Work Hour Limitations for Interns and Residents: Good or Bad for Patients?

A great piece by Sandeep Jauhar in Slate explores the effects of work hour limitations for medical residents on patient care. The article highlights trade-offs inherent in these policies. On the one hand, sleepy residents make more mistakes. On the other, work restrictions that reduce the total number of hours worked among all residents encourage the use of cross-cover mechanisms (the article talks a lot about night float) which may reduce the continuity of care. This, too, may adversely affect patient care if continuity is important. As Jauhar points out, the ultimate impact of work hour restrictions comes down to an empirical question, and the available evidence appears mixed.

The discontinuous introduction of residency work hour restrictions nationwide, as well as the random assignment of interns and residents to regular and night-float shifts, can be exploited to study the impact of both work hour restrictions as well as different cross-cover mechanisms. With such a transparent identification strategy available, I'm surprised that only two major studies have been done on this issue (even more so since the meta-evidence is inconclusive). Perhaps it is difficult to find data on outcomes or on how the time of residents is allocated?

I'd be curious to start looking at some new data on this if anyone is interested.

Air Pollution and Infant Health

A recent working paper by Janet Currie and collaborators finds the following:

We examine the impact of three "criteria" air pollutants on infant health in New Jersey in the 1990s by combining information about mother's residential location from birth certificates with information from air quality monitors. In addition to large sample size, our work offers three important innovations: First, because we know the exact addresses of mothers, we select those mothers closest to air monitors to ensure a more accurate measure of air quality. Second, since we follow mothers over time, we control for unobserved characteristics of mothers using maternal fixed effects. Third, we examine interactions of air pollution with smoking and other predictors of poor infant health outcomes. We find consistently negative effects of exposure to pollution, especially carbon monoxide, both during and after birth. The effects are considerably larger for smokers than for nonsmokers as well as for older mothers. Since automobiles are the main source of carbon monoxide emissions, our results have important implications for regulation of automobile emissions.

See here for an earlier post on the subject, discussing a paper looking at the relationship between pollution from forest fires and infant mortality.

Do Better Trained Physicians Provide Better Care?

A while back, I blogged about how medical care varies in quality and quantity across different areas in the United States, as well as the reasons why such "small area variation" might exist. This post looks at the same topic but from a slightly different perspective: to what extent can differences in physician quality (where they were trained and where they currently work) explain the variance in medical care seen across groups of patients and regions?

This isn't an easy question to answer: getting at causal effects of physician quality is really hard. For example, an association between patient outcomes and physician quality could simply reflect the fact that wealthier or smarter patients, who are better able to translate directions from their physician to better health outcomes, happen to choose better doctors themselves. As such, conventional estimates using observational data may be biased.

In a very clever study, Joseph Doyle and co-authors get around this selection issue using a natural experiment methodology. In particular, they utilize the randomization of patients in the Veterans Affairs (VA) system to clinical teams from two academic medical centers. One center happens to be very highly rated and the other not so much. Their results suggest that physician quality matters in terms of costs and length of stay, though not so much for ultimate health outcomes:

Those treated by physicians from the higher-ranked institution have 10-25% shorter and less expensive stays than patients assigned to the lower-ranked institution. Health outcomes are not related to the physician team assignment, and the estimates are precise. Procedure differences across the teams are consistent with the ability of physicians in the lower-ranked institution to substitute time and diagnostic tests for the faster judgments of physicians from the top-ranked institution.

Interesting stuff.

Contest Winners

Hi all. This summer's 'Dar he Blogs winners are Christi H and James Hudspeth, for the professional eating and p-value contests, respectively. I thought Christi's answer really hit it on all cylinders as far as pointing out the physical and mental strength required to succeed in competitive eating. James ran unopposed in his contest. While I didn't quite get the answer I wanted, he did alert me to "The Lady Tasting Tea," which is turning out to be a great book (anyone interested in a breezy account of how statistics has contributed to the practice of science in the 20th century must absolutely read this book!).

Christi and James: Congrats, and get in touch with me about your prize, which will be a popular economics book of your choice.

Contest Reminder!

You have until Saturday (the 19th) morning to submit your entries for the "Competitive Eating" and "P-value" contests. The prizes are excellent and are outlined in the second link (and see here for proof that I actually deliver on the prizes).

Bring it.

Economics of Love

A good friend, Rucheeta Kulkarni, sent me this interesting piece by Ben Stein. My sense is that it takes basic (I mean, VERY basic) concepts from neoclassical theory to generate some insights on how to approach relationships.

One thing I'd like to see is parallel piece from the standpoint of behavioral economics. Many people systematically DO NOT follow Stein's advice and it would be worth understanding (the patterns underlying) why. Hmmm....now THAT would make for a good column in Cosmo, Maxim, etc.

Corruption in India

Neil Vaishnavi (of Wash U fame) sent me this interesting article from CNN on corruption in India. The main thrust is that a third of individuals below the poverty line pay bribes in order "to file a police report, to enroll a child in school, to admit a family member into a hospital or to get electricity turned on." All of these are public services that are theoretically provided free of charge. Regarding hospitals more specifically, a 2005 report from Transparency International India suggests that corruption, on a per visit basis, is most rampant here, in comparison to other institutions such as schools.

There are two questions that arise when thinking about corruption. First, is it efficient? Does corruption sufficiently grease the wheels and create an effective price in markets with artificial price ceilings? Or do the negatives of corruption outweigh these positive effects. See here for a great discussion, peppered with some experimental evidence from India.

Another question: who bears the larger burden of corruption - the rich or the poor? There a two ways to look at this. The first is in the strict income sense: does the fraction of one's income allocated to bribes vary for the rich vis-a-vis the poor? Or is the marginal bribe dollar or rupee more valuable to one socioeconomic group or the other? The latter question gets at the second issue: do rich willingly pay bribes out of convenience, whereas the poor are coerced? As mentioned in an earlier post, Paul Lagunes, Brian Fried (both of the Yale Political Science department) and I tried to get at this with an audit study of traffic officers in Latin America. We fix the interactions so as to rule out the convenience story and found that traffic officers more frequently targeted lower class drivers for bribes than their upper class counterparts. The expected bribe payment appeared to be the same across both groups, which leads us to believe that corruption, at least in this context, might be regressive.

The One Year Mark

Today marks the 1 year anniversary of 'Dar he blogs. I just wanted to thank everyone for reading and for posting such thoughtful comments. This whole outfit started as a travel blog, but now has taken on a life of its' own. I definitely plan on continuing the blog for at least another year.

Anyhow, I've had a lot of fun doing this, and I hope you've enjoyed the blog, too. Thanks again for reading.

Contest: Is Professional Eating a Sport?

Along with America's birthday (though not really?), July 4th is also home to another fun spectacle: the Nathan's Famous Hot Dog Eating Contest. For those of you not in the know, the winner of the contest is the man or woman who can eat the most buns and franks in a 12 minute span. In recent years, this contest has been dominated by Takeru Kobeyashi, a Japanese man who looks more like an ultimate fighter contestant than someone who is capable of packing in 60 buns and franks in 12 minutes. In 2007, after winning six Nathan's contests in a row, Kobeyashi was upended by American Joey "Jaws" Chestnut, 66 - 63. Prior to this defeat, the string of victories led some observers to suggest that Kobeyashi was, relative to his sport, the greatest and most dominant athlete in the world.

And herein lies the motivation for this contest: is professional eating a "real" sport? Whoever makes the best argument for or against will receive a prize (details here, which also links you to my other summer contest). As always, the only parameters for the prize winning entry is that I have to like it, so you are open to argue by induction, analogy, contradiction, whatever. Please leave your entry as a comment; the contest closes two weeks from today.

Finally, be sure to watch the 2008 Nathan's contest, noon eastern on ESPN.

Alcohol Use and Mortality in Mexico

There is a well-crafted and important paper by Gretchen Stevens and coauthors on the leading causes of death and their attributable factors in Mexico in the June 2008 issue of PLoS Medicine. Here's the punchline:

Mexico is at an advanced stage in the epidemiologic transition, with the majority of the disease and injury burden from noncommunicable diseases. A unique characteristic of the epidemiological transition in Mexico is that overweight and obesity, high blood glucose, and alcohol use are responsible for larger burden of disease than other noncommunicable disease risks such as tobacco smoking. The Southern region is least advanced in the epidemiological transition and suffers from the largest burden of ill health in all disease and injury groups.

Alcohol use holds the plurality share of all deaths among men, with obesity and high blood glucose (separately) close behind. This is certainly different than the pattern in the United States: alcohol abuse comes in a fairly distant third behind tobacco use and diet/physical inactivity. Myself and several others I spoke to regarding this were rather surprised by the Mexican statistics: we hear so much about Mexico being on its way becoming the world's fattest nation, but little about its' alcohol use. Perhaps another example of a single issue hijacking the policy agenda?

Interestingly, alcohol use appears to be responsible for a non-trivial percentage of female deaths as well (though this number is well below obesity and associated metabolic conditions). Sadly, the authors of the paper point out that much of it may be secondary to abuse from men who abuse alcohol.

As with the literature in the United States, I wonder if there are studies using Mexican data that use time and cross-sectional variation in alcohol laws to identify the causal impacts of public policy (via alcohol use) on domestic violence, crime, etc. A quick Google search on this revealed little. However, I did find this interesting piece by Manuela Angelucci, examining the relationship between income and alcohol use and use related violence towards women. To identify the causal effect of income, the paper uses shocks from (then) randomly assigned access to the Oportunidades conditional cash transfer program (which pay women for meeting targets in child and household health, education, etc) and weather and natural disaster shocks that affect rural households. She finds that the marginal peso accruing to women leads to significant decreases in their partners' alcohol use and violent behavior. The effect of a shock to the partners income is minimal. Yet another good example of why public transfers of cash to women accrues much greater benefits to households than does targeting men.