Timing of social distancing policies and COVID-19 mortality: county-level evidence from the U.S.

Using county-level data on COVID-19 mortality and infections, along with county-level information on the adoption of non-pharmaceutical interventions (NPIs), we examine how the speed of NPI adoption affected COVID-19 mortality in the United States. Our estimates suggest that adopting safer-at-home orders or non-essential business closures 1 day before infections double can curtail the COVID-19 death rate by 1.9%. This finding proves robust to alternative measures of NPI adoption speed, model specifications that control for testing, other NPIs, and mobility and across various samples (national, the Northeast, excluding New York, and excluding the Northeast). We also find that the adoption speed of NPIs is associated with lower infections and is unrelated to non-COVID deaths, suggesting these measures slowed contagion. Finally, NPI adoption speed appears to have been less effective in Republican counties, suggesting that political ideology might have compromised their efficacy.

Investing Early: Taking Stock of Outcomes and Economic Returns from Early Childhood Programs.

The past two decades have been characterized by a growing body of research from diverse disciplines-child development, psychology, neuroscience, and economics, among others-demonstrating the importance of establishing a strong foundation in the early years of life. The research evidence has served to document the range of early childhood services that can successfully put children and families on the path toward lifelong health and well-being, especially those at greatest risk of poor outcomes. As early childhood interventions have proliferated, researchers have evaluated whether the programs improve children's outcomes and, when they do, whether the improved outcomes generate benefits that can outweigh the program costs. This study examines a set of evaluations that meet criteria for scientific rigor and synthesizes their results to better understand the outcomes, costs, and benefits of early childhood programs. The authors focus on evaluations of 115 early childhood programs serving children or parents of children from the prenatal period to age 5. Although preschool is perhaps the best-known early childhood intervention, the study also reviewed such programs as home visiting, parent education, government transfers providing cash and in-kind benefits, and those that use a combination of approaches. The findings demonstrate that most of the reviewed programs have favorable effects on at least one child outcome and those with an economic evaluation tend to show positive economic returns. With this expanded evidence base, policymakers can be highly confident that well-designed and -implemented early childhood programs can improve the lives of children and their families.

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

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

Modifying State Laws for Nurse Practitioners and Physician Assistants Can Reduce Cost Of Medical Services.

"Bending the cost curve" for health care services in the United States challenges policymakers. A cost analysis was undertaken based on what would occur if more physician assistants (PAs) and nurse practitioners (NPs) per capita were deployed over a 10-year period. The State of Alabama was used as a case study because it is one of a handful of U.S. states with restrictive legislation impacting the scope of practice of PAs and NPs. Changing PA and NP scope of practice legislation in Alabama to match states in the upper quartile of collaborative legislation such as Washington and Arizona would increase the employment and distribution of PAs and NPs. Even modest changes in legislation will result in a net savings of $729 million over the 10-year period. Underutilization of PAs and NPs by restrictive licensure inhibits the cost benefits of increasing the supply of PAs and NPs and reducing the reliance on a stagnant supply of primary care physicians in meeting the needs of its citizens.

Doctor of nursing practice by 2015: an examination of nursing schools' decisions to offer a doctor of nursing practice degree.

OBJECTIVES: The American Association of Colleges of Nursing recommends that nursing schools transition their advanced practice registered nurse (APRN) programs to doctor of nursing practice (DNP) programs by 2015. However, most schools have not yet made this full transition. The purpose of this study was to understand schools' decisions regarding the full transition to the DNP. METHODS: Key informant interviews and an online survey of nursing school deans and program directors were performed. DISCUSSION: The vast majority of schools value the DNP in preparing APRNs for the future of the health care system. However, other important factors influence many schools to fully transition or not to the postbaccalaureate DNP, including perceived student and employer demand, issues concerning accreditation and certification, and resource constraints. CONCLUSION: Multiple pathways to becoming an APRN are likely to remain until various factors (e.g., student and employer demand, certification and accreditation issues, and resource constraints) yield a more favorable environment for a full transition to the DNP.

The DNP by 2015: A Study of the Institutional, Political, and Professional Issues that Facilitate or Impede Establishing a Post-Baccalaureate Doctor of Nursing Practice Program.

In 2004, members of the American Association of Colleges of Nursing (AACN) voted to endorse a position statement identifying the doctor of nursing practice (DNP) degree as the most appropriate degree for advanced-practice registered nurses (APRNs) to enter practice. At the same time, AACN members voted to approve the position that all master's programs that educate APRNs to enter practice should transition to the DNP by 2015. While the number of DNP programs for APRNs has grown significantly and steadily over this period, at this time, not all nursing schools have made this transition. To better understand why, the AACN contracted with RAND to investigate schools' progress toward this goal and the factors that facilitate or impede this transition. This article describes the results of a mixed-method RAND study undertaken between October 2013 and April 2014 that sought to understand schools' program offerings to prepare APRNs to enter practice and the reasons for those offerings, as well as the barriers or facilitators to nursing schools' full adoption of the DNP.

The 2013 census of licensed physician assistants.

A census of physician assistants in the United States is necessary to help legislators make policy decisions about the profession. In 2013, a PA status analysis was undertaken using a novel data source derived from state licensure. The Provider 360 Database was probed for all licensed PAs, and 84,064 were identified. Duplicates, sanctioned, deceased, and dual-licensed were reconciled. In the aggregate, the mean age was 42 years (median 45; mode 32; range 22-74) and 75% of US licensed PAs were women. Statewide distribution per capita ranged from 60 per 100,000 in Alaska to 3.9 per 100,000 in Mississippi; the US mean was 26.8. The robustness of this database draws on active licensure data to identify clinically active PAs. Such refinements and details contribute to health workforce research such as census, modeling, retirement trends, and labor participation rates.

Supply of physician assistants: 2013-2026.

As part of healthcare reform, physician assistants (PAs) are needed to help mitigate the physician shortage in the United States. This requires understanding the population of clinically active PAs for accurate prediction purposes. An inventory projection model of PAs drew on historical trends, the PA stock, graduation estimates, retirement trends, and PA intent to retire data. A new source of licensed health professionals, Provider 360 Database, was obtained to augment association information. Program growth and graduate projections indicated an annual 4.7% trend in new entrants to the workforce, offset by annual attrition estimates of 2.9%. As of 2013, there were 84,064 licensed PAs in the United States. The stock and flow equation conservatively predicts the supply of PAs to be 125,847 by 2026. Although the number of clinically active PAs is projected to increase at least by half by 2026, substantial gaps remain in understanding career trends and early attrition influences. Furthermore, education production could be constrained by inadequate clinical training sites and scarcity of faculty.