Economics of Child Protection: Maltreatment, Foster Care, and Intimate Partner Violence.

Violence within families and child neglect are strikingly common: 700,000 children are found to be victims of abuse or neglect in the United States each year; over the course of childhood, 6% of children are placed in foster care, and 18% witness intimate partner violence. These children are at much higher risks of homelessness, criminal justice involvement, unemployment, and chronic health conditions compared to their neighbors. This article reviews the state of the economics literature on the causes and consequences of child maltreatment and intimate partner violence and calls for greater research into interventions aimed at improving child well-being.

Uncovering waste in US healthcare: Evidence from ambulance referral patterns.

There is widespread agreement that the US healthcare system wastes as much as 5% of GDP, yet much less agreement on the source of the waste. This paper uses the effectively random assignment of patients to ambulance companies to generate comparisons across similar patients treated at different hospitals. We find that assignment to hospitals whose patients receive large amounts of care over the three months following a health emergency have only modestly better survival outcomes compared to hospitals whose patients receive less. Outcomes are related to different forms of spending. Patients assigned to hospitals with high levels of inpatient spending are more likely to survive to one year, while high levels of outpatient spending result in lower survival. In particular, we discovered that downstream spending at skilled nursing facilities (SNF) is a strong predictor of mortality. Our results highlight SNF admissions as a quality measure to complement the commonly used measure of hospital readmissions and suggest that in the search for waste in the US healthcare, post-acute SNF care is a prime candidate.

Blood Pressure Success Zone: You Auto Know. A worksite-based program to improve blood pressure control among auto workers.

Worksite-based wellness programs can be a means to improve employee health awareness and potentially reduce health care costs. The "BP Success Zone: You Auto Know" program was a worksite-based intervention to reduce the incidence of hypertension among auto workers at Chrysler LLC. This 6-month program comprised an intervention consisting of education, awareness, and support intended to intensify the engagement of Chrysler employees at moderate-to-high cardiovascular risk who were not adequately controlling their blood pressure. The 539 participants had systolic blood pressure of ≥ 120 mmHg, diastolic blood pressure of ≥ 80 mmHg, or were told by a health care provider that they had hypertension. Questionnaires compared awareness and knowledge of hypertension and lifestyle choices before and at the end of the intervention. After the 6-month intervention, mean systolic blood pressure had decreased from a baseline value of 133 mmHg to 129 mmHg (P < 0.0001) and mean blood diastolic pressure had decreased from 85 mmHg to 82 mmHg (P < 0.0001). The proportion of participants with controlled blood pressure increased from 52% to 62% (P < 0.0001) over the course of the intervention. Eighty-six percent of the participants reported that the program helped them to better understand and control their blood pressure and 84% reported that they had a better understanding of their treatment options. In conclusion, a program of hypertension awareness, education, and lifestyle modification helped to improve blood pressure control among a group of Chrysler LLC employees.

A health outcome assessment of the Cardio Metabolic Mission Health Program at Novartis.

OBJECTIVE: To assess the impact of the Novartis Cardio Metabolic Program--an education, awareness, and health management initiative--on hypertension, hyperlipidemia, diabetes mellitus, and obesity within the Novartis employee population. METHODS: A prospective, 6-month pre-/post assessment to determine improvement in blood pressure (BP) control and risk factors after implementation of Novartis Cardio Metabolic. RESULTS: A total of 238 subjects with cardiovascular risk factors participated. In the hypertension cohort, overall BP control improved from 38% at baseline to 79% at follow-up (P < 0.0001). In the hyperlipidemia cohort, low-density lipoprotein cholesterol control improved significantly between baseline and study end (22% to 34%, P = 0.0004). In the diabetes mellitus cohort, the rate of glycosylated hemoglobin control increased from 83.7% to 86.2% (P = 0.69). There was a significant decrease in body mass index at follow-up (P < 0.0001). CONCLUSION: Novartis Cardio Metabolic educational and health interventions helped to improve health awareness among Novartis employees.

Understanding barriers to medication adherence in the hypertensive population by evaluating responses to a telephone survey.

BACKGROUND: Although hypertension is a major risk factor for cardiovascular disease, adherence to hypertensive medications is low. Previous research identifying factors influencing adherence has focused primarily on broad, population-based approaches. Identifying specific barriers for an individual is more useful in designing meaningful targeted interventions. Using customized telephonic outreach, we examined specific patient-reported barriers influencing hypertensive patients' nonadherence to medication in order to identify targeted interventions. METHODS: A telephone survey of 8692 nonadherent hypertensive patients was conducted. The patient sample comprised health plan members with at least two prescriptions for antihypertensive medications in 2008. The telephone script was based on the "target" drug associated with greatest nonadherence (medication possession ratio [MPR] <80%) during the four-month period preceding the survey. RESULTS: The response rate was 28.2% of the total sample, representing 63.8% of commercial members and 37.2% of Medicare members. Mean age was 63.4 years. Mean MPR was 61.0% for the target drug. Only 58.2% of Medicare respondents and 60.4% of commercial respondents reported "missing a dose of medication". The primary reason given was "forgetfulness" (61.8% Medicare, 60.8% commercial), followed by "being too busy" (2.7% Medicare, 18.5% commercial) and "other reasons" (21.9% Medicare, 8.1% commercial) including travel, hospitalization/sickness, disruption of daily events, and inability to get to the pharmacy. Prescription copay was a barrier for less than 5% of surveyed patients. CONCLUSION: Our findings indicate that events interfering with daily routine had a significant impact on adherence. Medication adherence appears to be a patterned behavior established through the creation of a routine and a reminder system for taking the medication. Providers should assess patients' daily schedules and medication-taking competency to develop and promote a medication routine.

Returns to Local-Area Healthcare Spending: Evidence from Health Shocks to Patients Far From Home.

Healthcare spending varies widely across markets, and previous empirical studies find little evidence that higher spending translates into better health outcomes. The main innovation in this paper exploits this cross-sectional variation in hospital spending in a new way by considering patients who are exposed to healthcare systems not designed for them: patients far from home when a health emergency strikes. Visitors to Florida who become ill in high-spending areas have significantly lower mortality rates compared to visitors in lower-spending areas. The results are robust within groups of similar visitors and within groups of destinations that appear to be close demand substitutes-areas that likely attract similar visitors.

The role of hospital heterogeneity in measuring marginal returns to medical care: a reply to Barreca, Guldi, Lindo, and Waddell.

In Almond et al. (2010), we describe how marginal returns to medical care can be estimated by comparing patients on either side of diagnostic thresholds. Our application examines at-risk newborns near the very low birth weight threshold at 1500 g. We estimate large discontinuities in medical care and mortality at this threshold, with effects concentrated at "low-quality" hospitals. Although our preferred estimates retain newborns near the threshold, when they are excluded the estimated marginal returns decline, although they remain large. In low-quality hospitals, our estimates are similar in magnitude regardless of whether these newborns are included or excluded.

Returns to physician human capital: evidence from patients randomized to physician teams.

Physicians play a major role in determining the cost and quality of healthcare, yet estimates of these effects can be confounded by patient sorting. This paper considers a natural experiment where nearly 30,000 patients were randomly assigned to clinical teams from one of two academic institutions. One institution is among the top medical schools in the U.S., while the other institution is ranked lower in the distribution. Patients treated by the two programs have similar observable characteristics and have access to a single set of facilities and ancillary staff. Those treated by physicians from the higher ranked institution have 10-25% less expensive stays than patients assigned to the lower ranked institution. Health outcomes are not related to the physician team assignment. Cost differences are most pronounced for serious conditions, and they largely stem from diagnostic-testing rates: the lower ranked program tends to order more tests and takes longer to order them.

ESTIMATING MARGINAL RETURNS TO MEDICAL CARE: EVIDENCE FROM AT-RISK NEWBORNS.

A key policy question is whether the benefits of additional medical expenditures exceed their costs. We propose a new approach for estimating marginal returns to medical spending based on variation in medical inputs generated by diagnostic thresholds. Specifically, we combine regression discontinuity estimates that compare health outcomes and medical treatment provision for newborns on either side of the very low birth weight threshold at 1500 grams. First, using data on the census of US births in available years from 1983-2002, we find that newborns with birth weights just below 1500 grams have lower one-year mortality rates than do newborns with birth weights just above this cutoff, even though mortality risk tends to decrease with birth weight. One-year mortality falls by approximately one percentage point as birth weight crosses 1500 grams from above, which is large relative to mean infant mortality of 5.5% just above 1500 grams. Second, using hospital discharge records for births in five states in available years from 1991-2006, we find that newborns with birth weights just below 1500 grams have discontinuously higher charges and frequencies of specific medical inputs. Hospital costs increase by approximately $4,000 as birth weight crosses 1500 grams from above, relative to mean hospital costs of $40,000 just above 1500 grams. Under an assumption that observed medical spending fully captures the impact of the "very low birth weight" designation on mortality, our estimates suggest that the cost of saving a statistical life of a newborn with birth weight near 1500 grams is on the order of $550,000 in 2006 dollars.

Economic impact of the BP DownShift Program on blood pressure control among commercial driver license employees.

OBJECTIVE: To assess the economic impact of a hypertension educational and awareness program ("BP Downshift") on improvement in blood pressure among commercial driver license (CDL) employees in a large southeastern U.S. electric utility company. METHODS: An economic simulation model was developed to evaluate the costs/cost savings the company realized from implementation of the BP DownShift Program in terms of changes in work productivity, CDL certification status, hypertension treatment, cardiovascular disease events, and diabetes care. RESULTS: Model results showed a 16.3% (more than $540,000) reduction in costs for a sample of 499 CDL employees over 2 years. On a per-employee basis, 2-year cost savings were estimated to be $1084, or $542 annually. CONCLUSIONS: Study results will interest employers who are considering using disease management and health promotion programs to control costs of hypertension and other chronic illnesses.

Blood pressure control among diabetes patients within a managed care setting.

Blood pressure (BP) control is a key component of diabetes management. BP control in patients with diabetes was assessed across 4 Colorado health plans. BP was obtained through retrospective chart reviews, and BP control was defined as <130/80 mm Hg. The study included 1,445 diabetic patients in 2004 and 1,423 diabetic patients in 2005. BP control did not improve significantly from 2004 to 2005; in 2004, 33.1% had controlled BP, compared with 35.2% in 2005. Women were more likely to have controlled BP than men, and younger patients were more likely to have controlled BP than older patients. Two of the 4 plans showed significant improvement in BP control, whereas the proportion of patients with BP controlled declined in 2 health plans. More aggressive disease management and pharmacologic treatment of blood pressure is needed to improve the cardiovascular health of patients with diabetes.

Impact of a hypertension management/health promotion program on commercial driver's license employees of a self-insured utility company.

OBJECTIVE: Federal regulations governing transportation safety disqualify commercial drivers with persistent uncontrolled hypertension. We sought to determine whether a hypertension management and health promotion program designed for commercial drivers improved blood pressure (BP) outcomes among drivers employed by a self-insured utility company. METHODS: This retrospective study examined the employment-related medical examinations of 501 randomly selected commercial drivers for measurements of BP, height, and weight taken before and after the intervention. RESULTS: After the program, significantly fewer employees had uncontrolled hypertension according to the Department of Transportation hypertension guidelines (17.2% vs 26.1%, P < 0.01). This improvement was consistent across subgroups defined by diabetes, obesity, and use of antihypertensive medication. CONCLUSIONS: An education program improved control of BP among commercial drivers, improving their health and safety, and reducing the number at high risk of medical disqualification.

The impact of psoriasis on health care costs and patient work loss.

BACKGROUND: There are few comprehensive estimates of the cost of psoriasis in the United States. OBJECTIVE: We sought to quantify the incremental direct medical and indirect work loss costs associated with psoriasis. METHODS: A de-identified claims database from 31 self-insured employers during the period 1998 to 2005 was used. Patients with at least two psoriasis diagnosis claims (N = 12,280) were compared with 3 control subjects (matched on year of birth and sex) without psoriasis. Multivariate two-part regression analysis was used to isolate the incremental cost of psoriasis by controlling for comorbidities and other confounding factors. RESULTS: After multivariate adjustment, the incremental direct and indirect costs of psoriasis were approximately $900 and $600 (P < .001) per patient per year, respectively. LIMITATIONS: The database used in this study does not contain information on patient out-of-pocket costs or loss of productivity costs at work. CONCLUSION: The incremental cost of psoriasis is approximately $1500 per patient per year, with work loss costs accounting for 40% of the cost burden.

The direct and indirect cost burden of atopic dermatitis: an employer-payer perspective.

The goal of this study was to quantify the incremental direct medical and indirect work-loss costs associated with patients diagnosed with atopic dermatitis (AD). A de-identified administrative claims database was used comprising 5.1 million covered beneficiaries from 31 Fortune 500 self-insured employers between 1998 and 2005. Patients with at least two AD diagnosis claims (N = 13,749) were compared with three matched controls (based on yr of birth and gender) with no AD diagnosis (N = 41,247). In addition, a multivariate two-part regression analysis was used to isolate the cost increase attributable to AD by controlling for confounding factors such as age, gender, health plan type, comorbidities, organ transplantation, industry of employer, region, and year. Direct medical and indirect work-loss costs for the AD group were higher on average by $88 and $64 per patient per month, respectively (both P< .001). After multivariate adjustment, the total incremental cost per patient per month for the AD group was $83 (direct: $52, P< .001; indirect: $31, P< .001). Employer-payers experience a significant annual cost burden of $991 per patient attributable to AD. Employee disability and increased sick days account for 38% of the cost burden.

Child Protection and Child Outcomes: Measuring the Effects of Foster Care.

Little is known about the effects of placing children who are abused or neglected into foster care. This paper uses the placement tendency of child protection investigators as an instrumental variable to identify causal effects of foster care on long-term outcomes--including juvenile delinquency, teen motherhood, and employment--among children in Illinois where a rotational assignment process effectively randomizes families to investigators. Large marginal treatment effect estimates suggest caution in the interpretation, but the results suggest that children on the margin of placement tend to have better outcomes when they remain at home, especially older children.

Patient and physician perspectives vary on atopic dermatitis.

We compared the written responses of physicians (n=303) and patients (n=961) from a nationwide US survey concerning atopic dermatitis (AD). Physicians, primarily dermatologists, responded to 32 questions, and patients responded to 44 questions about AD and its management. Most physicians and patients were in agreement regarding disease severity, the relative lack of effectiveness of over-the-counter products, concerns about drug adverse effects, and the need for more patient support groups. However, physicians were more concerned about long-term adverse effects than were patients. Additionally, 91% of physicians versus 46% of patients rated prescription medications as "moderately" or "very" effective. Patients were generally pleased with their overall AD-related medical care: 42% were "a lot" or "very" satisfied, while only 8% were dissatisfied. Although physician and patient perceptions sometimes differed, both groups preferred treatments offering greater effectiveness, fewer adverse effects, and greater applicability to the pediatric population.

Perceptions of physicians and pediatric patients about atopic dermatitis, its impact, and its treatment.

The National Eczema Association for Science and Education surveyed 429 patients with atopic dermatitis or their parents and 303 physicians about atopic dermatitis, its effect on quality of life (QOL), and the adequacy of available treatments. The physician survey focused on disease severity and management; the patient survey, on disease severity, impact on QOL, and treatment preferences. Physician and patient/parent respondents generally agreed about their assessments of disease severity, poor effectiveness of over-the-counter products, and the need for more patient support groups and toll-free phone information. Atopic dermatitis significantly impacts QOL in children, particularly in those with moderate-to-severe disease. New treatments should offer enhanced efficacy, less frequent application, and fewer adverse effects.

Atopic dermatitis is associated with a decrement in health-related quality of life.

BACKGROUND: Although atopic dermatitis is a chronic skin disease that can have a major impact on a patient's life, the burden of illness associated with this condition has not been well characterized. OBJECTIVE: To determine the health-related quality of life (HRQL) of patients with atopic dermatitis by disease severity and to compare it with that of the general public and of patients suffering from other chronic illnesses or skin disorders. METHODS: Two hundred and thirty-nine atopic dermatitis patients aged 4-70 years completed the Medical Outcomes Study Short Form-36 Health Survey (SF-36) and the Dermatology Life Quality Index (DLQI) or the Children's Dermatology Life Quality Index. These HRQL scores were compared by self-reported patient disease severity ratings. Health-related quality of life scores were compared with those of the general population and those of patients with other chronic conditions (clinical depression, hypertension, type 2 diabetes) or skin disease (psoriasis). Dermatology Life Quality Index scores were also compared with those of other skin diseases (such as psoriasis, Darier's disease, and Hailey-Hailey disease). RESULTS: Patients with atopic dermatitis had inferior scores on the SF-36 vitality, social functioning, and mental health subscales compared with individuals in the general population. In seven of eight subscales, individuals reporting more severe disease had inferior DLQI and SF-36 scores. Patients with atopic dermatitis had inferior mental health scores compared with those with diabetes or hypertension, and inferior social functioning scores compared with patients with hypertension. When compared with a psoriasis cohort, patients with atopic dermatitis had inferior scores in the role-physical, vitality, social functioning, role-emotional, and mental health SF-36 domains. Patients with atopic dermatitis had similar DLQI scores to patients with other chronic dermatologic diseases. CONCLUSIONS: These results demonstrate that atopic dermatitis has an impact on HRQL, particularly in social functioning and psychological wellbeing. Patient-assessed severity of atopic dermatitis correlates with HRQL decrements, indicating greater HRQL impact with greater disease severity. Atopic dermatitis has as large an impact on HRQL as several chronic conditions and other dermatologic conditions.