Living proof
How Effective are Public Health Departments at Preventing Mortality?
Timothy Tyler Brown
Economics & Human Biology, forthcoming
Abstract:
This study estimates the causal impact of variation in the expenditures of California county departments of public health on all-cause mortality rates and the associated value of lives saved. Since the activities of county departments of public health are likely to affect mortality rates with a lag, Koyck distributed lag models are estimated using the Lewbel instrumental variables estimator. The findings show that an additional $10 per capita of public health expenditures reduces all-cause mortality by 9.1 deaths per 100,000. At current funding levels, the long-run annual number of lives saved by the presence of county departments of public health in California is estimated to be approximately 27,000 (26,937 lives, 95% confidence interval: [11,963,41,911]). The annual value of these lives is estimated to be worth $212.8 billion using inflation-adjusted standard U.S. government estimates of the value of a statistical life ($7.9 million).
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The Effect of Mandatory Seat Belt Laws on Seat Belt Use by Socioeconomic Position
Sam Harper et al.
Journal of Policy Analysis and Management, Winter 2014, Pages 141–161
Abstract:
We investigated the differential effect of mandatory seat belt laws on seat belt use among socioeconomic subgroups. We identified the differential effect of legislation across higher versus lower education individuals using a difference-in-differences model based on state variations in the timing of the passage of laws. We find strong effects of mandatory seat belt laws for all education groups, but the effect is stronger for those with fewer years of education. In addition, we find that the differential effect by education is larger for mandatory seat belt laws with primary rather than secondary enforcement. Our results imply that existing socioeconomic differences in seat belt use would be further mitigated if all states upgraded to primary enforcement.
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Geographic Divergence in Mortality in the United States
Andrew Fenelon
Population and Development Review, December 2013, Pages 611–634
Abstract:
The United States trails other developed countries in adult mortality, a process that has become more pronounced over the past several decades. However, comparisons are complicated by substantial geographic variations in mortality within the United States. The second half of the twentieth century was characterized by a substantial divergence in adult mortality between the South and the rest of the United States. The article examines trends in US geographic variation in mortality between 1965 and 2004, in particular the aggregate divergence in mortality between the southern states and states with more favorable mortality experience. Relatively high smoking-attributable mortality in the South explains 50–100 percent of the divergence for men between 1965 and 1985 and up to 50 percent for women between 1985 and 2004. There is also a geographic correspondence between the contribution of smoking and other factors, suggesting that smoking may be one piece of a more complex health-related puzzle.
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Association of Nut Consumption with Total and Cause-Specific Mortality
Ying Bao et al.
New England Journal of Medicine, 21 November 2013, Pages 2001-2011
Background: Increased nut consumption has been associated with a reduced risk of major chronic diseases, including cardiovascular disease and type 2 diabetes mellitus. However, the association between nut consumption and mortality remains unclear.
Methods: We examined the association between nut consumption and subsequent total and cause-specific mortality among 76,464 women in the Nurses' Health Study (1980–2010) and 42,498 men in the Health Professionals Follow-up Study (1986–2010). Participants with a history of cancer, heart disease, or stroke were excluded. Nut consumption was assessed at baseline and updated every 2 to 4 years.
Results: During 3,038,853 person-years of follow-up, 16,200 women and 11,229 men died. Nut consumption was inversely associated with total mortality among both women and men, after adjustment for other known or suspected risk factors. The pooled multivariate hazard ratios for death among participants who ate nuts, as compared with those who did not, were 0.93 (95% confidence interval [CI], 0.90 to 0.96) for the consumption of nuts less than once per week, 0.89 (95% CI, 0.86 to 0.93) for once per week, 0.87 (95% CI, 0.83 to 0.90) for two to four times per week, 0.85 (95% CI, 0.79 to 0.91) for five or six times per week, and 0.80 (95% CI, 0.73 to 0.86) for seven or more times per week (P<0.001 for trend). Significant inverse associations were also observed between nut consumption and deaths due to cancer, heart disease, and respiratory disease.
Conclusions: In two large, independent cohorts of nurses and other health professionals, the frequency of nut consumption was inversely associated with total and cause-specific mortality, independently of other predictors of death.
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Life Satisfaction and Frequency of Doctor Visits
Eric Kim et al.
Psychosomatic Medicine, forthcoming
Objective: Identifying positive psychological factors that reduce health care use may lead to innovative efforts that help build a more sustainable and high-quality health care system. Prospective studies indicate that life satisfaction is associated with good health behaviors, enhanced health, and longer life, but little information about the association between life satisfaction and health care use is available. We tested whether higher life satisfaction was prospectively associated with fewer doctor visits. We also examined potential interactions between life satisfaction and health behaviors.
Methods: Participants were 6379 adults from the Health and Retirement Study, a prospective and nationally representative panel study of American adults older than 50 years. Participants were tracked for 4 years. We analyzed the data using a generalized linear model with a gamma distribution and log link.
Results: Higher life satisfaction was associated with fewer doctor visits. On a 6-point life satisfaction scale, each unit increase in life satisfaction was associated with an 11% decrease in doctor visits — after adjusting for sociodemographic factors (relative risk = 0.89, 95% confidence interval = 0.86–0.93). The most satisfied respondents (n = 1121; 17.58%) made 44% fewer doctor visits than did the least satisfied (n = 182; 2.85%). The association between higher life satisfaction and reduced doctor visits remained even after adjusting for baseline health and a wide range of sociodemographic, psychosocial, and health-related covariates (relative risk = 0.96, 95% confidence interval = 0.93–0.99).
Conclusions: Higher life satisfaction is associated with fewer doctor visits, which may have important implications for reducing health care costs.
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The Cold-War Origins of the Value of Statistical Life (VSL)
Spencer Banzhaf
Georgia State University Working Paper, November 2013
Abstract:
This paper traces the history of the "Value of Statistical Life" (VSL), which today is used routinely in benefit-cost analysis of life-saving investments. Schelling (1968) made the crucial move of thinking in terms of risk rather than individual lives, with the hope to dodge the moral thicket of valuing "life." But as recent policy debates have illustrated, his move only thickened it. Tellingly, interest in the subject can be traced back another twenty years before Schelling's essay, to a controversy at the RAND Corporation following its earliest application of operation research to defense planning. RAND wanted to avoid valuing pilot's lives, but the Air Force insisted they confront the issue. Thus, the VSL is not only well acquainted with political controversy; it was born from it.
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Socioeconomic inequalities in health after age 50: Are health risk behaviors to blame?
Benjamin Shaw et al.
Social Science & Medicine, forthcoming
Abstract:
Recent studies indicate that socioeconomic inequalities in health extend into the elderly population, even within the most highly developed welfare states. One potential explanation for socioeconomic inequalities in health focuses on the role of health behaviors, but little is known about the degree to which health behaviors account for health inequalities among older adults, in particular. Using data from the Health and Retirement Study (N=19,245), this study examined the degree to which four behavioral risk factors – smoking, obesity, physical inactivity, and heavy drinking – are associated with socioeconomic position among adults aged 51 and older, and whether these behaviors mediate socioeconomic differences in mortality, and the onset of disability among those who were disability-free at baseline, over a 10-year period from 1998-2008. Results indicate that the odds of both smoking and physical inactivity are higher among persons with lower wealth, with similar stratification in obesity, but primarily among women. The odds of heavy drinking decrease at lower levels of wealth. Significant socioeconomic inequalities in mortality and disability onset are apparent among older men and women; however, the role that health behaviors play in accounting for these inequalities differs by age and gender. For example, these health behaviors account for between 23-45% of the mortality disparities among men and middle aged women, but only about 5% of the disparities found among women over 65 years. Meanwhile, these health behaviors appear to account for about 33% of the disparities in disability onset found among women survivors, and about 9-14% among men survivors. These findings suggest that within the U.S. elderly population, behavioral risks such as smoking and physical inactivity contribute moderately to maintaining socioeconomic inequalities in health. As such, promoting healthier lifestyles among the socioeconomically disadvantaged older adults should help to reduce later life health inequalities.
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The Impact of Biomedical Knowledge Accumulation on Mortality: A Bibliometric Analysis of Cancer Data
Frank Lichtenberg
NBER Working Paper, October 2013
Abstract:
I examine the relationship across diseases between the long-run growth in the number of publications about a disease and the change in the age-adjusted mortality rate from the disease. The diseases analyzed are almost all the different forms of cancer, i.e. cancer at different sites in the body (lung, colon, breast, etc.). Time-series data on the number of publications pertaining to each cancer site were obtained from PubMed. For articles published since 1975, it is possible to distinguish between publications indicating and not indicating any research funding support. My estimates indicate that mortality rates: (1) are unrelated to the (current or lagged) stock of publications that had not received research funding; (2) are only weakly inversely related to the contemporaneous stock of published articles that received research funding; and (3) are strongly inversely related to the stock of articles that had received research funding and been published 5 and 10 years earlier. The effect after 10 years is 66% larger than the contemporaneous effect. The strong inverse correlation between mortality growth and growth in the lagged number of publications that were supported by research funding is not driven by a small number of outliers.
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Nicola Lacetera, Mario Macis & Sarah Stith
Journal of Health Economics, January 2014, Pages 43–56
Abstract:
Many U.S. states passed legislation providing leave to organ and bone marrow donors and/or tax benefits for live and deceased organ and bone marrow donations and to employers of donors. We exploit cross-state variation in the timing of such legislation to analyze its impact on organ donations by living and deceased persons, on measures of the quality of the transplants, and on the number of bone marrow donations. We find that these provisions do not have a significant impact on the quantity of organs donated. The leave laws, however, do have a positive impact on bone marrow donations, and the effect increases with the size of the population of beneficiaries and with the generosity of the legislative provisions. Our results suggest that this legislation works for moderately invasive procedures such as bone marrow donation, but these incentives may be too low for organ donation, which is riskier and more burdensome.
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Judd Kessler & Alvin Roth
Journal of Public Economics, forthcoming
Abstract:
Giving registered organ donors priority on organ waiting lists, as has been implemented in Israel and Singapore, provides an incentive for registration and has the potential to increase the pool of deceased donor organs. However, the implementation of a priority rule might allow for loopholes — as is the case in Israel — in which an individual can register to receive priority but avoid ever being in a position to donate organs. We experimentally investigate how such a loophole affects donation and find that the majority of subjects use the loophole when available. The existence of a loophole completely eliminates the increase in donation generated by the priority rule. When information about loophole use is made public, subjects respond to others’ use of the loophole by withholding donation such that the priority system with a loophole generates fewer donations than an allocation system without priority.
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Marcie Rubin, Sean Clouston & Bruce Link
Social Science & Medicine, January 2014, Pages 54–61
Abstract:
This study examines how associations between socioeconomic status (SES) and lung and pancreatic cancer mortality have changed over time in the U.S. The fundamental cause hypothesis predicts as diseases become more preventable due to innovation in medical knowledge or technology, individuals with greater access to resources will disproportionately benefit, triggering the formation or worsening of health disparities along social cleavages. We examine socioeconomic disparities in mortality due to lung cancer, a disease that became increasingly preventable with the development and dissemination of knowledge of the causal link between smoking cigarettes and lung cancer, and compare it to that of pancreatic cancer, a disease for which there have been no major prevention or treatment innovations. County-level disease-specific mortality rates for those ≥ 45 years, adjusted for sex, race, and age during 1968-2009 are derived from death certificate and population data from the National Center for Health Statistics. SES is measured using five county-level variables from four decennial censuses, interpolating values for intercensal years. Negative binomial regression was used to model mortality. Results suggest the impact of SES on lung cancer mortality increases 0.5% per year during this period. Although lung cancer mortality rates are initially higher in higher SES counties, by 1980 persons in lower SES counties are at greater risk and by 2009 the difference in mortality between counties with SES one SD above compared to one SD below average was 33 people per 100,000. In contrast, we find a small but significant reverse SES gradient in pancreatic cancer mortality that does not change over time. These data support the fundamental cause hypothesis: social conditions influencing access to resources more greatly impact mortality when preventative knowledge exists. Public health interventions and policies should facilitate more equitable distribution of new health-enhancing knowledge and faster uptake and utilization among lower SES groups.
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About time: Daylight Saving Time transition and individual well-being
Yiannis Kountouris & Kyriaki Remoundou
Economics Letters, January 2014, Pages 100–103
Abstract:
Daylight Saving Time is controversial due to its alleged negative impact on individual well-being. Using longitudinal data from Germany we find evidence that the transition to summer time has negative influence on general life satisfaction and mood, which is stronger for those in full time employment.
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A statin a day keeps the doctor away: Comparative proverb assessment modelling study
Adam Briggs, Anja Mizdrak & Peter Scarborough
British Medical Journal, December 2013
Objective: To model the effect on UK vascular mortality of all adults over 50 years old being prescribed either a statin or an apple a day.
Intervention: Either a statin a day for people not already taking a statin or an apple a day for everyone, assuming 70% compliance and no change in calorie consumption. The modelling used routinely available UK population datasets; parameters describing the relations between statins, apples, and health were derived from meta-analyses.
Results: The estimated annual reduction in deaths from vascular disease of a statin a day, assuming 70% compliance and a reduction in vascular mortality of 12% (95% confidence interval 9% to 16%) per 1.0 mmol/L reduction in low density lipoprotein cholesterol, is 9400 (7000 to 12 500). The equivalent reduction from an apple a day, modelled using the PRIME model (assuming an apple weighs 100 g and that overall calorie consumption remains constant) is 8500 (95% credible interval 6200 to 10 800).
Conclusions: Both nutritional and pharmaceutical approaches to the prevention of vascular disease may have the potential to reduce UK mortality significantly. With similar reductions in mortality, a 150 year old health promotion message is able to match modern medicine and is likely to have fewer side effects.
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Do Interviewer and Physician Health Ratings Predict Mortality?: A Comparison with Self-Rated Health
Megan Todd & Noreen Goldman
Epidemiology, November 2013, Pages 913-920
Background: Despite the serious biases that characterize self-rated health, researchers rely heavily on these ratings to predict mortality. Using newly collected survey data, we examine whether simple ratings of participants’ health provided by interviewers and physicians can markedly improve mortality prediction.
Methods: We use data from a prospective cohort study based on a nationally representative sample of older adults in Taiwan. We estimate proportional-hazard models of all-cause mortality between the 2006 interview and 30 June 2011 (mean 4.7 years’ follow-up).
Results: Interviewer ratings were more strongly associated with mortality than physician or self-ratings, even after controlling for a wide range of covariates. Neither respondent nor physician ratings substantially improve mortality prediction in models that include interviewer ratings. The predictive power of interviewer ratings likely arises in part from interviewers’ incorporation of information about the respondents’ physical and mental health into their assessments.
Conclusions: The findings of this study support the routine inclusion of a simple question at the end of face-to-face interviews, comparable to self-rated health, asking interviewers to provide an assessment of respondents’ overall health. The costs of such an undertaking are minimal and the potential gains substantial for demographic and health researchers. Future work should explore the strength of the link between interviewer ratings and mortality in other countries and in surveys that collect less detailed information on respondent health, functioning, and well-being.
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The social side of accidental death
Justin Denney & Monica He
Social Science Research, January 2014, Pages 92–107
Abstract:
Mortality from unintentional injuries, or accidents, represents major and understudied causes of death in the United States. Epidemiological studies show social factors, such as socioeconomic and marital status, relate with accidental death. But social theories posit a central role for social statuses on mortality risk, stipulating greater relevance for causes of death that have been medically determined to be more preventable than others. These bodies of work are merged to examine deaths from unintentional injuries using 20 years of nationally representative survey data, linked to prospective mortality. Results indicate that socially disadvantaged persons were significantly more likely to die from the most preventable and equally likely to die from the least preventable accidental deaths over the follow-up, compared to their more advantaged counterparts. This study extends our knowledge of the social contributors to a leading cause of death that may have substantial implications on overall disparities in length of life.
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Variation in U.S. traffic safety policy environments and motor vehicle fatalities 1980–2010
D. Silver et al.
Public Health, December 2013, Pages 1117–1125
Objective: To examine the impact of variation in state laws governing traffic safety on motor vehicle fatalities.
Methods: Fixed effects regression models estimate the relationship between state motor vehicle fatality rates and the strength of the state law environment for 50 states, 1980–2010. The strength of the state policy environment is measured by calculating the proportion of a set of 27 evidence-based laws in place each year. The effect of alcohol consumption on motor vehicle fatalities is estimated using a subset of alcohol laws as instrumental variables.
Results: Once other risk factors are controlled in statistical models, states with stronger regulation of safer driving and driver/passenger protections had significantly lower motor vehicle fatality rates for all ages. Alcohol consumption was strongly associated with higher MVC death rates, as were state unemployment rates.
Conclusions: Encouraging laggard states to adopt the full range of available laws could significantly reduce preventable traffic-related deaths in the U.S. – especially those among younger individuals. Estimating the relationship between different policy environments and health outcomes can quantify the result of policy gaps.