Present bias and health

The hidden cost of sophistication: economic complexity and obesity

Obesity has become a global health crisis, affecting people of all ages, regions, and socio-economic backgrounds. While individual behaviour and genetic factors contribute to obesity, the role of economic complexity in the evolution of obesity rates has not yet been empirically studied. Using a large panel of 110 countries over the period 1976-2015, this article estimates the linear and non-linear links between obesity and economic complexity. According to baseline results, an improvement in economic complexity will lead to an increase in obesity up to a certain threshold. Beyond this turning point, any further increase in economic complexity will significantly contribute to obesity reduction. The issue of simultaneity is tackled using the two-stage instrumental variable method. Our findings support the Obesity Kuznets Curve (OKC) pattern, which suggests that economic progress and obesity have an inverted U-shaped relationship. Our results suggest that greater embeddedness of knowledge in the products produced and exported by a country increases the likelihood of obesity in society, at least up to a threshold. From these results, some important policy implications are discussed.

Results From a Pilot Study of an Automated Directly Observed Therapy Intervention Using Artificial Intelligence With Conditional Economic Incentives Among Young Adults With HIV

BACKGROUND

Despite improvements in antiretroviral therapy (ART) availability, suboptimal adherence is common among youth with HIV (YWH) and can increase drug resistance and poor clinical outcomes. Our study examined an innovative mobile app-based intervention that used automated directly observed therapy (aDOT) using artificial intelligence, along with conditional economic incentives (CEIs) to improve ART adherence and enhance viral suppression among YWH.

SETTING

We conducted a pilot study of the aDOT-CEI intervention, informed by the operant framework of Key Principles in Contingency Management Implementation, to improve ART adherence among YWH (18-29) in California and Florida who had an unsuppressed HIV viral load.

METHODS

We recruited 28 virally unsuppressed YWH from AIDS Healthcare Foundation clinics, who used the aDOT platform for 3 months. Study outcomes included feasibility and acceptability, self-reported ART adherence, and HIV viral load.

RESULTS

Participants reported high satisfaction with the app (91%), and 82% said that it helped them take their medication. Comfort with the security and privacy of the app was moderate (55%), and 59% indicated the incentives helped improve daily adherence.

CONCLUSIONS

Acceptability and feasibility of the aDOT-CEI intervention were high with potential to improve viral suppression, although some a priori metrics were not met. Pilot results suggest refinements which may improve intervention outcomes, including increased incentive amounts, provision of additional information, and reassurance about app privacy and security. Additional research is recommended to test the efficacy of the aDOT-CEI intervention to improve viral suppression in a larger sample.

Ethical considerations in the use of RhD-positive blood products in trauma

BACKGROUND

Prehospital and early in-hospital use of low titer group O whole blood (LTOWB) for life-threatening bleeding has been independently associated with improved survival compared to component therapy. However, when RhD-positive blood products are administered to RhD-negative females of childbearing potential (FCP), there is a small future risk of hemolytic disease of the fetus and newborn (HDFN). This raises important ethical questions that must be explored in order to justify the use of RhD-positive blood products, including LTOWB, both in clinical practice and research.

METHODS

This essay explores the ethical challenges related to RhD-positive blood product administration to RhD-negative or RhD-unknown FCPs as a first-line resuscitation fluid in the trauma setting. These ethical issues include: issues related to decision-making, ethical analysis based on the doctrine of double effect (DDE), and attendant obligations incurred by hospitals that administer RhD-positive blood to FCPs.

RESULTS

Ethical analysis through the use of the DDE demonstrates that utilization of RhD-positive blood products, including LTOWB, in the early resuscitation of FCPs is an ethically appropriate approach. By accepting the risk of HDFN, hospitals generate obligations to promote blood donation, evaluate for alloimmunization and counsel patients on the future risk of HDFN, and maintain an understanding of the ethical rationale for RhD-positive blood transfusion.

Factors associated with medication adherence among older adults with multimorbidity: A culture perspective

Multimorbidity is a healthcare concern. To manage diseases, older adults with multimorbidity are expected to practice health behaviors, particularly medication adherence. Studies have examined adherence issues in older patients with multiple diseases, but it remains unclear which factors affect medication adherence. Therefore, this study aimed to identify the factors affecting medication adherence among older adults with multimorbidity. The participants were recruited from the outpatient departments of two hospitals in the Republic of Korea using convenience sampling. Data were collected using structured questionnaires and analyzed using multiple regression analysis. The results showed that those with a lower education level, no side effects, better health literacy, higher medication self-efficacy, and more social support exhibited better medication adherence. In addition, beliefs about medication were not related to medication adherence. These results suggest that providing individualized education, strengthening social support, and decreasing harmful side effects can improve medication adherence.

Giving more detailed information about health insurance encourages consumers to choose compromise options

Introduction

To investigate how the provision of additional information about the health events and procedures covered by a healthcare plan affect the level of coverage chosen by young adults taking their first full time job.

Methods

University students were recruited for a study at two behavioral laboratories (one located at the University of Toronto and the other located at INSEAD-Sorbonne University in Paris) in which they imagine they are making choices about the healthcare coverage associated with the taking a new job in Chicago, Illinois. Every participant made choices in four categories: Physician Care, Clinical Care, Hospital Care, and Dental Care. Participants were randomly assigned to one of two conditions: Low Detail or High Detail coverage information and they chose between three levels of coverage: Basic, Enhanced, and Superior. The study took place in March 2017 with 120 students in Toronto and 121 students in Paris.

Results

The provision of more detailed information about the health events and procedures covered by a healthcare plan leads to a compromise effect in which participants shift their choices significantly towards Enhanced (moderate coverage) from Basic (low coverage) and Superior (high coverage). The compromise effect was observed at both locations; however, Paris participants choose significantly higher levels of coverage than Toronto participants.

Discussion

Providing more detail to employees about the health events and procedures covered by a healthcare plan will increase the fraction of employees who choose the intermediate level of coverage. It is beyond the scope of this study to conclude whether this is good or bad; however, in a context where employees gravitate to either insufficient or excessive coverage, providing additional detail may reduce these tendencies.

Time Matters: Time Perspectives Predict Intertemporal Prosocial Preferences

The study utilizes the Chinese version of the Zimbardo Time Perspective Inventory (ZTPI-C) and a novelty intertemporal prosocial discounting paradigm to explore the preferences of individuals with the Present Impulsive Time Perspective (PITP) and the Future Time Perspective (FTP) in intertemporal prosocial choices, and uncovers the cognitive mechanisms underpinning intertemporal altruism from the personality traits. The findings revealed: (1) The donation behaviors of both groups decreased as time delay rose, aligning with the hyperbolic model. (2) PITP individuals had significantly higher discount rates than those with FTP, and the scores of FTP individuals on the "Future" dimension of the ZTPI-C were positively correlated with the amount of money they were willing to forgo. These results suggest that time perspective, as a stable personality trait, can predict individuals' intertemporal prosocial preferences. Our research enriches the theory of intertemporal choices and extends the Perceived-time-based model (PTBM) to the domain of intertemporal social preferences.

Heuristics and biases in medical decision-making under uncertainty: The case of neuropronostication for consciousness disorders

Neuropronostication for consciousness disorders can be very complex and prone to high uncertainty. Despite notable advancements in the development of dedicated scales and physiological markers using innovative paradigms, these technical progressions are often overshadowed by factors intrinsic to the medical environment. Beyond the scarcity of objective data guiding medical decisions, factors like time pressure, fatigue, multitasking, and emotional load can drive clinicians to rely more on heuristic-based clinical reasoning. Such an approach, albeit beneficial under certain circumstances, may lead to systematic error judgments and impair medical decisions, especially in complex and uncertain environments. After a brief review of the main theoretical frameworks, this paper explores the influence of clinicians' cognitive biases on clinical reasoning and decision-making in the challenging context of neuroprognostication for consciousness disorders. The discussion further revolves around developing and implementing various strategies designed to mitigate these biases and their impact, aiming to enhance the quality of care and the patient safety.

A qualitative exploration of health-related present bias among HIV-positive adults in Uganda

Decision-making errors such as present bias (PB) can have important consequences for health behaviors, but have been largely studied in the financial domain. We conducted a mixed-method study on PB in the context of ART adherence among clinic-enrolled adults in Uganda (n = 39). Specifically, we quantified PB by asking about preferences between medication available sooner to minimize headaches versus available later to cure headaches. We describe demographic similarities among PB participants and qualitatively explored how participants reflected on their PB (or absence thereof) in the context of health. Participants reporting PB were predominantly male, single/unmarried, older, had higher levels of education and income and more advanced HIV progression. Three common reasons for more present-biased choices provided were: (1) wanting to avoid pain, (2) wanting to return to work, and (3) fear of one's health worsening if s/he did not address their illness immediately. While PB in the financial domain often suggests that poorer individuals are more likely to prefer immediate rewards over their wealthier counterparts, our results suggest poor health is potentially a driving factor of PB. Further research is needed to build on these finding and inform how programs can frame key messages regarding ART adherence to patients displaying PB.Trial registration: ClinicalTrials.gov identifier: NCT03494777.

Time and risk preferences and the perceived effectiveness of incentives to comply with diabetic retinopathy screening among older adults with type 2 diabetes

Behavioral economics has the potential to inform the design of incentives to improve disease screening programs by accounting for various behavioral biases. We investigate the association between multiple behavioral economics concepts and the perceived effectiveness of incentive strategies for behavioral change among older patients with a chronic disease. This association is examined by focusing on diabetic retinopathy screening, which is recommended but very variably followed by persons living with diabetes. Five time and risk preference concepts (i.e., utility curvature, probability weighting, loss aversion, discount rate, and present-bias) are estimated simultaneously in a structural econometric framework, based on a series of deliberately-designed economic experiments offering real money. We find that higher discount rates and loss aversion and lower probability weighting are significantly associated with lower perceived effectiveness of intervention strategies whereas present-bias and utility curvature have an insignificant association with it. Finally, we also observe strong urban vs. rural heterogeneity in the association between our behavioral economic concepts and the perceived effectiveness of intervention strategies.

Lottery incentives for smoking cessation at the workplace: design and protocol of the smoke-free lottery - a cluster randomized trial

BACKGROUND

Smoking is the leading behavioral risk factor for the loss of healthy life years. Many smokers want to quit, but have trouble doing so. Financial incentives in workplace settings have shown promising results in supporting smokers and their design influences their impact. Lotteries that leverage behavioral economic insights might improve the effectiveness of workplace cessation support.

METHODS AND DESIGN

We examine in a cluster randomized trial if a workplace cessation group training paired with lottery deadlines will increase continuous abstinence rates over and above the cessation training alone. Organizations are randomized to either the control arm or lottery arm. The lotteries capitalize regret aversion by always informing winners at the deadline, but withholding prizes if they smoked. In the lottery-arm, winners are drawn out of all participants within a training group, regardless of their smoking status. In weeks 1-13 there are weekly lotteries. Winners are informed about their prize (€50), but can only claim it if they did not smoke that week, validated biochemically. After 26 weeks, there is a long-term lottery where the winners are informed about their prize (vacation voucher worth €400), but can only claim it if they were abstinent between weeks 13 and 26. The primary outcome is continuous abstinence 52 weeks after the quit date.

DISCUSSION

There is a quest for incentives to support smoking cessation that are considered fair, affordable and effective across different socioeconomic groups. Previous use of behavioral economics in the design of lotteries have shown promising results in changing health behavior. This cluster randomized trial aims to demonstrate if these lotteries are also effective for supporting smoking cessation. Therefore the study design and protocol are described in detail in this paper. Findings might contribute to the application and development of effective cessation support at the workplace.

TRIAL REGISTRATION

Netherlands Trial Register Identifier: NL8463 . Date of registration: 17-03-2020.

Time preference, illness, and death

This paper investigates the power of time preference to predict illness and premature mortality in adulthood. Using a unique Swedish cohort of 12,956 individuals born in 1953, interviewed in 1966, and followed with register data up to 2018, the paper reports that more patient adolescents are 17-21% less likely to die before the age of 65 years. More patient adolescents have fewer hospitalizations and diagnoses in their adult life and are less likely to be diagnosed with conditions associated with lifestyle risk factors. The investigated channels for the relationship between time preference and future health include lifestyle, education attainment, and future income. Controlling for education and income reduces the coefficient for time preference on premature mortality by one-fourth.

A novel behavioral science-based health checkup program and subsequent metabolic risk reductions in a workplace: Checkup championship

The effectiveness of general health checkups and lifestyle counseling has been questioned. This study examined whether a workplace health promotion program implemented during a health checkup was associated with metabolic syndrome-related indicators. Hakuhodo DY group, one of Japan's largest advertising agencies, implemented a behavioral science-based program called "Checkup Championship" (Kenshin-sen in Japanese) in 2019, in which all employees could voluntarily participate. We studied 3697 employees (2818 men and 879 women, mean age: 40.7 years), consisting of 1509 program participants and 2188 non-participants. The characteristics of participants and non-participants were balanced using inverse probability weighting. We used their data from the health checkups in 2018 and 2019 together with other covariates and performed a difference-in-differences analysis using a linear mixed model. After program implementation, greater reductions were observed among participants compared with non-participants in weight (-0.66 kg, 95% confidence interval: -0.84 to -0.47), body mass index (-0.23 kg/m², -0.29 to -0.16), waist circumference (-0.67 cm, -0.91 to -0.43), systolic blood pressure (-1.13 mmHg, -2.10 to -0.16), and diastolic blood pressure (-0.84 mmHg, -1.53 to -0.15). In addition, we observed greater reductions in weight, body mass index, waist circumference, and low-density lipoprotein cholesterol among participants who were with two or more risk factors for metabolic syndrome than other participants. We found that participation in a health checkup program based on behavioral science was associated with reduced metabolic syndrome-related indicators. There may be room for improvement in the effectiveness of general health checkups.

Investigating Rewards and Deposit Contract Financial Incentives for Physical Activity Behavior Change Using a Smartphone App: Randomized Controlled Trial

BACKGROUND

Financial incentive interventions for improving physical activity have proven to be effective but costly. Deposit contracts (in which participants pledge their own money) could be an affordable alternative. In addition, deposit contracts may have superior effects by exploiting the power of loss aversion. Previous research has often operationalized deposit contracts through loss framing a financial reward (without requiring a deposit) to mimic the feelings of loss involved in a deposit contract.

OBJECTIVE

This study aimed to disentangle the effects of incurring actual losses (through self-funding a deposit contract) and loss framing. We investigated whether incentive conditions are more effective than a no-incentive control condition, whether deposit contracts have a lower uptake than financial rewards, whether deposit contracts are more effective than financial rewards, and whether loss frames are more effective than gain frames.

METHODS

Healthy participants (N=126) with an average age of 22.7 (SD 2.84) years participated in a 20-day physical activity intervention. They downloaded a smartphone app that provided them with a personalized physical activity goal and either required a €10 (at the time of writing: €1=US $0.98) deposit up front (which could be lost) or provided €10 as a reward, contingent on performance. Daily feedback on incentive earnings was provided and framed as either a loss or gain. We used a 2 (incentive type: deposit or reward) × 2 (feedback frame: gain or loss) between-subjects factorial design with a no-incentive control condition. Our primary outcome was the number of days participants achieved their goals. The uptake of the intervention was a secondary outcome.

RESULTS

Overall, financial incentive conditions (mean 13.10, SD 6.33 days goal achieved) had higher effectiveness than the control condition (mean 8.00, SD 5.65 days goal achieved; P=.002; ηp2=0.147). Deposit contracts had lower uptake (29/47, 62%) than rewards (50/50, 100%; P<.001; Cramer V=0.492). Furthermore, 2-way analysis of covariance showed that deposit contracts (mean 14.88, SD 6.40 days goal achieved) were not significantly more effective than rewards (mean 12.13, SD 6.17 days goal achieved; P=.17). Unexpectedly, loss frames (mean 10.50, SD 6.22 days goal achieved) were significantly less effective than gain frames (mean 14.67, SD 5.95 days goal achieved; P=.007; ηp2=0.155).

CONCLUSIONS

Financial incentives help increase physical activity, but deposit contracts were not more effective than rewards. Although self-funded deposit contracts can be offered at low cost, low uptake is an important obstacle to large-scale implementation. Unexpectedly, loss framing was less effective than gain framing. Therefore, we urge further research on their boundary conditions before using loss-framed incentives in practice. Because of limited statistical power regarding some research questions, the results of this study should be interpreted with caution, and future work should be done to confirm these findings.

TRIAL REGISTRATION

Open Science Framework Registries osf.io/34ygt; https://osf.io/34ygt.

Lay perceptions of diabetes mellitus and prevention costs and benefits among adults undiagnosed with the condition in Singapore: a qualitative study

Background

Therapeutic lifestyle changes can reduce individual risk of type 2 diabetes (T2D) by up to 58%. In Singapore, rates of preventive practices were low, despite a high level of knowledge and awareness of T2D risk and prevention. The study explored the context of the discrepancy between knowledge and practices in T2D prevention among adults undiagnosed with the condition.

Methods

In-depth interviews with 41 adults explored lay beliefs of T2D and the sources of these perceptions, subjective interpretation of how T2D may impact lives, and perceived costs and benefits of practising preventative behaviours. Purposive sampling was used to maximise the variability of participants in demographic characteristics. Thematic analysis was conducted to identify themes related to the domains of inquiry.

Results

Participants’ risk perceptions were influenced by familial, social, and cultural contexts of the representation and management of T2D conditions. The adverse effects of T2D were often narrated in food culture. The cost of adopting a healthy diet was perceived at a high cost of life pleasure derived from food consumption and social interactions. Inconveniences, loss of social functions, dependency and distress were the themes related to T2D management. Participants’ motivation to preventive practices, such as exercise and weight loss, were influenced by short-term observable benefits.

Conclusions

T2D risk communication needs to be addressed in emotionally impactful and interpersonally salient ways to increase the urgency to adopt preventative behaviours. Shifting perceived benefits from long-term disease prevention to short-term observable wellbeing could reduce the response cost of healthy eating.

The Effect of a Future-Self Avatar Mobile Health Intervention (FutureMe) on Physical Activity and Food Purchases: Randomized Controlled Trial

BACKGROUND

Insufficient physical activity and unhealthy diets are contributing to the rise in noncommunicable diseases. Preventative mobile health (mHealth) interventions may help reverse this trend, but present bias might reduce their effectiveness. Future-self avatar interventions have resulted in behavior change in related fields, yet evidence of whether such interventions can change health behavior is lacking.

OBJECTIVE

We aimed to investigate the impact of a future-self avatar mHealth intervention on physical activity and food purchasing behavior and examine the feasibility of a novel automated nutrition tracking system. We also aimed to understand how this intervention impacts related attitudinal and motivational constructs.

METHODS

We conducted a 12-week parallel randomized controlled trial (RCT), followed by semistructured interviews. German-speaking smartphone users aged ≥18 years living in Switzerland and using at least one of the two leading Swiss grocery loyalty cards, were recruited for the trial. Data were collected from November 2020 to April 2021. The intervention group received the FutureMe intervention, a physical activity and food purchase tracking mobile phone app that uses a future-self avatar as the primary interface and provides participants with personalized food basket analysis and shopping tips. The control group received a conventional text- and graphic-based primary interface intervention. We pioneered a novel system to track nutrition by leveraging digital receipts from loyalty card data and analyzing food purchases in a fully automated way. Data were consolidated in 4-week intervals, and nonparametric tests were conducted to test for within- and between-group differences.

RESULTS

We recruited 167 participants, and 95 eligible participants were randomized into either the intervention (n=42) or control group (n=53). The median age was 44 years (IQR 19), and the gender ratio was balanced (female 52/95, 55%). Attrition was unexpectedly high with only 30 participants completing the intervention, negatively impacting the statistical power. The FutureMe intervention led to small statistically insignificant increases in physical activity (median +242 steps/day) and small insignificant improvements in the nutritional quality of food purchases (median -1.28 British Food Standards Agency Nutrient Profiling System Dietary Index points) at the end of the intervention. Intrinsic motivation significantly increased (P=.03) in the FutureMe group, but decreased in the control group. Outcome expectancy directionally increased in the FutureMe group, but decreased in the control group. Leveraging loyalty card data to track the nutritional quality of food purchases was found to be a feasible and accepted fully automated nutrition tracking system.

CONCLUSIONS

Preventative future-self avatar mHealth interventions promise to encourage improvements in physical activity and food purchasing behavior in healthy population groups. A full-powered RCT is needed to confirm this preliminary evidence and to investigate how future-self avatars might be modified to reduce attrition, overcome present bias, and promote sustainable behavior change.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04505124; https://clinicaltrials.gov/ct2/show/NCT04505124.

Diabetes And The Fragmented State Of US Health Care And Policy

Progress in the prevention and treatment of type 2 diabetes-the dominant form of diabetes-appears to have stalled in the US over the past decade, and diabetes-related morbidity has increased nationally. The most geographically and socioeconomically disadvantaged segments of the population have been especially hard hit, and interventions that reduce the risk for diabetes have not reached these populations. In this overview article we lay out how fragmentation in health policy and governance, payers and reimbursement design, and service delivery in the US has contributed to low accountability and coordination, and thus stagnation and persistent inequities. We also review the evidence regarding past, ongoing, and new reforms that may help address fragmentation, lower diabetes burdens, and narrow disparities.

Boosting healthier choices

Thomas Rouyard and colleagues discuss use of the boosting approach as an alternative to nudging in developing non-coercive interventions to promote health

Patient-reported Reasons for Stopping Care or Switching Clinics in Zambia: A Multisite, Regionally Representative Estimate Using a Multistage Sampling-based Approach in Zambia

BACKGROUND

Understanding patient-reported reasons for lapses of retention in human immunodeficiency virus (HIV) treatment can drive improvements in the care cascade. A systematic assessment of outcomes among a random sample of patients lost to follow-up (LTFU) from 32 clinics in Zambia to understand the reasons for silent transfers and disengagement from care was undertaken.

METHODS

We traced a simple random sample of LTFU patients (>90 days from last scheduled visit) as determined from clinic-based electronic medical records from a probability sample of facilities. Among patients found in person, we solicited reasons for either stopping or switching care and predictors for re-engagement. We coded reasons into structural, psychosocial, and clinic-based barriers.

RESULTS

Among 1751 LTFU patients traced and found alive, 31% of patients starting antiretroviral therapy (ART) between 1 July 2013 and 31 July 2015 silently transferred or were disengaged (40% male; median age, 35 years; median CD4 level, 239 cells/μL); median time on ART at LTFU was 480 days (interquartile range, 110-1295). Among the 544 patients not in care, median prevalences for patient-reported structural, psychosocial, and clinic-level barriers were 27.3%, 13.9%, and 13.4%, respectively, and were highly variable across facilities. Structural reasons, including, "relocated to a new place" were mostly cited among 289 patients who silently transferred (35.5%). We found that men were less likely to re-engage in care than women (odds ratio, .39; 95% confidence interval, .22-.67; P = .001).

CONCLUSIONS

Efforts to improve retention of patients on ART may need to be tailored at the facility level to address patient-reported barriers.

Using Community-Based Prevention Marketing to Generate Demand for Healthy Diets in Jordan

Jordan has been experiencing a nutrition transition with high rates of micronutrient deficiencies and rising overweight and obesity rates. This highlights the need to generate demand for healthy diets. This study used a community-based prevention marketing approach and worked with local communities as partners to develop a set of behavior change interventions to improve healthy eating within vulnerable communities. Individual, family, and paired-friendship interviews, and co-creation workshops were conducted with 120 people. The aim of these interviews was to gain an in-depth understand of school-aged children and their families’ nutrition knowledge, attitudes, and practices, including social and cultural norms and behavioral determinants, and then use this information to co-create interventions, activities and materials targeted at supporting school-aged child nutrition. Analysis of the interviews revealed that dietary habits are both deeply personal and profoundly entwined by emotions and social norms, and that parents often gave in to their children’s demands for unhealthy foods and beverages due to their perception of what a ‘good parent’ looks like and the desire to see their child ‘smile’. These key insights were then shared during the co-creation workshops to develop behavior change interventions—ensuring that interventions were developed by the community, for the community.

The link between health and economic preferences: Evidence from 22 OECD countries

We study the link between health status and economic preferences using survey data from 22 Organisation for Economic Co-operation and Development (OECD) countries. We hypothesize that there is a relationship between poor health and the preferences that people hold, and therefore their choices and decisions. We find that individuals with a limiting health condition are more risk averse and less patient, and that this is true for physical and mental health conditions. The magnitudes of the health gap are approximately 60% and 70% of the gender gap in risk and time preferences, respectively. Importantly, the health gaps are large for males, females, young, old, school dropouts, degree holders, employed, nonemployed, rich, and poor. They also hold for countries with different levels of gross domestic product (GDP), inequality, social expenditure, and disease burden.

Oral or Topical Pain Therapy-How Would Patients Decide? A Discrete Choice Experiment in Patients with Peripheral Neuropathic Pain

To ensure an adequate pain therapy with high patient adherence, it is necessary to know and consider patient preferences. A discrete choice experiment was used to obtain patients' preferences regarding treatment with systemic or topical pain medication. Patients with peripheral neuropathic pain (pNP) were recruited in two pain-focused practices in Germany. To identify relevant attributes of topical or systemic pain medication, a literature review and face-to-face interviews with experts for pain treatment were conducted. The attributes used in the choice scenarios were noticeable onset of effect, time spent in medical office, risk of systemic and local side effects, and impairment of daily life with regard to sleep quality and sexuality. The model was estimated with a mixed multinomial logit regression model. The study included 153 participants suffering from moderate to severe pNP. Most important attributes from patient's perspective was noticeable onset of effect (odds ratio 2.141 [95% confidence interval 1.837 to 2.494]), followed by risk of systemic side effects (2.038 [1.731 to 2.400]) and risk of sexual dysfunction (1.839 [1.580 to 2.140]), while risk of local side effects regarding skin ranked fourth (1.612 [1.321 to 1.966]). The impairment of sleep quality was also significant but less important (1.556 [1.346 to 1.798]). Local side effects were more likely to be accepted than systemic side effects. The risk of sexual dysfunction as a side effect of treatment is very important for patients, although it has received little attention in the literature.

A COVID-19-Based Modified Epidemiological Model and Technological Approaches to Help Vulnerable Individuals Emerge from the Lockdown in the UK

COVID-19 has shown a relatively low case fatality rate in young healthy individuals, with the majority of this group being asymptomatic or having mild symptoms. However, the severity of the disease among the elderly as well as in individuals with underlying health conditions has caused significant mortality rates worldwide. Understanding this variance amongst different sectors of society and modelling this will enable the different levels of risk to be determined to enable strategies to be applied to different groups. Long-established compartmental epidemiological models like SIR and SEIR do not account for the variability encountered in the severity of the SARS-CoV-2 disease across different population groups. The objective of this study is to investigate how a reduction in the exposure of vulnerable individuals to COVID-19 can minimise the number of deaths caused by the disease, using the UK as a case study. To overcome the limitation of long-established compartmental epidemiological models, it is proposed that a modified model, namely SEIR-v, through which the population is separated into two groups regarding their vulnerability to SARS-CoV-2 is applied. This enables the analysis of the spread of the epidemic when different contention measures are applied to different groups in society regarding their vulnerability to the disease. A Monte Carlo simulation (100,000 runs) along the proposed SEIR-v model is used to study the number of deaths which could be avoided as a function of the decrease in the exposure of vulnerable individuals to the disease. The results indicate a large number of deaths could be avoided by a slight realistic decrease in the exposure of vulnerable groups to the disease. The mean values across the simulations indicate 3681 and 7460 lives could be saved when such exposure is reduced by 10% and 20% respectively. From the encouraging results of the modelling a number of mechanisms are proposed to limit the exposure of vulnerable individuals to the disease. One option could be the provision of a wristband to vulnerable people and those without a smartphone and contact-tracing app, filling the gap created by systems relying on smartphone apps only. By combining very dense contact tracing data from smartphone apps and wristband signals with information about infection status and symptoms, vulnerable people can be protected and kept safer.

Impact of a Multicomponent Digital Therapeutic Mobile App on Medication Adherence in Patients with Chronic Conditions: Retrospective Analysis

BACKGROUND

Strategies to improve medication adherence are widespread in the literature; however, their impact is limited in real practice. Few patients persistently engage long-term to improve health outcomes, even when they are aware of the consequences of poor adherence. Despite the potential of mobile phone apps as a tool to manage medication adherence, there is still limited evidence of the impact of these innovative interventions. Real-world evidence can assist in minimizing this evidence gap.

OBJECTIVE

The objective of this study was to analyze the impact over time of a previously implemented digital therapeutic mobile app on medication adherence rates in adults with any chronic condition.

METHODS

A retrospective observational study was performed to assess the adherence rates of patients with any chronic condition using Perx Health, a digital therapeutic that uses multiple components within a mobile health app to improve medication adherence. These components include gamification, dosage reminders, incentives, educational components, and social community components. Adherence was measured through mobile direct observation of therapy (MDOT) over 3-month and 6-month time periods. Implementation adherence, defined as the percentage of doses in which the correct dose of a medication was taken, was assessed across the study periods, in addition to timing adherence or percentage of doses taken at the appropriate time (±1 hour). The Friedman test was used to compare differences in adherence rates over time.

RESULTS

We analyzed 243 and 130 patients who used the app for 3 months and 6 months, respectively. The average age of the 243 patients was 43.8 years (SD 15.5), and 156 (64.2%) were female. The most common medications prescribed were varenicline, rosuvastatin, and cholecalciferol. The median implementation adherence was 96.6% (IQR 82.1%-100%) over 3 months and 96.8% (IQR 87.1%-100%) over 6 months. Nonsignificant differences in adherence rates over time were observed in the 6-month analysis (Fr(2)=4.314, P=.505) and 3-month analysis (Fr(2)=0.635, P=.728). Similarly, the timing adherence analysis revealed stable trends with no significant changes over time.

CONCLUSIONS

Retrospective analysis of users of a medication adherence management mobile app revealed a positive trend in maintaining optimal medication adherence over time. Mobile technology utilizing gamification, dosage reminders, incentives, education, and social community interventions appears to be a promising strategy to manage medication adherence in real practice.

Lower socioeconomic status predicts higher mortality and morbidity in patients with heart failure

OBJECTIVE

It is not fully understood whether and how socioeconomic status (SES) has a prognostic impact in patients with heart failure (HF). We assessed SES and its association with patient characteristics and outcomes in a contemporary and well-characterised HF cohort.

METHODS

Socioeconomic risk factors (SERF) were defined in the Swedish HF Registry based on income (low vs high according to the annual median value), education level (no degree/compulsory school vs university/secondary school) and living arrangement (living alone vs cohabitating).

RESULTS

Of 44 631 patients, 21% had no, 33% one, 30% two and 16% three SERF. Patient characteristics strongly and independently associated with lower SES were female sex and no specialist referral. Additional independent associations were older age, more severe HF, heavier comorbidity burden, use of diuretics and less use of HF devices. Lower SES was associated with higher risk of HF hospitalisation/mortality, and overall cardiovascular and non-cardiovascular events. These associations persisted after extensive adjustment for patient characteristics, treatments and care. The magnitude of the association increased linearly with the increasing number of coexistent SERF: HR (95% CI) 1.09 (1.05 to 1.13) for one, 1.16 (1.12 to 1.20) for two and 1.22 (1.18 to 1.28) for three SERF (p<0.01).

CONCLUSIONS

In a contemporary and well-characterised HF cohort and after comprehensive adjustment for confounders, lower SES was linked with multiple factors such as less use of HF devices and age, but most strongly with female sex and lack of specialist referral; and associated with greater risk of morbidity/mortality.

Time preferences and their life outcome correlates: Evidence from a representative survey

We collect data on time preferences of a representative sample of the Hungarian adult population in a non-incentivized way and investigate how patience and present bias associate with important life outcomes in five domains: i) educational attainment, ii) unemployment, iii) income and wealth, iv) financial decisions and difficulties, and v) health. Based on the literature, we formulate the broad hypotheses that patience relates positively, while present bias associates negatively with positive outcomes in the domains under study. With the exception of unemployment, we document a consistent and often significant positive relationship between patience and the corresponding domain, with the strongest associations in educational attainment, wealth and financial decisions. We find that present bias associates significantly with saving decisions and financial difficulties.

Examining the effect of underlying individual preferences for present over future on lung cancer screening participation: a cross-sectional analysis of a Korean National Cancer Screening Survey

OBJECTIVES

This study aimed to examine the effect of underlying individual preferences for the present over that for the future on lung cancer screening participation.

SETTING

We analysed the data from the Korean National Cancer Screening Survey in 2018.

PARTICIPANTS

4500 adults aged 20-74 years old participated in the study.

DESIGN

In this cross-sectional survey, multivariate logistic regression analysis was carried out to examine the association between subjects' intention to participate in lung cancer screening and individual preferences. The underlying individual preferences were measured on the basis of the self-reported general willingness to spend money now in order to save money in the future and general preferences with regard to financial planning.

PRIMARY OUTCOME MEASURE

Intention to participate in lung cancer screening.

RESULTS

Individuals eligible for lung cancer screening who place less value on their future were around four times less likely to report an intention to participate in lung cancer screening than were those who valued their future (OR 3.86, 95% CI 1.89 to 7.90). A present-biassed individual (one with a tendency for immediate gratification) was also about four times less likely to report an intention to participate in screening than an individual with no present bias (OR 0.26, 95% CI 0.12 to 0.57).

CONCLUSIONS

Underlying individual preferences regarding the present and future significantly affect individuals' intention to participate in lung cancer screening. Hence, provision of incentives may be necessary to encourage the targeted heavy smokers who may have a strong preferences for the present over future.

Cost-effectiveness of a Stepwise Approach vs Standard Care for Diabetes Prevention in India

IMPORTANCE

A stepwise approach that includes screening and lifestyle modification followed by the addition of metformin for individuals with high risk of diabetes is recommended to delay progression to diabetes; however, there is scant evidence regarding whether this approach is cost-effective.

OBJECTIVE

To estimate the cost-effectiveness of a stepwise approach in the Diabetes Community Lifestyle Improvement Program.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation study included 578 adults with impaired glucose tolerance, impaired fasting glucose, or both. Participants were enrolled in the Diabetes Community Lifestyle Improvement Program, a randomized clinical trial with 3-year follow-up conducted at a diabetes care and research center in Chennai, India.

INTERVENTIONS

The intervention group underwent a 6-month lifestyle modification curriculum plus stepwise addition of metformin; the control group received standard lifestyle advice.

MAIN OUTCOMES AND MEASURES

Cost, health benefits, and incremental cost-effectiveness ratios (ICERs) were estimated from multipayer (including direct medical costs) and societal (including direct medical and nonmedical costs) perspectives. Costs and ICERs were reported in 2019 Indian rupees (INR) and purchasing power parity-adjusted international dollars (INT $).

RESULTS

The mean (SD) age of the 578 participants was 44.4 (9.3) years, and 364 (63.2%) were men. Mean (SD) body mass index was 27.9 (3.7), and the mean (SD) glycated hemoglobin level was 6.0% (0.5). Implementing lifestyle modification and metformin was associated with INR 10 549 (95% CI, INR 10 134-10 964) (INT $803 [95% CI, INT $771-834]) higher direct costs; INR 5194 (95% CI, INR 3187-INR 7201) (INT $395; 95% CI, INT $65-147) higher direct nonmedical costs, an absolute diabetes risk reduction of 10.2% (95% CI, 1.9% to 18.5%), and an incremental gain of 0.099 (95% CI, 0.018 to 0.179) quality-adjusted life-years per participant. From a multipayer perspective (including screening costs), mean ICERs were INR 1912 (INT $145) per 1 percentage point diabetes risk reduction, INR 191 090 (INT $14 539) per diabetes case prevented and/or delayed, and INR 196 960 (INT $14 986) per quality-adjusted life-year gained. In the scenario of a 50% increase or decrease in screening and intervention costs, the mean ICERs varied from INR 855 (INT $65) to INR 2968 (INT $226) per 1 percentage point diabetes risk reduction, from INR 85 495 (INT $6505) to INR 296 681 (INT $22 574) per diabetes case prevented, and from INR 88 121 (INT $6705) to INR 305 798 (INT $23 267) per quality-adjusted life-year gained.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that a stepwise approach for diabetes prevention is likely to be cost-effective, even if screening costs for identifying high-risk individuals are added.

Time preferences, diabetes self-management behaviours and outcomes: a systematic review

AIM

Time preferences, i.e. individuals' degree of patience/impatience in intertemporal choice, have been found to be associated with suboptimal health behaviours and health outcomes such as smoking, physical inactivity, unhealthy food intake and obesity. In this systematic review, we aimed to synthesise reported associations between time preferences, diabetes self-management behaviours, including use of diabetes technology, and outcomes.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, EconLit and all databases in the Web of Science Core Collection. Peer-reviewed studies of people with diabetes that included at least one diabetes-related behaviour or outcome and a measure of time preferences were included. Non-English language studies were excluded.

RESULTS

A total of 961 records were identified, of which 12 articles were included. Three studies analysed both time-consistent and time-inconsistent preferences, three studies solely analysed time-inconsistent preferences and six studies did not explicitly define a time preference model. Measured outcomes across studies included self-care activities, such as medication-taking, exercising and eating a healthy diet, and biomedical outcomes, such as HbA_1c and diabetes-related complications. There were 10 cross-sectional studies and two panel-data studies. No studies explicitly analysed the relationship between time preferences and diabetes technology use.

CONCLUSIONS

Associations between measures of time preferences, diabetes self-management behaviours and clinical outcomes exist. Higher discount rates determined by both time-consistent and time-inconsistent models predict less diabetes-related self-care and worse outcomes. These findings may add to explanations of the observed variation in diabetes-related health and provide new insights for tailoring interventions and policies aimed at improving diabetes self-management.