David S. Salkever

Evaluation of Hawaii's Healthy Start Program

Hawaiis Healthy Start Program (HSP) is designed to prevent child abuse and neglect and to promote child health and development in newborns of families at risk for poor child outcomes. The program operates statewide in Hawaii and has inspired national and international adaptations, including Healthy Families America. This article describes HSP, its ongoing evaluation study, and evaluation findings at the end of two of a planned three years of family program participation and follow-up. After two years of service provision to families, HSP was successful in linking families with pediatric medical care, improving maternal parenting efficacy, decreasing maternal parenting stress, promoting the use of nonviolent discipline, and decreasing injuries resulting from partner violence in the home. No overall positive program impact emerged after two years of service in terms of the adequacy of well-child health care; maternal life skills, mental health, social support, or substance use; child development; the childs home learning environment or parent-child interaction; pediatric health care use for illness or injury; or child maltreatment (according to maternal reports and child protective services reports). However, there were agency-specific positive program effects on several outcomes, including parent-child interaction, child development, maternal confidence in adult relationships, and partner violence. Significant differences were found in program implementation between the three administering agencies included in the evaluation. These differences had implications for family participation and involvement levels and, possibly, for outcomes achieved. The authors conclude that home visiting programs and evaluations should monitor program implementation for faithfulness to the program model, and should employ comparison groups to determine program impact.

Alcohol Interventions for Trauma Patients Treated in Emergency Departments and Hospitals: A Cost Benefit Analysis

Objective:To determine if brief alcohol interventions in trauma centers reduce health care costs. Summary Background Data:Alcohol-use disorders are the leading cause of injury. Brief interventions in trauma patients reduce subsequent alcohol intake and injury recidivism but have not yet been widely implemented. Methods:This was a cost-benefit analysis. The study population consisted of injured patients treated in an emergency department or admitted to a hospital. The analysis was restricted to direct injury-related medical costs only so that it would be most meaningful to hospitals, insurers, and government agencies responsible for health care costs. Underlying assumptions used to arrive at future benefits, including costs, injury rates, and intervention effectiveness, were derived from published nationwide databases, epidemiologic, and clinical trial data. Model parameters were examined with 1-way sensitivity analyses, and the cost-benefit ratio was calculated. Monte Carlo analysis was used to determine the strategy-selection confidence intervals. Results:An estimated 27% of all injured adult patients are candidates for a brief alcohol intervention. The net cost savings of the intervention was

A nationwide US study of post-traumatic stress after hospitalization for physical injury

89 per patient screened, or

The Value of Trauma Center Care

330 for each patient offered an intervention. The benefit in reduced health expenditures resulted in savings of

The use of dummy variables to compute predictions, prediction errors, and confidence intervals

3.81 for every

The Supply of Charity Services by Nonprofit Hospitals: Motives and Market Structure

1.00 spent on screening and intervention. This finding was robust to various assumptions regarding probability of accepting an intervention, cost of screening and intervention, and risk of injury recidivism. Monte Carlo simulations found that offering a brief intervention would save health care costs in 91.5% of simulated runs. If interventions were routinely offered to eligible injured adult patients nationwide, the potential net savings could approach

The Impact of Certificate-of Need Controls on Hospital Investment

1.82 billion annually. Conclusions:Screening and brief intervention for alcohol problems in trauma patients is cost-effective and should be routinely implemented.

Measures and Predictors of Community-Based Employment and Earnings of Persons With Schizophrenia in a Multisite Study

BACKGROUND Injured survivors of individual and mass trauma are at risk for developing post-traumatic stress disorder (PTSD). Few investigations have assessed PTSD after injury in large samples across diverse acute care hospital settings. METHOD A total of 2931 injured trauma survivors aged 18-84 who were representative of 9983 in-patients were recruited from 69 hospitals across the USA. In-patient medical records were abstracted, and hospitalized patients were interviewed at 3 and 12 months after injury. Symptoms consistent with a DSM-IV diagnosis of PTSD were assessed with the PTSD Checklist (PCL) 12 months after injury. RESULTS Approximately 23% of injury survivors had symptoms consistent with a diagnosis of PTSD 12 months after their hospitalization. Greater levels of early post-injury emotional distress and physical pain were associated with an increased risk of symptoms consistent with a PTSD diagnosis. Pre-injury, intensive care unit (ICU) admission [relative risk (RR) 1.17, 95% confidence interval (CI) 1.02-1.34], pre-injury depression (RR 1.33, 95% CI 1.15-1.54), benzodiazepine prescription (RR 1.46, 95% CI 1.17-1.84) and intentional injury (RR 1.32, 95% CI 1.04-1.67) were independently associated with an increased risk of symptoms consistent with a PTSD diagnosis. White injury survivors without insurance demonstrated approximately twice the rate of symptoms consistent with a diagnosis of PTSD when compared to white individuals with private insurance. By contrast, for Hispanic injury survivors PTSD rates were approximately equal between uninsured and privately insured individuals. CONCLUSIONS Nationwide in the USA, more than 20% of injured trauma survivors have symptoms consistent with a diagnosis of PTSD 12 months after acute care in-patient hospitalization. Coordinated investigative and policy efforts could target mandates for high-quality PTSD screening and intervention in acute care medical settings.

Impacts of age of onset of substance use disorders on risk of adult incarceration among disadvantaged urban youth: a propensity score matching approach.

BACKGROUND The cost of trauma center care is high, raising questions about the value of a regionalized approach to trauma care. To address these concerns, we estimate 1-year and lifetime treatment costs and measure the cost-effectiveness of treatment at a Level I trauma center (TC) compared with a nontrauma center hospital (NTC). METHODS Estimates of cost-effectiveness were derived using data on 5,043 major trauma patients enrolled in the National Study on Costs and Outcomes of Trauma, a prospective cohort study of severely injured adult patients cared for in 69 hospitals in 14 states. Data on costs were derived from multiple sources including claims data from the Centers for Medicare and Medicaid Services, UB92 hospital bills, and patient interviews. Cost-effectiveness was estimated as the ratio of the difference in costs (for treatment at a TC vs. NTC) divided by the difference in life years gained (and lives saved). We also measured cost-effectiveness per quality-adjusted life year gained where quality of life was measured using the SF-6D. We used inverse probability of treatment weighting to adjust for observable differences between patients treated at TCs and NTCs. RESULTS The added cost for treatment at a TC versus NTC was

Children's Health Problems and Maternal Work Status

36,319 per life-year gained (