HHe ea al lt th h E Ec co on no om mi ic cs s a an nd d D De ec ci is si io on n S Sc ci ie en nc ce e D Di is sc cu us ss si io on n P Pa ap pe er r S Se er ri ie es s No. 08/02A review of studies mapping (or cross walking) from non-preference based measures of health to generic preference-based measures INTRODUCTIONA common approach to assessing the outcomes of health care is to obtain patient reported descriptions of health status across various dimensions and then to apply a standardised numerical scoring system. There are many different measures of health, including several hundred condition specific measures of health designed for use in specific medical conditions or groups of condition (Spilker et al, 1990), and a number of generic measures designed to cover the core dimensions of health that are relevant across all medical conditions. Health measures can also be distinguished in terms of whether they generate a profile of dimension scores or a single index and if they produce a single index, whether or not the index has been derived using simple summation of item scores or by using preference weights obtained from patients or the general public (known as preference-based measures or multi-attribute utility scales).Patient reported measures of health have become widely used in clinical trials as primary or secondary outcomes. There is little agreement on which specific instruments should be used for this purpose. For assessing clinical efficacy, there is disagreement on whether to use a generic or condition specific measure, and between condition specific measures there is often disagreement amongst clinical researchers on the most appropriate instrument. As a result clinical trials around the world often use different measures for the same patient groups. This presents a substantial barrier to the synthesis of evidence.Preference-based measures of health are necessary to generate the health state utility values required to calculate QALYs for assessing the cost effectiveness of interventions.These are usually based on generic instruments (e.g. EQ-5D) that permit comparisons between patient groups, though there are examples of condition specific preference-based measures . Even for assessing clinical effectiveness, it could be argued that a preference-based index is necessary to deal with trade-offs made between outcomes. There has been a debate amongst health economists about the most appropriate preference-based generic measure to use in cost effectiveness analyses. Whilst the EQ-5D is the most widely applied in recent years (Brooks et al, 1996), the HUI3 (Feeny et al, 3 2002), QWB (Kaplan and Andersen, 1988), SF-6D (Brazier et al, 2002) and others continue to be used. However, different preference-based measures have been shown to generate different values on the same sample of patients (Marra et al, 2005; Feeny et al, 2004;Barton et al, 2004). Furthermore, many key clinical trials on the efficacy of new interventions do not have a generic measure and the recent FDA Guidance on using Patient Rep...

Brain imaging studies suggest that antisocial and violent behavior is associated with structural and functional deficits in the prefrontal cortex, but there is heterogeneity in findings and it is unclear whether findings apply to psychopaths, non-violent offenders, community-based samples, and studies employing psychiatric controls. A meta-analysis was conducted on 43 structural and functional imaging studies and results show significantly reduced prefrontal structure and function in antisocial individuals. Effect sizes were significant for both structural and functional studies. With minor exceptions, no statistically significant moderating effects of sample characteristics and methodological variables were observed. Findings were localized to the right orbitofrontal cortex, right anterior cingulate cortex, and left dorsolateral prefrontal cortex. Findings confirm the replicability of prefrontal structural and functional impairments in antisocial populations and highlight the involvement of orbitofrontal, dorsolateral frontal, and anterior cingulate cortex in antisocial behavior.

This project was funded by the UK Medical Research Council (MRC) as part of the MRC-NIHR methodology research programme (reference G0901486) and will be published in full in Health Technology Assessment; Vol. 18, No. 9. See the NIHR Journals Library website for further project information.

A common feature of the antisocial, rule-breaking behavior that is central to criminal, violent and psychopathic individuals is the failure to follow moral guidelines. This review summarizes key findings from brain imaging research on both antisocial behavior and moral reasoning, and integrates these findings into a neural moral model of antisocial behavior. Key areas found to be functionally or structurally impaired in antisocial populations include dorsal and ventral regions of the prefrontal cortex (PFC), amygdala, hippocampus, angular gyrus, anterior cingulate and temporal cortex. Regions most commonly activated in moral judgment tasks consist of the polar/medial and ventral PFC, amygdala, angular gyrus and posterior cingulate. It is hypothesized that the rule-breaking behavior common to antisocial, violent and psychopathic individuals is in part due to impairments in some of the structures (dorsal and ventral PFC, amygdala and angular gyrus) subserving moral cognition and emotion. Impairments to the emotional component that comprises the feeling of what is moral is viewed as the primary deficit in antisocials, although some disruption to the cognitive and cognitive-emotional components of morality (particularly self-referential thinking and emotion regulation) cannot be ruled out. While this neurobiological predisposition is likely only one of several biosocial processes involved in the etiology of antisocial behavior, it raises significant moral issues for the legal system and neuroethics.

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