Difference In Difference Analysis Research Articles

The impact of policies controlling government hospital development on the number and scale of government and private hospitals: A DID analysis

Since 2013, the state has introduced a number of policies to strictly control the number and scale of public hospitals and to control the rapid expansion of public hospitals. After the introduction of this series of policies, the number of public hospitals in China did not continue to grow, but the number of beds in public hospitals continued to grow. This paper uses difference-in-difference (DID) method to analyze the number of public hospitals with the corresponding data of the development of private hospitals after the introduction of the policy, and the results proves that the introduction of relevant policies has an impact on the number of public hospitals, but has a limited impact on the expansion of the scale of public hospitals. At the end of the article, positive policy suggestions are given to the development of hospitals in China, such as controlling the expansion of public hospitals, strictly controlling the number of beds in public hospitals, and vigorously developing private hospitals. Promoting the development of private hospitals is an important economic supplement to China’s health care.

The Impact of Medicaid Expansion on Stage at Diagnosis of Melanoma Patients: A Retrospective Study.

This study addresses the lack of research on Medicaid expansion's impact on melanoma staging, treatment utilization, and outcomes by evaluating its effects under the Affordable Care Act (ACA), particularly focusing on staging at diagnosis, treatment use, and 3-year mortality outcomes. The objective is to determine whether Medicaid expansion led to earlier melanoma diagnosis and improved survival rates among non-elderly adults (ages 40-64) by analyzing data from the National Cancer Database (NCDB). A total of 12,667 patients, aged 40-64, diagnosed with melanoma from 2010 to 2020 were identified using the NCDB. Difference-in-difference (DID) analysis was performed to analyze tumor staging at presentation between Medicaid expansion states and non-Medicaid expansion states both prior to the expansion and after the expansion. Of the total patients, 2307 were from the pre-expansion time period residing in Medicaid expansion states (MES) and 1804 in non-Medicaid expansion states. In the post-expansion time period there were 5571 residing in the MES and 2985 in the non-MES. DID analysis revealed a decrease in stage IV melanoma at diagnosis (DID -0.222, p < 0.001) between MES and non-MES before and after Medicaid expansion. After expansion, in stage IV, the occurrence of primary surgery was 0.42 in non-MES and 0.44 (difference 0.02); DID analysis was not statistically significant. The use of immunotherapy in MES was significantly higher than in non-MES after expansion (p < 0.001), although DID analysis did not reveal a statistically significant difference. DID analysis showed a statistically significant decrease in 3-year mortality (DID -0.05, p = 0.001) between MES and non-MES before and after Medicaid expansion. This study revealed the positive impact of the ACA's Medicaid expansion on melanoma stage at presentation, highlighting the importance of public health policies in reducing disparities in mortality rates and early-stage diagnoses. Future research should explore additional barriers to care and evaluate the long-term outcomes of Medicaid expansion to optimize cancer care for vulnerable populations.

Medicare’s comprehensive care for joint replacement model increased public hospitals' inpatient length of stay

BackgroundThe Comprehensive Care for Joint Replacement (CJR) model is an alternative Medicare payment model for joint replacement that mandated participation by hospitals in randomly selected Metropolitan Statistical Areas (MSAs). On average, the program decreased inpatient length of stay and increased home discharge rates. It is unclear if these effects differed based on hospital ownership type, even though ownership may impact care redesign opportunities.MethodsWe used the 2014–2017 California Patient Discharge Datasets. The study included 113,590 hospitalizations for hip and knee joint replacement from 287 hospitals in the treated and control MSAs in California. The primary outcomes were inpatient length of stay and home discharge rates. Home discharge status included self-care, the use of home health, and hospice care at home. To determine whether the impact of the CJR model differed by hospital ownership type, we used event study, difference-in-differences (DID), and triple differences (DDD) models to estimate changes in health care services utilization in treated relative to control areas before versus after CJR implementation (April 2016) by hospital ownership type.ResultsOf the 113,590 hospitalizations, 51,708 (45.52%) were in treated MSAs and 61,882 (54.48%) were in control MSAs; 81,649 (71.88%) were from nonprofit hospitals, 20,247 (17.82%) were from for-profit hospitals, and 11,694 (10.29%) were from government-owned hospitals. DID analyses showed that after policy implementation, nonprofit and for-profit hospitals experienced a decrease in inpatient length of stay of 0.02 days (95% CI, -0.04 to -0.01) and 0.04 days (95% CI, -0.06 to -0.01), respectively, while government-owned hospitals experienced an increase by 0.11 days (95% CI, 0.04 to 0.18). For home discharge rates, nonprofit hospitals experienced an increase of 0.02 (95% CI, 0.01 to 0.03), while other hospitals did not show statistically significant changes. DDD analyses confirmed that inpatient length of stay increased in public compared to nonprofit hospitals in treated relative to control MSAs after policy implementation.ConclusionsThe impacts of the CJR program differed by hospital ownership type. Government-owned hospitals, with their unique financial circumstances, may have faced challenges that hindered the reductions in inpatient length of stay observed in other types of hospitals under the CJR Model.

Effectiveness of glucagon-like peptide-1 receptor agonists for reduction of body mass index and blood glucose control in patients with type 2 diabetes mellitus and obesity: A retrospective cohort study and difference-in-difference analysis

ObjectiveThis study aimed to evaluate the effectiveness of glucagon-like peptide-1 receptor agonists (GLP-1RA) in reducing body mass index (BMI) and blood glucose levels in individuals with type 2 diabetes mellitus...

Abstract 4120515: Impact of 2022 AHA/ACC/HFSA Heart Failure Guideline Value Statement Publication on Medicare Drug Coverage Policies

Background: Patients with heart failure (HF) often have difficulty obtaining life-saving medications due to coverage barriers, such as prior authorizations (PA) and high out of pocket (OOP) costs. To promote better insurance coverage of high value therapies, the AHA/ACC/HFSA added Value Statements to HF guidelines to inform policymakers about medication cost effectiveness. We assessed whether these guidelines influenced Medicare drug coverage policies for two life-saving, costly HF medications: angiotensin receptor neprilysin inhibitors (ARNI – guideline “high value”) and sodium glucose cotransporter 2 inhibitors (SGLT2i – guideline “intermediate value”). Methods: We performed an observational study of Medicare drug plans from 4/2020-4/2023 to assess for changes in ARNI and SGLT2i coverage after Value Statement publication (4/2022), and subsequent Medicare plan online update (10/2022). The primary outcome was any barrier to drug coverage (PA, tier ≥ 3 OOP cost-sharing, step therapy, or no coverage). Analysis utilized interrupted time series and difference-in-difference (DiD) approaches. DiD analyses used direct oral anticoagulants as a control due to similar cost and utilization as ARNI and SGLT2i, but with no Value Statement. Results: Among 7,396 Medicare drug plans, 94.3%-97.4% had coverage barriers to ARNI and 93.2%-96.6% to SGLT2i. The majority of barriers were due to tier ≥ 3 OOP cost-sharing requirements (ARNI: 94.3%-95.8%; SGLT2i: 93.2%-95.6%). Coverage barriers remained stable in 4/2022, and declined slightly in 10/2022 (Figure). In DiD analyses, the presence of a Value Statement was associated with a ~1 percentage point decline in coverage barriers for ARNI and SGLT2i. Conclusion: Coverage barriers to ARNI and SGLT2i were common and did not change much in response to Value Statements in HF Guidelines. Increased consideration for Value Statements by Medicare policy-makers is needed to meaningfully improve access to high value therapies.

The Impact of High-Standard Scenic Areas Construction on County-Level Carbon Emissions and Its Spatial Spillover Effects: Evidence from a Quasi-Natural Experiment

This study investigated for the first time the tourism–carbon emissions nexus based on the destination construction perspective, using the China’s national scenic areas (CNSA) construction as a vehicle for concretization. A multi-source county panel dataset of 29,628 samples was constructed. The staggered Difference-in-Differences (DID) model and spatial DID model were further formulated. The findings show that: (1) the CNSA resulted in a 0.1024% reduction in carbon emission intensity (CEI) in treatment counties relative to non-treatment counties, and although the effect exhibits a delay, it persists and intensifies over time; (2) our heterogeneity results indicate that the inhibiting effect is significantly more pronounced in the western, eastern, and county subsamples; and (3) the spatial DID analysis reveals that the CNSA exerts a negative spatial spillover effect on CEI. This work enhances comprehension of the tourism–carbon emissions nexus, with implications for advancing regional carbon emission reduction policy strategies.

ANALYZING THE IMPACT OF INDONESIAN SUSTAINABLE PALM OIL (ISPO) CERTIFICATION AND THE FACTORS THAT INFLUENCE CRUDE PALM OIL (CPO) EXPORTS VOLUME

This study examines the impact of Indonesian Sustainable Palm Oil (ISPO) certification on Indonesian Crude Palm Oil exports and other factors, such as commodity production and prices, exchange rates, and production levels. The data covers total CPO volume (HS codes 15111000 and 15119000) from January 2006 to December 2022, focusing on ISPO certification for large State-owned and Private Enterprises in palm oil cultivation and processing. The analysis employs the Difference-in-Differences (DID) method and multiple linear regression (MLR) to identify the linear relationship between the dependent and independent variables. The DID analysis revealed that Indonesian CPO production and global CPO prices significantly affected CPO export volumes, while soybean oil prices and effective exchange rates were not statistically significant in the regression model. The results provide valuable insights for policymakers and industry stakeholders in developing strategies that support sustainable growth, enhance competitiveness, and maintain Indonesia's leading position in the global palm oil market. Policymakers should focus on encouraging broader adoption of ISPO among palm oil producers through incentives, training, and technical support, especially for smaller producers.

Assessing the impact of a gastrointestinal cancer diagnosis on mental health claims among coinsured household family members

BackgroundGastrointestinal (GI) cancer diagnosis can adversely affect the mental health (MH) of household members, including spouses and children. We sought to examine potential changes in MH claims in households following an index patient’s GI cancer diagnosis. MethodsHouseholds of patients with a GI cancer diagnosis were identified using the IBM MarketScan database (2014–2019) and matched with households of patients without cancer. MH-related visits of spouses and children were assessed in the 12 months before and after the index date of diagnosis. Changes were compared between the two cohorts using difference-in-difference (DID) analysis. ResultsAmong 40,650 households in the spouse analysis and 20,014 households in the child analysis, 25.1% (n = 10,210) and 26.8% (n = 5,368) were households in which there was a patient with a GI cancer. Univariable DID analysis demonstrated that households with a GI cancer had a greater increase in anxiety-related (spouses, 2.2% vs 0.7%; children, 2.0% vs 1.1%), mental illness (MI)–related (spouses, 3.2% vs 1.2%; children, 3.0% vs 1.6%), and overall MH-related visits (spouses, 3.3% vs 1.4%) versus the control group (all P < .05). In adjusted DID analysis, spouses, children, and households with a GI cancer diagnosis had a 2.1%, 1.6%, and 2.3% absolute risk increase of MI-related visits, respectively, compared with non-cancer households (all P < .05). ConclusionIn a cohort of privately insured households, coinsured spouses and children of patients with a GI cancer diagnosis had a higher risk of MH-related claims versus households without a GI cancer diagnosis. The data highlight the importance of family counseling and psychological support when a loved one is diagnosed with cancer.

School Mask Mandates and COVID-19: The Challenge of Using Difference-in-Differences Analysis of Observational Data to Estimate the Effectiveness of a Public Health Intervention.

There are considerable challenges when using difference-in-differences (DiD) analysis of ecological data to estimate the effectiveness of public health interventions in rapidly changing situations. To discuss the shortcomings of DiD methodology for the estimation of the effects of public health interventions using ecological data. As an example, the authors consider an analysis that used DiD methodology and reported a causal reduction in COVID-19 cases due to the maintenance of school mask mandates. They did alternate analyses using various control groups to assess the robustness of the prior analysis. School districts in the greater Boston area and Massachusetts during the 2021-to-2022 academic year. Students and school staff. Changes in COVID-19 case rates in districts that did and did not lift mask mandates. Important potential confounders rendered DiD methodology inappropriate for causal inference, including prior immunity, temporal variation in rates of infection, and changes in testing practices. The racial composition and income of intervention and control groups also differed substantially. Compared with maintaining the mask requirement, dropping the requirement was associated with anywhere from an increase of 5.64 cases (95% CI, 3.00 to 8.29 cases) per 1000 persons to a decrease of 2.74 cases (CI, 0.63 to 4.85 cases) per 1000 persons, depending on choice of control group and whether students or staff were examined. Ecological data were used; detailed data on all potential confounders were unavailable. Alternate analyses yielded estimates consistent with a wide range of both negative and positive associations in COVID-19 case rates after removal of mask mandates. The findings highlight the challenges of using DiD analysis of ecological data to estimate the effectiveness of interventions in divergent intervention and control groups during rapidly changing circumstances. None.

Impact of community-based multidomain preventive health program on healthcare utilisation among elderly persons in Singapore: a propensity score matched and difference-in-differences study

ObjectivesAgeing populations present substantial challenges for healthcare systems. Community-based health worker (CHW) interventions for promoting healthy ageing and preventing/managing non-communicable diseases have gained considerable attention in recent years. This study...

Public Periodontal Screening Increases Subsequent Regular Dental Visits: The Life Study.

A public oral health screening, periodontal disease screening, has been implemented in Japan, but it remains unclear whether screening encourages subsequent regular dental visits. This study aimed to examine whether people who underwent periodontal disease screening were more likely to regularly visit dentists after undergoing the screening than before using a difference-in-differences (DID) approach. This study used health care claims data of municipality residents who underwent periodontal disease screening in 2017 or 2018. For each screening recipient, 4 individuals were extracted from those who did not undergo screening as controls. In the DID analysis, we assessed the change in the proportion of dentist visits at least once every 180 d after undergoing screening. A total of 4,050 participants were included in the analysis. The proportion of participants visiting dentists was consistent throughout the study period (approximately 45%) among the participants who did not undergo the screening. However, among the participants who underwent the screening, while the proportion who visited dentists was consistent before screening (approximately 60%), the proportion was higher after screening (1-180 d after, 81.2%). DID analysis indicated that the proportion increased by 12.9% after the screening. In addition, the age-subgroup DID estimates were higher in the younger population (aged 20-35 y, 13.9%; 40-55 y, 12.8%; 60 y, 12.6%). Among people who underwent periodontal disease screening, a higher proportion visited dentists after undergoing the screening than before, suggesting that periodontal disease screening was associated with an increase in subsequent regular dental visits. Our results provide evidence that a public oral health screening could increase regular dental visits, which has the potential to improve and maintain people's oral health, especially in the younger population.

Effects of community water fluoridation on child dental caries in remote Northern Territory, Australia: a difference-in-difference analysis.

Community water fluoridation (CWF) is a cost-effective intervention to reduce dental caries at population level. This Australian study used a difference-in-difference (DiD) analysis to measure dental caries in children exposed to CWF in the Northern Territory (NT), Australia. Oral health data obtained from the NT Department of Health contained 64 399 person-year observations from 2008 to 2020, totalling 24 546 children aged 1-17 years. Drinking water quality data for fluoride levels, held by the Power and Water Corporation, were obtained for 50 remote communities and linked to the oral health dataset. The DiD analysis used a treatment group and two control groups to compare the effects of CWF on dental caries outcomes in children, measured using the decayed, missing and filled teeth (dmft/DMFT) index. The treatment group consisted of records from children residing in five remote NT communities that implemented CWF in 2014.The control 1 group included records of children residing in communities with naturally occurring fluoride in drinking water supplies at levels at or above the Department of Health policy threshold of 0.5 mg/L. The control 2 group included records of children residing in communities with naturally occurring fluoride in drinking water supplies below the level recommended by the Department of Health policy (<0.5 mg/L). The data were grouped into time periods prior to the inception of CWF in five remote communities in 2014 (pre-intervention) and after 2014 (post-intervention). Our results demonstrated that dental caries was significantly decreased for children in the treatment group following the implementation of CWF at a greater magnitude than both control groups for the same time period. Overall, children assigned to the treatment group exhibited a decline in the number of teeth affected by caries by an average of 0.28 (p=0.001). Notably, children of ages 7-10 years and 11-17 years experienced significantly greater post-intervention declines in average dmft/DMFT, by 0.32 (p=0.051) and 0.40 (p=0.012) fewer affected teeth respectively. While dental caries disproportionately impacts Aboriginal children in remote and very remote NT, it is clear that CWF produces population-level reductions in overall dental caries for these populations. Additionally, our study demonstrates the application of the DiD method in a public health policy evaluation. Our findings suggest that the longstanding policy position of the NT Department of Health on CWF has supported improvements in oral health among child populations that experience high levels of dental caries in remote NT communities.

Factors associated with facility childbirth and skilled birth attendance in Migori County, Kenya and the effect of Lwala Community Alliance intervention: a cross-sectional assessment from the 2019 and 2021 Lwala household surveys

BackgroundDespite evidence of the beneficial effects of skilled birth attendance (SBA) on maternal health and childbirth outcomes, there are disparities in access across counties in Kenya. These include Migori County which has historically recorded high maternal mortality rates. In 2007, the Lwala Community Alliance was founded to improve health outcomes in this county. The objective of this study is to provide a baseline status of facility childbirth and SBA in Migori and to characterize the effect of Lwala intervention on these outcomes.MethodsA cross-sectional household survey was designed for a 10-year study to evaluate the effectiveness of Lwala initiatives. The 2019 and 2021 household surveys were conducted in Lwala intervention wards and in comparison wards with sample sizes of 3,846 and 5,928 mothers, respectively. The survey captured demographic, health, and socioeconomic data at each household, data on SBA and facility childbirth, and explanatory variables. A generalized linear model was used to determine factors associated with SBA. A secondary trend analysis was conducted to determine change over time in the explanatory variables and SBA. To determine the change in SBA rate due to Lwala intervention, controlling for background temporal trends, a difference-in-differences (DiD) model compared SBA rates in intervention wards and comparison wards.ResultsSBA increased in all surveyed wards and across all explanatory variables from 2019 to 2021. The DiD analysis showed that the SBA rate increased more in Lwala intervention wards than in comparison wards (Adjusted Prevalence Rate Ratio 1.05, p &amp;lt; 0.001, 95%CI 1.03–1.08). The 2021 survey found the highest rates of both facility childbirths (97.9%, 95%CI 96.5–98.7) and SBA (98.2%, 95%CI 97.0–99.0) in North Kamagambo, the oldest ward of Lwala intervention. Higher educational status, four or more ANC visits, marriage/cohabitation, and wealth were significantly associated with increased SBA.ConclusionsWe provide the first quasi-experimental evidence that Lwala interventions are significantly improving SBA which may inform related initiatives in similar settings. The household-survey data provides a baseline for continued evaluation of Lwala programs, and the breakdown by ward allows for development of specific programmatic targets.

Estimating community-wide indirect effects of influenza vaccination: triangulation using mathematical models and bias analysis.

Understanding whether influenza vaccine promotion strategies produce community-wide indirect effects is important for establishing vaccine coverage targets and optimizing vaccine delivery. Empirical epidemiologic studies and mathematical models have been used to estimate indirect effects of vaccines but rarely for the same estimand in the same dataset. Using these approaches together could be a powerful tool for triangulation in infectious disease epidemiology because each approach is subject to distinct sources of bias. We triangulated evidence about indirect effects from a school-located influenza vaccination program using two approaches: a difference-in-difference (DID) analysis, and an age-structured, deterministic, compartmental model. The estimated indirect effect was substantially lower in the mathematical model than in the DID analysis (2.1% (95% Bayesian credible intervals 0.4 - 4.4%) vs. 22.3% (95% CI 7.6% - 37.1%)). To explore reasons for differing estimates, we used sensitivity analyses and probabilistic bias analyses. When we constrained model parameters such that projections matched the DID analysis, results only aligned with the DID analysis with substantially lower pre-existing immunity among school-age children and older adults. Conversely, DID estimates corrected for potential bias only aligned with mathematical model estimates under differential outcome misclassification. We discuss how triangulation using empirical and mathematical modelling approaches could strengthen future studies.

Clinical evaluation of a machine learning-based early warning system for patient deterioration.

The implementation and clinical impact of machine learning-based early warning systems for patient deterioration in hospitals have not been well described. We sought to describe the implementation and evaluation of a multifaceted, real-time, machine learning-based early warning system for patient deterioration used in the general internal medicine (GIM) unit of an academic medical centre. In this nonrandomized, controlled study, we evaluated the association between the implementation of a machine learning-based early warning system and clinical outcomes. We used propensity score-based overlap weighting to compare patients in the GIM unit during the intervention period (Nov. 1, 2020, to June 1, 2022) to those admitted during the pre-intervention period (Nov. 1, 2016, to June 1, 2020). In a difference-indifferences analysis, we compared patients in the GIM unit with those in the cardiology, respirology, and nephrology units who did not receive the intervention. We retrospectively calculated system predictions for each patient in the control cohorts, although alerts were sent to clinicians only during the intervention period for patients in GIM. The primary outcome was non-palliative in-hospital death. The study included 13 649 patient admissions in GIM and 8470 patient admissions in subspecialty units. Non-palliative deaths were significantly lower in the intervention period than the pre-intervention period among patients in GIM (1.6% v. 2.1%; adjusted relative risk [RR] 0.74, 95% confidence interval [CI] 0.55-1.00) but not in the subspecialty cohorts (1.9% v. 2.1%; adjusted RR 0.89, 95% CI 0.63-1.28). Among high-risk patients in GIM for whom the system triggered at least 1 alert, the proportion of non-palliative deaths was 7.1% in the intervention period, compared with 10.3% in the pre-intervention period (adjusted RR 0.69, 95% CI 0.46-1.02), with no meaningful difference in subspecialty cohorts (10.4% v. 10.6%; adjusted RR 0.98, 95% CI 0.60-1.59). In the difference-indifferences analysis, the adjusted relative risk reduction for non-palliative death in GIM was 0.79 (95% CI 0.50-1.24). Implementing a machine learning-based early warning system in the GIM unit was associated with lower risk of non-palliative death than in the pre-intervention period. Machine learning-based early warning systems are promising technologies for improving clinical outcomes.

A produce prescription program for patients with low incomes in North Carolina resulted in increased produce purchases

ObjectivesTo assess if participation in a North Carolina produce prescription program for Supplemental Nutrition Assistance Program (SNAP) participants with diet-sensitive health conditions (SuperSNAP) is associated with changes in purchase composition and spending source. MethodsThis study used loyalty-card transaction data (October 2019–April 2022). We applied a linear mixed-effects model with overlap weights to perform a difference-indifferences analysis of purchases by SuperSNAP program enrollees compared to the control group. ResultsThe sample included 1440 SuperSNAP shoppers and 45,851 control shoppers. Compared to shoppers only on SNAP, SuperSNAP shoppers spent $82.98 (95% CI (75.6, 90.3), p-value <0.001) more per month, $76.09 (95% CI (69.4, 82.8), pvalue <0.001) of which were spent strictly on food and beverage products. Among SuperSNAP shoppers, out of the $40 SuperSNAP benefit each month, an estimated $34.86 (95% CI (33.9, 35.8), p-value <0.001) of it was spent on fruits and vegetables. ConclusionsThis study shows the promise of targeted produce prescription programs for SNAP participants in encouraging shifts in purchase composition.

Assessing long-term effects of gaseous air pollution exposure on mortality in the United States using a variant of difference-in-differences analysis

Long-term mortality effects of particulate air pollution have been investigated in a causal analytic frame, while causal evidence for associations with gaseous air pollutants remains extensively lacking, especially for carbon monoxide (CO) and sulfur dioxide (SO2). In this study, we estimated the causal relationship of long-term exposure to nitrogen dioxide (NO2), CO, SO2, and ozone (O3) with mortality. Utilizing the data from National Morbidity, Mortality, and Air Pollution Study, we applied a variant of difference-in-differences (DID) method with conditional Poisson regression and generalized weighted quantile sum regression (gWQS) to investigate the independent and joint effects. Independent exposures to NO2, CO, and SO2 were causally associated with increased risks of total, nonaccidental, and cardiovascular mortality, while no evident associations with O3 were identified in the entire population. In gWQS analyses, an interquartile range-equivalent increase in mixture exposure was associated with a relative risk of 1.067 (95% confidence interval: 1.010–1.126) for total mortality, 1.067 (1.009–1.128) for nonaccidental mortality, and 1.125 (1.060–1.193) for cardiovascular mortality, where NO2 was identified as the most significant contributor to the overall effect. This nationwide DID analysis provided causal evidence for independent and combined effects of NO2, CO, SO2, and O3 on increased mortality risks among the US general population.

Does the combined assurance model affect tax avoidance? The case of South African companies

PurposeThis paper aims to investigate the impact of combined assurance on tax avoidance in South Africa.Design/methodology/approachThis study is founded on a sample of 76 South African firms listed on the Johannesburg Stock Exchange over the 2014–2022 period. The authors used the feasible generalized least squares regression estimation technique to test the hypothesis. To address endogeneity issues, this study conducted a difference-in-differences (DID) analysis based on propensity score matching.FindingsThe results reveal that combined assurance negatively impacts tax avoidance. Implementing combined assurance, as an integrated risk management approach, significantly minimizes tax risk. The DID analysis provides well-founded evidence attributing the decline in tax avoidance levels to the availability of combined assurance. The inferences are robust to using alternative measures of tax avoidance, testing combined assurance impact across various tax avoidance levels and controlling for the COVID-19 effect.Practical implicationsThis study presents valuable insights for firms, managers and policymakers. The findings encourage companies to bolster their risk management practices, opting for combined assurance over a sole risk monitoring mechanism. This approach enables the company to ensure better compliance with tax regulations, thereby enhancing overall efficiency. Besides, the disciplining effect of combined assurance motivates managers to make informed decisions, avoid tax avoidance strategies and safeguard corporate reputation. Moreover, this research calls upon policymakers to promote effective global regulatory frameworks for combined assurance practices.Originality/valueThe research brings original insights by exploring the influence of combined assurance on tax avoidance. This addresses a gap in the current literature that has predominantly focused on the relationship between tax avoidance and individual lines of defense.

Effects of Patient-Initiated Brief Admissions on Psychiatric Care Consumption in Borderline Personality Disorder: ARegister-Based Study.

Previous studies have reported that patients with borderline personality disorder (BPD) often have negative experiences in psychiatric inpatient care. To address this issue, a novel intervention known as patient-initiated brief admission (PIBA) has been developed. PIBA offers a constructive approach to crisis management insituations of heightened anxiety, as well as during instances of self-harm and suicidal ideation. The intervention allows patients to directly contact the psychiatric ward to initiate a brief admission lasting 1-3 days. This easily accessible care option during a crisis has the potential to prevent harm to the patient and reduce the need for prolonged hospital stays. The aim of the present study is to investigate the effects of PIBA on psychiatric care consumption among patients diagnosed with BPD. This retrospective register-based study includes data from both inpatient and outpatient care registries for patients diagnosed with BPD. Data were extracted from the National Board of Health and Welfare in Sweden. The study period encompasses 2013-2020, with the PIBA intervention occurring between 2016 and 2019. The sample included 107 patients in the PIBA group and 5659 matched controls. Data were analysed using a difference-in-differences (DiD) approach through ordinary least squares (OLS) regression and ordinal logistic regression. Throughout the 3-year follow-up, both groups exhibited a reduction in the number of days of utilisation of psychiatric inpatient care services. The DiD analysis indicated an additional decrease of 1.5 days at the 6-month mark for the PIBA group (β = -1.436, SE = 1.531), expanding to 3 days fewer at the 12-month follow-up (β = -3.590, SE = 3.546), although not statistically significant. For outpatient care, the PIBA group displayed an increase in the number of visits, averaging to half a visit more every 6 months (β = 0.503, SE = 0.263) compared with the controls. Statistically significant differences were observed for two out of six measurements at the 12-month (β = 0.960, SE = 0.456) and 18-month follow-up period (β = 0.436, SE = 0.219). The PIBA group had a statistically significant lower odds of experiencing extended lengths of inpatient care days after the index date than the controls (OR 0.56, 95% CI: 0.44-0.72). In conclusion, PIBA was associated with a significant reduction in the length of individual hospital stays, but not in the overall number of inpatient care days. PIBA may be linked to a shift from longer inpatient care utilisation to outpatient care utilisation. These findings suggest that PIBA may reduce the risk of prolonged hospitalisations for patients who have access to the intervention. Future research should explore the impact of PIBA on healthcare costs and cost-effectiveness, both in relation to health care for the individual and cost-effectiveness in relation to recovery and health.

Impact of American Society of Breast Surgeons (ASBS) guidelines on genetic testing (GT) rates among patients with breast cancer (BC).

e22537 Background: Identifying patients with pathogenic germline genetic variants can inform clinical decision-making and risk assessment. Previous studies have suggested low rates of GT in BC patients overall and disproportionately lower rates of GT among black patients. This may be explained in part by clinicians failing to understand the current National Comprehensive Cancer Network (NCCN) GT guidelines, which are complex. In February 2019, the ASBS released updated guidelines recommending GT for all patients with a personal history of BC. The objective of this study was to evaluate the impact of the ASBS guideline change on GT utilization for all BC patients, and for black BC patients in particular. Methods: This retrospective cohort study included 4386 BC patients who were diagnosed and/or treated at the Siteman Cancer Center (SCC) in St. Louis, MO from January 1, 2017 to December 31, 2020. The pre-guideline period included those patients diagnosed between January 1, 2017 and July 25th, 2019 and the post-guideline period included those diagnosed between July 26, 2019 and December 31, 2020. Within the study period, Myriad Genetics was used almost exclusively for GT by breast oncologists and surgeons at SCC. Myriad data was queried to identify all BC patients at SCC with GT. Data including self-reported race/ethnicity, BC subtype (triple negative breast cancer (TNBC) vs other), insurance type (public vs private), and family history of BC (yes vs no) was collected from the electronic medical record (EMR) independently by authors. Multivariate logistic regression analyses and difference in difference (DiD) analyses were performed to compare GT rates pre- and post-guideline change. Results: There was no significant difference in the rate of GT among BC patients pre- vs post-guideline change (17% vs 14.8%, p = 0.05). Similarly, there was no significant difference in GT rates pre- vs post-guideline change for non-Hispanic black (NHB) (14.6% vs 13.1%) and non-Hispanic white (NHW) subgroups (17.8% vs 15.2%) using DiD analysis (p = 0.96). Patients with a family history of BC (odds ratio (OR) 1.41, 95% confidence interval (CI) 1.17-1.69, p &lt; 0.01) and TNBC (OR 1.47, 95% CI 1.15-1.86, p &lt; 0.01) were more likely to receive GT. Patients aged greater than 50 years (OR 0.44, 95% CI 0.37-0.54, p &lt; 0.001) and those with public insurance were less likely to receive GT (OR 0.82, 95% CI 0.67-1.02, p = 0.07). DiD analyses identified no significant differences pre- and post-guideline change for these subgroups. Conclusions: Despite the recent broadening of GT guidelines by ASBS, GT rates remain low among patients with BC. We found no significant impact of the guideline change on the uptake of GT among our population of BC patients overall or by race/ethnicity, family history, BC subtype, age, or insurance status. Multidisciplinary efforts are needed to improve guideline implementation and uptake of GT in BC patients.