Understanding forms of childhood adversities and associations with adult health outcomes: A regression tree analysis.

BACKGROUND: Empirical studies have demonstrated associations between ten original adverse childhood experiences (ACEs) and multiple health outcomes. Identifying expanded ACEs can capture the burden of other childhood adversities that may have important health implications. OBJECTIVE: We sought to identify childhood adversities that warrant consideration as expanded ACEs. We hypothesized that experiencing expanded and original ACEs would be associated with poorer adult health outcomes compared to experiencing original ACEs alone. PARTICIPANTS: The 11,545 respondents of the National Longitudinal Surveys (NLS) and Child and Young Adult Survey were 48.9 % female, 22.7 % Black, 15.8 % Hispanic, 36.1 % White, 1.7 % Asian/Native Hawaiian/Pacific Islander/Native American/Native Alaskan, and 7.5 % Other. METHODS: This study used regression trees and generalized linear models to identify if/which expanded ACEs interacted with original ACEs in association with six health outcomes. RESULTS: Four expanded ACEs-basic needs instability, lack of parental love and affection, community stressors, and mother's experience with physical abuse during childhood -significantly interacted with general health, depressive symptom severity, anxiety symptom severity, and violent crime victimization in adulthood (all p-values <0.005). Basic needs instability and/or lack of parental love and affection emerged as correlates across multiple outcomes. Experiencing lack of parental love and affection and original ACEs was associated with greater anxiety symptoms (p = 0.022). CONCLUSIONS: This is the first study to use supervised machine learning to investigate interaction effects among original ACEs and expanded ACEs. Two expanded ACEs emerged as predictors for three adult health outcomes and warrant further consideration in ACEs assessments.

Adaptive selection of the optimal strategy to improve precision and power in randomized trials.

Benkeser et al. demonstrate how adjustment for baseline covariates in randomized trials can meaningfully improve precision for a variety of outcome types. Their findings build on a long history, starting in 1932 with R.A. Fisher and including more recent endorsements by the U.S. Food and Drug Administration and the European Medicines Agency. Here, we address an important practical consideration: how to select the adjustment approach-which variables and in which form-to maximize precision, while maintaining Type-I error control. Balzer et al. previously proposed Adaptive Pre-specification within TMLE to flexibly and automatically select, from a prespecified set, the approach that maximizes empirical efficiency in small trials (N < 40). To avoid overfitting with few randomized units, selection was previously limited to working generalized linear models, adjusting for a single covariate. Now, we tailor Adaptive Pre-specification to trials with many randomized units. Using V-fold cross-validation and the estimated influence curve-squared as the loss function, we select from an expanded set of candidates, including modern machine learning methods adjusting for multiple covariates. As assessed in simulations exploring a variety of data-generating processes, our approach maintains Type-I error control (under the null) and offers substantial gains in precision-equivalent to 20%-43% reductions in sample size for the same statistical power. When applied to real data from ACTG Study 175, we also see meaningful efficiency improvements overall and within subgroups.

Impact of State Stroke Systems of Care Laws on Stroke Outcomes.

Since 2003, 38 US states and Washington, DC have adopted legislation and/or regulations to strengthen stroke systems of care (SSOCs). This study estimated the impact of SSOC laws on stroke outcomes. We used a coded legal dataset of 50 states and DC SSOC laws (years 2003-2018), national stroke accreditation information (years 1997-2018), data from the Healthcare Cost and Utilization Project (years 2012-2018), and National Vital Statistics System (years 1979-2019). We applied a natural experimental design paired with longitudinal modeling to estimate the impact of having one or more SSOC policies in effect on outcomes. On average, states with one or more SSOC policies in effect achieved better access to primary stroke centers (PSCs) than expected without SSOC policies (ranging from 2.7 to 8.0 percentage points (PP) higher), lower inpatient hospital costs (USD 610-1724 less per hospital stay), lower age-adjusted stroke mortality (1.0-1.6 fewer annual deaths per 100,000), a higher proportion of stroke patients with brain imaging results within 45 min of emergency department arrival (3.6-5.0 PP higher), and, in some states, lower in-hospital stroke mortality (5 fewer deaths per 1000). Findings were mixed for some outcomes and there was limited evidence of model fit for others. No effect was observed in racial and/or rural disparities in stroke mortality.

The Effectiveness of Active Learning Strategies in Gatekeeper Training on Behavioral Outcomes.

Background: Studies of suicide prevention gatekeeper trainings (GKT) show temporary enhancements in short-term behavioral outcomes and limited enhancements in intermediate behavioral outcomes. Aims: We aimed to examine the impact of two training enhancements (role-play and booster) on intermediate GKT outcomes. Method: The study used a factorial randomized controlled design to assign participants to one of four groups. Three indicators of gatekeeper behavior at 6-month follow-up were the primary outcomes of interest. We used propensity score-based techniques to address observed imbalances. Results: At 6 months, among participants assigned to role-play, a significantly larger proportion of those assigned to booster performed identifications and referrals followed by a notification to the referral source, and followed by escorting the youth to the resource. Limitations: While observed imbalances were addressed, unobserved differences may persist. The validity of self-reported indicators to measure actual behavior remains unknown. Conclusion: Results suggest that active learning strategies can, in combination, enhance the effectiveness of trainings. The strategies seem to increase the comprehensiveness of gatekeeper behaviors.

Long-term impact of the Garrett Lee Smith Youth Suicide Prevention Program on youth suicide mortality, 2006-2015.

BACKGROUND: Comprehensive suicide prevention programs funded through the Garrett Lee Smith Memorial Youth Suicide Prevention Program (GLS) have previously been shown to be associated with lower youth suicide mortality rates 1 year following program implementation. However, longer term effects of GLS have yet to be examined. METHODS: The impact of GLS implementation on youth suicide mortality through 2015 was estimated for U.S. counties initially exposed to state and tribal GLS activities between 2006 and 2009. The analytic approach combined propensity score-based techniques to address potential confounding arising from differences between counties exposed and not exposed to the program along an extensive set of characteristics, including historical suicide rates. RESULTS: Counties exposed to GLS during a single year had youth suicide mortality rates lower than expected and for longer than previously reported following implementation of GLS activities. Youth suicide mortality rates in counties implementing GLS were estimated to be 0.9 per 100,000 youths lower than control counties (p = .029) 1 year after the implementation, and 1.1 per 100,000 youths lower than control counties (p = .010) 2 years after the implementation. Further, persistent implementation during multiple years was associated with larger effects during longer periods. Additionally, among rural counties, the youth suicide rates 2 years after exposure were estimated to be 2.4 per 100,000 youths lower than in the absence of the program (p = .003). There was no significant evidence of a decrease in youth suicide rates three or more years after the GLS activities were discontinued. CONCLUSIONS: The effects of GLS comprehensive suicide prevention program were found to be stronger and longer lasting than previously reported, particularly in rural counties. In the face of well-documented increases in national suicide prevention rates, these results support the widespread and persistent implementation of comprehensive, community-based youth suicide prevention programs.

Comparing the Effectiveness of Brief Versus In-Depth Gatekeeper Training on Behavioral Outcomes for Trainees.

BACKGROUND: A common suicide prevention strategy is training gatekeepers to identify at-risk individuals and refer them to services. AIMS: The study aimed to examine whether differences in training outcomes were observed for brief versus in-depth gatekeeper trainings for trainees from varied professional settings while controlling for differences in trainee characteristics and community context. METHOD: Trainees' identification and referral behavior 3 months after gatekeeper training was compared with a sample of respondents matched on individual- and community-level variables using propensity score-based techniques. The value was estimated, in terms of additional identification and associated costs, of adopting in-depth training. RESULTS: A higher proportion of trainees who participated in in-depth trainings from K-12 and community settings identified at-risk youth, and a higher proportion of in-depth trainees from mental health settings referred youth to services compared with participants of brief trainings from the same setting and with similar characteristics. The effect of training type on outcomes varied by professional role and community context. LIMITATIONS: Self-report measures were used to assess outcomes. Similar measures are used in other studies; their validity has not been conclusively established. CONCLUSION: Findings suggest certain individuals may benefit from in-depth training more than others, which favors targeting this intervention to particular gatekeepers.

Examining the Unanticipated Adverse Consequences of Youth Suicide Prevention Strategies: A Literature Review with Recommendations for Prevention Programs.

OBJECTIVE: Youth suicide is a public health problem in the United States. Suicide prevention programs have been shown to be beneficial; however, knowledge of unanticipated adverse consequences of programs is limited. The objective of this review is to present what is known about these consequences so informed decisions and appropriate planning can be made prior to implementation of suicide prevention interventions. METHOD: A narrative but systematic review was conducted assessing what is known about adverse consequences utilizing a comprehensive keyword search of EBSCO and PubMed databases. Study populations beyond youth were included. RESULTS: Unanticipated adverse consequences of suicide prevention interventions were included in 22 publications. Consequences occur at three levels: at the level of the youth, those who identify or intervene with at-risk youth, and at the system level. While rare, unanticipated adverse consequences include an increase in maladaptive coping and a decrease in help-seeking among program targets, overburden or increased suicide ideation among program implementers, and inadequate systemic preparedness. CONCLUSIONS: Overall, the benefits of youth suicide prevention outweigh the unanticipated adverse consequences. Nevertheless, these results may be utilized for informed decision-making regarding suicide prevention programming, and to ensure appropriate infrastructure is in place prior to prevention efforts.

An Economic Evaluation of the Garrett Lee Smith Memorial Suicide Prevention Program.

For more than a decade, the Garrett Lee Smith Youth Suicide Prevention Program has provided funding for community-based suicide prevention programs to states, tribes, and colleges across the United States. Recent studies provided evidence of the program's effectiveness in reducing suicide mortality and suicide attempts among youth. This study compares the cost of implementing the program with the estimated savings resulting from avoided hospitalization and emergency department visits associated with the averted suicide attempts. The findings suggest that the cost of implementing multifaceted community-based suicide prevention strategies may be more than outweighed by savings in the health sector.

Effect of the Garrett Lee Smith Memorial Suicide Prevention Program on Suicide Attempts Among Youths.

IMPORTANCE: Youth suicide prevention is a major public health priority. Studies documenting the effectiveness of community-based suicide prevention programs in reducing the number of nonlethal suicide attempts have been sparse. OBJECTIVE: To determine whether a reduction in suicide attempts among youths occurs following the implementation of the Garrett Lee Smith Memorial Suicide Prevention Program (hereafter referred to as the GLS program), consistent with the reduction in mortality documented previously. DESIGN, SETTING, AND PARTICIPANTS: We conducted an observational study of community-based suicide prevention programs for youths across 46 states and 12 tribal communities. The study compared 466 counties implementing the GLS program between 2006 and 2009 with 1161 counties that shared key preintervention characteristics but were not exposed to the GLS program. The unweighted rounded numbers of respondents used in this analysis were 84 000 in the control group and 57 000 in the intervention group. We used propensity score-based techniques to increase comparability (on background characteristics) between counties that implemented the GLS program and counties that did not. We combined information on program activities collected by the GLS national evaluation with information on county characteristics from several secondary sources. The data analysis was performed between April and August 2014. P < .05 was considered statistically significant. EXPOSURES: Comprehensive, multifaceted suicide prevention programs, including gatekeeper training, education and mental health awareness programs, screening activities, improved community partnerships and linkages to service, programs for suicide survivors, and crisis hotlines. MAIN OUTCOMES AND MEASURES: Suicide attempt rates for each county following implementation of the GLS program for youths 16 to 23 years of age at the time the program activities were implemented. We obtained this information from the National Survey on Drug Use and Health administered to a large national probabilistic sample between 2008 and 2011. RESULTS: Counties implementing GLS program activities had significantly lower suicide attempt rates among youths 16 to 23 years of age in the year following implementation of the GLS program than did similar counties that did not implement GLS program activities (4.9 fewer attempts per 1000 youths [95% CI, 1.8-8.0 fewer attempts per 1000 youths]; P = .003). More than 79 000 suicide attempts may have been averted during the period studied following implementation of the GLS program. There was no significant difference in suicide attempt rates among individuals older than 23 years during that same period. There was no evidence of longer-term differences in suicide attempt rates. CONCLUSIONS AND RELEVANCE: Comprehensive GLS program activities were associated with a reduction in suicide attempt rates. Sustained suicide prevention programming efforts may be needed to maintain the reduction in suicide attempt rates.

Evaluating the effects of community-based organization engagement on HIV and AIDS-related risk behavior in Kenya.

International donors have increasingly shifted AIDS funding directly to community-based organizations (CBOs) with the assumption that responding to the epidemic is best achieved at the community level. The World Bank, ICF Macro, and the National Council for Population and Development in Kenya, conducted a study to evaluate the community response in Kenya. The study used a quasi-experimental design comparing seven study communities and seven comparison communities in Nyanza Province and Western Province. We examined the impact of CBO activity on individual and community-level outcomes, including HIV knowledge, awareness and perceptions, sexual risk behavior, and social transformation (gender ideology and social capital). The study consisted of two components: a household survey conducted in all 14 communities, and qualitative data collected in a subset of communities. Individuals in communities with higher CBO engagement were significantly more likely to have reported consistent condom use. Higher CBO engagement was associated with some measures of social capital, including participation in local and national elections, and participation in electoral campaigns. CBOs provide added value in addressing the HIV and AIDS epidemic in very targeted and specific ways that are closely tied to the services they provide (e.g., prevention education); thus, increasing CBO engagement can be an effective measure in scaling up prevention efforts in those areas.

Estrategias económicas y financiamiento del medicamemnto / Economics strategies and medicament finanancing

Los esfuerzos por regular el mercado de medicamentos se incrementaron durante la última década, y en especial en los países desarrollados. El presente artículo analiza las experiencias obtenidas en aquellos esfuerzos regulatorios y presenta un conjunto de herramientas y estrategias útiles para la formulación de políticas de regulación del mercado de medicamentos. Las medidas de política son presentadas distinguiéndose sus objetivos, su operación y sus mecanismos de implemetación. Aunque el abanico de alternativas remite mayormente a la experienciade países desarrollados como Estados Unidos y países de Europa, se intenta también una síntesis del estado actual de la cuestión en países de America Latina

Estrategias económicas y financiamiento del medicamemnto / Economics strategies and medicament finanancing

Los esfuerzos por regular el mercado de medicamentos se incrementaron durante la última década, y en especial en los países desarrollados. El presente artículo analiza las experiencias obtenidas en aquellos esfuerzos regulatorios y presenta un conjunto de herramientas y estrategias útiles para la formulación de políticas de regulación del mercado de medicamentos. Las medidas de política son presentadas distinguiéndose sus objetivos, su operación y sus mecanismos de implemetación. Aunque el abanico de alternativas remite mayormente a la experienciade países desarrollados como Estados Unidos y países de Europa, se intenta también una síntesis del estado actual de la cuestión en países de America Latina(AU)

Políticas de Medicamentos: Estrategias para mejorar el acceso a los medicamentos

El presente informe reseña los principales resultados de la investigación realizada, que indaga el comportamiento de un conjunto de variables presumiblemente asociadas a los resultados de la política de medicamentos. Analiza los efectos de los cambios en el marco regulatorio nacional y provincial respecto de la utilización del nombre genérico sobre las prácticas de prescripción y dispensación. Explora pautas de utilización de servicios de salud, en particular Medicamentos, de la población genera . Explorar fenómenos vinculados al acto de compra que puedan condicionar el resultado de la política de medicamentos (promoción del uso del nombre genérico, cambios en el esquema de cobertura de obras sociales), cómo también la asociación entre características de la oferta de medicamentos y resultados de la política de medicamentos .El propósito es identificar nuevas estrategias para mejorar el acceso de la población a los medicamentos.