Clinical features and outcomes of elderly hospitalised patients with chronic obstructive pulmonary disease, heart failure or both

Background and objective: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) mutually increase the risk of being present in the same patient, especially if older. Whether or not this coexistence may be associated with a worse prognosis is debated. Therefore, employing data derived from the REPOSI register, we evaluated the clinical features and outcomes in a population of elderly patients admitted to internal medicine wards and having COPD, HF or COPD + HF. Methods: We measured socio-demographic and anthropometric characteristics, severity and prevalence of comorbidities, clinical and laboratory features during hospitalization, mood disorders, functional independence, drug prescriptions and discharge destination. The primary study outcome was the risk of death. Results: We considered 2,343 elderly hospitalized patients (median age 81 years), of whom 1,154 (49%) had COPD, 813 (35%) HF, and 376 (16%) COPD + HF. Patients with COPD + HF had different characteristics than those with COPD or HF, such as a higher prevalence of previous hospitalizations, comorbidities (especially chronic kidney disease), higher respiratory rate at admission and number of prescribed drugs. Patients with COPD + HF (hazard ratio HR 1.74, 95% confidence intervals CI 1.16-2.61) and patients with dementia (HR 1.75, 95% CI 1.06-2.90) had a higher risk of death at one year. The Kaplan-Meier curves showed a higher mortality risk in the group of patients with COPD + HF for all causes (p = 0.010), respiratory causes (p = 0.006), cardiovascular causes (p = 0.046) and respiratory plus cardiovascular causes (p = 0.009). Conclusion: In this real-life cohort of hospitalized elderly patients, the coexistence of COPD and HF significantly worsened prognosis at one year. This finding may help to better define the care needs of this population

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Financial Disclosure, Risk Perception and Investment Choices: Evidence from a Consumer Testing Exercise

This paper investigates the subjective understanding and perception of financial information and their impact on investment decisions. A consumer testing approach is applied in order to explore: i) how different representation formats (or Templates) are appraised in terms of complexity, usefulness and information content, ii) how different Templates influence risk perception, iii) how different Templates affect willingness to invest. A sample of 254 Italian investors were submitted different Templates, each delivering in different modes the same information on risk, return and costs of four financial instruments (two structured bonds -- one outstanding and the other newly issued -- negotiated on the Italian retail bond market and two Italian listed stocks). Risk is alternatively disclosed through four approaches. The first relies on a synthetic risk indicator, aggregating information on market, liquidity and credit risks. The second discloses unbundled quantitative measures of the market risk (volatility and value at risk), the liquidity risk (turn-over ratio) and the credit risk (Moody’s official rating and expected default probability). Both the synthetic and unbundled formats compare the risk/return characteristics of the product with the risk/return attributes of a benchmark portfolio. The third mode is based on what-if scenarios. The fourth resorts to probabilistic modelling of expected returns. Costs are disclosed according to three options. The first shows the impact of costs on the internal rate of return. The second highlights the impact of costs on principal and interest. The third unbundles the product fair value into its bond and derivative components, with specific indication about costs. First, investors were asked to rate the complexity and the usefulness of the Templates and to assess the riskiness of the presented products. In order to control for familiarity bias, in the first stage of the test neither the issuer’s name nor the type of the assets were disclosed. Perceived complexity turns out to rise moving from the synthetic representation to the unbundled one and reaches its highest for the performance scenarios (both what-if and probabilistic). As for usefulness, both what-if and probabilistic modelling are perceived to be less useful than the synthetic and unbundled representations. Perceived complexity and perceived usefulness of financial information are generally inversely related: in other words, the higher the complexity of the information, the lower the perceived usefulness. Second, in order to assess the relation between information disclosure and risk perception investors were asked to rank products by their riskiness. In general, risk perception results to be positively affected by perceived complexity of the information disclosure. The percentage of respondents correctly ranking the risk of products is higher when unbundled formats are used, whereas performance scenario representations are associated with a higher percentage of wrong answers in ranking products’ riskiness. In details, risk tends to be more frequently over-estimated when participants inspect the what-if scenario representation and to be more frequently under-estimated when probabilistic modelling is taken into account. Finally, respondents were asked how much they would invest in each product, given an initial endowment, a time horizon and an investment objective. This allowed observing propensity towards investment driven exclusively by the representation of the financial information. As expected, perceived complexity results to be the main driver of the willingness to invest, since it always contributes to reduce propensity to invest. To this respect, perceived complexity seems to trigger a standard adverse selection problem: it is as if difficulty of understanding cast individuals into uncertainty, leading them to abstain from entering into the market. Financial knowledge, personal traits and investment habits do play a role in the perception of complexity and risk as well as in the attitude towards investment, although with a certain degree of heterogeneity across different representation modes. Higher levels of financial knowledge are generally negatively associated with perceived complexity and with indecision individuals may experience in the assessment of products’ risk. However, being less hesitant is generally associated with the wrong risk ranking. Another interesting consideration is that, in line with the insights of the behavioural literature, in our sample high financial ‘literate’ individuals are not necessarily free of inclination towards behavioural biases. This evidence, coupled with a positive correlation between risk propensity (as measured through the Grable & Lytton test) and the inclination towards behavioural biases, would point to a latent variable, i.e. the overconfidence fed by a good level of financial knowledge, driving the positive relation between high knowledge and inclination towards behavioural biases. This point claims for financial education initiatives attuned also as debiasing programs, in order to be an effective investor protection tool. Finally, making frequently investment decisions, delegating investment choices to an expert, trusting financial advisors are all associated with an easier understanding of financial information and a higher propensity to invest. This evidence indirectly confirms that financial experts and advisors may actually make the difference, by playing an educational role and, by this way, changing individuals’ attitude towards financial choices. Overall, the present paper shows that risk perception is context-dependent and mainly determined by the way financial information is disclosed. It adds to the existing literature by providing new evidence on the impact of framing of different representation modes, partially overlapping with the formats mandated by regulators and super-visors and/or used by the industry. Relying on the actual appraisal elicited from a sample of Italian investors, the study provides insights on how people actually read and understand financial information, which may turn useful in the design of financial disclosure and investor education programmes. For instance, it highlights that simplifying financial disclosure is not sufficient to ensure correct risk perception and unbiased investment choices. Moreover, evidence about investors’ heterogeneity and behavioural biases affecting risk perception supports the idea that the ‘optimal’ disclosure may not exist and the ‘one-size-fits-all’ approach cannot be effective in ensuring a suitable level of investors protection. This paper is in line with the approach adopted by some regulators increasingly engaged in the definition of evidence-based rules and may offer useful insights for the design of effective investor education programmes

How financial information disclosure affects risk perception. Evidence from Italian investors'\u80\u99 behaviour

This paper investigates how different representations of financial information may be appraised in terms of complexity and usefulness, and how financial disclosure influences individuals’ risk perception. By using a consumer testing analytical approach, we run a survey on a sample of Italian investors: 254 bank customers were submitted 4 different templates, each combining a different typology of data (historical and prospective) and framing (words, numbers and charts) to indicate the same level of risk and return of four real-life financial instruments. Representation formats partially overlap with those mandated by regulators and used within the financial industry. Results show that the perceived riskiness of financial products is affected by the way information is disclosed. Perceived complexity of the financial information disclosure intensifies perception of riskiness of the product solicited. Gender, age, personal traits, behavioural biases and financial knowledge, do also play a role. Overall, given investors’ heterogeneity and behavioural biases, neither simplifying disclosure nor a ‘one-sizefits- all’ approach may be sufficient to ensure correct risk perception and to prevent unbiased investment choices

Attitudine alla pianificazione finanziaria delle famiglie italiane

Employing structured financial planning to manage personal finances is associated with higher levels of financial well-being and increased resiliency to shocks. Therefore, it is important to understand the factors associated with the propensity to plan and what it is that promotes financial planning. This issue is especially relevant in Italy, where financial planning is not widespread among households yet. This study brings empirical evidence on this by using CONSOB survey data on the financial investments of Italian households over 2019-2021. Estimation results of a probit model show a positive association between financial planning and financial knowledge, and the relevance of financial control (control over savings, spending and indebtedness) and financial conditions. Also personal traits such as financial self-efficacy and financial anxiety play a main role, resulting to be associated with a reduced propensity to plan: in particular, financial decision-makers who find it easy to resolve financial problems and to be able to cope with them in any case, and respondents who prefer not to think about their financial conditions, in order to mitigate perceived anxiety, are less likely to set a financial plan. These findings provide useful insights for the design of financial education initiatives and for an interaction between client and intermediary aimed at promoting appropriate attitudes and choices towards money management. Since the perceived ability to solve financial issues plays a role in financial planning, more attention should be paid to enabling the population to have a better and unbiased awareness of their financial skills. It is also important to take into account additional personal traits, such as financial anxiety, when considering individual segmentation and the definition of content and methods. In this respect, the tools used to elicit individuals’ personal traits will be crucial. The use of multi-item questionnaires, corroborated by the experimental literature, could help to mitigate the risk of unreliable self-assessments

Do investors rely on robots? Evidence from an experimental study

Robo advice has moved its first steps in the Anglo-Saxon countries and is now rapidly gaining market share at a global level. The phenomenon fueled a growing and still not conclusive institutional debate about potential benefits and risks to financial consumers, based also on investors’ biases and behaviours that online platforms could trigger to the detriment of robo advisees. The present paper provides some insights into attitudes and behaviours that might prevail in a digital environment among young investors, representing the category of users potentially more involved by the development of the automated advice. In detail, the study investigates whether individuals’ propensity to follow the recommendation received from an advisor changes depending on whether the advisor is a human or a robot. The analysis is based on data collected through an ad hoc developed laboratory experiment run in the Cesare Lab of LUISS University with a sample of 180 students. Students were given an initial monetary endowment and were asked to choose between six different portfolios of financial activities; after being profiled through a questionnaire aimed at eliciting their risk tolerance (Grable and Lytton’s Risk Tolerance Quiz; 2003), they received the advice, either from a human advisor or from a robo advisor (i.e. via a computer platform) depending on the treatment they had randomly assigned before entering the experimental session. Then, they were asked again to choose among the six portfolios in order to capture whether the propensity to follow the recommendation depends on its source (human versus robo). Finally, participants were asked to answer several questions eliciting risk preferences, financial literacy (actual and perceived) and digital literacy, serving as control variables when modelling the probability to follow the advice. Our results show that the probability to follow the advice does not depend on the source of the recommendation but rather on the alignment between the self-directed choice made before receiving the advice and the recommendation subsequently received: the propensity to follow the advisor (either human or robo) increases if the advice confirms individual’s own beliefs about her/his investor profile. This result might be explained by referring to individuals’ attitude towards the so called ‘confirmation bias’. However, when the self-directed choice differs from the recommendation received, participants may be more likely to follow the advice given by a human advisor and less likely to follow the advice formulated by an algorithm. Also the gender of the advisor seems to matter: women tend to follow the advice provided by a female advisor more frequently compared to the case of the recommendation given by a male advisor. This work is part of a wider research on FinTech that CONSOB started in 2016, in collaboration with several Italian universities, with the aim of exploring opportunities and risks for investor protection and the financial system as a whole, related to the application of technological innovation to the provision of financial services. In particular, supplementing Lener, Linciano and Soccorso (2019, edited by) and Caratelli et al. (2019), this document widens the field of investigation by referring to a specific target of the population - the so called millennials and post-millennials – and using complementary and innovative methods. According to an evidence-based approach, insights from the present study may suggest specific investor protection initiatives, also in terms of financial education activities designed for a clearly-identified segment of the population (the so called millennials and post-millennials, in this case). Evidence from the present work might be extended further with respect to the consumers’ perception of the fairness of algorithms used to provide financial services, the cognitive heuristics and biases underlying decision making process and investments in the digital environment and nudges which may be used to enhance investor protection

Do Investors Rely on Robots? Evidence from an Experimental Study

Robo advice has moved its first steps in the Anglo-Saxon countries and is now rapidly gaining market share at a global level. The phenomenon fueled a growing and still not conclusive institutional debate about potential benefits and risks to financial consumers, based also on investors’ biases and behaviours that online platforms could trigger to the detriment of robo advisees. The present paper provides some insights into attitudes and behaviours that might prevail in a digital environment among young investors, representing the category of users potentially more involved by the development of the automated advice. In detail, the study investigates whether individuals’ propensity to follow the recommendation received from an advisor changes depending on whether the advisor is a human or a robot. The analysis is based on data collected through an ad hoc developed laboratory experiment run in the Cesare Lab of LUISS University with a sample of 180 students. Students were given an initial monetary endowment and were asked to choose between six different portfolios of financial activities; after being profiled through a questionnaire aimed at eliciting their risk tolerance (Grable and Lytton’s Risk Tolerance Quiz; 2003), they received the advice, either from a human advisor or from a robo advisor (i.e. via a computer platform) depending on the treatment they had randomly assigned before entering the experimental session. Then, they were asked again to choose among the six portfolios in order to capture whether the propensity to follow the recommendation depends on its source (human versus robo). Finally, participants were asked to answer several questions eliciting risk preferences, financial literacy (actual and perceived) and digital literacy, serving as control variables when modelling the probability to follow the advice. Our results show that the probability to follow the advice does not depend on the source of the recommendation but rather on the alignment between the self-directed choice made before receiving the advice and the recommendation subsequently received: the propensity to follow the advisor (either human or robo) increases if the advice confirms individual’s own beliefs about her/his investor profile. This result might be explained by referring to individuals’ attitude towards the so called ‘confirmation bias’. However, when the self-directed choice differs from the recommendation received, participants may be more likely to follow the advice given by a human advisor and less likely to follow the advice formulated by an algorithm. Also the gender of the advisor seems to matter: women tend to follow the advice provided by a female advisor more frequently compared to the case of the recommendation given by a male advisor. This work is part of a wider research on FinTech that CONSOB started in 2016, in collaboration with several Italian universities, with the aim of exploring opportunities and risks for investor protection and the financial system as a whole, related to the application of technological innovation to the provision of financial services. In particular, supplementing Lener, Linciano and Soccorso (2019, edited by) and Caratelli et al. (2019), this document widens the field of investigation by referring to a specific target of the population - the so called millennials and post-millennials – and using complementary and innovative methods. According to an evidence-based approach, insights from the present study may suggest specific investor protection initiatives, also in terms of financial education activities designed for a clearly-identified segment of the population (the so called millennials and post-millennials, in this case). Evidence from the present work might be extended further with respect to the consumers’ perception of the fairness of algorithms used to provide financial services, the cognitive heuristics and biases underlying decision making process and investments in the digital environment and nudges which may be used to enhance investor protection

La digitalizzazione della consulenza in materia di investimenti finanziari

La consulenza automatizzata (robo advice) è un fenomeno sempre più diffuso, al quale regolatori nazionali e istituzioni sovranazionali dedicano un’attenzione crescente, come attestano le numerose ricognizioni disponibili e le iniziative tese ad adeguare i presidi normativi esistenti alle innovazioni derivanti dall’automazione. Il lavoro traccia una ricognizione del fenomeno in Italia e valuta i profili di attenzione per la tutela dell’investitore retail