Societal Preferences for Subsidizing Treatments Targeting Patients With Advanced Illness: A Discrete Choice Experiment.

OBJECTIVES: Cost-effectiveness analyses are increasingly used to inform subvention decisions for moderately life extending treatments but apply several simplifying assumptions that may be inconsistent with public preferences. Contrary to standard assumptions, we hypothesize that societal willingness to allocate public funding toward these treatments is (1) diminishing for incremental improvements in survival and quality of life (QoL) and (2) greater for subvention policies that exclude the oldest old (>80 years). METHODS: We tested these hypotheses using a web-based discrete choice experiment (n = 425) in Singapore. In each of 5 questions, respondents were shown 2 hypothetical treatments targeting patients with an expected prognosis of 2 months at very poor QoL and asked which treatment they wanted the government to subsidize, if any. Treatments were defined by 4 attributes: cost to the government, age of beneficiaries, expected gain in survival (2-12 months), and QoL (poor, fair, and good). RESULTS: Latent class models were used to analyze results. Results revealed 2 classes. In the majority class (69.7% of sample), respondents value incremental gains in survival and QoL at a diminishing rate. Their willingness to allocate public funding estimates (Singapore dollars 16 825-91 027 per patient per month) were much higher than traditional cost-effectiveness thresholds. In the second class, respondents were unwilling to subsidize treatments offering less than 2 months of life extension or poor QoL. Neither class preferred subvention policies that exclude the oldest old. CONCLUSIONS: These findings suggest that the Singapore government should consider cost-effectiveness thresholds that rise with increases in life extension. Age-based restrictions should not be imposed.

Risk preferences over health: Empirical estimates and implications for medical decision-making.

Mainstream health economic theory implies that an expected gain in health-related quality of life (HRQoL) produces the same value for consumers, regardless of baseline health. Several strands of recent research call this implication into question. Generalized Risk-Adjusted Cost-Effectiveness (GRACE) demonstrates theoretically that baseline health status influences value, so long as consumers are not risk-neutral over health. Prior empirical literature casts doubt on risk-neutral expected utility-maximization in the health domain. We estimate utility over HRQoL in a nationally representative U.S. population and use our estimates to measure risk preferences over health. We find that individuals are risk-seeking at low levels of health, become risk-averse at health equal to 0.485 (measured on a 0-1 scale), and are most risk-averse at perfect health (coefficient of relative risk aversion = 4.51). We develop the resulting implications for medical decision making, cost-effectiveness analyses, and the proper theory of health-related decision making under uncertainty.

Explaining the higher COVID-19 mortality rates among disproportionately Black counties: A decomposition analysis.

Background: Why is COVID-19 mortality higher in counties with a disproportionately large (>13.4%) share of Black residents (hereafter "Black counties") relative to others ("non-Black counties")? Existing literature points to six categories of determinants: (1) social distancing, (2) COVID-19 testing, (3) socioeconomic characteristics, (4) environmental characteristics, (5) prevalence of (pre-existing) chronic health conditions, and (6) demographic characteristics. The relative importance of these determinants has not yet been thoroughly examined. Methods: We built a dataset consisting of 21 sub-indicators across the six categories of determinants for 3108 US counties and their COVID-19 mortality over the period of January 22, 2020-December 31, 2020. Applying the Gelbach's decomposition, we quantified which determinants were most (or least) associated with the COVID-19 mortality disparity between Black and non-Black counties. Results: We find that COVID-19 death rates were 26 percent higher in Black counties compared to non-Black counties. This disparity was almost completely explained by the six categories of determinants included in our model. Decomposition analyses indicate that county-level demographic and population health characteristics explained most of this disparity. Among all sub-indicators considered, the greater proportion of females and smaller proportion of rural residents in Black counties were the two largest contributors to the COVID-19 mortality gap between Black and non-Black counties. Proportions of diabetic residents, uninsured residents, and the degree of income inequality also significantly contributed to the gap in COVID-19 mortality. Conclusion: The COVID-19 mortality gap between Black and non-Black counties was largely explained by pre-pandemic differences in demographic and population health characteristics. Policies aiming to reduce the prevalence of chronic conditions and uninsured residents in Black counties would have helped narrow the COVID-19 mortality gap between Black and non-Black counties in 2020.

Explaining obesity disparities by urbanicity, 2006 to 2016: A decomposition analysis.

OBJECTIVE: A large, and potentially growing, disparity in obesity prevalence exists between large central metros and less urban United States counties. This study examines its key predictors. METHODS: Using a rich county-year data set spanning 2006 to 2016, the authors conducted a Gelbach decomposition to examine the relative importance of demographic, socioeconomic, environmental, and behavioral factors in shaping the baseline obesity gap and the growth rate over time between large central metros and other counties. RESULTS: Predictors included in this model explain almost the entire obesity gap between large central metros and other counties in the baseline year but can explain only ~32% of the growing gap. At baseline, demographic predictors explain more than half the obesity gap, and socioeconomic and behavioral predictors explain the other half. Behavioral and socioeconomic predictors explain more than half the growing gap over time whereas controlling for environmental and demographic predictors decreases the obesity gap by urbanicity over time. CONCLUSIONS: Results suggest policy makers should prioritize interventions targeting health behaviors of residents in non-large central metros to slow the growth of the obesity gap between large central metros and other counties. However, to fundamentally eliminate the obesity gap, in addition to improving health behaviors, policies addressing socioeconomic inequalities are needed.

Impact of noncommunicable diseases on direct medical costs and worker productivity, Saudi Arabia.

Background: The prevalence of noncommunicable diseases (NCDs) has been increasing in Saudi Arabia. Aims: Our objective was to estimate the effect of NCDs on direct medical costs and workforce productivity in Saudi Arabia. Methods: To estimate direct medical costs, we estimated the unit cost of treating 10 NCDs, then multiplied the unit cost by disease prevalence and summed across diseases. To estimate workforce productivity losses, we multiplied gross domestic product per person in the labour force by the loss in productivity from each NCD and the prevalence in the labour force of each NCD. Results: We estimated annual direct medical costs of 11.8 billion international dollars (Int$) for the 10 NCDs assessed (13.6% of total annual health expenditure). We estimated workforce productivity losses of Int$ 75.7 billion (4.5% of gross domestic product). Conclusion: The economic burden of NCDs in Saudi Arabia - particularly the effect on worker productivity - is substantial.

The economic burden of overweight and obesity in Saudi Arabia.

CONTEXT: The prevalence of overweight and obesity in Saudi Arabia has been rising. Although the health burden of excess weight is well established, little is known about the economic burden. AIMS: To assess the economic burden-both direct medical costs and the value of absenteeism and presenteeism-resulting from overweight and obesity in Saudi Arabia. SETTINGS AND DESIGN: The cost of overweight and obesity in Saudi Arabia was estimated from a societal perspective using an epidemiologic approach. METHODS AND MATERIALS: Data were obtained from previously published studies and secondary databases. STATISTICAL ANALYSIS USED: Overweight/obesity-attributable costs were calculated for six major noncommunicable diseases; sensitivity analyses were conducted for key model parameters. RESULTS: The impact of overweight and obesity for these diseases is found to directly cost a total of $3.8 billion, equal to 4.3 percent of total health expenditures in Saudi Arabia in 2019. Estimated overweight and obesity-attributable absenteeism and presenteeism costs a total of $15.5 billion, equal to 0.9 percent of GDP in 2019. CONCLUSIONS: Even when limited to six diseases and a subset of total indirect costs, results indicate that overweight and obesity are a significant economic burden in Saudi Arabia. Future studies should identify strategies to reduce the health and economic burden resulting from excess weight in Saudi Arabia.

Accuracy incentives and framing effects to minimize the influence of cognitive bias among advanced cancer patients.

Many patients with advanced illness have unrealistic survival expectations, largely due to cognitive biases. Studies suggests that when people are motivated to be accurate, they are less prone to succumb to these biases. Using a randomized survey design, we test whether offering advanced cancer patients (n = 200) incentives to estimate their prognosis improves accuracy. We also test whether presenting treatment benefits in terms of a loss (mortality) rather than a gain (survival) reduces willingness to take up a hypothetical treatment. Results are not consistent with the proposed hypotheses for either accuracy incentives or framing effects.

What is a Good Death? A Choice Experiment on Care Indicators for Patients at End of Life.

CONTEXT: Health systems should aim to deliver on what matters most to patients. With respect to end of life (EOL) care, knowledge on patient preferences for care is currently lacking. OBJECTIVES: To quantify preference weights for key EOL care indicators. METHODS: We developed a discrete choice experiment survey with 13 key indicators related to patients' experience in the last six weeks of life. We fielded the survey to a web-panel of caregiver proxies for recently deceased care recipients. We obtained 250 responses in each of five countries: India, Singapore, Kenya, the UK and the US. Latent-class analysis was used to evaluate preference weights for each indicator within and across countries. RESULTS: A 2-class latent-class model was the best fit. Class 1 (average class probability = 64.7%) preference weights were logically ordered and highly significant, while Class 2 estimates were generally disordered, suggesting poor data quality. Class 1 results indicated health care providers' ability to control patients' pain to desired levels was most important (11.5%, 95% CI: 10.3%-12.6%), followed by clean, safe, and comfortable facilities (10.0%, 95% CI: 9.0%-11.0%); and kind and sympathetic health care providers (9.8%, 95% CI: 8.8%-10.9%). Providers' support for nonmedical concerns had the lowest preference weight (4.4%, 95% CI: 3.6%-5.3%). Differences in preference weights across countries were not statistically significant. CONCLUSION: Results reveal that not all aspects of EOL care are equally valued. Not accounting for these differences would lead to inappropriate conclusions on how best to improve EOL care.

Cross Country Comparison of Expert Assessments of the Quality of Death and Dying 2021.

CONTEXT: Few efforts have attempted to quantify how well countries deliver end-of-life (EOL) care. OBJECTIVES: To score, grade, and rank countries (and Hong Kong and Taiwan) on the quality of EOL care based on assessments from country experts using a novel preference-based scoring algorithm. METHODS: We fielded a survey to country experts around the world, asking them to assess the performance of their country on 13 key indicators of EOL care. Results were combined with preference weights from caregiver-proxies of recently deceased patients to generate a preference-weighted summary score. The scores were then converted to grades (from A-F) and a ranking was created for all included countries. RESULTS: The final sample included responses from 181 experts representing 81 countries with 2 or more experts reporting. The 6 countries who received the highest assessment scores and a grade of A were United Kingdom, Ireland, Taiwan, Australia, Republic of Korea, and Costa Rica. Only Costa Rica (upper middle) is not a high income country. Not until Uganda (ranked 31st) does a low-income country appear on the ranking. Based on the assessment scores, twenty-one countries received a failing grade, with only two - Czech Republic (66th), and Portugal (75th) - being high income countries. CONCLUSION: This study provides an example of how a preference-based scoring algorithm and input from key stakeholders can be used to assess EOL health system performance. Results highlight the large disparities in assessments of the quality of EOL care across countries, and especially between the highest income countries and others.

Development and Validation of a Preference-Based Glaucoma Utility Instrument Using Discrete Choice Experiment.

IMPORTANCE: A glaucoma-specific instrument for estimating utilities across the spectrum of glaucoma severity is currently lacking, hindering the assessment of the cost-effectiveness of glaucoma treatments. OBJECTIVE: To develop and validate the preference-based Glaucoma Utility Instrument (Glau-U) and to ascertain the association between Glau-U utilities and severity of glaucoma and vision impairment. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was conducted in 2 stages at the Singapore National Eye Centre glaucoma clinics. Stage 1 focused on the identification and pretesting of the Glau-U attributes and was carried out between June 2009 and May 2016. Stage 2 involved the development and administration of the discrete choice experiment (DCE) survey and tasks and was conducted between May 7, 2018, and December 11, 2019. Stage 2 participants were English- or Mandarin-speaking Singaporean citizens or permanent residents of Chinese, Malay, or Indian ethnicity who were 40 years or older and had a clinical diagnosis of glaucoma in at least 1 eye. EXPOSURES: Glau-U comprised 6 quality-of-life attributes: activities of daily living, lighting and glare, movement, eye discomfort, other effects of glaucoma, and social and emotional effects. The descriptions or response options for these attributes were no difficulty or never, some difficulty or sometimes, or severe difficulty or often. MAIN OUTCOMES AND MEASURES: Utility weights for Glau-U were developed using a DCE questionnaire, which was interviewer administered to participants. Mixed logit regression determined utility weights for each health state. Glau-U utility weights across better- or worse-eye glaucoma and vision impairment severity were calculated using 1-way analysis of variance. Correlations between Glau-U utilities and better- or worse-eye visual fields and EuroQol 5-Dimension utilities were ascertained to assess convergent and divergent validity. RESULTS: Of the 304 participants (mean [SD] age, 68.3 [8.7] years; 182 men [59.9%]), 281 (92.4%) had no vision impairment in the better eye, 13 (4.3%) had mild impairment, and 10 (3.3%) had moderate to severe vision impairment. Mean (SD) Glau-U utilities decreased as better-eye glaucoma severity increased (none: 0.73 [0.21]; mild: 0.66 [0.21]; moderate: 0.66 [0.20]; severe: 0.60 [0.28]; and advanced or end-stage: 0.22 [0.38]; P < .001), representing reductions of 20.7% to 76.1% in quality-adjusted life-years compared with a health state that included preperimetric glaucoma. Mean (SD) Glau-U utilities also decreased as better-eye vision impairment worsened from 0.67 (0.23) for none to 0.58 (0.32) for mild to 0.46 (0.29) for moderate to severe vision impairment. Glau-U utilities demonstrated moderate correlations with better-eye (r = 0.34; P < .001) and worse-eye (r = 0.33; P < .001) mean deviation scores and low correlations with EuroQol 5-Dimension utilities (r = 0.22; P < .001), supporting convergent and divergent validity. CONCLUSIONS AND RELEVANCE: Use of Glau-U revealed large decrements in utility that were associated with late-stage glaucoma, suggesting that this new instrument may be useful for cost-effectiveness analyses of interventions and informing resource allocation policies for glaucoma and vision loss.

The impact of seven major noncommunicable diseases on direct medical costs, absenteeism, and presenteeism in Gulf Cooperation Council countries.

AIMS: To estimate the current burden of seven major noncommunicable diseases on direct medical costs, absenteeism, and presenteeism in the six countries in the Gulf Cooperation Council: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates. MATERIALS AND METHODS: We used data from pre-existing datasets and the literature. We identified seven major noncommunicable diseases for which data were available: coronary heart disease, stroke, type-2 diabetes mellitus, breast cancer, colon cancer, chronic obstructive pulmonary disease, and asthma. We estimated the per unit cost (the annual cost of treating each illness for one person) of each disease, multiplied per unit cost by disease prevalence counts to generate disease-specific costs, and then summed across diseases. We calculated the cost of absenteeism and presenteeism by multiplying the gross domestic product per person in the labor force by the loss in productivity from each disease due to absenteeism and presenteeism, respectively, and the prevalence in the labor force of each disease. RESULTS: We estimate that the direct medical costs of seven major noncommunicable diseases in Gulf Cooperation Council countries are $16.7 billion (2019 International $), equal to 0.6% of gross domestic product. We estimate that absenteeism and presenteeism due to these seven noncommunicable diseases cost 0.5 and 2.2% of gross domestic product, respectively. LIMITATIONS: Our study does not capture all noncommunicable diseases and does not capture all types of indirect costs. Our cost estimates are particularly sensitive to our assumptions regarding type-2 diabetes mellitus. CONCLUSION: The economic burden of noncommunicable diseases in Gulf Cooperation Council countries is substantial, suggesting that successful preventive interventions have the potential to improve both population health and reduce costs. Further research is needed to capture a broader array of noncommunicable diseases and to develop more precise estimates.

Return on Investment of Workplace Wellness Programs for Chronic Disease Prevention: A Systematic Review.

CONTEXT: Individuals with noncommunicable diseases account for a disproportionate share of medical expenditures, absenteeism, and presenteeism. Therefore, employers are increasingly looking to worksite wellness programs as a cost-containment strategy. Previous reviews examining whether worksite wellness programs deliver a positive return on investment have shown mixed results, possibly because the more optimistic findings come from studies with poorer methodologic quality. The purpose of this systematic review is to critically revisit and update this literature to explore that hypothesis. EVIDENCE ACQUISITION: A total of 4 databases were systematically searched for studies published before June 2019. Included studies were economic evaluations of worksite wellness programs that were based in the U.S., that lasted for at least 4 weeks, and that were with at least 1 behavior change component targeting 1 of the 4 primary modifiable behaviors for chronic disease: physical activity, healthy diet, tobacco use, and harmful consumption of alcohol. Methodologic quality was assessed using Consensus for Health Economic Criteria guidelines and the risk for selection bias associated with the study design. Data extraction (September 2019-February 2020) was followed by a narrative synthesis of worksite wellness programs characteristics and return on investment estimates. EVIDENCE SYNTHESIS: A total of 25 relevant studies were identified. After conducting a quality and bias assessment, only 2 of the 25 studies were found to have both high methodologic rigor and lower risk for selection bias. These studies found no evidence of a positive return on investment in the short term. CONCLUSIONS: The highest-quality studies do not support the hypothesis that worksite wellness programs deliver a positive return on investment within the first few years of initiation.

Hope, bias and survival expectations of advanced cancer patients: A cross-sectional study.

OBJECTIVE: Many patients with advanced illness are unrealistically optimistic about their prognosis. We test for the presence of several cognitive biases, including optimism bias, illusion of superiority, self-deception, misattribution, and optimistic update bias, that could explain unrealistically optimistic prognostic beliefs among advanced cancer patients and quantifies the extent to which hope exacerbates these biases. METHODS: A cross-sectional survey was administered to 200 advanced cancer patients with physician-estimated prognoses of one year or less. Hope was measured using the Herth Hope Index (HHI). Hypotheses were tested using linear and logistic regressions and a structural-equation model. RESULTS: Results are consistent with the presence of optimism bias, illusion of superiority, self-deception, and misattribution. All of these biases are amplified by higher levels of hope. Each 1-point higher HHI is associated with a 6% (OR: 1.06; 95% CI: 1.01-1.11) greater odds of believing their illness is curable, a 0.33-year (95% CI: 0.17-0.49) longer expected survival, a 6% (OR: 1.06; 95% CI: 1.02-1.11) higher probability of believing that survival outcomes are better than the average patient, a 5% higher odds of believing primary intent of treatment is curative (OR: 1.05; 95% CI: 1.00-1.10), and a 12% (OR: 1.12; 95% CI: 1.05-1.17) higher odds of believing they are well-informed. Mediation analyses revealed that hope significantly mediates the effect of mental-well-being and loneliness on expected survival. CONCLUSIONS: Results suggest advanced cancer patients succumb to several cognitive biases which are exacerbated by greater levels of hope. As a result, they are susceptible to possible over-treatment and regret.

Patient Preferences for Medications in Managing Type 2 Diabetes Mellitus: A Discrete Choice Experiment.

OBJECTIVES: To quantify patients' maximum acceptable risk (MAR) of urinary and genital tract infections (UGTI) in exchange for benefits associated with treatments for managing type 2 diabetes mellitus (T2DM). METHODS: In a discrete choice experiment, adult patients with T2DM and currently on metformin and/or sulphonylurea (first-line treatments) were asked to choose between 2 hypothetical medications defined by 6 attributes: years of medication effectiveness in controlling blood glucose, weight reduction, UGTI risk, risk of hospitalization from heart failure, all-cause mortality risk, and out-of-pocket medication cost. We used latent class logistic regression parameters to estimate the conditional relative importance of treatment attributes and MAR of UGTI for various treatment benefits. RESULTS: A 2-class latent class model was identified as the best fit for the responses from 147 patients. The first class (49% of sample), termed as "survival-conscious," stated that they were willing to accept 46% (95% confidence interval [CI]: 2%-90%) UGTI risk in exchange for a reduction from 6% to 1% in all-cause mortality risk. The second class (51% of sample), termed as "UGTI/cost-conscious" were willing to accept significantly lower (6%; CI: 2%-11%, and 5%; CI: 2%-8%) UGTI risk in exchange for the same reduction in all-cause mortality and hospitalization risks, respectively. CONCLUSIONS: On average, patients were willing to trade higher UGTI risk for a more effective medication. Our findings suggest that physicians should present the benefits and potential side effects of all available treatments and consider patient preferences in their treatment recommendations.

Family caregivers of advanced cancer patients: self-perceived competency and meaning-making.

BACKGROUND: Family caregivers of patients with advanced cancer have been reported to provide long hours of care and be at risk for poor psychological outcomes. Although research has focused on the nature of caregiving burden, little attention has been paid to identifying protective factors that improve caregiver psychological outcomes. AIM: We examined the relationship between caregivers' time spent caregiving and the following psychological outcomes: anxiety, depression and caregiving esteem. Subsequently, we explored the main and moderating effects of caregiver-perceived self-competency and sense of meaning on caregiver psychological outcomes. DESIGN/PARTICIPANTS: Cross-sectional analysis was conducted using the baseline data from an ongoing cohort study. Family caregivers of advanced cancer patients (n=287) were recruited from two tertiary hospitals in Singapore. RESULTS: Time spent caregiving was not significantly associated with caregiver anxiety, depression or caregiving esteem. However, significant main effects of self-competency on anxiety and caregiving esteem; and sense of meaning on anxiety, depression and caregiving esteem were observed. Moderator analyses further indicated that self-competency attenuated the positive relationship between time spent caregiving and anxiety, while sense of meaning attenuated the negative relationship between time spent caregiving and caregiving esteem. CONCLUSION: Greater perceived self-competency and sense of meaning are related to better caregiver psychological outcomes, and protect caregivers from worsening outcomes as caregiving hours increase. Our findings suggest that screening caregivers for distress is an important part of care, and that supportive interventions for caregivers should aim to enhance their perceived caregiving competencies and the ability to make meaning of their caregiving role.

Effectiveness and cost-effectiveness of incentives as a tool for prevention of non-communicable diseases: A systematic review.

The rising epidemic of non-communicable diseases (NCDs) poses substantial health and economic challenges to both individuals and society. Application of incentive-based strategies based on traditional and behavioural economic theory has emerged as a potential strategy to address rising rates of NCDs. Yet, whether or not incentives truly represent a promising strategy for addressing NCDs has not been systematically addressed nor is it clear whether certain behavioural economic strategies outperform others or simply offering a cash-based incentive for meeting a goal. In this systematic review we aim to determine whether there is an evidence base for any of these strategies. Forty-eight published randomized controlled trials (70 contrasts) evaluating the effectiveness of incentive-based strategies for improvements in NCD risk-factors were reviewed. Our primary conclusion is that there is a lack of compelling evidence that incentives of any form represent a compelling NCD reduction strategy. More evidence for long-term effectiveness and cost-effectiveness is needed to justify third party funding of any incentive based strategy.