Showing papers by "RAND Corporation published in 2010"

Children on the Homefront: The Experience of Children From Military Families

Abstract: 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 P 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.

Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial.

Abstract: {CI}, �3.59 to �1.40], �2.63 [95% CI, �3.73 to �1.54], and �1.63 [95% CI, �2.73 to �0.53] at 6, 12, and 18 months, respectively). At 12 months, response and remission rates (CALM vs UC) were 63.66% (95% CI, 58.95%-68.37%) vs 44.68% (95% CI, 39.76%-49.59%), and 51.49% (95% CI, 46.60%-56.38%) vs 33.28% (95% CI, 28.62%-37.93%), with a number needed to treat of 5.27 (95% CI, 4.18-7.13) for response and 5.50 (95% CI, 4.32-7.55) for remission. Conclusion For patients with anxiety disorders treated in primary care clinics, CALM compared with UC resulted in greater improvement in anxiety symptoms, depression symptoms, functional disability, and quality of care during 18 months of follow-up.

Changes in undergraduate students’ psychological well‐being as they progress through university

Abstract: This article investigates the psychological well‐being of students from all faculties across their undergraduate degree from pre‐registration to semester two of year three at one UK university. Data were collected on seven occasions, with 66% of students who began their studies between 2000 and 2002 taking part in the project. Psychological well‐being was assessed using the General Population Clinical Outcomes in Routine Evaluation (GP‐CORE). Results show that greater strain is placed on well‐being once students start university compared to pre‐university levels. Levels of strain are generally highest during semester one, with significant reduction in levels of distress from semester one to semester two being observed in both year one and year three. At no time did levels of distress fall to pre‐registration levels. Given these results show university to be a time of heightened distress, there is a need to ensure that students receive the support necessary throughout their studies to enable them to succes...

Development, implementation, and public reporting of the HCAHPS survey.

Abstract: The authors describe the history and development of the CAHPS Hospital Survey (also known as HCAHPS) and its associated protocols. The randomized mode experiment, vendor training, and "dry runs" that set the stage for initial public reporting are described. The rapid linkage of HCAHPS data to annual payment updates ("pay for reporting") is noted, which in turn led to the participation of approximately 3,900 general acute care hospitals (about 90% of all such United States hospitals). The authors highlight the opportunities afforded by this publicly reported data on hospital inpatients' experiences and perceptions of care. These data, reported on www.hospitalcompare.hhs. gov, facilitate the national comparison of patients' perspectives of hospital care and can be used alone or in conjunction with other clinical and outcome measures. Potential benefits include increased transparency, improved consumer decision making, and increased incentives for the delivery of high-quality health care.

Many Emergency Department Visits Could Be Managed At Urgent Care Centers And Retail Clinics

Abstract: 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.

Back to Work: Expectations and Realizations of Work after Retirement

Abstract: This paper analyzes a puzzling aspect of retirement behavior known as "unretirement." Nearly 50 percent of retirees follow a nontraditional retirement path that involves partial retirement or unretirement, and at least 26 percent of retirees later unretire. I explore two possible explanations: 1) unretirement transitions result from failures in planning or financial shocks; and 2) unretirement transitions are anticipated prior to retirement, reflecting a more complex retirement process. I show that unretirement was anticipated for the vast majority of those returning to work, and is not a result of financial shocks, poor planning or low wealth accumulation.

Evidence-Based Mental Health Programs in Schools: Barriers and Facilitators of Successful Implementation

Abstract: Although schools can improve children’s access to mental health services, not all school-based providers are able to successfully deliver evidence-based practices. Indeed, even when school clinicians are trained in evidence-based practices (EBP), the training does not necessarily result in the implementation of those practices. This study explores factors that influence implementation of a particular EBP, Cognitive Behavioral Intervention for Trauma in Schools (CBITS). Semi-structured telephone interviews with 35 site administrators and clinicians from across the United States were conducted 6–18 months after receiving CBITS training to discuss implementation experiences. The implementation experiences of participants differed, but all reported similar barriers to implementation. Sites that successfully overcame such barriers differed from their unsuccessful counterparts by having greater organizational structure for delivering school services, a social network of other clinicians implementing CBITS, and administrative support for implementation. This study suggests that EBP implementation can be facilitated by having the necessary support from school leadership and peers.

The health and health care of lesbian, gay, and bisexual adolescents.

Abstract: Adolescents face a variety of challenges in their transition to adulthood; lesbian, gay, and bisexual adolescents face these typical challenges as well as additional challenges that are related to the social stigma of their sexual orientation. For some lesbian, gay, and bisexual adolescents, this stigma may induce psychosocial stress, leading to increased health risk behaviors and poorer health outcomes. In this article, we review data on the health and health care of LGB adolescents. We examine health indicators and health risks for LGB youth, including substance use, eating disorders, suicidality, risky sexual behaviors, violence exposure and victimization, and homelessness. We also examine health care provision and utilization for LGB youth. Lastly, we discuss ways in which researchers and clinicians can improve LGB adolescent health and health care.

Physician factors associated with discussions about end‐of‐life care

Abstract: BACKGROUND: Guidelines recommend advanced care planning for terminally ill patients with <1 year to live. Few data are available regarding when physicians and their terminally ill patients typically discuss endof-life issues. METHODS: A national survey was conducted of physicians caring for cancer patients about timing of discussions regarding prognosis, do not resuscitate (DNR) status, hospice, and preferred site of death with their terminally ill patients. Logistic regression was used to identify physician and practice characteristics associated with earlier discussions. RESULTS: Among 4074 respondents, 65% would discuss prognosis ‘‘now’’ (defined as patient has 4 months to 6 months to live, asymptomatic). Fewer would discuss DNR status (44%), hospice (26%), or preferred site of death (21%) immediately, with most physicians waiting for patient symptoms or until there are no more treatments to offer. In multivariate analyses, younger physicians more often discussed prognosis, DNR status, hospice, and site of death ‘‘now’’ (all P < .05). Surgeons and oncologists were more likely than noncancer specialists to discuss prognosis ‘‘now’’ (P ¼ .008), but noncancer specialists were more likely than cancer specialists to discuss DNR status, hospice, and preferred site of death ‘‘now’’ (all P < .001). CONCLUSIONS: Most physicians report they would not discuss end-of-life options with terminally ill patients who are feeling well, instead waiting for symptoms or until there are no more treatments to offer. More research is needed to understand physicians’ reasons for timing of discussions and how their propensity to aggressively treat metastatic disease influences timing, as well as how the timing of discussions influences patient and family experiences at the end of life. Cancer 2010;116:000–000. V C 2010 American Cancer Society.

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

Abstract: 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.

What Explains the Gender Gap in Financial Literacy? The Role of Household Decision-Making

Abstract: Research has shown that financial illiteracy is widespread among women, and that many women are unfamiliar with even the most basic economic concepts needed to make saving and investment decisions. This gender gap in financial literacy may contribute to the differential levels of retirement preparedness between women and men. However, little is known about the determinants of the gender gap in financial literacy. Using data from the RAND American Life Panel, the authors examined potential explanations for the gender gap including the role of marriage and division of financial decision-making among couples. They found that differences in the demographic characteristics of women and men did not explain much of the financial literacy gap, whereas education, income and current and past marital status reduced the observed gap by around 25%. Oaxaca decomposition revealed the great majority of the gender gap in financial literacy is not explained by differences in covariates - characteristics of men and women - but due to coefficients, or how literacy is produced. They did not find strong support for specialization in financial decision-making within couples by gender. Instead, they found that decision-making within couples was sensitive to the relative education level of spouses for both women and men.

Children's mental health care following Hurricane Katrina: a field trial of trauma-focused psychotherapies.

Abstract: New Orleans school children participated in an assessment and field trial of two interventions 15 months after Hurricane Katrina. Children (N = 195) reported on hurricane exposure, lifetime trauma exposure, peer and parent support, posttraumatic stress disorder (PTSD), and depressive symptoms. Teachers reported on behavior. At baseline, 60.5% screened positive for PTSD symptoms and were offered a group intervention at school or individual treatment at a mental health clinic. Uptake of the mental health care was uneven across intervention groups, with 98% beginning the school intervention, compared to 37% beginning at the clinic. Both treatments led to significant symptom reduction of PTSD symptoms, but many still had elevated PTSD symptoms at posttreatment. Implications for future postdisaster mental health work are discussed.

Primary Care: A Critical Review Of The Evidence On Quality And Costs Of Health Care

Abstract: Despite contentious debate over the new national health care reform law, there is an emerging consensus that strengthening primary care will improve health outcomes and restrain the growth of health care spending. Policy discussions imply three general definitions of primary care: a specialty of medical providers, a set of functions served by a usual source of care, and an orientation of health systems. We review the empirical evidence linking each definition of primary care to health care quality, outcomes, and costs. The available evidence most directly supports initiatives to increase providers' ability to serve primary care functions and to reorient health systems to emphasize delivery of primary care.

Where Americans Get Acute Care: Increasingly, It’s Not At Their Doctor’s Office

Abstract: Historically, general practitioners provided first-contact care in the United States. Today, however, only 42 percent of the 354 million annual visits for acute care—treatment for newly arising health problems—are made to patients’ personal physicians. The rest are made to emergency departments (28 percent), specialists (20 percent), or outpatient departments (7 percent). Although fewer than 5 percent of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of such visits by the uninsured. Health reform provisions in the Patient Protection and Affordable Care Act that advance patient-centered medical homes and accountable care organizations are intended to improve access to acute care. The challenge for reform will be to succeed in the current, complex acute care landscape.

Anxiety Sensitivity and PTSD Symptom Severity Are Reciprocally Related: Evidence From a Longitudinal Study of Physical Trauma Survivors

Abstract: Cross-lagged panel analysis of interview data collected from survivors of traumatic physical injury (N = 677) was used to examine the temporal relationship between anxiety sensitivity and posttraumatic stress disorder (PTSD) symptom severity. The 2 constructs were assessed at 3 time points: within days of physical injury, at 6-month follow-up, and at 12-month follow-up. Results indicated that anxiety sensitivity and PTSD symptom severity were reciprocally related such that anxiety sensitivity predicted subsequent PTSD symptom severity, and symptom severity predicted later anxiety sensitivity. Findings have both theoretical and clinical implications.

What Explains the Gender Gap in Financial Literacy? The Role of Household Decision Making.

Abstract: Using newly collected data from the RAND American Life Panel, we examine potential explanations for the gender gap in financial literacy, including the role of marriage and who within a couple makes the financial decisions. Blinder–Oaxaca decomposition reveals the majority of the gender gap in financial literacy is not explained by differences in the characteristics of men and women—but rather differences in coefficients, or how literacy is produced. We find that financial decision making of couples is not centralized in one spouse although it is sensitive to the relative education level of spouses.

The Role of Community in Disaster Response: Conceptual Models

Abstract: We focus on the role that community plays in the continuum of disaster preparedness, response and recovery, and we explore where community fits in conceptual frameworks concerning disaster decision-making. We offer an overview of models developed in the literature as well as insights drawn from research related to Hurricane Katrina. Each model illustrates some aspect of the spectrum of disaster preparedness and recovery, beginning with risk perception and vulnerability assessments, and proceeding to notions of resiliency and capacity building. Concepts like social resilience are related to theories of “social capital,” which stress the importance of social networks, reciprocity, and interpersonal trust. These allow individuals and groups to accomplish greater things than they could by their isolated efforts. We trace two contrasting notions of community to Tocqueville. On the one hand, community is simply an aggregation of individual persons, that is, a population. As individuals, they have only limited capacity to act effectively or make decisions for themselves, and they are strongly subject to administrative decisions that authorities impose on them. On the other hand, community is an autonomous actor, with its own interests, preferences, resources, and capabilities. This definition of community has also been embraced by community-based participatory researchers and has been thought to offer an approach that is more active and advocacy oriented. We conclude with a discussion of the strengths and weaknesses of community in disaster response and in disaster research.

Soda taxes, soft drink consumption, and children's body mass index

Abstract: Taxes on sugar-sweetened beverages have been proposed to combat obesity. Using data on state sales taxes for soda and individual-level data on children, we examine whether small taxes are likely to change consumption and weight gain or whether larger tax increases would be needed. We find that existing taxes on soda, which are typically not much higher than 4 percent in grocery stores, do not substantially affect overall levels of soda consumption or obesity rates. We do find, however, that subgroups of at-risk children—children who are already overweight, come from low-income families, or are African American—may be more sensitive than others to soda taxes, especially when soda is available at school. A greater impact of these small taxes could come from the dedication of the revenues they generate to other obesity prevention efforts rather than through their direct effect on consumption.

Efficiency of static and computer adaptive short forms compared to full-length measures of depressive symptoms

Abstract: Purpose Short-form patient-reported outcome measures are popular because they minimize patient burden. We assessed the efficiency of static short forms and computer adaptive testing (CAT) using data from the Patient-Reported Outcomes Measurement Information System (PROMIS) project.

FDI World Dental Federation - clinical criteria for the evaluation of direct and indirect restorations. Update and clinical examples.

Abstract: In 2007, new clinical criteria were approved by the FDI World Dental Federation and simultaneously published in three dental journals. The criteria were categorized into three groups: esthetic parameters (four criteria), functional parameters (six criteria), and biological parameters (six criteria). Each criterion can be expressed with five scores, three for acceptable and two for non-acceptable (one for reparable and one for replacement). The criteria have been used in several clinical studies since 2007, and the resulting experience in their application has led to a requirement to modify some of the criteria and scores. The two major alterations involve staining and approximal contacts. As staining of the margins and the surface have different causes, both phenomena do not appear simultaneously. Thus, staining has been differentiated into marginal staining and surface staining. The approximal contact now appears under the name "approximal anatomic form" as the approximal contour is a specific, often non-esthetic issue that cannot be integrated into the criterion "esthetic anatomical form". In 2008, a web-based training and calibration tool called e-calib (www.e-calib.info) was made available. Clinical investigators and other research workers can train and calibrate themselves interactively by assessing clinical cases of posterior restorations, which are presented as high quality pictures. Currently, about 300 clinical cases are included in the database which is regularly updated. Training for 8 of the 16 clinical criteria is available in the program: "Surface luster"; "Staining (surface, margins)"; "Color match and translucency"; "Esthetic anatomical form"; "Fracture of material and retention"; "Marginal adaptation"; "Recurrence of caries, erosion, abfraction"; and "Tooth integrity (enamel cracks, tooth fractures)". Typical clinical cases are presented for each of these eight criteria and their corresponding five scores.

Medicare spending and outcomes after postacute care for stroke and hip fracture.

Abstract: Background—Elderly patients who leave an acute care hospital after a stroke or a hip fracture may be discharged home or undergo post-acute rehabilitative care in an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF). Since 15% of Medicare expenditures are for these types of post-acute care, it is important to understand their relative costs and the health outcomes they produce. Objective—To assess Medicare payments for and outcomes of patients discharged from acute care to an IRF, a SNF, or home after an inpatient diagnosis of stroke or hip fracture between January 2002 and June 2003. Research Design—This is an observational study based on Medicare administrative data. We adjust for observable differences in patient severity across post-acute care sites and we use instrumental variables estimation to account for unobserved patient selection. Study Outcomes—Mortality, return to community residence, and total Medicare post-acute payments by 120 days after acute care discharge. Results—Relative to discharge home, IRFs improve health outcomes for hip fracture patients. SNFs reduce mortality for hip fracture patients, but increase rates of institutionalization for stroke patients. Both sites of care are far more expensive than discharge to home. Conclusions—When there is a choice between IRF and SNF care for stroke and hip fracture patients, the marginal patient is better off going to an IRF for post-acute care. However, given the marginal cost of an IRF stay compared to returning home, the gains to these patients should be considered in light of the additional costs.

Financial Decision Making and Cognition in a Family Context

Abstract: In this paper, we studied the association of cognitive traits and in particular numeracy of both spouses on financial outcomes of the family. We found significant effects, particularly for numeracy for financial and non-financial respondents alike, but much larger effects for the financial decision maker in the family. We also examined who makes these financial decisions in the family and why. Once again, cognitive traits such as numeracy were an important component of that decision with larger effects of numeracy for husbands compared to wives.