Bottom Decile Research Articles

Commercial prices and care for Medicare beneficiaries with prostate cancer

ObjectiveTo examine the relationship between market dynamics, in the form of commercial prices paid to urologists, and utilization of services, as measured by Medicare spending, in men with newly diagnosed prostate cancer. MethodsWe performed a retrospective national cohort study of Medicare beneficiaries with newly diagnosed prostate cancer between 2014 and 2019, with follow-up through 2020.The primary exposure was the commercial price index (i.e., the ratio of commercial prices to Medicare prices for a common set of services performed by urologists). The primary outcome was Medicare spending for prostate cancer, in the 12-month period after diagnosis. ResultsAcross zip codes, commercial prices were, on average, 190% of Medicare prices (range 102-421%), with mean spending per beneficiary of $16,704. There was an inverse relationship between the price index and Medicare spending for men for prostate cancer. Specifically, standardized Medicare spending was $1,485 (95%CI $939 to $2,030) higher per beneficiary among those managed in zip codes at the bottom decile for commercial prices compared to the top decile. This effect was similar in the subgroup of men who underwent treatment, where standardized Medicare spending was $1,461 (95%CI $848 to $2,073) higher per beneficiary among those managed in zip codes in the bottom decile for commercial prices compared to the top decile. Conclusions and RelevanceCommercial prices for a set of frequently performed services are substantial higher than those paid by Medicare and vary widely across zip codes. Higher commercial prices were associated with significantly lower utilization, as measured by standardized Medicare spending, in men with newly diagnosed prostate cancer.

Commercial prices and their influence on urology practices: Prostate cancer care among men with Medicare.

For men with prostate cancer, there is substantial variation in the use of conservative management, such as active surveillance. Commercial prices, which vary across urology practices, may afford incentives that foster physician behaviors associated with utilization. Such behaviors may "spillover" to the Medicare population and affect quality. This study evaluated the effects of practice-level commercial prices on health care utilization and quality in men with prostate cancer insured by traditional Medicare. From a 20% Medicare sample, the authors identified men with newly diagnosed prostate cancer between 2014-2019 (n=44,653). Using commercial payments from the MarketScan database, they developed a practice-level commercial price index (ratio of commercial prices to Medicare prices). They examined the association of the price index with price standardized spending, overtreatment (treatment among those with >50% noncancer mortality within 10 years), and underuse of diagnostic testing in active surveillance (at least one prostate-specific antigen test and one confirmatory test-MRI, prostate biopsy, genomic test-within 12 months of diagnosis). Practice-level commercial price indices varied from 1.34 (134% of Medicare prices), for practices in the bottom decile, to 3.00, for practices in the top decile. Increasing price index was associated with lower odds of overtreatment (odds ratio, 0.86; 95% confidence interval, 0.76-0.97; p=.01), but not price standardized spending or underuse of diagnostic testing in active surveillance. Commercial prices vary markedly across urology practices. Among newly diagnosed men with traditional Medicare, those managed by practices with higher commercial price indices had lower odds of overtreatment, suggesting improved prostate cancer care quality.

Who Bears the Welfare Costs of Monopoly? The Case of the Credit Card Industry

Abstract We measure the distribution of welfare losses from non-competitive behaviour in the U.S. credit card industry during the 1970s and 1980s. The early credit card industry was characterized by regional monopolies. Ensuing legal decisions led to competitive reforms that resulted in greater, but still limited, oligopolistic competition. We measure the distributional consequences of these reforms by developing and estimating a heterogeneous agent, defaultable debt framework with oligopolistic lenders. The transition from monopoly to oligopolistic competition yields welfare gains equivalent to a one-time transfer worth $3,600 (in 2016 dollars) for the bottom decile of earners (roughly 50% of their annual income) versus $1,200 for the top decile of earners. As the credit market expands, low-income households benefit more since they rely disproportionately on credit to smooth consumption. Greater competition also explains rising bankruptcies, chargeoffs, and credit to income ratios. Lastly, we bound the welfare gains from competition by computing a perfectly competitive benchmark. Aggregate welfare gains are 40% larger from perfect competition but distributed similarly to oligopolistic competition.

Unionization rates, inequality, and poverty in Canadian provinces 2000–2020

Unions can increase the power of workers through both collective bargaining and political avenues, potentially creating less income inequality and poverty. However, this potential may not be realized. Drawing on power resource theory, this study uses panel data to investigate the connection between unionization and two measures of after-tax inequality – the income share of the top 1% and the Gini coefficient – and three measures of poverty – the percentage of the population below the low-income cut-off, the average income of the bottom decile, and the percent of the population below the low-income measure – between Canadian provinces from 2000 to 2020. We find that unionization is negatively associated with income inequality in Canada. This relationship is statistically significant. However, we do not find evidence of any statistical association between unionization and poverty in Canada.

Exploring the linguistic complexity of third-grade numerical literacy

Reading numbers aloud, a central aspect of numerical literacy, is a challenging skill to acquire, but the origins of this difficulty remain poorly understood. To investigate this matter, we examined the performance of 127 third- and fourth-grade children who read aloud, in Hebrew, numbers with 2–5 digits. We found several key observations. First, we observed a substantial variation among the 3rd graders—7% and 59% errors in the top and bottom deciles, respectively. Second, the task difficulty stemmed from syntactic processing: Most errors were distortions of the number’s syntax, as opposed to digit substitutions or transpositions, and the main factor affecting a specific number’s difficulty was not its magnitude, as is commonly assumed, but rather its syntactic structure. Third, number reading performance was not predicted by a school-like task that assessed syntactic-conceptual knowledge of the decimal system structure, but rather by knowledge of specific syntactic-verbal rules, suggesting that the syntactic-verbal knowledge is separate from the syntactic-conceptual knowledge. Last, there was a double dissociation between 4-digit numbers and 5-digit numbers, which in Hebrew have completely different syntactic structures: Half of the children showed a significant advantage in one number length compared to the other, with equal numbers of children preferring either length. This indicates that the different syntactic-verbal rules are learned relatively independently of each other, with little or no generalization from one rule to another. In light of these findings, we propose that schools should specifically teach number reading, with focus on specific syntactic-verbal rules.

A polygenic risk score for alcohol-associated cirrhosis among heavy drinkers with European ancestry.

Polygenic Risk Scores (PRS) based on results from genome-wide association studies offer the prospect of risk stratification for many common and complex diseases. We developed a PRS for alcohol-associated cirrhosis by comparing single-nucleotide polymorphisms among patients with alcohol-associated cirrhosis (ALC) versus drinkers who did not have evidence of liver fibrosis/cirrhosis. Using a data-driven approach, a PRS for ALC was generated using a meta-genome-wide association study of ALC (N=4305) and an independent cohort of heavy drinkers with ALC and without significant liver disease (N=3037). It was validated in 2 additional independent cohorts from the UK Biobank with diagnosed ALC (N=467) and high-risk drinking controls (N=8981) and participants in the Indiana Biobank Liver cohort with alcohol-associated liver disease (N=121) and controls without liver disease (N=3239). A 20-single-nucleotide polymorphisms PRS for ALC (PRSALC) was generated that stratified risk for ALC comparing the top and bottom deciles of PRS in the 2 validation cohorts (ORs: 2.83 [95% CI: 1.82 -4.39] in UK Biobank; 4.40 [1.56 -12.44] in Indiana Biobank Liver cohort). Furthermore, PRSALC improved the prediction of ALC risk when added to the models of clinically known predictors of ALC risk. It also stratified the risk for metabolic dysfunction -associated steatotic liver disease -cirrhosis (3.94 [2.23 -6.95]) in the Indiana Biobank Liver cohort -based exploratory analysis. PRSALC incorporates 20 single-nucleotide polymorphisms, predicts increased risk for ALC, and improves risk stratification for ALC compared with the models that only include clinical risk factors. This new score has the potential for early detection of heavy drinking patients who are at high risk for ALC.

Reduced Ejection Fraction in Elite Endurance Athletes: Clinical and Genetic Overlap With Dilated Cardiomyopathy.

Exercise-induced cardiac remodeling can be profound, resulting in clinical overlap with dilated cardiomyopathy, yet the significance of reduced ejection fraction (EF) in athletes is unclear. The aim is to assess the prevalence, clinical consequences, and genetic predisposition of reduced EF in athletes. Young endurance athletes were recruited from elite training programs and underwent comprehensive cardiac phenotyping and genetic testing. Those with reduced EF using cardiac magnetic resonance imaging (defined as left ventricular EF <50%, or right ventricular EF <45%, or both) were compared with athletes with normal EF. A validated polygenic risk score for indexed left ventricular end-systolic volume (LVESVi-PRS), previously associated with dilated cardiomyopathy, was assessed. Clinical events were recorded over a mean of 4.4 years. Of the 281 elite endurance athletes (22±8 years, 79.7% male) undergoing comprehensive assessment, 44 of 281 (15.7%) had reduced left ventricular EF (N=12; 4.3%), right ventricular EF (N=14; 5.0%), or both (N=18; 6.4%). Reduced EF was associated with a higher burden of ventricular premature beats (13.6% versus 3.8% with >100 ventricular premature beats/24 h; P=0.008) and lower left ventricular global longitudinal strain (-17%±2% versus -19%±2%; P<0.001). Athletes with reduced EF had a higher mean LVESVi-PRS (0.57±0.13 versus 0.51±0.14; P=0.009) with athletes in the top decile of LVESVi-PRS having an 11-fold increase in the likelihood of reduced EF compared with those in the bottom decile (P=0.034). Male sex and higher LVESVi-PRS were the only significant predictors of reduced EF in a multivariate analysis that included age and fitness. During follow-up, no athletes developed symptomatic heart failure or arrhythmias. Two athletes died, 1 from trauma and 1 from sudden cardiac death, the latter having a reduced right ventricular EF and a LVESVi-PRS >95%. Reduced EF occurs in approximately 1 in 6 elite endurance athletes and is related to genetic predisposition in addition to exercise training. Genetic and imaging markers may help identify endurance athletes in whom scrutiny about long-term clinical outcomes may be appropriate. URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374976&isReview=true; Unique identifier: ACTRN12618000716268.

Genome-wide analysis in over 1 million individuals of European ancestry yields improved polygenic risk scores for blood pressure traits.

Hypertension affects more than one billion people worldwide. Here we identify 113 novel loci, reporting a total of 2,103 independent genetic signals (P < 5 × 10-8) from the largest single-stage blood pressure (BP) genome-wide association study to date (n = 1,028,980 European individuals). These associations explain more than 60% of single nucleotide polymorphism-based BP heritability. Comparing top versus bottom deciles of polygenic risk scores (PRSs) reveals clinically meaningful differences in BP (16.9 mmHg systolic BP, 95% CI, 15.5-18.2 mmHg, P = 2.22 × 10-126) and more than a sevenfold higher odds of hypertension risk (odds ratio, 7.33; 95% CI, 5.54-9.70; P = 4.13 × 10-44) in an independent dataset. Adding PRS into hypertension-prediction models increased the area under the receiver operating characteristic curve (AUROC) from 0.791 (95% CI, 0.781-0.801) to 0.826 (95% CI, 0.817-0.836, ∆AUROC, 0.035, P = 1.98 × 10-34). We compare the 2,103 loci results in non-European ancestries and show significant PRS associations in a large African-American sample. Secondary analyses implicate 500 genes previously unreported for BP. Our study highlights the role of increasingly large genomic studies for precision health research.

Boomerang children and parental retirement outcomes

AbstractAs the share of U.S. adult children living with their parents increases, it is important to understand how children who “boomerang” back home impact their parents in their pre-retirement and post-retirement years. We use data from the Health and Retirement Study (HRS) to examine the effects of boomerang children on their parents’ labor market expectations and choices, as well as on their wealth, health, and life satisfaction. Event study analysis suggests that boomerang children return home due to short-term instabilities, such as negative shocks to marriage, income, and employment. We find that boomerang children are associated with a small increase in their parents’ subjective probability of working after age 65, and with a temporary increase in their parents’ non-housing debt. However, in the aggregate, we find no clear evidence that boomerang children impact parents’ current or future labor market choices, overall wealth, health, or life satisfaction. (We do find some evidence of an increase in hours worked among parents in the bottom wealth decile). One possible explanation for the lack of aggregate impact is that boomerang children contribute to household expenses. We find that boomerang events are associated with an increase in financial transfers from children to parents, particularly among parents in the bottom half of the wealth distribution.

Strengthening Quality Measurement to Predict Success for Total Knee Arthroplasty: Results from a Nationally Representative Total Knee Arthroplasty Cohort.

When performed well on appropriate patients, total knee arthroplasty (TKA) can dramatically improve quality of life. Patient-reported outcome measures (PROMs) are increasingly used to measure outcome following TKA. Accurate prediction of improvement in PROMs after TKA potentially plays an important role in judging the surgical quality of the health-care institutions as well as informing preoperative shared decision-making. Starting in 2027, the U.S. Centers for Medicare & Medicaid Services (CMS) will begin mandating PROM reporting to assess the quality of TKAs. Using data from a national cohort of patients undergoing primary unilateral TKA, we developed an original model that closely followed a CMS-proposed measure to predict success, defined as achieving substantial clinical benefit, specifically at least a 20-point improvement on the Knee injury and Osteoarthritis Outcome Score, Joint Arthroplasty (KOOS, JR) at 1 year, and an enhanced model with just 1 additional predictor: the baseline KOOS, JR. We evaluated each model's performance using the area under the receiver operator characteristic curve (AUC) and the ratio of observed to expected (model-predicted) outcomes (O:E ratio). We studied 5,958 patients with a mean age of 67 years; 63% were women, 93% were White, and 87% were overweight or obese. Adding the baseline KOOS, JR improved the AUC from 0.58 to 0.73. Ninety-four percent of those in the top decile of predicted probability of success under the enhanced model achieved success, compared with 34% in its bottom decile. Analogous numbers for the original model were less discriminating: 77% compared with 57%. Only the enhanced model predicted success accurately across the spectrum of baseline scores. The findings were virtually identical when we replicated these analyses on only patients ≥65 years of age. Adding a baseline knee-specific PROM score to a quality measurement model in a nationally representative cohort dramatically improved its predictive power, eliminating ceiling and floor effects and mispredictions for readily identifiable patient subgroups. The enhanced model neither favors nor discourages care for those with greater knee dysfunction and requires no new data collection. Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Genetic and Environmental Factors and Cardiovascular Disease Risk in Adolescents

Cardiovascular risk factors in youth have been associated with future cardiovascular disease (CVD), but conventional observational studies are vulnerable to genetic and environmental confounding. To examine the role of genetic and environmental factors shared by full siblings in the association of adolescent cardiovascular risk factors with future CVD. This is a nationwide cohort study with full sibling comparisons. All men who underwent mandatory military conscription examinations in Sweden between 1972 and 1995 were followed up until December 31, 2016. Data analysis was performed from May 1 to November 10, 2022. Body mass index (BMI), cardiorespiratory fitness, blood pressure, handgrip strength, and a combined risk z score in late adolescence. The primary outcome was fatal or nonfatal CVD, as recorded in the National Inpatient Register or the Cause of Death Register before 2017. A total of 1 138 833 men (mean [SD] age, 18.3 [0.8] years), of whom 463 995 were full brothers, were followed up for a median (IQR) of 32.1 (26.7-37.7) years, during which 48 606 experienced a CVD outcome (18 598 among full brothers). All risk factors were associated with CVD, but the effect of controlling for unobserved genetic and environmental factors shared by full siblings varied. In the sibling analysis, hazard ratios for CVD (top vs bottom decile) were 2.10 (95% CI, 1.90-2.32) for BMI, 0.77 (95% CI, 0.68-0.88) for cardiorespiratory fitness, 1.45 (95% CI, 1.32-1.60) for systolic blood pressure, 0.90 (95% CI, 0.82-0.99) for handgrip strength, and 2.19 (95% CI, 1.96-2.46) for the combined z score. The percentage attenuation in these hazard ratios in the sibling vs total cohort analysis ranged from 1.1% for handgrip strength to 40.0% for cardiorespiratory fitness. Consequently, in the sibling analysis, the difference in cumulative CVD incidence at age 60 years (top vs bottom decile) was 7.2% (95% CI, 5.9%-8.6%) for BMI and 1.8% (95% CI, 1.0%-2.5%) for cardiorespiratory fitness. Similarly, in the sibling analysis, hypothetically shifting everyone in the worst deciles of BMI to the middle decile would prevent 14.9% of CVD at age 60 years, whereas the corresponding number for cardiorespiratory fitness was 5.3%. In this Swedish national cohort study, cardiovascular risk factors in late adolescence, especially a high BMI, were important targets for CVD prevention, independently of unobserved genetic and environmental factors shared by full siblings. However, the role of adolescent cardiorespiratory fitness in CVD may have been overstated by conventional observational studies.

Genetic Risk Assessment of Degenerative Eye Disease (GRADE): study protocol of a prospective assessment of polygenic risk scores to predict diagnosis of glaucoma and age-related macular degeneration

BackgroundGlaucoma and age-related macular degeneration (AMD) account for a substantial portion of global blindness. Both conditions are highly heritable, with recognised monogenic and polygenic inheritance patterns. Current screening guidelines lack decisive recommendations. Polygenic risk scores (PRS) allow for cost-effective broad population risk stratification for these conditions. The predictive potential of PRS could facilitate earlier diagnosis and treatment, and prevent unnecessary vision loss.MethodsThe Genetic Risk Assessment of Degenerative Eye disease (GRADE) study is a prospective study designed to generate high-quality evidence about the feasibility of PRS to stratify individuals from the general population, enabling identification of those at highest risk of developing glaucoma or AMD. The targeted recruitment is 1000 individuals aged over 50 years, from which blood or saliva samples will be used for genotyping and an individual PRS for glaucoma and AMD will be derived. Individuals with PRS values in the bottom decile (n = 100), top decile (n = 100) and middle 80% (n = 100) for both glaucoma and AMD will undergo a detailed eye examination for glaucoma and/or AMD.DiscussionThe primary objective will be to compare the prevalence of glaucoma and AMD cases between low, intermediate, and high PRS risk groups. We expect to find a higher prevalence of both diseases in the high PRS risk group, as compared to the middle and low risk groups. This prospective study will assess the clinical validity of a PRS for glaucoma and AMD in the general Australian population. Positive findings will support the implementation of PRS into clinical practice.

Water affordability across and within European countries: a microdata analysis

We analyze water affordability in 23 European countries using the latest microdata from the European Household Budget Survey.Average affordability ratios vary considerably across countries, from 0.85% (Ireland) to 4.7% (Poland).The prevalence of affordability problems is highest in Poland (60%), while intensity is greatest in Finland (families with problems spend, on average, 9% of their income). The analysis by income deciles shows a gradient, with affordability problems generally concentrated in bottom deciles, though they are not exclusive to the poorest. This variation in affordability problems occurs within countries regardless of their high or low average affordability ratio.

194-LB: Aggregate Effect of Hemoglobin A1c–Related Genetic Variants on A1c–Glycemia Discordance by Ancestry

Introduction: The aggregate effect of genetic variants reported to lower A1c independently of glycemia by ancestry remains unclear. Methods: We recalled 177 patients from the Mass General Brigham biobank with genetic data, enriching recruitment for carriers of the African G6PD variant (rs1050828), α thalassemia 3.7kb deletion, and people in the tails of a European polygenic score (PS) composed of variants associated with A1c but not glucose in GWAS. Subjects underwent 14 days of continuous glucose monitoring (CGM). We defined genetic ancestry using principal component analysis, and calculated A1c-glycemia discordance (measured A1c minus estimated A1c by CGM; ADAG study equation). Results: Measured A1c and mean glucose were correlated in all groups (r2&amp;gt;0.9). Mean A1c-glycemia discordance was 0.4%-unit higher in African vs. European ancestry. In African ancestry, discordance was 0.5%-unit lower in carriers of the G6PD T allele vs. noncarriers. The bottom decile of PS had 0.3%-unit lower discordance vs. top decile (Figure; p&amp;lt;0.01; all comparisons). Discordance was similar regardless of α thalassemia deletion. Conclusions: While A1c is an excellent proxy for glycemia in all groups, the A1c-glucose relationship differed by genotype and ancestry. Genetic variation should be considered to promote care equity in diverse populations and avoid misestimating glycemia when using A1c in clinical practice. Disclosure N. Thangthaeng: None. M. N. Facibene: None. S. Kartik: None. R. Mandla: None. P. H. Schroeder: None. N. R. Norgil: None. J. M. Mercader: None. A. Leong: Other Relationship; Merck &amp; Co., Inc. Funding Doris Duke Charitable Foundation (2020096)

Genome-wide polygenic risk score for major osteoporotic fractures in postmenopausal women using associated single nucleotide polymorphisms

BackgroundOsteoporosis is highly polygenic and heritable, with heritability ranging from 50 to 80%; most inherited susceptibility is associated with the cumulative effect of many common genetic variants. However, existing genetic risk scores (GRS) only provide a few percent predictive power for osteoporotic fracture.MethodsWe derived and validated a novel genome-wide polygenic score (GPS) comprised of 103,155 common genetic variants to quantify this susceptibility and tested this GPS prediction ability in an independent dataset (n = 15,776).ResultsAmong postmenopausal women, we found a fivefold gradient in the risk of major osteoporotic fracture (MOF) (p < 0.001) and a 15.25-fold increased risk of severe osteoporosis (p < 0.001) across the GPS deciles. Compared with the remainder of the GPS distribution, the top GPS decile was associated with a 3.59-, 2.48-, 1.92-, and 1.58-fold increased risk of any fracture, MOF, hip fracture, and spine fracture, respectively. The top GPS decile also identified nearly twofold more high-risk osteoporotic patients than the top decile of conventional GRS based on 1103 conditionally independent genome-wide significant SNPs. Although the relative risk of severe osteoporosis for postmenopausal women at around 50 is relatively similar, the cumulative incident at 20-year follow-up is significantly different between the top GPS decile (13.7%) and the bottom decile (< 1%). In the subgroup analysis, the GPS transferability in non-Hispanic White is better than in other racial/ethnic groups.ConclusionsThis new method to quantify inherited susceptibility to osteoporosis and osteoporotic fracture affords new opportunities for clinical prevention and risk assessment.

The Inequity Z: Income Fairness Perceptions in Europe across the Income Distribution

Using data from the European Social Survey, we examine income fairness evaluations of 17,605 respondents from 28 countries. Respondents evaluated the fairness of their own incomes as well as the fairness of the incomes of the top and bottom income deciles in their countries. Depicted on a single graph, these income fairness evaluations take on a Z-shaped form, which we call the “inequity Z”. The inequity Z reveals an extensive level of consensus within each country regarding the degree of unfairness of top and bottom incomes. With rising income, respondents consistently judge their own incomes to be less unfair. Across countries, the gap in fairness ratings between top and bottom incomes rises with income inequality. Perceived underreward of bottom incomes is more pronounced in countries where bottom incomes are objectively lower. Thus, this visualization suggests that, when people are confronted with information about actual income levels, perceived inequity increases with inequality.

The impact of ESG tilting on the performance of stock portfolios in times of crisis

This paper investigates whether there exists a clear relationship between ESG indicators and financial performance with specific reference to the CoVid-19 crisis and to discover what are, if any, the key takeaways for issuers that emerge from such relationship. To assess this connection, we carried out an ESG scores based long-short portfolio analysis in the spirit of Fama and French (1992) on the European market in the period 2016‒2021. The results indicate that there is robust evidence that the bottom decile portfolio provides negative alphas and some weak evidence that the long-short portfolio provides some positive abnormal returns compared to all three most prominent asset pricing models (CAPM, Fama-French three-factor model and Fama-French five-factor model).

Understanding Hospital-Level Patterns of Nonoperative Management for Low-risk Thyroid and Kidney Cancer

There is a growing trend toward conservative management for certain low-risk cancers. Hospital and health-system factors may play a role in determining how these patients are managed. To explore the contribution of hospitals on patients' odds of nonoperative management for low-risk cancer. In this cross-sectional study, individuals with low-risk papillary thyroid cancer and solitary kidney masses were identified, and those receiving nonoperative management vs surgery were compared. Patients with low-risk thyroid cancer and kidney cancer from 2015 to 2017 eligible for nonoperative management according to National Comprehensive Cancer Network guidelines within the National Cancer Database were included. Data were analyzed from October 2021 to March 2022. For each facility, the proportion of these patients who received operative and nonoperative management was calculated. A mixed-effects logistic regression model with a hospital-level random effects term was used to calculate factors associated with nonoperative management. Between-hospital variability was assessed using ranked caterpillar plots. There were 19 570 individuals with low-risk thyroid cancer (15 344 women [78.4%]; mean [SD] age, 51.74 [95% CI, 51.39-52.08] years) and 41 403 with kidney cancer (25 253 men [61.0%]; mean [SD] age, 61.93 [95% CI, 61.70-62.17] years). In the group with low-risk thyroid cancer, 2.1% (419 patients) received nonoperative management, and in the group with kidney cancer, 9.5% (3928 patients) received nonoperative management. This varied between hospitals from 1.1% (95% CI, 1.0%-1.1%) in the bottom decile to 10.3% (95% CI, 8.0%-12.4%) in the top decile for low-risk thyroid cancer, and from 4.3% (95% CI, 4.1%-4.4%) in the bottom decile to 24.6% (95% CI, 22.7%-26.5%) in the top decile for small kidney masses. For both cancers, age was associated with increased odds of nonoperative treatment. The hospital-level odds of nonoperative management of thyroid and kidney cancer using unadjusted probabilities (observed proportions) were minimally correlated (Spearman ρ = .33; P < .001). The findings of this study suggest that although health systems factors may be associated with the tendency to pursue nonoperative management, hospital-level factors may differ when comparing unrelated cancers.

Globally unequal effect of extreme heat on economic growth.

Increased extreme heat is among the clearest impacts of global warming, but the economic effects of heat waves are poorly understood. Using subnational economic data, extreme heat metrics measuring the temperature of the hottest several days in each year, and an ensemble of climate models, we quantify the effect of extreme heat intensity on economic growth globally. We find that human-caused increases in heat waves have depressed economic output most in the poor tropical regions least culpable for warming. Cumulative 1992-2013 losses from anthropogenic extreme heat likely fall between $5 trillion and $29.3 trillion globally. Losses amount to 6.7% of Gross Domestic Product per capita per year for regions in the bottom income decile, but only 1.5% for regions in the top income decile. Our results have the potential to inform adaptation investments and demonstrate how global inequality is both a cause and consequence of the unequal burden of climate change.

Profiles of GPs with high and low self-reported physician empathy—personal, professional, and antibiotic prescribing characteristics

BackgroundGeneral Practitioners’ (GPs) professional empathy has been hypothesized to have substantial impact on their healthcare delivery and medication prescribing patterns. This study compares profiles of personal, professional, and antibiotic prescribing characteristics of GPs with high and low empathy.MethodsWe apply an extreme group approach to a unique combined set of survey and drug register data. The survey included questions about demographic, professional, and antibiotic prescribing characteristics, as well as the Jefferson Scale of Empathy for Health Professionals (JSE-HP) to assess self-reported physician empathy. It was sent to a stratified sample of 1,196 GPs comprising 30% of the Danish GP population of whom 464 (38.8%) GPs responded. GPs in the top and bottom decile of empathy levels were identified. All intra- and inter-profile descriptive statistics and differences were bootstrapped to estimate the variability and related confidence intervals. Results61% of GPs in the top decile of the empathy score were female. GPs in this decile reported the following person-centered factors as more important for their job satisfaction than the bottom decile: The Patient-physician relationship, interaction with colleagues, and intellectual stimulation. High-empathy scoring GPs prescribed significantly less penicillin than the low-empathy GPs. This was true for most penicillin subcategories. There were no significant differences in age, practice setting (urban vs. rural), practice type (partnership vs. single-handed), overall job satisfaction, or GP’s value of prestige and economic profit for their job satisfaction. The intra profile variation index and confidence intervals show less prescribing uncertainty among GPs with high empathy.ConclusionsThis study reveals that high empathy GPs may have different personal, professional, and antibiotic prescribing characteristics than low empathy GPs and have less variable empathy levels as a group. Furthermore, person-centered high empathy GPs on average seem to prescribe less penicillins than low empathy GPs.