Essays on the Economics of Health

This thesis presents three empirical studies related to the economics of health interventions. All of them use data from England and are related to preventive care. The first study estimates the potential impact of early diagnosis programmes on medication, subjective health and lifestyle. By taking advantage of the survey design of the English Longitudinal Study of Ageing (ELSA), a regression discontinuity design based on the blood pressure of the respondents allows for estimates free of selection bias due to screening. There is evidence of a temporal increase in the use of medication as a treatment for the condition, and induced lifestyle changes. The second study proposes a structural dynamic life-cycle model for studying the economic value of the adoption of medical innovations. It allows for both cost-benefit and cost-effectiveness calculations, by considering long-run gains on productivity and on welfare derived from adjusting savings and labour supply throughout life. In particular, the case of a medication that reduces the odds of developing cardiovascular diseases, namely statins, is considered. Using data from ELSA, it is possible to calculate the value of such treatment, and to consider counterfactual policy scenarios. The last study proposes an empirical test for determining whether rewarded tasks are cost complements or substitutes in a pay for performance scheme with kinks on linear task-specific reward functions. The test is based on the insensitivity of effort exerted on a particular task to variations in the price of competing tasks for agents who are bunched near the kink. As a case study, we consider the case of the Quality and Outcomes Framework, which is a pay for performance scheme for family doctors in the UK. We found no evidence of effort-diversion as a result of the changes introduced in 2011

Measuring the Quality of Postgraduate Physician Assistant Fellowship/Residency Programs with a Surgical Focus

Introduction Postgraduate programs for PAs provide formal postgraduate training for clinical specialty areas. These programs are intended to provide intense specialty training in various fields, as well as to standardize education beyond the entry level. The purpose of this descriptive study was to determine if there are consistent trends or clear differences in program length, approach to training, validation of learning, and accreditation through the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) for postgraduate programs with a surgical focus in the United States. Methods This study is a non-experimental and descriptive research design. Program directors were mailed a survey consisting of questions about program information, prerequisites, curriculum, training, evaluation, and perspective of graduates after completion of program. Results Of the 29 program directors who were mailed a survey, 62% responded with completed surveys (n=18). 38% of respondents (n=11) stated the annual salary ranged from $40,000 to$60,000. Five programs were accredited by the ARC-PA and four programs were actively seeking accreditation. The majority of program directors believed the attitude of the medical community is higher towards PAs who complete a postgraduate education program. Conclusion As postgraduate programs increase in popularity, it is important to evaluate the standardization of the programs nationally. Papers like this will help drive a consistent approach to PA fellowship development and evolution. As healthcare evolves, there is a need to develop highly specialized physician assistants and place a premium on retaining them within the healthcare systems. Obtaining information on standard practices across postgraduate PA programs helps determine what requirements should be upheld nationally

Obesity and contraceptive use: impact on cardiovascular risk.

Obesity and oestrogen containing contraceptive products are well-known independent cardiovascular risk factors. However, a significant number of obese women continue to receive prescriptions of hormonal products that contain oestrogens for their contraception. We have conducted a narrative review to discuss the latest evidence, ongoing research, and controversial issues on the synergistic effect of obesity and contraceptive use, in terms of cardiovascular risk. There is compelling evidence of an interplay between obesity and contraception in increasing cardiovascular risk. Women who present both obesity and use of combined oral contraceptives (COCs) have a greater risk (between 12 and 24 times) to develop venous thromboembolism than non-obese non-COC users. Data here discussed offer new insights to increase clinicians' awareness on the cardiovascular risk in the clinical management of obese women. The synergistic effect of obesity and COCs on deep venous thrombosis risk must be considered when prescribing hormonal contraception. Progestin-only products are a safer alternative to COCs in patients with overweight or obesity. Obese women taking contraceptives should be viewed as an 'at risk' population, and as such, they should receive advice to change their lifestyle, avoiding other cardiovascular risk factors, as a form of primary prevention. This indication should be extended to young women, as data show that COCs should be avoided in obese women of any age

A qualitative study of anticipated barriers and facilitators to the implementation of nurse-delivered alcohol screening, brief intervention, and referral to treatment for hospitalized patients in a Veterans Affairs medical center

Background: Unhealthy alcohol use includes the spectrum of alcohol consumption from risky drinking to alcohol use disorders. Routine alcohol screening, brief intervention (BI) and referral to treatment (RT) are commonly endorsed for improving the identification and management of unhealthy alcohol use in outpatient settings. However, factors which might impact screening, BI, and RT implementation in inpatient settings, particularly if delivered by nurses, are unknown, and must be identified to effectively plan randomized controlled trials (RCTs) of nurse-delivered BI. The purpose of this study was to identify the potential barriers and facilitators associated with nurse-delivered alcohol screening, BI and RT for hospitalized patients. Methods: We conducted audio-recorded focus groups with nurses from three medical-surgical units at a large urban Veterans Affairs Medical Center. Transcripts were analyzed using modified grounded theory techniques to identify key themes regarding anticipated barriers and facilitators to nurse-delivered screening, BI and RT in the inpatient setting. Results: A total of 33 medical-surgical nurses (97% female, 83% white) participated in one of seven focus groups. Nurses consistently anticipated the following barriers to nurse-delivered screening, BI, and RT for hospitalized patients: (1) lack of alcohol-related knowledge and skills; (2) limited interdisciplinary collaboration and communication around alcohol-related care; (3) inadequate alcohol assessment protocols and poor integration with the electronic medical record; (4) concerns about negative patient reaction and limited patient motivation to address alcohol use; (5) questionable compatibility of screening, BI and RT with the acute care paradigm and nursing role; and (6) logistical issues (e.g., lack of time/privacy). Suggested facilitators of nurse-delivered screening, BI, and RT focused on provider- and system-level factors related to: (1) improved provider knowledge, skills, communication, and collaboration; (2) expanded processes of care and nursing roles; and (3) enhanced electronic medical record features. Conclusions: RCTs of nurse-delivered alcohol BI for hospitalized patients should include consideration of the following elements: comprehensive provider education on alcohol screening, BI and RT; record-keeping systems which efficiently document and plan alcohol-related care; a hybrid model of implementation featuring active roles for interdisciplinary generalists and specialists; and ongoing partnerships to facilitate generation of additional evidence for BI efficacy in hospitalized patients

On the Performance of Spatially Correlated Large Antenna Arrays for Millimeter-Wave Frequencies

A spatially correlated large antenna array operating at millimeter-wave (mmWave) frequencies is considered. Based on a Saleh-Valenzuela channel model, closed-form expressions of the 3-D spatial correlation (SC) for wide, narrow, and Von Mises power elevation spectra (PESs) are analytically derived. The effects of the PES on the convergence to massive multiple-input-multiple-output properties are then illustrated by defining and deriving a diagonal dominance metric. Numerically, the effects of antenna element mutual coupling (MC) are shown on the effective SC, eigenvalue structure, and mmWave user rate for different antenna topologies. It is concluded that although MC can significantly reduce SC for side-by-side dipole antenna elements, the change in antenna effective gain (and, therefore, signal-to-noise ratio) caused by MC becomes a dominating effect and ultimately determines the antenna array performance. The user rate of an mmWave system with hybrid beamforming, using an orthogonal matching pursuit (OMP) algorithm, is then shown for different antenna topologies with dipole and cross-polarized (x-pol) antenna elements. It is seen that even for small numbers of radio frequency chains, the OMP algorithm works well relative to the fully digital case for channels with high SC, such as the x-pol antenna array

KCC2 is required for the survival of mature neurons but not for their development

The K+/Cl- co-transporter KCC2 (SLC12A5) allows mature neurons in the CNS to maintain low intracellular Cl- levels that are critical in mediating fast hyperpolarizing synaptic inhibition via type A γ-aminobutyric acid receptors (GABAARs). In accordance with this, compromised KCC2 activity results in seizures, but whether such deficits directly contribute to the subsequent changes in neuronal structure and viability that lead to epileptogenesis, remains to be assessed. Canonical hyperpolarizing GABAAR currents develop postnatally which reflect a progressive increase in KCC2 expression levels and activity. To investigate the role that KCC2 plays in regulating neuronal viability and architecture we have conditionally ablated KCC2 expression in developing and mature neurons. Decreasing KCC2 expression in mature neurons resulted in the rapid activation of the extrinsic apoptotic pathway. Intriguingly, direct pharmacological inhibition of KCC2 in mature neurons was sufficient to rapidly induce apoptosis, an effect that was not abrogated via blockade of neuronal depolarization using Tetrodotoxin (TTX). In contrast, ablating KCC2 expression in immature neurons had no discernable effects on their subsequent development, arborization or dendritic structure. However, removing KCC2 in immature neurons was sufficient to ablate the subsequent postnatal development of hyperpolarizing GABAAR currents. Collectively, our results demonstrate that KCC2 plays a critical role in neuronal survival by limiting apoptosis, and mature neurons are highly sensitive to the loss of KCC2 function. In contrast, KCC2 appears to play a minimal role in mediating neuronal development or architecture

Giant aneurysm of the atrial septum associated with premature closure of foramen ovale

Premature closure or restriction of foramen ovale (PCFO) is a rare congenital anomaly that can lead to a wide spectrum of cardiac malformations. This spectrum of secondary malformations appears to depend on the gestational timing of closure of the foramen ovale and to the degree of restriction. Earlier in the gestation, closure of the foramen has been associated with severe hypoplasia of the left ventricle whereas later closure has been associated with right heart failure and rarely with the formation of an aneurysm of the atrial septum. We describe the case of a 1 day old infant in whom PCFO resulted in severe right heart failure in addition to the formation of a giant atrial septal aneurysm

How to Constrain Your M Dwarf. II. The Mass–Luminosity–Metallicity Relation from 0.075 to 0.70 Solar Masse

The mass-luminosity relation for late-type stars has long been a critical tool for estimating stellar masses. However, there is growing need for both a higher-precision relation and a better understanding of systematic effects (e.g., metallicity). Here we present an empirical relationship between Mks and mass spanning $0.075M_\odot<M<0.70M_\odot$. The relation is derived from 62 nearby binaries, whose orbits we determine using a combination of Keck/NIRC2 imaging, archival adaptive optics data, and literature astrometry. From their orbital parameters, we determine the total mass of each system, with a precision better than 1% in the best cases. We use these total masses, in combination with resolved Ks magnitudes and system parallaxes, to calibrate the mass-Mks relation. The result can be used to determine masses of single stars with a precision of 2-3%, which we confirm by a comparison to dynamical masses from the literature. The precision is limited by scatter around the best-fit relation beyond mass uncertainties, perhaps driven by intrinsic variation in the mass-Mks relation or underestimated measurement errors. We find the effect of [Fe/H] on the mass-Mks relation is likely negligible for metallicities in the Solar neighborhood (0.0+/-2.2% change in mass per dex change in [Fe/H]). This weak effect is consistent with predictions from the Dartmouth Stellar Evolution Database, but inconsistent with those from MESA Isochrones and Stellar Tracks. A sample of binaries with a wider range of abundances will be required to discern the importance of metallicity in extreme populations (e.g., in the Galactic Halo or thick disk).Comment: Published in ApJ/AAS Journals. Comments welcome. Code for computing mass posteriors from Ks+distance at https://github.com/awmann/M_-M_K

Tuning ultrafast electron thermalization pathways in a van der Waals heterostructure

Ultrafast electron thermalization - the process leading to Auger recombination, carrier multiplication via impact ionization and hot carrier luminescence - occurs when optically excited electrons in a material undergo rapid electron-electron scattering to redistribute excess energy and reach electronic thermal equilibrium. Due to extremely short time and length scales, the measurement and manipulation of electron thermalization in nanoscale devices remains challenging even with the most advanced ultrafast laser techniques. Here, we overcome this challenge by leveraging the atomic thinness of two-dimensional van der Waals (vdW) materials in order to introduce a highly tunable electron transfer pathway that directly competes with electron thermalization. We realize this scheme in a graphene-boron nitride-graphene (G-BN-G) vdW heterostructure, through which optically excited carriers are transported from one graphene layer to the other. By applying an interlayer bias voltage or varying the excitation photon energy, interlayer carrier transport can be controlled to occur faster or slower than the intralayer scattering events, thus effectively tuning the electron thermalization pathways in graphene. Our findings, which demonstrate a novel means to probe and directly modulate electron energy transport in nanoscale materials, represent an important step toward designing and implementing novel optoelectronic and energy-harvesting devices with tailored microscopic properties.Comment: Accepted to Nature Physic