Nudging intensive care unit personnel towards sustainable behaviour.

BACKGROUND: The health care sector is among the most carbon-intensive sectors, contributing to societal problems like climate change. Previous research demonstrated that especially the use of personal protective equipment (e.g., aprons) in critical care contributes to this problem. To reduce personal protective equipment waste, new sustainable policies are needed. AIMS: Policies are only effective if people comply. Our aim is to examine whether compliance with sustainable policies in critical care can be increased through behavioural influencing. Specifically, we examined the effectiveness of two sets of nudges (i.e., a Prime + Visual prompt nudge and a Social norm nudge) on decreasing apron usage in an intensive care unit (ICU). STUDY DESIGN: We conducted a field experiment with a pre- and post-intervention measurement. Upon the introduction of the new sustainable policy, apron usage data were collected for 9 days before (132 observations) and 9 days after (114 observations) the nudge interventions were implemented. RESULTS: Neither the Prime + Visual prompt nudge, nor the Social norm nudge decreased apron usage. CONCLUSIONS: While previous studies have found that primes, visual nudges and social norm nudges can increase sustainable behaviour, we did not find evidence for this in our ICU field experiment. Future research is needed to determine whether this null finding reflects reality, or whether it was due to methodological decisions and limitations of the presented experiment. RELEVANCE TO CLINICAL PRACTICE: The presented study highlights the importance of studying behavioural interventions that were previously proven successful in the lab and in other field contexts, in the complex setting of critical care. Results previously found in other contexts may not generalize directly to a critical care context. The unique characteristics of the critical care context also pose methodological challenges that may have affected the outcomes of this experiment.

Comparison of antipsychotic drug use in children and adolescents in the Netherlands before and during the COVID-19 pandemic.

This study aims to describe the patterns and trends in antipsychotic prescription among Dutch youth before and during the corona virus disease 2019 (COVID-19) pandemic (between 2017 and 2022). The study specifically aims to determine whether there has been an increase or decrease in antipsychotic prescription among this population, and whether there are any differences in prescription patterns among different age and sex groups. The study utilized the IADB database, which is a pharmacy prescription database containing dispensing data from approximately 120 community pharmacies in the Netherlands, to analyze the monthly prevalence and incidence rates of antipsychotic prescription among Dutch youth before and during the pandemic. The study also examined the prescribing patterns of the five most commonly used antipsychotics and conducted an autoregressive integrated moving average (ARIMA) analysis using data prior to the pandemic, to predict the expected prevalence rate during the pandemic. The prescription rate of antipsychotics for Dutch youth was slightly affected by the pandemic, with a monthly prevalence of 4.56 [4.50-4.62] per 1000 youths before COVID-19 pandemic and 4.64 [4.59-4.69] during the pandemic. A significant increase in prevalence was observed among adolescent girls aged 13-19 years. The monthly incidence rate remained stable overall, but rose for adolescent girls aged 13-19 years. Aripiprazole, and Quetiapine had higher monthly prevalence rates during the pandemic, while Risperidone and Pipamperon had lower rates. Similarly, the monthly incidence rates of Aripiprazole and Olanzapine went up, while Risperidone went down. Furthermore, the results from the ARIMA analysis revealed that despite the pandemic, the monthly prevalence rate of antipsychotic prescription was within expectation. The findings of this study suggest that there has been a moderate increase in antipsychotic prescription among Dutch youth during the COVID-19 pandemic, particularly in adolescent females aged 13-19 years. However, the study also suggests that factors beyond the pandemic may be contributing to the rise in antipsychotic prescription in Dutch youth.

Association of neighbourhood socioeconomic trajectories with preterm birth and small-for-gestational-age in the Netherlands: a nationwide population-based study.

BACKGROUND: Adverse birth outcomes have serious health consequences, not only during infancy but throughout the entire life course. Most evidence linking neighbourhood socioeconomic status (SES) to birth outcomes is based on cross-sectional SES measures, which do not reflect neighbourhoods' dynamic nature. We investigated the association between neighbourhood SES trajectories and adverse birth outcomes, i.e. preterm birth and being small-for-gestational-age (SGA), for births occurring in the Netherlands between 2003 and 2017. METHODS: We linked individual-level data from the Dutch perinatal registry to the Netherlands Institute for Social Research neighbourhood SES scores. Based on changes in their SES across four-year periods, neighbourhoods were categorised into seven trajectories. To investigate the association between neighbourhood SES trajectories and birth outcomes we used adjusted multilevel logistic regression models. FINDINGS: Data on 2 334 036 singleton births were available for analysis. Women living in stable low-SES neighbourhoods had higher odds of preterm birth (OR[95%CI]= 1·12[1·07-1·17]) and SGA (OR[95%CI]= 1·19[1·15-1·23]), compared to those in high SES areas. Higher odds of preterm birth (OR[95%CI]= 1·12[1·05-1·20]) and SGA (OR[95%CI]=1·12[1·06-1·18]) were also observed for those living in areas declining to low SES. Women living in a neighbourhood where SES improved from low to medium showed higher odds of preterm birth (OR[95%CI]= 1·09[1·02-1·18]), but not of SGA (OR[95%CI]= 1·04[0.98-1·10]). The odds of preterm or SGA birth in other areas were comparable to those seen in high SES areas. INTERPRETATION: In the Netherlands, disadvantaged neighbourhood SES trajectories were associated with higher odds of adverse birth outcomes. Longitudinal neighbourhood SES measures should also be taken into account when selecting a target population for public health interventions. FUNDING: Erasmus Initiative Smarter Choices for Better Health.

Association Between Income and Perinatal Mortality in the Netherlands Across Gestational Age.

Importance: The association between household income and perinatal health outcomes has been understudied. Examining disparities in perinatal mortality within strata of gestational age and before and after adjusting for birth weight centile can reveal how the income gradient is associated with gestational age, birth weight, and perinatal mortality. Objectives: To investigate the association between household income and perinatal mortality, separately by gestational age strata and time of death, and the potential role of birth weight centile in mediating this association. Design, Setting, and Participants: This cross-sectional study used individually linked data of all registered births in the Netherlands with household-level income tax records. Singletons born between January 1, 2004, and December 31, 2016, at 24 weeks to 41 weeks 6 days of gestation with complete information on birth outcomes and maternal characteristics were studied. Data analysis was performed from March 1, 2018, to August 30, 2021. Exposures: Household income rank (adjusted for household size). Main Outcomes and Measures: Perinatal mortality, stillbirth (at ≥24 weeks of gestation), and early neonatal mortality (at ≤7 days after birth). Disparities were expressed as bottom-to-top ratios of projected mortality among newborns with the poorest 1% of households vs those with the richest 1% of households. Generalized additive models stratified by gestational age categories, adjusted for potential confounding by maternal age at birth, maternal ethnicity, parity, sex, and year of birth, were used. Birth weight centile was included as a potential mediator. Results: Among 2 036 431 singletons in this study (1 043 999 [51.3%] males; 1 496 579 [73.5%] with mother of Dutch ethnicity), 121 010 (5.9%) were born before 37 weeks of gestation, and 8720 (4.3 deaths per 1000) died during the perinatal period. Higher household income was positively associated with higher rates of perinatal survival, with an unadjusted bottom-to-top ratio of 2.18 (95% CI, 1.87-2.56). The bottom-to-top ratio decreased to 1.30 (95% CI, 1.22-1.39) after adjustment for potential confounding factors and inclusion of birth weight centile as a possible mediator. The fully adjusted ratios were lower for stillbirths (1.27; 95% CI, 1.20-1.36) than for early neonatal deaths (1.35; 95% CI, 1.14-1.66). Inequalities in perinatal mortality were found for newborns at greater than 26 weeks of gestation but not between 24 and 26 weeks of gestation (fully adjusted bottom-to-top ratio, 0.89; 95% CI, 0.77-1.04). Conclusions and Relevance: The results of this large nationally representative cross-sectional study suggest that a large part of the increased risk of perinatal mortality among low-income women is mediated via a lower birth weight centile. The absence of disparities at very low gestational ages suggests that income-related risk factors for perinatal mortality are less prominent at very low gestational ages. Further research should aim to understand which factors associated with preterm birth and lower birth weight can reduce inequalities in perinatal mortality.

The Effect of Changes in Cost Sharing on the Consumption of Prescription and Over-the-Counter Medicines in Catalonia.

Many universal health care systems have increased the share of the price of medicines paid by the patient to reduce the cost pressure faced after the Great Recession. This paper assesses the impact of cost-sharing changes on the propensity to consume prescription and over-the-counter medicines in Catalonia, a Spanish autonomous community, affected by three new cost-sharing policies implemented in 2012. We applied a quasi-experimental difference-in-difference method using data from 2010 to 2014. These reforms were heterogeneous across different groups of individuals, so we define three intervention groups: (i) middle-income working population-co-insurance rate changed from 40% to 50%; (ii) low/middle-income pensioners-from free full coverage to 10% co-insurance rate; (iii) unemployed individuals without benefits-from 40% co-insurance rate to free full coverage. Our control group was the low-income working population whose co-insurance rate remained unchanged. We estimated the effects on the overall population as well as on the group with long-term care needs. We evaluated the effect of these changes on the propensity to consume prescription or over-the-counter medicines, and explored the heterogeneity effects across seven therapeutic groups of prescription medicines. Our findings showed that, on average, these changes did not significantly change the propensity to consume prescription or over-the-counter medicines. Nonetheless, we observed that the propensity to consume prescription medicines for mental disorders significantly increased among unemployed without benefits, while the consumption of prescribed mental disorders medicines for low/middle-income pensioners with long-term care needs decreased after becoming no longer free. We conclude that the propensity to consume medicines was not affected by the new cost-sharing policies, except for mental disorders. However, our results do not preclude potential changes in the quantity of medicines individuals consume.

Cutting fertility? Effects of cesarean deliveries on subsequent fertility and maternal labor supply.

Despite the growing incidence of cesarean deliveries (CDs), procedure costs and benefits continue to be controversially discussed. In this study, we identify the effects of CDs on subsequent fertility and maternal labor supply by exploiting the fact that obstetricians are less likely to undertake CDs on weekends and public holidays and have a greater incentive to perform them on Fridays and days preceding public holidays. To do so, we adopt high-quality administrative data from Austria. Women giving birth on different days of the week are pre-treatment observationally identical. Our instrumental variable estimates show that a non-planned CD at parity 0 decreases lifecycle fertility by almost 13.6%. This reduction in fertility translates into a temporary increase in maternal employment.

Thank goodness for stickiness: Unravelling the evolution of income-related health inequalities before and after the Great Recession in Europe.

The Great Recession in Europe sparked concerns that the crisis would lead to increased income related health inequalities (IRHI). Did this come to pass, and what role, if any, did government transfers play in the evolution of these inequalities? Motivated by these questions, this paper seeks to (i) study the evolution of IRHI during the crisis, and (ii) decompose these evolutions to examine the separate roles of government versus market transfers. Using panel data for 7 EU countries from 2004 to 2013, we find no evidence that IRHI persistently rose after 2008, even in countries most affected by the crisis. Our decomposition reveals that, while the health of the poorest did indeed worsen during the crisis, IRHI were prevented from increasing by the relative stickiness of old age pension benefits compared to the market incomes of younger groups. Austerity measures weakened the IRHI reducing effect of government transfers.

The kids are alright - labour market effects of unexpected parental hospitalisations in the Netherlands.

Unexpected negative health shocks of a parent may reduce adult children's labour supply via informal caregiving and stress-induced mental health problems. We link administrative data on labour market outcomes, hospitalisations and family relations for the full Dutch working age population for the years 1999-2008 to evaluate the effect of an unexpected parental hospitalisation on the probability of employment and on conditional earnings. Using an event study difference-in-differences model combined with coarsened exact matching and individual fixed effects, we find no effect of an unexpected parental hospitalisation on either employment or earnings for Dutch men and women, and neither for the full population nor for the subpopulations most likely to become caregivers. These findings suggest that the extensive public coverage of formal long-term care in the Netherlands combined with widespread acceptance of part-time work provides sufficient opportunities to deal with adverse health events of family members without having to compromise one's labour supply.

Saved by retirement: Beyond the mean effect on mental health.

We analyze the causal effect of retirement on mental health, exploiting differences in retirement eligibility ages across countries and over time using data from the Survey of Health, Ageing and Retirement in Europe. We estimate not only average effects, but also use distributional regression to examine whether these effects are unequally distributed across the mental health distribution. We find unequally distributed protective effects of retirement on mental health. These gains are larger among those just below and above the clinically defined threshold of being at risk of depression. The preserving effects are larger for women and blue collar workers. Our results suggest that the magnitude of the protective effect is independent of the availability of family support.

Does €1 Per Prescription Make a Difference? Impact of a Capped Low-Intensity Pharmaceutical Co-Payment.

BACKGROUND: Increasing patient contributions and reducing the population exempt from pharmaceutical co-payment and co-insurance rates were one of the most common measures in the reforms adopted in Europe during 2010-2015. OBJECTIVE: We estimated the association between the introduction of a capped co-payment of €1 per prescription and drug consumption of the publicly insured population of Catalonia (Spain). METHODS: We used administrative data on monthly pharmaceutical consumption (defined daily doses [DDDs]) from January 2012 to December 2014, for a representative sample of 85,000 people. RESULTS: Our results showed that consumption increased in the 2 months previous to the introduction of the measure, and fell with the introduction of the 'Euro per prescription' co-payment. The average net response associated with the reform (including anticipation) was a reduction of 4.1 DDDs per person per month, representing a 6.4% reduction. The decrease in pharmaceutical consumption was larger for those individuals who had free medicines prior to the reform compared with those who already paid a co-insurance rate (9.7 vs. 1.4 DDDs per person per month). The largest reduction in DDDs per person occurred in the following groups: dermatologic drugs, antihypertensives, non-insulin antidiabetic drugs, insulin antidiabetic drugs, and laxatives. CONCLUSION: A uniform capped low co-payment may give rise to a major reduction in drug consumption to a much greater extent among those who previously had free prescriptions.

Mortality effects of containing moral hazard: Evidence from disability insurance reform.

We exploit an age discontinuity in a Dutch disability insurance reform to identify the health impact of stricter eligibility criteria and reduced generosity. Our results show substantial adverse effects on life expectancy for women subject to the more stringent criteria. A €1,000 reduction in annual benefits leads to a 2.4 percentage points higher probability of death more than 10 years after the reform. This negative health effect is restricted to women with low pre-disability earnings. We find that the mortality rate of men subject to the stricter rules is reduced by 0.7 percentage points. The evidence for the existence of substantial health effects implies that policymakers considering a disability insurance reform should carefully balance the welfare gains from reduced moral hazard against losses not only from less coverage of income risks but also from deteriorated health.

Decentralization of health care systems and health outcomes: Evidence from a natural experiment.

While many countries worldwide are shifting responsibilities for their health systems to local levels of government, there is to date insufficient evidence about the potential impact of these policy reforms. We estimate the impact of decentralization of the health services on infant and neonatal mortality using a natural experiment: the devolution of health care decision making powers to Spanish regions. The devolution was implemented gradually and asymmetrically over a twenty-year period (1981-2002). The order in which the regions were decentralized was driven by political factors and hence can be considered exogenous to health outcomes. In addition, we exploit the dynamic effect of decentralization of health services and allow for heterogeneous effects by the two main types of decentralization implemented across regions: full decentralization (political and fiscal powers) versus political decentralization only. Our difference in differences results based on a panel dataset for the 50 Spanish provinces over the period 1980 to 2010 show that the lasting benefit of decentralization accrues only to regions which enjoy almost full fiscal and political powers and which are also among the richest regions.

Health Disparities by Income in Spain Before and After the Economic Crisis.

Little is known about how health disparities by income change during times of economic crisis. We apply a decomposition method to unravel the contributions of income growth, income inequality and differential income mobility across socio-demographic groups to changes in health disparities by income in Spain using longitudinal data from the Survey of Income and Living Conditions for the period 2004-2012. We find a modest rise in health inequality by income in Spain in the 5 years of economic growth prior to the start of the crisis in 2008, but a sharp fall after 2008. The drop mainly derives from the fact that loss of employment and earnings has disproportionately affected the incomes of the younger and healthier groups rather than the (mainly stable pension) incomes of the groups over 65 years. This suggests that unequal distribution of income protection by age may reduce health inequality in the short run after an economic recession. Copyright © 2016 John Wiley & Sons, Ltd.

Free Medicines Thanks to Retirement: Impact of Coinsurance Exemption on Pharmaceutical Expenditures and Hospitalization Offsets in a national health service.

This paper examines the impact of coinsurance exemption for prescription medicines applied to elderly individuals in Spain after retirement. We use a rich administrative dataset that links pharmaceutical consumption and hospital discharge records for the full population aged 58 to 65 years in January 2004 covered by the public insurer in a Spanish region, and we follow them until December 2006. We use a difference-in-differences strategy and exploit the eligibility age for Social Security to control for the endogeneity of the retirement decision. Our results show that this uniform exemption increases the consumption of prescription medicines on average by 17.5%, total pharmaceutical expenditure by 25% and the costs borne by the insurer by 60.4%, without evidence of any offset effect in the form of lower short term probability of hospitalization. The impact is concentrated among consumers of medicines for acute and other non-chronic diseases whose previous coinsurance rate was 30% to 40%. Copyright © 2015 John Wiley & Sons, Ltd.

Inequity in the Face of Death.

We apply the theory of inequality of opportunity to the measurement of inequity in mortality. Using a rich data set linking records of mortality and health events to survey data on lifestyles for the Netherlands (1998-2007), we test the sensitivity of estimated inequity to different normative choices and conclude that the location of the responsibility cut is of vital importance. Traditional measures of inequity (such as socioeconomic and regional inequalities) only capture part of more comprehensive notions of unfairness. We show that distinguishing between different routes via which variables might be associated to mortality is essential to the application of different normative positions. Using the fairness gap (direct unfairness), measured inequity according to our implementation of the 'control' and 'preference' approaches ranges between 0.0229 and 0.0239 (0.0102-0.0218), while regional and socioeconomic inequalities are smaller than 0.0020 (0.0001). The usual practice of standardizing for age and gender has large effects on measured inequity. Finally, we use our model to measure inequity in simulated counterfactual situations. While it is a big challenge to identify all causal relationships involved in this empirical context, this does not affect our main conclusions regarding the importance of normative choices in the measurement of inequity. Copyright © 2014 John Wiley & Sons, Ltd.

Inequity in long-term care use and unmet need: two sides of the same coin.

We investigate the determinants of several LTC services and unmet need using data from a representative sample of the non-institutionalised disabled population in Spain in 2008. We measure the level of horizontal inequity and compare results using self-reported versus a more objective indicator of unmet needs. Evidence suggests that after controlling for a wide set of need variables, there is not an equitable distribution of use and unmet need of LTC services in Spain; formal services are concentrated among the better-off, while intensive informal care is concentrated among the worst-off. The distribution of unmet needs for LTC services depends on the service considered and on whether we focus on subjective or objective measures. In 2008, only individuals with the highest dependency level had universal coverage. Our results show that inequities in most LTC services and unmet needs among this group either remain or even increase for formal services.