Do Misconceptions About Health-Related Quality of Life Affect General Population Valuations of Health States?

OBJECTIVES: Healthcare resource allocation decisions are often informed by the expected gains in patients' quality-adjusted life-years. Misconceptions about ill-health's consequences for quality of life (QOL) may however affect evaluations of health states by the general population and hence affect resource allocation decisions informed by quality-adjusted life-years. We examine whether people selectively misestimate the QOL consequences of moderate anxiety or depression compared with other dimensions of health, and we test whether informing people of actual changes in QOL associated with health states changes appraisals of their relative undesirability. METHODS: UK general population participants (N = 1259; in 2017) expressed preferences over moderate problems: anxiety or depression, self-care, and pain or discomfort. A randomized control trial design was used whereby a control group was given a functional description of each health state, and 2 intervention groups were additionally given information on the actual differences in either life satisfaction (LS) or day affect (DA) associated with experiencing each health state. RESULTS: The LS (DA) group reported a higher preference for avoiding living with moderate anxiety or depression, being 13.4% (13.9%) more likely to choose it as most undesirable. CONCLUSION: Informing people of the change in LS or DA associated with health states before they appraise them is a feasible way to obtain informed preferences.

Combined chemotherapy and endoscopic ultrasound-guided intratumoral 32P implantation for locally advanced pancreatic adenocarcinoma: a pilot study.

BACKGROUND: This study evaluated clinical outcomes of combined chemotherapy and endoscopic ultrasound (EUS)-guided intratumoral radioactive phosphorus-32 (32P) implantation in locally advanced pancreatic adenocarcinoma (LAPC). METHODS: Consecutive patients with newly diagnosed LAPC were recruited over 20 months. Baseline computed tomography and 18F-2-fluoro-2-deoxy-D-glucose (18FDG) positron emission tomography-computed tomography were performed and repeated after 12 weeks to assess treatment response. Following two cycles of conventional chemotherapy, patients underwent EUS-guided 32P implantation followed by six chemotherapy cycles. RESULTS: 12 patients with LAPC (median age 69 years [interquartile range 61.5-73.3]; 8 male) completed treatment. Technical success was 100 % with no procedural complications. At 12 weeks, median reduction in tumor volume was 8.2 cm3 (95 % confidence interval 4.95-10.85; P = 0.003), with minimal or no 18FDG uptake in nine patients (75 %). Tumor downstaging was achieved in six patients (50 %), leading to successful resection in five (42 %), including four R0 resections (80 %). CONCLUSIONS: EUS-guided 32P implantation was feasible, well tolerated, and resulted in a 42 % surgical resection rate. Further evaluation in a larger randomized multicenter trial is warranted.

The dark side of belief in Covid-19 scientists and scientific evidence.

We draw from an interdisciplinary literature on convictions to examine the manifestations and consequences of firmly held beliefs in Covid-19 (C19) science. Across three studies (N = 743), we assess participants' beliefs in C19 experts, and beliefs in supported and unsupported empirical evidence. Study 1 establishes the basic theoretical links and we show that an individual's belief in science on C19 is associated with dispositional belief in science and moralization of C19 mitigation measures. Our subsequent two studies show how stronger belief in C19 science influences distrust in unmasked individuals past the mandates, and greater endorsement of pandemic mitigation authoritarianism. We document the dark side that emerges when belief in C19 science extends beyond the generally desirable scientific literacy and manifests as a conviction that public health experts are the only ones who can handle the pandemic, and that even unsupported claims about C19 are supported by scientific evidence (e.g., risk of outdoor transmission is high). We also highlight our political ideology findings showing that both liberals and conservatives mis-calibrate C19 risks in different ways, and we conclude with discussing how examining the darker side of scientific beliefs can inform our understanding of people's reactions to the pandemic.

Exploring pre-surgery donor-specific antibodies in the context of organ shortage in liver transplant.

BACKGROUND: There is a growing disparity between the number of liver transplant (LT) candidates and availability of suitable liver allografts. Antibody-mediated rejection (AMR), secondary to positive donor-specific antibodies (DSA), remains a concern in liver transplantation. This study aimed to correlate expression of DSA on pre-transplant screening and outcomes of LT, specifically development of AMR in liver allografts and liver function profile in the post-operative period. METHODS: Data of consecutive patients undergoing orthotopic LT (OLT) at the South Australian Liver Transplant Unit was analysed. All patients underwent DSA testing pre-transplant. RESULTS: Within a cohort of 96 patients, over a post-OLT median follow-up of 849 days, only 2 patients (2%) developed AMR. While both patients had a positive DSA test preoperatively, overall DSA positivity was noted in 31% patients, with a specificity for prediction of AMR of 0.708. No significant association was noted between AMR (p = 0.092), T cell-mediated rejection/TCMR (p = 0.797) or late hepatic artery thrombosis/LHAT (p = 0.521). There was no significant interaction effect between DSA positivity and serum bilirubin or transaminases over a period of 100 days. CONCLUSION: AMR following LT is uncommon. A positive DSA pre-transplant does not imply a definite risk of AMR. Also, there does not exist a significant interaction in time between DSA expression and serum bilirubin or transaminase levels. Until there emerges evidence to the contrary, it appears reasonable to consider DSA-positive donors within the broad context of marginal donors in the context of a worldwide shortage of LT donor allografts.

Changing health behaviors using financial incentives: a review from behavioral economics.

BACKGROUND: Incentives are central to economics and are used across the public and private sectors to influence behavior. Recent interest has been shown in using financial incentives to promote desirable health behaviors and discourage unhealthy ones. MAIN TEXT: If we are going to use incentive schemes to influence health behaviors, then it is important that we give them the best chance of working. Behavioral economics integrates insights from psychology with the laws of economics and provides a number of robust psychological phenomena that help to better explain human behavior. Individuals' decisions in relation to incentives may be shaped by more subtle features - such as loss aversion, overweighting of small probabilities, hyperbolic discounting, increasing payoffs, reference points - many of which have been identified through research in behavioral economics. If incentives are shown to be a useful strategy to influence health behavior, a wider discussion will need to be had about the ethical dimensions of incentives before their wider implementation in different health programmes. CONCLUSIONS: Policy makers across the world are increasingly taking note of lessons from behavioral economics and this paper explores how key principles could help public health practitioners design effective interventions both in relation to incentive designs and more widely.

Liver resection for colorectal cancer metastases: a comparison of outcomes over time in South Australia.

BACKGROUND: The aim of the current study was to assess outcomes following liver resection in metastatic CRC (mCRC) in South Australia across two study periods (pre-2006 versus post-2006). METHODS: The South Australian (SA) Clinical Registry for mCRC maintains data prospectively on all patients in SA with mCRC diagnosed from 01 February 2006. This data was linked with a prospectively collated database on liver resections for mCRC from 01/01/1992 to 01/02/2006. The primary end point was overall survival. RESULTS: 757 patients underwent liver resection for mCRC. Liver resection was performed on 286 patients pre-2006 and 471 patients post-2006. The median age of the study population was 62 years, and this was similar across both eras. Overall survival was significantly better in the post-2006 era (hazard ratio HR = 0.45, p = 0.001). Complications (59% pre-2006 versus 23% post-2006) and transfusion rates (34% pre-2006 versus 2% post-2006) were significantly higher in the pre-2006 era. Repeat liver resection rates were significantly higher in the post-2006 era (1% pre-2006 versus 10% post-2006). CONCLUSIONS: Outcomes following liver resection for mCRC have improved over time, with significantly better overall survival in the post-2006 era compared to pre-2006.

Distribution and pathological features of pancreatic, ampullary, biliary and duodenal cancers resected with pancreaticoduodenectomy.

BACKGROUND: Pancreatic cancer (PC) has the worst survival of all periampullary cancers. This may relate to histopathological differences between pancreatic cancers and other periampullary cancers. Our aim was to examine the distribution and histopathologic features of pancreatic, ampullary, biliary and duodenal cancers resected with a pancreaticoduodenectomy (PD) and to examine local trends of periampullary cancers resected with a PD. METHODS: A retrospective review of PD between January 2000 and December 2012 at a public metropolitan database was performed. The institutional ethics committee approved this study. RESULTS: There were 142 PDs during the study period, of which 70 cases were pre-2010 and 72 post-2010, corresponding to a recent increase in the number of cases. Of the 142 cases, 116 were for periampullary cancers. There were also proportionately more PD for PC (26/60, 43% pre-2010 vs 39/56, 70% post-2010, P = 0.005). There were 65/116 (56%) pancreatic, 29/116 (25%), ampullary, 17/116 (15%) biliary and 5/116 (4%) duodenal cancers. Nodal involvement occurred more frequently in PC (78%) compared to ampullary (59%), biliary (47%) and duodenal cancers (20%), P = 0.002. Perineural invasion was also more frequent in PC (74%) compared to ampullary (34%), biliary (59%) and duodenal cancers (20%), P = 0.002. Microvascular invasion was seen in 57% pancreatic, 38% ampullary, 41% biliary and 20% duodenal cancers, P = 0.222. Overall, clear margins (R0) were achieved in fewer PC 41/65 (63%) compared to ampullary 27/29 (93%; P = 0.003) and biliary cancers 16/17 (94%; P = 0.014). CONCLUSIONS: This study highlights that almost half of PD was performed for cancers other than PC, mainly ampullary and biliary cancers. The volume of PD has increased in recent years with an increased proportion being for PC. PC had higher rates of nodal and perineural invasion compared to ampullary, biliary and duodenal cancers.

Oestrogen hormone receptors in focal nodular hyperplasia.

BACKGROUND: The role of hormones in focal nodular hyperplasia (FNH) has been investigated with conflicting results. OBJECTIVE: The aim of this study was to evaluate oestrogen and progesterone receptor immunohistochemical expression in FNH and surrounding normal liver (control material). METHODS: Biopsy materials from FNH and control tissue were investigated using an immunostainer. Receptor expression was graded as the proportion score (percentage of nuclear staining) and oestrogen receptor intensity score. RESULTS: Study material included tissue from 11 resected FNH lesions and two core biopsies in 13 patients (two male). Twelve samples showed oestrogen receptor expression. The percentage of nuclear oestrogen receptor staining was <33% in eight FNH biopsies, 34-66% in two FNH biopsies, and >67% in both core biopsies. The better staining in core biopsies relates to limitations of the staining technique imposed by the fibrous nature of larger resected FNH. Control samples from surrounding tissue were available for nine of the resected specimens and all showed oestrogen receptor expression. Progesterone receptor expression was negligible in FNH and control samples. CONCLUSIONS: By contrast with previous studies, the majority of FNH and surrounding liver in this cohort demonstrated oestrogen receptor nuclear staining. The implications of this for continued oral contraceptive use in women of reproductive age with FNH remain uncertain given the lack of consistent reported growth response to oestrogen stimulation or withdrawal.

Greasy roads: the impact of bad financial news on road traffic accidents.

We use evidence from a natural experiment in Greece to study the effect of the announcement of austerity measures on road traffic accidents (RTAs). We use daily RTA data from 2010 and 2011, during which a number of austerity measures were announced, including salary and pension cuts and an increase in direct and indirect taxes. We find that controlling for other factors potentially influencing RTAs, the number of RTAs increased significantly on the first two days following the announcements of austerity measures. We put forward some tentative suggestions for why this happens.

Patients' subjective well-being: Determinants and its usage as a metric of healthcare service quality.

It is commonly suggested that patients' subjective well-being (SWB) can be affected by pre-treatment conditions and treatment experiences, and hence SWB can be used to measure and improve healthcare quality. With data collected in a hospital in the UK (N = 446), we investigated the determinants of patients' SWB and evaluated its use in healthcare research. Our findings showed strong relationships between pre-treatment conditions and patients' SWB: anxiety and depression negatively predicted SWB across all three domains, mobility positively predicted the life satisfaction and happiness domains, while the ability to self care and pain and discomfort also predicted SWB in some domains. In contrast, patients' satisfaction with the treatment only played minor roles in determining SWB, much less so the characteristics of their nurses. The general lack of associations between treatment experiences and patient's SWB highlighted the challenges of using SWB to measure healthcare quality and inform policy making.

Les Misérables: An analysis of low SWB across the world.

Global trends indicate that the prevalence of low subjective wellbeing is on the rise, though not all regions are equal in terms of both absolute levels and their trajectories. In this paper, we explore the relative importance of individual- and country-level factors in predicting low SWB. Put differently, we ask if a person found themselves behind a veil of ignorance, should they want to know who they will be or what country they will live in to better understand their risk of having low wellbeing. To answer this question, we leverage data from the most extensive wellbeing survey in the world-the Gallup World Poll. We explore people's likelihood of reporting low evaluative wellbeing (that their life is close to the worst possible life on the Cantril ladder) and low experiential wellbeing (reporting having felt angry, sad, stressed, and worried for most of the day yesterday). Using multilevel models on both measures, we show that individual factors have the greatest explanatory power across both measures, but that country level factors are almost four times more important in explaining the variation in low evaluative wellbeing than low experiential wellbeing around the world. We also present evidence that individual and country-level factors interact, suggesting that a complex system of people and places determines people's likelihood of reporting low SWB.

Public preferences for responsibility versus public preferences for reducing inequalities.

In cost-utility analysis, the numbers of quality-adjusted life years (QALYs) gained are aggregated by placing the same weight on each QALY. Deviations from this rubric have been proposed on a number of grounds, including the degree to which persons might be deemed responsible for the illness faced, and inequality in lifetime health between groups. Most research has looked at these factors in isolation. This paper analyses public preferences about the relative importance of these factors. Over 500 members of the general public in the UK are interviewed in their homes. Where "blameworthy" groups experience a moderate drop in quality of life due to their behaviour, they appear to receive higher priority than an otherwise "trustworthy" group if they also experience poorer health prospects because the latter is weighted more heavily than the former.

It is the lifetime that matters: public preferences over maximising health and reducing inequalities in health.

Scarce healthcare resources can be allocated in many ways. The National Institute for Health and Clinical Excellence in the UK focuses on the size of the benefit relative to costs, yet we know that there is support among clinicians and the general public for reducing inequalities in health. This paper shows how the UK general public trade-off these sometimes competing objectives, and the data we gather allow us to show the weight given to different population groups, for example, 1 extra year of life in full health to someone who would otherwise die at the age of 60 years is worth more than twice as much as an additional year of life to someone who would otherwise die at the age of 70 years. Such data can help inform the rationing decisions faced by all healthcare systems around the world.

Falciform ligament abscess from left sided portal pyaemia following malignant obstructive cholangitis.

Abscess formation of the falciform ligament is incredibly rare and perplexing when encountered for the first time. It is reported to occur in the setting of cholecystitis and cholangitis, but the pathophysiology is poorly understood.In this case report, we present a 73-year-old man with falciform ligament abscess following cholangitis from an obstructive ampullary carcinoma. The patient was referred to the Royal Adelaide Hospital from a country hospital, with progressive jaundice, anorexia and nausea. Prior to transfer, he deteriorated with cholangitis, dehydration and renal failure. On arrival, his abdomen was exquisitely tender along the course of the falciform ligament. His blood tests revealed an elevated white cell count of 14.9 x 10(3)/µl, bilirubin of 291 µmol/l and creatinine of 347 µmol/l. His CA 19-9 was markedly elevated at 35,000 kU/l. A non-contrast computed tomography (CT) demonstrated gross biliary dilatation and a collection tracking along the path of the falciform ligament to the umbilicus. The patient was commenced on intravenous antibiotics and underwent an urgent endoscopic retrograde cholangiopancreatogram (ERCP) with sphincterotomy and biliary stent drainage. Cholangiogram revealed a grossly dilated biliary tree, with abrupt transition at the ampulla, which on biopsy confirmed an obstructing ampullary carcinoma. Following ERCP, his jaundice and abdominal tenderness resolved. He was optimized over 4 weeks for an elective pancreaticoduodenectomy. At operation, we found abscess transformation of the falciform ligament. Copious amounts of pus and necrotic material was drained. Part of the round ligament was resected along the undersurface of the liver. Histology showed that there was prominent histiocytic inflammation with granular acellular eosinophilic components. The patient recovered slowly but uneventfully. A contrast CT scan undertaken 2 weeks post-operatively (approximately 7 weeks after the initial CT) revealed left portal venous thrombosis, which was likely to be a delayed discovery and was managed conservatively. We present this patient's operative images and radiographic findings, which may explain the pathophysiology behind this rare complication. We hypothesize that cholangitis, with secondary portal pyaemia and tracking via the paraumbilical veins, can cause infectious seeding of the falciform ligament, with consequent abscess formation.

Moving to Personalized Medicine Requires Personalized Health Plans.

When individuals, families, and employers select health plans in the United States, they are typically only shown the financial structure of the plans and their provider networks. This variation in financial structure can lead patients to have health plans aligned with their financial needs, but not with their underlying nonfinancial preferences. Compounding the challenge is the fact that managed care organizations have historically used a combination of population-level budget impact models, cost-effectiveness analyses, medical necessity criteria, and current medical consensus to make coverage decisions. This approach to creating and presenting health plan options does not consider heterogeneity in patient and family preferences and values, as it treats populations as uniform. Similarly, it does not consider that there are some situations in which patients are price-insensitive. We seek to highlight the challenges posed by presenting health plans to patients in strictly financial terms, and to call for more consideration of nonfinancial patient preferences in the health plan design and selection process.

The duration of daily activities has no impact on measures of overall wellbeing.

It is widely assumed that the longer we spend in happier activities the happier we will be. In an intensive study of momentary happiness, we show that, in fact, longer time spent in happier activities does not lead to higher levels of reported happiness overall. This finding is replicated with different samples (student and diverse, multi-national panel), measures and methods of analysis. We explore different explanations for this seemingly paradoxical finding, providing fresh insight into the factors that do and do not affect the relationship between how happy we report feeling as a function of how long it lasts. This work calls into question the assumption that spending more time doing what we like will show up in making us happier, presenting a fundamental challenge to the validity of current tools used to measure happiness.

Corrigendum: The Welleye: A Conceptual Framework for Understanding and Promoting Wellbeing.

[This corrects the article DOI: 10.3389/fpsyg.2021.716572.].

"Better the devil you know": Are stated preferences over health and happiness determined by how healthy and happy people are?

Most people want to be both happy and healthy. But which matters most when there is a trade-off between them? This paper addresses this question by asking 4000 members of the UK and US public to make various choices between being happy or being physically healthy. The results suggest that these trade-offs are determined in substantial part by the respondent's own levels of happiness and health, with unhappy people more likely to choose unhappy lives and unhealthy people more likely to choose unhealthy ones: "better the devil you know, than the devil you don't". Age also plays an important role; older people are more likely to choose being healthy over being happy. Information about adaptation to physical health conditions matters too, but less so than respondent characteristics. These results further our understanding of public preferences with important implications for policymakers concerned with satisfying those preferences.

Mental Health Reform: Design and Implementation of a System to Optimize Outcomes for Veterans and Their Families.

The social, health, and economic burden of mental health problems in the veteran community is heavy. Internationally, the array of services and support available to veterans and their families are extensive but vary in quality, are often disconnected, complex to navigate, and lack clear coordination. This paper describes a conceptual framework to guide the design and implementation of a system of services and supports to optimize the mental health and wellbeing of all veterans and their families. The framework recognizes the diversity of veterans across intersecting identities that uniquely shape experiences of posttraumatic mental health and wellbeing. It brings together several strands of research: the values and principles that should underpin the system; the needs of diverse veterans and their families; challenges in the current services and supports; evidence-based interventions; and principles of effective implementation. Central to the future system design is a next generation stepped model of care that organizes best and next practice interventions in a coherent system, matches service provision to level of need and addresses access and navigation. Practical guidance on implementation provides an aspirational and flexible structure for system evolution, and a template for all stakeholders-individuals, groups, agencies and organizations-to effect system change.

Thinking about it: thoughts about health and valuing QALYs.

When valuing health states (e.g., for use in the assessment of health technologies), health economists often ask respondents how many years of life in poor health they would be willing to trade-off in order to live in full health. Problems with preferences of this kind have led to calls for the use of more direct measures of the utility associated with experiencing a health state. The fact remains, however, that individuals are often willing to make large sacrifices in life expectancy to alleviate conditions for which there appears to be a considerable degree of hedonic adaptation. The purpose of this study is to investigate this important discrepancy in more detail. Data from 1173 internet and telephone surveys in the United States suggest that time trade-off responses are related to the frequency and intensity of negative thoughts about health in ways that may not be very well captured by any of the proposed valuation methods.