Affirmative Action Bans and Enrollment of Students From Underrepresented Racial and Ethnic Groups in U.S. Public Medical Schools.

BACKGROUND: The percentage of U.S. physicians who identify as being from an underrepresented racial or ethnic group remains low relative to their proportion in the U.S. population. How this percentage may have been affected by state bans on affirmative action in public postsecondary institutions has received relatively little attention. OBJECTIVE: To examine the association between state affirmative action bans and percentage of enrollment in U.S. public medical schools from underrepresented racial and ethnic groups. DESIGN: Event study comparing public medical schools in states that implemented affirmative action bans with those in states without bans. SETTING: U.S. public medical schools. PARTICIPANTS: 21 public medical schools in 8 states with affirmative action bans matched to 32 public medical schools in 24 states without bans from 1985 to 2019. MEASUREMENTS: Percentage of total enrollment from racial and ethnic groups underrepresented in medicine (Black, Hispanic, American Indian or Alaska Native, and Native Hawaiian or other Pacific Islander). RESULTS: The percentage of enrollment from underrepresented racial and ethnic groups was 14.8% in U.S. public medical schools in the year before ban implementation in states with bans. The adjusted percentage of underrepresented students in ban schools decreased by 4.8 percentage points (95% CI, -6.3 to -3.2 percentage points) 5 years after ban implementation relative to the year before implementation, whereas the adjusted percentage in control schools increased by 0.7 percentage point (CI, -0.1 to 1.6 percentage points), for a relative difference, or difference-in-differences estimate, of -5.5 percentage points (CI, -7.1 to -3.9 percentage points). LIMITATION: Inability to account for the effect of these bans on undergraduate enrollment. CONCLUSION: State affirmative action bans were associated with significant reductions in the percentage of students in U.S. public medical schools from underrepresented racial and ethnic groups. PRIMARY FUNDING SOURCE: None.

Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use.

BACKGROUND: Increasing overuse of opioids in the United States may be driven in part by physician prescribing. However, the extent to which individual physicians vary in opioid prescribing and the implications of that variation for long-term opioid use and adverse outcomes in patients are unknown. METHODS: We performed a retrospective analysis involving Medicare beneficiaries who had an index emergency department visit in the period from 2008 through 2011 and had not received prescriptions for opioids within 6 months before that visit. After identifying the emergency physicians within a hospital who cared for the patients, we categorized the physicians as being high-intensity or low-intensity opioid prescribers according to relative quartiles of prescribing rates within the same hospital. We compared rates of long-term opioid use, defined as 6 months of days supplied, in the 12 months after a visit to the emergency department among patients treated by high-intensity or low-intensity prescribers, with adjustment for patient characteristics. RESULTS: Our sample consisted of 215,678 patients who received treatment from low-intensity prescribers and 161,951 patients who received treatment from high-intensity prescribers. Patient characteristics, including diagnoses in the emergency department, were similar in the two treatment groups. Within individual hospitals, rates of opioid prescribing varied widely between low-intensity and high-intensity prescribers (7.3% vs. 24.1%). Long-term opioid use was significantly higher among patients treated by high-intensity prescribers than among patients treated by low-intensity prescribers (adjusted odds ratio, 1.30; 95% confidence interval, 1.23 to 1.37; P<0.001); these findings were consistent across multiple sensitivity analyses. CONCLUSIONS: Wide variation in rates of opioid prescribing existed among physicians practicing within the same emergency department, and rates of long-term opioid use were increased among patients who had not previously received opioids and received treatment from high-intensity opioid prescribers. (Funded by the National Institutes of Health.).

Delays in Emergency Care and Mortality during Major U.S. Marathons.

BACKGROUND: Large marathons frequently involve widespread road closures and infrastructure disruptions, which may create delays in emergency care for nonparticipants with acute medical conditions who live in proximity to marathon routes. METHODS: We analyzed Medicare data on hospitalizations for acute myocardial infarction or cardiac arrest among Medicare beneficiaries (≥65 years of age) in 11 U.S. cities that were hosting major marathons during the period from 2002 through 2012 and compared 30-day mortality among the beneficiaries who were hospitalized on the date of a marathon, those who were hospitalized on the same day of the week as the day of the marathon in the 5 weeks before or the 5 weeks after the marathon, and those who were hospitalized on the same day as the marathon but in surrounding ZIP Code areas unaffected by the marathon. We also analyzed data from a national registry of ambulance transports and investigated whether ambulance transports occurring before noon in marathon-affected areas (when road closures are likely) had longer scene-to-hospital transport times than on nonmarathon dates. We also compared transport times on marathon dates with those on nonmarathon dates in these same areas during evenings (when roads were reopened) and in areas unaffected by the marathon. RESULTS: The daily frequency of hospitalizations was similar on marathon and nonmarathon dates (mean number of hospitalizations per city, 10.6 and 10.5, respectively; P=0.71); the characteristics of the beneficiaries hospitalized on marathon and nonmarathon dates were also similar. Unadjusted 30-day mortality in marathon-affected areas on marathon dates was 28.2% (323 deaths in 1145 hospitalizations) as compared with 24.9% (2757 deaths in 11,074 hospitalizations) on nonmarathon dates (absolute risk difference, 3.3 percentage points; 95% confidence interval, 0.7 to 6.0; P=0.01; relative risk difference, 13.3%). This pattern persisted after adjustment for covariates and in an analysis that included beneficiaries who had five or more chronic medical conditions (a group that is unlikely to be hospitalized because of marathon participation). No significant differences were found with respect to where patients were hospitalized or the treatments they received in the hospital. Ambulance scene-to-hospital transport times for pickups before noon were 4.4 minutes longer on marathon dates than on nonmarathon dates (relative difference, 32.1%; P=0.005). No delays were found in evenings or in marathon-unaffected areas. CONCLUSIONS: Medicare beneficiaries who were admitted to marathon-affected hospitals with acute myocardial infarction or cardiac arrest on marathon dates had longer ambulance transport times before noon (4.4 minutes longer) and higher 30-day mortality than beneficiaries who were hospitalized on nonmarathon dates. (Funded by the National Institutes of Health.).

Sex Differences in Faculty Rank Among Academic Cardiologists in the United States.

BACKGROUND: Studies demonstrate that women physicians are less likely than men to be full professors. Comprehensive evidence examining whether sex differences in faculty rank exist in academic cardiology, adjusting for experience and research productivity, is lacking. Therefore, we evaluated for sex differences in faculty rank among a comprehensive, contemporary cohort of US cardiologists after adjustment for several factors that impact academic advancement, including measures of clinical experience and research productivity. METHODS: We identified all US cardiologists with medical school faculty appointments in 2014 by using the American Association of Medical Colleges faculty roster and linked this list to a comprehensive physician database from Doximity, a professional networking website for doctors. Data on physician age, sex, years since residency, cardiology subspecialty, publications, National Institutes of Health grants, and registered clinical trials were available for all academic cardiologists. We estimated sex differences in full professorship, adjusting for these factors and medical school-specific fixed effects in a multivariable regression model. RESULTS: Among 3810 cardiologists with faculty appointments in 2014 (13.3% of all US cardiologists), 630 (16.5%) were women. Women faculty were younger than men (mean age, 48.3 years versus 53.5 years, P<0.001), had fewer total publications (mean number: 16.5 publications versus 25.2 publications; P<0.001), were similarly likely to have National Institutes of Health funding (proportion with at least 1 National Institutes of Health award, 10.8% versus 10.4%; P=0.77), and were less likely to have a registered clinical trial (percentage with at least 1 clinical trial, 8.9% versus 11.1%; P=0.10). Among 3180 men, 973 (30.6%) were full professors in comparison with 100 (15.9%) of 630 women. In adjusted analyses, women were less likely to be full professors than men (adjusted odds ratio, 0.63; 95% confidence interval, 0.43-0.94; P=0.02; adjusted proportions, 22.7% versus 26.7%; absolute difference, -4.0%; 95% confidence interval, -7.5% to -0.7%). CONCLUSIONS: Among cardiology faculty at US medical schools, women were less likely than men to be full professors after accounting for several factors known to influence faculty rank.

Association Between Treatment by Locum Tenens Internal Medicine Physicians and 30-Day Mortality Among Hospitalized Medicare Beneficiaries.

Importance: Use of locum tenens physicians has increased in the United States, but information about their quality and costs of care is lacking. Objective: To evaluate quality and costs of care among hospitalized Medicare beneficiaries treated by locum tenens vs non-locum tenens physicians. Design, Setting, and Participants: A random sample of Medicare fee-for-service beneficiaries hospitalized during 2009-2014 was used to compare quality and costs of hospital care delivered by locum tenens and non-locum tenens internal medicine physicians. Exposures: Treatment by locum tenens general internal medicine physicians. Main Outcomes and Measures: The primary outcome was 30-day mortality. Secondary outcomes included inpatient Medicare Part B spending, length of stay, and 30-day readmissions. Differences between locum tenens and non-locum tenens physicians were estimated using multivariable logistic regression models adjusted for beneficiary clinical and demographic characteristics and hospital fixed effects, which enabled comparisons of clinical outcomes between physicians practicing within the same hospital. In prespecified subgroup analyses, outcomes were reevaluated among hospitals with different levels of intensity of locum tenens physician use. Results: Of 1 818 873 Medicare admissions treated by general internists, 38 475 (2.1%) received care from a locum tenens physician; 9.3% (4123/44 520) of general internists were temporarily covered by a locum tenens physician at some point. Differences in patient characteristics, demographics, comorbidities, and reason for admission between locum tenens and non-locum tenens physicians were not clinically relevant. Treatment by locum tenens physicians, compared with treatment by non-locum tenens physicians (n = 44 520 physicians), was not associated with a significant difference in 30-day mortality (8.83% vs 8.70%; adjusted difference, 0.14%; 95% CI, -0.18% to 0.45%). Patients treated by locum tenens physicians had significantly higher Part B spending ($1836 vs $1712; adjusted difference, $124; 95% CI, $93 to $154), significantly longer mean length of stay (5.64 days vs 5.21 days; adjusted difference, 0.43 days; 95% CI, 0.34 to 0.52), and significantly lower 30-day readmissions (22.80% vs 23.83%; adjusted difference, -1.00%; 95% CI -1.57% to -0.54%). Conclusions and Relevance: Among hospitalized Medicare beneficiaries treated by a general internist, there were no significant differences in overall 30-day mortality rates among patients treated by locum tenens compared with non-locum tenens physicians. Additional research may help determine hospital-level factors associated with the quality and costs of care related to locum tenens physicians.

Sex Differences in Academic Rank in US Medical Schools in 2014.

IMPORTANCE: The proportion of women at the rank of full professor in US medical schools has not increased since 1980 and remains below that of men. Whether differences in age, experience, specialty, and research productivity between sexes explain persistent disparities in faculty rank has not been studied. OBJECTIVE: To analyze sex differences in faculty rank among US academic physicians. DESIGN, SETTING, AND PARTICIPANTS: We analyzed sex differences in faculty rank using a cross-sectional comprehensive database of US physicians with medical school faculty appointments in 2014 (91,073 physicians; 9.1% of all US physicians), linked to information on physician sex, age, years since residency, specialty, authored publications, National Institutes of Health (NIH) funding, and clinical trial investigation. We estimated sex differences in full professorship, as well as a combined outcome of associate or full professorship, adjusting for these factors in a multilevel (hierarchical) model. We also analyzed how sex differences varied with specialty and whether differences were more prevalent at schools ranked highly in research. EXPOSURES: Physician sex. MAIN OUTCOMES AND MEASURES: Academic faculty rank. RESULTS: In all, there were 30,464 women who were medical faculty vs 60,609 men. Of those, 3623 women (11.9%) vs 17,354 men (28.6%) had full-professor appointments, for an absolute difference of -16.7% (95% CI, -17.3% to -16.2%). Women faculty were younger and disproportionately represented in internal medicine and pediatrics. The mean total number of publications for women was 11.6 vs 24.8 for men, for a difference of -13.2 (95% CI, -13.6 to -12.7); the mean first- or last-author publications for women was 5.9 vs 13.7 for men, for a difference of -7.8 (95% CI, -8.1 to -7.5). Among 9.1% of medical faculty with an NIH grant, 6.8% (2059 of 30,464) were women and 10.3% (6237 of 60,609) were men, for a difference of -3.5% (95% CI, -3.9% to -3.1%). In all, 6.4% of women vs 8.8% of men had a trial registered on ClinicalTrials.gov, for a difference of -2.4% (95% CI, -2.8% to -2.0%). After multivariable adjustment, women were less likely than men to have achieved full-professor status (absolute adjusted difference in proportion, -3.8%; 95% CI, -4.4% to -3.3%). Sex-differences in full professorship were present across all specialties and did not vary according to whether a physician's medical school was ranked highly in terms of research funding. CONCLUSIONS AND RELEVANCE: Among physicians with faculty appointments at US medical schools, there were sex differences in academic faculty rank, with women substantially less likely than men to be full professors, after accounting for age, experience, specialty, and measures of research productivity.

Physicians' political preferences and the delivery of end of life care in the United States: retrospective observational study.

OBJECTIVES: To compare the delivery of end of life care given to US Medicare beneficiaries in hospital by internal medicine physicians with Republican versus Democrat political affiliations. DESIGN: Retrospective observational study. SETTING: US Medicare. PARTICIPANTS: Random sample of Medicare beneficiaries, who were admitted to hospital in 2008-12 with a general medical condition, and died in hospital or shortly thereafter. MAIN OUTCOME MEASURES: Total inpatient spending, intensive care unit use, and intensive end of life treatments (eg, mechanical ventilation and gastrostomy tube insertion) among patients dying in hospital, and hospice referral among patients discharged but at high predicted risk of 30 day mortality after discharge. Physicians were categorized as Democrat, Republican, or non-donors, using federal political contribution data. RESULTS: Among 1 480 808 patients, 93 976 (6.3%) were treated by 1523 Democratic physicians, 58 876 (4.0%) by 768 Republican physicians, and 1 327 956 (89.6%) by 23 627 non-donor physicians. Patient demographics and clinical characteristics were similar between groups. Democrat physicians were younger, more likely to be female, and more likely to have graduated from a top 20 US medical school than Republican physicians. Mean end of life spending, after adjustment for patient covariates and hospital specific fixed effects, was US$17 938 (£12 872; €14 612) among Democrat physicians (95% confidence interval $17 176 to $18 700) and $18 409 among Republican physicians ($17 362 to $19 456; adjusted Republican v Democrat difference, $472 (-$803 to $1747), P=0.47). Intensive end of life treatments for patients who died in hospital did not vary by physician political affiliation. The proportion of patients discharged from hospital to hospice did not vary with physician political affiliation. Among patients in the top 5% of predicted risk of death 30 days after hospital discharge, adjusted proportions of patients discharged to hospice were 15.8%, 15.0%, and 15.2% among Democrat, Republican, and non-donor physicians, respectively (adjusted difference in proportion between Republicans v Democrats, -0.8% (-2.7% to 0.9%), P=0.43). CONCLUSIONS: This study provided no evidence that physician political affiliation is associated with the intensity of end of life care received by patients in hospital. Other treatments for politically polarised healthcare issues should be investigated.

A Health Plan's Formulary Led To Reduced Use Of Extended-Release Opioids But Did Not Lower Overall Opioid Use.

Many insurers are using formulary design to influence opioid prescribing, but it is unclear if these changes lead to reduced use or just substitution between opioids. We evaluated the effect of a new prior authorization process implemented in July 2015 for extended-release (ER) oxycodone by Blue Shield of California. Compared to other commercially insured Californians, among 880,000 Blue Shield enrollees, there was a 36 percent drop in monthly rates of ER opioid initiation relative to control-group members, driven entirely by decreases in ER oxycodone initiation and without any substitution toward other ER opioids. This reduction was offset by a 1.4 percent relative increase in the rate of short-acting opioid fills. There was no significant change in the overall use of any opioids prescribed, measured as morphine milligram equivalents. This suggests that though insurers can play a meaningful role in reducing the prescribing of high-risk ER opioids, a formulary change focused on ER opioids alone is insufficient to decrease total opioid prescribing.

Acute Myocardial Infarction Mortality During Dates of National Interventional Cardiology Meetings.

BACKGROUND: Previous research has found that patients with acute cardiovascular conditions treated in teaching hospitals have lower 30-day mortality during dates of national cardiology meetings. METHODS AND RESULTS: We analyzed 30-day mortality among Medicare beneficiaries hospitalized with acute myocardial infarction (overall, ST-segment-elevation myocardial infarction, and non-ST-segment-elevation myocardial infarction) from January 1, 2007, to November 31, 2012, in major teaching hospitals during dates of a major annual interventional cardiology meeting (Transcatheter Cardiovascular Therapeutics) compared with identical nonmeeting days in the ±5 weeks. Treatment differences were assessed. We used a database of US physicians to compare interventional cardiologists who practiced and did not practice during meeting dates ("stayers" and "attendees," respectively) in terms of demographic characteristics and clinical and research productivity. Unadjusted and adjusted 30-day mortality rates were lower among patients admitted during meeting versus nonmeeting dates (unadjusted, 15.3% [482/3153] versus 16.7% [5208/31 556] [P=0.04]; adjusted, 15.4% versus 16.7%; difference -1.3% [95% confidence interval, -2.7% to -0.1%] [P=0.05]). Rates of interventional cardiologist involvement were similar between dates (59.5% versus 59.8% of hospitalizations; P=0.88), as were percutaneous coronary intervention rates (30.2% versus 29.1%; P=0.20). Mortality reductions were largest among patients with non-ST-segment-elevation myocardial infarction not receiving percutaneous coronary intervention (16.9% versus 19.5% adjusted 30-day mortality; P=0.008). Compared with stayers, attendees were of similar age and sex, but had greater publications (18.9 versus 6.3; P<0.001), probability of National Institutes of Health funding (5.3% versus 0.4%; P<0.001), and clinical trial leadership (10.3% versus 3.9%; P<0.001), and they performed more percutaneous coronary interventions annually (85.6 versus 63.3; P<0.001). CONCLUSIONS: Hospitalization with acute myocardial infarction during Transcatheter Cardiovascular Therapeutics meeting dates was associated with lower 30-day mortality, predominantly among patients with non-ST-segment-elevation myocardial infarction who were medically managed.

Patient Mortality During Unannounced Accreditation Surveys at US Hospitals.

Importance: In the United States, hospitals receive accreditation through unannounced on-site inspections (ie, surveys) by The Joint Commission (TJC), which are high-pressure periods to demonstrate compliance with best practices. No research has addressed whether the potential changes in behavior and heightened vigilance during a TJC survey are associated with changes in patient outcomes. Objective: To assess whether heightened vigilance during survey weeks is associated with improved patient outcomes compared with nonsurvey weeks, particularly in major teaching hospitals. Design, Setting, and Participants: Quasi-randomized analysis of Medicare admissions at 1984 surveyed hospitals from calendar year 2008 through 2012 in the period from 3 weeks before to 3 weeks after surveys. Outcomes between surveys and surrounding weeks were compared, adjusting for beneficiaries' sociodemographic and clinical characteristics, with subanalyses for major teaching hospitals. Data analysis was conducted from January 1 to September 1, 2016. Exposures: Hospitalization during a TJC survey week vs nonsurvey weeks. Main Outcomes and Measures: The primary outcome was 30-day mortality. Secondary outcomes were rates of Clostridium difficile infections, in-hospital cardiac arrest mortality, and Patient Safety Indicators (PSI) 90 and PSI 4 measure events. Results: The study sample included 244 787 and 1 462 339 admissions during survey and nonsurvey weeks with similar patient characteristics, reason for admission, and in-hospital procedures across both groups. There were 811 598 (55.5%) women in the nonsurvey weeks (mean [SD] age, 72.84 [14.5] years) and 135 857 (55.5%) in the survey weeks (age, 72.76 [14.5] years). Overall, there was a significant reversible decrease in 30-day mortality for admissions during survey (7.03%) vs nonsurvey weeks (7.21%) (adjusted difference, -0.12%; 95% CI, -0.22% to -0.01%). This observed decrease was larger than 99.5% of mortality changes among 1000 random permutations of hospital survey date combinations, suggesting that observed mortality changes were not attributable to chance alone. Observed mortality reductions were largest in major teaching hospitals, where mortality fell from 6.41% to 5.93% during survey weeks (adjusted difference, -0.38%; 95% CI, -0.74% to -0.03%), a 5.9% relative decrease. We observed no significant differences in admission volume, length of stay, or secondary outcomes. Conclusions and Relevance: Patients admitted to hospitals during TJC survey weeks have significantly lower mortality than during nonsurvey weeks, particularly in major teaching hospitals. These results suggest that changes in practice occurring during periods of surveyor observation may meaningfully affect patient mortality.

Association between rainfall and diagnoses of joint or back pain: retrospective claims analysis.

OBJECTIVE: To study the relation between rainfall and outpatient visits for joint or back pain in a large patient population. DESIGN: Observational study. SETTING: US Medicare insurance claims data linked to rainfall data from US weather stations. PARTICIPANTS: 1 552 842 adults aged ≥65 years attending a total of 11 673 392 outpatient visits with a general internist during 2008-12. MAIN OUTCOME MEASURES: The proportion of outpatient visits for joint or back pain related conditions (rheumatoid arthritis, osteoarthritis, spondylosis, intervertebral disc disorders, and other non-traumatic joint disorders) was compared between rainy days and non-rainy days, adjusting for patient characteristics, chronic conditions, and geographic fixed effects (thereby comparing rates of joint or back pain related outpatient visits on rainy days versus non-rainy days within the same area). RESULTS: Of the 11 673 392 outpatient visits by Medicare beneficiaries, 2 095 761 (18.0%) occurred on rainy days. In unadjusted and adjusted analyses, the difference in the proportion of patients with joint or back pain between rainy days and non-rainy days was significant (unadjusted, 6.23% v 6.42% of visits, P<0.001; adjusted, 6.35% v 6.39%, P=0.05), but the difference was in the opposite anticipated direction and was so small that it is unlikely to be clinically meaningful. No statistically significant relation was found between the proportion of claims for joint or back pain and the number of rainy days in the week of the outpatient visit. No relation was found among a subgroup of patients with rheumatoid arthritis. CONCLUSION: In a large analysis of older Americans insured by Medicare, no relation was found between rainfall and outpatient visits for joint or back pain. A relation may still exist, and therefore larger, more detailed data on disease severity and pain would be useful to support the validity of this commonly held belief.

Sex Differences in Physician Salary in US Public Medical Schools.

IMPORTANCE: Limited evidence exists on salary differences between male and female academic physicians, largely owing to difficulty obtaining data on salary and factors influencing salary. Existing studies have been limited by reliance on survey-based approaches to measuring sex differences in earnings, lack of contemporary data, small sample sizes, or limited geographic representation. OBJECTIVE: To analyze sex differences in earnings among US academic physicians. DESIGN, SETTING, AND PARTICIPANTS: Freedom of Information laws mandate release of salary information of public university employees in several states. In 12 states with salary information published online, salary data were extracted on 10 241 academic physicians at 24 public medical schools. These data were linked to a unique physician database with detailed information on sex, age, years of experience, faculty rank, specialty, scientific authorship, National Institutes of Health funding, clinical trial participation, and Medicare reimbursements (proxy for clinical revenue). Sex differences in salary were estimated after adjusting for these factors. EXPOSURES: Physician sex. MAIN OUTCOMES AND MEASURES: Annual salary. RESULTS: Among 10 241 physicians, female physicians (n = 3549) had lower mean (SD) unadjusted salaries than male physicians ($206 641 [$88 238] vs $257 957 [$137 202]; absolute difference, $51 315 [95% CI, $46 330-$56 301]). Sex differences persisted after multivariable adjustment ($227 783 [95% CI, $224 117-$231 448] vs $247 661 [95% CI, $245 065-$250 258] with an absolute difference of $19 878 [95% CI, $15 261-$24 495]). Sex differences in salary varied across specialties, institutions, and faculty ranks. For example, adjusted salaries of female full professors ($250 971 [95% CI, $242 307-$259 635]) were comparable to those of male associate professors ($247 212 [95% CI, $241 850-$252 575]). Among specialties, adjusted salaries were highest in orthopedic surgery ($358 093 [95% CI, $344 354-$371 831]), surgical subspecialties ($318 760 [95% CI, $311 030-$326 491]), and general surgery ($302 666 [95% CI, $294 060-$311 272]) and lowest in infectious disease, family medicine, and neurology (mean income, <$200 000). Years of experience, total publications, clinical trial participation, and Medicare payments were positively associated with salary. CONCLUSIONS AND RELEVANCE: Among physicians with faculty appointments at 24 US public medical schools, significant sex differences in salary exist even after accounting for age, experience, specialty, faculty rank, and measures of research productivity and clinical revenue.

Do heads of government age more quickly? Observational study comparing mortality between elected leaders and runners-up in national elections of 17 countries.

OBJECTIVES: To determine whether being elected to head of government is associated with accelerated mortality by studying survival differences between people elected to office and unelected runner-up candidates who never served. DESIGN: Observational study. SETTING: Historical survival data on elected and runner-up candidates in parliamentary or presidential elections in Australia, Austria, Canada, Denmark, Finland, France, Germany, Greece, Ireland, Italy, New Zealand, Norway, Poland, Spain, Sweden, United Kingdom, and United States, from 1722 to 2015. PARTICIPANTS: Elected and runner-up political candidates. MAIN OUTCOME MEASURE: Observed number of years alive after each candidate's last election, relative to what would be expected for an average person of the same age and sex as the candidate during the year of the election, based on historical French and British life tables. Observed post-election life years were compared between elected candidates and runners-up, adjusting for life expectancy at time of election. A Cox proportional hazards model (adjusted for candidate's life expectancy at the time of election) considered years until death (or years until end of study period for those not yet deceased by 9 September 2015) for elected candidates versus runners-up. RESULTS: The sample included 540 candidates: 279 winners and 261 runners-up who never served. A total of 380 candidates were deceased by 9 September 2015. Candidates who served as a head of government lived 4.4 (95% confidence interval 2.1 to 6.6) fewer years after their last election than did candidates who never served (17.8 v 13.4 years after last election; adjusted difference 2.7 (0.6 to 4.8) years). In Cox proportional hazards analysis, which considered all candidates (alive or deceased), the mortality hazard for elected candidates relative to runners-up was 1.23 (1.00 to 1.52). CONCLUSIONS: Election to head of government is associated with a substantial increase in mortality risk compared with candidates in national elections who never served.