Legal Services for Veterans (LSV): Protocol for evaluating the grant-based LSV initiative supporting community organizations' delivery of legal services to veterans.

BACKGROUND: 1.8 million Veterans are estimated to need legal services, such as for housing eviction prevention, discharge upgrades, and state and federal Veterans benefits. While having one's legal needs met is known to improve one's health and its social determinants, many Veterans' legal needs remain unmet. Public Law 116-315 enacted in 2021 authorizes VA to fund legal services for Veterans (LSV) by awarding grants to legal service providers including nonprofit organizations and law schools' legal assistance programs. This congressionally mandated LSV initiative will award grants to about 75 competitively selected entities providing legal services. This paper describes the protocol for evaluating the initiative. The evaluation will fulfill congressional reporting requirements, and inform continued implementation and sustainment of LSV over time. METHODS: Our protocol calls for a prospective, mixed-methods observational study with a repeated measures design, aligning to the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) and Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) frameworks. In 2023, competitively selected legal services-providing organizations will be awarded grants to implement LSV. The primary outcome will be the number of Veterans served by LSV in the 12 months after the awarding of the grant. The evaluation has three Aims. Aim 1 will focus on measuring primary and secondary LSV implementation outcomes aligned to RE-AIM. Aim 2 will apply the mixed quantitative-qualitative Matrixed Multiple Case Study method to identify patterns in implementation barriers, enablers, and other i-PARIHS-aligned factors that relate to observed outcomes. Aim 3 involves a mixed-methods economic evaluation to understand the costs and benefits of LSV implementation. DISCUSSION: The LSV initiative is a new program that VA is implementing to help Veterans who need legal assistance. To optimize ongoing and future implementation of this program, it is important to rigorously evaluate LSV's outcomes, barriers and enablers, and costs and benefits. We have outlined the protocol for such an evaluation, which will lead to recommending strategies and resource allocation for VA's LSV implementation.

A Time-Driven Activity-Based Costing Analysis of Simultaneous Versus Staged Bilateral Total Hip Arthroplasty and Total Knee Arthroplasty.

BACKGROUND: Although studies have compared the claims costs of simultaneous and staged bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA), whether a simultaneous procedure is cost-effective to the facility remains unknown. This study aimed to compare facility costs and perioperative outcomes of simultaneous vs staged bilateral THA and TKA. METHODS: We reviewed a consecutive series of 560 bilateral THA (170 staged and 220 simultaneous) and 777 bilateral TKA (163 staged and 451 simultaneous). Itemized facility costs were calculated using time-driven activity-based costing. Ninety-day outcomes were compared. Margin was standardized to unadjusted Medicare Diagnosis Related Group payments (simultaneous, $18,523; staged, $22,386). Multivariate regression was used to determine the independent association between costs/clinical outcomes and treatment strategy (staged vs simultaneous). RESULTS: Simultaneous bilateral patients had significantly lower personnel, supply, and total facility costs compared with staged patients with no difference in 90-day complications between the groups. Multivariate analyses showed that overall facility costs were $1,210 lower in simultaneous bilateral THA (P < .001) and $704 lower in TKA (P < .001). Despite lower costs, margin for the facility was lower in the simultaneous group ($6,569 vs $9,225 for THA; $6,718 vs $10,067 for TKA; P < .001). CONCLUSION: Simultaneous bilateral TKA and THA had lower facility costs than staged procedures because of savings associated with a single hospitalization. With the increased Medicare reimbursement for 2 unilateral procedures, however, margin was higher for staged procedures. In the era of value-based care, policymakers should not penalize facilities for performing cost-effective simultaneous bilateral arthroplasty in appropriately selected patients.

Gap Year Research Fellowship Opportunities for Medical Students Interested in Orthopaedic Surgery.

INTRODUCTION: Orthopaedic surgery is becoming an increasingly competitive specialty. The purpose of this study was to identify existing orthopaedic research fellowships in the United States and to determine important characteristics including the number of positions offered by each program and the average number of publications from completing the program. METHODS: An online search was performed to identify year-long orthopaedic research fellowship programs available for medical students and recent medical school graduates. The number of positions per program and average number of publications of recent program graduates were also obtained. RESULTS: A total of 30 research fellowship programs were identified throughout the United States (13 in the northeast; six in the south; nine in the midwest; and two in the west) that are offered consistently each year. The average number of fellows per program was 3.1 (range 1 to 10) and the average number of publications was 10.8 (range 2 to 20). CONCLUSION: At least 30 orthopaedic research fellowships in the United States are available to students who are looking to acquire more research experience and strengthen their application for orthopaedic residency. These fellowships can help medical students increase their probability of matching into orthopaedics through publications, networking, and clinical exposure.

Diabetic ketoacidosis presentations in a low socio-economic area: are services suitable?

BACKGROUND: Diabetic ketoacidosis causes a significant number of hospitalisations worldwide, with rates tending to increase with remoteness and socioeconomic disadvantage. Our study aimed to explore healthcare professionals' perceptions of factors affecting presentation of people with type 1 diabetes in a low socioeconomic area of Queensland, Australia. METHODS: This was a qualitative study. Individual semi-structured face-to-face or telephone interviews were completed with patients with type 1 diabetes who had presented in diabetic ketoacidosis, and healthcare professionals who have experience in related care. Data were analysed using Gibbs's framework of thematic analysis. RESULTS: Four patients with type 1 diabetes and 18 healthcare professionals were interviewed. Restricted access was identified as a factor contributing to diabetic ketoacidosis and delayed presentation, with ketone testing supplies, continuous glucose monitoring technology and transport considered barriers. Many of these factors were arguably preventable. Opportunities to improve the care available to patients with type 1 diabetes were detailed, with particularly strong support for dedicated out of hours telephone help lines for adults with type 1 diabetes. CONCLUSIONS: Gaps in support for patient self-care to avoid diabetic ketoacidosis presentations and prevent late presentation of diabetic ketoacidosis revealed by this study require service reconfiguration to support care delivery. Until change is made, people with type 1 diabetes will continue to make both avoidable and delayed, acutely unwell, presentations to Emergency Departments.

Veterans Justice Programs: Assessing Population Risks for Suicide Deaths and Attempts.

OBJECTIVES: Understanding suicide risks among Veteran subpopulations is a national priority. This study assessed risks of suicide, suicide attempts, and other-cause mortality among recipients of Veterans Health Administration (VHA) Veterans Justice Program services as compared to other Veteran VHA users. METHODS: Per VHA records, the cohort included 5,401,192 Veterans alive as of January 1, 2013 and with VHA utilization in 2012. Receipt of Veterans Justice Outreach (VJO) or Health Care for Reentry Veterans (HCRV) services in 2012 was assessed using encounter codes. Multivariable proportional hazards regression assessed risks of suicide (per National Death Index search results from the VA/DoD Mortality Data Repository) and attempts (per diagnoses and site reports) in 2013-2016, adjusting for demographic and clinical indicators. RESULTS: Compared to other patients, Veterans with VJO encounters had greater risk of suicide (unadjusted HR = 2.80, 95% confidence interval [CI] = 2.30-3.40; adjusted HR = 1.25, 95% CI = 1.02-1.53) and attempts (unadjusted HR = 8.88, 95% CI = 8.45-9.35; adjusted HR = 1.06, 95% CI = 1.00-1.11). Veterans with HCRV encounters had elevated risk of suicide attempts (unadjusted HR = 4.56, 95% CI = 4.00-5.20; adjusted HR = 1.42, 95% CI = 1.24-1.62). Risks were also elevated for other external causes of mortality. CONCLUSIONS: Findings document increased risk of suicidal behavior among Veterans Justice Program recipients. These results have informed VHA suicide prevention activities.

Assessment of Patient Education about Statin Therapy on Quality Measures and Knowledge in an Independent Community Pharmacy.

OBJECTIVES: The objectives were to 1) assess the possible impact of face-to-face patient education on Electronic Quality Improvement Platform for Plans and Pharmacies (EQuIPP) performance scores, 2) determine if face-to-face patient education increased overall knowledge and number of identified patients on statin therapy, and 3) identify barriers to statin therapy in targeted patients with diabetes. DESIGN: Participants received an anonymous survey tool collecting demographic data and assessing barriers, baseline knowledge, and perceptions about statin therapy. Following the initial survey, participants received education from the pharmacist describing the risks and benefits of statin therapy and were given a supplemental pamphlet. A second post-education survey tool was given to assess posteducation knowledge and perceptions. At the end of the study period, investigators assessed the number of participants started on statin therapy and calculated the predicted percentage change in EQuIPP score. SETTING AND PARTICIPANTS: This study was conducted at Waterfront Family Pharmacy in Morgantown, West Virginia from December 2017 until April 2018. Participants were included if aged 40 to 75, received at least two fills of a diabetes medication at the pharmacy in the last year, had not taking a statin within a year prior to participating in the study, and could read and write in English. OUTCOME MEASURES: The primary outcome measure was the predicted percentage change in the "Statin Use in Diabetes" EQuIPP Score. Secondary measures included post-educational knowledge and perceptions of statin therapy. RESULTS: During the study period, 10 participants completed the surveys and educational intervention. The predicted change in "Statin Use in Diabetes" EQuIPP score was an increase from 75% to 76.9% (+ 1.9%). Prior to the educational intervention, none of the participants could identify a benefit of statin therapy aside from lowering cholesterol. After the intervention, 80% of participants could identify at least one additional benefit of statin therapy. Before the intervention, 30% of participants stated they would consider taking a statin, which increased to 80% following the pharmacist-led education. Lastly, no participants felt they needed to be on statin therapy prior to the intervention. Following the intervention, 40% stated they believed they were candidates for statin therapy. CONCLUSIONS: Patients are willing to receive education from pharmacists about their medications and are receptive to general recommendations. A common modifiable barrier to statin therapy is patient knowledge, emphasizing the importance of pharmacistprovided education. Education about statin therapy may also increase EQuIPP scores in an independent community pharmacy, leading to better outcomes for patients and improvement of common performance measures. Overall, it appears patients require more education about statin therapy and the benefit these drugs can provide aside from their cholesterol lowering properties. Pharmacistprovided education regarding statins in patients with diabetes can increase performance measures monitored by third party payers.

Sustainability evaluation of pasteurized milk production with a life cycle assessment approach: An Iranian case study.

Agro-food systems play a significant role in the economies of all nations due to energy use and the resulting environmental consequences. The sustainability of these systems is determined by a multitude of interacting economic, social and environmental factors. Dairy production presents a relevant example of the sustainability trade-offs that occur within such systems. On the one hand, dairy production constitutes an important part of the human diet, but it is also responsible for significant emissions of potent greenhouse gases and other pollutants. In this study, the environmental aspects of pasteurized milk production in Iran were investigated using a life-cycle approach. Three sub-systems, namely feed production, dairy farm and dairy factory, were taken into account to determine how and where Iranian pasteurized milk production might be made more environmentally friendly and energy efficient. The results clearly demonstrate that the feed production stage was the hot spot in pasteurized milk production in terms of energy consumption, environmental burdens and economic costs. The largest share of the total production costs belonged to animal feeds (43%), which were part of the feed production stage. The largest consumers of energy in the production of raw milk were alfalfa (30.3%), concentrate (24%), straw (17.8%) and maize (10.9%) for cows, followed by diesel fuel (6.6%) and electricity (5.6%). The global warming potential for the production of 1000kg of raw milk at the dairy-farm gate was estimated at 457kg CO2,eq. Thus, more than 69% of the total impact at the milk-processing gate resulted from the previous two sub-systems (feed production and dairy farm), with the feed-production stage accounting for the largest fractions of the environmental burdens.

Evaluation of traditional and consolidated rice farms in Guilan Province, Iran, using life cycle assessment and fuzzy modeling.

In this study the environmental impact of consolidated rice farms (CF) - farms which have been integrated to increase the mechanization index - and traditional farms (TF) - small farms with lower mechanization index - in Guilan Province, Iran, were evaluated and compared using Life cycle assessment (LCA) methodology and adaptive neuro-fuzzy inference system (ANFIS). Foreground data were collected from farmers using face-to-face questionnaires and background information about production process and inventory data was taken from the EcoInvent®2.0 database. The system boundary was confined to within the farm gate (cradle to farm gate) and two functional units (land and mass based) were chosen. The study also included a comparison of the input-output energy flows of the farms. The results revealed that the average amount of energy consumed by the CFs was 57 GJ compared to 74.2 GJ for the TFs. The energy ratios for CFs and TFs were 1.6 and 0.9, respectively. The LCA results indicated that CFs produced fewer environmental burdens per ton of produced rice. When compared according to the land-based FU the same results were obtained. This indicates that the differences between the two types of farms were not caused by a difference in their production level, but rather by improved management on the CFs. The analysis also showed that electricity accounted for the greatest share of the impact for both types of farms, followed by P-based and N-based chemical fertilizers. These findings suggest that the CFs had superior overall environmental performance compared to the TFs in the study area. The performance metrics of the model based on ANFIS show that it can be used to predict the environmental burdens of rice production with high accuracy and minimal error.

The U.S. Department of Veterans Affairs Veterans Justice programs and the sequential intercept model: case examples in national dissemination of intervention for justice-involved veterans.

Veterans are a significant subpopulation in criminal justice populations, comprising between 9% and 10% of arrestee, jail, prison, and community-supervision populations. In order to address the needs of justice-involved veterans, the U.S. Department of Veterans Affairs (VA) Veterans Justice Programs (VJP) offer services to veterans at multiple points in their involvement in the criminal justice system. Within the context of the VA's national mandate to develop VJP, this article presents best practice case examples using the Sequential Intercept Model as the intervention frame, and discusses each in context of a community psychology framework for innovation dissemination. The case examples demonstrate how central program guidance is adapted locally to meet the national mandate using strategies that fit the local environment, illustrating the innovations in action orientation, boundary spanning, and flexibility of organizations. This review provides examples of creative reinvention that expand on the mandate and work to meet local needs. To optimize services to veterans released from custody or supervised in the community, future study of the implementation of this national mandate should examine all VJP sites to identify the full range of best practices in local program implementation.