Child health and its effect on adult social capital accumulation.

Although studies have demonstrated important effects of poor health in childhood on stocks of human and health capital, little research has tested economic theories to investigate the effect of child health on social capital in adulthood. Studies on the influence of child health on adult social capital are mixed and have not used sibling fixed effects models to account for unmeasured family and genetic characteristics, that are likely to be important. Using the Add-Health sample, health in childhood was assessed as self-rated health, the occurrence of a physical health condition or mental health condition, while social capital in adulthood was measured as volunteering, religious service attendance, team sports participation, number of friends, social isolation, and social support. We used sibling fixed effects models, which attenuated several associations to non-significance. In sibling fixed effects models there was significant positive effects of greater self-rated health on participation in team sports and social support, and negative effect of mental health in childhood on social isolation in adulthood. These results suggest that children with poor health require additional supports to build and maintain their stock of social capital and highlight further potential benefits to efforts that address poor child health.

COVID-19 Pandemic, Physical Distancing Policies, and the Non-Profit Sector Volunteer Force.

Although COVID-19-related physical distancing has had large economic consequences, the impact on volunteerism is unclear. Using volunteer position postings data from Canada's largest volunteer center (Volunteer Toronto) from February 3, 2020, to January 4, 2021, we evaluated the impact of different levels of physical distancing on average views, total views, and total number of posts. There was about a 50% decrease in the total number of posts that was sustained throughout the pandemic. Although a more restrictive physical distancing policy was generally associated with fewer views, there was an initial increase in views during the first lockdown where total views were elevated for the first 4 months of the pandemic. This was driven by interest in COVID-19-related and remote work postings. This highlights the community of volunteers may be quite flexible in terms of adapting to new ways of volunteering, but substantial challenges remain for the continued operations of many non-profit organizations.

Family health conditions and parental occupational status modify the relationship between pediatric-onset multiple sclerosis and parental health-related quality of life.

BACKGROUND: The health-related quality of life (HRQoL) of children with multiple sclerosis (MS) is mediated by the HRQoL of their parents. Understanding factors that modify the relationship between the child's MS diagnosis and parental HRQoL would inform interventions to improve the HRQoL of both parents and children living with MS. OBJECTIVE: We evaluated whether the association between an MS diagnosis during childhood and parental HRQoL is modified by the presence of a family health condition or low socioeconomic position (SEP). METHODS: Parents of children with MS or the transient illness, monophasic-acquired demyelinating syndromes (monoADS), were enrolled in a prospective Canadian study. Multivariable models evaluated whether the association between a child's MS diagnosis (vs. monoADS) and parental HRQoL was modified by ⩾1 family health conditions or low SEP. RESULTS: Two hundred seven parents and their children with MS (n = 65) or monoADS (n = 142) were included. We found a synergistic effect of an MS diagnosis and a family health condition on parental HRQoL. We also found a synergistic effect of having MS and a low SEP on parental HRQoL. CONCLUSION: Parents of children with MS who have another family health condition or a low SEP are at particularly high risk for low HRQoL.

Public drug insurance, moral hazard and children's use of mental health medication: Latent mental health risk-specific responses to lower out-of-pocket treatment costs.

Studies have shown that reducing out-of-pocket costs can lead to higher medication initiation rates in childhood. Whether the cost of such initiatives is inflated by moral hazard issues remains a question of concern. This paper looks to the implementation of a public drug insurance program in Québec, Canada, to investigate potential low-benefit consumption in children. Using a nationally representative longitudinal sample, we harness machine learning techniques to predict a child's risk of developing a mental health disorder. Using difference-in-differences analyses, we then assess the impact of the drug program on children's mental health medication uptake across the distribution of predicted mental health risk. Beyond showing that eliminating out-of-pocket costs led to a 3 percentage point increase in mental health drug uptake, we show that demand responses are concentrated in the top two deciles of risk for developing mental health disorders. These higher-risk children increase take-up of mental health drugs by 7-8 percentage points. We find even stronger effects for stimulants (8-11 percentage point increases among the highest risk children). Our results suggest that reductions in out-of-pocket costs could achieve better uptake of mental health medications, without inducing substantial low-benefit care among lower-risk children.

Health Reporting from Different Data Sources: Does it Matter for Mental Health?

BACKGROUND: Mental disorders are typically stigmatized conditions associated with negative stereotypes, which may lead individuals to underreport them. Thus, survey data may be subject to biases. Although administrative data has some limitations, it is an alternative data source that may be considered more objective. AIMS OF THE STUDY: This study aimed to identify the degree of agreement between survey and administrative health care data for mental health conditions, factors affecting underreporting, and whether underreporting also occurs for physical health conditions. METHODS: We used Ontario data from the Canadian Community Health Survey linked to health records to examine the presence of mental health conditions (i.e., schizophrenia and mood disorders) and select physical health conditions (i.e., diabetes and cancer). Using administrative data as the reference standard, we created four categories for each health condition based on the level of agreement between the two data sources: consistent cases and non-cases (i.e. individuals with concordant data based on their reported health condition), and people who were found to underreport and overreport a condition (i.e. where the condition was present in the administrative data, but not in the survey data and vice-versa, respectively). The overall level of agreement was assessed using Cohen's kappa statistic. Probit regressions were estimated to determine the factors affecting underreporting. RESULTS: The Kappa statistics for mood disorder was fair (k= 0.26) and moderate for schizophrenia (k = 0.49). Physical health conditions had higher kappa values (diabetes, k = 0.81; ever having cancer, k = 0.68), with the exception of currently having cancer (k = 0.24). Underreporting was highest for the most stigmatizing condition, schizophrenia (63%), followed by mood disorders (39%) and cancer (39%), and lowest for diabetes (25%). Older age, being born in Africa and Asia, and being employed all increased the probability of underreporting among individuals identified in the administrative data; the opposite held for social assistance. DISCUSSION: We extended previous work on mental health reporting by combining survey data with administrative data to examine the level of agreement between respondents' self-reported mental health and administrative records. The data include some mental disorders not studied previously. We examined the entire adult population; this is important because prevalence of schizophrenia may be less common among older population groups due to higher mortality among this patient population. Additionally, there may be potential age-related differences in stigma and mental health conditions. The administrative health data captured only health services covered by the public provincial health insurance plan and thus did not capture medical care provided by psychologists, social workers, and nurses. While this would affect Kappa statistic values, it does not directly affect the underreporting analyses. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Our results suggest that disclosure of mental health conditions may differ by the level of stigma, which has implications for obtaining accurate estimates of mental health prevalence from self-reported data sources.

The health-related quality of life of children with multiple sclerosis is mediated by the health-related quality of life of their parents.

BACKGROUND: We previously found that children with the chronic disease multiple sclerosis (MS) reported lower health-related quality of life (HRQoL) when compared to children who experienced the transient illness termed monophasic acquired demyelinating syndromes (monoADS). Parents of children with MS also reported lower HRQoL. OBJECTIVES: We evaluated whether parental HRQoL mediated the relationship between the diagnosis of MS and the HRQoL of affected children. To ascertain the effect of an MS diagnosis, we compared children with MS to those with monoADS. METHODS: Children were enrolled in a prospective multi-site Canadian study. Random effects models evaluated whether parental HRQoL mediated the relationship between the diagnosis of MS and the HRQoL of affected children, adjusting for child and family characteristics. RESULTS: 207 parent-child dyads (65 MS; 142 monoADS) completed HRQoL questionnaires. When we modeled the child's HRQoL adjusting for covariates, but not the parent's HRQoL, the diagnosis of MS associated with lower HRQoL of the child (p = 0.004). When we added parental HRQOL to the model, the association between the diagnosis of MS and the child's HRQoL diminished (p = 0.13). CONCLUSIONS: Parental HRQoL mediated the relationship between the diagnosis of MS and the HRQoL of affected children, emphasizing the importance of family-centered care.

ADHD misdiagnosis: Causes and mitigators.

ADHD diagnoses increase discontinuously by a child's school starting age, with young-for-grade students having much higher ADHD diagnostic rates. Whether these higher rates reflect over-diagnosis or under-diagnosis remains unknown. To decompose this diagnostic discrepancy, we exploit differences in parent and teacher pre-diagnostic assessments within a regression discontinuity strategy based on school starting age. We show that being young-for-grade or male generates over-assessment of symptoms specifically from teacher assessment. However, under-assessments of the oldest students in a grade, especially the oldest females, account for a large part of the observed school starting age assessment gap. We argue that this difference by sex and higher school starting age effects in lower-income schools may exacerbate known gaps in educational attainment by gender and socioeconomic status. Importantly, we fail to find evidence that teachers who receive special education training make such errors.

Evaluation of a Heart Failure Telemonitoring Program Through a Microsimulation Model: Cost-Utility Analysis.

BACKGROUND: Heart failure (HF) is a major public health issue in Canada that is associated with high prevalence, morbidity, and mortality rates and high financial and social burdens. Telemonitoring (TM) has been shown to improve all-cause mortality and hospitalization rates in patients with HF. The Medly program is a TM intervention integrated as standard of care at a large Canadian academic hospital for ambulatory patients with HF that has been found to improve patient outcomes. However, the cost-effectiveness of the Medly program is yet to be determined. OBJECTIVE: This study aims to conduct a cost-utility analysis of the Medly program compared with the standard of care for HF in Ontario, Canada, from the perspective of the public health care payer. METHODS: Using a microsimulation model, individual patient data were simulated over a 25-year time horizon to compare the costs and quality-adjusted life years (QALYs) between the Medly program and standard care for patients with HF treated in the ambulatory care setting. Data were sourced from a Medly Program Evaluation study and literature to inform model parameters, such as Medly's effectiveness in reducing mortality and hospitalizations, health care and intervention costs, and model transition probabilities. Scenario analyses were conducted in relation to HF severity and TM deployment models. One-way deterministic effectiveness analysis and probabilistic sensitivity analysis were performed to explore the impact on the results of uncertainty in model parameters. RESULTS: The Medly program was associated with an average total cost of Can $102,508 (US $77,626) per patient and total QALYs of 5.51 per patient compared with the average cost of Can $97,497 (US $73,831) and QALYs of 4.95 per patient in the Standard Care Group. This led to an incremental cost of Can $5011 (US $3794) and incremental QALY of 0.566, resulting in an incremental cost-effectiveness ratio of Can $8850 (US $6701)/QALY. Cost-effectiveness improved in relation to patients with advanced HF and with deployment models in which patients used their own equipment. Baseline and alternative scenarios consistently showed probabilities of cost-effectiveness greater than 85% at a willingness-to-pay threshold of Can $50,000 (US $37,718). Although the results showed some sensitivity to assumptions about effectiveness parameters, the intervention was found to remain cost-effective. CONCLUSIONS: The Medly program for patients with HF is cost-effective compared with standard care using commonly reported willingness-to-pay thresholds. This study provides evidence for decision makers on the use of TM for HF, supports the use of a nurse-led model of TM that embeds clinically validated algorithms, and informs the use of economic modeling for future evaluations of early-stage health informatics technology.

Smoking patterns based on birth-cohort-specific histories from 1965 to 2013, with projections to 2041.

BACKGROUND: Characterizing smoking patterns over time is essential for evaluating the impact of tobacco control interventions and predicting smoking-related mortality. Beginning with a 1920s birth cohort, smoking histories (i.e., estimates of smoking initiation and cessation, and prevalence of current and former smokers) were generated. DATA: The Ontario sample (n = 238,411) of the 2003 to 2013 cycles of the Canadian Community Health Survey, which is conducted biennially, was used to obtain cross-sectional information on current smoking behaviour. METHODS: Age at smoking initiation and age at smoking cessation were used to construct smoking histories for each respondent, up to the survey date. An age-period-cohort model was generated and used to examine survival differences by smoking status. Using the model, and adjusting for survival differences in smoking status, the prevalence of current, former and never smokers was estimated in cohorts from 1920 to 1985. Smoking initiation, cessation and intensity were then estimated for age-specific distributions of each birth cohort. These rates were projected forward through to 2041. Smoking patterns by highest level of education were generated using education-stratified models. RESULTS: Smoking histories show clear trends over time by sex, cohort and age. If current patterns persist, smoking prevalence is projected to decline to single digits (below 10%) by 2023 for women and 2040 for men. DISCUSSION: Birth-cohort-specific smoking histories can be generated using cross-sectional health surveys. These cohort histories can describe smoking patterns over time and into the future. In turn, these histories can be used in micro-simulation models to evaluate historic or planned tobacco control interventions, and to project smoking prevalence.

Pediatric-onset multiple sclerosis is associated with reduced parental health-related quality of life and family functioning.

BACKGROUND: Diagnosis of multiple sclerosis (MS) during childhood has the potential to impact the affected child's self-perception and the health-related quality of life (HRQoL) of the family. OBJECTIVE: To evaluate the impact of chronic disease, in children ascertained as having MS and their families, when compared to those with monophasic acquired demyelinating syndrome (monoADS). METHODS: In a national prospective cohort study of pediatric acquired demyelinating syndromes (ADS), the HRQoL of children and their families was captured using the Pediatric Quality of Life Inventory (PedsQL™) Modules. RESULTS: Participants (58 MS; 178 monoADS) provided cross-sectional HRQoL data a median (interquartile range (IQR)) of 4.1 (2.0-6.0) years after disease onset. The HRQoL of parents of children with MS and their family functioning was lower when compared to that of parents and families of children with monoADS (both p < 0.001); parents of children with MS reported greater emotional dysfunction, worry, worse communication, and lower family functioning irrespective of clinical disease activity. Self-reports of the MS and monoADS participants did not suggest a difference in overall HRQoL or fatigue after adjusting for age of the child at the time of assessment. CONCLUSION: While children with MS did not self-report lower HRQoL compared to children who experienced monoADS, the diagnosis of MS during childhood was negatively associated with parental HRQoL and family functioning.

The Association between Stroke, Integrated Stroke Systems, and the Employability and Productivity of Canadian Stroke Survivors.

BACKGROUND: Integrated stroke systems have been associated with reduced disability in stroke survivors, but their impact on employability and productivity (hours worked/week and hourly wages) of stroke survivors is unclear. METHODS: We used Canadian Community Health Surveys (2000-2014) to conduct a quasi-experimental study with the aim of determining the impact of stroke on employability and productivity, and whether the implementation of integrated stroke systems was associated with improvements in the employability and productivity of adult Canadian stroke survivors. Multivariable generalized Poisson regression models were used to determine the effect of stroke on employability; multivariable Heckman models were used to estimate the effect of stroke on productivity. A difference in differences analysis was used to determine the impact of stroke systems on the primary outcomes. RESULTS: The study sample included 400,797 respondents, of whom 5,786 (1.4%) were stroke survivors. Compared to the general population, stroke survivors were less likely to be employed (adjusted incidence rate ratio 0.62, 95% CI 0.59-0.66) and earned an hourly wage that was 5.3% lower (95% CI 1.1-9.3) and worked an average of 1.9 fewer hours per week (95% CI 0.9-2.9). Over the study period, the employability of stroke survivors improved but not productivity. After accounting for temporal changes in overall employment, there was no association between the implementation of integrated stroke systems and either employability or productivity. CONCLUSION: Employability of stroke survivors improved over the study period but remained lower than the general population, with no differences in provinces with and without integrated stroke systems.

Relationships between work outcomes, work attitudes and work environments of health support workers in Ontario long-term care and home and community care settings.

BACKGROUND: Our overarching study objective is to further our understanding of the work psychology of Health Support Workers (HSWs) in long-term care and home and community care settings in Ontario, Canada. Specifically, we seek novel insights about the relationships among aspects of these workers' work environments, their work attitudes, and work outcomes in the interests of informing the development of human resource programs to enhance elder care. METHODS: We conducted a path analysis of data collected via a survey administered to a convenience sample of Ontario HSWs engaged in the delivery of elder care over July-August 2015. RESULTS: HSWs' work outcomes, including intent to stay, organizational citizenship behaviors, and performance, are directly and significantly related to their work attitudes, including job satisfaction, work engagement, and affective organizational commitment. These in turn are related to how HSWs perceive their work environments including their quality of work life (QWL), their perceptions of supervisor support, and their perceptions of workplace safety. CONCLUSIONS: HSWs' work environments are within the power of managers to modify. Our analysis suggests that QWL, perceptions of supervisor support, and perceptions of workplace safety present particularly promising means by which to influence HSWs' work attitudes and work outcomes. Furthermore, even modest changes to some aspects of the work environment stand to precipitate a cascade of positive effects on work outcomes through work attitudes.

A Canadian Population-Based Cohort to the Study Cost and Burden of Surgically Resected Hidradenitis Suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic debilitating disease with long-lasting comorbidities that impose direct and indirect costs on the health care system. However, limited studies have estimated the burden of this disease in Canada, and no population-based studies have previously addressed this condition. OBJECTIVES: This work describes the characteristics of a population-based HS cohort to address the existing knowledge gap on the burden of HS for the Canadian health care system. This cohort will provide a foundation for further studies about clinical outcomes and risk factors of HS by providing opportunities for merging additional databases. METHODS: Data on demographic information, morbidities, relative resource use, and the cost of sectorial services were obtained from the Institute for Clinical Evaluative Sciences (ICES). All residents of Ontario covered by the Ontario Health Insurance Plan (OHIP) between April 1, 2002, and March 31, 2013, who underwent surgery for HS, defined by OHIP billing codes, were included. RESULTS: A total of 6244 cases were included in the analysis, following quality control procedures. Twice as many females were treated surgically relative to males. The majority of individuals treated were under the age of 64, with more than half having a moderate level of morbidity (according to Resource Utilization Bands defined by the Johns Hopkins Adjusted Clinical Group Classification System). CONCLUSIONS: This cohort study is the first population-based resource about HS in Canada. Administrative population-based databases provide essential information to assess the burden of chronic diseases and identify factors associated with higher cost.

Costs of health care across primary care models in Ontario.

BACKGROUND: The purpose of this study is to analyze the relationship between newly introduced primary care models in Ontario, Canada, and patients' primary care and total health care costs. A specific focus is on the payment mechanisms for primary care physicians, i.e. fee-for-service (FFS), enhanced-FFS, and blended capitation, and whether providers practiced as part of a multidisciplinary team. METHODS: Utilization data for a one year period was measured using administrative databases for a 10% sample selected at random from the Ontario adult population. Primary care and total health care costs were calculated at the individual level and included costs from physician services, hospital visits and admissions, long term care, drugs, home care, lab tests, and visits to non-medical health care providers. Generalized linear model regressions were conducted to assess the differences in costs between primary care models. RESULTS: Patients not enrolled with a primary care physicians were younger, more likely to be males and of lower socio-economic status. Patients in blended capitation models were healthier and wealthier than FFS and enhanced-FFS patients. Primary care and total health care costs were significantly different across Ontario primary care models. Using the traditional FFS as the reference, we found that patients in the enhanced-FFS models had the lowest total health care costs, and also the lowest primary care costs. Patients in the blended capitation models had higher primary care costs but lower total health care costs. Patients that were in multidisciplinary teams (FHT), where physicians are also paid on a blended capitation basis, had higher total health care costs than non-FHT patients but still lower than the FFS reference group. Primary care and total health care costs increased with patients' age, morbidity, and lower income quintile across all primary care payment types. CONCLUSIONS: The new primary care models were associated with lower total health care costs for patients compared to the traditional FFS model, despite higher primary care costs in some models.

Achalasia-Specific Quality of Life After Pneumatic Dilation or Laparoscopic Heller Myotomy With Partial Fundoplication: A Multicenter, Randomized Clinical Trial.

OBJECTIVES: Achalasia is a chronic, progressive, and incurable esophageal motility disease. There is clinical uncertainty about which treatment should be recommended as first-line therapy. Our objective was to evaluate the effectiveness of pneumatic dilation compared with laparoscopic Heller myotomy with partial fundoplication in improving achalasia-specific quality of life. METHODS: This was a prospective, multicenter, randomized trial at five academic hospitals in Canada. Fifty previously untreated adults with a clinical diagnosis of primary achalasia, confirmed by manometric testing, were enrolled between November 2005 and March 2010, and followed for 5 years after treatment. Randomization was stratified by site, in random blocks of size four and with balanced allocation. Patients were treated with pneumatic dilation or laparoscopic Heller myotomy with partial fundoplication. The primary outcome was the difference between the treatments in the mean improvement of the achalasia severity questionnaire (ASQ) score at 1 year from baseline. Prespecified secondary outcomes included general and gastrointestinal quality of life, symptoms, esophageal physiology measures (lower esophageal sphincter relaxation and pressure, esophageal emptying, abnormal esophageal acid exposure), complications, and incidence of retreatment. Functional and imaging studies were performed blinded and all outcome assessors were blinded. RESULTS: There were no significant differences between treatments in the improvement of ASQ score at 1 year from baseline (27.5 points in the Heller myotomy arm vs. 20.2 points in the pneumatic dilation arm; difference 7.3 points, 95% confidence interval -4.7 to 19.3; P=0.23). There were no differences between treatments in improvement of symptoms, general and gastrointestinal quality of life, or measures of esophageal physiology. Improvements in ASQ score diminished over time for both interventions. At 5 years, there were no differences between treatments in improvement of ASQ score, symptoms, and general or gastrointestinal quality of life. There were no serious adverse events. No patient who received Heller myotomy required retreatment, whereas five patients treated initially with pneumatic dilation required retreatment. CONCLUSIONS: Treatment with pneumatic dilation or laparoscopic Heller myotomy similarly improves achalasia-specific disease severity at 1 year. Either of the therapeutic approaches can be used as first-line therapy for previously untreated adults with achalasia.

Lost Productivity in Stroke Survivors: An Econometrics Analysis.

BACKGROUND: Stroke leads to a substantial societal economic burden. Loss of productivity among stroke survivors is a significant contributor to the indirect costs associated with stroke. We aimed to characterize productivity and factors associated with employability in stroke survivors. METHODS: We used the Canadian Community Health Survey 2011-2012 to identify stroke survivors and employment status. We used multivariable logistic models to determine the impact of stroke on employment and on factors associated with employability, and used Heckman models to estimate the effect of stroke on productivity (number of hours worked/week and hourly wages). RESULTS: We included data from 91,633 respondents between 18 and 70 years and identified 923 (1%) stroke survivors. Stroke survivors were less likely to be employed (adjusted OR 0.39, 95% CI 0.33-0.46) and had hourly wages 17.5% (95% CI 7.7-23.7) lower compared to the general population, although there was no association between work hours and being a stroke survivor. We found that factors like older age, not being married, and having medical comorbidities were associated with lower odds of employment in stroke survivors in our sample. CONCLUSIONS: Stroke survivors are less likely to be employed and they earn a lower hourly wage than the general population. Interventions such as dedicated vocational rehabilitation and policies targeting return to work could be considered to address this lost productivity among stroke survivors.

Towards a Community-Based Dementia Care Strategy: How Do We Get There from Here?

As recent policy reports in Ontario and elsewhere have emphasized, most older persons would prefer to age at home. This desire does not diminish for the growing numbers of persons living with dementia (PLWD). Nevertheless, many PLWD end up in residential long-term care (LTC) or in hospital beds. While LTC is valuable for PLWD with highly progressed cognitive and functional impairment requiring high-intensity care, it can be a costly and avoidable option for those who could remain at home if given early access to a coordinated mix of community-based supports. In this lead paper, we begin by exploring the "state of the art" in community-based care for PLWD, highlighting the importance of early and ongoing intervention. We then offer a brief history of dementia care policy in Ontario as an illustrative case study of the challenges faced by policy makers in all jurisdictions as they aim to re-direct healthcare systems focused on "after-the-fact" curative care towards "before-the-fact" prevention and maintenance in the community. Drawing on results from a "balance of care" study, which we conducted in South West Ontario, we examine how, in the absence of viable community-based care options, PLWD can quickly "default" to institutional care. In the final section, we draw from national and international experience to identify the following three key strategic pillars to guide action towards a community-based dementia care strategy: engage PLWD to the extent possible in decisions around their own care; acknowledge and support informal caregivers in their pivotal roles supporting PLWD and consequently the formal care; and enable "ground-up" change through policies and funding mechanisms designed to ensure early intervention across a continuum of care with the aim of maintaining PLWD and their caregivers as independently as possible, for as long as possible, "closer to home."

Do public smoking bans have an impact on active smoking? Evidence from the UK.

The literature on the effects of public smoking bans on smoking behaviour presents conflicting results and there is limited evidence on their impact on active smoking. This paper evaluates the impact of smoking bans on active smoking using data from the British Household Panel Survey and exploiting the policy experiment provided by the differential timing of the introduction of the bans in Scotland and England. We assess the short-term impact of the smoking bans by employing a series of flexible difference-in-differences fixed effects panel data models. We find that the introduction of the public smoking bans in England and Scotland had limited short-run effects on both smoking prevalence and the total level of smoking. Although we identify significant differences in trends in smoking consumption across the survey period by population sub-groups, we find insufficient evidence to conclude that these were affected by the introduction of the smoking bans. These results challenge those found in the public health literature but are in line with the most recent strand of economic literature indicating that there is no firm evidence on the effects of smoking bans on smoking.

Paying for Primary Care: The Factors Associated with Physician Self-selection into Payment Models.

To determine the factors associated with primary care physician self-selection into different payment models, we used a panel of eight waves of administrative data for all primary care physicians who practiced in Ontario between 2003/2004 and 2010/2011. We used a mixed effects logistic regression model to estimate physicians' choice of three alternative payment models: fee for service, enhanced fee for service, and blended capitation. We found that primary care physicians self-selected into payment models based on existing practice characteristics. Physicians with more complex patient populations were less likely to switch into capitation-based payment models where higher levels of effort were not financially rewarded. These findings suggested that investigations aimed at assessing the impact of different primary care reimbursement models on outcomes, including costs and access, should first account for potential selection effects.

Genetic endowments for social capital: An investigation accounting for genetic nurturing effects.

Despite social capital having been shown to be important for health and well-being, relatively little research has examined genetic determinants. Genetic endowments for education have been shown to influence human, financial, and health capital, but few studies have examined social capital, and those conducted have yet to account for genetic nurturing. We used the Add-Health data to study the effect of genetic endowments on individual social capital using the education polygenic score (PGS). We used sibling fixed effects models and controlled for the family environment to account for genetic nurturing. After accounting for the family environment, we found moderately large significant associations between the education PGS and volunteering, but associations with religious service attendance and number of friends were completely attenuated in sibling fixed effects models. These findings highlight that genetic endowments play an important role in influencing volunteering and the importance of accounting for genetic nurturing.