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Health state utility (HSU) is a core component of QALYs and cost-effectiveness analysis, although HSU is rarely estimated among a representative sample of patients. We explored the feasibility of assessing HSU in head and neck cancer from the French National Hospital Discharge database.
An exhaustive sample of 53,258 incident adult patients with a first diagnosis of head and neck cancer was identified in 2010–2012. We used a cross-sectional approach to define five health states over two periods: three "cancer stages at initial treatment" (early, locally advanced or metastatic stage); a "relapse state" and otherwise a "relapse-free state" in the follow-up of patients initially treated at early or locally advanced stage. In patients admitted in post-acute care, a two-parameter graded response model (Item Response Theory) was estimated from all 144,012 records of six Activities of Daily Living (ADLs) and the latent health state scale underlying ADLs was calibrated with the French EQ-5D-3 L social value set. Following linear interpolation between all assessments of the patient, daily estimates of utility in post-acute care were averaged by health state, patient and month of follow-up. Finally, HSU was estimated by health state and month of follow-up for the whole patient population after controlling for survivorship and selection in post-acute care.
Head and neck cancer was generally associated with poor HSU estimates in a real-life setting. As compared to “distant metastasis at initial treatment”, mean HSU was higher in other health states, although numerical differences were small (0.45 versus around 0.54). It was primarily explained by the negative effects on HSU of an older age (38.4% aged ≥70 years in “early stage at initial treatment”) and comorbidities (> 50% in other health states). HSU estimates significantly improved over time in the “relapse-free state” (from 8 to 12 months of follow-up).
HSU estimates in head and neck cancer were primarily driven by age at diagnosis, comorbidities, and time to assessment of cancer survivors. This feasibility study highlights the potential of estimating HSU within and across severe conditions in a systematic way at the national level.
We evaluate the introduction of various forms of antihypertensive treatments in France with a distribution-sensitive cost-benefit analysis. Compared to traditional cost-benefit analysis, we implement distributional weighting based on equivalent incomes, a new concept of individual well-being that does respect individual preferences but is not subjectively welfarist. Individual preferences are estimated on the basis of a contingent valuation question, introduced into a representative survey of the French population. Compared to traditional cost-effectiveness analysis in health technology assessment, we show that it is feasible to go beyond a narrow evaluation of health outcomes while still fully exploiting the sophistication of medical information. Sensitivity analysis illustrates the relevancy of this richer welfare framework, the importance of the distinction between an ex ante and an ex post approach, and the need to consider distributional effects in a broader institutional setting.
Dementia is a prevalent condition, affecting 5-7% of people aged 60 years and older, and a leading cause of disability in people aged 60 years and older globally. We aimed to examine the association between alcohol use disorders and dementia risk, with an emphasis on early-onset dementia (<65 years).
We analysed a nationwide retrospective cohort of all adult (≥20 years) patients admitted to hospital in metropolitan France between 2008 and 2013. The primary exposure was alcohol use disorders and the main outcome was dementia, both defined by International Classification of Diseases, tenth revision discharge diagnosis codes. Characteristics of early-onset dementia were studied among prevalent cases in 2008-13. Associations of alcohol use disorders and other risk factors with dementia onset were analysed in multivariate Cox models among patients admitted to hospital in 2011-13 with no record of dementia in 2008-10.
Of 31 624 156 adults discharged from French hospitals between 2008 and 2013, 1 109 343 were diagnosed with dementia and were included in the analyses. Of the 57 353 (5·2%) cases of early-onset dementia, most were either alcohol-related by definition (22 338 [38·9%]) or had an additional diagnosis of alcohol use disorders (10 115 [17·6%]). Alcohol use disorders were the strongest modifiable risk factor for dementia onset, with an adjusted hazard ratio of 3·34 (95% CI 3·28-3·41) for women and 3·36 (3·31-3·41) for men. Alcohol use disorders remained associated with dementia onset for both sexes (adjusted hazard ratios >1·7) in sensitivity analyses on dementia case definition (including Alzheimer's disease) or older study populations. Also, alcohol use disorders were significantly associated with all other risk factors for dementia onset (all p<0·0001).
Alcohol use disorders were a major risk factor for onset of all types of dementia, and especially early-onset dementia. Thus, screening for heavy drinking should be part of regular medical care, with intervention or treatment being offered when necessary. Additionally, other alcohol policies should be considered to reduce heavy drinking in the general population.
We focus on the design of an institutional device aimed to foster coordination through communication. We explore whether the social psychology theory of commitment, implemented via a truth-telling oath, can reduce coordination failure. Using a classic coordination game, we ask all players to sign voluntarily a truth-telling oath before playing the game with cheap talk communication. Three results emerge with commitment under oath: (1) coordination increased by nearly 50%; (2) senders’ messages were significantly more truthful and actions more efficient, and (3) receivers’ trust of messages increased.
This article presents an assessment of individual uncertainty about longevity. A survey performed on 3,331 French people enables us to record several survival probabilities per individual. On this basis, we compute subjective life expectancies (SLE) and subjective uncertainty regarding longevity (SUL), the standard deviation of each individual’s subjective distribution of her or his own longevity. It is large and equal to more than 10 years for men and women. Its magnitude is comparable to the variability of longevity observed in life tables for individuals under 60, but it is smaller for those older than 60, which suggests use of private information by older respondents. Our econometric analysis confirms that individuals use private information—mainly their parents’ survival and longevity—to adjust their level of uncertainty. Finally, we find that SUL has a sizable impact, in addition to SLE, on risky behaviors: more uncertainty on longevity significantly decreases the probability of unhealthy lifestyles. Given that individual uncertainty about longevity affects prevention behavior, retirement decisions, and demand for long-term care insurance, these results have important implications for public policy concerning health care and retirement.
Stated preference surveys are usually carried out in one session, without any follow-up interview after respondents have had the opportunity to experience the public goods or policies they were asked to value. Consequently, a stated preference survey needs to be designed so as to provide respondents with all the relevant information, and to help them process this information so they can perform the valuation exercise properly. In this paper, we study experimentally an elicitation procedure in which respondents are provided with a sequence of different types of information (social cues and objective information) that allows them to sequentially revise their willingness-to-pay (WTP) values. Our experiment was carried out in large groups using an electronic voting system which allows us to construct social cues in real time. To analyse the data, we developed an anchoring-type structural model that allows us to estimate the direct effect (at the current round) and the indirect effect (on subsequent rounds) of information. Our results shed new light on the interacted effect of social cues and objective information: social cues have little or no direct effect on WTP values but they have a strong indirect effect on how respondents process scientific information. Social cues have the most noticeable effect on respondents who initially report a WTP below the group average but only after receiving additional objective information about the valuation task. We suggest that the construction and the provision of social cues should be added to the list of tools and controls for stated preference methods.
Herein we explore whether a solemn oath can eliminate hypothetical bias in a voting referenda, a popular elicitation mechanism promoted in non-market valuation exercises for its incentive compatibility properties. First, we reject the null hypothesis that a hypothetical bias does not exist. Second, we observe that people who sign an oath are significantly less likely to vote for the public good in a hypothetical referenda. We complement this evidence with a self-reported measure of honesty which confirms that the oath increases truthfulness in answers. This result opens interesting avenues for improving the elicitation of preferences in the lab and beyond.
FR : Malgré un intérêt croissant pour les déterminants non-monétaires des comportements fiscaux (tax morale), la littérature récente apporte peu d'éléments empiriques sur le lien entre les caractéristiques de personnalité reliées à la moralité et la propension à l'évasion fiscale. Or de telles mesures sont nécessaires pour comprendre les canaux de transmission des dispositifs de lutte contre l'évasion fiscale. Pour pallier cette lacune, le présent article rend compte d'une expérience en laboratoire permettant d'observer à la fois les comportements de déclaration de revenu des participants et des mesures psychologiques issues de la littérature en psychométrie : soumission à la norme, empathie affective et cognitive, et propension à ressentir la honte et la culpabilité. Ces mesures sont combinées à l'aide d'une analyse en composantes principales afin d'en extraire les facteurs indépendants. Nos résultats montrent que la décision de frauder comme son intensité sont fortement liées à l'empathie affective, l'empathie cognitive et la dimension publique de la moralité (mesurée par la soumission à la norme et la propension à la honte). La propension à ressentir la culpabilité, en revanche, est sans effet. Surtout, le pouvoir explicatif global de ces mesures de moralité individuelles est relativement faible. Ce résultat remet en cause l'hypothèse d'une moralité fiscale intrinsèque, et met l'accent sur l'importance du contexte institutionnel pour comprendre les comportements d'évasion.
EN: Despite an increasing interest in the non-monetary determinants of tax behaviors (also known as tax morale), the recent literature offers few empirical elements on the link between moral personality characters and tax evasion propensity. However, such measures are necessary to understand the transmission channels of policies targeted at fighting against tax evasion. To fill this gap, this paper reports a lab experiment allowing to observe participants' behaviors of income declaration and psychological measures from the psychometric literature: norm-submission, affective empathy, cognitive empathy, propensity to feel guilt and shame. These measures are combined through a Principal Component Analysis to extract independent factors. Results show that the decision to evade as well as its intensity are very highly related to affective empathy, cognitive empathy and public dimension of morality (measured by norm submission and propensity to feel shame). The propensity to feel guiltiness is, however, without significant effects. More importantly, the explanatory power of these individual morality measures is rather weak. This result challenges the assumption of an intrinsical tax morale and highlights the importance of the institutional context to understand evasion behaviors.
Sous l’impulsion, notamment, de l’essor de l’économie expérimentale, la littérature récente a mis en évidence un large éventail de situations dans lesquelles les incitations monétaires échouent à orienter les comportements dans le sens désiré. Ce constat conduit à rechercher des mécanismes institutionnels alternatifs, capables de se substituer aux incitations monétaires. Cet article propose une revue des travaux s’inspirant de la psychologie sociale de l’engagement afin de développer des mécanismes non monétaires susceptibles d’affecter les comportements. Ces travaux étudient une procédure d’engagement particulière : un serment à dire la vérité. Cette procédure a été appliquée avec succès (1) au problème du biais hypothétique dans la révélation des préférences pour les biens non marchands, (2) aux défauts de coordination, et (3) à la propension à dire la vérité. Pris ensemble, ces travaux confirment la capacité de mécanismes d’engagement à guider l’élaboration d’institutions non monétaires capables d’orienter efficacement les comportements économiques.