Thesis Thursday: Edward Webb

On the third Thursday of every month, we speak to a recent graduate about their thesis and their studies. This month’s guest is Dr Edward Webb who graduated with a PhD from the University of Copenhagen. If you would like to suggest a candidate for an upcoming Thesis Thursday, get in touch.

Title
Attention and perception in decision-making and interactions
Supervisors
Alexander Sebald, Peter Norman Sørensen
Repository link
http://www.econ.ku.dk/forskning/Publikationer/ph.d_serie_2007-/Ph.D.181.pdf

Attention and perception aren’t things we often talk about in health economics. Why are they important?

There’s been a lot of work done on attention and perception in economics recently, which I think is a great development. They are really vital topics since unless you know how people perceive the information available to them, and what aspects of their environment are most likely to command their attention, it’s difficult to forecast their behaviour.

I think attention and perception will become more widely talked about in health in future, as there’s many cases in which they have a lot of relevance. For example, you might want to know whether rare symptoms grab doctors’ attention because they’re unusual, or whether they don’t notice them because they’re not expecting them. (There’s a great study by Drew, Vo and Wolfe where radiologists looking at CT scans of the chest failed to notice a picture of a gorilla embedded in them by the experimenters.)

Or if you’re planning some dietary intervention, you might want to take into account how unhealthy food such as pizza and chips attracts people’s attention much more than healthy food, and to look at why this is the case.

What can the new theoretical frameworks described in your thesis tell us about individual behaviour?

Most of the literature in psychology is about how individuals behave. I tried a lot in my thesis to move beyond studying individual decision making to look at how the effects of attention and perception change in different economic environments, as this can often be counter-intuitive.

As an example, in one of the chapters of my thesis I explore the effects of individuals having limited ability to tell the quality of different products apart. It turns out that the effects on a market can be radically different depending on whether there are fixed or marginal costs of quality.

I was also very interested in looking at how individuals with limited or biased attention interact with profit maximising firms. There’s an expectation that companies will rip people off and exploit them, and certainly, that can happen, but I was able to show that it’s not necessarily the case. The case of individuals having limited ability to tell products’ quality apart which I mentioned above is a good example. When firms rely on product differentiation to earn profits, they’re actually harmed by people with this limitation, rather than exploiting them.

Did you find yourself reaching beyond the economics literature for guidance, either in the subject matter or the techniques that you used?

Yes, I read quite a lot outside the standard economics literature during my thesis. Behavioural and experimental economics more or less sits on the boundary between economics and psychology, so it felt very natural to seek guidance from other disciplines. This was especially the case for the eye-tracking experiment that I carried out with the help of my co-authors Andreas Gotfredsen, Carsten S. Nielsen and Alexander Sebald. I needed to learn quite a bit about psychological work on visual attention.

I like that economics is as much a set of analytic tools as a subject area, which gives it the advantage of being able to take on nontraditional topics.

You studied in Denmark, yet your thesis is written in English. Did this raise any additional challenges in completing your PhD?

Danish people speak better English than what I can! Language really wasn’t a problem at all at work, since English is very much the language of academia. Seminars were in English, PhD students and a lot of masters students wrote their theses in English and nearly all postgraduate and some undergraduate teaching was in English. I did feel quite privileged to have the advantage of being a native speaker of the language, and appreciative that most of my colleagues were fine with working in a second language. That’s why I was always very willing to help people out with proofreading English. I only hope I didn’t make too many mistakes!

On the social side, you can get away with living in Denmark without speaking Danish, and many people do. Indeed, I probably wouldn’t have made the effort of becoming a (moderate) Danish speaker if my partner wasn’t Danish.

Copenhagen, and Denmark in general, is a fantastic place to live and work, and I’d urge anyone who is thinking about moving there not to be put off by the language barrier.

How did your experiences during your PhD contribute to your decision to work in the field of health economics?

The question makes it sound like I had a coherent plan! In reality, I’m terrible about thinking about the long term. (I must be a natural Keynesian.) I ended up moving back to the UK after I graduated ironically because of my Danish partner, as she had found a job here. She also works in health, as a medical physicist and cancer researcher at Leeds. I applied for economics jobs in the area and was over the moon to secure a place at the Academic Unit of Health Economics at Leeds.

It’s a little more applied and hands-on than what I was working on before, which is great. I came into economics because I was interested in finding out how people act and interact, and so it’s fantastic to have the opportunity now to work principally with discrete choice experiments, trying to work out patients’ and clinicians’ preferences.

Since I started at Leeds a few months ago I’ve really enjoyed my time. The environment is very stimulating and all my colleagues are extremely friendly and easy going and are always willing to help out or discuss an interesting new idea.

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Chris Sampson’s journal round-up for 13th March 2017

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

The effects of exercise and relaxation on health and wellbeing. Health Economics [PubMedPublished 9th Month 2017

Encouraging self-management of health sounds like a good idea, but the evidence is pretty weak. As economists, we know that something must be displaced in order to do it. This study considers the opportunity cost of time and how it might affect self-management activity and any associated benefits. Employment and education are likely to increase income and thus facilitate more expenditure on exercise. But the time cost of exercise is also likely to increase, meaning that the impact on demand is ambiguous. The study uses data from a trial of self-management support that included people with diabetes, COPD or IBS. EQ-5D, self-assessed health and the amount of time spent ‘being happy’ were all collected. Information was available for 12 different self-management activities, including ‘do exercises’ and ‘rest and relax’, and the extent to which individuals did these. Outcomes for 3,472 people at 12-month follow-up are estimated, controlling for outcomes at baseline and 6 months. The study assumes that employment and education affect health via their influence on exercise and relaxation. That seems a bit questionable and the other 10 self-management indicators could have been looked at to test this. People in full-time employment were 11 percentage points less likely to use relaxation to manage their condition, suggesting that the substitution effect on time dominates as the opportunity cost of self-management increases. Having a degree or professional qualification increased the probability of using exercise by 5 percentage points, suggesting that the income effect dominates. Those who are more likely to use either exercise or relaxation are also more likely to do the other. An interesting suggestion is that time preference might explain things here. Those with more education may prefer to exercise (as an investment) than to get the instant gratification of rest and relaxation. It’s important that policy recommendations take into consideration the fact that different groups will respond differently to incentives for self-management, at least partly due to their differing time constraints. The thing I find most interesting is the analysis of the different outcomes (something I’ve worked on). Exercise is found to improve self-assessed health, while relaxation increases happiness. Neither exercise or relaxation had a (statistically significant) effect on EQ-5D. Depending on your perspective, this either suggests that the EQ-5D is failing to identify important changes in broad health-related domains or it means that self-management does not achieve the goals (QALYs to the max) of the health service.

New findings from the time trade-off for income approach to elicit willingness to pay for a quality adjusted life year. The European Journal of Health Economics [PubMedPublished 8th March 2017

The question ‘what is a QALY worth’ could invoke any number of reactions in a health economist, from chin scratching to eye rolling. The perspective that we’re probably most familiar with in the UK is that the value of a QALY is the value of health foregone in order to achieve it (i.e. opportunity cost within the health care perspective). An alternative perspective is that the value of a QALY is the consumption value of health; how much consumption would individuals be willing to give up in order to obtain an additional QALY? This second perspective facilitates a broader societal perspective. It can tell us whether or not the budget is set at an appropriate level, while the health care perspective can only take the budget as given. This study relates mainly to decisions made with the ‘consumption value’ perspective. One approach that has been proposed is to assess willingness to pay for a QALY using a time trade-off exercise that incorporates trade-offs between length and quality of life and income. This study builds on the original work by using a multiplicative utility function to estimate willingness to pay and also bringing in prospect theory to allow for reference dependence and loss aversion. 550 participants were asked to choose between living 10 years in their current health state with their current salary or to live a reduced number of years in their current health state with a luxury income (pre-specified by the participant). Respondents were also asked to make a similar choice, but framed as a loss of income, between living 10 years at a subsistence income or fewer years with their current income. A quality of life trade-off exercise was also conducted, in which people traded reduced health and a lower income. The findings support the predictions of prospect theory. Loss aversion is found to be stronger for duration than for quality of life. Individuals were more willing to sacrifice life years to move from subsistence income to current income than to move from current income to luxury income. The results imply that quality of life and income are closer substitutes than longevity and income. That makes sense, given the all-or-nothing nature of being alive. Crucially, the findings highlight the need to better understand the shape of the underlying lifetime utility function. In all tasks, more than half of respondents were either non-traders or over-traded, indicating a negative willingness to pay. That should give pause for thought when it comes to any aggregation of the results. Willingness to pay studies often throw up more questions than answers. This one does so more than most, particularly about sources of bias in people’s responses. The authors identify plenty of opportunities for future research.

Beyond QALYs: multi-criteria based estimation of maximum willingness to pay for health technologies. The European Journal of Health Economics [PubMed] Published 3rd March 2017

Life is messy. Evaluating things in terms of a single outcome, whether that be QALYs, £££s or whatever, is necessarily simplifying and restrictive. That’s not necessarily a bad thing, but we’d do well to bear it in mind. In this paper, Erik Nord sets out a kind of cost value analysis that does away with QALYs (gasp!). The author starts by outlining some familiar criticisms of the QALY approach, such as its failure to consider the inherent value of life and people’s differing reference points. Generally, I see these as features rather than bugs, and it isn’t QALYs themselves in the crosshairs here so much as cost-per-QALY analysis. The proposed method flips current practice by putting societal preferences about fair and efficient resource allocation before attaching values to the outcomes. As such, it acknowledges the fact that society’s preferences for gains in quality of life differ from those for gains in length of life. For example, society may prefer treating the more severely ill (independent of age) but also exhibit a ‘fair innings’ preference that is related to age. Thus, quality and quantity of life are disaggregated and the QALY is no more. A set of tables is presented that can be read to assess ‘value’ in alternative scenarios, given the assumptions set out in the paper. There is merit in the approach and a lot that I like about the possibilities of its use. But for me, the whole thing was made less attractive by the way it is presented in the paper. The author touts willingness to pay – for quality of life gains and for longevity gains – as the basis for value. Anything that makes resource allocation more dependent on willingness to pay values for things without a price (health, life) is a big no-no for me. But the method doesn’t depend on that. Furthermore, as is so often the case, most of the criticisms within relate to ways of using QALYs, rather than the fundamental basis for their estimation. This only weakens the argument for an alternative. But I can think of plenty of problems with QALYs, some of which might be addressed by this alternative approach. It’s unfortunate that the paper doesn’t outline how these more fundamental problems might be addressed. There may come a day when we do away with QALYs, and we may end up doing something similar to what’s outlined here, but we need to think harder about how this alternative is really better.

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How to cite The Academic Health Economists’ Blog

Occasionally we get emails from people who would like to cite our blog posts. Usually, these requests are framed as ‘is this going to be published in a journal?’. It’s no surprise that people are more comfortable citing the traditional academic literature. But researchers are increasingly citing blog posts. Indeed, some of our blog posts have been cited in published academic literature.

There are plenty of guides out there for citing blog posts. You may like to refer to them for specific formatting styles. Cite This For Me is a useful tool for generating references in a variety of styles. Here I’d like to provide a few specific recommendations for citing posts from this blog.

1. Cite the author

Our blog posts are written by lots of different authors, not by ‘the blog’. The author’s name – assuming they have not claimed anonymity – will appear at the top of the blog post. Let’s take a recent example. To start with, your citation should look something like:

Watson, S. (2017). Variations in NHS admissions at a glance. The Academic Health Economists’ Blog. Available at: https://aheblog.com/2017/01/25/variations-in-nhs-admissions-at-a-glance/ [Accessed 8 Mar. 2017].

2. Use our ISSN

As of this week, the blog now has its own International Standard Serial Number (ISSN). This number uniquely identifies and distinguishes the blog. Our ISSN is 2514-3441. You can find it at the bottom of the sidebar and on our About page. So your citation could become:

Watson, S. (2017). Variations in NHS admissions at a glance. The Academic Health Economists’ Blog (ISSN 2514-3441). Available at: https://aheblog.com/2017/01/25/variations-in-nhs-admissions-at-a-glance/ [Accessed 8 Mar. 2017].

3. Use WebCite

Unlike journal articles, websites can change. One of our authors could (in principle) completely change the content of their blog post after publishing it. More importantly, it is possible that our URLs may change in the future. If this were to happen, the link in the reference above would become redundant and the citation would not be useful to readers. What needs to be cited, therefore, is the blog post at the time at which you accessed it. Enter WebCite. WebCite is a service that archives a webpage and provides a permanent link for citation. This can be achieved by completing an archiving form. Our citation becomes:

Watson, S. (2017). Variations in NHS admissions at a glance. The Academic Health Economists’ Blog (ISSN 2514-3441). Available at: https://aheblog.com/2017/01/25/variations-in-nhs-admissions-at-a-glance/ [Accessed 8 Mar. 2017]. (Archived by WebCite® at http://www.webcitation.org/6ooALaGyF)

4. Check the comments

Finally, authors may choose to subsequently publish their blog post elsewhere in another format or to upload it to a service such as figshare in order to obtain a DOI. Check the comments below a blog post to see if this is the case as there may be an alternative source that you might prefer to cite.

But as ever, if you’re struggling, get in touch.

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