Finckh A, Bansback N, Marra CA, Anis AH, Michaud K, Lubin S, White M, Sizto S, Liang MH

BACKGROUND: Long-term control or remission of rheumatoid arthritis (RA) may be possible with very early treatment. However, no optimal first therapeutic strategy has been determined. OBJECTIVE: To assess the potential cost-effectiveness of major therapeutic strategies for very early RA. DESIGN: Decision analytic model with probabilistic sensitivity analyses. DATA SOURCES: Published data, the National Data Bank for Rheumatic Diseases, and actual 2007 hospital costs. TARGET POPULATION: U.S. adults with very early RA (symptom duration <or=3 months). TIME HORIZON: Lifetime. PERSPECTIVE: Health care provider and societal. INTERVENTION: 3 management strategies were compared: a symptomatic or “pyramid” strategy with initial nonsteroidal anti-inflammatory drugs, patient education, pain management, and low-dose glucocorticoids, and disease-modifying antirheumatic drugs (DMARDs) at 1 year for nonresponders; early DMARD therapy with methotrexate; and early therapy with biologics and methotrexate. OUTCOME MEASURES: Cost per quality-adjusted life-year (QALY) gained. RESULTS OF BASE-CASE ANALYSIS: By reducing the progression of joint erosions and subsequent functional disability, both early intervention strategies increase quality-adjusted life more than the pyramid strategy and save long-term costs. When the cost of very early intervention is factored in, the cost-effectiveness ratio of the early DMARD strategy is $4849 per QALY (95% CI, $0 to $16 354 per QALY) compared with the pyramid strategy, whereas the benefits gained through the early biologic strategy come at a substantial incremental cost. The early DMARD strategy maximizes the effectiveness of early DMARDs and reserves the use of biologics for patients with more treatment-resistant disease of longer duration, for which the incremental benefit of biologics is greater.Results of Sensitivity Analysis:The early biologic strategy becomes more cost-effective if drug prices are reduced, risk for death is permanently lowered through biologic therapy, patients experience drug-free remission, responders can be selected before therapy initiation, or effective alternative antirheumatic agents are available for patients for whom several biologics have failed. LIMITATIONS: Data on the long-term effect of very early therapeutic interventions on the natural progression in disability and joint erosions are limited. The study considered only tumor necrosis factor inhibitors and not the newer biologics. CONCLUSION: According to the most objective measures of RA progression, very early intervention with conventional DMARDs is cost-effective. The cost-effectiveness of very early intervention with biologics remains uncertain.

Ann Intern Med. 2009 Nov 3;151(9):612-21

Bansback N, Sizto S, Sun H, Feldman S, Willian MK, Anis A

AIMS: To compare the efficacy of psoriasis treatments through a systematic literature review and meta-analysis. METHODS: Randomized controlled trials evaluating the Psoriasis Area and Severity Index (PASI) were identified and assessed for quality. PASI responses were modeled using a mixed-treatment comparison, which enabled the estimation of the relative effectiveness of several treatments. Sensitivity analyses were performed. RESULTS: Twenty-two trials were included. Tumor necrosis factor (TNF) inhibitors were most likely to achieve PASI 75, with a mean relative risk (RR) of 15.57 (95% CI 12.46-19.25) versus mean RRs of 9.24 (95% CI 5.33-13.91) for systemic and 5.65 (95% CI 3.74-7.97) for T-cell therapies. Infliximab (81%) and adalimumab (71%) had greater probabilities of achieving PASI 75 than etanercept (50%). Dosage was an important determinant of outcome. CONCLUSIONS: TNF inhibitors were more effective than T cell agents; adalimumab and infliximab were more effective than systemic therapies and etanercept. Evidence-based comparisons support patient and physician decisions. (c) 2009 S. Karger AG, Basel.

Dermatology. 2009;219(3):209-18

Bansback N, Ara R, Ward S, Anis A, Choi HK

HMG-CoA reductase inhibitors (statins) are potentially excellent candidate agents for patients with rheumatoid arthritis (RA). They reduce both cardiovascular risks and RA disease activity. To evaluate the potential long-term effects of statin therapy among patients with RA, and to determine their associated cost effectiveness by incorporating both the cardiovascular and the anti-rheumatic benefits. A Markov decision-analytic model was developed to simulate cardiovascular and RA disease profiles over time. The impact of statin therapy was estimated by adjusting the risk of coronary heart disease (CHD) events and changes in the RA Disease Activity Score (DAS28), based on the results of a randomized trial. The benefits (QALYs) and costs (in year 2005 values) were evaluated from a US payer perspective. A full uncertainty analysis, including a value-of-information (VOI) analysis, was undertaken to evaluate the importance of individual parameters. Using a 10-year time horizon, the additional cost and QALYs of statin therapy were estimated to be USD4690 and 0.44 QALYs, respectively, resulting in an incremental cost-effectiveness ratio (ICER) of USD10 650 per QALY (95% CI 1525, 156 565). The QALY gain associated with statin therapy depended more on the anti-rheumatic effects of statin therapy than on its cardiovascular prevention effect. The VOI analysis found the long-term benefit of statin therapy (i.e. >or=12 months) and the consequent impact on quality of life to be the most uncertain and, therefore, influential parameters. Our analysis indicates that the dual anti-inflammatory/cardiovascular benefits of statins could make this therapy highly cost effective in RA. However, uncertainties remain in the available data, warranting further research on refining the precise RA disease-activity benefits and health-utility changes associated with statin therapy, at least over a 12-month period.

Pharmacoeconomics. 2009;27(1):25-37. doi: 10.2165/00019053-200927010-00004

Kopec JA, Sayre EC, Flanagan WM, Fines P, Cibere J, Rahman MM, Bansback NJ, Anis AH, Jordan JM, Sobolev B, Aghajanian J, Kang W, Greidanus NV, Garbuz DS, Hawker GA, Badley EM

OBJECTIVES: The purpose of the study was to develop a population-based simulation model of osteoarthritis (OA) in Canada that can be used to quantify the future health and economic burden of OA under a range of scenarios for changes in the OA risk factors and treatments. In this article we describe the overall structure of the model, sources of data, derivation of key input parameters for the epidemiological component of the model, and preliminary validation studies. DESIGN: We used the Population Health Model (POHEM) platform to develop a stochastic continuous-time microsimulation model of physician-diagnosed OA. Incidence rates were calibrated to agree with administrative data for the province of British Columbia, Canada. The effect of obesity on OA incidence and the impact of OA on health-related quality of life (HRQL) were modeled using Canadian national surveys. RESULTS: Incidence rates of OA in the model increase approximately linearly with age in both sexes between the ages of 50 and 80 and plateau in the very old. In those aged 50+, the rates are substantially higher in women. At baseline, the prevalence of OA is 11.5%, 13.6% in women and 9.3% in men. The OA hazard ratios for obesity are 2.0 in women and 1.7 in men. The effect of OA diagnosis on HRQL, as measured by the Health Utilities Index (HUI3), is to reduce it by 0.10 in women and 0.14 in men. CONCLUSIONS: We describe the development of the first population-based microsimulation model of OA. Strengths of this model include the use of large population databases to derive the key parameters and the application of modern microsimulation technology. Limitations of the model reflect the limitations of administrative and survey data and gaps in the epidemiological and HRQL literature.

Osteoarthritis Cartilage. 2009 Oct 23

Harrison MJ, Davies LM, Bansback NJ, McCoy MJ, Verstappen SM, Watson K, Symmons DP; The British Society for Rheumatology Biologics Register Control Centre Consortium, on behalf of the BSRBR

PURPOSE: Comparative evidence regarding the responsiveness of the EQ-5D and SF-6D in arthritis patients is conflicting and insufficient across the range of disease severity. We examined the comparative responsiveness of the EQ-5D and SF-6D in cohorts of patients with early inflammatory disease through to severe rheumatoid arthritis (RA). METHODS: Responsiveness was tested using the effect size (ES) and standardised response mean (SRM). Correlation of change in EQ-5D and SF-6D with disease specific measures was tested using Pearson correlations and the Steiger’s Z test. Treatment response and self-reported change were used as anchors of important change. RESULTS: The EQ-5D was more responsive to deterioration (ES ratio (EQ-5D/SF-6D): 1.6-3.0) and the SF-6D more responsive to improvement (ES ratio (SF-6D/EQ-5D): 1.1-1.8) in health. The SF-6D did not respond well to deterioration in patients with established severe RA (ES and SRM 0.08). The EQ-5D provided larger absolute mean change estimates but with greater variance compared to the SF-6D. CONCLUSIONS: The comparative responsiveness of the EQ-5D and SF-6D differs according to the direction of change. The level of mean change of the EQ-5D relative to the SF-6D has implications for cost-effectiveness analysis. Use of the SF-6D in patients with severe progressive disease may be inappropriate.

Qual Life Res. 2009 Sep 24

Nosyk B, Sun H, Bansback N, Guh DP, Li X, Barnett P, Bayoumi A, Griffin S, Joyce V, Holodniy M, Owens DK, Anis AH

OBJECTIVES: To assess the concurrent validity and responsiveness of the Health Utility Index 3 (HUI3) in patients with advanced HIV/AIDS, and to determine the responsiveness of this measure, the MOS-HIV and EQ-5D to HIV-related clinical events. METHODS: Data from the OPTIMA (OPTions In Management with Antiretrovirals) trial was analyzed. Two aspects of the validity of the HUI3 were considered: concurrent validity was evaluated using Spearman correlations with MOS-HIV component and summary scores. Responsiveness to AIDS-defining events (ADE) and all adverse events (our external change criterion) was assessed using area under the receiver operating characteristic (AUROC) curves. RESULTS: The study enrolled 368 patients (mean follow-up: 3.66 years); 82% had at least one severe adverse event and 27% had at least one ADE. The HUI3 scale and items showed good concurrent validity, with 85% of the expected relationships with the MOS-HIV subscales verified. The HUI3 was responsive to both adverse events (AUROC [95%CI]: 0.68 [0.57, 0.80]) and ADEs (0.62 [0.51, 0.74]). The EQ-5D was responsive to ADEs (0.66 [0.56, 0.76]), but not responsive to adverse events (0.56 [0.46, 0.68]). CONCLUSION: The HUI3 is a valid and responsive measure of the change in HRQoL associated with clinical events in an advanced HIV/AIDS population.

Qual Life Res. 2009 Sep;18(7):815-24

Harrison MJ, Davies LM, Bansback NJ, McCoy MJ, Farragher TM, Verstappen SM, Hassell A, Symmons DP

OBJECTIVE: Using inflammatory arthritis patients as an example, we investigate EuroQol-5D (EQ-5D) profiles resulting in states worse than death (WTD), and the heath status of patients occupying these states. METHODS: Baseline data from two UK trials were used that reflected the range of arthritis states/severity found in routine practice. EQ-5D profiles resulting in negative valuations (i.e., states WTD) based on UK weights were identified. EQ-5D scores for these profiles from alternative valuation sets, including a reanalysis of the UK weights, were compared. The health status and characteristics of patients, and factors associated with patients in the low distribution of the EQ-5D and those with WTD EQ-5D scores were identified. RESULTS: Seven hundred patients were included in the analysis. Sixty-two (9%) patients occupied states WTD. Patients occupied 9 of the possible 84 health profiles with negative scores (53% occupied one profile); this profile was not rated WTD by any of the alternative EQ-5D scoring algorithms. All WTD profiles included severe pain/discomfort plus moderate problems in >or=3 other domains. Patients with WTD valuations reported higher levels of pain, and feeling downhearted and low on alternative health status measures. CONCLUSIONS: Pain was the predominant factor in the WTD EQ-5D profiles occupied by arthritis patients. Patients occupying states WTD have poorer health-related quality of life than patients in low “better than death” states. Valuations of profiles vary according to how sets of preference weights for health profiles were developed. Further research should explore whether WTD valuations are supported by qualitative evidence and reflect the patient’s health and experience of disease.

Value Health. 2009 Sep;12(6):1026-34

Anis AH, Nosyk B, Sun H, Guh DP, Bansback N, Li X, Barnett PG, Joyce V, Swanson KM, Kyriakides TC, Holodniy M, Cameron DW, Brown ST; OPTIMA Team1

OBJECTIVE: To investigate the relative magnitude and duration of impact of AIDS-defining events (ADEs) and non-AIDS serious adverse events (SAEs) on health-related quality of life (HRQoL) among patients with advanced HIV/AIDS. METHODS: We use data from OPTIMA (OPTions In Management with Antiretrovirals), a multinational, randomized, open, control, clinical management trial of treatment strategies for patients with multidrug-resistant HIV and advanced immune disease. Longitudinal models were used to determine the effects of ADEs and SAEs on HRQoL across periods before, during, and after event onset. The Medical Outcomes Study HIV Health Survey (MOS-HIV) physical and mental health summary scores (MOS-PHS and MOS-MHS), EQ-5D, and the Health Utilities Index Mark 3 HRQoL measures were all assessed at regular follow-up intervals during the trial. RESULTS: ADEs occurred much less frequently than SAEs (n = 147 vs. n = 821) in the study sample population of 368 patients, during median follow-up of 3.96 years. Although both ADEs and SAEs had significant negative impacts on HRQoL, SAEs had at least as large an impact upon HRQoL as ADEs when both were included in a multivariate linear regression model, controlling for other covariates. However, the effect of ADEs on HRQoL was more persistent, with larger magnitude of effect across all instruments in time intervals further from the onset of the event. CONCLUSIONS: Non-AIDS SAEs occurring in patients with late-stage HIV/AIDS seem to have at least as important an immediate impact on patient HRQoL as ADEs; however, the impact of ADEs seems to be more persistent. Our findings call for a greater emphasis on the detection and active prevention of non-AIDS SAEs in patients with late-stage HIV/AIDS.

J Acquir Immune Defic Syndr. 2009 Aug 15;51(5):631-9

Sizto S, Bansback N, Feldman SR, Willian MK, Anis AH

BACKGROUND: New biologics have dramatically changed therapeutic options for psoriasis, albeit at additional cost. OBJECTIVES: To determine the cost-effectiveness and optimal treatment sequence for moderate to severe psoriasis. METHODS: Psoriasis Area and Severity Index (PASI) response rates from 22 randomized controlled trials evaluating biologic (adalimumab, efalizumab, etanercept, infliximab) and nonbiologic systemic (methotrexate, ciclosporin) agents were considered. Short-term efficacy was based on relative probabilities of achieving PASI response (50/75/90) in a meta-analysis of trials. Published evidence and assumptions were used to predict long-term efficacy. Treatment benefits were determined by the relationship between PASI response and the EuroQOL 5D health utility measure. Costs included therapy, administration, monitoring and hospitalization. Incremental cost-effectiveness ratios (ICERs) were calculated and treatments ranked relative to supportive care. RESULTS: Infliximab provided the most incremental quality-adjusted life-years (QALYs) vs. supportive care (0.18 QALYs; 95% confidence interval, CI 0.13-0.24), followed by adalimumab (0.16 QALYs; 95% CI 0.11-0.22). Methotrexate and ciclosporin were less beneficial (0.13 and 0.08 QALYs, respectively) but were cost saving and considered the first two treatments in the optimal sequence. Comparing biologics, adalimumab was most cost effective (ICER pound30 000 per QALY), followed by etanercept ( pound37 000 per QALY), efalizumab ( pound40 000 per QALY) and infliximab ( pound42 000 per QALY). CONCLUSIONS: Methotrexate and ciclosporin are cost effective but require monitoring for toxicities. Of the biologics, adalimumab was most cost effective following conventional systemic treatment failure or inadequate response. Payers and policymakers will have to decide how to utilize their budgets effectively for treating patients with moderate to severe psoriasis.

Br J Dermatol. 2009 Jun;160(6):1264-72

Bansback N, Ara R, Ward S, Anis A, Choi HK.

HMG-CoA reductase inhibitors (statins) are potentially excellent candidate agents for patients with rheumatoid arthritis (RA). They reduce both cardiovascular risks and RA disease activity. To evaluate the potential long-term effects of statin therapy among patients with RA, and to determine their associated cost effectiveness by incorporating both the cardiovascular and the anti-rheumatic benefits. A Markov decision-analytic model was developed to simulate cardiovascular and RA disease profiles over time. The impact of statin therapy was estimated by adjusting the risk of coronary heart disease (CHD) events and changes in the RA Disease Activity Score (DAS28), based on the results of a randomized trial. The benefits (QALYs) and costs (in year 2005 values) were evaluated from a US payer perspective. A full uncertainty analysis, including a value-of-information (VOI) analysis, was undertaken to evaluate the importance of individual parameters. Using a 10-year time horizon, the additional cost and QALYs of statin therapy were estimated to be USD4690 and 0.44 QALYs, respectively, resulting in an incremental cost-effectiveness ratio (ICER) of USD10 650 per QALY (95% CI 1525, 156 565). The QALY gain associated with statin therapy depended more on the anti-rheumatic effects of statin therapy than on its cardiovascular prevention effect. The VOI analysis found the long-term benefit of statin therapy (i.e. >or=12 months) and the consequent impact on quality of life to be the most uncertain and, therefore, influential parameters. Our analysis indicates that the dual anti-inflammatory/cardiovascular benefits of statins could make this therapy highly cost effective in RA. However, uncertainties remain in the available data, warranting further research on refining the precise RA disease-activity benefits and health-utility changes associated with statin therapy, at least over a 12-month period.

Pharmacoeconomics. 2009;27(1):25-37

Nixon RM, O’Hagan A, Oakley J, Madan J, Stevens JW, Bansback N, Brennan A

The development of a new drug is a major undertaking and it is important to consider carefully the key decisions in the development process. Decisions are made in the presence of uncertainty and outcomes such as the probability of successful drug registration depend on the clinical development programmme.The Rheumatoid Arthritis Drug Development Model was developed to support key decisions for drugs in development for the treatment of rheumatoid arthritis. It is configured to simulate Phase 2b and 3 trials based on the efficacy of new drugs at the end of Phase 2a, evidence about the efficacy of existing treatments, and expert opinion regarding key safety criteria.The model evaluates the performance of different development programmes with respect to the duration of disease of the target population, Phase 2b and 3 sample sizes, the dose(s) of the experimental treatment, the choice of comparator, the duration of the Phase 2b clinical trial, the primary efficacy outcome and decision criteria for successfully passing Phases 2b and 3. It uses Bayesian clinical trial simulation to calculate the probability of successful drug registration based on the uncertainty about parameters of interest, thereby providing a more realistic assessment of the likely outcomes of individual trials and sequences of trials for the purpose of decision making.In this case study, the results show that, depending on the trial design, the new treatment has assurances of successful drug registration in the range 0.044-0.142 for an ACR20 outcome and 0.057-0.213 for an ACR50 outcome. Copyright (c) 2009 John Wiley & Sons, Ltd.

Pharm Stat. 2009 Apr 1

Nixon RM, Bansback N, Stevens JW, Brennan A, Madan J

A model is presented to generate a distribution for the probability of an ACR response at six months for a new treatment for rheumatoid arthritis given evidence from a one- or three-month clinical trial. The model is based on published evidence from 11 randomized controlled trials on existing treatments. A hierarchical logistic regression model is used to find the relationship between the proportion of patients achieving ACR20 and ACR50 at one and three months and the proportion at six months. The model is assessed by Bayesian predictive P-values that demonstrate that the model fits the data well. The model can be used to predict the number of patients with an ACR response for proposed six-month clinical trials given data from clinical trials of one or three months duration. Copyright 2008 John Wiley & Sons, Ltd.

Pharm Stat. 2009 Apr-Jun;8(2):150-62

Anis AH, Zhang W, Bansback N, Guh DP, Amarsi Z, Birmingham CL

Summary This study is to update the estimates of the economic burden of illness because of overweight and obesity in Canada by incorporating the increase in prevalence of overweight and obesity, findings of new related comorbidities and rise in the national healthcare expenditure. The burden was estimated from a societal perspective using the prevalence-based cost-of-illness methodology. Results from a literature review of the risks of 18 related comorbidities were combined with prevalence of overweight and obesity in Canada to estimate the extent to which each comorbidity is attributable to overweight and obesity. The direct costs were extracted from the National Health Expenditure Database and allocated to each comorbidity using weights principally from the Economic Burden of Illness in Canada. The study showed that the total direct costs attributable to overweight and obesity in Canada were $6.0 billion in 2006, with 66% attributable to obesity. This corresponds to 4.1% of the total health expenditures in Canada in 2006. The inclusion of newly identified comorbidities increased the direct cost estimates of obesity by 25%, while the rise in national healthcare expenditure accounted for a 19% increase. Policies to reduce being overweight and obese could potentially save the Canadian healthcare system millions of dollars.

Obes Rev. 2009 Apr 1.

Guh DP, Zhang W, Bansback N, Amarsi Z, Birmingham CL, Anis AH

BACKGROUND: Overweight and obese persons are at risk of a number of medical conditions which can lead to further morbidity and mortality. The primary objective of this study is to provide an estimate of the incidence of each co-morbidity related to obesity and overweight using a meta-analysis. METHODS: A literature search for the twenty co-morbidities identified in a preliminary search was conducted in Medline and Embase (Jan 2007). Studies meeting the inclusion criteria (prospective cohort studies of sufficient size reporting risk estimate based on the incidence of disease) were extracted. Study-specific unadjusted relative risks (RRs) on the log scale comparing overweight with normal and obese with normal were weighted by the inverse of their corresponding variances to obtain a pooled RR with 95% confidence intervals (CI). RESULTS: A total of 89 relevant studies were identified. The review found evidence for 18 co-morbidities which met the inclusion criteria. The meta-analysis determined statistically significant associations for overweight with the incidence of type II diabetes, all cancers except esophageal (female), pancreatic and prostate cancer, all cardiovascular diseases (except congestive heart failure), asthma, gallbladder disease, osteoarthritis and chronic back pain. We noted the strongest association between overweight defined by body mass index (BMI) and the incidence of type II diabetes in females (RR = 3.92 (95% CI: 3.10-4.97)). Statistically significant associations with obesity were found with the incidence of type II diabetes, all cancers except esophageal and prostate cancer, all cardiovascular diseases, asthma, gallbladder disease, osteoarthritis and chronic back pain. Obesity defined by BMI was also most strongly associated with the incidence of type II diabetes in females (12.41 (9.03-17.06)). CONCLUSION: Both overweight and obesity are associated with the incidence of multiple co-morbidities including type II diabetes, cancer and cardiovascular diseases. Maintenance of a healthy weight could be important in the prevention of the large disease burden in the future. Further studies are needed to explore the biological mechanisms that link overweight and obesity with these co-morbidities.

BMC Public Health. 2009 Mar 25;9:88

Bansback N, Marra CA, Finckh A, Anis A

Recent years have witnessed a shift in the therapeutic approach for patients with early rheumatoid arthritis (RA). The focus of interest has been the improved outcomes achieved through the use of early aggressive disease-modifying therapy, including the use of biologic agents. Such strategies have acquisition costs which typically exceed those of older anti-rheumatic strategies. However, improved outcomes might lead to fewer hospitalizations and physician visits and improved employability, leading to future cost savings. This is in addition to the health benefits which patients value as improvements in quality of life. With many services competing to spend often limited health-care budgets, information on the relative benefits and costs of new approaches for treating RA can be useful in deciding on efficient allocation and treatment decisions.

Best Pract Res Clin Rheumatol. 2009 Feb;23(1):83-92

This is a presentation surrounding direct to consumer genetic tests provided by companies such as 23andme given by Aslam Anis at iHEA. The slides are available here.

Background: The popularity and awareness of genetics has increased since the completion of the mapping of the human genome. Direct-to-consumer (DTC) genetic tests that provide consumers with a personalized assessment of their genetic risk for a list of diseases and conditions are now being offered over the internet.

Objective: To evaluate the impact of personal information obtained from DTC genetic test results on health care utilization and consumer welfare.

Methods: A web survey using conjoint analysis was conducted on a panel of Canadian adults. Mimicking the results provided by online DTC genetic tests, hypothetical scenarios were created comprising disease type, personal risk (relative to the average population), and quality of the research evidence on which the personal risk estimate was based. In each of 12 scenarios shown to participants, 4 diseases were selected from a group of 8. For each disease, average population risk, a personal risk level from 5 levels ranging from much lower than average to much higher than average (represented with absolute numbers) and a research quality level (low/medium/high) were selected. Respondents were asked to state whether or not they would (1)schedule an additional doctor’s visit, (2)change to a healthier lifestyle and (3)become more worried, based on each given risk profile. In the analysis, personal risk profiles were classified into one of 4 groups (very high/high/moderate/low), according to the proportions of personal risk levels that were higher than, equal to or lower than the average level. Diseases were grouped into preventable and non-preventable. Age, gender, self-reported general health and education level were modeled as covariates. Logistic regression models were fitted for each outcome.

Results: A total of 316 respondents (47% male, median age=52 yr, IQR:41-65) completed the survey. More respondents reported their health status as very good (33%), good (44%), or fair (11%) vs. excellent (8%) or poor (4%) and the proportion of respondents with high school, college and university education was 36%, 34% and 30% respectively. Of the 3782 scenarios included in the analysis, distribution of personal risk profile was 17% (very high), 16% (high), 48% (moderate) and 18% (low). Results from the analysis suggest that higher levels of personal risk within a scenario were associated with a higher likelihood of making an additional appointment with a doctor, adopting a healthier lifestyle, and feeling more anxious and worried. Respondents with poorer health were more likely to make an unscheduled doctor’s appointment. Females, older respondents and those with family histories of the diseases were also more likely to adopt a healthier lifestyle. Males and those with at least a university education were less likely to be worried. No significant difference was found by whether or not a disease is preventable or the quality of the evidence.

Conclusion: Our findings showed that personal genetic information increases demand for health care in the short run (increased physician visits) and there is some evidence that lifestyle modifications would also be made. When including the effect of anxiety, the overall impact on consumer welfare remains to be further investigated.