Publications

Selected publications in peer-reviewed journals

Primary healthcare costs associated with the AstraZeneca COVID-19 vaccine in England, 2025,
Vaccine 72, 128067.
(joint with Catia Nicodemo, Stavros Petrou and Simon de Lusignan)

Abstract

Current research on the effectiveness of COVID-19 vaccines has demonstrated their role in reducing hospitalizations and deaths due to SARS-CoV-2. However, evidence regarding the healthcare costs incurred by vaccinated versus unvaccinated individuals in the community remains limited, especially in primary care, the first point of access for most patients. This study estimated the total (all-cause) primary healthcare costs for individuals who received the AstraZeneca COVID-19 vaccine (AZD1222) in England between 2020 and 2021. We conducted an economic analysis utilizing electronic primary healthcare records from the Oxford-Royal College of General Practitioners Clinical Informatics Digital Hub (ORCHID) database, with costs valued according to NHS tariffs. Exact coarsened matching in a time-varying setting was employed to balance patient characteristics between the vaccinated and unvaccinated groups. Our results indicate that vaccinated individuals who received the first dose of the AstraZeneca vaccine incurred significantly lower primary healthcare costs compared to their unvaccinated counterparts. Specifically, at 15 days post-vaccination, vaccinated individuals had total costs that were £47.5 (95 % CI: £42.6 to £52.4) lower. This difference increased to £87.1 (95 % CI: £79.6 to £94.6) at 30 days and £124.0 (95 % CI: £114.3 to £133.7) at 45 days post-vaccination, reflecting a reduction of approximately 33.1 % during this period. These findings carry important implications for healthcare budgeting, resource allocation, and pandemic response policies.

Socioeconomic inequality and access to emergency care: understanding the pathways to the emergency department in the UK, 2025,
BMJ Open 15, 12.
(joint with Catia Nicodemo, Adrian Boyle, James Ray, Alex Novak, Catherine Pope, Bella Wheeler, Stavros Petrou, and Raphael Wittenberg)

Abstract

Objective: To examine how socioeconomic deprivation influences referral pathways to emergency departments (EDs) and to assess how these pathways affect subsequent hospital outcomes. Design: Retrospective observational study. Setting: Emergency department of a large teaching hospital in the East of England, providing secondary and tertiary care. Participants: 482 787 ED attendances by patients aged 16 years and over, recorded between January 2019 and December 2023. Patients were assigned Index of Multiple Deprivation (IMD) deciles based on residential postcode. Main outcome measures: Referral source (general practitioner (GP), National Health Service (NHS) 111, ambulance, self-referral, other), total ED time, 4-hour breach, hospital admission and unplanned return within 72 hours. Results:Substantial socioeconomic inequalities were observed in referral pathways. Patients from the most deprived areas were significantly less likely to be referred by a GP (4.7%) than those from the least deprived areas (14.7%) and more likely to arrive via ambulance (32% vs 24%). These differences persisted after adjusting for demographic, clinical and contextual variables. Ambulance referrals showed the longest ED stays, ranging from 347 to 351 min across IMD deciles (overall 95% CI 343 to 363) and the highest probability of 4-hour breaches (51%; 95% CI 50% to 53%). Self-referrals had the greatest rates of unplanned returns within 7 days (up to 7.1%; 95% CI 5.5% to 8.7%). In contrast, NHS 111 and GP referrals were associated with shorter stays, lower breach rates and fewer reattendances. Minimal variation in outcomes was observed across deprivation levels once referral source was accounted for. Conclusions Inequalities in how patients access emergency care, particularly reduced GP and NHS 111 referrals among more deprived groups, appear to underpin disparities in ED outcomes. Referral source captures important clinical and system-level factors that influence patient experience and resource use. Interventions to improve equitable access to structured referral pathways, particularly in more deprived areas, may enhance both the efficiency and fairness of emergency care delivery. Further research using national data is needed to assess broader policy implications and economic costs associated with differential access.

Overseas general practitioners (GPs) and opioid prescriptions in England, 2025,
Health Policy 159, 105362.
(joint with Catia Nicodemo, Cristina Tealdi, and Cristina E. Orso)

Abstract

The substantial recent rise in opioid prescription rates, along with increasing evidence of misuse and associated morbidity and mortality, raises serious concerns about the appropri- ateness of these drugs for pain management. This study investigates prescription behaviour differences across opioid drug categories between UK-trained and overseas-trained GPs. Us- ing panel data covering all English practices from 2018 to 2021, we find a strong association between practices with more overseas GPs and opioid prescription patterns. Regional dif- ferences emerge, with GPs from North America prescribing more opioids and those from Africa and Asia prescribing less, relative to the UK-trained counterparts. Heterogeneous cultural norms, different training environments, and varying epidemiological patterns might explain these different prescribing behaviours. Comprehensive cross-country assessments of GP competencies could identify areas for targeted training, helping to align the practices of foreign-trained GPs with UK standards while supporting the attraction of global talent.

Bridging the pulse: Exploring inequalities in diabetes and hypertension medication prescriptions in Spain’s immigrant and native communities, 2025,
Economics & Human Biology 57, 101489.
(joint with Luigi Boggian and Catia Nicodemo)

Abstract

Migrants often face barriers in accessing high quality healthcare, leading to unequal treatment. This research investigates the disparities in medication utilization for cardiovascular risk factors between immigrant and native-born populations in Spain. The study specifically examines differences in drug prescriptions for managing diabetes and hypertension, two key contributors to cardiovascular disease. We analyze administrative healthcare records to examine the probability of patients receiving prescriptions for antidiabetic and antihypertensive medications. Additionally, we assess the likelihood of patients undergoing tests to measure glycated hemoglobin levels and blood pressure, two crucial indicators for monitoring diabetes and hypertension management.The analysis is stratified across different levels of medical needs, by also controlling for individual socioeconomic status, physician diagnoses, biometric data and primary care centers fixed effects. The findings reveal that all immigrant groups have lower probabilities of being prescribed medications for diabetes and hypertension and this is especially true for people with higher levels of healthcare needs. These findings underscore the importance of addressing healthcare disparities to achieve more equitable outcomes for immigrant communities.

Immigrant status and likelihood of opioid treatment. Lessons from Spain’s National Health Service, 2024,
Journal of Economic Behavior & Organization 227, 106754.
(joint with Luigi Boggian, Francesco Moscone, and Cristina E. Orso)

Abstract

This study investigates opioid prescription patterns among immigrants and native populations in Spain, using novel patient health records from the Base de Datos Clínicos de Atención Primaria (BDCAP). We examined two subsets of data from 2017 and 2018, specifically targeting individuals diagnosed with musculoskeletal (MSK) issues and new cancer diagnoses, as these conditions frequently involve pain management. Our empirical analysis involved estimating a series of linear and count data models to explore the relationship between regions of origin, socioeconomic factors, and the probability of opioid use, controlling for a rich set of health conditions, and primary care centers fixed effects. Despite previously documented healthcare inequities, Spain demonstrates no major differences in opioid prescriptions between immigrants and natives, highlighting the effectiveness of its National Health Service (NHS). This contrasts sharply with the opioid crises in the United States and Canada. The absence of significant disparities underscores the importance of comprehensive healthcare systems and stringent regulations on opioid prescribing practices, as observed in European guidelines. Policy implications include the need to maintain and strengthen public healthcare systems to ensure equitable access to essential medications like opioids and to continue monitoring and regulating opioid prescribing practices to safeguard public health.

Transforming public health and economic outcomes by reducing risky behaviors: the potential for South Korea, 2024,
Discover Social Science and Health 4, 54.
(joint with Ji Yoon Baek and Aesun Shin )

Abstract

South Korea faces a diminishing workforce driven by the world's lowest fertility rate, restrictive immigration, and low female labor participation. This paper explores reducing non-communicable diseases from risky behaviors as a solution. We investigate how many cases could be prevented if South Koreans changed risky consumption patterns, and the associated economic healthcare burden impact. Utilizing the Preventable Risk Integrated Model (PRIME), we model hypothetical 2022 reductions in tobacco, alcohol, and unhealthy diet risks to estimate disease case and economic cost impacts. We contrast actual 2022 consumption against a moderate harm reduction scenario. Findings reveal potentially preventing approximately 73,400 new non-communicable disease cases, 69% among working-age Koreans, benefiting the workforce. This reduction could save $13 billion from avoided treatment costs, absenteeism, and premature deaths, including $3.7 billion in 2022 and $9.3 billion in future economic losses. The study emphasizes needing a harm reduction regulatory approach balancing public health and societal realities. We advocate risk-proportionate taxation policies incentivizing consumers toward less harmful alternatives. Given government responsibilities preserving both public health and productivity, smart regulation of risky consumption is critical. This timely research quantifies the significant potential gains from strategic interventions on key risk factors, informing policymakers navigating health promotion and economic objectives.

Ethnicity and health at work during the COVID-19, 2025,
Regional Science and Urban Economics 111, 104083.
(joint with Catia Nicodemo and Francesco Moscone)

Abstract

This paper explores how health-work-related illnesses and injuries have changed during the COVID-19 pandemic for different ethnic groups and by gender. We find that not all groups were affected in the same way. While almost all men in all ethnic groups were on average less likely to work during the pandemic period, women were more likely to work. We also find that Mixed Ethnic and Pakistani women who reported a higher probability of working in the reference week had a higher risk of illness/injuries at work. Meanwhile, White men and Other ethnic groups with a reduced probability of working during the pandemic had a lower risk of illness/injuries at work. Long-term illness varied by ethnicity and gender, with men experiencing a reduction and women an increase in physical and mental health issues. This research provides valuable insights into the multifaceted impact of the COVID-19 pandemic on the health and work patterns of different ethnic groups and gender. Understanding and identifying these disparities is crucial for formulating targeted policies aimed at mitigating adverse effects and promoting equitable outcomes in regional studies and urban economics.

Immigration and health outcomes: A study on native health perception and limitations in Europe, 2024,
Economic Modelling 134, 106627.
(joint with Martina Bazzoli, Federico Podesta, and Catia Nicodemo)

Abstract

This study examines the impact of immigration on the self-perceived health of natives in 16 European countries from 2006 to 2018. Utilizing data from the European Union Statistics on Income and Living Conditions (EU-SILC) and the European Union Labor Force Survey (EU-LFS), we focus on two health outcomes: natives’ self-perceived health and health-related limitations in daily activities. Contrary to concerns, our findings indicate a positive influence of immigration on natives’ health perception and a reduction in health-related limitations. Noteworthy variations by gender and age emerge, with more pronounced benefits in countries with lower human capital. These results underscore the potential health advantages of immigration, emphasizing the necessity for nuanced immigration policies that consider societal impact and call for a comprehensive evaluation of immigration’s effects.

Studying informal care during the pandemic: mental health, gender and job status, 2023,
Economics & Human Biology 50, August 2023,101245.
(joint with Francesco Moscone and Catia Nicodemo)

Abstract

Unexpected negative health shocks such as COVID-19 put pressure on households to provide more care to relatives and friends. This study uses data from the UK Household Longitudinal Study to investigate the impact of informal caregiving on mental health during the COVID-19 pandemic. Using a difference-in-differences analysis, we find that individuals who started providing care after the pandemic began reported more mental health issues than those who never provided care. Additionally, the gender gap in mental health widened during the pandemic, with women more likely to report mental health issues. We also find that those who began providing care during the pandemic reduced their work hours compared to those who never provided care. Our results suggest that the COVID-19 pandemic has had a negative impact on the mental health of informal caregivers, particularly for women.

Diverging mental health after Brexit: Evidence from a longitudinal survey, 2022,
Social Science and Medicine 302, June 2022, 114993.
(joint with Charlotte Herby, Nicolo Cavalli, and Catia Nicodemo)

Abstract

This study analyses the changes in mental health in the UK that occurred as a result of the 2016 referendum on UK membership of the EU (Brexit). Using the Household Longitudinal Study, we compare the levels of self-reported mental distress, mental functioning and life satisfaction be-fore and after the referendum. A linear fixed effects analysis revealed an overall decrease in mental health post-referendum with higher levels of mental distress, and a decline in the SF-12 Mental Component Summary score. Furthermore, the study does not find evidence of significant changes in overall life satisfaction in the two years after the referendum. Younger men, highly educated and Natives, especially those living in stronger “Remain areas”, seem to be the groups most affected by the Brexit in terms of mental health. Overall, the results of this study suggest that the outcome of the referendum and the economic uncertainty that it brought impacted the mental health of voters in a negative and diverging way.

Informal care, older people, and COVID-19: Evidence from the UK, 2023,
Journal of Economic Behavior and Organization 205, January 2023, Pages 468-488.
(joint with Francesco Moscone and Catia Nicodemo)

Abstract

The negative health effects and mortality caused by the COVID-19 pandemic disproportionately fell upon older and disabled people. Protecting these vulnerable groups has been a key policy priority throughout the pandemic and related vaccination campaigns. Using data from the latest survey of the UK Household Longitudinal Study on COVID-19 we found that people who receive informal care have higher probability of being infected when compared to those not receiving informal care. Further, we found that care recipients who are in the lowest income groups have a higher probability of catching the virus when compared to those in the highest income groups. We also estimated the likelihood of being infected for informal carers versus those who did not provide any care during the pandemic and found no significant differences between these two groups. Our empirical findings suggest that the standard measures introduced with the aim of protecting vulnerable groups, such as closing care homes or prioritising the vaccination of their staff, were not sufficient to avoid the spread of the virus amongst disabled and older people. Informal carers play an important role in the social care sector. As such, protecting vulnerable people by investing in the informal care sector should be a priority for future health policy.

The impact of school exclusion in childhood on health and well‐being outcomes in adulthood: Estimating causal effects using inverse probability of treatment weighting, 2023,
British Journal of Educational Psychology , 28 December 2023.
(joint with Ingrid Obsuth, Aja L. Murray, Ian Thompson, and Harry Daniels)

Abstract

Book chapters

Ethnicity and Inequality during the COVID-19 Pandemic in the UK, 2023,
The Economics of COVID-19:Volume 296, Edited by Badi H. Baltagi, Francesco Moscone, and Elisa Tosetti Emerald, 1 June 2022, 9781800716940.
(joint with Stuart Reading and Catia Nicodemo)

Abstract

This chapter presents a summary of existent evidence regarding the effects of the COVID-19 pandemic on Minority Ethnic Groups (MEGs) in the United Kingdom Compared to White British, MEGs have historically experienced lower levels of health and socioeconomic outcomes and the COVID-19 crisis seems to have widened these inequalities. In particular, evidence gathered between 2020 and early 2021 suggests that MEGs, and especially MEGs women, experienced a substantive deterioration in mental health. Furthermore, Black and South Asian groups were more likely to contract the infection and die than any other ethnic group. Access to preventative services and healthcare, plus residential and employment segregation seem to be important factors in explaining mortality rates due to COVID-19. Finally, data released by NHS on vaccinations (until August 2021) show that Black, Pakistani and Bangladeshi communities are lagging behind the rest, with a very low proportion of these groups receiving the first dose. Getting everyone vaccinated should be a priority for the Government in order to reduce the impact of COVID-19 and avoid new outbreaks. The evidence collected and summarised in this chapter calls for further attention on, and action to mitigate, the widening gaps in health and socioeconomic attainments across ethnic groups.

Migration and Health During COVID-19 Period, 2023,
Handbook of Labor, Human Resources and Population Economics, 1-18, Edited by Klaus F. Zimmermann, Springer, 2022.
(joint with Catia Nicodemo)

Abstract

This chapter explores how the COVID-19 pandemic has affected the health of migrants and refugees in Europe. In particular, it focuses on how the pandemic has affected migrants’ mental health and their access to vaccination and healthcare services. Throughout the pandemic, migrants were at higher risk of COVID19 infection and death, with a high rate of hesitancy to get vaccinated. Migrants are more likely to work in jobs that are at high risk of accidents and in sectors that are key for society, especially during the pandemic, such as transport and healthcare, among others. This fact, jointly with cultural barriers, socioeconomic disadvantages, and, in some cases, discrimination, has directly and indirectly deteriorated migrants’ health outcomes, or created new vulnerabilities in this population. European governments should make further effort on addressing these issues, by, for example, adopting new public health interventions to mitigate and prevent the negative consequences of COVID-19 on migrants.

Middle and Below Living Standards: What Can We Learn from Beyond Income Measures of Economic Well-being?, 2018,
Generating Prosperity for Working Families in Affluent Countries, Edited by Brian Nolan, Oxford University Press, September 2018, 9780191844836.
(joint with Marii Paskov and Tim Goedemé)

Abstract

This chapter complements the income-based measures of living standards on which earlier chapters have focused by incorporating non-income dimensions of economic well-being into its analysis, including indicators of material deprivation, economic burdens, and financial stress. It analyses how working-age households around and below the middle of the income distribution fared in European countries in the years before, during, and after the Great Recession. Harmonized household-level data across the members of the EU are analysed to see whether the evolution of these various non-income measures present a similar or different picture to household incomes over time. To probe what lies behind the patterns this reveals, four quite different countries are then examined in greater depth. Finally, the chapter also explores the relationship between material deprivation for households around and below the middle and overall income inequality.

Pre-prints and Working Papers

Does Children’s Education Improve Parental Longevity? Evidence from Two Educational Reforms in England, R&R
(joint with Christiaan Monden and Patrick Praeg)

Abstract

Parents of better-educated children are healthier and live longer. Is this a non-monetary return to education which crosses generational boundaries, or is this the consequence of unobserved factors (e.g. shared genes or living conditions) driving both children’s education and parental health? Using data from the English Longitudinal Study of Aging (ELSA) and two educational reforms that raised the mandatory school-leaving age from age 14 to 15 years in 1947 and from age 15 to 16 years in 1972, we investigate the causal effect of children’s education on parental longevity. Results suggest that both one-year increases in school-leaving age significantly reduced the hazard of dying for fathers as well as for mothers. We do not find a consistent pattern when comparing differences in the effects of daughters’ and sons’ education. Lower class parents benefitted more from the 1972 reform than higher class parents. We discuss these results against the backdrop of generational conflict and the specific English context.

Under review

Workforce Expansion and Persistent Backlogs: A Multivariable Analysis of Elective Surgery Waiting Lists in the NHS England, R&R
(joint with Cristina Tealdi, Ahmar Shah, Aziz Sheikh, and Catia Nicodemo)

Abstract

Background: The COVID-19 pandemic exacerbated longstanding challenges within the NHS, contributing to a de-cline in healthcare productivity and a growing backlog of patients on waiting lists. Despite an increase in the NHS workforce (compared to January 2023, the full-time equivalent (FTE) medical workforce in England increased by 5.5%, reaching 1,338,753 in January 2024), the waiting list for elective surgery has continued to grow. We investi- gated factors contributing to the decline in average complete elective surgery cases and the rise in incomplete elective surgery cases, focusing on workforce dynamics, resource allocation, and systemic inefficiencies. Methods: Using data from NHS Digital (2018-2023), we analysed monthly records of waiting lists, workforce numbers, and healthcare system performance. Our primary metrics were the average per capita complete cases, a proxy for productivity, and the ratio of incomplete to average complete cases, a proxy for the additional resources required to meet service demand, calculated at the Trust level. We employed regression and Generalized Method of Moments (GMM) models to assess the impact of variables such as staff sickness rates, administrative turnover, and investment levels on our two key metrics. Findings: Key factors that contributed to the backlog were: i) staff sickness rates, a one percentage point increase in the NHS workforce sickness rate was associated with a 4.4% decrease in the number of average complete waiting list cases, holding all else constant; ii) lower administrative turnover, a higher net gain in admin staff reduced backlogs, 1-unit increase in turnover implied 14.4% decrease in excess incomplete cases. Interpretation: Our analysis highlights a complex interplay between workforce capacity, resource allocation, and systemic inefficiencies in the NHS. While increasing the workforce is necessary, it is insufficient to address the growing elective surgery backlog without addressing underlying issues such as staff burnout, turnover, and investment in infrastructure. Policymakers must focus on improving workforce wellbeing and resilience, and optimise resource allocation, to reduce waiting times for elective surgery.

The Economic Burden of COVID-19 Undervaccination: Costs of Hospitalisation, ICU Admission, and Death in Scotland, R&R
(joint with Steven Kerr, Aziz Sheikh, and Catia Nicodemo)

Abstract

The COVID-19 pandemic has imposed substantial financial and operational pressures on healthcare systems globally. While vaccines were known to reduce severe outcomes, their broader economic impacts -especially in publicly funded health systems—requires clearer quantification. This study evaluates the direct healthcare costs associated with COVID-19 outcomes in relation to vaccination status, using linked individual-level data from Scotland's EAVE II cohort (June to September 2022). We defined "under-vaccination" as the shortfall between recommended and received COVID-19 vaccine doses, stratified by age group. Retrospective cohort analysis employing Cox proportional hazards and linear regression models were used to assess the associations between undervaccination and the risk, frequency, and duration of hospitalisation, intensive care unit ICU admission, and death. We also conducted a counterfactual analysis to estimate averted costs and quality-adjusted life years gained (QALYs) under a full vaccination scenario. Findings demonstrate a strong dose–response relationship between undervaccination and severe COVID-19 outcomes. Among individuals aged 75+, those with higher undervaccination levels showed significantly increased hazard ratios for hospitalisation (up to 3.92 for sub-optimal level 2), ICU admission (up to 12.53 for sub-optimal level 2), and mortality (up to 6.63 for sub-optimal level 3). The economic consequences were substantial: hospitalisation costs reached £4.7 million for the 75+ group and £2.6 million for the 16–74 group. Under a full vaccination scenario, potential savings were estimated at £1.4 million for the 75+ group and £0.5 million for the 16–74 group. ICU costs totalled £246,486 for the 16–74 age group and £70,489 for those 75+. Vaccination rates were lower among younger individuals, ethnic minorities, and residents in more deprived areas—highlighting persistent health inequalities. Of the total cohort of 4,992,498 individuals, 65.8% were fully vaccinated on June 1 2022, while 34.2% were undervaccinated. These inequalities were not only clinically consequential but also economically costly: undervaccinated individuals generated more than five-fold the COVID-19 healthcare spend of their fully vaccinated peers, accounting for NHS outlays of £4.7 million in hospital care and £70 k in ICU care among adults 75+ years, and £2.6 million plus £246 k, respectively, among those aged 16–74; universal full vaccination could have averted about £1.4 million (75 +) and £0.5 million (16–74) in hospital costs—and a further £38,000 in ICU costs—during summer 2022 alone.

Temporary GPs and the Effects on Patients’ Health Outcomes
(joint with Francesco Moscone, Catia Nicodemo, Cristina Tealdi, and Cristina Orso)

Abstract

The impact of temporary work has been studied extensively in the literature, but little is known about the implications of temporary work in the healthcare sector. In this paper, we investigate the impact of locum GPs on patients' satisfaction, prescription behaviours, and emergency admissions using a unique dataset that matches the information on temporary contracts for the general practices in England from 2017 to 2021, along with patient satisfaction ratings and psychotropic medication prescriptions. We employ panel data techniques that leverage both the cross-sectional and temporal dimensions of the dataset to analyse the relationship between locum GPs and patients' health outcomes. Our findings indicate that patient satisfaction is lower in practices with more temporary job contracts. This result supports the hypothesis that patients may prefer a less precarious relationship with their healthcare providers. We also find a negative association between the higher share of locums GPs and antibiotic, infection, analgesic, and statin prescriptions and positive effects on mental health. The reduced time that locums GPs may have to engage with their patients may incentivise them to under-prescribe all these types of medications. This suggests that locum doctors may have an adverse impact on the appropriateness of treatments for patients. However, we do not find any significant effect on the number of emergency admissions at the practice level. Our results have significant implications for policy interventions aimed at increasing the flexibility of the labour market in the healthcare sector. Such reforms should also consider the economic and social costs of the changes, including the psychological well-being of patients and the appropriateness of their treatments. Our study highlights the importance of ensuring that temporary work arrangements in healthcare do not compromise the quality of patient care and treatment outcomes.

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