Instrumental Variable Analysis Research Articles

Sjögren’s Disease and Oral Health: A Genetic Instrumental Variable Analysis

Epidemiological studies have consistently shown that Sjögren’s disease (SjD) increases the risk of dental caries. Despite similar evidence indicating an elevated risk of periodontitis, SjD remains a disputed risk factor for this disease. The risk of bias in observational research is a major impediment to confirming this link. Within an instrumental variable framework, genetic variants associated with a risk factor can be used to proxy its effect on an outcome while avoiding common sources of observational study bias. In this study, we leveraged an instrumental variable approach to investigate whether SjD affects the risk of caries and periodontitis. A total of 57 genetic variants strongly associated with SjD were identified from a genome-wide association study of 2,247 European descent cases and 332,115 controls. We tested for associations of these genetic instruments with caries (measured as the number of decayed, missing, and filled surfaces in 26,792 individuals) and periodontitis (17,353 clinical periodontitis cases and 28,210 European controls). Several sensitivity analyses were used to further validate the primary inverse variance weighted (IVW) estimate. IVW analysis revealed an adverse effect of SjD on caries (β = 0.039, P = 6.3e-16) and periodontitis (odds ratio = 1.033, P = 2.3e-05). Sensitivity analyses, conducted to assess the robustness to potential violations of instrumental variable assumptions, further support these findings. Our results showed that SjD has a detrimental effect on caries and also suggest that SjD promotes periodontitis.

Does financial literacy drive entrepreneurship in rural China?

Developing financial literacy is a crucial part of entrepreneurship. It can aid aspiring entrepreneurs to learn how to analyze market trends, formulate business plans, conduct cost accounting activities, and navigate fiscal risks in their businesses. Therefore, we investigated the most recent dataset on rural residents in China to determine the effects of financial literacy on their entrepreneurial behaviors. Our observations reveal that individuals with high financial literacy, that is, those who have attained advanced financial knowledge, are more likely to start a business than those with low financial literacy. We employed instrumental variable analysis to mitigate the endogeneity of financial literacy. Results show a causal relationship between Chinese rural residents’ financial literacy and entrepreneurship. Finally, we demonstrate that the aggressive risk attitudes of rural families magnify the effects of financial literacy on entrepreneurship.

A Continuous Transversus Abdominis Plane Block Decreases Hospital Length of Stay Compared to Thoracic Epidural Analgesia After Open Radical Cystectomy Surgery: A Retrospective Study

Background: Poorly managed postoperative pain can prolong hospital stays and increase the risk of complications in patients undergoing open radical cystectomy (ORC). Despite strong support from the clinical guidelines for using surgical site-specific peripheral regional anesthetic techniques and neuraxial analgesia, their effects on postoperative outcomes are unclear. Objectives: This study aims to fill the above knowledge gap by comparing thoracic epidural analgesia (TEA) and continuous transversus abdominis plane (CTAP) blocks in ORC patients. Methods: In this retrospective observational study, we conducted chart reviews at a quaternary care academic hospital in Boston, Massachusetts, between March 2015 and September 2017. Patients undergoing ORC and receiving either CTAP or TEA were included. The primary outcome was the hospital length of stay (HLOS), and secondary outcomes included time until ambulation, postoperative narcotic usage, and renal function as measured by the glomerular filtration rate (GFR). Results: We studied 146 patients, 124 of whom met our inclusion criteria. Patients receiving CTAP had a 17.4% reduction in HLOS (95% CI: 3.2, 29.4; P = 0.02) and a 13.9% reduction in time until ambulation (95% CI: 3.4, 23.3; P = 0.01) compared to those receiving TEA. This was equivalent to a relative decrease in HLOS of approximately 2.1 days in the CTAP group as compared to the TEA group. No significant differences were observed in narcotic usage or GFR between the two groups. Our sensitivity analyses using instrumental variables analysis yielded similar results. Conclusions: Continuous transversus abdominis plane was associated with a shorter HLOS and quicker time to ambulate compared to TEA, without affecting narcotic usage or renal function. These findings suggest that CTAP may be a viable alternative to TEA for perioperative analgesia in ORC patients. Further research is needed to confirm these findings.

Does cycle commuting reduce the risk of mental ill-health? An instrumental variable analysis using distance to nearest cycle path.

Previous studies have linked cycling with improved mental wellbeing but these studies tend to use cross-sectional survey data that have small sample sizes and self-reported health measures, and are potentially susceptible to omitted-variable bias and reverse causation. We use an instrumental variable approach and an objective measure of mental ill-health taken from linked administrative data to ask: 'Does cycle commuting reduce the risk of mental ill-health?' Our study links data on commuting in Edinburgh and Glasgow from the Scottish population census with mental health prescriptions from the National Health Service Prescribing Information System records. We use road distance from home to nearest cycle path as an instrumental variable for cycle commuting. In total, 378 253 people aged 16-74years living and working in the City of Edinburgh and Glasgow City council areas at the 2011 census were included in our study; 1.85% of commuters in Glasgow and 4.8% of commuters in Edinburgh cycled to work. Amongst cyclists, 9% had a prescription for mental health compared with 14% amongst non-cyclists. Using a bivariate probit model, we estimate a mean average reduction in prescriptions for antidepressants and/or anxiolytics in the 5years following the census of -15.1% (95% CI: -15.3% to -15.0%) amongst cycle commuters compared with those who use any other mode to commute. This work suggests that cycle commuting is causally related to reduced mental ill-health and provides further evidence in support of the promotion of active travel to encourage commuters travelling shorter distances to shift to cycle commutes.

Serum apolipoproteins and mortality risk: evidence from observational and Mendelian randomization analyses

BackgroundApolipoproteins (APOs) have emerged as significant players in lipid metabolism that affects the risk of chronic disease. However, the impact of circulating APO concentrations on premature death remains undetermined. ObjectivesThis study aimed to investigate the associations of serum APOs with all-cause, cardiovascular disease (CVD)-related, and cancer-related mortality. MethodsWe included 340,737 participants who had serum APO measurements from the UK Biobank. Restricted cubic splines and multivariable Cox regression models were used to assess the associations between APOs and all-cause and cause-specific mortality by computing hazard ratios (HRs) and 95% confidence intervals (CIs). Based on 1-sample Mendelian randomization (MR) design, including 398,457 participants of White ancestry who had genotyping data from the UK Biobank, we performed instrumental variable analysis with 2-stage least squares regression to assess the association between genetically predicted APOs and mortality. ResultsAfter adjusting for potential confounders including high-density and low-density lipoprotein particles, we observed nonlinear inverse relationships of APOA1 with all-cause, CVD-related, and cancer-related mortality (P-nonlinear < 0.001). By contrast, positive relationships were observed for APOB and all-cause (P-nonlinear < 0.001), CVD-related (P-linear < 0.001), and cancer-related (P-linear = 0.03) mortality. MR analysis showed consistent results, except that the association between APOB and cancer mortality was null. Furthermore, both observational and MR analyses found an inverse association between APOA1 and lung cancer–related mortality (HR comparing extreme deciles: 0.46; 95% CI: 0.26, 0.80; and HR: 0.78; 95% CI: 0.63, 0.97, respectively). ConclusionsOur findings indicate that circulating APOA1 has potential beneficial effects on all-cause, CVD-related, and lung cancer–related death risk, whereas APOB may confer detrimental effects on all-cause and CVD-related death risk.

Surgical stabilization of rib fractures for flail chest: Analysis of center-based variability in practice and outcomes.

Given the lack of high-quality data on patient selection for surgical stabilization of rib fractures (SSRF), significant variability in practice likely exists across trauma centers. We aimed to determine whether centers with a more liberal approach to SSRF had improved outcomes. We performed a retrospective cohort study of adult patients with flail chest admitted to Level I or II trauma centers participating in the American College of Surgeons' Trauma Quality Improvement Program. The primary outcome was hospital mortality; secondary outcomes included discharge status, tracheostomy, duration of mechanical ventilation, and hospital length of stay. Logistic regression was performed to calculate center-level observed/expected rates of SSRF and centers were grouped into quintiles from "most liberal" to "most restrictive." Multivariable regression was used to determine the association between these quintiles and outcomes. We also used an instrumental variable analysis to evaluate the association between SSRF and mortality at the patient level. Among 23,619 patients with flail chest across 354 centers, 22% underwent SSRF. Center rates of fixation ranged from 0% to 88%. Higher rates of SSRF were not associated with lower mortality overall (highest vs. lowest quintile: odds ratio, 0.86; 95% confidence interval, 0.63-1.17). However, centers with a more liberal approach to SSRF had lower rates of independent status at discharge, higher tracheostomy rates, longer duration of mechanical ventilation, and longer hospital and ICU length of stay. The patient level analysis demonstrated that SSRF as was associated with a 25% lower risk of death. Overall, centers with a liberal approach to SSRF do not show improved outcomes among patients with a flail chest, but have higher resource utilization. Results at the patient level suggest that there is a population likely to benefit but these patients remain to be identified through further research. Prognostic and Epidemiological; Level III.

Marital decision-making power and husband’s happiness: evidence from a micro dataset in China

Using a micro-level representative dataset of China, the very first paper empirically analyzes the relationship between marital decision-making power and husband’s happiness. While employing the OLS and ordinal logit model, the paper finds a negative effect of husband’s marital decision-making power on his happiness in contemporary transitioning China. The conclusion remains consistent even after conducting additional robustness tests, such as propensity score matching and instrument variable analysis. The negative effect is particularly noticeable among educated men and those men living in environments that emphasize egalitarian gender ideologies, as they tend to reject the notion of men being dominant in the family. Our findings highlight the increasing acceptance of egalitarian gender ideologies among Chinese men, especially those with higher socioeconomic status, as a result of socioeconomic advancements.

Financial Technology and Poverty Alleviation in Indonesia During the COVID-19 : Impact Evaluation Analysis

The COVID-19 pandemic has brought significant changes, especially to each country's economic and financial sectors. Economic growth in Indonesia experienced a contraction entering mid-2021. This also impacted limiting economic activity, decreasing household consumption, unemployment risk, and increased poverty. In addition, there are changes in people's behavior, such as digital financing systems, non-cash payment systems, and online buying and selling transaction systems. Efforts to improve the economy are encouraged by stimulating people's economic productivity through adaptation to digital technology developments, especially using digital finance. However, the development of digital finance needs to be supported by public financial literacy and inclusion so that it can positively alleviate poverty. This study aims to analyze the impact of financial technology lending on poverty in Indonesia during the COVID-19 pandemic using instrumental variable analysis (IV) for 2019-202. The results of the study show that fintech lending has a negative effect on the poverty rate. However, it is not significant when other variables are added. E-commerce and the use of credit cards have a negative and significant impact on the poverty rate in Indonesia. In maximizing the role of Fintech in Indonesia, support and cooperation from the government, financial institutions, and various relevant stakeholders are needed.

The heterogeneous impact of college education on happiness by gender

AbstractObjectiveThis study examines the heterogeneous impacts of college education on happiness by gender.MethodsTo yield unbiased impact estimates, we take advantage of a natural experiment known as the graduation quota program, which suddenly and massively expanded the opportunities to attend college in the early 1980s in South Korea. Using whether the birth cohorts were exposed to the graduation quota program as an instrumental variable (IV), this study estimates the longer‐term effects of college education on happiness by gender.ResultsThe estimated local average treatment effect by the IV analysis indicates that men who were induced to attend college by the graduation quota program became happier. However, there was no noticeable impact on women's happiness.ConclusionsConsidering that the subjective happiness in our study was measured in their late 30s and 40s, the impact of college on happiness seems to be long‐lasting for men but not for women.

The Role of Passive Investors in Corporate Governance and Socially Responsible Investing: Evidence from Shareholder Proposals

We study whether the substantial rise in passive ownership reshapes activist shareholders’ behavior in sponsoring shareholder proposals, which shareholders use to address issues they believe are crucial for the sustainable growth of a company. Our findings reveal a positive impact of passive investors on the initiation of governance, socially responsible investing (SRI), and an aggregate of both proposals. Interestingly, we show that managerial ability and board co-option potentially moderate their link. In the subsequent analysis, we note a constructive influence of passive investors on post-initiation outcomes, evidenced by an increase in withdrawal and voting percentage of proposals corresponding to heightened levels of passive ownership. These findings suggest that passive investors foster communication between activists and management and endorse the case even when it progresses to the voting stage. More importantly, the market values these proposals positively as reflected in higher observed buy-and-hold returns. Finally, our results are robust to instrumental variable analysis using Russell reconstitution as an exogenous shock. Taken together, our study offers broad implications that passive investors can indirectly engage in promoting sustainable practices by encouraging activist investors to sponsor governance and socially responsible proposals, a collaborative approach where shareholders contribute to sustainability efforts.

Association with menopausal hormone therapy and asymptomatic gallstones in US women in the third National Health and Nutrition Examination Study

15% of US adults have gallstones, most of which are clinically “silent”. Several studies show that menopausal hormone therapy (MHT) increases symptomatic gallstones and cholecystectomy risk. MHT use may be contraindicated in women with gallstones and population studies may be biased by “confounding by contraindication” while the true association between MHT and gallstones remains underestimated. We sought to examine whether MHT use was associated with asymptomatic gallstones using instrumental variable (IV) analysis to account for confounding by contraindication. We used 2018 postmenopausal women from the Third National Health and Nutrition Examination Survey to estimate associations of MHT use with asymptomatic gallstones. A traditional logistic regression analysis was compared to instrumental variable (IV) analysis to account for confounding by contraindication. 12% of women with asymptomatic gallstones and 25% of women without gallstones were current MHT users (P < 0.001). The traditional analysis suggested a decreased odds of asymptomatic gallstones in current versus never users (OR 0.58, 95% CI 0.37, 0.89), but increased odds (OR 1.51, 95% CI 0.44, 5.16) in the IV analysis. The traditional analysis consistently underestimated the odds of asymptomatic gallstones with MHT use compared to the IV analysis. Accounting for confounding by contraindication, we found a suggestive, though imprecise, positive association between MHT use and asymptomatic gallstones among postmenopausal women. Failure to consider contraindication can produce incorrect results.

Estimating the effect of corporate integrity culture on tax avoidance using a text-based approach: A research note.

Tax avoidance holds immense importance due to its substantial implications for government revenues and the fair allocation of resources. Consequently, understanding the factors that shape tax avoidance is critically important. Exploiting a cutting-edge measure of corporate integrity derived from state-of-the-art machine learning algorithms and textual analysis, we explore the effect of corporate integrity on tax avoidance. Our text-based measure is based on a textual analysis of earnings conference call transcripts. Our findings show that companies with greater corporate integrity are significantly less involved in tax avoidance. Further analysis corroborates the results, i.e., propensity score matching, entropy balancing, and an instrumental variable analysis. Our findings are especially noteworthy as they demonstrate that corporate culture, although intangible in nature, exerts a substantial influence on corporate behavior.

인과적 타당성을 위한 도구변수 분석법: 교육 연구에의 활용 가능성 탐색

Instrumental variable (IV) analysis is a statistical approach that enables valid estimation of causal effects, even in non-experimental settings where randomization is not possible. Despite its potential utility, IV analysis remains underutilized in Korean education research. The purpose of this paper is to introduce the fundamental principles of IV analysis and its applications. Specifically, the paper employs causal graphs to provide a more intuitive explanation of the key assumptions and mechanism underlying IV analysis. In addition to providing theoretical explanations, the paper explores the applicability of IV analysis in the context of education research through examining randomized encouragement designs, perceived construct studies, and treatment noncompliance. By doing so, this paper aims to facilitate a better understanding of theoretical foundations and practical considerations when applying IV analysis in education research.

Tax avoidance, managerial ownership, and agency conflicts

We examine how corporate tax avoidance is influenced by managerial ownership. Our results, based on a large sample of nearly 30,000 observations across a quarter of a century, demonstrate that firms where managers hold more shares exhibit less tax avoidance. Our findings corroborate the notion that corporate tax avoidance is primarily motivated by agency conflicts and is significantly mitigated by higher managerial ownership, which brings managers and shareholders’ interests into better alignment. Further analysis corroborates the results, i.e., propensity score matching, an instrumental variable analysis, and using alternative measures of tax avoidance.

Debt overhang and carbon emissions

PurposeThis study investigates the association between debt overhang and carbon emissions (both direct and indirect emissions) using a sample of US publicly listed firms.Design/methodology/approachThe study applies generalized least squares (GLS) regression analyses to a sample of 2,043 US firm-year observations over a period of 14 years from 2007 to 2020. The methods include contemporaneous effect, lagged effect, alternative measures of carbon emissions and debt overhang, intensive versus non-intensive analysis, channel analysis, firm fixed effects, change analysis, controlling for credit rating analysis, propensity score matching approach, instrumental variable analysis with industry and year fixed effect.FindingsThis study's findings reveal that the debt overhang problem increases carbon emissions. This finding holds when the authors use alternative measures of carbon emissions and debt overhang. The authors find that carbon abatement investment is a channel that is negatively impacted by debt overhang, which in turn increases carbon emissions. This study's results are robust for several endogeneity tests, including firm fixed effects, change analysis, propensity score matching approach and two-stage least squares (2SLS) instrumental variable analysis.Practical implicationsThe outcome of this research has policy implications for several stakeholders, including investors, firms, market participants and regulators. This study's findings offer insights for investors and firms, helping them allocate resources effectively and make financing decisions aimed at reducing carbon emissions. Regulators and policymakers can also use the findings to formulate policies that promote alternative sustainable finance practices.Originality/valueThe outcome of this research is likely to help firms develop their understanding of the debt overhang problem and undertake strategies that yield a significant amount of funding to invest in reducing carbon emissions.

STATE GENEROSITY IN HOME- AND COMMUNITY-BASED SERVICES (HCBS): VARIATIONS AND IMPACT ON DEMENTIA OUTCOMES

Abstract To meet the needs of community-living older adults and reduce overall medical spending, home- and community-based services (HCBS) provide assistance and care for persons with significant physical and cognitive limitations. Together, Medicaid long-term services and supports (LTSS) coverage and the Title III program under the Older Americans Act (OAA) of 1965 support the majority of the HCBS for older adults living in the U.S. with low-income and/or disabilities. We evaluated state variations in generosity of supporting HCBS in recent years and how these variations affect the healthcare outcomes of community-living older adults and socio-economic and racial disparities in dementia outcomes. State HCBS generosity from the perspectives of program participation and intensity of services was defined by the exploratory and the confirmatory factor analysis with data from multiple sources, including state reports from the National Association of State Budget Officers. State data was linked to a nationally representative sample of older adults who enrolled in the Health and Retirement Study in 2020. Analyses revealed that overall state supports for HCBS increased over time in recent years while state Medicaid expenditures for institutional long-term care remained largely stable. State supports through both Medicaid and the OAA programs for HCBS varied substantially and persisted in recent years. Discussion will focus on instrumental variable analyses that determine the causal impact of state variations in HCBS generosity on health outcomes (i.e., unmet need; hospitalization) for persons living with dementia persons.

INSTITUTIONAL EXPERIENCES OF RACIAL DISCRIMINATION AND COGNITIVE FUNCTION: INSTRUMENTAL VARIABLE ANALYSIS

Abstract In addition to enduring the ongoing and persistent legacy of structural racism in the United States, Black adults often encounter sources of social stress, like racial discrimination, that have documented associations with health outcomes. As inequities in cognitive aging persist for Black adults, research has worked to examine modifiable factors, like racial discrimination, that may serve as the basis for intervention development. The dysregulation of inflammatory biomarkers has been proposed as one pathway through which racial discrimination becomes embodied to contribute to racial inequities in cognitive function. We assessed how racial discrimination occurring in institutional settings affects cognitive function among a sample of Black and white adults from the Coronary Artery Risk Development in Young Adults (CARDIA) study. To mitigate the influences of measurement error and unmeasured or residual confounding on our findings, we used an instrumental variable analysis to estimate the unbiased, causal association between racial discrimination in institutional settings and a battery of standardized cognitive function measures. We found that increased experiences of racial discrimination had adverse impacts on cognitive function. Understanding how racial discrimination in these settings influences cognitive outcomes supplies insight into points of potential intervention at institutional and policy levels.

Instrumental variables for implementation science: exploring context-dependent causal pathways between implementation strategies and evidence-based interventions

BackgroundThe impact of both implementation strategies (IS) and evidence-based interventions (EBI) can vary across contexts, and a better understanding of how and why this occurs presents fundamental but challenging questions that implementation science as a field will need to grapple with. We use causal epidemiologic methods to explore the mechanisms of why sharp distinctions between implementation strategies (IS) and efficacy of an evidence-based intervention (EBI) may fail to recognize that the effect of an EBI can be deeply intertwined and dependent on the context of the IS leading to its uptake.MethodsWe explore the use of instrumental variable (IV) analyses as a critical tool for implementation science methods to isolate three relevant quantities within the same intervention context when exposure to an implementation strategy is random: (1) the effect of an IS on implementation outcomes (e.g., uptake), (2) effect of EBI uptake on patient outcomes, and (3) overall effectiveness of the IS (i.e., ~ implementation*efficacy). We discuss the mechanisms by which an implementation strategy can alter the context, and therefore effect, of an EBI using the underlying IV assumptions. We illustrate these concepts using examples of the implementation of new ART initiation guidelines in Zambia and community-based masking programs in Bangladesh.ResultsCausal questions relevant to implementation science are answered at each stage of an IV analysis. The first stage assesses the effect of the IS (e.g., new guidelines) on EBI uptake (e.g., same-day treatment initiation). The second stage leverages the IS as an IV to estimate the complier average causal effect (CACE) of the EBI on patient outcomes (e.g., effect of same-day treatment initiation on viral suppression). The underlying assumptions of CACE formalize that the causal effect of EBI may differ in the context of a different IS because (1) the mechanisms by which individuals uptake an intervention may differ and (2) the subgroup of individuals who take up an EBI may differ. IV methods thus provide a conceptual framework for how IS and EBIs are linked and that the IS itself needs to be considered a critical contextual determinant. Moreover, it also provides rigorous methodologic tools to isolate the effect of an IS, EBI, and combined effect of the IS and EBI.DiscussionLeveraging IV methods when exposure to an implementation strategy is random helps to conceptualize the context-dependent nature of implementation strategies, EBIs, and patient outcomes. IV methods formalize that the causal effect of an EBI may be specific to the context of the implementation strategy used to promote uptake. This integration of implementation science concepts and theory with rigorous causal epidemiologic methods yields novel insights and provides important tools for exploring the next generation of questions related to mechanisms and context in implementation science.

Impact of financial literacy on household stock profit level in China.

The popularization of financial literacy has become a global trend, with governments across the world expressing commitment to continuously enhancing the financial literacy of their citizens to improve the country's overall financial well-being. However, there is a lack of research evaluating the actual effects of financial literacy on Chinese households. This study first investigated the micro impact of financial literacy on the household stock profit level using data from the 2019 China Household Finance Survey. As most existing studies use factor analysis to measure financial literacy from a single dimension of financial knowledge, our study additionally used the entropy method to construct a composite evaluation system of financial literacy from four dimensions: financial skills, knowledge, attitudes, and behaviors. The ordinary least squares model was utilized as the primary regression model to estimate the correlation, and the average financial literacy of other households in the same community was selected as an instrumental variable. Further instrumental variable regression analysis was conducted using the two-stage least squares method. Three robustness tests were performed to ensure the reliability of the research findings. The results demonstrate that financial literacy significantly enhances household stock profit levels. The mediation effect analysis indicates that financial literacy affects stock profit levels through financial information attention. Moreover, financial literacy has a more substantial promoting effect on stock profit levels for households with members working for state-owned enterprises and those living in first-tier cities. This study confirms the value of financial literacy; identifies important channels for residents to increase their property income; and provides important guidance for the government, educational organizations, and financial institutions. This also injects more vigor into market participation to improve the persistently sluggish Chinese stock market.

Antimicrobial Prophylaxis With Ampicillin-sulbactam Compared With Cefazolin for Esophagectomy: Nationwide Inpatient Database Study in Japan.

To assess the effect of antimicrobial prophylaxis with ampicillin-sulbactam (ABPC/SBT) compared with cefazolin (CEZ) on the short-term outcomes after esophagectomy. CEZ is widely used for antimicrobial prophylaxis in esophagectomy without procedure-specific evidence, whereas ABPC/SBT is preferred in some hospitals to target both aerobic and anaerobic oral bacteria. Data of patients who underwent esophagectomy for cancer between July 2010 and March 2019 were extracted from a nationwide Japanese inpatient database. Overlap propensity score weighting was conducted to compare the short-term outcomes [including surgical site infection (SSI), anastomotic leakage, and respiratory failure] between antimicrobial prophylaxis with CEZ and ABPC/SBT after adjusting for potential confounders. Sensitivity analyses were also performed using propensity score matching and instrumental variable analyses. Among 17,772 eligible patients, 16,077 (90.5%) and 1695 (9.5%) patients were administered CEZ and ABPC/SBT, respectively. SSI, anastomotic leakage, and respiratory failure occurred in 2971 (16.7%), 2604 (14.7%), and 2754 patients (15.5%), respectively. After overlap weighting, ABPC/SBT was significantly associated with a reduction in SSI [odds ratio 0.51 (95% CI: 0.43-0.60)], anastomotic leakage [0.51 (0.43-0.61)], and respiratory failure [0.66 (0.57-0.77)]. ABPC/SBT was also associated with reduced respiratory complications, postoperative length of stay, and total hospitalization costs. The proportion of Clostridioides difficile colitis and noninfectious complications did not differ between the groups. Propensity score matching and instrumental variable analyses demonstrated equivalent results. The administration of ABPC/SBT as antimicrobial prophylaxis for esophagectomy was associated with better short-term postoperative outcomes compared with CEZ.