Using data on biomarkers and siblings to study early-life economic determinants of type-2 diabetes.

We study the effect of economic conditions early in life on the occurrence of type-2 diabetes in adulthood using contextual economic indicators and within-sibling pair variation. We use data from Lifelines: a longitudinal cohort study and biobank including 51,270 siblings born in the Netherlands from 1950 onward. Sibling fixed-effects account for selective fertility. To identify type-2 diabetes we use biomarkers on the hemoglobin A1c concentration and fasting glucose in the blood. We find that adverse economic conditions around birth increase the probability of type-2 diabetes later in life both in males and in females. Inference based on self-reported diabetes leads to biased results, incorrectly suggesting the absence of an effect. The same applies to inference that does not account for selective fertility.

The persistence of child and adolescence mental healthcare: results from registry data.

BACKGROUND: Previous studies on the persistence of child and adolescent mental healthcare do not consider the role of time-invariant individual characteristics. Estimating persistence of healthcare using standard linear models yields biased estimates due to unobserved heterogeneity and the autoregressive structure of the model. This study provides estimates of the persistence of child and adolescent mental healthcare taking these statistical issues into account. METHODS: We use registry data of more than 80,000 Dutch children and adolescents between 2000 and 2012 from the Psychiatric Case Registry Northern Netherlands (PCR-NN). In order to account for autocorrelation due to the presence of a lagged dependent variable and to distinguish between persistence caused by time-invariant individual characteristics and a direct care effect we use difference GMM-IV estimation. In further analyses we assess the robustness of our results to policy reforms, different definitions of care and diagnosis decomposition. RESULTS: All estimation results for the direct care effect (true state-dependence) show a positive coefficient smaller than unity with a main effect of 0.215 (p<0.01), which indicates that the process is stable. Persistence of care is found to be 0.065 (p<0.05) higher for females. Additionally, the majority of persistence of care appears to be associated with time-invariant characteristics. Further analyses indicate that (1) results are robust to different definitions of care and (2) persistence of care does not differ significantly across subgroups. CONCLUSIONS: The results indicate that the majority of mental healthcare persistence for children and adolescents is due to time-invariant individuals characteristics. Additionally, we find that in the absence of further shocks a sudden increase of 10 care contacts in the present year is associated with an average of less than 3 additional care contacts at some point in the future. This result provides essential information about the necessity of budget increases for future years in the case of exogenous increases in healthcare use.

Moral hazard and selection for voluntary deductibles.

This paper investigates whether the voluntary deductible in the Dutch health insurance system reduces moral hazard or acts only as a cost reduction tool for low-risk individuals. We use a sample of 14,089 observations, comprising 2,939 individuals over seven waves from the Longitudinal Internet Studies for the Social sciences panel for the analysis. We employ bivariate models that jointly model the choice of a deductible and health care utilization and supplement the identification with an instrumental variable strategy. The results show that the voluntary deductible reduces moral hazard, especially in the decision to visit a doctor (extensive margin) compared with the number of visits (intensive margin). In addition, a robustness test shows that selection on moral hazard is not present in this context.

Factors influencing short-term effectiveness and efficiency of the care provided by Dutch general practice mental health professionals.

Introduction: This study examined whether factors related to general practice mental health professionals (GP-MHPs), that is, characteristics of the professional, the function, and the care provided, were associated with short-term effectiveness and efficiency of the care provided by GP-MHPs to adults in Dutch general practice. Methods: A prospective cohort study was conducted among 320 adults with anxiety or depressive symptoms who had an intake consultation with GP-MHPs (n = 64). Effectiveness was measured in terms of change in quality-adjusted life years (QALYs) 3 months after intake; and efficiency in terms of net monetary benefit (NMB) at 3-month follow-up. A range of GP-MHP-related predictors and patient-related confounders was considered. Results: Patients gained on average 0.022 QALYs at 3-month follow-up. The mean total costs per patient during the 3-month follow-up period (€3,864; 95% confidence interval [CI]: €3,196-€4,731) decreased compared to that during the 3 months before intake (€5,220; 95% CI: €4,639-€5,925), resulting largely from an increase in productivity. Providing mindfulness and/or relaxation exercises was associated with QALY decrement. Having longer work experience as a GP-MHP (≥2 years) and having 10-20 years of work experience as a mental health care professional were negatively associated with NMB. Furthermore, a higher number of homework exercises tended to be related to less efficient care. Finally, being self-employed and being seconded from an organization in which primary care and mental health care organizations collaborate were related to a positive NMB, while being seconded from a mental health organization tended towards such a relationship. Conclusions: Findings seem to imply that the care provided by GP-MHPs contributes to improving patients' functioning. Some GP-MHP-related characteristics appear to influence short-term effectiveness and efficiency of the care provided. Further research is needed to confirm and better explain these findings and to examine longer-term effects.

Costs of people with diabetes in relation to average glucose control: an empirical approach controlling for year of onset cohorts.

OBJECTIVE: To estimate the impact of glycaemic control and time since diabetes diagnosis on care costs incurred by people with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS: Random-effects linear regression models were run to test the impact of average glucose control (HbA1c) and time since diabetes diagnosis on total care spending in people with T2DM, adjusting for year of onset and other covariates. Two datasets were linked, Vektis (healthcare costs reimbursed by the Dutch mandatory health insurance) and Zodiac (clinical and sociodemographic data). The sample includes 22,612 observations, grouped in 5653 individuals from the Northern part of the Netherlands, covering 4 years (2008-2011). RESULTS: A 1% point increase in HbA1c is associated with a 2.2% higher total care costs. However, when treatment modality is included, the results are modified. A 1% point increase (11 mol/mol) in HbA1c is significantly associated with 3.4% higher total care costs for individuals without glucose-lowering treatment. Being treated with insulin is significantly associated with an increase in costs of 30-38% for every additional percentage point of HbA1c, depending on the covariates included. Without controlling for year of onset, an additional year of diabetes duration relates to 2.6% higher care costs, while this is 4.9% controlling for year of onset. The effect of HbA1c and diabetes duration differs between types of costs. CONCLUSION: HbA1c, insulin treatment and diabetes duration are the main drivers of increasing care costs. The results signal the relevance of controlling for HbA1c together with treatment modality, diabetes duration and year of diagnosis effects.

Economic conditions at birth and cardiovascular disease risk in adulthood: Evidence from post-1950 cohorts.

Much of the literature that studies long-run effects of early-life economic conditions on health outcomes is based on pre-1940 birth cohorts. Early in these individuals' lives, public social safety nets were at best rudimentary, and female labor force participation was relatively low. We complement the evidence by studying the effects of regional business cycle variations in the post-1950 Netherlands on cardiovascular disease risk in adulthood. We use data from Lifelines, a large cohort study that covers socio-economic, biological and health information from over 75,000 individuals aged between 20 and 63. Cardiovascular risk index is constructed from an extensive set of biomarkers. The results show that for women a 1 percentage point increase in the provincial unemployment level leads to a 0.02 percentage point increase in the risk of a fatal cardiovascular event in the coming 10 years while the effect in men is not significant. We conclude that women born in adverse economic conditions experience higher cardiovascular risk.

Diabetes-Associated Factors as Predictors of Nursing Home Admission and Costs in the Elderly Across Europe.

OBJECTIVE: To identify the main factors associated with the use of nursing home facilities and to calculate their costs among older people with diabetes in Europe. METHODS: The sample included 48,464 individuals aged 50 years and older in 12 European countries participating in the Survey of Health, Aging, and Retirement in Europe study from 2004 to 2010. Cost data were obtained from the Organization for Economic Cooperation and Development and the World Bank. Logit regressions were used to assess the impact of diabetes, comorbidities, and functional status on the frequency of nursing home admission. Etiologic fractions were calculated to obtain the nursing home costs attributable to diabetes and its clinical and functional complications. RESULTS: Diabetes is a predictor for institutionalization. When adjusted for clinical and functional complications, impairment of physical function [mild: odds ratio (OR) 3.27; 95% confidence interval (CI) 2.60-4.19; moderate: OR 8.48, 95% CI 6.02-13.09; severe: OR 12.53, 95% CI 8.03-19.98] and cognition (OR 2.00, 95% CI 1.60-2.68), as well as stroke (OR 2.08, 95% CI 1.61-2.80) showed the strongest association with increased risk of institutionalization. Moreover, this relationship between diabetes, function, and cost was age-dependent, increasing as people get older. Total average nursing home costs incurred by patients with diabetes reached nearly US $13/capita, ranging between countries from US $61 to $0.5. Diabetes-related complications accounted for one-third of these costs (US $4) and, of these, 78% resulted from functional impairment. CONCLUSIONS: Diabetes is associated with higher risk of institutionalization even after adjusting for complications. Among them, functional impairment explains the major part of the association between diabetes and nursing home admission and leads to increasing costs.

The association between individual income and remaining life expectancy at the age of 65 in the Netherlands.

This article quantifies the association between individual income and remaining life expectancy at the statutory retirement age (65) in the Netherlands. For this purpose, we estimate a mortality risk model using a large administrative data set that covers the 1996-2007 period. Besides age and marital status, the model includes as covariates individual and spouse's income as well as a random individual specific effect. It thus allows for dynamic selection based on both observed and unobserved characteristics. We find that conditional on marital status, individual income is about equally strong and negatively associated with mortality risk for men and women and that spouse's income is only weakly associated with mortality risk for women. For both men and women, we quantify remaining life expectancy at age 65 for low-income individuals as approximately 2.5 years less than that for high-income individuals.