Determinants of the Cost-Effectiveness of Telemedicine: Systematic Screening and Quantitative Analysis of the Literature.

Background and Objectives: Telemedicine holds the promise of increasing access-to-care at a lower cost. Yet, for years, the evidence of telemedicine's cost-effectiveness was scarce. Faced with a rapidly expanding literature, we conduct both manual and systematic selection of the literature, and analyzed the data to determine: (1) the characteristics of economic evaluations of telemedicine, and (2) the determinants of economically efficient telemedicine interventions. Methods: We reviewed all published economic evaluations of telemedicine in Cochrane, Embase, and Pubmed from 2008 to 2018. Articles were screened by two researchers first on title and abstract (Stage 1), then on full article (Stage 2), (protocol available on PROSPERO, ref. CRD42019143032). We proposed an alternative method for screening articles using machine learning based on textual classification and compared these two approaches. We constructed an exclusive dataset on the characteristics of the selected articles and enriched it using OECD data at the country level. We identified the determinants of efficient telemedicine interventions using multiple logit models. Results and Conclusion: We included 156 articles out of 2,639. Most economic studies of our sample regard telemonitoring. A majority (73.7%) of studies found that telemedicine intervention is efficient, regardless of the medical domain. Articles with higher standards of economic evaluation (cost-effectiveness analysis, randomized trials with high sample size) were less likely to report an efficient intervention. We found no effect of the publication year, signifying that the nature of the evidence has not changed over time.

Where Are Populations Aging Better? A Global Comparison of Healthy Aging Across Organization for Economic Cooperation and Development Countries.

OBJECTIVES: Global comparisons and large samples are needed to inform policy makers about aging trends among people aged older than 60 years. Using harmonized data gathered from the Gateway to Global Aging data, we introduce a new framework to measure healthy aging across 13 OECD countries. METHODS: First, we developed an original measure of physiological age (PA), that is, a measure of age weighted for the influence of frailty, activities of daily living limitations, and comorbidities. Second, we compared healthy aging measures across 13 countries based on a ranking of the countries according to the discrepancy between estimated PA and chronological age (CA). Third, we explored the socioeconomic factors associated with healthy aging. RESULTS: We found a strong correlation between our PA measure and biological age. Italy, Israel, and the United States are the 3 countries where PA is the highest (independent of CA), thus indicating aging in poor health. In contrast, Switzerland, The Netherlands, Greece, Sweden, and Denmark have much lower PA than CA, thus indicating healthy aging. Finally, the PA-CA discrepancy is higher among poorer, less educated, and single older individuals. CONCLUSIONS: Countries with higher PA need to implement or reinforce healthy aging measures and target the disadvantaged populations.

Adherence to medical follow-up recommendations reduces hospital admissions: Evidence from diabetic patients in France.

The aim of this study was to document the extent to which diabetic patients who adhered to required medical follow-ups in France experienced reduced hospital admissions over time. The main assumption was that enhanced monitoring and follow-up of diabetic patients in the primary care setting could be a substitute for hospital use. Using longitudinal claim data of diabetic patients between 2010 and 2015 from MGEN, a leading mutuelle insurance company in France, we estimated a dynamic logit model with lagged measures of the quality of adherence to eight medical follow-up recommendations. This model allowed us to disentangle follow-up care in hospitals from other forms of inpatient care that could occur simultaneously. We found that a higher adherence to medical guidance is associated with a lower probability of hospitalization and that the take-up of each of the eight recommendations may help reduce the rates of hospital admission. The reasons for the variation in patient adherence and implications for health policy are discussed.

The dynamics of frailty and change in socio-economic conditions: evidence for the 65+ in Europe.

BACKGROUND: The frailty phenotype for older people is defined as an increased vulnerability to stressors, leading to adverse health outcomes. It is acknowledged as a specific precursor of disability besides chronic diseases that allows for some reversibility in the loss of autonomy. Although the literature on the socio-economic determinants of frailty is emerging in cross-sectional settings, little is known about the dynamics of this relationship over time. This article examines the joint evolution of frailty and change in economic conditions for the 65+ in Europe. METHODS: Individual and longitudinal data from SHARE (Survey on Health, Ageing and Retirement in Europe) over the period 2004-12 has been used. The sample contains 31 044 observations from 12 002 respondents aged 65 or more. A fixed effect Poisson model is estimated in order to control for unobserved individual heterogeneity. Three types of explanative economic variables have been considered in turn: income, wealth and a subjective variable of deprivation. RESULTS: Our results indicate that individuals with worsening economic conditions (wealth and subjective deprivation) over time simultaneously experience a rapid increase in the frailty symptoms. Results also show that the nature of economic variable does not affect the frailty process in the same way. Subjective measure of deprivation seems to better evaluate the household's financial difficulties than objective measure. CONCLUSION: From a public policy perspective, these results show that policies fostering economic conditions of the elderly could have a significant impact on frailty and henceforth, could reduce the risks of disability.

Implementation and evaluation of the water safety plan approach for buildings.

The World Health Organization (WHO) promotes water safety plans (WSPs) - a risk-based management approach - for premise plumbing systems in buildings to prevent deterioration of drinking-water quality. Experience with the implementation of WSPs in buildings were gathered within a pilot project in Germany. The project included an evaluation of the feasibility and advantages of WSPs by all stakeholders who share responsibility in drinking-water safety. While the feasibility of the concept was demonstrated for all buildings, benefits reported by building operators varied. The more technical standards were complied with before implementing WSP, the less pronounced were the resulting improvements. In most cases, WSPs yielded an increased system knowledge and awareness for drinking-water quality issues. WSPs also led to improved operation of the premise plumbing system and provided benefits for surveillance authorities. A survey among the European Network of Drinking-Water Regulators on the existing legal framework regarding drinking-water safety in buildings exhibited that countries are aware of the need to manage risks in buildings' installations, but experience with WSP is rare. Based on the successful implementation and the positive effects of WSPs on drinking-water quality, we recommend the establishment of legal frameworks that require WSPs for priority buildings whilst accounting for differing conditions in buildings and countries.

Resource Use and Cost of Alzheimer's Disease in France: 18-Month Results from the GERAS Observational Study.

BACKGROUND: There is little longitudinal data on resource use and costs associated with Alzheimer's disease (AD) in France. OBJECTIVES: To evaluate resource use and societal costs associated with AD in a French cohort of patients and their caregivers and the effect of patient cognitive decline on costs over an 18-month period. METHODS: Community-dwelling patients with mild, moderate, or moderately severe/severe AD dementia (n = 419) were followed-up for 18 months. Total societal costs were estimated by applying 2010 unit costs to resource use, including outpatient visits, hospital days, institutionalization, and caregiver hours. Cognitive function was assessed by Mini-Mental State Examination scores. RESULTS: Mean cumulative total costs over the 18-month period were €24,140 for patients with mild AD dementia, €34,287 for those with moderate AD dementia, and €44,171 for those with moderately severe/severe AD dementia (P < 0.001; ANOVA comparison between severity groups). The biggest contributor to total societal costs was caregiver informal care (>50% of total costs at all stages of AD dementia). Cognitive decline (≥3-point decrease in Mini-Mental State Examination score or institutionalization) was associated with a 12.5% increase in total costs (P = 0.02). Significant differences were observed across severity groups for caregiver time (P < 0.001); mean monthly caregiver time increased at each time point over the 18 months in each severity group. CONCLUSIONS: Increasing severity of AD dementia in France is associated with increased use of resources as well as increased total societal and patient costs; informal care was the greatest cost contributor. Clinically meaningful cognitive decline is associated with significantly increased costs.

Preventing mobility disability in Europe: a health economics perspective from the SPRINTT study.

In a global context of population aging, gaining better knowledge of the mechanisms leading to loss of autonomy has become a major objective, notably with the aim of implementing effective preventive health policies. The concept of frailty, originally introduced in gerontology and geriatrics as a precursor state to functional dependency, appears as a useful tool in this specific context. The "Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies" (SPRINTT) project will provide a unique opportunity to explore health economics issues associated with frailty. In terms of health economics, the loss of autonomy approach retained here focuses on the economic and social causes and consequences of the onset of frailty in older adults, and examines the challenges not only in terms of health system efficiency but also in terms of social protection.

An Analysis of the Public Financial Support Eligibility Rule for French Dependent Elders with Alzheimer's Disease.

BACKGROUND: It is crucial to define health policies that target patients with the highest needs. In France, public financial support is provided to dependent patients: it can be used to finance informal care time and nonmedical care use. Eligibility for public subsidies and reimbursement of costs is associated with a specific tool: the autonomie gérontologie groupes iso-ressources (AGGIR) scale score. OBJECTIVE: Our objective was to explore whether patients with Alzheimer's disease who are eligible for public financial support have greater needs than do noneligible patients. METHODS: Using data from the Dépendance des patients atteints de la maladie d'Alzheimer en France study, we calculated nonmedical care expenditures (in €) using microcosting methods and informal care time demand (hours/month) using the Resource Use in Dementia questionnaire. We measured the burden associated with informal care provision with Zarit Burden Interview. We used a modified two-part model to explore the correlation between public financial support eligibility and these three variables. RESULTS: We find evidence of higher informal care use, higher informal caregivers' burden, and higher care expenditures when patients have an AGGIR scale score corresponding to public financial support eligibility. CONCLUSIONS: The AGGIR scale is useful to target patients with the highest costs and needs. Given our results, public subsidies could be used to further sustain informal caregivers networks by financing programs dedicated to lowering informal caregivers' burden.

State home and community-based services expenditures and unmet care needs in the United States: Has everyone benefitted equally?

OBJECTIVE: To test whether the impacts of Medicaid's Home and Community-Based Services (HCBS) expenditures have been equitable. DATA SOURCES AND STUDY SETTING: This is a secondary data analysis. We linked annual data on state-level Medicaid HCBS expenditures with individual data from U.S. Health and Retirement Study (HRS; 2006-2016). STUDY DESIGN: We evaluated the association between state-level HCBS expenditure quartiles and the risk of experiencing challenges in basic or instrumental activities of daily living (I/ADLs) without assistance (unmet needs for care). We fitted generalized estimating equations (GEE) with a Poisson distribution, log link function, and an unstructured covariance matrix. We controlled demographics, time, and place-based fixed effects and estimated models stratified by race and ethnicity, gender, and urbanicity. We tested the robustness of results with negative controls. DATA COLLECTION/EXTRACTION METHODS: Our analytic sample included HRS Medicaid beneficiaries, aged 55+, who had difficulty with ≥1 I/ADL (n = 2607 unique respondents contributing 4719 person-wave observations). PRINCIPAL FINDINGS: Among adults with IADL difficulty, higher quartiles of HCBS expenditure (vs. the lowest quartile) were associated with a lower overall prevalence of unmet needs for care (e.g., Prevalence Ratio [PR], Q4 vs. Q1: 0.91, 95% CI: 0.84-0.98). This protective association was concentrated among non-Hispanic white respondents (Q4 vs. Q1: 0.82, 95% CI: 0.73-0.93); estimates were imprecise for Hispanic individuals and largely null for non-Hispanic Black participants. We found no evidence of heterogeneity by gender or urbanicity. Negative control robustness checks indicated that higher quartiles of HCBS expenditure were not associated with (1) the risk of reporting I/ADL difficulty among 55+ Medicaid beneficiaries, and (2) the risk of unmet care needs among non-Medicaid beneficiaries. CONCLUSION: The returns to higher state-level HCBS expenditures under Medicaid for older adults with I/ADL disability do not appear to have been equitable by race and ethnicity.

[Analyzing and comparing healthy aging in France and OECD countries based on a new physiological age measure]. / Le bien-vieillir en France et dans les pays de l'OCDE - Une analyse à partir d'une nouvelle mesure d'âge physiologique.

We introduce a new individual measure of healthy aging on a sample of more than 39,000 individuals and compare the results for France with 11 other European countries and the United States. Our healthy aging measure is based on the discrepancy between the calendar age of populations with their estimated physiological age, which corresponds to a measure of age adjusted for the effects of comorbidities and functional health. France is ranked in the lower middle of our healthy aging scale, with the Nordic countries (Denmark, Sweden, Netherlands), Switzerland and Greece being ahead. Economic capital has a strong impact on the estimated physiological age and on healthy aging trajectories. Socioeconomic inequalities are particularly marked in France as well as in Italy and the United States. The generosity of long-term care policies seems to be positively associated with the level of healthy aging of the populations. More work is required to identify the drivers of healthy aging among individuals living in OECD countries.

Title: Le bien-vieillir en France et dans les pays de l'OCDE - Une analyse à partir d'une nouvelle mesure d'âge physiologique. Abstract: Dans cette synthèse, nous relatons les résultats d'une étude utilisant une nouvelle mesure individuelle du bien-vieillir. À partir d'un échantillon de plus de 39 000 individus, nous avons comparé les résultats de la France avec ceux observés dans 11 autres pays européens et aux États-Unis. Le bien-vieillir a été estimé en comparant l'âge calendaire des populations et leur âge physiologique, qui correspond à une mesure de l'âge ajustée des effets liés à la présence de comorbidités et à la santé fonctionnelle. Sur notre échelle de bien-vieillir, la France se situe dans le milieu bas du classement des pays. Elle est devancée par les pays nordiques (Danemark, Suède, Pays-Bas), la Suisse et la Grèce. Le capital économique a un fort impact sur l'âge physiologique estimé et sur les trajectoires de bien-vieillir. Les inégalités socio-économiques sont particulièrement marquées en France, comme en Italie et aux États-Unis.

Quantification and stability assessment of 7,9-di­tert­butyl­1-oxaspiro(4,5)deca-6,9-diene-2,8­dione leaching from cross-linked polyethylene pipes using gas and liquid chromatography.

This study assesses the formation and stability of the water contaminant 7,9-di­tert­butyl­1-oxaspiro(4,5)deca-6,9-diene-2,8­dione ([1]) which repeatedly occurs in the migration waters of cross-linked polyethylene (PE-X) pipes. In aqueous solution [1] is partially transformed to 3-(3,5-di­tert­butyl­1­hydroxy-4-oxo-2,5-cyclohexadien-1-yl)propionic acid ([2]). For a better understanding of the formation of [1] and its transformation into [2] an analytical method was established to allow the analysis of both species separately. Because of thermal instability [2] cannot be detected with GC-MS. Therefore, two methods were validated for a reliable and reproducible quantification: GC-MS for [1] and HPLC-MS/MS for both [1] and [2]. Comparative measurements of migration waters from PE-X pipes using GC-MS and HPLC-MS/MS methods showed that the concentrations of [1] detected with GC-MS corresponds to the sum of [1] and [2] measured with HPLC-MS/MS. In the migration waters [1] was detected in higher concentrations than [2]. The highest concentrations of [1], detected with GC-MS, were > 300 µg/L. The longer the materials are stored without contact with water, the more [1] is measured in the migration waters. Most of the previous values reported in the literature for [1] were based on semi-quantification. Hence, we compared results of the semi-quantitative determination according to EN 15768 with those of a quantitative method with a standard. The results gained with the semi-quantitative method represent less than 50% of the quantified values for the amount leaching from the pipes, which means that the semi-quantification method according to EN 15768 leads to a significant underestimation of [1]. Finally, stability assessment showed that [1] developed an equilibrium with [2] under acidic conditions, whereas it will completely be transferred to [2] at pH 10. At pH 7, it takes more than 50 days for [1] to reach an equilibrium with [2]. However, at increasing the temperature to 60 °C, [1] will be rapidly transformed into [2]. Besides [1] and [2], other currently unknown degradation products are formed. As there is no comprehensive toxicological assessment for both substances available today, our findings underline the need for regulatory consequences.

Do not PIMP my nursing home ride! The impact of Potentially Inappropriate Medications Prescribing on residents' emergency care use.

Nursing home residents often are poly-medicated, which increases their risks of receiving potentially inappropriate medications. This problem has become a major public health issue in many countries, and in particular in France. Indeed, high uses of potentially inappropriate medication prescriptions can lead to adverse effects that are likely to increase emergency room (ER) visits. However, there is a lack of empirical evidence on the causal relationship between the amount of use of potentially inappropriate medications and ER visit risks among nursing homes residents. Indeed, this question is subject to endogeneity issues due to omitted variables that simultaneously affect inappropriate medications prescriptions and ER use. We take advantage of the IDEM Randomized Clinical Trial (Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers) to overcome that issue. Indeed, randomization in the IDEM intervention group created exogenous variations in potentially inappropriate prescriptions, and was thus used as an instrument. Using an instrumental variable model, we show that over a 12-month period, a 1% increase in the share of potentially inappropriate medications spending in total medication spending leads to a 5.7 percentage point increase in residents' ER use risks (p < 0.001). This effect is robust to various model specifications. Moreover, the intensity of this correlation persists over an 18-month period. While tackling wasteful spending has become a priority in most countries, our results have important policy implications. Indeed, reducing potentially inappropriate medication spending in nursing homes should be a key component of value-based aging policies, which objectives are to reduce inefficient care, and provide health care services centered in people's interest.

Preventing autonomy loss with multicomponent geriatric interventions: A resource-saving strategy? Evidence from the SPRINT-T study.

Background: The objective of healthy aging strategies is to support interventions targeting autonomy loss prevention, with the assumption that these interventions are likely to be efficient by simultaneously improving clinical outcomes and saving costs. Methods: We compare the economic impact of two interventions targeting frailty prevention in older European populations: a multicomponent intervention including physical activity monitoring, nutrition management, information and communications technology use and a relatively simple healthy aging lifestyle education program based on a series of workshops. Our sample includes 1,519 male and female participants from 11 European countries aged 70 years or older. Our econometric model explores trends in several outcomes depending on intervention receipt and frailty status at baseline. Results: Implementing a multicomponent intervention among frail older people does not lead to a lower use of care and do not prevent quality of life losses associated with aging. However, it impacts older people's sense of priorities and interest in the future. We find no statistically significant differences between the two interventions, suggesting that the implementation of a multicomponent intervention may not be the most efficient strategy. The impact of the interventions does not differ by frailty status at baseline. Conclusions: Our results show the need to implement healthy aging strategies that are more focused on people's interests.

Caregiving across generations: Do older adults with more grandchildren get another bite at the "sandwich" generation?

Understanding the influence of grandchildren on long-term care use is a growing issue. Indeed, many countries, middle-aged adults provide unpaid care for aging family members, often their parents, at home. Although the influence of adult children's availability on their aging parents' caregiving decisions has been widely studied, the influence of grandchildren remains largely unstudied. Parental time allocated to childcare may compete with elder care, necessitating paid home care or transfer to a nursing home. Alternatively, grandparents may provide childcare, increasing incentives to keep grandparents at home. Using data from the Survey of Health, Ageing and Retirement in Europe (75,296 observations from 11 countries covering years 2004-2018), we exploit an instrumental variable strategy to study the effect of grandchildren on grandparents' long-term care decisions, specifically, use of paid home care or transfer to a nursing home. We use the generosity of maternity leave policies in time and across countries as an instrumental variable to identify the effect of the number of grandchildren. We find that the presence of grandchildren significantly increases the likelihood of having grandparents live at home: the probability of paid home care significantly increases while the probability of nursing home admission falls significantly. In conclusion, policies influencing the number of grandchildren in families have an indirect impact on long-term care use trajectories, confirming that family policies and long-term care policies are strongly imbricated and should not be considered separately.

Costs and Survival of Patients having Experienced a Hospitalized Fall-Related Injury in France: A Population-Based Study.

OBJECTIVES: To assess the annual costs 2 years before and 2 years after a hospitalized fall-related injury (HFRI) and the 2-year survival among the population 75+ years old. DESIGN: We performed a population-based, retrospective cohort study using the French national health insurance claims database. SETTING AND PARTICIPANTS: Patients 75+ years old who had experienced a fall followed by hospitalization, identified using an algorithm based on International Classification of Diseases codes. Data related to a non-HFRI population matched on the basis of age, sex, and geographical area were also extracted. METHODS: Cost analyses were performed from a health insurance perspective and included direct costs. Survival analyses were conducted using Kaplan-Meier curves and Cox regression. Descriptive analyses of costs and regression modeling were carried out. Both regression models for costs and on survival were adjusted for age, sex, and comorbidities. RESULTS: A total of 1495 patients with HFRI and 4484 non-HFRI patients were identified. Patients with HFRI were more comorbid than the non-HFRI patients over the entire periods, particularly in the year before and the year after the HFRI. Patients with HFRI have significantly worse survival probabilities, with an adjusted 2.14-times greater risk of death over 2-year follow-up and heterogeneous effects determined by sex. The annual incremental costs between patients with HFRI and non-HFRI individuals were €1294 and €2378, respectively, 2 and 1 year before the HFRI, and €11,796 and €1659, respectively, 1 and 2 years after the HFRI. The main cost components differ according to the periods and are mainly accounted for by paramedical acts, hospitalizations, and drug costs. When fully adjusted, the year before the HFRI and the year after the HFRI are associated with increase in costs. CONCLUSIONS AND IMPLICATIONS: We have provided real-world estimates of the cost and the survival associated with patients with HFRI. Our results highlight the urgent need to manage patients with HFRI at an early stage to reduce the significant mortality as well as substantial additional cost management. Special attention must be paid to the fall-related increasing drugs and to optimizing management of comorbidities.

Exploring the relationship between Alzheimer's disease severity and longitudinal costs.

OBJECTIVE: The joint impact of cognitive, functional, and behavioral statuses must be measured when exploring the impact of new drugs on Alzheimer's disease (AD) costs. There are very few recent studies of AD costs by all dimensions of disease severity. Our objective was to improve estimation of the relationship between AD severity and costs of AD care by using more comprehensive AD data severity and a large sample size. METHODS: Participants were community-dwelling AD patients recruited between 2003 and 2005 and followed annually during a 2-year period in 50 French memory clinics. We used the Resource Use in Dementia questionnaire to estimate costs from a societal perspective. We explored the presence of potential endogeneity bias by using instrumental variable regressions. RESULTS: Cognitive declines impacted informal costs more than medical and nonmedical costs, while functional declines impacted nonmedical costs more than medical and informal costs. Both cognitive and function declines increased the total costs of care. We found that the endogeneity of these variables led to a large underestimation of their impact of AD severity on costs. CONCLUSION: Potential endogeneity should be controlled for to prevent biased estimations of the impact of AD severity measures on costs.

Impact of formal care consumption on informal care use in Europe: What is happening at the beginning of dependency?

Little is known about care use decisions at the beginning of the disability process, when older people are vulnerable. This article investigates the impact of formal care (FC) consumption on informal care (IC) utilization in Europe in a population of frail older people. We use data from the Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies (SPRINTT) study, which involves a sample of 1515 elderly (70+) people surveyed in 11 European countries. We explore the impact of home-based FC use on IC use at the extensive and intensive margins. The use of FC is instrumented with a dichotomous variable reproducing the eligibility criteria for public home-based FC in each country. We show that receiving home-based FC positively and significantly affects the probability of using IC. Therefore, we conclude that home-based FC and IC are complementary at the beginning of the dependency process.

The Living Alone with Cognitive Impairment Project's Policy Advisory Group on Long-Term Services and Supports: Setting a Research Equity Agenda.

(1) Background: A United States national policy advisory group (PAG) was convened to identify barriers and facilitators to expand formal long-term services and support (LTSS) for people living alone with cognitive impairment (PLACI), with a focus on equitable access among diverse older adults. The PAG's insights will inform the research activities of the Living Alone with Cognitive Impairment Project, which is aimed at ensuring the equitable treatment of PLACI. (2) Methods: The PAG identified barriers and facilitators of providing effective and culturally relevant LTSS to PLACI via one-on-one meetings with researchers, followed by professionally facilitated discussions among themselves. (3) Results: The PAG identified three factors that were relevant to providing effective and culturally relevant LTSS to PLACI: (i) better characterization of PLACI, (ii) leveraging the diagnosis of cognitive impairment, and (iii) expanding and enhancing services. For each factor, the PAG identified barriers and facilitators, as well as directions for future research. (4) Conclusions: The barriers and facilitators the PAG identified inform an equity research agenda that will help inform policy change.

Are long-term care jobs harmful? Evidence from Germany.

Like many OECD countries, Germany is currently facing a shortage of long-term care (LTC) workers. This situation is concerning in the context of the ageing of the German population. A potential reason why Germany fails to recruit and retain LTC workers is that LTC jobs are particularly demanding (physical and psychological strain) which may be harmful to health. However, there is a lack of empirical evidence demonstrating this effect. This article fills the gap in the literature by exploring to what extent LTC jobs reduce workers' health over time. We estimate a dynamic panel data model on the German Socio-Economic Panel (v.35; 1984-2018), which allows adressing selection issues into occupations. Our paper provides innovative findings on the impact of LTC occupations on workers' health. We confirm that LTC jobs have a negative impact on self-reported health. Our results have strong policy implications: we emphasize the need to provide sufficient assistance to LTC workers, who are at risk of facing more health issues than other workers. This issue is key to increase the attractiveness of LTC jobs and reduce turnover in the LTC workforce.