Predictors of Sickness Absence in a Clinical Population With Chronic Pain

Chronic pain-related sickness absence is an enormous socioeconomic burden globally. Optimized interventions are reliant on a lucid understanding of the distribution of social insurance benefits and their predictors. This register-based observational study analyzed data for a 7-year period from a population-representative sample of 44,241 chronic pain patients eligible for interdisciplinary treatment (IDT) at specialist clinics. Sequence analysis was used to describe the sickness absence over the complete period and to separate the patients into subgroups based on their social insurance benefits over the final 2 years. The predictive performance of features from various domains was then explored with machine learning-based modeling in a nested cross-validation procedure. Our results showed that patients on sickness absence increased from 17% 5 years before to 48% at the time of the IDT assessment, and then decreased to 38% at the end of follow-up. Patients were divided into 3 classes characterized by low sickness absence, sick leave, and disability pension, with eight predictors of class membership being identified. Sickness absence history was the strongest predictor of future sickness absence, while other predictors included a 2008 policy, age, confidence in recovery, and geographical location. Information on these features could guide personalized intervention in the specialized healthcare. PERSPECTIVE: This study describes sickness absence in patients who visited a Swedish pain specialist interdisciplinary treatment clinic during the period 2005 to 2016. Predictors of future sickness absence are also identified that should be considered when adapting IDT programs to the patient's needs.

Prevalence, Indirect Costs, and Risk Factors for Work Disability in Patients with Crohn's Disease at a Tertiary Care Center in Rio de Janeiro

BACKGROUND AND AIMS

Crohn's disease (CD) can lead to work disability with social and economic impacts worldwide. In Brazil, where its prevalence is increasing, we assessed the indirect costs, prevalence, and risk factors for work disability in the state of Rio de Janeiro and in a tertiary care referral center of the state.

METHODS

Data were retrieved from the database of the Single System of Social Security Benefits Information, with a cross-check for aid pension and disability retirement. A subanalysis was performed with CD patients followed up at the tertiary care referral center using a prospective CD database, including clinical variables assessed as possible risk factors for work disability.

RESULTS

From 2010 to 2018, the estimated prevalence of CD was 26.05 per 100,000 inhabitants, while the associated work disability was 16.6%, with indirect costs of US$ 8,562,195.86. Permanent disability occurred more frequently in those aged 40 to 49 years. In the referral center, the prevalence of work disability was 16.7%, with a mean interval of 3 years between diagnosis and the first benefit. Risk factors for absence from work were predominantly abdominal surgery, anovaginal fistulas, disease duration, and the A2 profile of the Montreal classification.

CONCLUSIONS

In Rio de Janeiro, work disability affects one-sixth of CD patients, and risk factors are associated with disease duration and complications. In the context of increasing prevalence, as this disability compromises young patients after a relatively short period of disease, the socioeconomic burden of CD is expected to increase in the future.

The impact of occupational structures on ethnic and gendered employment gaps: An event history analysis using social security register data

Ethnic and gendered employment gaps are mainly explained by individual characteristics, while less attention is paid to occupational structures. Drawing on administrative data, this article analyses the impact of occupational characteristics on top of individual attributes in the urban labour market of Vienna. Both set of variables can explain observed employment gaps to a large extent, but persistent gaps remain, in particular among females. The article's main finding is that the occupational structure appears to have gendered effects. While men tend to benefit from ethnic segregation, women face difficulties when looking for jobs with high shares of immigrant workers. Looking for jobs in occupations that recruit from relatively few educational backgrounds (credentials) is beneficial for both sexes at the outset unemployment, but among females this competitive advantage diminishes over time. The article concludes by discussing potential strategies to avoid the traps of occupational segregation.

Trajectory of excess healthcare consultations, medication use, and work disability in newly diagnosed knee osteoarthritis: a matched longitudinal register-based study

PURPOSE

To estimate the excess healthcare use and work disability attributable to knee osteoarthritis (OA) in the first 5 years following diagnosis.

METHODS

Among individual aged 40-80 years who resided in Skåne on 31^st December 2008, we identified those with a main diagnosis of knee OA during 2009-2014 and no previous diagnosis of any OA from 1998 (n = 16,888). We created a comparison cohort matched (1:1) by sex, age, and municipality from individuals with no OA diagnosis (at any site) during 1998-2016. We compared healthcare use and net disability days for 60 months following diagnosis between the two groups. We applied a survival-adjusted regression technique controlling for sociodemographic characteristics as well as pre-diagnosis outcome and comorbidity.

RESULTS

The estimated 5-year incremental effects of knee OA per-patient were 16.8 (95% CI: 15.8, 17.7) healthcare consultations, 0.7 (0.4, 1.1) inpatient days, 420 (372, 490) defined daily dose of prescribed medications, and 21.8 (15.2, 30.0) net disability days. Primary care consultations constituted about 73% of the excess healthcare consultations. Most of these incremental effects occurred in the first year after diagnosis. Better survival in the knee OA group accounted for 0.7 (95% CI: 0.5, 0.8) and 1.4 (0.7, 2.6) of the excess healthcare consultations and net disability days, respectively. Both estimated total and incremental resources use were generally greater for women than men with knee OA.

CONCLUSION

Knee OA was associated with considerable excess healthcare use and work disability independent of pre-diagnosis resources use, comorbidity, and sociodemographic characteristics.

Analysis of Patient Income in the 5 Years Following a Fracture Treated Surgically

IMPORTANCE

Orthopedic injury is assumed to bear negative socioeconomic consequences. However, the magnitude and duration of a fracture's impact on patient income and social insurance benefits remain poorly quantified.

OBJECTIVE

To characterize the association between orthopedic injury and patient income using state tax records.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included adult patients surgically treated for an orthopedic fracture at a US academic trauma center from January 2003 through December 2014. Hospital data were linked to individual-level state tax records using a difference-in-differences analysis performed from November 2019 through August 2020. The control group comprised of data resampled from fracture patients at least 6 years prior to injury.

EXPOSURES

An operatively treated fracture of the appendicular skeleton.

MAIN OUTCOMES AND MEASURES

The primary outcome was individual annual earnings up to 5 years postinjury. Secondary outcomes included annual household income and US Social Security benefits for 5 years postinjury and catastrophic wage loss within 2 years of injury.

RESULTS

A total of 9997 fracture patients (mean [SD] age, 44.6 [18.9] years; 6725 [67.3%] men) to 34 570 prefracture control participants (mean [SD] age, 40.0 [20.5] years; 21 666 [62.7%] men). The median (interquartile range) of preinjury wage earnings was $16 847 ($0 to $52 221). The mean annual decline in individual earnings during the 5 years following injury was $9865 (95% CI, -$10 686 to -$8862). Annual household income declined by $5259 (95% CI, -$6337 to -$4181) over the same period. A fracture was associated with a $206 (95% CI, $147 to $265) mean annual increase in Social Security benefits in the 5 years after injury. An injury increased the risk of catastrophic wage loss by 11.6% (95% CI, 10.5% to 12.7%). Substantial relative income loss was observed in patients with preinjury earnings in the top 3 quartiles, but changes in income were negligible for patients with preinjury earnings in the bottom quartile (19%; 95% CI, -4% to 48%).

CONCLUSIONS AND RELEVANCE

In this cohort study of patients surgically treated for an orthopedic fracture at a US academic trauma center, fractures were associated with substantial individual and household income loss up to 5 years after injury, and 1 in 5 patients sustained catastrophic income loss in the 2 years after fracture. Gains in Social Security benefits offset less than 10% of annual income losses.

Ethnic disparities in receiving benefits for disability following postpartum mental illness during first two years after delivery: an Israeli nationwide study

BACKGROUND

Despite relatively high rates of Postpartum Depression (PPD), little is known about the granting of social security benefits to women who are disabled as a result of PPD or of other postpartum mood and anxiety disorders (PMAD). This study aims to identify populations at risk for underutilization of social security benefits due to PMAD among Israeli women, with a focus on ethnic minorities.

METHODS

This retrospective cohort study is based on the National Insurance Institute (NII) database. The study population included a simple 10% random sample of 79,391 female Israeli citizens who gave birth during 2008-2016 (these women delivered a total of 143,871 infants during the study period), and who had not been eligible for NII mental health disability benefits before 2008. The dependent variable was receipt of Benefit Entitlement (BE) due to mental illness within 2 years following childbirth. Maternal age at delivery, population group, Socio-Economic Status (SES), family status, employment status of the mother and her spouse, and infant mortality were the independent variables. Left truncation COX proportional hazard model with time-dependent variables was used, and birth number served as a time discrete variable.

RESULTS

Bedouin and Arab women had significantly lower likelihood of BE (2.6 times lower and twice lower) compared with other ethnic groups (HR = 0.38; 95% CI: 0.26-0.56; HR = 0.47; 95% CI: 0.37-0.60 respectively). The probability of divorced or widowed women for BE was significantly higher compared to those living with a spouse (HR = 3.64; 95% CI: 2.49-5.33). Lack of employment was associated with higher likelihood of BE (HR = 1.54; 95% CI: 1.30-1.82). Income had a dose-response relationship with BE in multivariable analysis: lower income was associated with the nearly four-fold greater probability compared to the highest income quartile (HR = 3.83; 95% CI: 2.89-5.07).

CONCLUSIONS

Despite the exceptionally high prevalence of PMAD among ethnic minorities, Bedouins and Arabs had lowest likelihood of Benefit Entitlement. In addition to developing programs for early identification of postpartum emotional disorders among unprivileged ethnic groups, awareness regarding entitlement to a mental health disability allowance among ethnic minorities should be improved.

Increased risk of long-term sickness absence, lower rate of return to work and higher risk of disability pension among people with type 1 and type 2 diabetes mellitus: a Danish retrospective cohort study with up to 17 years' follow-up

AIM

To evaluate labour market outcomes in type 1 or type 2 diabetes.

METHODS

Individuals with type 1 (n = 431) and type 2 diabetes (n = 4047) were identified in Danish national registers from 1994 to 2011 and compared with individuals without diabetes (n = 101 295). Multi-state Cox proportional hazards analyses estimated hazard ratios (HR) with 95% confidence intervals (CI) for transitions between work, sickness absence, unemployment and disability pension.

RESULTS

We observed significantly higher HR of sickness absence in type 1 diabetes (women: 1.34, 95% CI 1.12-1.62; men: 1.43, 1.01-2.03) and type 2 diabetes (women: 1.46, 95% CI 1.35-1.58; men: 1.64, 1.46-1.85) compared with people without diabetes. HR of unemployment was higher for men with type 1 diabetes (1.25, 95% CI 1.01-1.53) and women with type 2 diabetes (1.09, 95% CI 1.03-1.16) and men with type 2 diabetes (1.17, 95% CI 1.08-1.27). HR of disability pension was higher in type 1 diabetes (women: 1.90, 95% CI 1.46-2.46; men: 2.09, 1.38-3.18) and type 2 diabetes (women: 1.78, 95% CI 1.62-1.96; men: 2.11, 1.86-2.40). Only women with type 2 diabetes were less likely to return to work from sickness absence (HR 0.91, 95% CI 0.86-0.98) or unemployment (0.89, 95% CI 0.85-0.94). We found no significant difference between the two types of diabetes. Hazard ratios for diabetes regarding unemployment, sickness absence while unemployed and disability pension were significantly higher for men than for women.

CONCLUSIONS

Both type 1 and type 2 diabetes affect labour market outcomes, but future studies should also consider comorbidity and social gradient.

What are the potential advantages and disadvantages of merging health insurance funds? A qualitative policy analysis from Iran

BACKGROUND

In countries with health insurance systems, the number and size of insurance funds along with the amount of risk distribution among them are a major concern. One possible solution to overcome problems resulting from fragmentation is to combine risk pools to create a single pool. This study aimed to investigate the potential advantages and disadvantages of merging health insurance funds in Iran.

METHODS

In this qualitative study, a purposeful sampling with maximum variation was used to obtain representativeness and rich data. To this end, sixty-seven face-to-face interviews were conducted. Moreover, a documentary review was used as a supplementary source of data collection. Content analysis using the 'framework method' was used to analyze the data. Four trustworthiness criteria, including credibility, transferability, dependability, and confirmability, were used to assure the quality of results.

RESULTS

The potential consequences were grouped into seven categories, including stewardship, financing, population, benefit package, structure, operational procedures, and interaction with providers. According to the interviewees, controlling total health care expenditures; improving strategic purchasing; removing duplication in population coverage; centralizing the profile of providers in a single database; controlling the volume of provided health care services; making hospitals interact with single insurance with a single set of instructions for contracting, claiming review, and reimbursement; and reducing administrative costs were among the main benefits of merging health insurance funds. The interviewees enumerated the following drawbacks as well: the social security organization's unwillingness to collect insurance premiums from private workers actively as before; increased dissatisfaction among population groups enjoying a generous basic benefits package; risk of financial fraud and corruption due to gathering all premiums in a single bank; and risk of putting more financial pressure on providers in case of delay in reimbursement with a single-payer system.

CONCLUSION

Merging health insurance schemes in Iran is influenced by a wide range of potential merits and drawbacks. Thus, to facilitate the process and lessen opponents' objection, policy makers should act as brokers by taking into account contextual factors and adopting tailored policies to respectively maximize and minimize the potential benefits and drawbacks of consolidation in Iran.

Seeking care in the context of social health insurance in Kenya and Ghana

BACKGROUND

Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC). While evidence suggests that SHI is a promising strategy for achieving UHC, low-income countries often struggle to implement and sustain SHI systems. It is therefore important to understand how SHI enrollees use health insurance and how it affects their health-seeking behavior. This paper examines how SHI affects patient decision-making regarding when and where to seek care in Kenya and Ghana, two countries with established SHI systems in sub-Saharan Africa.

METHODS

This paper draws from two datasets collected under the African Health Markets for Equity (AHME) program. One dataset, collected in 2013 and 2017 as part of the AHME qualitative evaluation, consists of 106 semi-structured clinic exit interviews conducted with patients in Ghana and Kenya. This data was analyzed using an inductive, thematic approach. The second dataset was collected internally by the AHME partner organizations. It derives from a cross-sectional survey of social franchise clients at three social franchise networks supported by AHME. Data collection took place from February - May 2018 and in December 2018.

RESULTS

Many clients appreciated that insurance coverage made healthcare more affordable, reported seeking care more frequently when covered with SHI. Clients also noted that the coverage gave them access to a wider variety of providers, but rarely sought out SHI-accredited providers specifically. However, clients sometimes were charged for services that should have been covered by insurance. Due to a lack of understanding of SHI benefits, clients rarely knew they had been charged inappropriately.

CONCLUSIONS

Clients and providers would benefit from education on what is included in the SHI package. Providers should be monitored and held accountable for charging clients inappropriately; in Ghana this should be accompanied by reforms to make government financing for SHI sustainable. Since clients valued provider proximity and both Kenya and Ghana have a dearth of providers in rural areas, both countries should incentivize providers to work in these areas and prioritize accrediting rural facilities into SHI schemes to increase accessibility and reach.

Mexico: Health System Review

This analysis of the Mexican health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Mexican health system consists of three main components operating in parallel: 1) employment-based social insurance schemes, 2) public assistance services for the uninsured supported by a financial protection scheme, and 3) a private sector composed of service providers, insurers, and pharmaceutical and medical device manufacturers and distributors. The social insurance schemes are managed by highly centralized national institutions while coverage for the uninsured is operated by both state and federal authorities and providers. The largest social insurance institution - the Mexican Social Insurance Institute (IMSS) - is governed by a corporatist arrangement, which reflects the political realities of the 1940s rather than the needs of the 21st century. National health spending has grown in recent years but is lower than the Latin America and Caribbean average and considerably lower than the OECD average in 2015. Public spending accounts for 58% of total financing, with private contributions being mostly comprised of out-of-pocket spending. The private sector, while regulated by the government, mostly operates independently. Mexico's health system delivers a wide range of health care services; however, nearly 14% of the population lacks financial protection, while the insured are mostly enrolled in diverse public schemes which provide varying benefits packages. Private sector services are in high demand given insufficient resources among most public institutions and the lack of voice by the insured to ensure the fulfilment of entitlements. Furthermore, the system faces challenges with obesity, diabetes, violence, as well as with health inequity. Recognizing the inequities in access created by its segmented structure, both civil society and government are calling for greater integration of service delivery across public institutions, although no consensus yet exists as to how to bring this about.

Evaluating Survey Report of Social Security Disability Benefit Receipt Using Linked National Health Interview Survey and Social Security Administration Data

Linking nationally representative population health survey data with Social Security Administration (SSA) disability program data provides a rich source of information on program recipients. Survey participant data from the 1998-2005 National Health Interview Survey (NHIS) were linked to SSA administrative records from 1997 through 2005. The goal of this study was to assess agreement between the actual benefit receipt based on the SSA administrative records and the survey report of benefit receipt in the linked NHIS and SSA file for the U.S. civilian noninstitutionalized population. This evaluation provides information on the expected accuracy of survey report of Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) benefit receipt, including how participant characteristics may be associated with reporting misclassification. The results indicate that there is some underreporting of SSA disability benefit receipt based on the NHIS responses compared with the SSA administrative records. The analysis identified some differences between the concordant and discordant groups for selected characteristics, but there were no clear patterns among the different survey questions or the different survey participant characteristics.

How should recruitment to public health surveys be conducted?

BACKGROUND

The aim of the public health survey in the Norwegian counties is to obtain information that is useful for public health work. In 2018, two parallel data collection processes were undertaken in Hordaland county. Both samples were drawn randomly from the National Population Register, but one of these was limited to users of the helsenorge.no website. The purpose of this article is to investigate the degree to which limiting users to the helsenorge.no website leads to selection bias beyond the selection that occurs through ordinary non-participation.

MATERIAL AND METHOD

Services for Sensitive Data (TSD) was used in the data collection for the sample drawn from the National Population Register (n = 36 000), and the helsenorge.no platform was used in the data collection for the sample limited to users of helsenorge.no (n = 30 000). The response rate was 40.8 % and 41.5 %, respectively.

RESULTS

For some outcome measures, the differences between the two datasets were modest (gender distribution, age, education and health habits). For variables that were more directly related to health, the differences were greater. In the helsenorge.no sample a higher proportion reported generally poorer health (29.4 vs. 24.0 %), mental health problems (13.6 vs. 11.6 %), disability pension (10.5 vs. 7.8 %) and long-term illness (13.3 vs. 9.3 %). Analyses of subgroups showed more pronounced differences in the proportion with generally poorer health and mental health problems between those with low education in the helsenorge.no sample and the corresponding group in the sample from the National Population Register.

INTERPRETATION

Systematic and pronounced differences between the samples show that limiting recruitment to users of helsenorge.no's services results in further selection problems.

[Factors associated with dropout in outpatient clinic in a Peruvian Social Security hospital]

BACKGROUND

dropout is considered a problem because attention is interrupted, causing in many cases, complications and important sequelae. The prevalence and factors associated with outpatient referral (DECE) in a national hospital in Peru, 2014-2015, were evaluated.

METHODS

analytical cross-sectional design. The DECE is that medical appointment by external office that was not specified. Demographic factors related to the medical appointment were collected. To assess the factors associated with DECE, a generalized linear model of the Poisson family with robust standard errors (crude and adjusted) was used.

RESULTS

Of 592160 medical appointments granted, the prevalence of DECE was 20.2%. The average age was 51.10 ± 23.23 years and 59.6% were women. The factors associated with a greater probability of DECE were: being a woman, being under 18 years of age or adult, programming schedule, type of patient of the service and the hospital; and have more than 15 days of deferral in the appointment.

CONCLUSIONS

Conclusions: One out of every five patients did not make an appointment in the outpatient clinic. There were demographic and health system factors associated with a higher prevalence of DECE, which could be considered to propose strategies to reduce it.

Work-Related Outcomes in Self-Employed Cancer Survivors: A European Multi-country Study

Purpose To describe: (i) patterns of self-employment and social welfare provisions for self-employed and salaried workers in several European countries; (ii) work-related outcomes after cancer in self-employed people and to compare these with the work-related outcomes of salaried survivors within each sample; and (iii) work-related outcomes for self-employed cancer survivors across countries. Methods Data from 11 samples from seven European countries were included. All samples had cross-sectional survey data on work outcomes in self-employed and salaried cancer survivors who were working at time of diagnosis (n = 22-261 self-employed/101-1871 salaried). The samples included different cancers and assessed different outcomes at different times post-diagnosis. Results Fewer self-employed cancer survivors took time off work due to cancer compared to salaried survivors. More self-employed than salaried survivors worked post-diagnosis in almost all countries. Among those working at the time of survey, self-employed survivors had made a larger reduction in working hours compared to pre-diagnosis, but they still worked more hours per week post-diagnosis than salaried survivors. The self-employed had received less financial compensation when absent from work post-cancer, and more self-employed, than salaried, survivors reported a negative financial change due to the cancer. There were differences between self-employed and salaried survivors in physical job demands, work ability and quality-of-life but the direction and magnitude of the differences differed across countries. Conclusion Despite sample differences, self-employed survivors more often continued working during treatment and had, in general, worse financial outcomes than salaried cancer survivors. Other work-related outcomes differed in different directions across countries.

Socioeconomic inequalities in survival of children with acute lymphoblastic leukemia insured by social security in Mexico: a study of the 2007-2009 cohorts

BACKGROUND

Although acute lymphoblastic leukemia (ALL) 5 years survival in minors has reached 90%, socioeconomic differences have been reported among and within countries. Within countries, the difference has been related to the socioeconomic status of the parents, even in the context of public health services with universal coverage. In Mexico, differences in the mortality of children with cancer have been reported among sociodemographic zones. The Instituto Mexicano del Seguro Social (IMSS), the country's main social security institution, has reported socioeconomic differences in life expectancy within its affiliated population. Here, the socioeconomic inequalities in the survival of children (< 15 years old) enrolled in the IMSS were analyzed.

METHODS

Five-year survival data were analyzed in cohorts of patients diagnosed with ALL during the period 2007-2009 in the two IMSS networks of medical services that serve 7 states of the central region of Mexico. A Cox proportional risk model was developed and adjusted for the socioeconomic characteristics of family, community of residence and for the clinical characteristics of the children. The slope of socioeconomic inequality of the probability of dying within five years after the diagnosis of ALL was estimated.

RESULTS

For the 294 patients studied, the 5 years survival rate was 53.7%; the median survival was 4.06 years (4.9 years for standard-risk diagnosis; 2.5 years for high-risk diagnosis). The attrition rate was 12%. The Cox model showed that children who had been IMSS-insured for less than half their lives had more than double the risk of dying than those who had been insured for their entire lives.

CONCLUSIONS

We did not find evidence of socioeconomic inequalities in the survival of children with ALL associated with family income, educational and occupational level of parents. However, we found a relevant gradient related social security protection: the longer children's life insured by social security, the higher their probability of surviving ALL was. These results add evidence of the effectiveness of social security, as a mechanism of wealth redistribution and a promoter of social mobility. Extending these social security benefits to the entire Mexican population could promote better health outcomes.

Social Assistance Payments and Food Insecurity inAustralia: Evidence from the HouseholdExpenditure Survey

It is widely understood that households with low economic resources and poor labour market attachment are at considerable risk of food insecurity in Australia. However, little is known about variations in food insecurity by receipt of specific classes of social assistance payments that are made through the social security system. Using newly released data from the 2016 Household Expenditure Survey, this paper reports on variations in food insecurity prevalence across a range of payment types. We further investigated measures of financial wellbeing reported by food-insecure households in receipt of social assistance payments. Results showed that individuals in receipt of Newstart allowance (11%), Austudy/Abstudy (14%), the Disability Support Pension (12%), the Carer Payment (11%) and the Parenting Payment (9%) were at significantly higher risk of food insecurity compared to those in receipt of the Age Pension (<1%) or no payment at all (1.3%). Results further indicated that food-insecure households in receipt of social assistance payments endured significant financial stress, with a large proportion co-currently experiencing “fuel” or “energy” poverty. Our results support calls by a range of Australian non-government organisations, politicians, and academics for a comprehensive review of the Australian social security system.

Alive or dead: Validity of the Social Security Administration Death Master File after 2011

OBJECTIVE

To determine the reliability of the Social Security Death Master File (DMF) after the November 2011 changes limiting the inclusion of state records.

DATA SOURCES

Secondary data from the DMF, New York State (NYS) and New Jersey (NJ) Vital Statistics (VS), and institutional data warehouse.

STUDY DESIGN

Retrospective study. Two cohorts: discharge date before November 1, 2011, (pre-2011) or after (post-2011). Death in-hospital used as gold standard. NYS VS used for out-of-hospital death. Sensitivity, specificity, Cohen's Kappa, and 1-year survival calculated.

DATA COLLECTION METHODS

Patients matched to DMF using Social Security Number, or date of birth and Soundex algorithm. Patients matched to NY and NJ VS using probabilistic linking.

PRINCIPAL FINDINGS

97 069 patients January 2007-March 2016: 39 075 pre-2011; 57 994 post-2011. 3777 (3.9 percent) died in-hospital. DMF sensitivity for in-hospital death 88.9 percent (κ = 0.93) pre-2011 vs 14.8 percent (κ = 0.25) post-2011. DMF sensitivity for NY deaths 74.6 percent (κ = 0.71) pre-2011 vs 26.6 percent (κ = 0.33) post-2011. DMF sensitivity for NJ deaths 62.6 percent (κ = 0.64) pre-2011 vs 10.8 percent (κ = 0.15) post-2011. DMF sensitivity for out-of-hospital death 71.4 percent pre-2011 (κ = 0.58) vs 28.9 percent post-2011 (κ = 0.34). Post-2011, 1-year survival using DMF data was overestimated at 95.8 percent, vs 86.1 percent using NYS VS.

CONCLUSIONS

The DMF is no longer a reliable source of death data. Researchers using the DMF may underestimate mortality.

The Effect of Lower Transaction Costs on Social Security Disability Insurance Application Rates and Participation

Transaction costs pose significant barriers to participation in public programs. We analyze how Social Security Disability Insurance (SSDI) application behavior was affected by iClaim, a 2009 innovation that streamlined the online application process. We use a difference-in-differences design to compare application rates before and after 2009 across counties with varying degrees of access to high-speed internet. We estimate that counties with internet connectivity one standard-deviation above the mean experienced a 1.6 percent increase in SSDI applications, and a 2.8 percent increase in appeals after the reform. We estimate that the increase in applications due to iClaim can explain 15 percent of the overall increase in applications between 2008 and 2011. Higher exposure to the online application led to a slightly larger increase in SSDI awards, meaning there was a small but significant increase in the overall award rate. Application rates increased the most in rural areas, while appeals and awards had more significant increases in urban areas. These results suggest that the online application reduced transaction costs to applicants, and the lower costs improved the overall targeting efficiency of the application process.

Longevity-Related Options for Social Security: a Microsimulation Approach to Retirement Age and Mortality Adjustments

We consider the distributional implications of Social Security policy changes in the context of increases in life expectancy and differential mortality. Using a robust microsimulation model, we examine how several options for raising the retirement age, including a scenario that applies a mortality adjustment in combination with such policies, affect different types of individuals and households. Policy changes are simulated for Social Security beneficiaries in 2030 using the Modeling Income in the Near Term (MINT) microsimulation model. The analysis shows that increasing either the age at which individuals receive their full retirement benefit alone or the early eligibility and full retirement ages together result in across-the-board reductions in benefit levels. The policies are projected to result in slightly higher poverty, but the expected rise is sharper among groups known to experience higher rates of mortality, as well as many disadvantaged groups. Analysis of a hypothetical adjustment to offset the historical impacts of differential mortality by lifetime earnings on lifetime benefit receipt, when combined with these retirement age increases, shows varied results. While some groups of individuals experience sharper reductions in median monthly benefits, the adjustment has an offsetting and protective effect for the benefits of disadvantaged groups when combined with options that would raise the retirement age. This combined package of policies, as well as simulations that incorporate a behavioral adjustment in benefit claiming ages, result in an increase of less than one percentage point in the average poverty rate.

Early Identification of Potential SSDI Entrants in California: The Predictive Value of State Disability Insurance and Workers' Compensation Claims

Purpose Examine the potential for using information in short-term disability claims to identify workers at high risk of leaving the workforce and entering Social Security Disability Insurance (SSDI). Methods We analyze state-wide California data on claimants of State Disability Insurance (SDI) and Workers' Compensation (WC) and present statistics on: (1) characteristics (primary diagnosis, sex, age, geography, wage level) by claim duration (0-3, 4-6, 7-12, 12 + months); and (2) the ability of initial claim characteristics to predict duration of at least 12 months. All data are for claims with disability lasting more than 1 week. Results 22.2% of SDI claims last longer than 6 months and 12.5% last 12 months. More WC claims reach these durations: 33.7 and 18.6%, respectively. Long-term SDI and WC claimants are similar to SSDI awardees, nationwide, but differ in age distribution; they are typically younger. Conclusions Characteristics of SDI and WC claims can help predict claims likely to last 12 months, but more information is needed to effectively target early intervention services. Waiting longer to intervene improves targeting but risks missing opportunities where early intervention could be more effective. Collecting additional information at SDI or WC entry or soon thereafter could improve both the efficiency and timing of interventions.

Analysis of Time in Rehabilitation and Incidence of Successful Rehabilitation Within Individuals with Disabilities Receiving Occupational/Vocational Training

Objective To investigate the incidence of successful rehabilitation, defined as 90 successive days in employment, within individuals with disabilities receiving occupational/vocational training (OVT) service. Method The follow-up records between January 1, 2004 and December 31, 2012 of 5313 individuals aged 15-55 who obtained OVT in the vocational rehabilitation (VR) program of the State of Illinois were examined. Cox regression models were used to analyze the effect of study factors on VR outcomes. Results After controlling for the other factors, males (incidence ratio [IR] 1.11, 95% CI 1.03-1.20), individuals with learning disability (IR 1.14, 95% CI 1.03-1.26), had existing employment (IR 1.40, 95% CI 1.26-1.56), and persons who were referred from educational institutions (IR 1.17, 95% CI 1.01-1.36) or community agencies (IR 1.30, 95% CI 1.14-1.48) appeared to have a relatively high incidence of successful rehabilitation. In contrast, those who lived in densely populated areas (IR ranged from 0.56 to 0.89), had physical disability (IR 0.77, 95% CI 0.68-0.88), had disability of most significant degree (IR 0.85, 95% CI 0.79-0.93), and persons with Supplemental Security Income/Social Security Disability Insurance supports (IR 0.84, 95% CI 0.76-0.94), tended to have a lower incidence of rehabilitation than their counterparts. Conclusion The incidence of successful rehabilitation seems to be related to the demographic, disability, and pre-service characteristics, but not necessarily the provider factors.

Does retirement improve health and life satisfaction?

We utilize panel data from the Health and Retirement Study to investigate the impact of retirement on physical and mental health, life satisfaction, and health care utilization. Because poor health can induce retirement, we instrument for retirement using eligibility for Social Security and employer-sponsored pensions and coverage by the Social Security earnings test. We find strong evidence that retirement improves reported health, mental health, and life satisfaction. In addition, we find evidence of improvements in functional limitations in the long run. Although the impact on life satisfaction occurs within the first 4 years of retirement, many of the improvements in health show up four or more years later, consistent with the view that health is a stock that evolves slowly. We find no evidence that the health improvements are driven by increased health care utilization. In fact, results suggest decreased utilization in some categories.

Indirect costs and public finance consequences of heart failure in Poland, 2012-2015

BACKGROUND

As a consequence of unfavourable epidemiological trends and the development of disease management, the economic aspects of heart failure (HF) have become more and more important. The costs of treatment (direct costs) appear to be the most frequently addressed topic in the economic research on HF; however, less is known about productivity losses (indirect costs) and the public finance burden attributable to the disease. Therefore, the aim of this study was to estimate the indirect costs and public finance consequences of HF in Poland in the period 2012-2015.

METHODS

The study uses a societal perspective and a prevalence-based top-down approach to estimate the following components of HF indirect costs: absenteeism of the sick and their caregivers, presenteeism of the sick, disability, and premature mortality. The human capital method has been chosen to identify the value of productivity losses attributable to HF and the public finance consequences of the disease. Deterministic sensitivity analysis was performed to assess the robustness of the results.

RESULTS

The total indirect costs of HF in Poland were €871.9 million in 2012, and they increased to €945.3 million in 2015. In the period investigated, these costs accounted for 0.212-0.224% of GDP, an equivalent of 22.63€-24.59€ per capita. Mortality proved to be the main driver of productivity losses, with 59.3-63.4% of the total costs depending on year, followed by presenteeism (21.1-22.5%), disability (11.1-14.2%) and the sick's absenteeism (3.3-4.0%). The cost of caregivers' absenteeism was unimportant. The social insurance expenditure for benefits associated with HF accounted for €40.7 million in 2012 and €45.6 million in 2015 (0.56-0.59% expenditure for all diseases). The potential public revenue losses associated with HF were €262.7-€287.9 million. Sensitivity analysis showed that the costs varied by - 12.1% to + 28.8% depending on the model parameter values.

CONCLUSION

HF is a substantial burden on the economy and public finance in Poland. By confronting the disease more effectively, the length and quality of life for those affected by HF could be improved, but society as a whole could also benefit from the increased economic output.

Attention Deficit Hyperactivity Disorder (ADHD) and its Comorbid Mental Disorders: An Evaluation of their Labor Market Outcomes

BACKGROUND

Attention-deficit/hyper-activity disorder's (ADHD) prevalence rate has been increasing during the last decade. Evidence from different studies suggests that the effect of ADHD on earnings and employment could be more detrimental than other disorders such as depression or anxiety. Although it is widely known that these mental disorders can coexist with ADHD, none of these studies has considered the joint evaluation of ADHD and its comorbidities.

OBJECTIVE

In this paper, we evaluate whether ADHD is a more severe disorder than three other comorbid mental disorders -- learning disabilities, depression, and anxiety -- regarding their effects on earnings and employment.

METHODS

We use the National Longitudinal Study of Adolescent to Adult Health to estimate regression models of earnings and employment. We consider the use of the sampling weights, school fixed effects, and multiple imputation of missing values. Robustness checks include a more exogenous measure of depression.

RESULTS

On average, an individual with ADHD or depression (but not both) has around 20% lower earnings than those without any of these disorders. The earnings gap for learning disabilities is around 25%. The probability of being employed is 5 percentage points lower for an individual who has any of these disorders. Anxiety is not associated with lower earnings. Females with learning disabilities have an earnings gap that is 20 percentage points larger than males. The employment gap for females or African Americans with learning disabilities is 8%.

DISCUSSION AND LIMITATIONS

In contrast to existing evidence, we find that ADHD is not more serious than learning disabilities or depression. Although the magnitude of each employment gap is not substantial, the fact that these are comorbid disorders indicates that their joint occurrence could be detrimental for employment. Females and African Americans with learning disabilities could face more adverse labor market outcomes. Even though our results are robust to a more exogenous measure of depression, the potential endogeneity of the diagnosis of ADHD or anxiety could still bias the estimates. However, baseline results are also robust when individuals with an age of diagnosis equal to the year of the interview are dropped from the estimations.

IMPLICATIONS FOR HEALTH POLICY AND FOR FUTURE RESEARCH

The increasing number of Supplemental Security Income beneficiaries with ADHD is in line with the observed tendency to screen for ADHD more frequently than for other comorbid disorders, and with the evidence of ADHD overdiagnosis. Since our study shows that other disorders are equally or potentially more disabling than ADHD in terms of labor market outcomes, mental health policies should be reoriented to prevent policies targeting ADHD from crowding out those for other mental disorders. It would be interesting to verify our findings using a more recent cohort with a higher rate of ADHD diagnosis. Since we show that there are unexplained gender and race differences that persist after controlling for educational attainment or the number of hours worked, more research is needed to determine the reason behind these differences. Further research about the positive school effect on the adulthood performance of ADHD children is needed.

The costs of diabetes among Australians aged 45-64 years from 2015 to 2030: projections of lost productive life years (PLYs), lost personal income, lost taxation revenue, extra welfare payments and lost gross domestic product from Health&WealthMOD2030

OBJECTIVES

To project the number of people aged 45-64 years with lost productive life years (PLYs) due to diabetes and related costs (lost income, extra welfare payments, lost taxation revenue); and lost gross domestic product (GDP) attributable to diabetes in Australia from 2015 to 2030.

DESIGN

A simulation study of how the number of people aged 45-64 years with diabetes increases over time (based on population growth and disease trend data) and the economic losses incurred by individuals and the government. Cross-sectional outputs of a microsimulation model (Health&WealthMOD2030) which used the Australian Bureau of Statistics' Survey of Disability, Ageing and Carers 2003 and 2009 as a base population and integrated outputs from two microsimulation models (Static Incomes Model and Australian Population and Policy Simulation Model), Treasury's population and labour force projections, and chronic disease trends data.

SETTING

Australian population aged 45-64 years in 2015, 2020, 2025 and 2030.

OUTCOME MEASURES

Lost PLYs, lost income, extra welfare payments, lost taxation revenue, lost GDP.

RESULTS

18 100 people are out of the labour force due to diabetes in 2015, increasing to 21 400 in 2030 (18% increase). National costs consisted of a loss of $A467 million in annual income in 2015, increasing to $A807 million in 2030 (73% increase). For the government, extra annual welfare payments increased from $A311 million in 2015 to $A350 million in 2030 (13% increase); and lost annual taxation revenue increased from $A102 million in 2015 to $A166 million in 2030 (63% increase). A loss of $A2.1 billion in GDP was projected for 2015, increasing to $A2.9 billion in 2030 attributable to diabetes through its impact on PLYs.

CONCLUSIONS

Individuals incur significant costs of diabetes through lost PLYs and lost income in addition to disease burden through human suffering and healthcare costs. The government incurs extra welfare payments, lost taxation revenue and lost GDP, along with direct healthcare costs.

[Incidence of diabetes from the perspective of social security benefits]

The article analyzes the development of the activity of Medical Assessment Service for people with diabetes mellitus for selected assessment categories in the assessment of health conditions from 2012 to 2016. The assessment criteria for assessing disability, the degree of dependency for care allowance and the health status for grant for special aid, and certificate of person with disability are set out in the legislation. The incidence of disability for diabetes declined by 13 % between 2012 and 2016 and by 10 % for the degree of dependency for care allowance. The assessment for grant for special aid increased by 57 %, for grant in the case when the aid is a "vehicle" decreased by 8 %. Most importantly increased assessing for certificate of person with disability by 150 %. The epidemic of diabetes in the population is not reflected in the incidence of disability and the degree of dependence. Both of these assessment categories were decreased, in spite of the fact that there account for almost 70 % of the whole assessment activity. The assessment for grant for special aid, and certificate of person with disability was increased. The cause may be due to incorrect statistical reporting, not up to date expert medical criteria, or poor patient awareness.

Scraping by: Income and Program Participation After the Loss of Extended Unemployment Benefits

Many Unemployment Insurance (UI) recipients do not find new jobs before exhausting their benefits, even when benefits are extended during recessions. Using Survey of Income and Program Participation (SIPP) panel data covering the 2001 and 2007 to 2009 recessions and their aftermaths, we identify individuals whose jobless spells outlasted their UI benefits (exhaustees) and examine household income, program participation, and health-related outcomes during the six months following UI exhaustion. For the average exhaustee, the loss of UI benefits is only slightly offset by increased participation in other safety net programs (e.g., food stamps), and family poverty rates rise substantially. Self-reported disability also rises following UI exhaustion. These patterns do not vary dramatically across household demographic groups, broad income level prior to job loss, or the two business cycles. The results highlight the unique, important role of UI in the U.S. social safety net.

Aging without Medicare? Evidence from New York City

Medicare and Social Security often are assumed to provide universal coverage for the population age 65 and older. Evidence from New York City raises doubts. Data from the Statewide Planning and Research Cooperative System, the Centers for Medicare and Medicaid Services, the Social Security Administration, and the U.S. Bureau of the Census provide evidence that 16% to 20% of New York City residents age 65 and older lack such coverage. Noncoverage is not unique to this city, but it may be particularly common there. Noncoverage is pronounced in, but not limited to, certain immigrant groups. Because the population share covered by Medicare increases with age and most hospitalizations not covered by Medicare are paid by Medicaid, Medicaid gradually may be replacing Medicare as the payer for hospitalizations for a substantial share of the 65+ population in New York City.

Return-to-Work Interval and Surgery for Carpal Tunnel Syndrome. Results of a Prospective Series of 233 Patients

Aim of the study

To evaluate the connection between the type of patient insurance and the time taken to return to work after carpal tunnel surgery.

Patients and methods

Two hundred and thirty-three patients in full-time work were operated on for carpal tunnel syndrome between 1 January and 30 June 1998. They were divided into three groups: independent workers ( n=87), wage earners in the private sector ( n=90) and civil servants ( n=56). Four categories were defined: manual workers, non-manual workers, patients with social security insurance and patients with workers compensation. The average return-to-work interval after surgery for each of the groups was evaluated and compared group by group.

Results

For independent workers the average time off work is 17 days, for those in the private sector it is 35 days, and for civil servants it is 56 days. Patients with social security insurance were off work for 32 days and those with workers compensation for 49 days.

Discussion

The comparison shows significant differences with regard to social security insurance: the return-to-work interval in civil servants is larger than for private sector workers, and this is higher than in independent workers. The difference between patients with workers compensation and those with social security insurance is 17 days and significant. There is a significant difference between manual and non-manual workers in independent and private sector workers. There is no significant difference between the sub-groups in the civil servants. These cross references enable us to work out the influence that social security status has on the return-to-work time following surgery.

Future marginalisation and mortality in young Swedish men with non-psychotic psychiatric disorders and the resilience effect of cognitive ability: a prospective, population-based study

OBJECTIVE

Large-scale studies examining future trajectories of marginalisation and health in adolescents with mental illness are scarce. The aim of this study was to examine if non-psychotic psychiatric disorders (NPDs) were associated with future indicators of marginalisation and mortality. We also aimed to determine whether these associations might be mediated by education level and attenuated by high cognitive ability.

DESIGN

This is a prospective cohort study with baseline data from the Swedish Conscription register.

SETTING

The study was carried out in Sweden from 1969 to 2005.

PARTICIPANTS

All of the participants were 18-year-old men at mandatory conscription in Sweden between 1969 and 2005 (n=1 609 690).

MEASURES

NPDs were clinically diagnosed at conscription. Cognitive ability was measured by a standardised IQ test at conscription. National register data covered information on welfare support, long-term unemployment, disability pension (DP) and mortality over a period of 1-36 years.

RESULTS

NPD at the age of 18 years was a predictor of future welfare support, OR 3.73 (95% CI 3.65 to 3.80); long-term unemployment, OR 1.97 (95% CI 1.94 to 2.01); DP, HR 2.95 (95% CI 2.89 to 3.02); and mortality, HR 2.45 (2.33-2.52). The adjusted models suggested that these associations were not confounded by fathers' educational level, cognitive ability had only a minor attenuating effect on most associations and the mediating effect of own educational level was small.

CONCLUSIONS

The present study underlines a higher prevalence of future adversities in young men experiencing NPDs at the age of 18 years. It also indicates that higher cognitive ability may work as a potential resilience factor against future marginalisation and mortality.

Identifying patients with cost-related medication non-adherence: a big-data approach

BACKGROUND

Millions of Americans encounter access barriers to medication due to cost; however, to date, there is no effective screening tool that identifies patients at risk of cost-related medication non-adherence (CRN).

OBJECTIVE

By utilizing a big-data approach to combining the survey data and electronic health records (EHRs), this study aimed to develop a method of identifying patients at risk of CRN.

METHODS

CRN data were collected by surveying patients about CRN behaviors in the past 3 months. By matching the dates of patients' receipt of monthly Social Security (SS) payments and the dates of prescription orders for 559 Medicare beneficiaries who were primary SS claimants at high risk of hospitalization in an urban academic medical center, this study identified patients who ordered their outpatient prescription within 2 days of receipt of monthly SS payments in 2014. The predictive power of this information on CRN was assessed using multivariate logistic regression analysis.

RESULTS

Among the 559 Medicare patients at high risk of hospitalization, 137 (25%) reported CRN. Among those with CRN, 96 (70%) had ordered prescriptions on receipt of SS payments one or more times in 2014. The area under the Receiver Operating Curve was 0.70 using the predictive model in multivariate logistic regression analysis.

CONCLUSION

With a new approach to combining the survey data and EHR data, patients' behavior in delaying filling of prescription until funds from SS checks become available can be measured, providing some predictive value for cost-related medication non-adherence. The big-data approach is a valuable tool to identify patients at risk of CRN and can be further expanded to the general population and sub-populations, providing a meaningful risk-stratification for CRN and facilitating physician-patient communication to reduce CRN.

Life Expectancy Among U.S.-born and Foreign-born Older Adults in the United States: Estimates From Linked Social Security and Medicare Data

In recent decades, the geographic origins of America's foreign-born population have become increasingly diverse. The sending countries of the U.S. foreign-born vary substantially in levels of health and economic development, and immigrants have arrived with distinct distributions of socioeconomic status, visa type, year of immigration, and age at immigration. We use high-quality linked Social Security and Medicare records to estimate life tables for the older U.S. population over the full range of birth regions. In 2000-2009, the foreign-born had a 2.4-year advantage in life expectancy at age 65 relative to the U.S.-born, with Asian-born subgroups displaying exceptionally high longevity. Foreign-born individuals who migrated more recently had lower mortality compared with those who migrated earlier. Nonetheless, we also find remarkable similarities in life expectancy among many foreign-born subgroups that were born in very different geographic and socioeconomic contexts (e.g., Central America, western/eastern Europe, and Africa).

Sickness impact in people with muscular dystrophy: a longitudinal study over 10 years

Objective: To describe changes of function in terms of sickness impact over 10 years in adult patients with different types of muscular dystrophy.

Design: Patients with muscular dystrophy answered the Sickness Impact Profile and Self-report ADL questionnaires in 1991 and 2001.

Setting: The study population was identified in a comprehensive prevalence study in the county of Örebro, Sweden.

Subjects: The study group comprised 44 people grouped according to whether they had myotonic dystrophy or muscular dystrophy with proximal or distal muscles affected.

Main measures: Comparison was made between assessments of sickness impact in terms of function at the two time points.

Results: Most obvious deterioration over time was in activities of daily living that require finger and arm strength. Ambulation was significantly decreased in myotonic dystrophy and proximal muscular dystrophy. Those walking without assistive devices decreased from 91% to 52%, and the number with a disability pension increased from 36 to 55%. There was a relatively small influence with regard to psychosocial dysfunction assessed by the Sickness Impact Profile.

Conclusions: This longitudinal study shows the deteriorating functions reported by patients with muscular dystrophy. This knowledge could be used to formulate new interventions in order to offer appropriate support and treatment to this patient group.

Using Big Data to Assess Prescribing Patterns in Greece: The Case of Chronic Obstructive Pulmonary Disease

Introduction

Chronic Obstructive Pulmonary Disease (COPD) is one of the top leading causes of death and disability, and its management is focused on reducing risk factors, relieving symptoms, and preventing exacerbations. The study aim was to describe COPD prescribing patterns in Greece by using existing health administrative data for outpatients.

Methods

This is a retrospective cross-sectional study based on prescriptions collected by the largest social insurance fund, during the first and last trimester of 2012. Selection criteria were the prescription of specific active substances and a COPD diagnosis. Extracted information included active substance, strength, pharmaceutical form and number of packages prescribed, diagnosis, time of dispensing, as well as insurees’ age, gender, percentage of co-payment and social security unique number. Statistical analysis included descriptive statistics and logistic regression.

Results

174,357 patients received medicines for COPD during the study period. Patients were almost equally distributed between male and female, and age above 55 years was strongly correlated with COPD. Most patients received a long-acting beta agonist plus inhaled corticosteroid combination (LABA +ICS), followed by long-acting muscarinic agonist (LAMA). 63% patients belonging in the 35–54 age received LABA+ICS. LAMA was prescribed more frequently among males and was strongly correlated with COPD.

Conclusion

The study provides big data analysis of Greek COPD prescribing patterns. It highlights the need for appropriate COPD classification in primary care illustrating the role of electronic prescribing in ensuring appropriate prescribing. Moreover, it indicates possible gender differences in treatment response or disease severity, and the impact of statutory co-payments on prescribing.

Factors Associated with Long-Term Sickness Absence Due to Mental Disorders: A Cohort Study of 7.112 Patients during the Spanish Economic Crisis

Background

Mental health problems are very common and often lead to prolonged sickness absence, having serious economic repercussions for most European countries. Periods of economic crisis are important social phenomena that are assumed to increase sickness absence due to mental disorders, although research on this topic remains scarce. The aim of this study was to gather data on long-term sickness absence (and relapse) due to mental disorders in Spain during a period of considerable socio-economic crisis.

Methods

Relationships were analyzed (using chi-squared tests and multivariate modelling via binary logistic regression) between clinical, social/employment-related and demographic factors associated and long-term sickness absence (>60 consecutive days) due to mental disorders in a cohort of 7112 Spanish patients during the period 2008–2012.

Results

Older age, severe mental disorders, being self-employed, having a non-permanent contract, and working in the real estate and construction sector were associated with an increased probability of long-term sickness absence (gender had a mediating role with respect to some of these variables). Relapses were associated with short-term sick leave (return to work due to ‘improvement’) and with working in the transport sector and public administration.

Conclusions

Aside from medical factors, other social/employment-related and demographic factors have a significant influence on the duration of sickness absence due to mental disorders.

[Social security and labor absenteeism in a regional health service]

BACKGROUND

Absenteism can generate important economic costs.

AIM

To analyze the determinants of the time off work for sick leaves granted to workers of a regional health service.

MATERIAL AND METHODS

Information about 2033 individuals, working at a health service, that were granted at least one sick leave during 2012, was analyzed. Personal identification was censored. Special emphasis was given to the type of health insurance system of the workers (public or private).

RESULTS

Workers ascribed to the Chilean public health insurance system (FONASA) had 11 days more off work than their counterparts ascribed to private health insurance systems. A higher amount of time off work was observed among older subjects and women.

CONCLUSIONS

Age, gender and the type of health insurance system influence the number of day off work due to sick leaves.

[Musculoskeletal pain in Central American workers: results of the First Survey on Working Conditions and Health in Central America]

OBJECTIVE

Examine the prevalence of musculoskeletal pain (MSP) in the six Spanish-speaking countries of Central America using a single standardized instrument, the First Survey on Working Conditions and Health in Central America in workers from all manual and non-manual labor sectors, using social security coverage as an indicator of formal versus informal employment.

METHODS

The workers (n = 12 024) were surveyed in their homes. The age-adjusted prevalence of MSP during the previous month was calculated for pain in the back (upper, or cervical; middle, or thoracic; and lower, or lumbar) and arm joints (shoulder, elbow, and wrist). Prevalence was estimated by sex, occupation (manual or non-manual), economic sector (agriculture, industry, or services), and social security coverage. Poisson regression models were used to calculate the prevalence rates and 95% confidence intervals, with stratification by country and anatomical site.

RESULTS

By sites, the age-adjusted prevalence of cervical-dorsal MSP was the highest, especially in El Salvador (47.8%) and Nicaragua (45.9%), and lumbar MSP was less prevalent, especially in Panama (12.8%) and Guatemala (14.8%). After additional adjustments, the prevalence of MSP was higher in women and manual workers for all the sites and in all the countries. There were no differences in MSP in terms of social security coverage or sector of economic activity.

CONCLUSIONS

The high prevalence of MSP in Central America, regardless of sector of activity or social security coverage, indicates that the prevention of MSP should be a priority in occupational health programs in low- and middle-income countries, especially for women and manual workers.

Incorporating the Last Four Digits of Social Security Numbers Substantially Improves Linking Patient Data from De-identified Hospital Claims Databases

OBJECTIVE

Assess algorithms for linking patients across de-identified databases without compromising confidentiality.

DATA SOURCES/STUDY SETTING

Hospital discharges from 11 Mayo Clinic hospitals during January 2008-September 2012 (assessment and validation data). Minnesota death certificates and hospital discharges from 2009 to 2012 for entire state (application data).

STUDY DESIGN

Cross-sectional assessment of sensitivity and positive predictive value (PPV) for four linking algorithms tested by identifying readmissions and posthospital mortality on the assessment data with application to statewide data.

DATA COLLECTION/EXTRACTION METHODS

De-identified claims included patient gender, birthdate, and zip code. Assessment records were matched with institutional sources containing unique identifiers and the last four digits of Social Security number (SSNL4).

PRINCIPAL FINDINGS

Gender, birthdate, and five-digit zip code identified readmissions with a sensitivity of 98.0 percent and a PPV of 97.7 percent and identified postdischarge mortality with 84.4 percent sensitivity and 98.9 percent PPV. Inclusion of SSNL4 produced nearly perfect identification of readmissions and deaths. When applied statewide, regions bordering states with unavailable hospital discharge data had lower rates.

CONCLUSION

Addition of SSNL4 to administrative data, accompanied by appropriate data use and data release policies, can enable trusted repositories to link data with nearly perfect accuracy without compromising patient confidentiality. States maintaining centralized de-identified databases should add SSNL4 to data specifications.

Informal employment and health status in Central America

BACKGROUND

Informal employment is assumed to be an important but seldom studied social determinant of health, affecting a large number of workers around the world. Although informal employment arrangements constitute a permanent, structural pillar of many labor markets in low- and middle-income countries, studies about its relationship with health status are still scarce. In Central America more than 60% of non-agricultural workers have informal employment. Therefore, we aimed to assess differences in self-perceived and mental health status of Central Americans with different patterns of informal and formal employment.

METHODS

Employment profiles were created by combining employment relations (employees, self-employed, employers), social security coverage (yes/no) and type of contract--only for employees--(written, oral, none), in a cross-sectional study of 8,823 non-agricultural workers based on the I Central American Survey of Working Conditions and Health of 2011. Using logistic regression models, adjusted odds ratios (aOR) by country, age and occupation, of poor self-perceived and mental health were calculated by sex. Different models were first fitted separately for the three dimensions of employment conditions, then for employment profiles as independent variables.

RESULTS

Poor self-perceived health was reported by 34% of women and 27% of men, and 30% of women and 26% of men reported poor mental health. Lack of social security coverage was associated with poor self-perceived health (women, aOR: 1.38, 95% CI: 1.13-1.67; men, aOR: 1.36, 95% CI: 1.13-1.63). Almost all employment profiles with no social security coverage were significantly associated with poor self-perceived and poor mental health in both sexes.

CONCLUSIONS

Our results show that informal employment is a significant factor in social health inequalities among Central American workers, which could be diminished by policies aimed at increasing social security coverage.

Examining Trends and Coexisting Conditions Among Children Qualifying for SSI Under ADHD, ASD, and ID

OBJECTIVE

To examine the prevalence trends and coexisting conditions in attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and intellectual disability (ID) in the pediatric Supplemental Security Income (SSI) population and general population.

METHODS

The Social Security Administration (SSA) provided data on primary and secondary diagnoses of children qualifying for SSI for years 2000 to 2011. We compared SSA data with 2000-2011 National Health Interview Survey data on the prevalence of mental health diagnoses among children in the general population living between 0 and 199% of the federal poverty line. We utilized linear regression analysis to test the statistical significance of differences in the trends of the conditions' prevalence.

RESULTS

Over this time period, the SSI population experienced increases in ADHD (5.8%) and ASD (7.2%) and a decrease in ID (-10.3%). Comparison with change in the general population indicated no significant difference in ADHD but significant differences in ASD and ID. Relative percentage changes reflect similar changes. The SSI population qualifying for SSI with ADHD (70.8%) had higher rates of coexisting conditions than the general population (66.1%), but lower rates of coexisting conditions for ASD and ID.

CONCLUSIONS

ADHD is on the rise among children receiving SSI and in the general population. This suggests that the rise of ADHD in the SSI population is expected and does not represent a misallocation of resources. Changes described among the SSI population in ASD and ID may allude to diagnostic/coding trends and/or true changes in prevalence. Limitations arise from the comparability of the 2 data sets.

The use of VA Disability Compensation and Social Security Disability Insurance among working-aged veterans

BACKGROUND

Although there is substantial disability among veterans, relatively little is known about working-aged veterans' uptake of Department of Veterans Affairs (VA) Disability Compensation and Social Security Disability Insurance (DI).

OBJECTIVES

This study identifies levels of veteran participation in VA disability and/or DI benefit programs, examines transitions into and out of VA and DI programs among veterans, and estimates the size and composition of the veteran population receiving VA and/or DI benefits over time.

METHODS

Data from the 1992, 1993, 1996, 2001, 2004, and 2008 Survey of Income and Program Participation (SIPP) are used to describe VA and DI program participation among veterans under the age of 65.

RESULTS

The majority of working-aged veterans do not receive VA or DI benefits and joint participation is low, but use of these programs has increased over time. A higher percentage of veterans receive VA compensation, which ranges from 4.9% in 1992 to 13.2% in 2008, than DI compensation, which ranges from 2.9% in 1992 to 6.7% in 2008. The rate of joint participation ranges from less than 1% in 1992 to 3.6% in 2008. Veterans experience few transitions between VA and DI programs during the 36-48 months they are observed. The number of veterans receiving benefits from VA and/or DI nearly doubled between 1992 and 2008. There have been substantial shifts in the composition of veterans using these programs, as cohorts who served prior to 1964 are replaced by those who served after 1964.

CONCLUSIONS

The findings suggest potential gaps in veterans' access to disability programs that might be addressed through improved coordination of VA and DI benefits.

Cumulative expenditures under the DI, SSI, Medicare, and Medicaid programs for a cohort of disabled working-age adults

OBJECTIVE

To estimate cumulative DI, SSI, Medicare, and Medicaid expenditures from initial disability benefit award to death or age 65.

DATA SOURCES

Administrative records for a cohort of new CY2000 DI and SSI awardees aged 18-64.

STUDY DESIGN

Actual expenditures were obtained for 2000-2006/7. Subsequent expenditures were simulated using a regression-adjusted Markov process to assign individuals to annual disability benefit coverage states. Program expenditures were simulated conditional on assigned benefit coverage status. Estimates reflect present value of expenditures at initial award in 2000 and are expressed in constant 2012 dollars. Expenditure estimates were also updated to reflect benefit levels and characteristics of new awardees in 2012.

DATA COLLECTION

We matched records for a 10 percent nationally representative sample.

PRINCIPAL FINDINGS

Overall average cumulative expenditures are $292,401 through death or age 65, with 51.4 percent for cash benefits and 48.6 percent for health care. Expenditures are about twice the average for individuals first awarded benefits at age 18-30. Overall average expenditures increased by 10 percent when updated for a simulated 2012 cohort.

CONCLUSIONS

Data on cumulative expenditures, especially combined across programs, are useful for evaluating the long-term payoff of investments designed to modify entry to and exit from the disability rolls.

The effects of income on mental health: evidence from the social security notch

BACKGROUND

Mental health is a key component of overall wellbeing and mental disorders are relatively common, including among older adults. Yet the causal effect of income on mental health status among older adults is poorly understood.

AIMS

This paper considers the effects of a major source of transfer income, Social Security retirement benefits, on the mental health of older adults.

METHODS

The Social Security benefit "Notch" is as a large, permanent, and exogenous shock to Social Security income in retirement. The "Notch" is used to identify the causal effect of Social Security income on mental health among older ages using data from the AHEAD cohort of the Health and Retirement Study.

RESULTS

We find that increases in Social Security income significantly improve mental health status and the likelihood of a psychiatric diagnosis for women, but not for men.

DISCUSSION

The effects of income on mental health for older women are statistically significant and meaningful in magnitude. While this is one of the only studies to use plausibly exogenous variation in household income to identify the effect of income on mental health, a limitation of this work is that the results only directly pertain to lower-education households.

IMPLICATIONS

Public policy proposals that alter retirement benefits for the elderly may have important effects on the mental health of older adults.

Crowding out of long-term care insurance: evidence from European expectations data

Long-term care (LTC) is the largest insurable risk that old-age individuals face in most western societies. However, the demand for LTC insurance is still ostensibly small in comparison with the financial risk. One explanation that has received limited support is that expectations of either 'public sector funding' and 'family support' crowd out individual incentives to seek insurance. This paper aims to investigate further the aforementioned motivational crowding-out hypothesis by developing a theoretical model and by drawing on an innovative empirical analysis of representative European survey data containing records on individual expectations of LTC funding sources (including private insurance, social insurance, and the family). The theoretical model predicts that, when informal care is treated as exogenously determined, expectations of both state support and informal care can potentially crowd out LTC insurance expectations, while this is not necessarily the case when informal care is endogenous to insurance, as happens when intra-family moral hazard is integrated in the insurance decision. We find evidence consistent with the presence of family crowding out but no robust evidence of public sector crowding out.

Do generous unemployment benefit programs reduce suicide rates? A state fixed-effect analysis covering 1968-2008

The recent economic recession has led to increases in suicide, but whether US state unemployment insurance programs ameliorate this association has not been examined. Exploiting US state variations in the generosity of benefit programs between 1968 and 2008, we tested the hypothesis that more generous unemployment benefit programs reduce the impact of economic downturns on suicide. Using state linear fixed-effect models, we found a negative additive interaction between unemployment rates and benefits among the US working-age (20-64 years) population (β = -0.57, 95% confidence interval: -0.86, -0.27; P < 0.001). The finding of a negative additive interaction was robust across multiple model specifications. Our results suggest that the impact of unemployment rates on suicide is offset by the presence of generous state unemployment benefit programs, though estimated effects are small in magnitude.

Association between lumbopelvic pain, disability and sick leave during pregnancy – a comparison of three Scandinavian cohorts

OBJECTIVE

To explore the association between disability and sick leave due to lumbopelvic pain in pregnant women in 3 cohorts in Sweden and Norway and to explore possible factors of importance to sick leave. A further aim was to compare the prevalence of sick leave due to lumbopelvic pain.

DESIGN/SUBJECTS

Pregnant women (n = 898) from two cohorts in Sweden and one in Norway answered to questionnaires in gestational weeks 10–24; two of the cohorts additionally in weeks 28–38.

METHODS

Logistic regression models were performed with sick leave due to lumbopelvic pain as dependent factor. Disability, pain, age, parity, cohort, civilian status, and occupational classification were independents factors.

RESULTS

In gestational weeks 10–24 the regression model included 895 cases; 38 on sick leave due to lumbopelvic pain. Disability, pain and cohort affiliation were associated with sick leave. In weeks 28–38, disability, pain and occupation classification were the significant factors. The prevalence of lumbopelvic pain was higher in Norway than in Sweden (65%, vs 58% and 44%; p < 0.001).

CONCLUSION

Disability, pain intensity and occupation were associated to sick leave due to lumbopelvic pain. Yet, there were significant variations between associated factors among the cohorts, suggesting that other factors than workability and the social security system are also of importance.

Unemployment under the flex job scheme increases the risk of permanent social security benefits

INTRODUCTION

In Denmark, a flex job scheme was introduced in 1998 in the expectation that more people could remain in the workforce despite a reduced working capacity. The aim of this study was to characterise the group that did not obtain a flex job after having been included in the flex job scheme.

MATERIAL AND METHODS

Persons included in the flex job scheme from 1 January 2001 to 30 March 2008 were identified via the Ministry of Employment's DREAM register. Data were linked to Statistics Denmark and The Danish National Patient Registry. Among the individuals who did not obtain employment in a flex job within the first three months, we identified those who did not obtain employment before they were transferred to disability pension or flex benefit.

RESULTS

A total of 74,277 persons were included in the flex job scheme. Among these persons 33% received unemployment benefit for more than three months and the rest obtained a flex job within the first three months. Overall, 23% of the unemployment benefit recipients never entered the labour market, but were awarded early retirement pension or flex benefit. This percentage varied among different socio-demographic variables and regions.

CONCLUSION

The present study demonstrates that attention should be paid to the flex job scheme, especially for those who do not obtain employment within the first three months.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

What causes EBRI retirement readiness ratings to vary: results from the 2014 Retirement Security Projection Model

RETIREMENT INCOME ADEQUACY IMPROVED SLIGHTLY IN 2013: Due to the increase in financial market and housing values during 2013, the probability that Baby Boomers and Generation Xers would NOT run short of money in retirement increases between 0.5 and 1.6 percentage points, based on the Employee Benefit Research Institute (EBRI) Retirement Readiness Ratings (RRRs). ELIGIBILITY FOR PARTICIPATION IN AN EMPLOYER-SPONSORED DEFINED CONTRIBUTION PLAN REMAINS ONE OF THE MOST IMPORTANT FACTORS FOR RETIREMENT INCOME ADEQUACY: RRR values double for Gen Xers in the lowest-income quartile when comparing those with 20 or more years of future eligibility with those with no years of future eligibility, while those in the middle income quartiles experience increases in RRR values by 27.1-30.3 percentage points. FUTURE SOCIAL SECURITY BENEFITS MAKE A HUGE DIFFERENCE FOR THE RETIREMENT INCOME ADEQUACY OF SOME HOUSEHOLDS, ESPECIALLY GEN XERS IN THE LOWEST-INCOME QUARTILE: If Social Security benefits are subject to proportionate decreases beginning in 2033 (according to the values in Figure 8), the RRR values for those households will drop by more than 50 percent: from 20.9 percent to 10.3 percent. LONGEVITY RISK AND STOCHASTIC HEALTH CARE RISK ARE ASSOCIATED WITH HUGE VARIATIONS IN RETIREMENT INCOME ADEQUACY: For both of these factors, a comparison between the most "risky" quartile with the least risky quartile shows a spread of approximately 30 percentage points for the lowest income range, approximately 25 to 40 percentage points for the highest income range, and even larger spreads for those in the middle income ranges. A GREAT DEAL OF THE VARIABILITY IN RETIREMENT INCOME ADEQUACY COULD BE MITIGATED BY APPROPRIATE RISK-MANAGEMENT TECHNIQUES AT OR NEAR RETIREMENT AGE: For example, the annuitization of a portion of the defined contribution and IRA balances may substantially increase the probability of not running short of money in retirement. Moreover, a well-functioning market in long-term care insurance would appear to provide an extremely useful technique to help control the volatility from the stochastic, long-term health care risk, especially for those in the middle income quartiles.