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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The Economic Impact of AIDS Treatment: Labor Supply in Western Kenya.

Using longitudinal survey data collected in collaboration with a treatment program, this paper estimates the economic impacts of antiretroviral treatment. The responses in two outcomes are studied: (1) labor supply of treated adult AIDS patients; and (2) labor supply of individuals in patients' households. Within six months after treatment initiation, there is a 20 percent increase in the likelihood of the patient participating in the labor force and a 35 percent increase in weekly hours worked. Young boys in treated patients' households work significantly less after treatment initiation, while girls and adult household members do not change their labor supply.

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.

Cost-effectiveness of single-level anterior cervical discectomy and fusion for cervical spondylosis.

STUDY DESIGN: Cost-effectiveness analysis with retrospective cost analysis and literature review. OBJECTIVE: To determine the relative cost-effectiveness of anterior cervical discectomy and fusion (ACDF) with autograft, allograft, and allograft with plating for single-level anterior cervical spondylosis. SUMMARY OF BACKGROUND DATA: There are several accepted methods of surgically treating single-level cervical spondylosis anteriorly. No study has clearly demonstrated the superiority of one method over the alternatives. The techniques may differ in their operative risks and resource use, perioperative complications, short-term outcome, and long-term outcome and complications. Formal cost-effectiveness analysis (CEA) provides a structure for analyzing many variables and comparing different treatment outcomes. Sensitivity analysis is used to test the robustness of the model and to determine variables that have significant effects on the results. Future areas of research and refinements of the CEA model can be developed from these findings. METHODS: A retrospective review of hospital charges was performed for 78 patients who underwent single-level ACDF with allograft alone or ACDF with allograft and plating (ACDFP). The charges were converted to estimated costs for fiscal year 2000 using the ratio of costs to charges method. A CEA model was developed consisting of a decision-analysis model for the first year postsurgery and a Markov model for the next 4 years after surgery. Probabilities and outcome utilities were estimated from the literature. Outcome was measured in quality-adjusted life years (QALYs), and incremental CEA was performed. Several variables were tested in one-way sensitivity analysis. RESULTS: Compared with ACDF with autograft, ACDF with allograft offered an improvement in quality of life at a cost of 496 dollars per QALY. ACDFP provided additional gains in quality of life compared with ACDF with allograft at a cost of 32,560 dollars per QALY in the base case analysis. In sensitivity analysis, these estimates varied between 417 dollars and 741 dollars per QALY and between 19,090 dollars per QALY and domination of ACDFP by ACDF with allograft, respectively. The results were most sensitive to assumptions regarding differences in the length of the postoperative recovery period. CONCLUSIONS: ACDF with allograft offers a benefit relative to ACDF with autograft at a cost of 496 dollars per QALY. ACDFP has a benefit relative to ACDF with allograft at an approximate cost of 32,560 dollars per QALY. CEA provides a method for comparing the benefits and risks of these three procedures. Further research needs to be performed regarding these procedures, particularly examining the postoperative recovery period.

Managing febrile respiratory illnesses during a hypothetical SARS outbreak.

Since the World Health Organization declared the global outbreak of severe acute respiratory syndrome (SARS) contained in July 2003, new cases have periodically reemerged in Asia. This situation has placed hospitals and health officials worldwide on heightened alert. In a future outbreak, rapidly and accurately distinguishing SARS from other common febrile respiratory illnesses (FRIs) could be difficult. We constructed a decision-analysis model to identify the most efficient strategies for managing undifferentiated FRIs within a hypothetical SARS outbreak in New York City during the season of respiratory infections. If establishing reliable epidemiologic links were not possible, societal costs would exceed 2.0 billion US dollars per month. SARS testing with existing polymerase chain reaction assays would have harmful public health and economic consequences if SARS made up <0.1% of circulating FRIs. Increasing influenza vaccination rates among the general population before the onset of respiratory season would save both money and lives.

How will employers respond to coverage reforms.

Any change in the health insurance market could prompt a reaction by employers in what kind and at what cost they offer coverage. This policy brief examines the research on employer decision-making. Key findings include: Firms are most likely to offer plans that respond to the preferences of their most valuable, hard-to-retain workers. Firms are more likely to offer health insurance if they employ high-wage workers; if they are unionized; or if they are in the manufacturing or public sectors. While theory suggests that employers will shift the cost of premiums to employees in the form of lower wages, this is not the case in practice. There are serious gaps in research, including: an absence of detailed data about individuals; little information about earnings distribution; ages and other characteristics within firms of different sizes; and little study of employer behavior.

Outcome versus service based payments in health care: lessons from African traditional healers.

We compare the more common physician compensation method of fee-for-service to the less common payment-for-outcomes method. This paper combines an investigation of the theoretical properties of both of these payment regimes with a unique data set from rural Cameroon in which patients can choose between outcome and service based payments. We show that consideration of the role of patient effort in the production of health leads to important differences in the performance of these contracts. Theory and empirical evidence show that when illnesses require (or are responsive to) large amounts of both patient and practitioner effort, outcome based payment schemes are superior to effort based schemes. The traditional healer--a practitioner who offers health services on an outcome-contingent basis--is advanced as an important example of how patient effort can be better understood and tapped in health care.