See Your Doctor
Returns to Physician Human Capital: Evidence from Patients Randomized to Physician Teams
Joseph Doyle, Steven Ewer & Todd Wagner
Journal of Health Economics, forthcoming
Abstract:
Physicians play a major role in determining the cost and quality of healthcare, yet estimates of these effects can be confounded by patient sorting. This paper considers a natural experiment where nearly 30,000 patients were randomly assigned to clinical teams from one of two academic institutions. One institution is among the top medical schools in the U.S., while the other institution is ranked lower in the distribution. Patients treated by the two programs have similar observable characteristics and have access to a single set of facilities and ancillary staff. Those treated by physicians from the higher-ranked institution have 10-25% less expensive stays than patients assigned to the lower-ranked institution. Health outcomes are not related to the physician team assignment. Cost differences are most pronounced for serious conditions, and they largely stem from diagnostic-testing rates: the lower-ranked program tends to order more tests and takes longer to order them.
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Robert Levine et al.
American Journal of Public Health, forthcoming
Objectives: We explored whether the introduction of 3 lifesaving innovations increased, decreased, or had no effect on disparities in Black-White mortality in the United States.
Methods: Centers for Disease Control and Prevention data were used to assess disease-, age-, gender-, and race-specific changes in mortality after the introduction of highly active anti-retroviral therapy (HAART) for treatment of HIV, surfactants for neonatal respiratory distress syndrome, and Medicare reimbursement of mammography screening for breast cancer.
Results: Disparities in Black-White mortality from HIV significantly increased after the introduction of HAART, surfactant therapy, and reimbursement for screening mammography. Between 1989 and 2006, these circumstances may have accounted for an estimated 22441 potentially avoidable deaths among Blacks.
Conclusions: These descriptive data contribute to the formulation of the hypothesis that federal laws promote increased disparities in Black-White mortality by inadvertently favoring Whites with respect to access to lifesaving innovations. Failure of legislation to address known social factors is a plausible explanation, at least in part, for the observed findings. Further research is necessary to test this hypothesis, including analytic epidemiological studies designed a priori to do so.
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Lenny López, Andrew Wilper, Marina Cervantes, Joseph Betancourt & Alexander Green
Academic Emergency Medicine, August 2010, Pages 801-808
Objectives: This study assessed whether sociodemographic differences exist in triage assignment and whether these differences affect initial diagnostic testing in the emergency department (ED) for patients presenting with chest pain.
Methods: A nationally representative ED data sample for all adults (≥18 years) was obtained from the National Hospital Ambulatory Health Care Survey of EDs for 1997-2006. Weighted logistic regression was used to examine the associations between race and presenting symptom, triage assignment, and test ordering, adjusting for patient and hospital characteristics.
Results: Over 10 years, an estimated 78 million visits to the ED presented with a complaint of chest pain. Of those presenting with chest pain, African Americans (odds ratio [OR] = 0.70; 99% confidence interval [CI] = 0.53 to 0.92), Hispanics (OR = 0.74; 99% CI = 0.51to 0.99), Medicaid patients (OR = 0.72; 99% CI = 0.54 to 0.94), and uninsured patients (OR = 0.65; 99% CI = 0.51 to 0.84) were less likely to be triaged emergently. African Americans (OR = 0.86; 99% CI = 0.70 to 0.99), Medicaid patients (OR = 0.70; 99% CI = 0.55 to 0.88), and uninsured patients (OR = 0.70; 99% CI = 0.55 to 0.89) were less likely to have an electrocardiogram (ECG) ordered. African Americans (OR = 0.69; 99% CI = 0.49 to 0.97), Medicaid patients (OR = 0.67; 99% CI = 0.47 to 0.95), and uninsured patients (OR = 0.66; 99% CI = 0.44 to 0.96) were less likely to have cardiac enzymes ordered. Similarly, African Americans and Hispanics were less likely to have a cardiac monitor and pulse oximetry ordered, and Medicaid and uninsured patients were less likely to have a cardiac monitor ordered.
Conclusions: Persistent racial, sex, and insurance differences in triage categorization and basic cardiac testing exist. Eliminating triage disparities may affect "downstream" clinical care and help eliminate observed disparities in cardiac outcomes.
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James Poterba, Steven Venti & David Wise
NBER Working Paper, September 2010
Abstract:
This paper examines the correlation between poor health and asset accumulation for households in the first nine waves of the Health and Retirement Survey. Rather than enumerating the specific costs of poor health, such as out of pocket medical expenses or lost earnings, we estimate how the evolution of household assets is related to poor health. We construct a simple measure of health status based on the first principal component of HRS survey responses on self-reported health status, diagnoses, ADLs, IADL, and other indicators of underlying health. Our estimates suggest large and substantively important correlations between poor health and asset accumulation. We compare persons in each 1992 asset quintile who were in the top third of the 1992 distribution of latent health with those in the same 1992 asset quintile who were in the bottom third of the latent health distribution. By 2008, those in the top third of the health distribution had accumulated, on average, more than 50 percent more assets than those in the bottom third of the health distribution. This "asset cost of poor health" appears to be larger for persons with substantial 1992 asset balances than for those with lower balances.
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The importance of relative standards in ADHD diagnoses: Evidence based on exact birth dates
Todd Elder
Journal of Health Economics, September 2010, Pages 641-656
Abstract:
This paper presents evidence that diagnoses of attention-deficit/hyperactivity disorder (ADHD) are driven largely by subjective comparisons across children in the same grade in school. Roughly 8.4 percent of children born in the month prior to their state's cutoff date for kindergarten eligibility - who typically become the youngest and most developmentally immature children within a grade - are diagnosed with ADHD, compared to 5.1 percent of children born in the month immediately afterward. A child's birth date relative to the eligibility cutoff also strongly influences teachers' assessments of whether the child exhibits ADHD symptoms but is only weakly associated with similarly measured parental assessments, suggesting that many diagnoses may be driven by teachers' perceptions of poor behavior among the youngest children in a classroom. These perceptions have long-lasting consequences: the youngest children in fifth and eighth grades are nearly twice as likely as their older classmates to regularly use stimulants prescribed to treat ADHD.
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The Cost of Pursuing a Medical Career in the Military: A Tale of Five Specialties
William Cronin, Jessica Morgan & William Weeks
Academic Medicine, August 2010, Pages 1316-1320
Purpose: The physician payment system is a focus of potential reform in the United States. The authors explored the effects of the military's method of physician payment on physicians' returns on educational investment for several specialties.
Method: This retrospective, observational study used national data from 2003 and standard financial techniques to calculate the net present value-the current value of an expected stream of cash flows at a particular rate of interest-of the educational investments of medical students in ten 30-year career paths: either military or civilian careers in internal medicine, psychiatry, gastroenterology, general surgery, or orthopedics.
Results: At a 5% discount rate, in the civilian world, the lowest return on an educational investment accrued to psychiatrists ($1.136 million) and the highest to orthopedists ($2.489 million), a range of $1.354 million. In the military, the lowest returns accrued to internists ($1.377 million) and the highest to orthopedists ($1.604 million); however, the range was only $0.227 million, one-sixth that found in the civilian sector. The authors also found that most military physicians do not remain in the military for their full careers.
Conclusions: Choosing a military career substantially decreases the net present value of an educational investment for interventionalists, but it does so only modestly for primary care physicians. Further, a military career path markedly diminishes specialty-specific variation in the net present values of educational investment. Adopting a military structure for engaging medical students might help reverse the current trend of declining interest in primary care.
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Race, Neighborhood Characteristics, and Disparities in Chemotherapy for Colorectal Cancer
Yongping Hao, Hope Landrine, Ahmedin Jemal, Kevin Ward, Rana Bayakly, John Young, Dana Flanders & Elizabeth Ward
Journal of Epidemiology and Community Health, forthcoming
Background: Studies have found significant race/ethnic and age differences in receipt of adjuvant chemotherapy for stages III colon and II/III rectal cancers. Little is known about the role of neighborhood factors in these disparities.
Methods: The 4,748 Black and White patients from the Georgia Comprehensive Cancer Registry were diagnosed with stages III colon and II/III rectal cancers between 2000 and 2004. Neighborhood poverty, segregation (% Black residents), and rurality were linked to each patient using census tract identifiers. Multilevel analyses explored the role of neighborhood characteristics, and the nested association of patient race within categories of neighborhoods in receipt of chemotherapy.
Results: Odds of receiving chemotherapy for urban and suburban patients were 38% (95% CI: 1.09-1.74) and 53% (95% CI: 1.20-1.94) higher than for rural patients. However, odds of receiving chemotherapy for urban Black patients were 24% (95% CI: 0.62-0.94) lower than for their White counterparts. Receipt of chemotherapy did not significantly differ between Blacks and Whites residing in suburban or rural areas.
Conclusion: Black-White disparities in receipt of chemotherapy among Georgia colorectal cancer patients were confined to urban patients. Disparities in receipt of this treatment for rural patients were found irrespective of patient race. Our findings highlight geographic areas where targeted interventions might be needed.
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Investing in Preventive Dental Care for the Medicare Population: A Preliminary Analysis
John Moeller, Haiyan Chen & Richard Manski
American Journal of Public Health, forthcoming
Objectives: We estimated the use of preventive dental care services by the US Medicare population, and we assessed whether money spent on preventive dental care resulted in less money being spent on expensive nonpreventive procedures.
Methods: We used data from the 2002 Medicare Current Beneficiary Survey to estimate a multinomial logistic model to analyze the influence of predisposing, enabling, and need variables in identifying those beneficiaries who used preventive dental care, only nonpreventive dental care, or no dental care in a multiple-variable context. We used regression models with similar controls to estimate the influence of preventive care on the utilization and cost of nonpreventive dental care and all dental care.
Results: Our analyses showed that beneficiaries who used preventive dental care had more dental visits but fewer visits for expensive nonpreventive procedures and lower dental expenses than beneficiaries who saw the dentist only for treatment of oral problems.
Conclusions: Adding dental coverage for preventive care to Medicare could pay off in terms of both improving the oral health of the elderly population and limiting the costs of expensive nonpreventive dental care for the dentate beneficiary population.
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Andrea Shamaskin, Jospeh Mikels & Andrew Reed
Psychology and Aging, September 2010, Pages 746-751
Abstract:
Although valenced health care messages influence impressions, memory, and behavior (Levin, Schneider, & Gaeth, 1998) and the processing of valenced information changes with age (Carstensen & Mikels, 2005), these 2 lines of research have thus far been disconnected. This study examined impressions of, and memory for, positively and negatively framed health care messages that were presented in pamphlets to 25 older adults and 24 younger adults. Older adults relative to younger adults rated positive pamphlets more informative than negative pamphlets and remembered a higher proportion of positive to negative messages. However, older adults misremembered negative messages to be positive. These findings demonstrate the age-related positivity effect in health care messages with promise as to the persuasive nature and lingering effects of positive messages.
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Health selection operating between classes and across employment statuses
Myung Ki, Amanda Sacker, Yvonne Kelly & James Nazroo
Journal of Epidemiology and Community Health, forthcoming
Backgrounds: The debate on health selection which describes the influence of health on subsequent social mobility is highly contested. The authors set out to examine the effect of health selection by looking at the effect of previous health status on changes in socio-economic position (SEP) over two time periods.
Method: Data were pooled from 13 waves (1991-2003) of the British Household Panel Survey (BHPS). Using a multilevel multinomial approach, the presence of health selection between classes and into/out of employment was concurrently tested and compared.
Results: In the descriptive analysis, poor health was consistently associated with moving downward, while the outcome was inverse for upward movement. After accounting for the data structure using multilevel analysis, health was a predictor for social mobility when leaving and entering employment, but the effect was minimal for transitions between classes for both men and women.
Conclusion: The non-significant impact of health on mobility inside employment may reflect the presence of the significant impact of health on mobility between employment and non-employment. This implies that the effect of health was not evenly spread over all social mobility, but rather tends to concentrate on some types of mobility. The effect of each predictor on social mobility is more concentrated among specific transitions, and health and age were likely to be substantial in moving into/out of the labour force, whereas education was a relevant predictor for mobility into/out of upper classes, in particular, classes I/II.
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Does doctors' experience matter in LASIK surgeries?
Juan Contreras, Beomsoo Kim & Ignez Tristao
Health Economics, forthcoming
Abstract:
In this article, we use a longitudinal census of laser in situ keratomileusis (LASIK) eye surgeries collected directly from patient charts to examine the learning-by-doing hypothesis in medicine. LASIK surgery has precise measures of presurgical condition and postsurgical outcomes. Unlike other types of surgery, the impact of unobservable underlying patient conditions on outcomes is minimal. Individual learning by doing is identified through observations of surgical outcomes over time, based on the cumulative number of surgeries performed. Collective learning is identified separately, through changes in a group adjustment rule determined jointly by all the surgeons in a structured internal review process. Our unique data set overcomes some of the measurement problems in patient outcomes encountered in other studies and improves the possibility of identifying and separating the impact of learning by doing from other effects. We cannot conclude that the outcome of LASIK surgery improves as an individual surgeon's experience increases, but we find strong evidence that experience accumulated by surgeons as a group in a clinic significantly improves outcomes.
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Evaluating The Quality Of Care Provided By Graduates Of International Medical Schools
John Norcini, John Boulet, Dale Dauphinee, Amy Opalek, Ian Krantz & Suzanne Anderson
Health Affairs, August 2010, Pages 1461-1468
Abstract:
One-quarter of practicing physicians in the United States are graduates of international medical schools. The quality of care provided by doctors educated abroad has been the subject of ongoing concern. Our analysis of 244,153 hospitalizations in Pennsylvania found that patients of doctors who graduated from international medical schools and were not U.S. citizens at the time they entered medical school had significantly lower mortality rates than patients cared for by doctors who graduated from U.S. medical schools or who were U.S. citizens and received their degrees abroad. The patient population consisted of those with congestive heart failure or acute myocardial infarction. We found no significant mortality difference when comparing all international medical graduates with all U.S. medical school graduates.
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From mainstream to marginal? Trends in the use of Chinese medicine in China from 1991 to 2004
Lei Jin
Social Science & Medicine, September 2010, Pages 1063-1067
Abstract:
In many Western societies, alternative healing options, including Chinese medicine, have started to move from the marginal to mainstream. In China, Chinese medicine has been an established component in the official health care system, but its relevance and effectiveness have often been challenged in a society committed to modernization. Despite abundant speculation, little research has established empirical facts regarding the use of Chinese medicine in China. This paper uses a longitudinal dataset to examine the trends from 1991 to 2004, and explore the extent to which changing population demographic and socioeconomic characteristics contributed to the observed trends. It finds that in the formal medical sector, the use of Chinese medicine has contracted, particularly in cities. Changing population demographic and socioeconomic characteristics cannot entirely account for the contraction. Rather, shifts in cultural values and structural changes in the health care system may have led to the observed decline.
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Dasha Cherepanov, Mari Palta, Dennis Fryback & Stephanie Robert
Quality of Life Research, October 2010, Pages 1115-1124
Purpose: The purpose of this study was to describe gender differences in self-reported health-related quality-of-life (HRQoL) and to examine whether differences are explained by sociodemographic and socioeconomic status (SES) differentials between men and women.
Methods: Data were from four US nationally representative surveys: US Valuation of the EuroQol EQ-5D Health States Survey (USVEQ), Medical Expenditure Panel Survey (MEPS), National Health Measurement Study (NHMS) and Joint Canada/US Survey of Health (JCUSH). Gender differences were estimated with and without adjustment for sociodemographic and SES indicators using regression within and across data sets with SF-6D, EQ-5D, HUI2, HUI3 and QWB-SA scores as outcomes.
Results: Women have lower HRQoL scores than men on all indexes prior to adjustment. Adjusting for age, race, marital status, education and income reduced but did not remove the gender differences, except with HUI3. Adjusting for marital status or income had the largest impact on estimated gender differences.
Conclusions: There are clear gender differences in HRQoL in the United States. These differences are partly explained by sociodemographic and SES differentials.