article and has given final approval for the current ver-sion to be published. RN contributed to the study design,data collection and interpretation of the data; she wasinvolved in the drafting of the article and has given finalapproval for the current version to be published. CL con-tributed to the study design, data collection and interpre-tation of the data; she was involved in the drafting of thearticle and has given final approval for the current versionto be published. ST contributed to the study design, datacollection and interpretation of the data; she was involvedin the drafting the article and has given final approval forthe current version to be published. BF contributed to thestudy design, data collection and interpretation of thedata; she was involved in the drafting of the article and hasgiven final approval for the current version to be pub-lished. PJ was the coordinating investigator, made sub-stantial contributions to the conception, design, analysisand interpretation of the data; he was involved in thedrafting of the article and revising it critically for intellec-tual content and has given final approval for the currentversion to be published. All authors take public responsi-bility for appropriate portions of the content of the man-uscript and all authors have read and approved the finalmanuscript.Additional materialAcknowledgementsThe investigators are (or were) members of the Pharmaceutical Sciences Clinical Service Unit at VHHSC and this work was conducted as part of their professional and academic obligation to the institution, and to the patients we serve. We thank these patients, and our colleagues for their contributions to this effort.References1. Stiver HG, Telford GO, Mossey JM, Cote DD, van Middlesworth EJ,Trosky SK, McKay NL, Mossey WL: Intravenous antibiotic ther-apy at home.  Ann Intern Med 1978, 89:690-3.2. Kind AC, Williams DN, Persons G, Gibson JA: Intravenous antibi-otic therapy at home.  Arch Intern Med 1979, 139:413-5.3. Poretz DM: Home intravenous antibiotic therapy.  Clin GeriatrMed 1991, 7:749-63.4. Poretz DM, Eron LJ, Goldenberg RI, Gilbert AF, Rising J, Sparks S,Horn CE: Intravenous antibiotic therapy in an outpatientsetting.  JAMA 1982, 248:336-9.5. Grayson ML, Silvers J, Turnidge J: Home intravenous antibiotic6. Tice AD: Experience with a physician-directed, clinic-basedprogram for outpatient parenteral antibiotic therapy in theUSA.  Eur J Clin Microbiol Infect Dis 1995, 14:655-61.7. Montalto M: Patient's and carers' satisfaction with hospital-in-the-home care.  Int J Qual Health Care 1996, 8:243-51.8. Balinsky W, Nesbitt S: Cost-effectiveness of outpatientparenteral antibiotics: a review of the literature.  Am J Med1989, 87:301-5.9. Williams DN, Bosch D, Boots J, Schneider J: Safety, efficacy, andcost savings in an outpatient intravenous antibiotic program.Clin Ther 1993, 15:169-79.10. Chamberlain TM, Lehman ME, Groh MJ, Munroe WP, Reinders TP:Cost analysis of a home intravenous antibiotic program.  AmJ Hosp Pharm 1988, 45:2341-5.11. Parker SE, Nathwani D, O'Reilly D, Parkinson S, Davey PG: Evalua-tion of the impact of non-inpatient i.v. antibiotic treatmentfor acute infections on the hospital, primary care servicesand the patient.  J Antimicrobiol Chem 1998, 42:373-80.12. Thickson ND: Economics of home intravenous services.  Phar-macoeconomics 1993, 3:220-7.13. Cote D, Oruck J, Thickson N: A review of the Manitoba homei.v. antibiotic program.  Can J Hosp Pharm 1989, 42:137-41.14. Stiver G, Wai A, Chase L, Frighetto L, Marra C, Jewesson P: Outpa-tient intravenous antibiotic therapy: The Vancouver Hospi-tal experience.  Can J Infect Dis 2000, 11(Suppl A):11A-14A.15. Gafni A: Willingness to pay. What's in a name?  Pharmacoeco-nomics 1998, 14:465-70.16. O'Brien B, Viramontes JL: Willingness to pay: a valid and reliablemeasure of health state preference.  Medical Decision Making1994, 14:289-98.17. O'Brien B, Gafni A: When do the dollars make sense? Towarda conceptual framework for contingent valuation studies inhealth care.  Med Decis Making 1996, 16:288-99.18. Bala MV, Mauskopt JA, Wood LL: Willingness to pay as a meas-ure of health benefits.  Pharmacoeconomics 1999, 15:9-18.19. McIntosh E, Donaldson C, Ryan M: Recent advances in the meth-ods of cost-benefit analysis in healthcare.  Pharmacoeconomics1999, 15:357-367.20. Wai AO, Frighetto L, Marra CA, Chan E, Jewesson PJ: Cost analysisof an adult Outpatient Parenteral Antibiotic Therapy(OPAT) Programme. A Canadian teaching hospital and Min-istry of Health perspective.  Pharmacoecon 2000, 18:451-7.21. Donaldson C, Hundley V, Mapp T: Willingness to pay: A methodfor measuring preferences for maternity care?  Birth 1998,25:32-39.22. Drummond MF, O'Brien B, Stoddart GL, Torrance GW, eds: Methodsfor the Economic Evaluation of Health Care Programmes 2nd edition.Oxford University Press, Oxford; 1997. Pre-publication historyThe pre-publication history for this paper can be accessedhere:http://www.biomedcentral.com/1472-6963/5/43/prepubAdditional File 1WTP BMC HSR Version 1 PJJ appendix 1.doc. This file contains the ques-tionnaire used for this studyClick here for file[http://www.biomedcentral.com/content/supplementary/1472-6963-5-43-S1.doc]yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 6 of 6(page number not for citation purposes)therapy. A safe and effective alternative to inpatient care.Med J Aust 1995, 162:249-53.

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