Using Crowd-Sourced Data to Assess the Temporal and Spatial Relationship between Indoor and Outdoor Particulate Matter.

Using hourly measures across a full year of crowd-sourced data from over 1000 indoor and outdoor pollution monitors in the state of California, we explore the temporal and spatial relationship between outdoor and indoor particulate matter (PM) concentrations for different particle sizes. The scale of this study offers new insight into both average penetration rates and drivers of heterogeneity in the outdoor-indoor relationship. We find that an increase in the daily outdoor PM concentration of 10% leads to an average increase of 4.2-6.1% in indoor concentrations. The penetration of outdoor particles to the indoor environment occurs rapidly and almost entirely within 5 h. We also provide evidence showing that penetration rates are associated with building age and climatic conditions in the vicinity of the monitor. Since people spend a substantial amount of each day indoors, our findings fill a critical knowledge gap and have significant implications for government policies to improve public health through reductions in exposure to ambient air pollution.

Early-Life Exposure to the Great Smog of 1952 and the Development of Asthma.

RATIONALE: Little is known about the long-term effects of air pollution exposure and the root causes of asthma. We use exposure to intense air pollution from the 1952 Great Smog of London as a natural experiment to examine both issues. OBJECTIVES: To determine whether exposure to extreme air pollution in utero or soon after birth affects asthma development later in life. METHODS: This was a natural experiment using the unanticipated pollution event by comparing the prevalence of asthma between those exposed to the Great Smog in utero or the first year of life with those conceived well before or after the incident and those residing outside the affected area at the time of the smog. MEASUREMENTS AND MAIN RESULTS: Prevalence of asthma during childhood (ages 0-15) and adulthood (ages >15) is analyzed for 2,916 respondents to the Life History portion of the English Longitudinal Study on Aging born from 1945 to 1955. Exposure to the Great Smog in the first year of life increases the likelihood of childhood asthma by 19.87 percentage points (95% confidence interval [CI], 3.37-36.38). We also find suggestive evidence that early-life exposure led to a 9.53 percentage point increase (95% CI, -4.85 to 23.91) in the likelihood of adult asthma and exposure in utero led to a 7.91 percentage point increase (95% CI, -2.39 to 18.20) in the likelihood of childhood asthma. CONCLUSIONS: These results are the first to link early-life pollution exposure to later development of asthma using a natural experiment, suggesting the legacy of the Great Smog is ongoing.

The mobility of elite life scientists: Professional and personal determinants

As scientists' careers unfold, mobility can allow researchers to find environments where they are more productive and more effectively contribute to the generation of new knowledge. In this paper, we examine the determinants of mobility of elite academics within the life sciences, including individual productivity measures and for the first time, measures of the peer environment and family factors. Using a unique data set compiled from the career histories of 10,051 elite life scientists in the U.S., we paint a nuanced picture of mobility. Prolific scientists are more likely to move, but this impulse is constrained by recent NIH funding. The quality of peer environments both near and far is an additional factor that influences mobility decisions. We also identify a significant role for family structure. Scientists appear to be unwilling to move when their children are between the ages of 14­17, and this appears to be more pronounced for mothers than fathers. These results suggest that elite scientists find it costly to disrupt the social networks of their children during adolescence and take these costs into account when making career decisions.

Something in the water: contaminated drinking water and infant health.

This paper provides estimates of the effects of in utero exposure to contaminated drinking water on fetal health. To do this, we examine the universe of birth records and drinking water testing results for the state of New Jersey from 1997 to 2007. Our data enable us to compare outcomes across siblings who were potentially exposed to differing levels of harmful contaminants from drinking water while in utero. We find small effects of drinking water contamination on all children, but large and statistically significant effects on birth weight and gestation of infants born to less educated mothers. We also show that those mothers who were most affected by contamination were the least likely to move between births in response to contamination.

AIDS Treatment and Intrahousehold Resource Allocation: Children's Nutrition and Schooling in Kenya.

The provision of antiretroviral medications is a central component of the response to HIV/AIDS and consumes substantial public resources from around the world, but little is known about this intervention's impact on the welfare of children in treated persons' households. Using longitudinal survey data from Kenya, we examine the relationship between the provision of treatment to adults and the schooling and nutrition outcomes of children in their households. Weekly hours of school attendance increase by over 20 percent within six months after treatment is initiated for the adult patient. We find some weak evidence that young children's short-term nutritional status also improves. These results suggest how intrahousehold allocations of time and resources may be altered in response to health improvements of adults.

Analysis of Educational Debt and Income Among Pharmacists and Other Health Professionals.

Objective. To evaluate educational debt-to-income trends in pharmacy, dentistry, medicine, optometry, and veterinary medicine in the United States from 2010 to 2016. Methods. A retrospective analysis of educational debt and income for selected health professions was conducted. Data on student loan debt were collected from professional organizations and data on income were collected from the American Community Survey. Ratios of the mean educational debt of graduating students to the median annual income for their respective profession were calculated for 2010 through 2016. Average change per year in debt, income, and debt-to-income ratio were calculated. Results. Debt-to-income ratios for all selected health professions except medicine exceeded 100%. For physicians, debt-to-income ratios ranged from 89% to 95%. On average, physicians (-0.3 percentage point) and optometrists (-0.5 percentage point) had negative changes in their debt-to-income ratios from 2010 to 2016. Average increases per year in debt-to-income ratio of veterinarians, pharmacists, and dentists were 5.5, 5.7, and 6.0 percentage points, respectively. From 2010 to 2016, dentists had the largest average increase per year in debt ($10,525), while physicians had the largest average increase per year in income ($6667) and a minimal average debt increase per year ($5436). Pharmacists had the second largest average increase per year in debt ($8356). Conclusion. Educational debt-to-income ratios in the United States increased considerably over the past decade among pharmacists, dentists, and veterinarians and can negatively impact health professionals as well as patient care. Innovative strategies are needed to alleviate the educational debt burden.

Global drug-resistance patterns and the management of latent tuberculosis infection in immigrants to the United States.

BACKGROUND: In the United States, an increasingly disproportionate burden of tuberculosis among the foreign-born population has led to calls for improvements in the detection and treatment of latent infection in new immigrants. Current treatment guidelines do not take into account global differences in drug-resistance patterns or their implications for the treatment of immigrants. The use of multinational surveillance systems to guide the management of latent infection according to region-specific drug-resistance profiles could improve the efficiency of efforts to reduce the burden of tuberculosis in immigrants to the United States. METHODS: We constructed a decision-analysis model by using a hypothetical cohort of all documented immigrants entering the United States from developing nations. Region-specific drug-resistance profiles were derived from data on 30,388 cases of infection. The model examined the effectiveness and cost effectiveness of four strategies: no intervention or tuberculin skin testing followed by treatment with isoniazid, treatment with rifampin, or treatment with rifampin plus pyrazinamide for those with a positive test result. RESULTS: A strategy of detecting and treating latent tuberculosis infection was cost-saving among immigrants from Mexico, Haiti, sub-Saharan Africa, South Asia, and developing nations in East Asia and the Pacific. This strategy was highly cost effective among immigrants from other developing nations. Rifampin plus pyrazinamide was the preferred strategy for treating latent infection in immigrants from Vietnam, Haiti, and the Philippines. CONCLUSIONS: For new immigrants to the United States from developing nations, a strategy of detecting and treating latent tuberculosis infection would lead to substantial health and economic benefits. Because of the high prevalence of resistance to isoniazid, treatment with a rifampin-containing regimen should be strongly considered for immigrants from Vietnam, Haiti, and the Philippines.

Cost-effectiveness of preventive strategies for women with a BRCA1 or a BRCA2 mutation.

BACKGROUND: For BRCA1 or BRCA2 mutation carriers, decision analysis indicates that prophylactic surgery or chemoprevention leads to better survival than surveillance alone. OBJECTIVE: To evaluate the cost-effectiveness of the preventive strategies that are available to unaffected women carrying a single BRCA1 or BRCA2 mutation with high cancer penetrance. DESIGN: Markov modeling with Monte Carlo simulations and probabilistic sensitivity analyses. DATA SOURCES: Breast and ovarian cancer incidence and mortality rates, preference ratings, and costs derived from the literature; the Surveillance, Epidemiology, and End Results (SEER) Program; and the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services). TARGET POPULATION: Unaffected carriers of a single BRCA1 or BRCA2 mutation 35 to 50 years of age. TIME HORIZON: Lifetime. PERSPECTIVE: Health policy, societal. INTERVENTIONS: Tamoxifen, oral contraceptives, bilateral salpingo-oophorectomy, mastectomy, both surgeries, or surveillance. OUTCOME MEASURES: Cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: For mutation carriers 35 years of age, both surgeries (prophylactic bilateral mastectomy and oophorectomy) had an incremental cost-effectiveness ratio over oophorectomy alone of 2352 dollars per life-year for BRCA1 and 100 dollars per life-year for BRCA2. With quality adjustment, oophorectomy dominated all other strategies for BRCA1 and had an incremental cost-effectiveness ratio of 2281 dollars per life-year for BRCA2. RESULTS OF SENSITIVITY ANALYSIS: Older age at intervention increased the cost-effectiveness of prophylactic mastectomy for BRCA1 mutation carriers to 73,755 dollars per life-year. Varying the penetrance, mortality rates, costs, discount rates, and preferences had minimal effects on outcomes. LIMITATIONS: Results are dependent on the accuracy of model assumptions. CONCLUSION: On the basis of this model, the most cost-effective strategies for BRCA mutation carriers, with and without quality adjustment, were oophorectomy alone and oophorectomy and mastectomy, respectively.

Health Shocks and Natural Resource Management: Evidence from Western Kenya.

Poverty and altered planning horizons brought on by the HIV/AIDS epidemic can change individual discount rates, altering incentives to conserve natural resources. Using longitudinal household survey data from western Kenya, we estimate the effects of health status on investments in soil quality, as indicated by households' agricultural land fallowing decisions. We first show that this effect is theoretically ambiguous: while health improvements lower discount rates and thus increase incentives to conserve natural resources, they also increase labor productivity and make it more likely that households can engage in labor-intensive resource extraction activities. We find that household size and composition are predictors of whether the effect of health improvements on discount rates dominates the productivity effect, or vice-versa. Since households with more and younger members are better able to reallocate labor to cope with productivity shocks, the discount rate effect dominates for these households and health improvements lead to greater levels of conservation. In smaller families with less substitutable labor, the productivity effect dominates and health improvements lead to greater environmental degradation.

How do doctors behave when some (but not all) of their patients are in managed care?

Most physicians today treat a variety of patients within their practices where a variety of insurance arrangements co-exist. In this paper, we propose several theoretical explanations for physician treatment patterns when the patient population is heterogeneous at the practice level. Data from the 1993-1996 National Ambulatory Medical Care Survey (NAMCS) are used to test how practice level managed care penetration affects treatment intensity. Practice composition has strong effects on treatment. Visit duration appears to be constant across patients within a practice, while medications prescribed appear to be converging as managed care penetration increases.

To err on humans is not benign. Incentives for adoption of medical error-reporting systems.

Concerns about frequent and harmful medical errors have led policy makers to advocate the creation of a system for medical error reporting. Health providers, fearing that reported information about errors would be used against them under the current medical malpractice system, have been reluctant to participate in such reporting systems. We propose a re-design of the malpractice system -- one in which penalties are a function of the health provider's reporting efforts -- to overcome this incentive problem. We also consider some alternatives to this mechanism that address two important ways in which reporting effort may not be observable: hospitals may have interests distinct from individual physicians and may not be able to observe their reporting efforts, and a regulatory agency or a court may not be able to adequately observe reporting efforts by a provider.

Effectiveness and cost-effectiveness of four treatment modalities for substance disorders: a propensity score analysis.

OBJECTIVE: To assess the effectiveness and cost-effectiveness of four treatment modalities for substance abuse. DATA SOURCES: The study used data from the Services Research Outcomes Study (SROS), a survey of 3,047 clients in a random sample of 99 drug treatment facilities across the United States. Detailed sociodemographic, substance use, and clinical data were abstracted from treatment records. Substance abuse outcome and treatment history following discharge from index facilities were assessed using a comprehensive interview with 1,799 of these individuals five years after discharge. Treatment success was defined in two ways: as abstinence and as any reduction in substance use. STUDY DESIGN: Effectiveness and cost-effectiveness of four modalities were compared: inpatient, residential, outpatient detox/methadone, and outpatient drug-free. Clients were stratified based on propensity scores and analyses were conducted within these strata. Sensitivity analyses examined the impact of future substance abuse treatment on effectiveness and cost-effectiveness estimates. PRINCIPAL FINDINGS: Treatment of substance disorders appears to be cost-effective compared to other health interventions. The cost per successfully treated abstinent case in the least costly modality, the outpatient drug-free programs, was 6,300 dollars (95 percent confidence intervals: 5,200-7,900 dollars) in 1990 dollars. There were only minor differences between various modalities of treatment with regard to effectiveness. However, modalities varied considerably with regard to cost-effectiveness. Outpatient drug-free programs were the most cost-effective. There was little evidence that relative effectiveness or cost-effectiveness of programs varied according to factors that were associated with selection into different programs. CONCLUSIONS: Substance disorders can be treated most cost-effectively in outpatient drug-free settings. Savings from transitioning to the most cost-effective treatment modality may free resources that could be reinvested to improve access to substance abuse treatment for a larger number of individuals in need of such treatment.

Addressing risk preferences in cost-effectiveness analyses.

Cost-effectiveness analysis is a form of economic evaluation that compares that compares the costs and effectiveness of health interventions, where effectiveness is measured in a single scale. Despite the growth in the popularity of cost-effectiveness analysis, very few cost-effectiveness analyses adequately measure and account for uncertainty. In the health economics literature, two schools of thought are emerging. The first takes a statistical approach to uncertainty by focusing on the likelihood that a decision making error will be made. The second approach applies and develops economic theories of risk preference that consider the welfare implications for a patient when they are presented with interventions that have uncertain health outcomes. Cost-effectiveness analyses need to account for risk preferences if they claim to be increasing patient welfare.

The Effect of Absenteeism and Clinic Protocol on Health Outcomes: The Case of Mother-to-Child Transmission of HIV in Kenya.

Absenteeism of health workers in developing countries is widespread with some estimates indicating rates of provider absence of nearly 40% (Chaudhury et. al. 2006). This is the first paper to present evidence of the impact of health provider absence combined with limitations in health clinic protocol on health outcomes. Using longitudinal data from nearly 600 ante-natal care seekers at a rural ante-natal clinic in Western Kenya, we find that nurse absence on a patient's first visit significantly reduces the probability that a woman tests for HIV over her entire pregnancy. Since the benefits of PMTCT services depend on HIV status, we proxy HIV status with self-reported pre-test expectations of being HIV-positive and estimate the heterogeneous impact of absence based on these self-reported expectations. We find that women with a high pre-test expectation of testing HIV-positive and whose first ANC visit coincides with nurse attendance are 25 percentage points more likely to deliver in a hospital or health center, 7.4 percentage points more likely to receive PMTCT medication, 9 percentage points less likely to breastfeed and 10 percentage points more likely to enroll in the free AIDS treatment program at the clinic than similar women whose first visit coincides with nurse absence. The procedural shortcomings in our study setting, shortcomings that do not enable pregnant women to test on a subsequent clinic visit, appear common in other countries in sub-Saharan Africa. They suggest that nurse absence in the context of this medical system translates into sizable reductions in child and maternal health.

Health and labor supply in the context of HIV/AIDS: the long-run economic impacts on antiretroviral therapy().

Using longitudinal survey data collected in Kenya, this paper estimates the longer-term impacts of antiretroviral therapy (ART) on the labor supply of treated adults and their household members. Building upon previous work in Kenya, data collected from 2004-2006 indicate that early evidence on the short-run impacts of ART tends to be upheld over the long-term as well. The results show that the labor supply response among treated adults occurs rapidly and is sustained through the 3-year observation period in our study. These results underscore the strong relationship between health and labor supply that has been observed in other contexts.

Behavioral Responses of Patients in AIDS Treatment Programs: Sexual Behavior in Kenya.

We estimate changes in sexual behavior for HIV-positive individuals enrolled in an AIDS treatment program using longitudinal household survey data collected in western Kenya. We find that sexual activity is lowest at the time that treatment is initiated and increases significantly in the subsequent six months, consistent with the health improvements that result from ART treatment. More importantly, we find large and significant increases of 10 to 30 percentage points in the reported use of condoms during last sexual intercourse. The increases in condom use appear to be driven primarily by a program effect, applying to all HIV clinic patients regardless of treatment status.

ARV Treatment and Time Allocation to Household Tasks: Evidence from Kenya.

Using longitudinal survey data collected over a period of two years, this paper examines the impact of antiretroviral (ARV) treatment on the time allocated to various household tasks by treated HIV-positive patients and their household members. We study outcomes such as time devoted to housework, firewood and water collection, as well as care-giving and care-seeking. As treatment improves the health and productivity of patients, we find that female patients in particular are able to increase the amount of time they devote to water and firewood collection. This increased productivity of patients coupled with large decreases in the amount of time they spend seeking medical care leads to a reduced burden on children and other household members. We find evidence that boys and girls in treated patients' households devote less time to housework and other chores. These results suggest that the provision of ARV treatment generates a wide variety of benefits to households in resource-poor settings.