Caroline Rudisill

Optimism and the perceptions of new risks.

While many risks, especially new ones, are not objectively quantifiable, individuals still form perceptions of risks using incomplete or unclear evidence about the true nature of those risks. In the case of well known risks, such as smoking, individuals perceive risks to be smaller for themselves than others, exhibiting ‘optimism bias’. Although existing evidence supports optimism bias occurring in the case of risks about which individuals are familiar, evidence does not yet exist to suggest that optimism bias applies for new risks. This paper addresses this question by examining the gap in perceptions of risks individuals have for themselves versus society and the environment, conceptualised as social and/or environmental optimism biases. We draw upon the 2002 UEA‐MORI Risk Survey to examine the existence of optimism bias and its effects on risk perceptions and acceptance regarding five science and technology‐related topics: climate change, mobile phones, radioactive waste, GM food and genetic testing. Our findings provide evidence of social and environmental optimism bias following similar patterns and optimism bias appearing greater for those risks bringing sizeable benefit to individuals (e.g. mobile phone radiation) rather than those more acutely affecting society or the environment (e.g. GM food or climate change). Social optimism bias is found to reduce risk perceptions for risks that have received large amounts of media attention, namely, climate change and GM food. On the other hand, optimism bias appears to increase risk perceptions about genetic testing.

Coding, Recording and Incidence of Different Forms of Coronary Heart Disease in Primary Care

Objectives To evaluate the coding, recording and incidence of coronary heart disease (CHD) in primary care electronic medical records. Methods Data were drawn from the UK General Practice Research Database. Analyses evaluated the occurrence of 271 READ medical diagnostic codes, including categories for ‘Angina’, ‘Myocardial Infarction’, ‘Coronary Artery Bypass Grafting’ (CABG), ‘percutaneous transluminal coronary angioplasty’ (PCTA) and ‘Other Coronary Heart Disease’. Time-to-event analyses were implemented to evaluate occurrences of different groups of codes after the index date. Results Among 300,020 participants aged greater than 30 years there were 75,197 unique occurrences of coronary heart disease codes in 24,244 participants, with 12,495 codes for incident events and 62,702 for prevalent events. Among incident event codes, 3,607 (28.87%) were for angina, 3,262 (26.11%) were for MI, 514 (4.11%) for PCTA, 161 (1.29%) for CABG and 4,951 (39.62%) were for ‘Other CHD’. Among prevalent codes, 20,254 (32.30%) were for angina, 3,644 (5.81%) for MI, 34,542 (55.09%) for ‘Other CHD’ and 4,262 (6.80%) for CABG or PCTA. Among 3,685 participants initially diagnosed exclusively with ‘Other CHD’ codes, 17.1% were recorded with angina within 5 years, 5.6% with myocardial infarction, 6.3% with CABG and 8.6% with PCTA. From 2000 to 2010, the overall incidence of CHD declined, as did the incidence of angina, but the incidence of MI did not change. The frequency of CABG declined, while PCTA increased. Conclusion In primary care electronic records, a substantial proportion of coronary heart disease events are recorded with codes that do not distinguish between different clinical presentations of CHD. The results draw attention to the need to improve coding practice in primary care. The results also draw attention to the importance of code selection in research studies and the need for sensitivity analyses using different sets of codes.

Attitudes as an Expression of Knowledge and “Political Anchoring”: The Case of Nuclear Power in the United Kingdom

Attitudes toward the use of nuclear energy pose fundamental issues in the political debate about how to meet future energy needs. Development of new nuclear power facilities faces significant opposition both from knowledgeable individuals who display an understanding of the risks attached to various forms of power generation and those who follow strict politically based ideological dogmas. This article employs data from a 2005 Eurobarometer survey of UK citizens to examine the influence of both political preferences and knowledge in explaining support of nuclear power. Findings reveal that attitudes about nuclear power are highly politically motivated while the influence of knowledge about radioactive waste is dependent upon beliefs about the consequences of nuclear energy use. Perceptions of being informed about radioactive waste and trust in sources providing information about radioactive waste management also predict attitudes toward nuclear power generation.

Incidence of type 2 diabetes after bariatric surgery: population-based matched cohort study

BACKGROUND The effect of currently used bariatric surgical procedures on the development of diabetes in obese people is not well defined. We aimed to assess the effect of bariatric surgery on development of type 2 diabetes in a large population of obese individuals. METHODS We did a matched cohort study of adults (age 20–100 years) identified from a UK-wide database of family practices, who were obese (BMI ≥30 kg/m2) and did not have diabetes. We enrolled 2167 patients who had undergone bariatric surgery between Jan 1, 2002, and April 30, 2014, and matched them--according to BMI, age, sex, index year, and HbA1c--with 2167 controls who had not had surgery. Procedures included laparoscopic gastric banding (n=1053), gastric bypass (795), and sleeve gastrectomy (317), with two procedures undefined. The primary outcome was development of clinical diabetes, which we extracted from electronic health records. Analyses were adjusted for matching variables, comorbidity, cardiovascular risk factors, and use of antihypertensive and lipid-lowering drugs. FINDINGS During a maximum of 7 years of follow-up (median 2·8 years [IQR 1·3–4·5]), 38 new diagnoses of diabetes were made in bariatric surgery patients and 177 were made in controls. By the end of 7 years of follow-up, 4·3% (95% CI 2·9–6·5) of bariatric surgery patients and 16·2% (13·3–19·6) of matched controls had developed diabetes. The incidence of diabetes diagnosis was 28·2 (95% CI 24·4–32·7) per 1000 person-years in controls and 5·7 (4·2–7·8) per 1000 person-years in bariatric surgery patients; the adjusted hazard ratio was 0·20 (95% CI 0·13–0·30, p<0·0001). This estimate was robust after varying the comparison group in sensitivity analyses, excluding gestational diabetes, or allowing for competing mortality risk. INTERPRETATION Bariatric surgery is associated with reduced incidence of clinical diabetes in obese participants without diabetes at baseline for up to 7 years after the procedure. FUNDING UK National Institute for Health Research.

Impact of deprivation on occurrence, outcomes and health care costs of people with multiple morbidity

Objective This study aimed to estimate the impact of deprivation on the occurrence, health outcomes and health care costs of people with multiple morbidity in England. Methods Cohort study in the UK Clinical Practice Research Datalink, using deprivation quintile (IMD2010) at individual postcode level. Incidence and mortality from diabetes mellitus, coronary heart disease, stroke and colorectal cancer, and prevalence of depression, were used to define multidisease states. Costs of health care use were estimated for each state from a two-part model. Results Data were analysed for 141,535 men and 141,352 women aged ≥30 years, with 33,862 disease incidence events, and 13,933 deaths. Among incidences of single conditions, 22% were in the most deprived quintile and 19% in the least deprived; dual conditions, most deprived 26%, least deprived 16% and triple conditions, most deprived 29%, least deprived 14%. Deaths in participants without disease were distributed most deprived 22%, least deprived 19%; in participants with single conditions, most deprived 24%, least deprived 18%; dual conditions, most deprived 27%, least deprived 15%, and triple conditions, most deprived 33%, least deprived 17%. The relative rate of depression in most deprived participants with triple conditions, compared with least deprived and no disease, was 2.48 (1.74 to 3.54). Costs of health care use were associated with increasing deprivation and level of morbidity. Conclusions The higher incidence of disease, associated with deprivation, channels deprived populations into categories of multiple morbidity with a greater prevalence of depression, higher mortality and higher costs. This has implications for the way that resources are allocated in England’s National Health Service.

Are healthcare costs from obesity associated with body mass index, comorbidity or depression? Cohort study using electronic health records

The objective of this study was to evaluate the association between body mass index (BMI) and healthcare costs in relation to obesity‐related comorbidity and depression. A population‐based cohort study was undertaken in the UK Clinical Practice Research Datalink (CPRD). A stratified random sample was taken of participants registered with general practices in England in 2008 and 2013. Person time was classified by BMI category and morbidity status using first diagnosis of diabetes (T2DM), coronary heart disease (CHD), stroke or malignant neoplasms. Participants were classified annually as depressed or not depressed. Costs of healthcare utilization were calculated from primary care records with linked hospital episode statistics. A two‐part model estimated predicted mean annual costs by age, gender and morbidity status. Linear regression was used to estimate the effects of BMI category, comorbidity and depression on healthcare costs. The analysis included 873 809 person‐years (62% female) from 250 046 participants. Annual healthcare costs increased with BMI, to a mean of £456 (95% CI 344–568) higher for BMI ≥40 kg m−2 than for normal weight based on a general linear model. After adjusting for BMI, the additional cost of comorbidity was £1366 (£1269–£1463) and depression £1044 (£973–£1115). There was evidence of interaction so that as the BMI category increased, additional costs of comorbidity (£199, £74–£325) or depression (£116, £16–£216) were greater. High healthcare costs in obesity may be driven by the presence of comorbidity and depression. Prioritizing primary prevention of cardiovascular disease and diabetes in the obese population may contribute to reducing obesity‐related healthcare costs.

Costs and Outcomes of Increasing Access to Bariatric Surgery: Cohort Study and Cost-Effectiveness Analysis Using Electronic Health Records

Objectives To estimate costs and outcomes of increasing access to bariatric surgery in obese adults and in population subgroups of age, sex, deprivation, comorbidity, and obesity category. Methods A cohort study was conducted using primary care electronic health records, with linked hospital utilization data, for 3,045 participants who underwent bariatric surgery and 247,537 participants who did not undergo bariatric surgery. Epidemiological analyses informed a probabilistic Markov model to compare bariatric surgery, including equal proportions with adjustable gastric banding, gastric bypass, and sleeve gastrectomy, with standard nonsurgical management of obesity. Outcomes were quality-adjusted life-years (QALYs) and net monetary benefits at a threshold of £30,000 per QALY. Results In a UK population of 250,000 adults, there may be 7,163 people with morbid obesity including 1,406 with diabetes. The immediate cost of 1,000 bariatric surgical procedures is £9.16 million, with incremental discounted lifetime health care costs of £15.26 million (95% confidence interval £15.18–£15.36 million). Patient-years with diabetes mellitus will decrease by 8,320 (range 8,123–8,502). Incremental QALYs will increase by 2,142 (range 2,032–2,256). The estimated cost per QALY gained is £7,129 (range £6,775–£7,506). Net monetary benefits will be £49.02 million (range £45.72–£52.41 million). Estimates are similar for subgroups of age, sex, and deprivation. Bariatric surgery remains cost-effective if the procedure is twice as costly, or if intervention effect declines over time. Conclusions Diverse obese individuals may benefit from bariatric surgery at acceptable cost. Bariatric surgery is not cost-saving, but increased health care costs are exceeded by health benefits to obese individuals.

Pathos & ethos: emotions and willingness to pay for tobacco products

In this article we use data from a multi-country Randomized Control Trial study on the effect of anti-tobacco pictorial warnings on an individual’s emotions and behavior. By exploiting the exogenous variations of images as an instrument, we are able to identify the effect of emotional responses. We use a range of outcome variables, from cognitive (risk perception and depth of processing) to behavioural (willingness to buy and willingness to pay). Our findings suggest that the odds of buying a tobacco product can be reduced by 80% if the negative affect elicited by the images increases by one standard deviation. More importantly from a public policy perspective, not all emotions behave alike, as eliciting shame, anger, or distress proves more effective in reducing smoking than fear and disgust. JEL Classification C26, C99, D03, I18 PsycINFO classification 2360; 3920

Provider incentives and prescribing behavior in Europe

European policy makers have increasingly moved from primarily focusing on supply-side regulation of pharmaceutical costs to offering incentives for providers’ prescribing behavior. The nature and implementation of these provider-focused policies are as diverse as the health systems in which they are enacted. Some policies have undergone significant alteration since their initial implementation as health system design has changed and experience has yielded greater knowledge of the types of policy that achieve results in practice. Evaluation of prescribing incentive policies in several European countries is constrained by a lack of comprehensive information systems tracking prescriptions. Analysis of policy experience suggests that policy ought to be formulated with clarity and transparency of objectives, also keeping in mind the ethical concerns associated with rewards and fines for prescribing levels when the professional aspirations of doctors include maintenance of quality care and some degree of autonomous decision making.

How do we handle new health risks? Risk perception, optimism, and behaviors regarding the H1N1 virus

During Autumn 2009, individuals worldwide were confronted with a new risk, the H1N1 (swine flu) virus and vaccination programs aimed at reducing this risk. We examine the hypothesis that risk perceptions for H1N1 as well as optimism about one’s own chances of contracting H1N1 vs. those of others would impact intentions to get vaccinated against the virus as well as avoidance behaviors such as avoiding air travel, public places where people gather, and those exhibiting flu-like symptoms. To examine this hypothesis, this study uses a survey of 944 residents of Great Britain taken from 2 to 8 October 2009 by Ipsos MORI, prior to the start of the National Health Service (NHS) swine flu vaccination campaign. Controlling for respondents’ personal characteristics as well as their risk perceptions for a familiar risk (food poisoning), we find that higher perceptions about the risk of H1N1 for oneself, trust in the NHS, avoiding those with flu-like symptoms, and having an at-risk condition for H1N1 are all significant and positive predictors of intent to vaccinate against the virus. While 42% of the sample exhibited optimism about their personal risk of contracting H1N1 relative to that of the average UK resident, optimism did not predict vaccination intentions, or avoidance behaviors. Higher risk perceptions for oneself regarding susceptibility to H1N1 as well as knowing friends who have had H1N1 and having an at-risk condition for H1N1 were associated with undertaking avoidance behaviors in general and a higher number of them. We conclude that for a risk about which individuals have limited reference points and great uncertainty because of the new nature of the risk, optimism does not influence the likelihood of associated preventive or avoidance behaviors as individuals rely on their risk perceptions only about themselves.