RAND Corporation

About: RAND Corporation is a nonprofit organization based out in Santa Monica, California, United States. It is known for research contribution in the topics: Population & Health care. The organization has 9602 authors who have published 18570 publications receiving 744658 citations.

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.

Modeling the Ice-Age Climate

Abstract: Using the boundary conditions of seasurface temperature, ice sheet topography, and surface albedo assembled by CLIMAP for 18,000 B.P., the global ice-age July climate has been simulated with a two-level dynamical atmospheric model. Compared with the simulation for present July climate, the ice age is substantially cooler and drier over the unglaciated continental areas, with the maximum zonal westerlies in the Northern Hemisphere displaced southward in the vicinity of the ice sheets. The simulated changes of surface air temperature agree reasonably well with the estimates available from the analysis of fossil pollen and periglacial data, and are consistent with the simulated changes of other climatic variables. These results are generally supported by independent investigations with simpler models. In spite of this qualified success, further analysis of both simulated and verification data is needed to establish the details of ice-age climate, especially the precipitation regimes, and to document the role of eddy fluxes in maintaining the heat, momentum, and moisture balances of the ice-age general circulation. New paleoclimatic data bases for both July and January of 18,000 B.P. are being assembled by CLIMAP and will be used in new simulations of the seasonal ice-age climate.

Heterogeneity in Healthy Aging

Abstract: For a surprisingly large segment of the older population, chronological age is not a relevant marker for understanding, measuring, or experiencing healthy aging. Using the 2003 Medical Expenditure Panel Survey and the 2004 Health and Retirement Study to examine the proportion of Americans exhibiting five markers of health and the variation in health-related quality of life across each of eight age groups, we find that a significant proportion of older Americans is healthy within every age group beginning at age 51, including among those aged 85+. For example, 48% of those aged 51-54 and 28% of those aged 85+ have excellent or very good self-reported health status; similarly, 89% of those aged 51-54 and 56% of those aged 85+ report no health-based limitations in work or housework. Also, health-related quality of life ranges widely within every age group, yet there is only a comparatively small variation in median quality of life across age groups, suggesting that older Americans today may be experiencing substantially different age-health trajectories than their predecessors. Patterns are similar for medical expenditures. Several policy implications are explored.

Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data.

Abstract: BACKGROUND: In 2008 over 300000 women died during pregnancy or childbirth mostly in poor countries. While there are proven interventions to make childbirth safer there is uncertainty about the best way to deliver these at large scale. In particular there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate we examined delivery location and attendance and the reasons women report for giving birth at home. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a secondary analysis of maternal delivery data from Demographic and Health Surveys in 48 developing countries from 2003 to the present. We stratified reported delivery locations by wealth quintile for each country and created weighted regional summaries. For sub-Saharan Africa (SSA) where death rates are highest we conducted a subsample analysis of motivations for giving birth at home. In SSA South Asia and Southeast Asia more than 70% of all births in the lowest two wealth quintiles occurred at home. In SSA 54.1% of the richest women reported using public facilities compared with only 17.7% of the poorest women. Among home births in SSA 56% in the poorest quintile were unattended while 41% were attended by a traditional birth attendant (TBA); 40% in the wealthiest quintile were unattended while 33% were attended by a TBA. Seven per cent of the poorest women reported cost as a reason for not delivering in a facility while 27% reported lack of access as a reason. The most common reason given by both the poorest and richest women for not delivering in a facility was that it was deemed "not necessary" by a household decision maker. Among the poorest women "not necessary" was given as a reason by 68% of women whose births were unattended and by 66% of women whose births were attended. CONCLUSIONS: In developing countries most poor women deliver at home. This suggests that at least in the near term efforts to reduce maternal deaths should prioritize community-based interventions aimed at making home births safer.

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.