Curbing the Opioid Epidemic at Its Root: The Effect of Provider Discordance After Opioid Initiation

Although medical research has addressed the clinical management of chronic opioid users, little is known about how operational interventions shortly after opioid initiation can impact a patient’s likelihood of long-term opioid use. Using a nationwide U.S. database of medical and pharmaceutical claims, we investigate the care delivery process at the most common entry point to opioid use: the primary care setting. For patients who return to primary care for a follow-up appointment within 30 days of opioid initiation, we ask who should revisit and potentially revise the opioid-based treatment plan: the initial prescriber (provider concordance) or an alternate clinician (provider discordance)? First, using a fully controlled logistic model, we find that provider discordance reduces the likelihood of long-term opioid use 12 months after opioid initiation by 31% (95% Confidence Interval: [18%, 43%]). Both the instrumental variable analysis technique and propensity-score matching (utilizing the minimum-bias estimator approach) account for omitted variable bias and indicate that this is a conservative estimate of the true causal effect. Second, looking at patient activities immediately after the follow-up appointment, we find that this long-term reduction is at least partially explained by an immediate reduction in opioids prescribed after the follow-up appointment. Third, the data suggest that the benefit associated with provider discordance remains significant regardless of whether the patient’s initial prescriber was their regular primary care provider or another clinician. Overall, our analysis indicates that systematic, operational changes in the early stages of managing new opioid patients may offer a promising, and hitherto overlooked, opportunity to curb the opioid epidemic. This paper was accepted by David Simchi-Levi, healthcare management.

LGBT-supportive corporate policies, risk aversion and mitigation and economic policy uncertainty

PurposeThe paper aims to investigate the effect of uncertain times on LGBT-supportive corporate policies, exploiting a novel text-based measure of economic policy uncertainty (EPU) that was recently constructed by Baker et al. (2016). LGBT-supportive policies have attracted a great deal of attention in the media lately. There is also a rapidly growing area of the literature that addresses LGBT-supportive policies specifically.Design/methodology/approachThe authors execute a regression analysis and several other robustness checks including propensity score matching (PSM) and an instrumental-variable analysis to mitigate endogeneity.FindingsThe authors' results show that companies significantly raise their investments in LGBT-supportive policies in times of greater uncertainty, reinforcing the risk mitigation view where LGBT-supportive policies create moral capital with an insurance-like effect that mitigates adverse consequences during uncertain times. The effect of EPU on LGBT-supportive policies is above and beyond its effect on corporate social responsibility (CSR) in general.Originality/valueThe authors' study is the first to explore the effect of uncertain times on LGBT-supportive corporate policies. The authors contribute to a crucial area of the literature that examines how firms respond to EPU. In addition, the authors enrich the literature on LGBT-friendly policies by showing that EPU is one of the significant determinants of LGBT-friendly policies.

Immigration and anti-immigrant voting in the 2017 German parliamentary election

We empirically examine the relationship between immigration and votes for the Alternative für Deutschland (AfD) in the 2017 German parliamentary election. We conduct a cross-sectional analysis, exploiting election results and socio-demographic as well as geographic features of the 401 German administrative districts. We find that immigration has a negative effect on AfD voting. A 1 percentage point increase in the share of foreigners is associated with a decrease in the AfD vote share of up to 0.37 percentage points. The result is robust to several estimation variations, such as addressing the potentially endogenous distribution of foreigners with an instrumental variable analysis.

Effectiveness of Pediatric Concurrent Hospice Care to Improve Continuity of Care

Background The 2010 Patient Protection and Affordable Care Act (ACA) mandated landmark hospice care legislation for children at end of life. Little is known about the impact of pediatric concurrent hospice care. Objective The purpose of this study was to examine the effect of pediatric concurrent vs standard hospice care on end-of-life care continuity among Medicaid beneficiaries. Methods Using national Medicaid data, we conducted a quasi-experimental designed study to estimate the effect of concurrent vs standard hospice care to improve end-of-life care continuity for children. Care continuity (i.e., hospice length of stay, hospice disenrollment, emergency room transition, and inpatient transition) was measured via claims data. Exposures were concurrent hospice vs standard hospice care. Using instrumental variable analysis, the effectiveness of exposures on care continuity was compared. Results Concurrent hospice care affected care continuity. It resulted in longer lengths of stays in hospice ( β = 2.76, P < .001) and reduced hospice live discharges ( β = −2.80, P < .05), compared to standard hospice care. Concurrent care was not effective at reducing emergency room ( β = 2.09, P < .001) or inpatient care ( β = .007, P < .05) transitions during hospice enrollment. Conclusion Our study provides critical insight into the quality of care delivered for children at end of life. These findings have policy implications.

Prophylactic Magnesium Supplementation and New-Onset Atrial Fibrillation in a General Critical Care Population: A Prescribing Preference Instrumental Variable Analysis

Aims Atrial fibrillation is frequently encountered in critical illness and causes adverse effects including haemodynamic decompensation, stroke and longer hospital stay. It is common to supplement serum magnesium for the purpose of preventing new-onset atrial fibrillation. However, no randomised studies support this practice in the non-cardiac surgery critical care population, and its effectiveness is unclear. We sought to investigate the effectiveness of magnesium supplementation in preventing new-onset atrial fibrillation in a mixed critical care population. Methods We conducted a single centre retrospective observational study of adult critical care patients. We employed a natural experiment design, using the supplementation preference of the bedside critical care nurse as an instrumental variable. Using the electronic patient record, magnesium supplementation opportunities were defined and linked to the bedside nurse. Nurse preference for administering magnesium was obtained using multilevel modelling. The results were used to define pro and anti supplementation groups, which were inputted into an instrumental variable regression to obtain an estimate of the effect of magnesium supplementation. Results 9,114 magnesium supplementation opportunities were analysed, representing 2,137 critical care admissions for 1,914 patients. There was significant variation in magnesium supplementation practices attributable to the individual nurse, after accounting for covariates. The instrumental variable analysis showed magnesium supplementation was associated with a 3% decreased chance of experiencing new-onset atrial fibrillation (95% CI -0.06 to -0.04, p = 0.03). Conclusions This study supports the strategy of routine magnesium supplementation, but further work is required to identify optimal serum magnesium targets for prophylaxis of atrial fibrillation.

Instrumental variable analysis using offspring BMI in childhood as an indicator of parental BMI in relation to mortality

Childhood BMI shows associations with adult mortality, but these may be influenced by effects of ill health in childhood on BMI and later mortality. To avoid this, we used offspring childhood BMI as an instrumental variable (IV) for own BMI in relation to mortality and compared it with conventional associations of own childhood BMI and own mortality. We included 36,097 parent–offspring pairs with measured heights and weights from the Copenhagen School Health Records Register and register-based information on death. Hazard ratios (HR) were estimated using adjusted Cox regression models. For all-cause mortality, per zBMI at age 7 the conventional HR = 1.07 (95%CI: 1.04–1.09) in women and 1.02 (95%CI: 0.92–1.14) in men, whereas the IV HR = 1.23 (95%CI: 1.15–1.32) in women and 1.05 (95%CI: 0.94–1.17) in men. Per zBMI at age 13, the conventional HR = 1.11 (95%CI: 1.08–1.15) in women and 1.03 (95%CI: 0.99–1.06) in men, whereas the IV HR = 1.30 (95%CI: 1.19–1.42) in women and 1.15 (95%CI: 1.04–1.29) in men. Only conventional models showed indications of J-shaped associations. Our IV analyses suggest that there is a causal relationship between BMI and mortality that is positive at both high and low BMI values.

The Effects of Retirement on Sense of Purpose in Life: Crisis or Opportunity?

Does retirement lead to an existential crisis or present an opportunity to experience a renewed sense of purpose in life? Prior research has documented a negative association between retirement and sense of purpose in life, suggesting that retirement could lead people to feel aimless and lost. We revisited these findings using a quasiexperimental approach and identified the causal impact of retirement on purpose in life. In a nationally representative panel of American adults ( N = 8,113), we applied an instrumental-variable analysis to assess how Social Security retirement incentives in the United States drove differences in the likelihood of retirement. Results showed a sizable increase in purpose in life as an outcome of retirement. These improvements were driven by individuals with lower socioeconomic status who retired from dissatisfying jobs. The findings suggest that retirement may provide an opportunity to experience a renewed sense of purpose, especially among socioeconomically disadvantaged populations.

Does board independence influence asset redeployability? Evidence from a quasi-natural experiment

Purpose Exploiting an exogenous regulatory shock and a novel measure of asset redeployability, this paper aims to explore the effect of independent directors on asset redeployability. In particular, the authors use an innovative measure of asset redeployability recently developed by Kim and Kung (2016). This novel index has been rapidly adopted in recent literature. Design/methodology/approach Relying on a quasi-natural experiment, the authors execute a difference-in-difference analysis based on an exogenous regulatory shock to board independence. To mitigate endogeneity and demonstrate causation, the authors also perform propensity score matching, instrumental-variable analysis and Oster’s (2019) approach for testing coefficient stability. Findings The difference-in-difference estimates show that firms forced to raise board independence have significantly fewer redeployable assets after the shock than those not required to change board composition. This is consistent with the managerial myopia hypothesis. Subject to more intense monitoring, managers behave more myopically, focusing more on assets that are currently useful to the firm and less on redeployability in the future. Originality/value The study makes key contributions to the literature. First, the study is the first to examine the effect of board governance on asset redeployability. Second, the authors exploit an innovative index of asset redeployability that has been recently constructed in the literature. Third, by using a natural experiment, the results are much more likely to reflect causality than merely an association.

Does board gender diversity weaken or strengthen executive risk-taking incentives?

We investigate the effect of board gender diversity on managerial risk-taking incentives. Our results demonstrate that companies with stronger board gender diversity provide more powerful executive risk-taking incentives. It appears that female directors’ risk aversion exacerbates managers’ risk aversion, resulting in a sub-optimal level of risk-taking. To offset this tendency for too little risk, companies are induced to provide stronger risk-taking incentives. Specifically, an increase in board gender diversity by one standard deviation raises vega by 10.3%. Further analysis corroborates the results, including propensity score matching, entropy balancing, and an instrumental-variable analysis. Endogeneity appears to be unlikely, suggesting that female directors are not merely associated with, but probably bring about stronger risk-taking incentives.