The impact of physical activity on short-run healthcare utilization and costs in U.S. adults

As healthcare costs have grown well in excess of inflation, policy debate has frequently focused on whether and how prevention behaviors could reduce healthcare utilization and costs. I attempt to identify the extent of substitution between physical activity, a form of health investment, and medical utilization in the short-run. The short-run is an important duration for employers and health insurers with high employee and member turnover rates. My model posits two benefits of physical activity--a reduction in the probability or extent of disease and a signal which reduces uncertainty regarding one\u27s health. The \u27signaling\u27 effect likely substitutes for diagnostic care while the \u27physiological effect\u27 more likely substitutes for relatively low-intensity forms of treatment in the short run. Unlike prior statistical efforts examining physical activity; my empirical approach uses various novel instrumental variables, including spouse\u27s physical activity, which are correlated with one\u27s own activity pattern, but plausibly is not related to one\u27s medical utilization in particular scenarios. Evidence from the National Health Interview Survey/Medical Expenditure Panel Survey (2002-4) suggests that individuals respond to their physical activity by reducing more discretionary forms of care. Specifically, several specifications indicate that physical activity reduces check-up and physician office visits by approximately 15-20 percent in the short run. However, there were no significant changes in the probability of less discretionary forms of care such as hospitalization or ER visits. This result is consistent with a model in which the signaling or near-term physiological benefit from physical activity substitutes for more discretionary forms of short-run utilization, but not the decision to seek intensive treatment-focused care. Overall, these shifts do not appreciably affect overall utilization or costs

Cost-Effectiveness of Rural Incentive Packages for Graduating Medical Students in Lao PDR

Background The dearth of health workers in rural settings in Lao People’s Democratic Republic (PDR) and other developing countries limits healthcare access and outcomes. In evaluating non-wage financial incentive packages as a potential policy option to attract health workers to rural settings, understanding the expected costs and effects of the various programs ex antecan assist policy-makers in selecting the optimal incentive package. Methods We use discrete choice experiments (DCEs), costing analyses and recent empirical results linking health worker density and health outcomes to estimate the future location decisions of physicians and determine the costeffectiveness of 15 voluntary incentives packages for new physicians in Lao PDR. Our data sources include a DCE survey completed by medical students (n = 329) in May 2011 and secondary cost, economic and health data. Mixed logit regressions provide the basis for estimating how each incentive package influences rural versus urban location choice over time. We estimate the expected rural density of physicians and the cost-effectiveness of 15 separate incentive packages from a societal perspective. In order to generate the cost-effectiveness ratios we relied on the rural uptake probabilities inferred from the DCEs, the costing data and prior World Health Organization (WHO) estimates that relate health outcomes to health worker density. Results Relative to no program, the optimal voluntary incentive package would increase rural physician density by 15% by 2016 and 65% by 2041. After incorporating anticipated health effects, seven (three) of the 15 incentive packages have anticipated average cost-effectiveness ratio less than the WHO threshold (three times gross domestic product [GDP] per capita) over a 5-year (30 year) period. The optimal package’s incremental cost-effectiveness ratio is $1454/QALY (quality-adjusted life year) over 5 years and$2380/QALY over 30 years. Capital intensive components, such as housing or facility improvement, are not efficient. Conclusion Conditional on using voluntary incentives, Lao PDR should emphasize non-capital intensive options such as advanced career promotion, transport subsidies and housing allowances to improve physician distribution and rural health outcomes in a cost-effective manner. Other countries considering voluntary incentive programs can implement health worker/trainee DCEs and costing surveys to determine which incentive bundles improve rural uptake most efficiently but should be aware of methodological caveats

Health Care Expenditures Associated With Pollution: Exploratory Methods and Findings

BackgroundThe research done for this paper is part of the background analysis undertaken to support the work of the Global Commission on Pollution, Health and Development, an initiative of The Lancet, the Global Alliance on Health and Pollution, and the Icahn School of Medicine at Mount Sinai. The paper expands on areas where the current literature has gaps in knowledge related to the health care cost of pollution. Objectives. This study aims to generate an initial estimate of total tangible health care expenditure attributable to man-made pollution affecting air, soil and water.MethodsWe use two methodologies to establish an upper and lower bounds for pollution related health expenditure. Key data points in both models include (a) burden-of-disease (BoD) at the national level in different countries attributable to pollution; and (b) the total cost of health care at the national level in different countries using standard national health accounts expenditure data.FindingsDepending on which determinist model we apply, annual expenditures range from US$630 billion (upper bound) to US$240 billion (lower bound) or approximately three to nine percent of global spending on health care in 2013 (the reference year for the analysis). Although only 14 percent of global total for pollution related health care spending is in lower- and middle-income countries (LMICs) in our primary (lower bound) model, the relative share of spending for pollution related illness is substantial, especially in very low-income countries. Cancer, chronic respiratory and cardio/cerebrovascular illnesses account for the largest health care spending items linked to pollution even in LMICs.ConclusionsThese conditions have historically received less attention by national governments, international public health organizations and development/financial agencies than infectious disease and maternal/child health sectors. Other studies posit that intangible costs associated with environmental pollution include lower productivity and reduced income – components which our models do not attempt to capture. The financial and health impacts are substantial even when we exclude intangible costs, yet it is likely that in many LMICs poor households simply forgo medical treatment and lose household income as a result of man-made environmental degradation.RecommendationsWhen evaluating the value of public health or environmental programs which prevent or limit pollution-related illness, policy makers should consider the health benefits, the tangible cost offsets (estimated in our models) and the opportunity costs

Structural hemodynamic valve deterioration durability of RESILIA-tissue versus contemporary aortic bioprostheses

Aim: Durability of aortic valve replacement is becoming increasingly important. Aortic bioprostheses with RESILIA tissue have demonstrated outstanding outcomes thus far, but only in single-arm studies. Methods: We compared structural valve deterioration (SVD)-related hemodynamic valve deterioration (HVD) of grade ≥2 of RESILIA tissue valves from the COMMENCE trial (n = 689) to those from the PARTNER 2A contemporary AVR arm (n = 936) based upon annual core laboratory echocardiograms through 5 years of follow-up. Results: SVD-related HVD in the COMMENCE and PARTNER 2A cohorts were 1.8 versus 3.5%, respectively (one-sided 95% lower-bound hazard ratio of 0.92; p = 0.07). In propensity-matched cohorts (n = 239), these outcomes were 1.0 versus 4.8%, respectively (one-sided 95% lower-bound hazard ratio of 1.15; p = 0.03). Conclusion: RESILIA tissue-based AVR exhibited reduced SVD-related HVD compared with a contemporary AVR cohort devoid of RESILIA tissue