Health status and the Great Recession. Evidence from electronic health records.

We investigate the impact of the Great Recession in Italy on the incidence of chronic diseases using new individual longitudinal data from Electronic Health Records. We exploit the exogenous shock in the economic conditions occurred in 2008 to estimate heterogeneous effects of an unprecedented rise in local unemployment rates in an individual fixed-effects model. Our results document that harsh economic downturns have a negative long-lasting effect on cardiovascular disease and a temporary effect on depression. This effect is heterogeneous across gender, increases with age and is stronger right before the retirement age. An important policy recommendation emerging from this study is that prolonged economic downturns constitute an additional external risk for individual health and not a temporary benefit.

The changing relationship between bodyweight and longevity in high- and low-income countries.

Standard measures of bodyweight (overweight and obese, for example) fail to reflect differences across populations and technological progress over time. This paper builds on the pioneering work of Hans Waaler (1984) and Robert Fogel (1994) to empirically estimate how the relationship between body mass index (BMI) and longevity varies across high-, middle-, and low-income countries. Importantly, we show that these differences are so profound that the share of national populations above mortality-minimizing bodyweight is not clearly greater in countries with higher overweight and obesity rates (as traditionally defined)-and in fact, relative to current standards, a larger share of low-income countries' populations can be unhealthily heavy.

Psychotropic drug purchases during the COVID-19 pandemic in Italy and their relationship with mobility restrictions.

Recent literature on the mental health consequences of social distancing measures has found a substantial increase in self-reported sleep disorders, anxiety and depressive symptoms during lockdown periods. We investigate this issue with data on monthly purchases of psychotropic drugs from the universe of Italian pharmacies during the first wave of the COVID-19 pandemic and find that purchases of mental health-related drugs have increased with respect to 2019. However, the excess volumes do not match the massive increase in anxiety and depressive disorders found in survey-based studies. We also study the interplay between mobility, measured with anonymized mobile phone data, and mental health and report no significant effect of mobility restrictions on antidepressants and anxiolytics purchases during 2020. We provide three potential mechanisms that could drive the discrepancy between self-reported mental health surveys and psychotropic drugs prescription registries: (1) stockpiling practices in the early phases of the pandemic; (2) the adoption of compensatory behavior and (3) unexpressed and unmet needs due to both demand- and supply-side shortages in healthcare services.

LongITools: Dynamic longitudinal exposome trajectories in cardiovascular and metabolic noncommunicable diseases.

The current epidemics of cardiovascular and metabolic noncommunicable diseases have emerged alongside dramatic modifications in lifestyle and living environments. These correspond to changes in our "modern" postwar societies globally characterized by rural-to-urban migration, modernization of agricultural practices, and transportation, climate change, and aging. Evidence suggests that these changes are related to each other, although the social and biological mechanisms as well as their interactions have yet to be uncovered. LongITools, as one of the 9 projects included in the European Human Exposome Network, will tackle this environmental health equation linking multidimensional environmental exposures to the occurrence of cardiovascular and metabolic noncommunicable diseases.

When particulate matter strikes cities: Social disparities and health costs of air pollution.

We investigate the heterogeneous effects of particle pollution on Italian daily hospitalizations and their costs by exploiting public transportation strikes as plausibly-exogenous shocks in pollution exposure. We find that a one standard deviation increase in PM10 causes additional 0.79 hospitalizations per 100,000 residents, and the effect is stronger for the elderly, low educated individuals and migrants. Furthermore, we find that young individuals, an arguably healthy age group, exhibit economically meaningful responses to air pollution with an effect ranging between 0.45 and 1.04. Our results imply a large role of avoidance behavior driving heterogeneous marginal health effects. Total daily costs of a one standard deviation increase in PM10 represent 0.5% of the total daily health expenditure, and 85% of this additional spending comes from more patients hospitalized, while the remaining 15% can be attributable to more costly, and likely more complex, hospitalizations.

Heterogeneity in long term health outcomes of migrants within Italy.

This article examines the long term physical and mental health effects of internal migration focusing on a relatively unique migration experience concentrated over a short period between 1950 and 1970 from the South to the North of Italy. We find a positive and statistically significant association between migration, its timing and physical health for migrant females, which we show are likely to represent rural females in both the early and the late cohort. We find less defined evidence of migration-health association for mental health. We link our findings to the economic transition and labor market transformation that Italy witnessed in that era. Male migrants were likely to be positively selected to migration, but harsh working conditions were likely to downplay this differential. On the contrary, women migrants, by and large, would not engage in the formal labor market avoiding the ill effects of working environments, at the same time benefiting from better living conditions and health care in the destination regions.

How health policy shapes healthcare sector productivity? Evidence from Italy and UK.

The English (NHS) and the Italian (SSN) healthcare systems share many similar features: basic founding principles, financing, organization, management, and size. Yet the two systems have faced diverging policy objectives since 2000, which may have affected differently healthcare sector productivity in the two countries. In order to understand how different healthcare policies shape the productivity of the systems, we assess, using the same methodology, the productivity growth of the English and Italian healthcare systems over the period from 2004 to 2011. Productivity growth is measured as the rate of change in outputs over the rate of change in inputs. We find that the overall NHS productivity growth index increased by 10% over the whole period, at an average of 1.39% per year, while SSN productivity increased overall by 5%, at an average of 0.73% per year. Our results suggest that different policy objectives are reflected in differential growth rates for the two countries. In England, the NHS focused on increasing activity, reducing waiting times and improving quality. Italy focused more on cost containment and rationalized provision, in the hope that this would reduce unjustified and inappropriate provision of services.

Trends in age-related disease burden and healthcare utilization.

Aging is a strong risk factor for many chronic diseases. However, the impact of an aging population on the prevalence of chronic diseases and related healthcare costs are not known. We used a prevalence-based approach that combines accurate clinical and drug prescription data from Health Search CSD-LPD. This is a longitudinal observational data set containing computer-based patient records collected by Italian general practitioners (GP) and up-to-date healthcare expenditures data from the SiSSI Project. The analysis is based on data collected by 900 GP on an unbalanced sample of more than 1 million patients aged 35+, observed in different time periods between 2005 and 2014. In 2014, 86% of the Italian adults older than 65 had at least one chronic condition, and 56.7% had two or more. Prevalence of multiple chronic diseases and healthcare utilization increased among older and younger adults between 2004 and 2014. Indeed, in the last 10 years, average number of prescriptions increased by approximately 26%, while laboratory and diagnostic tests by 27%. The average number of DDD prescribed increased with age in all the observed years (from 114 in 2005 to 119.9 in 2014 for the 35-50 age group and from 774.9 to 1,178.1 for the 81+ patients). The alarming rising trends in the prevalence of chronic disease and associated healthcare costs in Italy, as well as in many other developed countries, call for an urgent implementation of interventions that prevent or slow the accumulation of metabolic and molecular damage associated with multiple chronic disease.

Excess body weight increases the burden of age-associated chronic diseases and their associated health care expenditures.

Aging and excessive adiposity are both associated with an increased risk of developing multiple chronic diseases, which drive ever increasing health costs. The main aim of this study was to determine the net (non-estimated) health costs of excessive adiposity and associated age-related chronic diseases. We used a prevalence-based approach that combines accurate data from the Health Search CSD-LPD, an observational dataset with patient records collected by Italian general practitioners and up-to-date health care expenditures data from the SiSSI Project. In this very large study, 557,145 men and women older than 18 years were observed at different points in time between 2004 and 2010. The proportion of younger and older adults reporting no chronic disease decreased with increasing BMI. After adjustment for age, sex, geographic residence, and GPs heterogeneity, a strong J-shaped association was found between BMI and total health care costs, more pronounced in middle-aged and older adults. Relative to normal weight, in the 45-64 age group, the per-capita total cost was 10% higher in overweight individuals, and 27 to 68% greater in patients with obesity and very severe obesity, respectively. The association between BMI and diabetes, hypertension and cardiovascular disease largely explained these elevated costs.

Body weight, eating patterns, and physical activity: the role of education.

In this article, we empirically study the role of education attainment on individual body mass index (BMI), eating patterns, and physical activity. We allow for endogeneity of schooling choices for females and males in a mean and quantile instrumental variables framework. We find that completion of lower secondary education has a significant positive impact on reduction of individual BMI, containment of calorie consumption, and promotion of physical activity. Interestingly, these effects are heterogeneous across genders and distributions. In particular, for BMI and calorie expenditure, the effect of education is significant for females and is more pronounced for women with high body mass and low physical activity. On the other hand, the effect of education on eating patterns is significant mainly for males, being more beneficial for men with elevated calorie consumption. We also show that education attainment is likely to foster productive and allocative efficiency of individuals in the context of BMI formation. Given that the literature suggests that education fosters development of cognition, self-control, and a variety of skills and abilities, in our context it is thus likely to promote lifetime preferences and means of individuals, which in turn enable them to achieve better health outcomes. Education also provides exposure to physical education and to school subjects enhancing individual deliberative skills, which are important factors shaping calorie expenditure and intake. Finally, we show that in the presence of strong socioeconomic inequalities in BMI, education is likely to have a pronounced impact on healthy BMI for the disadvantaged groups, represented in our framework by females.

The impact of cost-sharing schemes on drug compliance in Italy: evidence based on quantile regression.

OBJECTIVES: In this article we investigate the causal effect of cost-sharing schemes on compliance with statins in a quantile regression framework. METHODS: We use the health search CSD-LPD data, a longitudinal observational dataset containing computer-based patient records collected by Italian general practitioners. We exploit a series of natural experiments referring to several introductions of co-payment schemes in some of the Italian regions between 2000 and 2009. We adopt an extended difference-in-differences approach to provide quantile estimates of the impact of co-payments on compliance. RESULTS: We find that (i) introduction of co-payments hurts residents of regions with worse quality and provision of health care; (ii) within these regions, co-payments were particularly harmful for high compliers; (iii) gender, clinical history and geographic residence are important determinants of compliance among poor compliers; (iv) compliance decreases with the potency and dosage of statins, particularly for poor compliers. CONCLUSIONS: In the presence of inefficient health-care provision, co-payments are harmful for drug compliance, and this is especially true for patients who are originally good compliers.