Longitudinal association of health behaviors and health-related quality of life with military spouse readiness.

BACKGROUND: Unhealthy behaviors impose costs on health-related quality of life (HRQOL) reducing productivity and readiness among military members (Hoge et al., JAMA 295:1023-32, 2006; Mansfield et al. 362:101-9, 2010). Among married personnel in particular, patterns of spouse health behaviors may play an interdependent role. As a result, the identification of military spouse health factors related to readiness may inform strategies to screen for and identify those in need of greater support and enhance readiness. This study explored behavioral and HRQOL predictors and potential mediators of military spouse readiness utilizing data from the Millennium Cohort Family Study. METHODS: The analytic sample comprised of 3257 spouses of active-duty, non-separated service members who responded to both waves 1 and 2 of the survey. Sample characteristics are described with respect to demographics (e.g., age, sex, race/ethnicity, etc.), readiness measures (i.e., military satisfaction, lost workdays, health care utilization, military-related stress, and satisfaction), health behaviors (i.e., exercise, sleep, smoking, and alcohol use) and HRQOL (Veterans RAND 12-Item Short Form Survey). We conducted multivariate mediation analyses to evaluate the role of mental and physical HRQOL as mediators between the baseline health behaviors and the health readiness outcomes at follow-up, while adjusting for spouse and service member demographics. RESULTS: HRQOL had direct effects for all five readiness outcomes examined. Multiple health behaviors (insomnia, smoking, binge drinking, and exercise) were further significantly associated with spouse readiness outcomes, although most effects were mediated through HRQOL, suggesting this may be a useful index of military spouse readiness. Insomnia was the specific health behavior most consistently associated with poorer readiness across outcomes, and effects were only partially mediated by physical and mental HRQOL. CONCLUSIONS: The results show spouse health behaviors are directly and indirectly (through HRQOL) associated with readiness indicators. This suggests that assessments of modifiable health behaviors (e.g., insomnia symptoms) and mental and physical HRQOL are important indicators of readiness among military spouses and should be used to inform future programs designed to improve population health.

Partner Effects: Analyzing Service Member and Spouse Drinking Over Time.

INTRODUCTION: Excessive alcohol use is a significant problem in the military. Although there is a growing emphasis on family-centered alcohol prevention approaches, little is known about the interplay between partners' drinking behaviors. This study examines how service members and their spouses influence each other's drinking behavior over time and explores the complex individual, interpersonal, and organizational factors that may contribute to alcohol use. METHODS: A sample of 3,200 couples from the Millennium Cohort Family Study was surveyed at baseline (2011-2013) and follow-up (2014-2016). The research team estimated how much partners' drinking behaviors influenced one another from baseline to follow-up using a longitudinal structural equation modeling approach. Data analyses were conducted in 2021 and 2022. RESULTS: Drinking patterns converged between spouses from baseline to follow-up. Participants' own baseline drinking had a small but significant effect on changes in their partners' drinking from baseline to follow-up. Results from a Monte Carlo simulation showed that the longitudinal model could reliably estimate this partner effect in the presence of several potential sources of bias, including partner selection. The model also identified several common risk and protective factors for drinking shared by both service members and their spouses. CONCLUSIONS: Findings suggest that changing the drinking habits of one spouse could lead to a change in the drinking habits of the other, which supports family-centered alcohol prevention approaches in the military. Dual-military couples especially may benefit from targeted interventions because they face a higher risk of unhealthy alcohol consumption.

Longitudinal Patterns of Military Spousal Alcohol Consumption: Findings From the Millennium Cohort Family Study.

OBJECTIVE: Alcohol use in the military is prevalent and has short- and long-term health, safety, and career consequences. Although several studies have examined service members' alcohol consumption, few have focused on alcohol use among military spouses. This study assessed factors at individual, interpersonal, and organizational levels to determine associations with risky alcohol use among military spouses. METHOD: Data from baseline and first follow-up of the Millennium Cohort Family Study were used (N = 5,475; 4,923 female) to model spousal self-reported risky drinking (heavy and/or binge drinking) at follow-up. Predictors included demographic characteristics, spousal adverse childhood experiences and mental health, smoking status, marital status, family satisfaction, social support, military stress, and service member military characteristics. Logistic regression models assessed the adjusted associations between spouse and service member characteristics and spousal risky drinking at follow-up. RESULTS: Among spouses in this sample, 19% were risky drinkers at follow-up. Baseline alcohol use status was associated with risky drinking at follow-up. Most spouses (64.2%) did not change their drinking behavior between baseline and follow-up; those who did change were nearly evenly split between an increasing (17.0%) versus decreasing (18.7%) pattern. Risk factors included male gender, cigarette smoking, elevated symptoms of post-traumatic stress, marital separation, and service member deployment with combat. CONCLUSIONS: Although most military spouses were not engaging in risky drinking, one in five were, with about half of these having moved into the risky drinking category over time. Risky alcohol use among spouses has ramifications for themselves, the service member, and the family unit.

Association between staff turnover and nursing home quality - evidence from payroll-based journal data.

BACKGROUND: Staff turnover is considered an important indicator of nursing home quality. We used auditable staffing data from the Centers for Medicare & Medicaid Services (CMS) Payroll-Based Journal (PBJ) system to calculate turnover measures for nurse staff and administrators and examined the relationship between turnover and nursing home quality. METHODS: Our analyses included data from 13,631 nursing homes that submitted complete staffing data through PBJ for 2018Q3 - 2019Q4. We identified turnover based on gaps in days worked by eligible employees, allowing us to calculate turnover measures that do not depend on termination dates reported by nursing homes, which are not captured in PBJ. We linked staff turnover measures to nursing home quality measures and star ratings published on CMS' Care Compare website in January 2020 and examined the relationship between turnover and quality of care. We used ordinary least squared models for continuous outcomes and ordered logit models for categorical outcomes, controlling for facility, and county characteristics. RESULTS: Mean annual turnover rates were about 44% for RNs and 46% for total nurse staff. On average, there was one administrator leaving each nursing home during this period although about half of nursing homes had no administrator turnover. Turnover rates varied greatly across nursing homes. For-profit and larger nursing homes had higher turnover rates. Higher turnover was consistently associated with lower quality of care. CONCLUSIONS: Our study highlights the importance of staff turnover due to its relationship to nursing home quality. In January 2022, CMS started posting turnover measures on Care Compare to allow consumers to use this information in their assessment of nursing home quality and to motivate nursing homes to implement innovative strategies to retain staff. While these actions are challenging, they are nonetheless warranted for improving the quality of care for nursing home residents.

Families serve too: military spouse well-being after separation from active-duty service.

BACKGROUND AND OBJECTIVES: Transitioning from military to civilian life can be challenging for families, but most research focuses only on the service member. We applied a life course model to assess spouse well-being following this important transition. DESIGN: Prospective, longitudinal survey of service members and their spouses. METHODS: We captured three spouse well-being domains: psychological health, physical health, and family relationships. We identified differences between families who separated from service and those still affiliated (N = 4,087) and assessed baseline factors associated with spouse well-being after the family separated from service (N = 1,199). RESULTS: Spouses of service members who had separated from the military (versus those who had not) reported poorer mental health and family relationship quality at baseline and follow-up. After controlling for baseline differences, spouses whose families transitioned experienced a greater increase in PTSD symptoms and a steeper decline in quality of marriage. Spouses of active-duty service members reported greater increases in work-family conflict. Among families who had transitioned, the most consistent predictor of positive outcomes was baseline well-being. Protective factors included having more psychological and social resources and less financial stress. CONCLUSIONS: Several protective and risk factors identified in the study may inform programming for families transitioning from active duty.

The association of nursing home quality ratings and spread of COVID-19.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has severely affected nursing home residents. Given the continued high incidence of COVID-19, and the likelihood that new variants and other infectious agents may cause future outbreaks, we sought to understand the relationship of nursing home quality ratings and measures of COVID-19 outbreak severity and persistence. DESIGN: We analyzed nursing home facility-level data on COVID-19 cases and deaths, county-level COVID-19 rates, and nursing home data from the Centers for Medicare & Medicaid Services (CMS), including ratings from the CMS Nursing Home Five-Star Quality Rating System. We used regression analysis to examine the association between star ratings and cumulative COVID-19 incidence and mortality as well as persistent high resident incidence. SETTING: All nursing homes in the CMS COVID-19 Nursing Home Dataset reporting data that passed quality assurance checks for at least 20 weeks and that were included in the January 2021 Nursing Home Care Compare update. PARTICIPANTS: Residents of the included nursing homes. MEASUREMENTS: Cumulative resident COVID-19 incidence and mortality through January 10, 2021; number of weeks with weekly resident incidence of COVID-19 in the top decile nationally. RESULTS: As of January 10, 2021, nearly all nursing homes (93.6%) had reported at least one case of COVID-19 among their residents, more than three-quarters (76.9%) had reported at least one resident death, and most (83.5%) had experienced at least 1 week in the top decile of weekly incidence. In analyses adjusted for facility and county-level characteristics, we found generally consistent relationships between higher nursing home quality ratings and lower COVID-19 incidence and mortality, as well as with fewer high-incidence weeks. CONCLUSION: Nursing home quality ratings are associated with COVID-19 incidence, mortality, and persistence. Nursing homes receiving five-star ratings, for overall quality as well as for each domain, had lower COVID-19 rates among their residents.

Demographic Variation in Military Life Stress and Perceived Support Among Military Spouses.

INTRODUCTION: Military spouses play a critical role in supporting military service members, and thus, their experiences may have a significant impact on the well-being, readiness, and resilience of the U.S. Armed Forces. Research suggests that military spouses experience unique stressors as a result of military life, but few studies have assessed demographic factors associated with their experiences of military life and perceived support. MATERIALS AND METHODS: Using data from the Millennium Cohort Family Study, a nationwide survey of 9,872 married spouses of service members with 2 to 5 years of military service, this study examined differences in experiences of military life and perceived support across multiple understudied subgroups of military spouses. Key outcomes included military-related stressors (e.g., deployment-related experiences), perceived social support, and perceived military efforts to provide support. RESULTS: Military life stress and perceived support differed across military spouse, service member, and family characteristics. Results indicated that spouses who are older than age 35 or are married to enlisted service members in the Army, Navy, or Marines are more likely to experience heightened military stress or less perceived social support. Dual-military couples reported experiencing less stress associated with military life and perceiving more social support and support from the military, compared with spouses who have never served in the military. CONCLUSION: These findings may help guide effective channeling of resources and outreach to potentially vulnerable military families.

Association of military life experiences and health indicators among military spouses.

BACKGROUND: The health and well-being of military spouses directly contribute to a robust military force by enabling the spouse to better support the active duty member's career. In order to understand the overall health and well-being of military spouses, we assessed health indicators among military spouses using the Healthy People 2020 framework and examined associations of these health indicators with military experiences and psychosocial factors. METHODS: Using data from the Millennium Cohort Family Study, a U.S. Department of Defense-sponsored survey of 9872 spouses of service members with 2-5 years of military service, we examined attainment of Healthy People 2020 goals for spouses and service members, including healthy weight, exercise, sleep, and alcohol and tobacco use. Multivariable logistic regression models assessed associations of spouse health indicators with stressful military life experiences and social support, adjusting for demographics and military descriptors. The spousal survey was administered nationwide in 2011. RESULTS: The majority of military spouses met each health goal assessed. However, less than half met the healthy weight and the strength training goals. Reporting greater perceived family support from the military was associated with better behavioral health outcomes, while having no one to turn to for support was associated with poorer outcomes. Using the Healthy People 2020 objectives as a framework for identifying key health behaviors and benchmarks, this study identified factors, including military-specific experiences, that may contribute to physical health behaviors and outcomes among military spouses. With respect to demographic characteristics, the findings are consistent with other literature that women are more likely to refrain from risky substance use and that greater education is associated with better overall health outcomes. CONCLUSIONS: Findings suggest that enhanced social and military support and tailored programming for military spouses may improve health outcomes and contribute to the well-being of military couples. Such programming could also bolster force readiness and retention.

Relationships between use of dietary supplements, caffeine and sensation seeking among college students.

Objective: Caffeine and dietary supplement (DS) use by college students is not well-documented. Given reported associations between energy drink consumption and sensation seeking, we used the Sensation Seeking Scale Form V (SSS-V) to assess relationships between sensation-seeking, caffeine, and DS use. Participants: Data from 1,248 college students from five US institutions were collected from 2009 to 2011. Methods: Linear regression was used to examine relationships between scores on the SSS-V and caffeine and DS use, demographic, and lifestyle characteristics. Results: Male sex, nonHispanic race-ethnicity, higher family income, tobacco use, consuming caffeinated beverages, more than 400 mg caffeine per day, and energy drinks with alcohol at least 50% of the time, were significantly associated with higher total SSS-V scores (P < 0.001). Those using protein DSs had higher total, disinhibition, and boredom susceptibility SSS-V scores (Ps < 0.001). Conclusions: Results demonstrate a positive correlation between sensation-seeking attitudes and habitual caffeine, energy drink, and DS consumption.

Likelihood of Sustaining an Injury in the Setting of Multiple Falls.

OBJECTIVES: To evaluate the relationship between number of falls and risk of injury after a specific fall. DESIGN: Prospective cohort study. SETTING: Greater New Haven, Connecticut. PARTICIPANTS: Probability sample of 1,103 community-living persons aged 72 and older. MEASUREMENTS: Falls and fall-related injuries were ascertained monthly for 3 years using a fall calendar and follow-up telephone interviews. RESULTS: Of 606 participants with a fall, 164 (27.0%) had at least 1 fall with a serious injury, and 455 (75.1%) had at least 1 fall with any injury; mean number of falls was 2.6±2.3 (range 1-18), of falls with serious injury was 0.3±0.6 (range 0-4), and of falls with any injury was 1.4±1.4 (range 0-9). On a per-participant basis, risk of serious injury and any injury increased progressively as the number of falls increased (P < .001). On a per-fall basis, risk of serious injury and any injury increased from 1 to 2 falls but then decreased from 2 to 3 or 4 falls and from 3 or 4 to 5 or more falls, although these differences were not statistically significant. The results were consistent for women and men and for analyses that evaluated the proportion of falls with injuries. CONCLUSION: In community-living older persons, risk of injury from a specific fall did not differ as the number of falls increased. Falls appear to operate independently in terms of conferring risk of injury in the setting of multiple falls. J Am Geriatr Soc 67:119-123, 2019.

Engaging military couples in marital research: does requesting referrals from service members to recruit their spouses introduce sample bias?

BACKGROUND: While enrolling dyads in research studies is not uncommon, there is limited literature on the utility of different recruitment strategies and the resulting selection biases. This paper examined two recruitment strategies used to enroll military couples in a longitudinal study, assessing the impact of both strategies on the representativeness of the final study sample. METHOD: Descriptive and bivariate analyses were conducted to 1) identify characteristics associated with spouse referral, 2) compare response rates based on recruitment strategy and assess whether recruitment strategy modified correlates of response propensity among spouses, and 3) assess whether referred spouse characteristics differed from non-referred spouses in the final sample. The study sample consisted of married US service members with 2-5 years of military service as of October 2011 and their spouses. RESULTS: Service members who referred their spouses to participate in the Millennium Cohort Family Study were more likely to be male, have children, serve in the Army, and have combat deployment experience than those who did not refer their spouse. Nearly two-thirds (n = 5331, 64.9%) of referred spouses participated in the Family Study, compared with less than one-third (n = 3458, 29.5%) of directly contacted spouses. Spouse characteristics also differed significantly between recruitment groups. CONCLUSIONS: Overall results suggest that minimal bias was introduced by using a referral recruitment methodology. Service members appeared to be more likely to refer their spouses if they perceived the research topic as relevant to their spouse, such that male service members with combat deployment experience were more likely to refer female spouses caring for multiple children. Referred spouses were significantly more likely to respond to the Millennium Cohort Family Study survey than those who were directly contacted; however, the overall success rate of using a referral strategy was less than recruiting spouses through direct contact. Differences between referred spouses and spouses contacted directly mirrored service member referring characteristics.

Development and Validation of a Functional Outcome Measure in the National Health and Aging Trends Study.

Background: Despite the rich array of data available on seven self-care and mobility activities, a functional outcome measure, which sums the scores across these activities, has not yet been developed or validated for use in the National Health and Aging Trends Study (NHATS). Methods: Using longitudinal data from NHATS, we evaluted 7,609 participants who were living in community settings. Development of the functional outcome measure was guided by the presence of consistent mortality gradients across a 5-category, 4-category, and two 3-category scales for each of the seven activities, whereas validation was based on predictive accuracy for mortality and concurrent change in physical performance. Results: Consistent mortality gradients were observed only for the two 3-category scales (with each activity scored as 1 [fully able/independent], 2 [vulnerable], or 4 [assistance]). Each version of the corresponding functional outcome measure, which had a range of composite scores from 7 (no disability) to 28 (highest disability), demonstrated strong predictive validity for mortality and concurrent change in physical performance, with a 2-point change being clinically meaningful. The version that defined vulnerability on the basis of accommodations, reduced activities, or difficulty, rather than difficulty alone, is preferable for use in NHATS based on a more even distribution of composite scores, a wider and more consistent mortality gradient without any mortality reversals, and slightly stronger associations with the two outcomes. Conclusions: These results provide strong, albeit preliminary evidence supporting the value of a new functional outcome measure for use in NHATS, a rich resource for investigating late-life disability.

Fostering Activation Among Latino Parents of Children With Mental Health Needs: An RCT.

OBJECTIVE: Latino families raising children with mental health and other special health care needs report greater dissatisfaction with care compared with other families. Activation is a promising strategy to eliminate disparities. This study examined the comparative effectiveness of MePrEPA, an activation intervention for Latino parents whose children receive mental health services. METHODS: A randomized controlled trial (N=172) was conducted in a Spanish-language mental health clinic to assess the effectiveness of MePrEPA, a four-week group psychoeducational intervention to enhance parent activation among Latino parents, compared with a parent-support control group. Inclusion criteria were raising a child who receives services for mental health needs and ability to attend weekly sessions. Outcomes were parent activation, education activation, quality of school interaction, and parent mental health. Effectiveness of the intervention was tested with a difference-in-difference approach estimating linear mixed models. Heterogeneity of treatment effect was examined. RESULTS: MePrEPA enhanced parent activation (ß=5.98, 95% confidence interval [CI]=1.42-10.53), education activation (ß=7.98, CI=3.01-12.94), and quality of school interaction (ß=1.83, CI=.14-3.52) to a greater degree than did a parent-support control group. The intervention's impact on parent activation and education outcomes was greater for participants whose children were covered by Medicaid and were novices to therapy and those with low activation at baseline. No statistically significant effects were observed in parent mental health. CONCLUSIONS: Activation among Latino parents was improved with MePrEPA, which can be readily incorporated in current practices by mental health clinics. Future work should replicate findings in a large number of sites, adding behavioral measures and distal impacts while examining MePrEPA's effects across settings and populations.

Evaluating Distinctions in the Assessment of Late-Life Disability.

BACKGROUND: By including categories for accommodations and reduced frequency, to supplement earlier classifications of difficulty and dependence, a new 5-category functional scale has the potential to distinguish finer gradations in disability but the hierarchical nature and advantages of this scale over alternative scales are uncertain. METHODS: Using data from the National Health and Aging Trends Study (N = 7,609), we conducted a series of: cross-sectional analyses that focused on the hierarchical consistency of responses in the 5-category scale; and longitudinal analyses that focused on predictive accuracy for mortality and functional dependence, comparing the 5-category scale with three simpler scales, having only three or four categories. RESULTS: Although there was considerable variability across the seven functional activities, the prevalence of inconsistencies in the hierarchy of the 5-category scale (eg, reports difficulty but no accommodations) was relatively high. In addition, the predictive accuracy of the 5-category scale for mortality and functional dependence was only modestly better than that of the two 3-category scales and was comparable to that of the 4-category scale. Finally, when evaluated as summative disability scores, there was little difference in predictive accuracy between the 5-category scale and three alternative scales. CONCLUSIONS: Despite inconsistencies in its hierarchy, the 5-category scale is more effective in stratifying risk for mortality and functional dependence than the two 3-category scales but not the 4-category scale. When assessing changes over time, however, the addition of questions on accommodations and reduced frequency to those on difficulty and dependence, to form a summative disability score, offers little benefit and increases the burden of the assessment.

Assessing and adjusting for non-response in the Millennium Cohort Family Study.

BACKGROUND: In conducting population-based surveys, it is important to thoroughly examine and adjust for potential non-response bias to improve the representativeness of the sample prior to conducting analyses of the data and reporting findings. This paper examines factors contributing to second stage survey non-response during the baseline data collection for the Millennium Cohort Family Study, a large longitudinal study of US service members and their spouses from all branches of the military. METHODS: Multivariate logistic regression analysis was used to develop a comprehensive response propensity model. RESULTS: Results showed the majority of service member sociodemographic, military, and administrative variables were significantly associated with non-response, along with various health behaviours, mental health indices, and financial and social issues. However, effects were quite small for many factors, with a few demographic and survey administrative variables accounting for the most substantial variance. CONCLUSIONS: The Millennium Cohort Family Study was impacted by a number of non-response factors that commonly affect survey research. In particular, recruitment of young, male, and minority populations, as well as junior ranking personnel, was challenging. Despite this, our results suggest the success of representative population sampling can be effectively augmented through targeted oversampling and recruitment, as well as a comprehensive survey weighting strategy.

Examination of Parent Insurance Ratings, Child Expenditures, and Financial Burden Among Children With Autism: A Mismatch Suggests New Hypotheses to Test.

OBJECTIVE: Families raising children with autism contribute significant amounts to the cost of care. In this era of health care reform, families have more insurance choices, but people are unfamiliar with health insurance terms. This study uses 2 national data sets to examine health insurance ratings from parents raising children with autism and child expenditures to explore how these measures align. METHODS: Children with autism who met criteria for special health care needs and were continuously insured were examined. Data from the National Survey of Children With Special Health Care Needs 2009-2010 were used to examine parent report of adequate insurance (n = 3702). Pooled data from the Medical Expenditure Panel Survey 2002-2011 were used to examine expenditures (n = 346). Types of health insurance included private alone, Medicaid alone, and combined private and wrap-around Medicaid. RESULTS: Having Medicaid doubled the odds of reporting adequate insurance compared with private insurance alone (P < .0001), and children on Medicaid had the lowest out-of-pocket costs ($150, P < .0001). Children covered by combined private and wrap-around Medicaid had the highest total expenditures ($11 596, P < .05) and the highest expenditures paid by their insurance ($10 638, P < .05). CONCLUSIONS: These findings highlight a mismatch between parent ratings of insurance adequacy, child expenditures, and relative financial burden. Findings generate a number of questions to address within single sources of data. By elaborating the frameworks families use to judge the adequacy of their insurance, future research can develop policy strategies to improve both their satisfaction with their insurance coverage and the service use of children with autism.

PTSD and Use of Outpatient General Medical Services Among Veterans of the Vietnam War.

OBJECTIVE: The primary goal of this analysis was to assess whether recent use of outpatient services for general medical concerns by Vietnam veterans varies according to level of posttraumatic stress disorder (PTSD) symptomatology over time. Another goal was to determine whether PTSD symptomatology was associated with veterans' reports of discussing behavioral health issues as part of a general medical visit. METHODS: Self-reported service use data and measures of PTSD were from a nationally representative sample of 848 male and female Vietnam theater veterans (individuals who were deployed to the Vietnam theater of operations) who participated in the National Vietnam Veterans Longitudinal Study, a 25-year follow-up of a cohort of veterans originally interviewed from 1984-1988 as part of the National Vietnam Veterans Readjustment Study. Four categories of PTSD symptomatology course over 25 years were defined, and logistic regression models were used to assess their relationship with recent use of outpatient general medical services. RESULTS: Male and female theater veterans with high or increasing PTSD symptomatology over the period were more likely than those with low symptomatology to report recent VA outpatient visits. Males in the increasing and high categories were also more likely to discuss behavioral health issues at general medical visits. CONCLUSIONS: Vietnam veterans with high and increasing PTSD symptomatology over time were likely to use VA outpatient general health services. Attention to stressors of the aging process and to persistence of PTSD symptoms is important for Vietnam veterans, as is addressing PTSD with other psychiatric and medical comorbidities within the context of outpatient general medical care.

Parent-Reported Health Consequences and Relationship to Expenditures in Children with ADHD.

OBJECTIVES: (1) To describe parents' report of special needs for children with ADHD on the Children with Special Health Care Needs (CSHCN) Screener; and (2) to assess the association between responses to Screener items and annual mental health and total health expenditures per child. METHODS: In pooled 2002-2011 Medical Expenditure Panel Survey (MEPS) data, we identify children ages 4-17 years with ADHD. We use OLS and two-part regressions to model the relationship between CSHCN Screener items and mental health and total health expenditures. Based on these models we estimate adjusted, average total health expenditures for children with ADHD-both with and without a co-morbid mental health condition-and different combinations of endorsed Screener items. This research was conducted in accordance with prevailing ethical principles. RESULTS: There were 3883 observations on 2591 children with ADHD. Without a co-morbid mental health condition, average total expenditures per year from adjusted, model-based estimates were $865 for those meeting no Screener items, $2664 for those meeting only the medication item, $3595 for those meeting the medication and counseling items, and $4203 for those meeting the medication, counseling, and use of more health services items. Children with a co-morbid mental health condition had greater total health expenditures for each combination of Screener items. The associations between Screener items and mental health expenditures were similar, but with a slightly lower marginal effect of the medication item (p < 0.001 for all comparisons). CONCLUSIONS: Parents' responses on the CSHCN Screener are associated with meaningful variation in expenditures for children with ADHD. Though cross-sectional, this study suggests that the CSHCN Screener can be a useful categorization scheme for children with ADHD. It may be an efficient, standardized tool at the point of care for identifying children who need more resources and for targeting intensive interventions in the context of population health management.

A Prospective Study of Mortality and Trauma-Related Risk Factors Among a Nationally Representative Sample of Vietnam Veterans.

Because Vietnam veterans comprise the majority of all living veterans and most are now older adults, the urgency and potential value of studying the long-term health effects of service in the Vietnam War, including effects on mortality, is increasing. The present study is the first prospective mortality assessment of a representative sample of Vietnam veterans. We used one of the longest follow-up periods to date (spanning older adulthood) and conducted one of the most comprehensive assessments of potential risk factors. Vital status and cause of death were ascertained for the 1,632 veterans who fought in the Vietnam theater (hereafter referred to as theater veterans) and for 716 Vietnam War-era veterans (hereafter referred to as era veterans) who participated in the National Vietnam Veterans Readjustment Study (1987-2011). As of April 2011, 16.0% (95% confidence interval: 13.1, 19.0) of all Vietnam veterans who were alive in the 1980s were deceased. Male theater veterans with a high probability of posttraumatic stress disorder (PTSD) were nearly 2 times more likely to have died than were those without PTSD, even after adjustment for sociodemographic and other characteristics. A high level of exposure to war zone stress was independently associated with mortality for both male and female theater veterans after adjustment for sociodemographic characteristics, PTSD, and physical comorbid conditions. Theater veterans with a high level of exposure to war zone stress and a high probability of PTSD had the greatest mortality risk (adjusted hazard ratio = 2.34, 95% confidence interval: 1.24, 4.43).

Course of Posttraumatic Stress Disorder 40 Years After the Vietnam War: Findings From the National Vietnam Veterans Longitudinal Study.

IMPORTANCE: The long-term course of readjustment problems in military personnel has not been evaluated in a nationally representative sample. The National Vietnam Veterans Longitudinal Study (NVVLS) is a congressionally mandated assessment of Vietnam veterans who underwent previous assessment in the National Vietnam Veterans Readjustment Study (NVVRS). OBJECTIVE: To determine the prevalence, course, and comorbidities of war-zone posttraumatic stress disorder (PTSD) across a 25-year interval. DESIGN, SETTING, AND PARTICIPANTS: The NVVLS survey consisted of a self-report health questionnaire (n = 1409), a computer-assisted telephone survey health interview (n = 1279), and a telephone clinical interview (n = 400) in a representative national sample of veterans who served in the Vietnam theater of operations (theater veterans) from July 3, 2012, through May 17, 2013. Of 2348 NVVRS participants, 1920 were alive at the outset of the NVVLS, and 81 died during recruitment; 1450 of the remaining 1839 (78.8%) participated in at least 1 NVVLS study phase. Data analysis was performed from May 18, 2013, through January 9, 2015, with further analyses continued through April 13, 2015. MAIN OUTCOMES AND MEASURES: Study instruments included the Mississippi Scale for Combat-Related PTSD, PTSD Checklist for DSM-IV supplemented with PTSD Checklist for DSM-5 items (PCL-5+), Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), and Structured Clinical Interview for DSM-IV, Nonpatient Version. RESULTS: Among male theater veterans, we estimated a prevalence (95% CI) of 4.5% (1.7%-7.3%) based on CAPS-5 criteria for a current PTSD diagnosis; 10.8% (6.5%-15.1%) based on CAPS-5 full plus subthreshold PTSD; and 11.2% (8.3%-14.2%) based on PCL-5+ criteria for current war-zone PTSD. Among female veterans, estimates were 6.1% (1.8%-10.3%), 8.7% (3.8%-13.6%), and 6.6% (3.5%-9.6%), respectively. The PCL-5+ prevalence (95% CI) of current non-war-zone PTSD was 4.6% (2.6%-6.6%) in male and 5.1% (2.3%-8.0%) in female theater veterans. Comorbid major depression occurred in 36.7% (95% CI, 6.2%-67.2%) of veterans with current war-zone PTSD. With regard to the course of PTSD, 16.0% of theater veterans reported an increase and 7.6% reported a decrease of greater than 20 points in Mississippi Scale for Combat-Related PTSD symptoms. The prevalence (95% CI) of current PCL-5+-derived PTSD in study respondents was 1.2% (0.0%-3.0%) for male and 3.9% (0.0%-8.1%) for female Vietnam veterans. CONCLUSIONS AND RELEVANCE: Approximately 271,000 Vietnam theater veterans have current full PTSD plus subthreshold war-zone PTSD, one-third of whom have current major depressive disorder, 40 or more years after the war. These findings underscore the need for mental health services for many decades for veterans with PTSD symptoms.