Veteran suicide and associated community characteristics in Oregon.

Developing a public health approach to suicide prevention among United States (US) military veterans requires additional data and guidance on where, when, for whom, and what prevention resources should be deployed. This study examines veteran suicide mortality across one US state (Oregon) to identify county-level "hotspots" for veteran suicide, identify community characteristics associated with increased suicide among veterans, and examine excess spatial risk after accounting for space, time, and community characteristics. We linked Oregon mortality data with VA databases to identify veterans who had resided in Oregon and died by suicide between January 1, 2009 and December 31, 2018 (n = 1727). Community characteristic data were gathered at the county level from publicly available datasets on social determinants of health known to be associated with poor health outcomes, including suicide risk. We estimated spatial generalized linear mixed models for the full 10-year period and for each 5-year period using integrated nested Laplace approximation with county as the higher hierarchy. Smoothed standardized mortality ratios were used to identify counties with higher risk of veteran suicide. We found a small clustering of counties in the southwestern corner of Oregon that held the highest risk for veteran suicide across the ten years studied. In multivariable models, higher prevalence of unmarried persons was the only community measure significantly associated with increased veteran suicide risk. However, social contextual factors as a group, along with geographic space, explained most risk for suicide among veterans at the population level.

Using data science to improve outcomes for persons with opioid use disorder.

Medication treatment for opioid use disorder (MOUD) is an effective evidence-based therapy for decreasing opioid-related adverse outcomes. Effective strategies for retaining persons on MOUD, an essential step to improving outcomes, are needed as roughly half of all persons initiating MOUD discontinue within a year. Data science may be valuable and promising for improving MOUD retention by using "big data" (e.g., electronic health record data, claims data mobile/sensor data, social media data) and specific machine learning techniques (e.g., predictive modeling, natural language processing, reinforcement learning) to individualize patient care. Maximizing the utility of data science to improve MOUD retention requires a three-pronged approach: (1) increasing funding for data science research for OUD, (2) integrating data from multiple sources including treatment for OUD and general medical care as well as data not specific to medical care (e.g., mobile, sensor, and social media data), and (3) applying multiple data science approaches with integrated big data to provide insights and optimize advances in the OUD and overall addiction fields.

Adjustment to the COVID-19 pandemic: associations with global and situational meaning.

COVID-19 has created pervasive upheaval and uncertainty in communities around the world. This investigation evaluated associations between discrete dimensions of personal meaning and psychological adjustment to the pandemic among community residents in a southern US state. In this cross-sectional study, 544 respondents were assessed during a period of reopening but accelerating infection rates. Validated measures were used to evaluate theoretically distinct dimensions of perceived global meaning (Meaning-in-Life Questionnaire) and pandemic-specific meaning (Meaning in Illness Scale). Adjustment outcomes included perceived stress, pandemic-related helplessness, and acceptance of the pandemic. In multivariate models that controlled for demographic and pandemic-related factors, stronger attained global meaning (i.e., perceptions that life is generally meaningful) and attained situational meaning (i.e., perceptions that the pandemic experience was comprehensible) were related to better adjustment on all three outcomes (all p's < .001). In contrast, seeking situational meaning (i.e., ongoing efforts to find coherence in the situation) was associated with poorer adjustment on all indices (all p's < .001). Results offer novel information regarding theoretically salient dimensions of meaning, which may have direct relevance for understanding how community residents adapt to the challenges of a major public health crisis.

Enrollee Experience with Providers in the Arkansas Medicaid Expansion Program.

BACKGROUND: Patient ratings of their healthcare experience as a quality measure have become critically important since the implementation of the Affordable Care Act (ACA). The ACA enabled states to expand Medicaid eligibility to reduce uninsurance nationally. Arkansas gained approval to use Medicaid funds to purchase a qualified health plan (QHP) through the ACA marketplace for newly eligible beneficiaries. OBJECTIVE: We compare patient-reported satisfaction between fee-for-service Medicaid and QHP participants. DESIGN: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) was used to identify differences in Medicaid and QHP enrollee healthcare experiences. Data were analyzed using a regression discontinuity design. PARTICIPANTS: Newly eligible Medicaid expansion participants enrolled in Medicaid during 2013 completed the Consumer Assessment of Health Providers and Systems (CAHPS) survey in 2014. Survey data was analyzed for 3156 participants (n = 1759 QHP/1397 Medicaid). MEASURES: Measures included rating of personal and specialist provider, rating of all healthcare received, and whether the provider offered to communicate electronically. Demographic and clinical characteristics of the enrollees were controlled for in the analyses. METHODS: Regression-discontinuity analysis was used to evaluate differential program effects on positive ratings as measured by the CAHPS survey while controlling for demographic and health characteristics of participants. KEY RESULTS: Adjusted logistic regression models for overall healthcare (OR = 0.71, 95%CI = 0.56-0.90, p = 0.004) and personal doctor (OR = 0.68, 95%CI = 0.53-0.87, p = 0.002) predicted greater satisfaction among QHP versus Medicaid participants. Results were not significant for specialists or for use of electronic communication with provider. CONCLUSIONS: Using a quasi-experimental statistical approach, we were able to control for observed and unobserved heterogeneity showing that among participants with similar characteristics, including income, QHP participants rated their personal providers and healthcare higher than those enrolled in Medicaid. Access to care, utilization of care, and healthcare and health insurance literacy may be contributing factors to these results.

Increased Vascular Pathology in Older Veterans With a Purple Heart Commendation or Chronic Post-Traumatic Stress Disorder.

The goal of this retrospective cohort study was to determine whether stressors related to military service, determined by a diagnosis of chronic post-traumatic stress disorder (cPTSD) or receiving a Purple Heart (PH), are associated with an increased risk of vascular risk factors and disease, which are of great concern for veterans, who constitute a significant portion of the aging US population. The Veterans Integrated Service Network (VISN) 16 administrative database was searched for individuals 65 years or older between October 1, 1997 to September 30, 1999 who either received a PH but did not have cPTSD (PH+/cPTSD-; n = 1499), had cPTSD without a PH (PH-/cPTSD+; n = 3593), had neither (PH-/cPTSD-; n = 5010), or had both (PH+/cPTSD+; n = 153). In comparison to the control group (PH-/cPTSD-), the PH+/cPTSD- group had increased odds ratios for incidence and prevalence of diabetes mellitus, hypertension, and hyperlipidemia. The PH-/cPTSD+ group had increased odds ratios for prevalence of diabetes mellitus and for the incidence and prevalence of hyperlipidemia. The PH-/cPTSD+ and PH+/cPTSD- groups were associated with ischemic heart disease and cerebrovascular disease, but not independently of the other risk factors. The PH+/cPTSD+ group was associated only with an increase in the incidence and prevalence of hyperlipidemia, though this group's much smaller sample size may limit the reliability of this finding. We conclude that certain physical and psychological stressors related to military service are associated with a greater incidence of several vascular risk factors in veterans aged 65 years or older, which in turn are associated with greater rates of ischemic heart disease and cerebrovascular disease.

Prevalence of Chronic Kidney Disease, Thrombotic Cardiovascular Events, and Use of Oral P2Y12 Inhibitors among Veterans.

BACKGROUND: Contemporary prevalence of chronic kidney disease (CKD) and thrombotic cardiovascular (CV) events remains unclear in Veterans enrolled in the Veterans Affairs Health Care System (VA) care. Although oral P2Y12 inhibitors (P2Y12i) are increasingly being prescribed to this patient population, the overall prescription trend for P2Y12i remains unclear. METHODS: Using national VA corporate warehouse data, we used International Classification of Diseases-9 codes to identify Veterans with CKD, dialysis-dependent CKD, and CV events. VA pharmacy data were used to count P2Y12i prescriptions for the federal fiscal years (FY) 2011 through 2015. RESULTS: The period prevalence of Veterans with CKD was 378,233 (6.1%). The point prevalence of CKD increased by 49% from 132,979 (2.30%) in FY11 to 213,444 (3.42%) in FY15. The period prevalence of Veterans with dialysis-dependent CKD was 150,298 (2.4%). In all, 128,703 (56.7%) CV events occurred in Veterans with CKD. Veterans with CKD were given 50.1% of prescriptions for clopidogrel, 49.3% for prasugrel, and 60.4% for ticagrelor. In this patient population, year-to-year increases in P2Y12i prescriptions were observed with a dramatic increase in ticagrelor prescriptions. CONCLUSION: CKD is common among Veterans and its true prevalence is likely being underestimated. The prevalence of dialysis-dependent CKD is higher among Veterans than the non-Veteran US population. CV events are widely co-prevalent and these patients are commonly prescribed P2Y12i. The recent increase in ticagrelor prescriptions in this patient population and large cost differences between the 3 P2Y12i underline the need for future studies to identify the preferred P2Y12i for these patients.

Factors Associated with Opioid Initiation in OEF/OIF/OND Veterans with Traumatic Brain Injury.

Objective: These analyses examined opioid initiation and chronic use among Iraq (OIF) and Afghanistan (OEF/OND) veterans with a new diagnosis of traumatic brain injury (TBI) in the Veterans Health Administration (VHA). Methods: Data were obtained from national VHA data repositories. Analyses included OEF/OIF/OND veterans with a new TBI diagnosis in 2010-2012 who used the VHA at least twice, had not received a VHA opioid prescription in the 365 days before diagnosis, and had at least 365 days of data available after TBI diagnosis. Results: Analyses included 35,621 veterans. Twenty-one percent initiated opioids; among new initiators, 23% used chronically. The mean dose was 24.0 mg morphine equivalent dose (MED) daily (SD = 24.26); mean days supplied was 60.52 (SD = 74.69). Initiation was significantly associated with age 36-45 years (odds ratio [OR] = 1.09, 95% CI = 1.01-1.17, P = 0.04), female gender (OR = 1.22, P < 0.001), having back pain (OR = 1.38, P < 0.0001), arthritis/joint pain (OR = 1.24, P < 0.0001), or neuropathic pain (OR = 1.415, P < 0.02). In veterans age 36-45 years, those living in small rural areas had higher odds of chronic opioid use (OR = 1.31, P < 0.0001, and OR = 1.33, P = 0.006, respectively) and back pain (OR = 1.36, P = 0.003). Headache/migraine pain was associated with decreased odds of chronic opioid use (OR = 0.639, P = 0.003). Conclusions: Prevalence of opioid use is relatively low among OEF/OIF/OND veterans with newly diagnosed TBI who are using VHA. Among those who initiated opioids, about 25% use them chronically. Prescribing was mostly limited to moderate doses, with most veterans using opioids for approximately two months of the 12-month study period.

Impact of the INBRE summer student mentored research program on undergraduate students in Arkansas.

The Institutional Development Award (IDeA) program, housed within the National Institute for General Medical Sciences, administers the Networks of Biomedical Research Excellence (INBRE) as a strategic mission to broaden the geographic distribution of National Institutes of Health (NIH) funding within the United States. Undergraduate summer student mentored research programs (SSMRP) are a common feature of INBRE programs and are designed to increase undergraduate student interest in research careers in the biomedical sciences. Little information is available about student perspectives on how these programs impact their choices relative to education and careers. Therefore, we conducted qualitative interviews with 20 participants from the Arkansas INBRE SSMRP in the years 2002-2012. Each telephone interview lasted 30-45 min. An interview guide with a broad "grand tour" question was used to elicit student perspectives on SSMRP participation. Interviews were digitally recorded, then transcribed verbatim, and the transcript checked for accuracy. Content analysis and constant comparison were used to identify nine themes that were grouped into three temporal categories: before, during, and after the SSMRP experience. Students viewed the experience as positive and felt it impacted their career choices. They emphasized the value of mentoring in the program, and some reported maintaining a relationship with the mentor after the summer experience ended. Students also valued learning new laboratory and presentation skills and felt their research experience was enhanced by meeting students and scientists with a wide range of career interests. These data suggest that the Arkansas INBRE and the NIH IDeA program are successfully meeting the goal of increasing interest in research among undergraduates.

The influence of propoxyphene withdrawal on opioid use in veterans.

PURPOSE: Our aim is to determine if propoxyphene withdrawal from the US market was associated with opioid continuation, continued chronic opioid use, and secondary propoxyphene-related adverse events (emergency department visits, opioid-related events, and acetaminophen toxicity). METHODS: Medical service use and pharmacy data from 19/11/08 to 19/11/11 were collected from the national Veterans Healthcare Administration healthcare databases. A quasi-experimental pre-post retrospective cohort design utilizing a historical comparison group provided the study framework. Logistic regression controlling for baseline covariates was used to estimate the effect of propoxyphene withdrawal. RESULTS: There were 24,328 subjects (policy affected n = 10,747; comparison n = 13,581) meeting inclusion criteria. In the policy-affected cohort, 10.6% of users ceased using opioids, and 26.6% stopped chronic opioid use compared with 3.8% and 13.5% in the historical comparison cohort, respectively. Those in the policy-affected cohort were 2.7 (95%CI: 2.5-2.8) and 3.2 (95%CI: 2.9-3.6) times more likely than those in the historical comparison cohort to discontinue chronic opioid and any opioid use, respectively. Changes in adverse events and Emergency Department (ED) visits were not different between policy-affected and historical comparison cohorts (p > 0.05). CONCLUSIONS: The withdrawal of propoxyphene-containing products resulted in rapid and virtually complete elimination in propoxyphene prescribing in the veterans population; however, nearly 90% of regular users of propoxyphene switched to an alternate opioid, and three quarters continued to use opioids chronically.

The impact of Purple Heart commendation and PTSD on mortality rates in older veterans.

BACKGROUND: To determine whether having received a Purple Heart (PH) or having been diagnosed with posttraumatic stress disorder (PTSD) affected mortality in older veterans. METHODS: We compared mortality rates of older veterans with a PH but without PTSD (PH+/PTSD-) to veterans with a PH and PTSD (PH+/PTSD+), veterans without a PH but with PTSD (PH-/PTSD+), and a comparison group without a PH or PTSD (PH-/PTSD-). Administrative data from the Veterans Integrated Service Network 16 were collected between 10/01/97 and 09/30/99 for veterans who were 65 years or older. Proportional hazards regression was used to compare the survival times for the four groups (n = 10,255) from entry into the study until death or study termination (9/30/2008). The Charleson co-morbidity index was used to control for potential co-morbid illness burden differences between the groups. RESULTS: Older veterans with a PH (PH+/PTSD- and PH+/PTSD+) had significantly lower mortality rates than PH-/PTSD- veterans (hazard ratio [HR] = 0.6, 95% confidence interval [CI] 0.5 to 0.6, P<.0001; and HR = 0.5, 95% CI 0.4 to 0.7, P<.0001). The PH-/PTSD+ group had a higher mortality rate than the PH-/PTSD- group (HR = 1.1, 95% CI 1.0 to 1.2, P<.01). CONCLUSIONS: Veterans who had PH citations and survived into their seventh decade had half the mortality rate of veterans without PH citations with or without PTSD. Veterans with PTSD but without a PH had a significantly higher mortality rate compared to (PH-/PTSD-). Veterans who suffer combat injury without developing PTSD may provide a useful study population for determining the factors that confer resilience.

Does PTSD impair cognition beyond the effect of trauma?

This systematic review analyzed data from studies examining memory and cognitive function in subjects with posttraumatic stress disorder (PTSD), compared with subjects exposed to trauma (but without PTSD). Based on analysis of 21 articles published in English from 1968 to 2009, the conclusion is that individuals with PTSD, particularly veterans, show signs of cognitive impairment when tested with neuropsychological instruments, more so than individuals exposed to trauma who do not have PTSD.

Veterans self-reported reasons for non-attendance in psychotherapy for posttraumatic stress disorder.

This study explored rates of non-attendance (i.e., non-initiation, inconsistent attendance, early discontinuation) in cognitive processing therapy (CPT) and other posttraumatic stress disorder (PTSD) focused individual and group psychotherapies (i.e., interventions with at least some PTSD and/or trauma-related content) and characterized veterans' self-reported reasons for non-attendance in these treatments. Baseline and 6-month follow-up data from the Telemedicine Outreach for PTSD study, a pragmatic randomized effectiveness trial conducted in 11 Veterans Health Administration community-based outpatient clinics, was examined (N = 265 veterans). Over 90% of veterans with a scheduled psychotherapy appointment attended at least one appointment by 6-month follow-up. Self-reported treatment completion was higher for veterans attending individual CPT (25%) than for those attending PTSD-focused individual (4.4%) and group psychotherapy (15.5%). However, rates of inconsistent attendance (13.3%) and early discontinuation (18.3%) were also higher in veterans attending CPT when compared to other forms of PTSD-focused psychotherapy (inconsistent attendance-individual: 2.2%, group: 6.9%; early discontinuation-individual: 14.6%; group: 10.3%). Issues with scheduling appointments was one of the most frequently reported reasons for non-attendance across treatments (> 20%). Logistical barriers, including transportation (CPT), therapy taking too much time (PTSD-focused individual psychotherapy) and not being able to afford counseling (PTSD-focused group psychotherapy), were also commonly cited (i.e., > 15%). Those scheduled to attend CPT (26%) or PTSD-focused individual psychotherapy (11%) also cited treatment efficacy concerns as a reason for non-attendance. Findings suggest logistical barriers, particularly scheduling convenient appointments, and beliefs about treatment may be important to address when engaging veterans in psychotherapy for PTSD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A program evaluation of Arkansas Improving Multidisciplinary Pain Care and Treatment (AR-IMPACT).

OBJECTIVE: Arkansas Improving Multidisciplinary Pain Care and Treatment (AR-IMPACT) is an interprofessional team that delivers televideo case conferences to help providers optimize treatment of pain using nonopioid, evidence-based therapies. This article assesses AR-IMPACT using the RE-AIM (reach, efficacy, adoption, implementation, maintenance) framework. DESIGN: A cross-sectional study. SETTING: Large, academic medical center. PARTICIPANTS: Healthcare providers. INTERVENTIONS: Televideo case conferences. MAIN OUTCOME MEASURES: Reach was evaluated by the number of participants, professions represented, and counties/states in which providers resided. Efficacy was assessed via a participant evaluation survey. Adoption was evaluated by calculating the number of repeat participants and soliciting information on barriers to adoption of conference recommendations in clinical practice using the participant evaluation survey. Implementation was evaluated by calculating the time and cost burden of the program. RESULTS: Reach was widespread; continuing education (CE) credits have been claimed by 395 providers in 54 of the 75 counties in Arkansas and 18 states outside Arkansas. For efficacy, the majority of providers noted increases in their knowledge due to AR-IMPACT (89.6 percent). Like reach, adoption was also extensive; approximately 42 percent of AR-IMPACT participants attended more than one conference, and close to 56 percent of participants noted no barriers to adopting the changes discussed in the conferences. With implementation, the time requirements for developing a case conference ranged from 2 to 4 hours, and the cost per CE credit was $137, which is on par with other programs. CONCLUSIONS: AR-IMPACT was successful, particularly in reach and efficacy. Entities that implement programs similar to AR-IMPACT will likely experience extensive uptake by providers.

Anxiety, depressive, and trauma symptoms during the COVID-19 pandemic: Evaluating the role of disappointment with God.

BACKGROUND: The COVID-19 pandemic has led to pervasive social and economic disruptions. This cross-sectional investigation aimed to evaluate associations between religious/spiritual factors and mental health symptoms among community residents in a southern US state. In particular, we focused on perceptions of God's distance, a salient aspect of religious/spiritual struggle that has received little scrutiny in health research. METHODS: Participants included 551 respondents assessed during a period of gradual reopening but rising infection rates. Mental health outcomes were assessed using standardized measures of generalized anxiety, depression, and trauma symptoms. Perceptions of an affirming relationship with God, anger at God, and disappointment at God's distance were evaluated using an adapted version of the Attitudes-Toward-God Scale-9. RESULTS: In multivariate analyses that accounted for pandemic-related and demographic factors, positive relationships with God were related to diminished symptoms on all three mental heatlh indices (all p's ≤.003), whereas disappointment with God's distance was associated with more pronounced difficulties (all p's ≤.014). LIMTATIONS: The cross-sectional design precludes causal conclusions. CONCLUSIONS: Findings suggest that perceived relationships with God are tied to clinically relevant mental health outcomes during periods of major upheaval. Disappointment with God's distance may be an important, understudied dimension of religious/spiritual struggle meriting further investigation.

Mental health outcomes associated with the COVID-19 pandemic: Prevalence and risk factors in a southern US state.

The COVID-19 pandemic has had a dramatic effect on the functioning of individuals and institutions around the world. This cross-sectional registry-based study examined some of the burdens of the pandemic, the prevalence of mental health difficulties, and risk factors for psychosocial morbidity among community residents in Arkansas. The study focused on a period of gradual reopening but rising infection rates. The investigation included validated screening measures of depressive symptoms (PHQ-9), generalized anxiety (GAD-7), trauma-related symptoms (PCL-5), and alcohol use (AUDIT-C). A notable percentage of participants reported elevated symptoms on each of these outcomes. In separate multivariable analyses that accounted for a number of demographic and pandemic-related covariates, individuals who reported greater pandemic-related disruption in daily life, and those with a prior history of mental health concerns, were more likely to screen positive for depressive, anxiety and trauma-related symptoms. Findings illuminate burdens experienced by community residents during a period of phased reopening, and offer a foundation for future screening and intervention initiatives.

Therapeutic alliance across trauma-focused and non-trauma-focused psychotherapies among veterans with PTSD.

Trauma-focused psychotherapies for posttraumatic stress disorder (PTSD) are not widely utilized. Clinicians report concerns that direct discussion of traumatic experiences could undermine the therapeutic alliance, which may negatively impact retention and outcome. Studies among adolescents with PTSD found no difference in alliance between trauma-focused and non-trauma-focused psychotherapies, but this has not been tested among adults. The present study is a secondary analysis of a randomized trial of collaborative care, also known as care management, for PTSD. We examined patient-reported therapeutic alliance among 117 veterans with PTSD who participated in cognitive processing therapy (CPT, now called CPT + A; n = 54) or non-trauma-focused supportive psychotherapy for PTSD (n = 73) at VA community outpatient clinics. We tested the hypothesis that alliance in CPT would be noninferior to (i.e., not significantly worse than) non-trauma-focused psychotherapy using patient ratings on the Revised Helping Alliance Questionnaire. Patients' therapeutic alliance scores were high across both groups (CPT: M = 5.13, SD = 0.71, 95% CI [4.96, 5.30]; non-trauma-focused psychotherapy: M = 4.89, SD = 0.64, 95% CI [4.73, 5.05]). The difference between groups (0.23, 95% CI [0.01, 0.48]) was less than the "noninferiority margin" based on suggested clinical cutoffs (0.58 points on a 1-6 scale). These results held even after adjusting for veterans' demographic and clinical characteristics and change in PTSD symptoms from baseline to follow-up. Although there are concerns that direct discussion of traumatic experiences could worsen therapeutic alliance, patients report similar levels of alliance in CPT and non-trauma-focused supportive psychotherapy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Prospective validation of eight different adherence measures for use with administrative claims data among patients with schizophrenia.

OBJECTIVE: The aim of this study was to compare the predictive validity of eight different adherence measures by studying the variability explained between each measure and hospitalization episodes among Medicaid-eligible persons diagnosed with schizophrenia on antipsychotic monotherapy. METHODS: This study was a retrospective analysis of the Arkansas Medicaid administrative claims data. Continuously eligible adult schizophrenia (ICD-9-CM = 295.**) patients on antipsychotic monotherapy were identified in the recruitment period from July 2000 through April 2004. Adherence rates to antipsychotic therapy in year 1 were calculated using eight different measures identified from the literature. Univariate and multivariable logistic regression models were used to prospectively predict all-cause and mental health-related hospitalizations in the follow-up year. RESULTS: Adherence rates were computed for 3395 schizophrenic patients with a mean age of 42.9 years, of which 52.5% (n = 1782) were females, and 52.8% (n = 1793) were white. The proportion of days covered (PDC) and continuous measure of medication gaps measures of adherence had equal C-statistics of 0.571 in predicting both all-cause and mental health-related hospitalizations. The medication possession ratio (MPR) continuous multiple interval measure of oversupply were the second best measures with equal C-statistics of 0.568 and 0.567 for any-cause and mental health-related hospitalizations. The multivariate adjusted models had higher C-statistics but provided the same rank order results. CONCLUSIONS: MPR and PDC were among the best predictors of any-cause and mental health-related hospitalization, and are recommended as the preferred adherence measures when a single measure is sought for use with administrative claims data for patients not on polypharmacy.

Prevalence, Health and Resource Utilization, and Unmet Healthcare Needs of Native Hawaiian and Pacific Islander Children With Developmental Disabilities.

Little is known about health limitations and service utilization among the Native Hawaiian and Pacific Islander (NHPI) children with developmental disabilities (DDs) due to limited data. Our study examined the prevalence of DDs, health limitations, services used, and the unmet needs of NHPI children aged 3 to 17 years using cross-sectional data from the 2014 NHPI National Health Interview Survey. Results showed that prevalence of DDs among NHPI children was lower than American children of other races. DDs were negatively associated with health and functioning of NHPI children. There is a need to promote understanding of DDs among NHPI families and to inform public policy makers to identify appropriate intervention services for NHPI children.

Utilization of Interactive Clinical Video Telemedicine by Rural and Urban Veterans in the Veterans Health Administration Health Care System.

PURPOSE: Interactive clinical video telemedicine (CVT) has the potential to benefit health care systems and patients by improving access, lowering costs, and more efficiently distributing providers. However, there is a gap in current knowledge around the demand for and potential uses of CVT in large integrated health care systems. METHODS: We conducted an observational study using Veterans Health Administration (VHA) administrative databases to analyze trends in CVT utilization, and types of care received, among 7.65 million veterans during fiscal years (FY) 2009-2015 (October 1, 2008-September 30, 2015). Trends were stratified by veteran rurality and analyzed using linear regression. Among 4.95 million veterans in FY2015, we used logistic regression to identify characteristics associated with CVT utilization for any care, mental health care, and major specialties. FINDINGS: Over 6 years, the annual CVT utilization grew from 30 to 124 encounters per 1,000 veterans (>300% increase), with faster growth among rural veterans than urban veterans. Over the study period, ≥50% of all CVT-delivered care was mental health care. In FY2015, 3.2% of urban and 7.2% of rural veterans utilized CVT for nearly 725,000 clinical encounters. Rural residence, younger age, longer driving distance to VHA facilities, one or more comorbidities, and higher rates of traditional, non-video utilization were independently associated with higher odds of CVT use. CONCLUSIONS: CVT utilization in VHA has increased quickly and exceeds published rates in the private health care market. The availability of CVT has likely increased access to VHA care for rural veterans, especially for mental health care.

An empirical basis for standardizing adherence measures derived from administrative claims data among diabetic patients.

OBJECTIVE: To compare the predictive validity of 8 different adherence measures by studying the variability explained between each measure and 2 outcome measures: hospitalization episodes and total nonpharmacy cost among Medicaid eligible persons diagnosed with diabetes. RESEARCH DESIGN: This study was a retrospective analysis of the Arkansas Medicaid administrative claims data from January 2000 to December 2006. SUBJECTS: Diabetic (ICD-9-CM = 250.0 x - 250.9 x, where x = 0 or 2) patients were identified in the recruitment period July 2000 through April 2004. Patients had to be >or=18 years old and have at least 2 prescription fills in the index period for an oral antidiabetic drug. MEASURES: : Adherence rates to oral antidiabetic therapy were contrasted using the following 8 measures; including the medication possession ratio (MPR), proportion of days covered (PDC), refill compliance rate (RCR), compliance ratio (CR), medication possession ratio, modified (MPRm), continuous measure of medication gaps (CMG), and continuous multiple interval measure of oversupply (CMOS and continuous, single interval measure of medication acquisition (CSA). Multivariate and univariate linear and logistic regression models were used to prospectively predict nonpharmacy costs and hospitalizations in the follow-up year. RESULTS: A total of 4943 diabetic patients were studied. In predicting any cause hospitalization, univariate models with PDC and CMG had the highest predictive validity (C-statistic: 0.544). Multivariate models with MPR, PDC, CMG or continuous multiple interval measure of oversupply (CMOS) as adherence measures had the highest C-statistics of 0.701 in predicting diabetes specific hospitalizations. None of the adherence measures were significantly associated with nonpharmacy cost. CONCLUSIONS: MPR and PDC had the highest predictive validity for hospitalization episodes. These 2 measures should be considered first when selecting among adherence measures when using administrative prescription claims data.