Emmanuelle Piérard

Life-expectancy gains from pharmaceutical drugs: a critical appraisal of the literature.

Objectives: Several studies suggest that, on the basis of life-expectancy regressions, pharmaceutical drugs are responsible for much of the marked gains in life expectancy observed over the last 50 years. In this article, we critically appraise these studies. Methods: We point out several modeling issues: identification of the contribution of new drugs from advances in disease management, changes in the distribution of healthcare and other confounding factors. Results: We suggest that some models produce estimates of pharmaceutical productivity that are implausibly high. Other models have very large forecast errors. Finally, the models that we replicated were found to be sensitive to seemingly innocuous changes in specification. Conclusion: It is difficult to estimate the biomedical determinants of life expectancy using aggregate data. Analyses using individual level data or perhaps disease-specific data will probably produce more compelling results.

The effect of physician supply on health status: Canadian evidence

We estimate the relationship between per capita supply of physicians, both general practitioners and specialists, and health status of Canadians. We use data from the Canadian National Population Health Survey and the Canadian Institute for Health Information. Two measures of quality of life, self-assessed health status and the Health Utility Index, are explored. Random effects ordered probits are used to model self-assessed health status, and quantile regressions are used for the Health Utility Index. A higher supply of general practitioners is correlated with better health outcomes as measured by both measures of health status, albeit for different age groups, and it is correlated with a higher HUI for some individuals who report having a chronic condition. A higher supply of specialists is correlated with worse health outcomes for the HUI for some individuals. It is possible that a higher supply of general practitioners increases the likelihood of diagnosing and treating health conditions in a timely manner and that this in turn affects health status. Specialists, due to the nature of their expertise could affect negatively health, both through the use of riskier procedures and due to their clientele being in relatively worse health. Based on our findings, we therefore would recommend maintaining a robust supply and distribution of GPs across Canada.

Do downturns cause desperation? The effect of economic conditions on suicide rates in Canada

There is conflicting evidence concerning the impact of macroeconomic conditions on suicide rates. To help resolve this pertinent question, we present evidence using Canadian data. We estimate feasible generalized least squares models of annual gender-specific suicide rates in the working age population (aged 25–64) using data from each of the 10 Canadian provinces over the period 1982 to 2007. We allow for heteroscedasticity across provinces and first-order autocorrelation common to all provinces. We posit that suicide rates in this population are a function of macroeconomic conditions (current and lagged unemployment rates and real per capita GDP) and other determinants that might be correlated with macro conditions, such as physician supply. We find that different factors affect suicide rates across genders and that some of the results are sensitive to the specification of the model we use and the regressors included. Generally, economic conditions affect men more than women; suicide rates are counter-cyclical and a higher supply of psychiatrists in a province is correlated with lower suicide rates.

Estimating the Effects of Cigarette Taxes on Birth Outcomes

Dans cet article, nous estimons l’impact, sur les issues de la grossesse, des taxes sur les cigarettes; pour ce faire, nous avons recours à des données provinciales couvrant la période 1979–2004, et nous examinons la situation qui a prévalu avant et après février 1994, moment où la taxe d’accise sur les cigarettes a été réduite dans l’Est du Canada. Nos estimations empiriques suggèrent qu’une augmentation des taxes sur les cigarettes est reliée de façon significative à une réduction de la mortalité infantile. Toutefois, nos résultats indiquent également une corrélation positive entre les taxes et les morts foetales qui est contraire à l’intuition. Globalement, et sous réserve de la méthodologie utilisée, nous observons une relation significative entre, d’une part la hausse des dépenses en santé par habitant et l’augmentation du nombre de médecins, et d’autre part des améliorations dans les issues de la grossesse.

The time-varying relationship between mortality and business cycles in the USA

We examine the relationship between total mortality, deaths due to motor vehicle accidents, cardiovascular disease and measures of business cycles for the USA, using a time-varying parameter model for the periods 1961-2010. We first present a theoretical model to outline the transmission mechanism from business cycles to health status, to motivate our empirical framework and to explain why the relationship between mortality and the economy may have changed over time. We find overwhelming evidence of structural breaks in the relationship between mortality and business cycles over the sample period. Overall, the relationship between total mortality, cardiovascular mortality and the economy has become less procyclical over time and even countercyclical in recent times for certain age groups. Deaths due to motor vehicle accidents have remained strongly procyclical. Using drugs and medical patent data and data on hours worked, we argue that important advances in medical technology and changes in the effects that working hours have on health are important reasons for this time-varying relationship. Copyright

Substitutes or complements? An exploration of the effect of wait times and availability of conventional care on the use of alternative health therapies in Canada.

OBJECTIVES We explore how alternative and complementary care use is affected by wait list length and availability of conventional care in Canada. DESIGN We use data from the 2003 Canadian Community Health Survey, Statistics Canada and the Fraser Institute to explore the effect of longer wait times on the use of alternative therapies in general and for specific therapies: Registered Massage Therapy, Chiropractics, Physiotherapy, Homeopathy and Acupuncture. OUTCOME MEASURES We use binary variables indicating whether the individual used various types of alternative care in the year preceding the survey. RESULTS Wait times for specialists are associated with lower probabilities of using alternative care, but the effect are usually not statistically significant. Longer wait times for non-emergency surgery are associated with lower probabilities of using alternative care when using data from CANSIM, but very small higher probabilities of using alternative care when using data from the Fraser Institute which includes wait times for treatments for other procedures than non-emergency surgery. We find positive but extremely small effects for total wait times from the Fraser Institute. Individuals reporting unmet health care needs are more likely to use alternative care while individuals who do not have a regular physician are less likely to use it. CONCLUSIONS Reporting unmet health care needs or no family physician have more of an impact on the use of alternative therapies than wait lists do. The evidence is not clear as to whether alternative care is sometimes used as a substitute to conventional care rather than a complement.

The effect of health care expenditures on self-rated health status and the Health Utility Index: Evidence from Canada

Studies of the effect of health care expenditures on health status suggest conflicting evidence of a relationship using data from numerous countries. We use data from the Canadian National Population Health Survey and the Canadian Institute for Health Information to estimate the relationship between per capita provincial health care expenditures and both self-assessed health status and the Health Utility Index. Our sample includes all individuals who were 18 years old or over at the beginning of the survey in 1994. We use random effects ordered probits for self-assessed health status and quantile regressions for the Health Utility Index (HUI). Our results show that provincial health care expenditures have a limited effect on self-rated health status and the HUI. It may be that self-rated health status and the HUI are noisy measures of heath status and as such, combined with the small variation observed in health care expenditure trends over the period, make the magnitude of the relationship between health care expenditures and health difficult to estimate.

Response to Lichtenberg

• Claim 1: GPS do not clearly distinguish between the effect of pharmaceutical expenditure on LE and the effect of pharmaceutical innovation on LE; • Claim 2: GPS overstate the degree of consensus about the value of pharmaceuticals (or pharmaceutical innovation); • Claim 3: GPS fail to completely appraise the literature; • Claim 4: GPS claim that “policy-makers typically are concerned with the impact of individual drugs (or perhaps groups of therapeutically similar drugs) on health outcomes,” but some important pharmaceutical policy questions depend on the impact of drugs in general; • Claim 5: GPS make conclusions that are less robust to their sensitivity analysis than some key findings from previous studies; • Claim 6: GPS misinterpret estimates of the parameters of this model; • Claim 7: GPS do not provide any evidence to support their claim that “analyses of mortality using individual-level data or aggregated disease-specific data are more promising,” or acknowledge the limitations of those analyses.