Population Registry Data Research Articles

Income-related differences in out-of-hours primary care telephone triage using national registration data

BackgroundTelephone triage is used to facilitate efficient and adequate acute care allocation, for instance in out-of-hours primary care services (OPCSs). Remote assessment of health problems is challenging and could be...

Genetic contributions to bipolar disorder: current status and future directions.

Bipolar disorder (BD) is a highly heritable mental disorder and is estimated to affect about 50 million people worldwide. Our understanding of the genetic etiology of BD has greatly increased in recent years with advances in technology and methodology as well as the adoption of international consortiums and large population-based biobanks. It is clear that BD is also highly heterogeneous and polygenic and shows substantial genetic overlap with other psychiatric disorders. Genetic studies of BD suggest that the number of associated loci is expected to substantially increase in larger future studies and with it, improved genetic prediction of the disorder. Still, a number of challenges remain to fully characterize the genetic architecture of BD. First among these is the need to incorporate ancestrally-diverse samples to move research away from a Eurocentric bias that has the potential to exacerbate health disparities already seen in BD. Furthermore, incorporation of population biobanks, registry data, and electronic health records will be required to increase the sample size necessary for continued genetic discovery, while increased deep phenotyping is necessary to elucidate subtypes within BD. Lastly, the role of rare variation in BD remains to be determined. Meeting these challenges will enable improved identification of causal variants for the disorder and also allow for equitable future clinical applications of both genetic risk prediction and therapeutic interventions.

Immigrant Political Representation and Local Ethnic Concentration: Evidence from a Swedish Refugee Placement Program

AbstractThis study leverages population registry data from Sweden to examine whether immigrants who live in areas with a high concentration of ethnic minorities are more or less likely to be nominated for political office. It exploits a refugee placement program in place in Sweden during the late 1980s and early 1990s that restricted refugees' opportunities to freely choose their place of residence. The article presents evidence that immigrants who live in areas with a high ethnic density are less likely to be nominated for political office. The findings have important implications for local integration policies as well as refugee placement policies, as many countries consider local context when resettling refugees.

Changing Practice Patterns Among Canadian Primary Care Physicians: Cross-Provincial Analysis of Linked Health Data

IntroductionCanadians report persistent problems accessing primary care despite an increasing per-capita supply of primary care physicians (PCPs). There is speculation that PCPs, especially those early in their careers, may be working less and/or choosing to practice in focused clinical areas rather than comprehensive family medicine.
 Objectives and ApproachOur objectives were to compare practice patterns among early-career (<10 years in practice) and established (10+ years) PCPs and to determine if any changes over time reflect cohort effects (attributes unique to recent cohorts of PCPs), or period effects (changes over time across all PCPs). We accessed linked population and physician registry data, physician billing data, hospital discharge records, and vital statistics in each of three Canadian provinces from 1996/7 to 2017/8. Physician fee schedules are negotiated separately by province which means that while fields capturing service dates, dollars billed, and diagnosis codes are directly comparable, other fields capture similar, but not identical information across provinces (e.g. specific fee codes and service location codes). We developed measures of services volume, continuity, and comprehensiveness of primary care that could be applied across provinces and used these to describe practice patterns over two decades and explore cohort and period effects.
 ResultsMeasures of service volume (total patient contacts, number of unique patients seen) and continuity are lower among early-career physicians but the gap between early-career and established physicians has not changed. Measures of comprehensiveness of care, including provision of services in home, long-term care, hospital, and emergency department, as well as indicators of focused practice, hospitalist and locum care show more varied patterns, with declines in comprehensiveness across all physicians, but more evidence of focused practice among early-career physicians.
 Conclusion / ImplicationsFindings have implications both for health workforce planning and organizational reforms to support access to comprehensive primary care.

How Transitions in Dementia Care Trajectories Affect Health Problems in Partners: A Longitudinal Analysis With Linked Health and Administrative Data.

To evaluate whether the prevalence of health problems in cohabiting partners of people with dementia differs between the year before and the year after 3 transitions: the diagnosis of dementia, institutionalization, and the death of the person with dementia. Individuals with dementia and their partners were identified on the basis of data in the electronic health records (EHRs) of 451 Dutch general practices. EHRs were also the data source on their health problems, which were linked to the Dutch population registry and health administration data with demographic characteristics, date of institutionalization, and date of death. Differences in the prevalence of 16 groups of health problems and of specific health problems in partners during the year before and the year after the 3 transitions were examined using a generalized estimating equation. About 1,110 partners of persons with dementia were identified. Problems related to the illness and/or loss of the person with dementia were significantly more prevalent in the year after the dementia diagnosis (32% vs. 17%) and in the year after the death of the person with dementia (59% vs. 41%) than in the years before. Unspecified health problems were more prevalent in the year after the diagnosis than in the year before (30% vs. 22%). After institutionalization, an increase was found in digestive problems and urological problems (30% vs. 18% and 24% vs. 17%). Transitions during the dementia care trajectory, namely, the diagnosis, institutionalization, and death of the person with dementia, significantly affect the cohabiting partner's health.

Deep learning-based artificial intelligence for predicting risk and prognosis in patients with cardiovascular disease

Cardiovascular disease (CVD) is a major healthcare problem worldwide. Risk stratification and prognosis prediction are critical in identifying high-risk patients and in decision making to devise treatment strategies for patients with CVD. For this purpose, various models have been developed and validated against large amounts of population registry data by using conventional statistical methods such as regression-based models. However, these conventional models have a problem of over-generalization and are not applicable to all individual patients. Deep learning is a branch of artificial intelligence in which artificial neural networks are used to analyze data patterns; it is similar to functioning of the human neural system. An advantage of deep learning is the automatic learning of features and relationships from given data. Recently, deep learning achieved high performance in several medical domains, such as image classification, diagnosis, clinical outcome prediction, and gene analysis. The focus of this review is to summarize deep learning-based prediction models in patients with CVD in terms of accuracy in comparison with conventional models.

Association between asbestos exposure and pericardial and tunica vaginalis testis malignant mesothelioma: a case-control study and epidemiological remarks.

Objectives:The purposes of this study are to describe the epidemiology of pericardial and tunica vaginalis testis mesothelioma and assess the role of asbestos exposure for these rare diseases.Methods:Based on incident pericardial and tunica vaginalis testis mesothelioma cases collected from the Italian national mesothelioma registry (ReNaM) in the period 1993–2015, incidence rates, survival median period and prognostic factors have been evaluated. A case–control study has been performed to analyze the association with asbestos exposure (occupational and non-occupational) for these diseases.Results:Between 1993 and 2015, 58 pericardial (20 women and 38 men) and 80 tunica vaginalis testis mesothelioma cases have been registered with a mean annual standardized (world standard population as reference) incidence rates of 0.049 (per million) in men and 0.023 in women for the pericardial site, and 0.095 for tunica vaginalis testis mesothelioma. Occupational exposure to asbestos was significantly associated with the risk of the diseases [odds ratio (OR) 3.68, 95% confidence interval (CI) 1.85–7.31 and OR 3.42, 95% CI 1.93–6.04 in pericardial and tunica vaginalis testis mesothelioma, respectively]. The median survival was 2.5 months for pericardial and 33.0 months for tunica vaginalis testis mesotheliomas. Age was the main predictive factor for survival for both anatomical sites.Conclusions:For the first time in an analytical study, asbestos exposure was associated with pericardial and tunica vaginalis testis mesothelioma risk, supporting the causal role of asbestos for all anatomical sites. The extreme rarity of the diseases, the poor survival and the prognostic role of age have been confirmed based on population and nationwide mesothelioma registry data.

Estimation of Absolute Risk of Colorectal Cancer Based on Healthy Lifestyle, Genetic Risk, and Colonoscopy Status in a Population-Based Study

Estimates of absolute risk of colorectal cancer (CRC) are needed to facilitate communication and better inform the public about the potentials and limits of cancer prevention. Using data from a large population-based case-control study in Germany (Darmkrebs: Chancen der Verhütung durch Screening [DACHS] study, which began in 2003) and population registry data, we calculated 30-year absolute risk estimates for development of CRC based on a healthy lifestyle score (derived from 5 modifiable lifestyle factors: smoking, alcohol consumption, diet, physical activity, and body fatness), a polygenic risk score (based on 90 single-nucleotide polymorphisms), and colonoscopy history. We analyzed data from 4220 patients with CRC and 3338 individuals without CRC. Adherence to a healthy lifestyle and colonoscopy in the preceding 10 years were associated with a reduced relative risk of CRC in men and women. We observed a higher CRC risk in participants with high or intermediate genetic risk scores. For 50-year-old men and women without a colonoscopy, the absolute risk of CRC varied according to the polygenic risk score and the healthy lifestyle score (men, 3.5%-13.4%; women, 2.5%-10.6%). For 50-year-old men and women with a colonoscopy, the absolute risk of developing CRC was much lower but still varied according to the polygenic risk score and the healthy lifestyle score (men, 1.2%-4.8%; women, 0.9%-4.2%). Among all risk factor profiles, the 30-year absolute risk estimates consistently decreased with adherence to a healthy lifestyle. In a population-based study, we found that a colonoscopy can drastically reduce the absolute risk of CRC and that the genetically predetermined risk of CRC can be further reduced by adherence to a healthy lifestyle. Our results show the magnitude of CRC prevention possible through colonoscopy and lifestyle at a predefined genetic risk. This observational study has been registered in the German Clinical Trials Register (DRKS00011793), which is a primary registry in the World Health Organization Registry Network.

Schizophrenia polygenic risk scores, urbanicity and treatment-resistant schizophrenia

IntroductionTo investigate the impact of a polygenic risk score for schizophrenia (PRS-SZ) and urbanicity on the risk of treatment-resistant schizophrenia (TRS) in people diagnosed with schizophrenia and to evaluate the association between PRS-SZ and TRS across levels of urbanicity. MethodsCohort study of people born after 1981 with a first registered diagnosis of schizophrenia between 1996 and 2012 using Danish population registry data. Through linkage to genome-wide data, we calculated PRS-SZ based on a Psychiatric Genomics Consortium meta-analysis. We assessed urbanicity at birth (capital, provincial and rural areas). TRS was defined using prescription and hospital data. Performing Cox regression analysis, we calculated hazard rate ratios (HRs) and 95% confidence intervals (CI). ResultsAmong 4475 people with schizophrenia, we identified 593 (13.3%) with TRS during 17,558 person years of follow-up. The adjusted HR for TRS associated with one standard deviation (SD) increase in the PRS-SZ was 1.11 (95% CI: 1.00–1.24). The adjusted HRs for TRS across levels of urbanicity were 1.20 (95% CI: 0.98–1.47) for provincial areas and 1.19 (95% CI 0.96–1.47) for rural areas compared with the capital area. Within strata of urbanicity, the adjusted HR for TRS was 1.39 (95% CI: 1.14–1.70) in the capital area with 1 SD increase in the PRS-SZ, 0.99 (95% CI 0.84–1.17) in provincial areas, and 1.03 (95% CI: 0.86–1.25) in rural areas. ConclusionThe effect of genetic liability (i.e. PRS) on risk of TRS varied across urbanicity levels and was highest for people with schizophrenia born in the capital areas.

Marriage migration and the economic trajectories of first- and second-generation immigrants in Norway

Although marriage migration is an important route for immigration to Western Europe, little is known about how it is associated with the labour market trajectories of the minority populations involved. Using longitudinal population registry data on residents from a non-Western migrant background in Norway, this study compares the employment and earnings of those who ‘marry back home’, with those who find a spouse among Norwegian residents with the same national origin background. Following individuals up to 10 years before and after their first marriage (279,527 observations between 1993 and 2010), distributed fixed effects estimations suggest that the labour market trajectory is weaker in the years after marriage for those who have married marriage migrants, albeit the differences are small for men. For women from the first generation, marrying a marriage migrant is associated with lower employment and earnings, progressively declining with time. For women from the second generation, this relative decrease only holds for the labour earnings of employed women. Supplementary analyses indicate that the falling labour market trajectories of women marrying marriage migrants are related to lower educational attainment, higher fertility and stronger associations between motherhood and the labour market.

Highlights of This Issue

Observational studies on polyunsaturated fatty acids (PUFAs) and overall cancer outcomes have yielded mixed findings, and more importantly, are limited by their ability to infer causality. In this study, Liyanage, Ong, and colleagues evaluated whether there is genetic evidence to support causal claims for the relationship between several PUFAs and cancer outcomes through a series of mendelian randomization analyses using data from the UK Biobank cohort. Among all the PUFAs tested, most presented limited evidence for an effect on the risk of being diagnosed/dying from cancer except ALA, where increased genetically predicted ALA was associated with a reduction in risk. For individual common cancers, higher LA concentrations were shown to be protective for colorectal cancer risk.Wiemels and colleagues demonstrated using high quality population registry data evidence that early clinically-diagnosed CMV infection (during pregnancy for the mother or within the neonate) is a strong risk factor for childhood hematologic malignancies. This provocative observation suggests that prevention of vertical CMV transmission during pregnancy would be an effective approach at leukemia prevention. While additional research is needed on the mechanisms, the results support a scenario where the timing of infection of this ubiquitous virus; that is, before an infant can mount an adaptive immune response, may be critical in the etiology of leukemia.Increased intratumoral synthesis of cholesterol has been described in primary prostate cancers from patients who ultimately develop metastases. Khan, Stopsack, and colleagues studied the vitamin D-regulated enzyme sterol-27-hydroxylase (CYP27A1), which lowers intracellular cholesterol by converting it to 27-hydroxycholesterol. Among participants of the Health Professionals Follow-up Study and the Physicians’ Health Study with prostate cancer, low CYP27A1 mRNA was associated with higher cholesterol synthesis and with higher risk of metastases and prostate cancer death. There were no strong associations with markers of vitamin D signaling. These findings further support the hypothesis that cholesterol accumulation is a feature of lethal prostate cancer.Numerous systemic treatments, including targeted therapies, have been developed for advanced-stage non-small cell lung cancer but many patients remain untreated. Maguire and colleagues used California Cancer Registry data to examine the role that health insurance plays in the receipt of systemic treatments. Only half (51%) of patients received such treatment and those with Medicaid were significantly less likely to receive it compared with their privately insured counterparts. Source of health insurance influences care received. Further research is warranted to better understand the barriers to treatment that patients with Medicaid face.

Untangling the ethical intersection of epidemiology, human subjects research, and public health

PurposeMembers of the American College of Epidemiology (ACE) Ethics Committee identified current ethics and epidemiology topic areas to consider for further discussion, consultation, teaching opportunities, and conference presentation. This article reflects on the activities of the Committee at the ACE Annual Meeting in New Orleans, Louisiana, September 24–26, 2017. MethodsThe overall aim for the Ethics Committee was to engage members of the College and other audiences and highlight the evolution of ethics and epidemiology since the inception of the original Ethics Guidelines published by the ACE Ethics and Standards of Practice Committee in 2000. The Ethics Committee organized a symposium session at the 2017 Annual Meeting of ACE on the ethics of human subjects research as it relates to specialized areas of epidemiology and the intersecting role of public health. This article presents a summary and further discussion of that symposium session. ResultsThree topic areas were presented: an overview of ethics and epidemiology (E.S.P.), very high biomarker levels in environmental epidemiology research (S.M.P.), and the interface of epidemiology, human subjects research, and public health interventions (S.M.). This article begins by reviewing the foundations of epidemiology and public health and the well-known ethical principles of human subjects research. Then, it considers the ethical considerations in the use of population registry data in epidemiological research, environmental epidemiology, and epidemic surveillance and response. This article may form the basis of teaching of ethics principles related to epidemiology and public health and may serve as a companion piece to the original ACE Ethics Guidelines. ConclusionsResearchers are increasingly faced with ethical considerations in diverse, nontraditional, and specialized areas of epidemiology and public health. This article illustrates these challenges with real-world examples of clinical and population registry data, the study of environmental biomarkers, and Zika virus epidemic; it also reviews relevant ethical principles underpinning these examples and identifies where gaps in knowledge may exist.

Unfolding The Genetic Basis of ADHD

Overall Abstract Attention Deficit Hyperactivity Disorder (ADHD) is a childhood behavioral disorder affecting 5% of school-age children and 2.5% of adults. The disorder is diagnosed more frequently in males than in females, in particular in children where the diagnosis rate is 3-7 times higher in males compared to females. Results from more than 30 twin studies indicate that the heritability (h^2) of ADHD is 70-80%, and a very recent genome-wide association study (GWAS) of 20,183 ADHD cases and 35,191 controls succeeded in identifying the first 12 genome-wide significant loci based on a large international collaboration anchored at the PGC-ADHD and iPSYCH-Broad consortia. This GWAS also found that the proportion of variance attributable to genome-wide common variants (liability-scale SNP heritability, h_SNP^2) is around 22%. Thus, the h_SNP^2 accounts for between a third and a quarter of the overall h^2, leaving a substantial part of the h^2 unaccounted for, which could potentially be explained in part by rare risk variants contributing to the etiology. Furthermore, analysis of the recent ADHD GWAS data revealed strong genetic correlations with other psychiatric disorders, including autism spectrum disorder and major depression, both showing genetic correlations of 0.3-0.4. In this symposium, we examine the genetic architecture of ADHD by assessing both the common and rare variant contributions. First, we expand upon the results from the aforementioned GWAS by incorporating additional samples of non-European ancestry to advance locus discovery, improve fine-mapping of the identified loci, and evaluate transferability of ADHD risk prediction across ancestries. Second, we examine the difference in prevalence between males and females using Swedish whole population registry data and Swedish twin data. Third, we report on cross-disorder studies between ADHD and, respectively, autism and major depression, using the largest and newly updated GWAS data from the PGC based studies of these disorders. Fourth, we present results from analyses of rare variants identified by whole exome sequencing of several thousand cases and controls, focusing on the impact on ADHD risk of ultra-rare deleterious variants.

Genetics of Attention Deficit Hyperactivity Disorder Across The Lifespan

Overall Abstract Attention Deficit Hyperactivity Disorder (ADHD) is the most commonly diagnosed childhood-onset neuropsychiatric condition, with impairing symptoms persisting into adulthood in the majority of cases. ADHD-diagnosed children, adolescents and adults share similar clinical features, co-morbidities and failures in major life domains. These associated problems increase the burden of disease and, consequently, global impairment, resistance to treatment and costs of illness. As most genetic studies on ADHD so far have been focusing on its childhood form only, there is limited knowledge about the genetics of ADHD at different ages, in clinical subgroups and across comorbid conditions. This symposium will present recent advances in our understanding of the genetics of ADHD and its major comorbid conditions across the lifespan. Speakers will address ADHD traits from a dimensional perspective using quantitative measures from national twin registry data, as well as unpublished genome wide molecular genetic data collected from large international multi-center clinical samples at different age groups. In this integrated symposium hosted by the International Multi-center persistent ADHD Collaboration (IMpACT), we will first present an updated review on ADHD heritability across the lifespan (presentation 1). We will then present a new international genome-wide association study of the adult form of ADHD (presentation 2), address genetic aspects of ADHD co-morbidity with adult obesity (presentation 3), and finally explore genetic correlations between ADHD dimensions in childhood and neuropsychiatric phenotypes in adulthood (presentation 4). As we gather more knowledge about ADHD, it is becoming clear that a full understanding of the disorder requires research from a lifetime perspective, integrating data from adults and children, using clinical samples as well as population registry data. Combination of different research traditions into a joint symposium will aid the exchange of information and future development of this important field.

The Manifestation Of Genetic Risk For Attention Deficit Hyperactivity Disorder In Females And Males In The General Population

Attention Deficit Hyperactivity Disorder (ADHD) is a common, heritable childhood disorder that is more commonly diagnosed in males than females. Several family and molecular genetic studies suggest that females may require a higher burden of genetic risk to manifest the disorder, however the evidence for this effect is mixed and requires replication. Another possibility for the discrepancy in prevalence rate by sex is that females at high genetic risk for ADHD are routinely under-diagnosed with ADHD and instead this genetic risk manifests itself in other ways, e.g. through other diagnoses. To address these possibilities, we utilised Swedish whole population registry data and data on a subset of Swedish twins who were genotyped. In a sample of N=21,784 individuals, we found evidence that full siblings of females with diagnosed ADHD are at higher risk for an ADHD diagnosis than siblings of diagnosed males [OR=1.14 (1.11-1.18), p=1.5E-15]. However, we found no difference in ADHD polygenic risk scores (PRS) between males and females with traits of ADHD [N=1,226, OR=0.98 (0.87-1.11), p=0.70] or related neurodevelopmental disorders [N=2,719, OR=1.04 (0.96-1.13), p=0.32]. On the other hand, females diagnosed with anxiety had higher ADHD PRS than males with anxiety [N=265, OR=1.49 (1.13-1.98), p=0.0048], suggesting that genetic risk for ADHD may manifest differently in females. A replication of these analyses in a second sample will also be presented. The results of this study provide additional evidence for an increased genetic burden of ADHD risk in females diagnosed with ADHD and their relatives, although it would appear that common genetic variants may not play a substantial role. On the other hand, common variants related to ADHD appear to predispose females more than males to anxiety, which may partly explain the lower prevalence of ADHD seen in females.

Born to be Wise: a population registry data linkage protocol to assess the impact of modifiable early-life environmental exposures on the health and development of children

IntroductionDeficiencies in childhood development is a major global issue and inequalities are large. The influence of environmental exposures on childhood development is currently insufficiently explored. This project will analyse the...

Using hospital registries in Australia to extend data availability on vulval cancer treatment and survival

BackgroundThe value of hospital registries for describing treatment and survival outcomes for vulval cancer was investigated. Hospital registry data from four major public hospitals in 1984–2016 were used because population-based data lacked required treatment and outcomes data. Unlike population registries, the hospital registries had recorded FIGO stage, grade and treatment.MethodsUnadjusted and adjusted disease-specific survival and multiple logistic regression were used. Disease-specific survivals were explored using Kaplan-Meier product-limit estimates. Hazards ratios (HRs) were obtained from proportional hazards regression for 1984–1999 and 2000–2016. Repeat analyses were undertaken using competing risk regression.ResultsFive-year disease-specific survival was 70%, broadly equivalent to the five-year relative survivals reported for Australia overall (70%), the United Kingdom (70%), USA (72%), Holland (70%), and Germany (Munich) (68%). Unadjusted five-year survival tended to be lower for cancers diagnosed in 2000–2016 than 1984–1999, consistent with survival trends reported for the USA and Canada, but higher for 2000–2016 than 1984–1999 after adjusting for stage and other covariates, although differences were small and did not approach statistical significance (p ≥ 0.40). Surgery was provided as part of the primary course of treatment for 94% of patients and radiotherapy for 26%, whereas chemotherapy was provided for only 6%. Less extensive surgical procedures applied in 2000–2016 than 1984–1999 and the use of chemotherapy increased over these periods. Surgery was more common for early FIGO stages, and radiotherapy for later stages with a peak for stage III. Differences in treatment by surgery and radiotherapy were not found by geographic measures of remoteness and socioeconomic status in adjusted analyses, suggesting equity in service delivery.ConclusionsThe data illustrate the complementary value of hospital-registry data to population-registry data for informing local providers and health administrations of trends in management and outcomes, in this instance for a comparatively rare cancer that is under-represented in trials and under-reported in national statistics. Hospital registries can fill an evidence gap when clinical data are lacking in population-based registries.

Can Supervised Machine Learning Be Used to Identify Family Firms Using a Sophisticated Definition?

The ability to identify family firms is a critical element of any empirical family businesses study, however obtaining representative time series data that applies complex family firm definitions can be challenging and resource consuming. In this method development paper, I propose that supervised machine learning may be used as a scalable imputation approach after a ‘learner’ has been trained with a combination of survey and registry data. I demonstrate this technique using survey data from 7,153 firms that applies the ‘European definition’ of family firms, which captures elements of voting rights and governance. I combine this data with population registry data containing person- level family relationships who are affiliated with the firms through ownership, board membership, or several other ways. After training several random forest, boosting tree and neural network machine learners, I find that random forest and boosting tree learners obtained the best performance by being able to correctly classify ...

Socioeconomic distribution of GP visits following patient choice reform and differences in reimbursement models: Evidence from Sweden

ObjectiveThis study aims to analyse changes in the socioeconomic distribution of GP visits following primary care patient choice reform, and to compare their magnitude and direction in pure capitation, versus capitation/activity-based mixed, provider reimbursement settings. MethodsWe compute absolute and relative concentration indices using total population registry data from three Swedish counties (N∼3.6 million) two years pre, to two years post, reform. We decompose the indices by the contribution of first, non-recurrent and recurrent visits, and compare their changes in the different provider reimbursement settings. ResultsIn all three counties, the number of visits increased for all population groups. Increases were larger, and distributional changes more pro-poor, in the county with mixed reimbursement. Visit increases were mostly driven by recurrent and, especially, non-recurrent, visits, which were increasingly pro-poor in all counties in absolute, but not in relative, terms. First visits either became decreasingly pro-poor, or did not change significantly. Exclusion of high users removed the pro-poor patterns in the two counties with pure capitation. ConclusionsThe reform led to increased access to GP visits, but implied small changes in their socioeconomic distribution. In combination with provider reimbursement models with incentives for higher visit volumes, changes were more pro-poor over time, but it is not clear whether this was at the expense of reduced visit length or content.

Consequences of Forced Residential Relocation: Early Impacts of Urban Renewal Strategies on Forced Relocatees’ Housing Opportunities and Socioeconomic Outcomes

Policymakers have actively pursued urban renewal and dispersal programs to deconcentrate poverty in urban neighborhoods. Relocation strategies lead to new housing opportunities and may encourage employment opportunities for relocated residents if resourceful contacts and job information become more easily available after the move. This study provides an innovative evaluation of the early impacts of involuntary relocation programs in the Netherlands on the housing careers, earnings and employment rates of forced relocatees. It establishes a quasi-experimental design by employing unique longitudinal individual-level population registry data from Statistics Netherlands: forced relocatees are tracked and matched to a control group consisting of similar residents that were not forced to move. A difference-in-difference design shows that forced relocatees are living in less deprived neighborhoods after the move. However, we find no conclusive evidence that this upgrade in housing leads to more socioeconomic opportunities for the forced relocatees.