Wisdom of the expert crowd prediction of response for 3 neurology randomized trials.

OBJECTIVE: To explore the accuracy of combined neurology expert forecasts in predicting primary endpoints for trials. METHODS: We identified one major randomized trial each in stroke, multiple sclerosis (MS), and amyotrophic lateral sclerosis (ALS) that was closing within 6 months. After recruiting a sample of neurology experts for each disease, we elicited forecasts for the primary endpoint outcomes in the trial placebo and treatment arms. Our main outcome was the accuracy of averaged predictions, measured using ordered Brier scores. Scores were compared against an algorithm that offered noncommittal predictions. RESULTS: Seventy-one neurology experts participated. Combined forecasts of experts were less accurate than a noncommittal prediction algorithm for the stroke trial (pooled Brier score = 0.340, 95% subjective probability interval [sPI] 0.340 to 0.340 vs 0.185 for the uninformed prediction), and approximately as accurate for the MS study (pooled Brier score = 0.107, 95% confidence interval [CI] 0.081 to 0.133 vs 0.098 for the noncommittal prediction) and the ALS study (pooled Brier score = 0.090, 95% CI 0.081 to 0.185 vs 0.090). The 95% sPIs of individual predictions contained actual trial outcomes among 44% of experts. Only 18% showed prediction skill exceeding the noncommittal prediction. Independent experts and coinvestigators achieved similar levels of accuracy. CONCLUSION: In this first-of-kind exploratory study, averaged expert judgments rarely outperformed noncommittal forecasts. However, experts at least anticipated the possibility of effects observed in trials. Our findings, if replicated in different trial samples, caution against the reliance on simple approaches for combining expert opinion in making research and policy decisions.

Comparing physicians personal prevention practices and their recommendations to patients.

BACKGROUND: Hypothetical choice studies suggest that physicians often take more risk for themselves than on their patient's behalf. OBJECTIVE: To examine if physicians recommend more screening tests than they personally undergo in the real-world context of breast cancer screening. DESIGN: Within-subjects survey. PARTICIPANTS: A national sample of female obstetricians and gynecologists (N = 135, response rate 54%) from the United States. In total, they provided breast care to approximately 2,800 patients per week. MEASURES: Personal usage history and patient recommendations regarding mammography screening and breast self-examination, a measure of defensive medicine practices. RESULTS: Across age groups, female physicians were more likely to recommend mammography screening than to have performed the procedure in the past 5 years (86% vs. 81%, p = .10). In respondents aged 40-49 this difference was significant (91% vs. 82%, p < .05), whereas no differences were detected for younger or older physicians. Among respondents in their 40s, 18% had undergone annual screenings in the past 5 years, compared to 48% of their colleagues above 50. Respondents were as likely to practice breast self-examination (98%) as to recommend it (93%), a pattern that was consistent across age groups. A logistic regression model of personal use of mammography significantly predicted recommending the procedure to patients (OR = 15.29, p = .001). Similarly, number of breast self-examinations performed over the past 2 years positively predicted patient recommendations of the procedure (OR = 1.31, p < .001). CONCLUSIONS: Obstetricians and gynecologists tended to recommend early mammography screening to their patients, though their personal practices indicated later start than their own recommendations and lower frequency of screening than peers in recent studies have recommended.

The psychology of intelligence analysis: drivers of prediction accuracy in world politics.

This article extends psychological methods and concepts into a domain that is as profoundly consequential as it is poorly understood: intelligence analysis. We report findings from a geopolitical forecasting tournament that assessed the accuracy of more than 150,000 forecasts of 743 participants on 199 events occurring over 2 years. Participants were above average in intelligence and political knowledge relative to the general population. Individual differences in performance emerged, and forecasting skills were surprisingly consistent over time. Key predictors were (a) dispositional variables of cognitive ability, political knowledge, and open-mindedness; (b) situational variables of training in probabilistic reasoning and participation in collaborative teams that shared information and discussed rationales (Mellers, Ungar, et al., 2014); and (c) behavioral variables of deliberation time and frequency of belief updating. We developed a profile of the best forecasters; they were better at inductive reasoning, pattern detection, cognitive flexibility, and open-mindedness. They had greater understanding of geopolitics, training in probabilistic reasoning, and opportunities to succeed in cognitively enriched team environments. Last but not least, they viewed forecasting as a skill that required deliberate practice, sustained effort, and constant monitoring of current affairs.

CAD or MAD? Anger (not disgust) as the predominant response to pathogen-free violations of the divinity code.

The CAD triad hypothesis (Rozin, Lowery, Imada, & Haidt, 1999) stipulates that, cross-culturally, people feel anger for violations of autonomy, contempt for violations of community, and disgust for violations of divinity. Although the disgust-divinity link has received some measure of empirical support, the results have been difficult to interpret in light of several conceptual and design flaws. Taking a revised methodological approach, including use of newly validated (Study 1), pathogen-free violations of the divinity code, we found (Study 2) little evidence of disgust-related phenomenology (nausea, gagging, loss of appetite) or action tendency (desire to move away), but much evidence of anger-linked desire to retaliate, as a major component of individuals' projected response to "pure" (pathogen-free) violations of the divinity code. Study 3 replicated these results using faces in lieu of words as a dependent measure. Concordant findings emerged from an archival study (Study 4) examining the aftermath of a real-life sacred violation-the burning of Korans by U.S. military personnel. Study 5 further corroborated these results using continuous measures based on everyday emotion terms and new variants of the divinity-pure scenarios featuring sacrilegious acts committed by a theologically irreverent member of one's own group rather than an ideologically opposed member of another group. Finally, a supplemental study found the anger-dominant attribution pattern to remain intact when the impious act being judged was the judge's own. Based on these and related results, we posit anger to be the principal emotional response to moral transgressions irrespective of the normative content involved.

Putting Health Back Into Health Insurance Choice.

What are the barriers to voluntary take-up of high-deductible plans? We address this question using a large-scale employer survey conducted after an open-enrollment period in which a new high-deductible plan was first introduced. Only 3% of the employees chose this plan, despite the respondents' recognition of its financial advantages. Employees who believed that the high-deductible plan provided access to top physicians in the area were three times more likely to choose it than employees who did not share this belief. A framed field experiment using a similar choice menu showed that displaying additional financial information did not increase high-deductible plan take-up. However, when plans were presented as identical except for the deductible, respondents were highly likely to choose the high-deductible plan, especially in a two-way choice. These results suggest that informing plan choosers about high-deductible plans' health access provisions may affect choice more strongly than focusing on their financial advantages.

Psychological strategies for winning a geopolitical forecasting tournament.

Five university-based research groups competed to recruit forecasters, elicit their predictions, and aggregate those predictions to assign the most accurate probabilities to events in a 2-year geopolitical forecasting tournament. Our group tested and found support for three psychological drivers of accuracy: training, teaming, and tracking. Probability training corrected cognitive biases, encouraged forecasters to use reference classes, and provided forecasters with heuristics, such as averaging when multiple estimates were available. Teaming allowed forecasters to share information and discuss the rationales behind their beliefs. Tracking placed the highest performers (top 2% from Year 1) in elite teams that worked together. Results showed that probability training, team collaboration, and tracking improved both calibration and resolution. Forecasting is often viewed as a statistical problem, but forecasts can be improved with behavioral interventions. Training, teaming, and tracking are psychological interventions that dramatically increased the accuracy of forecasts. Statistical algorithms (reported elsewhere) improved the accuracy of the aggregation. Putting both statistics and psychology to work produced the best forecasts 2 years in a row.

Are culturally specific measures of trauma-related anxiety and depression needed? The case of Sri Lanka.

The hypothesis that psychometric instruments incorporating local idioms of distress predict functional impairment in a non-Western, war-affected population above and beyond translations of already established instruments was tested. Exploratory factor analysis was conducted on the War-Related Psychological and Behavioral Problems section of the Penn/RESIST/Peradeniya War Problems Questionnaire (PRPWPQ; N. Jayawickreme, Jayawickreme, Goonasekera, & Foa, 2009), a measure that incorporates local idioms of distress, using data from 197 individuals living in Northern and Eastern Sri Lanka. Three subscales--Anxiety, Depression, and Negative Perception--were identified. Regression analyses were conducted to test whether these 3 subscales better predicted functional impairment than the PTSD Symptom Scale-Self Report (PSS; Foa, Riggs, Dancu, & Rothbaum, 1993) and the Beck Depression Inventory (BDI; Beck & Steer, 1987), both widely used self-report measures of posttraumatic stress disorder and depression, respectively. Two of the 3 subscales from the PRPWPQ--Anxiety and Depression--were significantly associated with higher rates of functional impairment after controlling for age, the PSS and the BDI. After the inclusion of PRPWPQ, the PSS and the BDI did not significantly contribute to the final regression model predicting functional impairment. These findings suggest that the scores of measures with local idioms of distress have incremental validity in non-Western war-affected populations, predicting functional impairment above and beyond translations of established self-report measures that have been developed in the Western world.

Direct costs associated with initiating NPH insulin versus glargine in patients with type 2 diabetes: a retrospective database analysis.

AIMS: To compare total costs and risk of hypoglycemia in patients with type 2 diabetes (T2D) initiated on NPH insulin versus glargine in a real-world setting. METHODS: This study used claims data (10/2001 to 06/2005) from a privately insured U.S. population of adult T2D patients who were initiated on NPH or glargine following a 6-month insulin-free period. A sample of 1698 glargine-treated and 400 NPH-treated patients met the inclusion criteria. Total and diabetes-related costs (inflation-adjusted to 2006) were calculated for 6-month pre- and post-index periods and compared between 400 patient pairs matched by a propensity score method. RESULTS: In the post-index 6-month period, glargine patients incurred higher diabetes-related drug costs than NPH patients ($785 versus $632, p<0.0001) but there were no significant differences in diabetes-related medical or total costs, or all other total cost categories. Compared to the pre-index period, glargine patient costs declined by $2420 (p=0.058) whereas NPH patient costs declined by $4200 (p=0.046), with no statistically significant group differences (p=0.469). Among patients with hypoglycemia-related claims (0.75% in both groups), mean hypoglycemia-related costs were $85 and $202 for NPH and glargine patients, respectively (p=0.564). CONCLUSION: Initiation of either NPH or glargine was associated with major cost reductions and infrequent hypoglycemia-related claims.

Cost utility of adalimumab versus infliximab maintenance therapies in the United States for moderately to severely active Crohn's disease.

OBJECTIVE: To determine and compare the cost utilities of the tumour necrosis factor (TNF) antagonists adalimumab and infliximab as maintenance therapies for patients in the US with moderately to severely active Crohn's disease. METHODS: Maintenance regimens of adalimumab (40 mg every other week) and infliximab (5 mg/kg) were compared using primary data from the CHARM and published data from the ACCENT I clinical trials. Differences in study samples were minimized by matching and weighting baseline characteristics (Crohn's Disease Activity Index score, age and sex) between the patient groups using the primary clinical trial data. Utilization data were estimated from trial data. Unit costs of TNF antagonists (year 2007 values), hospitalizations (year 2006 values), and other medical costs (year 2006 values) were derived from a systematic literature search. Standard gamble-calculated primary data were used to derive health-utility estimates. Data were analysed in a cost-utility framework from a private payer perspective over a 56-week time horizon. Univariate and probabilistic sensitivity analyses were used to explore uncertainty related to the base-case cost-utility analysis. Given the time horizon, costs and effects were not discounted. RESULTS: Adalimumab- and infliximab-treated patients were in remission for 47.2% and 37.1% of the 56-week period, respectively. Hospital admissions were 34-40% lower for adalimumab than for infliximab, based on the model and observed data, respectively. Patients treated with adalimumab accrued greater expected QALYs (0.014; 95% CI 0.000, 0.022) and lower costs (-$US4852; 95% CI -6758, 491) in the first year of therapy than patients treated with infliximab. Compared with infliximab maintenance therapy, adalimumab had lower drug and administration costs, less drug waste, and lower hospitalization rates. Univariate and multivariate probabilistic sensitivity analyses suggested that these results were robust. CONCLUSIONS: This analysis suggests that adalimumab maintenance therapy is a dominant strategy versus infliximab maintenance therapy for patients with moderate to severe Crohn's disease. Adalimumab appeared more effective and less costly than infliximab.

Resource utilization and costs of schizophrenia patients treated with olanzapine versus quetiapine in a Medicaid population.

OBJECTIVE: Compare annual health-care costs and resource utilization associated with olanzapine versus quetiapine for treating schizophrenia in a Medicaid population. METHODS: Adult schizophrenia patients were selected from deidentified Pennsylvania Medicaid claims database (1999­2003). Included patients were continuously enrolled and initiated with olanzapine or quetiapine monotherapy after a 90-day washout period. Treatment costs were calculated for 1-year post-therapy initiation and inflation adjusted to year 2003. To control for selection bias, olanzapine and quetiapine patients were 1:1 matched using an optimal matching algorithm on propensity score, which was generated using logistic regression controlling for demographics, prior drug therapy, utilization, and costs. Treatment costs for the matched cohorts were compared directly, as well as using a difference-in-difference analysis. RESULTS: A total of 6929 patients treated with olanzapine and 2321 with quetiapine met inclusion criteria. Quetiapine patients appeared more severe at baseline. After propensity score matching, 2321 patient pairs had similar baseline characteristics, including total costs. Compared with matched quetiapine patients, for the 1-year postindex period, olanzapine patients had similar drug costs ($6131 vs. $6014, P = 0.326), lower medical costs ($9897 vs. $11,218, P = 0.0128), and lower total health-care costs ($16,028 vs. $17,232, P = 0.0279). Lower psychiatric hospitalization costs account for most of the total cost difference. Difference-in-difference regression analysis confirmed olanzapine's economic advantage. Further adjusting for baseline variations, the total cost advantage of olanzapine patients was $962 (P = 0.032), and was mostly because of reduced psychiatric hospitalization costs of $992 (P = 0.004). CONCLUSION: Schizophrenia patients treated with olanzapine had lower total costs than quetiapine patients, mostly attributable to reductions in psychiatric hospitalization costs.

Comparing the treatment patterns of patients with schizophrenia treated with olanzapine and quetiapine in the Pennsylvania Medicaid population.

OBJECTIVE: Compare treatment patterns for patients with schizophrenia treated with olanzapine versus quetiapine in the Pennsylvania Medicaid population. METHODS: Patients (18-64 years) with a diagnosis of schizophrenia (ICD-9-CM: 295.xx) and treated with olanzapine or quetiapine were identified from the Pennsylvania Medicaid claims database (1999-2003). Patients were continuously enrolled in the 12-month pre- and 12-month post-initiation periods. To control for selection bias, propensity score method with optimal matching algorithm was used to match patients from the two treatment groups. The key study outcomes including rates of augmentation, polypharmacy, discontinuation, and switching were analyzed using Kaplan-Meier survival analysis. Medication possession ratio and use of concurrent psychotropic drugs were also compared between the two groups. RESULTS: A total of 2321 quetiapine and 6929 olanzapine patients were identified. In all, 2321 pairs of patients were matched between the two groups and they had similar baseline characteristics. Over the 12-month study period, olanzapine patients had a better medication adherence (0.47 vs. 0.43; p < 0.0001), and were less likely to use other psychotropic medications concomitantly (all p < 0.05). Olanzapine patients had a significantly lower risk of augmentation and polypharmacy with other antipsychotics. The 6-month augmentation rates with antipsychotics were 12.9% and 16.7% for olanzapine and quetiapine, respectively (p < 0.05); the polypharmacy rates with any antipsychotics were 12.5% and 18.6% for olanzapine and quetiapine, respectively (p < 0.001). No significant differences were observed for discontinuation and switching between the two treatment groups. Sensitivity analysis with a 60-day minimum monotherapy requirement showed similar results. LIMITATIONS: This study's limitations include the analysis of a single Medicaid state, which may limit the generalizability to the entire Medicaid population with schizophrenia or to all patients with schizophrenia. CONCLUSION: This large Medicaid claims database analysis showed that olanzapine patients were significantly more compliant to treatment and less likely to augment or have polypharmacy with antipsychotics during the course of treatment compared to quetiapine patients.