Efficiency-Morality Trade-Offs in Repugnant Transactions: A Choice Experiment

Objective We investigated asthma quality measures to understand patient characteristics associated with non-attainment of quality care and measure the association with asthma-related emergency department (ED) visits or inpatient hospitalizations (IPs). Methods Using administrative data from ALL Kids, Alabama’s Children’s Health Insurance Program, from 2013 to 2019 we calculated non-attainment of the Medication Management for Asthma (MMA) and Asthma Medication Ratio (AMR) quality measures. Patient characteristics and asthma-related ED visits and IPs associated with non-attainment of the MMA and AMR measures were assessed using logit regression models and Marginal effects at the mean. Results Among 2528 children with asthma, 53.2% failed to attain the MMA measure and 8.5% the AMR measure. Prior asthma-related ED visits or IP stays increased likelihood of non-attainment by 14.8 percentage points (95% CI 8.6–20.9) for MMA and 7.3 percentage points (95% CI 2.8–11.8) for AMR. Among 868 children (34.3%) with three years of continuous enrollment, AMR non-attainment was associated with a 6.1 percentage point increase in ED or IP utilization (95% CI 1.3–10.9), however MMA non-attainment was not associated with either outcome. Prior ED visit/IP stay was associated with a 17.2 percentage point (95% CI 8.3–26.1) increase in the likelihood of a subsequent ED visit/IP stay among those with non-attainment MMA and a 15.5 percentage point increase (95% CI 6.9–24.2) for non-attainment AMR. Conclusions Patient characteristics associated with non-attainment of asthma quality measures presents actionable evidence to guide improvement efforts as non-attainment AMR increases the risk of subsequent ED visits and IP stays.

The study examined 1999-2005 data on first-time nursing home admissions of individuals with mental illness, dementia, or both to identify trends and characteristics. The Minimum Data Set was used to estimate the number and percentage of persons newly admitted to nursing homes who had mental illness (schizophrenia, bipolar disorder, depression, or an anxiety disorder), dementia, or both from 1999 to 2005. Data from 2005 were used to compare demographic characteristics and comorbid conditions of the three groups and treatments received. The number of individuals admitted with mental illness increased from 168,721 in 1999 to 187,478 in 2005. The 2005 number is more than 50% higher than the number admitted with dementia only (118,290 in 2005). The increase was driven by growth in admissions of persons with depression--from 128,566 to 154,262 in 2005. Persons admitted with depression had higher rates of comorbid conditions than those admitted with dementia or with neither dementia nor mental illness. They also had high rates of antidepressant treatment and high rates of receipt of training in skills required to return to the community. Current trends show that the proportion of nursing home admissions with mental illness, in particular depression, has overtaken the proportion with dementia. These changes may be related to increased recognition of depression, availability of alternatives to nursing homes for persons with dementia, and increased specialization among nursing homes in the care of postacute, rehabilitation residents. In light of these trends, it is critical to ensure that nursing homes have resources to adequately treat residents with mental illness to facilitate community reintegration.

The strong link between health insurance and employment in the United States may cause workers to delay retirement until they become eligible for Medicare at age 65. However, some employers extend health insurance benefits to their retirees, and individuals who are eligible for such retiree health benefits need not wait until age 65 to retire with group health coverage. We investigate the impact of retiree health insurance on early retirement using employee-level data from 64 diverse firms that are clients of Towers Watson, a leading benefits consulting firm. We find that retiree health coverage has its strongest effects at ages 62 and 63, resulting in a 3.7 percentage point (21.2 percent) increase in the probability of turnover at age 62 and a 5.1 percentage point (32.2 percent) increase in the probability of turnover at age 63; it has a more modest effects for individuals under the age of 62. A more generous employer contribution of 50 percent or more raises turnover by 1-3 percentage points at ages 56-61, by 5.9 percentage points (33.7 percent) at age 62, and by 6.9 percentage points (43.7 percent) at age 63. Overall, an employer contribution of 50 percent or more reduces the total number of person-years worked between ages 56 and 64 by 9.6 percent relative to no coverage.

France: alcohol today

We examined the impact of the Affordable Care Act (ACA) on healthcare coverage, access, health status, and affordability, as well as disparities in these outcomes by race/ethnicity among low-income Californians. We used nationally representative survey data from the Behavioral Risk Factor Surveillance Survey 2011-2019 and a difference-in-differences approach that compared California with nonexpansion states. We examined the impact of Medicaid expansion on health insurance coverage, having a usual source of care, self-reported health status, frequent (≥14) unhealthy days in the past month (physical, mental, and both), and foregone care due to cost. The sample population included low-income Californians (<100% of the federal poverty guidelines) aged 19-64 and low-income childless adults. Low-income adults, childless adults, and white childless adults in California saw post-ACA gains in six of seven outcomes, including a 7.7 percentage point increase in having a usual source of care for all low-income adults (CI: 0.051 to 0.104). Childless adult people of color (POC) reported significant improvements in three measures, with a 6.6 percentage point increase in having a usual source of care (CI: 0.013 to 0.120). All of the groups we examined had coverage gains, ranging from 3.9 percentage points for all low-income adults (CI: 0.013 0.066) to 8.4 percentage points for white childless adults (CI: 0.025 to 0.143). Additionally, all groups reported improved mental health, including an 8.2 percentage point decrease in frequent mental distress for childless adults (CI: -0.120 to -0.044). These findings indicate that the ACA coverage expansion benefitted the targeted population of low-income Californians. Additionally, the disparity between white and non-white Californians decreased for the unadjusted mean rate of having a usual source of care. However, unadjusted means showed that white low-income adults remained more likely to have health insurance coverage and a usual source of care compared with POC in both California and nonexpansion states.

This study employs a fixed-effects panel regression model with Driscoll-Kraay standard errors to analyze the relationship between agricultural export performance and Sustainable Development Goal (SDG) indicators across 45 African nations from 2000 to 2022. Export performance is measured through the per capita value of agricultural exports and a Herfindahl-Hirschman Index (HHI) of export product concentration, while controlling for GDP per capita, institutional quality, and population dynamics. The empirical results reveal statistically significant yet dualistic associations. A 1% increase in agricultural exports per capita is associated with a 1.25 percentage point reduction in poverty (p<0.05) and a 0.89 percentage point increase in annual GDP growth (p<0.01), suggesting a positive link to SDGs 1 and 8. However, this export growth is also correlated with a 0.83 point increase in the Gini coefficient (p<0.05), a 2.15% rise in agricultural CO₂ emissions (p<0.01), and a 1.98 percentage point loss in forest cover (p<0.01), highlighting severe trade-offs for SDGs 10, 13, and 15. Furthermore, a one-unit increase in export concentration (HHI) is associated with a 2.18 percentage point increase in poverty and a 1.12 percentage point decrease in forest area (p<0.05). The findings indicate that the scale and composition effects of export expansion dominate, overwhelming any potential technique effect from economic gains. We conclude that while agricultural exports are a significant correlate of macroeconomic growth in Africa, their benefits are not automatically inclusive or sustainable. The results robustly indicate that export diversification and strong institutions are critical mitigating factors against these trade-offs. Policy must therefore pivot from promoting raw commodity volume to strategically fostering value-added, diversified, and sustainably certified export sectors to align trade with the holistic 2030 Agenda.

Although financial toxicity from cancer care is well documented, how cancer and other high-mortality chronic diseases affect credit overuse and high-risk borrowing remains unknown. We retrospectively analyzed households in the 2012-2018 Health and Retirement Study. Outcomes included nonhousing financial debt and credit card debt. For homeowning households, outcomes also included access to a home equity line of credit (HELOC) and a loan against HELOC. Linear probability regression models compared changes in financial outcomes among households with new cancer diagnosis or major chronic diseases (diabetes, stroke, or heart disease) with those without health shocks. Analyses were stratified by wealth. Among 14,188 households (age 68 years, 42% male, 21% Black, 13% Hispanic), 33% had financial debt, 26% had credit card debt, and 10% of homeowners used HELOC. Below-median wealth households were more likely to be Black or Hispanic. They were less likely to be headed by a female and to have college-level education. In these households, 22% had negative financial wealth (v 0% for above-median wealth), and new cancer was associated with a 4.9 percentage point (PPT) increase in rates of financial debt (13.1% effect size; P = .03; 95% CI, 0.005 to 0.094) and a 3.9 PPT increase in HELOC use (65%; P = .04; 95% CI, 0.002 to 0.076) compared with households with no new health changes. Households developing major chronic diseases were 3.6 PPT more likely to develop financial debt (9.6%; P = .015; 95% CI, 0.007 to 0.065) without affecting HELOC use. Such differences disappeared in above-median wealth households. Below-median wealth households with cancer incurred higher financial debt and refinanced their home more often compared with those without cancer, highlighting credit overuse and borrowing even in a fully insured population.

The Affordable Care Act-dependent coverage expansion provision implemented in 2010 allows young adults to be covered under their parents' health insurance until age 26 years, and millions of young adults have gained insurance as a result. The impact of this policy on cancer patients has yet to be determined. Using 2007 to 2012 data from 18 registries of the Surveillance, Epidemiology, and End Results Program, comparing cancer patients age 19 to 25 years to a control group of patients age 26 to 34 years who were not affected by the provision, we observed a 2.0 (95% confidence interval [CI] = 0.7 to 3.4) percentage point decrease in uninsured rate and a 2.7 (95% CI = 0.6 to 4.8) percentage point increase in diagnosis at stage I disease for patients age 19-25 years. Further analyses by specific cancer site revealed that the statistically significant shifts were confined to carcinoma of cervix (21.2, 95% CI = 9.6 to 32.7 percentage points) and osseous and chondromatous neoplasms (14.4, 95% CI = 0.3 to 28.5 percentage points), which are detectable by either screening or clinical manifestation. These early observations suggest the policy has had positive benefits in cancer outcomes.

Peer Effects on the United States Supreme Court

This article examines the dynamic relationship between the Reserve Bank of Australia's (RBA's) cash rate and the variable interest rate for lending to small businesses. The relationship is evaluated via an asymmetric GARCH model using monthly data spanning from August 1990 to October 2012. Our results show that a 1 percentage point increase in the cash rate results in an instantaneous 1.086 percentage point rise in the variable rate for small businesses, whereas an equivalent 1 percentage point cut only leads to a 0.862 percentage point fall with a delay of up to 2 months. This outcome has obvious implications for the RBA's monetary policy transmission mechanism and the effectiveness of the expansionary policy versus contractionary policy.

Individuals with schizophrenia exposed to second-generation antipsychotics (SGA) have an increased risk for diabetes, with aripiprazole purportedly a safer drug. Less is known about the drugs' mortality risk or whether serious mental illness (SMI) diagnosis or race/ethnicity modify these effects. Authors created a retrospective cohort of non-elderly adults with SMI initiating monotherapy with an SGA (olanzapine, quetiapine, risperidone, and ziprasidone, aripiprazole) or haloperidol during 2008-2013. Three-year diabetes incidence or all-cause death risk differences were estimated between each drug and aripiprazole, the comparator, as well as effects within SMI diagnosis and race/ethnicity. Sensitivity analyses evaluated potential confounding by indication. 38 762 adults, 65% White and 55% with schizophrenia, initiated monotherapy, with haloperidol least (6%) and quetiapine most (26·5%) frequent. Three-year mortality was 5% and diabetes incidence 9.3%. Compared with aripiprazole, haloperidol and olanzapine reduced diabetes risk by 1.9 (95% CI 1.2-2.6) percentage points, or a 18.6 percentage point reduction relative to aripiprazole users' unadjusted risk (10.2%), with risperidone having a smaller advantage. Relative to aripiprazole users' unadjusted risk (3.4%), all antipsychotics increased mortality risk by 1.1-2.2 percentage points, representing 32.4-64.7 percentage point increases. Findings within diagnosis and race/ethnicity were generally consistent with overall findings. Only quetiapine's higher mortality risk held in sensitivity analyses. Haloperidol's, olanzapine's, and risperidone's lower diabetes risks relative to aripiprazole were not robust in sensitivity analyses but quetiapine's higher mortality risk proved robust. Findings expand the evidence on antipsychotics' risks, suggesting a need for caution in the use of quetiapine among individuals with SMI.

Textbooks attribute 80% of meconium-related small bowel obstructions to cystic fibrosis and 15% of colonic obstructions to Hirschsprung disease. It is unknown whether these estimates are accurate, particularly among preterm infants, whose immature bowel predisposes them to meconium-related obstruction (MRO). To estimate the incidence of MRO by type and to assess its association with clinical outcomes. This retrospective cohort study of live-born infants included in the National Inpatient Sample from January 1, 2016, to December 31, 2020, used survey weighting methods to estimate the national incidence of MRO by etiology. Data were analyzed from November 27, 2023, to November 12, 2024. MRO. The primary outcome was diagnosis with MRO. Secondary outcomes included mortality, need for abdominal surgery, hospitalization duration, and cost. Multivariable regression models were developed to evaluate characteristics associated with MRO and to assess the association of MRO of prematurity with clinical outcomes after adjusting for demographic and clinical covariates. Of 3 550 796 infants, 51.2% were male and 46.7% were privately insured. Overall, 9.1% (n = 322 499) were born preterm. Of 1844 (0.1%) infants treated for MRO, 41 (2.2%) had cystic fibrosis, 60 (3.3%) had Hirschsprung disease, and 1743 (94.5%) had neither predisposing condition. Preterm infants were at highest risk for MRO, with 4.7 MRO cases per 100 000 births associated with cystic fibrosis, 4.7 MRO cases per 100 000 births associated with Hirschsprung disease, and 187.3 MRO cases per 100 000 births associated with neither predisposing condition. Among infants with neither cystic fibrosis nor Hirschsprung disease, those with gestational ages from 28 weeks to 31 weeks 6 days were most likely to develop MRO compared with term infants (adjusted odds ratio, 6.08 [95% CI, 4.27-8.67]). Among preterm infants, having an MRO was associated with a 4.2 percentage point increase in the probability of abdominal surgery (95% CI, 3.1-5.4 percentage points), a 7.3-day increase in length of stay (95% CI, 5.8-8.8 days), and a $23 215 increase in hospitalization costs (95% CI, $17 739-$28 690) compared with infants who did not have an obstruction, with no change in mortality rate (0.1 percentage point change [95% CI, -0.6 to 0.8 percentage points]). In this cohort study of over 3.5 million infants, MRO was most likely to occur among preterm infants without cystic fibrosis or Hirschsprung disease. These infants more frequently required surgery and had longer and more costly hospitalizations, indicating a need for dedicated prevention and treatment pathways for this understudied disease.

Far too few adults getting recommended vaccines

Introduction: Research suggests obesity may be transmitted through social networks. A possible pathway is social influence on food choice. We investigated peer influence on the healthfulness of worksite food choices using social network analysis in a large hospital employee population, hypothesizing that socially-connected employees’ food choices would be correlated. Methods: Data on all food purchases in 2016 were obtained from the hospital’s cash register database. The cafeteria system uses traffic light labels to mark foods as healthy (green), less healthy (yellow), or unhealthy (red). Employees’ food purchases were identified through the use of cafeteria debit cards; social ties among employees were inferred based on a validated algorithm using demographics and time/location of purchases. We used spatial autoregression (SAR) and generalized estimating equation (GEE) models to calculate associations between the proportions of employees’ and coworkers’ purchases that were labeled green (or red). SAR models assessed concurrent purchases of an employee and coworker, weighting the association between their purchases by the frequency and inferred strength of the social tie. GEE models assessed longitudinal relationships between purchases coworkers’ made in the presence of an employee in one 8-week period and the employee’s purchases in the next 8-week period. Food and beverages were analyzed separately. Models adjusted for employee and coworker confounders (age, sex, race/ethnicity, job type, education). Results: In all, 5,118 employees used cafeteria debit cards to make purchases. Up to 536,240 employee/coworker interactions were observed, depending on the model (SAR, GEE) and outcomes (green/red, food/beverages). SAR models showed that a 1 percentage point increase in the network-weighted average of coworkers’ green-labeled (healthy) food purchases was associated with a 0.39 percentage point increase in an employee’s concurrent green-labeled food purchases (p<.001). Positive associations were also observed for red foods (0.20), and green (0.14) and red (0.31) beverages (all p<.001). Longitudinal GEE models showed that employees, as a population, increased purchases of green-labeled items by 0.013 percentage points on average when coworkers with whom they visited cafeterias in the prior 8 weeks increased their purchases of green items by 1 percentage point (p<.001). Similar associations were observed for red foods (0.013), and for green (0.006) and red beverages (0.020) (all p<.003). Conclusions: Employees’ healthy and unhealthy food choices are correlated. Although one explanation is that people eat with others who have similar preferences, the longitudinal findings suggest that people create social norms for eating that influence peers. Worksite and other social networks may be novel targets for population-level interventions to promote healthy diet.

Your development or mine? Effects of donor–recipient cultural differences on the aid-growth nexus