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ABSTRACT: To assess the association between obstetricians' years of experience after training and the maternal complications of their patients during their first 40 years of post-residency practice.
Retrospective cohort analysis.
Obstetrical discharges from acute care hospitals in Florida and New York between academic years 1992 and 2009.
6 704 311 deliveries performed by 5175 obstetricians.
Three composite measures of maternal complication rates per physician year from vaginal and cesarean births separately and combined, adjusted for secular trends.
Obstetricians' maternal complication rates declined during the first three decades after completion of residency. The improvement was largest in the first decade and diminished thereafter. For all deliveries, the change was -0.21 (95% confidence interval -0.23 to -0.19) percentage points per year in the first decade, -0.11 (-0.13 to -0.09) percentage points per year in the second decade, and -0.05 (-0.08 to -0.01) percentage points in the third decade (P<0.001 for second to first decade comparison; P=0.001 for third to second decade comparison). The patterns were comparable for cesarean deliveries and vaginal deliveries and across several sensitivity checks.
Among obstetricians practicing in Florida and New York, those with more years of experience had fewer maternal complications. This association persisted over the first three decades of practice but diminished in magnitude.
BMJ (Clinical research ed.). 01/2013; 346:f1596.
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ABSTRACT: Economic theory indicates that firms can match workers to jobs and promote productivity-enhancing specialization better than markets, yet few data exist. We empirically test whether firms enhance matching and specialization in the context of obstetrics. We then examine whether consumers benefit from this. We find that high-risk patients in group practices match with specialists more than patients of solo physicians, and this improves patients' health outcomes. Matching based on a patient's clinical need for a cesarean section delivery and a physician's cesarean section skill also occurs, but less extensively. These results support the hypothesis that firms facilitate matching and specialization. Copyright (c) 2010, RAND..
The RAND Journal of Economics 11/2010; 41(4):811-834. · 1.49 Impact Factor
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ABSTRACT: Over 4 million women give birth annually in the United States, making delivery one of the most common reasons for hospital care.
We examined 15-year trends in risk-adjusted maternal complications following childbirth.
We examined maternal obstetrical outcomes from 1992-2006 among women undergoing cesarean delivery (CD) and vaginal delivery (VD). A composite measure of major maternal complications including infection, hemorrhage, laceration, and other major operative and thrombotic complications was evaluated.
Population-based sample of over 6 million women from Florida and New York hospital discharge data.
Obstetric procedures and maternal complications postdelivery.
During the 15-year time period, the CD rate decreased from 24.7% in 1992 to 23% in 1996 and increased to 34.7% in 2006. The risk-adjusted rate of any major complication declined from 14.7% in 1992 to 10.7% in 2006 for all deliveries; from 14.4% to 11.6% for VD; and from 15.7% to 8.5% for CD. During 1992 to 2006, the average number of comorbidities increased from 0.65 to 0.93 for patients overall, from 0.43 to 0.58 for VD patients, and 1.34 to 1.59 for CD patients.
As evidenced by New York and Florida, the US has seen large reductions in major maternal complications over the past 15 years. Concurrently, the average number of comorbidities increased. These results reflect substantial improvements in maternal delivery outcomes.
Medical care 05/2010; 48(5):487-93. · 3.24 Impact Factor
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ABSTRACT: Patient outcomes have been used to assess the performance of hospitals and physicians; in contrast, residency programs have been compared based on nonclinical measures.
To assess whether obstetrics and gynecology residency programs can be evaluated by the quality of care their alumni deliver.
A retrospective analysis of all Florida and New York obstetrical hospital discharges between 1992 and 2007, representing 4 906 169 deliveries performed by 4124 obstetricians from 107 US residency programs.
Nine measures of maternal complications from vaginal and cesarean births reflecting laceration, hemorrhage, and all other complications after vaginal delivery; hemorrhage, infection, and all other complications after cesarean delivery; and composites for vaginal and cesarean deliveries and for all deliveries regardless of mode.
Obstetricians' residency program was associated with substantial variation in maternal complication rates. Women treated by obstetricians trained in residency programs in the bottom quintile for risk-standardized major maternal complication rates had an adjusted complication rate of 13.6%, approximately one-third higher than the 10.3% adjusted rate for women treated by obstetricians from programs in the top quintile (absolute difference, 3.3%; 95% confidence interval, 2.8%-3.8%). The rankings of residency programs based on each of the 9 measures were similar. Adjustment for medical licensure examination scores did not substantially alter the program ranking.
Obstetrics and gynecology training programs can be ranked by the maternal complication rates of their graduates' patients. These rankings are stable across individual types of complications and are not associated with residents' licensing examination scores.
JAMA The Journal of the American Medical Association 09/2009; 302(12):1277-83. · 30.03 Impact Factor
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ABSTRACT: Small-area-variation studies have shown that physician treatment styles differ substantially both between and within markets, controlling for patient characteristics. Using data on the universe of deliveries in Florida and New York over a 15-year period, we examine why treatment styles differ across obstetricians at a point in time and why styles change over time. We find that variation in c-section rates across physicians within a market is about twice as large as variation between markets. Surprisingly, residency programs explain no more than four percent of the variation in physicians' risk-adjusted c-section rates, even among newly trained physicians. Although we find evidence that physicians learn from their peers, they do not substantially revise their prior beliefs regarding treatment due to the local exchange of information. Our results indicate that physicians are not likely to converge over time to a community standard; thus, within-market variation in treatment styles is likely to persist.
Journal of Health Economics 08/2009; 28(6):1126-40. · 2.34 Impact Factor
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ABSTRACT: Most private and public health insurers are implementing pay-for-performance (P4P) programs in an effort to improve the quality of medical care. This article offers a paradigm for evaluating how P4P programs should be structured and how effective they are likely to be.
This article assesses the current comprehensiveness of evidence-based medicine by estimating the percentage of outpatient medical spending for eighteen medical processes recommended by the Institute of Medicine.
Three conditions must be in place for outcomes-based P4P programs to improve the quality of care: (1) health insurers must not fully understand what medical processes improve health (i.e., the health production function); (2) providers must know more about the health production function than insurers do; and (3) health insurers must be able to measure a patient's risk-adjusted health. Only two of these conditions currently exist. Payers appear to have incomplete knowledge of the health production function, and providers appear to know more about the health production function than payers do, but accurate methods of adjusting the risk of a patient's health status are still being developed.
This article concludes that in three general situations, P4P will have a different impact on quality and costs and so should be structured differently. When information about patients' health and the health production function is incomplete, as is currently the case, P4P payments should be kept small, should be based on outcomes rather than processes, and should target physicians' practices and health systems. As information improves, P4P incentive payments could be increased, and P4P may become more powerful. Ironically, once information becomes complete, P4P can be replaced entirely by "optimal fee-for-service."
Milbank Quarterly 10/2008; 86(3):435-57. · 5.62 Impact Factor
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ABSTRACT: This paper reports on a study of manager perceptions of the cost to employers of on-the-job employee illness, sometimes termed 'presenteeism,' for various types of jobs. Using methods developed previously, the authors analyzed data from a survey of more than 800 US managers to determine the characteristics of various jobs and the relationship of those characteristics to the manager's view of the cost to the firm of absenteeism and presenteeism. Jobs with characteristics that suggest unusually high cost (relative to wages) were similar in terms of their 'absenteeism multipliers' and their 'presenteeism multipliers.' Jobs with high values of team production, high requirements for timely output, and high difficulties of substitution for absent or impaired workers had significantly higher indicators of cost for both absenteeism and presenteeism, although substitution was somewhat less important for presenteeism.
Health Economics 05/2008; 17(4):469-85. · 2.12 Impact Factor
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ABSTRACT: Corruption in the public sector erodes tax compliance and leads to higher tax evasion. Moreover, corrupt public officials abuse their public power to extort bribes from the private agents. In both types of interaction with the public sector, the private agents are bound to face uncertainty with respect to their disposable incomes. To analyse effects of this uncertainty, a stochastic dynamic growth model with the public sector is examined. It is shown that deterministic excessive red tape and corruption deteriorate the growth potential through income redistribution and public sector inefficiencies. Most importantly, it is demonstrated that the increase in corruption via higher uncertainty exerts adverse effects on capital accumulation, thus leading to lower growth rates.
National Bureau of Economic Research, Inc, NBER Working Papers. 01/2008;
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JAMA The Journal of the American Medical Association 10/2007; 298(9):1049-51. · 30.03 Impact Factor
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ABSTRACT: We examine the determinants and effects of M&A activity in the pharmaceutical|biotechnology industry using SDC data on 383 firms from 1988 to 2001. For large firms, mergers are a response to expected excess capacity due to patent expirations and gaps in a firm's product pipeline. For small firms, mergers are primarily an exit strategy in response to financial trouble (low Tobin's q, few marketed products, low cash-sales ratios). In estimating effects of mergers, we use a propensity score to control for selection based on observed characteristics. Controlling for merger propensity, large firms that merged experienced a similar change in enterprise value, sales, employees, and R&D, and had slower growth in operating profit, compared with similar firms that did not merge. Thus mergers may be a response to trouble, but they are not a solution. Copyright © 2007 John Wiley & Sons, Ltd.
Managerial and Decision Economics 02/2007; 28(4-5):307-328.
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Sean Nicholson
The American journal of managed care 01/2007; 12 Spec no.:SP20-6. · 2.46 Impact Factor
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Sean Nicholson
The American journal of managed care 01/2007; 12 Spec no.:SP3-4. · 2.46 Impact Factor
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ABSTRACT: Using data from a survey of 800 managers in 12 industries, we find empirical support for the hypothesis that the cost associated with missed work varies across jobs according to the ease with which a manager can find a perfect replacement for the absent worker, the extent to which the worker functions as part of a team, and the time sensitivity of the worker's output. We then estimate wage 'multipliers' for 35 different jobs, where the multiplier is defined as the cost to the firm of an absence as a proportion (often greater than one) of the absent worker's daily wage. The median multiplier is 1.28, which supports the view that the cost to the firm of missed work is often greater than the wage.
Health Economics 03/2006; 15(2):111-23. · 2.12 Impact Factor
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ABSTRACT: To determine how the characteristics of the health benefits offered by employers affect worker insurance coverage decisions.
The 1996-1997 and the 1998-1999 rounds of the nationally representative Community Tracking Study Household Survey.
We use multinomial logistic regression to analyze the choice between own-employer coverage, alternative source coverage, and no coverage among employees offered health insurance by their employer. The key explanatory variables are the types of health plans offered and the net premium offered. The models include controls for personal, health plan, and job characteristics.
When an employer offers only a health maintenance organization married employees are more likely to decline coverage from their employer and take-up another offer (odds ratio (OR)=1.27, p<.001), while singles are more likely to accept the coverage offered by their employer and less likely to be uninsured (OR=0.650, p<.001). Higher net premiums increase the odds of declining the coverage offered by an employer and remaining uninsured for both married (OR=1.023, p<.01) and single (OR=1.035, p<.001) workers.
The type of health plan coverage an employer offers affects whether its employees take-up insurance, but has a smaller effect on overall coverage rates for workers and their families because of the availability of alternative sources of coverage. Relative to offering only a non-HMO plan, employers offering only an HMO may reduce take-up among those with alternative sources of coverage, but increase take-up among those who would otherwise go uninsured. By modeling the possibility of take-up through the health insurance offers from the employer of the spouse, the decline in coverage rates from higher net premiums is less than previous estimates.
Health Services Research 10/2005; 40(5 Pt 1):1259-78. · 2.16 Impact Factor
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ABSTRACT: The objective of this study was to determine the prevalence and estimate total costs for chronic health conditions in the U.S. workforce for the Dow Chemical Company (Dow).
Using the Stanford Presenteeism Scale, information was collected from workers at five locations on work impairment and absenteeism based on self-reported "primary" chronic health conditions. Survey data were merged with employee demographics, medical and pharmaceutical claims, smoking status, biometric health risk factors, payroll records, and job type.
Almost 65% of respondents reported having one or more of the surveyed chronic conditions. The most common were allergies, arthritis/joint pain or stiffness, and back or neck disorders. The associated absenteeism by chronic condition ranged from 0.9 to 5.9 hours in a 4-week period, and on-the-job work impairment ranged from a 17.8% to 36.4% decrement in ability to function at work. The presence of a chronic condition was the most important determinant of the reported levels of work impairment and absence after adjusting for other factors (P < 0.000). The total cost of chronic conditions was estimated to be 10.7% of the total labor costs for Dow in the United States; 6.8% was attributable to work impairment alone.
For all chronic conditions studied, the cost associated with performance based work loss or "presenteeism" greatly exceeded the combined costs of absenteeism and medical treatment combined.
Journal of Occupational and Environmental Medicine 06/2005; 47(6):547-57. · 2.06 Impact Factor
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ABSTRACT: Using data on over 900 firms for the period 1988-2000, we estimate the effect on phase-specific biotech and pharmaceutical R&D success rates of a firm's overall experience, its experience in the relevant therapeutic category, the diversification of its experience across categories, the industry's experience in the category, and alliances with large and small firms. We find that success probabilities vary substantially across therapeutic categories and are negatively correlated with mean sales by category, which is consistent with a model of dynamic, competitive entry. Returns to experience are statistically significant but economically small for the relatively straightforward phase 1 trials. We find evidence of large, positive and diminishing returns to a firm's overall experience (across all therapeutic categories) for the larger and more complex late-stage trials that focus on a drug's efficacy. There is some evidence that a drug is more likely to complete phase 3 if developed by firms whose experience is focused rather than broad (diseconomies of scope). There is evidence of positive knowledge spillovers across firms for phase 1. However, for phase 2 and phase 3 the estimated effects of industry-wide experience are negative, which may reflect either higher Food and Drug Administration (FDA) approval standards in crowded therapeutic categories or that firms in such categories must pursue more difficult targets. Products developed in an alliance tend to have a higher probability of success, at least for the more complex phase 2 and phase 3 trials, and particularly if the licensee is a large firm.
Journal of Health Economics 03/2005; 24(2):317-39. · 2.34 Impact Factor
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ABSTRACT: Many employers in the US are investing in new programmes to improve the quality of medical care and simultaneously shifting more of the healthcare costs to their employees without understanding the implications on the amount and type of care their employees will receive. These seemingly contradictory actions reflect an inability by employers to accurately assess how their health benefit decisions affect their profits. This paper proposes a practical method that employers can use to determine how much they should invest in the health of their workers and to identify the best benefit designs to encourage appropriate healthcare delivery and use. This method could also be of value to employers in other countries who are considering implementing programmes to improve employee health. The method allows a programme that improves workers' health to generate four financial benefits for an employer - reduced medical costs, reduced absences, improved on-the-job productivity, and reduced turnover - and uses accurate estimates of the benefits of reducing absences and improving productivity.
Applied Health Economics and Health Policy 02/2005; 4(4):209-18.
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Sean Nicholson
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ABSTRACT: We examine the determinants of biotech-pharmaceutical alliance prices to determine whether the market for alliances is characterized by asymmetric information. We find that inexperienced biotech companies receive substantially discounted payments when forming their first alliance. A jointly developed drug is more likely to advance in clinical trials than a drug developed by a single company, so the first-deal discount is not consistent with the drug's subsequent performance. Biotech companies receive substantially higher valuations from venture capitalists and the public equity market after forming their first alliance, which implies that alliances send a positive signal to prospective investors.
The Journal of Business. 02/2005; 78(4):1433-1464.
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ABSTRACT: To determine whether health maintenance organizations (HMOs) attract enrollees who use relatively few medical resources and whether a simple risk-adjustment system could mitigate or eliminate the inefficiency associated with risk selection.
The first and second rounds of the Community Tracking Study Household Survey (CTSHS), a national panel data set of households in 60 different markets in the United States.
We use regression analysis to examine medical expenditures in the first round of the survey between enrollees who switched plan types (i.e., from a non-HMO plan to an HMO plan, or vice versa) between the first and second rounds of the survey versus enrollees who remained in their original plan. The dependent variable is an enrollee's medical resource use, measured in dollars, and the independent variables include gender, age, self-reported health status, and other demographic variables.
We restrict our analysis to the 6,235 non-elderly persons who were surveyed in both rounds of the CTSHS, received health insurance from their employer or the employer of a household member in both years of the survey, and were offered a choice of an HMO and a non-HMO plan in both years.
We find that people who switched from a non-HMO to an HMO plan used 11 percent fewer medical services in the period prior to switching than people who remained in a non-HMO plan, and that this relatively low use persisted once they enrolled in an HMO. Furthermore, people who switched from an HMO to a non-HMO plan used 18 percent more medical services in the period prior to switching than those who remained in an HMO plan.
HMOs are experiencing favorable risk selection and would most likely continue to do so even if employers adjusted health plan payments based on enrollees' gender and age because the selection is based on enrollee characteristics that are difficult to observe, such as preferences for medical care and health status.
Health Services Research 01/2005; 39(6 Pt 1):1817-38. · 2.16 Impact Factor
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ABSTRACT: Corruption in the public sector erodes tax compliance and leads to higher tax evasion. Moreover, corrupt public officials abuse their public power to extort bribes from the private agents. In both types of interaction with the public sector, the private agents are bound to face uncertainty with respect to their disposable incomes. To analyse effects of this uncertainty, a stochastic dynamic growth model with the public sector is examined. It is shown that deterministic excessive red tape and corruption deteriorate the growth potential through income redistribution and public sector inefficiencies. Most importantly, it is demonstrated that the increase in corruption via higher uncertainty exerts adverse effects on capital accumulation, thus leading to lower growth rates.
esocialsciences.com, Working Papers. 01/2005;
