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Item Racial Differences in Response to Neoadjuvant Chemotherapy: Impact on Breast and Axillary Surgical Management(Springer, 2021) Relation, Theresa; Obeng-Gyasi, Samilia; Bhattacharyya, Oindrila; Li, Yaming; Eskander, Mariam F.; Tsung, Allan; Oppong, Bridget A.; Economics, School of Liberal ArtsBackground: Neoadjuvant chemotherapy (NAC), an increasingly used method for breast cancer patients, has the potential to downstage patient tumors and thereby have an impact on surgical options for treatment of the breast and axilla. Previous studies have identified racial disparities in tumor heterogeneity, nodal recurrence, and NAC completion. This report compares the effects of NAC response among non-Hispanic white women and black women in relation to surgical treatment of the breast and axilla. Methods: A retrospective review of 85,303 women with stages 1 to 3 breast cancer in the National Cancer Database who received NAC between 1 January 2010 and 31 December 2016 was conducted. Differences in sociodemographic and clinical variables between black patients and white patients with breast cancer were tested. Results: The study identified 68,880 non-Hispanic white and 16,423 non-Hispanic black women who received NAC. The average age at diagnosis was 54.8 years for the white women versus 52.5 years for the black women. A higher proportion of black women had stage 3 disease, more poorly differentiated tumors, and triple-negative subtype. The black women had lower rates of complete pathologic response, more breast-conservation surgery, and higher rates of axillary lymph node dissection, but fewer sentinel lymph node biopsies. Axillary management for the women who were downstaged showed more use of axillary lymph node dissection for black women compared with sentinel lymph node biopsy. Conclusions: The black patients were younger at diagnosis, had more advanced disease, and were more likely to have breast-conservation surgery. De-escalating axillary surgery is being adopted increasingly but used disproportionately for white women.Item Comparison of health information exchange data with self-report in measuring cancer screening(BMC, 2023-07-25) Bhattacharyya, Oindrila; Rawl, Susan M.; Dickinson, Stephanie L.; Haggstrom, David A.; Economics, School of Liberal ArtsBackground: Efficient measurement of the receipt of cancer screening has been attempted with electronic health records (EHRs), but EHRs are commonly implemented within a single health care setting. However, health information exchange (HIE) includes EHR data from multiple health care systems and settings, thereby providing a more population-based measurement approach. In this study, we set out to understand the value of statewide HIE data in comparison to survey self-report (SR) to measure population-based cancer screening. Methods: A statewide survey was conducted among residents in Indiana who had been seen at an ambulatory or inpatient clinical setting in the past year. Measured cancer screening tests included colonoscopy and fecal immunochemical test (FIT) for colorectal cancer, human papilloma virus (HPV) and Pap tests for cervical cancer, and mammogram for breast cancer. For each screening test, the self-reported response for receipt of the screening (yes/no) and 'time since last screening' were compared with the corresponding information from patient HIE to evaluate the concordance between the two measures. Results: Gwet's AC for HIE and self-report of screening receipt ranged from 0.24-0.73, indicating a fair to substantial concordance. For the time since receipt of last screening test, the Gwet's AC ranged from 0.21-0.90, indicating fair to almost perfect concordance. In comparison with SR data, HIE data provided relatively more additional information about laboratory-based tests: FIT (19% HIE alone vs. 4% SR alone) and HPV tests (27% HIE alone vs. 12% SR alone) and less additional information about procedures: colonoscopy (8% HIE alone vs. 23% SR alone), Pap test (13% HIE alone vs. 19% SR alone), or mammography (9% HIE alone vs. 10% SR alone). Conclusion: Studies that use a single data source should consider the type of cancer screening test to choose the optimal data collection method. HIE and self-report both provided unique information in measuring cancer screening, and the most robust measurement approach involves collecting screening information from both HIE and patient self-report.Item Sri Lanka teeters on economic edge, from pandemic-fueled financial crisis and Ukraine war spillovers(The Conversation U.S, 2022-03-31) Tennekoon, Vidhura S.; Economics, School of Liberal ArtsItem Optimal equilibrium contracts in the infinite horizon with no commitment across periods(Springer, 2023-04) Chakrabarti, Subir K.; Kim, Jaesoo; Economics, School of Liberal ArtsThe paper studies equilibrium contracts under adverse selection when there is repeated interaction between a principal and an agent over an infinite horizon, without commitment across periods. We show the second-best contract is offered in a perfect Bayesian equilibrium of the infinite horizon model. Unlike the equilibrium contracts in the finite-horizon, the equilibrium contracts in the infinite horizon are not subject to either the ratchet effect or take-the-money-and-run strategy, but rely on a carrot and stick strategy. We study two important applications, one of which is about the optimal regulation of a publicly-held firm. This application has a mixture of both moral hazard and adverse selection. The other application is to the problem of optimal nonlinear pricing when the valuation of the buyers are drawn from a continuum.Item Effects of Purchase Restrictions on Smoking During Pregnancy: An Analysis of U.S. Birth Records(Oxford, 2023-05) Tennekoon, Vidhura S. B. W.; Economics, School of Liberal ArtsIntroduction In December 2019, the minimum legal sales age (MLSA) for tobacco products in the United States was raised from 18 to 21 years as a measure of preventing smoking initiation. Smoking during pregnancy, which causes maternal, fetal, and infant morbidity and mortality, is a major public health concern. We first study the effects of purchase restrictions on smoking during different stages of pregnancy covering the entire United States and using the records of all live births during 2014–2018 by birthing people aged 18–21 years. Aims and Methods Our identification strategy utilizes the variation in the MLSA of tobacco products over time and across counties in the United States during 2014–2018 using a two-way fixed effects model, modified to accommodate a partially observable treatment indicator. Results The results show that 37.4% of potential smokers in our study population would have been prevented from smoking before pregnancy, 50.5% during the first trimester, 53.4% during the second trimester, and 14.8% during the third trimester if the law prevented selling tobacco products to them in the locality they live. A purchase restriction is estimated to cause the smoking intensity of those who smoke, the intensive margin, to drop by 5.4% before pregnancy, 10.4% during the first trimester, 14.8% during the second trimester, and 5.2% during the third trimester. Conclusions Our results show that purchase restrictions are highly effective in preventing smoking among birthing people in the 18–21 years age group. The effect on smoking prevalence during the first and second trimesters is more pronounced. Implications Many countries around the world have recently tightened age-based purchase restriction policies as a tobacco control measure. We first study the effects of purchase restrictions on smoking during different stages of pregnancy using the birth records of all pregnancies in the United States by birthing people aged 18–21 years during 2014–2018. The study utilizes the variation in the MLSA of tobacco products over time and across counties during that period. Our results show that purchase restrictions are highly effective in preventing smoking among birthing people in the 18–21 years age group.Item Trends in Abortion- and Contraception-Related Internet Searches After the US Supreme Court Overturned Constitutional Abortion Rights: How Much Do State Laws Matter?(American Medical Association, 2023-04-07) Gupta, Sumedha; Perry, Brea; Simon, Kosali; Economics, School of Liberal ArtsImportance: The US Supreme Court ruling in Dobbs v Jackson Women's Health Organization on June 24, 2022, revealed immediate and distinct differences between states regarding abortion legality. Whether the ruling was associated with population-level changes in seeking information on reproductive health care-related information is unknown. Objective: To determine whether the US Supreme Court ruling on Dobbs v Jackson Women's Health Organization was associated with increased information seeking for reproductive health care access in the states with immediately effective (trigger and pre-Roe) abortion laws vs other states. Design, setting, and participants: This was a retrospective cross-sectional study of nationwide real-time internet search data by state-week from January 1, 2021, through July 16, 2022. Difference-in-difference event study estimates were used to evaluate abortion- and contraception-related internet searches after the Supreme Court draft majority decision was leaked on May 2, 2022, and the final ruling was issued on June 24, 2022, in states immediately affected vs other states. Data analyses were performed from July 18 to January 14, 2022. Exposures: The Supreme Court's draft majority decision leaked on May 2, 2022, and the final ruling on Dobbs v Jackson Women's Health Organization on June 24, 2022. Preexisting state trigger laws and pre-Roe bans that became effective immediately when Roe was overturned by the decision on Dobbs. Main outcomes and measures: Number of searches per 10 million Google queries in a state-week for terms related to abortion or contraception. Results: Searches for abortion-related terms increased from 16 302 to 75 746 per 10 million searches per state-week during the weeks before vs after the May 2, 2022, leak of the draft majority decision in states with trigger laws or abortion bans. This was a 42% (95% CI, 24%-59%) higher increase than in states with laws that protect abortion access. Searches for contraception also increased from 56 055 to 82 133 searches per state-week after the ruling in the states with abortion bans, 25% (95% CI, 13%-36%) higher than the increase in states protecting abortion access. Conclusions and relevance: The findings of this retrospective cross-sectional study suggest that changes in internet searching for terms related to reproductive health care can capture immediate population-level changes in information-seeking behavior regarding reproductive health care access. These data are critical for shaping health policy discussions.Item The impact of IOM recommendations on gestational weight gain among US women: An analysis of birth records during 2011-2019(Public Library of Science, 2022-07-21) Tennekoon, Vidhura S.; Economics, School of Liberal ArtsThe prevailing guidelines of the Institute of Medicine (IOM) of United States on gestational weight gain (GWG) are based on women's prepregnancy body mass index (BMI) categories. Previous research has shown that the guidelines issued in 1990 and revised in 2009 had no effect. We investigate the effectiveness of new guidelines issued in 2009 analyzing the records of all singleton births in the U.S. during 2011-2019 (34.0 million observations). We use the discontinuity in recommended guidelines at the threshold values of BMI categories in a regression discontinuity (RD) research design to investigate the effect of IOM guidelines on GWG. We also use an RD analysis in a difference in difference (DID) framework where we compare the effect on women who had any prenatal care to others who did not receive prenatal care. The naïve RD estimator predicts an effect in the expected direction at the threshold BMI values of 18.5 and 25.0 but not at 30.0. After the DID based correction, the RD analyses show that the GWG, measured in kg, drop at the BMI values of 18.5, 25.0 and 30.0 by 0.189 [CI: 0.341, 0.037], 0.085 [CI: 0.179, -0.009] and 0.200 [CI: 0.328, 0.072] respectively when the midpoint of the recommended range in kg drops by 1.5, 4.5 and 2.25. This implies a responsiveness of 12.6%, 1.9% and 8.9% respectively to changes in guidelines at these BMI values. The findings show that the national guidelines have induced some behavioral changes among US women during their pregnancy resulting in a change in GWG in the expected direction. However, the magnitude of the change has not been large compared to the expectations, implying that the existing mechanisms to implement these guidelines have not been sufficiently strong.Item Quantifying risk of injury from usual alcohol consumption: An instrumental variable analysis(Wiley, 2021) Ye, Yu; Cherpitel, Cheryl J.; Terza, Joseph V.; Kerr, William C.; Economics, School of Liberal ArtsBackground: There have been numerous studies of roadside accidents among emergency room patients showing elevated risk of injury from acute alcohol consumption, i.e. recent drinking prior to the injury event, with large effect size and a dose-response relationship observed. In contrast, studies quantifying the association between injury risk and chronic consumption such as past year average volume show that relative risk estimates are low compared to those from acute consumption. Methods: Using the US National Alcohol Surveys (NAS) combining four waves for years 2000–2015 (N=29,571, 53% overall cooperation rate), risk of any past-year injury was first estimated by past-year volume using logistic regression. An instrumental variable (IV) analysis utilizing the two-stage residual inclusion (2SRI) approach was then conducted to estimate injury risk from volume, further adjusting for unobserved confounders, using state beer and spirits tax rates, zip code-level outlet and bar density, and control state status as instruments. Results: Based on the combined US population surveys and controlling for socio-demographics, odds ratios of injury from average volume of 1, 2 and 5 drinks per day were 1.12 [95% confidence interval: 1.02, 1.24], 1.10 [1.00, 1.22], and 1.04 [0.88, 1.22], respectively, using conventional logistic regression, compared to 1.67 [1.00, 2.78], 2.38 [0.87, 6.54] and 6.98 [0.57, 85.89] using the IV method. The proportion of injury attributed to alcohol also increased in magnitude, from 6.2% [0.3%, 11.9%] using the conventional approach to 17.9% [8.2%, 27.7%] using the IV method. Conclusions: Findings suggest that the association between injury and chronic alcohol consumption may be confounded by unobserved factors, with the risk estimate possibly biased downward.Item Racial and Ethnic Disparities in Buprenorphine and Extended-Release Naltrexone Filled Prescriptions During the COVID-19 Pandemic(American Medical Association, 2022) Nguyen, Thuy; Ziedan, Engy; Simon, Kosali; Miles, Jennifer; Crystal, Stephen; Samples, Hillary; Gupta, Sumedha; Economics, School of Liberal ArtsImportance: COVID-19 disrupted delivery of buprenorphine and naltrexone treatment for opioid use disorder (OUD), and during the pandemic, members of racial and ethnic minority groups experienced increased COVID-19 and opioid overdose risks compared with White individuals. However, whether filled buprenorphine and naltrexone prescriptions varied across racial and ethnic groups during the COVID-19 pandemic remains unknown. Objective: To investigate whether disruptions in filled buprenorphine and naltrexone prescriptions differed by race and ethnicity and insurance status or payer type. Design, setting, and participants: This cross-sectional study used retail pharmacy claims from May 2019 to June 2021 from the Symphony Health database, which includes 92% of US retail pharmacy claims, with race and ethnicity data spanning all insurance status and payer categories. Interrupted time series were used to estimate levels and trends of dispensed buprenorphine and naltrexone prescriptions before and after pandemic onset. Included individuals were those who filled buprenorphine and extended-release naltrexone prescriptions. Data were analyzed from July 2021 through March 2022. Main outcomes and measures: Weekly rates of dispensed buprenorphine and extended-release naltrexone prescription fills per 1000 patients and proportion of longer (ie, ≥14 days' supply) buprenorphine prescription fills were calculated. Analyses were stratified by patient race and ethnicity and further by insurance status and payer type for White and Black patients. Results: A total of 1 556 860 individuals who filled buprenorphine prescriptions (4359 Asian [0.3%], 94 657 Black [6.1%], 55 369 Hispanic [3.6%], and 664 779 White [42.7%]) and 127 506 individuals who filled extended-release naltrexone prescriptions (344 Asian [0.3%], 8186 Black [6.4%], 5343 Hispanic [4.2%], and 53 068 White [41.6%]) from May 6, 2019, to June 5, 2021, were analyzed. Prepandemic increases in buprenorphine fill rate flattened for all groups after COVID-19 onset (30.5 percentage point difference in trend; P < .001) compared with prepandemic trends. Significant level decreases in buprenorphine fills (ranging from 2.5% for Black patients; P = .009 to 4.0% for Hispanic patients; P = .009) at pandemic onset were observed for members of racial and ethnic minority groups but not White patients. At pandemic onset, rate of buprenorphine fills decreased in level for Medicare and cash-paying patients but with greater decreases for Black patients (Medicare: 10.0%; P < .001; cash: 20.0%; P < .001) than White patients (Medicare: 3.5%; P = .004; cash: 15.0%; P < .001). No decreases were found among Medicaid patients. Unlike buprenorphine, extended-release naltrexone had uniform level (from 10.0% for White patients with private insurance; P < .001 to 23.3% for Black patients with Medicare; P < .001) and trend (from 15.5 percentage points for White patients with Medicaid; P = .001 to 52.0 percentage points for Black patients with private insurance; P < .001) decreases across groups. Conclusions and relevance: This study found that the COVID-19 pandemic was associated with immediate decreases in filled buprenorphine prescriptions by members of racial and ethnic minority groups but not White individuals. These findings suggest that members of racial and ethnic minority groups had larger losses in buprenorphine access during the pandemic across payer types.Item Estimation of a selectivity model with misclassified selection(Taylor & Francis, 2022) Tennekoon, Vidhura S. B. W.; Caudill, Steven B.; Economics, School of Liberal ArtsDespite the great interest in models of self-selection and models with misclassification, there have been few studies combining the two. Notable exceptions are given by McCarthy, Millimet, and Roy and Shiu. None of these models have been developed in a contingent valuation setting that we are interested in. The goal of this note is to add to this literature by presenting a model for estimating willingness to pay using data collected through a contingent valuation survey. We examine the case of a selectivity model in which the outcome equation is interval censored but the decision indicator is not observed.