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Objectives Mortality rates generally decline during economic recessions in high-income countries, however gaps remain in our understanding of the underlying mechanisms. This study estimates the impacts of increases in unemployment rates on both all-cause and cause-specific mortality across U.S. metropolitan regions during the Great Recession. Methods We estimate the effects of economic conditions during the recent and severe recessionary period on mortality, including differences by age and gender subgroups, using fixed effects regression models. We identify a plausibly causal effect by isolating the impacts of within-metropolitan area changes in unemployment rates and controlling for common temporal trends. We aggregated vital statistics, population, and unemployment data at the area-month-year-age-gender-race level, yielding 527,040 observations across 366 metropolitan areas, 2005–2010. Results We estimate that a one percentage point increase in the metropolitan area unemployment rate was associated with a decrease in all-cause mortality of 3.95 deaths per 100,000 person years (95%CI −6.80 to −1.10), or 0.5%. Estimated reductions in cardiovascular disease mortality contributed 60% of the overall effect and were more pronounced among women. Motor vehicle accident mortality declined with unemployment increases, especially for men and those under age 65, as did legal intervention and homicide mortality, particularly for men and adults ages 25–64. We find suggestive evidence that increases in metropolitan area unemployment increased accidental drug poisoning deaths for both men and women ages 25–64. Conclusions Our finding that all-cause mortality decreased during the Great Recession is consistent with previous studies. Some categories of cause-specific mortality, notably cardiovascular disease, also follow this pattern, and are more pronounced for certain gender and age groups. Our study also suggests that the recent recession contributed to the growth in deaths from overdoses of prescription drugs in working-age adults in metropolitan areas. Additional research investigating the mechanisms underlying the health consequences of macroeconomic conditions is warranted. [ABSTRACT FROM AUTHOR]

Introduction: Policies that allow directly citing motorists for seat belt non-use (primary enforcement) have been shown to reduce motor vehicle crash deaths relative to secondary enforcement, but the evidence base is dated and does not account for recent improvements in vehicle designs and road safety. The purpose of this study was to test whether recent upgrades to primary enforcement still reduce motor vehicle crash deaths.Methods: In 2016, researchers used motor vehicle crash death data from the Fatal Analysis Reporting System for 2000-2014 and calculated rates using both person- and exposure-based denominators. Researchers used a difference-in-differences design to estimate the effect of primary enforcement on death rates, and estimated negative binomial regression models, controlling for age, substance use involvement, fixed state characteristics, secular trends, state median household income, and other state-level traffic safety policies.Results: Models adjusted only for crash characteristics and state-level covariates models showed a protective effect of primary enforcement (rate ratio, 0.88, 95% CI=0.77, 0.98; rate difference, -1.47 deaths per 100,000 population, 95% CI= -2.75, -0.19). After adjustment for fixed state characteristics and secular trends, there was no evidence of an effect of upgrading from secondary to primary enforcement in the whole population (rate ratio, 0.98, 95% CI=0.92, 1.04; rate difference, -0.22, 95% CI= -0.90, 0.46) or for any age group.Conclusions: Upgrading to primary enforcement no longer appears protective for motor vehicle crash death rates. [ABSTRACT FROM AUTHOR]

Motor vehicle accident (MVA) mortality has been declining overall, but little is known about trends by socioeconomic position. We examined trends in education-related inequalities in US MVA death rates from 1995 to 2010. We used mortality data from the National Center for Health Statistics and population estimates from the Current Population Survey, and we calculated vehicle- and person-miles traveled using data from the National Household Travel Survey. We used negative binomial regression to estimate crude and age-, sex-, and race-adjusted mortality rates among adults aged 25 years or more. We found larger mortality decreases among the more highly educated and some evidence of mortality increases among the least educated. Adjusted death rates were 15.3 per 100,000 population (95% confidence interval (CI): 10.7,19.9) higher at the bottom of the education distribution than at the top of the education distribution in 1995, increasing to 17.9 per 100,000 population (95% CI: 14.8, 21.0) by 2010. In relative terms, adjusted death rates were 2.4 (95% CI: 1.7, 3.0) times higher at the bottom of the education distribution than at the top in 1995, increasing to 4.3 times higher (95% CI: 3.4,5.3) by 2010. Inequality increases were larger in terms of vehicle-miles traveled. Although overall MVA death rates declined during this period, socioeconomic differences in MVA mortality have persisted or worsened over time. [ABSTRACT FROM AUTHOR]

Background: Several studies have suggested strong associations between economic downturns and suicide mortality, but are at risk of bias due to unmeasured confounding. The rationale for our study was to provide more robust evidence by using a quasi-experimental design. Methods: We analysed 955 561 suicides occurring in the USA from 1980 to 2010 and used a broad index of economic activity in each US state to measure economic conditions. We used a quasi-experimental, fixed-effects design and we also assessed whether the effects were heterogeneous by demographic group and during periods of official recession. Results: After accounting for secular trends, seasonality and unmeasured fixed characteristics of states, we found that an economic downturn similar in magnitude to the 2007 Great Recession increased suicide mortality by 0.14 deaths per 100 000 population [95% confidence interval (CI) 0.00, 0.28] or around 350 deaths. Effects were stronger for men (0.28, 95% CI 0.07, 0.49) than women and for those with less than 12 years of education (1.22 95% CI 0.83, 1.60) compared with more than 12 years of education. The overall effect did not differ for recessionary (0.11, 95% CI -0.02, 0.25) vs non-recessionary periods (0.15, 95% CI 0.01, 0.29). The main study limitation is the potential for misclassified death certificates and we cannot definitively rule out unmeasured confounding. Conclusions: We found limited evidence of a strong, population-wide detrimental effect of economic downturns on suicide mortality. The overall effect hides considerable heterogeneity by gender, socioeconomic position and time period. [ABSTRACT FROM AUTHOR]

Background The adoption of healthier behaviours has been hypothesised as a mechanism to explain empirical findings of population health improvements during some economic downturns. Methods We estimated the effect of the local unemployment rate on health behaviours using pooled annual surveys from the 2003-2010 Behavioral Risk Factor Surveillance Surveys, as well as population-based telephone surveys of the US adult general population. Analyses were based on approximately 1 million respondents aged 25 years or older living in 90 Metropolitan Statistical Areas and Metropolitan Divisions (MMSAs). The primary exposure was the quarterly MMSA-specific unemployment rate. Outcomes included alcohol consumption, smoking status, attempts to quit smoking, body mass index, overweight/obesity and past month physical activity or exercise. Results The average unemployment rate across MMSAs increased from a low of 4.5% in 2007 to a high of 9.3% in 2010. In multivariable models accounting for individual-level sociodemographic characteristics and MMSA and quarter fixed effects, a one percentage-point increase in the unemployment rate was associated with 0.15 (95% CI -0.31 to 0.01) fewer drinks consumed in the past-month and a 0.14 (95% CI -0.28 to 0.00) percentage-point decrease in the prevalence of past-month heavy drinking; these effects were driven primarily by men. Changes in the unemployment rate were not consistently associated with other health behaviours. Although individual-level unemployment status was associated with higher levels of alcohol consumption, smoking and obesity, the MMSA-level effects of the recession were largely invariant across employment groups. Conclusions Our results do not support the hypothesis that health behaviours mediate the effects of local-area economic conditions on mortality. [ABSTRACT FROM AUTHOR]

Objective To understand whether US and Canadian breast, colorectal and prostate cancer screening test utilization is consistent with US and Canadian cancer screening guideline information with respect to the age of screening initiation. Design Cross-sectional, regression discontinuity. Setting Canada and the US. Participants Canadian and American women of ages 30–60 and men of ages 40–60. Interventions None. Main Outcomes Measures Mammography, prostate-specific antigen (PSA) and colorectal cancer test use within the past 2 years. Methods We identify US and Canadian compliance with age screening information in a novel manner, by comparing test utilization rates of individuals who are immediately on either side of the guideline recommended initiation ages. Results US mammography utilization within the last 2 years increased from 33% at age 39 to 48% at age 40 and 60% at age 41. US colorectal cancer test utilization, within the last 2 years, increased from 15% at age 49 to 18% at age 50 and 28% at age 51. US PSA utilization within the last 2 years increased from 37% at age 49 to 44% at age 50 and 54% at age 51. In Canada, mammography utilization within the last 2 years increased from 47% at age 49 to 57% at age 50 and 66% at age 51. Conclusion American and Canadian cancer screening utilization is generally consistent with each country's guideline recommendations regarding age. US and Canadian differences in screening due to guidelines can potentially explain cross-country differences in breast cancer mortality and affect interpretation of international comparisons of cancer statistics. [ABSTRACT FROM AUTHOR]

The recent housing crisis offers the opportunity to understand the effects of unique indicators of macroeconomic conditions on health. We linked data on the proportion of mortgage borrowers per US metropolitan-area who were at least 90 days delinquent on their payments with individual-level outcomes from a representative sample of 1,021,341 adults surveyed through the Behavioral Risk Factor Surveillance System (BRFSS) between 2003 and 2010. We estimated the effects of metropolitan-area mortgage delinquency on individual health behaviors, medical coverage, and health status, as well as whether effects varied by race/ethnicity. Results showed that increases in the metropolitan-area delinquency rate resulted in decreases in heavy alcohol consumption and increases in exercise and health insurance coverage. However, the delinquency rate was also associated with increases in smoking and obesity in some population groups, suggesting the housing crisis may have induced stress-related behavioral change. Overall, the effects of metropolitan-area mortgage delinquency on population health were relatively modest. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To identify whether a hospital's vaginal birth after cesarean delivery rate, trial of labor after cesarean delivery rate, or trial of labor success rate decrease after the occurrence of a uterine rupture. METHODS: The study population was drawn from the Nationwide Inpatient Sample, a sample of U.S. hospitals, between 1998 and 2010. We extracted deliveries to women with a previous cesarean delivery. International Classification of Diseases, 9th Revision, Clinical Modification codes were used to identify severe uterine ruptures and rates of vaginal birth, trial of labor, and trial of labor success. We used the difference-in-differences design and compared the rates of the outcomes before and after a rupture across hospitals using hospitals without ruptures to control for secular trends. Included in the analysis were 1,202,284 delivery records from 7,975 hospital-years without ruptures and 211,850 records from 510 hospital-years with uterine ruptures. RESULTS: Before the occurrence of a severe uterine rupture, there were an estimated 60 successful vaginal deliveries for every 100 women with a previous cesarean delivery who entered labor. In the month after the rupture, the trial of labor success rate decreased by an estimated 25 cases per 1,000 labors (95% confidence interval [CI] 6-44/1,000, P=.01) before returning to baseline. The percentage of women with a previous cesarean delivery who attempted vaginal delivery did not significantly change after the rupture. Overall, there were 17 more cesarean deliveries per 1,000 women with a previous cesarean delivery (95% CI 4-31/1,000, P=.01) in the month after the uterine rupture. CONCLUSION: The decrease in the trial of labor success rate after a recent uterine rupture is likely the result of short-term changes in risk evaluation. [ABSTRACT FROM AUTHOR]

Importance: Acute respiratory tract infections are the leading cause of emergency department visits and hospitalizations in US children, with highest risks in the first 2 months after birth. Out-of-home childcare settings increase the spread of respiratory tract infections. The study team hypothesized that access to state-paid family leave could reduce acute care encounters (hospital admissions or emergency department visits) for respiratory tract infections in young infants by reducing out-of-home childcare transmissions., Objective: To determine if the 2018 introduction of paid family leave in New York state reduced acute care encounters for respiratory tract infections in infants 8 weeks or younger., Design, Setting, and Participants: This population-based study of acute care encounters took place in New York state and New England control states (Maine, Massachusetts, New Hampshire, Vermont) from October 2015 through February 2020. Participants included infants aged 8 weeks or younger. Controlled time series analysis using Poisson regression was used to estimate the impact of paid family leave on acute care encounters for respiratory tract infections, comparing observed counts during respiratory virus season (October through March) with those predicted in the absence of the policy. Acute care encounters for respiratory tract infections in 1-year-olds (who would not be expected to benefit as directly from the policy) were modeled as a placebo test., Intervention: New York State Paid Family Leave policy, introduced on January 1, 2018, providing 8 weeks of paid leave for eligible parents., Main Outcomes and Measures: Emergency department visits or hospitalizations with International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD) codes for upper or lower respiratory tract infections or associated symptoms (ie, fever, cough), excluding newborn hospitalizations. The secondary outcome was acute care encounters for respiratory syncytial virus (RSV) bronchiolitis., Results: There were 52 943 acute care encounters for respiratory infection among infants 8 weeks or younger. There were 15 932 encounters that were hospitalizations (30%) and 33 304 of the encounters were paid for by Medicaid (63%). Encounters were 18% lower than predicted (relative percentage change = -17.9; 95% CI, -20.3 to -15.7) after the introduction of paid family leave. RSV encounters were 27.0% lower (95% CI, -30.9 to -23.5) than predicted. Similar reductions were not observed in 1-year-olds (relative percentage change = -1.5; 95% CI, -2.5 to -0.6)., Conclusions: New York state's paid family leave policy was associated with reduced acute care encounters for respiratory tract infections in young infants. These findings may be useful for informing implementation of paid family leave federally and in the states that have not enacted paid family leave policies.

Purpose: To replicate a prior study that found greater adolescent marijuana use in states that have passed medical marijuana laws (MMLs), and extend this analysis by accounting for confounding by unmeasured state characteristics and measurement error., Methods: We obtained state-level estimates of marijuana use from the 2002 through 2009 National Survey on Drug Use and Health. We used 2-sample t-tests and random-effects regression to replicate previous results. We used difference-in-differences regression models to estimate the causal effect of MMLs on marijuana use, and simulations to account for measurement error., Results: We replicated previously published results showing higher marijuana use in states with MMLs. Difference-in-differences estimates suggested that passing MMLs decreased past-month use among adolescents by 0.53 percentage points (95% confidence interval [CI], 0.03-1.02) and had no discernible effect on the perceived riskiness of monthly use. Models incorporating measurement error in the state estimates of marijuana use yielded little evidence that passing MMLs affects marijuana use., Conclusions: Accounting for confounding by unmeasured state characteristics and measurement error had an important effect on estimates of the impact of MMLs on marijuana use. We find limited evidence of causal effects of MMLs on measures of reported marijuana use., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Research suggests that racial/ethnic concordance (matching) between patients and physicians improves quality of care for minority patients by reducing discrimination in the clinical encounter., Objective: Examine the impacts of patient and physician race/ethnicity, and racial/ethnic concordance, on primary care outcomes including blood pressure, tobacco use, and cholesterol screening and tobacco use counseling., Research Design: Multivariate regression analysis of 8160 visits by white and minority patients to 661 primary care physicians using the 2001 to 2003 National Ambulatory Medical Care Survey. I estimated models based on physicians who see both white and minority patients and include physician fixed-effects to correctly measure the contribution of concordance., Results: Conditional on accessing a primary care physician, patient race does not explain differences in rates of these guideline-recommended preventive screenings. Concordance is generally not an important predictor of outcomes, though it is associated with rates of cholesterol screening 2 to 3 times higher among black and Hispanic men compared with whites. In contrast, practice patterns vary quite markedly by physicians' race/ethnicity., Conclusions: Given that physician race is a more powerful predictor of preventive screening than patient-physician concordance, minority patients may receive some guideline-recommended care at lower rates in concordant pairs. Addressing physician education and training to ensure practice that is consistent with preventive care guidelines may be important. Forms of discrimination in the clinical encounter thought to be modified by concordance do not appear to drive disparities in these outcomes.

States and employers use a number of different programs and techniques to increase rates of insurance coverage. Successful strategies--whether based on Medicaid/SCHIP expansion, strengthening employer-based coverage, or regulating the individual market--require both flexibility to tailor approaches that best serve their residents and employees and basic protections to ensure that new programs do not leave vulnerable groups behind. In addition, continued financial, regulatory, and administrative support from the federal level is crucial for states and employers to explore innovative solutions to cover the uninsured.

Current approaches to reducing the number of uninsured include insurance tax credits for individuals and employers, expanding private group coverage, expanding eligibility for public programs, creating new public programs, and reforming insurance markets. Proposals vary in how they would expand coverage, how many uninsured would be covered, and how much they would cost. Although the costs of expanding coverage are significant, so are the costs of high uninsured rates. Moreover, expanding coverage would likely lead to substantial gains in health and productivity.