Accounting for repeat intervention costs in the economic comparison of laser interstitial thermal therapy and anterior temporal lobectomy for treatment of refractory temporal lobe epilepsy.

OBJECTIVE: Laser interstitial thermal therapy (LITT) is an alternative to anterior temporal lobectomy (ATL) for the treatment of temporal lobe epilepsy that has been found by some to have a lower procedure cost but is generally regarded as less effective and sometimes results in a subsequent procedure. The goal of this study is to incorporate subsequent procedures into the cost and outcome comparison between ATL and LITT. METHODS: This single-center, retrospective cohort study includes 85 patients undergoing ATL or LITT for temporal lobe epilepsy during the period September 2015 to December 2022. Of the 40 patients undergoing LITT, 35 % (N = 14) underwent a subsequent ATL. An economic cost model is derived, and difference in means tests are used to compare the costs, outcomes, and other hospitalization measures. RESULTS: Our model predicts that whenever the percentage of LITT patients undergoing subsequent ATL (35% in our sample) exceeds the percentage by which the LITT procedure alone is less costly than ATL (7.2% using total patient charges), LITT will have higher average patient cost than ATL, and this is indeed the case in our sample. After accounting for subsequent surgeries, the average patient charge in the LITT sample ($103,700) was significantly higher than for the ATL sample ($88,548). A second statistical comparison derived from our model adjusts for the difference in effectiveness by calculating the cost per seizure-free patient outcome, which is $108,226 for ATL, $304,052 for LITT only, and $196,484 for LITT after accounting for the subsequent ATL surgeries. SIGNIFICANCE: After accounting for the costs of subsequent procedures, we found in our cohort that LITT is not only less effective but also results in higher average costs per patient than ATL as a first course of treatment. While cost and effectiveness rates will vary across centers, we also provide a model for calculating cost effectiveness based on individual center data.

Does Trust Always Help Gender Role Attitudes? The Role of Individualism and Collectivism.

Social trust has a complex interrelationship with attitudes toward gender equality. Social trust has its origins in exchange relationships in preindustrial societies, lowering uncertainty in transactions and easing interpersonal exchanges. The degree to which this trust was extended to opportunities for women in commercial and societal roles, however, differed across cultures. Prior literature finds attitudes toward individualism and collectivism have significant implications for gender equality and patriarchal attitudes. We combine these ideas arguing that the degree to which social trust fosters gender equality depends upon the degrees of individualism and collectivism. Employing World Values Survey data across countries over time, we find that with low levels of individualism, and high degrees of collectivism, higher levels of trust are not effective in reducing the prevalence of gendered patriarchal attitudes-in fact it entrenches them further, worsening gender equality. However, as individualism rises, and collectivism falls, higher levels of trust become effective in reducing the prevalence of patriarchal beliefs. Thus, collectivistic beliefs stand as a barrier to future improvements in women's equality and economic rights in many societies; preventing social trust from being extended beyond traditional gendered roles.

Marginal decision-making in the treatment of refractory epilepsy.

OBJECTIVE: Epilepsy surgery is one of the most effective treatments in modern medicine. Yet, it remains largely under-utilized, in spite of its proven efficacy. The referrals for epilepsy surgery are often delayed until it is too late to prevent the detrimental psychosocial effects of refractory seizures. The reluctance towards epilepsy surgery is influenced by the perceived risks of the procedure by practitioners and patients. This review discusses how, in general decision-making processes, one faces a natural tendency towards emphasizing the risks of the most immediate and operational decision (surgery), at times without contrasting these risks with the alternative (uncontrolled epilepsy). METHODS: In the field of economics, this bias is well recognized and can be overcome through marginal analysis, formally defined as focusing on incremental changes as opposed to absolute levels. RESULTS: Regarding epilepsy surgery, the risks and benefits of surgery are considered separately from the risks of uncontrolled epilepsy. For instance, even though surgery carries an ∼0.1-0.5% risk of perioperative mortality, the chance of sudden unexpected death with refractory epilepsy can be as high as 0.6-0.9% per year. It is suggested that the inadequate way of phrasing clinical questions can be a crucial contributing factor for the under-utilization of epilepsy surgery. SIGNIFICANCE: It is proposed that examining decision-making for epilepsy surgery in the context of marginal analysis may enable providers and patients to make more accurate informed decisions.

Setting Win Limits: An Alternative Approach to "Responsible Gambling"?

Social scientists, governments, and the casino industry have all emphasized the need for casino patrons to "gamble responsibly." Strategies for responsible gambling include self-imposed time limits and loss limits on gambling. Such strategies help prevent people from losing more than they can afford and may help prevent excessive gambling behavior. Yet, loss limits also make it more likely that casino patrons leave when they are losing. Oddly, the literature makes no mention of "win limits" as a potential approach to responsible gambling. A win limit would be similar to a loss limit, except the gambler would leave the casino upon reaching a pre-set level of winnings. We anticipate that a self-imposed win limit will reduce the gambler's average loss and, by default, also reduce the casino's profit. We test the effect of a self-imposed win limit by running slot machine simulations in which the treatment group of players has self-imposed and self-enforced win and loss limits, while the control group has a self-imposed loss limit or no limit. We find that the results conform to our expectations: the win limit results in improved player performance and reduced casino profits. Additional research is needed, however, to determine whether win limits could be a useful component of a responsible gambling strategy.