Three essays on hospital efficiency

This dissertation analyzes hospital efficiency using various econometric techniques. The first essay provides additional and recent evidence to the presence of contract management behavior in the U.S. hospital industry. Unlike previous studies, which focus on either an input-demand equation or the cost function of the firm, this paper estimates the two jointly using a system of nonlinear equations. Moreover, it addresses the longitudinal problem of institutions adopting contract management in different years, by creating a matched control group of non-adopters with the same longitudinal distribution as the group under study. The estimation procedure then finds that labor, and not capital, is the preferred input in U.S. hospitals regardless of managerial contract status. With institutions that adopt contract management benefiting from lower labor inefficiencies than the simulated non-contract adopters. These results suggest that while there is a propensity for expense preference behavior towards the labor input, contract managed firms are able to introduce efficiencies over conventional, owner controlled, firms. Using data for the years 1998 through 2007, the second essay investigates the production technology and cost efficiency faced by Florida hospitals. A stochastic frontier multiproduct cost function is estimated in order to test for economies of scale, economies of scope, and relative cost efficiencies. The results suggest that small-sized hospitals experience economies of scale, while large and medium sized institutions do not. The empirical findings show that Florida hospitals enjoy significant scope economies, regardless of size. Lastly, the evidence suggests that there is a link between hospital size and relative cost efficiency. The results of the study imply that state policy makers should be focused on increasing hospital scale for smaller institutions while facilitating the expansion of multiproduct production for larger hospitals. The third and final essay employs a two staged approach in analyzing the efficiency of hospitals in the state of Florida. In the first stage, the Banker, Charnes, and Cooper model of Data Envelopment Analysis is employed in order to derive overall technical efficiency scores for each non-specialty hospital in the state. Additionally, input slacks are calculated and reported in order to identify the factors of production that each hospital may be over utilizing. In the second stage, we employ a Tobit regression model in order to analyze the effects a number of structural, managerial, and environmental factors may have on a hospital’s efficiency. The results indicated that most non-specialty hospitals in the state are operating away from the efficient production frontier. The results also indicate that the structural make up, managerial choices, and level of competition Florida hospitals face have an impact on their overall technical efficiency.

Trajetória de vida dos pescadores vítimas de lesão medular por mergulho: experiências, representações sociais e estresse

Spinal cord injury causes permanent disabling manifestations, affecting the anatomic integrity, bodily changes and functional limitations related to the disability state. It was aimed to analyze the social representation, stress level and experiences of fishermen victims of spinal cord injury caused by diving accident in the Northern beaches of Brazil. It is a descriptive - exploratory study with quantitative, qualitative and representational data developed i n fishermen’s villages in nine beaches of Northern shore/RN, between October 2013 to August 2014, after the approval of the Ethics Committee in Research of the Universidade Federal do Rio Grande do Norte, under the number 431.891/2013, CAAE 20818913.0.0000 .5537. The sample was composed by 44 fishermen with spinal cord injury, defined from inclusion and exclusion criteria of the participants. It was used as instrument to collect the data a semi structured interview. Quantitative data was analyzed by descrip tive statistics, showing the data through table, boxes and graphics by Microsoft Excel. Data from interviews were submitted to the software called Analyse Lexicale par Contexte d’un Ensemble de Segments de Texte (ALCESTE) using the analysis of the Social R epresentation Theory and Center Core Theory. It is shown the outcomes of the research through four articles, following the normative recommendations of the journals. Participants of the study were all male, age mean 49,6 years, elementary school (68,2%), m arried (77,3%); paraplegia sequel (50,0%). Most of them showed stress (75,0%), almost in the exhaustion stage (33,3%), prevalent insomnia symptoms (95,5%) in the last hours; hypertension (97,7%) in the last week and sexual troubles (95,5%) in the last mont h). Decompressive illness caused spinal cord injury (57,1%), occurred prevalently in low summer (75,0%), northern shore (96,4%), having as main consequences the paresthesia and pain in the upper and lower limbs (67,9%), followed by death (25,0%). Interview analysis under the understanding of Social Representation of spinal cord injury allowed the appearance of seven categories: Treatment: limitation and expectative; Spinal Cord injury: before and after; Retirement: reality yet to come; Disability: dependenc y, incapacity, vulnerability; Overcoming and autonomy; Self feelings: physics losses and new start; Life and labor: impediments, plans and changes. The center core of the representation is found in the first category by the expectative and limitation on th e treatment, meanwhile the outskirt elements are in seventh and third categories. Physics limitation for fishing activities and retirement expectative is the most outstanding of the structure. Social representation concerning spinal cord injury is found in a transaction moment between before and after with the prevented fishing activity, coping of the situation with the potential remaining. The anchoring is established in the desire for changes related to the improvements of life and health conditions exper ienced day by day through faith. This study finishes pointing out the range of the objectives, which topic is relevant for public health of fishermen. It is suggested prevention measures, promotion and health recovery of fishermen, besides safe, healthy an d worthy conditions as a compromise of social and health politics.

Essays on Job Search and Labor Market Dynamics

This dissertation consists of three separate essays on job search and labor market dynamics. In the first essay, “The Impact of Labor Market Conditions on Job Creation: Evidence from Firm Level Data”, I study how much changes in labor market conditions reduce employment fluctuations over the business cycle. Changes in labor market conditions make hiring more expensive during expansions and cheaper during recessions, creating counter-cyclical incentives for job creation. I estimate firm level elasticities of labor demand with respect to changes in labor market conditions, considering two margins: changes in labor market tightness and changes in wages. Using employer-employee matched data from Brazil, I find that all firms are more sensitive to changes in wages rather than labor market tightness, and there is substantial heterogeneity in labor demand elasticity across regions. Based on these results, I demonstrate that changes in labor market conditions reduce the variance of employment growth over the business cycle by 20% in a median region, and this effect is equally driven by changes along each margin. Moreover, I show that the magnitude of the effect of labor market conditions on employment growth can be significantly affected by economic policy. In particular, I document that the rapid growth of the national minimum wages in Brazil in 1997-2010 amplified the impact of the change in labor market conditions during local expansions and diminished this impact during local recessions.

In the second essay, “A Framework for Estimating Persistence of Local Labor

Demand Shocks”, I propose a decomposition which allows me to study the persistence of local labor demand shocks. Persistence of labor demand shocks varies across industries, and the incidence of shocks in a region depends on the regional industrial composition. As a result, less diverse regions are more likely to experience deeper shocks, but not necessarily more long lasting shocks. Building on this idea, I propose a decomposition of local labor demand shocks into idiosyncratic location shocks and nationwide industry shocks and estimate the variance and the persistence of these shocks using the Quarterly Census of Employment and Wages (QCEW) in 1990-2013.

In the third essay, “Conditional Choice Probability Estimation of Continuous- Time Job Search Models”, co-authored with Peter Arcidiacono and Arnaud Maurel, we propose a novel, computationally feasible method of estimating non-stationary job search models. Non-stationary job search models arise in many applications, where policy change can be anticipated by the workers. The most prominent example of such policy is the expiration of unemployment benefits. However, estimating these models still poses a considerable computational challenge, because of the need to solve a differential equation numerically at each step of the optimization routine. We overcome this challenge by adopting conditional choice probability methods, widely used in dynamic discrete choice literature, to job search models and show how the hazard rate out of unemployment and the distribution of the accepted wages, which can be estimated in many datasets, can be used to infer the value of unemployment. We demonstrate how to apply our method by analyzing the effect of the unemployment benefit expiration on duration of unemployment using the data from the Survey of Income and Program Participation (SIPP) in 1996-2007.

Market reforms and privatisation in the English National Health Service

The article examines developments in the marketisation and privatisation of the English National Health Service, primarily since 1997. It explores the use of competition and contracting out in ancillary services and the levering into public services of private finance for capital developments through the Private Finance Initiative. A substantial part of the article examines the repeated restructuring of the health service as a market in clinical services, initially as an internal market but subsequently as a market increasing opened up to private sector involvement. Some of the implications of market processes for NHS staff and for increased privatisation are discussed. The article examines one episode of popular resistance to these developments, namely the movement of opposition to the 2011 health and social care legislative proposals. The article concludes with a discussion of the implications of these system reforms for the founding principles of the NHS and the sustainability of the service.

Un poison même à petite dose : étude de la structure latente et des facteurs développementaux du sadisme sexuel

Les délinquants sexuels sadiques sont généralement décrits comme une entité clinique particulière commettant des délits graves. Or, la notion même de sadisme sexuel pose un nombre important de problèmes. Parmi ceux-ci, on retrouve des problèmes de validité et de fidélité. Perçu comme une maladie dont on est atteint ou pas, le sadisme a été étudié comme si les sadiques étaient fondamentalement différents. À l’heure actuelle, plusieurs travaux laissent croire que la majorité des troubles psychologiques se présentent comme une différence d'intensité (dimension) plutôt qu’une différence de nature (taxon). Même si la conception médicale prévaut encore en ce qui concerne le sadisme sexuel, plusieurs évoquent l’idée qu’il pourrait être mieux conceptualisé à l’aide d’une approche dimensionnelle. En parallèle, nos connaissances sur les facteurs contributifs au développement du sadisme sexuel sont limitées et reposent sur de faibles appuis empiriques. Jusqu'à présent, très peu d'études se sont intéressées aux facteurs menant au développement du sadisme sexuel et encore moins ont tenté de valider leurs théories. En outre, nos connaissances proviennent majoritairement d'études de cas portant sur les meurtriers sexuels, un sous-groupe très particulier de délinquants fréquemment motivé par des intérêts sexuels sadiques. À notre connaissance, aucune étude n'a proposé jusqu'à présent de modèle développemental portant spécifiquement sur le sadisme sexuel. Pourtant, l'identification de facteurs liés au développement du sadisme sexuel est essentielle dans notre compréhension ainsi que dans l'élaboration de stratégie d'intervention efficace. La présente thèse s'inscrit dans un contexte visant à clarifier le concept de sadisme sexuel. Plus spécialement, nous nous intéressons à sa structure latente, à sa mesure et à ses origines développementales. À partir d'un échantillon de 514 délinquants sexuels évalué au Massachusetts Treatment Center, la viabilité d’une conception dimensionnelle du sadisme sexuel sera mise à l’épreuve à l'aide d'analyses taxométriques permettant d'étudier la structure latente d'un construit. Dans une seconde étape, à l'aide d'analyses de Rasch et d'analyses appartenant aux théories de la réponse à l'item à deux paramètres, nous développerons la MTC Sadism Scale (MTCSS), une mesure dimensionnelle du sadisme sexuel. Dans une troisième et dernière étape, un modèle développemental sera élaboré à l'aide d'équations structurales. La présente thèse permettra de contribuer à la clarification du concept de sadisme sexuel. Une clarification de la structure latente et des facteurs développementaux permettra de saisir les devis de recherche les plus à même de capturer les aspects essentiels. En outre, ceci permettra d'identifier les facteurs pour lesquels une intervention est la plus appropriée pour réduire la récidive, ou la gravité de celle-ci.

Three essays in labor economics and applied econometrics

Méthodologie:Cadre conceptuel: Principal-agent

Global Trade Governance and ASEAN: Studies of Trade-Related Aspects of Labor, Environment and Culture in Southeast Asia

Thesis (Ph.D.)--University of Washington, 2016-08

Constructing Personal and Couple Narratives in Late Stage Cancer: A Narrative Analysis

An increasing number of people with terminal cancer are being cared for at home, often by their partner. This study explores the identity, experiences and relationships of people caring for their partner at the end of life and how they construct their experience through personal and couple narratives. It draws upon dialogical approaches to narrative analysis to focus on caring partners and the care relationship. Six participants were recruited for the study. Two methods of data collection are used: narrative interviews and journals. Following individual case analysis, two methods of cross-narrative analysis are used: an analysis of narrative themes and an identification of narrative types. The key findings can be summarised as follows. First, in the period since their partner's terminal prognosis, participants sustained and reconstructed self and couple relationship narratives. These narratives aided the construction of meaning and coherence at a time of major biographical disruption: the anticipated loss of a partner. Second, the study highlights the complexity of spoken and unspoken narratives in terminal cancer and how these relate to individual and couple identities. Third, a typology of archetypal narratives based upon the data is identified. The blow-by-blow narratives illustrate how participants sought to construct coherence and meaning in the illness story, while champion and resilience narratives demonstrate how participants utilised positive self and relational narratives to manage a time of biographical disruption. The study highlights how this narrative approach can enhance understanding of the experiences and identities of people caring for a terminally ill partner.

Early stage memory loss interventions: utilization, impact, and the experience of living alone.

Thesis (Ph.D.)--University of Washington, 2016-08

Studying the Causes and Consequences of Internal Labor Migration Using Survey and Administrative Data Sources

This dissertation comprises three chapters. The first chapter motivates the use of a novel data set combining survey and administrative sources for the study of internal labor migration. By following a sample of individuals from the American Community Survey (ACS) across their employment outcomes over time according to the Longitudinal Employer-Household Dynamics (LEHD) database, I construct a measure of geographic labor mobility that allows me to exploit information about individuals prior to their move. This enables me to explore aspects of the migration decision, such as homeownership and employment status, in ways that have not previously been possible. In the second chapter, I use this data set to test the theory that falling home prices affect a worker’s propensity to take a job in a different metropolitan area from where he is currently located. Employing a within-CBSA and time estimation that compares homeowners to renters in their propensities to relocate for jobs, I find that homeowners who have experienced declines in the nominal value of their homes are approximately 12% less likely than average to take a new job in a location outside of the metropolitan area where they currently reside. This evidence is consistent with the hypothesis that housing lock-in has contributed to the decline in labor mobility of homeowners during the recent housing bust. The third chapter focuses on a sample of unemployed workers in the same data set, in order to compare the unemployment durations of those who find subsequent employment by relocating to a new metropolitan area, versus those who find employment in their original location. Using an instrumental variables strategy to address the endogeneity of the migration decision, I find that out-migrating for a new job significantly reduces the time to re-employment. These results stand in contrast to OLS estimates, which suggest that those who move have longer unemployment durations. This implies that those who migrate for jobs in the data may be particularly disadvantaged in their ability to find employment, and thus have strong short-term incentives to relocate.

Efficacy of early skin-to-skin contact on the rate of exclusive breastfeeding in term neonates: a randomized controlled trial

Background: Despite multiple benefits of breast milk, the rates of exclusive breastfeeding in developing countries are low. Objective: To evaluate the efficacy of early skin -to -skin contact (SSC) on the rate of exclusive breastfeeding (EBF) at 6 weeks of age among term neonates born by vaginal delivery. Methods: Term neonates born by vaginal delivery and did not require any resuscitation were randomized at birth to SSC (n=100) and control (n=100) group. Immediately after clamping the umbilical cord, SSC group neonates were placed on the bare bosom of mother and control group neonates were placed under a radiant warmer for a period of 45 minutes each while mothers underwent management of the third stage of labor and episiotomy repair. Pain experienced by mother during episiotomy repair was recorded using a numerical pain scale The primary outcome evaluated was the rate of exclusive breastfeeding at 6 weeks of postnatal age. Results: A significantly higher proportion of neonates were exclusively breastfeed at 6 weeks of age in the SSC group than in the control group (72% vs. 57.6%, p=0.04, relative risk: 1.3, 95% confidence interval: 1.0 -1.6). The pain score during episiotomy repair in mothers of the SSC group was significantly lower than the control group (4.74±0.85 versus 5.34±0.81; P <0.01). Conclusions: Early SSC significantly improved the rate of exclusively breastfeeding at 6 weeks of age among healthy term neonates. An important additional effect was a decrease in the amount of pain that mothers in the SSC group experienced during episiotomy repair.

Un poison même à petite dose : étude de la structure latente et des facteurs développementaux du sadisme sexuel

Les délinquants sexuels sadiques sont généralement décrits comme une entité clinique particulière commettant des délits graves. Or, la notion même de sadisme sexuel pose un nombre important de problèmes. Parmi ceux-ci, on retrouve des problèmes de validité et de fidélité. Perçu comme une maladie dont on est atteint ou pas, le sadisme a été étudié comme si les sadiques étaient fondamentalement différents. À l’heure actuelle, plusieurs travaux laissent croire que la majorité des troubles psychologiques se présentent comme une différence d'intensité (dimension) plutôt qu’une différence de nature (taxon). Même si la conception médicale prévaut encore en ce qui concerne le sadisme sexuel, plusieurs évoquent l’idée qu’il pourrait être mieux conceptualisé à l’aide d’une approche dimensionnelle. En parallèle, nos connaissances sur les facteurs contributifs au développement du sadisme sexuel sont limitées et reposent sur de faibles appuis empiriques. Jusqu'à présent, très peu d'études se sont intéressées aux facteurs menant au développement du sadisme sexuel et encore moins ont tenté de valider leurs théories. En outre, nos connaissances proviennent majoritairement d'études de cas portant sur les meurtriers sexuels, un sous-groupe très particulier de délinquants fréquemment motivé par des intérêts sexuels sadiques. À notre connaissance, aucune étude n'a proposé jusqu'à présent de modèle développemental portant spécifiquement sur le sadisme sexuel. Pourtant, l'identification de facteurs liés au développement du sadisme sexuel est essentielle dans notre compréhension ainsi que dans l'élaboration de stratégie d'intervention efficace. La présente thèse s'inscrit dans un contexte visant à clarifier le concept de sadisme sexuel. Plus spécialement, nous nous intéressons à sa structure latente, à sa mesure et à ses origines développementales. À partir d'un échantillon de 514 délinquants sexuels évalué au Massachusetts Treatment Center, la viabilité d’une conception dimensionnelle du sadisme sexuel sera mise à l’épreuve à l'aide d'analyses taxométriques permettant d'étudier la structure latente d'un construit. Dans une seconde étape, à l'aide d'analyses de Rasch et d'analyses appartenant aux théories de la réponse à l'item à deux paramètres, nous développerons la MTC Sadism Scale (MTCSS), une mesure dimensionnelle du sadisme sexuel. Dans une troisième et dernière étape, un modèle développemental sera élaboré à l'aide d'équations structurales. La présente thèse permettra de contribuer à la clarification du concept de sadisme sexuel. Une clarification de la structure latente et des facteurs développementaux permettra de saisir les devis de recherche les plus à même de capturer les aspects essentiels. En outre, ceci permettra d'identifier les facteurs pour lesquels une intervention est la plus appropriée pour réduire la récidive, ou la gravité de celle-ci.

Trade Shocks and Local Labor Markets' Linkages: Theory and Evidence

In the past few years, there has been a concern among economists and policy makers that increased openness to international trade affects some regions in a country more than others. Recent research has found that local labor markets more exposed to import competition through their initial employment composition experience worse outcomes in several dimensions such as, employment, wages, and poverty. Although there is evidence that regions within a country exhibit variation in the intensity with which they trade with each other and with other countries, trade linkages have been ignored in empirical analyses of the regional effects of trade, which focus on differences in employment composition. In this dissertation, I investigate how local labor markets' trade linkages shape the response of wages to international trade shocks. In the second chapter, I lay out a standard multi-sector general equilibrium model of trade, where domestic regions trade with each other and with the rest of the world. Using this benchmark, I decompose a region's wage change resulting from a national import cost shock into a direct effect on prices, holding other endogenous variables constant, and a series of general equilibrium effects. I argue the direct effect provides a natural measure of exposure to import competition within the model since it summarizes the effect of the shock on a region's wage as a function of initial conditions given by its trade linkages. I call my proposed measure linkage exposure while I refer to the measures used in previous studies as employment exposure. My theoretical analysis also shows that the assumptions previous studies make on trade linkages are not consistent with the standard trade model. In the third chapter, I calibrate the model to the Brazilian economy in 1991--at the beginning of a period of trade liberalization--to perform a series of experiments. In each of them, I reduce the Brazilian import cost by 1 percent in a single sector and I calculate how much of the cross-regional variation in counterfactual wage changes is explained by exposure measures. Over this set of experiments, employment exposure explains, for the median sector, 2 percent of the variation in counterfactual wage changes while linkage exposure explains 44 percent. In addition, I propose an estimation strategy that incorporates trade linkages in the analysis of the effects of trade on observed wages. In the model, changes in wages are completely determined by changes in market access, an endogenous variable that summarizes the real demand faced by a region. I show that a linkage measure of exposure is a valid instrument for changes in market access within Brazil. By using observed wage changes in Brazil between 1991-2000, my estimates imply that a region at the 25th percentile of the change in domestic market access induced by trade liberalization, experiences a 0.6 log points larger wage decline (or smaller wage increase) than a region at the 75th percentile. The estimates from a regression of wages changes on exposure imply that a region at the 25th percentile of exposure experiences a 3 log points larger wage decline (or smaller wage increase) than a region at the 75th percentile. I conclude that estimates based on exposure overstate the negative impact of trade liberalization on wages in Brazil. In the fourth chapter, I extend the standard model to allow for two types of workers according to their education levels: skilled and unskilled. I show that there is substantial variation across Brazilian regions in the skill premium. I use the exogenous variation provided by tariff changes to estimate the impact of market access on the skill premium. I find that decreased domestic market access resulting from trade liberalization resulted in a higher skill premium. I propose a mechanism to explain this result: that the manufacturing sector is relatively more intensive in unskilled labor and I show empirical evidence that supports this hypothesis.

Outcome Prediction of Consciousness Disorders in the Acute Stage Based on a Complementary Motor Behavioural Tool.

INTRODUCTION: Attaining an accurate diagnosis in the acute phase for severely brain-damaged patients presenting Disorders of Consciousness (DOC) is crucial for prognostic validity; such a diagnosis determines further medical management, in terms of therapeutic choices and end-of-life decisions. However, DOC evaluation based on validated scales, such as the Revised Coma Recovery Scale (CRS-R), can lead to an underestimation of consciousness and to frequent misdiagnoses particularly in cases of cognitive motor dissociation due to other aetiologies. The purpose of this study is to determine the clinical signs that lead to a more accurate consciousness assessment allowing more reliable outcome prediction. METHODS: From the Unit of Acute Neurorehabilitation (University Hospital, Lausanne, Switzerland) between 2011 and 2014, we enrolled 33 DOC patients with a DOC diagnosis according to the CRS-R that had been established within 28 days of brain damage. The first CRS-R assessment established the initial diagnosis of Unresponsive Wakefulness Syndrome (UWS) in 20 patients and a Minimally Consciousness State (MCS) in the remaining13 patients. We clinically evaluated the patients over time using the CRS-R scale and concurrently from the beginning with complementary clinical items of a new observational Motor Behaviour Tool (MBT). Primary endpoint was outcome at unit discharge distinguishing two main classes of patients (DOC patients having emerged from DOC and those remaining in DOC) and 6 subclasses detailing the outcome of UWS and MCS patients, respectively. Based on CRS-R and MBT scores assessed separately and jointly, statistical testing was performed in the acute phase using a non-parametric Mann-Whitney U test; longitudinal CRS-R data were modelled with a Generalized Linear Model. RESULTS: Fifty-five per cent of the UWS patients and 77% of the MCS patients had emerged from DOC. First, statistical prediction of the first CRS-R scores did not permit outcome differentiation between classes; longitudinal regression modelling of the CRS-R data identified distinct outcome evolution, but not earlier than 19 days. Second, the MBT yielded a significant outcome predictability in the acute phase (p<0.02, sensitivity>0.81). Third, a statistical comparison of the CRS-R subscales weighted by MBT became significantly predictive for DOC outcome (p<0.02). DISCUSSION: The association of MBT and CRS-R scoring improves significantly the evaluation of consciousness and the predictability of outcome in the acute phase. Subtle motor behaviour assessment provides accurate insight into the amount and the content of consciousness even in the case of cognitive motor dissociation.

Essays on labor economics.

Doctor of Philosophy in subject of Economics