Difference-in-Differences for Health Policy and Practice: A Review of Modern Methods

Abstract: Difference-in-differences (DiD) is the most popular observational causal inference method in health policy, employed to evaluate the real-world impact of policies and programs. To estimate treatment effects, DiD relies on the "parallel trends assumption", that on average treatment and comparison groups would have had parallel trajectories in the absence of an intervention. Historically, DiD has been considered broadly applicable and straightforward to implement, but recent years have seen rapid advancements in DiD methods. This paper reviews and synthesizes these innovations for medical and health policy researchers. We focus on four topics: (1) assessing the parallel trends assumption in health policy contexts; (2) relaxing the parallel trends assumption when appropriate; (3) employing estimators to account for staggered treatment timing; and (4) conducting robust inference for analyses in which normal-based clustered standard errors are inappropriate. For each, we explain challenges and common pitfalls in traditional DiD and modern methods available to address these issues.