Triple Difference Research Articles

How Does the Effect of the Comprehensive Care for Joint Replacement Model Vary Based on Surgical Volume and Costs of Care?

The Center for Medicare and Medicaid Innovation revised the comprehensive Care for Joint Replacement (CJR) program, a mandatory 90-day bundled payment for lower extremity joint replacement, in December 2017, retaining 34 of the original 67 metropolitan statistical areas with higher volume and historic episode payments. We describe differences in costs, quality, and patient selection between hospitals that continued to participate compared with those that withdrew from CJR before and after the implementation of CJR. We used a triple difference approach to compare the magnitude of the policy effect for elective admissions between hospitals that were retained in the CJR revision or not, before and after the implementation of CJR, and compared with hospitals in nonparticipant metropolitan statistical areas. 694,275 Medicare beneficiaries undergoing elective lower extremity joint replacement from January 1, 2013 to August 31, 2017. The treatment effect heterogeneity of CJR. Hospitals retained in the CJR policy revision had a greater reduction in 90-day episode-of-care cost compared with those that were allowed to discontinue (-$846, 95% CI: -$1,338, -$435) and had greater cost reductions in the more recent year (2017). We also found evidence that retained CJR hospitals disproportionately reduced treating patients who were older than 85 years. Hospitals that continued to participate in CJR after the policy revision achieved a greater cost reduction. However, the cost reductions were partly attributed to avoiding potential higher - cost patients, suggesting that a bundled payment policy might induce disparities in care delivery.

Access to Medicaid dental services and distant-stage oral cancer diagnoses in Utah: A quasi-experimental approach.

106 Background: Late detection may contribute to disparities in oral cancer outcomes, as most low-income oral cancer patients are diagnosed at distant stages. Because dentists are the most likely provider to screen for oral cancer, access to Medicaid dental services could improve outcomes. However, states are not mandated to cover adult Medicaid dental benefits. In 2010, Utah’s Medicaid program added dental benefits. My study leverages this policy change to test if dental coverage is associated with distant stage diagnoses and if this association changes with the number of dentists per capita. Methods: I analyzed SEER data for all oral cancers diagnosed between 2007-2013. The outcome is a binary variable, indicating if the oral cancer patient was diagnosed at a distant stage. All analyses control for age, race, and gender as well as state and year fixed-effects. Under a Difference-in-Differences design, where DD = Post2010*Utah, I estimate the effect of adding dental coverage for Medicaid enrollees in Utah compared to Medicaid enrollees in states that did not change their Medicaid program. Then, to account for differential trends, I implement a Triple Differences design, where DDD = Post2010*Utah*Medicaid, and estimate the effect of adding dental coverage for Medicaid enrollees in Utah compared to adults in Utah who are not on Medicaid. Finally, I interact the DDD variable with a variable measuring Utah's dentists per 100,000 population (county-level data from AHRQ). Results: Compared to Medicaid enrollees in other states, adding Medicaid dental coverage in Utah was associated with a decline in the probability of a distant-stage oral cancer diagnosis (DD = -0.046; ci = -0.078, -0.014). The Triple Difference result was similar (DDD = -0.074; ci = -0.107, -0.041). The heterogeneity analysis reveals that the association between adding Medicaid dental coverage and distant stage diagnoses are small and insignificant in Utah counties without dentists. However, the interaction term between adding dental coverage and dentists per capita yields a significant decline for every additional dentist in the county (DDD*Dentists/100,000Capita. = -.001 ci = [-0.002, -0.0009]. Putting these results into context, the marginal effect of adding dental coverage in counties with 80 dentists/100,000 is associated with a 0.104-percentage point decline in distant diagnoses: a 20% decline relative to pre-2010 rates. Conclusions: Access to dental services could improve outcomes for low-income oral cancer patients, but the persistent barriers to dental care may perpetuate disparities.

Practice radiation patterns among oncologists in the Oncology Care Model.

CMS created the Oncology Care Model (OCM) to increase the delivery of cost-efficient cancer care, but in linking medical oncologist compensation to total costs of care, the model also prompted concerns about reductions in radiation therapy utilization. We compare practices that participated in the model with those that did not through its launch to estimate whether radiation therapy utilization was reduced under the OCM. Retrospective analysis of a secondary claims-based data set. We used 5 years of reimbursement claims data from a large community oncology network in which approximately half of the practices participated in the OCM to measure the relative change in utilization following OCM participation compared with practices that did not participate in the OCM. We evaluated use of radiation therapy for all cancer diagnoses and, more specifically, bone metastases, lung cancer, and breast cancer to assess whether effects varied by setting using 3 quasi-experimental estimation techniques (difference-in-differences, event study, and triple differences regressions). We found no evidence of reductions in radiation therapy utilization associated with the OCM between participant and nonparticipant practices in any of the specifications or subpopulations analyzed. Despite the potential incentives for medical oncologists to reduce radiation therapy utilization, we found no evidence that such reduction occurred.

Impact of Resource-Saving and Environment-Friendly Society Construction on Sustainability

Promoting coordinated and environmentally sustainable development of the Chinese economy is one of the primary tasks at the moment, as well as one of the sustainable development goals of the United Nations. The Resource-saving and Environment-friendly Society (RES) has created a pilot promotion policy aimed at China, with the goal of supporting the sustainable development of economic production activities while preserving natural ecosystems. In this investigation, we used the global Malmquist–Luenberger index with a slack-based measure of the directional distance function to calculate the industrial green total factor productivity (IGTFP) of 105 prefecture-level cities along the Yangtze River from 2004 to 2019; IGTFP was used as a proxy for sustainable development. Then, by considering the RES construction as a quasi-natural experiment, we used propensity score matching difference-in-differences (PSM-DID) to determine the effect of RES construction on sustainable development of the Yangtze River economic belt. We also employed the mediating effect model and triple difference (DDD) model to further analyze the mechanisms underlying the heterogeneous impacts of different urban characteristics. The results revealed three key findings. (1) According to the IGTFP calculation results, RES construction can effectively promote green technological progress while inhibiting green technological efficiency. (2) After carrying out a series of robustness tests, we found that RES construction increased the IGTFP of pilot cities by 4%, indicating that RES construction can significantly promote the sustainable development of pilot cities along the Yangtze River. (3) The results of the mechanism analysis showed that RES construction had a significantly positive impact on sustainable development through technological innovation, human capital, energy conservation, and emission control. In terms of different urban characteristics, the RES construction promoted sustainable development in first-tier cities, second-tier cities, and resource-based cities. We summarized the practical experience of the RES construction as a typical pilot promotion policy. It provides an empirical basis for planning the construction of eco-friendly urban areas in the 21st century and responding to the international community’s sustainable development goals from a Chinese perspective.

Children mirror adults for the worse: evidence of suicide rates due to air pollution and unemployment

BackgroundEvery year, more than 700,000 people die due to suicide, one of the most common reasons for youth death. While many studies have revealed two main factors for suicidal behavior: impulsive suicidal behavior due to mental illness and financial stress, it is not clear what happens if individuals face deterioration of mental health and economic recession. This paper attempts to answer this question and how suicide rates are correlated with these factors.MethodsWe empirically investigate whether economic recessions and air pollution trigger suicides by examining Japan, a country with one of the highest suicide rates, from 2014 to 2021. We take advantage of the characteristics of the COVID-19 pandemic and the periods before the pandemic, when both economic recessions and reductions in air pollution occurred simultaneously. Using monthly and municipal- level data, we construct a triple difference model that takes air pollution and unemployment as treatments.ResultsOur findings show that high (upper half of each period) levels of air pollution and unemployment have substantial impacts on the suicide rates of adults (22.9% in the short term) and children (42.7% in the short term, 36.0% in the long term), indicating that the increase in suicide rates among children is almost twice as high as that among adults. Our study finds that unemployment and air pollution alone are not associated with increased suicide rates but their simultaneous occurrence triggers suicides during the pandemic.ConclusionsOur study urges suicide prevention, particularly among children, as an essential consideration for public health. Furthermore, our results indicate the need for the government to allocate resources to recover air quality and the economy simultaneously during a recession to reduce suicide mortality of both child and adults.

The effects of multi-disciplinary integrated care on healthcare utilization: Evidence from a natural experiment in the UK.

Better integration is a priority for most international health systems. However, multiple interventions are often implemented simultaneously, making evaluation difficult and providing limited evidence for policy makers about specific interventions. We evaluate a common integrated care intervention, multi-disciplinary group (MDG) meetings for discussion of high-risk patients, introduced in one socio-economically deprived area in the UK in spring 2015. Using data from multiple waves of the national GP Patient Survey and Hospital Episode Statistics, we estimate its effects on primary and secondary care utilization and costs, health status and patient experience. We use triple differences, exploiting the targeting at people aged 65years and over, parsing effects from other population-level interventions implemented simultaneously. The intervention reduced the probability of visiting a primary care nurse by three percentage points and decreased length of stay by 1day following emergency care admission. However, since planned care use increased, overall costs were unaffected. MDG meetings are presumably fulfilling public health objectives by decreasing length of stay and detecting previously unmet needs. However, the effect of MDGs on health system cost is uncertain and health remains unchanged. Evaluations of specific integrated care interventions may be more useful to public decision makers facing budget constraints.

Evaluating environmental outcome and process-adaptivity of regional collaboration: An empirical study from China

Since the 2000s, China has enforced regional collaboration as a way of resolving cross-diffused air pollution and jurisdictional limitations. It is, however, a hotly debated issue as to whether authority-driven regional collaboration can be sustained and effective, and no consensus has been achieved by the theoretical discussion. Despite extensive empirical research on the topic, most studies judged the sustainability of collaborations by analyzing the environmental outcomes within a short period after their initiation. To provide more comprehensive empirical evidence to the open question, this paper introduces the criterion of adaptivity to determine whether collaboration is sustainable. Taking the changing collaboration in Beijing-Tianjin-Hebei and its surroundings as a quasi-natural experiment, Difference-in-Difference model and Triple Difference Model are used to verify the adaptivity from two aspects. Results show that authority-driven collaboration adjustment yields better environmental outcomes. Additionally, the better environmental outcome is observed in original collaborators, implying that local governments can learn by doing and form interdependence through repeated collaborative actions. The adaptive collaboration, however, has two limitations. First, the collaboration mechanism is formed primarily based on performance evaluation and target assessment instruments, without showing adaptivity in reducing soft control indicators of air pollution. Second, the different regulation pressure between non-collaborating and collaboration cities results in undesirable spillover effects within a range of 40–100 km. This study not only contributes to empirical and theoretical studies on regional collaboration but also provides support to the improvement of the collaboration system in practice.

Simulated power analyses for observational studies: An application to the Affordable Care Act Medicaid expansion

Power is an important factor in assessing the likely validity of a statistical estimate. An analysis with low power is unlikely to produce convincing evidence of a treatment effect even when one exists. Of greater concern, a statistically significant estimate from a low-powered analysis is likely to misstate the true effect size, including finding estimates of the wrong sign or that are several times too large. Yet statistical power is rarely reported in published economics work. This is in part because many modern research designs are complex enough that power cannot be easily ascertained using simple formulae. Power can also be difficult to estimate in observational settings. Using an applied example–the link between gaining health insurance and mortality–we conduct a simulated power analysis to outline the importance of power and ways to estimate power in complex research settings. We find that standard difference-in-differences and triple differences analyses of Medicaid expansions using county or state mortality data would need to induce reductions in population mortality of at least 2% to be well powered. While there is no single, correct method for conducting a simulated power analysis, our manuscript outlines how applied researchers can conduct simulations appropriate to their settings.

Impact of the Coming-of-Age Day and ceremony on the risk of SARS-CoV-2 transmission in Japan: A natural-experimental study based on national surveillance data.

BackgroundQuantifying the impact on COVID‐19 transmission from a single event has been difficult due to the virus transmission dynamics, such as lag from exposure to reported infection, non‐linearity arising from the person‐to‐person transmission, and the modifying effects of non‐pharmaceutical interventions over time. To address these issues, we aimed to estimate the COVID‐19 transmission risk of social events focusing on the Japanese Coming‐of‐Age Day and Coming‐of‐Age ceremony in which “new adults” practice risky behavior on that particular day.MethodsUsing national surveillance data in Japan in 2021 and 2022, we conducted difference‐in‐differences regression against COVID‐19 incidences by setting “new adults” cases as the treatment group and the cases 1 year younger or older than these “new adults” as the control group. In addition, we employed a triple differences approach to estimate the risk of holding the Coming‐Age ceremony by using a binary variable regarding the presence or absence of the ceremony in each municipality.ResultsWe estimated the relative risks (RRs) of the Coming‐of‐Age Day as 1.27 (95% confidence interval [CI] 1.02–1.57) in 2021 and 3.22 (95% CI 2.68–3.86) in 2022. The RR of the Coming‐of‐Age ceremony was also large, estimated as 2.83 (1.81–4.43) in 2022.ConclusionsWhen planning large social events, it is important to be aware of the unique risks associated with these gatherings, along with effective public health messages to best communicate these risks.

Effects of Medicaid expansion on insurance coverage and health services use among adults with disabilities newly eligible for Medicaid.

To estimate the effects of Affordable Care Act (ACA) Medicaid expansion on insurance and health services use for adults with disabilities who were newly eligible for Medicaid. 2008-2018 Medical Expenditure Panel Survey data. We used the Agency for Healthcare Research and Quality (AHRQ) PUBSIM model to identify adults aged 26-64 years with disabilities who were newly Medicaid-eligible in expansion states or would have been eligible in non-expansion states had those states opted to expand. Outcomes included insurance coverage; access to care; receipt of primary care, outpatient specialty physician services, and preventive services; and out-of-pocket health care spending. To estimate the effects of Medicaid expansion, we used two-way fixed effects models and a triple differences framework to compare pre-post changes in each outcome in expansion and non-expansion states for adults with and without disabilities. We simulated Medicaid eligibility with the AHRQ PUBSIM model, which uses state-specific Medicaid rules and MEPS data on family relationships, state of residence, and income. Among adults with disabilities who were newly eligible for Medicaid, Medicaid expansion was associated with significant increases in full-year Medicaid coverage (35.9 percentage points [pp], p < 0.001), receipt of primary care (15.5pp, p < 0.01), and receipt of flu shots (19.2pp, p < 0.01), and a significant decrease in out-of-pocket spending (-$457, p < 0.01). There were larger improvements for adults with disabilities compared to those without disabilities in full-year Medicaid coverage (11.0pp, p < 0.01) and receipt of flu shots (18.0pp, p < 0.05). Medicaid expansion was associated with improvements in full-year insurance coverage, receipt of primary and preventive care, and out-of-pocket spending for adults with disabilities who were newly eligible for Medicaid. For insurance coverage, preventive care, and some primary care measures, there were differentially larger improvements for adults with disabilities than for those without disabilities.

Mortality risk, perception, and human capital investments: The legacy of landmines in Cambodia

The paper provides credible evidence for life expectancy as a key determinant of optimal decisions on children's human capital accumulation. The widespread use of landmines in Cambodia's civil conflict since the 1970s, followed by a large-scale international landmine clearance effort, allows for the examination of a causal relationship between life expectancy and human capital investment. A twofold increase in landmine clearance efforts in affected areas during the 2004-2005 period led to a sharp decline in the intensity of landmine casualty. I use a triple difference model that exploits spatial and temporal variations in landmine accidents together with the male-biased nature of landmine accidents to estimate the causal impacts of prime-age mortality risk on human capital outcomes. The estimates show a sizeable, negative effect of landmine mortality on both school attainments and health investments. When the source of mortality risk is replaced by common road traffic accidents, any mortality effect on schooling outcomes disappears, suggesting that household optimal decisions may respond differently to different sources of risk.

Impact of trade policy uncertainty on export products quality: new evidence by considering role of social capital

ABSTRACT An increase in trade policy uncertainty raises policymakers’ concerns, as it can be harmful to investments and growth globally. This study examines the impact of reducing trade policy uncertainty on export product quality. Based on the ASEAN–China Free Trade Area (ACFTA), the difference-in-difference, two-way fixed, and triple difference methods were used to conduct benchmark tests. The results show that reducing trade policy uncertainty improves export product quality. Social capital has strengthened the role of the changing trade environments. The results were robust after the PSM-DID, placebo test, and deletion of outliers. Furthermore, the role of social capital is incorporated into the regression model. From the perspective of informal internal systems, this study expands the theoretical view of regional trade integration research and answers the current trade strategy adjustment and export transformation policy concerns.

Education Universalization, Rural School Participation, and Population Density

AbstractIn many developing countries, low population density may be a major reason for low school participation in rural areas, and the problem is likely to worsen with rapid urbanization. However, few studies have investigated empirically the role of population density in rural education, especially the moderating effect of population density on the outcomes of education policies. This study aims to fill this gap in the literature. From 1999 through the early 2000s, China launched a set of major nationwide policies aimed at universalizing 9‐year compulsory education in rural areas. Using difference‐in‐differences and triple difference strategies, we show that the policies significantly increased the probability of junior high school enrollment of rural children and, more importantly, these policies were more effective in densely populated regions. These findings confirm the importance of population density to rural education.

Air pollution and health outcomes: Evidence from Black Saturday Bushfires in Australia

This paper presents new evidence of the causal effect of air pollution on Australian health outcomes, using the Black Saturday bushfires (BSB) in 2009 as a natural experiment. This event was one of the largest bushfires in Australian history and emitted approximately four million tonnes of CO2 into the atmosphere. We use data from the Household Income and Labour Dynamic Australia (HILDA) panel and compare the health status of individuals who were living in affected and unaffected regions before and after the event. Using a triple differences procedure, we further examine whether a difference in vulnerability to bushfire smoke exists comparing people living in urban or regional areas. We find that ambient air pollution had significant negative effects on health and that the magnitudes were actually larger for individuals residing in urban areas.

The effect of social pension on consumption among older adults in Korea

Focusing on the Korean case of social pensions, we evaluated the extent to which the basic pension scheme (BPS), a means-tested public assistance program, affects consumption. Data came from two years (2013 and 2015) of the Korea Welfare Panel Study (KoWePS) (N = 3615 households). Applying the Propensity Score Matching (PSM), Difference in Difference (DiD), and triple difference (DDD) approach, we used linear regression models with the fixed-effect model to estimate the effects of BPS. We found a significant increase in the expenditure ratio in absolute and relative poverty levels and total expenditure. BPS led to increased spending on essential living items (food, clothing) and health care, but not leisure. The results also supported that the social pension positively affects spending among the more disadvantaged population as the beneficial effects were more prominent among those living alone than those living with other household members. However, we did not find a significant effect among the poor, likely because the Korean policies reduce the benefits obtained from other public assistance programs if the poor old adult receives BPS benefits. Our findings provide useful insights for economies that encounter challenges associated with rapid population aging.

The impact of the Compact with Africa initiative on foreign direct investments and environmental pollution

PurposeThis study is motivated by the Compact with Africa (CWA) initiative to promote foreign direct investment (FDI) in Africa. However, FDI is argued to be one of the primary causes of environmental pollution (CO2 emissions). In that regard, this study estimates the impact of the CWA initiative on FDI and environmental pollution.Design/methodology/approachThe study utilized the difference-in-difference (DID) and triple difference (DDD) estimation strategies to examine the causal impact of the CWA initiative on FDI and environmental pollution from 2005 to 2019. The study selected nine CWA countries and nine non-CWA countries as treatment and control samples.FindingsThe authors found that the CWA initiative positively promotes FDI in the participant countries compared to non-participant countries. The CWA initiative also promoted environmental pollution in the CWA countries compared to non-CWA countries. Furthermore, the DDD estimates show that the effect of the CWA initiative on environmental pollution is through FDI.Practical implicationsThe authors recommend policies to attract environmentally friendly FDI for both Compact and non-Compact economies.Originality/valueThe study is the first to provide empirical evidence on the CWA initiative on FDI and environmental pollution in Africa. The study used a quasi-experimental method on the relationship between FDI and environmental pollution in Africa.

Associations of Expanding Parental Medicaid Eligibility and Parental Health and Family Functioning.

To examine the effects of parental Medicaid eligibility on parental health, parenting practices, and child development in low-income families. Longitudinal analysis using data from the Early Child Longitudinal Study-Kindergarten: 2011 to 2016. Outcomes included parental self-rated health, parental depressive symptoms, parents' communication and warmth toward children, and children's social skills and externalizing and internalizing behaviors. We estimated 2-way (individual and year) fixed effects models using Medicaid eligibility as a continuous variable, controlling for changing economic conditions, changes in family structure, and state-specific trends. We then estimated triple difference models comparing lower income families to those with higher incomes. Finally, we estimated difference-in-difference models and used entropy weights in order to account for differences in trends prior to 2014 for some outcomes. In fixed effects models, expanding Medicaid eligibility by 100% of the federal poverty line is associated with a 12.7 percentage point reduction in parents' report of having fair or poor health (95% confidence interval [CI], -23.9, -1.5) and a 1.15-point improvement on a 12-point scale of parental warmth towards children (95% CI, 0.15, 2.16). Results were substantively similar in entropy-balanced difference-in-differences models. In triple difference models, expanded Medicaid eligibility is associated with a 0.46 point improvement in warmth (95% CI, 0.10, 0.83) but not improved parental health. No significant effects for child behavior or other outcomes were detected. Expanding Medicaid for parents may have implications for intergenerational family functioning that could lead to broader social benefits.

The impact of India's demonetization on domestic agricultural trade

AbstractWe examine the impact of an extreme monetary shock, India's demonetization of 2016, on domestic agricultural trade. Using data from around 3000 regulated markets for 35 major crops, we find that trade value fell by 16.3–16.8% in the short run, settling at 11.8–12.1% after eight months, driven primarily by a decline in prices. Triple difference estimates suggest sharpest impacts for kharif crops, perishables and crops with minimal government intervention. Markets far away from banks fared worse. Our results suggest that the implosion of value of agricultural trade domestically persisted two growing seasons beyond the one that coincided with the shock, whereas existing findings suggest that the negative impact on the economy as a whole dissipates in that time.

Impermanence and failure: the legacy of conservation-based payments in Sumatra, Indonesia

Projects that pay communities or individuals to conserve natural areas rarely continue indefinitely. When payments cease, the behaviors they motivate can change. Previous research on conservation-based payments recognizes the impermanence of conservation success, but it does not consider the legacy of payments that failed to effect change. This research assesses impermanence and failure by investigating the legacy of village-level conservation payments made through one of the largest Integrated Conservation and Development Projects in Indonesia. The Kerinci-Seblat Integrated Conservation and Development Project aimed to conserve forest area and promote local development through voluntary conservation agreements (VCAs) that provided payments for pro-conservation pledges and activities from 2000 through 2003. Project documentation and previous research find that payments failed to incentivize additional forest conservation, producing nonsignificant differences in forest-cover change during the project period. To examine the legacy of these payments in the post-project period, this research uses matched difference-in-differences and triple differences models to analyze forest cover change in villages (n = 263) from 2000 through 2016 as well as matched binary logistic regression models to assess enduring differences in household (n = 1303) livelihood strategies within VCA villages in 2016. The analysis finds that VCA villages contained significantly more forest loss than the most similar non-VCA villages outside the national park, and greater payments predict increased forest loss in the post-project period. In addition, farming high-value tree crops and cultivating private land were the most important attributes for modeling VCA affiliation among randomly selected households. These results demonstrate that, after payments ceased, project failures increased in severity over time.Those who design and implement conservation-based payments bear great responsibility to ensure their projects are informed by local voice, align with community preferences, and provide sufficient benefits, lest they result in a conservation legacy of increased failure.

The Effectiveness of the Capacity Building and Mentorship Program in Improving Evidence-Based Decision-making in the Amhara Region, Northwest Ethiopia: Difference-in-Differences Study.

BackgroundWeak health information systems (HISs) hobble countries’ abilities to effectively manage and distribute their resources to match the burden of disease. The Capacity Building and Mentorship Program (CBMP) was implemented in select districts of the Amhara region of Ethiopia to improve HIS performance; however, evidence about the effectiveness of the intervention was meager.ObjectiveThis study aimed to determine the effectiveness of routine health information use for evidence-based decision-making among health facility and department heads in the Amhara region, Northwest Ethiopia.MethodsThe study was conducted in 10 districts of the Amhara region: five were in the intervention group and five were in the comparison group. We employed a quasi-experimental study design in the form of a pretest-posttest comparison group. Data were collected from June to July 2020 from the heads of departments and facilities in 36 intervention and 43 comparison facilities. The sample size was calculated using the double population formula, and we recruited 172 participants from each group. We applied a difference-in-differences analysis approach to determine the effectiveness of the intervention. Heterogeneity of program effect among subgroups was assessed using a triple differences method (ie, difference-in-difference-in-differences [DIDID] method). Thus, the β coefficients, 95% CIs, and P values were calculated for each parameter, and we determined that the program was effective if the interaction term was significant at P<.05.ResultsData were collected using the endpoint survey from 155 out of 172 (90.1%) participants in the intervention group and 166 out of 172 (96.5%) participants in the comparison group. The average level of information use for the comparison group was 37.3% (95% CI 31.1%-43.6%) at baseline and 43.7% (95% CI 37.9%-49.5%) at study endpoint. The average level of information use for the intervention group was 52.2% (95% CI 46.2%-58.3%) at baseline and 75.8% (95% CI 71.6%-80.0%) at study endpoint. The study indicated that the net program change over time was 17% (95% CI 5%-28%; P=.003). The subgroup analysis also indicated that location showed significant program effect heterogeneity, with a DIDID estimate equal to 0.16 (95% CI 0.026-0.29; P=.02). However, sex, age, educational level, salary, and experience did not show significant heterogeneity in program effect, with DIDID estimates of 0.046 (95% CI –0.089 to 0.182), –0.002 (95% CI –0.015 to 0.009), –0.055 (95% CI –0.190 to 0.079), –1.63 (95% CI –5.22 to 1.95), and –0.006 (95% CI –0.017 to 0.005), respectively.ConclusionsThe CBMP was effective at enhancing the capacity of study participants in using the routine HIS for decision-making. We noted that urban facilities had benefited more than their counterparts. The intervention has been shown to produce positive outcomes and should be scaled up to be used in other districts. Moreover, the mentorship modalities for rural facilities should be redesigned to maximize the benefits.Trial RegistrationPan African Clinical Trials Registry PACTR202001559723931; https://tinyurl.com/3j7e5ka5