Insights From the Health Profession Opportunity Grant Program's Three-Armed, Multi-Site Experiment for Policy Learning and Evaluation Practice.

Administered by the Office of Family Assistance in the U.S. Department of Health and Human Services' Administration for Children and Families (ACF), the Health Profession Opportunity Grants (HPOG) Program provided education and training to Temporary Assistance for Needy Families (TANF) recipients and other adults with low incomes for occupations in the healthcare field. The impact evaluation for the first cohort of grantees (HPOG 1.0) leveraged the program's implementation across many locations, using a three-armed evaluation design (including a second treatment arm) in some places, as a way to examine whether any of three selected program components, or enhancements, contributed to the program's overall impact. This article tells the story of the evaluation and draws lessons from that experience, discussing implications for future implementation of multi-armed experiments in a multi-site evaluation.

How Three-Arm Random Assignment Within Sites can Improve Non-Experimental Cross-Site Estimates of the Relationship Between Program Characteristics and Impact.

This article considers a new method, called Cross-Site Attributional Model Improved by Calibration to Within-Site Individual Randomization Findings (abbreviated as "CAMIC"), which seeks to reduce bias in analyses of the contributions of a program's various design, implementation, and contextual characteristics to its overall impacts. It requires a multi-site experiment where some (or all) sites randomize individuals to one of three arms: a standard treatment group, an enhanced treatment group (that receives the standard treatment plus a program "enhancement"), or a control group (that has no access to the program). A recent evaluation-that of the Health Profession Opportunity Grants (HPOG) program-provides a motivating example of this design and its potential for both methodological and substantive lessons; and the article considers other evaluations that would be fitting for deploying and learning from CAMIC. We conclude that the promise for CAMIC lies in situations where the correlations between the selected program enhancement and alternative program characteristics of interest are relatively high, implying that producing an experimental estimate of the enhancement can reduce bias in the estimation of other non-randomized program characteristics.

Laparoscopic Ligamentum Teres cardiopexy to the rescue; an old procedure with a new use in managing reflux after sleeve gastrectomy.

BACKGROUND: Severe reflux after sleeve-gastrectomy (SG) often requires conversion to Roux-en-Y-Gastric Bypass (RYGB). We performed laparoscopic Ligamentum Teres Cardiopexy (LLTC) as an alternative operation. MATERIALS & METHODS: Ten patients had LLTC between June 2019-June 2020. Pre-operative work-up included Barium swallow, upper endoscopy with pH monitoring. The percent excess body mass index (%EBMI) loss before LLTC was 70 ± 0.2%. RESULTS: Pre-operative DeMeester score was 69 ± 50 (normal = 14.72). All patients underwent repair of hiatal hernia and gastric plication in addition to LLTC. The average operative-time was 110 ± 26 min. The follow up was 7 ± 3 months. Eight patients had resolution of their reflux. Two patients resumed medication for recurrent mild reflux. CONCLUSION: LLTC is a safe technique and may be considered a rescue operation in lieu of conversion to RYGB in managing severe reflux after SG. Long term results are needed to confirm its durable effectiveness.

Examining satisfaction of older adult patients and their caregivers following traumatic injury: a cross-sectional study of three level I trauma centres.

OBJECTIVE: To explore satisfaction of care received by older adult patients and their primary caregivers following traumatic injury. DESIGN: Prospective, cross-sectional study using the FAMCARE (Family Satisfaction with Advanced Cancer Care Scale) satisfaction surveys prior to discharge. SETTING: Three level I trauma centres in Colorado from November 2016 to December 2017. PARTICIPANTS: Trauma patients ≥55 years old and their primary caregivers. OUTCOME MEASURES: Overall mean (SD) satisfaction, satisfaction <80% vs ≥80%, and mean satisfaction by survey conceptual structures. RESULTS: Of the 319 patients and 336 caregivers included, the overall mean (SD) patient satisfaction was 81.7% (15.0%) and for caregivers was 83.6% (13.4%). The area with the highest mean for patient and caregiver satisfaction was psychosocial care (85.4% and 86.9%, respectively). Information giving was the lowest for patients (80.4%) and caregivers (80.9%). When individual items were examined, patients were significantly more satisfied with 'availability of nurses to answer questions' (84.5 (15.3) vs 87.4 (14.8), p=0.02) and significantly less satisfied with 'speed with which symptoms were treated' (80.6 (17.9) vs 84.0 (17.0), p=0.03) compared with caregivers. Patients with a history of smoking (least squares mean difference: -0.096 (-0.18 to -0.07), p<0.001) and hospital discharge destination to an outside facility of care (adjusted OR: 1.6 (1.0 to 2.4), p=0.048) were identified as independent predictors of lower overall satisfaction in generalised linear and logistic models, respectively. CONCLUSIONS: Our data suggest that patients' medical history was driving both patient and caregiver satisfaction. Patient characteristics and expectations need to be considered when tailoring healthcare interventions.

High on drugs: Multi-institutional pilot study examining the effects of substance use on acute pain management.

INTRODUCTION: Substance use and abuse may have the significant, but unanticipated, consequence of lessening the efficacy of opioid analgesics for acute pain management. We hypothesized that pre-injury substance use increases opioid analgesic consumption following traumatic injury. METHODS: This retrospective multi-institutional pilot study included admitted patients to four level 1 trauma centers with vehicular trauma over four months (n = 176). We examined the effect of positive urine drug screen (UDS; 7-drug panel, examined individually and combined, yes/no) and positive blood alcohol content (BAC, ≥80 mg/dL) on pain management with opioid analgesics over the hospital stay. Average daily opioid consumption was examined using a repeated measures mixed model, by positive UDS and BAC findings, adjusting for age, injury severity score, and non-opioid analgesia. Opioid analgesics were converted to milligram morphine equivalents (MME) and analyzed with a square-root transformation due to non-normality. RESULTS: A positive drug or alcohol test was reported in 33.5% (59/176), including 12.5% (n = 22) with positive UDS and 26% (n = 45) with a positive BAC. There were no differences in gender, injury severity scores, Glasgow coma scores, or cause of vehicular trauma between substance users and non-users; only age was significantly different. Patients with a positive UDS consumed significantly more opioids compared to those with a negative UDS (34.7 MME vs. 24.7 MME, p = 0.04), after adjustment. Individually, detection of opiates, THC, cocaine, and amphetamines were associated with increased opioid consumption compared to their UDS negative counterparts; on the other hand, benzodiazepines and alcohol intoxication were associated with reduced opioid consumption during the course of hospitalization. However, none of the individual UDS results reached statistical significance. The largest effect of all the individual drugs was with opiates, which was associated with a borderline significant increase in opioid analgesic consumption (p = 0.06). CONCLUSIONS: Our preliminary data suggest drug use may significantly alter acute pain management following traumatic injury, corresponding to 40% increase in opioid analgesia for substance users than non-users. These results may have broad reaching implications because of the high prevalence of substance use in the trauma population.

The grass is not always greener: a multi-institutional pilot study of marijuana use and acute pain management following traumatic injury.

BACKGROUND: Widespread legislative efforts to legalize marijuana have increased the prevalence of marijuana use and abuse. The effects of marijuana on pain tolerance and analgesic pain management in the acute pain setting have not been reported. Although marijuana has been shown to have antinociceptive effects and is approved for medical use to treat chronic pain, anecdotal evidence suggests marijuana users admitted with traumatic injuries experience poorer pain control than patients who do not use marijuana. We hypothesized that marijuana users would report higher pain scores and require more opioid analgesia following traumatic injury. METHODS: This retrospective pilot study included all patients involved in motor vehicle crashes, consecutively admitted to four trauma centers from 1/1/2016-4/30/2016. Marijuana status was examined as non-use and use, and was further categorized as chronic and episodic use. We performed a repeated measures mixed model to examine the association between marijuana use and a) average daily opioid consumption and b) average daily pain scores (scale 0-10). Opioid analgesics were converted to be equianalgesic to 1 mg IV hydromorphone. RESULTS: Marijuana use was reported in 21% (54/261), of which 30% reported chronic use (16/54). Marijuana use was reported more frequently in Colorado hospitals (23-29%) compared to the hospital in Texas (6%). Drug use with other prescription/street drugs was reported in 9% of patients. Other drug use was a significant effect modifier and results were presented after stratification by drug use. After adjustment, marijuana users who did not use other drugs consumed significantly more opioids (7.6 mg vs. 5.6 mg, p <  0.001) and reported higher pain scores (4.9 vs. 4.2, p <  0.001) than non-marijuana users. Conversely, in patients who used other drugs, there were no differences in opioid consumption (5.6 mg vs. 6.1 mg, p = 0.70) or pain scores (5.3 vs. 6.0, p = 0.07) with marijuana use compared to non-use, after adjustment. Chronic marijuana use was associated with significantly higher opioid consumption compared to episodic marijuana use in concomitant drug users (11.3 mg vs. 4.4 mg, p = 0.008) but was similar in non-drug users (p = 0.41). CONCLUSION: These preliminary data suggest that marijuana use, especially chronic use, may affect pain response to injury by requiring greater use of opioid analgesia. These results were less pronounced in patients who used other drugs.

A Design-Based Approach to Improve External Validity in Welfare Policy Evaluations.

BACKGROUND: Large-scale randomized experiments are important for determining how policy interventions change average outcomes. Researchers have begun developing methods to improve the external validity of these experiments. One new approach is a balanced sampling method for site selection, which does not require random sampling and takes into account the practicalities of site recruitment including high nonresponse. METHOD: The goal of balanced sampling is to develop a strategic sample selection plan that results in a sample that is compositionally similar to a well-defined inference population. To do so, a population frame is created and then divided into strata, which "focuses" recruiters on specific subpopulations. Units within these strata are then ranked, thus identifying "replacements" similar to sites that can be recruited when the ideal site refuses to participate in the experiment. RESULT: In this article, we consider how a balanced sample strategic site selection method might be implemented in a welfare policy evaluation. CONCLUSION: We find that simply developing a population frame can be challenging, with three possible and reasonable options arising in the welfare policy arena. Using relevant study-specific contextual variables, we craft a recruitment plan that considers nonresponse.

Using cluster analysis in program evaluation.

The conventional way to measure program impacts is to compute the average treatment effect; that is, the difference between a treatment group that received some intervention and a control group that did not. Recently, scholars have recognized that looking only at the average treatment effect may obscure impacts that accrue to subgroups. In an effort to inform subgroup analysis research, this article explains the challenge of treatment group heterogeneity. It then proposes using cluster analysis to identify otherwise difficult-to-identify subgroups within evaluation data. The approach maintains the integrity of the experimental evaluation design, thereby producing unbiased estimates of program impacts by subgroup. This method is applied to data from the evaluation of New York State's Child Assistance Program, a reform that intended to increase work and earnings among welfare recipients. The article interprets the substantive findings and then addresses the advantages and disadvantages of the proposed method.

Prenatal HIV counseling and testing in California: women's experiences and providers' practices.

Two concurrent surveys were conducted in four California counties to compare the prenatal HIV counseling and voluntary testing (C&VT) experiences of women with the self-reported practices of prenatal care providers. Participants were 850 women currently or recently receiving prenatal care and 254 providers. Although 79.9% of women reported being offered an HIV test during a prenatal visit, only 56.2% said they were told about the risks and benefits of taking an HIV test. Almost all providers (98.4%) indicated they offer an HIV test, and 76.8% reported offering counseling, to every patient. One third of the women (65.9%) knew that treatment exists for reducing the chance of prenatal transmission of HIV, and 78.7% of women said they were more likely to be tested given knowledge of such therapy. Women may have underreported prenatal C&VT because providers spend insufficient time discussing related issues or because C&VT information is not presented in a way that is relevant to all patients.