Eliciting risk preferences that predict risky health behaviour: A comparison of two approaches

Information on attitudes to risk could increase understanding of and explain risky health behaviors. We investigate two approaches to eliciting risk preferences in the health domain, a novel “indirect” lottery elicitation approach with health states as outcomes and a “direct” approach where respondents are asked directly about their willingness to take risks. We compare the ability of the two approaches to predict health-related risky behaviors in a general adult population. We also investigate a potential framing effect in the indirect lottery elicitation approach. We find that risk preferences elicited using the direct approach can better predict health-related risky behavior than those elicited using the indirect approach. Moreover, a seemingly innocuous change to the framing of the lottery question results in significantly different risk preference estimates, and conflicting conclusions about the ability of the indicators to predict risky health behaviors

Reducing demand for antibiotic prescriptions: evidence from an online survey of the general public on the interaction between preferences, beliefs and information, United Kingdom, 2015

Background: Antimicrobial resistance (AMR), a major public health threat, is strongly associated with human antibiotic consumption. Influenza-like illnesses (ILI) account for substantial inappropriate antibiotic use; patient understanding and expectations probably play an important role. Aim: This study aimed to investigate what drives patient expectations of antibiotics for ILI and particularly whether AMR awareness, risk preferences (attitudes to taking risks with health) or time preferences (the extent to which people prioritise good health today over good health in the future) play a role. Methods: In 2015, a representative online panel survey of 2,064 adults in the United Kingdom was asked about antibiotic use and effectiveness for ILI. Explanatory variables in multivariable regression included AMR awareness, risk and time preferences and covariates. Results: The tendency not to prioritise immediate gain over later reward was independently strongly associated with greater awareness that antibiotics are inappropriate for ILI. Independently, believing antibiotics were effective for ILI and low AMR awareness significantly predicted reported antibiotic use. However, 272 (39%) of those with low AMR awareness said that the AMR information we provided would lead them to ask a doctor for antibiotics more often, significantly more than would do so less often, and in contrast to those with high AMR awareness (p < 0.0001). Conclusion: Information campaigns to reduce AMR may risk a paradoxical consequence of actually increasing public demand for antibiotics. Public antibiotic stewardship campaigns should be tested on a small scale before wider adoption

The challenge of antimicrobial resistance: What economics can contribute

BACKGROUND: Antimicrobial resistance (AMR) is increasing, driven by widespread antibiotic use. The wide availability of effective antibiotics is under threat, jeopardizing modern health care. Forecasts of the economic costs are similar to those of a 2°C rise in global average surface temperature, above preindustrial levels. AMR is becoming an urgent priority for policy-makers, and pressure is mounting to secure international commitments to tackle the problem. // ADVANCES: Estimating the value of interventions to reduce antibiotic use requires predictions of future levels of antibiotic resistance. However, modeling the trajectory of antibiotic resistance, and how marginal changes in antibiotic consumption contribute to resistance, is complex. The challenge of estimating the resulting impact on health and the economy is similarly daunting. As with the cost of climate change, estimates of total AMR costs are fraught with uncertainty and may be far too low. Much of the uncertainty arises from the complexity of estimating the cost of changes in overall resistance levels. This cost depends on various factors: which drug and pathogen are involved, the mechanism of antibiotic resistance, the prevalence of that pathogen, the types of infections it causes and their level of transmissibility, the health burden of those infections, and whether alternative treatments are available. Effective new antibiotics are urgently needed. However, without government intervention, R&D for antibiotics is rarely profitable, and most major pharmaceutical companies have left the field. New ways are needed to make antibiotic development profitable, decoupling profits from volumes sold. // OUTLOOK: Analogies can be drawn between climate change and AMR, both of which have been described as a global “tragedy of the commons.” There is some consensus that we should treat carbon emissions reduction as an insurance policy against the possibility of a catastrophic climate outcome—and avoid waiting for a definitive optimum-abatement policy. A similar paradigm shift is needed to incentivize both the introduction and valuation of interventions to reduce antibiotic use and R&D of new antibiotics. Rather than taxing the price and letting the market dictate the quantity of antibiotics supplied, an alternative may be to establish a regulatory body that issues prescribers tradable permits and to allow the market to determine the price. Such an approach could create a predictable revenue stream through more-foreseeable licensing fees for important antibiotics by decoupling the return on investment from the volume used. Approaches such as this could incentivize industry to develop new antibiotics for which there would otherwise be too small a market to provide a sufficient return on investment. Reducing inappropriate antibiotic use while expanding essential access is a difficult challenge, especially in low- and middle-income countries. However, policy-makers and philanthropists are alert to the importance of AMR and increasingly are making substantial research funds available, with much of these funds devoted to the social sciences. We need economists, across many different fields, to engage with this pressing global problem

Awareness of appropriate antibiotic use in primary care for influenza-like illness: Evidence of improvement from UK population-based surveys

Supplementary Materials: The following are available online at https://www.mdpi.com/2079-6382/9/10/690/s1, Figure S1: Changes from Survey 1 (red) to Survey 3 (blue) in the percentage of individuals who would go to the GP with ILI by population subgroup; Figure S2. Changes from Survey 1 (red) to Survey 3 (blue) in the percentage of individuals would ask for antibiotics by population subgroup; Figure S3. Changes from Survey 1 (red) to Survey 3 (blue) in the percentage of individuals that have taken antibiotics for ILI in the past 12 months by population subgroup; Figure S4. Changes from Survey 1 (red) to Survey 3 (blue) in the percentage of individuals that would go to GP with a child with ILI by population subgroup; Figure S5. Changes from Survey 1 (red) to Survey 3 (blue) in the percentage of individuals that would ask for antibiotics for a child with ILI by population subgroup; Figure S6. Changes from Survey 1 (red) to Survey 3 (blue) in the percentage of individuals that think antibiotics would help for a child with ILI by population subgroup; Figure S7. Changes from Survey 1 (red) to Survey 3 (blue) in the percentage of individuals for which child has taken an antibiotic for ILI in the past 12 months by population subgroup; Figure S8. Changes from Survey 1 (red) to Survey 3 (blue) in the percentage of individuals for which AMR information was surprising/new by population subgroup.Copyright © 2020 by the authors. Influenza-like illnesses (ILI) account for a significant portion of inappropriate antibiotic use. Patient expectations for antibiotics for ILI are likely to play a substantial role in ‘unnecessary’ antibiotic consumption. This study aimed to investigate trends in awareness of appropriate antibiotic use and antimicrobial resistance (AMR). Three sequential online surveys of independent representative samples of adults in the United Kingdom investigated expectations for, and consumption of, antibiotics for ILI (May/June 2015 (n = 2064); Oct/Nov 2016 (n = 4000); Mar 2017 (n = 4000)). Respondents were asked whether they thought antibiotics were effective for ILI and about their antibiotic use. Proportions and 95% confidence intervals (CI) were calculated for each question and interactions with respondent characteristics were tested using logistic regression. Over the three surveys, the proportion of respondents who believed antibiotics would “definitely/probably” help an ILI fell from 37% (95% CI 35–39%) to 28% (95% CI 26–29%). Those who would “definitely/probably” visit a doctor in this situation fell from 48% (95% CI 46–50%) to 36% (95% CI 34–37%), while those who would request antibiotics during a consultation fell from 39% (95% CI 37–41%) to 30% (95% CI 29–32%). The percentage of respondents who found the information we provided about AMR “new/surprising” fell from 34% (95% CI 32–36%) to 28% (95% CI 26–31%). Awareness improved more among black, Asian and minority ethnic (BAME) than white people, with little other evidence of differences in improvements between subgroups. Whilst a degree of selection bias is unavoidable in online survey samples, the results suggest that awareness of AMR and appropriate antibiotic use has recently significantly improved in the United Kingdom, according to a wide range of indicators.The research was funded by the National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford in partnership with Public Health England (PHE) [grant numbers HPRU-2012-10041 and NIHR200915], and the NIHR HPRU in Evaluation of Interventions at the University of Bristol, also in partnership with PHE [grant number HPRU-2012-10026]. Michele Peters is an Associate Professor supported by the NIHR funded Policy Research Unit on Quality, Safety and Outcomes (QSO), a collaboration between the Universities of Kent and Oxford, the London School of Hygiene and Tropical Medicine, the Hull-York Medical School and the Picker Institute. Laurence S. J. Roope, James Buchanan, Derrick W. Crook, Tim Peto, A. Sarah Walker and Sarah Wordsworth are partly funded by the Oxford NIHR Biomedical Research Centre. Tim Peto, Christopher C. Butler and A. Sarah Walker are NIHR Senior Investigators. Enrique Castro-Sánchez is affiliated with the NIHR HPRU in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London in partnership with Public Health England [grant number HPRU-2012-10047], is a National Institute for Health Research Senior Nurse and Midwife Research Leader and acknowledges the support of the BRC. The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research (NIHR), the Department of Health, or Public Health England (PHE)

Antibiotic Review Kit for Hospitals (ARK-Hospital): study protocol for a stepped-wedge cluster-randomised controlled trial.

BACKGROUND: To ensure patients continue to get early access to antibiotics at admission, while also safely reducing antibiotic use in hospitals, one needs to target the continued need for antibiotics as more diagnostic information becomes available. UK Department of Health guidance promotes an initiative called 'Start Smart then Focus': early effective antibiotics followed by active 'review and revision' 24-72 h later. However in 2017, < 10% of antibiotic prescriptions were discontinued at review, despite studies suggesting that 20-30% of prescriptions could be stopped safely. METHODS/DESIGN: Antibiotic Review Kit for Hospitals (ARK-Hospital) is a complex 'review and revise' behavioural intervention targeting healthcare professionals involved in antibiotic prescribing or administration in inpatients admitted to acute/general medicine (the largest consumers of non-prophylactic antibiotics in hospitals). The primary study objective is to evaluate whether ARK-Hospital can safely reduce the total antibiotic burden in acute/general medical inpatients by at least 15%. The primary hypotheses are therefore that the introduction of the behavioural intervention will be non-inferior in terms of 30-day mortality post-admission (relative margin 5%) for an acute/general medical inpatient, and superior in terms of defined daily doses of antibiotics per acute/general medical admission (co-primary outcomes). The unit of observation is a hospital organisation, a single hospital or group of hospitals organised with one executive board and governance framework (National Health Service trusts in England; health boards in Northern Ireland, Wales and Scotland). The study comprises a feasibility study in one organisation (phase I), an internal pilot trial in three organisations (phase II) and a cluster (organisation)-randomised stepped-wedge trial (phase III) targeting a minimum of 36 organisations in total. Randomisation will occur over 18 months from November 2017 with a further 12 months follow-up to assess sustainability. The behavioural intervention will be delivered to healthcare professionals involved in antibiotic prescribing or administration in adult inpatients admitted to acute/general medicine. Outcomes will be assessed in adult inpatients admitted to acute/general medicine, collected through routine electronic health records in all patients. DISCUSSION: ARK-Hospital aims to provide a feasible, sustainable and generalisable mechanism for increasing antibiotic stopping in patients who no longer need to receive them at 'review and revise'. TRIAL REGISTRATION: ISRCTN Current Controlled Trials, ISRCTN12674243 . Registered on 10 April 2017

The economic challenges of new drug development

The COVID-19 pandemic has witnessed highly successful efforts to produce effective vaccines and treatments at an unprecedented pace. This perspective discusses factors that made this possible, from long-term investments in research infrastructure to major government interventions that absorbed much of the risk from research and development. We discuss key economic obstacles in the discovery of new drugs for infectious diseases, from novel antibiotics to diseases that primarily affect the poor. The world's collective experience of the pandemic may present an opportunity to reform traditional economic models of drug discovery to better address unmet needs. A tax-funded global institution could provide incentives for drug discovery based on their global health impact. International co-operation would be needed to agree and commit to adequate funding mechanisms, and the necessary political will would require strong public support. With the current heightened appreciation of the need for global health system resilience, there may be no better opportunity than now

Characterizing inequality benchmark incomes

Many inequality measures have the property that for any income distribution there exists a benchmark income, above which adding incremental income increases inequality, and below which it decreases inequality. This note provides social preference conditions which guarantee the existence of such a benchmark income. The key condition is a strong version of the Pigou–Dalton transfer principle. The results imply that benchmark incomes exist for virtually all known inequality measures

First estimates of inequality benchmark incomes for a range of countries

It is known that virtually all inequality measures imply the existence of a ‘benchmark income’, above which adding incremental income increases inequality, and below which it decreases inequality. Benchmark incomes can be interpreted as social reference levels that identify the richest individual for whom it would be just to subsidize their income. Despite the intuitive appeal of benchmark incomes, there have been hardly any empirical applications to date. This paper provides the first estimates of benchmark incomes for a range of contrasting countries and different inequality measures. All benchmark incomes lie far above official national poverty lines. The results suggest that economic growth together with falling inequality need not necessarily be poverty reducing

Characterizing inequality benchmark incomes

Many inequality measures have the property that for any income distribution there exists a benchmark income, above which adding incremental income increases inequality, and below which it decreases inequality. This note provides social preference conditions which guarantee the existence of such a benchmark income. The key condition is a strong version of the Pigou–Dalton transfer principle. The results imply that benchmark incomes exist for virtually all known inequality measures

On intertemporal poverty measures: the role of affluence and want

This paper proposes classes of intertemporal poverty measures which take into account both the debilitating impact of prolonged spells in poverty and the mitigating effect of periods of a­ffluence on subsequent poverty. The weight assigned to the level of poverty in each time period depends on the length of the preceding spell of poverty or of non-poverty. The proposed classes of intertemporal poverty measures are quite general and allow for a range of possible judgements as to the overall impact on a poor period of preceding spells of poverty or a­ffluence. We discuss the properties of the proposed classes of measures and axiomatically characterize these measures