Featured Publications

Low- to moderate-intensity statins were associated with a greater reduction in LDL-C levels in older persons than younger persons and may be more appealing as initial treatment in older adults who are at increased risk for adverse events.

The authority of states and localities to require vaccination is a bedrock principle of public health law. Since 1905, when the US Supreme Court upheld compulsory smallpox inoculations, there has been sustained judicial consensus that the Constitution “does not import an absolute right to be…wholly freed from restraint.” Otherwise, “organized society could not exist with safety to its members.” Until recently, objections to mandatory vaccinations were confined to a small minority of US residents. However, civic values eroded during the COVID-19 pandemic, creating a groundswell of resistance. With state legislatures now sharply limiting public health authority and a bevy of legal challenges mounted vaccination mandates—an old and highly effective public health tool—face legal uncertainty that only a few years ago seemed inconceivable.

Under the current US kidney allocation system, older candidates receive a disproportionately small share of deceased donor kidneys despite a reserve of potentially usable kidneys that could shorten their wait times. To consider potential health gains from increasing access to kidneys for these candidates, we developed and calibrated a microsimulation model of the transplantation process and long-term outcomes for older deceased donor kidney transplant candidates.

Is government guiding the invisible hand at the top of the labor market? We use new administrative data to measure physicians' earnings and estimate the influence of healthcare policies on these earnings, physicians' labor supply, and allocation of talent. Combining the administrative registry of U.S. physicians with tax data, Medicare billing records, and survey responses, we find that physicians' annual earnings average $350,000 and comprise 8.6% of national healthcare spending. The age-earnings profile is steep; business income comprises one quarter of earnings and is systematically underreported in survey data. There are major differences in earnings across specialties, regions, and firm sizes, with an unusual geographic pattern compared with other workers. We show that health policy has a major impact on the margin: 25% of physician fee revenue driven by Medicare reimbursements accrues to physicians personally. Physicians earn 6% of public money spent on insurance expansions. We find that these policies in turn affect the type and quantity of medical care physicians supply in the short run; retirement timing in the medium run; and earnings affect specialty choice in the long run.

One-time CKD screening at age 55 years had an ICER of $86 300 per QALY gained by increasing costs from $249 800 to $259 000 and increasing QALYs from 12.61 to 12.72; this was accompanied by a decrease in the incidence of kidney failure requiring dialysis or kidney transplant of 0.29 percentage points and an increase in life expectancy from 17.29 to 17.45 years. Other options were also cost-effective. During ages 35 to 75 years, screening once prevented dialysis or transplant in 398 000 people and screening every 10 years until age 75 years cost less than $100 000 per QALY gained.

The Spring 2023 issue of Dædalus takes a transdisciplinary approach to understanding the dilemmas facing humanitarian health actors, and to finding room for innovation in humanitarian health delivery. Recognizing that shared compassion cannot be proscribed but must be felt, the issue also draws on the power of the arts, and features paintings, poetry, photography, fiction, and creative nonfiction by artists whose lives have been shaped by violent conflict and displacement.

Preterm birth (PTB) is the leading cause of death in children under five, yet comprehensive studies are hindered by its multiple complex etiologies. Epidemiological associations between PTB and maternal characteristics have been previously described. This work used multiomic profiling and multivariate modeling to investigate the biological signatures of these characteristics. Maternal covariates were collected during pregnancy from 13,841 pregnant women across five sites. Plasma samples from 231 participants were analyzed to generate proteomic, metabolomic, and lipidomic datasets. Machine learning models showed robust performance for the prediction of PTB (AUROC = 0.70), time-to-delivery (r = 0.65), maternal age (r = 0.59), gravidity (r = 0.56), and BMI (r = 0.81). Time-to-delivery biological correlates included fetal-associated proteins (e.g., ALPP, AFP, and PGF) and immune proteins (e.g., PD-L1, CCL28, and LIFR). Maternal age negatively correlated with collagen COL9A1, gravidity with endothelial NOS and inflammatory chemokine CXCL13, and BMI with leptin and structural protein FABP4. These results provide an integrated view of epidemiological factors associated with PTB and identify biological signatures of clinical covariates affecting this disease.

ChatGPT has exploded into the national consciousness. The potential for large language models (LLMs) such as ChatGPT, Bard, and many others to support or replace humans in a range of areas is now clear—and medical decisions are no exception. This has sharpened a perennial medicolegal question: How can physicians incorporate promising new technologies into their practice without increasing liability risk?

In this JAMA Health Forum commentary, SHP's Michelle Mello and colleagues argue that the $1.7 trillion omnibus bill that Congress passed in December 2022 responds to several urgent public health needs, yet only narrowly addresses some of the critical determinants of pandemic preparedness.

Objective: To evaluate the cost effectiveness of California's statewide perinatal quality collaborative for reducing severe maternal morbidity (SMM) from hemorrhage.

Results: The collaborative was cost effective, exhibiting strong dominance when compared with the baseline or standard of care. In a theoretical cohort of 480,000 births, collaborative implementation added 182 QALYs (0.000379/birth) by averting 913 cases of SMM, 28 emergency hysterectomies, and one maternal mortality. Additionally, it saved $9 million ($17.78/birth) due to averted SMM costs. Although sensitivity analyses across parameter uncertainty ranges provided cases where the intervention was not cost saving, it remained cost effective throughout all analyses. Additionally, scenario-based sensitivity analysis found the intervention cost effective regardless of birth volume and implementation costs.

Abstract

Low rates of vaccination, emergence of novel variants of SARS-CoV-2, and increasing transmission relating to seasonal changes and relaxation of mitigation measures leave many US communities at risk for surges of COVID-19 that might strain hospital capacity, as in previous waves. The trajectories of COVID-19 hospitalizations differ across communities depending on their age distributions, vaccination coverage, cumulative incidence, and adoption of risk mitigating behaviors. Yet, existing predictive models of COVID-19 hospitalizations are almost exclusively focused on national- and state-level predictions. This leaves local policymakers in urgent need of tools that can provide early warnings about the possibility that COVID-19 hospitalizations may rise to levels that exceed local capacity. In this work, we develop a framework to generate simple classification rules to predict whether COVID-19 hospitalization will exceed the local hospitalization capacity within a 4- or 8-week period if no additional mitigating strategies are implemented during this time. This framework uses a simulation model of SARS-CoV-2 transmission and COVID-19 hospitalizations in the US to train classification decision trees that are robust to changes in the data-generating process and future uncertainties. These generated classification rules use real-time data related to hospital occupancy and new hospitalizations associated with COVID-19, and when available, genomic surveillance of SARS-CoV-2. We show that these classification rules present reasonable accuracy, sensitivity, and specificity (all ≥ 80%) in predicting local surges in hospitalizations under numerous simulated scenarios, which capture substantial uncertainties over the future trajectories of COVID-19. Our proposed classification rules are simple, visual, and straightforward to use in practice by local decision makers without the need to perform numerical computations.

The COVID-19 pandemic spurred a rapid expansion of wastewater-based infectious disease surveillance systems to monitor and anticipate disease trends in communities.The Centers for Disease Control and Prevention (CDC) launched the National Wastewater Surveillance System in September 2020 to help coordinate and build upon those efforts. Produced at the request of CDC, this report reviews the usefulness of community-level wastewater surveillance during the pandemic and assesses its potential value for control and prevention of infectious diseases beyond COVID-19.

Federal courts in Texas are fast becoming known as the graveyards of U.S. health policies.1 Decisions concerning a range of statutes, from the Affordable Care Act (ACA) to the Emergency Medical Treatment and Labor Act, have chipped away at federal powers to protect the public’s health. The latest case in this series, Braidwood Management Inc. v. Becerra,2 targets the ACA’s use of U.S. Preventive Services Task Force (USPSTF) recommendations as a basis for mandating insurance coverage for preventive care. The Braidwood decision not only destabilizes efforts to ensure access to essential insurance benefits but also illustrates an emerging strategy among litigants with antiregulatory agendas: wielding heretofore sleepy doctrines of administrative and constitutional law to undercut health initiatives.

Objective: To develop a measure for fair inclusion in pivotal trials by assessing transparency and representation of enrolled women, older adults (aged 65 years and older), and racially and ethnically minoritized patients.

In this cross-sectional study of nearly 800,000 U.S. participants aged 5 to 17 years with family income under 200% of the federal poverty threshold, researchers found that higher family income was significantly associated with a lower prevalence of diagnosed infections, mental health disorders, injury, asthma, anemia, and substance use disorders and lower 10-year mortality. Read the full original investigation in JAMA.

During the first year of the pandemic, East Asian countries have reported fewer infections, hospitalizations, and deaths from COVID-19 disease than most countries in Europe and the Americas. Our goal in this paper is to generate and evaluate hypothesis that may explain this striking fact. We consider five possible explanations: (1) population age structure (younger people tend to have less severe COVID-19 disease upon infection than older people); (2) the early adoption of lockdown strategies to control disease spread; (3) genetic differences between East Asian population and European and American populations that confer protection against COVID-19 disease; (4) seasonal and climactic contributors to COVID-19 spread; and (5) immunological differences between East Asian countries and the rest of the world. The evidence suggests that the first four hypotheses are unlikely to be important in explaining East Asian COVID-19 exceptionalism. Lockdowns, in particular, fail as an explanation because East Asian countries experienced similarly good infection outcomes despite vast differences in lockdown policies adopted by different countries to control the COVID-19 epidemic. The evidence to date is consistent with our fifth hypothesis – pre-existing immunity unique to East Asia – but there are still essential parts of this story left for scientists to check.

Abstract

This paper analyzes the impact of paid family leave (PFL) policies in California, New Jersey, and New York on the labor market and mental health outcomes of individuals whose spouses or children experience health shocks. We use data from the 1996-2019 restricted-use version of the Medical Expenditure Panel Survey (MEPS), which provides state of residence and the precise timing of hospitalizations and surgeries, our health shock measures. We use difference-in-difference and event-study models to compare the differences in post-health-shock labor market and mental health outcomes between spouses and parents before and after PFL implementation relative to analogous differences in states with no change in PFL access. We find that PFL access leads to a 7.0 percentage point decline in the likelihood that the (healthy) wives of individuals with medical conditions or limitations who experience a hospitalization or surgery report “leaving a job to care for home or family” in the post-health-shock rounds. Impacts of PFL access on women's mental health outcomes and on men whose spouses have health shocks are more mixed, and we find no effects on parents of children with health shocks. Lastly, we show that improvements in job continuity are concentrated among caregivers with 12 or fewer years of education, suggesting that government-provided PFL might reduce disparities in leave access.

Importance  Statin-associated muscle symptoms (SAMS) are common and may lead to discontinuation of indicated statin therapy. Observational studies suggest that vitamin D therapy is associated with reduced statin intolerance, but no randomized studies have been reported.

Objective  To test whether vitamin D supplementation was associated with prevention of SAMS and a reduction of statin discontinuation.

We evaluated the protection conferred by mRNA vaccines and previous infection against infection with the omicron variant in two high-risk populations: residents and staff in the California state prison system. We used a retrospective cohort design to analyze the risk of infection during the omicron wave using data collected from December 24, 2021, through April 14, 2022. Weighted Cox models were used to compare the effectiveness (measured as 1 minus the hazard ratio) of vaccination and previous infection across combinations of vaccination history (stratified according to the number of mRNA doses received) and infection history (none or infection before or during the period of B.1.617.2 [delta]–variant predominance). A secondary analysis used a rolling matched-cohort design to evaluate the effectiveness of three vaccine doses as compared with two doses.

We use linked administrative data that combines the universe of California birth records, hospitalizations, and death records with parental income from Internal Revenue Service tax records and the Longitudinal Employer-Household Dynamics file to provide novel evidence on economic inequality in infant and maternal health. We find that birth outcomes vary nonmonotonically with parental income, and that children of parents in the top ventile of the income distribution have higher rates of low birth weight and preterm birth than those in the bottom ventile. However, unlike birth outcomes, infant mortality varies monotonically with income, and infants of parents in the top ventile of the income distribution---who have the worst birth outcomes---have a death rate that is half that of infants of parents in the bottom ventile. When studying maternal health, we find a similar pattern of non-monotonicity between income and severe maternal morbidity, and a monotonic and decreasing relationship between income and maternal mortality. At the same time, these disparities by parental income are small when compared to racial disparities, and we observe virtually no convergence in health outcomes across racial and ethnic groups as income rises. Indeed, infant and maternal health in Black families at the top of the income distribution is markedly worse than that of white families at the bottom of the income distribution.Lastly, we benchmark the health gradients in California to those in Sweden, finding that infant and maternal health is worse in California than in Sweden for most outcomes throughout the entire income distribution.

Men living alone may have particular difficulty in managing chronic medical conditions. Anticoagulation control, a sensitive indicator of self-management, was significantly worse among men living alone.

We use linked survey and administrative data to document and decompose the striking differences across demographic groups in both economic and health impacts of the first year of the COVID-19 pandemic in the United States. The impacts of the pandemic on all-cause mortality and on employment were concentrated in the same racial, ethnic, and education groups, with non-White individuals and those without a college degree experiencing higher excess all-cause mortality as well as a greater employment loss. Observable differences in living arrangements and the nature of work – which likely affected exposure to the virus and to economic contractions – can explain 15 percent of the Hispanic-White difference in excess mortality, almost one-quarter of the non- Hispanic Black-White difference, and almost half of the difference between those with and without a Bachelor’s degree; they can also explain 35 to 40 percent of the differences in economic damages between these groups. These findings underscore the importance of non-medical factors in contributing to the disparate impacts of public health shocks.

Abstract

Professions play a key role in determining the division of labor and the returns to skilled work. This paper studies the productivity difference between physicians and nurse practitioners (NPs), two health care professions performing overlapping tasks but with stark differences in background, training, and pay. Using data from the Veterans Health Administration and quasi-experimental variation in the patient probability of being treated by physicians versus NPs in the emergency department, we find that, compared to physicians, NPs significantly increase resource utilization but achieve worse patient outcomes. We find evidence suggesting mechanisms relating to lower human capital among NPs relative to physicians and worker-task assignment responding to the lower skill of NPs. Counterfactual analysis suggests a net increase in medical costs with NPs, even when accounting for NPs’ wages that are half as much as physicians’. Despite large productivity differences between professions, we find even larger productivity differences within professions and substantial productivity overlap between professions. Yet there is little overlap in wages between NPs and physicians and, within professions, no significant correlation between productivity and wages.