Selected RAND Abstracts

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A Guide to RAND Publications

Volume 52 January–December 2014

Annual Cumulation ii

Printed and Online Indexes

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ISSN: 0037-1343

Abstracts of all publicly releasable RAND publications are available through RAND’s home page on the World Wide Web (www. rand.org/search/advanced-search.html). The database may be searched by author, title, keyword, or document number. All publicly available documents published since January 1998 in the Monograph, Monograph/Report, Research Report, Technical Report, Tool, Perspective, Presentation, Issue Paper, Conference Report, Occasional Paper, Documented Briefing, orkingW Paper, and Brief series are available on the RAND website in their entirety, as well as some of our older classics. iii

CONTENTS

INTRODUCTION...... iv

SUFFIX LIST...... 1

SERIAL LIST...... 4 INDEXES Author...... 9 Subject...... 69 Title...... 133

ABSTRACTS Conference Proceedings...... 187 Corporate Publications...... 188 Testimony ...... 189 Documented Briefings ...... 191 External Publications ...... 191 Monographs ...... 341 Perspectives ...... 348 Presentations ...... 352 Briefs ...... 354 RAND Graduate School Dissertations...... 361 Research Reports ...... 366 Tools ...... 459 Technical Reports ...... 461 Working Papers...... 464 iv

INTRODUCTION

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND focuses on the issues that matter most, such as health, education, national security, international affairs, law and business, the environment, and more. Our research is commissioned by a global clientele that includes government agencies, foundations, and private-sector firms. Additionally, generous philanthropic contributions, combined with earnings from RAND’s endowment and operations, make possible RAND’s Investment in People and Ideas program, which is used to support innovative research on issues crucial to the policy debate but that reach beyond the boundaries of traditional client funding. All final research documents are peer reviewed. The methods and findings of RAND research are reported chiefly in RAND’s publications. Many RAND studies appear also as articles in professional, scholarly, and technical journals (published in our External Publications series), and as books published by other commercial publishers and university presses. Selected RAND Abstracts (SRA) is a complete guide to current unclassified RAND publications. The numbered publication series includes:

CF Conference Proceedings CP Corporate Publications CT Testimony DB Documented Briefings EP External Publications MG Monographs PE Perspectives PT Presentations RB Briefs RGSD Dissertations RR (Research) Reports TL Tool TR (Technical) Reports WR Working Papers

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Selected RAND Abstracts is divided into an index section and an abstract section.

INDEX SECTION

Each issue of SRA contains author, subject, and title indexes covering all the material abstracted in the current volume. Author Index. The entries under the authors’ names give the document numbers and titles of their publications abstracted in this volume of SRA. Title Index. Each title is followed by its document number. Suffix Index. The suffix following each document number indicates the sponsor of the research. Subject Index. Each publication is indexed under one or more appropriate subjects. The lines that follow the subject headings are titles. The document number following the modifier refers the user to the abstract appearing in the abstract section.

Note that in all sections, titles and headings are alphabetized by first letter—including “A” and “The.” v

ABSTRACT SECTION

Abstracts are arranged serially by document number. A complete serial list of publications included in this volume appears immediately preceding the author index.

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A CMEPP United States Army Center for Middle East Public Policy

A/OSD CMHSA United States Army and the Office of the California Mental Health Services Authority Secretary of Defense (CalMHSA)

ACPO CMS Prepared for the Association of Chief Police Centers for Medicare and Medicaid Services Officers¹ Mounted Working Group COHF AETNA Colorado Health Foundation Aetna, Inc. CSM AF City of Santa Monica and Santa-Monica-Malibu United States Air Force Unified School District

ASAI CSMC American Society of Anesthesiologists Cedars-Sinai Medical Center

ASPE DARPA Office of the Assistant Secretary for Planning and Defense Advanced Research Projects Agency Evaluation DEFRA AUS Department for Environment, Food, and Rural Australia Affairs

BJA DEIES Bureau of Justice Assistance Institute of Education Sciences, U.S. Department of Education BLC Betsy Lehman Center DFT UK Department for Transport BMGF Bill and Melinda Gates Foundation DH UK Department of Health, England CFAT College for All Texans Foundation DHHS Department of Health and Human Services CFGNH New Haven Promise DHHSNCH DHHS Office of the National Coordinator for CHSWC Health California Commission on Health and Safety and Workers' Compensation DIR California Department of Industrial Relations/ Division of Workers' Compensation 2

DOEL JPMCF Delaware Office of Early Learning JP Morgan Chase & Co.

DOL KRG U.S. Department of Labor Kurdistan Regional Government

DOS LACPD U.S. Department of State Los Angeles County Probation Department

DTRA ME Defense Threat Reduction Agency Sponsored by Microsoft Europe

WMD MM Weapons of Mass Destruction Prepared for Mott MacDonald

DWP MOJ Department of Work and Pensions Ministry of Justice

DWP MPS Department of Water and Power Israel Ministry of Public Security

EC MTF European Commission Directorate General- McCormick Tribune Foundation Justice and Fundamental Rights NAVY EP United States Navy European Parliament NIDA EPIM National Institute on Drug Abuse European Programme for Integration and Migration NIH/NIA National Institute of Health/National Institute On GECO Aging General Electric Company NIJ HBI National Institute of Justice Homeboy Industries NIMSP IBO National Institute on Money in State Politics International Baccalaureate Organization NL ICJ New Leaders RAND Institute for Civil Justice NRPA IFMO National Recreation and Park Association Institute for Mobility Research NYSHF JNI New York State Health Foundation Juniper Networks 3

OFCOM SOCOM Prepared for Ofcom U.S. Special Operations Command

ONDCP SOY-NIA Office of National Drug Control Policy State of Yucatan and the National Institute on Aging OSD Office of the Secretary of Defense SRF Smith Richardson Foundation OSI Open Society Foundations TEDF Elizabeth Dole Foundation PI Pfizer Pharmaceuticals Ltd. TII TRACE International, Inc. PNC PNC Bank UCLA University of California, Los Angeles PRGS Pardee RAND Graduate School UNHF United Health Foundation RC RAND Corporation USCG United States Coast Guard RCN Research Council of Norway USSOCOM United States Special Operations Command RE RAND Europe WF The Wallace Foundation REC State of New Mexico, Children Youth and WFHF Families Department William and Flora Hewlett Foundation

RF WODC Rockefeller Foundation Research and Documentation Centre (Wetenschappelijk Onderzoek- en SANI Documentatiecentrum WODC) Sandoz Inc. WRF SDS Water Research Foundation Sentry Data Systems WT SFSC Wellcome Trust Superior Court of California, County of San Francisco WT Wekkcine Trust SGC Structural Geonomics Consortium WWP Wounded Warrior Project 4 SERIAL LIST

CONFERENCE EXTERNAL EP-50483 EP-50540 PROCEEDINGS PUBLICATIONS EP-50484 EP-50541 EP-50485 EP-50542 CF-317 EP-19610402 EP-50488 EP-50543 CF-322-CCEG EP-50425 EP-50489 EP-50544 CF-323-BEFI EP-50426 EP-50490 EP-50545 CF-325-CCRMC EP-50427 EP-50491 EP-50546 CF-326 EP-50428 EP-50492 EP-50547 CF-327-PRGS EP-50429 EP-50493 EP-50548 EP-50430 EP-50494 EP-50549 CORPORATE EP-50431 EP-50495 EP-50550 PUBLICATIONS EP-50433 EP-50496 EP-50551 EP-50434 EP-50497 EP-50552 CP-1 (2014) EP-50435 EP-50498 EP-50553 CP-22 (4/14) EP-50436 EP-50499 EP-50554 CP-22 (8/14) EP-50437 EP-50500 EP-50555 EP-50438 EP-50501 EP-50556 TESTIMONY EP-50439 EP-50502 EP-50557 EP-50440 EP-50503 EP-50558 CT-403 EP-50441 EP-50504 EP-50559 CT-403/1 EP-50442 EP-50505 EP-50616 CT-404 EP-50443 EP-50506 EP-51639 CT-406 EP-50444 EP-50507 EP-51640 CT-407 EP-50445 EP-50508 EP-51641 CT-407/1 EP-50446 EP-50509 EP-51642 CT-408 EP-50447 EP-50510 EP-51643 CT-409 EP-50448 EP-50511 EP-51644 CT-409/1 EP-50449 EP-50512 EP-51645 CT-410 EP-50450 EP-50513 EP-51646 CT-411 EP-50451 EP-50514 EP-51647 CT-411/1 EP-50452 EP-50515 EP-51648 CT-412 EP-50453 EP-50516 EP-51649 CT-412/1 EP-50454 EP-50517 EP-51650 CT-413 EP-50455 EP-50519 EP-51651 CT-414 EP-50456 EP-50520 EP-51652 CT-415 EP-50457 EP-50521 EP-51653 CT-415/1 EP-50458 EP-50522 EP-51654 CT-416 EP-50459 EP-50523 EP-51655 CT-417 EP-50460 EP-50524 EP-51656 CT-418 EP-50461 EP-50525 EP-51657 CT-419 EP-50462 EP-50526 EP-51659 CT-420 EP-50463 EP-50527 EP-51661 CT-421 EP-50464 EP-50528 EP-51662 EP-50465 EP-50529 EP-51663 DOCUMENTED EP-50466 EP-50530 EP-51664 BRIEFINGS EP-50467 EP-50531 EP-51665 EP-50468 EP-50532 EP-51666 DB-573-OSD EP-50469 EP-50533 EP-51667 EP-50470 EP-50534 EP-51668 EP-50471 EP-50535 EP-51669 EP-50472 EP-50536 EP-51670 EP-50473 EP-50537 EP-51671 EP-50481 EP-50538 EP-51672 EP-50482 EP-50539 EP-51673 5

EP-51674 EP-51736 EP-51824 EP-66118 EP-51675 EP-51737 EP-51825 EP-66119 EP-51676 EP-51738 EP-51826 EP-66120 EP-51677 EP-51739 EP-51827 EP-66121 EP-51678 EP-51742 EP-51828 EP-66122 EP-51679 EP-51743 EP-51829 EP-66123 EP-51680 EP-51744 EP-51830 EP-66124 EP-51681 EP-51745 EP-51831 EP-66125 EP-51682 EP-51746 EP-51832 EP-66126 EP-51683 EP-51747 EP-51833 EP-66127 EP-51684 EP-51748 EP-51834 EP-66128 EP-51685 EP-51749 EP-51835 EP-66129 EP-51686 EP-51750 EP-51837 EP-66130 EP-51687 EP-51751 EP-51838 EP-66131 EP-51688 EP-51754 EP-51839 EP-66132 EP-51689 EP-51755 EP-51840 EP-66133 EP-51690 EP-51756 EP-51841 EP-66134 EP-51691 EP-51757 EP-51842 EP-66135 EP-51692 EP-51758 EP-51843 EP-66136 EP-51693 EP-51759 EP-51844 EP-66137 EP-51694 EP-51772 EP-51845 EP-66138 EP-51695 EP-51779 EP-51846 EP-66139 EP-51696 EP-51787 EP-51847 EP-66140 EP-51697 EP-51790 EP-51848 EP-66141 EP-51698 EP-51791 EP-51849 EP-66142 EP-51699 EP-51792 EP-51850 EP-66143 EP-51700 EP-51793 EP-51851 EP-66144 EP-51701 EP-51794 EP-51852 EP-66145 EP-51702 EP-51795 EP-51853 EP-66146 EP-51703 EP-51796 EP-51854 EP-66147 EP-51704 EP-51797 EP-51855 EP-66148 EP-51705 EP-51798 EP-51856 EP-66149 EP-51706 EP-51799 EP-51857 EP-66150 EP-51707 EP-51800 EP-51858 EP-66151 EP-51708 EP-51801 EP-51859 EP-66152 EP-51709 EP-51802 EP-51860 EP-66153 EP-51710 EP-51803 EP-51861 EP-66154 EP-51711 EP-51804 EP-51863 EP-66155 EP-51712 EP-51805 EP-51864 EP-66156 EP-51713 EP-51806 EP-51865 EP-66157 EP-51714 EP-51807 EP-66101 EP-66158 EP-51715 EP-51808 EP-66102 EP-66159 EP-51716 EP-51809 EP-66103 EP-66160 EP-51717 EP-51810 EP-66104 EP-66161 EP-51718 EP-51811 EP-66105 EP-66163 EP-51719 EP-51812 EP-66106 EP-66164 EP-51720 EP-51813 EP-66107 EP-66165 EP-51723 EP-51814 EP-66108 EP-66166 EP-51724 EP-51815 EP-66109 EP-66167 EP-51725 EP-51816 EP-66110 EP-66168 EP-51727 EP-51817 EP-66111 EP-66169 EP-51728 EP-51818 EP-66112 EP-66170 EP-51730 EP-51819 EP-66113 EP-66171 EP-51731 EP-51820 EP-66114 EP-66172 EP-51732 EP-51821 EP-66115 EP-66173 EP-51733 EP-51822 EP-66116 EP-66174 EP-51734 EP-51823 EP-66117 EP-66175 6

EP-66176 EP-66233 PT-130/3-USSOCOM RGS DISSERTATIONS EP-66177 EP-66234 PT-132-NIH/NIA EP-66178 EP-66235 RGSD-325 EP-66179 EP-66236 RESEARCH BRIEFS RGSD-326 EP-66180 EP-66237 RGSD-327 EP-66181 EP-66238 RB-9696-1 RGSD-328 EP-66182 EP-66239 RB-9727-CMHSA RGSD-329 EP-66183 EP-66240 RB-9737-CMHSA RGSD-330 EP-66184 EP-66241 RB-9744-DOL RGSD-331 EP-66185 RB-9753-RC RGSD-332 EP-66186 MONOGRAPHS RB-9755-RC RGSD-333 EP-66187 RB-9756-CMHSA RGSD-334 EP-66188 MG-1117-1-KRG RB-9757-CMHSA RGSD-335 EP-66189 MG-1117/1-1-KRG RB-9758-OSD RGSD-336 EP-66190 MG-1117/2-1-KRG RB-9759-AF RGSD-340 EP-66191 MG-1140-1-KRG RB-9760-OSD RGSD-341 EP-66192 MG-1140/1-1-KRG RB-9762-OSD RGSD-342 EP-66193 MG-1140/2-1-KRG RB-9763-BJA RGSD-344 EP-66194 MG-1148-1-KRG RB-9764-TEDF EP-66195 MG-1148/1-1-KRG RB-9764/1-TEDF RESEARCH REPORTS EP-66196 MG-1148/2-1-KRG RB-9764/2-TEDF EP-66197 MG-1171/5-OSD RB-9764/3-TEDF RR-102-AF EP-66198 MG-1171/6-OSD RB-9764/4-TEDF RR-103-AF EP-66199 MG-1184-1-KRG RB-9765-SRF RR-105-AF EP-66200 MG-1184/1-1-KRG RB-9766-WFHF RR-125-A EP-66201 MG-1184/2-1-KRG RB-9767 RR-132-AF EP-66202 MG-1210-AF RB-9768-ICJ RR-174-OSD EP-66203 MG-850/2-AF RB-9769 RR-176-OSD EP-66204 MG-915/2-AF RB-9770-ONDCP RR-185-EC EP-66205 RB-9771-CMHSA RR-186-MM EP-66206 PERSPECTIVES RB-9772-CMHSA RR-209-A/OSD EP-66207 RB-9776 RR-218-OSD EP-66208 PE-111-OSD RB-9779-DOS RR-245 EP-66209 PE-113-A RB-9780 RR-247-OSD EP-66210 PE-115-RC RB-9781-CSMC RR-251-WODC EP-66211 PE-119-PNC RB-9782 RR-257-A EP-66212 PE-120-OSD RB-9784-A RR-259-AF EP-66213 PE-121-SDS RB-9785-OSD RR-261-AF EP-66214 PE-122-RC RB-9786-NL RR-267-OSD EP-66215 PE-123-RC RB-9789-DHHS RR-273-MM EP-66216 PE-124-RC RB-9791 RR-274-A EP-66217 PE-125-RC RB-9792 RR-276-AF EP-66218 PE-126-OSD RB-9794-IFMO RR-277-KRG EP-66219 PE-127-SANI RB-9795 RR-277/1-KRG EP-66220 PE-129-RC RB-9796-BMGF RR-277/2-KRG EP-66221 PE-130-RC RB-9797-A RR-284-OSD EP-66222 PRESENTATIONS RB-9798-DHHS RR-287/1-MPS EP-66223 RB-9799 RR-289-CSM EP-66224 PT-119 RB-9801 RR-289/1-CSM EP-66225 PT-120-UCLA RB-9802-A RR-290-WWP EP-66226 PT-123-USSOCOM RB-9803 RR-293-KRG EP-66227 PT-124-TEDF RB-9804-MTF RR-293/1-KRG EP-66228 PT-125 RB-9805-RC RR-293/2-KRG EP-66229 PT-128-USSOCOM RB-9806-NYSHF RR-302-A EP-66230 PT-130-USSOCOM RB-9809-UNHF RR-306-ASPE EP-66231 PT-130/1-USSOCOM RB-9811/1-CFGNH RR-306/1-ASPE EP-66232 PT-130/2-USSOCOM RB-9811/2-CFGNH RR-308 RB-9814-A 7

RR-309-A RR-483-WFHF RR-564-BJA RR-688-CMHSA RR-314-MM RR-486-ICJ RR-567-OSD RR-689-CMHSA RR-315-NAVY RR-487/1-OSD RR-569-NIJ RR-695-AF RR-321-A RR-487/2-OSD RR-570-A RR-698-DEFRA RR-327-DOL RR-487/3-OSD RR-571-RE RR-706-CMS RR-334-OSI RR-487/4-OSD RR-572-HBI RR-707-WT RR-334/1-OSI RR-489-KRG RR-573-CCRMC RR-708-DHHS RR-337-AF RR-489/1-KRG RR-576-A RR-714-RF RR-342-OSD RR-489/2-KRG RR-577-SRF RR-719-MTF RR-344-AF RR-490-1-KRG RR-581-AF RR-725-EC RR-348-EC RR-490-KRG RR-596-RE RR-728-DH RR-350-A RR-490/1-KRG RR-597 RR-729-GECO RR-357-NAVY RR-490/2-KRG RR-600-1-AETNA RR-732-BMGF RR-360-SOCOM RR-493-ICJ RR-600-AETNA RR-735-SFSC RR-362-EC RR-495-AF RR-604-OFCOM RR-736-AF RR-363-EC RR-499-TEDF RR-605-DOS RR-743-DTRA RR-364-EC RR-499/1-TEDF RR-606-DOEL RR-745-CFAT RR-365-EC RR-500-OSD RR-609-OSD RR-745/1-CFAT RR-369-A RR-501-OSD RR-610-JNI RR-748-OSD RR-374-OSD RR-504-A RR-611-CCRMC RR-750-AF RR-378-DTRA RR-506-DH RR-614-OSD RR-754-CMHSA RR-380-OSD RR-507-NL RR-616 RR-755-CMHSA RR-382-OSD RR-507/1-NL RR-617-AF RR-761-CMS RR-387-A RR-512-SGC RR-624-LACPD RR-764-OSD RR-388-OSD RR-512/1-SGC RR-626-OSD RR-767-AUS RR-390-RC RR-513-SRF RR-627-WT RR-768-RC RR-395-1-DIR RR-514-OSD RR-628-RCN RR-770-A RR-398-OSD RR-521-OSD RR-629-OSD RR-774-NRPA RR-407-DWP RR-522-WWP RR-636-IFMO RR-777-CFGNH RR-410-OSD RR-524-DIR RR-637-OSD RR-777/1-CFGNH RR-412-ICJ RR-525-AF RR-639-REC RR-780-A RR-417-1-A RR-527-1-WFHF RR-641-DEFRA RR-782-COHF RR-418-NIJ RR-527-WFHF RR-641/1-DEFRA RR-787-CMHSA RR-425-CHSWC RR-527/1-WFHF RR-643-CCRMC RR-789-EPIM RR-426-OSD RR-529 RR-644-OSD RR-791-NIMSP RR-429-AF RR-530-A RR-650-ASAI RR-794-DOS RR-430 RR-531-NIJ RR-654-DHHSNCH RR-797 RR-437-RC RR-534-ONDCP RR-655-OSD RR-806-UNHF RR-438-CMHSA RR-534/1-ONDCP RR-656-RC RR-814-AF RR-438/1-CMHSA RR-538-OSD RR-657-CMS RR-815-WF RR-438/2-CMHSA RR-539-CSMC RR-659-AF RR-816-A RR-438/3-CMHSA RR-541-RC RR-660-OSD RR-818-CMHSA RR-438/4-CMHSA RR-543-OSD RR-670-NYSHF RR-819-CMHSA RR-440-OSD RR-544-PI RR-671-EC RR-828-A RR-443-1-RC RR-546-DHHS RR-671/1-EC RR-830/1-ACPO RR-443-RC RR-548/1 RR-673/1-PNC RR-836-JPMCF RR-448-A RR-548/2 RR-673/2-PNC RR-839-TII RR-449-RC RR-550-BJA RR-673/3-PNC RR-854-RC RR-455-OSD RR-551-OSD RR-673/4-PNC RR-858-RC RR-462-EC RR-553-EC RR-673/5-PNC RR-862-EP RR-467-NIJ RR-554-EC RR-678-OSD RR-863-WFHF RR-469-OSD RR-555-EC RR-681-CMHSA RR-870-OSD RR-471-AF RR-556-CMEPP RR-682-CMHSA RR-870/1-OSD RR-473-MOJ RR-557-ME RR-683-CMHSA RR-887-DFT RR-474-A RR-559-OSD RR-684-CMHSA RR-891-BLC RR-477-AF RR-560-DARPA RR-685-CMHSA RR-899-DH RR-482-OSD RR-561-DH RR-686-CMHSA RR-911-WT 8

RR-944-USCG WR-1061-BMGF RR-977-WRF WR-1062-BMGF WR-1063 TOOLS WR-1068 WR-987-1 TL-109/1 TL-129-A TL-130-AF TL-133-AF TL-136-NIDA TL-136/1-NIDA TL-141 TL-145 TL-153-OSD

TECHNICAL REPORTS

TR-1288/1-SOY/NIA TR-1288/2-SOY/NIA TR-1288/3-SOY-NIA TR-1288/4-SOY-NIA TR-1288/5-SOY-NIA TR-1288/6-SOY-NIA TR-1288/7-SOY-NIA TR-1288/8-SOY-NIA

WORKING PAPERS

WR-1014-ICJ WR-1016-DIR WR-1023 WR-1027 WR-1028 WR-1028-1 WR-1029 WR-1032 WR-1033-BMGF WR-1034-BMGF WR-1035-DOS WR-1036-BMGF WR-1038 WR-1039 WR-1040 WR-1041-1-BMGF WR-1041-BMGF WR-1042-OSD WR-1043 WR-1044-IBO WR-1047 WR-1049 WR-1050-DEIES WR-1051-DOEL WR-1052 WR-1053 WR-1054 WR-1055 WR-1060 9 AUTHOR INDEX

Ablon, Lillian RR-686-CMHSA RR-610-JNI Adults Exposed to "Know the Signs" Are More Markets for Cybercrime Tools and Stolen Data: Confident Intervening with Those At Risk for Sui- Hackers' Bazaar cide

CP-22 (8/14) RR-818-CMHSA RAND Review: Vol. 38, No. 2, Summer 2014 "Know the Signs" Suicide Prevention Media Campaign Is Aligned with Best Practices and Highly Regarded by Experts Abramzon, Shmuel RR-293-KRG Capacity Building at the Kurdistan Region Sta- Adams, John L. tistics Office Through Data Collection EP-66218 Better-than-average and worse-than-average RR-293/1-KRG hospitals may not significantly differ from average Capacity Building at the Kurdistan Regional hospitals: an analysis of Medicare Hospital Com- Statistics Organization Through Data Collection: pare ratings Appendixes EP-66218 Focus on Women's Health RR-293/2-KRG Capacity Building at the Kurdistan Region Statistics Office Through Data Collection: Arabic Adams, John L. translation EP-66218 About RAND Health handout RGSD-340 Strategies for Managing Sovereign Debt: A Robust Decision Making Approach Agha, Zia EP-51859 pSCANNER: patient-centered Scalable Na- tional Network for Effectiveness Research

Acosta, Joie D. RR-487/1-OSD The Development and Application of the Aguila, Emma RAND Program Classification Tool: The RAND TR-1288/1-SOY/NIA A Noncontributory Pension Program for Older Toolkit, Volume 1 Persons in Yucatan, Mexico: Implementing and Designing the Evaluation of the Program in Val- RR-487/2-OSD ladolid The RAND Online Measure Repository for Evaluating Psychological Health and Traumatic Brain Injury Programs: The RAND Toolkit, Volume TR-1288/2-SOY/NIA A Noncontributory Pension Program for Older 2 Persons in Yucatan, Mexico: Implementing and Designing the Evaluation of the Program in Me- RR-426-OSD rida Mental Health Stigma in the Military 10

TR-1288/3-SOY-NIA EP-51711 Un Programa de Pensión No Contributiva para Effectiveness of a Community-Based Inter- los Adultos Mayores en Yucatán, México: Diseño, vention to Improve Nutrition in Young Children in implementación y Evaluacióndel Programa en Senegal: A Difference in Difference Analysis Valladolid

TR-1288/4-SOY-NIA Programa de Pensiones No Contributivas para Alpert, Abby Adultos Mayores en Yucatán, México: Diseño, WR-987-1 implementación y Evaluación del Programa en Estimating Intensive and Extensive Tax Re- Mérida sponsiveness: Do Older Workers Respond to Income Taxes? TR-1288/5-SOY-NIA Geographic Targeting in Urban Areas: A So- EP-51858 cial-Welfare Program for Older People in Mexico The state of innovative emergency medical service programs in the United States TR-1288/6-SOY-NIA Mortality Expectations of Older Mexicans: De- velopment and Testing of Survey Measures An, Ruopeng TR-1288/7-SOY-NIA EP-51830 Distributing Noncontributory Pension Benefits Obesity and economic environments by Debit Card in Mexico: A Pilot Test EP-66159 TR-1288/8-SOY-NIA Impact of a patient incentive program on re- Developing and Testing Informed-Consent ceipt of preventive care Methods in a Study of the Elderly in Mexico

WR-1023 How Do Management Fees Affect Retirement Anderson, James M. Wealth Under Mexico’s Personal Retirement Ac- RR-412-ICJ counts System? The Changing Role of Criminal Law in Control- ling Corporate Behavior

RR-443-RC Aharoni, Eyal Autonomous Vehicle Technology: A Guide for RR-550-BJA Policymakers An Assessment of Program Sustainability in Three Bureau of Justice Assistance Criminal Jus- RB-9755-RC tice Domains Autonomous Vehicle Technology: How to Best Realize Its Social Benefits

RR-443-1-RC Alderman, Harold Autonomous Vehicle Technology: A Guide for EP-51709 Policymakers Anemia in Low-Income Countries Is Unlikely to Be Addressed by Economic Development Without Additional Programs 11

Angus, Derek C. Arkes, Jeremy EP-66190 EP-50509 Assessing the validity of using serious game Decomposing racial disparities in prison and technology to analyze physician decision making drug treatment commitments for criminal offenders in California

Anthony, C. Ross RR-490-KRG Arora, Neeraj K. Health Sector Reform in the Kurdistan Re- EP-66165 gion—Iraq: Financing Reform, Primary Care, and Discussions about clinical trials among pa- Patient Safety tients with newly diagnosed lung and colorectal cancer RR-490/1-KRG Health Sector Reform in the Kurdistan Re- gion—Iraq: Financing Reform, Primary Care, and Patient Safety (Arabic-language version) Asch, Beth J. RR-501-OSD RR-490/2-KRG Toward Meaningful Military Compensation Re- Health Sector Reform in the Kurdistan Re- form: Research in Support of DoD’s Review gion—Iraq: Financing Reform, Primary Care, and Patient Safety (Kurdish-language version) RR-514-OSD The Federal Civil Service Workforce: Assess- RR-490-1-KRG ing the Effects on Retention of Pay Freezes, Health Sector Reform in the Kurdistan Re- Unpaid Furloughs, and Other Federal-Employee gion—Iraq: Financing Reform, Primary Care, and Compensation Changes in the Department of Patient Safety Defense

RR-678-OSD How Do Federal Civilian Pay Freezes and Re- Arena, Mark V. tirement Plan Changes Affect Employee Reten- MG-1171/5-OSD tion in the Department of Defense? DoD and Commercial Advanced Waveform Developments and Programs with Multiple Nunn- McCurdy Breaches, Volume 5 Auerbach, David I. MG-1171/6-OSD RR-493-ICJ Management Perspectives Pertaining to Root How Will the Patient Protection and Affordable Cause Analyses of Nunn-McCurdy Breaches, Care Act Affect Liability Insurance Costs? Volume 6: Contractor Motivations and Anticipating Breaches RB-9768-ICJ The Impact of the Affordable Care Act on Li- TL-153-OSD ability Insurance Identifying Acquisition Framing Assumptions Through Structured Deliberation 12

EP-50531 Bair, Matthew J. Examining the value of inpatient nurse staffing: EP-51856 an assessment of quality and patient care costs Patient Aligned Care Teams (PACT): VA's journey to implement patient-centered medical homes

EP-50553 Paying for telemedicine Baird, Matthew RR-650-ASAI The Anesthesiologist Workforce in 2013: A Ayanian, John Z. Final Briefing to the American Society of Anesthe- EP-50552 siologists Integrating the use of patient-reported outcomes for both clinical practice and performance WR-1060 measurement: views of experts from 3 countries Cross Validation Bandwidth Selection for De- rivatives of Multidimensional Densities

Ayer, Lynsay EP-66154 Ball, Sarah Examining the sustainment of the adolescent- EP-50546 community reinforcement approach in community Organisational interventions to reduce length addiction treatment settings: protocol for a longitu- of stay in hospital: a rapid evidence assessment dinal mixed method study EP-50546 EP-66154 A Health Care Puzzler CAPP One Pager

Barham, Leela Ayer, Lynsay EP-66185 EP-66154 Healthy work: challenges and opportunities to RAND at a Glance 2030

EP-66154 Focus on Veterans brochure Barrett, Marguerite L. EP-66154 EP-51724 JIE Making a Difference Handout Surgical site infections following ambulatory surgery procedures EP-66154 Youth, Education, and Labor Markets

EP-66154 Becker, Amariah CGRS One Pager RR-681-CMHSA Where Would California Adults Prefer to Get Help If They Were Feeling Suicidal? 13

Becker, Joachim EP-66114 EP-51818 The curse of wealth: Middle Eastern coun- Answers for an Agile Military: Forces and Re- tries need to address the rapidly rising burden of sources Policy Center (NDRI version) diabetes Bellatorre, Anna EP-51818 EP-51748 Answers for an Agile Military: Forces and Re- Structural stigma and all-cause mortality in sources Policy Center (NSRD version) sexual minority populations Bird, Chloe E. RR-539-CSMC Mapping Gender Differences in Cardiovascular Disease and Diabetes Care: A Pilot Assessment Bennett, Bruce W. of LDL Cholesterol Testing Rates in a California CT-404 Health Plan Preparing for the Possibility of a North Korean Collapse PT-120-UCLA Women's Heart Health: Research That Matters

EP-51696 Berry, Sandra H. Will Extending the Women's Health Initiative MG-1184-1-KRG Lead to Better Research and Policy? Designing a System for Collecting Policy-Rele- vant Data for the Kurdistan Region—Iraq RB-9781-CSMC Mapping Gender Gaps in Health Care MG-1184/1-1-KRG Designing a System for Collecting Policy-Rele- RB-9781-CSMC vant Data for the Kurdistan Region—Iraq: Arabic- Women's Health Research Center language version EP-50542 MG-1184/2-1-KRG A test of biological and behavioral explana- Designing a System for Collecting Policy- tions for gender differences in telomere length: Relevant Data for the Kurdistan Region—Iraq: the multi-ethnic study of atherosclerosis Kurdish-language version EP-51855 EP-51851 Comprehensive healthcare: why is the inclu- Symptom persistence in a community cohort sion of reproductive health controversial for wom- of women with interstitial cystitis/bladder pain syn- en but not men? drome (IC/BPS): 3-, 6-, 9-, and 12-month follow- up from the RICE cohort

Blank, Jonah RR-644-OSD Bhattacharya, Jay Drivers of Long-Term Insecurity and Instability EP-51818 in Pakistan: Urbanization Heterogeneity in healthy aging 14

Blendon, Robert J. Bonds, Timothy M. EP-66178 RR-541-RC Predicting support for non-pharmaceutical Strategy-Policy Mismatch: How the U.S. Army interventions during infectious outbreaks: a four Can Help Close Gaps in Countering Weapons of region analysis Mass Destruction Bloom, David WR-1043 RB-9805-RC Longitudinal Aging Study In India: Biomarker Closing the Strategy–Policy Gap in Countering Data Documentation Weapons of Mass Destruction

Boustead, Anne Bodine-Baron, Elizabeth Anne PT-128-USSOCOM EP-51820 Using Network Analysis Methods to Support Words can be deceiving: a review of variation the Global SOF Network among legally effective medical marijuana laws in the United States PT-128-USSOCOM Answers for an Agile Military: NDRI flyer

PT-128-USSOCOM Boyle, Patricia Answers for an Agile Military: NDRI flyer (Jack PT-132-NIH/NIA Riley version) Cognitive Aging, Neuropathology, and Resil- ience

Bogart, Laura M. EP-50526 Middle school student attitudes about school Brady, Stephen D. drinking fountains and water intake DB-573-OSD Assessing Stop-Loss Policy Options Through EP-50532 Personnel Flow Modeling Medical mistrust is related to lower longitudinal medication adherence among African-American males with HIV Bray, Robert M. EP-51744 EP-50540 An intervention to reduce HIV-related stigma Implementing collaborative primary care for in partnership with African American and Latino depression and posttraumatic stress disorder: de- churches sign and sample for a randomized trial in the U.S. military health system EP-51744 Join the Circle: Upcoming Policy Circle Events

EP-51744 Bresee, Catherine EP-50558 Join the Circle: The RAND Policy Circle Measuring the quality of care provided to women with pelvic organ prolapse 15

Breslau, Joshua Bui, Leena EP-66125 EP-51860 Beliefs about the causes of schizophrenia Perceptions of behavioral health care among among Aymara and non-Aymara patients and veterans with substance use disorders: results their primary caregivers in the Central-Southern from a national evaluation of mental health ser- Andes vices in the Veterans Health Administration

Breugelmans, Gabrielle Burge, Peter EP-50529 RR-571-RE Africa mapping: current state of health re- Understanding the impact of differential univer- search on poverty-related and neglected infec- sity fees in England tious diseases in Sub-Saharan Africa EP-50507 Public acceptability of population-level interventions to reduce alcohol consumption: a dis- Brown, Ryan Andrew crete choice experiment RR-556-CMEPP Youth in Jordan: Transitions from Education to Employment Burger, Nicholas EP-66220 RR-714-RF Understanding condom use decision making The Socioeconomic Effects of the Working among homeless youth using event-level data Poor Moving to Permanent Dwellings: The Case of the Ashray Affordable Housing Pilot Project in India

Bruine de Bruin, Wandi RR-714-RF EP-51700 RAND Behavioral Finance Webinar: Craig Fox Assessing Small Non-Zero Perceptions of Presents "Metacognitive Knowledge and Finan- Chance: The Case of H1N1 (Swine) Flu Risks cial Decision Making"

CF-323-BEFI RAND Behavioral Finance Forum 2014: Le- Buerhaus, Peter veraging Behavioral Insights to Improve Financial EP-50446 Health Strengthening Hospital Nursing WR-1055 EP-50519 Soft versus Hard Commitments: A Test on Registered nurses are delaying retirement, a Savings Behaviors shift that has contributed to recent growth in the nurse workforce 16

Burkhauser, Susan Cai, Li RR-374-OSD EP-66130 Elements of Success: How Type of Second- Methodology for developing and evaluating the ary Education Credential Helps Predict Enlistee PROMIS® smoking item banks Attrition

RR-374-OSD Evaluation of the California Mental Health Ser- Caloyeras, John P. vices Authority's Prevention and Early Interven- EP-50433 tion Initiatives: Progress and Preliminary Findings Managing Manifest Diseases, but Not Health Risks, Saved PepsiCo Money Over Seven Years RR-374-OSD Evaluation of the California Mental Health EP-66179 Services Authority's Prevention and Early Inter- Comparative effectiveness of fidaxomicin for vention Initiatives: Executive Summary and Com- treatment of Clostridium difficile infection mentary

RB-9771-CMHSA What Has the CalMHSA Statewide Mental Campbell, John Health Prevention and Early Intervention Imple- EP-66209 mentation Program Done So Far? Key Results Understanding high and low patient experi- from the Baseline RAND General Population ence scores in primary care: analysis of patients' Survey survey data for general practices and individual doctors RB-9771-CMHSA What Has the CalMHSA Statewide Mental Health Prevention and Early Intervention Imple- mentation Program Done So Far? Summary and Canning, David Commentary for Year 1 Evaluation EP-51708 Fertility choice, mortality expectations, and in- RR-787-CMHSA terdependent preferences--: An Empirical Analysis Recommendations for Sustaining California's Statewide Mental Health Prevention and Early Intervention Programs Carey, Timothy S. EP-66112 A proposed approach may help systematic Buta, Eugenia reviews retain needed expertise while minimizing EP-66237 bias from nonfinancial conflicts of interest Methodological considerations when studying the association between patient-reported care experiences and mortality Carman, Katherine Grace RR-656-RC Cabe, Jennifer Changes in Health Insurance Enrollment EP-50510 Since 2013: Evidence from the RAND Health Re- A prescription is not enough: improving public form Opinion Study health with health literacy 17

RR-854-RC Chambers, Jay Methodology of the RAND Midterm 2014 Elec- WR-1041-BMGF tion Panel How Are School Leaders and Teachers Allo- cating Their Time Under the Partnership Sites to Empower Effective Teaching Initiative? WR-1041-1-BMGF Caston, Lauren How Are School Leaders and Teachers Allo- MG-1210-AF cating Their Time Under the Partnership Sites to The Future of the U.S. Intercontinental Ballistic Empower Effective Teaching Initiative? Missile Force

Chandra, Anita Cataife, Guido TL-109/1 EP-51679 Building Resilient Communities: Spanish The Effect of Surgical Care Improvement Proj- translation ect (SCIP) Compliance on Surgical Site Infections (SSI) TL-109/1 The Future of Cities: Making Metros More Re- silient, Sustainable, and Efficient

Caulkins, Jonathan P. EP-66120 EP-66152 Are users' most recent drug purchases repre- The Los Angeles County Community Disas- sentative? ter Resilience Project: a community-level, public health initiative to build community disaster resil- EP-66120 ience Suicide Rates in California: Trends and Im- plications for Prevention and Early Intervention EP-66163 Programs Developing a global cancer stigma index

RR-522-WWP Health and Economic Outcomes Among the Alumni of the Wounded Warrior Project: 2013 Cheney, Ann M. EP-50557 The role of gender in moderating treatment outcomein collaborative care for anxiety Chalmers, Iain EP-51647 EP-50557 How to Increase Value and Reduce Waste NSRD Overview Brochure When Research Priorities Are Set

Cheney, Ann M. EP-50557 RAND NSRD Annual Report 2013–2014 18

EP-50557 Clarke, Colin P. Saving the Government Money: Recent Ex- RR-469-OSD amples from RAND's Federally Funded Research From Stalemate to Settlement: Lessons for Af- and Development Centers ghanistan from Historical Insurgencies That Have Been Resolved Through Negotiations

RB-9762-OSD Chinman, Matthew Lessons for a Negotiated Settlement in Af- RR-639-REC ghanistan—If History Serves as a Guide Process Evaluation of the New Mexico Mater- nal, Infant, and Early Childhood Home Visiting Competitive Development Grant Cleary, Paul EP-66102 Development and evaluation of the CAHPS Chivvis, Christopher S. (Consumer Assessment of Healthcare Providers PE-111-OSD and Systems) Survey for In-Center Hemodialysis Initial Thoughts on the Impact of the Iraq War patients on U.S. National Security Structures

RR-577-SRF Libya After Qaddafi: Lessons and Implications Cliff, Roger for the Future MG-915/2-AF Shaking the Heavens and Splitting the Earth: Chinese translation (traditional characters)

Choudhry, Niteesh K. EP-51815 Equity in the receipt of oseltamivir in the Cochrane, Gavin United States during the H1N1 pandemic RR-707-WT The African Institutions Initiative: Insights from the First Four Years

Chung, Paul J. EP-51802 Parents' views on engaging families of middle Cohen, Deborah A. school students in obesity prevention and control EP-51654 in a multiethnic population The Potential for Pocket Parks to Increase Physical Activity EP-66171 Time off to care for a sick child: why family- EP-51665 leave policies matter School Design and Physical Activity Among Middle School Girls EP-66238 Drinking behaviors and life course socioeco- RR-774-NRPA nomic status during the transition from adoles- Quantifying the Contribution of Public Parks to cence to adulthood among whites and blacks Physical Activity and Health: Introducing SOPARC 19

EP-50528 RR-819-CMHSA Distance to store, food prices, and obesity in Beliefs Related to Mental Illness Stigma urban food deserts Among California Young Adults

EP-66168 How much neighborhood parks contribute to local residents' physical activity in the City of Los Concannon, Thomas W. Angeles: a meta-analysis EP-51701 A National Strategy to Develop Pragmatic Clinical Trials Infrastructure

Cohen, Susan G. EP-51842 Information technology and high-performance Connable, Ben teams: creating value through knowledge RR-382-OSD Modeling, Simulation, and Operations Analysis in Afghanistan and Iraq: Operational Vignettes, Lessons Learned, and a Survey of Selected Ef- Coleman, Katie forts EP-50455 Untangling Practice Redesign from Disease RB-9758-OSD Management: How Do We Best Care for the The Utility of Modeling and Analysis in the Iraq Chronically Ill? and Afghanistan Wars

CT-418 Defeating the Islamic State in Iraq Coller, Karen M. EP-66118 Successful schools and risky behaviors among low-income adolescents Connor, Kathryn PE-113-A Cost Considerations in Cloud Computing

Collins, Rebecca L. RB-9756-CMHSA What Has the Stigma and Discrimination Re- Constant, Louay duction Initiative Done So Far? Year 1 Findings RR-277-KRG Improving Technical Vocational Education and RR-438/2-CMHSA Training in the Kurdistan Region—Iraq Evaluating the California Mental Health Ser- vices Authority's Stigma and Discrimination Re- RR-277/1-KRG duction Initiative: Year 1 Findings Improving Technical Vocational Education and Training in the Kurdistan Region—Iraq: Arabic- RR-684-CMHSA language version Racial and Ethnic Differences in Mental Illness Stigma in California 20

RR-277/2-KRG D'Amico, Elizabeth J. Improving Technical Vocational Education and EP-51844 Training in the Kurdistan Region—Iraq: Kurdish- Covariance among multiple health risk behav- language version iors in adolescents

Cordova, Amado Damberg, Cheryl L. EP-51653 RR-306-ASPE The COMPARE Microsimulation Model and Measuring Success in Health Care Value- the U.S. Affordable Care Act Based Purchasing Programs: Findings from an Environmental Scan, Literature Review, and Ex- pert Panel Discussions

Cox, Amy G. RR-306/1-ASPE RR-267-OSD Measuring Success in Health Care Value- Identifying and Eliminating Barriers Faced by Based Purchasing Programs: Summary and Nontraditional Department of Defense Suppliers Recommendations

Crane, Keith Darolia, Rajeev RR-245 WR-1054 The Effectiveness of China's Industrial Policies Do Employers Prefer Workers Who Attend For- in Commercial Aviation Manufacturing Profit Colleges? Evidence from a Field Experi- ment CT-416 The Effectiveness of China’s Industrial Policies in Commercial Aviation Manufacturing Das, Lopamudra EP-51857 Safety of vaccines used for routine immuniza- Crowley, James C. tion of US children: a systematic review RR-448-A Changing the Army's Weapon Training Strat- egies to Meet Operational Requirements More Efficiently and Effectively Daugherty, Lindsay PE-119-PNC Using Early Childhood Education to Bridge the Digital Divide Curry Hall, Kimberly RR-836-JPMCF RR-673/1-PNC Veteran Employment: Lessons from the Getting on the Same Page: Identifying Goals 100,000 Jobs Mission for Technology Use in Early Childhood Education 21

David, Daniel RR-673/2-PNC EP-66193 Moving Beyond Screen Time: Redefining Acceptance and use of health information Developmentally Appropriate Technology Use in technology by community-dwelling elders Early Childhood Education

RR-673/3-PNC How Much and What Kind? Identifying an Ad- Davis, Anna C. equate Technology Infrastructure for Early Child- EP-50515 hood Education Disproportionate-share hospital payment reductions may threaten the financial stability of RR-673/4-PNC safety-net hospitals Getting Early Childhood Educators Up and Running: Creating Strong Technology Curators, Facilitators, Guides, and Users Davis, Lois M. RR-673/5-PNC RR-564-BJA Families, Powered On: Improving Family En- How Effective Is Correctional Education, and gagement in Early Childhood Education Through Where Do We Go from Here? The Results of a Technology Comprehensive Evaluation

RR-745-CFAT RB-9763-BJA Assessing the Potential to Expand Community Correctional Education in the United States: College Baccalaureate Programs in Texas How Effective Is It, and How Can We Move the Field Forward? RR-745/1-CFAT Assessing the Potential to Expand Community College Baccalaureate Programs in Texas: Execu- tive Summary Davis, Lynn E. RR-449-RC Armed and Dangerous? UAVs and U.S. Secu- rity DaVanzo, Julie RR-527-WFHF PE-125-RC Evaluation of the Population and Poverty Re- The Days After a Deal with Iran: U.S. Policies search Initiative (PopPov) of Hedging and Engaging

RR-527/1-WFHF Evaluation of the Population and Poverty Re- search Initiative (PopPov): Executive Summary Davis, Paul K. RR-482-OSD RR-527-1-WFHF Analysis to Inform Defense Planning Despite Evaluation of the Population and Poverty Re- Austerity search Initiative (PopPov) WR-1027 Toward Theory for Dissuasion (or Deterrence) by Denial: Using Simple Cognitive Models of the Adversary to Inform Strategy 22

CT-417 WR-1049 Catastrophic Risk in California: Are Homeown- Deterrence, Influence, Cyber Attack, and Cy- ers and Communities Prepared? berwar

Doctor, Jason N. Deary, Vincent EP-66186 EP-51725 Time of day and decision to prescribe antibiot- The role of perceived partner alliance on the ics efficacy of CBT-I: preliminary findings from the Partner Alliance in Insomnia Research Study EP-66216 (PAIRS) Nudging physician prescription decisions by partitioning the order set: results of a vignette- based study

Derose, Kathryn Pitkin EP-66232 Impact of food support on food security and Donohue, Julie M. body weight among HIV antiretroviral therapy EP-51666 recipients in Honduras: a pilot intervention trial Changes in Physician Antipsychotic Prescrib- ing Preferences, 2002-2007

Dick, Andrew W. EP-51664 Douglass, Sara Long-term Survival and Healthcare Utilization EP-66126 Outcomes Attributable to Sepsis and Pneumonia Feeling (Mis)understood and intergroup friendships in interracial interactions EP-66124 Rates of major obstetrical complications vary almost fivefold among U. S. hospitals Dour, Halina J. EP-50425 Perceived Social Support Mediates Anxiety Disley, Emma and Depressive Symptom Changes Following RR-473-MOJ Primary Care Intervention Phase 2 report from the payment by results Social Impact Bond pilot at HMP Peterborough EP-50555 Anxiety and depressive symptoms and medical illness among adults with anxiety disorders

Dixon, Lloyd CF-325-CCRMC The Future of the Terrorism Risk Insurance Act Drabble, Samuel EP-50530 Attractiveness of initial vocational education and training: identifying what matters 23

EP-50530 EP-50530 Implementing the Affordable Care Act Stay Informed: Free Offerings from RAND

EP-50530 EP-50530 Setting Politics Aside New Website handout

EP-50530 EP-50530 Preparing Children for Success Selected RAND Abstracts: A Guide to RAND Publications, Volume 51, January - December EP-50530 2013 Exploring Energy Options--and Implications EP-50530 EP-50530 The Charles Wolf, Jr., Endowed Tribute Fund Cutting Through the Smoke in Drug Policy flyer Debates EP-50530 EP-50530 Join the Circle: Upcoming Policy Circle Events Tackling the World's Toughest Governance Challenges EP-50530 RAND Advisory Boards brochure: An Invitation EP-50530 to Make a Difference Creating a Sustainable Palestinian State EP-50530 EP-50530 RAND Australia flyer Helping Military Families EP-50530 EP-50530 RAND Institutute for Civil Justice brochure Connecting Ideas to Create a Global Economy EP-50530 EP-50530 The Charles Wolf, Jr., Endowed Tribute Fund Renewing Communities and Building Resil- flyer ience Drabble, Samuel EP-50530 EP-50530 Preparing the Next Generation of Policy Lead- Financial Statements: Fiscal Year Ended Sep- ers tember 29, 2013

EP-50530

2013 RAND Annual Report Dunigan, Molly RB-9753-RC EP-50530 Out of the Shadows: What We Know About the Policy Circle brochure: Pittsburgh version Well-Being and Experiences of Private Contrac- tors Working in Conflict Environments EP-50530 Answers for an Agile Military: Arroyo Center flyer 24

Dunn, Erin C. EP-66136 EP-51803 Development of the PROMIS® negative Contributions of the social environment to first- psychosocial expectancies of smoking item banks onset and recurrent mania

Edelstein, Richard Dworsky, Michael EP-50512 RR-643-CCRMC Bring the world to California The Impact on Workers’ Compensation In- surance Markets of Allowing the Terrorism Risk EP-50512 Insurance Act to Expire RAND Arroyo Center Annual Report 2013

Ecola, Liisa Edelstein, Richard RR-636-IFMO EP-50512 The Future of Driving in Developing Countries Standards for High-Quality Research and Analysis RB-9794-IFMO Driving in the Future in Developing Countries EP-50512 RAND Arroyo Center flyer

EP-66203 Edelen, Maria Orlando Equity in competency education: realizing the RB-9803 potential, overcoming the obstacles Advancing Behavioral Health Measurement: The PROMIS® Smoking Assessment Toolkit EP-66204 Equity in competency education: realizing the EP-51737 potential, overcoming the obstacles : executive The psychometric development and initial summary validation of the DCI-A short form for adolescent therapeutic community treatment process

EP-66122 Eibner, Christine Development and validation of the RAND RR-708-DHHS asthma control measure Assessing Alternative Modifications to the Affordable Care Act: Impact on Individual Market EP-66131 Premiums and Insurance Coverage Development of the PROMIS® coping expectancies of smoking item banks RB-9798-DHHS Premiums and Stability in the Individual Health EP-66132 Insurance Market: The Effects of Young Adult En- Development of the PROMIS® nicotine rollment and Subsidies dependence item banks 25

Eisenman, David EP-66233 EP-51821 Common versus specific correlates of fifth- Design of the Violence and Stress Assess- grade conduct disorder and oppositional defiant ment (ViStA) study: a randomized controlled trial disorder symptoms: comparison of three racial/ of care management for PTSD among predomi- ethnic groups nantly Latino patients in safety net health centers EP-66234 Media violence exposure and physical aggression in fifth-grade children Elliott, Marc N. EP-50472 EP-66239 School programs and characteristics and their Clinician advice to quit smoking among se- influence on student BMI: findings from Healthy niors Passages

EP-50520 Examining the role of patient experience sur- Engberg, John veys in measuring health care quality EP-51756 The health consequences of relocation for EP-51718 nursing home residents following Hurricane Ka- Peer victimization in fifth grade and health in trina tenth grade EP-66196 EP-51728 The opportunity costs of informal elder-care in Early puberty, negative peer influence, and the United States: new estimates from the Ameri- problem behaviors in adolescent girls can time use survey

EP-51801 Consequences of interstitial cystitis/bladder pain symptoms on women's work participation Eusebi, Christopher A. and income: results from a national household RR-629-OSD sample Identification and Analysis of Technology Emergence Using Patent Classification EP-51808 Identifying older adults at high risk of mortality using the Medicare health outcomes survey Fain, Terry EP-66208 RR-624-LACPD Changes in obesity between fifth and tenth Los Angeles County Juvenile Justice Crime grades: a longitudinal study in three metropolitan Prevention Act: Fiscal Year 2012–2013 Report areas RB-9791 EP-66217 Is Multisystemic Therapy (MST) Effective for Should health care providers be accountable Hispanic Youth? An Evaluation of Outcomes for for patients' care experiences? Juvenile Offenders in Los Angeles County 26

Farmer, Carrie M. Fleur van Veenstra, Anne RR-218-OSD EP-51691 Pre-Deployment Stress, Mental Health, and Ubiquitous Developments of the Digital Single Help-Seeking Behaviors Among Marines Market

EP-66230 The Affordable Care Act: an opportunity for improving care for substance use disorders? Florez, Karen R. RR-105-AF Nutritional Fitness and Resilience: A Review of Relevant Constructs, Measures, and Links to Farris, Coreen Well-Being RR-538-OSD Targeting Alcohol Misuse: A Promising Strat- egy for Reducing Military Sexual Assaults? Fox, James RR-186-MM PRISM 2011 Base: Mode-Destination Model Faxon-Mills, Susannah Estimation RB-9766-WFHF Can New Tests Lead to Better Teaching and RR-273-MM Deeper Learning? PRISM 2011 Base: Frequency and Car Owner- ship Models

RR-314-MM Feng, Chaoling PRISM 2011 Base: Demand Model Implemen- RGSD-344 tation Competition and Collaboration: A Compari- son of U.S. and Chinese Energy Outward Direct Investment Frakt, Austin B. EP-50447 Voluntary Partial Capitation: the Community Feng, Qiushi Nursing Organization Medicare Demonstration EP-66166 Trends in functional and activity limitations among Chinese oldest-old, 1998 to 2008 Friedberg, Mark W. EP-50440 Does Affiliation of Physician Groups with One Finch, Brian Karl Another Produce Higher Quality Primary Care? EP-51854 Contextual predictors of cumulative biological EP-50443 risk: segregation and allostatic load Reporting Hospitals Antibiotic Timing in Pneu- monia: Adverse Consequences for Patients? 27

EP-50437 Garber, Steven Readiness for the Patient-Centered Medical RR-308 Home: Structural Capabilities of Massachusetts Redirecting Innovation in U.S. Health Care: Primary Care Practices Options to Decrease Spending and Increase Value EP-50442 Satisfied to Death: A Spurious Result? RB-9767 Healing Medical Product Innovation EP-50441 A Guide to the Medical Home as a Practice- Level Intervention Gareen, Ilana F. EP-50465 EP-50543 Association Between Participation in a Multi- Cost-effectiveness of CT screening in the Na- payer Medical Home Intervention and Changes in tional Lung Screening Trial Quality, Utilization, and Costs of Care

EP-50473 Training tomorrow's comprehensive primary Gates, Susan M. care internists: a way forward for internal medi- RR-507-NL cine education Preparing Principals to Raise Student Achieve- ment: Implementation and Effects of the New EP-66236 Leaders Program in Ten Districts Comparing the implementation of team approaches for improving diabetes care in commu- RB-9786-NL nity health centers Principal Preparation Matters: How Leadership Affects Student Achievement

RR-507/1-NL Fuster, Melissa Improving School Leadership Through District EP-50516 Partnerships: Implementation and Effects of New A systematic review of stakeholder engage- Leaders—Appendix ment in comparative effectiveness and patient- centered outcomes research

Geissler, Kimberley H. EP-51680 Galvan, David A. Motivators and Barriers to Using Patient Expe- RR-560-DARPA rience Reports for Performance Improvement Satellite Anomalies: Benefits of a Centralized Anomaly Database and Methods for Securely Sharing Information Among Satellite Operators Giacomantonio, Chris RR-830/1-ACPO Making and Breaking Barriers: Assessing the value of mounted police units in the UK: Sum- mary report 28

Gidengil, Courtney A. RR-551-OSD EP-50517 Improving Interagency Information Sharing Safety of vaccines used for routine immuniza- Using Technology Demonstrations: The Legal Ba- tion in the United States sis for Using New Sensor Technologies for Coun- terdrug Operations Along the U.S. Border

RR-626-OSD Gierlack, Keith Designing Unmanned Systems with Greater RR-467-NIJ Autonomy: Using a Federated, Partially Open License Plate Readers for Law Enforcement: Systems Architecture Approach Opportunities and Obstacles

RR-467-NIJ Center for Latin America Social Policy Gonzalez, Gabriella C. RR-655-OSD An Evaluation of the Implementation and Perceived Utility of the Airman Resilience Training Godlonton, Susan Program EP-66113 Doing wrong to do right? social preferences RR-777-CFGNH and dishonest behavior Transforming an Urban School System: Prog- ress of New Haven School Change and New Haven Promise Education Reforms (2010–2013)

Goggin, Kathy RB-9811/1-CFGNH EP-66188 New Haven Promise: An Early Look at Col- Correlates of use of timed unprotected inter- lege Preparation, Access, and Enrollment of New course to reduce horizontal transmission among Haven Public School Students (2010–2013) Ugandan HIV clients with fertility intentions RB-9811/2-CFGNH Transforming an Urban Public School District: Tracking the Progress of the New Haven Public Gompert, David C. Schools' Educational Reforms and the New Ha- RR-768-RC ven Promise Scholarship Program Blinders, Blunders, and Wars: What America and China Can Learn

Gordon, Adam J. EP-66172 Gonzales, Daniel Supply of buprenorphine waivered physicians: RR-174-OSD the influence of state policies Wireless Emergency Alerts: Mobile Penetra- tion Strategy

Gordon, John IV RR-309-A Enhanced Army Airborne Forces: A New Joint Operational Capability 29

Grant, Jonathan Greenwood, Peter W. RR-628-RCN EP-66161 Supporting the development of a new health Maricopa County's drug court: an innovative R&D strategy: A rapid review of international program for first-time drug offenders on probation theory and practice for Norway’s HelseOmsorg21

Gresenz, Carole Roan Grant, Sean EP-50466 EP-66205 Opportunities and Challenges in Supply-Side Challenges in systematic reviews of qualitative Simulation: Physician-Based Models research

Griffin, Beth Ann Greathouse, Sarah Michal EP-66164 EP-50513 Provision of mental health services as a qual- Effectiveness of multisystemic therapy for mi- ity indicator for adolescent substance abuse treat- nority youth: outcomes over 8 years in Los Ange- ment facilities les County

Gross, Alden L. Green, Harold D. EP-66145 EP-66117 Association of vascular risk factors with cogni- The impact of public housing on social net- tion in a multiethnic sample works: a natural experiment

Groves, David G. Greenberg, Michael D. RR-437-RC CF-322-CCEG Strengthening Coastal Planning: How Coastal Transforming Compliance: Emerging Para- Regions Could Benefit from Louisiana’s Planning digms for Boards, Management, Compliance and Analysis Framework Officers, and Government CP-22 (4/14) EP-66194 RAND Review: Vol. 38, No. 1, Spring 2014 The effect of malpractice reform on emergency department care RB-9696-1 Addressing Coastal Vulnerabilities Through Comprehensive Planning: How RAND Supported the Development of Louisiana’s Comprehensive Greenblatt, Jeffery B. Master Plan EP-66214 A wedge-based approach to estimating health co-benefits of climate change mitigation activities in the United States 30

RR-977-WRF Haddad, Abigail Developing Robust Strategies for Climate TL-130-AF Change and Other Risks: A Water Utility Frame- Diversity Outreach and Recruiting Event Site work Selection (DORESS)

Guerin, Benoit Hafner, Marco RR-553-EC RR-862-EP Breaking the cycle of disadvantage: Early The Cost of Non-Europe in the Single Market: Childhood interventions and progression to higher Free Movement of Goods education in Europe

Hale, Lauren Gunn, Heather E. EP-51714 EP-51699 Acculturation and Sleep Among a Multiethnic Interpersonal Distress Is Associated with Sample of Women: The Study of Women's Health Sleep and Arousal in Insomnia and Good Sleep- Across the Nation (SWAN) ers

Hamilton, Laura S. Guo, Christopher WR-1033-BMGF RR-748-OSD Using Teacher Evaluation Data to Inform Pro- Retention and Promotion of High-Quality Civil fessional Development in the Intensive Partner- Service Workers in the Department of Defense ship Sites Acquisition Workforce

Hanauer, Larry Guthrie, Susan RR-388-OSD RR-627-WT Evaluating the Impact of the Department of Investigating time lags and attribution in the Defense Regional Centers for Security Studies translation of cancer research: A case study approach RR-521-OSD Chinese Engagement in Africa: Drivers, Reac- tions, and Implications for U.S. Policy

Haas, Ann C. RB-9760-OSD EP-66151 China in Africa: Implications of a Deepening Predictors of the existence of congregational Relationship HIV programs: similarities and differences compared with other health programs WR-1052 Security Cooperation Amidst Political Uncer- tainty: An Agenda for Future Research 31

Hanlin, Rebecca Haviland, Amelia M. EP-51863 EP-50461 Inclusive innovation: an architecture for policy A New Estimate of the Impact of OSHA In- development spections on Manufacturing Injury Rates, 1998- 2005

EP-66221 Hansen, Michael L. How much do additional mailings and tele- MG-1117-1-KRG phone calls contribute to response rates in a Strategies for Private-Sector Development and survey of Medicare beneficiaries? Civil-Service Reform in the Kurdistan Region— Iraq

MG-1117/1-1-KRG Hays, Ron D. Strategies for Private-Sector Development and EP-51746 Civil-Service Reform in the Kurdistan Region— Don't middle your MIDs: regression to the Iraq: Arabic-language version mean shrinks estimates of minimally important differences MG-1117/2-1-KRG Strategies for Private-Sector Development and Civil-Service Reform in the Kurdistan Region— Iraq: Kurdish-language version Helland, Eric WR-1014-ICJ Tort Reform and Physician Labor Supply: A Review of the Evidence Harold, Scott Warren EP-51755 EP-50535 An "assertive" China? insights from interviews Medical malpractice reform: noneconomic damages caps reduced payments 15 percent, with varied effects by specialty

Harrington, Lisa M. RR-659-AF Air Force-Wide Needs for Science, Technol- Hemenway, Brett ogy, Engineering, and Mathematics (STEM) RR-344-AF Academic Degrees Achieving Higher-Fidelity Conjunction Analy- ses Using Cryptography to Improve Information Sharing

Harris, Katherine M. EP-51819 Issuance of patient reminders for influenza Henry, Ryan vaccination by U.S.-based primary care physi- WR-1035-DOS cians during the first year of universal influenza Portfolio Assessment of Department of State vaccination recommendations Internet Freedom Program: An Annotated Briefing 32

RR-794-DOS WR-1040 Portfolio Assessment of the Department of Source of Health Insurance Coverage and State Internet Freedom Program Employment Survival Among Newly Disabled Workers: Evidence from the Health and Retire- ment Study

Herman, Patricia M. WR-1047 EP-66160 Employer Accommodation and Labor Supply When a whole practice model is the interven- of Disabled Workers tion: developing fidelity evaluation components using program theory-driven science for an integrative medicine primary care clinic Hoffmann, Dick EP-66228 Special warfare: the missing middle in U.S. Hermann, Richard C. coercive options EP-50453 Quality Indicators for International Benchmark- ing of Mental Health Care Hoover, Matthew RGSD-327 It Takes a Village: Network Effects on Rural Herndon, Jill Boylston Education in Afghanistan EP-51641 Anti-Inflammatory Medication Adherence, EP-66215 Healthcare Utilization and Expenditures Among Social, relational and network determinants of Medicaid and Children's Health Insurance Pro- unprotected anal sex and HIV testing among men gram Enrollees with Asthma who have sex with men in Beirut, Lebanon

EP-66215 PRGS Graduate School Ph.D. in Policy Analy- Herschell, Amy D. sis Handout EP-50426 Evaluation of an Implementation Initiative for Embedding Dialectical Behavior Therapy in Com- munity Settings Howe, Chanelle J. EP-50556 Education and coronary Heart disease risk: potential mechanisms such as literacy, perceived Hill, Matthew J. constraints, and depressive symptoms RB-9776 Effects of Employer Health Insurance on Dis- ability Insurance Claiming Hu, Yisong EP-66144 Cohort profile: the China health and retirement longitudinal study (CHARLS) 33

Huckfeldt, Peter J. Isley, Steven C. EP-51657 RGSD-331 Effects of Medicare Payment Reform: Evi- The Political Sustainability of Carbon Control dence from the Home Health Interim and Pro- Policies in an Evolutionary Economics Setting spective Payment Systems

Jackson, Brian A. Hunt, Priscillia RR-380-OSD RR-531-NIJ How Do We Know What Information Shar- Evaluation of the Shreveport Predictive Polic- ing Is Really Worth? Exploring Methodologies to ing Experiment Measure the Value of Information Sharing and Fusion Efforts

RR-569-NIJ Hunter, Sarah B. Police Department Investments in Information RR-572-HBI Technology Systems: Challenges Assessing Their Substance Use Treatment and Reentry (STAR) Payoff Program: Final Evaluation Report CT-411 EP-51697 Applying Lessons Learned from Past Re- Continuous Quality Improvement (CQI) in Ad- sponse Operations to Strengthening National diction Treatment Settings: Design and Interven- Preparedness tion Protocol of a Group Randomized Pilot Study CT-411/1 Applying Lessons Learned from Past Re- sponse Operations to Strengthening National Hurd, Michael D. Preparedness: Addendum CT-406 The Monetary Costs of Dementia in the United States James, A. Everette RB-9792 EP-50431 More Americans May Be Adequately Prepared Implications of New Insurance Coverage for for Retirement Than Previously Thought Access to Care, Cost-Sharing, and Reimburse- ment

Hussey, Peter S. RB-9795 Janta, Barbara Continuity of Care and the Cost of Treating RR-554-EC Chronic Disease Caring for children in Europe: How childcare, parental leave and flexible working arrangements interact in Europe 34

RR-555-EC Jensen, Carl Social protection during the economic crisis: EP-51750 How do changes to benefits systems affect chil- Working smarter on cold cases: identifying fac- dren? tors associated with successful cold case investigations

Jaycox, Lisa H. EP-66206 Johnston, Jennifer M. Effects of trauma on students: early interven- EP-66222 tion through the cognitive behavioral intervention A systematic scoping review of complementary for trauma in schools and alternative medicine mind and body practices to improve the health of veterans and military personnel

Jena, Anupam B. EP-51648 Mortality Among High-Risk Patients with Acute Johnston, Patrick B. Myocardial Infarction Admitted to U.S. Teaching- CT-419 Intensive Hospitals in July: A Retrospective Ob- Countering ISIL’s Financing servational Study EP-51839 Aid under fire: development projects and civil conflict Jenkins, Brian Michael CF-317 Identifying Enemies Among Us: Evolving Ter- rorist Threats and the Continuing Challenges of Jones, Seth G. Domestic Intelligence Collection and Information CT-403 Sharing The Extremist Threat to the U.S. Homeland

PE-115-RC RR-637-OSD The Dynamics of Syria's Civil War A Persistent Threat: The Evolution of al Qa'ida and Other Salafi Jihadists PE-123-RC Brothers Killing Brothers: The Current Infight- CT-403/1 ing Will Test al Qaeda's Brand The Extremist Threat to the U.S. Homeland: Addendum PE-130-RC When Jihadis Come Marching Home: The Ter- CT-408 rorist Threat Posed by Westerners Returning from Counterterrorism and the Role of Special Op- Syria and Iraq erations Forces

CT-414 Jihadist Sanctuaries in Syria and Iraq: Implica- tions for the United States 35

Jones, Spencer S. and Human Services National Action Plan to Pre- EP-50444 vent Healthcare Associated Infections: Roadmap Health Information Technology: An Updated to Elimination Systematic Review with a Focus on Meaningful Use EP-51693 The National Response for Preventing Health- care-Associated Infections: Research and Adop- tion of Prevention Practices Juday, Timothy EP-50482 HIV care providers emphasize the importance of the Ryan White Program for access to and Kanouse, David E. quality of care EP-50525 Sexual minorities in England have poorer EP-51759 health and worse health care experiences: a na- Early HIV treatment led to life expectancy tional survey gains valued at $80 billion for people infected in 1996-2009

Kapteyn, Arie RR-858-RC Kaffine, Daniel T. Methodology of the RAND Continuous 2012 EP-66115 Presidential Election Poll Did California's hand-held cell phone ban reduce accidents?

Karam, Rita EP-50539 Kahn, Jeremy M. Predicting child development knowledge and EP-66180 engagement of Moroccan parents Barriers and facilitators to pediatric emergency telemedicine in the United States

Karoly, Lynn A. WR-1051-DOEL Kahn, Katherine L. Validation Studies for Early Learning and Care EP-51683 Quality Rating and Improvement Systems: A Re- Introduction: Taking National Action to Prevent view of the Literature and Eliminate Healthcare-Associated Infections EP-66240 EP-51682 Improving QRISs through the use of existing The National Response for Preventing Health- data: a virtual pilot of the California QRIS care-Associated Infections: Data and Monitoring

EP-51685 Approach for Conducting the Longitudinal Pro- gram Evaluation of the U.S. Department of Health 36

Kavanagh, Jennifer Kenyon, Chen C. TL-133-AF EP-51715 A Database of U.S. Security Treaties and Rehospitalization for Childhood Asthma: Tim- Agreements ing, Variation, and Opportunities for Intervention

RR-736-AF U.S. Security-Related Agreements in Force Since 1955: Introducing a New Database Khodyakov, Dmitry EP-51734 What does the evidence really say about culture change in nursing homes? Kaye, Dalia Dassa PE-122-RC The Days After a Deal with Iran: Regional Re- sponses to a Final Nuclear Agreement Kilburn, M. Rebecca CT-407 Evidence on Home Visiting and Suggestions for Implementing Evidence-Based Home Visiting Kaysen, Debra L. Through MIECHV EP-50471 Impact of daily assessments in distress and CT-407/1 PTSD symptoms in trauma-exposed women Evidence on Home Visiting and Suggestions for Implementing Evidence-Based Home Visiting Through MIECHV: Addendum

Keller, Kirsten M. CT-407/1 RR-581-AF Programs That Work, from the Promising Prac- Promoting Airmen with the Potential to Lead: A tices Network on Children, Families and Commu- Study of the Air Force Master Sergeant Promotion nities System

Kilmer, Beau Kelly, Terrence K. RR-534-ONDCP RR-474-A What America's Users Spend on Illegal Drugs, The U.S. Army in Asia, 2030–2040 2000–2010

RB-9802-A RR-534/1-ONDCP Developing a U.S. Strategy for Dealing with What America's Users Spend on Illegal Drugs, China--Now and into the Future 2000–2010: Technical Report

EP-51864 RB-9770-ONDCP Tailored deterrence: strategic context to guide How Big is the U.S. Market for Illegal Drugs? Joint Force 2020 37

Kooreman, Peter EP-51702 EP-66184 Losing Your "License to Drink": The Radical Probability perceptions and preventive health South Dakota Approach to Heavy Drinkers Who care Threaten Public Safety

RR-735-SFSC Does San Francisco’s Community Justice Krull, Heather Center Reduce Criminal Recidivism? RR-290-WWP Health and Economic Outcomes in the Alumni EP-51731 of the Wounded Warrior Project: 2010–2012 Criminal justice costs of prohibiting marijuana in California

EP-66109 Krull, Jennifer L. Cocaine's fall and marijuana's rise: questions EP-66198 and insights based on new estimates of con- An examination of the bidirectional relationship sumption and expenditures in U. S. drug markets between functioning and symptom levels in patients with anxiety disorders in the CALM study

Kim, Yool CT-413 Kumar, Krishna B. Risks and Mitigation Options Regarding Use CF-327-PRGS of Foreign Components in U.S. Launch Vehicles The Power of Innovation to Drive Inclusive Growth: Proceeds from the 2014 L.A. Policy Sym- posium

King, Sarah EP-50527 RR-698-DEFRA University R&D funding strategies in a chang- The Health Risks of Bathing in Recreational ing federal funding environment Waters: A Rapid Evidence Assessment of Water Quality and Gastrointestinal Illness

Kups, Sarah RGSD-326 Klimas, Joshua Topics in Migration Research RR-417-1-A Assessing the Army’s Active-Reserve Compo- nent Force Mix Lai, Julie EP-51852 Comparative effectiveness of shock wave litho- Knutson, Kristen L. tripsy and ureteroscopy for treating patients with EP-66187 kidney stones Implications of sleep and energy drink use for health disparities 38

Lambie, Laura Lavelle, Tara A. EP-50449 EP-50458 Economic Burden of Childhood Autism Spec- trum Disorders

EP-50514 Landrum, Mary Beth Costs and benefits of treating maternal de- EP-51804 pression Physicians' propensity to discuss prognosis is associated with patients' awareness of prognosis for metastatic cancers Leonard, Robert S. RR-477-AF Air Force Major Defense Acquisition Program Langley, Audra Cost Growth Is Driven by Three Space Programs EP-51694 and the F-35A: Fiscal Year 2013 President's Bud- Trauma Exposure and Mental Health Problems get Selected Acquisition Reports Among School Children 15 Months Post-Hurri- cane Katrina

EP-66213 Lesser, Lenard I. Early intervention for abused children in the EP-51668 school setting Changing Eating Habits for the Medical Pro- fession

Lanjouw, Peter EP-51742 Lewis, Terri Small area estimation-based prediction meth- EP-51823 ods to track poverty: validation and applications Prevalence and correlates of firearm ownership in the homes of fifth graders: Birmingham, AL, Houston, TX, and Los Angeles, CA

LaTourrette, Tom RR-611-CCRMC The Impact on Federal Spending of Allowing Lewith, George the Terrorism Risk Insurance Act to Expire EP-66141 Research methodology: choices, logistics, and challenges

Lau, Christopher RGSD-328 New Medical Technology Development and Libicki, Martin C. Diffusion: Policy Challenges and Considerations RR-430 Hackers Wanted: An Examination of the Cy- bersecurity Labor Market 39

RR-567-OSD Randomized Nutrition Program in the Presence of Ramifications of DARPA’s Programming Com- Crossover putation on Encrypted Data Program EP-51754 Factors associated with intention to conceive and its communication to providers among HIV Lichten, Catherine A clients in Uganda RR-506-DH Venture Research: Fostering trust and freedom in research funding Liu, Jodi L. RR-390-RC Small Ideas for Saving Big Health Care Dollars Liepman, Andrew M. PE-129-RC Alternative Futures for Syria: Regional Implica- tions and Challenges for the United States Lombardero, Anayansi EP-51698 Prevalence and Correlates of Smoking Status Among Veterans Affairs Primary Care Patients Light, Thomas with Probable Major Depressive Disorder EP-50616 Preparing state transportation agencies for an uncertain energy future Loredo, Elvira N. RR-360-SOCOM Authorities and Options for Funding USSO- Lim, Nelson COM Operations RR-495-AF Improving Demographic Diversity in the U.S. RR-369-A Air Force Officer Corps Methods for Identifying Part Quality Issues and Estimating Their Cost with an Application Us- ing the UH-60 CF-326 The 2014 Technology Summit for Victim Ser- vice Providers: Identifying Challenges and Pos- sible Solutions Lorell, Mark A. RB-9759-AF The Department of Defense Should Avoid a Joint Acquisition Approach to Sixth-Generation Linnemayr, Sebastian Fighter EP-51710 Consumption Smoothing and HIV/AIDS: The Case of Two Communities in South Africa

EP-51713 Almost Random: Evaluating a Large-Scale 40

Lorenz, Karl Lynch, Kristin F. EP-50533 RR-259-AF Community-partnered collaboration to build Implementation Actions for Improving Air Force an integrated palliative care clinic: the view from Command and Control Through Enhanced Agile urology Combat Support Planning, Execution, Monitoring, and Control Processes

RR-261-AF Loughran, David S. An Operational Architecture for Improving Air RR-284-OSD Force Command and Control Through Enhanced Why Is Veteran Unemployment So High? Agile Combat Support Planning, Execution, Moni- toring, and Control Processes

Lu, Hui RR-641-DEFRA Madden, Dan Estimating the value of mobile telephony in RR-828-A mobile network not-spots Special Warfare: The Missing Middle in U.S. Coercive Options RR-641/1-DEFRA Estimating the value of mobile telephony in mobile network not-spots: Summary Maestas, Nicole WR-1029 Disability Insurance and Health Insurance Luft, Harold S. Reform: Evidence from Massachusetts EP-51845 Public reporting of provider performance at RB-9769 a crossroads in the United States: summary of Effects of Health Care Reform on Disability current barriers and recommendations on how to Insurance Claiming move forward WR-1063 The Effect of Population Aging on Economic Growth Lundberg, Russell EP-51822 Why changes in price matter when thinking about marijuana policy: a review of the literature Maglione, Margaret A. on the elasticity of demand RB-9799 U.S. Vaccines Deemed Extremely Safe, with Serious Side Effects Rare Among Children

Luoto, Jill E. WR-1039 Mobile phones, rent-to-own payments & water filters: Evidence from Kenya 41

Mahrer, Nicole E. Mare, Robert D. EP-66211 EP-66121 Cost-benefit analysis of a preventive interven- The schooling of offspring and the survival of tion for divorced families: reduction in mental parents health and justice system service use costs 15 years later Marsh, Terry EP-51806 Involving community stakeholders to increase park use and physical activity Malchiodi, Alessandro RGSD-325 Three Essays on Education Policy: Empirical Analyses of the Challenges and Opportunities with For-Profit Colleges, Military Enlistment and Marshall, Grant N. Immigration EP-51865 Are mental disorders more common in urban than rural areas of the United States?

EP-66138 Manoli, Day WR-1068 A comparison of Cambodian-American ado- Policy Variation, Labor Supply Elasticities, and lescent substance use behavior to national and a Structural Model of Retirement local norms

Manski, Richard J. Marshall, Martin EP-50559 EP-50452 Response error in reporting dental coverage OECD Health Care Quality Indicator Project: by older Americans in the Health and Retirement The Expert Panel on Primary Care Prevention Study and Health Promotion

Marcellino, William Martin, Laurie T. EP-51639 RR-487/3-OSD Talk Like a Marine: USMC Linguistic Accultura- A Systematic Process to Facilitate Evidence- tion and Civil-Military Argument Informed Decisionmaking Regarding Program Expansion: The RAND Toolkit, Volume 3

Marcus, J. Scott EP-51690 RR-782-COHF How to Build a Ubiquitous EU Digital Society Barriers to Enrollment in Health Coverage in Colorado EP-51692 Entertainment X.0 to Boost Broadband De- ployment 42

Martin, Leslie A. Matheny, Jason WR-1038 EP-51662 In with the Big, Out with the Small: Removing Incentives for Biodefense Countermeasure Small-Scale Reservations in India Development

EP-51662 Answers for an Agile Military: Project AIR Martin, Linda G. FORCE flyer EP-51833 Modeling disability trajectories and mortality of the oldest-old in China Matheny, Jason EP-51840 EP-51662 Declines in late-life disability: the role of early - Leveraging Partnerships to Enhance the Im- and mid-life factors pact of Principal-Preparation Programs

Martinez, Homero Matteis, Sara de EP-66119 EP-50468 Effect of supplementation with ferrous sulfate A regression model for risk difference estima- or iron bis-glycinate chelate on ferritin concen- tion in population-based case-control studies tration in Mexican schoolchildren: a randomized clarifies gender differences in lung cancer risk of controlled trial smokers and never smokers

Martorell, Paco Mattke, Soeren RR-342-OSD RR-327-DOL Effects of Military Service on Earnings and Final Report: Evaluation of Tools and Metrics Education Revisited: Variation by Service Dura- to Support Employer Selection of Health Plans tion, Occupation, and Civilian Unemployment RB-9744-DOL EP-66227 Do Workplace Wellness Programs Save Em- Percent plans, automatic admissions, and col- ployers Money? lege outcomes EP-50451 The OECD Health Care Quality Indicators Project: History and Background Masek, Bruce J. EP-50448 EP-51758 Reporting Quality of Nursing Home Care to Clinicians' utilization of child mental health Consumers: The Maryland Experience telephone consultation in primary care: findings from Massachusetts RR-600-AETNA The Role of Health Care Transformation for the Chinese Dream: Powering Economic Growth, Promoting a Harmonious Society 43

McCauley, Heather L. RR-600-1-AETNA EP-66192 The Role of Health Care Transformation for Early menarche and childhood adversities in a the Chinese Dream: Powering Economic Growth, nationally representative sample Promoting a Harmonious Society

RR-729-GECO Quantitative Evaluation of the Impact of the McCombs, Jennifer Sloan Healthy Communities Initiative in Cincinnati RR-815-WF Ready for Fall? Near-Term Effects of Voluntary EP-50467 Summer Learning Programs on Low-Income Stu- Do workplace wellness programs reduce med- dents' Learning Opportunities and Outcomes ical costs? evidence from a Fortune 500 company

McCreath, Heather Mattock, Michael G. EP-66123 RR-530-A Randomized clinical trial of an emergency Making the Reserve Retirement System department observation syncope protocol versus Similar to the Active System: Retention and Cost routine inpatient admission Estimates

RR-764-OSD Toward Improved Management of Officer McGovern, Geoffrey Retention: A New Capability for Assessing Policy RR-486-ICJ Options Who Pays for Justice? Perspectives on State Court System Financing and Governance

RR-791-NIMSP Mattox, Teryn Shining a Light on State Campaign Finance: RR-797 An Evaluation of the Impact of the National Insti- Evidence-Based Practices in Child and Family tute on Money in State Politics Services

McGrath, Cecile Hoareau McCaffrey, Daniel F. RR-725-EC TL-136-NIDA The international dimension of research and Toolkit for Weighting and Analysis of Non- innovation cooperation addressing the grand equivalent Groups: A Tutorial for the TWANG SAS challenges in the global context Macros

McGuire, Anthony W. EP-51667 Depression Screening: Utility of the Patient Health Questionnaire in Patients with Acute Coro- nary Syndrome 44

McLaren, Christopher F. Medeiros, Evan S. RGSD-330 MG-850/2-AF Reducing the Economic Burden of Work-Re- China's International Behavior: Chinese translated Injuries lation (traditional characters)

McLoughlin, Vivienne Meeker, Daniella EP-50445 EP-51716 Selecting Indicators for Patient Safety at the Nudging Guideline-Concordant Antibiotic Pre- Health System Level in OECD Countries scribing: A Randomized Clinical Trial

EP-66235 Understanding data requirements of retrospec- McNamara, Peggy tive studies EP-51816 Postscript: research agenda to guide the next generation of public reports for consumers Mehrotra, Ateev CT-409 Expanding the Use of Telehealth: Promise and McNerney, Michael J. Potential Pitfalls RR-350-A Assessing Security Cooperation as a Preven- CT-409/1 tive Tool Expanding the Use of Telehealth: Promise and Potential Pitfalls: Addendum RR-605-DOS New Security and Justice Sector Partnership Models: Implications of the Arab Uprisings Mendel, Peter RB-9779-DOS EP-51695 A New Approach to Security and Justice Sec- The National Response for Preventing Health- tor Assistance: An Enhanced Partnership Plan- care-Associated Infections: Infrastructure Devel- ning Model opment

EP-51686 The National Response for Preventing Health- Meadows, Sarah O. care-Associated Infections: System Capacity and RR-132-AF Sustainability for Improvement The Association Between Base-Area Social and Economic Characteristics and Airmen's Out- EP-51684 comes Lessons learned and future directions: the national response for preventing healthcare-associated infections 45

Mendeloff, John Millard, Jeremy EP-50462 EP-50554 Using OSHA Inspection Data to Analyze Res- Bringing online in line: contribution to an im- pirator Protection Program Compliance pact assessment for the Delegated Act to implement the online provisions of the revised Energy EP-50460 Related Products Directive States with Low Non-Fatal Injury Rates Have High Fatality Rates and Vice-Versa

Miller, Laura L. RR-695-AF Menthe, Lance Information and Communication Technologies RR-276-AF to Promote Social and Psychological Well-Being The Effectiveness of Remotely Piloted Aircraft in the Air Force: A 2012 Survey of Airmen in a Permissive Hunter-Killer Scenario

Miller, Paul D. Meredith, Lisa S. PE-120-OSD EP-66116 Democracy in Afghanistan: The 2014 Election Huddle up! the adoption and use of structured and Beyond team communication for VA medical home implementation PE-126-OSD Getting to Negotiations in Syria: The Shadow of the Future in the Syrian Civil War

Miani, Celine RR-348-EC Parents at work: Men and women participat- Miller, Trey ing in the labour force: Short Statistical Report EP-66139 No. 2 Measuring value-added in higher education: possibilities and limitations in the use of adminis- RR-544-PI trative data Health and Healthcare: Assessing the Real World Data Policy Landscape in Europe EP-66140 In-state college tuition policies for undocu- RR-622-KBV mented immigrants: implications for high school Best practice: Medical training from an inter- enrollment among non-citizen Mexican youth national perspective

Mills, Melinda Miles, Jeremy N. V. RR-185-EC EP-50548 Use of childcare in the EU Member States and The effects of mental health symptoms and progress towards the Barcelona targets: Short marijuana expectancies on marijuana use and Statistical Report No. 1 consequences among at-risk adolescents 46

RR-363-EC MG-1148/2-1-KRG Gender inequalities in the school-to-work tran- The Future of Health Care in the Kurdistan sition in Europe: Short Statistical Report No. 4 Region—Iraq: Toward an Effective, High-Quality System with an Emphasis on Primary Care (Kurd- RR-462-EC ish-language version) Gender equality in the workforce: Reconciling work, private and family life in Europe EP-66142 Using exercises to improve public health preparedness in Asia, the Middle East and Africa

Mills, Patrick RR-337-AF Balancing Agile Combat Support Manpower to Moore, Nancy Y. Better Meet the Future Security Environment RR-410-OSD Small Business and Strategic Sourcing: Les- sons from Past Research and Current Data

Mindry, Deborah RR-614-OSD EP-51712 Findings from Existing Data on the Depart- Fertility Desires Among HIV-infected Men and ment of Defense Industrial Base Women in Los Angeles County: Client Needs and Provider Perspectives

Moreno, Candice EP-66104 Mohanan, Manoj Well-child care clinical practice redesign for EP-50427 serving low-income children Effect of Chiranjeevi Yojana on Institutional De- liveries and Neonatal and Maternal Outcomes in Gujarat, India: A Difference-In-Differences Analy- sis Morgan Jones, Molly RR-512-SGC The Structural Genomics Consortium: A knowledge platform for drug discovery Moore, Melinda MG-1148-1-KRG RR-596-RE The Future of Health Care in the Kurdistan Mapping Pathways: Community-driven strate- Region—Iraq: Toward an Effective, High-Quality gies for the use of antiretrovirals as prevention: System with an Emphasis on Primary Care United States Workshop Report RR-512/1-SGC The Structural Genomics Consortium: A knowledge platform for drug discovery: A summary MG-1148/1-1-KRG The Future of Health Care in the Kurdistan Region—Iraq: Toward an Effective, High-Quality System with an Emphasis on Primary Care (Ara- bic-language version) 47

RR-512/1-SGC Sexual Assault and Sexual Harassment in the EP-50551 U.S. Military: Top-Line Estimates for Active-Duty The relationship between influenza vaccina- Service Members from the 2014 RAND Military tion habits and location of vaccination Workplace Study

Mullen, Kathleen J. Morgan Jones, Molly EP-51843 RR-512/1-SGC Disability insurance and health insurance re- Sexual Assault and Sexual Harassment in the form: evidence from Massachusetts U.S. Military: Volume 1. Design of the 2014 RAND Military Workplace Study

RR-512/1-SGC Mundell, Benjamin F. Sexual Assault and Sexual Harassment in the EP-50435 U.S. Military: Top-Line Estimates for Active-Duty US Military Primary Care: Problems, Solutions, Coast Guard Members from the 2014 RAND Mili- and Implications for Civilian Medicine tary Workplace Study

Myers, Ursula S. Mosca, Ilaria EP-66137 EP-51832 The role of alcohol expectancies in drinking Who takes up free flu shots? Examining the behavior among women with alcohol use disorder effects of an expansion in coverage and comorbid posttraumatic stress disorder

Motala, Aneesa Nader, Alireza EP-66224 RR-616 Usage and effect of health information ex- Iran’s Influence in Afghanistan: Implications for change: a systematic review the U.S. Drawdown

PE-124-RC The Days After a Deal with Iran: Continuity and Mulcahy, Andrew W. Change in Iranian Foreign Policy PE-121-SDS The 340B Prescription Drug Discount Pro- gram: Origins, Implementation, and Post-Reform Future Najnin, Nusrat EP-51743 PE-127-SANI What point-of-use water treatment products The Cost Savings Potential of Biosimilar Drugs do consumers use? Evidence from a randomized in the United States controlled trial among the urban poor in Bangla- desh 48

Nataraj, Shanthi Newberry, Sydne RR-543-OSD EP-66167 Options for Department of Defense Total Comparative effectiveness of pharmacologic Workforce Supply and Demand Analysis: Poten- treatments to prevent fractures: an updated sys- tial Approaches and Available Data Sources tematic review

RR-576-A The Future of the Army’s Civilian Workforce: Comparing Projected Inventory with Anticipated Nghiem, Tuyen Requirements and Estimating Cost Under Differ- EP-51751 ent Personnel Policies An exploration of how perceptions of the risk of avian influenza in poultry relate to urbanization in Vietnam

Needleman, Jack EP-51675 Nurse Staffing in Hospitals: Is There a Busi- Ngo, Victoria K. ness Case for Quality? EP-66101 INtegration of DEPression Treatment into HIV EP-51669 care in Uganda (INDEPTH-Uganda): study proto- Measuring Hospital Quality: Can Medicare col for a randomized controlled trial Data Substitute for All-Payer Data?

EP-51676 Nurse-Staffing Levels and the Quality of Care Nicolucci, Antonio in Hospitals EP-50450 Selecting Indicators for the Quality of Diabetes Care at the Health Systems Level in OECD Coun- tries Negrusa, Sebastian EP-51661 Gone to War: Have Deployments Increased Divorces? Nolte, Ellen RR-728-DH EP-51800 The changing hospital landscape: An explora- Home front: post-deployment mental health tion of international experiences and divorces RR-899-DH International variation in drug usage: An ex- Nelson, Bergen B. EP-66210 ploratory analysis of the "causes" of variation Preventing hospitalizations in children with medical complexity: a systematic review Noyes, Katia EP-51677 What Is the Risk of Developing Parkinsonism Following Neuroleptic Use? 49

Nuckols, Teryl K. Oguz, Mustafa EP-51670 RGSD-341 Opioid Prescribing: A Systematic Review and Improving Turkish-Iraqi Border Security: An Critical Appraisal of Guidelines for Chronic Pain Agent-Based Modeling and Simulation Approach

Nuys, Karen E. van Ojo, Ifelayo P. EP-51705 EP-51824 Practice Economics and the Decision to Pre- Does stewardship make a difference in the scribe Oral Oncolytics quality of care? Evidence from clinics and pharmacies in Kenya and Ghana

O'Connell, Caolionn RR-570-A Okeke, Edward N. Measuring and Retaining the U.S. Army's De- EP-51659 ployment Experience Brain Drain: Do Economic Conditions "Push" Doctors Out of Developing Countries?

O'Mahony, Angela PT-130-USSOCOM Ong, Michael SOF Partner Assessment: Introduction to EP-66219 Country Characteristics 12-month outcomes of community engagement versus technical assistance to implement PT-130/1-USSOCOM depression collaborative care: a partnered, clus- SOF Partner Assessment: Measuring Foreign ter, randomized, comparative effectiveness trial Relations

PT-130/2-USSOCOM SOF Partner Assessment: Measuring State Osburg, Jan Stability RR-387-A Assessing Locally Focused Stability Opera- PT-130/3-USSOCOM tions SOF Partner Assessment: Measuring State Stability RB-9784-A Best Practices for Assessing Locally Focused PT-130/3-USSOCOM Stability Operations Challenges in U.S. National Security Policy: A Festschrift Honoring Edward L. (Ted) Warner RB-9784-A CT-420 JIE Making a Difference Handout The Role of Maritime and Air Power in DoD’s Osilla, Karen Chan Third Offset Strategy RR-755-CMHSA A Case Study Evaluating the Fidelity of Sui- cide Prevention Workshops in California 50

EP-66202 Pangilinan, Maria Longitudinal family effects on substance use EP-66110 among an at-risk adolescent sample Using claims data to generate clinical flags predicting short-term risk of continued psychiatric hospitalizations

Ostwald, Jordan EP-51861 Terrorism and the labor force: evidence of an Parker, Andrew M. effect on female labor force participation and the EP-51717 labor gender gap Evaluating Simulation-Derived Scenarios for Effective Decision Support

EP-50534 Pacula, Rosalie Liccardo Social network effects of nonlifesaving early- EP-51650 stage breast cancer detection on mammography Marijuana Liberalization Policies: Why We rates Can't Learn Much from Policy Still in Motion

EP-51649 Natural Experiments in a Complex and Dy- Patruni, Bhanu namic Environment: The Need for a Measured EP-50464 Assessment of the Evidence Public Perception of Security and Privacy: As- sessing Knowledge, Collecting Evidence, Trans- lating Research Into Action

Palladino, Dianna K. EP-66176 Relationships and health among emerging Paul, Christopher adults with and without Type 1 diabetes RR-548/1 Mexico Is Not Colombia: Alternative Histori- cal Analogies for Responding to the Challenge of Violent Drug-Trafficking Organizations Pane, John F. WR-1050-DEIES RR-548/2 Addendum to Effectiveness of Cognitive Tutor Mexico Is Not Colombia: Alternative Histori- Algebra I at Scale cal Analogies for Responding to the Challenge of Violent Drug-Trafficking Organizations, Support- WR-1061-BMGF ing Case Studies Methods Used to Estimate Achievement Ef- fects in Personalized Learning Schools RR-780-A The Other Quiet Professionals: Lessons for Future Cyber Forces from the Evolution of Special Forces

EP-66181 A promising thaw 51

Paves, Andrew P. Persell, Stephen D. EP-51847 EP-51644 Comparing perceived public stigma and per- Use of Behavioral Economics and Social sonal stigma of mental health treatment seeking Psychology to Improve Treatment of Acute Re- in a young adult sample spiratory Infections (BEARI): Rationale and De- sign of a Cluster Randomized Controlled Trial [1rc4ag039115-01] - Study Protocol and Baseline Practice and Provider Characteristics Pedersen, Eric R. EP-66169 Study design to develop and pilot-test a web intervention for partners of military service mem- Peskin, Melissa F. bers with alcohol misuse EP-66111 Daily violent video game playing and depres- EP-66170 sion in preadolescent youth Proximal and distal social influence on alcohol consumption and marijuana use among middle school adolescents Peyronnin, Natalie EP-66174 EP-51645 Alcohol and marijuana use in middle school: Louisiana's 2012 Coastal Master Plan: Over- comparing solitary and social-only users view of a Science-Based and Publicly Informed Decision-Making Process EP-66177 The effects of purchasing alcohol and marijuana among adolescents at-risk for future substance use Pierson, Ashley RR-289-CSM EP-66177 Early and School-Age Care in Santa Monica: RAND Corporation Maritime Programs: Com- Current System, Policy Options, and Recommen- mand, Control, Communications, Computers, and dations Intelligence (C4I) RR-289/1-CSM Early and School-Age Care in Santa Monica: Current System, Policy Options, and Recommen- Peltz, Eric dations: Executive Summary RR-398-OSD DoD Depot-Level Reparable Supply Chain RGSD-336 Management: Process Effectiveness and Oppor- What Makes a Successful Principal? Incorpo- tunities for Improvement rating School Principal Background in State and District Policy

RGSD-336 Perlman, Michal Congressional Briefing flyer: Correctional Edu- EP-50541 cation: How Effective Is It and What Can We Do to How Moroccan mothers and fathers view child Make It Better? development and their role in their children's education 52

Pierson, Ashley Powell, David RGSD-336 WR-1028 Congressional Briefing flyer: Hidden Heroes: Medical Care Spending and Labor Market America's Military Caregivers Outcomes: Evidence from Workers' Compensa- tion Reforms RGSD-336 Congressional Briefing flyer WR-1032 Moral Hazard and Adverse Selection in Private RGSD-336 Health Insurance Congressional Briefing flyer: The Future of the Terrorism Risk Insurance Act: Expiration, Reau- WR-1028-1 thorization, Modification Medical Care Spending and Labor Market Outcomes: Evidence from Workers' Compensa- RGSD-336 tion Reforms Congressional Briefing flyer: A New Way to Pay for Transportation: Exporing a Shift from Fuel EP-50537 Taxes to Mileage-Based User Fees Assessing the effects of medical marijuana laws on marijuana use: the devil is in the details RGSD-336 Congressional Briefing flyer: RAND Public Policy Analysis Workshop Präg, Patrick RGSD-336 RR-365-EC Congressional Briefing flyer: Congressional Family-related working schedule flexibility Options and Their Likely Consequences for a across Europe: Short Statistical Report No. 6 Nuclear Deal with iran

Prasad, Vinay Popovici, Ioana EP-66103 EP-51651 Long-term effects of the 2003 ACGME resi- Cannabis Use and Antisocial Behavior Among dent duty hour reform on hospital mortality Youth

Price, Rebecca Anhang Popper, Steven W. RR-657-CMS EP-51646 Hospice Experience of Care Survey: Develop- Strategic Issues Facing Transportation ment and Field Test

Porche, Isaac R. III Pulido, Esmeralda RR-315-NAVY EP-51817 Data Flood: Helping the Navy Address the Ris- Community-partnered research conference ing Tide of Sensor Information model: the experience of community partners in care study 53

Pulido, Jose E. EP-66182 RR-438/4-CMHSA Daily mean temperature and clinical kidney Evaluating the California Mental Health Ser- stone presentation in five U. S. metropolitan ar- vices Authority's Suicide Prevention Initiative: Year eas: a time-series analysis 1 Findings

RR-559-OSD Developing a Research Strategy for Suicide Prevention in the Department of Defense: Status EP-66200 of Current Research, Prioritizing Areas of Need, Use of and regional variation in initial CT im- and Recommendations for Moving Forward aging for kidney stones RB-9764-TEDF Military Caregivers: Who are They? And Who Is Supporting Them? Qaseem, Amir EP-51813 RR-499/1-TEDF Design and use of performance measures to Hidden Heroes: America's Military Caregivers decrease low-value services and achieve cost- — Executive Summary conscious care RB-9764/1-TEDF Supporting Military Caregivers: Options for Congress Quigley, Denise D. EP-66149 RB-9764/2-TEDF Use of CAHPS patient experience surveys to Military Caregivers in the Workplace assess the impact of health care innovations RB-9764/3-TEDF Supporting Military Caregivers: The Role of Health Providers Radovic, Ana EP-50430 RB-9764/4-TEDF Primary Care Providers' Initial Treatment Deci- Support Resources for Military Caregivers sions and Antidepressant Prescribing for Adoles- cent Depression PT-124-TEDF Key Facts and Statistics from the RAND Mili- tary Caregivers Study RR-682-CMHSA Ramchand, Rajeev Racial and Ethnic Differences in Exposure RB-9727-CMHSA to Suicide Prevention Messaging, Confidence in What Has the Suicide Prevention Initiative One's Ability to Intervene with Someone at Risk, Done So Far? Year 1 Findings and Resource Preferences

RR-499-TEDF RR-754-CMHSA Hidden Heroes: America's Military Caregivers Language Differences in California Adults' Ex- posure to Suicide Prevention Messaging, Confi- dence in One's Ability to Intervene with Someone at Risk, and Resource Preferences 54

CT-421 Reeve, Bryce B. Hidden Heroes: Caregivers to America’s Ill, EP-51671 Injured, and Wounded Service Members and ISOQOL Recommends Minimum Standards Veterans for Patient-Reported Outcome Measures Used in Patient-Centered Outcomes and Comparative EP-51747 Effectiveness Research Estimating the causal effects of cumulative treatment episodes for adolescents using marginal structural models and inverse probability of treatment weighting Resnick, Adam C. RR-125-A EP-51747 Sourcing and Global Distribution of Medical Spotlight on 2013: Building trust in policymak- Supplies ing RR-257-A EP-51747 How Deployments Affect the Capacity and Fact Sheet: European Platform for Investing in Utilization of Army Treatment Facilities Children

Reynolds, Kerry A. Raven, Maria Catherine EP-50538 EP-51663 Relations of behavioral autonomy to health Vulnerable Patients' Perceptions of Health outcomes among emerging adults with and with- Care Quality and Quality Data out type 1 diabetes

EP-66241 Cognitive adaptation theory as a predictor of Reagan, Julie adjustment to emerging adulthood for youth with EP-66133 and without type 1 diabetes The association of state legal mandates for data submission of central line–associated bloodstream infections in neonatal intensive care units with process and outcomes measures Ridgeway, Greg TL-136/1-NIDA Toolkit for Weighting and Analysis of Non- Reding, Anais RR-251-WODC equivalent Groups: A Tutorial for the R TWANG Handling ethical problems in counterterrorism: Package An inventory of methods to support ethical decisionmaking Riley, K. Jack CT-415 Strategic Planning for Border Security

CT-415/1 Strategic Planning for Border Security: Adden- dum 55

Riper, Heleen Robinson, Neil EP-50456 RR-557-ME Treatment of Comorbid Alcohol Use Disor- Information Security and Data Protection Legal ders and Depression with Cognitive-Behavioural and Policy Frameworks Applicable to European Therapy and Motivational Interviewing: A Meta- Union Institutions and Agencies Analysis RR-604-OFCOM Living Room Connected Devices: Opportuni- ties, security challenges and privacy implications Riposo, Jessie for users and industry RR-455-OSD Prolonged Cycle Times and Schedule Growth in Defense Acquisition: A Literature Review Robson, Sean RR-102-AF Psychological Fitness and Resilience: A Re- Robbert, Albert A. view of Relevant Constructs, Measures, and RR-429-AF Links to Well-Being Suitability of Missions for the Air Force Re- serve Components RR-103-AF Behavioral Fitness and Resilience: A Review RR-617-AF of Relevant Constructs, Measures, and Links to Air Force Manpower Requirements and Com- Well-Being ponent Mix: A Focus on Agile Combat Support RR-750-AF Enhancing Performance Under Stress: Stress Inoculation Training for Battlefield Airmen Roberts, Martin J. EP-66201 Common patterns of morbidity and multi-morbidity and their impact on health-related quality of Rodriguez, Daniel life: evidence from a national survey EP-51672 Identifying Walking Trips from GPS and Accel- erometer Data in Adolescent Females

Robinson, Linda RR-816-A Improving Strategic Competence: Lessons Rohr, Charlene from 13 Years of War EP-50434 Modelling Long-Distance Travel in Great Brit- RB-9814-A ain Lessons from 13 Years of War Point to a Better U.S. Strategy RR-887-DFT Evidence review of car traffic levels in Britain: A rapid evidence assessment 56

Rosenthal, Meredith B. Saavedra, Anna Rosefsky EP-50438 WR-1044-IBO Effect of a Multipayer Patient-Centered Medi- Academic Civic Mindedness and Model Citi- cal Home on Health Care Utilization and Quality: zenship in the International Baccalaureate Diplo- The Rhode Island Chronic Care Sustainability ma Programme Initiative Pilot Program

EP-66108 Practice environments and job satisfaction in Saigal, Christopher S. patient-centered medical homes EP-51809 The impact of unplanned postprocedure visits in the management of patients with urinary stones Rostker, Bernard D. RR-247-OSD Recruiting Older Youths: Insights from a New Survey of Army Recruits Saltzman, Evan RR-529 RR-440-OSD Evaluating the "Keep Your Health Plan Fix": Building Toward an Unmanned Aircraft System Implications for the Affordable Care Act Compared Training Strategy to Legislative Alternatives

Rubin, Jennifer Samaras, Constantine RR-334-OSI EP-50547 Intolerance in Western Europe: Analysis of Estimating the consumptive use costs of shale trends and associated factors natural gas extraction on Pennsylvania roadways

RR-334/1-OSI Intolerance in Western Europe: Analysis of trends and associated factors: Summary report Samek, Anya Savikhin PT-125 RAND Behavioral Finance Webinar: Anya Samek Presents "The Power of Visual Tools for Ruggeri, Kai Financial Literacy and Decision-Making" RR-362-EC Single parents and employment in Europe: Short Statistical Report No.3 Saunders, Jessica RR-287/1-MPS Effective Policing for 21st-Century Israel: Dual Ryan, Gery W. English and Hebrew edition RR-487/4-OSD A Program Manager’s Guide for Program RR-287/1-MPS Improvement in Ongoing Psychological Health RAND Europe ...on a page and Traumatic Brain Injury Programs: The RAND Toolkit, Volume 4 57

Scarpati, Mike RR-777/1-CFGNH RGSD-334 Transforming an Urban School System: Prog- Designing Efficient Systematic Reviews Using ress of New Haven School Change and New Ha- Economical Allocation, Creation and Synthesis of ven Promise Education Reforms (2010–2013)— Medical Evidence Technical Appendixes

Schank, John F. Schnaubelt, Christopher M. RR-767-AUS TL-129-A Keeping Major Naval Ship Acquisitions on Vulnerability Assessment Method Pocket Course: Key Considerations for Managing Austra- Guide: A Tool for Center of Gravity Analysis lia's SEA 5000 Future Frigate Program

Schneider, Eric C. Scharf, Deborah M. RR-654-DHHSNCH RR-546-DHHS Promoting Patient Safety Through Effective Evaluation of the SAMHSA Primary and Be- Health Information Technology Risk Management havioral Health Care Integration (PBHCI) Grant Program: Final Report (Task 13) RR-891-BLC Patient Safety in the Commonwealth of Mas- RR-670-NYSHF sachusetts: Current Status and Opportunities for An Examination of New York State’s Integrated Improvement Primary and Mental Health Care Services for Adults with Serious Mental Illness EP-66225 Reimagining quality measurement RB-9789-DHHS Improving the Physical Health of Adults with Serious Mental Illness RB-9806-NYSHF Schoeni, Robert F. Caring for Brain and Body: Integrating Care EP-51807 for Adults with Serious Mental Illness in New York Trends in disability and related chronic condi- State tions among the forty-and-over population: 1997- 2010 EP-51850 Focusing on the five A's: a comparison of EP-51831 homeless and housed patients' access to and Trends in health of older adults in the United use of pharmacist-provided smoking cessation States: past, present, future treatment EP-51831 The New York City RAND Institute: Final Re- port 1969–1976 Scherer, Ethan RGSD-335 Three Essays on Education Reform in the United States 58

Schumm, Jeremiah Seabury, Seth A. EP-66106 RR-425-CHSWC Cognitive processing therapy for veterans with Identifying Permanently Disabled Workers with comorbid PTSD and alcohol use disorders Disproportionate Earnings Losses for Supple- mental Payments

EP-50459 Schwartz, Heather L. Is Occupational Injury Risk Higher at New RR-606-DOEL Firms? Evaluation of Delaware Stars for Early Suc- cess: Year 1 Report EP-51703 The Role of Specialty Drugs in Private Sector Healthcare Spending

Schweppenstedde, Daniel EP-51704 RR-561-DH American Medical Association Impairment Regulating quality and safety of health and Ratings and Earnings Losses Due to Disability social care: International experiences

Serena, Chad C. Scobell, Andrew RR-302-A RR-525-AF Lessons Learned from the Afghan Mission China's Strategy Toward South and Central Network: Developing a Coalition Contingency Asia: An Empty Fortress Network

PT-123-USSOCOM China: The Reluctant Partner Serxner, Seth EP-51678 Testing the DMAA's Recommendations for Scott, Victoria C. S. Disease Management Program Evaluation EP-51811 Setodji, Claude Messan Quality-of-care indicators for pelvic organ pro- EP-66146 lapse: development of an infrastructure for quality Causal inference using mixture models: a word assessment of caution

Scraggs, Emily Shadel, William G. RR-789-EPIM EP-66134 Evaluation of EPIM III: Emerging insights from Development of the PROMIS® positive the evaluation so far emotional and sensory expectancies of smoking item banks

EP-66135 Development of the PROMIS® social motivations for smoking item banks 59

EP-66155 Alternative tobacco product use and smoking cessation among homeless youth in Los Angeles Sherman, Karen J. County EP-66156 Yoga vs. physical therapy vs. education for chronic low back pain in predominantly minority populations: study protocol for a randomized controlled trial Shaefer, H. Luke EP-51681 The Supplemental Nutrition Assistance Pro- EP-66158 gram and Material Hardships Among Low-Income Comparison of complementary and alterna- Households with Children tive medicine with conventional mind–body therapies for chronic back pain: protocol for the Mind–body Approaches to Pain (MAP) randomized controlled trial

Shatz, Howard J. RR-489-KRG An Assessment of the Present and Future Labor Market in the Kurdistan Region—Iraq: Im- Shier, Victoria plications for Policies to Increase Private-Sector EP-51730 Employment Transforming nurse home culture: evidence for practice and policy RR-489/1-KRG An Assessment of the Present and Future Labor Market in the Kurdistan Region—Iraq: Im- plications for Policies to Increase Private-Sector Shih, Regina A. Employment (Arabic-language version) RR-597 Improving Dementia Long-Term Care: A Policy Blueprint RR-489/2-KRG An Assessment of the Present and Future RB-9780 Labor Market in the Kurdistan Region—Iraq: Im- What to Do About Dementia? Policy Options plications for Policies to Increase Private-Sector for Crucial Long-Term Care Employment (Kurdish-language version)

Shulaker, Bianca D. EP-51655 Shekelle, Paul G. EP-51846 Partnerships for Parks and Physical Activity Reporting of context and implementation in studies of global health interventions: a pilot study

Shurkin, Michael RR-770-A France's War in Mali: Lessons for an Expedi- Shelton, Shoshana R. EP-66197 tionary Army Updated guidelines for the control of legionella in Western Pennsylvania 60

Siegel, Sari Smith, Alexandria C. EP-51687 EP-51838 Regional Interventions to Eliminate Health- Updated trends in imaging use in men diag- care-Associated Infections nosed with prostate cancer

Silberglitt, Richard Soland, Jim RR-500-OSD EP-50463 Soldier-Portable Battery Supply: Foreign De- Measuring 21st Century Competencies: Guid- pendence and Policy Options ance for Educators

Siler-Evans, Kyle Sontag-Padilla, Lisa WR-1062-BMGF RR-685-CMHSA Personalized Learning Instructional Staff Sur- CalMHSA Student Mental Health Campus- vey Results (Spring 2014) Wide Survey: 2013 Summary Report Speier, Richard H. RR-378-DTRA Penaid Nonproliferation: Hindering the Spread Sims, Carra S. of Countermeasures Against Ballistic Missile RR-471-AF Defenses Strength Testing in the Air Force: Current Pro- cesses and Suggestions for Improvements RR-743-DTRA Cruise Missile Penaid Nonproliferation: Hin- dering the Spread of Countermeasures Against Cruise Missile Defenses

RR-814-AF Air Force Personnel Research: Recommenda- tions for Improved Alignment Spillman, Brenda C. EP-51834 Trends in late-life activity limitations in the Unit- ed States: an update from five national surveys Singer, Sara J. EP-50439 Defining and Measuring Integrated Patient Care: Promoting the Next Frontier in Health Care Springgate, Benjamin Delivery EP-50503 Community engagement in disaster preparedness and recovery: a tale of two cities – Los Angeles and New Orleans

EP-50436 Development and Preliminary Validation of the Patient Perceptions of Integrated Care Survey 61

Srinivasan, Sinduja V. Stein, Bradley D. WR-1053 RB-9757-CMHSA Impact of Public Works on Household Occupa- What Has the Student Mental Health Initiative tional Choice: Evidence from NREGS in India Done So Far? Year 1 Findings

RGSD-342 RR-438/3-CMHSA Essays on Family Welfare and Indian Develop- Evaluating the California Mental Health Ser- ment Policy vices Authority's Student Mental Health Initiative: Year 1 Findings

EP-66148 Stanley, Karlyn D. Reengagement of high-need individuals with RR-839-TII serious mental illness after discontinuation of Business Bribery Risk Assessment services EP-66173 Geographic variation in receipt of psychother- Stecher, Brian M. WR-1034-BMGF apy in children receiving attention-deficit/hyperac- Introduction to the Evaluation of the Intensive tivity disorder medications Partnerships for Effective Teaching (IP)

WR-1034-BMGF The American Teacher Panel and the Ameri- Stockdale, Susan can School Leader Panel: Two Innovative New EP-50492 Tools to “Take the Pulse” of America’s Educators A patient-centered primary care practice approach using evidence-based quality improve- RR-863-WFHF ment: rationale, methods, and early assessment Measuring Hard-to-Measure Student Compe- of implementation tencies: A Research and Development Plan

Stolk, Christian van RR-407-DWP Steele, Jennifer L. WR-1036-BMGF Psychological Wellbeing and Work: Improving Trends in the Distribution of Teacher Effective- service provision and outcomes ness in the Intensive Partnerships for Effective Teaching RR-407-DWP Measuring the capacity of government to de- RR-732-BMGF liver policy Competency-Based Education in Three Pilot Programs: Examining Implementation and Out- RR-407-DWP comes The Economic Cost of Social Security Fraud and Error RB-9796-BMGF Competency-Based Education in Three Pilot EP-66226 Programs: What It Is, How It’s Implemented, and A case of partial convergence: the Europe- How It’s Working anization of central government in Central and Eastern Europe 62

Straus, Susan G. Sturm, Roland RR-321-A RB-9801 Developing Army Leaders: Lessons for Teach- Too Much of a Good Thing? How the Eco- ing Critical Thinking in Distributed, Resident, and nomic Environment Plays a Role in the Obesity Mixed-Delivery Venues Epidemic

RR-504-A Innovative Leader Development: Evaluation of the U.S. Army Asymmetric Warfare Adaptive Subramanian, Saskia K Leader Program EP-50454 Application of Patient Safety Indicators Inter- RB-9797-A nationally: A Pilot Study Among Seven Countries Evaluating Innovative Leader Development in the U.S. Army

Sussell, Jesse RGSD-329 Changing Constituencies and Rising Polariza- Strough, JoNell EP-66183 tion in the Congress: Three Essays Getting older isn't all that bad: better decisions and coping when facing "sunk costs"

Szczurko, Orest EP-51749 A naturopathic approach to the prevention of Stucky, Brian D. EP-51673 cardiovascular disease: cost-effectiveness analy- Developing an Item Bank and Short Forms sis of a pragmatic multi-worksite randomized That Assess the Impact of Asthma on Quality of clinical trail Life

EP-51739 Development and psychometric properties of Talisuna-Alamo, Stella the PROMIS® pediatric fatigue item banks EP-51640 Strategies for Optimizing Clinic Efficiency in a EP-51810 Community-Based Antiretroviral Treatment Pro- Assessing the validity of the RAND negative gramme in Uganda impact of asthma on quality of life short forms

EP-66129 The PROMIS® smoking initiative: initial Tanielian, Terri validity evidence for six new smoking item banks RR-209-A/OSD The Deployment Life Study: Methodological Overview and Baseline Sample Description

RR-719-MTF Enhancing Capacity to Address Mental Health Needs of Veterans and Their Families: The Wel- come Back Veterans Initiative 63

RR-806-UNHF Taylor, Jirka Ready to Serve: Community-Based Provider RR-671-EC Capacity to Deliver Culturally Competent, Quality Mapping Diasporas in the European Union Mental Health Care to Veterans and Their Fami- and United States: Comparative analysis and lies recommendations for engagement

RB-9804-MTF RR-671/1-EC Welcome Back Veterans: A Program Steps Mapping Diasporas in the European Union Up to the Plate to Aid Vets, Families with Mental and United States: Comparative analysis and rec- Health Care—and Offers Future Playbook ommendations for engagement: summary report

RR-911-WT Estimating the economic costs of antimicrobial resistance: Model and Results RB-9809-UNHF Therapeutic Measures Required: To Ensure Millions of Veterans and Their Families Get High- Quality Care, Community Mental Health Providers Thissen, David Need More Training, Support, Resources EP-51736 PROMIS Pediatric Peer Relationships Scale: RB-9809-UNHF development of a peer relationships item bank as 2015 RAND Calendar part of social health measurement

RB-9809-UNHF The American Life Panel Timbie, Justin W. RB-9809-UNHF RR-706-CMS Join the Circle: Upcoming Policy Circle Events Medicare Imaging Demonstration Final Evalu- ation: Report to Congress

Tassot, Caroline RGSD-332 Tisnado, Diana M. Three Essays on Subjective Well-Being EP-66199 Physician-reported barriers to referring cancer patients to specialists: prevalence, factors, and association with career satisfaction Taubman, Sarah L. EP-51812 The Oregon experiment—effects of Medicaid on clinical outcomes Tjia, Jennifer EP-66231 Factors associated with ordering laboratory monitoring of high-risk medications 64

Tohme, Johnny EP-66127 EP-50506 Development of the PROMIS® health ex- HIV prevalence and demographic determi- pectancies of smoking item banks nants of unprotected anal sex and HIV testing among men who have sex with men in Beirut, EP-66189 Lebanon A prospective study of marijuana use change and cessation among adolescents EP-50506 RAND Experts Guide: Terrorism, Counterin- surgency, and Cybercrime - Fall 2014 Tumwine, Christopher EP-51642 An Exploratory Study of HIV-Prevention Advo- Tortorello, Frank cacy by Persons in HIV Care in Uganda EP-66150 EP-51643 "I don't think I would have recovered": a per- Reasons Why High Religiosity Can Co-Exist sonal and sociocultural study of resilience among with and Precipitate Discontinuation of Anti- U. S. Marines Retroviral Therapy Among Different HIV Clients in Troxel, Wendy M. Uganda: An Exploratory Study EP-50428 Predictors of Treatment Response to Brief Behavioral Treatment of Insomnia (BBTI) in Older Adults Uscher-Pines, Lori EP-50429 EP-51656 The Promise and Pitfalls of Community Resil- Single-Parent Family Structure and Sleep ience Problems in Black and White Adolescents EP-50457 WR-1042-OSD Analysis of Teladoc Use Seems to Indicate Ex- Sleep in the Armed Forces: Working Group panded Access to Care for Patients Without Prior Proceedings Connection to a Provider

Tsang, Flavia Van Busum, Kristin R. RR-364-EC TL-141 Emerging trends in earnings structures of Five Steps to a Successful Workplace Well- couples in Europe: Short Statistical Report No. 5 ness Program: A RAND Toolkit

Tucker, Joan S. Vernez, Georges EP-50524 MG-1140-1-KRG Providing smoking cessation programs to Strategic Priorities for Improving Access to homeless youth: the perspective of service pro- Quality Education in the Kurdistan Region—Iraq viders 65

MG-1140/1-1-KRG Wagner, Zachary Strategic Priorities for Improving Access to EP-50481 Quality Education in the Kurdistan Region—Iraq: Research and Policy in International Develop- Arabic-language version ment (RAPID)

MG-1140/2-1-KRG Strategic Priorities for Improving Access to Quality Education in the Kurdistan Region—Iraq: Wagner, Zachary Kurdish-language version EP-50481 10 Proven Steps to Better Programs (and Out- comes Funders Expect) Vries, David De EP-50523 Bundled payment fails to gain a foothold in California: the experience of the IHA bundled payment demonstration Wagner, Zachary EP-50481 PRGS Alumni Directory Wagner, Glenn EP-51652 Wallander, Jan The Role of Depression in Work-Related Out- EP-50545 comes of HIV Treatment in Uganda Regular physical activity has differential association with reduced obesity among diverse youth in the United States EP-51706 Changes in Condom Use During the First Year of HIV Treatment in Uganda and the Relationship EP-51805 to Depression TV viewing, perceived similarity coviewing, and mental well-being among African American, Latino, and White children EP-66212 Giving ''sadness'' a name: the need for integrating depression treatment into HIV care in EP-66157 Uganda Associations between socioeconomic status and obesity in diverse, young adolescents: variation across race/ethnicity and gender

Wagner, Zachary EP-50481 The Affordable Care Act may increase the Wanyenze, Rhoda K. number of people getting tested for HIV by nearly EP-50470 500,000 by 2017 Fertility desires and intentions and the relationship to consistent condom use and provider communication regarding childbearing among EP-50481 RAND Labor and Population: Research and HIV clients in Uganda Analysis to Improve Social and Economic Well- Being Around the World

Ward, Phillip EP-51674 Physical Activity Surveillance in Parks Using Direct Observation 66

Watts, Stephen Wells, Kenneth B. RR-513-SRF EP-66229 Countering Others' Insurgencies: Understand- Comorbid depression and substance abuse ing U.S. Small-Footprint Interventions in Local among safety-net clients in Los Angeles: a com- Context munity participatory study

RB-9765-SRF Partner Capacity in Counterinsurgency Cam- paigns Wen, Fang EP-51853 Assessing the contribution of parks to physical activity using global positioning system and Waxman, Daniel accelerometry RGSD-333 The Impact of Tort Reform, Medicare Plan Choice, and Geography on Health Care Process- es, Outcomes, and Expenditures White, Chapin EP-66105 Variation in inpatient hospital prices and outpatient service quantities drive geographic differ- Webb, Tim ences in private spending in Texas RR-176-OSD Venture Capital and Strategic Investment for Developing Government Mission Capabilities Wiley, Joshua F. EP-66195 Changes in self-efficacy and outcome expec- Weinberg, Daniel tancy as predictors of anxiety outcomes from the EP-51688 CALM study An Examination of Longitudinal CAUTI, SSI, and CDI Rates from Key HHS Data Systems

Williams, Shara RR-274-A Weinick, Robin M. Rapid Acquisition of Army Command and Con- RR-761-CMS trol Systems Emergency Department Patient Experience of Care Survey: Development and Field Test

Williamson, Hannah C. EP-51707 Weiss, Bahr Does Premarital Education Decrease or In- EP-66175 crease Couples' Later Help-Seeking? The Vietnam multicomponent collaborative care for depression program: development of depression care for low- and middle-income nations 67

Willis, Henry H. Wong, Eunice C. RR-573-CCRMC RR-683-CMHSA National Security Perspectives on Terrorism Findings from the School-Based Theatrical Risk Insurance in the United States Performance "Walk In Our Shoes"

CT-410 EP-51814 Securing America's Ports Faith to move mountains: religious coping, spirituality, and interpersonal trauma recovery Wong, Jennifer S. CT-412 EP-50536 Building on the Quadrennial Homeland Secu- Is previous removal from the United States rity Review to Improve the Effectiveness and Ef- a marker for high recidivism risk? results from a ficiency of the Department of Homeland Security 9-year follow-up study of criminally involved unauthorized immigrants CT-412/1 Building on the Quadrennial Homeland Secu- rity Review to Improve the Effectiveness and Ef- ficiency of the Department of Homeland Security: Woodbridge, Michelle W. Addendum RR-688-CMHSA California K-12 Schools and Communities Col- laborate to Support Student Mental Health

RR-689-CMHSA Wilmoth, Pete EP-66147 California Colleges and Universities Collabo- A web-based platform to support an evidence- rate to Support Student Mental Health based mental health intervention: lessons from the CBITS web site

Wooding, Steven EP-50493 Understanding Factors Associated with the Winpenny, Eleanor EP-50508 Translation of Cardiovascular Research: A Multi- Youth exposure to alcohol advertising on tele- national Case Study Approach vision in the UK, the Netherlands and Germany

Wu, Vivian Y. EP-66107 Wong, Carolyn RR-357-NAVY How do hospitals cope with sustained slow Authority to Issue Interoperability Policy growth in Medicare prices?

RR-418-NIJ Evaluation of National Institute of Justice– Funded Geospatial Software Tools: Technical and Wynn, Barbara O. Utility Assessments to Improve Tool Development, WR-1016-DIR Dissemination, and Usage Fee Schedule Options for Services Furnished by Hospitals to Outpatients under the California Workers’ Compensation Program 68

RR-524-DIR Zeledon, Luis R. Ambulatory Surgical Services Provided Under EP-51848 California Workers’ Compensation: An Assess- Depression and health risk behaviors: towards ment of the Feasibility and Advisability of Expand- optimizing primary care service strategies for ad- ing Coverage dressing risk

RR-395-1-DIR Implementing a Resource-Based Relative Value Scale Fee Schedule for Physician Services: Zenk, Shannon N. An Assessment of Policy Options for the Califor- EP-50544 nia Workers’ Compensation Program Healthy food access for urban food desert residents: examination of the food environment, food purchasing practices, diet and BMI

Young, Stephanie RR-660-OSD Measuring Cooperative Biological Engage- Zickmund, Susan L. ment Program (CBEP) Performance: Capacities, EP-50522 Capabilities, and Sustainability Enablers for Bior- Development of telehealth dialogues for moni- isk Management and Biosurveillance toring suicidal patients with schizophrenia: consumer feedback

Young, William RR-609-OSD Spillover from the Conflict in Syria: An As- sessment of the Factors that Aid and Impede the Spread of Violence

RB-9785-OSD The Conflict in Syria: Understanding and Avoiding Regional Spillover Effects

Yuan, Kun RR-483-WFHF Measuring Deeper Learning Through Cog- nitively Demanding Test Items: Results from the Analysis of Six National and International Exams 69 SUBJECT INDEX

Academic Achievement Iran’s Influence in Afghanistan: Implications for the U.S. Drawdown Four Ways to Foster Successful RR-616 School LEADERSHIP IG-112 It Takes a Village: Network Effects on Rural Education in Afghanistan Improving School Leadership Through RGSD-327 District Partnerships: Implementation and Effects of New Leaders—Appendix Modeling, Simulation, and Operations RR-507/1-NL Analysis in Afghanistan and Iraq: Operational Vignettes, Lessons Learned, Measuring Deeper Learning Through and a Survey of Selected Efforts Cognitively Demanding Test Items: RR-382-OSD Results from the Analysis of Six National and International Exams The Utility of Modeling and Analysis in RR-483-WFHF the Iraq and Afghanistan Wars RB-9758-OSD Preparing Principals to Raise Student Achievement: Implementation and Effects of Africa the New Leaders Program in Ten Districts RR-507-NL Assessing Locally Focused Stability Operations RR-387-A Principal Preparation Matters: How Best Practices for Assessing Locally Leadership Affects Student Achievement RB-9786-NL Focused Stability Operations RB-9784-A adolescents China in Africa: Implications of a Deepening Relationship Dropping Out, Opting In: Why the National RB-9760-OSD Guard’s Youth ChalleNGe Program for High School Dropouts is a Solid Social Investment Chinese Engagement in Africa: Drivers, IG-103 Reactions, and Implications for U.S. Policy RR-521-OSD Adult Populations Data Flood: Helping the Navy Address the Topics in Migration Research Rising Tide of Sensor Information RGSD-326 RR-315-NAVY

Afghanistan Evaluation of the Population and Poverty Research Initiative (PopPov) China's Strategy Toward South and RR-527-WFHF Central Asia: An Empty Fortress RR-525-AF Evaluation of the Population and Poverty Research Initiative (PopPov) Democracy in Afghanistan: The RR-527-1-WFHF 2014 Election and Beyond PE-120-OSD 70

Evaluation of the Population and Air Defense Poverty Research Initiative (PopPov): Executive Summary Shaking the Heavens and Splitting the Earth: RR-527/1-WFHF Chinese translation (traditional characters) MG-915/2-AF Improving Interagency Information Sharing Using Technology Demonstrations: The Legal Air Transportation Basis for Using New Sensor Technologies for Counterdrug Operations Along the U.S. Border The Effectiveness of China’s Industrial Policies RR-551-OSD in Commercial Aviation Manufacturing CT-416 After-School Programs Air Warfare Competency-Based Education in Three Pilot Programs: What It Is, How It’s Implemented, Shaking the Heavens and Splitting the Earth: and How It’s Working Chinese translation (traditional characters) RB-9796-BMGF MG-915/2-AF

Early and School-Age Care in Santa Simplified Model of a Symmetric Tactical Air War Monica: Current System, Policy RM-711-PR Options, and Recommendations RR-289-CSM Aircraft

Early and School-Age Care in Santa Monica: The Effectiveness of China's Industrial Policies Current System, Policy Options, and in Commercial Aviation Manufacturing Recommendations: Executive Summary RR-245 RR-289/1-CSM Al Qaida Age Discrimination A Persistent Threat: The Evolution of al How have Levels of Intolerance Changed in Qa'ida and Other Salafi Jihadists Western Europe? RR-637-OSD IG-117 Brothers Killing Brothers: The Current Intolerance in Western Europe: Analysis Infighting Will Test al Qaeda's Brand of trends and associated factors PE-123-RC RR-334-OSI Alzheimer's Disease Intolerance in Western Europe: Analysis of trends and associated factors: Summary report What to Do About Dementia? Policy Options for RR-334/1-OSI Crucial Long-Term Care RB-9780 Aging Parents Improving Dementia Long-Term What to Do About Dementia? Policy Options for Care: A Policy Blueprint Crucial Long-Term Care RR-597 RB-9780 71

Arms Proliferation and Control The Future of the U.S. Intercontinental Ballistic Missile Force Armed and Dangerous? UAVs and U.S. Security MG-1210-AF RR-449-RC Penaid Nonproliferation: Hindering Banking And Finance Legislation the Spread of Countermeasures Against Ballistic Missile Defenses Potential Economic Effects on Individual RR-378-DTRA Retirement Account Markets and Investors of DOL’s Proposed Rule Concerning The Days After a Deal with Iran: Regional the Definition of a ‘Fiduciary’ Responses to a Final Nuclear Agreement OP-368-DOL PE-122-RC Biotechnology The Days After a Deal: Iran, Its Neighbors, and U.S. Policy Following a Nuclear Agreement The Structural Genomics Consortium: A CF-320 knowledge platform for drug discovery RR-512-SGC Assumption Based Planning The Structural Genomics Consortium: Analysis to Inform Defense A knowledge platform for drug Planning Despite Austerity discovery: A summary RR-482-OSD RR-512/1-SGC

Asymmetric warfare BORDER AND PORT SECURITY

Assessing Locally Focused Stability Operations Improving Interagency Information Sharing RR-387-A Using Technology Demonstrations: The Legal Basis for Using New Sensor Technologies for Best Practices for Assessing Locally Counterdrug Operations Along the U.S. Border Focused Stability Operations RR-551-OSD RB-9784-A

Business Strategies Modeling, Simulation, and Operations Analysis in Afghanistan and Iraq: Shining a Light on State Campaign Finance: Operational Vignettes, Lessons Learned, An Evaluation of the Impact of the National and a Survey of Selected Efforts RR-382-OSD Institute on Money in State Politics RR-791-NIMSP The Utility of Modeling and Analysis in California the Iraq and Afghanistan Wars RB-9758-OSD A Case Study Evaluating the Fidelity of Suicide Vulnerability Assessment Method Pocket Prevention Workshops in California Guide: A Tool for Center of Gravity Analysis RR-755-CMHSA TL-129-A Adults Exposed to "Know the Signs" BALLISTIC MISSILES Are More Confident Intervening with Those At Risk for Suicide Penaid Nonproliferation: Hindering RR-686-CMHSA the Spread of Countermeasures Against Ballistic Missile Defenses RR-378-DTRA 72

California Colleges and Universities Collaborate Implementing a Resource-Based Relative Value to Support Student Mental Health Scale Fee Schedule for Physician Services: RR-689-CMHSA An Assessment of Policy Options for the California Workers’ Compensation Program California K-12 Schools and Communities RR-395-1-DIR Collaborate to Support Student Mental Health RR-688-CMHSA Language Differences in California Adults' Exposure to Suicide Prevention Messaging, CalMHSA Student Mental Health Campus- Confidence in One's Ability to Intervene with Wide Survey: 2013 Summary Report Someone at Risk, and Resource Preferences RR-685-CMHSA RR-754-CMHSA

Evaluating the California Mental Health Los Angeles County Juvenile Justice Crime Services Authority's Stigma and Discrimination Prevention Act: Fiscal Year 2012–2013 Report Reduction Initiative: Year 1 Findings RR-624-LACPD RR-438/2-CMHSA Mapping Gender Differences in Cardiovascular Evaluating the California Mental Health Disease and Diabetes Care: A Pilot Services Authority's Student Mental Assessment of LDL Cholesterol Testing Health Initiative: Year 1 Findings Rates in a California Health Plan RR-438/3-CMHSA RR-539-CSMC

Evaluating the California Mental Health Mapping Gender Gaps in Health Care Services Authority's Suicide Prevention RB-9781-CSMC Initiative: Year 1 Findings RR-438/4-CMHSA Racial and Ethnic Differences in Exposure to Suicide Prevention Messaging, Confidence Evaluation of the California Mental Health in One's Ability to Intervene with Someone Services Authority's Prevention and at Risk, and Resource Preferences Early Intervention Initiatives: Executive RR-682-CMHSA Summary and Commentary RR-438/1-CMHSA Racial and Ethnic Differences in Mental Illness Stigma in California Evaluation of the California Mental RR-684-CMHSA Health Services Authority's Prevention and Early Intervention Initiatives: Recommendations for Sustaining California's Progress and Preliminary Findings Statewide Mental Health Prevention RR-438-CMHSA and Early Intervention Programs RR-787-CMHSA Findings from the School-Based Theatrical Performance "Walk In Our Shoes" Suicide Rates in California: Trends RR-683-CMHSA and Implications for Prevention and Early Intervention Programs Identifying Permanently Disabled Workers RB-9737-CMHSA with Disproportionate Earnings Losses for Supplemental Payments What Has the CalMHSA Statewide RR-425-CHSWC Mental Health Prevention and Early Intervention Implementation Program Done So Far? Summary and Commentary for Year 1 Evaluation RB-9772-CMHSA 73

What Has the CalMHSA Statewide Mental Cardiovascular Disorders Health Prevention and Early Intervention Implementation Program Done So Mapping Gender Differences in Cardiovascular Far? Key Results from the Baseline Disease and Diabetes Care: A Pilot RAND General Population Survey Assessment of LDL Cholesterol Testing RB-9771-CMHSA Rates in a California Health Plan RR-539-CSMC What Has the Stigma and Discrimination Reduction Initiative Mapping Gender Gaps in Health Care Done So Far? Year 1 Findings RB-9781-CSMC RB-9756-CMHSA Women's Heart Health: Research That Matters What Has the Student Mental Health PT-120-UCLA Initiative Done So Far? Year 1 Findings RB-9757-CMHSA Caregivers

What Has the Suicide Prevention Initiative Hidden Heroes: America's Military Caregivers Done So Far? Year 1 Findings RR-499-TEDF RB-9727-CMHSA Hidden Heroes: America's Military Where Would California Adults Prefer to Get Caregivers — Executive Summary Help If They Were Feeling Suicidal? RR-499/1-TEDF RR-681-CMHSA Improving Dementia Long-Term Cancer Care: A Policy Blueprint RR-597 Investigating time lags and attribution in the translation of cancer research: A case study Key Facts and Statistics from the approach RAND Military Caregivers Study RR-627-WT PT-124-TEDF Military Caregivers in the Workplace Capabilities Based Planning RB-9764/2-TEDF

An Assessment of Program Sustainability in Military Caregivers: Who are They? Three Bureau of Justice Assistance Criminal And Who Is Supporting Them? Justice Domains RB-9764-TEDF RR-550-BJA RAND Review: Vol. 38, No. 1, Spring 2014 Analysis to Inform Defense CP-22 (4/14) Planning Despite Austerity RR-482-OSD Support Resources for Military Caregivers RB-9764/4-TEDF Venture Capital and Strategic Investment for Developing Government Mission Capabilities Supporting Military Caregivers: RR-176-OSD Options for Congress RB-9764/1-TEDF

Supporting Military Caregivers: The Role of Health Providers RB-9764/3-TEDF 74

What to Do About Dementia? Policy Caring for children in Europe: How childcare, Options for Crucial Long-Term Care parental leave and flexible working RB-9780 arrangements interact in Europe RR-554-EC Central Asia

China's Strategy Toward South and Children and Families Central Asia: An Empty Fortress RR-525-AF Evidence on Home Visiting and Suggestions for Implementing Evidence-Based CHEMICAL WEAPONS AND WARFARE Home Visiting Through MIECHV CT-407 Developing Navy Capability to Recover Forces in Chemical, Biological, and Evidence on Home Visiting and Suggestions Radiological Hazard Environments for Implementing Evidence-Based Home RR-155-OSD Visiting Through MIECHV: Addendum CT-407/1 The Dynamics of Syria's Civil War PE-115-RC Social protection during the economic crisis: How do changes to benefits systems affect children? Child Health RR-555-EC

Process Evaluation of the New Mexico U.S. Vaccines Deemed Extremely Safe, with Maternal, Infant, and Early Childhood Home Serious Side Effects Rare Among Children Visiting Competitive Development Grant RB-9799 RR-639-REC Children's Access to Health Care U.S. Vaccines Deemed Extremely Safe, with Serious Side Effects Rare Among Children Process Evaluation of the New Mexico RB-9799 Maternal, Infant, and Early Childhood Home Visiting Competitive Development Grant Child Welfare RR-639-REC

Social protection during the economic crisis: How China do changes to benefits systems affect children? RR-555-EC China in Africa: Implications of a Deepening Relationship Child Well-Being RB-9760-OSD

Process Evaluation of the New Mexico Maternal, China: The Reluctant Partner Infant, and Early Childhood Home Visiting PT-123-USSOCOM Competitive Development Grant RR-639-REC China's International Behavior: Chinese translation (traditional characters) MG-850/2-AF Children

Breaking the cycle of disadvantage: Early Childhood interventions and progression to China's Strategy Toward South and Central Asia: higher education in Europe An Empty Fortress RR-553-EC RR-525-AF 75

Chinese Engagement in Africa: Drivers, Chronic Obstructive Pulmonary Disease Reactions, and Implications for U.S. Policy RR-521-OSD Continuity of Care and the Cost of Treating Chronic Disease Improving Interagency Information Sharing RB-9795 Using Technology Demonstrations: The Legal Basis for Using New Sensor Technologies for Civil-Military Relations Counterdrug Operations Along the U.S. Border RR-551-OSD A New Approach to Security and Justice Sector Assistance: An Enhanced Shaking the Heavens and Splitting the Earth: Partnership Planning Model Chinese translation (traditional characters) RB-9779-DOS MG-915/2-AF Assessing Locally Focused Stability Operations The Effectiveness of China's Industrial Policies RR-387-A in Commercial Aviation Manufacturing RR-245 Best Practices for Assessing Locally Focused Stability Operations The Effectiveness of China’s Industrial Policies RB-9784-A in Commercial Aviation Manufacturing CT-416 From Stalemate to Settlement: Lessons for Afghanistan from Historical Insurgencies That The Role of Health Care Transformation for Have Been Resolved Through Negotiations the Chinese Dream: Powering Economic RR-469-OSD Growth, Promoting a Harmonious Society RR-600-AETNA Initial Thoughts on the Impact of the Iraq War on U.S. National Security Structures The U.S. Army in Asia, 2030–2040 PE-111-OSD RR-474-A Lessons for a Negotiated Settlement in Choice-Based Education Reform Afghanistan—If History Serves as a Guide RB-9762-OSD Understanding the impact of differential university fees in England Vulnerability Assessment Method Pocket RR-571-RE Guide: A Tool for Center of Gravity Analysis TL-129-A Chronic Diseases and Conditions Civilian military workforce Continuity of Care and the Cost of Treating Chronic Disease Out of the Shadows: What We Know About RB-9795 the Well-Being and Experiences of Private Contractors Working in Conflict Environments Do Workplace Wellness Programs RB-9753-RC Save Employers Money? RB-9744-DOL Out of the Shadows: What We Know About the Well-Being and Experiences of Private The Skinny on Workplace Wellness Programs Contractors Working in Conflict Environments IG-101 IG-111-RC

The Future of the Army’s Civilian Workforce: Communication Systems Comparing Projected Inventory with Anticipated Requirements and Estimating Cost Under Autonomous Vehicle Technology: Different Personnel Policies A Guide for Policymakers RR-576-A RR-443-1-RC

College-Bound Students Autonomous Vehicle Technology: How to Best Realize Its Social Benefits An Assessment of the Present and RB-9755-RC Future Labor Market in the Kurdistan Region—Iraq: Implications for Policies to Wireless Emergency Alerts: Mobile Increase Private-Sector Employment Penetration Strategy RR-489-KRG RR-174-OSD

Communities COMBAT MEDICINE Developing Navy Capability to Recover Forces in Chemical, Biological, and How have Levels of Intolerance Radiological Hazard Environments Changed in Western Europe? RR-155-OSD IG-117 Intolerance in Western Europe: Analysis COMBAT SERVICE SUPPORT of trends and associated factors Balancing Agile Combat Support Manpower to RR-334-OSI Better Meet the Future Security Environment RR-337-AF Intolerance in Western Europe: Analysis of trends and associated factors: Summary report RR-334/1-OSI COMBAT SUPPORT OPERATIONS

An Operational Architecture for Improving Psychological Fitness and Resilience: Air Force Command and Control Through A Review of Relevant Constructs, Enhanced Agile Combat Support Planning, Measures, and Links to Well-Being Execution, Monitoring, and Control Processes RR-102-AF RR-261-AF Community Health Implementation Actions for Improving Air Force Command and Control Through Enhanced Road to Resilience: Building Stronger, Agile Combat Support Planning, Execution, More Sustainable Communities Monitoring, and Control Processes G-114-DHHS RR-259-AF Community Resilience COMMERCIAL SATELLITES Building Resilient Communities: Satellite Anomalies: Benefits of a Centralized Spanish translation Anomaly Database and Methods for Securely TL-109/1 Sharing Information Among Satellite Operators RR-560-DARPA Strengthening Coastal Planning: How Coastal Regions Could Benefit from Louisiana’s Planning and Analysis Framework RR-437-RC 77

The Impact on Federal Spending of Allowing the Congestive Heart Failure Terrorism Risk Insurance Act to Expire RR-611-CCRMC Continuity of Care and the Cost of Treating Chronic Disease Community-Based Health Care RB-9795

California Colleges and Universities Collaborate CONTINUING EDUCATION to Support Student Mental Health RR-689-CMHSA Dropping Out, Opting In: Why the National Guard’s Youth ChalleNGe Program for High California K-12 Schools and Communities School Dropouts is a Solid Social Investment Collaborate to Support Student Mental Health IG-103 RR-688-CMHSA CORRECTIONS Evaluation of the SAMHSA Primary and Behavioral Health Care Integration (PBHCI) Correctional Education in the United Grant Program: Final Report (Task 13) States: How Effective Is It, and How RR-546-DHHS Can We Move the Field Forward? RB-9763-BJA Improving the Physical Health of Adults with Serious Mental Illness How Effective Is Correctional Education, RB-9789-DHHS and Where Do We Go from Here? The Results of a Comprehensive Evaluation Computer and Information RR-564-BJA Science and Technology Is Multisystemic Therapy (MST) Effective for Information Security and Data Protection Hispanic Youth? An Evaluation of Outcomes Legal and Policy Frameworks Applicable to for Juvenile Offenders in Los Angeles County European Union Institutions and Agencies RB-9791 RR-557-ME Serving Time or Wasting Time? Correctional Markets for Cybercrime Tools and Education Programs Improve Job Prospects, Stolen Data: Hackers' Bazaar Reduce Recidivism, and Save Taxpayer Dollars RR-610-JNI IG-113-BJA

Computer Crime Cost-Effectiveness in Health Care

Markets for Cybercrime Tools and Ambulatory Surgical Services Provided Stolen Data: Hackers' Bazaar Under California Workers’ Compensation: RR-610-JNI An Assessment of the Feasibility and RAND Review: Vol. 38, No. 2, Summer 2014 Advisability of Expanding Coverage CP-22 (8/14) RR-524-DIR

Counterterrorism Computer Viruses

Markets for Cybercrime Tools and A Persistent Threat: The Evolution of al Stolen Data: Hackers' Bazaar Qa'ida and Other Salafi Jihadists RR-610-JNI RR-637-OSD 78

Handling ethical problems in counterterrorism: Criminal Justice An inventory of methods to support ethical decisionmaking Is Multisystemic Therapy (MST) Effective for RR-251-WODC Hispanic Youth? An Evaluation of Outcomes for Juvenile Offenders in Los Angeles County How Do We Know What Information RB-9791 Sharing Is Really Worth? Exploring Methodologies to Measure the Value of Phase 2 report from the payment by results Information Sharing and Fusion Efforts Social Impact Bond pilot at HMP Peterborough RR-380-OSD RR-473-MOJ

Courts Data mining

Who Pays for Justice? Perspectives on State License Plate Readers for Law Enforcement: Court System Financing and Governance Opportunities and Obstacles RR-486-ICJ RR-467-NIJ

Crime Databases and Data Collection, Analysis, and Processing In Broad Daylight: New Calculator Brings Crime Costs—and the Value of Police—Out of the Designing a System for Collecting Policy- Shadows Relevant Data for the Kurdistan Region—Iraq IG-105 MG-1184-1-KRG

Phase 2 report from the payment by results Designing a System for Collecting Policy- Social Impact Bond pilot at HMP Peterborough Relevant Data for the Kurdistan Region— RR-473-MOJ Iraq: Arabic-language version MG-1184/1-1-KRG Crime and Violence Prevention Designing a System for Collecting Policy- Effective Policing for 21st-Century Israel: Relevant Data for the Kurdistan Region— Dual English and Hebrew edition Iraq: Kurdish-language version RR-287/1-MPS MG-1184/2-1-KRG

Evaluation of the Shreveport How Do We Know What Information Predictive Policing Experiment Sharing Is Really Worth? Exploring RR-531-NIJ Methodologies to Measure the Value of Information Sharing and Fusion Efforts In Broad Daylight: New Calculator RR-380-OSD Brings Crime Costs—and the Value of Police—Out of the Shadows Modeling, Simulation, and Operations IG-105 Analysis in Afghanistan and Iraq: Operational Vignettes, Lessons Learned, Los Angeles County Juvenile Justice Crime and a Survey of Selected Efforts Prevention Act: Fiscal Year 2012–2013 Report RR-382-OSD RR-624-LACPD The Utility of Modeling and Analysis in the Iraq and Afghanistan Wars RB-9758-OSD 79

Decisionmaking Democracy

Analysis to Inform Defense Planning Despite Democracy in Afghanistan: The Austerity 2014 Election and Beyond RR-482-OSD PE-120-OSD

Modeling, Simulation, and Operations Demography Analysis in Afghanistan and Iraq: Operational Vignettes, Lessons Learned, An Assessment of the Present and and a Survey of Selected Efforts Future Labor Market in the Kurdistan RR-382-OSD Region—Iraq: Implications for Policies to Increase Private-Sector Employment RAND Behavioral Finance Webinar: Craig RR-489-KRG Fox Presents "Metacognitive Knowledge and Financial Decision Making" Catastrophic Risk in California: Are PT-119 Homeowners and Communities Prepared? CT-417

The Utility of Modeling and Analysis in Data Flood: Helping the Navy Address the the Iraq and Afghanistan Wars Rising Tide of Sensor Information RB-9758-OSD RR-315-NAVY

Toward Improved Management of Designing a System for Collecting Policy- Officer Retention: A New Capability Relevant Data for the Kurdistan Region—Iraq for Assessing Policy Options MG-1184-1-KRG RR-764-OSD Designing a System for Collecting Policy- DEFENSE INFRASTRUCTURE Relevant Data for the Kurdistan Region— Iraq: Arabic-language version Sourcing and Global Distribution MG-1184/1-1-KRG of Medical Supplies RR-125-A Designing a System for Collecting Policy- Relevant Data for the Kurdistan Region— Dementia Iraq: Kurdish-language version MG-1184/2-1-KRG Improving Dementia Long-Term Care: A Policy Blueprint Evaluation of the Population and Poverty RR-597 Research Initiative (PopPov) RR-527-WFHF The Monetary Costs of Dementia in the United States Evaluation of the Population and Poverty CT-406 Research Initiative (PopPov) RR-527-1-WFHF

What to Do About Dementia? Policy Options for Evaluation of the Population and Crucial Long-Term Care Poverty Research Initiative RB-9780 (PopPov): Executive Summary RR-527/1-WFHF 80

Evidence on Home Visiting and Suggestions Evaluation of the Population and for Implementing Evidence-Based Poverty Research Initiative Home Visiting Through MIECHV (PopPov): Executive Summary CT-407 RR-527/1-WFHF

Evidence on Home Visiting and Suggestions Libya After Qaddafi: Lessons and for Implementing Evidence-Based Home Implications for the Future Visiting Through MIECHV: Addendum RR-577-SRF CT-407/1 Diabetes The Monetary Costs of Dementia in the United States Continuity of Care and the Cost of CT-406 Treating Chronic Disease RB-9795 Depression Mapping Gender Differences in Cardiovascular Out of the Shadows: What We Know About Disease and Diabetes Care: A Pilot the Well-Being and Experiences of Private Assessment of LDL Cholesterol Testing Contractors Working in Conflict Environments Rates in a California Health Plan RB-9753-RC RR-539-CSMC

Out of the Shadows: What We Know About Mapping Gender Gaps in Health Care the Well-Being and Experiences of Private RB-9781-CSMC Contractors Working in Conflict Environments IG-111-RC Disadvantaged students

Developing Countries Using Early Childhood Education to Bridge the Digital Divide An Assessment of the Present and PE-119-PNC Future Labor Market in the Kurdistan Region—Iraq: Implications for Policies to Disaster Recovery Operations Increase Private-Sector Employment RR-489-KRG Building Resilient Communities: Spanish translation Data Flood: Helping the Navy Address the TL-109/1 Rising Tide of Sensor Information RR-315-NAVY Road to Resilience: Building Stronger, More Sustainable Communities Democracy in Afghanistan: The IG-114-DHHS 2014 Election and Beyond PE-120-OSD Strengthening Coastal Planning: How Coastal Regions Could Benefit from Louisiana’s Evaluation of the Population and Poverty Planning and Analysis Framework Research Initiative (PopPov) RR-437-RC RR-527-WFHF

Evaluation of the Population and Poverty Research Initiative (PopPov) The Impact on Federal Spending of Allowing the RR-527-1-WFHF Terrorism Risk Insurance Act to Expire RR-611-CCRMC 81

Discrete Choice Modeling Intolerance in Western Europe: Analysis of trends and associated factors: Summary report PRISM 2011 Base: Demand RR-334/1-OSI Model Implementation RR-314-MM What Has the Stigma and Discrimination Reduction Initiative PRISM 2011 Base: Frequency and Done So Far? Year 1 Findings Car Ownership Models RB-9756-CMHSA RR-273-MM Domestic Intelligence PRISM 2011 Base: Mode- Destination Model Estimation How Do We Know What Information RR-186-MM Sharing Is Really Worth? Exploring Methodologies to Measure the Value of Understanding the impact of differential Information Sharing and Fusion Efforts university fees in England RR-380-OSD RR-571-RE Domestic Partnership Discrimination Based on Sexual Orientation How Do We Know What Information How have Levels of Intolerance Sharing Is Really Worth? Exploring Changed in Western Europe? Methodologies to Measure the Value of IG-117 Information Sharing and Fusion Efforts RR-380-OSD Intolerance in Western Europe: Analysis of trends and associated factors Drug Policy and Trends RR-334-OSI

Intolerance in Western Europe: Analysis of trends How Big is the U.S. Market for Illegal Drugs? RB-9770-ONDCP and associated factors: Summary report RR-334/1-OSI What America's Users Spend on Illegal Drugs, 2000–2010 Discriminatory Practices RR-534-ONDCP Evaluating the California Mental Health e-Government Services Authority's Stigma and Discrimination Reduction Initiative: Year 1 Findings Shining a Light on State Campaign Finance: RR-438/2-CMHSA An Evaluation of the Impact of the National Findings from the School-Based Theatrical Institute on Money in State Politics RR-791-NIMSP Performance "Walk In Our Shoes" RR-683-CMHSA Early Childhood Education How have Levels of Intolerance Changed in Western Europe? Breaking the cycle of disadvantage: Early IG-117 Childhood interventions and progression to higher education in Europe Intolerance in Western Europe: Analysis RR-553-EC of trends and associated factors RR-334-OSI 82

Early and School-Age Care in Santa Economic Development Monica: Current System, Policy Options, and Recommendations An Assessment of the Present and Future RR-289-CSM Labor Market in the Kurdistan Region—Iraq: Implications for Policies to Increase Private- Early and School-Age Care in Santa Monica: Sector Employment Current System, Policy Options, and RR-489-KRG Recommendations: Executive Summary RR-289/1-CSM Designing a System for Collecting Policy- Relevant Data for the Kurdistan Region—Iraq Evaluation of Delaware Stars for MG-1184-1-KRG Early Success: Year 1 Report RR-606-DOEL Designing a System for Collecting Policy- Relevant Data for the Kurdistan Region— Using Early Childhood Education Iraq: Arabic-language version to Bridge the Digital Divide MG-1184/1-1-KRG PE-119-PNC Designing a System for Collecting Policy- Earthquakes Relevant Data for the Kurdistan Region— Iraq: Kurdish-language version Catastrophic Risk in California: Are MG-1184/2-1-KRG Homeowners and Communities Prepared? CT-417 ECONOMIC POLICY

Econometric Models Data Flood: Helping the Navy Address the Rising Tide of Sensor Information Venture Capital and Strategic Investment for RR-315-NAVY Developing Government Mission Capabilities RR-176-OSD Evaluation of the Population and Poverty Research Initiative (PopPov) Economic Analysis Methodology RR-527-WFHF

Analysis to Inform Defense Evaluation of the Population and Poverty Planning Despite Austerity Research Initiative (PopPov) RR-482-OSD RR-527-1-WFHF

Venture Capital and Strategic Investment for Evaluation of the Population and Developing Government Mission Capabilities Poverty Research Initiative RR-176-OSD (PopPov): Executive Summary RR-527/1-WFHF Economic Burden of Health Care Potential Economic Effects on Individual Effects of Employer Health Insurance Retirement Account Markets and Investors on Disability Insurance Claiming of DOL’s Proposed Rule Concerning RB-9776 the Definition of a ‘Fiduciary’ OP-368-DOL Effects of Health Care Reform on Disability Insurance Claiming RB-9769 83

Economics Education Policy

Data Flood: Helping the Navy Address the Breaking the cycle of disadvantage: Early Rising Tide of Sensor Information Childhood interventions and progression RR-315-NAVY to higher education in Europe RR-553-EC Evaluation of the Population and Poverty Research Initiative (PopPov) Can New Tests Lead to Better RR-527-WFHF Teaching and Deeper Learning? RB-9766-WFHF Evaluation of the Population and Poverty Research Initiative (PopPov) Four Ways to Foster Successful RR-527-1-WFHF School Leadership IG-112 Evaluation of the Population and Poverty Research Initiative Improving Technical Vocational Education and (PopPov): Executive Summary Training in the Kurdistan Region—Iraq RR-527/1-WFHF RR-277-KRG

Education and the Arts Improving Technical Vocational Education and Training in the Kurdistan Region— Findings from the School-Based Theatrical Iraq: Arabic-language version Performance "Walk In Our Shoes" RR-277/1-KRG RR-683-CMHSA Improving Technical Vocational Education It Takes a Village: Network Effects on and Training in the Kurdistan Region— Rural Education in Afghanistan Iraq: Kurdish-language version RGSD-327 RR-277/2-KRG

Three Essays on Education Policy: Measuring Deeper Learning Through Empirical Analyses of the Challenges and Cognitively Demanding Test Items: Opportunities with For-Profit Colleges, Results from the Analysis of Six Military Enlistment and Immigration National and International Exams RGSD-325 RR-483-WFHF

Education Curriculum Understanding the impact of differential university fees in England Competency-Based Education in RR-571-RE Three Pilot Programs: Examining Implementation and Outcomes Youth in Jordan: Transitions from RR-732-BMGF Education to Employment RR-556-CMEPP Competency-Based Education in Three Pilot Programs: What It Is, How It’s Education Reform Implemented, and How It’s Working RB-9796-BMGF Competency-Based Education in Three Pilot Programs: Examining Implementation and Outcomes RR-732-BMGF 84

Competency-Based Education in Three Intolerance in Western Europe: Analysis Pilot Programs: What It Is, How It’s of trends and associated factors Implemented, and How It’s Working RR-334-OSI

Measuring Deeper Learning Through Intolerance in Western Europe: Analysis of trends Cognitively Demanding Test Items: and associated factors: Summary report Results from the Analysis of Six RR-334/1-OSI National and International Exams RR-483-WFHF Educational Equity

Strategic Priorities for Improving Competency-Based Education in Three Access to Quality Education in Pilot Programs: What It Is, How It’s the Kurdistan Region—Iraq Implemented, and How It’s Working MG-1140-1-KRG RB-9796-BMGF

Strategic Priorities for Improving Access Educational facilities to Quality Education in the Kurdistan Region—Iraq: Arabic-language version Evaluation of Delaware Stars for MG-1140/1-1-KRG Early Success: Year 1 Report RR-606-DOEL Strategic Priorities for Improving Access to Quality Education in the Kurdistan Educational Program Evaluation Region—Iraq: Kurdish-language version MG-1140/2-1-KRG Competency-Based Education in Three Pilot Programs: What It Is, How It’s Educational Administration Implemented, and How It’s Working RB-9796-BMGF Strategic Priorities for Improving Access to Quality Education in Correctional Education in the United the Kurdistan Region—Iraq States: How Effective Is It, and How MG-1140-1-KRG Can We Move the Field Forward? RB-9763-BJA Strategic Priorities for Improving Access to Quality Education in the Kurdistan Developing Army Leaders: Lessons for Region—Iraq: Arabic-language version Teaching Critical Thinking in Distributed, MG-1140/1-1-KRG Resident, and Mixed-Delivery Venues RR-321-A

Strategic Priorities for Improving Access to Quality Education in the Kurdistan Region— Four Ways to Foster Successful School Iraq: Kurdish-language version Leadership MG-1140/2-1-KRG IG-112

Educational Discrimination How Effective Is Correctional Education, and Where Do We Go from Here? The How have Levels of Intolerance Results of a Comprehensive Evaluation Changed in Western Europe? RR-564-BJA IG-117 Serving Time or Wasting Time? Correctional Education Programs Improve Job Prospects, 85

Reduce Recidivism, and Save Taxpayer Dollars the Kurdistan Region—Iraq IG-113-BJA MG-1140-1-KRG

Educational Technology Strategic Priorities for Improving Access to Quality Education in the Kurdistan Competency-Based Education in Region—Iraq: Arabic-language version Three Pilot Programs: Examining MG-1140/1-1-KRG Implementation and Outcomes RR-732-BMGF Strategic Priorities for Improving Access to Quality Education in the Kurdistan Competency-Based Education in Three Region—Iraq: Kurdish-language version Pilot Programs: What It Is, How It’s MG-1140/2-1-KRG Implemented, and How It’s Working RB-9796-BMGF EMERGENCY MEDICAL SERVICES

Developing Army Leaders: Lessons for Road to Resilience: Building Stronger, More Teaching Critical Thinking in Distributed, Sustainable Communities Resident, and Mixed-Delivery Venues IG-114-DHHS RR-321-A Small Ideas for Saving Big Health Care Dollars Using Early Childhood Education RR-390-RC to Bridge the Digital Divide PE-119-PNC EMERGENCY PREPAREDNESS

Egypt Road to Resilience: Building Stronger, More Sustainable Communities A New Approach to Security and Justice IG-114-DHHS Sector Assistance: An Enhanced Partnership Planning Model Wireless Emergency Alerts: Mobile RB-9779-DOS Penetration Strategy RR-174-OSD Electronic Medical Records Health and Healthcare: Assessing the Real Emergency Responders World Data Policy Landscape in Europe RR-544-PI Wireless Emergency Alerts: Mobile Penetration Strategy Promoting Patient Safety Through RR-174-OSD Effective Health Information Technology Risk Management Emergency Services and Response RR-654-DHHSNCH Elementary education Wireless Emergency Alerts: Mobile Penetration Strategy Measuring Deeper Learning Through Cognitively RR-174-OSD Demanding Test Items: Results from the Emerging Technologies Analysis of Six National and International Exams RR-483-WFHF Venture Capital and Strategic Investment for Developing Government Mission Capabilities Strategic Priorities for Improving RR-176-OSD Access to Quality Education in 86

EMPLOYER SPONSORED HEALTH INSURANCE Topics in Migration Research RGSD-326 A Bitter Pill: Soaring Health Care Spending and the American Family Why Is Veteran Unemployment So High? IG-106 RR-284-OSD

Changes in Health Insurance Enrollment Youth in Jordan: Transitions from Since 2013: Evidence from the RAND Education to Employment RR-556-CMEPP Health Reform Opinion Study RR-656-RC Enlisted Personnel Five Steps to a Successful Workplace Wellness Program: A RAND Toolkit Elements of Success: How Type of TL-141 Secondary Education Credential Helps Predict Enlistee Attrition How the Great State of Arkansas May RR-374-OSD Fare Under the Affordable Care Act IG-109 Recruiting Older Youths: Insights from a New Survey of Army Recruits Employment and Unemployment RR-247-OSD

Capacity Building at the Kurdistan Region The Future of the U.S. Intercontinental Statistics Office Through Data Collection Ballistic Missile Force RR-293-KRG MG-1210-AF

Health and Economic Outcomes Among the Environmental and Natural Alumni of the Wounded Warrior Project: 2013 Resource Management RR-522-WWP Strengthening Coastal Planning: How Coastal Health and Economic Outcomes in the Alumni Regions Could Benefit from Louisiana’s of the Wounded Warrior Project: 2010–2012 Planning and Analysis Framework RR-290-WWP RR-437-RC

Psychological Wellbeing and Work: Improving Europe service provision and outcomes RR-407-DWP Breaking the cycle of disadvantage: Early Childhood interventions and progression to higher education in Europe Strategies for Private-Sector Development and RR-553-EC Civil-Service Reform in the Kurdistan Region— Iraq Caring for children in Europe: How childcare, MG-1117-1-KRG parental leave and flexible working arrangements interact in Europe Strategies for Private-Sector Development RR-554-EC and Civil-Service Reform in the Kurdistan Region—Iraq: Arabic-language version Health and Healthcare: Assessing the Real MG-1117/1-1-KRG World Data Policy Landscape in Europe RR-544-PI Strategies for Private-Sector Development and Civil-Service Reform in the Kurdistan Social protection during the economic crisis: How Region—Iraq: Kurdish-language version do changes to benefits systems affect children? MG-1117/2-1-KRG RR-555-EC 87

European Union arrangements interact in Europe RR-554-EC Information Security and Data Protection Legal and Policy Frameworks Applicable to European Union Institutions and Agencies FAMILY PLANNING RR-557-ME

Libya After Qaddafi: Lessons and Data Flood: Helping the Navy Address the Implications for the Future Rising Tide of Sensor Information RR-577-SRF RR-315-NAVY

RAND Review: Vol. 38, No. 1, Spring 2014 Evaluation of the Population and Poverty CP-22 (4/14) Research Initiative (PopPov) RR-527-WFHF Evidence Based Health Practice Evaluation of the Population and Poverty Mapping Pathways: Community-driven Research Initiative (PopPov) RR-527-1-WFHF strategies for the use of antiretrovirals as prevention: United States Workshop Report Evaluation of the Population and RR-596-RE Poverty Research Initiative (PopPov): Executive Summary EXPLORATORY MODELING RR-527/1-WFHF Driving in the Future in Developing Countries Fighter Aircraft RB-9794-IFMO The Department of Defense Should Avoid a Joint Acquisition Approach The Future of Driving in Developing Countries to Sixth-Generation Fighter RR-636-IFMO RB-9759-AF

Venture Capital and Strategic Investment for Finance Developing Government Mission Capabilities RR-176-OSD Authorities and Options for Funding USSOCOM Operations Extracurricular Activities RR-360-SOCOM

Early and School-Age Care in Santa RAND Behavioral Finance Forum Monica: Current System, Policy 2014: Leveraging Behavioral Insights Options, and Recommendations to Improve Financial Health RR-289-CSM CF-323-BEFI

Early and School-Age Care in Santa Monica: RAND Behavioral Finance Webinar: Craig Current System, Policy Options, and Fox Presents "Metacognitive Knowledge Recommendations: Executive Summary and Financial Decision Making" RR-289/1-CSM PT-119

Families Venture Capital and Strategic Investment for Developing Government Mission Capabilities Caring for children in Europe: How childcare, RR-176-OSD parental leave and flexible working 88

Evaluation of the Shreveport Financial Decision Making Predictive Policing Experiment RR-531-NIJ Potential Economic Effects on Individual Retirement Account Markets and Investors Freight Transportation of DOL’s Proposed Rule Concerning the Definition of a ‘Fiduciary’ Autonomous Vehicle Technology: OP-368-DOL A Guide for Policymakers RR-443-1-RC RAND Behavioral Finance Webinar: Anya Samek Presents "The Power of Visual Tools Autonomous Vehicle Technology: How for Financial Literacy and Decision-Making" to Best Realize Its Social Benefits PT-125 RB-9755-RC

RAND Behavioral Finance Webinar: Craig Game Theory Fox Presents "Metacognitive Knowledge and Financial Decision Making" Venture Capital and Strategic Investment for PT-119 Developing Government Mission Capabilities RR-176-OSD Social protection during the economic crisis: How do changes to benefits systems affect children? Gender Discrimination RR-555-EC How have Levels of Intolerance FLOODING Changed in Western Europe? IG-117 Addressing Coastal Vulnerabilities Through Intolerance in Western Europe: Analysis Comprehensive Planning: How RAND of trends and associated factors Supported the Development of Louisiana’s RR-334-OSI Comprehensive Master Plan RB-9696-1 Intolerance in Western Europe: Analysis of trends and associated factors: Summary report Strengthening Coastal Planning: How Coastal RR-334/1-OSI Regions Could Benefit from Louisiana’s Planning and Analysis Framework Gender Equity in the Workplace RR-437-RC Youth in Jordan: Transitions from Forecasting Methodology Education to Employment RR-556-CMEPP Addressing Coastal Vulnerabilities Through Comprehensive Planning: How RAND Genetics Supported the Development of Louisiana’s Comprehensive Master Plan The Structural Genomics Consortium: A RB-9696-1 knowledge platform for drug discovery RR-512-SGC An Assessment of Program Sustainability in Three Bureau of Justice Assistance The Structural Genomics Consortium: Criminal Justice Domains A knowledge platform for drug RR-550-BJA discovery: A summary RR-512/1-SGC 89

Genomic Medicine Countering Others' Insurgencies: Understanding U.S. Small-Footprint The Structural Genomics Consortium: A Interventions in Local Context knowledge platform for drug discovery RR-513-SRF RR-512-SGC Evaluating the Impact of the Department of The Structural Genomics Consortium: Defense Regional Centers for Security Studies A knowledge platform for drug RR-388-OSD discovery: A summary RR-512/1-SGC Mexico Is Not Colombia: Alternative Historical Analogies for Responding to the Challenge Geriatrics of Violent Drug-Trafficking Organizations RR-548/1 A Noncontributory Pension Program for Older Persons in Yucatan, Mexico: Mexico Is Not Colombia: Alternative Implementing and Designing the Historical Analogies for Responding to Evaluation of the Program in Valladolid the Challenge of Violent Drug-Trafficking TR-1288/1-SOY/NIA Organizations, Supporting Case Studies RR-548/2 Improving Dementia Long-Term Care: A Policy Blueprint Partner Capacity in Counterinsurgency RR-597 Campaigns RB-9765-SRF Un Programa de Pensión No Contributiva para los Adultos Mayores en Yucatán, Health and Health Care México: Diseño, implementación y Evaluacióndel Programa en Valladolid TR-1288/3-SOY-NIA Evidence on Home Visiting and Suggestions for Implementing Evidence-Based Home Visiting Global Climate Change Through MIECHV CT-407 RAND Review: Vol. 38, No. 1, Spring 2014 CP-22 (4/14) Evidence on Home Visiting and Suggestions for Implementing Evidence-Based Home Strengthening Coastal Planning: How Coastal Visiting Through MIECHV: Addendum Regions Could Benefit from Louisiana’s CT-407/1 Planning and Analysis Framework RR-437-RC Expanding the Use of Telehealth: Promise and Potential Pitfalls CT-409 Global Security Environment Expanding the Use of Telehealth: Promise A Persistent Threat: The Evolution of al and Potential Pitfalls: Addendum Qa'ida and Other Salafi Jihadists CT-409/1 RR-637-OSD Investigating time lags and attribution China's Strategy Toward South and in the translation of cancer research: Central Asia: An Empty Fortress RR-525-AF A case study approach RR-627-WT 90

New Medical Technology Development and Psychological Fitness and Resilience: Diffusion: Policy Challenges and Considerations A Review of Relevant Constructs, RGSD-328 Measures, and Links to Well-Being RR-102-AF Psychological Wellbeing and Work: Improving service provision and outcomes The Skinny on Workplace Wellness Programs RR-407-DWP IG-101

Reducing the Economic Burden Health Care Access of Work-Related Injuries RGSD-330 CalMHSA Student Mental Health Campus- Wide Survey: 2013 Summary Report HEALTH AND WELLNESS PROMOTION RR-685-CMHSA

Do Workplace Wellness Programs Racial and Ethnic Differences in Exposure to Save Employers Money? Suicide Prevention Messaging, Confidence RB-9744-DOL in One's Ability to Intervene with Someone at Risk, and Resource Preferences Evaluation of the SAMHSA Primary and RR-682-CMHSA Behavioral Health Care Integration (PBHCI) Grant Program: Final Report (Task 13) Where Would California Adults Prefer to Get RR-546-DHHS Help If They Were Feeling Suicidal? RR-681-CMHSA Final Report: Evaluation of Tools and Metrics to Support Employer Selection of Health Plans RR-327-DOL HEALTH CARE ACCOUNTABLE CARE ORGANIZATIONS Five Steps to a Successful Workplace Wellness Program: A RAND Toolkit Measuring Success in Health Care Value- TL-141 Based Purchasing Programs: Findings from an Environmental Scan, Literature Review, and Improving the Physical Health of Adults Expert Panel Discussions with Serious Mental Illness RR-306-ASPE RB-9789-DHHS Measuring Success in Health Care Psychological Fitness and Resilience: Value-Based Purchasing Programs: A Review of Relevant Constructs, Summary and Recommendations Measures, and Links to Well-Being RR-306/1-ASPE RR-102-AF HEALTH CARE COST INFLATION Road to Resilience: Building Stronger, More Sustainable Communities A Bitter Pill: Soaring Health Care IG-114-DHHS Spending and the American Family IG-106 The Skinny on Workplace Wellness Programs IG-101 Health Care Costs

HEALTH BEHAVIORS Continuity of Care and the Cost of Do Workplace Wellness Programs Treating Chronic Disease RB-9795 Save Employers Money? RB-9744-DOL 91

Evaluating the "Keep Your Health Plan Fix": Health Care Financing Implications for the Affordable Care Act Compared to Legislative Alternatives The 340B Prescription Drug Discount RR-529 Program: Origins, Implementation, and Post-Reform Future Healing Medical Product Innovation PE-121-SDS RB-9767 The changing hospital landscape: An Implementing a Resource-Based Relative Value exploration of international experiences Scale Fee Schedule for Physician Services: RR-728-DH An Assessment of Policy Options for the California Workers’ Compensation Program The Future of Health Care in the Kurdistan RR-395-1-DIR Region—Iraq: Toward an Effective, High-Quality System with an Emphasis on Primary Care More Americans May Be Adequately Prepared MG-1148-1-KRG for Retirement Than Previously Thought RB-9792 The Future of Health Care in the Kurdistan Region—Iraq: Toward an Effective, High- Redirecting Innovation in U.S. Quality System with an Emphasis on Health Care: Options to Decrease Primary Care (Arabic-language version) Spending and Increase Value MG-1148/1-1-KRG RR-308

Small Ideas for Saving Big Health Care Dollars RR-390-RC The Future of Health Care in the Kurdistan Region—Iraq: Toward an Effective, High-Quality Health Care Delivery Approaches System with an Emphasis on Primary Care (Kurdish-language version) Ambulatory Surgical Services Provided MG-1148/2-1-KRG Under California Workers’ Compensation: An Assessment of the Feasibility and Advisability of Expanding Coverage Health Care Organization and Administration RR-524-DIR Regulating quality and safety of health and Continuity of Care and the Cost of social care: International experiences Treating Chronic Disease RR-561-DH RB-9795 The changing hospital landscape: An Health Care Education and Training exploration of international experiences RR-728-DH Supporting the development of a new health R&D strategy: A rapid review The Future of Health Care in the Kurdistan of international theory and practice Region—Iraq: Toward an Effective, High-Quality for Norway’s HelseOmsorg21 System with an Emphasis on Primary Care RR-628-RCN MG-1148-1-KRG

Health Care Facilities The Future of Health Care in the Kurdistan Region—Iraq: Toward an Effective, High- The changing hospital landscape: An Quality System with an Emphasis on exploration of international experiences Primary Care (Arabic-language version) RR-728-DH MG-1148/1-1-KRG 92

The Future of Health Care in the Kurdistan Primary Care (Kurdish-language version) Region—Iraq: Toward an Effective, High- MG-1148/2-1-KRG Quality System with an Emphasis on Primary Care (Kurdish-language version) What Has the CalMHSA Statewide MG-1148/2-1-KRG Mental Health Prevention and Early Intervention Implementation HEALTH CARE PAYMENT APPROACHES Program Done So Far? Summary and Commentary for Year 1 Evaluation Measuring Success in Health Care Value- RB-9772-CMHSA Based Purchasing Programs: Findings from an Environmental Scan, Literature What Has the CalMHSA Statewide Mental Review, and Expert Panel Discussions Health Prevention and Early Intervention RR-306-ASPE Implementation Program Done So Far? Key Results from the Baseline Measuring Success in Health Care RAND General Population Survey Value-Based Purchasing Programs: RB-9771-CMHSA Summary and Recommendations RR-306/1-ASPE Health Care Quality

Health Care Program Evaluation Continuity of Care and the Cost of Treating Chronic Disease Evaluation of the California Mental Health RB-9795 Services Authority's Prevention and Final Report: Evaluation of Tools and Metrics to Early Intervention Initiatives: Executive Support Employer Selection of Health Plans Summary and Commentary RR-327-DOL RR-438/1-CMHSA Mapping Gender Differences in Cardiovascular Evaluation of the California Mental Disease and Diabetes Care: A Pilot Health Services Authority's Prevention Assessment of LDL Cholesterol Testing and Early Intervention Initiatives: Rates in a California Health Plan Progress and Preliminary Findings RR-539-CSMC RR-438-CMHSA Mapping Gender Gaps in Health Care The Future of Health Care in the Kurdistan RB-9781-CSMC Region—Iraq: Toward an Effective, High-Quality Promoting Patient Safety Through System with an Emphasis on Primary Care MG-1148-1-KRG Effective Health Information Technology Risk Management The Future of Health Care in the Kurdistan RR-654-DHHSNCH Region—Iraq: Toward an Effective, High- Regulating quality and safety of health and Quality System with an Emphasis on social care: International experiences Primary Care (Arabic-language version) RR-561-DH MG-1148/1-1-KRG Small Ideas for Saving Big Health Care Dollars The Future of Health Care in the Kurdistan RR-390-RC Region—Iraq: Toward an Effective, High- Quality System with an Emphasis on Women's Heart Health: Research That Matters PT-120-UCLA 93

Health Care Quality Measurement The Role of Health Care Transformation for the Chinese Dream: Powering Economic Final Report: Evaluation of Tools and Metrics to Growth, Promoting a Harmonious Society Support Employer Selection of Health Plans RR-600-AETNA RR-327-DOL Health Care Services Capacity Hospice Experience of Care Survey: Development and Field Test Hidden Heroes: America's Military Caregivers RR-657-CMS RR-499-TEDF

Measuring Success in Health Care Value- Hidden Heroes: America's Military Based Purchasing Programs: Findings Caregivers — Executive Summary from an Environmental Scan, Literature RR-499/1-TEDF Review, and Expert Panel Discussions RR-306-ASPE Key Facts and Statistics from the RAND Military Caregivers Study Measuring Success in Health Care PT-124-TEDF Value-Based Purchasing Programs: Summary and Recommendations Military Caregivers in the Workplace RR-306/1-ASPE RB-9764/2-TEDF

Process Evaluation of the New Mexico Military Caregivers: Who are They? Maternal, Infant, and Early Childhood Home And Who Is Supporting Them? RB-9764-TEDF Visiting Competitive Development Grant RR-639-REC Support Resources for Military Caregivers RB-9764/4-TEDF Health Care Reform Supporting Military Caregivers: Effects of Employer Health Insurance Options for Congress on Disability Insurance Claiming RB-9764/1-TEDF RB-9776 Supporting Military Caregivers: The Effects of Health Care Reform on Role of Health Providers Disability Insurance Claiming RB-9764/3-TEDF RB-9769 The changing hospital landscape: An How the Great State of Arkansas May exploration of international experiences Fare Under the Affordable Care Act RR-728-DH IG-109 The Future of Health Care in the Kurdistan Measuring Success in Health Care Value- Region—Iraq: Toward an Effective, High-Quality Based Purchasing Programs: Findings System with an Emphasis on Primary Care from an Environmental Scan, Literature MG-1148-1-KRG Review, and Expert Panel Discussions RR-306-ASPE The Future of Health Care in the Kurdistan Region—Iraq: Toward an Effective, High- Measuring Success in Health Care Quality System with an Emphasis on Value-Based Purchasing Programs: Primary Care (Arabic-language version) Summary and Recommendations MG-1148/1-1-KRG RR-306/1-ASPE 94

The Future of Health Care in the Kurdistan Region—Iraq: Toward an Effective, High- How the Great State of Arkansas May Quality System with an Emphasis on Fare Under the Affordable Care Act Primary Care (Kurdish-language version) IG-109 MG-1148/2-1-KRG Implementing a Resource-Based Relative Value Health Care Technology Scale Fee Schedule for Physician Services: An Assessment of Policy Options for the Healing Medical Product Innovation California Workers’ Compensation Program RB-9767 RR-395-1-DIR

New Medical Technology Development and Investigating time lags and attribution Diffusion: Policy Challenges and Considerations in the translation of cancer research: RGSD-328 A case study approach RR-627-WT RAND Review: Vol. 38, No. 2, Summer 2014 CP-22 (8/14) HEALTH EDUCATION

Redirecting Innovation in U.S. Do Workplace Wellness Programs Health Care: Options to Decrease Save Employers Money? Spending and Increase Value RB-9744-DOL RR-308 The Skinny on Workplace Wellness Programs Supporting the development of a new IG-101 health R&D strategy: A rapid review of international theory and practice Health Information Privacy for Norway’s HelseOmsorg21 RR-628-RCN Health and Healthcare: Assessing the Real World Data Policy Landscape in Europe Health Care Workforce Supply and Distribution RR-544-PI

The Anesthesiologist Workforce in 2013: A Markets for Cybercrime Tools and Final Briefing to the American Society of Stolen Data: Hackers' Bazaar Anesthesiologists RR-610-JNI RR-650-ASAI Health Information Technology Health Disparities Health and Healthcare: Assessing the Real Mapping Gender Differences in Cardiovascular World Data Policy Landscape in Europe Disease and Diabetes Care: A Pilot RR-544-PI Assessment of LDL Cholesterol Testing Promoting Patient Safety Through Rates in a California Health Plan RR-539-CSMC Effective Health Information Technology Risk Management Mapping Gender Gaps in Health Care RR-654-DHHSNCH RB-9781-CSMC The Role of Health Care Transformation for Health Economics the Chinese Dream: Powering Economic Growth, Promoting a Harmonious Society Evaluating the "Keep Your Health Plan Fix": RR-600-AETNA Implications for the Affordable Care Act Compared to Legislative Alternatives RR-529 95

Health Information Technology Interoperability Health Insurance Markets

Health and Healthcare: Assessing the Real Changes in Health Insurance Enrollment World Data Policy Landscape in Europe Since 2013: Evidence from the RAND RR-544-PI Health Reform Opinion Study RR-656-RC Health Insurance Health Legislation A Health Care Puzzler RB-9782 Effects of Employer Health Insurance on Disability Insurance Claiming Changes in Health Insurance Enrollment RB-9776 Since 2013: Evidence from the RAND Health Reform Opinion Study Effects of Health Care Reform on RR-656-RC Disability Insurance Claiming RB-9769 Do Workplace Wellness Programs Save Employers Money? Health Literacy RB-9744-DOL A Health Care Puzzler Effects of Employer Health Insurance RB-9782 on Disability Insurance Claiming RB-9776 Health Screening Effects of Health Care Reform on Disability Insurance Claiming Five Steps to a Successful Workplace RB-9769 Wellness Program: A RAND Toolkit TL-141 Final Report: Evaluation of Tools and Metrics to Support Employer Selection of Health Plans Hispanic Populations RR-327-DOL Is Multisystemic Therapy (MST) Effective for The Skinny on Workplace Wellness Programs IG-101 Hispanic Youth? An Evaluation of Outcomes for Juvenile Offenders in Los Angeles County RB-9791 Health Insurance Benefit Design

HIV and AIDS Five Steps to a Successful Workplace Wellness Program: A RAND Toolkit TL-141 Mapping Pathways: Community-driven strategies for the use of antiretrovirals as HEALTH INSURANCE COST SHARING prevention: United States Workshop Report RR-596-RE A Bitter Pill: Soaring Health Care HIV treatment Spending and the American Family IG-106 Mapping Pathways: Community-driven HEALTH INSURANCE MANDATES strategies for the use of antiretrovirals as prevention: United States Workshop Report How the Great State of Arkansas May RR-596-RE Fare Under the Affordable Care Act IG-109 96

Hospice Care of Violent Drug-Trafficking Organizations RR-548/1 Hospice Experience of Care Survey: Development and Field Test Mexico Is Not Colombia: Alternative RR-657-CMS Historical Analogies for Responding to the Challenge of Violent Drug-Trafficking Hospitals Organizations, Supporting Case Studies RR-548/2 The changing hospital landscape: An exploration of international experiences What America's Users Spend on RR-728-DH Illegal Drugs, 2000–2010 RR-534-ONDCP HURRICANES India Addressing Coastal Vulnerabilities Through The Socioeconomic Effects of the Working Comprehensive Planning: How RAND Poor Moving to Permanent Dwellings: The Supported the Development of Louisiana’s Case of the Ashray Affordable Housing Pilot Comprehensive Master Plan Project in India RB-9696-1 RR-714-RF

Strengthening Coastal Planning: How Coastal Infants Regions Could Benefit from Louisiana’s Planning and Analysis Framework Early and School-Age Care in Santa RR-437-RC Monica: Current System, Policy Options, and Recommendations Illegal Drug Trade RR-289-CSM

How Big is the U.S. Market for Illegal Drugs? Early and School-Age Care in Santa Monica: RB-9770-ONDCP Current System, Policy Options, and Recommendations: Executive Summary Improving Interagency Information Sharing RR-289/1-CSM Using Technology Demonstrations: The Legal Basis for Using New Sensor Technologies for Evaluation of Delaware Stars for Counterdrug Operations Along the U.S. Border Early Success: Year 1 Report RR-551-OSD RR-606-DOEL

What America's Users Spend on INFORMATION PRIVACY Illegal Drugs, 2000–2010 RR-534-ONDCP License Plate Readers for Law Enforcement: Opportunities and Obstacles Illegal Drugs RR-467-NIJ

How Big is the U.S. Market for Illegal Drugs? INFORMATION SECURITY RB-9770-ONDCP Achieving Higher-Fidelity Conjunction Analyses Mexico Is Not Colombia: Alternative Historical Using Cryptography to Improve Information Analogies for Responding to the Challenge Sharing RR-344-AF 97

Hackers Wanted: An Examination of Intelligence analysis the Cybersecurity Labor Market RR-430 Modeling, Simulation, and Operations Analysis in Afghanistan and Iraq: How Do We Know What Information Operational Vignettes, Lessons Learned, Sharing Is Really Worth? Exploring and a Survey of Selected Efforts Methodologies to Measure the Value of RR-382-OSD Information Sharing and Fusion Efforts RR-380-OSD The Utility of Modeling and Analysis in the Iraq and Afghanistan Wars Information Security and Data Protection RB-9758-OSD Legal and Policy Frameworks Applicable to European Union Institutions and Agencies Intelligence Community RR-557-ME Brothers Killing Brothers: The Current Markets for Cybercrime Tools and Infighting Will Test al Qaeda's Brand Stolen Data: Hackers' Bazaar PE-123-RC RR-610-JNI International affairs RAND Review: Vol. 38, No. 2, Summer 2014 CP-22 (8/14) Assessing Locally Focused Stability Operations RR-387-A Infrastructure finance

Satellite Anomalies: Benefits of a Centralized Assessing Security Cooperation as a Preventive Anomaly Database and Methods for Securely Tool Sharing Information Among Satellite Operators RR-350-A RR-560-DARPA Back to the Future: The Resurgence Insurance of Salafi-Jihadists CT-405 Catastrophic Risk in California: Are Homeowners and Communities Prepared? Best Practices for Assessing Locally CT-417 Focused Stability Operations RB-9784-A How Will the Patient Protection and Affordable Care Act Affect Liability Insurance Costs? China's International Behavior: Chinese RR-493-ICJ translation (traditional characters) MG-850/2-AF The Impact of the Affordable Care Act on Liability Insurance Preparing for the Possibility of a RB-9768-ICJ North Korean Collapse CT-404 Intellectual Piracy Satellite Anomalies: Benefits of a Centralized Markets for Cybercrime Tools and Stolen Data: Anomaly Database and Methods for Securely Hackers' Bazaar Sharing Information Among Satellite Operators RR-610-JNI RR-560-DARPA

The Effectiveness of China’s Industrial Policies in Commercial Aviation Manufacturing CT-416 98

International Diplomacy International Economic Relations

A New Approach to Security and Justice China in Africa: Implications of a Sector Assistance: An Enhanced Deepening Relationship Partnership Planning Model RB-9760-OSD RB-9779-DOS Chinese Engagement in Africa: Drivers, China in Africa: Implications of a Reactions, and Implications for U.S. Policy Deepening Relationship RR-521-OSD RB-9760-OSD Improving Interagency Information Sharing China: The Reluctant Partner Using Technology Demonstrations: The Legal PT-123-USSOCOM Basis for Using New Sensor Technologies for Counterdrug Operations Along the U.S. Border Chinese Engagement in Africa: Drivers, RR-551-OSD Reactions, and Implications for U.S. Policy RR-521-OSD International Trade

Democracy in Afghanistan: The The Effectiveness of China's Industrial Policies 2014 Election and Beyond in Commercial Aviation Manufacturing PE-120-OSD RR-245

Iran From Stalemate to Settlement: Lessons for Afghanistan from Historical Insurgencies That Iran’s Influence in Afghanistan: Implications for Have Been Resolved Through Negotiations RR-469-OSD the U.S. Drawdown RR-616 Getting to Negotiations in Syria: The Shadow The Days After a Deal with Iran: Continuity of the Future in the Syrian Civil War PE-126-OSD and Change in Iranian Foreign Policy PE-124-RC Improving Interagency Information Sharing The Days After a Deal with Iran: Regional Using Technology Demonstrations: The Legal Responses to a Final Nuclear Agreement Basis for Using New Sensor Technologies for PE-122-RC Counterdrug Operations Along the U.S. Border RR-551-OSD The Days After a Deal with Iran: U.S. Policies of Hedging and Engaging Lessons for a Negotiated Settlement in PE-125-RC Afghanistan—If History Serves as a Guide RB-9762-OSD The Days After a Deal: Iran, Its Neighbors, and U.S. Policy Following a Nuclear Agreement The Days After a Deal with Iran: Continuity CF-320 and Change in Iranian Foreign Policy PE-124-RC Iraq The Days After a Deal with Iran: U.S. A New Approach to Security and Justice Policies of Hedging and Engaging PE-125-RC Sector Assistance: An Enhanced Partnership Planning Model 99

RB-9779-DOS How Effective Is Correctional Education, and Where Do We Go from Here? The Initial Thoughts on the Impact of the Iraq Results of a Comprehensive Evaluation War on U.S. National Security Structures RR-564-BJA PE-111-OSD Is Multisystemic Therapy (MST) Effective for Modeling, Simulation, and Operations Hispanic Youth? An Evaluation of Outcomes Analysis in Afghanistan and Iraq: for Juvenile Offenders in Los Angeles County Operational Vignettes, Lessons Learned, RB-9791 and a Survey of Selected Efforts RR-382-OSD Los Angeles County Juvenile Justice Crime Prevention Act: Fiscal Year 2012–2013 Report The Utility of Modeling and Analysis in RR-624-LACPD the Iraq and Afghanistan Wars RB-9758-OSD Substance Use Treatment and Reentry (STAR) Program: Final Evaluation Report Israel RR-572-HBI

A New Approach to Security and Justice Labor Markets Sector Assistance: An Enhanced Partnership Planning Model An Assessment of the Present and RB-9779-DOS Future Labor Market in the Kurdistan Region—Iraq: Implications for Policies to Increase Private-Sector Employment Effective Policing for 21st-Century Israel: Dual RR-489-KRG English and Hebrew edition RR-287/1-MPS Strategies for Private-Sector Development and Civil-Service Reform in the The Days After a Deal with Iran: Regional Kurdistan Region—Iraq Responses to a Final Nuclear Agreement MG-1117-1-KRG PE-122-RC Strategies for Private-Sector Development Jordan and Civil-Service Reform in the Kurdistan Region—Iraq: Arabic-language version A New Approach to Security and Justice MG-1117/1-1-KRG Sector Assistance: An Enhanced Partnership Planning Model Strategies for Private-Sector Development RB-9779-DOS and Civil-Service Reform in the Kurdistan Region—Iraq: Kurdish-language version Youth in Jordan: Transitions from MG-1117/2-1-KRG Education to Employment RR-556-CMEPP The Anesthesiologist Workforce in 2013: A Final Briefing to the American JUVENILE DELINQUENCY Society of Anesthesiologists RR-650-ASAI Correctional Education in the United States: How Effective Is It, and How Land warfare Can We Move the Field Forward? RB-9763-BJA Assessing Locally Focused Stability Operations RR-387-A 100

Best Practices for Assessing Locally Partnership Planning Model Focused Stability Operations RB-9779-DOS RB-9784-A LIABILITY RISK MANAGEMENT Law Enforcement How Will the Patient Protection and Affordable Effective Policing for 21st-Century Israel: Care Act Affect Liability Insurance Costs? Dual English and Hebrew edition RR-493-ICJ RR-287/1-MPS The Impact of the Affordable Care Evaluation of National Institute of Justice– Act on Liability Insurance Funded Geospatial Software Tools: Technical RB-9768-ICJ and Utility Assessments to Improve Tool Development, Dissemination, and Usage Libya RR-418-NIJ A New Approach to Security and Justice Evaluation of the Shreveport Sector Assistance: An Enhanced Predictive Policing Experiment Partnership Planning Model RR-531-NIJ RB-9779-DOS

How Do We Know What Information Libya After Qaddafi: Lessons and Sharing Is Really Worth? Exploring Implications for the Future Methodologies to Measure the Value of RR-577-SRF Information Sharing and Fusion Efforts RR-380-OSD Los Angeles

License Plate Readers for Law Enforcement: In Broad Daylight: New Calculator Opportunities and Obstacles Brings Crime Costs—and the Value RR-467-NIJ of Police—Out of the Shadows IG-105 Markets for Cybercrime Tools and Stolen Data: Hackers' Bazaar Louisiana RR-610-JNI Addressing Coastal Vulnerabilities Through Mexico Is Not Colombia: Alternative Historical Comprehensive Planning: How RAND Analogies for Responding to the Challenge Supported the Development of Louisiana’s of Violent Drug-Trafficking Organizations Comprehensive Master Plan RR-548/1 RB-9696-1

Mexico Is Not Colombia: Alternative Strengthening Coastal Planning: How Coastal Historical Analogies for Responding to Regions Could Benefit from Louisiana’s the Challenge of Violent Drug-Trafficking Planning and Analysis Framework Organizations, Supporting Case Studies RR-437-RC RR-548/2 Low-intensity conflict Lebanon Assessing Locally Focused Stability Operations A New Approach to Security and Justice RR-387-A Sector Assistance: An Enhanced Best Practices for Assessing Locally Focused Stability Operations RB-9784-A 101

Democracy in Afghanistan: The What America's Users Spend on 2014 Election and Beyond Illegal Drugs, 2000–2010 PE-120-OSD RR-534-ONDCP

From Stalemate to Settlement: Lessons for Markets Afghanistan from Historical Insurgencies That Have Been Resolved Through Negotiations Markets for Cybercrime Tools and Stolen Data: RR-469-OSD Hackers' Bazaar RR-610-JNI

Marriage and Divorce Lessons for a Negotiated Settlement in Afghanistan—If History Serves as a Guide More Americans May Be Adequately Prepared RB-9762-OSD for Retirement Than Previously Thought RB-9792 Mexico Is Not Colombia: Alternative Historical Analogies for Responding to the Challenge MEASURING HEALTH CARE COSTS of Violent Drug-Trafficking Organizations RR-548/1 A Bitter Pill: Soaring Health Care Spending and the American Family Mexico Is Not Colombia: Alternative IG-106 Historical Analogies for Responding to the Challenge of Violent Drug-Trafficking Media Influences on Health Organizations, Supporting Case Studies RR-548/2 Adults Exposed to "Know the Signs" Are More Confident Intervening Vulnerability Assessment Method Pocket with Those At Risk for Suicide Guide: A Tool for Center of Gravity Analysis RR-686-CMHSA TL-129-A

Medicaid MAINTENANCE, REPAIR, AND OVERHAUL How the Commonwealth of Pennsylvania DoD Depot-Level Reparable Supply Chain May Fare Under the Affordable Care Act Management: Process Effectiveness IG-108 and Opportunities for Improvement RR-398-OSD MEDICAL MALPRACTICE Methods for Identifying Part Quality How Will the Patient Protection and Affordable Issues and Estimating Their Cost with Care Act Affect Liability Insurance Costs? an Application Using the UH-60 RR-493-ICJ RR-369-A The Impact of the Affordable Care Managed Health Care Act on Liability Insurance RB-9768-ICJ Final Report: Evaluation of Tools and Metrics to Support Employer Selection of Health Plans Medicare RR-327-DOL Continuity of Care and the Cost of Marijuana Treating Chronic Disease RB-9795 How Big is the U.S. Market for Illegal Drugs? RB-9770-ONDCP 102

Implementing a Resource-Based Relative Value Evaluation of the California Mental Health Scale Fee Schedule for Physician Services: Services Authority's Prevention and Early An Assessment of Policy Options for the Intervention Initiatives: Executive Summary and California Workers’ Compensation Program Commentary RR-395-1-DIR RR-438/1-CMHSA

Small Ideas for Saving Big Health Care Dollars Evaluation of the California Mental RR-390-RC Health Services Authority's Prevention and Early Intervention Initiatives: Medicare and Medicaid Progress and Preliminary Findings RR-438-CMHSA How the Great State of Arkansas May Fare Under the Affordable Care Act Findings from the School-Based Theatrical IG-109 Performance "Walk In Our Shoes" RR-683-CMHSA Mental Health and Illness Health and Economic Outcomes Among the Adults Exposed to "Know the Signs" Alumni of the Wounded Warrior Project: 2013 Are More Confident Intervening RR-522-WWP with Those At Risk for Suicide RR-686-CMHSA Psychological Wellbeing and Work: Improving service provision and outcomes An Evaluation of the Implementation RR-407-DWP and Perceived Utility of the Airman Resilience Training Program Racial and Ethnic Differences in Mental RR-655-OSD Illness Stigma in California RR-684-CMHSA California Colleges and Universities Collaborate to Support Student Mental Health Recommendations for Sustaining California's RR-689-CMHSA Statewide Mental Health Prevention and Early Intervention Programs California K-12 Schools and Communities RR-787-CMHSA Collaborate to Support Student Mental Health RR-688-CMHSA Suicide Rates in California: Trends and Implications for Prevention and CalMHSA Student Mental Health Campus- Early Intervention Programs Wide Survey: 2013 Summary Report RB-9737-CMHSA RR-685-CMHSA The Deployment Life Study: Methodological Evaluating the California Mental Health Overview and Baseline Sample Description Services Authority's Stigma and Discrimination RR-209-A/OSD Reduction Initiative: Year 1 Findings RR-438/2-CMHSA The Monetary Costs of Dementia in the United States Evaluating the California Mental Health CT-406 Services Authority's Student Mental Health Initiative: Year 1 Findings What Has the CalMHSA Statewide RR-438/3-CMHSA Mental Health Prevention and Early Intervention Implementation Program Done So Far? Summary and Commentary for Year 1 Evaluation RB-9772-CMHSA 103

What Has the CalMHSA Statewide Mental Methamphetamines Health Prevention and Early Intervention Implementation Program Done So How Big is the U.S. Market for Illegal Drugs? Far? Key Results from the Baseline RB-9770-ONDCP RAND General Population Survey RB-9771-CMHSA What America's Users Spend on Illegal Drugs, 2000–2010 What Has the Stigma and RR-534-ONDCP Discrimination Reduction Initiative Done So Far? Year 1 Findings Methodology RB-9756-CMHSA RAND Behavioral Finance Webinar: Anya What Has the Student Mental Health Samek Presents "The Power of Visual Tools Initiative Done So Far? Year 1 Findings for Financial Literacy and Decision-Making" RB-9757-CMHSA PT-125

Where Would California Adults Prefer to Get Mexico Help If They Were Feeling Suicidal? RR-681-CMHSA A Noncontributory Pension Program for Older Persons in Yucatan, Mexico: Mental Health Treatment Implementing and Designing the Evaluation of the Program in Valladolid California Colleges and Universities Collaborate TR-1288/1-SOY/NIA to Support Student Mental Health RR-689-CMHSA A Noncontributory Pension Program for Older Persons in Yucatan, Mexico: CalMHSA Student Mental Health Campus- Implementing and Designing the Wide Survey: 2013 Summary Report Evaluation of the Program in Merida RR-685-CMHSA TR-1288/2-SOY/NIA

Evaluation of the SAMHSA Primary and Distributing Noncontributory Pension Benefits Behavioral Health Care Integration (PBHCI) by Debit Card in Mexico: A Pilot Test Grant Program: Final Report (Task 13) TR-1288/7-SOY-NIA RR-546-DHHS Geographic Targeting in Urban Areas: A Social- Improving the Physical Health of Adults Welfare Program for Older People in Mexico with Serious Mental Illness TR-1288/5-SOY-NIA RB-9789-DHHS Mexico Is Not Colombia: Alternative Historical Recommendations for Sustaining California's Analogies for Responding to the Challenge Statewide Mental Health Prevention of Violent Drug-Trafficking Organizations and Early Intervention Programs RR-548/1 RR-787-CMHSA Mexico Is Not Colombia: Alternative What Has the Suicide Prevention Initiative Historical Analogies for Responding to Done So Far? Year 1 Findings the Challenge of Violent Drug-Trafficking RB-9727-CMHSA Organizations, Supporting Case Studies RR-548/2 104

Mortality Expectations of Older Mexicans: Methods for Identifying Part Quality Development and Testing of Survey Measures Issues and Estimating Their Cost with TR-1288/6-SOY-NIA an Application Using the UH-60 RR-369-A Programa de Pensiones No Contributivas para Adultos Mayores en Yucatán, Prolonged Cycle Times and Schedule Growth México: Diseño, implementación y in Defense Acquisition: A Literature Review Evaluación del Programa en Mérida RR-455-OSD TR-1288/4-SOY-NIA Rapid Acquisition of Army Command Un Programa de Pensión No Contributiva and Control Systems para los Adultos Mayores en Yucatán, RR-274-A México: Diseño, implementación y Evaluacióndel Programa en Valladolid Small Business and Strategic Sourcing: Lessons TR-1288/3-SOY-NIA from Past Research and Current Data RR-410-OSD Middle East Soldier-Portable Battery Supply: Foreign Brothers Killing Brothers: The Current Dependence and Policy Options RR-500-OSD Infighting Will Test al Qaeda's Brand PE-123-RC Sourcing and Global Distribution of Medical Supplies The Days After a Deal: Iran, Its Neighbors, and RR-125-A U.S. Policy Following a Nuclear Agreement CF-320 The Department of Defense Should Avoid a Joint Acquisition Approach Migration to Sixth-Generation Fighter RB-9759-AF How have Levels of Intolerance Venture Capital and Strategic Investment for Changed in Western Europe? IG-117 Developing Government Mission Capabilities RR-176-OSD Intolerance in Western Europe: Analysis Military Aircraft of trends and associated factors RR-334-OSI RAND Review: Vol. 38, No. 1, Spring 2014 Intolerance in Western Europe: Analysis of trends CP-22 (4/14) and associated factors: Summary report RR-334/1-OSI Military Budgets and Defense Spending Topics in Migration Research RGSD-326 Assessing Security Cooperation as a Preventive Tool Military acquisition and procurement RR-350-A

Authority to Issue Interoperability Policy Authorities and Options for Funding RR-357-NAVY USSOCOM Operations RR-360-SOCOM

How Much Will Be Enough? Assessing Changing Defense Strategies' Implications 105

for Army Resource Requirements Military Doctrine RR-239-A Shaking the Heavens and Splitting the Earth: Small Business and Strategic Sourcing: Lessons Chinese translation (traditional characters) from Past Research and Current Data MG-915/2-AF RR-410-OSD Military Education and Training Sourcing and Global Distribution of Medical Supplies An Evaluation of the Implementation RR-125-A and Perceived Utility of the Airman Resilience Training Program The Future of the Army’s Civilian Workforce: RR-655-OSD Comparing Projected Inventory with Anticipated Requirements and Estimating Building Toward an Unmanned Aircraft Cost Under Different Personnel Policies System Training Strategy RR-576-A RR-440-OSD

MILITARY CAREER FIELD MANAGEMENT Changing the Army's Weapon Training Strategies to Meet Operational Requirements The Future of the U.S. Intercontinental More Efficiently and Effectively Ballistic Missile Force RR-448-A MG-1210-AF Developing Army Leaders: Lessons for MILITARY COMMAND AND CONTROL Teaching Critical Thinking in Distributed, Resident, and Mixed-Delivery Venues An Operational Architecture for Improving RR-321-A Air Force Command and Control Through Enhanced Agile Combat Support Planning, Enhancing Performance Under Stress: Stress Execution, Monitoring, and Control Processes Inoculation Training for Battlefield Airmen RR-261-AF RR-750-AF

Implementation Actions for Improving Air Force MILITARY EQUIPMENT Command and Control Through Enhanced Agile Combat Support Planning, Execution, DoD Depot-Level Reparable Supply Chain Monitoring, and Control Processes Management: Process Effectiveness RR-259-AF and Opportunities for Improvement RR-398-OSD

Methods for Identifying Part Quality Rapid Acquisition of Army Command and Control Issues and Estimating Their Cost with Systems an Application Using the UH-60 RR-274-A RR-369-A

MILITARY COMPENSATION Soldier-Portable Battery Supply: Foreign Dependence and Policy Options Effects of Military Service on Earnings RR-500-OSD and Education Revisited: Variation by Service Duration, Occupation, Military Families and Civilian Unemployment RR-342-OSD Hidden Heroes: America's Military Caregivers RR-499-TEDF 106

Hidden Heroes: America's Military MILITARY FORCE PLANNING Caregivers — Executive Summary RR-499/1-TEDF An Operational Architecture for Improving Air Force Command and Control Through How Deployments Affect the Capacity and Enhanced Agile Combat Support Planning, Utilization of Army Treatment Facilities Execution, Monitoring, and Control Processes RR-257-A RR-261-AF

Key Facts and Statistics from the Analysis to Inform Defense RAND Military Caregivers Study Planning Despite Austerity PT-124-TEDF RR-482-OSD

Military Caregivers in the Workplace Assessing Stop-Loss Policy Options RB-9764/2-TEDF Through Personnel Flow Modeling DB-573-OSD Military Caregivers: Who are They? And Who Is Supporting Them? Assessing the Army’s Active-Reserve RB-9764-TEDF Component Force Mix RR-417-1-A Support Resources for Military Caregivers RB-9764/4-TEDF Balancing Agile Combat Support Manpower to Supporting Military Caregivers: Better Meet the Future Security Environment RR-337-AF Options for Congress RB-9764/1-TEDF How Deployments Affect the Capacity and Supporting Military Caregivers: The Utilization of Army Treatment Facilities RR-257-A Role of Health Providers RB-9764/3-TEDF Implementation Actions for Improving Air Force Command and Control Through Enhanced The Deployment Life Study: Methodological Agile Combat Support Planning, Execution, Overview and Baseline Sample Description Monitoring, and Control Processes RR-209-A/OSD RR-259-AF military force deployment Suitability of Missions for the Air Force Reserve Components Modeling, Simulation, and Operations RR-429-AF Analysis in Afghanistan and Iraq: The Future of the Army’s Civilian Workforce: Operational Vignettes, Lessons Learned, Comparing Projected Inventory with and a Survey of Selected Efforts RR-382-OSD Anticipated Requirements and Estimating Cost Under Different Personnel Policies The Deployment Life Study: Methodological RR-576-A Overview and Baseline Sample Description RR-209-A/OSD The U.S. Army in Asia, 2030–2040 RR-474-A The Utility of Modeling and Analysis in Military Health and Health Care the Iraq and Afghanistan Wars RB-9758-OSD Health and Economic Outcomes Among the Alumni of the Wounded Warrior Project: 2013 RR-522-WWP 107

How Deployments Affect the Capacity and MILITARY OFFICERS Utilization of Army Treatment Facilities RR-257-A The Future of the U.S. Intercontinental Ballistic Missile Force Sourcing and Global Distribution MG-1210-AF of Medical Supplies RR-125-A Military Personnel

The Deployment Life Study: Methodological Assessing the Army’s Active-Reserve Overview and Baseline Sample Description Component Force Mix RR-209-A/OSD RR-417-1-A

Military Information Technology Systems How Deployments Affect the Capacity and Utilization of Army Treatment Facilities Lessons Learned from the Afghan RR-257-A Mission Network: Developing a Coalition Contingency Network Implementation of the DoD Diversity and RR-302-A Inclusion Strategic Plan: A Framework for Change Through Accountability Military Intelligence RR-333-OSD

Lessons Learned from the Afghan Improving Demographic Diversity in Mission Network: Developing a the U.S. Air Force Officer Corps Coalition Contingency Network RR-495-AF RR-302-A Psychological Fitness and Resilience: MILITARY LOGISTICS A Review of Relevant Constructs, Measures, and Links to Well-Being DoD Depot-Level Reparable Supply Chain RR-102-AF Management: Process Effectiveness The Association Between Base-Area and Opportunities for Improvement Social and Economic Characteristics RR-398-OSD and Airmen's Outcomes RR-132-AF Methods for Identifying Part Quality Issues and Estimating Their Cost with Military personnel retention an Application Using the UH-60 RR-369-A Assessing Stop-Loss Policy Options Through Personnel Flow Modeling Sourcing and Global Distribution DB-573-OSD of Medical Supplies RR-125-A Effects of Military Service on Earnings and Education Revisited: Variation Military Mobilization by Service Duration, Occupation, and Civilian Unemployment Assessing the Army’s Active-Reserve RR-342-OSD Component Force Mix RR-417-1-A Elements of Success: How Type of Secondary Education Credential Helps Predict Enlistee Attrition RR-374-OSD 108

Toward Improved Management of Best Practices for Assessing Locally Officer Retention: A New Capability Focused Stability Operations for Assessing Policy Options RB-9784-A RR-764-OSD China: The Reluctant Partner Military Recruitment PT-123-USSOCOM

Elements of Success: How Type of Military Strategy Secondary Education Credential Helps Predict Enlistee Attrition Evaluating the Impact of the Department of RR-374-OSD Defense Regional Centers for Security Studies RR-388-OSD Recruiting Older Youths: Insights from a New Survey of Army Recruits How Much Will Be Enough? Assessing RR-247-OSD Changing Defense Strategies' Implications for Army Resource Requirements Military Reserves RR-239-A

Assessing the Army’s Active-Reserve Initial Thoughts on the Impact of the Iraq Component Force Mix War on U.S. National Security Structures RR-417-1-A PE-111-OSD

Making the Reserve Retirement Shaking the Heavens and Splitting the Earth: System Similar to the Active System: Chinese translation (traditional characters) MG-915/2-AF Retention and Cost Estimates RR-530-A The U.S. Army in Asia, 2030–2040 RR-474-A Military satellites Vulnerability Assessment Method Pocket Guide: A Tool for Center of Gravity Analysis Satellite Anomalies: Benefits of a Centralized TL-129-A Anomaly Database and Methods for Securely Sharing Information Among Satellite Operators Military Tactics RR-560-DARPA Building Toward an Unmanned Aircraft MILITARY SHIPS AND NAVAL VESSELS System Training Strategy RR-440-OSD Developing Navy Capability to Recover Forces in Chemical, Biological, and The Effectiveness of Remotely Piloted Aircraft Radiological Hazard Environments in a Permissive Hunter-Killer Scenario RR-155-OSD RR-276-AF

Military special operations Vulnerability Assessment Method Pocket Guide: A Tool for Center of Gravity Analysis Assessing Locally Focused Stability Operations TL-129-A RR-387-A Military Technology Authorities and Options for Funding USSOCOM Operations Armed and Dangerous? UAVs and U.S. Security RR-360-SOCOM RR-449-RC 109

Improving Interagency Information Sharing Minority Populations Using Technology Demonstrations: The Legal Basis for Using New Sensor Technologies for How have Levels of Intolerance Counterdrug Operations Along the U.S. Border Changed in Western Europe? RR-551-OSD IG-117

Methods for Identifying Part Quality Intolerance in Western Europe: Analysis Issues and Estimating Their Cost with of trends and associated factors an Application Using the UH-60 RR-334-OSI RR-369-A Intolerance in Western Europe: Analysis of trends Rapid Acquisition of Army Command and associated factors: Summary report and Control Systems RR-334/1-OSI RR-274-A Racial and Ethnic Differences in Exposure to Soldier-Portable Battery Supply: Foreign Suicide Prevention Messaging, Confidence Dependence and Policy Options in One's Ability to Intervene with Someone RR-500-OSD at Risk, and Resource Preferences RR-682-CMHSA The Effectiveness of Remotely Piloted Aircraft in a Permissive Hunter-Killer Scenario Racial and Ethnic Differences in Mental RR-276-AF Illness Stigma in California RR-684-CMHSA Venture Capital and Strategic Investment for Developing Government Mission Capabilities MISSILE DEFENSE RR-176-OSD Penaid Nonproliferation: Hindering the Spread of Countermeasures MILITARY VEHICLES Against Ballistic Missile Defenses RR-378-DTRA Methods for Identifying Part Quality Issues and Estimating Their Cost with an Application Using Modeling and Simulation the UH-60 RR-369-A Addressing Coastal Vulnerabilities Through Comprehensive Planning: How RAND Military Veterans Supported the Development of Louisiana’s Comprehensive Master Plan Health and Economic Outcomes Among the RB-9696-1 Alumni of the Wounded Warrior Project: 2013 RR-522-WWP Analysis to Inform Defense Planning Despite Austerity Health and Economic Outcomes in the Alumni RR-482-OSD of the Wounded Warrior Project: 2010–2012 RR-290-WWP Assessing Stop-Loss Policy Options Through Personnel Flow Modeling RAND Review: Vol. 38, No. 1, Spring 2014 DB-573-OSD CP-22 (4/14) Modeling, Simulation, and Operations Why Is Veteran Unemployment So High? RR-284-OSD Analysis in Afghanistan and Iraq: Operational Vignettes, Lessons Learned, and a Survey of Selected Efforts RR-382-OSD 110

The Future of the Army’s Civilian Workforce: Hackers Wanted: An Examination of Comparing Projected Inventory with the Cybersecurity Labor Market Anticipated Requirements and Estimating RR-430 Cost Under Different Personnel Policies RR-576-A Risks and Mitigation Options Regarding Use of Foreign Components in U.S. Launch Vehicles The Utility of Modeling and Analysis in CT-413 the Iraq and Afghanistan Wars RB-9758-OSD The Extremist Threat to the U.S. Homeland CT-403 Toward Improved Management of Officer Retention: A New Capability The Extremist Threat to the U.S. for Assessing Policy Options Homeland: Addendum RR-764-OSD CT-403/1

National security legislation Nation Building

Getting to Negotiations in Syria: The Shadow Authority to Issue Interoperability Policy RR-357-NAVY of the Future in the Syrian Civil War PE-126-OSD Natural Hazards

Initial Thoughts on the Impact of the Iraq War on Building Resilient Communities: U.S. National Security Structures Spanish translation PE-111-OSD TL-109/1 NAVAL WARFARE Iran’s Influence in Afghanistan: Implications for the U.S. Drawdown Developing Navy Capability to Recover Forces in RR-616 Chemical, Biological, and Radiological Hazard Environments Libya After Qaddafi: Lessons and RR-155-OSD Implications for the Future RR-577-SRF NEIGHBORHOODS

National Security The Association Between Base-Area Social and Economic Characteristics A Persistent Threat: The Evolution of al and Airmen's Outcomes Qa'ida and Other Salafi Jihadists RR-132-AF RR-637-OSD Netherlands Back to the Future: The Resurgence of Salafi-Jihadists Handling ethical problems in counterterrorism: CT-405 An inventory of methods to support ethical Counterterrorism and the Role of decisionmaking RR-251-WODC Special Operations Forces CT-408 No-Fault Automobile Insurance

Autonomous Vehicle Technology: A Guide for Policymakers RR-443-1-RC 111

Autonomous Vehicle Technology: How Obesity to Best Realize Its Social Benefits RB-9755-RC Health and Economic Outcomes Among the Alumni of the Wounded Warrior Project: 2013 Norway RR-522-WWP

Supporting the development of a new Occupational Health and Safety health R&D strategy: A rapid review of international theory and practice Identifying Permanently Disabled Workers for Norway’s HelseOmsorg21 with Disproportionate Earnings Losses RR-628-RCN for Supplemental Payments RR-425-CHSWC Nuclear Deterrence

The Days After a Deal with Iran: Continuity Psychological Wellbeing and Work: Improving and Change in Iranian Foreign Policy service provision and outcomes PE-124-RC RR-407-DWP

Occupational training The Days After a Deal with Iran: U.S. Policies of Hedging and Engaging Enhancing Performance Under Stress: Stress PE-125-RC Inoculation Training for Battlefield Airmen RR-750-AF The Future of the U.S. Intercontinental Ballistic Missile Force Occupations MG-1210-AF An Assessment of the Present and Nuclear Disarmament Future Labor Market in the Kurdistan The Days After a Deal with Iran: Continuity Region—Iraq: Implications for Policies to and Change in Iranian Foreign Policy Increase Private-Sector Employment PE-124-RC RR-489-KRG

The Days After a Deal with Iran: U.S. Youth in Jordan: Transitions from Policies of Hedging and Engaging Education to Employment PE-125-RC RR-556-CMEPP

Nuclear Sciences OPERATIONAL READINESS

Notes on the Polonium Engine Balancing Agile Combat Support Manpower to RM-0002-PR Better Meet the Future Security Environment RR-337-AF Nuclear Weapons and Warfare Changing the Army's Weapon Training The Days After a Deal with Iran: Regional Strategies to Meet Operational Requirements Responses to a Final Nuclear Agreement More Efficiently and Effectively PE-122-RC RR-448-A

The Days After a Deal: Iran, Its Neighbors, and The Deployment Life Study: Methodological U.S. Policy Following a Nuclear Agreement Overview and Baseline Sample Description CF-320 RR-209-A/OSD 112

Operations Research Patient Protection and Affordable Care Act

Analysis to Inform Defense A Health Care Puzzler Planning Despite Austerity RB-9782 RR-482-OSD Changes in Health Insurance Enrollment Assessing Locally Focused Stability Operations Since 2013: Evidence from the RAND RR-387-A Health Reform Opinion Study RR-656-RC Best Practices for Assessing Locally Focused Stability Operations Do Workplace Wellness Programs RB-9784-A Save Employers Money? RB-9744-DOL

Otitis Media Effects of Employer Health Insurance on Disability Insurance Claiming Small Ideas for Saving Big Health Care Dollars RB-9776 RR-390-RC Effects of Health Care Reform on Pakistan Disability Insurance Claiming RB-9769 China's Strategy Toward South and Central Asia: An Empty Fortress Evaluating the "Keep Your Health Plan Fix": RR-525-AF Implications for the Affordable Care Act Compared to Legislative Alternatives Countering Others' Insurgencies: RR-529 Understanding U.S. Small-Footprint Interventions in Local Context Final Report: Evaluation of Tools and Metrics to RR-513-SRF Support Employer Selection of Health Plans RR-327-DOL Partner Capacity in Counterinsurgency Campaigns How the Commonwealth of Pennsylvania RB-9765-SRF May Fare Under the Affordable Care Act IG-108 Parenting How the Great State of Arkansas May Caring for children in Europe: How childcare, Fare Under the Affordable Care Act parental leave and flexible working IG-109 arrangements interact in Europe RR-554-EC How Will the Patient Protection and Affordable Care Act Affect Liability Insurance Costs? RR-493-ICJ Passenger Traffic The 340B Prescription Drug Discount Autonomous Vehicle Technology: Program: Origins, Implementation, A Guide for Policymakers and Post-Reform Future RR-443-1-RC PE-121-SDS

Autonomous Vehicle Technology: How The Impact of the Affordable Care to Best Realize Its Social Benefits Act on Liability Insurance RB-9755-RC RB-9768-ICJ 113

The Skinny on Workplace Wellness Programs IG-101 Getting to Negotiations in Syria: The Shadow of the Future in the Syrian Civil War Patient Safety PE-126-OSD

Promoting Patient Safety Through Initial Thoughts on the Impact of the Iraq Effective Health Information War on U.S. National Security Structures Technology Risk Management PE-111-OSD RR-654-DHHSNCH Lessons for a Negotiated Settlement in Regulating quality and safety of health and Afghanistan—If History Serves as a Guide social care: International experiences RB-9762-OSD RR-561-DH Modeling, Simulation, and Operations Small Ideas for Saving Big Health Care Dollars Analysis in Afghanistan and Iraq: RR-390-RC Operational Vignettes, Lessons Learned, and a Survey of Selected Efforts U.S. Vaccines Deemed Extremely Safe, with RR-382-OSD Serious Side Effects Rare Among Children RB-9799 Partner Capacity in Counterinsurgency Campaigns Patient Satisfaction RB-9765-SRF

Hospice Experience of Care Survey: The Utility of Modeling and Analysis in Development and Field Test the Iraq and Afghanistan Wars RR-657-CMS RB-9758-OSD

Peacekeeping and stability operations Pennsylvania

Assessing Locally Focused Stability Operations How the Commonwealth of Pennsylvania RR-387-A May Fare Under the Affordable Care Act IG-108 Best Practices for Assessing Locally Focused Stability Operations Performance Measurement RB-9784-A Final Report: Evaluation of Tools and Metrics to Countering Others' Insurgencies: Support Employer Selection of Health Plans Understanding U.S. Small-Footprint RR-327-DOL Interventions in Local Context RR-513-SRF PERSONAL FINANCE

Democracy in Afghanistan: The Money Under the Mattress? New findings 2014 Election and Beyond show growing rates of unbanked Americans PE-120-OSD IG-104

From Stalemate to Settlement: Lessons for More Americans May Be Adequately Prepared Afghanistan from Historical Insurgencies That for Retirement Than Previously Thought Have Been Resolved Through Negotiations RB-9792 RR-469-OSD 114

Potential Economic Effects on Individual License Plate Readers for Law Enforcement: Retirement Account Markets and Investors Opportunities and Obstacles of DOL’s Proposed Rule Concerning RR-467-NIJ the Definition of a ‘Fiduciary’ OP-368-DOL Politics and Government

Changing Constituencies and Rising RAND Behavioral Finance Webinar: Anya Polarization in the Congress: Three Essays Samek Presents "The Power of Visual Tools for RGSD-329 Financial Literacy and Decision-Making" PT-125 POPULATION AND AGING

Pharmaceutical Drugs A Noncontributory Pension Program for Older Persons in Yucatan, Mexico: Mapping Pathways: Community-driven Implementing and Designing the strategies for the use of antiretrovirals as Evaluation of the Program in Valladolid prevention: United States Workshop Report TR-1288/1-SOY/NIA RR-596-RE A Noncontributory Pension Program Philippines for Older Persons in Yucatan, Mexico: Implementing and Designing the Countering Others' Insurgencies: Evaluation of the Program in Merida Understanding U.S. Small-Footprint TR-1288/2-SOY/NIA Interventions in Local Context RR-513-SRF Distributing Noncontributory Pension Benefits by Debit Card in Mexico: A Pilot Test Partner Capacity in Counterinsurgency TR-1288/7-SOY-NIA Campaigns RB-9765-SRF Geographic Targeting in Urban Areas: A Social- Welfare Program for Older People in Mexico Physicians TR-1288/5-SOY-NIA

The Anesthesiologist Workforce in Improving Dementia Long-Term 2013: A Final Briefing to the American Care: A Policy Blueprint Society of Anesthesiologists RR-597 RR-650-ASAI Programa de Pensiones No Contributivas Police-Community Relations para Adultos Mayores en Yucatán, México: Diseño, implementación y Effective Policing for 21st-Century Israel: Dual Evaluación del Programa en Mérida English and Hebrew edition TR-1288/4-SOY-NIA RR-287/1-MPS The Monetary Costs of Dementia Evaluation of the Shreveport in the United States Predictive Policing Experiment CT-406 RR-531-NIJ The Role of Health Care Transformation for In Broad Daylight: New Calculator the Chinese Dream: Powering Economic Brings Crime Costs—and the Value Growth, Promoting a Harmonious Society of Police—Out of the Shadows RR-600-AETNA IG-105 115

Un Programa de Pensión No Contributiva para los Adultos Mayores en Yucatán, Military Caregivers: Who are They? And Who Is México: Diseño, implementación y Supporting Them? Evaluacióndel Programa en Valladolid RB-9764-TEDF TR-1288/3-SOY-NIA Out of the Shadows: What We Know About Populations the Well-Being and Experiences of Private Contractors Working in Conflict Environments Catastrophic Risk in California: Are RB-9753-RC Homeowners and Communities Prepared? CT-417 Out of the Shadows: What We Know About the Well-Being and Experiences of Private Data Flood: Helping the Navy Address the Contractors Working in Conflict Environments Rising Tide of Sensor Information IG-111-RC RR-315-NAVY Support Resources for Military Caregivers Evaluation of the Population and Poverty RB-9764/4-TEDF Research Initiative (PopPov) RR-527-WFHF Supporting Military Caregivers: Options for Congress Evaluation of the Population and Poverty RB-9764/1-TEDF Research Initiative (PopPov) RR-527-1-WFHF Supporting Military Caregivers: The Role of Health Providers Evaluation of the Population and RB-9764/3-TEDF Poverty Research Initiative Postsecondary Education Programs (PopPov): Executive Summary RR-527/1-WFHF An Assessment of the Present and Post-Traumatic Stress Disorder Future Labor Market in the Kurdistan Region—Iraq: Implications for Policies to An Evaluation of the Implementation Increase Private-Sector Employment and Perceived Utility of the Airman RR-489-KRG Resilience Training Program RR-655-OSD Dropping Out, Opting In: Why the National Guard’s Youth ChalleNGe Program for High Hidden Heroes: America's Military Caregivers School Dropouts is a Solid Social Investment RR-499-TEDF IG-103

Hidden Heroes: America's Military Improving Technical Vocational Education and Caregivers — Executive Summary Training in the Kurdistan Region—Iraq RR-499/1-TEDF RR-277-KRG

Key Facts and Statistics from the Improving Technical Vocational Education RAND Military Caregivers Study and Training in the Kurdistan Region— PT-124-TEDF Iraq: Arabic-language version RR-277/1-KRG Military Caregivers in the Workplace RB-9764/2-TEDF 116

Improving Technical Vocational Education Prescription Drug Benefits and Training in the Kurdistan Region— Iraq: Kurdish-language version Small Ideas for Saving Big Health Care Dollars RR-277/2-KRG RR-390-RC Understanding the impact of differential university fees in England The 340B Prescription Drug Discount RR-571-RE Program: Origins, Implementation, and Post-Reform Future Poverty PE-121-SDS

Programa de Pensiones No Contributivas Preventive Health Care para Adultos Mayores en Yucatán, México: Diseño, implementación y An Evaluation of the Implementation Evaluación del Programa en Mérida and Perceived Utility of the Airman TR-1288/4-SOY-NIA Resilience Training Program RR-655-OSD Prenatal Health Care Primary Care Process Evaluation of the New Mexico Maternal, Infant, and Early Childhood Home Visiting Evaluation of the SAMHSA Primary and Competitive Development Grant Behavioral Health Care Integration (PBHCI) RR-639-REC Grant Program: Final Report (Task 13) RR-546-DHHS Preschool Improving the Physical Health of Adults Early and School-Age Care in Santa Monica: with Serious Mental Illness Current System, Policy Options, and RB-9789-DHHS Recommendations RR-289-CSM The Future of Health Care in the Kurdistan Region—Iraq: Toward an Effective, High-Quality Early and School-Age Care in Santa Monica: System with an Emphasis on Primary Care Current System, Policy Options, and MG-1148-1-KRG Recommendations: Executive Summary RR-289/1-CSM The Future of Health Care in the Kurdistan Region—Iraq: Toward an Effective, High- Preschool Children Quality System with an Emphasis on Primary Care (Arabic-language version) Early and School-Age Care in Santa MG-1148/1-1-KRG Monica: Current System, Policy The Future of Health Care in the Kurdistan Options, and Recommendations RR-289-CSM Region—Iraq: Toward an Effective, High- Quality System with an Emphasis on Early and School-Age Care in Santa Monica: Primary Care (Kurdish-language version) Current System, Policy Options, and MG-1148/2-1-KRG Recommendations: Executive Summary RR-289/1-CSM Principals

Evaluation of Delaware Stars for Four Ways to Foster Successful Early Success: Year 1 Report School Leadership RR-606-DOEL IG-112 117

Improving School Leadership Through An Assessment of Program Sustainability District Partnerships: Implementation and in Three Bureau of Justice Assistance Effects of New Leaders—Appendix Criminal Justice Domains RR-507/1-NL RR-550-BJA

Preparing Principals to Raise Student Analysis to Inform Defense Achievement: Implementation and Effects of Planning Despite Austerity the New Leaders Program in Ten Districts RR-482-OSD RR-507-NL Assessing Locally Focused Stability Operations Principal Preparation Matters: How RR-387-A Leadership Affects Student Achievement RB-9786-NL Best Practices for Assessing Locally Focused Stability Operations PRISONER REENTRY RB-9784-A

Correctional Education in the United Evaluating the Impact of the Department of States: How Effective Is It, and How Defense Regional Centers for Security Studies RR-388-OSD Can We Move the Field Forward? RB-9763-BJA Evaluation of National Institute of Justice– How Effective Is Correctional Education, Funded Geospatial Software Tools: Technical and Where Do We Go from Here? The and Utility Assessments to Improve Tool Results of a Comprehensive Evaluation Development, Dissemination, and Usage RR-564-BJA RR-418-NIJ

Serving Time or Wasting Time? Correctional Mortality Expectations of Older Mexicans: Education Programs Improve Job Prospects, Development and Testing of Survey Measures TR-1288/6-SOY-NIA Reduce Recidivism, and Save Taxpayer Dollars IG-113-BJA Phase 2 report from the payment by results Substance Use Treatment and Reentry Social Impact Bond pilot at HMP Peterborough RR-473-MOJ (STAR) Program: Final Evaluation Report RR-572-HBI Shining a Light on State Campaign Finance: An Evaluation of the Impact of the National Probation Institute on Money in State Politics RR-791-NIMSP Is Multisystemic Therapy (MST) Effective for Hispanic Youth? An Evaluation of Outcomes PUBLIC HEALTH PREPAREDNESS for Juvenile Offenders in Los Angeles County RB-9791 Road to Resilience: Building Stronger, Los Angeles County Juvenile Justice Crime More Sustainable Communities IG-114-DHHS Prevention Act: Fiscal Year 2012–2013 Report RR-624-LACPD

Public Safety Program Evaluation Building Resilient Communities: Spanish A Case Study Evaluating the Fidelity of translation Suicide Prevention Workshops in California TL-109/1 RR-755-CMHSA 118

Phase 2 report from the payment by results Social Impact Bond pilot at HMP Peterborough Los Angeles County Juvenile Justice Crime RR-473-MOJ Prevention Act: Fiscal Year 2012–2013 Report RR-624-LACPD Serving Time or Wasting Time? Correctional Education Programs Improve Job Prospects, Phase 2 report from the payment by results Reduce Recidivism, and Save Taxpayer Dollars Social Impact Bond pilot at HMP Peterborough IG-113-BJA RR-473-MOJ

Public Sector Governance Serving Time or Wasting Time? Correctional Education Programs Improve Job Prospects, Shining a Light on State Campaign Finance: Reduce Recidivism, and Save Taxpayer Dollars An Evaluation of the Impact of the National IG-113-BJA Institute on Money in State Politics RR-791-NIMSP REFUGEES

Racial Discrimination The Dynamics of Syria's Civil War PE-115-RC How have Levels of Intolerance Changed in Western Europe? Regression Analysis IG-117 Evaluation of the Shreveport Predictive Policing Intolerance in Western Europe: Analysis Experiment of trends and associated factors RR-531-NIJ RR-334-OSI RESIDENTIAL HOUSING Intolerance in Western Europe: Analysis of trends and associated factors: Summary report The Socioeconomic Effects of the Working RR-334/1-OSI Poor Moving to Permanent Dwellings: The Case of the Ashray Affordable Racial and Ethnic Differences in Mental Housing Pilot Project in India Illness Stigma in California RR-714-RF RR-684-CMHSA

RETIREMENT AND RETIREMENT BENEFITS Rapid Force Deployment A Noncontributory Pension Program Assessing the Army’s Active-Reserve for Older Persons in Yucatan, Mexico: Component Force Mix Implementing and Designing the RR-417-1-A Evaluation of the Program in Merida TR-1288/2-SOY/NIA Making the Reserve Retirement RECIDIVISM System Similar to the Active System: Correctional Education in the United States: How Retention and Cost Estimates Effective Is It, and How Can We Move the Field RR-530-A Forward? More Americans May Be Adequately Prepared RB-9763-BJA for Retirement Than Previously Thought How Effective Is Correctional Education, RB-9792 and Where Do We Go from Here? The Results of a Comprehensive Evaluation RR-564-BJA 119

Potential Economic Effects on Individual School-based Health Care Program Evaluation Retirement Account Markets and Investors of DOL’s Proposed Rule Concerning California K-12 Schools and Communities the Definition of a ‘Fiduciary’ Collaborate to Support Student Mental Health OP-368-DOL RR-688-CMHSA

Programa de Pensiones No Contributivas School-to-Work Transitions para Adultos Mayores en Yucatán, México: Diseño, implementación y An Assessment of the Present and Evaluación del Programa en Mérida Future Labor Market in the Kurdistan TR-1288/4-SOY-NIA Region—Iraq: Implications for Policies to Increase Private-Sector Employment Robust Decision Making RR-489-KRG

Analysis to Inform Defense Planning Despite Science and Technology Austerity RR-482-OSD Investigating time lags and attribution in the translation of cancer research: A case study Santa Monica approach RR-627-WT Early and School-Age Care in Santa Monica: Current System, Policy The Structural Genomics Consortium: A Options, and Recommendations knowledge platform for drug discovery RR-289-CSM RR-512-SGC

Early and School-Age Care in Santa Monica: The Structural Genomics Consortium: Current System, Policy Options, and A knowledge platform for drug Recommendations: Executive Summary discovery: A summary RR-289/1-CSM RR-512/1-SGC

SATELLITES Venture Capital and Strategic Investment for Developing Government Mission Capabilities Achieving Higher-Fidelity Conjunction RR-176-OSD Analyses Using Cryptography to Improve Information Sharing Science and technology legislation RR-344-AF Authority to Issue Interoperability Policy Saudi Arabia RR-357-NAVY

The Days After a Deal with Iran: Regional Science, Technology, and Innovation Policy Responses to a Final Nuclear Agreement PE-122-RC Healing Medical Product Innovation RB-9767 School readiness Redirecting Innovation in U.S. Using Early Childhood Education Health Care: Options to Decrease to Bridge the Digital Divide PE-119-PNC Spending and Increase Value RR-308 120

Supporting the development of a new Security Cooperation health R&D strategy: A rapid review of international theory and practice A New Approach to Security and Justice Sector for Norway’s HelseOmsorg21 Assistance: An Enhanced Partnership Planning RR-628-RCN Model RB-9779-DOS Science, Technology, Engineering, and Math Education Assessing Locally Focused Stability Operations RR-387-A Hackers Wanted: An Examination of the Cybersecurity Labor Market Assessing Security Cooperation RR-430 as a Preventive Tool RR-350-A Secondary Education Best Practices for Assessing Locally An Assessment of the Present and Focused Stability Operations RB-9784-A Future Labor Market in the Kurdistan Region—Iraq: Implications for Policies to Evaluating the Impact of the Department of Increase Private-Sector Employment Defense Regional Centers for Security Studies RR-489-KRG RR-388-OSD

Dropping Out, Opting In: Why the National From Stalemate to Settlement: Lessons for Guard’s Youth ChalleNGe Program for High Afghanistan from Historical Insurgencies That School Dropouts is a Solid Social Investment Have Been Resolved Through Negotiations IG-103 RR-469-OSD

Measuring Deeper Learning Through Initial Thoughts on the Impact of the Iraq Cognitively Demanding Test Items: War on U.S. National Security Structures Results from the Analysis of Six PE-111-OSD National and International Exams RR-483-WFHF Lessons for a Negotiated Settlement in Afghanistan—If History Serves as a Guide Strategic Priorities for Improving RB-9762-OSD Access to Quality Education in the Kurdistan Region—Iraq Lessons Learned from the Afghan MG-1140-1-KRG Mission Network: Developing a Coalition Contingency Network Strategic Priorities for Improving Access RR-302-A to Quality Education in the Kurdistan Region—Iraq: Arabic-language version RAND Review: Vol. 38, No. 2, Summer 2014 MG-1140/1-1-KRG CP-22 (8/14) Strategic Priorities for Improving Access The Days After a Deal with Iran: Continuity to Quality Education in the Kurdistan and Change in Iranian Foreign Policy Region—Iraq: Kurdish-language version PE-124-RC MG-1140/2-1-KRG The Days After a Deal with Iran: U.S. Policies of Hedging and Engaging PE-125-RC 121

Small Businesses RR-714-RF

Small Business and Strategic Sourcing: Lessons Using Early Childhood Education from Past Research and Current Data to Bridge the Digital Divide RR-410-OSD PE-119-PNC

Social Determinants of Health SPACE SCIENCE AND TECHNOLOGY

Road to Resilience: Building Stronger, More Achieving Higher-Fidelity Conjunction Sustainable Communities Analyses Using Cryptography to IG-114-DHHS Improve Information Sharing RR-344-AF The Association Between Base-Area Social and Economic Characteristics STANDARDS BASED EDUCATION REFORM and Airmen's Outcomes RR-132-AF Can New Tests Lead to Better Teaching and Deeper Learning? Social Security RB-9766-WFHF

Effects of Employer Health Insurance Standards-based education reform on Disability Insurance Claiming RB-9776 Evaluation of Delaware Stars for Early Success: Year 1 Report Effects of Health Care Reform on RR-606-DOEL Disability Insurance Claiming RB-9769 Improving School Leadership Through District Partnerships: Implementation and More Americans May Be Adequately Prepared Effects of New Leaders—Appendix for Retirement Than Previously Thought RR-507/1-NL RB-9792 Preparing Principals to Raise Student Social Services and Welfare Achievement: Implementation and Effects of the New Leaders Program in Ten Districts Psychological Wellbeing and Work: Improving RR-507-NL service provision and outcomes RR-407-DWP Principal Preparation Matters: How Leadership Affects Student Achievement Socioeconomic Status RB-9786-NL STATISTICAL ANALYSIS METHODOLOGY Geographic Targeting in Urban Areas: A Social- Welfare Program for Older People in Mexico Driving in the Future in Developing Countries TR-1288/5-SOY-NIA RB-9794-IFMO

Money Under the Mattress? New findings The Future of Driving in Developing Countries show growing rates of unbanked Americans RR-636-IFMO IG-104 Students The Socioeconomic Effects of the Working Poor Moving to Permanent Dwellings: Early and School-Age Care in Santa Monica: The Case of the Ashray Affordable Current System, Policy Options, and Housing Pilot Project in India Recommendations RR-289-CSM 122

Early and School-Age Care in Santa Monica: Racial and Ethnic Differences in Exposure to Current System, Policy Options, and Suicide Prevention Messaging, Confidence Recommendations: Executive Summary in One's Ability to Intervene with Someone RR-289/1-CSM at Risk, and Resource Preferences RR-682-CMHSA Evaluating the California Mental Health Services Authority's Student Mental Suicide Rates in California: Trends Health Initiative: Year 1 Findings and Implications for Prevention and RR-438/3-CMHSA Early Intervention Programs RB-9737-CMHSA What Has the Student Mental Health Initiative Done So Far? Year 1 Findings What Has the Suicide Prevention Initiative RB-9757-CMHSA Done So Far? Year 1 Findings RB-9727-CMHSA Substance Abuse Prevention Where Would California Adults Prefer to Get Evaluation of the SAMHSA Primary and Help If They Were Feeling Suicidal? Behavioral Health Care Integration (PBHCI) RR-681-CMHSA Grant Program: Final Report (Task 13) RR-546-DHHS Summer Learning

Improving the Physical Health of Adults Early and School-Age Care in Santa with Serious Mental Illness Monica: Current System, Policy RB-9789-DHHS Options, and Recommendations RR-289-CSM Substance Abuse Treatment Early and School-Age Care in Santa Monica: Substance Use Treatment and Reentry Current System, Policy Options, and (STAR) Program: Final Evaluation Report Recommendations: Executive Summary RR-572-HBI RR-289/1-CSM

Suicide Supply Chain Management

A Case Study Evaluating the Fidelity of Soldier-Portable Battery Supply: Foreign Suicide Prevention Workshops in California Dependence and Policy Options RR-755-CMHSA RR-500-OSD Adults Exposed to "Know the Signs" Are More Confident Intervening Sourcing and Global Distribution with Those At Risk for Suicide of Medical Supplies RR-686-CMHSA RR-125-A

Evaluating the California Mental Health Surface Traffic Models Services Authority's Suicide Prevention Initiative: Year 1 Findings Autonomous Vehicle Technology: RR-438/4-CMHSA A Guide for Policymakers RR-443-1-RC Language Differences in California Adults' Exposure to Suicide Prevention Messaging, Autonomous Vehicle Technology: How Confidence in One's Ability to Intervene with to Best Realize Its Social Benefits Someone at Risk, and Resource Preferences RB-9755-RC RR-754-CMHSA 123

PRISM 2011 Base: Demand RR-754-CMHSA Model Implementation RR-314-MM Mortality Expectations of Older Mexicans: Development and Testing of Survey Measures PRISM 2011 Base: Frequency and TR-1288/6-SOY-NIA Car Ownership Models RR-273-MM What Has the CalMHSA Statewide Mental Health Prevention and PRISM 2011 Base: Mode- Early Intervention Implementation Destination Model Estimation Program Done So Far? Summary and RR-186-MM Commentary for Year 1 Evaluation RB-9772-CMHSA Surface Transportation What Has the CalMHSA Statewide Mental Driving in the Future in Developing Countries Health Prevention and Early Intervention RB-9794-IFMO Implementation Program Done So Far? Key Results from the Baseline The Future of Driving in Developing Countries RAND General Population Survey RR-636-IFMO RB-9771-CMHSA

Survey Research Methodology Syria

An Assessment of the Present and A New Approach to Security and Justice Future Labor Market in the Kurdistan Sector Assistance: An Enhanced Region—Iraq: Implications for Policies to Partnership Planning Model Increase Private-Sector Employment RB-9779-DOS RR-489-KRG Getting to Negotiations in Syria: The Shadow Capacity Building at the Kurdistan Region of the Future in the Syrian Civil War Statistics Office Through Data Collection PE-126-OSD RR-293-KRG The Dynamics of Syria's Civil War Evaluation of the California Mental Health PE-115-RC Services Authority's Prevention and Early Intervention Initiatives: Executive TEACHER EFFECTIVENESS Summary and Commentary RR-438/1-CMHSA Can New Tests Lead to Better Teaching and Deeper Learning? Evaluation of the California Mental RB-9766-WFHF Health Services Authority's Prevention and Early Intervention Initiatives: Terrorism Progress and Preliminary Findings RR-438-CMHSA Counterterrorism and the Role of Special Operations Forces Hospice Experience of Care Survey: CT-408 Development and Field Test RR-657-CMS The Dynamics of Syria's Civil War PE-115-RC Language Differences in California Adults' Exposure to Suicide Prevention Messaging, Confidence in One's Ability to Intervene with Someone at Risk, and Resource Preferences 124

Terrorism and Homeland Security Terrorism Risk Insurance

Applying Lessons Learned from Past RAND Review: Vol. 38, No. 2, Summer 2014 Response Operations to Strengthening CP-22 (8/14) National Preparedness CT-411 The Impact on Workers’ Compensation Insurance Markets of Allowing the Applying Lessons Learned from Past Terrorism Risk Insurance Act to Expire Response Operations to Strengthening RR-643-CCRMC National Preparedness: Addendum CT-411/1 Terrorism Risk Insurance Act of 2002

Back to the Future: The Resurgence National Security Perspectives on Terrorism of Salafi-Jihadists Risk Insurance in the United States CT-405 RR-573-CCRMC

Building on the Quadrennial Homeland RAND Review: Vol. 38, No. 2, Summer 2014 Security Review to Improve the CP-22 (8/14) Effectiveness and Efficiency of the Department of Homeland Security The Impact on Federal Spending of Allowing CT-412 the Terrorism Risk Insurance Act to Expire RR-611-CCRMC Building on the Quadrennial Homeland Security Review to Improve the Effectiveness The Impact on Workers’ Compensation and Efficiency of the Department of Insurance Markets of Allowing the Homeland Security: Addendum Terrorism Risk Insurance Act to Expire CT-412/1 RR-643-CCRMC

Jihadist Sanctuaries in Syria and Iraq: Terrorism Risk Management Implications for the United States CT-414 National Security Perspectives on Terrorism Risk Insurance in the United States RR-573-CCRMC Road to Resilience: Building Stronger, More Sustainable Communities IG-114-DHHS The Impact on Federal Spending of Allowing the Terrorism Risk Insurance Act to Expire Securing America's Ports RR-611-CCRMC CT-410 The Impact on Workers’ Compensation Strategic Planning for Border Security Insurance Markets of Allowing the CT-415 Terrorism Risk Insurance Act to Expire RR-643-CCRMC The Extremist Threat to the U.S. Homeland CT-403 Terrorism Threat Assessment

The Extremist Threat to the U.S. A Persistent Threat: The Evolution of al Homeland: Addendum Qa'ida and Other Salafi Jihadists CT-403/1 RR-637-OSD 125

THE ELDERLY The Kurdistan Region of Iraq

A Noncontributory Pension Program An Assessment of the Present and for Older Persons in Yucatan, Mexico: Future Labor Market in the Kurdistan Implementing and Designing the Region—Iraq: Implications for Policies to Evaluation of the Program in Valladolid Increase Private-Sector Employment TR-1288/1-SOY/NIA RR-489-KRG

A Noncontributory Pension Program Capacity Building at the Kurdistan Region for Older Persons in Yucatan, Mexico: Statistics Office Through Data Collection Implementing and Designing the RR-293-KRG Evaluation of the Program in Merida TR-1288/2-SOY/NIA Designing a System for Collecting Policy- Relevant Data for the Kurdistan Region—Iraq Distributing Noncontributory Pension Benefits MG-1184-1-KRG by Debit Card in Mexico: A Pilot Test TR-1288/7-SOY-NIA Designing a System for Collecting Policy- Relevant Data for the Kurdistan Region— More Americans May Be Adequately Prepared Iraq: Arabic-language version for Retirement Than Previously Thought MG-1184/1-1-KRG RB-9792 Designing a System for Collecting Policy- Mortality Expectations of Older Mexicans: Relevant Data for the Kurdistan Region— Development and Testing of Survey Measures Iraq: Kurdish-language version TR-1288/6-SOY-NIA MG-1184/2-1-KRG

Programa de Pensiones No Contributivas Improving Technical Vocational Education and para Adultos Mayores en Yucatán, Training in the Kurdistan Region—Iraq México: Diseño, implementación y RR-277-KRG Evaluación del Programa en Mérida TR-1288/4-SOY-NIA

Un Programa de Pensión No Contributiva Improving Technical Vocational Education and para los Adultos Mayores en Yucatán, Training in the Kurdistan Region—Iraq: Arabic- México: Diseño, implementación y language version Evaluacióndel Programa en Valladolid RR-277/1-KRG TR-1288/3-SOY-NIA Improving Technical Vocational Education What to Do About Dementia? Policy and Training in the Kurdistan Region— Options for Crucial Long-Term Care Iraq: Kurdish-language version RB-9780 RR-277/2-KRG

The Internet Strategic Priorities for Improving Access to Quality Education in Markets for Cybercrime Tools and the Kurdistan Region—Iraq Stolen Data: Hackers' Bazaar MG-1140-1-KRG RR-610-JNI Strategic Priorities for Improving Access RAND Review: Vol. 38, No. 2, Summer 2014 to Quality Education in the Kurdistan CP-22 (8/14) Region—Iraq: Arabic-language version MG-1140/1-1-KRG 126

Strategic Priorities for Improving Access Early and School-Age Care in Santa Monica: to Quality Education in the Kurdistan Current System, Policy Options, and Region—Iraq: Kurdish-language version Recommendations: Executive Summary MG-1140/2-1-KRG RR-289/1-CSM

Strategies for Private-Sector Development Evaluation of Delaware Stars for and Civil-Service Reform in the Early Success: Year 1 Report Kurdistan Region—Iraq RR-606-DOEL MG-1117-1-KRG Trade Strategies for Private-Sector Development and Civil-Service Reform in the Kurdistan Markets for Cybercrime Tools and Region—Iraq: Arabic-language version Stolen Data: Hackers' Bazaar MG-1117/1-1-KRG RR-610-JNI

Strategies for Private-Sector Development Traffic Accidents and Civil-Service Reform in the Kurdistan Region—Iraq: Kurdish-language version Autonomous Vehicle Technology: MG-1117/2-1-KRG A Guide for Policymakers RR-443-1-RC The Future of Health Care in the Kurdistan Region—Iraq: Toward an Effective, High-Quality Autonomous Vehicle Technology: How System with an Emphasis on Primary Care to Best Realize Its Social Benefits MG-1148-1-KRG RB-9755-RC

The Future of Health Care in the Kurdistan Region—Iraq: Toward an Effective, High- Traffic Congestion Quality System with an Emphasis on Primary Care (Kurdish-language version) Autonomous Vehicle Technology: A Guide for MG-1148/2-1-KRG Policymakers RR-443-1-RC The Future of Health Care in the Kurdistan Region—Iraq: Toward an Effective, High- Autonomous Vehicle Technology: How Quality System with an Emphasis on to Best Realize Its Social Benefits Primary Care (Arabic-language version) RB-9755-RC MG-1148/1-1-KRG Transportation Economics Threat Assessment The Effectiveness of China's Industrial Policies Armed and Dangerous? UAVs and U.S. Security in Commercial Aviation Manufacturing RR-449-RC RR-245

The U.S. Army in Asia, 2030–2040 Transportation Modeling RR-474-A PRISM 2011 Base: Demand Toddlers Model Implementation RR-314-MM Early and School-Age Care in Santa Monica: Current System, Policy PRISM 2011 Base: Frequency and Options, and Recommendations Car Ownership Models RR-289-CSM RR-273-MM 127

PRISM 2011 Base: Mode-Destination Model Trauma Estimation RR-186-MM Out of the Shadows: What We Know About the Well-Being and Experiences of Private Transportation Planning Contractors Working in Conflict Environments RB-9753-RC Autonomous Vehicle Technology: A Guide for Policymakers Out of the Shadows: What We Know About RR-443-1-RC the Well-Being and Experiences of Private Contractors Working in Conflict Environments Autonomous Vehicle Technology: How IG-111-RC to Best Realize Its Social Benefits RB-9755-RC Traumatic Brain Injury

Driving in the Future in Developing Countries Hidden Heroes: America's Military Caregivers RB-9794-IFMO RR-499-TEDF

License Plate Readers for Law Enforcement: Hidden Heroes: America's Military Opportunities and Obstacles Caregivers — Executive Summary RR-467-NIJ RR-499/1-TEDF

PRISM 2011 Base: Demand Key Facts and Statistics from the Model Implementation RAND Military Caregivers Study RR-314-MM PT-124-TEDF Military Caregivers in the Workplace PRISM 2011 Base: Frequency and RB-9764/2-TEDF Car Ownership Models RR-273-MM Military Caregivers: Who are They? And Who Is Supporting Them? PRISM 2011 Base: Mode- RB-9764-TEDF Destination Model Estimation RR-186-MM Support Resources for Military Caregivers RB-9764/4-TEDF The Future of Driving in Developing Countries RR-636-IFMO Supporting Military Caregivers: Options for Congress Transportation Safety RB-9764/1-TEDF

Autonomous Vehicle Technology: Supporting Military Caregivers: The A Guide for Policymakers Role of Health Providers RR-443-1-RC RB-9764/3-TEDF

Autonomous Vehicle Technology: How United Kingdom to Best Realize Its Social Benefits RB-9755-RC Handling ethical problems in counterterrorism: An inventory of methods Transportation technology to support ethical decisionmaking RR-251-WODC License Plate Readers for Law Enforcement: Opportunities and Obstacles RR-467-NIJ 128

United Nations Mapping Pathways: Community-driven strategies for the use of antiretrovirals as Libya After Qaddafi: Lessons and prevention: United States Workshop Report Implications for the Future RR-596-RE RR-577-SRF Money Under the Mattress? New findings United Republic of Tanzania show growing rates of unbanked Americans IG-104 More Americans May Be Adequately Prepared for Retirement Than Previously Thought More Americans May Be Adequately Prepared RB-9792 for Retirement Than Previously Thought RB-9792 United States National Security Perspectives on Terrorism A Bitter Pill: Soaring Health Care Spending and Risk Insurance in the United States RR-573-CCRMC the American Family IG-106 Prolonged Cycle Times and Schedule Growth China: The Reluctant Partner in Defense Acquisition: A Literature Review PT-123-USSOCOM RR-455-OSD

Continuity of Care and the Cost of Promoting Patient Safety Through Treating Chronic Disease Effective Health Information RB-9795 Technology Risk Management RR-654-DHHSNCH Redirecting Innovation in U.S. Correctional Education in the United States: How Health Care: Options to Decrease Effective Is It, and How Can We Move the Field Spending and Increase Value Forward? RR-308 RB-9763-BJA Small Ideas for Saving Big Health Care Dollars Evaluating the Impact of the Department of RR-390-RC Defense Regional Centers for Security Studies RR-388-OSD The Impact on Federal Spending of Allowing the Terrorism Risk Insurance Act to Expire Healing Medical Product Innovation RR-611-CCRMC RB-9767 The Impact on Workers’ Compensation How Effective Is Correctional Education, Insurance Markets of Allowing the and Where Do We Go from Here? The Terrorism Risk Insurance Act to Expire Results of a Comprehensive Evaluation RR-643-CCRMC RR-564-BJA What to Do About Dementia? Policy Improving Dementia Long-Term Options for Crucial Long-Term Care Care: A Policy Blueprint RB-9780 RR-597 United States Air Force Improving Interagency Information Sharing An Operational Architecture for Improving Using Technology Demonstrations: The Legal Air Force Command and Control Through Basis for Using New Sensor Technologies for Enhanced Agile Combat Support Planning, Counterdrug Operations Along the U.S. Border Execution, Monitoring, and Control Processes RR-551-OSD RR-261-AF 129

Balancing Agile Combat Support Manpower to Implementation of the DoD Diversity and Better Meet the Future Security Environment Inclusion Strategic Plan: A Framework RR-337-AF for Change Through Accountability RR-333-OSD Enhancing Performance Under Stress: Stress Inoculation Training for Battlefield Airmen Prolonged Cycle Times and Schedule Growth RR-750-AF in Defense Acquisition: A Literature Review RR-455-OSD Implementation Actions for Improving Air Force Command and Control Through Enhanced Toward Improved Management of Agile Combat Support Planning, Execution, Officer Retention: A New Capability Monitoring, and Control Processes for Assessing Policy Options RR-259-AF RR-764-OSD

Improving Demographic Diversity in United States Navy the U.S. Air Force Officer Corps RR-495-AF Authority to Issue Interoperability Policy RR-357-NAVY Psychological Fitness and Resilience: A Review of Relevant Constructs, Developing Navy Capability to Recover Forces in Measures, and Links to Well-Being Chemical, Biological, and Radiological Hazard RR-102-AF Environments RR-155-OSD Suitability of Missions for the Air Force Reserve Components Unmanned Aerial Vehicles RR-429-AF Armed and Dangerous? UAVs and U.S. Security The Association Between Base-Area RR-449-RC Social and Economic Characteristics and Airmen's Outcomes Building Toward an Unmanned Aircraft RR-132-AF System Training Strategy RR-440-OSD The Future of the U.S. Intercontinental Ballistic Missile Force The Effectiveness of Remotely Piloted Aircraft MG-1210-AF in a Permissive Hunter-Killer Scenario RR-276-AF United States Army Urban Planning Changing the Army's Weapon Training Strategies to Meet Operational Requirements Autonomous Vehicle Technology: More Efficiently and Effectively A Guide for Policymakers RR-448-A RR-443-1-RC

Making the Reserve Retirement Autonomous Vehicle Technology: How System Similar to the Active System: to Best Realize Its Social Benefits Retention and Cost Estimates RB-9755-RC RR-530-A The Socioeconomic Effects of the Working United States Department of Defense Poor Moving to Permanent Dwellings: The Case of the Ashray Affordable Authority to Issue Interoperability Policy Housing Pilot Project in India RR-357-NAVY RR-714-RF 130

Vaccination Support Resources for Military Caregivers U.S. Vaccines Deemed Extremely Safe, with RB-9764/4-TEDF Serious Side Effects Rare Among Children RB-9799 Supporting Military Caregivers: Options for Congress Value-Based Purchasing in Health Care RB-9764/1-TEDF Supporting Military Caregivers: The Measuring Success in Health Care Value- Role of Health Providers Based Purchasing Programs: Findings RB-9764/3-TEDF from an Environmental Scan, Literature Review, and Expert Panel Discussions Violent Crime RR-306-ASPE In Broad Daylight: New Calculator Measuring Success in Health Care Brings Crime Costs—and the Value Value-Based Purchasing Programs: of Police—Out of the Shadows Summary and Recommendations IG-105 RR-306/1-ASPE Mexico Is Not Colombia: Alternative Historical Veteran Health Care Analogies for Responding to the Challenge of Violent Drug-Trafficking Organizations Health and Economic Outcomes Among the RR-548/1 Alumni of the Wounded Warrior Project: 2013 RR-522-WWP Mexico Is Not Colombia: Alternative Historical Analogies for Responding to Hidden Heroes: America's Military Caregivers RR-499-TEDF the Challenge of Violent Drug-Trafficking Organizations, Supporting Case Studies Hidden Heroes: America's Military RR-548/2 Caregivers — Executive Summary RR-499/1-TEDF Vocational Education

Key Facts and Statistics from the Improving Technical Vocational Education and RAND Military Caregivers Study Training in the Kurdistan Region—Iraq PT-124-TEDF RR-277-KRG

Military Caregivers in the Workplace Improving Technical Vocational Education RB-9764/2-TEDF and Training in the Kurdistan Region— Iraq: Arabic-language version Military Caregivers: Who are They? RR-277/1-KRG And Who Is Supporting Them? RB-9764-TEDF Improving Technical Vocational Education and Training in the Kurdistan Region— Out of the Shadows: What We Know About Iraq: Kurdish-language version the Well-Being and Experiences of Private RR-277/2-KRG Contractors Working in Conflict Environments RB-9753-RC wages and compensation Toward Improved Management of Officer Out of the Shadows: What We Know About Retention: A New Capability for Assessing the Well-Being and Experiences of Private Policy Options Contractors Working in Conflict Environments RR-764-OSD IG-111-RC 131

Youth in Jordan: Transitions from Mapping Gender Gaps in Health Care Education to Employment RB-9781-CSMC RR-556-CMEPP Women's Heart Health: Research That Matters warfare and military operations PT-120-UCLA

Developing Navy Capability to Recover Work-Family Conflicts Forces in Chemical, Biological, and Radiological Hazard Environments Caring for children in Europe: How childcare, RR-155-OSD parental leave and flexible working Enhancing Performance Under Stress: Stress arrangements interact in Europe Inoculation Training for Battlefield Airmen RR-554-EC RR-750-AF Workers' Compensation Libya After Qaddafi: Lessons and Implications for the Future Implementing a Resource-Based Relative Value RR-577-SRF Scale Fee Schedule for Physician Services: An Assessment of Policy Options for the The Dynamics of Syria's Civil War California Workers’ Compensation Program PE-115-RC RR-395-1-DIR

Water Resources Management The Impact on Workers’ Compensation Insurance Markets of Allowing the RAND Review: Vol. 38, No. 1, Spring 2014 Terrorism Risk Insurance Act to Expire CP-22 (4/14) RR-643-CCRMC

Strengthening Coastal Planning: How Coastal Ambulatory Surgical Services Provided Regions Could Benefit from Louisiana’s Under California Workers’ Compensation: Planning and Analysis Framework An Assessment of the Feasibility and RR-437-RC Advisability of Expanding Coverage RR-524-DIR WEAPONS OF MASS DESTRUCTION How Will the Patient Protection and Affordable Developing Navy Capability to Recover Care Act Affect Liability Insurance Costs? Forces in Chemical, Biological, and RR-493-ICJ Radiological Hazard Environments RR-155-OSD Identifying Permanently Disabled Workers with Disproportionate Earnings Losses Penaid Nonproliferation: Hindering for Supplemental Payments the Spread of Countermeasures RR-425-CHSWC Against Ballistic Missile Defenses RR-378-DTRA The Impact of the Affordable Care Act on Liability Insurance Women's Health RB-9768-ICJ

Mapping Gender Differences in Cardiovascular Workforce Diversity Management Disease and Diabetes Care: A Pilot Assessment of LDL Cholesterol Testing Implementation of the DoD Diversity and Rates in a California Health Plan Inclusion Strategic Plan: A Framework for RR-539-CSMC Change Through Accountability RR-333-OSD 132

Improving Demographic Diversity in the U.S. Air Force Officer Corps RR-495-AF

Workforce Management

An Assessment of the Present and Future Labor Market in the Kurdistan Region—Iraq: Implications for Policies to Increase Private-Sector Employment RR-489-KRG

Workplace Discrimination

How have Levels of Intolerance Changed in Western Europe? IG-117

Intolerance in Western Europe: Analysis of trends and associated factors RR-334-OSI

Intolerance in Western Europe: Analysis of trends and associated factors: Summary report RR-334/1-OSI

Workplace Injury Prevention

Reducing the Economic Burden of Work-Related Injuries RGSD-330

Yemen

A New Approach to Security and Justice Sector Assistance: An Enhanced Partnership Planning Model RB-9779-DOS 133 TITLE INDEX

12-month outcomes of community engagement versus technical assistance to A naturopathic approach to the prevention implement depression collaborative care: a of cardiovascular disease: cost-effectiveness partnered, cluster, randomized, comparative analysis of a pragmatic multi-worksite effectiveness trial randomized clinical trail EP-66219 EP-51749

2014 RAND Annual Report A New Approach to Security and Justice CP-1 (2014) Sector Assistance: An Enhanced Partnership Planning Model RB-9779-DOS A case of partial convergence: the Europeanization of central government in Central and Eastern Europe A New Estimate of the Impact of OSHA EP-66226 Inspections on Manufacturing Injury Rates, 1998- 2005 EP-50461 A Case Study Evaluating the Fidelity of Suicide Prevention Workshops in California RR-755-CMHSA A Noncontributory Pension Program for Older Persons in Yucatan, Mexico: Implementing and Designing the Evaluation of the Program in A comparison of Cambodian-American Valladolid adolescent substance use behavior to national TR-1288/1-SOY/NIA and local norms EP-66138 A Noncontributory Pension Program for Older Persons in Yucatan, Mexico: Implementing and A Database of U.S. Security Treaties and Designing the Evaluation of the Program in Agreements Merida TL-133-AF TR-1288/2-SOY/NIA A patient-centered primary care practice approach using evidence-based quality A Guide to the Medical Home as a Practice- improvement: rationale, methods, and Level Intervention early assessment of implementation EP-50441 EP-50492

A Health Care Puzzler A Persistent Threat: The Evolution of al Qa'ida RB-9782 and Other Salafi Jihadists RR-637-OSD

A National Strategy to Develop Pragmatic Clinical Trials Infrastructure EP-51701 134

A prescription is not enough: improving public A systematic review of stakeholder health with health literacy engagement in comparative effectiveness and EP-50510 patient-centered outcomes research EP-50516

A Program Manager’s Guide for Program Improvement in Ongoing Psychological Health A systematic scoping review of complementary and Traumatic Brain Injury Programs: The RAND and alternative medicine mind and body Toolkit, Volume 4 practices to improve the health of veterans and RR-487/4-OSD military personnel EP-66222

A promising thaw EP-66181 A test of biological and behavioral explanations for gender differences in telomere length: the multi-ethnic study of atherosclerosis A proposed approach may help systematic EP-50542 reviews retain needed expertise while minimizing bias from nonfinancial conflicts of interest EP-66112 A web-based platform to support an evidence- based mental health intervention: lessons from the CBITS web site A prospective study of marijuana use change EP-66147 and cessation among adolescents EP-66189 A wedge-based approach to estimating health co-benefits of climate change mitigation activities A Randomized Controlled Trial of Students in the United States for Nutrition and Exercise: A Community-Based EP-66214 Participatory Research Study EP-51792 ACADEMIC CIVIC MINDEDNESS AND MODEL CITIZENSHIP IN THE INTERNATIONAL BACCALAUREATE DIPLOMA PROGRAMME WR-1044-IBO A regression model for risk difference estimation in population-based case-control studies clarifies gender differences in lung Acceptance and use of health information cancer risk of smokers and never smokers technology by community-dwelling elders EP-50468 EP-66193

A Systematic Process to Facilitate Evidence- Acculturation and Sleep Among a Multiethnic Informed Decisionmaking Regarding Program Sample of Women: The Study of Women's Health Expansion: The RAND Toolkit, Volume 3 Across the Nation (SWAN) RR-487/3-OSD EP-51714 135

Achieving Higher-Fidelity Conjunction Air Force Manpower Requirements and Analyses Using Cryptography to Improve Component Mix: A Focus on Agile Combat Information Sharing Support RR-344-AF RR-617-AF

Addendum to Effectiveness of Cognitive Tutor Air Force Personnel Research: Algebra I at Scale Recommendations for Improved Alignment WR-1050-DEIES RR-814-AF

Addressing Coastal Vulnerabilities Through Air Force-Wide Needs for Science, Comprehensive Planning: How RAND Supported Technology, Engineering, and Mathematics the Development of Louisiana’s Comprehensive (STEM) Academic Degrees Master Plan RR-659-AF RB-9696-1

Alcohol and marijuana use in middle school: Adults Exposed to "Know the Signs" Are More comparing solitary and social-only users Confident Intervening with Those At Risk for EP-66174 Suicide RR-686-CMHSA Almost Random: Evaluating a Large-Scale Randomized Nutrition Program in the Presence Advancing Behavioral Health Measurement: of Crossover The PROMIS® Smoking Assessment Toolkit EP-51713 RB-9803

Alternative Futures for Syria: Regional Africa mapping: current state of health Implications and Challenges for the United research on poverty-related and neglected States infectious diseases in Sub-Saharan Africa PE-129-RC EP-50529 Alternative tobacco product use and smoking cessation among homeless youth in Los Angeles County AID UNDER FIRE: DEVELOPMENT EP-66155 PROJECTS AND CIVIL CONFLICT EP-51839 Ambulatory Surgical Services Provided Air Force Major Defense Acquisition Program Under California Workers’ Compensation: Cost Growth Is Driven by Three Space Programs An Assessment of the Feasibility and and the F-35A: Fiscal Year 2013 President's Advisability of Expanding Coverage RR-524-DIR Budget Selected Acquisition Reports RR-477-AF

America's Poor and the Great Recession, by Kristin S. Seefeldt and John D. Graham EP-50489 136

American Medical Association Impairment An Examination of New York State’s Integrated Ratings and Earnings Losses Due to Disability Primary and Mental Health Care Services for EP-51704 Adults with Serious Mental Illness RR-670-NYSHF

An "assertive" China? insights from interviews EP-51755 An examination of the bidirectional relationship between functioning and symptom levels in patients with anxiety disorders in the CALM An Assessment of Program Sustainability in study Three Bureau of Justice Assistance Criminal EP-66198 Justice Domains RR-550-BJA An exploration of how perceptions of the risk of avian influenza in poultry relate to urbanization An Assessment of the Present and Future in Vietnam Labor Market in the Kurdistan Region—Iraq: EP-51751 Implications for Policies to Increase Private- Sector Employment RR-489-KRG An Exploratory Study of HIV-Prevention Advocacy by Persons in HIV Care in Uganda EP-51642 An Assessment of the Present and Future Labor Market in the Kurdistan Region—Iraq: Implications for Policies to Increase Private- An intervention to reduce HIV-related stigma Sector Employment (Arabic-language version) in partnership with African American and Latino RR-489/1-KRG churches EP-51744

An Assessment of the Present and Future Labor Market in the Kurdistan Region—Iraq: An Operational Architecture for Improving Air Implications for Policies to Increase Private- Force Command and Control Through Enhanced Sector Employment (Kurdish-language version) Agile Combat Support Planning, Execution, RR-489/2-KRG Monitoring, and Control Processes RR-261-AF An Evaluation of the Implementation and Perceived Utility of the Airman Resilience Training Program Analysis of Teladoc Use Seems to Indicate RR-655-OSD Expanded Access to Care for Patients Without Prior Connection to a Provider EP-50457 An Examination of Longitudinal CAUTI, SSI, and CDI Rates from Key HHS Data Systems EP-51688 Analysis to Inform Defense Planning Despite Austerity RR-482-OSD 137

Anemia in Low-Income Countries Is Unlikely Are users' most recent drug purchases to Be Addressed by Economic Development representative? Without Additional Programs EP-66120 EP-51709

Armed and Dangerous? UAVs and U.S. Anti-Inflammatory Medication Adherence, Security Healthcare Utilization and Expenditures Among RR-449-RC Medicaid and Children's Health Insurance Program Enrollees with Asthma EP-51641 Assessing Alternative Modifications to the Affordable Care Act: Impact on Individual Market Premiums and Insurance Coverage Anxiety and depressive symptoms and RR-708-DHHS medical illness among adults with anxiety disorders EP-50555 Assessing Locally Focused Stability Operations RR-387-A Application of Patient Safety Indicators Internationally: A Pilot Study Among Seven Countries Assessing Security Cooperation as a EP-50454 Preventive Tool RR-350-A

Applying Lessons Learned from Past Response Operations to Strengthening National Assessing Small Non-Zero Perceptions of Preparedness Chance: The Case of H1N1 (Swine) Flu Risks CT-411 EP-51700

Applying Lessons Learned from Past Assessing Stop-Loss Policy Options Through Response Operations to Strengthening National Personnel Flow Modeling Preparedness: Addendum DB-573-OSD CT-411/1

Assessing the Army’s Active-Reserve Approach for Conducting the Longitudinal Component Force Mix Program Evaluation of the U.S. Department of RR-417-1-A Health and Human Services National Action Plan to Prevent Healthcare Associated Infections: Roadmap to Elimination Assessing the Chiral Switch: Approval and Use EP-51685 of Single-Enantiomer Drugs, 2001 to 2011 EP-51772

Are mental disorders more common in urban than rural areas of the United States? EP-51865 138

Assessing the contribution of parks to physical Associations Among Body Size, Body Image activity using global positioning system and Perceptions, and Weight Loss Attempts Among accelerometry African American, Latino, and White Youth: A Test EP-51853 of a Mediational Model EP-51745

Assessing the effects of medical marijuana laws on marijuana use: the devil is in the details Associations between socioeconomic status EP-50537 and obesity in diverse, young adolescents: variation across race/ethnicity and gender EP-66157 Assessing the Potential to Expand Community College Baccalaureate Programs in Texas RR-745-CFAT Attractiveness of initial vocational education and training: identifying what matters EP-50530 Assessing the Potential to Expand Community College Baccalaureate Programs in Texas: Executive Summary Authorities and Options for Funding RR-745/1-CFAT USSOCOM Operations RR-360-SOCOM

Assessing the validity of the RAND negative impact of asthma on quality of life short forms Authority to Issue Interoperability Policy EP-51810 RR-357-NAVY

Assessing the validity of using serious game Autonomous Vehicle Technology: A Guide for technology to analyze physician decision making Policymakers EP-66190 RR-443-RC

Association Between Participation in a Autonomous Vehicle Technology: A Guide for Multipayer Medical Home Intervention and Policymakers Changes in Quality, Utilization, and Costs of RR-443-1-RC Care EP-50465 Autonomous Vehicle Technology: How to Best Realize Its Social Benefits Association of vascular risk factors with RB-9755-RC cognition in a multiethnic sample EP-66145 Balancing Agile Combat Support Manpower to Better Meet the Future Security Environment RR-337-AF 139

Barriers and facilitators to pediatric emergency Brain Drain: Do Economic Conditions "Push" telemedicine in the United States Doctors Out of Developing Countries? EP-66180 EP-51659

Barriers to Enrollment in Health Coverage in Breaking the cycle of disadvantage: Early Colorado Childhood interventions and progression to RR-782-COHF higher education in Europe RR-553-EC

Behavioral Fitness and Resilience: A Review of Relevant Constructs, Measures, and Links to Bring the world to California Well-Being EP-50512 RR-103-AF

Bringing online in line: contribution to an Beliefs about the causes of schizophrenia impact assessment for the Delegated Act to among Aymara and non-Aymara patients and implement the online provisions of the revised their primary caregivers in the Central-Southern Energy Related Products Directive Andes EP-50554 EP-66125

Brothers Killing Brothers: The Current Beliefs Related to Mental Illness Stigma Infighting Will Test al Qaeda's Brand Among California Young Adults PE-123-RC RR-819-CMHSA

Building on the Quadrennial Homeland Best practice: Medical training from an Security Review to Improve the Effectiveness international perspective and Efficiency of the Department of Homeland RR-622-KBV Security CT-412

Best Practices for Assessing Locally Focused Stability Operations Building on the Quadrennial Homeland RB-9784-A Security Review to Improve the Effectiveness and Efficiency of the Department of Homeland Security: Addendum Better-than-average and worse-than-average CT-412/1 hospitals may not significantly differ from average hospitals: an analysis of Medicare Hospital Compare ratings Building Resilient Communities: Spanish EP-66218 translation TL-109/1

Blinders, Blunders, and Wars: What America and China Can Learn RR-768-RC 140

Building Toward an Unmanned Aircraft System Capacity Building at the Kurdistan Region Training Strategy Statistics Office Through Data Collection: Arabic RR-440-OSD translation RR-293/2-KRG

Bundled payment fails to gain a foothold in California: the experience of the IHA bundled Capacity Building at the Kurdistan Regional payment demonstration Statistics Organization Through Data Collection: EP-50523 Appendixes RR-293/1-KRG

Business Bribery Risk Assessment RR-839-TII Caring for Brain and Body: Integrating Care for Adults with Serious Mental Illness in New York State California Colleges and Universities RB-9806-NYSHF Collaborate to Support Student Mental Health RR-689-CMHSA Caring for children in Europe: How childcare, parental leave and flexible working arrangements California K-12 Schools and Communities interact in Europe Collaborate to Support Student Mental Health RR-554-EC RR-688-CMHSA

Catastrophic Risk in California: Are CalMHSA Student Mental Health Campus- Homeowners and Communities Prepared? Wide Survey: 2013 Summary Report CT-417 RR-685-CMHSA

Causal inference using mixture models: a word Can New Tests Lead to Better Teaching and of caution Deeper Learning? EP-66146 RB-9766-WFHF

Challenges in systematic reviews of qualitative Cannabis Use and Antisocial Behavior Among research Youth EP-66205 EP-51651

Challenges in U.S. National Security Policy: A Capacity Building at the Kurdistan Region Statistics Office Through Data Collection Changes in Condom Use During the First Year RR-293-KRG of HIV Treatment in Uganda and the Relationship to Depression EP-51706 141

Changes in Health Insurance Enrollment China: The Reluctant Partner Since 2013: Evidence from the RAND Health PT-123-USSOCOM Reform Opinion Study RR-656-RC China's International Behavior: Chinese translation (traditional characters) Changes in obesity between fifth and tenth MG-850/2-AF grades: a longitudinal study in three metropolitan areas EP-66208 China's Strategy Toward South and Central Asia: An Empty Fortress RR-525-AF Changes in Physician Antipsychotic Prescribing Preferences, 2002-2007 EP-51666 Chinese Engagement in Africa: Drivers, Reactions, and Implications for U.S. Policy RR-521-OSD Changes in self-efficacy and outcome expectancy as predictors of anxiety outcomes from the CALM study Clinician advice to quit smoking among EP-66195 seniors EP-66239

Changing Constituencies and Rising Polarization in the Congress: Three Essays Clinicians' utilization of child mental health RGSD-329 telephone consultation in primary care: findings from Massachusetts EP-51758 Changing Eating Habits for the Medical Profession EP-51668 Closing the Strategy–Policy Gap in Countering Weapons of Mass Destruction RB-9805-RC Changing the Army's Weapon Training Strategies to Meet Operational Requirements More Efficiently and Effectively Cocaine's fall and marijuana's rise: questions RR-448-A and insights based on new estimates of consumption and expenditures in U. S. drug markets China and Taiwan: balance of rivalry with EP-66109 weapons of mass democratization EP-51791 Cognitive adaptation theory as a predictor of adjustment to emerging adulthood for youth with China in Africa: Implications of a Deepening and without type 1 diabetes Relationship EP-66241 RB-9760-OSD 142

Cognitive Aging, Neuropathology, and Comorbid depression and substance abuse Resilience among safety-net clients in Los Angeles: a PT-132-NIH/NIA community participatory study EP-66229

Cognitive processing therapy for veterans with comorbid PTSD and alcohol use disorders Comparative effectiveness of fidaxomicin for EP-66106 treatment of Clostridium difficile infection EP-66179

Cohort profile: the China health and retirement longitudinal study (CHARLS) Comparative effectiveness of pharmacologic EP-66144 treatments to prevent fractures: an updated systematic review EP-66167 Common patterns of morbidity and multi- morbidity and their impact on health-related quality of life: evidence from a national survey Comparative effectiveness of shock wave EP-66201 lithotripsy and ureteroscopy for treating patients with kidney stones EP-51852 Common versus specific correlates of fifth- grade conduct disorder and oppositional defiant disorder symptoms: comparison of three racial/ Comparing perceived public stigma and ethnic groups personal stigma of mental health treatment EP-66233 seeking in a young adult sample EP-51847

Community engagement in disaster preparedness and recovery: a tale of two cities – Comparing the implementation of team Los Angeles and New Orleans approaches for improving diabetes care in EP-50503 community health centers EP-66236

Community-partnered collaboration to build an integrated palliative care clinic: the view from Comparison of complementary and alternative urology medicine with conventional mind–body therapies EP-50533 for chronic back pain: protocol for the Mind– body Approaches to Pain (MAP) randomized controlled trial Community-partnered research conference EP-66158 model: the experience of community partners in care study EP-51817 Competency-Based Education in Three Pilot Programs: Examining Implementation and Outcomes RR-732-BMGF 143

Competency-Based Education in Three Pilot Continuous Quality Improvement (CQI) Programs: What It Is, How It’s Implemented, and in Addiction Treatment Settings: Design and How It’s Working Intervention Protocol of a Group Randomized RB-9796-BMGF Pilot Study EP-51697

Competition and Collaboration: A Comparison of U.S. and Chinese Energy Outward Direct Contributions of the social environment to Investment first-onset and recurrent mania RGSD-344 EP-51803

Correctional Education in the United States: Comprehensive healthcare: why is the How Effective Is It, and How Can We Move the inclusion of reproductive health controversial for Field Forward? women but not men? RB-9763-BJA EP-51855

Correlates of use of timed unprotected Consequences of interstitial cystitis/bladder intercourse to reduce horizontal transmission pain symptoms on women's work participation among Ugandan HIV clients with fertility and income: results from a national household intentions sample EP-66188 EP-51801

Correspondence Between the RAND- Consistent assignment of nurse aides: negative Impact of Asthma on Quality of Life association with turnover and absenteeism Item Bank and the Marks Asthma Quality of Life EP-51757 Questionnaire EP-51796

Consumption Smoothing and HIV/AIDS: The Case of Two Communities in South Africa Cost Considerations in Cloud Computing EP-51710 PE-113-A

Contextual predictors of cumulative biological Cost-benefit analysis of a preventive risk: segregation and allostatic load intervention for divorced families: reduction in EP-51854 mental health and justice system service use costs 15 years later EP-66211 Continuity and the Costs of Care for Chronic Disease EP-51779 Cost-effectiveness of CT screening in the National Lung Screening Trial EP-50543 Continuity of Care and the Cost of Treating Chronic Disease RB-9795 144

Costs and benefits of treating maternal Cutting Medicare hospital prices leads to a depression spillover reduction in hospital discharges for the EP-50514 nonelderly EP-51825

Countering ISIL’s Financing CT-419 Daily mean temperature and clinical kidney stone presentation in five U. S. metropolitan areas: a time-series analysis Countering Others' Insurgencies: EP-66182 Understanding U.S. Small-Footprint Interventions in Local Context RR-513-SRF Daily violent video game playing and depression in preadolescent youth EP-66111 Counterterrorism and the Role of Special Operations Forces CT-408 Data Flood: Helping the Navy Address the Rising Tide of Sensor Information RR-315-NAVY Covariance among multiple health risk behaviors in adolescents EP-51844 Declines in late-life disability: the role of early - and mid-life factors EP-51840 Creating constituencies for long-term, radical change EP-50469 Decomposing racial disparities in prison and drug treatment commitments for criminal offenders in California Criminal justice costs of prohibiting marijuana EP-50509 in California EP-51731 Defeating the Islamic State in Iraq CT-418 Cross Validation Bandwidth Selection for Derivatives of Multidimensional Densities WR-1060 Defining and Measuring Integrated Patient Care: Promoting the Next Frontier in Health Care Delivery Cruise Missile Penaid Nonproliferation: EP-50439 Hindering the Spread of Countermeasures Against Cruise Missile Defenses RR-743-DTRA Democracy in Afghanistan: The 2014 Election and Beyond PE-120-OSD 145

Demographic and Predeparture Factors Designing a System for Collecting Policy- Associated with Drinking and Alcohol-Related Relevant Data for the Kurdistan Region—Iraq: Consequences for College Students Completing Arabic-language version Study Abroad Experiences MG-1184/1-1-KRG EP-50499

Designing a System for Collecting Policy- Depression and health risk behaviors: towards Relevant Data for the Kurdistan Region—Iraq: optimizing primary care service strategies for Kurdish-language version addressing risk MG-1184/2-1-KRG EP-51848

Designing Efficient Systematic Reviews Using Depression Screening: Utility of the Patient Economical Allocation, Creation and Synthesis of Health Questionnaire in Patients with Acute Medical Evidence Coronary Syndrome RGSD-334 EP-51667

Designing Unmanned Systems with Greater Depressive Symptoms and Longitudinal Autonomy: Using a Federated, Partially Open Changes in Cognition: Women's Health Initiative Systems Architecture Approach Study of Cognitive Aging RR-626-OSD EP-51798

Deterrence, Influence, Cyber Attack, and Design and use of performance measures to Cyberwar decrease low-value services and achieve cost- WR-1049 conscious care EP-51813 Developing a global cancer stigma index EP-66163 Design of the Violence and Stress Assessment (ViStA) study: a randomized controlled trial of care management for PTSD Developing a Research Strategy for Suicide among predominantly Latino patients in safety Prevention in the Department of Defense: Status net health centers of Current Research, Prioritizing Areas of Need, EP-51821 and Recommendations for Moving Forward RR-559-OSD

Designing a System for Collecting Policy- Relevant Data for the Kurdistan Region—Iraq Developing a U.S. Strategy for Dealing with MG-1184-1-KRG China--Now and into the Future RB-9802-A 146

Developing an Item Bank and Short Forms Development of telehealth dialogues for That Assess the Impact of Asthma on Quality of monitoring suicidal patients with schizophrenia: Life consumer feedback EP-51673 EP-50522

Developing and Testing Informed-Consent Development of the PROMIS® coping Methods in a Study of the Elderly in Mexico expectancies of smoking item banks TR-1288/8-SOY-NIA EP-66131

Developing Army Leaders: Lessons for Development of the PROMIS® health Teaching Critical Thinking in Distributed, expectancies of smoking item banks Resident, and Mixed-Delivery Venues EP-66127 RR-321-A

Development of the PROMIS® negative Developing Public Health Regulations for psychosocial expectancies of smoking item Marijuana: Lessons from Alcohol and Tobacco banks EP-50498 EP-66136

Developing Robust Strategies for Climate Development of the PROMIS® nicotine Change and Other Risks: A Water Utility dependence item banks Framework EP-66132 RR-977-WRF

Development of the PROMIS® positive Development and evaluation of the CAHPS emotional and sensory expectancies of smoking (Consumer Assessment of Healthcare Providers item banks and Systems) Survey for In-Center Hemodialysis EP-66134 patients EP-66102 Development of the PROMIS® social motivations for smoking item banks Development and Preliminary Validation of the EP-66135 Patient Perceptions of Integrated Care Survey EP-50436 Did California's hand-held cell phone ban reduce accidents? Development and psychometric properties of EP-66115 the PROMIS® pediatric fatigue item banks EP-51739 Disability Insurance and Health Insurance Reform: Evidence from Massachusetts Development and validation of the RAND WR-1029 asthma control measure EP-66122 147

Disability insurance and health insurance DoD and Commercial Advanced Waveform reform: evidence from Massachusetts Developments and Programs with Multiple Nunn- EP-51843 McCurdy Breaches, Volume 5 MG-1171/5-OSD

Discussions about clinical trials among patients with newly diagnosed lung and DoD Depot-Level Reparable Supply Chain colorectal cancer Management: Process Effectiveness and EP-66165 Opportunities for Improvement RR-398-OSD

Disproportionate-share hospital payment reductions may threaten the financial stability of Does Affiliation of Physician Groups with One safety-net hospitals Another Produce Higher Quality Primary Care? EP-50515 EP-50440

Distance to store, food prices, and obesity in Does Diversity Matter? The Need for urban food deserts Longitudinal Research on Adolescent Alcohol EP-50528 and Drug Use Trajectories EP-51795

Distributing Noncontributory Pension Benefits by Debit Card in Mexico: A Pilot Test Does Group Cognitive–behavioral Therapy TR-1288/7-SOY-NIA Module Type Moderate Depression Symptom Changes in Substance Abuse Treatment Clients? EP-50500 Diversity Outreach and Recruiting Event Site Selection (DORESS) TL-130-AF Does Premarital Education Decrease or Increase Couples' Later Help-Seeking? EP-51707 Do Employers Prefer Workers Who Attend For-Profit Colleges? Evidence from a Field Experiment Does San Francisco’s Community Justice WR-1054 Center Reduce Criminal Recidivism? RR-735-SFSC

Do workplace wellness programs reduce medical costs? evidence from a Fortune 500 Does stewardship make a difference in the company quality of care? Evidence from clinics and EP-50467 pharmacies in Kenya and Ghana EP-51824

Do Workplace Wellness Programs Save Employers Money? Doing wrong to do right? social preferences RB-9744-DOL and dishonest behavior EP-66113 148

Don't middle your MIDs: regression to the Early menarche and childhood adversities in a mean shrinks estimates of minimally important nationally representative sample differences EP-66192 EP-51746

Early puberty, negative peer influence, and Dragon Watching Its Tail: China's Evolving problem behaviors in adolescent girls Engagement Strategy in Africa EP-51728 EP-50485

Economic Burden of Childhood Autism Drinking behaviors and life course Spectrum Disorders socioeconomic status during the transition from EP-50458 adolescence to adulthood among whites and blacks EP-66238 Economic shocks, federalism and redistribution: exploring the future of Europe through a comparison of the evolution of student Drivers of Long-Term Insecurity and Instability financial aid in the United States and the in Pakistan: Urbanization European Union RR-644-OSD EP-50511

Driving in the Future in Developing Countries Education and coronary Heart disease risk: RB-9794-IFMO potential mechanisms such as literacy, perceived constraints, and depressive symptoms EP-50556 Early and School-Age Care in Santa Monica: Current System, Policy Options, and Recommendations Effect of a Multipayer Patient-Centered RR-289-CSM Medical Home on Health Care Utilization and Quality: The Rhode Island Chronic Care Sustainability Initiative Pilot Program Early and School-Age Care in Santa EP-50438 Monica: Current System, Policy Options, and Recommendations: Executive Summary RR-289/1-CSM Effect of Chiranjeevi Yojana on Institutional Deliveries and Neonatal and Maternal Outcomes in Gujarat, India: A Difference-In-Differences Early HIV treatment led to life expectancy Analysis gains valued at $80 billion for people infected in EP-50427 1996-2009 EP-51759 Effect of supplementation with ferrous sulfate or iron bis-glycinate chelate on ferritin Early intervention for abused children in the concentration in Mexican schoolchildren: a school setting randomized controlled trial EP-66213 EP-66119 149

Effective Policing for 21st-Century Israel: Dual Elements of Success: How Type of Secondary English and Hebrew edition Education Credential Helps Predict Enlistee RR-287/1-MPS Attrition RR-374-OSD

Effectiveness of a Community-Based Intervention to Improve Nutrition in Young Emergency Department Patient Experience of Children in Senegal: A Difference in Difference Care Survey: Development and Field Test Analysis RR-761-CMS EP-51711

Emerging trends in earnings structures of Effectiveness of multisystemic therapy for couples in Europe: Short Statistical Report No. 5 minority youth: outcomes over 8 years in Los RR-364-EC Angeles County EP-50513 Employer Accommodation and Labor Supply of Disabled Workers Effects of Employer Health Insurance on WR-1047 Disability Insurance Claiming RB-9776 Engagement in HIV prevention advocacy associated with increased consistent condom Effects of Health Care Reform on Disability use among HIV clients in Uganda Insurance Claiming EP-50550 RB-9769

Enhanced Army Airborne Forces: A New Joint Effects of Medicare Payment Reform: Operational Capability Evidence from the Home Health Interim and RR-309-A Prospective Payment Systems EP-51657 Enhancing Capacity to Address Mental Health Needs of Veterans and Their Families: The Effects of Military Service on Earnings Welcome Back Veterans Initiative and Education Revisited: Variation by RR-719-MTF Service Duration, Occupation, and Civilian Unemployment RR-342-OSD Enhancing Performance Under Stress: Stress Inoculation Training for Battlefield Airmen RR-750-AF Effects of trauma on students: early intervention through the cognitive behavioral intervention for trauma in schools Entertainment X.0 to Boost Broadband EP-66206 Deployment EP-51692 150

Equity in competency education: realizing the Estimating the value of mobile telephony in potential, overcoming the obstacles mobile network not-spots: Summary EP-66203 RR-641/1-DEFRA

Equity in competency education: realizing the potential, overcoming the obstacles : executive summary Evaluating Innovative Leader Development in EP-66204 the U.S. Army RB-9797-A

Equity in the receipt of oseltamivir in the United States during the H1N1 pandemic Evaluating Simulation-Derived Scenarios for EP-51815 Effective Decision Support EP-51717

Essays on Family Welfare and Indian Development Policy Evaluating the "Keep Your Health Plan RGSD-342 Fix": Implications for the Affordable Care Act Compared to Legislative Alternatives RR-529 Estimating Intensive and Extensive Tax Responsiveness: Do Older Workers Respond to Income Taxes? Evaluating the California Mental Health WR-987-1 Services Authority's Stigma and Discrimination Reduction Initiative: Year 1 Findings RR-438/2-CMHSA Estimating the causal effects of cumulative treatment episodes for adolescents using marginal structural models and inverse Evaluating the California Mental Health probability of treatment weighting Services Authority's Student Mental Health EP-51747 Initiative: Year 1 Findings RR-438/3-CMHSA

Estimating the consumptive use costs of shale natural gas extraction on Pennsylvania roadways Evaluating the California Mental Health EP-50547 Services Authority's Suicide Prevention Initiative: Year 1 Findings RR-438/4-CMHSA Estimating the economic costs of antimicrobial resistance: Model and Results RR-911-WT Evaluating the Impact of the Department of Defense Regional Centers for Security Studies RR-388-OSD Estimating the value of mobile telephony in mobile network not-spots RR-641-DEFRA 151

Evaluation of an Implementation Initiative Evaluation of the Population and Poverty for Embedding Dialectical Behavior Therapy in Research Initiative (PopPov): Executive Community Settings Summary EP-50426 RR-527/1-WFHF

Evaluation of Delaware Stars for Early Evaluation of the SAMHSA Primary and Success: Year 1 Report Behavioral Health Care Integration (PBHCI) RR-606-DOEL Grant Program: Final Report (Task 13) RR-546-DHHS

Evaluation of EPIM III: Emerging insights from the evaluation so far Evaluation of the Shreveport Predictive RR-789-EPIM Policing Experiment RR-531-NIJ

Evaluation of National Institute of Justice– Funded Geospatial Software Tools: Technical Evidence on Home Visiting and Suggestions and Utility Assessments to Improve Tool for Implementing Evidence-Based Home Visiting Development, Dissemination, and Usage Through MIECHV RR-418-NIJ CT-407

Evaluation of the California Mental Health Evidence on Home Visiting and Suggestions Services Authority's Prevention and Early for Implementing Evidence-Based Home Visiting Intervention Initiatives: Progress and Preliminary Through MIECHV: Addendum Findings CT-407/1 RR-438-CMHSA

Evidence review of car traffic levels in Britain: Evaluation of the California Mental Health A rapid evidence assessment Services Authority's Prevention and Early RR-887-DFT Intervention Initiatives: Executive Summary and Commentary RR-438/1-CMHSA Evidence-Based Practices in Child and Family Services RR-797 Evaluation of the Population and Poverty Research Initiative (PopPov) RR-527-WFHF Examining the role of patient experience surveys in measuring health care quality EP-50520 Evaluation of the Population and Poverty Research Initiative (PopPov) RR-527-1-WFHF 152

Examining the sustainment of the adolescent- Fee Schedule Options for Services Furnished community reinforcement approach in community by Hospitals to Outpatients under the California addiction treatment settings: protocol for a Workers’ Compensation Program longitudinal mixed method study WR-1016-DIR EP-66154

Feeling (Mis)understood and intergroup Examining the value of inpatient nurse staffing: friendships in interracial interactions an assessment of quality and patient care costs EP-66126 EP-50531

Fertility choice, mortality expectations, and Expanding the Use of Telehealth: Promise and interdependent preferences--: An Empirical Potential Pitfalls Analysis CT-409 EP-51708

Expanding the Use of Telehealth: Promise and Fertility Desires Among HIV-infected Men and Potential Pitfalls: Addendum Women in Los Angeles County: Client Needs CT-409/1 and Provider Perspectives EP-51712

Factors associated with intention to conceive and its communication to providers among HIV Fertility desires and intentions and the clients in Uganda relationship to consistent condom use and EP-51754 provider communication regarding childbearing among HIV clients in Uganda EP-50470 Factors associated with ordering laboratory monitoring of high-risk medications EP-66231 Final Report: Evaluation of Tools and Metrics to Support Employer Selection of Health Plans RR-327-DOL Faith to move mountains: religious coping, spirituality, and interpersonal trauma recovery EP-51814 Findings from Existing Data on the Department of Defense Industrial Base RR-614-OSD Families, Powered On: Improving Family Engagement in Early Childhood Education Through Technology Findings from the School-Based Theatrical RR-673/5-PNC Performance "Walk In Our Shoes" RR-683-CMHSA

Family-related working schedule flexibility across Europe: Short Statistical Report No. 6 Five Steps to a Successful Workplace RR-365-EC Wellness Program: A RAND Toolkit TL-141 153

Fluid consumption by Mexican women during Geographic variation in receipt of pregnancy and first semester of lactation psychotherapy in children receiving attention- EP-51727 deficit/hyperactivity disorder medications EP-66173

Fluid intake in Mexican adults: a cross- sectional study Getting Early Childhood Educators Up and EP-50521 Running: Creating Strong Technology Curators, Facilitators, Guides, and Users RR-673/4-PNC

Focusing on the five A's: a comparison of homeless and housed patients' access to and Getting older isn't all that bad: better decisions use of pharmacist-provided smoking cessation and coping when facing "sunk costs" treatment EP-66183 EP-51850

Getting on the Same Page: Identifying Goals France's War in Mali: Lessons for an for Technology Use in Early Childhood Education Expeditionary Army RR-673/1-PNC RR-770-A

Getting to Negotiations in Syria: The Shadow From Stalemate to Settlement: Lessons for of the Future in the Syrian Civil War Afghanistan from Historical Insurgencies That PE-126-OSD Have Been Resolved Through Negotiations RR-469-OSD Giving ''sadness'' a name: the need for integrating depression treatment into HIV care in Gender equality in the workforce: Reconciling Uganda work, private and family life in Europe EP-66212 RR-462-EC

Gone to War: Have Deployments Increased Gender inequalities in the school-to-work Divorces? transition in Europe: Short Statistical Report EP-51661 No. 4 RR-363-EC Good friends, good food ... what more could we want? Assessing the links between Geographic Targeting in Urban Areas: A social relationships and dietary behaviors. A Social-Welfare Program for Older People in commentary on Conklin et al. Mexico EP-51723 TR-1288/5-SOY-NIA

Hackers Wanted: An Examination of the Cybersecurity Labor Market RR-430 154

Handling ethical problems in counterterrorism: Health Sector Reform in the Kurdistan An inventory of methods to support ethical Region—Iraq: Financing Reform, Primary Care, decisionmaking and Patient Safety RR-251-WODC RR-490-1-KRG

Healing Medical Product Innovation Healthy food access for urban food desert RB-9767 residents: examination of the food environment, food purchasing practices, diet and BMI EP-50544 Health and Economic Outcomes Among the Alumni of the Wounded Warrior Project: 2013 RR-522-WWP Healthy work: challenges and opportunities to 2030 EP-66185 Health and Economic Outcomes in the Alumni of the Wounded Warrior Project: 2010–2012 RR-290-WWP Heterogeneity in healthy aging EP-51818 Health and Healthcare: Assessing the Real World Data Policy Landscape in Europe RR-544-PI Hidden Heroes: America's Military Caregivers RR-499-TEDF

Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Hidden Heroes: America's Military Caregivers Use — Executive Summary EP-50444 RR-499/1-TEDF

Health Sector Reform in the Kurdistan Hidden Heroes: Caregivers to America’s Ill, Region—Iraq: Financing Reform, Primary Care, Injured, and Wounded Service Members and and Patient Safety Veterans RR-490-KRG CT-421

Health Sector Reform in the Kurdistan HIV care providers emphasize the importance Region—Iraq: Financing Reform, Primary Care, of the Ryan White Program for access to and and Patient Safety (Arabic-language version) quality of care RR-490/1-KRG EP-50482

Health Sector Reform in the Kurdistan HIV prevalence and demographic Region—Iraq: Financing Reform, Primary Care, determinants of unprotected anal sex and HIV and Patient Safety (Kurdish-language version) testing among men who have sex with men in RR-490/2-KRG Beirut, Lebanon EP-50506 155

Home front: post-deployment mental health How Do Management Fees Affect Retirement and divorces Wealth Under Mexico’s Personal Retirement EP-51800 Accounts System? WR-1023

Hospice Experience of Care Survey: Development and Field Test How Do We Know What Information Sharing RR-657-CMS Is Really Worth? Exploring Methodologies to Measure the Value of Information Sharing and Fusion Efforts How Are School Leaders and Teachers RR-380-OSD Allocating Their Time Under the Partnership Sites to Empower Effective Teaching Initiative? WR-1041-BMGF How Effective Is Correctional Education, and Where Do We Go from Here? The Results of a Comprehensive Evaluation How Are School Leaders and Teachers RR-564-BJA Allocating Their Time Under the Partnership Sites to Empower Effective Teaching Initiative? WR-1041-1-BMGF How Moroccan mothers and fathers view child development and their role in their children's education How Big is the U.S. Market for Illegal Drugs? EP-50541 RB-9770-ONDCP

How Much and What Kind? Identifying an How can schools help youth increase physical Adequate Technology Infrastructure for Early activity? an economic analysis comparing Childhood Education school-based programs RR-673/3-PNC EP-50549

How much do additional mailings and How Deployments Affect the Capacity and telephone calls contribute to response rates in a Utilization of Army Treatment Facilities survey of Medicare beneficiaries? RR-257-A EP-66221

How Do Federal Civilian Pay Freezes and How much neighborhood parks contribute to Retirement Plan Changes Affect Employee local residents' physical activity in the City of Los Retention in the Department of Defense? Angeles: a meta-analysis RR-678-OSD EP-66168

How do hospitals cope with sustained slow How to Build a Ubiquitous EU Digital Society growth in Medicare prices? EP-51690 EP-66107 156

How to Increase Value and Reduce Waste Identifying Permanently Disabled Workers When Research Priorities Are Set with Disproportionate Earnings Losses for EP-51647 Supplemental Payments RR-425-CHSWC

How Will the Patient Protection and Affordable Care Act Affect Liability Insurance Costs? Identifying Walking Trips from GPS and RR-493-ICJ Accelerometer Data in Adolescent Females EP-51672

Huddle up! the adoption and use of structured team communication for VA medical home IMPACT - Integrative Medicine Primary Care implementation Trial: Protocol for a Comparative Effectiveness EP-66116 Study of the Clinical and Cost Outcomes of an Integrative Primary Care Clinic Model EP-50491 "I don't think I would have recovered": a personal and sociocultural study of resilience among U. S. Marines Impact of a patient incentive program on EP-66150 receipt of preventive care EP-66159

Identification and Analysis of Technology Emergence Using Patent Classification Impact of daily assessments in distress and RR-629-OSD PTSD symptoms in trauma-exposed women EP-50471

Identifying Acquisition Framing Assumptions Through Structured Deliberation Impact of food support on food security and TL-153-OSD body weight among HIV antiretroviral therapy recipients in Honduras: a pilot intervention trial EP-66232 Identifying and Eliminating Barriers Faced by Nontraditional Department of Defense Suppliers RR-267-OSD Impact of HIV antiretroviral therapy on depression and mental health among clients with HIV in Uganda Identifying Enemies Among Us: Evolving EP-50504 Terrorist Threats and the Continuing Challenges of Domestic Intelligence Collection and Information Sharing Impact of Public Works on Household CF-317 Occupational Choice: Evidence from NREGS in India WR-1053 Identifying older adults at high risk of mortality using the Medicare health outcomes survey EP-51808 157

Implementation Actions for Improving Air Air Force Officer Corps Force Command and Control Through Enhanced RR-495-AF Agile Combat Support Planning, Execution, Monitoring, and Control Processes RR-259-AF Improving Interagency Information Sharing Using Technology Demonstrations: The Legal Basis for Using New Sensor Technologies for Implementing a Resource-Based Relative Counterdrug Operations Along the U.S. Border Value Scale Fee Schedule for Physician RR-551-OSD Services: An Assessment of Policy Options for the California Workers’ Compensation Program RR-395-1-DIR Improving QRISs through the use of existing data: a virtual pilot of the California QRIS EP-66240 Implementing collaborative primary care for depression and posttraumatic stress disorder: design and sample for a randomized trial in the Improving School Leadership Through District U.S. military health system Partnerships: Implementation and Effects of New EP-50540 Leaders—Appendix RR-507/1-NL

Implementing Psychological First-Aid Training for Medical Reserve Corps Volunteers Improving Strategic Competence: Lessons EP-50483 from 13 Years of War RR-816-A

Implications of New Insurance Coverage Improving Technical Vocational Education and for Access to Care, Cost-Sharing, and Training in the Kurdistan Region—Iraq Reimbursement RR-277-KRG EP-50431

Improving Technical Vocational Education and Implications of sleep and energy drink use for Training in the Kurdistan Region—Iraq: Arabic- health disparities language version EP-66187 RR-277/1-KRG

Improving Dementia Long-Term Care: A Policy Improving Technical Vocational Education and Blueprint Training in the Kurdistan Region—Iraq: Kurdish- RR-597 language version RR-277/2-KRG

Improving Demographic Diversity in the U.S. Improving the Physical Health of Adults with Serious Mental Illness RB-9789-DHHS 158

Improving the Value of Analysis for Initial Thoughts on the Impact of the Iraq War Biosurveillance on U.S. National Security Structures EP-51787 PE-111-OSD

Improving Turkish-Iraqi Border Security: An Innovative Leader Development: Evaluation Agent-Based Modeling and Simulation Approach of the U.S. Army Asymmetric Warfare Adaptive RGSD-341 Leader Program RR-504-A

In with the Big, Out with the Small: Removing Small-Scale Reservations in India Integrating the use of patient-reported WR-1038 outcomes for both clinical practice and performance measurement: views of experts from 3 countries In-state college tuition policies for EP-50552 undocumented immigrants: implications for high school enrollment among non-citizen Mexican youth INtegration of DEPression Treatment into EP-66140 HIV care in Uganda (INDEPTH-Uganda): study protocol for a randomized controlled trial EP-66101 Incentives for Biodefense Countermeasure Development EP-51662 International variation in drug usage: An exploratory analysis of the "causes" of variation RR-899-DH Inclusive innovation: an architecture for policy development EP-51863 Interpersonal Distress Is Associated with Sleep and Arousal in Insomnia and Good Sleepers Information and Communication Technologies EP-51699 to Promote Social and Psychological Well-Being in the Air Force: A 2012 Survey of Airmen RR-695-AF Interventions to improve late life EP-51841

Information Security and Data Protection Legal and Policy Frameworks Applicable to European Intolerance in Western Europe: Analysis of Union Institutions and Agencies trends and associated factors RR-557-ME RR-334-OSI

Information technology and high-performance Intolerance in Western Europe: Analysis of teams: creating value through knowledge trends and associated factors: Summary report EP-51842 RR-334/1-OSI 159

Introduction to the Evaluation of the Intensive ISOQOL Recommends Minimum Standards Partnerships for Effective Teaching (IP) for Patient-Reported Outcome Measures Used WR-1034-BMGF in Patient-Centered Outcomes and Comparative Effectiveness Research EP-51671 Introduction: Taking National Action to Prevent and Eliminate Healthcare-Associated Infections EP-51683 Issuance of patient reminders for influenza vaccination by U.S.-based primary care physicians during the first year of universal Investigating time lags and attribution in the influenza vaccination recommendations translation of cancer research: A case study EP-51819 approach RR-627-WT It Takes a Village: Network Effects on Rural Education in Afghanistan Involving community stakeholders to increase RGSD-327 park use and physical activity EP-51806 Jihadist Sanctuaries in Syria and Iraq: Implications for the United States Iran’s Influence in Afghanistan: Implications for CT-414 the U.S. Drawdown RR-616 Juvenile crime and juvenile justice EP-51829 Is Multisystemic Therapy (MST) Effective for Hispanic Youth? An Evaluation of Outcomes for Juvenile Offenders in Los Angeles County Keeping Major Naval Ship Acquisitions on RB-9791 Course: Key Considerations for Managing Australia's SEA 5000 Future Frigate Program RR-767-AUS Is Occupational Injury Risk Higher at New Firms? EP-50459 Key Facts and Statistics from the RAND Military Caregivers Study PT-124-TEDF Is previous removal from the United States a marker for high recidivism risk? results from a 9-year follow-up study of criminally involved "Know the Signs" Suicide Prevention Media unauthorized immigrants Campaign Is Aligned with Best Practices and EP-50536 Highly Regarded by Experts RR-818-CMHSA 160

Language Differences in California Adults' Long-term effects of the 2003 ACGME Exposure to Suicide Prevention Messaging, resident duty hour reform on hospital mortality Confidence in One's Ability to Intervene with EP-66103 Someone at Risk, and Resource Preferences RR-754-CMHSA Long-term Survival and Healthcare Utilization Outcomes Attributable to Sepsis and Pneumonia Learning from the HIV/AIDS experience to EP-51664 improve NCD interventions EP-51689 Longitudinal Aging Study In India: Biomarker Data Documentation Lessons for a Negotiated Settlement in WR-1043 Afghanistan—If History Serves as a Guide RB-9762-OSD Longitudinal family effects on substance use among an at-risk adolescent sample Lessons from 13 Years of War Point to a Better EP-66202 U.S. Strategy RB-9814-A Los Angeles County Juvenile Justice Crime Prevention Act: Fiscal Year 2012–2013 Report Lessons learned and future directions: the RR-624-LACPD national response for preventing healthcare- associated infections EP-51684 Losing Your "License to Drink": The Radical South Dakota Approach to Heavy Drinkers Who Threaten Public Safety Lessons Learned from the Afghan Mission EP-51702 Network: Developing a Coalition Contingency Network RR-302-A Louisiana's 2012 Coastal Master Plan: Overview of a Science-Based and Publicly Informed Decision-Making Process Libya After Qaddafi: Lessons and Implications EP-51645 for the Future RR-577-SRF Making and Breaking Barriers: Assessing the value of mounted police units in the UK: License Plate Readers for Law Enforcement: Summary report Opportunities and Obstacles RR-830/1-ACPO RR-467-NIJ

Making the Reserve Retirement System Living Room Connected Devices: Similar to the Active System: Retention and Cost Opportunities, security challenges and privacy Estimates implications for users and industry RR-530-A RR-604-OFCOM 161

Management Perspectives Pertaining Marijuana Liberalization Policies: Why We to Root Cause Analyses of Nunn-McCurdy Can't Learn Much from Policy Still in Motion Breaches, Volume 6: Contractor Motivations and EP-51650 Anticipating Breaches MG-1171/6-OSD Markets for Cybercrime Tools and Stolen Data: Hackers' Bazaar Managing Manifest Diseases, but Not Health RR-610-JNI Risks, Saved PepsiCo Money Over Seven Years EP-50433 Maternal Work and Children's Diet, Activity, and Obesity Mapping Diasporas in the European Union EP-51720 and United States: Comparative analysis and recommendations for engagement RR-671-EC Measuring 21st Century Competencies: Guidance for Educators EP-50463 Mapping Diasporas in the European Union and United States: Comparative analysis and recommendations for engagement: summary Measuring Agreement Between Egos and report Alters: Understanding Informant Accuracy in RR-671/1-EC Personal Network Studies EP-51732

Mapping Gender Differences in Cardiovascular Disease and Diabetes Care: A Pilot Assessment Measuring and Retaining the U.S. Army's of LDL Cholesterol Testing Rates in a California Deployment Experience Health Plan RR-570-A RR-539-CSMC

Measuring Cooperative Biological Mapping Gender Gaps in Health Care Engagement Program (CBEP) Performance: RB-9781-CSMC Capacities, Capabilities, and Sustainability Enablers for Biorisk Management and Biosurveillance Mapping Pathways: Community-driven RR-660-OSD strategies for the use of antiretrovirals as prevention: United States Workshop Report RR-596-RE Measuring Deeper Learning Through Cognitively Demanding Test Items: Results from the Analysis of Six National and International Maricopa County's drug court: an innovative Exams program for first-time drug offenders on probation RR-483-WFHF EP-66161 162

Measuring Hard-to-Measure Student Medical Care Spending and Labor Competencies: A Research and Development Market Outcomes: Evidence from Workers' Plan Compensation Reforms RR-863-WFHF WR-1028-1

Measuring Hospital Quality: Can Medicare Medical malpractice reform: noneconomic Data Substitute for All-Payer Data? damages caps reduced payments 15 percent, EP-51669 with varied effects by specialty EP-50535

Measuring Success in Health Care Value- Based Purchasing Programs: Findings from an Medical mistrust is related to lower longitudinal Environmental Scan, Literature Review, and medication adherence among African-American Expert Panel Discussions males with HIV RR-306-ASPE EP-50532

Measuring Success in Health Care Value- Medicare Imaging Demonstration Final Based Purchasing Programs: Summary and Evaluation: Report to Congress Recommendations RR-706-CMS RR-306/1-ASPE

Mental Health Stigma in the Military Measuring the quality of care provided to RR-426-OSD women with pelvic organ prolapse EP-50558 Methodological considerations when studying the association between patient-reported care Measuring value-added in higher education: experiences and mortality possibilities and limitations in the use of EP-66237 administrative data EP-66139 Methodology for developing and evaluating the PROMIS® smoking item banks Media violence exposure and physical EP-66130 aggression in fifth-grade children EP-66234 Methodology of the RAND Continuous 2012 Presidential Election Poll Medical Care Spending and Labor RR-858-RC Market Outcomes: Evidence from Workers' Compensation Reforms WR-1028 Methodology of the RAND Midterm 2014 Election Panel RR-854-RC 163

Methods for Identifying Part Quality Issues Modeling, Simulation, and Operations Analysis and Estimating Their Cost with an Application in Afghanistan and Iraq: Operational Vignettes, Using the UH-60 Lessons Learned, and a Survey of Selected RR-369-A Efforts RR-382-OSD

Methods Used to Estimate Achievement Effects in Personalized Learning Schools Modelling Long-Distance Travel in Great WR-1061-BMGF Britain EP-50434

Mexico Is Not Colombia: Alternative Historical Analogies for Responding to the Challenge of Moral Hazard and Adverse Selection in Private Violent Drug-Trafficking Organizations Health Insurance RR-548/1 WR-1032

Mexico Is Not Colombia: Alternative Historical More Americans May Be Adequately Prepared Analogies for Responding to the Challenge for Retirement Than Previously Thought of Violent Drug-Trafficking Organizations, RB-9792 Supporting Case Studies RR-548/2 Mortality Among High-Risk Patients with Acute Myocardial Infarction Admitted to U.S. Teaching- Middle school student attitudes about school Intensive Hospitals in July: A Retrospective drinking fountains and water intake Observational Study EP-50526 EP-51648

Military Caregivers in the Workplace Mortality Expectations of Older Mexicans: RB-9764/2-TEDF Development and Testing of Survey Measures TR-1288/6-SOY-NIA

Military Caregivers: Who are They? And Who Is Supporting Them? Motivators and Barriers to Using Patient RB-9764-TEDF Experience Reports for Performance Improvement EP-51680 Mobile phones, rent-to-own payments & water filters: Evidence from Kenya WR-1039 Moving Beyond Screen Time: Redefining Developmentally Appropriate Technology Use in Early Childhood Education Modeling disability trajectories and mortality of RR-673/2-PNC the oldest-old in China EP-51833 164

National Security Perspectives on Terrorism Nutritional Fitness and Resilience: A Review Risk Insurance in the United States of Relevant Constructs, Measures, and Links to RR-573-CCRMC Well-Being RR-105-AF

Natural Experiments in a Complex and Dynamic Environment: The Need for a Measured Obesity and economic environments Assessment of the Evidence EP-51830 EP-51649

OECD Health Care Quality Indicator Project: New Haven Promise: An Early Look at College The Expert Panel on Primary Care Prevention Preparation, Access, and Enrollment of New and Health Promotion Haven Public School Students (2010–2013) EP-50452 RB-9811/1-CFGNH

Older Depressed Latinos' Experiences with New Medical Technology Development and Primary Care Visits for Personal, Emotional Diffusion: Policy Challenges and Considerations And/Or Mental Health Problems: A Qualitative RGSD-328 Analysis EP-50495

New Security and Justice Sector Partnership Models: Implications of the Arab Uprisings Opioid Prescribing: A Systematic Review and RR-605-DOS Critical Appraisal of Guidelines for Chronic Pain EP-51670 Nudging Guideline-Concordant Antibiotic Prescribing: A Randomized Clinical Trial EP-51716 Opportunities and Challenges in Supply-Side Simulation: Physician-Based Models EP-50466 Nudging physician prescription decisions by partitioning the order set: results of a vignette- based study Options for Department of Defense Total EP-66216 Workforce Supply and Demand Analysis: Potential Approaches and Available Data Sources Nurse Staffing in Hospitals: Is There a RR-543-OSD Business Case for Quality? EP-51675 Organisational interventions to reduce length of stay in hospital: a rapid evidence assessment Nurse-Staffing Levels and the Quality of Care EP-50546 in Hospitals EP-51676 165

Out of the Shadows: What We Know About Peer victimization in fifth grade and health in the Well-Being and Experiences of Private tenth grade Contractors Working in Conflict Environments EP-51718 RB-9753-RC

Penaid Nonproliferation: Hindering the Spread Parents at work: Men and women of Countermeasures Against Ballistic Missile participating in the labour force: Short Statistical Defenses Report No. 2 RR-378-DTRA RR-348-EC

Perceived Social Support Mediates Anxiety Parents' views on engaging families of middle and Depressive Symptom Changes Following school students in obesity prevention and control Primary Care Intervention in a multiethnic population EP-50425 EP-51802

Percent plans, automatic admissions, and Partner Capacity in Counterinsurgency college outcomes Campaigns EP-66227 RB-9765-SRF

Perceptions of behavioral health care among Partnerships for Parks and Physical Activity veterans with substance use disorders: results EP-51655 from a national evaluation of mental health services in the Veterans Health Administration EP-51860 Patient Aligned Care Teams (PACT): VA's journey to implement patient-centered medical homes Personalized Learning Instructional Staff EP-51856 Survey Results (Spring 2014) WR-1062-BMGF Patient Safety in the Commonwealth of Massachusetts: Current Status and Opportunities for Improvement Perspective: some possible pitfalls in the RR-891-BLC design and use of PERT networking EP-51828

Paying for telemedicine EP-50553 Phase 2 report from the payment by results Social Impact Bond pilot at HMP Peterborough RR-473-MOJ Peer Support Services for Individuals with Serious Mental Illnesses: Assessing the Evidence Physical Activity Surveillance in Parks Using EP-51719 Direct Observation EP-51674 166

Physician-reported barriers to referring cancer Practice environments and job satisfaction in patients to specialists: prevalence, factors, and patient-centered medical homes association with career satisfaction EP-66108 EP-66199

Pre-Deployment Stress, Mental Health, and Physicians' propensity to discuss prognosis is Help-Seeking Behaviors Among Marines associated with patients' awareness of prognosis RR-218-OSD for metastatic cancers EP-51804 Predicting child development knowledge and engagement of Moroccan parents Police Department Investments in Information EP-50539 Technology Systems: Challenges Assessing Their Payoff RR-569-NIJ Predicting support for non-pharmaceutical interventions during infectious outbreaks: a four region analysis Policy Designs for Cannabis Legalization: EP-66178 Starting with the Eight Ps EP-51790 Predictors of the existence of congregational HIV programs: similarities and differences Policy Variation, Labor Supply Elasticities, and compared with other health programs a Structural Model of Retirement EP-66151 WR-1068

Predictors of Treatment Response to Brief Portfolio Assessment of Department of State Behavioral Treatment of Insomnia (BBTI) in Older Internet Freedom Program: An Annotated Briefing Adults WR-1035-DOS EP-50428

Portfolio Assessment of the Department of Premiums and Stability in the Individual Health State Internet Freedom Program Insurance Market: The Effects of Young Adult RR-794-DOS Enrollment and Subsidies RB-9798-DHHS

Postscript: research agenda to guide the next generation of public reports for consumers Preparedness of Americans for the Affordable EP-51816 Care Act EP-50484

Practice Economics and the Decision to Prescribe Oral Oncolytics Preparing for the Possibility of a North Korean EP-51705 Collapse CT-404 167

Preparing Principals to Raise Student Principal Preparation Matters: How Leadership Achievement: Implementation and Effects of the Affects Student Achievement New Leaders Program in Ten Districts RB-9786-NL RR-507-NL

PRISM 2011 Base: Demand Model Preparing state transportation agencies for an Implementation uncertain energy future RR-314-MM EP-50616

PRISM 2011 Base: Frequency and Car Ownership Models Prevalence and correlates of firearm RR-273-MM ownership in the homes of fifth graders: Birmingham, AL, Houston, TX, and Los Angeles, CA PRISM 2011 Base: Mode-Destination Model EP-51823 Estimation RR-186-MM

Prevalence and Correlates of Smoking Status Among Veterans Affairs Primary Care Patients Probability perceptions and preventive health with Probable Major Depressive Disorder care EP-51698 EP-66184

Prevalence of Mental Health Problems Among Probiotics for diarrhoea Iraq and Afghanistan Veterans Who Have and EP-66143 Have Not Received VA Services EP-50496 Process Evaluation of the New Mexico Maternal, Infant, and Early Childhood Home Preventing hospitalizations in children with Visiting Competitive Development Grant medical complexity: a systematic review RR-639-REC EP-66210

Programa de Pensiones No Contributivas para Adultos Mayores en Yucatán, México: Diseño, implementación y Evaluación del Programa en Mérida Primary Care Providers' Initial Treatment TR-1288/4-SOY-NIA Decisions and Antidepressant Prescribing for Adolescent Depression EP-50430 Programs That Work, from the Promising Practices Network on Children, Families and Communities Primary healthcare system and practice TL-145 characteristics in Singapore EP-66191 168

Project JOINTS: what factors affect bundle pSCANNER: patient-centered Scalable adoption in a voluntary quality improvement National Network for Effectiveness Research campaign? EP-51859 EP-66207

Psychological Fitness and Resilience: A Prolonged Cycle Times and Schedule Growth Review of Relevant Constructs, Measures, and in Defense Acquisition: A Literature Review Links to Well-Being RR-455-OSD RR-102-AF

PROMIS Pediatric Peer Relationships Scale: Psychological Wellbeing and Work: Improving development of a peer relationships item bank as service provision and outcomes part of social health measurement RR-407-DWP EP-51736

Psychometric Properties of the PROMIS® Promoting Airmen with the Potential to Lead: Pediatric Scales: Precision, Stability, and A Study of the Air Force Master Sergeant Comparison of Different Scoring and Promotion System Administration Options RR-581-AF EP-51738

Promoting Patient Safety Through Effective Public acceptability of population-level Health Information Technology Risk Management interventions to reduce alcohol consumption: a RR-654-DHHSNCH discrete choice experiment EP-50507

Providing smoking cessation programs to homeless youth: the perspective of service Public Perception of Security and Privacy: providers Assessing Knowledge, Collecting Evidence, EP-50524 Translating Research Into Action EP-50464

Provision of mental health services as a quality indicator for adolescent substance abuse Public reporting of provider performance at treatment facilities a crossroads in the United States: summary of EP-66164 current barriers and recommendations on how to move forward EP-51845 Proximal and distal social influence on alcohol consumption and marijuana use among middle school adolescents Quality Indicators for International EP-66170 Benchmarking of Mental Health Care EP-50453 169

Quality-of-care indicators for pelvic organ Financial Decision Making" prolapse: development of an infrastructure for PT-119 quality assessment EP-51811

RAND Review: Vol. 38, No. 1, Spring 2014 Quantifying the Contribution of Public Parks CP-22 (4/14) to Physical Activity and Health: Introducing SOPARC RR-774-NRPA RAND Review: Vol. 38, No. 2, Summer 2014 CP-22 (8/14)

Quantitative Evaluation of the Impact of the Healthy Communities Initiative in Cincinnati Randomized clinical trial of an emergency RR-729-GECO department observation syncope protocol versus routine inpatient admission EP-66123 Racial and Ethnic Differences in Exposure to Suicide Prevention Messaging, Confidence in One's Ability to Intervene with Someone at Risk, Rapid Acquisition of Army Command and and Resource Preferences Control Systems RR-682-CMHSA RR-274-A

Racial and Ethnic Differences in Mental Illness Rates of major obstetrical complications vary Stigma in California almost fivefold among U. S. hospitals RR-684-CMHSA EP-66124

Ramifications of DARPA’s Programming Readiness for the Patient-Centered Medical Computation on Encrypted Data Program Home: Structural Capabilities of Massachusetts RR-567-OSD Primary Care Practices RAND Behavioral Finance Forum EP-50437 2014: Leveraging Behavioral Insights to Improve Financial Health CF-323-BEFI Ready for Fall? Near-Term Effects of Voluntary Summer Learning Programs on Low-Income Students' Learning Opportunities and Outcomes RAND Behavioral Finance Webinar: Anya RR-815-WF Samek Presents "The Power of Visual Tools for Financial Literacy and Decision-Making" PT-125 Ready to Serve: Community-Based Provider Capacity to Deliver Culturally Competent, Quality Mental Health Care to Veterans and Their RAND Behavioral Finance Webinar: Craig Families Fox Presents "Metacognitive Knowledge and RR-806-UNHF 170

Reasons Why High Religiosity Can Co-Exist Registered nurses are delaying retirement, a with and Precipitate Discontinuation of Anti- shift that has contributed to recent growth in the Retroviral Therapy Among Different HIV Clients nurse workforce in Uganda: An Exploratory Study EP-50519 EP-51643

Regular physical activity has differential Recommendations for Sustaining California's association with reduced obesity among diverse Statewide Mental Health Prevention and Early youth in the United States Intervention Programs EP-50545 RR-787-CMHSA

Regulating quality and safety of health and Recruiting Older Youths: Insights from a New social care: International experiences Survey of Army Recruits RR-561-DH RR-247-OSD

Rehospitalization for Childhood Asthma: Redirecting Innovation in U.S. Health Care: Timing, Variation, and Opportunities for Options to Decrease Spending and Increase Intervention Value EP-51715 RR-308

Reimagining quality measurement Reducing the Burden of Suicide in the U.S.: EP-66225 The Aspirational Research Goals of the National Action Alliance for Suicide Prevent Research Prioritization Task Force Relations of behavioral autonomy to health EP-51793 outcomes among emerging adults with and without type 1 diabetes EP-50538 Reducing the Economic Burden of Work- Related Injuries RGSD-330 Relationships and health among emerging adults with and without Type 1 diabetes EP-66176 Reengagement of high-need individuals with serious mental illness after discontinuation of services EP-66148 Reporting Hospitals Antibiotic Timing in Pneumonia: Adverse Consequences for Patients? Regional Interventions to Eliminate EP-50443 Healthcare-Associated Infections EP-51687 171

Reporting of context and implementation in Satisfied to Death: A Spurious Result? studies of global health interventions: a pilot EP-50442 study EP-51846 School Design and Physical Activity Among Middle School Girls Reporting Quality of Nursing Home Care to EP-51665 Consumers: The Maryland Experience EP-50448 School programs and characteristics and their influence on student BMI: findings from Healthy Research methodology: choices, logistics, and Passages challenges EP-50472 EP-66141

Securing America's Ports Response error in reporting dental coverage CT-410 by older Americans in the Health and Retirement Study EP-50559 Security Cooperation Amidst Political Uncertainty: An Agenda for Future Research WR-1052 Retention and Promotion of High-Quality Civil Service Workers in the Department of Defense Acquisition Workforce RR-748-OSD Selecting Indicators for Patient Safety at the Health System Level in OECD Countries EP-50445 Risks and Mitigation Options Regarding Use of Foreign Components in U.S. Launch Vehicles CT-413 Selecting Indicators for the Quality of Diabetes Care at the Health Systems Level in OECD Countries Safety of vaccines used for routine EP-50450 immunization in the United States EP-50517

Sexual Assault and Sexual Harassment in the Safety of vaccines used for routine U.S. Military: Top-Line Estimates for Active-Duty immunization of US children: a systematic review Coast Guard Members from the 2014 RAND EP-51857 Military Workplace Study RR-944-USCG

Satellite Anomalies: Benefits of a Centralized Anomaly Database and Methods for Securely Sharing Information Among Satellite Operators RR-560-DARPA 172

Sexual Assault and Sexual Harassment in the Small area estimation-based prediction U.S. Military: Top-Line Estimates for Active-Duty methods to track poverty: validation and Service Members from the 2014 RAND Military applications Workplace Study EP-51742 RR-870-OSD

Small Business and Strategic Sourcing: Sexual Assault and Sexual Harassment in the Lessons from Past Research and Current Data U.S. Military: Volume 1. Design of the 2014 RAND RR-410-OSD Military Workplace Study RR-870/1-OSD Small Ideas for Saving Big Health Care Dollars RR-390-RC Sexual minorities in England have poorer health and worse health care experiences: a national survey Social network effects of nonlifesaving early- EP-50525 stage breast cancer detection on mammography rates EP-50534 Shaking the Heavens and Splitting the Earth: Chinese translation (traditional characters) MG-915/2-AF Social protection during the economic crisis: How do changes to benefits systems affect children? Shining a Light on State Campaign Finance: RR-555-EC An Evaluation of the Impact of the National Institute on Money in State Politics RR-791-NIMSP Social, relational and network determinants of unprotected anal sex and HIV testing among men who have sex with men in Beirut, Lebanon Should health care providers be accountable EP-66215 for patients' care experiences? EP-66217 Sociotechnical reinvention: implementation dynamics and collaboration tools Single parents and employment in Europe: EP-51835 Short Statistical Report No.3 RR-362-EC SOF Partner Assessment: Introduction to Country Characteristics Single-Parent Family Structure and Sleep PT-130-USSOCOM Problems in Black and White Adolescents EP-51656 SOF Partner Assessment: Measuring Foreign Relations Sleep in the Armed Forces: Working Group PT-130/1-USSOCOM Proceedings WR-1042-OSD 173

SOF Partner Assessment: Measuring State Spillover from the Conflict in Syria: An Stability Assessment of the Factors that Aid and Impede PT-130/2-USSOCOM the Spread of Violence RR-609-OSD

SOF Partner Assessment: Measuring State Stability States with Low Non-Fatal Injury Rates Have PT-130/3-USSOCOM High Fatality Rates and Vice-Versa EP-50460

Soft versus Hard Commitments: A Test on Savings Behaviors Statistical benchmarks for health care provider WR-1055 performance assessment: a comparison of standard approaches to a hierarchical Bayesian histogram-based method Soldier-Portable Battery Supply: Foreign EP-51733 Dependence and Policy Options RR-500-OSD Strategic Issues Facing Transportation EP-51646 Some things to think and some to do EP-19610402 Strategic Planning for Border Security CT-415 Source of Health Insurance Coverage and Employment Survival Among Newly Disabled Workers: Evidence from the Health and Strategic Planning for Border Security: Retirement Study Addendum WR-1040 CT-415/1

Sourcing and Global Distribution of Medical Strategic Priorities for Improving Access to Supplies Quality Education in the Kurdistan Region—Iraq RR-125-A MG-1140-1-KRG

Special Warfare: The Missing Middle in U.S. Strategic Priorities for Improving Access to Coercive Options Quality Education in the Kurdistan Region—Iraq: RR-828-A Arabic-language version MG-1140/1-1-KRG

Special warfare: the missing middle in U.S. coercive options Strategic Priorities for Improving Access to EP-66228 Quality Education in the Kurdistan Region—Iraq: Kurdish-language version MG-1140/2-1-KRG Sphere drag in a low-density supersonic flow EP-51827 174

Strategies for Managing Sovereign Debt: A Strengthening Hospital Nursing Robust Decision Making Approach EP-50446 RGSD-340

Structural stigma and all-cause mortality in Strategies for Optimizing Clinic Efficiency in sexual minority populations a Community-Based Antiretroviral Treatment EP-51748 Programme in Uganda EP-51640 Study design to develop and pilot-test a web intervention for partners of military service Strategies for Private-Sector Development and members with alcohol misuse Civil-Service Reform in the Kurdistan Region— EP-66169 Iraq MG-1117-1-KRG Substance Use Treatment and Reentry (STAR) Program: Final Evaluation Report Strategies for Private-Sector Development and RR-572-HBI Civil-Service Reform in the Kurdistan Region— Iraq: Arabic-language version MG-1117/1-1-KRG Successful schools and risky behaviors among low-income adolescents EP-66118 Strategies for Private-Sector Development and Civil-Service Reform in the Kurdistan Region— Iraq: Kurdish-language version Suicide Rates in California: Trends and MG-1117/2-1-KRG Implications for Prevention and Early Intervention Programs RB-9737-CMHSA Strategy-Policy Mismatch: How the U.S. Army Can Help Close Gaps in Countering Weapons of Mass Destruction Suitability of Missions for the Air Force RR-541-RC Reserve Components RR-429-AF

Strength Testing in the Air Force: Current Processes and Suggestions for Improvements Supply of buprenorphine waivered physicians: RR-471-AF the influence of state policies EP-66172

Strengthening Coastal Planning: How Coastal Regions Could Benefit from Louisiana’s Planning Support Resources for Military Caregivers and Analysis Framework RB-9764/4-TEDF RR-437-RC

Supporting Military Caregivers: Options for Congress RB-9764/1-TEDF 175

Supporting Military Caregivers: The Role of Targeting Alcohol Misuse: A Promising Health Providers Strategy for Reducing Military Sexual Assaults? RB-9764/3-TEDF RR-538-OSD

Supporting the development of a new health Technology-facilitated Depression Care R&D strategy: A rapid review of international Management Among Predominantly Latino theory and practice for Norway’s HelseOmsorg21 Diabetes Patients Within a Public Safety Net RR-628-RCN Care System: Comparative Effectiveness Trial Design EP-50497 Surgical site infections following ambulatory surgery procedures EP-51724 Temporal Associations Between Substance Use and Delinquency Among Youth with a First Time Offense Sustaining critical social services during EP-51797 extended regional power blackouts EP-51849 Terrorism and the labor force: evidence of an effect on female labor force participation and the Symptom persistence in a community cohort labor gender gap of women with interstitial cystitis/bladder pain EP-51861 syndrome (IC/BPS): 3-, 6-, 9-, and 12-month follow-up from the RICE cohort EP-51851 Testing the DMAA's Recommendations for Disease Management Program Evaluation EP-51678

Tailored deterrence: strategic context to guide The 2014 Technology Summit for Victim Joint Force 2020 Service Providers: Identifying Challenges and EP-51864 Possible Solutions CF-326

Tailored Nutrition Education and Food Assistance Improve Adherence to HIV The 340B Prescription Drug Discount Program: Antiretroviral Therapy: Evidence from Honduras Origins, Implementation, and Post-Reform Future EP-51799 PE-121-SDS

Talk Like a Marine: USMC Linguistic The Academic Impact of Enrollment in Acculturation and Civil-Military Argument International Baccalaureate Diploma Programs: A EP-51639 Case Study of Chicago Public Schools EP-50488 176

The Affordable Care Act may increase the The COMPARE Microsimulation Model and number of people getting tested for HIV by nearly the U.S. Affordable Care Act 500,000 by 2017 EP-51653 EP-50481

The Conflict in Syria: Understanding and The Affordable Care Act: an opportunity for Avoiding Regional Spillover Effects improving care for substance use disorders? RB-9785-OSD EP-66230

The Cost of Non-Europe in the Single Market: The African Institutions Initiative: Insights from Free Movement of Goods the First Four Years RR-862-EP RR-707-WT

The Cost Savings Potential of Biosimilar Drugs in the United States The Anesthesiologist Workforce in 2013: PE-127-SANI A Final Briefing to the American Society of Anesthesiologists RR-650-ASAI The curse of wealth: Middle Eastern countries need to address the rapidly rising burden of diabetes The Association Between Base-Area Social EP-66114 and Economic Characteristics and Airmen's Outcomes RR-132-AF The Days After a Deal with Iran: Continuity and Change in Iranian Foreign Policy PE-124-RC The association of state legal mandates for data submission of central line–associated bloodstream infections in neonatal intensive care The Days After a Deal with Iran: Regional units with process and outcomes measures Responses to a Final Nuclear Agreement EP-66133 PE-122-RC

The changing hospital landscape: An The Days After a Deal with Iran: U.S. Policies exploration of international experiences of Hedging and Engaging RR-728-DH PE-125-RC

The Changing Role of Criminal Law in The Department of Defense Should Avoid a Controlling Corporate Behavior Joint Acquisition Approach to Sixth-Generation RR-412-ICJ Fighter RB-9759-AF 177

The Deployment Life Study: Methodological The effects of mental health symptoms and Overview and Baseline Sample Description marijuana expectancies on marijuana use and RR-209-A/OSD consequences among at-risk adolescents EP-50548

The Development and Application of the RAND Program Classification Tool: The RAND The effects of purchasing alcohol and Toolkit, Volume 1 marijuana among adolescents at-risk for future RR-487/1-OSD substance use EP-66177

The Dynamics of Syria's Civil War PE-115-RC The exchange between quantity and quality EP-51826

The effect of malpractice reform on emergency department care The Extremist Threat to the U.S. Homeland EP-66194 CT-403

The Effect of Population Aging on Economic The Extremist Threat to the U.S. Homeland: Growth Addendum WR-1063 CT-403/1

The Effect of Surgical Care Improvement The Federal Civil Service Workforce: Project (SCIP) Compliance on Surgical Site Assessing the Effects on Retention of Pay Infections (SSI) Freezes, Unpaid Furloughs, and Other Federal- EP-51679 Employee Compensation Changes in the Department of Defense RR-514-OSD The Effectiveness of China's Industrial Policies in Commercial Aviation Manufacturing RR-245 The Future of Driving in Developing Countries RR-636-IFMO The Effectiveness of China’s Industrial Policies in Commercial Aviation Manufacturing CT-416 The Future of Health Care in the Kurdistan Region—Iraq: Toward an Effective, High-Quality System with an Emphasis on Primary Care The Effectiveness of Remotely Piloted Aircraft MG-1148-1-KRG in a Permissive Hunter-Killer Scenario RR-276-AF 178

The Future of Health Care in the Kurdistan The Impact of the Affordable Care Act on Region—Iraq: Toward an Effective, High-Quality Liability Insurance System with an Emphasis on Primary Care RB-9768-ICJ (Arabic-language version) MG-1148/1-1-KRG The Impact of Tort Reform, Medicare Plan Choice, and Geography on Health Care The Future of Health Care in the Kurdistan Processes, Outcomes, and Expenditures Region—Iraq: Toward an Effective, High-Quality RGSD-333 System with an Emphasis on Primary Care (Kurdish-language version) MG-1148/2-1-KRG The impact of unplanned postprocedure visits in the management of patients with urinary stones The Future of the Army’s Civilian Workforce: EP-51809 Comparing Projected Inventory with Anticipated Requirements and Estimating Cost Under Different Personnel Policies The Impact on Federal Spending of Allowing RR-576-A the Terrorism Risk Insurance Act to Expire RR-611-CCRMC

The Future of the Terrorism Risk Insurance Act CF-325-CCRMC The Impact on Workers’ Compensation Insurance Markets of Allowing the Terrorism Risk Insurance Act to Expire The Future of the U.S. Intercontinental Ballistic RR-643-CCRMC Missile Force MG-1210-AF The international dimension of research and innovation cooperation addressing the grand The health consequences of relocation for challenges in the global context nursing home residents following Hurricane RR-725-EC Katrina EP-51756 The Los Angeles County Community Disaster Resilience Project: a community-level, public The Health Risks of Bathing in Recreational health initiative to build community disaster Waters: A Rapid Evidence Assessment of Water resilience Quality and Gastrointestinal Illness EP-66152 RR-698-DEFRA

The Monetary Costs of Dementia in the United The impact of public housing on social States networks: a natural experiment CT-406 EP-66117 179

The National Response for Preventing The Political Sustainability of Carbon Control Healthcare-Associated Infections: Data and Policies in an Evolutionary Economics Setting Monitoring RGSD-331 EP-51682

The Potential for Pocket Parks to Increase The National Response for Preventing Physical Activity Healthcare-Associated Infections: Infrastructure EP-51654 Development EP-51695 The Power of Innovation to Drive Inclusive Growth: Proceeds from the 2014 L.A. Policy The National Response for Preventing Symposium Healthcare-Associated Infections: Research and CF-327-PRGS Adoption of Prevention Practices EP-51693 The PROMIS® smoking assessment toolkit— background and introduction to supplement The National Response for Preventing EP-66128 Healthcare-Associated Infections: System Capacity and Sustainability for Improvement EP-51686 The PROMIS® smoking initiative: initial validity evidence for six new smoking item banks EP-66129 The OECD Health Care Quality Indicators Project: History and Background EP-50451 The Promise and Pitfalls of Community Resilience EP-50429 The opportunity costs of informal elder-care in the United States: new estimates from the American time use survey The psychometric development and initial EP-66196 validation of the DCI-A short form for adolescent therapeutic community treatment process EP-51737 The Oregon experiment—effects of Medicaid on clinical outcomes EP-51812 The RAND Online Measure Repository for Evaluating Psychological Health and Traumatic Brain Injury Programs: The RAND Toolkit, The Other Quiet Professionals: Lessons Volume 2 for Future Cyber Forces from the Evolution of RR-487/2-OSD Special Forces RR-780-A The relationship between influenza vaccination habits and location of vaccination EP-50551 180

The response of an expert panel to nutritional The role of perceived partner alliance on the armor for the warfighter: can omega-3 fatty acids efficacy of CBT-I: preliminary findings from the enhance stress resilience, wellness, and military Partner Alliance in Insomnia Research Study performance? (PAIRS) EP-66223 EP-51725

The role of alcohol expectancies in drinking The Role of Specialty Drugs in Private Sector behavior among women with alcohol use Healthcare Spending disorder and comorbid posttraumatic stress EP-51703 disorder EP-66137 The schooling of offspring and the survival of parents The Role of Depression in Work-Related EP-66121 Outcomes of HIV Treatment in Uganda EP-51652 The Socioeconomic Effects of the Working Poor Moving to Permanent Dwellings: The Case The Role of Early-Life Educational Quality of the Ashray Affordable Housing Pilot Project in and Literacy in Explaining Racial Disparities in India Cognition in Late Life RR-714-RF EP-50502

The state of innovative emergency medical The role of gender in moderating treatment service programs in the United States outcomein collaborative care for anxiety EP-51858 EP-50557

The Structural Genomics Consortium: A The Role of Health Care Transformation for knowledge platform for drug discovery the Chinese Dream: Powering Economic Growth, RR-512-SGC Promoting a Harmonious Society RR-600-AETNA The Structural Genomics Consortium: A knowledge platform for drug discovery: A The Role of Health Care Transformation for summary the Chinese Dream: Powering Economic Growth, RR-512/1-SGC Promoting a Harmonious Society RR-600-1-AETNA The Supplemental Nutrition Assistance Program and Material Hardships Among Low- The Role of Maritime and Air Power in DoD’s Income Households with Children Third Offset Strategy EP-51681 CT-420

The U.S. Army in Asia, 2030–2040 RR-474-A 181

The Utility of Modeling and Analysis in the Iraq and Afghanistan Wars Tobacco Use and Smoking Intentions Among RB-9758-OSD U.S. Fifth-Grade Students EP-50501

The Vietnam multicomponent collaborative care for depression program: development of Too Much of a Good Thing? How the depression care for low- and middle-income Economic Environment Plays a Role in the nations Obesity Epidemic EP-66175 RB-9801

Therapeutic Measures Required: To Ensure Toolkit for Weighting and Analysis of Millions of Veterans and Their Families Get Nonequivalent Groups: A Tutorial for the R High-Quality Care, Community Mental Health TWANG Package Providers Need More Training, Support, TL-136/1-NIDA Resources RB-9809-UNHF Toolkit for Weighting and Analysis of Nonequivalent Groups: A Tutorial for the TWANG Three Essays on Education Policy: Empirical SAS Macros Analyses of the Challenges and Opportunities TL-136-NIDA with For-Profit Colleges, Military Enlistment and Immigration RGSD-325 Topics in Migration Research RGSD-326

Three Essays on Education Reform in the United States Tort Reform and Physician Labor Supply: A RGSD-335 Review of the Evidence WR-1014-ICJ

Three Essays on Subjective Well-Being RGSD-332 Toward Improved Management of Officer Retention: A New Capability for Assessing Policy Options Time of day and decision to prescribe RR-764-OSD antibiotics EP-66186 Toward Meaningful Military Compensation Reform: Research in Support of DoD’s Review Time off to care for a sick child: why family- RR-501-OSD leave policies matter EP-66171 182

Toward Theory for Dissuasion (or Deterrence) Transforming nurse home culture: evidence for by Denial: Using Simple Cognitive Models of the practice and policy Adversary to Inform Strategy EP-51730 WR-1027

Trauma Exposure and Mental Health Problems Towards a Common Terminology: A Simplified Among School Children 15 Months Post- Framework of Interventions to Promote and Hurricane Katrina Integrate Evidence Into Health Practices, EP-51694 Systems and Policies EP-51794 Treatment of Comorbid Alcohol Use Disorders and Depression with Cognitive-Behavioural Training tomorrow's comprehensive primary Therapy and Motivational Interviewing: A Meta- care internists: a way forward for internal Analysis medicine education EP-50456 EP-50473

Trends in disability and related chronic Transforming an Urban Public School District: conditions among the forty-and-over population: Tracking the Progress of the New Haven Public 1997-2010 Schools' Educational Reforms and the New EP-51807 Haven Promise Scholarship Program RB-9811/2-CFGNH Trends in functional and activity limitations among Chinese oldest-old, 1998 to 2008 Transforming an Urban School System: EP-66166 Progress of New Haven School Change and New Haven Promise Education Reforms (2010–2013) RR-777-CFGNH Trends in health of older adults in the United States: past, present, future EP-51831 Transforming an Urban School System: Progress of New Haven School Change and New Haven Promise Education Reforms (2010– Trends in late-life activity limitations in the 2013)—Technical Appendixes United States: an update from five national RR-777/1-CFGNH surveys EP-51834

Transforming Compliance: Emerging Paradigms for Boards, Management, Compliance Trends in the Distribution of Teacher Officers, and Government Effectiveness in the Intensive Partnerships for CF-322-CCEG Effective Teaching WR-1036-BMGF 183

TV viewing, perceived similarity coviewing, Understanding high and low patient and mental well-being among African American, experience scores in primary care: analysis of Latino, and White children patients' survey data for general practices and EP-51805 individual doctors EP-66209

U.S. Security-Related Agreements in Force Since 1955: Introducing a New Database Understanding the impact of differential RR-736-AF university fees in England RR-571-RE

U.S. Vaccines Deemed Extremely Safe, with Serious Side Effects Rare Among Children University R&D funding strategies in a RB-9799 changing federal funding environment EP-50527

Ubiquitous Developments of the Digital Single Market Untangling Practice Redesign from Disease EP-51691 Management: How Do We Best Care for the Chronically Ill? EP-50455 Un Programa de Pensión No Contributiva para los Adultos Mayores en Yucatán, México: Diseño, implementación y Evaluacióndel Programa en Updated guidelines for the control of legionella Valladolid in Western Pennsylvania TR-1288/3-SOY-NIA EP-66197

Understanding condom use decision making Updated trends in imaging use in men among homeless youth using event-level data diagnosed with prostate cancer EP-66220 EP-51838

Understanding data requirements of US Military Primary Care: Problems, Solutions, retrospective studies and Implications for Civilian Medicine EP-66235 EP-50435

Understanding Factors Associated with the Usage and effect of health information Translation of Cardiovascular Research: A exchange: a systematic review Multinational Case Study Approach EP-66224 EP-50493

Use of and regional variation in initial CT imaging for kidney stones EP-66200 184

Use of Behavioral Economics and Social Using OSHA Inspection Data to Analyze Psychology to Improve Treatment of Acute Respirator Protection Program Compliance Respiratory Infections (BEARI): Rationale and EP-50462 Design of a Cluster Randomized Controlled Trial [1rc4ag039115-01] - Study Protocol and Baseline Practice and Provider Characteristics Using Teacher Evaluation Data to Inform EP-51644 Professional Development in the Intensive Partnership Sites WR-1033-BMGF Use of CAHPS patient experience surveys to assess the impact of health care innovations EP-66149 Validation Studies for Early Learning and Care Quality Rating and Improvement Systems: A Review of the Literature Use of childcare in the EU Member States and WR-1051-DOEL progress towards the Barcelona targets: Short Statistical Report No. 1 RR-185-EC Variation in inpatient hospital prices and outpatient service quantities drive geographic differences in private spending in Texas Using claims data to generate clinical flags EP-66105 predicting short-term risk of continued psychiatric hospitalizations EP-66110 Venture Capital and Strategic Investment for Developing Government Mission Capabilities RR-176-OSD Using Early Childhood Education to Bridge the Digital Divide PE-119-PNC Venture Research: Fostering trust and freedom in research funding RR-506-DH Using exercises to improve public health preparedness in Asia, the Middle East and Africa EP-66142 Veteran Employment: Lessons from the 100,000 Jobs Mission RR-836-JPMCF Using Medicaid and CHIP claims data to support pediatric quality measurement: lessons from 3 centers of excellence in measure Veterans' Perceptions of Behavioral Health development Care in the Veterans Health Administration: A EP-66153 National Survey EP-50490

Using Network Analysis Methods to Support the Global SOF Network Voluntary Partial Capitation: the Community PT-128-USSOCOM Nursing Organization Medicare Demonstration EP-50447

Vulnerability Assessment Method Pocket 185

Guide: A Tool for Center of Gravity Analysis What Has the CalMHSA Statewide Mental TL-129-A Health Prevention and Early Intervention Implementation Program Done So Far? Summary and Commentary for Year 1 Evaluation Vulnerable Patients' Perceptions of Health RB-9772-CMHSA Care Quality and Quality Data EP-51663 What Has the Stigma and Discrimination Reduction Initiative Done So Far? Year 1 Welcome Back Veterans: A Program Steps Findings Up to the Plate to Aid Vets, Families with Mental RB-9756-CMHSA Health Care—and Offers Future Playbook RB-9804-MTF What Has the Student Mental Health Initiative Done So Far? Year 1 Findings Welfare reform and abortion RB-9757-CMHSA EP-51837

What Has the Suicide Prevention Initiative Well-child care clinical practice redesign for Done So Far? Year 1 Findings serving low-income children RB-9727-CMHSA EP-66104

What Is the Risk of Developing Parkinsonism What America's Users Spend on Illegal Drugs, Following Neuroleptic Use? 2000–2010 EP-51677 RR-534-ONDCP

What Makes a Successful Principal? What America's Users Spend on Illegal Drugs, Incorporating School Principal Background in 2000–2010: Technical Report State and District Policy RR-534/1-ONDCP RGSD-336

What does the evidence really say about What point-of-use water treatment products do culture change in nursing homes? consumers use? Evidence from a randomized EP-51734 controlled trial among the urban poor in Bangladesh EP-51743 What Has the CalMHSA Statewide Mental Health Prevention and Early Intervention Implementation Program Done So Far? Key What to Do About Dementia? Policy Options Results from the Baseline RAND General for Crucial Long-Term Care Population Survey RB-9780 RB-9771-CMHSA 186

When a whole practice model is the Women and Academic Medicine: A Review of intervention: developing fidelity evaluation the Evidence on Female Representation components using program theory-driven EP-50494 science for an integrative medicine primary care clinic EP-66160 Women's Heart Health: Research That Matters PT-120-UCLA

When Jihadis Come Marching Home: The Terrorist Threat Posed by Westerners Returning Words can be deceiving: a review of variation from Syria and Iraq among legally effective medical marijuana laws in PE-130-RC the United States EP-51820

Where Would California Adults Prefer to Get Help If They Were Feeling Suicidal? Working smarter on cold cases: identifying RR-681-CMHSA factors associated with successful cold case investigations EP-51750 Who Pays for Justice? Perspectives on State Court System Financing and Governance RR-486-ICJ Yoga vs. physical therapy vs. education for chronic low back pain in predominantly minority populations: study protocol for a randomized Who takes up free flu shots? Examining the controlled trial effects of an expansion in coverage EP-66156 EP-51832

You've shown the program model is effective: Why changes in price matter when thinking now what? about marijuana policy: a review of the literature EP-50505 on the elasticity of demand EP-51822 Youth exposure to alcohol advertising on television in the UK, the Netherlands and Why Is Veteran Unemployment So High? Germany RR-284-OSD EP-50508

Will Extending the Women's Health Initiative Youth in Jordan: Transitions from Education to Lead to Better Research and Policy? Employment EP-51696 RR-556-CMEPP

Wireless Emergency Alerts: Mobile Penetration Strategy RR-174-OSD 187 ABSTRACTS

CONFERENCE PROCEEDINGS mind, RAND convened a symposium on May 28, CF-317 2014, entitled “Transforming Compliance: Emerg- Identifying Enemies Among Us: Evolving Ter- ing Paradigms for Boards, Management, Compli- rorist Threats and the Continuing Challenges of ance Officers, and Government.” The objective Domestic Intelligence Collection and Information was to stimulate a forward-looking conversation Sharing. Brian Michael Jenkins, Andrew M. Liep- about compliance as a field, factors that are likely man, Henry H. Willis. 2014 to contribute to its transformational change, and practical implications for key stakeholder groups. This report summarizes the discussions at a Several of the participants presented white pa- seminar organized and hosted by the RAND Cor- pers on selected transformational pressures now poration at which a group of acting and former affecting the compliance field. The following ses- senior government and law enforcement officials, sion of the symposium involved a moderated dis- practitioners, and experts examined domestic in- cussion on the emerging paradigm for compliance telligence operations and information sharing as programs of the future and the broad implications these relate to terrorist threats. Topics discussed that can be gleaned from transformative factors include changes in the direction and scope of the now operating on the field. The final session was threat; the differences in the focus of local, state, a moderated discussion of related concerns and and federal agencies; the need for better commu- next steps from the varied perspectives of boards, nication among law enforcement and intelligence executives, chief ethics and compliance officers, agencies; the role of Joint Terrorism Task Forces; and policymakers. These proceedings summarize the shortcomings of fusion centers; the political the discussions and include the white papers. sensitivity of collecting domestic intelligence; and the consequences of reductions in counterter- CF-323-BEFI rorism funding on the level of risk the American RAND Behavioral Finance Forum 2014: Le- people will accept. veraging Behavioral Insights to Improve Financial Health. Jeremy Burke, Krishna B. Kumar, Warren CF-322-CCEG Cormier, Annamaria Lusardi, Anuj Shah, Stephen Transforming Compliance: Emerging Paradigms Wendel, Anya Savikhin Samek, Michael Finke, for Boards, Management, Compliance Officers, Stefano DellaVigna, Julie R. Agnew, Xavier Giné, and Government. Michael D. Greenberg. 2014 Angela A. Hung, Pamela Chan. 2014 Recent decades have witnessed a notable Video compilation of the 2014 Behavioral Fi- trend in corporate compliance and governance nance (BeFi) Forum in Washington, D.C., a day- oversight. Many companies have made consid- long event that included a series of topical panels erable progress in strengthening their corporate on curated presentations of academic research compliance programs. That progress has been followed by discussion by leading researchers, achieved, in part, in response to the Federal Sen- practitioners, and policymakers. tencing Guidelines. In the wake of policy developments, compliance programs, and the chief eth- CF-325-CCRMC ics and compliance officers who helm them, have The Future of the Terrorism Risk Insurance gained in visibility and prominence. The voice of Act. Lloyd Dixon, Michael Dworsky, Brian Michael the compliance officer is increasingly being heard Jenkins, Tom LaTourrette, Henry H. Willis. 2014 at board and C-suite levels, in part as the tactical Since the Terrorism Risk Insurance Act (TRIA) head of an empowered compliance effort and also was last reauthorized in 2007, terrorism insurance as a focal point for building an ethical culture with- has remained widely available and the price has in the corporation. With these developments in 188 fallen. However, challenges remain from both a eighth year, the LA Policy Symposium is an event social and an insurance point of view. Roughly jointly hosted by Pardee RAND Graduate School 40 percent of policyholders still do not purchase (PRGS), University of California Los Angeles terrorism coverage, and uncertainty remains re- (UCLA), University of Southern California (USC), garding how much coverage would be available Pepperdine University, and Claremont Graduate without TRIA. What is more, the program is set to University. The core mission of the symposium is expire on December 31, 2014, and it is unclear to bring together the best minds in the region to whether the improvements in the market since address the toughest policy problems through de- TRIA was first passed in 2002 can be sustained bate and collaboration. The theme for this year's without it.On June 10, 2014, a conference was event was “The Power of Innovation to Drive Inclu- convened in Washington, D.C., to present findings sive Growth.” of recent RAND research and to address additional facets of this complex issue, including the pros and cons of proposed modifications to TRIA. CORPORATE PUBLICATIONS This conference brought together stakeholders to not only discuss the varying implications of TRIA's expiration, modification, and extension, but also to CP-1 (2014) frame how it is debated in the halls of Congress 2014 RAND Annual Report. 2014 and across the country. RAND's research and analysis address issues that affect families and communities around the CF-326 world, including security, health, education, sus- The 2014 Technology Summit for Victim Service tainability, technology, growth, and development. Providers: Identifying Challenges and Possible RAND's 2014 Annual Report describes the many Solutions. Nelson Lim, Sarah Michal Greathouse, ways in which RAND develops solutions to public Douglas Yeung. 2014 policy challenges to help make people around the On July 24, 2014, the RAND Corporation host- world safer and more secure, healthier and more ed a national summit on leveraging technology prosperous. to enable victims of crime to more quickly and effectively obtain the help they need. The summit CP-22 (4/14) brought together technical experts, victim service RAND Review: Vol. 38, No. 1, Spring 2014. providers, and other key stakeholders to identify David G. Groves, Jordan R. Fischbach, Evan requirements, capabilities, and strategies to cre- Bloom, Rajeev Ramchand, Terri Tanielian, David ate a mutually reinforcing technological ecosys- M. Adamson, Mark A. Lorell, Michael Kennedy, tem for victims of crime. This document summa- Robert S. Leonard, Robert A. Guffey, Stijn Hoo- rizes discussions and observations made by the rens, Michael D. Rich, John Godges. 2014 summit attendees. The document also highlights The cover story describes ways to factor cli- challenges, research questions, and possible so- mate change—and the uncertainty surrounding lutions to use technology to improve various as- it—in to water management plans, using the Colo- pects of victim services. rado River Basin and the Sierra Nevada as case studies and recommending greater conservation, CF-327-PRGS efficiency, and surface water storage. The first ad- The Power of Innovation to Drive Inclusive ditional feature story examines the burdens borne Growth: Proceeds from the 2014 L.A. Policy Sym- by military caregivers, contrasting the experience posium. Krishna B. Kumar, Trey Miller, Rafiq Dos- of those caring for veterans of the recent conflicts sani. 2014 in Afghanistan and Iraq with that of those caring Video of the 8th Annual LA Policy Sympo- for veterans of the pre-9/11 era. The second looks sium, which was held on April 4, 2014. Now in its at the history of joint aircraft programs, conclud- 189 ing that they have failed to deliver expected sav- CT-403/1 ings and have resulted in other problems, such The Extremist Threat to the U.S. Homeland: as compromises in requirements and capability. A Addendum. Seth G. Jones. 2014 third warns of growing divisions across the Euro- Document submitted on March 12, 2014 as pean Union (EU), including an age gap, a techno- an addendum to testimony presented before the logical divide, an income and skills gap, and the House Homeland Security Committee on January particular vulnerability of single-adult households. 15, 2014. The voices in Public Square comment on the employment difficulties that a unified Korea would CT-404 face, the threat of Salafi-jihadism, Syria's wors- Preparing for the Possibility of a North Korean ening conditions, Ukraine's uncertain integration Collapse. Bruce W. Bennett. 2014 with the EU, Franco-U.S. relations, the limits of Briefing presented before the U.S.- China Eco- nutrition education, and Walmart's support for the nomic and Security Review Commission on Janu- fair treatment of agricultural workers. ary 29, 2014. CP-22 (8/14) RAND Review: Vol. 38, No. 2, Summer 2014. CT-406 The Monetary Costs of Dementia in the United Lillian Ablon, Martin C. Libicki, Michael D. Rich, States. Michael D. Hurd. 2014 John Godges. 2014 Testimony presented before the Senate Ap- The cover story describes the growing black propriations Committee, Subcommittee on Labor, markets for cybercrime and explains how private Health and Human Services, Education, and Re- companies, defense contractors, and law enforce- lated Agencies on February 26, 2014 ment and other government agencies could rise to this challenge. Another feature highlights re- CT-407 search on medical innovation, listing ten ways that Evidence on Home Visiting and Suggestions policymakers could encourage innovators to focus for Implementing Evidence-Based Home Visiting on products that curb health spending while also Through MIECHV. M. Rebecca Kilburn. 2014 boosting health. A "Window on the World" graphic maps the effectiveness of U.S. security coopera- Testimony presented before the House Ways tion efforts around the globe, while a "Numbers and Means Committee, Subcommittee on Human in the News" entry details the potential costs of Resources on April 2, 2014. allowing the Terrorism Risk Insurance Act to expire. The voices in Public Square comment on CT-407/1 the growth of telehealth, a strategic approach to Evidence on Home Visiting and Suggestions homeland security, care for dementia, exchang- for Implementing Evidence-Based Home Visit- ing prisoners with the Taliban, investing in Africa, ing Through MIECHV: Addendum. M. Rebecca and the unrest in Ukraine, Syria, and Iraq. Guest Kilburn. 2014 speakers present "barrier-breaking stories" and Document submitted on April 16, 2014 as an ad- "breathtaking medical frontiers." dendum to testimony presented before the House Ways and Means Committee, Subcommittee on TESTIMONY Human Resources on April 2, 2014.

CT-403 CT-408 The Extremist Threat to the U.S. Homeland. Counterterrorism and the Role of Special Op- Seth G. Jones. 2014 erations Forces. Seth G. Jones. 2014 Testimony presented before the House Home- Testimony presented before the House Foreign land Security Committee on January 15, 2014. Affairs Committee, Subcommittee on Terrorism, Non-Proliferation, and Trade on April 8, 2014. 190

CT-409 CT-412/1 Expanding the Use of Telehealth: Promise and Building on the Quadrennial Homeland Secu- Potential Pitfalls. Ateev Mehrotra. 2014 rity Review to Improve the Effectiveness and Ef- ficiency of the Department of Homeland Security: Testimony presented before the House Ener- Addendum. Henry H. Willis. 2014 gy and Commerce Committee, Subcommittee on Health on May 1, 2014. Document submitted on July 18, 2014 as an addendum to testimony presented before the House CT-409/1 Homeland Security Committee, Subcommittee on Expanding the Use of Telehealth: Promise and Oversight and Management Efficiency on June Potential Pitfalls: Addendum. Ateev Mehrotra. 20, 2014. 2014 CT-413 Document submitted on June 5, 2014 as an ad- Risks and Mitigation Options Regarding Use dendum to testimony presented before the House of Foreign Components in U.S. Launch Vehicles. Energy and Commerce Committee, Subcommit- Yool Kim. 2014 tee on Health on May 1, 2014. Testimony presented before a joint hearing CT-410 of the Senate Armed Services Committee, Sub- Securing America's Ports. Henry H. Willis. 2014 committee on Strategic Forces and Senate Com- merce, Science, and Transportation Committee Testimony submitted before the Senate Home- on July 16, 2014. land Security and Governmental Affairs Commit- tee on June 4, 2014. CT-414 Jihadist Sanctuaries in Syria and Iraq: Implica- CT-411 tions for the United States. Seth G. Jones. 2014 Applying Lessons Learned from Past Response Operations to Strengthening National Prepared- Testimony presented before the House Home- ness. Brian A. Jackson. 2014 land Security Committee, Subcommittee on Coun- terterrorism and Intelligence on July 24, 2014. Testimony presented before the House Home- land Security Committee on June 18, 2014. CT-415 Strategic Planning for Border Security. K. Jack CT-411/1 Riley. 2014 Applying Lessons Learned from Past Response Operations to Strengthening National Prepared- Testimony presented before the House Sci- ness: Addendum. Brian A. Jackson. 2014 ence, Space, and Technology Committee, Sub- committee on Research and Technology and Sub- Document submitted on July 11, 2014 as an ad- committee on Oversight on July 31, 2014. dendum to testimony presented before the House Homeland Security Committee on June 18, 2014. CT-415/1 Strategic Planning for Border Security: Adden- CT-412 dum. K. Jack Riley. 2014 Building on the Quadrennial Homeland Secu- rity Review to Improve the Effectiveness and Ef- Document submitted on September 18, 2014 as ficiency of the Department of Homeland Security. an addendum to testimony presented before the Henry H. Willis. 2014 House Science, Space, and Technology Commit- tee, Subcommittee on Research and Technology Testimony presented before the House Home- and Subcommittee on Oversight on July 31, 2014. land Security Committee, Subcommittee on Over- sight and Management Efficiency on June 20, CT-416 2014. The Effectiveness of China's Industrial Poli- 191 cies in Commercial Aviation Manufacturing. Keith Personnel Flow Modeling. Stephen D. Brady. 2014 Crane. 2014 The practice of stop-loss retains soldiers who Testimony presented before the Senate Com- are scheduled to end their voluntary terms of ac- merce, Science, & Transportation Committee, tive service during an impending or ongoing de- Subcommittee on Aviation, Operations, Safety, ployment. Because stop-loss keeps soldiers in and Security on July 31, 2014. their units, it generally fills deployment needs in the least amount of time possible and minimizes CT-417 the budgetary impact of added recruitment, train- Catastrophic Risk in California: Are Homeown- ing, and personnel reassignment. However, the ers and Communities Prepared?. Lloyd Dixon. benefits of stop-loss come at an undeniable price 2014 in the form of direct and indirect costs to the Army Testimony presented before the California State and individual soldiers. When the Office of the Senate Committee on Insurance on May 14, 2014. Secretary of Defense began reexamining the Ar- my's stop-loss policy, it put forth a set of potential CT-418 alternatives. This briefing documents the detailed Defeating the Islamic State in Iraq. Ben Con- manpower flow simulations used to address each nable. 2014 of these proposed alternative policies, focusing on their quantitative effects on deployed-unit fill, per- Testimony presented before the Senate Foreign sonnel stability, and individual deployment tempo Relations Committee on September 17, 2014. for the active enlisted force. The analysis compared CT-419 the options for two military occupational special- Countering ISIL's Financing. Patrick B. John- ties that have very different representations in the ston. 2014 force: 11B (infantryman) and 92Y (unit supply specialist). The same tests were also performed on Testimony presented before the House Finan- the force as a whole, using a composite, or mix, of cial Services Committee on November 13, 2014. specialties. To enrich the discussion of the effects of a new stop-loss policy, the study also consid- CT-420 ered—in combination with limited changes in ac- The Role of Maritime and Air Power in DoD's cession—brigade combat team cycle lengths and Third Offset Strategy. David Ochmanek. 2014 the number of units being rotated into theaters. Testimony presented before the House Armed Early results supported the policy review process, Services Committee, Subcommittee on Seapower and the decision to suspend stop-loss for the ac- and Projection Forces on December 2, 2014. tive Army was consistent with the study's findings. CT-421 The ultimate utility of this research is in describing Hidden Heroes: Caregivers to America's Ill, and documenting these considerations in view of Injured, and Wounded Service Members and Vet- their likely value if and when stop-loss is consid- erans. Rajeev Ramchand. 2014 ered in the future. Testimony presented before the House Veter- ans' Affairs Committee, Subcommittee on Health EXTERNAL PUBLICATIONS on December 3, 2014. EP-50425 Perceived Social Support Mediates Anxiety and DOCUMENTED BRIEFINGS Depressive Symptom Changes Following Primary Care Intervention. Halina J. Dour, Joshua F. Wiley, Peter Roy-Byrne. 2014 DB-573-OSD Assessing Stop-Loss Policy Options Through BACKGROUND: The current study tested whether perceived social support serves as a me- 192 diator of anxiety and depressive symptom change ticipating in DBT training was associated with following evidence-based anxiety treatment in the positive changes over time, including improved primary care setting. Gender, age, and race were therapist attitudes toward consumers with BPD, tested as moderators. METHODS: Data were improved confidence in the effectiveness of DBT, obtained from 1004 adult patients (age M = 43, and increased use of DBT components. Thera- SD = 13; 71% female; 56% White, 20% Hispanic, pists who had the lowest baseline scores on the 12% Black) who participated in a randomized ef- study outcomes had the greatest self-reported fectiveness trial (coordinated anxiety learning and positive change in outcomes over time. More- management [CALM] study) comparing evidence- over, there were notable positive correlations in based intervention (cognitive-behavioral therapy therapist characteristics; therapists who had the and/or psychopharmacology) to usual care in the lowest baseline attitudes toward individuals with primary care setting. Patients were assessed with BPD, confidence in the effectiveness of DBT, or a battery of questionnaires at baseline, as well as who were least likely to use DBT modes and com- at 6, 12, and 18 months following baseline. Mea- ponents were the therapists who had the great- sures utilized in the mediation analyses included est reported increase over time in each respective the Abbreviated Medical Outcomes (MOS) Social area. DBT training with ongoing support resulted Support Survey, the Brief Symptom Index (BSI)– in changes not commonly observed in standard Somatic and Anxiety subscales, and the Patient training approaches typically used in community Health Questionnaire (PHQ-9). RESULTS: There settings. It is encouraging to observe positive out- was a mediating effect over time of perceived so- comes in therapist self-reported skill, perceived cial support on symptom change following treat- self-efficacy and DBT component use, all of which ment, with stronger effects for 18-month depres- are important to evidence-based treatment (EBT) sion than anxiety. None of the mediating pathways implementation. Our results underscore the im- were moderated by gender, age, or race. CON- portance to recognize and target therapist diver- CLUSIONS: Perceived social support may be cen- sity of learning levels, experience, and expertise tral to anxiety and depressive symptom changes in EBT implementation. over time with evidence-based intervention in the primary care setting. These findings possibly have EP-50427 important implications for development of anxiety Effect of Chiranjeevi Yojana on Institutional De- interventions. liveries and Neonatal and Maternal Outcomes in Gujarat, India: A Difference-In-Differences Analy- EP-50426 sis. Manoj Mohanan, Sebastian Bauhoff, Gerard Evaluation of an Implementation Initiative La Forgia. 2014 for Embedding Dialectical Behavior Therapy in OBJECTIVE: To evaluate the effect of the Community Settings. Amy D. Herschell, Oliver J. Chiranjeevi Yojana pro- Lindhiem, Jane N. Kogan. 2014 gramme, a public–private partnership to improve We examined the effectiveness of Dialectical maternal and neonatal health in Gujarat, In- Behavior Therapy (DBT) training in community- dia. METHODS: A household survey (n = 5597 based agencies. Data were gathered at four time households) was conducted in Gujarat to collect points over a 2-year period from front-line men- retrospective data on births within the preced- tal health therapists (N = 64) from 10 commu- ing 5 years. In an observational study using a nity-based agencies that participated in a DBT difference-in-differences design, the relationship implementation initiative. We examined change between the Chiranjeevi Yojana</ on therapist attitudes toward consumers with Bor- em> programme and the probability of deliv- derline Personality Disorder (BPD), confidence in ery in health-care institutions, the probability of the effectiveness of DBT, and use of DBT model obstetric complications and mean household components. All measures were self-report. Par- expenditure for deliveries was subsequently examined. In multivariate regressions, individual 193 and household characteristics as well as district of insomnia according to standard diagnostic and year fixed effects were controlled for. Data criteria. Logistic regression examined whether from the most recent District Level Household baseline demographic, clinical, or sleep charac- and Facility Survey (DLHS-3) wave conducted teristics predicted treatment outcomes at 1 month in Gujarat (n = 6484 households) were used in follow-up. RESULTS: Demographic variables did parallel analyses. FINDINGS: Between 2005 not predict treatment outcomes for either criterion. and 2010, the Chiranjeevi Yojana</ Higher anxiety, depression, poorer sleep quality, em> programme was not associated with a and longer polysomnography (PSG)-assessed statistically significant change in the probability sleep latency predicted greater likelihood of re- of institutional delivery (2.42 percentage points; sponse at follow-up (p < 0.05). Longer sleep du- 95% confidence interval, CI: −5.90 ration at baseline (measured by sleep diary and to 10.74) or of birth-related complications (6.16 PSG) predicted greater likelihood of the remission percentage points; 95% CI: −2.63 to at follow-up (p < 0.05). CONCLUSION: Patients 14.95). Estimates using DLHS-3 data were simi- with insomnia who have greater distress at base- lar. Analyses of household expenditures indicated line or prolonged sleep latency are more likely to that mean household expenditure for private- show positive response to BBTI. In contrast, short sector deliveries had either not fallen or had sleepers at baseline are less likely to have reso- fallen very little under the Chiranjeevi lution of insomnia diagnosis following BBTI, per- Yojana programme. CONCLUSION: haps due to the sleep restriction component of The Chiranjeevi Yojana pro- the treatment. Identifying the characteristics that gramme appears to have had no significant impact predict positive BBTI treatment outcomes can fa- on institutional delivery rates or maternal health cilitate personalized behavioral treatments to im- outcomes. The absence of estimated reductions prove outcomes. in household spending for private-sector deliveries deserves further study. EP-50429 The Promise and Pitfalls of Community Resil- EP-50428 ience. Lori Uscher-Pines, Anita Chandra, Joie D. Predictors of Treatment Response to Brief Acosta. 2014 Behavioral Treatment of Insomnia (BBTI) in Older Adults. Wendy M. Troxel, Tyler S. Conrad, Anne An important shift in terminology has occurred Germain. 2014 in emergency preparedness, and the concept of community resilience has become ubiquitous. Al- STUDY OBJECTIVES: The extant literature though enhancing community resilience is broad- on predictors of treatment response to behavioral er than preparedness, and emphasizes a distinct treatments for insomnia is equivocal and limited in set of activities and participants, the terms are of- scope. The current study examined demographic, ten used interchangeably. The implications of this clinical, and sleep characteristics as predictors of shift have not been fully explored. This commen- clinically significant treatment response to brief tary describes the potential promise and pitfalls of behavioral treatment of insomnia (BBTI) in older the concept of community resilience and recom- adults with insomnia. METHODS: Thirty-nine old- mends strategies to overcome its limitations. We er adults with insomnia (67% females, mean age: believe that resilience has the power to dramati- 72.54 years) were randomized to BBTI treatment. cally change this field in immense, positive ways, Treatment outcomes were defined according to but some important challenges such as confusion 2 criteria: (1) "response," defined as about definitions and lack of accountability must change in Pittsburgh Sleep Quality Index (PSQI) first be overcome. score ≥ 3 points or increase in sleep diary sleep efficiency ≥ 10%); or (2) remis- EP-50430 sion, defined as absence of a clinical diagnosis Primary Care Providers' Initial Treatment Deci- 194 sions and Antidepressant Prescribing for Adoles- EP-50431 cent Depression. Ana Radovic, Coreen Farris, Implications of New Insurance Coverage for Kerry A. Reynolds. 2014 Access to Care, Cost-Sharing, and Reimburse- ment. A. Everette James, Walid F. Gellad, Brian A. OBJECTIVE: Adolescent depression is a se- Primack. 2014 rious and undertreated public health problem. Nonetheless, pediatric primary care providers Many physician practices will face a set of (PCPs) may have low rates of antidepressant pre- critical decisions in the coming years that may scribing due to structural and training barriers. This contribute to the ultimate success or failure of the study examined the impact of symptom severity ACA. In particular, small primary care practices and provider characteristics on initial depression must weigh the opportunity to absorb patients treatment decisions in a setting with fewer struc- newly insured under the ACA against the financial tural barriers, an integrated behavioral health net- and regulatory risks of doing so. work. METHODS: A cross-sectional survey was administered to 58 PCPs within a large pediat- EP-50433 ric practice network. PCP reports of initial treat- Managing Manifest Diseases, but Not Health ment decisions were compared in response to 2 Risks, Saved PepsiCo Money Over Seven Years. vignettes describing depressed adolescents with John P. Caloyeras, Hangsheng Liu, Ellen Exum. either moderate or severe symptoms. PCP de- 2014 pression knowledge, attitudes toward addressing Workplace wellness programs are increasingly psychosocial concerns, demographics, and prac- popular. Employers expect them to improve em- tice characteristics were measured. RESULTS: ployee health and well-being, lower medical costs, Few PCPs (25% for moderate, 32% for severe) increase productivity, and reduce absenteeism. To recommended an antidepressant. Compared with test whether such expectations are warranted, treatment recommendations for moderate depres- we evaluated the cost impact of the lifestyle and sion, severe depression was associated with a disease management components of PepsiCo's greater likelihood of child psychiatry referral (odds wellness program, Healthy Living. We found that ratio [OR], 5.50; 95% confidence interval [CI], seven years of continuous participation in one or 2.47-12.2] p < .001). Depression severity did both components was associated with an average not affect the likelihood of antidepressant recom- reduction of $30 in health care cost per member mendation (OR, 1.58 [95% CI, 0.80-3.11] p = .19). per month. When we looked at each component Antidepressants were more likely to be recom- individually, we found that the disease manage- mended by PCPs with greater depression knowl- ment component was associated with lower costs edge (OR, 1.72 [95% CI, 1.14-2.59] p = .009) and and that the lifestyle management component access to an on-site mental health provider (OR, was not. We estimate disease management to re- 5.13 [95% CI, 1.24-21.2] p = .02) and less likely to duce health care costs by $136 per member per be recommended by PCPs who reported higher month, driven by a 29 percent reduction in hos- provider burden when addressing psychosocial pital admissions. Workplace wellness programs concerns (OR, 0.85 [95% CI, 0.75-0.98] p = .02). may reduce health risks, delay or avoid the onset CONCLUSION: PCPs infrequently recommended of chronic diseases, and lower health care costs antidepressants for adolescents, regardless of de- for employees with manifest chronic disease. But pression severity. Continued PCP support through employers and policy makers should not take for experiential training, accounting for provider bur- granted that the lifestyle management component den when addressing psychosocial concerns, and of such programs can reduce health care costs or co-management with mental health providers may even lead to net savings. increase PCPs' antidepressant prescribing. 195

EP-50434 faces challenges in delivering cost-effective, high- Modelling Long-Distance Travel in Great Britain. quality primary care while maintaining a provider Charlene Rohr, Andrew Daly, Bhanu Patruni. 2014 workforce capable of meeting both peacetime and Trips longer than 50 mi account for less than wartime needs. The MHS has implemented work- one-fortieth of all trips but nearly one-third of all force management strategies to address these distance traveled within Great Britain. Because of challenges, including "medical home" the small proportion of all travel that they form, teams for primary care and other strategies that long-distance trips may not be adequately repre- expand the roles of nonphysician providers such sented in national databases and models. How- as physician assistants, nurse practitioners, and ever, because they account for a substantial pro- medical technicians. Because these workforce portion of total distance traveled, particularly on strategies have been implemented relatively re- motorways and rail, these trips are important for cently, there is limited evidence of their effective- transport policy and have a substantial impact on ness. If they prove successful, they could serve as congestion. Moreover, study of existing data in- a model for the civilian sector. However, because dicates that travelers' behavior in long-distance the MHS model features a broad mix of provider journeys differs substantially from that in routine types, changes to civilian scope-of-practice regu- journeys. Not only is the set of available modes lations for nonphysician providers would be nec- different, but the profile of travelers is also sub- essary before the civilian provider mix could repli- stantially different, with income playing an impor- cate that of the MHS. tant role in both travel frequency and mode choice. EP-50436 In addition, model responsiveness and values of Development and Preliminary Validation of the time vary significantly with journey length. For Patient Perceptions of Integrated Care Survey. these reasons, treatment of the specific properties Sara J. Singer, Mark W. Friedberg, Mathew V. of long-distance travel is essential for appraising Kiang. 2014 the impact of transport policy aimed at this market, such as high-speed rail, highway construction The HCAHPS Survey obtains hospital patients' and management policies, and policies directed experiences using four modes: Mail Only, Phone toward domestic air travel. This paper describes Only, Mixed (mail/phone follow-up), and Touch- the development of a model to address these pol- Tone (push-button) Interactive Voice Response icy issues. The specific aim of the modeling work with option to transfer to live interviewer (TT-IVR/ is to provide empirical evidence on the relative Phone). A new randomized experiment examines importance of mode, destination, and frequency two less expensive modes: Web/Mail (mail invita- responses for long-distance travel models. The tion to participate by Web or request a mail survey) models that have been developed form the ba- and Speech-Enabled IVR (SE-IVR/Phone; speak- sis for a forecasting model that can be used for ing to a voice recognition system; optional transfer the appraisal of a wide range of transport policy to an interviewer). Web/Mail had a 12% response aimed at long-distance journeys. rate (vs. 32% for Mail Only and 33% for SE-IVR/ Phone); Web/Mail respondents were more edu- EP-50435 cated and less often Black than Mail Only respon- US Military Primary Care: Problems, Solutions, dents. SE-IVR/Phone respondents (who usually and Implications for Civilian Medicine. Benjamin switched to an interviewer) were less often older F. Mundell, Mark W. Friedberg, Christine Eibner. than 75 years, more often English-preferring, and 2014 reported better care than Mail Only respondents. The US Military Health System (MHS), which is Concerns regarding inconsistencies across imple- responsible for providing care to active and retired mentations, low adherence to primary modes, or members of the military and their dependents, low response rate may limit the applicability of the 196

SE-IVR/Phone and Web/Mail modes in HCAHPS der to achieve PCMH designation, smaller non- and similar standardized environments. affiliated practices may require the greatest investments. EP-50437 Readiness for the Patient-Centered Medical EP-50438 Home: Structural Capabilities of Massachusetts Effect of a Multipayer Patient-Centered Medical Primary Care Practices. Mark W. Friedberg, Dana Home on Health Care Utilization and Quality: The Gelb Safran, Kathryn L. Coltin. 2014 Rhode Island Chronic Care Sustainability Initia- tive Pilot Program. Meredith B. Rosenthal, Mark BACKGROUND: The Patient-Centered Medi- W. Friedberg, Sara J. Singer. 2014 cal Home (PCMH), a popular model for primary care reorganization, includes several structural IMPORTANCE: The patient-centered medical capabilities intended to enhance quality of care. home is advocated to reduce health care costs The extent to which different types of primary care and improve the quality of care. OBJECTIVE: To practices have adopted these capabilities has not evaluate the effects of the pilot program of a mul- been previously studied. OBJECTIVE: To measure tipayer patient-centered medical home on health the prevalence of recommended structural capa- care utilization and quality. DESIGN: An inter- bilities among primary care practices and to deter- rupted time series design with propensity score– mine whether prevalence varies among practices matched comparison practices, including multi- of different size (number of physicians) and admin- payer claims data from 2 years before (October 1, istrative affiliation with networks of practices. DE- 2006–September 30, 2008) and 2 years after (Oc- SIGN: Cross-sectional analysis. PARTICIPANTS: tober 1, 2008–September 30, 2010) the launch One physician chosen at random from each of of the pilot program. Uptake of the intervention 412 primary care practices in Massachusetts was was measured with audit data from the National surveyed about practice capabilities during 2007. Committee for Quality Assurance patient-centered Practice size and network affiliation were obtained medical home recognition process. SETTING: from an existing database. MEASUREMENTS: Five independent primary care practices and 3 Presence of 13 structural capabilities represent- private insurers in the Rhode Island Chronic Care ing 4 domains relevant to quality: patient assis- Sustainability Initiative. PARTICIPANTS: Patients tance and reminders, culture of quality, enhanced in 5 pilot and 34 comparison practices. INTER- access, and electronic health records (EHRs). VENTIONS: Financial support, care managers, MAIN RESULTS: Three hundred eight (75%) phy- and technical assistance for quality improvement sicians responded, representing practices with a and practice transformation. MAIN OUTCOMES median size of 4 physicians (range 2–74). Among AND MEASURES: Hospital admissions, emer- these practices, 64% were affiliated with 1 of 9 gency department visits, and 6 process measures networks. The prevalence of surveyed capabili- of quality of care (3 for diabetes mellitus and 3 for ties ranged from 24% to 88%. Larger practice size colon, breast, and cervical cancer screening). RE- was associated with higher prevalence for 9 of SULTS: The mean National Committee for Quality the 13 capabilities spanning all 4 domains (P&a Assurance recognition scores of the pilot practic- mp;thinsp;< 0.05). Network affilia- es increased from 42 to 90 points of a possible tion was associated with higher prevalence of 5 100 points. The pilot and comparison practices capabilities (P < 0.05) had statistically indistinguishable baseline patient in 3 domains. Associations were not substantively characteristics and practice patterns, except for altered by statistical adjustment for other prac- higher numbers of attributed member months per tice characteristics. CONCLUSIONS: Larger and year in the pilot practices (31 130 per practice vs network-affiliated primary care practices are more 14 779, P = .01) and lower rates of cervical cancer likely than smaller, non-affiliated practices to have screening in the comparison practices. Although adopted several recommended capabilities. In or- estimates of the emergency department visits and 197 inpatient admissions of patients in the pilot prac- tient care, and patient outcomes, providing valu- tices trended toward lower utilization, the only sig- able guidance to health systems reformers. nificant difference was a lower rate of ambulatory care sensitive emergency department visits in the EP-50440 pilot practices. The Chronic Care Sustainability Does Affiliation of Physician Groups with One Initiative pilot program was associated with a re- Another Produce Higher Quality Primary Care?. duction in ambulatory care–sensitive emergency Mark W. Friedberg, Kathryn L. Coltin, Steven D. department visits of approximately 0.8 per 1000 Pearson. 2014 member months or approximately 11.6% com- PURPOSE: Recent reports have emphasized pared with the baseline rate of 6.9 for emergency the importance of delivery systems in improving department visits per 1000 member months (P = health care quality. However, few prior studies .002). No significant improvements were found in have assessed differences in primary care qual- any of the quality measures. CONCLUSION and ity between physician groups that differ in size RELEVANCE: After 2 years, a pilot program of a and organizational configuration. We examined patient-centered medical home was associated whether larger physician group size and affiliation with substantial improvements in medical home with networks of multiple groups are associated recognition scores and a significant reduction in with higher quality of care. METHODS: We con- ambulatory care sensitive emergency department ducted a cross-sectional observational analysis visits. Although not achieving significance, there of 132 physician groups (including 4,358 physi- were downward trends in emergency department cians) who delivered primary care services in visits and inpatient admissions. Massachusetts in 2002. We compared physician groups on performance scores for 12 Health Plan EP-50439 Employer Data and Information Set (HEDIS) mea- Defining and Measuring Integrated Patient sures reflecting processes of adult primary care. Care: Promoting the Next Frontier in Health Care RESULTS: Network-affiliated physician groups Delivery. Sara J. Singer, Jako Burgers, Mark W. had higher performance scores than non-affiliat- Friedberg. 2014 ed groups for 10 of the 12 HEDIS measures (p& Integration of care is emerging as a central amp;thinsp;< 0.05). There was no challenge of health care delivery, particularly consistent relationship between group size and for patients with multiple, complex chronic con- performance scores. Multivariable models includ- ditions. The authors argue that the concept of ing group size, network affiliation, and health plan "integrated patient care" would benefit showed that network-affiliated groups had higher from further clarification regarding (a) the object of performance scores than non-affiliated groups on integration and (b) its essential components, par- 8 of the 12 HEDIS measures (p <& ticularly when constructing measures. To address amp;thinsp;0.05), and larger group size was not these issues, the authors propose a definition of associated with higher performance scores. Ad- integrated patient care that distinguishes it from justed differences in the performance scores of integrated delivery organizations, acknowledging network-affiliated and non-affiliated groups ranged that integrated organizational structures and pro- from 2% to 15%. For 4 HEDIS measures related to cesses may fail to produce integrated patient care. diabetes care, performance score differences be- The definition emphasizes patients' central role as tween network-affiliated and non-affiliated groups active participants in managing their own health by were most apparent among the smallest groups. including patient centeredness as a key element CONCLUSIONS: Physician group affiliation with of integrated patient care. Measures based on the networks of multiple groups was associated with proposed definition will enable empirical assess- higher quality, and for measures of diabetes care ment of the potential relationships between the the quality advantage of network-affiliation was integration of organizations, the integration of pa- most evident among smaller physician groups. 198

EP-50441 reporting hospital scores on antibiotic timing in A Guide to the Medical Home as a Practice- pneumonia (percentage of patients with pneu- Level Intervention. Mark W. Friedberg, Deborah monia receiving antibiotics within 4 hours) has Lai, Peter S. Hussey. 2014 led to unintended adverse consequences for pa- The medical home (also known as patient-cen- tients. STUDY DESIGN: Retrospective analyses tered medical home or advanced medical home) of 13,042 emergency department (ED) visits by is a composite policy construct representing a set adult patients with respiratory symptoms in the of interventions intended to revitalize primary care National Hospital Ambulatory Medical Care Sur- practices and improve patient care. As an ideal- vey, 2001-2005. METHODS: Rates of pneumonia ized vision, the medical home has gained the sup- diagnosis, antibiotic use, and waiting times to see port of stakeholders including employers, health a physician were compared before and after public professional societies, health plans, not-for-profit reporting, using a nationally representative hospi- entities, and government agencies. Expectations tal sample. These outcomes also were compared of the medical home include improvements in between hospitals with different antibiotic timing healthcare quality, patient experience, provider scores. RESULTS: There were no differences in work-life satisfaction, costs of care, and increased rates of pneumonia diagnosis (10% vs 11% of recruitment of medical students into primary care all ED visits, P = .72) or antibiotic administration careers. However, multiple definitions of the medi- (34% vs 35%, P = .21) before and after antibiotic cal home exist, and the degree to which some of- timing score reporting. Mean waiting times to be ten-cited examples of "medical home" seen by a physician increased similarly for patients successes match these definitions is unclear. with and without respiratory symptoms (11-minute Scant evidence currently supports the effective- vs 6-minute increase, respectively; P = .29). After ness of practice-level medical home interven- adjustment for confounders, hospitals with higher tions for improving quality and reducing costs, but 2005 antibiotic timing scores had shorter mean demonstration projects are only recently under waiting times for all patients, but there were no way. Carefully specifying the exact components significant score-related trends for rates of pneu- of "medical home" interventions-and monia diagnosis or antibiotic use. CONCLUSION: interpreting their results in the context of these Despite concerns, public reporting of hospital specifications-will help build a coherent body of antibiotic timing scores has not led to increased evidence to guide the revitalization of primary pneumonia diagnosis, antibiotic use, or a change care. in patient prioritization.

EP-50442 EP-50444 Satisfied to Death: A Spurious Result?. Mark Health Information Technology: An Updated W. Friedberg, Dana Gelb Safran, Eric C. Schnei- Systematic Review with a Focus on Meaningful der. 2014 Use. Spencer S. Jones, Robert S. Rudin, Tanja This letter suggests several methodological Perry. 2014 reasons why patients who have higher patient ex- BACKGROUND: Incentives offered by the U.S. perience scores may also have greater hospital- government have spurred marked increases in ization rates, total expenditures, and mortality. use of health information technology (IT). PUR- POSE: To update previous reviews and examine EP-50443 recent evidence that relates health IT function- Reporting Hospitals Antibiotic Timing in Pneu- alities prescribed in meaningful use regulations monia: Adverse Consequences for Patients?. to key aspects of health care. DATA SOURCES: Mark W. Friedberg, Ateev Mehrotra, Jeffrey A. English-language articles in PubMed from Janu- Linder. 2014 ary 2010 to August 2013. STUDY SELECTION: OBJECTIVE: To determine whether publicly 236 studies, including pre–post and time-series 199 designs and clinical trials that related the use of these are not yet mature enough for international health IT to quality, safety, or efficiency. DATA EX- exchange. This project reviewed routine data col- TRACTION: Two independent reviewers extracted lections as a starting point. RESULTS: Of an initial data on functionality, study outcomes, and con- set of 59 candidate indicators identified, 21 were text. DATA SYNTHESIS: Fifty-seven percent of the selected which cover known areas of harm to pa- 236 studies evaluated clinical decision support tients. CONCLUSIONS: This project is an impor- and computerized provider order entry, whereas tant initial step towards defining a usable set of other meaningful use functionalities were rarely patient safety indicators that will allow compari- evaluated. Fifty-six percent of studies reported sons to be made internationally and will support uniformly positive results, and an additional 21% mutual learning and quality improvement in health reported mixed-positive effects. Reporting of con- care. Measures of harm should be complemented text and implementation details was poor, and over time with measures of effective improvement 61% of studies did not report any contextual de- factors tails beyond basic information. LIMITATION: Po- tential for publication bias, and evaluated health IT EP-50446 systems and outcomes were heterogeneous and Strengthening Hospital Nursing. Peter Buer- incompletely described. CONCLUSION: Strong haus, Jack Needleman, Soeren Mattke. 2014 evidence supports the use of clinical decision Hospitals, nurses, the media, Congress, and support and computerized provider order entry. the private sector are increasingly concerned However, insufficient reporting of implementation about shortages of registered nurses (RNs) and and context of use makes it impossible to deter- the impact on safety and quality of patient care. mine why some health IT implementations are Findings from a growing number of studies pro- successful and others are not. The most impor- vide evidence of a relationship between hospital tant improvement that can be made in health IT nurse staffing and adverse outcomes experienced evaluations is increased reporting of the effects of by medical and surgical patients. These findings implementation and context. have policy implications for strengthening the nursing profession, monitoring the quality of hos- EP-50445 pital care associated with nursing, and improving Selecting Indicators for Patient Safety at the the relationship between hospitals and the nurs- Health System Level in OECD Countries. Vivienne ing profession. McLoughlin, John Millar, Soeren Mattke. 2014 BACKGROUND: Concerns about patient safety EP-50447 have arisen with growing documentation of the ex- Voluntary Partial Capitation: the Community tent and nature of harm. Yet there are no robust Nursing Organization Medicare Demonstration. and meaningful data that can be used internation- Austin B. Frakt, Steven D. Pizer, Robert J. Schmitz. ally to assess the extent of the problem and con- 2014 siderable methodological difficulties. PURPOSE: In a recently concluded Medicare demonstra- This article describes a project undertaken as tion, Community Nursing Organizations (CNOs) part of the Organization for Economic Coopera- received capitated payment to provide a subset of tion and Development (OECD) Quality Indicator Medicare services through a nursing case man- Project, which aimed at developing an initial set of agement delivery system. Demonstration partici- patient safety indicators. METHODS: Patient safe- pation was voluntary, both for CNOs and recruited ty indicators from OECD countries were identified beneficiaries, raising several challenging issues and then rated against three principal criteria: im- associated with selection. We investigate provider portance to patient safety, scientific soundness, and beneficiary selection, as well as Medicare and potential feasibility. Although some countries costs, using multiple evaluation methodologies. are developing multi-source monitoring systems, We find that CNO enrollment is associated with 200 increased payment by Medicare for CNO-covered critical design and execution choices were laid out services. Results showing CNO enrollees to be explicitly and debated with stakeholders in a pub- more costly to Medicare for non-CNO services are lic forum, and realism and honesty regarding the consistent with cost shifting, but could also be ac- limitations of the system. counted for by biased provider selection into the demonstration. EP-50449 . Laura Lambie, Soeren Mattke, Vin McLaugh- EP-50448 lin. 2014 Reporting Quality of Nursing Home Care to BACKGROUND: Cardiovascular (CV) diseases Consumers: The Maryland Experience. Soeren are major causes of morbidity and death in adults Mattke, Karen Reilly, Enrique Martinez-Vidal. 2014 in the world. Major differences have been reported OBJECTIVE: To design and implement a re- in the management strategies and the outcome porting system for quality of long-term care to of CV diseases within and between countries. To empower consumers and to create incentives better understand and address these differences, for quality improvement. To identify a model to there is a need for quantitative information on approach this technically and politically difficult patient management, outcome, and prognosis. task. APPROACH: Establishment of a credible OBJECTIVE: This article describes the develop- and transparent decision process using a public ment of a set of quality indicators for cardiac care forum. Development of the system based on: (1) and summarizes work undertaken by the Cardiac review of the literature and existing systems, and Care Panel of the OECD Health Care Quality In- discussions with stakeholders about strengths dicators Project. METHODS: A list of 61 poten- and weaknesses; (2) focus on consumer prefer- tial indicators was identified through a literature ences in the design; and (3) responsiveness to search, review of national measurement systems, industry concerns in the implementation. LES- and nomination from countries participating in SONS LEARNED: None of the existing systems the project. The Cardiac Care Panel then used a appeared to be a suitable model. We decided to modified Delphi process developed originally by develop an entirely new system based on three RAND to select indicators. Panel members indi- key design principles that allowed us to tailor the vidually rated each indicator on a scale of 1–9 for system to consumer needs: (1) designing a deci- scientific soundness and importance. All indica- sion tool rather than a database; (2) summariz- tors receiving scores of 7 or more for both impor- ing rather than simplifying information; and (3) tance and soundness were included in the final accounting for the target audience in the creative set. RESULTS: Seventeen cardiac indicators were execution. Industry concerns focused on the bur- selected for the final set of indicators from the fol- den of the system, the potential for errors, and lowing areas: acute coronary syndromes, cardiac the possible communication of a negative im- interventions, secondary prevention, and conges- pression of the industry. As methodological and tive heart failure. CONCLUSIONS: The final set of data limitations prevented us from resolving those 17 indicators selected by the Cardiac Care Panel concerns, we addressed them by using caution- constitutes a comprehensive set of measures for ary language in the presentation and by making the most relevant domains of CV care. Neverthe- a commitment to incorporate improvements in the less, gaps remain in the area of primary preven- future. All stakeholders regarded the final design tion and in particular in areas with rapidly chang- as an acceptable compromise. CONCLUSIONS: ing technology and improving treatment options. Despite its potentially controversial nature and many methodological challenges, the system has EP-50450 been well received by both the public and the in- Selecting Indicators for the Quality of Diabe- dustry. We attribute this success to two key fac- tes Care at the Health Systems Level in OECD tors: a collaborative decision process, in which all Countries. Antonio Nicolucci, Sheldon Greenfield, 201

Soeren Mattke. 2014 history, and approach of the OECD Health Care PURPOSE: In the context of the Organization for Quality Indicators (HCQI) Project, an initiative Economic Cooperation and Development (OECD) to implement quality measures for international Quality Indicators Project, a set of quality indica- benchmarking of medical care at the health sys- tors for diabetes care was developed, to be used tem level. METHOD: The participating countries for benchmarking the performance of health care and international organizations selected five prior- systems. BACKGROUND: Diabetes complications ity areas (cardiac care, diabetes, mental health, markedly reduce quality and length of life and are patient safety, and primary care/prevention) and also responsible for enormous health care costs. developed a conceptual framework to guide the A large body of evidence has shown that several project. International expert panels were formed effective treatments and practices may substan- to identify clinically important, scientifically sound, tially reduce this burden. However, a marked vari- and feasible measures based on a structured con- ability has been documented in preventive and sensus process. RESULTS: The consensus pro- therapeutic approaches, thus suggesting that the cess was successfully completed in all five priority level of diabetes care currently delivered may not areas leading to a recommendation of 86 indica- produce the possible health-related gains. METH- tors. Nine indicators were selected for diabetes, ODS: Existing quality indicators have been re- 12 for mental health, 17 for cardiac care, 21 for viewed, with particular attention to the work done patient safety, and 27 for primary care and pre- by the National Diabetes Quality Improvement Al- vention. CONCLUSIONS: The initial experience of liance (NDQIA) in the US. All the measures identi- the HCQI Project demonstrates that international fied were evaluated for their importance, scientific consensus can be achieved in how to measure soundness, and feasibility. In addition, the panel the quality of care in priority areas, suggesting members selected new distal outcome measures. substantial demand for and interest in compara- These measures are currently not used in pro- tive information at the health system level. How- vider comparisons, but they could reveal valuable ever, much additional work remains necessary insight into the differential performance of health before the project can supply policymakers and systems. RESULTS: Four process and two proxi- researchers with ongoing, comprehensive, and mal outcome measures were selected among reliable data on the quality of care in industrial- those endorsed by the NDQIA. In addition, three ized countries. new long-term outcome measures have been pro- EP-50452 posed to gain insight into whether and to what de- OECD Health Care Quality Indicator Project: gree differences in the processes and intermedi- The Expert Panel on Primary Care Prevention ate outcomes that are captured by the established and Health Promotion. Martin Marshall, Niek S. measures translate into better outcomes for pa- Klazinga, Sheila Leatherman. 2014 tients. CONCLUSIONS: The measures selected can contribute to policymakers' and researchers' PURPOSE: This article describes a project understanding of differences in the quality of dia- undertaken as part of the Organization for Eco- betes care between health systems. Further work nomic Co-operation and Development (OECD)'s is required to assess the availability of reliable and Healthcare Quality Indicator (HCQI) Project, which comparable data across OECD countries. aimed to develop a set of quality indicators representing the domains of primary care, prevention EP-50451 and health promotion, and which could be used The OECD Health Care Quality Indicators to assess the performance of primary care sys- Project: History and Background. Soeren Mattke, tems. METHODS: Existing quality indicators from Arnold M. Epstein, Sheila Leatherman. 2014 OBJECTIVE: To describe the background, 202 around the world were mapped to an organizing public health, and public policy. MEASURES: Mea- framework which related primary care, prevention, sures with a final median score of at least 7.0 for and health promotion. The indicators were judged both importance and soundness, and data avail- against the US Institute of Medicine's assessment ability rated as 'possible' or better in at least half of criteria of importance and scientific soundness, participating countries, were included in the final and only those which met these criteria and were set. Measures with median scores ≤3.0 or likely to be feasible were included. An initial large data availability rated as 'unlikely' were excluded. set of indicators was reduced by the primary care Measures with intermediate scores were subject expert panel using a modified Delphi process. to further discussion by the panel, leading to their RESULTS: A set of 27 indicators was produced. adoption or rejection on a case-by-case basis. Six of them were related to health promotion, cov- RESULTS: From an initial set of 134 candidate ering health-related behaviours that are typically measures, the panel identified 12 measures that targeted by health education and outreach cam- achieved moderate to high scores on desired attri- paigns, 13 to preventive care with a focus on pre- butes. CONCLUSIONS: Although limited, the pro- natal care and immunizations and eight to primary posed measure set provides a starting point for in- clinical care mainly addressing activities related to ternational benchmarking of mental health care. It risk reduction. The indicators selected placed a addresses known quality problems and achieves strong emphasis on the public health aspects of some breadth across diverse dimensions of men- primary care. CONCLUSIONS: This project repre- tal health care. sents an important but preliminary step towards a set of measures to evaluate and compare primary EP-50454 care quality. Further work is required to assess Application of Patient Safety Indicators Inter- the operational feasibility of the indicators and the nationally: A Pilot Study Among Seven Countries. validity of any benchmarking data drawn from in- Saskia K Subramanian, Niek S. Klazinga. 2014 ternational comparisons. A conceptual framework OBJECTIVE: To explore the potential for inter- needs to be developed that comprehensively cap- national comparison of patient safety as part of tures the complex construct of primary care as a the Health Care Quality Indicators project of the basis for the selection of additional indicators. Organization for Economic Co-operation and De- velopment (OECD) by evaluating patient safety EP-50453 indicators originally published by the US Agency Quality Indicators for International Benchmark- for Healthcare Research and Quality (AHRQ). ing of Mental Health Care. Richard C. Hermann, DESIGN: A retrospective cross-sectional study. Soeren Mattke, David Somekh. 2014 SETTING: Acute care hospitals in the USA, UK, OBJECTIVE: To identify quality measures for Sweden, Spain, Germany, Canada and Australia international benchmarking of mental health care in 2004 and 2005/2006. DATA SOURCES: Rou- that assess important processes and outcomes of tine hospitalization-related administrative data care, are scientifically sound, and are feasible to from seven countries were analyzed. Using algo- construct from preexisting data. DESIGN: An in- rithms adapted to the diagnosis and procedure ternational expert panel employed a consensus coding systems in place in each country, authori- development process to select important, sound, ties in each of the participating countries reported and feasible measures based on a framework summaries of the distribution of hospital-level and that balances these priorities with the additional overall (national) rates for each AHRQ Patient goal of assessing the breadth of mental health Safety Indicator to the OECD project secretariat. care across key dimensions. PARTICIPANTS: Six RESULTS: Each country's vector of national in- countries and one international organization nom- dicator rates and the vector of American patient inated seven panelists consisting of mental health safety indicators rates published by AHRQ (and administrators, clinicians, and services research- re-estimated as part of this study) were highly ers with expertise in quality of care, epidemiology, 203 correlated (0.821–0.966). However, there was has heightened the importance of workplace well- substantial systematic variation in rates across ness programs. This paper used administrative countries. CONCLUSIONS: This pilot study re- data from 2002 to 2007 for PepsiCo's self-insured veals that AHRQ Patient Safety Indicators can be plan members to evaluate the effect of its wellness applied to international hospital data. However, program on medical costs and utilization. We used the analyses suggest that certain indicators (e.g. propensity score matching to identify a compari- 'birth trauma', 'complications of anesthesia') may son group who were eligible for the program but be too unreliable for international comparisons. did not participate. No significant changes were Data quality varies across countries; undercoding observed in inpatient admissions, emergency may be a systematic problem in some countries. room visits, or per-member per-month (PMPM) Efforts at international harmonization of hospital costs. The discrepancy between our findings and discharge data sets as well as improved accuracy those of prior studies may be due to the difference of documentation should facilitate future compar- in intervention intensity or program implementa- ative analyses of routine databases. tion.

EP-50455 EP-50468 Untangling Practice Redesign from Disease A regression model for risk difference estimation Management: How Do We Best Care for the in population-based case-control studies clarifies Chronically Ill?. Katie Coleman, Soeren Mattke, gender differences in lung cancer risk of smok- Patrick J. Perrault. 2014 ers and never smokers. Sara de Matteis, Maria Teresa Landi. 2014 In the past 10 years, a wide spectrum of chronic care improvement interventions has been tried BACKGROUND: Additive risk models are nec- and evaluated to improve health outcomes and essary for understanding the joint effects of expo- reduce costs for chronically ill individuals. On one sures on individual and population disease risk. end of the spectrum are disease-management Yet technical challenges have limited the consid- interventions—often organized by commercial eration of additive risk models in case–control vendors—that work with patients but do little to studies. METHODS: Using a flexible risk regres- engage medical practice. On the other end are sion model that allows additive and multiplicative quality-improvement efforts aimed at redesign- components to estimate absolute risks and risk ing the organization and delivery of primary care differences, we report a new analysis of data from and better supporting patient self-management. the population-based case–control Environment This qualitative review finds that carve-out dis- And Genetics in Lung cancer Etiology study, con- ease management interventions that target only ducted in Northern Italy between 2002–2005. The patients may be less effective than those that analysis provides estimates of the gender-specific also work to redesign care delivery. Imprecise no- absolute risk (cumulative risk) for non-smoking- menclature and poor study design methodology and smoking-associated lung cancer, adjusted for limit quantitative analysis. More innovation and demographic, occupational, and smoking history research are needed to understand how disease- variables. RESULTS: In the multiple-variable lex- management components can be more meaning- pit regression, the adjusted 3-year absolute risk of fully embedded within practice to improve patient lung cancer in never smokers was 4.6 per 100,000 care. persons higher in women than men. However, the absolute increase in 3-year risk of lung cancer EP-50467 for every 10 additional pack-years smoked was Do workplace wellness programs reduce medi- less for women than men, 13.6 versus 52.9 per cal costs? evidence from a Fortune 500 company. 100,000 persons. CONCLUSIONS: In a Northern Soeren Mattke. 2014 Italian population, the absolute risk of lung cancer The recent passage of the Affordable Care Act among never smokers is higher in women than 204 men but among smokers is lower in women than was greater among those with intentions. Partner men. Lexpit regression is a novel approach to ad- HIV status was not associated with fertility desires ditive-multiplicative risk modeling that can contrib- or intentions. These findings highlight the need for ute to clearer interpretation of population-based reproductive health programs for HIV clients to case–control studies. incorporate safer conception counseling and improve communication regarding childbearing. EP-50469 Creating constituencies for long-term, radical EP-50471 change. 2014 Impact of daily assessments in distress and PTSD symptoms in trauma-exposed women. Climate change presents a global, long-term Debra L. Kaysen, Kristen P. Lindgren. 2014 policy challenge. This essay will argue that long- term emissions reduction goals currently pro- As more advanced methodologies are devel- posed before Congress at best only highlight the oped for symptom assessment in traumatic stress magnitude of the climate change challenge, with- studies, it is important to examine how these out contributing much to a solution. The robust de- methodologies can exacerbate distress or con- cision making approach suggests that a different tribute to symptoms among study participants. framework for long-term climate policy may prove Using a sample of 202 female college students, more effective. Rather than emphasize long-term we examined the changes in posttraumatic stress goals, Congress might focus on shaping the op- disorder (PTSD) symptoms and general psycho- tions available to its successors. logical symptomatology among groups of trauma-exposed and non-trauma-exposed women EP-50470 randomly assigned to complete 30 days of daily Fertility desires and intentions and the rela- monitoring of traumatic symptoms and substance tionship to consistent condom use and provider use behaviors using personal digital assistants communication regarding childbearing among (PDAs). These two groups were compared with HIV clients in Uganda. Rhoda K. Wanyenze. 2014 a trauma-exposed sample of women who did not Family planning services emphasize prevention complete daily monitoring assessments and only of unplanned pregnancies, but rarely account for completed pre- and post-monitoring online as- the childbearing desires of HIV clients. We exam- sessments. While trauma-exposed participants in ined the correlates of fertility desires and inten- the monitoring group reported more distress from tions among 767 HIV clients (34% male) starting the daily assessments than those in the monitor- antiretrovirals in Uganda. Half of participants had ing group with no history of trauma, this distress a primary sex partner. Among those with a desire level was relatively low. Online surveys delivered (31%) or intention (24%) for having a child in the pre- and post-monitoring showed a similar pat- near future, 60% had not discussed this with pro- tern. Trauma-exposed participants in monitoring viders. Over one quarter (27%) were told by their and no-monitoring groups reported a decrease in provider that they should not bear a child because general psychological symptoms over the 30 days; of their HIV status. In regression analysis, male however, monitoring participants reported in- gender, younger age, higher CD4, having fewer creased levels of PTSD severity over time. Closer children, and having a primary partner were as- examination revealed the observed changes were sociated with fertility desires and intentions; hav- relatively moderate. Participants expressed ben- ing been told by provider not to have a child was efits and risks regarding study participation sup- associated with intentions but not desires. Among porting the findings that repeated assessments of participants with a primary partner, consistent traumatic symptoms using personal handheld de- condom use was greater among those with no vices may lead to small increases in distress and fertility intentions, as was receipt of advise about PTSD symptoms, but that these approaches may family planning, while HIV disclosure to partner be generally well tolerated. 205

The ground has shifted in US health care. With EP-50472 President Obama's reelection in November 2012, School programs and characteristics and their the Affordable Care Act is here to stay, and tens influence on student BMI: findings from Healthy of millions of Americans soon will gain access to Passages. Marc N. Elliott. 2014 health insurance. Numerous experiments are un- BACKGROUND: Little is known about the con- derway to better organize and coordinate care at tribution of school contextual factors to individ- the levels of the individual practice, the "medical ual student body mass index (BMI). We set out neighborhood," and the larger health system. Un- to determine if school characteristics/resources: derlying these activities is a fundamental switch (1) are associated with student BMI; (2) explain from a reactive care system oriented toward sick- racial/ethnic disparities in student BMI; and (3) ness (in which individual providers were paid for explain school-level differences in student BMI. discrete elements of care) to a proactive care sys- METHODS: Using gender-stratified multi-level tem oriented toward wellness, where teams and modeling strategies we examined the association systems share accountability for the health of in- of school characteristics/resources and individu- dividual patients and populations. How can inter- al BMI in 4,387 5th graders in the Healthy Pas- nal medicine graduate medical education (GME) sages Longitudinal Study of Adolescent Health. help meet this challenge? This article presents Additionally, we examined the association of the evidence-based recommendations and opin- race/ethnicity and individual BMI as well as the ions of selected leaders in general internal medi- between-school variance in BMI before and after cine based on iterative conversations before, dur- adding individual and school characteristics to ing, and after the 2011 Society of General Internal test for attenuation. RESULTS: The school-level Medicine (SGIM) Education Summit. Recogniz- median household income, but not physical ac- ing that today's physician training programs may tivity or nutrition resources, was inversely associ- not adequately prepare physicians for tomorrow's ated with female BMI (β = −0.12, CI: models of health care delivery, there have been −0.21,−0.02). Neither school demo- many calls over the past decade for medical ed- graphics nor physical activity/nutrition resources ucation reform. As we consider the future of US were predictive of individual BMI in males. In Black health reform, it is clear we need to address at females, school characteristics attenuated the as- least 3 interdependent problems. We must (1) im- sociation of race/ethnicity and BMI. Individual stu- prove quality, (2) drive out waste, and (3) expand dent characteristics—not school characteristics/ the notion of health care to include the social de- resources-reduced the between-school variation terminants of health that account for 70% of the in BMI in males by nearly one-third and eliminated burden of disease. These problems require us to it in females. CONCLUSIONS: In this cohort of reconsider the formation of tomorrow's workforce. 5th graders, school SES was inversely associated Our article focuses on the specific implications of with female BMI while school characteristics and US health reform for internal medicine GME. We resources largely explained Black/White dispari- describe the required competencies that will allow ties in female weight status. Between-school dif- tomorrow's comprehensive primary care internist ferences in average student weight status were to thrive in a proactive US care system. We then largely explained by the composition of the stu- propose 3 recommendations for reforming inter- dent body not by school characteristics or pro- nal medicine GME training to foster that vision. gramming. EP-50481 EP-50473 The Affordable Care Act may increase the Training tomorrow's comprehensive primary number of people getting tested for HIV by nearly care internists: a way forward for internal medicine 500,000 by 2017. Zachary Wagner, Yanyu Wu. education. Mark W. Friedberg. 2014 2014 206

People are much less likely to engage in risky agement as especially valuable and important sexual behavior if they know that they are HIV- to the entire continuum of care and for all patient positive. Unfortunately, more than 18 percent of subpopulations. Whether care is supplied by the people living with HIV/AIDS in the United States Ryan White Program, Medicaid, or other means, are unaware of their HIV status, and about half our findings suggest that case management ser- of new HIV infections are transmitted from that vices will remain critical in treating HIV/AIDS as "HIV unaware" population. For these reasons, HIV the health care landscape continues to evolve. testing is at the forefront of HIV prevention strategies in the United States. The Affordable Care Act EP-50483 (ACA) may support these strategies, since gaining Implementing Psychological First-Aid Train- coverage increases the likelihood of being tested ing for Medical Reserve Corps Volunteers. Anita for HIV. We modeled the impact of the ACA on HIV Chandra, Jee Kim, Huibrie C. Peters. 2014 testing, diagnoses, and awareness of being HIV- OBJECTIVE: We assessed the feasibility and positive, assuming that only the eighteen states impact on knowledge, attitudes, and reported (and the District of Columbia) that had committed practices of psychological first-aid (PFA) training to expand Medicaid as of July 2013 did expand the in a sample of Medical Reserve Corps (MRC) program. We found that the ACA will result in an members. Data have been limited on the uptake additional 466,153 people's being tested for HIV of PFA training in surge responders (eg, MRC) and 2,598 new diagnoses of HIV by 2017. Among who are critical to community response. METH- people living with HIV/AIDS who gain insurance ODS: Our mixed-methods approach involved self- through the ACA, the share of the HIV unaware administered pre- and post-training surveys and will decline by 22 percent. The impact on both HIV within-training focus group discussions of 76 MRC testing and new diagnoses would be nearly 30 members attending a PFA training and train-the- percent larger if all fifty states expanded Medicaid. trainer workshop. Listen, protect, connect (a PFA Policy makers should consider such epidemiologi- model for lay persons) focuses on listening and cal benefits when analyzing insurance expansion understanding both verbal and nonverbal cues; policies. protecting the individual by determining realistic ways to help while providing reassurance; and EP-50482 connecting the individual with resources in the HIV care providers emphasize the importance community. RESULTS: From pre- to post-train- of the Ryan White Program for access to and qual- ing, perceived confidence and capability in using ity of care. Timothy Juday. 2014 PFA after an emergency or disaster increased With the implementation of the Affordable Care from 71% to 90% (P < .01), but no significant Act (ACA) under way, some policy makers have increase was found in PFA-related knowledge. questioned the continued relevance of the Ryan Qualitative analyses suggest that knowledge and White HIV/AIDS Program as a safety net for peo- intentions to use PFA increased with training. Brief ple living with HIV/AIDS. We surveyed HIV care training was feasible, and while results were mod- providers to understand the role of the Ryan White est, the PFA training resulted in greater reported Program and to identify concerns regarding the confidence and perceived capability in addressing ACA implementation. We also addressed whether psychological distress of persons affected by pub- the program is still relevant after ACA implementa- lic health threats. CONCLUSION: PFA training is tion and, if so, what elements should be retained. a promising approach to improve surge responder We found that providers consider the Ryan White confidence and competency in addressing postdi- Program to be critical in facilitating high-quality saster needs. care for people living with HIV/AIDS. Most of the providers highlighted the program's support for EP-50484 providing medical and nonmedical case man- Preparedness of Americans for the Affordable 207

Care Act. Silvia Helena Barcellos, Amelie Wup- greater extent than in the past. This article seeks permann, Katherine Grace Carman. 2014 to highlight China's evolving approach to the con- This paper investigates whether individuals are tinent. While it is true that growing tensions and sufficiently informed to make reasonable choices contradictions have challenged China's growing in the health insurance exchanges established presence in Africa, China has by no means been by the Affordable Care Act (ACA). We document a passive actor in the face of change. To the con- knowledge of health reform, health insurance lit- trary, it has addressed many of these problems eracy, and expected changes in healthcare using through subtle policy adjustments based on feed- a nationally representative survey of the US popu- back from African governments and its people. lation in the 5 wk before the introduction of the EP-50488 exchanges, with special attention to subgroups The Academic Impact of Enrollment in Interna- most likely to be affected by the ACA. Results sug- tional Baccalaureate Diploma Programs: A Case gest that a substantial share of the population is Study of Chicago Public Schools. Anna Rosefsky unprepared to navigate the new exchanges. One- Saavedra. 2014 half of the respondents did not know about the exchanges, and 42% could not correctly describe BACKGROUND: In schools accredited as a deductible. Those earning 100–250% of federal "IB World Schools" by the International poverty level (FPL) correctly answered, on aver- Baccalaureate Organization (IBO), teachers use age, 4 out of 11 questions about health reform IB curriculum and pedagogy to teach a range of and 4.6 out of 7 questions about health insurance. courses that are intended to prepare IB-enrolled This compares with 6.1 and 5.9 correct answers, students for college. Over the past 18 years, the respectively, for those in the top income category number of U.S. schools that implement IB pro- (400% of FPL or more). Even after controlling for grams has increased nearly tenfold, from 133 in potential confounders, a low-income person is 1994 to 1,390 in 2013. Despite the IB program's 31% less likely to score above the median on ACA rapid expansion, little is known about whether IB knowledge questions, and 54% less likely to score enrollment causally improves students' academic above the median on health insurance knowledge outcomes, including their high school academic than a person in the top income category. Unin- achievement, probability of high school graduation sured respondents scored lower on health insur- and/or subsequent probability of college enroll- ance knowledge, but their knowledge of ACA is ment. PURPOSE: This study examines whether similar to the overall population. We propose that enrollment in the IB Diploma Program increases simplified options, decision aids, and health in- students' academic achievement as measured by surance product design to address the limited their composite ACT college admissions exami- understanding of health insurance contracts will nation scores, probability of high school gradu- be crucial for ACA's success. Contains supporting ation, and probability of college enrollment, and information online at http://www.pnas.org/lookup/ whether the estimates differ by gender. SETTING, suppl/doi:10.1073/pnas.1320488111/-/DCSupple POPULATION, & DATA: This study uses data mental. on the demographic characteristics, IB enrollment status, ACT scores, high school graduation status EP-50485 and college enrollment status of 20,422 students Dragon Watching Its Tail: China's Evolving En- attending 13 Chicago Public Schools (CPS) high gagement Strategy in Africa. Lyle J. Morris, Larry schools from 2002-2008. Data sources include Hanauer. 2014 the CPS and the National Student Clearinghouse. At both the government and grassroots levels, RESEARCH DESIGN: The analytic strategy is to China seems to be taking seriously feedback and first assume students are selected into the IB Di- criticism of certain Chinese policies that nega- ploma Program based on their observed charac- tively affect the lives and interests of Africans to a teristics, and then to use a propensity score ap- 208 proach to estimate the impact of IB enrollment on Survey. Kimberly A. Hepner, Susan M. Paddock, three measures of students' academic success. Katherine E. Watkins. 2014 The second step, following Rosenbaum (2002), OBJECTIVE: This study provided national esis to test the sensitivity of the estimates to differ- timates of perceptions of behavioral health care ent levels of selection bias. RESULTS: This study services among patients of the Veterans Health shows that IB enrollment increases students' ac- Administration (VHA) with a diagnosis of bipolar ademic achievement, probability of high school I disorder, major depression, posttraumatic stress graduation and probability of college enrollment. disorder, schizophrenia, or substance use disor- Though selection bias may contribute to overstat- der. METHODS: A stratified random sample of ing the propensity score estimates, the conclu- 6,190 patients completed telephone interviews sion from the sensitivity analyses is that it is un- from November 2008 through August 2009. Pa- likely that this internal-validity challenge negates tients (N=5,185) who reported receiving VHA be- the principal finding. All estimates are greater for havioral health care in the prior 12 months were boys than for girls. Calculations demonstrate that asked about their need for housing and employ- the IB Diploma Program is a cost-effective way to ment services, timeliness and recovery orientation increase high school graduation rates. CONCLU- of their care, satisfaction with care, and perceived SIONS: The results are valuable for three reasons. improvement. RESULTS: Half of patients reported First, they provide valuable information with which always receiving routine appointments as soon to make decisions about future investments in as requested, and 42% were highly satisfied with IB. Second, they contribute to knowledge of the their VHA mental health care. Approximately 74% means through which to improve high school edu- of patients reported being helped by the treat- cation for disadvantaged urban youth. Finally, the ment they received, yet only 32% reported that results suggest that IB enrollment is especially their symptoms had improved. After controlling beneficial for boys, for whom the probability of for covariates, the analyses showed that patients graduating from high school and enrolling in col- with a substance use disorder reported lower sat- lege—in CPS and at the national level—is sub- isfaction with care and perceived their treatment stantially less than for girls. to be less helpful compared with patients without a substance use disorder. CONCLUSIONS: Al- EP-50489 though matched sample comparison data were America's Poor and the Great Recession, by not available, the results showed that overall pa- Kristin S. Seefeldt and John D. Graham. Eric tient perceptions of VHA mental health care were Apaydin. 2014 favorable, but there was significant room for im- Review of America's Poor and the Great Reces- provement across all areas of assessment. A ma- sion, by Kristin S. Seefeldt and John D. Graham, jority reported being helped by treatment, but few Bloomington and Indianapolis: Indiana University reported symptom improvement. Variations in per- Press, 2013, 158 pp., $21.00, paperback. While ceptions among patients with different disorders U.S. absolute poverty has increased sharply since suggest the potential importance of psychiatric the start of the Great Recession, it was, despite diagnosis, particularly substance use disorder, in historic ups and downs, at roughly the same level assessing patient perceptions of care. in 2007 as in 1980. Wholesale reform of American antipoverty programs is unlikely in the near future. EP-50491 Until the day comes when grand poverty bargains IMPACT - Integrative Medicine Primary Care can be struck, this book has much to say in cur- Trial: Protocol for a Comparative Effectiveness rent policy debates. Study of the Clinical and Cost Outcomes of an Integrative Primary Care Clinic Model. Patricia M. EP-50490 Herman, Sally E. Dodds, Melanie D. Logue. 2014 Veterans' Perceptions of Behavioral Health Care in the Veterans Health Administration: A National 209

BACKGROUND: Integrative medicine (IM) sustainable financial paradigm for our nation. This is a patient-centered, healing-oriented clinical protocol has been designed to test whether the paradigm that explicitly includes all appropriate UAIHC can achieve this potential. therapeutic approaches whether they originate in EP-50492 conventional or complementary medicine (CM). A patient-centered primary care practice ap- While there is some evidence for the clinical and proach using evidence-based quality improve- cost-effectiveness of IM practice models, the ex- ment: rationale, methods, and early assessment isting evidence base for IM depends largely on of implementation. Susan Stockdale. 2014 studies of individual CM therapies. This may in part be due to the methodological challenges in- BACKGROUND: Healthcare systems and their herent in evaluating a complex intervention (i.e., primary care practices are redesigning to achieve many interacting components applied flexibly and goals identified in Patient-Centered Medical with tailoring) such as IM. METHODS/DESIGN: Home (PCMH) models such as Veterans Affairs This study will use a combination of observational (VA)'s Patient Aligned Care Teams (PACT). Imple- quantitative and qualitative methods to rigorous- mentation of these models, however, requires ly measure the health and healthcare utilization major transformation. Evidence-Based Quality outcomes of the University of Arizona Integrative Improvement (EBQI) is a multi-level approach for Health Center (UAIHC), an IM adult primary care supporting organizational change and innovation clinic in Phoenix, Arizona. There are four groups spread. OBJECTIVE: To describe EBQI as an ap- of study participants. The primary group consists proach for promoting VA's PACT and to assess of clinic patients for whom clinical and cost out- initial implementation of planned EBQI elements. comes will be tracked indicating the impact of the DESIGN: Descriptive. PARTICIPANTS: Regional UAIHC clinic (n = 500). In addition to comparing and local interdisciplinary clinical leaders, patient outcomes pre/post clinic enrollment, where pos- representatives, Quality Council Coordinators, sible, these outcomes will be compared to those practicing primary care clinicians and staff, and of two matched control groups, and for some self- researchers from six demonstration site practices report measures, to regional and national data. in three local healthcare systems in one VA region. The second and third study groups consist of INTERVENTION: EBQI promotes bottom-up local clinic patients (n = 180) and clinic personnel (n innovation and spread within top-down organiza- = 15-20) from whom fidelity data (i.e., data indi- tional priorities. EBQI innovations are supported cating the extent to which the IM practice model by a research-clinical partnership, use continuous was implemented as planned) will be collected. quality improvement methods, and are developed These data will be analyzed to determine the ex- in regional demonstration sites. APPROACH: act nature of the intervention as implemented and We developed a logic model for EBQI for PACT to provide covariates to the outcomes analyses (EBQI-PACT) with inputs, outputs, and expected as the clinic evolves. The fourth group is made up outcomes. We describe implementation of logic of patients (n = 8) whose path through the clinic model outputs over 18 months, using qualitative will be studied in detail using qualitative (periodic data from 84 key stakeholders (104 interviews semi-structured interviews) methods. These data from two waves) and review of study documents. will be used to develop hypotheses regarding how RESULTS: Nearly all implementation elements of the clinic works. DISCUSSION: The US health the EBQI-PACT logic model were fully or partially care system needs new models of care that are implemented. Elements not fully achieved includ- more patient-centered and empower patients to ed patient engagement in Quality Councils (4/6) make positive lifestyle changes. These models and consistent local primary care practice inter- have the potential to reduce the burden of chronic disciplinary leadership (4/6). Fourteen of 15 re- disease, lower the cost of healthcare, and offer a gionally approved innovation projects have been completed, three have undergone initial spread, 210 five are prepared to spread, and two have com- and wider impacts. We identified various factors pleted toolkits that have been pretested in two to associated with high impact. Interaction between three sites and are now ready for external spread. researchers and practitioners and the public is DISCUSSION: EBQI-PACT has been feasible to associated with achieving high academic impact implement in three participating healthcare sys- and translation into wider impacts, as is basic re- tems in one VA region. Further development of search conducted with a clinical focus. Strategic methods for engaging patients in care design and thinking by clinical researchers, in terms of think- for promoting interdisciplinary leadership is needing through pathways by which research could po- ed. tentially be translated into practice, is associated with high wider impact. Finally, we identified the EP-50493 complexity of factors behind research translation Understanding Factors Associated with the that can arise in a single case. CONCLUSIONS: Translation of Cardiovascular Research: A Multi- We can systematically assess research impacts national Case Study Approach. Steven Wooding, and use the findings to promote translation. Re- Stephen Hanney, Alexandra Pollitt. 2014 search funders can justify funding research of BACKGROUND: Funders of health research diverse types, but they should not assume aca- increasingly seek to understand how best to al- demic impacts are proxies for wider impacts. They locate resources in order to achieve maximum should encourage researchers to consider path- value from their funding. We built an international ways towards impact and engage potential re- consortium and developed a multinational case search users in research processes. study approach to assess benefits arising from health research. We used that to facilitate analysis EP-50494 Women and Academic Medicine: A Review of of factors in the production of research that might the Evidence on Female Representation. Maryse be associated with translating research findings Penny, Rosanna Jeffries, Jonathan Grant. 2014 into wider impacts, and the complexities involved. METHODS: We built on the Payback Framework In 2008, the then Chief Medical Officer com- and expanded its application through conducting missioned Baroness Deech to chair an Indepen- co-ordinated case studies on the payback from dent Working Group looking at the position and cardiovascular and stroke research in Australia, participation of women in the medical profession. Canada and the United Kingdom. We selected a We update and extend the Deech report to cover stratified random sample of projects from leading academic medicine in the UK, and demonstrate medical research funders. We devised a series that although women are equally represented in of innovative steps to: minimize the effect of re- medicine, they are under-represented in academ- searcher bias; rate the level of impacts identified ic medicine. in the case studies; and interrogate case study narratives to identify factors that correlated with EP-50495 achieving high or low levels of impact. RESULTS: Older Depressed Latinos' Experiences with Twenty-nine detailed case studies produced many Primary Care Visits for Personal, Emotional And/ and diverse impacts. Over the 15 to 20 years ex- Or Mental Health Problems: A Qualitative Analysis. amined, basic biomedical research has a greater Adriana Izquierdo, Catherine A. Sarkisian, Gery impact than clinical research in terms of academic W. Ryan. 2014 impacts such as knowledge production and re- OBJECTIVE: To describe salient experiences search capacity building. Clinical research has with a primary care visit (eg, the context leading greater levels of wider impact on health policies, up to the visit, the experience and/or outcomes practice, and generating health gains. There was of that visit) for emotional, personal and/or mental no correlation between knowledge production 211 health problems older Latinos with a history of de- tion (VHA). This study assessed probable post- pression and recent depressive symptoms and/or traumatic stress disorder (PTSD) and depression antidepressant medication use reported 10 years among OEF/OIF veterans by receipt of VHA ser- after enrollment into a randomized controlled trial vices. METHODS: In 2010 a mixed-mode survey of quality-improvement for depression in primary assessing symptoms and VHA services utilization care. DESIGN: Secondary analysis of existing was fielded in a random sample of 913 New York qualitative data from the second stage of the con- State OEF/OIF veterans. RESULTS: Probable tinuation study of Partners in Care (PIC). PARTIC- PTSD and depression were roughly three times IPANTS: Latino ethnicity, aged > or =50 years, more common among veterans who had received recent depressive symptoms and/or antidepres- VHA services (N=537) (PTSD, 23%; depression, sant medication use, and a recent primary care 21%) than those who had not (N=376) (PTSD, visit for mental health problems. Of 280 second- 6%; depression, 8%). CONCLUSIONS: Studies stage participants, 47 were eligible. Both stages of veterans receiving VHA services likely over- of the continuation study included participants state the prevalence of mental health problems from the PIC parent study control and 2 interven- among the broader OEF/OIF veteran population. tion groups, and all had a history of depression. However, many veterans with mental health prob- METHODS: Data analyzed by a multidisciplinary lems are not receiving VHA services. Policies that team using grounded theory methodology. RE- improve outreach to this population may improve SULTS: Five themes were identified: beliefs about health outcomes. the nature of depression; prior experiences with mental health disorders/treatments; sociocultural EP-50497 context (eg, social relationships, caregiving, the Technology-facilitated Depression Care Man- media); clinic-related features (eg, accessibility agement Among Predominantly Latino Diabetes of providers, staff continuity, amount of visit time); Patients Within a Public Safety Net Care System: and provider attributes (eg, interpersonal skills, Comparative Effectiveness Trial Design. Shin-Yi holistic care approach). CONCLUSIONS: Find- Wu, Kathleen Ell, Sandra Gross-Schulman. 2014 ings emphasize the importance of key features Health disparities in minority populations are for shaping the context leading up to primary care well recognized. Hispanics and Latinos constitute visits for help-seeking for mental health problems, the largest ethnic minority group in the United and the experience and/or outcomes of those vis- States; a significant proportion receives their care its, among older depressed Latinos at long-term via a safety net. The prevalence of diabetes mel- follow-up, and may help tailor chronic depression litus and comorbid depression is high among this care for the clinical management of this vulner- group, but the uptake of evidence-based collab- able population. orative depression care management has been suboptimal. The study design and baseline char- EP-50496 acteristics of the enrolled sample in the Diabe- Prevalence of Mental Health Problems Among tes-Depression Care-management Adoption Trial Iraq and Afghanistan Veterans Who Have and (DCAT) establishes a quasi-experimental compar- Have Not Received VA Services. Christine Anne ative effectiveness research clinical trial aimed at Vaughan, Terry L. Schell, Terri Tanielian. 2014 accelerating the adoption of collaborative depres- OBJECTIVE: Roughly half of veterans who sion care in safety net clinics. Conducted in col- served in Operation Enduring Freedom and Oper- laboration with the Los Angeles County Depart- ation Iraqi Freedom (OEF/OIF) have not received ment of Health Services at eight county-operated services from the Veterans Health Administra- clinics. DCAT has enrolled 1,406 low-income, predominantly Hispanic/Latino patients with diabetes to test a translational model of depression care management. This three-group study compares 212 usual care with a collaborative care team support OBJECTIVE: Study abroad students are at-risk model and a technology-facilitated depression for increased and problematic drinking behavior. care model that provides automated telephonic As few efforts have been made to examine this depression screening and monitoring tailored to at-risk population, we predicted drinking and al- patient conditions and preferences. Call results are cohol-related consequences abroad from prede- integrated into a diabetes disease management parture and site-specific factors. PARTICIPANTS: registry that delivers provider notifications, gener- The sample consisted of 339 students complet- ates tasks, and issues critical alerts. All subjects ing study abroad programs. METHOD: Partici- receive comprehensive assessments at baseline, pants filled out online measures at predeparture, 6, 12, and 18 months by independent English- abroad, and at post-return. RESULTS: We found Spanish bilingual interviewers. Study outcomes drinking and consequences abroad were predict- include depression outcomes, treatment adhered by a number of factors including demograph- ence, satisfaction, acceptance of assessment ics (e.g., younger age, male sex, Greek affiliation, and monitoring technology, social and economic White ethnicity), student factors (e.g. low GPA, stress reduction, diabetes self-care management, major area of study), study abroad site factors health care utilization, and care management (e.g., apartment living abroad, study in Europe), model cost and cost-effectiveness comparisons. predeparture levels of drinking and consequenc- DCAT's goal is to optimize depression screening, es, sensation seeking, and goals related to social treatment, follow-up, outcomes, and cost savings gathering. CONCLUSIONS: Findings can be used to reduce health disparities. to inform campus policies for admission to study abroad programs as well as assist in the develop- EP-50498 ment of interventions targeted toward preventing Developing Public Health Regulations for risk for students during abroad experiences. Marijuana: Lessons from Alcohol and Tobacco. Rosalie Liccardo Pacula, Beau Kilmer, Alexander EP-50500 C. Wagenaar. 2014 Does Group Cognitive–behavioral Therapy Until November 2012, no modern jurisdiction Module Type Moderate Depression Symptom had removed the prohibition on the commercial Changes in Substance Abuse Treatment Clients?. production, distribution, and sale of marijuana for Susan M. Paddock, Sarah B. Hunter, Thomas J. nonmedical purposes—not even the Netherlands. Leininger. 2014 Government agencies in Colorado and Wash- Little is known about the effect of group therapy ington are now charged with granting production treatment modules on symptom change during and processing licenses and developing regula- treatment and on outcomes post-treatment. Sec- tions for legal marijuana, and other states and ondary analyses of depressive symptoms collect- countries may follow. Our goal is not to address ed from two group therapy studies conducted in whether marijuana legalization is a good or bad substance use treatment settings were examined idea but, rather, to help policymakers understand (n = 132 and n = 44). Change in PHQ-9 scores the decisions they face and some lessons learned was modeled using longitudinal growth modeling from research on public health approaches to reg- combined with random effects modeling of ses- ulating alcohol and tobacco over the past century. sion effects, with time-in-treatment interacted with module theme to test moderation. In both studies, EP-50499 depressive symptoms significantly decreased dur- Demographic and Predeparture Factors Asso- ing the active treatment phase. Symptom reduc- ciated with Drinking and Alcohol-Related Conse- tions were not significantly moderated by module quences for College Students Completing Study theme in the larger study. However, the smaller Abroad Experiences. Eric R. Pedersen, Jessica pilot study's results suggest future examination of R. Skidmore, Giovanni Aresi. 2014 module effects is warranted, given the data are 213 compatible with differential reductions in reported munication and expressed disapproval of smok- symptoms being associated with attending Peo- ing. ple-themed module sessions versus Thoughts- themed sessions. EP-50502 The Role of Early-Life Educational Quality and EP-50501 Literacy in Explaining Racial Disparities in Cogni- Tobacco Use and Smoking Intentions Among tion in Late Life. Shannon Sisco, Alden L. Gross, U.S. Fifth-Grade Students. Joseph A. Ladapo, Regina A. Shih. 2014 Marc N. Elliott, David E. Kanouse. 2014 OBJECTIVES: Racial disparities in late-life PURPOSE: To identify the risk and protec- cognition persist even after accounting for educa- tive factors for cigarette smoking and future intentional attainment. We examined whether early-life tions among racially/ethnically diverse preadoles- educational quality and literacy in later life help cent children. METHODS: We analyzed data from explain these disparities. METHOD: We used lon- 5,119 fifth-grade children and their parents living in gitudinal data from the Washington Heights-In- three U.S. metropolitan areas. Using the multivari- wood Columbia Aging Project (WHICAP). Educa- ate logistic regression models, we examined how tional quality (percent white students; urban/rural cigarette smoking and intentions to smoke within school; combined grades in classroom) was op- 1 year are associated with (1) number of friends erationalized using canonical correlation analysis. who smoke, (2) parental disapproval of smoking, Late-life literacy (reading comprehension and abil- (3) parental communication about not smoking, ity, writing) was operationalized using confirma- (4) performance in school, and (5) educational tory factor analysis. We examined whether these aspirations. RESULTS: Twenty-nine percent of factors attenuated race-related differences in late- the children were black, 44% were Hispanic, 22% life cognition. RESULTS: The sample consisted of were white, and 5% were of another race/ethnicity. 1,679U.S.-born, non-Hispanic, community-living Mean age was 11.1 years. The prevalence of ever adults aged 65–102 (71% black, 29% white; 70% smoking a cigarette among black, Hispanic, and women). Accounting for educational quality and white children was 9.8%, 5.6%, and 4.9%, respec- literacy reduced disparities by 29% for general tively. In adjusted analyses, children were more cognitive functioning, 26% for memory, and 32% likely to have smoked a cigarette if their friends for executive functioning but did not predict differ- smoked (adjusted odds ratio [aOR] 5.1, 95% ences in rate of cognitive change. DISCUSSION: confidence interval [CI] 3.8–6.9), they frequently Early-life educational quality and literacy in late had trouble with schoolwork (aOR 2.1, 95% CI life explain a substantial portion of race-related 1.5–3.1), or their parents were not college grad- disparities in late-life cognitive function. uates (aOR 2.0, 95% CI 1.2–3.5 for high school graduate). They were less likely to have smoked EP-50503 cigarettes if their parents disapproved of smoking Community engagement in disaster prepared- (aOR .3, 95% CI .1–.6). Parental communication ness and recovery: a tale of two cities – Los Ange- (aOR .1, 95% CI .0–.6) and disapproval (aOR .2, les and New Orleans. Benjamin Springgate. 2014 95% CI .1–.7) had protective associations for fu- Awareness of the impact of disasters globally ture intentions among children who had ever and on mental health is increasing. Known difficulties had never smoked, respectively. CONCLUSIONS: in preparing communities for disasters and a lack Fifth-graders share many of the same risk factors of focus on relationship building and organization- for smoking identified in older adolescents, some al capacity in preparedness and response have of which are modifiable. Antismoking policies and led to a greater policy focus on community resil- programs should be designed for preadolescents iency as a key public health approach to disaster as well as adolescents, and campaigns targeting response. In this article, the authors describe how parents should place greater emphasis on com- an approach to community engagement for im- 214 proving mental health services, disaster recovery, health is stabilized, in which case mental health and preparedness from a community resiliency treatment may be needed. perspective emerged from their work in applying a partnered, participatory research framework, it- EP-50505 eratively, in Los Angeles County and the City of You've shown the program model is effective: New Orleans. now what?. 2014 Rigorous tests of theory-based programs re- EP-50504 quire faithful implementation. Otherwise, lack of Impact of HIV antiretroviral therapy on depres- results might be attributable to faulty program de- sion and mental health among clients with HIV in livery, faulty theory, or both. However, once the Uganda. 2014 evidence indicates the model works and merits OBJECTIVE: With wide-reaching harmful ef- broader dissemination, implementation issues do fects of depression, and the absence of psychi- not fade away. How can developers enhance the atric treatment in most HIV care programs in likelihood that the program will be delivered as sub-Saharan Africa, we examined the effects of designed and thus get results close to what was antiretroviral therapy (ART) on depression and possible under controlled conditions? How can other mental health indicators. METHODS: 602 they address program weaknesses without under- patients (302 non-ART, 300 ART) were followed mining conceptual integrity? What role can they for the first 12 months of HIV care in Uganda, play in making the program visible and attractive with assessments at entry into care and Months to institutional adopters? This chapter uses field 6 and 12. Mental health was assessed with mea- experience from a theory-based program, Project sures of depression, hopelessness, and internal- ALERT, to suggest possible strategies for enhanc- ized HIV stigma; physical health functioning was ing program attractiveness to potential adopters assessed as an explanatory variable. RESULTS: and users, facilitating program fidelity while main- Thirteen percent had clinical depression, 57% taining room for adaptation and taking a program had elevated depressive symptoms, and CD4 cell to scale. count was negatively correlated with measures of depression at baseline. Significant reductions EP-50506 in elevated depressive symptoms (time: odds ra- HIV prevalence and demographic determinants tio [95% confidence interval] = 0.53 [0.43–0.64]) of unprotected anal sex and HIV testing among and hopelessness (time: β = −0.12, men who have sex with men in Beirut, Lebanon. p < .001) were observed in both the ART and Johnny Tohme, Matthew Hoover. 2014 non-ART groups, but the drop in depression was The limited epidemiological data in Lebanon greater among ART patients in intention-to-treat suggest that HIV incident cases are predominant- multivariate analysis (ART × time: p < .001). ly among men who have sex with men (MSM). We When added to the regression models, change assessed the prevalence of HIV and demographic in physical health functioning predicted positive correlates of condom use and HIV testing among longitudinal change on measures of depression, MSM in Beirut. Respondent-driven sampling was hopelessness, and internalized stigma (all p val- used to recruit 213 participants for completion of a ues < .001), yet ART status remained a significant behavioral survey and an optional free rapid HIV independent predictor of each (ART × time: test. Multivariate regression analysis was used to p values ranged from < .05 to < .001). Most men- examine demographic correlates of unprotected tal health benefits of ART were experienced in the anal sex and any history of HIV testing. Nearly first 6 months of care. CONCLUSIONS: These half (47%) were under age 25 years and 67% self- findings demonstrate the mental health benefits identified as gay. Nearly two-thirds (64%) reported of HIV care and ART. However, in some people, any unprotected anal intercourse (UAI) with men mental health problems persist once physical 215 in the prior 3 months, including 23% who had un- tions increased by the greatest extent: from 43% protected anal intercourse with men whose HIV to 63% preferring MUP of £1 to the status status was positive or unknown (UAIPU) to the quo. Respondents' own drinking behaviour also participant. Three men (1.5% of 198 participants influenced preferences, with around 90% of non- tested) were HIV-positive; 62% had any history drinkers being predicted to choose all interven- of HIV testing prior to the study and testing was tions over the status quo, and with more moderate less common among those engaging in UAIPU than heavy drinkers favouring a given policy over compared to others (33% vs. 71%). In regression the status quo. Importantly, the study findings sug- analysis, men in a relationship had higher odds of gest public acceptability of alcohol interventions is having UAI but lower odds of UAIPU and any uni- dependent on both the nature of the policy and its versity education was associated with having UAI; expected effectiveness. Policy-makers struggling those with any prior history of HIV testing were to mobilise support for hitherto unpopular but more likely to be in a relationship and have any promising policies should consider giving greater university education. HIV prevention efforts for prominence to their expected outcomes. MSM need to account for the influence of relationship dynamics and promotion of testing needs to EP-50508 target high-risk MSM. Youth exposure to alcohol advertising on television in the UK, the Netherlands and Germany. EP-50507 Eleanor Winpenny. 2014 Public acceptability of population-level interven- BACKGROUND: Exposure of young people tions to reduce alcohol consumption: a discrete to alcohol advertising is a risk factor for underage choice experiment. Peter Burge. 2014 drinking. This study assessed youth exposure to Public acceptability influences policy action, television alcohol advertising in the UK, the Neth- but the most acceptable policies are not always erlands and Germany, from December 2010 to the most effective. This discrete choice experi- May 2011. METHODS: A negative binomial regres- ment provides a novel investigation of the ac- sion model predicted number of alcohol advertise- ceptability of different interventions to reduce al- ments from the proportion of the television viewer- cohol consumption and the effect of information ship in each age group. This allowed comparison on expected effectiveness, using a UK general of alcohol advertisement incidence for each youth population sample of 1202 adults. Policy options age category relative to an adult reference cat- included high, medium and low intensity versions egory. RESULTS: In the UK, those aged 10–15 of: Minimum Unit Pricing (MUP) for alcohol; reduc- years were significantly more exposed to alcohol ing numbers of alcohol retail outlets; and regu- advertisements per viewing hour than adults aged lating alcohol advertising. Outcomes of interven- ≥25 years [incidence rate ratio (IRR) = 1.11; tions were predicted for: alcohol-related crimes; 95% confidence interval (95% CI): 1.06, 1.18; P < alcohol-related hospital admissions; and heavy 0.01]; in the Netherlands, those aged 13–19 years drinkers. First, the models obtained were used to were more exposed per viewing hour than adults predict preferences if expected outcomes of in- aged ≥ 20 years (IRR = 1.29; 95% CI: 1.19, terventions were not taken into account. In such 1.39; P < 0.01). Conversely, in Germany, those models around half of participants or more were aged 10–15 years were less exposed to alcohol predicted to prefer the status quo over implement- advertisements than adults aged ≥25 years ing outlet reductions or higher intensity MUP. Sec- (IRR = 0.79; 95% CI: 0.73, 0.85; P < 0.01). In each ond, preferences were predicted when information country, young children (aged 4–9 years in the on expected outcomes was considered, with most UK and Germany, 6–12 years in the Netherlands) participants now choosing any given intervention were less exposed than adults. CONCLUSION: over the status quo. Acceptability of MUP interven- Adolescents in the UK and the Netherlands, but not Germany, had higher exposure to television 216 alcohol advertising relative to adults than would of state, local, tribal, and territorial public health be expected from their television viewing. Further efforts is reduced and public health suffers. Suc- work across a wider range of countries is needed cessfully integrating the best practices and knowl- to understand the relationship between national edge of health literacy into public health practice policies and youth exposure to alcohol advertising is likely the most significant opportunity that cur- on television. rently exists to improve individual, community, and public health. EP-50509 EP-50511 Decomposing racial disparities in prison and Economic shocks, federalism and redistribution: drug treatment commitments for criminal offend- exploring the future of Europe through a compari- ers in California. Jeremy Arkes. 2014 son of the evolution of student financial aid in the We assess whether black-white disparities in United States and the European Union. 2014 commitments to prison or diversions to treatment This chapter explores the potential mecha- for drug offenders in California can be explained by nisms through which the Europe of Knowledge differences in the characteristics of criminal cases extends the boundaries of European integration and whether case characteristics are weighed dif- by concentrating on the evolution of a policy do- ferently by race. We also examine whether the in- main which is not commonly attributed to Euro- fluence of case characteristics changed after Cali- pean competency, namely redistributive mecha- fornia implemented a mandatory prison diversion nisms in the higher education domain. program for eligible drug offenders. Our results show that black-white disparities in prison commit- EP-50512 ments are fully explained by criminal case charac- Bring the world to California. Richard Edelstein, teristics, but a significant share of the differences Cecile Hoareau McGrath. 2014 in treatment diversions remains unexplained. The This article argues that California colleges and unexplained racial disparity in treatment diversions universities should make a concerted effort to did not change after California implemented man- work together to attract more foreign students by datory diversion for eligible drug offenders. These forming education hubs. The authors argue that findings suggest that case characteristics play a such "EdHubs" can relieve the intense pressure larger role in explaining prison commitments for on schools' budgets by enrolling more higher- drug offenders than the discretion of prosecutors paying out-of-state students, while schools in the and judges. Diversion to treatment appears to be same geographic regions can share the burden driven more by the discretion of court officials, and of supporting such students, particularly with in- racial disparities remain prominent. vestment from local industry. The authors argue that schools that work together can increase their EP-50510 capacity to educate more students, particularly in A prescription is not enough: improving public science, technology, engineering, and mathemat- health with health literacy. Jennifer Cabe, Laurie ics, thereby increasing opportunities not just for T. Martin. 2014 foreign students but Californians as well. This article focuses on the use—and the lack of use—of health literacy within efforts to address EP-50513 public health in the United States. While a grow- Effectiveness of multisystemic therapy for mi- ing body of evidence strongly suggests that health nority youth: outcomes over 8 years in Los Ange- literacy can be effective in public health when ex- les County. Sarah Michal Greathouse. 2014 plicitly addressed, the concept and associated Previous research on Multisystemic best practices of health literacy do not seem to Therapy© (MST), an intensive family and be consistently or universally used within public community-based treatment for juvenile offenders health organizations. As a result, the effectiveness between 12 and 18 years of age, has been based 217 on small samples that have included very few His- (uncompensated care costs and Medicaid short- panic youth. This paper examines juvenile justice falls) will change as a result of insurance expan- outcomes and costs for 757 MST participants and sion and the offsetting DSH reductions. Decreas- 380 comparison group youth over an 8-year peri- es in uncompensated care costs resulting from od in Los Angeles County. More than 90% of youth the ACA insurance expansion may not match the were either Hispanic or Black. Hispanic MST par- act's DSH reductions because of the high number ticipants had significantly more positive outcomes of people who will remain uninsured, low Medic- on three of six juvenile justice measures, com- aid reimbursement rates, and medical cost infla- pared to Hispanic comparison youth. Black MST tion. Taking these three factors into account, we participants did not show more positive outcomes estimate that California public hospitals' total DSH than Black comparison youth. costs will increase from $2.044 billion in 2010 to $2.363–$2.503 billion in 2019, with unmet DSH EP-50514 costs of $1.381–$1.537 billion. Costs and benefits of treating maternal depression. Tara A. Lavelle, Dana Schultz. 2014 EP-50516 An estimated 15 million mothers with young chil- A systematic review of stakeholder engagement dren in the U.S. suffer from depression. Untreated in comparative effectiveness and patient-centered maternal depression has serious consequences outcomes research. Melissa Fuster, Tully Saun- for the mother's long-term health and for her child's ders. 2014 development and functioning. It can also be costly, OBJECTIVES: We conducted a review of the driving up health care use, reducing employment, peer-reviewed literature since 2003 to catalogue and creating the need for early childhood inter- reported methods of stakeholder engagement in ventions. Treatments for depression, usually com- comparative effectiveness research and patient- bining medication and psychotherapy, have been centered outcomes research. METHODS AND proven effective in the general population, but RESULTS: We worked with stakeholders before, there is limited evidence for how much they help during and after the review was conducted to: de- mothers and for their cost-effectiveness. Stronger fine the primary and key research questions; con- evidence about what works in treating maternal duct the literature search; screen titles, abstracts depression, and the value of alternative treatment and articles; abstract data from the articles; and options, could inform best practices and improve analyze the data. The literature search yielded the lives of millions of mothers and children. 2,062 abstracts. The review was conducted on 70 articles that reported on stakeholder engagement EP-50515 in individual research projects or programs. FIND- Disproportionate-share hospital payment INGS: Reports of stakeholder engagement are reductions may threaten the financial stability of highly variable in content and quality. We found safety-net hospitals. Anna C. Davis, Jack Needle- frequent engagement with patients, modestly fre- man. 2014 quent engagement with clinicians, and infrequent Safety-net hospitals rely on disproportionate- engagement with stakeholders in other key de- share hospital (DSH) payments to help cover un- cision-making groups across the healthcare sys- compensated care costs and underpayments by tem. Stakeholder engagement was more common Medicaid (known as Medicaid shortfalls). The Af- in earlier (prioritization) than in later (implementa- fordable Care Act (ACA) anticipates that insurance tion and dissemination) stages of research. The expansion will increase safety-net hospitals' rev- roles and activities of stakeholders were highly enues and will reduce DSH payments accordingly. variable across research and program reports. We examined the impact of the ACA's Medicaid RECOMMENDATIONS: To improve on the quality DSH reductions on California public hospitals' fi- and content of reporting, we developed a 7-Item nancial stability by estimating how total DSH costs Stakeholder Engagement Reporting Question- naire. We recommend three directions for future 218 research: 1) descriptive research on stakeholder- complications (i.e., meningitis, encephalitis) in in- engagement in research; 2) evaluative research dividuals with demonstrated immunodeficiencies. on the impact of stakeholder engagement on the There is moderate SOE that vaccines against relevance, transparency and adoption of research; rotavirus are associated with intussusception in and 3) development and validation of tools that children; risk was estimated as 1 to 5 cases per can be used to support stakeholder engagement 100,000 vaccine doses, depending on brand. in future work. Moderate-strength evidence exists regarding human papillomavirus vaccine and a lack of asso- EP-50517 ciation with onset of juvenile rheumatoid arthritis, Safety of vaccines used for routine immuniza- type 1 diabetes, and GBS. Moderate-strength evi- tion in the United States. Courtney A. Gidengil. dence shows no association between inactivated 2014 influenza vaccine and serious AEs in pregnant OBJECTIVES: To conduct a systematic review women. Evidence was insufficient to make con- of the literature on the safety of vaccines recom- clusions regarding whether several routinely rec- mended for routine immunization of children, ad- ommended vaccines are associated with serious olescents, and adults in the United States as of conditions such as multiple sclerosis, transverse 2011. REVIEW METHODS: We reviewed the meth- myelitis, and acute disseminated encephalomyeli- odology of the 2011 Institute of Medicine (IOM) tis. CONCLUSIONS: There is evidence that some consensus report "Adverse Effects of Vaccines: vaccines are associated with serious adverse Evidence and Causality" and accepted their find- events; however, these events are extremely rare ings. We augmented their work with new studies and must be weighed against the protective ben- and additional vaccines. We were unable to pool efits that vaccines provide. Careful consideration results; we rated the overall strength of evidence should be given to the investigation of research (SOE) as high, moderate, low, or insufficient. RE- gaps, including patient risk factors that may be SULTS: A total of 20,478 titles were identified; af- associated with AEs; however, important factors ter title, abstract, and full-text review, 166 studies must be taken into account when determining were accepted for abstraction. The vast majority whether studies are warranted, including the se- of studies either did not investigate or could not verity and frequency of the AE being studied and identify risk factors for adverse events (AEs) as- the challenges of conducting sufficiently powered sociated with vaccination. Similarly, the severity studies when investigating rare events. of AEs was inconsistently reported, as was information that would make independent severity EP-50519 Registered nurses are delaying retirement, determination possible. SOE was high for the fol- a shift that has contributed to recent growth in lowing associations in nonpregnant adults: sea- the nurse workforce. Peter Buerhaus, Douglas sonal influenza vaccine and arthralgia, myalgia, Staiger. 2014 malaise, fever, pain at injection site; 2009 mon- ovalent H1N1 vaccine and Guillain-Barré The size of the registered nurse (RN) work- syndrome (GBS); and a lack of association be- force has surpassed forecasts from a decade ago, tween influenza and pneumococcal vaccines and growing to 2.7 million in 2012 instead of peaking cardiovascular events in the elderly. Risk of GBS at 2.2 million. Much of the difference is the result was estimated at 1.6 excess cases per million per- of a surge in new nursing graduates. However, the sons vaccinated. SOE was high for the following size of the RN workforce is particularly sensitive to associations in children and adolescents: mea- changes in retirement age, given the large num- sles, mumps, rubella (MMR) vaccine and febrile ber of baby-boomer RNs now in the workforce. We seizures in children under age 5; lack of associa- found that in the period 1969–90, for a given num- tion between MMR vaccine and autism spectrum ber of RNs working at age fifty, 47 percent were still disorders; and varicella vaccine and disseminated working at age sixty-two and 9 percent were work- Oka strain varicella zoster virus with associated 219 ing at age 69. In contrast, in the period 1991–2012 usual daily consumption of fluids (water and all the proportions were 74 percent at age 62 and 24 other beverages) by a selective sample of Mexi- percent at age 69. This trend, which largely pre- can population. METHODS: Cross-sectional sam- dates the recent recession, extended nursing ca- ple of 1,492 male and female adults between 18- reers by 2.5 years after age fifty and increased the 65 years of age, drawn from 16 cities throughout 2012 RN workforce by 136,000 people. Because Mexico. Self-reported fluid intake data collected many RNs tend to shift out of hospital settings as over a 7-day consecutive period, recording in- they age, employers seeking RNs for nonhospital take of water, milk and derivatives, hot beverag- roles may welcome (and seek to capitalize on) the es, sugar sweetened beverages (SSB), alcoholic growing numbers of experienced RNs potentially beverages and others. RESULTS: We found that able to fill these positions. 87.5% of adult males and 65.4% of adult females reported drinking below their recommended daily EP-50520 fluid intake (3 L for males and 2 L for females), Examining the role of patient experience sur- and in 80% of the population SSB, not including veys in measuring health care quality. Marc N. hot beverages or milk and derivatives, accounted Elliott. 2014 for a larger amount and proportion of fluid intake Patient care experience surveys evaluate the than plain water. Sixty-five percent of adult males degree to which care is patient-centered. This ar- and 66% of adult females consumed more than ticle reviews the literature on the association be- 10% of their estimated daily caloric intake from tween patient experiences and other measures of fluids. Fluid intake did not differ significantly by health care quality. Research indicates that bet- gender, but showed a declining trend with age. ter patient care experiences are associated with CONCLUSION: Our findings may have important higher levels of adherence to recommended pre- implications for policy recommendations, as part vention and treatment processes, better clinical of comprehensive strategies to promote the adop- outcomes, better patient safety within hospitals, tion of healthy life styles, in this case, promoting and less health care utilization. Patient experience consumption of plain water while discouraging ex- measures that are collected using psychometri- cessive consumption of caloric beverages. cally sound instruments, employing recommend- EP-50522 ed sample sizes and adjustment procedures, and Development of telehealth dialogues for moni- implemented according to standard protocols are toring suicidal patients with schizophrenia: con- intrinsically meaningful and are appropriate com- sumer feedback. Susan L. Zickmund, Armando J. plements for clinical process and outcome mea- Rotondi. 2014 sures in public reporting and pay-for-performance Suicide is a health concern among individuals programs. with schizophrenia. A telehealth system for moni- EP-50521 toring suicidal patients with schizophrenia was Fluid intake in Mexican adults: a cross-sectional developed using the Health Buddy©. The study. 2014 existing dialogues were improved using an expert panel; the new dialogues were tested in 10 con- INTRODUCTION: An adequate hydration is crit- sumers with schizophrenia and a history of sui- ical for a series of body functions, including proper cidal behavior. Using qualitative editing, several regulation of core body temperature, elimination themes emerged: (1) Certain topics elicited strong of waste metabolites by the kidney and mainte- emotional responses; (2) There were concerns nance of normal physical and cognitive functions. with confidentiality; (3) Some content was too Some institutions have set recommendations for vague and (4) There were problems with vocabu- adequate intake of water, but these recommendations vary widely. OBJECTIVE: To estimate the 220 lary and wording. The process yielded information fer smoking cessation services, although nearly for improving the intervention and demonstrated all (91%) were interested in doing so. Barriers to that the approach is feasible in this population. implementing formal smoking cessation programs on site included lack of resources (e.g., money, EP-50523 personnel) to support the programs, staff training, Bundled payment fails to gain a foothold in and concern that smoking cessation may not be a California: the experience of the IHA bundled pay- high priority for homeless youth themselves. Over- ment demonstration. David De Vries. 2014 all, service providers seemed to prefer a less in- To determine whether bundled payment could tensive smoking cessation program that could be be an effective payment model for California, the delivered at their site by existing staff. Data from Integrated Healthcare Association convened a this formative needs assessment will be useful for group of stakeholders (health plans, hospitals, developing and evaluating a smoking cessation ambulatory surgery centers, physician organiza- treatment that could be integrated into the busy, tions, and vendors) to develop, through a consen- complex environment that characterizes agencies sus process, the methods and means of imple- that serve homeless youth. menting bundled payment. In spite of a high level of enthusiasm and effort, the pilot did not succeed EP-50525 Sexual minorities in England have poorer health in its goal to implement bundled payment for or- and worse health care experiences: a national thopedic procedures across multiple payers and survey. David E. Kanouse. 2014 hospital-physician partners. An evaluation of the pilot documented a number of barriers, such as BACKGROUND: The health and healthcare administrative burden, state regulatory uncer- of sexual minorities have recently been identi- tainty, and disagreements about bundle definition fied as priorities for health research and policy. and assumption of risk. Ultimately, few contracts OBJECTIVE: To compare the health and health- were signed, which resulted in insufficient volume care experiences of sexual minorities with het- to test hypotheses about the impact of bundled erosexual people of the same gender, adjusting payment on quality and costs. Although bundled for age, race/ethnicity, and socioeconomic status. payment failed to gain a foothold in California, the DESIGN: Multivariate analyses of observational evaluation provides lessons for future bundled data from the 2009/2010 English General Practice payment initiatives. Patient Survey. PARTICIPANTS: The survey was EP-50524 mailed to 5.56 million randomly sampled adults Providing smoking cessation programs to registered with a National Health Service general homeless youth: the perspective of service provid- practice (representing 99 % of England's adult ers. Joan S. Tucker. 2014 population). In all, 2,169,718 people responded There is almost no information available on cig- (39 % response rate), including 27,497 people arette smoking among homeless youth, whether who described themselves as gay, lesbian, or they are currently receiving services for smoking bisexual. MAIN MEASURES: Two measures of cessation, and how to best help them quit. This health status (fair/poor overall self-rated health paper presents data collected from a series of and self-reported presence of a longstanding psy- semi-structured telephone interviews with service chological condition) and four measures of poor providers from 23 shelters and drop-in centers patient experiences (no trust or confidence in the serving homeless youth in Los Angeles County doctor, poor/very poor doctor communication, about their current smoking cessation program- poor/very poor nurse communication, fairly/very ming, interest in providing smoking cessation ser- dissatisfied with care overall). KEY RESULTS ; vices to their clients, potential barriers to providing Sexual minorities were two to three times more this service, and ways to overcome these barriers. likely to report having a longstanding psychologi- Results indicated that 84% of facilities did not of- cal or emotional problem than heterosexual coun- 221 terparts (age-adjusted for 5.2 % heterosexual, water at school. Fifty-nine percent reported that 10.9 % gay, 15.0 % bisexual for men; 6.0 % het- school fountains were unclean, 48% that fountain erosexual, 12.3 % lesbian and 18.8 % bisexual for water does not taste good, 33% that fountains women; p < 0.001 for each). Sex- could make them sick, 31% that it was not okay to ual minorities were also more likely to report fair/ drink from fountains, and 24% that fountain water poor health (adjusted 19.6 % heterosexual, 21.8 % is contaminated. In adjusted analyses, attitudes gay, 26.4 % bisexual for men; 20.5 % heterosexu- about school drinking fountains were related to al, 24.9 % lesbian and 31.6 % bisexual for women; intentions to drink water at school (β = 0.41; p < 0.001 for each). Adjusted for P < .001); intentions to drink water at school were sociodemographic characteristics and health sta- also associated with overall water intake (β = tus, sexual minorities were about one and one- 0.20; P < .001). CONCLUSIONS: Students have half times more likely than heterosexual people negative attitudes about school fountains. To in- to report unfavorable experiences with each of crease overall water intake, it may be important to four aspects of primary care. Little of the overall promote and improve drinking water sources not disparity reflected concentration of sexual minori- only at school but also at home and in other com- ties in low-performing practices. CONCLUSIONS: munity environments. Sexual minorities suffer both poorer health and worse healthcare experiences. Efforts should be EP-50527 made to recognize the needs and improve the ex- University R&D funding strategies in a changing periences of sexual minorities. Examining patient federal funding environment. Krishna B. Kumar. experience disparities by sexual orientation can 2014 inform such efforts. This paper evaluates how changes in US Nation- al Institutes of Health (NIH) funding levels affected EP-50526 US universities' total biomedical R&D efforts, over Middle school student attitudes about school a period of dramatic change in the federal funding drinking fountains and water intake. Laura M. environment. Instrumental variables estimation Bogart. 2014 reveals that during the NIH budget doubling pe- OBJECTIVE: To describe middle school stu- riod (1998–2003), each federal dollar that US uni- dent attitudes about school drinking fountains, versities received spurred an additional $0.26 in investigate whether such attitudes are associated research support from non-federal sources, with with intentions to drink water at school, and deter- stronger complementarity found among historical- mine how intentions relate to overall water intake. ly less-research-intensive institutions. However, METHODS: Students (n = 3211) in 9 California in the more competitive post-doubling environ- middle schools completed surveys between 2009 ment (2006 onwards), the more research-inten- and 2011. We used multivariate linear regression, sive PhD-granting universities substituted funding adjusting for school sociodemographic character- from non-federal sources to maintain stable levels istics, to examine how attitudes about fountains of R&D expenditures. In contrast, at non-PhD- (5-point scale; higher scores indicating more posi- granting and historically less-research-intensive tive attitudes) were associated with intentions to institutions, total R&D funding and expenditures drink water at school and how intentions to drink declined overall with reduced availability of feder- water at school were related to overall water inal funds. However, the effect of successful federal take. RESULTS: Mean age of students was 12.3 applications on subsequent non-federal invest- (SD = 0.7) years; 75% were Latino, 89% low in- ment remained significant and positive for this lat- come, and 39% foreign born. Fifty-two percent ter group, suggesting federal R&D funding may reported lower than recommended overall water play an important signaling role. intake (<3 glasses/day), and 30% reported that they were unlikely or extremely unlikely to drink EP-50528 222

Distance to store, food prices, and obesity in ments for poverty-related and neglected infec- urban food deserts. Deborah A. Cohen. 2014 tious diseases (PRNIDs) has shown a marked BACKGROUND: Lack of access to healthy increase. Not only have the MDGs attracted fund- foods may explain why residents of low-income ing from new sources, such as the Global Fund neighborhoods and African Americans in the U.S. to Fight AIDS, Tuberculosis and Malaria, and Stop have high rates of obesity. The findings on where TB, but also increased funding from existing do- people shop and how that may influence health nors, such as those countries belonging to the are mixed. However, multiple policy initiatives are Development Assistance Committee (DAC) of the underway to increase access in communities that Organisation for Economic Co-operation and De- velopment (OECD). Many sub-Saharan African currently lack healthy options. Few studies have countries are, however, still heavily dependent simultaneously measured obesity, distance, and on external funding for research and international prices of the store used for primary food shopping. PURPOSE: To examine the relationship development assistance for health services. In among distance to store, food prices, and obe- 2012, the European & Developing Countries Clini- sity. METHODS: The Pittsburgh Hill/Homewood cal Trials Partnership (EDCTP) commissioned a study to conduct a landscape analysis of health Research on Eating, Shopping, and Health study research and national funding commitments for conducted baseline interviews with 1,372 households between May and December 2011 in two PRNIDs in sub-Saharan Africa. The overall aim low-income, majority African American neighbor- of this exercise was to review the current state of hoods without a supermarket. Audits of 16 stores sub-Saharan African health research, the funding where participants reported doing their major landscape and research capacity in the field of food shopping were conducted. Data were ana- HIV/AIDS, tuberculosis (TB), malaria, neglected lyzed between February 2012 and February 2013. infectious diseases (NIDs), and health systems/ RESULTS: Distance to store and prices were operational research. The study also aimed to positively associated with obesity (p<0.05). When identify how these research activities and capaci- distance to store and food prices were jointly mod- ties relate to the mission of EDCTP. The study eled, only prices remained significant (p<0.01), comprised a combination of deskbased research with higher prices predicting a lower likelihood of and fieldwork. obesity. Although low- and high-price stores did EP-50530 not differ in availability, they significantly differed Attractiveness of initial vocational education in their display and marketing of junk foods rela- and training: identifying what matters. Samuel tive to healthy foods. CONCLUSIONS: Placing Drabble. 2014 supermarkets in food deserts to improve access Stereotypes prevail: many Europeans still opt may not be as important as simultaneously offer- for a vocational educational pathway as second ing better prices for healthy foods relative to junk choice when deciding about a future career. De- foods, actively marketing healthy foods, and en- spite being high on European and national policy abling consumers to resist the influence of junk agendas for more than a decade, and despite all food marketing. efforts made, VET is no more attractive in most countries today than it was some years ago. Build- EP-50529 ing on a system approach, and drawing on quanti- Africa mapping: current state of health research tative and qualitative analysis, this research paper on poverty-related and neglected infectious dis- explores how several drivers affect the attractive- eases in Sub-Saharan Africa. Gabrielle Breugel- ness of IVET. Endogenous drivers having impact mans, Catriona Manville. 2014 on IVET systems and outcomes are relevant, but With the establishment of the Millennium De- context also matters. IVET outcomes need to be velopment Goals (MDGs) in 2000, the volume of communicated in the right way to highlight the global research and development (R&D) invest- attractiveness of this educational path to young 223 people. A total of 10 case studies of policy initia- White counterparts. In a 6-month longitudinal tives from six countries are analysed to see what study, we investigated whether medical mistrust works, and why, in different national contexts. among African-American males with HIV (214 enrolled, 140 with longitudinal data) predicted lower EP-50531 electronically monitored antiretroviral medication Examining the value of inpatient nurse staffing: adherence. General medical mistrust (e.g. susan assessment of quality and patient care costs. picion toward providers), but not racism-related David I. Auerbach. 2014 mistrust (e.g. belief that providers treat African- BACKGROUND: Inpatient quality deficits have Americans poorly due to race), predicted lower important implications for the health and well-be- continuous medication adherence over time (b = ing of patients. They also have important financial -.08, standard error = .04, p = .03). Medical mis- implications for payers and hospitals by leading trust may contribute to poor health outcomes. In- to longer lengths of stay and higher intensity of tervention efforts that address mistrust may im- treatment. Many of these costly quality deficits prove adherence among African-Americans with are particularly sensitive to nursing care. OBJEC- HIV. TIVE: To assess the effect of nurse staffing on quality of care and inpatient care costs. DESIGN: EP-50533 Community-partnered collaboration to build an Longitudinal analysis using hospital nurse staffing integrated palliative care clinic: the view from urol- data and the Healthcare Cost and Utilization Proj- ogy. Karl Lorenz. 2014 ect State Inpatient Databases from 2008 through 2011. SUBJECTS: Hospital discharges from Cali- BACKGROUND: We partnered with patients, fornia, Nevada, and Maryland (n=18,474,860). families, and palliative care clinicians to develop METHODS: A longitudinal, hospital-fixed effect an integrated urology–palliative care clinic for pa- model was estimated to assess the effect of nurse tients with metastatic cancer. We assessed clini- staffing levels and skill mix on patient care costs, cian satisfaction with a multidisciplinary pallia- length of stay, and adverse events, adjusting for tive care clinic model. METHODS: We conducted patient clinical and demographic characteristics. semi-structured interviews with 18 clinicians who RESULTS: Increases in nurse staffing levels were practice in our integrated clinic. We analyzed tran- associated with reductions in nursing-sensitive scripts using a multistage, cutting-and-sorting adverse events and length of stay, but did not lead technique in an inductive approach based on to increases in patient care costs. Changing skill grounded theory analysis. Finally, we adminis- mix by increasing the number of registered nurs- tered a validated physician job satisfaction survey. es, as a proportion of licensed nursing staff, led RESULTS: Clinicians found that referring a patient to reductions in costs. CONCLUSIONS: The study to palliative care in the urology clinic was feasible findings provide support for the value of inpatient and appropriate. Patients were receptive to sup- nurse staffing as it contributes to improvements portive care, and clinicians perceived that quality in inpatient care; increases in staff number and of care improved following the intervention. CON- skill mix can lead to improved quality and reduced CLUSION: An integrated, patient-centered model length of stay at no additional cost. for individuals with advanced urologic malignan- cies is feasible and well received by practitioners. EP-50532 Medical mistrust is related to lower longitudinal EP-50534 medication adherence among African-American Social network effects of nonlifesaving early- males with HIV. Laura M. Bogart. 2014 stage breast cancer detection on mammography rates. Andrew M. Parker. 2014 African-Americans living with HIV show worse health behaviors (e.g. medication adherence) and OBJECTIVES: We estimated the effect of outcomes (e.g. viral suppression) than do their 224 anecdotes of early-stage, screen-detected can- The effect of the caps overall varied according to cer for which screening was not lifesaving on specialty, with the largest impact being on claims the demand for mammography. METHODS: We involving pediatricians and the smallest on claims constructed an agent-based model of mammog- involving surgical subspecialties and ophthalmol- raphy decisions, in which 10 000 agents ogists. that represent women aged 40 to 100 years were linked together on a social network, which was EP-50536 parameterized with a survey of 716 women con- Is previous removal from the United States ducted through the RAND American Life Panel. a marker for high recidivism risk? results from a Our model represents a population in equilibrium, 9-year follow-up study of criminally involved unau- with demographics reflecting the current US pop- thorized immigrants. Jennifer S. Wong. 2014 ulation based on the most recent available census The present study examines the long-term re- data. RESULTS: The aggregate effect of women cidivism patterns of a group of unauthorized im- learning about 1 category of cancers—those that migrants identified to be at high risk of recidivism. would be detected but would not be lethal in the Using a sample of 517 male unauthorized immi- absence of screening—was a 13.8 percentage grants, we used three measures of recidivism to point increase in annual screening rates. CON- assess 9-year rearrest differences between unau- CLUSIONS: Anecdotes of detection of early-stage thorized immigrants who have and who have not cancers relayed through social networks may been previously removed from the United States. substantially increase demand for a screening Results indicate that prior removal was a signifi- test even when the detection through screening cant risk marker for recidivism, with previously was nonlifesaving. (Am J Public Health. Published removed immigrants showing a higher likelihood online ahead of print October 16, 2014: e1–e6. of rearrest, a greater frequency of rearrest, and doi:10.2105/AJPH.2014.302153) a more rapid time-to-first rearrest. While the present study does not establish whether previous re- EP-50535 moval is a consistent indicator of high recidivism, Medical malpractice reform: noneconomic dam- it suggests that this group of unauthorized immi- ages caps reduced payments 15 percent, with grants may be worthy of review and policy consid- varied effects by specialty. Eric Helland. 2014 eration. Much potential value for law enforcement The impact of medical malpractice reforms on lies in the sharing of federal immigration records the average size of malpractice payments in spe- with academics to further study the outcomes of cific physician specialties is unknown and subject unauthorized immigrants. to debate. We analyzed a national sample of malpractice claims for the period 1985-2010, merged EP-50537 with information on state liability reforms, to esti- Assessing the effects of medical marijuana mate the impact of state noneconomic damages laws on marijuana use: the devil is in the details. caps on average malpractice payment size for David Powell. 2014 physicians overall and for ten different specialty This paper sheds light on previous inconsisten- categories. We then compared how the effects dif- cies identified in the literature regarding the rela- fered according to the restrictiveness of the cap tionship between medical marijuana laws (MMLs) ($250,000 versus $500,000). We found that, over- and recreational marijuana use by closely examin- all, noneconomic damages caps reduced average ing the importance of policy dimensions (registra- payments by $42,980 (15 percent), compared to tion requirements, home cultivation, dispensaries) having no cap at all. A more restrictive $250,000 and the timing of when particular policy dimen- cap reduced average payments by $59,331 (20 sions are enacted. Using data from our own legal percent), and a less restrictive $500,000 cap had analysis of state MMLs, we evaluate which fea- no significant effect, compared to no cap at all. 225 tures are associated with adult and youth recre- havioral autonomy for emerging adults with type 1 ational and heavy use by linking these policy vari- diabetes require careful consideration. ables to data from the Treatment Episode Data Set (TEDS) and National Longitudinal Survey of Youth EP-50539 (NLSY97). We employ differences-in-differences Predicting child development knowledge and techniques, controlling for state and year fixed engagement of Moroccan parents. Rita Karam. effects, allowing us to exploit within-state policy 2014 changes. We find that while simple dichotomous A growing body of empirical evidence points to a indicators of MML laws are not positively associ- child's earliest years as a critical period for devel- ated with marijuana use or abuse, such measures oping the foundation for later learning. Yet neither hide the positive influence legal dispensaries have parents nor public policy in the Middle East and on adult and youth use, particularly heavy use. North Africa actively support such development. Sensitivity analyses that help address issues of We developed, tested, and administered a survey policy endogeneity and actual implementation of to a small number of parents of children aged six dispensaries support our main conclusion that not years and under in Casablanca, Morocco in 2013 all MML laws are the same. Dimensions of these to assess parents' child development knowledge policies, in particular legal protection of dispen- and how they view their role as teachers of their saries, can lead to greater recreational marijuana young children. We used multiple regression mod- use and abuse among adults and those under the els to predict parental knowledge and parental legal age of 21 relative to MMLs without this sup- engagement in learning activities with their sons ply source. and separately with their daughters. Results indicate that nearly half of parents believe that brain EP-50538 development does not begin until after a child's Relations of behavioral autonomy to health out- first year of life. Consistent with these beliefs, par- comes among emerging adults with and without ents report engaging in learning activities with type 1 diabetes. Kerry A. Reynolds. 2014 their young children less frequently than Western OBJECTIVE: To examine the relation of be- parents; they also relate that they would be un- havioral autonomy to psychological, behavioral, likely to enroll their young children in high quality and physical health among emerging adults with child care programs, even if cost were not a fac- and without type 1 diabetes. METHODS: High tor. Parents who indicated feeling a high level of school seniors with (n = 118) and without type individual control over life events were less knowl- 1 diabetes (n = 122) completed online question- edgeable about child development. Those who naires for three consecutive years. Behavioral au- believe that God controls life events were both tonomy, psychological health, risk behaviors, and more knowledgeable and reported more engage- diabetes outcomes were assessed. Regression ment in learning activities. Parents who reported analyses were conducted to predict Time 2 and turning to professional sources for information on 3 outcomes, controlling for Time 1 outcomes. RE- child development were likelier to engage in learn- SULTS: There were no group differences in behav- ing activities. The general view that teaching and ioral autonomy. Behavioral autonomy predicted learning in the first years are unimportant may better psychological health but only for emerging help to explain the poor academic performance of adults without diabetes. Behavioral autonomy was Moroccan children later in life relative to those of related to increased risk behavior for both groups. children from other nations with similar economic Behavioral autonomy was unrelated to self-care status. Education of the public regarding the im- but predicted better glycemic control for females. portance of early-years development could help CONCLUSIONS: Behavioral autonomy may be inform parents and policymakers. Services that beneficial for psychological health, but is related might be offered to reinforce this message are dis- to increased risk behavior. The implications of be- cussed. 226

development and their role in their children's edu- EP-50540 cation. Michal Perlman. 2014 Implementing collaborative primary care for depression and posttraumatic stress disorder: Despite the documented importance of parental design and sample for a randomized trial in the engagement in early learning, little is known about U.S. military health system. Robert M. Bray, Lisa how parents in the Middle East and North Africa H. Jaycox. 2014 understand child development. To inform the literature, a small-scale study involving four focus BACKGROUND: War-related trauma, posttrau- groups was conducted with parents of children matic stress disorder (PTSD), depression and sui- aged six years and under living in Casablanca. cide are common in US military members. Often, The purpose of this study was to explore parents' those affected do not seek treatment due to stig- understanding of and support for their children's ma and barriers to care. When care is sought, it of- early development. Results reveal that parents ten fails to meet quality standards. A randomized see a vital role for themselves in their children's trial is assessing whether collaborative primary upbringing as supporters and nurturers, but little care improves quality and outcomes of PTSD and role as teachers. Across different education and depression care in the US military health system. income levels, parents in this small-scale qualita- OBJECTIVE: The aim of this study is to describe tive study believe that children's experiences in the design and sample for a randomized effec- their first years of life do not affect their longer- tiveness trial of collaborative care for PTSD and term intellectual development or school success depression in military members attending primary and see little value in early intellectual stimulation care. METHODS: The STEPS-UP Trial (STepped or formal preschool education. Our results sug- Enhancement of PTSD Services Using Primary gest that parents need to understand their role as Care) is a 6 installation (18 clinic) randomized ef- their child's first educators. Also, it is essential that fectiveness trial in the US military health system. parents are taught how to promote their children's Study rationale, design, enrollment and sample early cognitive development without undermining characteristics are summarized. FINDINGS: Mili- their nurturing roles. tary members attending primary care with sus- pected PTSD, depression or both were referred to EP-50542 care management and were recruited for the trial A test of biological and behavioral explana- (2592) and 1041 gave permission to contact for re- tions for gender differences in telomere length: search participation. Of those, 666 (64%) met eli- the multi-ethnic study of atherosclerosis. Chloe gibility criteria, completed baseline assessments, E. Bird. 2014 and were randomized to 12 months of usual collaborative primary care versus STEPS-UP collab- The purpose of this study was to examine bio- orative care. Implementation was locally managed logical and behavioral explanations for gender for usual collaborative care and centrally managed differences in leukocyte telomere length (LTL), for STEPS-UP. Research reassessments occurred a biomarker of cell aging that has been hypoth- at 3-, 6-, and 12-months. Baseline characteristics esized to contribute to women's greater longev- were similar across the two intervention groups. ity. Data are from a subsample (n = 851) of the CONCLUSIONS: STEPS-UP will be the first large Multi-Ethnic Study of Atherosclerosis, a popula- scale randomized effectiveness trial completed in tion-based study of women and men aged 45 to the US military health system, assessing how an 84. Mediation models were used to examine study implementation model affects collaborative care hypotheses. We found that women had longer LTL impact on mental health outcomes. It promises than men, but the gender difference was smaller lessons for health system change. at older ages. Gender differences in smoking and processed meat consumption partially mediated EP-50541 gender differences in telomere length, whereas How Moroccan mothers and fathers view child gender differences in estradiol, total testosterone, 227 oxidative stress, and body mass index did not. in subgroup and sensitivity analyses. CONCLU- Neither behavioral nor biological factors explained SIONS: We estimated that screening for lung why the gender difference in LTL was smaller at cancer with low-dose CT would cost $81,000 per older ages. Longitudinal studies are needed to QALY gained, but we also determined that modest assess gender differences in the rate of change changes in our assumptions would greatly alter in LTL over time; to identify the biological, behav- this figure. The determination of whether screen- ioral, and psychosocial factors that contribute to ing outside the trial will be cost-effective will de- these differences throughout the life course; and pend on how screening is implemented. to determine whether gender differences in LTL explain the gender gap in longevity. EP-50544 Healthy food access for urban food desert resi- EP-50543 dents: examination of the food environment, food Cost-effectiveness of CT screening in the purchasing practices, diet and BMI. Shannon N. National Lung Screening Trial. Ilana F. Gareen, Zenk. 2014 Samir S. Soneji. 2014 OBJECTIVE: To provide a richer understanding BACKGROUND: The National Lung Screening of food access and purchasing practices among Trial (NLST) showed that screening with low-dose US urban food desert residents and their asso- computed tomography (CT) as compared with ciation with diet and BMI. DESIGN: Data on food chest radiography reduced lung-cancer mortality. purchasing practices, dietary intake, height and We examined the cost-effectiveness of screening weight from the primary food shopper in randomly with low-dose CT in the NLST. METHODS: We es- selected households (n 1372) were collected. Au- timated mean life-years, quality-adjusted life-years dits of all neighbourhood food stores (n 24) and (QALYs), costs per person, and incremental cost- the most-frequented stores outside the neighbour- effectiveness ratios (ICERs) for three alternative hood (n 16) were conducted. Aspects of food ac- strategies: screening with low-dose CT, screen- cess and purchasing practices and relationships ing with radiography, and no screening. Estima- among them were examined and tests of their tions of life-years were based on the number of associations with dietary quality and BMI were observed deaths that occurred during the trial and conducted. SETTING: Two low-income, predomi- the projected survival of persons who were alive nantly African-American neighbourhoods with at the end of the trial. Quality adjustments were limited access to healthy food in Pittsburgh, PA, derived from a subgroup of participants who were USA. SUBJECTS: Household food shoppers. RE- selected to complete quality-of-life surveys. Costs SULTS: Only one neighbourhood outlet sold fresh were based on utilization rates and Medicare reproduce; nearly all respondents did major food imbursements. We also performed analyses of shopping outside the neighbourhood. Although subgroups defined according to age, sex, smok- the nearest full-service supermarket was an av- ing history, and risk of lung cancer and performed erage of 2.6 km from their home, respondents sensitivity analyses based on several assump- shopped an average of 6.0 km from home. The tions. RESULTS: As compared with no screening, average trip was by car, took approximately 2 h for screening with low-dose CT cost an additional the round trip, and occurred two to four times per $1,631 per person (95% confidence interval [CI], month. Respondents spent approximately $US 37 1,557 to 1,709) and provided an additional 0.0316 per person per week on food. Those who made life-years per person (95% CI, 0.0154 to 0.0478) longer trips had access to cars, shopped less of- and 0.0201 QALYs per person (95% CI, 0.0088 to ten and spent less money per person. Those who 0.0314). The corresponding ICERs were $52,000 travelled further when they shopped had higher per life-year gained (95% CI, 34,000 to 106,000) BMI, but most residents already shopped where and $81,000 per QALY gained (95% CI, 52,000 healthy foods were available, and physical dis- to 186,000). However, the ICERs varied widely tance from full-service supermarkets was unre- 228 lated to weight or dietary quality. CONCLUSIONS: and System for Information on Grey Literature in Improved access to healthy foods is the target of Europe for the period January 1995 to January current policies meant to improve health. Howev- 2013 with no limitation of publication type. METH- er, distance to the closest supermarket might not ODS: We conducted a rapid evidence synthesis be as important as previously thought, and thus of the peer-reviewed literature on organisational policy and interventions that focus merely on im- interventions set in or initiated from acute hospi- proving access may not be effective. tals. We considered evidence published between 2003 and 2013. Data were analysed drawing on EP-50545 the principles of narrative synthesis. We also car- Regular physical activity has differential as- ried out interviews with eight NHS managers and sociation with reduced obesity among diverse clinical leads in four sites in England. RESULTS: youth in the United States. Jan Wallander, Marc A total of 53 studies met our inclusion criteria, N. Elliott. 2014 including 19 systematic reviews and 34 primary This study examined whether daily or almost studies. Although the overall evidence base was daily lower-intensity physical activity was associ- varied and frequently lacked a robust study de- ated with reduced obesity, among 4,824 African sign, we identified a range of interventions that American, Hispanic, and White youth assessed in showed potential to reduce length of stay. These 5th and 7th grades. Regular lower-intensity physi- were multidisciplinary team working, for example cal activity was associated with reduced obesity some forms of organised stroke care; improved only among Hispanic and White males and only discharge planning; early supported discharge in 7th grade, and not among youth in 5th grade, programmes; and care pathways. Nursing-led in- females, or African American males or females. patient units were associated with improved out- Findings from this study suggest that the reduced comes but, if anything, increased length of stay. obesity risk generally attributed to physical activ- Factors influencing the impact of interventions on ity may not be consistent across racial/ethnic and length of stay included contextual factors and the gender groups of early adolescents. population targeted. The evidence was mixed with regard to the extent to which interventions seek- EP-50546 ing to reduce length of stay were associated with Organisational interventions to reduce length cost savings. LIMITATIONS: We only considered of stay in hospital: a rapid evidence assessment. assessments of interventions which provided a Sarah Ball. 2014 quantitative estimate of the impact of the given organisational intervention on length of hospital stay. BACKGROUND: Available evidence on effec- There was a general lack of robust evidence and tive interventions to reduce length of stay in hos- poor reporting, weakening the conclusions that pital is wide-ranging and complex, with underlying can be drawn from the review. CONCLUSIONS: factors including those acting at the health sys- The design and implementation of an intervention tem, organisational and patient levels, and the in- seeking to reduce (directly or indirectly) the length terface between these. There is a need to better of stay in hospital should be informed by local con- understand the diverse literature on reducing the text and needs. This involves understanding how length of hospital stay. OBJECTIVES: This study the intervention is seeking to change processes sought to (i) describe the nature of interventions and behaviours that are anticipated, based on the that have been used to reduce length of stay in available evidence, to achieve desired outcomes acute care hospitals; (ii) identify the factors that are ('theory of change'). It will also involve assessing known to influence length of stay; and (iii) assess the organisational structures and processes that the impact of interventions on patient outcomes, will need to be put in place to ensure that staff who service outcomes and costs. DATA SOURCES: are expected to deliver the intervention are appro- We searched MEDLINE (Ovid), EMBASE, the Health Management Information Consortium 229 priately prepared and supported. With regard to marijuana expectancies on marijuana use and future research, greater attention should be giv- consequences among at-risk adolescents. Jer- en to the theoretical underpinning of the design, emy N. V. Miles. 2014 implementation and evaluation of interventions or Based on expectancy theory, adolescents at programmes. There is a need for further research risk for mental health symptoms, such as those in- using appropriate methodology to assess the ef- volved in the juvenile court system, may use mari- fectiveness of different types of interventions in juana due to the belief that use will attenuate anxi- different settings. Different evaluation approaches ety and depressive symptoms. In a diverse sample may be useful, and closer relationships between of youth involved in the Santa Barbara Teen Court researchers and NHS organisations would enable system (N = 193), we examined the association more formative evaluation. Full economic costing between mental health symptoms and marijuana should be undertaken where possible, including expectancies on marijuana use and consequenc- considering the cost implications for the wider lo- es. In general, stronger positive expectancies and cal health economy. weaker negative expectancies were both associated with increased marijuana use. Youth who EP-50547 Estimating the consumptive use costs of shale reported more symptoms of both anxiety and de- natural gas extraction on Pennsylvania roadways. pression, and stronger positive expectancies for Constantine Samaras. 2014 marijuana also reported more consequences. We found that youth experiencing the greatest level The development of natural gas resources in of consequences from marijuana were those who the Marcellus Shale formation has progressed reported more depressive symptoms and stronger rapidly in the last several years, particularly in the positive expectancies for marijuana. Findings sug- Commonwealth of Pennsylvania. These activi- gest that these symptoms, combined with strong ties require many heavy truck trips for equipment positive expectancies about marijuana's effects, and materials, which can damage state and local have implications for consequences among at- roads that were not designed for high volumes of risk youth. heavy truck traffic. For state transportation agencies, one measure of costs of shale gas devel- EP-50549 opment is the potential degradation of roadways How can schools help youth increase physical resulting from shale gas development. This techni- activity? an economic analysis comparing school- cal note provides a first-order estimate of roadway based programs. 2014 consumptive use costs of additional heavy truck OBJECTIVE: For optimal health, physical activ- traffic on Pennsylvania state-maintained roadways ity should be an integral and routine part of daily from Marcellus Shale natural gas development in life. Youth spend a significant amount of time at 2011, estimated at about $13,000-$23,000 per school yet rarely achieve the recommended 60 well for all state roadway types, or $5,000-$10,000 min of moderate and vigorous physical activity in per well if state roads with the lowest traffic vol- physical education (PE) classes or recess. This umes are excluded. This initial estimate of costs study assessed the following types of school- is based on data on the distribution of well activ- based opportunities to improve physical activity ity and roadway type in Pennsylvania, estimates for youth: after-school programs, before-school for the number of heavy truck trips to construct programs, PE classes, extended-day PE, and and operate a single well, the corresponding short physical activity breaks during the school equivalent single-axle loadings, and estimates of day. METHOD: An economic analysis conducted roadway life and reconstruction costs by roadway in 2013 compared school-based approaches to maintenance class in Pennsylvania. increasing physical activity. Analysis factors in- EP-50548 The effects of mental health symptoms and 230 cluded costs, reach, effects on physical activity The relationship between influenza vaccina- gains, cost-effectiveness, and other potentially tion habits and location of vaccination. Andrew W. augmenting benefits. RESULTS: Two programs Mulcahy. 2014 were significantly superior in terms of reach and OBJECTIVE: Although use of non-medical set- cost per student: (1) extending the school day with tings for vaccination such as retail pharmacies has mandatory PE participation and (2) offering short grown in recent years, little is known about how (10-minute) physical activity breaks during regular various settings are used by individuals with dif- classroom hours. After-school program costs per ferent vaccination habits. We aimed to assess the student are high and the programs have a smaller relationship between repeated, annual influenza reach, but they offer benefits (such as childcare) vaccination and location of vaccination. STUDY that may justify their higher costs. Before-school DESIGN: We conducted a cross-sectional survey programs did not appear feasible. CONCLUSION: of 4,040 adults in 2010. METHODS: We fielded a Incorporating short physical activity breaks into nationally representative survey using an online the existing school day would be a cost-effective research panel operated by Knowledge Networks. way to increase school-based activity. This type The completion rate among sampled panelists of program is inexpensive and has broad reach. was 73%. RESULTS: 39% of adults reported that Inserting activity breaks throughout the day is ap- they have never received a seasonal influenza propriate, especially when youth are otherwise vaccination. Compared to those who were usu- largely sedentary. ally or always vaccinated from year to year, those who sometimes or rarely received influenza vac- EP-50550 Engagement in HIV prevention advocacy as- cinations were significantly more likely to be vac- sociated with increased consistent condom use cinated in a medical setting in 2009–2010. CON- among HIV clients in Uganda. 2014 CLUSIONS: Results indicate that while medical settings are the dominant location for vaccina- We examined whether engagement in prevention overall, they play an especially critical role in tion advocacy among HIV clients is associated serving adults who do not regularly receive vac- with their own condom use and HIV care adher- cinations. By exploring vaccination habits, we can ence. Longitudinal data merged from three stud- more appropriately choose among interventions ies in Uganda produced a sample of 1,882 par- designed to encourage the initiation vs. mainte- ticipants who were administered assessments at nance of desired behaviors. baseline and months 6 and 12. The measure of prevention advocacy was the mean of two Likert EP-50552 scale items assessing encouragement of others Integrating the use of patient-reported out- to (1) use condoms, and (2) get HIV tested. In re- comes for both clinical practice and performance gression analyses controlling for demographics measurement: views of experts from 3 countries. and known correlates of the dependent variables, John Z. Ayanian. 2014 increased prevention advocacy from baseline to POLICY POINTS: * The patient-reported out- month 12 was significantly associated with income (PRO) is a standardized method for mea- creased consistent condom use and marginally suring patients' views of their health status. Our associated with increased antiretroviral adher- international study showed that experts in clini- ence and clinic attendance. These results suggest cal practice and performance measurement sup- that empowering HIV clients to engage in preven- ported the integrated collection of PRO data for tion advocacy with others may benefit their own use in both clinical care and performance mea- HIV protective behaviors and should be promoted surement. * The measurement of PROs to sup- as a component to interventions targeting positive port patient-provider decisions and the use of living among people living with HIV. PRO performance measures to evaluate health care providers have developed both separately EP-50551 231 and in parallel. * The use of PROs would benefit of PROs in health care are underdeveloped, need from a shared vision by health care providers, pur- better integration with clinical care, and must be chasers of care, and patients regarding the aims tailored to the characteristics of the health care and purposes of the various applications; and system. Enabling the sustainable use of PROs will the establishment of trust among stakeholders require a shared vision of clinical professionals, concerning the prudent use of PRO performance purchasers, and patients, with a prudent selection measures. CONTEXT: Patient-reported outcomes of the steps in implementing PROs that will maxi- (PROs) can play an important role in patient- mize their impact on the quality of health care. centered health care by focusing on the patient's health goals guiding therapeutic decisions. When EP-50553 aggregated, PROs also can be used for other Paying for telemedicine. David I. Auerbach. purposes, including comparative effectiveness re- 2014 search, practice improvement, assessment of the Telemedicine offers the potential for better care, performance of clinicians and organizations, and lower costs, and increased convenience. Expand- as a metric for value-based payments. The feasi- ing existing fee-for-service payment models to bility of integrating the use of PROs for these vari- include telemedicine may lead to its overuse. Al- ous purposes on a wide scale has not yet been ready there are many skeptics among payers and demonstrated. Our study was conducted to inform providers regarding this method of payment. The policymakers of prudent next steps for implement- greatest potential for effective and efficient use of ing PROs in clinical practice and performance telemedicine services lies in the use of emerging measurement programs in order to maximize their payment models. impact on the quality of health care. METHODS: We conducted a qualitative study, interviewing 58 EP-50554 experts and leaders from 37 organizations (re- Bringing online in line: contribution to an impact sponse rate: 88%) in the United States, England, assessment for the Delegated Act to implement and the Netherlands. Respondents included clini- the online provisions of the revised Energy Re- cal practitioners (n = 30), measure developers (n lated Products Directive. Jeremy Millard, Maarten = 11), and leaders of performance measurement Botterman. 2014 programs (n = 17). We used a qualitative content This study assesses the likely impacts of im- analysis to assess current strategies for applying plementing the online provisions of the revised PROs in clinical practice and performance mea- Energy Related Products Labelling Directive. It is surement and to identify barriers to and facilitators foreseen in the revised Directive that these provi- of further implementation. FINDINGS: The use sions be implemented using a Delegated Act. The of PROs in clinical practice and for performance study makes clear recommendations as to how measurement has developed both separately and the act should be framed and provides the nec- in parallel. Experts across the stakeholder spec- essary supporting analysis and evidence for its trum support the collection of PRO data in an in- conclusions. tegrated manner that would enable using the data for these distinct purposes. We identified 2 main EP-50555 concerns about the feasibility for integrated use of Anxiety and depressive symptoms and medi- PRO data: the complexity of establishing routine cal illness among adults with anxiety disorders. data collection and the tension among stakehold- Halina J. Dour, Annette L. Stanton. 2014 ers when using PRO data for different purposes. These contrasting stakeholder views suggested OBJECTIVE: Anxiety is linked to a number varying interests among clinicians, measure devel- of medical conditions, yet few studies have exam- opers, and purchasers of care. CONCLUSIONS: ined how symptom severity relates to medical co- Data collection approaches that support the use morbidity. PURPOSE: The current study assessed associations between severity of anxiety and de- 232 pression and the presence of medical conditions mediation analyses were performed. RESULTS: in adults diagnosed with anxiety disorders. Meth- Regression analyses adjusting for age, race/eth- od: Nine-hundred eighty-nine patients diagnosed nicity, and childhood confounders (e.g., parental with panic, generalized anxiety, social anxiety, socioeconomic status, intelligence) demonstrated and posttraumatic stress disorders reported on that relative to those with greater than or equal to the severity of anxiety and depressive symptoms college education, men and women with less than and on diagnoses of 11 medical conditions. RE- high school had 73.7% (95% confidence interval SULTS: Severity of anxiety and depressive symp- [CI; 29.5, 133.0]) and 48.2% (95% CI [17.5, 86.8]) toms was strongly associated with having more higher 10-year CHD risk, respectively. Mediation medical conditions over and above control vari- analyses demonstrated significant indirect effects ables, and the association was as strong as that for reading comprehension in women (7.2%; 95% between BMI and disease. Odds of having asth- CI [0.7, 19.4]) and men (7.2%; 95% CI [0.8, 19.1]), ma, heart disease, back problems, ulcer, migraine and depressive symptoms (11.8%; 95% CI [2.5, headache and eyesight difficulties also increased 26.6]) and perceived constraint (6.7%, 95% CI as anxiety and depressive symptom severity in- [0.7, 19.1]) in women. CONCLUSIONS: Evidence creased. Anxiety symptoms were independently suggested that reading comprehension in wom- associated with ulcer, whereas depressive symp- en and men, and depressive symptoms and per- toms were independently associated with heart ceived constraint in women, may mediate some of disease, migraine, and eyesight difficulties. CON- the association between education and CHD risk. CLUSIONS: These findings add to a growing body If these mediated effects are interpreted causally, of research linking anxiety disorders with physi- interventions targeting reading, depressive symp- cal health problems and indicate that anxiety and toms, and perceived constraint could reduce edu- depressive symptoms deserve greater attention in cational inequalities in CHD. their association with disease. EP-50557 EP-50556 The role of gender in moderating treatment Education and coronary Heart disease risk: outcomein collaborative care for anxiety. Ann M. potential mechanisms such as literacy, perceived Cheney, John Fortney. 2014 constraints, and depressive symptoms. Chanelle OBJECTIVE: The aim of this study was to test J. Howe. 2014 whether gender moderates intervention effects OBJECTIVE: Education is inversely associated in the Coordinated Anxiety Learning and Man- with coronary heart disease (CHD) risk; however agement (CALM) intervention, a 12-month, ran- the mechanisms are poorly understood. The study domized controlled trial of a collaborative care objectives were to evaluate the extent to which intervention for anxiety disorders (panic disorder, rarely measured factors (literacy, time preference, generalized anxiety disorder, posttraumatic stress sense of control) and more commonly measured disorder, and social anxiety disorder) in 17 pri- factors (income, depressive symptomatology, mary care clinics in California, Washington, and body mass index) in the education-CHD literature Arkansas. METHODS: Participants (N=1,004) explain the associations between education and completed measures of symptoms (Brief Symp- CHD risk. METHOD: The study sample included tom Inventory [BSI]) and functioning (mental and 346 participants, aged 38 to 47 years (59.5% physical health components of the 12-Item Short women), of the New England Family Study birth Form [MCS and PCS] and Healthy Days, Restrict- cohort. Ten-year CHD risk was calculated used Activity Days Scale) at baseline, six, 12, and 18 ing the validated Framingham risk algorithm that months. Data on dose, engagement, and beliefs utilizes diabetes, smoking, blood pressure, total about psychotherapy were collected for patients cholesterol, high-density lipoprotein cholesterol, in the collaborative care group. RESULTS: Gender age, and gender. Multivariable regression and moderated the relationship between treatment 233 and its outcome on the BSI, MCS, and Healthy only 48% had a concomitant vault suspension. Days measures but not on the PCS. Women who Although 71% had documentation about the risk received collaborative care showed clinical im- of postoperative stress incontinence, only 14.5% provements on the BSI, MHC, and Healthy Days had documented counseling regarding risks of that were significantly different from outcomes for mesh. Only 37% of patients implanted with mesh women in usual care. There were no differences for POP had documented follow-up at 1 year. An for men in collaborative care compared with usual intraoperative cystoscopy was performed in 86% care on any measures. In the intervention group, undergoing cystocele repair or apical surgery. women compared with men attended more ses- CONCLUSION: The quality of care for women sions of psychotherapy, completed more modules with POP can be feasibly measured with QIs. Pro- of therapy, expressed more commitment, and cesses of care were deficient in many areas, and viewed psychotherapy as more helpful. CONCLU- our findings can serve as a basis for quality im- SIONS: These findings contribute to the broader provement interventions. literature on treatment heterogeneity, in particular the influence of gender, and may inform personal- EP-50559 ized care for people seeking anxiety treatment in Response error in reporting dental coverage primary care settings. by older Americans in the Health and Retirement Study. Richard J. Manski, Nancy A. Mathiowetz. EP-50558 2014 Measuring the quality of care provided to wom- The aim of this research was to analyze the en with pelvic organ prolapse. Catherine Bresee, inconsistency in responses to survey questions Karyn Eilber. 2014 within the Health and Retirement Study (HRS) OBJECTIVE: Health care providers are in- regarding insurance coverage of dental services. creasingly being evaluated by the quality of care Self-reports of dental coverage in the dental ser- they provide. Our aim was to assess the feasibility vices section were compared with those in the of recently developed quality indicators (QIs) for insurance section of the 2002 HRS to identify in- pelvic organ prolapse (POP) and identify possible consistent responses. Logistic regression identi- deficits in care. STUDY DESIGN: A panel ranked fied characteristics of persons reporting discrep- 14 QIs based on the RAND appropriateness meth- ancies and assessed the effect of measurement od assessing screening and diagnosis, pessary error on dental coverage coefficient estimates in management, and surgery for POP. Retrospec- dental utilization models. In 18% of cases, data re- tive chart abstraction was performed after identi- ported in the insurance section contradicted data fying patients with a diagnosis of POP evaluated reported in the dental use section of the HRS by within a hospital-based multispecialty group using those who said insurance at least partially cov- International Classification of Diseases, ninth edi- ered (or would have covered) their (hypothetical) tion, diagnosis codes. RESULTS: Of 283 patients dental use. Additional findings included distinct identified, 98% of those with a new complaint of characteristics of persons with potential reporting vaginal bulge had a pelvic examination. The POP errors and a downward bias to the regression coef- was described but not staged in 6% and not docu- ficient for coverage in a dental use model without mented at all in 25.1%. Among those managed controls for inconsistent self-reports of coverage. with pessaries, 98% had vaginal examinations at This study offers evidence for the need to validate least every 6 months. Forty-nine percent of the self-reports of dental insurance coverage among patients who had surgery had complete preopera- a survey population of older Americans to obtain tive POP staging. Only 20% of women undergoing more accurate estimates of coverage and its im- apical surgery had documentation of counseling pact on dental utilization. regarding different surgical options, and of the women who underwent a hysterectomy for POP, EP-50616 Preparing state transportation agencies for an 234 uncertain energy future. Thomas Light. 2014 ciency in a community-based program in Uganda. This report examines how the mandate, role, We compared time waiting to see and time spent funding, and operations of state departments of with providers for various patient categories and transportation (DOTs) will likely be affected by examined patient and provider satisfaction with changes in energy supply and demand in the next the triage. Overall, median time spent at the clinic 30 to 50 years. The report also identifies poten- reduced from 206 to 83 min. Total median time tial strategies and actions that DOTs can employ waiting to see providers for stable-ART patients to plan and prepare for these effects. In addition, reduced from 102 to 20 min while that for patients the report describes how robust decision-making undergoing ART preparation reduced 88–37 min. techniques can be used to help navigate the po- Improved patient flow, patient and provider satis- tential risks and rewards of different policy and faction and reduced waiting times allowed for ser- management responses under differing surface vice delivery to more patients using the same staff transportation energy supply-and-demand sce- following the implementation of triage. narios. EP-51641 Anti-Inflammatory Medication Adherence, EP-51639 Talk Like a Marine: USMC Linguistic Accultura- Healthcare Utilization and Expenditures Among tion and Civil-Military Argument. William Marcel- Medicaid and Children's Health Insurance Pro- lino. 2014 gram Enrollees with Asthma. Jill Boylston Hern- don, Soeren Mattke, Alison Evans Cuellar. 2014 This study examines the relationship between US Marine discourse and civil-military public ar- BACKGROUND: Underuse of controller thera- gument. A computer-aided semantic analysis of py among Medicaid-enrolled children is common public record speech from senior Marine officers and leads to more emergency department (ED) shows a style of cohesion, marked by future-ori- visits and hospitalizations. However, there is little ented, inclusive, highly certain language. An ap- evidence about the relationship between medica- praisal theory discourse analysis of interviews tion adherence, outcomes and costs once con- with US Marines conducted during an ethnogra- troller therapy is initiated. OBJECTIVE: This study phy of communication shows their talk argues dis- examined the relationship between adherence to cursively for cohesion. This way of speaking may two commonly prescribed anti-inflammatory med- constrain Marines in public argument, as they re- ications, inhaled corticosteroids (ICS) and leukot- peat ways of talking appropriate within the com- riene inhibitors (LI), and healthcare utilization and munity, even when situationally inappropriate for expenditures among children enrolled in Medic- civilian audiences. aid and the Children's Health Insurance Program in Florida and Texas in the US. METHODS: The EP-51640 sample for this retrospective observational study Strategies for Optimizing Clinic Efficiency in consisted of 18456 children aged 2–18 years di- a Community-Based Antiretroviral Treatment Pro- agnosed with asthma, who had been continuously gramme in Uganda. Stella Talisuna-Alamo, Glenn enrolled for 24 months during 2004–7 and were Wagner, Joseph Ouma. 2014 on monotherapy with ICS or LI. State administrative enrolment files were linked to medical claims We address a critical aspect of antiretroviral data. Children were grouped into three adherence therapy (ART) scale-up: poor clinic organization categories based on the percentage of days per leading to long waiting times and reduced patient year they had prescriptions filled (medication pos- retention. Using a before and after study design, session ratio). Bivariate and multivariable regres- time and motion studies and qualitative meth- sion analyses that adjusted for the children's de- ods we evaluated the impact of triage and longer mographic and health characteristics were used clinic appointment intervals (triage) on clinic effi- 235 to examine the relationship between adherence in higher-risk behaviour, due to observed changes and ED visits, hospitalizations, and expenditures. in the target's health, and to convey information RESULTS: Average adherence was 20% for ICS- after receiving treatment at the clinic. The partici- treated children and 28% for LI-treated children. pants mostly reported positive or neutral respons- Children in the highest adherence category had es to these advocacy events; negative responses lower odds of an ED visit than those in the low- were rare. Interventions to empower PLHIV to be est adherence category (p < 0.001). We did not agents of change could represent a new frontier detect a statistically significant relationship be- for HIV prevention. tween adherence and hospitalizations; however, only 3.7% of children had an asthma-related hos- EP-51643 pitalization. Overall asthma care expenditures Reasons Why High Religiosity Can Co-Exist with increased with greater medication adherence. and Precipitate Discontinuation of Anti-Retroviral CONCLUSIONS: Although greater adherence Therapy Among Different HIV Clients in Uganda: was associated with lower rates of ED visits, high- An Exploratory Study. Christopher Tumwine, er medication expenditures outweighed the sav- Stella Neema, Glenn Wagner. 2014 ings. The overall low adherence rates suggest that In-depth interviews were conducted with 39 quality improvement initiatives should continue to very religious people living with HIV (16 had ever target adherence regardless of the class of medi- and 23 had never discontinued antiretroviral ther- cation used. However, low baseline hospitalization apy — ART) to assess the role of religion in these rates may leave little opportunity to significantly treatment decisions and in coping with HIV. Partic- decrease costs through better disease manage- ipants who had ever discontinued ART gave rea- ment, without also decreasing medication costs. sons such as: teachings and prophecies from religious leaders, and supporting Biblical scriptures EP-51642 all of which led them to feel that God and their An Exploratory Study of HIV-Prevention Advo- faith, not ART, would help them; and testimonies cacy by Persons in HIV Care in Uganda. Chris- by their "already healed" peers who topher Tumwine, Annet Nannungi, Eric Ssegujja. had stopped ART. Participants who had never dis- 2014 continued ART gave reasons such as continuous To explore how people living with HIV (PLHIV) adherence counseling from multiple sources, im- and in care encourage others to adopt HIV-protec- provement in physical health as a result of ART, tive behaviours, we conducted in-depth interviews and beliefs that God heals in different ways and with a purposive sample of 40 HIV clinic patients that non-adherence is equal to putting God to a in Kampala, Uganda. Content analysis was used test. High religiosity was reported to help partici- to examine the message content, trigger events, pants cope with HIV through engagement in per- and outcomes of HIV-prevention advocacy events sonal and or community protective behaviours, initiated by the HIV clients with members of their "taking care of other illness", and re- social networks. The content themes included en- ducing worries. When high religiosity among peo- couraging specific behaviours, such as HIV testing ple living with HIV (PHAs) becomes a barrier to and treatment, condom use and non-promiscuity, ART adherence, the adherence counseling pro- as well as more general cautionary messages vided can draw on experiences of PHAs with high about protecting oneself from HIV infection. Com- religiosity who have sustained good adherence to mon triggers for bringing up HIV-prevention advo- ART and achieved good health outcomes. cacy information in a discussion or conversation included: wanting to prevent the targeted person EP-51645 from 'falling into the same problems,' wanting to Louisiana's 2012 Coastal Master Plan: Over- benefit oneself with regard to avoiding re-infec- view of a Science-Based and Publicly Informed tion, out of concern that the target would engage Decision-Making Process. Natalie Peyronnin, Mandy Green, Carol Richards. 2014 236

Louisiana is in the midst of a land loss crisis that EP-51647 has claimed more than 4800 km2</ How to Increase Value and Reduce Waste sup> since the 1930s. Unless aggressive, When Research Priorities Are Set. Iain Chalmers, large-scale action is taken, Louisiana could lose Michael B. Bracken, Ben Djulbegovic. 2014 an additional 4500 km2 in the next 50 years, resulting in a projected increase The increase in annual global investment in in annual damages from hurricane storm surge biomedical research—reaching US$240 billion in flooding of more than $23 billion. Louisiana's 2012 2010—has resulted in important health dividends Coastal Master Plan is a long-term plan with clear for patients and the public. However, much re- economic, social, and environmental benefits, search does not lead to worthwhile achievements, such as decreasing potential damages from storm partly because some studies are done to improve surge by $5.3 billion to $18 billion. Implementation understanding of basic mechanisms that might of projects in the master plan should result in no not have relevance for human health. Additionally, net loss of land after 20 years and an annual net good research ideas often do not yield the antici- gain of land after 30 years. To develop the plan, pated results. As long as the way in which these the Coastal Protection and Restoration Author- ideas are prioritised for research is transparent ity (CPRA) utilized a state-of-the-art systems ap- and warranted, these disappointments should not proach to coastal planning and a science-based be deemed wasteful; they are simply an inevitable decision-making process that resulted in a fund- feature of the way science works. However, some ing- and resource-constrained plan that makes sources of waste cannot be justified. In this report, the greatest progress toward achieving a sustain- we discuss how avoidable waste can be consid- able coast. A series of integrated, coastwide pre- ered when research priorities are set. We have dictive models were developed to provide data for four recommendations. First, ways to improve the a new planning tool used to identify the suite of yield from basic research should be investigated. projects that would make the greatest progress Second, the transparency of processes by which toward meeting the master plan objectives while funders prioritise important uncertainties should considering uncertainties in future environmental be increased, making clear how they take account conditions. Recognizing that the success of the of the needs of potential users of research. Third, plan hinges on stakeholder support, as well as investment in additional research should always science, the CPRA also implemented a compre- be preceded by systematic assessment of exist- hensive outreach plan to obtain input and feed- ing evidence. Fourth, sources of information about back from key stakeholders and the public. The research that is in progress should be strength- resulting plan recommends a specific list of res- ened and developed and used by researchers. toration and protection projects and has achieved Research funders have primary responsibility for widespread support. reductions in waste resulting from decisions about what research to do. EP-51646 Strategic Issues Facing Transportation. Steven EP-51648 W. Popper, Nidhi Kalra, Richard Silberglitt. 2014 Mortality Among High-Risk Patients with Acute Myocardial Infarction Admitted to U.S. Teaching- STREAM is a process that transportation agen- Intensive Hospitals in July: A Retrospective Ob- cies can use to identify, assess, shape, and adopt servational Study. Anupam B. Jena, Eric Sun, new and emerging technologies to help achieve John A. Romley. 2014 long-term system performance objectives. The process reflects relevant trends in technologies BACKGROUND: Studies of whether inpatient and their applications and is designed to help mortality in US teaching hospitals rises in July as transportation agencies anticipate, adapt to, and a result of organizational disruption and relative shape the future. inexperience of new physicians (July effect) find 237 small and mixed results, perhaps because study effects of marijuana use on health and mental populations primarily include low-risk inpatients health, the role of potency and other cannabinoids whose mortality outcomes are unlikely to exhibit in influencing health and safety outcomes, the a July effect. METHODS and RESULTS: Using impact of regulated and unregulated markets on the US Nationwide Inpatient sample, we esti- prices and youth consumption, and the impact of mated difference-in-difference models of mortal- legalization on the consumption of related goods ity, percutaneous coronary intervention rates, and (alcohol and prescription drugs). bleeding complication rates, for high- and low-risk patients with acute myocardial infarction admitted EP-51650 to 98 teaching-intensive and 1353 non–teaching- Marijuana Liberalization Policies: Why We Can't intensive hospitals during May and July 2002 to Learn Much from Policy Still in Motion. Rosalie 2008. Among patients in the top quartile of pre- Liccardo Pacula, Eric Sevigny. 2014 dicted acute myocardial infarction mortality (high Much remains unanswered about the poten- risk), adjusted mortality was lower in May than tial effects of marijuana liberalization policies be- July in teaching-intensive hospitals (18.8% in May, cause the most relevant questions have yet to be 22.7% in July, P<0.01), but similar in non–teach- fully considered and addressed. Existing policy ing-intensive hospitals (22.5% in May, 22.8% in experiments have not been used to answer the July, P=0.70). Among patients in the lowest three most important questions, namely are public quartiles of predicted acute myocardial infarction health harms from marijuana use a function of the mortality (low risk), adjusted mortality was similar person consuming it (age, polysubstance user, in May and July in both teaching-intensive hos- or other identifying factor)? Amount consumed? pitals (2.1% in May, 1.9% in July, P=0.45) and Activities engaged in while under the influence? non–teaching-intensive hospitals (2.7% in May, Method of consumption? Potency? Or duration 2.8% in July, P=0.21). Differences in percutane- of use? How responsive is problematic use to ous coronary intervention and bleeding compli- changes in price? To answer these questions de- cation rates could not explain the observed July finitively, researchers need a bit more time and a mortality effect among high risk patients. CON- lot better data. CLUSIONS: High-risk acute myocardial infarction patients experience similar mortality in teaching- EP-51651 and non–teaching-intensive hospitals in July, but Cannabis Use and Antisocial Behavior Among lower mortality in teaching-intensive hospitals in Youth. Ioana Popovici, Michael Thomas French, May. Low-risk patients experience no such July ef- Olena Antonaccio. 2014 fect in teaching-intensive hospitals. Despite the numerous efforts to curb substance EP-51649 use and abuse through legislation and interven- Natural Experiments in a Complex and Dynamic tions, marijuana consumption continues to be a Environment: The Need for a Measured Assess- major social problem, particularly among young ment of the Evidence. Rosalie Liccardo Pacula, adults in the United States. We provide new infor- Eric Sevigny. 2014 mation on the relationship between cannabis use and antisocial behavior by analyzing a sample of The shift from punitive prohibition to legaliz- young adults (aged 18–20) from the National Epi- ing marijuana at the state (or federal) level may demiological Survey of Alcohol and Related Con- produce a net social benefit. However the avail- ditions (NESARC). We examine a broad set of able evidence suggests we should be cautious in cannabis use patterns and multiple dimensions of making definitive claims of either net benefits or antisocial behaviors and test the empirical impor- net costs given the current state of the science. tance of two prominent criminological theories— We need a better understanding of the long-term general strain and social bond—in explaining as- 238 sociations between cannabis use and antisocial all independently associated with improvement behavior. We include important socioeconomic, in both work outcomes, even after accounting demographic, health and health behaviors, and for the direct effect of ART. CONCLUSIONS: Im- contextual information in all regressions to control provement in physical and mental health plays a for confounding factors. Our results imply that can- key role in the positive impact of HIV treatment nabis use is positively and significantly related to on work activity and function, suggesting potential antisocial behavior among young adults, and gen- economic benefits of integrating depression treat- eral strain and social bond theories cannot fully ment into HIV care. explain our findings. As expected, the estimated association with antisocial behavior is stronger for EP-51653 more frequent cannabis users. The COMPARE Microsimulation Model and the U.S. Affordable Care Act. Amado Cordova, EP-51652 Federico Girosi, Sarah A. Nowak. 2014 The Role of Depression in Work-Related In anticipation of upcoming health care leg- Outcomes of HIV Treatment in Uganda. Glenn islation, the RAND Corporation developed a mi- Wagner, Bonnie Ghosh-Dastidar, Mary Ellen crosimulation model to forecast the responses of Slaughter. 2014 individuals, families and firms to such legislation. PURPOSE: The primary goal of this analysis was The COMPARE (COMPrehensive Assessment of to examine the influence of depression above and Reform Efforts) microsimulation has been used beyond the effects of HIV treatment on work activ- to estimate the impact of major policy changes in ity and function. METHODS: We combined data the United States, such as the Affordable Care Act from three longitudinal studies of patients starting on uninsurance rates, participation in the group antiretroviral therapy (ART) and/or entering HIV and the non-group insurance markets, firms' in- care in Uganda. Assessments were conducted surance offer rates, enrollment in public programs at baseline and months 6 and 12. The nine-item such as Medicaid and CHIP, private insurance Patient Health Questionnaire (PHQ-9) was used premiums and costs to the federal and state gov- to assess depressive symptoms, as well as Ma- ernments. The team selected utility maximization jor (scores >9) and Minor (scores 5-9) Depres- to model behaviors, a methodology that is better sion status; work functioning was assessed using suited than spreadsheet or econometric models to a subscale of the Medical Outcomes Study HIV predict how individuals, households and firms will Health Survey (MOS-HIV). Multivariate random- respond to wholly new insurance options, such as effects logistic regression models for longitudinal the Health Insurance Marketplace and the Small data were used to examine the impact of treatment Business Health Options Program (SHOP) Ex- on work status and optimal work functioning, with changes created by the Affordable Care Act. Mod- measures of both baseline and change in physical eling can be done both at the national and at a health functioning, cognitive functioning and de- state-specific levels. In this paper we provide a pression in the models, controlling for baseline de- summary of COMPARE's basic principles, its na- mographics, and CD4 cell count. RESULTS: The tionally representative databases, its utility-max- sample of 1,731 participants consisted of 1,204 imization behavioral models, and how we have starting ART and 527 not yet eligible for ART. At used COMPARE to estimate the consequences of baseline, 35 % were not working, and 37 % had the Affordable Care Act. sub-optimal work functioning. Intention-to-treat analyses revealed that those on ART experienced EP-51654 greater improvement in both work outcomes over The Potential for Pocket Parks to Increase 12 months relative to non-ART patients, and that Physical Activity. Deborah A. Cohen, Terry Marsh, baseline and change in physical health function- Stephanie Williamson. 2014 ing, continuous and categorical depression were PURPOSE: To assess the use of new pocket 239 parks in low-income neighborhoods. DESIGN: build the framework for future collaboration. SET- The design of the study was a quasi-experimental TING: These partners worked together from 2009 post-test only comparison. SETTING: Los Ange- to 2012 to design, renovate, and study parks in les, California, was the setting for the study. SUB- San Francisco, California. SUBJECTS: The three JECTS: Subjects were park users and residents partnering organizations are the focus of this ar- living within .5 mile of three pocket parks and 15 ticle. INTERVENTION: The Trust for Public Land's neighborhood parks. INTERVENTION: The cre- Parks for People-Bay Area Program raised more ation of pocket parks. MEASURES: We used the than $16 million to renovate three San Francisco System of Observing Play and Recreation in Com- parks, which served as the intervention for a study munities (SOPARC) tool to measure park use and that initially brought the three partnering organi- park-based physical activity, and then surveyed zations together. MEASURES: The authors, who park users and residents about their park use. represent the three partners, collaborated to de- ANALYSIS: We surveyed 392 and 432 household velop the lessons learned. ANALYSIS: This article members within .5 mile of the three pocket parks is a description and commentary about a partner- before and after park construction, respectively, ship that emphasized community involvement and as well as 71 pocket park users, and compared rigorous evaluation. RESULTS: Lessons learned them to 992 neighborhood park users and 342 and elements for successful partnerships include residents living within .5 mile of other neighbor- collaborating with organizations with differing ex- hood parks. We compared pocket park use to play- pertise, deciding upon goals initially, finding a com- ground area use in the larger neighborhood parks. mon language, involving local communities, and We used descriptive statistics and generalized recognizing the importance and appropriate role estimating equations for the analysis. RESULTS: of evaluations. CONCLUSION: The model for col- Overall, pocket park use compared favorably in laboration and community involvement presented promoting moderate-to-vigorous physical activity supports and encourages other organizations to with that of existing playground space in nearby use strategic, multidisciplinary partnerships and parks, and they were cost-effective at $0.73/MET highlights the importance of evaluation. hour (metabolic equivalent hour) gained. Pocket park visitors walked an average of .25 miles to EP-51656 get to a park. CONCLUSION: Pocket parks, when Single-Parent Family Structure and Sleep Prob- perceived as attractive and safe destinations, may lems in Black and White Adolescents. Wendy M. increase physical activity by encouraging families Troxel, Laisze Lee, Martica Hall. 2014 with children to walk there. Additional strategies OBJECTIVES: Sleep is critical for adolescent and programs may be needed to encourage more health and is influenced by the family environment. residents to use these parks. In our study, we examined if family structure defined as single- vs 2-parent households affected EP-51655 adolescent sleep. METHODS: Participants were Partnerships for Parks and Physical Activity. 242 (57% black; 47% boys) healthy adolescents Bianca D. Shulaker, Jennifer W. Isacoff, Deborah (mean age, 15.7 years). Sleep was measured us- A. Cohen. 2014 ing self-report and wrist actigraphy over 7 consec- PURPOSE: Given the need for comprehensive utive nights. Outcomes were actigraphy-assessed and multidisciplinary active living interventions, sleep duration and sleep efficiency (SE) for the this article describes an innovative partnership for full week and weekends and weekdays separate- park design and evaluation. DESIGN: The Trust ly, as well as self-reported sleep-wake problems for Public Land partnered with the RAND Cor- and variability in bedtimes. Linear regression ex- poration and the San Francisco Department of amined the relationship between family structure Public Health to generate context-sensitive active and sleep, after adjusting for age, sex, race, body park design, establish evaluation methods, and mass index, and depressive symptoms, paren- 240 tal education, family conflict, and financial strain. To our knowledge, this is one of the first papers Race and sex were examined as potential mod- to do so. A major contribution of this paper is the erators. RESULTS: After adjusting for covariates, introduction of a new panel dataset on migration adolescents from single-parent households had to the US and the UK from 31 sub-Saharan Africa poorer SE across the week and shorter sleep countries. The data spans the period 1975–2004. duration on weekends. White adolescents from Using this data, we estimate the impact of chang- 2-parent households had the fewer sleep-wake es in economic conditions on physician migration. problems and lower bedtime variability, whereas In our preferred specification that allows for coun- black adolescents from single-parent households try-specific time trends, we find that a temporary had the lowest weekend SE. There were no sig- one percentage point decline in GDP per capita nificant differences in family structure sex interac- increases physician migration in the next period tions. CONCLUSION: Our findings are the first to by approximately. 3 percent. In our IV models a demonstrate that single-parent family structure is one percentage point decline in GDP per capita an independent correlate of sleep problems in ad- increases physician migration in the next period by olescents, and they highlight the moderating role between 3.4 and 3.6 percent. Overall, our results of race. suggest a significant effect of developing country economic conditions on physician migration. EP-51657 Effects of Medicare Payment Reform: Evidence EP-51661 from the Home Health Interim and Prospective Gone to War: Have Deployments Increased Payment Systems. Peter J. Huckfeldt, Neeraj Divorces?. Sebastian Negrusa, Brighita Negrusa, Sood, Jose J. Escarce. 2014 James Hosek. 2014 Medicare continues to implement payment re- Owing to the armed conflicts in Iraq and Af- forms that shift reimbursement from fee-for-service ghanistan, members of the US military have expe- toward episode-based payment, affecting average rienced very high rates of deployment overseas. and marginal payment. We contrast the effects of Because military personnel have little to no control two reforms for home health agencies. The home over their deployments, the military setting offers health interim payment system in 1997 lowered a unique opportunity to study the causal effect of both types of payment; our conceptual model pre- major disruptions on marital dissolution. In this dicts a decline in the likelihood of use and costs, paper, we use longitudinal individual-level admin- both of which we find. The home health prospec- istrative data from 1999 to 2008 and find that an tive payment system in 2000 raised average but additional month in deployment increases the di- lowered marginal payment with theoretically am- vorce hazard of military families, with females be- biguous effects; we find a modest increase in use ing more affected. A standard conceptual frame- and costs. We find little substantive effect of either work of marital formation and dissolution predicts policy on readmissions or mortality. a differential effect of these types of shocks depending on the degree to which they are anticipat- EP-51659 ed when a couple gets married. Consistent with Brain Drain: Do Economic Conditions "Push" this prediction, we find a larger effect for couples Doctors Out of Developing Countries?. Edward N. married before 9/11, who clearly expected a lower Okeke. 2014 risk of deployment than what they faced post 9/11. Health worker migration is an issue of first EP-51662 order concern in global health policy circles and Incentives for Biodefense Countermeasure De- continues to be the subject of much policy debate. velopment. Jason Matheny, Michael Mair, Andrew In this paper, we contribute to the discussion by W. Mulcahy. 2014 studying the impact of economic conditions on the migration of physicians from developing countries. 241

Therapeutics and vaccines are available for only cus groups were used to explore a representative a fraction of biological threats, leaving populations sample of 24 patients' health care decision mak- vulnerable to attacks involving biological weapons. ing and views of quality. Data from focus group Existing U.S. policies to accelerate commercial transcripts were iteratively coded and analyzed by development of biodefense products have thus far the authors. RESULTS: Focus group participants induced insufficient investment by the biopharma- were similar to the broader diverse, low-income ceutical industry. In this article, we examine the clinic population. Participants reported exercising technical, regulatory, and market risks associated choice in making decisions about where to seek with countermeasure development and review ex- health care. Multiple sources influenced decision- isting and proposed federal incentives to increase making processes including participants' own be- industrial investment. We conclude with several liefs and values, social influences, and prior expe- recommendations. To increase industry's engage- riences. Hospital quality data were notably absent ment in biodefense countermeasure develop- as a source of influence in health care decision ment, Congress should expand BioShield fund- making for this population largely because partici- ing, giving HHS the flexibility to fund a portfolio pants were unaware of its existence. Participants' of biodefense countermeasures whose revenues views of hospital quality were influenced by the are comparable to those of commercial drugs. quality and efficiency of services provided (with Congress should establish tradable priority review an emphasis on the doctor-patient relationship) vouchers for developers of new countermeasures. and patient centeredness. When presented with A National Academy of Sciences or National Bio- it, patients appreciated the hospital quality data defense Science Board should formally evaluate and, with guidance, were interested in incorporat- incentive programs and a government-managed ing it into health care decision making. CONCLU- "Virtual Pharma," in which HHS con- SIONS: Results suggest directions for optimizing tracts separate stages of research, development, the presentation, content, and availability of hos- and production to individual firms. pital quality data. Future research will explore how similar populations form and make choices based EP-51663 on presentation of hospital quality data. Vulnerable Patients' Perceptions of Health Care Quality and Quality Data. Maria Catherine Raven, EP-51664 Colleen C. Gillespie, Rebecca DiBennardo. 2014 Long-term Survival and Healthcare Utilization BACKGROUND: Little is known about how pa- Outcomes Attributable to Sepsis and Pneumonia. tients served by safety-net hospitals utilize and Andrew W. Dick, Hangsheng Liu, Jack Zwanziger. respond to hospital quality data. OBJECTIVE: 2014 To understand how vulnerable, lower income pa- BACKGROUND: Hospital associated infections tients make health care decisions and define qual- are major problems, which are increasing in inci- ity of care and whether hospital quality data factor dence and very costly. However, most research into such decisions and definitions. METHODS: has focused only on measuring consequences Mixed quantitative and qualitative methods were associated with the initial hospitalization. We ex- used to gather primary data from patients at an plored the long-term consequences of infections urban, tertiary-care safety-net hospital. The study in elderly Medicare patients admitted to an inten- hospital is a member of the first public hospital sive care unit (ICU) and discharged alive, focusing system to voluntarily post hospital quality data on: sepsis, pneumonia, central-line-associated online for public access. Patients were recruited bloodstream infections (CLABSI), and ventilator- from outpatient and inpatient clinics. Surveys associated pneumonia (VAP); the relationships were used to collect data on participants' sociode- between the infections and long-term survival and mographic characteristics, health literacy, health resource utilization; and how resource utilization care experiences, and satisfaction variables. Fo- was related to impending death during the fol- 242 low up period. METHODS: Clinical data and one and 16% of all MET-weight moderate-to-vigorous year pre- and five years post-index hospitalization physical activity (MW-MVPA) during school hours. Medicare records were examined. Hazard ratios Active outdoor amenities accounted for 29% of (HR) and healthcare utilization incidence ratios all MW-MVPA during school. School design ap- (IR) were estimated from state of the art econo- pears to be associated with physical activity, but metric models. Patient demographics (i.e., age, it is likely that programming (eg, physical educa- gender, race and health status) and Medicaid tion, intramurals, club sports), social factors, and status (i.e., dual eligibility) were controlled for in school siting are more important determinants of these models. RESULTS: In 17,537 patients, there total physical activity. were 1,062 sepsis, 1,802 pneumonia, 42 CLABSI and 52 VAP cases. These subjects accounted for EP-51666 62,554 person-years post discharge. The sepsis Changes in Physician Antipsychotic Prescrib- and CLABSI cohorts were similar as were the ing Preferences, 2002-2007. Julie M. Donohue, A. pneumonia and VAP cohorts. Infection was as- James O'Malley, Marcela Horvitz-Lennon. 2014 sociated with increased mortality (sepsis HR&a OBJECTIVE: Physician antipsychotic prescrib- mp;thinsp;= 1.39, P < ing behavior may be influenced by comparative  0.01; and pneumonia HR&thin effectiveness evidence, regulatory warnings, and sp;= 1.58, P <&t formulary and other restrictions on these drugs. hinsp;0.01) and the risk persisted throughout the This study measured changes in the degree to follow-up period. Persons with sepsis and pneu- which physicians are able to customize treatment monia experienced higher utilization than controls choices and changes in physician preferences for (e.g., IR for long-term care utilization for those specific agents after these events. METHODS: with sepsis ranged from 2.67 to 1.93 in years 1 The study used 2002–2007 prescribing data from through 5); and, utilization was partially related to the IMS Health Xponent database and data on impending death. CONCLUSIONS: The infections physician characteristics from the American Medi- had significant and lasting adverse consequences cal Association for a longitudinal cohort of 7,399 among the elderly. Yet, many of these infections physicians. Descriptive and multivariable regres- may be preventable. Investments in infection pre- sion analyses were conducted of the concentra- vention interventions are needed in both commu- tion of prescribing (physician-level Herfindahl nity and hospitals settings. index) and preferences for and likelihood of prescribing two first-generation antipsychotics and EP-51665 six second-generation antipsychotics. Analyses School Design and Physical Activity Among adjusted for prescribing volume, specialty, demo- Middle School Girls. Deborah A. Cohen, Molly M. graphic characteristics, practice setting, and edu- Scott, Frank Zhen Wang. 2014 cation. RESULTS: Antipsychotic prescribing was Building design and grounds might contrib- highly concentrated at the physician level, with a ute to physical activity, and youth spend much of mean unadjusted Herfindahl index of .33 in 2002 their daylight hours at school. We examined the and .29 in 2007. Psychiatrists reduced the concen- associations among school building footprints, tration of their prescribing more over time than did the size of school grounds, and in-school physical other physicians. High-volume psychiatrists had a activity of 1566 sixth-grade girls from medium to Herfindahl index that was half that of low-volume large middle schools enrolled in the Trial of Activity physicians in other specialties (.18 versus .36), for Adolescent Girls (TAAG). The school building a difference that remained significant (p<.001) footprint and the number of active outdoor ameni- after adjustment for physician characteristics. The ties were associated with physical activity among share of physicians preferring olanzapine dropped adolescent girls. On average, the school footprint from 29.9% in 2002 to 10.3% in 2007 (p<.001) size accounted for 4% of all light physical activity while the share favoring quetiapine increased 243 from 9.4% to 44.5% (p<.001). Few physicians longer versions when administered by nurses. (<5%) preferred a first-generation antipsychotic Further study is needed to determine if screening in 2002 or 2007. CONCLUSIONS: Preferences with this tool changes clinical decision making or for specific antipsychotics changed dramatically improves outcomes in these patients. during this period. Although physician prescribing remained heavily concentrated, the concentration EP-51668 decreased over time, particularly among psychia- Changing Eating Habits for the Medical Profes- trists. sion. Lenard I. Lesser, Deborah A. Cohen, Robert H. Brook. 2014 EP-51667 Health professionals spend a great deal of Depression Screening: Utility of the Patient time at meetings. Grand rounds, noon seminars, Health Questionnaire in Patients with Acute Coro- research meetings, and medical conferences are nary Syndrome. Anthony W. McGuire, Jo Ann part of the life of a health professional. At many of Eastwood, Aurelia Macabasco-O'Connell. 2014 these activities, food is available. Although some BACKGROUND: Depression screening in members of the health professional community cardiac patients has been recommended by the have called for changes to the food environment in American Heart Association, but the best ap- the community in which they live, they have paid proach remains unclear. OBJECTIVES: To evalu- less attention to the quality of food served at hos- ate nurse-administered versions of the Patient pitals, physician offices, and at conferences. Health Questionnaire for depression screening EP-51669 in patients hospitalized for acute coronary syn- Measuring Hospital Quality: Can Medicare Data drome. METHODS: Staff nurses in an urban car- Substitute for All-Payer Data?. Jack Needleman, diac care unit administered versions 2, 9, and 10 Peter Buerhaus, Soeren Mattke. 2014 of the questionnaire to 100 patients with acute coronary syndrome. The Depression Interview OBJECTIVES: To assess whether adverse out- and Structured Hamilton was administered by ad- comes in Medicare patients can be used as a sur- vanced practice nurses blinded to the results of rogate for measures from all patients in quality-of- the Patient Health Questionnaire. With the results care research using administrative datasets. DATA of the Depression Interview and Structured Ham- SOURCES: Patient discharge abstracts from ilton as a criterion, receiver operating character- state data systems for 799 hospitals in 11 states. istic analyses were done for each version of the National MedPAR discharge data for Medicare Patient Health Questionnaire. The Delong method patients from 3,357 hospitals. State hospital staff- was used for pairwise comparisons. Cutoff scores ing surveys or financial reports. American Hospital balancing false-negatives and false-positives Association Annual Survey. STUDY DESIGN: We were determined by using the Youden Index. RE- calculate rates for 10 adverse patient outcomes, SULTS: Each version of the questionnaire had examine the correlation between all-patient and excellent area-under- the-curve statistics: 91.2%, Medicare rates, and conduct negative binomial 92.6%, and 93.4% for versions 2, 9, and 10, re- regressions of counts of adverse outcomes on spectively. Differences among the 3 versions were expected counts, hospital nurse staffing, and oth- not significant. Each version yielded higher symp- er variables to compare results using all-patient tom scores in depressed patients than in nonde- and Medicare patient data. DATA COLLECTION/ pressed patients: version 2 scores, 3.4 vs 0.6, P = EXTRACTION: Coding rules were established for .001; version 9 scores, 13 vs 3.4, P < .001; and eight adverse outcomes applicable to medical and version 10 scores, 14.5 vs 3.6, P < .001. CON- surgical patients plus two outcomes applicable CLUSIONS: For depression screening in hospital- only to surgical patients. The presence of these ized patients with acute coronary syndrome, the outcomes was coded for 3 samples: all patients Patient Health Questionnaire 2 is as accurate as in the 11-state sample, Medicare patients in the 244

11-state sample, and Medicare patients in the na- II (AGREE II) instrument and A Measurement Tool tional Medicare MedPAR sample. Logistic regres- to Assess Systematic Reviews (AMSTAR), respec- sion models were used to construct estimates of tively, and recommendations for mitigating opioid- expected counts of the outcomes for each hos- related risks were compared. DATA SYNTHESIS: pital. Variables for teaching, metropolitan status, Thirteen guidelines met selection criteria. Overall and bed size were obtained from the AHA Annual AGREE II scores were 3.00 to 6.20 (on a scale of Survey. PRINCIPAL FINDINGS: For medical pa- 1 to 7). The AMSTAR ratings were poor to fair for tients, Medicare rates were consistently higher 10 guidelines. Two received high AGREE II and than all-patient rates, but the two were highly cor- AMSTAR scores. Most guidelines recommend that related. Results from regression analysis were clinicians avoid doses greater than 90 to 200 mg consistent across the 11-state all-patient, 11-state of morphine equivalents per day, have additional Medicare, and national Medicare samples. For knowledge to prescribe methadone, recognize surgery patients, Medicare rates were generally risks of fentanyl patches, titrate cautiously, and re- higher than all-patient rates, but correlations of duce doses by at least 25% to 50% when switch- Medicare and all-patient rates were lower, and re- ing opioids. Guidelines also agree that opioid risk gression results less consistent. CONCLUSIONS: assessment tools, written treatment agreements, Analyses of quality of care for medical patients us- and urine drug testing can mitigate risks. Most ing Medicare-only and all-patient data are likely to recommendations are supported by observational have similar findings. Measures applied to surgery data or expert consensus. LIMITATION: Exclusion patients must be used with more caution, as those of non–English-language guidelines and reliance tested only in Medicare patients may not provide on published information. CONCLUSION: Despite results comparable to those from all-patient sam- limited evidence and variable development meth- ples or across different samples of Medicare pa- ods, recent guidelines on chronic pain agree on tients. several opioid risk mitigation strategies, including upper dosing thresholds; cautions with certain EP-51670 medications; attention to drug–drug and drug– Opioid Prescribing: A Systematic Review and disease interactions; and use of risk assessment Critical Appraisal of Guidelines for Chronic Pain. tools, treatment agreements, and urine drug test- Teryl K. Nuckols, Laura Anderson, Ioana Popescu. ing. Future research should directly examine the 2014 effectiveness of opioid risk mitigation strategies. BACKGROUND: Deaths due to prescription opioid overdoses have increased dramatically. EP-51671 ISOQOL Recommends Minimum Standards High-quality guidelines could help clinicians miti- for Patient-Reported Outcome Measures Used in gate risks associated with opioid therapy. PUR- Patient-Centered Outcomes and Comparative Ef- POSE: To evaluate the quality and content of fectiveness Research. Bryce B. Reeve, Kathleen guidelines on the use of opioids for chronic pain. W. Wyrwich, Albert W. Wu. 2014 DATA SOURCES: MEDLINE, National Guideline Clearinghouse, specialty society Web sites, and PURPOSE: An essential aspect of patient-cen- international guideline clearinghouses (searched tered outcomes research (PCOR) and compara- in July 2013). STUDY SELECTION: Guidelines tive effectiveness research (CER) is the integra- published between January 2007 and July 2013 tion of patient perspectives and experiences with addressing the use of opioids for chronic pain in clinical data to evaluate interventions. Thus, PCOR adults were selected. Guidelines on specific set- and CER require capturing patient-reported out- tings, populations, and conditions were excluded. come (PRO) data appropriately to inform research, DATA EXTRACTION: Guidelines and associated healthcare delivery, and policy. This initiative's goal systematic reviews were evaluated using the Ap- was to identify minimum standards for the design praisal of Guidelines for Research and Evaluation and selection of a PRO measure for use in PCOR 245 and CER. METHODS: We performed a literature ber of walking trips with Kappa statistics and count review to find existing guidelines for the selection regression models, while agreement in locations of PRO measures. We also conducted an online visited by walking was examined with geographic survey of the International Society for Quality of information systems. RESULTS: Agreement var- Life Research (ISOQOL) membership to solicit in- ied based on the parameters of the algorithm, put on PRO standards. A standard was designat- with algorithms exhibiting moderate to substan- ed as "recommended" when >50% tial agreement with self-reported daily (Kappa respondents endorsed it as "required as = 0.33–0.48) and weekly (Kappa = 0.41–0.64) a minimum standard." RESULTS: The lit- walking trips. Comparison of reported locations erature review identified 387 articles. Survey re- reached by walking and GPS data suggest that sponse rate was 120 of 506 ISOQOL members. reported locations are accurate. CONCLUSIONS: The respondents had an average of 15 years ex- The use of GPS and accelerometers is promising perience in PRO research, and 89% felt compe- for assessing the number of walking trips and the tent or very competent providing feedback. Final walking locations of adolescent females. recommendations for PRO measure standards included: documentation of the conceptual and EP-51673 measurement model; evidence for reliability, valid- Developing an Item Bank and Short Forms That ity (content validity, construct validity, responsive- Assess the Impact of Asthma on Quality of Life. ness); interpretability of scores; quality translation, Brian D. Stucky, Maria Orlando Edelen, Cathy D. and acceptable patient and investigator burden. Sherbourne. 2014 CONCLUSION: The development of these mini- The present work describes the process of de- mum measurement standards is intended to pro- veloping an item bank and short forms that mea- mote the appropriate use of PRO measures to in- sure the impact of asthma on quality of life (QoL) form PCOR and CER, which in turn can improve that avoids confounding QoL with asthma symp- the effectiveness and efficiency of healthcare tomatology and functional impairment. Using a di- delivery. A next step is to expand these minimum verse national sample of adults with asthma (N = standards to identify best practices for selecting 2032) we conducted exploratory and confirmatory decision-relevant PRO measures. factor analyses, and item response theory and differential item functioning analyses to develop a 65- EP-51672 item unidimensional item bank and separate short Identifying Walking Trips from GPS and Ac- form assessments. A psychometric evaluation of celerometer Data in Adolescent Females. Daniel the RAND Impact of Asthma on QoL item bank Rodriguez, Gi-Hyoug Cho, John Elder. 2014 (RAND-IAQL) suggests that though the concept BACKGROUND: Studies that have combined of asthma impact on QoL is multi-faceted, it may accelerometers and global positioning systems be measured as a single underlying construct. (GPS) to identify walking have done so in carefully The performance of the bank was then evaluated controlled conditions. This study tested algorithms with a real-data simulated computer adaptive test. for identifying walking trips from accelerometer From the RAND-IAQL item bank we then devel- and GPS data in free-living conditions. The study oped two short forms consisting of 4 and 12 items also assessed the accuracy of the locations where (reliability = 0.86 and 0.93, respectively). A real- walking occurred compared with what participants data simulated computer adaptive test suggests reported in a diary. METHODS: A convenience that as few as 4–5 items from the bank are needed sample of high school females was recruited (N = to obtain highly precise scores. Preliminary valid- 42) in 2007. Participants wore a GPS unit and an ity results indicate that the RAND-IAQL measures accelerometer, and recorded their out-of-school distinguish between levels of asthma control. To travel for 6 days. Split-sample validation was used measure the impact of asthma on QoL, users of to examine agreement in the daily and total num- these items may choose from two highly reliable 246 short forms, computer adaptive test administra- reductions in days, deaths, and adverse outcomes. tion, or content-specific subsets of items from the Raising the proportion of nursing hours provided bank tailored to their specific needs. by registered nurses (RNs) without increasing total nursing hours is associated with a net reduction in EP-51674 costs. Increasing nursing hours, with or without in- Physical Activity Surveillance in Parks Using creasing the proportion of hours provided by RNs, Direct Observation. Phillip Ward, Thomas L. McK- reduces days, adverse outcomes, and patient enzie, Deborah A. Cohen. 2014 deaths, but with a net increase in hospital costs INTRODUCTION: Primary features of obser- of 1.5 percent or less at the staffing levels mod- vational public health surveillance instruments are eled. Whether or not staffing should be increased that they are valid, can reliably estimate physical depends on the value patients and payers assign activity behaviors, and are useful across diverse to avoided deaths and complications. geographic settings and seasons by different users. Previous studies have reported the validity EP-51676 and reliability of Systematic Observation of Play Nurse-Staffing Levels and the Quality of Care and Recreation in Communities (SOPARC) to es- in Hospitals. Jack Needleman, Peter Buerhaus, timate park and user characteristics. The purpose Soeren Mattke. 2014 of this investigation was to establish the use of BACKGROUND: It is uncertain whether lower SOPARC as a surveillance instrument and to situ- levels of staffing by nurses at hospitals are as- ate the findings from the study in the context of sociated with an increased risk that patients will the previous literature. METHODS: We collected have complications or die. METHODS: We used data by using SOPARC for more than 3 years in 4 administrative data from 1997 for 799 hospitals in locations: Philadelphia, Pennsylvania; Columbus, 11 states (covering 5,075,969 discharges of medi- Ohio; Chapel Hill/Durham, North Carolina; and Al- cal patients and 1,104,659 discharges of surgi- buquerque, New Mexico during spring, summer, cal patients) to examine the relation between the and autumn. RESULTS: We observed a total of amount of care provided by nurses at the hospital 35,990 park users with an overall observer reliabil- and patients' outcomes. We conducted regres- ity of 94% (range, 85%–99%) conducted on 15% sion analyses in which we controlled for patients' of the observations. We monitored the proportion risk of adverse outcomes, differences in the nurs- of park users engaging in moderate-to-vigorous ing care needed for each hospital's patients, and physical activity (MVPA) and found marginal dif- other variables. RESULTS: The mean number of ferences in MVPA by both city and season. Park hours of nursing care per patient-day was 11.4, of users visited parks significantly more on weekend which 7.8 hours were provided by registered nurs- days than weekdays and visitation rates tended to es, 1.2 hours by licensed practical nurses, and 2.4 be lower during summer than spring. CONCLU- hours by nurses' aides. Among medical patients, SION: SOPARC is a highly reliable observation a higher proportion of hours of care per day pro- instrument that can be used to collect data across vided by registered nurses and a greater abso- diverse geographic settings and seasons by dif- lute number of hours of care per day provided by ferent users and has potential as a surveillance registered nurses were associated with a shorter system. length of stay (P=0.01 and P<0.001, respectively) and lower rates of both urinary tract infections EP-51675 (P<0.001 and P=0.003, respectively) and upper Nurse Staffing in Hospitals: Is There a Busi- gastrointestinal bleeding (P=0.03 and P=0.007, re- ness Case for Quality?. Jack Needleman, Peter spectively). A higher proportion of hours of care Buerhaus, Maureen Stewart. 2014 provided by registered nurses was also associated We construct national estimates of the cost of with lower rates of pneumonia (P=0.001), shock increasing hospital nurse staffing and associated or cardiac arrest (P=0.007), and "failure to 247 rescue," which was defined as death from exclusions of high-cost conditions and claims, pneumonia, shock or cardiac arrest, upper gastro- and the length of the baseline period for deter- intestinal bleeding, sepsis, or deep venous throm- mined health care costs. A pre-post study design bosis (P=0.05). Among surgical patients, a higher was used. The data for this research came from 2 proportion of care provided by registered nurses large employers in the consumer goods industry was associated with lower rates of urinary tract in- with comprehensive Health and Productivity Man- fections (P=0.04), and a greater number of hours agement programs. It contained medical and pre- of care per day provided by registered nurses scription drug claims and health plan enrollment was associated with lower rates of "failure data as well as program activity data from 2001 to rescue" (P=0.008). We found no associa- to 2005, covering an average yearly sample size tions between increased levels of staffing by reg- of 201,037 members with 12 consecutive months istered nurses and the rate of in-hospital death or of enrollment. Analyses were done on group-level between increased staffing by licensed practical averages using nominal cost data and were run to nurses or nurses' aides and the rate of adverse reflect the impact of a DM-only intervention. While outcomes. CONCLUSIONS: A higher proportion the trend estimate and length of baseline had the of hours of nursing care provided by registered largest effects on estimated program impact, the nurses and a greater number of hours of care by use of exclusions had an important effect as well. registered nurses per day are associated with bet- These findings demonstrate the importance of deter care for hospitalized patients. veloping and instituting a standardized evaluation methodology. Without increasing consistency in EP-51677 the way evaluators develop their methodologies, What Is the Risk of Developing Parkinsonism it will remain difficult to be able to compare one Following Neuroleptic Use?. Katia Noyes, Hang- evaluation to another, or to have faith in the results sheng Liu, Robert G. Holloway. 2014 at hand. Use of neuroleptic medications is common among elderly patients. Using multivariate models, EP-51679 The Effect of Surgical Care Improvement Proj- the authors found that use of antipsychotic medi- ect (SCIP) Compliance on Surgical Site Infections cations, age, and disability were strong predictors (SSI). Guido Cataife, Daniel Weinberg, Hui-Hsing of developing self-reported Parkinson disease Wong. 2014 (PD) in the subsequent year among 1992 to 2000 Medicare Current Beneficiary Survey participants. BACKGROUND: The Surgical Care Improve- Although more research is needed, these data ment Project (SCIP) has developed a set of pro- suggest that 126 Medicare beneficiaries would cess compliance measures in an attempt to re- need to be treated with neuroleptic medications duce the incidence of surgical site infections to cause one additional case of self-reported PD. (SSIs). Previous research has been inconclusive on whether compliance with these measures is EP-51678 associated with lower SSI rates. OBJECTIVES: Testing the DMAA's Recommendations for To determine whether hospitals with higher levels Disease Management Program Evaluation. Seth of compliance with SCIP measures have lower Serxner, Soeren Mattke, Sarah Zakowski. 2014 incidence of SSIs and to identify the measures The objective of this study was to compare that are most likely to drive this association. DATA and contrast findings regarding the financial sav- AND METHODS: Analysis of linked SCIP compli- ings projections of the disease management (DM) ance rates and SSIs on 295 hospital groups ob- programs of 2 large employers based on different served annually over the study period 2007–2010. evaluation methods. In particular, this research A hospital group comprises all hospitals sharing tests the impact of differences in assumptions on the underlying growth rate of group health costs, 248 identical categories for location by state, teach- professional case for patient experience and ening status, bed size, and urban/rural location. hancing the content and timing of performance re- We used a generalized linear model regression ports may be important. with logistic link and binomial family to estimate the association between 3 SCIP measures and EP-51681 SSI rates. RESULTS: Hospital groups with higher The Supplemental Nutrition Assistance Pro- compliance rates had significantly lower SSI rates gram and Material Hardships Among Low-Income for 2 SCIP measures: antibiotic timing and appro- Households with Children. H. Luke Shaefer, Italo priate antibiotic selection. For a hospital group of Gutierrez. 2014 median characteristics, a 10% improvement in the This study estimates the effects of participa- measure provision of antibiotic 1 hour before in- tion in the Supplemental Nutrition Assistance tervention led to a 5.3% decrease in the SSI rates Program (SNAP) on the risk of food as well as (P<0.05). Rural hospitals had effect sizes sev- nonfood material hardships experienced by low- eral times larger than urban hospitals (P<0.05). income households with children. Data are drawn A third-core measure, Timely Antibiotic Stop, from the 1996, 2001, and 2004 panels of the Sur- showed no robust association. CONCLUSIONS: vey of Income and Program Participation (SIPP). This analysis supports a clinically and statistically We examine the relationship between SNAP and meaningful relationship between adherence to 2 material hardships by modeling jointly the likeli- SCIP measures and SSI rates, supporting the va- hood of household participation in SNAP and the lidity of the 2 publicly available healthcare–associ- risk of experiencing material hardships using a ated infection metrics. bivariate probit model. We estimate that SNAP reduces household food insecurity by 12.8 percent- EP-51680 age points, reduces the risk that households will Motivators and Barriers to Using Patient Ex- fall behind on their nonfood essential expenses, perience Reports for Performance Improvement. including housing (by 7.2 percentage points) and Kimberley H. Geissler, Mark W. Friedberg, Gillian utilities (by 15.3 percentage points), and reduces K. Steelfisher. 2014 the risk of medical hardship (by 8.5 percentage Increasingly, patient experience surveys are points). available to provide performance feedback to physician groups. However, limited published lit- EP-51682 erature addresses factors influencing use of these The National Response for Preventing Health- reports for performance improvement. To address care-Associated Infections: Data and Monitoring. this gap, we conducted semistructured interviews Katherine L. Kahn, Daniel Weinberg, Kristin J. with leaders of Massachusetts physician groups. Leuschner. 2014 We asked about factors influencing groups' use BACKGROUND: Historically, the ability to ac- of performance data and report characteristics. curately track healthcare–associated infections Motivating characteristics included having group (HAIs) was hindered due to a lack of coordination leaders who emphasized a positive patient expe- among data sources and shortcomings in individ- rience and prioritized patient retention; public re- ual data sources. OBJECTIVES: This paper pres- porting was not an important motivator for most ents the results of the evaluation of the HAI data groups. Full physician panels were perceived as and the monitoring component of the Action Plan, a barrier to use of reports. Performance reports focusing on context (goals), inputs, and process- from a statewide public reporting collaborative es. RESEARCH DESIGN: We used the Content- were not sufficient for the majority of groups, with Input-Process-Product framework, together with many seeking external reports. As policy makers the HAI prevention system framework, to describe create financial incentives to support performance the transformative processes associated with data improvement, assisting leaders to articulate the 249 and monitoring efforts. RESULTS: Six HAI priority HAIs, in 2009 HHS released the HHS National Ac- conditions in the 2009 Action Plan created a focus tion Plan to Prevent Healthcare-associated Infec- for the selection of goals and activities. Key Ac- tions, which was updated and expanded in 2012. tion Plan decisions included a phased-in data and The Action Plan established national goals for monitoring approach, commitment to linking the HAI prevention and identified key actions needed selection of priority HAIs to highly visible national to reduce, prevent, and eventually eliminate the 5-year prevention targets, and the development of burden posed by HAIs. CONCLUSIONS: Broad a comprehensive HAI database inventory. Remain- lessons learned from the Action Plan evaluation ing challenges relate to data validation, resources, document changes in structures, processes, and and the opportunity to integrate electronic health outcomes pertinent to eradicating HAIs, and iden- and laboratory records with other provider data tify lessons that are applicable to other large fed- systems. CONCLUSIONS: The Action Plan's data eral implementation efforts. and monitoring program has developed a sound EP-51684 infrastructure that builds upon technological ad- Lessons learned and future directions: the vances and embodies a firm commitment to pri- national response for preventing healthcare- oritization, coordination and alignment, account- associated infections. Peter Mendel. 2014 ability and incentives, stakeholder engagement, In this special issue, we have described re- and an awareness of the need for predictable sults from the IMPAQ-RAND team's formal longi- resources. With time, and adequate resources, it tudinal evaluation of HHS's National Action Plan is likely that the investment in data-related infra- to Prevent Healthcare-associated Infections and structure during the Action Plan's initial years will have discussed efforts to address healthcare–as- reap great rewards. sociated infections (HAIs) at the state, regional, and local levels. In this final article, we take a step EP-51683 back to consider briefly the overall impact of the Introduction: Taking National Action to Prevent Action Plan and to describe some possible future and Eliminate Healthcare-Associated Infections. directions for addressing HAIs. Katherine L. Kahn, James B. Battles. 2014 BACKGROUND: The widespread prevalence EP-51685 and enormous cost of healthcare–associated in- Approach for Conducting the Longitudinal Pro- fections (HAIs) constitute a major public health gram Evaluation of the U.S. Department of Health problem and patient safety concern. OBJEC- and Human Services National Action Plan to Pre- TIVES: In 2009, IMPAQ International and the vent Healthcare Associated Infections: Roadmap RAND Corporation initiated an independent, out- to Elimination. Katherine L. Kahn, Peter Mendel, side evaluation of Health and Human Services' Daniel Weinberg. 2014 HAI prevention efforts as guided and driven by BACKGROUND: In response to mounting the Action Plan. The 3-year evaluation, whose evidence about skyrocketing morbidity, mortality, findings are presented in this special issue, was and costs associated with healthcare–associated intended to assess the outcomes of the US De- infections (HAIs), in 2009, the US Department of partment of Health and Human Services' (HHS's) Health and Human Services (HHS) issued the past efforts, and also to provide ongoing, forma- HHS HAI Action Plan to enhance collaboration tive feedback to Action Plan leadership to guide and coordination and to strengthen the impact of their efforts. RESEARCH DESIGN: This special national efforts to address HAIs. To optimize time- issue presents results from the evaluation of the ly understanding of the Action Plan's approach Action Plan, along with related articles intended and outcomes, as well as improve the likely suc- to examine the issue of HAIs from many angles. cess of this effort, HHS requested an independent RESULTS: To address the national epidemic of longitudinal and formative program evaluation. OBJECTIVES: This article describes the evalua- 250 tion approach to assessing HHS's progress and with worse mental and physical health, greater the challenges encountered as HHS attempted depression symptoms, and lower self-worth over to transform the national strategy to HAI elimina- time. Health was significantly worse for children tion. RESEARCH DESIGN: The Context-Input- with both past and present bullying experiences, Process-Product (CIPP) model, a structured-yet- followed by children with present-only experienc- flexible formative and summative evaluation tool, es, children with past-only experiences, and chil- supported the assessment of: (1) the Context in dren with no experiences. For example, 44.6% of which the Action Plan developed, (2) the Inputs children bullied in both the past and present were and decisions made about selecting activities for at the lowest decile of psychosocial health, com- implementation, (3) Processes or implementation pared with 30.7% of those bullied in the present of selected activities, and (4) Products and out- only (P = .005), 12.1% of those bullied in the past comes. MEASURES: A system framework consist- only (P < .001), and 6.5% of those who had not ing of 4 system functions and 5 system properties. been bullied (P < .001). CONCLUSIONS: Both RESULTS: The CIPP evaluation model provides a chronic and current bullying are associated with structure for tracking the components of the pro- substantially worse health. Clinicians who recog- gram, the relationship between components, and nize bullying when it first starts could intervene the way in which components change with time. to reverse the downward health trajectory experi- The system framework allows the evaluation team enced by youth who are repeated targets. to understand what the Action Plan is doing and how it aims to facilitate change in the healthcare EP-51719 system to address the problem of HAIs. CONCLU- Peer Support Services for Individuals with Se- SIONS: With coordination and alignment becom- rious Mental Illnesses: Assessing the Evidence. ing increasingly important among large programs Matthew Chinman, Preethy George, Richard H. within healthcare and other fields, program evalu- Dougherty. 2014 ations like this can inform the policy community OBJECTIVE: This review assessed the level of about what works and why, and how future com- evidence and effectiveness of peer support ser- plex large-scale programs should be evaluated. vices delivered by individuals in recovery to those with serious mental illnesses or co-occurring EP-51718 mental and substance use disorders. METHODS: Peer victimization in fifth grade and health in Authors searched PubMed, PsycINFO, Applied tenth grade. Marc N. Elliott. 2014 Social Sciences Index and Abstracts, Sociological BACKGROUND AND OBJECTIVES: Children Abstracts, Social Services Abstracts, Published who experience bullying, a type of peer victimiza- International Literature on Traumatic Stress, the tion, show worse mental and physical health cross- Educational Resources Information Center, and sectionally. Few studies have assessed these rela- the Cumulative Index to Nursing and Allied Health tionships longitudinally. We examined longitudinal Literature for outcome studies of peer support associations of bullying with mental and physical services from 1995 through 2012. They found 20 health from elementary to high school, comparing studies across three service types: peers added effects of different bullying histories. METHODS: to traditional services, peers in existing clinical We analyzed data from 4297 children surveyed at roles, and peers delivering structured curricula. 3 time points (fifth, seventh, and tenth grades) in Authors judged the methodological quality of the 3 cities. We used multivariable regressions to test studies using three levels of evidence (high, mod- longitudinal associations of bullying with mental erate, and low). They also described the evidence and physical health by comparing youth who ex- of service effectiveness. RESULTS: The level of perienced bullying in both the past and present, evidence for each type of peer support service experienced bullying in the present only, experi- was moderate. Many studies had methodological enced bullying in the past only, or did not experi- shortcomings, and outcome measures varied. The ence bullying. RESULTS: Bullying was associated 251 effectiveness varied by service type. Across the likely due to organized physical activities, the BMI range of methodological rigor, a majority of stud- and obesity results suggest that the deterioration ies of two service types—peers added and peers in diet and increase in sedentary behaviors domi- delivering curricula—showed some improvement nate. favoring peers. Compared with professional staff, peers were better able to reduce inpatient use and EP-51723 improve a range of recovery outcomes, although Good friends, good food ... what more could one study found a negative impact. Effectiveness we want? Assessing the links between social rela- of peers in existing clinical roles was mixed. CON- tionships and dietary behaviors. A commentary on CLUSIONS: Peer support services have demon- Conklin et al.. 2014 strated many notable outcomes. However, studies This commentary on Conklin, et al, "Social that better differentiate the contributions of the relationships and healthful dietary behaviour: peer role and are conducted with greater speci- evidence from over-50s in the EPIC cohort, UK ficity, consistency, and rigor would strengthen the (Social Science and Medicine, 2013) explores the evidence. contributions made by the article to understanding how spouses and friends influence our food EP-51720 choices, and calls for further research to for inves- Maternal Work and Children's Diet, Activity, and tigate more closely the mechanisms underlying Obesity. Ashlesha Datar, Nancy Nicosia, Victoria this influence. Shier. 2014 Mothers' work hours are likely to affect their EP-51724 time allocation towards activities related to chil- Surgical site infections following ambulatory dren's diet, activity and well-being. For example, surgery procedures. Marguerite L. Barrett, Susan mothers who work more may be more reliant on O. Raetzman. 2014 processed foods, foods prepared away from home IMPORTANCE: Surgical site infections can and school meal programs for their children's result in substantial morbidity following inpatient meals. A greater number of work hours may also surgery. Little is known about serious infections lead to more unsupervised time for children that following ambulatory surgery. OBJECTIVE: To may, in turn, allow for an increase in unhealthy determine the incidence of clinically significant behaviors among their children such as snacking surgical site infections (CS-SSIs) following low- to and sedentary activities such as TV watching. Us- moderate-risk ambulatory surgery in patients with ing data on a national cohort of children, we ex- low risk for surgical complications. DESIGN, SET- amine the relationship between mothers' average TING, AND PARTICIPANTS: Retrospective analy- weekly work hours during their children's school sis of ambulatory surgical procedures complicat- years on children's dietary and activity behaviors, ed by CS-SSIs that require a postsurgical acute BMI and obesity in 5th and 8th grade. Our results care visit (defined as subsequent hospitalization are consistent with findings from the literature that or ambulatory surgical visit for infection) using the maternal work hours are positively associated 2010 Healthcare Cost and Utilization Project State with children's BMI and obesity especially among Ambulatory Surgery and State Inpatient Databas- children with higher socioeconomic status. Unlike es for 8 geographically dispersed states (Califor- previous papers, our detailed data on children's nia, Florida, Georgia, Hawaii, Missouri, Nebraska, behaviors allow us to speak directly to affected New York, and Tennessee) representing one- behaviors that may contribute to the increased third of the US population. Index cases included BMI. We show that children whose mothers work 284 098 ambulatory surgical procedures more consume more unhealthy foods (e.g. soda, (general surgery, orthopedic, neurosurgical, gy- fast food) and less healthy foods (e.g. fruits, veg- necologic, and urologic) in adult patients with low etables, milk) and watch more television. Although they report being slightly more physically active, 252 surgical risk (defined as not seen in past 30 days influence (65%). Additionally, the production of in acute care, length of stay less than 2 days, no more positive partner statements was associated other surgery on the same day, and discharged with better treatment outcome (using the Insom- home and no infection coded on the same day). nia Severity Index). The integration of perceived MAIN OUTCOMES AND MEASURES: Rates of partner alliance into CBT-I is discussed. 14- and 30-day postsurgical acute care visits for CS-SSIs following ambulatory surgery. RESULTS: EP-51727 Postsurgical acute care visits for CS-SSIs occurred Fluid consumption by Mexican women during in 3.09 (95% CI, 2.89-3.30) per 1000 ambulatory pregnancy and first semester of lactation. 2014 surgical procedures at 14 days and 4.84 (95% CI, The objective of this study was to describe daily 4.59-5.10) per 1000 at 30 days. Two-thirds (63.7%) fluid consumption in a sample of pregnant or lac- of all visits for CS-SSI occurred within 14 days tating adult women. Women between 18 and 45 of the surgery; of those visits, 93.2% (95% CI, years of age, residents of Mexico City, stratified by 91.3%-94.7%) involved treatment in the inpatient socioeconomic status were asked to register their setting. All-cause inpatient or outpatient postsurgi- total fluid intake during 7 consecutive days. A total cal visits, including those for CS-SSIs, following of 153 pregnant and 155 lactating women were ambulatory surgery occurred in 19.99 (95% CI, recruited. On average, they drank 2.62 L/ 19.48-20.51) per 1000 ambulatory surgical proce- day and 2.75 L/day, respectively. Forty- dures at 14 days and 33.62 (95% CI, 32.96-34.29) one percent of pregnant women drank less than per 1000 at 30 days. CONCLUSIONS AND REL- the recommended 2.3 L fluids/day, and EVANCE: Among patients in 8 states undergoing 54% of women drank less than the recommended ambulatory surgery, rates of postsurgical visits for intake of 2.7 L/day during the first semes- CS-SSIs were low relative to all causes; however, ter of lactation. Plain water contributed to 33% of they may represent a substantial number of ad- total fluid intake, and sugar-sweetened beverages verse outcomes in aggregate. Thus, these seri- (SSB) contributed to 38% of total fluid intake. Up to ous infections merit quality improvement efforts to 50% of pregnant and lactating women drank more minimize their occurrence. than 1 L/day of SSB, which contributed to 632 kcal/day (27.5% of recommended EP-51725 dietary intake) and to 700 kcal/day (28% The role of perceived partner alliance on the ef- of recommended dietary intake), respectively. ficacy of CBT-I: preliminary findings from the Part- The high rates of overweight and obesity found in ner Alliance in Insomnia Research Study (PAIRS). Mexican population, particularly among women, Vincent Deary, Wendy M. Troxel. 2014 should alert us to the consumption of SSB during Despite cognitive behavioral therapy for insom- pregnancy and lactation, as excessive intake of nia (CBT-I) being effective, barriers to adherence these beverages may increase the risks of obesi- have been documented. Perceived partner alli- ty, diabetes mellitus, and other chronic disorders. ance has been shown to influence adherence and treatment outcome across a range of other health EP-51728 conditions. The present study examined patients' Early puberty, negative peer influence, and perceptions regarding the role of their partner in problem behaviors in adolescent girls. Marc N. CBT-I and the impact of perceived partner alliance Elliott. 2014 on treatment outcome. Twenty-one patients were OBJECTIVE: To determine how early puberty interviewed, following CBT-I, to examine the areas and peer deviance relate to trajectories of aggres- where partners were thought to influence the pro- sive and delinquent behavior in early adolescence cess of CBT-I. The majority of statements made and whether these relationships differ by race/eth- during interviews explicitly mentioned a partner's nicity. METHODS: In this longitudinal study, 2607 253 girls from 3 metropolitan areas and their parents addressed existing and emerging evidence in the were interviewed at ages 11, 13, and 16 years. field. This review and analysis provide a context for Girls reported on their age of onset of menarche, how 9 accompanying papers in this supplemental best friend's deviant behavior, delinquency, and issue of The Gerontologist fill identified evidence physical, relational, and nonphysical aggression. gaps and provide evidence for future practice and Parents provided information on family sociode- policies that aim to transform nursing home cul- mographic characteristics and girls' race/ethnicity. ture. RESULTS: Sixteen percent of girls were classified EP-51731 as early maturers (defined by onset of menarche Criminal justice costs of prohibiting marijuana before age 11 years). Overall, relational and non- in California. Beau Kilmer. 2014 physical aggression increased from age 11 to age A common argument for legalizing marijuana is 16, whereas delinquency and physical aggression that it would save the criminal justice system time remained stable. Early puberty was associated and resources; however, there is a lot of uncer- with elevated delinquency and physical aggres- tainty about how many resources are dedicated to sion at age 11. The relationship with early puberty prohibiting marijuana. For California, the existing diminished over time for physical aggression but estimates range from $200 million to almost $2 not for delinquency. Best friend's deviant behavior billion a year. This chapter assesses these previ- was linked with higher levels of all problem be- ous efforts and describes a bottom-up approach haviors, but the effect lessened over time for most to estimate the criminal justice costs of prohibiting outcomes. Early puberty was associated with a marijuana in California. Since most legalization stronger link between best friend's deviance and proposals keep marijuana illegal for those under delinquency, suggesting increased vulnerability to 21 (a group that accounts for roughly 45% of all negative peer influences among early-maturing marijuana arrests in California), we only estimate girls. A similar vulnerability was observed for re- the costs associated with prohibiting marijuana for lational and nonphysical aggression among girls those 21 and older. This chapter finds that enforc- in the "other" racial/ethnic minority group only. ing marijuana prohibition against adults cost the CONCLUSIONS: Early puberty and friends' devi- California criminal justice system approximately ance may increase the risk of problem behavior in $150 million in 2010. Since SB 1449 went into ef- young adolescent girls. Although many of these fect on January 1, 2011 and eliminated bookings associations dissipate over time, early-maturing and court cases for those caught with less than girls are at risk of persistently higher delinquency one ounce of marijuana, these 2010 figures may and stronger negative peer influences. overstate the current cost of prohibiting marijuana for adults in California. EP-51730 EP-51732 Transforming nurse home culture: evidence for Measuring Agreement Between Egos and practice and policy. Victoria Shier. 2014 Alters: Understanding Informant Accuracy in Per- The nursing home culture change movement sonal Network Studies. Harold D. Green, Matthew aims to improve resident quality of life and quality Hoover, Glenn Wagner. 2014 of care by emphasizing the deinstitutionalization In personal network studies, respondents (egos) of nursing home culture and focusing on person- are asked to report information about members centered care. This article briefly reviews the his- of their personal network (alters); egos respond tory of culture change, discusses some of the based on their perceptions. Previous studies of in- challenges related to culture change in nursing formant accuracy present a varied picture: Some homes, and overviews the conceptualization and find egos' reporting on their relationships with al- select models of culture change. Building from ters to be accurate; others do not. In our study of this background, it critiques current understand- people living with HIV/AIDS in Uganda, egos were ing, identifies critical research questions, and asked to invite up to four alters named during their notes key issues arising during a workshop that 254 interview to answer questions about their relation- mance distribution should be examined. ship with ego. Using Gower's general coefficient of similarity, we calculated a measure of accuracy EP-51734 both by variable and by alter. Our analysis by vari- What does the evidence really say about culture able tends to confirm informant accuracy research, change in nursing homes?. Dmitry Khodyakov. while our analysis by alter adds to the literature by 2014 identifying how accurate a particular ego is when PURPOSE OF THE STUDY: Although nursing discussing an alter and what characteristics might home culture change efforts are becoming more be associated with accuracy or inaccuracy. widespread, there have been few efforts to systematically compile the evidence related to the ef- EP-51733 ficacy of culture change. This study uses an ana- Statistical benchmarks for health care pro- lytic framework to evaluate the existing evidence vider performance assessment: a comparison of for the impact of culture change on nursing home standard approaches to a hierarchical Bayesian quality. We focus on the nature and scope of cul- histogram-based method. 2014 ture change interventions, measurement of cul- OBJECTIVE: Examine how widely used statis- ture change and adherence to interventions, mea- tical benchmarks of health care provider perfor- surement of culture change outcomes, and the mance compare with histogram-based statistical relationship between culture change and its out- benchmarks obtained via hierarchical Bayesian comes. DESIGN AND METHODS: We conducted modeling. DATA SOURCES: Publicly available a comprehensive review of peer-reviewed and data from 3,240 hospitals during April 2009– gray literature published between 2005 and 2012 March 2010 on two process-of-care measures to identify intervention evaluations that addressed reported on the Medicare Hospital Compare web- at least one culture change domain. Of 4,982 site. STUDY DESIGN: Secondary data analyses of identified publications, 625 underwent full review; two process-of-care measures comparing statisti- 27 peer-reviewed and 9 gray literature studies met cal benchmark estimates and threshold exceed- inclusion criteria. RESULTS: Studies varied wide- ance determinations under various combinations ly in scope and outcomes. Most addressed more of hospital performance measure estimates and than one culture change domain; resident direc- benchmarking approaches. PRINCIPAL FIND- tion, home environment, and close relationships INGS: Statistical benchmarking approaches for were most common. Few studies measured cul- determining top 10 percent performance varied ture change implementation, but most used vali- with respect to which hospitals exceeded the per- dated tools to measure outcomes. Although few formance benchmark; such differences were not studies reported negative outcomes, there was found at the 50 percent threshold. Benchmarks little consistent evidence of positive effects. IMPLI- derived from the histogram of provider perfor- CATIONS: Nursing home culture change remains mance under hierarchical Bayesian modeling pro- an evolving field. Although culture change has vide a compromise between benchmarks based clear face validity, the current evidence does not on direct (raw) estimates, which are overdispersed give providers sufficient information for selecting relative to the true distribution of provider perfor- interventions based on the expectation of improv- mance and prone to high variance for small pro- ing outcomes. Rigorous research on implementa- viders, and posterior mean provider performance, tion and outcomes of culture change is needed to for which over-shrinkage and under-dispersion rel- determine the specific impact of culture change ative to the true provider performance distribution on quality and to provide guidance to providers is a concern. CONCLUSIONS: Given the rewards and policy makers. and penalties associated with characterizing top performance, the ability of statistical benchmarks EP-51736 to summarize key features of the provider perfor- 255

PROMIS Pediatric Peer Relationships Scale: goal of this study was to use bifactor modeling to development of a peer relationships item bank as derive a unidimensional DCI-A short-form (DCI-A- part of social health measurement. David This- SF) that would represent content from the original sen, Brian D. Stucky. 2014 DCI-A factors. Data are from 442 adolescents re- OBJECTIVE: This study's objective was to devel- ceiving treatment at one of seven residential TC op a measure of social health using item response programs. Bifactor analyses suggested selection theory as part of the Patient Reported Outcomes of seven DCI-A items to comprise the short form. Measurement Information System (PROMIS). Three items are from the treatment motivation fac- METHODS: After candidate items were generated tor, and one item was selected from each of the from review of prior literature, focus groups, expert remaining four factors. Confirmatory factor analy- input, and cognitive interviews, items were admin- sis suggested that the 7-item DCI-A-SF is strongly istered to youth aged 8–17 as part of the PRO- unidimensional, and unidimensional IRT analysis MIS pediatric large scale testing. Exploratory and of the items indicated good internal consistency. confirmatory factor analyses were used to assess A structural equation model that demonstrates dimensionality and to identify instances of local the mediating relationship of DCI-A-SF with other dependence. Items that met the unidimensional- measures, including demographic and pre-treat- ity criteria were subsequently calibrated using ment characteristics, and subsequent treatment Samejima's Graded Response Model. Differen- completion, provides preliminary evidence of in- tial item functioning was examined by gender and ternal validity. age. RESULTS: The sample included 3,048 youth EP-51738 who completed the questionnaire (51.8% female, Psychometric Properties of the PROMIS® Pedi- 60% white, and 22.7% with chronic illness). The atric Scales: Precision, Stability, and Comparison initial conceptualization of social function and so- of Different Scoring and Administration Options. ciability did not yield unidimensional item banks. James W. Varni, Brooke Magnus, Brian D. Stucky. Rather, factor analysis revealed dimensions con- 2014 trasting peer relationships and adult relationships. The analysis also identified dimensions formed by OBJECTIVES: The objectives of the present responses to positively versus negatively worded study are to investigate the precision of static items. The resulting 15-item bank measures qual- (fixed-length) short forms versus computerized ity of peer relationships and has strong psycho- adaptive testing (CAT) administration, response metric characteristics as a full bank or an 8-item pattern scoring versus summed score conversion, short form. CONCLUSIONS: The PROMIS pedi- and test–retest reliability (stability) of the Patient- atric peer relationships scale demonstrates good Reported Outcomes Measurement Information psychometric characteristics and addresses an System (PROMIS®) pediatric self-report scales important aspect of child health. measuring the latent constructs of depressive EP-51737 symptoms, anxiety, anger, pain interference, peer The psychometric development and initial relationships, fatigue, mobility, upper extremity validation of the DCI-A short form for adolescent functioning, and asthma impact with polytomous therapeutic community treatment process. Maria items. METHODS: Participants (N = 331) be- Orlando Edelen. 2014 tween the ages of 8 and 17 were recruited from The 5-factor client-report Dimensions of outpatient general pediatrics and subspecialty Change in Therapeutic Communities Treatment clinics. Of the 331 participants, 137 were diag- Instrument-Adolescent (DCI-A) was developed nosed with asthma. Three scores based on item to assess adolescent substance abuse treatment response theory (IRT) were computed for each process in the therapeutic community (TC). The respondent: CAT response pattern expected a posteriori estimates, short-form response pattern expected a posteriori estimates, and short-form summed score expected a posteriori estimates. 256

Scores were also compared between participants rately using IRT: Tired and (Lack of) Energy, which with and without asthma. To examine test–retest consisted of 23 and 11 items, respectively; 10- and reliability, 54 children were selected for retesting 8-item short-forms were created. CONCLUSION: approximately 2 weeks after the first assessment. The PROMIS assessment of self-reported fatigue RESULTS: A short CAT (maximum 12 items with in pediatrics includes two item banks: Tired and a standard error of 0.4) was found, on average, (Lack of) Energy. Both demonstrated satisfactory to be less precise than the static short forms. The psychometric properties and can be used for re- CAT appears to have limited usefulness over and search settings. above what can be accomplished with the existing static short forms (8–10 items). Stability of the EP-51742 scale scores over a 2-week period was generally Small area estimation-based prediction meth- supported. CONCLUSION: The study provides ods to track poverty: validation and applications. further information on the psychometric proper- Peter Lanjouw, Jill E. Luoto. 2014 ties of the PROMIS pediatric scales and extends Tracking poverty is predicated on the availabil- the previous IRT analyses to include precision es- ity of comparable consumption data and reliable timates of dynamic versus static administration, price deflators. However, regular series of strictly test–retest reliability, and validity of administration comparable data are only rarely available. Price across groups. Both the positive and negative as- deflators are also often missing or disputed. In pects of using CAT versus short forms are high- response, poverty prediction methods that track lighted. consumption correlates as opposed to consumption itself have been developed. These methods EP-51739 typically assume that the estimated relation be- Development and psychometric properties of tween consumption and its predictors is stable over the PROMIS® pediatric fatigue item banks. Brian time—assumptions that cannot usually be tested D. Stucky. 2014 directly. This study analyzes the performance of PURPOSE: This paper reports on the develop- poverty prediction models based on small area ment and psychometric properties of self-reported estimation (SAE) techniques. Predicted poverty pediatric fatigue item banks as part of the Patient- estimates are compared with directly observed Reported Outcomes Measurement Information levels in two country settings where data compa- System (PROMIS). METHODS: Candidate items rability over time is not a problem. Prediction mod- were developed by using PROMIS qualitative els that employ either non-staple food or non-food methodology. The resulting 39 items (25 tiredness expenditures or a full set of assets as predictors related and 14 energy related) were field tested are found to yield poverty estimates that match in a sample that included 3,048 participants aged observed poverty well. This offers some support to 8–17 years. We used confirmatory factor analysis the use of such methods to approximate the evo- (CFA) to evaluate dimensionality and differential lution of poverty. Two further country examples il- item functioning (DIF) analysis to evaluate param- lustrate how an application of the method employ- eter stability between genders and by age; we ing models based on household assets can help examined residual correlations to evaluate local to adjudicate between alternative price deflators. dependence (LD) among items and estimated the parameters of item response theory (IRT) mod- EP-51743 els. RESULTS: Of 3,048 participants, 48 % were What point-of-use water treatment products males, 60 % were white, and 23 % had at least do consumers use? Evidence from a randomized one chronic condition. CFA results suggest two controlled trial among the urban poor in Bangla- moderately correlated factors. Two items were re- desh. Nusrat Najnin, Minhaj Mahmud. 2014 moved due to high LD, and three due to gender- BACKGROUND: There is evidence that house- based DIF. Two item banks were calibrated sepa- hold point-of-use (POU) water treatment prod- 257 ucts can reduce the enormous burden of water- tion and care, and community-based interventions borne illness. Nevertheless, adoption among the are needed. Here we describe the development of global poor is very low, and little evidence exists a multi-ethnic, faith-based intervention to reduce on why. METHODS: We gave 600 households HIV stigma that included: educational workshops in poor communities in Dhaka, Bangladesh ran- on HIV, testing, and stigma; peer leader work- domly-ordered two-month free trials of four water shops using role plays and drawing on principles treatment products: dilute liquid chlorine (sodium of motivational interviewing; a pastor-delivered hypochlorite solution, marketed locally as Wa- sermon on HIV that incorporated theological re- ter Guard), sodium dichloroisocyanurate tablets flection and an imagined contact scenario; and (branded as Aquatabs), a combined flocculant- congregation-based HIV testing events. Lessons disinfectant powdered mixture (the PUR Purifier learned include: partnership development is es- of Water), and a silver-coated ceramic siphon filter. sential and requires substantial investment; tailor- Consumers also received education on the dan- ing intervention components to single race-ethnic gers of untreated drinking water. We measured groups may not be preferable in diverse commu- which products consumers used with self-reports, nity settings; and adapting testing processes to be observation (for the filter), and chlorine tests (for able to serve larger numbers of people in shorter the other products). We also measured drinking time frames is needed for congregational settings. water's contamination with E. coli (compared to This development process successfully combined 200 control households). FINDINGS: Households the rigorous application of social science theory reported highest usage of the filter, although no and community engagement to yield a multifac- product had even 30% usage. E. coli concentra- eted HIV stigma reduction intervention appropri- tions in stored drinking water were generally low- ate for Protestant and Catholic churches in African est when households had Water Guard. House- American and Latino communities. holds that self-reported product usage had large reductions in E. coli concentrations with any prod- EP-51745 uct as compared to controls. CONCLUSION: Tra- Associations Among Body Size, Body Image ditional arguments for the low adoption of POU Perceptions, and Weight Loss Attempts Among products focus on affordability, consumers' lack African American, Latino, and White Youth: A Test of information about germs and the dangers of of a Mediational Model. Anna E. Epperson, Anna unsafe water, and specific products not meshing V. Song, Jan Wallander. 2014 with a household's preferences. In this study we OBJECTIVE: Little is known about influences provided free trials, repeated informational mes- on weight loss attempts, yet about one-half re- sages explaining the dangers of untreated water, port making such attempts during adolescence. and a variety of product designs. The low usage of The aim was to examine the relationships among all products despite such efforts makes clear that weight loss attempts, body size, and body percep- important barriers exist beyond cost, information, tion in racially/ethnically diverse young adoles- and variation among these four product designs. cents. METHODS: 3954 African American, Latino, Without a better understanding of the choices and and White 5th-graders completed the Self-Per- aspirations of the target end-users, household- ception Profile-Physical Appearance Scale and based water treatment is unlikely to reduce mor- questions regarding body perceptions and past bidity and mortality substantially in urban Bangla- and current weight loss attempts, and had their desh and similar populations. weight and height measured. RESULTS: Latino youth most often and White youth least often re- EP-51744 ported weight loss attempts. Larger body size and An intervention to reduce HIV-related stigma negative body perception were related to more re- in partnership with African American and Latino ported weight loss attempts in White and Latino churches. Laura M. Bogart. 2014 youth. Body perception mediated the relationship HIV-related stigma negatively affects preven- 258 between body size and weight loss attempts for were estimated using generalized boosted mod- White youth. CONCLUSION:&emsp;Motivat els. RESULTS: Each additional period of treat- ions to lose weight appear to differ among racial/ ment (representing at least one day, 1 session, or ethnic groups, suggesting that interventions for 1 BDS during the 90 day period between follow- healthy weight control in youth may need to target up visits) yielded reductions in average substance racial/ethnic groups differently. use frequency at 1-year relative to no treatment during the 90-day period. For residential treatment EP-51746 it was a 16% decrease (95% CI = −27%, Don't middle your MIDs: regression to the mean −7%), for outpatient treatment it was a 9% shrinks estimates of minimally important differ- decrease (95% CI = −18%, −0%), ences. Ron D. Hays. 2014 and for BDS (with no additional outpatient or resi- Minimal important differences (MIDs) for patient- dential treatment) it was an 11% decrease (95% reported outcomes (PROs) are often estimated by CI = −20%, −3%). CONCLUSIONS: selecting a clinical variable to serve as an anchor. Using robust statistical methods, we find promis- Then, differences in the clinical anchor regarded ing (albeit preliminary) evidence that additional as clinically meaningful or important can be used periods of outpatient and residential treatment, as to estimate the corresponding value of the PRO. well as biological drug screening, lead to reduc- Although these MID values are sometimes esti- tions in substance use outcomes at one year. mated by regression techniques, we show that this is a biased procedure and should not be used; EP-51748 alternative methods are proposed. Structural stigma and all-cause mortality in sexual minority populations. Anna Bellatorre, EP-51747 Yeonjin Lee. 2014 Estimating the causal effects of cumulative Stigma operates at multiple levels, including treatment episodes for adolescents using mar- intrapersonal appraisals (e.g., self-stigma), inter- ginal structural models and inverse probability of personal events (e.g., hate crimes), and structural treatment weighting. Rajeev Ramchand. 2014 conditions (e.g., community norms, institutional BACKGROUND: Substance use treatment is policies). Although prior research has indicated rarely a one-time event for individuals with sub- that intrapersonal and interpersonal forms of stance use disorders. Sustained reductions in stigma negatively affect the health of the stig- substance use and its related symptoms may re- matized, few studies have addressed the health sult from multiple treatment episodes. METHODS: consequences of exposure to structural forms We use a marginal structural model with inverse- of stigma. To address this gap, we investigated probability-of-treatment weighting to estimate the whether structural stigma—operationalized as causal effects of cumulative treatment experiences living in communities with high levels of anti-gay over a period of 9 months on drug use at the end prejudice—increases risk of premature mortality of 1-year among 2870 adolescents receiving care for sexual minorities. We constructed a measure in community-based treatment settings. During the capturing the average level of anti-gay prejudice 9 months, adolescents move in and out of outpa- at the community level, using data from the Gen- tient and residential treatment with periods where eral Social Survey, which was then prospectively they only receive biological drug screening (BDS) linked to all-cause mortality data via the National or no treatment at all. The use of inverse-proba- Death Index. Sexual minorities living in commu- bility-of-treatment weighting reduces confounding nities with high levels of anti-gay prejudice expe- bias due to observed baseline and time-varying rienced a higher hazard of mortality than those measures over the course of follow-up; weights living in low-prejudice communities (Hazard Ra- tio [HR] = 3.03, 95% Confidence Interval [CI] = 259

1.50, 6.13), controlling for individual and commu- factors associated with successful cold case in- nity-level covariates. This result translates into a vestigations. Carl Jensen. 2014 shorter life expectancy of approximately 12 years Cold case squads have garnered much atten- (95% C.I.: 4–20 years) for sexual minorities living tion; however, they have yet to undergo significant in high-prejudice communities. Analysis of spe- empirical scrutiny. In the present study, the au- cific causes of death revealed that suicide, homi- thors interviewed investigators and reviewed 189 cide/violence, and cardiovascular diseases were solved and unsolved cold cases in Washington, substantially elevated among sexual minorities in D.C., to determine whether there are factors that high-prejudice communities. Strikingly, there was can predict cold case solvability. In the interviews, an 18-year difference in average age of complet- new information from witnesses or information ed suicide between sexual minorities in the high- from new witnesses was cited as the most preva- prejudice (age 37.5) and low-prejudice (age 55.7) lent reason for case clearance. The case reviews communities. These results highlight the impor- determined that there were factors in each of the tance of examining structural forms of stigma and following domains that predicted whether cases prejudice as social determinants of health and would be solved during cold case investigations: longevity among minority populations. Crime Context, Initial Investigation Results, Basis for Opening Cold Case, and Cold Case Investiga- EP-51749 A naturopathic approach to the prevention of tor Actions. The results suggest that it is possible cardiovascular disease: cost-effectiveness analy- to prioritize cold case work based on the likelihood sis of a pragmatic multi-worksite randomized clini- of investigations leading to clearances. cal trail. Orest Szczurko, Kieran Cooley. 2014 EP-51751 OBJECTIVE: To determine the cost-effective- An exploration of how perceptions of the risk of ness of a worksite-based naturopathic (individual- avian influenza in poultry relate to urbanization in ized lifestyle counseling and nutritional medicine) Vietnam. Tuyen Nghiem, Sumeet Saksena. 2014 approach to primary prevention of cardiovascular This research examined how perceptions of out- disease (CVD). METHODS: Economic evaluation breaks of highly pathogenic avian influenza (HPAI) alongside a pragmatic, multi-worksite, random- subtype H5N1 in poultry are related to urbaniza- ized controlled trial comparing enhanced usual tion. Via in-depth interviews with village leaders, care (EUC; usual care plus biometric screening) household farmers, and large farm operators in to the addition of a naturopathic approach to CVD modern, transitional, and traditional communes in prevention (NC+EUC). RESULTS: After 1 year, the north of Vietnam, we explored behaviors, at- NC+EUC resulted in a net decrease of 3.3 (con- titudes, cultural values, and traditions that might fidence interval: 1.7 to 4.8) percentage points in amplify or attenuate HPAI outbreaks. We also ex- 10-year CVD event risk (number needed to treat = plored conceptualizations of urbanization and its 30). These risk reductions came with average net impacts on animal husbandry and disease out- study-year savings of $1138 in societal costs and breaks. Qualitative theme analyses identified the $1187 in employer costs. There was no change in key impacts, factors related to HPAI outbreaks, quality-adjusted life years across the study year. and disease prevention and management strat- CONCLUSIONS: A naturopathic approach to CVD egies. The analyses also highlighted how urban- primary prevention significantly reduced CVD risk ization improves some aspects of life (e.g., food over usual care plus biometric screening and re- security, family wealth and health, more employ- duced costs to society and employers in this multi- ment opportunities, and improved infrastructure), worksite—based study. but simultaneously poses significant challenges for poultry farming and disease management. EP-51750 Working smarter on cold cases: identifying Awareness of qualitative aspects of HPAI risk perceptions and behaviors and how they vary with 260 urbanization processes may help to improve the based analysts, China's assertiveness between prevention and management of emerging infec- 2008 and 2010 can be divided into two waves, tious diseases. each triggered by a different cause. The first wave seems triggered by a sense in Beijing that Wash- EP-51754 ington, DC was more differential to China's inter- Factors associated with intention to conceive ests, and less committed to East Asia. The second and its communication to providers among HIV wave seems best explained as China's response clients in Uganda. Sebastian Linnemayr. 2014 to what it perceived as a far more assertive and Persons living with HIV/AIDS (PLHA) must dis- threatening United States. Both waves were am- cuss their fertility intentions with healthcare pro- plified by two domestic challenges: Chinese lead- viders to receive the support needed to have chil- ers' hypersensitivity to popular nationalism and dren safely and limit transmission risks. However, poor bureaucratic coordination among an expand- few quantitative studies have examined correlates ing number of foreign policy actors. of fertility intentions, let alone the communication of such intentions with providers. We exam- EP-51756 ined the prevalence and correlates of intentions to The health consequences of relocation for nurs- have children, and comfort discussing such plans ing home residents following Hurricane Katrina. with one's providers, in HIV clients at two HIV clin- John Engberg. 2014 ics in Uganda. Cross-sectional self-report data In this research, the authors examine whether were collected from 233 patients who had primary the relocation of nursing home residents following partners. Bivariate correlates significant at the P Hurricane Katrina is associated with subsequent < 0.10 level were included in logistic regression lower physical or mental health. All nursing homes analysis. Of the 233 participants, 103 (44%) re- in Louisiana that were closed following Hurricane ported an intention to conceive a child in the near Katrina (N = 12) were used, with 439 residents future. In multivariate analysis, younger age of who could be followed to a new location. The au- both the patient and their partner, better physi- thors compare the subsequent health outcomes cal health functioning and higher internalized HIV of these residents to that of a matched sample of stigma were associated with having fertility inten- other nursing home residents in Southern states, tions. One-third (35%) of those with fertility inten- with the match based on prior health status as tions expressed having difficulty discussing these well as other resident and facility characteristics. intentions with their providers, which was asso- Relocated residents were more likely to die than ciated with receiving care at the rural clinic and non-relocated residents. In addition, relocated greater internalized HIV stigma. These findings residents were more likely to have pressure ul- highlight the need for reproductive health services cers; they were, however, less likely to be physi- that help clients accept themselves as PLHA and cally restrained. Relocated residents were also their fertility rights, thus promoting patient-doctor less likely to have behavioral health issues. These communication needed to promote safe child con- results would appear to have both practical and ception and delivery outcomes. policy relevance.

EP-51755 EP-51757 An "assertive" China? insights from interviews. Consistent assignment of nurse aides: associa- Scott Warren Harold. 2014 tion with turnover and absenteeism. 2014 Recent years have witnessed the emergence Consistent assignment refers to the same care- of a more assertive China. What happened to Chi- givers consistently caring for the same residents na's "peaceful rise" and "charm offensive"? What almost every time caregivers are on duty. This explains the changes in China's foreign policy? Ac- article examines the association of consistent as- cording to interviews with Beijing and Shanghai- signment of nurse aides with turnover and absen- 261 teeism. Data came from a survey of nursing home consultation services address treatment with psy- administrators, the Online Survey Certification and chotropic medications, particularly polypharmacy. Reporting data, and the Area Resource File. The Joint public-private funding should be considered measures were from 2007 and came from 3,941 for such public programs that serve privately in- nursing homes. Multivariate logistic regression sured children. models were used to examine turnover and ab- EP-51759 senteeism. An average of 68% of nursing homes Early HIV treatment led to life expectancy gains reported using consistent assignment, with 28% valued at $80 billion for people infected in 1996- of nursing homes using nurse aides consistent as- 2009. Timothy Juday, Matthew D. Solomon. 2014 signment at the often recommended level of 85% In late 2009 US guidelines for HIV treatment (or more). Nursing homes using recommended were revised to recommend the initiation of com- levels of consistent assignment had significantly bination antiretroviral therapy (cART) earlier in lower rates of turnover and of absenteeism. In the the course of the disease. We analyzed the life multivariate analyses, consistent assignment was expectancy gains of people infected with HIV be- significantly associated with both lower turnover tween the introduction of cART in 1996 and the and lower absenteeism (p < .01). Consistent as- 2009 guideline revisions. Compared to people signment is a practice recommended by many who initiated cART late (defined as having a CD4 policy makers, government agencies, and indus- cell count of less than 350 per cubic millimeter of try advocates. The findings presented here pro- blood), those who initiated treatment early (with vide some evidence that the use of this staffing a CD4 count of 350–500) could expect to live practice can be beneficial. 6.1 years longer, and the earliest initiators (with a CD4 count of more than 500) could expect an EP-51758 extra 9.0 years of life. The total value of life expec- Clinicians' utilization of child mental health tancy gains to the early and earliest initiators of telephone consultation in primary care: findings treatment was $80 billion, with each life-year val- from Massachusetts. Bruce J. Masek, Jeffrey Q. ued at $150,000. The value of the survival gains Bostic. 2014 was more than double the increase in drug manu- OBJECTIVE: The authors examined utiliza- facturers' revenues from early cART initiation. Our tion of the Massachusetts Child Psychiatry Ac- results clarify the economic implications of adher- cess Project, a mental health telephone consulta- ence to treatment guidelines. tion service for primary care, hypothesizing that greater use would be related to severe psychiatric EP-51772 diagnoses and polypharmacy. METHODS: The Assessing the Chiral Switch: Approval and Use authors examined the association between utili- of Single-Enantiomer Drugs, 2001 to 2011. Walid zation, defined as the mean number of contacts F. Gellad, Phillip Choi, Margaret Mizah. 2014 per patient during the 180 days following the initial OBJECTIVES: A "chiral switch" oc- contact (July 2008–June 2009), and character- curs in the pharmaceutical market when a drug istics of the initial contact, including consultation made up of 2 enantiomer forms is replaced with question, the child's primary mental health prob- a purified single-enantiomer version, often in the lem, psychotropic medication regimen, insurance context of a patent expiration. We studied the status, and time of year. RESULTS: Utilization prevalence of chiral switching in the United States (N=4,436 initial contacts, mean=3.83 contacts) over the past decade, including trends in use of, was associated with initial contacts about medi- and expenditures on, these products in Medicaid. cation management, polypharmacy, public and STUDY DESIGN: Retrospective analysis. METH- private health insurance, and time of year. The ODS: We used US Adopted Names prefixes (lev/ child's primary mental health problem did not levo/ar/es/dex/dextro) to identify all single-enan- predict utilization. CONCLUSIONS: Telephone tiomer drugs approved from 2001 to 2011. From 262 publicly available US Food and Drug Administra- beneficiaries experiencing a 12-month episode of tion (FDA) approval documents, we extracted the care for congestive heart failure (CHF, n&th characteristics of the pivotal premarket trials for insp;= 53 488), chronic the single enantiomers. Specifically, we evalu- obstructive pulmonary disease (COPD, n&am ated whether the single enantiomer was directly p;thinsp;= 76 520), or compared with the precursor racemic drug and type 2 diabetes mellitus (DM, n = whether there was evidence of superior efficacy.  166 654) in 2008 and We used quarterly drug expenditure data from 2009. MAIN OUTCOMES AND MEASURES: each state Medicaid program to chart trends in Hospitalizations, emergency department visits, use of, and spending on, the single-enantiomer complications, and costs of care associated with products and their racemic precursors during the Bice-Boxerman continuity of care (COC) in- the study period. RESULTS: From 2001 to 2011, dex, a measure of the outpatient COC related to the FDA approved 9 single-enantiomer products: conditions of interest. RESULTS: The mean (SD) dexlansoprazole, levoleucovorin, levocetirizine, COC index was 0.55 (0.31) for CHF, 0.60 (0.34) armodafinil, arformoterol, eszopiclone, escitalo- for COPD, and 0.50 (0.32) for DM. After multivari- pram, dexmethylphenidate, and esomeprazole. Of able adjustment, higher levels of continuity were those 9 drugs, 3 had at least 1 pre-approval ran- associated with lower odds of inpatient hospital- domized trial that included the racemic precursor ization (odds ratios for a 0.1-unit increase in COC as a direct comparator, but there was no evidence were 0.94 [95% CI, 0.93-0.95] for CHF, 0.95 [0.94- of superiority of the single enantiomer over the ra- 0.96] for COPD, and 0.95 [0.95-0.96] for DM), cemic at comparable doses. Between 2001 and lower odds of emergency department visits (0.92 2011, US Medicaid programs spent approximately [0.91-0.92] for CHF, 0.93 [0.92-0.93] for COPD, $6.3 billion on these 9 single-enantiomer drugs. and 0.94 [0.93-0.94] for DM), and lower odds of CONCLUSIONS: Recently approved single-en- complications (odds ratio range, 0.92-0.96 across antiomer drugs showed no evidence of superior the 3 complication types and 3 conditions; all efficacy over the older racemic precursors in the P <  .001). For every pivotal trials leading to their approval, and in a ma- 0.1-unit increase in the COC index, episode costs jority of cases, they were not directly compared. of care were 4.7% lower for CHF (95% CI, 4.4%- 5.0%), 6.3% lower for COPD (6.0%-6.5%), and EP-51779 5.1% lower for DM (5.0%-5.2%) in adjusted analy- Continuity and the Costs of Care for Chronic ses. CONCLUSIONS AND RELEVANCE: Modest Disease. Peter S. Hussey, Eric C. Schneider, differences in care continuity for Medicare benefi- Robert S. Rudin. 2014 ciaries are associated with sizable differences in IMPORTANCE: Better continuity of care is ex- costs, use, and complications. pected to improve patient outcomes and reduce health care costs, but patterns of use, costs, and EP-51787 Improving the Value of Analysis for Biosurveil- clinical complications associated with the current lance. Henry H. Willis, Melinda Moore. 2014 patterns of care continuity have not been quantified. OBJECTIVE: To measure the association Biosurveillance provides information that im- between care continuity, costs, and rates of hos- proves decisions about mitigating the effects of pitalizations, emergency department visits, and disease outbreaks and bioterrorism. The success complications for Medicare beneficiaries with of biosurveillance depends on the effectiveness of chronic disease. DESIGN, SETTING, AND PAR- at least four key processes: data collection, data TICIPANTS: Retrospective cohort study of insur- analysis and interpretation, data integration from ance claims data for a 5% sample of Medicare across organizations, and action (including public responses) based upon results of the analysis. Questions typically arise about whether informa- 263 tion from biosurveillance systems represents a ons of mass democratization. 2014 threat that justifies a response. To begin answering The author's analysis exposes fragility in Bei- these questions, the Institute of Medicine Stand- jing's soft power--the limitations of the Chinese ing Committee on Health Threats Resilience has Communist Party's political legitimacy and vul- been undertaking discussions of strategies that nerabilities in China's rise. The example that illus- the Department of Homeland Security Nation- trates a real Achilles's heel hits close to home: the al Biosurveillance Integration Center could use issue of Taiwan. to strengthen its decision support and decision analysis functions. As part of these discussions, EP-51792 this paper applies two standard decision analy- A Randomized Controlled Trial of Students sis tools to biosurveillance–decision trees and for Nutrition and Exercise: A Community-Based value-of-information analysis—to assess the im- Participatory Research Study. Laura M. Bogart, plications of strategies to enhance biosurveillance Burton O. Cowgill, Marc N. Elliott. 2014 and to improve decisions about whether and how to act after detection of a biosurveillance signal. PURPOSE: To conduct a randomized con- This application demonstrates how decision anal- trolled trial of Students for Nutrition and eXercise, ysis tools can be used to improve public health a 5-week middle school-based obesity-prevention preparedness decision making by developing a intervention combining school-wide environmen- road map for how best to enhance biosurveillance tal changes, multimedia, encouragement to eat through better analytic tools and methods. healthy school cafeteria foods, and peer-led education. METHODS: We randomly selected schools EP-51790 (five intervention, five waitlist control) from the Los Policy Designs for Cannabis Legalization: Start- Angeles Unified School District. School records ing with the Eight Ps. Beau Kilmer. 2014 were obtained for number of fruits and vegetables served, students served lunch, and snacks sold The cannabis policy landscape is changing per attending student, representing an average of rapidly. In November 2012 voters in Colorado and 1,515 students (SD = 323) per intervention school Washington State passed ballot initiatives to re- and 1,524 students (SD = 266) per control school. move the prohibition on the commercial produc- A total of 2,997 seventh-graders (75% of seventh- tion, distribution, and possession of cannabis. This graders across schools) completed pre- and pos- paper does not address the question of whether tintervention surveys assessing psychosocial cannabis should be legal; it instead focuses on variables. Consistent with community-based par- the design considerations confronting jurisdic- ticipatory research principles, the school district tions that are pondering a change in cannabis was an equal partner, and a community advisory policy. Indeed, whether or not cannabis legaliza- board provided critical input. RESULTS: Relative tion is net positive or negative for public health to control schools, intervention schools showed and public safety largely depends on regulatory significant increases in the proportion of students decisions and how they are implemented. This es- served fruit and lunch and a significant decrease say presents eight of these design choices which in the proportion of students buying snacks at all conveniently begin with the letter ''P'': produc- school. Specifically, the intervention was associ- tion, profit motive, promotion, prevention, potency, ated with relative increases of 15.3% more fruits purity, price, and permanency. served (p = .006), 10.4% more lunches served (p < .001), and 11.9% fewer snacks sold (p < .001) EP-51791 China and Taiwan: balance of rivalry with weap- than would have been expected in its absence. Pre-to-post intervention, intervention school students reported more positive attitudes about cafeteria food (p = .02) and tap water (p = .03), greater obesity-prevention knowledge (p = .006), 264 increased intentions to drink water from the tap (p rent phase of research development but tended = .04) or a refillable bottle (p = .02), and greater to prioritize practical solutions over theoretical ad- tap water consumption (p = .04) compared with vancement. Other complex public health problems control school students. CONCLUSIONS: Mul- requiring input from a broad-based constituency tilevel school-based interventions may promote might benefit from web-based tools that facilitate healthy adolescent dietary behaviors. such community input.

EP-51793 EP-51794 Reducing the Burden of Suicide in the U.S.: Towards a Common Terminology: A Simpli- The Aspirational Research Goals of the National fied Framework of Interventions to Promote and Action Alliance for Suicide Prevent Research Pri- Integrate Evidence Into Health Practices, Systems oritization Task Force. Cynthia A. Claassen, Jane and Policies. Heather Colquhoun, Jennifer Lee- Pearson, Dmitry Khodyakov. 2014 man, Susan Michie. 2014 BACKGROUND: The National Action Alliance BACKGROUND: A wide range of diverse for Suicide Prevention Research Prioritization and inconsistent terminology exists in the field Task Force (RPTF) has created a prioritized na- of knowledge translation. This limits the conduct tional research agenda with the potential to rapidly of evidence syntheses, impedes communication and substantially reduce the suicide burden in the and collaboration, and undermines knowledge U.S. if fully funded and implemented. PURPOSE: translation of research findings in diverse set- Viable, sustainable scientific research agendas tings. Improving uniformity of terminology could addressing challenging public health issues such help address these challenges. In 2012, we con- as suicide often need to incorporate perspectives vened an international working group to explore from multiple stakeholder groups (e.g., research- the idea of developing a common terminology and ers, policymakers, and other end-users of new an overarching framework for knowledge transla- knowledge) during an agenda-setting process. tion interventions. FINDINGS: Methods included The Stakeholder Survey was a web-based survey identifying and summarizing existing frameworks, conducted and analyzed in 2011−2012 mapping together a subset of those frameworks, to inform the goal-setting step in the RPTF agenda and convening a multi-disciplinary group to begin development process. The survey process, and working toward consensus. The group considered the final list of "aspirational" research four potential approaches to creating a simplified goals it produced, are presented here. METH- framework: melding existing taxonomies, creating ODS: Using a modified Delphi process, diverse a framework of intervention mechanisms rather constituent groups generated and evaluated can- than intervention strategies, using a consensus didate research goals addressing pressing suicide process to expand one of the existing models/ prevention research needs. RESULTS: A total of frameworks used by the group, or developing a 716 respondents representing 49 U.S. states and new consensus framework. CONCLUSIONS: The 18 foreign countries provided input that ultimately work group elected to draft a new, simplified con- produced 12 overarching, research-informed aspi- sensus framework of interventions to promote and rational goals aimed at reducing the U.S. suicide integrate evidence into health practices, systems burden. Highest-rated goals addressed preven- and policies. The framework will include four key tion of subsequent suicidal behavior after an ini- components: strategies and techniques (active tial attempt, strategies to retain patients in care, ingredients), how they function (causal mecha- improved healthcare provider training, and gen- nisms), how they are delivered (mode of delivery), erating care models that would ensure accessi- and what they aim to change (intended targets). ble treatment. CONCLUSIONS: The Stakeholder The draft framework needs to be further developed Survey yielded widely valued research targets. by feedback and consultation with the research Findings were diverse in focus, type, and cur- community and tested for usefulness through ap- 265 plication and evaluation. RAND–Negative Impact of Asthma on Quality of Life item bank [RAND-IAQL-Bank]) by using an EP-51795 item response theory (IRT)-based linking method. Does Diversity Matter? The Need for Longitu- METHODS: Our sample of adults with asthma (N dinal Research on Adolescent Alcohol and Drug = 2032) completed 2 measures of asthma-specific Use Trajectories. Elizabeth J. D'Amico, Joan S. quality of life: the AQLQ-Marks and the RAND- Tucker, Regina A. Shih. 2014 IAQL-Bank. We use IRT-based co-calibration of The existing research aimed at understanding the 2 measures to provide a linkage, or a com- alcohol and drug (AOD) use patterns from early mon metric, between the 2 measures. Co-calibra- to late adolescence typically does not examine tion refers to the process of using IRT to estimate samples with substantial racial and ethnic diver- item parameters that describe the responses to sity. This is a critical research gap because stud- the scales' items according to a common metric; ies have suggested that non-white adolescents in this case, a normal distribution transformed to often have worse health outcomes compared to a T scale with a mean of 50 and an SD of 10. RE- white adolescents, even with less AOD use. In this SULTS: Respondents had an average age of 43 paper, we discuss the need for future research (15), were 60% female, and predominantly non- on this topic, given demographic shifts in the ra- Hispanic White (56%), with 19% African Ameri- cial and ethnic composition of the USA. We also can, 14% Hispanic, and 11% Asian. Most had at outline how this research can provide information least some college education (83%), and 90% on what periods might be most relevant for each had experienced an asthma attack during the last racial/ethnic group, and suggest measures that 12 months. Our results indicate that the AQLQ- epidemiological studies on early substance use Marks and RAND-IAQL-Bank scales measured should assess to capture the underlying cultural, highly similar constructs and were sufficiently uni- acculturation, psychosocial, and contextual fac- dimensional for IRT co-calibration. Once linked, tors that explain racial/ethnic differences in AOD scores from the 2 measures were invariant across trajectories. subgroups. A crosswalk is provided that allows researchers and clinicians using AQLQ-Marks to EP-51796 crosswalk to the RAND-IAQL toolkit. CONCLU- Correspondence Between the RAND-negative SIONS: The ability to translate scores from the Impact of Asthma on Quality of Life Item Bank and RAND-IAQL toolkit to other "legacy" the Marks Asthma Quality of Life Questionnaire. (ie, commonly used) measures increases the val- Maria Orlando Edelen, Brian D. Stucky, Cathy D. ue of the new toolkit, aids in interpretation, and will Sherbourne. 2014 hopefully facilitate adoption by asthma researchers and clinicians. More generally, the techniques BACKGROUND: In many research and clini- we illustrate can be applied to other newly devel- cal settings in which patient-reported outcome oped or existing measures in the PRO research (PRO) measures are used, it is often desirable to field to obtain crosswalks with widely used tradi- link scores across disparate measures or to use tional legacy instruments. scores from 1 measure to describe scores on a separate measure. However, PRO measures are EP-51797 scored by using a variety of metrics, making such Temporal Associations Between Substance Use comparisons difficult. OBJECTIVE: The objec- and Delinquency Among Youth with a First Time tive of this article was to provide an example of Offense. Sarah B. Hunter, Jeremy N. V. Miles, Eric how to transform scores across disparate mea- R. Pedersen. 2014 sures (the Marks Asthma Quality of Life Ques- tionnaire [AQLQ-Marks] and the newly developed OBJECTIVE: Substance use and delinquency among adolescents have been shown to be posi- 266 tively associated; however, the temporal relation- longitudinally) for figural memory and fine motor ship is not well understood. Examining the asso- speed. Future studies should investigate the role ciation between delinquency and substance use of nonvascular mechanisms linking DS and cogni- is especially relevant among adolescents with a tive decline. first-time substance use related offense as they are at-risk for future problems. METHOD: Data EP-51799 from 193 adolescents at time of diversion program Tailored Nutrition Education and Food As- entry and six months later was examined using sistance Improve Adherence to HIV Antiretroviral cross-lagged path analysis to determine wheth- Therapy: Evidence from Honduras. Homero Mar- er substance use and related consequences tinez, Kartika Palar, Sebastian Linnemayr. 2014 were associated with other types of delinquency Food insecurity and malnutrition negatively af- across time. RESULTS: Results demonstrated fect adherence to antiretroviral therapy (ART) and that delinquency at program entry was related to are associated with poor HIV clinical outcomes. subsequent reports of heavy drinking and alco- We examined the effect of providing household hol consequences, but not marijuana use or its food assistance and nutrition education on ART consequences. In contrast, alcohol and marijuana adherence. A 12-month prospective clinical trial use at program entry were not related to future compared the effect of a monthly household food reports of delinquency. CONCLUSIONS: Findings basket (FB) plus nutrition education (NE) versus emphasize the need to build in comprehensive as- NE alone on ART adherence on 400 HIV pa- sessments and interventions for youth with a first tients at four clinics in Honduras. Participants had time offense in order to prevent further escalation been receiving ART for an average of 3.7 years of substance use and criminal behaviors. and were selected because they had suboptimal adherence. Primary outcome measures were EP-51798 missed clinic appointments, delayed prescription Depressive Symptoms and Longitudinal refills, and self-reported missed doses of ART. Changes in Cognition: Women's Health Initiative These three adherence measures improved for Study of Cognitive Aging. Joseph S. Goveas, both groups over 12 months (p < 0.01), mostly Mark A. Espeland, Patricia E. Hogan. 2014 within 6 months. On-time prescription refills im- Elevated depressive symptoms (DS) are asso- proved for the FB plus NE group by 19.6 % more ciated with incident mild cognitive impairment and than the group receiving NE alone after 6 months probable dementia in postmenopausal women. (p < 0.01), with no further change at 12 months. We examined the association of elevated DS with Change in missed appointments and self-report- domain-specific cognitive changes and the mod- ed missed ART doses did not significantly differ by erating role of cardiovascular risk factor severity intervention group. and cardiovascular disease (CVD). A total of 2221 elderly women who participated in the Women's EP-51800 Health Initiative Study of Cognitive Aging were Home front: post-deployment mental health separated into those with (N = 204) and without and divorces. Sebastian Negrusa. 2014 (N = 2017) elevated DS. The DS and multidomain Since 2003, about 14 % of U.S. Army soldiers cognitive outcomes were measured annually for have reported symptoms of posttraumatic stress an average follow-up of 5.04 years. Women with disorder (PTSD) following deployments. In this ar- elevated DS showed baseline multidomain cogni- ticle, we examine how post-deployment symptoms tive deficits but longitudinal declines in global cog- of PTSD and of other mental health conditions are nition only. Persistent DS was related to greater related to the probability of divorce among married global cognition, verbal knowledge and fluency, active-duty U.S. Army soldiers. For this purpose, and memory declines. Significant DS-CVD inter- we combine Army administrative individual-level actions were observed cross-sectionally (but not longitudinal data on soldiers' deployments, mari- 267 tal history, and sociodemographic characteristics missed more work days and working more days with their self-reported post-deployment health in- with symptoms. More depressive symptomatology formation. Our estimates indicate that time spent and greater number of comorbidities predicted re- in deployment increases the divorce risk among duced work participation. Women experienced no Army enlisted personnel and that PTSD symp- growth in real income since symptom onset. Mea- toms are associated with further increases in the sures of symptom severity were not associated odds of divorce. Although officers are generally with any of the economic outcomes. CONCLU- less likely to screen positive for PTSD than en- SIONS: Greater interstitial cystitis/bladder pain listed personnel, we find a stronger relationship syndrome symptom impact, depressive symp- between PTSD symptoms and divorces among tomatology and count of comorbidities (but not Army officers who are PTSD-symptomatic than symptom severity) were each associated with less among enlisted personnel. We estimate a larger work participation and leveling of women's long- impact of deployments on the divorce risk among term earnings. Management of bladder symptom female soldiers, but we do not find a differential impact on nonwork related activities and depres- impact of PTSD symptoms by gender. Also, we sive symptomatology may improve women's work find that most of the effect of PTSD symptoms outcomes. occurs early in the career of soldiers who deploy multiple times. EP-51802 Parents' views on engaging families of middle EP-51801 school students in obesity prevention and control Consequences of interstitial cystitis/bladder in a multiethnic population. Paul J. Chung. 2014 pain symptoms on women's work participation INTRODUCTION: Overweight and obesity and income: results from a national household remain significant public health risks for youth in sample. Marc N. Elliott. 2014 the United States, particularly among racial/eth- PURPOSE: We describe differences in work nic minority groups. Efforts at obesity prevention participation and income by bladder symptom im- and control have targeted youth and family mem- pact and comorbidities among women with inter- bers in diverse settings. Although involving par- stitial cystitis/bladder pain syndrome. MATERIALS ents in obesity prevention programs for youth may AND METHODS: Cross-sectional data from 2,767 improve the potential of these programs, less is respondents younger than 65 years identified with known about parents' preferred methods of en- interstitial cystitis/bladder pain syndrome symp- gagement, especially among racial/ethnic minor- toms were analyzed. The data were taken from the ity parents and parents whose primary language RAND Interstitial Cystitis Epidemiology (RICE) is not English. In this qualitative study, parents survey, and included retrospective self-reports of of middle-school–aged children were asked how interstitial cystitis/bladder pain syndrome impact, best to engage their children in obesity preven- severity, years since onset, related comorbidities tion and control efforts. METHODS: We recruited (depressive symptomatology, number of condi- 38 parents whose children attended Los Angeles tions), work participation and income, and per- middle schools to participate in focus groups. Two sonal characteristics. Multiple regressions predict- English-language focus groups with 14 parents of ed 5 current work outcomes of works now, kept different racial/ethnic backgrounds and 2 Span- from working by pain, missed work days, days ish language groups with 24 Latino parents were worked when bothered by symptoms and real in- conducted from 2010 through 2011. We analyzed come change since symptom onset. RESULTS: focus group transcripts by using content analysis Controlling for work status at symptom onset and using inductive and deductive techniques. RE- personal characteristics, greater bladder symptom SULTS: Findings from focus groups confirmed impact predicted a greater likelihood of not now that parents want to help their children avoid obe- working, kept more days from working by pain, sity but feel constrained in their ability to take ac- 268 tion. Participants identified an overarching desire potentiated the effects of recent stressors on adult to become better parents as a potential incentive mania. Our findings demonstrate a role of social to engage in obesity prevention efforts. Parents experiences in the initial onset of bipolar disorder, advocated for family-focused approaches in obe- as well as in its prospective course, and are con- sity prevention programs, including family sports sistent with etiologic models of bipolar disorder leagues and cooking classes. Most findings were that implicate deficits in developmentally estab- consistent between language groups, but parents lished stress-response pathways. in the Spanish language groups cited language- related barriers. CONCLUSION: The development EP-51804 and testing of simple programs that are sustain- Physicians' propensity to discuss prognosis is able, community-based, and family-focused may associated with patients' awareness of prognosis empower families to address obesity prevention for metastatic cancers. Mary Beth Landrum, Jane and control. Weeks. 2014 BACKGROUND: Prognosis discussion is an EP-51803 essential component of informed decision-mak- Contributions of the social environment to first- ing. However, many terminally ill patients have onset and recurrent mania. Erin C. Dunn. 2014 a limited awareness of their prognosis and the In treated cohorts, individuals with bipolar dis- causes are unclear. OBJECTIVE: To explore the order are more likely to report childhood adver- impact of physicians' propensity to discuss prog- sities and recent stressors than individuals with- nosis on advanced cancer patients' prognosis out bipolar disorder; similarly, in registry-based awareness. DESIGN: Cancer Care Outcomes Re- studies, childhood adversities are more common search and Surveillance Consortium (CanCORS) among individuals who later become hospitalized study, a prospective cohort study with patient and for bipolar disorder. Because these types of stud- physician surveys. SETTING/SUBJECTS: We in- ies rely on treatment-seeking samples or hospital vestigated 686 patients with metastatic lung or diagnoses, they leave unresolved the question of colorectal cancer at diagnosis who participated whether or not social experiences are involved in in the CanCORS study and reported about their the etiology of bipolar disorder. We investigated life expectancy. Data were linked to the physi- the role of childhood adversities and adulthood cian survey from 486 physicians who were iden- stressors in liability for bipolar disorder using data tified by these patients as filling important roles from the National Epidemiologic Survey on Alco- in their cancer care. RESULTS: Few patients with hol and Related Conditions (n=33 375). metastatic cancers (16.5%) reported an accurate We analyzed risk for initial-onset and recurrent awareness of their prognosis, defined as report- DSM-IV (Diagnostic and Statistical Manual of ing a life expectancy of less than 2 years for lung Mental Disorders, Fourth Edition) manic episodes cancer or less than 5 years for colorectal cancer. during the study's 3-year follow-up period. Child- Patients whose most-important-doctor (in help- hood physical abuse and sexual maltreatment ing patient make decisions) reported discussing were associated with significantly higher risks of prognosis with terminally ill patients earlier were both first-onset mania (odds ratio (OR) for abuse: more likely than those whose doctors deferred 2.23; 95% confidence interval (CI)=1.71, 2.91; OR these discussions to have an accurate prognosis for maltreatment: 2.10; CI=1.55, 2.83) and recur- awareness (adjusted proportion, 18.5% versus rent mania (OR for abuse: 1.55; CI=1.00, 2.40; OR 7.6%; odds ratio, 3.23; 95% confidence interval, for maltreatment: 1.60; CI=1.00, 2.55). In addition, 1.39–7.52; p=0.006). CONCLUSIONS: Few pa- past-year stressors in the domains of interperson- tients with advanced cancer could articulate an al instability and financial hardship were associ- accurate prognosis estimate, despite most having ated with a significantly higher risk of incident and received chemotherapy and many physicians re- recurrent mania. Exposure to childhood adversity 269 ported they would discuss prognosis early. Physi- characteristics to: park director (PD, 17 parks); cians' propensity to discuss prognosis earlier was PD and park advisory board of interested com- associated with more accurate patient reports of munity members (PD + PAB, 16 parks); and no-in- prognosis. Enhancing the communication skills of tervention control (17 parks) arms. Between 2007 providers with important roles in cancer care may and 2012, PDs and PABs from the 33 intervention help to improve cancer patients' understanding of parks participated in community engagement, their prognosis. baseline assessment, marketing training, intervention design and implementation, and follow-up EP-51805 assessment. RESULTS: Intervention parks (PD TV viewing, perceived similarity coviewing, and PD + PAB) invested in new and diversified and mental well-being among African American, signage, promotional items, outreach or support Latino, and White children. Jan Wallander, Marc for group activities like fitness classes and walk- N. Elliott. 2014 ing clubs, and various marketing strategies. Scal- Research among adults has demonstrated ing up CBPR methods across parks in 33 diverse concurrent and prospective negative associa- neighborhoods was challenging. Working with de- tions between TV viewing and mental health, yet partmental management and established struc- little research has examined these associations tures for community input (PABs) and park policy among African American and Latino youth or ex- (PDs) facilitated implementation and sustainability. amined the role of children's involvement with TV CONCLUSION: Scaling up CBPR methods across and parental mediation of TV viewing via coview- diverse communities involved tradeoffs. CBPR is ing. The purpose of the present study is to exam- useful for tailoring research and enhancing com- ine associations between TV viewing, perceived munity impact and sustainability, but more work is similarity, and coviewing and mental well-being needed to understand how to conduct multi-site in African American, Latino, and White children. trials across diverse settings using CBPR. Results from Healthy Passages™, a study of 4,824 African American (30%), Latino (47%), EP-51807 Trends in disability and related chronic condi- and White (23%) fifth graders, indicated that TV tions among the forty-and-over population: 1997- viewing and perceived similarity were negatively 2010. Robert F. Schoeni. 2014 associated with mental well-being among most groups of children, and coviewing was positively BACKGROUND: Downward trends in activity associated with mental well-being among Latinos. limitations among the older U.S. population have This study extends findings from adult research recently plateaued, while activity limitation among on media exposure and mental well-being into a the pre-retirement population has increased. OB- diverse sample of fifth graders and illuminates the JECTIVES: Update temporal trends in limitations role of perceived similarity and coviewing. in sensory and physical functions, instrumental activities of daily living (IADLs), and activities of EP-51806 daily living (ADLs) for the 40–64 and 65-and- Involving community stakeholders to increase over U.S. populations; assess the extent to which park use and physical activity. Terry Marsh. 2014 trends in education, smoking, and obesity could OBJECTIVE: The aim of this study is to de- account for the trends in limitations; and exam- scribe implementation of a randomized controlled ine trends in conditions cited as causes of limita- trial of community-based participatory research tions, their durations, and proportion of life spent (CBPR) approaches to increase park use and with them. METHODS: Multivariate analysis of the physical activity across 33 diverse neighborhoods 1997–2010 National Health Interview Survey. RE- in Los Angeles. METHODS: Fifty parks were ran- SULTS: For the younger group, there have been domly assigned based on park size, facilities and increases in all limitations, except trouble hearing, programs, and neighborhood socio-demographic which has declined. Increased obesity could ac- 270 count for the increases in vision, physical function, percutaneous nephrostolithotomy, ureteroscopy, and IADL limitations. Musculoskeletal conditions, or shock-wave lithotripsy for stone disease. The such as arthritis and back/neck problems, are fre- primary outcome was occurrence of an emergen- quently cited as causes of limitation, and there are cy department visit or hospital admission within growing roles for depression and nervous system 30 days of the procedure. Multivariable models conditions. For the 65-and-over group, there have estimated the odds of an unplanned visit and the been decreases in all limitations, except difficulty incremental cost of those visits, controlling for with physical functions, which is up. Increased important covariates. RESULTS: We identified education could account for the decline in ADL 93,523 initial procedures to fragment or remove limitation, and increased obesity could account for stones. Overall, 1 in 7 patients had an unplanned increased difficulty with physical functions. postprocedural visit. Unplanned visits were least common after shock-wave lithotripsy (12%) and EP-51808 occurred with similar frequency after ureterosco- Identifying older adults at high risk of mortality py and percutaneous nephrostolithotomy (15%). using the Medicare health outcomes survey. Marc Procedures at high-volume facilities were sub- N. Elliott. 2014 stantially less likely to result in an unplanned visit The Vulnerable Elders Survey (VES), a screen- (odds ratio 0.80, 95% confidence interval [95% ing tool for at-risk elderly, has been validated in CI] 0.74–0.87, P < .001). When an unplanned visit the community. This study used VES-based cri- occurred, adjusted incremental expenditures per teria to develop a modified version that can be episode were greater after shock-wave lithotripsy calculated from the Medicare Health Outcomes ($32,156 [95% CI $30,453–33,859]) than after Survey (HOS) to identify Medicare members at ureteroscopy ($23,436 [95% CI $22,281–24,590]). high risk of mortality. Data were from 97,258 HOS CONCLUSION: Patients not infrequently experi- respondents in 164 plans. Using age, self-rated ence an unplanned, high-acuity visit after low-risk health, and function items from the 2005 HOS, procedures to remove urinary stones, and the cost an a priori approach modeled on VES scoring of these encounters is substantial. Interventions and items predicted two-year mortality (c-statistic are indicated to identify and reduce preventable 0.74). Routinely-collected Medicare survey data unplanned visits. may be used to assess patterns of enrollment of high-risk beneficiaries across health plans. EP-51810 Assessing the validity of the RAND negative EP-51809 impact of asthma on quality of life short forms. The impact of unplanned postprocedure visits Brian D. Stucky. 2014 in the management of patients with urinary stones. BACKGROUND: In response to recommenda- Christopher S. Saigal. 2014 tions from the 2010 National Institutes of Health BACKGROUND: Unplanned follow-up care Asthma Outcomes Workshop, we developed a is the focus of intense health policy interest, as system for measuring the negative impact of asth- evidenced by recent financial penalties imposed ma on quality of life (QoL), which was referred under the Affordable Care Act. To date, however, to as the RAND Negative Impact of Asthma on unplanned postoperative care remains poorly Quality of Life (RAND-IAQL) item bank. The bank characterized, particularly for patients with kidney contains 65 items that focus on the patient's per- stones. Our objective was to describe the frequen- ception of the impact or bother of asthma on his or cy, variation, and financial impact of unplanned, her life. OBJECTIVE: Evidence for the validity of high-acuity, follow-up visits in the treatment of pa- 2 short forms, the RAND-IAQL 4-item and 12-item tients with urinary stone disease. METHODS: We Short Forms, from the bank is presented. METH- identified privately insured patients undergoing ODS: Using a sample of 2032 adults with asthma, 271 we validated our short forms against the Asthma re-rated the indicators. QIs with median scores of Quality of Life Questionnaire–Marks (AQLQ-M), at least 7 were considered valid. RESULTS: QIs the Asthma Control Test, and generic measures of were developed that addressed screening, diag- QoL developed by the Patient-reported Outcomes nosis, work-up, and both nonsurgical and surgi- Measurement Information System (PROMIS). cal management. Areas of controversy included Discriminant validity was examined by comparing whether screening should be performed to identify scores of respondents who differed according to prolapse, whether pessary users should undergo multiple health indicators. RESULTS: Our sam- a vaginal examination by a health professional ev- ple ranged in age from 18 to 99 years (mean, 43 ery 6 months versus annually, and whether a col- years), with 14% Hispanic, 11% Asian, 19% Afri- pocleisis should be offered to older women plan- can American, and 56% non-Hispanic white race/ ning to undergo surgery for POP. Fourteen out of ethnicity. Men had a significantly worse impact of 21 potential indicators were rated as valid for pel- asthma on QoL than women. The impact of asth- vic organ prolapse (median score ≥7). CON- ma on QoL was greatest in African American and CLUSION: We developed and rated 14 potential Hispanic subjects compared with that seen in non- quality indicators for the care of women with POP. Hispanic white subjects. Our measures correlated Once these QIs are tested for feasibility they can highly with the AQLQ-M and more strongly with be used on a larger scale to measure and com- the PROMIS global physical than mental scales. pare the care provided to women with prolapse in They differentiated between adults with asthma different clinical settings. according to their perceived severity, level of control, presence or absence of exacerbations, and EP-51812 physical comorbidity. CONCLUSION: The RAND- The Oregon experiment—effects of Medicaid IAQL item bank, measuring the impact of asthma on clinical outcomes. Sarah L. Taubman, Heidi L. on QoL, will complement other patient-reported Allen. 2014 outcomes, such as measures of asthma symp- BACKGROUND: Despite the imminent expan- toms, functioning, and control. sion of Medicaid coverage for low-income adults, the effects of expanding coverage are unclear. EP-51811 The 2008 Medicaid expansion in Oregon based Quality-of-care indicators for pelvic organ pro- on lottery drawings from a waiting list provided lapse: development of an infrastructure for quality an opportunity to evaluate these effects. METH- assessment. Victoria C. S. Scott, Krista Kiyosaki. ODS: Approximately 2 years after the lottery, we 2014 obtained data from 6387 adults who were ran- INTRODUCTION AND HYPOTHESIS: A pauci- domly selected to be able to apply for Medicaid ty of data exists addressing the quality of care pro- coverage and 5842 adults who were not select- vided to women with pelvic organ prolapse (POP). ed. Measures included blood-pressure, choles- We sought to develop a means of measuring this terol, and glycated hemoglobin levels; screening quality through the development of quality-of-care for depression; medication inventories; and self- indicators (QIs). METHODS: QIs were modeled reported diagnoses, health status, health care after those previously described in the Assessing utilization, and out-of-pocket spending for such the Care of Vulnerable Elders (ACOVE) project. services. We used the random assignment in the The indicators were then presented to a panel of lottery to calculate the effect of Medicaid cover- nine experts. Using the RAND Appropriateness age. RESULTS: We found no significant effect of Method, we analyzed each indicator's preliminary Medicaid coverage on the prevalence or diagno- rankings. A forum was then held in which each sis of hypertension or high cholesterol levels or on indicator was thoroughly discussed by the panel- the use of medication for these conditions. Med- ists as a group, after which panelists individually icaid coverage significantly increased the probability of a diagnosis of diabetes and the use of 272 diabetes medication, but we observed no signifi- Faith to move mountains: religious coping, spiri- cant effect on average glycated hemoglobin levels tuality, and interpersonal trauma recovery. Eunice or on the percentage of participants with levels of C. Wong. 2014 6.5% or higher. Medicaid coverage decreased the Interpersonal trauma is pervasive globally and probability of a positive screening for depression may result in long-term consequences physically, (−9.15 percentage points; 95% confidence cognitively, behaviorally, socially, and spiritually interval, −16.70 to −1.60; P=0.02), (Bryant-Davis, 2005b). One of the protective fac- increased the use of many preventive services, tors that have emerged in the literature is religious and nearly eliminated catastrophic out-of-pocket coping. Religious coping, spirituality, and faith- medical expenditures. CONCLUSIONS: This ran- based approaches to trauma recovery include en- domized, controlled study showed that Medicaid dorsement of beliefs, engagement in behaviors, coverage generated no significant improvements and access to support from faith communities. in measured physical health outcomes in the first Compared with negative religious coping, spiritu- 2 years, but it did increase use of health care ser- ality and positive religious coping have been as- vices, raise rates of diabetes detection and man- sociated with decreased psychological distress, a agement, lower rates of depression, and reduce finding established with survivors of child abuse, financial strain. sexual violence, intimate partner violence, community violence, and war. This article focuses on EP-51813 spiritual and religious coping among survivors of Design and use of performance measures to child abuse, sexual violence, and war; however, decrease low-value services and achieve cost- research demonstrates increased use of positive conscious care. Amir Qaseem. 2014 religious coping among some survivors with high- Improving quality of care while decreasing the er rates of posttraumatic stress disorder. Much of cost of health care is a national priority. The Amer- the scholarship in this area includes qualitative ican College of Physicians recently launched its studies with populations who face increased vul- High-Value Care Initiative to help physicians and nerability to interpersonal trauma. Research in this patients understand the benefits, harms, and area covers the life span from childhood to later costs of interventions and to determine whether adulthood and encompasses both domestic and services provide good value. Public and private international studies. The implications of research payers continue to measure underuse of high- findings are explored, and future research needs value services (for example, preventive services, are described. This line of research supports the medications for chronic disease), but they are now American Psychological Association (2010) ethi- widely using performance measures to assess cal standards that note the recognition of spiritual use of low-value interventions (such as imaging and religious faith traditions as important aspects for patients with uncomplicated low back pain) and of the provision of ethical treatment. Researchers, using the results for public reporting and pay-for- clinicians, and advocates for trauma survivors are performance. This paper gives an overview of per- encouraged to attend to the faith traditions and formance measures that target low-value services beliefs of persons confronting the potential devas- to help physicians understand the strengths and tation of traumatic events. limitations of these measures, provides specific examples of measures that assess use of low-val- EP-51815 ue services, and discusses how these measures Equity in the receipt of oseltamivir in the United can be used in clinical practice and policy. States during the H1N1 pandemic. Niteesh K. Choudhry. 2014 EP-51814 OBJECTIVE: We assessed the relationship between individual characteristics and receipt of oseltamivir (Tamiflu) in the United States dur- 273 ing the H1N1 pandemic and other flu seasons. EP-51817 METHODS: In a cohort of individuals enrolled in Community-partnered research conference pharmacy benefit plans, we used a multivariate model: the experience of community partners in logistic regression model to measure associations care study. Esmeralda Pulido, Ana Ramos. 2014 between subscriber characteristics and filling a prescription for oseltamivir during 3 flu seasons THE PROBLEM: Conducting community-part- (October 2006–May 2007, October 2007–May nered research conferences is a powerful yet un- 2008, and October 2008–May 2010). In 19 states derutilized approach to translating research into with county-level influenza rates reported, we practice and improving result dissemination and controlled for disease burden. RESULTS: Ap- intervention sustainability strategies. Nonethe- proximately 56 million subscribers throughout the less, detailed descriptions of conference features United States were included in 1 or more study and ways to use them in empirical research are periods. During pandemic flu, beneficiaries in the rare. PURPOSE: We describe how community- highest income category had 97% greater odds of partnered conferences may be integrated into receiving oseltamivir than those in the lowest cate- research projects by using an example of Com- gory (P < .001). After we controlled munity Partners in Care (CPIC), a large, cluster- for disease burden, subscribers in the 2 highest randomized, controlled, trial (RCT) that uses com- income categories had 2.18 and 1.72 times the munity-partnered participatory research (CPPR) odds of receiving oseltamivir compared with those principles. KEY POINTS: Our conceptual model in the lowest category (P < .001 for illustrates the role community-partnered research both). CONCLUSIONS: Income was a stronger conferences may play in three study phases and predictor of oseltamivir receipt than prevalence describes how different conference features may of influenza. These findings corroborate concerns increase community engagement, build two-way about equity of treatment in pandemics, and they capacity, and ensure equal project ownership. call for improved approaches to distributing poten- CONCLUSIONS: As the number of community- tially life-saving treatments. partnered studies grows, so too does the need for practical tools to support this work. Community- EP-51816 partnered research conferences may be effective- Postscript: research agenda to guide the next ly employed in translational research to increase generation of public reports for consumers. Peggy two-way capacity building and promote long-term McNamara. 2014 intervention success. There is significant interest in building the next EP-51818 generation of public reporting tools that will more Heterogeneity in healthy aging. Jay Bhattacha- effectively engage consumers and better enable rya. 2014 them to make use of comparative performance information when selecting a provider. Demand For a surprisingly large segment of the older for public reporting tools that make health care population, chronological age is not a relevant cost and quality information transparent is fueled marker for understanding, measuring, or expe- by a variety of market forces underway. A host of riencing healthy aging. Using the 2003 Medical public reporting efforts and studies have identi- Expenditure Panel Survey and the 2004 Health fied a number of challenges, highlighting that, we and Retirement Study to examine the proportion still do not understand how best to design public of Americans exhibiting five markers of health and reports to meet the needs of the consumer. We the variation in health-related quality of life across identify five areas for additional research that, if each of eight age groups, we find that a significant addressed, could foster better design and delivery proportion of older Americans is healthy within of quality and cost information to consumers. every age group beginning at age 51, including among those aged 85+. For example, 48% of those 274 aged 51–54 and 28% of those aged 85+ have ex- clarify the characteristics of state MMLs in place cellent or very good self-reported health status; since 1990 that are most relevant to consumers/ similarly, 89% of those aged 51–54 and 56% of patients and categorizes those aspects most likely those aged 85+ report no health-based limitations to affect the prevalence of use, and consequently in work or housework. Also, health-related qual- the intensity of public health and welfare effects. ity of life ranges widely within every age group, Evidence shows treating MMLs as homogeneous yet there is only a comparatively small variation in across states is misleading and does not reflect median quality of life across age groups, suggest- the reality of MML making. This variation likely has ing that older Americans today may be experienc- implications for use and health outcomes, and ing substantially different age-health trajectories thus states' public health. than their predecessors. Patterns are similar for medical expenditures. Several policy implications EP-51821 are explored. Design of the Violence and Stress Assessment (ViStA) study: a randomized controlled trial of care EP-51819 management for PTSD among predominantly La- Issuance of patient reminders for influenza vac- tino patients in safety net health centers. David cination by U.S.-based primary care physicians Eisenman. 2014 during the first year of universal influenza vaccina- Posttraumatic stress disorder (PTSD) is a com- tion recommendations. Katherine M. Harris. 2014 mon problem in primary care. Although effective To estimate the number of physician-reported treatments are available, little is known about influenza vaccination reminders during the 2010– whether such treatments are effective within the 2011 influenza season, the first influenza season context of Federally Qualified Health Centers after universal vaccination recommendations for (FQHCs) that serve as national "safety nets" for influenza were introduced, we interviewed 493 providing primary care for low income and un- members of the Physicians Consulting Network. derinsured patients. The Violence and Stress Patient vaccination reminders are a highly effec- Assessment (ViStA) study is the first random- tive means of increasing influenza vaccination; ized controlled trial (RCT) to test the impact of a nonetheless, only one quarter of the primary care care management intervention for treating PTSD physicians interviewed issued influenza vaccina- in FQHCs. To develop a PTSD management in- tion reminders during the first year of universal tervention appropriate for lower resource FQHCs vaccination recommendations, highlighting the and the predominantly Latino patients they serve, need to improve office-based promotion of influ- formative work was conducted through a collab- enza vaccination. orative effort between researchers and an FQHC practice-based research network. This article de- EP-51820 scribes how FQHC stakeholders were convened Words can be deceiving: a review of variation to review, assess, and prioritize evidence-based among legally effective medical marijuana laws in strategies for addressing patient, clinician, and the United States. Anne Boustead. 2014 system-level barriers to care. This multi-compo- When voters in two US states approved the nent care management intervention incorporates recreational use of marijuana in 2012, public de- diagnosis with feedback, patient education and bates for how best to promote and protect pub- activation; navigation and linkage to community lic health and safety started drawing implications resources; clinician education and medication from states' medical marijuana laws (MMLs). guidance; and structured cross-disciplinary com- However, many of the discussions were simplified munication and continuity of care, all facilitated to the notion that states either have an MML or do by care managers with FQHC experience. We not; little reference was made to the fact that legal also describe the evaluation design of this five- provisions differ across states. This study seeks to year RCT and the characteristics of the 404 Eng- 275 lish or Spanish speaking patients enrolled in the self-reported sociodemographic characteristics study and randomized to either the intervention or (child's race/ethnicity, child's gender, family so- to usual care. Patients are assessed at baseline, cioeconomic status, and study site) and reasons six months, and 12 months to examine interven- for ownership. Eighteen percent (n = 880) of the tion effectiveness on PTSD, other mental health families reported firearms in the home. Families symptoms, health-related quality-of-life, health with African American and Hispanic children had care service use; and perceived barriers to care lower odds of owning firearms than families with and satisfaction with care. non-Hispanic White children. The most common reasons for ownership were protection from crime EP-51822 and hunting. Six percent (n = 56) of the families Why changes in price matter when thinking with firearms stored at least one firearm unlocked, about marijuana policy: a review of the literature assembled, without a trigger lock, and with un- on the elasticity of demand. Russell Lundberg. locked ammunition. Compared with families with 2014 non-Hispanic White children, families with African Recent debates regarding liberalization of mari- American children engaged in safer storage prac- juana policies often rest on assumptions regard- tices. Results can inform childhood firearm injury ing the extent to which such policy changes would prevention activities. lead to a change in marijuana consumption and by whom. This paper reviews the economics liter- EP-51824 ature assessing the responsiveness of consump- Does stewardship make a difference in the qual- tion to changes in price and enforcement risk and ity of care? Evidence from clinics and pharmacies explicitly considers how this responsiveness var- in Kenya and Ghana. Ifelayo P. Ojo, Nicholas ies by different user groups. In doing so, it demon- Burger. 2014 strates how most of the research has examined OBJECTIVE: To measure level and variation responsiveness to prevalence of use, which is a of healthcare quality provided by different types of composite of different user groups, rather than healthcare facilities in Ghana and Kenya and which level of consumption among regular or heavy factors (including levels of government engage- users, which represent the largest share of total ment with small private providers) are associated quantities consumed. Thus, it is not possible to with improved quality. DESIGN: Provider knowl- generate reliable estimates of the impact of liber- edge was assessed through responses to clini- alizing policies on either tax revenues or harms, cal vignettes. Associations between performance as these outcomes are most directly influenced by on vignettes and facility characteristics, provider the amounts consumed by regular or heavy users, characteristics and self-reported interaction with not prevalence rates. government were examined using descriptive EP-51823 statistics and multivariate regressions. SETTING: Prevalence and correlates of firearm ownership Survey of 300 healthcare facilities each in Ghana in the homes of fifth graders: Birmingham, AL, and Kenya including hospitals, clinics, nursing Houston, TX, and Los Angeles, CA. Terri Lewis, homes, pharmacies and chemical shops. Private Thomas R. Simon. 2014 facilities were oversampled. PARTICIPANTS: Per- son who generally saw the most patients at each Firearms in the home are associated with in- facility. MAIN OUTCOME MEASURE(S): Percent creased injury risk, especially when loaded and of items answered correctly, measured against unlocked. In this study, 5,010 fifth-graders and clinical practice guidelines and World Health Or- their caregivers in three U.S. metropolitan areas ganization's protocol. RESULTS: Overall, average participated in the 2004-2006 Healthy Passag- quality was low. Over 90% of facilities performed es study on adolescent health. Firearm owner- less than half of necessary items. Incorrect anti- ship and storage patterns were examined by four biotic use was frequent. Some evidence of posi- 276 tive association between government stewardship care price growth under the Affordable Care Act and quality among clinics, with the greatest effect may result in a spillover slowdown in hospital utili- (7% points increase, P = 0.03) for clinics reporting zation and spending among the nonelderly. interactions with government across all six stewardship elements. No analogous association was EP-51826 found for pharmacies. No significant effect for any The exchange between quantity and quality. of the stewardship elements individually, nor ac- 2014 cording to type of engagement. CONCLUSIONS: In economic analysis, the cost isoquant be- Government stewardship appears to have some tween two different commodities from the point of cumulative association with quality for clinics, view of a purchaser or a producer is in the gen- suggesting that comprehensive engagement with eral (possibly noncompetitive) case assumed to providers may influence quality. However, our re- be concave to the origin — the limiting case being search indicates that continued medical education that of a purchasing unit with no monopsonistic (CME) by itself is not associated with improved power forced to move along a budget curve which care. is a straight line. EP-51825 Cutting Medicare hospital prices leads to a EP-51827 spillover reduction in hospital discharges for the Sphere drag in a low-density supersonic flow. nonelderly. 2014 2014 OBJECTIVE: To measure spillover effects of Sphere drag coefficients were measured in the Medicare inpatient hospital prices on the non- Berkeley Low Density Wind Tunnel at Mach equals elderly (under age 65). PRIMARY DATA SOURC- 2, 4, and 6, and free stream Reynolds numbers ES: Healthcare Cost and Utilization Project State between 10 and 10,000 for both insulated and Inpatient Databases (10 states, 1995–2009) and cold wall conditions. The measurements indicate Medicare Hospital Cost Reports. STUDY DESIGN: that sphere drag in this regime is strongly depen- Outcomes include nonelderly discharges, length dent on the Reynolds number behind a normal of stay and case mix, staffed hospital bed-days, shock wave, and only weakly dependent on Mach and the share of discharges and days provided to number. In addition, it was found that a decrease the elderly. We use metropolitan statistical areas in wall temperature/stagnation temperature (T sub as our markets. We use descriptive analyses com- w/T sub o) from 1 to 0.26 was accompanied by a 5 paring 1995 and 2009 and panel data fixed-effects - 10% decrease in the drag coefficient. A precision regressions. We instrument for Medicare prices microbalance was used to obtain data for insulat- using accumulated changes in the Medicare pay- ed spheres, and a moving model technique was ment formula. PRINCIPAL FINDINGS: Medicare used to obtain data for small spheres falling freely price reductions are strongly associated with re- through a wind tunnel jet. These latter tests were ductions in nonelderly discharges and hospital performed using both cold and insulated models. capacity. A 10-percent reduction in the Medicare The results on insulated spheres at M equal 2 and price is estimated to reduce discharges among 4 were in good agreement with the measurements the nonelderly by about 5 percent. Changes in the of other investigators. The results of the cold wall Medicare price are not associated with changes in tests indicate that for Mach numbers greater than the share of inpatient hospital care provided to the 5 in air, sphere drag coefficients are a function elderly versus nonelderly. CONCLUSIONS: Medi- only of T sub w/T sub o and the post normal shock care price reductions appear to broadly constrain Reynolds number. hospital operations, with significant reductions in utilization among the nonelderly. The slow Medi- EP-51828 Perspective: some possible pitfalls in the design and use of PERT networking. 2014 277

This article presents a diagnostic review of in time; however, there are clear disparities). It the PERT (Program Evaluation and Review Tech- suggests that if one wants to understand the role nique) technique, and defines the technique and of the environment in the obesity epidemic, one outlines some of the problematic aspects of de- needs to understand changes over time affecting signing a PERT Cost system that may have an im- all groups, not differences between subgroups at pact on schedule and cost performance. The au- a given time. Although economic and technologi- thor discusses observations on the construction of cal changes in the environment drove the obesity proposal networks and pitfalls in networking, such epidemic, the evidence for effective economic as the sophistry of the black boxes, the vendor policies to prevent obesity remains limited. Taxes nose constraining the vertical fin design, grouping on foods with low nutritional value could nudge of engineering releases, waiting time, the reversal behavior toward healthier diets, as could subsi- of constraints, acceptable level of technical risk, dies/discounts for healthier foods. However, even and updating of subsidiary networks. He reminds a large price change for healthy foods could close users of the PERT technique that a sound, syn- only part of the gap between dietary guidelines thesized system design is complex and necessi- and actual food consumption. Political support has tates adherence to the prescribed procedures. been lacking for even moderate price interven- EP-51829 tions in the United States and this may continue Juvenile crime and juvenile justice. 2014 until the role of environmental factors is accepted From coverage provided by the news media more widely. As opinion leaders, clinicians play an juveniles are perceived as committing more vio- important role in shaping the understanding of the lence, and popular media also conveys the im- causes of obesity. pression that their violence is becoming more cal- lous and gratuitous. Many juvenile killings appear EP-51831 Trends in health of older adults in the United to take place without any rational cause or pur- States: past, present, future. Robert F. Schoeni. pose. It is this latter characteristic, hardened mal- 2014 ice, that has caused many to question the concept of protecting and rehabilitating youth--upon which The decline in late-life disability prevalence in the juvenile justice system has historically been the United States was one of the most important based. This section will attempt to reconcile the developments in the well-being of older Ameri- available data with these common perceptions. cans in the 1980s and 1990s, but there is no guarantee that it will continue into the future. We review EP-51830 the past literature on trends in disability and other Obesity and economic environments. Ruopeng health indicators and then estimate the most re- An. 2014 cent trends in biomarkers and limitations for both This review summarizes current understanding the population aged 65 and older and those aged of economic factors during the obesity epidemic 40 to 64, the future elderly. We then investigate and dispels some widely held, but incorrect, be- the extent to which trends in education, smoking, liefs. Rising obesity rates coincided with increases and obesity can account for recent trends in limi- in leisure time (rather than increased work hours), tations and discuss how these three factors might increased fruit and vegetable availability (rather influence future prospects for late-life health. We than a decline in healthier foods), and increased find that improvements in the health of the older exercise uptake. As a share of disposable income, population generally have continued into the first Americans now have the cheapest food avail- decade of the twenty-first century. The recent in- able in history, which fueled the obesity epidem- crease in the proportion of the younger popula- ic. Weight gain was surprisingly similar across tion needing help with activities of daily living is sociodemographic groups or geographic areas, concerning, as is the doubling of obesity in the rather than specific to some groups (at every point last few decades. However, the increase in obe- 278 sity has recently paused, and favorable trends in heterogeneity of survival among the least advan- education and smoking are encouraging. taged, as well as a possible expansion of morbidity among a small advantaged group. EP-51832 Who takes up free flu shots? Examining the EP-51834 effects of an expansion in coverage. Ilaria Mosca. Trends in late-life activity limitations in the Unit- 2014 ed States: an update from five national surveys. Brenda C. Spillman, Patricia M. Andreski. 2014 The risk of costly complications and the externalities of contagious diseases lead many coun- This article updates trends from five national tries provide free flu shots to certain populations. U.S. surveys to determine whether the prevalence In 2008, the Netherlands expanded their flu shot of activity limitations among the older popula- program to cover all individuals over the age of 60, tion continued to decline in the first decade of the instead of 65. We investigate the effects of the ex- twenty-first century. Findings across studies sug- pansion and examine those factors that influence gest that personal care and domestic activity limi- people to change their behavior. We find that the tations may have continued to decline for those main barrier to take up of free flu shots is labor ages 85 and older from 2000 to 2008, but gener- force participation. Expansion of the program did ally were flat since 2000 for those ages 65–84. little to change the behavior of those at increased Modest increases were observed for the 55- to risk, primarily because these individuals were al- 64-year-old group approaching late life, although ready getting flu shots. prevalence remained low for this age group. Inclu- sion of the institutional population is important for EP-51833 assessing trends among those ages 85 and older Modeling disability trajectories and mortality in particular. of the oldest-old in China. Linda G. Martin. 2014 This article uses a group-based modeling ap- EP-51835 proach to jointly estimate disability and mortality Sociotechnical reinvention: implementation trajectories over time based on data from the pop- dynamics and collaboration tools. 2014 ulation aged 80 and older in China, and explores Sociotechnical systems theory suggests sev- relations of demographic, socioeconomic, and eral themes about implementation, including con- early-life characteristics to membership in gender- tinuous mutual adaptation of tool and context, task specific trajectory groups. A three-group model emphasis, the priority of process, and changes in best fits the data for both males and females. For evaluative criteria over time. The effectiveness of most groups, predicted numbers of limitations in these ideas is illustrated in the experience of the activities of daily living (ADLs) increase with age, World Bank in its implementation of a group deci- but the pace is gradual in some cases and rapid sion support system, GroupSystems. in others. For each gender, the estimated mortality probability trajectories for the three groups EP-51837 follow a hierarchy that is related to the predicted Welfare reform and abortion. 2014 ADL counts at age 80. Only a few characteristics This chapter has considered the likely effects of predict trajectory-group membership. Prior non- the Personal Responsibility and Work Opportunity agricultural occupation is associated with less Reconciliation Act of 1996 on abortion and the re- favorable disability trajectories for both genders. search considerations in exploring that issue. For females, rural residence, a greater number of children ever born, and having a father who did EP-51838 not work in agriculture are associated with more Updated trends in imaging use in men diag- favorable trajectories. For a small group of males who received education, disability is moderate but changes little with age. Findings may reflect 279 nosed with prostate cancer. Alexandria C. Smith. initiated incidents in the early stages of program 2014 preparation. Our results are consistent with the BACKGROUND: Previous studies have found hypothesis that insurgents try to sabotage the persistent overuse of imaging for clinical staging program because its success would weaken their of men with low-risk prostate cancer. We aimed to support in the population. determine imaging trends in three cohorts of men. EP-51840 METHODS: We analyzed imaging trends of men Declines in late-life disability: the role of early - with prostate cancer who were a part of Cancer and mid-life factors. Linda G. Martin. 2014 of the Prostate Strategic Urologic Research En- deavor (CaPSURE) (1998–2006), were insured Investigations into the reasons for declines by Medicare (1998–2006), or privately insured (In- in late-life disability have largely focused on the genix database, 2002–2006). The rates of com- role of contemporaneous factors. Adopting a life- puted tomography (CT), magnetic resonance im- course perspective as a backdrop, in this paper aging (MRI) and bone scan (BS) were determined we ask whether there also has been a role for and time trends were analyzed by linear regres- selected early- and mid-life factors in the decline, sion. For men in CaPSURE, demographic and and if so whether these factors have been operat- clinical predictors of test use were explored using through changes in the risks of disability on- ing a multivariable regression model. RESULTS: set or recovery. Drawing on five waves from 1995 Since 1998, there was a significant downward to 2004 of the U.S. Health and Retirement Study, trend in BS (16%) use in the CaPSURE cohort we found for the 75 years and older population (N=5156). There were slight downward trends (2.4 in the United States that the prevalence of diffi- and 1.7%, respectively) in the use of CT and MRI. culty with activities of daily living (ADL) declined Among 54 322 Medicare patients, BS, CT from 30.2% in 1995 to 26.0% in 2004, whereas and MRI use increased by 2.1, 10.8 and 2.2% and the trend in difficulty with instrumental activities of among 16 161 privately insured patients, daily living (IADL) was flat. Onset of ADL limita- use increased by 7.9, 8.9 and 3.7%, respectively. tions also was reduced during this period while In CaPSURE, the use of any imaging test was recovery increased. Changes in the educational greater in men with higher-risk disease. In addi- composition of the older population were linked to tion, type of insurance and treatment affected the declines in the prevalence of ADL limitations, but use of imaging tests in this population. CONCLU- there were also modest contributions of changes SIONS: There is widespread misuse of imaging in mother's education, self-rated childhood health, tests in men with low-risk prostate cancer, particu- and lifetime occupation. Declines in late-life vi- larly for CT. These findings highlight the need for sion impairments and increases in wealth also examination of factors that drive decision making contributed substantially to the downward trend, with respect to imaging in this setting. and had chronic conditions not increased, it would have been even larger. Reductions in the onset of EP-51839 ADL limitations were partly driven by changes in Aid under fire: development projects and civil educational attainment of respondents and their conflict. Patrick B. Johnston. 2014 mothers and, in late-life, better vision and wealth. We estimate the causal effect of a large de- In contrast, the recovery trend was not account- velopment program on conflict in the Philippines ed for by changes in early- or mid-life factors. We through a regression discontinuity design that ex- conclude that early- and mid-life factors have con- ploits an arbitrary poverty threshold used to assign tributed along with late-life factors to U.S. late-life eligibility for the program. We find that barely eli- disability trends mainly through their influence on gible municipalities experienced a large increase the onset of, rather than recovery from, limitations. in conflict casualties compared to barely ineligible EP-51841 ones. This increase is mostly due to insurgent- 280

Interventions to improve late life. 2014 tion of low-nutrient energy-dense food. We tested Comments on the future of the demography differences in the associations of unhealthy be- of aging at an invited session of the 2008 annual haviors over time, and by gender, race/ethnicity, meeting of the Population Association of America. and socioeconomic status. METHODS: Partici- The author proposes that population scientists pants were 8360 students from 16 middle schools working in aging emulate those studying fertility in California (50% female; 52% Hispanic, 17% and family planning in previous decades, learning Asian, 16% White, and 15% Black/multiethnic/ from interventions (in this case, aimed at increas- other). Behaviors were measured with surveys in ing retirement savings and reducing disability at Spring 2010 and Spring 2011. Confirmatory factor older ages). analysis was used to assess if an underlying factor accounted for the covariance of multiple behav- EP-51842 iors, and composite reliability methods were used Information technology and high-performance to determine the degree to which behaviors were teams: creating value through knowledge. Susan related. RESULTS: The measured behaviors were G. Cohen. 2014 explained by two moderately correlated factors: a 'substance use risk factor' and an 'unhealthy eat- In this chapter, the authors examine how digital ing and sedentary factor'. Physical inactivity did information and communication media help make not reflect the latent factors as expected. There teams more effective. were few differences in the associations among these behaviors over time or by demographic EP-51843 characteristics. CONCLUSIONS: Two distinct, yet Disability insurance and health insurance re- related groups of health compromising behav- form: evidence from Massachusetts. Kathleen J. iors were identified that could be jointly targeted Mullen. 2014 in multiple health behavior change interventions As health insurance becomes available outside among early adolescents of diverse backgrounds. of the employment relationship as a result of the Affordable Care Act (ACA), the cost of applying EP-51845 for Social Security Disability Insurance (SSDI)– Public reporting of provider performance at potentially going without health insurance cover- a crossroads in the United States: summary of age during a waiting period totaling 29 months current barriers and recommendations on how to from disability onset–will decline for many people move forward. Harold S. Luft. 2014 with employer-sponsored health insurance. At the Twenty-seven years after the first public release same time, the value of SSDI and Supplemental by the U.S. government of data on the quality of Security Income (SSI) participation will decline for hospital care, public reporting for consumers has individuals who otherwise lacked access to health expanded substantially. Despite the growth in pub- insurance. We study the 2006 Massachusetts lic reporting activities, there is limited evidence of health insurance reform to estimate the potential their use by consumers in ways that significantly effects of the ACA on SSDI and SSI applications. affect health care delivery. Support for public reporting continues, in part, because of the face val- EP-51844 ue of transparency. The limited impact of reporting Covariance among multiple health risk behav- efforts is plausibly due to flaws in the content, de- iors in adolescents. Elizabeth J. D'Amico. 2014 sign, and implementation of existing public reports PURPOSE: In a diverse group of early ado- rather than inherent limitations of reporting. Sub- lescents, this study explores the co-occurrence of stantial work is still needed for public reports to a broad range of health risk behaviors: alcohol, achieve their potential for engaging and informing cigarette, and marijuana use; physical inactivity; consumers. We present a vision statement and 10 sedentary computing/gaming; and the consump- recommendations to achieve this potential. 281

sonal stigma of mental health treatment seeking EP-51846 in a young adult sample. Andrew P. Paves. 2014 Reporting of context and implementation in studies of global health interventions: a pilot study. Perceived public stigma regarding seeking men- Paul G. Shekelle. 2014 tal health treatment can be a barrier to accessing services for young adults. While factors associat- BACKGROUND: There is an increasing push ing with personal stigma regarding how one would for 'evidence-based' decision making in global view and treat others have been identified, the health policy circles. However, at present there discrepancies between perceived and personal are no agreed upon standards or guidelines for stigma have received less research attention. We how to evaluate evidence in global health. Recent designed the current study to expand on previous evaluations of existing evidence frameworks that research and examine the discrepancies between could serve such a purpose have identified details perceived public stigma and personal stigma of program context and project implementation as among a sample of 386 primarily White and Asian missing components needed to inform policy. We college students. Participants completed surveys performed a pilot study to assess the current state of mental health symptoms, treatment experience of reporting of context and implementation in stud- and attitudes, perceived public, and personal stig- ies of global health interventions. METHODS: We ma. Overall, participants generally reported great- identified three existing criteria sets for implemen- er perceived public stigma than personal stigma; tation reporting and selected from them 10 criteria an effect that was particularly evident for women potentially relevant to the needs of policy makers and those with mental health symptoms. The main global health contexts. We applied these 10 cri- jority of participants disagreed with items assess- teria to 15 articles included in the evidence base ing personal stigma. Negative attitudes toward for three global health interventions chosen to treatment and anxiety symptoms associated with represent a diverse set of advocated global health perceived public stigma, while male gender, Asian programs or interventions: household water chlo- ethnicity, and negative attitudes toward treatment rination, prevention of mother-to-child transmis- associated with personal stigma. Findings have sion of HIV, and lay community health workers to implications for interventions and marketing pro- reduce child mortality. We used a good-fair-poor/ grams to help change perceptions about mental none scale for the ratings. RESULTS: The propor- health stigma to encourage utilization of services tion of criteria for which reporting was poor/none for those young people who could benefit from ranged from 11% to 54% with an average of 30%. care. Eight articles had 'good' or 'fair' documentation for greater than 75% of criteria, while five articles had EP-51848 'poor or none' documentation for 50% of criteria or Depression and health risk behaviors: towards more. Examples of good reporting were identified. optimizing primary care service strategies for CONCLUSIONS: Reporting of context and imple- addressing risk. Luis R. Zeledon, Elizabeth J. mentation information in studies of global health D'Amico. 2014 interventions is mostly fair or poor, and highly variable. The idiosyncratic variability in reporting PURPOSE: Depression and health risk behav- indicates that global health investigators need iors in adolescents are leading causes of prevent- more guidance about what aspects of context able morbidity and mortality. Primary care visits and implementation to measure and how to report provide prime opportunities to screen and provide them. This lack of context and implementation in- preventive services addressing risk behaviors/ formation is a major gap in the evidence needed conditions. This study evaluated the co-occur- by global health policy makers to reach decisions. rence of depression and health risk behaviors (focusing on smoking, drug and alcohol misuse, risky EP-51847 sexual behavior, and obesity-risk) with the goal of Comparing perceived public stigma and per- informing preventive service strategies. METH- 282

ODS: Consecutive primary care patients (n=217), weeks and extends over hundreds of kilometers. ages 13 to 18 years, selected to over-sample for depression, completed a Health Risk Behavior EP-51850 Survey and the Diagnostic Interview Schedule Focusing on the five A's: a comparison of for Children and Adolescents (DISC) depression homeless and housed patients' access to and use module. RESULTS: Youths with DISC-defined of pharmacist-provided smoking cessation treat- past-year depression were significantly more like- ment. Deborah M. Scharf. 2014 ly to report risk across multiple risk-areas, Wald INTRODUCTION: The prevalence of smoking X2(1)=14.39, p<.001, and to have significantly remains high among the medically underserved higher rates of past-month smoking, X2(1)=5.86, and could be related to disparities in access to p=.02, substance misuse, X2(1)=15.12, p<.001, and use of smoking cessation treatments. METH- risky sex,X2 (1) =5.04, p=.03, but not obesity- ODS: This study implemented and tracked provid- risk, X2 (1) =0.19,p=.66. Crosssectional pre- ers' use of the 5 A's intervention for tobacco use dictors of risk behaviors across risk areas were (Ask, Assess, Advise, Assist, Arrange) with home- similar. Statistically significant predictors across less (n = 260) and housed (n = 226) adults attend- all risk domains included: youths' expectancies ing a free medical clinic, including referrals to and about future risk behavior; attitudes regarding the use of an on-site pharmacist-led smoking cessa- risk behavior; and risk behaviors in peers/others tion service. RESULTS: Among patients whose to- in their environments. CONCLUSIONS: Depres- bacco use was Asked about and Assessed (97%), sion in adolescents is associated with a cluster of homeless (vs. housed) patients were more likely health risk behaviors that likely contribute to the to smoke (59% vs. 39%; P = 0.008). Among cur- high morbidity and mortality associated with both rent smokers, there were no homeless-housed depression and health risk behaviors. Consistent disparities in receipt of Advice to quit smoking with the United States National Prevention Strat- (84% vs. 78%; P = 0.22) or Arrangement of treat- egy (2011) and the focus on integrated behavioral ment (36% vs. 31%; P = 0.46). Overall, among pa- and medical health care, results suggest the value tients for whom treatment was Arranged, home- of screening and preventive services using combi- less patients were less likely than housed patients nation strategies that target depression and mul- to attend the smoking cessation program (25% vs. tiple areas of associated health risk. 48%; P = 0.04). However, among those that attended any treatment (i.e., were Assisted to quit), EP-51849 homeless and housed patients attended similar Sustaining critical social services during ex- numbers of sessions and used pharmacotherapy tended regional power blackouts. 2014 at similar rates. CONCLUSIONS: Providers may Despite continuing efforts to make the elec- reduce homeless-housed disparities in smok- tric power system robust, some risk remains of ing by offering special Assist(ance) to homeless widespread and extended power outages due to smokers that reduces barriers to initially access- extreme weather or acts of terrorism. One way to ing treatment services. alleviate the most serious effects of a prolonged blackout is to find local means to secure the contin- EP-51851 ued provision of critical social services upon which Symptom persistence in a community cohort the health and safety of society depend. This arti- of women with interstitial cystitis/bladder pain syn- cle outlines and estimates the incremental cost of drome (IC/BPS): 3-, 6-, 9-, and 12-month follow-up a strategy that uses small distributed generation, from the RICE cohort. Sandra H. Berry. 2014 distribution automation, and smart meters to keep INTRODUCTION AND HYPOTHESIS: The a set of critical social services operational during persistence of interstitial cystitis/bladder pain syn- a prolonged power outage that lasts for days or drome (IC/BPS) symptoms has been described in women seeking medical care. The purpose of this 283 study was to determine whether symptoms per- created uncertainty regarding the comparative ef- sist among a population-based sample of women. fectiveness of these 2 treatment options. OBJEC- METHODS: A probability sample of US women TIVE: To compare the effectiveness of SWL and was identified through a two-stage telephone URS to fragment or remove urinary stones in a screening process using the Research and Devel- large private payer cohort. DESIGN, SETTING, opment (RAND) Interstitial Cystitis Epidemiology AND PARTICIPANTS: We performed a retrospec- (RICE) high-sensitivity case definition. A randomly tive cohort study of privately insured beneficiaries selected subgroup (n = 508) was who had an emergency department visit for a kid- enrolled in a longitudinal study and interviewed ney stone and subsequently underwent SWL or about their symptoms at baseline, 3, 6, 9, and URS. Using an instrumental variable approach to 12 months. Bivariate and multivariate linear re- control for observed and unobserved differences gression analyses determined predictors of per- between the 2 groups, we created a bivariate pro- sistence of symptoms over the four waves. RE- bit model to estimate the probability of repeat inter- SULTS: A total of 436 women with a mean age vention following an initial procedure. MAIN OUT- of 47.5 years responding to all waves were in- COMES AND MEASURES: A second procedure cluded in the analysis. Forty-one percent met the (SWL or URS) within 120 days of an initial inter- RICE high-sensitivity case definition at baseline vention to fragment or remove or a kidney stone. and in all four waves; an additional 21 % met the RESULTS: Following an acute care visit for a kid- definition at baseline and in three waves. Wom- ney stone, 21 937 patients (45.8%) under- en with a college degree (+12 % vs. no college, went SWL and 25 914 patients (54.2%) p = 0.02) and who were young- underwent URS to fragment or remove the stone. er (−5 % per decade of age, p After the initial URS, 4852 patients (18.7%) under- < 0.01) had higher chances of symptom went an additional fragmentation or removal pro- persistence at each wave. Scoring one standard cedure compared with 5186 patients (23.6%) after deviation higher on the continuity of symptoms the initial SWL (P < .001). After and the O'Leary–Sant Interstitial Cystitis Symp- adjusting for observed and unobserved variables, tom index increased the chances of symptom the estimated probabilities of repeat intervention persistence by 4 % and 2 %, respectively (both were 11.0% (95% CI, 10.9-11.1) following SWL p < 0.01). CONCLUSIONS: The and 0.3% (95% CI, 0.325-0.329) following URS. majority of women demonstrated symptom per- CONCLUSIONS AND RELEVANCE: Among pri- sistence across at least three of four waves over vately insured beneficiaries requiring procedural 12 months. These women tended to be younger, intervention to remove a symptomatic stone, re- college-educated, and to have reported a history peat intervention is more likely following SWL. For of greater continuity of symptoms and higher se- the marginal patient (as opposed to the average verity of symptoms at baseline. patient), the probability of repeat intervention is substantially higher. EP-51852 Comparative effectiveness of shock wave litho- EP-51853 tripsy and ureteroscopy for treating patients with Assessing the contribution of parks to physical kidney stones. Julie Lai. 2014 activity using global positioning system and accelerometry. Fang Wen, Amy Hillier. 2014 IMPORTANCE: Shock wave lithotripsy (SWL) and ureteroscopy (URS) account for more than PURPOSE: Parks offer a free option for physi- 90% of procedural interventions for kidney stones, cal activity in many communities. How much time which affect 1 in 11 persons in the United States. people spend using parks and the contribution Efficacy data for SWL are more than 20 years old. that parks makes to their physical activity is not Advances in URS, along with emerging evidence known. This study describes patterns of park use of reduced efficacy of modern lithotripters, have and physical activity among a diverse adult sam- 284 ple. METHODS: From five US states, 248 adults Examination Survey III, 1988–1994. We utilized enrolled in or near 31 study parks. Participants random-intercept hierarchical generalized Pois- wore a global positioning system (GPS) monitor son regression models to conduct our multivariate (Qstarz BT-Q1000X) and an ActiGraph acceler- analyses. RESULTS: We find that inflammatory ometer (GT1M) concurrently for 3 wk. Parks were response is related to both the evenness and ex- mapped from local and national park shape files. posure domains of segregation. That is, both the Park visits and travel to and from the parks were unequal distribution of minority groups over areal derived from the objective data. RESULTS: Par- units as well as the degree of potential contact be- ticipants visited parks a median of 2.3 times per tween minority and majority group members are week, and park visits lasted a median of 42.0 related to these predisease pathways. CONCLU- min. Overall, participants engaged in a median SIONS: In this study, we build on prior research of 21.7 min•d-1 of moderate activity and 0.1 by Massey (2004) to investigate the relationships min•d-1 of vigorous activity, with an average between two distinct dimensions of segregation of 8.2% of all moderate and 9.4% of all vigorous and allostatic load. Our results indicate that seg- activity occurring within the parks. Among those regation is a significant predictor of allostatic load, with at least one park visit (n = 218), counts per net of individual-level characteristics. minute, moderate, moderate-to-vigorous physical activity (MVPA), number and time in MVPA bouts EP-51855 per day, and sedentary behavior were all higher on Comprehensive healthcare: why is the inclusion days when a park was visited compared with days of reproductive health controversial for women but when a park was not visited. Considering several not men?. Chloe E. Bird. 2014 definitions of active travel, walking or bicycling Whether comprehensive healthcare for women to and from the park added an additional 3.7-6.6 includes birth control, abortion, or even reproduc- mean minutes of MVPA per park visit. CONCLU- tive healthcare remains controversial in the United SIONS: Parks contributed as a place and destina- States. Women have long been faced with health tion for physical activity but were underused. One insurance options that could exclude pregnancy, of the next steps in this line of inquiry is to under- even when it was not a preexisting condition. Mul- stand characteristics of parks used more often as tiple arguments have recently been made as to a place and destination for physical activity. why birth control should not be mandated coverage for women. Comprehensive care for women EP-51854 that broadly includes reproductive care is not yet Contextual predictors of cumulative biological the standard of care, despite recognition of the risk: segregation and allostatic load. Brian Karl gaps and the many consequences for women's Finch. 2014 health. OBJECTIVES: Segregation is considered to EP-51856 be a fundamental cause of race/ethnic disparities Patient Aligned Care Teams (PACT): VA's jour- in health. However, very few studies have tested ney to implement patient-centered medical homes. whether levels of segregation are related to health Matthew J. Bair, Olveen Carrasquillo. 2014 outcomes using multilevel data and appropriate methodologies. In this study, we investigate the In 2010, the US Department of Veterans Affairs relationships between two distinct dimensions (VA) launched national implementation of patient- of segregation and allostatic load to determine centered medical homes (PCMH) through the Pa- whether the experiences of individuals in segre- tient Aligned Care Teams (PACT) initiative, as de- gated neighborhoods are related to allostatic load scribed by Gordon Schectman and Richard Stark, as a possible predisease indicator. METHODS: the chief architects of PACT, in their commentary To test our hypotheses, we utilized publicly avail- to this Supplement. Concurrently, the PACT initia- able data from the National Health and Nutrition 285 tive aimed to incorporate rigorous formative and was high for measles/mumps/rubella (MMR) vac- summative evaluation of PACT implementation cine and febrile seizures; the varicella vaccine and to promote PACT-related innovation develop- was associated with complications in immunode- ment and testing. To accomplish these goals, the ficient individuals. There is strong evidence that initiative established a national evaluation team MMR vaccine is not associated with autism. There (based in Seattle) and competitively funded five is moderate evidence that rotavirus vaccines are PACT Demonstration Laboratories (in Ann Arbor, associated with intussusception. Limitations of Los Angeles, Iowa City, Philadelphia, and Port- the study include that the majority of studies did land). In addition, embedded health services re- not investigate or identify risk factors for AEs; and searchers and clinical leader partners from out- the severity of AEs was inconsistently reported. side the Demonstration Laboratories undertook CONCLUSIONS: We found evidence that some relevant studies. Together, the implementation vaccines are associated with serious AEs; how- and evaluation components of PACT as reported ever, these events are extremely rare and must be in this Supplement's articles document opportuni- weighed against the protective benefits that vac- ties. cines provide. EP-51858 EP-51857 The state of innovative emergency medical ser- Safety of vaccines used for routine immuniza- vice programs in the United States. Abby Alpert. tion of US children: a systematic review. Lopamu- 2014 dra Das. 2014 BACKGROUND: The primary objective of this BACKGROUND: Concerns about vaccine safe- study was to determine how EMS organizations ty have led some parents to decline recommended that are piloting patient-centered treatment and vaccination of their children, leading to the resur- transport protocols are approaching the challeng- gence of diseases. Reassurance of vaccine safety es of implementation, reimbursement, and qual- remains critical for population health. This study ity assurance. We were particularly interested in systematically reviewed the literature on the safety determining if these pilot efforts have raised any of routine vaccines recommended for children in patient safety concerns. METHODS: We conduct- the United States. METHODS: Data sources ined a set of discussions with a small group of key cluded PubMed, Advisory Committee on Immu- EMS stakeholders regarding the status of pioneer- nization Practices statements, package inserts, ing efforts to develop and evaluate innovative ap- existing reviews, manufacturer information pack- proaches to EMS in the United States. RESULTS: ets, and the 2011 Institute of Medicine consensus We had discussions with 9 EMS agencies to bet- report on vaccine safety. We augmented the Insti- ter understand their innovative programs, includ- tute of Medicine report with more recent studies ing: the history of their service policy and proce- and increased the scope to include more vaccines. dure for transports that do not require emergency Only studies that used active surveillance and had department care; the impact of their innovative a control mechanism were included. Formulations program on service costs and/or cost savings; any not used in the United States were excluded. Ad- reimbursement issues or changes; patient safety; verse events and patient and vaccine characteris- patient satisfaction; and overall impression as well tics were abstracted. Adverse event collection and as recommendations for other EMS systems con- reporting was evaluated by using the McHarm sidering adoption of this policy. CONCLUSIONS: scale. We were unable to pool results. Strength In general, EMS systems are not reimbursed for of evidence was rated as high, moderate, low, or service unless the patient is transported to an ED. insufficient. RESULTS: Of 20 478 titles Spokespersons for all nine sites covered by this identified, 67 were included. Strength of evidence project said that this policy creates a powerful dis- 286 incentive to implementing pilot programs to safely EP-51860 reduce EMS use by directing patients to more ap- Perceptions of behavioral health care among propriate sites of care or proactively treating them veterans with substance use disorders: results in their homes. Even though private and public from a national evaluation of mental health servic- hospitals and payers typically benefit from these es in the Veterans Health Administration. Leena programs, they have been generally reluctant to Bui, Alex H. S. Harris. 2014 offer support. This raises serious questions about the long-term viability of these programs. Understanding patients' perceptions of care is essential for health care systems. We exam- EP-51859 ined predictors of perceptions of behavioral pSCANNER: patient-centered Scalable Na- health care (satisfaction with care, helpfulness tional Network for Effectiveness Research. Zia of care, and perceived improvement) among Agha, Douglas S. Bell. 2014 veterans with substance use disorders (SUD; This article describes the patient-centered Scal- n = 1,581) who participated in a able National Network for Effectiveness Research phone survey as part of a national evaluation of (pSCANNER), which is part of the recently formed mental health services in the U.S. Veterans Health PCORnet, a national network composed of learn- Administration. In multivariate analyses, SUD spe- ing healthcare systems and patient-powered re- cialty care utilization and higher mental health search networks funded by the Patient Centered functioning were associated positively with all per- Outcomes Research Institute (PCORI). It is de- ceptions of care, and comorbid schizophrenia, bi- signed to be a stakeholder-governed federated polar, and PTSD were associated positively with network that uses a distributed architecture to in- multiple perceptions of care. Perceived helpful- tegrate data from three existing networks cover- ness of care was associated with receipt of SUD ing over 21 million patients in all 50 states: (1) VA specialty care in the prior 12 months Informatics and Computing Infrastructure (VINCI), (adjusted OR = 1.77, with data from Veteran Health Administration's 151 p < .001). Controlling for patient inpatient and 909 ambulatory care and commu- characteristics, satisfaction with care exhibited nity-based outpatient clinics; (2) the University of strong associations with perceptions of staff as California Research exchange (UC-ReX) network, supportive and empathic, whereas perceived im- with data from UC Davis, Irvine, Los Angeles, San provement was strongly linked to the perception Francisco, and San Diego; and (3) SCANNER, a that staff helped patients develop goals beyond consortium of UCSD, Tennessee VA, and three symptom management. Survey responses that federally qualified health systems in the Los An- account for variation in SUD patients' perceptions geles area supplemented with claims and health of care could inform and guide quality improve- information exchange data, led by the University ment efforts with this population. of Southern California. Initial use cases will focus EP-51861 on three conditions: (1) congestive heart failure; Terrorism and the labor force: evidence of an (2) Kawasaki disease; (3) obesity. Stakeholders, effect on female labor force participation and the such as patients, clinicians, and health service re- labor gender gap. Jordan Ostwald. 2014 searchers, will be engaged to prioritize research Recent studies have identified correlational as- questions to be answered through the network. We sociations linking terrorism and females' standing will use a privacy-preserving distributed computa- in the labor market. Theories have been proposed tion model with synchronous and asynchronous to explain these associations. Some concluded modes. The distributed system will be based on a that women's participation in the labor force could common data model that allows the construction be the driver that moves terrorism; others pro- and evaluation of distributed multivariate models posed that terrorism motivates the deviations in for a variety of statistical analyses. the labor force. No study has adequately explored 287 causality and the direction of this association. Us- globally absolute poor (incomes below $1pd) and ing a panel data set of 165 countries and terror- those with discretionary cash incomes living in the ism data from 1980 to 2007, we find that terrorist margins above $1pd. The paper concludes with a attacks decrease female labor force participa- call for a more holistic and balanced approach to tion and increase the gender gap between male inclusive innovation to be adopted by a range of and female labor force participation. By exploit- stakeholders so that resources are deployed most ing variation across countries and time, we are effectively to aid the recoupling of growth and de- able to identify and quantify these effects; we are velopment. also able to address endogeneity concerns by using two novel instrumental variable approaches. EP-51864 The results are statistically significant and robust Tailored deterrence: strategic context to guide across a multitude of model specifications. Joint Force 2020. Terrence K. Kelly. 2014 The Nation's defense and security strategies EP-51863 seek to deter enemies, yet DOD does not define Inclusive innovation: an architecture for policy precisely what or who is to be deterred or the development. Rebecca Hanlin, Raphael Kaplin- cost that can be met to achieve it. Accordingly, sky. 2014 force-sizing draws on assumptions, operational The past two decades have been character- concepts, and programmatic priorities that may ized by an increasing uncoupling of economic or may not relate directly to articulate defense growth and social and economic development. policies regarding tangible threats. For instance, Outside of China, the numbers living in absolute there is overinvestment in offensive capabilities to poverty have remained stubbornly large; in Africa, defeat China in Air-Sea Battle when a defensive they have increased substantially. Although this posture and A2/AD efforts with partners would be uncoupling has multiple sources, the trajectory of more cost-effective; simultaneously, there is un- innovation (large in scale, capital intensive in na- derinvestment in combined arms measures for ture and destructive of the environment) has con- confronting such regional powers as North Ko- tributed to these outcomes. Reorienting towards a rea and Syria and securing WMD in failed or fail- more 'inclusive innovation' path has an important ing states. DOD must array its resources against role to play in overcoming exclusion. However, we clearly identified threats and tasks. have only a weak understanding of the definition, nature and dynamics of inclusive innovation, and EP-51865 this paper seeks to fill this conceptual gap. It ar- Are mental disorders more common in urban gues that inclusive innovation needs to be under- than rural areas of the United States?. Grant N. stood and developed in the context of a holistic Marshall. 2014 conception of the innovation cycle, the distinction Urban vs. rural residence is commonly cited as between process and product innovation and the a risk factor for depression and other mental dis- roles played by the poor as both producers and orders, but epidemiological evidence for this rela- consumer. It further charts the growing interest of tionship in the US is inconclusive. We examined private sector actors in inclusive innovation (in- three consecutive annual samples (2009–2011) of cluding, but not confined to transnational corpora- adolescents (age 12–17, N = 55,583) and adults tions seeking the 'fortune at the bottom of the pyr- (age 18 and over, N = 116,459) from the Nation- amid') and large global funds working in tandem al Survey of Drug Use and Health (NSDUH) to with the private sector and governments. Con- compare the prevalence of major depression and sideration is also given to the role which growth other serious mental illness across four catego- trajectories play in determining the direction of innovation and in promoting linkages between the 288 ries of urbanicity: 1) large metropolitan areas, 2) lies on the clinical acumen of trained providers to small metropolitan areas, 3) semi-rural areas, and provide depression care in ten public health HIV 4) rural areas, with and without adjustment for clinics in Uganda. In addition to data abstracted other demographic risk factors. For adolescents, from routine data collection mechanisms and su- no association was observed between urbanic- pervision logs, survey data will be collected from ity and the prevalence of major depression, with patient and provider longitudinal cohorts; at each or without statistical adjustments. For adults, no site, a random sample of 150 medically stable pa- differences were found in the prevalence of ma- tients who are depressed according to the PHQ-2 jor depression or serious mental illness between screening will be followed for 12 months, and pro- large metropolitan areas and rural areas, but the viders involved in depression care implementation prevalence of both was slightly higher in the two will be followed over 24 months. These data will be intermediate urbanicity categories than in large used to assess whether the two models differ on metropolitan areas, with statistically significant implementation outcomes (proportion screened, odds ratios after adjustment ranging from 1.12 to diagnosed, treated; provider fidelity to model of 1.19. Contrary to expectations, the prevalence of care), provider adoption of treatment care knowl- mental disorders was not higher in the most urban edge and practices, and depression alleviation. compared with the most rural areas, suggesting A cost-effectiveness analysis will be conducted that the move to identify mechanistic explanations to compare the relative use of resources by each for risk associated with the urban environment is model. DISCUSSION: If effective and resource- premature. Evidence of slightly higher prevalence efficient, the task-shifting, protocolized model will in small urban and semi-rural areas relative to provide an approach to building the capacity for large urban areas, reported for the first time, re- sustainable integration of depression treatment in quires additional investigation. HIV care settings across sub-Saharan Africa and improving key public health outcomes. EP-66101 INtegration of DEPression Treatment into HIV EP-66102 care in Uganda (INDEPTH-Uganda): study proto- Development and evaluation of the CAHPS col for a randomized controlled trial. Victoria K. (Consumer Assessment of Healthcare Providers Ngo. 2014 and Systems) Survey for In-Center Hemodialysis patients. Paul Cleary. 2014 BACKGROUND: Despite 10 to% of persons living with HIV in sub-Saharan Africa having BACKGROUND: The US Centers for Medicare clinical depression, and the consequences of & Medicaid Services assess patient experiences depression for key public health outcomes (HIV of care as part of the end-stage renal disease pro- treatment adherence and condom use), depres- spective payment system and Quality Incentive sion treatment is rarely integrated into HIV care Program. This article describes the development programs. Task-shifting, protocolized approaches and evaluation of the Consumer Assessment of to depression care have been used to overcome Healthcare Providers and Systems (CAHPS) In- severe shortages of mental health specialists in Center Hemodialysis Survey. STUDY DESIGN: developing countries, but not in sub-Saharan Af- We conducted formative research to generate sur- rica and not with HIV clients. The aims of this trial vey questions and performed statistical analyses are to evaluate the implementation outcomes and to evaluate the survey's measurement properties. cost-effectiveness of a task-shifting, protocolized SETTING & PARTICIPANTS: Formative research model of antidepressant care for HIV clinics in included focus groups, cognitive interviews, and Uganda. METHODS/DESIGN: INDEPTH-Uganda field testing the survey with dialysis patients. is a cluster randomized controlled trial that com- MEASUREMENTS & OUTCOMES: We assessed pares two task-shifting models of depression care internal consistency reliability (Cronbach alpha) - a protocolized model versus a model that re- and center-level reliability for 3 multi-item scales. 289

We evaluated construct validity using correlations Our objective was to conduct a rigorous, struc- of the scales with global ratings of the kidney tured process to create a new model of well-child doctor, staff, and dialysis center. RESULTS: Re- care (WCC) in collaboration with a multisite com- sponse rate was 46% (1,454 completed surveys). munity health center and 2 small, independent Analyses support 3 multi-item scales: Nephrolo- practices serving predominantly Medicaid-insured gists' Communication and Caring (7 items, alpha children. Working groups of clinicians, staff, and = 0.89), Quality of Dialysis Center Care and Op- parents (called "Community Advisory Boards" erations (22 items, alpha = 0.93), and Providing [CABs]) used (1) perspectives of WCC stakehold- Information to Patients (11 items, alpha = 0.75). ers and (2) a literature review of WCC practice re- The communication scale was correlated the design to create 4 comprehensive WCC models most strongly with the global rating of the "kidney for children ages 0 to 3 years. An expert panel, doctor" (r = 0.78). The Dialysis Center Care and following a modified version of the Rand/UCLA Operations scale was correlated most strongly Appropriateness Method, rated each model for with global ratings of staff (r = 0.75) and the cen- potential effectiveness on 4 domains: (1) receipt ter (r = 0.69). Providing Information to Patients of recommended services, (2) family-centered- was correlated most strongly with the global rating ness, (3) timely and appropriate follow-up, and (4) of the staff (r = 0.41). LIMITATIONS: A relatively feasibility and efficiency. Results were provided to small number of patients completed the survey in the CABs for selection of a final model to imple- Spanish. CONCLUSION: This study provides sup- ment. The newly developed models rely heavily port for the reliability and validity of the CAHPS on a health educator for anticipatory guidance In-Center Hemodialysis Survey for assessing pa- and developmental, behavioral, and psychosocial tient experiences of care at dialysis facilities. The surveillance and screening. Each model allots a survey can be used to compare care provided at small amount of time with the pediatrician to per- different facilities. form a brief physical examination and to address parents' physical health concerns. A secure Web- EP-66103 based tool customizes the visit to parents' needs Long-term effects of the 2003 ACGME resi- and facilitates previsit screening. Scheduled, dent duty hour reform on hospital mortality. Vinay non–face-to-face methods (text, phone) for parent Prasad, John A. Romley. 2014 communication with the health care team are also In 2003, the Accreditation Council for Gradu- critical to these new models of care. A structured ate Medical Education (ACGME) implemented process that engages small community practices resident duty hour reform that established a maxi- and community health centers in clinical practice mum 80-hour workweek among other provisions. redesign can produce comprehensive, site-spe- Despite an important series of studies that ana- cific, and innovative models for delivery of WCC. lyzed the reform's short-term impact on mortal- This process, as well as the models developed, ity in teaching hospitals (2003-2005), long-term may be applicable to other small practices and studies have been lacking. The long-term effects clinics interested in practice redesign. of reform are important to consider because adherence to duty hour restrictions was limited in the EP-66105 first few years after the transition, and oversight of Variation in inpatient hospital prices and out- residents since the transition may have changed. patient service quantities drive geographic differences in private spending in Texas. Chapin White. EP-66104 2014 Well-child care clinical practice redesign for OBJECTIVE: To measure the contribution of serving low-income children. Candice Moreno, market-level prices, utilization, and health risk to Paul G. Shekelle. 2014 medical spending variation among the Blue Cross Blue Shield of Texas (BCBSTX) privately insured 290 population and the Texas Medicare population. obtained through chart review of 536 veterans di- DATA SOURCES: Claims data for all BCBSTX agnosed with PTSD who had received at least 1 members and publicly available CMS data for Tex- session of CPT at a Midwestern US Veterans Af- as in 2011. STUDY DESIGN: We used observa- fairs hospital. Nearly half (n = 264, 49.3%) of the tional data and decomposed overall and service- veterans in the study exhibited a current or past specific spending into health status and health AUD diagnosis. Participants were grouped into status adjusted utilization and input prices and in- the following diagnostic groups: current AUD (past put prices adjusted for the BCBSTX and Medicare 12 months), past AUD (prior to 12 months), and populations. PRINCIPAL FINDINGS: Variation in no AUD. Participants completed an average of overall BCBSTX spending across HRRs appeared 9 sessions of CPT with no significant difference driven by price variation, whereas utilization varia- between AUD diagnostic groups on the number tion factored more prominently in Medicare. The of CPT sessions completed. Individuals with past contribution of price to spending variation differed AUD had higher initial symptoms of self-report- by service category. Price drove inpatient spend- ed PTSD symptoms than those with no AUD. All ing variation, while utilization drove outpatient groups reported significant reductions in PTSD and professional spending variation in BCBSTX. symptoms and depression over time. Overall, the The context in which negotiations occur may help results suggest that CPT appears well tolerated explain the patterns across services. CONCLU- among veterans with comorbid AUD and is asso- SIONS: The conventional wisdom that Medicare ciated with significant reductions in symptoms of does a better job of controlling prices and private PTSD and depression in an outpatient treatment plans do a better job of controlling volume is an setting. oversimplification. BCBSTX does a good job of controlling outpatient and professional prices, EP-66107 but not at controlling inpatient prices. Strategies How do hospitals cope with sustained slow to manage the variation in spending may need to growth in Medicare prices?. Vivian Y. Wu. 2014 differ substantially depending on the service and OBJECTIVE: To estimate the effects of chang- payer. es in Medicare inpatient hospital prices on hospitals' overall revenues, operating expenses, profits, EP-66106 assets, and staffing. PRIMARY DATA SOURCE: Cognitive processing therapy for veterans with Medicare hospital cost reports (1996–2009). comorbid PTSD and alcohol use disorders. Jer- STUDY DESIGN: For each hospital, we quantify emiah Schumm, Eric R. Pedersen. 2014 the year-to-year price impacts from changes in the Posttraumatic stress disorder (PTSD) and Medicare payment formula. We use cumulative alcohol-use disorders (AUD) frequently present simulated price impacts as instruments for Medi- comorbidly in veteran populations. Traditionally care inpatient revenues. We use a series of two- those with alcohol dependence have been exclud- stage least squares panel data regressions to esti- ed from PTSD treatment outcome studies, thus mate the effects of changes in Medicare revenues we do not know how those with alcohol depen- among all hospitals, and separately among not-for- dence may tolerate or respond to PTSD-specific profit versus for-profit hospitals, and among hospi- interventions; no studies to date have examined tals experiencing real price increases ("gainers") the extent to which cognitive PTSD interventions versus decreases ("losers"). PRINCIPAL FIND- are tolerated or effective for those with comorbid INGS: Medicare price cuts are associated with re- PTSD/AUD. The present study examines the ex- ductions in overall revenues even larger than the tent to which CPT is tolerated by and effective in direct Medicare price effect, consistent with price treating PTSD symptoms for veterans with PTSD spillovers. Among not-for-profit hospitals, revenue and AUD, as compared to veterans with PTSD reductions are fully offset by reductions in operat- only in an outpatient treatment setting. Data were ing expenses, and profits are unchanged. Among 291 for-profit hospitals, revenue reductions decrease nication while minimizing office chaos may offer profits one-for-one. Responses of gainers and los- the best chances of improving job satisfaction. ers are roughly symmetrical. CONCLUSIONS: On average, hospitals do not appear to make up for EP-66109 Medicare cuts by "cost shifting," but by adjusting Cocaine's fall and marijuana's rise: questions their operating expenses over the long run. The and insights based on new estimates of consump- Medicare price cuts in the Affordable Care Act will tion and expenditures in U. S. drug markets. Beau "bend the curve," that is, significantly slow the Kilmer. 2014 growth in hospitals' total revenues and operating AIMS: Drug policy strategies and discussions expenses. often use prevalence of drug use as a primary performance indicator. However, three other in- EP-66108 dicators are at least as relevant: the number of Practice environments and job satisfaction heavy users, total expenditures and total amount in patient-centered medical homes. Meredith B. consumed. This paper stems from our efforts to Rosenthal, Eric C. Schneider. 2014 develop annual estimates of these three mea- PURPOSE: We undertook a study to evalu- sures for cocaine (including crack), heroin, mari- ate the effects of medical home transformation on juana and methamphetamine in the United States. job satisfaction in the primary care setting. METH- METHODS: The estimates exploit complementary ODS: We collected primary data from 20 primary strengths of a general population survey (National care practices participating in medical home pilot Survey on Drug Use and Health) and both survey projects in Rhode Island and Colorado from 2009 and urinalysis test result data for arrestees (Ar- to 2011. We surveyed clinicians and staff about restee Drug Abuse Monitoring Program), supple- the quality of their practice environments (eg, of- mented by many other data sources. RESULTS: fice chaos, communication, difficulties in provid- Throughout the 2000s US drug users spent in ing safe, high-quality care) and job satisfaction the order of $100 billion annually on these drugs, at baseline and 30 months, and about stress, although the spending distribution and use pat- burnout, and intention to leave at 30 months. We terns changed dramatically. From 2006 to 2010, interviewed practice leaders about the impact of the amount of marijuana consumed in the United pilot project participation. We assessed longitudi- States probably increased by more than 30%, nal changes in the practice environment and job while the amount of cocaine consumed in the satisfaction and, in the final pilot year, examined United States fell by approximately 50%. These cross-sectional associations between the practice figures are consistent with supply-side indicators, environment and job satisfaction, stress, burnout, such as seizures and production estimates. For all and intention to leave. RESULTS: Between base- the drugs, total consumption and expenditures are line and 30 months, job satisfaction improved in driven by the minority of users who consume on 21 Rhode Island (P =.03) but not in Colorado. For or more days each month. CONCLUSIONS: Even both pilot projects, reported difficulties in providing for established drugs, consumption can change safe, high-quality care decreased (P <.001), but rapidly. The halving of the cocaine market in five emphasis on quality and the level of office cha- years and the parallel (but independent) large rise os did not change significantly. In cross-sectional in daily/near-daily marijuana use are major events analyses, fewer difficulties in providing safe, high- that were not anticipated by the expert commu- quality care and more open communication were nity and raise important theoretical, research, and associated with greater job satisfaction. Greater policy issues. office chaos and an emphasis on electronic information were associated with greater stress and EP-66110 burnout. CONCLUSIONS: Medical home transfor- Using claims data to generate clinical flags mations that emphasize quality and open commu- predicting short-term risk of continued psychiatric hospitalizations. Maria Pangilinan, Mark J. 292

Sorbero. 2014 games and depression, especially among preado- OBJECTIVE: As health information technol- lescent youth. In this study, we investigated wheth- ogy advances, efforts to use administrative data er daily violent video game playing over the past to inform real-time treatment planning for individu- year is associated with a greater number of deals are increasing, despite few empirical studies pressive symptoms among preadolescent youth, demonstrating that such administrative data pre- after controlling for several well-known correlates dict subsequent clinical events. Medicaid claims of depression among youth. We analyzed cross- for individuals with frequent psychiatric hospital- sectional data collected from 5,147 fifth-grade stu- izations were examined to test how well patterns dents and their primary caregivers who participat- of service use predict subsequent high short-term ed in Wave I (2004–2006) of Healthy Passages, a risk of continued psychiatric hospitalizations. community-based longitudinal study conducted in METHODS: Medicaid claims files from New York three U.S. cities. Linear regression was conduct- and Pennsylvania were used to identify Medicaid ed to determine the association between violent recipients ages 18–64 with two or more inpatient video game exposure and number of depressive psychiatric admissions during a target year end- symptoms, while controlling for gender, race/eth- ing March 31, 2009. Definitions from a quality- nicity, peer victimization, witnessing violence, be- improvement initiative were used to identify pating threatened with violence, aggression, family terns of inpatient and outpatient service use and structure, and household income level. We found prescription fills suggestive of clinical concerns. that students who reported playing high-violence Generalized estimating equations and Markov video games for ≥2 hours per day had signifi- models were applied to examine claims through cantly more depressive symptoms than those who March 2011, to see what patterns of service use reported playing low-violence video games for <2 were sufficiently predictive of additional hospital- hours per day (p<0.001). The magnitude of this izations to be clinically useful. RESULTS: A total of association was small (Cohen's d=0.16), but this 11,801 individuals in New York and 1,859 in Penn- association was consistent across all racial/ethnic sylvania identified met the cohort definition. In subgroups and among boys (Cohen's d values both Pennsylvania and New York, multiple recent ranged from 0.12 to 0.25). Our findings indicate hospitalizations, but not failure to use outpatient that there is an association between daily expo- services or failure to fill medication prescriptions, sure to violent video games and number of de- were significant predictors of high risk of contin- pressive symptoms among preadolescent youth. ued frequent hospitalizations, with odds ratios More research is needed to examine this association and, if confirmed, to investigate its causality, greater than 4.0. CONCLUSIONS: Administrative persistence over time, underlying mechanisms, data can be used to identify individuals at high risk and clinical implications. of continued frequent hospitalizations. Payers and system administrators could use such informa- EP-66112 tion to authorize special services (such as mobile A proposed approach may help systematic outreach) for such individuals to promote service reviews retain needed expertise while minimizing engagement and prevent rapid rehospitalizations. bias from nonfinancial conflicts of interest. Timo- thy S. Carey, Suzanne E. Belinson. 2014 EP-66111 Daily violent video game playing and depres- OBJECTIVES: Groups such as the Institute sion in preadolescent youth. Melissa F. Peskin, of Medicine emphasize the importance of atten- Elizabeth R. Baumler. 2014 tion to financial conflicts of interest. Little guidance Most studies on the impact of playing violent exists, however, on managing the risk of bias for video games on mental health have focused on systematic reviews from nonfinancial conflicts of aggression. Relatively few studies have examined the relationship between playing violent video 293 interest. We sought to create practical guidance less consistent with a pure self-interest motive. on ensuring adequate clinical or content expertise while maintaining independence of judgment on EP-66114 systematic review teams. STUDY DESIGN AND The curse of wealth: Middle Eastern countries SETTING: Workgroup members built on existing need to address the rapidly rising burden of diabe- guidance from international and domestic institutes. Joachim Becker, Soeren Mattke. 2014 tions on managing conflicts of interest. We then The energy boom of the last decade has led to developed practical guidance in the form of an rapidly increasing wealth in the Middle East, par- instrument for each potential source of conflict. ticularly in the oil and gas-rich Gulf Cooperation RESULTS: We modified the Institute of Medi- Council (GCC) countries. This exceptional growth cine's definition of conflict of interest to arrive at in prosperity has brought with it rapid changes in a definition specific to nonfinancial conflicts. We lifestyles that have resulted in a significant rise in propose questions for funders and systematic re- chronic disease. In particular the number of peo- view principal investigators to evaluate the risk of ple diagnosed with diabetes has increased dra- nonfinancial conflicts of interest. Once risks have matically and health system capacity has not kept been identified, options for managing conflicts pace. In this article, we summarize the current lit- include disclosure followed by no change in the erature to illustrate the magnitude of the problem, systematic review team or activities, inclusion on its causes and its impact on health and point to the team along with other members with differing options how to address it. viewpoints to ensure diverse perspectives, exclusion from certain activities, and exclusion from EP-66115 the project entirely. CONCLUSION: The feasibil- Did California's hand-held cell phone ban re- ity and utility of this approach to ensuring needed duce accidents?. Daniel T. Kaffine, Bob Yu. 2014 expertise on systematic reviews and minimizing On July 1st, 2008, California enacted a ban bias from nonfinancial conflicts of interest must be on hand-held cell phone use while driving. Using investigated. California Highway Patrol panel accident data for EP-66113 California freeways from January 1st, 2008 to De- Doing wrong to do right? social preferences cember 31st, 2008, we examine whether this pol- and dishonest behavior. Susan Godlonton. 2014 icy reduced the number of accidents on California highways. To control for unobserved time-varying Can pro-social preferences lead to dishonest or effects that could be correlated with the ban, we unethical behavior? Lab evidence suggests that it use high-frequency data and a regression discon- can. In this paper, we document some of the first tinuity design. We find no evidence that the ban field evidence of this phenomenon. In this study, on hand-held cell phone use led to a reduction in individuals were hired as field staff and tasked with traffic accidents. distributing subsidized price vouchers following a clearly specified protocol. We find substantial de- EP-66116 viation from the protocol, i.e., cheating. We study Huddle up! the adoption and use of structured the mis-allocation of the vouchers to gain some team communication for VA medical home imple- insight into motivations for dishonesty. In our main mentation. Lisa S. Meredith. 2014 result we find that the field staff were significantly BACKGROUND: Daily clinical team meetings more likely to allocate the higher value vouchers (i.e., "huddles") may be helpful in implementing (those representing a greater subsidy) to the poor- new roles and responsibilities for patient care est beneficiaries. While we are not able to defini- because they provide a regular opportunity for tively establish the motivations for this observed member learning and feedback. PURPOSES: We pro-social behavior, we argue that this result is examined how huddles were implemented in the consistent with a model of social preferences and context of the VA patient-centered medical home 294

(PCMH) transformation, including assessing bar- housing projects—were associated with the per- riers and facilitators to regular huddling among ceived health and health behaviors of residents' small teams ("teamlets"). We assessed the ex- social networks. METHOD: Leveraging a natural tent to which teamlet members that huddled had experiment in Montgomery County, Maryland, in higher self-efficacy for PCMH changes, reported which residents were randomly assigned to dif- better teamwork experiences, and perceived more ferent types of public housing, we surveyed 453 supportive practice environments. METHODOL- heads of household in 2011. We asked residents OGY/APPROACH: We used a convergent mixed- about their own health as well as the perceived methods approach to analyze 79 teamlet member health of their network members, including their interviews from six VA primary care practices and neighbors. RESULTS: Residents in scattered- 418 clinician and staff PCMH survey responses site public housing perceived that their neighbors from the six interviewed practices and 13 addi- were more likely to exercise than residents of clus- tional practices in the same region. FINDINGS: tered public housing (24.7% of network members Most members reported participating in teamlet vs 14.0%; P < .001). There were huddles when asked in surveys (85%). A minor- no significant differences in the proportion of net- ity of interview participants, however, described work members who were perceived to have ma- routine huddling focused on previsit planning that jor health problems, depressed mood, poor diet, included all members. When members reported or obesity. Having more network members who routine teamlet huddling, activities included (a) smoked was associated with a significantly higher previsit planning, (b) strategizing treatment plans likelihood of smoking. CONCLUSIONS: Different for patients with special or complex needs, (c) types of public housing have a modest impact on addressing daily workflow and communication is- the health composition of one's social network, sues through collective problem solving, and (d) suggesting the importance of housing policy for ensuring awareness of what team members do health. and what actions are happening on the teamlet EP-66118 and in the practice. Primary care providers (PCPs) Successful schools and risky behaviors among were least likely to report routine huddling. PCP low-income adolescents. Karen M. Coller, Re- huddlers reported greater self-efficacy for imple- becca N. Dudovitz. 2014 menting PCMH changes. All huddlers, irrespective of role, reported better teamwork and more OBJECTIVES: We examined whether expo- supportive practice climates. The most common sure to high-performing schools reduces the rates barriers to teamlet huddling were limited time and of risky health behaviors among low-income mi- operational constraints. PRACTICE IMPLICA- nority adolescents and whether this is due to TIONS: In order to improve the impact of huddles better academic performance, peer influence, on patient care, practice leaders should clearly or other factors. METHODS: By using a natural communicate the goals, requirements, and bene- experimental study design, we used the random fits of huddling and provide adequate time and readmissions lottery into high-performing public sources to ensure that frontline teams use huddle charter high schools in low-income Los Angeles time to improve patient care. neighborhoods to determine whether exposure to successful school environments leads to fewer EP-66117 risky (eg, alcohol, tobacco, drug use, unprotected The impact of public housing on social networks: sex) and very risky health behaviors (eg, binge a natural experiment. Harold D. Green. 2014 drinking, substance use at school, risky sex, gang participation). We surveyed 521 ninth- through OBJECTIVE: We assessed whether 2 types twelfth-grade students who were offered admis- of public housing—scattered among market-rate sion through a random lottery (intervention group) housing developments or clustered in small public and 409 students who were not offered admission (control group) about their health behaviors and 295 obtained their state-standardized test scores. RE- assigned to a daily supplement of 30 mg/day of el- SULTS: The intervention and control groups had emental iron as ferrous sulfate or iron bis-glycinate similar demographic characteristics and eighth- chelate for 12 weeks. Iron status was evaluated at grade test scores. Being offered admission to a baseline, one week post-supplementation (short high-performing school (intervention effect) led to term), and 6 months (medium term) after supple- improved math (P < .001) and English (P = .04) mentation. RESULTS: Ferritin concentration in- standard test scores, greater school retention creased significantly between baseline and post- (91% vs 76%; P < .001), and lower rates of en- supplementation as well as between baseline gaging in ≥1 very risky behaviors (odds ratio = and 6 months after supplementation. One week 0.73, P < .05) but no difference in risky behaviors, post-supplementation no difference was found in such as any recent use of alcohol, tobacco, or ferritin concentration between iron compounds, drugs. School retention and test scores explained but 6 months after supplementation ferritin con- 58.0% and 16.2% of the intervention effect on en- centration was higher in the group that received gagement in very risky behaviors, respectively. bis-glycinate chelate iron. However, there is no dif- CONCLUSIONS: Increasing performance of pub- ference in the odds for low iron storage between lic schools in low-income communities may be a 6 months after supplementation versus the odds powerful mechanism to decrease very risky health after supplementation; nor were these odds differ- behaviors among low-income adolescents and to ent by type of supplement. Hemoglobin concen- decrease health disparities across the life span. tration did not change significantly in either group after supplementation. CONCLUSIONS: Supple- EP-66119 menting with 30 mg/d of elementary iron, either Effect of supplementation with ferrous sulfate as ferrous sulfate or iron bis-glycinate chelate for or iron bis-glycinate chelate on ferritin concentra- 90 days, showed positive effects on increasing fer- tion in Mexican schoolchildren: a randomized ritin concentration in schoolchildren with low iron controlled trial. Homero Martinez. 2014 stores, and this effect persisted 6 months after BACKGROUND: Iron deficiency is one of the supplementation. most common nutritional deficiencies worldwide. It is more prevalent when iron requirements are EP-66120 Are users' most recent drug purchases repre- increased during pregnancy and during growth sentative?. Jonathan P. Caulkins. 2014 spurts of infancy and adolescence. The last stage in the process of iron depletion is characterized by BACKGROUND: Various surveys now ask re- a decrease in hemoglobin concentration, result- spondents to describe their most recent purchase ing in iron deficiency anemia. Iron deficiency, even of illicit drugs, as one mechanism through which before it is clinically identified as anemia, compro- market size can be estimated. This raises the mises the immune response, physical capacity question of whether issues surrounding the timing for work, and intellectual functions such as atten- of survey administration might make a sample of tion level. Therefore, interventions addressing iron most recent purchases differ from a random sam- deficiency should be based on prevention rather ple of all purchases. We investigate these issues than on treatment of anemia. The aim of this study through a series of questions which ask about was to compare short- and medium-term effects the three most recent purchases, and about drug on ferritin concentration of daily supplementation use. METHODS: Data were drawn from 688 re- with ferrous sulfate or iron bis-glycinate chelate spondents in the Melbourne Injecting Drug User in schoolchildren with iron deficiency but without Cohort Study across the period 2008–2013 and anemia. METHODS: Two hundred schoolchildren 2782 respondents to the Washington Cannabis from public boarding schools in Mexico City who Consumption Study in 2013. Responses to ques- had low iron stores as assessed by serum ferritin tions about the most recent purchases were com- concentration but without anemia were randomly pared to larger subsets of all recent purchases. 296

RESULTS: For heroin, methamphetamine and one way to influence the health of the elderly is cannabis no differences were found between the through their offspring. To harness the full value of amount spent by participants on their most re- schooling for health, then, a family and multigen- cent purchase and the average amount spent on erational perspective is needed. three or more recent purchases. There were also no differences concerning the locations and types EP-66122 of deals, and the duration between consecutive Development and validation of the RAND cannabis purchases was the same for first and asthma control measure. Maria Orlando Edelen. second most recent, and second and third most 2014 recent. CONCLUSIONS: Asking about the most Patient-based measures for asthma control recent purchase appears to be an economical are important in assessing the worldwide impact way to learn about purchases more generally, with of this highly prevalent chronic illness. We sought little evidence of substantial variation between the to refine an asthma symptom scale that RAND most recent purchase and other recent purchas- had previously developed to shorten it and vali- es reported by participants. In spite of consistent date it further, as well as reflect updated interna- findings across our two surveys, further replica- tional expert definitions of asthma control. We tion of the work reported in this paper involving conducted rigorous psychometric testing of new other populations of users is warranted. and adapted self-administered survey items in a sample of 2032 adults with asthma. The reliabil- EP-66121 ity and preliminary validity of the resulting mea- The schooling of offspring and the survival of sure, henceforth referred to as the RAND Asthma parents. Robert D. Mare. 2014 Control Scale (RAND-ACM), matched or exceed- Contemporary stratification research on devel- ed that of the original RAND measure and oth- oped societies usually views the intergenerational ers in the literature. RAND-ACM scores for worse transmission of educational advantage as a one- asthma control were significantly associated with way effect from parent to child. However, parents' worse asthma-related quality of life, increased investment in their offspring's schooling may yield asthma-related healthcare use, Hispanic ethnicity significant returns for parents themselves in later and lower educational level. Evidence for internal life. For instance, well-educated offspring have consistency was strong with a Cronbach's α greater knowledge of health and technology to of 0.84. We also found adequate concordance be- share with their parents and more financial means tween the RAND-ACM and the Global Initiative to provide for them than do their less-educated for Asthma categories of "uncontrolled", "partly counterparts. We use data from the 1992–2006 controlled" and "controlled" asthma. The RAND- Health and Retirement Study (HRS) to examine ACM, a five-item self-reported asthma control whether adult offspring's educational attainments survey measure, performs well in a large ethnical- are associated with parents' survival in the United ly-diverse sample of US adults with asthma and States. We show that adult offspring's educational provides a cost-free alternative to other asthma attainments have independent effects on their par- control measures currently available. ents' mortality, even after controlling for parents' own socioeconomic resources. This relationship is EP-66123 more pronounced for deaths that are linked to be- Randomized clinical trial of an emergency havioral factors: most notably, chronic lower respi- department observation syncope protocol versus ratory disease and lung cancer. Furthermore, at routine inpatient admission. Heather McCreath. least part of the association between offspring's 2014 schooling and parents' survival may be explained STUDY OBJECTIVE: Older adults are frequent- by parents' health behaviors, including smoking ly hospitalized from the emergency department and physical activity. These findings suggest that (ED) after an episode of unexplained syncope. 297

Current admission patterns are costly, with little stetrical complications vary across hospitals in the evidence of benefit. We hypothesize that an ED United States is unknown. We used multivariable observation syncope protocol will reduce resource logistic regression models to examine the varia- use without adversely affecting patient-oriented tion in obstetrical complication outcomes across outcomes. METHODS: This randomized trial at 5 US hospitals among a large, nationally represen- EDs compared an ED observation syncope pro- tative sample of more than 750,000 obstetrical tocol to inpatient admission for intermediate-risk deliveries in 2010. We found that 22.55 percent adults (≥50 years) presenting with syncope or of patients delivering vaginally at low-performing near syncope. Primary outcomes included inpa- hospitals experienced major complications, com- tient admission rate and length of stay. Secondary pared to 10.42 percent of similar patients deliv- outcomes included 30-day and 6-month serious ering vaginally at high-performing hospitals. Hos- outcomes after hospital discharge, index and 30- pitals were classified as having low, average, or day hospital costs, 30-day quality-of-life scores, high performance based on a calculation of the and 30-day patient satisfaction. RESULTS: Study relative risk that a patient would experience a ma- staff randomized 124 patients. Observation re- jor complication. Patients undergoing a cesarean sulted in a lower inpatient admission rate (15% delivery at low-performing hospitals had nearly versus 92%; 95% confidence interval [CI] differ- five times the rate of major complications that pa- ence −88% to −66%) and shorter tients undergoing a cesarean delivery at high-per- hospital length of stay (29 versus 47 hours; 95% forming hospitals had (20.93 percent compared to CI difference −28 to −8). Serious 4.37 percent). Our finding that the rate of major outcome rates after hospital discharge were simi- obstetrical complications varies markedly across lar for observation versus admission at 30 days US hospitals should prompt clinicians and policy (3% versus 0%; 95% CI difference −1% to makers to develop comprehensive quality metrics 8%) and 6 months (8% versus 10%; 95% CI differ- for obstetrical care and focus on improving obstet- ence −13% to 9%). Index hospital costs in rical outcomes. the observation group were $629 (95% CI differ- EP-66125 ence −$1,376 to −$56) lower than in Beliefs about the causes of schizophrenia the admission group. There were no differences in among Aymara and non-Aymara patients and 30-day quality-of-life scores or in patient satisfac- their primary caregivers in the Central-Southern tion. CONCLUSION: An ED observation syncope Andes. Joshua Breslau. 2014 protocol reduced the primary outcomes of admis- AIM: The aim of this study is to investigate sion rate and hospital length of stay. Analyses of differences in the beliefs about the causes of secondary outcomes suggest reduction in index schizophrenia between Aymara and non-Ayma- hospital costs, with no difference in safety events, ra patients with schizophrenia and their primary quality of life, or patient satisfaction. Our findings caregivers. Ethnic background plays an impor- suggest that an ED observation syncope protocol tant role in the formation of beliefs regarding the can be replicated and safely reduce resource use. causes of schizophrenia, and there have been no prior studies on such beliefs among the Aymara, EP-66124 an indigenous community with a population of Rates of major obstetrical complications vary about 2 million people living in the Andes. almost fivefold among U. S. hospitals. Andrew W. We focused on three systems of beliefs distin- Dick. 2014 guished in the literature: biological, psychosocial Of the approximately four million women who and magical–religious. METHODS: The sample give birth each year in the United States, nearly 13 comprised 253 patients (n = 117 percent experience one or more major complica- Aymara, and n = 136 non-Ay- tions. But the extent to which the rates of major ob- mara) of public mental health centers in Chile (33.6%), Peru (33.6%) and Bolivia (32.8%) with 298 a diagnosis of schizophrenia, and each patient's Development of the PROMIS® health expec- primary caregiver. We administered to patients tancies of smoking item banks. Joan S. Tucker. and caregivers a questionnaire with scales as- 2014 sessing the perceived causes of schizophrenia. INTRODUCTION: Smokers' health-related out- Linear regression models were fitted to compare come expectancies are associated with a number differences in the levels of causal beliefs between of important constructs in smoking research, yet Aymara and non-Aymara patients and caregivers, there are no measures currently available that and to identify socio-demographic and clinical focus exclusively on this domain. This paper de- predictors of different types of beliefs about the scribes the development and evaluation of item causes of schizophrenia. RESULTS: Adjusted for banks for assessing the health expectancies of socio-demographic and clinical covariates, levels smoking. METHODS: Using data from a sample of psychosocial beliefs were significantly higher of daily (N = 4,201) and nondaily (N = 1,183) for Aymara caregivers (0.33, 95% confidence in- smokers, we conducted a series of item factor terval (CI) = 0.05, 0.62) than non- analyses, item response theory analyses, and Aymara caregivers. CONCLUSIONS: Contrary to differential item functioning analyses (according expectations, beliefs about the causes of schizo- to gender, age, and race/ethnicity) to arrive at a phrenia among Aymara are not more magical–re- unidimensional set of health expectancies items ligious than those of their non-Aymara counter- for daily and nondaily smokers. We also evalu- parts. It may be necessary for mental health staff ated the performance of short forms (SFs) and members to evaluate beliefs about the disorder, computer adaptive tests (CATs) to efficiently as- especially in ethnic minorities, before applying a sess health expectancies. RESULTS: A total of 24 standard model of treatment. items were included in the Health Expectancies item banks; 13 items are common across daily EP-66126 and nondaily smokers, 6 are unique to daily, and 5 Feeling (Mis)understood and intergroup friend- are unique to nondaily. For both daily and nondai- ships in interracial interactions. Sara Douglass, ly smokers, the Health Expectancies item banks Randi L. Garcia. 2014 are unidimensional, reliable (reliability = 0.95 and The present research investigated whether hav- 0.96, respectively), and perform similarly across ing out-group friends serves as a buffer for feeling gender, age, and race/ethnicity groups. A SF com- misunderstood in interracial interactions. Across mon to daily and nondaily smokers consists of 6 three experience sampling studies, we found items (reliability = 0.87). Results from simulated that among ethnic minorities who have few White CATs showed that health expectancies can be friends or are not interacting with White friends, assessed with good precision with an average of daily interracial interactions are associated with 5–6 items adaptively selected from the item banks. feeling less understood. By contrast, we found that CONCLUSIONS: Health expectancies of smoking among ethnic minorities who have more White can be assessed on the basis of these item banks friends or are interacting with White friends, the via SFs, CATs, or through a tailored set of items relationship between daily interracial interactions selected for a specific research purpose. and feeling understood is not significant. We did not find similar results for Whites; that is, having EP-66128 ethnic minority friends did not play a role in the The PROMIS® smoking assessment toolkit— relationship between daily interracial interactions background and introduction to supplement. 2014 and feeling understood. Together, these studies INTRODUCTION: The PROMIS® Smoking demonstrate the beneficial effects of intergroup Initiative has developed an assessment toolkit friendships for ethnic minorities. for measuring 6 domains of interest to cigarette smoking research: nicotine dependence, coping EP-66127 expectancies, emotional and sensory expectan- 299 cies, health expectancies, psychosocial expec- pendence, Coping Expectancies, Emotional and tancies, and social motivations for smoking. The Sensory Expectancies, Health Expectancies, papers in this supplement describe the methods Psychosocial Expectancies, and Social Motiva- used to develop these item banks, their psycho- tions). METHODS: Using data from a large sam- metric properties, and the preliminary evidence ple of daily (N = 4,201) and nondaily (N = 1,183) for their validity. This commentary is meant to pro- smokers, we generated mean daily and nondaily vide background information for the material in this smoking bank scores according to select demo- supplement. METHODS: After discussing the use graphic groups. We also examined correlations of item response theory in behavioral measure- among the 6 banks and examined the associa- ment, I will briefly review the initial developmental tions of bank scores with smoking behavior items steps for the smoking assessment toolkit. Finally, I (e.g., quantity of smoking, interest in quitting) will describe the contents of this supplement and and select health-related quality of life measures provide some closing remarks. RESULTS: Psy- (i.e., physical functioning, anxiety, alcohol con- chometric evidence strongly supports the utility of sumption). RESULTS: Correlations among the 6 the toolkit of item banks, short forms (SFs), and banks are moderate (daily mean r = .48, range = computer adaptive tests (CATs). The item banks .04–.80; nondaily mean r = .47, range = .12–.75). for daily smokers produce scores with reliability The pattern of associations between bank scores estimates above 0.90 for a wide range of each and other measures provides validity evidence for cigarette smoking domain continuum, and SF and the bank domains (e.g., nicotine dependence is CAT administrations also achieve high reliability most strongly associated with smoking quantity (generally greater than 0.85) using very few items and time to first cigarette of the day; health and (4–7 items for most banks). Performance of the psychosocial expectancies are most related to banks for nondaily smokers is similar. Preliminary quitting recency and interest; coping expectancies evidence supports the concurrent and the dis- are strongly associated with anxiety). CONCLU- criminant validity of the bank domains. CONCLU- SIONS: These analyses provide useful descriptive SIONS: The new smoking assessment toolkit has information about the 6 smoking item banks as attractive measurement features that are likely to well as preliminary evidence for their validity. Inde- benefit smoking research as researchers begin to pendent sample data are currently being collected utilize this resource. Information about the toolkit to replicate these findings, to establish test–retest and access to the assessments is available at the reliability, and to develop crosswalks to existing project Web site (http://www.rand.org/health/proj smoking measures (e.g., nicotine dependence to ects/promis-smoking-initiative.html) and can also Fagerström Test for Nicotine Dependence). be accessed via the PROMIS Assessment Center Future research will also evaluate the bank scores' (www.assessmentcenter.net). sensitivity to change.

EP-66129 EP-66130 The PROMIS® smoking initiative: initial validity Methodology for developing and evaluating the evidence for six new smoking item banks. Brian PROMIS® smoking item banks. Li Cai, Brian D. D. Stucky. 2014 Stucky. 2014 INTRODUCTION: The Patient-Reported Out- INTRODUCTION: This article describes the comes Measurement Information System (PRO- procedures used in the PROMIS® Smoking Ini- MIS®) Smoking Initiative has developed 6 item tiative for the development and evaluation of banks for assessing smoking behaviors and bio- item banks, short forms (SFs), and computer- psychosocial correlates of smoking among daily ized adaptive tests (CATs) for the assessment of and nondaily adult cigarette smokers. This paper 6 constructs related to cigarette smoking: nicotine presents descriptive information and preliminary dependence, coping expectancies, emotional and validity evidence for the item banks (Nicotine De- sensory expectancies, health expectancies, psychosocial expectancies, and social motivations for 300 smoking. METHODS: Analyses were conducted analyses, and differential item functioning (DIF) using response data from a large national sample analyses (according to gender, age, and ethnic- of smokers. Items related to each construct were ity) to arrive at a unidimensional set of items for subjected to extensive item factor analyses and daily and nondaily smokers. We also evaluated evaluation of differential item functioning (DIF). performance of short forms (SFs) and computer Final item banks were calibrated, and SF assess- adaptive tests (CATs) for assessing coping ex- ments were developed for each construct. The pectancies of smoking. RESULTS: For both daily performance of the SFs and the potential use of and nondaily smokers, the unidimensional Coping the item banks for CAT administration were ex- Expectancies item banks (21 items) are relatively amined through simulation study. RESULTS: Item DIF free and are highly reliable (0.96 and 0.97, selection based on dimensionality assessment respectively). A common 4-item SF for daily and and DIF analyses produced item banks that were nondaily smokers also showed good reliability essentially unidimensional in structure and free (0.85). Adaptive tests required an average of 4.3 of bias. Simulation studies demonstrated that the and 3.7 items for simulated daily and nondaily re- constructs could be accurately measured with spondents, respectively, and achieved reliabilities a relatively small number of carefully selected of 0.91 for both when the maximum test length items, either through fixed SFs or CAT-based as- was 10 items. CONCLUSIONS: This research sessment. Illustrative results are presented, and provides a new set of items that can be used to subsequent articles provide detailed discussion reliably assess coping expectancies of smoking, of each item bank in turn. CONCLUSIONS: The through a SF, CAT, or a tailored set selected for a development of the PROMIS smoking item banks specific research purpose. provides researchers with new tools for measuring smoking-related constructs. The use of the EP-66132 calibrated item banks and suggested SF assess- Development of the PROMIS® nicotine depen- ments will enhance the quality of score estimates, dence item banks. Maria Orlando Edelen. 2014 thus advancing smoking research. Moreover, the INTRODUCTION: Nicotine dependence is a methods used in the current study, including in- core construct important for understanding ciga- novative approaches to item selection and SF rette smoking and smoking cessation behavior. construction, may have general relevance to item This article describes analyses conducted to de- bank development and evaluation. velop and evaluate item banks for assessing nicotine dependence among daily and nondaily smok- EP-66131 ers. METHODS: Using data from a sample of daily Development of the PROMIS® coping expec- (N = 4,201) and nondaily (N =1,183) smokers, tancies of smoking item banks. Maria Orlando we conducted a series of item factor analyses, Edelen. 2014 item response theory analyses, and differential OBJECTIVE: Smoking is a coping strategy item functioning analyses (according to gender, for many smokers who then have difficulty finding age, and race/ethnicity) to arrive at a unidimen- new ways to cope with negative affect when they sional set of nicotine dependence items for daily quit. This paper describes analyses conducted and nondaily smokers. We also evaluated perfor- to develop and evaluate item banks for assess- mance of short forms (SFs) and computer adap- ing the coping expectancies of smoking for daily tive tests (CATs) to efficiently assess dependence. and nondaily smokers. METHODS: Using data RESULTS: A total of 32 items were included in from a large sample of daily (N = 4,201) and non- the Nicotine Dependence item banks; 22 items daily (N = 1,183) smokers, we conducted a se- are common across daily and nondaily smokers, ries of item factor analyses, item response theory 301

5 are unique to daily smokers, and 5 are unique dates in place >3 years in 52 (49%). More NICUs to nondaily smokers. For both daily and nondaily in states with mandates reported ≥95% com- smokers, the Nicotine Dependence item banks pliance to at least 1 CLABSI prevention practice are strongly unidimensional, highly reliable (reli- (52.3%–66.4%) than NICUs in states without ability = 0.97 and 0.97, respectively), and perform mandates (28.9%–48.2%). Mandates were pre- similarly across gender, age, and race/ethnicity dictors of ≥95% compliance with all practices groups. SFs common to daily and nondaily smok- (odds ratio, 2.8; 95% confidence interval, 1.4–6.1). ers consist of 8 and 4 items (reliability = 0.91 and NICUs in states with mandates reported lower 0.81, respectively). Results from simulated CATs mean CLABSI rates in the ≤750-g birth weight showed that dependence can be assessed with group (2.4 vs 5.7 CLABSIs/1,000 central line– very good precision for most respondents using days) but not in others. Mandates were not asso- fewer than 6 items adaptively selected from the ciated with SIR <1. CONCLUSIONS: State man- item banks. CONCLUSIONS: Nicotine depen- dates for NICU CLABSI data submission were dence on cigarettes can be assessed on the basis significantly associated with ≥95% compliance of these item banks via one of the SFs, by using with CLABSI prevention practices, which declined CATs, or through a tailored set of items selected with the duration of mandate but not with lower for a specific research purpose. CLABSI rates.

EP-66133 EP-66134 The association of state legal mandates for Development of the PROMIS® positive emo- data submission of central line–associated blood- tional and sensory expectancies of smoking item stream infections in neonatal intensive care units banks. William G. Shadel. 2014 with process and outcomes measures. Julie Rea- INTRODUCTION: The positive emotional and gan. 2014 sensory expectancies of cigarette smoking in- OBJECTIVE: To determine the association be- clude improved cognitive abilities, positive affec- tween state legal mandates for data submission tive states, and pleasurable sensorimotor sen- of central line–associated bloodstream infections sations. This paper describes development of (CLABSIs) in neonatal intensive care units (NICUs) Positive Emotional and Sensory Expectancies of with process and outcome measures. DESIGN: Smoking item banks that will serve to standard- Cross-sectional study. PARTICIPANTS: National ize the assessment of this construct among dai- sample of level II/III and III NICUs participating ly and nondaily cigarette smokers. METHODS: in National Healthcare Safety Network (NHSN) Data came from daily (N = 4,201) and nondaily (N surveillance. METHODS: State mandates for data =1,183) smokers who completed an online survey. submission of CLABSIs in NICUs in place by 2011 To identify a unidimensional set of items, we con- were compiled and verified with state healthcare- ducted item factor analyses, item response theory associated infection coordinators. A web-based analyses, and differential item functioning analy- survey of infection control departments in Octo- ses. Additionally, we evaluated the performance of ber 2011 assessed CLABSI prevention practices, fixed-item short forms (SFs) and computer adap- ie, compliance with checklist/bundle components tive tests (CATs) to efficiently assess the con- (process measures) in ICUs including NICUs. Cor- struct. RESULTS: Eighteen items were included responding 2011 NHSN NICU CLABSI rates (out- in the item banks (15 common across daily and come measures) were used to calculate standard- nondaily smokers, 1 unique to daily, 2 unique to ized infection ratios (SIRs). Association between nondaily). The item banks are strongly unidimen- mandates and process and outcome measures sional, highly reliable (reliability = 0.95 for both), was assessed by multivariable logistic regression. and perform similarly across gender, age, and RESULTS: Among 190 study NICUs, 107 (56.3%) race/ethnicity groups. A SF common to daily and were located in states with mandates, with man- nondaily smokers consists of 6 items (reliability = 0.86). Results from simulated CATs indicated that, 302 on average, less than 8 items are needed to as- manner for daily and nondaily smokers. In addition sess the construct with adequate precision using to using the full item banks, efficient assessment the item banks. CONCLUSIONS: These analyses can be achieved by using SFs, employing CATs, identified a new set of items that can assess the or selecting items tailored to specific research or positive emotional and sensory expectancies of clinical purposes. smoking in a reliable and standardized manner. Considerable efficiency in assessing this con- EP-66136 struct can be achieved by using the item bank SF, Development of the PROMIS® negative psy- employing computer adaptive tests, or selecting chosocial expectancies of smoking item banks. subsets of items tailored to specific research or Maria Orlando Edelen. 2014 clinical purposes. INTRODUCTION: Negative psychosocial expectancies of smoking include aspects of social EP-66135 disapproval and disappointment in oneself. This Development of the PROMIS® social motiva- paper describes analyses conducted to develop tions for smoking item banks. William G. Shadel. and evaluate item banks for assessing psychoso- 2014 cial expectancies among daily and nondaily smok- INTRODUCTION: Smoking behavior is influ- ers. METHODS: Using data from a sample of daily enced by social motivations such as the expected (N = 4,201) and nondaily (N =1,183) smokers, we social benefits of smoking and the social cues conducted a series of item factor analyses, item that induce craving. This paper describes devel- response theory analyses, and differential item opment of the PROMIS® Social Motivations for functioning analyses (according to gender, age, Smoking item banks, which will serve to stan- and race/ethnicity) to arrive at a unidimensional dardize assessment of these social motivations set of psychosocial expectancies items for daily among daily and nondaily smokers. METHODS: and nondaily smokers. We also evaluated perfor- Daily (N = 4,201) and nondaily (N =1,183) smok- mance of short forms (SFs) and computer adap- ers completed an online survey. Item factor anal- tive tests (CATs) to efficiently assess psychoso- yses, item response theory analyses, and differ- cial expectancies. RESULTS: A total of 21 items ential item functioning analyses were conducted were included in the Psychosocial Expectancies to identify a unidimensional set of items for each item banks: 14 items are common across daily group. Short forms (SFs) and computer adaptive and nondaily smokers, 6 are unique to daily, and tests (CATs) were evaluated as tools for more ef- 1 is unique to nondaily. For both daily and nondai- ficiently assessing this construct. RESULTS: A to- ly smokers, the Psychosocial Expectancies item tal of 15 items were included in the item banks banks are strongly unidimensional, highly reliable (9 items common to daily and nondaily smokers, (reliability = 0.95 and 0.93, respectively), and per- 3 unique to daily, 3 unique to nondaily). Scores form similarly across gender, age, and race/eth- based on full item banks are highly reliable (reli- nicity groups. A SF common to daily and nondaily ability = 0.90–0.91). Additionally, the item banks smokers consists of 6 items (reliability = 0.85). are strongly unidimensional and perform similarly Results from simulated CATs showed that, on av- across gender, age, and race/ethnicity groups. erage, fewer than 8 items are needed to assess A fixed SF for use with both daily and nondaily psychosocial expectancies with adequate preci- smokers consists of 4 items (reliability = 0.80). sion when using the item banks. CONCLUSIONS: Results from simulated CATs showed that, on av- Psychosocial expectancies of smoking can be as- erage, fewer than 5 items are needed to assess sessed on the basis of these item banks via the this construct with adequate precision using the SF, by using CAT, or through a tailored set of items item banks. CONCLUSIONS: A new set of items selected for a specific research purpose. has been identified for assessing the social motivations for smoking in a reliable, standardized EP-66137 303

The role of alcohol expectancies in drinking grade- and gender-matched nationally represen- behavior among women with alcohol use disorder tative data from the Monitoring the Future study and comorbid posttraumatic stress disorder. Ur- and data from the California Healthy Kids Survey sula S. Myers, Kendall C. Browne. 2014 of students within the same school district. RE- Understanding how alcohol expectancies relate SULTS: Overall, the Cambodian-American youth to alcohol use among individuals with concurrent were less likely than nationally- and regionally- alcohol use disorder (AUD) and Posttraumatic representative youth to use alcohol, marijuana, Stress Disorder (PTSD) is important to under- and cigarettes. Specifically, relative to estimates standing and treating this comorbidity. This study obtained for the general population and students examined the role of positive and negative alcohol attending school in the same school district, Cam- expectancies and PTSD symptoms in drinking be- bodian-American youth were significantly less havior in a comorbid female sample. Participants likely to use alcohol and marijuana. Cambodian- were women (n = 33; 56% Caucasian) seeking American youth were also less likely than youth in AUD and PTSD treatment in an outpatient com- the general population to smoke cigarettes, but did munity co-occurring disorders program. Hypothe- not differ statistically from youth within their same ses related to drinking days and alcohol problems school district. CONCLUSIONS: As a group, Cam- outcomes were evaluated using negative binomial bodian-American youth may not be at especially hierarchical regression. PTSD symptoms were high risk for substance use. As is the case with associated with fewer reported days of alcohol- virtually all populations, some individuals within related problems. Negative expectancies related the Cambodian-American group are likely to have to negative changes in social behavior associated more difficulty than others with substance use with drinking days and cognitive and motor impair- concerns. Thus, additional research is needed to ment associated with problems. Both the general identify factors that might help to identify high us- positive expectancies score and specific global ers with potential service needs. positive change subscale were uniquely associ- EP-66139 ated with drinking and alcohol-related problems Measuring value-added in higher education: days after controlling for PTSD symptom severity possibilities and limitations in the use of adminis- and negative expectancies scores. Results sug- trative data. Trey Miller. 2014 gest that both negative and positive expectancies about alcohol's effects are important correlates of This paper develops a general methodology drinking behavior among women with AUD and for measuring the value added of institutions of PTSD, with positive expectancies playing a poten- higher education using commonly available ad- tially more salient role on use and consequences ministrative data. Our approach recognizes the than symptom severity and negative expectan- data limitations and selection problems inherent cies. in higher education, and highlights the challenges these issues pose for education policy. Combining EP-66138 information from different administrative sources A comparison of Cambodian-American adoles- in the state of Texas, we follow the universe of cent substance use behavior to national and local Texas college applicants from the time of appli- norms. Grant N. Marshall. 2014 cation (pre-enrollment) through public college and into the labor market. In specifications that do not INTRODUCTION: This study was designed to control for selection, we find large, significant dif- compare rates of alcohol, marijuana, and cigarette ferences across colleges in terms of persistence, use in Cambodian-American adolescents with graduation, and earnings; however, these differ- norms from nationally- and regionally-representa- ences decrease substantially when we control tive peers. METHODS: Substance use data from for selection. In light of the growing interest in us- 439 10th grade Cambodian-American adolescents in Long Beach, California were compared to 304 ing value-added measures in higher education approaches such as health information technol- for both funding and incentivizing purposes, our ogies. Each of these provides new and exciting methodology offers unique evidence and lessons possibilities for CAM/IHC but equally each also for policy makers. provides new challenges. The collection of articles in this volume explores in various ways several of EP-66140 these challenges from the perspective of CAM/ In-state college tuition policies for undocu- IHC research. CONCLUSION: Sufficient evidence mented immigrants: implications for high school exists now to suggest that the complexity of the enrollment among non-citizen Mexican youth. health encounter in both CAM/IHC and conven- Trey Miller. 2014 tional medicine, whatever therapy is utilized, re- This paper examines the secondary effects of quires a nonreductionist methodology if we are policies that extend or deny in-state tuition to chil- to advance beyond efficacy studies to studies of dren of undocumented immigrants. Drawing upon real-world effectiveness. repeated cross-sections of 15–17-year-olds in the Current Population Survey across 1997–2010, EP-66142 we assess changes in high school enrollment Using exercises to improve public health pre- rates among Mexican-born non-citizen youth—a paredness in Asia, the Middle East and Africa. proxy for the undocumented youth population. We Melinda Moore. 2014 find that Mexican-born non-citizen youth living in BACKGROUND: Exercises are increasingly states that deny in-state tuition benefits to undoc- common tools used by the health sector and oth- umented youth are 49 % less likely to be enrolled er sectors to evaluate their preparedness to re- in school than their peers living in states with no spond to public health threats. Exercises provide explicit policy. Conversely, Mexican-born non-citi- an opportunity for multiple sectors to practice, test zen youth living in states that grant in-state tuition and evaluate their response to all types of public benefits to undocumented youth are 65 % more health emergencies. The information from these likely to be enrolled in school than their peers liv- exercises can be used to refine and improve pre- ing in states with no explicit policy. The enactment paredness plans. There is a growing body of litera- of these policies is unrelated to changes in school ture about the use of exercises among local, state enrollment among naturalized citizens. Our find- and federal public health agencies in the United ings lend support to the proposition that that the States. There is much less information about implementation of in-state tuition policies sends the use of exercises among public health agen- signals to immigrant youth about their future ed- cies in other countries and the use of exercises ucational possibilities in the long-term, which in that involve multiple countries. RESULTS: We de- turn influences the extent to which they engage in veloped and conducted 12 exercises (four sub- school in the short-term. national, five national, three sub-regional) from August 2006 through December 2008. These 12 EP-66141 exercises included 558 participants (average 47) Research methodology: choices, logistics, and and 137 observers (average 11) from 14 countries. challenges. George Lewith, Raheleh Khorsan. Participants consistently rated the overall quality 2014 of the exercises as very good or excellent. They The field of complementary and alternative rated the exercises lowest on their ability to iden- medicine and integrative health care (CAM/IHC) tifying key gaps in performance. The vast major- is contributing exciting new developments in this ity of participants noted that they would use the challenging field. CAM/IHC has experienced rapid information they gained at the exercise to improve growth in acceptance and use. Growth has also their organization's preparedness to respond to an occurred in CAM internationally, and CAM servic- influenza pandemic. Participants felt the exercises es are now being provided by new and innovative were particularly good at raising awareness and 305 understanding about public health threats, assist- or older and their spouses, including assessments ing in evaluating plans and identifying priorities of social, economic, and health circumstances of for improvement, and building relationships that community-residents. CHARLS examines health strengthen preparedness and response across and economic adjustments to rapid ageing of the sectors and across countries. Participants left the population in China. The national baseline survey exercises with specific ideas about the most im- for the study was conducted between June 2011 portant actions that they should engage in after and March 2012 and involved 17 708 respondents. the exercise such as improved planning coordina- CHARLS respondents are followed every 2 years, tion across sectors and countries and better train- using a face-to-face computer-assisted personal ing of health workers and response personnel. interview (CAPI). Physical measurements are CONCLUSIONS: These experiences suggest that made at every 2-year follow-up, and blood sample exercises can be a valuable, low-burden tool to collection is done once in every two follow-up pe- improve emergency preparedness and response riods. A pilot survey for CHARLS was conducted in countries around the world. They also demon- in two provinces of China in 2008, on 2685 indi- strate that countries can work together to develop viduals, who were resurveyed in 2012. To ensure and conduct successful exercises designed to the adoption of best practices and international improve regional preparedness to public health comparability of results, CHARLS was harmo- threats. The development of standardized evalu- nized with leading international research studies ation methods for exercises may be an additional in the Health and Retirement Study (HRS) model. tool to help focus the actions to be taken as a re- Requests for collaborations should be directed to sult of the exercise and to improve future exercis- Dr Yaohui Zhao ([email protected]). All data in es. Exercises show great promise as tools to im- CHARLS are maintained at the National School prove public health preparedness across sectors of Development of Peking University and will be and countries. accessible to researchers around the world at the study website. The 2008 pilot data for CHARLS EP-66143 are available at: http://charls.ccer.edu.cn/charls/. Probiotics for diarrhoea. 2014 National baseline data for the study are expected Empirical evidence for the clinical effectiveness to be released in January 2013. of probiotics has shown mixed results and we still know very little about which probiotics work EP-66145 for which indication and group of patients. In or- Association of vascular risk factors with cog- der to be of informational value, the effectiveness nition in a multiethnic sample. Alden L. Gross, of probiotics needs to be demonstrated in strong Katherine J. Bangen. 2014 research designs, such as randomized controlled OBJECTIVES: To examine the relationship trials, that hold up to scientific scrutiny. The study between cardiovascular risk factors (CVRFs) and by Aggarwal and colleagues in this issue shows cognitive performance in a multiethnic sample of an application of probiotics that has increasingly older adults. METHOD: We used longitudinal data become the subject of research interest for the from the Washington Heights-Inwood Columbia treatment of acute childhood diarrhoea. Aging Project. A composite score including smok- EP-66144 ing, stroke, heart disease, diabetes, hypertension, Cohort profile: the China health and retirement and central obesity represented CVRFs. Multiple longitudinal study (CHARLS). Yisong Hu, James group parallel process multivariate random effects P. Smith. 2014 regression models were used to model cognitive functioning and examine the contribution of The China Health and Retirement Longitudinal CVRFs to baseline performance and change in Study (CHARLS) is a nationally representative lon- general cognitive processing, memory, and ex- gitudinal survey of persons in China 45 years of age ecutive functioning. RESULTS: Presence of each 306

CVRF was associated with a 0.1 SD lower score Schools intervention viewed more implementation in general cognitive processing, memory, and assistance and online community pages than did executive functioning in black and Hispanic par- other user groups. CONCLUSIONS: Web-based ticipants relative to whites. Baseline CVRFs were platforms have the potential to support training associated with poorer baseline cognitive perfor- and implementation of evidence-based interven- mances among black women and Hispanic men. tions for clinicians of varying levels of experience CVRF increase was related to baseline cognitive and may facilitate more rapid dissemination. Web- performance only among Hispanics. CVRFs were based platforms may be promising for trauma- not related to cognitive decline. After adjustment related interventions, because training and im- for medications, CVRFs were not associated with plementation support should be readily available cognition in Hispanic participants. DISCUSSION: after a traumatic event. CVRFs are associated with poorer cognitive functioning, but not cognitive decline, among minority EP-66148 older adults. These relationships vary by gender Reengagement of high-need individuals with and medication use. Consideration of unique ra- serious mental illness after discontinuation of ser- cial, ethnic, and cultural factors is needed when vices. Bradley D. Stein. 2014 examining relationships between CVRFs and OBJECTIVE: The study determined rates of cognition. reengagement in services for individuals with serious mental illness who had discontinued services. EP-66146 METHODS: As part of a quality assurance pro- Causal inference using mixture models: a word gram in New York City involving continuous review of caution. Claude Messan Setodji. 2014 of Medicaid claims and other administrative data, Mixture models are useful for monitoring the clinician care monitors identified 2,834 individuals behavior of data and for offering comparisons to with serious mental illness who were apparently supplemental data, especially in the presence in need of care but disengaged from services. The of unobserved heterogeneity, but one should be care monitors reviewed monthly updates of Med- highly cautious when drawing causal inferences icaid claims, encouraged outreach from providers as to which population each component of the fit- who had previously worked with identified indi- ted mixture model represents. viduals, and determined whether individuals had reengaged in services. RESULTS: Reengage- EP-66147 ment rates over a 12-month follow-up period were A web-based platform to support an evidence- low, particularly for individuals who had been in- based mental health intervention: lessons from carcerated or for whom no service provider was the CBITS web site. Pete Wilmoth. 2014 available to provide outreach. CONCLUSIONS: OBJECTIVE: To explore the role of Web-based Subgroups of disengaged individuals with serious platforms in behavioral health, the study examined mental illness have different rates of reengage- usage of a Web site for supporting training and im- ment. Active outreach by providers might benefit plementation of an evidence-based intervention. some, but such targeting is inefficient when the METHODS: Using data from an online registration individual cannot be located. survey and Google Analytics, the investigators examined user characteristics and Web site utiliza- EP-66149 Use of CAHPS patient experience surveys tion. RESULTS: Site engagement was substantial to assess the impact of health care innovations. across user groups. Visit duration differed by reg- Denise D. Quigley. 2014 istrants' characteristics. Less experienced clinicians spent more time on the Web site. The train- BACKGROUND: The Consumer Assessment of ing section accounted for most page views across Healthcare Providers and Systems (CAHPS®) user groups. Individuals previously trained in the surveys are the standard for collecting informa- Cognitive-Behavioral Intervention for Trauma in 307 tion about patient experience of care in the United superior explanatory power and plausibility over States. However, despite their widespread use, in- mechanistic and reductive frameworks that treat cluding in pay-for-performance and public report- resilience as automated functions of human bio- ing efforts and various provisions of the Affordable psychological systems. Marines dynamically pur- Care Act, knowledge about the use of CAHPS in sue their values in context, and this resilience assessing the impact of quality improvement ef- can only be defined in local, variable context, not forts is limited. A study was conducted to exam- globally and generally. USMC resilience training ine the use of patient experience surveys in as- should focus on skills and concepts needed to sessing the impact of innovations implemented resolve challenges to values in the lives of Ma- in health care settings. METHODS: Innovation rines. Technical-medical interventions should be profiles identified on the Agency for Healthcare reserved for clinical populations. Research and Quality (AHRQ) Health Care In- novations Exchange website that included patient EP-66151 experience (including patient satisfaction) as an Predictors of the existence of congregational outcome (N = 201), were analyzed with a variety HIV programs: similarities and differences com- of qualitative analysis methods. RESULTS: Fewer pared with other health programs. Ann C. Haas. than half of the innovations used a patient experi- 2014 ence measure, most commonly employing global PURPOSE: Identify and compare predictors of measures such as an overall rating. Most innova- the existence of congregational human immuno- tions assessed patient experience at a single time deficiency virus (HIV) and other health programs. point, with only one third using techniques such DESIGN: Cross-sectional study. SETTING: United as pre-post comparisons, time trends, or compari- States. SUBJECTS: A nationally representative sons to control groups. Ten domains of measures sample of 1506 U.S. congregations surveyed in addressed reports of patient experience, all of the National Congregations Study (2006–2007). which could be assessed by existing CAHPS in- MEASURES: Key informants at each congrega- struments. Similarly, CAHPS measures are avail- tion completed in-person and telephone inter- able to assess all of the organizational processes views on congregational HIV and other health pro- that are addressed by innovations in the profiles grams and various congregation characteristics and for which patients are the best source of infor- (response rate = 78%). County-level HIV preva- mation. While 120 of the innovations that use pa- lence and population health data from the Robert tient experience measures report using surveys to Wood Johnson Foundation's 2007 County Health collect these data, only 6 reported using a CAHPS Rankings were linked to the congregational data. measure. CONCLUSIONS: Although innovations ANALYSIS: Multinomial logistic regression was targeting quality improvement are often evaluated used to assess factors that predict congregational using surveys, there is considerable untapped po- health programs relative to no health programs; tential for using CAHPS measures or surveys to and of HIV programs relative to other health ac- assess their effectiveness. tivities. RESULTS: Most congregations (57.5%) had at least one health-related program; many EP-66150 fewer (5.7%) had an HIV program. Predictors of "I don't think I would have recovered": a per- health vs. HIV programs differed. The number of sonal and sociocultural study of resilience among adults in the congregation was a key predictor of U. S. Marines. Frank Tortorello. 2014 health programs, while having an official state- Ethnographic research among US Marines ment welcoming gay persons was a significant shows resilience is in their practices, not biol- predictor of HIV programs (p < .05). Other signifi- ogy. Empirical evidence supports our claim that cant characteristics varied by size of congregation a personal-social understanding of resilience has and type of program (HIV vs. other health). CON- CLUSION: Organizations interested in partnering 308 with congregations to promote health or prevent provide public health and academic researchers HIV should consider congregational size as well with new tools to conduct their community resil- as other factors that predict involvement. Results ience programs and evaluation research. Results of this study can inform policy interventions to in- are not yet available and will be presented in fu- crease the capacity of religious congregations to ture reports. address HIV and health. EP-66153 EP-66152 Using Medicaid and CHIP claims data to sup- The Los Angeles County Community Disas- port pediatric quality measurement: lessons from ter Resilience Project: a community-level, public 3 centers of excellence in measure development. health initiative to build community disaster resil- 2014 ience. Anita Chandra. 2014 OBJECTIVE: We sought to explore the claims Public health officials need evidence-based data-related issues relevant to quality measure methods for improving community disaster resil- development for Medicaid and the Children's ience and strategies for measuring results. This Health Insurance Program (CHIP), illustrating the methods paper describes how one public health challenges encountered and solutions developed department is addressing this problem. This paper around 3 distinct performance measure topics: provides a detailed description of the theoretical care coordination for children with complex needs, rationale, intervention design and novel evaluation quality of care for high-prevalence conditions, of the Los Angeles County Community Disaster and hospital readmissions. METHODS: Each of Resilience Project (LACCDR), a public health pro- 3 centers of excellence presents an example that gram for increasing community disaster resilience. illustrates the challenges of using claims data for The LACCDR Project utilizes a pretest–posttest quality measurement. RESULTS: Our Centers method with control group design. Sixteen com- of Excellence in pediatric quality measurement munities in Los Angeles County were selected used innovative methods to develop algorithms and randomly assigned to the experimental com- that use Medicaid claims data to identify children munity resilience group or the comparison group. with complex needs; overcome some shortcom- Community coalitions in the experimental group ings of existing data for measuring quality of care receive training from a public health nurse trained for common conditions such as otitis media; and in community resilience in a toolkit developed for identify readmissions after hospitalizations for the project. The toolkit is grounded in theory and lower respiratory infections. CONCLUSIONS: Our uses multiple components to address education, experience constructing quality measure specifi- community engagement, community and individ- cations using claims data suggests that it will be ual self-sufficiency, and partnerships among com- challenging to measure key quality of care con- munity organizations and governmental agencies. structs for Medicaid-insured children at a national The comparison communities receive training level in a timely and consistent way. Without better in traditional disaster preparedness topics of di- data to underpin pediatric quality measurement, saster supplies and emergency communication Medicaid and CHIP will have difficulty using some plans. Outcome indicators include longitudinal existing measures for accountability, value-based changes in inter-organizational linkages among purchasing, and quality improvement both across community organizations, community member states and within states. responses in table-top exercises, and changes in household level community resilience behaviors EP-66154 and attitudes. The LACCDR Project is a significant Examining the sustainment of the adolescent- opportunity and effort to operationalize and mean- community reinforcement approach in community ingfully measure factors and strategies to increase addiction treatment settings: protocol for a longitu- community resilience. This paper is intended to dinal mixed method study. Lynsay Ayer. 2014 309

BACKGROUND: Although evidence-based tions of harm and reasons for using this product. treatments are considered the gold standard for METHODS: We surveyed 292 unaccompanied clinical practice, it is widely recognized that evi- homeless youth who were randomly sampled dence-based treatment implementation in real from street sites. Participants smoked at least 100 world practice settings has been limited. To ad- cigarettes in lifetime and 1 cigarette in the past dress this gap, the federal government provided month. RESULTS: Seventy-two percent of youth three years of funding, training and technical assis- reported past month ATP use (e-cigarettes = 51%; tance to 84 community-based treatment programs little cigars/cigarillos = 46%; hookah = 31%; other to deliver an evidence-based treatment called the smokeless tobacco product = 24%; chewing to- Adolescent-Community Reinforcement Approach bacco/moist snuff = 19%). Current ATP use was (A-CRA). Little is known about whether such ef- unrelated to most demographic characteristics or forts lead to long-term A-CRA sustainment after having a past year quit attempt. However, youth the initial funding ends. METHODS/DESIGN: We who planned to quit smoking in the next 30 days will use a longitudinal mixed method data analytic were significantly less likely to report current use approach to characterize sustainment over time of hookahs, other smokeless tobacco products, or and to examine the factors associated with the e-cigarettes. Among lifetime e-cigarette users, the extent to which A-CRA is sustained. We will use most common reasons for use included not hav- implementation data collected during the funding ing to go outside to smoke (38%) and to deal with period (e.g., organizational functioning, staff certi- situations or places where they cannot smoke fication rates and penetration) and supplement it (36%); it was less common to report using e-ciga- with additional data collected during the proposed rettes to quit smoking (17%–18%). DISCUSSION: project period regarding implementation quality Dual use of ATPs among homeless youth smok- and the hypothesized predictors of sustainment ers is common, and more likely among those who (i.e., inner and outer contextual variables) col- have no immediate plans to quit smoking. Effective lected over three waves from 2013 to 2015 rep- and easily disseminable strategies for reducing all resenting program sustainment up to five years forms of tobacco use among homeless youth are post-initial funding. DISCUSSION: Gaining a bet- urgently needed. ter understanding of the factors that influence the evidence-based treatment sustainment may lead EP-66156 to more effective dissemination strategies and ulti- Yoga vs. physical therapy vs. education for mately improve the quality of care being delivered chronic low back pain in predominantly minority in community-based addiction treatment settings. populations: study protocol for a randomized controlled trial. Karen J. Sherman, Anthony M. Delitto. EP-66155 2014 Alternative tobacco product use and smoking BACKGROUND: Chronic low back pain causes cessation among homeless youth in Los Angeles substantial morbidity and cost to society while County. William G. Shadel. 2014 disproportionately impacting low-income and mi- INTRODUCTION: Approximately 70% of home- nority adults. Several randomized controlled tri- less youth smoke cigarettes, but their use of al- als show yoga is an effective treatment. However, ternative tobacco products (ATPs) is unknown. the comparative effectiveness of yoga and physi- This paper reports on ATP use among past month cal therapy, a common mainstream treatment for smokers in Los Angeles County, including wheth- chronic low back pain, is unknown. METHODS/ er it differs by demographic characteristics, home- DESIGN: This is a randomized controlled trial for lessness severity, past year quit attempts, and 320 predominantly low-income minority adults readiness to quit smoking. Given the growing pop- with chronic low back pain, comparing yoga, phys- ularity of e-cigarettes, we also report on percep- ical therapy, and education. Inclusion criteria are adults 18–64 years old with non-specific low back 310 pain lasting ≥12 weeks and a self-reported av- White 5th graders (ages 10–11) in a population- erage pain intensity of ≥4 on a 0–10 scale. Re- based, longitudinal study conducted in 3 U.S. met- cruitment takes place at Boston Medical Center, ropolitan areas, and assessed them again 2 years an urban academic safety-net hospital and seven later. Weight status was classified from measured federally qualified community health centers locat- body mass index using standard criteria into non- ed in diverse neighborhoods. The 52-week study obese and obese (27% in 5th grade). SES was has an initial 12-week Treatment Phase where indexed based on highest education attainment participants are randomized in a 2:2:1 ratio into i) in the household. RESULTS: Youth in the highest a standardized weekly hatha yoga class supple- SES had a significantly lower prevalence of obe- mented by home practice; ii) a standardized ev- sity than those of lower SES at both 5th and 7th idence-based exercise therapy protocol adapted grades when disregarding race/ethnicity. Within- from the Treatment Based Classification method, racial/ethnic group analyses mostly confirmed this individually delivered by a physical therapist and pattern for Hispanic and White youth, but not for supplemented by home practice; and iii) educa- African American youth. When also considering tion delivered through a self-care book. Co-prima- gender, the SES differential in obesity risk was ry outcome measures are 12-week pain intensity more pronounced among White girls and 5th- measured on an 11-point numerical rating scale grade Hispanic boys. CONCLUSION: Growing up and back-specific function measured using the in a high SES home, marked by having a member modified Roland Morris Disability Questionnaire. with at least a college degree, is associated with In the subsequent 40-week Maintenance Phase, lower risk for obesity among Hispanic and White yoga participants are re-randomized in a 1:1 ratio youth. For African American youth, there appears to either structured maintenance yoga classes or to be no association between SES and obesity. home practice only. Physical therapy participants Thus the health advantage generally attributed to are similarly re-randomized to either five booster higher SES does not appear consistently across sessions or home practice only. Education par- racial/ethnic groups for obesity in youth. Further ticipants continue to follow recommendations of research should identify influences on weight sta- educational materials. We will also assess cost tus beyond SES, especially among African Ameri- effectiveness from the perspectives of the indi- can youth. vidual, insurers, and society using claims databases, electronic medical records, self-report cost EP-66158 data, and study records. Qualitative data from in- Comparison of complementary and alternative terviews will add subjective detail to complement medicine with conventional mind–body therapies quantitative data. for chronic back pain: protocol for the Mind–body Approaches to Pain (MAP) randomized controlled EP-66157 trial. Karen J. Sherman, Benjamin H. Balderson. Associations between socioeconomic status 2014 and obesity in diverse, young adolescents: varia- BACKGROUND: The self-reported health and tion across race/ethnicity and gender. Jan Wal- functional status of persons with back pain in the lander, Marc N. Elliott. 2014 United States have declined in recent years, de- OBJECTIVE: This study examined the asso- spite greatly increased medical expenditures due ciation between socioeconomic status (SES) and to this problem. Although patient psychosocial fac- obesity risk during early adolescence, ages 10–13 tors such as pain-related beliefs, thoughts and cop- years, and whether this association is present in ing behaviors have been demonstrated to affect different racial/ethnic and gender groups during 2 how well patients respond to treatments for back time points in early adolescence. METHOD: Data pain, few patients receive treatments that address were from the Healthy Passages study, which these factors. Cognitive-behavioral therapy (CBT), enrolled 4,824 African American, Hispanic, and which addresses psychosocial factors, has been 311 found to be effective for back pain, but access to tive care. These points translate into discounts on qualified therapists is limited. Another treatment retail goods such as airline tickets, movie tickets, option with potential for addressing psychoso- or cell phones. METHODS: We chose 8 preven- cial issues, mindfulness-based stress reduction tive care services over the years 2005 to 2011 and (MBSR), is increasingly available. MBSR has been compared the change between those who entered found to be helpful for various mental and physi- the incentive program and those that did not. We cal conditions, but it has not been well-studied for used multivariate regression models with individu- application with chronic back pain patients. In this al random effects to try to address selection bias. trial, we will seek to determine whether MBSR is RESULTS: Of the 4,186,047 unique individuals an effective and cost-effective treatment option for enrolled in the health plan, 65.5% (2,742,268) vol- persons with chronic back pain, compare its ef- untarily enrolled in the incentive program. Joining fectiveness and cost-effectiveness compared with the incentive program was associated with statisti- CBT and explore the psychosocial variables that cally higher odds of receiving all 8 preventive care may mediate the effects of MBSR and CBT on pa- services. The odds ratio (and estimated percent- tient outcomes. METHODS/DESIGN: In this trial, age point increase) for receipt of cholesterol test- we will randomize 397 adults with nonspecific ing was 2.70 (8.9%); glucose testing 1.51 (4.7%); chronic back pain to CBT, MBSR or usual care glaucoma screening 1.34 (3.9%); dental exam arms (99 per group). Both interventions will con- 1.64 (6.3%); HIV test 3.47 (2.6%); prostate specific sist of eight weekly 2-hour group sessions sup- antigen testing 1.39 (5.6%); Papanicolaou screen- plemented by home practice. The MBSR protocol ing 2.17 (7.0%); and mammogram 1.90 (3.1%) (P also includes an optional 6-hour retreat. Interview- <.001 for all 8 services). However, preventive care ers masked to treatment assignments will assess rates among those in the incentive program was outcomes 5, 10, 26 and 52 weeks postrandom- still low. CONCLUSIONS: Voluntary participation ization. The primary outcomes will be pain-related in a patient incentive program was associated functional limitations (based on the Roland Dis- with a significantly higher likelihood of receiving ability Questionnaire) and symptom bothersome- preventive care, though receipt of preventive care ness (rated on a 0 to 10 numerical rating scale) at among those in the program was still lower than 26 weeks. DISCUSSION: If MBSR is found to be ideal. an effective and cost-effective treatment option for patients with chronic back pain, it will become a EP-66160 valuable addition to the limited treatment options When a whole practice model is the intervention: available to patients with significant psychosocial developing fidelity evaluation components using contributors to their pain. program theory-driven science for an integrative medicine primary care clinic. Patricia M. Herman. EP-66159 2014 Impact of a patient incentive program on receipt Integrative medicine (IM) is a clinical paradigm of preventive care. Ruopeng An. 2014 of whole person healthcare that combines appro- OBJECTIVES: Patient financial incentives are priate conventional and complementary medicine being promoted as a mechanism to increase re- (CM) treatments. Studies of integrative healthcare ceipt of preventive care, encourage healthy be- systems and theory-driven evaluations of IM prac- havior, and improve chronic disease management. tice models need to be undertaken. Two health However, few empirical evaluations have assessed services research methods can strengthen the such incentive programs. STUDY DESIGN: In validity of IM healthcare studies, practice theory, South Africa, a private health plan has introduced and fidelity evaluation. The University of Arizona a voluntary incentive program which costs enroll- Integrative Health Center (UAIHC) is a member- ees approximately $20 per month. In the program, ship-supported integrative primary care clinic in enrollees earn points when they receive preven- Phoenix, AZ. A comparative effectiveness evalu- 312 ation is being conducted to assess its clinical and Despite increasing recognition about the stig- cost outcomes. A process evaluation of the clinic's ma associated with cancer screening, diagnosis, practice theory components assesses model fi- and treatment-seeking behaviors, there has been delity for four purposes: (1) as a measure of inter- relatively little attention paid to how to assess vention integrity to determine whether the practice and intervene to reduce that stigma. An index to model was delivered as intended; (2) to describe measure cancer stigma could empower health an integrative primary care clinic model as it is be- program developers and policymakers by identi- ing developed and refined; (3) as potential covari- fying the key areas in which a population could ates in the outcomes analyses, to assist in inter- benefit from education to change perceptions and pretation of findings, and for external validity and address misinformation. The index also could be replication; and (4) to provide feedback for needed used to rank countries and communities based on corrections and improvements of clinic operations their level of cancer stigma to assess where inter- over time. This paper provides a rationale for the ventions are needed. We used structured litera- use of practice theory and fidelity evaluation in ture review and expert review to generate a can- studies of integrative practices and describes the cer stigma item pool. The item pool was subject approach and protocol used in fidelity evaluation to cognitive interviews for cultural appropriateness of the UAIHC. and comprehension; and data from initial pilot testing were used to reduce the pool of items for EP-66161 translation and field testing. The field test was con- Maricopa County's drug court: an innovative ducted using a web-based survey in four samples program for first-time drug offenders on probation. representing two regions and three languages— Peter W. Greenwood. 2014 English and Arabic speakers in Jordan and Egypt, The nationwide drug court movement repre- and English and Mandarin Chinese speakers in sents one of the most recent innovations in our China. Factor analyses and item response theory criminal justice system aimed at decreasing the were applied to finalize the index. The analyses number of drug-involved offenders by providing resulted in a 12-item cancer stigma index (CSI) drug treatment and intensive court supervision. that was reliable across all four samples. The CSI Although the majority of drug courts are diversion scores were highly correlated with a general ill- programs, the Maricopa County (Arizona) Drug ness stigma scale, and operated as expected not- Court is a postadjudication program for proba- ing higher cancer stigma among men and those tioners with a first-time felony conviction for drug with lower income. The CSI can be used to inform possession. Probationers are required to partici- initial cancer education efforts, identifying overall pate in an outpatient comprehensive drug treat- stigma levels in a country or community and par- ment program, and their progress is monitored by ticular issue areas requiring intervention. the judge. The drug court emphasizes individual accountability through a system of rewards and EP-66164 Provision of mental health services as a quality sanctions. A total of 639 offenders sentenced in indicator for adolescent substance abuse treat- 1992 or 1993 were randomly assigned to the drug ment facilities. Beth Ann Griffin. 2014 court or standard probation for RAND's experimental evaluation. Preliminary results show that OBJECTIVE: The study tested whether ado- 40 percent of drug court participants successfully lescents receiving substance abuse treatment at completed the treatment program within twelve facilities offering full (can treat all psychiatric con- months. ditions) or partial (cannot treat severe or persistent mental illness) mental health services have EP-66163 better 12-month substance use and mental health Developing a global cancer stigma index. Anita outcomes than youths at facilities with no mental Chandra. 2014 health services. METHODS: Data were collected 313 from 3,235 adolescents who were assessed at who received chemotherapy for advanced (stage baseline and at 12 months at one of 50 adoles- III/IV lung or stage IV colorectal) cancer, 25.7% cent treatment facilities. Propensity scores were discussed trials, and 7.6% (29.5% of trial discus- applied to compare client outcomes from three sants) enrolled. Discussions were less frequent types of facilities (full, partial, or no mental health among older patients, African American or Asian services); weighted linear models were estimated vs white patients, and those with lower incomes to examine outcomes. RESULTS: Youths attend- and more comorbidity. Enrollment was higher ing facilities offering full or partial mental health among patients reporting shared vs physician- services had better substance abuse treatment driven decisions (all P < .05). CONCLUSIONS: In outcomes than youths attending facilities offer- this population-based cohort, only 14% of patients ing no such services. There was no evidence of discussed participation in clinical trials. Discus- a difference in substance use outcomes between sions were more frequent among advanced can- facilities offering full versus partial services, nor cer patients but were still reported by a minority of was there evidence of differences in mental health patients. Strategies to expand access to trials and outcomes. CONCLUSIONS: These preliminary facilitate patient-provider communication about findings suggest that the availability of mental participation may accelerate development of bet- health services may be a useful quality indicator ter cancer therapeutics. for adolescent substance abuse treatment facilities. More research is needed to examine specific EP-66166 types of mental health services offered at different Trends in functional and activity limitations facilities. among Chinese oldest-old, 1998 to 2008. Qiushi Feng, Robert F. Schoeni. 2014 EP-66165 China has the world's largest oldest-old pop- Discussions about clinical trials among patients ulation, but information on trends in late-life dis- with newly diagnosed lung and colorectal cancer. ability is lacking. We use data from the Chinese Neeraj K. Arora, Deborah Schrag. 2014 Longitudinal Healthy Longevity Survey for 1998 to BACKGROUND: Clinical trials are essential to 2008 to determine whether prevalence of limita- establish the effectiveness of new cancer thera- tions with physical functions and daily activities pies, but less than 5% of adults with cancer enroll has changed recently among the Chinese popula- in trials. In addition to ineligibility or lack of avail- tion aged 80 to 105 and, if so, to investigate the able trials, barriers to enrollment may include lim- factors associated with the change. We find that ited patient awareness about the option of partici- prevalence of need for assistance with activities pation. METHODS: We surveyed a multiregional of daily living and inability to independently con- cohort of patients with lung or colorectal cancer duct instrumental activities of daily living declined (or their surrogates) three to six months after diag- substantially. Males did not experience improve- nosis. We assessed whether respondents report- ment in ability to carry out underlying physical ed learning that clinical trial participation might be functions over the same period, but females did. an option, and, if so, with whom they discussed Variables associated with trends in one or more of trials. We used logistic regression to assess the these outcomes were adequacy of medical care association of patient characteristics with disas a child, childhood hunger, father's occupation cussing trial participation and enrolling in trials. in agriculture, main occupation before age 60 in All statistical tests were two-sided. RESULTS: agriculture, adequacy of current medical care, Of 7887 respondents, 1114 (14.1%) reported dis- and body weight. cussing the possibility of clinical trial participation; most learned about trials from their physicians, EP-66167 and 287 patients (3.6% of all patients, 25.8% of Comparative effectiveness of pharmacologic trial discussants) enrolled. Among 2173 patients treatments to prevent fractures: an updated sys- 314 tematic review. Sydne Newberry. 2014 using systematic observation and surveys of park BACKGROUND: Osteoporosis is a major con- users and local residents. We observed park use tributor to the propensity to fracture among older at least 3–4 times per day over 4–7 clement days. adults, and various pharmaceuticals are available We conducted a meta-analysis to estimate total, to treat it. PURPOSE: To update a review about age group and gender-specific park use and total the benefits and harms of pharmacologic treat- MVPA time in parks. RESULTS: An average park ments used to prevent fractures in adults at risk. measuring 10 acres and with 40,000 local resi- DATA SOURCES: Multiple computerized data- dents in a one-mile radius accrued 5301 h of use bases were searched between 2 January 2005 (SE = 1083) during one week, with 35% (1850 h) and 4 March 2014 for English-language studies. spent in MVPA and 12% (635 h) spent in vigor- STUDY SELECTION: Trials, observational stud- ous physical activity (VPA). As much as a 10.7-fold ies, and systematic reviews. DATA EXTRAC- difference in weekly MVPA hours was estimated TION: Duplicate extraction and assessment of across study parks. Parks' main contribution to data about study characteristics, outcomes, and population-level MVPA is for males, teenagers, quality. DATA SYNTHESIS: From more than 52 and residents living within a half mile. CONCLU- 000 titles screened, 294 articles were included in SION: Neighborhood parks contribute substantial- this update. There is high-strength evidence that ly to population MVPA. The contribution may de- bisphosphonates, denosumab, and teriparatide pend less on size and facilities than on "demand reduce fractures compared with placebo, with goods" – programming and activities--that draw relative risk reductions from 0.40 to 0.60 for ver- users to a park. tebral fractures and 0.60 to 0.80 for nonvertebral EP-66169 fractures. Raloxifene has been shown in placebo- Study design to develop and pilot-test a web controlled trials to reduce only vertebral fractures. intervention for partners of military service mem- Since 2007, there is a newly recognized adverse bers with alcohol misuse. Eric R. Pedersen. 2014 event of bisphosphonate use, atypical subtro- chanteric femur fracture. Gastrointestinal side ef- BACKGROUND: Alcohol misuse among mili- fects, hot flashes, thromboembolic events, and tary service members from the recent conflicts in infections vary among drugs. LIMITATIONS: Few Iraq and Afghanistan is over two times higher com- studies have directly compared drugs used to treat pared to misuse in the civilian population. Unfortu- osteoporosis. Data in men are very sparse. Costs nately, in addition to experiencing personal conse- were not assessed. CONCLUSION: Good-quality quences from alcohol misuse, partners and family evidence supports that several medications for members of alcohol-misusing service members bone density in osteoporotic range and/or preex- also suffer in negative ways from their loved one's isting hip or vertebral fracture reduce fracture risk. drinking. These family members represent impor- Side effects vary among drugs, and the compara- tant catalysts for helping their loved ones identify tive effectiveness of the drugs is unclear. problem drinking and overcoming the barriers to seeking care. This paper describes the protocol to EP-66168 a pilot study evaluating a 4-session, web-based How much neighborhood parks contribute to intervention (WBI) for concerned partners (CPs) local residents' physical activity in the City of Los of service members with alcohol misuse. METH- Angeles: a meta-analysis. Deborah A. Cohen. ODS/DESIGN: The WBI will be adapted from the 2014 Community Reinforcement and Family Training OBJECTIVE: To quantify the contribution of (CRAFT) intervention. In the first phase, we will neighborhood parks to population-level, moder- develop and beta-test the WBI with 15–20 CPs. ate-to-vigorous physical activity (MVPA). METH- In the second phase, we will randomize CPs to OD: We studied park use in 83 neighborhood WBI (n = 50) or to delayed-WBI parks in Los Angeles between 2003 and 2014 (n = 50) and evaluate the impact 315 of the WBI on CPs' perceptions of service mem- remain stable, whereas perceived norms became ber help-seeking and drinking, as well as the CP's less influential. CONCLUSION: Findings suggest well-being and relationship satisfaction 3 months that perceived peer norms may be more influen- after the intervention. In the third phase, we will tial in early adolescence; whereas proximal social recruit 15–20 service members whose partners determinants (e.g., being in the presence of other have completed the study. We will interview the peers who consume) become more influential as service members to learn how the CP-focused youth enter middle adolescence. Prevention pro- WBI affected them and to assess whether they grams should continue to address misperception would be receptive to a follow-on WBI module to of norms with younger adolescents to decrease help them. DISCUSSION: This project has the the chances of initiation, but also utilize strategies potential to benefit a large population of military such as refusal skills and alternate coping mecha- service members who may be disproportionately nisms for older adolescents. affected by recent conflicts and whose drinking misuse would otherwise go undetected and un- EP-66171 treated. It also develops a new prevention model Time off to care for a sick child: why family-leave that does not rely on service members or partners policies matter. Paul J. Chung. 2014 attending a hospital or clinical facility to access There is substantial unmet need for parental care. leave to care for chronically ill children. Yet about half of U.S. employees do not receive any paid EP-66170 sick days that they are allowed to use to care for Proximal and distal social influence on alcohol family members. When parents without such sick consumption and marijuana use among middle days stay home from work to care for an ill child, school adolescents. Eric R. Pedersen. 2014 they can be fired or otherwise penalized. Flexible OBJECTIVES: This study assesses the inde- schedules and telecommuting can help, especial- pendent and combined effects of (1) perceived ly for parents with a chronically ill child. Although peer norms, (2) best friend use, and (3) being in some employers have raised concerns about po- the presence of others who use on middle school tential misuse of paid-sick-leave benefits, the risk adolescents' consumption of marijuana and alco- of fraud can be minimized through employer poli- hol, and how the effects of these sources of so- cies requiring certification of health conditions. Ul- cial influence evolve over time as youth progress timately sensible family leave benefits help fami- through middle school. METHODS: The analytic lies and employers. Studies have shown that most sample consisted of 11,667 adolescents (50% fe- employees use these types of benefits to deal with male; >65% Hispanic) in 6th, 7th or 8th grade from the real demands of real illnesses, which reduces 16 middle schools across three school districts in health care costs to employers. Southern California. Participants were assessed at 5 time points from 2008 to 2011. RESULTS: All EP-66172 sources of social influence were predictive of al- Supply of buprenorphine waivered physicians: cohol and marijuana consumption. As youth grew the influence of state policies. Adam J. Gordon, older, spending time with other adolescents who Andrew W. Dick. 2014 drink increased adolescents' likelihood of drinking Buprenorphine, an effective opioid use dis- alcohol, whereas perceived norms became less order treatment, can be prescribed only by bu- influential. Furthermore, as adolescents spent prenorphine-waivered physicians. We calculated more time around other youths who drink, the pre- the number of buprenorphine-waivered physi- dictive value of perceived norms on alcohol con- cians/100,000 county residents using 2008-11 sumption decreased. Similarly, as youth grew old- Buprenorphine Waiver Notification System data, er, the influence of best friend's use and spending and used multivariate regression models to pre- time with other adolescents who use marijuana dict number of buprenorphine-waivered physi- 316 cians/100,000 residents in a county as a function of lifetime marijuana users. Those with a history of of county characteristics, state policies and efforts solitary use of either substance were more likely to promote buprenorphine use. In 2011, 43% of US to hold positive expectancies about their use but counties had no buprenorphine-waivered physi- also reported more negative consequences dur- cians and 7% had 20 or more waivered physicians. ing the past year. Solitary users tended to have Medicaid funding, opioid overdose deaths, and greater exposure to substance-using peers and specific state guidance for office-based buprenor- more difficulty resisting offers to use. Compared phine use were associated with more buprenor- with social-only drinkers, those with a history of phine-waivered physicians, while encouraging solitary drinking perceived that more of their peers methadone programs to promote buprenorphine were alcohol users. Significant group differences use had no impact. Our findings provide impor- were not found on negative outcome expectan- tant empirical information to individuals seeking to cies or attempts to cut down on substance use. identify effective approaches to increase the num- CONCLUSIONS: Solitary use is an important, ber of physicians able to prescribe buprenorphine. yet, overlooked problem among middle school students who have just begun drinking or using EP-66173 marijuana. Results suggest that positive expec- Geographic variation in receipt of psychotherapy tancies, peer influences, resistance self-efficacy, in children receiving attention-deficit/hyperactivity and normative beliefs may be important areas to disorder medications. Bradley D. Stein. 2014 target in reducing solitary use and the risk it poses In the more than 1500 counties studied, fewer for problematic use in young adulthood. than 25% of children prescribed ADHD drugs received talk therapy in the same year they received EP-66175 The Vietnam multicomponent collaborative medication. The percentage of children who re- care for depression program: development of de- ceived both drugs and therapy varied across pression care for low- and middle-income nations. counties and did not always reflect the number of Bahr Weiss, Trung Lam. 2014 available psychologists. In this article, we discuss the Vietnam Multicom- EP-66174 ponent Collaborative Care for Depression Program Alcohol and marijuana use in middle school: , which was designed to provide evidence-based comparing solitary and social-only users. Eric R. depression care services in low-resource, non- Pedersen. 2014 Western settings such as Vietnam. The article PURPOSE: Middle school students with a provides the program development background; history of solitary substance use are at elevated the social, economic, and political context in which risk for substance problems by young adulthood. the program was developed; and the structure Understanding how these students differ from so- and content of the program and their underlying cial-only users on substance use behaviors and rationale in the context of rural Vietnam. Although consequences, normative beliefs, social influ- the program was found to be acceptable, feasible, ences, and attitudes can inform efforts to reduce and effective in reducing depression outcomes, solitary use and its related negative consequenc- we did face challenges in implementation, which es. METHODS: Sixth- to seventh-grade students are outlined in this article. Key challenges includ- completed an in-school survey. We compared ed cultural factors (e.g., a lack of recognition of those with a history of solitary versus social-only depression as a health-related entity amenable to alcohol use (n = 202 and n = 616, respectively) professional treatment, relatively low levels of psy- and marijuana use (n = 92 and n = 208, respec- chological mindedness useful for understanding tively) on a range of substance use–related char- of psychological interventions) and health system acteristics. RESULTS: Any solitary use was re- (e.g., lack of mental health specialists, overbur- ported by 25% of lifetime alcohol users and 31% dened health providers unfamiliar with behavioral 317 interventions) factors. We discuss the strategies EP-66177 we employed to resolve these challenges and our The effects of purchasing alcohol and marijuana successes and failures therein. We conclude with among adolescents at-risk for future substance recommendations for others interested in imple- use. Eric R. Pedersen. 2014 menting similar programs in low- and middle-income countries settings. BACKGROUND: Among high-risk youth, those who may be at increased risk for adverse alcohol EP-66176 and other drug (AOD) use outcomes may benefit Relationships and health among emerging from targeted prevention efforts; how youth acquire adults with and without Type 1 diabetes. Dianna AOD may provide an objective means of identi- K. Palladino, Kerry A. Reynolds. 2014 fying youth at elevated risk. METHODS: We as- OBJECTIVE: The study's goal was to exam- sessed how youth acquired alcohol and marijua- ine the impact of parent and peer relationships na (purchasing vs. other means), demographics, on health behaviors and psychological well-being AOD behaviors/consequences, and environment of those with and without Type 1 diabetes over among adolescents referred to a diversion pro- the transition to emerging adulthood. Emerging gram called Teen Court (N = 180) adulthood is an understudied developmental peat two time points (prior to the program and 180 riod and a high-risk period—especially for those days from baseline). Participants were predomi- with Type 1 diabetes. METHOD: Youth with (n = nantly White and Hispanic/Latino(a). RESULTS: 117) and without Type 1 diabetes (n = 122) com- In cross-sectional analyses among alcohol and pleted questionnaires during their senior year of marijuana users, purchasing marijuana was as- high school and 1 year later. Measures included sociated with more frequent marijuana use and supportive and problematic aspects of parent and consequences, time spent around teens who use peer relationships, health behaviors, psychologi- marijuana, higher likelihood of substance use dis- cal well-being, and, for those with diabetes, self- orders, and lower resistance self-efficacy com- care behavior and glycemic control. RESULTS: pared to non-purchasers. Teens who purchased Prospective multiple and logistic regression analy- both alcohol and marijuana experienced similar sis revealed that friend conflict was a more potent outcomes to those who purchased only marijua- predictor than friend support of changes in health na, and also reported more frequent and higher behaviors and psychological well-being. Parent quantity of drinking, greater alcohol-related conse- support was associated with positive changes quences, time spent around teens who use other in psychological well-being and decreases in drugs, and prescription drug misuse. Longitudinal- smoking, whereas parent control was related to ly, purchasing alcohol and marijuana at baseline increases in smoking and depressive symptoms. was associated with more frequent and higher There was some evidence of cross-domain buffer- quantity of drinking compared to non-purchasers ing such that supportive relationships in one do- at follow-up. Marijuana only purchasers had a main buffered adverse effects of problematic rela- greater likelihood of substance use disorders at tionships in the other domain on health outcomes. follow-up compared to non-purchasers. CONCLU- CONCLUSIONS: This longitudinal study showed SIONS: In an era where drinking is commonplace that parent relationships remain an important in- and attitudes towards marijuana use are becom- fluence on, and peer relationships continue to in- ing more tolerant, it is essential to evaluate how fluence, the health behaviors and psychological accessibility to AOD and subsequent purchasing well-being of emerging adults with and without behaviors affect youth consumption and intervene Type 1 diabetes. Parent relationships also have accordingly to prevent future consequences. the potential to buffer the adverse effects of dif- EP-66178 ficulties with peers. Predicting support for non-pharmaceutical interventions during infectious outbreaks: a four re- 318 gion analysis. Robert J. Blendon, Alan Zaslavsky. The fidaxomicin-based path was superior across 2014 all the clinical outcomes considered. The incre- Non-pharmaceutical interventions (NPIs) are mental cost per recurrence avoided was $6109 an important public health tool for responding to to $13,027 higher for the fidaxomicin-based path infectious disease outbreaks, including pandem- compared with all others. For fidaxomicin to be ics. However, little is known about the individual cost neutral, the cost per recurrence would need characteristics associated with support for NPIs, to be between $25,000 and $48,000 depending or whether they are consistent across regions. This on the comparator treatment. CONCLUSIONS: study draws on survey data from four regions— A treatment path beginning with fidaxomicin pro- Hong Kong, Singapore, Taiwan, and the United duced superior clinical outcomes but higher costs States—collected following the Severe Acute Re- relative to 3 other treatment paths. However, fidax- spiratory Syndrome (SARS) outbreak of 2002–03, omicin would be cost neutral or cost saving for pa- and employs regression techniques to estimate tient subgroups with higher recurrence costs. Our predictors of NPI support. It finds that character- simulations provide guidance for decision makers istics associated with NPI support vary widely by to optimize use of this. region, possibly because of cultural variation and EP-66180 prior experience, and that minority groups tend to Barriers and facilitators to pediatric emergency be less supportive of NPIs when arrest is the con- telemedicine in the United States. Jeremy M. sequence of noncompliance. Prior experience of Kahn. 2014 face-mask usage also results in increased support for future usage, as well as other NPIs. Policymak- BACKGROUND: Pediatric emergency telemed- ers should be attentive to local preferences and to icine has the potential to improve the quality of the application of compulsory interventions. It is pediatric emergency care in underserved areas, speculated here that some public health interven- reducing socioeconomic disparities in access tions may serve as 'gateway' exposures to future to care. Yet, telemedicine in the pediatric emer- public health interventions. gency setting remains underutilized. We aimed to assess the current state of pediatric emergency EP-66179 telemedicine and identify unique success factors Comparative effectiveness of fidaxomicin for and barriers to widespread use. MATERIALS AND treatment of Clostridium difficile infection. John P. METHODS: We conducted a telephone survey of Caloyeras. 2014 current, former, and planned pediatric emergen- OBJECTIVE: To assess the differential clinical cy telemedicine programs in the United States. and economic value of fidaxomicin compared with RESULTS: We surveyed 25 respondents at 20 metronidazole and vancomycin in the treatment unique sites, including 12 current, 5 planned, and of Clostridium difficile infection (CDI). STUDY 3 closed programs. Existing programs were lo- DESIGN: Cohort-level Markov model simulation. cated primarily in academic medical centers and METHODS: We defined 4 treatment paths that served an average of 12.5 spoke sites (range, varied the drugs used for initial and recurrent CDI 1–30). Respondents identified five major barri- infections. A population of adult inpatients at risk ers, including difficulties in cross-hospital cre- of developing CDI passed through health states, dentialing, integration into established workflows, including the initial CDI treatment episode, recur- usability of technology, lack of physician buy-in, rent CDI treatment episodes, persistent CDI re- and misaligned incentives between patients and quiring retreatment, vancomycin-resistant Entero- providers. Uneven reimbursement was also cited coccus (VRE) colonization, and VRE infection. as a barrier, although this was not seen as ma- Each health state was associated with risks and jor because most programs were able to operate costs. Our primary outcome of interest was the in- independent of reimbursement, and many were cremental cost per recurrence avoided. RESULTS: 319 not actively seeking reimbursement even when al- sylvania. RESULTS: Associations between mean lowed. Critical success factors included selecting daily temperature and kidney stone presentation spoke hospitals based on receptivity rather than were not monotonic, and there was variation in perceived need and cultivating clinical champions the exposure–response curve shapes and the at local sites. CONCLUSIONS: Although pediat- strength of associations at different temperatures. ric emergency telemedicine confronts many of the However, in most cases RRs increased for tem- same challenges of other telemedicine applica- peratures above the reference value of 10°C. tions, reimbursement is relatively less significant, The cumulative RR for a daily mean temperature and workflow disruption are relatively more sig- of 30°C versus 10°C was 1.38 in At- nificant in this setting. Although certain challenges lanta (95% CI: 1.07, 1.79), 1.37 in Chicago (95% such as credentialing can be addressed with avail- CI: 1.07, 1.76), 1.36 in Dallas (95% CI: 1.10, 1.69), able policy options, others such as the culture of 1.11 in Los Angeles (95% CI: 0.73, 1.68), and transfer at rural emergency departments require 1.47 in Philadelphia (95% CI: 1.00, 2.17). Kidney innovative approaches. stone presentations also were positively associated with temperatures < 2°C in Atlanta, and EP-66181 < 10°C in Chicago and Philadelphia. In four A promising thaw. Christopher Paul. 2014 cities, the strongest association between kidney The relationship between New Zealand and the stone presentation and a daily mean temperature United States has seen ups and downs over the of 30°C versus 10°C was estimated for past 60 years, but the two countries have entered lags of ≤ 3 days. CONCLUSIONS: In general, a new era characterized by the ability to agree to kidney stone presentations increased with higher disagree. daily mean temperatures, with the strongest associations estimated for lags of only a few days. EP-66182 These findings further support an adverse effect Daily mean temperature and clinical kidney of high temperatures on nephrolithiasis. stone presentation in five U. S. metropolitan areas: a time-series analysis. Jose E. Pulido, Antonio EP-66183 Gasparrini. 2014 Getting older isn't all that bad: better decisions and coping when facing "sunk costs". JoNell BACKGROUND: High ambient temperatures Strough, Andrew M. Parker. 2014 are a risk factor for nephrolithiasis, but the precise relationship between temperature and kidney Because people of all ages face decisions that stone presentation is unknown. OBJECTIVES: affect their quality of life, decision-making compe- Our objective was to estimate associations be- tence is important across the life span. According tween mean daily temperature and kidney stone to theories of rational decision making, one cru- presentation according to lag time and tempera- cial decision skill involves the ability to discontinue tures. METHODS: Using a time-series design and failing commitments despite irrecoverable invest- distributed lag nonlinear models, we estimated ments also referred to as "sunk costs." We find the relative risk (RR) of kidney stone presenta- that older adults are better than younger adults at tion associated with mean daily temperatures, in- making decisions to discontinue such failing com- cluding cumulative RR for a 20-day period, and mitments especially when irrecoverable losses RR for individual daily lags through 20 days. Our are large, as well as at coping with the associated analysis used data from the MarketScan Com- irrecoverable losses. Our results are relevant to mercial Claims database for 60,433 patients who interventions that aim to promote better decision- sought medical evaluation or treatment of kid- making competence across the life span. ney stones from 2005–2011 in the U.S. cities of Atlanta, Georgia; Chicago, Illinois; Dallas, Texas; EP-66184 Probability perceptions and preventive health Los Angeles, California; and Philadelphia, Penn- 320 care. Peter Kooreman. 2014 each day. The cumulative cognitive demand of We study the effect of perceptions in com- these decisions may erode clinicians' abilities to parison with more objective measures of risk on resist making potentially inappropriate decisions. individuals' decisions to decline or accept risk In primary care, prescribing unnecessary antibiot- reducing interventions such as flu shots, mam- ics for acute respiratory infections (ARIs) is a com- mograms, and aspirin for the prevention of heart mon, inappropriate service. Clinicians may predisease. In particular, we elicit individuals' subjec- scribe unnecessary antibiotics—again, the easy, tive probabilities of risk, with and without the inter- safe option—due to perceived or explicit patient ventions, and compare these perceptions to indi- demand, desire to do something meaningful for vidually predicted risk based on epidemiological patients, a desire to conclude visits quickly, or an models. Respondents, especially women, appear unrealistic fear of complications. We hypothesized to be aware of some of the qualitative relation- that decision fatigue, if present, would increase ships between risk factors and probabilities. How- clinicians' likelihood of prescribing antibiotics for ever, on average they have very poor perceptions patients presenting with ARIs as clinic sessions of the absolute probability levels as reported in wore on. To test this hypothesis, we analyzed ARI the epidemiological literature. Perceptions of the visits by adults which occurred during two 4-hour level of risk are less accurate if a respondent is sessions—8 AM to noon and 1 PM to 5 PM—Mon- female and has poor numeracy skills. We find that day through Friday. Clinicians worked in 4-hour perceived probabilities significantly affect the sub- morning and afternoon sessions; many clinicians sequent take-up rate of flu shots, mammograms, worked only 1 session on a given day. We found and aspirin, even after controlling for individually that primary care clinicians' likelihood of prescrib- predicted risk using epidemiological models. ing antibiotics for ARIs increased as clinic sessions wore on, consistent with the hypothesis that EP-66185 decision fatigue progressively impairs clinicians' Healthy work: challenges and opportunities to ability to resist ordering inappropriate treatments. 2030. Leela Barham. 2014 Remedies for decision fatigue might include time- dependent decision support, modified schedules, Unless addressed, the worsening health of the shorter sessions, mandatory breaks, or snacks. workforce will damage the long-term productivity Further studies could clarify the sources of the of British companies large and small. By 2030, an problem and test solutions. ageing workforce and higher rates of chronic disease among employees will pose a serious threat EP-66187 to business success. This report, led by Bupa, Implications of sleep and energy drink use for the health and care company, and published in health disparities. Kristen L. Knutson, Wendy M. partnership with The Work Foundation, The Ox- Troxel. 2014 ford Health Alliance and RAND Europe, brings to- The popularity of energy drinks has increased gether for the first time more than 200 pieces of rapidly in the past decade. One of the main reasons research to provide in-depth insight into how the people use energy drinks is to counteract effects health of British workers will change over the next of insufficient sleep or sleepiness. Risks associ- 20 years. It argues that work – and in particular ated with energy drink use, including those related good work – must be placed at the centre of ef- to sleep loss, may be disproportionately borne by forts to improve health. racial minorities and those of lower socioeconom- EP-66186 ic status. In this review, a brief introduction to the Time of day and decision to prescribe antibiot- issue of health disparities is provided, population- ics. Jason N. Doctor, Mark W. Friedberg. 2014 level disparities and inequalities in sleep are described, and the social-ecological model of sleep Clinicians make many patient care decisions 321 and health is presented. Social and demographic BACKGROUND: With marijuana use increasing patterns of energy drink use are then presented, among American adolescents, better understand- followed by discussion of the potential ways in ing of the factors associated with decreasing use which energy drink use may contribute to health and quitting can help inform cessation efforts. This disparities, including the following: 1) effects of ex- study evaluates a range of neighborhood, family, cessive caffeine in energy drinks, 2) effects of en- peer network, and individual factors as predictors ergy drinks as sugar-sweetened beverages, 3) as- of marijuana use, change, and non-use over one sociation between energy drinks and risk-taking year, and cessation over six years. METHODS: behaviors when mixed with alcohol, 4) association Data come from adolescents in Waves I and II between energy drink use and short sleep dura- of the National Longitudinal Study of Adolescent tion, and 5) role of energy drinks in cardiometabol- Health (N = 458, one-year sample), or Waves I and ic disease. The review concludes with a research III (N = 358, six-year sample), and reported using agenda of critical unanswered questions. marijuana at least four times in the past month EP-66188 at Wave I. RESULTS: Eighteen percent of adoles- Correlates of use of timed unprotected inter- cents stopped using marijuana after six years. Re- course to reduce horizontal transmission among sults suggest neighborhood context affects over- Ugandan HIV clients with fertility intentions. Kathy all use level, whereas neighborhood context and Goggin, Deborah Mindry. 2014 friends were critical to cessation vs. continuation of use. Decrease in use were more likely among We examined the correlates of use of safer con- adolescents in disadvantaged or less cohesive ception methods (SCM) in a sample of 400 Ugan- neighborhoods, or who moved between waves. dan HIV clients (75 % female; 61 % on antiretro- Non-use after one year was more likely among viral therapy; 61 % with HIV-negative or unknown adolescents who did not move, had fewer mari- status partners) in heterosexual relationships with juana-using friends, and did not exclusively have fertility intentions. SCM assessed included timed outside-of-school friends. Cessation at six years unprotected intercourse, manual self-insemina- was more likely among adolescents in less disad- tion, sperm washing, and pre-exposure prophy- vantaged and more cohesive neighborhoods, and laxis (PrEP). In the 6 months prior to baseline, for those with within-school friends. CONCLU- 47 (12 %) reported using timed unprotected inter- SIONS: Results highlight the importance of both course to reduce risk of HIV infection (or re-infec- objective and subjective neighborhood charac- tion), none had used manual self-insemination or teristics, as well as peer networks, on adolescent sperm washing, and two had used PrEP. In multi- marijuana use. Factors associated with decreases ple regression analysis, correlates of use of timed in use appear distinct from those that predict quit- unprotected intercourse included greater percep- ting, suggesting that continuation vs. cessation is tions of partner's willingness to use SCM and pro- linked to peers as well as neighborhood context. viders' stigma of childbearing among people living Relocated and isolated individuals may face chal- with HIV, higher SCM knowledge, and desire for lenges with cessation. a child within the next 6 months. These findings highlight the need for policy and provider training EP-66190 regarding integration of couples' safer conception Assessing the validity of using serious game counselling into HIV care. technology to analyze physician decision making. Derek C. Angus, Daniel Ricketts. 2014 EP-66189 A prospective study of marijuana use change BACKGROUND: Physician non-compliance and cessation among adolescents. Joan S. with clinical practice guidelines remains a critical Tucker. 2014 barrier to high quality care. Serious games (using gaming technology for serious purposes) have emerged as a method of studying physician deci- 322 sion making. However, little is known about their care experts in Singapore about the state of pri- validity. METHODS: We created a serious game mary care in Singapore, and to compare this with and evaluated its construct validity. We used the the state of primary care in other countries. Not- decision context of trauma triage in the Emer- withstanding ranked 2nd in terms of efficiency of gency Department of non-trauma centers, given health care, Singapore is facing significant health widely accepted guidelines that recommend the care challenges. Emails were sent to 85 experts, transfer of severely injured patients to trauma cen- where they were asked to rate Singapore's prima- ters. We designed cases with the premise that the ry care system based on nine internationally ad- representativeness heuristic influences triage (i.e. opted health system characteristics and six prac- physicians make transfer decisions based on ar- tice characteristics (response rate = 29%). The chetypes of severely injured patients rather than primary care system in Singapore received an av- guidelines). We randomized a convenience sam- erage of 10.9 out of 30 possible points. Lowest rat- ple of emergency medicine physicians to a control ings were given to: earnings of primary care physi- or cognitive load arm, and compared performance cians compared to specialists, requirement for 24 (disposition decisions, number of orders entered, hr accessibility of primary care services, standard time spent per case). We hypothesized that cog- of family medicine in academic departments, re- nitive load would increase the use of heuristics, flection of community served by practices in pa- increasing the transfer of representative cases tient lists, and the access to specialists without and decreasing the transfer of non-representative needing to be referred by primary care physicians. cases. FINDINGS: We recruited 209 physicians, Singapore was categorized as a 'low' primary care of whom 168 (79%) began and 142 (68%) com- country according to the experts. pleted the task. Physicians transferred 31% of severely injured patients during the game, consistent EP-66192 with rates of transfer for severely injured patients in Early menarche and childhood adversities in a practice. They entered the same average number nationally representative sample. Heather L. Mc- of orders in both arms (control (C): 10.9 [SD 4.8] Cauley, Elizabeth Miller. 2014 vs. cognitive load (CL):10.7 [SD 5.6], p = 0.74), BACKGROUND: Epidemiological evidence despite spending less time per case in the control suggests that early menarche, defined as onset arm (C: 9.7 [SD 7.1] vs. CL: 11.7 [SD 6.7] minutes, of menses at age 11 or earlier, has increased in p<0.01). Physicians were equally likely to transfer prevalence in recent birth cohorts and is associ- representative cases in the two arms (C: 45% vs. ated with multiple poor medical and mental health CL: 34%, p = 0.20), but were more likely to trans- outcomes in adulthood. There is evidence that fer non-representative cases in the control arm childhood adversities occurring prior to menarche (C: 38% vs. CL: 26%, p = 0.03). CONCLUSIONS: contribute to early menarche. METHODS: Data We found that physicians made decisions consis- collected in face-to-face interviews with a nation- tent with actual practice, that we could manipulate ally representative sample of women age 18 and cognitive load, and that load increased the use of over (N = 3288), as part of the National Comor- heuristics, as predicted by cognitive theory. bidity Survey-Replication, were analyzed. Asso- ciations between pre-menarchal childhood ad- EP-66191 versities and menarche at age 11 or earlier were Primary healthcare system and practice char- estimated in discrete time survival models with acteristics in Singapore. 2014 statistical adjustment for age at interview, ethnic- It is crucial to adapt and improve the (primary) ity, and body mass index. Adversities investigated health care systems of countries to prepare for fu- included physical abuse, sexual abuse, neglect, ture patient profiles and their related needs. The biological father absence from the home, other main aim of this study was to acquire a compre- parent loss, parent mental illness, parent sub- hensive overview of the perceptions of primary stance abuse, parent criminality, inter-parental vi- 323 olence, serious physical illness in childhood, and healthcare decision-making, including issues with family economic adversity. RESULTS: Mean age familiarity, willingness to ask for help, trust of the at menarche varied across decadal birth cohorts technology, privacy, and design challenges. CON- (X2(4) = 21.41, p < .001) ranging from a high of CLUSIONS: Barriers must be addressed for these 12.9 years in the oldest cohort (age 59 or older at tools to be available to this growing population. the time of interview) to a low of 12.4 in the sec- Design, education, research, and policy all play ond youngest cohort (age 28-37). Childhood ad- roles in addressing these barriers to acceptance versities were also more common in younger than and use. older cohorts. Of the 11 childhood adversities, 5 were associated with menarche at age 11 or earli- EP-66194 er, with OR of 1.3 or greater. Each of these five ad- The effect of malpractice reform on emergency versities is associated with a 26% increase in the department care. Michael D. Greenberg. 2014 odds of early menarche (OR = 1.26, 95% CI 1.14- BACKGROUND: Many believe that fear of mal- 1.39). The relationship between childhood sexual practice lawsuits drives physicians to order oth- abuse and early menarche was sustained after erwise unnecessary care and that legal reforms adjustment for co-occurring adversities. (OR = could reduce such wasteful spending. Emergen- 1.77, 95% CI 1.21-2.6). CONCLUSIONS: Evidence cy physicians practice in an information-poor, from this study is consistent with hypothesized resource-rich environment that may lend itself to physiological effects of early childhood family en- costly defensive practice. Three states, Texas (in vironment on endocrine development. Childhood 2003), Georgia (in 2005), and South Carolina (in sexual abuse is the adversity most strongly asso- 2005), enacted legislation that changed the mal- ciated with early menarche. However, because of practice standard for emergency care to gross the complex way that childhood adversities cluster negligence. We investigated whether these sub- within families, the more generalized influence of stantial reforms changed practice. METHODS: highly dysfunctional family environments cannot Using a 5% random sample of Medicare fee-for- be ruled out. service beneficiaries, we identified all emergency department visits to hospitals in the three reform EP-66193 states and in neighboring (control) states from Acceptance and use of health information 1997 through 2011. Using a quasi-experimental technology by community-dwelling elders. Daniel design, we compared patient-level outcomes, David, Bradley H. Crotty. 2014 before and after legislation, in reform states and OBJECTIVES: With the worldwide population control states. We controlled for characteristics growing in age, information technology may help of the patients, time-invariant hospital character- meet important needs to prepare and support pa- istics, and temporal trends. Outcomes were pol- tients and families for aging. We sought to explore icy-attributable changes in the use of computed the use and acceptance of information technology tomography (CT) or magnetic resonance imaging for health among the elderly by reviewing the ex- (MRI), per-visit emergency department charges, isting literature. METHODS: Review of literature and the rate of hospital admissions. RESULTS: using PubMed and Google Scholar, references For eight of the nine state–outcome combinations from relevant papers, and consultation with ex- tested, no policy-attributable reduction in the in- perts. RESULTS: Elderly people approach the tensity of care was detected. We found no reduc- Internet and health information technology differ- tion in the rates of CT or MRI utilization or hospital ently than younger people, but have growing rates admission in any of the three reform states and of adoption. Assistive technology, such as sensors no reduction in charges in Texas or South Caro- or home monitors, may help 'aging in place', but lina. In Georgia, reform was associated with a these have not been thoroughly evaluated. El- 3.6% reduction (95% confidence interval, 0.9 to ders face many barriers in using technology for 6.2) in per-visit emergency department charges. 324

CONCLUSIONS: Legislation that substantially EP-66196 changed the malpractice standard for emergency The opportunity costs of informal elder-care in physicians in three states had little effect on the in- the United States: new estimates from the Ameri- tensity of practice, as measured by imaging rates, can time use survey. John Engberg. 2014 average charges, or hospital admission rates. OBJECTIVES: To provide nationally representa- EP-66195 tive estimates of the opportunity costs of informal Changes in self-efficacy and outcome expec- elder-care in the United States. DATA SOURCES: tancy as predictors of anxiety outcomes from the Data from the 2011 and 2012 American Time Use CALM study. Joshua F. Wiley. 2014 Survey. STUDY DESIGN: Wage is used as the BACKGROUND: Although self-efficacy (SE) measure of an individual's value of time (oppor- and outcome expectancy (OE) have been well tunity cost), with wages being imputed for non- researched as predictors of outcome, few stud- working individuals using a selection-corrected ies have investigated changes in these variables regression methodology. PRINCIPAL FINDINGS: across treatments. We evaluated changes in OE The total opportunity costs of informal elder-care and SE throughout treatment as predictors of amount to $522 billion annually, while the costs of outcomes in a large sample with panic disorder, replacing this care by unskilled and skilled paid generalized anxiety disorder, social anxiety disor- care are $221 billion and $642 billion, respectively. der, or posttraumatic stress disorder. We hypoth- CONCLUSIONS: Informal caregiving remains a esized that increases in SE and OE would predict significant phenomenon in the United States with reductions in anxiety and depression as well as a high opportunity cost, although it remains more improvement in functioning. METHODS: Partici- economical (in the aggregate) than skilled paid pants (mean age = 43.3 years, SD = 13.2, 71.1% care. female, 55.5% white) were recruited from primary EP-66197 care centers throughout the United States and Updated guidelines for the control of legionella were randomized to receive either Coordinated in Western Pennsylvania. Shoshana R. Shelton. Anxiety Learning and Management (CALM) treat- 2014 ment – composed of cognitive behavioral therapy, psychotropic medication, or both – or usual care. Legionnaires' disease (LD) is a pneumonia SE and OE ratings were collected at each ses- caused by different varieties of Legionella bacte- sion for participants in the CALM treatment (n = ria. Pennsylvania is within the U.S. region that has 482) and were entered into a structural equation the highest incidence of reported LD. In 2013, the model as predictors of changes in Brief Symp- Pittsburgh Regional Health Initiative (PRHI) and tom Inventory, Anxiety Sensitivity Index, Patient Allegheny County Health Department decided to Health Questionnaire (PHQ), and Sheehan Dis- update the county's guidelines. The purpose of ability Scale outcomes at 6, 12, and 18 months these updated guidelines is to provide interested after baseline. RESULTS: The best-fitting models persons and organizations in western Pennsyl- predict symptom levels from OE and SE and not vania—especially community hospitals, nursing vice versa. The slopes and intercept of OE signifi- homes, assisted living and high-rise retirement cantly predicted change in each outcome variable facilities—with updated information on Legionella except PHQ-8. The slope and intercept of SE sig- and how to minimize its occurrence and impact in nificantly predicted change in each outcome vari- people and in the environment. able. CONCLUSION: Over and above absolute level, increases in SE and OE were significant EP-66198 predictors of decreases in symptoms and increas- An examination of the bidirectional relation- es in functioning. Implications for treatment are ship between functioning and symptom levels in discussed, as well as future directions of research. patients with anxiety disorders in the CALM study. 325

Jennifer L. Krull. 2014 cancer patients for specialized care. Referral bar- BACKGROUND: Patients with anxiety disor- riers may also lessen physician career satisfac- ders suffer marked functional impairment in their tion. The study was aimed at determining what activities of daily living. Many studies have docu- factors are associated with these barriers and mented that improvements in anxiety symptom se- whether greater barriers are associated with low verity predict functioning improvements. However, career satisfaction. METHODS: This cross-sec- no studies have investigated how improvements tional study examined 1562 primary care physi- in functioning simultaneously predict symptom re- cians (PCPs) and 2144 specialists responding duction. We hypothesized that symptom levels at to the multiregional Cancer Care Outcomes Re- a given time point will predict functioning at the search and Surveillance Consortium physician subsequent time point, and simultaneously that survey. The prevalence of physician-reported bar- functioning at a given time point will predict symp- riers to referring cancer patients for more special- tom levels at a subsequent time point. METHOD: ized care (restricted provider networks, preautho- Patients were recruited from primary-care centers rization requirements, patient inability to pay, lack for the Coordinated Anxiety Learning and Man- of surgical subspecialists, and excessive patient agement (CALM) study and were randomized to travel time) was assessed. The 5 items were aver- receive either computer-assisted cognitive-be- aged to calculate a barrier score. A multivariate havioral therapy and/or medication management linear regression was used to determine physician (ITV) or usual care (UC). A cross-lagged panel de- and practice setting characteristics associated sign examined the relationship between functional with the barrier score, and a multivariate logistic impairment and anxiety and depression symptom regression was used to analyze the association severity at baseline, 6-, 12-, and 18-month follow- of the barrier score with physician career satisfac- up assessments. RESULTS: Prospective prediction. RESULTS: Three in 5 physicians reported tion of functioning from symptoms and symptoms always, usually, or sometimes encountering any from functioning were both important in modeling barrier to cancer patient specialty referrals. In ad- these associations. Anxiety and depression pre- justed analyses of PCPs and specialists, interna- dicted functioning as strongly as functioning pre- tional medical graduates, physicians practicing in dicted anxiety and depression. There were some solo or government-owned practices, and physi- differences in these associations between UC and cians with <90% of their patients in managed care ITV. Where differences emerged, the UC group plans had higher barrier scores than others (P was best modeled with prospective paths predict- < .05). High barrier scores were associated with ing functioning from symptoms, whereas symp- lower physician career satisfaction among PCPs toms and functioning were both important predic- and specialists (P < .05). CONCLUSIONS: Many tors in the ITV group. CONCLUSIONS: Treatment physicians experience barriers to specialty refer- outcome is best captured by measures of func- ral for cancer patients. Uniform systems for pro- tional impairment as well as symptom severity. Im- viding and tracking timely referrals may enhance plications for treatment are discussed, as well as care and promote physician career satisfaction. future directions of research. EP-66200 Use of and regional variation in initial CT imag- EP-66199 Physician-reported barriers to referring cancer ing for kidney stones. Jose E. Pulido, Ron Keren. patients to specialists: prevalence, factors, and 2014 association with career satisfaction. Diana M. OBJECTIVE: We sought to determine the Tisnado, Nancy L. Keating. 2014 prevalence of initial computed tomography (CT) BACKGROUND: Quality care for patients with utilization and to identify regions in the United cancer often requires access to specialty provid- States where CT is highly used as the first imag- ers, but little is known about barriers to referring ing study for children with nephrolithiasis. METH- 326

ODS: We performed a cross-sectional study in term health problem. We investigated differences 9228 commercially insured children aged 1 to in HRQoL (EQ-5D scores) associated with combi- 17 years with nephrolithiasis who underwent di- nations of these conditions after adjusting for age, agnostic imaging in the United States between gender, ethnicity, socio-economic deprivation and 2003 and 2011. Data were obtained from Mar- the presence of a recent illness or injury. Analyses ketScan, a commercial insurance claims data- were based on 831,537 responses from patients base of 17 827 229 children in all aged 18 years or older in 8,254 primary care prac- 50 states. We determined the prevalence of ini- tices in England. RESULTS: Of respondents, 23 tial CT use, defined as CT alone or CT performed % reported two or more chronic conditions (rang- before ultrasound in the emergency department, ing from 7 % of those under 45 years of age to inpatient unit, or outpatient clinic, and identified 51 % of those 65 years or older). Multi-morbidity regions of high CT utilization by using logistic re- was more common among women, White indi- gression. RESULTS: Sixty-three percent of chil- viduals and respondents from socio-economically dren underwent initial CT study and 24% had ul- deprived areas. Neurological problems, men- trasound performed first. By state, the proportion tal health problems, arthritis and long-term back of children who underwent initial CT ranged from problem were associated with the greatest HRQoL 41% to 79%. Regional variations persisted after deficits. The presence of three or more conditions adjusting for age, gender, year of presentation, was commonly associated with greater reduction and insurance type. Relative to children living in in quality of life than that implied by the sum of the West South Central states, the highest odds of differences associated with the individual condi- initial CT utilization were observed for children liv- tions. The decline in quality of life associated with ing in the East South Central US Census division an additional condition in people with two and (odds ratio: 1.27; 95% confidence interval: 1.06– three physical conditions was less for older peo- 1.54). The lowest odds of initial CT were observed ple than for younger people. Multi-morbidity was for children in the New England states (odds ratio: associated with a substantially worse HRQoL in 0.48; 95% confidence interval: 0.38–0.62). CON- diabetes than in other long-term conditions. With CLUSIONS: Use of CT as the initial imaging study the exception of neurological conditions, the pres- for children with nephrolithiasis is highly prevalent ence of a comorbid mental health problem had a and shows extensive regional variability in the more adverse effect on HRQoL than any single United States. Current imaging practices deviate comorbid physical condition. CONCLUSION: Pa- substantially from recently published guidelines tients with multi-morbid diabetes, arthritis, neuro- that recommend ultrasound as the initial imaging logical, or long-term mental health problems have study. significantly lower quality of life than other people. People with long-term health conditions require in- EP-66201 tegrated mental and physical healthcare services. Common patterns of morbidity and multi-morbidity and their impact on health-related quality EP-66202 of life: evidence from a national survey. Martin J. Longitudinal family effects on substance use Roberts, Gary A. Abel. 2014 among an at-risk adolescent sample. Karen Chan Osilla. 2014 BACKGROUND: There is limited evidence about the impact of specific patterns of multi- OBJECTIVE: Adult and peer factors may influ- morbidity on health-related quality of life (HRQoL) ence whether adolescents use alcohol and other from large samples of adult subjects. METHODS: drugs (AOD). This longitudinal study examined We used data from the English General Practice the direct effects of adult monitoring, perceived Patient Survey 2011–2012. We defined multi-mor- adult AOD use, and cultural values on adoles- bidity as the presence of two or more of 12 self- cent AOD use. METHODS: Participants were 193 reported conditions or another (unspecified) long- at-risk adolescents referred to a California diver- 327 sion program called Teen Court for a first-time Equity in competency education: realizing the AOD offense. We assessed youth reports of past potential, overcoming the obstacles : executive 30 day AOD use (any alcohol use, heavy drink- summary. Rick Eden. 2014 ing, marijuana use), demographics, changes in Equity is both a central goal and fundamen- parental monitoring and family values (from base- tal value of competency education. Competency- line to follow-up 180 days later), as well as family based approaches are designed to promote eq- structure and perceived adult substance use at uity by preventing students from falling behind follow-up. RESULTS: Adolescents who reported or staying behind. In practice, however, poorly that a significant adult in their life used marijuana implemented competency-based programs could were more likely to have increased days of drink- inadvertently increase inequity—in opportunities ing, heavy drinking, and marijuana use at follow- and in outcomes. Equity in Competency Educa- up. Higher levels of familism (importance the teen tion: Realizing the Potential, Overcoming the Ob- places on their family's needs over their own stacles—the second paper of Students at the needs) and being in a nuclear family served as Center's Competency Education Research Se- protective factors for future alcohol use. Addition- ries—examines equity concerns in competency ally, poor family management was associated with education through the lens of family income, ex- increased alcohol use and heavy drinking. CON- ploring the effects and implications, as well as CLUSION: Findings highlight how family manage- proposing potential mitigations. ment and perceptions of adult marijuana use influence subsequent adolescent AOD use, and how EP-66205 an increase in familism over time is associated Challenges in systematic reviews of qualitative with a decrease in adolescent drinking. Tailoring research. Sean Grant. 2014 interventions, by including the teen's family and/or providing support to adults who use AOD may be Systematic reviews of qualitative research are crucial for improving interventions for adolescent useful, but pose challenges for researchers. Many AOD use. debates over their value arise from the tension between the positivistic, aggregative approach of EP-66203 systematic reviews of intervention effectiveness Equity in competency education: realizing the and the interpretive nature of most qualitative re- potential, overcoming the obstacles. Rick Eden. search. 2014 EP-66206 Equity is both a central goal and fundamen- Effects of trauma on students: early interven- tal value of competency education. Competency- tion through the cognitive behavioral intervention based approaches are designed to promote eq- for trauma in schools. Lisa H. Jaycox. 2014 uity by preventing students from falling behind or staying behind. In practice, however, poorly The potential negative consequences of expo- implemented competency-based programs could sure to traumatic events on the academic success inadvertently increase inequity—in opportunities and mental health of children and adolescents are and in outcomes. Equity in Competency Educa- well documented, particularly the development of tion: Realizing the Potential, Overcoming the Ob- posttraumatic stress disorder. Providing school- stacles—the second paper of Students at the based interventions for students who are expe- Center's Competency Education Research Se- riencing trauma symptoms has great potential ries—examines equity concerns in competency to meet unmet mental health needs, build resil- education through the lens of family income, ex- ience, and support students' academic success. ploring the effects and implications, as well as The current chapter provides an overview of the proposing potential mitigations. effect of trauma on students, and describes the development and core components of the Cogni- EP-66204 328 tive Behavioral Intervention for Trauma in Schools EP-66208 (CBITS). The chapter also summarizes the re- Changes in obesity between fifth and tenth search evidence and implementation experiences grades: a longitudinal study in three metropolitan with CBITS, and highlights future directions for areas. Marc N. Elliott. 2014 research and practice for supporting students exposed to traumatic events. BACKGROUND: Despite epidemic childhood obesity levels, we know little about how BMI EP-66207 changes from preadolescence to adolescence Project JOINTS: what factors affect bundle and what factors influence changes. METHODS: adoption in a voluntary quality improvement cam- We studied 3961 randomly selected public school paign?. 2014 students and 1 parent per student in 3 US met- BACKGROUND: Diffusion and adoption of ef- ropolitan areas in fifth and again in tenth grades. fective evidence-based clinical practices can be In each grade, we measured child and parent slow, especially if complex changes are required height/weight and calculated BMI category. We to implement new practices. OBJECTIVE: To ex- examined whether baseline sociodemographic amine how hospital adherence to quality improve- characteristics, child health-related factors, and ment (QI) methods and hospital engagement parental obesity were significantly associated with with a large-scale QI campaign could facilitate exit from and entry into obesity from fifth to tenth the adoption of an enhanced prevention bundle grade. RESULTS: Fifth- and tenth-graders were designed to reduce surgical site infection (SSI) 1%/2% underweight, 53%/60% normal weight, rates after orthopaedic surgery (hip and knee ar- 19%/18% overweight, and 26%/20% obese, re- throplasty). METHODS: We conducted telephone spectively. Among obese tenth-graders, 83% had interviews with hospital QI leaders from 73 of the been obese as fifth-graders and 13% had been 109 hospitals (67% response rate) in five states overweight. Sixty-five percent of obese fifth-grad- that participated in Project JOINTS (Joining Or- ers remained obese as tenth-graders, and 23% ganizations IN Tackling SSIs), a QI campaign run transitioned to overweight. Multivariately, obese by Institute for Healthcare Improvement (IHI). Us- fifth-graders who perceived themselves to be ing QI methods grounded in the IHI Model for Im- much heavier than ideal (P = .01) and those who provement, this campaign encouraged hospitals had lower household education (P = .006) were to implement an enhanced SSI prevention bundle. less likely to exit obesity; by contrast, overweight Hospital QI leaders reported on their hospital's fifth-graders were more likely to become obese if adherence to the Project JOINTS QI methods; they had an obese parent (P < .001) or watched their level of engagement with Project JOINTS ac- more television (P = .02). CONCLUSIONS: Obese tivities; and adoption of the SSI prevention bundle fifth-graders face challenges in reducing obesity, components. Interview data were analysed quan- especially when they lack advantages associated titatively and qualitatively. RESULTS: Both adher- with higher socioeconomic status or when they ence to the QI methods and hospital engagement have a negative body image. Clinicians and others were positively associated with complete bundle should educate parents on the importance of pre- adoption. Hospital engagement, especially the use venting obesity very early in development. Chil- of project materials and tools, was also positively dren who are not yet obese by fifth grade but who associated with the initiation of and improved ad- have an obese parent or who watch considerable herence to individual bundle components. CON- television might benefit from monitoring, as might CLUSIONS: Our findings suggest that greater children who have negative body images. adherence to the QI methods and active hospital EP-66209 engagement in a QI campaign facilitate adoption of evidence-based patient safety bundles in orthopaedic practice. 329

Understanding high and low patient experience scores in primary care: analysis of patients' survey EP-66210 data for general practices and individual doctors. Preventing hospitalizations in children with John Campbell, Gary A. Abel. 2014 medical complexity: a systematic review. Bergen OBJECTIVES: To determine the extent to which B. Nelson, Daniel J. Sklansky. 2014 practice level scores mask variation in individual BACKGROUND AND OBJECTIVES: Children performance between doctors within a practice. with medical complexity (CMC) account for dispro- DESIGN: Analysis of postal survey of patients' portionately high hospital use, and it is unknown if experience of face-to-face consultations with in- hospitalizations may be prevented. Our objective dividual general practitioners in a stratified quo- was to summarize evidence from (1) studies char- ta sample of primary care practices. SETTING: acterizing potentially preventable hospitalizations Twenty five English general practices, selected in CMC and (2) interventions aiming to reduce to include a range of practice scores on doctor- such hospitalizations. METHODS: Our data sourc- patient communication items in the English na- es include Medline, Cochrane Central Register of tional GP Patient Survey. PARTICIPANTS: 7721 Controlled Trials, Web of Science, and Cumulative of 15 172 patients (response rate 50.9%) Index to Nursing and Allied Health Literature data- who consulted with 105 general practitioners in 25 bases from their originations, and hand search of practices between October 2011 and June 2013. article bibliographies. Observational studies (n = MAIN OUTCOME MEASURE: Score on doctor- 13) characterized potentially preventable hospital- patient communication items from post-consul- izations, and experimental studies (n = 4) evalu- tation surveys of patients for each participating ated the efficacy of interventions to reduce them. general practitioner. The amount of variance in Data were extracted on patient and family char- each of six outcomes that was attributable to the acteristics, medical complexity and preventable practices, to the doctors, and to the patients and hospitalization indicators, hospitalization rates, other residual sources of variation was calculated costs, and days. Results of interventions were using hierarchical linear models. RESULTS: After summarized by their effect on changes in hospi- control for differences in patients' age, sex, ethnic- tal use. RESULTS: Preventable hospitalizations ity, and health status, the proportion of variance in were measured in 3 ways: ambulatory care sen- communication scores that was due to differences sitive conditions, readmissions, or investigator- between doctors (6.4%) was considerably more defined criteria. Postsurgical patients, those with than that due to practices (1.8%). The findings also neurologic disorders, and those with medical de- suggest that higher performing practices usually vices had higher preventable hospitalization rates, contain only higher performing doctors. Howev- as did those with public insurance and nonwhite er, lower performing practices may contain doc- race/ethnicity. Passive smoke exposure, nonad- tors with a wide range of communication scores. herence to medications, and lack of follow-up after CONCLUSIONS: Aggregating patients' ratings of discharge were additional risks. Hospitalizations doctors' communication skills at practice level can for ambulatory care sensitive conditions were mask considerable variation in the performance less common in more complex patients. Patients of individual doctors, particularly in lower perform- receiving home visits, care coordination, chronic ing practices. Practice level surveys may be better care-management, and continuity across settings used to "screen" for concerns about performance had fewer preventable hospitalizations. CONCLU- that require an individual level survey. Higher scor- SIONS: There were a limited number of published ing practices are unlikely to include lower scoring studies. Measures for CMC and preventable hos- doctors. However, lower scoring practices require pitalizations were heterogeneous. Risk of bias further investigation at the level of the individual was moderate due primarily to limited controlled doctor to distinguish higher and lower scoring experimental designs. Reductions in hospital use general practitioners. 330 among CMC might be possible. Strategies should Giving ''sadness'' a name: the need for integrat- target primary drivers of preventable hospitaliza- ing depression treatment into HIV care in Uganda. tions. Glenn Wagner. 2014 Depression is common among people living EP-66211 Cost-benefit analysis of a preventive interven- with HIV/AIDS (PLWHA) in sub-Saharan Africa tion for divorced families: reduction in mental (SSA), and can have significant consequences health and justice system service use costs 15 for HIV disease progression, treatment response years later. Nicole E. Mahrer. 2014 and prevention. Yet mental health services are limited in most HIV care programs in this region, This cost-benefit analysis compared the costs in part due to severe shortages of mental health of implementing the New Beginnings Program professionals. To address the need for establish- (NBP), a preventive intervention for divorced fami- ing an effective, sustainable model for integrating lies to monetary benefits saved in mental health- depression treatment into HIV care in SSA, we care service use and criminal justice system have embarked upon a 3-year research project, costs. NBP was delivered when the offspring were INDEPTH Uganda (INtegrating DEPression Treat- 9–12 years old. Benefits were assessed 15 years ment and in HIV care in Uganda), to evaluate a later when the offspring were young adults (ages task-sharing, protocolized approach to providing 24–27). This study estimated the costs of deliv- antidepressant care in ten HIV clinics in Uganda. ering two versions of NBP, a single-component In this paper we share our experiences with two parenting-after-divorce program (Mother Program, treated cases identified during the initial days of MP) and a two-component parenting-after-divorce implementation, which we believe highlight the po- and child-coping program (Mother-Plus-Child Pro- tential value and policy implications for task shift- gram, MPCP), to costs of a literature control (LC). ing depression care models in under-resourced Long-term monetary benefits were determined settings. from actual expenditures from past-year mental healthcare service use for mothers and their EP-66213 young adult (YA) offspring and criminal justice sys- Early intervention for abused children in the tem involvement for YAs. Data were gathered from school setting. Audra Langley, Bradley D. Stein. 202 YAs and 194 mothers (75.4 % of families ran- 2014 domly assigned to condition). The benefits, as as- This chapter describes the Cognitive Behav- sessed in the 15th year after program completion, ioral Intervention for Trauma in Schools (CBITS) were $1630/family (discounted benefits $1077/ program, how it addresses child abuse specifi- family). These 1-year benefits, based on conser- cally, the theoretical rationale for the program, and vative assumptions, more than paid for the cost of the evidence supporting its effectiveness. The au- MP and covered the majority of the cost of MPCP. thors discuss when and why CBITS might be an Because the effects of MP versus MPCP on men- appropriate intervention and the advantages and tal health and substance use problems have not disadvantages of its use. been significantly different at short-term or long- term follow-up assessments, program managers EP-66214 would likely choose the lower-cost option. Given A wedge-based approach to estimating health that this evaluation only calculated economic ben- co-benefits of climate change mitigation activities efit at year 15 and not the previous 14 (nor future in the United States. Jeffery B. Greenblatt, Ramya years), these findings suggest that, from a soci- Chari. 2014 etal perspective, NBP more than pays for itself in future benefits. While it has been recognized that actions reducing greenhouse gas (GHG) emissions can EP-66212 have significant positive and negative impacts on 331 human health through reductions in ambient fine 2014 particulate matter (PM2.5) concentrations, these BACKGROUND: Healthcare professionals are impacts are rarely taken into account when ana- rapidly adopting electronic health records (EHRs). lyzing specific policies. This study presents a new Within EHRs, seemingly innocuous menu design framework for estimating the change in health out- configurations can influence provider decisions comes resulting from implementation of specific for better or worse. OBJECTIVE: The purpose of carbon dioxide (CO2) reduction activities, allow- this study was to examine whether the grouping ing comparison of different sectors and options for of menu items systematically affects prescribing climate mitigation activities. Our estimates sug- practices among primary care providers. PAR- gest that in the year 2020, the reductions in ad- TICIPANTS: We surveyed 166 primary care pro- verse health outcomes from lessened exposure to viders in a research network of practices in the PM2.5 would yield economic benefits in the range greater Chicago area, of whom 84 responded (51 of $6 to $30 billion (in 2008 USD), depending on % response rate). Respondents and non-respon- the specific activity. This equates to between $40 dents were similar on all observable dimensions and $198 per metric ton of CO2 in health ben- except that respondents were more likely to work efits. Specific climate interventions will vary in in an academic setting. DESIGN: The question- the health co-benefits they provide as well as in naire consisted of seven clinical vignettes. Each potential harms that may result from their imple- vignette described typical signs and symptoms mentation. Rigorous assessment of these health for acute respiratory infections, and providers impacts is essential for guiding policy decisions chose treatments from a menu of options. For as efforts to reduce GHG emissions increase in each vignette, providers were randomly assigned scope and intensity. to one of two menu partitions. For antibiotic-inappropriate vignettes, the treatment menu either EP-66215 listed over-the-counter (OTC) medications indi- Social, relational and network determinants vidually while grouping prescriptions together, of unprotected anal sex and HIV testing among or displayed the reverse partition. For antibiotic- men who have sex with men in Beirut, Lebanon. appropriate vignettes, the treatment menu either Matthew Hoover. 2014 listed narrow-spectrum antibiotics individually Social, relational and network determinants while grouping broad-spectrum antibiotics, or dis- of condom use and HIV testing were examined played the reverse partition. MAIN MEASURES: among 213 men who have sex with men (MSM) in The main outcome was provider treatment choice. Beirut. 64% reported unprotected anal intercourse For antibiotic-inappropriate vignettes, we catego- (UAI), including 23% who had UAI with unknown rized responses as prescription drugs or OTC- HIV status partners (UAIU); 62% had HIV-tested. only options. For antibiotic-appropriate vignettes, In multivariate analysis, being in a relationship was we categorized responses as broad- or narrow- associated with UAI and HIV testing; lower con- spectrum antibiotics. KEY RESULTS: Across vi- dom self-efficacy was associated with UAIU and gnettes, there was an 11.5 percentage point re- HIV testing; gay discrimination was associated duction in choosing aggressive treatment options with UAIU; MSM disclosure was associated with (e.g., broad-spectrum antibiotics) when aggres- UAI, UAIU and HIV testing; and network central- sive options were grouped compared to when ization was associated with HIV testing. Multi-level those same options were listed individually (95 % social factors influence sexual health in MSM. CI: 2.9 to 20.1 %; p = .008). CON- CLUSIONS: Provider treatment choice appears to EP-66216 be influenced by the grouping of menu options, Nudging physician prescription decisions by suggesting that the layout of EHR order sets is not partitioning the order set: results of a vignette- an arbitrary exercise. The careful crafting of EHR based study. Jason N. Doctor, Stephen D. Persell. order sets can serve as an important opportunity 332 to improve patient care without constraining physi- statistically significantly above or below average or cians' ability to prescribe what they believe is best not statistically significantly different from average. for their patients. To further enhance the salience of public reporting to consumers, report card websites often allow EP-66217 a user to compare a subset of selected providers Should health care providers be accountable for on tiered performance rather than direct statistical patients' care experiences?. Marc N. Elliott. 2014 comparisons of the providers in a consumer's per- Measures of patients' care experiences are sonal choice set. OBJECTIVE: We illustrate the increasingly used as quality measures in account- differences in conclusions drawn about relative ability initiatives. As the prominence and financial provider performance using tiers versus conduc- impact of patient experience measures have in- ing statistical tests to assess performance differ- creased, so too have concerns about the relevance ences. METHODS: Using publicly available cross- and fairness of including them as indicators of sectional data from Medicare Hospital Compare health care quality. Using evidence from the Con- on three mortality and three readmission outcome sumer Assessment of Healthcare Providers and measures, we compared each provider in the top Systems (CAHPS®) surveys, the most widely or bottom performance tier with those in the mid- used patient experience measures in the United dle tier and assessed the proportion of such com- States, we address seven common critiques of parisons that exhibited no statistically significant patient experience measures: (1) consumers do differences. RESULTS: Across the six outcomes, not have the expertise needed to evaluate care 1.3–6.1% of hospitals were classified in the top quality; (2) patient "satisfaction" is subjective and tier. Each top-tier hospital did not statistically sig- thus not valid or actionable; (3) increasing empha- nificantly differ in performance from at least one sis on improving patient experiences encourages mid-tier hospital. The percentages of mid-tier hos- health care providers and plans to fulfill patient pitals that were not statistically significantly differ- desires, leading to care that is inappropriate, inef- ent from a given top-tier hospital were 74.3–81.1%. fective, and/or inefficient; (4) there is a trade-off The percentages of hospitals classified as bot- between providing good patient experiences and tom tier were 0.6–4.0%. Each bottom-tier hospital providing high-quality clinical care; (5) patient showed no statistically significant difference from scores cannot be fairly compared across health at least one mid-tier hospital. The percentage of care providers or plans due to factors beyond pro- mid-tier hospitals that were not significantly differ- viders' control; (6) response rates to patient expe- ent from a bottom-tier hospital ranged from 60.4% rience surveys are low, or responses reflect only to 74.8%. CONCLUSIONS: Our analyses illustrate patients with extreme experiences; and (7) there the need for further innovations in the design of are faster, cheaper, and more customized ways to public report cards to enhance their salience for survey patients than the standardized approaches consumers. mandated by federal accountability initiatives. EP-66219 EP-66218 12-month outcomes of community engagement Better-than-average and worse-than-average versus technical assistance to implement depres- hospitals may not significantly differ from average sion collaborative care: a partnered, cluster, ran- hospitals: an analysis of Medicare Hospital Com- domized, comparative effectiveness trial. Michael pare ratings. John L. Adams. 2014 Ong, Susan L. Ettner. 2014 BACKGROUND: Public report card design- BACKGROUND: Depression collaborative care ers aim to provide comprehensible provider per- implementation using community engagement formance information to consumers. Report cards and planning (CEP) across programs improves often display classifications of providers into per- 6-month client outcomes in minority communities, formance tiers that reflect whether performance is compared with technical assistance to individual 333 programs (resources for services [RS]). However, through which multiple factors influence condom 12-month outcomes are unknown. OBJECTIVE: use decision making among homeless youth. To compare effects of CEP and RS on mental Event-level interviews that explore characteris- health–related quality of life (MHRQL) and use of tics of the environment surrounding sexual events services among depressed clients at 12 months. were conducted with 29 youth who were asked DESIGN: Matched health and community pro- to describe two recent sexual encounters. In the- grams (n = 93) in 2 communities randomly as- matic analyses of data across events, reasons signed to receive CEP or RS. (ClinicalTrials.gov: that youth gave for engaging in unprotected sex NCT01699789). MEASUREMENTS: Self-reported included the expectation of having sex and use MHRQL and services use at baseline, 6 months, of alternative methods of protection against preg- and 12 months. SETTING: Los Angeles, Califor- nancy. Other nonevent factors that influenced nia. PATIENTS: 1018 adults with depressive symp- condom use decision making were related to at- toms (8-item Patient Health Questionnaire score tributes of the partnership (e.g., testing, trust and ≥10), 88% of whom were an ethnic minority. love, and assessments of risk) and attributes of INTERVENTION: CEP and RS to implement de- the youth (e.g., perceptions of diseases, concerns pression collaborative care. MEASUREMENTS: over pregnancy, and discomfort using condoms). The primary outcome was poor MHRQL (12-item Additional event analyses conducted within the mental health composite score ≤40) at baseline, same individuals found that decision making was 6 months, and 12 months; the secondary outcome influenced by multiple interacting factors, with dif- was use of services at 12 months. RESULTS: At ferent pathways operating for event and nonevent 6 months, the finding that CEP outperformed RS factors. Future interventions should consider tak- to reduce poor MHRQL was significant but sen- ing a multilevel and individualized approach that sitive to underlying statistical assumptions. At 12 focuses on event-based determinants of risky sex months, some analyses suggested that CEP was in this population. advantageous to MHRQL, whereas others did not confirm a significant difference favoring CEP. The EP-66221 finding that CEP reduced behavioral health hos- How much do additional mailings and telephone pitalizations at 6 months was less evident at 12 calls contribute to response rates in a survey of months and was sensitive to underlying statistical Medicare beneficiaries?. Amelia M. Haviland. assumptions. Other services use did not signifi- 2014 cantly differ between interventions at 12 months. Surveys often spend substantial money on mul- LIMITATION: Data are self-reported, and findings tiple mailings and telephone calls to ensure high are sensitive to modeling assumptions. CONCLU- overall response rates and adequate representa- SION: In contrast to 6-month results, no consistent tion of hard-to-reach demographic subgroups. We effects of CEP on reducing the likelihood of poor examine the extent to which an additional mailing MHRQL and behavioral health hospitalizations and additional sets of telephone calls are effective were found at 12 months. Still, given the needs of in attaining these goals across a variety of sub- underresourced communities, the favorable pro- groups in a large, national multimode survey of file of CEP, and the lack of evidence-based alter- Medicare beneficiaries. We also examine the rela- natives, CEP remains a viable strategy for policy- tive data quality of the responses that come with makers and communities to consider. each level of extra effort. We find that additional EP-66220 mailings appear more effective in some groups, Understanding condom use decision making while additional telephone calls appear more ef- among homeless youth using event-level data. fective in others. Tailoring the fielding strategy dif- Ryan Andrew Brown. 2014 ferently by subgroup may improve response rates at a lower cost per complete than using the same This is one of the first qualitative event-based fielding protocol for all potential respondents, al- studies to understand the various mechanisms 334 though data quality is likely to decline with addi- derstudied among veterans and military person- tional efforts in either mode. nel. A repository of mind and body intervention outcome measures may further future research EP-66222 efforts, as would conducting pragmatic trials and A systematic scoping review of complementary more robust RCTs. and alternative medicine mind and body practices to improve the health of veterans and military EP-66223 personnel. Jennifer M. Johnston, Jill E. Bormann. The response of an expert panel to nutritional 2014 armor for the warfighter: can omega-3 fatty acids enhance stress resilience, wellness, and military BACKGROUND: Meditation, imagery, acu- performance?. 2014 puncture, and yoga are the most frequently offered mind and body practices in the Department of Vet- BACKGROUND: Recommendations of an Ex- erans Affairs. Yet, the research on mind and body pert Panel on 5 central questions addressed dur- practices has been critiqued as being too limited ing the workshop. METHODS: The Panel reviewed in evidence and scope to inform clinical treatment. available scientific literature, workshop presen- OBJECTIVES: We conducted a systematic scop- tations, and comments from workshop guests. ing review of mind and body practices used with RESULTS: The Panel unanimously agreed that a veterans or active duty military personnel to iden- military Daily Recommended Intake for long-chain tify gaps in the literature and make recommen- omega-3 fatty acids (FAs) should be established dations for future primary research. RESEARCH within the context of lowering current intakes of DESIGN: Following systematic literature review omega-6 FAs. The Panelists also felt that there was methodology, we searched 5 databases using 27 sufficient evidence to support increasing omega-3 different National Center for Complementary and intake to receive cardiovascular, immunological, Alternative Medicine-defined mind and body prac- and surgical benefits. In addition, research indi- tices as text words, keywords, and MeSH terms cates that preloading with omega-3 FAs before through June 30, 2014. We also conducted hand- combat exposure may be beneficial. Evidence for searches of 4 previous reviews. SUBJECTS: Ac- reduction of depressive symptoms and suicide tive duty military members or veterans 18 years prevention was felt to be strong. Insufficient data or older participating in mind and body practice were available to evaluate post-traumatic stress interventions globally. MEASURES: Data were disorder and impulsive aggression. Benefits for extracted from studies meeting 5 inclusion cri- traumatic brain injury were promising. Adverse teria. The quality of randomized controlled trials side effects were deemed negligible. CONCLU- (RCTs) was assessed using an existing checklist. SION: The Panel concluded that based on stud- RESULTS: Of 1819 studies identified, 89 inter- ies analyzing omega-3 and omega-6 FA balance, ventions (50 RCTs) published between 1976 and it would be unethical to not attempt elevating the 2014, conducted in 9 countries, using 152 differ- omega-3 status among U.S. military personnel. ent measures to assess 65 health and well-being outcomes met our inclusion criteria. Most inter- EP-66224 ventions took place in the United States (n=78). Usage and effect of health information exchange: Meditation practices (n=25), relaxation techniques a systematic review. Aneesa Motala. 2014 including imagery (n=20), spinal manipulation in- BACKGROUND: Health information exchange cluding physical therapy (n=16), and acupuncture (HIE) is increasing in the United States, and it is (n=11) were the most frequently studied practices. incentivized by government policies. PURPOSE: Methodological quality of most RCTs was rated To systematically review and evaluate evidence of poorly. CONCLUSIONS: Meditation and acupunc- the use and effect of HIE on clinical care. DATA ture practices are among the most frequently of- SOURCES: Selected databases from 1 January fered and studied mind and body practices. Future 2003 to 31 May 2014. STUDY SELECTION: Eng- research should include yoga as it is currently un- 335 lish-language hypothesis-testing or quantitative Europe. Christian van Stolk. 2014 studies of several types of data exchange among This article compares the Europeanization of unaffiliated organizations for use in clinical care central government in four Central and Eastern that addressed health outcomes, efficiency, utili- European countries (CEECs): Estonia, Latvia, zation, costs, satisfaction, HIE usage, sustainabil- Poland, and Slovakia. Using a large N survey of ity, and attitudes or barriers. DATA EXTRACTION: ministerial civil servants, it finds that the Europe- Data extraction was done in duplicate. DATA SYN- anization of central government is characterized THESIS: Low-quality evidence from 12 hypothe- by partial convergence. The scope of European- sis-testing studies supports an effect of HIE use ization is large and similar among CEECs, reach- on reduced use or costs in the emergency depart- ing widely and deeply into government ministries. ment. Direct evidence that HIEs were used by pro- Moreover, patterns of Europeanization are similar viders was reported in 21 studies involving 13 dis- among CEECs: the same ministries form the 'in- tinct HIE organizations, 6 of which were located ner core' and 'outer circle' of Europeanized minis- in New York, and generally showed usage in less tries; only a small proportion of civil servants work than 10% of patient encounters. Findings from 17 full-time on EU issues and routinely engage in ac- studies of sustainability suggest that approximate- tivities that 'project' national policies at EU level. ly one quarter of existing HIE organizations con- Compared to old member states, patterns of Eu- sider themselves financially stable. Findings from ropeanization show signs of convergence, while 38 studies about attitudes and barriers showed the scope of Europeanization is larger in CEECs. that providers, patients, and other stakeholders consider HIE to be valuable, but barriers include EP-66227 technical and workflow issues, costs, and privacy Percent plans, automatic admissions, and col- concerns. LIMITATION: Publication bias, possible lege outcomes. Paco Martorell. 2014 selective reporting of outcomes, and a dearth of reporting on context and implementation process- Access to selective universities is highly cov- es. CONCLUSION: Health information exchange eted because of the perception that attending use probably reduces emergency department us- one provides opportunities otherwise difficult age and costs in some cases. Effects on other to obtain. To broaden access to the state's flag- outcomes are unknown. All stakeholders claim to ship universities in a manner that does not rely value HIE, but many barriers to acceptance and on conventional affirmative action, Texas passed sustainability exist. A small portion of operational the Top Ten Percent Plan in 1997, which guaran- HIEs have been evaluated, and more research is tees automatic admission to any public university needed to identify and understand success fac- in the state to students in the top decile of their tors. high school class. We estimate the effect of eligibility for automatic admissions on college choice EP-66225 and persistence for students in a diverse urban Reimagining quality measurement. Eric C. school district. Regression discontinuity estimates Schneider. 2014 show that eligibility for guaranteed admissions has a substantial impact on enrollments at Texas In a reimagined approach, quality measure- flagship universities and increases the number of ment in health care would be integrated with care semesters enrolled at flagships. The increase in delivery, address the challenges that confront flagship enrollments appears to displace enroll- doctors every day, and reflect individual patients' ments in private universities but has no effect on preferences and goals for treatment and health overall college enrollment or the quality of college outcomes. attended. The effects are concentrated in schools that have high college-sending rates (relative to EP-66226 A case of partial convergence: the Europeaniza- other schools in the district), suggesting that au- tion of central government in Central and Eastern tomatic admissions may have little doc=effect on 336 students in the most disadvantaged schools. care, mental health, and social and community programs. Sociodemographic, health status, and EP-66228 services utilization variables were examined. RE- Special warfare: the missing middle in U.S. SULTS: Of the 957 depressed clients, 217 (23%) coercive options. Dick Hoffmann. 2014 were from substance abuse programs; 269 (28%) In the face of adversaries exploiting regional clients from other sectors had a substance abuse social divisions by using special operations forces history, and 471 (49%) did not. Most clients from and intelligence services, and dwindling American substance abuse programs or with a substance appetite for intervention, the United States needs abuse history were unemployed and impover- to employ a more sophisticated form of special ished, lacked health insurance, and had high warfare to secure its interests. Special warfare rates of arrests and homelessness. They were campaigns stabilize or destabilize a regime by also more likely than clients without a substance operating "through and with" local state or non- abuse history to have depression or anxiety disor- state partners, rather than through unilateral U.S. ders, psychosis, and mania and to use emergency action. Special operations forces are typically the rooms. CONCLUSIONS: Clients with depression primary U.S. military forces employed, but suc- and a substance abuse history had significant psy- cessful campaigns depend on bringing to bear a chosocial stressors and high rates of service use, broad suite of U.S. government capabilities. The which suggests that communitywide approaches figure below differentiates special warfare from may be needed to address both depression and more familiar forms of conflict. Special warfare has substance abuse in this safety-net population. particular relevance to the current global security environment as policymakers seek options short EP-66230 The Affordable Care Act: an opportunity for im- of large-scale intervention to manage both acute proving care for substance use disorders?. Carrie crises (e.g., ISIL, Ukraine) and chronic challenges M. Farmer. 2014 (e.g., insurgency in the Philippines). The Patient Protection and Affordable Care Act EP-66229 (ACA) will greatly increase coverage for treatment Comorbid depression and substance abuse of substance use disorders. To realize the benefits among safety-net clients in Los Angeles: a com- of this opportunity, it is critical to develop reliable, munity participatory study. Kenneth B. Wells. 2014 valid, and feasible measures of quality to ensure OBJECTIVE: Depression and substance that treatment is accessible and of high quality. abuse are common among low-income adults The authors review the availability of current qual- from racial-ethnic minority groups who receive ity measures for substance use disorder treatment services in safety-net settings, although little is and conclude there is a pressing need for devel- known about how clients differ by service setting. opment, validation, and use of quality measures. This study examined characteristics and service They provide recommendations for research and use among depressed, low-income persons from policy changes to increase the likelihood that pa- minority groups in underresourced communities tients, families, and society benefit from the in- who did and did not have a substance abuse his- creased coverage provided by the ACA. tory. METHODS: The study used cross-sectional EP-66231 baseline client data (N=957) from Community Factors associated with ordering laboratory Partners in Care, an initiative to improve depres- monitoring of high-risk medications. Jennifer Tjia, sion services in Los Angeles County. Clients with George Reed. 2014 probable depression (eight-item Patient Health BACKGROUND: Knowledge about factors as- Questionnaire) from substance abuse programs sociated with provider ordering of appropriate test- were compared with depressed clients with and ing is limited. OBJECTIVE: To determine physician without a history of substance abuse from primary 337 factors associated with ordering recommended recipients in Honduras: a pilot intervention trial. laboratory monitoring tests for high-risk medica- Kathryn Pitkin Derose. 2014 tions. METHODS: Retrospective cohort study of Optimal strategies to improve food security and patients prescribed a high-risk medication requir- nutrition for people living with HIV (PLHIV) may ing laboratory monitoring in a large multispecialty differ in settings where overweight and obesity group practice between 1 January 2008 and 31 are prevalent and cardiovascular disease risk is a December 2008. Analyses are based on admin- concern. However, no studies among PLHIV have istrative claims and electronic medical records. investigated the impact of food support on nutri- The outcome is a physician order for each rectional outcomes in these settings. We therefore ommended laboratory test for each prescribed assessed the effect of food support on food inse- medication. Key predictor variables are physician curity and body weight in a population of PLHIV characteristics, including age, gender, specialty with high prevalence of overweight and obesity. training, years since completing training, and pre- We implemented a pilot intervention trial in four scribing volume. Additional variables are patient government-run HIV clinics in Honduras. The trial characteristics such as age, gender, comorbidity tested the effect of a monthly household food ra- burden, whether the medication requiring moni- tion plus nutrition education (n = 203), compared toring is new or chronic, and drug-test character- to nutrition education alone (n = 197), over 12 istics such as inclusion in black box warnings. We months. Participants were clinic patients receiving used multivariable logistic regression, accounting antiretroviral therapy (ART). Assessments were for clustering of drugs within patients and patients obtained at baseline, 6 and 12 months. Primary within providers. RESULTS: Physician orders for outcomes for this analysis were food security, us- laboratory testing varied across drug-test pairs ing the validated Latin American and Caribbean and ranged from 9 % (Primidone–Phenobarbital Food Security Scale and body weight (kg). Thir- level) to 97 % (Azathioprine–CBC), with half of ty-one percent of participants were overweight the drug-test pairs in the 85-91 % ordered range. (22%) or obese (8%) at baseline. At 6 months, the Test ordering was associated with higher provider probability of severe food insecurity decreased by prescribing volume for study drugs and specialist 48.3% (p < 0.01) in the food support group, com- status (primary care providers were less likely to pared to 11.6% in the education-only group (p < order tests than specialists). Patients with higher 0.01). Among overweight or obese participants, comorbidity burden and older patients were more food support led to average weight gain of 1.13 likely to have appropriate tests ordered. Drug-test kg (p < 0.01), while nutrition education alone was combinations with black box warnings were more associated with average weight loss of 0.72 kg (p likely to have tests ordered. CONCLUSIONS: < 0.10). Nutrition education alone was associated Interventions to improve laboratory monitoring with weight gain among underweight and normal should focus on areas with the greatest potential weight participants. Household food support may for improvement: providers with lower frequencies improve food security but not necessarily nutri- of prescribing medications with monitoring recom- tional status of ART recipients above and beyond mendations and those prescribing these medica- nutrition education. Improving nutritional tailoring tions for healthier and younger patients; patients of food support and testing the impact of nutrition with less interaction with the health care system education should be prioritized for PLHIV in Latin are at particular risk of not having tests ordered. America and similar settings. Black box warnings were associated with higher ordering rates and may be a tool to increase ap- EP-66233 propriate test ordering. Common versus specific correlates of fifth- grade conduct disorder and oppositional defiant EP-66232 disorder symptoms: comparison of three racial/ Impact of food support on food security and ethnic groups. Marc N. Elliott. 2014 body weight among HIV antiretroviral therapy 338

The extent to which risk profiles or correlates quency Scale. RESULTS: Child-reported media of conduct disorder (CD) and oppositional defiant violence exposure was associated with physical disorder (ODD) symptoms overlap among youth aggression after multivariable adjustment for so- continues to be debated. Cross-sectional data ciodemographics, family and community violence, from a large, representative community sample and child mental health symptoms (partial correla- (N = 4,705) of African-American, tion coefficients: TV, 0.17; video games, 0.15; mu- Latino, and White fifth graders were used to ex- sic, 0.14). This association was significant and in- amine overlap in correlates of CD and ODD dependent for television, video games, and music symptoms. About 49 % of the children were boys. violence exposure in a model including all 3 me- Analyses were conducted using negative binomial dia types (partial correlation coefficients: TV, 0.11; regression models, accounting for several con- video games, 0.09; music, 0.09). There was a sig- founding factors (e.g., attention deficit/hyperactiv- nificant positive interaction between media time ity disorder symptoms), sampling weights, stratifi- and media violence for video games and music cation, and clustering. Results indicated that CD but not for television. Effect sizes for the associa- and ODD symptoms had very similar correlates. tion of media violence exposure and physical ag- In addition to previously established correlates, gression were greater in magnitude than for most several social skills dimensions were significantly of the other examined variables. CONCLUSIONS: related to ODD and CD symptoms, even after con- The association between physical aggression and trolling for other correlates. In contrast, tempera- media violence exposure is robust and persistent; mental dimensions were not significantly related to the strength of this association of media violence CD and ODD symptoms, possibly because more may be at least as important as that of other fac- proximal correlates (e.g., social skills) were also tors with physical aggression in children, such taken into account. Only two factors (gender and as neighborhood violence, home violence, child household income) were found to be specific cor- mental health, and male gender. relates of CD, but not ODD, symptoms. The pattern of common and specific correlates of CD and EP-66235 ODD symptoms was replicated fairly consistently Understanding data requirements of retrospec- across the three racial/ethnic subgroups. Implica- tive studies. Daniella Meeker. 2014 tions of these findings for further research and in- BACKGROUND AND OBJECTIVE: Usage tervention efforts are discussed. of data from electronic health records (EHRs) in clinical research is increasing, but there is little EP-66234 empirical knowledge of the data needed to sup- Media violence exposure and physical aggres- port multiple types of research these sources sup- sion in fifth-grade children. Marc N. Elliott. 2014 port. This study seeks to characterize the types OBJECTIVE: To examine the association of and patterns of data usage from EHRs for clini- media violence exposure and physical aggres- cal research. MATERIALS AND METHODS: We sion in fifth graders across 3 media types. METH- analyzed the data requirements of over 100 ret- ODS: We analyzed data from a population-based, rospective studies by mapping the selection cri- cross-sectional survey of 5,147 fifth graders and teria and study variables to data elements of two their parents in 3 US metropolitan areas. We used standard data dictionaries, one from the health- multivariable linear regression and report partial care domain and the other from the clinical re- correlation coefficients to examine associations search domain. We also contacted study authors between children's exposure to violence in televi- to validate our results. RESULTS: The majority of sion/film, video games, and music (reported time variables mapped to one or to both of the two dic- spent consuming media and reported frequency tionaries. Studies used an average of 4.46 (range of violent content: physical fighting, hurting, shoot- 1–12) data element types in the selection crite- ing, or killing) and the Problem Behavior Fre- ria and 6.44 (range 1–15) in the study variables. 339

The most frequently used items (e.g., procedure, management support activities. Importantly, CHW condition, medication) are often available in cod- and MA responsibilities converged over time to fo- ed form in EHRs. Study criteria were frequently cus on health coaching of diabetic patients. MA complex, with 49 of 104 studies involving relation- health coaches experienced difficulty in allocating ships between data elements and 22 of the stud- dedicated time due to other MA responsibilities ies using aggregate operations for data variables. that often crowded out time for diabetic patient Author responses supported these findings. DIS- health coaching. Time constraints also limited the CUSSION AND CONCLUSION: The high propor- personal introduction of patients to health coach- tion of mapped data elements demonstrates the es by clinicians. Participants highlighted the im- significant potential for clinical data warehousing portance of a supportive team climate and proac- to facilitate clinical research. Unmapped data ele- tive leadership as important enablers for MAs and ments illustrate the difficulty in developing a com- CHWs to implement their health coaching respon- plete data dictionary. sibilities and also promoted professional growth. CONCLUSION: Implementation of team-based EP-66236 strategies to improve diabetes care for vulnerable Comparing the implementation of team ap- populations was diverse, however all practices proaches for improving diabetes care in commu- converged in their foci on health coaching roles of nity health centers. Mark W. Friedberg. 2014 CHWs and MAs. Our study suggests that a flex- BACKGROUND: Patient panel management ible approach to implementing health coaching is and community-based care management may be more important than fidelity to rigid models that do viable strategies for community health centers to not allow for variable allocation of responsibilities improve the quality of diabetes care for vulnerable across team members. Clinicians play an instru- patient populations. The objective of our study was mental role in supporting health coaches to grow to clarify implementation processes and experi- into their new patient care responsibilities. ences of integrating office-based medical assistant (MA) panel management and community health EP-66237 Methodological considerations when studying worker (CHW) community-based management the association between patient-reported care ex- into routine care for diabetic patients. METHODS: periences and mortality. Eugenia Buta, Rebecca Mixed methods study with interviews and surveys Anhang Price. 2014 of clinicians and staff participating in a study comparing the effectiveness of MA and CHW health OBJECTIVE: To illustrate methodological con- coaching for improving diabetes care. Participants siderations when assessing the relationship be- included 24 key informants in five role categories tween patient care experiences and mortality. and 249 clinicians and staff survey respondents DATA SOURCE: Medical Expenditure Panel Sur- from 14 participating practices. We conducted vey data (2000–2005) linked to National Health thematic analyses of key informant interview tran- Interview Survey and National Death Index mor- scripts to clarify implementation processes and tality data through December 31, 2006. STUDY describe barriers to integrating the new roles into DESIGN: We estimated Cox proportional hazards practice. We surveyed clinicians and staff to as- models with mortality as the dependent variable sess differences in practice culture among inter- and patient experience measures as indepen- vention and control groups. We triangulated find- dent variables and assessed consistency of ex- ings to identify concordant and disparate results periences over time. DATA EXTRACTION METH- across data sources. RESULTS: Implementation ODS: We used data from respondents age 18 or processes and experiences varied considerably older with at least one doctor's office or clinic visit among the practices implementing CHW and MA during the year prior to the round 2 interview. We team-based approaches, resulting in differences excluded subjects who died in the baseline year. in the organization of health coaching and self- PRINCIPAL FINDINGS: The association between 340 overall care experiences and mortality was signifi- capital groups reported higher abstinence. Persis- cant for deaths not amenable to medical care and tently low Blacks, however, reported higher HED, all-cause mortality, but not for amenable deaths. whereas persistently low Whites did not. More- More than half of respondents were in a different over, economically upward Whites reported lower care experience quartile over a 1-year period. In HED, whereas upwardly mobile Blacks did not. the five individual experience questions we ana- CONCLUSIONS: Racial disparities were evident lyzed, only time spent with the patient was signifi- by economic and human capital during the transi- cantly associated with mortality. CONCLUSIONS: tion into adulthood. Although abstinence profiles Deaths not amenable to medical care and the were similar for Whites and Blacks, both persis- time-varying and multifaceted nature of patient tently low and upward trajectory groups signified care experience are important issues to consider differential HED risks. Future research should ex- when assessing the relationship between care examine the mechanisms by which SES trajectories perience and mortality. affect drinking behaviors.

EP-66238 EP-66239 Drinking behaviors and life course socioeco- Clinician advice to quit smoking among seniors. nomic status during the transition from adoles- Marc N. Elliott. 2014 cence to adulthood among whites and blacks. OBJECTIVE: Little smoking research in the Paul J. Chung. 2014 past 20 years includes persons 50 and older; OBJECTIVE: This study sought to determine herein we describe patterns of clinician cessa- how socioeconomic status (SES) changes during tion advice to US seniors, including variation by the transition from adolescence into adulthood, Medicare beneficiary characteristics. METHOD: and to understand the effects of SES on drinking In 2012–4, we analyzed 2010 Consumer As- behaviors in early adulthood among U.S. Whites sessment of Healthcare Providers and Systems and Blacks. METHOD: Secondary data analysis (CAHPS) survey data from Medicare beneficiaries was conducted using three waves of the National over age 64 (n = 346,674). We estimated smoking Longitudinal Study of Adolescent to Adult Health rates and the proportion of smokers whose clini- (Add Health), a school-based sample of adoles- cians encouraged cessation. RESULTS: 12% of cents (Grades 7–12) followed through adulthood male and 8% of female respondents aged 65 and (age range: 25–31 years). Through latent class older smoke. The rate decreases with age (14% of analysis, SES was operationalized as economic 65–69, 3% of 85 +) and education (12–15% with (i.e., income, home ownership) and human capi- no high school degree, 5–6% with BA +). Rates tal (i.e., education, occupation). Drinking behav- are highest among American Indian/Alaskan Na- ior was categorized into no past-year use, current tive (16%), multiracial (14%), and African–Ameri- drinking without weekly heavy episodic drinking can (13%) seniors, and in the Southeast (14%). (HED), and weekly HED. Models were stratified by Only 51% of smokers say they receive cessation race: Whites (n = 5,248) and Blacks (n = 1,875). advice "always" or "usually" at doctor visits, with RESULTS: For Whites, four economic capital advice more often given to the young, those in groups (persistently low, upward, downward, and low-smoking regions, Asians, and women. For all persistently high) and five human capital groups results cited p < 0.05. CONCLUSIONS: Smoking (persistently low, upward with work, upward with cessation advice to seniors is variable. Providers school, downward with work, and persistently may focus on groups or areas in which smoking high) were found. Blacks had roughly similar SES is less common or when they are most comfort- groups as Whites but with lower economic and hu- able giving advice. More consistent interventions man capital levels across all groups and without are needed, including cessation advice from clini- downward groups in either domain. Among both cians. Whites and Blacks, lower economic and human 341

EP-66240 out type 1 diabetes (n = 122), who were part of Improving QRISs through the use of existing a previous longitudinal study during adolescence, data: a virtual pilot of the California QRIS. Lynn A. completed on-line questionnaires during their se- Karoly. 2014 nior year of high school and one and two years Available research underscores the value of us- later. They were average age 18, 53% female, and ing data to make and modify the many decisions 93% white. Questionnaires assessed cognitive required to design a child care quality rating and adaptation theory (CAT) indicators (self-esteem, improvement system (QRIS). This paper argues mastery, optimism) and psychological, relation- for analyzing existing program data to address key ship, behavioral, vocational, and, for those with questions and decisions in the early design stag- diabetes, diabetes outcomes. RESULTS: The CAT es of a QRIS, even in advance of pilot activities. index at baseline predicted reduced psychologi- We employed two datasets covering California cal distress, enhanced psychological well-being, ECE programs to provide cost-effective and timely increased friend support, reduced friend conflict, input to policymakers for the proposed California the presence of romantic relationships, reduced QRIS, a block design system with five quality ele- likelihood of romantic breakups, higher GPA, high- ments and five rating tiers. The first data source er work satisfaction, and lower work stress during is the provider sample component of the 2007 the transition to emerging adulthood. Among those RAND California Preschool Study (CPS), which with diabetes, the CAT index predicted better self- represents all California providers. The second care behavior and revealed a marginal relation dataset derives from quality measurement of the to better glycemic control. Analyses controlled for ECE providers required to participate in San Fran- baseline levels when appropriate. Findings were cisco County's Gateway to Quality (GTQ) initia- stronger one year than two years post high school tive. To address the study questions, we replicated graduation, and findings were stronger for those as closely as possible the proposed QRIS rating with than without diabetes. Youth with diabetes structure for the available quality elements. Our also scored lower on the CAT index than youth "virtual pilot" analysis had limitations: we could without diabetes. CONCLUSIONS: These findings examine only three of the five quality elements. suggest that the implications of CAT include not Findings revealed that most programs in our only psychological health but also relationship, statewide center-based sample would rate better vocational, and diabetes outcomes. Those who on some quality elements than others. GTQ data score lower on CAT indicators should be identi- revealed that center-based classrooms serving in- fied as children so that interventions designed to fants and toddlers did not score as well as those enhance resilience can be implemented. serving preschool-age children and home-based programs scored considerably lower on the ap- MONOGRAPHS plicable Environmental Rating Scale (ERS) than center-based programs. MG-1117-1-KRG EP-66241 Strategies for Private-Sector Development and Cognitive adaptation theory as a predictor of Civil-Service Reform in the Kurdistan Region— adjustment to emerging adulthood for youth with Iraq. Michael L. Hansen, Howard J. Shatz, Louay and without type 1 diabetes. Kerry A. Reynolds. Constant, Alexandria C. Smith, Krishna B. Kumar, 2014 Heather Krull, Artur Usanov, with Harun Dogo, OBJECTIVE: The purpose of the study was to Jeffrey Martini. 2014 determine whether resilience, defined by cognitive This monograph provides strategies to re- adaptation theory, predicted emerging adulthood employ civil-service workers in the private sector outcomes among youth with and without type 1 di- and to increase private-sector employment in the abetes. METHODS: Youth with (n = 118) and with- 342

Kurdistan Region—Iraq. Prepared for and at the ernment officials and private-sector employers. request of the Kurdistan Regional Government The KRG can develop its private sector by remov- (KRG), this monograph is based on a variety of ing obstacles to starting or expanding a business, research methods and analyses. These include a by identifying sectors for which conditions are par- review of the existing literature, analyses of sur- ticularly favorable for private-sector growth and vey data, analysis of Kurdistan regional and Iraqi supporting them, and by outsourcing and priva- national documents and laws, and a qualitative tizing some functions that the KRG currently per- assessment of numerous conversations with gov- forms. However, private-sector growth does not ernment officials and private-sector employers. guarantee that civil-service workers will leave for The KRG can develop its private sector by remov- private-sector employment. Civil-service workers ing obstacles to starting or expanding a business, will need the qualifications necessary for private- by identifying sectors for which conditions are par- sector jobs and will have to expect that the ben- ticularly favorable for private-sector growth and efits of private-sector employment outweigh the supporting them, and by outsourcing and priva- benefits of civil-service employment. At the same tizing some functions that the KRG currently per- time, as the KRG devises methods for encourag- forms. However, private-sector growth does not ing civil-service workers to leave for the private guarantee that civil-service workers will leave for sector, a key challenge will be to ensure that the private-sector employment. Civil-service workers KRG is able to retain the employees it needs in will need the qualifications necessary for private- order to ensure the proper functioning of govern- sector jobs and will have to expect that the ben- ment. efits of private-sector employment outweigh the benefits of civil-service employment. At the same MG-1117/2-1-KRG time, as the KRG devises methods for encourag- Strategies for Private-Sector Development and ing civil-service workers to leave for the private Civil-Service Reform in the Kurdistan Region— sector, a key challenge will be to ensure that the Iraq: Kurdish-language version. Michael L. Han- KRG is able to retain the employees it needs in sen, Howard J. Shatz, Louay Constant, Alexandria order to ensure the proper functioning of govern- C. Smith, Krishna B. Kumar, Heather Krull, Artur ment. Usanov, with Harun Dogo, Jeffrey Martini. 2014 This monograph provides strategies to re- MG-1117/1-1-KRG employ civil-service workers in the private sector Strategies for Private-Sector Development and and to increase private-sector employment in the Civil-Service Reform in the Kurdistan Region— Kurdistan Region—Iraq. Prepared for and at the Iraq: Arabic-language version. Michael L. Han- request of the Kurdistan Regional Government sen, Howard J. Shatz, Louay Constant, Alexandria (KRG), this monograph is based on a variety of C. Smith, Krishna B. Kumar, Heather Krull, Artur research methods and analyses. These include a Usanov, with Harun Dogo, Jeffrey Martini. 2014 review of the existing literature, analyses of sur- This monograph provides strategies to re- vey data, analysis of Kurdistan regional and Iraqi employ civil-service workers in the private sector national documents and laws, and a qualitative and to increase private-sector employment in the assessment of numerous conversations with gov- Kurdistan Region—Iraq. Prepared for and at the ernment officials and private-sector employers. request of the Kurdistan Regional Government The KRG can develop its private sector by remov- (KRG), this monograph is based on a variety of ing obstacles to starting or expanding a business, research methods and analyses. These include a by identifying sectors for which conditions are par- review of the existing literature, analyses of sur- ticularly favorable for private-sector growth and vey data, analysis of Kurdistan regional and Iraqi supporting them, and by outsourcing and priva- national documents and laws, and a qualitative tizing some functions that the KRG currently per- assessment of numerous conversations with gov- forms. However, private-sector growth does not 343 guarantee that civil-service workers will leave for teachers, improve teacher training for both practic- private-sector employment. Civil-service workers ing and new teachers, increase instructional time, will need the qualifications necessary for private- provide high-performing students with broad- sector jobs and will have to expect that the ben- ened learning opportunities, restructure the role efits of private-sector employment outweigh the of supervisors, redesign the system for evaluating benefits of civil-service employment. At the same teacher performance, increase the principal's role, time, as the KRG devises methods for encourag- reward high-performing schools, measure student ing civil-service workers to leave for the private achievement and progress and make the results sector, a key challenge will be to ensure that the public, and involve parents and the public in pro- KRG is able to retain the employees it needs in moting education. RAND also suggested ways to order to ensure the proper functioning of govern- implement the recommendations that would make ment. the process manageable.

MG-1140-1-KRG MG-1140/1-1-KRG Strategic Priorities for Improving Access to Strategic Priorities for Improving Access to Quality Education in the Kurdistan Region—Iraq. Quality Education in the Kurdistan Region—Iraq: Georges Vernez, Shelly Culbertson, Louay Con- Arabic-language version. Georges Vernez, Shelly stant. 2014 Culbertson, Louay Constant. 2014 The Kurdistan Regional Government (KRG) The Kurdistan Regional Government (KRG) began an ambitious reform of the Kurdistan Re- began an ambitious reform of the Kurdistan Re- gion—Iraq's (KRI's) kindergarten through grade gion—Iraq's (KRI's) kindergarten through grade 12 (K–12) education system beginning in 2007 12 (K–12) education system beginning in 2007 in an effort to modernize the curriculum, upgrade in an effort to modernize the curriculum, upgrade school facilities, and raise the quality of instruc- school facilities, and raise the quality of instruction. In 2010, RAND was asked to conduct a one- tion. In 2010, RAND was asked to conduct a one- year study to assess the status of the K–12 system year study to assess the status of the K–12 system and its reform, and to develop strategic priorities and its reform, and to develop strategic priorities and make practical recommendations for improv- and make practical recommendations for improving access to and quality of education in Kurdis- ing access to and quality of education in Kurdis- tan. In a one-year, multi-method study, RAND re- tan. In a one-year, multi-method study, RAND researchers analyzed school data from the KRG's searchers analyzed school data from the KRG's Ministry of Education, as well as data from other Ministry of Education, as well as data from other KRI government sources and Iraq; interviewed a KRI government sources and Iraq; interviewed a wide variety of stakeholders; surveyed teachers; wide variety of stakeholders; surveyed teachers; reviewed the new K–12 curriculum and the cur- reviewed the new K–12 curriculum and the curriculum used in the teacher colleges; developed riculum used in the teacher colleges; developed a model to project future student enrollment; used a model to project future student enrollment; used geographic information system mapping to display geographic information system mapping to display the distribution of schools and assess the feasibil- the distribution of schools and assess the feasibility of proposed actions; and reviewed the literature ity of proposed actions; and reviewed the literature on best practices and relevant educational poli- on best practices and relevant educational policies. The outcome was three strategic priorities cies. The outcome was three strategic priorities for improving the K–12 system: expand capacity for improving the K–12 system: expand capacity to meet the rapidly growing demand for education, to meet the rapidly growing demand for education, improve the quality of instruction, and strengthen improve the quality of instruction, and strengthen stakeholders' accountability and incentives. In line stakeholders' accountability and incentives. In line with these priorities, RAND recommended that the with these priorities, RAND recommended that the KRG build new schools and classrooms, hire new KRG build new schools and classrooms, hire new 344 teachers, improve teacher training for both practic- KRG build new schools and classrooms, hire new ing and new teachers, increase instructional time, teachers, improve teacher training for both practic- provide high-performing students with broad- ing and new teachers, increase instructional time, ened learning opportunities, restructure the role provide high-performing students with broad- of supervisors, redesign the system for evaluating ened learning opportunities, restructure the role teacher performance, increase the principal's role, of supervisors, redesign the system for evaluating reward high-performing schools, measure student teacher performance, increase the principal's role, achievement and progress and make the results reward high-performing schools, measure student public, and involve parents and the public in pro- achievement and progress and make the results moting education. RAND also suggested ways to public, and involve parents and the public in pro- implement the recommendations that would make moting education. RAND also suggested ways to the process manageable. implement the recommendations that would make the process manageable. MG-1140/2-1-KRG Strategic Priorities for Improving Access to MG-1148-1-KRG Quality Education in the Kurdistan Region—Iraq: The Future of Health Care in the Kurdistan Re- Kurdish-language version. Georges Vernez, gion—Iraq: Toward an Effective, High-Quality Sys- Shelly Culbertson, Louay Constant. 2014 tem with an Emphasis on Primary Care. Melinda Moore, C. Ross Anthony, Yee-Wei Lim, Spencer The Kurdistan Regional Government (KRG) S. Jones, Adrian Overton, Joanne K. Yoong. 2014 began an ambitious reform of the Kurdistan Re- gion—Iraq's (KRI's) kindergarten through grade At the request of the Kurdistan Regional Gov- 12 (K–12) education system beginning in 2007 ernment (KRG), RAND researchers undertook a in an effort to modernize the curriculum, upgrade yearlong analysis of the health care system in the school facilities, and raise the quality of instruc- Kurdistan Region of Iraq, with a focus on primary tion. In 2010, RAND was asked to conduct a one- care. RAND staff reviewed available literature on year study to assess the status of the K–12 system the Kurdistan Region and information relevant to and its reform, and to develop strategic priorities primary care; interviewed a wide range of policy and make practical recommendations for improv- leaders, health practitioners, patients, and gov- ing access to and quality of education in Kurdis- ernment officials to gather information and un- tan. In a one-year, multi-method study, RAND re- derstand their priorities; collected and studied all searchers analyzed school data from the KRG's available data related to health resources, ser- Ministry of Education, as well as data from other vices, and conditions; and projected future supply KRI government sources and Iraq; interviewed a and demand for health services in the Kurdistan wide variety of stakeholders; surveyed teachers; Region; and laid out the health financing chal- reviewed the new K–12 curriculum and the cur- lenges and questions. In this volume, the authors riculum used in the teacher colleges; developed describe the strengths of the health care system a model to project future student enrollment; used in the Kurdistan Region as well as the challenges geographic information system mapping to display it faces. The authors suggest that a primary care– the distribution of schools and assess the feasibil- oriented health care system could help the KRG ity of proposed actions; and reviewed the literature address many of these challenges. The authors on best practices and relevant educational poli- discuss how such a system might be implemented cies. The outcome was three strategic priorities and financed, and they make recommendations for improving the K–12 system: expand capacity for better utilizing resources to improve the quality, to meet the rapidly growing demand for education, access, effectiveness, and efficiency of primary improve the quality of instruction, and strengthen care. stakeholders' accountability and incentives. In line with these priorities, RAND recommended that the MG-1148/1-1-KRG 345

The Future of Health Care in the Kurdistan leaders, health practitioners, patients, and gov- Region—Iraq: Toward an Effective, High-Quality ernment officials to gather information and un- System with an Emphasis on Primary Care (Ar- derstand their priorities; collected and studied all abic-language version). Melinda Moore, C. Ross available data related to health resources, ser- Anthony, Yee-Wei Lim, Spencer S. Jones, Adrian vices, and conditions; and projected future supply Overton, Joanne K. Yoong. 2014 and demand for health services in the Kurdistan At the request of the Kurdistan Regional Gov- Region; and laid out the health financing chal- ernment (KRG), RAND researchers undertook a lenges and questions. In this volume, the authors yearlong analysis of the health care system in the describe the strengths of the health care system Kurdistan Region of Iraq, with a focus on primary in the Kurdistan Region as well as the challenges care. RAND staff reviewed available literature on it faces. The authors suggest that a primary care– the Kurdistan Region and information relevant to oriented health care system could help the KRG primary care; interviewed a wide range of policy address many of these challenges. The authors leaders, health practitioners, patients, and gov- discuss how such a system might be implemented ernment officials to gather information and un- and financed, and they make recommendations derstand their priorities; collected and studied all for better utilizing resources to improve the quality, available data related to health resources, ser- access, effectiveness, and efficiency of primary vices, and conditions; and projected future supply care. and demand for health services in the Kurdistan MG-1171/5-OSD Region; and laid out the health financing chal- DoD and Commercial Advanced Waveform lenges and questions. In this volume, the authors Developments and Programs with Multiple Nunn- describe the strengths of the health care system McCurdy Breaches, Volume 5. Mark V. Arena, in the Kurdistan Region as well as the challenges Irv Blickstein, Daniel Gonzales, Sarah Harting, it faces. The authors suggest that a primary care– Jennifer Lamping Lewis, Michael McGee, Megan oriented health care system could help the KRG McKernan, Charles Nemfakos, Jan Osburg, Rena address many of these challenges. The authors Rudavsky, Jerry M. Sollinger. 2014 discuss how such a system might be implemented and financed, and they make recommendations The report presents the results of two studies: for better utilizing resources to improve the quality, The first compares the capabilities and develop- access, effectiveness, and efficiency of primary ment approaches used in the Joint Tactical Radio care. System wideband networking waveform (WNW) and the commercial long-term evolution wave- MG-1148/2-1-KRG form, and the second analyzes military acquisition The Future of Health Care in the Kurdistan programs that have repeatedly exceeded certain Region—Iraq: Toward an Effective, High-Quality cost thresholds. The first study compares differ- System with an Emphasis on Primary Care (Kurd- ences in system designs, technical requirements, ish-language version). Melinda Moore, C. Ross intellectual property protection schemes, and cost Anthony, Yee-Wei Lim, Spencer S. Jones, Adrian in the development of WNW. It also examined how Overton, Joanne K. Yoong. 2014 technical risks and challenging requirements con- At the request of the Kurdistan Regional Gov- tributed to schedule and cost increases. The sec- ernment (KRG), RAND researchers undertook a ond study attempts to identify unique characteris- yearlong analysis of the health care system in the tics of programs that overrun their budgets more Kurdistan Region of Iraq, with a focus on primary than once. care. RAND staff reviewed available literature on MG-1171/6-OSD the Kurdistan Region and information relevant to Management Perspectives Pertaining to Root primary care; interviewed a wide range of policy Cause Analyses of Nunn-McCurdy Breaches, 346

Volume 6: Contractor Motivations and Anticipating KRI ministries, assessed available data within the Breaches. Mark V. Arena, John Birkler, Irv Blick- KRI, conducted cross-country benchmarking, and stein, Charles Nemfakos, Abby Doll, Jeffrey A. studied best practices in data-collection method- Drezner, Gordon T. Lee, Megan McKernan, Brian ologies. In this volume, the authors describe the McInnis, Carter C. Price, Jerry M. Sollinger, Erin KRG's statistical institutions; identify ten high- York. 2014 priority areas for the KRI and the types of data With an eye to making defense acquisition more that should be collected to support policymaking effective and efficient, the authors explore defense in these areas; and outline a system to collect and contractor motivations in pursuing defense con- disseminate these data on an ongoing basis. The tracts and identify mechanisms that might more authors conclude with a series of recommenda- closely align those incentives with Department of tions on the topics that should be addressed by Defense goals. They enumerate several motiva- statistics legislation, the structure and oversight of tions that drive contractors, most of which center data institutions, the implementation and use of on the financial aspects of running an enterprise. surveys and censuses, and the use of administra- Then, they turn to the other side of the negotiating tive data. Together, these recommendations pro- table and identify areas of influence or levers that vide a road map that will help the KRG assemble the government can use to align the contracting the core elements of a quality data system, which, process more closely with contractor motivations. in turn, will increase the availability of data to help They also analyze major defense acquisition pro- KRG leaders achieve their most important policy grams to determine if it is possible to identify pro- goals. grams that might incur a future Nunn-McCurdy MG-1184/1-1-KRG breach by reviewing a number of acquisition pro- Designing a System for Collecting Policy- grams that have incurred breaches in the past and Relevant Data for the Kurdistan Region—Iraq: analyzing them for common characteristics. Their Arabic-language version. Sandra H. Berry, analytic framework enables oversight officials to Nicholas Burger, Harun Dogo, Krishna B. Kumar, identify programs with a greater risk of incurring Alessandro Malchiodi, Jeffrey Martini, Tewodaj a critical cost breach, which enables officials to Mengistu, Howard J. Shatz, Alexandria C. Smith, focus more intently on a smaller set of programs Artur Usanov, Joanne K. Yoong. 2014 and which provides hypotheses about what to look for in these programs. Comprehensive and reliable statistics are crucial for policy formulation in any region or country. MG-1184-1-KRG The Kurdistan Region—Iraq (KRI) is hampered by Designing a System for Collecting Policy-Rele- the lack of such statistics as it aims to improve vant Data for the Kurdistan Region—Iraq. Sandra infrastructure, encourage private-sector devel- H. Berry, Nicholas Burger, Harun Dogo, Krishna opment, attract foreign investment, and create a B. Kumar, Alessandro Malchiodi, Jeffrey Martini, sustainable economy. The authors of this study, Tewodaj Mengistu, Howard J. Shatz, Alexandria C. which was funded by the Kurdistan Regional Gov- Smith, Artur Usanov, Joanne K. Yoong. 2014 ernment (KRG), interviewed officials in several Comprehensive and reliable statistics are cru- KRI ministries, assessed available data within the cial for policy formulation in any region or country. KRI, conducted cross-country benchmarking, and The Kurdistan Region—Iraq (KRI) is hampered by studied best practices in data-collection method- the lack of such statistics as it aims to improve ologies. In this volume, the authors describe the infrastructure, encourage private-sector devel- KRG's statistical institutions; identify ten high- opment, attract foreign investment, and create a priority areas for the KRI and the types of data sustainable economy. The authors of this study, that should be collected to support policymaking which was funded by the Kurdistan Regional Gov- in these areas; and outline a system to collect and ernment (KRG), interviewed officials in several disseminate these data on an ongoing basis. The 347 authors conclude with a series of recommenda- goals. tions on the topics that should be addressed by statistics legislation, the structure and oversight of MG-1210-AF data institutions, the implementation and use of The Future of the U.S. Intercontinental Ballistic surveys and censuses, and the use of administra- Missile Force. Lauren Caston, Robert S. Leonard, tive data. Together, these recommendations pro- Christopher A. Mouton, Chad J. R. Ohlandt, S. vide a road map that will help the KRG assemble Craig Moore, Raymond E. Conley, Glenn Buchan. the core elements of a quality data system, which, 2014 in turn, will increase the availability of data to help In the lead-up to the Air Force Ground Based KRG leaders achieve their most important policy Strategic Deterrent Analysis of Alternatives, RAND goals. was asked to examine and assess possible intercontinental ballistic missile (ICBM) alternatives MG-1184/2-1-KRG against the current Minuteman III system and to Designing a System for Collecting Policy- provide insights into the potential impact of further Relevant Data for the Kurdistan Region—Iraq: force reductions. The researchers developed a Kurdish-language version. Sandra H. Berry, framework consisting of five categories—basing, Nicholas Burger, Harun Dogo, Krishna B. Kumar, propulsion, boost, reentry, and payload—to char- Alessandro Malchiodi, Jeffrey Martini, Tewodaj acterize alternative classes of ICBM and to assess Mengistu, Howard J. Shatz, Alexandria C. Smith, the survivability and effectiveness of possible al- Artur Usanov, Joanne K. Yoong. 2014 ternatives. Using existing cost analyses and cost Comprehensive and reliable statistics are cru- data from historical ICBM programs, they derived cial for policy formulation in any region or country. likely cost bounds on alternative classes of ICBM The Kurdistan Region—Iraq (KRI) is hampered by systems. Finally, they developed force reduction the lack of such statistics as it aims to improve scenarios, examined their impacts on several key infrastructure, encourage private-sector devel- nuclear specialty career fields to understand the opment, attract foreign investment, and create a implications of reductions on the current organiza- sustainable economy. The authors of this study, tional structure, and compared sustainment and which was funded by the Kurdistan Regional Gov- requirement profiles within the various reduction ernment (KRG), interviewed officials in several scenarios. KRI ministries, assessed available data within the KRI, conducted cross-country benchmarking, and MG-850/2-AF studied best practices in data-collection method- China's International Behavior: Chinese trans- ologies. In this volume, the authors describe the lation (traditional characters). Evan S. Medeiros. KRG's statistical institutions; identify ten high- 2014 priority areas for the KRI and the types of data Chinese translation (traditional characters) of that should be collected to support policymaking China's International Behavior: Activism, Oppor- in these areas; and outline a system to collect and tunism, and Diversification.China is now a global disseminate these data on an ongoing basis. The actor of significant and growing importance. It is authors conclude with a series of recommenda- active in regions and on issues that were once tions on the topics that should be addressed by only peripheral to its interests, and it is effectively statistics legislation, the structure and oversight of using tools previously unavailable. It is no longer data institutions, the implementation and use of appropriate to talk of integrating China into the in- surveys and censuses, and the use of administra- ternational system; by and large, it is already there. tive data. Together, these recommendations pro- Its international behavior is clearly altering the dy- vide a road map that will help the KRG assemble namics of the current international system, but it the core elements of a quality data system, which, is not transforming its structure.China's global ac- in turn, will increase the availability of data to help tivism is continually changing and has so many KRG leaders achieve their most important policy 348 dimensions that it immediately raises questions tenth anniversary of the U.S. invasion of Iraq was about its current and future intentions and the im- understandably backward-looking, including of- plications for global stability and prosperity. This ten heated debates over who did what wrong and volume examines how China views its security when. This paper takes a slightly different tack, environment, how it defines its international ob- surveying the overall impact of the Iraq War on jectives, how it is pursuing these objectives, and U.S. national security structures by examining the the consequences for U.S. economic and security major changes the war wrought in the intellectual interests. and institutional underpinnings of U.S. security and defense policy. The authors assess the future MG-915/2-AF implications of these changes and argue that, de- Shaking the Heavens and Splitting the Earth: spite a decade of painful and often acrimonious Chinese translation (traditional characters). Roger debates in Washington about what went wrong, Cliff, John F. Fei, Jeff Hagen, Elizabeth Hague, the United States is at best only modestly better Eric Heginbotham, John Stillion. 2014 prepared to fight a war like Iraq again. They begin Chinese translation (traditional characters) of with some basic data on the war and then focus Shaking the Heavens and Splitting the Earth: Chi- on four key, interrelated issues: counterinsurgen- nese Air Force Employment Concepts in the 21st cy operations, civilian state-making, security force Century.Less than a decade ago, China's air force assistance, and our capacity for understanding was an antiquated service equipped almost exclu- the specific needs of different kinds of interven- sively with weapons based on 1950s-era Soviet tions, allocating resources and adjusting expecta- designs and operated by personnel with question- tions accordingly. able training according to outdated employment concepts. Today, the People's Liberation Army Air PE-113-A Cost Considerations in Cloud Computing. Force (PLAAF) appears to be on its way to becom- Kathryn Connor, Ian P. Cook, Isaac R. Porche III, ing a modern, highly capable air force for the 21st Daniel Gonzales. 2014 century. This monograph analyzes publications of the Chinese military, previously published West- Cloud computing has garnered the attention of ern analyses of China's air force, and information the Department of Defense as data and computer available in published sources about current and processing needs grow and budgets shrink. Pro- future capabilities of the PLAAF. It describes the grams are interested in the potential of cloud com- concepts for employing forces that the PLAAF is puting to control growing data management costs, likely to implement in the future, analyzes how but reliable literature on the costs of cloud com- those concepts might be realized in a conflict puting in the government is still limited. Research- over Taiwan, assesses the implications of China ers found that cloud provider costs can vary in val- implementing these concepts, and provides rec- ue compared with traditional information system ommendations about actions that should be taken alternatives because of cost structure variations, in response. and analyzed the cost drivers for several data management approaches for one acquisition program to develop structured cost considerations for PERSPECTIVES analysts evaluating new cloud investments. These considerations can help analysts be comprehen- PE-111-OSD sive in their analysis until the DoD develops official Initial Thoughts on the Impact of the Iraq War guidance on cloud computing cost analysis. on U.S. National Security Structures. Christopher S. Chivvis, Olga Oliker, Andrew M. Liepman, Ben PE-115-RC Connable, George Willcoxon, William Young. 2014 The Dynamics of Syria's Civil War. Brian Mi- chael Jenkins. 2014 Much of the analyses that appeared with the 349

As the ongoing conflict in Syria enters its third cussion on these subjects by exploring the role year, persistent uncertainty regarding the circum- of early childhood education in bridging the digital stances on the ground, potential outcomes, and divide. We highlight five key questions that need long-term consequences continues to confound to be considered in the discussion of integrating analysis and possible policy responses. This es- technology into early childhood education. say explores the dynamics of the Syrian conflict, including the characteristics and interests PE-120-OSD of the belligerents, the interests of foreign pow- Democracy in Afghanistan: The 2014 Election ers involved, and the implications that the present and Beyond. Paul D. Miller. 2014 course of events has for the future of Syria and Afghanistan's upcoming presidential election is the wider region.It is concluded that the possibil- the most important political event in that country's ity of reaching a political settlement is becoming decade-long transition to democracy. A successful increasingly unlikely as the sectarian nature of election would be a major blow to the Taliban and the conflict intensifies and the unity of the rebel al Qaida, and would renew Afghan efforts to bring groups remains fractious—no end to the current the war to a favorable conclusion. The defeat of stalemate is in sight. The conflict has become an the Taliban in Afghanistan would be a major set- existential struggle for all concerned, so not even back for similar groups worldwide, many of which the fall of Assad will bring an end to the violence. look to Afghanistan as a sort of template for how Also, the involvement of Islamic extremist groups to accomplish a jihadist takeover. By contrast, a and other hardliners poses a future international failed election and a renewed push by the Taliban terrorist threat that could be directed against the could become a rallying cry and a morale boost West. By the end of 2014, more than half of the to the same groups. Because the stakes are high, Syrian population could be living as refugees, the international community should recognize which will exacerbate existing sectarian tensions that, despite a dozen years of frustration and halt- in neighboring countries—another factor condu- ing progress, Afghanistan's political and economic cive to terrorism. We will be dealing with the efflu- reconstruction needs one more push before the ent of Syria's civil war for decades. milestone election. Helping Afghanistan across the electoral finish line will increase the odds that PE-119-PNC the country will find some sort of solution to its Using Early Childhood Education to Bridge the internal stability and, thus, be able to deny safe Digital Divide. Lindsay Daugherty, Rafiq Dossani, haven to al Qaida and its affiliates. Erin-Elizabeth Johnson, Mustafa Oguz. 2014 Technology literacy plays an important role in PE-121-SDS a child's ability to succeed in school and later life. The 340B Prescription Drug Discount Program: Yet, despite rapid growth in society's use of digital Origins, Implementation, and Post-Reform Future. technology, many children in low-income families Andrew W. Mulcahy, Courtney Armstrong, Jeffrey in the United States are not able to access and Lewis, Soeren Mattke. 2014 use technology in the same ways as their more- The federal 340B Drug Pricing Program lowers advantaged peers. This means they have fewer outpatient drug prices for specific categories of opportunities to learn, explore, and communicate “covered entity” hospitals and clinics. Covered en- digitally, and fewer chances to develop the work- tities can access 340B drug pricing for all of their force skills they will need to succeed in later life. eligible patients, including those with insurance. Early childhood education can play a valuable The program has always generated some level of role in ensuring that low-income children can ac- controversy, but more in recent times. Drug man- cess technology and learn how to use it. However, ufacturers and safety net providers are using a there are a number of important issues that need wide array of tools and outlets—including interest to be addressed. This Perspective frames a dis- groups, lobbying, and media—to share their diver- 350 gent perspectives on the purpose and appropriate attack that killed Abu Khaled al-Suri, the leader of role of 340B. While interest groups are becoming a rival coalition of Islamist rebel groups in Syria. more vocal, the federal government is simultane- In response, Ayman al-Zawahiri took the unprec- ously implementing changes in program adminis- edented step of publicly expelling ISIL from al Qa- tration and oversight in response to internal and eda. An open break like this creates real risks for external calls for transparency and accountability. both ISIL's and al Qaeda's leadership, setting up a This Perspective presents the history, current sta- showdown that could turn an internal dispute into tus, and future trajectory of the 340B program. a schism that cleaves across the jihadist universe. In addition, it could create new intelligence and PE-122-RC propaganda opportunities for the United States. If The Days After a Deal with Iran: Regional ISIL turns out to be the stronger movement, al Qa- Responses to a Final Nuclear Agreement. Dalia eda's command over the global movement would Dassa Kaye, Jeffrey Martini. 2014 be seriously weakened. The biggest opportunities This Perspective begins by positing that a final for exploiting al Qaeda's internal disputes may lie nuclear agreement is reached between the P5+1 in countering al Qaeda's future recruitment. The (the five permanent members of the UN Security prospect of killing or being killed by fellow jihadists Council plus Germany) and Iran and then exam- ought to be a less-attractive proposition than de- ines the potential responses of two of the most im- fending Islam against perceived infidel aggression. portant U.S. partners in the region: Israel and Sau- However, exploiting the favorable circumstances di Arabia. The authors argue that because each created by the current divisions requires detailed partner's concerns about Iran run deeper than local knowledge and political-warfare know-how. Tehran's nuclear program, both Israel and Saudi Pursuing this unprecedented opportunity will re- Arabia are not likely to welcome a final agreement. quire the creation of a dedicated task force to act On the other hand, the authors do not anticipate as a focal point for analysis and action. that Israel and Saudi Arabia will adopt their most aggressive counters to the implementation of the PE-124-RC The Days After a Deal with Iran: Continuity and final agreement: for Israel a military strike on Ira- Change in Iranian Foreign Policy. Alireza Nader. nian nuclear infrastructure and for Saudi Arabia 2014 acquisition of its own nuclear deterrent. Further- more, the authors present a range of measures One of a series of RAND perspectives on what the United States could employ to address the Middle East and U.S. policy might look like in “the concerns of its partners and prevent destabilizing days after a deal”, this perspective examines the actions. possible effects on Iranian foreign policy stem- ming from a final nuclear agreement between Iran PE-123-RC and the United States, United Kingdom, France, Brothers Killing Brothers: The Current Infighting Russia, China, and Germany (the P5+1). More Will Test al Qaeda's Brand. Brian Michael Jen- specifically, it details President Hassan Rouhani's kins. 2014 likely hopes for a post-deal foreign policy, the do- Terrorists often resolve internal disputes the mestic constraints on his goals, and how a final old-fashioned way: They kill each other. Battles deal might affect Iran's relations with Saudi Ara- between rival rebel groups and within terrorist bia, Israel, Turkey, and, finally, the United States. organizations are not uncommon. Internal feuds have characterized terrorist movements through- PE-125-RC The Days After a Deal with Iran: U.S. Policies of out modern history, from the Russian Revolution to Hedging and Engaging. Lynn E. Davis. 2014 the Palestinian civil war. In February 2014, members of the Islamic State of Iraq and the Levant One of a series of RAND perspectives on what (ISIL) are believed to have carried out the suicide the Middle East and U.S. policy might look like in 351

“the days after a deal”, this perspective examines ations, make reasonable demands, and agree to a the choices the United States will confront in its peace agreement's terms. The international com- policies toward Iran and its regional partners in the munity's best option, then, is to promise a peace- event that a final nuclear agreement is reached be- keeping and reconstruction intervention that will tween Iran and the United States, Britain, France, start after the combatants have agreed to peace. Russia, China, and Germany (the P5+1). A framework is in place for the achievement of a nuclear PE-127-SANI agreement with Iran. Without predicting that a deal The Cost Savings Potential of Biosimilar Drugs will be signed, the potential for reaching an agree- in the United States. Andrew W. Mulcahy, Zachary ment is great enough to warrant planning for such Predmore, Soeren Mattke. 2014 an outcome. In this planning, policymakers need The U.S. Food and Drug Administration (FDA) to consider whether the current consensus that is is expected to release final regulations outlining developing (a cautious hedging/accommodating lower-cost approval pathway requirements for so- partner perspectives) risks losing the opportuni- called biosimilar drugs. The introduction of bio- ties presented by a nuclear agreement with Iran similars is expected to reduce prices, albeit to a and even Iran's willingness to proceed with its lesser degree than small-molecule generics. This implementation. Perspective combines prior research and recent data to estimate cost savings in the U.S. market. PE-126-OSD We predict that biosimilars will lead to a $44.2 bil- Getting to Negotiations in Syria: The Shadow of lion reduction in direct spending on biologic drugs the Future in the Syrian Civil War. Paul D. Miller. from 2014 to 2024, or about 4 percent of total bio- 2014 logic spending over the same period, with a range It appears that there is almost no prospect for of $13 billion to $66 billion. While our estimate a negotiated solution to the civil war in Syria in uses recent data and transparent assumptions, the near term. This is because the Syrian factions we caution that actual savings will hinge on the believe—perhaps rightly—that they have more to specifics of the final FDA regulations and on the gain by carrying on the fight than by negotiating level of competition. toward peace.At root, for combatants to choose negotiations, a key factor is their beliefs about the PE-129-RC future: Will fighting continue to be costly? Will it Alternative Futures for Syria: Regional Impli- ever yield better results? Will the other side be cations and Challenges for the United States. willing to talk? Will talks yield greater benefits than Andrew M. Liepman, Brian Nichiporuk, Jason fighting? These are estimations about future pos- Killmeyer. 2014 sibilities. Thus, the “shadow of the future” plays a The civil war in Syria poses a thorny problem significant role in bringing combatants to the ne- for U.S. policymakers. The conflict has morphed gotiating table. Because combatants are not the from a popular uprising against an autocratic re- only players that affect their fate—outsiders also gime into a multi-sided battle involving govern- influence the future—this is the area in which the ment forces, pro-government militias, Hezbollah, international community can most effectively play Iraqi Shi'ite militias, secular/moderate rebels, a role. International actors have a range of options Kurdish separatists, traditional Islamist rebels, that can decisively influence Syria's belligerents' nationalist Salafi-jihadist rebels, and the transna- expectations about the future. If the Syrian fac- tional Salafi-jihadist Islamic State of Iraq and al- tions believed that all sides will abide by an even- Sham (ISIS) movement. Most neighboring states tual peace agreement that protects their interests and several Persian Gulf states have sent arms and that an impartial third party will guarantee the and money to one or more of the factions in this peace and provide resources for reconstruction, war. Iran and Russia have consistently supported they would be much more likely to agree to negoti- the Assad regime, including providing advanced 352 weaponry, since the onset of the conflict. The out- required. come of the conflict will affect Middle East stability and regional political dynamics for years—per- PRESENTATIONS haps decades—and could exacerbate a wider Shi'a-versus-Sunni sectarian conflict in the region. PT-119 Momentum has shifted several times during the RAND Behavioral Finance Webinar: Craig Fox course of the conflict. Defections from the Syr- Presents "Metacognitive Knowledge and Financial ian army, rapidly growing rebel ranks, and the Decision Making". Craig R. Fox. 2014 regime's loss of key ground convinced many observers early on that the Assad's demise was only Craig R. Fox discusses the importance of both a matter of time. The Assad regime has exploited subjective and objective knowledge in financial rebel weaknesses and its own superior weaponry decision making. and external support to shift the momentum once PT-120-UCLA again in its favor. The lineup of antagonists is com- Women's Heart Health: Research That Matters. plex and confused. While still seeing the Assad re- Chloe E. Bird. 2014 gime as an adversary based on its patron-client relationship with Iran and its implacable hostility The care that women receive for cardiovas- toward Israel, U.S. decisionmakers are also deal- cular disease (CVD) and related outcomes lag ing with the threats caused by the dramatic recent behind those of men, despite the fact that more gains made in Iraq by ISIS and the influence it women have died from CVD each year for de- wields within the Syrian rebel movement. To ex- cades. RAND senior sociologist Chloe Bird and amine these challenges, this perspective draws cardiologists Tamara Horwich and Karol Watson on a December 2013 RAND workshop to assess explain CVD within the context of women's health, four possible future scenarios for the conflict in outlining possible solutions for improving quality Syria: prolonged conflict, regime victory, regime of care. Finally, two heart disease survivors who collapse, and negotiated settlement. The authors have become patient advocates share their per- update and reassess these scenarios based on sonal experiences. developments in Syria and Iraq through August 2014 and explore the implications that each has PT-123-USSOCOM for Syria, the region, and the United States. China: The Reluctant Partner. Andrew Scobell, William Welser IV, Thomas S. Szayna. 2014 PE-130-RC U.S. Special Operations Command (USSO- When Jihadis Come Marching Home: The Ter- COM) has developed and put forth its Global SOF rorist Threat Posed by Westerners Returning from Network vision, which calls for a distributed over- Syria and Iraq. Brian Michael Jenkins. 2014 seas posture for Special Operations Forces (SOF). Although the numbers of Westerners slipping There's a high probability that the establishment off to join the jihadist fronts in Syria and Iraq are of a U.S. Global SOF Network will reinforce Bei- murky, U.S. counterterrorism officials believe that jing's extreme insecurities about Washington's those fighters pose a clear and present danger to intentions towards China, and heighten Chinese American security. This Perspective seeks to ex- perceptions of enhanced US military encirclement amine the scope of the threat posed by Western capabilities. However, if China is invited to partner fighters who return to their homes after fighting in with U.S. SOF, this may alter Chinese thinking on Syria and Iraq; what can be done to reduce the military cooperation. While there is likely to be sig- threat, and whether military action is necessary in nificant initial reluctance in Beijing, there may be combating it, as well as whether a more ambitious considerable receptiveness to active cooperation American military intervention in Iraq and Syria is in counterterrorism and counterpiracy activities. This video podcast is based on research for US- 353

SOCOM that is not available to the general public. ers examined where SOF are engaged and present, partner capability and capacity development PT-124-TEDF in regions of interest to the United States, and Key Facts and Statistics from the RAND Military what kinds of authorities SOF need to function in Caregivers Study. Rajeev Ramchand, Terri Tan- a new security environment. Parts of this effort re- ielian, Michael P. Fisher, Christine Anne Vaughan, lied on network analysis methodology to identify Thomas E. Trail, Caroline Epley, Phoenix Voorhies, important or influential nodes and the roles they Michael Robbins, Eric Robinson, Bonnie Ghosh- play in a given network. In this video podcast, the Dastidar. 2014 importance and use of two network metrics—“in- This presentation slide deck offers key facts and degree”, and “betweenness centrality”—are ex- statistics from RAND's Military Caregivers study. plained using an example network of South Asian The results of the study are fully documented in countries. This video describes research methods Ramchand R, Tanielian T, et al., Hidden Heroes: used during a study for USSOCOM that is not America's Military Caregivers, RAND Corporation, available to the general public. 2014 (available at www.rand.org/military-caregiv ers). These charts and figures are offered in both PT-130-USSOCOM Microsoft PowerPoint and .PDF formats for ease SOF Partner Assessment: Introduction to of insertion into other presentation slide decks. Country Characteristics. Angela O'Mahony, Wil- liam Welser IV, Thomas S. Szayna. 2014 PT-125 U.S. Special Operations Command (USSO- RAND Behavioral Finance Webinar: Anya COM) has developed and put forth its Global SOF Samek Presents "The Power of Visual Tools for Network vision, which calls for a distributed over- Financial Literacy and Decision-Making". Anya seas posture for Special Operations Forces (SOF). Savikhin Samek. 2014 In order to help the United States Special Opera- This talk provides an overview of work in the tions Command identify countries to participate in area of using visual representations of data to as- the Global SOF Network, researchers needed to sist individuals with financial decisionmaking and assess countries' political attractiveness and reli- improve financial literacy. The talk includes disability as SOF partners comparatively, objectively, cussion of the methodology that used to develop and transparently. Part one of a four-part video se- and assess the value of these tools. Following the ries describes how three consistent, multidimen- overview, there is exploration of a new project on sional metrics were established to do so: foreign using visual representations of data to mitigate as- relations with the United States, state stability, and set market bubbles in the laboratory (paper written domestic political environment. Parts two, three, together with Tim Cason, Purdue), and discussion and four describe each of these metrics in detail. of different contexts to which visual analytic tools This video podcast series is based on research should be applied in practice. for USSOCOM that is not available to the general public. PT-128-USSOCOM Using Network Analysis Methods to Support PT-130/1-USSOCOM the Global SOF Network. Elizabeth Anne Bodine- SOF Partner Assessment: Measuring Foreign Baron, William Welser IV, Thomas S. Szayna. Relations. Angela O'Mahony, William Welser IV, 2014 Thomas S. Szayna. 2014 U.S. Special Operations Command (USSO- U.S. Special Operations Command (USSO- COM) has developed and put forth its Global COM) has developed and put forth its Global SOF Network vision, which calls for a distributed SOF Network vision, which calls for a distributed overseas posture for Special Operations Forces overseas posture for Special Operations Forces (SOF). In support of this effort, RAND research- (SOF). In order to help the United States Special 354

Operations Command identify countries to par- Thomas S. Szayna. 2014 ticipate in the Global SOF Network, researchers U.S. Special Operations Command (USSO- needed to assess countries' political attractive- COM) has developed and put forth its Global SOF ness and reliability as SOF partners comparative- Network vision, which calls for a distributed over- ly, objectively, and transparently. To do so, three seas posture for Special Operations Forces (SOF). consistent, multidimensional metrics were estab- In order to help the United States Special Opera- lished: foreign relations with the United States, tions Command identify countries to participate in state stability, and domestic political environment. the Global SOF Network, researchers needed to Part two of a four-part video series explains the assess countries' political attractiveness and reli- sources of measurement data for the Foreign Af- ability as SOF partners comparatively, objectively, fairs metric, describes how countries' foreign rela- and transparently. The fourth and final video in this tions with the U.S. were measured by examining series describes a method to evaluate countries' their political, military, and economic ties with the domestic political environment based on six re- U.S., and presents an example of the result. This lated but conceptually distinct measures that esti- video podcast series is based on research for US- mate countries' quality of democracy, respect for SOCOM that is not available to the general public. the rule of law, and recourse to violence to enforce governance. The data sources for each of the six PT-130/2-USSOCOM SOF Partner Assessment: Measuring State variables are described, and an example of the Stability. Angela O'Mahony, William Welser IV, combined result is presented. This video podcast Thomas S. Szayna. 2014 series is based on research for USSOCOM that is not available to the general public. U.S. Special Operations Command (USSO- COM) has developed and put forth its Global SOF PT-132-NIH/NIA Network vision, which calls for a distributed over- Cognitive Aging, Neuropathology, and Resil- seas posture for Special Operations Forces (SOF). ience. Patricia Boyle. 2014 In order to help the United States Special Opera- The RAND Summer Institute (RSI) is comprised tions Command identify countries to participate in of conferences addressing critical issues facing the Global SOF Network, researchers needed to our aging population. The primary aim of the RSI assess countries' political attractiveness and reli- is to expose scholars interested in the study of ag- ability as SOF partners comparatively, objectively, ing to a wide range of research being conducted and transparently. To do so, three consistent, mul- in fields beyond their own specialties. The video tidimensional metrics were established: foreign here is of a session from the 21st Annual RAND relations with the United States, state stability, Summer Institute, held July 7–11, 2014, in Santa and domestic political environment. Part three of Monica, California. a four-part video series examines the State Sta- bility metric in detail, and explains how a state's stability can be measured by examining its vulner- RESEARCH BRIEFS ability to domestic instability and the intensity of its inter- and intra-state conflicts. The sources of information used for the evaluation are described, RB-9696-1 and an example of the result is presented. This Addressing Coastal Vulnerabilities Through video podcast series is based on research for US- Comprehensive Planning: How RAND Supported SOCOM that is not available to the general public. the Development of Louisiana's Comprehensive Master Plan. David G. Groves, Jordan R. Fis- PT-130/3-USSOCOM chbach, Debra Knopman, Christopher Sharon, SOF Partner Assessment: Measuring State David R. Johnson, David S. Ortiz, Benjamin P. Stability. Angela O'Mahony, William Welser IV, Bryant, Matthew Hoover, Jordan Ostwald. 2014 355

The Coastal Protection and Restoration Author- RB-9755-RC ity of Louisiana used a new analytic approach, de- Autonomous Vehicle Technology: How to Best veloped in part by RAND, that incorporates results Realize Its Social Benefits. James M. Anderson, from predictive models in a decision tool to allow Nidhi Kalra, Karlyn D. Stanley, Paul Sorensen, formulation and comparison of alternatives. Constantine Samaras, Oluwatobi A. Oluwatola. 2014 RB-9727-CMHSA RAND researchers examined the technological What Has the Suicide Prevention Initiative Done advances in the field of autonomous vehicles, the So Far? Year 1 Findings. Rajeev Ramchand, Joie benefits and risks of this technology, and the po- D. Acosta, Amariah Becker, Patricia A. Ebener, tential effects of various regulations and absence Lisa H. Jaycox, Karen Chan Osilla. 2014 of same on the development of this technology. This fact sheet summarizes the first-year evaluation of California's Suicide Prevention Initiative. RB-9756-CMHSA What Has the Stigma and Discrimination Re- RB-9737-CMHSA duction Initiative Done So Far? Year 1 Findings. Suicide Rates in California: Trends and Im- Rebecca L. Collins, Jennifer L. Cerully, Eunice C. plications for Prevention and Early Intervention Wong, Shari Golan, Jennifer Yu, Gabrielle Filip- Programs. Rajeev Ramchand, Amariah Becker. Crawford. 2014 2014 This fact sheet summarizes the first-year evalu- This fact sheet summarizes the first-year evaluation of California's Stigma and Discrimination ation of California's Suicide Prevention Initiative. Reduction Initiative.

RB-9744-DOL RB-9757-CMHSA Do Workplace Wellness Programs Save Em- What Has the Student Mental Health Initiative ployers Money?. Soeren Mattke, Hangsheng Liu, Done So Far? Year 1 Findings. Bradley D. Stein, John P. Caloyeras, Christina Y. Huang, Kristin R. Michelle W. Woodbridge, Lisa Sontag-Padilla, Van Busum, Dmitry Khodyakov, Victoria Shier, El- Karen Chan Osilla, Courtney Ann Kase, Asha len Exum, Megan Broderick. 2014 Goldweber, Lisa H. Jaycox, Elizabeth J. D'Amico. Examines the return on investment (ROI) that 2014 companies realize from workplace wellness pro- This fact sheet summarizes the first-year evalu- grams, focusing on the ROI provided by disease ation of California's Student Mental Health Initia- management programs versus lifestyle manage- tive. ment programs. RB-9758-OSD RB-9753-RC The Utility of Modeling and Analysis in the Iraq Out of the Shadows: What We Know About the and Afghanistan Wars. Ben Connable, Walter L. Well-Being and Experiences of Private Contrac- Perry, Abby Doll, Natasha Lander, Dan Madden. tors Working in Conflict Environments. Molly Du- 2014 nigan, Carrie M. Farmer, Rachel M. Burns, Alison RAND examined the utility of operations analy- Hawks, Claude Messan Setodji. 2014 sis, modeling, and simulation for supporting de- Private contractors deployed in conflict zones cisionmaking in counterinsurgency and irregular experience stressors known to have negative warfare, with the focus on Operation Enduring physical and mental health implications for mili- Freedom and Operation Iraqi Freedom. tary personnel. We examine how this "shadow force" is coping with the after-effects of working in a war zone. 356

RB-9759-AF Military Caregivers: Who are They? And Who Is The Department of Defense Should Avoid a Supporting Them?. Rajeev Ramchand, Terri Tan- Joint Acquisition Approach to Sixth-Generation ielian, Michael P. Fisher, Christine Anne Vaughan, Fighter. Mark A. Lorell, Michael Kennedy, Robert Thomas E. Trail, Caroline Epley, Phoenix Voorhies, S. Leonard, Ken Munson, Shmuel Abramzon, Da- Michael Robbins, Eric Robinson, Bonnie Ghosh- vid L. An, Robert A. Guffey. 2014 Dastidar. 2014 Incorporating different service requirements Presents an overview of findings and recom- in a single joint aircraft design can lead to greater mendations from RAND's sweeping study of mili- program complexity, increased technical risk, and tary caregivers and their support environment. weight in excess of what an individual service needs, and these factors can increase program RB-9764/1-TEDF costs. Supporting Military Caregivers: Options for Congress. Rajeev Ramchand, Terri Tanielian, Mi- RB-9760-OSD chael P. Fisher, Christine Anne Vaughan, Thomas China in Africa: Implications of a Deepening E. Trail, Caroline Epley, Phoenix Voorhies, Michael Relationship. Larry Hanauer, Lyle J. Morris. 2014 Robbins, Eric Robinson, Bonnie Ghosh-Dastidar. Discusses China's engagement with African 2014 countries, including what each side wants from Presents options Congress might take to sup- these relationships, how Africans view China's in- port military caregivers based on RAND's sweep- volvement and how China has reacted to that, and ing study of this population and their support en- whether the United States and China are compet- vironment. ing in Africa. RB-9764/2-TEDF RB-9762-OSD Military Caregivers in the Workplace. Rajeev Lessons for a Negotiated Settlement in Af- Ramchand, Terri Tanielian, Michael P. Fisher, ghanistan—If History Serves as a Guide. Colin P. Christine Anne Vaughan, Thomas E. Trail, Caro- Clarke, Christopher Paul. 2014 line Epley, Phoenix Voorhies, Michael Robbins, Historical insurgencies that ended in settlement Eric Robinson, Bonnie Ghosh-Dastidar. 2014 after a stalemate have generally followed a seven- Presents findings from RAND's sweeping study step path. A “master narrative” distilled from these of military caregivers on the effect of military care- cases could help guide and assess the progress giving on employment and the workplace. toward a negotiated settlement in Afghanistan. RB-9764/3-TEDF RB-9763-BJA Supporting Military Caregivers: The Role of Correctional Education in the United States: Health Providers. Rajeev Ramchand, Terri Tan- How Effective Is It, and How Can We Move the ielian, Michael P. Fisher, Christine Anne Vaughan, Field Forward?. Lois M. Davis, Jennifer L. Steele, Thomas E. Trail, Caroline Epley, Phoenix Voorhies, Robert Bozick, Malcolm V. Williams, Susan Turner, Michael Robbins, Eric Robinson, Bonnie Ghosh- Jeremy N. V. Miles, Jessica Saunders, Paul S. Dastidar. 2014 Steinberg. 2014 Examines how health care providers can best Assesses the effectiveness of correctional edu- support military caregivers based on RAND's cation for both incarcerated adults and juveniles, sweeping study of this population and their sup- presents the results of a survey of U.S. state cor- port environment. rectional education directors, and offers recommendations for improving correctional education. RB-9764/4-TEDF

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Support Resources for Military Caregivers. Ra- ability Insurance. David I. Auerbach, Paul Heaton, jeev Ramchand, Terri Tanielian, Michael P. Fisher, Ian Brantley. 2014 Christine Anne Vaughan, Thomas E. Trail, Caro- Summarizes a report that identifies potential line Epley, Phoenix Voorhies, Michael Robbins, mechanisms through which health care reform Eric Robinson, Bonnie Ghosh-Dastidar. 2014 might affect claim costs for several major types Provides an overview of support resources for of liability coverage, especially auto insurance, military caregivers based on RAND's sweeping workers' compensation coverage, and medical study of this population and their support environ- malpractice. ment. RB-9769 Effects of Health Care Reform on Disability RB-9765-SRF Insurance Claiming. Nicole Maestas, Kathleen J. Partner Capacity in Counterinsurgency Cam- Mullen, Alexander Strand. 2014 paigns. Stephen Watts, Jason H. Campbell, Pat- rick B. Johnston, Sameer Lalwani, Sarah H. Bana. The Affordable Care Act lowered the value of dis- 2014 ability insurance over other options for health insurance, increased SSDI applications in counties “Success stories” in small-footprint U.S. inter- with high health insurance rates, and increased ventions have occurred in countries with inclusive public expenditures on health care. politics and reasonable state capacity. Unfortu- nately, most insurgencies seek to overthrow re- RB-9770-ONDCP gimes that are weak in inclusion and capacity. How Big is the U.S. Market for Illegal Drugs?. Beau Kilmer, Susan S. Everingham, Jonathan RB-9766-WFHF P. Caulkins, Gregory Midgette, Rosalie Liccardo Can New Tests Lead to Better Teaching and Pacula, Peter H. Reuter, Rachel M. Burns, Bing Deeper Learning?. Susannah Faxon-Mills, Laura Han, Russell Lundberg. 2014 S. Hamilton, Mollie Rudnick, Brian M. Stecher. 2014 Using data from 2000 to 2010, RAND researchers estimated the number of users, expenditures, Summarizes how testing of K–12 students af- and consumption for four illicit drugs: cocaine (in- fects teaching practice, and identifies character- cluding crack), heroin, marijuana, and metham- istics of assessment systems that can promote phetamine (meth). deeper-learning skills, such as critical thinking and problem-solving. RB-9771-CMHSA What Has the CalMHSA Statewide Mental RB-9767 Health Prevention and Early Intervention Imple- Healing Medical Product Innovation. Steven mentation Program Done So Far? Key Results Garber, Susan M. Gates, Emmett B. Keeler, Mary from the Baseline RAND General Population Sur- E. Vaiana, Andrew W. Mulcahy, Christopher Lau, vey. M. Audrey Burnam, Sandra H. Berry, Jennifer Arthur L. Kellermann. 2014 L. Cerully, Nicole K. Eberhart. 2014 Identifies promising policy options to spur the This fact sheet summarizes findings from a creation of new medical technologies that will re- baseline statewide survey of Californians regard- duce total U.S. health care spending or will pro- ing their knowledge, beliefs, and attitudes regard- vide health benefits that justify any increase in ing the mental health issues that are the focus of spending. the state's prevention and early intervention pro- RB-9768-ICJ gram. The Impact of the Affordable Care Act on Li- RB-9772-CMHSA 358

What Has the CalMHSA Statewide Mental Mapping Gender Gaps in Health Care. Chloe Health Prevention and Early Intervention Imple- E. Bird, Allen Fremont, Mark Hanson. 2014 mentation Program Done So Far? Summary and Mapping regional rates of cholesterol screening Commentary for Year 1 Evaluation. M. Audrey among patients with cardiovascular disease and Burnam, Sandra H. Berry, Jennifer L. Cerully, Ni- diabetes reveals significant gender gaps: Women cole K. Eberhart. 2014 are often less likely to receive screenings. This fact sheet assesses the progress that partners in California's Prevention and Early In- RB-9782 tervention (PEI) Program have made so far in de- A Health Care Puzzler. 2014 veloping capacities and reaching Californians in An American Life Panel survey finds that a accordance with the statewide strategic PEI plan. lack of knowledge about health reform and health insurance is especially acute among the poor, RB-9776 less educated, young, and females. This presents Effects of Employer Health Insurance on Dis- challenges for implementation of the Affordable ability Insurance Claiming. Matthew J. Hill, Nicole Care Act. Maestas, Kathleen J. Mullen. 2014 National health reform makes it easier for RB-9784-A disabled workers to stop working and apply for Best Practices for Assessing Locally Focused disability insurance. This study finds that some Stability Operations. Jan Osburg, Christopher disabled workers continue working to keep their Paul, Lisa Saum-Manning, Dan Madden, Leslie health insurance but disability applications do not Adrienne Payne. 2014 increase. Locally focused stability operations (LFSO) to build security, development, and governance are RB-9779-DOS difficult to assess because of the complexity of A New Approach to Security and Justice Sector operational environments. This brief outlines cre- Assistance: An Enhanced Partnership Planning ation of an assessment plan for a notional LFSO Model. Michael J. McNerney, Jennifer D. P. Mo- scenario. roney, Peter Mandaville, Terry Hagen. 2014 RAND researchers examined ways to reshape RB-9785-OSD security and justice sector assistance programs, The Conflict in Syria: Understanding and Avoid- and designed a new approach—an Enhanced ing Regional Spillover Effects. William Young, Partnership Planning Model that can be tailored David Stebbins, Bryan A. Frederick, Omar Al- to partner-nation needs and particular U.S. strate- Shahery. 2014 gic interests. Researchers examined the literature of armed RB-9780 conflict to determine the main factors that are likely What to Do About Dementia? Policy Options for to contribute to or impede the spread of violence Crucial Long-Term Care. Regina A. Shih, Thomas from civil war and insurgency, then examined how W. Concannon, Jodi L. Liu, Esther M. Friedman. they apply to Turkey, Lebanon, Iraq, and Jordan. 2014 RB-9786-NL Policy options to improve dementia long-term Principal Preparation Matters: How Leadership care include those that increase public awareness Affects Student Achievement. Susan M. Gates, and promote earlier detection, improve access to Laura S. Hamilton, Paco Martorell, Susan Bur- and quality of services, increase support to family khauser, Paul Heaton, Ashley Pierson, Matthew caregivers, and reduce the cost burden. Baird, Mirka Vuollo, Jennifer J. Li, Diana Catherine

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Lavery, Melody Harvey, Kun Gu. 2014 Liisa Ecola, Charlene Rohr, Johanna Zmud, To- Summarizing a larger report, this briefing pres- bias Kuhnimhof, Peter Phleps. 2014 ents evidence of the effect that New Leaders, a Automobility—travel in personal vehicles—var- nonprofit dedicated to preparing principals to lead ies between countries. This brief summarizes a schools to greater achievement, has on student study of the factors besides economic develop- achievement. ment that affect automobility and how automobility might evolve in developing countries. RB-9789-DHHS Improving the Physical Health of Adults with RB-9795 Serious Mental Illness. Deborah M. Scharf, Nicole Continuity of Care and the Cost of Treating K. Eberhart, John W. Schmidt, Marcela Horvitz- Chronic Disease. Peter S. Hussey, Eric C. Schnei- Lennon, Robin Beckman, Bing Han, Susan L. der, Robert S. Rudin, D. Steven Fox, Julie Lai, Lovejoy, Harold Alan Pincus, M. Audrey Burnam. Craig Evan Pollack. 2014 2014 Modest improvements in continuity of care RAND's evaluation of the Primary and Be- correlate with sizable reductions in service use, havioral Health Care Integration grants program complications, and costs for Medicare patients found that programs improved access to integrat- with congestive heart failure, chronic obstructive ed primary and behavioral health care for people pulmonary disease, and type 2 diabetes mellitus. with serious mental illness but had mixed success improving health. RB-9796-BMGF Competency-Based Education in Three Pilot RB-9791 Programs: What It Is, How It's Implemented, and Is Multisystemic Therapy (MST) Effective for How It's Working. Jennifer L. Steele, Matthew W. Hispanic Youth? An Evaluation of Outcomes for Lewis, Lucrecia Santibanez, Susannah Faxon- Juvenile Offenders in Los Angeles County. Terry Mills, Mollie Rudnick, Brian M. Stecher, Laura S. Fain, Sarah Michal Greathouse, Susan Turner, H. Hamilton. 2014 Dawn Weinberg. 2014 In 2011, the Bill & Melinda Gates Foundation ex- Multisystemic Therapy improves outcomes for tended grants to three organizations involved with Hispanic youth in the Los Angeles County juve- competency-based education approaches. RAND nile justice system. Although initial program costs examined these organizations' implementation, are high, decreased criminal justice costs over student experiences, and student outcomes. time for high-risk youth could eventually outweigh them. RB-9797-A RB-9792 Evaluating Innovative Leader Development More Americans May Be Adequately Prepared in the U.S. Army. Susan G. Straus, Michael G. for Retirement Than Previously Thought. Michael Shanley, Carra S. Sims, Bryan W. Hallmark, Anna D. Hurd, Susann Rohwedder. 2014 Rosefsky Saavedra, Stoney Trent, Sean Duggan. Because spending in retirement tends to de- 2014 cline with age, a new study finds that 72 percent This brief summarizes an assessment of an of Americans are adequately prepared for retire- Army program to enhance adaptability in leaders ment: 81 percent of married persons and 57 per- and promote innovative solutions in training for cent of single persons. Women are less prepared and conducting unified land operations. than men.

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RB-9798-DHHS taries. Premiums and Stability in the Individual Health Insurance Market: The Effects of Young Adult En- RB-9803 rollment and Subsidies. Christine Eibner, Evan Advancing Behavioral Health Measurement: Saltzman. 2014 The PROMIS® Smoking Assessment Toolkit. Maria Orlando Edelen, Joan S. Tucker, William Reduced young-adult enrollment in the individ- G. Shadel, Brian D. Stucky, Mark Hansen, Li Cai, ual health insurance market created under the Af- Jennifer L. Cerully, Megan Kuhfeld, Zhen Li. 2014 fordable Care Act would lead to modest premium increases; however, eliminating tax credits would The PROMIS Smoking Initiative developed an substantially increase premiums and reduce en- assessment toolkit that enables the measurement rollment. of current adult smokers' standing in domains of importance to smoking research, including nico- RB-9799 tine dependence and using smoking to cope with U.S. Vaccines Deemed Extremely Safe, with stress. Serious Side Effects Rare Among Children. Mar- garet A. Maglione, Lopamudra Das, Laura Raaen, RB-9804-MTF Alexandria C. Smith, Ramya Chari, Sydne New- Welcome Back Veterans: A Program Steps berry, Roberta M. Shanman, Tanja Perry, Matthew Up to the Plate to Aid Vets, Families with Mental Bidwell Goetz, Courtney A. Gidengil. 2014 Health Care—and Offers Future Playbook. Terri Tanielian, Laurie T. Martin, Caroline Epley. 2014 RAND researchers systematically reviewed scientific studies on routine vaccines recommended Describes the Welcome Back Veterans Initia- for children age 6 and younger in the United States tive, which has issued grants to academic medical and found that vaccines are very safe overall, and institutions to create and implement programs and serious side effects are extremely rare. services designed to address the mental health needs of returning veterans and their families. RB-9801 Too Much of a Good Thing? How the Economic RB-9805-RC Environment Plays a Role in the Obesity Epidemic. Closing the Strategy–Policy Gap in Counter- Roland Sturm, Ruopeng An. 2014 ing Weapons of Mass Destruction. Timothy M. Bonds, Eric V. Larson, Derek Eaton, Richard E. RAND researchers looking at the growth of Darilek. 2014 obesity rates over time found that the epidemic has been fueled by historically low food prices Two presidents have declared counterprolifera- relative to income and constant availability, which tion of weapons of mass destruction (WMD) a top have driven high consumption. national priority, but it has not been budgeted or resourced as such. This brief summarizes ground RB-9802-A force capacities and capabilities needed to elimi- Developing a U.S. Strategy for Dealing with nate WMD. China--Now and into the Future. Terrence K. Kelly, James Dobbins, David A. Shlapak, David C. Gom- RB-9806-NYSHF pert, Eric Heginbotham, Peter Chalk, Lloyd Thrall. Caring for Brain and Body: Integrating Care 2014 for Adults with Serious Mental Illness in New York State. Deborah M. Scharf, Joshua Breslau, John U.S. military strategy in Asia should include a W. Schmidt, Daniela Kusuke, B. Lynette Staple- framework that allows the United States and Chi- foote, Harold Alan Pincus. 2014 na to pursue common and individual goals, deters China's use of force to intimidate its neighbors, This report examines several New York state and postures U.S. forces to support partner mili- 361 initiatives to promote integrated health care for Raphael S. Cohen. 2014 adults with serious mental illness. This brief summarizes seven lessons from the past 13 years of war and identifies critical require- RB-9809-UNHF ments for land forces, special operations forces, Therapeutic Measures Required: To Ensure and partners to collaborate successfully. Millions of Veterans and Their Families Get High- Quality Care, Community Mental Health Providers Need More Training, Support, Resources. Terri RGS DISSERTATIONS Tanielian, Coreen Farris, Caroline Epley, Carrie M. Farmer, Eric Robinson, Charles C. Engel, Michael Robbins, Lisa H. Jaycox. 2014 RGSD-325 Three Essays on Education Policy: Empirical A new RAND study found very few community Analyses of the Challenges and Opportunities civilian providers surveyed met key thresholds for with For-Profit Colleges, Military Enlistment and military cultural competency and use of evidence- Immigration. Alessandro Malchiodi. 2014 based care, indicating few are ready overall to assist service members, veterans, and their families. This dissertation comprises three essays that empirically examine the educational outcomes of RB-9811/1-CFGNH for-profit college students, military enlistees and New Haven Promise: An Early Look at College immigrant youth. All of these are groups of “non- Preparation, Access, and Enrollment of New Hav- average” students that, in different contexts, pose en Public School Students (2010–2013). Gabriella challenges to the traditional provision of educa- C. Gonzalez, Robert Bozick, Lindsay Daugherty, tion. Therefore, their outcomes need to be studied Ethan Scherer, Reema Singh, Monica Jacobo Su- in order to assess the need and room for public arez, Sarah Ryan, Jonathan David Schweig. 2014 policy measures to intervene.

This brief highlights findings of a study of early RGSD-326 progress of New Haven Promise, a place-based Topics in Migration Research. Sarah Kups. scholarship program focusing on college prepara- 2014 tion, access, and enrollment. With respective emigrant and immigrant stocks RB-9811/2-CFGNH that are among the largest in the world, Mexico Transforming an Urban Public School District: and Germany are affected by migration like few Tracking the Progress of the New Haven Public other countries are. They also exemplify that mi- Schools' Educational Reforms and the New Haven gratory movements need not be permanent, but Promise Scholarship Program. Gabriella C. Gon- are also often less temporary than initially as- zalez, Robert Bozick, Lindsay Daugherty, Ethan sumed. This dissertation explores topics related to Scherer, Reema Singh, Monica Jacobo Suarez, the determinants and consequences of migration Sarah Ryan, Jonathan David Schweig. 2014 in these two countries.

This brief summarizes a study of baseline con- RGSD-327 ditions and early progress of two educational ef- It Takes a Village: Network Effects on Rural forts in Connecticut: New Haven School Change, Education in Afghanistan. Matthew Hoover. 2014 a sweeping K–12 educational reform, and New Haven Promise, a scholarship program. Often, development organizations confront a tradeoff between program priorities and opera- RB-9814-A tional constraints. These constraints may be fi- Lessons from 13 Years of War Point to a Bet- nancial, capacity, or logistical; regardless, the ter U.S. Strategy. Linda Robinson, Paul D. Miller, tradeoff often requires sacrificing portions of a John Gordon IV, Jeffrey Decker, Michael Schwille, program. This work is concerned with figuring out 362 how, when constrained, an organization or pro- cal technology development has created a large gram manager can utilize social networks to take array of drugs, medical devices and healthcare advantage of inherent tendencies that will allow a services, many of which have greatly expanded program to thrive. Specifically, this study looked the scope of treatable diseases. The diffusion of at the playmate networks of children in 31 rural these technologies in the U.S. has helped count- villages of central Afghanistan and how that re- less individuals realize substantial improvements lational information could improve programming in life expectancy and overall quality of life. How- of a rural schooling program.To accomplish this, ever, the development and diffusion of new medi- a two-stage approach was used, where network cal technology have also presented several chal- structure and composition was estimated using lenges for U.S. policy makers. The three papers exponential random graph models (ERGMs) and that comprise this dissertation examine three then related to individual child outcomes in math policy issues that center on some of these chal- and language performance using multi-level mod- lenges. The first paper examines how markets can els (MLMs). Unique in this work was translating fail to incentivize the development of new medi- ERGM parameters to MLM covariates by using cal technology that address a public need and the t-statistics from network estimations. Results explore the lessons learned from the implementa- of the MLMs indicated that individual ability drove tion of four different policy solutions. The second most of a child's achievement, however, both net- paper examines the role of the National Institutes work structure and composition were important in of Health in new medical technology development explaining children's academic achievement. Spe- and the extent to which its research grant program cifically, children maintained many reciprocated has encouraged the formation of biopharmaceuti- ties with other children, though more advanced cal commercial alliances. The last paper examines network structures - such as triadic closure - were the Centers for Medicare and Medicaid Service's not fully developed in the networks. Composition- Accountable Care Organization program and ally, children tended to befriend others of the same whether its participants are changing the way that gender and similar academic performance (ho- new medical technologies are used and adopted. mophily measures). This translated into MLM results of children doing better academically if they RGSD-329 were friends with other children of a similar ability. Changing Constituencies and Rising Polariza- Ultimately, the primary concern was how network tion in the Congress: Three Essays. Jesse Sus- information could improve programmanagement, sell. 2014 performance, and ultimately, impact. Key recom- Three essays on changing constituencies and mendations for utilizingnetworks included build- rising polarization in the Congress. The first em- ing in playtime during the school day to facilitate pirically examines the so-called “Big Sort hypoth- tie formation,identifying isolates and working to esis”– the notion that in recent years, liberal and integrate them into the existing network, creat- conservative Americans have become increasing- inga “buddy" system for learning within schools ly spatially isolated from one another. The second that could provide the catalyst for more complex addresses two questions: First, whether over the network structure, like triadic closure, and using last 40 years the spatial distribution of the Ameri- visual depictions of networks to identify targeting can electorate has become more geographically opportunities for communication within networks. clustered with respect to party voting and socioeconomic attributes, and second whether this RGSD-328 sorting process has contributed to rising polar- New Medical Technology Development and ization in the US House of Representatives. The Diffusion: Policy Challenges and Considerations. third considers gridlock itself as a problem to be Christopher Lau. 2014 solved and addresses the question of how it might Over the past decade, the rapid pace of medi- be lessened. 363

nine of the top twelve contributing firms based on RGSD-330 PAC contributions. Reducing the Economic Burden of Work- Related Injuries. Christopher F. McLaren. 2014 RGSD-332 Three Essays on Subjective Well-Being. Caro- This dissertation consists of three distinct pa- line Tassot. 2014 pers focusing on understanding and reducing the economic burden of work-related injuries and ill- This dissertation comprises three essays that nesses. The first paper evaluates the effectiveness empirically study different aspects of subjective of employer based return to work programs using well-being (SWB) indictors. The first approach a unique dataset that combines information from takes a methodological angle to assess the reli- an employer-level survey about disability manage- ability and validity of SWB indicators. The second ment and return to work practices with worker's and third essays study the determinants of SWB compensation claims and five years of post-injury at the individual level and macroeconomic level, employment outcomes. The second paper analyz- respectively. In particular, the second essay esti- es the Medical Expenditure Panel Survey (MEPS) mates the effect of work transitions on SWB, while and systematically reviews the literature to ad- the third examines the relationship between in- dresses the impact of California workers' compen- come inequality and SWB. sation reforms that limit two controversial medical treatments: chiropractic care and physical therapy. RGSD-333 The third paper uses the Health and Retirement The Impact of Tort Reform, Medicare Plan Study (HRS) to estimate the impact of exposure to Choice, and Geography on Health Care Pro- occupational hazards on disease rates and costs cesses, Outcomes, and Expenditures. Daniel among the elderly. Waxman. 2014 This dissertation, in a three paper format, ex- RGSD-331 plores structural determinants of health care pro- The Political Sustainability of Carbon Control cesses, outcomes, and expenditures. The first Policies in an Evolutionary Economics Setting. paper examines the influence of the legal envi- Steven C. Isley. 2014 ronment on emergency medical care. The second This work represents a first attempt at ana- and third papers examine variation in home health lyzing the long term coevolution of market struc- care outcomes and utilization according to type tures, technological change and government of Medicare coverage and across geographic re- institutions. An empirical analysis of the U.S. elec- gions. tric power sector was conducted to validate the Grossman and Helpman (1994) “Protection for RGSD-334 Sale” framework for use in modeling the interac- Designing Efficient Systematic Reviews Using tion between the government and market actors. Economical Allocation, Creation and Synthesis of An agent based model with endogenous techno- Medical Evidence. Mike Scarpati. 2014 logical change was then used to explore how lob- Medical literature and the actions of policymak- bying affects different carbon control policies as ers have emphasized the importance of evidence- they evolve over time. In the empirical analysis, based medicine in recent years, but basing clini- many electric power companies were found to cal practice on an exploding base of evidence is benefit greatly from high carbon prices and can challenging. Systematic reviews, which are very be expected to lobbying for such policies. In fact, resource-intensive, are a crucial channel in the in many situations the total near-term profit of the pathway from medical literature to clinical prac- electric power industry increases with a price on tice. This thesis begins by estimating the value carbon. The model was able to correctly identify of one systematic review, finding that synthe- 364 sized evidence regarding treatments to prevent provement efforts. The paper concentrates on a osteoporotic fractures generated a net benefit previously unstudied potential consequence of of approximately $450M. Next, the time taken to the reform: Whether the information on school ac- screen articles in systematic reviews is analyzed, ademic performance, which had been previously showing that user interface changes can result in unavailable, enabled voters to hold local lead- significant reductions in resource requirements. ership accountable. The second and third pa- Presenting multiple articles on one screen while pers assess a comprehensive reform to improve reviewing titles leads to a seven-fold reduction teacher and principal talent in high-poverty, low- in time taken per article. Experience and mental performing schools. While the reform has various state are also related to screening times, with ab- components, its main features are recruitment, stracts reviewed at ideal session lengths requiring retention, and performance bonuses for teachers 33% less time than those at the beginning of a and principals in schools with a greater concen- session. To further increase the speed at which tration of high-poverty students. articles can be screened and decrease the cost of preparing systematic reviews, machine learning RGSD-336 techniques allow avoidance of up to 80% of ar- What Makes a Successful Principal? Incorpo- ticles. When updating an existing review, savings rating School Principal Background in State and are increased by utilizing the information present District Policy. Ashley Pierson. 2014 in original screening decisions to train the ma- School principals' education and professional chine learning model. Finally, implementation is- experience shape their approach to school lead- sues are addressed, paying attention to technical, ership and how successful their students will be. organizational, and institutional challenges and However, it is not clear from existing research opportunities. which aspects of principal education and professional experience are related to student outcomes RGSD-335 and principal retention. This dissertation explores Three Essays on Education Reform in the aspects of a potential principal's education and United States. Ethan Scherer. 2014 professional experience that states and school It has long been thought that the United States districts should look for and cultivate in candi- education system is the great equalizer, lifting less dates for the position of school principal. The work advantaged children out of poverty and improv- was guided by two research questions: 1) how are ing their chances for success in adulthood. The principals' education and professional experience opportunity for economic and social mobility de- related to student outcomes and principal reten- pends heavily, however, on access to high quality tion? and 2) how can state certification and dis- education. Recent research has raised concerns trict hiring policies better incorporate information about degradation in the quality of schools serv- about a principal's education and professional ex- ing higher-poverty neighborhoods: The achieve- perience to improve principal effectiveness? Us- ment gap between low- and high-poverty students ing information on principals trained by the New appears to have widened over the last quarter Leaders program and school-level data from four century (Reardon, 2011). In response to these large urban districts, I analyzed the relationships concerns, federal, state, and local officials have between principal education and professional ex- enacted countless education reforms to improve perience and student outcomes and principal re- the outcomes of low-income students. This dis- tention. I examined state certification and district sertation examines two of those reforms to bet- hiring policies for the four urban districts used in ter understand how and if they are working. The the analysis and conducted a survey of 33 dis- first paper focuses on California's state education tricts regarding their hiring policies and practices. accountability reform, which allowed the state to From this research, I provide recommendations identify low-performing schools and target im- designed to inform state certification policy, dis- 365 trict hiring policy, and training program curricula. of increasing the percentage of militant infiltration attempts interdicted and decreasing soldier casu- RGSD-340 alties in outposts. Strategies for Managing Sovereign Debt: A Robust Decision Making Approach. Shmuel RGSD-342 Abramzon. 2014 Essays on Family Welfare and Indian Develop- ment Policy. Sinduja V. Srinivasan. 2014 Sovereign debt portfolios are affected by financial and economic factors that are themselves deeply My dissertation is concerned with family welfare uncertain. Building on methodological develop- and economic development in India. In my first two ments for policy making under deep uncertainty, papers, I consider the potential for India's public this dissertation examines and demonstrates how works program to contribute to long-term growth the Robust Decision Making (RDM) methodology and poverty reduction by examining the impact on could be applied to the problem of selecting the household entrepreneurship and investments in government's debt portfolio. Using a large set of child health. The third paper analyzes the impact non-probabilistic simulations coupled with data of increasing male earnings inequality on female mining tools, the analysis identifies and character- marital and education outcomes. izes bond issuance strategies that appear to perform well across a large set of possible assump- RGSD-344 tions and scenarios. This approach introduces a Competition and Collaboration: A Comparison new framework for assessing funding strategies of U.S. and Chinese Energy Outward Direct In- based on varying assumptions regarding the gov- vestment. Chaoling Feng. 2014 ernment's liquidity buffer. This proof-of-principle The U.S. and China are the world's largest en- analysis illustrates possible improvements to debt ergy importing countries. In 2011, both countries management practices, both in government and imported approximately half of their total oil sup- in the private sector. plies from overseas. Due to this great reliance on foreign energy supplies, energy companies from RGSD-341 both countries continue to pursue energy outward Improving Turkish-Iraqi Border Security: An direct investments (EODIs) as an approach to in- Agent-Based Modeling and Simulation Approach. crease their access to global energy reserves. In Mustafa Oguz. 2014 this context, my study will compare and contrast This dissertation analyzes several policy op- the characteristics, current positions, and future tions that could help increase border security trends of both the U.S. and Chinese EODIs--spe- by reducing militant actions from safe havens in cifically their exploration and development invest- foreign territory. In particular, this dissertation fo- ments. Based on the analysis of current U.S. and cuses on a section of the Turkish-Iraqi border that Chinese EODI positions, the study goes further is particularly difficult to protect. The main threat to analyze their objectives and determinants, ex- along the border is militant infiltrations and mili- plaining both the similar and different aspects tant attacks on border security outposts. Policy of EODI characteristics, positions and historical options considered are relocating outposts, ad- trends. By integrating the positions, objectives, ditional soldiers, unattended ground sensors and and determinants of U.S. and Chinese EODIs foreign border guards that provide early warning into an interactive and dynamic mechanism, the of militant movements. A simulation model is de- study designs a partial equilibrium model system, veloped to evaluate the effects of these options. in order to predict the future operational outcomes Infiltrators and border guards are assigned simple (production, sales, exploration, and profitability) behavior rules. Outcomes are collected from their and the competitive positions of U.S. and Chinese interaction on a virtual segment of the border. The EODIs. However, the study's conclusions should results are analyzed to find the least costly way be interpreted with caution, since the analysis is based on data and trends up to 2011, and in some 366 cases up to 2008, 2009, and 2011. The major tech- cilitate resilience and can protect Airmen, civilian nological breakthroughs in the field, especially in employees, and Air Force families from the nega- hydraulic fracturing and horizontal drilling technol- tive effects of conduct, routines, and habits that ogies, may affect future demand, lifting costs, and are detrimental to fitness. The report also reviews geographic locations of energy reserves, and thus behavioral fitness construct measures and resil- may affect the prospects of EODIs in significant ience outcomes as well as interventions designed ways. to promote behavioral fitness.

RR-105-AF RESEARCH REPORTS Nutritional Fitness and Resilience: A Review of Relevant Constructs, Measures, and Links to RR-102-AF Well-Being. Karen R. Florez, Regina A. Shih, Mar- Psychological Fitness and Resilience: A Review gret T. Martin. 2014 of Relevant Constructs, Measures, and Links to This report is one of a series designed to sup- Well-Being. Sean Robson. 2014 port Air Force leaders in promoting resilience This report is one of a series designed to sup- among its Airmen, civilian employees, and Air port Air Force leaders in promoting resilience Force family members. It examines the relation- among its Airmen, civilian employees, and Air ship between nutritional fitness and resilience, Force family members. It examines the relation- using key constructs found in the scientific litera- ship between psychological fitness and resilience, ture that address self-regulation, positive affect, using key constructs found in the scientific litera- perceived control, self-efficacy, self-esteem, and ture that address self-regulation, positive affect, optimism. Supporting or increasing the levels of perceived control, self-efficacy, self-esteem, and the key measures of nutritional fitness identified in optimism. Supporting or increasing the levels of this report may facilitate resilience and can protect the key measures of psychological fitness identi- Airmen, civilian employees, and Air Force families fied in this report may facilitate resilience and can from the negative effects of stress. The report also protect Airmen, civilian employees, and Air Force reviews construct measures, well-being, and resil- families from the negative effects of stress. The re- ience outcomes as well as interventions designed port also reviews construct measures, well-being, to promote the nutritional fitness constructs. and resilience outcomes as well as interventions RR-125-A designed to promote the psychological fitness Sourcing and Global Distribution of Medical constructs. Supplies. Adam C. Resnick, William Welser IV, RR-103-AF Keenan D. Yoho. 2014 Behavioral Fitness and Resilience: A Review The Department of Defense (DoD) provides of Relevant Constructs, Measures, and Links to medical care to service members all over the Well-Being. Sean Robson, Nicholas Salcedo. world and must ensure that health care providers 2014 have the proper quantity and quality of medical This report is one of a series designed to support materiel. RAND investigated opportunities to gain Air Force leaders in promoting resilience among efficiencies in the global military medical logistics its Airmen, civilian employees, and Air Force fam- enterprise without sacrificing capability, notably ily members. It examines the relationship between through minimizing intermediate materiel han- behavioral fitness and resilience, using key con- dling, seeking the greatest value from commercial structs found in the scientific literature that relate freight, and streamlining warehouse operations. to sleep, alcohol use, and tobacco use. Support- RAND suggests DoD take steps to optimize its ing or increasing the levels of the key measures of global medical logistic enterprise by maximiz- behavioral fitness identified in this report may fa- ing direct delivery to end users, exercising con- 367 trol over the materiel catalog, managing inventory a set of area profiles that make up the RAND held overseas to support surges and bridge sup- Base Area Social and Economic Index, or RAND ply chain interruptions, and managing inventory BASE-I, measuring aspects of household compo- and contracts to maximize supplier responsive- sition, employment, income and poverty, housing, ness.To minimize intermediate materiel handling, social, and transportation of area residents (both the study recommended closing the U.S. Army military and civilian). These factors are outside of Medical Materiel Center in Southwest Asia as a Air Force control; however, Air Force Services may Central Command distribution point because its be able to help offset potential negative impacts efforts are duplicative of those in Europe. Com- of community characteristics on Airmen and their bined with renegotiating European shipping con- families. Using existing Air Force survey data, the tracts, closing this distribution point could save authors then assessed whether these base-area $10-$20 million annually.The study recommends characteristics were associated with Airmen's out- against consolidating distribution of medical items comes related to health and well-being, military with other items handled by the Defense Logis- and neighborhood cohesion, ratings of neighbor- tics Agency (DLA). The greatest barrier to con- hood resources, use of on-base resources, satis- solidation is the inability of the DLA warehouse faction, and career intentions. The analysis also management information technology system to tested whether Airmen who live off base and com- download item information using the commercial mute to work may be more exposed to social and stock numbers, which identify the bulk of military economic conditions in the larger base area than medical items. Thousands of new medical items Airmen who primarily live and work on base. The enter military use each year, and it is infeasible for report includes recommendations for future use of the organizations tasked with assigning military- these and similar data by decisionmakers and re- specific stock numbers to do so for these items. searchers.

RR-132-AF RR-174-OSD The Association Between Base-Area Social Wireless Emergency Alerts: Mobile Penetration and Economic Characteristics and Airmen's Strategy. Daniel Gonzales, Edward Balkovich, Outcomes. Sarah O. Meadows, Laura L. Miller, Brian A. Jackson, Jan Osburg, Andrew M. Parker, Jeremy N. V. Miles. 2014 Evan Saltzman, Ricardo Sanchez, Shoshana R. To help Air Force Services tailor support for Air- Shelton, Chuck Stelzner, Dulani Woods. 2014 men and their families through analyses of the rel- This report characterizes the factors that affect evance of neighborhood, or area, characteristics wireless emergency alert (WEA) coverage, identi- of major Air Force installations located within the fies barriers to public access to WEA alerts, and United States, researchers applied established suggests options for increasing mobile penetra- social indicators and neighborhood methodology tion (adoption) of WEA nationwide. to identify which areas may have greater need for Air Force resources. This document reports the RR-176-OSD results of that analysis. It examines whether and Venture Capital and Strategic Investment for how base-area characteristics are associated with Developing Government Mission Capabilities. individual-level Airman outcomes across several Tim Webb, Christopher Guo, Jennifer Lamping different domains. The objective is to help the Air Lewis, Daniel Egel. 2014 Force identify communities where Airmen and A wide range of military capability improvement their families may have greater levels of need so that it can adapt programs or resources to counteract stressors related to the base areas and the lack of nonmilitary resources in the area. Using census and personnel data, the authors created 368 efforts have benefited from development and RR-186-MM procurement methods that accommodate urgent PRISM 2011 Base: Mode-Destination Model operational needs. Changes in the threat environ- Estimation. James Fox, Bhanu Patruni, Andrew ment suggest a need for a fresh examination of Daly, Sunil Patil. 2014 the adequacy and suitability of acquisition methods for the coming decade. This report examines PRISM West Midlands is a travel demand mod- one class of acquisition method, known as gov- el forecasting system which was developed by ernment venture capital (GVC), or government RAND Europe and Mott MacDonald on behalf of strategic investment (GSI). The research extracts the seven metropolitan districts in the West Mid- general observations from previous cases and lands Metropolitan Area, the Highways Agency from a partial economic model of the GSI type and Centro. The model system is required to be of initiative. Taken together, these analyses will responsive to a wide range of policy levers, and to help government acquisition managers to judge assess the impact of different policies on specific more thoroughly the suitability of strategic invest- segments of the population. The original model ment methods for motivating future government development was undertaken between 2002 and mission–oriented innovation by private firms.The 2004, with a base year of 2001, and a number of report does not explicitly compare GSIs and al- enhancements have been made to the model sys- ternatives for their efficacy in advancing govern- tem since 2004, including adding incomes to the ment mission objectives. If it had, it is likely that model, and an improved treatment of cost sensi- the main advantage of GSI would be improved activity and updating the base year to 2006. In the cess to information about alternative approaches PRISM Refresh project, the demand and network available in the commercial market, resulting from models in PRISM have been more fundamentally the close relationships the GSI structure engen- updated to reflect a 2011 base year. RAND Eu- ders between government and business. rope's role was to re-estimate the demand models using household interview data collected between RR-185-EC 2009 and 2012, and deliver to Mott MacDonald an Use of childcare in the EU Member States and operational demand model implementation that progress towards the Barcelona targets: Short Sta- can run together with the network models in the tistical Report No. 1. Melinda Mills, Patrick Präg, overall PRISM model system. The work was again Flavia Tsang, Katia Begall, James Derbyshire, undertaken on behalf of the seven metropolitan Laura Kohle, Celine Miani, Stijn Hoorens. 2014 districts in the West Midlands Metropolitan Area, This report provides a current analysis of Member the Highways Agency and Centro.This report doc- States' progress towards meeting the Barcelona uments the development of the updated mode- targets'. It initially examines the progress towards destination models. Models have been developed reaching the Barcelona targets by comparing and for 14 travel purposes, all of which represent trav- then extending the results presented in 2008. How- ellers' choices of travel mode and destination. The ever, it also extends the previous 2008 analysis in models for some travel purposes also include the a number of ways, namely it examines: the impact choice of access mode and station for train and of parenthood on employment, public spending on metro travel, allowing park-and-ride travel to be childcare and the cost, affordability and quality of explicitly represented. However, bus park-and-ride childcare. The report also summarises the extent travel is not modelled. Choice of time of day of to which the Barcelona targets have been met by travel for car drivers is also incorporated to allow Member States by the agreed deadline of 2010. representation of peak pricing policies and the im- Where possible, data were examined for 27 EU pact of increased congestion in the peak periods. Member States and where available, EFTA coun- For other models of travel, all-day demand is al- tries Norway and Iceland, the cost, affordability located to the model time periods using fixed fac- and quality of childcare. tors. 369

improve the early recognition and intervention of RR-209-A/OSD marines exhibiting signs of stress. The Defense The Deployment Life Study: Methodological Centers of Excellence for Psychological Health Overview and Baseline Sample Description. Terri and Traumatic Brain Injury have asked RAND Tanielian, Benjamin R. Karney, Anita Chandra, to evaluate the OSCAR program. As part of this Sarah O. Meadows. 2014 evaluation, RAND conducted a large survey of In the past decade, U.S. military families have marines who were preparing for a deployment to experienced extreme stress, as U.S. soldiers, sail- Iraq or Afghanistan in 2010 or 2011. This report de- ors, airmen, and marines have experienced ex- scribes the methods and findings from this survey. tended and repeated deployments. As a result, The results are among the first to shed light on the U.S. policymakers and Department of Defense pre-deployment mental health status of marines, leadership have placed an emphasis on family as well as the social resources they draw on when readiness for deployment and other military-relat- coping with stress and their attitudes about seek- ed stressors. However, family readiness is not a ing help for stress-related problems. The 2,620 well-understood construct. The Deployment Life marines in the survey sample had high rates of Study was designed to provide a deeper under- positive screens for current major depressive dis- standing of family readiness and to address the order (12.5 percent) and high-risk drinking (25.7 sources of readiness among military families. percent) and reported having experienced more It is a longitudinal study of military families over potentially traumatic events over their lifetime than the course of a full deployment cycle—predeploy- adult males in the general population. Marines in ment, during deployment, and postdeployment. the sample also reported relying on peers for sup- Over the course of three years, the study will follow port with stress and perceiving moderate levels 2,724 families from each service and component, of support from the Marine Corps for addressing interviewing service members, their spouses, and stress problems. one child between the ages of 11 and 17 in each family (if applicable) every four months. Baseline RR-245 data are weighted to be representative of mar- The Effectiveness of China's Industrial Poli- ried service members who were eligible to deploy cies in Commercial Aviation Manufacturing. Keith sometime between June 1, 2012, and December Crane, Jill E. Luoto, Scott Warren Harold, David 31, 2012. This report describes the Deployment Yang, Samuel K. Berkowitz, Xiao Wang. 2014 Life Study theoretical model; the content of the Since economic reforms began in 1978, China baseline assessment; the design and procedures has enjoyed rapid growth in exports, which have associated with data collection, sampling and re- contributed to the country's impressive economic cruiting procedures; and the baseline sample of growth. Improvements in the quality of China's military families. workforce, manufacturing technologies, and materials have enabled the country to enter new, more RR-218-OSD technologically sophisticated industries. In several Pre-Deployment Stress, Mental Health, and such industries, which the Chinese government Help-Seeking Behaviors Among Marines. Carrie has frequently denoted as strategic, the Chinese M. Farmer, Christine Anne Vaughan, Jeffrey Gar- government has employed industrial policies, for- nett, Robin M. Weinick. 2014 mal and informal, to foster the development of The Marine Corps Operational Stress Control national champions. As part of this strategy, the and Readiness (OSCAR) program is designed Chinese government has attempted to induce the to provide mental health support to marines by transfer of technologies from foreign manufactur- embedding mental health personnel within Ma- ers to Chinese companies. To the extent that these rine Corps units and increasing the capability of policies have been successful, they have acceler- officers and senior noncommissioned officers to ated shifts in production and employment from in- 370 dustries located in other countries to China. This sionmaking. Anais Reding, Anke Van Gorp, Kate report explores the emerging commercial aviation Robertson, Agnieszka Walczak, Chris Giacoman- manufacturing industry in China to examine the tonio, Stijn Hoorens. 2014 effectiveness of the policies and mechanisms the This document presents the findings of a study Chinese government has used to create “nation- into methods that may help counterterrorism pro- al champions;” evaluate the effectiveness of the fessionals make decisions about ethical problems. steps taken by foreign manufacturers to prevent The study was commissioned by the Research transfers of key technologies to potential future and Documentation Centre (Wetenschappelijk Chinese competitors when setting up manufactur- Onderzoek- en Documentatiecentrum, WODC) of ing facilities in China; provide policy options that the Dutch Ministry of Security and Justice (Minis- allow foreign governments to effectively respond terie van Veiligheid en Justitie), on behalf of the to Chinese industrial policies; and alert Chinese National Coordinator for Counterterrorism and policymakers to the downsides of China's current Security (Nationaal Coördinator Terrorismebe- industrial policies. strijding en Veiligheid, NCTV). The study provides an inventory of methods to support ethical RR-247-OSD Recruiting Older Youths: Insights from a New decision-making in counterterrorism, drawing on Survey of Army Recruits. Bernard D. Rostker, Ja- the experience of other public sectors – health- cob Alex Klerman, Megan Zander-Cotugno. 2014 care, social work, policing and intelligence – and multiple countries, primarily the Netherlands and Since the advent of the all-volunteer force, little United Kingdom. The report introduces the field attention has been paid to high school graduates of applied ethics; identifies key characteristics of who do not enlist immediately after graduation, pri- ethical decision-making in counterterrorism; and marily those who seek employment in the private describes methods that may help counterterror- sector of the economy. However, over time, this ism professionals make decisions in these situ- group has made up a significant and increasing ations. Finally, it explores how methods used in portion of total enlistments. However, since 2005, other sectors may be applied to ethical decision- the majority of the Army's recruits has not joined making in counterterrorism. It also describes the directly out of high school but has instead made level of effectiveness that can be expected from the decision to join at a later time. Why these re- the various methods. The report is based on a cruits initially chose not to join when they had the structured literature search and interviews with opportunity after graduating from high school and professionals and academics with expertise in ap- why they changed their minds several years later plied ethics. This report will be of interest to coun- and enlisted are the subjects of this report. Given terterrorism professionals who are responsible for the importance of older recruits to the Army, the strengthening ethical decision-making in their or- authors examine what is known about these re- ganisation. It may also provide insights for coun- cruits, their performance during military service, terterrorism professionals who seek new methods and why they came to join the Army after first to help them make ethical decisions. The findings choosing another postsecondary path. The re- may additionally be relevant for professionals in sults of a survey of 5,000 Army recruits designed other sectors, if complemented with a review of to answer this question are presented. Finally, the decision-making characteristics in their sector of implications of the survey results are discussed, specialism. along with suggestions of ways to gain additional insights by tracking this survey cohort through RR-257-A their Army careers. How Deployments Affect the Capacity and RR-251-WODC Utilization of Army Treatment Facilities. Adam C. Handling ethical problems in counterterrorism: Resnick, Mireille Jacobson, Srikanth Kadiyala, An inventory of methods to support ethical deci- Nicole K. Eberhart, Susan D. Hosek. 2014 371

The Army was concerned about how the Army ation requirements. Using the vision for enhanced Force Generation (ARFORGEN) cycle, estab- command and control (C2) presented in the ar- lished to provide a predictable process by which chitecture developed as a companion piece to Army units deploy, reset, and train to become this analysis, this report identifies and describes ready and available to deploy again, affected the where shortfalls or major gaps exist between cur- lives of Army soldiers and their families. In par- rent ACS processes and the vision for integrating ticular, the Vice Chief of Staff of the Army asked enhanced ACS processes into Air Force C2. It RAND Arroyo Center to determine whether AR- evaluates C2 nodes from the level of the Presi- FORGEN resulted in ebbs and flows in the abil- dent and Secretary of Defense to the units and ity of Army military treatment facilities (MTFs) to sources of supply. It also evaluates these nodes provide medical care and respond to changes in across operational phases and suggests mitiga- family needs as soldiers and care providers de- tion strategies needed to facilitate an efficient and ploy and return home. This concern is especially effective global C2 network. well-founded because military health research has shown that family members of service mem- RR-261-AF bers utilize health care differently during deploy- An Operational Architecture for Improving Air ment than when the soldier is at home. This study Force Command and Control Through Enhanced found that MTF capacity is not greatly affected Agile Combat Support Planning, Execution, Moni- when soldiers and care providers deploy, and toring, and Control Processes. Kristin F. Lynch, that MTFs may be slightly less busy than when John G. Drew, Robert S. Tripp, Daniel M. Romano, soldiers and care providers are both at home. In Jin Woo Yi, Amy L. Maletic. 2014 aggregate, family member access to health care Currently, agile combat support (ACS) plan- does not appear to be impinged when soldiers ning, execution, monitoring, and control process- deploy, and soldiers who did not deploy with their es are poorly integrated with operational planning unit slightly increase their utilization of health care processes and have little ability to show how re- during those times. source allocation decisions would impact planned and potential operations. This report presents an RR-259-AF architecture that depicts how enhanced ACS pro- Implementation Actions for Improving Air Force cesses could be integrated into Air Force com- Command and Control Through Enhanced Agile mand and control (C2) as it is defined in Joint Combat Support Planning, Execution, Monitoring, Publications. This architecture, which focuses on and Control Processes. Kristin F. Lynch, John G. the near term (the next 4–5 years) using current Drew, Robert S. Tripp, Daniel M. Romano, Jin Woo Air Force assets, was created by (1) evaluating Yi, Amy L. Maletic. 2014 previous RAND-developed operational architec- There has always been disparity between the tures from 2002 and 2006 and (2) refining those availability of combat support resources and pro- architectures in light of the current operational and cess performance and the capabilities needed to fiscal environments. It first identifies C2 processes support military operations, and the current de- and the echelons of command responsible for ex- fense environment will likely exacerbate this im- ecuting those processes and then describes how balance. Therefore, operational commanders, au- enhanced ACS planning, execution, monitoring, thorities who prioritize and allocate resources, and and control processes could be integrated with resource providers all need to know how combat operational-level and strategic-level C2 processes support enterprise constraints and alternative re- to provide senior leaders with enterprise ACS ca- source allocation decisions would impact planned pability and constraint information. and potential operations and when agile combat support (ACS) process performance breaches the RR-267-OSD control parameters set to meet contingency oper- Identifying and Eliminating Barriers Faced by Nontraditional Department of Defense Suppliers. Amy G. Cox, Nancy Y. Moore, Clifford A. Gram- 372 mich. 2014 overall PRISM model system. The work was again The report seeks to identify barriers that compa- undertaken on behalf of the seven metropolitan nies face when attempting to enter into contracts districts in the West Midlands Metropolitan Area, with the Department of Defense (DoD), especially the Highways Agency and Centro.This report when they are not traditional DoD suppliers. To documents the development of the updated travel learn more about barriers, the authors interviewed frequency and car ownership models. Frequency personnel in companies that are in industries of models have been developed for 14 travel purpos- likely interest to DoD and interviewed DoD per- es. Travel frequency is predicted by applying two sonnel who work with suppliers. The interviews re- linked sub-models to predict the total amount of vealed some shared experiences that reportedly travel an individual makes on an average week- made some suppliers less willing to bid on DoD day in school term time. The first sub-model pre- contracts: lack of access to and communication dicts whether an individual makes any travel, the from DoD; DoD's complex and inefficient bid and second sub-model predicts how much travel will selection process; the extra work and delays en- be made given that an individual makes at least tailed in DoD's administration and management of some travel. contracts; and the lengthy funding time line and RR-274-A delays in final payments. DoD personnel inter- Rapid Acquisition of Army Command and Con- viewed had different perceptions, although they trol Systems. Shara Williams, Jeffrey A. Drezner, did confirm the existence of some barriers. Megan McKernan, Douglas Shontz, Jerry M. Sollinger. 2014 RR-273-MM PRISM 2011 Base: Frequency and Car Own- The Global War on Terrorism (subsequently ership Models. James Fox, Sunil Patil, Bhanu Overseas Contingency Operation), Operation En- Patruni, Andrew Daly. 2014 during Freedom, and Operation Iraqi Freedom all PRISM West Midlands is a travel demand mod- presented urgent technological challenges for the el forecasting system which was developed by U.S. military. These challenges, particularly coun- RAND Europe and Mott MacDonald on behalf of tering the use of improvised explosive devices, the seven metropolitan districts in the West Mid- forced the Department of Defense (DoD) to ac- lands Metropolitan Area, the Highways Agency quire materiel solutions at unprecedented speeds. and Centro. The model system is required to be With a particular focus on command and control responsive to a wide range of policy levers, and to (C2) systems, this study examines how the Army assess the impact of different policies on specific can better manage the acquisition of systems us- segments of the population. The original model ing rapid, nontraditional means (i.e., outside the development was undertaken between 2002 and formal processes defined by DoD Instructions 2004, with a base year of 2001, and a number of 5000.02). The research identifies issues, challeng- enhancements have been made to the model sys- es, and problems associated with nontraditional tem since 2004, including adding incomes to the rapid acquisition processes and recommends model, and an improved treatment of cost sensi- ways DoD can more rapidly develop, procure, and tivity and updating the base year to 2006. In the field effective C2 systems within the framework of PRISM Refresh project, the demand and network current policies and processes. The research as- models in PRISM have been more fundamentally sesses past and current experience in the rapid updated to reflect a 2011 base year. RAND Eu- acquisition of C2 systems through nontraditional rope's role was to re-estimate the demand models means, including detailed case studies of three using household interview data collected between such systems. 2009 and 2012, and deliver to Mott MacDonald an RR-276-AF operational demand model implementation that The Effectiveness of Remotely Piloted Aircraft can run together with the network models in the in a Permissive Hunter-Killer Scenario. Lance 373

Menthe, Myron Hura, Carl Rhodes. 2014 efforts to transform education, the Kurdistan Re- This report analyzes the operational effec- gional Government asked the RAND Corporation tiveness of three RPA design concepts, plus the to assess its Technical and Vocational Education MQ-9 Reaper as a baseline, on a “hunter-killer” and Training (TVET) system. The findings suggest mission: to find and destroy a specific moving several recommendations for improving TVET, vehicle. The findings are based on the modeling particularly at the secondary level. Rather than results for a permissive scenario involving a rela- implementing all of these at once, the report sug- tively small search area, a short time frame, and gests three phases (short term, medium term and restrictive rules of engagement in an urban set- long term) to allow for measured implementation. ting and includes such environmental factors as RR-277/1-KRG fog and clouds. This scenario allowed researchers Improving Technical Vocational Education and to focus on trade-offs between platform size and Training in the Kurdistan Region—Iraq: Arabic- number; sensor performance; and the complicat- language version. Louay Constant, Shelly Culb- ing effects of darkness, fog, and cloud cover. With ertson, Cathleen Stasz, Georges Vernez. 2014 these limitations in mind, the authors offer a series of conclusions, among them that the MQ-9 shows As the Kurdistan Region—Iraq develops rapid- reasonably well against the other design concepts ly, it is creating jobs that require a solid education and that improving its sensor capabilities may be and technical skills. The government has launched cost-effective. an ambitious reform of basic and secondary education to increase its quality and has expanded RR-277-KRG opportunities for tertiary technical and university Improving Technical Vocational Education and education. But expansion of secondary vocational Training in the Kurdistan Region—Iraq. Louay education has lagged, leaving many students who Constant, Shelly Culbertson, Cathleen Stasz, cannot or do not want to pursue post-secondary Georges Vernez. 2014 education without the necessary preparation to As the Kurdistan Region—Iraq develops rapid- compete in the evolving labor market and contrib- ly, it is creating jobs that require a solid education ute to its economy. Enrollment in secondary voca- and technical skills. The government has launched tional education has diminished in recent years, an ambitious reform of basic and secondary edu- and graduates often have difficulty finding em- cation to increase its quality and has expanded ployment because their programs have not given opportunities for tertiary technical and university them the skills required by employers. At the same education. But expansion of secondary vocational time, employers complain that graduates from lo- education has lagged, leaving many students who cal general and vocational educational institutions cannot or do not want to pursue post-secondary do not possess the skills they need, and are said education without the necessary preparation to to resort to hiring foreign labor whenever they can- compete in the evolving labor market and contrib- not find local graduates. As part of its sweeping ute to its economy. Enrollment in secondary voca- efforts to transform education, the Kurdistan Re- tional education has diminished in recent years, gional Government asked the RAND Corporation and graduates often have difficulty finding em- to assess its Technical and Vocational Education ployment because their programs have not given and Training (TVET) system. The findings suggest them the skills required by employers. At the same several recommendations for improving TVET, time, employers complain that graduates from lo- particularly at the secondary level. Rather than cal general and vocational educational institutions implementing all of these at once, the report sug- do not possess the skills they need, and are said gests three phases (short term, medium term and to resort to hiring foreign labor whenever they can- long term) to allow for measured implementation. not find local graduates. As part of its sweeping RR-277/2-KRG 374

Improving Technical Vocational Education and were, on average, 3.4 percentage points more Training in the Kurdistan Region—Iraq: Kurdish- likely to be unemployed than similarly situated language version. Louay Constant, Shelly Culb- younger non-veterans. However, this difference ertson, Cathleen Stasz, Georges Vernez. 2014 between veteran and non-veteran unemployment As the Kurdistan Region—Iraq develops rapid- falls rapidly with age and time since military sepa- ly, it is creating jobs that require a solid education ration. The report concludes that the best available and technical skills. The government has launched evidence supports the hypothesis that relatively an ambitious reform of basic and secondary edu- high rates of veteran unemployment reflect the cation to increase its quality and has expanded fact that veterans, especially younger veterans, opportunities for tertiary technical and university are more likely to have recently separated from a job⎯namely, military service⎯and, consequently, education. But expansion of secondary vocational education has lagged, leaving many students who are more likely to be engaged in job search, which cannot or do not want to pursue post-secondary takes time, especially during periods of slow eco- education without the necessary preparation to nomic growth. The available evidence lends little compete in the evolving labor market and contrib- support to the hypothesis that veterans are inher- ute to its economy. Enrollment in secondary voca- ently disadvantaged in the civilian labor market. tional education has diminished in recent years, Limiting unemployment benefits available to re- and graduates often have difficulty finding em- cently separated veterans would likely reduce the ployment because their programs have not given length of unemployment spells, but the net effect them the skills required by employers. At the same of such a policy action on the long-term federal time, employers complain that graduates from lo- budget is unclear. There is very limited evidence cal general and vocational educational institutions on the effectiveness of other federal policies do not possess the skills they need, and are said aimed at facilitating the transition of veterans into to resort to hiring foreign labor whenever they can- the civilian labor market. not find local graduates. As part of its sweeping RR-287/1-MPS efforts to transform education, the Kurdistan Re- Effective Policing for 21st-Century Israel: Dual gional Government asked the RAND Corporation English and Hebrew edition. Jessica Saunders, to assess its Technical and Vocational Education Steven W. Popper, Andrew R. Morral, Robert C. and Training (TVET) system. The findings suggest Davis, Claude Berrebi, Kristin J. Leuschner, Shira several recommendations for improving TVET, Efron, Boaz Segalovitz, K. Jack Riley. 2014 particularly at the secondary level. Rather than implementing all of these at once, the report sug- Israel has changed dramatically since its found- gests three phases (short term, medium term and ing, especially in the past two decades. There is a long term) to allow for measured implementation. public interest in having the police provide a type and level of service that keeps pace with these RR-284-OSD changes. Despite relatively low crime rates, the Why Is Veteran Unemployment So High?. Da- public in Israel still perceives threats to personal vid S. Loughran. 2014 security and expresses concern over quality of According to official statistics, the unemploy- police service. The Ministry of Public Security, the ment rate of young military veterans ages 18–24 Ministry of Finance, and the Israel Police asked reached 29 percent in 2011. This report seeks to the RAND Corporation to conduct a study that put that statistic in perspective by examining the would help these organizations address several historical time-series of veteran unemployment, issues of mutual concern. They requested that comparing the veteran unemployment rate to that RAND address issues of public perceptions and of non-veterans, and examining how veteran un- public trust in the police, benchmarking the po- employment varies with time since military sepa- lice against other police organizations, perfor- ration. Between 2000 and 2011, younger veterans mance measurement, and deterrence and crime prevention. This document reports the outcome of 375 the resulting two-year project.Please note: Sepa- is complex, with numerous providers and funding rate files for English and Hebrew are available for streams. This complexity reflects its evolution in download. The printed version of this report in- response to changes in federal, state, and local cludes the Hebrew translation. priorities and initiatives. Future shifts in funding levels, program auspices, and other features are RR-289-CSM likely. In July 2012, the City of Santa Monica Hu- Early and School-Age Care in Santa Monica: man Services Division and the Santa Monica– Current System, Policy Options, and Recommen- Malibu Unified School District contracted with the dations. Ashley Pierson, Lynn A. Karoly, Gail L. RAND Corporation to conduct an assessment of Zellman, Megan K. Beckett. 2014 child care programs in Santa Monica. The study The landscape of early learning and out-of- was motivated in part by the perception of some school-time programs in the City of Santa Monica stakeholders that the system of care had become is complex, with numerous providers and funding fragmented and complex. Additional motivations streams. This complexity reflects its evolution in were the uncertainty of resource streams stem- response to changes in federal, state, and local ming from recent and anticipated state and federal priorities and initiatives. Future shifts in funding budget cuts and a desire to ensure youth well-be- levels, program auspices, and other features are ing in the community. The project sought to assess likely. In July 2012, the City of Santa Monica Hu- how well Santa Monica's child care programs meet man Services Division and the Santa Monica– the needs of families, including child care and ear- Malibu Unified School District contracted with the ly education programs serving children from birth RAND Corporation to conduct an assessment of to kindergarten entry, as well as care for school- child care programs in Santa Monica. The study aged children (focusing on kindergarten through was motivated in part by the perception of some eighth grade) in the hours before and after school stakeholders that the system of care had become and in the summer. Overall, recommendations for fragmented and complex. Additional motivations improvement focused on advancing access, qual- were the uncertainty of resource streams stem- ity, service delivery, and financial sustainability. ming from recent and anticipated state and federal budget cuts and a desire to ensure youth well-be- RR-290-WWP Health and Economic Outcomes in the Alumni ing in the community. The project sought to assess of the Wounded Warrior Project: 2010–2012. how well Santa Monica's child care programs meet Heather Krull, Mustafa Oguz. 2014 the needs of families, including child care and early education programs serving children from birth The Wounded Warrior Project (WWP) has to kindergarten entry, as well as care for school- developed programs to help care for injured ser- aged children (focusing on kindergarten through vice members and veterans. In order to assess eighth grade) in the hours before and after school the mental, physical, and economic health of its and in the summer. Overall, recommendations for member population, as well as to gain an under- improvement focused on advancing access, qual- standing of WWP participation, WWP is engaged ity, service delivery, and financial sustainability. in a five-year survey effort. The RAND Corpora- tion was asked to analyze the first three survey RR-289/1-CSM waves in order to take a more in-depth look at Early and School-Age Care in Santa Monica: survey responses to explore whether outcomes Current System, Policy Options, and Recommen- differ across various subsets of WWP's database dations: Executive Summary. Ashley Pierson, of members and, where possible, compare the Lynn A. Karoly, Gail L. Zellman, Megan K. Beckett. experiences and outcomes of alumni with those 2014 of other ill and injured populations. This report The landscape of early learning and out-of- describes specifically how WWP alumni who re- school-time programs in the City of Santa Monica sponded to the surveys are faring in domains related to mental health and resiliency, physical 376 health, and employment and finances. The study translation. Shmuel Abramzon, Nicholas Burger, finds that WWP goals are being met across a wide Bonnie Ghosh-Dastidar, Peter Glick, Krishna range of outcomes of interest but that individuals B. Kumar, Francisco Perez-Arce, Alexandria C. who have never been married, who are male, who Smith. 2014 are employed, and who are in higher ranks enjoy Comprehensive and reliable statistics are cru- better mental health outcomes. On the other hand, cial for designing economic policies. The Kurdis- women and those in junior ranks report more fa- tan Region of Iraq lacks the statistics it needs to vorably on their physical health. Finally, married improve infrastructure, encourage private-sector respondents and officers are more likely to have development, attract foreign investment, and cre- higher levels of education, be employed, and own ate sustained economic growth. The Kurdistan homes. These outcomes enable WWP to target Region Statistics Office needs to build capacity to its programming and messaging to the alumni in collect the data. RAND worked closely with the of- need of support in these areas. fice and in consultation with relevant ministries to build capacity by preparing, conducting, and ana- RR-293-KRG Capacity Building at the Kurdistan Region lyzing the first round of a survey of the region's Statistics Office Through Data Collection. Shm- labor force critical to government policymak- uel Abramzon, Nicholas Burger, Bonnie Ghosh- ing. RAND provided overall guidance and both Dastidar, Peter Glick, Krishna B. Kumar, Francisco analytical and hands-on training to organization Perez-Arce, Alexandria C. Smith. 2014 staff. Further, by being involved in the complete life cycle of the survey, from conception through Comprehensive and reliable statistics are cru- data collection to policy analysis, and by being re- cial for designing economic policies. The Kurdis- sponsible for the final execution and analysis of tan Region of Iraq lacks the statistics it needs to the surveys, that staff benefited from learning by improve infrastructure, encourage private-sector doing. Future rounds of the survey will provide up- development, attract foreign investment, and cre- to-date information on how these and other im- ate sustained economic growth. The Kurdistan portant indicators are changing over time and in Region Statistics Office needs to build capacity to response to policies. collect the data. RAND worked closely with the office and in consultation with relevant ministries to RR-302-A build capacity by preparing, conducting, and ana- Lessons Learned from the Afghan Mission lyzing the first round of a survey of the region's Network: Developing a Coalition Contingency labor force critical to government policymak- Network. Chad C. Serena, Isaac R. Porche III, ing. RAND provided overall guidance and both Joel B. Predd, Jan Osburg, Bradley Lossing. 2014 analytical and hands-on training to organization Recent and likely future U.S. military operations staff. Further, by being involved in the complete depend on coalitions of foreign military and non- life cycle of the survey, from conception through military partners, and a coalition mission network data collection to policy analysis, and by being re- is necessary to support those operations. The sponsible for the final execution and analysis of Afghan Mission Network (AMN) is the primary the surveys, that staff benefited from learning by network for the International Security Assistance doing. Future rounds of the survey will provide up- Force (ISAF) in Afghanistan, allowing the United to-date information on how these and other im- States and its coalition partners to share informa- portant indicators are changing over time and in tion and data across a common Secret system. response to policies. Many view the AMN as a successful enabler of coalition information sharing. It is thus critical that RR-293/2-KRG Capacity Building at the Kurdistan Region the Army understand the principal lessons of the Statistics Office Through Data Collection: Arabic development of this network as it plans to develop future coalition contingency networks. To this 377 end, the Army Chief Information Officer/G-6 asked grams, (2) accountable care organizations, and RAND Arroyo Center to provide an independent (3) bundled payment programs. The authors re- review and assessment of the operational and port on VBP program goals and what constitutes technical history of the AMN and to identify les- success; the evidence on the impact of these sons learned for future coalition networks. The programs; factors that characterize high- and low- history of the AMN provides an example of how performing providers in VBP programs; the mea- to develop information systems to support oper- sures, incentive structures, and benchmarks used ational missions, but perhaps more important, it by VBP programs; evidence on spillover effects also yields tactical, operational, and policy-rele- and unintended consequences; and gaps in the vant lessons that can inform future efforts to cre- knowledge base. ate contingency networks that are both effective across the range of military operations and useful RR-306/1-ASPE to a host of military and nonmilitary partners. This Measuring Success in Health Care Value-Based report presents findings drawn from interviews Purchasing Programs: Summary and Recommen- with key AMN developers and maintainers and dations. Cheryl L. Damberg, Melony E. Sorbero, the documentation they produced during the net- Susan L. Lovejoy, Grant R. Martsolf, Laura Raaen, work's development. Daniel Mandel. 2014 Value-based purchasing (VBP) refers to a broad RR-306-ASPE set of performance-based payment strategies that Measuring Success in Health Care Value-Based link financial incentives to health care providers' Purchasing Programs: Findings from an Envi- performance on a set of defined measures in an ronmental Scan, Literature Review, and Expert effort to achieve better value. The U.S. Department Panel Discussions. Cheryl L. Damberg, Melony of Health and Human Services (HHS) is advanc- E. Sorbero, Susan L. Lovejoy, Grant R. Martsolf, ing the implementation of VBP across an array of Laura Raaen, Daniel Mandel. 2014 health care settings in the Medicare program in Value-based purchasing (VBP) refers to a broad response to requirements in the 2010 Patient Pro- set of performance-based payment strategies that tection and Affordable Care Act, and policymakers link financial incentives to health care providers' are grappling with many decisions about how best performance on a set of defined measures in an to design and implement VBP programs so that effort to achieve better value. The U.S. Depart- they are successful in achieving stated goals.This ment of Health and Human Services is advanc- report summarizes the current state of knowledge ing the implementation of VBP across an array of about VBP programs, focusing on pay-for-perfor- health care settings in the Medicare program in mance programs, accountable care organizations, response to requirements in the 2010 Patient Pro- and bundled payment programs. The authors dis- tection and Affordable Care Act, and policymakers cuss VBP program goals and what constitutes are grappling with many decisions about how best success; the evidence on the impact of these to design and implement VBP programs so that programs; factors that characterize high- and low- they are successful in achieving stated goals.This performing providers in VBP programs; the mea- report summarizes the current state of knowledge sures, incentive structures, and benchmarks used about VBP based on a review of the published lit- by VBP programs; evidence on spillover effects erature, a review of publicly available documen- and unintended consequences; and gaps in the tation from VBP programs, and discussions with knowledge base. The report concludes with a set an expert panel composed of VBP program spon- of recommendations for the design, implementa- sors, health care providers and health systems, tion, and monitoring and evaluation of VBP pro- and academic researchers with VBP evaluation grams and a discussion of HHS's efforts in this expertise. Three types of VBP models were the regard. focus of the review: (1) pay-for-performance pro- RR-308 378

Redirecting Innovation in U.S. Health Care: Baxter, Scott Boston, Michael McGee, Todd Nich- Options to Decrease Spending and Increase ols, Elizabeth Tencza. 2014 Value. Steven Garber, Susan M. Gates, Emmett At the request of U.S. Army Training and Doc- B. Keeler, Mary E. Vaiana, Andrew W. Mulcahy, trine Command, a RAND research team exam- Christopher Lau, Arthur L. Kellermann. 2014 ined options to increase the mobility, protection, New medical technologies are a leading driver and firepower of the Army's airborne forces, given of U.S. health care spending. This report identifies likely future missions and threats, identifying a promising policy options to change which medical concept for enhancing today's forces by adding technologies are created, with two related policy a light armored infantry capability. Because the goals: (1) Reduce total health care spending with Army requested near-term options, the new con- the smallest possible loss of health benefits, and cept incorporates equipment and platforms that (2) ensure that new medical products that increase are already available within the U.S. Department spending are accompanied by health benefits that of Defense. The near-term focus also meant that are worth the spending increases. The analysis the current Air Force airlift fleet was an important synthesized information from peer-reviewed and consideration, since Army airborne forces rely on other literature, a panel of technical advisors con- Air Force transport aircraft to deploy. The research vened for the project, and 50 one-on-one expert team examined notional future brigade- and bat- interviews. The authors also conducted case stud- talion-sized airborne units, including the numbers ies of eight medical products. The following fea- and types of vehicles that would be needed to cre- tures of the U.S. health care environment tend to ate an airborne light armored force that could be increase spending without also conferring major airdropped or air-landed from Air Force transport health benefits: lack of basic scientific knowledge planes. The primary light armored vehicle possi- about some disease processes, costs and risks bilities studied were the Stryker (currently used by of U.S. Food and Drug Administration (FDA) ap- the Army) and the Light Armored Vehicle, second proval, limited rewards for medical products that generation (LAV-II, used by the Marine Corps and could lower spending, treatment creep, and the the militaries of several other nations). Each family medical arms race.The authors identified ten poli- of vehicles would have advantages and disadvan- cy options that would help advance the two policy tages for the Army's airborne force, with the LAV-II goals. Five would do so by reducing the costs and/ provisionally identified as the preferred candidate. or risks of invention and obtaining FDA approval: A tabletop exercise with subject-matter experts, (1) Enable more creativity in funding basic sci- using scenarios developed through a review of ence, (2) offer prizes for inventions, (3) buy out historical Army missions, identified how the addi- patents, (4) establish a public-interest investment tion of light armor could enhance the performance fund, and (5) expedite FDA reviews and approvals. of airborne units. The other five options would do so by increasing market rewards for products: (1) Reform Medicare RR-314-MM payment policies, (2) reform Medicare coverage PRISM 2011 Base: Demand Model Implemen- policies, (3) coordinate FDA approval and Centers tation. James Fox, Bhanu Patruni, Andrew Daly. for Medicare & Medicaid Services coverage pro- 2014 cesses, (4) increase demand for technologies that PRISM West Midlands is a travel demand mod- decrease spending, and (5) produce more and el forecasting system which was developed by more-timely technology assessments. RAND Europe and Mott MacDonald on behalf of the seven metropolitan districts in the West Mid- RR-309-A lands Metropolitan Area, the Highways Agency Enhanced Army Airborne Forces: A New Joint and Centro. The model system is required to be Operational Capability. John Gordon IV, Agnes responsive to a wide range of policy levers, and to Gereben Schaefer, David A. Shlapak, Caroline assess the impact of different policies on specific 379 segments of the population. The original model times, workstations cluttered with applications, development was undertaken between 2002 and and stovepiped databases and networks—chal- 2004, with a base year of 2001, and a number of lenges that are only going to intensify as the Navy enhancements have been made to the model sys- fields new and additional sensors in the coming tem since 2004, including adding incomes to the years. Indeed, if the Navy does not change the way model, and an improved treatment of cost sensi- it collects, processes, exploits, and disseminates tivity and updating the base year to 2006. In the information, it will reach an ISR “tipping point”— PRISM Refresh project, the demand and network the point at which its analysts are no longer able models in PRISM have been more fundamentally to complete a minimum number of exploitation updated to reflect a 2011 base year. RAND Eu- tasks within given time constraints—as soon as rope's role was to re-estimate the demand models 2016.The authors explore options for solving the using household interview data collected between Navy's “big data” challenge, considering changes 2009 and 2012, and deliver to Mott MacDonald an across four dimensions: people, tools and tech- operational demand model implementation that nology, data and data architectures, and demand can run together with the network models in the and demand management. They recommend that overall PRISM model system. The work was again the Navy pursue a cloud solution—a strategy sim- undertaken on behalf of the seven metropolitan ilar to those adopted by Google, the Intelligence districts in the West Midlands Metropolitan Area, Community, and other large organizations grap- the Highways Agency and Centro.This report doc- pling with big data's challenges and opportunities. uments the implementation of the new demand models. The implementation comprises three RR-321-A main components: the Population Model, which Developing Army Leaders: Lessons for Teach- predicts the future West Midlands population by ing Critical Thinking in Distributed, Resident, and geographical zone and population segment, the Mixed-Delivery Venues. Susan G. Straus, Michael travel demand models, which predict total trans- G. Shanley, James C. Crowley, Douglas Yeung, port demand for that future population, and dis- Sarah H. Bana, Kristin J. Leuschner. 2014 tributes that demand over mode, destination and The U.S. Army uses the Command and Gen- time period alternatives, and the Final Processing eral Staff Officer Course (CGSOC) as a key com- Model, which processes the outputs from the travel ponent of its system for developing critical thinking demand models and applies a pivoting procedure skills and abilities in its officer corps. The Common in order to generate trip matrices for assignment Core is the first phase of CGSOC. The Common to the highway and public transport networks. Core is taught in three venues: a resident course taught at Fort Leavenworth and at satellite cam- RR-315-NAVY puses; Advanced Distributed Learning (ADL), a Data Flood: Helping the Navy Address the Ris- web-based, self-paced course that uses interac- ing Tide of Sensor Information. Isaac R. Porche III, tive multimedia instruction; and The Army School Bradley Wilson, Erin-Elizabeth Johnson, Shane System (TASS), primarily for Reserve Component Tierney, Evan Saltzman. 2014 officers, which combines resident and interactive In the U.S. Navy, there is a growing demand multimedia instruction and is taught by the U.S. for intelligence, surveillance, and reconnaissance Army Reserve Command's 97th Brigade and its (ISR) data, which help Navy commanders obtain three subordinate battalions. CGSOC consists of situational awareness and help Navy vessels per- nine blocks of instruction taught as stand-alone form a host of mission-critical tasks. The amount modules in the resident course (14-16 weeks of data generated by ISR sensors has, however, long) and organized into three phases in TASS become overwhelming, and Navy analysts are and ADL (designed to be taken over a period of up struggling to keep pace with this data flood. Their to 18 months). In response to the interests of Army challenges include extremely slow download 380 leadership, this study sought to answer the follow- Mafalda Pardal. 2014 ing questions about the Common Core, focusing This study, commissioned by the Open So- on the 2009-2010 academic year: Based on cur- ciety Foundations, aimed to situate the widely- rent methods of evaluation, how effective is the shared perception of rising intolerance in Western Common Core, and to what extent are there dif- Europe in the context of empirical evidence on ferences among distributed, resident, and mixed- high-level trends in intolerant attitudes in Western delivery venues? Based on current measures, Europe. Through analysis of European datasets, how can course delivery be improved? How well a review of empirical literature, and assessments do current methods of evaluation gauge course of trends in selected individual countries, we ex- success and point to needed improvements? To plored whether intolerance has risen more in answer these questions, the authors analyzed some countries than others, whether it has risen available data from Command and General Staff more against particular groups, if such attitudes School, including responses to student surveys, are particularly prevalent among subgroups of the grades on assignments, and student characteris- population and if there are clear patterns of as- tics. In addition, the authors conducted a quasi- sociation with trends in wider political, social, eco- experimental study to assess consistency in grad- nomic and cultural factors. ing among faculty members. RR-334/1-OSI RR-327-DOL Intolerance in Western Europe: Analysis of Final Report: Evaluation of Tools and Metrics trends and associated factors: Summary report. to Support Employer Selection of Health Plans. Jennifer Rubin, Jirka Taylor, Alexandra Pollitt, Soeren Mattke, Kristin R. Van Busum, Grant R. Joachim Krapels, Mafalda Pardal. 2014 Martsolf. 2014 This study, commissioned by the Open So- The Patient Protection and Affordable Care Act ciety Foundations, aimed to situate the widely- (ACA) places strong emphasis on quality of care shared perception of rising intolerance in Western as a means to improve outcomes for Americans Europe in the context of empirical evidence on and promote the financial sustainability of our high-level trends in intolerant attitudes in Western health care system. Included in the ACA are new Europe. Through analysis of European datasets, disclosure requirements that require health plans a review of empirical literature, and assessments to provide a summary of benefits and coverage of trends in selected individual countries, we ex- that accurately describes the benefits under the plored whether intolerance has risen more in plan or coverage. These requirements are intend- some countries than others, whether it has risen ed to support employers' procurement of high- more against particular groups, if such attitudes value health coverage for their employees. This are particularly prevalent among subgroups of the report attempts to help employers understand the population and if there are clear patterns of as- structural differences between health plans and sociation with trends in wider political, social, eco- the performance dimensions along which plans nomic and cultural factors. can differ, as well as to educate employers about available tools that can be used to evaluate plan RR-337-AF options. The report also discusses the extent to Balancing Agile Combat Support Manpower which these and other tools or resources are used to Better Meet the Future Security Environment. by employers to inform choices between health Patrick Mills, John G. Drew, John A. Ausink, Daniel plans. M. Romano, Rachel Costello. 2014

RR-334-OSI The U.S. Air Force's (USAF's) current approach Intolerance in Western Europe: Analysis of to sizing and shaping non-maintenance agile trends and associated factors. Jennifer Rubin, combat support (ACS) manpower often results in Jirka Taylor, Alexandra Pollitt, Joachim Krapels, 381 a discrepancy between the supply of ACS forces tors and policies affect these impacts. To do this, and operational demands because much of ACS they examined how economic conditions in the is sized and shaped to meet the requirements of civilian labor market when individuals exit active home-station installation operations, not expedi- duty affect postservice earnings, and they studied tionary operations. This report proposes a more the effect on earnings of an Army recruiting pro- enterprise-oriented approach to measuring ACS gram, Partnership for Youth Success, designed to manpower requirements by synthesizing combat- promote enlistment but with the potential to ease ant commander operational plans, Defense Plan- the financial transition from military to civilian life. ning Scenarios, functional area deployment rules, and subject-matter expert input. Using these new RR-344-AF expeditionary metrics to assess the capacity of Achieving Higher-Fidelity Conjunction Analyses the current ACS manpower mix to support expe- Using Cryptography to Improve Information Shar- ditionary operations, this report finds that there ing. Brett Hemenway, William Welser IV, Dave are imbalances among its career fields relative to Baiocchi. 2014 expeditionary demands. To address these imbal- Space debris—the man-made orbital junk that ances, it develops and assesses several rebal- represents a collision risk to operational satel- anced manpower mixes and finds that the USAF lites—is a growing threat that will increasingly af- can achieve more expeditionary ACS capacity fect future space-related mission designs and op- than it currently has by realigning manpower, and erations. Since 2007, the number of orbiting debris it can realize substantial savings by reducing end objects has increased by over 40 percent as a re- strength and substituting civilian billets for military sult of the 2007 Chinese antisatellite weapon test billets. and the Iridium/Cosmos collision in 2009. With this sudden increase in debris, there is a renewed RR-342-OSD interest in reducing future debris populations us- Effects of Military Service on Earnings and ing political and technical means.The 2010 U.S. Education Revisited: Variation by Service Dura- Space Policy makes several policy recommendation, Occupation, and Civilian Unemployment. tions for addressing the space congestion prob- Paco Martorell, Trey Miller, Lindsay Daugherty, lem. One of the policy's key suggestions instructs Mark Borgschulte. 2014 U.S. government agencies to promote the sharing The overriding objective of U.S. military com- of satellite positional data, as this can be used to pensation policy is to attract and retain the force predict (and avoid) potential collisions. This type necessary to meet the nation's national security of information is referred to as space situational objectives. Whether and how military service af- awareness (SSA) data, and, traditionally, it has fects earnings and an individual's likelihood of been treated as proprietary or sensitive by the or- completing college (one determinant of future ganizations that keep track of it because it could earnings) has implications for military policies re- be used to reveal potential satellite vulnerabilities. lated to compensation, recruiting, and retention. This document examines the feasibility of using Estimating the effect of military service is compli- modern cryptographic tools to improve SSA. Spe- cated by the fact that veterans are likely to differ cifically, this document examines the applicability from nonveterans in ways that are correlated with and feasibility of using cryptographically secure subsequent economic outcomes but are not ob- multiparty computation (MPC) protocols to se- servable to the researcher. This report builds on curely compute the collision probability between earlier work to understand how military service af- two satellites. These calculations are known as fects earnings, especially how these effects differ conjunction analyses. MPC protocols currently ex- by the number of years of service and their military ist in the cryptographic literature and would pro- occupational specialties while serving. The au- vide satellite operators with a means of computing thors also sought to understand how external fac- conjunction analyses while maintaining the priva- 382 cy of each operator's orbital information. Authority to Issue Interoperability Policy. Caro- lyn Wong, Daniel Gonzales. 2014 RR-348-EC Parents at work: Men and women participating Achieving interoperability among systems is in the labour force: Short Statistical Report No. 2. instrumental to enabling critical functions, such Celine Miani, Stijn Hoorens. 2014 as timely information exchange during operations and efficiencies in acquisition, so it is important to This statistical paper focuses on the relationship understand what parties have authority to issue between parenthood and employment. The report policy that governs the facets of interoperability. looks into a number of related aspects and gen- This report presents an approach and framework der differences are then investigated by examining for determining what parties have authority to is- these various aspects and contrasting men and sue interoperability policy, the legal and policy women. The analysis of these aspects focused origins and implementation paths of the authority, on employment rate differences between parents and the extent of the authority. The approach in- and nonparents; working hours among parents cludes rigorous analysis by researchers to identify and non-parents; gender inequalities with regard pertinent authorities in federal law supplemented to work interruption and parental leave; and atti- by a means to facilitate discovery of roles and tudes towards parental involvement in work and responsibilities in Department of Defense and care. Service-level policies. The approach results in a roles and responsibilities network that traces the RR-350-A paths of authority available to issue interoperabil- Assessing Security Cooperation as a Preven- ity policy. The authors use as a case study the tive Tool. Michael J. McNerney, Angela O'Mahony, authority of the Assistant Secretary of the Navy, Thomas S. Szayna, Derek Eaton, Caroline Baxter, Research, Development, and Acquisition, Chief Colin P. Clarke, Emma Cutrufello, Michael McGee, Systems Engineer to issue Navy interoperability Heather Peterson, Leslie Adrienne Payne, Calin policy related to mission area systems engineer- Trenkov-Wermuth. 2014 ing (MASE) to demonstrate the use of the frame- The report tested the assertion that U.S. se- work and methodology. They find that there are curity cooperation (SC) can help reduce fragility 13 different paths of authority that could be cited in partner states. The test used statistical analy- by four different parties to claim authority to influ- sis to assess SC data and state fragility scores ence interoperability policy related to MASE. The for 107 countries in 1991–2008. After controlling approach used in this report might be developed, for a variety of factors, the main finding was that along with complementary analytic techniques, to provision of SC by the United States and a reduc- provide the government with the ability to create tion in partner state fragility were correlated. The and maintain consistent and comprehensive bod- strength of correlation did not increase propor- ies of policy that will ensure the effective and ef- tionally with additional funding; most of the effect ficient operation of defense agencies. was concentrated at the low end of SC funding. In addition, the correlation depended on recipient RR-360-SOCOM country characteristics. Correlation was stronger Authorities and Options for Funding USSOCOM in more democratic states and in states with stron- Operations. Elvira N. Loredo, John E. Peters, Kar- ger institutions. In especially fragile states, there lyn D. Stanley, Matthew E. Boyer, William Welser was only a weak or no correlation of SC with fra- IV, Thomas S. Szayna. 2014 gility decrease. Of the types of SC provided, the This report examines mechanisms, sources, correlation was strongest with education-focused and inter-Service agreements for funding special SC. Foreign Military Financing, a type of SC, did operations forces (SOF) operations and provides not correlate with reductions in fragility. recommendations to reduce the frequency and RR-357-NAVY duration of disputes between the United States 383

Special Operations Command (SOCOM), the Mil- ers with young children are the least-employed itary Departments, and Geographic Combatant parent groups, and that this is exacerbated for Commands over their respective funding respon- single mothers. This is relevant to policy consid- sibilities for SOF, especially with respect to when erations, as the age composition of single-parent Service Common (Major Force Program (MFP) 2) households also differs from nation to nation. and SOF Peculiar (MFP 11) funds should be used. The Geographic Combatant Commanders, in ac- RR-363-EC cordance with guidance received from the Presi- Gender inequalities in the school-to-work tran- dent and Secretary of Defense, generate requests sition in Europe: Short Statistical Report No. 4. for unplanned activities and operations, some- Melinda Mills, Patrick Präg. 2014 times in response to unanticipated events. Such The school-to-work transition is a crucial life events fall outside planned and programmed ac- stage for young people, and research has often tivities, creating validated operational support re- shown that this stage has important effects on quirements that are unfunded and/or unbudgeted. their entire life courses. In recent years, young Each time this occurs, it leads to prolonged ne- people willing to enter the labour market have gotiations to work out funding responsibility dis- been challenged by increasing uncertainty and putes among a variety of stakeholders to secure comparatively high unemployment. These labour the funding necessary to execute the new require- market trends have been attributed to several ment. SOCOM's Global SOF Network (GSN) en- structural changes, including globalisation, rise visions increased use of SOF, which would fur- in international competition, technological change ther increase the frequency of such disputes and and the recent economic crisis. At the same time, could be hindered by current funding processes, the structure of labour supply has changed. Tertia- motivating the research conducted to produce this ry education in EU Member States has substan- report. If the President and Congress agree to ex- tially expanded and the educational attainment of pand the use of SOF as described by the GSN recent female graduates is now at parity or even concept, it would be necessary to increase the exceeds that of their male counterparts. However, flexibility of funding available for validated but un- research has also demonstrated that even with funded operations. To increase the effectiveness considerable gains in education, women continue of SOF, the Department of Defense needs fund- to have unequal labour market outcomes. Isolat- ing solutions that are responsive to global events ing gender differences in the transition from school while enabling effective financial stewardship that to work and examining why these differences satisfies the needs of all stakeholders. may emerge, has been largely ignored until now. Our report uses directly comparable data across RR-362-EC the EU to examine whether there is a gendered Single parents and employment in Europe: transition from school to work, which can provide Short Statistical Report No.3. Kai Ruggeri, Chloe evidence to allow nations to reform their social E. Bird. 2014 welfare systems in a more tailored way by learn- This paper examines the key characteristics of ing from each other and identifying policies and single parents through descriptive and compara- institutional systems that work the best. For our tive perspectives. Our analyses suggest that the empirical analyses, we draw on the EU Labour experiences and needs of single-parent house- Force Survey 2009 ad hoc module 2009 Entry holds differ according to the age of both the par- of Young People into the Labour Market', which ent and child, and that the vast majority of such focuses on individuals aged 15–34 years living in households are single-mother households. The 27 EU Member States plus Iceland and Norway. analysis shows that younger mothers and moth- RR-364-EC Emerging trends in earnings structures of 384 couples in Europe: Short Statistical Report No. 5. to reconcile family, work, and private life. This view Flavia Tsang, Michael S. Rendall, Charlene Rohr, is based on the assumption that granting work- Stijn Hoorens. 2014 ers greater discretion and more control over their Are couples in Europe becoming more gen- working times should empower them to better bal- der-equal? This paper examines (i) the emerging ance their work and non-work demands. Previous trends in couples' earnings structures; and (ii) research has been able to show that flexible work- the extent to which more equal earnings relates ing arrangements can indeed be helpful in im- to more equal domestic work contributions. Our proving work-life reconciliation, even though find- analysis of recent trends (2007–2010), using the ings are sometimes mixed and effects are often European Union Statistics on Income and Liv- small in magnitude. Our findings reveal remark- ing Conditions (EU-SILC), indicated a continued able variation in work schedule flexibility across majority of male sole- or main-earners, but also a countries. While less than ten per cent of workers decline in this gender imbalance over the three- in Romania report being able to make use of the year period. It is not yet known, however, whether two options in question, in countries like the Neth- this will ultimately be seen to have been driven by erlands, Austria and the UK, this share exceeds the economic crisis or to be part of a continuing sixty per cent of the workforce. Further country- trend towards more gender-equal couple earnings level analyses confirmed that GDP per capita is a structures. Our empirical findings also addressed major predictor of the availability of work schedule the tension between more gender-equal earnings flexibility, with greater availability in more affluent that is expected to promote more gender-equal do- countries. In a second step, we analyse which so- mestic work contributions and gender-role norms cial groups across countries report the availability that perpetuate unequal domestic work contribu- of work schedule flexibility. Firstly, women report- tions. We found that women spent much greater ed substantially less access to family-related work time in domestic work tasks than men, and that schedule flexibility. Secondly, younger workers there is a relatively small difference in domestic (under the age of 30) reported less access to a work hours between men who contribute all most family-related work schedule. of the couple's earnings and men who contrib- RR-369-A ute smaller proportions of the couple's earnings. Methods for Identifying Part Quality Issues In contrast, we found that women who contribute and Estimating Their Cost with an Application Us- smaller proportions or none of the couple's earning the UH-60. Elvira N. Loredo, Shawn McKay, ings spent many more hours in domestic work Amber Jaycocks. 2014 tasks. These findings suggested an important factor that is likely to continue to act as a drag This research report demonstrates how the on change towards more equality within couples Army can use readily available demand and end even in the presence of effective work/family rec- item maintenance history to identify potential is- onciliation policies: a highly unequal gender divi- sues with repair part or process quality and esti- sion of labour in the home. mate their associated incremental costs.The Army relies on Product Quality Deficiency Reports and RR-365-EC subject matter experts from various organizations Family-related working schedule flexibil- to monitor and react to repair part quality prob- ity across Europe: Short Statistical Report No. 6. lems. Because of the high number of weapon sys- Patrick Präg, Melinda Mills. 2014 tems, suppliers, and parts, the current approach tends to focus either on very expensive parts, such One of the major innovations in human resource as transmissions, rotor blades, and engines, or practices in the last decades has been the prolif- on safety-critical items. However, there are other eration of flexible work practices, such as working costs associated with a reduction in the reliability from home or work schedule flexibility. The latter of a part, including the cost to remove, repair, and especially are often seen as an important means 385 reinstall the part; the system down-time created than 50. The results also support classifying dis- by the failure and repair cycle; additional inven- tance learning credentials as Tier 2 regardless of tory to replace the faulty part; and any disposal AFQT score. costs. If the frequency of failure is great enough, then even a less-expensive item, in terms of pro- RR-378-DTRA curement cost, could become an important cost Penaid Nonproliferation: Hindering the Spread driver.This study presents a novel application of of Countermeasures Against Ballistic Missile the Crow-AMSAA statistical model, which is com- Defenses. Richard H. Speier, K. Scott McMahon, monly used in reliability engineering, and applies George Nacouzi. 2014 the model's power to detect trends in part usage The proliferation of weapons of mass destruc- rates. The approach analyzes thousands of parts, tion (WMD) becomes a greater threat when ac- detecting trends and identifying parts for further companied by the proliferation of effective means analysis based on the estimated total system cost of delivery. As proliferator nations acquire ballis- of poor quality, allowing the Army to focus on high- tic missiles for this purpose, it will be important marginal-cost items regardless of a part's unit to establish effective measures to counter WMD price.A case study using the UH-60M Black Hawk attacks. But the benefits will be lost or reduced demonstrates the potential for the new approach. if proliferators can acquire effective countermeasures against missile defenses. Such countermea- RR-374-OSD sures, when incorporated in an attacker's missile, Elements of Success: How Type of Secondary are known as penetration aids, or penaids. This Education Credential Helps Predict Enlistee At- research was designed to assist U.S. agencies trition. Susan Burkhauser, Lawrence M. Hanser, charged with generating policies to discourage Chaitra M. Hardison. 2014 the proliferation of WMD and ballistic missile de- The U.S. military services have traditionally used livery systems, thereby strengthening deterrence. a tiering system, including education credentials Specifically, it recommends controls on potential such as high school diplomas, in combination with exports of penaid-related items according to the Armed Forces Qualification Test (AFQT) scores to structure of the current international policy against help gauge the likelihood of a recruit persevering the proliferation of missiles capable of delivering through his or her first term of service. But what WMD, the Missile Technology Control Regime. about less traditional credentials, such as diplo- The recommendations account for 19 classes of mas earned through homeschooling and distance such items and are based on structured interviews learning? The Office of the Under Secretary of De- with government and nongovernment experts, as fense (Personnel and Readiness) asked RAND to well as an independent technical assessment examine whether its current education-credential to develop a preliminary characterization of the tiering policy is still useful in predicting first-term technologies and equipment most critical to the attrition. The authors examined attrition rates at emerging penaid threat. The project also brought 12, 24, and 36 months of service for all enlistees together a selected group of experts to participate from 2000 through 2011. Using statistical regres- in a workshop to review the initial characterization sion techniques, they compared attrition rates for of penaid technologies and equipment. those with distance learning or homeschool credentials to those of high school diploma holders, RR-380-OSD after controlling for other observable population How Do We Know What Information Sharing Is differences. Overall, the analyses support current Really Worth? Exploring Methodologies to Mea- tiering policy classifying homeschool diplomas as sure the Value of Information Sharing and Fusion Tier 1 if a recruit's AFQT score is 50 or higher (i.e., Efforts. Brian A. Jackson. 2014 they are treated the same as high school diploma Since the terrorist attacks of September 11, holders) or Tier 2 if a recruit's AFQT score is lower 2001, the sharing of intelligence and law enforcement information has been a central part 386 of U.S. domestic security efforts. Though much Assessing Locally Focused Stability Opera- of the public debate about such sharing focuses tions. Jan Osburg, Christopher Paul, Lisa Saum- on addressing the threat of terrorism, organiza- Manning, Dan Madden, Leslie Adrienne Payne. tions at all levels of government routinely share 2014 varied types of information through multiagency This report describes how the Army and oth- information systems, collaborative groups, and er services can better measure and assess the other links. Given resource constraints, there are progress and outcomes of locally focused stabil- concerns about the effectiveness of information- ity operations (LFSO), which are defined as the sharing and fusion activities and, therefore, their missions, tasks, and activities that build secu- value relative to the public funds invested in them. rity, governance, and development by, with, and Solid methods for evaluating these efforts are through the directly affected community, in order lacking, however, limiting the ability to make in- to increase stability at the local level. A number of formed policy decisions. Drawing on a substantial issues related to assessing LFSO are identified, literature review and synthesis, this report lays out along with foundational challenges that include the challenges of evaluating information-sharing an inherently complex operational environment, efforts that frequently seek to achieve multiple limited doctrinal guidance, competing visions of goals simultaneously; reviews past evaluations of stability, untested assumptions, and redundant information-sharing programs; and lays out a path or excessive reporting requirements. The report to improving the evaluation of such efforts going offers solutions to these and other challenges, forward. and provides concrete recommendations and implementation-related guidance for designing RR-382-OSD Modeling, Simulation, and Operations Analysis and conducting assessments of LFSO. The report in Afghanistan and Iraq: Operational Vignettes, concludes with an assessment plan for a notional Lessons Learned, and a Survey of Selected Ef- African LFSO scenario that illustrates the practi- forts. Ben Connable, Walter L. Perry, Abby Doll, cal application of those insights. Natasha Lander, Dan Madden. 2014 RR-388-OSD RAND conducted a lessons learned examina- Evaluating the Impact of the Department of tion of operations analysis, modeling, and simu- Defense Regional Centers for Security Studies. lation in support of Operation Enduring Freedom Larry Hanauer, Stuart E. Johnson, Christopher and Operation Iraqi Freedom. This report identi- Springer, Chaoling Feng, Michael J. McNerney, fies ways in which analysts have attempted to sup- Stephanie Pezard, Shira Efron. 2014 port commanders' decisions in counterinsurgency The five U.S. Department of Defense (DoD) and irregular warfare, describes many of the mod- Regional Centers for Security Studies have been els and tools they employed, provides insight into helping partner nations build strategic capacity the challenges they faced, and suggests ways in for almost 20 years. However, recent DoD budget which the application of modeling, simulation, and constraints have put pressure on the regional cen- analysis might be improved for current and future ters (RCs) to increase efficiency. The Office of the operations. RAND identified four broad catego- Secretary of Defense (OSD) asked RAND to con- ries of decisions: force protection, logistics, cam- duct a study on the overall impact of the RCs, their paign assessment, and force structuring. Model- effectiveness in advancing DoD policy priorities, ing, simulation, and analysis were most effective the ways in which they assess their programs, and in supporting force protection and logistics deci- ways in which they could improve their impact and sions, and least effective in supporting campaign efficiency and the resulting outcomes.The RAND assessment and force structuring. study team found that centers have had great success at the missions they have undertaken. RR-387-A They are high-impact components of U.S. secu- 387 rity cooperation and engagement efforts, despite (2) ventilator-associated pneumonia, and (3) their relatively small budgets. The team identified catheter-associated urinary tract infections; use 24 ways in which the centers advance U.S. inter- preoperative and anesthesia checklists to prevent ests, including building partner capacity, building operative and postoperative events; prevent in-fa- relationships, fostering pro-U.S. outlooks, offering cility pressure ulcers; use ultrasound guidance for unique opportunities for engagement, and pro- central line placement; and prevent recurrent falls. moting regional dialogue that reduces tensions. Small ideas do not require systemic change; thus, However, RCs should improve impact-oriented they may be both more feasible to operationalize data collection and analysis for improved as- and less likely to encounter stiff political and orga- sessment, methodically collecting such data over nizational resistance. time. OSD and the combatant commands should improve their oversight and management of the RR-395-1-DIR RCs to ensure alignment with department- and Implementing a Resource-Based Relative theater-level objectives. In addition, OSD should Value Scale Fee Schedule for Physician Services: maintain the RCs' focus on regional security chal- An Assessment of Policy Options for the Califor- lenges rather than refashioning them to address nia Workers' Compensation Program. Barbara O. specific threats. Options to consider for greater Wynn, Hangsheng Liu, Andrew W. Mulcahy, Ed- impact include evaluating the balance between ward N. Okeke, Neema Iyer, Lawrence S. Painter. core residential courses and in-region workshops 2014 and determining whether and to what extent the A RAND study used 2011 medical data to ex- centers should develop customized programs for amine the impact of implementing a resource- DoD components so as to secure funds beyond based relative value scale to pay for physician the core budget they receive from OSD. services under the California workers' compensation system. Current allowances under the Of- RR-390-RC ficial Medical Fee Schedule are approximately Small Ideas for Saving Big Health Care Dollars. 116 percent of Medicare-allowed amounts and, Jodi L. Liu, Deborah Lai, Jeanne S. Ringel, Mary by law, will transition to 120 percent of Medicare E. Vaiana, Jeffrey Wasserman. 2014 over four years. Using Medicare policies to estab- A focused review of recent RAND Health re- lish the fee-schedule amounts, aggregate allow- search identified small ideas that could save ances are estimated to decrease for four types of the U.S. health care system $13 to $22 billion service by the end of the transition in 2017: an- per year, in the aggregate, if successfully imple- esthesia (–16.5 percent), surgery (–19.9 percent), mented. In the substituting lower-cost treatments radiology (–16.5 percent), and pathology (–29.0 category, ideas are to reduce use of anesthesia percent). Aggregate allowances for evaluation and providers in routine gastroenterology procedures management visits are estimated to increase by for low-risk patients, change payment policy for 39.5 percent. Allowances for services classified emergency transport, increase use of lower-cost as “medicine” in the Current Procedural Terminol- antibiotics for treatment of acute otitis media, shift ogy codebook will increase by 17.3 percent. In the care from emergency departments to retail clin- aggregate, across all services, allowances are ics when appropriate, eliminate co-payments for projected to increase 11.9 percent. Because most higher-risk patients taking cholesterol-lowering specialties furnish different types of services, the drugs, increase use of $4 generic drugs, and re- impacts by specialty are generally less than the duce Medicare Part D use of brand-name pre- impacts by type of service. scription drugs by patients with diabetes. In the RR-398-OSD patient safety category, ideas are to prevent three DoD Depot-Level Reparable Supply Chain types of health care–associated infections: (1) Management: Process Effectiveness and Op- central line–associated bloodstream infections, portunities for Improvement. Eric Peltz, Marygail 388

K. Brauner, Edward G. Keating, Evan Saltzman, number of recommendations. These include: us- Daniel Tremblay, Patricia Boren. 2014 ing evidence-based models to provide services The RAND National Defense Research Institute that combine employment and mental health examined Department of Defense depot-level rep- support; increasing integration between existing arable (DLR) supply chain management to assess treatment and employment services to improve how it could be improved to enhance customer outcomes in both areas; applying evidence-based support and reduce costs. This report concludes models in new ways or a using combination of that DLR supply chain management appears to approaches; and providing timely access to co- be done relatively effectively across the services. ordinated treatment and employment support for What on the surface appears to be substantial in- a greater number of people with common mental ventory excess and high disposals of assets is in- health problems. stead a reflection of the fact that DLRs are durable RR-410-OSD assets very much like weapon systems and other Small Business and Strategic Sourcing: Lessons end items. Most DLRs have very low condemna- from Past Research and Current Data. Nancy Y. tion rates, with depot maintenance economically Moore, Clifford A. Grammich, Judith D. Mele. 2014 repairing them time and again through the life of the supported end item. So when they are re- The Department of Defense (DoD) may face placed by upgraded versions or weapon systems challenges as it attempts to maintain its goal of are phased out, demand disappears but the as- spending about 23 percent of its prime-contract sets remain, leading first to “excess” inventory and dollars for goods and services with small busi- then to disposals. This is a cost of doing business. nesses and at the same time apply strategic- As a result, no large, “silver bullet” solutions were sourcing practices to reduce total costs and im- found. Still, a number of modest opportunities for prove performance in ways that will not conflict improving DLR supply chain management were with small-business goals while making DoD identified. The first is improving parts supportabili- purchasing more effective and efficient. Strategic ty, including taking a total cost perspective that en- sourcing practices, for example, recommend con- compasses supply and maintenance costs when solidation of the supply base to reduce total costs, planning inventory in support of depot production. which can lead to fewer, larger, longer-term con- The second is to shift the Army more toward pull tracts with fewer and, often, larger suppliers. production. The third is to reduce lead times for all types of contracts affecting DLR supply chain RR-412-ICJ management. And the fourth is to better account The Changing Role of Criminal Law in Con- for all resource lead times in planning DLR pro- trolling Corporate Behavior. James M. Anderson, duction and for anticipatable shifts in procurement Ivan Waggoner. 2014 and repair needs. All of these enhancements What should be the role of the criminal law in would improve customer support, with better parts controlling corporate behavior, and how can the support likely reducing maintenance costs and execution of that role be improved? On the one pull production reducing the buildup of inventory. hand, corporations have enormous power, and, when a corporation causes harm, there is a natu- RR-407-DWP ral instinct to apply criminal sanctions, society's Psychological Wellbeing and Work: Improving most serious expression of moral disapproval. In service provision and outcomes. Christian van the wake of a harm in which a corporation had Stolk, Joanna Hofman, Marco Hafner, Barbara a prominent role, there are often calls for an in- Janta. 2014 creased use of the criminal law to tame corporate This report explores proposals to improve em- excesses. On the other hand, criminal liability has ployment and health outcomes for people with historically usually required criminal intent, a con- common mental health problems and makes a cept that applies oddly to a legal construction, 389 such as a corporation. And more recently, critics aviation units have an advantage in the AC. Policy- have decried what they have termed the overcrim- makers should consider both capability and cost inalization of corporate behavior, suggesting that as they weigh AC-RC force mix decisions. there has been an overreliance on the use of criminal law in this context.To provide guidance to poli- RR-418-NIJ cymakers on the proper role of criminal sanctions Evaluation of National Institute of Justice– in this context, RAND Corporation researchers (1) Funded Geospatial Software Tools: Technical and measure the current use of criminal sanctions in Utility Assessments to Improve Tool Development, controlling corporate behavior, (2) describe how Dissemination, and Usage. Carolyn Wong, Paul the current regime developed, and (3) offer sug- Sorensen, John S. Hollywood. 2014 gestions about how the use of criminal sanctions A geospatial software tool-evaluation study to control corporate behavior might be improved. conducted for the National Institute of Justice (NIJ) assessed 14 recent tool developments fund- RR-417-1-A ed by NIJ. The study integrates input from tool de- Assessing the Army's Active-Reserve Com- velopers and tool users with RAND Corporation ponent Force Mix. Joshua Klimas, Richard E. researchers' independent tool assessments. The Darilek, Caroline Baxter, James Dryden, Thomas evaluation finds that 12 of the 14 NIJ development F. Lippiatt, Laurie L. McDonald, J. Michael Polich, awards resulted in fully functional tools for the law Jerry M. Sollinger, Stephen Watts. 2014 enforcement community. Collectively, the tools New defense strategic guidance and budget provided the law enforcement community with reductions as the United States draws down its access to new and enhanced geospatial capa- forces in Afghanistan have led the Army to reas- bilities to improve crime analysis. From a holistic sess how it balances the mix of forces between its perspective of NIJ's tool-development efforts, the active component (AC) and its two reserve com- evaluation finds that NIJ can maximize benefits ponents (RCs), the Army National Guard and the on future tool developments by addressing sever- U.S. Army Reserve. Multiple factors should influ- al apparent policy gaps and inconsistencies with ence AC-RC force mix decisions, including the ca- respect to awardee requirements and oversight, pabilities that AC and RC forces provide and their including ensuring that policies assign NIJ or De- cost. This report describes analyses from an on- partment of Justice officials roles and responsibili- going stream of RAND research on the Army's AC- ties for the latter phases of software development, RC force mix. It focuses on two critical aspects of including integration and test, implementation, op- capabilities and cost: (1) the time needed to make erations and maintenance, and disposition; devel- forces ready to deploy abroad in a crisis and (2) oping tool-dissemination plans; establishing go-to the costs of AC and RC forces to sustain the same sources for tool-deployment notifications; estab- level of deployed output for rotational missions. It lishing a process and source of funding to address finds that the factors that make RC units cost less limitations in the initial version of the tool, such as than AC units, on average, can also make them a small post–tool-delivery modification fund; and less rapidly deployable in the event of unexpected taking the lead to address emerging interoperabili- contingencies—namely in terms of the amount of ty and information-sharing issues. Acting on these time personnel are available to train. The report recommendations will ensure that NIJ consistently also identifies the circumstances under which ei- maximizes benefits to the law enforcement com- ther AC or RC forces can sustain a given level of munity from its future tool development awards. deployed output at a lower cost. Finally, it shows that differences in capabilities and cost depend of RR-425-CHSWC the type of unit. For example, many smaller sup- Identifying Permanently Disabled Workers with port and logistics units tend to have an advantage Disproportionate Earnings Losses for Supplemen- in the RC, while some larger ground combat and tal Payments. Seth A. Seabury, Ethan Scherer. 390

2014 RAND researchers used five complementary California workers with permanently disabling methods: (1) literature review, (2) a microsimula- workplace injuries have traditionally had high tion modeling of costs, (3) interviews with program earnings losses, poor return to work outcomes, staff, (4) prospective policy analysis, and (5) an and a low percentage of earnings losses replaced expert panel. The priorities outlined in this report by workers' compensation benefits. In September represent a first step for where additional program 2012, California adopted legislation that includes and policy development and research and evalua- changes in the calculation of permanent disability tion are needed to improve understanding of how ratings, increases in permanent disability com- best to get service members with mental health pensation, and a program to provide supplemen- disorders the needed treatment as efficiently and tal payments to injured workers whose permanent effectively as possible. disability benefits are disproportionately low in RR-429-AF comparison to their earnings loss. However, the Suitability of Missions for the Air Force Re- language in the statute does not expressly deserve Components. Albert A. Robbert, James H. fine “disproportionately low.” This report makes Bigelow, John E. Boon, Jr., Lisa M. Harrington, Mi- several recommendations about the design and chael McGee, S. Craig Moore, Daniel M. Norton, implementation of this program: Payments can William W. Taylor. 2014 be targeted to workers whose actual measured earnings after the disability award are below what The composition of Air Force active and reserve would be expected based on the severity of their forces is often contentious, especially during a disability. force drawdown. This report builds on previous RAND research that found that the distribution of RR-426-OSD force structure to the active component (AC) and Mental Health Stigma in the Military. Joie D. reserve components (RC) in some missions is Acosta, Amariah Becker, Jennifer L. Cerully, Mi- not cost-optimal. This document seeks to inform chael P. Fisher, Laurie T. Martin, Raffaele Varda- force composition decisions by clarifying issues vas, Mary Ellen Slaughter, Terry L. Schell. 2014 that affect the suitability of missions for assign- Despite the efforts of both the U.S. Depart- ment to the RC. The authors considered informa- ment of Defense (DoD) and the Veterans Health tion contrasting AC and RC characteristics on a Administration to enhance mental health services, variety of factors that bear on suitability of mission many service members are not regularly seeking assignments. From these considerations, the au- needed care when they have mental health prob- thors distilled criteria that could be used to weigh lems. Without appropriate treatment, these mental the suitability of missions for assignment to the health problems can have wide-ranging and nega- RC, and finally they applied these criteria to a rep- tive impacts on the quality of life and the social, resentative set of missions.The authors identify emotional, and cognitive functioning of affected surge demand, the duration of activations, and service members. The services have been ac- continuation training requirements as the three tively engaged in developing policies, programs, main criteria for evaluating whether a given mis- and campaigns designed to reduce stigma and sion is suitable for assignment to the RC. They increase service members' help-seeking behav- also identify seven other factors, such as whether ior. However, there has been no comprehensive the mission involves high levels of stress-related assessment of these efforts' effectiveness and the deployment or overseas basing and consideration extent to which they align with service members' of the need to sustain a sufficiently experienced needs or evidence-based practices. The goal of workforce. The authors conclude with several rec- this research was to assess DoD's approach to ommendations, including changes to policies and stigma reduction—how well it is working and how procedures to more fully utilize the RC and more it might be improved. To address these questions, widespread consideration of cost and outcome 391 measures in force composition decisions. Johnson, Kate Giglio. 2014 Like many coastal regions, Louisiana faces RR-430 Hackers Wanted: An Examination of the Cy- significant risks from storms and resulting storm bersecurity Labor Market. Martin C. Libicki, David surge and flooding, as well as coastal land loss. Senty, Julia Pollak. 2014 Furthermore, these risks are likely to be exacerbated by continued population growth, economic There is a general perception that there is a development, and climate change. In recent years shortage of cybersecurity professionals within the the need to address these challenges has grown United States, and a particular shortage of these more compelling as a consequence of the expe- professionals within the federal government, work- riences with hurricanes Katrina, Rita, Isaac, and ing on national security as well as intelligence. Sandy.Louisiana's Coastal Protection and Resto- Shortages of this nature complicate securing the ration Authority (CPRA) took a major step forward nation's networks and may leave the United States to confront these challenges in its groundbreaking ill-prepared to carry out conflict in cyberspace. 2012 report, Louisiana's Comprehensive Master RAND examined the current status of the labor Plan for a Sustainable Coast, a 50-year, $50 bil- market for cybersecurity professionals—with an lion coast-wide strategy for reducing flood risk and emphasis on their being employed to defend the coastal land loss. RAND researchers supported United States. This effort was in three parts: first, CPRA's efforts by developing (1) a structured and a review of the literature; second, interviews with analytical approach to support CPRA's decision- managers and educators of cybersecurity profes- making, called the Planning Tool, and (2) a com- sionals, supplemented by reportage; and third, an puter simulation model of coastal conditions to examination of the economic literature about labor estimate property and other damage associated markets. RAND also disaggregated the broad def- with storm surge and flooding, called the Coastal inition of “cybersecurity professionals” to unearth Louisiana Risk Assessment (CLARA) model.This skills differentiation as relevant to this study.In report highlights RAND's contributions to CPRA's general, we support the use of market forces (and Master Plan, with the goal of helping policymakers preexisting government programs) to address the in other coastal regions understand the value of strong demand for cybersecurity professionals in a solid technical foundation to support decision- the longer run. Increases in educational opportu- making on strategies to reduce flood risks, rebuild nities and compensation packages will draw more or restore coastal environments, and increase the workers into the profession over time. Cybersecu- resilience of developed coastal regions. It brings rity professionals take time to reach their potential; together and makes accessible previously pub- drastic steps taken today to increase their quantity lished RAND technical descriptions of both the and quality would not bear fruit for another five Planning Tool and the CLARA model. to ten years. By then, the current concern over cybersecurity could easily abate, driven by new RR-438-CMHSA technology and more secure architectures. Push- Evaluation of the California Mental Health Ser- ing too many people into the profession now could vices Authority's Prevention and Early Interven- leave an overabundance of highly trained and nar- tion Initiatives: Progress and Preliminary Findings. rowly skilled individuals who could better be serv- M. Audrey Burnam, Sandra H. Berry, Jennifer L. ing national needs in other vocations. Cerully, Nicole K. Eberhart. 2014 The California Mental Health Services Authority RR-437-RC (CalMHSA) statewide Prevention and Early Inter- Strengthening Coastal Planning: How Coastal vention (PEI) program comprises three strategic Regions Could Benefit from Louisiana's Plan- ning and Analysis Framework. David G. Groves, Jordan R. Fischbach, Debra Knopman, David R. 392 initiatives: (1) reduction of stigma and discrimina- When California voters passed Proposition tion toward those with mental illness, (2) preven- 63—the Mental Health Services Act—in 2004, the tion of suicide, and (3) improvement in student state and counties were mandated to develop an mental health. Community agencies serve as PEI approach to providing prevention and early inter- program partners to perform activities intended to vention services and education for Californians. meet the goals of the initiatives. This report eval- In turn, the California Mental Health Services uates the progress of the PEI program partners Authority—a coalition of California counties de- in achieving their goals and establishes baseline signed to provide economic and administrative population tracking of key risk factors and long- support to mental health service delivery—began term outcomes targeted by the initiatives. Based a program to reduce adverse outcomes for Cali- on a model to assess the program partners' ca- fornians who experience mental illness through pacities and resources and a recent survey of Cal- three strategic initiatives by developing statewide ifornia adults, this report shows that the partners capacities and implementing interventions to (1) have greatly expanded their abilities to launch nu- reduce stigma and discrimination toward those merous PEI activities and programs. with mental illness, (2) prevent suicide, and (3) improve student mental health.This document RR-438/1-CMHSA summarizes first-year findings from an ongoing Evaluation of the California Mental Health Ser- evaluation of the program's stigma and discrimi- vices Authority's Prevention and Early Intervention nation reduction (SDR) initiative. It describes what Initiatives: Executive Summary and Commentary. the activities partners in the SDR initiative are en- M. Audrey Burnam, Sandra H. Berry, Jennifer L. gaging in; what they have accomplished in terms Cerully, Nicole K. Eberhart. 2014 of developing policies, protocols, procedures, in- In 2004, California voters passed Proposi- formational and online resources, education and tion 63, the Mental Health Services Act (MHSA), trainings, and media-related strategies to reduce which includes a mandate that the state provide stigma and discrimination; and what the plans for prevention and early intervention (PEI) services the future evaluation of the SDR initiative are. and education for people who experience mental illness in the state of California. The California RR-438/3-CMHSA Evaluating the California Mental Health Ser- Mental Health Services Authority (CalMHSA), a vices Authority's Student Mental Health Initiative: coalition of California counties formed to provide Year 1 Findings. Bradley D. Stein, Michelle W. economic and administrative support to men- Woodbridge, Lisa Sontag-Padilla, Karen Chan tal health service delivery, formed the Statewide Osilla, Courtney Ann Kase, Asha Goldweber, Lisa PEI Implementation Program based on extensive H. Jaycox, Elizabeth J. D'Amico. 2014 recommendations from a large number of stakeholders statewide. The Statewide PEI program is When California voters passed Proposition made up of three strategic initiatives: (1) reduction 63—the Mental Health Services Act—in 2004, the of stigma and discrimination towards those with state and counties were mandated to develop an mental illness, (2) prevention of suicide, and (3) approach to providing prevention and early inter- improvement in student mental health.This docu- vention services and education for Californians. In ment provides a summary and commentary on turn, the California Mental Health Services Author- a more detailed interim RAND evaluation of the ity—a coalition of California counties designed to CalMHSA Statewide PEI Program. provide economic and administrative support to RR-438/2-CMHSA mental health service delivery—began a program Evaluating the California Mental Health Services to reduce adverse outcomes for Californians who Authority's Stigma and Discrimination Reduction experience mental illness through three strategic Initiative: Year 1 Findings. Rebecca L. Collins, initiatives by developing statewide capacities and Jennifer L. Cerully, Eunice C. Wong, Shari Golan, implementing interventions to (1) reduce stigma Jennifer Yu, Gabrielle Filip-Crawford. 2014 393 and discrimination toward those with mental ill- Training Strategy. Bernard D. Rostker, Charles ness, (2) prevent suicide, and (3) improve stu- Nemfakos, Henry A. Leonard, Elliot Axelband, dent mental health.This document summarizes Abby Doll, Kimberly N. Hale, Brian McInnis, Rich- first-year findings from an ongoing evaluation of ard Mesic, Daniel Tremblay, Roland J. Yardley, the program's student mental health (SMH) initia- Stephanie Young. 2014 tive. It describes what the activities partners in the Unmanned aircraft systems (UASs) have be- SMH initiative are engaging in; what they have ac- come increasingly prevalent in and important to complished thus far in terms of developing net- U.S. military operations. Initially serving only as re- works and collaborations, informational and on- connaissance or intelligence platforms, they now line resources, education and trainings; and what carry out such other missions as attacking enemy the plans for the future evaluation of the SMH ini- forces. The swift expansion in their numbers and tiative are. in the demand for their employment has, however, significantly increased demands on logistics and RR-438/4-CMHSA Evaluating the California Mental Health Ser- training systems. The challenge is not simply train- vices Authority's Suicide Prevention Initiative: Year ing system operators but also training operational 1 Findings. Rajeev Ramchand, Joie D. Acosta, forces and their commanders to integrate the sys- Amariah Becker, Patricia A. Ebener, Lisa H. Jay- tems into combat operations. Much of that aspect cox, Karen Chan Osilla. 2014 of training has thus far happened as units employ the systems in actual operations—essentially, on- When California voters passed Proposition the-job training. UAS training, particularly for the 63—the Mental Health Services Act—in 2004, the employment of UASs, now needs to be integrated state and counties were mandated to develop an more formally and cost-effectively into service and approach to providing mental health prevention joint training programs. This report develops a gen- and early intervention services and education for eral concept for training military forces in employ- Californians. In turn, the California Mental Health ment of UASs and a framework for addressing the Services Authority—a coalition of California coun- training requirements and discusses the limits of ties designed to provide economic and adminis- existing infrastructure in supporting UAS training. trative support to mental health service delivery— Interoperability among services is another issue, began a program to reduce adverse outcomes because services have thus far mainly developed for Californians who experience mental illness training suitable for their own needs. But the ser- through three strategic initiatives by developing vices have established a set of multiservice tac- statewide capacities and implementing interven- tics, techniques, and procedures for UASs, which tions to (1) reduce stigma and discrimination to- should facilitate interoperability training. At pres- ward those with mental illness, (2) prevent sui- ent, units are not always ready for joint training, so cide, and (3) improve student mental health.This the focus should be on improving training at the document summarizes first-year findings from an unit level in the employment of UAS capabilities, ongoing evaluation of the program's suicide pre- with the overall guiding principle being to “train as vention initiative. It describes what the activities we fight.” partners in the initiative are engaging in; what they have accomplished so far; what California suicide RR-443-1-RC rates were prior to the start of the initiative, for lat- Autonomous Vehicle Technology: A Guide for er comparison; and what the plans for the future Policymakers. James M. Anderson, Nidhi Kalra, evaluation of the suicide prevention initiative are. Karlyn D. Stanley, Paul Sorensen, Constantine Samaras, Oluwatobi A. Oluwatola. 2014 RR-440-OSD For the past hundred years, innovation within Building Toward an Unmanned Aircraft System the automotive sector has created safer, cleaner, 394 and more affordable vehicles, but progress has the many issues that this technology raises. Af- been incremental. The industry now appears ter surveying the advantages and disadvantages close to substantial change, engendered by au- of the technology, RAND researchers determined tonomous, or “self-driving,” vehicle technologies. that the benefits of the technology likely outweigh This technology offers the possibility of significant the disadvantages. However, many of the benefits benefits to social welfare—saving lives; reducing will accrue to parties other than the technology's crashes, congestion, fuel consumption, and pollu- purchasers. These positive externalities may tion; increasing mobility for the disabled; and ulti- justify some form of subsidy. The report also ex- mately improving land use. This report is intended plores policy issues, communications, regulation as a guide for state and federal policymakers on and standards, and liability issues raised by the the many issues that this technology raises. Af- technology; and concludes with some tentative ter surveying the advantages and disadvantages guidance for policymakers, guided largely by the of the technology, RAND researchers determined principle that the technology should be allowed that the benefits of the technology likely outweigh and perhaps encouraged when it is superior to an the disadvantages. However, many of the benefits average human driver. will accrue to parties other than the technology's purchasers. These positive externalities may RR-448-A justify some form of subsidy. The report also ex- Changing the Army's Weapon Training Strate- plores policy issues, communications, regulation gies to Meet Operational Requirements More and standards, and liability issues raised by the Efficiently and Effectively. James C. Crowley, technology; and concludes with some tentative Bryan W. Hallmark, Michael G. Shanley, Jerry M. guidance for policymakers, guided largely by the Sollinger. 2014 principle that the technology should be allowed The ability of soldiers to engage the enemy and perhaps encouraged when it is superior to effectively is fundamental to the operational suc- an average human driver. This version of the recess of the U.S. Army. As a result, the Army de- port, RR-443-1, replaces an earlier version that votes considerable effort and resources to weapon contained several errors in the description of state training. The Army's current challenge is to adapt laws concerning autonomous vehicles in Chapter weapon training strategies to meet complex oper- 3, none of which affected the findings of the report. ational environments and changing unit readiness processes; take full advantage of training technol- RR-443-RC ogies; and, in an era of declining defense budgets, Autonomous Vehicle Technology: A Guide for make weapon training strategies more efficient. Policymakers. James M. Anderson, Nidhi Kalra, This report documents the findings, conclusions, Karlyn D. Stanley, Paul Sorensen, Constantine and implications of a two-year project support- Samaras, Oluwatobi A. Oluwatola. 2014 ing the Army's efforts to adapt its weapon training For the past hundred years, innovation within strategies and the processes through which they the automotive sector has created safer, cleaner, are developed. The potential of emerging tech- and more affordable vehicles, but progress has nologies to make weapon training strategies more been incremental. The industry now appears effective and efficient is also examined. The report close to substantial change, engendered by au- outlines directions the Army could take to improve tonomous, or “self-driving,” vehicle technologies. its weapon training strategies and the processes This technology offers the possibility of significant for adapting them. It concludes that improving the benefits to social welfare—saving lives; reducing processes for adapting weapon training to new crashes, congestion, fuel consumption, and pollu- requirements can make them more effective and tion; increasing mobility for the disabled; and ulti- efficient, but that improvements should be made mately improving land use. This report is intended in the context of holistically improving the Army's as a guide for state and federal policymakers on training and leader development programs. In addition, while there are many potential benefits 395 to increasing the use of technologies in weapon critical analysis or an assessment of the strengths training strategies, there are many factors that act or weaknesses of the claims made in the litera- to limit the amount of improvement that must be ture. Rather, it provides a starting point for further considered before deciding on implementation. research or consideration by government acquisition professionals, oversight organizations, and RR-449-RC the analytic community. We identified the following Armed and Dangerous? UAVs and U.S. Secu- reasons for schedule delays in the literature: (1) rity. Lynn E. Davis, Michael J. McNerney, James the difficulty of managing technical risk (e.g., pro- S. Chow, Thomas Hamilton, Sarah Harting, Daniel gram complexity, immature technology, and unan- Byman. 2014 ticipated technical issues), (2) initial assumptions Armed drones are making the headlines, es- or expectations that were difficult to fulfill (e.g., pecially in their role in targeted killings. In this re- schedule estimates, risk control, requirements, port, RAND researchers stepped back and asked and performance assumptions), and (3) funding whether these weapons are transformative. The instability. The most commonly cited recommen- answer is no, though they offer significant ca- dations for reducing cycle time and controlling pabilities to their users, especially in counterter- schedule growth in the literature are strategies that rorism operations as has been the case for the manage or reduce technical risk. Some of those United States. Will they proliferate? Yes, but upon recommendations include using incremental field- a closer look at the types of systems, only a few ing or evolutionary acquisition strategies, devel- rich countries will be in a position to develop the oping derivative products (rather than brand-new higher technology and longer range systems. U.S. designs), using mature or proven technology (i.e., adversaries and others will likely find weapons commercial, off-the-shelf components), maintain- such as aircraft and air defenses more cost and ing stable funding, and using atypical contracting militarily effective. Their proliferation will not create vehicles. the kinds of global dangers that call for new arms control efforts, but the risks to regional stability RR-462-EC Gender equality in the workforce: Reconciling cannot be dismissed entirely, as is the case of any work, private and family life in Europe. Melinda conventional weapon. How the United States will Mills, Flavia Tsang, Patrick Präg, Kai Ruggeri, use these weapons today and into the future will Celine Miani, Stijn Hoorens. 2014 be important in shaping a broader set of international norms that discourage their misuse by oth- Are couples in Europe becoming more gender- ers. equal? This short statistical paper examines two specific aspects of the question: (i) the emerg- RR-455-OSD ing trends in couples' earnings structures; and (ii) Prolonged Cycle Times and Schedule Growth in the extent to which more equal earnings relates Defense Acquisition: A Literature Review. Jessie to more equal domestic work contributions. Our Riposo, Megan McKernan, Chelsea Kaihoi Duran. analysis of recent trends (2007–2010), using the 2014 European Union Statistics on Income and Liv- This report summarizes a selection of the de- ing Conditions (EU-SILC), indicated a continued fense acquisition literature from the 1960s to the majority of male sole- or main-earners, but also a present on potential sources of prolonged acquisi- decline in this gender imbalance over the three- tion cycle times and schedule growth, as well as year period. It is not yet known, however, whether potential opportunities for improvement. It pres- this will ultimately be seen to have been driven by ents the range of possible causes of schedule- the economic crisis or to be part of a continuing related problems and various recommendations trend towards more gender-equal couple earnings cited for improving schedules by various authors structures. Our empirical findings also addressed and organizations. This report does not provide the tension between more gender-equal earnings 396 that is expected to promote more gender-equal do- technical and bureaucratic impediments to shar- mestic work contributions and gender-role norms ing data among law enforcement agencies, and that perpetuate unequal domestic work contribu- constraints on the availability of staffing and train- tions. We found that women spent much greater ing needed to support LPR systems. time in domestic work tasks than men, and that there is a relatively small difference in domestic RR-469-OSD work hours between men who contribute all most From Stalemate to Settlement: Lessons for of the couple's earnings and men who contrib- Afghanistan from Historical Insurgencies That ute smaller proportions of the couple's earnings. Have Been Resolved Through Negotiations. Colin In contrast, we found that women who contribute P. Clarke, Christopher Paul. 2014 smaller proportions or none of the couple's earn- In June 2013, the Afghan Taliban opened a ings spent many more hours in domestic work political office in Qatar to facilitate peace talks with tasks. These findings suggested an important the U.S. and Afghan governments. Negotiations factor that is likely to continue to act as a drag between the United States and the group that on change towards more equality within couples sheltered al-Qaeda would have been unthinkable even in the presence of effective work/family rec- 12 years ago, but the reality is that a negotiated onciliation policies: a highly unequal gender divi- settlement in Afghanistan is one of several pos- sion of labour in the home. sible end games under the current U.S. withdrawal plan. Negotiating an end to an insurgency can be RR-467-NIJ a long and arduous process beset by false starts License Plate Readers for Law Enforcement: and continued violence, but a comprehensive re- Opportunities and Obstacles. Keith Gierlack, view of historical cases that ended in settlement Shara Williams, Tom LaTourrette, James M. An- shows that these negotiations followed a similar derson, Lauren A. Mayer, Johanna Zmud. 2014 path that can be generalized into a “master narra- Law enforcement agencies across the coun- tive.” This research examines 13 historical cases try have quickly been adopting a new technology of insurgencies that were resolved through negoti- to combat auto theft and other crimes: automated ated settlement in which neither side (insurgents license plate reader (LPR) systems. These sys- or counterinsurgents) unambiguously prevailed. tems can capture the image of the license plate Taken together, these cases reveal that the path of a passing vehicle and compare the plate num- to negotiated settlement generally proceeds in ber against official “hotlists” that show an array of seven steps in a common sequence. Although infractions or reasons why it may be of interest this resulting master narrative does not necessar- to authorities. But because LPR technology is ily conform precisely to every conflict brought to relatively new in the United States, opportunities resolution through negotiation, it can serve as an and obstacles in its use in law enforcement are important tool to guide the progress of a similar still under exploration. To examine issues about approach to resolving the conflict in Afghanistan this technology, RAND conducted interviews with as U.S. forces prepare to withdraw. law enforcement officers and others responsible for procuring, maintaining, and operating the sys- RR-471-AF tems. Champions of LPR technology exist at many Strength Testing in the Air Force: Current Pro- levels, from tech-savvy officers who use it every cesses and Suggestions for Improvements. Carra day, to chiefs who promote it, to other officials and S. Sims, Chaitra M. Hardison, Maria C. Lytell, Abby policymakers who believe LPR technology is a Robyn, Eunice C. Wong, Erin N. Gerbec. 2014 significant force multiplier for police departments. Since 1987, the Air Force has used the Strength Challenges exist, however, to realizing more wide- Aptitude Test (SAT), a test of physical strength that spread acceptance and use of the technology. uses the incremental lift machine, to screen and Chief among these are privacy concerns related classify enlisted personnel into career special- to the retention and potential misuse of LPR data, 397 ties. In this study RAND evaluated the usefulness, ment. In September 2010 the first ever SIB was validity, and fairness of the SAT—something not launched in the UK. Approximately £5 million was done for more than two decades. RAND's re- invested by private individuals and charities is be- search focused on two areas. The first area was ing used to pay for interventions for offenders dis- implementation of the SAT at military entrance charged after serving short prison sentences (less processing stations. The researchers observed than 12 months) at HMP Peterborough, a prison that SAT administration, while fairly consistent, in eastern England. RAND Europe has been com- could be improved: SAT machines need to be missioned to evaluate the development, imple- inventoried on a regular basis to identify and re- mentation and operation of this first ever SIB. This pair damage; a standardized training procedure report is the second from the independent evalu- is needed for all test administrators; and recruits ation. need to be fully informed prior to taking the test as to its purpose and the value of preparation. The RR-474-A second area was the process for setting strength The U.S. Army in Asia, 2030–2040. Terrence K. requirements for career fields. The researchers Kelly, James Dobbins, David A. Shlapak, David C. concluded that the method of collecting physical Gompert, Eric Heginbotham, Peter Chalk, Lloyd requirements information might be deficient be- Thrall. 2014 cause it involves only limited input. As an alterna- For the next 20 or more years, the U.S. relation- tive, they developed and tested an online survey ship with China will be the fulcrum on which the tool for defining strength requirements. The survey East Asian security order balances. As a result, asked respondents in eight Air Force Specialties U.S. policy should seek to prevent the emergence to describe aspects of the job's physical require- of an overtly hostile U.S.-China relationship while ments that are vital for defining strength require- hedging against the possibility that one could ments. Analysis of the data collected validates the nonetheless emerge. Such a strategy must bal- potential effectiveness of the survey, and the re- ance between protecting U.S. interests in East searchers suggest it can be used in conjunction Asia, where clashes with China's preferences are with the Air Force's existing occupational analysis most likely, and cooperating with Beijing globally survey. Further, they recommend the Air Force es- where the two sides have common objectives. tablish a new method for calculating SAT scores. Crafting and sustaining such a strategy will be a major challenge. It must have clear and realistic RR-473-MOJ goals flowing from larger U.S. interests and strat- Phase 2 report from the payment by results egy in the region, take into account the need for Social Impact Bond pilot at HMP Peterborough. U.S.-China cooperation on a host of global secu- Emma Disley, Jennifer Rubin. 2014 rity and economic matters, be flexible and respon- At a time when government finances are sive to Chinese moves, seek to channel Chinese stretched there is growing interest in finding new conduct in favorable directions, and reflect the new ways to fund public services. One new funding realities of Asia resulting from China's increased model currently being tested is a Social Impact military and economic power. The U.S. Army will Bond (SIB). A SIB is a form of payment by results have an important role to play in supporting U.S. in which funding is obtained from private inves- strategy in the Asia-Pacific, primarily by providing tors to pay for interventions to improve social out- training and support to allies and partners; help- comes. If these interventions are effective, this ing to defend key facilities from enemy ground, air, should result in savings to government and wider and missile attack; providing key enabling support benefits to society. As part of a SIB, the govern- to the joint force; projecting expeditionary combat ment agrees to pay a proportion of these savings forces into the theater; contributing to new conven- back to the investors. If outcomes do not improve, tional deterrent options; and helping to encourage investors do not receive a return on their invest- China's participation in cooperative military-to-mil- 398 itary engagements. undergirding results with depth as necessary. It will emphasize balancing across objectives and RR-477-AF hedging against both uncertainty and disagree- Air Force Major Defense Acquisition Program ment among policymakers. Modern methods for Cost Growth Is Driven by Three Space Programs doing so are available but they require displacing and the F-35A: Fiscal Year 2013 President's some familiar processes and demanding more Budget Selected Acquisition Reports. Robert S. from analysis. Once decisions are made, analysis Leonard, Akilah Wallace. 2014 should help policymakers explain, convince, and During the past four decades, the military ser- shape implementation guidance with sharpened vices and the Office of the Secretary of Defense requirements, forcing functions, and metrics for (OSD) have managed hundreds of very large monitoring, feedback, and adaptation. weapon system acquisition programs. These programs, designated Major Defense Acquisi- RR-483-WFHF Measuring Deeper Learning Through Cog- tion Programs (MDAPs), account for more than nitively Demanding Test Items: Results from the 40 percent of weapon-system acquisition fund- Analysis of Six National and International Exams. ing appropriated by Congress. RAND maintains Kun Yuan, Vi-Nhuan Le. 2014 an internal database of costs and schedules for these programs, as reported in Selected Acquisi- In 2010, the William and Flora Hewlett Foun- tion Reports (SARs) dating back to the 1960s. In dation's Education Program has established the this report, researchers analyze cost growth in Air Deeper Learning Initiative, which focuses on stu- Force–managed MDAPs. Differing definitions of dents' development of deeper learning skills (i.e., cost growth provide differing insights into program the mastery of core academic content, critical- outcomes. The analysis focuses on those MDAPs thinking, problem-solving, collaboration, com- that contain the highest levels of development munication, and “learn-how-to-learn” skills). Two activity and that, at a minimum, have proceeded test consortia are developing the next generation through the acquisition process to a point at which of tests to measure students' attainment of the a portion of the production units envisioned at Common Core State Standards. These tests are the program's Milestone (MS) B were produced expected to assess deeper learning skills to a and delivered to the warfighter. These MDAPs are greater extent than existing large-scale tests. A broken into two groups: continuing and complete. RAND study rated the cognitive demand of math- Controlling costs in continuing MDAPs is essen- ematics and English language arts items on six tial to the overall affordability of Air Force modern- nationally and internationally administered exams: ization plans. A handful of ongoing and recently Advanced Placement, International Baccalau- terminated programs account for substantially reate, the National Assessment of Educational higher cost growth in recent Air Force programs Progress, the Programme for International Stu- compared with complete programs. Cost growth dent Assessment, the Progress in International to date in four continuing large-dollar programs Reading Literacy Study, and the Trends in Inter- must be contained to ensure affordability of the Air national Mathematics and Science Study, using Force's long-term investment plans. Norman Webb's Depth of Knowledge framework and the Partnership for Assessment of Readiness RR-482-OSD for College and Career's self-developed frame- Analysis to Inform Defense Planning Despite works. It found that these tests were more cog- Austerity. Paul K. Davis. 2014 nitively demanding than previously studied state Defense analysis can do a better job sup- achievement tests in both subjects, on average. porting policymakers dealing with multiple ob- The test items' level of cognitive demand varied jectives and deep uncertainties. This will involve by subject and format. The six tests varied in their seeing through the fog with simple analysis and percentages of cognitively demanding items, with 399 only two tests meeting both criteria proposed by this area, RAND compiled a comprehensive cat- a panel of education researchers for high-quality alog of DoD-funded programs that address psy- measures of deeper learning. Moreover, the tests' chological health and TBI. In creating the catalog cognitive demand levels varied with test purpose of programs, RAND recognized the need to con- and the characteristics of the targeted students. sistently describe and compare multiple programs The findings establish a benchmark for comparing according to a set of core program characteristics, how well the new generation of tests performs in driven largely by the lack of a single, clear, widely- assessing deeper learning. accepted operational definition of what constitutes a program. To do this, RAND developed the RAND RR-486-ICJ Program Classification Tool (R-PCT) to allow us- Who Pays for Justice? Perspectives on State ers to describe and compare programs, particu- Court System Financing and Governance. Geof- larly those related to psychological health and TBI, frey McGovern, Michael D. Greenberg. 2014 along eight key dimensions. The tool consists of Many state judicial systems experienced sig- a set of questions and responses for consistently nificant cuts to their operating budgets following describing various aspects of programs, along the 2008 financial crisis and during the ensuing with detailed guidance regarding how to select the years of reduced state treasuries. Researchers appropriate responses. The purpose of this report surveyed experts from five states that use a va- is to describe the R-PCT, to help potential users riety of approaches to funding state court sys- understand how it was developed, and to explain tems. The report documents that there is ample how the tool can be used. variation across the states in terms of how their court systems receive their annual funding, how RR-487/2-OSD The RAND Online Measure Repository for they account for and track their budgets, and how Evaluating Psychological Health and Traumatic the court systems are governed. An apprecia- Brain Injury Programs: The RAND Toolkit, Volume tion of these dimensions of difference is crucial 2. Joie D. Acosta, Kerry A. Reynolds, Emily M. Gil- for policymakers, court administrators, and those len, Kevin Carter Feeney, Carrie M. Farmer, Robin concerned about ensuring high levels of access to M. Weinick. 2014 justice through the state courts and the long-term stability of the courts as an institution of govern- Since 2001, U.S. military forces have been ment. engaged in extended conflicts in Iraq and Af- ghanistan. While most military personnel cope RR-487/1-OSD well across the deployment cycle, the opera- The Development and Application of the RAND tional tempo may raise the risk of mental health Program Classification Tool: The RAND Toolkit, problems, such as post-traumatic stress disorder Volume 1. Joie D. Acosta, Gabriella C. Gonzalez, (PTSD) and major depression, and consequenc- Emily M. Gillen, Jeffrey Garnett, Carrie M. Farmer, es from traumatic brain injury (TBI). To support Robin M. Weinick. 2014 servicemembers and their families as they cope As a result of extended military engagements with these challenges, the U.S. Department of De- in Iraq and Afghanistan during the past decade, fense has implemented numerous programs ad- the U.S. Department of Defense (DoD) has imple- dressing biological, social, spiritual, and holistic mented numerous programs to support service- influences on psychological health along the resil- members and family members who experience ience, prevention, and treatment continuum that difficulty handling stress, face mental health chal- focus on a variety of clinical and nonclinical con- lenges, or are affected by a traumatic brain injury cerns.As these efforts have proliferated, evaluat- (TBI). As these efforts have proliferated, it has ing their effectiveness has become increasingly become more challenging to monitor these pro- important. To support the design and implementa- grams and to avoid duplication. To support DoD in tion of program evaluation, RAND developed the 400

RAND Online Measure Repository (ROMR) which the design of the program evaluation used to as- indexes and describes measures related to psy- sess program effectiveness, as a poor evaluation chological health and TBI. The ROMR is a publicly design may lead to incorrect conclusions about the accessible, online, searchable database contain- effectiveness of the program. The second is the ing 171 measures related to psychological health RAND Program Expansion Tool, which provides a and TBI. This report describes the rationale for standardized summary of the quality and outcome developing the ROMR, the content included in the of a program evaluation. The focus of these tools ROMR, and its potential in both civilian and mili- is on decisionmaking around program expansion, tary populations. The ROMR includes information and does not preclude or address initial funding about measure domains, psychometrics, number decisions of particularly promising new programs of items, and costs, which can inform the selec- that may not yet have a solid evidence base. tion of measures for program evaluations. Includ- ed measures address domains of primary impor- RR-487/4-OSD tance to psychological health (PTSD, depression, A Program Manager's Guide for Program Im- anxiety, suicidal ideation, and resiliency) and TBI provement in Ongoing Psychological Health and (cognition, executive functioning, and memory). Traumatic Brain Injury Programs: The RAND Tool- Also identified are measures relevant to military kit, Volume 4. Gery W. Ryan, Carrie M. Farmer, units, such as unit cohesion and force readiness David M. Adamson, Robin M. Weinick. 2014 and preservation. Between 2001 and 2011, the U.S. Department of Defense has implemented numerous programs RR-487/3-OSD to support service members and their families in A Systematic Process to Facilitate Evidence- coping with the stressors from a decade of the Informed Decisionmaking Regarding Program longstanding conflicts in Iraq and Afghanistan. Expansion: The RAND Toolkit, Volume 3. Laurie T. These programs, which address both psychologi- Martin, Coreen Farris, David M. Adamson, Robin cal health and traumatic brain injury (TBI), num- M. Weinick. 2014 ber in the hundreds and vary in their size, scope, While the Department of Defense supports and target population. To ensure that resources more than 200 psychological health and traumatic are wisely invested and maximize the benefits of brain injury programs, it lacks an approach and such programs, RAND developed a tool to help process to systematically develop, track, and as- assess program performance, consider options sess the performance of this portfolio of programs. for improvement, implement solutions, then as- Further, there is not yet a uniform approach to sess whether the changes worked, with the inten- decisionmaking around program support and ex- tion of helping those responsible for managing or pansion of particularly promising, evidence-based implementing programs to conduct assessments programs. This lack of centralized oversight may of how well the program is performing and to result in the proliferation of untested programs implement solutions for improving performance. that are developed without an evidence base; an Specifically, the tool is intended to provide practi- inefficient use of resources; and added cost and cal guidance in program improvement and con- administrative inefficiencies. RAND researchers tinuous quality improvement for all programs. developed a potential model and tools to support a centralized, systematic, and ongoing process to RR-489-KRG help in making decisions around continued pro- An Assessment of the Present and Future gram support, and by which expansion can be fa- Labor Market in the Kurdistan Region—Iraq: Im- cilitated. This report includes two tools. The first is plications for Policies to Increase Private-Sector a Program Abstraction Form, which collects rel- Employment. Howard J. Shatz, Louay Constant, evant background information from programs and Jill E. Luoto, Alexandria C. Smith, Shmuel Abram- asks explicitly about program effectiveness and 401 zon. 2014 The study addresses the question of how the RR-489/2-KRG Kurdistan Regional Government can improve the An Assessment of the Present and Future private-sector labor market in the Kurdistan Re- Labor Market in the Kurdistan Region—Iraq: Im- gion–Iraq (KRI). Doing so will involve creating plications for Policies to Increase Private-Sector mechanisms by which job-seekers can develop Employment (Kurdish-language version). Howard the right skills and find employers who will hire J. Shatz, Louay Constant, Jill E. Luoto, Alexandria them, employers can find the employees they C. Smith, Shmuel Abramzon. 2014 need, and the government can create an enabling The study addresses the question of how the environment in which the best matches between Kurdistan Regional Government can improve the job-seekers and employers can be made. The private-sector labor market in the Kurdistan Re- study estimates the likely number and education gion–Iraq (KRI). Doing so will involve creating levels of new job-seekers through 2020. It con- mechanisms by which job-seekers can develop ducts an original, scientific survey to learn about the right skills and find employers who will hire employer perceptions of skill gaps in the KRI. them, employers can find the employees they Then, it investigates sectoral employment growth need, and the government can create an enabling in comparison economies to identify promising environment in which the best matches between growth sectors. Finally, it outlines policy steps for job-seekers and employers can be made. The the government to take to improve the functioning study estimates the likely number and education of the private-sector labor market. levels of new job-seekers through 2020. It con- ducts an original, scientific survey to learn about RR-489/1-KRG employer perceptions of skill gaps in the KRI. An Assessment of the Present and Future Then, it investigates sectoral employment growth Labor Market in the Kurdistan Region—Iraq: Im- in comparison economies to identify promising plications for Policies to Increase Private-Sector growth sectors. Finally, it outlines policy steps for Employment (Arabic-language version). Howard the government to take to improve the functioning J. Shatz, Louay Constant, Jill E. Luoto, Alexandria of the private-sector labor market. C. Smith, Shmuel Abramzon. 2014 The study addresses the question of how the RR-490-1-KRG Kurdistan Regional Government can improve the Health Sector Reform in the Kurdistan Re- private-sector labor market in the Kurdistan Re- gion—Iraq: Financing Reform, Primary Care, and gion–Iraq (KRI). Doing so will involve creating Patient Safety. C. Ross Anthony, Melinda Moore, mechanisms by which job-seekers can develop Lee H. Hilborne, Andrew W. Mulcahy. 2014 the right skills and find employers who will hire In 2010, the Kurdistan Regional Government them, employers can find the employees they asked the RAND Corporation to help guide re- need, and the government can create an enabling form of the health care system in the Kurdistan environment in which the best matches between Region of Iraq. The overarching goal of reform job-seekers and employers can be made. The was to help establish a health system that would study estimates the likely number and education provide high-quality services efficiently to every- levels of new job-seekers through 2020. It con- one to prevent, treat, and manage physical and ducts an original, scientific survey to learn about mental illnesses and injuries. This report summa- employer perceptions of skill gaps in the KRI. rizes the second phase of RAND's work, when re- Then, it investigates sectoral employment growth searchers analyzed three distinct but intertwined in comparison economies to identify promising health policy issue areas: development of financ- growth sectors. Finally, it outlines policy steps for ing policy, implementation of early primary care the government to take to improve the functioning recommendations, and evaluation of quality and of the private-sector labor market. patient safety. For health financing, the research- 402 ers reviewed the relevant literature, explored the W. Mulcahy. 2014 issue in discussions with key stakeholders, devel- In 2010, the Kurdistan Regional Government oped and assessed various policy options, and asked the RAND Corporation to help guide re- developed plans or approaches to overcome bar- form of the health care system in the Kurdistan riers and achieve stated policy objectives. In the Region of Iraq. The overarching goal of reform area of primary care, they developed and helped was to help establish a health system that would to implement a new management information sys- provide high-quality services efficiently to every- tem. In the area of quality and patient safety, they one to prevent, treat, and manage physical and reviewed relevant literature, discussed issues and mental illnesses and injuries. This report summa- options with health leaders, and recommended an rizes the second phase of RAND's work, when re- approach toward incremental implementation. searchers analyzed three distinct but intertwined health policy issue areas: development of financ- RR-490-KRG Health Sector Reform in the Kurdistan Re- ing policy, implementation of early primary care gion—Iraq: Financing Reform, Primary Care, and recommendations, and evaluation of quality and Patient Safety. C. Ross Anthony, Melinda Moore, patient safety. For health financing, the research- Lee H. Hilborne, Andrew W. Mulcahy. 2014 ers reviewed the relevant literature, explored the issue in discussions with key stakeholders, devel- In 2010, the Kurdistan Regional Government oped and assessed various policy options, and asked the RAND Corporation to help guide re- developed plans or approaches to overcome bar- form of the health care system in the Kurdistan riers and achieve stated policy objectives. In the Region of Iraq. The overarching goal of reform area of primary care, they developed and helped was to help establish a health system that would to implement a new management information sys- provide high-quality services efficiently to every- tem. In the area of quality and patient safety, they one to prevent, treat, and manage physical and reviewed relevant literature, discussed issues and mental illnesses and injuries. This report summa- options with health leaders, and recommended an rizes the second phase of RAND's work, when re- approach toward incremental implementation. searchers analyzed three distinct but intertwined health policy issue areas: development of financ- RR-490/2-KRG ing policy, implementation of early primary care Health Sector Reform in the Kurdistan Re- recommendations, and evaluation of quality and gion—Iraq: Financing Reform, Primary Care, and patient safety. For health financing, the research- Patient Safety (Kurdish-language version). C. ers reviewed the relevant literature, explored the Ross Anthony, Melinda Moore, Lee H. Hilborne, issue in discussions with key stakeholders, devel- Andrew W. Mulcahy. 2014 oped and assessed various policy options, and In 2010, the Kurdistan Regional Government developed plans or approaches to overcome bar- asked the RAND Corporation to help guide re- riers and achieve stated policy objectives. In the form of the health care system in the Kurdistan area of primary care, they developed and helped Region of Iraq. The overarching goal of reform to implement a new management information sys- was to help establish a health system that would tem. In the area of quality and patient safety, they provide high-quality services efficiently to every- reviewed relevant literature, discussed issues and one to prevent, treat, and manage physical and options with health leaders, and recommended an mental illnesses and injuries. This report summa- approach toward incremental implementation. rizes the second phase of RAND's work, when researchers analyzed three distinct but intertwined RR-490/1-KRG Health Sector Reform in the Kurdistan Re- health policy issue areas: development of financ- gion—Iraq: Financing Reform, Primary Care, and ing policy, implementation of early primary care Patient Safety (Arabic-language version). C. Ross recommendations, and evaluation of quality and Anthony, Melinda Moore, Lee H. Hilborne, Andrew patient safety. For health financing, the research- 403 ers reviewed the relevant literature, explored the more significant effects on insurance claim costs, issue in discussions with key stakeholders, devel- including shifts in tort law, changes in physician oped and assessed various policy options, and supply, new pricing approaches under the ac- developed plans or approaches to overcome bar- countable care organization model, and changes riers and achieve stated policy objectives. In the in population health. area of primary care, they developed and helped to implement a new management information sys- RR-495-AF tem. In the area of quality and patient safety, they Improving Demographic Diversity in the U.S. reviewed relevant literature, discussed issues and Air Force Officer Corps. Nelson Lim, Louis T. options with health leaders, and recommended an Mariano, Amy G. Cox, David Schulker, Lawrence approach toward incremental implementation. M. Hanser. 2014 Despite the Air Force's efforts to create a force RR-493-ICJ that mirrors the racial, ethnic, and gender differ- How Will the Patient Protection and Affordable ences of the nation's population, minority groups Care Act Affect Liability Insurance Costs?. David I. and women are underrepresented in the active- Auerbach, Paul Heaton, Ian Brantley. 2014 duty line officer population, especially at senior The Patient Protection and Affordable Care levels (i.e., colonel and above). This report exam- Act (ACA) will greatly expand private coverage ines the reasons for this, with the goal of identifying and Medicaid while making major changes to potential policy responses.The authors analyzed payment rates and the health care delivery sys- data from multiple sources on Air Force eligibil- tem. These changes will affect traditional health ity, youths' intention to serve, accessions, reten- insurers, individuals, and government payers. In tion, and promotion. A key finding is that African addition, a considerable amount of health care is Americans and Hispanics are underrepresented paid for directly by or is indirectly paid for via legal in the Air Force compared with the nation's popu- settlements after the care occurs, by liability insur- lation mainly because they meet Air Force officer ers. This report identifies potential mechanisms eligibility requirements at lower rates (e.g., they through which the ACA might affect claim costs for are much less likely than whites to have a college several major types of liability coverage, especially degree). Another reason for lower representation auto insurance, workers' compensation coverage, of minorities and women among senior leaders and medical malpractice. The authors discuss the is that, once in the military, women and minori- conceptual basis for each mechanism, review ex- ties are less likely to choose career fields that give isting scholarly evidence regarding its importance, them the highest potential to become senior lead- and, where possible, develop rough estimates of ers. In addition, female officers have lower reten- the size and direction of expected impacts as of tion rates than male officers, and the reasons for 2016. They examine how each mechanism might this are not clear. Finally, the authors comprehen- operate across different liability lines and discuss sively examined the Air Force promotion system how variation across states in legal rules, demo- and found no evidence to suggest it treats wom- graphics, and other factors might moderate each en and minorities differently than white men with mechanism's operation. Overall, expected short- similar records. The authors recommend that the term effects of the ACA appear likely to be small Air Force should seek comparable quality across relative to aggregate liability insurer payouts in ethnic/minority groups in the accession process- the markets in question. However, under reason- es, since competitiveness even at this stage is a able assumptions, some mechanisms can gener- predictor of promotion success. More racial/ethnic ate potential cost changes as high as 5 percent minorities and women who are cadets and officers or more in particular states and insurance lines. should be in rated career fields, which have the The authors also discuss longer-run changes that highest promotion rates to the senior ranks. could be fostered by the ACA that might exert RR-499-TEDF 404

Hidden Heroes: America's Military Caregiv- and veterans. These caregivers play an essential ers. Rajeev Ramchand, Terri Tanielian, Michael role in caring for injured or wounded service mem- P. Fisher, Christine Anne Vaughan, Thomas E. bers and veterans. This enables those for whom Trail, Caroline Epley, Phoenix Voorhies, Michael they are caring to live better quality lives, and can Robbins, Eric Robinson, Bonnie Ghosh-Dastidar. result in faster and improved rehabilitation and 2014 recovery. Yet playing this role can impose a sub- While much has been written about the role of stantial physical, emotional, and financial toll on caregiving for the elderly and chronically ill and for caregivers. This summary distills a longer report, children with special needs, little is known about Hidden Heroes: America's Military Caregivers, “military caregivers”—the population of those who which describes the results of a study designed care for wounded, ill, and injured military person- to describe the magnitude of military caregiving in nel and veterans. These caregivers play an essen- the United States today, as well as to identify gaps tial role in caring for injured or wounded service in the array of programs, policies, and initiatives members and veterans. This enables those for designed to support military caregivers. Improv- whom they are caring to live better quality lives, ing military caregivers' well-being and ensuring and can result in faster and improved rehabilita- their continued ability to provide care will require tion and recovery. Yet playing this role can impose multifaceted approaches to reducing the current a substantial physical, emotional, and financial toll burdens caregiving may impose, and bolstering on caregivers. This report summarizes the results their ability to serve as caregivers more effectively. of a study designed to describe the magnitude of Given the systematic differences among military military caregiving in the United States today, as caregiver groups, it is also important that tailored well as to identify gaps in the array of programs, approaches meet the unique needs and charac- policies, and initiatives designed to support mili- teristics of post-9/11 caregivers. tary caregivers. Improving military caregivers' RR-500-OSD well-being and ensuring their continued ability to Soldier-Portable Battery Supply: Foreign De- provide care will require multifaceted approaches pendence and Policy Options. Richard Silberglitt, to reducing the current burdens caregiving may James T. Bartis, Kyle Brady. 2014 impose, and bolstering their ability to serve as caregivers more effectively. Given the systematic Batteries are a ubiquitous presence in equip- differences among military caregiver groups, it is ment carried by soldiers and critical to the per- also important that tailored approaches meet the formance of electronic devices such as radios, unique needs and characteristics of post-9/11 computers, night-vision goggles, and laser range caregivers. finders. These batteries are supplied by a variety of firms, and mostly assembled from cells that are RR-499/1-TEDF acquired through a supply chain that is driven by Hidden Heroes: America's Military Caregiv- commercial applications to mobile phones, lap- ers — Executive Summary. Rajeev Ramchand, top computers, tablets, and other electronic de- Terri Tanielian, Michael P. Fisher, Christine Anne vices, and is predominately based in Asia. RAND Vaughan, Thomas E. Trail, Caroline Epley, Phoe- found that government researchers and program nix Voorhies, Michael Robbins, Eric Robinson, managers and representatives of military bat- Bonnie Ghosh-Dastidar. 2014 tery suppliers have concerns associated with this While much has been written about the role of foreign-dependent supply chain. The report dis- caregiving for the elderly and chronically ill and for cusses alternative policy options to address these children with special needs, little is known about concerns, without evaluating the benefits versus “military caregivers”—the population of those who costs of these policy options. care for wounded, ill, and injured military personnel RR-501-OSD 405

Toward Meaningful Military Compensation Re- Shanley, Carra S. Sims, Bryan W. Hallmark, Anna form: Research in Support of DoD's Review. Beth Rosefsky Saavedra, Stoney Trent, Sean Duggan. J. Asch, James Hosek, Michael G. Mattock. 2014 2014 Pressure to reduce the federal deficit, planned The Asymmetric Warfare Group offers the reductions in strength, concerns about cost, and Asymmetric Warfare Adaptive Leader Program perceptions expressed by military leaders, past (AWALP)—a 10-day course designed to enhance commissions, and studies about the lack of fair- adaptive performance in leaders and promote ness of the military compensation system have innovative solutions in training in support of uni- placed increased attention on military compen- fied land operations. This report describes results sation as an area for reform. In September 2011, of a systematic evaluation of AWALP, offers rec- the Office of the Secretary of Defense convened a ommendations to improve the course, and pro- working group of senior representatives through- vides recommendations for ongoing evaluation of out the Department of Defense (DoD) to conduct AWALP and other courses or events that address a comprehensive review of military compensation, adaptive performance and acquisition of other in- focusing on retirement compensation. The group's tangible skills. The study used a pretest-posttest deliberations built on the findings of past reviews design and collected data from 104 students who and were informed by RAND's analysis over the 18 participated in AWALP. Results show substantial months that the group met. We used and extended improvement in training outcomes, including stu- RAND's dynamic retention model to assess many dents' self-efficacy for being adaptive and leading proposals for their effects on active and reserve re- adaptive teams and knowledge of course con- tention and cost—that culminated in assisting the cepts. Graduates also reported that they were ap- group to identify two broad design concepts. We plying course concepts on the job after returning also evaluated options for implementing reforms to their units. In addition, students had exception- in the transition to the steady state (i.e., when all ally favorable reactions to AWALP and remained service members are receiving retirement benefits extremely positive about the course three months under the new retirement system), and we evalu- after graduation. Results indicate few needs for ated proposals for disability compensation reform. improvement in the course; the most important The two design concepts retain positive aspects area to address is challenges in applying con- of the current system while addressing criticisms cepts on the job because of the command climate of the system related to the fairness and fiscal and entrenched leadership. Recommendations for sustainability. Our analysis shows that both con- ongoing evaluation focus on obtaining additional cepts are feasible, provide cost savings, improve measures of adaptive performance, particularly to equity, potentially add force management flexibil- establish the impact of AWALP on subsequent job ity, and simplify the DoD disability compensation performance. The current success of AWALP sug- system. We find that DoD cost savings begin at gests that its approach to training might be useful- once, while Treasury outlays initially increase and ly expanded in the Army, and the authors discuss later decrease below baseline outlays. Allowing strategies to achieve broader dissemination. Fi- members grandfathered under the old system to nally, the authors describe how the methods used participate in the new system hastens both effects. in this study might be applied to evaluating related Both concepts give rise to the same willingness to training in other contexts. stay in service, and so sustain readiness by maintaining force size and experience. RR-506-DH Venture Research: Fostering trust and freedom RR-504-A in research funding. Catherine A Lichten, Marco Innovative Leader Development: Evaluation Hafner, Steven Wooding. 2014 of the U.S. Army Asymmetric Warfare Adaptive This report is a summary of Donald Braben's Leader Program. Susan G. Straus, Michael G. work with BP's Venture Research Unit (VRU), a 406 research funding initiative that ran from 1980 to Leaders agrees to provide carefully selected and 1990. It is based on Braben's reports in his books trained principals who can be placed in schools Pioneering Research and Scientific Freedom. that need principals and to provide coaching and The VRU provided £20 million in research fund- other support after those principals are placed. ing to about 30 researchers and small teams from The districts and CMOs agree to establish work- Europe and North America. It aimed to fund de- ing conditions that support, rather than hinder, the termined researchers who questioned current principals' efforts to improve student outcomes. thinking and would do transformative work. An im- This report describes how the New Leaders pro- portant driver of the VRU approach was the idea gram was implemented in partner districts, and it that researchers with radical ideas would struggle provides evidence of the effect that New Leaders to obtain funding through traditional means. Trust has on student achievement. and freedom were considered essential aspects of the approach, and the unit's organisers sought RR-507/1-NL to minimise administrative burdens. Though VRU- Improving School Leadership Through District funded work led to several notable outcomes, Partnerships: Implementation and Effects of New similar initiatives have not been introduced on a Leaders—Appendix. Susan M. Gates, Laura S. large scale in the UK. RAND Europe researchers Hamilton, Paco Martorell, Susan Burkhauser, initially came across Don Braben's work in 2005 Paul Heaton, Ashley Pierson, Matthew Baird, in the course of supporting the UK Department of Mirka Vuollo, Jennifer J. Li, Diana Catherine Lav- Health's Research and Development Directorate ery, Melody Harvey, Kun Gu. 2014 in developing a new R&D strategy. We produced This document presents technical appendixes an initial summary of Braben's work for that direc- to supplement the main evaluation report. torate. Because it has generated ongoing interest, we have produced this brief report – an updated RR-512-SGC version of the original, intended for public distribu- The Structural Genomics Consortium: A knowl- tion. edge platform for drug discovery. Molly Morgan Jones, Sophie Castle-Clarke, Daniel Brooker, RR-507-NL Edward Nason, Farah Huzair, Joanna Chataway. Preparing Principals to Raise Student Achieve- 2014 ment: Implementation and Effects of the New Leaders Program in Ten Districts. Susan M. The Structural Genomics Consortium (SGC) Gates, Laura S. Hamilton, Paco Martorell, Susan supports drug discovery efforts through a unique, Burkhauser, Paul Heaton, Ashley Pierson, Mat- open access model of public-private collabora- thew Baird, Mirka Vuollo, Jennifer J. Li, Diana tion. This report presents the results of an inde- Catherine Lavery, Melody Harvey, Kun Gu. 2014 pendent evaluation of the Structural Genomics Consortium, conducted by RAND Europe with the New Leaders is a nonprofit organization with Institute on Governance. The evaluation aimed to a mission to ensure high academic achievement establish the role of the SGC within the wider drug for all students by developing outstanding school discovery and PPP landscape, assessing the mer- leaders to serve in urban schools. Its premise is its of the SGC open access model relative to al- that a combination of preparation and improved ternative models of funding R&D in this space, as working conditions for principals, especially great- well as the key trends and opportunities in the ex- er autonomy, would lead to improved student ternal environment that may impact on the future outcomes. Its approach involves both preparing of the SGC. It also established the incentives and principals and partnering with school districts and disincentives for investment, strengths and weak- charter management organizations (CMOs) to nesses of the SGC's model, and the opportunities improve the conditions in which its highly trained and threats the SGC will face in the future. This principals work. As part of the partnerships, New enabled us to assess the most convincing argu- 407 ments for funding the SGC at present; important RR-513-SRF trade-offs or limitations that should be addressed Countering Others' Insurgencies: Understand- in moving towards the next funding phase; and ing U.S. Small-Footprint Interventions in Local whether funders are anticipating changes either Context. Stephen Watts, Jason H. Campbell, Pat- to the SGC or the wider PPP landscape. Finally, rick B. Johnston, Sameer Lalwani, Sarah H. Bana. we undertook a quantitative analysis to ascertain 2014 what judgements can be made about the SGC's This study examines the counterinsurgency past and current performance track record, before strategies and practices adopted by threatened unpacking the role of the external environment regimes and the conditions under which U.S. and particular actors within the SGC in develop- “small-footprint” partnerships are likely to help ing scenarios for the future. these governments succeed. The report's findings are derived from a mixed-method research design RR-512/1-SGC incorporating both quantitative and qualitative The Structural Genomics Consortium: A knowl- analysis. Simple statistical analyses are applied to edge platform for drug discovery: A summary. a dataset of counterinsurgencies that have termi- Molly Morgan Jones, Sophie Castle-Clarke, Dan- nated since the end of the Cold War (72 in all), iel Brooker, Edward Nason, Farah Huzair, Joanna and more in-depth analyses are provided of two Chataway. 2014 recent cases of U.S. partnerships with counterin- The Structural Genomics Consortium (SGC) surgent regimes, in the Philippines and Pakistan. supports drug discovery efforts through a unique, The quantitative analysis finds that the cases of open access model of public-private collabora- small-footprint U.S. operations that are commonly tion. This report presents the results of an inde- touted as “success stories” all occurred in coun- pendent evaluation of the Structural Genomics tries approximating a best-case scenario. Such Consortium, conducted by RAND Europe with the a verdict is not meant to deny the importance of Institute on Governance. The evaluation aimed to U.S. assistance; rather, it is meant to highlight that establish the role of the SGC within the wider drug similar U.S. policies with less promising partner discovery and PPP landscape, assessing the mer- nations should not be expected to produce any- its of the SGC open access model relative to al- where near the same levels of success. The major- ternative models of funding R&D in this space, as ity of insurgencies have taken place in worst-case well as the key trends and opportunities in the ex- conditions, and in these environments, counter- ternal environment that may impact on the future insurgent regimes are typically unsuccessful in of the SGC. It also established the incentives and their efforts to end rebellion, and they often em- disincentives for investment, strengths and weak- ploy violence indiscriminately. The case studies nesses of the SGC's model, and the opportunities of the Philippines and Pakistan largely reinforce and threats the SGC will face in the future. This the findings of the quantitative analysis. They also enabled us to assess the most convincing argu- highlight the challenges the United States faces ments for funding the SGC at present; important in attempting to influence partner regimes to fight trade-offs or limitations that should be addressed counterinsurgencies in the manner that the Unit- in moving towards the next funding phase; and ed States would prefer. The study concludes with whether funders are anticipating changes either policy recommendations for managing troubled to the SGC or the wider PPP landscape. Finally, partnerships. we undertook a quantitative analysis to ascertain what judgements can be made about the SGC's RR-514-OSD past and current performance track record, before The Federal Civil Service Workforce: Assessing unpacking the role of the external environment the Effects on Retention of Pay Freezes, Unpaid and particular actors within the SGC in develop- Furloughs, and Other Federal-Employee Com- ing scenarios for the future. pensation Changes in the Department of Defense. Beth J. Asch, Michael G. Mattock, James Hosek. 408

2014 economic spheres and how they work to achieve Planners and policymakers must be able to them, (2) African perceptions of Chinese engage- assess how compensation policy, including pay ment, (3) how China has adjusted its policies to freezes and unpaid furloughs, affects retention. accommodate often-hostile African responses, This study begins to extend the dynamic reten- and (4) whether the United States and China are tion model (DRM)—a structural, stochastic, dy- competing for influence, access, and resources namic, discrete-choice model of individual behav- in Africa and how they might cooperate in the re- ior—to federal civil service employment. Models gion. The authors find that Chinese engagement are developed and estimated,using 24 years of in the region is primarily concerned with natural data, and then used to simulate the effects of pay resource extraction, infrastructure development, freezes and unpaid furloughs. A permanent three- and manufacturing, in contrast to the United year pay freeze decreases the size of the retained States' focus on higher-technology trade and ser- General Service (GS) workforce with at least a vices as well as aid policies aimed at promoting baccalaureate degree by 7.3 percent in the steady democracy, good governance, and human devel- state. A temporary pay freeze with pay immedi- opment. African governments generally welcome ately restored has virtually no impact on retention. engagement with China, as it brings them politi- When pay is restored after ten years, the retained cal legitimacy and contributes to their economic GS workforce falls by 2.8 percent five years after development. Some segments of African society the pay freeze and 3.5 percent ten years after it. criticize Chinese enterprises for their poor labor An unpaid furlough, similar to the six-day federal conditions, unsustainable environmental prac- furlough in 2013, has no discernible effect on re- tices, and job displacement, but China has been tention. For all subgroups of GS employees for modifying its approach to the continent to address which the model is estimated, the model fit to the these concerns. China and the United States are actual data is excellent, and all of the model pa- not strategic rivals in Africa, but greater American rameter estimates are statistically significant. In commercial engagement in African markets could future work, the DRM could be extended to pro- generate competition that would both benefit Afri- vide empirically based simulations of the impact can countries and advance U.S. interests. of other policies on retention; to estimate effects RR-522-WWP on other occupational areas, other pay systems, Health and Economic Outcomes Among the or specific demographic groups; or to create a “to- Alumni of the Wounded Warrior Project: 2013. tal force” model (military and civilian) of DoD re- Jennifer L. Cerully, Mustafa Oguz, Heather Krull, tention dynamics and the effects of compensation Kate Giglio. 2014 on those dynamics. The Wounded Warrior Project (WWP) offers RR-521-OSD support and raises public awareness of service Chinese Engagement in Africa: Drivers, Re- members who have experienced physical or men- actions, and Implications for U.S. Policy. Larry tal health conditions associated with their service Hanauer, Lyle J. Morris. 2014 on or after September 11, 2001. In this report, the Most analyses of Chinese engagement in Af- authors use WWP's 2013 survey of its members rica focus either on what China gets out of these (alumni) to understand the physical, mental, and partnerships or the impacts that China's aid and economic challenges that Wounded Warriors face. investment have had on African countries. This The researchers find that at least half of alumni re- analysis approaches Sino-African relations as a ported dealing with mental health conditions such vibrant, two-way dynamic in which both sides ad- as depression and posttraumatic stress disorder, just to policy initiatives and popular perceptions and many of these alumni reported difficulties or emanating from the other. The authors focus on (1) delays in seeking mental health care, or not doing Chinese and African objectives in the political and so at all. Alcohol misuse also poses a problem. 409

A large proportion of alumni are overweight or on an outpatient basis but does not include evi- obese, conditions that negatively affect their daily denced-based selection criteria to suggest which lives, exercise routines, and overall health. Almost patients are appropriate candidates for having the half of alumni are not working, and there is low procedures in an outpatient setting. participation in veteran-specific employment and education programs. This information can be used RR-525-AF to better understand the needs of WWP alumni China's Strategy Toward South and Central and the ways that WWP can serve and support Asia: An Empty Fortress. Andrew Scobell, Ely this constituency. Ratner, Michael Beckley. 2014 This study analyzes what is driving China's RR-524-DIR Central Asia and Afghanistan-Pakistan policies, Ambulatory Surgical Services Provided Un- identifies China's overarching strategy, examines der California Workers' Compensation: An As- the extent of Chinese activities in the region, and sessment of the Feasibility and Advisability of assesses their implications for the United States. Expanding Coverage. Barbara O. Wynn, John P. The authors contend that China's response to the Caloyeras, Nelson F. Soohoo. 2014 complex challenges on its western borders during The California Department of Industrial Rela- the past two decades has been to adopt an “Empty tions asked RAND to examine the feasibility and Fortress” strategy, whereby China boldly projects appropriateness of including procedures that are an image of considerable strength in Central and typically performed only in an inpatient setting on South Asia to mask serious frailty. They conclude the workers' compensation Official Medical Fee that China is not a major threat to U.S. interests in Schedule for ambulatory surgical center facility Central Asia, Afghanistan, or Pakistan and is un- fees. The authors used interviews, literature re- likely to pose one in the near future. view, and data analysis to assemble information on the requirements applicable to ASCs, assess RR-527-1-WFHF how the criteria that Medicare uses to assess Evaluation of the Population and Poverty Re- whether procedures can be safely performed in search Initiative (PopPov). Julie DaVanzo, Sebas- an outpatient setting apply to the workers' com- tian Linnemayr, Peter Glick, Eric Apaydin. 2014 pensation patient population, and to examine al- Since 2005, the William and Flora Hewlett ternative methods for establishing fee schedule Foundation, with collaboration and co-funding amounts. The study focused on 23 high-volume from research councils in the United Kingdom, workers' compensation inpatient procedures with the Netherlands, France, and Norway and from relatively short average lengths of stay. The report the World Bank, has invested in a portfolio of so- finds that most ASCs that are currently eligible cial science research on the relationship between for facility fees are equipped to provide services population dynamics and micro- and macroeco- that do not require a one-night stay. However, the nomic outcomes. It is known as the Population data analyses and literature review did not provide and Poverty Research Initiative (PopPov), and its strong support for adding any procedures to the geographic focus is on sub-Saharan Africa (SSA). fee schedule with the possible exception of pro- The starting premises that led to the development cedures related to cervical spinal fusions. Other of PopPov were that evidence showing that popu- than instrumentation used in conjunction with spi- lation dynamics could affect economic outcomes nal fusions, relatively few of the study procedures might increase the interest of ministers of finance are being performed in an ambulatory setting on in funding population policies and that they might either WC or privately insured patients ages 18– be most convinced by rigorous research done by 64. The literature suggests that two-level anterior respected economists. The core aim of the pro- cervical fusions and the use of instrumentation for gram has been to build or rebuild and advance the one- or two-level fusions can be performed safely field of economic demography, orienting the work 410 toward research that would be relevant for policy preparing their doctoral dissertations, (3) confer- and would increase recognition by economic poli- ences and workshops to support the development cymakers of the value of lowering the rate of popu- of networking opportunities, and (4) other dissem- lation growth and investing in family planning. The ination activities. This report provides results of a program also aimed to strengthen the capacity of RAND Corporation evaluation of PopPov. researchers in SSA. PopPov tried to achieve these aims through four main components: (1) grants to RR-527/1-WFHF support research on PopPov core topics of inter- Evaluation of the Population and Poverty Re- est, (2) fellowships to support graduate students search Initiative (PopPov): Executive Summary. preparing their doctoral dissertations, (3) confer- Julie DaVanzo, Sebastian Linnemayr, Peter Glick, ences and workshops to support the development Eric Apaydin. 2014 of networking opportunities, and (4) other dissem- Since 2005, the William and Flora Hewlett ination activities. This report provides results of a Foundation, with collaboration and co-funding RAND Corporation evaluation of PopPov. from research councils in the United Kingdom, the Netherlands, France, and Norway and from RR-527-WFHF the World Bank, has invested in a portfolio of so- Evaluation of the Population and Poverty Re- cial science research on the relationship between search Initiative (PopPov). Julie DaVanzo, Sebas- population dynamics and micro- and macroeco- tian Linnemayr, Peter Glick, Eric Apaydin. 2014 nomic outcomes. It is known as the Population Since 2005, the William and Flora Hewlett and Poverty Research Initiative (PopPov), and its Foundation, with collaboration and co-funding geographic focus is on sub-Saharan Africa (SSA). from research councils in the United Kingdom, The starting premises that led to the development the Netherlands, France, and Norway and from of PopPov were that evidence showing that popu- the World Bank, has invested in a portfolio of so- lation dynamics could affect economic outcomes cial science research on the relationship between might increase the interest of ministers of finance population dynamics and micro- and macroeco- in funding population policies and that they might nomic outcomes. It is known as the Population be most convinced by rigorous research done by and Poverty Research Initiative (PopPov), and its respected economists. The core aim of the pro- geographic focus is on sub-Saharan Africa (SSA). gram has been to build or rebuild and advance the The starting premises that led to the development field of economic demography, orienting the work of PopPov were that evidence showing that popu- toward research that would be relevant for policy lation dynamics could affect economic outcomes and would increase recognition by economic poli- might increase the interest of ministers of finance cymakers of the value of lowering the rate of popu- in funding population policies and that they might lation growth and investing in family planning. The be most convinced by rigorous research done by program also aimed to strengthen the capacity of respected economists. The core aim of the pro- researchers in SSA. PopPov tried to achieve these gram has been to build or rebuild and advance the aims through four main components: (1) grants to field of economic demography, orienting the work support research on PopPov core topics of inter- toward research that would be relevant for policy est, (2) fellowships to support graduate students and would increase recognition by economic poli- preparing their doctoral dissertations, (3) confer- cymakers of the value of lowering the rate of popu- ences and workshops to support the development lation growth and investing in family planning. The of networking opportunities, and (4) other dissem- program also aimed to strengthen the capacity of ination activities. This report provides results of a researchers in SSA. PopPov tried to achieve these RAND Corporation evaluation of PopPov. aims through four main components: (1) grants to support research on PopPov core topics of inter- RR-529 est, (2) fellowships to support graduate students Evaluating the "Keep Your Health Plan Fix": Implications for the Affordable Care Act Compared 411 to Legislative Alternatives. Evan Saltzman, Chris- enlisted personnel and officers and for both the tine Eibner. 2014 steady state and the transition to it. For reservists President Obama's promise that Americans with prior AC service, the analysis suggests that could keep their existing health care plans un- these potential changes to the retirement system der the Affordable Care Act (ACA) has received would lead to higher RC participation in midcareer increased scrutiny in the wake of millions of years and lower participation after retirement vest- Americans having their plans cancelled. These ing, relative to the current system. For reservists cancellations primarily occurred in the individual with no prior AC service, RC participation would or nongroup market, where individuals purchase be largely unchanged. AC retention would be high- health care plans directly from an insurer instead er in midcareer years but lower prior to 20 years of of through an employer. Many such plans do not service. Because these changes in AC retention meet the minimum coverage requirements of the are small, overall the RC retirement proposal is ACA, leading insurers to send plan-cancellation not likely to have an adverse consequence for the notices to their enrollees.This report describes a AC force. Army personnel costs would decrease comparative analysis of three proposals to reme- by $800 million per year, mainly because the AC dy the situation: one by the White House, another force would become more junior and its members by Senator Mary Landrieu (D-LA), and a third by would leave the Army with less seniority. Representative Fred Upton (R-MI). The proposals RR-531-NIJ are evaluated based on their potential impact on Evaluation of the Shreveport Predictive Policing the ACA-compliant market and the cost and cov- Experiment. Priscillia Hunt, Jessica Saunders, erage of health insurance. The possibility of each John S. Hollywood. 2014 proposal causing a “death spiral,” in which rising premiums and decreasing enrollment undermine Even though there is a growing interest in pre- the viability of the ACA-compliant market, is also dictive policing, to date there have been few, if any, addressed.The authors find that the three propos- formal evaluations of these programs. This report als vary from slight to moderate impact on ACA documents an assessment of a predictive polic- premiums, enrollment, and federal spending, but ing effort in Shreveport, Louisiana, in 2012, which none of them would result in the unraveling of the was conducted to evaluate the crime reduction ef- ACA-compliant market. fects of policing guided by statistical predictions. RAND researchers led multiple interviews and RR-530-A focus groups with the Shreveport Police Depart- Making the Reserve Retirement System Similar ment throughout the course of the trial to docu- to the Active System: Retention and Cost Esti- ment the implementation of the statistical predic- mates. Michael G. Mattock, Beth J. Asch, James tive and prevention models. In addition to a basic Hosek. 2014 assessment of the process, the report shows the The Army asked the RAND Arroyo Center to crime impacts and costs directly attributable to the analyze a proposal allowing vested reservists to strategy. It is hoped that this will provide a fuller receive military retirement benefits immediately picture for police departments considering if and upon retiring from the Selected Reserve, just as how a predictive policing strategy should be ad- vested members of the active component (AC) to- opted.There was no statistically significant change day receive retirement benefits immediately upon in property crime in the experimental districts that retiring from the active component. The study team applied the predictive models compared with the used RAND's dynamic retention model to analyze control districts; therefore, overall, the intervention the effects of this potential change on the size and was deemed to have no effect. There are both sta- experience mix of the Army reserve component tistical and substantive possibilities to explain this (RC) (Army National Guard and Army Reserve) null effect. In addition, it is likely that the predictive and the Army AC. This analysis was done for both 412 policing program did not cost any more than the implementation of sexual assault prevention pro- status quo. grams across the U.S. Department of Defense (DoD). Alcohol misuse is also a problem in the RR-534-ONDCP military: One-third of active-duty service members What America's Users Spend on Illegal Drugs, reported binge drinking, a rate that compares un- 2000–2010. Beau Kilmer, Susan S. Everingham, favorably with that of their civilian counterparts. Jonathan P. Caulkins, Gregory Midgette, Rosalie DoD has invested considerable resources in uni- Liccardo Pacula, Peter H. Reuter, Rachel M. versal sexual assault prevention programs and so- Burns, Bing Han, Russell Lundberg. 2014 cial media campaigns, but evaluation results are In January 2012, the U.S. White House Office not yet available, and the effectiveness of these of National Drug Control Policy (ONDCP) asked programs is unclear. Research on civilian popu- RAND to generate national estimates of the total lations—particularly college students, who share number of users, total expenditures, and total con- some characteristics with junior enlisted person- sumption for four illicit drugs from 2000 to 2010: nel—could provide insights for DoD. For example, cocaine (including crack), heroin, marijuana, the research indicates a connection between al- and methamphetamine. Drug users in the United cohol and aggression, including sexual aggres- States spend on the order of $100 billion annu- sion. Alcohol can also have a range of effects on ally on these drugs (in 2010 dollars). While this to- the risk of victimization—from a reduced aware- tal figure has been stable over the decade, there ness of risk indicators to incapacitation or uncon- have been important compositional shifts. From sciousness. An extensive review of the existing re- 2006 to 2010, the amount of marijuana consumed search provides some guidance for how DoD can in the United States likely increased more than 30 implement and evaluate efforts to reduce alcohol percent, while the amount of cocaine consumed misuse as part of a larger strategy to reduce the in the United States decreased by approximately incidence of sexual assault among members of 50 percent. These figures are consistent with sup- the armed forces. ply-side indicators, such as seizures and production estimates. Methamphetamine consumption RR-539-CSMC Mapping Gender Differences in Cardiovascular rose sharply from 2000 through the middle of the Disease and Diabetes Care: A Pilot Assessment decade, and this was followed by a large decline of LDL Cholesterol Testing Rates in a California through 2008. Heroin consumption remained fairly Health Plan. Chloe E. Bird, Allen Fremont, Mark stable throughout the decade, although there is Hanson. 2014 some evidence of an increase in the later years. For all of the drugs, total consumption and expen- Despite improvements over recent decades ditures are driven by the minority of users who in care for cardiovascular disease (CVD) and dia- consume on 21 or more days each month. betes, which is a major CVD risk factor, evidence suggests that the care women receive—and their RR-538-OSD health outcomes—continue to lag behind those Targeting Alcohol Misuse: A Promising Strategy of men, even for routine care, such as monitor- for Reducing Military Sexual Assaults?. Coreen ing and control of cholesterol. Awareness of and Farris, Kimberly A. Hepner. 2014 action to address gender gaps in women's CVD On the 2012 Workplace and Gender Rela- care are limited, in part, because quality of care tions Survey on Active Duty Service Members, 23 is not routinely measured and reported by gen- percent of female and 4 percent of male service der. This pilot project describes and maps gender members indicated that they had experienced differences in CVD and diabetes care using data a completed or attempted sexual assault during from a large health plan. The study aims to identify their military service. In addition, official numbers gender gaps in care in California and, where they show no decline in sexual assaults, despite the are found, to increase awareness of potential gen- 413 der disparities and begin to inform approaches to tions in a wide range of situations. address gaps in care. The study assesses gender differences in one key aspect of routine CVD RR-543-OSD care and related prevention among patients with Options for Department of Defense Total diabetes: low-density lipoprotein (LDL) cholesterol Workforce Supply and Demand Analysis: Potential screening. The results from this study are intended Approaches and Available Data Sources. Shanthi to provide the basis for further work to learn and Nataraj, Christopher Guo, Philip Hall-Partyka, document what it will take to rapidly spread map- Susan M. Gates, Douglas Yeung. 2014 ping approaches that prove to be helpful in under- This report provides a review of approaches standing and addressing disparities in health and used in the private sector and in government or- health care, particularly with regard to improving ganizations for determining workforce supply and women's health outcomes. Key findings include demand and describes the data sources available that men had higher rates of LDL screening than to U.S. Department of Defense managers to sup- did women in both the CVD and diabetes popu- port workforce analysis from a total force perspec- lations. These gaps varied by age and insurance tive. Each of the approaches discussed in this type. In addition, mapping gender gaps revealed document has strengths and weaknesses. The larger gaps at local levels than were apparent at best approach will depend on the question that the state or regional level. needs to be addressed and the resources (data and expertise) available. The report highlights crit- RR-541-RC ical workforce analysis choices facing managers Strategy-Policy Mismatch: How the U.S. Army regarding the scope of analysis, the level of ag- Can Help Close Gaps in Countering Weapons gregation, the type of projection techniques that of Mass Destruction. Timothy M. Bonds, Eric V. will be used, the time period over which histori- Larson, Derek Eaton, Richard E. Darilek. 2014 cal analysis of projections will be conducted, and Although two successive presidents have the data sources to be used. The authors describe determined that weapons of mass destruction existing data sources and discuss their strengths (WMD)—particularly nuclear weapons in the and weaknesses as an input into the workforce hands of violent extremists—pose the greatest supply and demand analysis approaches de- threat to the American people, and have decided scribed in this report. They also evaluate exist- that countering their proliferation is a top strategic ing data sources in light of their ability to support priority, neither administration has made counter- workforce gap analyses at the organizational and ing WMD a priority when it comes to allocating occupational levels, as well as by competency. budgetary resources to that overarching national mission. In the public domain, little analysis exists RR-544-PI that assesses the capacity and capabilities re- Health and Healthcare: Assessing the Real quired by military forces to conduct WMD elimina- World Data Policy Landscape in Europe. Celine tion (WMD-E) operations. As a result, public dis- Miani, Enora Robin, Veronika Horvath, Catriona cussion of what capabilities the military requires Manville, Jonathan Cave, Joanna Chataway. 2014 for such operations generally omits or gives short Real-world data (RWD) is an umbrella term shrift to requirements for the WMD-E mission. for different types of data that are not collected in The purpose of this report is to address and ana- conventional randomised controlled trials. RWD in lyze those requirements, namely, the ground force the healthcare sector comes from various sources capacity (force size) and capabilities (force struc- and includes patient data, data from clinicians, ture) needed to accomplish WMD-E missions and hospital data, data from payers and social data. tasks. In particular, these analyses provide an in- There are already examples of ways in which formed description of the types and size of U.S. research has contributed to the provision, con- Army forces required to conduct WMD-E opera- struction and capture of RWD to improve health 414

outcomes. However, to maximise the potential of Mental Health Services Administration's service these new pools of data in the healthcare sector, grant programs, is intended to improve the over- stakeholders need to identify pathways and pro- all wellness and physical health status of people cesses which will allow them to efficiently access with serious mental illness, including individuals and use RWD in order to achieve better research with co-occurring substance use disorders, by outcomes and improved healthcare delivery. Cur- making available an array of coordinated primary rent efforts to improve access to RWD and facil- care services in community mental health and itate its use take place in a context of resource other community-based behavioral health settings scarcity. Based on a literature review, case stud- where the population already receives care. This ies, a small set of interviews of experts from public report describes the results of a RAND Corpora- and private organisations and a scenario based tion evaluation of the PBHCI grants program. The workshop, the study outlined possible strategies to evaluation was designed to understand PBHCI im- illustrate how RWD standards development could plementation strategies and processes, whether facilitate RWD-based research. By investigating the program leads to improvements in outcomes, the current forms and uses of RWD in Europe, this and which program models and/or model features study has highlighted their significant potential for lead to better program processes and consumer assessing the (short- or long-term) impact of dif- outcomes. Results of the evaluation showed that ferent drugs or medical treatments and for inform- PBHCI grantee programs were diverse, varying ing and improving healthcare service delivery. in their structures, procedures, and the extent to Although the potential of RWD use seems quite which primary and behavioral health care was clear, this research reveals barriers that restrict integrated at the program level. Overall, PBHCI further development towards its full exploitation: programs also served many consumers with high the absence of common standards for defining rates of physical health care needs, although to- the content and quality of RWD methodologi- tal program enrollment was lower than expected. cal barriers that may limit the potential benefits of The results of a small, comparative effectiveness RWD analysis governance issues underlying the study showed that consumers served at PBHCI absence of standards for collaboration between clinics (compared to those served at matched con- stakeholders privacy concerns and binding data trol clinics) showed improvements on some (e.g., protection legislation which can be seen to restrict markers of dyslipidemia, hypertension, diabetes) access and use of data. but not all of the physical health indicators studied (e.g., smoking, weight). Finally, we found that pro- RR-546-DHHS gram features, such as clinic hours, regular staff Evaluation of the SAMHSA Primary and Be- meetings, and the degree of service integration, havioral Health Care Integration (PBHCI) Grant increased consumer access to integrated care, Program: Final Report (Task 13). Deborah M. but that access to integrated care was not directly Scharf, Nicole K. Eberhart, John W. Schmidt, Mar- associated with improvements in physical health. cela Horvitz-Lennon, Robin Beckman, Bing Han, Implications of the study results for programs and Susan L. Lovejoy, Harold Alan Pincus, M. Audrey the broader field, plus options for future PBHCI- Burnam. 2014 related research are discussed. Excess morbidity and mortality in persons with serious mental illness is a public health crisis. Nu- RR-548/1 Mexico Is Not Colombia: Alternative Historical merous factors contribute to this health disparity, Analogies for Responding to the Challenge of Vio- including illness and treatment-related factors, so- lent Drug-Trafficking Organizations. Christopher cioeconomic and lifestyle-related factors, and lim- Paul, Colin P. Clarke, Chad C. Serena. 2014 ited access to and poor quality of general medical care. Primary and Behavioral Health Care Integra- tion (PBHCI), one of the Substance Abuse and 415

Drug-related violence has become a very seri- Drug-related violence has become a very serious problem in Mexico. Of particular concern to ous problem in Mexico. Of particular concern to U.S. policymakers, violent drug-trafficking organi- U.S. policymakers, violent drug-trafficking organizations produce, transship, and deliver tens of bil- zations produce, transship, and deliver tens of bil- lions of dollars' worth of narcotics into the United lions of dollars worth of narcotics into the United States annually. The activities of these organiza- States annually. The activities of these organizations are not confined to drug trafficking; they ex- tions are not confined to drug trafficking; they extend to such criminal enterprises as human traf- tend to such criminal enterprises as human trafficking, weapon trafficking, kidnapping, money ficking, weapon trafficking, kidnapping, money laundering, extortion, bribery, and racketeering. laundering, extortion, bribery, and racketeering. Then, there is the violence: Recent incidents have Then, there is the violence: Recent incidents have included assassinations of politicians and judges; included assassinations of politicians and judges; attacks against rival organizations, associated ci- attacks against rival organizations, associated civilians, and the police and other security forces; vilians, and the police and other security forces; and seemingly random violence against innocent and seemingly random violence against innocent bystanders. Despite the scope of the threat to bystanders. Despite the scope of the threat to Mexico's security, these groups are not well un- Mexico's security, these groups are not well understood, and optimal strategies to combat them derstood, and optimal strategies to combat them have not been identified. Comparison between have not been identified. Comparison between Mexico and Colombia is a tempting and frequently Mexico and Colombia is a tempting and frequently made analogy and source for policy recommen- made analogy and source for policy recommendations. A review of these approaches, combined dations. A series of historical case studies of- with a series of historical case studies, offers a fers a foundation for a more thorough compara- more thorough comparative assessment. Regions tive assessment. Regions around the world have around the world have faced similar challenges faced similar challenges and may hold lessons for and may hold lessons for Mexico. One point is Mexico. One point is clear, however: Mexico is not clear, however: Mexico is not Colombia. In fact, Colombia. As the historical record shows, Mexico Mexico is not particularly like any other histori- is not particularly like any other case character- cal case characterized by “warlordism,” resource ized by “warlordism,” resource insurgency, ungov- insurgency, ungoverned spaces, and organized erned spaces, and organized crime. Despite the crime. Despite the lack of a perfectly analogous lack of a perfectly analogous case, Mexico stands case, Mexico stands to benefit from historical to benefit from historical lessons and efforts that lessons and efforts that were correlated with the were correlated with the greatest improvements greatest improvements in countries facing similar in countries facing similar challenges. A compan- challenges. A companion volume, Mexico Is Not ion volume, Mexico Is Not Colombia: Alternative Colombia: Alternative Historical Analogies for Re- Historical Analogies for Responding to the Chal- sponding to the Challenge of Violent Drug-Traf- lenge of Violent Drug-Trafficking Organizations, ficking Organizations—Supporting Case Studies, describes the study's approach to assessing each presents in-depth profiles of each of these con- historical case and presents findings from the flicts. overall analyses.

RR-548/2 RR-550-BJA Mexico Is Not Colombia: Alternative Historical An Assessment of Program Sustainability in Analogies for Responding to the Challenge of Vio- Three Bureau of Justice Assistance Criminal lent Drug-Trafficking Organizations, Supporting Justice Domains. Eyal Aharoni, Lila Rabinovich, Case Studies. Christopher Paul, Colin P. Clarke, Joshua Mallett, Andrew R. Morral. 2014 Chad C. Serena. 2014 The Bureau of Justice Assistance (BJA) aims to 416 improve community safety through effective pro- questions about whether such technology demon- gramming throughout the United States. To maxi- strations fully comply with U.S. law and whether mize the impact of its investments, BJA has an advanced DoD sensors can legally be used in interest in supporting programs that will be sus- domestic CD operations when they are operated tained beyond initial federal funding. This notion by U.S. military forces.In this report, the authors of program sustainability is becoming increasing- examine federal law and DoD policy to answer ly important as programs have been challenged these questions. Some parts of U.S. law mandate to operate with increasingly scarce resources. information sharing among federal departments RAND Corporation researchers aimed to better and agencies for national security purposes and understand the characteristics and environments direct DoD to play a key role in domestic CD op- of programs that are likely to persist beyond fed- erations in support of U.S. law enforcement agen- eral seed funding and to delineate strategies that cies, while other parts of the law place restrictions will enable BJA to assist programs that it funds on when the U.S. military may participate in law in their efforts to sustain themselves. Using ar- enforcement operations. Reviewing relevant fed- chival documentation and survey methods, they eral law and DoD policy, the authors conclude that assessed 231 BJA grantee programs spanning there is no legal reason why a DoD sensor should three BJA funding domains—drug courts, human be excluded from use in an interagency technolo- trafficking, and mental health—to identify charac- gy demonstration or in an actual CD operation as teristics associated with sustainability. They found long as a valid request for support is made by an evidence of program sustainment in most BJA appropriate law enforcement official and so long grantees studied, particularly in sustained fund- as no personally identifiable or private information ing. They also examined the association between is collected. The authors recommend DoD policy organizational and contextual factors and sus- on domestic CD operations be formally clarified tained operations and sustained funding. Finally, and that an approval process should be estab- they recommend a plan for ongoing measurement lished for technology demonstrations with a CD of sustainability. nexus.

RR-551-OSD RR-553-EC Improving Interagency Information Sharing Us- Breaking the cycle of disadvantage: Early ing Technology Demonstrations: The Legal Basis Childhood interventions and progression to higher for Using New Sensor Technologies for Counter- education in Europe. Benoit Guerin. 2014 drug Operations Along the U.S. Border. Daniel The early years of childhood are crucial for Gonzales, Sarah Harting, Jason Mastbaum, the development of the cognitive and social-be- Carolyn Wong. 2014 havioural skills of an adult. Thus, they represent The Department of Defense (DoD) has devel- a unique challenge and opportunity to invest in oped new sensor technologies to support military children. Extensive research has shown that Ear- forces operating in Iraq and Afghanistan. These ly Childhood Education and Care (ECEC) is ef- new capabilities may be useful in counterdrug fective in tackling the inequality which can tend (CD) operations along the southern U.S. border. to spring from different experiences during these DoD has held technology demonstrations to test early years, and that ECEC can help to break the and demonstrate new technologies along the cycle of disadvantage. Experts have concluded southern border—because the field conditions that most of the gaps in cognitive ability that partly along the border closely resemble those in cur- explain discrepancies in adult outcomes already rent military theaters of operation and because exist at the age of five, emphasising the crucial they can also reveal whether new technologies role of early intervention, and the relatively minor are useful for CD operations led by domestic law role of subsequent schooling by comparison.One enforcement agencies. However, there are legal potential long-term measure of the success of 417

ECEC is access to higher education, particularly How do changes to benefits systems affect chil- for underrepresented groups, such as those from dren?. Barbara Janta, Marie-Louise Henham. low socio-economic status (SES) backgrounds. 2014 However, the magnitude of this unused potential Children are more likely to be at risk of poverty has not yet been fully investigated in Europe, al- and social exclusion than adults, the European though the long-term returns of interventions and Commission concluded in its 2013 recommenda- their ability to raise academic standards have tion Investing in Children: breaking the cycle of been documented, as have the benefits of ECEC disadvantage'. The economic crisis and its wide- in the United States. What is clear is that in the spread effects have increased poverty and social long term, ECEC can boost the academic abilities exclusion risks, notably through cuts in public of disadvantaged students, thus enabling them to spending leading to underinvestment in child-fo- pursue higher studies. cused policies. However, authorities increasingly realise that the austerity measures affecting the RR-554-EC Caring for children in Europe: How childcare, expenditure on early intervention and preventive parental leave and flexible working arrangements policies may result in greater public spending in interact in Europe. Barbara Janta. 2014 the future. As a result, new initiatives have been launched, focusing on implementing cost-effective Most parents in Europe combine a variety of measures to improve childcare services, educa- methods to reconcile their working lives with child- tion, and health care, and designed to help tackle care duties, and their arrangements are related to unemployment and housing issues. All these ele- their preferences, the age of their children, and ments are crucial for improving the well-being of the labour market opportunities to which they have children and families, as well as for promoting sta- access. These arrangements include formal child- bility. A handful of European countries have pro- care settings such as nurseries, preschools or ceeded with measures to mitigate the impact of registered child minders; informal arrangements economic crisis on children and families. Austria, where care is most often provided by grandpar- Germany, France, and Italy have put in place new ents or unregistered nannies, and parental leave cash allowances, increased tax credit/breaks, arrangements.Paternity and maternity leave pro- childcare provision, and increased parental leave. vides opportunities for parents to provide their Such initiatives aim to sustain and increase effec- own childcare, though length of leave, compensa- tive support for vulnerable members of society, tion and the share of leave between parents varies who tend to be hit hardest by economic crises. considerably between EU Member States. At the same time women are much more likely to reduce RR-556-CMEPP their working hours in order to care for their chil- Youth in Jordan: Transitions from Education to dren and assume childcare responsibilities than Employment. Ryan Andrew Brown, Louay Con- men. This is the main cause of low labour market stant, Peter Glick, Audra K. Grant. 2014 inactivity and low female employment rates in Eu- Despite strong economic growth during the rope. High participation rates in formal childcare last decade, youth unemployment in Jordan re- settings are however not a prerequisite for high mains stubbornly high, and labor-force participa- levels of female market participation but it seems tion markedly low. Young women in particular face also questionable whether informal childcare is labor market barriers in access to many career enough to support women's full-time labour mar- paths, and their job aspirations are often discour- ket participation.. aged by their parents. Graduates of secondary and postsecondary institutions do not possess RR-555-EC the requisite technical and soft skills needed for Social protection during the economic crisis: the jobs they expect to get. Facing poor econom- 418 ic prospects and inadequate income, youth are would appear poorly aligned with many modern unable to marry, afford to live independently, or models of technology service delivery and use, support a family. The youth unemployment crisis and the potential for security and privacy require- appears set to plague the country as well as the ments to be built in from the start through Secu- Middle East region for years to come in the ab- rity Engineering or Privacy by Design principles sence of offsetting policy. This study examines the appears to have little visibility in many EU legal perceptions of young Jordanian men and women and policy frameworks.Mapping legal and policy on issues relevant to their transitions into adult frameworks, which cover policy domains that are roles, specifically aspirations for work and fam- unique to EU institutions and agencies, Chapter 4 ily. To achieve the study objectives, we conducted reveals that there is a complex landscape of very 13 focus groups and 14 one-on-one qualitative specific information security and data protection interviews with young Jordanians (ages 15–30). requirements for different EU policy domains. The Participants came from the nation's capital, Am- unique nature of some of these policy domains man, as well as the less urbanized nearby area of and their attendant security or privacy consider- Zarqa. We place these subjective perceptions into ations seem difficult to reconcile with the appetite perspective through a literature review and sec- for more innovative types of technology provision. ondary analysis of national statistics, as well as The Chapter concluded by highlighting that infor- interviews with experts. mation security governance and data protection remains a challenge within many EU frameworks, RR-557-ME which are often managed in a federated fashion Information Security and Data Protection Legal through obligatory standards and rules set at a and Policy Frameworks Applicable to European strategic EU level and implementation at the na- Union Institutions and Agencies. Neil Robinson, tional level. Jan Gaspers. 2014 This study reviews the legal and policy frame- RR-559-OSD Developing a Research Strategy for Suicide works that govern the use of information and Prevention in the Department of Defense: Status communications technology by European Union of Current Research, Prioritizing Areas of Need, institutions and agencies in terms of the extent to and Recommendations for Moving Forward. Ra- which they account for information security and jeev Ramchand, Nicole K. Eberhart, Christopher data privacy.The first set of findings is presented Guo, Eric Pedersen, Terrance Dean Savitsky, Terri in Chapter 2, which suggests that legacy equip- Tanielian, Phoenix Voorhies. 2014 ment, path dependency when it comes to law and policymaking, and the natural conservativeness of In response to the elevated rate of suicide a large and complex administrative machine may among U.S. service members, a congressionally act as inhibitors to building greater information mandated task force recommended that the U.S. security in EU institutions and agencies.Examin- Department of Defense (DoD) create a unified, ing legal and policy frameworks that govern and comprehensive strategic plan for suicide preven- regulate the use of ICT across EU institutions and tion research to ensure that DoD-funded studies agencies, Chapter 3 finds that the overall tone of align with DoD's goals. To help meet this objec- EU policy and legal frameworks governing and tive, a RAND study cataloged the research fund- regulating information security resonates with a ed by DoD and other entities that is directly rel- model of security based on an internally secure evant to military personnel, examined the extent organisation and insecure external environment, to which current research maps to DoD's strategic which appears to be inconsistent with the latest research needs, and provided recommendations evolving canon of best practice concerning inter- to ensure that proposed research strategies align organisational security. Moreover, key EU infor- with the national research strategy and integrate mation security and data protection frameworks 419 with DoD's data collection and program evaluation anomaly database is one way to build an empiri- strategies. The study found that although DoD is cal understanding of what situations are more or one of the largest U.S. funders of research related less likely to result in satellite anomalies, and help to suicide prevention, its current funding priori- determine causal relationships. These databas- ties do not consistently reflect its research needs. es can inform future design and orbital regimes, The study indexed each of 12 research goals ac- and can help determine measures to prolong the cording to rankings of importance, effectiveness, useful life of an on-orbit spacecraft experiencing cultural acceptability, cost, and learning potential problems. However, there is no centralized, up-to- provided by experts who participated in a multi- date, detailed, and broadly available database of step elicitation exercise. The results revealed that anomalies covering many different satellites. This research funding is overwhelmingly allocated to report describes the nature and causes of satellite prevention goals already considered by experts anomalies, and the potential benefits of a shared to be effective. Other goals considered by experts and centralized satellite anomaly database. Find- to be important and appropriate for the military ings indicate that a shared satellite anomaly data- context receive relatively little funding and have base would bring significant benefits to the com- been the subject of relatively few studies, mean- mercial community, and the main obstacles are ing that there is still much to learn about these reluctance to share detailed information with the strategies. Furthermore, DoD, like other organi- broader community, as well as a lack of dedicated zations, suffers from a research-to-practice gap. resources available to any trusted third party to The most promising results from studies funded build and manage such a database. Trusted third by DoD and other entities do not always find their parties and cryptographic methods such as se- way to those responsible for implementing suicide cure multiparty computing or differential privacy prevention programs that serve military personnel. are not complete solutions, but show potential to The RAND study recommended approaches to be further tailored to help resolve the issue of se- thoughtfully integrate the latest research findings curely sharing anomaly data. into DoD's operating procedures to ensure that evidence-based approaches can benefit suicide RR-561-DH prevention programs and prevent the further loss Regulating quality and safety of health and of lives to suicide. social care: International experiences. Daniel Schweppenstedde, Saba Hinrichs, Uzor C. Ogbu, RR-560-DARPA Eric C. Schneider, Dionne S. Kringos, Niek S. Satellite Anomalies: Benefits of a Centralized Klazinga, Judith Healy, Lauri Vuorenkoski, Re- Anomaly Database and Methods for Securely inhard Busse, Benoit Guerin, Emma Pitchforth, Sharing Information Among Satellite Operators. Ellen Nolte. 2014 David A. Galvan, Brett Hemenway, William Welser This report is concerned with standards of IV, Dave Baiocchi. 2014 quality and safety' within health and social care Satellite anomalies are mission-degrading systems. Care standards are intended to support events that negatively affect on-orbit operational efforts in maintaining and improving the quality of spacecraft. All satellites experience anomalies of care; they have been developed across countries, some kind during their operational lifetime. They although the ways in which they are implement- range in severity from temporary errors in non- ed and applied differs between nations. Taking a critical subsystems to loss-of-contact and com- range of six countries, we review the regulatory plete mission failure. There is a range of causes mechanisms that have been implemented to en- for these anomalies, and investigations by the sure that essential standards of care are applied satellite operator or manufacturer to determine and are being adhered to, and consider the range the cause of a specific anomaly are sometimes of policy instruments used to encourage and en- conducted at significant expense.Maintaining an sure continuous quality improvement. We report on 420

Australia, England, Finland, Germany, the Nether- cession's impact. The authors also compared the lands and the USA. The report is intended to indirect costs of correctional education with those of form policy thinking for the Department of Health reincarceration to put the recidivism findings into and others in developing the regulation of safety a broader context. and quality of health and social care in England. It was prepared as part of the project An “On-call” RR-567-OSD Facility for International Healthcare Comparisons' Ramifications of DARPA's Programming Com- funded by the Department of Health in England putation on Encrypted Data Program. Martin C. through its Policy Research Programme. Libicki, Olesya Tkacheva, Chaoling Feng, Brett Hemenway. 2014 RR-564-BJA Programming Computation on Encrypted Data How Effective Is Correctional Education, and (PROCEED) is a Defense Advanced Research Where Do We Go from Here? The Results of a Projects Agency program whose primary pur- Comprehensive Evaluation. Lois M. Davis, Jenni- pose is to improve the efficiency of algorithms fer L. Steele, Robert Bozick, Malcolm V. Williams, that allow people to carry out computations on Susan Turner, Jeremy N. V. Miles, Jessica Saun- encrypted data—without having to decrypt the ders, Paul S. Steinberg. 2014 data itself. RAND was asked to evaluate whether More than 2 million adults are incarcerated in PROCEED—which expands the knowledge base U.S. prisons, and each year more than 700,000 of the global cryptographic community—is likely to leave federal and state prisons and return to com- provide more benefits to the United States than it munities. Unfortunately, within three years, 40 per- does to its global rivals. The research team's as- cent will be reincarcerated. One reason for this is sessment focused on the degree to which PRO- that ex-offenders lack the knowledge, training, and CEED technologies may be adopted, under what skills to support a successful return to communi- circumstances, and for what purpose. The team ties. Trying to reduce such high recidivism rates is then used the analytic framework generated to partly why states devote resources to educating understand technological uptake decisions as a and training individuals in prison. This raises the way of ascertaining how such factors would work question of how effective—and cost-effective— in Russia and China vis-à-vis the United States correctional education is—an even more salient (and, by extension, countries similar to the United question given the funding environment states States).Analysis of online searches for informa- face from the 2008 recession and its continuing tion about data encryption, information security, aftermath. With funding from the Second Chance and data protection in Russia and China conclud- Act of 2007, the Bureau of Justice Assistance, ed that, given government approval of PROCEED U.S. Department of Justice, asked RAND to help technologies, their diffusion will be more rapid in answer this question as part of a comprehensive China than in Russia. Whether PROCEED tech- examination of the current state of correctional nologies will be adopted in the face of the process- education for incarcerated adults and juveniles. ing penalties that will be associated with using The RAND team conducted a systematic review them is difficult to determine at this time. If PRO- of correctional education programs for incarcer- CEED is adopted, it is likely to be adopted more ated adults and juveniles. This included a meta- rapidly in the United States (and similar developed analysis on correctional education's effects on re- countries) than it is in Russia and China, in large cidivism and postrelease employment outcomes part because PROCEED is compatible with the for incarcerated adults, as well as a synthesis of U.S. political culture, and in smaller part because evidence on programs for juveniles. The study it better accords to the U.S. business environment. also included a nationwide survey of state correctional education directors to understand how cor- RR-569-NIJ rectional education is provided today and the re- Police Department Investments in Information 421

Technology Systems: Challenges Assessing Their U.S. Army Reserve (USAR) provided 9 percent. Payoff. Brian A. Jackson, Victoria A. Greenfield, However, as combat operations in Afghanistan Andrew R. Morral, John S. Hollywood. 2014 conclude, soldiers separate from service, and In the wake of the economic downturn that Regular Army endstrength is reduced, the rate at began in 2007 and 2008, public service provid- which deployment experience is accumulated will ers, including police departments, have been decline, most likely resulting in a net decrease. asked to tighten their financial belts and, in some The ARNGUS and USAR provide an additional instances, do more with less. Whereas some de- option to retain deployment experience acquired partments have cut their information technology in the Regular Army; however, the percentage of (IT) investments and staffing as a way to avoid soldiers who transition to these components is on cutting sworn officers, others have increased their the decline. An analytical assessment of the ben- investments in IT, believing it can serve as a force efits garnered from deployment experience may multiplier, increasing the efficiency and effective- help the Army focus its efforts on retaining and ness of the department. IT has become increas- transferring relevant knowledge and skills during ingly integrated into modern police organizations, deployment. particularly for systems related to records man- RR-571-RE agement, dispatch, crime investigation, personnel Understanding the impact of differential uni- records, information sharing, fleet management, versity fees in England. Peter Burge, Chong Woo automated booking, and resource allocation. But Kim, Charlene Rohr, Michael Frearson, Benoit the trade-offs among personnel, technology, and Guerin. 2014 costs are not straightforward. With this report, the authors explored the rationale and evidence sup- From September 2012 universities and other porting the idea that IT investments can increase higher education institutions (HEIs) in England efficiency in policing, and do so cost-effectively. have been able to charge up to £9,000 per year in The correlation modeling suggested both ex- tuition fees, which had previously been capped at pected and unexpected relationships between IT £3,375 per year. Against this backdrop, this report and efficiency. For various reasons, the efforts to explores the relative importance of tuition fees on carry out a full statistical analysis of police IT use the choices made between universities by stu- matched with activity types using existing survey dents, and parents of students, intending to go to data did not succeed. However, they did yield in- university.The research uses a stated preference sights that are relevant to the design of future ef- survey approach, which consisted of asking indi- forts to assess the effects of IT systems on law viduals to make choices within a survey context enforcement performance. about which university they would choose across a range of hypothetical scenarios. From these RR-570-A choices it is then possible to analyse the decisions Measuring and Retaining the U.S. Army's De- made, the extent to which they are influenced by ployment Experience. Caolionn O'Connell, Jennie different factors, and to observe the trade-offs be- W. Wenger, Michael L. Hansen. 2014 ing made. We see that tuition fee levels are not The U.S. Army has contributed the bulk of de- the only consideration which influences the judge- ployed U.S. troops since September 11, 2001 and ment of parents and students when deciding to has accrued substantial levels of deployment-re- apply to university. Our analysis suggests that lated experience. Between September 2001 and several factors influence university choice apart December 2012, the Army provided 1.65 million from tuition fees, including employment pros- cumulative deployed troop-years; the Regular pects, living expenses, location and quality of the Army provided 70 percent of the Army's contribu- course offered. We also quantify the trade-offs that tion, while the Army National Guard of the United students and parents are willing to make; specifi- States (ARNGUS) provided 21 percent and the cally their willingness to pay, through tuition fees, for other aspects that may differentiate universi- 422 ties and their courses.This report provides new stance use treatment and recovery support. empirical evidence to support the debate around the relative influence that tuition fee levels have RR-573-CCRMC in influencing the decisions of those choosing be- National Security Perspectives on Terrorism tween universities, and provides a foundation for Risk Insurance in the United States. Henry H. Wil- future econometric analysis. lis, Omar Al-Shahery. 2014 Congress enacted the Terrorism Risk Insur- RR-572-HBI ance Act (TRIA) in 2002, in response to terrorism Substance Use Treatment and Reentry (STAR) insurance becoming unavailable or, when offered, Program: Final Evaluation Report. Sarah B. extremely costly in the wake of the 9/11 attacks. Hunter, Christina Y. Huang. 2014 The law provides a government reinsurance back- Substance use disorders are common among stop in the case of a terrorist attack by providing juvenile justice populations, and few resources mechanisms for avoiding an immediate drawdown exist to address this problem as young offend- of capital for insured losses or possibly covering ers transition into the community upon release. the most extreme losses. Extended first in 2005 To address this need, in October 2010, the Sub- and again in 2007, TRIA is set to expire at the stance Abuse and Mental Health Services Admin- end of 2014, and Congress is again reconsider- istration (SAMHSA), Center for Substance Abuse ing the appropriate government role in terrorism Treatment (CSAT), awarded three-year grants to insurance markets.This policy brief examines the community-based organizations to expand and/ potential national security implications of allow- or enhance substance abuse treatment and re- ing TRIA to expire. Examining the history of ter- covery and reentry services to sentenced offend- rorism in the United States since the passage of ers returning to the community. Homeboy Indus- TRIA and reviewing counterterrorism studies, the tries, Inc., in collaboration with Behavioral Health authors find that terrorism remains a real nation- Services, Inc., and the RAND Corporation, was al security threat, but one that is very difficult for awarded a grant to serve up to 220 16–25-year- insurers to model the risk of. They also find that olds recently released from juvenile detention to terrorism risk insurance can contribute to making receive substance use treatment and recovery communities more resilient to terrorism events, services at Homeboy Industries in downtown Los so, to the extent that terrorism insurance is more Angeles. This report represents the evaluation available with TRIA than without it, renewing the of that Substance Use Treatment and Reentry legislation would contribute to improved national (STAR) Program. Ninety-four percent of the pro- security. posed population was enrolled into the program. Ninety percent of participants received at least one RR-576-A substance use treatment session, and 73 percent The Future of the Army's Civilian Workforce: successfully completed the five-session treatment Comparing Projected Inventory with Anticipated in six months. Analysis of the client outcome data Requirements and Estimating Cost Under Differ- following participation showed improvements or ent Personnel Policies. Shanthi Nataraj, Lawrence stability over time in housing and social connect- M. Hanser, Frank Camm, Jessica Yeats. 2014 edness. Over 70 percent of participants who com- In keeping with the coming drawdown in military pleted a 12-month interview reported continued end strength, the Department of Defense is plan- employment, and self-reported arrests were be- ning to scale back its civilian workforce over the low 15 percent. Abstinence rates did not change next several years. After reaching nearly 295,000 much throughout the project (about 30 percent); full-time employees in fiscal year (FY) 2010, the however, those reporting use at intake showed re- size of the Army's civilian workforce has started to ductions in use over time. These findings reveal fall. It is necessary to manage this drawdown so a continued need among the population for sub- that sufficient people remain available in key posi- 423 tions. The authors projected the future supply of this newly freed nation could once again collapse Army civilians under various scenarios and exam- into civil war. Although Libya's fate is ultimately in ined how the Army might manage supply to meet the hands of Libyans themselves, international ac- projected demand, by bringing together workforce tors could have done more to help and could still supply and demand models. The RAND Inventory take steps to avert further deterioration of Libya Model was used to project the supply of Army civil- itself as well as the broader region. This report is ians, by command and occupation, based on his- based on research and interviews with officials in torical patterns of internal transfers and separa- Washington, London, Paris, Brussels, and Tripoli tions, and various scenarios for future hiring. The and draws on existing RAND work on post-conflict supply projections were matched with demand reconstruction. It explains the challenges that Lib- projections from RAND's Generating-Force-to- ya faced after the war, assesses the steps taken Operator model, which translates budgets for the to overcome them, draws implications for future Army's operating force into projected changes in post-conflict efforts, and sketches a way forward the institutional Army, to estimate the numbers of in Libya itself. new hires or force reductions needed to meet the demand for civilians. The findings suggest that RR-581-AF meeting future targets will require reducing hiring Promoting Airmen with the Potential to Lead: A rates below historical levels but that substantial Study of the Air Force Master Sergeant Promotion hiring will still be needed in most commands. If System. Kirsten M. Keller, Sean Robson, Kevin demand drops considerably below current projec- O'Neill, Paul D. Emslie, Lane F. Burgette, Lisa M. tions, larger cuts would likely be required. Work- Harrington, Dennis Curran. 2014 force cost is projected to change largely in line As operations become more jointly connected with the number of personnel. If requirements with other military services and the Air Force be- based on the FY 2014 President's Budget are met comes smaller, there is concern that more leader- by FY 2017, nominal costs are projected to remain ship responsibility and authority is being pushed approximately constant, with expected civilian pay down to noncommissioned officers. As the first raises offsetting workforce reductions. level of senior noncommissioned officers, the ability of master sergeants to be effective leaders is RR-577-SRF especially critical. A key component of ensuring Libya After Qaddafi: Lessons and Implications that master sergeants have the knowledge, skills, for the Future. Christopher S. Chivvis, Jeffrey and abilities to fulfill the required leadership re- Martini. 2014 sponsibilities is having an effective system to pro- In 2011, NATO and a number of Arab and other mote airmen with the greatest potential. Despite countries backed a rebel overthrow of longstand- changes in force size, operational requirements, ing Libyan dictator Muammar Qaddafi. When Qa- and airmen's responsibilities, the current promo- ddafi was killed in October, the intervening powers tion system has remained largely unchanged abruptly wrapped up military operations. A small since it was developed more than 40 years ago. United Nations mission was given responsibility Therefore, RAND researchers assessed the cur- for coordinating post-conflict stabilization support. rent system and explored areas for possible im- The essential tasks of establishing security, build- provement. ing political and administrative institutions, and RR-596-RE restarting the economy were left almost entirely Mapping Pathways: Community-driven strate- up to Libya's new leaders. The results of this very gies for the use of antiretrovirals as prevention: limited international approach have been lacklus- United States Workshop Report. Molly Morgan ter at best. Libya has fallen behind on a number Jones, Jim Pickett, Jessica Terlikowski, Gavin Co- of critical post-conflict fronts, jihadist groups have chrane, Jennie Corbett, Joanna Chataway. 2014 made inroads, and there is still a possibility that Launched in 2011, the multi-national Map- 424 ping Pathways project provides a community-led, LTSS.The authors undertook five major tasks that research-driven, multi-layered synthesis about resulted in a prioritized list of policy options and re- the use of antiretroviral-based prevention strat- search directions to help decisionmakers improve egies. Project partners included RAND, AIDS the dementia LTSS delivery system, workforce, Foundation of Chicago, AIDS United, Desmond and financing. These were to (1) identify weak- Tutu HIV Foundation, Naz India, and Bairds CMC. nesses in the LTSS system that may be particu- After two years of data collection and analysis larly severe for persons with dementia; (2) review in the United States, South Africa and India, we national and state strategies addressing dementia published a synthesis in a report titled Mapping or LTSS policy; (3) identify policy options from the Pathways: Developing Evidence-Based, People- perspective of a diverse group of stakeholders; (4) Centred Strategies for the Use of Antiretrovirals evaluate the policy options; and (5) prioritize pol- as Prevention.In the latter half of 2013, a subset icy options by impact and feasibility.Stakeholders of the Mapping Pathways team from RAND Eu- identified 38 policy options. RAND researchers in- rope and AIDS Foundation of Chicago conducted dependently evaluated these options against pre- a series of three “knowledge exchange” scenar- specified criteria, settling on 25 priority options. io development workshops with a focus on the These policy options can be summarized into five United States, held in San Francisco, California; objectives for the dementia LTSS system: (1) in- Atlanta, Georgia; and Washington, DC. The aim crease public awareness of dementia to reduce of the workshops was to further share the find- stigma and promote earlier detection; (2) improve ings of the report and to continue enhancing the access to and use of LTSS; (3) promote high- community-driven, locally informed approach to quality, person- and caregiver-centered care; (4) the wider evidence base for ARV-based preven- provide better support for family caregivers of peo- tion.This report summarizes the outputs of those ple with dementia; and (5) reduce the burden of three workshops. The intended audience extends dementia LTSS costs on individuals and families. beyond those who attended the workshops, to in- This policy blueprint provides a foundation upon terested policymakers, researchers, community which to build consensus among a larger set of members, advocates, activists, and other stake- stakeholders to set priorities and the sequencing holders in the HIV community. We aim to provide of policy recommendations. a report that is thought-provoking and one which will stimulate new ideas and thinking amongst lo- RR-600-1-AETNA cal, national, and global communities engaged in The Role of Health Care Transformation for HIV prevention. the Chinese Dream: Powering Economic Growth, Promoting a Harmonious Society. Soeren Mattke, RR-597 Hangsheng Liu, Lauren E. Hunter, Kun Gu, Sydne Improving Dementia Long-Term Care: A Policy Newberry. 2014 Blueprint. Regina A. Shih, Thomas W. Concan- After having successfully expanded health insur- non, Jodi L. Liu, Esther M. Friedman. 2014 ance coverage, China now faces the challenge of In 2010, 15 percent of Americans older than building an effective and efficient delivery system age 70 had dementia, and the number of new to serve its large and aging population. The coun- dementia cases among those 65 and older is ex- try finds itself at a crossroads—it can emulate the pected to double by the year 2050. As the baby models of Western countries with their well-known boomer generation ages, many older adults will limitations, or embark on an ambitious endeavor require dementia-related long-term services and to create an innovative and sustainable model. We supports (LTSS). This blueprint is the only na- recommend that China choose the second option tional document to date that engages local, state, and design and implement a health care system and national stakeholders to specifically focus on based on population health management princi- policy options at the intersection of dementia and ples and sophisticated health information technol- 425 ogy. Taking this path could yield a triple dividend growth of the connected living room and the im- for China: Health care will contribute to the growth plications of this growth for UK citizens and con- of service sector employment, stimulate domestic sumers. As the living room becomes an Internet demand by unlocking savings, and enable China connected space, this shift offers opportunities to to export its health system development capa- consumers and industry while also raising poten- bilities to other emerging economies, mirroring tial privacy and security concerns. Although cur- its success in building other critical infrastructure. rently a nascent market, the uptake of living room These forces can help turn the Chinese Dream connected devices is expected to grow significant- into a reality. ly in the coming years. However, it appears that there is a low awareness of how the capabilities RR-600-AETNA of living room connected devices might be used, The Role of Health Care Transformation for either legitimately by industry or illegitimately by the Chinese Dream: Powering Economic Growth, criminal actors. This report addresses the security Promoting a Harmonious Society. Soeren Mattke, and privacy implications of the Internet connected Hangsheng Liu, Lauren E. Hunter, Kun Gu, Sydne living room for both industry and consumers, dis- Newberry. 2014 cussing potential benefits and emerging threats After having successfully expanded health in- associated with living room connected devices surance coverage, China now faces the challenge and their technical capabilities. of building an effective and efficient delivery system to serve its large and aging population. The RR-605-DOS country finds itself at a crossroads—it can emu- New Security and Justice Sector Partnership late the models of Western countries with their Models: Implications of the Arab Uprisings. Mi- well-known limitations, or embark on an ambitious chael J. McNerney, Jennifer D. P. Moroney, Peter endeavor to create an innovative and sustainable Mandaville, Terry Hagen. 2014 model. RAND researchers recommend that China The United States faces a unique set of chal- choose the second option and design and imple- lenges and opportunities in strengthening secu- ment a health care system based on population rity and justice sector partnerships in the Middle health management principles and sophisticated East and North Africa. Against the backdrop of the health information technology. Taking this path Arab uprisings, the U.S. government has issued could yield a triple dividend for China: Health care policy guidance relating to foreign assistance will contribute to the growth of service sector em- more broadly and security sector assistance in ployment, stimulate domestic demand by unlock- particular. RAND researchers analyzed potential ing savings, and enable China to export its health new partnership models that could help imple- system development capabilities to other coun- ment this guidance, simultaneously strengthening tries, mirroring its success in building other criti- security and justice sector cooperation and pro- cal infrastructure. These forces can help turn the moting reform across the Arab world and beyond. Chinese Dream into a reality. They devised the Enhanced Partnership Planning Model, which focuses on improving collaborative RR-604-OFCOM planning, rather than on using assistance as le- Living Room Connected Devices: Opportunities, verage to require partner nations to do what the security challenges and privacy implications for United States wants. The model serves as a flex- users and industry. Neil Robinson, Jon Freeman, ible framework that could support tailored, rig- Jan Gaspers, Veronika Horvath, Tess Hellgren, orous SJS planning by U.S. and partner nation Alex Hull. 2014 stakeholders. This framework can support both RAND Europe was commissioned by Ofcom, policy-makers and program managers as they the UK communications regulator, to investigate seek to implement new policy guidelines that inte- and prepare an independent expert report on the grate elements of accountability and reform while 426 continuing to advance core U.S. interests and eq- All roads lead to Damascus and then back uities in a rapidly evolving regional context. out again, but in different directions. The financial and military aid flowing into Syria from patrons RR-606-DOEL and neighbors is intended to determine the out- Evaluation of Delaware Stars for Early Suc- come of the conflict between a loose confedera- cess: Year 1 Report. Heather L. Schwartz, Lynn tion of rebel factions and the regime in Damas- A. Karoly, Vi-Nhuan Le, Jennifer Tamargo, Claude cus. Instead, this outside support has the potential Messan Setodji. 2014 to perpetuate the existing civil war and to ignite Delaware was in the first group of states to re- larger regional hostilities between Sunni and Shia ceive a federal grant in 2012 to improve early care areas that could reshape the political geography and education services and increase the number of the Middle East. This report examines the main of infants, toddlers, and preschool-age children factors that are likely to contribute to or impede the in high-quality programs. One component of the spread of violence from civil war and insurgency state's grant is a rigorous validation process for in Syria, and then examines how they apply to Tur- Delaware Stars for Early Success, a voluntary key, Lebanon, Iraq, and Jordan. quality rating and improvement system (QRIS), including a study to assess the relationship be- RR-610-JNI Markets for Cybercrime Tools and Stolen Data: tween the quality ratings and the developmental Hackers' Bazaar. Lillian Ablon, Martin C. Libicki, outcomes of children. To support Delaware's ef- Andrea A. Golay. 2014 forts to ensure that the QRIS is working as intended, RAND researchers examined prior validation Criminal activities in cyberspace are increas- research, analyzed Delaware Stars administrative ingly facilitated by burgeoning black markets for data, conducted a series of key stakeholder inter- both tools (e.g., exploit kits) and take (e.g., credit views and focus groups, and implemented a virtu- card information). This report, part of a multiphase al pilot test of Delaware Stars using national data study on the future security environment, de- to identify relationships between program quality scribes the fundamental characteristics of these and child developmental outcomes. The results markets and how they have grown into their cur- provide a baseline understanding of the types of rent state to explain how their existence can harm child care providers that participate in Delaware the information security environment. Understand- Stars, their Delaware Stars quality ratings, how ing the current and predicted landscape for these quickly they progress to higher quality levels and markets lays the groundwork for follow-on explo- which standards they are meeting, how enrolled ration of options to minimize the potentially harm- children are distributed across participating and ful influence these markets impart. Experts agree nonparticipating programs, and the experiences that the coming years will bring more activity in of administrators, providers, and families with the darknets, more use of crypto-currencies, greater current system. Although this initial study was not anonymity capabilities in malware, and more at- intended to provide definitive recommendations tention to encrypting and protecting communica- for improving Delaware Stars, the findings point tions and transactions; that the ability to stage cy- to ways to reinforce initiatives already under way berattacks will likely outpace the ability to defend in Delaware Stars or that could be considered for against them; that crime will increasingly have a the future. networked or cyber component, creating a wider range of opportunities for black markets; and that RR-609-OSD there will be more hacking for hire, as-a-service Spillover from the Conflict in Syria: An As- offerings, and brokers. Experts disagree, however, sessment of the Factors that Aid and Impede the on who will be most affected by the growth of the Spread of Violence. William Young, David Steb- black market (e.g., small or large businesses, in- bins, Bryan A. Frederick, Omar Al-Shahery. 2014 dividuals), what products will be on the rise (e.g., 427 fungible goods, such as data records and credit most recent and its coverage of subaward dollars card information; non-fungible goods, such as in- is expanding as older contracts expire and are tellectual property), or which types of attacks will replaced with ones with FSRS reporting require- be most prevalent (e.g., persistent, targeted at- ments. Using these data can identify small-busi- tacks; opportunistic, mass “smash-and-grab” at- ness participation in the supply base as well as tacks). the vulnerability of contractors and subcontractors to changes in their federal government prime con- RR-611-CCRMC tract and subcontract revenue or environmental The Impact on Federal Spending of Allowing risks. Such information can help policymakers bet- the Terrorism Risk Insurance Act to Expire. Tom ter understand potential risks in the supply chain LaTourrette, Noreen Clancy. 2014 and better shape industrial-base policies. Adding Congress enacted the Terrorism Risk Insur- data on natural-disaster risks can also help iden- ance Act (TRIA) in 2002, in response to terrorism tify external sources of supply disruption and point insurance becoming unavailable or, when offered, to potential buffering strategies. extremely costly in the wake of the 9/11 attacks. The law creates an incentive for a functioning pri- RR-616 Iran's Influence in Afghanistan: Implications for vate terrorism insurance market by providing a the U.S. Drawdown. Alireza Nader, Ali G. Scotten, government reinsurance backstop for catastrophic Ahmad Idrees Rahmani, Robert Stewart, Leila terrorist attack losses. Extended first in 2005 and Mahnad. 2014 again in 2007, TRIA is set to expire at the end of 2014, and Congress is again considering the ap- This study explores Iranian influence in Afghan- propriate government role in terrorism insurance istan and the implications for the United States markets.This policy brief examines the potential after the departure of most American forces from federal spending implications of allowing TRIA to Afghanistan. Iran has substantial economic, politi- expire. Combining information on federal spend- cal, cultural, and religious leverage in Afghanistan. ing through TRIA, the influence of TRIA on the Kabul faces an obdurate insurgency that is likely availability of terrorism insurance coverage, and to exploit the U.S. and international drawdown. the relationship between uninsured losses and The Afghan government will also face many eco- federal disaster assistance spending, the authors nomic difficulties in future years, and Afghanistan find that, in the absence of a terrorist attack, TRIA is highly dependent on international economic aid. costs taxpayers relatively little, and in the event of Additionally, the biggest problem facing Afghani- a terrorist attack comparable to any experienced stan may be political corruption. Iranian influence before, it is expected to save taxpayers money. in Afghanistan following the drawdown of international forces need not necessarily be a cause of RR-614-OSD concern for the United States though. Although Findings from Existing Data on the Department Tehran will use its cultural, political, and economic of Defense Industrial Base. Nancy Y. Moore, Clif- sway in an attempt to shape a post-2016 Afghan- ford A. Grammich, Judith D. Mele. 2014 istan, Iran and the United States share core in- To demonstrate the potential of existing data terests there: to prevent the country from again to provide information on the defense supplier becoming dominated by the Taliban and a safe base, the researchers conducted some illustra- haven for al Qaeda.This study examines Iran's tive analyses using, among other sources, the historic interests in Afghanistan and its current System for Award Management, the Federal Pro- policies in that country, and explores the potential curement Data System—Next Generation, the implications for U.S. policy. The research is based Federal Funding Accountability and Transparency on field interviews in Afghanistan, the use of pri- Act Subaward Reporting System (FSRS), and the mary sources in Dari and Persian, and scholarly U.S. Geological Survey. Of these, the FSRS is the 428 research in English. tional perspective. Celine Miani, Saba Hinrichs, Emma Pitchforth, Teresa Bienkowska-Gibbs, Ste- RR-617-AF fanie Disbeschl, Martin Roland, Ellen Nolte. 2014 Air Force Manpower Requirements and Com- ponent Mix: A Focus on Agile Combat Support. This report seeks to help inform the further Albert A. Robbert, Lisa M. Harrington, Tara L. development of medical education and training for Terry, Hugh G. Massey. 2014 primary care in Germany. It explores approaches to medical education and training in a small Processes for determining U.S. Air Force man- number of high-income countries and how these power requirements vary considerably across and seek to address shortages of doctors practising within the variety of workforces employed to meet in primary or ambulatory care through reforming Air Force missions, including active duty military their education and training systems. It does so personnel, full-time and part-time Air Force Re- by means of an exploratory analysis of the expe- serve and Air National Guard military personnel, riences of three countries: England, France and civilian employees, and contractors. Distinctive the Netherlands, with Germany included for com- processes have been developed for quantifying parison. Data collection involved a review of the needs for operational, maintenance, and non- published and grey literature, using a structured maintenance agile combat support workforces. template, complemented by information provided The primary focus of this report is on those quan- by key informants in the selected countries. The titatively oriented manpower requirements pro- report sets out the general context within which cesses and the extent to which they are validated, the medical education and training systems in the coordinated, and consistent. Since some require- four countries operate, and describe the educa- ments are based on wartime or deployment tion and training pathways for general practice needs rather than peacetime or garrison needs, for each. We highlight options for medical educa- the report seeks to determine if a common-sight tion and training in Germany that arise from this picture of wartime demands is available. It also study by placing our observations in the context explores the qualitative side of personnel require- of ongoing reform activity. This study will be of rel- ments. The resources of the Air Force's manpower evance for decisionmakers and practitioners con- requirements squadrons and flights appear to be cerned with ensuring a medical workforce that is inadequate to their task, as evidenced by both the prepared for the demands in a changing health- limited coverage of requirements by standard pro- care environment. cesses and the age distribution of current manpower standards. Another area of concern is the RR-624-LACPD separation of manpower standards by component, Los Angeles County Juvenile Justice Crime leading to inefficiencies. Also, restrictions on the Prevention Act: Fiscal Year 2012–2013 Report. duties of reserve component personnel tend to Terry Fain, Sarah Michal Greathouse, Susan mandate more training than is needed and invite Turner. 2014 circumventions to allow greater participation by California's Juvenile Justice Crime Preven- reservists in active missions. In addition, the link- tion Act was designed to provide a stable fund- age between individual mobilization augmentee ing source for juvenile programs that have been authorizations and wartime requirements is tenu- proven effective in curbing crime among at-risk ous. Finally, looking at qualitative requirements, and young offenders. It provides funds to counties there appears to be a need for additional attention to add evidence-based programs and services for to officer education prerequisites. juvenile probationers identified with higher needs for special services than those identified for rou- RR-622-KBV tine probationers, at-risk youth who have not en- Best practice: Medical training from an interna- tered the probation system but who live or attend school in areas of high crime or who have other 429 factors that potentially predispose them to criminal Hanney, Jonathan Grant. 2014 activities, and youth in juvenile halls and camps. In 2012, RAND Europe and the Health Eco- The Board of State and Community Corrections nomics Research Group (Brunel University) were is required to submit annual reports to the Cali- commissioned by the Wellcome Trust, Cancer Re- fornia state legislature measuring the program's search UK, the National Institute for Health Re- success for six outcome measures: (1) success- search and the Academy of Medical Science to ful completion of probation, (2) arrests, (3) proba- conduct a study of the returns to the public/chari- tion violations, (4) incarcerations, (5) successful table investment in cancer-related research. This completion of restitution, and (6) successful com- study built on previous work published in the 2008 pletion of community service. Each county can What's it worth?' report that estimated the eco- also measure supplemental outcomes. For the six nomic returns to medical research in terms of spill- state-mandated outcomes, differences between over benefits and health gain. The 2008 study was program participants and comparison-group extensively quoted and cited as a clear justification youth are mostly positive, though relatively small. for the economic importance of medical research County-developed supplemental outcomes, which and appears to have played a role in achieving measure performance of program participants at the protection of the medical science budget in the program entry and again at a later time, tend to be recent public expenditure cuts.This cancer study more favorable. used a similar approach to that used in the previous study, but with some methodological develop- RR-626-OSD Designing Unmanned Systems with Greater ments. One of the methodological developments Autonomy: Using a Federated, Partially Open was the inclusion of case studies to examine the Systems Architecture Approach. Daniel Gonza- validity and variability of the estimates on elapsed les, Sarah Harting. 2014 time between funding and health gains, and the amount of health gains that can be attributed to Current unmanned systems (UxSs) use dif- UK research. This report provides the full text of ferent communication systems and have limited the five case studies conducted as well as some autonomy, which can contribute to interoperability discussion of observations emerging across the problems and limit the degree to which information case study set. collected by these systems can be shared with warfighters and other UxSs operating in the same RR-628-RCN area. UxSs may also face survivability and mis- Supporting the development of a new health sion effectiveness challenges when they operate R&D strategy: A rapid review of international in contested environments or against adversaries theory and practice for Norway's HelseOmsorg21. with significant electronic or cyber warfare capabil- Jonathan Grant, Alexandra Pollitt, Sophie Castle- ities. Improving UxS autonomy can address these Clarke, Gavin Cochrane, Susanne Sondergaard, challenges. This report identifies a partially open Veronika Horvath. 2014 systems architecture (POSA) approach that can The HelseOmsorg21 initiative was set up by the improve system interoperability and autonomy. A Ministry of Health and Care Services to develop a POSA reference model is proposed for unmanned new research and innovation strategy for health aircraft vehicles that can enable new autonomous and care services in Norway. The HelseOmsorg21 capability modules to be inserted into the system. Strategy Group, through the Research Council of Norway which is providing the secretariat for the RR-627-WT Investigating time lags and attribution in the strategy development, asked RAND Europe to translation of cancer research: A case study ap- support the strategic review process. RAND Eu- proach. Susan Guthrie, Alexandra Pollitt, Stephen rope's role was to conduct a series of rapid evidence reviews around the recommendations arising from the five working groups that comprise 430 the initiative. The reviews were conducted around the greater the amount of driving. However, levels networks and collaboration, data linkage and ex- of automobility vary quite substantially between change, culture, values and leadership, and in- countries even at similar levels of economic de- centives for innovation, while capacity building velopment. This suggests that countries follow dif- was a recurrent theme throughout. This report ferent mobility paths. The research detailed in this presents the rapid evidence reviews, summarising report sought to answer three questions: What relevant literature and highlighting international are the factors besides economic development examples of particularly relevant or innovative ap- that affect automobility? What is their influence on proaches. The issues and ideas identified around automobility? What will happen to automobility in each theme are then pulled together in a suggest- developing countries if they progress along similar ed conceptual representation of the Norwegian paths as developed countries? To answer these health and care research system. questions, the authors developed a methodology to identify these factors, model their impact on de- RR-629-OSD veloped countries, and forecast automobility (as Identification and Analysis of Technology Emer- defined by per capita vehicle-kilometers traveled gence Using Patent Classification. Christopher A. [VKT]) in four developing countries. This method- Eusebi, Richard Silberglitt. 2014 ology draws on quantitative analysis of historical This report describes a method for detecting, automobility development in four country case characterizing, and analyzing the development of studies (the United States, Australia, Germany, commercial interest in technology areas, which we and Japan) that represent very different levels call technology emergence. The U.S. Patent and of per capita automobility, in combination with Trademark Office's formal categorization system data derived from an expert-based qualitative has been used to classify literally millions of tech- approach. The authors used the latter to assess nical documents. The classification is not merely a how these experiences may affect the future of single technical descriptor, but a categorization of automobility in the BRIC countries: Brazil, Rus- all the areas of science and technology advanced sia, India, and China. According to this analysis, in the document as recognized by the patent ex- automobility levels in the four BRIC countries will aminer. A rapid increase in patent applications fall between those of the United States (which has filed related to a specific classification thus can the highest per capita VKT level of the four case represent its dissemination into new and often un- studies) and Japan (which has the lowest). Brazil related technological areas. This rapid increase in is forecasted to have the highest per capita VKT patent application filing is a signal of technology and India the lowest. emergence and industry acceptance. By placing their patent portfolios on s-curves, a patenting or- RR-637-OSD A Persistent Threat: The Evolution of al Qa'ida ganization or sponsor can learn: (1) the level of and Other Salafi Jihadists. Seth G. Jones. 2014 interest in the broader patenting community in the technology areas in which the organization (and This report examines the status and evolu- its staff) are patenting; and (2) how early or late tion of al Qa'ida and other Salafi-jihadist groups, their specific patents are with respect to when the a subject of intense debate in the West. Based technology area first emerged. on an analysis of thousands of primary source RR-636-IFMO documents, the report concludes that there has The Future of Driving in Developing Countries. been an increase in the number of Salafi-jihadist Liisa Ecola, Charlene Rohr, Johanna Zmud, To- groups, fighters, and attacks over the past sev- bias Kuhnimhof, Peter Phleps. 2014 eral years. The author uses this analysis to build a framework for addressing the varying levels of The level of automobility, defined as travel in threat in different countries, from engagement in personal vehicles, is often seen as a function of high-threat, low government capacity countries; to income: The higher a country's per capita income, 431 forward partnering in medium-threat, limited gov- RR-641-DEFRA ernment capacity environments; to offshore bal- Estimating the value of mobile telephony in ancing in countries with low levels of threat and mobile network not-spots. Hui Lu, Charlene Rohr, sufficient government capacity to counter Salafi- Peter Burge, Alison Grant. 2014 jihadist groups. In this study the social and economic impacts associated with eliminating mobile not-spots area RR-639-REC are examined using a mix of qualitative and quan- Process Evaluation of the New Mexico Ma- titative methods, including a survey incorporating ternal, Infant, and Early Childhood Home Visiting a stated preference discrete choice experiment. A Competitive Development Grant. Matthew Chin- high-quality representative sample of responses man, Sarah B. Hunter, Jill S. Cannon, M. Rebecca is collected, which forms the basis for the choice Kilburn, Melody Harvey, Mollie Rudnick. 2014 modelling analysis. The resulting models quantify This report describes the evaluation of the the value that residents and businesses in not- New Mexico Home Visiting Competitive Devel- spot areas and local visitors and tourists to not- opment Grant, which sought to pilot test the use spot areas are willing to pay for mobile phone cov- of implementation supports to improve the de- erage. We find that individuals are willing to pay velopment and implementation of home visiting to reduce the distances that they have to travel to programs. Each community was to use Getting obtain mobile phone coverage, and that they are To Outcomes® (GTO) and ECHO® (Extension willing to pay for a high-quality and reliable signal. for Community Healthcare Outcomes) to support These benefits can then be compared to the costs their work. The GTO framework promotes capac- of providing these services to provide an assess- ity for high-quality programming by specifying ten ment of the social benefit of these investments. steps that practitioners should take and by pro- We did not find substantial evidence for willing- viding support to complete those steps. ECHO in- ness to pay for better services (3G/4G), although volves specialists providing training and technical this may emerge as these services become more assistance via distance technology to community mainstream. Moreover, not-spots were found to practitioners in rural areas to improve the quality have a negative impact on local businesses locat- of services. The grant was delayed, and the proj- ed in these areas and may impact the long-term ect's scope shifted significantly from the original sustainability of rural communities. plan. The evaluation documents significant challenges in meeting grant goals. A local team hired RR-641/1-DEFRA to facilitate GTO did not use it as designed, and Estimating the value of mobile telephony in no communities were trained in GTO. The coali- mobile network not-spots: Summary. Hui Lu, tions that were developed operated with few re- Charlene Rohr, Peter Burge, Alison Grant. 2014 sources or accountability, and made little progress In this study the social and economic impacts on plans to enhance services. Only two of the four associated with eliminating mobile not-spots area communities started home visiting after nearly a are examined using a mix of qualitative and quan- year and a half. ECHO was used with fidelity with titative methods, including a survey incorporating those two programs. There was no change in the a stated preference discrete choice experiment. A continuum of services to support children and high-quality representative sample of responses families. Due to delays and lack of implementation is collected, which forms the basis for the choice of the proposed intervention, the evaluation was modelling analysis. The resulting models quantify not able to assess the project's impact on child the value that residents and businesses in not- or family outcomes, nor did the project serve as a spot areas and local visitors and tourists to not- robust pilot test of the use of GTO and ECHO to spot areas are willing to pay for mobile phone cov- improve home visiting implementation. erage. We find that individuals are willing to pay 432 to reduce the distances that they have to travel to largely be financed by businesses and taxpayers obtain mobile phone coverage, and that they are throughout the state in which the attack occurs, willing to pay for a high-quality and reliable signal. adding to the challenge of rebuilding in that state. These benefits can then be compared to the costs TRIA, in contrast, spreads such risk across the of providing these services to provide an assess- country. ment of the social benefit of these investments. We did not find substantial evidence for willing- RR-644-OSD ness to pay for better services (3G/4G), although Drivers of Long-Term Insecurity and Instability this may emerge as these services become more in Pakistan: Urbanization. Jonah Blank, Christo- mainstream. Moreover, not-spots were found to pher Clary, Brian Nichiporuk. 2014 have a negative impact on local businesses locat- Already one of the most urbanized nations in ed in these areas and may impact the long-term South Asia, Pakistan is projected to have a major- sustainability of rural communities. ity of its population living in cities within three decades. This demographic shift will alter Pakistan's RR-643-CCRMC politics and threaten its stability, but the political The Impact on Workers' Compensation Insur- and security implications of Pakistan's urbaniza- ance Markets of Allowing the Terrorism Risk Insur- tion remain underanalyzed. This report examines ance Act to Expire. Michael Dworsky, Lloyd Dixon. urbanization as a potential driver of long-term in- 2014 security and instability, with particular attention to Congress enacted the Terrorism Risk Insur- the cities of Karachi, Lahore, and Quetta. Drawing ance Act (TRIA) in 2002, in response to terror- on demographic trends, election results, and sur- ism insurance becoming unavailable or, when vey data, the authors conclude that urbanization offered, extremely costly in the wake of the 9/11 may fuel anti-American sentiment and help re- attacks. The law provides a government reinsur- cruitment by transnational Islamist groups (but not ance backstop in the case of a terrorist attack by necessarily Islamist political parties) in the short providing mechanisms for avoiding an immediate term. Urbanization is also likely to increase popu- drawdown of capital for insured losses or possibly lar demand for political reform in Pakistan. In the covering the most extreme losses. Extended first near future, a Pakistani government more directly in 2005 and again in 2007, TRIA is set to expire accountable to its electorate might be less willing at the end of 2014, and Congress is again recon- to cooperate with the United States in unpopular sidering the appropriate government role in terror- security policies. In the long run, however, a Paki- ism insurance markets.This policy brief examines stani government more responsive to its citizens how markets for workers' compensation (WC) in- could be a better security partner for the United surance would be affected if TRIA were to expire. States. By spurring Pakistani policymakers to fo- They explain that TRIA expiration would affect WC cus on provision of good governance and public insurance markets differently from other insurance services rather than on scapegoating external ac- markets because WC statutes rigidly define the tors, political reform may eventually help reduce terms of coverage, such that in a post-TRIA world anti-American attitudes. insurance companies would limit their terrorism risk exposure by declining coverage to employ- RR-650-ASAI ers facing high terrorism risk. Because WC cov- The Anesthesiologist Workforce in 2013: A Final erage is mandatory for nearly all U.S. employers, Briefing to the American Society of Anesthesiolo- employers that cannot purchase coverage would gists. Matthew Baird, Lindsay Daugherty, Krishna be forced to obtain coverage in markets of last re- B. Kumar, Aziza Arifkhanova. 2014 sort. Migration of terrorism risk to these markets Important changes are taking place in the of last resort would increase the likelihood that health care sector that have implications for future WC losses from a catastrophic terror attack would supply and demand of anesthesiologists, includ- 433 ing expansion of coverage, an aging population, but in most others, awareness of these risks greater movement of women into the physician was limited (especially in ambulatory practices). workforce, increasing cost pressures, and shifting The authors concluded that better tools like the modes of delivery. To determine what the implica- recently released Safety Assurance Factors for tions of these changes might be for the anesthesi- EHR Resilience (SAFER) Guides are needed to ologist workforce, RAND Corporation researchers help organizations optimize the safe use of health conducted a national survey of American Society IT. However, health care organizations will require of Anesthesiologists (ASA) members, who include a better understanding of the safety risks posed more than 90 percent of all practicing anesthesi- by electronic health record (EHR) use to take full ologists in the United States. This survey was a advantage of the SAFER Guides. There may also follow-up to a 2007 survey, also conducted by the be a need for additional tools and metrics (and RAND Corporation. The authors document large further usability studies of existing tools and met- and persistent regional differences in anesthesi- rics) to better support the needs of health care or- ologists' practices. In addition, there were several ganizations as they increasingly rely on health IT large differences by gender. With regard to short- to improve the quality and safety of patient care. age, the survey reveals substantial evidence for variation in anesthesiologist shortages across RR-655-OSD states, from which the authors argue that certain An Evaluation of the Implementation and Per- areas of the country are experiencing shortages. ceived Utility of the Airman Resilience Training However, the national level of shortage has de- Program. Gabriella C. Gonzalez, Reema Singh, creased since 2007 by approximately 2,000 full- Terry L. Schell, Robin M. Weinick. 2014 time-equivalent anesthesiologists. The authors Since 2001, the U.S. military has been func- estimate that midwestern and western states were tioning at an operational tempo that is historically more likely than states in other regions to have a high for the all-volunteer force in which service shortage of anesthesiologists in 2013. members are deploying for extended periods on a repeated basis. Even with the drawdown of troops RR-654-DHHSNCH from Iraq in 2011, some service members are re- Promoting Patient Safety Through Effective turning from deployment experiencing difficulties Health Information Technology Risk Manage- handling stress, mental health problems, or defi- ment. Eric C. Schneider, M. Susan Ridgely, Dani- cits caused by a traumatic brain injury (TBI). In ella Meeker, Lauren E. Hunter, Dmitry Khodyakov, response to these challenges, the U.S. Depart- Robert S. Rudin. 2014 ment of Defense (DoD) has implemented numer- The potential for health information technology ous programs to support service members and (IT) to improve health care delivery has been ap- their families in these areas. In 2009, the Assis- preciated for decades, but “digitizing” health care tant Secretary of Defense for Health Affairs asked can also introduce new risks and even harm. As the RAND National Defense Research Institute to the use of health IT has grown, these risks have develop a comprehensive catalog of existing pro- become more apparent. The authors of this report grams sponsored or funded by DoD to support evaluated the efforts of 11 hospitals and ambu- psychological health and care for TBI, to create latory practices to use an improvement strategy tools to support ongoing assessment and evalua- and tools developed to promote safe use of health tion of the DoD portfolio of programs, and to con- IT and to diagnose, monitor, and mitigate health duct evaluations of a subset of these programs. IT–related safety risks. Through interviews, the This report describes RAND's assessment of an authors discovered that some health care orga- Air Force program, Airman Resilience Training nizations (especially hospitals) with expertise in (ART), a psychoeducational program designed process improvement were able to identify and to improve airmen's reactions to stress during begin to mitigate health IT–related safety risks, and after deployment and to increase the use of 434 mental health services when needed. ART was in ESI and Medicaid. Enrollment in ESI plans in- initiated in November 2010, replacing a previous creased by 8.2 million and Medicaid enrollment in- program named Landing Gear, which had been creased by 5.9 million, although some individuals in place since April 2008. The RAND study took did lose coverage during this period. The authors place from August 2011 through November 2011. also found that 3.9 million people are now covered This report will be of particular interest to officials through the state and federal marketplaces—the within the Air Force who are responsible for the so called insurance exchanges—and less than psychological health and well-being of airmen, as 1 million people who previously had individual- well as to others within the military who are devel- market insurance became uninsured during the oping programs for service members to help them period in question. While the survey cannot tell if cope with stress while in combat situations and this latter group lost their insurance due to can- after returning from deployment. cellation or because they simply felt the cost was too high, the overall number is very small, repre- RR-656-RC senting less than 1 percent of people between the Changes in Health Insurance Enrollment Since ages of 18 and 64. 2013: Evidence from the RAND Health Reform Opinion Study. Katherine Grace Carman, Chris- RR-657-CMS tine Eibner. 2014 Hospice Experience of Care Survey: Devel- opment and Field Test. Rebecca Anhang Price, RAND's Health Reform Opinion Study (HROS) Denise D. Quigley, Melissa A. Bradley, Joan M. allows for an estimation of how many people have Teno, Layla Parast, Marc N. Elliott, Ann C. Haas, become enrolled in all sources of health care cov- Brian D. Stucky, Brianne Elizabeth Mingura, Karl erage since the implementation of the Affordable Lorenz. 2014 Care Act (ACA). The HROS is conducted using the RAND American Life Panel, a nationally represen- The Centers for Medicare & Medicaid Services tative panel of individuals who regularly partici- (CMS) has implemented care experience surveys pate in surveys; this particular analysis, is focused for a variety of settings but none for hospice care. on respondents age 18–64. In addition to asking In September 2012, CMS contracted the RAND them about their opinions of the ACA, each month Corporation to design and field-test a future Con- RAND collected information about enrollment in sumer Assessment of Healthcare Providers and health insurance, including employer-sponsored Systems (CAHPS®) survey to measure the ex- insurance (ESI), Medicaid, Medicare, insurance periences that patients and their caregivers have purchased on a marketplace, and other insurance with hospice care. The survey was developed to purchased on the individual market. This detailed (1) provide a source of information from which information about insurance coverage combined selected measures could be publicly reported to with the fact that the same individuals were sur- beneficiaries and their family members as a deci- veyed each month provides a unique ability to sion aid for selection of a hospice program, (2) aid track how insurance coverage has changed since hospices with their internal quality improvement the major health insurance coverage provisions of efforts and external benchmarking with other fa- the ACA took effect on January 1, 2014. The anal- cilities, and (3) provide CMS with information for ysis presented here examines changes in health monitoring the care provided. This report briefly insurance enrollment between September 2013 summarizes the work conducted to develop and and March 2014; overall, the authors estimate that field-test the new survey, the Hospice Experience 9.3 million more people have health care cover- of Care Survey (HECS). It provides an overview age in March 2014, lowering the uninsured rate of the survey development process, describes the from 20.5 percent to 15.8 percent. This increase in field test design and procedures, presents ana- coverage is driven not only by enrollment in health lytic methods and findings from the field test, and insurance marketplace plans, but also by gains presents the final survey instrument for national 435 implementation. isk Management and Biosurveillance. Stephanie Young, Henry H. Willis, Melinda Moore, Jeffrey RR-659-AF Engstrom. 2014 Air Force-Wide Needs for Science, Technology, Engineering, and Mathematics (STEM) Academic The Cooperative Biological Engagement Pro- Degrees. Lisa M. Harrington, Lindsay Daugherty, gram (CBEP) is the biological threat component of S. Craig Moore, Tara L. Terry. 2014 the Cooperative Threat Reduction program. It grew out of efforts to address risks associated with leg- In evaluating the health of its science, tech- acy biological agents, related materials, and technology, engineering, and mathematics workforce, nical expertise developed as part of the biologi- the U.S. Air Force has focused on functional ar- cal weapon program in the former Soviet Union. eas where STEM degrees are mandatory. To date CBEP now partners with about 20 countries in there has been no rigorous review of the needs for different regions around the world and works with STEM academic degrees in other functional areas. them to address diverse threats to international Understating the needs for officers and civilians security, including terrorist organizations seeking with STEM degrees can diminish the Air Force's to acquire pathogens of security concern; human, ability to maintain the technical skills it heavily re- animal, and agricultural facilities operating with in- lies upon to support air, space, and cyberspace adequate safety and security safeguards; and the operations. Analysis must begin with a definition spread of diseases with potential security or eco- of STEM versus non-STEM degrees. RAND re- nomic consequences. As the program has evolved searchers established a set of broad academic since its inception two decades ago, so too have disciplinary groups that should be considered in its content and approaches to performance mea- the set of STEM degrees, as well as disciplines at surement. The objective of the research reported the most detailed levels of Air Force degree codes. here was to build on existing work to develop a This categorization has been approved as the Air comprehensive evaluation framework and recom- Force definition of STEM.Career field managers mend metrics for assessing and communicating across the Air Force were interviewed and asked progress toward CBEP's goals. The report ulti- to identify the STEM academic degrees neces- mately recommends a number of qualitative and sary now and in the future for particular missions quantitative indicators of CBEP performance, in their functional areas. Senior functional authori- some that can be implemented immediately, some ties at the two- and three-star level reviewed and to be implemented later. in some cases revised what their own career field managers identified as STEM needs and validated RR-670-NYSHF the overall direction and the numbers of these de- An Examination of New York State's Integrated gree requirements.Although this approach lacks Primary and Mental Health Care Services for a method to determine the magnitude of future Adults with Serious Mental Illness. Deborah M. STEM needs in the programs identified, it does Scharf, Joshua Breslau, John W. Schmidt, Dan- point to specific areas that the Air Force should iela Kusuke, B. Lynette Staplefoote, Harold Alan review for emerging STEM needs, especially in Pincus. 2014 light of force management actions in key technol- The poor physical health of adults with serious ogy areas. mental illnesses is a public health crisis. Greater RR-660-OSD Measuring Cooperative Biological Engage- integration of mental health and primary medi- ment Program (CBEP) Performance: Capacities, cal care services at the clinic and system levels Capabilities, and Sustainability Enablers for Bior- could address this need. In New York state, there are several ongoing initiatives that promote integrated care for adults with serious mental illness, provided or coordinated by community mental health center staff. This report examines three ini- 436 tiatives.Data were collected by RAND through site cymakers better understand the characteristics, visits and surveys of mental health clinic admin- priorities and concerns of relevant diasporas. In istrators and associated professionals. Results comparison with their countries of origin, diaspora showed that Primary and Behavioral Health Care groups on the whole achieve better outcomes on Integration grantees developed infrastructure that a range of socioeconomic indicators. Diaspora supported a broad scope of primary and preven- groups generally show higher rates of high edu- tive health care services; these broad changes cational attainment, labour force participation in appeared to contribute to clinicwide culture shifts their receiving countries, and, unsurprisingly, tend toward integration and shared accountability for to have a higher share of working-age population consumers' “whole person” health. Clinics partici- compared with their counterparts in countries of pating in the Medicaid Incentive tended to imple- origin. The comparison with receiving countries ment only those services for which they could bill, offers a more complex picture. Diaspora groups which resulted in newly identified consumer physi- have a higher share of working-age population cal health care needs but did not help consumers than the populations in the countries where they to connect to physical health care services. Finally, settled, but are generally lagging behind with re- while administrators and providers were optimistic spect to labour force and education outcomes. that Medicaid Health Homes have potential to im- The size of this gap is much larger for labour force prove access to care for adults with serious men- participation rates than for educational outcomes. tal illness, the newness of the initiative made it dif- Through synthesis of our quantitative mapping ficult to assess the degree to which Health Home and analysis of engagement strategies and dias- networks would meet these goals. We conclude pora survey results, we provided a set of eight rec- with recommendations to state policymakers, clin- ommendations for actors seeking to engage with ical providers, and technical assistance providers diaspora groups. and recommendations for future research, all designed to strengthen New York state's integrated RR-671/1-EC care initiatives for adults with serious mental ill- Mapping Diasporas in the European Union ness. and United States: Comparative analysis and recommendations for engagement: summary report. RR-671-EC Jirka Taylor, Jennifer Rubin, Corrado Giulietti, Mapping Diasporas in the European Union and Chris Giacomantonio, Flavia Tsang, Amelie Con- United States: Comparative analysis and recom- stant, Linguere Mbaye, Maryam Naghsh Nejad, mendations for engagement. Jirka Taylor, Jenni- Kristy Kruithof, Mafalda Pardal, Alex Hull, Tess fer Rubin, Corrado Giulietti, Chris Giacomantonio, Hellgren. 2014 Flavia Tsang, Amelie Constant, Linguere Mbaye, The European Commission commissioned Maryam Naghsh Nejad, Kristy Kruithof, Mafalda RAND Europe and the Institute for the Study of Pardal, Alex Hull, Tess Hellgren. 2014 Labor (IZA) to conduct a study mapping diaspo- The European Commission commissioned ras in the European Union and the United States. RAND Europe and the Institute for the Study of This aimed to provide an overview of diasporas Labor (IZA) to conduct a study mapping diaspo- present in Europe and the US, and to deliver ras in the European Union and the United States. concrete recommendations for engaging with di- This study aimed to provide an overview of dias- asporas as a bridge to their countries of origin, poras present in Europe and the US, and to de- especially where improvement is sought in rela- liver concrete recommendations for engaging with tions with those countries. Our analysis revealed diasporas as a bridge to their countries of origin, several noteworthy patterns which may help poli- especially where improvement is sought in rela- cymakers better understand the characteristics, tions with those countries. Our analysis revealed priorities and concerns of relevant diasporas. In several noteworthy patterns which may help poli- comparison with their countries of origin, diaspora 437 groups on the whole achieve better outcomes on Early Childhood Education. Lindsay Daugherty, a range of socioeconomic indicators. Diaspora Rafiq Dossani, Erin-Elizabeth Johnson, Cameron groups generally show higher rates of high edu- Wright. 2014 cational attainment, labour force participation in Conversations about what constitutes “devel- their receiving countries, and, unsurprisingly, tend opmentally appropriate” use of technology in early to have a higher share of working-age population childhood education have, to date, focused large- compared with their counterparts in countries of ly on a single, blunt measure—screen time—that origin. The comparison with receiving countries fails to capture important nuances, such as what offers a more complex picture. Diaspora groups type of media a child is accessing and whether have a higher share of working-age population technology use is taking place solo or with peers. than the populations in the countries where they Using screen time as the primary measure of de- settled, but are generally lagging behind with re- velopmentally appropriate use has become in- spect to labour force and education outcomes. creasingly inappropriate as new technologies are The size of this gap is much larger for labour force ever more rapidly introduced and integrated into participation rates than for educational outcomes. all aspects of life, and as we learn more about Through synthesis of our quantitative mapping the potential benefits of technology. The authors and analysis of engagement strategies and dias- challenge the traditional emphasis on screen time pora survey results, we provided a set of eight rec- and discuss how to move toward a more compre- ommendations for actors seeking to engage with hensive definition of developmentally appropriate diaspora groups. technology use for young children. RR-673/1-PNC RR-673/3-PNC Getting on the Same Page: Identifying Goals How Much and What Kind? Identifying an Ad- for Technology Use in Early Childhood Education. equate Technology Infrastructure for Early Child- Lindsay Daugherty, Rafiq Dossani, Erin-Elizabeth hood Education. Lindsay Daugherty, Rafiq Dos- Johnson, Cameron Wright. 2014 sani, Erin-Elizabeth Johnson, Cameron Wright. Technology use among young children is in- 2014 creasingly a fact of life, and establishing a clear To realize the potential benefits of technology set of goals that are broadly accepted by stake- use in early childhood education (ECE), and to holders is critical to planning for the successful ensure that technology can help to address the integration of technology into early childhood ed- digital divide, providers, families of young children, ucation (ECE). However, debates about the role and young children themselves must have access of technology in ECE settings are ongoing, with to an adequate technology infrastructure. The some stakeholders unwilling to accept any role goals for technology use in ECE that a technology for technology in ECE. It has been difficult, there- infrastructure should support are to improve learn- fore, to make progress toward identifying coming and to build digital literacy. Identifying specific mon goals, and toward ensuring that technology requirements for this infrastructure of devices, is integrated in a way that aligns with those goals, software, and connectivity is neither a straightfor- once defined. Based on findings from a forum and ward nor an easy undertaking, because many fac- review of the literature, the authors offer ways to tors—such as the absence of agreed standards of move past that debate and suggest several core performance for technology infrastructure and the goals that might be adopted to guide technology rapid pace of technology development—make an use in ECE. “adequate infrastructure” a moving target. In this policy brief, the authors identify challenges and RR-673/2-PNC examine how a wide variety of government and Moving Beyond Screen Time: Redefining nongovernmental stakeholders might collaborate Developmentally Appropriate Technology Use in to define what constitutes an adequate technology 438 architecture, and to help ensure that it is realized. better educators at home, and strengthening connection and communication between school and RR-673/4-PNC home. Getting Early Childhood Educators Up and Running: Creating Strong Technology Curators, RR-678-OSD Facilitators, Guides, and Users. Lindsay Daugh- How Do Federal Civilian Pay Freezes and erty, Rafiq Dossani, Erin-Elizabeth Johnson, Retirement Plan Changes Affect Employee Reten- Cameron Wright. 2014 tion in the Department of Defense?. Beth J. Asch, Michael G. Mattock, James Hosek. 2014 Providers of early childhood education (ECE) are well positioned to help ensure that technol- Little is known about the effect of compensa- ogy is used effectively in ECE settings. Indeed, tion changes on the federal civilian workforce in the successful integration of technology into ECE the Department of Defense (DoD)—even as civil- depends on providers who have the ability to cu- ian employees experienced three straight years of rate the most appropriate devices and content, pay freezes between 2011 and 2013 and a man- facilitate effective patterns of use, guide families dated increase in the retirement contribution rate and caretakers on developmentally appropriate for employees hired after 2012. For civil service practice, and use technology to support provider managers, a key concern is whether the reduction needs. But ECE providers face significant obsta- in pay and benefits is making it more difficult for the cles that might limit their ability to successfully in- federal government to recruit and sustain an ad- corporate technology into the learning process. In equate workforce, especially in critical skill areas. this policy brief, we describe both the barriers pro- Understanding civil service retention is particularly viders face and the efforts that might be helpful in important for DoD, given the significant contribu- creating confident, knowledgeable providers who tion made by the federal civil service workforce to can help ensure appropriate, intentional, and pro- military readiness.RAND has begun to extend the ductive use of technology among young children. dynamic retention model to federal civil service employment. This study demonstrates the use of RR-673/5-PNC this capability to assess the effect of pay freezes, Families, Powered On: Improving Family En- unpaid furloughs, and changes to civil service re- gagement in Early Childhood Education Through tirement on retention in a portion of the federal Technology. Lindsay Daugherty, Rafiq Dossani, civil service workforce—specifically General Ser- Erin-Elizabeth Johnson, Cameron Wright. 2014 vice workers with at least a bachelor's degree. Family engagement in the education of young Our analysis showed that permanent pay freezes children is associated with numerous positive decrease the workforce retained by 7.3 percent. outcomes for those children, and parents and There is no discernable change in retention from other family members play an important role as a six-day unpaid furlough. The effect on retention “teachers” during the time children spend outside of increasing employee contributions to the fed- the classroom. Home-based involvement (e.g., a eral retirement defined-benefit plan, as recently parent-led educational activity), school-based in- mandated in law, depends on employees' savings volvement (e.g., volunteering in the classroom), behavior—for example, whether employees were and school-home conferencing (e.g., speaking already saving enough to cover the higher con- to a teacher about a child's progress) are the key tribution or whether they might shift contributions components of family engagement, but there are from one part of the retirement plan to another, barriers to all three. In this policy brief, we describe losing matched contributions by the employer by both the barriers that hinder family engagement doing so. RAND analyzed a number of cases and and the ways in which technology may afford new found that higher employee contributions could opportunities to improve early childhood educa- result in as much as an 8.6 percent drop in the tion outcomes—empowering families to become number of employees retained over the long run. 439

In the future, this capability could be used to as- within their own communities. sess a wide range of compensation policies—in other occupational areas; for demonstration pay RR-685-CMHSA systems such as for the STEM workforce; specific CalMHSA Student Mental Health Campus-Wide demographic groups, such as women and minori- Survey: 2013 Summary Report. Lisa Sontag- ties; and specific locations of interest. Padilla, Elizabeth Roth, Michelle W. Woodbridge, Courtney Ann Kase, Karen Chan Osilla, Elizabeth RR-681-CMHSA J. D'Amico, Lisa H. Jaycox, Bradley D. Stein. 2014 Where Would California Adults Prefer to Get Report provides the results of a California sur- Help If They Were Feeling Suicidal?. Amariah vey of colleges and universities on mental health Becker, Rajeev Ramchand. 2014 experiences and attitudes, perceptions of campus Report assesses the types of resources, ranging mental health services, and perceptions of overall from face-to-face interactions with mental health campus climate toward mental health and well- professionals to texting a crisis line, that adults in being. California prefer to utilize for suicidal thoughts or feelings. RR-686-CMHSA Adults Exposed to "Know the Signs" Are More RR-682-CMHSA Confident Intervening with Those At Risk for Sui- Racial and Ethnic Differences in Exposure cide. Joie D. Acosta, Rajeev Ramchand. 2014 to Suicide Prevention Messaging, Confidence in Report evaluates the effects of a California One's Ability to Intervene with Someone at Risk, mass media program that aims to prepare more and Resource Preferences. Rajeev Ramchand, Californians to prevent suicide by encouraging Elizabeth Roth. 2014 them to know the warning signs, offer support to Report assesses differences in racial and eth- persons at risk, and reach out to local resources. nic groups' exposure to suicide prevention messaging, preferences for suicide crisis services, RR-688-CMHSA and confidence in their ability to intervene with California K-12 Schools and Communities Col- persons at risk of suicide. laborate to Support Student Mental Health. Mi- chelle W. Woodbridge, Asha Goldweber, Jennifer RR-683-CMHSA Yu, Shari Golan, Bradley D. Stein. 2014 Findings from the School-Based Theatrical Per- Report evaluates the development, quality, and formance "Walk In Our Shoes". Eunice C. Wong, effectiveness of collaboration activities among Jennifer L. Cerully, Rebecca L. Collins, Elizabeth California K–12 Student Mental Health program Roth. 2014 partners. Report examines the effects of a school-based theatrical performance, Walk In Our Shoes, de- RR-689-CMHSA signed to educate youth about and reduce stigma California Colleges and Universities Collaborate and discrimination toward mental illness. to Support Student Mental Health. Michelle W. Woodbridge, Asha Goldweber, Jennifer Yu, Shari RR-684-CMHSA Golan, Bradley D. Stein. 2014 Racial and Ethnic Differences in Mental Illness Report evaluates the development, quality, and Stigma in California. Rebecca L. Collins, Eunice effectiveness of collaboration activities among C. Wong, Jennifer L. Cerully, Elizabeth Roth. 2014 California Student Mental Health program part- Report identifies racial and ethnic groups in ners in higher education. California that are more likely to stigmatize those with mental illness, thereby helping understand RR-695-AF who is at greatest risk of experiencing stigma 440

Information and Communication Technologies that a revision to the Directive would be justified. to Promote Social and Psychological Well-Being Overall, 21 papers (from 16 studies), including in the Air Force: A 2012 Survey of Airmen. Laura two RCTs, met the inclusion criteria; 12 were con- L. Miller, Laurie T. Martin, Douglas Yeung, Matthew ducted in marine waters and four were conducted D. Trujillo, Martha J. Timmer. 2014 in freshwater. Considerable heterogeneity existed This report presents the findings from a pio- between study protocols and the majority had neering exploratory survey of 3,479 active-duty, significant methodological limitations, including guard, and reserve Airmen on their use of infor- self-selection and misclassification biases. More- mation and communication technology (ICT), over, there was limited variation in water quality the association between ICT use and social and among studies, providing a limited evidence base psychological well-being, and the potential for Air on which to assess the classification standards. Force mental-health professionals to use ICT to Overall, there appears to be a consistent signifi- meet the needs of Airmen. The survey data were cant relationship between faecal indicator organ- weighted to ensure that the analytic sample would isms and GI in freshwater, but not marine water be representative of the gender, age group, rank studies. Given the apparent lack of relationship (officer, enlisted), and affiliation (active, guard, re- between GI and water quality, it is unclear wheth- serve) composition of the U.S. Air Force. Rates of er the boundaries of the Bathing Waters Directive ICT usage by Airmen are presented, along with are supported by studies published in the post- Airmen's perceptions of the relationship between 2003 period. We suggest that more epidemio- social support and ICT use, their attitudes about logical evidence is needed to disprove or confirm seeking and receiving health information via tech- the original work that was used to derive these nology, and the differences in ICT use, social sup- boundaries for marine waters. port, and psychological well-being among differ- RR-706-CMS ent groups of Airmen. Finally, recommendations Medicare Imaging Demonstration Final Evalu- are presented on ways the Air Force can leverage ation: Report to Congress. Justin W. Timbie, Peter ICT to promote the social and psychological well- S. Hussey, Lane F. Burgette, Neil S. Wenger, Afshin being of Airmen. Rastegar, Ian Brantley, Dmitry Khodyakov, Kristin J. Leuschner, Beverly A. Weidmer, Katherine L. RR-698-DEFRA The Health Risks of Bathing in Recreational Kahn. 2014 Waters: A Rapid Evidence Assessment of Water Increasing use of advanced medical imaging is Quality and Gastrointestinal Illness. Sarah King, often cited as a key driver of cost growth in medi- Josephine Exley, Eleanor Winpenny, Lottie Alves, cal spending. In 2011, the Medicare Imaging Dem- Marie-Louise Henham, Jody Larkin. 2014 onstration from the Centers for Medicare & Med- The European Bathing Directive (2006/7/EC) icaid Services began testing whether exposing stipulates water quality standards for recreational ordering clinicians to appropriateness guidelines bathing waters based on specified limits of fae- for advanced imaging would reduce ordering inap- cal indicator organisms (FIOs). Presence of FIOs propriate images. The evaluation examined trends above the limits is considered to be indicative of in advanced diagnostic imaging utilization starting poor water quality and to present a risk to bathers' January 1, 2009—more than two years before the health. The European Bathing Directive (2006) is beginning of the demonstration—to November 30, to be reviewed in 2020. We conducted a rapid evi- 2013—two months after the close of the demon- dence assessment on recreational bathing waters stration. Small changes in ordering patterns were and gastrointestinal illness (GI) to identify the ex- noted, but decision support systems were unable tent of the literature published since the previous to assign appropriateness ratings to many orders, review period in 2003 and to determine whether thus limiting the potential effectiveness of decision there is any new evidence which may indicate support. Many opportunities to refine decision 441 support systems have been identified. individuals (such as those with preexisting conditions) from being priced out of the market. The ACA RR-707-WT also instituted several policies to stabilize premi- The African Institutions Initiative: Insights from ums and to encourage enrollment among healthy the First Four Years. Gavin Cochrane, Enora individuals of all ages. The law's tax credits and Robin, Sonja Marjanovic, Stephanie Diepeveen, cost-sharing subsidies offer a “carrot” that may Rebecca Hanlin, David Kryl, Lucia Retter, Ohid encourage enrollment among some young and Yaqub, Joanna Chataway. 2014 healthy individuals who would otherwise remain In 2009, the Wellcome Trust launched a re- uninsured, while the individual mandate acts as search capacity strengthening programme known a “stick” by imposing penalties on individuals who as the African Institutions Initiative' (AII). The AII choose not to enroll.In this report, the authors use is innovative in its methods and organization. The the using the COMPARE microsimulation model, Initiative funded networked consortia (7 consor- an analytic tool that uses economic theory and tia involving 54 institutions in 18 African countries, data to predict the effects of health policy reforms, and Northern partners). RAND Europe was com- to estimate how eliminating the ACA's individual missioned to undertake a four year evaluation and mandate, eliminating the law's tax credits, and learning project for the AII. The aims of the project combined scenarios that change these and other were to (i) evaluate the performance of each con- provisions of the act might affect 2015 individual sortium and ultimately the Initiative as a whole, market premiums and overall insurance coverage. based on high quality evidence; (ii) to support Underlying these estimates is a COMPARE-based intra, inter and extra consortium networking for analysis of how premiums and insurance coverage learning and exchange; and (iii) to extract lessons outcomes depend on young adults' propensity to learnt from the Initiative and disseminate these to enroll in insurance coverage.The authors find that the Trust, other funders and relevant stakeholders eliminating the ACA's tax credits and eliminating in academic, policy and practice communities. The the individual mandate both increase premiums objectives of the Initiative represent an ambitious and reduce enrollment on the individual market. departure from traditional modes of strengthen- They also find that these key features of the ACA ing research capacity in LMICs. While the Initia- help to protect against adverse selection and sta- tive is at an early phase, evidence gathered in this bilize the market by encouraging healthy people evaluation show that consortia are contributing in to enroll and, in the case of the tax credit, shield- multiple ways to developing sustainable research ing subsidized enrollees from premium increases. capacity. The unique features of the Initiative — Further, they find that individual market premiums an African-led, networked approach — have facili- are only modestly sensitive to young adults' pro- tated many of these achievements. The diversity pensity to enroll in insurance coverage, and en- of networking models for capacity building de- suring market stability does not require that young veloped by consortia present the Wellcome Trust adults make up a particular share of enrollees. with a range of models with differing strengths and weaknesses. RR-714-RF The Socioeconomic Effects of the Working RR-708-DHHS Poor Moving to Permanent Dwellings: The Case Assessing Alternative Modifications to the Af- of the Ashray Affordable Housing Pilot Project in fordable Care Act: Impact on Individual Market India. Nicholas Burger, Italo Gutierrez, Krishna Premiums and Insurance Coverage. Christine B. Kumar, Jill E. Luoto, Dhaval Monani, Kavita Eibner, Evan Saltzman. 2014 Raichura. 2014 The goals of the Affordable Care Act (ACA) are RAND Corporation researchers assessed the to enable all legal U.S. residents to have access to socioeconomic effects that moving into perma- affordable health insurance and to prevent sicker nent dwellings—in particular, into the Ashray Af- 442 fordable Housing Pilot Project in India—has on ment programs and services designed to address the working poor. The aim of projects like Ashray the mental health needs of returning veterans and is to build houses in peri-urban zones on the out- their families. In 2010, the McCormick Foundation skirts of large metropolitan areas that are home asked RAND to join the WBV Initiative in a perfor- to manufacturing and industrial bases. By capi- mance monitoring role. RAND designed a system talizing on cheaper land, the demand for afford- of regular data reporting to assess performance able housing from local workers, and creditworthy and impact of the WBV-funded activities at each risk profiles of employed workers seeking home site. This report provides an overview of the WBV loans, low-cost housing projects may help low- Initiative, summarizes the impact of WBV-fund- income workers and their families improve their ed programs during their funding cycle between living conditions, while still allowing developers February 2011 and June 2013, and outlines the to recover their costs. RAND researchers, in col- lessons learned in implementing veteran support laboration with ISB, undertook a mixed-methods programs. It also discusses the role of partner- evaluation of the Ashray project as an initial step ships and innovative strategies for outreach. to understand the impacts that such private-sector affordable-housing projects can have on the well- RR-725-EC being of low-income households. They collected The international dimension of research and qualitative data through focus-group discussions innovation cooperation addressing the grand of current Ashray residents and carried out a challenges in the global context. Cecile Hoareau quantitative survey of the residents and owners McGrath, Veronika Horvath, Ben Baruch, Salil of the Ashray units in late 2013 and early 2014. Gunashekar, Hui Lu, Shelly Culbertson, Paulina Together, these two data sources provide early Pankowska, Joanna Chataway. 2014 evidence into the ways in which this new hous- Grand challenges, such as global warming ing project has affected the lives of its residents. or chronic and infectious diseases, areincreas- They asked residents about their living situations, ingly global and complex. Solving these chal- housing amenities, commute times to work, social lenges often requires international research col- networks, and financial situations, both prior to laboration. The European Commission is playing moving to Ashray and currently while living there. an increasing role in supporting research and innovation through Horizon 2020, the European RR-719-MTF Union's comprehensive Framework Programme Enhancing Capacity to Address Mental Health for Research and Technological Development. Needs of Veterans and Their Families: The Wel- This policy brief provides an overview of the main come Back Veterans Initiative. Terri Tanielian, research priorities, the maincollaborative efforts Laurie T. Martin, Caroline Epley. 2014 in international research collaboration regarding In the context of the conflicts in Iraq and Af- grand challenges, and summarises the outcomes ghanistan over the past decade, there have been of an expert and stakeholders' workshop conduct- a growing number of efforts designed to support ed on the 3rd of April 2014. The brief is written service members, veterans, and their families as to inform the European Research and Innovation they cope with deployment and ensure that those Area Board regarding the state of research col- who experience mental health problems following laboration on grand challenges and what the EU their service have access to high-quality care for could do to further improve research collaboration themselves and their families. Among these is the on these grand challenges. Welcome Back Veterans (WBV) Initiative, launched in 2008 by Major League Baseball and the Robert RR-728-DH R. McCormick Foundation. During 2011–2013, the The changing hospital landscape: An explo- WBV Initiative issued grants to academic medical ration of international experiences. Ellen Nolte, institutions around the nation to create and imple- Emma Pitchforth, Celine Miani, Sheena Mc Hugh. 443

2014 care providers in the Cincinnati area joined with The nature of hospital activity is changing in community organizations in an effort to improve many countries, with some experiencing a broad health care and population health, as well as re- trend towards the creation of hospitals groups or duce health care costs by focusing on five priority chains and multi-hospital networks. This report areas: coordinated primary care, health informa- seeks to contribute to the understanding of experi- tion exchange, quality improvement, public report- ences in other countries about the extent to which ing and consumer engagement, and payment in- different hospital models' may provide lessons novations. Spearheaded by General Electric (GE) for hospital provision in England by means of a Cincinnati, the resulting Healthy Communities Ini- review of four countries: France, Germany, Ireland tiative in Cincinnati was implemented in 2009. In and the United States, with England included for 2012, GE asked RAND Health Advisory Services comparison. We find that here has been a trend to assess progress over the first three years of towards privatisation and the formation of hospital the initiative. Overall, the findings were largely in- groups in France, Germany and the United States conclusive because of a concomitant marketwide although it is important to understand the underly- shift to high-deductible health policies (which are ing market structure in these countries explaining known to have profound effects on care-seeking the drivers for hospital consolidation. Thus, and in behavior) and the early stage of the intervention. contrast to the NHS, in France, Germany and the However, there were some encouraging signs that United States, private hospitals contribute to the better care coordination bears fruit, such as less delivery of publicly funded healthcare services. illness-related work loss and fewer avoidable hos- There is limited evidence suggesting that different pital admissions and readmissions. These early forms of hospital cooperation, such as hospital impacts suggest that the initiative may succeed groups, networks or systems, may have different in improving care, lowering cost, and improving impacts on hospital performance. Available evi- health status if given sufficient time. dence suggests that hospital consolidation may RR-732-BMGF lead to quality improvements as increased size al- Competency-Based Education in Three Pilot lows for more costly investments and the spread- Programs: Examining Implementation and Out- ing of investment risk. There is also evidence that comes. Jennifer L. Steele, Matthew W. Lewis, a higher volume of certain services such as surgi- Lucrecia Santibanez, Susannah Faxon-Mills, Mol- cal procedures is associated with better quality of lie Rudnick, Brian M. Stecher, Laura S. Hamilton. care. However, the association between size and 2014 efficiency is not clear-cut and there is a need to balance quality risk' associated with low volumes In 2011, the Bill & Melinda Gates Foundation and access risk' associated with the closure of created the Project Mastery grant program to sup- services at the local level. port competency-based education initiatives in large school systems that serve a high propor- RR-729-GECO tion of disadvantaged youth. Competency-based Quantitative Evaluation of the Impact of the education meets students where they are aca- Healthy Communities Initiative in Cincinnati. So- demically, provides students with opportunities for eren Mattke, Hangsheng Liu, Samuel Hirshman, choice, and awards credit for evidence of learning, Saw H. Wah, Sydne Newberry. 2014 not for the time students spend studying a subject. The Foundation asked RAND to evaluate these Metropolitan Cincinnati residents have tradi- efforts in terms of implementation, students' ex- tionally had among the highest health care costs periences, and student performance. This report in the United States, yet little evidence exists that presents final results from that evaluation, offering residents are getting their money's worth, espe- an overview of competency-based education and cially in terms of preventive and primary care. Re- the Project Mastery grant projects and describing cently, large employers, health plans, and health the implementation of competency-based educa- 444 tional features under each project. The report con- all U.S. portfolio of treaties and agreements can cludes with six lessons for policy, partnerships, offer insight into the distribution and depth of U.S. and practice. commitments internationally, including its military commitment, relationships, capabilities, and vul- RR-735-SFSC nerabilities in a given area. While there are many Does San Francisco's Community Justice Cen- sources of information on security-related treaties ter Reduce Criminal Recidivism?. Beau Kilmer, and agreements, there is currently no comprehen- Jesse Sussell. 2014 sive record of current or historical security-related In 2009, San Francisco opened a community treaties signed by the United States that can be court, the Community Justice Center (CJC), to used for empirical analysis. To address the short- serve the Tenderloin and adjacent neighborhoods, comings in existing datasets and indexes to con- a traditionally high-crime area. Community courts tribute to the study of U.S. security treaties and are expressly oriented toward improving out- agreements, the author has developed a new, comes for offenders by addressing factors often more comprehensive treaty database that will en- linked to criminal behavior (by incorporating ac- hance the ability of researchers to study the full cess to treatment and services within the criminal portfolio of U.S. security agreements. This report case management process); they also emphasize summarizes the approach used to identify and ties to a specific neighborhood. This report exam- code treaties included in the database. It provides ines whether the CJC reduces the risk of rearrest a definition of each data field as well as a brief when compared to more traditional approaches discussion of the methodological decisions made for addressing arrestees. Using a differences-in- during the development of the database. It also of- differences (DD) design that exploits temporal and fers a general review of the treaties included in the geographic variation in CJC eligibility, a RAND database and a limited treatment of the country- research team examined one-year rearrest rates year dataset that can be used in empirical anal- among those arrested for eligible offenses within ysis. Finally, it discusses some of the dataset's the four police districts that include a part of the limitations and possible next steps to expand the CJC catchment area, including offenses inside and database and its utility. outside the catchment area both before and after the CJC opened. After controlling for a number of RR-743-DTRA arrestee-level factors (including criminal history), Cruise Missile Penaid Nonproliferation: Hin- as well as month- and police district–level fixed ef- dering the Spread of Countermeasures Against fects, the DD estimator from our preferred models Cruise Missile Defenses. Richard H. Speier, ranges from –8.2 to –7.1 percentage points, which George Nacouzi, K. Scott McMahon. 2014 corresponds to an 8.9 percent to 10.3 percent re- The proliferation of weapons of mass destruc- duction in the probability of being rearrested with- tion (WMD) becomes a greater threat when ac- in one year. These findings support the hypothesis companied by the proliferation of effective means that the CJC reduces criminal recidivism and are of delivery. The threat of one means of delivery, robust to a number of sensitivity analyses. cruise missiles, will increase if proliferators can acquire effective countermeasures against mis- RR-736-AF sile defenses. Such countermeasures, when in- U.S. Security-Related Agreements in Force corporated in an attacker's missile, are known as Since 1955: Introducing a New Database. Jen- penetration aids or penaids. As proliferator na- nifer Kavanagh. 2014 tions acquire ballistic and cruise missiles for this Treaties and agreements are powerful foreign purpose, it will be important to establish effective policy tools that the United States uses to build and measures to counter WMD attacks. This research solidify relationships with partners and to influence was designed to assist U.S. agencies charged the behavior of other states. As a result, the over- with generating policies to discourage the proliferation of WMD and cruise missile delivery systems, 445 thereby strengthening deterrence. Specifically, it nurses, although rapidly growing distance learn- recommends controls on potential exports of pe- ing programs may be able to meet this need. The naid-related items according to the structure of the authors find varying needs for the four applied current international policy against missile prolifer- science occupations they examined: computer ation, the Missile Technology Control Regime. The and information technology, management of fire recommendations account for 18 classes of such sciences, management of production/operations items and are based on structured interviews with technicians, and health information technology. government and nongovernment experts, as well While expanding community college baccalau- as an independent technical assessment to devel- reate degree programs could help meet unmet op a preliminary characterization of the technolo- needs and increase degree attainment among gies and equipment most critical to the emerging students, there are concerns about costs, mission penaid threat. The project also brought together a creep at community colleges, counterproductive selected group of experts to participate in a work- competition between community colleges and shop to review the initial characterization of penaid universities, and a decline in the overall quality of technologies and equipment. An earlier report by a Texas baccalaureate. The authors discuss the the same authors, Penaid Nonproliferation: Hin- inherent tradeoffs that policymakers face in this dering the Spread of Countermeasures Against regard. Ballistic Missiles (RR-378-DTRA), presented a similar approach to controlling the proliferation of RR-745/1-CFAT ballistic missile penaids. Assessing the Potential to Expand Commu- nity College Baccalaureate Programs in Texas: RR-745-CFAT Executive Summary. Lindsay Daugherty, Charles Assessing the Potential to Expand Commu- A. Goldman, Lindsay Butterfield, Trey Miller. 2014 nity College Baccalaureate Programs in Texas. Many workforce-development needs, particu- Lindsay Daugherty, Charles A. Goldman, Lindsay larly those requiring baccalaureate degrees, re- Butterfield, Trey Miller. 2014 main unmet in some areas of Texas. Employers Many workforce-development needs, particu- and students are calling for additional programs to larly those requiring baccalaureate degrees, re- develop workplace skills and to provide opportu- main unmet in some areas of Texas. Employers nities for career advancement. On May 22, 2013, and students are calling for additional programs to the Texas Legislature approved a bill mandating develop workplace skills and to provide opportu- a study on whether community college baccalau- nities for career advancement. On May 22, 2013, reate degree programs should be expanded in the Texas Legislature approved a bill mandating a Texas. The Texas Higher Education Coordinating study on whether community college baccalaure- Board asked the RAND Corporation to partner ate degree programs should be expanded in Texas. with the Texas Higher Education Policy Initiative to The Texas Higher Education Coordinating Board conduct the study.This report summarizes a lon- asked the RAND Corporation to partner with the ger research report in which the authors assess Texas Higher Education Policy Initiative to con- unmet workforce-development needs in nursing duct the study.In this report, the authors assess and the applied sciences, assess the arguments unmet workforce-development needs in nursing for and against baccalaureate expansion, and and the applied sciences, assess the arguments recommend potential activities to support imple- for and against baccalaureate expansion, and mentation of any new policies undertaken to ex- recommend potential activities to support imple- pand community college baccalaureate programs. mentation of any new policies undertaken to ex- They find significant need for more baccalaureate pand community college baccalaureate programs. nurses, although rapidly growing distance learn- They find significant need for more baccalaureate ing programs may be able to meet this need. The authors find varying needs for the four applied 446 science occupations they examined: computer eral Schedule. and information technology, management of fire sciences, management of production/operations RR-750-AF technicians, and health information technology. Enhancing Performance Under Stress: Stress While expanding community college baccalau- Inoculation Training for Battlefield Airmen. Sean reate degree programs could help meet unmet Robson, Thomas Manacapilli. 2014 needs and increase degree attainment among USAF pararescue and combat controllers rou- students, there are concerns about costs, mission tinely recover downed or injured military person- creep at community colleges, counterproductive nel and direct military aircraft in hostile or denied competition between community colleges and regions. Consequently, to be effective in these universities, and a decline in the overall quality of careers requires the ability to cope with severe a Texas baccalaureate. The authors discuss the stress. The USAF uses many strategies to ensure inherent tradeoffs that policymakers face in this that battlefield airmen perform well under stress regard. but one strategy, termed stress inoculation training (SIT), has not been fully incorporated as a train- RR-748-OSD ing element. Current Air Force strategies include Retention and Promotion of High-Quality Civil screening out individuals unable to tolerate stress Service Workers in the Department of Defense during initial selection and in training, exposing Acquisition Workforce. Christopher Guo, Philip candidates to a variety of stressors during train- Hall-Partyka, Susan M. Gates. 2014 ing, and providing airmen with education and sup- The defense acquisition workforce (AW) includes port, both predeployment and postdeployment. more than 151,000 military and civilian person- Although some of these strategies are consistent nel who provide a range of acquisition, technol- with SIT principles, additional training should fo- ogy, and logistics support (products and services) cus on the cognitive and behavioral skills (e.g., to the nation's warfighters. This report examines goal-setting, energy/arousal control) to help air- data from Defense Manpower Data Center files men perform effectively under stress. The authors and draws from previous related RAND analyses conducted an extensive literature review to better to address questions about factors that affect per- understand modern stress theories, and they in- sonnel retention and career advancement in the terviewed Air Force instructors from the Air Edu- AW. First, it examines available measures of per- cation and Training Command and formed small sonnel quality and explores whether personnel focus groups with combat controllers and parares- retention and career advancement vary by quality. cuemen. The goal of the focus groups was to iden- A higher average performance rating is generally tify what preparation, if any, battlefield airmen had associated with an increased hazard of separa- to optimize their performance under stress. The tion (decreased retention). On the other hand, authors also reviewed key official training docu- individuals with advanced education degrees ments, training plans, and instruction plans. (bachelor's, master's, or PhD) are more likely to be retained than those with less than a bachelor's RR-754-CMHSA degree. Second, the report describes the charac- Language Differences in California Adults' teristics of workers who rise to the senior execu- Exposure to Suicide Prevention Messaging, Confi- tive service within the AW. Third, it explores how dence in One's Ability to Intervene with Someone being in the Acquisition Demonstration pay plan at Risk, and Resource Preferences. Rajeev Ram- or another demonstration pay plan affects reten- chand, Elizabeth Roth. 2014 tion, after controlling for workforce quality metrics. Assesses the results of a statewide survey to People who were in the Acquisition Demonstra- determine language differences among California tion pay plan and, in fact, any demonstration pay adults' exposure to suicide prevention messaging, plan were retained longer than those in the Gen- confidence to intervene with someone at risk of 447 suicide, and resource preferences. Toward Improved Management of Officer Retention: A New Capability for Assessing Policy RR-755-CMHSA Options. Michael G. Mattock, Beth J. Asch, James A Case Study Evaluating the Fidelity of Suicide Hosek, Christopher Whaley, Christina Panis. 2014 Prevention Workshops in California. Karen Chan Osilla, Dionne Barnes-Proby, Mary Lou Gilbert, The U.S. Department of Defense (DoD) needs Rajeev Ramchand. 2014 the capability to assess alternative policies to enhance the retention of officers. This capabil- Reports on an evaluation of California suicide ity should be founded on empirically based esti- intervention training workshops to provide evi- mates of behavioral response to policy and recog- dence that training is delivered with fidelity and nize that, when making decisions, members are adherence to the workshop's design, as well as forward-looking and take into account future op- with high quality. portunities and uncertainty and the outcomes of past decisions and policies. Further, the capability RR-761-CMS should enable DoD to simulate or predict the ef- Emergency Department Patient Experience of fects of alternative policies on officer retention and Care Survey: Development and Field Test. Robin the costs of those policies. This report documents M. Weinick, Kirsten Becker, Layla Parast, Brian efforts to implement such a capability for officers D. Stucky, Marc N. Elliott, Megan Mathews, Chris and illustrates its use. The authors statistically Chan, Virginia I. Kotzias. 2014 estimate the parameters of a dynamic retention The Centers for Medicare & Medicaid Services model of officer behavior and use the parameter (CMS) have implemented Consumer Assessment estimates in a simulation model to help evaluate of Healthcare Providers and Systems (CAHPS®) the effect that changes in compensation can have surveys to assess patient experience in a number on the retention of officers and to show how poli- of settings. Following CAHPS principles, RAND cies that change the retention behavior of these researchers designed and field tested an Emer- officers can also change the aggregate retention gency Department Patient Experience of Care of the population of officers at earlier or later years Survey that consists of three survey instruments of their careers. The model can also be used to for use with adult patients who have visited the gauge the effect of alternative policies to enhance emergency department (ED). One instrument is retention. In addition, the authors have created a for use with those patients who are discharged to spreadsheet version of the model that can provide the community following their ED visit; the other quick estimates of the effect that bonuses, gate two are for use with those patients who are admit- pays, and separation pays can have on retention ted to the hospital from the ED (one for use on its in all years of service. This report provides the own and one to supplement an existing inpatient mathematical foundations and the source code for survey). The authors conducted a field test of these the spreadsheet model. The spreadsheet model is instruments in 12 hospitals in late 2013 and early also available on request from the RAND Forces 2014 and analyzed the resulting data from 4,101 and Resources Policy Center. ED patients. The analyses identified four composite measures (measures composed of responses RR-767-AUS to multiple survey questions) and ten measures Keeping Major Naval Ship Acquisitions on that are each composed of a single survey ques- Course: Key Considerations for Managing Austra- tion. As of September 2014, CMS plans to conduct lia's SEA 5000 Future Frigate Program. John F. additional testing on these instruments, which are Schank, Mark V. Arena, Kristy N. Kamarck, Gor- presented in the report. don T. Lee, John Birkler, Robert E. Murphy, Roger Lough. 2014 RR-764-OSD This study provides a program overview of acquisition options available for the Commonwealth 448 of Australia's next generation naval surface com- information, there is no guarantee they will use batant and identifies internal and external factors it well when faced with choices concerning war that can influence a major ship acquisition pro- and peace. They can learn from Blinders, Blun- gram. The authors address questions relating to ders, and Wars. As a general remedy, the authors available ship design and build options; various recommend the establishment of a government phases, options, and decisions; and aspects that body providing independent analysis and advice can contribute to the success of an acquisition on war-and-peace decisions by critiquing informa- program. Three broad options for designing and tion use, assumptions, assessments, reasoning, building the new ship include a new design, tailor- options, and plans. For the Sino-U.S. case, they made to Royal Australian Navy specifications and offer a set of measures to bring the models each requirements; a military off-the-shelf design, which has of the other into line with objective reality. would involve making only minor modifications to an existing ship design; and an evolved military RR-770-A off-the-shelf design, which would involve making France's War in Mali: Lessons for an Expedi- more significant modifications to an existing ship tionary Army. Michael Shurkin. 2014 design. The authors discuss lessons learned as French Army operations in Mali (Operation they apply to different phases of a shipbuilding Serval) in 2013 provide a model for designing and program and highlight the lessons most applica- operating an expeditionary force, one that has a ble to the acquisition strategy selected. number of attributes and competencies that Unit- ed States Army Chief of Staff General Raymond RR-768-RC Odierno has indicated to be requirements for the Blinders, Blunders, and Wars: What America Army. The model therefore provides a living ex- and China Can Learn. David C. Gompert, Hans ample that illustrates what meeting those require- Binnendijk, Bonny Lin. 2014 ments entails, as well as the associated risks. As The history of wars caused by misjudgments, France's War in Mali: Lessons for an Expedition- from Napoleon's invasion of Russia to America's ary Army details, the French in Serval demonstrat- invasion of Iraq, reveals that leaders relied on cog- ed that they are adept at quickly fielding small yet nitive models, or simplified representations of their highly capable forces tailored for specific needs worlds, that were seriously at odds with objective and objectives and reiteratively task organizing as reality. Blinders, Blunders, and Wars analyzes the situation evolves. They have done so in part eight historical examples of strategic blunders re- by pushing modularity below the battalion level, garding war and peace and four examples of deci- enabling them to disaggregate and reaggregate sions that turned out well, and then applies those elements of their brigades. The French have also lessons to the current Sino-American case. Lead- invested in technologies and vehicles designed ers' egos, intuitions, unwarranted self-confidence, to enhance the capabilities of its units at all ech- and aversion to information that contradicted their elons. Moreover, the French Army, particularly its views prevented them from correcting their mod- expeditionary brigades, is for all intents and pur- els. Yet advisors and bureaucracies can be inad- poses a regionally aligned force that has a demon- equate safeguards and can, out of fawning or fear, strated ability to leverage its area-specific exper- reinforce leaders' flawed thinking.War between tise to compensate for its small size and to work China and the United States is more likely to oc- effectively with and among local populations. The cur by blunder than from rational premeditation. French Army also appears to have an operational Yet flawed Chinese and American cognitive mod- culture well suited for expeditionary warfare, par- els of one another are creating strategic distrust, ticularly in austere environments and with limited which could increase the danger of misjudgment resources. The aspects of French Army operations by either or both, the likelihood of crises, and the in Mali discussed in this report make the French possibility of war. Although these American and Army a model for building the kind of expedition- Chinese leaders have unprecedented access to ary force envisioned by Odierno, and perhaps one 449 that is also increasingly in line with future United the Community Foundation for Greater New Ha- States Army budgets. The French example also ven, NHPS, and Yale University in 2010 to create highlights compromises that are associated with New Haven Promise, a scholarship program that becoming more expeditionary and the attendant aims to improve the college-going culture in the risks. city and postsecondary enrollment and graduation rates of NHPS graduates as a way to en- RR-774-NRPA hance the economic development of the city, at- Quantifying the Contribution of Public Parks to tract more residents to New Haven, reduce crime Physical Activity and Health: Introducing SOPARC. and incarceration, and improve residents' quality Deborah A. Cohen, Roland Sturm, Bing Han, Terry of life. The 2010–2011 school year marked the first Marsh. 2014 year of a staged implementation for both efforts. As important venues for physical activity, public In June 2013, the New Haven Promise Board of parks contribute to the health and well-being of Directors asked the RAND Corporation to con- the communities that surround them. It is there- duct a study to document and describe baseline fore in the best interests of park administrators conditions and early progress of these programs. to have a method to measure this contribution. Researchers worked with state and district data This paper introduces the System for Observing and conducted interviews with Promise Scholars Play and Recreation in Communities (SOPARC), and parents to document early trends and pos- a reliable, valid, and easy-to-use tool for quanti- sible areas for improvement. This report and its fying park use and park-based physical activity. companion volume document the resulting study. Park administrators should understand how to use SOPARC to collect data that justify expenditures RR-777/1-CFGNH Transforming an Urban School System: Progress in parks and recreation departments. To that end, of New Haven School Change and New Haven this paper lays out in some detail what SOPARC Promise Education Reforms (2010–2013)—Tech- is and how it is used, as well as provides back- nical Appendixes. Ethan Scherer, Sarah Ryan, ground information on the importance of physical Lindsay Daugherty, Jonathan David Schweig, activity to health. Robert Bozick, Gabriella C. Gonzalez. 2014 RR-777-CFGNH In 2009, the City of New Haven and New Ha- Transforming an Urban School System: Prog- ven Public Schools (NHPS) announced a sweep- ress of New Haven School Change and New ing K-12 educational reform, New Haven School Haven Promise Education Reforms (2010–2013). Change. The district had three primary goals for Gabriella C. Gonzalez, Robert Bozick, Lindsay School Change: (1) close the gap between the Daugherty, Ethan Scherer, Reema Singh, Monica performance of NHPS students' and Connecticut Jacobo Suarez, Sarah Ryan. 2014 students' averages on state tests, (2) cut the high In 2009, the City of New Haven and New Ha- school dropout rate in half, and (3) ensure that ven Public Schools (NHPS) announced a sweep- every graduating student has the academic abil- ing K–12 educational reform, New Haven School ity and the financial resources to attend and suc- Change. The district had three primary goals for ceed in college. Concurrent with School Change, School Change: (1) close the gap between the in 2010 the City of New Haven partnered with the performance of NHPS students' and Connecti- Community Foundation for Greater New Haven, cut students' averages on state tests, (2) cut the NHPS, and Yale University to create New Haven high school dropout rate in half, and (3) ensure Promise, a scholarship program that aims to im- that every graduating student has the academ- prove the college-going culture in the city and ic ability and the financial resources to attend postsecondary enrollment and graduation rates and succeed in college. Concurrent with School of NHPS graduates as a way to enhance the Change, the City of New Haven partnered with 450 economic development of the city, attract more meet demand. The analogy holds for issues of residents to New Haven, reduce crime and incar- acquisition, the two forces' relationship with the ceration, and improve residents' quality of life. The conventional military, their applicability across 2010–2011 school year marked the first year of a the spectrum of combat, and their historic need staged implementation for both efforts. In June for a strong advocate for reform. The analogy is 2013, the New Haven Promise Board of Directors not perfect, however. In terms of core capabilities, asked the RAND Corporation to conduct a study force accession, and tradition, the forces are also to document and describe baseline conditions very different. But even these differences offer fun- and early progress of these programs. Research- damental lessons for both the U.S. Department of ers worked with state and district data and con- Defense and the U.S. Army with regard to the fu- ducted interviews with Promise Scholars and parture and potential of the cyber force. ents to document early trends and possible areas for improvement. This volume contains the study's RR-782-COHF supporting appendixes. Barriers to Enrollment in Health Coverage in Colorado. Laurie T. Martin, Nazleen Bharmal, RR-780-A Janice C. Blanchard, Melody Harvey, Malcolm V. The Other Quiet Professionals: Lessons for Williams. 2014 Future Cyber Forces from the Evolution of Special As part of the implementation of the Affordable Forces. Christopher Paul, Isaac R. Porche III, El- Care Act, Colorado has expanded Medicaid and liot Axelband. 2014 also now operates its own health insurance ex- With the establishment of U.S. Cyber Com- change for individuals (called Connect for Health mand in 2010, the cyber force is gaining visibility Colorado). As of early 2014, more than 300,000 and authority, but challenges remain, particularly Coloradans have newly enrolled in Medicaid or in the areas of acquisition and personnel recruit- health insurance through Connect for Health Col- ment and career progression. A review of com- orado, but there also continues to be a diverse monalities, similarities, and differences between mix of individuals in Colorado who remain eligible the still-nascent U.S. cyber force and early U.S. for but not enrolled in either private insurance or special operations forces, conducted in 2010, of- Medicaid. The Colorado Health Foundation com- fers salient lessons for the future direction of U.S. missioned the RAND Corporation to conduct a cyber forces. Although U.S. special operations study to better understand why these individuals forces (SOF) have a long and storied history and are not enrolled in health insurance coverage and now represent a mature, long-standing capabil- to develop recommendations for how Colorado ity, they struggled in the 1970s and 1980s before can strengthen its outreach and enrollment efforts winning an institutional champion and joint home during the next open enrollment period, which in the form of U.S. Special Operations Command. starts in November 2014.RAND conducted focus U.S. cyber forces similarly represent a new but groups with uninsured and newly insured indi- critical set of military capabilities. Both SOF and viduals across the state and interviews with local cyber forces are, at their operating core, small stakeholders responsible for enrollment efforts in teams of highly skilled specialists, and both com- their regions. The authors identified 11 commonly munities value skilled personnel above all else. cited barriers, as well as several that were specific Irregular warfare and SOF doctrine lagged opera- to certain regions or populations (such as young tional activities, and the same is true of the cy- adults and seasonal workers). Collectively, these ber force. Early SOF, like the contemporary cyber barriers point to a set of four priority recommen- force, lacked organizational cohesion, a unified dations that stakeholders in Colorado may wish development strategy, and institutionalized train- to consider: (1) Support and expand localized ing. Perhaps most importantly, the capabilities of outreach and tailored messaging; (2) Strengthen both forces have traditionally been inadequate to marketing and messaging to be clear, focused on 451 health benefits of insurance (rather than politics Evaluation of the Impact of the National Institute and mandates), and actionable; (3) Improve the on Money in State Politics. Geoffrey McGovern, clarity and transparency of insurance and health Michael D. Greenberg. 2014 care costs and enrollment procedures, and (4) The National Institute on Money in State Politics Revisit the two-stage enrollment process and im- collects, processes, and makes public information prove Connect for Health Colorado website navi- on campaign contributions made to state-level gation and technical support. candidates for public office. The Institute asked the RAND Corporation to probe user perspec- RR-787-CMHSA Recommendations for Sustaining California's tives on the Institute and its data, on how the data Statewide Mental Health Prevention and Early In- are being used, and on how the utility of the data tervention Programs. M. Audrey Burnam, Sandra might be improved in the future. Drawing on expe- H. Berry, Nicole K. Eberhart, Rebecca L. Collins, riences of a variety of users, as well as a review of Patricia A. Ebener, Rajeev Ramchand, Bradley D. the publications that have used the Institute's data Stein, Michelle W. Woodbridge. 2014 and research reports, this report provides an evaluation of the Institute's impact on the public dis- Provides preliminary advice about which of course over campaign finance at the state level. It the California Mental Health Services Authority's is our view that the Institute serves an important Prevention and Early Intervention activities seem purpose—to undertake the collection, centraliza- most valuable to sustain or, in some cases, en- tion, and dissemination of state-level campaign hance. finance data. No other organization has been successful in this effort or is likely to be so. All the RR-789-EPIM audiences that the Institute seeks to engage have Evaluation of EPIM III: Emerging insights from found value in the Institute's efforts. The most the evaluation so far. Emily Scraggs, Emma Dis- successful of these are the scholarly, journalistic, ley, Jennifer Rubin, Joachim Krapels, Ben Baruch. and advocacy communities. The interviewees we 2014 spoke with were impressed, felt indebted to the This report sets out some emerging insights Institute, and expressed an inability to do the sort from the ongoing evaluation of the European of research, reporting, and advocacy on state Programme for Integration and Migration (EPIM) campaign finance without the Institute. Overall, a 2012-2015 programme. The activities of EPIM and variety of influential users engaged in campaign this evaluation lie at the very heart of EPIM's ef- finance and public policy view the Institute's work forts to strengthen the capacity of NGOs active in as being of high quality and adding value. migration and integration issues, to engage with and influence decision-making at EU and Member RR-794-DOS state levels, and to do so by drawing on a rigor- Portfolio Assessment of the Department of ous evidence base, and through a pragmatic ap- State Internet Freedom Program. Ryan Henry, proach. Founded in 2005 as an activity of the Net- Stacie L. Pettyjohn, Erin York. 2014 work of European Foundations (NEF) in a unique The struggle between those promoting Inter- effort to fund European migration and integration net freedom and those trying to control and moni- organisations, EPIM's activities include strategic tor the Internet is a fast-paced game of cat and grant-making as well as networking, capacity- mouse, and the DRL Internet freedom program building, supporting advocacy and policy work. seeks to fund projects that promote preserving the The Programme has now disbursed over ¤3m to open character of the Internet. Employing portfolio more than 24 grantee organisations. analysis techniques, the authors assessed DRL's Internet freedom portfolio for fiscal year 2012– RR-791-NIMSP 2013. The assessment showed good alignment Shining a Light on State Campaign Finance: An 452 between the State Department's strategy and the program,” and so on. In making their judgments, cumulative effect of the 18 funded projects. Addi- some resources rely exclusively on very detailed tionally, the portfolio was assessed to be well bal- and explicit requirements for each of the criteria, anced with an unrealized potential for supporting while others also employ expert judgment from a emergent State Department needs in enlarging review panel. Strong research evidence on what political space within authoritarian regimes. The works to improve outcomes in child and family assessment revealed that the investment in devel- services has proliferated in the past decade and oping Internet freedom capacity and capabilities a half, along with resources on evidence-based would likely have residual value beyond the port- practices to help policymakers and others evalu- folio's funded lifespan, with positive, but indirect, ate the burgeoning research. While there is de- connections to civic freedom. Moreover, promoting bate on what constitutes an evidence-based prac- Internet freedom appears to be a cost-imposing tice, definitions have a number of evidence criteria strategy that simultaneously aligns well with both in common. Decisionmakers can use resources U.S. values and interests, pressuring authoritar- such as PPN and others discussed in this docu- ian rivals to either accept a free and open Internet ment to identify evidence-based practices. or devote additional security resources to control or repress Internet activities. Finally, the authors RR-806-UNHF determined that the value of such analysis is best Ready to Serve: Community-Based Provider realized over multiple stages of the portfolio's life- Capacity to Deliver Culturally Competent, Quality cycle. Among the authors' recommendations were Mental Health Care to Veterans and Their Families. for DRL to enhance the synergy within the port- Terri Tanielian, Coreen Farris, Caroline Epley, Car- folio and among its grantees and to maintain a rie M. Farmer, Eric Robinson, Charles C. Engel, relatively balanced Internet freedom strategy that Michael Robbins, Lisa H. Jaycox. 2014 includes projects working on access, anonymity, Ensuring that military veterans and their fami- awareness, and advocacy. lies have access to high-quality mental health care is a national priority. Over the past several RR-797 years, the Departments of Defense and Veter- Evidence-Based Practices in Child and Family ans Affairs have increased the number of mental Services. Teryn Mattox, M. Rebecca Kilburn. 2014 health professionals working within their facilities Between 1998 and 2014, the Promising Practic- and have rolled out training and quality improve- es Network (PPN) on Children, Families and Com- ment initiatives designed to promote the use of ev- munities website (www.promisingpractices.net) idence-based treatments. Despite these important provided information on programs and practices efforts, research continues to demonstrate that that credible research indicated are effective in im- many veterans prefer to seek services outside the proving outcomes for children, youth, and families. Department of Defense and/or the Department of This document was originally published as part of Veterans Affairs. Thus, providers working in the ci- PPN's Issue Brief series, and it is intended to help vilian sector are an increasingly important part of PPN visitors understand some of the variation in the overall workforce addressing veterans' mental how the field of child and family services defines health needs. To better understand a key aspect “best available research evidence.” The authors of our nation's ability to provide veterans and their describe the history of evidence-based practices families with access to high-quality mental health and review varying definitions of them, compar- care, RAND conducted a survey of civilian mental ing the PPN criteria with those from other organi- health providers to gather information about their zations.While the specifics may differ, substantial competency with military and veteran culture and similarities remain across resources for evidence- their training and experience treating posttrau- based practices in the requirements for a program matic stress disorder and depression. This report to be labeled “evidence-based,” “proven,” a “model provides the results of that survey. The findings 453 and recommendations from this study should be students lose more ground over the summer than relevant to individuals, organizations, and policy their higher-income peers. Prior research has officials concerned about the capacity of the ci- also shown that some summer learning programs vilian health care sector to deliver culturally com- can stem this loss, but we do not know whether petent, high-quality services to veterans and their large, district-run, voluntary programs can im- families. prove students' outcomes. To fill this gap, The Wal- lace Foundation launched the National Summer RR-814-AF Learning Study in 2011. This five-year study offers Air Force Personnel Research: Recommen- the first-ever assessment of the effectiveness of dations for Improved Alignment. Carra S. Sims, large-scale, voluntary, district-run, summer learn- Chaitra M. Hardison, Kirsten M. Keller, Abby ing programs serving low-income elementary Robyn. 2014 students. The study, conducted by RAND, uses a This document discusses how personnel re- randomized controlled trial to assess the effects search within the U.S. Air Force supports organi- of district-run voluntary summer programs on stu- zational policy decisions. It discusses the history dent achievement and social and emotional skills of personnel research in the Air Force and the over the short and long run. All students in the present personnel research efforts and the orga- study were in the third grade as of spring 2013 nizations that house them. Though the Air Force and enrolled in a public school in one of five urban has undergone a reorganization that affects some districts: Boston; Dallas; Duval County, Florida; of the organizational units we discuss herein, to Pittsburgh; or Rochester, New York. This report, the extent that these units undertake the same the second of five that will result from the study, independent personnel research–related activi- looks at how summer programs affected student ties, the findings still pertain. The authors highlight performance on mathematics, reading, and social some challenges in the situation and the compo- and emotional assessments in fall 2013. nents that need to be included in the Air Force's solution. The report focuses on three objectives: RR-816-A Improving Strategic Competence: Lessons from (1) describe the Air Force organizations collecting 13 Years of War. Linda Robinson, Paul D. Miller, personnel-related data and conducting personnel- John Gordon IV, Jeffrey Decker, Michael Schwille, related research, identifying the type of data col- Raphael S. Cohen. 2014 lected, type of research and studies conducted, and how these initiatives fit into the organization's This report contributes to the ongoing debate mission; (2) examine how much these organiza- about the lessons from the past 13 years of war tions communicate and coordinate their efforts, and the requirements for addressing future con- share data, potentially overlap in their current flicts. It addresses a particular disconnect in the work, and have the necessary resource capac- current debate on the future of national security ity and expertise; and (3) identify potential gaps strategy and the role of landpower caused by an in the structure of personnel research efforts and inadequate examination of the national level of recommend strategies for eliminating those gaps. strategy made by the U.S. government. The disconnect exists because there has been no sys- RR-815-WF tematic effort to collect and analyze insights from Ready for Fall? Near-Term Effects of Volun- those who have been actively engaged in making tary Summer Learning Programs on Low-Income policy and strategy from 2001 to 2014. A RAND Ar- Students' Learning Opportunities and Outcomes. royo Center workshop provided a mechanism for Jennifer Sloan McCombs, John F. Pane, Cath- eliciting insights from policymakers and academic erine H. Augustine, Heather L. Schwartz, Paco experts involved in the formation of national-level Martorell, Laura Zakaras. 2014 strategy and its implementation over the past 13 Prior research has determined that low-income years. This study analyzes and develops those in- 454 sights in the context of the debate on future na- just its conceptual models for military campaigns tional security strategy. It applies those insights to achieve its goals through special warfare.The to the future operating environment, which will in- report has four specific aims: (1) to adapt conven- clude irregular and hybrid threats, and identifies tional operational art to the unique characteristics critical requirements for land forces and special of special warfare, (2) to identify the strategic ad- operations forces to operate successfully in con- vantages and risks associated with special war- junction with other joint, interagency, and multina- fare, (3) to explore how special warfare campaigns tional partners. could be used to address challenges identified in strategic guidance, and (4) to provide guidance to RR-818-CMHSA military and civilian leaders and planners in de- "Know the Signs" Suicide Prevention Media signing and executing these campaigns.RAND Campaign Is Aligned with Best Practices and authors recommend that DoD strengthen its spe- Highly Regarded by Experts. Joie D. Acosta, Ra- cial warfare planning capacity and culture, con- jeev Ramchand. 2014 duct institutional reforms to facilitate unified action Reports the findings of an evaluation by a panel among relevant U.S. government agencies, and of experts on the extent to which a suicide preven- place greater emphasis on developing capabilities tion media campaign in California is aligned with required to prevail in the human domain. best practices in the field. RR-830/1-ACPO RR-819-CMHSA Making and Breaking Barriers: Assessing the Beliefs Related to Mental Illness Stigma Among value of mounted police units in the UK: Summary California Young Adults. Rebecca L. Collins, Eliz- report. Chris Giacomantonio, Ben Bradford, Mat- abeth Roth, Jennifer L. Cerully, Eunice C. Wong. thew Davies, Richard Martin. 2014 2014 While the use of mounted police (i.e. police Report examines mental illness stigma and horses and riders) can be traced back to be- related beliefs among young adults in California, fore the advent of the modern police service in especially whether levels of stigma are higher or 1829, very little is known about the actual work lower than those observed in older adults. of mounted police from either academic or practitioner standpoints. In recent years, mounted units RR-828-A have come under resource scrutiny in the UK due Special Warfare: The Missing Middle in U.S. to austerity measures. Some forces have elimi- Coercive Options. Dan Madden, Dick Hoffmann, nated their mounted capacities altogether, while Michael Johnson, Fred T. Krawchuk, John E. Pe- others have developed collaborative or mutual as- ters, Linda Robinson, Abby Doll. 2014 sistance arrangements with neighbouring forces. The relative costs and benefits of the available This report demonstrates the need for special options – maintaining units, merging and central- warfare, a strategic and operational approach to izing mounted resources, or eliminating them in securing U.S. interests. The U.S. requires new ap- whole or part – cannot at present be assessed proaches for exerting influence to fill the missing confidently by individual forces or by national co- middle between the costly indefinite commitment ordinating agencies. To address this limitation in of conventional forces and the limitations of dis- available evidence, the Association of Chief Police tant-strike options presented by drones and Tom- Officers' Mounted Working Group commissioned ahawk missiles. Because special warfare works a project to consider ways in which the relative principally through local actors, employs political value of mounted police work may be measured warfare methods, and requires the integration of and understood, as well as provide evidence test- a much broader suite of U.S. government agency ing the value of mounted police in various deploy- capabilities than are typically envisioned in con- ment scenarios. The research undertaken for this ventional campaigns, the United States must ad- 455 project was multi-method and exploratory in na- RR-839-TII ture, examining mounted police in neighbourhood Business Bribery Risk Assessment. Karlyn D. policing, football policing and public order policing Stanley, Elvira N. Loredo, Nicholas Burger, Jeremy in festival and demonstration settings. This proj- N. V. Miles, Clinton W. Saloga. 2014 ect also includes research activities designed to understand the costs of mounted policing, and an Corruption is a major problem that can in- international survey of senior mounted police in hibit global business investment, especially in other countries. The project has been undertaken emerging markets; however, businesses operat- through the Centre for Criminology, University of ing overseas have inadequate tools for assess- Oxford in partnership with RAND Europe. ing business bribery risk and their potential risk of violating various anti-corruption laws. This report RR-836-JPMCF introduces a new index, the TRACE Matrix, for Veteran Employment: Lessons from the 100,000 business bribery risk assessment that we believe Jobs Mission. Kimberly Curry Hall, Margaret C. has advantages over existing alternatives. The Harrell, Barbara Bicksler, Robert Stewart, Michael TRACE Matrix provides a quick and useful guide P. Fisher. 2014 for businesses operating overseas that is based Eleven companies cofounded the 100,000 Jobs on a conceptual model of bribery risk and sup- Mission in 2011 to promote veteran employment, ported by data specific to firms. The objective of with a goal of hiring 100,000 veterans by 2020. this index is to help firms assess the propensity for The coalition has grown to over 175 companies, government bribery and its associated business which have exceeded the initial goal and are now risk and to provide data to inform compliance pro- on track to hire 200,000 veterans by the end of cesses. We have developed a business bribery 2014. These companies represent nearly every risk methodology using existing, publicly available U.S. industry and vary in size, geographic loca- cross-country data about risk factors, drawing on tion, and in the types of veterans they hire. Re- diverse data sources focused on business infor- flecting on the first three years of operation, JPM- mation. We have aggregated the data to provide organ Chase & Co. asked the RAND Corporation a composite score for each country based on dis- to capture the lessons and experiences from the tinct categories of risk, much like a health index 100,000 Jobs Mission to identify further improve- score that combines the key factors important to ments to veteran employment opportunities. RAND health (e.g., blood pressure, heart rate). Although researchers conducted qualitative interviews with countries are ranked by their composite scores, it representatives of a sample of member compa- is also possible to view the results for the different nies, delving into the ways they recruit and hire factors included in the composite score and iden- veterans, help veterans transition into their new tify the key drivers of that score. This allows firms jobs, and manage and develop veteran employ- to adjust their risk assessment and compliance ees and the value veterans bring as employees. practices to better suit country-specific conditions. Interviewees pointed out that veterans are most RR-854-RC noted for their leadership skills and teamwork; for Methodology of the RAND Midterm 2014 Elec- their flexibility and ability to work in a fast-paced, tion Panel. Katherine Grace Carman, Michael changing environment without undue stress; for Pollard. 2014 their dependability, integrity, and loyalty; and for their experience working in a culturally diverse or The RAND Midterm 2014 Election Panel uses global environment. This research also explored the American Life Panel (ALP) to study voting in- the challenges to hiring and employing veterans tentions, public opinion, and voter behavior. The and provides recommendations to assist employ- ALP is a scientifically recruited Internet panel. Us- ers and promote veteran employment opportuni- ing the ALP allows us to contact the same people ties more broadly. over time to study the evolution of their voting in- 456 tentions, behavior, and opinions. Furthermore, we exports up to 7 per cent in the long-term. These follow previous RAND election polling by asking effects will vary by Member State, and by sector of respondents about their voting intentions in prob- the internal market. abilistic terms (percent chance), which improves forecasts. This document provides a detailed de- RR-863-WFHF scription of our methodology. Measuring Hard-to-Measure Student Compe- tencies: A Research and Development Plan. Brian RR-858-RC M. Stecher, Laura S. Hamilton. 2014 Methodology of the RAND Continuous 2012 Efforts to prepare students for college, ca- Presidential Election Poll. Arie Kapteyn, Erik Mei- reers, and civic engagement have traditionally jer, Bas Weerman. 2014 emphasized academic skills, but a growing body The RAND Continuous 2012 Presidential Elec- of research suggests that interpersonal and intra- tion Poll (CPEP) is conducted within the American personal competencies, such as communication Life Panel, which is an internet panel recruited and resilience, are important predictors of post- through traditional probability sampling to ensure secondary success and citizenship. One of the representativeness. The CPEP differs from other major challenges in designing educational inter- polls in that it asks the same respondents repeat- ventions to support these outcomes is a lack of edly about their voting preferences. Thus, it leads high-quality measures that could help educators, to more stable outcomes and changes are due to students, parents, and others understand how stu- individuals' changing their minds and not due to dents perform and monitor their development over random sampling fluctuations. The CPEP is also time. This report provides guidelines to promote different because it asks respondents to state thoughtful development of practical, high-quality their preferences for a candidate and the likeli- measures of interpersonal and intrapersonal com- hood that they will vote in probabilistic terms (per- petencies that practitioners and policymakers can cent chance), which has been shown to improve use to improve valued outcomes for students. forecasts several months before the election. This documents gives a detailed account of the meth- RR-870-OSD odology underlying the CPEP. Sexual Assault and Sexual Harassment in the U.S. Military: Top-Line Estimates for Active-Duty RR-862-EP Service Members from the 2014 RAND Military The Cost of Non-Europe in the Single Market: Workplace Study. Andrew R. Morral, Kristie L. Free Movement of Goods. Marco Hafner, Enora Gore, Terry L. Schell. 2014 Robin, Stijn Hoorens. 2014 In early 2014, the Department of Defense Cost of Non-Europe Reports identify the possi- (DoD) Sexual Assault Prevention and Response bilities for economic or other gains and/or the real- Office (SAPRO) asked the RAND National De- isation of a public good' through common action fense Research Institute (NDRI) to conduct an at EU level in specific policy areas and sectors. independent assessment of sexual assault, sex- This Cost of Non-Europe Report seeks to anal- ual harassment, and gender discrimination in the yse the costs for citizens, businesses and relevant military—an assessment last conducted in 2012 stake-holders of remaining gaps and bariers in the by the department itself with the Workplace and European Single Market, building on and updat- Gender Relations Survey of Active Duty Person- ing the 1988 Cecchini Report, which quantified its nel (WGRA). This report provides initial top-line potential benefits. This particular study uses an estimates from the resulting study, the RAND Mili- econometric model to estimate the potential ben- tary Workplace Study (RMWS), which included a efits of removing existing barriers to foreign direct survey of 560,000 U.S. service members fielded investment and non-tariff trade barriers within the in August and September of 2014. Compared to European Union. The removal of existing trade barriers could boost total intra-EU merchandise 457 the prior DoD studies, the RMWS takes a new ap- Evidence review of car traffic levels in Britain: proach to counting individuals in the military who A rapid evidence assessment. Charlene Rohr, experienced sexual assault, sexual harassment, James Fox. 2014 or gender discrimination. Our measurement of This study presents findings of a rapid evidence sexual assault aligns closely with the definitions assessment of literature to understand the factors and criteria in the Uniform Code of Military Justice and trends influencing the recent levelling off in (UCMJ) for Article 120 crimes. The survey mea- total miles driven in Britain since the 1990s. We sures of sexual harassment and gender discrimi- find that the literature provides a good descrip- nation, which together we refer to as sex-based tion of trends influencing car mileage; including: military equal opportunity (MEO) violations, use (i) changes in traditional economic factors, includ- criteria drawn directly from DoD Directive 1350.2. ing fuel price increases and income growth, (ii) Compared with past surveys that were designed reductions in driving levels for young people, (iii) to measure a climate of sexual misconduct asso- population increases in urban areas, where car ciated with illegal behavior, the approach used in ownership and car use levels are lower (although the RMWS offers greater precision in estimating the impact of growing population in conurbations the number of crimes and MEO violations that and cities on per capita car mileage appears to be have occurred. However, recognizing that DoD is relatively small), (iv) increasing levels of car travel also interested in trends in sexual assault, sexual for women, although women are observed to still harassment, and gender discrimination, RAND drive less than men, (v) that the elderly drive less fielded a portion of the 2014 surveys using the than other population groups, although their car same questions as previous DoD surveys on this mileage is also increasing, (vi) increased immigra- topic. tion levels, although migrants are observed to use their cars less than the those born in Britain, even RR-870/1-OSD after taking account that migrants tend to live in Sexual Assault and Sexual Harassment in the urban areas, (vii) reductions in company car own- U.S. Military: Volume 1. Design of the 2014 RAND ership, and associated reductions in car mileage, Military Workplace Study. Andrew R. Morral, Kris- particularly for men. However, the size of many of tie L. Gore, Terry L. Schell. 2014 these trends on overall car mileage levels, and the In early 2014, the Department of Defense drivers impacting these trends, are less clear. We Sexual Assault Prevention and Response Office found little information on how the following trends asked the RAND National Defense Research In- impact car travel: (i) employment levels or type, stitute to conduct an independent assessment of (ii) use of internet technology, (iii) substitutes, in sexual assault, sexual harassment, and gender terms of mode shifts or switching to new destina- discrimination in the military—an assessment last tions, (iv) network supply effects, such as conges- conducted in 2012 by the department itself with its tion, and (v) attitudinal changes. Workplace and Gender Relations Survey of Ac- tive Duty Personnel. This volume documents the RR-891-BLC methodology used in the resulting RAND Military Patient Safety in the Commonwealth of Mas- Workplace Study, which invited close to 560,000 sachusetts: Current Status and Opportunities service members to participate in a survey fielded for Improvement. Eric C. Schneider, M. Susan in August and September of 2014. It describes the Ridgely, Dmitry Khodyakov, Lauren E. Hunter, survey methods, how the new questionnaire was Zachary Predmore, Robert S. Rudin. 2014 designed, and how sampling, recruitment, and Twenty years ago, Betsy Lehman, an award- analytic weighting were pursued. It also includes winning health columnist for the Boston Globe, the entire survey instrument. received a massive overdose of chemotherapy at one of the nation's most prestigious cancer hos- RR-887-DFT pitals. The discovery of these and other avoidable 458 errors and adverse events was a wake-up call. Dur- health system and service organisation that were ing the 1990s, health care leaders and research- shown to have a direct or indirect impact on drug ers began studying and documenting the scale usage, such as reimbursement mechanisms, ac- of the safety problem in health care. However, ur- cess to diagnosis and treatment more broadly. We gent questions about patient safety remain unan- also provide a summary overview of key features swered. To begin to answer these questions, the of the health systems and of the principles of drug Betsy Lehman Center for Patient Safety and Med- assessment or approval processes across the ical Error Reduction commissioned a RAND study countries included in the OHE analysis. We find about the landscape of patient safety in the Com- that a range of factors are likely to play a role in ex- monwealth of Massachusetts. RAND research- plaining international variation in medicines use, ers interviewed expert observers (patients, health but their relative importance will vary depending care leaders, academic experts, advocates, and on the disease area in question and the system others) about progress to date and future opportu- context. Any given level of use of a given medi- nities to produce safer patient care. These expert cine in one country is likely determined by a set of observers asserted that some progress has been factors the combination and the relative weight of made in Massachusetts but that it has mostly set which will be different in another country. the stage for the vital work that remains. Key areas for progress include standardization of care, RR-911-WT improvements in communication across settings, Estimating the economic costs of antimicrobial reducing diagnostic error, and transferring the les- resistance: Model and Results. Jirka Taylor, Marco sons learned in the hospital to other care settings. Hafner, Erez Yerushalmi, Richard Smith, Jacopo This report summarizes the results of the inter- Bellasio, Raffaele Vardavas, Teresa Bienkowska- views and suggests several questions that could Gibbs, Jennifer Rubin. 2014 guide the design of an organized effort to improve The independent Review on AMR led by the patient safety in Massachusetts. economist Jim O'Neill commissioned RAND Eu- rope to conduct a study estimating the global RR-899-DH costs of antimicrobial resistance until 2050 in the International variation in drug usage: An explor- absence of any progress in tackling the challenge. atory analysis of the "causes" of variation. Ellen We developed a general equilibrium model, which Nolte, Jennie Corbett. 2014 calculated the extent of losses to the world econ- This report explores the range of possible omy caused by decreases in the supply of labour causes that might explain observed international resulting from resistant hospital acquired infec- variations in the usage of medicines for selected tions and selected major infectious diseases (HIV, disease areas: dementia, osteoporosis, cancer, TB, malaria). Our approach incorporated a set of diabetes and hepatitis C. Commissioned by the seven scenarios with varying rates of future re- UK Department of Health, through its Policy Re- sistance, time of onset of increases in resistance, search Programme, it complements a quantitative and availability of effective second-line therapy. analysis of medicines uptake carried out by the Office for Health Economics (OHE) of medicines RR-944-USCG uptake across 16 classes of medicines in 13 high- Sexual Assault and Sexual Harassment in the income countries in 2012/13. Both studies build on U.S. Military: Top-Line Estimates for Active-Duty an earlier study led by Professor Sir Mike Richards Coast Guard Members from the 2014 RAND Mili- (UK) into the extent and causes of international tary Workplace Study. Andrew R. Morral, Kristie L. variations in drug usage, published in 2010. Draw- Gore, Terry L. Schell. 2014 ing on a rapid evidence assessment, we explore, In early 2014, the Department of Defense (DoD) for each of the five disease areas, epidemiological Sexual Assault Prevention and Response Office factors such as the disease burden and aspects of (SAPRO) asked the RAND National Defense Re- 459 search Institute (NDRI) to conduct an independent assessment of sexual assault, sexual harassment, TOOLS and gender discrimination in the military—an assessment last conducted in 2012 by the department itself with the Workplace and Gender Rela- tions Survey of Active Duty Personnel (WGRA). TL-109/1 Separately, the Coast Guard requested that we Building Resilient Communities: Spanish trans- expand the 2014 study to include an assess- lation. Anita Chandra, Joie D. Acosta. 2014 ment of its active and reserve force. This report Emergency preparedness can get you through provides initial top-line active-duty Coast Guard the first few days following a disaster. But how estimates from the resulting RAND Military Work- can your community bounce back over the long place Study, which invited close to 560,000 ser- term? With disasters becoming more common vice members to participate in a survey fielded in and costly, and with some areas enduring multiple August and September of 2014. The RMWS takes disasters, the importance of building community an approach to counting individuals in the military resilience has never been greater.This video is a who experienced sexual assault, sexual harass- Spanish translation of an excerpt from Building ment, or gender discrimination that measures the Resilient Communities: An Online Training, which incidence of specific crimes and violations. Our shows organizations and communities how to measurement of sexual assault aligns closely with strengthen their resilience against manmade and the definitions and criteria in the Uniform Code natural disasters. of Military Justice (UCMJ) for Article 120 crimes. The survey measures of sexual harassment and TL-129-A gender discrimination, which together we refer to Vulnerability Assessment Method Pocket Guide: as sex-based military equal opportunity (MEO) A Tool for Center of Gravity Analysis. Christopher violations, use criteria drawn from DoD Directive M. Schnaubelt, Eric V. Larson, Matthew E. Boyer. 1350.2. Compared with past surveys that were de- 2014 signed to measure a climate of sexual misconduct The U.S. Army Asymmetric Warfare Group has associated with illegal behavior, the approach used the Vulnerability Assessment Method (VAM) used in the RMWS offers greater precision in esti- for a variety of large-scale interagency exercises mating the number of crimes and MEO violations at the operational and theater levels and previ- that have occurred. ously commissioned a handbook for that purpose. Because the group also advises deployed tactical RR-977-WRF Developing Robust Strategies for Climate units, it asked RAND Arroyo Center to revise the Change and Other Risks: A Water Utility Frame- existing handbook to make it more useful at the work. David G. Groves, Jordan R. Fischbach, operational and tactical levels, with a primary au- Nidhi Kalra, Edmundo Molina-Perez, David Yates, dience of brigade combat team commanders and David Purkey, Amanda Fencl, Vishal K. Mehta, staffs. The resulting document is designed to fit Ben Wright, Grantley Pyke. 2014 into a cargo pocket. It explains how the VAM can be embedded into doctrinal planning processes RAND researchers and collaborators present a and describes a process for identifying adver- comprehensive approach for water utilities to as- sary, friendly, and other key stakeholder centers sess climate risks to their systems and evaluate of gravity to support the development of plans that adaptation strategies. The approach, based on will exploit adversary vulnerabilities while protect- Robust Decision Making, is demonstrated through ing friendly ones. It can help commanders and pilot studies with two water utilities: Colorado staffs, and other leaders and planners, identify Springs Utilities and New York City Department of what is most important in the adversary and non- Environmental Protection. adversary systems to avoid wasting resources by 460 pursuing less-productive courses of action. sive record of current or historical security-related treaties signed by the United States that can be TL-130-AF used for empirical analysis. To address the short- Diversity Outreach and Recruiting Event Site comings in existing datasets and indexes to con- Selection (DORESS). Abigail Haddad, Nelson tribute to the study of U.S. security treaties and Lim, Lisa Miyashiro, Henu Zhao, Gary J. Briggs. agreements, the author has developed a tool— 2014 displayed in an Excel spreadsheet—that provides This is a user guide for Diversity Outreach a new, more comprehensive treaty database that and Recruiting Event Site Selection (DORESS), a will enhance the ability of researchers to study the piece of software created by RAND to assist the full portfolio of U.S. security agreements. Air Force in identifying diversity outreach and recruiting event sites. By combining user preferenc- TL-136-NIDA es with information on student populations and Air Toolkit for Weighting and Analysis of Non- Force locations, DORESS helps users find sites at equivalent Groups: A Tutorial for the TWANG SAS which to locate events. The populations that users Macros. Daniel F. McCaffrey, Lane F. Burgette, can search for include college students; college Beth Ann Griffin, Craig Martin, Greg Ridgeway. students from selective schools; college students 2014 majoring in science, technology, engineering, and The Toolkit for Weighting and Analysis of Non- math (STEM) fields; college students majoring in equivalent Groups, or TWANG, contains a set of STEM fields at schools with U.S. News & World functions to support causal modeling of observa- Report–ranked STEM programs; public high tional data through the estimation and evaluation school students; and public high school students of propensity score weights. The TWANG package from highly ranked high schools. Users can then was first developed in 2004 by RAND research- select gender and racial/ethnic groups from within ers for the R statistical computing language and these populations. Users can also see where Air environment. The R version of the package con- Force bases, Air Force recruiters, and Air Force tains functions for creating high-quality propensity Reserve Officers' Training Corps (ROTC) detach- score weights which can be used to estimate treatments are located. There are three broad func- ment effects with two or more treatment groups.In tions of this tool: evaluating a specific area, alloca- 2014, TWANG macros were developed for SAS to tion, and planning events. We have also provided support the use of these tools without requiring re- a layer for use in Google Earth containing the Air searchers and analysts to learn R. At this time, the Force data and some of the student data. SAS TWANG macros can support estimation of propensity scores and their associated weights for TL-133-AF comparisons involving two treatment groups. SAS A Database of U.S. Security Treaties and Agree- macros will be made available shortly for handling ments. Jennifer Kavanagh. 2014 the case of three or more treatment groups. Treaties and agreements are powerful foreign policy tools that the United States uses to build and TL-136/1-NIDA solidify relationships with partners and to influence Toolkit for Weighting and Analysis of Nonequiva- the behavior of other states. As a result, the over- lent Groups: A Tutorial for the R TWANG Package. all U.S. portfolio of treaties and agreements can Greg Ridgeway, Daniel F. McCaffrey, Andrew R. offer insight into the distribution and depth of U.S. Morral, Lane F. Burgette, Beth Ann Griffin. 2014 commitments internationally, including its military This tutorial describes the use of the TWANG commitment, relationships, capabilities, and vul- package in R to estimate propensity score weights nerabilities in a given area. While there are many when there are two treatment groups, and how to sources of information on security-related treaties use TWANG to estimate nonresponse weights. and agreements, there is currently no comprehen- Specifically, it describes the "ps" function (which 461 stands for Propensity Scores), the proper syntax sionmakers access high-quality research relevant for using the function, and the features the func- to child and family policy.This document contains tion contains. the summaries of the Programs That Work section of the PPN website, as of June 2014. PPN staff TL-141 reviewed hundreds of programs' evaluations and Five Steps to a Successful Workplace Wellness assessed whether the evidence of effectiveness Program: A RAND Toolkit. Kristin R. Van Busum, met the preestablished criteria. Programs with evi- Hangsheng Liu, Soeren Mattke. 2014 dence meeting the criteria were summarized in a Well-designed, well-executed workplace well- brief description in this section of the PPN website. ness programs can reduce health risks (such as We reproduce the summaries here to serve as a smoking and physical inactivity), lower health care permanent archive for policymakers, researchers, costs, and improve productivity. RAND research- and other stakeholders. ers determined that these programs are becoming a standard component of benefits packages TL-153-OSD but that not all of them are created equal: Some Identifying Acquisition Framing Assumptions generate cost savings whereas others do not, and Through Structured Deliberation. Mark V. Arena, there are substantial differences in how programs Lauren A. Mayer. 2014 are being designed and implemented. This toolkit This report documents the structured process synthesizes the lessons learned and best prac- that was developed to help project teams identi- tices from multiple projects and many years of fy acquisition framing assumptions (FAs), which research into a five-step guide for the planning, are useful in defining and tracking key program implementation, and evaluation of a successful assumptions throughout the life of an acquisition workplace wellness program. program. The process describes a structured deliberation workshop (in the form of a briefing) used TL-145 to facilitate a deliberation with the aim of identify- Programs That Work, from the Promising Prac- ing candidate FAs. The report provides an intro- tices Network on Children, Families and Commu- duction to the concept of FAs and an overview of nities. M. Rebecca Kilburn, Jill S. Cannon, Teryn the approach used in the briefing to identify FAs. Mattox, Rebecca Shaw. 2014 It includes an overview of structured deliberation, The Promising Practices Network (PPN) on some of the important concepts in having a suc- Children, Families and Communities (www.prom cessful session, and suggestions on how to tailor isingpractices.net) began as a partnership be- questions related to program risk areas to help tween four state-level organizations that help elucidate FAs. public and private organizations improve the well- being of children and families. The PPN website, TECHNICAL REPORTS archived in June 2014, featured summaries of programs and practices that are proven to improve outcomes for children. The information on this TR-1288/1-SOY/NIA website pertained to children from the prenatal A Noncontributory Pension Program for Older period to age 18, as well as the families and com- Persons in Yucatan, Mexico: Implementing and munities in which they live. This site provided use- Designing the Evaluation of the Program in Val- ful information to decisionmakers, practitioners, ladolid. Emma Aguila, Arie Kapteyn, Rosalba and program funders who had to choose among Robles, Oscar Vargas, Beverly A. Weidmer. 2014 many possibilities for improving results for children, youth, and families. The website content in- Mexico's population is aging, and a high propor- cluded summaries of evidence-based programs, tion of its elderly are poor. This report describes issue briefs, and other products that helped deci- a collaborative effort by the Yucatan government and the RAND Corporation to design, implement, 462 and evaluate a state government program to pro- parison groups. For the Merida evaluation, the vide cash benefits to the elderly to improve their surveys used in Valladolid were modified includ- well-being as measured by a comprehensive so- ing new questions about the educational perfor- cioeconomic survey and more than 15 anthropo- mance (school enrollment and attendance and metric and biomedical indicators. The program time spent in educational activities) of children has been introduced in phases in 37 localities in age 5 to 13 living with the older adult, questions Yucatan over a period of four years. Phases I and on mortality expectations, and collection of dried II, Reconocer Rural, were implemented in rural ar- blood spots for possible indicators (e.g., high lev- eas. Phase III, Reconocer Urbano, expanded the els of blood sugar) of chronic diseases in older program to urban areas. Program evaluation, Es- adults. This document provides context and back- cuchar, began when the program was expanded ground for the program and describes its design in phase III to the cities of Valladolid and Merida. and implementation. It also describes the design The evaluation is gathering extensive data on proof the evaluation of the program impact in Merida. gram beneficiaries, as well as control or compari- Later documents will provide more details about son groups. This document provides context and the data analysis and findings from all the evalu- background for the program and describes its de- ations. sign and implementation. It also describes the design of the first evaluation of the program impact in TR-1288/3-SOY-NIA Valladolid. Later documents will provide more de- Un Programa de Pensión No Contributiva para tails about the data analysis, the expansion of the los Adultos Mayores en Yucatán, México: Diseño, program into Merida (the capital city of Yucatan), implementación y Evaluacióndel Programa en and findings from all the evaluations. Valladolid. Emma Aguila, Arie Kapteyn, Rosalba Robles, Oscar Vargas, Beverly A. Weidmer. 2014 TR-1288/2-SOY/NIA Mexico's population is aging, and a high propor- A Noncontributory Pension Program for Older tion of its elderly are poor. This report describes Persons in Yucatan, Mexico: Implementing and a collaborative effort by the Yucatan government Designing the Evaluation of the Program in Me- and the RAND Corporation to design, implement, rida. Emma Aguila, Abril Borges, Arie Kapteyn, and evaluate a state government program to pro- Rosalba Robles, Beverly A. Weidmer. 2014 vide cash benefits to the elderly to improve their Mexico's population is aging, and a high propor- well-being as measured by a comprehensive so- tion of its elderly are poor. This report describes cioeconomic survey and more than 15 anthropo- a collaborative effort by the Yucatan government metric and biomedical indicators. The program and the RAND Corporation to design, implement, has been introduced in phases in 37 localities in and evaluate a state government program to pro- Yucatan over a period of four years. Phases I and vide cash benefits to the elderly to improve their II, Reconocer Rural, were implemented in rural ar- well-being as measured by a comprehensive so- eas. Phase III, Reconocer Urbano, expanded the cioeconomic survey and more than 15 anthropo- program to urban areas. Program evaluation, Es- metric and biomedical indicators. The program cuchar, began when the program was expanded has been introduced in phases in 37 localities in in phase III to the cities of Valladolid and Merida. Yucatan over a period of four years. Phases I and The evaluation is gathering extensive data on pro- II, Reconocer Rural, were implemented in rural ar- gram beneficiaries, as well as control or compari- eas. Phase III, Reconocer Urbano, expanded the son groups. This document provides context and program to urban areas. Program evaluation, Es- background for the program and describes its de- cuchar, began when the program was expanded sign and implementation. It also describes the de- in phase III to the cities of Valladolid and Merida. sign of the first evaluation of the program impact in The evaluation is gathering extensive data on Valladolid. Later documents will provide more de- program beneficiaries, as well as control or com- tails about the data analysis, the expansion of the 463 program into Merida (the capital city of Yucatan), Emma Aguila, Arie Kapteyn, Nelly Mejia, Rosalba and findings from all the evaluations. Robles, Oscar Vargas, Beverly A. Weidmer. 2014 In 2007, the government of Yucatan, Mexico, TR-1288/4-SOY-NIA Programa de Pensiones No Contributivas para and the RAND Corporation established a col- Adultos Mayores en Yucatán, México: Diseño, laborative agreement to design and implement a implementación y Evaluación del Programa en noncontributory pension program and simultane- Mérida. Emma Aguila, Abril Borges, Arie Kapteyn, ously evaluate it through a longitudinal study. This Rosalba Robles, Beverly A. Weidmer. 2014 report describes the administration and results of two surveys in Merida, a social observation and Mexico's population is aging, and a high propor- a local observation designed to measure socio- tion of its elderly are poor. This report describes economic characteristics by geographic unit. In a collaborative effort by the Yucatan government particular, it discusses application of observation and the RAND Corporation to design, implement, instruments in May and June 2009 to 112 blocks and evaluate a state government program to pro- for 22 basic geostatistical areas to create a social- vide cash benefits to the elderly to improve their gap index. The goal was to compare the results well-being as measured by a comprehensive so- of the social-gap index based on local and social cioeconomic survey and more than 15 anthropo- observations at the block level with other margin- metric and biomedical indicators. The program alization and social-gap rates used to target other has been introduced in phases in 37 localities in social-welfare programs in Mexico and to assess Yucatan over a period of four years. Phases I and the feasibility of targeting delivery of noncontribu- II, Reconocer Rural, were implemented in rural ar- tory pensions for older persons who live in urban eas. Phase III, Reconocer Urbano, expanded the areas. program to urban areas. Program evaluation, Es- cuchar, began when the program was expanded TR-1288/6-SOY-NIA in phase III to the cities of Valladolid and Merida. Mortality Expectations of Older Mexicans: The evaluation is gathering extensive data on Development and Testing of Survey Measures. program beneficiaries, as well as control or com- Emma Aguila, Abril Borges, Cielo Margot Castille- parison groups. For the Merida evaluation, the jos, Ashley Pierson, Beverly A. Weidmer. 2014 surveys used in Valladolid were modified includ- Individual subjective forecasts of one's own ing new questions about the educational perfor- mortality or survival, referred to as mortality ex- mance (school enrollment and attendance and pectations, can affect economic decisions, such time spent in educational activities) of children as consumption and saving. Such measures may age 5 to 13 living with the older adult, questions be particularly useful when evaluating social pro- on mortality expectations, and collection of dried grams serving older populations or otherwise blood spots for possible indicators (e.g., high lev- analyzing populations with potentially high mortal- els of blood sugar) of chronic diseases in older ity rates. In an evaluation of a pension program in adults. This document provides context and back- Yucatan, researchers found that low literacy, lan- ground for the program and describes its design guage barriers, and cultural biases hindered older and implementation. It also describes the design adult respondents' ability to answer mortality-ex- of the evaluation of the program impact in Merida. pectation questions and experimented with new Later documents will provide more details about ways of asking the questions. The initial version the data analysis and findings from all the evalu- of the questions used a ruler with a numeric scale ations. representing a percentage chance of living five more years. Researchers tried direct and indirect TR-1288/5-SOY-NIA Geographic Targeting in Urban Areas: A Social- versions of the questions, versions with possible Welfare Program for Older People in Mexico. answers being contingent on answers to previous questions, and versions incorporating use of vi- 464 sual aids, and combinations of these variations. of information be able to provide informed consent Through cognitive interviewing, they studied how when doing so. Obtaining consent from older peo- respondents understood, processed, and re- ple and from people with low levels of literacy or sponded to the survey items. They then used what limited language fluency can pose challenges. For they learned to revise the survey measures. The field trials, researchers evaluating the impact of a visual aids tested were the original numeric-scale pension program in Yucatan sought to develop an ruler, a sliding ruler, stones, and stick figures. With informed-consent procedure that was culturally their survey population, they had the most suc- sensitive and complied with Mexican norms and cess using the stick figures for conditional ques- standards and with U.S. government and RAND tions and the stones for direct questions. Corporation ethical standards for conducting research with human subjects. This report docu- TR-1288/7-SOY-NIA ments the process the research team developed Distributing Noncontributory Pension Benefits to obtain informed consent from those choosing to by Debit Card in Mexico: A Pilot Test. Emma Agu- participate in the research; provides background ila, Abril Borges, Ashley Pierson, Rosalba Robles, on the development of norms and regulations for Jose Eduardo Del Torno, Beverly A. Weidmer. conducting research involving human subjects in 2014 the United States and Mexico; and reviews how In an effort to improve the quality of life for older the team developed and tested a culturally sen- adults, the government of Yucatan, Mexico, and sitive approach for collecting informed consent the RAND Corporation collaborated to design, im- among the elderly in Yucatan, including testing of plement, and evaluate a noncontributory pension methods and subsequent adaptations. Finally, it program in Yucatan. Although the program initially reviews the implications of the findings for similar distributed its monthly benefit in cash, it later se- future research efforts. lected a small group of recipients to receive the pension through a debit card. From March 2010 WORKING PAPERS to February 2012, a pilot study was conducted in the city of Merida, the Yucatan state capital. The program paid monthly pensions of MXN $550 WR-1014-ICJ through deposits to a bank account established Tort Reform and Physician Labor Supply: A for each beneficiary that is linked to a debit card. Review of the Evidence. Eric Helland, Seth A. This report is one of a series of RAND reports de- Seabury. 2014 scribing the noncontributory pension program in Yucatan, its implementation, its evaluation, and There is a large empirical literature examining related topics. This report describes how the pilot the relationship between medical liability reform test was conducted and explores the results from and the supply of physician services. Despite the several surveys of this pilot group. Results indicat- general consensus that malpractice reform leads ed that debit-card pension disbursal is feasible for to an increase in physician supply, usually target- an elderly Mexican population and that the state ed amongst a subset of physicians, debates rage should expand the number of beneficiaries receiv- at the state level over the effectiveness of any giving the benefit through the debit-card method. en reform. This paper reviews the evidence on the relationship between tort reform and physician TR-1288/8-SOY-NIA supply and assess the implications for any given Developing and Testing Informed-Consent state. Although our difference in difference meth- Methods in a Study of the Elderly in Mexico. odology prevents drawing conclusions about the Emma Aguila, Maria Dolores Cervera, Homero impact of reforms on overall physician supply, we Martinez, Beverly A. Weidmer. 2014 find that noneconomic damage caps increase the Ethical and legal considerations require that hu- supply of physicians in high risk specialties. How- man research subjects who provide certain kinds 465 ever, these effects, even for the high risk special- increase in overall expenditures for hospital out- ties, vary significantly across states. It is unclear patient services under California's workers' com- whether these differences represent heteroge- pensation program. neous treatment effects across states, or simply random error in the estimates. New approaches WR-1023 are needed to estimating state-specific effects of How Do Management Fees Affect Retirement tort reform to have the most impact on local policy Wealth Under Mexico's Personal Retirement Ac- debates. counts System?. Emma Aguila, Michael D. Hurd, Susann Rohwedder. 2014 WR-1016-DIR In 1997, Mexico transformed its pay-as-you- Fee Schedule Options for Services Furnished go social-security system to a fully funded system by Hospitals to Outpatients under the California with personal retirement accounts, including man- Workers' Compensation Program. Barbara O. agement fees. This paper examines changes in Wynn, Hangsheng Liu, Andrew W. Mulcahy, Ed- retirement wealth resulting from this new system. ward N. Okeke, Neema Iyer, Lawrence S. Painter. It found management fees drained a significant 2014 proportion of individuals' retirement wealth and A RAND study used 2011 medical data to ex- had the effect of increasing the number of persons amine fee schedule options for setting maximum claiming a government-subsidized minimum pen- allowable amounts for certain facility services pro- sion, particularly from the time the system was in- vided by hospitals on an outpatient basis under troduced in 1997 until adjustment to management California's workers' compensation system. These fees in 2008. Since 2008, retirement wealth accu- are mostly diagnostic procedures and clinic visits mulation has been similar to that of the previous that prior to January 1, 2014 were paid under the system. same fee schedule as physician and other practitioner services. They account for approximately WR-1027 seven percent of total workers' compensation al- Toward Theory for Dissuasion (or Deterrence) lowances for hospital outpatient services. In con- by Denial: Using Simple Cognitive Models of the sultation with the California Division of Workers' Adversary to Inform Strategy. Paul K. Davis. 2014 Compensation, two fee schedule options based This Working Paper grew out a conference on Medicare fee schedules were modeled. The first paper presented at the Munk School of the Uni- option set the allowances for the hospital's facility versity of Toronto, October 18-20, 2013. The con- costs at 1.2 times the Medicare allowance paid to ference, Deterrence by Denial: Theory, Practice, physicians for their practice expenses when com- and Empiricism, was co-organized by the Munk parable services are provided in office settings. School of Global Affairs and the Center for Secu- This is the same as the amount paid for practice rity Studies, ETH Zurich. It included a number of expenses under the resource-based relative value international scholars from a broad range of uni- scale that was implemented for physician and oth- versity and research institutions. This Working Pa- er practitioner services effective January 1, 2014. per extends the author's conference paper and is Under this option, aggregate allowances for the intended to invite informal peer review before it is services would decrease 7.6 percent, which repre- completed it at a later date. sents an estimated 0.5 percent reduction in total WR-1028 expenditures for services furnished by hospitals Medical Care Spending and Labor Market Out- to outpatients. The second option set the allow- comes: Evidence from Workers' Compensation ances at the Medicare payment rates for hospital Reforms. David Powell, Seth A. Seabury. 2014 outpatient services (with no multiplier). This option There is considerable controversy over whether would increase aggregate allowances 48-65 per- much of the spending on health care in the United cent, which represents an estimated 3-5 percent States delivers enough value to justify the cost. 466

This paper contributes to this literature by study- reduced medical care spending for injured working the causal relationship between medical care ers with a disproportionate effect on workers suf- spending and labor outcomes, exploiting a poli- fering low back injuries. We study the differential cy which directly impacted medical spending for impact of this reduction in medical care generos- reasons unrelated to health and using a unique ity on post-injury outcomes, using administrative data set which includes medical spending and data which includes claim-level medical costs, labor earnings. The focus on labor outcomes is pre- and post-injury labor earnings, and earnings motivated by its potential usefulness as a mea- information for matched (uninjured) workers at the sure of health, the importance of understanding same preinjury firm. Our focus on labor outcomes the relationship between health and labor pro- is motivated by the importance of understanding ductivity, and the policy interest in improving labor the relationship between health and labor pro- outcomes for the population that it studies - in- ductivity more broadly and by the policy interest jured workers. It exploits the 2003-2004 California in mechanisms to improve the labor outcomes of workers' compensation reforms which reduced injured workers. Adjusting for injury severity and medical care spending for injured workers with a selection into workers' compensation, we find that disproportionate effect on workers suffering lower workers with lower back injuries experienced a back injuries. It links administrative data on work- 7.3% greater decline in medical care after the reers' compensation claims to earnings and test forms, and that this led to an 8.3% reduction in the effect of the reforms on labor force outcomes post-injury earnings relative to other injured work- for workers who experienced the biggest drop in ers. We estimate that this earnings decline is due medical care costs. Adjusting for the severity of both to an increase in injury duration and to lower injury and selection into workers' compensation, earnings conditional on working. it Þnds that workers with low back injuries experienced a 7.3% greater decline in medical care after WR-1029 the reforms, and that this led to an 8.3% drop in Disability Insurance and Health Insurance post-injury earnings relative to other injured work- Reform: Evidence from Massachusetts. Nicole ers. These results suggest jointly that medical Maestas, Kathleen J. Mullen, Alexander Strand. care spending can impact health and that health 2014 affects labor outcomes. As health insurance becomes available outside of the employment relationship as a result of the WR-1028-1 Affordable Care Act (ACA), the cost of applying for Medical Care Spending and Labor Market Out- Social Security Disability Insurance (SSDI)—po- comes: Evidence from Workers' Compensation tentially going without health insurance coverage Reforms. David Powell, Seth A. Seabury. 2014 during a waiting period totaling 29 months from Injuries sustained at work represent large disability onset—will decline for many people income and welfare losses to households and with employer-sponsored health insurance. At the there is a significant policy interest in reducing same time, the value of SSDI and Supplemental these burdens. Workers' compensation program Security Income (SSI) participation will decline for is a large government program which provides individuals who otherwise lacked access to health monetary and medical benefits to injured work- insurance. This paper studies the 2006 Massa- ers. Despite the potential importance of medical chusetts health insurance reform to estimate the care in improving the health and labor productivity potential effects of the ACA on SSDI and SSI ap- of injured workers, little research has addressed plications. the relationship between medical care provided through workers' compensation and post-injury la- WR-1032 bor outcomes. This paper exploits the 2003-2004 Moral Hazard and Adverse Selection in Private California workers' compensation reforms which Health Insurance. David Powell, Dana P. Gold- man. 2014 467

Moral hazard and adverse selection create Schools (HCPS), Shelby County Schools (SCS, inefficiencies in private health insurance markets. formerly Memphis City Schools), Pittsburgh Public The authors use claims data from a large firm to Schools (PPS), and the four charter management study the independent roles of both moral hazard organizations that operate under the umbrella and adverse selection. Previous studies have at- of The College Ready Promise (TCRP). These tempted to estimate moral hazard in private health charter management organizations include Alli- insurance by assuming that individuals respond ance College-Ready Public Schools, Aspire Pub- only to the spot price, end-of-year price, average lic Schools, Green Dot Public Schools, and Part- price, or a related metric. There is little econom- nerships to Uplift Communities (PUC). This report ic justification for such assumptions and, in fact, briefly describes the approach each site is taking economic intuition suggests that the nonlinear to link TE data to PD opportunities and compare budget constraints generated by health insurance the main features of those efforts across sites. It plans make these assumptions especially poor. also documents the responses of teachers to the They study the differential impact of the health in- PD opportunities provided as of spring 2013. The surance plans offered by the firm on the entire dis- report presents interim evidence regarding one of tribution of medical expenditures without param- the key tenets of the IP reform – the idea that evi- eterizing the plans by a specific metric. They use dence regarding teachers' performance using mul- a new instrumental variable quantile estimation tiple data sources can be used to create profes- technique introduced in Powell [2013b] that pro- sional development opportunities tailored to meet vides the quantile treatment effects for each plan, teachers' individual needs. The report addresses while conditioning on a set of covariates for iden- two broad research questions: (1) What programs tification purposes. This technique allows us to and practices have IP sites adopted to offer PD map the resulting estimated medical expenditure that is customized to teachers' needs, and how distributions to the nonlinear budget sets gener- do key features of these efforts differ across the ated by each plan. Their method also allows them sites? (2) What opinions have teachers (and, to to separate moral hazard from adverse selection a lesser extent, school leaders) expressed about and estimate their relative importance. They esti- the evaluation and PD practices their sites have mate that 77% of the additional medical spending adopted? observed in the most generous plan in their data relative to the least generous is due to adverse WR-1034-BMGF selection. The remainder can be attributed to mor- Introduction to the Evaluation of the Intensive al hazard. A policy which resulted in each person Partnerships for Effective Teaching (IP). Brian M. enrolling in the least generous plan would cause Stecher, Michael Garet. 2014 the annual premium of that plan to rise by over On November 19, 2009, the Bill & Melinda Gates $1,500. Foundation announced that it would invest $290 million to support effective teaching as a means WR-1033-BMGF to ensure all students receive the education they Using Teacher Evaluation Data to Inform Profes- need to succeed in high school and beyond. The sional Development in the Intensive Partnership foundation made six-year grants to support four Sites. Laura S. Hamilton, Elizabeth D. Steiner, Intensive Partnership for Effective Teaching (IP) Deborah Holtzman, Eleanor S. Fulbeck, Abby sites that have developed plans to improve teach- Robyn, Jeffrey Poirier, Caitlin O'Neil. 2014 er effectiveness. Each site has obtained commit- This report describes the implementation of ments from local organizations to match the foun- professional development (PD) reforms and ef- dation grants. Each site has embarked on efforts forts to use teacher effectiveness (TE) data to to develop its own measure of teacher effective- inform PD through the third year of the initiative ness and use the measure to manage its teacher for all seven sites: Hillsborough County Public workforce in more strategic ways. A team from the 468

RAND Corporation and the American Institutes for WR-1038 Research (AIR) was chosen to conduct a broad, In with the Big, Out with the Small: Remov- longitudinal evaluation of these strategic human ing Small-Scale Reservations in India. Leslie A. resource (HR) reforms. Beginning in 2010-11 and Martin, Shanthi Nataraj, Ann E. Harrison. 2014 continuing through 2015-16, RAND/AIR is collect- For the past 60 years, India has promoted ing information annually from the IP sites to ex- small-scale industries (SSI). Industrial promotion plore how reforms are being implemented and to took the form of reserving certain products for examine the impact of the IP reforms on students manufacture by small and medium firms. The stat- and teachers. ed goal of Indian policy makers was to promote employment growth and income redistribution. In WR-1035-DOS this paper, the authors use a new version of the Portfolio Assessment of Department of State Annual Survey of Industries (ASI) that allows them Internet Freedom Program: An Annotated Briefing. to follow plants over time, and to examine whether Ryan Henry, Stacie L. Pettyjohn, Erin York. 2014 small factories in India exhibit faster employment RAND researchers conducted an assessment growth than larger factories. They find that, as in of the State Department's Bureau of Democracy, the United States, larger, younger factories grow Human Rights, Labor (DRL) Internet freedom more quickly, and create more jobs than smaller, portfolio for Fiscal Year 2012-13. Applying an ana- older factories. They then exploit the fact that India lytical methodology employing both multi-attribute eliminated SSI reservations for more than half of utility analysis and portfolio analysis techniques, all reserved products between 1997 and 2007 to the assessment showed good alignment between identify the consequences of removing these poli- State's strategy and the cumulative effect of the cies. They find that districts more exposed to the eighteen funded projects. Additionally, the portfo- de-reservation experienced higher employment lio was assessed to be well balanced with an un- and wage growth than those that were less ex- realized potential for supporting emergent State posed. These effects are driven by the growth of Department needs in enlarging political space factories that moved into the de-reserved product within authoritarian regimes. They found that the space, whose expansion more than compensated investment in developing Internet freedom ca- for the shrinking of smaller, incumbent firms. pacity and capabilities would likely have residual value beyond the portfolio's funded lifespan, with WR-1039 positive, but indirect, connections to civic freedom. Mobile phones, rent-to-own payments & water Moreover, promoting Internet freedom appears to filters: Evidence from Kenya. Jill E. Luoto, David I. be a cost-imposing strategy that simultaneously Levine. 2014 aligns well with both U.S. values and interests, Uptake of safe water products remains low, pressuring authoritarian rivals to either accept a in spite of modest cost. We experimented with a free and open Internet or devote additional secu- sales offer that combined a free trial and rent-to- rity resources to control or repress Internet ac- own payments for durable filters. Purchase rates tivities. Finally, it was assessed that the value of doubled under this sales offer to 31% compared such analysis is best realized over multiple stages to a traditional lump-sum sales contract. To lower of the portfolio's lifecycle. transaction costs we collected payments using WR-1036-BMGF Kenya's vast mobile banking network, MPESA. Trends in the Distribution of Teacher Effective- Mobile repayment rates were low; many filters ness in the Intensive Partnerships for Effective were paid only when a vendor came in-person Teaching. Jennifer L. Steele, Matthew Baird, John to request payment, which adds social pressure. Engberg, Gerald Paul Hunter. 2014 While the rent-to-own offer is attractive, more work Studies the distribution of teacher effectiveness is needed to reduce transaction costs in rural and in the Intensive Partnerships for Effective Teach- peri-urban Kenya. ing program. 469

WR-1040 WR-1041-1-BMGF Source of Health Insurance Coverage and Em- How Are School Leaders and Teachers Al- ployment Survival Among Newly Disabled Work- locating Their Time Under the Partnership Sites ers: Evidence from the Health and Retirement to Empower Effective Teaching Initiative?. Jay Study. Matthew J. Hill, Nicole Maestas, Kathleen Chambers, Iliana Brodziak de los Reyes, Antonia J. Mullen. 2014 Wang, Caitlin O'Neil. 2014 The onset of a work-limiting disability sets in Summarizes key findings about how school motion a sequence of events that for a growing leaders and teachers have changed the way they number of workers ends in early retirement from allocate their time among various activities in the the labor force, SSDI application and, ultimately, Intensive Partnership initiative. long-term program participation. Exactly how this sequence of events plays out is not well under- WR-1041-BMGF stood. While there exist large bodies of literature How Are School Leaders and Teachers Al- that address the effects of health insurance cov- locating Their Time Under the Partnership Sites erage on a wide range of outcomes, few papers to Empower Effective Teaching Initiative?. Jay have sought to examine how source of health in- Chambers, Iliana Brodziak de los Reyes, Antonia surance coverage generally and employer spon- Wang, Caitlin O'Neil. 2014 sored health insurance (ESHI) specifically affect Summarizes key findings about how school the employment trajectory following onset of dis- leaders and teachers have changed the way they ability. The authors use the nationally representa- allocate their time among various activities in the tive, longitudinal data from the Health and Retire- Intensive Partnership initiative. ment Study (HRS) to observe individuals before and after they experience a self-reported work WR-1042-OSD limiting disability. To estimate the effect of ESHI on Sleep in the Armed Forces: Working Group labor supply and disability claiming, they compare Proceedings. Wendy M. Troxel, Regina A. Shih, individuals covered by ESHI with no other employ- David M. Adamson, Peter Buryk, Kristie L. Gore, er-sponsored option (i.e., spousal coverage) with Lily Geyer, Michael P. Fisher, Jeremy R. Kurz. individuals covered by ESHI but whose spouses 2014 are offered coverage from their own employer. As the United States continues its draw-down They find evidence of an “employment lock” effect from Afghanistan and Iraq, and with an increasing of ESHI only among the 20 percent of individu- number of troops returning home, the challenges als whose disabilities do not impact their immedi- of reintegration have become critical foci for the ate physical capacity but are associated with high U.S. forces. Understanding factors that may either medical costs. They do not find any evidence of promote or hinder servicemembers' ability to re- differential disability insurance application rates integrate and rebuild their lives post-deployment between those with ESHI and the comparison is therefore essential to support service mem- group. With the passage of the Affordable Care Act, ber mental and physical health and operational there is concern that disability insurance applica- readiness. The Department of Defense's (DoD) tions may swell because the incentive to remain Defense Centers of Excellence for Psychological employed will diminish for disabled workers reliant Health and Traumatic Brain Injury (DCoE) com- on ESHI. Their results suggest that the availability missioned RAND National Defense Research of non-employment-based health insurance may Institute (RAND NDRI) in August 2012 to con- cause disabled workers with high cost/low sever- duct a 2-year independent study to review exist- ity conditions to leave the workforce but it will not ing policies and programs related to sleep in the necessarily lead to increased disability insurance post-deployment period, with the ultimate goal of application among individuals with ESHI. optimizing healthy sleep in service members. As part of this project, RAND convened a multi-disciplinary group of stakeholders across all servic- 470 es to identify barriers to achieving healthy sleep lomats' children to earn an internationally recog- among servicemembers, and recommendations nized high school diploma, today the International to address those barriers. The current report is a Baccalaureate (IB) Diploma Programme (DP) working paper that describes the proceedings of serves students from a variety of backgrounds in this one-day meeting on sleep in the armed forces 144 countries. The IB mission and Learner Pro- held in RAND's Arlington Office on February 21, file—consisting of ten attributes to foster in stu- 2014. The goal of this working paper document dents—suggest that development of students' citi- is to provide preliminary findings to DCoE and the zenship is the core purpose of an IB education. In meeting attendees. this study, in four public schools in California that offer the DP, I interviewed DP Coordinators, teach- WR-1043 ers (n=15) and students (n=24) to learn their per- Longitudinal Aging Study In India: Biomarker spectives about how and the extent to which the Data Documentation. David Bloom, Perry Hu, DP develops students' citizenship. I also surveyed P. Arokiasamy, Arun Risbud, T. V. Sekher, S. K. students using items that were administered as Mohanty, Varsha Kale, Jennifer O'Brien, Chiaying part of other surveys to large samples of high Sandy Chien, Jinkook Lee. 2014 school-enrolled 17 and 18 year olds. The results The Longitudinal Aging Study in India (LASI) is indicate that the DP's heavy pedagogical reliance designed to be a nationally representative study on discussions, debates, oral presentations, writ- of the physical, financial, and social well-being ten assignments and teamwork, enables students of India's 45+ population. The instrument is de- to develop many of the skills that are necessary for signed to be comparable to the Health and Retire- civic advocacy. Results also indicate that the DP ment Study (HRS), which is a model for several places a strong emphasis on students' knowledge studies across the world. This harmonization in of issues related to public policy. Interview results instruments allows for cross-national comparative indicate that the DP does not seem to strongly studies. In addition to a harmonized set of core prioritize students' knowledge of U.S. government questions, the instrument also reflects circum- structure and functioning. The student survey re- stances specific to Indian culture and institutions. sults, however, show that compared to nationally The LASI instrument has three components: (1) representative samples of similarly aged 12th- the household survey; (2) the individual survey; grade students, the sample of IB students scored and (3) the biomarker collection. Direct assess- higher on nine of ten items that tested their knowl- ment of biomarkers, which can yield objective edge of U.S. government history and functioning. health measures, is particularly important in India. The DP develops students' citizenship through This report describes the following: (1) Data col- promoting their awareness of political and social lection protocol, including sample sizes and re- issues and required active engagement with a lo- sponse rate; (2) Laboratory protocol for the DBS cal or global issue. Most IB students and teachers assays (with the description of our quality control feel that the DP develops students' academic civic protocol) and the results of validation study; and mindedness and model citizenship to a consider- (3) The distributional characteristics of biomarker ably greater extent than other curricular alterna- data, the list of biomarker variables available in tives (including California College Prep and Ad- public data file, and the application procedure to vanced Placement courses). Finally, teachers feel obtain restricted biomarker data file. that the strongest limitation to their prioritization of students' citizenship development is their lack WR-1044-IBO of clarity on how to frame the civic implications of Academic Civic Mindedness and Model Citizen- the knowledge, skills and attitudes they seek to ship in the International Baccalaureate Diploma develop. Programme. Anna Rosefsky Saavedra. 2014 WR-1047 Originally founded as a private means for dip- Employer Accommodation and Labor Supply of 471

Disabled Workers. Matthew J. Hill, Nicole Maes- presents alternative analyses of data from large- tas, Kathleen J. Mullen. 2014 scale effectiveness studies of Cognitive Tutor Al- The authors use longitudinal data from the gebra I in middle schools and high schools. These Health and Retirement Study to examine what fac- alternative analyses produce results that are sub- tors influence employer accommodation of newly stantively the same as previously reported. It finds disabled workers and how effective such accom- a significant positive effect of .21 standard devia- modations are in retaining workers and discourag- tion units for high school students in the second ing disability insurance applications. They find that year of the study. only a quarter of newly disabled older workers are WR-1051-DOEL accommodated by their employers in some way Validation Studies for Early Learning and Care following onset of a disability. Importantly, they find Quality Rating and Improvement Systems: A Re- that few employer characteristics explain which view of the Literature. Lynn A. Karoly. 2014 workers are accommodated; rather, employee characteristics, particularly the presence of cer- As early care and education (ECE) quality tain personality traits correlated with assertive- rating and improvement systems (QRISs) have ness and open communication, are highly predic- advanced and matured, a number of states and tive of accommodation. This suggests that policies localities have undertaken evaluations to validate targeting employer incentives may not be particu- the systems. Such efforts stem from the desire larly effective at increasing accommodation rates to ensure that the system is designed and op- since employers may not even be aware of their erating in the ways envisioned when the system employees' need for accommodation. They also was established. Given that a central component find that if employer accommodation rates can be in a QRIS is the rating system, a key concern is increased, disabled workers would be significantly whether the rating process, including the use of more likely to delay labor force exit, at least for two particular measures and the manner in which they years. However, they do not find significant effects are combined and cut scores are applied, pro- on the disability insurance claiming margin. duces accurate and understandable ratings that capture meaningful differences in program quality WR-1049 across rating levels. The aim of this paper is to re- Deterrence, Influence, Cyber Attack, and Cy- view the set of studies that seek to validate QRIS berwar. Paul K. Davis. 2014 rating systems in one of several ways: by examin- This Working Paper stems from a workshop, ing the relationship between program ratings and Navigating Deterrence: Law, Strategy, andSecu- objective measures of program quality; by deter- rity in the Twenty-First Century, organized by New mining if program ratings increase over time; and York University's Center on Law and Security and by estimating the relationship between program held in Abu Dhabi, United Arab Emirates, March ratings and child developmental outcomes. Spe- 19-20, 2014. A final version of the paper will be cifically, we review 14 such validation studies that included early in 2015 in a special journal issue address one or more of these three questions. based on the workshop . In the meantime, the Together, these 14 studies cover 12 QRISs in 11 Working Paper provides an opportunity for infor- states or substate areas: Colorado, Florida (two mal peer review. counties), Indiana, Maine, Minnesota, Missouri, North Carolina, Oklahoma, Pennsylvania, Tennes- WR-1050-DEIES see, and Virginia. In reviewing the literature, we Addendum to Effectiveness of Cognitive Tutor are interested in the methods and measures they Algebra I at Scale. John F. Pane, Beth Ann Griffin, employ, as well as the empirical results. To date, Daniel F. McCaffrey, Rita Karam. 2014 most validation studies have found that programs with higher ratings had higher environment rating This addendum to previously published results scores (ERSs), but the ERS is often one of the 472 rating elements. Independent measures of qual- ernment should consider before deciding whether ity have not always shown the expected positive or not to offer military training and equipment to relationship with quality. The handful of studies potential partners operating amidst uncertainty: that have examined how ratings change over time (1) Identifying the parameters that guide security have generally shown that programs participat- cooperation decisions, including statutory require- ing in the QRIS did improve their quality or qual- ments that may prevent the provision of certain ity ratings. Studies that examine the relationship types of assistance to certain types of recipients; between QRIS ratings and child development are (2) Identifying the criteria according to which the the most challenging to implement and can be United States will decide which party to a conflict costly to conduct when independent child assess- it should support; (3) Assessing potential partments are performed. Consequently, there has ners; (4) Evaluating the potential usefulness of been considerable variation in methods to date security cooperation tools in different scenarios; across these studies. Among the four studies with and finally, (5) Examining the potentially adverse the stronger designs, two found the expected re- implications of offering security assistance in the lationship between QRIS ratings and child devel- midst of political uncertainty, including the dan- opmental gains. The lack of robust findings across gers of choosing the “wrong” partner, choosing these studies indicate that QRISs, as currently the “wrong” timing for intervention, or remaining configured, do not necessarily capture differences uninvolved in circumstances in which the United in program quality that are predictive of gains in States would have benefited from direct interven- key developmental domains. Based on these find- tion. Based on a careful review of these five chal- ings, the paper discusses the opportunities for lenges, the working paper suggests avenues for future QRIS validation studies, including those future research. conducted as part of the Race to the Top–Early WR-1053 Learning Challenge grants, to advance the meth- Impact of Public Works on Household Occu- ods used and contribute not only to improvement pational Choice: Evidence from NREGS in India. of the QRIS in any given state, but also to add to Sinduja V. Srinivasan. 2014 the knowledge base about effective systems more generally. I analyze the impact of India's public employment generation program (NREGS) on entrepreneur- WR-1052 ship. One of the main barriers to entrepreneurship Security Cooperation Amidst Political Uncer- in India is a lack of access to capital. My hypoth- tainty: An Agenda for Future Research. Larry esis is that NREGS allows liquidity constrained Hanauer, Stephanie Pezard. 2014 individuals to accumulate savings, enabling sub- Security cooperation, through which the United sequent investment in a risky, but more profitable, States provides a wide range of military training venture, and ideally, permanent graduation from and assistance to partner states, is a central el- poverty. Taking advantage of the quasi-experi- ement of U.S. foreign policy. This working paper mental nature of the program, I use a nationally examines the challenges that may arise when the representative data set to estimate the impact of United States seeks to intervene in uncertain po- NREGS on selection into entrepreneurship. I find litical environment, such as instances in which the that rates of non-agricultural entrepreneurship in- United States' partner – which may be a besieged crease by 3 percentage points in NREGS districts government or a non-state actor – is actively en- (increasing rates from 15% to 18%), compared to gaged in military conflict. A fair amount of litera- areas that did not receive the program. This re- ture exists that can help assess whether and to sult is robust to various specifications, including what extent security cooperation may be a useful two falsification tests. The results suggest that tool for shaping such environments. This litera- by acting as a source of credit, NREGS impacts ture identifies five key issues that the U.S. gov- household occupational choice, contributing to in- 473 creased income, and ultimately promoting current think about their savings goals, how it would feel and future family welfare. to achieve them, and make a pledge to work towards these goals (potentially increasing one's in- WR-1054 trinsic motivation), yet has no external restrictions Do Employers Prefer Workers Who Attend on savings behavior. In a six-month randomized For-Profit Colleges? Evidence from a Field Experi- savings experiment we find that such soft commitment. Rajeev Darolia, Cory Koedel, Paco Mar- ments can significantly increase amounts saved torell, Katie Wilson, Francisco Perez-Arce. 2014 on day one relative to either a hard commitment This paper reports results from a resume-based account (with external restrictions on withdraw- field experiment designed to examine employer als) or a traditional savings account. Additionally, preferences for job applicants who attended for- the soft commitments significantly increased final profit colleges. For-profit colleges have seen sharp savings balances relative to no form of commit- increases in enrollment in recent years despite ment and were particularly effective for impatient alternatives such as public community colleges individuals. However, despite the inherent illiquid- being much cheaper. We sent almost 9,000 ficti- ity, the hard commitment account proved most ef- tious resumes of young applicants who recently fective in building savings balances amongst our completed their schooling to online job postings in participants at the end of six months. six occupational categories and tracked employer callback rates. We find no evidence that employ- WR-1060 ers prefer applicants with resumes listing a for- Cross Validation Bandwidth Selection for De- profit college relative to those whose resumes list rivatives of Multidimensional Densities. Matthew either a community college or no college at all. Baird. 2014 Little attention has been given to the effect of WR-1055 Soft versus Hard Commitments: A Test on higher order kernels for bandwidth selection for Savings Behaviors. Jeremy Burke, Jill E. Luoto, multidimensional derivatives of densities. This pa- Francisco Perez-Arce. 2014 per investigates the extension of cross validation methods to higher dimensions for the derivative Many Americans save too little, leaving them of an unconditional joint density. I present and de- vulnerable to unexpected financial shocks. Find- rive different cross validation criteria for arbitrary ing ways to help Americans develop emergency kernel order and density dimension, and show savings funds could greatly improve welfare. A consistency of the estimator. Doing a Monte Car- wealth of previous literature has demonstrated the lo simulation study for various orders of kernels central roles played by patience and self-control in the Gaussian family and additionally compar- in achieving sufficient savings. When people lack ing a weighted integrated square error criterion, patience or self-control, well-designed interven- I find that higher order kernels become increas- tions may help improve financial stability. Increas- ingly important as the dimension of the distribu- ingly, interventions intended to improve savings tion increases. I find that standard cross validation behavior have taken the form of externally re- selectors generally outperform the weighted inte- stricted accounts such as commitment accounts' grated square error cross validation criteria. Using that include hefty fees for early withdrawal or that the infinite order Dirichlet kernel tends to have the disallow withdrawals altogether for a pre-specified best results. time. Yet, such hard commitment accounts may not appeal to impatient individuals, those who WR-1061-BMGF do not anticipate their own self-control problems, Methods Used to Estimate Achievement Effects or to the poor for whom restrictions on scarce in Personalized Learning Schools. John F. Pane, funds can be particularly painful. We test a new Matthew Baird. 2014 soft' commitment account that asks borrowers to 474

The purpose of this document is to describe differential growth rates occur partially for reasons the methods RAND used to analyze achievement unrelated to economic growth, providing a natural for 23 personalized learning (PL) schools for the approach to isolate the impact of aging on growth. 2012-13 through 2013-14 academic years. This We predict the magnitude of population aging at work was performed at the request of the Bill & the state-level given the state's age structure in Melinda Gates Foundation (BMGF), as part of an initial period and exploit this predictable differ- a multi-year evaluation contract. The 23 schools ential growth to estimate the impact of population were selected from a larger portfolio of PL schools aging on Gross Domestic Product (GDP) growth, funded directly or indirectly by BMGF because they and its constituent parts, labor force and produc- implemented PL school-wide during both of the tivity growth. We estimate that a 10% increase in two academic years and they also administered the fraction of the population ages 60+ decreases Northwest Evaluation Association's (NWEA) Mea- GDP per capita by 5.7%. We find that this reduc- sures of Academic Progress (MAP) both years. tion in economic growth caused by population aging is primarily due to a decrease in growth in the WR-1062-BMGF supply of labor. To a lesser extent, it is also due Personalized Learning Instructional Staff to a reduction in productivity growth. We present Survey Results (Spring 2014). Kyle Siler-Evans, evidence of downward adjustment of earnings Elizabeth D. Steiner, Laura S. Hamilton, John F. growth to reflect the reduction in productivity. Pane. 2014 The purpose of this document is to descrip- WR-1068 Policy Variation, Labor Supply Elasticities, and tively summarize instructional staff responses to a a Structural Model of Retirement. Day Manoli, survey administered by RAND in 23 personalized Kathleen J. Mullen, Mathis Wagner. 2014 learning (PL) schools in Spring 2014. This work was performed at the request of the Bill & Melinda This paper exploits a combination of policy Gates Foundation (BMGF), as part of a multi-year variation from multiple pension reforms in Austria evaluation contract. The 23 schools were selected and administrative data from the Austrian Social from a larger portfolio of PL schools funded directly Security Database. Using the policy changes for or indirectly by BMGF because they implemented identiÞcation, we estimate social security wealth PL school-wide during both of the two academic and accrual elasticities in individuals' retirement years and they also administered Northwest Eval- decisions. Next, we use these elasticities to es-ti- uation Association's (NWEA) Measures of Aca- mate a dynamic programming model of retirement demic Progress (MAP) both years. decisions. Finally, we use the estimated model WR-1063 to examine the labor supply and welfare conse- The Effect of Population Aging on Economic quences of potential social security reforms. Growth. Nicole Maestas, Kathleen J. Mullen, Da- WR-987-1 vid Powell. 2014 Estimating Intensive and Extensive Tax Re- Population aging is widely expected to have det- sponsiveness: Do Older Workers Respond to rimental effects on aggregate economic growth. Income Taxes?. Abby Alpert, David Powell. 2014 However, we have little empirical evidence about This paper studies the impact of income taxes the actual existence or magnitude of such effects. on intensive and extensive labor supply decisions In this paper, we exploit differential aging patterns for older workers. The literature provides little at the state level in the United States between evidence about the responsiveness of the older 1980 and 2010. Many states have already expe- population to tax incentives, though the tax code rienced high growth rates of the 60+ population, is a potentially important mechanism for affecting comparable to the predicted national growth rate over the next several decades. Furthermore, these 475 retirement behavior. We estimate the intensive and extensive margins jointly with a new approach accounting for selection into labor force participation. On the extensive margin, we find substantial effects of income taxes on labor force participation and retirement decisions, estimating participation elasticities with respect to after-tax labor income of 0.76 for women and 0.55 for men. About half of the magnitude of these labor force participation elasticities are associated with tax-driven reductions in retirement. We find statistically insig- nificant compensated elasticities on the intensive margin. We simulate the effects on labor supply of two possible age-targeted tax reforms. We find that eliminating the employee portion of the payroll tax at age 65 would decrease the percentage of workers exiting the labor force by 6-7%. An EITC expansion which extends the tax credit to older ages (irrespective of their number of dependents) would decrease the probability that workers exit the labor force by 3 percentage points for men and by 6 percentage points for women, reductions of 11% and 23% from baseline rates.