Research
Working Papers
Where Does it Hurt? Primary Care Practice Closures, Individual Health, and Hospital Utilization
with Anna-Theresa Renner
(Working Paper available on request)
Abstract
In this paper we study the implications of local practice closures in Germany on the population's health status and hospital utilization. This is especially relevant considering existing and expected GP shortages due to a wave of retirement among physicians of the baby-boomer generation. To identify causal effects we collate a list of geocoded practice closures in Germany between 2011 and 2016, and spatially match them with the affected patient population using a catchment area approach. Exploiting detailed survey data from the German Socio-Economic Panel (GSOEP) with the exact geographical location of the participants, we estimate the effects of GP practice closures on individual health status and inpatient stay using a difference-in-differences framework. We contribute to the literature on GP market exits by disentangling the two pathways through which care discontinuity might impact patient health: (temporary) unavailability of care and re-matching with a new physician. We find small negative effects of a primary care discontinuity for self-reported health but not for quasi-objective physical health. Further, we find sizeable positive effects for overall hospitalization risk in a given year (+18%) and for the number inpatient stays (+20%). We show that these effects differ by local GP supply which reflects different re-matching probabilities. The negative effect on health status is driven by individuals in areas with lower GP supply likely showing perceived health effects of temporary GP absence. The positive effect on hospitalizations is driven by individuals in areas with higher GP supply, likely showing referral effects upon patient re-assessment after GP re-matching. Results are stable across a breadth of sensitivity checks, reported as a specification matrix. Our results show that in settings with high GP supply, care discontinuity results in increased hospital utilization in the short run, while in settings with low supply, care discontinuity is consequential for patient health.
Journal Publications: Health Economics
Financial incentives and antibiotic prescribing patterns: Evidence from dispensing physicians in a public healthcare system
Barbara Stacherl, Anna-Theresa Renner & Daniela Weber
Social Science and Medicine (2023), 321: 115791.
Abstract
To ensure sufficient access to healthcare in remote areas, some countries allow physicians to directly dispense prescribed drugs through on-site pharmacies. Depending on the medication prescribed, this may pose a significant financial incentive for physicians to over-prescribe. This study, therefore, explored the effect of on-site pharmacies on antibiotic dispensing in a social health insurance system. Investigating physicians’ prescribing behavior is especially relevant in the case of antibiotics, as over-utilization expedites antimicrobial resistance, leading to the development of untreatable bacterial infections. The empirical analysis was based on comprehensive administrative data on 13,741 antibiotic prescriptions issued by all 4044 public general practitioners (GPs) in Austria between 2016 and 2019. Switches from dispensing to non-dispensing status (and vice versa) were exploited in a difference-in-difference framework to mitigate a potential selection bias. GPs with the right to dispense over the entire observed period were used as the control group, and those who had either lost or gained the right to dispense as the treatment group. The results from a log-linear mixed model show that not currently operating an on-site pharmacy is associated with a 9.2% lower dispensing rate (i.e., antibiotics per 1000 yearly consultations). The results are robust to potential differences between GPs who switch from dispensing to non-dispensing and those who switch from non-dispensing to dispensing, to potential patient sorting, and to different functional forms. A prescribing effect interpretation (i.e., financial incentives give rise to more prescriptions for antibiotics) explains the observed volume effect provided that the share of unfilled antibiotic prescriptions issued by non-dispensing physicians does not exceed 4%.
Journal Publications: Public Health
From feeling depressed to getting diagnosed: Determinants of a diagnosis of depression after experiencing symptoms
International Journal of Social Psychiatry (2024)
Barbara Stacherl & Theresa M. Entringer
Abstract
Receiving a formal diagnosis for a depressive disorder is a prerequisite for getting treatment, yet the illness inherently complicates care-seeking. Thus, understanding the process from depression symptoms to diagnosis is crucial. This study aims to disentangle (1) risk factors for depression symptoms from (2) facilitators and barriers to receiving a diagnosis after experiencing depression symptoms. We used data from the German Socio-Economic Panel. Within a sample of 40,238 individuals, we investigated factors predicting depression symptoms, assessed with the SF-12 Mental Component Summary score. Additionally, within a subsample of 3,444 individuals with depression symptoms, we analyzed factors associated with receiving a first-ever diagnosis in the subsequent year. These factors included health status, demographics, socioeconomic characteristics, personality traits, and health infrastructure. Depression symptoms were associated with chronic physical conditions, female gender, middle age, living alone, fewer close friends, being unemployed or not working, lower income, lower agreeableness, conscientiousness, or extraversion, and higher neuroticism. Additionally, poorer overall mental and physical health, female gender, older age, unemployment, and neuroticism were positively associated with receiving a formal diagnosis. Access to general practitioners and psychotherapists was not associated with receiving a formal diagnosis. Our results replicated previous research on risk factors for depression symptoms. Moreover, some risk factors for experiencing symptoms (female gender, middle age, unemployment, and higher neuroticism) subsequently also facilitated receiving a formal depression diagnosis. Thus, this study underscores the importance of considering the chronological sequence in the process from depression symptoms to diagnosis.
Equal waiting times for all? Empirical evidence for elective surgeries in the Austrian public healthcare system
Public Health (2024)
Markus Kraus, Barbara Stacherl, Thomas Czypionka & Susanne Mayer
Abstract
This study analyses waiting times for elective surgeries and potential determinants, including supplementary private health insurance, visits in the operating physician's private practice and informal payments for faster treatment. The survey was conducted in eleven Austrian rehabilitation centres in 2019. Data was analysed based on bivariate tests (n = 400) and a multivariate negative-binomial regression model (n = 310) with institution- and patient-related characteristics as independent variables. Median waiting times were 8.9 weeks (IQR: 4.5–18.0) for hip replacement and 8.4 weeks (IQR: 5.0–20.0) for knee replacement surgery. 10.9% of the patients reported having received an offer to shorten their waiting time through a visit in the operating physician's private practice before the surgery or through an informal payment directly to the operating physician. Surgery in private for-profit hospitals, supplementary private health insurance and severe pain were associated with shorter waiting times. While waiting times for elective surgeries in Austria are below international levels, shorter waits for patients with private health insurance and offers to reduce waiting times through informal payments point to equitable access concerns in a public healthcare system.
Loneliness in Germany—prevalence, development over time, and regional differences (Einsamkeit in Deutschland – Prävalenz, Entwicklung über die Zeit und regionale Unterschiede)
Bundesgesundheitsblatt
Theresa M. Entringer & Barbara Stacherl
Abstract
Loneliness is widespread and has negative health consequences. The present study seeks to answer the following questions: (1) how many people in Germany are highly lonely, (2) how has loneliness changed in Germany over time—in particular with regard to the COVID-19 pandemic, and (3) how is loneliness distributed regionally in Germany today? The present study uses data from the 2013, 2017, and 2021 waves of the Socio-Economic Panel, a population representative panel study from Germany. Based on the University of California, Los Angeles (UCLA) loneliness scale, we estimate prevalences for high loneliness for different risk groups in Germany. Further, using multi-level models, we estimate the changes in loneliness from 2013 to 2021. Finally, we generate regional maps to display the relative regional distribution of loneliness in Germany over the three assessment waves. The results show that around 2% of all people living in Germany are highly lonely, and this proportion has not changed during the COVID-19 pandemic. However, mean overall loneliness in Germany increased in the last decade, particularly during the pandemic. Additionally, the regional distribution of loneliness also changed. While eastern Germany was particularly affected by loneliness in 2013, western Lower Saxony, Rhineland-Palatine, and Hesse were the most affected regions during the pandemic. Reasons for these changes could be structural changes in the German society over the past 10 years or the COVID-19 pandemic and the different measures implemented to combat the spread of the COVID-19 virus. However, since the latest representative data on loneliness stems from 2021, further data collection is urgently needed to depict the current state of loneliness in Germany.
Chronic disease onset and wellbeing development: Longitudinal analysis and the role of healthcare access
European Journal of Public Health (2024)
Barbara Stacherl & Odile Sauzet
Abstract
Experiencing the onset of a chronic disease is a serious health event impacting living conditions and wellbeing. Investigating wellbeing development and its predictors is crucial to understand how individuals adapt to chronic illnesses. This study (i) analyzed the impact of a chronic disease on wellbeing development, and (ii) explored spatial healthcare access as potential moderating factor. Data were obtained from the German Socio-economic Panel, a nationally representative household survey. A prospective sample of 3847 individuals was identified for whom the onset of cancer, cardiopathy, diabetes or stroke was observed between 2008 and 2020. Mixed models using an interrupted time series approach were performed to identify immediate level changes and longitudinal trend changes in wellbeing (operationalized with health and life satisfaction) after disease onset. Further, spatial access to healthcare (operationalized by two-stage floating catchment area measures) as potential moderating factor was examined using interaction effects. Chronic disease onset had an immediate negative level impact on health and life satisfaction. For health satisfaction, a negative pre-onset wellbeing trend was offset (but not reversed). A small positive trend was observed for life satisfaction after disease onset. Spatial access to healthcare was not associated with the magnitude of wellbeing reduction at onset. Health and life satisfaction levels drop with the onset of a chronic disease with no recovery trend for health and little recovery for life satisfaction, implying persistently lower wellbeing levels after a chronic illness onset. Spatial access to healthcare does not affect the wellbeing change after disease onset.
Gravity models for potential spatial healthcare access measurement: A systematic methodological review
International Journal of Health Geographics (2023)
Barbara Stacherl & Odile Sauzet
Abstract
Quantifying spatial access to care—the interplay of accessibility and availability—is vital for healthcare planning and understanding implications of services (mal-)distribution. A plethora of methods aims to measure potential spatial access to healthcare services. The current study conducts a systematic review to identify and assess gravity model-type methods for spatial healthcare access measurement and to summarize the use of these measures in empirical research. A two-step approach was used to identify (1) methodological studies that presented a novel gravity model for measuring spatial access to healthcare and (2) empirical studies that applied one of these methods in a healthcare context. The review was conducted according to the PRISMA guidelines. EMBASE, CINAHL, Web of Science, and Scopus were searched in the first step. Forward citation search was used in the second step. We identified 43 studies presenting a methodological development and 346 empirical application cases of those methods in 309 studies. Two major conceptual developments emerged: The Two-Step Floating Catchment Area (2SFCA) method and the Kernel Density (KD) method. Virtually all other methodological developments evolved from the 2SFCA method, forming the 2SFCA method family. Novel methodologies within the 2SFCA family introduced developments regarding distance decay within the catchment area, variable catchment area sizes, outcome unit, provider competition, local and global distance decay, subgroup-specific access, multiple transportation modes, and time-dependent access. Methodological developments aimed to either approximate reality, fit a specific context, or correct methodology. Empirical studies almost exclusively applied methods from the 2SFCA family while other gravity model types were applied rarely. Distance decay within catchment areas was frequently implemented in application studies, however, the initial 2SFCA method remains common in empirical research. Most empirical studies used the spatial access measure for descriptive purposes. Increasingly, gravity model measures also served as potential explanatory factor for health outcomes. Gravity models for measuring potential spatial healthcare access are almost exclusively dominated by the family of 2SFCA methods—both for methodological developments and applications in empirical research. While methodological developments incorporate increasing methodological complexity, research practice largely applies gravity models with straightforward intuition and moderate data and computational requirements.
Policy Reports
Loneliness in Germany: Low-income earners at highest risk of loneliness
DIW Weekly Report (5/2025)
Theresa M. Entringer, Linda Kumrow, & Barbara Stacherl (authors in alphabetical order)
Mental health: Difference between East and West Germany is getting smaller (Psychische Gesundheit hat sich in Ost und West angenähert)
DIW Weekly Report Mattis Beckmannshagen, Daniel Graeber & Barbara Stacherl (authors in alphabetical order)
Select Work in Progress
Spillover Effects of Organized Cancer Screening Programs
with Erin Strumpf
Moving in the Right Direction? Internal Migration, Person-Environment Fit, and Well-Being
with Theresa M. Entringer, Jakob Erhard