Business cycles and healthcare employment.

Is healthcare employment recession-proof? We examine the long-standing hypothesis that healthcare employment is stable across the business cycle. We explicitly distinguish between negative aggregate demand and supply shocks in studying how healthcare employment responds to recessions, and show that this response depends largely on the type of the exogenous shock triggering the recession. First, aggregate healthcare employment responds procyclically during demand-induced recessions but remains stable during supply-induced recessions. Second, healthcare utilization drops significantly during demand-induced recessions, explaining the decline in healthcare employment during these periods. Finally, there is significant heterogeneity in the employment responses of the healthcare sub-sectors. While healthcare employment in most sub-sectors responds procyclically during recessions caused by both negative demand and supply shocks, it responds countercyclically in nursing-dominant sectors. Importantly, by isolating the recessionary impact of negative aggregate demand shocks from supply shocks on healthcare employment, we provide new empirical evidence that healthcare employment, in general, is not recession-proof.

A single dose for me, A wealth of protection for us: The public health cost of individualism in the rollout of COVID-19 vaccine.

OBJECTIVE: This study examines whether individualism weakens the effectiveness of the COVID-19 vaccine eligibility expansions in the United States in 2021, and assesses the associated social benefits or costs associated with individualism. METHODS: We construct a county-level composite individualism index as a proxy of culture and the fraction of vaccine eligible population as a proxy of vaccination campaign (mean: 41.34%). We estimate whether the COVID-19 vaccine eligibility policy is less effective in promoting vaccine coverage, reducing in COVID-19 related hospitalization and death using a linear two-way fixed effect model in a sample of 2866 counties for the period between early December 2020 and July 1, 2021. We also test whether individualism shapes people's attitudes towards vaccine using a linear probability model in a sample of 625,308 individuals aged 18-65 (mean age: 43.3; 49% male; 59.1% non-Hispanic white, 19.1% Hispanic, 12% African American; 5.9% Asian) from the Household Pulse Survey. RESULTS: The effects of expanded vaccine eligibility are diminished in counties with greater individualism, as evidenced by lower effectiveness in increasing vaccination rates and reducing outpatient doctor visits primarily for COVID-related symptoms and COVID deaths. Moreover, our results show that this cultural influence on attitudes towards vaccine is more pronounced among the less educated, but unrelated to race. CONCLUSION: Assuming an average level of vaccine eligibility policies and an average intensity of individualism across the nation, we calculate that the average social cost associated with an individualistic culture amid the pandemic is approximately $50.044 billion, equivalent to 1.32% of the total U.S. health care spending in 2019. Our paper suggests that strategies to promote public policy compliance should be tailored to accommodate cultural and social contexts.

The prediction of Alzheimer's disease through multi-trait genetic modeling.

To better capture the polygenic architecture of Alzheimer's disease (AD), we developed a joint genetic score, MetaGRS. We incorporated genetic variants for AD and 24 other traits from two independent cohorts, NACC (n = 3,174, training set) and UPitt (n = 2,053, validation set). One standard deviation increase in the MetaGRS is associated with about 57% increase in the AD risk [hazard ratio (HR) = 1.577, p = 7.17 E-56], showing little difference from the HR for AD GRS alone (HR = 1.579, p = 1.20E-56), suggesting similar utility of both models. We also conducted APOE-stratified analyses to assess the role of the e4 allele on risk prediction. Similar to that of the combined model, our stratified results did not show a considerable improvement of the MetaGRS. Our study showed that the prediction power of the MetaGRS significantly outperformed that of the reference model without any genetic information, but was effectively equivalent to the prediction power of the AD GRS.

Alzheimer's Disease Variant Portal: A Catalog of Genetic Findings for Alzheimer's Disease.

BACKGROUND: Recent Alzheimer's disease (AD) genetics findings from genome-wide association studies (GWAS) span progressively larger and more diverse populations and outcomes. Currently, there is no up-to-date resource providing harmonized and searchable information on all AD genetic associations found by GWAS, nor linking the reported genetic variants and genes with functional and genomic annotations. OBJECTIVE: Create an integrated/harmonized, and literature-derived collection of population-specific AD genetic associations. METHODS: We developed the Alzheimer's Disease Variant Portal (ADVP), an extensive collection of associations curated from >200 GWAS publications from Alzheimer's Disease Genetics Consortium and other consortia. Genetic associations were systematically extracted, harmonized, and annotated from both the genome-wide significant and suggestive loci reported in these publications. To ensure consistent representation of AD genetic findings, all the extracted genetic association information was harmonized across specifically designed publication, variant, and association categories. RESULTS: ADVP V1.0 (February 2021) catalogs 6,990 associations related to disease-risk, expression quantitative traits, endophenotypes, or neuropathology. This extensive harmonization effort led to a catalog containing >900 loci, >1,800 variants, >80 cohorts, and 8 populations. Besides, ADVP provides investigators with a seamless integration of genomic and publicly available functional annotations across multiple databases per harmonized variant and gene records, thus facilitating further understanding and analyses of these genetics findings. CONCLUSION: ADVP is a valuable resource for investigators to quickly and systematically explore high-confidence AD genetic findings and provides insights into population-specific AD genetic architecture. ADVP is continually maintained and enhanced by NIAGADS and is freely accessible at https://advp.niagads.org.

Comparing the Impact of Online Ratings and Report Cards on Patient Choice of Cardiac Surgeon: Large Observational Study.

BACKGROUND: Patients may use two information sources about a health care provider's quality: online physician reviews, which are written by patients to reflect their subjective experience, and report cards, which are based on objective health outcomes. OBJECTIVE: The aim of this study was to examine the impact of online ratings on patient choice of cardiac surgeon compared to that of report cards. METHODS: We obtained ratings from a leading physician review platform, Vitals; report card scores from Pennsylvania Cardiac Surgery Reports; and information about patients' choices of surgeons from inpatient records on coronary artery bypass graft (CABG) surgeries done in Pennsylvania from 2008 to 2017. We scraped all reviews posted on Vitals for surgeons who performed CABG surgeries in Pennsylvania during our study period. We linked the average overall rating and the most recent report card score at the time of a patient's surgery to the patient's record based on the surgeon's name, focusing on fee-for-service patients to avoid impacts of insurance networks on patient choices. We used random coefficient logit models with surgeon fixed effects to examine the impact of receiving a high online rating and a high report card score on patient choice of surgeon for CABG surgeries. RESULTS: We found that a high online rating had positive and significant effects on patient utility, with limited variation in preferences across individuals, while the impact of a high report card score on patient choice was trivial and insignificant. About 70.13% of patients considered no information on Vitals better than a low rating; the corresponding figure was 26.66% for report card scores. The findings were robust to alternative choice set definitions and were not explained by surgeon attrition, referral effect, or admission status. Our results also show that the interaction effect of rating information and a time trend was positive and significant for online ratings, but small and insignificant for report cards. CONCLUSIONS: A patient's choice of surgeon is affected by both types of rating information; however, over the past decade, online ratings have become more influential, while the effect of report cards has remained trivial. Our findings call for information provision strategies that incorporate the advantages of both online ratings and report cards.

Reconcile the debate over protective effects of BCG vaccine against COVID-19.

While awaiting the COVID-19 vaccines, researchers have been actively exploring the effectiveness of existing vaccines against the new virus, among which the BCG vaccine (Bacillus Calmette-Guérin) receives the most attention. While many reports suggest a potential role for BCG immunization in ameliorating SARS-CoV-2 infection, these findings remain controversial. With country-level COVID-19 outbreak data from Johns Hopkins University Coronavirus Resource Center, and BCG program data from World Atlas of BCG Policies and Practices and WHO/UNICE, we estimated a dynamic model to investigate the effect of BCG vaccination across time during the pandemic. Our results reconcile these varying reports regarding protection by BCG against COVID-19 in a variety of clinical scenarios and model specifications. We observe a notable protective effect of the BCG vaccine during the early stage of the pandemic. However, we do not see any strong evidence for protection during the later stages. We also see that a higher proportion of vaccinated young population may confer some level of communal protection against the virus in the early pandemic period, even when the proportion of vaccination in the older population is low. Our results highlight that while BCG may offer some protection against COVID-19, we should be cautious in interpreting the estimated effectiveness as it may vary over time and depend on the age structure of the vaccinated population.

Confirmatory bias in health decisions: Evidence from the MMR-autism controversy.

Since Wakefield et al. (1998), the public was exposed to mixed information surrounding the claim that measles-mumps-rubella vaccine causes autism. A persistent trend to delay the vaccination during 1998-2011 in the US was driven by children of college-educated mothers, suggesting that these mothers held biases against the vaccine influenced by the early unfounded claim. Consistent with confirmatory bias, exposures to negative information about the vaccine strengthened their biases more than exposures to positive information attenuated them. Positive online information, however, had strong impacts on vaccination decisions, suggesting that online dissemination of vaccine-safety information may help tackle the sticky misinformation.

Provider responses to a global budgeting system: The case of drug expenditures in Taiwan hospitals.

In July 2002, a global budgeting system was imposed on hospitals in Taiwan. This system set a fixed budget for all hospitals within a region but included special provisions that sheltered reimbursements for drug expenditures. We study the size and nature of changes in hospital physicians' use of drugs for outpatient care following this budgetary change and find that drug expenditures for outpatient care increased by 11.7%. Our results suggest that physicians began prescribing more expensive drugs, more drugs, and drugs for longer periods but that these different responses did not all occur at the same time. The overall response was strongest in for-profit hospitals, but drug-related decisions changed in all hospital types.

Provider and patient satisfaction with the integration of ambulatory and hospital EHR systems.

Objective: The installation of EHR systems can disrupt operations at clinical practice sites, but also lead to improvements in information availability. We examined how the installation of an ambulatory EHR at OB/GYN practices and its subsequent interface with an inpatient perinatal EHR affected providers' satisfaction with the transmission of clinical information and patients' ratings of their care experience. Methods: We collected data on provider satisfaction through 4 survey rounds during the phased implementation of the EHR. Data on patient satisfaction were drawn from Press Ganey surveys issued by the healthcare network through a standard process. Using multivariable models, we determined how provider satisfaction with information transmission and patient satisfaction with their care experience changed as the EHR system allowed greater information flow between OB/GYN practices and the hospital. Results: Outpatient OB/GYN providers became more satisfied with their access to information from the inpatient perinatal triage unit once system capabilities included automatic data flow from triage back to the OB/GYN offices. Yet physicians were generally less satisfied with how the EHR affected their work processes than other clinical and non-clinical staff. Patient satisfaction dropped after initial EHR installation, and we find no evidence of increased satisfaction linked to system integration. Conclusions: Dissatisfaction of providers with an EHR system and difficulties incorporating EHR technology into patient care may negatively impact patient satisfaction. Care must be taken during EHR implementations to maintain good communication with patients while satisfying documentation requirements.

The health implications of unconventional natural gas development in Pennsylvania.

We investigate the health impacts of unconventional natural gas development of Marcellus shale in Pennsylvania between 2001 and 2013 by merging well permit data from the Pennsylvania Department of Environmental Protection with a database of all inpatient hospital admissions. After comparing changes in hospitalization rates over time for air pollution-sensitive diseases in counties with unconventional gas wells to changes in hospitalization rates in nonwell counties, we find a significant association between shale gas development and hospitalizations for pneumonia among the elderly, which is consistent with higher levels of air pollution resulting from unconventional natural gas development. We note that the lack of any detectable impact of shale gas development on younger populations may be due to unobserved factors contemporaneous with drilling, such as migration.

Gender inequality, economic growth, and the intergenerational transmission of adverse health consequences at birth.

We estimate a gender differential in the intergenerational transmission of adverse birth outcomes. We link Taiwan birth certificates from 1978 to 2006 to create a sample of children born in the period 1999-2006 that includes information about their parents and their maternal grandmothers. We use maternal-sibling fixed effects to control for unobserved family-linked factors that may be correlated with birth outcomes across generations, and define adverse birth outcomes as small for gestational age. We find that when a mother is in the 5th percentile of birth weight for her gestational age, then her female children are 49-53% more likely to experience the same adverse birth outcome compared to other female children, while her male children are 27-32% more likely to experience this relative to other male children. We then investigate whether long-run improvements in local socio-economic conditions experienced by the child's family, as measured by intergenerational changes in town-level maternal education, affect the gender differential. We find no evidence that intergenerational improvements in socioeconomic conditions reduce the gender differential.

The Impact of Prenatal Exposure to Power Plant Emissions on Birth Weight: Evidence from a Pennsylvania Power Plant Located Upwind of New Jersey.

To examine the infant health impact of prenatal exposure to power plant emissions, we draw scientific evidence on the impacted region downwind of a large polluter, a coal-fired power plant located on the border of two states and proven to be the sole contributor to the violation of air quality standards of the impacted region. Our results show that among all live singleton births that occurred during 1990 through 2006, those born to mothers living as far as 20 to 30 miles away downwind from the power plant (which is also an affluent region) during pregnancy are at greater risks of low birth weight (LBW) and very low birth weight (VLBW): the likelihoods of LBW and VLBW could increase approximately by 6.50 and 17.12 percent, respectively. In light of the continual efforts of The U.S. Environmental Protection Agency in reducing cross-state air pollution caused by transboundary power plant emissions, our study is aimed at broadening the scope of cross-border pollution impact analysis by taking into account adverse infant health effects of upwind polluters, which can impose disproportionate burdens of health risks on downwind states due to air pollutants transported by wind.

The Intergenerational Transmission of Low Birth Weight and Intrauterine Growth Restriction: A Large Cross-generational Cohort Study in Taiwan.

Objectives Our research provides evidence on the intergenerational fetal programming effect by examining associations in the low birth weight (LBW, birth weight <2500 g) and intrauterine growth restriction (IUGR) status between two adjacent generations from both the maternal and paternal sides. Methods Birth certificate data of the entire Taiwanese population are used to construct three-consecutive-generational samples. The final samples consist of the third-generation children born during 1999-2006 to at least one second-generation (G2) parent born during 1978-1985. Maternal and paternal samples are distinguished based on the gender of G2. We first fit the samples with linear probability models while including extensive explanatory variables to control for myriad confounding factors. We then include G2 sibling fixed effects to account for family-specific heterogeneity. Alternative explanations of sample selection, parents' assortative mating, and grandmothers' postnatal investment are examined. Results We find that significant intergenerational associations in LBW and IUGR only occur matrilineally. Children born to LBW mothers are 2.28 (95% CI, 0.71-3.85; p < 0.01) percentage points, corresponding to 36%, more likely to be LBW compared to children born to non-LBW mothers who are sisters. These associations cannot be explained by the above alternative explanations. Conclusions Under G2 sibling comparisons, children born to LBW (IUGR) mothers are more likely to be LBW (IUGR), but children born to LBW (IUGR) fathers are not. The findings suggest that maternal health is pertinent and that socio-economic interventions may not yield the desired outcomes within a short period of time.

The impact of health insurance expansion on physician treatment choice: Medicare Part D and physician prescribing.

We test the effect of the introduction of Medicare Part D on physician prescribing behavior by using data on physician visits from the National Ambulatory Medical Care Survey (NAMCS) 2002-2004 and 2006-2009 for patients aged 60-69. We use regression discontinuity designs to estimate the effect of part D around the age of 65 before and after 2006 and then compare the discrete jump in outcomes at age 65 before and after Part D. We find a 32% increase in the number of prescription drugs prescribed or continued per visit and a 46% increase in the number of generic drugs prescribed or continued for the elderly after the introduction of Medicare Part D.

A mixed methods study of clinical information availability in obstetric triage and prenatal offices.

OBJECTIVE: To determine the effect of availability of clinical information from an integrated electronic health record system on pregnancy outcomes at the point of care. MATERIALS AND METHODS: We used provider interviews and surveys to evaluate the availability of pregnancy-related clinical information in ambulatory practices and the hospital, and applied multiple regression to determine whether greater clinical information availability is associated with improvements in pregnancy outcomes and changes in care processes. Our regression models are risk adjusted and include physician fixed effects to control for unobservable characteristics of physicians that are constant across patients and time. RESULTS: Making nonstress test results, blood pressure data, antenatal problem lists, and tubal sterilization requests from office records available to hospital-based providers is significantly associated with reductions in the likelihood of obstetric trauma and other adverse pregnancy outcomes. Better access to prenatal records also increases the probability of labor induction and decreases the probability of Cesarean section (C-section). Availability of lab test results and new diagnoses generated in the hospital at ambulatory offices is associated with fewer preterm births and low-birth-weight babies. DISCUSSION AND CONCLUSIONS: Increased availability of specific clinical information enables providers to deliver better care and improve outcomes, but some types of clinical data are more important than others. More available information does not always result from automated integration of electronic records, but rather from the availability of the source records. Providers depend upon information that they trust to be reliable, complete, consistent, and easily retrievable, even if this requires multiple interfaces.

The Short-Run and Long-Run Effects of Birth Weight: Evidence from Large Samples of Siblings and Twins in Taiwan.

In this paper, we assemble five large administrative data sets in Taiwan to investigate the short-run and long-run effects of birth weight. Comparing with previous studies, our results are more precisely estimated due to the large sample size. Using administrative data sets, the problems arising from self-reported samples are also mitigated. Moreover, we are able to examine both singletons by controlling sibling fixed effects and twins by controlling twin fixed effects. Our results show that an infant's birth weight has positive influence on health and education. Our twin fixed-effects estimates confirm the finding of a long-lasting, but diminishing in the longer run, effects of birth weight. Copyright © 2016 John Wiley & Sons, Ltd.

Medicaid Pay for Performance Programs and Childhood Immunization Status.

INTRODUCTION: Although pay for performance (P4P) programs are being increasingly used by state Medicaid programs to provide incentives for managed care plans to provide high-quality care, no national study has examined the effects of these plans on commonly targeted outcomes such as childhood immunization rates. METHODS: Information from the 1999-2011 National Immunization Survey combined with information on state Medicaid P4P programs from the Centers for Medicare and Medicaid Services was used to study the effect of Medicaid P4P programs on the immunization status of children aged 19-35 months. Difference-in-difference-in-difference models were used to study whether adoption of Medicaid P4P programs was associated with higher immunization rates among Medicaid-eligible children relative to non-Medicaid eligible children within states that adopted Medicaid P4P programs compared with states that did not. Linear probability models were used in all estimations, and models controlled for demographic factors. RESULTS: The study found no overall effect of Medicaid P4P on the chance that children aged 19-35 months had completed the 4:3:1:3:3:1 vaccination series. However, there was a 4 percentage point increase in the chance that a child 19-23 months had completed the series. CONCLUSIONS: This study provides some evidence that Medicaid P4P programs may be helpful in improving childhood vaccination rates. Further study of the effects on other targeted outcomes as well as the effects of different P4P program designs may increase understanding of the potential role of these programs in improving the quality of health care.

Strengthening or Weakening? The Impact of Universal Health Insurance on Intergenerational Coresidence in Taiwan.

In this article, we exploit a unique natural experiment-the implementation of National Health Insurance (NHI) in Taiwan in 1995-to examine how the introduction of universal health insurance increases or decreases the likelihood of intergenerational coresidence. Five waves of surveys from the Survey of Health and Living Status of the Elderly in Taiwan between 1989 and 2003 are employed, and models with various specifications are estimated. Our results indicate a mixed relationship between the likelihood of intergenerational coresidence and the enactment of NHI. Although NHI on average reduces the probability that elderly parents live with their adult children by approximately 6.6 %, the likelihood of intergenerational coresidence increases among families benefiting most from NHI, such as those with unhealthy elderly mothers and fewer children.

Hospital ownership and drug utilization under a global budget: a quantile regression analysis.

BACKGROUND: A global budgeting system helps control the growth of healthcare spending by setting expenditure ceilings. However, the hospital global budget implemented in Taiwan in 2002 included a special provision: drug expenditures are reimbursed at face value, while other expenditures are subject to discounting. That gives hospitals, particularly those that are for-profit, an incentive to increase drug expenditures in treating patients. METHODS: We calculated monthly drug expenditures by hospital departments from January 1997 to June 2006, using a sample of 348 193 patient claims to Taiwan National Health Insurance. To allow for variation among responses by departments with differing reliance on drugs and among hospitals of different ownerships, we used quantile regression to identify the effect of the hospital global budget on drug expenditures. RESULTS: Although drug expenditure increased in all hospital departments after the enactment of the hospital global budget, departments in for-profit hospitals that rely more heavily on drug treatments increased drug spending more, relative to public hospitals. CONCLUSIONS: Our findings suggest that a global budgeting system with special reimbursement provisions for certain treatment categories may alter treatment decisions and may undermine cost-containment goals, particularly among for-profit hospitals.

Competition and the impact of online hospital report cards.

Information on the quality of healthcare gives providers an incentive to improve care, and this incentive should be stronger in more competitive markets. We examine this hypothesis by studying Pennsylvanian hospitals during the years 1995-2004 to see whether those hospitals located in more competitive markets increased the quality of the care provided to Medicare patients after report cards rating the quality of their Coronary Artery Bypass Graft programs went online in 1998. We find that after the report cards went online, hospitals in more competitive markets used more resources per patient, and achieved lower mortality among more severely ill patients.