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Childbearing motivation may be conceptualized as based upon psychological traits and shaped by experiences during childhood, adolescence, and early adult life. This paper explores what those traits and developmental experiences are. Two measures of childbearing motivation, one positive and the other negative, are described. Using a sample of 362 married men and 354 married women, the paper systematically examines the factors associated with these measures. In addition to a set of basic personality traits, these factors include parental characteristics, teenage experiences, and a number of variables from young adult behavior domains such as marriage, education, work, religion, and parental relationships. Stepwise multiple regression analyses lead to two final constrained, simultaneous-equation regression models. These models indicate the importance of both personality traits and diverse life-cycle experiences in the development of childbearing motivation, the differential gender distribution of predictors, and the different experiential antecedents of positive and negative motivation. [ABSTRACT FROM AUTHOR]

Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran. [ABSTRACT FROM AUTHOR]

6–11-year-old children provide a critical window for physical activity (PA) interventions. The Virtual Fitness Buddy ecosystem is a precision health PA intervention for children integrating mixed reality technology to connect people and devices. A cluster randomized, controlled trial was conducted across 19 afterschool sites over two 6-month cohorts to test its efficacy in increasing PA and decreasing sedentary behavior. In the treatment group, a custom virtual dog via a mixed reality kiosk helped children set PA goals while sharing progress with parents to receive feedback and support. Children in the control group set PA goals using a computer without support from the virtual dog or parents. 303 children had 8+ hours of PA data on at least one day of each of the 3 intervention time intervals. Conversion of sedentary time was primarily to light-intensity PA and was strongest for children with low baseline moderate-to-vigorous PA than children above 45 min of baseline moderate-to-vigorous PA. Findings suggest that the VFB ecosystem can promote sustainable PA in children and may be rapidly diffused for widespread public health impact. [ABSTRACT FROM AUTHOR]

Racial-ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial-ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial-ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial-ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. [ABSTRACT FROM AUTHOR]

In this paper, we have traced changes in the patterns of first marriage in the United States for cohorts of men and women born in 1880 through 1965 and for the years from 1900 through 1983. There were striking changes in marriage rates associated with each of the world wars and with the depression of the 1930s. In addition to these short-term fluctuations, a long-term shift in marriage rates is observed over the period from after World War II until about 1970. By the end of the 1970s, however, marriage rates had returned to levels similar to those observed before the war. The basic similarity in the timing of changes in marriage rates across age levels and for both men and women, blacks and whites, is a striking characteristic of these marriage curves. There are also, however, important differences among these groups with respect to the magnitude and slopes of the shifts. The postwar marriage boom was strongest among the young (those under age 24) and among whites. Similarly, the declines in marriage rates observed in the 1970s were greatest among the young. The marriage rates for teenagers display trends that diverge in many respects from those of older persons. For example, the marriage rates of male teenagers did not show the "peaks" and "valley" associated with World War II for older age groups and female teenagers. Moreover, there is little sign of the postwar marriage boom among black teenagers of either sex. Indeed, the marriage rates of black teenagers began to decline soon after the war, and by the 1970s the marriage rates of both male and female black teenagers had fallen below those of their white counterparts, reversing the pattern that had existed through the first half of this century. During the twenty-five or so years of the postwar marriage boom, which we believe can be characterized best as a period phenomenon, there were trends-eddies within the mainstream-which are probably most easily interpreted as the consequence of a cohort effect.(ABSTRACT TRUNCATED AT 400 WORDS) [ABSTRACT FROM AUTHOR]

Recent work with samples of black and white urban American women showed a clear behavioral sequence relating age at menarche to age at first intercourse to age at first birth. This paper shows that the linking of ages at menarche, intercourse, marriage, and first birth is a pattern which occurs in very diverse cultures. We present confirmatory data from the United States, Belgium, and Pakistan, and from Malay and Chinese women in Malaysia. We interpret our findings as indicating a biological process leading to (a) social interpretations of readiness for reproduction, and (b) persisting biological differences between early and late maturing women. [ABSTRACT FROM AUTHOR]

While births may be dichotomous, fertility intentions are not inherently so. Intentions are predictions about the future and, as such, are couched in considerable uncertainty. Ignoring this uncertainty hides much of what could be learned from data on fertility intentions. This paper presents a model which allows analysis of the full range of intentions. This paper presents a model which allows analysis of the full range of intentions. After selecting a sample of women in the later stage of childbearing (e.g., those who intend fewer than two additional children) from the 1965 and 1970 National Fertility Studies, it is shown that: (1) substantial portions of women at this stage of the reproductive life cycle were indeed uncertain of their parity-specific intention; (2) this certainty, like more firm intentions, varies by age and parity as the model predicts; and (3) there were significant shifts in the level of certainty between 1965 and 1970. Specifically, while intentions for third, fourth, and fifth births declined, more women "didn't know" if they intended to have another child or not. Among those not intending another child, more seemed uncertain of this intention in 1970 than did comparable women in 1965. In contrast, those intending another child seemed more certain. These changes in intention and uncertainty indicate that the observed decline in intended parity was tentative. Post-1970 evidence suggests that this tentative decline has become an equivocal one. [ABSTRACT FROM AUTHOR]

Background: A common method of pain assessment is the numerical rating scale, where patients are asked to rate their pain on a scale from 0 to 10, where 0 is "no pain" and 10 is "pain as bad as you can imagine". We hypothesize such language is suboptimal as it involves a test of a cognitive skill, imagination, in the assessment of symptom severity. Methods: We used a large-scale online research registry, ResearchMatch, to conduct a randomized controlled trial to compare the distributions of pain scores of two different pain scale anchors. We recruited adults located in the United States who reported a chronic pain problem (> 3 months) and were currently in pain. Participants were randomized in a 1:1 ratio to receive pain assessment based on a modified Brief Pain Inventory (BPI), where the anchor for a score of 10 was either "extremely severe pain", or the original BPI, with the anchor "pain as bad as you can imagine". Participants in both groups also answered additional questions about pain, other symptomatology and creativity. Results: Data were obtained from 405 participants for the modified and 424 for the original BPI. Distribution of responses to pain questions were similar between groups (all p-values ≥ 0.12). We did not see evidence that the relationship between pain score and the anchor text differed based on self-perceived creativity (all interaction p-values ≥ 0.2). However, in the key analysis, correlations between current pain assessments and known correlates (fatigue, anxiety, depression, current pain compared to a typical day, pain compared to other people) were stronger for "extreme" vs. "imaginable" anchor text (p = 0.005). Conclusion: Pain rating scales should utilize the modified anchor text "extremely severe pain" instead of "pain as bad as you can imagine". Further research should explore the effects of anchors for other symptoms. [ABSTRACT FROM AUTHOR]

The After Breast Cancer Pooling Project was established to examine the role of physical activity, adiposity, dietary factors, supplement use, and quality of life (QOL) in breast cancer prognosis. This paper presents pooled and harmonized data on post-diagnosis lifestyle factors, clinical prognostic factors, and breast cancer outcomes from four prospective cohorts of breast cancer survivors (three US-based and one from Shanghai, China) for 18,314 invasive breast cancer cases diagnosed between 1976 and 2006. Most participants were diagnosed with stage I-II breast cancer (84.7%). About 60% of breast tumors were estrogen receptor (ER)+/progesterone receptor (PR)+; 21% were ER-/PR-. Among 8,118 participants with information on HER-2 tumor status, 74.8% were HER-2- and 18.5% were HER-2+. At 1-2 years post-diagnosis (on average), 17.9% of participants were obese (BMI ≥ 30 kg/m2), 32.6% were overweight (BMI 25-29 kg/m2), and 59.9% met the 2008 Physical Activity Guidelines for Americans (≥ 2.5 h per week of moderate activity). During follow-up (mean = 8.4 years), 3,736 deaths (2,614 from breast cancer) and 3,564 recurrences have been documented. After accounting for differences in year of diagnosis and timing of post-diagnosis enrollment, five-year overall survival estimates were similar across cohorts. This pooling project of 18,000 breast cancer survivors enables the evaluation of associations of post-diagnosis lifestyle factors, QOL, and breast cancer outcomes with an adequate sample size for investigation of heterogeneity by hormone receptor status and other clinical predictors. The project sets the stage for international collaborations for the investigation of modifiable predictors for breast cancer outcomes. [ABSTRACT FROM AUTHOR]

While great strides have been made recently in improving end-of-life care in the United States, people with dementia often die with inadequate pain control, with feeding tubes in place, and without the benefits of hospice care. In this paper, we discuss the most important and persistent challenges to providing excellent end-of-life care for patients with dementia, including dementia not being viewed as a terminal illness; the nature of the course and treatment decisions in advanced dementia; assessment and management of symptoms; the caregiver experience and bereavement; and health systems issues. We suggest approaches for overcoming these barriers in the domains of education, clinical practice, and public policy. As the population ages, general internists increasingly will be called upon to provide primary care for a growing number of patients dying with dementia. There are great opportunities to improve end-of-life care for this vulnerable and underserved population. [ABSTRACT FROM AUTHOR]

Prior presentations: None INTRODUCTION The epidemic of burnout among clinicians is well documented[1]. We examined burnout among all team members using data from a project on impact of payment reform on safety net health care clinicians, staff, and patients. Burnout: 1 = not burned out, 5 = very burned out * I p i <.05 DISCUSSION Among staff and clinicians in three safety net clinics, we found a wide range of burnout, from 12.5 to 87.5%. [Extracted from the article]

This paper examines the ways in which the behavior of twentieth century cohorts of American women changed simultaneously in the three components of fertility that determine age at last birth--age at first birth, spacing between subsequent births, and parity progression ratios of subsequent births--to produce changes in the timing of the completion of childbearing. It decomposes changes in the mean age at last birth among cohorts and between whites and nonwhites to changes in these three components. To perform these analyses, we developed and applied a method to estimate the distributions and means of ages and last births, birth intervals, and parity progression ratios from age- and parity-specific fertility rates available from vital statistics data. Results show that the cohorts increased and decreased their age at first birth, birth intervals, and parity progression ratios of lower and higher birth orders in almost every possible combination so as to achieve a relatively young age at final birth. [ABSTRACT FROM AUTHOR]

This paper examines the impact of induced abortion on birth outcomes by treating abortion as an endogenous input into the production of infant health. To gauge the direct and indirect effects of abortion, three measures of infant health are considered simultaneously: the neonatal mortality rate, the percentage of low-weight births, and the percentage of preterm births. All three are race specific and all pertain to large counties in the United States in 1977. The results suggest that by preventing unwanted births, abortion enhances the survivability of newborns of a given birth weight and improves the distribution of births among high-risk groups. [ABSTRACT FROM AUTHOR]

There was an increase from 62.8 to 79.1 million households in the United States during the 1970s. The number of households increased much more rapidly than the population. This paper decomposes this growth in the number of households into components associated with changing age and martial status composition and changing age by marital status-specific propensities to form households. About one-third of the increase in the number of households was due to increased age by marital status propensity to form households, and two-thirds was due to shifts in the age by marital status distribution and population growth. The increased propensity to form households had its major impact at ages under 35, and primarily among never-married persons. The composition component had its primary impact at ages 25-44 as a result of the baby boom, and also because of the increased fractions never married and separated and divorced. [ABSTRACT FROM AUTHOR]

This paper addresses the comparability of data from eight national fertility surveys conducted in the United States between 1955 and 1980. We examine the extent to which substantive conclusions about the levels and correlates of the timing of first birth vary across these data sources by comparing samples of women who were eligible to be included in more than one study. Results obtained from Ordinary Least Squares (OLS) and logistic regression analyses of several measures of timing indicate few study effects. Thus findings based on data from one survey can be replicated with comparable data from another. One notable exception is the relationship between contraceptive use prior to the first birth and the timing of that birth. The contraceptive variable appears to be poorly measured, leading to unstable estimates of the relationship. In general, our results suggest: (1) the feasibility of pooling data from the various surveys when modeling delayed childbearing; and (2) reasonable accuracy in assessing trends in the timing of first birth from multiple data sources. [ABSTRACT FROM AUTHOR]

It is difficult to obtain direct empirical estimates of chronic disease prevalence in the U.S. population. The available estimates are usually derived from epidemiological studies of selected populations. In this paper we present strategies for estimating morbidity distributions in the national population using auxiliary biomedical evidence and theory to estimate transitions to morbidity states from a cohort mortality time series. We present computational methods which employ these estimates of morbid state transitions to produce life table functions for both primary (morbidity) and secondary (mortality) decrements. These methods are illustrated using data on stomach cancer mortality for nine white male cohorts, aged 30 to 70 in 1950, observed for a 28-year period (1950 to 1977). [ABSTRACT FROM AUTHOR]

Recognizing that postwar trends in family size derive both from changes in the living arrangements of adults and from changes in the presence of children, this paper develops annual estimates of mean family size, mean members less than 18, and mean members 18 and older by race, by family type, and by age of head. Group differences in the course and source of changes in family size are evident as anticipated on the basis of group differences in family structure, economic resources and life cycle stage. [ABSTRACT FROM AUTHOR]

The proportional hazards life table is a recently developed approach to the analysis of survival data when mortality risks vary among individuals. It assumes that at a given age (or duration since the start of a life) the force of mortality is a constant (specific to that age) multiplied by a proportionality factor which is determined by the characteristics of the individual and does not change unless these covariates do. In this paper, the method is reviewed for the case where the covariates are fixed at the start of the lifetime and illustrated by an application to marital dissolution in the United States. [ABSTRACT FROM AUTHOR]

Objectives: Oxidative stress level takes part in the development of cognitive decline. However, the association between total antioxidant capacity (TAC) from diet and cognitive function is controversial. The aim of this study was to investigate the relationship between TAC and the cognitive function of older adults in the U.S. Design: A cross-sectional study. Setting: National Health and Nutrition Examination Surveys database. Participants: 2712 older adults aged over 60 years. Measurements: TAC was calculated from 8 antioxidative vitamins based on the reference values for vitamin C equivalent antioxidant capacity obtained from individuals' 24 h dietary recall. Four memory-related assessments were employed [Immediate Recall test (IRT), Delayed Recall test (DRT), Animal Fluency test (AFT), and Digit Symbol Substitution test (DSST)]. Results: Among the 2712 participants, the median age was 68 years, and 50.4% were women. Participants in the group with higher TAC levels had relatively higher IRT, AFT and DSST scores (P=0.025, P=0.008, P<0.001, respectively). In adjusted weighted linear regression, log-transformed TAC was positively associated with AFT (β=1.10, 95%CI: 0.51, 1.70) and DSST (β=2.81, 95%CI: 1.16, 4.45). Compared with the first quartile, the participants in the second (Q2 vs. Q1, OR=0.66, 95%CI: 0.43,1.02) and fourth quartile (Q4 vs. Q1, OR=0.47, 95%CI:0.28, 0.78) of log-transformed TAC showed a decreased risk of impaired cognitive function (ICF) after adjusting for confounders. The dose-response analysis indicated a gradual descent in the risk of ICF as TAC increases. Diabetes mellitus (DM) mediated part of the effect of TAC on ICF. The relationship between TAC and ICF was more pronounced in subjects with DM (Q4 vs Q1, OR=0.36, 95%CI:0.17, 0.74). Conclusion: Our findings support that higher dietary antioxidant potential was related to a decreased risk of cognitive dysfunction, particularly in the subjects with DM who may have oxidative injury. DM was one of the factors mediating the effect of TAC on ICF. [ABSTRACT FROM AUTHOR]

Background: Aspirations refer to wishes, ways of defining quality of life (QOL), and life goals. Living with chronic illness likely impacts a person's life aspirations. Duchenne Muscular Dystrophy (DMD) is an inherited disorder characterized by the inevitable and progressive loss of ambulation and independence. The present cross-sectional case–control study investigated how aspirations differed between people with DMD and a stratified comparison group of nationally representative children/adults. Methods: A web-based survey was administered October through December 2020. Recruitment was stratified by age group: 8–12, 13–17, and > = 18, reflecting the DMD disability trajectory. Aspirations were measured using qualitative (open-ended) and quantitative (closed-ended) questions. Qualitative prompts asked participants about wishes, how they would define "QOL"; and goals; answers to the prompts were then coded by six trained raters. Quantitative questions included 29 closed-ended goal-delineation items from the QOL Appraisal Profilev2. These data were analyzed using multivariate models adjusting for propensity scores (demographic differences), and testing for the effects of role (patient or comparison), age, and role-by-age interactions. Results: The study sample of DMD (n = 285) and comparison (n = 292) participants provided open-text data: 577 wishes statements, 283 QOL-definition statements, and 149 goals statements. Inter-rater reliability (kappa = 0.77) reflected good agreement between different raters' codes. Results suggested that people with DMD have aspirations that differ from their peers in several important ways. Both open-text and closed-ended data in both unadjusted and adjusted analyses generally showed that people with DMD were more focused on intrinsic aspirations such as health, healthcare, and independence than their peers. Compared to non-DMD persons, DMD individuals were much less focused on financial or housing concerns, community contributions, or spiritual growth. With age, patients' aspirations focused less on extrinsic aspirations such as careers and work and increasingly emphasized emotion-oriented goals. Patients were markedly less likely to give a direct answer to the open-ended goals question. Conclusion: There were important differences in aspirations between people with DMD and their peers. These findings may be helpful for developing psychosocial interventions. [ABSTRACT FROM AUTHOR]

Background: Many older adults in the U.S. do not receive appropriate colorectal cancer (CRC) screening. Although primary care physicians' recommendations to their patients are central to the screening process, little information is available about their recommendations in relation to guidelines for the menu of CRC screening modalities, including fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), colonoscopy, and double contrast barium enema (DCBE). The objective of this study was to explore potentially modifiable physician and practice factors associated with guideline-consistent recommendations for the menu of CRC screening modalities.Methods: We examined data from a nationally representative sample of 1266 physicians in the U.S. surveyed in 2007. The survey included questions about physician and practice characteristics, perceptions about screening, and recommendations for age of initiation and screening interval for FOBT, FS, colonoscopy and DCBE in average risk adults. Physicians' screening recommendations were classified as guideline consistent for all, some, or none of the CRC screening modalities recommended. Analyses used descriptive statistics and polytomous logit regression models.Results: Few (19.1%; 95% CI:16.9%, 21.5%) physicians made guideline-consistent recommendations across all CRC screening modalities that they recommended. In multivariate analysis, younger physician age, board certification, north central geographic region, single specialty or multi-specialty practice type, fewer patients per week, higher number of recommended modalities, use of electronic medical records, greater influence of patient preferences for screening, and published clinical evidence were associated with guideline-consistent screening recommendations (p < 0.05).Conclusions: Physicians' CRC screening recommendations reflect both overuse and underuse, and few made guideline-consistent CRC screening recommendations across all modalities they recommended. Interventions that focus on potentially modifiable physician and practice factors that influence overuse and underuse and address the menu of recommended screening modalities will be important for improving screening practice. [ABSTRACT FROM AUTHOR]

In this article, I make the case for using an integrative approach to health, broadly defined as social, emotional, mental, and physical well-being; for studying health among the young as an important marker for future health and well-being across the life course; and for understanding health disparities among the young as both causes and consequences of social stratification. An integrative approach bridges biomedical sciences with social and behavioral sciences by understanding the linkages between social, behavioral, psychological, and biological factors in health. It is furthermore vital that integration occur in all steps of the research process: in theory, design, data collection, and analysis. I use the National Longitudinal Study of Adolescent Health, or Add Health, as an example of an integrative approach to health and of the importance of adolescence and the transition to adulthood years for setting health trajectories into adulthood. Evidence is also presented on the linkages between health trajectories during adolescence and the transition to adulthood and social stratification in adulthood. [ABSTRACT FROM AUTHOR]

Background: Concerns exist about the ability of safety net health care organizations to participate in US health care reform. Primary care practices are key to several efforts, but little is known about how capabilities of primary care practices serving a high share of disadvantaged patients compare to other practices.Objective: To assess capabilities around access to and quality of care among primary care practices serving a high share of Medicaid and uninsured patients compared to practices serving a low share of these patients.Design: We analyzed data from the National Survey of Healthcare Organizations and Systems (response rate 46.8%), conducted 2017-2018.Participants: A total of 2190 medical practices with at least three adult primary care physicians.Main Measures: Our key exposures are payer mix and federally qualified health center (FQHC) designation. We classified practices as safety net if they reported a combined total of at least 25% of annual revenue from uninsured or Medicaid patients; we then further classified safety net practices into those that identified as an FQHC and those that did not.Key Results: FQHCs were more likely than other safety net practices and non-safety net practices to offer early or late appointments (79%, 55%, 62%; p=0.001) and weekend appointments (56%, 39%, 42%; p=0.03). FQHCs more often provided medication-assisted treatment for opioid use disorders (43%, 27%, 25%; p=0.004) and behavioral health services (82%, 50%, 36%; p<0.001). FQHCs were more likely to screen patients for social and financial needs. However, FQHCs and other safety net providers had more limited electronic health record (EHR) capabilities (61%, 71%, 80%; p<0.001).Conclusion: FQHCs were more likely than other types of primary care practices (both safety net practices and other practices) to possess capabilities related to access and quality. However, safety net practices were less likely than non-safety net practices to possess health information technology capabilities. [ABSTRACT FROM AUTHOR]

I estimate the frequencies of interracial kin relations, an important indicator of the isolation of racial groups in the United States. I use two techniques to estimate the size and heterogeneity of extended families. First, I develop a simple model that takes account only of kinship network sizes and intermarriage levels by race. This model allows a crude estimation of the frequency of multiracial kinship networks. Second, I produce more precise empirical estimates using a new hot-deck imputation method for synthesizing kinship networks from household-level survey data (the June 1990 Current Population Survey and the 1994 General Social Survey). One in seven whites, one in three blacks, four in five Asians, and more than 19 in 20 American Indians are closely related to someone of a different racial group. Despite an intermarriage rate of about 1%, about 20% of Americans count someone from a different racial group among their kin. [ABSTRACT FROM AUTHOR]

Background: While health-related social needs (HRSN) are known to compromise health, work to date has not clearly demonstrated the relationship between clinically acknowledged social needs, via ICD-10 Z-codes, and readmission.Objective: Assess the rate of 30-, 60-, and 90-day readmission by the level of ICD-10-identified social need. In addition, we examined the associations between demographics, social need, hospital characteristics, and comorbidities on 30-day readmission.Design: Retrospective study using the 2017 Nationwide Readmission Database PARTICIPANTS: We identified 5 domains of HRSN from ICD-10 diagnosis codes including employment, family, housing, psychosocial, and socioeconomic status (SES) and identified how many and which an individual was coded with during the year.Main Measures: The proportion of patients with 30-, 60-, and 90-day readmission stratified by the number of HRSN domains with a multivariable logistic regression to examine the relationship between the number/type of and readmission adjusting for sex, age, payer, hospital characteristics, functional limitations, and comorbidities.Key Results: From 13,217,506 patients, only 2.4% had at least one HRSN diagnosis. Among patients without HRSN, 11.5% had a 30-day readmission, compared to 27.0% of those with 1 domain, increasing to 63.5% for patients with codes in 5 domains. Similar trends were observed for 60- and 90-day readmission; 78.7% of patients with documented HRSN in all 5 domains were hospitalized again within 90 days. The adjusted odds ratio for readmission for individuals with all 5 domains was 12.55 (95% CI: 9.04, 17.43). Housing and employment emerged as two of the most commonly documented HRSN, as well as having the largest adjusted odds ratio.Conclusions: There is a dose-response relationship between the number of HRSN diagnoses and hospital readmission. This work calls attention to the need to develop interventions to reduce readmissions for those at social risk and demonstrates the significance of ICD-10 Z-codes in health outcomes studies. [ABSTRACT FROM AUTHOR]

A new interpretation of mathematical formulas developed by Keyfitz illustrates how the concept of entropy (H) can be applied to the analysis of marriage dissolution. The quantities H(divorce) and H(widowhood) indicate the changes in marriage duration which would result from small, constant changes in duration-specific divorce and widowhood rates, respectively. An examination of values for the United States, Nepal and Colombia illustrates the utility of H(i) in assessing the impact of changes in widowhood and divorce and clarifies the relationship between H and changes in life expectancy. [ABSTRACT FROM AUTHOR]

Urban scholars and planners look to evidence of recent gains in the number of nontraditional households as a potential source of increase to the population sizes and tax bases of declining central cities. While it is now well established that substantial gains in the numbers of small, nontraditional households have occurred since the 1950s, it has not been demonstrated that: (a) these households are more likely to relocate in the city than traditional family households (husband-wife with children under 18); or (b) their cityward relocation patterns will significantly alter trends toward smaller city household populations. This paper addresses these questions by examining changes in city-suburb migration stream rates by household type over periods 1955-60, 1965-70 and 1970-75 for large metropolitan areas, and assesses their implications for potential changes in the aggregate sizes of city household populations. [ABSTRACT FROM AUTHOR]

Accurately describing treatment effects using plain language and narrative statements is a critical step in communicating research findings to end users. However, the process of developing these narratives has not been historically guided by a specific framework. The Agency for Healthcare Research and Quality Evidence-based Practice Center Program developed guidance for narrative summaries of treatment effects that identifies five constructs. We explicitly identify these constructs to facilitate developing narrative statements: (1) direction of effect, (2) size of effect, (3) clinical importance, (4) statistical significance, and (5) strength or certainty of evidence. These constructs clearly overlap. It may not always be feasible to address all five constructs. Based on context and intended audience, investigators can determine which constructs will be most important to address in narrative statements. [ABSTRACT FROM AUTHOR]

Background: The Agency for Healthcare Research and Quality (AHRQ) could devote resources to collate and assess quality improvement studies to support learning health systems (LHS) but there is no reliable data on the consistency of data extraction for important criteria.Methods: We identified quality improvement studies and evaluated the consistency of data extraction from two experienced independent reviewers at three time points: baseline, first revision (where explicit instructions for each criterion were created), and final revision (where the instructions were revised). Six investigators looked at the data extracted by the two systematic reviewers and determined the extent of similarity on a scale of 0 to 10 (where 0 represented no similarity and 10 perfect similarity). There were 42 assessments for baseline, 42 assessments for the first revision, and 42 assessments for the final revision. We asked two LHS participants to assess the relative value of our criteria.Results: The consistency of extraction improved from 1.17 ± 1.85 at baseline to 6.07 ± 2.76 after revision 1 (P < 0.001) and to 6.81 ± 1.94 out of 10 for the final revision (P < 0.001). However, the final revision was not significantly improved over the first revision (P = 0.14). One key informant rated the difficulty in finding and using quality improvement studies a 6 (moderately difficult) while the other a 4 (moderately difficult). When asked how valuable it would be if AHRQ found and collated the demographic information about the health systems and the interventions used in published quality improvement studies, they rated it a 9 (highly valuable) and a 6 (moderately valuable).Conclusion: Creating explicit instructions for extracting data for quality improvement studies helps enhance the consistency of data extraction. This is important because it is difficult for LHS to vet these quality improvement studies on their own and they would value AHRQ's support in that regard. [ABSTRACT FROM AUTHOR]

Background: Narrow definitions of long-term opioid (LTO) use result in limited knowledge of the full range of LTO prescribing patterns and the rates of these patterns.Objective: To investigate a model of new LTO prescribing typologies using latent class analysis.Design: National administrative data from the VA Corporate Data Warehouse were accessed using the VA Informatics and Computing Infrastructure. Characterization of the typology of initial LTO prescribing was explored using latent class analysis.Participants: Veterans initiating LTO during 2016 through the Veteran's Administration Healthcare System (N = 42,230).Main Measures: Opioid receipt as determined by VA prescription data, using the cabinet supply methodology.Key Results: Over one-quarter (27.7%) of the sample fell into the fragmented new long-term prescribing category, 39.8% were characterized by uniform daily new LTO, and the remaining 32.7% were characterized by uniform episodic LTO. Each of these three broad sub-groups also included two additional sub-groups (6 classes total in the model), characterized by the presence or absence of prior opioid prescriptions.Conclusions: New LTO prescribing in the VA includes uniform daily prescribing, uniform episodic prescribing, and fragmented prescribing. Future work is needed to elucidate the safety and efficacy of these prescribing patterns. [ABSTRACT FROM AUTHOR]

Background: Adaptation of a patient-reported outcomes survey into a new language requires careful translation procedures as well as qualitative and quantitative psychometric testing. This study aimed to evaluate the basic psychometric properties of the new Saudi Arabian SF-36v2 and establish norm data for Saudi Arabia. Methods: Translation and adaptation of the SF-36v2 used standard methodology. Psychometric validation included two stages: 1) A qualitative study (n = 100) explored the components of health and health-related quality of life considered important in Saudi Arabia and evaluated the content validity of the SF-36v2 in Saudi Arabia, and 2) A quantitative study (n = 6166) evaluated the basic psychometric properties of the Saudi SF-36v2 and established norm data for Saudi Arabia. Comparison with US general population data (n = 4040) evaluated differential item function (DIF) and cross-national differences. Results: The qualitative study supported the content validity of the Saudi SF-36v2. Cognitive debriefing identified only few and minor problems. Psychometric analyses supported item convergence within scales and differentiation across scales of the SF-36v2. Scale level exploratory factor analyses did not support the typical distinction between physical health and mental health components. Internal consistency reliability was satisfactory for all scales except the social function scale (alpha = 0.67). Cross-national DIF was identified for 9 items. In the Saudi general population, the average vitality score was lower for women (− 2.71 points) compared to men. For men, older age groups scored lower on the physical function scale (− 3.31) and the physical health component (− 3.06). For women, older age groups scored lower on the role physical (− 3.72), bodily pain (− 3.66), and vitality (− 2.32) scales as well as the physical health component (− 3.52). Compared to the 2009 United States general population, and after adjusting for age, gender, and differential item function, persons in Saudi Arabia had lower average scores for the physical function (− 3.10), role physical (− 4.75), social function (− 4.23), role emotional (− 5.67), and mental health (− 4.82) scales, as well as the mental health component (− 4.57). Conclusion: This Saudi normative study of patient reported outcomes supported the validity and reliability of the new Saudi SF-36v2 and found cross-national differences with the USA. [ABSTRACT FROM AUTHOR]

Background: On July 1, 2018, the Veterans Health Administration (VA) National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI). Its goal is to identify, document, and honor LST decisions of seriously ill veterans. Providers document veterans' goals and decisions using a standardized LST template and order set.Objective: Evaluate the first 7 months of LSTDI implementation and identify predictors of LST template completion.Design: Retrospective observational study of clinical and administrative data. We identified all completed LST templates, defined as completion of four required template fields. Templates also include four non-required fields. Results were stratified by risk of hospitalization or death as estimated by the Care Assessment Need (CAN) score.Subjects: All veterans with VA utilization between July 1, 2018, and January 31, 2019.Main Measures: Completed LST templates, goals and LST preferences, and predictors of documentation.Results: LST templates were documented for 108,145 veterans, and 85% had one or more of the non-required fields completed in addition to the required fields. Approximately half documented a preference for cardiopulmonary resuscitation. Among those who documented specific goals, half wanted to improve or maintain function, independence, and quality of life while 28% had a goal of life prolongation irrespective of risk of hospitalization/death and 45% expressed a goal of comfort. Only 7% expressed a goal of being cured. Predictors of documentation included VA nursing home residence, older age, frailty, and comorbidity, while non-Caucasian race, rural residence, and receipt of care in a lower complexity medical center were predictive of no documentation.Conclusions: LST decisions were documented for veterans at high risk of hospitalization or death. While few expressed a preference for cure, half desire, cardiopulmonary resuscitation. Predictors of documentation were generally consistent with existing literature. Opportunities to reduce observed disparities exist by leveraging available VA resources and programs. [ABSTRACT FROM AUTHOR]

Approximately 1000 people are killed by police acting in the line of duty each year. Historically, research on these deaths, known as legal intervention homicides (LIH), has been limited by data that is either contextually rich but narrow in scope and not readily available to the public (e.g., police department reports from a single city), or detail-poor but geographically broad, large, and readily available (and maintained by federal agencies) (e.g., vital statistics and supplemental homicide reports). Over the past 5 years, however, researchers have turned to the National Violent Death Reporting System (NVDRS), which captures nearly all lethal police shootings in participating states while providing detailed incident and victim information. The current study extends prior work on police-involved lethal shootings in three important ways. First, we use latent class analysis to construct a data-driven, exhaustive, mutually exclusive typology of these events, using NVDRS data 2014-2015. Second, rather than fitting some, but not all cases into predefined sub-types, every case is assigned membership to a particular emergent class. Third, we use a validated case identification process in NVDRS to identify incidents of lethal police-involved shootings. Seven classes emerge. Classes differ across important incident and victim characteristics such as the event that brought the victim and law enforcement together, the highest level of force used by the victim against law enforcement, and the kind of weapon, if any, used by the victim during the incident. Demographic variables do not distribute uniformly across classes (e.g., the latent class in which the victim appeared to pose minimal threat to law enforcement was the only class in which the plurality of victims was a non-white race). Our approach to generating these typologies illustrates how data-driven techniques can complement subjective classification schemes and lay the groundwork for analogous analyses using police encounter data that include fatal and non-fatal outcomes. [ABSTRACT FROM AUTHOR]

Purpose: Current US health policy discussions regarding physician burnout have largely been informed by studies employing the Maslach Burnout Inventory (MBI); yet, there is little in the literature focused on interpreting MBI scores. We described the burnout symptoms and precision associated with MBI scores in US physicians. Methods: Using item response theory (IRT) analyses of secondary, cross-sectional survey data, we created response profiles describing the probability of burnout symptoms associated with US physicians' MBI emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) subscale scores. Response profiles were mapped to raw subscale scores and used to predict symptom endorsements at mean scores and commonly used cut-points. Results: The average US physician was likely to endorse feeling he/she is emotionally drained, used up, frustrated, and working too hard and all PA indicators once weekly or more but was unlikely to endorse feeling any DP symptoms once weekly or more. At the commonly used EE and DP cut-points of 27 and 10, respectively, a physician was unlikely to endorse feeling burned out or any DP symptoms once weekly or more. Each subscale assessed the majority of sample score ranges with ≥ 0.70 reliability. Conclusions: We produced a crosswalk mapping raw MBI subscale scores to scaled scores and response profiles calibrated in a US physician sample. Our results can be used to better understand the meaning and precision of MBI scores in US physicians; compare individual/group MBI scores against a reference population of US physicians; and inform the selection of subscale cut-points for defining categorical physician burnout outcomes. [ABSTRACT FROM AUTHOR]

Background: Heterogeneity of existing physician burnout studies impairs analyses of longitudinal trends, geographic distribution, and organizational factors impacting physician burnout. The Department of Veterans Affairs (VA) is one of the largest integrated healthcare systems in the USA, offering a unique opportunity to study burnout across VA sites and time.Objective: To characterize longitudinal burnout trends of VA physicians and assess organizational characteristics and geographic distribution associated with physician burnout.Design: Longitudinal study of the VA All Employee Survey during 2013-2017.Participants: Self-identified physicians practicing in one of nine clinical service areas at 140 VA sites nationwide.Main Measures: We identified burnout using a validated definition adapted from the Maslach Burnout Inventory and characterized burnout trends for physicians in different clinical service areas. We used clustering analysis to categorize sites based on their burnout rates over time, and compared organizational characteristics and geographic distribution of high, medium, and low burnout categories.Key Results: We identified 40,382 physician responses from 140 VA sites. Mean burnout rates across all physicians ranged from 34.3% in 2013 to a high of 39.0% in 2014. Primary care physicians had the highest burnout. High burnout sites were more likely to be rural and non-teaching, have lower complexity (i.e., offer fewer advanced clinical services), and have fewer unique patients per site.Conclusions: VA physician burnout was lower than previously described in many non-VA studies and was relatively stable over time. These findings may be due to unique characteristics of the VA practice environment. Nonetheless, with over a third of VA physicians reporting burnout, organizational interventions are needed. Primary care physicians and those practicing at small, rural sites have higher rates of burnout and may warrant more focused attention. Our results can guide targeted interventions to promote VA physician well-being and inform efforts to address burnout in diverse clinical settings. [ABSTRACT FROM AUTHOR]

Background: Short-term health care costs following completion of health risk assessments and coaching programs in the VA have not been assessed.Objective: To compare VA health care expenditures among veterans who participated in a behavioral intervention trial that randomized patients to complete a HRA followed by health coaching (HRA + coaching) or to complete the HRA without coaching (HRA-alone).Design: Four-hundred seventeen veterans at three Veterans Affairs (VA) Medical Centers or Clinics were randomized to HRA + coaching or HRA-alone. Veterans randomized to HRA-alone (n = 209) were encouraged to discuss HRA results with their primary care team, while veterans randomized to HRA + coaching (n = 208) received two brief telephone-delivered health coaching calls.Participants: We included 411 veterans with available cost data.Main Measures: Total VA health expenditures 6 months following trial enrollment were estimated using a generalized linear model with a gamma distribution and log link function. In exploratory analysis, model-based recursive partitioning was used to determine whether the intervention effect on short-term costs differed among any patient subgroups.Key Results: Most participants were male (85%); mean age was 56, and mean body mass index was 34. From the generalized linear model, 6-month estimated mean total VA expenditures were similar ($8665 for HRA + coaching vs $9900 for HRA-alone, p = 0.25). In exploratory subgroup analysis, among unemployed veterans with good sleep and fair or poor perceived health, mean observed expenditures in the HRA + coaching group were higher than in the HRA-alone group ($12,814 vs $7971). Among unemployed veterans with good sleep and good general health, mean observed expenditures in the HRA + coaching group were lower than in the HRA-alone group ($5082 vs $11,612).Conclusions: Compared to completing and receiving HRA results, working with health coaches to set actionable health behavior change goals following HRA completion did not reduce short-term health expenditures.Trial Registration: Clinicaltrials.gov identifier: NCT01828567. [ABSTRACT FROM AUTHOR]

Background: Little is known about the frequency, patterns, and determinants of readmissions among patients initially hospitalized for an ambulatory care-sensitive condition (ACSC). The degree to which hospitalizations in close temporal proximity cluster has also not been studied. Readmission patterns involving clustering likely reflect different underlying determinants than the same number of readmissions more evenly spaced.Objective: To characterize readmission rates, patterns, and predictors among patients initially hospitalized with an ACSC.Design: Retrospective analysis of the 2010-2014 Nationwide Readmissions Database.Participants: Non-pregnant patients aged 18-64 years old during initial ACSC hospitalization and who were discharged alive (N = 5,007,820).Main Measures: Frequency and pattern of 30-day all-cause readmissions, grouped as 0, 1, 2+ non-clustered, and 2+ clustered readmissions.Key Results: Approximately 14% of patients had 1 readmission, 2.4% had 2+ non-clustered readmissions, and 3.3% patients had 2+ clustered readmissions during the 270-day follow-up. A higher Elixhauser Comorbidity Index was associated with increased risk for all readmission groups, namely with adjusted odds ratios (AORs) ranging from 1.12 to 3.34. Compared to patients aged 80 years and older, those in younger age groups had increased risk of 2+ non-clustered and 2+ clustered readmissions (AOR range 1.27-2.49). Patients with chronic versus acute ACSCs had an increased odds ratio of all readmission groups compared to those with 0 readmissions (AOR range 1.37-2.69).Conclusions: Among patients with 2+ 30-day readmissions, factors were differentially distributed between clustered and non-clustered readmissions. Identifying factors that could predict future readmission patterns can inform primary care in the prevention of readmissions following ACSC-related hospitalizations. [ABSTRACT FROM AUTHOR]

Background: Post-traumatic stress disorder (PTSD) can be exacerbated by subsequent trauma, but it is unclear if symptoms are worsened by impending death. PTSD symptoms, including hyperarousal, negative mood and thoughts, and traumatic re-experiencing, can impact end-of-life symptoms, including pain, mood, and poor sleep. Thus, increased symptoms may lead to increased end-of-life healthcare utilization.Objectives: To determine if veterans with PTSD have increased end-of-life healthcare utilization or medication use and to examine predictors of medication administration.Design: Secondary analysis of a stepped-wedge design implementation trial to improve end-of-life care for Veterans Affairs (VA) inpatients. Outcome variables were collected via direct chart review. Analyses included hierarchical, generalized estimating equation models, clustered by medical center.Subjects: Veterans, inpatient at one of six VA facilities, dying between 2005 and 2011.Main Measures: Emergency room (ER) visits, hospitalizations, and medication administration in the last 7 days of life.Key Results: Of 5341 veterans, 468 (8.76%) had PTSD. Of those, 21.4% (100/468) had major depression and 36.5% (171/468) had anxiety. Veterans with PTSD were younger (mean age 65.4 PTSD, 70.5 no PTSD, p < 0.0001) and had more VA hospitalizations and ER visits in the last 12 months of life (admissions: PTSD 2.8, no PTSD 2.4, p < 0.0001; ER visits: 3.2 vs 2.5, p < 0.0001). PTSD was associated with antipsychotic administration (OR 1.52, 95% CI 1.06-2.18). Major depression (333/5341, 6.2%) was associated with opioid administration (OR 1.348, 95% CI 1.129-1.609) and benzodiazepines (OR 1.489, 95% CI 1.141-1.943). Anxiety disorders (778/5341, 14.6%) were only associated with benzodiazepines (OR 1.598, 95% CI 1.194-2.138).Conclusions: PTSD's association with increased end-of-life healthcare utilization and increased antipsychotic administration in the final days of life suggests increased symptom burden and potential for terminal delirium in individuals with PTSD. Understanding the burden of psychiatric illness and potential risks for delirium may facilitate the end-of-life care for these patients.Trial Registration: NCT00234286. [ABSTRACT FROM AUTHOR]

Background: Shared decision-making (SDM) is widely recommended and required by the Centers for Medicare and Medicaid for patients considering lung cancer screening (LCS).Objective: We examined clinicians' communication practices and perceived barriers of SDM for LCS at three medical centers with established screening programs.Design: Multicenter qualitative study of clinicians participating in LCS.Approach: We performed semi-structured interviews, which were transcribed and analyzed using directed content analysis, guided by a theoretical model of patient-clinician communication.Participants: We interviewed 24 clinicians including LCS coordinators (2), pulmonologists (3), and primary care providers (17), 4 of whom worked for the LCS program, a thoracic surgeon, and a radiologist.Results: All clinicians agreed with the goal of SDM, to ensure the screening decision was congruent with the patient's values. The depth and type of information presented by each clinician role varied considerably. LCS coordinators presented detailed information including numeric estimates of benefit and harm. Most PCPs explained the process more generally, focusing on logistics and the high rate of nodule detection. No clinician explicitly elicited values or communication preferences. Many PCPs tailored the conversation based on their implicit understanding of patients' values and preferences, gained from past experiences. PCPs reported that time, lack of detailed personal knowledge of LCS, and patient preferences were barriers to SDM. Many clinicians perceived that a significant proportion of patients were not interested in specific percentages and preferred to receive a clinician recommendation.Conclusions: Our results suggest that clinicians support the goal of SDM for LCS decisions but PCPs may not perform some of its elements. The lack of completion of some elements, such as PCPs' lack of in-depth information exchange, may reflect perceived patient preferences for communication. As LCS is implemented, further research is needed to support a personalized, patient-centered approach to produce better outcomes. [ABSTRACT FROM AUTHOR]

Background: The Veterans Health Administration (VHA) has a long history of addressing social determinants of health, including housing. In 2012, the VA integrated a two-question Homelessness Screening Clinical Reminder (HSCR) into the electronic medical record in outpatient clinics to identify Veterans experiencing housing instability and ensure referral to appropriate services.Objective: This study explores perspectives of VA clinical providers regarding administration of the HSCR, their role in addressing housing status, and how a patient's housing status impacts clinical decision-making.Design: We conducted a qualitative study using in-depth semi-structured interviewing.Participants: Twenty-two providers were interviewed (20 physicians and two nurse practitioners) between March and September 2016.Approach: Interviews were conducted with Veterans Health Administration (VHA) physician and non-physician practitioners who had administered the HSCR and documented at least five positive screens between 2013 and 2015. Our interview guide investigated provider experiences with administering the HSCR and addressing affirmative responses. The guide also elicited details about how patients' housing instability was identified (if at all) prior to implementation of the screening reminder, and how practices changed following implementation of the HSCR. Transcripts were analyzed using a modified grounded theory approach.Key Results: Providers reported that the HSCR prompted them to incorporate patient housing status into routine assessment, which they typically did not do prior to its implementation. Providers discussed adverse impacts of housing instability on patients' overall health and described how they factored patients' housing instability into clinical decision-making. Although providers viewed the health system as having an important role in addressing housing concerns, there were mixed opinions on whether it was the role of providers to directly administer the screening.Conclusions: Integration of a screener for housing instability into the electronic medical record increased provider attention to housing instability into the social history, and positive responses commonly impacted plans of care. [ABSTRACT FROM AUTHOR]

Background: Transitions of care are high risk for vulnerable populations such as rural Veterans, and adequate care coordination can alleviate many risks. Single-center care coordination programs have shown promise in improving transitional care practices. However, best practices for implementing effective transitional care interventions are unknown, and a common pitfall is lack of understanding of the current process at different sites. The rural Transitions Nurse Program (TNP) is a Veterans Health Administration (VA) intervention that addresses the unique transitional care coordination needs of rural Veterans, and it is currently being implemented in five VA facilities.Objective: We sought to employ and study process mapping as a tool for assessing site context prior to implementation of TNP, a new care coordination program.Design and Participants: Observational qualitative study guided by the Lean Six Sigma approach. Data were collected in January-March 2017 through interviews, direct observations, and group sessions with front-line staff, including VA providers, nurses, and administrative staff from five VA Medical Centers and nine rural Patient-Aligned Care Teams.Key Results: We integrated key informant interviews, observational data, and group sessions to create ten process maps depicting the care coordination process prior to TNP implementation at each expansion site. These maps were used to adapt implementation through informing the unique role of the Transitions Nurse at each site and will be used in evaluating the program, which is essential to understanding the program's impact.Conclusions: Process mapping can be a valuable and practical approach to accurately assess site processes before implementation of care coordination programs in complex systems. The process mapping activities were useful in engaging the local staff and simultaneously guided adaptations to the TNP intervention to meet local needs. Our approach-combining multiple data sources while adapting Lean Six Sigma principles into practical use-may be generalizable to other care coordination programs. [ABSTRACT FROM AUTHOR]

Objective: Understanding how to successfully implement care coordination programs across diverse settings is critical for disseminating best practices. We describe how we operationalized the Practical Robust Implementation and Sustainability Model (PRISM) to guide the assessment of local context prior to implementation of the rural Transitions Nurse Program (TNP) at five facilities across the Veterans Health Administration (VHA).Methods: We operationalized PRISM to create qualitative data collection techniques (interview guides, semi-structured observations, and a group brainwriting premortem) to assess local context, the current state of care coordination, and perceptions of TNP prior to implementation at five facilities. We analyzed data using deductive-inductive framework analysis to identify themes related to PRISM. We adapted implementation strategies at each site using these findings.Results: We identified actionable themes within PRISM domains to address during implementation. The most commonly occurring PRISM domains were "organizational characteristics" and "implementation and sustainability infrastructure." Themes included a disconnect between primary care and hospital inpatient teams, concerns about work duplication, and concerns that one nurse could not meet the demand for the program. These themes informed TNP implementation.Conclusions: The use of PRISM for pre-implementation site assessments yielded important findings that guided adaptations to our implementation approach. Further, barriers and facilitators to TNP implementation may be common to other care coordination interventions. Generating a common language of barriers and facilitators in care coordination initiatives will enhance generalizability and establish best practices.Impact Statements: TNP is a national intensive care coordination program targeting rural Veterans. We operationalized PRISM to guide implementation efforts. We effectively elucidated facilitators, barriers, and unique contextual factors at diverse VHA facilities. The use of PRISM enhances the generalizability of findings across care settings and may optimize implementation of care coordination interventions in the VHA. [ABSTRACT FROM AUTHOR]

Background: Michigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state's economy.Objective: To understand HMP's impact on enrollees' health, ability to work, and ability to seek employment DESIGN: Mixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%) PARTICIPANTS: Non-elderly adult HMP enrollees MAIN MEASURES: Changes in health status, ability to work, and ability to seek employment KEY RESULTS: Half (47.8%) of respondents reported better physical health, 38.2% better mental health, and 39.5% better dental health since HMP enrollment. Among employed respondents, 69.4% reported HMP helped them do a better job at work. Among out-of-work respondents, 54.5% agreed HMP made them better able to look for a job. Among respondents who changed jobs, 36.9% agreed HMP helped them get a better job. In adjusted analyses, improved health was associated with the ability to do a better job at work (aOR 4.08, 95% CI 3.11-5.35, p < 0.001), seek a job (aOR 2.82, 95% CI 1.93-4.10, p < 0.001), and get a better job (aOR 3.20, 95% CI 1.69-6.09, p < 0.001), but not with employment status (aOR 1.08, 95% CI 0.89-1.30, p = 0.44). In interviews, several HMP enrollees attributed their ability to get or maintain employment to improved physical, mental, and dental health because of services covered by HMP. Remaining barriers to work cited by enrollees included older age, disability, illness, and caregiving responsibilities.Conclusions: Many low-income HMP enrollees reported improved health, ability to work, and job seeking after obtaining health insurance through Medicaid expansion. [ABSTRACT FROM AUTHOR]

Background: The impact of back pain on disability in older women is well-understood, but the influence of back pain on mortality is unclear.Objective: To examine whether back pain was associated with all-cause and cause-specific mortality in older women and mediation of this association by disability.Design: Prospective cohort study.Setting: The Study of Osteoporotic Fractures.Participants: Women aged 65 or older.Measurement: Our primary outcome, time to death, was assessed using all-cause and cause-specific adjusted Cox models. We used a four-category back pain exposure (no back pain, non-persistent, infrequent persistent, or frequent persistent back pain) that combined back pain frequency and persistence across baseline (1986-1988) and first follow-up (1989-1990) interviews. Disability measures (limitations of instrumental activities of daily living [IADL], slow chair stand time, and slow walking speed) from 1991 were considered a priori potential mediators.Results: Of 8321 women (mean age 71.5, SD = 5.1), 4975 (56%) died over a median follow-up of 14.1 years. A higher proportion of women with frequent persistent back pain died (65.8%) than those with no back pain (53.5%). In the fully adjusted model, women with frequent persistent back pain had higher hazard of all-cause (hazard ratio [HR] = 1.24 [95% CI, 1.11-1.39]), cardiovascular (HR = 1.34 [CI, 1.12-1.62]), and cancer (HR = 1.33, [CI 1.03-1.71]) mortality. No association with mortality was observed for other back pain categories. In mediation analyses, IADL limitations explained 47% of the effect of persistent frequent back pain on all-cause mortality, slow chair stand time, and walking speed, explained 27% and 24% (all significant, p < 0.001), respectively.Limitations: Only white women were included.Conclusion: Frequent persistent back pain was associated with increased mortality in older women. Much of this association was mediated by disability. [ABSTRACT FROM AUTHOR]

Among the 2041 women in our cohort, 48.0% received at least one screening mammogram during the study period, with screening rate of 60.2% among women with > 10-year-predicted life expectancy and 27.0% among women with < 10-year-predicted life expectancy (Table 1). Participant Characteristics, Screening Mammogram Rates, and Clinician Specialties Associated with Screening Mammogram Referrals Among the 2041 Women Included in the Study. [Extracted from the article]

Although the number of older adults who are arrested and subject to incarceration in jail is rising dramatically, little is known about their emergency department (ED) use or the factors associated with that use. This lack of knowledge impairs the ability to design evidence-based approaches to care that would meet the needs of this population. This 6-month longitudinal study aimed to determine the frequency of 6-month ED use among 101 adults aged 55 or older enrolled while in jail and to identify factors associated with that use. The primary outcome was self-reported emergency department use within 6 months from baseline. Additional measures included baseline socio-demographics, physical and mental health conditions, geriatric factors (e.g., recent falls, incontinence, functional impairment, concern about post-release safety), symptoms (pain and other symptoms), and behavioral and social health risk factors (e.g., substance use disorders, recent homelessness). Chi-square tests were used to identify baseline factors associated with ED use over 6 months. Participants (average age 60) reported high rates of multimorbidity (61%), functional impairment (57%), pain (52%), serious mental illness (44%), recent homelessness (54%), and/or substance use disorders (69%). At 6 months, 46% had visited the ED at least once; 21% visited multiple times. Factors associated with ED use included multimorbidity (p = 0.01), functional impairment (p = 0.02), hepatitis C infection (p = 0.01), a recent fall (p = 0.03), pain (p < 0.001), loneliness (p = 0.04), and safety concerns (p = 0.01). In this population of older adults in a county jail, geriatric conditions and distressing symptoms were common and associated with 6-month community ED use. Jail is an important setting to develop geriatric care paradigms aimed at addressing comorbid medical, functional, and behavioral health needs and symptomatology in an effort to improve care and decrease ED use in the growing population of criminal justice-involved older adults. [ABSTRACT FROM AUTHOR]

Background: Decision makers are increasingly tasked with reducing health care costs, but the public may be mistrustful of these efforts. Public deliberation helps gather input on these types of issues by convening a group of diverse individuals to learn about and discuss values-based dilemmas.Objective: To explore public perceptions of health care costs and how they intersect with medical mistrust.Design and Participants: This mixed-methods study analyzed data from a randomized controlled trial including four public deliberation groups (n = 96) and a control group (n = 348) comprising English-speaking adults aged 18 years and older. Data were collected in 2012 in four U.S. regions.Approach: We used data from four survey items to compare attitude shifts about costs among participants in deliberation groups to participants in the control group. We qualitatively analyzed deliberation transcripts to identify themes related to attitude shifts and to provide context for quantitative results about attitude shifts.Key Results: Deliberation participants were significantly more likely than control group participants to agree that doctors and patients should consider cost when making treatment decisions (β = 0.59; p < 0.01) and that people should consider the effect on group premiums when making treatment decisions (β = 0.48; p < 0.01). Qualitatively, participants mistrusted the health care system's profit motives (e.g., that systems prioritize making money over patient needs); however, after grappling with patient/doctor autonomy and learning about and examining their own views related to costs during the process of deliberation, they largely concluded that payers have the right to set some boundaries to curb costs.Conclusions: Individuals who are informed about costs may be receptive to boundaries that reduce societal health care costs, despite their mistrust of the health care system's profit motives, especially if decision makers communicate their rationale in a transparent manner. Future work should aim to develop transparent policies and practices that earn public trust. [ABSTRACT FROM AUTHOR]

Background: Research using the Veterans Health Administration (VA) electronic medical records (EMR) has been limited by a lack of reliable smoking data.Objective: To evaluate the validity of using VA EMR "Health Factors" data to determine smoking status among veterans with recent military service.Design: Sensitivity, specificity, area under the receiver-operating curve (AUC), and kappa statistics were used to evaluate concordance between VA EMR smoking status and criterion smoking status.Participants: Veterans (N = 2025) with service during the wars in Iraq/Afghanistan who participated in the VA Mid-Atlantic Post-Deployment Mental Health (PDMH) Study.Main Measures: Criterion smoking status was based on self-report during a confidential study visit. VA EMR smoking status was measured by coding health factors data entries (populated during automated clinical reminders) in three ways: based on the most common health factor, the most recent health factor, and the health factor within 12 months of the criterion smoking status data collection date.Key Results: Concordance with PDMH smoking status (current, former, never) was highest when determined by the most commonly observed VA EMR health factor (κ = 0.69) and was not significantly impacted by psychiatric status. Agreement was higher when smoking status was dichotomized: current vs. not current (κ = 0.73; sensitivity = 0.84; specificity = 0.91; AUC = 0.87); ever vs. never (κ = 0.75; sensitivity = 0.85; specificity = 0.90; AUC = 0.87). There were substantial missing Health Factors data when restricting analyses to a 12-month period from the criterion smoking status date. Current smokers had significantly more Health Factors entries compared to never or former smokers.Conclusions: The use of computerized tobacco screening data to determine smoking status is valid and feasible. Results indicating that smokers have significantly more health factors entries than non-smokers suggest that caution is warranted when using the EMR to select cases for cohort studies as the risk for selection bias appears high. [ABSTRACT FROM AUTHOR]

Background/objectives: Evidence regarding the consumption of soy foods and isoflavones in relation to risk of type 2 diabetes (T2D) is scarce. Our study was to evaluate the association between soy food and isoflavone consumption and risk of T2D in US men and women.Subjects/methods: We followed 63 115 women in the Nurses' Health Study (1998-2012), 79 061 women in the Nurses' Health Study II (1999-2013) and 21 281 men in the Health Professionals Follow-Up Study (2002-2010). Diet was assessed by a validated food-frequency questionnaire and was updated every 4 years. Self-reports of incident T2D were confirmed by a validated supplementary questionnaire.Results: During 1 966 321 person-years of follow-up, 9185 incident T2D cases were documented. After multivariate adjustment for covariates, consumption of soy foods (tofu and soy milk) was not associated with a lower T2D risk. Compared with non-consumers of soy foods, the hazard ratio (HR) was 1.00 (95% confidence interval (CI): 0.93, 1.07) for <1 serving/week and 0.93 (95% CI: 0.83, 1.03) for ⩾1 serving/week of soy foods (P for trend=0.14). In contrast, intake of total isoflavones was inversely associated with T2D risk. Comparing extreme quintiles of isoflavones, the HR was 0.89 (95% CI: 0.83, 0.96; P for trend=0.009). Inverse associations were also found for consumption of major individual isoflavones, including daidzein and genistein, with risk of T2D.Conclusions: Intake of isoflavones was associated with a modestly lower T2D risk in US men and women who typically consumed low-to-moderate amounts of soy foods. These findings warrant replications in other populations with similar soy intake levels. [ABSTRACT FROM AUTHOR]

Background: The healthcare system is ill-equipped to meet the needs of adults on the autism spectrum.Objective: Our goal was to use a community-based participatory research (CBPR) approach to develop and evaluate tools to facilitate the primary healthcare of autistic adults.Design: Toolkit development included cognitive interviewing and test-retest reliability studies. Evaluation consisted of a mixed-methods, single-arm pre/post-intervention comparison.Participants: A total of 259 autistic adults and 51 primary care providers (PCPs) residing in the United States.Interventions: The AASPIRE Healthcare toolkit includes the Autism Healthcare Accommodations Tool (AHAT)-a tool that allows patients to create a personalized accommodations report for their PCP-and general healthcare- and autism-related information, worksheets, checklists, and resources for patients and healthcare providers.Main Measures: Satisfaction with patient-provider communication, healthcare self-efficacy, barriers to healthcare, and satisfaction with the toolkit's usability and utility; responses to open-ended questions.Key Results: Preliminary testing of the AHAT demonstrated strong content validity and adequate test-retest stability. Almost all patient participants (>94 %) felt that the AHAT and the toolkit were easy to use, important, and useful. In pre/post-intervention comparisons, the mean number of barriers decreased (from 4.07 to 2.82, p < 0.0001), healthcare self-efficacy increased (from 37.9 to 39.4, p = 0.02), and satisfaction with PCP communication improved (from 30.9 to 32.6, p = 0.03). Patients stated that the toolkit helped clarify their needs, enabled them to self-advocate and prepare for visits more effectively, and positively influenced provider behavior. Most of the PCPs surveyed read the AHAT (97 %), rated it as moderately or very useful (82 %), and would recommend it to other patients (87 %).Conclusions: The CBPR process resulted in a reliable healthcare accommodation tool and a highly accessible healthcare toolkit. Patients and providers indicated that the tools positively impacted healthcare interactions. The toolkit has the potential to reduce barriers to healthcare and improve healthcare self-efficacy and patient-provider communication. [ABSTRACT FROM AUTHOR]