Study protocol of a randomized trial of STRIPES: a schoolyear, peer-delivered high school intervention for students with ADHD

BACKGROUND

Youth with ADHD are at risk of academic impairments, dropping out of high school, and dysfunction in young adulthood. Interventions delivered early in high school could prevent these harmful outcomes, yet few high school students with ADHD receive treatment due to limited access to intervention providers. This study will test a peer-delivered intervention (STRIPES) for general education 9th grade students with impairing ADHD symptoms.

METHODS

A type 1 hybrid effectiveness-implementation design will be used to evaluate the effectiveness of STRIPES and explore the intervention's implementability. Analyses will test the impact of STRIPES vs. enhanced school services control on target mechanisms and determine whether differences in basic cognitive profiles moderate intervention response. The acceptability and feasibility of STRIPES and treatment moderators will also be examined.

DISCUSSION

This study will generate knowledge about the effectiveness and implementability of STRIPES, which will inform dissemination efforts in the future. A peer-delivered high school intervention for organization, time management, and planning skills can provide accessible and feasible treatment targeting declines in academic motivation, grades, and attendance during the ninth-grade year.

TRIAL REGISTRATION

This study is registered on OSF Registries (10.17605/OSF.IO/Q8V6S).

The Impact of Public Health Funding on Population Health Outcomes

Abstract The objective of this study was to assess the impact of local health department (LHD) expenditures on population health measures using counties as the unit of analysis. An observational research design is used to examine whether public health benefits are associated with higher levels of public health funding. Linear probability multivariate regression models with the use of local level cross-sectional and panel data are employed. A 1-year and a 2-year lag structure are also used to quantify the longer term public health effects of changes in LHD expenditures. Analyses were performed at the county level using local data representing 2120 LHDs, covering 48 US states. Expenditure data from the National Association of County and City Health Officials Profile Surveys and public health measures from County Health Rankings Annual Reports are used. Four public health measures are examined-obesity prevalence, sexually transmitted diseases, diabetes prevalence, and human immunodeficiency virus prevalence. Results from cross-sectional, pooled ordinary least squares, and panel data with fixed effects reveal that increased LHD expenditures per capita were not associated with any of the population health outcomes studied. Multivariate linear regression results using a 1- and 2-year lag structure reveal similar results: funding was not significantly predictive of better public health outcomes. The study design did not control for the potential endogeneity of public health funding. More detailed data and robust research approaches are needed to disentangle the effect and effectively answer whether increased public funding translates to improved population health.

The Impact of ADHD on Maternal Quality of Life

Childhood attention-deficit/hyperactivity disorder (ADHD) is associated with substantial burden to caregiver quality of life (QoL). However, a paucity of work has focused on quantifying QoL among caregivers of adolescents with a history of ADHD. The purpose of the current study was (1) to quantify maternal QoL in a sample of mothers of adolescents with and without childhood ADHD; and (2) to examine predictors (i.e., parent and child characteristics and behavior) associated with maternal QoL. Participants included mothers of adolescents with (N = 110) and without ADHD (N = 90) ranging in age from 13 to 18 (M = 16.09, 92% male). The Quality Adjusted Life-Year (QALY) was used to calculate maternal QoL using two health domains (i.e., anxiety/depression and disruption in daily activities) commonly impacted by raising youth with ADHD. QALYs are valued monetarily to estimate disease burden. Mothers of adolescents with childhood ADHD experienced significantly worse QoL relative to mothers in the comparison group. Maternal depression, as well as adolescent age, ADHD status, and discipline problems significantly predicted lower levels of maternal QALY health status index, with ADHD being the strongest predictor. This is equal to a reduction in 1.96 QALYs when summed over the course of a child's lifetime and is associated with a loss of $98,000 to $196,000. Results of the investigation help to further elucidate the health impacts incurred by families of adolescents with ADHD and have important public health implications. Further, parental QoL should be considered when conceptualizing the financial and negative health impact of ADHD.

Disparities in Emergency Department Visits for Opioid and Stimulant Overdoses in Florida During COVID-19

Emergency department (ED) visits for drug overdoses increased nationally during COVID-19 despite declines in all-cause ED visits. The study purpose was to compare characteristics of ED visits for opioid and stimulant overdoses before and during COVID-19 in Florida. This study tested for disparities in ED visits for opioid and stimulant overdoses by race/ethnicity, age, and insurance status. The study identified ED visits for opioid and stimulant overdose in Florida during quarters two and three of 2019 and compared them with quarters two and three of 2020. Overall, there was an increase in the number of opioid and stimulant overdoses during COVID-19. Combined with the decline in the number of all-cause ED visits, drug overdoses represented a larger share of ED visits during COVID-19 compared with before COVID-19. The study did not find evidence of disparities by race/ethnicity, as each group experienced similar increases in the likelihood of ED visits involving drug overdoses during COVID-19. Differences emerged according to age and insurance status. ED visits involving those under age 18 were more likely to involve opioid or stimulant overdose, and ED visits among those over age 65 were less likely to involve opioid overdose during COVID-19. ED visits among those with vulnerable insurance status were more likely to involve opioid overdose during COVID-19. Patterns of behavior change during periods of restricted activity due to a pandemic. These changes in behavior change the mix of risks that people face, suggesting the need for a reallocation of population health management resources during pandemics.

Redesign of US Medical Schools: A Shift from Health Service to Population Health Management

The integration of medical schools and clinical partners is effectively established through the formation of academic medical centers (AMCs). The tripartite mission of AMCs emphasizes the importance of providing critical clinical services, medical innovation through research, and the education of future health care leaders. Although AMCs represent only 5% of all hospitals, they contribute substantially to serving disadvantaged populations of patients, including an estimated 37% of all charity care and 26% of all Medicaid hospitalizations. Currently, most AMCs use a business model centered upon revenue generated from hospital services and/or practice plans. In the last decade, mounting financial demands have placed significant pressure on AMC finances because of the rising costs associated with complex clinical care and operating diverse graduate medical education programs. A shift toward population health-centric health care management strategies will profoundly influence the predominant forms of health care delivery in the United States in the foreseeable future. Health systems are increasingly pursuing new strategies to manage financial risk, such as forming Accountable Care Organizations and provider-sponsored plans to provide value-based care. Refocusing research and operational capacity toward population health management fosters collaboration and enables reintegration with hospital and clinical partners across care networks, and can potentially create new revenue streams for AMCs. Despite the benefits of population health integration, current literature lacks a blueprint to guide AMCs in the transformation toward sustainable population health management models. The purpose of this paper is to propose a modern conceptual framework that can be operationalized by AMCs in order to achieve a sustainable future.

A Call to Action: Preventing Opioid and Substance Abuse in South Florida Youth

Description The opioid crisis poses a substantial threat to youth throughout the nation. This crisis has been exacerbated by the COVID-19 pandemic, reversing some of the positive national trends in the fight against the opioid epidemic. Some risk factors for youth opioid use have been identified nationally. The South Florida tri-county region of Miami-Dade, Broward and Palm Beach is a culturally distinct region which may not follow national trends and likely has unique risk and protective factors. To address the concerning spike in youth opioid use in South Florida, a community coalition was formed to identify factors unique to South Florida and create a plan for early awareness and prevention.

Transitions in "Privatized" Prison Health Systems: Emergency Department Visits and Hospitalizations Among Incarcerated People in Florida, 2011-2018

Objectives. To examine rates of emergency department (ED) visits and hospitalizations among incarcerated people in Florida during a period when health care management in the state's prisons underwent transitions.Methods. We used Florida ED visit and hospital discharge data (2011-2018) to depict the trend in ED visit and hospital discharge rates among incarcerated people. We proxied incarcerated people using individuals admitted from and discharged or transferred to a court or law enforcement agency. We fitted a regression with year indicators to examine the significance of yearly changes.Results. Among incarcerated people in Florida, ED visit rates quadrupled, and hospitalization rates doubled, between 2015 and 2018, a period when no similar trends were evident in the nonincarcerated population.Public Health Implications. Increasing the amount and flexibility of payments to contractors overseeing prison health services may foster higher rates of hospital utilization among incarcerated people and higher costs, without addressing major quality of care problems. Hospitals and government agencies should transparently report on health care utilization and outcomes among incarcerated people to ensure better oversight of services for a highly vulnerable population.

Four-Year Follow-Up of High versus Low Intensity Summer Treatment for Adolescents with ADHD

OBJECTIVE

Despite an emergence of psychosocial treatments for adolescent ADHD, their long-term effects are unknown.

METHOD

We examine four-year outcomes of a randomized controlled trial (N = 218) comparing high-intensity (HI; 412 h, $4,373 per participant) versus low-intensity (LI; 24 h, $97 per participant) skills-based summer intervention delivered to adolescents with ADHD at two secondary school transitions (6th/9th grade). Quantitative and qualitative analyses evaluated group×time and group×grade×time effects on 4-year outcomes.

RESULTS

Relative to LI, a single dose of HI had modest but lasting effects on teen organization skills (d =.40) and ADHD symptoms (9th grade only: d =.27 to.31) at 4-year follow-up. There was no long-term incremental effect of HI (vs. LI) for parent-teen conflict, GPA, or parent use of contingency management. Treatment appeared most effective when delivered to older adolescents (i.e., 9th versus 6th grade), suggesting the long-term impact of ADHD treatment may increase with age. Qualitative data corroborated that the primary long-term benefit of HI (vs. LI) treatment was to organization skills; many of the remaining perceived benefits were to parent and teen psychological variables (i.e., increased self-esteem, self-awareness, parental optimism). HI offered no incremental benefit to long-term educational or clinical service utilization or costs.

CONCLUSIONS

Modest therapeutic benefits of adolescent ADHD treatment are maintained long term. However, HI treatment did not impact outcomes that could defray the intervention's high costs ($4,373) compared to LI treatment ($97).

Racial/Ethnic Disparities in Opioid Use Disorder and Poisoning Emergency Department Visits in Florida

OBJECTIVES

To examine the role of individual race/ethnicity and community racial/ethnic mix on the type of opioid-related emergency department (ED) visits in Florida.

METHODS

The study identifies opioid-related ED visits that involved heroin, non-heroin poisoning, and opioid use disorder (OUD) from the first quarter of 2010 to the second quarter of 2018 in Florida. The trend is depicted by patients' race/ethnicity and racial/ethnic mix of residential communities. Combined with zip code tabulation area data, the study builds a multilevel model and examines how individual-level and community-level covariates relate to the type of opioid-related ED visits.

RESULTS

While opioid-related ED visit rate was highest among white patients, majority-black communities caught up with the majority-white communities in the visit rate. The multilevel model results suggest that the likelihood of an opioid-related ED visit involving heroin, non-heroin poisoning, or OUD differed by patient race/ethnicity as well as community racial/ethnic mix. Opioid-related ED visits among minority patients were more likely to involve non-heroin poisoning than non-Hispanic white patients, whereas patients from minority-dominant communities were more likely to involve heroin poisoning than from majority-white communities. However, community racial/ethnic mix was not significantly or less significantly associated with the likelihood of involving OUD ED visits.

CONCLUSIONS

The study highlights the heterogeneity of the opioid overdose problem across racial/ethnic patients and communities with different racial/ethnic mixes. Future policies may consider the effect of living in different racial/ethnic mixed communities in addition to individual race/ethnicity.

The long-term financial outcome of children diagnosed with ADHD

OBJECTIVE

Characterize the early trajectories of financial functioning in adults with history of childhood ADHD and use these trajectories to project earnings and savings over the lifetime.

METHOD

Data were drawn from a prospective case-control study (PALS) following participants with a rigorous diagnosis of ADHD during childhood (N = 364) and demographically matched controls (N = 240) for nearly 20 years. Participants and their parents reported on an array of financial outcomes when participants were 25 and 30 years old.

RESULTS

At age 30, adults with a history of ADHD exhibited substantially worse outcomes than controls on most financial indicators, even when they and their parents no longer endorsed any DSM symptoms of ADHD. Between ages 25 and 30, probands had exhibited considerably slower growth than controls in positive financial indicators (e.g., monthly income) and substantially less reduction than controls in indicators of financial dependence (e.g., living with parents), indicating worsening or sustained deficits on nearly all measures. When earnings trajectories from age 25 to age 30 were extrapolated using matched census data, male probands were projected to earn $1.27 million less than controls over their working lifetime, reaching retirement with up to 75% lower net worth.

CONCLUSION

The financial deficit of adults with history of childhood ADHD grows across early adulthood. Projections based on early financial trajectories suggest very large cumulative differences in earnings and savings. With or without persistence of the DSM symptoms, the adult sequela of childhood ADHD can be conceptualized as a chronic condition often requiring considerable support from others during adulthood. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Randomized Trial of First-Line Behavioral Intervention to Reduce Need for Medication in Children with ADHD

A study conducted in an analogue summer treatment setting showed that when concurrently receiving behavioral intervention, many children with Attention-Deficit Hyperactivity Disorder (ADHD) did not need medication or maximized responsiveness at very low doses. The present study followed participants in that summer study into the subsequent school year to investigate whether the same pattern would extend to the natural school and home settings. There were 127 unmedicated children with ADHD between the ages of 5 and 13 who were randomly assigned to receive or not receive behavioral consultation (BC) at the start of the school year. Children were evaluated by teachers and parents each week to determine if central nervous system stimulant treatment was needed. Children who received BC were approximately half as likely those who did not (NoBC) to initiate medication use each week at school or home and used lower doses when medicated at school. This produced a 40% reduction in total methylphenidate exposure over the course of the school year. BC and NoBC groups did not significantly differ on end-of-year teacher or parent ratings of behavior, which were positive. Moreover, BC and NoBC groups did not significantly differ in cost of treatment; although children in the BC condition accrued additional costs via the BC, these costs were offset by the associated delay and reduction in medication use. Results add to a growing literature suggesting that the use of low-intensity behavioral intervention as a first-line treatment reduces or eliminates the need for medication in children with ADHD.

Evaluation of a Worksite-Based Small Group Team Challenge to Increase Physical Activity

PURPOSE

To investigate whether participants in a small group team challenge had greater completion rates in an institution-wide step-challenge than other participants.

DESIGN

A quasi-experimental, posttest-only design with a comparison group was used to evaluate group differences in completion rates.

SETTING

A large university system provided the opportunity to participate in a physical activity challenge.

PARTICIPANTS

The study was limited to employees who participated in the physical activity challenge.

INTERVENTION

Two institutions offered participants the chance to compete as smaller groups of teams within their institution. These team-challenge participants (N = 414) were compared to participants from the same institutions that did not sign up for a team and tracked their steps individually (N = 1454).

MEASURES

Participants who reported 50 000 steps per week for 5 of the 6 weeks were classified as challenge completers. We also evaluated total step count and controlled for several potential covariates including age, gender, and body mass index.

ANALYSIS

Logistic regression was used to model the dichotomous outcome of challenge completion.

RESULTS

Team-challenge participants were more likely to complete the physical activity challenge than other participants. Team-challenge participants had 1922 more steps per day than individual participants. However, at an institution level, overall completion rates were not higher at institutions that offered a team challenge.

A Cost Analysis of a Stepped Care Treatment Approach for Anxiety Disorders in Youth

To address the high demand for youth anxiety treatment, researchers have begun to evaluate stepped care approaches to use limited resources efficiently. Quantifying cost savings can inform policy decisions about optimal ways to use limited resources. This study presents a cost analysis of a stepped care treatment approach for anxiety disorders in youth. Youths (N = 112) completed an 8-session computer-administered attention bias modification treatment (Step 1), and families were given the option to "step up" to cognitive behavioral therapy (CBT; Step 2). Stepped care treatment cost estimates were based on (a) resources used in treatment (i.e., clinician/paraprofessional time, equipment/materials) and (b) Medicaid reimbursement rates for clinician and paraprofessional time. We compared these two cost estimates with a hypothetical standard treatment approach for youth anxiety disorders: CBT only. We also tested predictive models to determine whether they could guide decisions about which youths, based on baseline characteristics, should be assigned to stepped care or directly to CBT only to avoid the costs associated with Step 1. Compared to a hypothetical standard CBT approach, the stepped care treatment was associated with an overall cost savings of 44.4% for the Medicaid reimbursement model and 47.7% for the resource cost model. The predictive models indicated that assigning all youths to stepped care would be more cost-effective than assigning certain youths directly to CBT only. This study provides the first evidence that a stepped care treatment approach for youth anxiety is associated with substantial cost savings compared with a standard CBT.

Impact of Health Plan Deductibles and Health Insurance Marketplace Enrollment on Health Care Experiences

High-deductible health plans (HDHPs) have become increasingly prevalent among employer-sponsored health plans and plans offered through the Health Insurance Marketplace in the United States. This study examined the impact of deductible levels on health care experiences in terms of care access, affordability, routine checkup, out-of-pocket cost, and satisfaction using data from the Health Reform Monitoring Survey. The study also tested whether the experiences of Marketplace enrollees differed from off-Marketplace individuals, controlling for deductible levels. Results from multivariable and propensity score weighted regression models showed that many of the outcomes were adversely affected by deductible levels and Marketplace enrollment. These results highlight the importance of efforts to help individuals choose the plan that fits both their medical needs and their budgets. The study also calls for more attention to improving provider acceptance of HDHPs and Marketplace plans as these plans become increasingly common over time.

Surviving Siblings' Illnesses, Treatments/Health Services over 13 Months after a Sibling's Death

Two million children experience sibling death annually and have problems that require clinical intervention although few receive such help. Effects on surviving siblings' mental health has been well documented, however their physical health has not. This study described surviving siblings' illnesses, treatments/health services at 2, 4, 6, and 13 months post-sibling death. The 132 children (76 girls, 56 boys, M 10.6 years, SD 3.43); 30% Hispanic, 51% Black, 26% White were recruited via hospital ICUs and published obituaries. Using a longitudinal design, parents reported types and numbers of surviving siblings' illnesses, treatments/health services, and dates post-sibling death. Most of the 207 illnesses and 674 treatments/health services occurred in the first 6 months post-sibling death. While girls had more illnesses (131) than boys (76) and Hispanic children had more illnesses than White or Black children, these differences were not statistically significant. Girls accounted for 66% of the treatments/health services and boys 34%. There was no significant difference in treatments/health service use by gender of the children (F = 1.00, p = .32). Hispanic children had significantly more treatments/health service use than Black children (F = 6.81, p = .002). Sibling death affects surviving siblings' physical health. Study data document the importance of monitoring the health, treatments and health service use of surviving siblings especially in the first 6 months after a sibling death, regardless of the child' s gender. On average, Hispanic children had greater health service use, which may warrant greater attention.

Financial Dependence of Young Adults with Childhood ADHD

This study used data from the Pittsburgh ADHD Longitudinal Study (PALS) to evaluate financial outcomes of young adults (YA) with ADHD relative to comparisons. Participants for this study included 309 individuals who had been diagnosed with ADHD (DSM-III-R or DSM-IV) in childhood and 208 comparison YA without childhood ADHD diagnoses (total N = 517) who were followed through age 25. Participants were predominately male (88 %) and Caucasian (84 %). Diagnostic interviews were conducted in childhood. Young adults and their parents reported on financial outcomes and a number of predictor variables. Young adults with ADHD experienced greater financial dependence on family members (p < 0.05) and the welfare system (p < 0.01) and had lower earnings (p < 0.05) than comparisons. ADHD diagnostic status, education attainment, and delinquency were significant predictors of financial outcomes. A projection of lifetime earnings indicated that ADHD group participants could expect to earn $543,000-$616,000 less over their lifetimes than comparisons. Due to the propensity of individuals with ADHD to underreport problems, the data are likely to be underestimates. These findings support the need for interventions to improve labor market outcomes as well as the development of interventions that target the management of personal finances for individuals with ADHD in young adulthood.

Impact of Louisiana's HPV Vaccine Awareness Policy on HPV Vaccination Among 13- to 17-Year-Old Females

The Advisory Committee on Immunization Practices recommends routine human papillomavirus (HPV) immunization for 11- to 12-year-old adolescents. In 2008, Louisiana required the school boards to distribute HPV vaccine information to parents or guardian of students in Grades 6 to 12. This article investigates the impact of this policy on HPV vaccination among 13- to 17-year-old female adolescents using National Immunization Survey-Teen (NIS-Teen) data. Drawing on the data from the 2008 to 2012 NIS-Teen, we compared the difference in proportions of females who have been vaccinated before and after the policy. Using difference-indifference estimation, we explored the change in vaccination rates before and after the policy implementation in Louisiana compared with Alabama and Mississippi, two states that did not have such a policy in place. The difference-in-differences estimates for HPV vaccination were not significant. Physician recommendation for HPV vaccination was significantly associated with vaccination among females in Louisiana and Alabama (adjusted odds ratio [aOR] = 7.74; 95% confidence interval [CI; 5.22, 11.5]), and for those in Louisiana and Mississippi (aOR = 7.05; 95% CI [4.6, 10.5]). Compared to the proportion of female adolescents who had received physician recommendation in Alabama or Mississippi, the proportion in Louisiana did not increase significantly in the postpolicy period. HPV vaccination rates did not increase significantly in Louisiana compared to Alabama or Mississippi following the implementation of the policy. Despite Louisiana's policy, physician recommendation remains the key determinant of HPV vaccination. HPV vaccine awareness does not necessarily result in HPV vaccination.

Economic Evaluation of PCSK9 Inhibitors in Reducing Cardiovascular Risk from Health System and Private Payer Perspectives

The introduction of Proprotein covertase subtilisin/kexin type 9 (PCSK9) inhibitors has been heralded as a major advancement in reducing low-density lipoprotein cholesterol levels by nearly 50%. However, concerns have been raised on the added value to the health care system in terms of their costs and benefits. We assess the cost-effectiveness of PCSK9 inhibitors based on a decision-analytic model with existing clinical evidence. The model compares a lipid-lowering therapy based on statin plus PCSK9 inhibitor treatment with statin treatment only (standard therapy). From health system perspective, incremental cost per quality adjusted life years (QALYs) gained are presented. From a private payer perspective, return-on-investment and net present values over patient lifespan are presented. At the current annual cost of $14,000 to $15,000, PCSK9 inhibitors are not cost-effective at an incremental cost of about $350,000 per QALY. Moreover, for every dollar invested in PCSK9 inhibitors, the private payer loses $1.98. Our study suggests that the annual treatment price should be set at $4,250 at a societal willingness-to-pay of $100,000 per QALY. However, we estimate the breakeven price for private payer is only $600 per annual treatment. At current prices, our study suggests that PCSK9 inhibitors do not add value to the U.S. health system and their provision is not profitable for private payers. To be the breakthrough drug in the fight against cardiovascular disease, the current price of PCSK9 inhibitors must be reduced by more than 70%.

Impact of Booster Breaks and Computer Prompts on Physical Activity and Sedentary Behavior Among Desk-Based Workers: A Cluster-Randomized Controlled Trial

Introduction

The 15-minute work break provides an opportunity to promote health, yet few studies have examined this part of the workday. We studied physical activity and sedentary behavior among office workers and compared the results of the Booster Break program with those of a second intervention and a control group to determine whether the Booster Break program improved physical and behavioral health outcomes.

Methods

We conducted a 3-arm, cluster-randomized controlled trial at 4 worksites in Texas from 2010 through 2013 to compare a group-based, structured Booster Break program to an individual-based computer-prompt intervention and a usual-break control group; we analyzed physiologic, behavioral, and employee measures such as work social support, quality of life, and perceived stress. We also identified consistent and inconsistent attendees of the Booster Break sessions.

Results

We obtained data from 175 participants (mean age, 43 y; 67% racial/ethnic minority). Compared with the other groups, the consistent Booster Break attendees had greater weekly pedometer counts (P < .001), significant decreases in sedentary behavior and self-reported leisure-time physical activity (P < .001), and a significant increase in triglyceride concentrations (P = .02) (levels remained within the normal range). Usual-break participants significantly increased their body mass index, whereas Booster Break participants maintained body mass index status during the 6 months. Overall, Booster Break participants were 6.8 and 4.3 times more likely to have decreases in BMI and weekend sedentary time, respectively, than usual-break participants.

Conclusion

Findings varied among the 3 study groups; however, results indicate the potential for consistent attendees of the Booster Break intervention to achieve significant, positive changes related to physical activity, sedentary behavior, and body mass index.

Comparative Cost Analysis of Sequential, Adaptive, Behavioral, Pharmacological, and Combined Treatments for Childhood ADHD

We conducted a cost analysis of the behavioral, pharmacological, and combined interventions employed in a sequential, multiple assignment, randomized, and adaptive trial investigating the sequencing and enhancement of treatment for children with attention deficit hyperactivity disorder (ADHD; Pelham et al., 201X; N = 146, 76% male, 80% Caucasian). The quantity of resources expended on each child's treatment was determined from records that listed the type, date, location, persons present, and duration of all services provided. The inputs considered were the amount of physician time, clinician time, paraprofessional time, teacher time, parent time, medication, and gasoline. Quantities of these inputs were converted into costs in 2013 USD using national wage estimates from the Bureau of Labor Statistics, the prices of 30-day supplies of prescription drugs from the national Express Scripts service, and mean fuel prices from the Energy Information Administration. Beginning treatment with a low-dose/intensity regimen of behavior modification (large-group parent training) was less costly for a school year of treatment ($961) than beginning treatment with a low dose of stimulant medication ($1,669), regardless of whether the initial treatment was intensified with a higher "dose" or if the other modality was added. Outcome data from the parent study (Pelham et al., 201X) found equivalent or superior outcomes for treatments beginning with low-intensity behavior modification compared to intervention beginning with medication. Combined with the present analyses, these findings suggest that initiating treatment with behavior modification rather than medication is the more cost-effective option for children with ADHD.

CareHeroes Web and Android™ Apps for Dementia Caregivers: A Feasibility Study

The purpose of the current feasibility study was to examine the use, utility, and areas for refinement of a newly developed web-based and Android™ application (app) (i.e., CareHeroes) with multiple features to support individuals caring for loved ones with Alzheimer's disease or other forms of dementia (AD). The study was performed over an 11-week period with triads of AD caregivers, assigned home care case managers, and primary care providers (PCP). The study involved quantitative and qualitative methodologies. Eleven AD caregivers (seven daughters, two sons, and two spouses), six case managers, and five PCPs participated. Data demonstrate participants were mostly satisfied with the multiple features and ability to access and use CareHeroes. Barriers for use include concerns about time constraints and not being familiar with technology. Although the study findings are promising, a longer term study to evaluate the impact of the CareHeroes app is indicated.

The Impact of Comprehensive Pre-visit Preparation on Patient Engagement and Quality of Care in a Population of Underserved Patients with Diabetes: Evidence from the Care Management Medical Home Center Model

This study evaluated the impact of pre-visit preparation, a key component of Patient-Centered Medical Home guidelines, on compliance with recommended tests and screenings in a diabetic patient population receiving care in Federally Qualified Health Centers in Miami-Dade County. The pre-visit preparation consisted of a pre-visit phone call to review patient compliance with recommended tests and screenings, provide encouragement for self-care goal setting, answer patient questions, assure referrals and tests were scheduled, and notify an in-center patient care team about which services are required at the upcoming visit. Aggregated data from 7 health centers and a cohort analysis of 7491 patients showed significantly higher compliance among those who were successfully contacted prior to the visit compared to those who were not successfully contacted at 24 months for all compliance measures included in the study. These results included a 28.8 percentage point difference in compliance with HbA1c testing, a 14.6 percentage point difference in influenza immunization, a 27.7 percentage point difference in diabetic foot exam compliance, and a 33.2 percentage point difference in compliance with annual low-density lipoprotein testing. After 24 months, the patient no-show rate decreased by 6.8 percentage points (from 20.7% to 14.0%) among contacted patients and by 5.5 percentage points (from 20.7% to 15.2%) among patients who were not contacted. Study results suggest that proactive pre-visit preparation may be a key strategy for primary care practices to improve areas critical for chronic disease management, such as patient engagement, appointments kept, and compliance with recommended screenings, tests, and services. (Population Health Management 2016;19:171-177).

A cost analysis of web-enhanced training to reduce alcohol sales to intoxicated bar patrons

OBJECTIVE

The purpose of this study was to document the development and testing costs of the Enhanced Alcohol Risk Management (eARM) intervention, a web enhanced training program to prevent alcohol sales to intoxicated bar patrons and to estimate its implementation costs in a "real world", non-research setting.

METHODS

Data for this study were obtained retrospectively from a randomized controlled trial of the eARM intervention, which was conducted across 15 communities in a Midwestern metropolitan area. Inputs and their costs were obtained from records maintained during the randomized controlled trial. Total development and testing costs were computed, and implementation costs were estimated with input from the research team. The average implementation cost per establishment was calculated by dividing the total estimated implementation cost by the number of establishments that participated in the study. This provides an estimate of the resources needed to support a broader dissemination of interventions such as eARM.

RESULTS

Direct development and testing costs were $484,904. Including the University's overhead cost rate of 51 percent, total development and testing costs were $732,205. Total estimated implementation costs were $179,999 over a 12 month period. The average cost per establishment was $1,588.

CONCLUSIONS

Given the large damage liability awards faced by establishments that serve alcohol to drunk drivers, establishments or their insurance companies may be willing to pay the $1,588 estimated implementation cost in order to limit their exposure to these large damage awards. Therefore, making interventions such as eARM available could be an effective and sustainable policy for reducing alcohol-related incidents.

Intermediate outcomes of chronic disease self-management program offered by members of the Healthy Aging Regional Collaborative in South Florida

Currently, 80% of adults over the age of 65 have at least one chronic disease. The Chronic Disease Self-management Program (CDSMP) focuses on increasing self-efficacy for managing chronic disease. Few studies have evaluated the effectiveness of CDSMP when offered by multiple agencies, as a collaborative effort, in community-based settings. Seven agencies delivered 108 CDSMP workshops at 81 sites from October 1, 2008, to December 31, 2010. A total of 811 participants were eligible for analysis. Participants completed surveys at baseline and week 6, the end of instruction. Controlling for agency effect and general health at baseline, the general linear model was used to assess the significance of outcomes at 6 weeks. Outcomes showing significant improvement included self-efficacy to manage disease (p = .001), self-efficacy to manage emotions (p = .026), time spent walking (p = .008), and perceived social/role activities limitations (p = .001). Findings showed that CDSMP is an effective program at improving self-efficacy, increasing physical activity, and decreasing limitations.

Care Management Medical Home Center Model: Preliminary Results of a Patient-Centered Approach to Improving Care Quality for Diabetic Patients

This article presents preliminary findings of the impact of an innovative care management model for diabetic patients. The model was implemented by seven Federally Qualified Health Centers serving 10,000 diabetic patients in Miami-Dade County. A primary intervention of this model is a centralized care management team that makes previsit phone calls to diabetic patients who have scheduled appointments. These previsit phone calls optimize patient knowledge and self-management goals, and provide patient care coordinators with relevant clinical information to optimize the office visit and help to ensure completion of recommended diabetic preventive and chronic care services. Data suggest that following the implementation of this care management model, more diabetic patients are receiving regular care, and compliance with recommended tests and screenings has improved.

Implementation cost analysis of a community-based exercise program for seniors in South Florida

The objective of the study was to measure the costs of implementing the EnhanceFitness program to elderly residents of South Florida. The Health Foundation of South Florida's Healthy Aging Regional Collaborative implemented EnhanceFitness as part of their initiative to make evidence-based healthy aging programs available to South Florida seniors. Cost data were collected from agencies participating in the delivery of EnhanceFitness classes in South Florida. Cost questionnaires were e-mailed to program coordinators from agencies participating in the delivery of EnhanceFitness classes. Program coordinators worked with accounting staff to complete the questionnaires. Questionnaires were returned via e-mail. Costs were presented from the perspective of participating agencies. Total costs were divided by the number of classes being offered by each agency to determine cost per class per month. Average monthly costs per class were $1,713 during the first year of implementation and $873 during the second year of implementation. The cost measurements, combined with information from the literature on cost savings attributable to EnhanceFitness participation, suggest that EnhanceFitness has the potential to generate a net societal cost savings among program participants. The results are useful for community agencies considering implementing EnhanceFitness for their populations.

Intermediate outcomes of a chronic disease self-management program for Spanish-speaking older adults in South Florida, 2008-2010

Introduction

The prevalence and negative health effects of chronic diseases are disproportionately high among Hispanics, the largest minority group in the United States. Self-management of chronic conditions by older adults is a public health priority. The objective of this study was to examine 6-week differences in self-efficacy, time spent performing physical activity, and perceived social and role activities limitations for participants in a chronic disease self-management program for Spanish-speaking older adults, Tomando Control de su Salud (TCDS).

Methods

Through the Healthy Aging Regional Collaborative, 8 area agencies delivered 82 workshops in 62 locations throughout South Florida. Spanish-speaking participants who attended workshops from October 1, 2008, through December 31, 2010, were aged 55 years or older, had at least 1 chronic condition, and completed baseline and post-test surveys were included in analysis (N = 682). Workshops consisted of six, 2.5-hour sessions offered once per week for 6 weeks. A self-report survey was administered at baseline and again at the end of program instruction. To assess differences in outcomes, a repeated measures general linear model was used, controlling for agency and baseline general health.

Results

All outcomes showed improvement at 6 weeks. Outcomes that improved significantly were self-efficacy to manage disease, perceived social and role activities limitations, time spent walking, and time spent performing other aerobic activities.

Conclusion

Implementation of TCDS significantly improved 4 of 8 health promotion skills and behaviors of Spanish-speaking older adults in South Florida. A community-based implementation of TCDS has the potential to improve health outcomes for a diverse, Spanish-speaking, older adult population.

Asthma in underserved schoolchildren in Miami, Florida: results of a school- and community-based needs assessment

OBJECTIVE

Asthma is the most common chronic condition in childhood and disproportionately impacts the poorer and ethnic minorities. The objectives of the study were to estimate the prevalence of asthma in Miami-Dade County (MDC) schoolchildren to aid case-finding and linkage to care.

METHODS

We used the CDC Youth Risk Behavior Surveillance System (YRBSS) definition of possible asthma ("Ever told by a doctor or nurse that they had asthma and still had asthma") and analyzed data from four sources. These included the: (1)-MDC YRBSS 2009, (2)-MDC Health Connect Asthma Survey of school nurses (>2008), (3)-parents' survey in the five HealthConnect survey elementary schools with highest asthma prevalence, and (4)-focus group with parents of asthmatic children.

RESULTS

(1)-MDC YRBSS data showed that 21.3% of high- and 21.4% of middle-school students had been diagnosed with possible asthma. Prevalence was the highest in African-American middle-school girls (26.9%). (2)-HealthConnect survey responders reported that 4.9% of the students in 131 MDC schools had possible asthma. Asthma prevalence was higher in elementary schools (median = 7.1%) and in low-income MDC zip codes. (3)-Of the parent survey responders, 24.9% indicated that their child had possible asthma, and 19.2% reported that their children had no usual source of care. (4)-Focus group participants reported frequent loss of Medicaid coverage for their children, landlords' indifference to the role of poorly maintained housing in asthma, and unmet needs regarding knowledge of health system navigation.

CONCLUSIONS

Asthma may be common in MDC schoolchildren, particularly in poor communities. Formidable structural factors limit the caregivers' abilities to manage childhood asthma.

Cost analysis of a community-based fall prevention program being delivered in South Florida

The aim of this study was to measure the costs of delivering a fall prevention program by community agencies in South Florida. Cost data were collected from agencies participating in the delivery of Matter of Balance workshops in South Florida. Cost information included both initial implementation and ongoing workshop delivery costs. Average costs for implementation per program completer were $325 during the first year in which the program was offered and $176 during the second year of the program. Matter of Balance is a relatively inexpensive fall prevention program. This has implications for the further dissemination and sustainability of evidence-based programs for elderly individuals.

The Impact of Medicare's lifetime immunosuppression coverage on racial disparities in kidney graft survival

Beginning January 1, 2000, Medicare effectively extended its coverage of immunosuppression medications from 3 years to lifetime for patients eligible for Medicare on the basis of age or disability status. We examined the impact of this policy on racial disparities in kidney transplant outcomes at 5 years. Using data from the US Renal Data System, we identified cohorts of Medicare-insured kidney transplant recipients according to patient characteristics defining eligibility for lifetime immunosuppression coverage according to the year 2000 policy. We compared racial disparities in graft survival among those eligible for lifetime coverage with the Kaplan-Meier method. We modeled adjusted associations of patient race, patient income, benefits eligibility category and policy exposure with graft loss by multivariable Cox's regression. The racial disparity in graft survival between African American and non-African American among transplant recipients eligible for the lifetime benefit persisted. The graft survival disparity between high- and low-income African American recipients was insignificantly reduced among those eligible for the lifetime benefit. The results of the study suggest that insurance coverage of medication did not eliminate or reduce the racial disparity in graft survival.

Labor supply responses to government subsidized health insurance: evidence from kidney transplant patients

Between 1993 and 1995 Medicare increased the coverage of immunosuppression medication for kidney transplant recipients from 1 to 3 years following transplantation. The universal Medicare eligibility among kidney transplant patients provides a unique opportunity to explore labor supply responses to public insurance provision among a large number of men and women of prime working age and of all income levels. Although these patients are likely to be less healthy than the general population, upon receiving a kidney transplant, the main health problem of an individual with kidney failure, the lack of functioning kidneys, is removed. The income effects associated with the large transfer payment may discourage labor supply, while the potential health benefits of the coverage extension may promote labor supply. Results indicate that Medicare's increased medication coverage led to decreases in labor force participation among part time workers. These results suggest that potential labor supply reducing income effects should be taken into account when discussing the possibility of expanded public health insurance coverage, particularly for other groups of individuals with high expected medical expenditures, such as the elderly, or those with chronic conditions, such as diabetes. These results are useful considering the forthcoming expansion of government aid to purchase health insurance.

Income-related disparities in kidney transplant graft failures are eliminated by Medicare's immunosuppression coverage

Beginning January 1, 2000, Medicare extended coverage of immunosuppression medications from 3 years to lifetime based on age >65 years or disability. Using United States Renal Data System (USRDS) data for Medicare-insured recipients of kidney transplants between July 1995 and December 2000, we identified four cohorts of Medicare-insured kidney transplant recipients. Patients in cohort 1 were individuals who were both eligible and received lifetime coverage. Patients in cohort 2 would have been eligible, but their 3-year coverage expired before lifetime coverage was available. Patients in cohort 3 were ineligible for lifetime coverage because of youth or lack of disability. Patients in cohort 4 were transplanted between 1995 and 1996 and were ineligible for lifetime coverage. Incomes were categorized by ZIP code median household income from census data. Lifetime extension of Medicare immunosuppression was associated with improved allograft survival among low-income transplant recipients in the sense that the previously existing income-related disparities in graft survival in cohort 2 were not apparent in cohort 1. Ineligible individuals served as a control group; the income-related disparities in graft survival observed in the early cohort 4 persisted in more recent cohort 3. Multivariate proportional hazards models confirmed these findings. Future work should evaluate the cost effectiveness of these coverage increases, as well as that of benefits extensions to broader patient groups.

Cost of lifetime immunosuppression coverage for kidney transplant recipients

On January 1, 2000, Medicare extended the coverage of immunosuppression medications from 3 years to life for elderly and disabled kidney transplant recipients. This research estimates the impact of extending this lifetime coverage to all kidney transplant recipients on Medicare's cash flows. The study finds that extending coverage to all kidney transplant recipients would have increased Medicare's net cash outflows if the coverage were extended for patients of all income levels. There is evidence that extending coverage to only patients in the lowest income quartile could have resulted in a net cost savings to Medicare.

Shared or conflicting working models? Relationships in postdivorce families seen through the eyes of mothers and their preschool children

Marvin and Stewart and Byng-Hall proposed that effective family collaboration requires family members to construct "shared family working models," and that the renegotiation of these working models during family transitions is facilitated by family members' "interactional awareness" (ability to be perceptive observers of family relationships). We apply these constructs to data collected from 71 mothers and their 4.5- to 5.0-year-old preschool children, 2 years after parental divorce. Maternal representations of the father as coparent and ex-spouse, and of father- and mother-child relationships were assessed via two interviews. A family story completion task captured child representations of mother-child and father-child, coparental and ex-spousal interactions. Maternal accounts of mother-child conversations illustrated the negotiation of shared working models. Primarily qualitative analyses contrasting maternal and child perspectives are presented in the first section. Then we use regression analyses to predict children's story themes from maternal representations of flexible, sensitive, and effective discipline-related interactions; maternal depressive symptoms; and perception of the child's father. Finally, we identify gender differences in children's enactments of divorce-related and child-empathy themes. We conclude by considering how our findings could be used to assist post-divorce families in constructing shared rather than conflicting working models of family relations.

Metabolite of (-)-trans-delta 8-tetrahydrocannabinol: identification and synthesis

The major metabolite of (-)-trans-Delta(8)-tetrahydrocannabinol observed in vivo and formed by hepatic microsomes in vitro is 11-hydroxy-trans-Delta(8)-tetrahydrocannabinol. The metabolite was identified spectroscopically and was synthesized from trans-Delta(8)-tetrahydrocannabinol. In tests with rats, the metabolite produced behavioral effects similar to those imparted by Delta(8)- and Delta(9)-tetrahydrocannabinol.

Polywater: Proton Nuclear Magnetic Resonance Spectrum

In the presence of water, the resonance of the strongly hydrogenbonded protons characteristic of polywater appears at 5 parts per million lower applied magnetic field than water. Polywater made by a new method confirms the infrared spectrum reported originally.