Do Risk Attitudes Differ across Domains and Respondent Types?

Risk preferences over health: Empirical estimates and implications for medical decision-making

Mainstream health economic theory implies that an expected gain in health-related quality of life (HRQoL) produces the same value for consumers, regardless of baseline health. Several strands of recent research call this implication into question. Generalized Risk-Adjusted Cost-Effectiveness (GRACE) demonstrates theoretically that baseline health status influences value, so long as consumers are not risk-neutral over health. Prior empirical literature casts doubt on risk-neutral expected utility-maximization in the health domain. We estimate utility over HRQoL in a nationally representative U.S. population and use our estimates to measure risk preferences over health. We find that individuals are risk-seeking at low levels of health, become risk-averse at health equal to 0.485 (measured on a 0-1 scale), and are most risk-averse at perfect health (coefficient of relative risk aversion = 4.51). We develop the resulting implications for medical decision making, cost-effectiveness analyses, and the proper theory of health-related decision making under uncertainty.

Preference Variation: Where Does Health Risk Attitude Come Into the Equation?

OBJECTIVES

Decisions about health often involve risk, and different decision makers interpret and value risk information differently. Furthermore, an individual's attitude toward health-specific risks can contribute to variation in health preferences and behavior. This study aimed to determine whether and how health-risk attitude and heterogeneity of health preferences are related.

METHODS

To study the association between health-risk attitude and preference heterogeneity, we selected 3 discrete choice experiment case studies in the health domain that included risk attributes and accounted for preference heterogeneity. Health-risk attitude was measured using the 13-item Health-Risk Attitude Scale (HRAS-13). We analyzed 2 types of heterogeneity via panel latent class analyses, namely, how health-risk attitude relates to (1) stochastic class allocation and (2) systematic preference heterogeneity.

RESULTS

Our study did not find evidence that health-risk attitude as measured by the HRAS-13 distinguishes people between classes. Nevertheless, we did find evidence that the HRAS-13 can distinguish people's preferences for risk attributes within classes. This phenomenon was more pronounced in the patient samples than in the general population sample. Moreover, we found that numeracy and health literacy did distinguish people between classes.

CONCLUSIONS

Modeling health-risk attitude as an individual characteristic underlying preference heterogeneity has the potential to improve model fit and model interpretations. Nevertheless, the results of this study highlight the need for further research into the association between health-risk attitude and preference heterogeneity beyond class membership, a different measure of health-risk attitude, and the communication of risks.

Predicting medical practices using various risk attitude measures

This paper investigates the predictive power of several risk attitude measures on a series of medical practices. We elicit risk preferences on a sample of 1500 French general practitioners (GPs) using two different classes of tools: scales, which measure GPs' own perception of their willingness to take risks between 0 and 10; and lotteries, which require GPs to choose between a safe and a risky option in a series of hypothetical situations. In addition to a daily life risk scale that measures a general risk attitude, risk taking is measured in different domains for each tool: financial matters, GPs' own health, and patients' health. We take advantage of the rare opportunity to combine these multiple risk attitude measures with a series of self-reported or administratively recorded medical practices. We successively test the predictive power of our seven risk attitude measures on eleven medical practices affecting the GPs' own health or their patients' health. We find that domain-specific measures are far better predictors than the general risk attitude measure. Neither of the two classes of tools (scales or lotteries) seems to perform indisputably better than the other, except when we concentrate on the only non-declarative practice (prescription of biological tests), for which the classic money-lottery test works well. From a public health perspective, appropriate measures of willingness to take risks may be used to make a quick, but efficient, profiling of GPs and target them with personalized communications, or interventions, aimed at improving practices.

Comparing GPs' risk attitudes for their own health and for their patients' : a troubling discrepancy?

Background

In this paper, we report the results of risk attitudes elicitation of a French general practitioners national representative sample (N=1568).

Methods

Willingness to take risks in four different domains (daily life, financial matters, own health and patient health) was collected through a large-scale telephone interview of GPs using self-reported 11-point Likert scale questions.

Results

We uncover some specificities of the GPs population regarding their attitudes towards risk. In particular, we detect an important positive gap between their willingness to take risks in the domain of their own health and in the domain of the heath of their patients. This “patient-regarding” risk aversion is discussed with respect to its important consequences regarding medical behavior bias.

Conclusions

We confirm the self-other discrepancy found in the medical literature on physicians’ behaviors and emphasize the utility of the study and measures of personality traits such as “risk attitudes” for the medical professions and for the population they address.

Combined evaluation of personality, risk and coping in MS patients: A step towards individualized treatment choice - The PeRiCoMS-Study I

BACKGROUND

Multiple sclerosis (MS) is a chronic inflammatory neurological disease requiring disease-modifying treatment (DMT). To provide patients with the optimal individual therapeutic option, treatment recommendations should be based not only on individual disease course and DMT specific benefit-risk estimates, but also on patient's individual characteristics such as personality, risk attitude and coping strategies. However, these characteristics are difficult to objectify in clinical routine practice without the support of appropriate evaluation instruments.

OBJECTIVE

To identify and to assemble an objective test battery measuring personality, risk attitude and coping strategies in MS patients.

METHODS

A comprehensive literature search was performed to obtain all questionnaires assessing personality, risk attitude and coping strategies. Availability in German language, validation in a published normative collective and a reliability of >0.70 were required for our purposes. Based on these criteria, we chose the Big-Five-Personality Test, UPPS Impulsive Behaviour Scale, Domain-Specific Risk-Taking scale (DOSPERT), Brief-COPE and Stress & Coping Inventory (SCI). Results were compared to published normative controls of the respective questionnaires.

RESULTS

Out of 22 MS patients (7 males, 15 females) participating in this study, 19 (86.4%) completed all questionnaires. The median completion time was 45min (min-max range: 25-60min). The median scores of the MS group were within the average range of published control samples in all questionnaires.

CONCLUSIONS

We report that traits of personality, risk attitude and coping strategies can be effectively and feasibly tested in MS patients by the instruments used in our exploratory study. There were no differences between MS patients and healthy controls, thus enabling assessment without being influenced by the diagnosis of MS. After validation in a larger cohort the "PeRiCoMS"-battery will be useful as another step towards a more individualized shared-decision-making in every day routine practice.

Doctor-patient differences in risk and time preferences: A field experiment

We conduct a framed field experiment among patients and doctors to test whether the two groups have similar risk and time preferences. We elicit risk and time preferences using multiple price list tests and their adaptations to the healthcare context. Risk and time preferences are compared in terms of switching points in the tests and the structurally estimated behavioural parameters. We find that doctors and patients significantly differ in their time preferences: doctors discount future outcomes less heavily than patients. We find no evidence that doctors and patients systematically differ in their risk preferences in the healthcare domain.

Risk attitudes and risk perceptions in individuals with multiple sclerosis

BACKGROUND

Little is known about risk attitudes and risk perceptions in multiple sclerosis (MS).

OBJECTIVES

The objectives of this paper are to investigate the range of risk attitudes and risk perceptions and examine associations between risk attitudes and risk perceptions and demographic and clinical features of the disease.

METHODS

A total of 223 individuals completed a risk questionnaire. Risk attitude was measured using two rating scales and a standard gamble scenario. Risk perception was measured by asking participants to estimate the likelihood of disease progression and the likelihood of minor and serious side effects associated with common MS therapies.

RESULTS

Participants were risk neutral overall and risk averse on issues related to health and safety. There was a significant association between disease duration and risk attitude, with patients with longer disease duration showing greater tolerance for risk. On the standard gamble scenario, males were significantly more likely to take treatments with a likelihood of death of 1:10,000 or 1:100,000 than females. Individuals with higher disability or a progressive disease course were significantly more likely to expect progression at two, five and 10 years.

CONCLUSION

Individuals with MS demonstrate low tolerance for risk. Risk attitudes and perceptions are influenced by some demographic and clinical features of the disease.

In Sickness but Not in Wealth

We present results from a hypothetical framed field experiment assessing whether risk preferences significantly differ across the health and financial domains when they are elicited through the same multiple price list paired-lottery method. We consider a sample of 300 patients attending outpatient clinics in a university hospital in Athens during the Greek financial crisis. Risk preferences in finance were elicited using paired-lottery questions with hypothetical payments. The questions were adapted to the health domain by framing the lotteries as risky treatments in hypothetical health care scenarios. Using maximum likelihood methods, we estimated the degree of risk aversion, allowing for the estimates to be dependent on domain and individual characteristics. The subjects in our sample, who were exposed to both health and financial distress, tended to be less risk averse in the financial domain than in the health domain.

Predicting prostate cancer treatment choices: The role of numeracy, time discounting, and risk attitudes

Prostate cancer is the most common cancer among males in the United States, and there is lack of consensus as to whether active surveillance or radical prostatectomy is the best course of treatment. In this study, we examined the role of numeracy, time discounting, and risk taking on decision-making about prostate cancer treatment-in 279 men over age 50 without a prior prostate cancer diagnosis. Results showed that active surveillance was the most chosen option and its preference was predicted by numeracy and time discounting. However, radical prostatectomy was significantly predicted by participants' propensity to take risks.

A framework for estimating health state utility values within a discrete choice experiment: modeling risky choices

BACKGROUND

There has been recent interest in using the discrete choice experiment (DCE) method to derive health state utilities for use in quality-adjusted life year (QALY) calculations, but challenges remain.

OBJECTIVES

We set out to develop a risk-based DCE approach to derive utility values for health states that allowed 1) utility values to be anchored directly to normal health and death and 2) worse than dead health states to be assessed in the same manner as better than dead states. Furthermore, we set out to estimate alternative models of risky choice within a DCE model.

METHOD

A survey was designed that incorporated a risk-based DCE and a "modified" standard gamble (SG). Health state utility values were elicited for 3 EQ-5D health states assuming "standard" expected utility (EU) preferences. The DCE model was then generalized to allow for rank-dependent expected utility (RDU) preferences, thereby allowing for probability weighting. A convenience sample of 60 students was recruited and data collected in small groups.

RESULTS

Under the assumption of "standard" EU preferences, the utility values derived within the DCE corresponded fairly closely to the mean results from the modified SG. Under the assumption of RDU preferences, the utility values estimated are somewhat lower than under the assumption of standard EU, suggesting that the latter may be biased upward.

CONCLUSION

Applying the correct model of risky choice is important whether a modified SG or a risk-based DCE is deployed. It is, however, possible to estimate a probability weighting function within a DCE and estimate "unbiased" utility values directly, which is not possible within a modified SG. We conclude by setting out the relative strengths and weaknesses of the 2 approaches in this context.

Risk associated behavior in premorbid multiple sclerosis: A case-control study

BACKGROUND

It is generally accepted that individuals who subsequently develop MS are more likely to be smokers, have suffered glandular fever and to have a low blood vitamin D level. Previous research suggested that a unifying premise is risk-associated behavior before MS onset. This survey explores several health-adverse premorbid behaviors using a case-control design.

METHODS

A questionnaire was completed by 94 patients with clinically definite MS. Their responses were compared to a control group of 59 who were patients with benign headache. Questions explored pre-symptomatic experience of: (a) alcohol, smoking, substance abuse, glandular fever; (b) blood transfusion; (c) hazardous sport, gambling (d) sexual history, gynecologic infection, number of pregnancies, terminations of pregnancy. Data were adjusted for age of first symptoms, gender and smoking.

RESULTS

Compared to the headache group, MS subjects showed significant differences prior to symptom onset, adjusted for age of first symptoms, gender and smoking, with odds ratios for reporting or means and 95% confidence intervals as follows: (a) consuming alcoholic drinks, OR 6.91 (1.74 to 27.45; p=0.006) and at an earlier age, mean 16.9y (16.4 to 17.5; p=0.046) (b) cigarette smoking, OR 2.24 (1.09 to 4.59; p=0.028) and to have smoked more per day, mean 9.45 (5.55 to 13.35; p=0.001) (c) history of glandular fever/infectious mononucleosis, OR 3.07 (1.11 to 8.49; p=0.031); (d) consumed recreational drugs, OR 3.90 (1.32 to 11.50; p=0.014), notably cannabis, OR 4.10 (1.40 to 12.09; p=0.011); (e) used a car seat belt, OR 4.45 (1.43 to 13.83; p=0.010); (f) attended all-night parties, OR 2.45 (1.12 to 5.36; p=0.025); (g) sunbathed, OR 2.770 (1.02 to 7.52; p=0.046); (h) had more sexual partners, mean 3.97 (2.00 to 5.95; p<0.001), more pregnancies, mean 1.43 (0.99 to 1.86; p=0.015) and one or more terminations of pregnancy, OR 5.05 (1.003 to 25.386; p=0.049).

CONCLUSION

All but one of the statistically significant variables (use of car seat belt) supports our hypothesis that MS subjects lead a riskier premorbid lifestyle. Strong associations were found for smoking, alcohol and glandular fever as suggested by others. Novel associations were found for recreational drug use; attending all-night parties; gambling on the lottery; more sexual partners, more pregnancies and one or more terminations of pregnancy. Such behavior during the MS prodrome may expose an individual to a variety of hostile environmental agents.