Showing papers by "RAND Corporation published in 2019"

Association Between Long-term Exposure to Ambient Air Pollution and Change in Quantitatively Assessed Emphysema and Lung Function

Abstract: Importance While air pollutants at historical levels have been associated with cardiovascular and respiratory diseases, it is not known whether exposure to contemporary air pollutant concentrations is associated with progression of emphysema. Objective To assess the longitudinal association of ambient ozone (O3), fine particulate matter (PM2.5), oxides of nitrogen (NOx), and black carbon exposure with change in percent emphysema assessed via computed tomographic (CT) imaging and lung function. Design, Setting, and Participants This cohort study included participants from the Multi-Ethnic Study of Atherosclerosis (MESA) Air and Lung Studies conducted in 6 metropolitan regions of the United States, which included 6814 adults aged 45 to 84 years recruited between July 2000 and August 2002, and an additional 257 participants recruited from February 2005 to May 2007, with follow-up through November 2018. Exposures Residence-specific air pollutant concentrations (O3, PM2.5, NOx, and black carbon) were estimated by validated spatiotemporal models incorporating cohort-specific monitoring, determined from 1999 through the end of follow-up. Main Outcomes and Measures Percent emphysema, defined as the percent of lung pixels less than −950 Hounsfield units, was assessed up to 5 times per participant via cardiac CT scan (2000-2007) and equivalent regions on lung CT scans (2010-2018). Spirometry was performed up to 3 times per participant (2004-2018). Results Among 7071 study participants (mean [range] age at recruitment, 60 [45-84] years; 3330 [47.1%] were men), 5780 were assigned outdoor residential air pollution concentrations in the year of their baseline examination and during the follow-up period and had at least 1 follow-up CT scan, and 2772 had at least 1 follow-up spirometric assessment, over a median of 10 years. Median percent emphysema was 3% at baseline and increased a mean of 0.58 percentage points per 10 years. Mean ambient concentrations of PM2.5and NOx, but not O3, decreased substantially during follow-up. Ambient concentrations of O3, PM2.5, NOx, and black carbon at study baseline were significantly associated with greater increases in percent emphysema per 10 years (O3: 0.13 per 3 parts per billion [95% CI, 0.03-0.24]; PM2.5: 0.11 per 2 μg/m3[95% CI, 0.03-0.19]; NOx: 0.06 per 10 parts per billion [95% CI, 0.01-0.12]; black carbon: 0.10 per 0.2 μg/m3[95% CI, 0.01-0.18]). Ambient O3and NOxconcentrations, but not PM2.5concentrations, during follow-up were also significantly associated with greater increases in percent emphysema. Ambient O3concentrations, but not other pollutants, at baseline and during follow-up were significantly associated with a greater decline in forced expiratory volume in 1 second per 10 years (baseline: 13.41 mL per 3 parts per billion [95% CI, 0.7-26.1]; follow-up: 18.15 mL per 3 parts per billion [95% CI, 1.59-34.71]). Conclusions and Relevance In this cohort study conducted between 2000 and 2018 in 6 US metropolitan regions, long-term exposure to ambient air pollutants was significantly associated with increasing emphysema assessed quantitatively using CT imaging and lung function.

Early Evidence of the Impact of Cannabis Legalization on Cannabis Use, Cannabis Use Disorder, and the Use of Other Substances: Findings from State Policy Evaluations

Abstract: Background: The past decade has seen unprecedented shifts in the cannabis policy environment, and the public health impacts of these changes will hinge on how they affect patterns of cannabis use and the use and harms associated with other substances.Objectives: To review existing research on how state cannabis policy impacts substance use, emphasizing studies using methods for causal inference and highlighting gaps in our understanding of policy impacts on evolving cannabis markets.Methods: Narrative review of quasi-experimental studies for how medical cannabis laws (MCLs) and recreational cannabis laws (RCLs) affect cannabis use and use disorders, as well as the use of or harms from alcohol, opioids, and tobacco.Results: Research suggests MCLs increase adult but not adolescent cannabis use, and provisions of the laws associated with less regulated supply may increase adult cannabis use disorders. These laws may reduce some opioid-related harms, while their impacts on alcohol and tobacco use remain uncertain. Research on RCLs is just emerging, but findings suggest little impact on the prevalence of adolescent cannabis use, potential increases in college student use, and unknown effects on other substance use.Conclusions: Research on how MCLs influence cannabis use has advanced our understanding of the importance of heterogeneity in policies, populations, and market dynamics, but studies of how MCLs relate to other substance use often ignore these factors. Understanding effects of cannabis laws requires greater attention to differences in short- versus long-term effects of the laws, nuances of policies and patterns of consumption, and careful consideration of appropriate control groups.

Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits

Abstract: BACKGROUND AND OBJECTIVES: Use of commercial direct-to-consumer (DTC) telemedicine outside of the pediatric medical home is increasing among children, and acute respiratory infections (ARIs) are the most commonly diagnosed condition at DTC telemedicine visits. Our objective was to compare the quality of antibiotic prescribing for ARIs among children across 3 settings: DTC telemedicine, urgent care, and the primary care provider (PCP) office. METHODS: In a retrospective cohort study using 2015–2016 claims data from a large national commercial health plan, we identified ARI visits by children (0–17 years old), excluding visits with comorbidities that could affect antibiotic decisions. Visits were matched on age, sex, chronic medical complexity, state, rurality, health plan type, and ARI diagnosis category. Within the matched sample, we compared the percentage of ARI visits with any antibiotic prescribing and the percentage of ARI visits with guideline-concordant antibiotic management. RESULTS: There were 4604 DTC telemedicine, 38 408 urgent care, and 485 201 PCP visits for ARIs in the matched sample. Antibiotic prescribing was higher for DTC telemedicine visits than for other settings (52% of DTC telemedicine visits versus 42% urgent care and 31% PCP visits; P CONCLUSIONS: At DTC telemedicine visits, children with ARIs were more likely to receive antibiotics and less likely to receive guideline-concordant antibiotic management compared to children at PCP visits and urgent care visits.

Association Between State Laws Facilitating Pharmacy Distribution of Naloxone and Risk of Fatal Overdose.

Abstract: Importance Given high rates of opioid-related fatal overdoses, improving naloxone access has become a priority. States have implemented different types of naloxone access laws (NALs) and there is controversy over which of these policies, if any, can curb overdose deaths. We hypothesize that NALs granting direct authority to pharmacists to provide naloxone will have the greatest potential for reducing fatal overdoses. Objectives To identify which types of NALs, if any, are associated with reductions in fatal overdoses involving opioids and examine possible implications for nonfatal overdoses. Design, Setting, and Participants State-level changes in both fatal and nonfatal overdoses from 2005 to 2016 were examined across the 50 states and the District of Columbia after adoption of NALs using a difference-in-differences approach while estimating the magnitude of the association for each year relative to time of adoption. Policy environments across full state populations were represented in the primary data set. The association for 3 types of NALs was associated: NALs providing direct authority to pharmacists to prescribe, NALs providing indirect authority to prescribe, and other NALs. The study was conducted from January 2017 to January 2019. Exposures Fatal and nonfatal overdoses in states that adopted NAL laws were compared with those in states that did not adopt NAL laws. Further consideration was given to the type of NAL passed in terms of its association with these outcomes. We hypothesize that NALs granting direct authority to pharmacists to provide naloxone will have the greatest potential for reducing fatal overdoses. Main Outcomes and Measures Fatal overdoses involving opioids were the primary outcome. Secondary outcomes were nonfatal overdoses resulting in emergency department visits and Medicaid naloxone prescriptions. Results In this evaluation of the dispensing of naloxone across the United States, NALs granting direct authority to pharmacists were associated with significant reductions in fatal overdoses, but they may also increase nonfatal overdoses seen in emergency department visits. The effect sizes for fatal overdoses grew over time relative to adoption of the NALs. These policies were estimated to reduce opioid-rated fatal overdoses by 0.387 (95% CI, 0.119-0.656;P = .007) per 100 000 people in 3 or more years after adoption. There was little evidence of an association for indirect authority to dispense (increase by 0.121; 95% CI, −0.014 to 0.257;P = .09) and other NALs (increase by 0.094; 95% CI, −0.040 to 0.227;P = .17). Conclusions and Relevance Although many states have passed some type of law affecting naloxone availability, only laws allowing direct dispensing by pharmacists appear to be useful. Communities in which access to naloxone is improved should prepare for increases in nonfatal overdoses and link these individuals to effective treatment.

An open challenge to advance probabilistic forecasting for dengue epidemics.

Abstract: A wide range of research has promised new tools for forecasting infectious disease dynamics, but little of that research is currently being applied in practice, because tools do not address key public health needs, do not produce probabilistic forecasts, have not been evaluated on external data, or do not provide sufficient forecast skill to be useful. We developed an open collaborative forecasting challenge to assess probabilistic forecasts for seasonal epidemics of dengue, a major global public health problem. Sixteen teams used a variety of methods and data to generate forecasts for 3 epidemiological targets (peak incidence, the week of the peak, and total incidence) over 8 dengue seasons in Iquitos, Peru and San Juan, Puerto Rico. Forecast skill was highly variable across teams and targets. While numerous forecasts showed high skill for midseason situational awareness, early season skill was low, and skill was generally lowest for high incidence seasons, those for which forecasts would be most valuable. A comparison of modeling approaches revealed that average forecast skill was lower for models including biologically meaningful data and mechanisms and that both multimodel and multiteam ensemble forecasts consistently outperformed individual model forecasts. Leveraging these insights, data, and the forecasting framework will be critical to improve forecast skill and the application of forecasts in real time for epidemic preparedness and response. Moreover, key components of this project-integration with public health needs, a common forecasting framework, shared and standardized data, and open participation-can help advance infectious disease forecasting beyond dengue.

It's Still The Prices, Stupid: Why The US Spends So Much On Health Care, And A Tribute To Uwe Reinhardt

Abstract: A 2003 article titled “It’s the Prices, Stupid,” and coauthored by the three of us and the recently deceased Uwe Reinhardt found that the sizable differences in health spending between the US and o...

Community Interventions to Promote Mental Health and Social Equity

Abstract: We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions. There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.

Robust Decision Making (RDM)

Abstract: The quest for predictions—and a reliance on the analytical methods that require them—can prove counter-productive and sometimes dangerous in a fast-changing world. Robust Decision Making (RDM) is a set of concepts, processes, and enabling tools that use computation, not to make better predictions, but to yield better decisions under conditions of deep uncertainty. RDM combines Decision Analysis, Assumption-Based Planning, scenarios, and Exploratory Modeling to stress test strategies over myriad plausible paths into the future, and then to identify policy-relevant scenarios and robust adaptive strategies. RDM embeds analytic tools in a decision support process called “deliberation with analysis” that promotes learning and consensus-building among stakeholders. The chapter demonstrates an RDM approach to identifying a robust mix of policy instruments—carbon taxes and technology subsidies—for reducing greenhouse gas emissions. The example also highlights RDM’s approach to adaptive strategies, agent-based modeling, and complex systems. Frontiers for RDM development include expanding the capabilities of multi-objective RDM (MORDM), more extensive evaluation of the impact and effectiveness of RDM-based decision support systems, and using RDM’s ability to reflect multiple world views and ethical frameworks to help improve the way organizations use and communicate analytics for wicked problems.

Content analysis of cyber insurance policies: how do carriers price cyber risk?

Abstract: Thousands of data breaches occur each year with some costing millions of dollars. Consequently, cyber insurance has grown rapidly in the past decade. In this research, we conduct the first rigorous qualitative study of actual insurance policies.

Impact of Project ECHO Models of Medical Tele-Education: A Systematic Review

Abstract: Extension for Community Healthcare Outcomes (ECHO) and related models of medical tele-education are rapidly expanding; however, their effectiveness remains unclear. This systematic review examines the effectiveness of ECHO and ECHO-like medical tele-education models of healthcare delivery in terms of improved provider- and patient-related outcomes. We searched English-language studies in PubMed, Embase, and PsycINFO databases from 1 January 2007 to 1 December 2018 as well as bibliography review. Two reviewers independently screened citations for peer-reviewed publications reporting provider- and/or patient-related outcomes of technology-enabled collaborative learning models that satisfied six criteria of the ECHO framework. Reviewers then independently abstracted data, assessed study quality, and rated strength of evidence (SOE) based on Cochrane GRADE criteria. Data from 52 peer-reviewed articles were included. Forty-three reported provider-related outcomes; 15 reported patient-related outcomes. Studies on provider-related outcomes suggested favorable results across three domains: satisfaction, increased knowledge, and increased clinical confidence. However, SOE was low, relying primarily on self-reports and surveys with low response rates. One randomized trial has been conducted. For patient-related outcomes, 11 of 15 studies incorporated a comparison group; none involved randomization. Four studies reported care outcomes, while 11 reported changes in care processes. Evidence suggested effectiveness at improving outcomes for patients with hepatitis C, chronic pain, dementia, and type 2 diabetes. Evidence is generally low-quality, retrospective, non-experimental, and subject to social desirability bias and low survey response rates. The number of studies examining ECHO and ECHO-like models of medical tele-education has been modest compared with the scope and scale of implementation throughout the USA and internationally. Given the potential of ECHO to broaden access to healthcare in rural, remote, and underserved communities, more studies are needed to evaluate effectiveness. This need for evidence follows similar patterns to other service delivery models in the literature.

Resilience of the Eastern African electricity sector to climate driven changes in hydropower generation

Abstract: Notwithstanding current heavy dependence on gas-fired electricity generation in the Eastern African Power Pool (EAPP), hydropower is expected to play an essential role in improving electricity access in the region. Expansion planning of electricity infrastructure is critical to support investment and maintaining balanced consumer electricity prices. Variations in water availability due to a changing climate could leave hydro infrastructure stranded or result in underutilization of available resources. In this study, we develop a framework consisting of long-term models for electricity supply and water systems management, to assess the vulnerability of potential expansion plans to the effects of climate change. We find that the most resilient EAPP rollout strategy corresponds to a plan optimised for a slightly wetter climate compared to historical trends. This study demonstrates that failing to climate-proof infrastructure investments can result in significant electricity price fluctuations in selected countries (Uganda & Tanzania) while others, such as Egypt, are less vulnerable.

Association of Punitive and Reporting State Policies Related to Substance Use in Pregnancy With Rates of Neonatal Abstinence Syndrome.

Abstract: Importance Despite the rapidly changing policy environment regarding substance use during pregnancy, information is lacking on the association of state policies with neonatal abstinence syndrome (NAS). Objective To determine if punitive or reporting state policies related to substance use during pregnancy are associated with NAS rates. Design, Setting, and Participants This repeated cross-sectional study used retrospective, difference-in-difference analysis of live births in the State Inpatient Databases from 8 US states in varying years between January 1, 2003, and December 31, 2014. States without punitive or reporting policies were compared with states with policies before and after policy enactment using logistic regression models adjusted for individual and county-level factors and state and year fixed effects. Analyses were conducted from April 10, 2019, to July 30, 2019. Exposures Time since enactment of state policies related to substance use in pregnancy, county-level rurality and unemployment, and presence of specialized treatment programs for pregnant and postpartum women in a county. Main Outcome and Measures Rates of NAS. Results Among 4 567 963 live births, 23 377 neonates (0.5%) received a diagnosis of NAS. Among neonates with NAS, 3394 (14.5%) lived in counties without any treatment programs specifically for pregnant and postpartum women, 20 323 (86.9%) lived in metropolitan counties, and 8135 (34.8%) lived in counties in the highest unemployment quartile. In adjusted analyses among neonates in states with punitive policies, odds of NAS were significantly greater during the first full calendar year after enactment (adjusted odds ratio, 1.25; 95% CI, 1.06-1.46;P = .007) and more than 1 full year after enactment (adjusted odds ratio, 1.33; 95% CI, 1.17-1.51;P Conclusions and Relevance In this repeated cross-sectional analysis of 8 states, states with punitive policies were associated with greater odds of NAS immediately and in the longer term, but there was no association between NAS and states with reporting policies.

Growth and Distribution of Child Psychiatrists in the United States: 2007-2016.

Abstract: BACKGROUND: Historically, there has been a shortage of child psychiatrists in the United States, undermining access to care. This study updated trends in the growth and distribution of child psychiatrists over the past decade. METHODS: Data from the Area Health Resource Files were used to compare the number of child psychiatrists per 100 000 children ages 0 to 19 between 2007 and 2016 by state and county. We also examined sociodemographic characteristics associated with the density of child psychiatrists at the county level over this period using negative binomial multivariable models. RESULTS: From 2007 to 2016, the number of child psychiatrists in the United States increased from 6590 to 7991, a 21.3% gain. The number of child psychiatrists per 100 000 children also grew from 8.01 to 9.75, connoting a 21.7% increase. County- and state-level growth varied widely, with 6 states observing a decline in the ratio of child psychiatrists (ID, IN, KS, ND, SC, and SD) and 6 states increasing by >50% (AK, AR, NH, NV, OK, and RI). Seventy percent of counties had no child psychiatrists in both 2007 and 2016. Child psychiatrists were significantly more likely to practice in high-income counties (P CONCLUSIONS: Despite the increased ratio of child psychiatrists per 100 000 children in the United States over the past decade, there remains a dearth of child psychiatrists, particularly in parts of the United States with lower levels of income and education.

Types of cannabis and tobacco/nicotine co-use and associated outcomes in young adulthood.

Abstract: Cannabis and tobacco/nicotine use are highly comorbid. Given expanding access to cannabis through legalization for recreational use, it is important to understand how patterns of cannabis and tobacco/nicotine co-use are associated with young adult outcomes. A predominantly California-based sample of 2,429 young adults (mean age = 20.7) completed an online survey. Based on past-year reports of cannabis and tobacco/nicotine use, we defined 5 mutually exclusive groups: (a) single-product use; (b) concurrent use only (using both products, but only on separate occasions); (c) sequential use only (using both products on the same occasion, one right after the other, but not mixing them together); (d) coadministration only (using both products on the same occasion by mixing them in the same delivery device); and (e) both sequential use and coadministration. We examined group differences in use patterns, dependence, consequences of use, and psychosocial functioning. Fifty percent of respondents reported cannabis use, 43% tobacco/nicotine use, and 37% co-use of both substances. The most prevalent method of co-use involved smoking combustible products. Overall, individuals who co-used both substances on the same occasion in some way reported heavier use and greater problematic behaviors than those who did not. Sequential use (especially among those that also engaged in coadministration) was typically associated with worse physical and mental functioning overall compared to using each substance separately. Findings illuminate both prevalence and risks associated with co-use of cannabis and tobacco/nicotine products and can inform policies for states considering regulation of cannabis and tobacco/nicotine products. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Effectiveness of multifocal and monofocal intraocular lenses for cataract surgery and lens replacement: a systematic review and meta-analysis

Abstract: Multifocal intraocular lenses (IOLs) offer the possibility of spectacle-free vision following cataract surgery compared to standard IOLs. Existing systematic reviews have generally concluded that multifocal IOLs result in better uncorrected near vision and greater spectacle independence, but more unwanted visual phenomena such as glare and halos, compared to monofocal IOLs. However, the certainty of evidence has been low for most outcomes, and pooled analyses have grouped together technologically obsolete lenses with newer lenses, potentially obscuring differences in performance across different lens types. We performed a systematic review searching for RCTs of a multifocal IOL to a standard IOL or monovision that reported spectacle independence, visual acuity, or quality of life. Databases were searched from 1/1/2006–4/30/2017. Existing reviews were used to identify older studies. Title/abstract screening and data extraction were done in duplicate. Where possible, random effects meta-analysis was performed to synthesize results. In addition to comparing multifocal IOLs as a group to monofocal IOLs, we also compared newer diffractive lenses to obsolete or refractive lenses. Twenty-five eligible studies were identified. There was no difference in pooled estimates of corrected or uncorrected distance vision between multifocal and standard IOLs. Compared to monofocal IOLs, multifocal IOLs had statistically significantly better pooled results for the outcome of near vision (10 studies, 1025 patients, mean difference in logMAR of ‐0.26 (95% CI ‐0.37, ‐0.15)); spectacle dependence (12 studies, 1237 patients, relative risk of 0.27 (95% CI 0.20, 0.38)) and borderline significantly better quality of vision (6 studies, 596 patients, standardized mean difference of ‐0.54, (95% CI ‐1.12, 0.04)). Compared to monofocal IOLs, multifocal IOLs had statistically significantly worse pooled results for the outcomes of glare (9 studies, 847 patients, risk ratio of 1.36 (95% CI 1.15, 1.61) and halos (7 studies, 754 patients, risk ratio of 3.14 (95% CI 1.63, 6.08). Newer multifocal lenses had statistically significantly better outcomes than older diffractive lenses or refractive lenses, when compared to monofocal IOLs, in near vision, quality of vision, and risk of halos. Multifocal IOLs compared to standard IOLs or monovision result in better uncorrected near vision and a higher proportion of patients who achieve spectacle independence, but greater risk of unwanted visual phenomena. Newer diffractive lenses may be better than refractive lenses in near vision and quality of vision outcomes, with less risk of halos than older diffractive lenses and refractive lenses. (PROSPERO registration CRD42017069949)

Association Between State-Mandated Protocolized Sepsis Care and In-hospital Mortality Among Adults With Sepsis.

Abstract: Importance Beginning in 2013, New York State implemented regulations mandating that hospitals implement evidence-based protocols for sepsis management, as well as report data on protocol adherence and clinical outcomes to the state government. The association between these mandates and sepsis outcomes is unknown. Objective To evaluate the association between New York State sepsis regulations and the outcomes of patients hospitalized with sepsis. Design, Setting, and Participants Retrospective cohort study of adult patients hospitalized with sepsis in New York State and in 4 control states (Florida, Maryland, Massachusetts, and New Jersey) using all-payer hospital discharge data (January 1, 2011-September 30, 2015) and a comparative interrupted time series analytic approach. Exposures Hospitalization for sepsis before (January 1, 2011-March 31, 2013) vs after (April 1, 2013-September 30, 2015) implementation of the 2013 New York State sepsis regulations. Main Outcomes and Measures The primary outcome was 30-day in-hospital mortality. Secondary outcomes were intensive care unit admission rates, central venous catheter use,Clostridium difficileinfection rates, and hospital length of stay. Results The final analysis included 1 012 410 sepsis admissions to 509 hospitals. The mean age was 69.5 years (SD, 16.4 years) and 47.9% were female. In New York State and in the control states, 139 019 and 289 225 patients, respectively, were admitted before implementation of the sepsis regulations and 186 767 and 397 399 patients, respectively, were admitted after implementation of the sepsis regulations. Unadjusted 30-day in-hospital mortality was 26.3% in New York State and 22.0% in the control states before the regulations, and was 22.0% in New York State and 19.1% in the control states after the regulations. Adjusting for patient and hospital characteristics as well as preregulation temporal trends and season, mortality after implementation of the regulations decreased significantly in New York State relative to the control states (P = .02 for the joint test of the comparative interrupted time series estimates). For example, by the 10th quarter after implementation of the regulations, adjusted absolute mortality was 3.2% (95% CI, 1.0% to 5.4%) lower than expected in New York State relative to the control states (P = .004). The regulations were associated with no significant differences in intensive care unit admission rates (P = .09) (10th quarter adjusted difference, 2.8% [95% CI, −1.7% to 7.2%],P = .22), a significant relative decrease in hospital length of stay (P = .04) (10th quarter adjusted difference, 0.50 days [95% CI, −0.47 to 1.47 days],P = .31), a significant relative decrease in theC difficileinfection rate (P Conclusions and Relevance In New York State, mandated protocolized sepsis care was associated with a greater decrease in sepsis mortality compared with sepsis mortality in control states that did not implement sepsis regulations. Because baseline mortality rates differed between New York and comparison states, it is uncertain whether these findings are generalizable to other states.

Sex differences in adolescent physical aggression : Evidence from sixty-three low-and middle-income countries

Abstract: A great deal of research shows that adolescent and adult males are more likely to engage in physical aggression and violence than females are. However, few studies have examined cross-cultural variation in sex differences, particularly among low- and middle-income countries [LMICs]. Based on social role and sexual selection theories, we derived two hypotheses regarding possible variations in sex differences across societal contexts: 1) sex differences increase with societal gender polarization (social role theory) and 2) sex differences are exacerbated in societies where socio-economic opportunities are scarce, unequal, or insecure (prediction derived from sexual selection theory). The current study examined the prevalence of and variation in sex differences in physical aggression, as measured by frequent fighting, among 247,909 adolescents in 63 low- and middle-income countries. The results show that, overall, males were over twice as likely (OR = 2.68; 95% CI = 2.60–2.76) to report frequent fighting in the past 12 months than females. However, sex differences vary significantly across LMICs, wherein countries with higher female prevalence rates have smaller sex differences in frequent fighting. Contrary to expectations derived from social role theory, sex differences in physical aggression decrease as societal gender inequality increased. In regards to sexual selection theory, we find no evidence that sex differences in frequent fighting varies according to societal rule of law or income inequality.

Prevalence of Cannabis Use in Youths After Legalization in Washington State.

Abstract: This survey study examines changes in the use of marijuana by adolescents since legalization of recreational use in Washington State.

Comparison of 3 Safety-Net Hospital Definitions and Association With Hospital Characteristics.

Abstract: Importance No consensus exists on how to define safety-net hospitals (SNHs) for research or policy decision-making. Identifying which types of hospitals are classified as SNHs under different definitions is key to assessing policies that affect SNH funding. Objective To examine characteristics of SNHs as classified under 3 common definitions. Design, Setting, and Participants This cross-sectional analysis includes noncritical-access hospitals in the Healthcare Cost and Utilization Project State Inpatient Databases from 47 US states for fiscal year 2015, linked to the Centers for Medicare & Medicaid Services Hospital Cost Reports and to the American Hospital Association Annual Survey. Data were analyzed from March 1 through September 30, 2018. Exposures Hospital characteristics including organizational characteristics, scope of services provided, and financial attributes. Main Outcomes and Measures Definitions of SNH based on Medicaid and Medicare Supplemental Security Income inpatient days historically used to determine Medicare Disproportionate Share Hospital (DSH) payments; Medicaid and uninsured caseload; and uncompensated care costs. For each measure, SNHs were defined as those within the top quartile for each state. Results The 2066 hospitals in this study were distributed across the Northeast (340 [16.5%]), Midwest (587 [28.4%]), South (790 [38.2%]), and West (349 [16.9%]). Concordance between definitions was low; 269 hospitals (13.0%) or fewer were identified as SNHs under any 2 definitions. Uncompensated care captured smaller (200 of 523 [38.2%]) and more rural (65 of 523 [12.4%]) SNHs, whereas DSH index and Medicaid and uncompensated caseload identified SNHs that were larger (264 of 518 [51.0%] and 158 of 487 [32.4%], respectively) and teaching facilities (337 of 518 [65.1%] and 229 of 487 [47.0%], respectively) that provided more essential services than non-SNHs. Uncompensated care also distinguished remarkable financial differences between SNHs and non-SNHs. Under the uncompensated care definition, median (interquartile range [IQR]) bad debt ($27.1 [$15.5-$44.3] vs $12.8 [$6.7-$21.6] per $1000 of operating expenses;P Conclusions and Relevance Different SNH definitions identify hospitals with different characteristics and financial conditions. The new DSH formula, which accounts for uncompensated care, may lead to redistributed payments across hospitals. Our results may inform which types of hospitals will experience funding changes as DSH payment policies evolve.

Association Between Broadband Internet Availability and Telemedicine Use.

Abstract: This population-based study examines the availability of broadband in local communities for telemedicine.

Evaluation of a Whole-School Change Intervention: Findings from a Two-Year Cluster-Randomized Trial of the Restorative Practices Intervention.

Abstract: This study fills a gap in research on multi-level school-based approaches to promoting positive youth development and reducing bullying, in particular cyberbullying, among middle school youth. The study evaluates the Restorative Practices Intervention, a novel whole-school intervention designed to build a supportive environment through the use of 11 restorative practices (e.g., communication approaches that aim to build stronger bonds among leadership, staff, and students such as using "I" statements, encouraging students to express their feelings) that had only quasi-experimental evidence prior to this study. Studying multilevel (e.g., individual, peer group, school) approaches like the Restorative Practices Intervention is important because they are hypothesized to address a more complex interaction of risk factors than single level efforts, which are more common. Baseline and two-year post survey data was collected from 2771 students at 13 middle schools evenly split between grades 6 (48 percent) and 7 (52 percent), and primarily ages 11 (38 percent) or 12 (41 percent). Gender was evenly split (51 percent male), and 92 percent of students were white. The intervention did not yield significant changes in the treatment schools. However, student self-reported experience with restorative practices significantly predicted improved school climate and connectedness, peer attachment, and social skills, and reduced cyberbullying victimization. While more work is needed on how interventions can reliably produce restorative experiences, this study suggests that the restorative model can be useful in promoting positive behaviors and addressing bullying.

Practical Guidance for Involving Stakeholders in Health Research.

Abstract: Stakeholder engagement is increasingly common in health research, with protocols for engaging multiple stakeholder groups becoming normative in patient-centered outcomes research. Previous work has focused on identifying relevant stakeholder groups with whom to work and on working with stakeholders in evidence implementation. This paper draws on the expertise of a team from four countries—Canada, Australia, the UK, and the USA—to provide researchers with practical guidance for carrying out multi-stakeholder–engaged projects: we present a list of questions to assist in selecting appropriate roles and modes of engagement; we introduce a matrix to help summarize engagement activities; and we provide a list of online resources. This guidance, matrix, and list of resources can assist researchers to consider more systematically which stakeholder groups to involve, in what study roles, and by what modes of engagement. By documenting how stakeholders are paired up with specific roles, the matrix also provides a potential structure for evaluating the impact of stakeholder engagement.

Association Among County-Level Economic Factors, Clinician Supply, Metropolitan or Rural Location, and Neonatal Abstinence Syndrome

Abstract: Importance Neonatal abstinence syndrome (NAS) has increased over the last 2 decades, but limited data exist on its association with economic conditions or clinician supply. Objective To determine the association among long-term unemployment, clinician supply (as assessed by primary care and mental health clinician shortage areas), and rates of NAS and evaluate how associations differ based on rurality. Design, Setting, and Participants Ecological time-series analysis of a retrospective, repeated cross-sectional study using outcome data from all 580 counties in Florida, Kentucky, Massachusetts, Michigan, New York, North Carolina, Tennessee, and Washington from 2009 to 2015 and economic data from 2000 to 2015. Negative binomial models were used with year and county-level fixed effects. Interactions were tested and stratified analyses were conducted by metropolitan counties, rural counties adjacent to metropolitan counties, and rural remote counties. Exposures County-level 10-year unemployment rate and mental health and primary care clinician supply obtained from the Health Resources and Services Administration Area Health Resources Files. Main Outcomes and Measure Rates of NAS, excluding iatrogenic withdrawal, obtained from state inpatient databases. Results The sample included observations from 580 counties over 7 years (1803 county-years from metropolitan counties, 1268 county-years from rural counties adjacent to metropolitan counties, and 927 county-years from rural remote counties). During the study period, there were 6 302 497 births and 47 224 diagnoses of NAS. The median rate of NAS was 7.1 per 1000 hospital births (interquartile range [IQR], 2.2-15.8), the 10-year unemployment rate was 7.6% (IQR, 6.4%-9.0%), and 83.9% of county-years were partial or complete mental health shortage areas. In the adjusted analyses, mental health shortage areas had higher NAS rates (unadjusted rate in shortage areas of 14.0 per 1000 births vs unadjusted rate in nonshortage areas of 10.6 per 1000 births; adjusted incidence rate ratio [IRR], 1.17 [95% CI, 1.07-1.27]), occurring primarily in metropolitan counties (adjusted IRR, 1.28 [95% CI, 1.16-1.40];P = .02 for test of equivalence between metropolitan counties and rural counties adjacent to metropolitan counties). There was no significant association between primary care shortage areas and rates of NAS. The 10-year unemployment rate was associated with higher rates of NAS (unadjusted rate in highest unemployment quartile of 20.1 per 1000 births vs 7.8 per 1000 births in lowest unemployment quartile; adjusted IRR, 1.11 [95% CI, 1.00-1.23]) occurring primarily in rural remote counties (adjusted IRR, 1.34 [95% CI, 1.05-1.70];P = .04 for test of equivalence between metropolitan counties and rural remote counties). Conclusions and Relevance In this ecological analysis of counties in 8 US states, there was a significant association among higher long-term unemployment, higher mental health clinician shortage areas, and higher county-level rates of neonatal abstinence syndrome.

Depression in primary care: part 1-screening and diagnosis.

Abstract: Depression is a common and heterogeneous condition with a chronic and recurrent natural course that is frequently seen in the primary care setting. Primary care providers play a central role in managing depression and concurrent physical comorbidities, and they face challenges in diagnosing and treating the condition. In this two part series, we review the evidence available to help to guide primary care providers and practices to recognize and manage depression. In this first of two reviews, we outline an approach to screening and diagnosing depression in primary care that evaluates current evidence based guidelines and applies the recommendations to clinical practice. The second review presents an evidence based approach to the treatment of depression in primary care, detailing the recommended lifestyle, drug, and psychological interventions at the individual level. It also highlights strategies that are being adopted at an organizational level to manage depression more effectively in primary care.

Trust in genomic data sharing among members of the general public in the UK, USA, Canada and Australia.

Abstract: Trust may be important in shaping public attitudes to genetics and intentions to participate in genomics research and big data initiatives. As such, we examined trust in data sharing among the general public. A cross-sectional online survey collected responses from representative publics in the USA, Canada, UK and Australia (n = 8967). Participants were most likely to trust their medical doctor and less likely to trust other entities named. Company researchers were least likely to be trusted. Low, Variable and High Trust classes were defined using latent class analysis. Members of the High Trust class were more likely to be under 50 years, male, with children, hold religious beliefs, have personal experience of genetics and be from the USA. They were most likely to be willing to donate their genomic and health data for clinical and research uses. The Low Trust class were less reassured than other respondents by laws preventing exploitation of donated information. Variation in trust, its relation to areas of concern about the use of genomic data and potential of legislation are considered. These findings have relevance for efforts to expand genomic medicine and data sharing beyond those with personal experience of genetics or research participants.