State-level economic uncertainty and cardiovascular disease deaths: evidence from the United States.

The relationship between economic recessions and cardiovascular mortality has been widely explored. However, there is limited evidence on whether economic uncertainty alone is linked to cardiovascular disease deaths. This study examines the association between economic uncertainty and mortality from diseases of the circulatory system in the United States. We obtained monthly state-level mortality data from 2008 to 2017 and used indices capturing economic uncertainty from national/international sources and local sources. Panel data modelling was used to account for unobserved time-invariant differences between the states. Our findings suggest that economic uncertainty is independently linked to cardiovascular mortality. Uncertainty arising from national/international sources is associated with cardiovascular deaths, whereas the respective index capturing uncertainty from state/local sources is not. Deaths respond asymmetrically with respect to uncertainty fluctuations - with high levels of uncertainty driving the association. One- and two-month lagged uncertainty levels are also associated with mortality. Several robustness checks further validate the baseline findings. Overall, economic uncertainty is an independent predictor of cardiovascular mortality which appears to act as a psychosocial stressor and a short-term trigger. Public health strategies for cardiovascular disease need to consider factors driving economic uncertainty. Preventive measures and raising awareness can intensify in periods of economic uncertainty.

Economic uncertainty and cardiovascular disease mortality.

Previous studies have found a link between economic conditions, such as recessions and unemployment, and cardiovascular disease as well as other health outcomes. More recent research argues that economic uncertainty-independently of unemployment-can affect health outcomes. Using data from England and Wales, we study the association between fluctuations in economic uncertainty and cardiovascular disease mortality in the short term for the period 2001-2019. Controlling for several economic indicators (including unemployment), we find that economic uncertainty alone is strongly associated with deaths attributed to diseases of the circulatory system, ischemic heart disease and cerebrovascular disease. Our findings highlight the short-term link between economic conditions and cardiovascular health and reveal yet another health outcome that is associated with uncertainty.

Minimum Alcohol Pricing and Motor Vehicle Collisions in Scotland.

On May 1, 2018, Scotland introduced a minimum price of 50 pence per unit of alcohol, which led to a reduction in alcohol consumption. As drink-driving is an important risk factor for motor vehicle collisions, we examined whether the minimum alcohol pricing was followed by a decrease in collisions. We took advantage of a case where the minimum price was introduced to 1 population during the study period (Scotland) and another population that served as the control group did not experience this intervention (England and Wales). We used data on the daily number of motor vehicle collisions resulting in death or injury in 2018 and used a differences-in-differences econometric approach, comparing trends before and after the introduction of the minimum price. Controlling for seasonality, we found a small relative decrease in collisions in Scotland compared with England and Wales (difference-in-difference interaction coefficient, -0.35; 95% confidence interval: -0.65, -0.04; P = 0.03). Our results suggest that there was a relative decrease in motor vehicle collisions in Scotland of between 1.52 and 1.90, on average, in the first months after the introduction of the policy. More research is needed to understand any long-term impacts of minimum alcohol pricing.

COVID-19, lockdowns and motor vehicle collisions: empirical evidence from Greece.

Reduced mobility during COVID-19 lockdowns means not only fewer vehicles at risk of collision, but also an opportunity to speed on empty streets. The objective of this paper is to examine the impact of the first wave of the pandemic and the first lockdown on motor vehicle collisions (MVCs) and associated injuries and deaths in Greece. Using monthly data at the regional unit level, I provide descriptive evidence and subsequently follow a difference-in-differences econometric approach, comparing trends in 2020 with those of the previous 5 years while controlling for unemployment and petrol prices. I found a steep decline in collisions, injuries and deaths compared with what would have been otherwise expected. In March and April 2020, there were about 1226 fewer collisions, 72 fewer deaths, 40 fewer serious injuries and 1426 fewer minor injuries compared with what would have been expected in the absence of the pandemic.

Economic uncertainty and suicide in the United States.

Previous studies have found an association between recessions and increased rates of suicide. In the present study we widened the focus to examine the association between economic uncertainty and suicides. We used monthly suicide data from the US at the State level from 2000 to 2017 and combined them with the monthly economic uncertainty index. We followed a panel data econometric approach to study the association between economic uncertainty and suicide, controlling for unemployment and other indicators. Economic uncertainty is positively associated with suicide when controlling for unemployment [coeff: 8.026; 95% CI: 3.692-12.360] or for a wider range of economic and demographic characteristics [coeff: 7.478; 95% CI: 3.333-11.623]. An increase in the uncertainty index by one percent is associated with an additional 11-24.4 additional monthly suicides in the US. Economic uncertainty is likely to act as a trigger, which underlines the impulsive nature of some suicides. This highlights the importance of providing access to suicide prevention interventions (e.g. hotlines) during periods of economic uncertainty.

Invited Commentary: The Association Between Florida's Opioid Crackdown and Opioid-Related Mortality-The Roles of Economic Factors and Mortality Misclassification.

Opioid overdose mortality has been increasing in the United States, and other types of mortality, such as motor vehicle crash deaths, may also be linked to opioid use. In this issue of the Journal, Feder et al. (Am J Epidemiol. 2020;189(9):885-893) examine the association between Florida's opioid crackdown laws, implemented in 2010-2011, and opioid-related mortality. They found a decrease in numbers of opioid-overdose and car-crash deaths compared with what would have been expected in the absence of such policies. They also found no evidence of any unintended increase in suicides due to poor pain management. The results were robust to alternative methodological approaches. Florida's opioid policy reforms coincided with the state's convergence towards national unemployment rates, as well as a new state law prohibiting texting while driving. Because opioid overdose mortality is often associated with economic conditions and because car crashes and suicides may also be linked to the macroeconomic environment, future research should take such factors into account when studying the outcomes of opioid prescribing laws. Another data-related aspect to consider is the misclassification of suicides as car crashes or opioid overdoses. Overall, the findings by Feder et al. are encouraging and can inform policy in other countries facing increasing numbers of opioid overdose deaths.

The short-term impact of economic uncertainty on motor vehicle collisions.

Stress and anxiety lead to attention loss and sleep deprivation and may reduce driving performance, increasing the risk of motor vehicle collision. We used evidence from a natural experiment to examine whether daily changes in economic uncertainty, potentially leading to attention or sleep loss, are associated with collisions in Great Britain. Daily data from the economic policy uncertainty index, derived from analysis of daily UK newspapers, were linked to the daily number of motor vehicle collisions in Great Britain over the period 2005-2015, obtained from the Department for Transport. Exploiting daily variations in economic uncertainty, we used a GARCH approach to model daily rates of motor vehicle collisions as a function of economic uncertainty, controlling for month and day of the week, monthly unemployment rates and weekly unleaded petrol prices. A spike in the daily economic uncertainty index was associated with an immediate increase in the number of motor vehicle collisions. Results were robust to various sensitivity analyses. Overall, daily increases in economic uncertainty are associated with short-term spikes in motor vehicle collisions. Preventive and traffic control measures may need to increase during periods of economic uncertainty.

Therapeutic substitution post-patent expiry: the cases of ACE inhibitors and proton pump inhibitors.

This paper examines whether there is a switch in total (originator and generic) consumption after generic entry from molecules that face generic competition towards other molecules of the same class, which are still in-patent. Data from six European countries for the time period 1991 to 2006 are used to study the cases of angiotensin-converting enzyme inhibitors and proton pump inhibitors. Empirical evidence shows that patent expiry of captopril and enalapril led to a switch in total (off-patent originator and generic) consumption towards other in-patent angiotensin-converting enzyme inhibitors, whereas patent expiry of omeprazole led to a switch in consumption towards other proton pump inhibitors. This phenomenon makes generic policies ineffective and results in an increase in pharmaceutical expenditure due to the absence of generic alternatives in the market of in-patent molecules.

Greasy roads: the impact of bad financial news on road traffic accidents.

We use evidence from a natural experiment in Greece to study the effect of the announcement of austerity measures on road traffic accidents (RTAs). We use daily RTA data from 2010 and 2011, during which a number of austerity measures were announced, including salary and pension cuts and an increase in direct and indirect taxes. We find that controlling for other factors potentially influencing RTAs, the number of RTAs increased significantly on the first two days following the announcements of austerity measures. We put forward some tentative suggestions for why this happens.

Pharmaceutical policy reform in the Russian Federation.

Of Russia's 142 million citizens, fewer than 20 million are enrolled in outpatient drug coverage plans. The current government aims to establish universal health insurance including outpatient medicines. Based on the current political and regulatory environment, this report explores pharmaceutical pricing options for Russia that balance greater access to medicines with achieving government plans of boosting local pharmaceutical production. To match innovative medicine prices with their health benefits, in the long run, we suggest that Russia consider adopting value-based pricing, and in the short term, that it introduce direct price negotiations and price drugs according to reference countries that use health technology assessment. Although generic market shares are high, generic medicine prices are higher than they should be. We propose tenders at the manufacturer level for the pricing of high-selling generics, and free pricing for products with sufficient market competition. These policy recommendations are a jumping-off point for further discussion about how pharmaceutical policy could aid this major economy to achieve its population health and health service goals.

The association between economic uncertainty and suicide in Japan by age, sex, employment status, and population density: an observational study.

Background: Suicide is one of the ten leading causes of death globally, and previous research has revealed a link between economic conditions and mental health. However, the literature has focused primarily on recessions and unemployment, i.e. actual economic developments, as opposed to uncertainty, which relates to economic developments that have not (yet) materialised. This study examines the differential association between economic uncertainty and suicide in Japan, depending on age, sex, employment status, and population density, in order to identify the groups that are affected the most. Methods: Using monthly prefectural suicide mortality data from the Ministry of Health, Labour and Welfare and a monthly economic uncertainty index for the period 2009 to 2019, we employed a fixed effects panel data approach to examine the association between uncertainty and suicide by population group. Findings: We found that a 1% increase in economic uncertainty is associated with a 0.061 increase in the monthly number of suicides per 100,000 people per prefecture, on average (coefficient: 6.08; 95% CI: 5.07-7.08), which constitutes a 3.62% increase. Self-employed people, as well as men in their 50s and unemployed men, experience the highest additional risk of suicide when uncertainty increases. The association was approximately three times stronger for males than for females, and a strong association was observed for self-employed males living in more densely-populated areas. Interpretation: Uncertainty appears to relate to suicides for most groups, but self-employed people, males, and those living in more densely populated areas appear to be more at risk of suicide in periods of increased economic uncertainty. Our results provide an indication of which groups mental health services and prevention strategies can focus on in times of economic uncertainty. Funding: None.

Explaining why increases in generic use outpace decreases in brand name medicine use in multisource markets and the role of regulation.

BACKGROUND: Healthcare systems worldwide face escalating pharmaceutical expenditures despite interventions targeting pricing and generic substitution. Existing studies often overlook unwarranted volume increases in multisource markets due to differential physician perceptions of brand name and generics. OBJECTIVE: This study aims to explain the outpacing of generic medicine use over brand name use in multisource markets and assess the regulatory role, specifically examining the impact of reference pricing on volume and intensity increases. METHODS: Analyzing German multisource prescription medicine markets from 2011 to 2014, we evaluate regulatory mechanisms and explore whether brand name and generic medicines constitute separate market segments. Using an Oaxaca-Blinder decomposition approach, we divide the differential in brand name versus generic medicine use rates into market structure and unobserved segment effects. RESULTS: Generic use rates surpass same-market brand name substitution by 3.87 prescriptions per physician and medicine, on average. Reference pricing mitigated volume increase, treatment intensity and expenditure. Disparities in quantity and expenditure dynamics between brand name and generic segments are partially explained by market structure and segment effects. CONCLUSION: Generic medicine use effectively reduces expenditures but contributes to increased net prescription rates. Reference pricing may control medicine use, but divergent physician perceptions of brand name and generics, revealed by identified segment effects, call for nuanced policy interventions.

Have health trends worsened in Greece as a result of the financial crisis? A quasi-experimental approach.

BACKGROUND: Health in Greece deteriorated after the recent financial crisis, but whether this decline was caused by the recent financial crisis has not been established. This article uses a quasi-experimental approach to examine the impact of the recent financial crisis on health in Greece. METHODS: Data came from the European Union Statistics on Income and Living Conditions survey for the years 2006-09. We applied a difference-in-differences approach that compares health trends before and after the financial crisis in Greece with trends in a control population (Poland) that did not experience a recession and had health trends comparable with Greece before the crisis. We used logistic regression to model the impact of the financial crisis on poor self-rated health, controlling for demographic confounders. RESULTS: Results provide strong evidence of a statistically significant negative effect of the financial crisis on health trends. Relative to the control population, Greece experienced a significantly larger increase in the odds of reporting poor health after the crisis (odds ratio, 1.16; 95% confidence interval, 1.04-1.29). There was no difference in health trends between Poland and Greece before the financial crisis, supporting a causal interpretation of health declines in Greece as a result of the financial crisis. CONCLUSION: Results provide evidence that trends in self-rated health in Greece worsened as a result of the recent financial crisis. Findings stress the need for urgent health policy responses to the recent economic collapse in Greece as the full impact of austerity measures unfolds in the coming years.

Road traffic mortality and economic uncertainty: Evidence from the United States.

Previous studies have shown that financial turbulence is associated with a short-term increase in road traffic collisions, largely due to drivers' emotional state, distraction, sleep deprivation and alcohol consumption. In this paper we advance this debate by studying the association between economic uncertainty and road traffic mortality in the United States. We used a State-level uncertainty index and State fatalities for the period 2008-2017 and found that a one standard deviation increase in economic uncertainty is associated with an additional 0.013 monthly deaths per 100,000 people per State, on average (a 1.1% increase) - or 40 more monthly deaths in total nationwide. Results are robust to different model specifications. Our findings show that, similar to drink-driving, it is important to raise awareness about driving when distracted due to financial worries and during periods of economic uncertainty.

Police killings and suicide among Black Americans.

Black Americans are killed at higher rates by police than whites. Previous studies have shown that discrimination can lead to suicidal ideation, and that mental health of Black Americans deteriorates after police killings. The objective of this study is to examine whether police killings are associated with an increase in suicide rates amongst Black Americans. Controlling for a number of factors, we found that on months with at least one killing of a Black person by police, there were, on average, 0.0472 additional suicides per 100,000 Black Americans in the U.S. Census Division where the killing occurred. We did not find any spillover effects on other divisions. This association persisted when controlling for gun ownership, and did not seem to be a result of variance in deaths by assault. There was no association between killings of Black Americans and white suicides; white killings and Black suicides; or white killings and white suicides. This study highlights another reason for urgent action on reducing police killings.

COVID-19: Early evening curfews and mobility.

During the COVID-19 pandemic, some countries introduced early evening curfews. Several studies try to measure the effectiveness of such measures across different countries, but disentangling competing effects can be elusive. We examined the impact of an early evening curfew on mobility by studying a shift in curfews from 9pm to 6pm in Greece using Google mobility data. We followed a difference-in-differences (DiD) econometric approach, where we compared trends in mobility in residential spaces as well as groceries and pharmacies, before and after the introduction of the 6pm curfew in Attica with trends in three other comparable Regions. We found little or no evidence of an effect of the early curfew on daily mobility relating to groceries and pharmacies, and that an 18.75% reduction in hours where people were allowed to leave home led to a relatively small increase in time spent in residential spaces. This less-than-proportionate reduction in mobility outside the household suggests a possibility that the curfew led to more people coinciding in indoor public spaces, such as grocery shops - which constitutes a contagion risk factor. Results should be treated with caution, especially with regards to the magnitude of any effect, as Google mobility data do not report the time of the day, so the time density of activities cannot be estimated. Lockdowns and other measures are necessary to tackle Covid-19, but it is important to avoid substitution by activities that contribute further to spreading the virus. Interventions should therefore be based on a thorough analysis of human behaviour.

Household expenditures for medicines and the role of free medicines in the Brazilian public health system.

OBJECTIVES: We sought to investigate, across different socioeconomic groups, the proportion of household medicine expenses that were paid by households and the proportion paid by the Brazilian national health system. METHODS: We carried out a survey in Porto Alegre, Brazil, that included 2988 individuals of all ages. We defined 2 expenditure variables: "out-of-pocket medicines value" (the sum of retail prices of all medicines used by family members within the previous 15 days and paid for out of pocket) and "free medicines value" (a similar definition for medicines obtained without charge). RESULTS: In 2003, the Brazilian national health system provided, free of charge, 78% of the monetary value of medicines reported (79% in the bottom wealth quintile and 32% in the top 2 quintiles). The mean out-of-pocket expense for medicines was 6 times greater among the top wealth quintiles compared with those in lower quintiles, but free medicines constituted a 3-times-greater proportion of potential expenditures for medicines among the bottom quintile than among the top 2 quintiles. CONCLUSIONS: Free provision of medicines seems to be saving substantial amounts of medicine expenditures for poor people in Brazil.

Excess mortality during the Covid-19 pandemic: Early evidence from England and Wales.

The Covid-19 pandemic has claimed many lives in the UK and globally. The objective of this paper is to study whether the number of deaths not registered as Covid-19-related has increased compared to what would have been expected in the absence of the pandemic. Reasons behind this might include Covid-19 underreporting, avoiding visits to hospitals or GPs, and the effects of the lockdown. I used weekly ONS data on the number of deaths in England and Wales that did not officially involve Covid-19 over the period 2015-2020. Simply observing trends is not sufficient as spikes in deaths may occasionally occur. I thus followed a difference-in-differences econometric approach to study whether there was a relative increase in deaths not registered as Covid-19-related during the pandemic, compared to a control. Results suggest that there were an additional 968 weekly deaths that officially did not involve Covid-19, compared to what would have otherwise been expected. It is possible that some people are dying from Covid-19 without being diagnosed, and/or that there are excess deaths due to other causes as a result of the pandemic. Analysing the cause of death for any excess non-covid-19 deaths will shed light upon the reasons for the increase in such deaths and will help design appropriate policy responses to save lives.

The link between unemployment and opioid prescribing. An instrumental variable approach using evidence from England.

BACKGROUND: Unemployment has been associated with chronic pain, which is often treated with prescription opioids. Opioid mortality has been included in the so-called category of 'deaths of despair' due to the role of lack of opportunity. While previous studies have found an association between unemployment and opioids, the relationship is endogenous and examining any effect is challenging. OBJECTIVE: The objective of this paper is to study the association between unemployment and opioid prescribing in England. DATA AND METHODS: We used data from the GP prescribing database in England for the period 2011-2017 and followed ordinary least squares (OLS) and Instrumental Variable econometric approaches, controlling for other confounders. We used the number of foreign direct investment projects and the number of registered companies as instruments for unemployment, taking population size into account. RESULTS: The OLS model suggests that an increase in the unemployment rate by 1 percentage point is associated with 0.017 additional opioid defined daily doses per capita-a 0.9% increase compared with the mean of 1.745. According to the instrumental variable model, an increase in unemployment by 1 percentage point leads to an increase in the number of opioid doses prescribed per capita by between 0.315 and 0.437, which constitutes a 18-25% increase compared with the mean of 1.745. CONCLUSIONS: Unemployment appears to have an impact on opioid prescribing volume in England. This reveals yet another negative effect of unemployment on health. Relevant labour market policies may play a protective role with regards to opioid use.

The (Agri-)Cultural origins of obesity.

Previous research has shown that societies that historically focused on agricultural production demonstrate higher levels of long-term orientation. This suggests that the deep-rooted cultural origins of time preference may have a scarring impact on modern obesity rates through intergenerational transmission. We hypothesize that a historically long-term oriented culture could result in the behavioural choices of better diet and more exercise today, via the reinforced ability of individuals to delay gratification. Using a sample of 132 countries, we employ regression analysis to first estimate the historical determinants of time preference, and then examine the impact of long-term orientation on obesity. Controlling for other factors, we find that, on average, historically long-term oriented countries exhibit significantly lower obesity rates today. Results are robust to different methodological approaches and sensitivity analyses. Policies targeting obesity should consider those deep-rooted behavioural factors that can determine the differential response of individuals to policy instruments.