Two Essays on the Economics of Organ Transplantation.

My dissertation analyzes two important factors in organ transplantation, transplant center performance and organ donation. The two chapters contribute to the economics literature on organizational learning-by-doing and on the effect of legal interventions on pro-social behavior, respectively. In the first chapter, I analyze organizational learning-by-doing. Organizational learning-by-doing implies that production outcomes improve with increases in cumulative volume produced. Empirical research documents the existence of organizational learning-by-doing, primarily in manufacturing, but provides little insight into why some firms learn while others do not. Using patient-level data on 120 new liver transplant centers, I first establish that organizational learning-by-doing exists, but only shortly after entry. Second, I show that significant variation in organizational learning-by-doing exists across centers. Third, I test whether the timing of entry and pre-entry experience transplanting other organs affect the existence and magnitude of organizational learning-by-doing. I find that organizational learning-by-doing only exists early in the sample period when liver transplantation was a relatively experimental procedure. Pre-entry experience also influences the relationship between survival outcomes and cumulative volume. My results indicate that current policies discouraging entry into liver transplantation may reduce access without improving outcomes. The second chapter of my dissertation tests whether laws intended to increase organ and bone marrow donation increase donation, which may determine whether a patient receives a life-saving transplant or dies waiting. Many U.S. states passed legislation providing leave to organ and bone marrow donors and/or tax benefits for organ and bone marrow donations and to employers of donors. We exploit cross-state variation in the timing and passage of such legislation to analyze its impact on organ donations by living and deceased persons, on measures of the quality of the organs transplanted, and on the number of bone marrow donations. We find that these provisions did not affect the quantity of organs donated. The leave legislation, however, did increase bone marrow donations. Our results suggest that this legislation works for moderately invasive procedures such as bone marrow donation, but may be too low for organ donation, which is riskier and more burdensome to the donor.PHDBusiness AdministrationUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/100074/1/ssstith_1.pd

Are Transplant Centers That Meet Insurer Minimum Volume Requirements Better Quality?

A pervasive viewpoint in health care is that higher patient volume leads to better outcomes, implying that facility volume can be used to identify high-quality providers. Hundreds of studies documenting a positive correlation between hospital volume and patient survival have motivated payers to use arbitrary minimum volume standards for elective surgical procedures, though it is unknown whether these policies actually improve patient outcomes. Using an instrumental variables approach, we show that minimum volume requirements in kidney transplantation do not reduce posttransplant mortality. These results suggest minimum volume requirements are not a useful proxy measure for quality and that restricting the number of hospitals from which patients can receive care could reduce access to necessary health care services. </jats:p

Systematic combinations of major cannabinoid and terpene contents in Cannabis flower and patient outcomes: a proof-of-concept assessment of the Vigil Index of Cannabis Chemovars

Abstract Background Little is known about the frequency with which different combinations of phytochemicals (chemovars) arise in Cannabis flower or whether common chemovars are associated with distinct pharmacodynamics and patient health outcomes. This study created a clinically relevant, user-friendly, scalable chemovar indexing system summarizing primary cannabinoid and terpene contents and tested whether the most frequently consumed chemovars differ in their treatment effectiveness and experienced side effects. Methods Between 09/10/2016 and 03/11/2021, 204 people used the freely available, educational mobile software application, Releaf App, to record 6309 real-time consumption sessions using 633 distinct Cannabis flower products, unique at the user level, with terpene and cannabinoid potency information. The indexing system is based on retrospective data analysis of the products’ primary and secondary terpene contents and tetrahydrocannabinol (THC) and cannabidiol (CBD) potencies and yielded a total of 478 distinct chemovars. Analyses of covariances (ANCOVAs) were used to compare symptom levels and side effects experienced across the five most common chemovars before and after cannabis consumption for app users overall and for those treating chronic pain and depression or anxiety. Results Examination of the five most frequently consumed chemovars showed significant differences in symptom treatment effectiveness for chronic pain and for depression and anxiety (ps &lt; .001). While the effects varied in magnitude, the five chemovars were effective across conditions except for MC61 (mercene .01–0.49%/beta-caryophyllene .01 to 0.49%/THC 20–25%/CBD 0.01–1.0%), which exacerbated feelings of anxiety or depression. The chemovars also differed in their association with experiencing positive, negative, and context-specific side effects, with two chemovars, MC61 and MC62 (mercene .01–0.49%/beta-caryophyllene .01–0.49%/THC 20–25%/CBD 1–5%), generating two to three fewer positive side effects and as much as one more negative and two more context-specific side effects than the other three chemovars. Conclusions The findings provide “proof-of-concept” that a simple, yet comprehensive chemovar indexing system can be used to identify systematic differences in clinically relevant patient health outcomes and other common experiences across Cannabis flower products, irrespective of the product’s commercial or strain name. This study was limited by self-selection into cannabis and app use and a lack of user-specific information. Further research using this chemovar indexing system should assess how distinct combinations of phytochemicals interact with user-level characteristics to produce general and individualized Cannabis consumption experiences and health outcomes, ideally using randomized methods to assess differences in effects across chemovars. </jats:sec

How nurse gender influences patient priority assignments in US emergency departments

The goals of this study were to compare whether emergency department (ED) patients’ pain intensity (PI) is measured differently by male and female nurses and to determine whether PI, heart rate (HR) and respiratory rate (RR) we’re used to prioritize patient urgency differently by male and female nurses. The associations between patients’ PI|HR|RR and the Emergency Severity Index (ESI) scores they were assigned by attending nurses were analyzed using a national database of electronic medical records of U.S. Veterans Affairs ED patients from 2008 to 2012. A total of 129,991 patients presenting for emergency care (M(age) = 59.5, 92% males) and their triage nurses (n = 774, M(age) = 47.5, 18% males) were analyzed, resulting in a total of 359,642 patient/provider interactions. Patients’ PI did not differ by nurse’s gender; however a cross-classified mixed-effects model showed that nurse gender influenced how PI and RR measurements informed the ESI levels that male patients received. Higher PI levels were associated with more urgent (higher priority) ESI levels by female nurses, yet less urgent ESI levels by male nurses. In contrast, male patients with high RR received more urgent ESI levels by male nurses, while nurse gender did not influence ESI assignments for female patients. These findings show that ED patients receive disparate treatment based on inherent characteristics of their triage nurses, and more standardized (e.g., automated) protocols that can account for implicit social factors on healthcare practice for reliably assessing and prioritizing ED patients may be currently warranted