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Background Veterans transitioning to civilian life often have chronic pain from service-related musculoskeletal disorders (MSD) with higher risk for substance misuse. Many seek VA (Department of Veterans Affairs) compensation for MSD. Use of Screening, Brief Intervention, and Referral to Treatment for Pain Management (SBIRT-PM) by VA Post-9/11 Military2VA (M2VA) case managers presents an opportunity to engage these veterans in VA pain care and address substance misuse. Implementation facilitation might help case managers use SBIRT-PM and engage veterans in services to improve outcomes. Design This study is a 2-cohort multisite cluster-randomized hybrid type 2 effectiveness-implementation trial. Within 2 separate cohorts of 14 VA sites each, sites will be allocated to receive an implementation strategy through the use of a constrained randomization procedure: virtual implementation facilitation or training-as-usual. Sites and M2VA case managers will receive the assigned implementation strategy to support use of SBIRT-PM. Recently discharged veterans (n  = 1848) claiming service-connected MSD will be recruited, with case managers blind to veterans' study enrollment. The proportion of participants who receive any SBIRT-PM will be the primary implementation outcome. Veteran participants will complete baseline, 12-week, and 36-week assessments, irrespective of whether case managers conduct SBIRT-PM with them (intent-to-treat). Pain intensity and interference will be the primary clinical outcomes. The study emphasizes pragmatic over explanatory methodological features. Summary This pragmatic trial will examine implementation facilitation versus training-as-usual in implementing SBIRT-PM to promote veteran engagement in nonpharmacological pain services. Using innovative methods to train and support VA case managers in SBIRT-PM, study outcomes could have broad implications for case management systems of care across the VA. [ABSTRACT FROM AUTHOR]

Background: Thousands of health systems have been recognized as "Age‐Friendly" for implementing geriatric care practices aligned with the "4Ms" (What Matters, Medication, Mentation, and Mobility). However, the effect of Age‐Friendly recognition on patient outcomes is largely unknown. We sought to identify this effect in the Veterans Health Administration (VHA)—one of the largest Age‐Friendly integrated health systems in the United States. Methods: There were 50 VA medical centers (VAMCs) recognized as Age‐Friendly by December 2021. We used a time‐event difference‐in‐difference analysis to identify the association of a VAMC's recognition as Age‐Friendly on the change in facility‐free days (days outside the hospital or nursing home) among Veterans treated at that facility. We also evaluated this association in three subgroups: Veterans at particularly high risk of nursing home entry, Veterans who lived within 10 miles of a medical center, and facilities that had reached Level 2 Age‐Friendly recognition. We also evaluated individual components of the endpoint in terms of change in hospital and nursing home days separately. Results: We found Age‐Friendly recognition was associated with small statistically significant improvements in facility‐free days (0.2% on a base of 97% facility‐free days on average per year, or an additional 0.73 days per year on a base of 354 days). There were no differences in any subgroup, or any individual component of the endpoint across all groups. Conclusions: At the individual level, an increase of 0.2% in facility‐free days is a weak effect. However, sites were early in implementation, and facility‐free days may not be a responsive outcome measure. However, across an entire population, small changes in facility‐free days may accrue large cost savings. Future evaluations should consider a broader variety of process and outcome measures. [ABSTRACT FROM AUTHOR]

This paper estimates the medium‐ to long‐run effects of slavery in the United States in a spatial regression discontinuity design. Using the boundary between free and slave states immediately antebellum, we find that legal slavery decreased per capita manufacturing output by as much as 30% in the decades following the Civil War. Perhaps surprisingly, agricultural output and farm values were only briefly depressed in former slave states after the war. Although emancipation ended slavery, political forces kept the institution from being completely disintegrated, and we explore channels through which this was possible. We show that slavery affected the structure of the economy in a given region—specifically through agricultural production decisions—and that these structures persisted long after passage of the 13th Amendment. However, sharecropping played a relatively small role in this region. Our results support mounting evidence in recent literature of the significant and lasting effects of institutions on economic development. [ABSTRACT FROM AUTHOR]