Essays in Health Economics

This dissertation consists of three chapters, each of which examines a different topic within the sphere the health economics. In the first chapter, I use unique, proprietary medical practice data from 2019 to investigate the relationship between physicians, various categories of non-physician clinical staff, and other non-labor inputs in the production of patient office visits. Preliminary results suggest that, for some inputs, their marginal productivity has fallen over time. Cross-input elasticities generally match in terms of their historical classification as either compliments or substitutes, although the magnitudes of the elasticities have also fallen over time. One possible interpretation of these results is that medical practices have already adapted to changes in the economic, regulatory, and technological environment in which they practice and have achieved the easy efficiency gains that were once readily available to them. In the second chapter, I use 17 years of hospital cost report data and a difference-in-differences identification strategy to examine the financial performance and utilization of safety-net hospitals in Massachusetts following the state’s 2006 reform. The results suggest the largest safety-net hospitals experienced a decline in patient revenue because of the reform and may have responded by transferring operations from inpatient facilities to outpatient centers as a cost-cutting maneuver. Other safety-net hospitals, however, did not experience the same decline in patient revenue. Should states need to reduce their supplemental payments to safety-net hospitals as part of national health care reform, these results suggest they should target their remaining funds to their most financially vulnerable safety-net hospitals. The final chapter, co-authored with James Marton and Benjamin Ukert, evaluates the impact of the Affordable Care Act Medicaid expansion on health insurance coverage, access to care, and self-reported health for individuals with and without chronic conditions. Using five years of post-reform data (2014–2018) from the Behavioral Risk Factor Surveillance System and a difference-in-differences identification strategy, we find that the reform led to improvements in access to care and self-reported health for both groups. Although these improvements are mostly larger in magnitude for individuals with chronic conditions, the differences in magnitude are not statistically significant

Testing the Effects of Adaptive Learning Courseware on Student Performance: An Experimental Approach

An increasing number of college and university courses are being offered in an online format. Even for courses offered face-to-face, instructors are increasingly turning toward use of online platforms to help with student learning, especially for courses with high enrollment. This study tests the efficacy of adaptive learning platforms in a sample of undergraduate students in a large urban university, using an experimental design that compares the learning outcomes of students in classrooms that used an adaptive learning tool to those who did not. The results indicate that better performing students, particularly female students, benefit the most from using adaptive learning tools

Behavioral Self-management in an Inpatient Headache Treatment Unit: Increasing Adherence and Relationship to Changes in Affective Distress

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/74935/1/j.1526-4610.2000.00057.x.pd

Facilitation of Verbal Labeling in Adult Aphasia by Gestural, Verbal, or Verbal Plus Gestural Training

TB

Caregiver self-efficacy providing nutritional support for pediatric patients undergoing hematopoietic stem cell transplant is associated with psychosocial factors

IntroductionCaregiver self-efficacy in providing nutritional support to pediatric hematopoietic stem cell transplantation (HSCT) patients has been little studied despite the increased risk of these children potentially being over- or under-nourished after HSCT, and nutritional status could possibly affect treatment outcomes. The current study aimed to describe caregiver dietary self-efficacy and its associated psychosocial factors and barriers to following dietary recommendations.MethodsCaregivers completed questionnaires pre-HSCT and 30 days, 100 days, and one year post-HSCT. A subset provided a 24-h recall of food intake.ResultsResults showed generally high caregiver confidence and low difficulty supporting their child nutritionally. However, lower confidence was associated with higher caregiver depression, anxiety, and stress 30 days post-HSCT. Further, higher difficulty at various time points was correlated with lower income, higher depression and anxiety, stress, and miscarried helping (i.e., negative caregiver-child interactions surrounding eating), as well as child overweight status and failure to meet protein intake guidelines. Nutritional criteria for protein, fiber, added sugar, and saturated fat were met by 65%, 0%, 75%, and 75%, respectively. Caregiver attitudes and child behavior were the most frequently reported barriers to healthy eating.DiscussionResults suggest that directing resources to caregivers struggling emotionally, economically, or transactionally could support pediatric patients undergoing HSCT in maintaining optimal nutritional status

Parental stress before, during, and after pediatric stem cell transplantation: a review article

Goals of work: Pediatric stem cell transplantation (SCT) is a stressful treatment for children with relapsed or high-risk malignancies, immune deficiencies and certain blood diseases. Parents of children undergoing SCT can experience ongoing stress related to the SCT period. The aim of this article was to present a literature review of articles on parental distress and adaptation before, during, and after SCT and to identify risk and protective factors. Materials and methods: The review was conducted systematically by using PubMed, Web of Science, PsychInfo, and Picarta databases. Eighteen articles met our inclusion criteria: publishing date between January 1, 1990 and January 1, 2009; studies concerning parents of children undergoing SCT; studies examining the psychological adjustment and/or stress reactions of parents as primary outcomes and studies available in English. Main results: Highest levels of parental stress are reported in the period preceding SCT and during the acute phase. Stress levels decrease steadily after discharge in most parents. However, in a subgroup of parents, stress levels still remain elevated post-SCT. Parents most at risk in the longer term display highest levels of stress during the acute phase of the SCT. Conclusions: Psychosocial assessment before SCT, during the acute phase and in the longer term, is necessary to identify parents in need for support and follow-up care

Patient-Reported Outcomes and Socioeconomic Status as Predictors of Clinical Outcomes after Hematopoietic Stem Cell Transplantation: A Study from the Blood and Marrow Transplant Clinical Trials Network 0902 Trial

This secondary analysis of a large, multi-center Blood and Marrow Transplant Clinical Trials Network (BMT CTN) randomized trial assessed whether patient-reported outcomes (PROs) and socioeconomic status (SES) before hematopoietic stem cell transplantation (HCT) are associated with each other and predictive of clinical outcomes including time to hematopoietic recovery, acute graft-versus-host disease, hospitalization days, and overall survival (OS) among 646 allogeneic and autologous HCT recipients. Pre-transplant Cancer and Treatment Distress (CTXD), Pittsburgh Sleep Quality Index (PSQI), and mental and physical component scores (MCS and PCS) of the SF-36 were correlated with each other and with SES variables. PROs and SES variables were further evaluated as predictors of clinical outcomes, with the PSQI and CTXD evaluated as OS predictors (p<.01 considered significant given multiple testing). Lower attained education was associated with increased distress (p=.002); lower income was related to worse physical functioning (p=.005) and increased distress (p=.008); lack of employment pre-transplant was associated with worse physical functioning (p<.01); unmarried status was associated with worse sleep (p=.003). In this large heterogeneous cohort of HCT recipients, while PROs and SES variables were correlated at baseline, they were not associated with any clinical outcomes. Future research should focus on HCT recipients at greater psychosocial disadvantage