Aaron Kofner

The Effect of Light Rail Transit on Body Mass Index and Physical Activity

BACKGROUND The built environment can constrain or facilitate physical activity. Most studies of the health consequences of the built environment face problems of selection bias associated with confounding effects of residential choice and transportation decisions. PURPOSE To examine the cross-sectional associations between objective and perceived measures of the built environment; BMI; obesity (BMI>30 kg/m(2)); and meeting weekly recommended physical activity (RPA) levels through walking and vigorous exercise. To assess the effect of using light rail transit (LRT) system on BMI, obesity, and weekly RPA levels. METHODS Data were collected on individuals before (July 2006-February 2007) and after (March 2008-July 2008) completion of an LRT system in Charlotte NC. BMI, obesity, and physical activity levels were calculated for a comparison of these factors pre- and post-LRT construction. A propensity score weighting approach adjusted for differences in baseline characteristics among LRT and non-LRT users. Data were analyzed in 2009. RESULTS More-positive perceptions of ones neighborhood at baseline were associated with a -0.36 (p<0.05) lower BMI; 15% lower odds (95% CI=0.77, 0.94) of obesity; 9% higher odds (95% CI=0.99, 1.20) of meeting weekly RPA through walking; and 11% higher odds (95% CI=1.01, 1.22) of meeting RPA levels of vigorous exercise. The use of LRT to commute to work was associated with an average -1.18 reduction in BMI (p<0.05) and an 81% reduced odds (95% CI=0.04, 0.92) of becoming obese over time. CONCLUSIONS The results of this study suggest that improving neighborhood environments and increasing the publics use of LRT systems could provide improvements in health outcomes for millions of individuals.

How Much Does “How Much” Matter? Assessing the Relationship Between Children’s Lifetime Exposure to Violence and Trauma Symptoms, Behavior Problems, and Parenting Stress

The study explores whether and how lifetime violence exposure is related to a set of negative symptoms: child internalizing and externalizing behavior problems, child trauma symptoms, and parenting stress. Using a large sample of violence-exposed children recruited to participate in intervention research, the study employs different methods of measuring that exposure. These include total frequency of all lifetime exposure, total frequency of lifetime exposure by broad category (i.e., assault, maltreatment, sexual abuse, and witnessing violence), and polyvictimization defined as exposure to multiple violence categories. The results indicate that only polyvictimization, constructed as a dichotomous variable indicating two or more categories of lifetime exposure, emerged as a consistent predictor of negative symptoms. The total lifetime frequency of all violence exposure was not associated with negative symptoms, after controlling for the influence of polyvictimization. Likewise, in the presence of a dichotomous polyvictimization indicator the total lifetime frequency of exposure to a particular violence category was unrelated to symptoms overall, with the exception of trauma symptoms and experiences of sexual abuse. Taken together, these findings suggest that total lifetime exposure is not particularly important to negative symptoms, nor is any particular category of exposure after controlling for polyvictimization, with the single exception of sexual abuse and trauma symptoms. Instead, it is the mix of exposure experiences that predict negative impacts on children in this sample. Further research is needed to continue to explore and test these issues.

Implementation of Medical Homes in Federally Qualified Health Centers

BACKGROUND From 2011 through 2014, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration provided care management fees and technical assistance to a nationwide sample of 503 federally qualified health centers to help them achieve the highest (level 3) medical‐home recognition by the National Committee for Quality Assurance, a designation that requires the implementation of processes to improve access, continuity, and coordination. METHODS We examined the achievement of medical‐home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients’ experiences, and Medicare expenditures in demonstration sites versus comparison sites. Using difference‐in‐differences analyses, we compared changes in outcomes in the two groups of sites during a 3‐year period. RESULTS Level 3 medical‐home recognition was awarded to 70% of demonstration sites and to 11% of comparison sites. Although the number of visits to federally qualified health centers decreased in the two groups, smaller reductions among demonstration sites than among comparison sites led to a relative increase of 83 visits per 1000 beneficiaries per year at demonstration sites (P<0.001). Similar trends explained the higher performance of demonstration sites with respect to annual eye examinations and nephropathy tests (P<0.001 for both comparisons); there were no significant differences with respect to three other process measures. Demonstration sites had larger increases than comparison sites in emergency department visits (30.3 more per 1000 beneficiaries per year, P<0.001), inpatient admissions (5.7 more per 1000 beneficiaries per year, P=0.02), and Medicare Part B expenditures (

Evaluation of CMS' FQHC APCP Demonstration: Final First Annual Report

37 more per beneficiary per year, P=0.02). Demonstration‐site participation was not associated with relative improvements in most measures of patients’ experiences. CONCLUSIONS Demonstration sites had higher rates of medical‐home recognition and smaller decreases in the number of patients’ visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. Demonstration sites had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. (Funded by the Centers for Medicare and Medicaid Services.)

Federally Qualified Health Center Clinicians And Staff Increasingly Dissatisfied With Workplace Conditions

The statements contained in the report are solely those of the authors and do not necessarily reflect the views or policies of the Centers for Medicare & Medicaid Services. The RAND Corporation assumes responsibility for the accuracy and completeness of the information contained in the report. This document may not be cited, quoted, reproduced or transmitted without the permission of the RAND Corporation. RANDs publications do not necessarily reflect the opinions of its research clients and sponsors. RAND® is a registered trademark.

The Influence of Training, Reluctance, Efficacy, and Stigma on Suicide Intervention Behavior Among NCOs in the Army and Marine Corps

Better working conditions for clinicians and staff could help primary care practices implement delivery system innovations and help sustain the US primary care workforce. Using longitudinal surveys, we assessed the experience of clinicians and staff in 296 clinical sites that participated in the Centers for Medicare and Medicaid Services (CMS) Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration. Participating FQHCs were expected to achieve, within three years, patient-centered medical home recognition at level 3-the highest level possible. During 2013-14, clinicians and staff in these FQHCs reported statistically significant declines in multiple measures of professional satisfaction, work environment, and practice culture. There were no significant improvements on any surveyed measure. These findings suggest that working conditions in FQHCs have deteriorated recently. Whether findings would be similar in other primary care practices is unknown. Although we did not identify the causes of these declines, possible stressors include the adoption of health information technology, practice transformation, and increased demand for services.

Evaluation of CMS's Federally Qualified Health Center (FQHC) Advanced Primary Care Practice (APCP) Demonstration: Final Report

The Army and Marine Corps have consistently experienced the highest rates of suicide relative to the other services. In both the Army and Marine Corps, the service members responsible for identifying and referring individuals at risk for suicide are called “gatekeepers” and are typically noncommissioned officers (NCOs). We used structural equation modeling on survey responses from 1184 Army soldiers and 796 marines to estimate the relationships between training, intervention efficacy, reluctance, and mental health stigma on NCO intervention behaviors. Efficacy and reluctance were independently associated with intervention behaviors, and stigma was only associated with intervention behaviors among Army NCOs. Study results suggest that while quantity of training may help NCOs feel more confident about their ability to intervene, other efforts such as changing training content and delivery mode (e.g., interactive vs. didactic training) may be necessary in order to reduce reluctance and stigma to intervene with service members at risk for suicide.

Youth victimization profiles and change in mental health symptoms over one year

The statements contained in the report are solely those of the authors and do not necessarily reflect the views or policies of the Centers for Medicare & Medicaid Services. The RAND Corporation assumes responsibility for the accuracy and completeness of the information contained in the report. This document may not be cited, quoted, reproduced or transmitted without the permission of the RAND Corporation. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. RAND® is a registered trademark.

Evaluation of the Mental Health Services Act in Los Angeles County: Implementation and Outcomes for Key Programs

Objective: To understand how youth PTSD symptoms and externalizing problems emerge and change over time for youth with different profiles of victimization, including polyvictimization. Method: We conducted a latent class analysis (LCA) to identify empirically derived victimization profiles in a sample of 2,776 youth who participated in an evaluation study. We then conducted growth curve analyses to determine whether these victimization profiles predicted change in the course of PTSD symptoms and externalizing problems over a 1-year time period for youth engaged in a variety of community-based services. Results: The LCA revealed three profiles: a low victimization profile defined by relatively low endorsement of victimization across types; a witnessing profile defined by particularly high endorsement of witnessing violence; and a polyvictimization profile defined by high endorsement of multiple types of victimization. We found that overall, despite differing initial levels of PTSD symptoms and externalizing problems, all three groups’ symptoms improved over the year, but the polyvictimization class generally showed the steepest decreases, particularly in caregiver-reported PTSD symptoms. Conclusion: Polyvictimized youth participating in community-based services are at increased risk for developing PTSD and externalizing problems, but symptoms appear to decrease to levels similar to other victimized youth after one year.

The Mental Health Services Act in Los Angeles County: Evaluating Program Reach and Outcomes

Los Angeles County used Mental Health Services Act (MHSA) funds to greatly expand access to Full-Service Partnership (FSP) services and offer new prevention and early intervention (PEI) services. This study examines the reach of key MHSA-funded activities and what the impact of those activities has been, with a focus on PEI programs for children and transition-age youth (TAY) and FSP programs for children, TAY, and adults. The evaluation found evidence that the Los Angeles County Department of Mental Health (LAC DMH) is reaching the highly vulnerable population it seeks to reach with its FSP and youth PEI programs. Furthermore, those reached by the programs experience improvements in their mental health and life circumstances. Refining data collection will enable more-thorough evaluation of processes of care and would inform the programs quality-improvement efforts.