Health behaviors, health knowledge and economic well-being.

Using the Panel Study of Income Dynamics, this dissertation explores interactions between health behaviors and economic well-being and health knowledge. The first two chapters analyze the interaction between certain health behaviors and such indicators of economic well-being as wages and non-collateralized debt. Thus, chapter 1, Life Smoking Histories and Wages, examines the relationship between smoking behavior and wages. Analysis reveals that smoking is associated with an estimated wage gap of 4-11 percent. The wage gap between smokers and non-smokers is largely driven by persistent smokers and is likely to be explained by non-causal explanations such as a common factor associated with differences in preferences and/or behaviors that both reduce wages and lead to smoking. Chapter 2, Your Money or Your Life: Managing Health, Managing Money, reveals that various health behaviors, such as persistent smoking, obesity, and lack of regular exercising, are related to non-collateralized debt. Moreover, these relationships are robust with respect to income, wealth, age and various health conditions. Chapter 3, Obesity and Nutritional Knowledge, examines the relationship between obesity and nutritional knowledge. Analysis shows that nutritional knowledge could be either preventive or reactive to obesity. On the preventive side, more nutritional knowledge is related to a lower probability of being obese or overweight. On the reactive side, being obese or overweight appears to induce greater nutritional knowledge.Ph.D.Health and Environmental SciencesLabor economicsPublic healthSocial SciencesUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/125372/2/3192648.pd

The effect of friends on adolescent body weight

Using the first wave of the National Longitudinal Study of Adolescent Health (Add Health) survey, this paper examines the influence of peers on adolescent weight. A peer group is defined as a close circle of friends that are identified by a respondent adolescent. After controlling for school fixed effects and for a number of individual, demographic and family characteristics, we find that a higher Body Mass Index (BMI) of close friends is correlated to a higher BMI of the respondent adolescent. However, after instrumental variable analysis is performed, the effect remains significant only among women. We also found that adolescents are more responsive to the body weight of their same gender friends.BMI Adolescents Peer pressure

The Role of Marketing Practices and Tobacco Control Initiatives on Smokeless Tobacco Sales, 2005–2010

Background: Little is known about how policies and industry activities impact smokeless tobacco demand. We examined how tobacco control policies and retail promotion may affect smokeless tobacco sales. Methods: We used Nielsen market-level retail scanner data for smokeless tobacco sales in convenience stores in 30 US regions from 2005 to 2010. Tobacco policy variables, including excise taxes, state tobacco control program expenditures, and clean indoor air laws, were merged to Nielsen markets. We estimated regression models for per capita unit sales. Results: Higher cigarette tax was significantly associated with lower sales volume of smokeless tobacco. Sales of smokeless tobacco in markets with a weight-based SLT excise tax were higher than in markets with an ad valorem tax. A higher average product price was associated with decreased sales overall but results varied by package quantity and brand. Conclusions: This study observed that smokeless tobacco products were both complements and substitutes to cigarettes. Thus, smokeless tobacco may act as complements for some population segments and substitutes for others. A weight-based tax generally favors premium smokeless tobacco products

The source matters: Agreement and accuracy of race and ethnicity codes in Medicare administrativeand assessment data

Background: Errors in racial and ethnic classification of Medicare beneficiaries limit health services research on minority health and health disparities among priority populations, including American Indians and Alaskan Natives. Objective: To compare the agreement and accuracy of three sources of race and ethnicity information contained in the Medicare data warehouse: 1) the Enrollment Database (EDB) which originate from Social Security data; 2) the Research Triangle Institute (RTI) imputed data based on name and geography; and 3) self-reported race and ethnicity data collected during routine home health care assessments as part of the Outcome and Assessment Information Set (OASIS). Subjects: Medicare beneficiaries over the age of 18 who received home health care in 2015 (N = 4,243,090). Measures: Percent agreement, sensitivity, specificity, positive predictive value, and Cohen’s kappa coefficient. Results: Compared to self-reported race/ethnicity data from OASIS, the RTI race code is more accurate than the EDB race code. Non-Hispanic whites and blacks were correctly classified by the RTI race code with 97% accuracy. However, more than half of American Indians/Alaskan Natives, one-fourth of Asian American/Pacific Islanders, and nearly one-tenth of Hispanics were misclassified by the RTI race code. Misclassification of race/ethnicity occurred less often for men, compared to women. Discussion: These findings highlight the strengths and limitations of using race/ethnicity classifications contained in Medicare administrative data. Health services and policy researchers should consider using self-identified race/ethnicity information to augment administrative data sources. This is especially important for research that aims to include Asian Americans/Pacific Islanders and American Indians/Alaskan Natives

Place of care in the last three years of life for Medicare beneficiaries

Abstract Background Most older adults prefer aging in place; however, patients with advanced illness often need institutional care. Understanding place of care trajectory patterns may inform patient-centered care planning and health policy decisions. The purpose of this study was to characterize place of care trajectories during the last three years of life. Methods Linked administrative, claims, and assessment data were analyzed for a 10% random sample cohort of US Medicare beneficiaries who died in 2018, aged fifty or older, and continuously enrolled in Medicare during their last five years of life. A group-based trajectory modeling approach was used to classify beneficiaries based on the proportion of days of institutional care (hospital inpatient or skilled nursing facility) and skilled home care (home health care and home hospice) used in each quarter of the last three years of life. Associations between group membership and sociodemographic and clinical predictors were evaluated. Results The analytic cohort included 199,828 Medicare beneficiaries. Nine place of care trajectory groups were identified, which were categorized into three clusters: home, skilled home care, and institutional care. Over half (59%) of the beneficiaries were in the home cluster, spending their last three years mostly at home, with skilled home care and institutional care use concentrated in the final quarter of life. One-quarter (27%) of beneficiaries were in the skilled home care cluster, with heavy use of skilled home health care and home hospice; the remaining 14% were in the institutional cluster, with heavy use of nursing home and inpatient care. Factors associated with both the skilled home care and institutional care clusters were female sex, Black race, a diagnosis of dementia, and Medicaid insurance. Extended use of skilled home care was more prevalent in southern states, and extended institutional care was more prevalent in midwestern states. Conclusions This study identified distinct patterns of place of care trajectories that varied in the timing and duration of institutional and skilled home care use during the last three years of life. Clinical, socioregional, and health policy factors influenced where patients received care. Our findings can help to inform personal and societal care planning