Long-Term Health Benefits of Occupational Licensing: Evidence from Midwifery Laws.

During the late 19th and early 20th century, several states mandated midwifery licensing requirements to improve midwives' knowledge, education, and quality. Previous studies point to the health benefits of midwifery quality improvements for maternal and infant health outcomes. This paper exploits the staggered adoption of midwifery laws across states using event-study and difference-in-difference frameworks. We use the universe of death records in the US over the years 1979-2020 and find that exposure to a midwifery licensing law at birth is associated with a 2.5 percent reduction in cumulative mortality rates and an increase of 0.6 months in longevity during adulthood and old age. The effects are concentrated on deaths due to infectious diseases, neoplasm diseases, and suicide mortality. We also show that the impacts are confined among blacks and are slightly larger among males. Additional analyses using alternative data sources suggest small but significant increases in educational attainments, income, measures of socioeconomic status, employment, and measures of height as potential mechanism channels. We provide a discussion on the economic magnitude and policy implication of the results.

Outcomes of acupuncture for chronic pain in urban primary care.

PURPOSE: The purpose of this study was to describe outcomes of the Acupuncture to Decrease Disparities in Outcomes of Pain Treatment (ADDOPT) trial, testing acupuncture as an adjunct to usual treatment for chronic pain in urban health centers. METHOD: We conducted a quasi-experimental trial. Primary care patients (>21 years old) with chronic pain caused by osteoarthritis or neck or back pain at 4 hospital-owned safety net health centers in the Bronx, New York, received weekly acupuncture treatments provided by supervised acupuncture students for up to 14 weeks. Pain and functional status were assessed during a 6-week run-in period before acupuncture, during treatment, and after treatment. RESULTS: Of 495 referred patients, 226 (47%) initiated acupuncture. Back pain was the most common referring diagnosis (59.5%) followed by osteoarthritis (16.3%). Patients were older (mean age, 54.3 years), mostly insured by Medicaid (60.4%), often receiving disability (38.3%), and often in poor or fair overall health (46.7%). They had high baseline levels of pain (mean severity per the Brief Pain Inventory, 6.8; mean days with pain, 12.3 of 14). The mean number of treatments was 9.7 (standard deviation, 7.3). Pain severity improved from baseline (6.8 vs. 5.6 at 12 weeks and 5.5 at 24 weeks), as did physical well-being (31.8 vs. 35.7 at 12 weeks and 35.3 at 24 weeks). Using hierarchical linear modeling methods, reduction in pain severity between baseline and the treatment phase was significant (P < .001). Improvements in physical well-being were significant at 12 and 24 weeks after baseline (P < .001). CONCLUSIONS: Referred primary care patients experienced high levels of pain and pain-related disability. Weekly acupuncture was associated with short-term improvements in pain and quality of life.

The ADDOPT study (Acupuncture to Decrease Disparities in Outcomes of Pain Treatment): feasibility of offering acupuncture in the community health center setting.

OBJECTIVES: This article describes the feasibility and acceptability of the Acupuncture to Decrease Disparities in Outcomes of Pain Treatment (ADDOPT) trial, which incorporates acupuncture as an adjunct to usual treatment for chronic pain in urban health centers. DESIGN: The study assessed feasibility (ability to carry out in real-world practice; adequacy of resources; acceptability to patients, acupuncturists, and primary care clinicians). SETTING: Four (4) community health centers in the Bronx, NY, participating in the New York City Research and Improvement Networking Group (NYC RING), a practice-based research network dedicated to decreasing health disparities through primary care research and quality improvement in the urban safety net setting, were involved. SUBJECTS: The subjects comprised participants receiving care for chronic pain due to osteoarthritis, or neck or back pain at four Bronx health centers serving low-income families. INTERVENTION: The intervention involved up to 14 weekly acupuncture treatments. OUTCOME MEASURES: Pain and functional status are assessed during a 6-week run-in period before, during, and postacupuncture treatment using the Brief Pain Inventory and the 12-Item Short Form Health Survey. This article reports on baseline status, referral and recruitment, engagement with treatment, and delivery of the intervention across sites. RESULTS: Of 400 patients referred, 185 have initiated treatment. The majority of attending physicians have referred, most commonly for back pain (n=103; 60.6%). Participants' average age is 53.9 (standard deviation [SD] 14.1); 54.1% are Hispanic; and 57.6% are on Medicaid. Half (48%) report "poor" or "fair" overall health. Patients report an average disability score of 74 (SD 27.0) and baseline pain severity on the Brief Pain Inventory of 6 (SD 1.9). Patients have completed a mean of 8.0 (SD 4.7) treatments; 72.4% complete >5 sessions. CONCLUSIONS: Clinicians in this urban setting have incorporated acupuncture into chronic pain management. Despite disability and lack of familiarity, patients initiate acupuncture and show high levels of engagement with treatment.

Students as patients and teachers: evaluation of an experiential emergency contraception project.

BACKGROUND AND OBJECTIVES: Students on a required family medicine clerkship participated in an experiential project designed to teach them about emergency contraception (EC). This study describes students' changes in knowledge and attitudes about barriers to care after assuming the patient role and presenting their findings to peers and after hearing a presentation about EC from their peers. METHODS: This mixed-methods study used quantitative measures of knowledge and attitudes about EC before and after the students' family medicine clerkship. Qualitative in-depth interviews were conducted with all students who self-selected the EC Project and assumed the role of a patient and then taught their peers. RESULTS: All student groups showed improvement in knowledge and attitude scores, though gains were not statistically significant. Students who participated in the EC Project reported multiple benefits related to (1) assuming the role of the patient, (2) engaging in an experiential learning process, (3) teaching their peers, and (4) considering their future role as clinicians. CONCLUSIONS: Our findings demonstrate that playing the role of a patient and teaching their peers are valuable learning experiences, and students can learn well during peer-taught sessions. Students increased their medical knowledge and sensitivity to the barriers that patients face and began to consider their role in improving systems of health care.