Affiliates' Research in Medical Journals, Fall 2021

Workplace wellness programs have been adopted by most large and many small US employers to try to improve employee health, lower health care spending, and improve productivity. While observational studies have suggested positive financial returns, in randomized trials these programs have at most modest short-run effects on health behaviors. To understand the longer-run effects of these programs, the researchers analyze a clustered randomized trial of a workplace wellness program implemented at a large multisite US retail wholesale club. Twenty-five randomly selected treatment worksites received the program, with five of the worksites added at the trial’s midpoint, and 135 randomly selected control worksites did not. The program offered a series of optional modules on health management, nutrition, physical activity, and stress reduction, each lasting about four to eight weeks including education and incentive rewards, such as gift cards. At the end of three years, employees at the treatment worksites had better self-reported health behaviors, with the largest and most significant effects for physical activity (59.8 percent reported engaging in regular exercise at treatment sites versus 53.8 percent at control sites) and active weight management (68.2 percent reported actively managing their weight at treatment sites versus 61.5 percent at the control sites). These were effects of program availability; among those participating in at least one module, the differences between treatment and control were higher, by about a third for exercise and weight management. No significant differences were found in self-reported health, clinical markers of health (cholesterol, blood glucose, blood pressure, and body mass index), health care spending or use, or job performance, absenteeism, or tenure. The researchers acknowledge that the completion of questionnaires and biometric measurements among workers at control sites could have affected their behavior, and that they may have lacked the power to detect differences in some outcomes such as health care costs. They conclude that improvements in health behaviors after three years were similar to those at 18 months, but that the longer follow-up did not yield detectable improvements in clinical, economic, or employment outcomes.

Medical Debt in the US, 2009−2020
Kluender R, Mahoney N, Wong F, Yin W. JAMA 326(3), July 2021, pp. 250−256.
With medical debt an increasing concern in the US, the researchers undertook this study to learn more about the amount of this debt, its distribution, and its association with Medicaid expansion under the Affordable Care Act. Data on medical debt in collections were obtained from a nationally representative 10 percent panel of consumer credit reports between January 2009 and June 2020, reflecting care provided prior to the COVID-19 pandemic. Income data were obtained from the 2014–2018 American Community Survey. These data were used to estimate medical debt nationally, by geographic region, and by zip code income decile. In June 2020, an estimated 17.8 percent of individuals had medical debt, and 13.0 percent accrued debt during the prior year. The mean amount was $429 ($311 accrued during the prior year). The mean total medical debt was highest in the South and lowest in the Northeast ($616 versus $167) and higher in poor than in rich zip code income deciles ($677 versus $126). Between 2013 and 2020, the states that expanded Medicaid in 2014 experienced a greater decline in the mean flow of medical debt, from $330 to $175, than states that did not expand Medicaid (from $613 to $550). In the expansion states, the gap in the mean flow of medical debt between the lowest and highest zip code income deciles decreased by $145, while the gap increased by $218 in the nonexpansion states. Medical debt became more concentrated in lower-income communities in states that did not expand Medicaid.

Elevated Risk of COVID-19 Infection for Hospital-Based Health Care Providers
Sacks OA, Barnato AE, Skinner JS, Birkmeyer JD, Fowler A, Birkmeyer N. Journal of General Internal Medicine, August 2021.
There is limited data on the risk of hospital versus community exposure for US health care providers during the COVID-19 pandemic. This study examined COVID-19 infection rates between March and December 2020 among 3,108 physicians (MDs) and advance practice providers (APPs) with at least 100 patient contacts in hospital medicine and critical care at a national acute care medical practice with 200 community hospitals in 41 states. The number of COVID-19 patients in each hospital overall was used as a proxy for community COVID-19 exposure. To control for demographics that could influence hospitalization, researchers used data from the National Neighborhood Data Archive. Mixed-effects logistic regression was used to explore the relationship between provider infection, characteristics of the providers, and the number of COVID-19 patients at the hospital and treated by the providers. A total of 180 providers were tested, due to symptoms or exposure (without personal protective equipment) to an infected person; 88 were positive, 90 negative, and 2 pending. The provider cumulative infection rate was 2.8 percent (2.3 percent for MDs and 3.9 percent for APPs), and increased with the number of COVID-19 patients under direct care of the providers. The infection rate was 0.9 percent for providers who took care of fewer than 10 COVID-19 patients, 2.4 percent for providers caring for 10–49 COVID-19 patients, and 4.1 percent for providers caring for 50 or more COVID-19 patients. The overall number of hospital COVID-19 patients was not associated with provider COVID-19 infections. These findings suggest that the risk of virus transmission is increased not by the total number of COVID-19 patients hospitalized, which may reflect the number of COVID-19 patients in that hospital’s community, but the number of COVID-19 patients that providers directly treat.

Inequities in COVID-19 Vaccination Rates in the 9 Largest US Cities
Sacarny A, Daw JR. JAMA Health Forum 2(9), September 2021, e212415.
This cross-sectional study used neighborhood-level, deidentified, publicly available data to estimate inequities in COVID-19 vaccination rates in the nine largest US cities: New York, Los Angeles, Chicago, Houston, Phoenix, Philadelphia, San Antonio, San Diego, and Dallas (all including surrounding counties except for Chicago). Data on COVID-19 vaccination and death rates for these cities were obtained from health authority websites; sociodemographic information was drawn from the American Community Survey. Neighborhoods were defined using zip codes, except in Los Angeles, where communities were used instead. Within each city, the researchers divided neighborhoods into quartiles according to vaccination rate (adults with at least 1 dose) and calculated the mean sociodemographic characteristics and COVID-19 death rates in each quartile. They analyzed 1,127 neighborhoods with a mean COVID-19 vaccination rate of 42.3 percent. Neighborhoods in the lowest quartile had less than half the vaccination rate of those in the highest quartile (27.6 percent versus 59.7 percent). Neighborhoods with high vaccination rates had a greater share of White and Asian residents and a lower share of Black and Hispanic or Latino residents. These neighborhoods also had higher mean incomes, lower poverty rates, and higher four-year college completion rates. Employment in health care differed little across quartiles but, in neighborhoods with high vaccination rates, these workers were more likely to be health care practitioners or technologists and less likely to be in support occupations. COVID-19 death rates through April 13, 2021 were lowest in neighborhoods with the highest vaccination rates, even though these neighborhoods had more older adults. A 10 percentage-point increase in the vaccination rate was associated with 25 fewer historical COVID-19 deaths per 100,000 population. Of the 863 neighborhoods with death data, the 209 with the highest death rates accounted for half of all historical COVID-19 deaths but 26 percent of all vaccinations. The findings document substantial inequities in vaccination rates in the first five months of vaccine distribution.




The Structure and Financing of Health Care Systems Affected How Providers Coped with COVID‐19
Waitzberg R, Quentin W, Webb E, Glied S. The Milbank Quarterly 99(2), June 2021, pp. 542−564.

Dental Care Use, Edentulism, and Systemic Health among Older Adults
Meyerhoefer CD, Pepper JV, Manski RJ, Moeller JF. Journal of Dental Research, June 2021.

Adolescent Chronic Health Conditions and School Disconnectedness
James C, Corman H, Noonan K, Reichman NE, Jimenez NE. Journal of Developmental & Behavioral Pediatrics, June 2021.

Medicaid Expansions and Participation in Supplemental Security Income by Noncitizens
Muchomba FM, Kaushal N. American Journal of Public Health 111(6), June 2021, pp. 1106–1112.

Jelliffe E, Pangburn P, Pichler S, Ziebarth NR. PNAS 118(29), July 2021, e2107670118.

COVID-19 Vaccine Acceptance and Hesitancy in Low- and Middle-Income Countries
Solís Arce JS, Warren SS, Meriggi NF, Scacco A, McMurry N, Voors M, Syunyaev G, Malik AA, Aboutajdine S, Adeojo O, Anigo D, Armand A, Asad S, Atyera M, Augsburg B, Awasthi M, Ayesiga GE, Bancalari A, Björkman Nyqvist M, Borisova E, Bosancianu CM, Cabra García MR, Cheema A, Collins E, Cuccaro F, Farooqi AZ, Fatima T, Fracchia M, Galindo Soria ML, Guariso A, Hasanain A, Jaramillo S, Kallon S, Kamwesigye A, Kharel A, Kreps S, Levine M, Littman R, Malik M, Manirabaruta G, Mfura JLH, Momoh F, Mucauque A, Mussa I, Nsabimana JA, Obara I, Otálora MJ, Ouédraogo BW, Pare TB, Platas MR, Polanco L, Qureshi JA, Raheem M, Ramakrishna V, Rendrá I, Shah T, Shaked SE, Shapiro JN, Svensson J, Tariq A, Tchibozo AM, Tiwana HA, Trivedi B, Vernot C, Vicente PC, Weissinger LB, Zafar B, Zhang B, Karlan D, Callen M, Teachout M, Humphreys M, Mobarak AM, Omer SB. Nature Medicine 27, July 2021, pp. 1385–1394.


Embracing Uncertainty: The Value of Partial Identification in Public Health and Clinical Research
Mullahy J, Venkataramani A, Millimet DL, Manski CF. American Journal of Preventive Medicine 61(2), August 2021, pp. e103−e108.

Coming Up Short: Comparing Venous Blood, Dried Blood Spots & Saliva Samples for Measuring Telomere Length in Health Equity Research
Geronimus AT, Bound J, Mitchell C, Martinez-Cardoso A, Evans L, Hughes L, Schneper L, Notterman DA. PLOS ONE 16(8), August 2021, e0255237.


Estimated Mortality Increases during the COVID-19 Pandemic by Socioeconomic Status, Race, and Ethnicity
Miller S, Wherry LR, Mazumder B. Health Affairs Web Exclusive 40(8), August 2021, pp. 1252−1260.

Vaccinations against COVID-19 May Have Averted up to 140,000 Deaths in the United States
Gupta S, Cantor J, Simon KI, Bento AI, Wing C, Whaley CM. Health Affairs 40(9), August 2021.

Gestational Age at Term and Educational Outcomes at Age Nine
Hedges A, Corman H, Noonan K, Reichman NE. Pediatrics 148(2), August 2021, e2020021287.

Increases in Inpatient Psychiatry Beds Operated by Systems, For-Profits, and Chains, 2010−2016
Shields MC, Beaulieu ND, Lu S, Busch AB, Cutler DM, Chien AT. Psychiatric Services, August 2021.

Myocardial Infarction Care among the Elderly: Declining Treatment with Increasing Age in Two Countries
Hsu J, Iversen T, Price M, Moger TA, Tevis D, Hagen TP, Dow WH. Health Affairs Web Exclusive 40(9), September 2021, pp. 1483−1490.

Trends in US Health Insurance Coverage during the COVID-19 Pandemic
Bundorf MK, Gupta S, Kim C. JAMA Health Forum 2(9), September 2021, e212487.

Barnato AE, Birkmeyer JD, Skinner JS, O'Malley AJ, Birkmeyer NJO. Journal of the American Geriatrics Society, September 2021.


Nikzad A, Akbarpour M, Rees MA, Roth AE. PNAS 118(36), September 2021 e2106652118.

Measuring Family Planning Provider Bias: A Discrete Choice Experiment among Burkinabé, Pakistani, and Tanzanian Providers
Dieci M, Wagner Z, Friedman W, Burgess S, Vandermark J, McCoy SI, Shah M, Dow WH. Studies in Family Planning 52(3), September 2021, pp. 299−320.

Measuring the COVID-19 Mortality Burden in the United States: A Microsimulation Study
Reif J, Heun-Johnson H, Tysinger B, Lakdawalla D. Annals of Internal Medicine, September 2021.

US Trends in Opioid Access among Patients with Poor Prognosis Cancer near the End of Life
Enzinger AC, Ghosh K, Keating NL, Cutler DM, Landrum MB, Wright AA. Journal of Clinical Oncology 39(26), September 2021, pp. 2948−2958.

Trust in Scientists in Times of Pandemic: Panel Evidence from 12 Countries
Algan Y, Cohen D, Davoine E, Foucault M, Stantcheva S. PNAS 118(40), October 2021, e2108576118.

ENSO Impacts Child Undernutrition in the Global Tropics
Anttila-Hughes JK, Jina AS, McCord GC. Nature Communications 12, October 2021, 5785.

Child and Adolescent Psychosocial Support Programs following Natural Disasters — A Scoping Review of Emerging Evidence
Gibbs L, Marinkovic K, Nursey J, Tong LA, Tekin E, Ulubasoglu M, Callard N, Cowlishaw S, Cobham VE. Current Psychiatry Reports 23(12), October 2021, 82.