Food Insecurity Among Aging SNAP Participants and Eligible Nonparticipants in Two Predominantly Low-Income Black Neighborhoods: Implications for SNAP Enrollment and Outreach for Older Adults

BACKGROUND

The Supplemental Nutrition Assistance Program (SNAP) plays a critical role in alleviating poverty and food insecurity. Despite these benefits, many older Americans who are eligible for SNAP do not participate in the program. Few studies have explored household factors and food insecurity outcomes associated with nonparticipation among older Black Americans.

OBJECTIVES

The study aim was to explore changes in food insecurity and related financial hardship outcomes between 2020 and 2021 among SNAP participants, eligible nonparticipants, and ineligible nonparticipants; compare reasons for not participating in SNAP; and to compare household factors associated with SNAP nonparticipation.

METHODS

Longitudinal design examining data from 2020 and 2021 to assess changes in food insecurity over the course of the coronavirus disease 2019 pandemic.

PARTICIPANTS/SETTING

Participants were 528 adults (aged 30 to 97 years) in households randomly selected from a listing of all residential addresses in two predominantly Black neighborhoods with lower incomes in Pittsburgh, PA, and surveyed between March to May 2020 and May to December 2021.

MAIN OUTCOME MEASURES

Food security was measured using the validated 6-item US Department of Agriculture Adult Food Security Survey Module.

STATISTICAL ANALYSES PERFORMED

Findings are based on a descriptive analysis of food security and related indicators. Statistical testing was performed to assess differences between SNAP participation status and individual characteristics, food security, and financial hardship using Wald F test for continuous measures and Pearson χ2 test for categorical measures. A multivariable linear model was used to assess the association of SNAP participation and eligibility status with change in food insecurity.

RESULTS

In cross-sectional analyses of 2021 data, no differences were observed between SNAP participants and eligible nonparticipants for food insecurity, food bank use, mean weekly food spending per person, and difficulty paying for basics. However, with respect to changes in food insecurity over the course of the pandemic, SNAP participants experienced a greater improvement in mean food security scores between 2020 and 2021 (-0.52 reduction in mean food insecurity score or a 16% improvement in food security; P ≤ 0.05) relative to SNAP-eligible nonparticipants. Perceived ineligibility (71.3%) and perceived lack of need (23%) were the most common reasons for not participating in SNAP.

CONCLUSIONS

More than one-third of SNAP participants and eligible nonparticipants experienced food insecurity and financial hardship. However, there were differences in the changes in food insecurity between these groups.

Community Investments and Diet-Related Outcomes: A Longitudinal Study of Residents of Two Urban Neighborhoods

INTRODUCTION

Investments in historically oppressed neighborhoods through food retail, housing, and commercial development are hypothesized to improve residents' health, nutrition, and perceptions of their neighborhood as a place to live. Although place-based development (e.g., housing, retail, business assistance) is happening in many communities, there is little evidence of the long-term correlates of multiple investments such as health and nutrition among residents.

METHODS

A quasi-experimental longitudinal study was conducted using a cohort of randomly sampled households in two low-income, predominantly African American neighborhoods in Pittsburgh, PA, with surveys assessing residents' food insecurity, perception of their neighborhood as a place to live, perception of access to healthy foods, and dietary outcomes in 2011 and seven years later (2018), with an interim assessment in 2014. Analyses conducted in 2022 compared changes among residents of one neighborhood which had 2.6 times the investments over a 7-year period with changes among residents of a socio-demographically similar neighborhood that received fewer investments.

RESULTS

It was found that residents in the neighborhood receiving substantial investments demonstrated statistically significant improvements in neighborhood satisfaction (12.6% improvement compared with a 2.2% decrease) and perceived access to healthy food (52% improvement compared with 18.2% improvement), and marginally significant change in food security (14% compared with 4.8% improvement) compared with residents in the neighborhood receiving fewer investments.

CONCLUSIONS

Multiple place-based investments in neighborhoods can potentially induce positive change for residents in health and nutrition outcomes.

Police Bias and Low Relatability and Diet Quality: Examining the Importance of Psychosocial Factors in Predominantly Black Communities

How police bias and low relatability may contribute to poor dietary quality is poorly understood. In this cross-sectional study, we analyzed data from 2021 from a cohort of n = 724 adults living in predominantly Black communities in Pittsburgh, Pennsylvania; these adults were mostly Black (90.6%), low-income (median household income $17,500), and women (79.3%). We estimated direct and indirect paths between police mistrust and dietary quality (measured by Healthy Eating Index (HEI)-2015) through perceived stress, community connectedness, and subjective social status. Dietary quality was poor (mean HEI-2015 score was 50) and mistrust of police was high: 78% of participants either agreed or strongly agreed that something they say might be interpreted as criminal by the police due to their race/ethnicity. Police bias and low relatability was associated with lower perceived social status [Formula: see text]=  - 0.03 (95% confidence interval [CI]: - 0.05, - 0.01). Police bias and low relatability was marginally associated with low dietary quality β =  - 0.14 (95% CI: - 0.29, 0.02). Nineteen percent of the total association between police bias and low relatability and lower dietary quality β =  - 0.16 (- 0.01, - 0.31) was explained by an indirect association through lower community connectedness, or how close respondents felt with their community [Formula: see text] Police bias and low relatability may play a role in community connection, social status, and ultimately dietary disparities for Black Americans. Addressing police bias and low relatability is a continuing and pressing public health issue.

Associations between depression subtype and functional impairment and treatment utilization in a national sample of adolescents

BACKGROUND

Prior studies have characterized distinct major depressive episode (MDE) subtypes among adults, yet limited evidence exists regarding variation in MDE during adolescence.

METHODS

Using 2008-2016 National Survey of Drug Use and Health data, latent class analysis (LCA) was used to characterize depression subtypes (based on symptom presentation) among 9,896 youth ages 12-17 with recent first-onset MDE. Logistic regression was used to estimate associations of MDE subtype with functional outcomes and treatment utilization, adjusting for demographic characteristics and depression severity (i.e., number of MDE diagnostic criteria and recurrence status) RESULTS: A 5-class LCA model provided optimal fit. Three distinct categories of MDE symptoms generally clustered together, which we termed "somatic," "cognitive," and "self-worth;" classes were differentiated by distinct combinations of symptoms across these 3 categories. Subtypes were characterized as: Highly Symptomatic (39% of youth); Somatic & Cognitive (24%), Somatic (22%), Diffuse Symptoms (8%), and Somatic & Self-Worth (6%). The majority of youth reported at least moderate impairment across multiple domains; subtype was a significant predictor of functional impairment. Only 34% of youth received any past-year depression-related treatment; treatment utilization was significantly higher for MDE subtypes with the highest prevalences of suicidal ideation.

LIMITATIONS

Due to cross-sectional data, we cannot establish causal directionality.

CONCLUSIONS

Subtype was significantly predictive of functional impairment and treatment utilization, above and beyond number of MDE diagnostic criteria or recurrence status. Understanding distinct profiles of adolescent depression, as well as potential differential associations with impairment, can inform prevention, diagnosis, and treatment of depression among youth.

Examining contradictory evidence on racial/ethnic differences in perceived need for behavioral health treatment

OBJECTIVES

The study aims to investigate apparently contradictory evidence regarding racial/ethnic differences in perceived need for behavioral health treatment in two prominent surveys of the U.S. population, the National Comorbidity Survey Replication (NCS-R) and the National Survey of Drug Use and Health (NSDUH).

METHODS

The two surveys were compared with respect to two components of perceived need: service use and perceived need among the untreated. Logistic regression models were estimated to adjust comparisons for demographic characteristics. Comparisons were conducted in samples representing the entire population, without selection on a mental health assessment, and for samples meeting criteria for lifetime major depression.

RESULTS

The surveys are concordant with respect to racial/ethnic differences in service use and discordant with respect to perceived need among the untreated. For instance, among untreated individuals, the odds of perceiving a need for treatment are significantly higher in Blacks than Whites in the NCS-R (OR = 1.8, 95% CI [1.1, 2.9]) but do not differ between these groups in the NSDUH (OR = 0.9, 95% CI [0.7, 1.2]). Temporal trends do not appear to explain this discordance.

CONCLUSION

Assessments of racial/ethnic differences in perceived need among untreated individuals are affected by methodological differences across surveys. Resolving contradictory evidence is critical to efforts to reduce racial/ethnic disparities.

Impacts of the Dependent Care Expansion on the Allocation of Mental Health Care

We examine the impact of insurance expansion under the Affordable Care Act's Dependent Care Expansion (DCE) on allocation of mental health care across illness severity, types of care and racial/ethnic groups. Evidence suggests that the increase in mental health care utilization resulting from the DCE was restricted to individuals with clinically significant mental health conditions. There is no evidence suggesting that the increase occurred disproportionately in medication-only treatment or that it increased racial/ethnic disparities. The DCE appears to have been successful in increasing utilization of mental health care among a high need group without lowering quality or increasing disparities.

A population-based examination of trends and disparities in medication treatment for opioid use disorders among Medicaid enrollees

BACKGROUND

Medication treatment (MT) with methadone and buprenorphine are effective treatments for opioid use disorders, but little information is available regarding the extent to which buprenorphine's approval resulted in more individuals receiving MT nor to what extent receipt of such treatment was equitable across communities.

METHODS

To examine changes in MT utilization and the association between MT utilization and county-level indicators of poverty, race/ethnicity, and urbanicity, we used Medicaid claims of non-dually eligible Medicaid enrollees aged 18-64 from 14 states for 2002-2009. We generated county-level aggregate counts of MT (methadone, buprenorphine, and any MT) by year (N = 7760 county-years). We estimated count data models to identify associations between MT and county characteristics, including levels of poverty and racial/ethnic concentration.

RESULTS

The number of Medicaid enrollees receiving MT increased 62% from 2002 to 2009. The number of enrollees receiving methadone increased 20%, with the remaining increase resulting from buprenorphine. Urban county residents were significantly more likely to receive MT in both 2002 and 2009 than rural county residents. However, buprenorphine substantially increased MT in rural counties from 2002 to 2009. Receipt of MT increased at a much higher rate for residents of counties with lower poverty rates and lower concentrations of black and Hispanic individuals than for residents of counties without those characteristics.

CONCLUSIONS

The increase in Medicaid enrollees receiving MT in the years following buprenorphine's approval is encouraging. However, it is concerning that MT trends varied so dramatically by characteristics of the county population and that increases in utilization were substantially lower in counties with populations that historically have been disadvantaged with respect to health care access and quality. Concerted efforts are needed to ensure that MT benefits are equitably distributed across society and reach disadvantaged individuals who may be at higher risk of experiencing opioid use disorders.

Did the dependent coverage expansion increase risky substance use among young adults?

BACKGROUND

The dependent coverage expansion (DCE) enacted through the Affordable Care Act increased health insurance coverage among young adults. Increasing insurance coverage in this age group has the potential for unintended consequences on risky substance use.

METHODS

Repeated cross-sectional surveys were used to compare change in substance use during the period the DCE was implemented in the 19-25year old target age group (Pre-DCE n=15,772, Post-DCE n=22,719) with contemporaneous change in a slightly older age group that was not targeted by the policy (Pre-DCE=19,851, Post-DCE n=28,157). Outcomes include 11 measures of alcohol, illicit drug and cigarette use. Statistical controls were included for demographic and socioeconomic factors and for early initiation of substance use to adjust for historical trends in developmental trajectories.

RESULTS

Risky substance use decreased in young adults relative to the older age group over the period that the DCE was implemented. However, statistical adjustment for initiation of substance use prior to age 18, which is prior to exposure to the DCE, accounted for the differences between the age groups. In adjusted models, associations between the DCE and substance use outcomes range from 0.96 to 1.08 with p-values ranging from 0.330 to 0.963.

CONCLUSIONS

Historical trends in initiation of substance use prior to age 18, not the DCE, account for change in risky substance use among 19-25year olds relative to 26-34year olds. The evidence does not support the suggestion that health insurance coverage would increase risky substance use among young adults.

Did the Affordable Care Act's Dependent Coverage Expansion Affect Race/Ethnic Disparities in Health Insurance Coverage?

OBJECTIVE

To test the impact of the dependent coverage expansion (DCE) on insurance disparities across race/ethnic groups.

DATA SOURCES/STUDY SETTING

Survey data from the National Survey of Drug Use and Health (NSDUH).

STUDY DESIGN

Triple-difference (DDD) models were applied to repeated cross-sectional surveys of the U.S. adult population.

DATA COLLECTION/EXTRACTION METHODS

Data from 6 years (2008-2013) of the NSDUH were combined.

PRINCIPAL FINDINGS

Following the DCE, the relative odds of insurance increased 1.5 times (95 percent CI 1.1, 1.9) among whites compared to blacks and 1.4 times (95 percent CI 1.1, 1.8) among whites compared to Hispanics.

CONCLUSIONS

Health reform efforts, such as the DCE, can have negative effects on race/ethnic disparities, despite positive impacts in the general population.

Opioid analgesic and benzodiazepine prescribing among Medicaid-enrollees with opioid use disorders: The influence of provider communities

Opioid analgesic and benzodiazepine use in individuals with opioid use disorders can increase the risk for medical consequences and relapse. Little is known about rates of use of these medications or prescribing patterns among communities of prescribers. The goal of this study was to examine rates of prescribing to Medicaid-enrollees in the calendar year after an opioid use disorder diagnosis, and to examine individual, county, and provider community factors associated with such prescribing. 2008 Medicaid claims data were used from 12 states to identify enrollees diagnosed with opioid use disorders, and 2009 claims data were used to identify rates of prescribing of each drug. Social network analysis was used to identify provider communities, and multivariate regression analyses was used to to identify patient, county, and provider community level factors associated with prescribing these drugs. The authors also examined variation in rates of prescribing across provider communities. Among Medicaid-enrollees identified with an opioid use disorder, 45% filled a prescription for an opioid analgesic, 37% filled a prescription for a benzodiazepine, and 21% filled a prescription for both in the year following their diagnosis. Females, older individuals, individuals with pain syndromes, and individuals residing in counties with higher rates of poverty were more likely to fill prescriptions. Prescribing rates varied substantially across provider communities, with rates in the highest quartile of prescribing communities over 2.5 times the rates in the lowest prescribing communities. Prescribing opioid analgesics and benzodiazepines to individuals diagnosed with opioid use disorders may increase risk of relapse and overdose. Interventions should be considered that target provider communities with the highest rates of prescribing and individuals at the highest risk.

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the Department of Veterans Affairs (VA) current and projected health care capabilities and resources. An examination of data from a variety of sources, along with a survey of VA medical facility leaders, revealed the breadth and depth of VA resources and capabilities: fiscal resources, workforce and human resources, physical infrastructure, interorganizational relationships, and information resources. The assessment identified barriers to the effective use of these resources and capabilities. Analysis of data on access to VA care and the quality of that care showed that almost all veterans live within 40 miles of a VA health facility, but fewer have access to VA specialty care. Veterans usually receive care within 14 days of their desired appointment date, but wait times vary considerably across VA facilities. VA has long played a national leadership role in measuring the quality of health care. The assessment showed that VA health care quality was as good or better on most measures compared with other health systems, but quality performance lagged at some VA facilities. VA will require more resources and capabilities to meet a projected increase in veterans' demand for VA care over the next five years. Options for increasing capacity include accelerated hiring, full nurse practice authority, and expanded use of telehealth.

Psychosocial Treatment of Bipolar Disorder: Clinician Knowledge, Common Approaches, and Barriers to Effective Treatment

OBJECTIVE

Nonphysician mental health clinicians were surveyed to understand their knowledge about bipolar disorder, treatment approaches, and perceived barriers to optimal treatment.

METHODS

Nonphysician mental health clinicians (N=55) from five community mental health clinics reported on their therapeutic approach, knowledge, and skill related to treatment of bipolar disorder. Chi square and t tests were used to detect differences in responses by clinician characteristics.

RESULTS

Most clinicians wished to improve their treatment for bipolar disorder. They felt best prepared to provide counseling and least prepared to identify medication side effects. Among psychotherapies, CBT was the most familiar to clinicians. Although knowledgeable overall about bipolar disorder, the clinicians were less knowledgeable about pharmacotherapy. The most commonly reported treatment barrier was comorbid substance use disorders.

CONCLUSIONS

Clinicians would benefit from additional training in effective therapeutic approaches for bipolar disorder as well as information about pharmacotherapy and supporting individuals with comorbid substance use problems.

Where Is Buprenorphine Dispensed to Treat Opioid Use Disorders? The Role of Private Offices, Opioid Treatment Programs, and Substance Abuse Treatment Facilities in Urban and Rural Counties

POLICY POINTS

Buprenorphine is an effective opioid dependence treatment that has expanded access to care since its 2002 approval, but it can only be prescribed by physicians waivered to treat a limited number of individuals. We examined the impact of 2006 legislation that increased waivered physician patient limits from 30 to 100 on buprenorphine use, and found that 100-patient-waivered physicians were significantly associated with growth in buprenorphine use, with no such relationship for 30-patient-waivered physicians. Policies relaxing patient limits may be more effective in increasing buprenorphine use than alternatives such as opening new substance abuse treatment facilities or increasing the overall number of waivered physicians.

CONTEXT

Opioid use disorders are a significant public health problem. In 2002, the FDA approved buprenorphine as an opioid use disorder treatment when prescribed by waivered physicians who were limited to treating 30 patients at a time. In 2006, federal legislation raised this number to 100 patients. Although federal legislators are considering increasing these limits further and expanding prescribing privileges to nonphysicians, little information is available regarding the impact of such changes on buprenorphine use. We therefore examined the impact of the 2006 legislation-as well as the association between urban and rural waivered physicians, opioid treatment programs, and substance abuse treatment facilities-on buprenorphine distributed per capita over the past decade.

METHODS

Using 2004-2011 state-level data on buprenorphine dispensed and county-level data on the number of buprenorphine-waivered physicians and substance abuse treatment facilities using buprenorphine, we estimated a multivariate ordinary least squares regression model with state fixed effects of a state's annual total buprenorphine dispensed per capita as a function of the state's number of buprenorphine providers.

FINDINGS

The amount of buprenorphine dispensed has been increasing at a greater rate than the number of buprenorphine providers. The number of physicians waivered to treat 100 patients with buprenorphine in both rural and urban settings was significantly associated with increased amounts of buprenorphine dispensed per capita. There was no significant association in the growth of buprenorphine distributed and the number of physicians with 30-patient waivers.

CONCLUSIONS

The greater amounts of buprenorphine dispensed are consistent with the potentially greater use of opioid agonists for opioid use disorder treatment, though they also make their misuse more likely. The changes after the 2006 legislation suggest that policies focused on increasing the number of patients that a single waivered physician could safely and effectively treat could be more effective in increasing buprenorphine use than would alternatives such as opening new substance abuse treatment facilities or raising the overall number of waivered physicians.

Policies related to opioid agonist therapy for opioid use disorders: The evolution of state policies from 2004 to 2013

BACKGROUND

State Medicaid policies play an important role in Medicaid enrollees' access to and use of opioid agonists, such as methadone and buprenorphine, in the treatment of opioid use disorders. Little information is available, however, regarding the evolution of state policies facilitating or hindering access to opioid agonists among Medicaid enrollees.

METHODS

During 2013-2014, we surveyed state Medicaid officials and other designated state substance abuse treatment specialists about their state's recent history of Medicaid coverage and policies pertaining to methadone and buprenorphine. We describe the evolution of such coverage and policies and present an overview of the Medicaid policy environment with respect to opioid agonist therapy from 2004 to 2013.

RESULTS

Among our sample of 45 states with information on buprenorphine and methadone coverage, we found a gradual trend toward adoption of coverage for opioid agonist therapies in state Medicaid agencies. In 2013, only 11% of states in our sample (n = 5) had Medicaid policies that excluded coverage for methadone and buprenorphine, whereas 71% (n = 32) had adopted or maintained policies to cover both buprenorphine and methadone among Medicaid enrollees. We also noted an increase in policies over the time period that may have hindered access to buprenorphine and/or methadone.

CONCLUSIONS

There appears to be a trend for states to enact policies increasing Medicaid coverage of opioid agonist therapies, while in recent years also enacting policies, such as prior authorization requirements, that potentially serve as barriers to opioid agonist therapy utilization. Greater empirical information about the potential benefits and potential unintended consequences of such policies can provide policymakers and others with a more informed understanding of their policy decisions.

Implementing a Web-Based Intervention to Train Community Clinicians in an Evidence-Based Psychotherapy: A Pilot Study

OBJECTIVE

The authors conducted a feasibility assessment of online training plus an online learning collaborative to support implementation of an evidence-based psychosocial treatment in a community mental health system.

METHODS

Two mental health centers were randomly allocated to in-person training with local supervision, and three were assigned to online training plus an online learning collaborative supported by expert clinicians. Participants (N=36) were clinicians interested in interpersonal and social rhythm therapy (IPSRT), an evidence-based psychotherapy for bipolar disorder. After training, 136 patients reported monthly on the extent to which clinicians used 19 IPSRT techniques.

RESULTS

Clinicians from both training groups increased use of IPSRT techniques. Patients of clinicians receiving Internet-supported e-learning and of those receiving in-person training reported comparable clinician use of IPSRT techniques.

CONCLUSIONS

Internet-supported e-learning by community clinicians was found to be feasible and led to uptake of an evidence-based psychotherapy comparable to that by clinicians who received face-to-face training.

Growth In Buprenorphine Waivers For Physicians Increased Potential Access To Opioid Agonist Treatment, 2002-11

Opioid use disorders are a significant public health problem, affecting two million people in the United States. Treatment with buprenorphine, methadone, or both is predominantly offered in methadone clinics, yet many people do not receive the treatment they need. In 2002 the Food and Drug Administration approved buprenorphine for prescription by physicians who completed a course and received a waiver from the Drug Enforcement Administration, exempting them from requirements in the Controlled Substances Act. To determine the waiver program's impact on the availability of opioid agonist treatment, we analyzed data for the period 2002-11 to identify counties with opioid treatment shortages. We found that the percentage of counties with a shortage of waivered physicians fell sharply, from 98.9 percent in 2002 to 46.8 percent in 2011. As a result, the percentage of the US population residing in what we classified as opioid treatment shortage counties declined from 48.6 percent in 2002 to 10.4 percent in 2011. These findings suggest that the increase in waivered physicians has dramatically increased potential access to opioid agonist treatment. Policy makers should focus their efforts on further increasing the number and geographical distribution of physicians, particularly in more rural counties, where prescription opioid misuse is rapidly growing.

Establishing a population-based patient-reported outcomes study (PROMs) using national cancer registries across two jurisdictions: the Prostate Cancer Treatment, your experience (PiCTure) study

OBJECTIVE

To establish an international patient-reported outcomes (PROMs) study among prostate cancer survivors, up to 18 years postdiagnosis, in two countries with different healthcare systems and ethical frameworks.

DESIGN

A cross-sectional, postal survey of prostate cancer survivors sampled and recruited via two population-based cancer registries. Healthcare professionals (HCPs) evaluated patients for eligibility to participate. Questionnaires contained validated instruments to assess health-related quality of life and psychological well-being, including QLQ-C30, QLQ-PR25, EQ-5D-5L, 21-question Depression, Anxiety and Stress Scale (DASS-21) and the Decisional Regret Scale.

SETTING

Republic of Ireland (RoI) and Northern Ireland (NI).

PRIMARY OUTCOME MEASURES

Registration completeness, predictors of eligibility and response, data missingness, unweighted and weighted PROMs.

RESULTS

Prostate cancer registration was 80% (95% CI 75% to 84%) and 91% (95% CI 89% to 93%) complete 2 years postdiagnosis in NI and RoI, respectively. Of 12,322 survivors sampled from registries, 53% (n=6559) were classified as eligible following HCP screening. In the multivariate analysis, significant predictors of eligibility were: being ≤59 years of age at diagnosis (p<0.001), short-term survivor (<5 years postdiagnosis; p<0.001) and from RoI (p<0.001). 3348 completed the questionnaire, yielding a 54% adjusted response rate. 13% of men or their families called the study freephone with queries for assistance with questionnaire completion or to talk about their experience. Significant predictors of response in multivariate analysis were: being ≤59 years at diagnosis (p<0.001) and from RoI (p=0.016). Mean number of missing questions in validated instruments ranged from 0.12 (SD 0.71; EQ-5D-5L) to 3.72 (SD 6.30; QLQ-PR25). Weighted and unweighted mean EQ-5D-5L, QLQ-C30 and QLQ-PR25 scores were similar, as were the weighted and unweighted prevalences of depression, anxiety and distress.

CONCLUSIONS

It was feasible to perform PROMs studies across jurisdictions, using cancer registries as sampling frames; we amassed one of the largest, international, population-based data set of prostate cancer survivors. We highlight improvements which could inform future PROMs studies, including utilising general practitioners to assess eligibility and providing a freephone service.

Antibiotic prescribing for respiratory infections at retail clinics, physician practices, and emergency departments

OBJECTIVES

To compare antibiotic prescribing among retail clinics, primary care practices, and emergency departments (EDs) for acute respiratory infections (ARIs): antibiotics-may-be-appropriate ARIs (eg, sinusitis) and antibiotics-never-appropriate ARIs (eg, acute bronchitis).

STUDY DESIGN

We analyzed retail clinic data from the electronic health records of the 3 largest retail clinic chains in the United States, and data on visits to primary care practices and EDs from the nationally representative National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey.

METHODS

Using multivariate models, we estimated an adjusted antibiotic prescribing rate for each site of care, controlling for differences in patient characteristics and diagnosis.

RESULTS

From 2007 to 2009 in the United States, there were 3 million, 167 million, and 29 million ARI visits at retail clinics, primary care practices, and EDs, respectively. For all ARI visits, the adjusted antibiotic prescribing rate at retail clinics (58%) was similar to the rate at primary care practices (62%; P=.09) and EDs (59%; P=.48). For antibiotics-may-be-appropriate ARI visits, the adjusted antibiotic prescribing rate (95%) at retail clinics was higher than at primary care practices (85%; P<.01) and EDs (83%; P<.01). For antibiotics-never-appropriate ARI visits, the adjusted antibiotic prescribing rate (34%) at retail clinics was lower than at primary care practices (51%; P<.01) and EDs (48%; P<.01).

CONCLUSIONS

Compared with primary care practices and EDs, there was no difference at retail clinics in overall ARI antibiotic prescribing. At retail clinics, antibiotic prescribing was more diagnosis-appropriate.

Supply of buprenorphine waivered physicians: the influence of state policies

Buprenorphine, an effective opioid use disorder treatment, can be prescribed only by buprenorphine-waivered physicians. We calculated the number of buprenorphine-waivered physicians/100,000 county residents using 2008-11 Buprenorphine Waiver Notification System data, and used multivariate regression models to predict number of buprenorphine-waivered physicians/100,000 residents in a county as a function of county characteristics, state policies and efforts to promote buprenorphine use. In 2011, 43% of US counties had no buprenorphine-waivered physicians and 7% had 20 or more waivered physicians. Medicaid funding, opioid overdose deaths, and specific state guidance for office-based buprenorphine use were associated with more buprenorphine-waivered physicians, while encouraging methadone programs to promote buprenorphine use had no impact. Our findings provide important empirical information to individuals seeking to identify effective approaches to increase the number of physicians able to prescribe buprenorphine.

Out of the Shadows: The Health and Well-Being of Private Contractors Working in Conflict Environments

Over the past decade, private contractors have been deployed extensively around the globe. In addition to supporting U.S. and allied forces in Iraq and Afghanistan, contractors have assisted foreign governments, nongovernmental organizations, and private businesses by providing a wide range of services, including base support and maintenance, logistical support, transportation, intelligence, communications, construction, and security. At the height of the conflicts in Iraq and Afghanistan, contractors outnumbered U.S. troops deployed to both theaters. Although these contractors are not supposed to engage in offensive combat, they may nonetheless be exposed to many of the stressors that are known to have physical and mental health implications for military personnel. RAND conducted an online survey of a sample of contractors who had deployed on contract to a theater of conflict at least once between early 2011 and early 2013. The survey collected demographic and employment information, along with details about respondents' deployment experience (including level of preparation for deployment, combat exposure, and living conditions), mental health (including probable posttraumatic stress disorder, depression, and alcohol misuse), physical health, and access to and use of health care. The goal was to describe the contractors' health and well-being and to explore differences across the sample by such factors as country of citizenship, job specialty, and length and frequency of contract deployment. The findings provide a foundation for future studies of contractor populations and serve to inform policy decisions affecting contractors, including efforts to reduce barriers to mental health treatment for this population.

Perinatal depression treatment preferences among Latina mothers

The study described here was designed to determine treatment preferences among Latinas to identify treatment options that meet their needs and increase their engagement. Focus group interviews were conducted with 22 prenatal and postpartum Latinas at risk for depression. The group interviews were conducted in Spanish and English using a standardized interview protocol. Focus group transcripts were analyzed to identify themes regarding perinatal depression coping strategies, preferred approaches to treating perinatal depression, and recommendations for engaging perinatal Latinas in treatment. The results suggest that Latinas' treatment preferences consist of a pathway (i.e., hierarchical) approach that begins with the use of one's own resources, followed by the use of formal support systems (e.g., home-visiting nurse), and supplemented with the use of behavioral therapy. Antidepressant use was judged to be acceptable only in severe cases or after delivery. The data indicate that to increase health-seeking behaviors among perinatal Latinas, practitioners should first build trust.

Many emergency department visits could be managed at urgent care centers and retail clinics

Americans seek a large amount of nonemergency care in emergency departments, where they often encounter long waits to be seen. Urgent care centers and retail clinics have emerged as alternatives to the emergency department for nonemergency care. We estimate that 13.7-27.1 percent of all emergency department visits could take place at one of these alternative sites, with a potential cost savings of approximately $4.4 billion annually. The primary conditions that could be treated at these sites include minor acute illnesses, strains, and fractures. There is some evidence that patients can safely direct themselves to these alternative sites. However, more research is needed to ensure that care of equivalent quality is provided at urgent care centers and retail clinics compared to emergency departments.

Statistics on cannabis users skew perceptions of cannabis use

Collecting information about the prevalence of cannabis use is necessary but not sufficient for understanding the size, dynamics, and outcomes associated with cannabis markets. This paper uses two data sets describing cannabis consumption in the United States and Europe to highlight (1) differences in inferences about sub-populations based on the measure used to quantify cannabis-related activity; (2) how different measures of cannabis-related activity can be used to more accurately describe trends in cannabis usage over time; and (3) the correlation between frequency of use in the past-month and average grams consumed per use-day.

KEY FINDINGS

focusing on days of use instead of prevalence shows substantially greater increases in U.S. cannabis use in recent years; however, the recent increase is mostly among adults, not youth. Relatively more rapid growth in use days also occurred among the college-educated and Hispanics. Further, data from a survey conducted in seven European countries show a strong positive correlation between frequency of use and quantity consumed per day of use, suggesting consumption is even more skewed toward the minority of heavy users than is suggested by days-of-use calculations.

Hypoxaemia in patients with pulmonary arterial hypertension during simulated air travel

BACKGROUND

Recent air travel recommendations suggest patients with precapillary pulmonary hypertension (PCPH) in New York Heart Association (NYHA) functional class 3 and 4 should have in-flight oxygen without the need for pre-flight testing. However it remains unclear as to how best to determine patients fitness to fly.

METHODS

This study (i) investigates the effect of hypoxic challenge testing (HCT) on the arterial oxygen levels in a cohort of 36 patients with PCPH and (ii) compares the relative frequency with which FC and HCT predict the requirement for in-flight oxygen.

RESULTS

The degree of arterial hypoxaemia induced by HCT (fall in partial pressure of oxygen in arterial blood (PaO(2)) 2.36 kPa, 95% CI 2.06-2.66 kPa) was similar to the drop observed in other published studies of chronic respiratory diseases. Following current air travel recommendations based on FC, 25 patients of the cohort would require in-flight oxygen whilst 10 subjects failed the HCT. Fourteen subjects had flown post-diagnosis. Of these, nine subjects should have had in-flight oxygen based on FC but were asymptomatic without. Also one who passed the HCT had developed symptoms during the flight whilst three who failed the HCT were asymptomatic flying without in-flight oxygen.

CONCLUSIONS

Hypoxaemia induced by simulated air travel in patients with PCPH is similar to that seen in published studies of patients with other chronic respiratory diseases. HCT failed to predict correctly who had developed symptoms during an aircraft flight in a significant minority of the study subjects. Similarly guidelines based on functional class result in a major increase in the proportion of patients being advised to use oxygen, many of whom had been asymptomatic on previous flights without it. More work is required to improve prediction of need for in-flight oxygen in patients with PCPH.

A new estimate of the impact of OSHA inspections on manufacturing injury rates, 1998-2005

BACKGROUND

A prior study indicated that the effect of OSHA inspections on lost workday injuries had declined from 1979 through 1998. This study provides an updated estimate for 1998-2005.

METHODS

Injury data from the Pennsylvania workers' compensation program were linked with employment data from unemployment compensation records to calculate lost-time rates for single-establishment manufacturing firms with more than 10 employees. These rates were linked to OSHA inspection findings. The RAND Human Subjects Protection Committee determined that this study was exempt from review.

RESULTS

Inspections with penalties reduced injuries by an average of 19-24% annually in the 2 years following the inspection. These effects were not found for workplaces with fewer than 20 or more than 250 employees or for inspections without penalties.

CONCLUSIONS

These findings should be generalizable to the 29 states where federal OSHA directly enforces standards. They suggest that the impact of inspections has increased from the 1990s.

Assessing Operation Purple: A Program Evaluation of a Summer Camp for Military Youth

Parental military deployments pose a host of challenges for child and family well-being. Military family support programs have proliferated since the start of the wars in Afghanistan and Iraq a decade ago to address these emotional, social, and academic issues, but there has been little evaluation of whether these programs are meeting their key objectives. To help fill this gap, a RAND study team explored the curriculum, themes, and outcomes of Operation Purple, a free weeklong summer camp program for youth with a deployed parent. Using a quasi-experimental approach, the study incorporated youth and parent survey data (from both camp attendees and a control group of non-attendees) and camp after-action reports and visitor observation logs to determine whether there were differences between attendees and non-attendees in the four camp theme areas: comfort and skill in communicating about feelings, understanding and appreciation of military life, sense of service/stewardship, and outdoor education. The study also sought to determine how and to what extent the program's curriculum was implemented by participating camps in the summer of 2011. Despite limitations in the data (e.g., a non-random study sample, some variation in curriculum implementation across camps), the study found some positive effects from camp participation, particularly in communicating about feelings, as well as valuable youth and parent perspectives about camp, reflected in responses to open-ended questions. As such, it helps lay the groundwork for future investigation of similar support programs for military youth and their families.

The growth of retail clinics in vaccination delivery in the U.S

BACKGROUND

Retail clinics are a promising venue in which to promote and administer vaccinations; however, little is known about who receives vaccinations at a retail clinic.

PURPOSE

The aim of this paper was to describe the use of retail clinics in the delivery of recommended vaccinations.

METHODS

The three largest retail clinic operators in the U.S.--MinuteClinic, TakeCare, and LittleClinic--provided de-identified clinic data for 2007-2009. Descriptive statistics were generated in 2011 on visit type, type of vaccination, patient age, and payment method.

RESULTS

From 2007 to 2009, there were 8.9 million retail clinic visits across the three largest clinic operators. In 2009, vaccinations were administered at 1,952,610 visits, up from 469,330 visits in 2007. Visits in which vaccinations were administered accounted for 39.9%, 36.4%, and 42.0% of total visits in 2007, 2008, and 2009, respectively. In 2009, 1.8 million influenza vaccinations (including seasonal and H1N1 vaccinations) were administered by the two largest retail clinic operators (94% of all vaccination visits). Pneumococcal vaccination was administered at 59,849 visits (3% of all vaccination visits). In 2009, vaccinations were also administered in 0.8% of acute care visits (n=18,807); 0.8% of chronic care visits (n=261); and 1.3% of general medical exams (n=2497).

CONCLUSIONS

Results suggest that retail clinics play a growing role in vaccination delivery, and vaccinations constitute a substantial share of the business conducted by retail clinics. As such, retail clinics have the potential to play an important role in vaccination delivery in the U.S. Retail clinics potentially could deliver more vaccinations if they reviewed vaccination histories and counseled patients regarding the benefits of vaccination during acute care visits.

The War Within: Preventing Suicide in the U.S. Military

Since late 2001, U.S. military forces have been engaged in conflicts around the globe, most notably in Iraq and Afghanistan. These conflicts have exacted a substantial toll on soldiers, marines, sailors, and airmen, and this toll goes beyond the well-publicized casualty figures. It extends to the stress that repetitive deployments can have on the individual servicemember and his or her family. This stress can manifest itself in different ways-increased divorce rates, spouse and child abuse, mental distress, substance abuse-but one of the most troubling manifestations is suicide, which is increasing across the U.S. Department of Defense (DoD). The increase in suicides among members of the military has raised concern among policymakers, military leaders, and the population at large. While DoD and the military services have had a number of efforts under way to deal with the increase in suicides among their members, the Assistant Secretary of Defense for Health Affairs asked RAND to review the current evidence detailing suicide epidemiology in the military, identify "state-of-the-art" suicide-prevention programs, describe and catalog suicide-prevention activities in DoD and across each service, and recommend ways to ensure that the activities in DoD and across each service reflect state-of-the-art prevention science.

Views from the Homefront: The Experiences of Youth and Spouses from Military Families

As the United States continues deployments of service members to support operations in Iraq and Afghanistan, it is increasingly important to understand the effects of this military involvement, not only on service members but also on the health and well-being of their spouses and youth. This article shares highlights from a study that examined the functioning of a sample of youth in military families who applied to a free camp for children of military personnel and to specifically assess how these youth are coping with parental deployment. It addresses the general well-being of military youth during and after parental deployment, with attention to their emotional, social, and academic functioning. It also examines the challenges that their nondeployed caregivers face. The study included quantitative and qualitative components: three waves of phone surveys with youth and nondeployed caregivers, and in-depth interviews with a subsample of caregivers. The researchers found that children and caregivers who had applied to attend the camp confronted significant challenges to their emotional well-being and functioning. Four factors in particular-(1) caregiver emotional well-being, (2) more cumulative months of deployment, (3) National Guard or Reserve status, and (4) quality of caregiver-youth communication-were strongly associated with greater youth or caregiver difficulties.

The Pennsylvania certified safety committee program: an evaluation of participation and effects on work injury rates

BACKGROUND

Since 1994, Pennsylvania, like several other states, has provided a 5% discount on workers' compensation insurance premiums for firms with a certified joint labor management safety committee. This study explored the factors affecting program participation and evaluated the effect of this program on work injuries.

METHODS

Using Pennsylvania unemployment insurance data (1996-2006), workers' compensation data (1998-2005), and the safety committee audit data (1999-2007), we conducted propensity score matching and regression analysis on the program's impact on injury rates.

RESULTS

Larger firms, firms with higher injury rates, firms in high risk industries, and firms without labor unions were more likely to join the safety committee program and less likely to drop out of the program. The injury rates of participants did not decline more than the rates for non-participants; however, rates at participant firms with good compliance dropped more than the rates at participant firms with poor compliance.

CONCLUSIONS

Firm size and prior injury rates are key predictors of program participation. Firms that complied with the requirement to train their safety committee members did experience reductions in injuries, but non-compliance with that and other requirements was so widespread that no overall impact of the program could be detected.

Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: possible explanations

The authors reviewed 29 studies that provide prevalence estimates of posttraumatic stress disorder (PTSD) among service members previously deployed to Operations Enduring and Iraqi Freedom and their non-U.S. military counterparts. Studies vary widely, particularly in their representativeness and the way PTSD is defined. Among previously deployed personnel not seeking treatment, most prevalence estimates range from 5 to 20%. Prevalence estimates are generally higher among those seeking treatment: As many as 50% of veterans seeking treatment screen positive for PTSD, though much fewer receive a PTSD diagnosis. Combat exposure is the only correlate consistently associated with PTSD. When evaluating PTSD prevalence estimates among this population, researchers and policymakers should carefully consider the method used to define PTSD and the population the study sample represents.

Children on the homefront: the experience of children from military families

OBJECTIVE

Although studies have begun to explore the impact of the current wars on child well-being, none have examined how children are doing across social, emotional, and academic domains. In this study, we describe the health and well-being of children from military families from the perspectives of the child and nondeployed parent. We also assessed the experience of deployment for children and how it varies according to deployment length and military service component. PARTICIPANTS AND METHODS. Data from a computer-assisted telephone interview with military children, aged 11 to 17 years, and nondeployed caregivers (n = 1507) were used to assess child well-being and difficulties with deployment. Multivariate regression analyses assessed the association between family characteristics, deployment histories, and child outcomes.

RESULTS

After controlling for family and service-member characteristics, children in this study had more emotional difficulties compared with national samples. Older youth and girls of all ages reported significantly more school-, family-, and peer-related difficulties with parental deployment (P < .01). Length of parental deployment and poorer nondeployed caregiver mental health were significantly associated with a greater number of challenges for children both during deployment and deployed-parent reintegration (P < .01). Family characteristics (eg, living in rented housing) were also associated with difficulties with deployment.

CONCLUSIONS

Families that experienced more total months of parental deployment may benefit from targeted support to deal with stressors that emerge over time. Also, families in which caregivers experience poorer mental health may benefit from programs that support the caregiver and child.

Alternative vaccination locations: who uses them and can they increase flu vaccination rates?

Since many unvaccinated individuals do not regularly contact the traditional health care system, we sought to determine the role that alternative vaccination locations (e.g., workplaces and retail clinics) could play in increasing influenza vaccination coverage. Between February 14, 2008 and March 10, 2008, a 25-question influenza vaccine questionnaire was administered to a nationally representative, stratified sample of panelists. Our results found that while alternative locations are covering some segments not captured by the traditional health care system (e.g., younger, working, white individuals in metropolitan areas), they are not serving many other segments (e.g., minority, rural, or lower income patients).

Interaction of theophylline with erythromycin base in a patient with seizure activity

A pediatric patient who was taking carefully monitored doses of theophylline for chronic asthma, was placed on erythromycin base for bronchitis. She subsequently developed theophylline toxicity which caused her to experience seizure activity. Any patient taking a theophylline preparation who is then placed on ANY of the available erythromycin compounds must have close monitoring of serum theophylline levels.