Universal Versus Targeted Screening for Lynch Syndrome: Comparing Ascertainment and Costs Based on Clinical Experience.

BACKGROUND: Strategies to screen colorectal cancers (CRCs) for Lynch syndrome are evolving rapidly; the optimal strategy remains uncertain. AIM: We compared targeted versus universal screening of CRCs for Lynch syndrome. METHODS: In 2010-2011, we employed targeted screening (age < 60 and/or Bethesda criteria). From 2012 to 2014, we screened all CRCs. Immunohistochemistry for the four mismatch repair proteins was done in all cases, followed by other diagnostic studies as indicated. We modeled the diagnostic costs of detecting Lynch syndrome and estimated the 5-year costs of preventing CRC by colonoscopy screening, using a system dynamics model. RESULTS: Using targeted screening, 51/175 (29 %) cancers fit criteria and were tested by immunohistochemistry; 15/51 (29 %, or 8.6 % of all CRCs) showed suspicious loss of ≥1 mismatch repair protein. Germline mismatch repair gene mutations were found in 4/4 cases sequenced (11 suspected cases did not have germline testing). Using universal screening, 17/292 (5.8 %) screened cancers had abnormal immunohistochemistry suspicious for Lynch syndrome. Germline mismatch repair mutations were found in only 3/10 cases sequenced (7 suspected cases did not have germline testing). The mean cost to identify Lynch syndrome probands was ~$23,333/case for targeted screening and ~$175,916/case for universal screening at our institution. Estimated costs to identify and screen probands and relatives were: targeted, $9798/case and universal, $38,452/case. CONCLUSIONS: In real-world Lynch syndrome management, incomplete clinical follow-up was the major barrier to do genetic testing. Targeted screening costs 2- to 7.5-fold less than universal and rarely misses Lynch syndrome cases. Future changes in testing costs will likely change the optimal algorithm.

Toward an Understanding of Citywide Urban Environmental Governance: An Examination of Stewardship Networks in Baltimore and Seattle.

Efforts to create more sustainable cities are evident in the proliferation of sustainability policies in cities worldwide. It has become widely proposed that the success of these urban sustainability initiatives will require city agencies to partner with, and even cede authority to, organizations from other sectors and levels of government. Yet the resulting collaborative networks are often poorly understood, and the study of large whole networks has been a challenge for researchers. We believe that a better understanding of citywide environmental governance networks can inform evaluations of their effectiveness, thus contributing to improved environmental management. Through two citywide surveys in Baltimore and Seattle, we collected data on the attributes of environmental stewardship organizations and their network relationships. We applied missing data treatment approaches and conducted social network and comparative analyses to examine (a) the organizational composition of the network, and (b) how information and knowledge are shared throughout the network. Findings revealed similarities in the number of actors and their distribution across sectors, but considerable variation in the types and locations of environmental stewardship activities, and in the number and distribution of network ties in the networks of each city. We discuss the results and potential implications of network research for urban sustainability governance.

Message Delivery Strategy Influences Willingness to Comply With Biosecurity.

As the Covid-19 pandemic continues worldwide, it has become increasingly clear that effective communication of disease transmission risks associated with protective behaviors is essential, and that communication tactics are not ubiquitously and homogenously understood. Analogous to Covid-19, communicable diseases in the hog industry result in millions of animal deaths and in the United States costs hundreds of millions of dollars annually. Protective behaviors such as preventative biosecurity practices are implemented to reduce these costs. Yet even with the knowledge of the importance of biosecurity, these practices are not employed consistently. The efficacy of biosecurity practices relies on consistent implementation and is influenced by a variety of behavioral factors under the umbrella of human decision-making. Using an experimental game, we collected data to quantify how different messages that described the likelihood of a disease incursion would influence willingness to follow biosecurity practices. Here we show that graphical messages combined with linguistic phrases demarking infection risk levels are more effective for ensuring compliance with biosecurity practices, as contrasted with either simple linguistic phrases or graphical messages with numeric demarcation of risk levels. All three of these delivery methods appear to be more effective than using a simple numeric value to describe probability of infection. Situationally, we saw greater than a 3-fold increase in compliance by shifting message strategy without changing the infection risk, highlighting the importance of situational awareness and context when designing messages.

Effects of Social Cues on Biosecurity Compliance in Livestock Facilities: Evidence From Experimental Simulations.

Disease outbreaks in U.S. animal livestock industries have economic impacts measured in hundreds of millions of dollars per year. Biosecurity, or procedures intended to protect animals against disease, is known to be effective at reducing infection risk at facilities. Yet, to the detriment of animal health, humans do not always follow biosecurity protocols. Human behavioral factors have been shown to influence willingness to follow biosecurity protocols. Here we show how social cues may affect cooperation with a biosecurity practice. Participants were immersed in a simulated swine production facility through a graphical user interface and prompted to make a decision that addressed their willingness to comply with a biosecurity practice. We tested the effect of varying three experimental variables: (1) the risk of acquiring an infection, (2) the delivery method of the infection risk information (numerical vs. graphical), and (3) the behavior of an automated coworker in the facility. We provide evidence that participants changed their behavior when they observed a simulated worker making a choice to follow or not follow a biosecurity protocol, even though the simulated worker had no economic effect on the participants' payouts. These results advance the understanding of human behavioral effects on biosecurity protocol decisions, demonstrating that social cues need to be considered by livestock facility managers when developing policies to make agricultural systems more disease resilient.

Willingness to Comply With Biosecurity in Livestock Facilities: Evidence From Experimental Simulations.

Disease in U.S. animal livestock industries annually costs over a billion dollars. Adoption and compliance with biosecurity practices is necessary to successfully reduce the risk of disease introduction or spread. Yet, a variety of human behaviors, such as the urge to minimize time costs, may induce non-compliance with biosecurity practices. Utilizing a "serious gaming" approach, we examine how information about infection risk impacts compliance with biosecurity practices. We sought to understand how simulated environments affected compliance behavior with treatments that varied using three factors: (1) the risk of acquiring an infection, (2) the delivery method of the infection risk message (numerical, linguistic and graphical), and (3) the certainty of the infection risk information. Here we show that compliance is influenced by message delivery methodology, with numeric, linguistic, and graphical messages showing increasing efficacy, respectively. Moreover, increased situational uncertainty and increased risk were correlated with increases in compliance behavior. These results provide insight toward developing messages that are more effective and provide tools that will allow managers of livestock facilities and policy makers to nudge behavior toward more disease resilient systems via greater compliance with biosecurity practices.

Risk Attitudes Affect Livestock Biosecurity Decisions With Ramifications for Disease Control in a Simulated Production System.

Hog producers' operational decisions can be informed by an awareness of risks associated with emergent and endemic diseases. Outbreaks of porcine epidemic diarrhea virus (PEDv) have been re-occurring every year since the first onset in 2013 with substantial losses across the hog production supply chain. Interestingly, a decreasing trend in PEDv incidence is visible. We assert that changes in human behaviors may underlie this trend. Disease prevention using biosecurity practices is used to minimize risk of infection but its efficacy is conditional on human behavior and risk attitude. Standard epidemiological models bring important insights into disease dynamics but have limited predictive ability. Since research shows that human behavior plays a driving role in the disease spread process, the explicit inclusion of human behavior into models adds an important dimension to understanding disease spread. Here we analyze PEDv incidence emerging from an agent-based model (ABM) that uses both epidemiological dynamics and algorithms that incorporate heterogeneous human decisions. We investigate the effects of shifting fractions of hog producers between risk tolerant and risk averse positions. These shifts affect the dynamics describing willingness to increase biosecurity as a response to disease threats and, indirectly, change infection probabilities and the resultant intensity and impact of the disease outbreak. Our ABM generates empirically verifiable patterns of PEDv transmission. Scenario results show that relatively small shifts (10% of the producer agents) toward a risk averse position can lead to a significant decrease in total incidence. For significantly steeper decreases in disease incidence, the model's hog producer population needed at least 37.5% of risk averse. Our study provides insight into the link between risk attitude, decisions related to biosecurity, and consequent spread of disease within a livestock production system. We suggest that it is possible to create positive, lasting changes in animal health by nudging the population of livestock producers toward more risk averse behaviors. We make a case for integrating social and epidemiological aspects in disease spread models to test intervention strategies intended to improve biosecurity and animal health at the system scale.

Decision-making in livestock biosecurity practices amidst environmental and social uncertainty: Evidence from an experimental game.

Livestock industries are vulnerable to disease threats, which can cost billions of dollars and have substantial negative social ramifications. Losses are mitigated through increased use of disease-related biosecurity practices, making increased biosecurity an industry goal. Currently, there is no industry-wide standard for sharing information about disease incidence or on-site biosecurity strategies, resulting in uncertainty regarding disease prevalence and biosecurity strategies employed by industry stakeholders. Using an experimental simulation game, with primarily student participants, we examined willingness to invest in biosecurity when confronted with disease outbreak scenarios. We varied the scenarios by changing the information provided about 1) disease incidence and 2) biosecurity strategy or response by production facilities to the threat of disease. Here we show that willingness to invest in biosecurity increases with increased information about disease incidence, but decreases with increased information about biosecurity practices used by nearby facilities. Thus, the type or context of the uncertainty confronting the decision maker may be a major factor influencing behavior. Our findings suggest that policies and practices that encourage greater sharing of disease incidence information should have the greatest benefit for protecting herd health.