Featured Publications

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.

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.

Background

A population health approach to depression screening using patient portals may be a promising strategy to proactively engage and identify patients with depression.

In this JAMA Forum article by Stanford Health Policy's Michelle Mello, the professor of health policy and law writes that reports are mounting of pregnant patients being denied potentially lifesaving care in emergency departments.

ABSTRACT

Child servitude is a form of economic exploitation of children around the world. We examine this phenomenon with local specificity, in Liberia, where it represents a perennial failure of the government to protect children, who are among its most vulnerable citizens. Despite its persistence and high prevalence, child servitude has not been the focus of academic research on Liberia. This paper explores the interplay of transmuted American chattel slavery and indigenous specific Liberian cultural practices of human subjugation against a backdrop of socio-economic inequalities, and their linkages to contemporary child servitude in postwar Liberia. We discuss the impacts of child servitude on victims and recommend policy measures to protect the rights of Liberian children. If postwar Liberia is to achieve its pro-poor developmental agenda, policies must be formulated that address child servitude and other forms of exploitation against Liberian children.

The U.S. Centers for Disease Control and Prevention (CDC) is responsible for preventing the introduction, transmission, and spread of communicable diseases into the United States. It does this primarily through the Division of Global Migration and Quarantine (DGMQ), which oversees the federal quarantine station network. Over the past two decades, the frequency and volume of microbial threats worldwide have continued to intensify. The COVID-19 pandemic, in particular, has prompted a reevaluation of many of our current disease control mechanisms, including the use and role of quarantine as a public health tool.

The emergence of COVID-19 prompted CDC to request that the National Academies of Sciences, Engineering, and Medicine convene a committee to assess the role of DGMQ and the federal quarantine station network in mitigating the risk of onward communicable disease transmission in light of changes in the global environment, including large increases in international travel, threats posed by emerging infections, and the movement of animals and cargo. The committee was also tasked with identifying how lessons learned during COVID-19 and other public health emergencies can be leveraged to strengthen pandemic response. The report's findings and recommendations span five domains: organizational capacity, disease control and response efforts, new technologies and data systems, coordination and collaboration, and legal and regulatory authority.

Abstract

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.

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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.

Abstract

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.