The effect of involuntary retirement on healthcare use.

We analyze the causal effect of involuntary retirement on detailed indicators of healthcare use and mortality. We leverage a pension reform in Hungary which forced public sector workers above the statutory retirement age to full time retirement. Using rich administrative data, we find that on the 3-year horizon, involuntary retirement decreases the number of primary care doctor visits, the use of systemic antiinfectives and respiratory drugs, and the non-zero spending on antiinfectives, the drugs of the alimentary tract and metabolism and of the cardiovascular system. The impact on the latter two drug categories is driven by the drop in income due to involuntary retirement. We conclude that there is little evidence for health deteriorating effects of involuntary retirement and discuss the possible mechanisms behind our results.

Time patterns of precautionary health behaviours during an easing phase of the COVID-19 pandemic in Europe.

Using data from the COVID-19 questionnaire of the Survey of Health, Ageing and Retirement in Europe (SHARE), we investigate the time patterns of precautionary health behaviours of individuals aged 50 years and above during the summer of 2020, an easing phase of the COVID-19 pandemic in Europe. We also examine how these health behaviours differ by the presence of chronic conditions such as hypertension, high cholesterol level, heart disease, diabetes or chronic bronchitis, which can be considered as risk factors for COVID-19. Our results suggest that while on average, people became less precautious during the analysed time period, this is less so for those who are at higher risk. We also document large regional differences in precautionary health behaviours and show that higher-risk individuals are on average more cautious in all regions. We conclude that people adjusted their health behaviours in line with the generally understood risk of the COVID-19 disease. At the same time, our results also point out divergences in the level of willingness to take different precautionary steps.

Mind training, stress and behaviour-A randomised experiment.

In this paper, we evaluate the effects of a psychological training, called Mindfulness-Based Stress Reduction (MBSR) on stress and risk and time preferences. MBSR is a well-known psychological technique, which is believed to improve self-control and reduce stress. We conduct the experiment with 139 participants, half of whom receive the MBSR training, while the other half are asked to watch a documentary series, both over 4 consecutive weeks. Using a range of self-reported and physiological measures (such as cortisol measures), we find evidence that mindfulness training reduces perceived stress, but we only find weak evidence of effects on risk and inter-temporal attitudes.

Income gradient of pharmaceutical panic buying at the outbreak of the COVID-19 pandemic.

We analyze the timing, magnitude, and income dependence of pharmaceutical panic buying around the outbreak of the COVID-19 pandemic in Hungary. We use district-level monthly and daily administrative data on detailed categories of pharmaceutical purchases, merge them to income statistics, and estimate multilevel panel models. Our main results are as follows. First, the days of therapy (DOT) of pharmaceutical purchases increased by more than 30% in March 2020, when major lockdown measures were announced. This pattern holds for almost all categories of pharmaceuticals. Second, shortly after the panic reactions, the aggregate amount of pharmaceutical purchases returned to their preshock levels; however, the frequency of pharmacy visits decreased. Third, the panic buying reaction was significantly stronger in richer geographical areas, where-according to the daily data-people also reacted earlier to the pandemic-related news. Overall, the results suggest that panic buying of pharmaceuticals can have detrimental effects on vulnerable populations.

Mass media coverage and vaccination uptake: evidence from the demand for meningococcal vaccinations in Hungary.

We estimate the effect of mass media coverage of the meningococcal disease on the uptake of meningococcal vaccinations in Hungary. Our analysis is based on administrative county-level data on vaccination purchases linked to indicators of media coverage of the meningococcal disease and to administrative records of disease incidence. Using geographical and time variations in these indicators, our fixed effects estimates indicate a strong positive effect of mass media coverage of the disease on the rate of vaccination with all types of the meningococcal vaccine. At the same time, we do not find evidence that disease incidence itself has a positive impact on vaccination. These findings are broadly in line with imperfect information and the principles of bounded rationality and highlight the responsibility of mass media in influencing health-related behaviours.

Life expectancy inequalities in Hungary over 25 years: The role of avoidable deaths.

Using mortality registers and administrative data on income and population, we develop new evidence on the magnitude of life expectancy inequality in Hungary and the scope for health policy in mitigating this. We document considerable inequalities in life expectancy at age 45 across settlement-level income groups, and show that these inequalities have increased between 1991-96 and 2011-16 for both men and women. We show that avoidable deaths play a large role in life expectancy inequality. Income-related inequalities in health behaviours, access to care, and healthcare use are all closely linked to the inequality in life expectancy.Supplementary material for this article is available at: https://doi.org/10.1080/00324728.2021.1877332.

Regional differences in diabetes across Europe - regression and causal forest analyses.

We examine regional differences in diabetes within Europe, and relate them to variations in socio-economic conditions, comorbidities, health behaviour and diabetes management. We use the SHARE (Survey of Health, Ageing and Retirement in Europe) data of 15 European countries and 28,454 individuals, who participated both in the 4th and 7th (year 2011 and 2017) waves of the survey. First, we estimate multivariate regressions, where the outcome variables are diabetes prevalence, diabetes incidence, and weight loss due to diet as an indicator of management. Second, we study the heterogeneous impact of demographic, socio-economic, health and lifestyle indicators on the regional differences in diabetes incidence with causal random forests. Compared to Western Europe, the odds of a new diabetes diagnosis over a six-year horizon is 2.2-fold higher in Southern and 2.6-fold higher in Eastern Europe. Adjusting for individual characteristics, the odds ratio decreases to 1.8 in the South-West and to 2.0 in the East-West dimension. These remaining differences are mostly explained by country-specific healthcare indicators. Based on the causal forest approach, the adjusted East-West difference is essentially zero for the lowest risk groups (tertiary education, employment, no hypertension, no overweight) and increases substantially with these risk factors, but the South-West difference is much less heterogeneous. The prevalence of diet-related weight loss around the time of diagnosis also exhibits regional variation. The results suggest that the regional differences in diabetes incidence could be reduced by putting more emphasis on diabetes prevention among high-risk individuals in Eastern and Southern Europe.

Transition shocks during adulthood and health a few decades later in post-socialist Central and Eastern Europe.

BACKGROUND: Health of the population of post-socialist Central and Eastern European (CEE) countries lags behind the European Union average. Our aim in this paper is to analyse the link between transition shocks and health two-three decades later. METHODS: We use retrospective data from the Survey of Health, Ageing and Retirement in Europe. We estimate the implications of stressful periods, financial hardships and job loss occurring around the transition (1987-1993) on subjective and objective measures of health in 2017. We compare these implications across groups of CEE countries and with the health implications of similar difficulties reported by individuals from Western Europe. We also compare the health implications of difficulties occurring around the transition to difficulties occurring before or after the transition. RESULTS: In the CEE region there is a peak in the timing of difficulties around the transition. Stressful periods, financial difficulties and job loss around the period of transition are generally associated with worse subjective and objective health at older ages in all groups of CEE countries, even after netting out the effect of childhood health and demographic factors. However, the consequences of hardships due to the transition are not specific, health implications of these difficulties seem to be similar to the implications of other shocks possibly unrelated to the transition. CONCLUSIONS: The high fraction of individuals experiencing stress, financial difficulties and job loss around the transition contributed to the current health disadvantage in the CEE region. As similar shocks in the West and before or after the transition had similar health implications, our results draw the attention to the long-lasting impacts of psychosocial stress and financial hardship during adulthood on later health over the life course.

Caesarean delivery and the use of antidepressants.

BACKGROUND: The high ratio of caesarean sections (C-sections) is a major public health issue in the developed world; but its implications on maternal mental health are not well understood. METHODS: We use individual-level administrative panel data from Hungary between 2010 and 2016 to analyze the relationship between caesarean delivery and antidepressant consumption, an objective indicator of mental health. We focus on low-risk deliveries of mothers without subsequent birth in 3 years, and include around 135 000 observations. RESULTS: After controlling for medical and socio-economic variables, antidepressant use before delivery is associated with an elevated risk of C-section (adjusted OR = 1.10, 95% CI 1.05-1.14) and C-section is associated with a higher probability of antidepressant use within 1-3 years after delivery (e.g. adjusted OR = 1.21, 95% CI 1.12-1.30, within 3 years after delivery, among mothers without pre-delivery antidepressant consumption). Our data restriction ensures that the results are not driven by a mechanical impact of decreasing fertility on the continuation of antidepressant use after a C-section. CONCLUSIONS: The results suggest that C-section is associated with worse mental health over the 1- to 3-year horizon after birth. This relationship is particularly important if a caesarean delivery is not necessary due to medical reasons, and physicians as well as expectant mothers should be made aware of the potential mental health implications of the mode of delivery.

Healthcare spending inequality: Evidence from Hungarian administrative data.

Using administrative data on a random 50% of the Hungarian population, including individual-level information on incomes, healthcare spending, and mortality for the 2003-2011 period, we develop new evidence on the distribution of healthcare spending and mortality in Hungary by income and geography. By linking detailed administrative data on employment, income, and geographic location with measures of healthcare spending and mortality we are able to provide a more complete picture than the existing literature which has relied on survey data. We compute mean spending and 5-year and 8-year mortality measures by geography and income quantiles, and also present gender and age adjusted results. We document four patterns: (i) substantial geographic heterogeneity in healthcare spending; (ii) positive association between labor income and public healthcare spending; (iii) geographic variation in the strength of the association between labor income and healthcare spending; and (iv) negative association between labor income and mortality. In further exploratory analysis, we find no statistically significant correlation between simple county-level supply measures and healthcare spending. We argue that taken together, these patterns suggest that individuals with higher labor income are in better health but consume more healthcare because they have better access to services. Our work suggests new directions for research on the relationship between health inequalities and healthcare spending inequalities and the role of subtler barriers to healthcare access.

The effect of primary care availability on antibiotic consumption in Hungary: a population based panel study using unfilled general practices.

OBJECTIVE: We analyse the effect of primary care availability on antibiotic consumption and on the quality of antibiotic prescribing behaviour. DESIGN: Retrospective panel design, secondary analysis of settlement-level administrative panel data (n=2320 settlements, T=72 months). PARTICIPANTS AND SETTING: We analyse antibiotic consumption of the population of villages in Hungary, over years 2010 to 2015. We exploit the geographical and time variation in unfilled (mainly single-handed) general practices as a source of exogenous variation in the availability of primary care. We control for socioeconomic characteristics and settlement fixed effects in a panel regression framework. OUTCOME MEASURES: Antibiotic expenditures and days of therapy (DOT); consumption of narrow-spectrum and broad-spectrum antibiotics; consumption of Access, Watch and Reserve antibiotics according to the AWaRe categorisation; number of visits to the general practitioner (GP). RESULTS: If the general practice of a village becomes unfilled, the number of GP visits decreases on average by 9.3% (95% CI 5.6% to 12.9%), antibiotics DOT decrease on average by 3.2% (95% CI 1.0% to 5.4%) and expenditures on antibiotics decrease on average by 2.5% (95% CI 0.3% to 4.7%). The negative effect on antibiotic consumption is stronger in settlements where secondary care is less available, and where antibiotics were previously overprescribed. The quality of prescribing behaviour measured by the relative changes in the narrow-spectrum vs broad-spectrum as well as the Access versus Watch and Reserve antibiotics deteriorates significantly as a consequence of worse primary care availability. CONCLUSIONS: Limited availability of primary care reduces the consumption of antibiotics and at the same time impairs the quality of prescriptions through a decrease of the number of doctor-patient encounters.

Reduced user fees for antibiotics under age 5 in Hungary: Effect on antibiotic use and imbalances in the implementation.

OBJECTIVES: In August 2016, new prescription guidelines were introduced in Hungary to reduce the co-payments for antibiotics among children aged 0-4. This study aims at analysing the implementation of this policy and its effect on the use of antibiotics. METHODS: The analysis is based on administrative prescription records between January 2010-February 2018, covering the entire population of Hungary aged 0-7. Spatial autocorrelation indices are calculated and settlement level regression models are estimated to analyse the spatial variation in the application of the new guidelines. The effect of reduced co-payments on antibiotic use is estimated with a difference-in-differences type model: the treatment and control groups are children aged 0-4 and 5-7, respectively; the treatment and control periods are August 2016-February 2018 and January 2010-July 2016, respectively. RESULTS: The new prescription guidelines are more widely applied in settlements with higher per capita income and lower unemployment rate. Adherence to the new guidelines is spatially clustered. A 10-15% decrease in the out-of-pocket costs of antibiotics is estimated to increase the consumption of antibiotics by about 5% (95% CI: 2.63%-7.55%). CONCLUSIONS: In the absence of clear enforcement mechanisms, the adoption of the new prescription guidelines is selective, contradicting the aims of the policy of making antibiotics affordable for the poor children. The results point to the possible role of physicians' information networks in the application of prescription guidelines. The use of antibiotics among children aged 0-4 is responsive to the price subsidy of antibiotics.

How does retirement affect healthcare expenditures? Evidence from a change in the retirement age.

Using individual-level administrative panel data from Hungary, we estimate causal effects of retirement on outpatient and inpatient care expenditures and pharmaceutical expenditures. Our identification strategy is based on an increase in the official early retirement age of women, using that the majority of women retire upon reaching that age. According to our descriptive results, people who are working before the early retirement age have substantially lower healthcare expenditures than nonworkers, but the expenditure gap declines after retirement. Our causal estimates from a two-part (hurdle) model show that the shares of women with positive outpatient care, inpatient care, and pharmaceutical expenditures, respectively, decrease by 3.0, 1.4, and 1.3 percentage points in the short run due to retirement. These results are driven by the relatively healthy, by those who spent some time on sick leave and by the less educated. The effect of retirement on the size of positive healthcare expenditures is generally not significant.

Adaptation or recovery after health shocks? Evidence using subjective and objective health measures.

In this paper, we analyse the effect of an onset of a health shock on subjective survival probability and compare it with objective survival probability and self-reported health measures. In particular, we are interested in whether expectations of people respond to health shocks and whether these follow the evolution of objective life expectations and self-reported health measures over time. Using longitudinal data from the Health and Retirement Study, we estimate fixed effects models of adaptation for the objective and subjective survival probabilities and for some self-reported health measures. The results show that after cancer diagnosis, conditional on surviving, both the objective and subjective longevity and self-reported health measures drift back to the before diagnosis trajectories. For stroke and heart attack, in spite of their persistent negative effect on survival, subjective life expectations and self-reported health measures seem to indicate only a transient effect of the health shock. The differences between the objective and subjective measures are in line with the concept of adaptation. We discuss the policy implications of our results.

Determinants of biological drug survival in rheumatoid arthritis: evidence from a Hungarian rheumatology center over 8 years of retrospective data.

OBJECTIVE: To compare drug survival of biological therapies in patients with rheumatoid arthritis (RA), and analyze the determinants of discontinuation probabilities and switches to other biological therapies. MATERIALS AND METHODS: Consecutive RA patients initiating first biological treatment in one rheumatology center between 2006 and 2013 were included. Log-rank test was used to analyze the differences between the survival curves of different biological drugs. Cox regression was applied to analyze the discontinuation due to inefficacy, the occurrence of adverse events, or to any reasons. RESULTS: A total of 540 patients were included in the analysis. The most frequently used first-line biological treatments were infliximab (N=176, 33%), adalimumab (N=150, 28%), and etanercept (N=132, 24%). Discontinuation of first tumor necrosis factor-alpha (TNF-α) treatment was observed for 347 (64%) patients, due to inefficacy (n=209, 60%), adverse events (n=103, 30%), and other reasons (n=35, 10%). Drug survival rates for TNF-α and non-TNF-α therapies were significantly different, and were in favor of non-TNF-α therapies. Every additional number of treatment significantly increased the risk of inefficacy by 27% (p<0.001) and of adverse events by 35% (p=0.002). After the discontinuation of the initial TNF-α treatment, switching to rituximab and tocilizumab was associated with significantly longer treatment duration than switching to a second TNF-α. The non-TNF-α therapies resulted in significantly longer treatment duration, due to both less adverse events and longer maintenance of effectiveness. CONCLUSION: Non-TNF-α therapies resulted in significantly longer treatment duration, and lost their effectiveness later. Increase in the number of switches significantly increased the risk of discontinuation of any biological therapy.

Outpatient visits after retirement in Europe and the US.

I conduct an empirical analysis of the relation between retirement and outpatient care use in Europe and the US, and investigate the potential driving factors of that. I link the empirical analysis to a theoretical model of medical care demand. I document that pensioners tend to visit a doctor with higher probability and more often than the rest of the 50+ population. Ceteris paribus, being retired implies 3-10 % more outpatient visits in Europe. The estimates are of similar magnitude in the US. The paper contributes to the understanding of how population ageing plays a part in the rising health care expenditures. I find evidence that retirement related individual characteristics, increasing leisure time and stronger health preferences all contribute to the positive relation between retirement and outpatient care use, which is mainly driven by the healthier individuals. The gatekeeper role of general practitioners can mitigate the increased demand for outpatient care services after retirement.

Public-private sector interactions and the demand for supplementary health insurance in the United Kingdom.

We examine the demand for private health insurance (PHI) in the United Kingdom and relate this to changes in the supply of public and private healthcare. Using a novel collection of administrative, private sector and survey data, we re-assess the relationships between the quality and availability of public and private sector inpatient care, and the demand for PHI. We find that PHI coverage in the United Kingdom is positively related to the median of the region- and year-specific public sector waiting times. We find that PHI prevalence ceteris paribus increases with being self-employed and employed, while it decreases with having financial difficulties. In addition, we highlight the complexities of inter-sectoral relations and their impact on PHI demand. Within a region, we find that an increase in private healthcare supply is associated with a decrease in public sector waiting times, implying lower PHI demand. This may be explained by the usage of private facilities by NHS commissioners. These results have important implications for policymakers interested in the role of private healthcare supply in enhancing the availability of and equitable access to acute inpatient care.

Discount rates and the education gradient in mammography in the UK.

I analyse intertemporal decisions on undertaking breast cancer screening by women aged 50-64 years in the UK and provide estimates of the rate of discounting potential future benefits of screening. I also analyse education differences in mammography decisions and examine the underlying mechanisms by which education influences breast cancer screening attendance. I estimate a structural model, which reveals that although there are differences in the disutility of breast cancer screening between education groups, there is no difference in the estimated discount factor. These results suggest that the observed education gradient is mainly due to differences in health behaviours and healthcare attitudes.

Determinants of H1N1 vaccination uptake in England.

OBJECTIVE: This study aims to investigate which individual characteristics influenced the uptake of the 2009 H1N1 vaccination in England. The vaccination was provided for free to a specified target group who also received invitation letters, but the coverage rate was still far from universal among them. METHODS: Data from the 2010 edition of the Health Survey for England are used (size of the estimation sample: 7211). In order to partial out the effect of unobservable time costs, attitudes or access to vaccinations, immunisations against the seasonal and pandemic influenza are jointly estimated. RESULTS: Health risks, health behaviours and preferences, and exposure to various information help explain the immunisation decision. Receiving the seasonal flu vaccine increases the probability of H1N1 vaccination uptake by 20 percentage points. CONCLUSIONS: The widespread refusal of the vaccination can be worrying for the control of potential future pandemics. Providing clear, well targeted information, ensuring that high risk groups are contacted, and raising the level of health consciousness can increase the coverage rate with vaccinations.

Copayments, gatekeeping, and the utilization of outpatient public and private care at age 50 and above in Europe.

I analyze the relationship between health care institutions and the utilization of outpatient services by individuals aged 50 and above. I use cross-sectional micro data from thirteen European countries. I focus on the out-of-pocket costs of health care utilization, the gatekeeper role of general practitioners, and how these institutional settings are related to public and private care utilization. I find that copayments are related negatively to the probability of visiting a general practitioner among those in good health condition. I estimate the utilization of private specialist care to be higher in countries where copayments are required for public specialist care, and where the general practitioners have gatekeeper role. These estimated associations with private specialist care utilization are relatively large in magnitude, and are driven by individuals in the top income quartile.