Showing papers by "RAND Corporation published in 2016"

Driving to Safety: How Many Miles of Driving Would It Take to Demonstrate Autonomous Vehicle Reliability?

Abstract: How safe are autonomous vehicles? The answer is critical for determining how autonomous vehicles may shape motor vehicle safety and public health, and for developing sound policies to govern their deployment. One proposed way to assess safety is to test drive autonomous vehicles in real traffic, observe their performance, and make statistical comparisons to human driver performance. This approach is logical, but it is practical? In this paper, we calculate the number of miles of driving that would be needed to provide clear statistical evidence of autonomous vehicle safety. Given that current traffic fatalities and injuries are rare events compared to vehicle miles traveled, we show that fully autonomous vehicles would have to be driven hundreds of millions of miles and sometimes hundreds of billions of miles to demonstrate their reliability in terms of fatalities and injuries. Under even aggressive testing assumptions, existing fleets would take tens and sometimes hundreds of years to drive these miles—an impossible proposition if the aim is to demonstrate their performance prior to releasing them on the roads for consumer use. These findings demonstrate that developers of this technology and third-party testers cannot simply drive their way to safety. Instead, they will need to develop innovative methods of demonstrating safety and reliability. And yet, the possibility remains that it will not be possible to establish with certainty the safety of autonomous vehicles. Uncertainty will remain. Therefore, it is imperative that autonomous vehicle regulations are adaptive—designed from the outset to evolve with the technology so that society can better harness the benefits and manage the risks of these rapidly evolving and potentially transformative technologies.

Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Abstract: Importance Colorectal cancer (CRC) remains a significant cause of morbidity and mortality in the United States. Objective To systematically review the effectiveness, diagnostic accuracy, and harms of screening for CRC. Data Sources Searches of MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials for relevant studies published from January 1, 2008, through December 31, 2014, with surveillance through February 23, 2016. Study Selection English-language studies conducted in asymptomatic populations at general risk of CRC. Data Extraction and Synthesis Two reviewers independently appraised the articles and extracted relevant study data from fair- or good-quality studies. Random-effects meta-analyses were conducted. Main Outcomes and Measures Colorectal cancer incidence and mortality, test accuracy in detecting CRC or adenomas, and serious adverse events. Results Four pragmatic randomized clinical trials (RCTs) evaluating 1-time or 2-time flexible sigmoidoscopy (n = 458 002) were associated with decreased CRC-specific mortality compared with no screening (incidence rate ratio, 0.73; 95% CI, 0.66-0.82). Five RCTs with multiple rounds of biennial screening with guaiac-based fecal occult blood testing (n = 419 966) showed reduced CRC-specific mortality (relative risk [RR], 0.91; 95% CI, 0.84-0.98, at 19.5 years to RR, 0.78; 95% CI, 0.65-0.93, at 30 years). Seven studies of computed tomographic colonography (CTC) with bowel preparation demonstrated per-person sensitivity and specificity to detect adenomas 6 mm and larger comparable with colonoscopy (sensitivity from 73% [95% CI, 58%-84%] to 98% [95% CI, 91%-100%]; specificity from 89% [95% CI, 84%-93%] to 91% [95% CI, 88%-93%]); variability and imprecision may be due to differences in study designs or CTC protocols. Sensitivity of colonoscopy to detect adenomas 6 mm or larger ranged from 75% (95% CI, 63%-84%) to 93% (95% CI, 88%-96%). On the basis of a single stool specimen, the most commonly evaluated families of fecal immunochemical tests (FITs) demonstrated good sensitivity (range, 73%-88%) and specificity (range, 90%-96%). One study (n = 9989) found that FIT plus stool DNA test had better sensitivity in detecting CRC than FIT alone (92%) but lower specificity (84%). Serious adverse events from colonoscopy in asymptomatic persons included perforations (4/10 000 procedures, 95% CI, 2-5 in 10 000) and major bleeds (8/10 000 procedures, 95% CI, 5-14 in 10 000). Computed tomographic colonography may have harms resulting from low-dose ionizing radiation exposure or identification of extracolonic findings. Conclusions and Relevance Colonoscopy, flexible sigmoidoscopy, CTC, and stool tests have differing levels of evidence to support their use, ability to detect cancer and precursor lesions, and risk of serious adverse events in average-risk adults. Although CRC screening has a large body of supporting evidence, additional research is still needed.

Genetic variants associated with subjective well-being, depressive symptoms, and neuroticism identified through genome-wide analyses

Abstract: Very few genetic variants have been associated with depression and neuroticism, likely because of limitations on sample size in previous studies. Subjective well-being, a phenotype that is genetically correlated with both of these traits, has not yet been studied with genome-wide data. We conducted genome-wide association studies of three phenotypes: subjective well-being (n = 298,420), depressive symptoms (n = 161,460), and neuroticism (n = 170,911). We identify 3 variants associated with subjective well-being, 2 variants associated with depressive symptoms, and 11 variants associated with neuroticism, including 2 inversion polymorphisms. The two loci associated with depressive symptoms replicate in an independent depression sample. Joint analyses that exploit the high genetic correlations between the phenotypes (|ρ^| ≈ 0.8) strengthen the overall credibility of the findings and allow us to identify additional variants. Across our phenotypes, loci regulating expression in central nervous system and adrenal or pancreas tissues are strongly enriched for association.

Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial

Abstract: Importance Interventions based on behavioral science might reduce inappropriate antibiotic prescribing. Objective To assess effects of behavioral interventions and rates of inappropriate (not guideline-concordant) antibiotic prescribing during ambulatory visits for acute respiratory tract infections. Design, Setting, and Participants Cluster randomized clinical trial conducted among 47 primary care practices in Boston and Los Angeles. Participants were 248 enrolled clinicians randomized to receive 0, 1, 2, or 3 interventions for 18 months. All clinicians received education on antibiotic prescribing guidelines on enrollment. Interventions began between November 1, 2011, and October 1, 2012. Follow-up for the latest-starting sites ended on April 1, 2014. Adult patients with comorbidities and concomitant infections were excluded. Interventions Three behavioral interventions, implemented alone or in combination:suggested alternativespresented electronic order sets suggesting nonantibiotic treatments;accountable justificationprompted clinicians to enter free-text justifications for prescribing antibiotics into patients’ electronic health records;peer comparisonsent emails to clinicians that compared their antibiotic prescribing rates with those of “top performers” (those with the lowest inappropriate prescribing rates). Main Outcomes and Measures Antibiotic prescribing rates for visits with antibiotic-inappropriate diagnoses (nonspecific upper respiratory tract infections, acute bronchitis, and influenza) from 18 months preintervention to 18 months afterward, adjusting each intervention’s effects for co-occurring interventions and preintervention trends, with random effects for practices and clinicians. Results There were 14 753 visits (mean patient age, 47 years; 69% women) for antibiotic-inappropriate acute respiratory tract infections during the baseline period and 16 959 visits (mean patient age, 48 years; 67% women) during the intervention period. Mean antibiotic prescribing rates decreased from 24.1% at intervention start to 13.1% at intervention month 18 (absolute difference, −11.0%) for control practices; from 22.1% to 6.1% (absolute difference, −16.0%) for suggested alternatives (difference in differences, −5.0% [95% CI, −7.8% to 0.1%];P = .66 for differences in trajectories); from 23.2% to 5.2% (absolute difference, −18.1%) for accountable justification (difference in differences, −7.0% [95% CI, −9.1% to −2.9%];P Conclusions and Relevance Among primary care practices, the use of accountable justification and peer comparison as behavioral interventions resulted in lower rates of inappropriate antibiotic prescribing for acute respiratory tract infections. Trial Registration clinicaltrials.gov Identifier:NCT01454947

Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition–Heart Failure (BEAT-HF) Randomized Clinical Trial

Abstract: Importance It remains unclear whether telemonitoring approaches provide benefits for patients with heart failure (HF) after hospitalization. Objective To evaluate the effectiveness of a care transition intervention using remote patient monitoring in reducing 180-day all-cause readmissions among a broad population of older adults hospitalized with HF. Design, Setting, and Participants We randomized 1437 patients hospitalized for HF between October 12, 2011, and September 30, 2013, to the intervention arm (715 patients) or to the usual care arm (722 patients) of the Better Effectiveness After Transition–Heart Failure (BEAT-HF) study and observed them for 180 days. The dates of our study analysis were March 30, 2014, to October 1, 2015. The setting was 6 academic medical centers in California. Participants were hospitalized individuals 50 years or older who received active treatment for decompensated HF. Interventions The intervention combined health coaching telephone calls and telemonitoring. Telemonitoring used electronic equipment that collected daily information about blood pressure, heart rate, symptoms, and weight. Centralized registered nurses conducted telemonitoring reviews, protocolized actions, and telephone calls. Main Outcomes and Measures The primary outcome was readmission for any cause within 180 days after discharge. Secondary outcomes were all-cause readmission within 30 days, all-cause mortality at 30 and 180 days, and quality of life at 30 and 180 days. Results Among 1437 participants, the median age was 73 years. Overall, 46.2% (664 of 1437) were female, and 22.0% (316 of 1437) were African American. The intervention and usual care groups did not differ significantly in readmissions for any cause 180 days after discharge, which occurred in 50.8% (363 of 715) and 49.2% (355 of 722) of patients, respectively (adjusted hazard ratio, 1.03; 95% CI, 0.88-1.20; P = .74). In secondary analyses, there were no significant differences in 30-day readmission or 180-day mortality, but there was a significant difference in 180-day quality of life between the intervention and usual care groups. No adverse events were reported. Conclusions and Relevance Among patients hospitalized for HF, combined health coaching telephone calls and telemonitoring did not reduce 180-day readmissions. Trial Registration clinicaltrials.gov Identifier:NCT01360203

Estimation of Benefits, Burden, and Harms of Colorectal Cancer Screening Strategies: Modeling Study for the US Preventive Services Task Force

Abstract: Importance The US Preventive Services Task Force (USPSTF) is updating its 2008 colorectal cancer (CRC) screening recommendations. Objective To inform the USPSTF by modeling the benefits, burden, and harms of CRC screening strategies; estimating the optimal ages to begin and end screening; and identifying a set of model-recommendable strategies that provide similar life-years gained (LYG) and a comparable balance between LYG and screening burden. Design, Setting, and Participants Comparative modeling with 3 microsimulation models of a hypothetical cohort of previously unscreened US 40-year-olds with no prior CRC diagnosis. Exposures Screening with sensitive guaiac-based fecal occult blood testing, fecal immunochemical testing (FIT), multitarget stool DNA testing, flexible sigmoidoscopy with or without stool testing, computed tomographic colonography (CTC), or colonoscopy starting at age 45, 50, or 55 years and ending at age 75, 80, or 85 years. Screening intervals varied by modality. Full adherence for all strategies was assumed. Main Outcomes and Measures Life-years gained compared with no screening (benefit), lifetime number of colonoscopies required (burden), lifetime number of colonoscopy complications (harms), and ratios of incremental burden and benefit (efficiency ratios) per 1000 40-year-olds. Results The screening strategies provided LYG in the range of 152 to 313 per 1000 40-year-olds. Lifetime colonoscopy burden per 1000 persons ranged from fewer than 900 (FIT every 3 years from ages 55-75 years) to more than 7500 (colonoscopy screening every 5 years from ages 45-85 years). Harm from screening was at most 23 complications per 1000 persons screened. Strategies with screening beginning at age 50 years generally provided more LYG as well as more additional LYG per additional colonoscopy than strategies with screening beginning at age 55 years. There were limited empirical data to support a start age of 45 years. For persons adequately screened up to age 75 years, additional screening yielded small increases in LYG relative to the increase in colonoscopy burden. With screening from ages 50 to 75 years, 4 strategies yielded a comparable balance of screening burden and similar LYG (median LYG per 1000 across the models): colonoscopy every 10 years (270 LYG); sigmoidoscopy every 10 years with annual FIT (256 LYG); CTC every 5 years (248 LYG); and annual FIT (244 LYG). Conclusions and Relevance In this microsimulation modeling study of a previously unscreened population undergoing CRC screening that assumed 100% adherence, the strategies of colonoscopy every 10 years, annual FIT, sigmoidoscopy every 10 years with annual FIT, and CTC every 5 years performed from ages 50 through 75 years provided similar LYG and a comparable balance of benefit and screening burden.

Mental Health Conditions Among Patients Seeking and Undergoing Bariatric Surgery: A Meta-analysis

Abstract: Importance Bariatric surgery is associated with sustained weight loss and improved physical health status for severely obese individuals. Mental health conditions may be common among patients seeking bariatric surgery; however, the prevalence of these conditions and whether they are associated with postoperative outcomes remains unknown. Objective To determine the prevalence of mental health conditions among bariatric surgery candidates and recipients, to evaluate the association between preoperative mental health conditions and health outcomes following bariatric surgery, and to evaluate the association between surgery and the clinical course of mental health conditions. Data Sources We searched PubMed, MEDLINE on OVID, and PsycINFO for studies published between January 1988 and November 2015. Study quality was assessed using an adapted tool for risk of bias; quality of evidence was rated based on GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. Findings We identified 68 publications meeting inclusion criteria: 59 reporting the prevalence of preoperative mental health conditions (65 363 patients) and 27 reporting associations between preoperative mental health conditions and postoperative outcomes (50 182 patients). Among patients seeking and undergoing bariatric surgery, the most common mental health conditions, based on random-effects estimates of prevalence, were depression (19% [95% CI, 14%-25%]) and binge eating disorder (17% [95% CI, 13%-21%]). There was conflicting evidence regarding the association between preoperative mental health conditions and postoperative weight loss. Neither depression nor binge eating disorder was consistently associated with differences in weight outcomes. Bariatric surgery was, however, consistently associated with postoperative decreases in the prevalence of depression (7 studies; 8%-74% decrease) and the severity of depressive symptoms (6 studies; 40%-70% decrease). Conclusions and Relevance Mental health conditions are common among bariatric surgery patients—in particular, depression and binge eating disorder. There is inconsistent evidence regarding the association between preoperative mental health conditions and postoperative weight loss. Moderate-quality evidence supports an association between bariatric surgery and lower rates of depression postoperatively.

What is an evidence map? A systematic review of published evidence maps and their definitions, methods, and products

Abstract: The need for systematic methods for reviewing evidence is continuously increasing. Evidence mapping is one emerging method. There are no authoritative recommendations for what constitutes an evidence map or what methods should be used, and anecdotal evidence suggests heterogeneity in both. Our objectives are to identify published evidence maps and to compare and contrast the presented definitions of evidence mapping, the domains used to classify data in evidence maps, and the form the evidence map takes. We conducted a systematic review of publications that presented results with a process termed “evidence mapping” or included a figure called an “evidence map.” We identified publications from searches of ten databases through 8/21/2015, reference mining, and consulting topic experts. We abstracted the research question, the unit of analysis, the search methods and search period covered, and the country of origin. Data were narratively synthesized. Thirty-nine publications met inclusion criteria. Published evidence maps varied in their definition and the form of the evidence map. Of the 31 definitions provided, 67 % described the purpose as identification of gaps and 58 % referenced a stakeholder engagement process or user-friendly product. All evidence maps explicitly used a systematic approach to evidence synthesis. Twenty-six publications referred to a figure or table explicitly called an “evidence map,” eight referred to an online database as the evidence map, and five stated they used a mapping methodology but did not present a visual depiction of the evidence. The principal conclusion of our evaluation of studies that call themselves “evidence maps” is that the implied definition of what constitutes an evidence map is a systematic search of a broad field to identify gaps in knowledge and/or future research needs that presents results in a user-friendly format, often a visual figure or graph, or a searchable database. Foundational work is needed to better standardize the methods and products of an evidence map so that researchers and policymakers will know what to expect of this new type of evidence review. Although an a priori protocol was developed, no registration was completed; this review did not fit the PROSPERO format.

Risk Factors for Childhood Stunting in 137 Developing Countries: A Comparative Risk Assessment Analysis at Global, Regional, and Country Levels.

Abstract: Background Stunting affects one-third of children under 5 y old in developing countries, and 14% of childhood deaths are attributable to it. A large number of risk factors for stunting have been identified in epidemiological studies. However, the relative contribution of these risk factors to stunting has not been examined across countries. We estimated the number of stunting cases among children aged 24–35 mo (i.e., at the end of the 1,000 days’ period of vulnerability) that are attributable to 18 risk factors in 137 developing countries.

An open letter to The BMJ editors on qualitative research

Abstract: Seventy six senior academics from 11 countries invite The BMJ ’s editors to reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission

Latino Immigrants, Acculturation, and Health: Promising New Directions in Research.

Abstract: This article provides an analysis of novel topics emerging in recent years in research on Latino immigrants, acculturation, and health. In the past ten years, the number of studies assessing new ways to conceptualize and understand how acculturation-related processes may influence health has grown. These new frameworks draw from integrative approaches testing new ground to acknowledge the fundamental role of context and policy. We classify the emerging body of evidence according to themes that we identify as promising directions--intrapersonal, interpersonal, social environmental, community, political, and global contexts, cross-cutting themes in life course and developmental approaches, and segmented assimilation--and discuss the challenges and opportunities each theme presents. This body of work, which considers acculturation in context, points to the emergence of a new wave of research that holds great promise in driving forward the study of Latino immigrants, acculturation, and health. We provide suggestions to further advance the ideologic and methodologic rigor of this new wave.

A systematic review of St. John’s wort for major depressive disorder

Abstract: This systematic review evaluated St. John’s wort (SJW) for the treatment of Major Depressive Disorder (MDD). The objectives of this review are to (1) evaluate the efficacy and safety of SJW in adults with MDD compared to placebo and active comparator and (2) evaluate whether the effects vary by severity of MDD. We searched PubMed, CINAHL, PsycINFO, CENTRAL, Embase, AMED, MANTIS, Web of Science, and ICTRP and existing reviews to November 2014. Two independent reviewers screened the citations, abstracted the data, and assessed the risk of bias. We included randomized controlled trials (RCTs) examining the effect of at least a 4-week administration of SJW on depression outcomes against placebo or active comparator in adults with MDD. Risk of bias was assessed using the Cochrane Risk of Bias tool and USPSTF criteria. Quality of evidence (QoE) was assessed using the GRADE approach. Thirty-five studies examining 6993 patients met inclusion criteria; eight studies evaluated a hypericum extract that combined 0.3 % hypericin and 1–4 % hyperforin. The herb SJW was associated with more treatment responders than placebo (relative risk [RR] 1.53; 95 % confidence interval [CI] 1.19, 1.97; I2 79 %; 18 RCTs; N = 2922, moderate QoE; standardized mean differences [SMD] 0.49; CI 0.23, 0.74; 16 RCTs; I2 89 %, N = 2888, moderate QoE). Compared to antidepressants, SJW participants were less likely to experience adverse events (OR 0.67; CI 0.56, 0.81; 11 RCTs; moderate QoE) with no difference in treatment effectiveness (RR 1.01; CI 0.90, 1.14; 17 RCTs, I2 52 %, moderate QoE; SMD −0.03; CI −0.21, 0.15; 14 RCTs; I2 74 %; N = 2248, moderate QoE) in mild and moderate depression. SJW monotherapy for mild and moderate depression is superior to placebo in improving depression symptoms and not significantly different from antidepressant medication. However, evidence of heterogeneity and a lack of research on severe depression reduce the quality of the evidence. Adverse events reported in RCTs were comparable to placebo and fewer compared with antidepressants. However, assessments were limited due to poor reporting of adverse events and studies were not designed to assess rare events. Consequently, the findings should be interpreted with caution. PROSPERO CRD42015016406 .

The Effect of Population Aging on Economic Growth, the Labor Force and Productivity

Abstract: Population aging is widely assumed to have detrimental effects on economic growth yet there is little empirical evidence about the magnitude of its effects. This paper starts from the observation that many U.S. states have already experienced substantial growth in the size of their older population and much of this growth was predetermined by historical trends in fertility. We use predicted variation in the rate of population aging across U.S. states over the period 1980-2010 to estimate the economic impact of aging on state output per capita. We find that a 10% increase in the fraction of the population ages 60 decreases the growth rate of GDP per capita by 5.5%. Two-thirds of the reduction is due to slower growth in the labor productivity of workers across the age distribution, while one-third arises from slower labor force growth. Our results imply annual GDP growth will slow by 1.2 percentage points this decade and 0.6 percentage points next decade due to population aging.

Examining the costs and causes of cyber incidents

Abstract: In 2013, the US President signed an executive order designed to help secure the nation’s critical infrastructure from cyberattacks. As part of that order, he directed the National Institute for Standards and Technology (NIST) to develop a framework that would become an authoritative source for information security best practices. Because adoption of the framework is voluntary, it faces the challenge of incentivizing firms to follow along. Will frameworks such as that proposed by NIST really induce firms to adopt better security controls? And if not, why? This research seeks to examine the composition and costs of cyber events, and attempts to address whether or not there exist incentives for firms to improve their security practices and reduce the risk of attack. Specifically, we examine a sample of over 12 000 cyber events that include data breaches, security incidents, privacy violations, and phishing crimes. First, we analyze the characteristics of these breaches (such as causes and types of information compromised). We then examine the breach and litigation rate, by industry, and identify the industries that incur the greatest costs from cyber events. We then compare these costs to bad debts and fraud within other industries. The findings suggest that public concerns regarding the increasing rates of breaches and legal actions may be excessive compared to the relatively modest financial impact to firms that suffer these events. Public concerns regarding the increasing rates of breaches and legal actions, conflict, however, with our findings that show a much smaller financial impact to firms that suffer these events. Specifically, we find that the cost of a typical cyber incident in our sample is less than $200 000 (about the same as the firm’s annual IT security budget), and that this represents only 0.4% of their estimated annual revenues.

Wearing body cameras increases assaults against officers and does not reduce police use of force: Results from a global multi-site experiment:

Abstract: This is the final version of the article. It first appeared from Sage via https://doi.org/10.1177/1477370816643734.

Racial and Ethnic Disparities in ADHD Diagnosis and Treatment

Abstract: OBJECTIVES: We examined racial/ethnic disparities in attention-deficit/hyperactivity disorder (ADHD) diagnosis and medication use and determined whether medication disparities were more likely due to underdiagnosis or undertreatment of African-American and Latino children, or overdiagnosis or overtreatment of white children. METHODS: We used a population-based, multisite sample of 4297 children and parents surveyed over 3 waves (fifth, seventh, and 10th grades). Multivariate logistic regression examined disparities in parent-reported ADHD diagnosis and medication use in the following analyses: (1) using the total sample; (2) limited to children with an ADHD diagnosis or symptoms; and (3) limited to children without a diagnosis or symptoms. RESULTS: Across all waves, African-American and Latino children, compared with white children, had lower odds of having an ADHD diagnosis and of taking ADHD medication, controlling for sociodemographics, ADHD symptoms, and other potential comorbid mental health symptoms. Among children with an ADHD diagnosis or symptoms, African-American children had lower odds of medication use at fifth, seventh, and 10th grades, and Latino children had lower odds at fifth and 10th grades. Among children who had neither ADHD symptoms nor ADHD diagnosis by fifth grade (and thus would not likely meet ADHD diagnostic criteria at any age), medication use did not vary by race/ethnicity in adjusted analysis. CONCLUSIONS: Racial/ethnic disparities in parent-reported medication use for ADHD are robust, persisting from fifth grade to 10th grade. These findings suggest that disparities may be more likely related to underdiagnosis and undertreatment of African-American and Latino children as opposed to overdiagnosis or overtreatment of white children.

Utilization of Telemedicine Among Rural Medicare Beneficiaries

Abstract: Utilization of Telemedicine Among Rural Medicare Beneficiaries Telemedicine may increase access and improve quality, particularly in rural areas.1 Because inadequate reimbursement may limit telemedicine use, 29 states have passed telemedicine parity laws mandating that commercial insurers reimburse telemedicine visits.2 In contrast, Medicare limits telemedicine reimbursement to select live video encounters with the patient at a clinic or facility in a rural area.3 Federal legislation has been proposed to expand Medicare telemedicine coverage. To inform the debate regarding telemedicine expansion, we describe trends in telemedicine utilization in Medicare from 2004-2013.

Risk of suicide attempt and suicide death following completion of the Patient Health Questionnaire depression module in community practice.

Abstract: OBJECTIVE: To examine the association between thoughts of death or self-harm reported on item 9 of the Patient Health Questionnaire (PHQ) depression module and the risk of suicide attempt or suicide death over the following 2 years. METHOD: In 4 health care systems participating in the Mental Health Research Network, electronic records identified 509,945 adult outpatients completing 1,228,308 PHQ depression questionnaires during visits to primary care, specialty mental health, and other outpatient providers between January 1, 2007 and December 31, 2012. 9,203 nonfatal suicide attempts were identified using health system records of inpatient or outpatient encounters for self-inflicted injury. 484 suicide deaths were identified using cause-of-death codes from state mortality data. RESULTS: Cumulative hazard of suicide attempt during 2 years ranged from approximately 0.5% among those reporting thoughts of death or self-harm "not at all" to 3.5% among those reporting such thoughts "nearly every day." Cumulative hazard of suicide death during 2 years ranged from approximately 0.04% among those responding "not at all" to 0.19% among those responding "nearly every day." The excess hazard associated with thoughts of death or self-harm declined with time, but remained 2- to 5-fold higher for at least 18 months. Nevertheless, 39% of suicide attempts and 36% of suicide deaths within 30 days of completing a PHQ occurred among those responding "not at all" to item 9. CONCLUSIONS: In community practice, response to PHQ item 9 is a strong predictor of suicide attempt and suicide death over the following 2 years. For patients reporting thoughts of death or self-harm, suicide prevention efforts must address this enduring vulnerability. Language: en

Report: increases in police use of force in the presence of body-worn cameras are driven by officer discretion: a protocol-based subgroup analysis of ten randomized experiments

Abstract: Our multisite randomized controlled trial reported that police body-worn cameras (BWCs) had, on average, no effect on recorded incidents of police use of force. In some sites, rates of use of force decreased and in others increased. We wanted to understand these counter-intuitive findings and report pre-specified subgroup analyses related to officers’ discretion on activating the BWCs. Using pre-established criteria for experimental protocol breakdown in terms of treatment integrity, ten experimental sites were subgrouped into “high-compliance” (no officer discretion applied to when and where BWCs should be used; n = 3), “no-compliance” (treatment integrity failure in both treatment and control conditions; n = 4), and tests where officers applied discretion during treatment group but followed protocol in control conditions only (n = 4). When officers complied with the experimental protocol and did not use discretion, use of force rates were 37 % lower [SMD = (−.346); SE = .137; 95 % CI (−.614) – (−.077)]; when officers did not comply with treatment protocol (i.e., officers chose when to turn cameras on/off), use of force rates were 71 % higher [SMD = .392; SE = .130; 95 % CI (.136) – (.647)], compared to control conditions. When full discretion (i.e., overall breakdown of protocol) was applied to both treatment and control conditions, null effects were registered [SMD = .009; SE=.070; 95 % CI (−.127) – (.146)], compared to control conditions. BWCs can reduce police use of force when then officers’ discretion to turn cameras on or off is minimized—in terms of both case types as well as individual incidents. BWCs ought to be switched on and the recording announced to suspects at early stages of police–public interactions. Future BWCs tests should pay close attention to adherence to experimental protocols.

Access and Quality of Care in Direct-to-Consumer Telemedicine.

Abstract: Background: Direct-to-consumer (DTC) telemedicine serves millions of patients; however, there is limited research on the care provided. This study compared the quality of care at Teladoc (www.teladoc.com), a large DTC telemedicine company, with that at physician offices and compared access to care for Teladoc users and nonusers. Materials and Methods: Claims from all enrollees 18–64 years of age in the California Public Employees' Retirement System health maintenance organization between April 2012 and October 2013 were analyzed. We compared the performance of Teladoc and physician offices on applicable Healthcare Effectiveness Data and Information Set measures. Using geographic information system analyses, we compared Teladoc users and nonusers with respect to rural location and available primary care physicians. Results: Of enrollees offered Teladoc (n = 233,915), 3,043 adults had a total of 4,657 Teladoc visits. For the pharyngitis performance measure (ordering strep test), Teladoc performed w...

Predictions put into practice: a quasi-experimental evaluation of Chicago’s predictive policing pilot

Abstract: In 2013, the Chicago Police Department conducted a pilot of a predictive policing program designed to reduce gun violence. The program included development of a Strategic Subjects List (SSL) of people estimated to be at highest risk of gun violence who were then referred to local police commanders for a preventive intervention. The purpose of this study is to identify the impact of the pilot on individual- and city-level gun violence, and to test possible drivers of results. The SSL consisted of 426 people estimated to be at highest risk of gun violence. We used ARIMA models to estimate impacts on city-level homicide trends, and propensity score matching to estimate the effects of being placed on the list on five measures related to gun violence. A mediation analysis and interviews with police leadership and COMPSTAT meeting observations help understand what is driving results. Individuals on the SSL are not more or less likely to become a victim of a homicide or shooting than the comparison group, and this is further supported by city-level analysis. The treated group is more likely to be arrested for a shooting. It is not clear how the predictions should be used in the field. One potential reason why being placed on the list resulted in an increased chance of being arrested for a shooting is that some officers may have used the list as leads to closing shooting cases. The results provide for a discussion about the future of individual-based predictive policing programs.

Populations and Interventions for Palliative and End-of-Life Care: A Systematic Review

Abstract: Importance: Evidence supports palliative care effectiveness. Given workforce constraints and the costs of new services, payers and providers need help to prioritize their investments. They need to know which patients to target, which personnel to hire, and which services best improve outcomes. Objective: To inform how payers and providers should identify patients with “advanced illness” and the specific interventions they should implement, we reviewed the evidence to identify (1) individuals appropriate for palliative care and (2) elements of health service interventions (personnel involved, use of multidisciplinary teams, and settings of care) effective in achieving better outcomes for patients, caregivers, and the healthcare system. Evidence Review: Systematic searches of MEDLINE, EMBASE, PsycINFO, Web of Science, and Cochrane Database of Systematic Reviews databases (1/1/2001-1/8/2015). Results: Randomized controlled trials (124) met inclusion criteria. The majority of studies in cancer (49%, ...

The Impact of US Drone Strikes on Terrorism in Pakistan

Abstract: This study analyzes the effects of US drone strikes on terrorism in Pakistan. We find that drone strikes are associated with decreases in the incidence and lethality of terrorist attacks, as well as decreases in selective targeting of tribal elders. This matters for key ongoing debates. Some suggest that drone strikes anger Muslim populations and that consequent blowback facilitates recruitment and incites Islamist terrorism. Others argue that drone strikes disrupt and degrade terrorist organizations, reducing their ability to conduct attacks. We use detailed data on US drone strikes and terrorism in Pakistan from 2007–2011 to test each theory’s implications. The available data do not enable us to evaluate if drone strikes resulted in increased recruitment, but the data do allow us to examine if these strikes resulted in changes in terrorist activities. While our findings do not suggest long-term effects, the results still lend some credence to the argument that drone strikes, while unpopular, bolster US counterterrorism efforts in Pakistan.

In the weeds: a baseline view of cannabis use among legalizing states and their neighbours.

Abstract: Aims To describe patterns of cannabis use, the degree of overlap between medicinal and recreational users, and their differential use patterns, modes of consumption and sources of cannabis. Design An ongoing probability-based internet panel maintained by the market research firm GfK Group. Setting Households in Colorado, Washington, Oregon and New Mexico, USA. Participants A total of 2009 individuals from Washington (n = 787), Oregon (n = 506), Colorado (n = 503) and New Mexico (n = 213). Post stratification sampling weights were provided so that estimates could be made representative of the household population in each of these states. Respondents were aged between 18 and 91 years, with a mean age of 53 years. Methods We compare patterns of cannabis consumption for medicinal and recreational users as well as simultaneous use of alcohol and cannabis. We also examine the extent to which patterns of use differ across states that chose to legalize (Washington and Colorado) and those that did not (New Mexico and Oregon). Findings Rates of life-time medical cannabis use are similar in Colorado and Washington (8.8% and 8.2%) but lower in Oregon and New Mexico (6.5% and 1%). Recreational use is considerably higher than medical use across all states (41%), but highest in Oregon and Washington. Approximately 86% of people who report ever using cannabis for medicinal purposes also use it recreationally. Medical users are more likely to vaporize and consume edibles and report a higher amount (in grams) consumed, and spend more money per month than recreational users. Individuals who use cannabis do not commonly use it with alcohol, irrespective of whether they are consuming cannabis recreationally or medically. Fewer than one in five recreational users report simultaneous use of alcohol and cannabis most or all of the time and fewer than 3% of medicinal users report frequent simultaneous use of alcohol and cannabis. Conclusions In the United States, the degree of overlap between medicinal and recreational cannabis users is 86%. Medicinal and recreational cannabis users favor different modes and amounts of consumption. Only a small proportion (12%) of cannabis users usually consume cannabis and alcohol simultaneously, while concurrent use is common among recreational users.

Medical mistrust is related to lower longitudinal medication adherence among African-American males with HIV:

Abstract: African-Americans living with HIV show worse health behaviors (e.g. medication adherence) and outcomes (e.g. viral suppression) than do their White counterparts. In a 6-month longitudinal study, we...

An evidence map of the effect of Tai Chi on health outcomes.

Abstract: This evidence map describes the volume and focus of Tai Chi research reporting health outcomes. Originally developed as a martial art, Tai Chi is typically taught as a series of slow, low-impact movements that integrate the breath, mind, and physical activity to achieve greater awareness and a sense of well-being. The evidence map is based on a systematic review of systematic reviews. We searched 11 electronic databases from inception to February 2014, screened reviews of reviews, and consulted with topic experts. We used a bubble plot to graphically display clinical topics, literature size, number of reviews, and a broad estimate of effectiveness. The map is based on 107 systematic reviews. Two thirds of the reviews were published in the last five years. The topics with the largest number of published randomized controlled trials (RCTs) were general health benefits (51 RCTs), psychological well-being (37 RCTs), interventions for older adults (31 RCTs), balance (27 RCTs), hypertension (18 RCTs), fall prevention (15 RCTs), and cognitive performance (11 RCTs). The map identified a number of areas with evidence of a potentially positive treatment effect on patient outcomes, including Tai Chi for hypertension, fall prevention outside of institutions, cognitive performance, osteoarthritis, depression, chronic obstructive pulmonary disease, pain, balance confidence, and muscle strength. However, identified reviews cautioned that firm conclusions cannot be drawn due to methodological limitations in the original studies and/or an insufficient number of existing research studies. Tai Chi has been applied in diverse clinical areas, and for a number of these, systematic reviews have indicated promising results. The evidence map provides a visual overview of Tai Chi research volume and content. PROSPERO CRD42014009907