Explaining why increases in generic use outpace decreases in brand name medicine use in multisource markets and the role of regulation.

BACKGROUND: Healthcare systems worldwide face escalating pharmaceutical expenditures despite interventions targeting pricing and generic substitution. Existing studies often overlook unwarranted volume increases in multisource markets due to differential physician perceptions of brand name and generics. OBJECTIVE: This study aims to explain the outpacing of generic medicine use over brand name use in multisource markets and assess the regulatory role, specifically examining the impact of reference pricing on volume and intensity increases. METHODS: Analyzing German multisource prescription medicine markets from 2011 to 2014, we evaluate regulatory mechanisms and explore whether brand name and generic medicines constitute separate market segments. Using an Oaxaca-Blinder decomposition approach, we divide the differential in brand name versus generic medicine use rates into market structure and unobserved segment effects. RESULTS: Generic use rates surpass same-market brand name substitution by 3.87 prescriptions per physician and medicine, on average. Reference pricing mitigated volume increase, treatment intensity and expenditure. Disparities in quantity and expenditure dynamics between brand name and generic segments are partially explained by market structure and segment effects. CONCLUSION: Generic medicine use effectively reduces expenditures but contributes to increased net prescription rates. Reference pricing may control medicine use, but divergent physician perceptions of brand name and generics, revealed by identified segment effects, call for nuanced policy interventions.

The association between economic uncertainty and suicide in Japan by age, sex, employment status, and population density: an observational study.

Background: Suicide is one of the ten leading causes of death globally, and previous research has revealed a link between economic conditions and mental health. However, the literature has focused primarily on recessions and unemployment, i.e. actual economic developments, as opposed to uncertainty, which relates to economic developments that have not (yet) materialised. This study examines the differential association between economic uncertainty and suicide in Japan, depending on age, sex, employment status, and population density, in order to identify the groups that are affected the most. Methods: Using monthly prefectural suicide mortality data from the Ministry of Health, Labour and Welfare and a monthly economic uncertainty index for the period 2009 to 2019, we employed a fixed effects panel data approach to examine the association between uncertainty and suicide by population group. Findings: We found that a 1% increase in economic uncertainty is associated with a 0.061 increase in the monthly number of suicides per 100,000 people per prefecture, on average (coefficient: 6.08; 95% CI: 5.07-7.08), which constitutes a 3.62% increase. Self-employed people, as well as men in their 50s and unemployed men, experience the highest additional risk of suicide when uncertainty increases. The association was approximately three times stronger for males than for females, and a strong association was observed for self-employed males living in more densely-populated areas. Interpretation: Uncertainty appears to relate to suicides for most groups, but self-employed people, males, and those living in more densely populated areas appear to be more at risk of suicide in periods of increased economic uncertainty. Our results provide an indication of which groups mental health services and prevention strategies can focus on in times of economic uncertainty. Funding: None.

State-level economic uncertainty and cardiovascular disease deaths: evidence from the United States.

The relationship between economic recessions and cardiovascular mortality has been widely explored. However, there is limited evidence on whether economic uncertainty alone is linked to cardiovascular disease deaths. This study examines the association between economic uncertainty and mortality from diseases of the circulatory system in the United States. We obtained monthly state-level mortality data from 2008 to 2017 and used indices capturing economic uncertainty from national/international sources and local sources. Panel data modelling was used to account for unobserved time-invariant differences between the states. Our findings suggest that economic uncertainty is independently linked to cardiovascular mortality. Uncertainty arising from national/international sources is associated with cardiovascular deaths, whereas the respective index capturing uncertainty from state/local sources is not. Deaths respond asymmetrically with respect to uncertainty fluctuations - with high levels of uncertainty driving the association. One- and two-month lagged uncertainty levels are also associated with mortality. Several robustness checks further validate the baseline findings. Overall, economic uncertainty is an independent predictor of cardiovascular mortality which appears to act as a psychosocial stressor and a short-term trigger. Public health strategies for cardiovascular disease need to consider factors driving economic uncertainty. Preventive measures and raising awareness can intensify in periods of economic uncertainty.

Road traffic mortality and economic uncertainty: Evidence from the United States.

Previous studies have shown that financial turbulence is associated with a short-term increase in road traffic collisions, largely due to drivers' emotional state, distraction, sleep deprivation and alcohol consumption. In this paper we advance this debate by studying the association between economic uncertainty and road traffic mortality in the United States. We used a State-level uncertainty index and State fatalities for the period 2008-2017 and found that a one standard deviation increase in economic uncertainty is associated with an additional 0.013 monthly deaths per 100,000 people per State, on average (a 1.1% increase) - or 40 more monthly deaths in total nationwide. Results are robust to different model specifications. Our findings show that, similar to drink-driving, it is important to raise awareness about driving when distracted due to financial worries and during periods of economic uncertainty.

Economic uncertainty and cardiovascular disease mortality.

Previous studies have found a link between economic conditions, such as recessions and unemployment, and cardiovascular disease as well as other health outcomes. More recent research argues that economic uncertainty-independently of unemployment-can affect health outcomes. Using data from England and Wales, we study the association between fluctuations in economic uncertainty and cardiovascular disease mortality in the short term for the period 2001-2019. Controlling for several economic indicators (including unemployment), we find that economic uncertainty alone is strongly associated with deaths attributed to diseases of the circulatory system, ischemic heart disease and cerebrovascular disease. Our findings highlight the short-term link between economic conditions and cardiovascular health and reveal yet another health outcome that is associated with uncertainty.

Police killings and suicide among Black Americans.

Black Americans are killed at higher rates by police than whites. Previous studies have shown that discrimination can lead to suicidal ideation, and that mental health of Black Americans deteriorates after police killings. The objective of this study is to examine whether police killings are associated with an increase in suicide rates amongst Black Americans. Controlling for a number of factors, we found that on months with at least one killing of a Black person by police, there were, on average, 0.0472 additional suicides per 100,000 Black Americans in the U.S. Census Division where the killing occurred. We did not find any spillover effects on other divisions. This association persisted when controlling for gun ownership, and did not seem to be a result of variance in deaths by assault. There was no association between killings of Black Americans and white suicides; white killings and Black suicides; or white killings and white suicides. This study highlights another reason for urgent action on reducing police killings.

Minimum Alcohol Pricing and Motor Vehicle Collisions in Scotland.

On May 1, 2018, Scotland introduced a minimum price of 50 pence per unit of alcohol, which led to a reduction in alcohol consumption. As drink-driving is an important risk factor for motor vehicle collisions, we examined whether the minimum alcohol pricing was followed by a decrease in collisions. We took advantage of a case where the minimum price was introduced to 1 population during the study period (Scotland) and another population that served as the control group did not experience this intervention (England and Wales). We used data on the daily number of motor vehicle collisions resulting in death or injury in 2018 and used a differences-in-differences econometric approach, comparing trends before and after the introduction of the minimum price. Controlling for seasonality, we found a small relative decrease in collisions in Scotland compared with England and Wales (difference-in-difference interaction coefficient, -0.35; 95% confidence interval: -0.65, -0.04; P = 0.03). Our results suggest that there was a relative decrease in motor vehicle collisions in Scotland of between 1.52 and 1.90, on average, in the first months after the introduction of the policy. More research is needed to understand any long-term impacts of minimum alcohol pricing.

COVID-19, lockdowns and motor vehicle collisions: empirical evidence from Greece.

Reduced mobility during COVID-19 lockdowns means not only fewer vehicles at risk of collision, but also an opportunity to speed on empty streets. The objective of this paper is to examine the impact of the first wave of the pandemic and the first lockdown on motor vehicle collisions (MVCs) and associated injuries and deaths in Greece. Using monthly data at the regional unit level, I provide descriptive evidence and subsequently follow a difference-in-differences econometric approach, comparing trends in 2020 with those of the previous 5 years while controlling for unemployment and petrol prices. I found a steep decline in collisions, injuries and deaths compared with what would have been otherwise expected. In March and April 2020, there were about 1226 fewer collisions, 72 fewer deaths, 40 fewer serious injuries and 1426 fewer minor injuries compared with what would have been expected in the absence of the pandemic.

COVID-19: Early evening curfews and mobility.

During the COVID-19 pandemic, some countries introduced early evening curfews. Several studies try to measure the effectiveness of such measures across different countries, but disentangling competing effects can be elusive. We examined the impact of an early evening curfew on mobility by studying a shift in curfews from 9pm to 6pm in Greece using Google mobility data. We followed a difference-in-differences (DiD) econometric approach, where we compared trends in mobility in residential spaces as well as groceries and pharmacies, before and after the introduction of the 6pm curfew in Attica with trends in three other comparable Regions. We found little or no evidence of an effect of the early curfew on daily mobility relating to groceries and pharmacies, and that an 18.75% reduction in hours where people were allowed to leave home led to a relatively small increase in time spent in residential spaces. This less-than-proportionate reduction in mobility outside the household suggests a possibility that the curfew led to more people coinciding in indoor public spaces, such as grocery shops - which constitutes a contagion risk factor. Results should be treated with caution, especially with regards to the magnitude of any effect, as Google mobility data do not report the time of the day, so the time density of activities cannot be estimated. Lockdowns and other measures are necessary to tackle Covid-19, but it is important to avoid substitution by activities that contribute further to spreading the virus. Interventions should therefore be based on a thorough analysis of human behaviour.

Economic uncertainty and suicide in the United States.

Previous studies have found an association between recessions and increased rates of suicide. In the present study we widened the focus to examine the association between economic uncertainty and suicides. We used monthly suicide data from the US at the State level from 2000 to 2017 and combined them with the monthly economic uncertainty index. We followed a panel data econometric approach to study the association between economic uncertainty and suicide, controlling for unemployment and other indicators. Economic uncertainty is positively associated with suicide when controlling for unemployment [coeff: 8.026; 95% CI: 3.692-12.360] or for a wider range of economic and demographic characteristics [coeff: 7.478; 95% CI: 3.333-11.623]. An increase in the uncertainty index by one percent is associated with an additional 11-24.4 additional monthly suicides in the US. Economic uncertainty is likely to act as a trigger, which underlines the impulsive nature of some suicides. This highlights the importance of providing access to suicide prevention interventions (e.g. hotlines) during periods of economic uncertainty.

The link between unemployment and opioid prescribing. An instrumental variable approach using evidence from England.

BACKGROUND: Unemployment has been associated with chronic pain, which is often treated with prescription opioids. Opioid mortality has been included in the so-called category of 'deaths of despair' due to the role of lack of opportunity. While previous studies have found an association between unemployment and opioids, the relationship is endogenous and examining any effect is challenging. OBJECTIVE: The objective of this paper is to study the association between unemployment and opioid prescribing in England. DATA AND METHODS: We used data from the GP prescribing database in England for the period 2011-2017 and followed ordinary least squares (OLS) and Instrumental Variable econometric approaches, controlling for other confounders. We used the number of foreign direct investment projects and the number of registered companies as instruments for unemployment, taking population size into account. RESULTS: The OLS model suggests that an increase in the unemployment rate by 1 percentage point is associated with 0.017 additional opioid defined daily doses per capita-a 0.9% increase compared with the mean of 1.745. According to the instrumental variable model, an increase in unemployment by 1 percentage point leads to an increase in the number of opioid doses prescribed per capita by between 0.315 and 0.437, which constitutes a 18-25% increase compared with the mean of 1.745. CONCLUSIONS: Unemployment appears to have an impact on opioid prescribing volume in England. This reveals yet another negative effect of unemployment on health. Relevant labour market policies may play a protective role with regards to opioid use.

Excess mortality during the Covid-19 pandemic: Early evidence from England and Wales.

The Covid-19 pandemic has claimed many lives in the UK and globally. The objective of this paper is to study whether the number of deaths not registered as Covid-19-related has increased compared to what would have been expected in the absence of the pandemic. Reasons behind this might include Covid-19 underreporting, avoiding visits to hospitals or GPs, and the effects of the lockdown. I used weekly ONS data on the number of deaths in England and Wales that did not officially involve Covid-19 over the period 2015-2020. Simply observing trends is not sufficient as spikes in deaths may occasionally occur. I thus followed a difference-in-differences econometric approach to study whether there was a relative increase in deaths not registered as Covid-19-related during the pandemic, compared to a control. Results suggest that there were an additional 968 weekly deaths that officially did not involve Covid-19, compared to what would have otherwise been expected. It is possible that some people are dying from Covid-19 without being diagnosed, and/or that there are excess deaths due to other causes as a result of the pandemic. Analysing the cause of death for any excess non-covid-19 deaths will shed light upon the reasons for the increase in such deaths and will help design appropriate policy responses to save lives.

Invited Commentary: The Association Between Florida's Opioid Crackdown and Opioid-Related Mortality-The Roles of Economic Factors and Mortality Misclassification.

Opioid overdose mortality has been increasing in the United States, and other types of mortality, such as motor vehicle crash deaths, may also be linked to opioid use. In this issue of the Journal, Feder et al. (Am J Epidemiol. 2020;189(9):885-893) examine the association between Florida's opioid crackdown laws, implemented in 2010-2011, and opioid-related mortality. They found a decrease in numbers of opioid-overdose and car-crash deaths compared with what would have been expected in the absence of such policies. They also found no evidence of any unintended increase in suicides due to poor pain management. The results were robust to alternative methodological approaches. Florida's opioid policy reforms coincided with the state's convergence towards national unemployment rates, as well as a new state law prohibiting texting while driving. Because opioid overdose mortality is often associated with economic conditions and because car crashes and suicides may also be linked to the macroeconomic environment, future research should take such factors into account when studying the outcomes of opioid prescribing laws. Another data-related aspect to consider is the misclassification of suicides as car crashes or opioid overdoses. Overall, the findings by Feder et al. are encouraging and can inform policy in other countries facing increasing numbers of opioid overdose deaths.

The (Agri-)Cultural origins of obesity.

Previous research has shown that societies that historically focused on agricultural production demonstrate higher levels of long-term orientation. This suggests that the deep-rooted cultural origins of time preference may have a scarring impact on modern obesity rates through intergenerational transmission. We hypothesize that a historically long-term oriented culture could result in the behavioural choices of better diet and more exercise today, via the reinforced ability of individuals to delay gratification. Using a sample of 132 countries, we employ regression analysis to first estimate the historical determinants of time preference, and then examine the impact of long-term orientation on obesity. Controlling for other factors, we find that, on average, historically long-term oriented countries exhibit significantly lower obesity rates today. Results are robust to different methodological approaches and sensitivity analyses. Policies targeting obesity should consider those deep-rooted behavioural factors that can determine the differential response of individuals to policy instruments.

The relative risk of motor vehicle collision on cannabis celebration day in Great Britain.

Cannabis celebration day, also known as "420 day", takes place at 4:20pm on April 20 every year. The objective of this paper is to study whether there is an increase in road traffic collisions in Great Britain on that day. We used daily car crash data resulting in death or injury from all 51 local police forces covering Great Britain over the period 2011-2015. We compared crashes from 4:20pm onwards on April 20 to control days on the same day of the week in the preceding and succeeding two weeks, using panel data econometric models. On the average cannabis celebration day in Britain, there were an additional 23 police-reported collisions compared to control days, corresponding to a 17.9% increase in the relative risk of collision.

The EU referendum and mental health in the short term: a natural experiment using antidepressant prescriptions in England.

BACKGROUND: Previous research has highlighted the impact of economic conditions and uncertainty on physical and mental health. The unexpected result of the Brexit referendum in 2016 triggered high levels of economic uncertainty. OBJECTIVE: To examine whether prescriptions for antidepressants increased after the referendum result, benchmarking them against other drug classes. METHODS: We used GP practice prescribing data to compile the number of defined daily doses per capita every month in each of the 326 voting areas in England over the period 2011-2016. We used a difference-in-differences (DID) approach to identify the effects of Brexit on antidepressant prescriptions, compared with trends in a control group (antigout and iron preparations) that were unlikely to be associated with uncertainty and depression. RESULTS: Antidepressant prescribing continued to increase after the referendum but at a slower pace. Therapeutic classes used as controls showed a decrease. The DID approach shows that there was a relative increase of 13.4% in antidepressants compared with other therapeutic classes (DID coeff: 0.134; 95% CI 0.093 to 0.174). CONCLUSION: Our results are open to different interpretations and should be treated with caution. This relative increase in antidepressant prescribing after the referendum may be attributed to increased uncertainty for certain parts of the population, but does not rule out an improvement in mood for others. Alternatively, some other factor-for example, distraction, might have contributed to a decrease in the control therapeutic classes. A possible policy implication is that programmes for the promotion of mental health may need to be intensified during periods of uncertainty.

The association between economic uncertainty and suicide in the short-run.

RATIONALE: Previous research has shown that uncertainty can affect mental health, and that unemployment and economic recessions are associated with increased suicide rates. OBJECTIVE: The objective of this article was to examine whether daily fluctuations in economic uncertainty can result in short-term spikes in the number of suicides. While existing evidence has focused on medium- and long-term effects of economic conditions on suicide, this study examined immediate daily deviations from the background general trend. METHODS: We used daily suicide data from England and Wales that were matched to a daily economic policy uncertainty index over the period 2001-2015. We followed an econometric approach to examine the impact of uncertainty on suicides, controlling for unemployment rates. RESULTS: We found that a spike in daily economic uncertainty leads to an immediate, yet short-lived, impact on suicides. A one-day lag also has a positive effect, but there is no effect on subsequent days. The impact appears to be stronger for males than for females. Results are robust to different empirical approaches and model specifications. CONCLUSIONS: Overall, our study suggests that economic uncertainty may lead to an increase in the risk of suicide. This immediate effect indicates that uncertainty may act as a trigger, and is unlikely to be the sole cause of suicide, which reflects existing evidence on the impulsive nature of some suicides. This highlights the need to reduce 'access to means', and the importance of the timing of suicide prevention measures.

The short-term impact of economic uncertainty on motor vehicle collisions.

Stress and anxiety lead to attention loss and sleep deprivation and may reduce driving performance, increasing the risk of motor vehicle collision. We used evidence from a natural experiment to examine whether daily changes in economic uncertainty, potentially leading to attention or sleep loss, are associated with collisions in Great Britain. Daily data from the economic policy uncertainty index, derived from analysis of daily UK newspapers, were linked to the daily number of motor vehicle collisions in Great Britain over the period 2005-2015, obtained from the Department for Transport. Exploiting daily variations in economic uncertainty, we used a GARCH approach to model daily rates of motor vehicle collisions as a function of economic uncertainty, controlling for month and day of the week, monthly unemployment rates and weekly unleaded petrol prices. A spike in the daily economic uncertainty index was associated with an immediate increase in the number of motor vehicle collisions. Results were robust to various sensitivity analyses. Overall, daily increases in economic uncertainty are associated with short-term spikes in motor vehicle collisions. Preventive and traffic control measures may need to increase during periods of economic uncertainty.

Healthcare reforms in Cyprus 2013-2017: Does the crisis mark the end of the healthcare sector as we know it?

As part of a bailout agreement with the International Monetary Fund, the European Commission and the European Central Bank (known as the Troika), Cyprus had to achieve a fiscal surplus through budget constraints and efficiency enhancement. As a result, a number of policy changes were implemented, including a reform of the healthcare sector, and major healthcare reforms are planned for the upcoming years, mainly via the introduction of a National Health System. This paper presents the healthcare sector, provides an overview of recent reforms, assesses the recently implemented policies and proposes further interventions. Recent reforms targeting the demand and supply side included the introduction of clinical guidelines, user charges, introduction of coding for Diagnosis Related Groups (DRGs) and the revision of public healthcare coverage criteria. The latter led to a reduction in the number of people with public healthcare coverage in a time of financial crises, when this is needed the most, while co-payments must be reassessed to avoid creating barriers to access. However, DRGs and clinical guidelines can help improve performance and efficiency. The changes so far are yet to mark the end of the healthcare sector as we know it. A universal public healthcare system must remain a priority and must be introduced swiftly to address important existing coverage gaps.

The impact of the Great Recession on health-related risk factors, behaviour and outcomes in England.

This paper examines the impact that the Great Recession had on individuals' health behaviours and risk factors such as diet choices, smoking, alcohol consumption, and Body Mass Index, as well as on intermediate health outcomes in England. We exploit data on about 9000 households from the Health Survey for England for the period 2001-2013 and capture the change in macroeconomic conditions using regional unemployment rates and an indicator variable for the onset of the recession. Our findings indicate that the recession is associated with a decrease in the number of cigarettes smoked - which translated into a moderation in smoking intensity - and a reduction in alcohol intake. The recession indicator itself is associated with a decrease in fruit intake, a shift of the BMI distribution towards obesity, an increase in medicines consumption, and the likelihood of suffering from diabetes and mental health problems. These associations are often stronger for the less educated and for women. When they exist, the associations with the unemployment rate (UR) are nevertheless similar before and after 2008. Our results suggest that some of the health risks and intermediate health outcomes changes may be due to mechanisms not captured by worsened URs. We hypothesize that the uncertainty and the negative expectations generated by the recession may have influenced individual health outcomes and behaviours beyond the adjustments induced by the worsened macroeconomic conditions. The net effect translated into the erosion of the propensity to undertake several health risky behaviours but an exacerbation of some morbidity indicators. Overall, we find that the recession led to a moderation in risky behaviours but also to worsening of some risk factors and health outcomes.