The role of mindfulness and resilience in Navy SEAL training.

Mindfulness and resilience are thought to be essential qualities of the military's special operations community. Both are tested daily in Special Operations Forces (SOF) assessment and selection efforts to prepare candidates to persist through grueling training and complex combat situations; but these qualities are rarely measured. While military leadership places value on the concepts of mindfulness and resilience, there is minimal empirical research examining the role that they play in the completion of training. This longitudinal study followed three classes of SEAL candidates at Basic Underwater Demolition/SEAL (BUD/S) training over their six-month selection program. We estimated logit models predicting successful completion of BUD/S and specific types of failure in that training environment with indexes of mindfulness and resilience at the start of the program as predictors of completion. The results indicate that (1) mindfulness is unrelated to completion, while (2) resilience is positively related to completion, and (3) The results indicate that mindfulness is generally unrelated to completion, while resilience generally predicts completion.

Academic culture beyond the individual: Group-level norms and college enrollment.

Although many scholars have written about culture in schools and discuss culture as a group-level phenomenon, quantitative studies tend to empirically examine culture at the individual-level. This study presents a group-level conceptualization of academic culture known as cultural heterogeneity-the presence of a diverse array of competing and conflicting cultural models-to examine whether variation in school-level academic orientation predicts college enrollment. We use the Educational Longitudinal Study of 2002 (ELS) to show that whereas academic press (or average school academic culture) is positively related to enrollment, variation in school academic culture is associated with declines in enrollment. These findings hold net of students' own academic behaviors and beliefs, background factors, and school characteristics. Thus, exposure to conflicting models of culture can lead youth to make decisions that do not reflect broader societal goals. This study addresses the misalignment between the conceptual and empirical definitions of culture in education by examining the link between school academic culture measured as a group-level process, which is consistent with how scholars discuss culture, and college enrollment.

Psychological and physiological changes during basic, underwater, demolition/SEAL training.

This longitudinal study examines the growth of psychological characteristics and adaptation of physiological markers of stress during a six-month assessment and selection course for U.S. Navy SEALs. Resilience, hardiness, and grit instruments were used to evaluate the psychological characteristics. Blood samples were taken to determine physiological markers related to stress adaptation; specifically, evaluating DHEA, DHEA-to-cortisol ratio, BDNF, NPY, and cortisol. Data was collected at four timepoints throughout the assessment and selection course from 353 students over three classes. Results indicated that resilience and hardiness grow after an initial decline, DHEA and DHEA-to-cortisol increased suggesting physiological adaptation. However, psychological and physiological markers do not exhibit the same growth patterns for participants in the course. This study enhances the understanding of psychological growth and physiological adaptation in a high-stress environment over an extended duration.

Racial/Ethnic and Educational Disparities in the Impact of Diabetes on Population Health Among the U.S.-Born Population.

OBJECTIVES: This study examines total life expectancies (TLEs) for both healthy and diabetic U.S.-born populations and 2 measures capturing quality of life: (a) the proportion of remaining life to be spent without either other chronic conditions or activities of daily living disabilities (ADLs) and (b) the proportion of remaining life to be spent with ADLs for U.S.-born diabetic populations by race/ethnicity and educational attainment. METHODS: Using the 1998-2014 waves of the Health and Retirement Study (n = 16,983), we apply a Bayesian multistate life table method to calculate these quantities from the constructed life tables. RESULTS: TLE at age 50 is shorter for diabetic individuals than healthy individuals, for non-Hispanic Blacks than members of other racial/ethnic groups, and for less-educated individuals. Gaps in TLE at age 50 between healthy and diabetic populations range from 6.3 to 8.8 years across sex-race combinations and from 5.6 to 9.2 years across sex-education combinations. Among the diabetic population, those with at least a college degree on average have a higher proportion of remaining life to be spent without either other chronic conditions or ADLs. Hispanics and those without a college degree have a particularly high proportion of remaining life to be spent with ADLs. Although diabetic women on average live longer than men, their quality of life tends to be lower. DISCUSSION: The impact of diabetes on population health varies across racial/ethnic and educational groups. The findings support targeted interventions for vulnerable groups, such as people of color, women, and less-educated individuals.

Measuring Ethnic Diversity.

Researchers have investigated the effects of ethnic heterogeneity on a range of socioeconomic and political outcomes. However, approaches to measuring ethnic diversity vary not only across fields of study but even within subfields. In this review, we systematically dissect the computational approaches of prominent measures of diversity, including polarization, and discuss where and how differences emerge in their relationships with outcomes of interest to sociologists (social capital and trust, economic growth and redistribution, conflict, and crime). There are substantial similarities across computations, which are often generalizations or specializations of one another. Differences in how racial and ethnic groupings are constructed and in level of geographic analysis explain many divergences in empirical findings. We conclude by summarizing the type of measurement technique preferred by outcome, when relevant, and provide considerations for future researchers contemplating how best to operationalize diversity. Finally, we highlight two less widely used yet promising measures of diversity.

Bayesian Multistate Life Table Methods for Large and Complex State Spaces: Development and Illustration of a New Method.

Multistate life table methods are an important tool for producing easily understood measures of population health. Most contemporary uses of these methods involve sample data, thus requiring techniques for capturing uncertainty in estimates. In recent decades, several methods have been developed to do so. Among these methods, the Bayesian approach proposed by Lynch and Brown has several unique advantages. However, the approach is limited to estimating years to be spent in only two living states, such as "healthy" and "unhealthy." In this article, the authors extend this method to allow for large state spaces with "quasi-absorbing" states. The authors illustrate the new method and show its advantages using data from the Health and Retirement Study to investigate U.S. regional differences in years of remaining life to be spent with diabetes, chronic conditions, and disabilities. The method works well and yields rich output for reporting and subsequent analyses. The expanded method also should facilitate the use of multi-state life tables to address a wider array of social science research questions.

Disaggregating Heterogeneity among Non-Hispanic Whites: Evidence and Implications for U.S. Racial/Ethnic Health Disparities.

Research has made strides in disaggregating health data among racial/ethnic minorities, but less is known about the extent of diversity among Whites. Using logistic regression modeling applied to data on respondents aged 40+ from the 2008 to 2016 American Community Survey, we disaggregated the non-Hispanic White population by ancestry and other racial/ethnic groups (non-Hispanic Black, non-Hispanic Asian, and Hispanic) by common subgroupings and examined heterogeneity in disability. Using logistic regression models predicting six health outcome measures, we compared the spread of coefficients for each of the large racial/ethnic groups and all subgroupings within these large categories. The results revealed that health disparities within the White population are almost as large as disparities within other racial groups. In fact, when Whites were disaggregated by ancestry, mean health appeared to be more varied among Whites than between Whites and members of other racial/ethnic groups in many cases. Compositional changes in the ancestry of Whites, particularly declines in Whites of western European ancestry and increases in Whites of eastern European and Middle Eastern ancestry, contribute to this diversity. Together, these findings challenge the oft-assumed notion that Whites are a homogeneous group and indicate that the aggregate White category obscures substantial intra-ethnic heterogeneity in health.

Cognitively Intact and Happy Life Expectancy in the United States.

OBJECTIVES: We examined the number of years to be lived with and without cognitive impairment and with high self-assessed quality of life (i.e., happiness) among a nationally representative sample of Americans aged 65 years and older. Two key questions are addressed: Can people have a high quality of life despite being cognitively impaired? Which is longer: happy life expectancy or cognitively intact life expectancy? METHOD: Data from nine waves of the Health and Retirement Study (1998-2014) were used to estimate transition probabilities into and out of cognitively intact/impaired-un/happy states, as well as to death. Recently extended Bayesian multistate life table methods were used to estimate age-specific cognitively intact and happy life expectancy net of sex, race/ethnicity, education, and birth cohort. RESULTS: Happiness and cognitive impairment were shown to coexist in both the gross cross-tabulated data and in the life tables. Happy life expectancy is approximately 25% longer than cognitively intact life expectancy at age 65 years, and by age 85, happy life expectancy is roughly double cognitively intact life expectancy, on average. DISCUSSION: Lack of cognitive impairment is not a necessary condition for happiness. In other words, people can have a high quality of life despite being cognitively impaired.

Regional differences in the impact of diabetes on population health in the USA.

BACKGROUND: To evaluate regional disparities in the influence of diabetes on population health, we examine life expectancies at age 50 between population with diabetes and healthy population and life quality among the population with diabetes among native-born Americans by birth region and current residence. METHODS: Using data on a cohort of 17 686 native-born individuals from the Health and Retirement Survey (1998-2014), we applied a Bayesian multistate life table method to estimate life expectancies at age 50 between population with diabetes and healthy population by each birth/current region combination. We further estimate the proportion of life remaining without either chronic conditions or disabilities as a quality of life measure and the probabilities that one region is worse than the other in terms of different health outcomes. RESULTS: At age 50, persons with diabetes (PWD) were expected to live on average 5.8-10.8 years less than their healthy equivalents across regions. Diabetes had the greatest influence on life expectancy (LE) for older adults who lived in the South at the time of interviews. PWD born in the South were more likely to have developed chronic conditions or disabilities and spent greater proportions of life with these two issues compared to other regions. CONCLUSION: Diabetes is a significant threat to LE and healthy LE in the USA, particularly for people born or living in the South.

Demographic and Socioeconomic Disparities in Life Expectancy With Hearing Impairment in the United States.

OBJECTIVES: Hearing impairment is one of the most common disabilities among older people, and its prevalence will increase as the U.S. population ages. However, little is known about social disparities in onset or transitions into and out of hearing impairment, nor how these transitions impact years of life to be spent impaired. METHOD: We investigate the number of years an "average" person can expect to live with and without hearing impairment after age 50; sex, race, educational, and regional differences in these expectancies; and the implication of hearing impairment for remaining life expectancy. Bayesian multistate life table methods are applied to 9 waves of data from the Health and Retirement Study (1998-2014) to investigate social disparities in life expectancy with hearing impairment (n = 20,200) for the general population, people hearing impaired at age 50, and people hearing unimpaired at age 50. RESULTS: Men, Hispanics, persons with less educational attainment, and those born in the south can expect to live a larger proportion of their remaining lives hearing impaired. Although transitions from hearing impaired to unimpaired occur, those with some hearing impairment at age 50 can expect to live more years with hearing impairment, and hearing impairment does not shorten remaining life expectancy. DISCUSSION: Significant sociodemographic disparities in hearing impaired life expectancy exist. In contrast to past research, we find that hearing impairment does not affect total life expectancy. Future research should consider the consequences of hearing impairment for years to be lived with other age-related and potentially downstream health outcomes.

Access to routine care and risks for 30-day readmission in patients with cardiovascular disease.

BACKGROUND: Studies have shown that access to routine medical care is associated with the prevention, diagnosis, and treatment of chronic diseases. However, studies have not examined whether patient-reported difficulties in access to care are associated with rehospitalization in patients with cardiovascular disease. METHODS: Electronic medical records and a standardized survey were used to examine cardiovascular patients admitted to a large medical center from January 1, 2015 through January 10, 2017 (n=520). All-cause readmission within 30 days of discharge was the primary outcome for analysis. Logistic regression models were used to examine the association between access to care and 30-day readmission while adjusting for patient demographics, socioeconomic status, healthcare utilization, and health status. RESULTS: Nearly 1-in-6 patients (15.7%) reported difficulty in accessing routine medical care; and those who were younger, male, non-white, uninsured, with heart failure, and had low social support were significantly more likely to report difficulty. Patients who reported difficulty in accessing care had significantly higher rates of 30-day readmission than patients who did not report difficulty (33.3% vs. 17.9%; P=.001); and the risks remained largely unchanged after accounting for nearly two dozen covariates (unadjusted odds ratio [OR]=2.29; 95% CI, 1.46-3.60 vs. adjusted OR=2.17; 95% CI, 1.29-3.66). Risks for readmission were especially high for patients who reported issues with transportation (OR=3.24; 95% CI, 1.28-8.16) and scheduling appointments (OR=3.56; 95% CI, 1.43-8.84), but not for other reasons (OR=1.47; 95% CI, 0.61-3.54). CONCLUSIONS: Cardiovascular patients who reported difficulty in accessing routine care had substantial risks of readmission within 30 days after discharge. These findings have important implications for identifying high-risk patients and developing interventions to improve access to routine medical care.

Race Differences in ADL Disability Decline 1984-2004: Evidence From the National Long-Term Care Survey.

OBJECTIVE: Disability declined in lower levels of impairment during the late 20th century. However, it is unclear whether ADL disability also declined, or whether it did so across race. In this study, we examine cohorts entering later life between 1984 and 1999, by race, to understand changing ADL disability. METHOD: We used latent class methods to model trajectories of ADL disability and subsequent mortality in the National Long-Term Care Survey among cohorts entering older adulthood (ages 65-69) between 1984 and 1999. We examined patterns by race, focusing on chronic condition profiles. RESULTS: White cohorts experienced consistent declines in ADL disability but Blacks saw little improvement with some evidence for increased disability. Stroke, diabetes, and heart attack were predominant in predicting disability among Blacks. DISCUSSION: Declining disability trends were only observed consistently among Whites, suggesting previous and future disability trends and their underlying causes should be examined by race.

Socioeconomic, Psychosocial and Behavioral Characteristics of Patients Hospitalized With Cardiovascular Disease.

BACKGROUND: Recent studies have drawn attention to nonclinical factors to better understand disparities in the development, treatment and prognosis of patients with cardiovascular disease. However, there has been limited research describing the nonclinical characteristics of patients hospitalized for cardiovascular care. METHODS: Data for this study come from 520 patients admitted to the Duke Heart Center from January 1, 2015 through January 10, 2017. Electronic medical records and a standardized survey administered before discharge were used to ascertain detailed information on patients' demographic (age, sex, race, marital status and living arrangement), socioeconomic (education, employment and health insurance), psychosocial (health literacy, health self-efficacy, social support, stress and depressive symptoms) and behavioral (smoking, drinking and medication adherence) attributes. RESULTS: Study participants were of a median age of 65 years, predominantly male (61.4%), non-Hispanic white (67.1%), hospitalized for 5.11 days and comparable to all patients admitted during this period. Results from the survey showed significant heterogeneity among patients in their demographic, socioeconomic and behavioral characteristics. We also found that the patients' levels of psychosocial risks and resources were significantly associated with many of these nonclinical characteristics. Patients who were older, women, nonwhite and unmarried had generally lower levels of health literacy, self-efficacy and social support, and higher levels of stress and depressive symptoms than their counterparts. CONCLUSIONS: Patients hospitalized with cardiovascular disease have diverse nonclinical profiles that have important implications for targeting interventions. A better understanding of these characteristics will enhance the personalized delivery of care and improve outcomes in vulnerable patient groups.

Regional Variation in the Predictive Validity of Self-Rated Health for Mortality.

Self-rated health (SRH) is a commonly used measure for assessing general health in surveys in the United States. However, individuals from different parts of the United States may vary in how they assess their health. Geographic differences in health care access and in the prevalence of illnesses may make it difficult to discern true regional differences in health when using SRH as a health measure. In this article, we use data from the 1986 and 1989-2006 National Health Interview Survey Linked Mortality Files and estimate Cox regression models to examine whether the relationship between SRH and five-year all-cause mortality differs by Census region. Contrary to hypotheses, there is no evidence of regional variation in the predictive validity of SRH for mortality. At all levels of SRH, and for both non-Hispanic white and non-Hispanic black respondents, SRH is equally and strongly associated with five-year mortality across regions. Our results suggest that differences in SRH across regions are not solely due to differences in how respondents assess their health across regions, but reflect true differences in health. Future research can, therefore, employ this common measure to investigate the geographic patterning of health in the United States.

Identifying Nonclinical Factors Associated With 30-Day Readmission in Patients with Cardiovascular Disease: Protocol for an Observational Study.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of hospitalization in older adults and high readmission rates have attracted considerable attention as actionable targets to promote efficiency in care and to reduce costs. Despite a plethora of research over the past decade, current strategies to predict readmissions have been largely ineffective and efforts to identify novel clinical predictors have been largely unsuccessful. OBJECTIVE: The objective of this study is to examine a wide array of socioeconomic, psychosocial, behavioral, and clinical factors to predict risks of 30-day hospital readmission in cardiovascular patients. METHODS: The study includes patients (aged 18 years and older) admitted for the treatment of cardiovascular-related illnesses at the Duke Heart Center, which is among the nation's largest and top-ranked cardiovascular care hospitals. The study uses a novel standardized survey to ascertain data on a comprehensive array of patient characteristics that will be linked to their electronic medical records. A series of univariate and multivariate models will be used to estimate the associations between the patient-level factors and 30-day readmissions. The performance of the risk models will be examined based on 2 components of accuracy-model calibration and discrimination-to determine how closely the predicted outcome agrees with the observed (actual) outcome and how well the model distinguishes patients who were readmitted and those who were not. The purpose of this paper is to present the protocol for the implementation of this study. RESULTS: The study was launched in February 2014 and is actively recruiting patients from the Heart Center. Approximately 550 patients have been enrolled to date and the study is expected to continue recruitment until February 2018. Preliminary results show that participants in the study were aged 63.6 years on average (SD 14.0), predominately male (61.2%), and primarily non-Hispanic white (64.6%) or non-Hispanic black (31.7%). The demographic characteristics of study participants were not significantly different from all patients admitted to the Heart Center during this period with an average age of 65.0 years (SD 15.3) and predominately male (58.6%), non-Hispanic white (62.9%) or non-Hispanic black (31.8%) The integration of the interview data with clinical data from the patient electronic medical records is currently underway. The study has received funding and ethical approval. CONCLUSIONS: Many US hospitals continue to struggle with high readmission rates in patients with cardiovascular disease. The primary objective of this study is to collect and integrate a comprehensive array of patient attributes to develop a powerful yet parsimonious model to stratify risks of rehospitalization in cardiovascular patients. The results of this research also have the potential to identify actionable targets for tailored interventions to improve patient outcomes.

The Importance of the Baby Boom Cohort and the Great Recession in Understanding Age, Period, and Cohort Patterns in Happiness.

Twenge, Sherman, and Lyubomirsky (TSL) claim that long-term cultural changes have increased young adults' happiness while reducing mature adults' happiness. To establish their conclusion, TSL use trend analyses, as well as more sophisticated mixed-effects models, but their analyses are problematic. In particular, TSL's trend analyses ignore a crucial cohort effect: well-known lower happiness among baby boomers. Furthermore, their data aggregation obscures the ephemerality of a recent period effect: the Great Recession. Finally, TSL overlook a key finding of their mixed-effects models that both pre- and post-Boomer cohorts became happier as they aged from young to mature adults. Our reanalyses of the data establish that the Baby Boomer cohort, the short-lived Great Recession, and unfortunate data aggregation account for TSL's results. The well-established, long-term relationship between age and happiness remains as it has been for decades despite any cultural shifts that may have occurred disfavoring mature adults.

Economic outcomes with prasugrel versus clopidogrel in acute coronary syndrome patients: observations from prasugrel users and matched clopidogrel users.

OBJECTIVE: To compare healthcare costs between clopidogrel and prasugrel over 30-day and 365-day periods after discharge from the hospital or emergency room (ER) in patients treated with prasugrel who were hospitalized or had an ER visit for an acute coronary syndrome (ACS) event. METHODS: This retrospective observational study was based on claims from January 2009-July 2012 in the Truven Health Analytics MarketScan database. Clopidogrel patients were propensity-score matched 1:1 to prasugrel-treated patients. Lin's frequentist cost history method for censored data and Bayesian zero-inflated gamma regression models were used to analyze healthcare costs. RESULTS: The clopidogrel/prasugrel matched-cohort included 10,963 well-matched pairs of patients. Lin's frequentist analysis showed that outpatient visit costs were significantly lower for clopidogrel than prasugrel after 30 days of follow-up. At 30 days, Bayesian data analysis showed strong evidence that clopidogrel was superior to prasugrel for all-cause and ACS-related hospitalization costs and showed very strong evidence that clopidogrel was superior to prasugrel for all-cause and ACS-related outpatient visit costs. At 365 days, Bayesian data analysis showed strong evidence that clopidogrel was superior to prasugrel for all-cause outpatient visit costs and very strong evidence that clopidogrel was superior to prasugrel for ACS-related outpatient visit costs. Point estimates of the all-cause and ACS-related ER visit costs at 30 days and 365 days were similar, but statistical results were inconclusive because of the large variability in this outcome variable. CONCLUSION: Based on retrospective observational data in a real-world setting, all-cause and ACS-related hospitalization and outpatient visit costs were lower for clopidogrel than prasugrel over 30 days after discharge from a hospitalization or ER visit associated with ACS in patients treated with prasugrel. At 365 days the difference in all-cause and ACS-related outpatient costs remained, but there was little evidence of a difference in either all-cause or ACS-related hospitalization costs.

Exposure to stressors and trajectories of perceived stress among older adults.

OBJECTIVES: Models of stress incorporate both the environmental demands experienced by individuals (stressors) and the appraisal of these life events (perceptions). Because little is known about the extent to which experience and perceptions are related, we examine this relationship in a nationally representative population of older Taiwanese adults. METHOD: Using growth models applied to data from 3 waves (1999, 2003, and 2007) of the Taiwan Longitudinal Study of Aging, we (a) investigate patterns of change in perceived stress in later adulthood and (b) examine how experienced stressors influence perceived stress. Participants were asked to report the presence of, and in some cases the degree of, exposure to stressors including total number of medical conditions, difficulty with activities of daily living, difficulty with mobility functions, being financially worse off compared with the prior wave, experiencing the death of a child, and experiencing a marital disruption. Items reflecting perceived stress included concerns about various domains pertaining to the respondent and his/her family member. RESULTS: Our results indicate that exposure to stressors increases, whereas perceived stress decreases, over time. Change in exposure to stressors is not generally associated with change in perceptions of stress, with the exception of a summary measure of health-related exposure to stressors. An increase in poor health over time is related to an increase in perceived stress in all domains. DISCUSSION: The results underscore the importance of distinguishing between perceptions of stress and exposure to stressors when studying the links between stress and health among older adults. Furthermore, the diminishing linkage between experienced stressors and perceptions of stress suggests that older adults' appraisal may be an adaptive coping strategy that emerges to buffer some of the difficulties that are inevitable in later life.