Effects of Preoperative Intravenous Versus Subcutaneous Tranexamic Acid on Postoperative Periorbital Ecchymosis and Edema Following Upper Eyelid Blepharoplasty: A Prospective, Randomized, Double-Blinded, Placebo-Controlled, Comparative Study.

PURPOSE: To compare the effects of preoperative tranexamic acid (TXA) administered intravenously (IV) versus subcutaneously on postoperative ecchymosis and edema in patients undergoing bilateral upper eyelid blepharoplasty. METHODS: A prospective, double-blinded, placebo-controlled study of patients undergoing bilateral upper eyelid blepharoplasty at a single-center. Eligible participants were randomized to preoperatively receive either (1) 1 g of TXA in 100 ml normal saline IV, (2) 50 µl/ml of TXA in local anesthesia, or (3) no TXA. Primary outcomes included ecchymosis and edema at postoperative day 1 (POD1) and 7 (POD7). Secondary outcomes included operative time, pain, time until resuming activities of daily living, patient satisfaction, and adverse events. RESULTS: By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), ecchymosis scores were significantly lower on POD1 (1.31 vs. 1.56 vs. 2.09, p = 0.02) and on POD7 (0.51 vs. 0.66 vs. 0.98, p = 0.04) among those that received TXA. By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), significant reductions in edema scores occurred in those that received TXA on POD1 (1.59 vs. 1.43 vs. 1.91, p = 0.005) and on POD7 (0.85 vs. 0.60 vs. 0.99, p = 0.04). By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA) patients treated with intravenous and local subcutaneous TXA preoperatively were more likely to experience shorter operative times (10.8 vs. 11.8 vs. 12.9 minutes, p = 0.01), reduced time to resuming activities of daily livings (1.6 vs. 1.6 vs. 2.3 days, p < 0.0001), and higher satisfaction scores at POD1 (8.8 vs. 8.7 vs. 7.9, p = 0.0002). No adverse events occurred were reported. CONCLUSION: In an analysis of 106 patients, preoperative TXA administered either IV or subcutaneously safely reduced postoperative ecchymosis and edema in patients undergoing upper eyelid blepharoplasty. While statistical superiority between intravenous versus local subcutaneous TXA treatment was not definitively identified, our results suggest clinical superiority with IV dosing.

Sexual Assault Experiences in the Active-Component Army: Variation by Year, Gender, Sexual Orientation, and Installation Risk Level.

To better understand the circumstances surrounding sexual assault in the Army, RAND Arroyo Center researchers created descriptions of active-component soldiers' most serious sexual assault experiences using data from the 2016 and 2018 Workplace and Gender Relations Survey of Active Duty Members. In this study, researchers describe the most common types of behaviors that occurred, characteristics of alleged perpetrators, and times and places in which the experiences occurred. They also explore differences by gender, sexual orientation, and installation risk level. Nearly 90 percent of victims believed that the assault was committed for a sexual reason, and more than half indicated that the assault was meant to be abusive or humiliating. The typical perpetrator of victims' most serious sexual assault experiences was a male enlisted member of the military acting alone. Perpetrators were most often a military peer of the victim; perpetrators who were strangers to the victim were uncommon; and assaults by spouses, significant others, or family members were comparatively rare. Approximately two-thirds of victims' most serious experience of sexual assault occurred at a military installation. The authors found substantial differences by gender, especially in terms of the types of sexual assault behaviors victims experienced and in terms of the setting in which victims were sexually assaulted. The authors also found some evidence suggesting that sexual minorities-that is, individuals who identify with a sexual orientation other than heterosexual-may experience more-violent sexual assaults and more assaults that are meant to abuse, humiliate, haze, or bully, especially among men.

Just in Reach Pay for Success: Impact Evaluation and Cost Analysis of a Permanent Supportive Housing Program.

Discharging individuals from jails and prisons who may be poorly equipped for independent living-such as those with a history of chronic health conditions, including serious mental illness-is likely to reinforce a pattern of homelessness and recidivism. Permanent supportive housing (PSH)-which combines a long-term housing subsidy with supportive services-has been proposed as a mechanism to intervene directly on this relationship between housing and health. In Los Angeles County, jail has become a default housing and services provider to unhoused individuals with serious mental health issues. In 2017, the county initiated the Just in Reach Pay for Success (JIR PFS) project, which provided PSH as an alternative to jail for individuals with a history of homelessness and chronic behavioral or physical health conditions. The authors of this study assessed whether the project led to changes in use of several county services, including justice, health, and homeless services. The authors examined changes in county service use, before and after incarceration, by JIR PFS participants and a comparison control group and found that use of jail services was significantly reduced after JIR PFS PSH placement, while the use of mental health and other services increased. The researchers assess that the net cost of the program is highly uncertain but that it may pay for itself in terms of reducing the use of other county services and therefore provide a cost-neutral means of addressing homelessness among individuals with chronic health conditions involved with the justice system in Los Angeles County.

The Women's Reproductive Health Survey (WRHS) of Active-Duty Service Members.

The Women's Reproductive Health Survey (WRHS) of active-duty service members represents the first time since the 1990s that the U.S. Department of Defense (DoD) has sponsored a department-wide survey of only service women. Maintaining the readiness of the U.S. armed forces requires attention to the health and health care needs of all who serve, including active-duty service women (ADSW). With respect to reproductive health, Congress passed two pieces of legislation in the 2016 and 2017 National Defense Authorization Acts that required DoD to provide ADSW access to comprehensive family planning and counseling services and to do so at predeployment and annual physical exams. The legislation also required DoD to conduct a survey of ADSW's experiences with family planning services and counseling and use and availability of preferred birth control methods. RAND Corporation researchers developed the WRHS to address these two pieces of congressional legislation. The Coast Guard requested that RAND also field the survey among its ADSW. In this study, the authors detail the methodology, sample demographics, and results from the survey (conducted between early August and early November 2020) across a number of domains: health care utilization, birth control and contraceptive use, reproductive health during training and deployment, fertility and pregnancy, and infertility. Differences are examined by service branch, pay grade, age group, race/ethnicity, marital status, and sexual orientation. The results are intended to inform policy initiatives to help support the readiness, health, and well-being of ADSW.

Implementation and 12-Month Health Service Utilization and Cost Outcomes from a Managed Care Health Plan's Permanent Supportive Housing Program.

Homelessness, which refers to the lack of a fixed, regular, and adequate nighttime residence, is a pervasive public health issue. This article presents results from an implementation and outcome study of an ongoing permanent supportive housing (PSH) program-including service utilization and associated costs review-operated by a large not-for-profit Medicaid and Medicare managed care plan serving more than 1 million members in the Inland Empire area of Southern California. This PSH program combines a long-term housing subsidy with intensive case management services for adult plan members experiencing homelessness who have one or more chronic physical or behavioral health conditions and represent high utilizers of inpatient health care. The aim of this research was to determine whether programmatic costs incurred by the health plan supporting the PSH program were partially or fully offset by decreased costs attributable to health care utilization within the health system. The evaluation used a quasi-experimental research design with an observational control group. The authors differentiated the program's effect during the transitional period-that is, after program enrollment and prior to housing placement-from its effect during the period after members were housed. In addition, the authors present participant flow through the key program milestones (e.g., referral, enrollment, housing placement, program exit) and describe health care utilization and associated costs for members who exited the program. Finally, they report the PSH programmatic expenditures relative to the changes in health care costs to provide an overall picture of the intervention's benefits and costs to the health plan.

Comparative effectiveness of individual versus family-based substance use treatment on adolescent self-injurious thoughts and behaviors.

INTRODUCTION: Self-injurious thoughts and behaviors (SITB) are of increasing concern among adolescents, especially those who use substances. Some evidence suggests that existing evidence-based substance use treatments (EBTs) could impact not only their intended substance use targets but also SITB. However, which types of substance use treatments may have the greatest impact on youth SITB is not yet clear. Based on prior literature showing that family support and connection may buffer youth from SITB, we initially hypothesized that family-based EBTs would show greater improvement in SITB compared to those receiving individually focused EBTs and that the size of the effects would be small given the comparison between two active, evidence-based interventions, and base rates of SITB. METHODS: In a sample of 2893 youth in substance use treatment, we compared the effectiveness of individually and family-based EBTs in reducing SITBs. The study used entropy balancing and regression modeling to balance the groups on pre-treatment characteristics and examine change in outcomes over a one-year follow-up period. RESULTS: Both groups improved in self-injury and suicide attempts over the one-year study period, but only youth in individual treatment improved in suicidal ideation. However, the study found no significant difference between the changes over time in the two groups for any outcome. As expected, effect sizes were small and power was constrained in this study given the rarity of the outcomes, but effect sizes are similar to those observed with substance use outcomes. CONCLUSIONS: The results provide important exploratory evidence on the potential relative effectiveness of these two treatments for SITBs. This study supports prior findings that EBTs for youth substance use may help to improve SITB and suggests that different treatment formats (individual or family-based) could result in different benefits for SITB outcomes.

The Effect of the Medicare Advantage Value-Based Insurance Design Model Test on Utilization in 2017.

In 2015, the Centers for Medicare and Medicaid Services announced the Medicare Advantage (MA) Value-Based Insurance Design (VBID) model test, which allows MA insurers to use flexible benefit design strategies, such as reduced cost-sharing, to encourage beneficiaries with chronic disease to use high-value care. During the first year of implementation (2017), nine MA insurers offered VBID in 45 health plans to a total of 96 053 eligible beneficiaries. We used MA encounter data to estimate the impact of VBID on health services utilization in 2017 using a difference-in-differences research design. We found that VBID increased use of 10 out of 18 targeted services, and led to general increases in primary care visits, specialty care visits, and drug fills across eligible beneficiaries. The model was also associated with increases in ambulatory care sensitive inpatient and emergency department visits, an unanticipated effect that may be temporary. Overall, our findings suggest that VBID successfully increased the use of high-value services among eligible MA beneficiaries, an important first step along the pathway to better chronic disease management, lower spending, and improved beneficiary health.

A multi-institutional retrospective analysis on impact of RV acute mechanical support timing after LVAD implantation on 1-year mortality and predictors of RV acute mechanical support weaning.

BACKGROUND: There is little insight into which patients can be weaned off right ventricular (RV) acute mechanical circulatory support (AMCS) after left ventricular assist device (LVAD) implantation. We hypothesize that concomitant RV AMCS insertion instead of postoperative implantation will improve 1-year survival and increase the likelihood of RV AMCS weaning. METHODS: A multicenter retrospective database of 826 consecutive patients who received a HeartMate II or HVAD between January 2007 and December 2016 was analyzed. We identified 91 patients who had early RV AMCS on index admission. Cox proportional-hazards model was constructed to identify predictors of 1-year mortality post-RV AMCS implantation and competing risk modeling identified RV AMCS weaning predictors. RESULTS: There were 91 of 826 patients (11%) who required RV AMCS after CF-LVAD implantation with 51 (56%) receiving a concomitant RV AMCS and 40 (44%) implanted with a postoperative RV AMCS during their ICU stay; 48 (53%) patients were weaned from RV AMCS support. Concomitant RV AMCS with CF-LVAD insertion was associated with lower mortality (HR 0.45 [95% CI 0.26-0.80], p = 0.01) in multivariable model (which included age, BMI, angiotensin-converting enzyme inhibitor use, and heart transplantation as a time-varying covariate). In the multivariate competing risk analysis, a TPG < 12 (SHR 2.19 [95% CI 1.02-4.70], p = 0.04) and concomitant RV AMCS insertion (SHR 3.35 [95% CI 1.73-6.48], p < 0.001) were associated with a successful wean. CONCLUSIONS: In patients with RVF after LVAD implantation, concomitant RV AMCS insertion at the time of LVAD was associated with improved 1-year survival and increased chances of RV support weaning compared to postoperative insertion.

Nonparametric Estimation of Population Average Dose-Response Curves using Entropy Balancing Weights for Continuous Exposures.

Weighted estimators are commonly used for estimating exposure effects in observational settings to establish causal relations. These estimators have a long history of development when the exposure of interest is binary and where the weights are typically functions of an estimated propensity score. Recent developments in optimization-based estimators for constructing weights in binary exposure settings, such as those based on entropy balancing, have shown more promise in estimating treatment effects than those methods that focus on the direct estimation of the propensity score using likelihood-based methods. This paper explores recent developments of entropy balancing methods to continuous exposure settings and the estimation of population dose-response curves using nonparametric estimation combined with entropy balancing weights, focusing on factors that would be important to applied researchers in medical or health services research. The methods developed here are applied to data from a study assessing the effect of non-randomized components of an evidence-based substance use treatment program on emotional and substance use clinical outcomes.

Prediction of right heart failure after left ventricular assist implantation: external validation of the EUROMACS right-sided heart failure risk score.

AIMS: Prediction of right heart failure (RHF) after left ventricular assist device (LVAD) implant remains a challenge. The EUROMACS right-sided heart failure (EUROMACS-RHF) risk score was proposed as a prediction tool for post-LVAD RHF but lacks from large external validation. The aim of our study was to externally validate the score. METHODS AND RESULTS: From January 2007 to December 2017, 878 continuous-flow LVADs were implanted at three tertiary centres. We calculated the EUROMACS-RHF score in 662 patients with complete data. We evaluated its predictive performance for early RHF defined as either (i) need for short- or long-term right-sided circulatory support, (ii) continuous inotropic support for ≥14 days, or (iii) nitric oxide for ≥48 h post-operatively. Right heart failure occurred in 211 patients (32%). When compared with non-RHF patients, pre-operatively they had higher creatinine, bilirubin, right atrial pressure, and lower INTERMACS class (P < 0.05); length of stay and in-hospital mortality were higher. Area under the ROC curve for RHF prediction of the EUROMACS-RHF score was 0.64 [95% confidence interval (CI) 0.60-0.68]. Reclassification of patients with RHF was significantly better when applying the EUROMACS-RHF risk score on top of previous published scores. Patients in the high-risk category had significantly higher in-hospital and 2-year mortality [hazard ratio: 1.64 (95% CI 1.16-2.32) P = 0.005]. CONCLUSION: In an external cohort, the EUROMACS-RHF had limited discrimination predicting RHF. The clinical utility of this score remains to be determined.

Racial-Ethnic Differences in Mental Health Stigma and Changes Over the Course of a Statewide Campaign.

OBJECTIVE: The authors examined whether shifts in mental health-related stigma differed across racial-ethnic groups over the course of a California statewide antistigma campaign and whether racial-ethnic disparities were present at the beginning of the campaign and 1 year later. METHODS: Participants had taken part in the 2013 and 2014 California Statewide Surveys (CASSs), a longitudinal, random-digit-dialing telephone survey of California adults ages ≥18 years (N=1,285). Surveys were administered in English, Spanish, Mandarin, Cantonese, Vietnamese, Khmer, and Hmong. RESULTS: Compared with Whites, Latino and Asian respondents who preferred to take the survey in their native language had higher levels of mental health-related stigma on several domains of the 2013 CASS. Specifically, Latino and Asian respondents who completed the survey in their native language were more likely than White respondents to report social distance, prejudice, and perceptions of dangerousness toward people with mental illness. These racial-ethnic disparities persisted 1 year later on the 2014 CASS. Latino-Spanish respondents experienced significant decreases in social distance over the course of the campaign but not to a degree that eliminated disparities on the 2014 CASS. Of note, perceptions of dangerousness of people with mental illness significantly increased among Latino-Spanish respondents between the 2013 and 2014 CASSs. CONCLUSIONS: Future research is needed to better understand which components of antistigma campaigns are effective across racial-ethnic minority groups and whether more targeted efforts are needed, especially in light of the persistent and growing racial-ethnic disparities in mental health care.

Design of CLARO (Collaboration Leading to Addiction Treatment and Recovery from other Stresses): A randomized trial of collaborative care for opioid use disorder and co-occurring depression and/or posttraumatic stress disorder.

INTRODUCTION: Opioid use disorder (OUD) co-occurring with depression and/or posttraumatic stress disorder (PTSD) is common and, if untreated, may lead to devastating consequences. Despite the availability of evidence-based treatments for these disorders, receipt of treatment is low. Even when treatment is provided, quality is variable. Primary care is an important and underutilized setting for treating co-occurring disorders (COD) because OUD, depression and PTSD are frequently co-morbid with medical conditions and most people visit a primary care provider at least once a year. With rising rates of OUD and opioid-related fatalities, this is a critical treatment and quality gap in a vulnerable and stigmatized population. METHODS: CLARO (Collaboration Leading to Addiction Treatment and Recovery from Other Stresses) is a multi-site, randomized pragmatic trial of collaborative care (CC) for co-occurring disorders in 13 rural and urban primary care clinics in New Mexico to improve care for patients with OUD and co-occurring depression and/or PTSD. CC, a service delivery approach that uses multi-faceted interventions, has not been tested with COD. We will enroll and randomize 900 patients to either CC adapted for COD (CC-COD) or enhanced usual care (EUC) and will collect patient data at baseline, 3-, and 6-month follow-up. Our primary outcomes are medications for OUD (MOUD) access, MOUD continuity of care, depression symptoms, and PTSD symptoms. DISCUSSION: Although CC is effective for improving outcomes in primary care among patients with mental health conditions, it has not been tested for COD. This article describes the CLARO CC-COD intervention and clinical trial.

Adjustment of Patient Experience Surveys for How People Respond.

BACKGROUND: Patient surveys are the primary tool to measure patient experiences of care. Caution must be taken when analyzing these data, as responses can be influenced by factors that do not reflect the quality of care received. OBJECTIVES: To provide a practical overview of adjusting patient experience survey results to address bias related to patient case-mix, extreme response tendency, and mode of survey administration. RESEARCH DESIGN: We discuss options for adjustment for biases in how people respond to patient experience surveys. RESULTS: Case-mix adjustment (CMA) aims to compare provider performance that would have been observed if all providers had treated the same set of patients by removing the effects of patient characteristics that vary across providers. Extreme response tendency can bias the measurement of the disparities in patient experiences even after typical CMAs, since differences in patients' use of extreme response options may affect patient experience scores when they have a skewed distribution. Survey mode may affect scores for the provider entity being evaluated (eg, hospital) more than CMA if survey mode differs at the provider level. CONCLUSIONS: It is best practice to evaluate known source of bias when analyzing patient experience surveys. Failure to adjust for patient case-mix, extreme response tendency, and survey mode in patient experience surveys may lead to erroneous comparisons of providers.

Expanding outcomes when considering the relative effectiveness of two evidence-based outpatient treatment programs for adolescents.

The current study seeks to advance understanding about how to address substance use and co-occurring mental health problems in adolescents. Specifically, we compared the effectiveness of two evidence-based treatment programs (Motivational Enhancement Treatment/Cognitive Behavior Therapy, 5 Sessions [MET/CBT5] and Adolescent Community Reinforcement Approach [A-CRA]) for both substance use and mental health outcomes (i.e., crossover effects). We used statistical methods designed to approximate randomized controlled trials when comparing nonequivalent groups using observational study data. Our methods also included an assessment of the potential impact of omitted variables. We found that after applying balancing weighting to ensure similarity of the baseline samples (given the nonrandomized study design), both groups significantly improved on the two substance use outcomes (days abstinent and percent of youth in recovery) and on the two mental health outcomes (post-traumatic stress disorder (PTSD) symptoms and general emotional problems). Youth in A-CRA were significantly more likely to be in recovery at the 3-month follow-up compared to youth in MET/CBT5, but the size of this effect was very small. Youth receiving MET/CBT5 appeared to show significantly more improvement in the two mental health measures compared to youth in A-CRA, though these effect sizes were also very small. The findings indicate that adolescents with co-occurring substance use and mental health problems improve on both substance use and mental health outcomes with both treatments even though they are not specifically targeting mental health problems.

Distress, Impairment, and Racial/Ethnic Differences in Perceived Need for Mental Health Treatment in a Nationally Representative Sample.

OBJECTIVE: To advance our understanding of racial/ethnic differences in help seeking for mental health conditions, this article tests whether differences in serious psychological distress or functional impairment account for racial/ethnic differences in perceived need for treatment. METHOD: Data from the 2009-2014 National Survey of Drug Use and Health, a survey of a nationally representative sample of the U.S. population, were analyzed. Logistic regression models were used to test whether differences in psychological distress, assessed with the Kessler-6, or functional impairment, assessed with the WHO Disability Assessment Scale, account for racial/ethnic differences in perceived need for mental health treatment. RESULTS: Perceived need, psychological distress, and functional impairment all vary significantly across racial/ethnic groups; psychological distress is highest among Hispanics interviewed in English and lowest among Hispanics interviewed in Spanish, while functional impairment is highest among Non-Hispanic Whites and lowest among Hispanics interviewed in Spanish. Associations with perceived need vary across racial/ethnic groups for distress (X2 (5) = 22.14, p = .001), but not for impairment (X2 (5) = 8.73, p = .121). Associations between distress and perceived need are significantly weaker among Hispanics interviewed in Spanish than among Non-Hispanic Whites (OR = 1.13 vs. 1.08, p = .001). Differences across racial/ethnic groups in perceived need are sustained after adjustment for distress and impairment. CONCLUSIONS: Differences in perceived need across racial/ethnic groups are not attributable to differences in distress and impairment. Heterogeneity in the relationships of psychological distress and functional impairment with perceived need for mental health treatment is related to language, a strong indicator of country of birth.

State medical marijuana laws, cannabis use and cannabis use disorder among adults with elevated psychological distress.

BACKGROUND: Cannabis use and cannabis use disorder are more prevalent in U.S. states with medical marijuana laws (MMLs), as well as among individuals with elevated psychological distress. We investigated whether adults with moderate and serious psychological distress experienced greater levels of cannabis use and/or disorder in states with MMLs compared to states without MMLs. METHODS: National Survey of Drug Use and Health data (2013-2017) were used to compare past-month cannabis use, daily cannabis use, and cannabis use disorder prevalence among adults with moderate and serious psychological distress in states with versus without MMLs. We executed pooled multivariable logistic regression analyses to test main effects of distress, MMLs and their interaction, after adjustment. RESULTS: Compared to states without MMLs, states with MMLs had higher adjusted prevalence of past-month use (11.1 % vs. 6.8 %), daily use (4.0 % vs. 2.2 %), and disorder (1.7 % vs. 1.2 %). Adults with moderate and serious psychological distress had greater adjusted odds of any use (AORs of 1.72 and 2.22, respectively) and of disorder (AORs of 2.17 and 2.94, respectively), compared to those with no/mild distress. We did not find evidence of an interaction between MMLs and distress category for any outcome. CONCLUSIONS: Associations between elevated distress and cannabis use patterns are no greater in states with MML. However, cannabis use is more prevalent in MML states. Thus, higher base rates of cannabis use and disorder among adults with elevated distress are proportionally magnified in these states.

Impact on Nonfirearm Deaths of Firearm Laws Affecting Firearm Deaths: A Systematic Review and Meta-Analysis.

Background. There is debate whether policies that reduce firearm suicides or homicides are offset by increases in non-firearm-related deaths.Objectives. To assess the extent to which changes in firearm homicides and suicides following implementation of various gun laws affect nonfirearm homicides and suicides.Search Methods. We performed a literature search on 13 databases for studies published between 1995 and October 31, 2018 (PROSPERO CRD42019120105).Selection Criteria. We included studies if they (1) estimated an effect of 1 of 18 included classes of gun policy on firearm homicides or suicides, (2) included a control group or comparison group and evaluated time series data to establish that policies preceded their purported effects, and (3) provided estimated effects of the policy and inferential statistics for either total or nonfirearm homicides or suicides.Data Collection and Analysis. We extracted data from each study, including study timeframe, population, and statistical methods, as well as point estimates and inferential statistics for the effects of firearm policies on firearm deaths as well as either nonfirearm or overall deaths. We assessed quality at the estimate (study-policy-outcome) level by using prespecified criteria to evaluate the validity of inference and causal identification. For each estimate, we derived the mortality multiplier (i.e., the ratio of the policy's effect on total homicides or suicides; expressed as a change in the number of deaths) as a proportion of its effect on firearm homicides or suicides. Finally, we performed a meta-analysis to estimate overall mortality multipliers for suicide and homicide that account for both within- and between-study heterogeneity.Main Results. We identified 16 eligible studies (study timeframes spanning 1977-2015). All examined state-level policies in the United States, with most estimating effects of multiple policies, yielding 60 separate estimates of the mortality multiplier. From these, we estimated that a firearm law's effect on homicide, expressed as a change in the number of total homicide deaths, is 0.99 (95% confidence interval = 0.76, 1.22) times its effect on the number of firearm homicides. Thus, on average, changes in the number of firearm homicides caused by gun policies are neither offset nor compounded by second-order effects on nonfirearm homicides. There is insufficient evidence in the existing literature on suicide to indicate the extent to which the effects of gun policy changes on firearm suicides are offset or compounded by their effects on nonfirearm suicides.Authors' Conclusions. State gun policies that reduce firearm homicides are likely to reduce overall homicides in the state by approximately the same number. It is currently unknown whether the same holds for state gun policies that significantly reduce firearm suicides. The small number of studies meeting our inclusion criteria, issues of methodological quality within those studies, and the possibility of reporting bias are potential limitations of this review.Public Health Implications. Policies that reduce firearm homicides likely have large benefits for public health as there is little evidence to support a strong substitution effect between firearm and nonfirearm homicides at the population level. Further research is needed to determine whether policies that produce population-level reductions in firearm suicides will translate to overall declines in suicide rates.

Changes in firearm mortality following the implementation of state laws regulating firearm access and use.

Although 39,000 individuals die annually from gunshots in the US, research examining the effects of laws designed to reduce these deaths has sometimes produced inconclusive or contradictory findings. We evaluated the effects on total firearm-related deaths of three classes of gun laws: child access prevention (CAP), right-to-carry (RTC), and stand your ground (SYG) laws. The analyses exploit changes in these state-level policies from 1970 to 2016, using Bayesian methods and a modeling approach that addresses several methodological limitations of prior gun policy evaluations. CAP laws showed the strongest evidence of an association with firearm-related death rate, with a probability of 0.97 that the death rate declined at 6 y after implementation. In contrast, the probability of being associated with an increase in firearm-related deaths was 0.87 for RTC laws and 0.77 for SYG laws. The joint effects of these laws indicate that the restrictive gun policy regime (having a CAP law without an RTC or SYG law) has a 0.98 probability of being associated with a reduction in firearm-related deaths relative to the permissive policy regime. This estimated effect corresponds to an 11% reduction in firearm-related deaths relative to the permissive legal regime. Our findings suggest that a small but meaningful decrease in firearm-related deaths may be associated with the implementation of more restrictive gun policies.

The use of complementary and integrative health approaches for chronic musculoskeletal pain in younger US Veterans: An economic evaluation.

OBJECTIVES: To estimate the cost-effectiveness to the US Veterans Health Administration (VA) of the use of complementary and integrative health (CIH) approaches by younger Veterans with chronic musculoskeletal disorder (MSD) pain. PERSPECTIVE: VA healthcare system. METHODS: We used a propensity score-adjusted hierarchical linear modeling (HLM), and 2010-2013 VA administrative data to estimate differences in VA healthcare costs, pain intensity (0-10 numerical rating scale), and opioid use between CIH users and nonusers. We identified CIH use in Veterans' medical records through Current Procedural Terminology, VA workload tracking, and provider-type codes. RESULTS: We identified 30,634 younger Veterans with chronic MSD pain as using CIH and 195,424 with no CIH use. CIH users differed from nonusers across all baseline covariates except the Charlson comorbidity index. They also differed on annual pre-CIH-start healthcare costs ($10,729 versus $5,818), pain (4.33 versus 3.76), and opioid use (66.6% versus 54.0%). The HLM results indicated lower annual healthcare costs (-$637; 95% CI: -$1,023, -$247), lower pain (-0.34; -0.40, -0.27), and slightly higher (less than a percentage point) opioid use (0.8; 0.6, 0.9) for CIH users in the year after CIH start. Sensitivity analyses indicated similar results for three most-used CIH approaches (acupuncture, chiropractic care, and massage), but higher costs for those with eight or more CIH visits. CONCLUSIONS: On average CIH use appears associated with lower healthcare costs and pain and slightly higher opioid use in this population of younger Veterans with chronic musculoskeletal pain. Given the VA's growing interest in the use of CIH, further, more detailed analyses of its impacts are warranted.