Pain severity and healthcare resource utilization in patients with osteoarthritis in the United States.

OBJECTIVE: To evaluate healthcare resource utilization (HCRU) by osteoarthritis (OA) pain severity. METHODS: Cross-sectional surveys of US physicians and their patients were conducted between February and May 2017. Using the Numeric Rating Scale, patients were classified by self-reported pain intensity in the last week into mild (0-3), moderate (4-6), and severe (7-10) cohorts. Parameters assessed included clinical characteristics, HCRU, and current caregiver support. Descriptive statistics were obtained, and analysis of variance and chi-square tests were performed. RESULTS: Patients (n = 841) were mostly female (60.9%) and white (77.8%), with mean age of 64.6 years. Patients reported mild (45.4%), moderate (35.9%), and severe (18.7%) OA pain. Mean number of affected joints varied by pain severity (range mild: 2.7 to severe: 3.6; p < 0.0001). Pain severity was associated with an increased number of physician-reported and patient-reported overall healthcare provider visits (HCPs; both p < 0.001). As pain increased, patients reported an increased need for mobility aids, accessibility modifications to homes, and help with daily activities due to functional disability. The number of imaging tests used to diagnose OA was similar across pain severity but varied when used for monitoring (X-rays: p < 0.0001; computerized tomography scans: p < 0.0447). Hospitalization rates for OA were low but were significantly associated with pain severity (mild: 4.9%; severe: 11.5%). Emergency department visits were infrequent but increasing pain severity was associated with more prior and planned surgeries. CONCLUSION: Greater current pain was associated with more prior HCRU including imaging for monitoring progression, HCP visits including more specialty care, hospitalizations, surgery/planned surgery, and loss of independence due to functional disability. Yet rates of hospitalizations and X-ray use were still sizable even among patients with mild pain. These cross-sectional findings warrant longitudinal assessment to further elucidate the impact of pain on HCRU.

The impact of adolescent exposure to medical marijuana laws on high school completion, college enrollment and college degree completion.

BACKGROUND: There is concern that medical marijuana laws (MMLs) could negatively affect adolescents. To better understand these policies, we assess how adolescent exposure to MMLs is related to educational attainment. METHODS: Data from the 2000 Census and 2001-2014 American Community Surveys were restricted to individuals who were of high school age (14-18) between 1990 and 2012 (n=5,483,715). MML exposure was coded as: (i) a dichotomous "any MML" indicator, and (ii) number of years of high school age exposure. We used logistic regression to model whether MMLs affected: (a) completing high school by age 19; (b) beginning college, irrespective of completion; and (c) obtaining any degree after beginning college. A similar dataset based on the Youth Risk Behavior Survey (YRBS) was also constructed for confirmatory analyses assessing marijuana use. RESULTS: MMLs were associated with a 0.40 percentage point increase in the probability of not earning a high school diploma or GED after completing the 12th grade (from 3.99% to 4.39%). High school MML exposure was also associated with a 1.84 and 0.85 percentage point increase in the probability of college non-enrollment and degree non-completion, respectively (from 31.12% to 32.96% and 45.30% to 46.15%, respectively). Years of MML exposure exhibited a consistent dose response relationship for all outcomes. MMLs were also associated with 0.85 percentage point increase in daily marijuana use among 12th graders (up from 1.26%). CONCLUSIONS: Medical marijuana law exposure between age 14 to 18 likely has a delayed effect on use and education that persists over time.

Do changes in hospital outpatient payments affect the setting of care?

OBJECTIVE: To examine whether decreases in Medicare outpatient payment rates under the Outpatient Prospective Payment System (OPPS) caused outpatient care to shift toward the inpatient setting. DATA SOURCES/STUDY SETTING: Hospital inpatient and outpatient discharge files from the Florida Agency for Health Care Administration from 1997 through 2008. STUDY DESIGN: This study focuses on inguinal hernia repair surgery, one of the most commonly performed surgical procedures in the United States. We estimate multivariate regressions of inguinal hernia surgery counts in the outpatient setting and in the inpatient setting. The key explanatory variable is the time-varying Medicare payment rate specific to the procedure and hospital. Control variables include time-varying hospital and county characteristics and hospital and year-fixed effects. PRINCIPAL FINDINGS: Outpatient hernia surgeries fell in response to OPPS-induced rate cuts. The volume of inpatient hernia repair surgeries did not increase in response to reductions in the outpatient reimbursement rate. CONCLUSIONS: Potential substitution from the outpatient setting to the inpatient setting does not pose a serious threat to Medicare's efforts to contain hospital outpatient costs.

Racial and ethnic disparities in the surgical treatment of acute myocardial infarction: the role of hospital and physician effects.

Many studies document disparities between Blacks and Whites in the treatment of acute myocardial infarction on controlling for patient demographic factors and comorbid conditions. Other studies provide evidence of disparities between Hispanics and Whites in cardiac care. Such disparities may be explained by differences in the hospitals where minority and nonminority patients obtain treatment and by differences in the traits of physicians who treat minority and nonminority patients. We used 1997-2005 Florida hospital inpatient discharge data to estimate models of cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting in Medicare fee-for-service patients 65 years and older. Controlling for hospital fixed effects does not explain Black-White disparities in cardiac treatment but largely explains Hispanic-White disparities. Controlling for physician fixed effects accounts for some extent of the racial disparities in treatment and entirely explains the ethnic disparities in treatment.

Do cigarette taxes affect children's body mass index? The effect of household environment on health.

Several recent studies demonstrate a positive effect of cigarette prices and taxes on obesity among adults, especially those who smoke. If higher cigarette costs affect smokers' weights by increasing calories consumed or increasing food expenditures, then cigarette taxes and prices may also affect obesity in children of smokers. This study examines the link between child body mass index (BMI) and obesity status and cigarette costs using data from the National Longitudinal Survey of Youth-79 (NLSY79). Controlling for various child, mother, and household characteristics as well as child-fixed effects, I find that cigarette taxes and prices increase BMI in the children of smoking mothers. Interestingly, and unlike previous research findings for adults, higher cigarette taxes do not increase the likelihood of obesity in children. These findings are consistent with a causal mechanism in which higher cigarette costs reduce smoking and increase food expenditures and consumption in the household.

Religious participation and risky health behaviors among adolescents.

Previous studies have shown that adolescent religious participation is negatively associated with risky health behaviors such as cigarette smoking, alcohol consumption, and illicit drug use. One explanation for these findings is that religion directly reduces risky behaviors because churches provide youths with moral guidance or with strong social networks that reinforce social norms. An alternative explanation is that both religious participation and risky health behaviors are driven by some common unobserved individual trait. We use data from the National Longitudinal Study of Adolescent Health and implement an instrumental variables approach to identify the effect of religious participation on smoking, binge drinking, and marijuana use. Following Gruber (2005), we use a county-level measure of religious market density as an instrument. We find that religious market density has a strong positive association with adolescent religious participation, but not with secular measures of social capital. Upon accounting for unobserved heterogeneity, we find that religious participation continues to have a significant negative effect on illicit drug use. On the contrary, the estimated effects of attendance in instrumental variables models of binge drinking and smoking are statistically imprecise.

Predicting health behaviors with an experimental measure of risk preference.

We conduct a large-scale economics experiment paired with a survey to examine the association between individual risk preference and health-related behaviors among adults aged 18-87 years. Risk preference is measured by the lottery choice experiment designed by Holt and Laury [Holt, C.A., Laury, S.K., 2002. Risk aversion and incentive effects. The American Economic Review 92(5), 1644-1655]. Controlling for subject demographic and economic characteristics, we find that risk aversion is negatively and significantly associated with cigarette smoking, heavy drinking, being overweight or obese, and seat belt non-use. In additional specifications, we find that risk aversion is negatively and significantly associated with the likelihood a subject engaged in any of five risky behaviors and the number of risky behaviors reported.

The impact of child obesity on active parental consent in school-based survey research on healthy eating and physical activity.

Previous studies have shown that active consent procedures result in sampling bias in surveys dealing with adolescent risk behaviors such as cigarette smoking and illicit drug use. To examine sampling bias from active consent procedures when the survey topic pertains to childhood obesity and associated health behaviors, the authors pair data obtained from both active and passive consent procedures. The authors find that parents of children who are overweight or at risk for being overweight are significantly less likely to give active consent. In addition, parents of children enrolled in lower grades are more reluctant to consent to participate.

Is exposure to income inequality a public health concern? Lagged effects of income inequality on individual and population health.

OBJECTIVE: To examine the health consequences of exposure to income inequality. DATA SOURCES: Secondary analysis employing data from several publicly available sources. Measures of individual health status and other individual characteristics are obtained from the March Current Population Survey (CPS). State-level income inequality is measured by the Gini coefficient based on family income, as reported by the U.S. Census Bureau and Al-Samarrie and Miller (1967). State-level mortality rates are from the Vital Statistics of the United States, other state-level characteristics are from U.S. census data as reported in the Statistical Abstract of the United States. STUDY DESIGN: We examine the effects of state-level income inequality lagged from 5 to 29 years on individual health by estimating probit models of poor/fair health status for samples of adults aged 25-74 in the 1995 through 1999 March CPS. We control for several individual characteristics, including educational attainment and household income, as well as regional fixed effects. We use multivariate regression to estimate the effects of income inequality lagged 10 and 20 years on state-level mortality rates for 1990, 1980, 1970, and 1960. PRINCIPAL FINDINGS: Lagged income inequality is not significantly associated with individual health status after controlling for regional fixed effects. Lagged income inequality is not associated with all cause mortality, but associated with reduced mortality from cardiovascular disease and malignant neoplasms, after controlling for state fixed-effects. CONCLUSIONS: In contrast to previous studies that fail to control for regional variations in health outcomes, we find little support for the contention that exposure to income inequality is detrimental to either individual or population health.