Decision models can combine information from different sources to simulate the long-term consequences of alternative strategies in the presence of uncertainty. A cohort state-transition model (cSTM) is a decision model commonly used in medical decision making to simulate the transitions of a hypothetical cohort among various health states over time. This tutorial focuses on time-independent cSTM, in which transition probabilities among health states remain constant over time. We implement time-independent cSTM in R, an open-source mathematical and statistical programming language. We illustrate time-independent cSTMs using a previously published decision model, calculate costs and effectiveness outcomes, and conduct a cost-effectiveness analysis of multiple strategies, including a probabilistic sensitivity analysis. We provide open-source code in R to facilitate wider adoption. In a second, more advanced tutorial, we illustrate time-dependent cSTMs.
Millions of Americans may have asked themselves these questions, or versions of them—especially in the wake of horrific mass shootings like those in Buffalo and Uvalde. Record-breaking spikes in gun sales over the last two years, alongside surveys indicating that self-protection continues to be the dominant reason for buying guns, underscore a widely-held belief that a gun in the home has security benefits.
A new study from my research team, recently published in the Annals of Internal Medicine, shows no such benefits. We found the opposite: people living in homes with guns face substantially higher risks of being fatally assaulted.
Is operating overnight associated with worse outcomes for surgical procedures performed by the attending surgeon the subsequent day? In this cross-sectional study of 498,234 daytime operations performed by 1,131 surgeons at 20 US institutions, there was no significant association between operating the previous night and the incidence of in-hospital death or major complications (sepsis, pneumonia, myocardial infarction, thromboembolic event, or stroke) for daytime operations performed the subsequent day. After adjusting for confounders, the incidence of death or major complications was 5.89% among daytime operations when the attending surgeon operated the night before compared with 5.87% among daytime operations when the attending surgeon did not. These findings suggest that operating overnight does not appear to be associated with worse outcomes when the attending surgeon continues to operate the next day.
Does the risk of suicide change for women when someone they live with in a previously handgun-free household lawfully acquires a handgun? In this retrospective cohort study of 9.5 million women living in handgun-free homes, the suicide rate increased substantially after a cohabitant acquired a handgun compared with the rate among women whose cohabitants never acquired handguns. The increased rate of suicide was entirely from excess of firearm suicides.The findings suggest that the rate of suicide for women living in handgun-free homes increased significantly after an adult they lived with became a handgun owner.
The disruptive power of the pandemic has rippled across the social determinants of child health. Just several months after the first cases were detected in the United States, the unemployment rate reached levels not seen since the depths of the Great Depression, with the majority of lost jobs concentrated in low-wage industries. Two-thirds of child care centers closed by April 2020, one-third remaining closed by April 2021. Recent reports estimate that more than one-third of households with children were experiencing either housing hardships or inadequate food, privations that fell disproportionately on racial and ethnic minority families. School closures have been widespread with wildly uneven capacities to respond by district. This has resulted in disparities potentially affecting children’s long-term learning and patterns of mortality over the life course.
During COVID-19, the public health toll of vaccine misinformation has risen from bothersome to titanic. As many as 12 million persons may have forgone COVID-19 vaccination in the US because of misinformation, resulting in an estimated 1200 excess hospitalizations and 300 deaths per day. If 5 fully loaded 747s crashed each week due to wrong information, regulators would be apoplectic.
National Bureau of Economic Research,
February 1, 2022
We study public vs. private provision of health care for veterans aged 65 and older who may receive care provided by the US Department of Veterans Affairs (VA) and in private hospitals financed by Medicare. Utilizing the ambulance design of Doyle et al. (2015), we find that the VA reduces 28-day mortality by 46% (4.5 percentage points) and that these survival gains are persistent. The VA also reduces 28-day spending by 21% and delivers strikingly different reported services relative to private hospitals. We find suggestive evidence of complementarities between continuity of care, health IT, and integrated care.
Stanford health law experts Michelle Mello and David Studdert discuss the ongoing pandemic, proof of vaccination “passports” at the state and federal levels, and a July 19 ruling that Indiana University could require that its students be vaccinated.
Digital contact tracing has the potential to limit the spread of COVID-19. A contact-tracing smartphone app that has been readily adopted by people in England and Wales has shown efficacy in reducing disease spread.
American Economic Journal: Economic Policy,
February 1, 2021
I study team decisions among physician trainees. Exploiting a discontinuity in team roles across trainee tenure, I find evidence that teams alter decision-making, concentrating influence in the hands of senior trainees. I also demonstrate little convergence in variation of trainee effects despite intensive training. This general pattern of trainee effects on team decision-making exists in all types of decisions and settings that I examine. In analyses evaluating mechanisms behind this pattern, I find support for the idea that significant experiential learning occurs during training and that teams place more weight on judgments of senior trainees in order to aggregate information.