Abstract
Workplace wellness programs cover over 50 million U.S. workers and are intended to reduce medical spending, increase productivity, and improve well-being. Yet limited evidence exists to ...support these claims. We designed and implemented a comprehensive workplace wellness program for a large employer and randomly assigned program eligibility and financial incentives at the individual level for nearly 5,000 employees. We find strong patterns of selection: during the year prior to the intervention, program participants had lower medical expenditures and healthier behaviors than nonparticipants. The program persistently increased health screening rates, but we do not find significant causal effects of treatment on total medical expenditures, other health behaviors, employee productivity, or self-reported health status after more than two years. Our 95% confidence intervals rule out 84% of previous estimates on medical spending and absenteeism.
Bone marrow (BM) fibrosis in myeloproliferative neoplasms (MPNs) is associated with a poor prognosis. The development of myelofibrosis and differentiation of mesenchymal stromal cells to profibrotic ...myofibroblasts depends on macrophages. Here, we compared macrophage frequencies in BM biopsies of MPN patients and controls (patients with non-neoplastic processes), including primary myelofibrosis (PMF,
n
= 18), essential thrombocythemia (ET,
n
= 14), polycythemia vera (PV,
n
= 12), and Philadelphia chromosome–positive chronic myeloid leukemia (CML,
n
= 9). In PMF, CD68-positive macrophages were greatly increased compared to CML (
p
= 0.017) and control BM (
p
< 0.001). Similar findings were observed by CD163 staining (PMF vs. CML:
p
= 0.017; PMF vs. control:
p
< 0.001). Moreover, CD68-positive macrophages were increased in PV compared with ET (
p
= 0.009) and reactive cases (
p
< 0.001). PMF had higher frequencies of macrophages than PV (CD68:
p
< 0.001; CD163:
p
< 0.001) and ET (CD68:
p
< 0.001; CD163:
p
< 0.001). CD163 and CD68 were often co-expressed in macrophages with stellate morphology in Philadelphia chromosome–negative MPN, resulting in a sponge-like reticular network that may be a key regulator of unbalanced hematopoiesis in the BM space and may explain differences in cellularity and clinical course.
Physician treatment choices for observably similar patients vary dramatically across regions. This paper exploits cardiologist migration to disentangle the role of physician-specific factors such as ...preferences and learned behavior versus environment-level factors such as hospital capacity and productivity spillovers on physician behavior. Physicians starting in the same region and subsequently moving to dissimilar regions practice similarly before the move. After the move, physician behavior in the first year changes by 0.6–0.8 percentage points for each percentage point change in practice environment, with no further changes over time. This suggests environment factors explain between 60–80 percent of regional disparities in physician behavior.
We follow Medicare cohorts to estimate Hurricane Katrina’s long-run mortality effects on victims initially living in New Orleans. Including the initial shock, the hurricane improved eight-year ...survival by 2.07 percentage points. Migration to lower-mortality regions explains most of this survival increase. Those migrating to low-versus high-mortality regions look similar at baseline, but their subsequent mortality is 0.83–1.01 percentage points lower per percentage point reduction in local mortality, quantifying causal effects of place on mortality among this population. Migrants’ mortality is also lower in destinations with healthier behaviors and higher incomes but is unrelated to local medical spending and quality.
Life expectancy varies substantially across local regions within a country, raising conjectures that place of residence affects health. However, population sorting and other confounders make it ...difficult to disentangle the effects of place on health from other geographic differences in life expectancy. Recent studies have overcome such challenges to demonstrate that place of residence substantially influences health and mortality. Whether policies that encourage people to move to places that are better for their health or that improve areas that are detrimental to health are desirable depends on the mechanisms behind place effects, yet these mechanisms remain poorly understood.
Do environmental conditions pose greater health risks to individuals living in urban or rural areas? The answer is theoretically ambiguous: while urban areas have traditionally been associated with ...heightened exposure to environmental pollutants, the economies of scale and density inherent to urban environments offer unique opportunities for mitigating or adapting to these harmful exposures. To make progress on this question, we focus on the United States and consider how exposures – to air pollution, drinking water pollution, and extreme temperatures – and the response to those exposures differ across urban and rural settings. While prior studies have addressed some aspects of these issues, substantial gaps in knowledge remain, in large part due to historical deficiencies in monitoring and reporting, especially in rural areas. As a step toward closing these gaps, we present new evidence on urban–rural differences in air quality and population sensitivity to air pollution, leveraging recent advances in remote sensing measurement and machine learning. We find that the urban–rural gap in fine particulate matter (PM2.5) has converged over the last two decades and the remaining gap is small relative to the overall declines. Furthermore, we find that residents of urban counties are, on average, less vulnerable to the mortality effects of PM2.5 exposure. We also discuss promising areas for future research.
•Urban areas have traditionally faced higher pollution exposure than rural areas.•US cities have cleaned up remarkably, narrowing or reversing urban–rural gaps.•Improved infrastructure and policies have enhanced environmental quality in cities.
Local opinion leaders may play a key role in easing information frictions associated with technology adoption. This paper analyzes the influence of physician investigators who lead clinical trials ...for new cancer drugs. By comparing diffusion patterns across 21 new cancer drugs, we separate correlated regional demand for new technology from information spillovers. Patients in the lead investigator’s region are initially 36% more likely to receive the new drug, but utilization converges within four years. We also find that superstar physician authors, measured by trial role or citation history, have broader influence than less prominent authors.
We estimate the causal effects of acute fine particulate matter exposure on mortality, health care use, and medical costs among the US elderly using Medicare data. We instrument for air pollution ...using changes in local wind direction and develop a new approach that uses machine learning to estimate the life-years lost due to pollution exposure. Finally, we characterize treatment effect heterogeneity using both life expectancy and generic machine learning inference. Both approaches find that mortality effects are concentrated in about 25 percent of the elderly population.
IMPORTANCE: Many employers use workplace wellness programs to improve employee health and reduce medical costs, but randomized evaluations of their efficacy are rare. OBJECTIVE: To evaluate the ...effect of a comprehensive workplace wellness program on employee health, health beliefs, and medical use after 12 and 24 months. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial of 4834 employees of the University of Illinois at Urbana-Champaign was conducted from August 9, 2016, to April 26, 2018. Members of the treatment group (n = 3300) received incentives to participate in the workplace wellness program. Members of the control group (n = 1534) did not participate in the wellness program. Statistical analysis was performed on April 9, 2020. INTERVENTIONS: The 2-year workplace wellness program included financial incentives and paid time off for annual on-site biometric screenings, annual health risk assessments, and ongoing wellness activities (eg, physical activity, smoking cessation, and disease management). MAIN OUTCOMES AND MEASURES: Measures taken at 12 and 24 months included clinician-collected biometrics (16 outcomes), administrative claims related to medical diagnoses (diabetes, hypertension, and hyperlipidemia) and medical use (office visits, inpatient visits, and emergency department visits), and self-reported health behaviors and health beliefs (14 outcomes). RESULTS: Among the 4834 participants (2770 women; mean SD age, 43.9 11.3 years), no significant effects of the program on biometrics, medical diagnoses, or medical use were seen after 12 or 24 months. A significantly higher proportion of employees in the treatment group than in the control group reported having a primary care physician after 24 months (1106 of 1200 92.2% vs 477 of 554 86.1%; adjusted P = .002). The intervention significantly improved a set of employee health beliefs on average: participant beliefs about their chance of having a body mass index greater than 30, high cholesterol, high blood pressure, and impaired glucose level jointly decreased by 0.07 SDs (95% CI, −0.12 to −0.01 SDs; P = .02); however, effects on individual belief measures were not significant. CONCLUSIONS AND RELEVANCE: This randomized clinical trial showed that a comprehensive workplace wellness program had no significant effects on measured physical health outcomes, rates of medical diagnoses, or the use of health care services after 24 months, but it increased the proportion of employees reporting that they have a primary care physician and improved employee beliefs about their own health. TRIAL REGISTRATION: American Economic Association Randomized Controlled Trial Registry number: AEARCTR-0001368
We estimate how the mortality effects of temperature vary across U.S. climate regions to assess local and national damages from projected climate change. Using 22 years of Medicare data, we find that ...both cold and hot days increase mortality. However, hot days are less deadly in warm places while cold days are less deadly in cool places. Incorporating this heterogeneity into end-of-century climate change assessments reverses the conventional wisdom on climate damage incidence: cold places bear more, not less, of the mortality burden. Allowing places to adapt to their future climate substantially reduces the estimated mortality effects of climate change.
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