BACKGROUND AND OBJECTIVE: Best-worst scaling (BWS) is a stated preference elicitation method used for prioritizing attributes of healthcare interventions. Best-worst scaling attribute development is commonly based on literature review, qualitative work, and methodological/clinical expert input. There is limited research incorporating BWS in focus groups as part of the attribute development process. We sought to explore how incorporating BWS questions using the list of potential attributes in focus groups could be used to improve understanding of patient preferences and refine the list of potential BWS attributes as part of the attribute development process. METHODS: We administered BWS questions on healthcare priorities for inflammatory bowel disease in five focus groups with Canadian patients with inflammatory bowel disease to (1) understand the "what," "how," and "why" of participant choices and (2) note how participants understand the attributes and the language they use to refine the list of potential BWS attributes. A list of 20 potential attributes was used to generate the BWS questions. We coded most/least important choices ("what") and used a thematic analysis to derive subthemes indicating "how" and "why" participants made their choices. We coded how participants understood the attributes/BWS questions and language used when discussing the attributes. RESULTS: Across the 36 participants, the most frequently chosen most/least important attributes were summarized. Three subthemes explaining the "how" and "why" of participant choices were identified: perceived gain
influence of individual experiences
current health state and personal circumstances. Participants identified challenges understanding specific attributes and BWS questions, and provided suggestions for modifications to attribute language/descriptions. Administering BWS questions in focus groups provided: (1) insight into the assumptions participants made when completing the BWS questions
(2) clarity in language and attribute descriptions, and challenges participants had when completing the BWS questions that can be used to refine the list of potential attributes as part of the attribute development process
and (3) understanding of which attributes were most/least important and why to identify potential attributes to remove during the next steps of the attribute development process. CONCLUSIONS: Best-worst scaling questions conducted within focus groups can stimulate discussions around relative importance and prioritization of attributes. Through open dialogue, this method can unveil unforeseen responses or identify areas that are unclear and enable a transparent approach to refine the list of potential attributes as part of the attribute development process.