Background: Economic dimensions of implementing quality improvement for diabetes care are understudied worldwide. We describe the economic evaluation protocol within a randomised controlled trial that tested a multi-component quality improvement (QI) strategy for individuals with poorly-controlled type 2 diabetes in South Asia. Methods/design: This economic evaluation of the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) randomised trial involved 1146 people with poorly-controlled type 2 diabetes receiving care at 10 diverse diabetes clinics across India and Pakistan. The economic evaluation comprises both a within-trial cost-effectiveness analysis (mean 2.5 years follow up) and a microsimulation model-based cost-utility analysis (life-time horizon). Effectiveness measures include multiple risk factor control (achieving HbA1c < 7% and blood pressure < 130/80 mmHg and/or LDL-cholesterol< 100 mg/dl), and patient reported outcomes including quality adjusted life years (QALYs) measured by EQ-5D-3 L, hospitalizations, and diabetes related complications at the trial end. Cost measures include direct medical and non-medical costs relevant to outpatient care (consultation fee, medicines, laboratory tests, supplies, food, and escort/accompanying person costs, transport) and inpatient care (hospitalization, transport, and accompanying person costs) of the intervention compared to usual diabetes care. Patient, healthcare system, and societal perspectives will be applied for costing. Both cost and health effects will be discounted at 3% per year for within trial cost-effectiveness analysis over 2.5 years and decision modelling analysis over a lifetime horizon. Outcomes will be reported as the incremental cost-effectiveness ratios (ICER) to achieve multiple risk factor control, avoid diabetes-related complications, or QALYs gained against varying levels of willingness to pay threshold values. Sensitivity analyses will be performed to assess uncertainties around ICER estimates by varying costs (95% CIs) across public vs. private settings and using conservative estimates of effect size (95% CIs) for multiple risk factor control. Costs will be reported in US$ 2018. Discussion: We hypothesize that the additional upfront costs of delivering the intervention will be counterbalanced by improvements in clinical outcomes and patient-reported outcomes, thereby rendering this multi-component QI intervention cost-effective in resource constrained South Asian settings. Trial registration: ClinicalTrials.gov: NCT01212328.
Academic and policy literatures on intergenerational transmissions of poverty and inequality suggest that improving schooling attainment and income for parents in poor households will lessen poverty and inequality in their children's generation through increased human capital accumulated by their children. However, magnitudes of such effects are unknown. We use data on children born in the 21st century in four developing countries to simulate how changes in parents' schooling attainment and consumption would affect poverty and inequality in both the parent's and their children's generations. We find that increasing minimum schooling or income substantially reduces poverty and inequality in the parent's generation, but does not carry over to reducing poverty and inequality substantially in the children's generation. Therefore, while reductions in poverty and inequality in the parents' generation are desirable in themselves to improve welfare among current adults, they are not likely to have large impacts in reducing poverty and particularly in reducing inequality in human capital in the next generation.
This policy brief, which is based on an internal memo, summarizes the institutional and operational features observed in the 27 countries that have gained experience with inflation targeting (IT). It finds considerable convergence in many IT practices across countries over the past 10 to 15 years but much variation in policymakers ’ choices concerning such key issues as how they treat the borders of the target range. On the whole, most IT banks have chosen to practice inflation targeting in a more flexible and, thus, resilient fashion than many analysts once feared—seemingly without much loss of credibility. Currently, however, after a prolonged period of rapidly rising commodity and asset prices, followed by a period of sharp oil and asset price declines, IT is clearly facing the greatest challenges in its short history of relatively widespread use. Fortunately, one key lesson that emerges from our experience to date is that much of the ability of inflation targeting to help moor inflation expectations likely stems from the premium it places on improving transparency standards. These standards are available to all central banks, whether they choose to practice inflation targeting or not.
The disposition effect is a phenomenon in which investors hold onto losing assets longer than they hold onto gaining assets. In this study, we used functional magnetic resonance imaging (fMRI) to measure the response of valuation regions in the brain during the decision to keep or to sell an asset that followed a random walk in price. The most common explanation for the disposition effect is preference-based: namely, that people are risk-averse over gains and risk-seeking over losses. This explanation would predict correlations between individuals’ risk-preferences, the magnitude of their disposition effect, and activation in valuation structures of the brain. We did not observe these correlations. Nor did we find evidence for a realization utility explanation, which would predict differential responses in valuation regions during the decision to sell versus keep an asset that correlated with the magnitude of the disposition effect. Instead, we found an attenuated ventral striatum response to upticks in value below the purchase price in some individuals with a large disposition effect. Given the role of the striatum in signaling prediction error, the blunted striatal response is consistent with the expectation that an asset will rise when it is below the purchase price, thus spurring loss-holding behavior. This suggests that for some individuals, the disposition effect is likely driven by a belief that the asset will eventually return to the purchase price, also known as mean reversion.
The application of neuroimaging methods to product marketing — neuromarketing — has recently gained considerable popularity. We propose that there are two main reasons for this trend. First, the possibility that neuroimaging will become cheaper and faster than other marketing methods; and second, the hope that neuroimaging will provide marketers with information that is not obtainable through conventional marketing methods. Although neuroimaging is unlikely to be cheaper than other tools in the near future, there is growing evidence that it may provide hidden information about the consumer experience. The most promising application of neuroimaging methods to marketing may come before a product is even released — when it is just an idea being developed.
It is well-known that social influences affect consumption decisions. We used functional magnetic resonance imaging (fMRI) to elucidate the neural mechanisms associated with social influence with regard to a common consumer good: music. Our study population was adolescents, age 12–17. Music is a common purchase in this age group, and it is widely believed that adolescent behavior is influenced by perceptions of popularity in their reference group. Using 15-second clips of songs from MySpace.com, we obtained behavioral measures of preferences and neurobiological responses to the songs. The data were gathered with, and without, the overall popularity of the song revealed. Song popularity had a significant effect on the participants’ likability ratings of the songs. fMRI results showed a strong correlation between the participants’ rating and activity in the caudate nucleus, a region previously implicated in reward-driven actions. The tendency to change one’s evaluation of a song was positively correlated with activation in the anterior insula and anterior cingulate, two regions that are associated with physiological arousal and negative affective states. Sensitivity to popularity was linked to lower activation levels in the middle temporal gyrus, suggesting a lower depth of musical semantic processing. Our results suggest that a principal mechanism whereby popularity ratings affect consumer choice is through the anxiety generated by the mismatch between one’s own preferences and others’. This mismatch anxiety motivates people to switch their choices in the direction of the consensus. Our data suggest that this is a major force behind the conformity observed in music tastes in some teenagers.
There are two regularities we have learned from experimental studies of choice under risk. The first is that the majority of people weigh objective probabilities nonlinearly. The second regularity, although less commonly acknowledged, is that there is a large amount of heterogeneity in how people distort probabilities. Despite this, little effort has been made to identify the source of heterogeneity. We explore the possibility that personality type is linked to probability distortions. Using validated psychological questionnaires, we clustered participants into distinct personality types: motivated, impulsive, and affective. We found that the motivated participants viewed gambling as more attractive, whereas the impulsive participants were the most capable of discriminating non-extreme probabilities. Our results suggest that the observed heterogeneity in probability distortions may be explained by personality profiles, which can be elicited though standard psychological questionnaires.
Purpose: Advanced maternal age and altered recombination are known risk factors for Down syndrome cases due to maternal nondisjunction of chromosome 21, whereas the impact of other environmental and genetic factors is unclear. The aim of this study was to investigate an association between low maternal socioeconomic status and chromosome 21 nondisjunction. Methods: Data from 714 case and 977 control families were used to assess chromosome 21 meiosis I and meiosis II nondisjunction errors in the presence of three low socioeconomic status factors: (i) both parents had not completed high school, (ii) both maternal grandparents had not completed high school, and (iii) an annual household income of <$25,000. We applied logistic regression models and adjusted for covariates, including maternal age and race/ethnicity. Results: As compared with mothers of controls (n = 977), mothers with meiosis II chromosome 21 nondisjunction (n = 182) were more likely to have a history of one low socioeconomic status factor (odds ratio = 1.81; 95% confidence interval = 1.07-3.05) and ≥2 low socioeconomic status factors (odds ratio = 2.17; 95% confidence interval = 1.02-4.63). This association was driven primarily by having a low household income (odds ratio = 1.79; 95% confidence interval = 1.14-2.73). The same statistically significant association was not detected among maternal meiosis I errors (odds ratio = 1.31; 95% confidence interval = 0.81-2.10), in spite of having a larger sample size (n = 532). Conclusion: We detected a significant association between low maternal socioeconomic status and meiosis II chromosome 21 nondisjunction. Further studies are warranted to explore which aspects of low maternal socioeconomic status, such as environmental exposures or poor nutrition, may account for these results.
Importance: Expanding treatment for opioid addiction has been recognized as an essential component of a comprehensive national response to the opioid epidemic. The Drug Addiction Treatment Act and its amendments attempted to improve access to treatment by involving office-based physicians in the provision of buprenorphine treatment. Objectives: To estimate the association of availability of buprenorphine-waivered physicians with buprenorphine treatment use and, secondarily, with prescription opioid use among Medicaid enrollees. Design, Setting, and Participants: This economic evaluation study used state-level panel data analysis to estimate the association between the number of buprenorphine-waivered physicians and the Medicaid-covered buprenorphine prescribing rate and opioid prescribing rate among Medicaid fee-for-service and managed care enrollees throughout the United States between January 1, 2011, and December 31, 2016. Main Outcomes and Measures: Buprenorphine prescribing rate and opioid prescribing rate, measured as the number of buprenorphine prescriptions and opioid prescriptions covered by Medicaid on a quarterly basis per 1000 enrollees. Results: The sample included 1059 quarterly observations. Two additional 100-patient-waivered physicians per 1 000 000 residents (approximately a 10% increase) were associated with an increase in the quarterly number of Medicaid-covered buprenorphine prescriptions of 0.46 (95% CI, 0.24-0.67) per 1000 enrollees and a reduction in the quarterly number of opioid prescriptions of 1.01 (95% CI, -1.87 to -0.15) per 1000 enrollees. Furthermore, 5 additional 30-patient-waivered physicians per 1 000 000 residents (approximately a 10% increase) were associated with an increase in the quarterly number of Medicaid-covered buprenorphine prescriptions of 0.37 (95% CI, 0.22-0.52) per 1000 enrollees and a reduction in the quarterly number of opioid prescriptions of 0.96 (95% CI, -1.85 to -0.07) per 1000 enrollees. A 10% increase in the number of buprenorphine-waivered physicians was associated with an approximately 10% increase in the Medicaid-covered buprenorphine prescribing rate and a 1.2% reduction in the opioid prescribing rate. Conclusions and Relevance: Expanding capacity for buprenorphine treatment holds the potential to improve access to opioid addiction treatment, which may further reduce prescription opioid use and slow the ongoing opioid epidemic in the United States.
Poverty has numerous deleterious effects on health, and the Earned Income Tax Credit (EITC) is the major policy tool used to alleviate poverty in the U.S. We evaluate effects of four distinct changes in earned income tax credit law in Washington, DC on maternal behaviors and infant outcomes. An interrupted time-series design was used with 312 monthly measures from 1990 through 2015 analyzed in 2018 (total n = 225,933 births). States with no EITC were included as the comparison group; analyses involved ARIMA modeling. Outcomes were derived from birth certificates, and included percent of live births below 2500 g, mean birth weight, mean gestation weeks, first trimester prenatal care, and maternal smoking during pregnancy. We found a pattern of significant improvements across all three infant outcome measures, with the size of the effect estimate monotonically matching the magnitude of the tax credit—ranging from a 1.9 (-2.9, -0.9) reduction in rate per 100 births of low birth weight for the smaller 10% credit, to a 4.7 (-5.4, -4.0) reduction with the 40% credit. Results for maternal smoking and prenatal care were mixed. Results suggest that earned income tax credit policies improve birth outcomes; mechanisms for this effect deserve further study.