Geographic Variation In Access Research Articles

Variation in access to specialist services for neurosurgical procedures in adults with epilepsy in England, a cohort study.

To understand if primary consultation at tertiary epilepsy centres (TEC) in England impacts access to neurosurgical procedures (resective surgery, vagus nerve stimulator [VNS], deep brain stimulator [DBS]). Adults with epilepsy, and with a first neurology outpatient visit (index) between 01/01/2013 and 31/12/2015, were followed using English Hospital Episode Statistics from index date to 31/12/2019. Analyses were stratified by geographic location, learning disability record, and whether the index or follow-up visits were at a TEC. 84,093 people were included, with mean 5.5 years of follow-up. 12.4% of the cohort had learning disability (range 10.1%-17.4% across regions). TEC consultations varied by National Health Service regions and Clinical Commissioning Groups. 37.5% of people (11.2%-75.0% across regions) had their index visit at a TEC; and, of those not initially seen at a TEC, 10.6% (6.5%-17.7%) subsequently attended a tertiary centre. During follow-up, 11.1% people (9.5%-13.2%) visited a neurosurgery department, and 2.3% of those (0.9%-5.0%) then underwent a neurosurgical procedure, mainly VNS implantation. Median time from index date to first visit at a neurosurgery centre was 7 months (range 6-8 months across regions) and 40 months to procedure (36.5-49 months, 37.0 months in people with index visit at a TEC and 49.0 months otherwise). People with learning disability were less likely to have resective surgery (<0.5% versus 1.0% in those without) and more likely to undergo VNS implantation (5.8% versus 0.8%). Although clinically recommended for suitable individuals, neurosurgical procedures in epilepsy remain uncommon even after consultation at a TEC. Geographical variation in access to TECs was present.

Child Health and the Pediatric Pulmonology Workforce: 2020-2040.

There is concern as to whether the supply of pediatric pulmonology (PULM) subspecialists will be adequate to meet future demand. As part of an American Board of Pediatrics (ABP) Foundation-sponsored supplement investigating the future of the pediatric subspecialty workforce, this article assesses the current PULM clinical workforce and estimates the clinical workforce supply in the United States through 2040. The current workforce was assessed using ABP certification and Maintenance of Certification data, and a workforce supply model evaluating population growth, clinical effort, and geographic trends was developed after incorporating ABP data. Findings demonstrate that the number of pediatric pulmonologists has gradually increased over the past decade, and the ratio of subspecialists to children is likely to increase another 20% to 40% over the next 2 decades, although absolute numbers remain small. Geographic variation in access will persist in some regions. The proportion of women in the discipline has increased, but the proportion of pediatric pulmonologists from underrepresented in medicine backgrounds still lags behind the general population. Based on current trends, the PULM clinical workforce appears equipped to meet both population growth and the modest increase in demand for clinical services speculated to occur because of changes in the subspecialty's clinical portfolio. However, several factors could inhibit growth, and geographic maldistribution may continue to impact care access. Efforts to address variation in access and demographic diversity in the field are warranted. This article concludes by discussing the training, clinical practice, policy, and future workforce research implications of the data presented.

PRESIDENTIAL SYMPOSIUM: IMPACT OF DISCRIMINATORY POLICIES ON LGBTQ+ OLDER ADULTS’ HEALTH AND WELL-BEING AND HOW TO COMBAT THEM

Abstract Despite some advances in LGBTQ+ rights over the past few decades, many states lack legal protections against discrimination based on sexual orientation or gender identity, and the current political climate raises concerns about future challenges to LGBTQ+ rights. This symposium explores the implications of discriminatory policies on the health, housing, and economic well-being of LGBTQ+ older adults, and solutions for promoting empowerment, equity, and inclusion throughout the care continuum, from long-term services and supports to end-of-life care. The first presentation describes a complex paradox in which sexual and gender minority (SGM) older adults avoid formal services due to fear of discrimination and poor treatment despite significant health disparities and a lack of informal support, discusses opportunities to improve access and health through education and awareness, and elucidates implications for policy and research. The second presentation describes geographic variations in access to, and receipt of gender-affirming surgery among transgender and gender-diverse Medicare beneficiaries using national Medicare data and discusses policy implications. The third paper focuses the role of spirituality and faith in the lives of LGBTQ+ older adults and reports findings from a mixed-methods study on how involvement in faith communities shape their end-of-life care perceptions and preparation. The fourth presentation describes barriers and facilitators to communicating with SGM hospice patients and caregivers about their sexual orientation and gender identity and recommendations for developing communication training to promote authentic end-of-life care for this population. Karen Frederickson-Goldsen as discussant will provide policy and practice implications of these important works.

Geographic variability and operator trends of transcatheter edge-to-edge repair in the United States.

Transcatheter edge-to-edge repair (TEER) devices are used for primary mitral regurgitation (MR) and secondary MR. Despite the growing use of TEER devices, there have not been many studies on operator experience or procedure volumes by state. We aimed to investigate nationwide operator volume trends and geographic variation in access to TEER. The United States Center for Medicare and Medicaid Services (CMS) National Medicare Provider Utilization and Payment Database (MPUPD) was analyzed between 2015 and 2020 for initial TEER procedures. Procedure volume and total operators increased yearly from 2015 to 2019 but declined in 2020. Mean annual procedure volume per operator varied significantly by state, between 0 in multiple states and 35 in North Dakota. In 2019, 994 unique operators were identified, with 295 operators documented performing 10 or more procedures (29.68%). Operators performing 10 or more TEER procedures provided 68.46% of all operations in 2019, averaging 20.94 procedures per operator. TEER procedures are becoming increasingly common as more operators are being trained. However, significant variability exists in the procedural volume per operator.

Significant Geographic Variation in Access to Certified Collagenase Clostridium histolyticum Injectors for Peyronie's Disease Throughout the United States.

We characterize the geographic distribution of providers trained to inject Clostridium histolyticum and identify areas with low provider availability. We utilized a publicly available search tool to identify clinical sites offering Clostridium histolyticum in the US The data gathered included the provider's name, specialty, address, and whether the site was considered high-volume (ie, administer ≥20 Clostridium histolyticum injections per year). Data were compared to the AUA Census. In total, 2,388 clinical sites offering Clostridium histolyticum were identified. A total of 894 sites (37%) were high-volume sites. The mean number of locations offering Clostridium histolyticum per 100,000 state residents was 0.69 (SD 0.27). Georgia (1.28), Rhode Island (1.13), and Alaska (1.10) had the highest number, whereas New Mexico (0.10), Maine (0.22), and Delaware (0.30) had the lowest. The mean proportion of urologists providing Clostridium histolyticum to total urologists was 0.17 (SD 0.07). The 3 states with the highest proportion were Georgia (0.37), Alaska (0.31), and Utah (0.30), whereas New Mexico (0.03), Maine (0.05), and Vermont (0.06) had the lowest. States with low numbers of clinical sites offering Clostridium histolyticum per 100,000 residents relative to other states also had a low total ratio of urologists offering Clostridium histolyticum as a treatment. There is room for urologists in these states and others to expand their practice to offer Clostridium histolyticum and improve patient access to this important nonsurgical treatment option.

Geografisk variasjon i vaksnes bruk av avtalespesialistar og DPS i psykisk helsevern

Background: Equitable mental healthcare regardless of area of residence is a political aim in Norway. The purpose of this study is to evaluate geographical variation in private practitioner coverage, and explore differences between private practitioners with public reimbursement and local community mental health centers (CMHCs) in terms of diagnoses and scope of outpatient treatment, with a focus on mood and neurotic disorders. Method: Cross-sectional registry-based study of adults in outpatient mental healthcare at private practitioners or CMHCs in Norway in 2014–2018. We calculated distribution of diagnoses, geographical variation in rates of private practitioners, and analyzed scope of treatment for patients with mood and neurotic disorders (ICD-10 disorders F3, F4). We estimate cost per treated patient and report geographic variation for hospital catchment areas. Results: Patients with F3, F4 disorders accounted for 64.7 % at private practitioners, and 31.5 % at CMHCs, and received more treatment at private practitioners, five more consultations in a 42 day longer period. There is considerable geographical variation in private practitioner coverage, highest in South-East Norway and lowest in North Norway. Implications: As long as management and priority setting are differently organized for CMHCs and private practitioners in mental health care, we must expect geographical variation in access and use. It appears as an equity paradox that a group of patients, rejected by or not referred to CMHC, receive more treatment by private practitioners. Keywords: mental healthcare, outpatient consultations, private practitioners, CMHC, geographical variation, equal access, equity, priority setting

Provision of Food Allergy Care in the United Kingdom and United States: Current Issues and Future Directions.

Food allergy (FA) is a growing issue worldwide. The United Kingdom (UK) and United States (US) are high-income, industrialized countries with reported increases in FA prevalence over the past few decades. This review compares delivery of FA care in the UK and US and each country's response to the heightened demand and disparities for FA services. In the UK, allergy specialists are scarce and general practitioners (GPs) provide most allergy care. While the US has more allergists per capita than the UK, there is still a shortage of allergy services owing to the greater reliance on specialist care for FA in America and wide geographic variation in access to allergist services. At this time, generalists in these countries lack the specialty training and equipment to optimally diagnose and manage FA. Moving forward, the UK aims to enhance training for GPs so they may provide better quality frontline allergy care. In addition, the UK is implementing a new tier of semi-specialized GPs and increasing cross-center collaboration through clinical networks. The UK and US aim to increase the number of FA specialists, which is critical at a time of rapidly expanding management options for allergic and immunologic diseases requiring clinical expertise and shared decision-making to select appropriate therapies. While these countries aim to actively grow their supply of quality FA services, further efforts to build clinical networks, and perhaps, recruit international medical graduates and expand telehealth services, are necessary to reduce disparities in access to care. For the UK in particular, this will require additional support from the leadership of the centralized National Health Service, which remains challenging.

Risk factors of HIV and variation in access to clean needles among people who inject drugs in Pakistan

ABSTRACT We identified key risk factors for HIV among people who inject drugs (PWID) in Pakistan and explored access to free clean needles. Multivariable logistic regression was used to investigate associations between HIV prevalence and demographic, behavioral, and socio-economic characteristics of PWID. Data came from the Government of Pakistan’s Integrated Biological and Behavioral Surveillance (IBBS) Round 5 (2016–17; 14 cities). A secondary analysis investigated associations with reported access to clean needles. Unweighted HIV prevalence among 4,062 PWID (99% male) was 21.0%. Longer injecting duration (Odds ratio [OR] 1.06 [95% confidence interval: 1.02–1.10]; per year), higher injecting frequency (OR 1.67 [1.30–2.13]; per unit increase), and injecting heroin (OR 1.90 [1.11–3.25]) were positively associated with HIV prevalence. There was no association between using a used syringe at last injection and HIV. Having>10 years of education had lower odds of HIV than being illiterate (OR 0.58 [0.35–0.95]). Having a regular sexual partner (OR 0.74 [0.57–0.97]) or paying for sex with the opposite sex (OR = 0.62 [0.45–0.85]) had lower odds of HIV than not. Conversely, PWID paying a man/hijra for sex had higher odds of HIV (OR 1.20 [1.00–1.43]). Receipt of clean needles varied by city of residence (0–97% coverage), whilst PWID with knowledge of HIV service delivery programs had higher odds of receiving clean needles (OR 4.58 [3.50–5.99]). Injecting behaviors were associated with HIV prevalence among PWID, though risks related to paying for sex remain complicated. Geographical variation in access to clean needles suggests potential benefits of more widely spread public health services.

Sociodemographic and Geographic Variation in Access to Neuro-Ophthalmologists in the United States.

Neuro-ophthalmologists have expertise in rare and complex disorders, but the ability of patients to access neuro-ophthalmic care has not been examined at a nationwide level. Using the 2020 directory of all 502 members of the North American Neuro-Ophthalmology Society as a reference, we found the practice locations of 461 confirmed practicing members and converted each street address to latitude and longitude coordinates. We calculated the travel distance and time from each census tract to the nearest practice location and calculated population-weighted averages by state, region, and other prespecified factors. Choropleth maps were used to visualize the distribution of travel distances and times across the United States. California had the most practicing neuro-ophthalmologists out of any state (50), whereas 4 states (DE, MT, SD, and WY) had none. Washington, DC and MA had the most neuro-ophthalmologists per capita. The average travel distance and time to the nearest neuro-ophthalmologists were found to be 40.90 miles and 46.50 minutes, respectively, although a large portion of western plains and mountain regions had travel times of over 120 minutes. Patients in rural areas had longer travel times than those in urban areas, and Native American patients had the longest travel times of any racial or ethnic group. The travel time to see a neuro-ophthalmologist varies widely by state, region, and rurality, with Native American patients and rural patients being disproportionately affected. By identifying the areas with the greatest travel burdens, future policies can work to alleviate these potential barriers to care.

Geographic Variation in Access to Cardiac Rehabilitation

BackgroundThere is marked geographic variation in cardiac rehabilitation (CR) initiation, ranging from 10% to 40% of eligible patients at the state level. The potential causes of this variation, such as patient access to CR centers, are not well studied. ObjectivesThe authors sought to determine how access to CR centers affects CR initiation in Medicare beneficiaries. MethodsThe authors used Medicare files to identify CR-eligible Medicare beneficiaries and calculate CR initiation rates at the hospital referral region (HRR) level. We used linear regression to evaluate the percent variation in CR initiation accounted for by CR access across HRRs. We then employed geospatial hotspot analysis to identify CR deserts, or counties in which patient load per CR center is disproportionately high. ResultsA total of 1,133,657 Medicare beneficiaries were eligible for CR from 2014 to 2017, of whom 263,310 (23%) initiated CR. The West North Central Census Division had the highest adjusted CR initiation rate (35.4%) and the highest density of CR programs (6.58 per 1,000 CR-eligible Medicare beneficiaries). Density of CR programs accounted for 21.2% of geographic variation in CR initiation at the HRR level. A total of 40 largely urban counties comprising 14% of the United States population age ≥65 years had disproportionately low CR access and were identified as CR deserts. ConclusionsA substantial proportion of geographic variation in CR initiation was related to access to CR programs, with a significant amount of the U.S. population living in CR deserts. These data invite further study on interventions to increase CR access.

Relationship of Neighbourhood Social Deprivation and Ethnicity on Access to Transcatheter and Surgical Aortic Valve Replacement: A Population-Level Study.

Wide geographic variation in access to transcatheter (TAVR) and surgical (SAVR) aortic valve replacement exists, but the impact of socioethnic factors on the geographic variation of AS management in Ontario, Canada, is unknown. Neighbourhood rates of AS admissions, as a proxy for AS burden, and downstream TAVR and SAVR referrals and procedures were estimated for the 76 subregions in Ontario. To determine if the socioethnic geographic variations in referrals and procedures were concordant or discordant with AS burden, we calculated Pearson correlation coefficients to determine the relationship between AS burden and each of TAVR referrals, TAVR procedures, SAVR referrals, or SAVR procedures. We developed generalised linear models to determine the association between social deprivation indices captured in the Ontario Marginalization index and the rates of AS burden as well as TAVR/SAVR referral and procedures. There was wide geographic variation that was concordant between AS burden and the referral and procedure rates for TAVR and SAVR (correlation coefficients 0.86-0.96). Increased dependency was associated with higher rates of both TAVR/SAVR referrals and procedures (rate ratios 1.63-2.22). Neighbourhoods with a higher concentration of ethnic minorities were associated with lower AS burden as well as lower rates of both SAVR and TAVR referrals and procedures (rate ratios 0.57-0.85). An important ethnic gradient exists in AS burden and in both referral and completion of TAVR and SAVR in Ontario. Further research is necessary to understand if this gradient is appropriate or requires mitigation.

Less prevalent use of biologics for inflammatory bowel disease in patients from Non-Academic hospitals – a Danish register-based study of a region with 580,000 citizens

Introduction Biologic therapy is widely used for inflammatory bowel disease (IBD) and may decrease surgery rates. However, it remains uncertain if there is unwarranted geographic variation in access to biologic therapy. The aim of the study was to explore if all patients had equal access to biologic therapy in the North Denmark Region. Methods A cross-sectional register-based study of use of biologics, hospital contacts and surgery among all IBD patients having a hospital contact in the geographically well-defined North Denmark Region during 2016–2018. ICD-10 diagnosis codes, hospital contacts and procedure codes were retrieved from the region’s hospital registry. The population is served by an Academic Hospital and two Non-Academic Hospitals constituting three referral areas (according to postal codes). Results In total, 2371 patients with ulcerative colitis (UC) and 1383 patients with Crohn’s disease (CD) had a hospital contact in the region during 2016–2018. Compared to patients from the Academic Hospital, patients from the Non-Academic Hospitals experienced a lower incidence of biologic therapy for UC IRR 0.786 (0.621: 0.994), as well as for CD IRR 0.912 (0.781: 1.065). The incidence of bowel related hospital contacts were higher in patients from Non-Academic hospitals for both UC IRR 1.318 (1.207: 1.438) and CD IRR 1.165 (0.915: 1.483). Conclusions Patients with IBD living in a referral area to a Non-Academic Hospital in the North Denmark Region are less likely to receive biologics. This was associated with an increased prevalence of IBD related surgical procedures.

Il ruolo della tecnologia nella gestione del bambino e dell’adolescente con diabete di tipo 1

In Italy, it is estimated there are about 25,000 children and adolescents with type 1 diabetes between 0 and 18 years, most of whom using electronic devices for blood glucose control. Among these many have chosen a sensor for measuring blood glucose, often integrated, or combined with an insulin pump, preferably included in (advanced) hybrid closed-loop systems, that increasingly resemble artificial pancreases. This technology has seen an enormous progress in the last two decades, making these tools fundamental for improving glycemic control and the quality of life of patients with diabetes and their families. However, major challenges remain, including cybersecurity vulnerability, cost, and accessibility, with a substantial geographical variation in access to diabetes technologies. The hope is that the very recent guidelines of SID, AMD and SIEDP will help to rationalize and improve access to available technologies.

The schooling and labor market effects of eliminating university tuition in Ecuador

This paper estimates the effects of a 2008 policy that eliminated tuition fees at public universities in Ecuador. We use a difference-in-differences strategy that exploits variation across cohorts differentially exposed to the policy, as well as geographic variation in access to public universities. We find that the tuition fee elimination significantly increased college participation and shifted people into higher-skilled jobs. We detect no statistically significant effects on income, though standard errors are large. Overall, the bulk of the benefits of this fee elimination were enjoyed by those of higher socioeconomic status.

Epidemiology of shoulder instability in Italy: A 14-years nationwide registry study.

The aim of this study is to estimate the annual number of shoulder dislocation hospitalizations in Italy from 2001 to 2014, to explore geographical variation in access to hospitalizations between the 3 macro-regions of Italy (North, Centre and South) and to perform statistical projections of hospitalizations volumes and rates based on data from 2001 to 2014. Data of the Italian Ministry of Health regarding the National Hospital Discharge records (SDO) were analysed for the period of the survey (2001-2014). These data are anonymous and include the patient's age, sex, domicile, region of hospitalization, length of the hospitalization, and type of reimbursement (public or private). During the 14-year study period, 92,784 hospitalizations to treat shoulder dislocation were performed in Italy, which represented an incidence of 11.2 hospitalizations for every 100,000 Italian inhabitants. 56,514 patients underwent hospitalization for non-surgical treatment. 36,270 patients underwent hospitalization for surgical treatment. The higher hospitalizations rate was among males from 15 to 64 years of age. Increasing rates of surgical hospitalization and decreasing rates of hospitalization for non-surgical treatment of shoulder dislocation are observed over a 14-year period. This study confirms that the socioeconomic burden of shoulder dislocation surgery heavily affects the working population. Most shoulder instability procedures were performed on males. The present study provides a description of the frequency and national distribution of shoulder instability in Italy. This study shows an increase in surgical procedures for shoulder instability in Italy.

Greater complexity and monitoring of the new Kidney Allocation System: Implications and unintended consequences of concentric circle kidney allocation on network complexity.

The deceased donor kidney allocation system in the United States has undergone several rounds of iterative changes, but these changes were not explicitly designed to address the geographic variation in access to transplantation. The new allocation system, expected to start in December 2020, changes the definition of "local allocation" from the Donation Service Area to 250 nautical mile circles originating from the donor hospital. While other solid organs have adopted a similar approach, the larger number of both kidney transplant centers and transplant candidates is likely to have different consequences. Here, we discuss the incredible increase in complexity in allocation, discuss some of the likely intended and unintended consequences, and propose metrics to monitor the new system.

Spatial Analysis of Healthcare Offer and Request for Older People Aged 65 Years and Over in Quebec

With years, the health-needs of an individual become numerous and more complex, resulting in the requirement of an even more appropriate offer of health services. However, it is known that different factors make the services and the request of the population to health care unequally, especially the interregional variations. These are represented by a gap between the offer of healthcare and the need of the populations. The aim of this study was 1) to map the relationship between the location of the healthcare services in Quebec and population aged 65 years and over, and 2) to identify the characteristics related to the geographic variations in access to healthcare. We used data from “statcan.gc.ca”, “donneesquebec.ca” and “msss.gouv.qc.ca” regarding the facilities, their capacity, their services, and the populations’ characteristics. Analyses were performed on QGIS and R software. As expected, our results showed that there is a gap between the healthcare needs and the services: older people need a large amount of diverse services which are not always provided by secluded areas. Moreover, it also appeared that the deprivation index is related to the offer of health care. As this project takes part in a global project studying the health care trajectories of older people in Quebec using their administrative health databases, those findings will help better understand the impact of the geographic factors for the interregional variations of healthcare.

Adult cardiopulmonary bypass in Australian and New Zealand public hospitals: A survey of practice.

A telephone survey of cardiac anaesthetists and perfusionists at the 29 public hospitals providing adult cardiac surgical services in Australia and New Zealand was carried out between December 2019 and January 2020. The aim was to investigate current practice with regard to selected contentious elements of anaesthetic and perfusion management during cardiopulmonary bypass; primarily relating to bypass circuit priming, blood conservation methods and point-of-care coagulation testing. There was a 100% response rate. The average number of adult public cardiopulmonary bypass cases per hospital was 508 (160-1400). For cardiopulmonary bypass cases, ten hospitals (34%) routinely used a cell saver and the remainder used a cell saver selectively. Residual blood remaining in the cardiopulmonary bypass circuit was processed using a cell saver routinely in four hospitals (14%) and selectively in 23 (79%). Acute normovolaemic haemodilution was rarely used. Retrograde autologous priming was used routinely in seven hospitals (24%) and selectively in 16 (55%). All hospitals had access to point-of-care coagulation testing. The majority of hospitals targeted an activated clotting time of 480 s (range 400-500 s) prior to commencing cardiopulmonary bypass. There was marked geographic variation in access to fibrinogen concentrate. The cardiopulmonary bypass circuit prime solution was primarily a balanced crystalloid in most hospitals; however, there was significant variation regarding the addition of human albumin, mannitol, sodium bicarbonate and other medications. Many of the interventions examined were used on a case-by-case basis. These findings support the need for further research to define more evidence-based practice of these interventions.

Geographic Variation in Access to Pathology and Laboratory Services in Tanzania: A Cross-Sectional Geospatial Analysis

PURPOSE Increasing noncommunicable disease burden in sub-Saharan Africa requires the urgent scale-up of pathology and laboratory medicine (PALM) services. To identify service gaps at the district level, we studied geographic variation in the correlation between travel time to health facilities and population density. METHODS We linked geospatial data for Tanzania from multiple sources. Facility locations were extracted from a comprehensive facility list in Africa. Data on geographic factors, demographics, and roads were collected from government and nonprofit databases. We classified facilities assuming increasing PALM service readiness by level: dispensaries, health centers, district hospitals, and regional/referral hospitals. We input these data into the AccessMod 5 algorithm to estimate travel time across Tanzania with 1-km resolution for each PALM classification. We then calculated district-level averages of population and travel time for each PALM category. Associations between these variables were estimated using a bivariable local indicator of spatial autocorrelation, specifying immediate contiguity neighborhood definition. Spatial analysis was restricted to 172 contiguous districts (islands not included). Significance tests were two sided, with an α of .05. RESULTS Analysis included 5,342 dispensaries, 667 health centers, 185 district hospitals, and 34 regional/referral hospitals. Maps revealed clusters of estimated travel time in excess of 6 hours in less populated western and southern districts. More districts reported an average travel time of less than 1 hour to the nearest dispensary (69%) than to regional/referral hospitals (16%). Bivariable local indicators of spatial autocorrelation revealed few significant clusters of spatial correlations; however, significant correlations between low population density and longer travel times in neighboring districts were obtained for 13%, 16%, 15%, and 13% of districts for dispensaries, health centers, district hospitals, and regional/referral hospitals, respectively. CONCLUSION Limited variability of district-level spatial correlations suggests somewhat equitable geographic allocation of PALM services in Tanzania, with small areas of low population density and long travel times that demand additional intervention. Limitations include a lack of ascertainment of specific PALM services.

The Schooling and Labor Market Effects of Eliminating University Tuition in Ecuador

This paper estimates the effects of a 2008 policy that eliminated tuition fees at public universities in Ecuador. We use a difference-in-differences strategy that exploits variation across cohorts differentially exposed to the policy, as well as geographic variation in access to public universities. We find that the tuition fee elimination significantly increased college participation and affected occupation choice, shifting people into higher-skilled jobs. We detect no statistically significant effects on income. Overall, the bulk of the benefits of this fee elimination were enjoyed by individuals of higher socioeconomic status.