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Thesis advisor: Christopher Maxwell / Though much research has been done on the subject of substituting nurse practitioners for physicians as health care providers, both analytic methods and results have been inconsistent. Various studies have shown nurse practitioners to provide equivalent or improved care especially in primary care settings. However, no consensus has been reached on whether or not and under what conditions this substitution is economically efficient. Because of variation in productivity and substitution rates, the economic viability of nurse practitioners must be assessed on a department specific basis, taking into account differences in nurse practitioners’ job descriptions.One specific area this economic efficiency could be assessed in is in the diagnosis of ear infections. A study conducted through the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey showed that 15% of pediatric visits included a diagnosis of middle ear infection (Freid, 1998). If employed properly, nurse practitioners could be used to achieve significant cost savings in this area.This thesis is intended to address the economic efficiency of nurse practitioners as compared to physicians in diagnosing ear infections. First nurse practitioner quality in this specific area will be assessed by comparing nurse practitioner diagnosis error rates to physician error rates based on surveys asking both types of providers to provide diagnoses based on tympanic membrane images collected through previous telemedicine visits. Next the economic practicality of employing nurse practitioners in this field will be assessed in terms of the relative costs of these errors, measured as the cost of unnecessary prescriptions in the case of overdiagnosis and the cost of an unnecessary follow-up visit in the case of underdiagnosis. / Thesis (BA) — Boston College, 2012. / Submitted to: Boston College. College of Arts and Sciences. / Discipline: College Honors Program. / Discipline: Economics Honors Program. / Discipline: Economics.

My dissertation focuses on changes in health-related behavior in react to information-based intervention. The first chapter analyzes the results of a field experiment to investigate the effects of comparative information on the daily number of steps taken of adults. The second chapter further explores the effects using qualitative analysis. The third chapter intends to offer explanations in the mechanisms of the results from the first chapter. My first chapter uncovers how patterns in the daily number of steps of adults are affected by information that compares one with unknown peers. I conducted a field experiment that used fitness trackers to collect daily and minute-by-minute data on the total number of steps an individual takes in a day. Participants were randomized into a group that was provided with comparison information and a group that did not receive such information. I examined whether individuals in the two groups behaved differently during and after the intervention period. I find no clear evidence of an aggregate impact of social norms on the daily number of steps taken. However, I find individuals who are not overweight or nor married or cohabiting are more likely to be influenced by social norms. Greater treatment effects are found among individuals whose number of steps that are at the tails of the distribution curve. My second chapter reports the results of the textual data from the survey in the field experiment. I present dominant themes that emerged from answers to the open-ended essay questions in the survey. The results support that health concern, body image, appearance, psychological factors, peers and friends are major motives for being physically active. For participation in the study specifically, text messages that contain comparative information produced some improvement of the exercise level. However, participants also requested more interactions with peers, additional information provision, rewards for reaching goals. The results imply external incentives play a smaller role in promoting daily number of steps. In the third chapter, I conduct a survey experimentation to test the effectiveness of informing descriptive social norms and types of text messages in predictions about health-related behaviors. First, I investigate if errors in beliefs about activity levels exist and I find no evidence of over- or under-confidence in one’s own activity levels. Further analysis provide preliminary evidence of negative effects of informedness in predictions about one’s own behavior. However, the intention-to-treat effects of comparative information are unclear. The data provide evidence in favor of the correlation between first-order personal beliefs, not higher-order normative beliefs, in predicting an increase number of steps taken in response to intervention with text messages.

Since 2010 the Center for Disease Control (CDC) and its Advisory Committee on Immunization Practices (ACIP) have recommended annual influenza vaccinations for all persons aged six months and up (ACIP, 2017). In December of the same year, the Agency of Health and Human Services (AHHS) unveiled Healthy People 2020, a series of health indicators and corresponding 10-year objectives. This newest iteration of the Healthy People program set target influenza vaccination levels for healthy adults 18 and older at 80% (AHHS, 2010). Aside from the inherent health benefits, multiple studies conducted over the past decade suggest there may be significant economic benefits to a highly-vaccinated population. Depending on the effectiveness of seasonal vaccines, the cost of vaccinating a U.S. adult can be outweighed by the health care savings from the resulting reduction in direct and indirect infection treatment costs. As the state of Vermont considers including influenza vaccinations in its state-mandated Vermont Vaccine Purchasing Program (VVPP), it presents a unique opportunity to conduct a state-wide case study on the potential cost-saving implications of a universally available influenza vaccination. This study takes a historical perspective and looks back at Vermont’s influenza cost, usage, and treatment information since the vaccine was recommended in 2010. Using data generated from Vermont’s immunization registry, de-identified claims data, CDC-reported statistics, and numerous published economic studies, this research answers the question: “What societal costs/savings would have been witnessed if the influenza vaccine was included in the VVPP since 2010?” and, more important, what policy changes can be made now to realize savings in the future? Using a dynamic transmission model embedded in cost-benefit analysis, this research concludes that influenza-related savings of 6.2% would have been experienced over the five flu seasons between fall 2010 and summer 2015. Most of the savings are generated by the increased vaccination rate associated with a universal vaccination program. Creation of such a program in the state of Vermont would likely be economically beneficial.

This thesis focuses on how health care policies affect the labor supply of physicians and beneficiaries. Further, I examine how the labor supply responses of physicians vary based on the level of competition. In the first chapter, I focus on the labor supply response of physicians to two large public health insurance expansions, the State Children’s Health Insurance Program (SCHIP) and the Affordable Care Act (ACA). These insurance programs have significantly increased the number of patients with public health insurance and the demand for medical services, but it is not clear whether providers will supply additional services for newly-insured patients. In response to the introduction of SCHIP, my estimates suggest that physicians reallocate their total working hours between patient care and non-patient care activities. The size of the impact was greater in areas with high level of physician concentration prior to the expansion. Physicians in high concentration areas tend to decrease time spent on direct patient care, but increase hours on non-direct patient care. In response to the ACA, physicians’ working hours did not increase, but working hours and the probability of being employed increased for registered nurses. This suggests that physicians might utilize other healthcare providers to accommodate increases in demand for medical services after the expansion. In the second chapter, we analyzed the impact of expanding Medicaid on health insurance coverage and labor market outcomes. Expansions of public health insurance have the potential to reduce the uninsured rate, but also to reduce coverage through employer-sponsored insurance (ESI), reduce labor supply, and increase job mobility. In January 2014, twenty-five states expanded Medicaid as part of the Affordable Care Act to low-income parents and childless adults. We compare the changes in insurance coverage and labor market outcomes over time of adults in states that expanded Medicaid and in states that did not. Our estimates suggest that the recent expansion significantly increased Medicaid coverage with little decrease in ESI. Overall, the expansion did not impact labor market outcomes, including labor force participation, employment, and hours worked. In the third chapter, I examined the impact of competition among dentists on the labor supply of dentists. I focus on how dentists’ working hours will changes when the level of competition increases by examining the effect of the National Health Service Corps (NHSC). The NHSC was created to increase the supply of rural physicians, which might increase the competition in rural areas. I examine the number of dentists (extensive margins of labor supply) and the change in the working hours of dentists (intensive margins of labor supply) in response to the increased level of physician competition. I found that 1 percent increase in NHSC-approved sites increases 5.4% increases in the number of providers and 0.2% of competition in a rural county. In addition, I found that there is a positive relationship between the number of NHSC-approved sites and providers’ working hours. If the competition among dentists increases about 1, then working hours of providers increase about 6 hours per week.

Background: Uncertainty in parameters is present in many risk assessment and decision making problems and leads to uncertainty in model predictions. Therefore an analysis of the degree of uncertainty around the model inputs is often needed. Importance analysis involves use of quantitative methods aiming at identifying the contribution of uncertain input model parameters to output uncertainty. Expected value of partial perfect information (EVPPI) measure is a current gold- standard technique for measuring parameters importance in health economics models. The current standard approach of estimating EVPPI through performing double Monte Carlo simulation (MCS) can be associated with a long run time. Objective: To investigate different importance analysis techniques with an aim to find alternative technique with shorter run time that will identify parameters with greatest contribution to uncertainty in model output. Methods: A health economics model was updated and served as a tool to implement various importance analysis techniques. Twelve alternative techniques were applied: rank correlation analysis, contribution to variance analysis, mutual information analysis, dominance analysis, regression analysis, analysis of elasticity, ANCOVA, maximum separation distances analysis, sequential bifurcation, double MCS EVPPI,EVPPI-quadrature and EVPPI- single method. Results: Among all these techniques, the dominance measure resulted with the closest correlated calibrated scores when compared with EVPPI calibrated scores. Performing a dominance analysis as a screening method to identify subgroup of parameters as candidates for being most important parameters and subsequently only performing EVPPI analysis on the selected parameters will reduce the overall run time.

In the summer of 2003, David Cutler, Edward Glaeser, and Jesse Shapiro published the paper, “Why Have Americans Become More Obese?”1 In the paper, the authors explore changing trends in American weight and caloric intake over time and hypothesize as to the potential causes of these changes. In performing our tests, we hope to both replicate their results and update any analysis for the present.

Rheumatoid Arthritis (RA) is a chronic autoimmune disease that affects 0,5-1% of the general population worldwide. The disease is a complex genetic disease, meaning that several genes, environmental factors and stochastic factors act as players in the development of the disease. RA causes inflammation in the joints typically in the hands and feet. It also can affect surrounding tissue and organs in the body. RA affects mostly women in their middle age, but the disease can occur at every age and in both genders. New research indicates that early treatment can improve quality of life and living conditions for the patients since medical treatment of the disease can cause remission.   Thermo Fischer Scientific ImmunoDiagnostic Division in Uppsala started the development of a new diagnostic tool, ISAC, to provide early diagnosis for RA patients and consequently enable early treatment.   The report will discuss the costs associated with the disease today and in connection to diagnosis, medication, hospital admissions and sick leave in Sweden. This will lead to a discussion and presentation of a market strategy for the first phase of the introducing the product. The results from the latest study done with ISAC shows that ISAC is “as good as” the present and competitive diagnostic method such as ELISA/CCP2 tests but ISAC has the ability to diagnose 18% more patients. Early diagnosis allows cost savings and during year 4 and with patient base of 3600 patients the savings are 154 million SEK or more for the healthcare system. From the selected group of patients around 900 new patients will be added annually.   The associated cost savings for the healthcare system can be up to 25% for each patient compared to present methods. In addition, there is a great value for each additional year of working life for the patient. However this added value is extremely difficult to predict.

This dissertation consists of three studies in the field of health economics. The first chapter studies the market situation of the U.S. nursing home industry. It uses the most recent data available from the Annual Survey of Nursing Homes conducted in Wisconsin. In this study, we derive theoretical predictions from an optimization problem of a representative nursing home under various assumptions. We introduce a new measure, a home's bed-utilization rate, in our empirical strategy and find evidence of excess demand from Medicaid patients in Wisconsin. A positive relationship between Medicaid payment rates and private-pay prices is found in homes with high bed utilization. Additionally, we find strong adverse effects of higher reimbursement rates on quality measures. These findings prove there is an excess demand from Medicaid patients in Wisconsin. This conclusion has direct implications for the quality of care that a nursing home provides for its patients. The second study takes advantage of the "natural experiment" features of the major health care reform in Thailand in 2002 in order to estimate the price elasticity of health care demand among Thai citizens. We use the difference-in-difference technique to capture the pure effect of the reform on the health care utilization behavior of those who were directly affected by the reform. In order to capture any secular trend in health care utilization, we use data from a group of people who were not affected by the reform. We find that the reduction in health care price immediately induced those who lacked health insurance coverage to increase their visits to a public health care facility, although similar trends were not found a few years after the reform. The estimated change in visits is used to calculate the price elasticity of demand, which falls in the range of -1.36 to -0.58. The last study examines the relationship between risky behaviors among Americans aged 50-65 and their health insurance coverage. Despite the fact that moral hazard behaviors are predicted by economic theory, the study finds that health insurance has no significant effect on certain risky behaviors such as smoking. Surprisingly, we find a significantly positive relationship between health insurance coverage and healthy behaviors such as exercising regularly. This finding reflects the importance of health insurance companies in providing its customers with more health information that could encourage health-oriented attitudes. / text

Background: Gastric cancer is the fourth most common cancer in the world. Non-curative, metastatic disease is frequent in low incidence countries; management strategies for relief of symptoms include surgery, chemotherapy and radiotherapy. The resource utilization of metastatic gastric cancer patients is unstudied in the Canadian system, and predictors of major cost drivers and end-of-life care unknown. Our purpose was to describe the resource utilization of metastatic gastric cancer patients in Ontario, compare resource utilization among Local Health Integration Networks (LHINs) and examine predictors of inpatient hospital days and receipt of homecare. Methods: This is a retrospective cohort study of metastatic gastric adenocarcinoma patients registered in the Ontario Cancer Registry between April 1, 2005 and March 31st, 2008. Chart review and administrative healthcare data were linked to describe non-therapeutic endoscopic, radiologic and surgical investigations and treatment strategies from the healthcare system perspective, using a two-year and two month time horizon. Chi square tests were used to compare proportions of resource utilization, and non-parametric one-way ANOVA compared mean per patient usage. Negative binomial regression was used to model the number of inpatient hospital days. Modified Poisson regression was used to model receipt of homecare. Results: The cohort consisted of 1433 patients with metastatic disease. Less than half of the patients received chemotherapy (43%), gastrectomy (37%) or radiotherapy (28%). Geographic variation existed in the type of health services consumed and in the frequency of their use among LHINs. Location of the primary tumour, resource utilization band, receipt of a gastrectomy and care from a high volume physician were independent predictors of inpatient hospital days. Home care use was predicted by location of the primary tumour, receipt of care from a high volume physician and the number of days survived within the study period. Conclusion: Variation in healthcare resource utilization exists between LHINs in Ontario for the care of metastatic gastric cancer patients. Whether these differences reflect differential access to iii resources, patient preference or physician preference is not known. Further research needs to examine differences and how they impact on clinical disease outcomes. Next steps include incorporating predictors of resource utilization measures into clinical and policy-level decision-making. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2012-08-30 09:49:34.731