Subjective Risk Estimates Research Articles

Risk estimation in relation to anxiety and depression for low probability negative events

Foundational cognitive models propose that people with anxiety and depression show risk estimation bias, but most literature does not compute true risk estimation bias by comparing people's subjective risk estimates to their individualized reality (i.e., person-level objective risk). In a diverse community sample (N = 319), we calculated risk estimation bias by comparing people's subjective risk estimates for contracting COVID-19 to their individualized objective risk. Person-level objective risk was consistently low and did not differ across symptom levels, suggesting that for low probability negative events, people with greater symptoms show risk estimation bias that is driven by subjective risk estimates. Greater levels of anxiety, depression, and COVID-specific perseverative cognition separately predicted higher subjective risk estimates. In a model including COVID-specific perseverative cognition alongside anxiety and depression scores, the only significant predictor of subjective risk estimates was COVID-specific perseverative cognition, indicating that symptoms more closely tied to feared outcomes may more strongly influence risk estimation. Finally, subjective risk estimates predicted information-seeking behavior and eating when anxious, but did not significantly predict alcohol or marijuana use, drinking to cope, or information avoidance. Implications for clinical practitioners and future research are discussed.

Disease awareness and knowledge of stroke- and atrial fibrillation risk factors in cardiovascular patients

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): H2020-SC1-BHC-30-2019- 847770 Background Disease awareness is key for the uptake of preventive measures and positively affects self-management of atrial fibrillation patients (AF pat) or those at increased risk of AF. Less evidence exists about pat subjective risk awareness. We aims to identify the predictors of incorrect subjective risk estimation to guide future information of AF pat and stakeholders. Method In a prospective cardiology practice cohort (N=1200; age= 59.6 years; 34.4% women) with a median FU of 2.7 years we assessed the subjective estimation of: 1) the risk of stroke and AF in pat with an increased risk of AF (N=292) and 2) the stroke risk of AF pat (N=447). We used a 4-point Likert scale to measure the subjective risk estimation and matched the results with established risk scores and classified pat as "over", "under" and "correct" estimators. For non-AF cases we calculated the risk of incident AF using the CHARGE-AF- and the risk of stroke using a revised Framingham risk score to predict the 10-year probability of stroke. In AF pat we assessed their self-estimated risk of stroke compared to the CHA2DS2-VASc Score. We performed univariable association analyses of risk factors for over- or underestimation for stroke and AF with reference to correct estimators at baseline and FU and performed non-parametric tests for trend. Results At baseline N=52 AF pat, 10.6% and N=53 non-AF pat, 17.6% indicated that they are not able to estimate their stroke risk. This also applied for N=97 non-AF pat, 27.8% who were unable to estimate their AF risk. AF pat who underestimated their stroke risk were: significantly older (65.2 vs 59.8 years; p <.001), less frequently men (33.3% vs 44.4 %; p=0.023), had lower body weight (85.3 kg vs 82.5 kg p=0.023), fewer previous strokes (15.1% vs 8.3% p= 0.002) and had a higher chronic disease burden such as diabetes, hypertension, heart failure and coronary heart disease compared to AF pat with correct estimation. Non-AF cases at baseline estimated their AF risk (score value (vs): 1.0 vs 1.5; r= 0.216; p < 0.001) and the stroke risk (sv: 1.3 vs 1.9; r=0.263; p >.001) significantly higher than their current risk to develop the disease. AF risk estimation (sv: 1.2 vs 1.3; r=.216; p =098) and the stroke risk estimation (sv: 1.5 vs 1.4; r=0.035; p=0,458) were comparable to the score assessments in the FU for non-AF cases. AF pat estimated their stroke risk significantly higher than their current risk (sv: 1.0 vs 1.3; r= 0.125; p<.001). The same was observed during FU (score value 1.0 vs 1.3; r= 0.105; p<.001). Conclusions More than 10% of pat were unable to give an estimate of their risk due to lack of disease and risk factor knowledge. The minority correctly estimated their risk to develop AF and/or a stroke. Half of the pat overestimated their risk profile. The study identifies predictors related to the awareness and knowledge of the diseases and highlight the need for more explicit educational programs to improve AF awareness.

Association between subjective risk perception and objective risk estimation in patients with atrial fibrillation: a cross-sectional study

ObjectiveOral anticoagulation (OAC) is state-of-the-art therapy for atrial fibrillation (AF), the most common arrhythmia worldwide. However, little is known about the perception of patients with AF and how it correlates...

Measuring the end-of-life premium in cancer using individual ex ante willingness to pay.

For the assessment of value of new therapies in healthcare, Health Technology Assessment (HTA) agencies often review the cost per quality-adjusted life-year (QALY) gained. Some HTA agencies accept a higher cost per QALY gained when treatment is aimed at prolonging survival for patients with a short expected remaining lifetime, a so-called end-of-life (EoL) premium. The objective of this study is to elicit the existence and size of an EoL premium in cancer. Data was collected from 509 individuals in the Swedish general population 20-80years old using a web-based questionnaire. Preferences were elicited using subjective risk estimation and the contingent valuation (CV) method. A split-sample design was applied to test for order bias. The mean value of a QALY was MSEK4.8 (€528,000), and there was an EoL premium of 4-10% at 6months of expected remaining lifetime. Using subjective risk resulted in more robust and valid estimates of the value of a QALY. Order of scenarios did not have a significant impact on the WTP and the result showed scale sensitivity. Our result provides some support for the use of an EoL premium based on individual preferences when expected remaining lifetime is short and below 24months. Furthermore, we find support for a value of a QALY that is above the current threshold of several HTA agencies.

Impact of UKPDS risk estimation added to a first subjective risk estimation on management of coronary disease risk in type 2 diabetes – An observational study

AimsTo investigate the impact of the UKPDS risk engine on management of CHD risk in T2DM patients. MethodsObservational study among 139 GPs. Data from 933 consecutive patients treated with a maximum of two oral glucose lowering drugs, collected at baseline and after twelve months. GPs estimated the CHD risk themselves and afterwards they calculated this with the UKPDS risk engine. Under- and overestimation were defined as a difference >5 percentage points difference between both calculations. The impact of the UKPDS risk engine was assessed by measuring differences in medication adjustments between the over-, under- and accurately estimated group. ResultsIn 42.0% the GP accurately estimated the CHD risk, in 32.4% the risk was underestimated and in 25.6% overestimated. Mean difference between the estimated (18.7%) and calculated (19.1%) 10 years CHD risk was −0.36% (95% CI −1.24 to 0.52). Male gender, current smoking and total cholesterol level were associated with underestimation. Patients with an subjectively underestimated CHD risk received significantly more medication adjustments. Their UKPDS 10 year CHD risk did not increase during the follow-up period, contrary to the other two groups of patients. ConclusionsThe UKPDS risk engine may be of added value for risk management in T2DM.

Cardiovascular risk factor distribution and subjective risk estimation in urban women--the BEFRI study: a randomized cross-sectional study.

BackgroundAwareness represents a major modulator for the uptake of preventive measures and healthy life-style choices. Women underestimate the role of cardiovascular diseases as causes of mortality, yet little information is available about their subjective risk awareness.MethodsThe Berlin Female Risk Evaluation (BEFRI) study included a randomized urban female sample aged 25–74 years, in which 1,066 women completed standardized questionnaires and attended an extensive clinical examination. Subjective estimation was measured by a 3-point Likert scale question asking about subjective perception of absolute cardiovascular risk with a 10 year outlook to be matched to the cardiovascular risk estimate according to the Framingham score for women.ResultsAn expected linear increase with age was observed for hypertension, hyperlipidemia, obesity, and vascular compliance measured by pulse pressure. Knowledge about optimal values of selected cardiovascular risk factor indicators increased with age, but not the perception of the importance of age itself. Only 41.35% of all the participants correctly classified their own cardiovascular risk, while 48.65% underestimated it, and age resulted as the most significant predictor for this subjective underestimation (OR = 3.5 for age >50 years compared to <50, 95% CI = 2.6–4.8, P <0.0001). Therefore, although socioeconomic factors such as joblessness (OR = 1.9, 95% CI = 1.4–2.6, P <0.0001) and combinations of other social risk factors (low income, limited education, simple job, living alone, having children, statutory health coverage only; OR = 1.5, 95% CI = 1.1–2.1, P = 0.009) also significantly influenced self-awareness, age appeared as the strongest predictor of risk underestimation and at the same time the least perceived cardiovascular risk factor.ConclusionsLess than half of the women in our study population correctly estimated their cardiovascular risk. The study identifies age as the strongest predictor of risk underestimation in urban women and at the same time as the least subjectively perceived cardiovascular risk factor. Although age itself cannot be modified, our data highlights the need for more explicit risk counseling and information campaigns about the cardiovascular relevance of aging while focusing on measures to control coexisting modifiable risk factors.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-015-0304-9) contains supplementary material, which is available to authorized users.

Abstract 13863: Stress Echocardiography in Asymptomatic Patients: Impact of Clinical Risk Profile on Test Results

Introduction: Stress echocardiography (SE) has an established role in the evaluation of symptomatic patients, but its utility in asymptomatic patients is unclear. Current guidelines discourage the use of SE in most asymptomatic patients, citing lack of data to support its use. We therefore sought to describe the yield of SE in a group of asymptomatic individuals according to risk profile. Hypothesis: We hypothesized that SE would rarely be abnormal in asymptomatic individuals. Methods: We conducted a retrospective cohort study of all asymptomatic individuals who underwent exercise or pharmacologic SE between 2003 and 2013. Reasons for SE included screening for CAD, preoperative evaluation, abnormal ECG, coronary calcification, and assessment of established CAD (defined as prior myocardial infarction or coronary revascularization). We grouped subjects using both the 10-year Framingham risk equation and ATP3-suggested categories of low-risk (&lt;10%), intermediate-risk (10-20%), and high-risk (&gt;20%) for non-diabetic subjects without known CAD and by ACC/AHA Pooled Cohort risk estimates for subjects with and without diabetes. Subjects with established CAD were considered separately. Abnormal echocardiograms were defined as having ischemic, fixed, or mixed defects. Results: The study population comprised 19,170 subjects; 63% men, mean±SD age was 64±13 years, and 52% underwent pharmacologic SE. The likelihood of abnormal SE results was proportional to risk, with the highest yield in those with established CAD (59%). Those with diabetes had a yield similar to those with a 10 year risk of 10-20% by both ATP3/FRS and ACC/AHA. Conclusions: SE abnormalities are commonly seen in asymptomatic individuals; the likelihood of abnormal SE results was proportional to patients’ estimated risk. The frequency of SE abnormalities in diabetic patients is similar to that of intermediate-risk, but not high-risk patients.

Reply: Admission cardiotocography: practice based on evidence or assumptions and untested theories?

I thank Pelle Lindqvist for his interest in my commentary 1. The commentary 2 evaluated admission cardiotocography (CTG) from the perspective of clinical epidemiology – this is a part of evidence-based medicine. Lindqvist refers to his own experience, assumptions and untested theories indicating that admission CTG in all women improves outcomes in high-risk pregnancies. It is well known that it is difficult to draw conclusions from experiences on serious outcomes with very low frequencies. The subjective risk estimation is usually much higher than the objective (or epidemiological) risk estimation 3. When there is disagreement about which procedures or treatments are best, it is important to have academic discussions about the topic and to review the research literature carefully. Today the evidence is interpreted differently, as the test is recommended for all women in Finland and Sweden, but only for high-risk women in Denmark, Iceland and Norway. In Great Britain, where the traditions for making evidence-based guidelines are stronger than in the Nordic countries, the guidelines for intrapartum care among healthy women do not recommend admission CTG in low-risk women 4. In my view, the current evidence does not support routine use in low-risk women. It is possible that future research will provide other results but until then we should base our practice on evidence, not assumptions. As to the specific points in Pelle Lindqvist′s letter: The correct definition is of course that the admission CTG was introduced as a screening for fetal distress in labor, as defined by Ingemarsson et al. in 1986 5. Pelle Lindqvist states that admission CTG has never been used to predict later outcome. This is incorrect, and he is obviously not aware of the history on how and why the test was introduced 5. He also states that the commentary does not address perinatal mortality and serious morbidity. This, again, must rely on a misunderstanding. These important issues are addressed, as is the risk of type II errors because of insufficient sample size. The comment about skills in interpreting CTG-tracings was already discussed in a previous author reply 6. Pelle Lindqvist seems to imply that the labor admission test plays an important role in detecting cases of intrauterine fetal deaths (IUFD) upon admission to the hospital. I strongly disagree. If the midwife suspects IUFD after auscultation, the woman should have an ultrasound examination to verify the diagnosis, not a CTG.

Perceived risk following melanoma genetic testing: a 2-year prospective study distinguishing subjective estimates from recall.

A major goal of predictive genetic testing is to alert people to their risk before illness onset; however, little is known about how risk perceptions change following genetic testing and whether information is recalled accurately over time. In the United States, a CDKN2A/p16 mutation confers 76% lifetime risk of melanoma. Following genetic counseling and test reporting, subjective risk estimates and recall of counselor-provided risk estimates were assessed 5 times over the next 2years among 60 adult members of 2 extended CDKN2A/p16 kindreds. No sustained changes from baseline in risk perceptions were reported. Unaffected carriers (n = 15) consistently reported significantly lower subjective risk estimates (46%) than they were actually given (76%, p < 0.001) or recalled having been given (60%, p < 0.001). Noncarriers' (n = 27) risk estimates decreased following results disclosure, but rebounded, with both subjective and recalled estimates subsequently exceeding what they were told by the counselor (both ps < 0.001). Affected carriers' (n = 18) risk estimates for developing a new melanoma corresponded well to counselor-provided information (p = 0.362). For all 3 patient groups, results were consistent across multiple risk measures and remained similar when demographic, phenotypic, and baseline behavioral contributors to melanoma risk were statistically controlled. These findings are consistent with other studies of risk perception, but additional studies of more diverse populations are needed to understand the reasons behind both the persistence of initial risk estimates and their divergence from information provided by the counselor during genetic counseling. Additionally, determining whether holding subjective risk perceptions that differ from counselor-provided information ultimately affects adherence to management recommendations will help guide the presentation of risk information in genetic counseling practice.

Relatively drunk: subjective intoxication and estimated health consequences of alcohol consumption are conditional on the presence of less intoxicated individuals, not level of intoxication

According to the relative rank hypothesis (RRH), the magnitudes of sensory stimuli are estimated relative to their rank among related comparators. This study assessed the RRH in social drinkers and tested whether rank breath alcohol concentration is a better predictor of subjective alcohol risk estimates. The design was a cross-sectional alcometer street survey. Data from 1997 respondents (mean age, 26.96 years; 61.86% male) were used in analyses. Data were collected from five night-time economies characterized by excessive alcohol use. Prospective respondents were randomly approached to complete a short survey, including perceptions of the long-term health effects of their current state of intoxication and their self-perceived drunkenness, with those who consented to participate providing a breathalyzer score. Alcometer score was ranked according to other respondents and by discrete reference groups. Those whose breath alcohol content ranked high in their reference group reported that they felt more drunk and that they perceived the negative health consequences of alcohol misuse as more likely. No effect of breath score or social norm was observed. Our results generalize fundamental psychophysical theory and indicate that attitudes are spontaneous and relative to context; and that manipulating the social context in which alcohol is served—for example, by including more sober individuals—would increase perceived intoxication and increase the perceived likelihood of alcohol-related poor health. This is contrary to assumptions indicating attitudes are stable and informed by perceived social norms or absolute levels of consumption.

A meta-analysis on the association between bladder cancer and occupation

To date, many epidemiological studies have been conducted to examine the association between occupation and bladder cancer incidence. However, results from these studies often have been inconsistent, and significant associations have rarely been found, possibly owing to the lack of adequate statistical power in these studies. This meta-analysis summarizes the relevant literature regarding occupation and bladder cancer incidence to increase the statistical power to detect associations. The Medline and Embase databases were searched to retrieve epidemiological studies published up until May 2008. Individual risk estimates for subjects with an employment history in the occupation of interest were extracted from each included publication. For each occupation, a summary relative risk (SRR) was calculated by means of a random effects model. Significantly increased risks with an SRR greater than 1.20 were identified for miners [SRR=1.31, 95% confidence interval (CI) 1.09-1.57], bus drivers (SRR=1.29, 95% CI 1.08-1.53), rubber workers (SRR=1.29, 95% CI 1.06-1.58), motor mechanics (SRR=1.27, 95% CI 1.10-1.46), leather workers (SRR=1.27, 95% CI 1.07-1.49), blacksmiths (SRR=1.27, 95% CI 1.02-1.58), machine setters (SRR=1.24, 95% CI 1.09-1.42), hairdressers (SRR=1.23, 95% CI 1.11-1.37) and mechanics (SRR=1.21, 95% CI 1.12-1.31). In conclusion, the studies reviewed provide consistent support for a small but significant increased risk of bladder cancer among workers in these nine occupations. Although the relative risk of bladder cancer associated with these occupations is small, the public health impact may be significant, considering the substantial number of people who were and are employed in these occupations.

Opening the “Black Box” of Surgeons’ Risk Estimation: from Intuition to Quantitative Modeling

Woodfield et al. [1] reported that surgeons’ subjective riskestimates (as captured by visual analog scales) are usefulpredictors of postoperative complications over and aboveobjective criteria. Estimating risk accurately is a key pre-operative surgical task, essential for determining whetherto operate and for enabling surgical patients to provideinformed consent. However, little is known about howsurgeons produce risk estimates. In their commentary onthe above study, Clavien and Dindo [2] rightly argued thatto be useful risk estimation should be based solely onpreoperative factors. They contended that accurate sub-jective risk estimation depends on surgeons’ experience. Itis unclear, however, how accurate even experienced sur-geons’ subjective risk estimates are—in fact, the evidenceis virtually nonexistent. Risk estimation remains an uno-pened ‘‘black box’’ of surgical competence.In contrast to its ‘‘black box’’ treatment in the surgicalliterature, risk estimation has received considerable atten-tion by behavioral scientists. Estimating risk is a complexcognitive task that has been successfully modeled using aquantitative technique called judgment analysis (JA) [3, 4].The typical JA approach involves asking participants toprovide risk estimates for a series of scenarios that differwith respect to risk factors. These estimates are modeledquantitatively as a function of the factors present in thescenarios using linear regression. Data are analyzedseparately for each participant. The analysis yields betaweights for individual risk factors and model fit.This technique has been used to model surgeons’ pri-oritization decisions for general [5] and cardiac [6] surgery.We used JA to model surgeons’ risk estimates of conver-sion of laparoscopic cholecystectomy to an open operation[7]. Trainee surgeons provided risk estimates for a series ofvignettes in which the biliary history, previous upperabdominal surgery, patient’s sex, age/co-morbidity, bodyhabitus, and race were systematically varied. Risk esti-mates (0–100%) were modeled as a function of these cuesand compared to an existing outcomes-based gold standardmodel [8]. Whereas almost all trainee surgeons’ judgmentswere (appropriately) influenced by the biliary history andprevious surgery, there were significant individual differ-ences in how these factors were weighted. Moreover, somesurgeons were influenced by irrelevant cues (age/ASAscore, obesity, or race). Finally, correlations betweenindividuals’ estimates and gold standard-derived predic-tions ranged from 0.08 to 0.72, with lower correlationsindicating significant departures from the evidence-basedmodel.Judgment analysis offers systematic, quantifiable com-parisons of how differing risk factors influence surgeons’risk estimates. It allows comparisons between surgeons aswell as between surgeons and evidence-based risk models.It can address how surgeons integrate existing risk scores(e.g., ASA) with the ‘‘invasiveness’’ of the operation, aswell as the subjective impact of low-frequency factors,such as cirrhosis. We are currently exploring the effec-tiveness of JA for capturing differences in expertise amongsurgeons [9], modeling estimates of various surgical risks,and in a training intervention context using JA to providespecific, individualized feedback to surgical trainees. Sur-geons’ risk estimation may be an intuitive process, but it is

A Brief Inventory of Behavioral Influences on the Subjective Risk Adjusted Discount Rates in Project Appraisal

Behavioral finance has emerged as a new paradigm in financial economics. It deals primarily with the influences of psychology on market finance and with market inefficiencies. The field of psychology, already very present in organizational psychology and decision-making, is slowly opening up applications in corporate financial decisions and more specifically in corporate finance techniques. Among these corporate finance decisions is the project evaluation decision or the investment decision. This is based on first calculating expectations and risk estimates and then making a decision. This paper looks at how psychology can influence on the calculation of subjective risk estimates which are used to evaluate projects. We break down the risk factors used in project finance as the real time value of money, perceptions of inflation, market risk and Beta , financial risk and firm-specific risk and study some psychological factors which can influence each of these and why these may be important. The psychological factors we study in this paper include patience and impatience, optimism and pessimism, the notion of time in different cultures, inter-temporal differences/ dynamic inconsistency, inner tempo, achievement orientation, past or future orientation, addiction, frequency of evaluations, horizon / myopia, money illusion, loss aversion, values and lifestyles, agency problems,organizational decentralization, adverse selection, limited liability, venture capital firms, qualitative projects, example human capital, familiarity bias, confidence and hubris.

Satisfaction with breast reconstruction in women with bilateral prophylactic mastectomy: a descriptive study.

Prophylactic bilateral mastectomy is an option for women who are at an increased risk of developing breast cancer. Prophylactic mastectomy is often performed with immediate reconstruction (i.e., at the same time and under the same anesthetic as the mastectomy). Satisfaction with reconstruction has been described previously for women with mastectomy for breast cancer. However, the authors know of no previous research that has reported on satisfaction with reconstruction in patients who have electively sought mastectomy for the prevention of breast cancer. Women in the province of Ontario who had undergone prophylactic bilateral mastectomy plus breast reconstruction between 1991 and 2000 were asked to rate their level of satisfaction with the cosmetic results of their mastectomy and reconstruction and their overall satisfaction with their decision to have prophylactic mastectomy. Women were also asked whether they experienced complications associated with their surgery and what types of complications they experienced. Thirty-seven women completed questionnaires for this study, and all of them had immediate breast reconstruction after prophylactic mastectomy. The majority of women (70.3 percent) reported being satisfied or extremely satisfied with the cosmetic results of their breast reconstruction. Women with self-reported postsurgical complications (16.2 percent) were significantly less satisfied with reconstruction than those who did not report complications (p = 0.009). Personal subjective risk of breast cancer before prophylactic mastectomy was negatively correlated with satisfaction with reconstruction (r = -0.38, p = 0.024) and with subjective risk estimation after prophylactic surgery (r = -0.54, p = 0.001). Women who did not worry about developing breast cancer after prophylactic mastectomy had significantly higher levels of satisfaction with breast reconstruction than those who continued to worry (p < 0.001). Women who reported an improved body image after reconstruction were significantly more likely to report higher levels of satisfaction than those who reported a diminished body image (p = 0.007). The majority of women were satisfied with the cosmetic results of breast reconstruction after prophylactic mastectomy. Women who overestimated their breast cancer risk had lower satisfaction levels. Correcting overestimation of breast cancer risk in women who have prophylactic mastectomy may improve satisfaction with reconstruction following prophylactic mastectomy.

Environmental Risk and Uncertainty: Insights from Yucca Mountain

Abstract This study examines the effects of the risk from transporting high–level radioactive waste to the proposed Yucca Mountain repository on housing location decisions in Southern Nevada. Using data from a survey of southern Nevada households, we develop a model–based subjective risk estimate for each household. We then explore different factors that may influence the household's location decisions if the proposed transportation route is ultimately chosen for nuclear waste transport. We extend the conventional expected utility model to allow for uncertainty surrounding the actual risks borne by the household. Finally, we examine the impact of federal government compensation on households’ location decisions. The findings indicate that residents currently living near the proposed transportation route express subjective risk estimates much larger than those reported by the Department of Energy. In general, households that are uncertain about the future risks are more likely to relocate than those expressing certainty. When everything is considered, the model predicts that between one and three percent of households living near the transportation route are likely to relocate. Compensation can influence some households to remain at their present location and bear the transport risk.

Subjective and Objective Risks of Carrying a BRCA1/2 Mutation in Individuals of Ashkenazi Jewish Descent.

This repeated measures study examines (1) the change in subjective risk of mutations pre- to postcounseling, (2) the accuracy of BRCAPRO estimates of mutations, and (3) the discrepancy between subjective risk and BRCAPRO estimates of mutations before and after genetic counseling. Ninety-nine Ashkenazi Jewish individuals pursued testing for BRCA1/2 mutations. Most had a personal cancer history (N = 51; family only: N = 48); and received uninformative negative results (N = 66; positives: N = 23; informative negative: N = 10). The coping strategy of defensive pessimism predicts that individuals will believe the worst case scenario to better cope with a potential negative outcome. Consistent with this, most felt they would have a mutation, if not mutations in both genes. The BRCAPRO model appeared to overestimate risk of having a mutation in this sample (p < .001). BRCAPRO overestimates notwithstanding, genetic counseling increased accuracy of subjective risk (p < .01). Individuals with a family-only cancer history had the least accurate estimates of risk (p < .05) and may need further intervention to either manage anxiety or improve knowledge.

5.1.4 The Benefits of Integrated, Quantitative Risk Management

AbstractThere is no question that risk management (RM) has a value much greater than its financial cost for implementation. Hall1 reports return on investments (ROIs) on the order of 20–1. While our experience supports this finding, we believe that the return would be much higher given comprehensive metrics. To date, we have been unable to compile metrics as Hall has done because of the collateral effects that occur in application. Thus, we cannot calculate the true cost avoidance based solely on the application of risk management. This occurs because our approach is intense, focused on quantitative analysis, and designed to produce risk‐based decision support information for decision‐makers. We have dubbed the process risk‐based decision support, (RBDS). A particular characteristic of RBDS is the requirement that an ‘integrated’ result be presented to the decision‐maker. That is, the decision‐maker must have a result that integrates the various risk factors (i.e., cost, schedule, technical, mission, etc.) into a single, consistent, parameter for decision‐making – usually cost.The execution of such a risk management process means stringent demands for quality information are levied on projects. In fact, the coincidental discovery of deficient information during the process has yielded the greatest benefit to programs we have supported with RBDS.Qualitative techniques typically result in subjective risk estimates of likelihood and consequence such as high, medium, and low. Our intent is not to be critical of qualititative techniques; as a matter of fact, we use them. Furthermore, we find great value in qualitative processes, as they yield quick and efficient communication of risk issues across the program/project.However, we always go one step further. We implement a triage procedure to discriminate the ‘high’ risks that require further analysis using quantitative techniques. These quantitative techniques demand quality information from within the program. Typically, examples of deficient information discovered in our application of RBDS include low‐quality program plans, poor cost estimation, missing project elements, inconsistent integrated master plans and integrated master schedules, poor system‐level requirements, and unstable requirements. Each of these deficiencies themselves constitutes a risk to the program.In the following pages, we present a discussion of these management risks and how their identification has contributed to the success of numerous programs and projects. For some of our cases, we will provide semi‐quantitative judgments about the ROIs for RM.

Prognostication and certainty in the pediatric intensive care unit.

Prognostication is central to developing treatment plans and relaying information to patients, family members, and other health care providers. The degree of confidence or certainty that a health care provider has in his or her mortality risk assessment is also important, because a provider may deliver care differently depending on their assuredness in the assessment. We assessed the performance of nurse and physician mortality risk estimates with and without weighting the estimates with their respective degrees of certainty. Subjective mortality risk estimates from critical care attendings (n = 5), critical care fellows (n = 9), pediatric residents (n = 34), and nurses (n = 52) were prospectively collected on at least 94% of 642 eligible, consecutive admissions to a tertiary pediatric intensive care unit (PICU). A measure of certainty (continuous scale from 0 to 5) accompanied each mortality estimate. Estimates were evaluated with 2 x 2 outcome probabilities, the kappa statistic, the area under the receiver operating characteristics curve, and the Hosmer and Lemeshow goodness-of-fit chi(2) statistic. The estimates were then reevaluated after weighting predictions by their respective degree of certainty. Overall, there was a significant difference in the predictive accuracy between groups. The mean mortality predictions from the attendings (6.09%) more closely approximated the true mortality rate (36 deaths, 5.61%) whereas fellows (7.87%), residents (10.00%), and nurses (16.29%) overestimated the mean overall PICU mortality. Attendings were more certain of their predictions (4.27) than the fellows (4.01), nurses (3.79), and residents (3.75). All groups discriminated well (area under receiver operating characteristics curve range, 0.86-0.93). Only PICU attendings and fellows did not significantly differ from ideal calibration (chi(2)). When mortality predictions were weighted with their respective certainties, their performance improved. The level of medical training correlated with the provider's ability to predict mortality risk. The higher the level of certainty associated with the mortality prediction, the more accurate the prediction; however, high levels of certainty did not guarantee accurate predictions. Measures of certainty should be considered when assessing the performance of mortality risk estimates or other subjective outcome predictions.

Risk assessment: subjective or objective?

Identified are many common problems/misunderstandings that engineers involved in risk assessment have raised in dealing with the concepts of risk assessment (RA, as defined in the management of Health and Safety at Work Regulations 1992). In particular concerns, reservations and confusion about the use of subjective risk estimation and the development of procedures for risk estimation appear to be causing undue difficulties in dealing with the regulations. This article suggests that risk estimation by itself has, in fact, little direct value to safety improvement and that a more tentative approach to RA can be formulated wherein risk estimation becomes an occasional rather than pivotal element of the risk assessment process.

Thromboembolic Stroke in Young Women: A European Case-Control Study on Oral Contraceptives

A matched case-control study was performed between 1993 and 1996 in 16 centers in the United Kingdom, Germany, France, Switzerland, and Austria. The objective was to determine the influence of oral contraceptives (OC), particularly those containing modern progestins, on the risk for ischemic stroke in women aged 16–44 years. A total of 220 women who had had an incident ischemic stroke and were compared with 775 control subjects who were unaffected by stroke. At least one hospital and one community control subject per patient was matched and interviewed with the corresponding patient for 5-year age band and for area of residence. Crude odds ratios (95% confidence intervals [CI]) for ischemic stroke were as follows. For current use of any OC versus no use 2.3 (1.7–3.2), the adjusted odds ratio (OR) 3.6 (2.4–5.4). The OC associated risk was higher for first generation than for second or third generation OC. The risk estimates for patients versus community control subjects were always lower than for hospital control subjects. No major regional difference of the risk estimates was found. Compared with nonusers of OC without hypertension, women with hypertension who used OC had an almost 10-fold increased risk. However, OC users who had had a blood pressure check before OC prescription had a lower risk than did those without such a check. Smoking >10 cigarettes/day is associated with higher risk of stroke, particularly for OC users. No significant effect was found for duration of OC use. We conclude that although there is a small relative risk of occlusive stroke for healthy women currently using OC, the attributable risk is very small because the incidence in this age group is very low. The small increase in risk of OC use may be further reduced by preventive efforts for cardiovascular risk factors, particularly hypertension and smoking.