Cusimano, Corey, and Geoffrey Goodwin. 2020. “People Judge Others to Have More Control over Beliefs Than They Themselves Do.” PsyArXiv. April 3. doi:10.1037/pspa0000198
Abstract: People attribute considerable control to others over what those individuals believe. However, no work to date has investigated how people judge their own belief control, nor whether such judgments diverge from their judgments of others. We addressed this gap in seven studies and found that people judge others to be more able to voluntarily change what they believe than they themselves are. This occurs when people judge others who disagree with them (Study 1) as well as others agree with them (Studies 2-5, 7), and it occurs when people judge strangers (Studies 1-2, 4-5) as well as close others (Studies 3, 7). It appears not to be explained by impression management or self-enhancement motives (Study 3). Rather, there is a discrepancy between the evidentiary constraints on belief change that people access via introspection, and their default assumptions about the ease of voluntary belief revision. That is, people spontaneously tend to think about the evidence that supports their beliefs, which leads them to judge their beliefs as outside their control. But they apparently fail to generalize this feeling of constraint to others, and similarly fail to incorporate it into their generic model of beliefs (Studies 4-7). We discuss the implications of our findings for theories of ideology-based conflict, actor-observer biases, naïve realism, and on-going debates regarding people’s actual capacity to voluntarily change what they believe.
Saturday, April 4, 2020
The unique social sense of puerperium: Increased empathy and Schadenfreude in parents of newborns
The unique social sense of puerperium: Increased empathy and Schadenfreude in parents of newborns. Ana-María Gómez-Carvajal, Hernando Santamaría-García, Adolfo M. García, Mario Valderrama, Jhony Mejia, Jose Santamaría-García, Mateo Bernal, Jaime Silva, Agustín Ibáñez & Sandra Baez. Scientific Reports volume 10, Article number: 5760. April 2020. https://www.nature.com/articles/s41598-020-62622-7
Abstract: Pregnancy and puerperium are typified by marked biobehavioral changes. These changes, which are traceable in both mothers and fathers, play an important role in parenthood and may modulate social cognition abilities. However, the latter effects remain notably unexplored in parents of newborns (PNs). To bridge this gap, we assessed empathy and social emotions (envy and Schadenfreude) in 55 PNs and 60 controls (childless healthy participants without a romantic relationship or sexual intercourse in the previous 48 hours). We used facial electromyography to detect physiological signatures of social emotion processing. Results revealed higher levels of affective empathy and Schadenfreude in PNs, the latter pattern being accompanied by increased activity of the corrugator suppercilii region. These effects were not explained by potential confounding variables (educational level, executive functioning, depression, stress levels, hours of sleep). Our novel findings suggest that PNs might show social cognition changes crucial for parental bonding and newborn care.
Discussion
This is the first study investigating social cognition abilities in PNs. We found that, compared to controls, PNs exhibited higher levels of affective empathy and Schadenfreude, the latter pattern being accompanied by increased EMG modulations of the corrugator supercilii. These results further our understanding of social cognition changes during the puerperal period.
As expected, PNs showed higher scores than controls in both affective empathy subscales (i.e., empathic concern and personal distress), even after adjusting for executive functioning, educational levels, perceived stress levels and hours of sleep. Conversely, non-significant differences were observed between groups in cognitive empathy. Our results are consistent with previous suggestions7 that empathy is a key aspect of parenting, especially because babies’ needs are expressed non-verbally. Specifically, empathic concern and personal distress levels are highly related with the social cognition abilities required to recognize and care for others people’s feelings, and even turn to their aid45. In line with our findings, in the first stage of bonding, affective empathy is more important and essential than cognitive empathy58. Higher affective empathy levels are involved in better emotional communication, social attachment, and motivation to cooperate58. Increased parental empathy7 facilitates emotional communication, social attachment, parental caring58, and motivation to protect and care for the newborn1. Notably, given the nature of our empathy measure, our results suggest that higher affective empathy levels observed in PNs are not limited to parent-baby interactions, but are also present in scenarios involving other individuals.
Regarding social emotions, our results showed increased Schadenfreude levels in PNs, which were not explained by executive functioning, educational levels, stress levels or hours of sleep. By contrast, envy levels were similar between groups. This pattern may be associated with the multiple hormonal, emotional, and biological changes that take place during pregnancy and puerperium. However, as endocrine, physiological or other biological measures were not included in this study, interpretations about the relevance of these factors should be cautions. A possible explanation for the selective differences in Schadenfreude observed in PNs might be the pleasurable nature of this emotion33,59 and its strong relationship to reward mechanisms40, indexed by increased engagement of the ventral striatum33. In fact, this brain region, along with others (e.g., thalamus, hippocampus and amygdala), is crucially involved in oxytocinergic dynamics33,60. Previous studies suggest that the neurohor mone OXY may partly account for variations in parent-infant interactions7. Higher OXY levels may be associated a wide range of emotions and social behaviors, such as raising children, trusting others, attacking potential outsiders and competing with rivals, which can lead to trust and generosity, but at the same time to increased Schadenfreude61. Null differences in envy might be explained by the fact that, unlike Schadenfreude, this is a non-gratifying emotion that implies feelings of dissatisfaction with another person’s good fortune40. In fact, envy implies greater neuronal activity in pain circuits rather than in the reward and pleasure systems62. Promisingly, this new hypothesis, derived from our behavioral results, paves the way for new cross-methodological studies. Future studies should include neuroimaging measures as well as OXY and other hormones levels in order to test this interpretation.
Additionally, our social emotion task comprised a group of justice-related scenarios. Accordingly, the higher Schadenfreude scores in PNs could reflect an enhanced sensitivity to track unfair situations and respond to scenarios in which those situations are punished. In fact, Schadenfreude might play a positive role when unfair social situations are sanctioned63, which aligns with a widespread human trend to punish unfair or social inappropriate situations –namely, altruistic punishment64, a behavior that is likely underpinned by negative emotions towards defectors. Note, in this sense, that higher OXY levels seem to increase altruistic punishment behavior, by rendering cooperation and promoting cohesion in social groups65. Arguably, PNs exhibited higher Schadenfreude for unfair or threatening scenarios as an expression of an increased sensitivity to track social threats. Conversely, although the envy situations described unfair and inappropriate social situations, the lack of differences between PNs and controls might reflect the role of control mechanisms in the former, favoring proactive punishment over mere unpleasantness in the face of unfair social scenarios.
These interpretations are further supported by our EMG results. In line with previous EMG studies41,42, we found that activity of the zygomaticus major activity was higher for Schadenfreude than envy responses. Consistent with previous research41, this finding suggests that participants seem to exhibit a subtle contortions similar to those involved in the act of smiling when a misfortune happens to another person. In addition, we found that in control participants the depressor muscle activity was higher for envy than Schadenfreude. Depressor supercilii activity show increased activity in response to negative facial stimuli (i.e., angry faces)66. Increased activity of this muscle may be explained by the fact the envy stimuli employed here involve situations related to negative feelings of deservingness (e.g., a young man got a better test score for being the son of a professor) or morality/legality (e.g., a politician takes a vacation using taxpayers’ money). Furthermore, EMG results revealed that implicit muscular correlates of Schadenfreude involve higher activity in the corrugator supercilii for PNs than controls. Note that modulation of the corrugator supercilii indexes the disapproval of an action54, a process noticeably involved in Schadenfreude responses. Considering that linguistic properties of stimuli may affect the zygomaticus major and corrugator supercilii activities67, sentences for envy and Schadenfreude conditions were controlled in terms of length, complexity, and grammatical structure. Thus, our behavioral and EMG results can hardly be attributed to differences in the linguistic properties of both conditions stimuli.
Taken together, our results suggest that affective empathy and emotional reactivity to unfair or threating social situations (Schadenfreude) are increased in PNs. Accordingly, social cognition changes seem present in mothers and fathers of newborns, irrespective of type of delivery. In general, PNs seem more sensitive to the influence of others and to salient social cues, which are crucial for parental bonding. These patterns align with previous studies showing that the neural circuits underlying emotions in response to socially valued scenarios are partly targeted by the oxytocinergic system65. In fact, exogenous OXY levels correlate positively with levels of empathy68,69 and Schadenfreude61. Note, in this sense, that elevated OXY levels in PNs13,17 may selectively facilitate social cognition in certain conditions68,69 and increase the salience of social cues61. Consistent with previous suggestions70,71, it has been proposed that OXY has a dual effect on parental behavior, insofar as it inhibits aggression towards the offspring while promoting territoriality as well as aggressive and defensive behaviors against outsiders. As biological measures were not included in the present study, future research should correlate serum or salivary levels of OXY and other hormones levels (e.g., prolactin, OXY, progesterone, estrogen, and cortisol) of pregnant/puerperium women and their partners with performance in social cognition tasks. Furthermore, given that the relatively small sample size for EMG data is a limitation of this study, further studies should investigative social cognition domains, their associated muscle responses, and their peripheral and neural correlates in larger samples of PNs.
We have found a particular pattern of results as we observed at the same time increased affective empathy and Schadenfreude levels in PNs. Although it has been theoretically suggested that Schadenfreude is a counter-empathic emotion35,72, there is no direct evidence supporting such an association. Indeed, our results showed that empathy and Schadenfreude are not correlated. Thus, our results suggest that empathy and social emotions changes observed in PNs seem to be dissociable.
Besides, in our study we assessed the role of negative mood factors and cognitive factors in modulating Schadenfreude and empathy effects in PNs. In particular, we conducted covariation analyses to assess the extent in which depression and stress modulate the experience of Schadenfreude. These covariation analyses did not reach significant effects suggesting that increased Schadenfreude in PNs is not directly explained by the mediation of other emotional or cognitive changes occurred at afterbirth stages. In addition, puerperium is considered as a particular intense emotional milestone in PNs’ life, usually associated with emotional changes and stress73,74. However, this milestone could be also accompanied by happy mood and the experience of positive emotions such as joy, contempt or happiness. A potential limitation in our study was that we did not measure the role of positive emotions and happy mood in the experience of Schadenfreude. To date, the state-of-art of studies assessing Schadenfreude has shown dissociable neurocognitive and behavioral mechanisms underlying Schadenfreude and positive emotions33,34,63,75. Furthermore, note that this is arguably one of the reasons why previous studies on Schadenfreude have not controlled for the effects of joy or happy mood33,36,42,43,59,76. However, previous studies have revealed the complexity of positive emotions and its influences on secondary emotions77. Those influences could also impact on the experience of social emotions, including Schadenfreude. New studies should assess the extent to which dispositional emotions or instant and evoked emotional states could affect the intensity and experience of social emotions and social cognition in particular biological states as puerperium or pregnancy. Besides, the group of effects on social emotions and empathy observed in PNs could also be affected by general changes on emotional reactions including fear, anger, and happiness among other emotional manifestations. Future studies also should control the effects of primary emotions on the social emotions and empathy. Finally, the difference in the experimental testing contexts between PNs and controls represents a limitation of our study. However, the results of the complementary analyses (with a control group evaluated in the same setting as the experimental groups) suggest that our pattern of results is not explained by differences in testing sites. Future studies should use specific designs to evaluate the potential impact of different contextual variables on performance.
In sum, this report offers unprecedented evidence that PNs exhibit increased emotional reactivity, characterized by an exacerbation of affective empathy and Schadenfreude. These results open a new agenda to examine changes in social cognition and their relationship with neuroendocrine phenomena.
Abstract: Pregnancy and puerperium are typified by marked biobehavioral changes. These changes, which are traceable in both mothers and fathers, play an important role in parenthood and may modulate social cognition abilities. However, the latter effects remain notably unexplored in parents of newborns (PNs). To bridge this gap, we assessed empathy and social emotions (envy and Schadenfreude) in 55 PNs and 60 controls (childless healthy participants without a romantic relationship or sexual intercourse in the previous 48 hours). We used facial electromyography to detect physiological signatures of social emotion processing. Results revealed higher levels of affective empathy and Schadenfreude in PNs, the latter pattern being accompanied by increased activity of the corrugator suppercilii region. These effects were not explained by potential confounding variables (educational level, executive functioning, depression, stress levels, hours of sleep). Our novel findings suggest that PNs might show social cognition changes crucial for parental bonding and newborn care.
Discussion
This is the first study investigating social cognition abilities in PNs. We found that, compared to controls, PNs exhibited higher levels of affective empathy and Schadenfreude, the latter pattern being accompanied by increased EMG modulations of the corrugator supercilii. These results further our understanding of social cognition changes during the puerperal period.
As expected, PNs showed higher scores than controls in both affective empathy subscales (i.e., empathic concern and personal distress), even after adjusting for executive functioning, educational levels, perceived stress levels and hours of sleep. Conversely, non-significant differences were observed between groups in cognitive empathy. Our results are consistent with previous suggestions7 that empathy is a key aspect of parenting, especially because babies’ needs are expressed non-verbally. Specifically, empathic concern and personal distress levels are highly related with the social cognition abilities required to recognize and care for others people’s feelings, and even turn to their aid45. In line with our findings, in the first stage of bonding, affective empathy is more important and essential than cognitive empathy58. Higher affective empathy levels are involved in better emotional communication, social attachment, and motivation to cooperate58. Increased parental empathy7 facilitates emotional communication, social attachment, parental caring58, and motivation to protect and care for the newborn1. Notably, given the nature of our empathy measure, our results suggest that higher affective empathy levels observed in PNs are not limited to parent-baby interactions, but are also present in scenarios involving other individuals.
Regarding social emotions, our results showed increased Schadenfreude levels in PNs, which were not explained by executive functioning, educational levels, stress levels or hours of sleep. By contrast, envy levels were similar between groups. This pattern may be associated with the multiple hormonal, emotional, and biological changes that take place during pregnancy and puerperium. However, as endocrine, physiological or other biological measures were not included in this study, interpretations about the relevance of these factors should be cautions. A possible explanation for the selective differences in Schadenfreude observed in PNs might be the pleasurable nature of this emotion33,59 and its strong relationship to reward mechanisms40, indexed by increased engagement of the ventral striatum33. In fact, this brain region, along with others (e.g., thalamus, hippocampus and amygdala), is crucially involved in oxytocinergic dynamics33,60. Previous studies suggest that the neurohor mone OXY may partly account for variations in parent-infant interactions7. Higher OXY levels may be associated a wide range of emotions and social behaviors, such as raising children, trusting others, attacking potential outsiders and competing with rivals, which can lead to trust and generosity, but at the same time to increased Schadenfreude61. Null differences in envy might be explained by the fact that, unlike Schadenfreude, this is a non-gratifying emotion that implies feelings of dissatisfaction with another person’s good fortune40. In fact, envy implies greater neuronal activity in pain circuits rather than in the reward and pleasure systems62. Promisingly, this new hypothesis, derived from our behavioral results, paves the way for new cross-methodological studies. Future studies should include neuroimaging measures as well as OXY and other hormones levels in order to test this interpretation.
Additionally, our social emotion task comprised a group of justice-related scenarios. Accordingly, the higher Schadenfreude scores in PNs could reflect an enhanced sensitivity to track unfair situations and respond to scenarios in which those situations are punished. In fact, Schadenfreude might play a positive role when unfair social situations are sanctioned63, which aligns with a widespread human trend to punish unfair or social inappropriate situations –namely, altruistic punishment64, a behavior that is likely underpinned by negative emotions towards defectors. Note, in this sense, that higher OXY levels seem to increase altruistic punishment behavior, by rendering cooperation and promoting cohesion in social groups65. Arguably, PNs exhibited higher Schadenfreude for unfair or threatening scenarios as an expression of an increased sensitivity to track social threats. Conversely, although the envy situations described unfair and inappropriate social situations, the lack of differences between PNs and controls might reflect the role of control mechanisms in the former, favoring proactive punishment over mere unpleasantness in the face of unfair social scenarios.
These interpretations are further supported by our EMG results. In line with previous EMG studies41,42, we found that activity of the zygomaticus major activity was higher for Schadenfreude than envy responses. Consistent with previous research41, this finding suggests that participants seem to exhibit a subtle contortions similar to those involved in the act of smiling when a misfortune happens to another person. In addition, we found that in control participants the depressor muscle activity was higher for envy than Schadenfreude. Depressor supercilii activity show increased activity in response to negative facial stimuli (i.e., angry faces)66. Increased activity of this muscle may be explained by the fact the envy stimuli employed here involve situations related to negative feelings of deservingness (e.g., a young man got a better test score for being the son of a professor) or morality/legality (e.g., a politician takes a vacation using taxpayers’ money). Furthermore, EMG results revealed that implicit muscular correlates of Schadenfreude involve higher activity in the corrugator supercilii for PNs than controls. Note that modulation of the corrugator supercilii indexes the disapproval of an action54, a process noticeably involved in Schadenfreude responses. Considering that linguistic properties of stimuli may affect the zygomaticus major and corrugator supercilii activities67, sentences for envy and Schadenfreude conditions were controlled in terms of length, complexity, and grammatical structure. Thus, our behavioral and EMG results can hardly be attributed to differences in the linguistic properties of both conditions stimuli.
Taken together, our results suggest that affective empathy and emotional reactivity to unfair or threating social situations (Schadenfreude) are increased in PNs. Accordingly, social cognition changes seem present in mothers and fathers of newborns, irrespective of type of delivery. In general, PNs seem more sensitive to the influence of others and to salient social cues, which are crucial for parental bonding. These patterns align with previous studies showing that the neural circuits underlying emotions in response to socially valued scenarios are partly targeted by the oxytocinergic system65. In fact, exogenous OXY levels correlate positively with levels of empathy68,69 and Schadenfreude61. Note, in this sense, that elevated OXY levels in PNs13,17 may selectively facilitate social cognition in certain conditions68,69 and increase the salience of social cues61. Consistent with previous suggestions70,71, it has been proposed that OXY has a dual effect on parental behavior, insofar as it inhibits aggression towards the offspring while promoting territoriality as well as aggressive and defensive behaviors against outsiders. As biological measures were not included in the present study, future research should correlate serum or salivary levels of OXY and other hormones levels (e.g., prolactin, OXY, progesterone, estrogen, and cortisol) of pregnant/puerperium women and their partners with performance in social cognition tasks. Furthermore, given that the relatively small sample size for EMG data is a limitation of this study, further studies should investigative social cognition domains, their associated muscle responses, and their peripheral and neural correlates in larger samples of PNs.
We have found a particular pattern of results as we observed at the same time increased affective empathy and Schadenfreude levels in PNs. Although it has been theoretically suggested that Schadenfreude is a counter-empathic emotion35,72, there is no direct evidence supporting such an association. Indeed, our results showed that empathy and Schadenfreude are not correlated. Thus, our results suggest that empathy and social emotions changes observed in PNs seem to be dissociable.
Besides, in our study we assessed the role of negative mood factors and cognitive factors in modulating Schadenfreude and empathy effects in PNs. In particular, we conducted covariation analyses to assess the extent in which depression and stress modulate the experience of Schadenfreude. These covariation analyses did not reach significant effects suggesting that increased Schadenfreude in PNs is not directly explained by the mediation of other emotional or cognitive changes occurred at afterbirth stages. In addition, puerperium is considered as a particular intense emotional milestone in PNs’ life, usually associated with emotional changes and stress73,74. However, this milestone could be also accompanied by happy mood and the experience of positive emotions such as joy, contempt or happiness. A potential limitation in our study was that we did not measure the role of positive emotions and happy mood in the experience of Schadenfreude. To date, the state-of-art of studies assessing Schadenfreude has shown dissociable neurocognitive and behavioral mechanisms underlying Schadenfreude and positive emotions33,34,63,75. Furthermore, note that this is arguably one of the reasons why previous studies on Schadenfreude have not controlled for the effects of joy or happy mood33,36,42,43,59,76. However, previous studies have revealed the complexity of positive emotions and its influences on secondary emotions77. Those influences could also impact on the experience of social emotions, including Schadenfreude. New studies should assess the extent to which dispositional emotions or instant and evoked emotional states could affect the intensity and experience of social emotions and social cognition in particular biological states as puerperium or pregnancy. Besides, the group of effects on social emotions and empathy observed in PNs could also be affected by general changes on emotional reactions including fear, anger, and happiness among other emotional manifestations. Future studies also should control the effects of primary emotions on the social emotions and empathy. Finally, the difference in the experimental testing contexts between PNs and controls represents a limitation of our study. However, the results of the complementary analyses (with a control group evaluated in the same setting as the experimental groups) suggest that our pattern of results is not explained by differences in testing sites. Future studies should use specific designs to evaluate the potential impact of different contextual variables on performance.
In sum, this report offers unprecedented evidence that PNs exhibit increased emotional reactivity, characterized by an exacerbation of affective empathy and Schadenfreude. These results open a new agenda to examine changes in social cognition and their relationship with neuroendocrine phenomena.
Rats find occupancy of a restraint tube rewarding; these results are difficult to reconcile with accounts of rat empathy based on the thesis that tube restraint distresses occupants
Rats (Rattus norvegicus) find occupancy of a restraint tube rewarding. Yosuke Hachiga Alan Silberberg Burton Slotnick Maria Gomez. Journal of the Experimental Analysis of Behavior, April 1 2020. https://doi.org/10.1002/jeab.596
Abstract: Two experiments evaluated whether rats' occupancy of a restraint tube is reinforcing. In Experiment 1, each rat in the 0‐min group moved freely in a chamber where a wall blocked access to a restraint tube. After 10 min the wall was removed, permitting 15 min of chamber access and tube entry. The other 2 groups were locked in the tube for 10 and 20 min respectively before release into the chamber for 15 min. Across sessions, rats locked up for 10 and 20 min entered the tube more frequently than rats in the 0‐min group, and during the first 2 sessions rats in the 20‐min group stayed in the tube longer than the other groups. Over sessions this difference disappeared. However, for all groups and sessions the mean percentage of session time in the tube exceeded chance expectations. This result suggests tube occupation was reinforcing. In Experiment 2’s Phase 1, rats could enter an open tube. On exiting, the tube door closed. A lever press opened the door for the rest of the 1‐hr session. In Phase 2, these rats were locked in the tube for 10 min before the door opened. Upon exiting, the door closed. As in Phase 1, a lever press opened the door for the rest of the session. The latency between pressing and tube entry decreased over sessions, indicating that tube entry reinforced lever pressing. These results are difficult to reconcile with accounts of rat empathy based on the thesis that tube restraint distresses occupants.
Abstract: Two experiments evaluated whether rats' occupancy of a restraint tube is reinforcing. In Experiment 1, each rat in the 0‐min group moved freely in a chamber where a wall blocked access to a restraint tube. After 10 min the wall was removed, permitting 15 min of chamber access and tube entry. The other 2 groups were locked in the tube for 10 and 20 min respectively before release into the chamber for 15 min. Across sessions, rats locked up for 10 and 20 min entered the tube more frequently than rats in the 0‐min group, and during the first 2 sessions rats in the 20‐min group stayed in the tube longer than the other groups. Over sessions this difference disappeared. However, for all groups and sessions the mean percentage of session time in the tube exceeded chance expectations. This result suggests tube occupation was reinforcing. In Experiment 2’s Phase 1, rats could enter an open tube. On exiting, the tube door closed. A lever press opened the door for the rest of the 1‐hr session. In Phase 2, these rats were locked in the tube for 10 min before the door opened. Upon exiting, the door closed. As in Phase 1, a lever press opened the door for the rest of the session. The latency between pressing and tube entry decreased over sessions, indicating that tube entry reinforced lever pressing. These results are difficult to reconcile with accounts of rat empathy based on the thesis that tube restraint distresses occupants.
Friday, April 3, 2020
These findings suggest that regulatory risk is a major cost to firms, but the largest firms are able to manage that risk better
Measuring the Cost of Regulation: A Text-Based Approach Charles W. Calomiris, Harry Mamaysky, Ruoke Yang. NBER Working Paper No. 26856, March 2020. https://www.nber.org/papers/w26856
Abstract: We derive a measure of firm-level regulatory costs from the text of corporate earnings calls. We then use this measure to study the effect of regulation on companies’ operating fundamentals and cost of capital. We find that higher regulatory cost results in slower sales growth, an effect which is mitigated for large firms. Furthermore, we find a one-standard deviation increase in our preferred measure of regulatory cost is associated with an increase in firms’ cost of capital of close to 3% per year. These findings suggest that regulatory risk is a major cost to firms, but the largest firms are able to manage that risk better.
Abstract: We derive a measure of firm-level regulatory costs from the text of corporate earnings calls. We then use this measure to study the effect of regulation on companies’ operating fundamentals and cost of capital. We find that higher regulatory cost results in slower sales growth, an effect which is mitigated for large firms. Furthermore, we find a one-standard deviation increase in our preferred measure of regulatory cost is associated with an increase in firms’ cost of capital of close to 3% per year. These findings suggest that regulatory risk is a major cost to firms, but the largest firms are able to manage that risk better.
Women were 4x more likely than men to report to think it was right to limit people’s freedom in order to block the virus spread, and 3x more likely to request more severe punishment for risky behaviors
Simione, Luca, and Camilla Gnagnarella. 2020. “Differences Between Health Workers and General Population in Risk Perception, Behaviors, and Psychological Distress Related to COVID-19 Spread in Italy.” PsyArXiv. April 3. doi:10.31234/osf.io/84d2c
Abstract: In this study, we investigated the perception of risk and the worries about COVID-19 infection in both healthcare workers and general population in Italy. We studied the difference in risk perception in these two groups, and how this related to demographic variables and psychological factors such as stress, anxiety, and death anxiety. To this aim, we administered an online questionnaire about COVID-19 together with other questionnaires assessing the psychological condition of participants. First, we found that the exposition to infection risk, due to living area or job, increased the perceived stress and anxiety (i.e. medical staff in North Italy was more stressed and anxious respect to both medical- and non-medical participants from Center and South Italy). Then, we conducted hierarchical logistic regression models on our data to assess the response odds ratio relatively to each predictor on each dependent variable. We found that health workers reported higher risk perception, level of worry, and knowledge as related to COVID-19 infection compared to general population. Also psychological state, gender, and living area were important predictors of these factors. Instead, judgments about behaviors and containment rules were more linked to demographics, such as gender and alcohol consumption. We discussed these results in the light of risk factors for psychological distress and possible interventions to meet the psychological needs of healthcare workers.
---
Women were 4x more likely than men to report to think it was right to limit people’s freedom in order to block the virus spread, and 3x more likely to request more severe punishment for risky behaviors
Abstract: In this study, we investigated the perception of risk and the worries about COVID-19 infection in both healthcare workers and general population in Italy. We studied the difference in risk perception in these two groups, and how this related to demographic variables and psychological factors such as stress, anxiety, and death anxiety. To this aim, we administered an online questionnaire about COVID-19 together with other questionnaires assessing the psychological condition of participants. First, we found that the exposition to infection risk, due to living area or job, increased the perceived stress and anxiety (i.e. medical staff in North Italy was more stressed and anxious respect to both medical- and non-medical participants from Center and South Italy). Then, we conducted hierarchical logistic regression models on our data to assess the response odds ratio relatively to each predictor on each dependent variable. We found that health workers reported higher risk perception, level of worry, and knowledge as related to COVID-19 infection compared to general population. Also psychological state, gender, and living area were important predictors of these factors. Instead, judgments about behaviors and containment rules were more linked to demographics, such as gender and alcohol consumption. We discussed these results in the light of risk factors for psychological distress and possible interventions to meet the psychological needs of healthcare workers.
---
Women were 4x more likely than men to report to think it was right to limit people’s freedom in order to block the virus spread, and 3x more likely to request more severe punishment for risky behaviors
From 2019... Bacha posh in Afghanistan: factors associated with raising a girl as a boy
From 2019... Bacha posh in Afghanistan: factors associated with raising a girl as a boy. Julienne Corboz, Andrew Gibbs & Rachel Jewkes. Culture, Health & Sexuality, Volume 22, 2020 - Issue 5, Pages 585-598, Jun 17 2019. https://doi.org/10.1080/13691058.2019.1616113
Abstract: This paper examines the factors associated with the cultural phenomenon of bacha posh in Afghanistan (in which girls are dressed and raised as boys), which occurs against a background of rigid gender norms and the male-centric nature of Afghan families. Survey data were collected from 1463 women in two provinces of Afghanistan, Kabul and Nangarhar. The primary outcome is a nominal variable, derived from the question, ‘Do you have any girl in your family who has been raised for any time as a boy?’ Independent variables comprise women’s socio-demographic characteristics, family composition, economic characteristics, patriarchal gender attitudes and perceptions of community patriarchal attitudes. Factors associated with bacha posh include women having fewer sons and more daughters, working in the past three months and having less patriarchal gender attitudes. That bacha posh is often driven by a large number of daughters in the family with a corresponding low number of sons suggests that bacha posh is a response to very contextual features of Afghan life, including the preference for sons. Bacha posh in the family is linked to less patriarchal gender norms and can be a way for girls and women to acquire education, mobility and engagement in income-generating activities.
Keywords: Afghanistan, bacha posh, gender norms, gender segregation, women’s empowerment
Abstract: This paper examines the factors associated with the cultural phenomenon of bacha posh in Afghanistan (in which girls are dressed and raised as boys), which occurs against a background of rigid gender norms and the male-centric nature of Afghan families. Survey data were collected from 1463 women in two provinces of Afghanistan, Kabul and Nangarhar. The primary outcome is a nominal variable, derived from the question, ‘Do you have any girl in your family who has been raised for any time as a boy?’ Independent variables comprise women’s socio-demographic characteristics, family composition, economic characteristics, patriarchal gender attitudes and perceptions of community patriarchal attitudes. Factors associated with bacha posh include women having fewer sons and more daughters, working in the past three months and having less patriarchal gender attitudes. That bacha posh is often driven by a large number of daughters in the family with a corresponding low number of sons suggests that bacha posh is a response to very contextual features of Afghan life, including the preference for sons. Bacha posh in the family is linked to less patriarchal gender norms and can be a way for girls and women to acquire education, mobility and engagement in income-generating activities.
Keywords: Afghanistan, bacha posh, gender norms, gender segregation, women’s empowerment
Thursday, April 2, 2020
Lay People Are Unimpressed by the Effect Sizes Typically Reported in Psychology
McPhetres, Jonathon, and Gordon Pennycook. 2020. “Lay People Are Unimpressed by the Effect Sizes Typically Reported in Psychological Science.” PsyArXiv. April 2. doi:10.31234/osf.io/qu9hn
Abstract: It is recommended that researchers report effect sizes along with statistical results to aid in interpreting the magnitude of results. According to recent surveys of published research, psychologists typically find effect sizes ranging from r = .11 to r = .30. While these numbers may be informative for scientists, no research has examined how lay people perceive the range of effect sizes typically reported in psychological research. In two studies, we showed online participants (N = 1,204) graphs depicting a range of effect sizes in different formats. We demonstrate that lay people perceive psychological effects to be small, rather meaningless, and unconvincing. Even the largest effects we examined (corresponding to a Cohen’s d = .90), which are exceedingly uncommon in reality, were considered small-to-moderate in size by lay people. Science communicators and policymakers should consider this obstacle when attempting to communicate the effectiveness of research results.
Abstract: It is recommended that researchers report effect sizes along with statistical results to aid in interpreting the magnitude of results. According to recent surveys of published research, psychologists typically find effect sizes ranging from r = .11 to r = .30. While these numbers may be informative for scientists, no research has examined how lay people perceive the range of effect sizes typically reported in psychological research. In two studies, we showed online participants (N = 1,204) graphs depicting a range of effect sizes in different formats. We demonstrate that lay people perceive psychological effects to be small, rather meaningless, and unconvincing. Even the largest effects we examined (corresponding to a Cohen’s d = .90), which are exceedingly uncommon in reality, were considered small-to-moderate in size by lay people. Science communicators and policymakers should consider this obstacle when attempting to communicate the effectiveness of research results.
Why Do so Few People Share Fake News? It Hurts Their Reputation
Altay, Sacha, Anne-Sophie Hacquin, and Hugo Mercier. 2019. “Why Do so Few People Share Fake News? It Hurts Their Reputation.” PsyArXiv. October 1. doi:10.31234/osf.io/82r6q
Abstract: Despite their potential attractiveness, fake news is shared by a very small minority of internet users. As past research suggests a good reputation is more easily lost than gained, we hypothesized that the majority of people and media sources avoid sharing fake news stories so as to maintain a good reputation. In two pre-registered experiments (N = 3264) we found that the increase in trust that a source (media outlet or individual) enjoys when sharing one real news against a background of fake news is smaller than the drop in trust a source suffers when sharing one fake news against a background of real news. This asymmetry holds even when the outlet only shares politically congruent news. We suggest that individuals and media outlets avoid sharing fake news because it would hurt their reputation, reducing the social or economic benefits associated with being seen as a good source of information.
Abstract: Despite their potential attractiveness, fake news is shared by a very small minority of internet users. As past research suggests a good reputation is more easily lost than gained, we hypothesized that the majority of people and media sources avoid sharing fake news stories so as to maintain a good reputation. In two pre-registered experiments (N = 3264) we found that the increase in trust that a source (media outlet or individual) enjoys when sharing one real news against a background of fake news is smaller than the drop in trust a source suffers when sharing one fake news against a background of real news. This asymmetry holds even when the outlet only shares politically congruent news. We suggest that individuals and media outlets avoid sharing fake news because it would hurt their reputation, reducing the social or economic benefits associated with being seen as a good source of information.
How Many Jobs Can be Done at Home? About 34pct of the labor force could work from home in the US
How Many Jobs Can be Done at Home? Jonathan Dingel, Brent Neiman. Chicago U, March 27, 2020. https://bfi.uchicago.edu/wp-content/uploads/BFI_White-Paper_Dingel_Neiman_3.2020.pdf
1 Introduction
Evaluating the economic impact of “social distancing” measures taken to arrest the spread of COVID-19 raises a number of fundamental questions about the modern economy: How many jobs can be performed at home? What share of total wages are paid to such jobs? How does the scope for working from home vary across cities or industries? To answer these questions, we classify the feasibility of working at home for all occupations and merge this classification with occupational employment counts for the United States. Our feasibility measure is based on responses to two Occupational Information Network (O*NET) surveys covering “work context” and “generalized work activities.” For example, if answers to those surveys reveal that an occupation requires daily “work outdoors” or that “operating vehicles, mechanized devices, or equipment” is very important to that occupation’s performance, we determine that the occupation cannot be performed from home.1 We merge this classification of O*NET occupations with information from the U.S. Bureau of Labor Statistics (BLS) on the prevalence of each occupation in the aggregate as well as in particular metropolitan statistical areas and 2-digit NAICS industries
2 Results
Our classification implies that 34 percent of U.S. jobs can plausibly be performed at home. We obtain our estimate by identifying job characteristics that clearly rule out the possibility of working entirely from home, neglecting many characteristics that would make working from home difficult.2
1 Introduction
Evaluating the economic impact of “social distancing” measures taken to arrest the spread of COVID-19 raises a number of fundamental questions about the modern economy: How many jobs can be performed at home? What share of total wages are paid to such jobs? How does the scope for working from home vary across cities or industries? To answer these questions, we classify the feasibility of working at home for all occupations and merge this classification with occupational employment counts for the United States. Our feasibility measure is based on responses to two Occupational Information Network (O*NET) surveys covering “work context” and “generalized work activities.” For example, if answers to those surveys reveal that an occupation requires daily “work outdoors” or that “operating vehicles, mechanized devices, or equipment” is very important to that occupation’s performance, we determine that the occupation cannot be performed from home.1 We merge this classification of O*NET occupations with information from the U.S. Bureau of Labor Statistics (BLS) on the prevalence of each occupation in the aggregate as well as in particular metropolitan statistical areas and 2-digit NAICS industries
2 Results
Our classification implies that 34 percent of U.S. jobs can plausibly be performed at home. We obtain our estimate by identifying job characteristics that clearly rule out the possibility of working entirely from home, neglecting many characteristics that would make working from home difficult.2
When individuals are exposed to their own image in a mirror, known to increase self-awareness, they may show increased accessibility of suicide-related words (the mirror effect); replication fails in this paper
Monéger, J., Chatard, A., & Selimbegović, L. (2020). The Mirror Effect: A Preregistered Replication. Collabra: Psychology, 6(1), 18. http://doi.org/10.1525/collabra.321
Abstract: When individuals are exposed to their own image in a mirror, known to increase self-awareness, they may show increased accessibility of suicide-related words (a phenomenon labeled “the mirror effect”; Selimbegović & Chatard, 2013). We attempted to replicate this effect in a pre-registered study (N = 150). As in the original study, self-awareness was manipulated using a mirror and recognition latencies for accurately detecting suicide-related words, negative words, and neutral words in a lexical decision task were assessed. We found no evidence of the mirror effect in pre-registered analyses. A multiverse analysis revealed a significant mirror effect only when excluding extreme observations. An equivalence TOST test did not yield evidence for or against the mirror effect. Overall, the results suggest that the original effect was a false positive or that the conditions for obtaining it (in terms of statistical power and/or outlier detection method) are not yet fully understood. Implications for the mirror effect and recommendations for pre-registered replications are discussed.
Keywords: Self-awareness , Suicide thought accessibility , Median Absolute Deviation
Abstract: When individuals are exposed to their own image in a mirror, known to increase self-awareness, they may show increased accessibility of suicide-related words (a phenomenon labeled “the mirror effect”; Selimbegović & Chatard, 2013). We attempted to replicate this effect in a pre-registered study (N = 150). As in the original study, self-awareness was manipulated using a mirror and recognition latencies for accurately detecting suicide-related words, negative words, and neutral words in a lexical decision task were assessed. We found no evidence of the mirror effect in pre-registered analyses. A multiverse analysis revealed a significant mirror effect only when excluding extreme observations. An equivalence TOST test did not yield evidence for or against the mirror effect. Overall, the results suggest that the original effect was a false positive or that the conditions for obtaining it (in terms of statistical power and/or outlier detection method) are not yet fully understood. Implications for the mirror effect and recommendations for pre-registered replications are discussed.
Keywords: Self-awareness , Suicide thought accessibility , Median Absolute Deviation
4. Discussion
In the present study, we attempted to replicate the mirror effect. We expected recognition latencies to suicide-related words to be shorter in the mirror exposure condition than in the control condition, when controlling for neutral words latencies or negative words latencies. These predictions remained unsupported when using the pre-registered outlier detection method in the confirmatory analyses. However, a test assessing the equivalence of the observed effect to a null effect failed to significantly indicate that the mirror effect was equivalent to a null effect (considering d = 0.2 as the smallest effect size of interest). Moreover, an exploratory multiverse analyses showed increasing effect sizes as a function of the decreasing threshold of outlier exclusion, as detected by a robust outlier detection method (i.e, the median absolute deviation, Leys et al., 2013) such that the mirror effect was significant after excluding observations diverging from 2 or less median absolute deviations from the median, but only when using negative words’ RT as a covariate. This partial replication raises several interesting questions about the status of the mirror effect, the effect of outliers in a sample, and, more generally, about what allows for concluding that a replication is successful.
4.1. Mixed results concerning the mirror effect
Several large-scale replication projects show that about half of published findings fail to replicate in direct and high-powered replications in psychology (Klein et al., 2018; Open Science Collaboration, 2015; Simons, Holcombe, & Spellman, 2014). These recent studies point out that it is often difficult to replicate published effects. Between the noise inherent to behavioral sciences and the small-sized effects that we often encounter in psychology, observing statistically significant differences is not guaranteed in replication attempts, even when the effect exists in the population. Indeed, one must take into account the inevitable heterogeneity that exists between a study and its replications (Kenny & Judd, 2019), among other factors.
The present replication findings suggest that the original finding might be a false positive. At the same time, equivalence testing does not warrant a conclusion that the effect is equivalent to 0. Also, multiverse analyses show that the effect was significant in some cases, when using a robust method and a severe criterion for detecting outliers. We believe that if the effect exists, the effect size is likely to be smaller than initially thought. In sum, the study did not provide evidence for a robust mirror effect, but neither did it provide evidence for a null effect (i.e., an effect too trivial to be studied, as defined by a Cohen’s d smaller than 0.2). Therefore, further studies using larger samples are needed to establish more reliable estimates of the effect size and a better understanding of the mechanisms involved in this effect, if it exists.
4.2. Detecting outliers in a sample
Outliers are atypical data points that are abnormally different from the “bulk” of observations in a study, and therefore non-representative of the population (Leys, Delacre, Mora, Lakens, & Ley, 2019). There are many ways to define an outlier in a specific data set, as there are many statistical criteria that have been put forward in the literature. Studentized residuals and z-scores are among the most popular ways to detect outliers (Cousineau & Chartier, 2010). However, as underlined by Rousseeuw (1990), these criteria can underperform. The reason for this is that they are based on the sample standard deviation, which is itself a parameter highly sensitive to outliers (Wilcox, 2010). Robust estimators are hence needed to detect outliers. Contrary to studentized and standardized residuals, the median is highly insensitive to outliers (Leys et al., 2013). As one robust estimator, the median absolute deviation (MAD) is particularly relevant in this case, since the classic methods would have failed to detect influential data points (Leys et al., 2013; see also Wilcox, 2017).
How we manage the presence of outliers in a sample is a fundamental aspect of data analysis. However, to date, there is no consensus about which method is the most appropriate and what threshold should be used for detecting and excluding outliers (Leys et al., 2013). In an attempt to optimize the quality of the replication, the hypothesis, method, and statistical analysis were pre-registered. However, what we failed to predict was that excluding outliers on the basis of studentized residuals would not be sufficient to discard all influential data points. Hence, pre-registering a single outlier detection technique might be insufficient. In this view, Leys et al. (2019) recently provided specific recommendations concerning pre-registering and detecting outliers, one of which is to expand a priori reasoning in the registration, in order to manage unpredicted outliers. In our view, this amounts to the option of registering multiple ways to handle outliers. For instance, one could register a decision tree regarding the possible ways to handle outliers, as a function of the distribution. For instance, Nosek, Ebersole, DeHaven, and Mellor (2017) mention the possibility to define a sequence of tests and to determine the use of parametric or non-parametric approach according to the outcome of normality assumption tests. In a similar vein, standard operating procedures (SOPs) are procedures more general than decision trees that are shared in a given field of research in order to ground standardization of data handling (e.g., Lin & Green, 2016). The development of such standard procedures applied to outlier detection and exclusion could provide a useful tool for pre-registration.
Developing common, consensual procedures can thus be a solution for dealing with the unpredictable aspects of data, such as the presence of outliers. This would be a controlled, transparent, and probably the optimal manner of handling unpredictability, while suppressing the researchers’ degrees of freedom in post-hoc decisions concerning the method used to detect outliers (see Wicherts et al., 2016). In statistics and methodology, as in many fields, a perfect plan does not exist, so it is difficult to offer a perfect solution that fits all studies. In our view, there is a need to define a more general plan of how to handle data, a plan that could fit a large amount of studies. Among the issues that would need to be addressed in such a plan are, for instance, the question of outlier detection/exclusion criterion definition (intraindividually or interindividually), the question of the specific (robust) criterion to be used, and the question of the desired distribution.
Wednesday, April 1, 2020
High prevalence of lying to cover up others’ unethical behavior, which increased with increasing bribes; unethical loyalty decreased with individuals’ Honesty–Humility levels
Buying Unethical Loyalty: A Behavioral Paradigm and Empirical Test. Isabel Thielmann, Robert Böhm, Benjamin E. Hilbig. Social Psychological and Personality Science, April 1, 2020. https://doi.org/10.1177/1948550620905218
Abstract: Unethical behavior is often accompanied by others covering up a transgressor’s actions. We devised a novel behavioral paradigm, the Unethical Loyalty Game (ULG), to study individuals’ willingness to lie to cover up others’ dishonesty. Specifically, we examined (i) whether and to what extent individuals are willing to lie to cover up others’ unethical behavior, (ii) whether this unethical loyalty depends on the benefits (bribe) at stake, and (iii) whether trait Honesty–Humility accounts for interindividual variability in unethical loyalty. In a fully incentivized experiment (N = 288), we found a high prevalence of lying to cover up others’ unethical behavior, which increased with increasing bribes. In turn, unethical loyalty decreased with individuals’ Honesty–Humility levels. Overall, the findings show that most but not all individuals are corruptible to disguise others’ transgressions. Future research using the ULG can help to further illuminate (the determinants of) this prevalent type of unethical behavior.
Keywords: unethical loyalty, cover-up, dishonesty, bribing, Honesty–Humility
Abstract: Unethical behavior is often accompanied by others covering up a transgressor’s actions. We devised a novel behavioral paradigm, the Unethical Loyalty Game (ULG), to study individuals’ willingness to lie to cover up others’ dishonesty. Specifically, we examined (i) whether and to what extent individuals are willing to lie to cover up others’ unethical behavior, (ii) whether this unethical loyalty depends on the benefits (bribe) at stake, and (iii) whether trait Honesty–Humility accounts for interindividual variability in unethical loyalty. In a fully incentivized experiment (N = 288), we found a high prevalence of lying to cover up others’ unethical behavior, which increased with increasing bribes. In turn, unethical loyalty decreased with individuals’ Honesty–Humility levels. Overall, the findings show that most but not all individuals are corruptible to disguise others’ transgressions. Future research using the ULG can help to further illuminate (the determinants of) this prevalent type of unethical behavior.
Keywords: unethical loyalty, cover-up, dishonesty, bribing, Honesty–Humility
Going Upstream to Advance Psychosis Prevention and Improve Public Health
Going Upstream to Advance Psychosis Prevention and Improve Public Health. Deidre M. Anglin, Sandro Galea, Peter Bachman. JAMA Psychiatry, April 1, 2020. doi:10.1001/jamapsychiatry.2020.0142
The idea that we can reduce the incidence of psychotic disorders through detection and intervention in the prodromal stage of illness has generated increasing enthusiasm and research over the past 2 decades. This work has sought largely to identify individual-level changes in subjective experience, functioning, or brain volume or activity that immediately precede acute symptom onset. However, mental illnesses, including psychotic disorders, are particularly sensitive to the social, political, cultural, and economic context within which an individual lives.1 Prioritizing approaches to psychosis prevention that fail to give these social determinants a central role ignores compelling evidence and misses an opportunity to identify specific ways to help vulnerable youth.
Consider the example of racism’s pervasive detrimental association with the physical and mental well-being of disadvantaged people of color.2 Institutional racism creates differences in the average group member’s social, economic, and environmental circumstances, including living conditions in neighborhoods, work, and school. These social inequities distribute risk factors for mental disorders, such as exposure to violence, trauma, and chronic adversity and disadvantage, unevenly in the population in such a way that often disproportionately burdens group members with minority status (eg, people of color, poor people, and immigrants). In addition, the social experience of this oppression (ie, interpersonal discrimination) can further heighten the risk for mental illness because of the greater cumulative stress load associated with such lived experiences.
A growing body of US-based research has been providing data to inform our understanding of how social environmental inequities may enhance psychosis risk. For example, the association between social factors, such as racial discrimination3 and adverse childhood experiences,4 and the extended psychosis phenotype has been demonstrated in large national probability samples, developmental cohorts, smaller community-based samples, and even clinical high-risk studies. Despite this, the field’s focus on the role these underlying conditions play in shaping the incidence, duration, and treatment responsiveness of psychosis remains limited and falls short of the importance that these factors play in the etiology and course of psychosis. There are many reasons why there is a paucity of research on social risk factors for psychosis. Federal funding priorities have been a factor, as have concerns among researchers about the nonspecificity of social risk factors and the daunting prospect of large-scale societal change as an intervention. However, we suggest that from a public health perspective, some of these concerns represent opportunities.
Consider nonspecificity using the following example. High levels of air pollution have been found to be associated with depression, anxiety, and psychosis.5 This could indicate a common causal pathway among these 3 distinct syndromes through which pollution increases a disease process broadly (eg, inflammation), resulting in different possible outcomes. Air pollution could also contribute to the risk for depression in a way that is different from how it contributes to the risk for psychosis. We suggest that the significance of air pollution as a potential social determinant of mental illness remains regardless of whether it helps differentiate the risk of one disease from another. Moreover, it is not clear that a preferential focus on more microlevel foci (eg, genetic mutations) reveals evidence of such specificity of predictors.6 It stands to reason that the benefits of reducing air pollution would be widespread, providing more general social benefits that align with evolving views of the pluripotent nature of the risk for mental illness. The risk itself, including social risk, may be fairly nonspecific.
The notion that large-scale societal change as an intervention is too big or outside psychiatrists’ purview does not concord with the history of psychiatry, whose development has mirrored society’s evolving understanding of illness in general. For example, the advent of psychopharmacological interventions in the 1950s shifted the field from a more psychoanalytic understanding of psychopathology toward a strong biological perspective. Such discoveries shaped and changed the way psychiatrists were trained and practiced as clinicians, how research was conducted, and how psychiatrists understood mental illness. Similarly, social change during the 1960s and 1980s contributed to the deinstitutionalization of psychiatric hospitals, increasing the degree to which psychiatry was practiced as part of a larger service team in community-based mental health centers. Psychiatry can continue to evolve and be shaped by a richer appreciation and study of social determinants.
Conclusions and Recommendations
We propose a recalibration of priorities in which we focus on systemic, structural social risk factors with the same energy and investment that we apply to the search for individual-level signs, symptoms, and mechanisms, including physiological mechanisms. Thankfully, the association between social risk factors and physiological mechanisms does not have to be a zero-sum game. We have every reason to believe that moving upstream may demonstrate that these social risk factors operate with and via biological mechanisms to increase psychosis risk.7 Identifying the potential causal role of social mechanisms more explicitly will also require continued advancement in our epidemiologic methods of causal inference. Increasing our attention toward these social risk factors may help us take the next big step in predicting and preventing psychosis, and in doing so, positively affect the incidence and expression of other mental illnesses. Perhaps most important, understanding how forces like racism, poverty, and social marginalization affect mental illness is a step on the way to becoming a society in which the health of vulnerable youth is considered as important as their health care.
How do we get there? We recommend the following research, education, policy, and clinical actions. For us to understand how social risk factors contribute to outcomes such as psychosis, we need funding priorities from grant-making agencies to include the examination of social, cultural, economic, and political associations with risk for serious mental illness without requiring a priori links to identified neural circuits. Large-scale, longitudinal studies of risk for serious mental illness should systematically oversample populations with high levels of social disadvantage so hypotheses regarding the association of social risk factors can be tested. We are encouraged by recent funding efforts from the National Institute on Minority Health and Health Disparities to study the social epigenomics that drive health disparities. We believe psychosis risk should be included in such funding efforts.
Public mental health data quality and availability need to be improved. For example, we have had difficulty obtaining reliable stable estimates of clinical psychosis incidence at a population level across different socially constructed demographic groups (eg, racial groups with minority status) in national probability samples. Regarding the education of psychiatrists, training for clinicians should strive for structural competency, which includes cultural competency as well as facility in addressing other social, economic, and political factors that affect the lives of patients.8 On a policy level, a shift toward value-based care (and away from fee-for-service) would be a step in the right direction. Enacting such a change requires routinely assessing social risk factors as part of treatment planning and robust partnership with social service agencies that are incentivized to address these social disadvantages. Ideally, all policy decisions across all levels of government should consider the question, “would this policy make our constituents healthier or sicker?” Finally, from a clinical perspective, assessing and addressing social disadvantages should be the shared responsibility of professionals across systems of care and seen as a fundamental aspect of taking a whole-person or patient-centered approach to health care.
References, full text at the link above.
The idea that we can reduce the incidence of psychotic disorders through detection and intervention in the prodromal stage of illness has generated increasing enthusiasm and research over the past 2 decades. This work has sought largely to identify individual-level changes in subjective experience, functioning, or brain volume or activity that immediately precede acute symptom onset. However, mental illnesses, including psychotic disorders, are particularly sensitive to the social, political, cultural, and economic context within which an individual lives.1 Prioritizing approaches to psychosis prevention that fail to give these social determinants a central role ignores compelling evidence and misses an opportunity to identify specific ways to help vulnerable youth.
Consider the example of racism’s pervasive detrimental association with the physical and mental well-being of disadvantaged people of color.2 Institutional racism creates differences in the average group member’s social, economic, and environmental circumstances, including living conditions in neighborhoods, work, and school. These social inequities distribute risk factors for mental disorders, such as exposure to violence, trauma, and chronic adversity and disadvantage, unevenly in the population in such a way that often disproportionately burdens group members with minority status (eg, people of color, poor people, and immigrants). In addition, the social experience of this oppression (ie, interpersonal discrimination) can further heighten the risk for mental illness because of the greater cumulative stress load associated with such lived experiences.
A growing body of US-based research has been providing data to inform our understanding of how social environmental inequities may enhance psychosis risk. For example, the association between social factors, such as racial discrimination3 and adverse childhood experiences,4 and the extended psychosis phenotype has been demonstrated in large national probability samples, developmental cohorts, smaller community-based samples, and even clinical high-risk studies. Despite this, the field’s focus on the role these underlying conditions play in shaping the incidence, duration, and treatment responsiveness of psychosis remains limited and falls short of the importance that these factors play in the etiology and course of psychosis. There are many reasons why there is a paucity of research on social risk factors for psychosis. Federal funding priorities have been a factor, as have concerns among researchers about the nonspecificity of social risk factors and the daunting prospect of large-scale societal change as an intervention. However, we suggest that from a public health perspective, some of these concerns represent opportunities.
Consider nonspecificity using the following example. High levels of air pollution have been found to be associated with depression, anxiety, and psychosis.5 This could indicate a common causal pathway among these 3 distinct syndromes through which pollution increases a disease process broadly (eg, inflammation), resulting in different possible outcomes. Air pollution could also contribute to the risk for depression in a way that is different from how it contributes to the risk for psychosis. We suggest that the significance of air pollution as a potential social determinant of mental illness remains regardless of whether it helps differentiate the risk of one disease from another. Moreover, it is not clear that a preferential focus on more microlevel foci (eg, genetic mutations) reveals evidence of such specificity of predictors.6 It stands to reason that the benefits of reducing air pollution would be widespread, providing more general social benefits that align with evolving views of the pluripotent nature of the risk for mental illness. The risk itself, including social risk, may be fairly nonspecific.
The notion that large-scale societal change as an intervention is too big or outside psychiatrists’ purview does not concord with the history of psychiatry, whose development has mirrored society’s evolving understanding of illness in general. For example, the advent of psychopharmacological interventions in the 1950s shifted the field from a more psychoanalytic understanding of psychopathology toward a strong biological perspective. Such discoveries shaped and changed the way psychiatrists were trained and practiced as clinicians, how research was conducted, and how psychiatrists understood mental illness. Similarly, social change during the 1960s and 1980s contributed to the deinstitutionalization of psychiatric hospitals, increasing the degree to which psychiatry was practiced as part of a larger service team in community-based mental health centers. Psychiatry can continue to evolve and be shaped by a richer appreciation and study of social determinants.
Conclusions and Recommendations
We propose a recalibration of priorities in which we focus on systemic, structural social risk factors with the same energy and investment that we apply to the search for individual-level signs, symptoms, and mechanisms, including physiological mechanisms. Thankfully, the association between social risk factors and physiological mechanisms does not have to be a zero-sum game. We have every reason to believe that moving upstream may demonstrate that these social risk factors operate with and via biological mechanisms to increase psychosis risk.7 Identifying the potential causal role of social mechanisms more explicitly will also require continued advancement in our epidemiologic methods of causal inference. Increasing our attention toward these social risk factors may help us take the next big step in predicting and preventing psychosis, and in doing so, positively affect the incidence and expression of other mental illnesses. Perhaps most important, understanding how forces like racism, poverty, and social marginalization affect mental illness is a step on the way to becoming a society in which the health of vulnerable youth is considered as important as their health care.
How do we get there? We recommend the following research, education, policy, and clinical actions. For us to understand how social risk factors contribute to outcomes such as psychosis, we need funding priorities from grant-making agencies to include the examination of social, cultural, economic, and political associations with risk for serious mental illness without requiring a priori links to identified neural circuits. Large-scale, longitudinal studies of risk for serious mental illness should systematically oversample populations with high levels of social disadvantage so hypotheses regarding the association of social risk factors can be tested. We are encouraged by recent funding efforts from the National Institute on Minority Health and Health Disparities to study the social epigenomics that drive health disparities. We believe psychosis risk should be included in such funding efforts.
Public mental health data quality and availability need to be improved. For example, we have had difficulty obtaining reliable stable estimates of clinical psychosis incidence at a population level across different socially constructed demographic groups (eg, racial groups with minority status) in national probability samples. Regarding the education of psychiatrists, training for clinicians should strive for structural competency, which includes cultural competency as well as facility in addressing other social, economic, and political factors that affect the lives of patients.8 On a policy level, a shift toward value-based care (and away from fee-for-service) would be a step in the right direction. Enacting such a change requires routinely assessing social risk factors as part of treatment planning and robust partnership with social service agencies that are incentivized to address these social disadvantages. Ideally, all policy decisions across all levels of government should consider the question, “would this policy make our constituents healthier or sicker?” Finally, from a clinical perspective, assessing and addressing social disadvantages should be the shared responsibility of professionals across systems of care and seen as a fundamental aspect of taking a whole-person or patient-centered approach to health care.
References, full text at the link above.
Dreams: “A person now dead as alive” is more frequent in older people, while “A person now alive as dead” in children; adults & older adults dream more often of “Trying something again and again” and “Arriving too late”
Maggiolini, A., di Lorenzo, M., Falotico, E., & Morelli, M. (2020). The typical dreams in the life cycle. International Journal of Dream Research, 20(1), 17-28. https://doi.org/10.11588/ijodr.2020.1.61558
Abstract: Most dream content analyses have been carried out on young adult samples, taken as norms, with fewer researches on continuity and discontinuity in the life cycle. A research on dreams in the life cycle (1546 participants, from 8 to 70 years), with the Typical Dreams Questionnaire (Nielsen et al., 2003; Dumel, Nielsen, & Carr, 2012), shows that 55.8% of the dreams reports have one or more typical content, with quite a stable prevalence across ages, with more dreams with a TDQ item in children and in older adults, with the minimum percentage in young adults. Children have more diversity in typical themes than other ages.The most frequent items in children have content related to some threat or some magic topic. “A person now dead as alive” is more frequent in older people, while “A person now alive as dead” in children and preadolescents. “School, teachers and studying” is more frequent in adolescence and “Sexual experiences” in young adults. Adults and older adults dream more often of “Trying something again and again” and “Arriving too late”. Changes in typical dream themes can be related to emotional concerns typical of different phases of the life cycle.
Abstract: Most dream content analyses have been carried out on young adult samples, taken as norms, with fewer researches on continuity and discontinuity in the life cycle. A research on dreams in the life cycle (1546 participants, from 8 to 70 years), with the Typical Dreams Questionnaire (Nielsen et al., 2003; Dumel, Nielsen, & Carr, 2012), shows that 55.8% of the dreams reports have one or more typical content, with quite a stable prevalence across ages, with more dreams with a TDQ item in children and in older adults, with the minimum percentage in young adults. Children have more diversity in typical themes than other ages.The most frequent items in children have content related to some threat or some magic topic. “A person now dead as alive” is more frequent in older people, while “A person now alive as dead” in children and preadolescents. “School, teachers and studying” is more frequent in adolescence and “Sexual experiences” in young adults. Adults and older adults dream more often of “Trying something again and again” and “Arriving too late”. Changes in typical dream themes can be related to emotional concerns typical of different phases of the life cycle.
Population-Based Estimates of Health Care Utilization and Expenditures by Adults During the Last 2 Years of Life in Canada’s Single-Payer Health System: Costs going up
Population-Based Estimates of Health Care Utilization and Expenditures by Adults During the Last 2 Years of Life in Canada’s Single-Payer Health System. Laura C. Rosella et al. JAMA Netw Open. 2020;3(4):e201917, April 1, 2020. doi:10.1001/jamanetworkopen.2020.1917
Question What are the population-level trends in health care utilization and expenditures in the 2 years before death among adults in Ontario, Canada?
Findings This cohort study found that health care expenditures in the last 2 years of life increased in Ontario from CAD$5.12 billion in 2005 to CAD$7.84 billion in 2015, and the intensity of health care utilization and deaths in hospital varied by resource utilization gradients.
Meaning In this study, the observed trends demonstrated that costs and hospital-centered care before death are high in Ontario.
Abstract
Importance Measuring health care utilization and costs before death has the potential to initiate health care improvement.
Objective To examine population-level trends in health care utilization and expenditures in the 2 years before death in Canada’s single-payer health system.
Design, Setting, and Participants This population-based cohort included 966 436 deaths among adult residents of Ontario, Canada, from January 2005 to December 2015, linked to health administrative and census data. Data for deaths from 2005 to 2013 were analyzed from November 1, 2016, through January 31, 2017. Analyses were updated from May 1, 2019, to June 15, 2019, to include deaths from 2014 and 2015.
Exposures Sociodemographic exposures included age, sex, and neighborhood income quintiles, which were obtained by linking decedents’ postal codes to census data. Aggregated Diagnosis Groups were used as a general health service morbidity-resource measure.
Main Outcomes and Measures Health care services accessed for the last 2 years of life, including acute hospitalization episodes of care, intensive care unit visits, and emergency department visits. Total health care costs were calculated using a person-centered costing approach. The association of area-level income with high resource use 1 year before death was analyzed with Poisson regression analysis, controlling for age, sex, and Aggregated Diagnosis Groups.
Results Among 966 436 decedents (483 038 [50.0%] men; mean [SD] age, 76.4 [14.96] years; 231 634 [24.0%] living in the lowest neighborhood income quintile), health care expenditures increased in the last 2 years of life during the study period (CAD$5.12 billion [US $3.83 billion] in 2005 vs CAD$7.84 billion [US $5.86 billion] in 2015). In the year before death, 758 770 decedents (78.5%) had at least 1 hospitalization episode of care, 266 987 (27.6%) had at least 1 intensive care unit admission, and 856 026 (88.6%) had at least 1 emergency department visit. Overall, deaths in hospital decreased from 37 984 (45.6%) in 2005 to 39 474 (41.5%) in 2015. Utilization in the last 2 years, 1 year, 180 days, and 30 days of life varied by resource utilization gradients. For example, the proportion of individuals visiting the emergency department was slightly higher among the top 5% of health care users compared with other utilization groups in the last 2 years of life (top 5%, 45 535 [94.2%]; top 6%-50%, 401 022 [92.2%]; bottom 50%, 409 469 [84.7%]) and 1 year of life (top 5%, 43 007 [89.0%]; top 6%-50%, 381 732 [87.8%]; bottom 50%, 380 859 [78.8%]); however, in the last 30 days of life, more than half of individuals in the top 6% to top 50% (223 262 [51.3%]) and bottom 50% (288 480 [59.7%]) visited an emergency department, compared with approximately one-third of individuals in the top 5% (16 916 [35.0%]). No meaningful associations were observed in high resource use between individuals in the highest income quintile compared with the lowest income quintile (rate ratio, 1.02; 95% CI, 0.99-1.05) after adjusting for relevant covariates.
Conclusions and Relevance In this study, health care use and spending in the last 2 years of life in Ontario were high. These findings highlight a trend in hospital-centered care before death in a single-payer health system.
Introduction
Similar to those in other high-income countries, health care utilization and costs in Canada are expected to increase because of an expanding and aging population.1 A large proportion of these costs are incurred toward the end of life, with multiple studies demonstrating that health care utilization in the final months of life accounts for a substantial share of health care expenditures in comparison with other points in an individual’s life.2-5 In addition, most spending is concentrated in small groups of the population, who are characterized as high-cost users.6,7 Studies have shown that high-intensity medical care at the end of life can produce poor outcomes,8-10 can be associated with poor quality of life,11 and may conflict with patient preferences.9,12 To meet the growing needs of an aging population, a deeper understanding of the determinants and patterns of health care utilization and costs prior to death is required.
Most studies examining health care utilization prior to death have focused on a single aspect of care (eg, palliative services)13 or were specific to a particular cause of death.14-18 To our knowledge, few studies have examined health care use and costs at a population level and across an array of health sectors.5,19 Despite its potential to inform health care service delivery and improvement, evidence on health care utilization and cost patterns before death in a Canadian context is limited. A recent population-based study that examined health care expenditures in Ontario, Canada, from 2010 to 201319 reported that decedents who constituted less than 1% of the population consumed 10% of Ontario’s total health care budget, demonstrating that health care utilization occurs disproportionately. Using comprehensive multilinked mortality files, we analyzed population-level trends in health care utilization and expenditures prior to death in Ontario’s single-payer health system by looking at overall trends for more than a decade and by gradients of cost (ie, patients in the top 5%, top 6%-50%, and bottom 50% of health care costs).
Methods
Study Design
This retrospective cohort study used multiple linked vital statistics, population files, and health administrative data held at ICES to examine all deaths occurring in Ontario between January 2005 and December 2015. These data sets were linked using unique encoded identifiers and analyzed at ICES, an independent, nonprofit research institute whose legal status under Ontario’s health information privacy law allows it to collect and analyze health care and demographic data, without consent, for health system evaluation and improvement. This study received ethical approval from the University of Toronto’s Health Sciences research ethics board and the institutional review board at Sunnybrook Health Sciences Centre, Toronto, Canada. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Study Population
Data for all deaths registered in the province of Ontario were obtained from the Office of the Registrar General-Deaths (ORG-D) file. The ORG-D is linked to the Registered Persons Database (RPDB), which contains basic demographic information for those who have ever received an Ontario health card number for the province’s universal health care system (overall linkage rate, 96.5%).20 The study cohort consisted of all deaths registered in the ORG-D between January 1, 2005, and December 31, 2015, that were linked to the RPDB record (N = 966 436). Those who had an invalid Ontario health card number on their death date (n = 4433), were not residents of Ontario (n = 252), or were younger than 18 years (n = 8768) were excluded.
Measures
We examined health care utilization prior to death according to several sociodemographic exposures. Sex and age data were obtained from the RPDB. Categories for age at time of death were 18 to 24 years, 25 to 34 years, 35 to 44 years, 45 to 54 years, 55 to 64 years, 65 to 74 years, 75 to 85 years, and older than 85 years. Ecological-level measures of income and education status were estimated using data from the 2006 Canadian census21 and were applied to individuals according to the dissemination area, which represents the smallest geographic census area in which the individual resided. Based on their postal code at the time of death, individuals were assigned to a dissemination area. Education was characterized as the proportion of individuals who completed high school in a given dissemination area. Individuals were grouped into income and education quintiles ranging from 1 (lowest 20% of income or education) to 5 (highest 20% of income or education).
As a general health service morbidity-resource measure, we used The Johns Hopkins Adjusted Clinical Group system version 10.0.1 Aggregated Diagnosis Group (ADG) scores, a person-focused, diagnosis-based method of categorizing individuals’ illnesses.22 Aggregated Diagnosis Groups have been validated for health services research use in Ontario23 and were calculated for the 2 years prior to death.
We measured health care utilization and services accessed for 2 years, 1 year, 180 days, and 30 days before death. Hospitalization episodes of care and intensive care unit (ICU) visits were obtained from the Discharge Abstract Database. An acute hospitalization episode was defined as either an admission to an acute care setting from which the patient was discharged or a continuous sequence of hospital stays in different hospitals to which the patient was transferred. Transfers between 2 different institutions were defined using both the timing between admissions and transfer flags on either record. Specifically, the following situations were defined as a transfer: (1) any admission within 6 hours of the previous discharge, (2) any admission within 12 hours of the previous discharge in which the type of institution transferred from or to was type 1 (ie, acute care), or (3) any admission within 48 hours of the previous discharge in which the number of the institution transferred from matched the number of the institution or the institution transferred to. Length of stay for episodes of care and ICU visits were calculated by subtracting the date of the latest discharge from the date of the earliest admission. Emergency department visits were obtained from the National Ambulatory Care Reporting System and were counted as 1 claim per patient per registered day. Physician services (primary care and specialist) were obtained from the Ontario Health Insurance Plan claims database. A physician visit was counted as 1 claim per patient per service day per physician. Physician specialties listed as family practice and general practice, community medicine, and pediatrics were considered primary care visits. All other physician specialties were considered a specialist visit. Death in hospital was identified in the Discharge Abstract Database if a hospital discharge disposition code was recorded as died, indicating a death in hospital. In 423 580 of 427 859 in-hospital deaths (99.0%), the death date in ORG-D and hospital discharge date with a code indicating died in the Discharge Abstract Database were within 1 day apart.
We calculated comprehensive per-person health care costs for the time proceeding death (last 2 years of life). Annual health care utilization and costs were calculated from the health care payee perspective, using administrative data from across health care sectors, including inpatient hospital stay, emergency department visits, same day surgery, stays in complex continuing care hospitals and inpatient rehabilitation, inpatient psychiatric admissions, physician payments for patient visits and community laboratory tests, and prescriptions filled for individuals eligible for the Ontario Drug Benefit Plan. A person-centered costing macro was used to calculate total annual health care spending; the costing methodology has been described elsewhere.24 Expenditures were calculated in Canadian dollars for the year 2015. Individuals were categorized in resource utilization groups (top 5%, top 6%-50%, and bottom 50%) based on the total health care costs in the last year of their lives.
Statistical Analysis
The distribution of sociodemographic characteristics among decedents at the time of death was described using means and proportions according to health care utilization gradients. Overall and per-person health care utilization metrics were calculated for the 2 years, 1 year, 180 days, and 30 days before death using medians and proportions and are presented according to health care utilization gradients for the last year of life. We estimated temporal trends of total health care expenditures among adult deaths from 2005 to 2015 by health care utilization gradient.
Factors associated with being in the top 5% of health care users in the last year of life were assessed by a modified Poisson model.25 We chose to model risk directly using a modified Poisson regression because it provides a good approximation of the binomial distribution when the sample is large, and it is less likely than logistic regression to overestimate the relative risk.26 We used belonging to the top 5% as the outcome and sex, age, area-level income quintile, and ADG score as the covariates. Associations were calculated with rate ratios (RRs) with corresponding confidence intervals. Statistical significance was set at P < .05, and all tests were 2-tailed. All analyses were conducted using SAS Enterprise Guide statistical software, version 7.15 (SAS Institute).
Results
Sociodemographic Characteristics by Health Care Utilization Gradient
Sociodemographic characteristics of 966 436 adult decedents (438 038 [50.0%] men; 231 634 [24.0%] living in lowest neighborhood income quintile), stratified by health care utilization gradients (top 5%, top 6%-50%, and bottom 50%) are shown in Table 1. Those in the top 5% were younger, with a mean (SD) age of 71.1 (14.6) years compared with 76.4 (14.96) years for the total cohort. A larger percentage of those in the top 5% were male (26 818 [55.5%] vs 200 965 [46.2%] in the top 6%-50% and 255 255 [52.8%] in the bottom 50%) and had a higher mean (SD) number of ADGs compared with the overall cohort (14.9 [3.6] vs 11.2 [4.4]). In contrast, the distribution of area-level income and education were similar across health care utilization gradients. The number of deaths captured in the cohort per year was similar across years, from 83 227 deaths in 2005 to 95 044 deaths in 2015 (eTable 1 in the Supplement). The major causes of death in the cohort were cancer (287 308 [29.7%]) and diseases of the circulatory system (279 881 [29.0%]) (eTable 2 in the Supplement).
Health Care Utilization in the Last 2 Years, 1 Year, 180 Days, and 30 Days of Life
Health care utilization prior to death for the overall cohort is described in Table 2. In the last 2 years of life, most individuals (758 770 [78.5%]) had at least 1 acute hospitalization episode of care, with a median (interquartile range [IQR]) length of stay of 8 (5-15) days. Approximately one-third (266 987 [27.6%]) were admitted to the ICU with a median (IQR) length of stay of 69 (33-130) hours in acute care, and almost all (856 026 [88.6%]) had an emergency department visit. The median (IQR) number of visits to primary care and specialist physicians were similar, with 31 (17-53) visits and 34 (13-69) visits, respectively.
In the last 30 days of life, 143 225 decedents (14.8%) were admitted to the ICU, spending a median (IQR) of 59 (23-124) hours in acute care. In addition, most visited a primary care physician (856 679 [88.6%]; median [IQR] visits, 4 [1-9]) and a specialist (699 042 [72.3%]; median [IQR] visits, 4 [0-14]). In terms of proximity to death, 475 574 decedents (49.2%) had at least 1 hospitalization episode of care in the last 30 days of life, 662 628 (68.6%) in the last 180 days, 710 035 (73.5%) in the last year, and 758 770 (78.5%) in the last 2 years. Similarly, the proportion that visited the emergency department was 528 658 (54.7%) in the last 30 days of life, 750 558 (77.7%) in the last 180 days, 805 598 (83.4%) in the last year, and 856 026 (88.6%) in the last 2 years. The nominal difference in percentage demonstrates that a substantial portion of health care use occurred toward the end of life.
Health Care Utilization Metrics by Resource Utilization Gradients
Table 2 presents health care utilization metrics at the end of life according to resource utilization gradients. In the last 2 years of life, among those who experienced a hospitalization, individuals in the top 5% had a median (IQR) of 3 (2-6) episodes of care per person, compared with 1 (0-2) episode of care among individuals in the bottom 50%. In the same period, approximately two-thirds of those in the top 5% experienced an ICU admission (31 099 [64.4%]) with a median (IQR) length of stay of 143 (70-317) hours; in comparison, approximately one-fifth of individuals in the bottom 50% (100 959 [20.9%]) had an ICU admission, with a median (IQR) length of stay of 47 (22-89) hours. The proportion of individuals visiting the emergency department was slightly higher among the top 5% compared with other utilization groups in the last 2 years (top 5%, 45 535 [94.2%]; top 6%-50%, 401 022 [92.2%]; bottom 50%, 409 469 [84.7%]) and 1 year (top 5%, 43 007 [89.0%]; top 6%-50%, 381 732 [87.8%]; bottom 50%, 380 859 [78.8%]) of life. In contrast, in the last 30 days of life, more than half of individuals in the top 6% to top 50% (223 262 [51.3%]) and bottom 50% (288 480 [59.7%]) visited an emergency department, compared with approximately one-third of individuals in the top 5% (16 916 [35.0%]). In the last 2 years of life, the median (IQR) number of primary care visits was 57 (28-106) among the top 5% compared with 22 (11-37) among the bottom 50%. The median (IQR) number of specialist visits over this period was 163 (96-238) among the top 5% compared with 21 (8-40) among the bottom 50%.
Factors Associated With High Resource Utilization Prior to Death
In the Poisson model (Table 3), significant risk reductions for high resource utilization (ie, top 5%) in the last year of life were observed among women compared with men (RR, 0.90; 95% CI, 0.88-0.91) and among older age groups; the RR was 0.21 times lower in decedents older than 85 years compared with those aged 18 to 24 years (RR, 0.21; 95% CI, 0.19-0.23) after adjusting for income and ADGs (Table 3). No meaningful associations were observed between individuals in the highest area income quintile compared with individuals in the lowest quintile (RR, 1.02; 95% CI, 0.99-1.05) after adjusting for sex, age, and ADGs. The associations between high income (ie, quintile 5) and low income (ie, quintile 1) remained null in the sex-segregated models, in which the confidence interval included the null value.
Hospital Deaths by Resource Utilization Gradients
Table 4 displays trends in the percentage of deaths that occurred in hospital by resource utilization gradients. Overall, deaths in hospital decreased from 37 984 (45.6%) in 2005 to 39 474 (41.5%) in 2015. Throughout the study period, a total of 29 292 of 48 324 deaths (60.4%) and 203 792 of 483 213 (42.2%) occurred in the hospital among those in the top 5% and the bottom 50%, respectively, without much variation during the study period. Among the top 6% to top 50% resource gradient, deaths in hospital decreased from 14 975 of 28 792 (52.0%) in 2005 to 18 569 of 46 859 (39.6%) in 2015.
Temporal Trends in Health Care Expenditures According to Resource Utilization Gradients
Total health care expenditures in the last 2 years of life increased in Ontario from CAD$5.12 billion (US $3.83 billion) in 2005 to CAD$7.84 billion (US $5.86 billion) in 2015, an increase of approximately 35%. Similarly, expenditures during this period increased from CAD$3.59 billion (US $2.69 billion) to CAD$5.34 billion (US $4.01 billion) in the last year of life, an increase of 33%. In the last 180 days of life, expenditures increased from CAD$2.53 billion (US $1.90 billion) to CAD$3.67 billion (US $2.75 billion), a 31% increase, and for the last 30 days of life, they increased from CAD$1.04 billion (US $0.78 billion) to CAD$1.43 billion (US $1.07 million), a 27% increase (Figure, A). Mean per-person spending in the last 2 years of life increased among the top 5% from CAD$273 820 (95% CI, CAD$269 935 to CAD$277 760) (US $205 365; 95% CI, US $202 451 to US $208 320) in 2005 to CAD$295 183 (95% CI, CAD$291 811 to CAD$298 593) (US $221 387; 95% CI, US $218 858 to US $223 945) in 2015. In the same period, mean per-person spending in the bottom 50% decreased from CAD$33 489 (95% CI, CAD$33 210 to CAD$33 771) (US $25 117; 95% CI, US $24 908 to US $25 328) in 2005 to CAD$31 148 (95% CI, CAD$30 871 to CAD$31 427) (US $23 361; 95% CI, US $23 153 to $23 570) in 2015 (Figure, B). In the last 2 years of life, mean (SD) per-person spending for acute hospital care increased from CAD$4839 (CAD$ 14 053) (US $3629 [US $10 540]) in 2005 to CAD$6572 (CAD$19 722) (US $4928 [US $14 792]) in 2015 (Figure, C).
Discussion
This study examined population-wide health care utilization and costs at the end of life in the universal health care system of Ontario, which accounts for 40% of Canada. Our unique focus on health care utilization gradients and trends of health care use at the end of life was enabled by a mortality database that contained all deaths registered in Ontario during 11 years, linked with health administrative data. We demonstrated that overall health care expenditures in Ontario for the last 2 years of life increased by 35% from 2005 to 2015, with the largest proportional increase in average per-person spending observed in the top 5% and top 6% to top 50% of health care users. We demonstrated higher end-of-life utilization of health care services among those in the top 5% compared with the overall cohort for hospitalization episodes of care, ICU visits, emergency department visits, and physician visits. Exceptions to this pattern were identified for the last 30 days of life, in which utilization of certain services, such as emergency department visits, were higher among the top 6% to top 50% and bottom 50% of health care users than among the top 5%. However, the observed reduced utilization of these services could have been the result of individuals in the highest cost group already being admitted to a hospital in their last 30 days of life. Several studies have reported population-wide health care utilization prior to death,19,27,28 but they have not looked at differences among health care use gradients.
The study showed that in the last year of life, 74% of residents of Ontario had a hospitalization episode of care and 24% spent time in the ICU. Comparable patterns of end-of-life health care utilization have been reported in other high-income countries. For example, an Australian study looking at hospital-based services used by adults during the last year of life reported slightly higher rates of hospitalization (84%) and lower rates of ICU visits (12%).27 In the United States, ICU visit rates in the last month of life ranged from 24% to 29% among Medicare beneficiaries aged 66 years and older compared with 21% in our cohort.29
We observed a negatively linear association between older age groups and being in the top 5% of health care users in the last year of life, especially among men. A similar pattern of lower expenditures among older age groups in the last year of life was reported in the US Medicare population of adults aged 65 and older.30 In our analysis, we did not see meaningful associations for area-level income quintiles and high health care utilization in the last year of life after adjusting for sex, age, and ADGs. Similar findings were observed in a retrospective cohort analysis of health care use among deaths in Ontario from 2010 to 2013, in which total costs did not vary by neighborhood income quintile.19 In contrast, among the US Medicare population, individuals in the lowest-income area had slightly higher expenditures in the last year of life compared with those living in the highest-income areas.30 Furthermore, in a study of health care spending in the last year of life in the province of British Columbia, Canada, the highest 2 household income quintiles were shown to have approximately 4% less health care spending than those in the lowest income quintile.31 The differential income associations observed in these studies could be attributed to health system differences in access to health care services in the jurisdictions under study and differences in ecological-level vs individual-level income measures used.
A larger percentage of deaths occurred in hospital in our cohort compared with Switzerland, where it was reported that 34% of deaths were in a hospital,28 and in the United States, where deaths in acute care hospitals ranged from 25% to 33% among decedents older than 66 years.29 Furthermore, we observed that the proportion of deaths in hospital among the top 5% and bottom 50% of health care users in the last year of life was stable over the study period. The observed high-intensity care near the end of life and high percentage of deaths in hospitals highlights a need for a societal-level discussion about approaches to end-of-life care in Ontario.
We observed that high health care utilization was associated with multimorbidity, as measured by ADGs, and that hospital-centered care was the typical trajectory at the end of life. This points to the need to design appropriate integrated care strategies that could support patients at the end of life to be discharged from the hospital and receive care and management for their conditions through home care or long-term care services.
Limitations
It is important to note some limitations to our study. First, our study used ecological-level indicators of socioeconomic status based on postal code information at the time of death, which may have provided lower estimates of income gradients in health care utilization.32 Second, our database only included services covered by the provincial health care payee and not services that may be covered by supplemental insurance or paid for out of pocket (ie, nursing, personal care, medications, and therapy). Third, comprehensive recommendations regarding end-of-life care are difficult to make in the absence of information on the appropriateness of care and use of potentially avoidable health services, which were out of scope for this study. Nonetheless, the findings support understanding of end-of-life health care trends in a universal health care system.
Conclusions
This study reported on health care utilization in the 2 years before death with a focus on the characterization of high-cost users. It identified patterns of high utilization of health care services before death and a large proportion of deaths in hospital, with variation across health care utilization gradients. The findings suggest a trajectory of hospital-centered care prior to death in Ontario.
References and full text at the link above.
Question What are the population-level trends in health care utilization and expenditures in the 2 years before death among adults in Ontario, Canada?
Findings This cohort study found that health care expenditures in the last 2 years of life increased in Ontario from CAD$5.12 billion in 2005 to CAD$7.84 billion in 2015, and the intensity of health care utilization and deaths in hospital varied by resource utilization gradients.
Meaning In this study, the observed trends demonstrated that costs and hospital-centered care before death are high in Ontario.
Abstract
Importance Measuring health care utilization and costs before death has the potential to initiate health care improvement.
Objective To examine population-level trends in health care utilization and expenditures in the 2 years before death in Canada’s single-payer health system.
Design, Setting, and Participants This population-based cohort included 966 436 deaths among adult residents of Ontario, Canada, from January 2005 to December 2015, linked to health administrative and census data. Data for deaths from 2005 to 2013 were analyzed from November 1, 2016, through January 31, 2017. Analyses were updated from May 1, 2019, to June 15, 2019, to include deaths from 2014 and 2015.
Exposures Sociodemographic exposures included age, sex, and neighborhood income quintiles, which were obtained by linking decedents’ postal codes to census data. Aggregated Diagnosis Groups were used as a general health service morbidity-resource measure.
Main Outcomes and Measures Health care services accessed for the last 2 years of life, including acute hospitalization episodes of care, intensive care unit visits, and emergency department visits. Total health care costs were calculated using a person-centered costing approach. The association of area-level income with high resource use 1 year before death was analyzed with Poisson regression analysis, controlling for age, sex, and Aggregated Diagnosis Groups.
Results Among 966 436 decedents (483 038 [50.0%] men; mean [SD] age, 76.4 [14.96] years; 231 634 [24.0%] living in the lowest neighborhood income quintile), health care expenditures increased in the last 2 years of life during the study period (CAD$5.12 billion [US $3.83 billion] in 2005 vs CAD$7.84 billion [US $5.86 billion] in 2015). In the year before death, 758 770 decedents (78.5%) had at least 1 hospitalization episode of care, 266 987 (27.6%) had at least 1 intensive care unit admission, and 856 026 (88.6%) had at least 1 emergency department visit. Overall, deaths in hospital decreased from 37 984 (45.6%) in 2005 to 39 474 (41.5%) in 2015. Utilization in the last 2 years, 1 year, 180 days, and 30 days of life varied by resource utilization gradients. For example, the proportion of individuals visiting the emergency department was slightly higher among the top 5% of health care users compared with other utilization groups in the last 2 years of life (top 5%, 45 535 [94.2%]; top 6%-50%, 401 022 [92.2%]; bottom 50%, 409 469 [84.7%]) and 1 year of life (top 5%, 43 007 [89.0%]; top 6%-50%, 381 732 [87.8%]; bottom 50%, 380 859 [78.8%]); however, in the last 30 days of life, more than half of individuals in the top 6% to top 50% (223 262 [51.3%]) and bottom 50% (288 480 [59.7%]) visited an emergency department, compared with approximately one-third of individuals in the top 5% (16 916 [35.0%]). No meaningful associations were observed in high resource use between individuals in the highest income quintile compared with the lowest income quintile (rate ratio, 1.02; 95% CI, 0.99-1.05) after adjusting for relevant covariates.
Conclusions and Relevance In this study, health care use and spending in the last 2 years of life in Ontario were high. These findings highlight a trend in hospital-centered care before death in a single-payer health system.
Introduction
Similar to those in other high-income countries, health care utilization and costs in Canada are expected to increase because of an expanding and aging population.1 A large proportion of these costs are incurred toward the end of life, with multiple studies demonstrating that health care utilization in the final months of life accounts for a substantial share of health care expenditures in comparison with other points in an individual’s life.2-5 In addition, most spending is concentrated in small groups of the population, who are characterized as high-cost users.6,7 Studies have shown that high-intensity medical care at the end of life can produce poor outcomes,8-10 can be associated with poor quality of life,11 and may conflict with patient preferences.9,12 To meet the growing needs of an aging population, a deeper understanding of the determinants and patterns of health care utilization and costs prior to death is required.
Most studies examining health care utilization prior to death have focused on a single aspect of care (eg, palliative services)13 or were specific to a particular cause of death.14-18 To our knowledge, few studies have examined health care use and costs at a population level and across an array of health sectors.5,19 Despite its potential to inform health care service delivery and improvement, evidence on health care utilization and cost patterns before death in a Canadian context is limited. A recent population-based study that examined health care expenditures in Ontario, Canada, from 2010 to 201319 reported that decedents who constituted less than 1% of the population consumed 10% of Ontario’s total health care budget, demonstrating that health care utilization occurs disproportionately. Using comprehensive multilinked mortality files, we analyzed population-level trends in health care utilization and expenditures prior to death in Ontario’s single-payer health system by looking at overall trends for more than a decade and by gradients of cost (ie, patients in the top 5%, top 6%-50%, and bottom 50% of health care costs).
Methods
Study Design
This retrospective cohort study used multiple linked vital statistics, population files, and health administrative data held at ICES to examine all deaths occurring in Ontario between January 2005 and December 2015. These data sets were linked using unique encoded identifiers and analyzed at ICES, an independent, nonprofit research institute whose legal status under Ontario’s health information privacy law allows it to collect and analyze health care and demographic data, without consent, for health system evaluation and improvement. This study received ethical approval from the University of Toronto’s Health Sciences research ethics board and the institutional review board at Sunnybrook Health Sciences Centre, Toronto, Canada. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Study Population
Data for all deaths registered in the province of Ontario were obtained from the Office of the Registrar General-Deaths (ORG-D) file. The ORG-D is linked to the Registered Persons Database (RPDB), which contains basic demographic information for those who have ever received an Ontario health card number for the province’s universal health care system (overall linkage rate, 96.5%).20 The study cohort consisted of all deaths registered in the ORG-D between January 1, 2005, and December 31, 2015, that were linked to the RPDB record (N = 966 436). Those who had an invalid Ontario health card number on their death date (n = 4433), were not residents of Ontario (n = 252), or were younger than 18 years (n = 8768) were excluded.
Measures
We examined health care utilization prior to death according to several sociodemographic exposures. Sex and age data were obtained from the RPDB. Categories for age at time of death were 18 to 24 years, 25 to 34 years, 35 to 44 years, 45 to 54 years, 55 to 64 years, 65 to 74 years, 75 to 85 years, and older than 85 years. Ecological-level measures of income and education status were estimated using data from the 2006 Canadian census21 and were applied to individuals according to the dissemination area, which represents the smallest geographic census area in which the individual resided. Based on their postal code at the time of death, individuals were assigned to a dissemination area. Education was characterized as the proportion of individuals who completed high school in a given dissemination area. Individuals were grouped into income and education quintiles ranging from 1 (lowest 20% of income or education) to 5 (highest 20% of income or education).
As a general health service morbidity-resource measure, we used The Johns Hopkins Adjusted Clinical Group system version 10.0.1 Aggregated Diagnosis Group (ADG) scores, a person-focused, diagnosis-based method of categorizing individuals’ illnesses.22 Aggregated Diagnosis Groups have been validated for health services research use in Ontario23 and were calculated for the 2 years prior to death.
We measured health care utilization and services accessed for 2 years, 1 year, 180 days, and 30 days before death. Hospitalization episodes of care and intensive care unit (ICU) visits were obtained from the Discharge Abstract Database. An acute hospitalization episode was defined as either an admission to an acute care setting from which the patient was discharged or a continuous sequence of hospital stays in different hospitals to which the patient was transferred. Transfers between 2 different institutions were defined using both the timing between admissions and transfer flags on either record. Specifically, the following situations were defined as a transfer: (1) any admission within 6 hours of the previous discharge, (2) any admission within 12 hours of the previous discharge in which the type of institution transferred from or to was type 1 (ie, acute care), or (3) any admission within 48 hours of the previous discharge in which the number of the institution transferred from matched the number of the institution or the institution transferred to. Length of stay for episodes of care and ICU visits were calculated by subtracting the date of the latest discharge from the date of the earliest admission. Emergency department visits were obtained from the National Ambulatory Care Reporting System and were counted as 1 claim per patient per registered day. Physician services (primary care and specialist) were obtained from the Ontario Health Insurance Plan claims database. A physician visit was counted as 1 claim per patient per service day per physician. Physician specialties listed as family practice and general practice, community medicine, and pediatrics were considered primary care visits. All other physician specialties were considered a specialist visit. Death in hospital was identified in the Discharge Abstract Database if a hospital discharge disposition code was recorded as died, indicating a death in hospital. In 423 580 of 427 859 in-hospital deaths (99.0%), the death date in ORG-D and hospital discharge date with a code indicating died in the Discharge Abstract Database were within 1 day apart.
We calculated comprehensive per-person health care costs for the time proceeding death (last 2 years of life). Annual health care utilization and costs were calculated from the health care payee perspective, using administrative data from across health care sectors, including inpatient hospital stay, emergency department visits, same day surgery, stays in complex continuing care hospitals and inpatient rehabilitation, inpatient psychiatric admissions, physician payments for patient visits and community laboratory tests, and prescriptions filled for individuals eligible for the Ontario Drug Benefit Plan. A person-centered costing macro was used to calculate total annual health care spending; the costing methodology has been described elsewhere.24 Expenditures were calculated in Canadian dollars for the year 2015. Individuals were categorized in resource utilization groups (top 5%, top 6%-50%, and bottom 50%) based on the total health care costs in the last year of their lives.
Statistical Analysis
The distribution of sociodemographic characteristics among decedents at the time of death was described using means and proportions according to health care utilization gradients. Overall and per-person health care utilization metrics were calculated for the 2 years, 1 year, 180 days, and 30 days before death using medians and proportions and are presented according to health care utilization gradients for the last year of life. We estimated temporal trends of total health care expenditures among adult deaths from 2005 to 2015 by health care utilization gradient.
Factors associated with being in the top 5% of health care users in the last year of life were assessed by a modified Poisson model.25 We chose to model risk directly using a modified Poisson regression because it provides a good approximation of the binomial distribution when the sample is large, and it is less likely than logistic regression to overestimate the relative risk.26 We used belonging to the top 5% as the outcome and sex, age, area-level income quintile, and ADG score as the covariates. Associations were calculated with rate ratios (RRs) with corresponding confidence intervals. Statistical significance was set at P < .05, and all tests were 2-tailed. All analyses were conducted using SAS Enterprise Guide statistical software, version 7.15 (SAS Institute).
Results
Sociodemographic Characteristics by Health Care Utilization Gradient
Sociodemographic characteristics of 966 436 adult decedents (438 038 [50.0%] men; 231 634 [24.0%] living in lowest neighborhood income quintile), stratified by health care utilization gradients (top 5%, top 6%-50%, and bottom 50%) are shown in Table 1. Those in the top 5% were younger, with a mean (SD) age of 71.1 (14.6) years compared with 76.4 (14.96) years for the total cohort. A larger percentage of those in the top 5% were male (26 818 [55.5%] vs 200 965 [46.2%] in the top 6%-50% and 255 255 [52.8%] in the bottom 50%) and had a higher mean (SD) number of ADGs compared with the overall cohort (14.9 [3.6] vs 11.2 [4.4]). In contrast, the distribution of area-level income and education were similar across health care utilization gradients. The number of deaths captured in the cohort per year was similar across years, from 83 227 deaths in 2005 to 95 044 deaths in 2015 (eTable 1 in the Supplement). The major causes of death in the cohort were cancer (287 308 [29.7%]) and diseases of the circulatory system (279 881 [29.0%]) (eTable 2 in the Supplement).
Health Care Utilization in the Last 2 Years, 1 Year, 180 Days, and 30 Days of Life
Health care utilization prior to death for the overall cohort is described in Table 2. In the last 2 years of life, most individuals (758 770 [78.5%]) had at least 1 acute hospitalization episode of care, with a median (interquartile range [IQR]) length of stay of 8 (5-15) days. Approximately one-third (266 987 [27.6%]) were admitted to the ICU with a median (IQR) length of stay of 69 (33-130) hours in acute care, and almost all (856 026 [88.6%]) had an emergency department visit. The median (IQR) number of visits to primary care and specialist physicians were similar, with 31 (17-53) visits and 34 (13-69) visits, respectively.
In the last 30 days of life, 143 225 decedents (14.8%) were admitted to the ICU, spending a median (IQR) of 59 (23-124) hours in acute care. In addition, most visited a primary care physician (856 679 [88.6%]; median [IQR] visits, 4 [1-9]) and a specialist (699 042 [72.3%]; median [IQR] visits, 4 [0-14]). In terms of proximity to death, 475 574 decedents (49.2%) had at least 1 hospitalization episode of care in the last 30 days of life, 662 628 (68.6%) in the last 180 days, 710 035 (73.5%) in the last year, and 758 770 (78.5%) in the last 2 years. Similarly, the proportion that visited the emergency department was 528 658 (54.7%) in the last 30 days of life, 750 558 (77.7%) in the last 180 days, 805 598 (83.4%) in the last year, and 856 026 (88.6%) in the last 2 years. The nominal difference in percentage demonstrates that a substantial portion of health care use occurred toward the end of life.
Health Care Utilization Metrics by Resource Utilization Gradients
Table 2 presents health care utilization metrics at the end of life according to resource utilization gradients. In the last 2 years of life, among those who experienced a hospitalization, individuals in the top 5% had a median (IQR) of 3 (2-6) episodes of care per person, compared with 1 (0-2) episode of care among individuals in the bottom 50%. In the same period, approximately two-thirds of those in the top 5% experienced an ICU admission (31 099 [64.4%]) with a median (IQR) length of stay of 143 (70-317) hours; in comparison, approximately one-fifth of individuals in the bottom 50% (100 959 [20.9%]) had an ICU admission, with a median (IQR) length of stay of 47 (22-89) hours. The proportion of individuals visiting the emergency department was slightly higher among the top 5% compared with other utilization groups in the last 2 years (top 5%, 45 535 [94.2%]; top 6%-50%, 401 022 [92.2%]; bottom 50%, 409 469 [84.7%]) and 1 year (top 5%, 43 007 [89.0%]; top 6%-50%, 381 732 [87.8%]; bottom 50%, 380 859 [78.8%]) of life. In contrast, in the last 30 days of life, more than half of individuals in the top 6% to top 50% (223 262 [51.3%]) and bottom 50% (288 480 [59.7%]) visited an emergency department, compared with approximately one-third of individuals in the top 5% (16 916 [35.0%]). In the last 2 years of life, the median (IQR) number of primary care visits was 57 (28-106) among the top 5% compared with 22 (11-37) among the bottom 50%. The median (IQR) number of specialist visits over this period was 163 (96-238) among the top 5% compared with 21 (8-40) among the bottom 50%.
Factors Associated With High Resource Utilization Prior to Death
In the Poisson model (Table 3), significant risk reductions for high resource utilization (ie, top 5%) in the last year of life were observed among women compared with men (RR, 0.90; 95% CI, 0.88-0.91) and among older age groups; the RR was 0.21 times lower in decedents older than 85 years compared with those aged 18 to 24 years (RR, 0.21; 95% CI, 0.19-0.23) after adjusting for income and ADGs (Table 3). No meaningful associations were observed between individuals in the highest area income quintile compared with individuals in the lowest quintile (RR, 1.02; 95% CI, 0.99-1.05) after adjusting for sex, age, and ADGs. The associations between high income (ie, quintile 5) and low income (ie, quintile 1) remained null in the sex-segregated models, in which the confidence interval included the null value.
Hospital Deaths by Resource Utilization Gradients
Table 4 displays trends in the percentage of deaths that occurred in hospital by resource utilization gradients. Overall, deaths in hospital decreased from 37 984 (45.6%) in 2005 to 39 474 (41.5%) in 2015. Throughout the study period, a total of 29 292 of 48 324 deaths (60.4%) and 203 792 of 483 213 (42.2%) occurred in the hospital among those in the top 5% and the bottom 50%, respectively, without much variation during the study period. Among the top 6% to top 50% resource gradient, deaths in hospital decreased from 14 975 of 28 792 (52.0%) in 2005 to 18 569 of 46 859 (39.6%) in 2015.
Temporal Trends in Health Care Expenditures According to Resource Utilization Gradients
Total health care expenditures in the last 2 years of life increased in Ontario from CAD$5.12 billion (US $3.83 billion) in 2005 to CAD$7.84 billion (US $5.86 billion) in 2015, an increase of approximately 35%. Similarly, expenditures during this period increased from CAD$3.59 billion (US $2.69 billion) to CAD$5.34 billion (US $4.01 billion) in the last year of life, an increase of 33%. In the last 180 days of life, expenditures increased from CAD$2.53 billion (US $1.90 billion) to CAD$3.67 billion (US $2.75 billion), a 31% increase, and for the last 30 days of life, they increased from CAD$1.04 billion (US $0.78 billion) to CAD$1.43 billion (US $1.07 million), a 27% increase (Figure, A). Mean per-person spending in the last 2 years of life increased among the top 5% from CAD$273 820 (95% CI, CAD$269 935 to CAD$277 760) (US $205 365; 95% CI, US $202 451 to US $208 320) in 2005 to CAD$295 183 (95% CI, CAD$291 811 to CAD$298 593) (US $221 387; 95% CI, US $218 858 to US $223 945) in 2015. In the same period, mean per-person spending in the bottom 50% decreased from CAD$33 489 (95% CI, CAD$33 210 to CAD$33 771) (US $25 117; 95% CI, US $24 908 to US $25 328) in 2005 to CAD$31 148 (95% CI, CAD$30 871 to CAD$31 427) (US $23 361; 95% CI, US $23 153 to $23 570) in 2015 (Figure, B). In the last 2 years of life, mean (SD) per-person spending for acute hospital care increased from CAD$4839 (CAD$ 14 053) (US $3629 [US $10 540]) in 2005 to CAD$6572 (CAD$19 722) (US $4928 [US $14 792]) in 2015 (Figure, C).
Discussion
This study examined population-wide health care utilization and costs at the end of life in the universal health care system of Ontario, which accounts for 40% of Canada. Our unique focus on health care utilization gradients and trends of health care use at the end of life was enabled by a mortality database that contained all deaths registered in Ontario during 11 years, linked with health administrative data. We demonstrated that overall health care expenditures in Ontario for the last 2 years of life increased by 35% from 2005 to 2015, with the largest proportional increase in average per-person spending observed in the top 5% and top 6% to top 50% of health care users. We demonstrated higher end-of-life utilization of health care services among those in the top 5% compared with the overall cohort for hospitalization episodes of care, ICU visits, emergency department visits, and physician visits. Exceptions to this pattern were identified for the last 30 days of life, in which utilization of certain services, such as emergency department visits, were higher among the top 6% to top 50% and bottom 50% of health care users than among the top 5%. However, the observed reduced utilization of these services could have been the result of individuals in the highest cost group already being admitted to a hospital in their last 30 days of life. Several studies have reported population-wide health care utilization prior to death,19,27,28 but they have not looked at differences among health care use gradients.
The study showed that in the last year of life, 74% of residents of Ontario had a hospitalization episode of care and 24% spent time in the ICU. Comparable patterns of end-of-life health care utilization have been reported in other high-income countries. For example, an Australian study looking at hospital-based services used by adults during the last year of life reported slightly higher rates of hospitalization (84%) and lower rates of ICU visits (12%).27 In the United States, ICU visit rates in the last month of life ranged from 24% to 29% among Medicare beneficiaries aged 66 years and older compared with 21% in our cohort.29
We observed a negatively linear association between older age groups and being in the top 5% of health care users in the last year of life, especially among men. A similar pattern of lower expenditures among older age groups in the last year of life was reported in the US Medicare population of adults aged 65 and older.30 In our analysis, we did not see meaningful associations for area-level income quintiles and high health care utilization in the last year of life after adjusting for sex, age, and ADGs. Similar findings were observed in a retrospective cohort analysis of health care use among deaths in Ontario from 2010 to 2013, in which total costs did not vary by neighborhood income quintile.19 In contrast, among the US Medicare population, individuals in the lowest-income area had slightly higher expenditures in the last year of life compared with those living in the highest-income areas.30 Furthermore, in a study of health care spending in the last year of life in the province of British Columbia, Canada, the highest 2 household income quintiles were shown to have approximately 4% less health care spending than those in the lowest income quintile.31 The differential income associations observed in these studies could be attributed to health system differences in access to health care services in the jurisdictions under study and differences in ecological-level vs individual-level income measures used.
A larger percentage of deaths occurred in hospital in our cohort compared with Switzerland, where it was reported that 34% of deaths were in a hospital,28 and in the United States, where deaths in acute care hospitals ranged from 25% to 33% among decedents older than 66 years.29 Furthermore, we observed that the proportion of deaths in hospital among the top 5% and bottom 50% of health care users in the last year of life was stable over the study period. The observed high-intensity care near the end of life and high percentage of deaths in hospitals highlights a need for a societal-level discussion about approaches to end-of-life care in Ontario.
We observed that high health care utilization was associated with multimorbidity, as measured by ADGs, and that hospital-centered care was the typical trajectory at the end of life. This points to the need to design appropriate integrated care strategies that could support patients at the end of life to be discharged from the hospital and receive care and management for their conditions through home care or long-term care services.
Limitations
It is important to note some limitations to our study. First, our study used ecological-level indicators of socioeconomic status based on postal code information at the time of death, which may have provided lower estimates of income gradients in health care utilization.32 Second, our database only included services covered by the provincial health care payee and not services that may be covered by supplemental insurance or paid for out of pocket (ie, nursing, personal care, medications, and therapy). Third, comprehensive recommendations regarding end-of-life care are difficult to make in the absence of information on the appropriateness of care and use of potentially avoidable health services, which were out of scope for this study. Nonetheless, the findings support understanding of end-of-life health care trends in a universal health care system.
Conclusions
This study reported on health care utilization in the 2 years before death with a focus on the characterization of high-cost users. It identified patterns of high utilization of health care services before death and a large proportion of deaths in hospital, with variation across health care utilization gradients. The findings suggest a trajectory of hospital-centered care prior to death in Ontario.
References and full text at the link above.
Consistently, the only predictor of positive behavior change (e.g., social distancing, improved hand hygiene) was fear of COVID-19, with no effect of politically-relevant variables
Harper, Craig A., Liam Satchell, Dean Fido, and Robert Latzman. 2020. “Functional Fear Predicts Public Health Compliance in the COVID-19 Pandemic.” PsyArXiv. April 1. doi:10.31234/osf.io/jkfu3
Abstract: In the current context of the global pandemic of coronavirus disease-2019 (COVID-19), health professionals are working with social scientists to inform government policy on how to slow the spread of the virus. An increasing amount of social scientific research has looked at the role of public message framing, for instance, but few studies have thus far examined the role of individual differences in emotional and personality-based variables in predicting virus-mitigating behaviors. In this study we recruited a large international community sample (N = 324) to complete measures of self-perceived risk of contracting COVID-19, fear of the virus, moral foundations, political orientation, and behavior change in response to the pandemic. Consistently, the only predictor of positive behavior change (e.g., social distancing, improved hand hygiene) was fear of COVID-19, with no effect of politically-relevant variables. We discuss these data in relation to the potentially functional nature of fear in global health crises.
Abstract: In the current context of the global pandemic of coronavirus disease-2019 (COVID-19), health professionals are working with social scientists to inform government policy on how to slow the spread of the virus. An increasing amount of social scientific research has looked at the role of public message framing, for instance, but few studies have thus far examined the role of individual differences in emotional and personality-based variables in predicting virus-mitigating behaviors. In this study we recruited a large international community sample (N = 324) to complete measures of self-perceived risk of contracting COVID-19, fear of the virus, moral foundations, political orientation, and behavior change in response to the pandemic. Consistently, the only predictor of positive behavior change (e.g., social distancing, improved hand hygiene) was fear of COVID-19, with no effect of politically-relevant variables. We discuss these data in relation to the potentially functional nature of fear in global health crises.
Gay men displayed significantly higher pitch modulation patterns and less breathy voices compared to heterosexual men, with values shifted toward those of heterosexual women
Speech Acoustic Features: A Comparison of Gay Men, Heterosexual Men, and Heterosexual Women. Alexandre Suire, Arnaud Tognetti, Valérie Durand, Michel Raymond & Melissa Barkat-Defradas. Archives of Sexual Behavior, March 31 2020. https://rd.springer.com/article/10.1007/s10508-020-01665-3
Abstract: Potential differences between homosexual and heterosexual men have been studied on a diverse set of social and biological traits. Regarding acoustic features of speech, researchers have hypothesized a feminization of such characteristics in homosexual men, but previous investigations have so far produced mixed results. Moreover, most studies have been conducted with English-speaking populations, which calls for further cross-linguistic examinations. Lastly, no studies investigated so far the potential role of testosterone in the association between sexual orientation and speech acoustic features. To fill these gaps, we explored potential differences in acoustic features of speech between homosexual and heterosexual native French men and investigated whether the former showed a trend toward feminization by comparing theirs to that of heterosexual native French women. Lastly, we examined whether testosterone levels mediated the association between speech acoustic features and sexual orientation. We studied four sexually dimorphic acoustic features relevant for the qualification of feminine versus masculine voices: the fundamental frequency, its modulation, and two understudied acoustic features of speech, the harmonics-to-noise ratio (a proxy of vocal breathiness) and the jitter (a proxy of vocal roughness). Results showed that homosexual men displayed significantly higher pitch modulation patterns and less breathy voices compared to heterosexual men, with values shifted toward those of heterosexual women. Lastly, testosterone levels did not influence any of the investigated acoustic features. Combined with the literature conducted in other languages, our findings bring new support for the feminization hypothesis and suggest that the feminization of some acoustic features could be shared across languages.
Abstract: Potential differences between homosexual and heterosexual men have been studied on a diverse set of social and biological traits. Regarding acoustic features of speech, researchers have hypothesized a feminization of such characteristics in homosexual men, but previous investigations have so far produced mixed results. Moreover, most studies have been conducted with English-speaking populations, which calls for further cross-linguistic examinations. Lastly, no studies investigated so far the potential role of testosterone in the association between sexual orientation and speech acoustic features. To fill these gaps, we explored potential differences in acoustic features of speech between homosexual and heterosexual native French men and investigated whether the former showed a trend toward feminization by comparing theirs to that of heterosexual native French women. Lastly, we examined whether testosterone levels mediated the association between speech acoustic features and sexual orientation. We studied four sexually dimorphic acoustic features relevant for the qualification of feminine versus masculine voices: the fundamental frequency, its modulation, and two understudied acoustic features of speech, the harmonics-to-noise ratio (a proxy of vocal breathiness) and the jitter (a proxy of vocal roughness). Results showed that homosexual men displayed significantly higher pitch modulation patterns and less breathy voices compared to heterosexual men, with values shifted toward those of heterosexual women. Lastly, testosterone levels did not influence any of the investigated acoustic features. Combined with the literature conducted in other languages, our findings bring new support for the feminization hypothesis and suggest that the feminization of some acoustic features could be shared across languages.
Discussion
This study offers an interesting take on the interaction between sexual orientation and acoustic features of speech in a French speaker sample. First, our analysis of different acoustic features revealed well-known patterns of sexual dimorphism in human voices (i.e., F0, F0-SD, jitter, and HNR). Secondly, our findings showed that French homosexual men displayed a more modulated and less breathy voice than French heterosexual men, thus supporting and extending previous studies conducted mostly with English speakers. Our results for the LDA showed that French homosexual men attested a slight but significant vocal feminization when considering speech acoustic features altogether (up to 10.65%), which support the feminization hypothesis. (It is important to note, however, that no overlap was observed between heterosexual and homosexual men vs. heterosexual women.) Lastly, testosterone levels did not mediate the association between vocal patterns and sexual orientation.
Consistent with previous findings in English-speaking populations, no significant differences were observed in mean F0 between French-speaking heterosexual and homosexual men (Gaudio, 1994; Lerman & Damsté, 1969; Munson et al., 2006b; Rendall et al., 2008; Rogers et al., 2001; Smyth et al., 2003). The results did show a difference between homosexual and heterosexual men in intonation, the former displaying higher pitch variations than the latter. The relationship between pitch variations and sexual orientation was previously found in one Dutch (Baeck et al., 2011) and one American-English population (Gaudio, 1994), suggesting that feminized pitch variations might be characteristic of male homosexual speech across languages (but see Levon, 2006). In our study, the average difference in pitch variations reached ~ 4.11 Hz, which is largely above the just noticeable difference for pitch (Pisanski & Rendall, 2011). Hence, our findings suggest that pitch variations could be one of the acoustic correlates of sexual orientation that is used by listeners when they correctly assessed sexual orientation through speech only (Gaudio, 1994; Linville, 1998; Smyth et al., 2003; Valentova & Havlíček, 2013). Further investigations are nevertheless needed to confirm if such a difference in pitch variations between homosexual and heterosexual men is enough to be used as a cue for assessing sexual orientation.
To our knowledge, this is the first study to report an association between men’s vocal breathiness and sexual orientation. Interestingly, vocal breathiness has been suggested to be an important component of vocal femininity in female voices (Van Borsel et al., 2009) and significant relationships to vocal attractiveness have been reported in both sexes (Xu et al., 2013). Although the difference in vocal breathiness between homosexual and heterosexual men is rather low (mean average difference reached ~ 0.80 dB), further research should test whether it is perceptible by listeners to assess male sexual orientation and whether homosexual men’s voices, which are richer in harmonics compared to those of heterosexuals, are perceived as more attractive among homosexual men.
In our study, T-levels did not influence any of the acoustic parameters investigated. The methods to measure T-level and the sample size used in this study were similar to those used in previous studies finding a significant negative link between T-levels and F0 (e.g., Dabbs & Mallinger, 1999; Evans et al., 2008). However, testosterone is a multiple-effect hormone under the influence of numerous biological and environmental factors and pathways. As such, it is generally difficult to correlate T-levels with other biological or behavioral traits, especially with a unique measurement as realized here. Nevertheless, our results might suggest that other underlying processes, different than basal T-level, are involved in vocal differences between homosexual and heterosexual men.
Although our study does not aim to provide an explanation for why vocal differences were found between homosexual and heterosexual men, several biological and social mechanisms can be invoked. For instance, exposure to prenatal testosterone has been suggested to be responsible for the differences between homosexual and heterosexual men on a large range of characteristics such as physiological and behavioral traits including speech characteristics (Balthazart, 2017; Ehrhardt & Meyer-Bahlburg, 1981). Several studies have thus tested whether the 2D:4D ratio (relative length of the second and fourth digits), a proxy of testosterone prenatal exposure differs between homosexual and heterosexual men (Balthazart, 2017; Ehrhardt & Meyer-Bahlburg, 1981). However, there is currently no consensus regarding whether the 2D:4D ratio differs between heterosexual and homosexual men as studies have yielded mixed results (Breedlove, 2017; Grimbos, Dawood, Burriss, Zucker, & Puts, 2010; Rahman & Wilson, 2003; Robinson, 2000; Skorska & Bogaert, 2017; Williams et al., 2000). Regarding social mechanisms, a social imitation of women’s speech peculiarities by homosexual men could also explain the differences observed between homosexual and heterosexual men’s speech characteristics (at least for F0-SD and HNR). The use of more feminine acoustic characteristics by homosexual men could reflect a selective adoption model of opposite-sex speech patterns or a selective use of acoustic features for signaling in-group identity (Pierrehumbert et al., 2004), an ability called “gaydar” (i.e., the detection of homosexuality based on a set of specific cues). Interestingly, a recent study suggests that the acquisition of a distinctive speech style may happen before puberty, as boys aged from 5 to 13 with gender identity disorder (a diagnosis made when a child shows distress or discomfort due to a mismatch between his/her gender identity and his/her biological sex) display distinctive speech features (higher F0 and F2 as well as a misarticulation of/s/) from boys without it (Munson, Crocker, Pierrehumbert, Owen-Anderson, & Zucker, 2015). Because some homosexual men display a greater degree of gender nonconforming behavior (GNC) than others during childhood (Bailey & Zucker, 1995), one could thus hypothesize that the former would be more likely to have a more feminine speech in adulthood than the latter. Further work should investigate the relative importance of the mechanisms underlying homosexual men’s speech.
To conclude, although our study did not aim to test specific hypotheses against a formal theoretical framework to understand the differences between homosexual and heterosexual men’s speech, it provides some new descriptive findings. By examining for the first time native French speakers and some understudied acoustic features (i.e., namely, jitter and HNR), our results indicated that some vocal traits differed between heterosexual and homosexual men (i.e., variations of pitch and vocal breathiness) with values shifted toward heterosexual women’s vocal characteristics. Combined with the literature conducted in other languages, our findings bring new support for the feminization hypothesis (at least for some acoustic features) and suggest that the feminization of some acoustic features could be shared across languages. Further studies are needed to test whether intonation and vocal breathiness are perceptually salient to distinguish homosexual and heterosexual men, and whether overall differences are due to biological and/or sociolinguistic reasons.
Subscribe to:
Posts (Atom)
Posts
