The effect of a severe health shock on work behavior: Evidence from different health care regimes

Medical care use and mortality rate after the onset of disability: A 6-year follow-up study based on national data in Taiwan

BACKGROUND

The onset of disability is a major health challenge, and people with disability can be particularly underserved in the years immediately after the disability onset.

OBJECTIVE

To analyze the excess mortality rate of people with recent-onset disability and their health-care utilization during the period after disability onset (1-6 years after onset).

METHODS

We used whole-population claims data from 2015 to 2020 (for approximately 23 million individuals) from Taiwan's National Health Insurance (NHI) system. These NHI claims data were linked to the National Death Records and National Disability Registry. Each individual with a disability was followed until their death or December 31, 2020. The age-standardized mortality rate and outpatient and inpatient utilization were compared between individuals with and without disability. Finally, Cox regressions were estimated to determine excess mortality for the individuals with disability.

RESULTS

The age-standardized mortality rates for the people with disability and those without disability were 1020.35/10,000 and 463.83/10,000, respectively. The people with disability utilized significantly more medical care under the NHI system. Mortality rates differed substantially among disability types. The Cox regression revealed a hazard ratio of 1.47 (95% CI = 1.46, 1.48) for all-cause mortality for people with disability, and significant sex differences in mortality risk were observed for some causes of death.

CONCLUSION

According to the excess mortality rates within 6 years of disability onset observed in this study, the NHI may not be sufficient to reduce health disparity between people with and without disabilities. In addition, specific characteristics of each type of disability should be considered.

Inter- and intrapopulation differences in the association between physical multimorbidity and depressive symptoms

BACKGROUND

The association between physical multimorbidity and depression differs by populations. However, no direct inter- or intrapopulation comparison of the association has been conducted. Thus, this study aims to estimate the association in China and the United States and reveal inter- and intrapopulation differences in the association.

METHODS

Middle-aged and older adults from the China Health and Retirement Longitudinal Study and the Health and Retirement Study were included. Physical multimorbidity was defined as the simultaneous presence of two or more chronic physical conditions and depressive symptoms was measured by the Center for Epidemiologic Studies Depression Scale. Generalized estimating equation model and stratification multilevel method were the main statistical models.

RESULTS

The presence of physical multimorbidity was associated with a higher risk of depression in both China (RR = 1.360 [95 % CI: 1.325-1.395]) and the US (RR = 1.613 [95 % CI: 1.529-1.701]). For individuals at a low risk of multimorbidity, multimorbidity was associated with 47.4 % (95 % CI: 1.377-1.579) and 71.1 % (95 % CI: 1.412-2.074) increases in the likelihood of depression in China and the US. The effect size was smaller for individuals at a moderate or high risk. However, the cross-national differences were greater for those with a high risk of multimorbidity.

LIMITATIONS

The self-report measures, attribution bias.

CONCLUSIONS

Compared to Chinese adults, the presence of physical multimorbidity led to an additional increase in depressive symptoms for American counterparts. The association was stronger for individuals at a low risk of multimorbidity, but cross-national differences were observed mostly among individuals at a high risk.

Medication adherence in patients with type 2 diabetes after disability onset: a difference-in-differences analysis using nationwide data

BACKGROUND

Effectively managing the coexistence of both diabetes and disability necessitates substantial effort. Whether disability onset affects adherence to type 2 diabetes medication remains unclear. This study investigated whether disability onset reduces such adherence and whether any reduction varies by disability type.

METHODS

This study used the National Disability Registry and National Health Insurance Research Database from Taiwan to identify patients with type 2 diabetes who subsequently developed a disability from 2013 to 2020; these patients were matched with patients with type 2 diabetes without disability onset during the study period. Type 2 diabetes medication adherence was measured using the medication possession ratio (MPR). A difference-in-differences analysis was performed to determine the effect of disability onset on the MPR.

RESULTS

The difference-in-differences analysis revealed that disability onset caused a reduction of 5.76% in the 1-year MPR (P < 0.001) and 13.21% in the 2-year MPR (P < 0.001). Among all disability types, organ disabilities, multiple disabilities, rare diseases, and a persistent vegetative state exhibited the largest reductions in 2-year MPR.

CONCLUSIONS

Policies aimed at improving medication adherence in individuals with disabilities should consider not only the specific disability type but also the distinct challenges and barriers these patients encounter in maintaining medication adherence.

Labor supply and informal care responses to health shocks within couples: Evidence from the UK

Shocks to health have been shown to reduce labor supply for the individual affected. Less is known about household self-insurance through a partner's response. Previous studies have presented inconclusive empirical evidence on the existence of a health-related Added Worker Effect, and results limited to labor and income responses. We use UK longitudinal data to investigate within households both the labor supply and informal care responses of an individual to the event of an acute health shock to their partner. Relying on the unanticipated timing of shocks, we combine Coarsened Exact Matching and Entropy Balancing algorithms with parametric analysis and exploit lagged outcomes to remove bias from observed confounders and time-invariant unobservables. We find no evidence of a health-related Added Worker Effect but a significant and sizable Informal Carer Effect. This holds irrespective of spousal labor market position or household financial status and ability to purchase formal care provision, suggesting that partners' substitute informal care provision for time devoted to leisure activities.

Effect of Health Shocks on Poverty Status in South Korea: Exploring the Mechanism of Medical Impoverishment

BACKGROUND

South Korea has the highest out-of-pocket burden for medical expenses among the Organisation for Economic Co-operation and Development (OECD) member countries and has no formal sickness benefit system, along with United States and Switzerland, greatly increasing the risk of poverty due to a sudden illness.

METHODS

We identify the causal effect of health shocks on poverty status and explore the mechanisms of medical impoverishment by analyzing longitudinal data from 13 670 households that participated in the representative Korean Welfare Panel Study (KOWEPS) from 2007 to 2016. In this study, we define a health shock as a case in which no household members were hospitalized in the previous year, but together they had more than 30 days of hospitalization in this year. The propensity score matching method was combined with a mediation analysis in this work.

RESULTS

The proportion of households in absolute poverty increased by 4.6-8.0 percentage points among households that experienced a health shock compared with matched controls. The selection effects due to health shock were estimated to be 5.6-8.2 percentage points. On average, a sudden hospitalization reduces annual non-medical expenditures and equivalized disposable income by just over 3.2 million KRW (2500 USD) and 1.2 million KRW (1000 USD), respectively. Health shock induces impoverishment after one year through both the medical expense and work capacity pathways, which explain 12.8% and 12.8% of the total effect, respectively. However, when we decompose the mediation effect of a health shock on poverty status after two years, we find that a health shock leads to poverty mainly through labor force nonparticipation (9.9%).

CONCLUSION

Income stabilizing scheme to protect households that experience a health shock should be introduced as a policy alternative to confront the issue of medical impoverishment.

Health shocks and changes in preventive behaviors: Results from the China Health and Retirement Longitudinal Study

Background

China is facing the challenge of rising prevalence and ballooning burden of chronic non-communicable diseases (NCDs); however, the Chinese middle- and older-aged population considerably lack preventive behaviors. Health shocks (HS), widely defined as sudden health deterioration brought on by diseases or accidents, bring a “teachable moment” to motivate changes in preventive behaviors.

Objective

This study aims to examine the effect of HS on changes in preventive behaviors, including personal health practices and preventive care utilization.

Methods

HS was defined as any five chronic disease diagnoses (cancer, heart disease, stroke, diabetes, and hypertension). The impacts of HS on smoking, drinking, and exercise, physical examination were estimated. The panel data of 13,705 respondents were obtained from the latest two waves of the China Health and Retirement Longitudinal Study (CHARLS) in 2015 and 2018. A multilevel propensity score match difference-in-difference (multilevel PSM-DID) model was constructed.

Results

HS significantly decreased smoking (OR = 0.59, p &lt; 0.05) and drinking (OR = 0.62, p &lt; 0.01) and increased the utilization of auxiliary inspection in physical examination (OR = 1.19, p &lt; 0.1). Major HS had significantly considerable and specific effects on reducing smoking and drinking (OR = 0.37 and 0.56, p &lt; 0.01), while minor HS had relatively small effects on reducing smoking (OR = 0.74, p &lt; 0.05) and drinking (OR = 0.69, p &lt; 0.01), but extensive effects on initiating exercise (OR = 1.32, p &lt; 0.05), physical examination (OR = 1.18, p &lt; 0.1), and auxiliary inspection (OR = 1.30, p &lt; 0.05).

Conclusion

After HS, there is a teachable moment to promote positive changes in preventive behaviors. Guided by the 5A's brief intervention model (Ask, Advise, Assess, Assist, Arrange), tailored interventions should be targeted at these populations to reduce the risk of the progression and complications of existing diseases, prevent the related comorbidity, and prolong the expected life-span.

The cost of caring: How advanced cancer patients affect Caregiver's employment in Singapore

BACKGROUND

With ageing populations and rising cancer incidence, more people are becoming informal caregivers. Informal caregivers are less likely to work than non-caregivers, yet little is known about how their employment changes over time. This study aimed to examine the association between decline in cancer patient's health (termed health shock) and caregiver's employment. A secondary aim was to assess characteristics of caregivers who stayed employed despite the health shock and the burden of caring for advanced stage cancer patients.

METHOD

This study used data from 270 dyads of advanced cancer patients and their caregivers who participated in the Cost of Medical Care of Patients with Advanced Serious Illness in Singapore study. The dyads were interviewed every 3 months for 2 years. Fixed-effects regression was used to analyse the association between patient health shock and two caregiver employment outcomes (i.e., employment status and work disruptions).

RESULTS

Ninety-seven% of caregivers whose patient experienced a health shock reported work disruptions. About 13% of caregivers whose patient experienced at least one health shock left employment, compared to 5% of those whose patient did not experience any health shock. Following a patient health shock, caregivers were significantly less likely to be employed (β: -0.03; 95% CI, -0.05 to -0.001) and more likely to experience work disruptions (β: 0.06; 95% confidence interval [CI], -0.01 to 0.12). Caregivers who were young, educated, unmarried, not spousal caregivers, and not living with their patients were more likely to stay employed despite patient health shock (p < 0.01 for all).

CONCLUSION

Findings show that caregivers' employment is affected by their patients' health through the caregiving trajectory. Continuous support for caregivers catered to specific vulnerable subgroups may be important to keeping caregivers in the workforce.

Intergenerational health mobility: Evidence from Danish registers

This paper is one of the first to investigate mobility in overall health using high-quality administrative data. The attractiveness of this approach lies in objective health measures and large sample sizes allowing twin analyses. I operationalize health mobility by a variety of statistics: rank-rank slopes, intergenerational correlations (IGCs) and sibling and identical twin correlations. I find rank-rank slopes and IGCs in the range 0.11-0.15 and sibling correlations in the range 0.14-0.20. Mobility in health is thus relatively high, both when compared to similar US-based studies, and when contrasted with outcomes such as educational attainment and income. Comparing sibling and identical twin correlations with parent-child associations confirms earlier findings in the literature on equality of opportunity, namely that sibling correlations capture far more variation than traditional IGCs. I conclude that 14%-38% of the variation in individual health outcomes can be attributed to family background and genes, factors which the individual cannot be held accountable for. This finding suggests that simple parent-child associations may be a poor metric for measuring health mobility.

Health shocks and couples' labor market participation: A turning point or stuck in the trajectory?

A health shock can have lasting consequences for the employment of not only the individuals experiencing it, but also their spouses. In this article, we complement the individual approach to the impact of health shocks with a dyadic perspective and show how employment opportunities and restrictions within couples are interdependent in the face of severe illness. We investigate whether the association between male spouses' health shocks and couples' employment trajectories depends on household specialization and both spouses' education. Multichannel sequence analysis is applied to retrospective life-course data from the Survey for Health, Ageing and Retirement in Europe for couples with health shocks and their matched controls (N = 1022). By identifying typical employment trajectories, we find that health shocks are negatively associated with trajectories where both spouses continue in full-time employment and positively with trajectories where the man retires while the woman continues working and where both spouses retire simultaneously. Couples' trajectories differ according to the spouses' combined education levels. Findings suggest that health shocks may exacerbate economic inequalities within and between couples.

The joint effect of health shocks and eligibility for social security on labor supply

This paper investigates whether or not suffering a health shock, and becoming eligible for social security, have a joint effect on labor supply. Despite millions of people experiencing both of these events each year, no paper has focused exclusively on the joint effect that these events may have on work outcomes. This is surprising given that experiencing a health shock may impact on how a worker responds to becoming eligible for social security. With data from the Health and Retirement Study, I model weekly hours of work as a function of health shocks, social security eligibility, and their interaction. I find that this interaction leads to a 3-4 h reduction in weekly hours of work for men, but has no effect for women. The results are robust to using different work outcomes, age groups, health shock definitions, subgroups, as well as falsification and placebo tests. The results appear to be driven by men who would have had to return to work with impaired health. Policies that promote a more flexible work situation for older men may alleviate these problems in the future.

How do cardiovascular diseases harm labor force participation? Evidence of nationally representative survey data from Japan, a super-aged society

OBJECTIVE

To evaluate how cardiovascular diseases harm labor force participation (LFP) among the Japanese population and verify the validity of plasma biomarkers as instrumental variables of cardiovascular diseases after adjusting for a broad set of confounders including dietary intake.

DESIGN

Using nationally representative repeated cross-sectional surveys in Japan, the Comprehensive Survey of Living Conditions and National Health and Nutrition Survey, with plasma biomarkers as instrumental variables for quasi-randomization.

SETTING

Onset of cardiovascular diseases in those receiving regular treatment for hypertension, intracerebral hemorrhage, intracerebral infarction, angina pectoris, myocardial infarction, or other types of cardiovascular diseases.

PARTICIPANTS

A total of 65,615 persons aged ≥ 20 years (35,037 women and 30,578 men) who completed a survey conducted every three years from 1995 through 2013.

MAIN OUTCOME MEASURES

Respondent employment and weekly working hours during each survey year.

RESULTS

Cardiovascular diseases significantly and remarkably reduced the probability of working by 15.4% (95% CI: -30.6% to -0.2%). The reduction in working probability was detected for women only. Respondents aged ≥ 40 years were less likely to work once diagnosed and the reduction was enlarged for those aged ≥ 65 years, while those aged < 40 years appeared to be unaffected. Probability of engaging in manual labor significantly decreased once diagnosed; however, no impact was found for cognitive occupations. Among employed respondents, the adverse effects of cardiovascular diseases decreased working hours by five hours per week. Validity of the biomarker instrumental variables was generally verified.

CONCLUSIONS

A vicious circle is suggested between LFP and unfavorable health. However, the effects vary across age, sex, and occupation type, even after adjusting for causal effects, which could cause a downward bias in LFP impact.

ATTRIBUTES

cardiovascular disease, labor force participation, instrumental variable method as quasi-randomization, plasma biomarker, Comprehensive Survey of Living Conditions, National Health and Nutrition Survey.

The effect of cancer on the labor supply of employed men over the age of 65

This paper investigates the relationship between cancer diagnosis and the labor supply of employed men over the age of 65. While almost 60% of male cancers are diagnosed in men over the age of 65, no previous research has examined the effect that cancer has on this age group, which is surprising given the relevance of this group to public policy. With data from the Health and Retirement Study, I show that cancer has a significant negative effect on the labor supply of these workers. Using a combination of linear regression models and propensity score matching, I find that respondents who are diagnosed with cancer work 3 fewer hours per week than their non-cancer counterparts. They are also 10 percentage points more likely to stop working. This reduction seems to be driven by a deterioration in physical and mental health.

Smoking and early retirement due to chronic disability

This paper considers the long-term effects of smoking on disability retirement in Sweden. Smoking is known to have damaging effects on health, but there is limited evidence on how the effects of smoking translate into worse labour market outcomes, such as the inability to work. In contrast to the few previous studies on smoking and disability retirement, we use a large population sample with registry information on smoking, which is recorded for all women who give birth in Sweden. Thanks to these comprehensive data, we are able to account for a much broader range of potential confounders. In particular, by the use of sibling and twin fixed effects, we account for unobserved heterogeneity in childhood environment and family characteristics. Given that smoking is often initiated in adolescence, one would suspect such factors to play important roles. Among individuals aged 50-64 in 2011, a simple model suggested smokers to have a 5 percentage point higher probability of receiving (full) disability pension, making them more than twice as likely as non-smokers to receive this. However, in a model with sibling fixed effects, the size of the effect was reduced by more than a third. The results point to the importance of confounders, such as childhood circumstances or behaviours, which were not accounted for by previous studies. We also consider effects on disability due to different health conditions. In relative terms, effects are the largest for circulatory conditions and tumours. Results are largely driven by health problems severe enough to merit hospitalization, and there is no evidence of a role played by financial incentives.

The impact of self-reported health and register-based prescription medicine purchases on re-employment chances: A prospective study

In this paper, we investigate the influence of self-reported health and register-based prescription medicine purchases on re-employment chances, and whether these health indicators measure similar aspects of health in this analysis. Data came from a 2006 Danish unemployment survey among a random sample of unemployed individuals enriched with register data (2006–2008, N=1806). The survey participants all received unemployment benefits from the welfare system and had been unemployed for more than 20 weeks at the time of the interview in 2006. We combined these data with longitudinal register data on individual prescription medicine purchases for somatic illnesses and prescription medicine purchases for mental illnesses, information on re-employment and various socio-demographic variables. We conducted binary logistic regression analyses to investigate the impact of self-reported health and prescription medicine purchases measured in 2006 on re-employment chances in 2007 and 2008. Our analyses show that unemployed workers with poor self-reported health and workers who had prescription medicine purchases for mental illnesses were less likely to be re-employed in 2007 and 2008. Furthermore, the impact of both prescription medicine purchases for somatic illnesses and for mental illnesses increased when adding self-reported health to the model although prescription purchases for somatic illnesses became statistically insignificant. The impact of prescription medicine purchases for somatic illnesses was mediated by self-reported health, whilst prescription medicine purchases for mental illnesses was only partly mediated. Finally, SRH seemed a much stronger prediction than prescription medicines. From these results, we propose, when possible, the inclusion of both an indicator of self-reported health and an indicator of mental health in studies on re-employment.

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Poor health negatively affects re-employment chances of unemployed workers.

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Self-reported health indicates somatic health over prescription medicine purchases.

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Both self-reported health and mental health are relevant to re-employment chances.

Health as a predictor of early retirement before and after introduction of a flexible statutory pension age in Finland

BACKGROUND

Little is known of how pension reforms affect the retirement decisions of people with different health statuses, although this is crucial for the understanding of the broader societal impact of pension policies and for future policy development. We assessed how the Finnish statutory pension age reform introduced in 2005 influenced the role of health as a predictor of retirement.

METHODS

We used register-based data and cox regression analysis to examine the association of health (measured by purchases of psychotropic medication, hospitalizations due to circulatory and musculoskeletal diseases, and the number of any prescription medications) with the risk of retirement at age 63-64 among those subject to the old pension system with fixed age limit at 65 (pre-reform group born in 1937-1941) and the new flexible system with 63 as the lower age limit (post-reform group born in 1941-1945) while controlling for socio-demographic factors.

RESULTS

Retirement at age 63-64 was more likely among the post- than the pre-reform group (HR = 1.50; 95% CI 1.43-1.57). This reform-related increase in retirement was more pronounced among those without a history of psychotropic medication or hospitalizations due to circulatory and musculoskeletal diseases, as well as among those with below median level medication use. As a result, poor health became a weaker predictor of retirement after the reform.

CONCLUSION

Contrary to the expectations of the Finnish pension reform aimed at extending working lives, offering choice with respect to the timing of retirement may actually encourage healthy workers to choose earlier retirement regardless of the provided economic incentives for continuing in work.