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Objective Although the Affordable Care Act eliminated cost sharing for screening mammography, a concern is that grandfathered plans, diagnostic mammograms, and follow-up testing may still lead to out-of-pocket (OOP) spending. Our study examines how OOP spending among women at their baseline screening mammogram may impact the decision to receive subsequent screening. Methods The study included commercially insured women aged 40 to 41 years with a screening mammogram between 2011 and 2014. We estimated multivariate linear probability models of the effect of OOP spending at the baseline mammogram on subsequent screening 12 to 36 months later. Results Having any OOP payments for the baseline screening mammogram significantly reduced the probability of screening in the subsequent 12 to 24 months by 3.0 percentage points (pp) (95% confidence interval [CI]: 1.1-4.8 pp decrease). For every $100 increase in the OOP expenses for the baseline mammogram, the likelihood of subsequent screening within 12 to 24 months decreased by 1.9 pp (95% CI: 0.8-3.1 pp decrease). Similarly, any OOP spending for follow-up tests resulting from the baseline screening led to a 2.7 pp lower probability of screening 12 to 24 months later (95% CI: 0.9-4.1 pp decrease). Higher OOP expenses were associated with significantly lower screening 24 to 36 months later (coefficient = −0.014, 95% CI: −0.025 to −0.003). Discussion Although cost sharing has been eliminated for screening mammograms, OOP costs may still arise, particularly for diagnostic and follow-up testing services, both of which may reduce rates of subsequent screening. For preventive services, reducing or eliminating cost sharing through policy and legislation may be important to ensuring continued adherence to screening guidelines.

OBJECTIVE Examine whether Medicare Advantage (MA) coverage is associated with more efficient prescribing of Part B drugs than traditional Medicare (TM) coverage. DATA SOURCES 20% sample of 2016 outpatient and carrier TM claims and MA encounter records and Master Beneficiary Summary File data. STUDY DESIGN We analyzed whether MA enrollees compared to TM enrollees more often received the low-cost Part B drug in four clinical scenarios where multiple similarly effective drugs exist: 1) anti-VEGF agents to treat macular degeneration, 2) bone resorption inhibitors for osteoporosis, 3) bone resorption inhibitors for malignant neoplasms, and 4) intravenous iron for anemia. We then estimated differences in spending if TM prescribing aligned with MA prescribing. Finally, using linear probability models, we examined whether differences in MA and TM prescribing patterns were attributable to differences in the hospitals and clinician practices who treat MA and TM enrollees or differences in how these hospitals and clinician practices treat their MA versus TM patients. DATA COLLECTION/EXTRACTION METHODS N/A PRINCIPAL FINDINGS: In all cases, a larger share of MA enrollees received the low-cost drug compared to TM enrollees, ranging from 8 percentage points higher for anemia to 16 percentage points higher for macular degeneration in the unadjusted analysis. Results were similar in regression analyses controlling for enrollee characteristics and market factors (5 to 13 percentage points). If TM prescribing matched MA prescribing, we estimated savings ranging from 6-20% of TM spending for each scenario. Differences in prescribing patterns were driven both by MA enrollees receiving treatment at more efficient hospitals and clinician practices and hospitals and clinician practices more often prescribing low-cost drugs to their MA patients. CONCLUSIONS Our findings show MA enrollees were more likely than TM enrollees to receive low-cost Part B drugs in four clinical scenarios where multiple similarly or equally effective treatment options exist. This article is protected by copyright. All rights reserved.

Early evaluation of the Affordable Care Act's Medicaid expansion demonstrated persistent disparities among Medicaid beneficiaries in use of high-volume hospitals for pancreatic surgery. Longer-term effects of expansion remain unknown. This study evaluated the impact of expansion on the use of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients.State inpatient databases (2012-2017), the American Hospital Association Annual Survey Database, and the Area Resource File from the Health Resources and Services Administration, were used to examine 8,264 non-elderly adults who underwent pancreatic surgery in nine expansion and two non-expansion states. High-volume hospitals were defined as performing 20 or more resections/year. Linear probability triple differences models measured pre- and post-Affordable Care Act utilization rates of pancreatic surgery at high-volume hospitals among Medicaid and uninsured patients versus privately insured patients in expansion versus non-expansion states.The Affordable Care Act's expansion was associated with increased rates of utilization of high-volume hospitals for pancreatic surgery by Medicaid and uninsured patients (48% vs 55.4%, P = .047) relative to privately insured patients in expansion states (triple difference estimate +11.7%, P = .022). A pre-Affordable Care Act gap in use of high-volume hospitals among Medicaid and uninsured patients in expansion states versus non-expansion states (48% vs 77%, P.0001) was reduced by 15.1% (P = .001) post Affordable Care Act. A pre Affordable Care Act gap between expansion versus non-expansion states was larger for Medicaid and uninsured patients relative to privately insured patients by 24.9% (P.0001) and was reduced by 11.7% (P = .022) post Affordable Care Act. Rates among privately insured patients remained unchanged.Medicaid expansion was associated with greater utilization of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients. These findings are informative to non-expansion states considering expansion. Future studies should target understanding referral mechanism post-expansion.

OBJECTIVE: To examine the association between the generosity of Medicaid home‐ and community‐based services (HCBS) and the likelihood of community discharge among Medicare‐Medicaid dually enrolled older adults who were newly admitted to skilled nursing facilities (SNFs). DATA SOURCES: National datasets, including Medicare Master Beneficiary Summary File (MBSF), Medicare Provider and Analysis Review (MedPAR), Medicaid Analytic eXtract (MAX), minimum data set (MDS), and publicly available data at the SNF or county level, were linked. STUDY DESIGN: We measured Medicaid HCBS generosity by its breadth and intensity and described their variation at the county level. A set of linear probability models with SNF fixed effects were estimated to characterize the association between HCBS generosity and likelihood of community discharge from SNFs. We further stratified the analyses by the type of index hospitalizations (medical vs surgical events), age group, and the Medicaid cost‐sharing policy for SNF services. DATA EXTRACTION METHODS: The final analytical sample included 224 229 community‐dwelling dually enrolled older duals who were newly admitted to SNFs after an acute inpatient event between October 1, 2010, and September 30, 2013. PRINCIPAL FINDINGS: We observed substantial cross‐sectional and over‐time variations in HCBS breadth and intensity. Regression results indicate that on average, a 10 percentage‐point increase in HCBS breadth was associated with a 0.7 percentage‐point increase (P

Background: mothers’ and fathers’ participation in nonstandard employment across children’s lives is not well understood in the United Kingdom.Objective: the first objective is to describe the prevalence of nonstandard work schedules (e.g., evenings, weekends, nights) among employed mothers and fathers using longitudinal data. The second objective is to document the education gradient in parental nonstandard work schedules over the first decade of a child’s life.Methods: linear probability models predict participation in nonstandard work schedules, adjusting for demographic variables, at each survey wave by education for each parent, using the first five waves of the Millennium Cohort Study.Results: employed mothers with less than NVQ2 (or less than high school) were most likely to work nonstandard schedules across childhood. Among employed fathers, there was little difference in the probability of working nonstandard schedules by education. The most common type of shift for mothers (30%‒36%) and fathers (nearly 42%‒46%) was evening work. Mothers and fathers with NVQ4 or more (college degree or higher) were most likely to work regularly in the evening at all ages. Night working, the least common type of schedule, did not differ by education for both parents. Mothers and fathers with the least education were most likely to work weekend schedules at all ages.Contribution: this article documents the pervasiveness of parental nonstandard employment, which has received little attention in the UK; finds that the education gradient in nonstandard work schedules is contingent on type of schedule; and critically incorporates information about fathers’ nonstandard schedules.

Poor pregnancy outcomes include miscarriages, stillbirths, and low birth weights. Stress from heat and lack of resources play a potentially important role in producing these poor outcomes. Women and couples who experience these poor outcomes rather than a healthy birth suffer psychological, physical, social, and financial costs as well. We use detailed reproductive data in combination with fine-scale climate data to examine pregnancy outcomes among women in sub-Saharan Africa, a region that shelters some of the poorest families in the world. Fine-scale precipitation and temperature data allow each pregnancy to be matched to the relevant climate exposures. We investigate the linkages between climate and pregnancy outcomes using linear probability models with fixed effects to minimize confounding due to factors that vary by location, season, and year. We analyze retrospective pregnancy data from more than 65,000 pregnancies recorded in 23 surveys across 15 African countries. Our results indicate that pregnancy outcomes are indeed impacted by exposure to hot days even after considering other individual-level characteristics. This research provides insight into the linkages between climate and a major adverse health outcome faced by women. In doing so, this research expands scientific understanding of the impact of environmental factors on fertility outcomes.

Introduction\ud \ud Adolescent alcohol consumption has been declining in many high-income countries since the turn of this century. Research investigating the plausible explanations for these declines has been mostly based on individual-level studies, which are largely inconclusive. Changes in leisure time internet use and computer gaming (referred to in this article as ‘computer activities’) have been hypothesised to play a role in declining adolescent alcohol consumption at a country-level. The aim of this study was to examine the association between country-level changes over time in computer activities and adolescent drinking in 33 European countries.\ud \ud \ud \ud Methods\ud \ud This is a multi-level repeated cross-national study examining the role of changes over time in country-level and individual-level computer activities on regular drinking. We utilised four waves of the European School Survey Project on Alcohol and Drugs (ESPAD) from 2003, 2007, 2011 and 2015. At an individual-level the primary exposure of interest was daily engagement in computer activities and aggregated means were used to measure country-level daily computer activities in each included country. Data were analysed using three-level hierarchical linear probability methods.\ud \ud \ud \ud Results\ud \ud In the fully adjusted model, for between individual effects, we found significant positive association between daily computer activities and regular drinking (β = 0.043, p-value

According to a published report by the Palestine Central Bureau of Statistics in 2011, 37% of ever-married women in the occupied Palestinian territories (oPt) reported having experienced intimate partner violence (IPV) by their husband at least once in the previous year. However, less than 1% of women who had experienced IPV sought formal help. Thus, this study sought to identify factors associated with help-seeking among women in the oPt. We used linear probability regression to investigate factors associated with formal and informal help-seeking among survivors of IPV, using data from the Palestine Central Bureau of Statistics’ 2011 Violence Survey. Our results showed women in Gaza were more likely to seek formal help than those in the West Bank. Employed women were more likely to seek informal help, and higher education was inversely associated with informal help-seeking. Findings suggest both political and sociocultural barriers to help-seeking. We recommend policies that decrease barriers to IPV help-seeking, such as harmful gender norms, and support organizations that provide valuable services to women in the oPt.

We provide a systematic country and age group comparison of the gender gap in several generic health indicators and more specific morbidity outcomes. Using data from the Survey of Health, Ageing and Retirement (SHARE), we examined the gender gap in the prevalence of poor self-rated health, chronic health conditions, activity limitations, multimorbidity, pain, heart attacks, diabetes, and depression in three age groups (50–64, 65–79, and 80+) based on linear probability models with and without adjustment for covariates. While women were typically disadvantaged regarding poor self-rated health, chronic health conditions, activity limitations, multimorbidity, pain, and depression, men had a higher prevalence of heart attacks and diabetes. However, the gender gap’s magnitude and sometimes even its direction varied considerably with some age trends apparent. Regarding some health indicators, the gender gap tended to be higher in Southern and Eastern Europe than in Western and Northern Europe. All in all, the presence of a gender health gap cannot be regarded as a universal finding as the gap tended to widen, narrow or even reverse with age depending on the indicator and country.

This study uses linear probability models with student and teacher fixed effects to assess whether the racial match between teachers and students affects “at-risk” ratings on a teacher-completed universal screener of student internalizing and externalizing behavior. The data are from a large, urban California school district. I find that Asian and Black teachers are more likely to rate their same-race students “at-risk” for internalizing behavior compared with how the same Asian and Black students would be rated by White teachers. These findings have implications for policy and practice aimed at enhancing universal screening for externalizing and internalizing behavior.

Background Emerging research suggests that adverse childhood experiences (ACEs) may be a risk factor for prenatal marijuana use. This study is the first to use a representative sample from state surveillance systems to assess the connection between accumulating ACEs and marijuana use during pregnancy. Methods Data are from the North Dakota and South Dakota Pregnancy Risk Assessment Monitoring System (PRAMS) from years 2017-2019 (N = 5,399). The bivariate association between number of ACEs and marijuana use during pregnancy is assessed using a chi-square test. The multivariable association is assessed using linear probability modeling. Results Only 0.9% of women with zero ACEs reported marijuana use during pregnancy, compared to 11.7% of women with four or more ACEs. Findings from linear probability models showed that mothers reporting two ACEs (b =.023, 95% CI =.003,.043), three ACEs (b =.042, 95% CI =.014,.069), and four or more ACEs (b =.053, 95% CI =.035,.071) are more likely to report marijuana use during pregnancy relative to those with zero ACEs, net of demographic and socioeconomic control variables. Conclusions Accumulating maternal ACEs —especially four or more— is associated with increased likelihood of using marijuana during pregnancy. These findings demonstrate the early life trauma is a key social determinant of health over the life course and highlights how ACEs can contribute to intergenerational harm via the worsening of health behaviors during pregnancy.

Objective Despite broad electronic health record (EHR) adoption in U.S. hospitals, there is concern that an “advanced use” digital divide exists between critical access hospitals (CAHs) and non-CAHs. We measured EHR adoption and advanced use over time to analyzed changes in the divide. Materials and Methods We used 2008 to 2018 American Hospital Association Information Technology survey data to update national EHR adoption statistics. We stratified EHR adoption by CAH status and measured advanced use for both patient engagement (PE) and clinical data analytics (CDA) domains. We used a linear probability regression for each domain with year-CAH interactions to measure temporal changes in the relationship between CAH status and advanced use. Results In 2018, 98.3% of hospitals had adopted EHRs; there were no differences by CAH status. A total of 58.7% and 55.6% of hospitals adopted advanced PE and CDA functions, respectively. In both domains, CAHs were less likely to be advanced users: 46.6% demonstrated advanced use for PE and 32.0% for CDA. Since 2015, the advanced use divide has persisted for PE and widened for CDA. Discussion EHR adoption among hospitals is essentially ubiquitous; however, CAHs still lag behind in advanced use functions critical to improving care quality. This may be rooted in different advanced use needs among CAH patients and lack of access to technical expertise. Conclusions The advanced use divide prevents CAH patients from benefitting from a fully digitized healthcare system. To close the widening gap in CDA, policymakers should consider partnering with vendors to develop implementation guides and standards for functions like dashboards and high-risk patient identification algorithms to better support CAH adoption.

Background People with disabilities have higher health care needs, service utilization, and expenditures. They are also more likely to lack insurance and experience unmet need for medical care. There has been limited research on the effects of the Affordable Care Act Medicaid expansion on people with disabilities. Objective To examine the effects of the Medicaid expansion on health insurance coverage, access, and service use for working-age adults with disabilities. Methods A retrospective study using 11 years (2007–2017) of data from the Medical Expenditure Panel Survey - Household Components, linked to Area Health Resource Files and Local Area Unemployment Statistics (N = 40,995). Difference-in-differences multinomial logistic and linear probability models with state and year fixed-effects were used to estimate the effects. Results We found strong evidence of increased Medicaid coverage in expansion states (3.2 to 5.0 percentage points), reasonably strong evidence of reduced private insurance coverage (−2.2 to −2.5 percentage points), and some evidence of reduced uninsured rate (from no effect to −3.7 percentage points). Results suggest that the increase in Medicaid coverage was due at least in part to the “crowd-out” of private insurance in expansion states. No statistically significant effects were detected for access and use outcomes. Conclusions Findings suggest that state Medicaid expansions led to an increase in Medicaid coverage and a decrease in private insurance coverage as well as the uninsured. However, no evidence was found for health care access and use outcomes. Further research into access and use is needed when more data become available for the post-expansion period.

Contexts in which people live such as neighbourhoods, cities or regions influence individuals. However, research analysing effects of different contexts simultaneously is limited. Our paper's focus is to examine the interrelation between regional and neighbourhood conditions and their influence on school‐to‐work transitions. We investigate the process of transitioning from vocational training to employment, with a specific focus on adolescents from non‐Western immigrant origin. We link Dutch survey data on almost 15,000 graduates with spatial information from Statistics Netherlands and compare results across multilevel linear probability models. Overall, we find employment prospects to be reduced in neighbourhoods and regions that are socioeconomically unfavourable. However, neighbourhood influences diminish or even disappear once accounted for the region. Deprived conditions in urban regions are particularly detrimental for adolescents of immigrant descent. However, a high share of coethnics in the neighbourhood reduces the unemployment risk of second‐generation non‐Western minorities in deprived urban regions. This finding stresses the relevance of immigrants' neighbourhood networks for education and employment prospects.

We study the determinants of common European merger policy over its first 25 years, from 1990 to 2014. Using a novel dataset at the level of the relevant antitrust markets and containing all relevant merger cases notified to the European Commission, we evaluate how consistently arguments related to structural market parameters – dominance, rising concentration, barriers to entry, and foreclosure – were applied over time and across different geographic market definitions. On average, linear probability models overestimate the effects of structural indicators. Using non-parametric machine learning techniques, we find that dominance is positively correlated with competitive concerns, especially in markets with a substantial increase in post-merger concentration and in complex mergers. Yet, its importance decreased following the 2004 merger policy reform. Competitive concerns are also correlated with rising concentration, especially if entry barriers and foreclosure are of concern. The impact of these structural indicators in explaining competitive concerns is independent of the geographic market definition and does not change over time.

Introduction High-deductible health plans are often touted to motivate patients to become informed healthcare purchasers; however, racial/ethnic minorities report that high deductibles prevent them from seeking the needed care. One proposed way to mitigate the financial burden of high-deductible health plans is the use of health savings plans. This cross-sectional study investigates whether chronically ill Blacks and Hispanics enrolled in high-deductible health plans experience greater access to care difficulties than non-Hispanic Whites and whether racial/ethnic disparities are mitigated by the use of health savings plans. Methods Weighted, multivariate, linear probability regression models were estimated (analyses were conducted in December 2020), adjusting for individual attributes and contextual factors that may explain the variation in health care access. Chronically ill, U.S.-born Black, Hispanic, and White adults enrolled in a high-deductible health plan from the National Health Interview Survey in 2011–2018 were included. Associations were tested among 3 independent variables—being Black, being Hispanic, and health savings plan utilization (and their interaction)—and access to healthcare outcomes of interest, including affordability-related access, provider-related access, and delayed care. Results Blacks and Hispanics were less likely to use health savings plans, and Blacks were more likely to experience problems with access to health care. Although the use of health savings plans was found to have a minimal effect on reducing racial/ethnic disparities in affordability-related access, there was also evidence that health savings plans compounded racial/ethnic disparities in provider-related access. Conclusions Understanding how health savings plans function to improve access to care within racial/ethnic minority groups may help to inform policy approaches related to their use.

Objective We quantify the use of clinical decision support (CDS) and the specific barriers reported by ambulatory clinics and examine whether CDS utilization and barriers differed based on clinics’ affiliation with health systems, providing a benchmark for future empirical research and policies related to this topic. Materials and Methods Despite much discussion at the theoretic level, the existing literature provides little empirical understanding of barriers to using CDS in ambulatory care. We analyze data from 821 clinics in 117 medical groups, based on in Minnesota Community Measurement’s annual Health Information Technology Survey (2014-2016). We examine clinics’ use of 7 CDS tools, along with 7 barriers in 3 areas (resource, user acceptance, and technology). Employing linear probability models, we examine factors associated with CDS barriers. Results Clinics in health systems used more CDS tools than did clinics not in systems (24 percentage points higher in automated reminders), but they also reported more barriers related to resources and user acceptance (26 percentage points higher in barriers to implementation and 33 points higher in disruptive alarms). Barriers related to workflow redesign increased in clinics affiliated with health systems (33 points higher). Rural clinics were more likely to report barriers to training. Conclusions CDS barriers related to resources and user acceptance remained substantial. Health systems, while being effective in promoting CDS tools, may need to provide further assistance to their affiliated ambulatory clinics to overcome barriers, especially the requirement to redesign workflow. Rural clinics may need more resources for training.

Objective Despite evidence that mandatory pelvic examinations deter contraceptive use and are not clinically necessary, survey research suggests that clinicians regularly perform pelvic examinations prior to prescribing contraceptives. This study estimates prevalence of nonindicated pelvic exams during contraceptive encounters, and variation in prevalence by provider specialty. Study design Using a national sample of commercial claims data, we identified contraceptive encounters without concurrent indication for pelvic examination among females aged 15 to 49 from 2007 to 2017. We first calculated the nonindicated exam rate by provider specialty and patient age. Using data from 2017 and linear probability models with metropolitan statistical area fixed effects, we estimated the differences in adjusted rates of nonindicated pelvic examination by provider specialty. To assess trends by provider specialty, we used all years of data and interacted specialty with year. Results Of 7.9 million identified contraceptive encounters, 81.8% had no identified indications for pelvic exam. Exams were billed at 17.7% of these visits (2007–2017), and this rate increased from 13.4% in 2007 to 20.7% in 2017. The largest increase occurred among encounters with an obstetrician-gynecologist. In 2017, obstetrician-gynecologists were 20.3 percentage points (95% CI: 19%–21%) more likely to perform a concurrent pelvic exam compared to family physicians. Conclusions Pelvic examinations during contraceptive visits increased from 2007 to 2017. Increases occurred across all provider specialties, but were largely driven by obstetrician-gynecologists, who oversaw over half of all contraceptive encounters and performed non-indicated pelvic exams at the highest rate. Implications This research provides real-world evidence that suggests pelvic exams are increasingly performed during contraceptive encounters and that patients regularly undergo a low-value, invasive examination while obtaining contraceptive care. Continuing education, reimbursement reform, and more evidence on the harms of non-indicated pelvic exams will be necessary to change clinical practice.

The present study examined the extent to which beneficial and hazardous family relationships altered the link between childhood exposure to parent-to-child physical violence and self-reported adolescent-to-parent physical violence (APV). As moderating factors, current levels of family cohesion, family conflict, and interparental violence were assessed. Based on data from 2490 ninth graders who took part in a large school survey in the federal state of Lower Saxony, Germany, multilevel linear probability models with interaction terms were conducted, using Stata 14.2. In case of significant interactions, values at 1 standard deviation above and below the mean level of each moderator were used to calculate the simple slopes. Regression results indicated that physical APV was positively related to parent-to-child physical violence. Family cohesion buffered detrimental effects of parent-to-child physical violence on physical APV, while family conflict exacerbated this link. Specifically, parent-to-child physical violence had weaker effects on physical APV for students who reported greater levels of family cohesion, while stronger effects were observed for students who reported greater levels of family conflict. Gender was not found to influence the strength of the moderating relationships. Both hazardous and beneficial family relationships alter the way childhood exposure to parental physical violence relates to adolescents’ physical aggression toward parents. For intervention purposes, special attention should be given to potential buffering resources, such as cohesive family relationships. In sum, quality of family relationships deserve greater attention in discourse about lasting, adverse effects of childhood exposure to physical violence on adolescent-to-parent physical violence.

This study explores how armed conflict relates to contraceptive use in Colombia, combining data from the Uppsala Conflict Data Program and Demographic and Health Surveys 1990-2016. Our study is the first systematic effort to investigate whether and how violent conflict influences women's contraceptive use, using nationally representative data across all stages of women's reproductive careers. With fixed effects linear probability models, we adjust for location-specific cultural, social, and economic differences. The results show that although modern contraceptive use increased over time, it declined according to conflict intensity across location and time. We find no evidence that this relationship varied across socioeconomic groups. Increased fertility demand appears to explain a small portion of this relationship, potentially reflecting uncertainty about losing a partner, but conflict may also result in lack of access to contraceptive goods and services.

In this article, we employ the elementary inequalities arising from the sub-linearity of Choquet expectation to give a new proof for the generalized law of large numbers under Choquet expectations induced by 2-alternating capacities with mild assumptions. This generalizes the Linderberg–Feller methodology for linear probability theory to Choquet expectation framework and extends the law of large numbers under Choquet expectation from the strong independent and identically distributed (iid) assumptions to the convolutional independence combined with the strengthened first moment condition.

OBJECTIVE This study examines the use of temporary providers in federally qualified health centers (FQHCs) in recent years and identifies associated factors. METHODS Using 2013-2017 federal administrative data of 1,028 FQHCs, we describe trends in the number and percentage of FQHCs that used temporary primary care physicians and advanced practice providers (nurse practitioners, physician assistants, and certified nurse midwives). We employed descriptive statistics to compare facility and patient characteristics between FQHCs that used and did not use temporary providers and constructed multivariate linear probability models to identify factors associated with their use. FINDINGS Slightly over one-third of FQHCs used temporary primary care providers during 2013-2017. During this period, fewer FQHCs used temporary family physicians, while more FQHCs used nurse practitioners and physician assistants. Centers that used temporary providers were larger and less rural. Multivariate regression analysis showed that neither Health Professional Shortage Area facility scores (a measure of provider shortage), nor the county primary care provider-to-population ratio, was a predictor of temporary provider usage in FQHCs. Instead, facility regular primary care staff-to-patient ratio was positively associated with use of temporary providers. CONCLUSION Temporary providers tend to be used in FQHCs where measure of underservice appears to be less severe. Future research should use qualitative interviews or other data sources to explore further the underlying reasons for using temporary providers in FQHCs.

This paper examines the effect of extending the primary school day on maternal labor supply. I exploit the staggered nature of the recent German reform to extend school hours and assess whether or not gaining access to a full day school increases the likelihood that mothers enter into the labor market or extend their hours worked if already employed. I use the German Socio‐Economic Panel data set (GSOEP) and link it to a self‐collected school‐level data set with geographical information software (GIS). Using a flexible difference‐in‐difference approach in the estimation of linear probability and logit models, I find that the policy has a statistically significant effect of approximately five percentage points at the extensive margin, drawing more women into the labor market. I find no significant effect of the policy at the intensive margin; women who were already working do not extend their hours worked. This has implications for policies to extend the school day that do not correspond to the working day.

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Research tends to focus on the health implications of breastfeeding, but understanding associations that might drive maternal choice in infant feeding practice is also very important. To understand the relationship between women’s feeding strategies for their children and the context in which they live in Iraq, mixed methods are deployed through analysis of surveys and interviews. Using data from the 2000 and 2011 Multiple Indicator Cluster Survey, trends are quantitatively examined in breastfeeding and infant formula use for Iraq using linear probability models. Interviews are qualitatively analyzed that were collected from women in Sulaimani governorate in the Kurdish region of Iraq to begin understanding the reasons why Iraqi women initiate breastfeeding and formula use. Being urban, wealthier, and more educated increases the probability of a mother using infant formula, while only increasing wealth and increasing education are associated with increasing the probability of breastfeeding. In 2000, governorates significantly differ in the probability of mothers using infant formula (e.g. Karbala = 24.32 percentage points lower probability of using infant formula relative to Sulaimani, (p

Introduction The purpose of this study is to examine general time trends in childhood obesity legislative activity in all 50 states (overall and by health equity focus) and whether the Voices for Healthy Kids Campaign (Voices) was associated with increased legislative activity. Methods LexisNexis State Capital was used to identify bills related to childhood obesity from 2012 to 2016. Linear and linear probability models were used to assess general time trends and regression-based difference-in-difference models to assess whether time trends differed for states that received a Voices grant. The data were analyzed in 2017. Results A total of 989 bills were introduced (Year 1=304, Year 2=364; Year 3=321), and a total of 93 bills were enacted (Year 1=34, Year 2=24, Year 3=35) after baseline. The mean number of bills introduced (baseline=4.3, Year 1=6.6, Year 2=7.3, Year 3=7.0, p=0.007), and the average state enactment rate (baseline=11%, Year 1=16%, Year 2=8%, Year 3=27%, p-trend=0.02) increased significantly. States with Voices grantees introduced 2.1 more bills than non-grantee states (p=0.04). The estimated difference over time in bill enactment and health equity focus did not differ by Voices grantee status. Conclusions Childhood obesity bill introduction and enactment increased between 2013 and 2016. The evidence-based advocacy supported by Voices appears to be significantly associated with greater increases in state-level bill introduction, but not enactment of legislation to address childhood obesity.

In a large, pragmatic clinical trial, we calculated the costs of achieving four successful patient-centered outcomes using a tailored patient activation DXA result letter accompanied by a bone health brochure. The cost to achieve one successful outcome (e.g., a 0.5 standard deviation improvement in care satisfaction) ranged from $127.41 to $222.75. Pragmatic randomized controlled trials (RCTs) should focus on patient-centered outcomes and report the costs for achieving those outcomes. We calculated per person incremental intervention costs, the number-needed-to-treat (NNT), and incremental per patient costs (cost per NNT) for four patient-centered outcomes in a direct-to-patient bone healthcare intervention. The Patient Activation after DXA Result Notification (PAADRN) pragmatic RCT enrolled 7749 patients presenting for DXA at three health centers between February 2012 and August 2014. Interviews occurred at baseline and 52 weeks post-DXA. Intervention subjects received an individually tailored DXA result letter accompanied by an educational bone health brochure 4 weeks post-DXA, while the usual care subjects did not. Outcomes focused on patients (a) correctly identifying their results, (b) contacting their providers, (c) discussing their results with their providers, and (d) satisfaction with their bone healthcare. NNTs were determined using intention-to-treat linear probability models, per person incremental intervention costs were calculated, and costs per NNT were computed. Mean age was 66.6 years old, 83.8% were women, and 75.3% were non-Hispanic whites. The incremental per patient cost (costs per NNT) to increase the ability of a patient to (a) correctly identify their DXA result was $171.07; (b) contact their provider about their DXA result was $222.75; (c) discuss their DXA result with their provider was $193.55; and (d) achieve a 0.5 SD improvement in satisfaction with their bone healthcare was $127.41. An individually tailored DXA result letter accompanied by an educational brochure can improve four patient-centered outcomes at a modest cost. clinicaltrials.gov identifier NCT01507662

Objective The aim of the study was to analyze factors predicting (a) the transition to parenthood for female same‐sex couples in Sweden and (b) which partner is the birth mother for the first and (any) second child. Background Longitudinal studies in which couples become parents are rare for same‐sex couples in any context, even though these families are increasing. Childbearing in lesbian couples is an interesting case for testing theories linked to family utility maximization and household bargaining, as these couples can often choose who will carry a child. Method Discrete‐time event history and linear probability models are estimated on Swedish population register data (1995–2016) to analyze couples' transitions to first and second birth and the choice of birth mother. Results The higher the household income and partners' educational levels, the more likely couples are to become parents. However, within‐couple income gaps are small, and income and education are unrelated to the choice of first‐birth mother. Couples are more likely to have a second child and to switch birth mothers if both are highly educated or the first social mother is highly educated. Conclusion Factors predicting which couples become parents are similar in same‐sex and different‐sex couples. In same‐sex couples, short‐term within‐couple specialization is of little relevance for who becomes the birth mother. Analyses of the transition to a second birth suggest that long‐term planning matters for who becomes the first‐ and second‐birth mother.

Background and Objectives The Diabetes Self-Management Program (DSMP) and Programa de Manejo Personal de la Diabetes (PMPD) have been shown to reduce complications from poorly controlled diabetes. Only a few research studies have examined Latino individuals’ participation in them. This study examines workshop completion among DSMP and PMPD participants and the effects of race/ethnicity, workshop language, workshop type, and workshop site on program completion rates by participants. Research Design and Methods We used data from the National Council on Aging’s data repository of individuals who participated in DSMP or PMPD between January 2010 and March 2019. Using a pooled cross-sectional study design, we examined workshop completion among 8,321 Latino and 23,537 non-Latino white (NLW) participants. We utilized linear probability models to estimate the effects of race/ethnicity and workshop language/type among the full sample; a stratified model estimated the separate effects of workshop language, type, and delivery site among Latinos. Participant characteristics included age, sex, education, number of chronic health conditions, living arrangement, health insurance status, and geographic location of workshop. Results Compared to NLW participants in DSMP English workshops, Latinos enrolled in any workshop had a higher probability of completing at least four workshop sessions, and Latinos enrolled in PMPD Spanish workshops had a higher probability of completing six of six sessions. Among the Latino subsample, participation in PMPD Spanish or English workshops was associated with completing at least four sessions or all six sessions compared with participation in DSMP Spanish or English workshops. Among Latino participants, the effects of workshop site on completion rates were mixed. Discussion and Implications Diabetes self-management education programs tailored for Latino participants had higher completion rates. Further research is warranted to better understand the effect of workshop site and participant characteristics on completion of DSMP and PMPD programs.

OBJECTIVES: Following the 2012 launch of the National Partnership to Improve Dementia Care in Nursing Homes (the National Partnership), the use of antipsychotics has declined. However, little is known about the impact of this effort on quality of care and outcomes for nursing home (NH) residents with Alzheimer’s disease and related dementia (ADRD). The objective of this study is to examine changes in hospitalizations for NH long-stay residents with ADRD after the launch of the National Partnership. DESIGN: Observational cross-sectional study. SETTING/PARTICIPANTS: NH residents who were newly admitted into NHs and became long-stay residents between January 2011 and March 2015 (n = 565,885). METHODS: We estimated linear probability models to explore the relationship between the National Partnership and the likelihood of NH-originated hospitalizations for NH long-stay residents with ADRD, accounting for facility fixed-effect, individual covariates, and concurrent changes in hospitalizations among residents without ADRD. We further stratified the analysis by NHs according to their prevalence of antipsychotic use at baseline (i.e. prior to the National Partnership). RESULTS: We detected a 0.7 percentage-point relative increase (p-value

This research deals with the problem of the client&ndash, valuer relationship, possibly resulting in valuation biases. It aims to identify the influence of age and professional experience, along with other specific factors, on the perception and susceptibility of valuation professionals to pressure exerted by clients during the valuation process. We hypothesize that susceptibility to pressure from clients is conditioned by a number of factors, among which age and work experience are of key importance. The analysis is based on information obtained in a survey among Polish valuers who are members of professional associations. We used the linear probability and logit models. The conclusions of the analysis allow us to take a critical look at the existing institutional framework of the valuation profession in Poland. Our recommendations for revising the system may provide insights on the evolution of the profession, especially in Central and Eastern European countries where it is relatively new.

This paper investigates changes between, and inequalities within, birth-cohorts in Italy, surrounding homeownership. Italy is a homeownership and familialistic society, where in recent decades an increasing ‘generational divide’ in employment prospects has opened up, as a side-effect of a partial and targeted labour market deregulation. Drawing on the interplay of macro-level constraints with micro-level factors, we discuss patterns of inequality in attaining homeownership between cohorts, arising from greater instability of employment for young adults, and within cohorts, stemming from class-based patterns of intergenerational wealth transmission. Our analytical strategy combines a sequential cohort design with two levels of analysis that simultaneously consider young people around the normative age of housing independence and wealth transmission from their families triggered by their leaving the nest. Longitudinal analyses apply random-effects probit models and linear probability distributed fixed-effects to panel data from the Bank of Italy (SHIW 1989−2016). Results show a decrease in homeownership attainment across cohorts, which can be partially ascribed to employment disadvantages faced by younger cohorts. On top of this, class-specific patterns of intergenerational transmission are in place: lower classes rely on timely housing wealth transfers, whereas upper classes are prepared to provide their children with an extended stream of financial transfers.

OBJECTIVE: To study whether workplace social relations explain use of worksite health promotion (WHP), by examining colleagues' and team managers' WHP encouragement of a healthy lifestyle, and colleague WHP uptake. METHODS: Multilevel data came from the second wave of the European Sustainable Workforce Survey (4345 employees of 402 team in 9 countries). Linear probability models were used to test use of two types of WHP: healthy menus and sport facilities. RESULTS: Employees are more likely to use healthy menus and sport facilities when more colleagues do so too and when colleagues encourage a healthy lifestyle. Surprisingly, encouragement by one's manager plays no role. CONCLUSIONS: Social contact among colleagues can facilitate WHP use, and WHP initiatives should pay attention to the influential role of colleagues.

Alcohol consumption, in particular excessive alcohol consumption, imposes high costs on societies through consequences, such as lost productivity, early mortality, health-care costs, car accidents and crime. The main objective of this study is to examine how drinking behavior developed over an economic boom, subsequent crisis, and an eventual recovery. We use individual longitudinal data collected through a postal survey by The Directorate of Health in Iceland in 2007, 2009, and 2012. Pooled OLS and linear probability models are used to study four outcomes: Alcohol-consumption frequency, frequency of binge drinking, binge-drinking participation and alcohol dependence. Alcohol-consumption frequency declined during the crisis, with a further decline during the recovery period. This change is driven by female behavior between 2007 and 2009, but a combined gender effect between 2009 and 2012. This effect is suppressed by male labor-market-changes, but partly mediated by labor marked changes in the case of females. Alcohol dependence declined during the crisis, with suggestive evidence of partially reverting back to previous levels during the recovery. There is some indication that during the crisis real price changes of alcohol played a role in the decline in alcohol consumption but that is not a likely determinant of changes in alcohol consumption for the 3 year period post-crisis that we explore. Men’s consumption can partly be explained through income changes while women’s consumption changes are rather driven by changes in work hours or other factors.

This study examines the birth weight of second and third-generation Hispanics born in California and Florida, two of the major immigrant destination states in the US. I exploit a unique dataset of linked birth records for two generations of children born in California and Florida (1970–2009) and linear probability models to investigate the generational decline in the birth outcomes of Hispanics in the US. The data allow using an extensive set of socio-demographic controls and breaking down the results by country of origin. Second-generation children of Mexican and Cuban origin have better birth outcomes than children of US-born white women. Children of Puerto Rican origin have instead worse birth outcomes. The advantage observed among second-generation Hispanics erodes substantially in the third generation but third-generation Mexicans retain some of it., Highlights • This study examines the birth weight of second and third-generation Hispanics. • I exploit a unique dataset of linked birth from California and Florida (1970–2009). • I investigate the generational decline in the birth outcomes of Hispanics in the US. • 2nd gen. Mexicans and Cubans exhibit an advantage in birth outcomes. • The advantage erodes substantially in the third generation. • Third-generation Mexicans retain some of it.

In this study, presence of multi-scale behaviour in rainfall IDF relationship has been established using Linear Probability Weighted Moments (LPWMs) for some selected stations in India. Simple, non-central moments (SMs) have seen widespread use in similar scaling studies but these latter statistical attributes are known to mask the ‘true’ scaling pattern and, consequently, leading to inappropriate inferences. There is a general agreement amongst researchers that conventional higher order moments do indeed amplify the extreme observations and drastically affect scaling exponents. Additional advantage of LPWMs over SMs is that they exist even when the standard moments do not exist. As an alternative, this study presents a comparison with results based on use of the robust LPWMs which have revealed, in sharp contrast with the conventional moments, a definitive multi-scaling behaviour in all four rainfall observation stations that were selected from different climatic zones. The multi-scale IDF curves derived using LPWMs show a good agreement with observations and it is accordingly concluded that LPWMs provide a more reliable tool for investigating scaling in sequences of observed rainfall corresponding to various durations.

Objectives To examine whether racial differences in end-of-life (EOL) hospitalizations vary according to the presence of advance directives, specifically do-not-hospitalize (DNH) orders, and individual cognitive status in nursing home (NH) residents. Design National data, including Medicare data and Minimum Data Set (MDS) 2.0, between January 1, 2007, and September 30, 2010, were linked. EOL hospitalizations were hospitalizations in the last 30 days of life. Linear probability models with an interaction term (between race and DNH) and NH fixed-effects were estimated. The analyses were stratified according to cognitive status. Setting Nursing homes in the United States. Participants Dually eligible Medicare–Medicaid decedents enrolled in Medicare fee-for-service plans and long-stay NH residents (in NHs ≥ 90 days before death) (N = 394,948). Measurements Racial difference in EOL hospitalizations from a NH. Results End-of-life hospitalization rate was 31.7% for whites and 42.8% for blacks. For participants without DNH orders, adjusted probability of EOL hospitalization was higher for blacks than for whites: 2.7 percentage points in those with moderate cognitive impairment (P < .001) and 4.7 percentage points in those with severe cognitive impairment (P < .001). For those with DNH orders, adjusted racial differences in EOL hospitalization were not statistically significant in those with moderate (P = .25) or severe (P = .93) cognitive impairment, but blacks had a higher probability of EOL hospitalization than whites if they had relatively intact cognitive status. Conclusion Racial differences in EOL hospitalization varied with DNH orders and cognitive status in dying residents. Future research is necessary to understand the reasons behind these variations.