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

OBJECTIVE: Despite an emergence of psychosocial treatments for adolescent ADHD, their long-term effects are unknown. METHOD: We examine four-year outcomes of a randomized controlled trial (N = 218) comparing high-intensity (HI; 412 h, $4,373 per participant) versus low-intensity (LI; 24 h, $97 per participant) skills-based summer intervention delivered to adolescents with ADHD at two secondary school transitions (6th/9th grade). Quantitative and qualitative analyses evaluated group×time and group×grade×time effects on 4-year outcomes. RESULTS: Relative to LI, a single dose of HI had modest but lasting effects on teen organization skills (d =.40) and ADHD symptoms (9th grade only: d =.27 to.31) at 4-year follow-up. There was no long-term incremental effect of HI (vs. LI) for parent-teen conflict, GPA, or parent use of contingency management. Treatment appeared most effective when delivered to older adolescents (i.e., 9th versus 6th grade), suggesting the long-term impact of ADHD treatment may increase with age. Qualitative data corroborated that the primary long-term benefit of HI (vs. LI) treatment was to organization skills; many of the remaining perceived benefits were to parent and teen psychological variables (i.e., increased self-esteem, self-awareness, parental optimism). HI offered no incremental benefit to long-term educational or clinical service utilization or costs. CONCLUSIONS: Modest therapeutic benefits of adolescent ADHD treatment are maintained long term. However, HI treatment did not impact outcomes that could defray the intervention's high costs ($4,373) compared to LI treatment ($97).

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

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

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

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

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

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

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

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

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

INTRODUCTION: The 15-minute work break provides an opportunity to promote health, yet few studies have examined this part of the workday. We studied physical activity and sedentary behavior among office workers and compared the results of the Booster Break program with those of a second intervention and a control group to determine whether the Booster Break program improved physical and behavioral health outcomes. METHODS: We conducted a 3-arm, cluster-randomized controlled trial at 4 worksites in Texas from 2010 through 2013 to compare a group-based, structured Booster Break program to an individual-based computer-prompt intervention and a usual-break control group; we analyzed physiologic, behavioral, and employee measures such as work social support, quality of life, and perceived stress. We also identified consistent and inconsistent attendees of the Booster Break sessions. RESULTS: We obtained data from 175 participants (mean age, 43 y; 67% racial/ethnic minority). Compared with the other groups, the consistent Booster Break attendees had greater weekly pedometer counts (P < .001), significant decreases in sedentary behavior and self-reported leisure-time physical activity (P < .001), and a significant increase in triglyceride concentrations (P = .02) (levels remained within the normal range). Usual-break participants significantly increased their body mass index, whereas Booster Break participants maintained body mass index status during the 6 months. Overall, Booster Break participants were 6.8 and 4.3 times more likely to have decreases in BMI and weekend sedentary time, respectively, than usual-break participants. CONCLUSION: Findings varied among the 3 study groups; however, results indicate the potential for consistent attendees of the Booster Break intervention to achieve significant, positive changes related to physical activity, sedentary behavior, and body mass index.

Evaluating the Factors Associated With the Completion of a Community-Based Group Exercise Program Among Older Women.

Despite the well-known benefits of exercise, only 50% of U.S. women met recommended physical activity levels in 2014. To combat this issue, the Healthy Aging Regional Collaborative of South Florida has been offering the EnhanceFitness (EF) program in community-based settings since 2008. In the current study, we examined the factors associated with the program completion among older women (≥ 60 years). During the first 4 years, 3,829 older women attended EF sessions. Of these, 924 (24.2%) attended the recommended 32 sessions within first 4 months. Results revealed that women who lived in Miami-Dade County, were ≥ 80 years, and did not report depression and/or risk factors for chronic conditions were more likely to complete EF. Black women were less likely to complete the program. Recognition of these factors might help identify at-risk individuals. More efforts are needed to improve completion rates. Theory-based interventions would allow comprehensive understanding of all factors and, therefore, should be explored in the future.

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

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

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

OBJECTIVE: The purpose of this study was to document the development and testing costs of the Enhanced Alcohol Risk Management (eARM) intervention, a web enhanced training program to prevent alcohol sales to intoxicated bar patrons and to estimate its implementation costs in a "real world", non-research setting. METHODS: Data for this study were obtained retrospectively from a randomized controlled trial of the eARM intervention, which was conducted across 15 communities in a Midwestern metropolitan area. Inputs and their costs were obtained from records maintained during the randomized controlled trial. Total development and testing costs were computed, and implementation costs were estimated with input from the research team. The average implementation cost per establishment was calculated by dividing the total estimated implementation cost by the number of establishments that participated in the study. This provides an estimate of the resources needed to support a broader dissemination of interventions such as eARM. RESULTS: Direct development and testing costs were $484,904. Including the University's overhead cost rate of 51 percent, total development and testing costs were $732,205. Total estimated implementation costs were $179,999 over a 12 month period. The average cost per establishment was $1,588. CONCLUSIONS: Given the large damage liability awards faced by establishments that serve alcohol to drunk drivers, establishments or their insurance companies may be willing to pay the $1,588 estimated implementation cost in order to limit their exposure to these large damage awards. Therefore, making interventions such as eARM available could be an effective and sustainable policy for reducing alcohol-related incidents.

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

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

Opioid-Related Emergency Department Visits Before and During COVID-19: Association with Community-Level Factors.

Background: The purpose of the study was to investigate the relationship between community-level variables and emergency department (ED) visit rates before and during COVID-19. The focus was on opioid-related ED visits. Despite large declines in overall ED visits during COVID-19, opioid-related visits increased. While visits for avoidable conditions decreased, the opposite was true for opioid-related visits. Methods: We combined data from Florida EDs with community-level variables from the 2020 American Community Survey. The outcome measures of the study were quarterly ZIP code tabulation-area-level ED visit rates for opioid-related ED visits as well as visit rates for all other causes. Associations with opioid-related visit rates were estimated before and during COVID-19. Results: The associations between community-level variables and opioid-related visit rates did not match those found when analyzing overall ED visit rates. The increase in opioid-related visits during COVID-19 was not unique to or more prevalent in areas with a larger percentage of racial/ethnic minority populations. However, socioeconomic status was important, as areas with higher unemployment, lower income, lower home ownership, and higher uninsured had higher overall ED visit rates and opioid visit rates during the pandemic. In addition, the negative association with income increased during the pandemic. Conclusion: These results suggest socioeconomic status should be the focus of prevention and treatment efforts to reduce opioid-related visits in future pandemics. Healthcare organizations can use these results to target their prevention and treatment efforts during future pandemics.

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

OBJECTIVE: Asthma is the most common chronic condition in childhood and disproportionately impacts the poorer and ethnic minorities. The objectives of the study were to estimate the prevalence of asthma in Miami-Dade County (MDC) schoolchildren to aid case-finding and linkage to care. METHODS: We used the CDC Youth Risk Behavior Surveillance System (YRBSS) definition of possible asthma ("Ever told by a doctor or nurse that they had asthma and still had asthma") and analyzed data from four sources. These included the: (1)-MDC YRBSS 2009, (2)-MDC Health Connect Asthma Survey of school nurses (>2008), (3)-parents' survey in the five HealthConnect survey elementary schools with highest asthma prevalence, and (4)-focus group with parents of asthmatic children. RESULTS: (1)-MDC YRBSS data showed that 21.3% of high- and 21.4% of middle-school students had been diagnosed with possible asthma. Prevalence was the highest in African-American middle-school girls (26.9%). (2)-HealthConnect survey responders reported that 4.9% of the students in 131 MDC schools had possible asthma. Asthma prevalence was higher in elementary schools (median = 7.1%) and in low-income MDC zip codes. (3)-Of the parent survey responders, 24.9% indicated that their child had possible asthma, and 19.2% reported that their children had no usual source of care. (4)-Focus group participants reported frequent loss of Medicaid coverage for their children, landlords' indifference to the role of poorly maintained housing in asthma, and unmet needs regarding knowledge of health system navigation. CONCLUSIONS: Asthma may be common in MDC schoolchildren, particularly in poor communities. Formidable structural factors limit the caregivers' abilities to manage childhood asthma.

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

INTRODUCTION: The prevalence and negative health effects of chronic diseases are disproportionately high among Hispanics, the largest minority group in the United States. Self-management of chronic conditions by older adults is a public health priority. The objective of this study was to examine 6-week differences in self-efficacy, time spent performing physical activity, and perceived social and role activities limitations for participants in a chronic disease self-management program for Spanish-speaking older adults, Tomando Control de su Salud (TCDS). METHODS: Through the Healthy Aging Regional Collaborative, 8 area agencies delivered 82 workshops in 62 locations throughout South Florida. Spanish-speaking participants who attended workshops from October 1, 2008, through December 31, 2010, were aged 55 years or older, had at least 1 chronic condition, and completed baseline and post-test surveys were included in analysis (N=682). Workshops consisted of six, 2.5-hour sessions offered once per week for 6 weeks. A self-report survey was administered at baseline and again at the end of program instruction. To assess differences in outcomes, a repeated measures general linear model was used, controlling for agency and baseline general health. RESULTS: All outcomes showed improvement at 6 weeks. Outcomes that improved significantly were self-efficacy to manage disease, perceived social and role activities limitations, time spent walking, and time spent performing other aerobic activities. CONCLUSION: Implementation of TCDS significantly improved 4 of 8 health promotion skills and behaviors of Spanish-speaking older adults in South Florida. A community-based implementation of TCDS has the potential to improve health outcomes for a diverse, Spanish-speaking, older adult population.

Adding home health care to the discussion on health information technology policy.

The potential for health information technology to improve the efficiency and effectiveness of health care has resulted in several U.S. policy initiatives aimed at integrating health information technology into health care systems. However, home health care agencies have been excluded from incentive programs established through policies, raising concerns on the extent to which health information technology may be used to improve the quality of care for older adults with chronic illness and disabilities. This analysis examines the potential issues stemming from this exclusion and explores potential opportunities of integrating home health care into larger initiatives aimed at establishing health information technology systems for meaningful use.

Children's attachment-related self-worth: a multi-method investigation of postdivorce preschoolers' relationships with their mothers and peers.

Three related hypotheses derived from attachment theory were examined in this multi-informant and multi-method study of 71 postdivorce mothers and their preschool children (40 boys, 31 girls): (1) mother-child interactions observed at home will be related to attachment-related representations by children (Attachment Story Completion Task or ASCT) and mothers (Parent Attachment Interview or PAI); and (2) these variables will be inversely correlated with maternal depressive symptoms and positively with social support (from mother's parents and the child's father); and (3) mother-child observations and representations will predict teacher-rated peer behavior. Where appropriate, child gender, maternal income, and child receptive language were statistically controlled. More harmonious observed mother-child interactions were associated with children's sense of self-worth in family relationships (ASCT) and maternal accounts of sensitive-effective guidance (PAI). Observational and representational variables were inversely correlated with maternal depressive symptoms. Mothers' satisfaction with social support from their parents was indirectly linked to the family variables while social support from the child's father had no measurable effect on the mother-child variables. Mother-child variables and teacher ratings were uncorrelated but explained independent variance in ASCT self-worth scores.

The Impact of Public Health Funding on Population Health Outcomes.

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

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

BACKGROUND: Youth with ADHD are at risk of academic impairments, dropping out of high school, and dysfunction in young adulthood. Interventions delivered early in high school could prevent these harmful outcomes, yet few high school students with ADHD receive treatment due to limited access to intervention providers. This study will test a peer-delivered intervention (STRIPES) for general education 9th grade students with impairing ADHD symptoms. METHODS: A type 1 hybrid effectiveness-implementation design will be used to evaluate the effectiveness of STRIPES and explore the intervention's implementability. Analyses will test the impact of STRIPES vs. enhanced school services control on target mechanisms and determine whether differences in basic cognitive profiles moderate intervention response. The acceptability and feasibility of STRIPES and treatment moderators will also be examined. DISCUSSION: This study will generate knowledge about the effectiveness and implementability of STRIPES, which will inform dissemination efforts in the future. A peer-delivered high school intervention for organization, time management, and planning skills can provide accessible and feasible treatment targeting declines in academic motivation, grades, and attendance during the ninth-grade year. TRIAL REGISTRATION: This study is registered on OSF Registries (10.17605/OSF.IO/Q8V6S).

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

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

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

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

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

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