Understanding how to make the world a better place requires interdisciplinary knowledge. Public policy analysis helps policymakers arrive at informed policy decisions. The policy analysis process ...involves public problem definition and data collection, stakeholder identification, a rationale for government involvement, evaluation criteria, identification and analysis of policy alternatives, and a recommendation. Economics informs not only the identification of market failures but also how we think about public problems, evaluate relevant research, identify policy alternatives, weigh objective criteria (costs, benefits, equity), and select optimal solutions. Students of policy analysis gain experience through in-class examples of contemporary topics and an iterative policy paper, where each student selects a public problem, conducts research, and writes an analysis. Students become effective consumers and beginning producers of policy analysis.
Objective
This study examines the effect of physician medical malpractice liability exposure on primary Cesarean and vaginal births after Cesarean (VBACs).
Data Sources/Study Setting
Secondary data ...on hospital births from Florida Hospital Inpatient File, physician characteristics from American Medical Association Physician Masterfile, and physician malpractice claim history from Florida Office of Insurance Regulation.
Study Design
Our study estimates the effects of physician malpractice liability exposure on Cesareans and VBACs using panel data and a multivariate, fixed effects model.
Data Collection
We merge three secondary data sources based on unique physician license numbers between 1994 and 2010.
Principal Findings
We find no evidence that the first malpractice claim affects primary Cesarean deliveries. We find, however, that the first malpractice claim decreases the likelihood of a VBAC (conditional on a prior Cesarean delivery) by 1.2–1.9 percentage points (approximately 10 percent relative to mean VBAC incidence). This finding is robust to focusing on obstetrics‐related malpractice claims, as well as to considering different malpractice claims (first report, first severe report, and first lawsuit).
Conclusions
Given the increase in both primary and repeat Cesarean deliveries, our results suggest that physician malpractice liability exposure is responsible for a relatively small share of the VBAC decrease.
Objective
To examine the effects of a harm reduction policy, specifically Good Samaritan (GS) policy, on overdose deaths.
Data Sources/Study Setting
Secondary data from multiple cause of death, ...mortality records paired with state harm reduction and substance use prevention policy.
Study Design
We estimate fixed effects Poisson count models to model the effect of GS policy on overdose deaths for all, prescription, and illicit drugs, controlled substances, and opioids, while controlling for other harm reduction and substance use prevention policies.
Data Collection/Extraction Methods
We merge secondary data sources by state and year between 1999 and 2016.
Principal findings
We fail to identify a statistically significant effect of GS policy in reducing overdose deaths broadly.
Conclusions
While we are unable to identify an effect of GS policy on overdose deaths, GS policy may have important effects on first‐stage outcomes not investigated in this paper. Given recent state policy changes and rapid increase in many categories of overdose deaths, additional research should continue to examine the implementation and effects of harm reduction policy specifically and substance use prevention policy broadly.
This article looks at the behaviour of women facing different cancer screening options available to them from the age of 50 onward. The study was conducted in 2019 in four departments of the French ...territory with the objective of identifying the factors that influence acceptance of a population-based screening proposal.
A questionnaire was sent to women who had received three invitations to organised screenings (OS) for both breast and colorectal cancer. The categories of participants in both OS were designed from data from the regional cancer screening coordination centres in each department. Participation in opportunistic cervical cancer screening was evaluated as self-reported data.
4,634 questionnaires were returned out of the 17,194 sent, giving a global return rate of 27%. The highest rate of return (73.5%) was obtained from women who had participated at least once in both breast and colorectal cancer OS. An intermediate rate was obtained from women participating in breast cancer OS only (18.7%). Poor levels of return came from women who had participated in colorectal cancer OS only (3.6%) and from non-participants (4.1%). Our results suggest that women with lower educational levels tend to be the most regular attendants at OS (50.3%), compared to highly educated women (39.7%). 11.8% of women were overdue in their opportunistic cervical cancer screening. This percentage rose to 35.4% in the category of non-participants. In addition, women's comments provide a better understanding of the reasons for irregular attendance and non-participation.
Overall, similar behaviours towards screening were observed in the four departments. Our analysis suggests that participation in one cancer OS increases the likelihood of participating in others. This adhesion could be an interesting lever for raising women's awareness of other cancer screenings.
Price‐fixing cartels usually do not involve all members of an industry. To the extent that the nonconspiring industry members set their prices under the price umbrella of the cartel, the customers of ...the nonconspiring firms suffer overcharges just like customers of the conspiring firms. Whether these so‐called umbrella plaintiffs have standing to sue for antitrust damages is an unresolved policy question, because the Supreme Court has not spoken on “umbrella damages.” In this article, we identify the judicial concerns regarding umbrella damage claims, which can be traced to Mid‐West Paper and Petroleum Products Antitrust Litigation. These decisions raise concerns that the fact of injury is conjectural and the measurement of the damages is speculative. We first review the divided judicial treatment of standing for umbrella plaintiffs. Next, we describe the economics of umbrella pricing, which reveals that umbrella claims are not inherently conjectural. We then examine the econometric analysis necessary to estimate damages, demonstrating that umbrella damage estimates are not inherently speculative. We also examine some difficulties that exist in damage estimation generally and for umbrella plaintiffs in particular. Finally, we argue that granting standing to umbrella plaintiffs is consistent with the goals of antitrust policy. (JEL L1, L4, K2)
AIM To assess the interendoscopist variability in the detection of colorectal polyps according to their location and histological type.METHODS This study was a retrospective analysis of prospectively ...collected data from a regional colorectal cancer(CRC) screening program; 2979 complete colonoscopies from 18 endoscopists were included. Variability in performance between endoscopists for detection of at least one adenoma(A), one proximal adenoma(PA), one distal adenoma(DA), and one proximal serrated polyp(PSP) was assessed by using multilevel logistic regression models.RESULTS The observed detection rates among the 18 endoscopists ranged from 24.6% to 47.6%(mean = 35.7%) for A, from 19.1% to 39.0%(mean = 29.4%) for DA, from 6.0% to 22.9%(mean = 12.4%) for PA, and from 1.3% to 19.3%(mean = 6.9%) for PSP.After adjusting for patient-level variables(sex, age), the interendoscopist detection rates variability achieved a significant level for A, PA, and PSP but not for DA(P = 0.03, P = 0.02, P = 0.02 and P = 0.08, respectively). This heterogeneity, as measured by the variance partition coefficient, was approximately threefold higher for PA(6.6%) compared with A(2.1%), and twofold higher for PSP(12.3%) compared with PA.CONCLUSION These results demonstrate significant interendoscopist variability for proximal polyp particularly for serrated p o l y p s, b u t n o t f o r d i s t a l a d e n o m a d e t e c t i o n. These findings contribute to explain the decreased effectiveness of complete colonoscopies at preventing proximal CRCs and the need to carefully assess the proximal colon during scope procedure.
Federal and state agencies granted temporary regulatory waivers to prevent disruptions in access to medication for opioid use disorder (MOUD) during the COVID-19 pandemic, including expanding access ...to telehealth for MOUD. Little is known about changes in MOUD receipt and initiation among Medicaid enrollees during the pandemic.
To examine changes in receipt of any MOUD, initiation of MOUD (in-person vs telehealth), and the proportion of days covered (PDC) with MOUD after initiation from before to after declaration of the COVID-19 public health emergency (PHE).
This serial cross-sectional study included Medicaid enrollees aged 18 to 64 years in 10 states from May 2019 through December 2020. Analyses were conducted from January through March 2022.
Ten months before the COVID-19 PHE (May 2019 through February 2020) vs 10 months after the PHE was declared (March through December 2020).
Primary outcomes included receipt of any MOUD and outpatient initiation of MOUD via prescriptions and office- or facility-based administrations. Secondary outcomes included in-person vs telehealth MOUD initiation and PDC with MOUD after initiation.
Among a total of 8 167 497 Medicaid enrollees before the PHE and 8 181 144 after the PHE, 58.6% were female in both periods and most enrollees were aged 21 to 34 years (40.1% before the PHE; 40.7% after the PHE). Monthly rates of MOUD initiation, representing 7% to 10% of all MOUD receipt, decreased immediately after the PHE primarily due to reductions in in-person initiations (from 231.3 per 100 000 enrollees in March 2020 to 171.8 per 100 000 enrollees in April 2020) that were partially offset by increases in telehealth initiations (from 5.6 per 100 000 enrollees in March 2020 to 21.1 per 100 000 enrollees in April 2020). Mean monthly PDC with MOUD in the 90 days after initiation decreased after the PHE (from 64.5% in March 2020 to 59.5% in September 2020). In adjusted analyses, there was no immediate change (odds ratio OR, 1.01; 95% CI, 1.00-1.01) or change in the trend (OR, 1.00; 95% CI, 1.00-1.01) in the likelihood of receipt of any MOUD after the PHE compared with before the PHE. There was an immediate decrease in the likelihood of outpatient MOUD initiation (OR, 0.90; 95% CI, 0.85-0.96) and no change in the trend in the likelihood of outpatient MOUD initiation (OR, 0.99; 95% CI, 0.98-1.00) after the PHE compared with before the PHE.
In this cross-sectional study of Medicaid enrollees, the likelihood of receipt of any MOUD was stable from May 2019 through December 2020 despite concerns about potential COVID-19 pandemic-related disruptions in care. However, immediately after the PHE was declared, there was a reduction in overall MOUD initiations, including a reduction in in-person MOUD initiations that was only partially offset by increased use of telehealth.
Background There are few data about the performance variability among endoscopists participating to nationwide or regionwide colorectal cancer screening programs. Objective To assess the variability ...of neoplasia detection rates among endoscopists participating in a regional colorectal cancer screening program based on colonoscopy after biennial fecal occult blood testing (FOBT). Design Two rounds of colonoscopy were performed: round 1 took place in 2003 and 2004, and round 2 took place in 2005 and 2006. Secondary analysis of colonoscopy findings from the first 2 rounds was performed by using data drawn from all endoscopists who performed more than 30 colonoscopies in each round. Detection rates were adjusted for patient age and sex, and logistic regression analyses were conducted including these 2 variables and round number (1 or 2). Setting District of Ille-et-Vilaine in Brittany (population >900,000) between 2003 and 2007. Main Outcome Measurements The per-endoscopist adjusted rates of colonoscopies with at least 1, 2, or 3 adenomas, 1 adenoma 10 mm or larger, or a cancer. Results Among the 18 endoscopists who performed 3462 colonoscopies, the adjusted detection rates were in the following ranges: at least 1 adenoma, 25.4% to 46.8%; 2 adenomas, 5.1% to 21.7%; 3 adenomas, 2.7% to 12.4%; 1 adenoma 10 mm or larger, 14.2% to 28.0%; and cancer, 6.3% to 16.4%. Multivariate analyses showed that the endoscopist was not an independent predictor of cancer detection, but was an independent predictor of detecting adenomas, regardless of category; the R2 of the models ranged from 6% to 13% only. Limitations Other factors known to influence colorectal neoplasia occurrence and withdrawal time could not be taken into account. Conclusions In a screening program with a high compliance rate with colonoscopy after FOBT, interendoscopist variability had no effect on cancer detection, but did influence identification of adenomas. The clinical impact of such findings merits further evaluation.
Background Measuring neoplasia yield is a priority in the quality improvement process for colonoscopy. However, neither the most appropriate quality indicator nor the standard threshold has been ...established. Objective To determine the most appropriate quality indicators to assess the yield of routine colonoscopy. Design Retrospective. Setting Population-based colorectal cancer screening program in 3 French administrative areas. Subjects One hundred gastroenterologists and their average-risk asymptomatic patients aged 50 to 74 years undergoing colonoscopy for positive guaiac-based fecal occult blood test results. Main Outcome Measurements Comparison of several indicators, mainly the adenoma detection rate (ADR) and polyp detection rate (PDR), the mean number of adenomas per colonoscopy (MNA) and mean number of polyps (MNP) and the proportion of adenomas among polyps (PAP). Results Correlations were good between the ADR and PDR (Pearson coefficient r = 0.88 95% CI, 0.78-0.94) and between MNA and MNP ( r = 0.89 95% CI, 0.79-0.94) ( P < .0001 for both). Gastroenterologists were classified as higher or lower detectors in comparison with the lower limit of the 95% confidence interval of the median value for each indicator. The MNP (MNA) provided better discrimination than the PDR (ADR). Concordance between classifications of gastroenterologists according to their MNA and MNP was excellent (κ = 0.89). PAP varied dramatically from 38% to 95% between gastroenterologists and was very poorly correlated with the ADR ( r = −0.27 95% CI, −0.54 to 0.07; P = .11) and the MNA ( r = 0.03 95% CI, −0.29 to 0.36; P = .88). Limitations Some factors influencing the neoplasia yield were not taken into account. Conclusions The MNP could replace the ADR for the assessment of adenoma detection in routine practice. A separate indicator, PAP, would be necessary to assess adenoma discrimination ability.
The aim was to determine the rate of high-grade dysplasia among patients with all adenomas, and its prevalence in patients with adenomas of different sizes in a well-defined population-based study.
...We performed a secondary analysis of the 2295 colonoscopies performed following a positive fecal occult blood test result during the first round of colorectal cancer screening in one French district. The rates of high-grade dysplasia were calculated for 3 size categories of adenoma (diminutive, <or=5 mm; small, 6-9 mm; large, >or=10 mm). Predictive factors for high-grade dysplasia were assessed by univariate and multivariate analyses.
A total of 1284 adenomas were detected in 784 subjects. High-grade dysplasia was present in 32.1% of the 784 subjects and in 2.7%, 16.0%, and 51.1% of those whose adenomas were diminutive, small, and large, respectively. Among subjects with no more than 2 small adenomas, the proportion of those with high-grade dysplasia was 12.4%. Both adenoma size and a villous component within adenomas were found to be independent predictive factors for high-grade dysplasia by multivariate analysis.
Because of the high rate of high-grade dysplasia among small adenomas, our results reinforce the need to remove all small adenomas detected at colonoscopy. Furthermore, the results suggest that opting for CT colonography surveillance instead of colonoscopic removal among subjects with one or 2 small polyps revealed by CT colonography would have led to missed high-grade dysplasia in 12.4% of them.
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