• Elke Ge Mathijssen, Milou van Heuckelum, Liset van Dijk, Marcia Vervloet, Simone Mt Zonnenberg, Johanna E Vriezekolk, and Bart Jf van den Bemt.
• Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands, e.mathijssen@maartenskliniek.nl.
• Patient Prefer Adher. 2018 Jan 1; 12: 1537-1555.

ObjectiveTo comprehensively describe the identification, refinement, and selection of attributes and levels for a discrete choice experiment (DCE) on preferences of patients with rheumatoid arthritis (RA) regarding disease-modifying antirheumatic drugs (DMARDs).MethodsA mixed-methods approach, consisting of three consecutive steps: a literature review, expert recommendations, and focus groups. Attributes and levels were identified by a scoping review and compiled into a list that was evaluated on its relevance by an expert panel. The list that resulted thereafter was used to inform three focus groups, including 23 patients with RA. New attributes and levels could be identified during the focus groups. Also, a ranking exercise was performed. The patients individually ranked the attributes (ie, the ones on the list and newly identified attributes) by relevance. The patients' individual rankings were summed to derive a ranking at group level and make an a priori selection of the most relevant attributes. The group discussions were transcribed for qualitative analysis.ResultsNineteen attributes, each specified by two to seven levels, were identified by the scoping review. The expert recommendations resulted in the removal of one attribute. Furthermore, two new attributes and levels were identified and two attributes were split into two. One new attribute was identified during the focus groups. The results of the ranking exercise and qualitative analysis led to the refinement and selection of the following attributes: route of administration, frequency of administration, chance of efficacy, onset of action, risk of serious infections, risk of liver injury, and risk of cancer. Each attribute was specified by three levels.ConclusionThis study contributes to the limited literature on the development of attributes and levels. Future research should pay more attention to a comprehensive description of this process. It ensures transparency and thereby allows researchers to judge a DCE's quality and generalizability.

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