Testing an Intervention to Improve Health Care Worker Well-Being During the COVID-19 Pandemic: A Cluster Randomized Clinical Trial

Importance

Stress First Aid is an evidence-informed peer-to-peer support intervention to mitigate the effect of the COVID-19 pandemic on the well-being of health care workers (HCWs).

Objective

To evaluate the effectiveness of a tailored peer-to-peer support intervention compared with usual care to support HCWs' well-being at hospitals and federally qualified health centers (FQHCs) during the COVID-19 pandemic.

Design, Setting, and Participants

This cluster randomized clinical trial comprised 3 cohorts of HCWs who were enrolled from March 2021 through July 2022 at 28 hospitals and FQHCs in the US. Participating sites were matched as pairs by type, size, and COVID-19 burden and then randomized to the intervention arm or usual care arm (any programs already in place to support HCW well-being). The HCWs were surveyed before and after peer-to-peer support intervention implementation. Intention-to-treat (ITT) analysis was used to evaluate the intervention's effect on outcomes, including general psychological distress and posttraumatic stress disorder (PTSD).

Intervention

The peer-to-peer support intervention was delivered to HCWs by site champions who received training and subsequently trained the HCWs at their site. Recipients of the intervention were taught to respond to their own and their peers' stress reactions.

Main Outcomes and Measures

Primary outcomes were general psychological distress and PTSD. General psychological distress was measured with the Kessler 6 instrument, and PTSD was measured with the PTSD Checklist.

Results

A total of 28 hospitals and FQHCs with 2077 HCWs participated. Both preintervention and postintervention surveys were completed by 2077 HCWs, for an overall response rate of 28% (41% at FQHCs and 26% at hospitals). A total of 862 individuals (696 females [80.7%]) were from sites that were randomly assigned to the intervention arm; the baseline mean (SD) psychological distress score was 5.86 (5.70) and the baseline mean (SD) PTSD score was 16.11 (16.07). A total of 1215 individuals (947 females [78.2%]) were from sites assigned to the usual care arm; the baseline mean (SD) psychological distress score was 5.98 (5.62) and the baseline mean (SD) PTSD score was 16.40 (16.43). Adherence to the intervention was 70% for FQHCs and 32% for hospitals. The ITT analyses revealed no overall treatment effect for psychological distress score (0.238 [95% CI, -0.310 to 0.785] points) or PTSD symptom score (0.189 [95% CI, -1.068 to 1.446] points). Post hoc analyses examined the heterogeneity of treatment effect by age group with consistent age effects observed across primary outcomes (psychological distress and PTSD). Among HCWs in FQHCs, there were significant and clinically meaningful treatment effects for HCWs 30 years or younger: a more than 4-point reduction for psychological distress (-4.552 [95% CI, -8.067 to -1.037]) and a nearly 7-point reduction for PTSD symptom scores (-6.771 [95% CI, -13.224 to -0.318]).

Conclusions and Relevance

This trial found that this peer-to-peer support intervention did not improve well-being outcomes for HCWs overall but had a protective effect against general psychological distress and PTSD in HCWs aged 30 years or younger in FQHCs, which had higher intervention adherence. Incorporating this peer-to-peer support intervention into medical training, with ongoing support over time, may yield beneficial results in both standard care and during public health crises.

Trial Registration

ClinicalTrials.gov Identifier: NCT04723576.

The Promise and Challenges of VA Community Care: Veterans' Issues in Focus

Despite an overall decline in the U.S. veteran population, the number of veterans using VA health care has increased. To deliver timely care to as many eligible veterans as possible, VA supplements the care delivered by VA providers with private-sector community care, which is paid for by VA and delivered by non-VA providers. Although community care is a potentially important resource for veterans facing access barriers and long wait times for appointments, questions remain about its cost and quality. With recent expansions in veterans' eligibility for community care, accurate data are critical to policy and budget decisions and ensuring that veterans receive the high-quality health care they need.

Access to Health Care Among TRICARE-Covered Children

TRICARE, the U.S. Department of Defense insurance program for eligible service members and their dependents, provides health care coverage to nearly 2 million children under the age of 18. Survey data and prior evaluations indicate that TRICARE-covered children face challenges in accessing pediatric health care, with the greatest challenges among children who have experienced frequent relocations and children with special health care needs. However, TRICARE has not measured pediatric patient experiences in accessing care since 2010. To fill this gap, RAND researchers analyzed national survey data on the experiences of caregivers of TRICARE-covered children and children with commercial insurance, public insurance, and no insurance to identify differences in access to pediatric care, necessary referrals, care coordination support, ability to pay medical bills, and other factors. Additional analyses highlight variations between children with different TRICARE plans, between children who have changed addresses more and less frequently, and between children with special health care needs and those without. The findings should help inform efforts to increase access to care for children across the Military Health System, as well as improvements to programs designed to support military families during relocations and those with children who have special health care needs.

MACRA Palliative Care Quality Measure Development-Testing Summary Report: Measure Name: Feeling Heard and Understood

Palliative care has expanded rapidly in the past 20 years, especially in the ambulatory (office) setting, and there is growing consensus regarding the need to systematically measure and incentivize high-quality care. The Centers for Medicare & Medicaid Services entered a cooperative agreement with the American Academy of Hospice and Palliative Medicine (AAHPM) as part of the Medicare Access and CHIP Reauthorization Act of 2015 to develop two patient-reported measures of ambulatory palliative care experience: Feeling Heard and Understood and Receiving Desired Help for Pain. Under contract to AAHPM, RAND Health Care researchers developed and tested both measures over a three-year project period. Researcher efforts included identifying, developing, testing, and validating appropriate patient-reported data elements for each measure; developing and fielding a survey instrument to collect necessary data in a national beta field test with 44 ambulatory palliative care programs; and collecting and analyzing data about measure reliability and validity to establish measure performance and final specifications. Further, the authors elicited provider and program perspectives on the use and value of the performance measures and their implementation and elicited the perspectives of patients from racial and ethnic minorities to understand their experience of ambulatory palliative care and optimal approaches to measurement. In this study, the authors present results from their test of the Feeling Heard and Understood performance measure, which they demonstrate to be a reliable and valid measure that is ready for use in quality improvement and quality payment programs.

Trends in Department of Defense Disability Evaluation System Ratings and Awards for Posttraumatic Stress Disorder and Traumatic Brain Injury, 2002-2017

Since 2001, more than 3 million service members have deployed in support of multiple combat operations in Afghanistan, Iraq, and other theaters. Many have been diagnosed with the ""signature wounds"" of these conflicts: posttraumatic stress disorder (PTSD) and/or traumatic brain injury (TBI). During the intervening years, the process by which service members are evaluated for disability has evolved significantly, including a complete overhaul of the Disability Evaluation System (DES) beginning in 2007. Meanwhile, the Department of Defense (DoD) and the services made policy changes and initiated other efforts to improve screening for PTSD and TBI, encourage service members to seek treatment, improve quality of care, and reduce the stigma associated with treatment for these conditions. To explore these changes, as well as their potential effects on the numbers and characteristics of service members who are evaluated through DES, the authors identify and assess trends in DES outcomes for PTSD and TBI between 2002 and 2017.

Evolution of Department of Defense Disability Evaluation and Management of Posttraumatic Stress Disorder and Traumatic Brain Injury: Overview of Policy Changes, 2001-2018

For almost two decades, the United States has been engaged in continuous combat operations in Iraq, Afghanistan, and other theaters. Some service members have sustained injuries or developed medical conditions as a consequence of military service that affect their ability to perform their military duties. The process by which the U.S. Department of Defense (DoD) evaluates service members and determines whether they should be medically discharged has changed considerably since 2001. In particular, beginning in 2007, major changes to the Disability Evaluation System (DES) were implemented in response to concern about inefficiencies and confusion resulting from the practice of having DoD and the U.S. Department of Veterans Affairs (VA) conduct separate evaluations according to different criteria, thus producing different disability determinations. In 2008, DoD launched a pilot program to streamline the disability evaluation process, with VA conducting medical exams to be used by both DoD and VA. This system, the Integrated Disability Evaluation System (IDES), was formally adopted military-wide in 2011. Changes to DES also reflected changes in understanding of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), the signature injuries of the Iraq and Afghanistan wars. The authors review changes to disability evaluation policy and changes in the diagnosis and treatment of PTSD and TBI since 2001.

MACRA Palliative Care Quality Measure Development-Testing Summary Report: Measure Name: Receiving Desired Help for Pain

Palliative care has expanded rapidly in the past 20 years, especially in the ambulatory (office) setting, and there is growing consensus regarding the need to systematically measure and incentivize high-quality care. The Centers for Medicare & Medicaid Services entered a cooperative agreement with the American Academy of Hospice and Palliative Medicine (AAHPM) as part of the Medicare Access and CHIP Reauthorization Act of 2015 to develop two patient-reported measures of ambulatory palliative care experience: Feeling Heard and Understood and Receiving Desired Help for Pain. Under contract to AAHPM, RAND Health Care researchers developed and tested both measures over a three-year project period. Researcher efforts included identifying, developing, testing, and validating appropriate patient-reported data elements for each measure; developing and fielding a survey instrument to collect necessary data in a national beta field test with 44 ambulatory palliative care programs; and collecting and analyzing data about measure reliability and validity to establish measure performance and final specifications. Further, the authors elicited provider and program perspectives on the use and value of the performance measures and their implementation and elicited the perspectives of patients from racial and ethnic minorities to understand their experience of ambulatory palliative care and optimal approaches to measurement. In this study, the authors present results from their test of the Receiving Desired Help for Pain performance measure, which they demonstrate to be a reliable and valid measure that is ready for use in quality improvement and quality payment programs.

Protecting the mental and physical well-being of frontline health care workers during COVID-19: Study protocol of a cluster randomized controlled trial

Introduction

The COVID-19 pandemic has placed health care workers at unprecedented risk of stress, burnout, and moral injury. This paper describes the design of an ongoing cluster randomized controlled trial to compare the effectiveness of Stress First Aid (SFA) to Usual Care (UC) in protecting the well-being of frontline health care workers.

Methods

We plan to recruit a diverse set of hospitals and health centers (eight matched pairs of hospitals and six pairs of centers), with a goal of approximately 50 HCW per health center and 170 per hospital. Participating sites in each pair are randomly assigned to SFA or UC (i.e., whatever psychosocial support is currently being received by HCW). Each site identified a leader to provide organizational support of the study; SFA sites also identified at least one champion to be trained in the intervention. Using a “train the trainer” model, champions in turn trained their peers in selected HCW teams or units to implement SFA over an eight-week period. We surveyed HCW before and after the implementation period. The primary outcomes are posttraumatic stress disorder and general psychological distress; secondary outcomes include depression and anxiety symptoms, sleep problems, social functioning problems, burnout, moral distress, and resilience. In addition, through in-depth qualitative interviews with leaders, champions, and HCW, we assessed the implementation of SFA, including acceptability, feasibility, and uptake.

Discussion

Results from this study will provide initial evidence for the application of SFA to support HCW well-being during a pandemic.

Trial registration: (Clinicaltrials.govNCT04723576).

Development of Palliative Care Quality Measures for Outpatients in a Clinic-Based Setting: A Report on Information Gathering Activities

Palliative care has expanded rapidly in recent years. Hence, there has been a growing awareness of and emphasis on the importance of developing quality measures specific to palliative care. This article describes information-gathering activities conducted by RAND to develop two measures of palliative care quality for patients receiving such care in outpatient, clinic-based settings. The authors describe the consensus that has developed for measurement priorities in the palliative care community, provide a summary of clinical practice guidelines, and review the evidence base for palliative care. The authors also review current relevant regulations, existing measures of patient and caregiver experience, findings from a gap analysis on palliative care assessment, and findings from provider focus groups and interviews with patients and caregivers or family members.

Discussing measurement-based care with patients: An analysis of clinician-patient dyads

Abstract Measurement-based care (MBC) refers to the use of three integrated strategies to improve effectiveness of behavioral health care: routine outcomes monitoring using symptom measures; regularly sharing these data with patients; and using these data to inform treatment decisions. This study examined how clinicians discuss MBC data with patients, including identifying what aspects of these discussions contribute to clinician-patient agreement on the value of MBC, and how clinicians use MBC data to inform treatment decisions. Twenty-six clinician-patient dyads participated in semi-structured interviews and provided a treatment session recording in which MBC data were discussed. Qualitative data analyses revealed four subtypes of dyads: clinician and patient both valued MBC; clinician valued MBC, patient passively participated in MBC; clinician valued MBC, patient had mixed perceptions of MBC; clinician and patient reported moderate or low value for MBC. In dyads for whom both the clinician and patient valued MBC, the clinician provided clear and repeated rationale for MBC, discussed data with patients at every administration, and connected observed scores to patient skills or strategies. Emerging best practices for discussing MBC include providing a strong rationale, discussing results frequently, actively engaging patients in discussions, and using graphs to visualize progress.

A qualitative evaluation of Veterans Health Administration's implementation of measurement-based care in behavioral health

Measurement-based care (MBC) in behavioral health involves the repeated collection of patient-reported data that is used to track progress, inform care, and engage patients in shared decision making about their treatment. Research suggests that MBC increases the quality and effectiveness of mental health care. However, there can be challenges to implementing MBC, such as time burden, lack of resources to support MBC, and clinician attitudes. The Veterans Health Administration (VHA) is currently undertaking a multiphase MBC roll-out, the first phase of which included 59 sites across the country. The present study examined implementation of this initiative in an effort to learn more about the process of implementation, including best practices, challenges, and innovations. Semistructured interviews were conducted with 20 MBC site champions and 60 staff members from 25 VHA medical centers across the country. Qualitative data analysis was conducted to identify key themes related to MBC implementation. Results were described for 3 components of MBC implementation: preparing for implementation, administering measures, and using and sharing data. Training and staff buy-in were key to the preparation phase. Staff members reported a variety of methods and frequencies for the collection of MBC data, with many staff members identifying a need to streamline the collection process. Staff members reported using data to track progress and adjust treatment with patients. Efforts to use data on a programmatic level were identified as a next step. Innovative solutions across clinics and sites are described in an effort to inform future MBC implementation, both within and outside of VHA. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Integrating Department of Defense and Department of Veterans Affairs Purchased Care: Preliminary Feasibility Assessment

The U.S. Department of Defense (DoD) and U.S. Department of Veterans Affairs (VA) health systems provide services through a mix of direct care, delivered at government facilities, and purchased care, provided through the private sector, mainly by community-based providers who have entered into contracts with third-party administrators (TPAs). In the interest of expanding DoD-VA resource sharing that may lead to greater efficiencies and cost savings, the DoD/VA Joint Executive Committee is exploring options to integrate DoD and VA's purchased care programs. This preliminary feasibility assessment examined how an integrated approach to purchasing care could affect access, quality, and costs for beneficiaries, DoD, and VA and identified general legislative, policy, and contractual challenges to implementing an integrated purchased care program. An integrated approach to purchasing care is feasible under current legal and regulatory authorities, but policy changes may be needed-and the practicality of such an approach depends on the contract and network design. For example, legal/regulatory changes in how contracts are established would be required to achieve any real savings to the government. There are also differences in the populations served by TRICARE (DoD health care) and VA, particularly in terms of age and geographic location. Implementation would be further complicated by contractual differences in the TPA contracts for VA and DoD as they relate to network standards, provider payments, network participation requirements, and reporting requirements and incentive structures. As a result, there are significant uncertainties with respect to increased efficiency or cost savings for the government.

Programs Addressing Psychological Health and Resilience in the U.S. Department of Homeland Security

The U.S. Department of Homeland Security (DHS) was created in the aftermath of the September 11, 2001, terrorist attacks from all or part of 22 existing federal departments and agencies to oversee and coordinate a national strategy to protect the country from terrorism and to prevent future attacks. The unique organizational structure of DHS and differences in the number and type of employees in each of its components have resulted in a support system that includes both DHS-wide programs and component-specific programs to promote resilience and prevent psychological health problems that can result from long-term stress and exposure to trauma. However, little is known about the nature and effectiveness of these programs. This study provides an overview of the evidence base for common approaches used in workplace psychological health programs and identifies the extent to which programs across DHS that address psychological health, peer support, and resilience align with evidence-based practices. To ensure employees' psychological well-being, DHS must respond to their specific psychological health needs and concerns, as well as measure the effectiveness of existing programs that address psychological health. The study outlines a path forward for DHS to determine whether its investments in these programs are achieving their desired outcomes for the department, its employees, and their families.

Comparing Quality of Care in Veterans Affairs and Non-Veterans Affairs Settings

BACKGROUND

Congress, veterans' groups, and the press have expressed concerns that access to care and quality of care in Department of Veterans Affairs (VA) settings are inferior to access and quality in non-VA settings.

OBJECTIVE

To assess quality of outpatient and inpatient care in VA at the national level and facility level and to compare performance between VA and non-VA settings using recent performance measure data.

MAIN MEASURES

We assessed Patient Safety Indicators (PSIs), 30-day risk-standardized mortality and readmission measures, and ORYX measures for inpatient safety and effectiveness; Healthcare Effectiveness Data and Information Set (HEDIS®) measures for outpatient effectiveness; and Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS) and Survey of Healthcare Experiences of Patients (SHEP) survey measures for inpatient patient-centeredness. For inpatient care, we used propensity score matching to identify a subset of non-VA hospitals that were comparable to VA hospitals.

KEY RESULTS

VA hospitals performed on average the same as or significantly better than non-VA hospitals on all six measures of inpatient safety, all three inpatient mortality measures, and 12 inpatient effectiveness measures, but significantly worse than non-VA hospitals on three readmission measures and two effectiveness measures. The performance of VA facilities was significantly better than commercial HMOs and Medicaid HMOs for all 16 outpatient effectiveness measures and for Medicare HMOs, it was significantly better for 14 measures and did not differ for two measures. High variation across VA facilities in the performance of some quality measures was observed, although variation was even greater among non-VA facilities.

CONCLUSIONS

The VA system performed similarly or better than the non-VA system on most of the nationally recognized measures of inpatient and outpatient care quality, but high variation across VA facilities indicates a need for targeted quality improvement.

Delivering Clinical Practice Guideline-Concordant Care for PTSD and Major Depression in Military Treatment Facilities

Providing accessible, high-quality care for psychological health (PH) conditions, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), is important to maintaining a healthy, mission-ready force. It is unclear whether the current system of care meets the needs of service members with PTSD or MDD, and little is known about the barriers to delivering guideline-concordant care. RAND used existing provider workforce data, a provider survey, and key informant interviews to (1) provide an overview of the PH workforce at military treatment facilities (MTFs), (2) examine the extent to which care for PTSD and MDD in military treatment facilities is consistent with Department of Veterans Affairs/Department of Defense clinical practice guidelines, and (3) identify facilitators and barriers to providing this care. This study provides a comprehensive assessment of providers' perspectives on their capacity to deliver PH care within MTFs and presents detailed results by provider type and service branch. Findings suggest that most providers report using guideline-concordant psychotherapies, but use varied by provider type. The majority of providers reported receiving at least minimal training and supervision in at least one recommended psychotherapy for PTSD and for MDD. Still, more than one-quarter of providers reported that limits on travel and lack of protected time in their schedule affected their ability to access additional professional training. Finally, most providers reported routinely screening patients for PTSD and MDD with a validated screening instrument, but fewer providers reported using a validated screening instrument to monitor treatment progress.

Veterans' Health Insurance Coverage Under the Affordable Care Act and Implications of Repeal for the Department of Veterans Affairs

This article describes the Affordable Care Act's (ACA's) effects on nonelderly veterans' insurance coverage and demand for Department of Veterans Affairs (VA) health care and assesses the coverage and VA utilization changes that could result from repealing the ACA. Although prior research has shown that the number of uninsured veterans fell after the ACA took effect, the implications of ACA repeal for veterans and, especially, for VA have received less attention. Besides providing a new coverage option to veterans who are not enrolled in VA, the ACA also had the potential to affect health care use among VA patients. Findings include the following: In 2013, prior to the major coverage expansions under the ACA, nearly one in ten nonelderly veterans were uninsured, lacking access to both VA coverage and non-VA health insurance. Uninsurance among nonelderly veterans fell by an adjusted 36 percent (3.3 percentage points) after implementation of the ACA, from 9.1 percent in 2013 to 5.8 percent in 2015. By increasing non-VA health insurance coverage for VA patients, the ACA likely reduced demand for VA care; the authors estimate that, if the gains in insurance coverage that occurred between 2013 and 2015 had not occurred, nonelderly veterans would have used about 1 percent more VA health care in 2015: 125,000 more office visits, 1,500 more inpatient surgeries, and 375,000 more prescriptions. Recent congressional proposals to repeal and replace the ACA would increase the number of uninsured nonelderly veterans and further increase demand for VA health care.

Quality of care measures for the management of unhealthy alcohol use

There is a paucity of quality measures to assess the care for the range of unhealthy alcohol use, ranging from risky drinking to alcohol use disorders. Using a two-phase expert panel review process, we sought to develop an expanded set of quality of care measures for unhealthy alcohol use, focusing on outpatient care delivered in both primary care and specialty care settings. This process generated 25 candidate measures. Eight measures address screening and assessment, 11 address aspects of treatment, and six address follow-up. These quality measures represent high priority targets for future development, including creating detailed technical specifications and pilot testing them to evaluate their utility in terms of feasibility, reliability, and validity.

"You Should Drink Less": Frequency and Predictors of Discussions Between Providers and Patients About Reducing Alcohol Use

BACKGROUND

Brief intervention is recommended for individuals who misuse alcohol, but studies vary on how frequently patients talk with their providers about alcohol use.

OBJECTIVES

We examined whether veterans who had recently screened positive for alcohol misuse reported having conversations about their alcohol use with their providers.

METHODS

Following a positive screening for alcohol misuse during a primary care visit in 2013, veterans completed a telephone interview on alcohol use, conversations with their providers about drinking, and factors potentially associated with such conversations. The final analysis sample included 881 veterans; we conducted descriptive statistics and multivariable regression analyses.

RESULTS

Most veterans (83%) reported that their provider asked about drinking. Among these, 65% reported being advised to drink less, and 36% reported being advised to abstain. Veterans who received their healthcare from Veterans Health Administration (VA) had over twice the odds of reporting advice to reduce/abstain from drinking (adjusted odds ratio (AOR) = 2.34, 95% confidence interval (CI) = 1.46, 3.75). Veterans who reported heavy episodic drinking were more likely to report advice to reduce/abstain from drinking than those who did not report (AOR = 1.83, 95% CI = 1.30, 2.57) and veterans who reported heavy drinking were more likely to report such advice (AOR = 2.40, 95% CI = 1.69, 3.40). Conclusions/Importance: Most veterans with alcohol misuse reported receiving advice to reduce or abstain from drinking. Veterans with excessive alcohol use and those receiving all or most of their care from VA were more likely to report receiving such advice. Self-report of receiving advice may be an important approach to assessing appropriate follow-up after detection of alcohol misuse.

Supporting Veterans in Massachusetts: An Assessment of Needs, Well-Being, and Available Resources

Massachusetts is home to approximately 380,000 of the nation's more than 21 million veterans, but there has been little research on the resources available to this population at the state level. There are numerous resources available to veterans and other military-affiliated groups in Massachusetts, but there are still pockets of unmet need in the areas of education, employment, health care, housing, financial, and legal services-particularly for newer veterans and current National Guard/reserve members. Although Massachusetts veterans fare better overall than their peers in other states, they lag behind other Massachusetts residents in terms of health and financial status. Massachusetts veterans and National Guard/reserve members who need support and services face such barriers as a lack of knowledge about how to access services, a lack of awareness about eligibility, and geographic distance from service providers. As the veteran population changes both nationally and in Massachusetts, it will be important for public- and private-sector providers serving Massachusetts veterans and service members to continue addressing unmet needs while ensuring that resources are responsive to shifts in these populations. A better understanding of the unique needs of Massachusetts veterans can help inform investments in initiatives that target these populations and guide efforts to remedy barriers to accessing available support services and other resources.

Understanding Treatment of Mild Traumatic Brain Injury in the Military Health System

Traumatic brain injury (TBI) is considered a signature injury of modern warfare, though TBIs can also result from training accidents, falls, sports, and motor vehicle accidents. Among service members diagnosed with a TBI, the majority of cases are mild TBIs (mTBIs), also known as concussions. Many of these service members receive care through the Military Health System, but the amount, type, and quality of care they receive has been largely unknown. A RAND study, the first to examine the mTBI care of a census of patients in the Military Health System, assessed the number and characteristics (including deployment history and history of TBI) of nondeployed, active-duty service members who received an mTBI diagnosis in 2012, the locations of their diagnoses and next health care visits, the types of care they received in the six months following their mTBI diagnosis, co-occurring conditions, and the duration of their treatment. While the majority of service members with mTBI recover quickly, the study further examined a subset of service members with mTBI who received care for longer than three months following their diagnosis. Diagnosing and treating mTBI can be especially challenging because of variations in symptoms and other factors. The research revealed inconsistencies in the diagnostic coding, as well as areas for improvement in coordinating care across providers and care settings. The results and recommendations provide a foundation to guide future clinical studies to improve the quality of care and subsequent outcomes for service members diagnosed with mTBI.

Balancing Demand and Supply for Veterans' Health Care: A Summary of Three RAND Assessments Conducted Under the Veterans Choice Act

In response to concerns that the Department of Veterans Affairs (VA) has faced about veterans' access to care and the quality of care delivered, Congress enacted the Veterans Access, Choice, and Accountability Act of 2014 ("Veterans Choice Act") in August 2014. The law was passed to help address access issues by expanding the criteria through which veterans can seek care from civilian providers. In addition, the law called for a series of independent assessments of the VA health care system across a broad array of topics related to the delivery of health care services to veterans in VA-owned and -operated facilities, as well as those under contract to VA. RAND conducted three of these assessments: Veteran demographics and health care needs (A), VA health care capabilities (B), and VA authorities and mechanisms for purchasing care (C). This article summarizes the findings of our assessments and includes recommendations from the reports for improving the match between veterans' needs and VA's capabilities, including VA's ability to purchase necessary care from the private sector.

Authorities and Mechanisms for Purchased Care at the Department of Veterans Affairs

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the authorities and mechanisms by which the Department of Veterans Affairs (VA) pays for health care services from non-VA providers. Purchased care accounted for 10 percent, or around $5.6 billion, of VA's health care budget in fiscal year 2014, and the amount of care purchased from outside VA is growing rapidly. VA purchases non-VA care through an array of programs, each with different payment processes and eligibility requirements for veterans and outside providers. A review and analysis of statutes, regulations, legislation, and literature on VA purchased care, along with interviews with expert stakeholders, a survey of VA medical facilities, and an evaluation of local-level policy documents revealed that VA's purchased care system is complex and decentralized. Inconsistencies in procedures, unclear goals, and a lack of cohesive strategy for purchased care could have ramifications for veterans' access to care. Adding to the complexity of VA's purchased care system is a lack of systematic data collection on access to and quality of care provided through VA's purchased care programs. The analysis also explored concepts of "episodes of care" and their implications for purchased care by VA.

Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the current and projected demographics and health care needs of patients served by the Department of Veterans Affairs (VA). The number of U.S. veterans will continue to decline over the next decade, and the demographic mix and geographic locations of these veterans will change. While the number of veterans using VA health care has increased over time, demand will level off in the coming years. Veterans have more favorable economic circumstances than non-veterans, but they are also older and more likely to be diagnosed with many health conditions. Not all veterans are eligible for or use VA health care. Whether and to what extent an eligible veteran uses VA health care depends on a number of factors, including access to other sources of health care. Veterans who rely on VA health care are older and less healthy than veterans who do not, and the prevalence of costly conditions in this population is projected to increase. Potential changes to VA policy and the context for VA health care, including effects of the Affordable Care Act, could affect demand. Analysis of a range of data sources provided insight into how the veteran population is likely to change in the next decade.

Assessing the Quality and Value of Psychological Health Care in Civilian Health Plans: Lessons and Implications for the Military Health System

The Military Health System (MHS) strives to provide high-quality care and improve outcomes for individuals with psychological health conditions. Over the last decade, the MHS has provided care to a growing number of individuals with psychological health conditions, such as post-traumatic stress disorder (PTSD) and major depressive disorder (MDD). However, little is known about the extent to which the MHS delivers care that is consistent with evidence-based clinical practice guidelines or if it is achieving positive outcomes for its service members. To better understand these issues, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) asked the RAND Corporation to describe civilian health plansâ; approaches to systematically measuring the quality of psychological health care delivered by providers in their networks. This work was part of a larger effort by RAND to develop a framework and identify a set of measures for monitoring the quality of care provided by the MHS for psychological health conditions.

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the Department of Veterans Affairs (VA) current and projected health care capabilities and resources. An examination of data from a variety of sources, along with a survey of VA medical facility leaders, revealed the breadth and depth of VA resources and capabilities: fiscal resources, workforce and human resources, physical infrastructure, interorganizational relationships, and information resources. The assessment identified barriers to the effective use of these resources and capabilities. Analysis of data on access to VA care and the quality of that care showed that almost all veterans live within 40 miles of a VA health facility, but fewer have access to VA specialty care. Veterans usually receive care within 14 days of their desired appointment date, but wait times vary considerably across VA facilities. VA has long played a national leadership role in measuring the quality of health care. The assessment showed that VA health care quality was as good or better on most measures compared with other health systems, but quality performance lagged at some VA facilities. VA will require more resources and capabilities to meet a projected increase in veterans' demand for VA care over the next five years. Options for increasing capacity include accelerated hiring, full nurse practice authority, and expanded use of telehealth.

Measuring the Quality of Care for Psychological Health Conditions in the Military Health System: Candidate Quality Measures for Posttraumatic Stress Disorder and Major Depressive Disorder

In recent years, the number of U.S. service members treated for psychological health conditions has increased substantially. In particular, at least two psychological health conditions-posttraumatic stress disorder (PTSD) and major depressive disorder (MDD)-have become more common, with prevalence estimates up to 20 percent for PTSD and 37 percent for MDD. Delivering quality care to service members with these conditions is a high-priority goal for the military health system (MHS). Meeting this goal requires understanding the extent to which the care the MHS provides is consistent with evidence-based clinical practice guidelines and its own standards for quality. To better understand these issues, RAND Corporation researchers developed a framework to identify and classify a set of measures for monitoring the quality of care provided by the MHS for PTSD and MDD. The goal of this project was to identify, develop, and describe a set of candidate quality measures to assess care for PTSD and MDD. To accomplish this goal, the authors performed two tasks: (1) developed a conceptual framework for assessing the quality of care for psychological health conditions and (2) identified a candidate set of measures for monitoring, assessing, and improving the quality of care for PTSD and MDD. This article describes their research approach and the candidate measure sets for PTSD and MDD that they identified. The current task did not include implementation planning but provides the foundation for future RAND work to pilot a subset of these measures.

Care Transitions to and from the National Intrepid Center of Excellence (NICoE) for Service Members with Traumatic Brain Injury

Improvised explosive devices (IEDs) have been one of the leading causes of death and injury among U.S. troops. Those who survive an IED blast or other injuries may be left with a traumatic brain injury (TBI) and attendant or co-occurring psychological symptoms. In response to the need for specialized services for these populations, the U.S. Department of Defense (DoD) established the National Intrepid Center of Excellence (NICoE) in Bethesda, Maryland, in 2010. The NICoE's success in fulfilling its mission is impacted by its relationships with home station providers, patients, and their families. The RAND Corporation was asked to evaluate these relationships and provide recommendations for strengthening the NICoE's efforts to communicate with these groups to improve patients' TBI care. Through surveys, site visits, and interviews with NICoE staff, home station providers, service members who have received care at the NICoE, and the families of these patients, RAND's evaluation examined the interactions between the NICoE and the providers responsible for referring patients and implementing treatment plans.

Evaluation of the Operational Stress Control and Readiness (OSCAR) Program

The Marine Corps Operational Stress Control and Readiness (OSCAR) program embeds mental health personnel within Marine Corps units and extends their reach by training officers and noncommissioned officers to recognize Marines showing signs of stress and intervene early. RAND Corporation researchers conducted an outcome evaluation of the OSCAR program that included four components: (1) a quasi-experimental study that compared Marines in OSCAR-trained and non-OSCAR-trained battalions on a wide array of stress-related outcomes before and after deployment, (2) a longitudinal pre- and postdeployment survey of perceptions of OSCAR among Marines who attended OSCAR training, (3) focus groups with Marines, and (4) semistructured interviews with commanding officers of battalions that had received OSCAR training. Results indicated that, after the authors adjust for a wide array of baseline characteristics and deployment experiences, Marines in OSCAR-trained battalions were more likely than those in non-OSCAR-trained battalions to report having sought help with stress problems from a peer, leader, or corpsman-behavior that is consistent with OSCAR goals. In addition, Marines considered OSCAR a valuable tool for enhancing combat and operational stress response and recovery efforts in the Marine Corps. However, this evaluation did not find evidence that OSCAR affected the key mental health outcomes it was designed to address. Thus, the results of this evaluation do not support the continuation of OSCAR in its current form. Based on lessons learned about OSCAR from this evaluation, other research, and best practices for program improvement and implementation, recommendations for improving combat and operational stress training in the Marine Corps are offered.

Pre-Deployment Stress, Mental Health, and Help-Seeking Behaviors Among Marines

The Marine Corps Operational Stress Control and Readiness (OSCAR) program is designed to provide mental health support to marines by embedding mental health personnel within Marine Corps units and increasing the capability of officers and senior noncommissioned officers to improve the early recognition and intervention of marines exhibiting signs of stress. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury have asked RAND to evaluate the OSCAR program. As part of this evaluation, RAND conducted a large survey of marines who were preparing for a deployment to Iraq or Afghanistan in 2010 or 2011. This article describes the methods and findings from this survey. The results are among the first to shed light on the pre-deployment mental health status of marines, as well as the social resources they draw on when coping with stress and their attitudes about seeking help for stress-related problems. The 2,620 marines in the survey sample had high rates of positive screens for current major depressive disorder (12.5 percent) and high-risk drinking (25.7 percent) and reported having experienced more potentially traumatic events over their lifetime than adult males in the general population. Marines in the sample also reported relying on peers for support with stress and perceiving moderate levels of support from the Marine Corps for addressing stress problems.

Practice Guidance for Buprenorphine for the Treatment of Opioid Use Disorders: Results of an Expert Panel Process

BACKGROUND

Although the number of physicians credentialed to prescribe buprenorphine has increased over time, many credentialed physicians may be reluctant to treat individuals with opioid use disorders due to discomfort with prescribing buprenorphine. Although prescribing physicians are required to complete a training course, many have questions about buprenorphine and treatment guidelines have not been updated to reflect clinical experience in recent years. We report on an expert panel process to update and expand buprenorphine guidelines.

METHODS

We identified candidate guidelines through expert opinion and a review of the literature and used a modified RAND/UCLA Appropriateness Method to assess the validity of the candidate guidelines. An expert panel completed 2 rounds of rating, with a meeting to discuss the guidelines between the first and second ratings.

RESULTS

Through the rating process, expert panel members rated 90 candidate guideline statements across 8 domains, including candidacy for buprenorphine treatment, dosing of buprenorphine, psychosocial counseling, and treatment of co-occurring depression and anxiety. A total of 65 guideline statements (72%) were rated as valid. Expert panel members had agreement in some areas, such as the treatment of co-occurring mental health problems, but disagreement in others, including the appropriate dosing of buprenorphine given patient complexities.

CONCLUSIONS

Through an expert panel process, we developed an updated and expanded set of buprenorphine treatment guidelines; this additional guidance may increase credentialed physicians' comfort with prescribing buprenorphine to patients with opioid use disorders. Future efforts should focus on appropriate dosing guidance and ensuring that guidelines can be adapted to a variety of practice settings.

The Affordable Care Act: an opportunity for improving care for substance use disorders?

The Patient Protection and Affordable Care Act (ACA) will greatly increase coverage for treatment of substance use disorders. To realize the benefits of this opportunity, it is critical to develop reliable, valid, and feasible measures of quality to ensure that treatment is accessible and of high quality. The authors review the availability of current quality measures for substance use disorder treatment and conclude there is a pressing need for development, validation, and use of quality measures. They provide recommendations for research and policy changes to increase the likelihood that patients, families, and society benefit from the increased coverage provided by the ACA.

Supply of buprenorphine waivered physicians: the influence of state policies

Buprenorphine, an effective opioid use disorder treatment, can be prescribed only by buprenorphine-waivered physicians. We calculated the number of buprenorphine-waivered physicians/100,000 county residents using 2008-11 Buprenorphine Waiver Notification System data, and used multivariate regression models to predict number of buprenorphine-waivered physicians/100,000 residents in a county as a function of county characteristics, state policies and efforts to promote buprenorphine use. In 2011, 43% of US counties had no buprenorphine-waivered physicians and 7% had 20 or more waivered physicians. Medicaid funding, opioid overdose deaths, and specific state guidance for office-based buprenorphine use were associated with more buprenorphine-waivered physicians, while encouraging methadone programs to promote buprenorphine use had no impact. Our findings provide important empirical information to individuals seeking to identify effective approaches to increase the number of physicians able to prescribe buprenorphine.

Out of the Shadows: The Health and Well-Being of Private Contractors Working in Conflict Environments

Over the past decade, private contractors have been deployed extensively around the globe. In addition to supporting U.S. and allied forces in Iraq and Afghanistan, contractors have assisted foreign governments, nongovernmental organizations, and private businesses by providing a wide range of services, including base support and maintenance, logistical support, transportation, intelligence, communications, construction, and security. At the height of the conflicts in Iraq and Afghanistan, contractors outnumbered U.S. troops deployed to both theaters. Although these contractors are not supposed to engage in offensive combat, they may nonetheless be exposed to many of the stressors that are known to have physical and mental health implications for military personnel. RAND conducted an online survey of a sample of contractors who had deployed on contract to a theater of conflict at least once between early 2011 and early 2013. The survey collected demographic and employment information, along with details about respondents' deployment experience (including level of preparation for deployment, combat exposure, and living conditions), mental health (including probable posttraumatic stress disorder, depression, and alcohol misuse), physical health, and access to and use of health care. The goal was to describe the contractors' health and well-being and to explore differences across the sample by such factors as country of citizenship, job specialty, and length and frequency of contract deployment. The findings provide a foundation for future studies of contractor populations and serve to inform policy decisions affecting contractors, including efforts to reduce barriers to mental health treatment for this population.

A Program Manager's Guide for Program Improvement in Ongoing Psychological Health and Traumatic Brain Injury Programs

Between 2001 and 2011, the U.S. Department of Defense has implemented numerous programs to support service members and their families in coping with the stressors from a decade of the longstanding conflicts in Iraq and Afghanistan. These programs, which address both psychological health and traumatic brain injury (TBI), number in the hundreds and vary in their size, scope, and target population. To ensure that resources are wisely invested and maximize the benefits of such programs, RAND developed a tool to help assess program performance, consider options for improvement, implement solutions, then assess whether the changes worked, with the intention of helping those responsible for managing or implementing programs to conduct assessments of how well the program is performing and to implement solutions for improving performance. Specifically, the tool is intended to provide practical guidance in program improvement and continuous quality improvement for all programs.

The RAND Online Measure Repository for Evaluating Psychological Health and Traumatic Brain Injury Programs

Since 2001, U.S. military forces have been engaged in extended conflicts in Iraq and Afghanistan. While most military personnel cope well across the deployment cycle, the operational tempo may raise the risk of mental health problems, such as post-traumatic stress disorder (PTSD) and major depression, and consequences from traumatic brain injury (TBI). To support servicemembers and their families as they cope with these challenges, the U.S. Department of Defense has implemented numerous programs addressing biological, social, spiritual, and holistic influences on psychological health along the resilience, prevention, and treatment continuum that focus on a variety of clinical and nonclinical concerns. As these efforts have proliferated, evaluating their effectiveness has become increasingly important. To support the design and implementation of program evaluation, RAND developed the RAND Online Measure Repository (ROMR) which indexes and describes measures related to psychological health and TBI. The ROMR is a publicly accessible, online, searchable database containing 171 measures related to psychological health and TBI. This article describes the rationale for developing the ROMR, the content included in the ROMR, and its potential in both civilian and military populations. The ROMR includes information about measure domains, psychometrics, number of items, and costs, which can inform the selection of measures for program evaluations. Included measures address domains of primary importance to psychological health (PTSD, depression, anxiety, suicidal ideation, and resiliency) and TBI (cognition, executive functioning, and memory). Also identified are measures relevant to military units, such as unit cohesion and force readiness.

The Development and Application of the RAND Program Classification Tool

As a result of extended military engagements in Iraq and Afghanistan during the past decade, the U.S. Department of Defense (DoD) has implemented numerous programs to support servicemembers and family members who experience difficulty handling stress, face mental health challenges, or are affected by a traumatic brain injury (TBI). As these efforts have proliferated, it has become more challenging to monitor these programs and to avoid duplication. To support DoD in this area, RAND compiled a comprehensive catalog of DoD-funded programs that address psychological health and TBI. In creating the catalog of programs, RAND recognized the need to consistently describe and compare multiple programs according to a set of core program characteristics, driven largely by the lack of a single, clear, widely accepted operational definition of what constitutes a program. To do this, RAND developed the RAND Program Classification Tool (R-PCT) to allow users to describe and compare programs, particularly those related to psychological health and TBI, along eight key dimensions that that define a program. The tool consists of a set of questions and responses for consistently describing various aspects of programs, along with detailed guidance regarding how to select the appropriate responses. The purpose of this article is to describe the R-PCT, to help potential users understand how it was developed, and to explain how the tool can be used.

Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S. Military Servicemembers and Their Families

Over the last decade, U.S. military forces have been engaged in extended conflicts that are characterized by increased operational tempo, most notably in Iraq and Afghanistan. While most military personnel cope well across the deployment cycle, many will experience difficulties handling stress at some point; will face psychological health challenges, such as post-traumatic stress disorder or major depression; or will be affected by the short- and long-term psychological and cognitive consequences of a traumatic brain injury (TBI). Over the past several years, the Department of Defense (DoD) has implemented numerous programs that address various components of psychological health along the resilience, prevention, and treatment continuum and focus on a variety of clinical and nonclinical concerns. This article provides detail from an evaluation of 211 programs currently sponsored or funded by DoD to address psychological health and TBI, along with descriptions of how programs relate to other available resources and care settings. It also provides recommendations for clarifying the role of programs, examining gaps in routine service delivery that could be filled by programs, and reducing implementation barriers. Barriers include inadequate funding and resources, concerns about the stigma associated with receiving psychological health services, and inability to have servicemembers spend adequate time in programs. The authors found that there is significant duplication of effort, both within and across branches of service. As each program develops its methods independently, it is difficult to determine which approaches work and which are ineffective. Recommendations include strategic planning, centralized coordination, and information-sharing across branches of service, combined with rigorous evaluation. Programs should be evaluated and tracked in a database, and evidence-based interventions should be used to support program efforts.

Public and nonprofit funding for research on mental disorders in France, the United Kingdom, and the United States

OBJECTIVE

To document the investments made in research on mental disorders by both government and nonprofit nongovernmental organizations in France, the United Kingdom, and the United States.

DATA SOURCES

An exhaustive survey was conducted of primary sources of public and nonprofit organization funding for mental health research for the year 2007 in France and the United Kingdom and for fiscal year 2007-2008 in the United States, augmented with an examination of relevant Web sites and publications. In France, all universities and research institutions were identified using the Public Finance Act. In the United Kingdom, we scrutinized Web sites and hand searched annual reports and grant lists for the public sector and nonprofit charitable medical research awarding bodies. In the United States, we included the following sources: the National Institutes of Health, other administrative entities within the Department of Health and Human Services (eg, Centers for Disease Control and Prevention), the Department of Education, the Department of Veterans Affairs, the Department of Defense, and the National Science Foundation and, for nonprofit funding, The Foundation Center.

DATA EXTRACTION

We included research on all mental disorders and substance-related disorders using the same keywords. We excluded research on mental retardation and dementia and on the promotion of mental well-being. We used the same algorithm in each country to obtain data for only mental health funding in situations in which funding had a broader scope.

RESULTS

France spent $27.6 million (2%) of its health research budget on mental disorders, the United Kingdom spent $172.6 million (7%), and the United States spent $5.2 billion (16%). Nongovernmental funding ranged from 1% of total funding for mental health research in France and the United States to 14% in the United Kingdom.

CONCLUSIONS

Funding for research on mental disorders accounts for low proportions of research budgets compared with funding levels for research on other major health problems, whereas the expected return on investment is potentially high.

A Needs Assessment of New York State Veterans: Final Report to the New York State Health Foundation

Mental health disorders and other types of impairments resulting from deployment experiences are beginning to emerge, but fundamental gaps remain in our knowledge about the needs of veterans returning from Iraq and Afghanistan, the services available to meet those needs, and the experiences of veterans who have tried to use these services. This article highlights the findings of a study focused directly on the veterans living in New York state. The study included veterans who currently use U.S. Department of Veterans Affairs (VA) services as well as those who do not; and it looked at needs across a broad range of domains. The authors collected information and advice from a series of qualitative interviews with veterans of Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) residing in New York, as well as their family members. In addition, they conducted a quantitative assessment of the needs of veterans and their spouses from a sample that is broadly representative of OEF/OIF veterans in New York state. Finally, they conducted a review the services currently available in New York state for veterans. The study found substantially elevated rates of post-traumatic stress disorder (PTSD) and major depression among veterans. It also found that both VA and non-VA services are critically important for addressing veterans' needs, and that the health care systems that serve veterans are extremely complicated. Addressing veterans' mental health needs will require a multipronged approach: reducing barriers to seeking treatment; improving the sustainment of, or adherence to, treatment; and improving the quality of the services being delivered. Finally, veterans have other serious needs besides mental health care and would benefit from a broad range of services.

Temporal factors in motor vehicle crash deaths

OBJECTIVE

To summarize fatal motor vehicle crash deaths in the United States by time of day, day of week, month, and season, and to determine why some days of the year tend to experience a relatively high number of deaths.

METHOD

Crash deaths were identified and categorized using the Fatality Analysis Reporting System. Days of the year with relatively high crash deaths were compared to the two days that occurred exactly one week before and one week after.

RESULTS

On average, motor vehicle crashes in the United States result in more than 100 deaths per day, but there is much day-to-day variability. During 1986-2002 the single day fatality count ranged from a low of 45 to a high of 252. Summer and fall months experience more crash deaths than winter and spring, largely due to increased vehicle travel. July 4 (Independence Day) has more crash deaths on average than any other day of the year, with a relatively high number of deaths involving alcohol. January 1 (New Year's Day) has more pedestrian crash deaths on average, plus it has the fifth largest number of deaths per day overall, also due to alcohol impairment. On other days the high numbers of deaths are likely due to increases in holiday or recreational travel.

CONCLUSION

Every day of the year results in many crash deaths, but certain days stand out as particularly risky. The temporal and geographic spread of crash deaths, as well as the view of driving as a routine task, inures the public to this continuing problem. Innovative strategies are needed both to raise awareness and to work toward a solution.

Effectiveness of Ford's belt reminder system in increasing seat belt use

OBJECTIVES

The study investigated the effectiveness in increasing seat belt use of Ford's belt reminder system, a supplementary system that provides intermittent flashing lights and chimes for five minutes if drivers are not belted.

METHODS

Seat belt use of drivers in relatively new cars with and without the reminder system was unobtrusively observed as vehicles were brought to dealerships for service.

RESULTS

Overall use rates were estimated at 71% for drivers in vehicles without the reminder system and 76% for drivers in vehicles with belt reminders (p<0.01).

CONCLUSIONS

Seat belt use is relatively low in the United States. The present study showed that vehicle based reminder systems can be at least modestly effective in increasing belt use, which may encourage further development of such systems.

New evidence concerning fatal crashes of passenger vehicles before and after adding antilock braking systems

Fatal crash rates for passenger cars and vans were compared for the last model year before four-wheel antilock brakes were introduced and the first model year for which antilock brakes were standard equipment. A prior study, based on fatal crash experience through 1995, reported that vehicle models with antilock brakes were more likely than identical but 1-year-earlier models to be involved in crashes fatal to their own occupants, but were less likely to be involved in crashes fatal to occupants of other vehicles. Overall, there was no significant effect of antilocks on the likelihood of fatal crashes. Similar analyses, based on fatal crash experience during 1996-98, yielded very different results. During 1996-98, vehicles with antilock brakes were again less likely than earlier models to be involved in crashes fatal to occupants of other vehicles, but they were no longer overinvolved in crashes fatal to their own occupants.

Effect of Florida's graduated licensing program on the crash rate of teenage drivers

On 1 July 1996, Florida instituted a graduated licensing program for drivers younger than age 18. For the first 3 months, holders of learner's licenses are not allowed to drive at all between 19:00 and 06:00 h; thereafter, they may drive until 22:00 h. Learner's licenses must be held for 6 months prior to eligibility for the intermediate license. Sixteen-year-old intermediate license holders are not permitted to drive unsupervised from 23:00 to 06:00 h, 17 year-olds from 01:00 to 06:00 h. All drivers younger than 18 have strict limits on the number of traffic violations they can accumulate and, effective 1 January 1997, all drivers younger than 21 are subject to a zero tolerance law for drinking and driving. Florida crash data for 1995-1997 were obtained and compared with similar data from Alabama, a state that borders Florida but does not have graduated licensing. For 15, 16, and 17 year-olds combined, there was a 9% reduction in the fatal and injury crash involvement rate in Florida during 1997, the first full year of graduated licensing, compared with 1995. On a percentage basis, crashes declined most among 15 year-olds, followed by 16 year-olds and then 17 year-olds. Reductions were not seen among Alabama teenagers nor among 18 year-olds in Florida.

Visual perception and working memory in schizotypal personality disorder

OBJECTIVE

Patients affected by schizophrenia show deficits in both visual perception and working memory. The authors tested early-stage vision and working memory in subjects with schizotypal personality disorder, which has been biologically associated with schizophrenia.

METHOD

Eleven subjects who met DSM-III-R criteria for schizotypal personality disorder and 12 normal comparison subjects were evaluated. Performance thresholds were obtained for tests of visual discrimination and working memory. Both form and trajectory processing were evaluated for each task.

RESULTS

Subjects with schizotypal personality disorder showed intact discrimination of form and trajectory but were impaired on working memory tasks.

CONCLUSIONS

These data suggest that subjects with schizotypal personality disorder, unlike patients affected by schizophrenia, have relatively intact visual perception. Subjects with schizotypal personality disorder do show specific deficits on tasks of comparable difficulty when working memory demands are imposed. Schizotypal personality disorder may be associated with a more specific visual processing deficit than schizophrenia, possibly reflecting disruption of frontal lobe systems subserving visual working memory operations.

Relationship of head restraint positioning to driver neck injury in rear-end crashes

Insurance claims were examined for evidence of neck injuries to drivers of passenger cars struck in the rear. Neck injury rates were significantly lower for male drivers, elderly drivers, and drivers in less severe crashes. Even after accounting for differences in driver demographics and crash severity, neck injury rates were significantly lower for drivers of cars with head restraints that were more likely to be behind the heads of motorists.

Changes in motor vehicle occupant fatalities after repeal of the national maximum speed limit

Trends in motor vehicle occupant deaths over 8 years were studied for 24 states that raised interstate speed limits and seven states that did not following the 1995 repeal of the US National Maximum Speed Limit. Fatalities on interstates increased 15% in the 24 states that raised speed limits. After accounting for changes in vehicle miles of travel, fatality rates were 17% higher following the speed limit increases. Similar increases were reported following the 1987 speed limit increases on rural interstates. Deaths on roads other than interstates were essentially unchanged.

Evaluation of red light camera enforcement in Oxnard, California

Red light cameras are increasingly being used to supplement police efforts to enforce against noncompliance with traffic signals--a substantial contributing factor in urban motor vehicle crashes. Camera enforcement is intended to modify driver behavior through both general deterrence and punishment of individual violators. A before/after quasi-experimental design with controls was employed to evaluate the influence of a red light camera enforcement program on red light violation rates in the city of Oxnard, CA. A total of 14 intersections (nine camera sites, three non-camera sites, and two control sites) were studied. Overall, the red light violation rate was reduced approximately 42% several months after the enforcement program began. Increases in driver compliance with red lights were not limited to the camera-equipped intersections but spilled over to nonequipped intersections as well. Results of public opinion surveys conducted approximately 6 weeks before, 6 weeks after, and 6 months after the camera enforcement program began indicated that nearly 80% of Oxnard residents support using red light cameras as a supplement to police efforts to enforce traffic signal laws.

Fatal crashes of passenger vehicles before and after adding antilock braking systems

Fatal crash rates of passenger cars and vans were compared for the last model year before four-wheel antilock brakes were introduced and the first model year for which antilock brakes were standard equipment. Vehicles selected for analysis had no other significant design changes between the model years being compared, and the model years with and without antilocks were no more than two years apart. The overall fatal crash rates were similar for the two model years. However, the vehicles with antilocks were significantly more likely to be involved in crashes fatal to their own occupants, particularly single-vehicle crashes. Conversely, antilock vehicles were less likely to be involved in crashes fatal to occupants of other vehicles or nonoccupants (pedestrians, bicyclists). Overall, antilock brakes appear to have had little effect on fatal crash involvement. Further study is needed to better understand why fatality risk has increased for occupants of antilock vehicles.

Two-vehicle side impact crashes: the relationship of vehicle and crash characteristics to injury severity

Injury type and severity among front outboard occupants of passenger vehicles struck in the side by another passenger vehicle and recorded in the United States National Accident Sampling System Crashworthiness Data System were examined in relation to the location of impact, the angle of impact, occupant gender and age, seat belt use, the weight and body style of the side-impacted vehicle, and the weight and body style of the striking vehicle. Elderly occupants were three times as likely as younger occupants in similar crashes to be seriously injured. Serious injuries were also more likely for occupants seated on the struck side and occupants of lightweight passenger vehicles. After accounting for vehicle weight differences, struck-side occupants of cars were still much more likely to be seriously injured than struck-side occupants of light trucks. However, among occupants seated on the side of the vehicle opposite the impact, the likelihood of serious injury was higher for those seated in light trucks.