Federal Fiscal Years Research Articles

Differing needs for Advance Care Planning in the Veterans Health Administration: use of latent class analysis to identify subgroups to enhance Advance Care Planning via Group Visits for veterans

BackgroundAdvance Care Planning via Group Visits (ACP-GV) is a patient-centered intervention facilitated by a clinician using a group modality to promote healthcare decision-making among veterans. Participants in the group document a “Next Step” to use in planning for their future care needs. The next step may include documentation of preferences in an advance directive, discussing plans with family, or anything else to fulfill their ACP needs. This evaluation seeks to determine whether there are identifiable subgroups of group participants with differing needs prior to delivery of the ACP-GV program and, if so, to use information about the subgroups to enhance the program offered to veterans in United States Department of Veterans Affairs (VA) healthcare settings.MethodsWe conducted a secondary analysis of national data from a quality improvement evaluation. Patient- and provider-level data from administrative healthcare records for VA users in all 50 states, territories, and the District of Columbia provides data on veterans attending ACP-GV during federal fiscal years 2018–2022 (N = 26,857). Latent class analysis seeks to identify the various subgroups of veterans based on their level of ACP self-efficacy before attending ACP-GV and any demographic differences across the resulting subgroups of veterans attending ACP-GV. ACP self-efficacy is derived from seven items obtained from a participant worksheet used during the group.ResultsAnalysis revealed two distinct groups of veterans, distinguishable by their pre-ACP-GV levels of one aspect of ACP self-efficacy: prior knowledge of ACP. Veterans with higher prior knowledge of ACP are associated with an identified next step focused on checking their current AD status and updating it, and veterans with lower ACP prior knowledge are associated with identifying a next step to discuss ACP more fully with family. Differences in age, sex, race, ethnicity, and marital status exist across subgroups of veterans.ConclusionGreater attention must be paid to ACP and veterans’ prior knowledge of ACP to consistently encourage annual review and status updates.

Average Daily Dose Trajectories for Episodes of Buprenorphine Treatment for Opioid Use Disorder.

High-dose (≥24 mg) buprenorphine daily doses (BDD) may be important in treating patients with opioid use disorder (OUD) to improve retention and prevent overdose, particularly in the context of increased illicit fentanyl use. This study sought to: (1) identify trajectories for average BDD among patients initiating buprenorphine treatment for OUD and (2) assess patient characteristics associated with these identified trajectories. Buprenorphine treatment episodes among patients in the US Veterans Healthcare Administration (VHA) from federal fiscal years 2006 to 2020 were identified. Group-based trajectory modeling (GBTM) was used to identify BDD trajectories based on weekly averages of BDD over the 180 days after buprenorphine episode initiation. A total of 79 303 buprenorphine treatment episodes among 44 583 patients were included in the analytic sample. GBTM identified 9 latent trajectories for BDD: (1) moderate dose, early discontinuation (10.1%), (2) moderate dose, delayed discontinuation (4.5%), (3) moderate dose, moderate-paced discontinuation (5.2%), (4) low-moderate dose, delayed discontinuation (7.0%), and (5) low-moderate dose, early discontinuation (21.1%), (6) low dose retention (9.6%), (7) low-moderate dose retention (16.7%), (8) moderate dose retention (18.6%), and (9) high dose retention (7.4%). Patient BDD can broadly be characterized as low [2-4 mg/day], low-moderate (6-8 mg/day), moderate (12-18 mg/day), and high dose (≥ 24 mg/day). Patients with episodes in the high BDD trajectory have the lowest social risk (eg, lowest rate of past-year history of homelessness) and the lowest diagnosed rate of physical and mental health-related comorbidities compared to those following other trajectories. BDD ranges widely and patient characteristics are significantly different between those episodes following differing BDD trajectories. Future research on the association between BDD and subsequent patient outcomes (eg, overdose) needs to carefully consider these differences in baseline characteristics.

Alzheimer's disease and related dementia diagnoses among American Indian and Alaska Native adults aged ≥45 years, Indian Health Service System, 2016-2020.

Alzheimer's disease is the most common type of dementia and is responsible for up to 80% of dementia diagnoses and is the sixth leading cause of death in the United States. An estimated 38,000 American Indian/Alaska Native (AI/AN) people aged ≥65 years were living with Alzheimer's disease and related dementias (ADRD) in 2020, a number expected to double by 2030 and quadruple by 2050. Administrative healthcare data from the Indian Health Service (IHS) were used to estimate ADRD among AI/AN populations. Administrative IHS healthcare data from federal fiscal years 2016 to 2020 from the IHS National Data Warehouse were used to calculate the count and rate per 100,000 AI/AN adults aged ≥45 years with at least one ADRD diagnosis code on their medical record. This study identified 12,877 AI/AN adults aged ≥45 years with an ADRD diagnosis code, with an overall rate of 514 per 100,000. Of those, 1856 people were aged 45-64. Females were 1.2 times (95% confidence interval: 1.1-1.2) more likely than males to have a medical visit with an ADRD diagnosis code. Many AI/AN people with ADRD rely on IHS, tribal, and urban Indian health programs. The high burden of ADRD in AI/AN populations aged 45-64 utilizing IHS health services highlights the need for implementation of ADRD risk reduction strategies and assessment and diagnosis of ADRD in younger AI/AN populations. This study provides a baseline to assess future progress for efforts addressing ADRD in AI/AN communities.

Are gaps in rates of retention on buprenorphine for treatment of opioid use disorder closing among veterans across different races and ethnicities? A retrospective cohort study

IntroductionThe U.S. Veterans Health Administration has undertaken several initiatives to improve veterans' access to and retention on buprenorphine because it prevents overdose and reduces drug-related morbidity. We aimed to determine whether improvements in retention duration over time was equitable across veterans of different races and ethnicities. MethodsThis retrospective cohort study was conducted among veterans who initiated buprenorphine from federal fiscal years (FY) 2006 to 2020 after diagnosis of opioid use disorder. Using an accelerated failure time model, we estimated the association between time to buprenorphine discontinuation and FY of initiation, race and ethnicity, and other control covariates. We followed veterans from buprenorphine initiation until they discontinued or had a censoring event. We then estimated the predicted median days retained on buprenorphine, the average marginal effect of initiating in a later FY, the same measure by race and ethnicity, the incremental effect of the various racial and ethnic identities in contrast to non-Hispanic White, and the total change in the size of the gap over the 15 years of the study between veterans with a minoritized racial or ethnic identity compared to non-Hispanic White veterans. ResultsMost of the 31,797 veterans in the sample were non-Hispanic White (74.5 %), from urban areas (83.5 %), male (92.0 %), and had significant comorbidities, most frequently anxiety disorders (51.0 %) and depression (63.0 %). Overall, 49.8 % of veterans were retained at least 180 days. The average marginal effect of FY was 7.0 days [95%CI:5.3, 8.8] but was significantly smaller among veterans identifying as Black or African American [3.2 days; 95%CI:2.4, 4.1] or Asian [3.6 days; 95%CI:1.6, 5.7] compared to veterans who identify as non-Hispanic White [7.9 days; 95%CI:5.9, 9.9]. Additional measures of change were significant for veterans identifying as Hispanic White or with two or more races. ConclusionAlthough buprenorphine retention in OUD treatment improved for all veterans over the 15-year study period, veterans from most minoritized racial and ethnic groups fell further behind as gains in duration on therapy accrued primarily to non-Hispanic White veterans. Targeted interventions addressing specific challenges experienced by veterans with minoritized identities are needed to close gaps in retention on buprenorphine.

Adopting the RE-AIM analytic framework for rural program evaluation: experiences from the Advance Care Planning via Group Visits (ACP-GV) national evaluation.

To support rigorous evaluation across a national portfolio of grants, the United States Department of Veterans Affairs (VA) Office of Rural Health (ORH) adopted an analytic framework to guide their grantees' evaluation of initiatives that reach rural veterans and to standardize the reporting of outcomes and impacts. Advance Care Planning via Group Visits (ACP-GV), one of ORH's Enterprise-Wide Initiatives, also followed the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. ACP-GV is a national patient-centered intervention delivered in a large, veterans integrated healthcare system. This manuscript describes how RE-AIM was used to evaluate this national program and lessons learned from ORH's annual reporting feedback to ACP-GV on their use of the framework to describe evaluation impacts. We used patient, provider, and site-level administrative health care data from the VA Corporate Data Warehouse and national program management databases for federal fiscal years (FY) spanning October 1, 2018-September 30, 2023. Measures included cumulative and past FY metrics developed to assess program impacts. RE-AIM constructs included the following cumulative and annual program evaluation results. ACP-GV reached 54,167 unique veterans, including 19,032 unique rural veterans between FY 2018 to FY 2023. During FY 2023, implementation adherence to the ACP-GV model was noted in 91.7% of program completers, with 55% of these completers reporting a knowledge increase and 14% reporting a substantial knowledge increase (effectiveness). As of FY 2023, 66 ACP-GV sites were active, and 1,556 VA staff were trained in the intervention (adoption). Of the 66 active sites in FY 2023, 27 were sites previously funded by ORH and continued to offer ACP-GV after the conclusion of three years of seed funding (maintenance). Lessons learned developing RE-AIM metrics collaboratively with program developers, implementers, and evaluators allowed for a balance of clinical and scientific input in decision-making, while the ORH annual reporting feedback provided specificity and emphasis for including both cumulative, annual, and rural specific metrics. ACP-GV's use of RE-AIM metrics is a key step towards improving rural veteran health outcomes and describing real world program impacts.

Supplemental Nutrition Assistance Program Education reductions during COVID-19 may have exacerbated health inequities

ObjectiveDescribe, and assess disparities in, the changes in Supplemental Nutrition Assistance Program Education (SNAP-Ed) that occurred the year before vs. the year when COVID-19 restrictions were implemented. DesignObservational study comparing reach, intensity, and dose of California Local Health Department (LHD) SNAP-Ed interventions in Federal Fiscal years 2019 and 2020 (FFY19, FFY20). AnalysisStudent t-tests determined significance of differences in the number of Direct Education (DE) programs, Policy, Systems and Environmental change (PSE) sites, people reached, and intervention intensity and dose between FFY19 and FFY20 using data reported online by LHDs. Linear regression assessed associations between census tract-level characteristics (urbanicity; percentages of population with income <185% of federal poverty level, under 18 years of age, and belonging to various racial/ethnic groups; and California Healthy Places Index) and changes in number of DE programs, PSE sites, people reached, and intervention dose between FFY19 and FFY20. ResultsFrom FFY19 to FFY20, the number of DE programs, PSE sites, people reached, and census tract-level intervention intensity and dose decreased. Higher census tract poverty, higher proportions of Black and Latino residents, and less healthy neighborhood conditions were associated with greater decreases in some intervention characteristics including PSE sites, PSE reach, DE programs, and DE dose. Conclusions and implicationsThese reductions in LHD SNAP-Ed interventions indicate reduced access to education and environments that support healthy eating and obesity prevention during a time when this support was especially needed to reduce risk of COVID-19 infection and complications. Disproportionately reduced access, may have worsened health disparities in already-disadvantaged communities. Assuring maintenance of SNAP-Ed interventions, especially in disadvantaged communities, should be a priority during public health emergencies.

Retention in nursing education and scholarship programs: Survival analysis of the Veterans Health Administration National Nursing Education Initiative Data.

To investigate factors affecting non-completion by registered nurses (RNs) participating in degree programs supported by the scholarship program of the National Nursing Education Initiative of the United States Veterans Health Administration. Secondarily, to assess overall retention in the scholarship program over time. Retrospective longitudinal design using administrative data. Defining retention time as the time elapsed from enrollment date to non-completion, we performed survival (retention) analysis (i.e.,Kaplan-Meier survival functions, log-rank tests and Cox regressions) to retrospectively analyzea national sample of RNs (N =15,908) enrolled in the scholarship program between the United States federal fiscal years 2000 and 2020. Nurses' mean age was 44 years (range: 19-71), and 86% were females. Six- and 12-month cumulative educational program retention rates were 92% and 84% respectively. The newest group of enrollees (2016-2020), younger nurses (<50 years), and nurses in traditional degree programtype were more likely to complete their academic programs than the earlier groups, older nurses and nurses in non-traditional type, respectively. Male nurses who aspired to advanced occupational levels upon completion were more likely to complete their academic programs compared to those who expected no change from their current level of practice. Multiple factors affected non-completion of academic degree programs by RNs enrolled in the scholarship program. More work is needed to examine these plus additional plausible factors and their correlates extensively. Our findings highlighted areas for quality improvement in employee scholarship programs for RNs. The findings are expected to inform tailoring of proactive helpful intervention towards individual needs and prioritization of limited resources to maximize graduation rate from academic programs for scholarship recipients. The study will have impact on nursing workforce policy makers interested in implementing employee scholarship programs, and on their scholarship recipients.

Diet Quality and Nutrition Behavior of Federal Nutrition Education Program Participants before and during the COVID-19 Pandemic

Despite challenges due to the COVID-19 pandemic, reports from regional and national meetings of the Expanded Food and Nutrition Education program (EFNEP) have provided anecdotal evidence that the program has persevered, pivoted, and continued to positively impact the lives of some of the nation's most vulnerable populations. However, there have been necessary changes to program delivery, inevitable changes in the lives of participants, and changes in the food environment that may have impacted program outcomes. This study compares national EFNEP data (demographics, behavior change data, and 24 h dietary recall data) of participants from two federal fiscal years, before the COVID-19 pandemic and during the pandemic. Linear mixed model analysis of variance and covariance were used to assess the effects of year on program outcomes. Results of this study provide quantitative evidence of the resiliency of EFNEP to facilitate positive behavior changes related to diet quality, physical activity, food safety, food resource management, and food security. Amidst changes in the food environment during the COVID-19 pandemic, these results emphasize the importance and value of federal nutrition education programs in any food environment.

Use of Customized Employment in State Vocational Rehabilitation Programs: A Retrospective Study 2017–2020

The purpose of this study was to examine the outcomes of customized employment via an analysis using the U.S. Rehabilitation Services Administration Case Service Report (RSA-911) from Federal Fiscal Years of 2017 through 2020. The independent variables were demographics, barriers to employment, and types of state vocational rehabilitation agency (SVRA) services, and the dependent variables were competitive integrated employment status and weekly earnings at exit. Descriptive analyses, multiple logistic regression, and hierarchical multiple regression comprised data analysis. The study sample ( N = 2,280) was 57.9% male and 42.1% female and had a mean age of 32.69 years ( SD = 12.83). Seventy-seven percent identified themselves as White and 46.7% had a cognitive disability. The results of this study indicated that consumers who have cognitive disability and cultural barriers; are migrant farmworkers and/or dependents; and receive job placement assistance, short-term job supports, maintenance services, benefits counseling, and supported employment are more likely to get competitive integrated employment at exit ( R2 = .34). Multiple variables were found to be significantly related to weekly earnings at exit and explained 24% of the variance. Rehabilitation counselors should take into consideration the findings of this study to determine from which supports consumers may benefit to attain successful employment goals, particularly for customized employment.

Child maltreatment reporting during the initial weeks of COVID-19 in the US: Findings from NCANDS

BackgroundAfter the national COVID-19 emergency declaration in the U.S. in March 2020, child welfare agencies observed large reductions in maltreatment reporting. ObjectiveTo quantify the impact of the COVID-19 pandemic on child maltreatment reporting nationally to inform policy for future emergencies. Participants and settingAdministrative data from the National Child Abuse and Neglect Data System (NCANDS) for 48 states for federal fiscal years (FFYs) 2017 through 2020. MethodsAnalyses focused on reports to child protective services (CPS) between weeks 12 and 24 of calendar years 2017 through 2020 (mid-March through mid-June). Report sources of screened in and substantiated reports were compared with those during the prior year. Likelihood of a report being substantiated in 2020 compared with 2019 based on report source was calculated using odds ratios. ResultsIn 2020, CPS screened in 39 % fewer reports than during the same period in 2019 and the proportion of reports substantiated increased from 18 to 22 %. Reports from all report sources decreased, especially from education personnel (90 % decrease) and child daycare providers (65 % decrease). The odds for substantiation were significantly higher during 2020 than in 2019 for reports from all but three sources. ConclusionDuring the initial weeks following the national COVID-19 emergency declaration, the number of reports to CPS declined sharply at the national level and across all states, primarily in association with a large reduction in referrals from education sentinels. Explanations for the increase in percent of substantiation in the context of reduction of reports are considered.

LCRR Compliance Involves More Than Lead Service Lines

LCRR Compliance Involves More Than Lead Service Lines

Direct Mailing Education Campaign Impacts on the Adoption of Grazing Management Practices

AbstractThe Texas Commission on Environmental Quality facilitates the Clean Rivers Program where many of Texas' waters are monitored for various parameters. A common approach to address water quality impairments is to develop and implement Watershed Protection Plans, where a key management measure is to increase the adoption of best management practices through existing government programs that provide technical and financial assistance. A key role for watershed managers during implementation is to raise awareness that technical and financial resources are available to assist producers with adoption. Outreach approaches thus far have included in‐person education programs, attendance at local Soil and Water Conservation District (SWCD) meetings, newsletters, and other efforts that have only had minimal reach. As a result, we initiated a mass mailing campaign where 4,921 landowners within Lavaca County, Texas were reached four times in approximately six months with the same message. Partnering with the local SWCD and United States Department of Agriculture Natural Resources Conservation Service offices, the number of individual best management practices were acquired for the current and previous five federal fiscal years to measure changes. Results suggest directly mailing educational materials to landowners is an effective outreach approach to increase the adoption of best management practices. Model results indicate a significant 300% increase in adoption of practices compared to historic levels.

State Spending on Public Benefit Programs and Child Maltreatment.

To determine the association between states' total spending on benefit programs and child maltreatment outcomes. This was an ecological study of all US states during federal fiscal years 2010-2017. The primary predictor was states' total annual spending on local, state, and federal benefit programs per person living ≤100% federal poverty limit, which was the sum of (1) cash, housing, and in-kind assistance, (2) housing infrastructure, (3) child care assistance, (4) refundable Earned Income Tax Credit, and (5) Medical Assistance Programs. The main outcomes were rates of maltreatment reporting, substantiations, foster care placements, and fatalities after adjustment for relevant confounders. Generalized estimating equations adjusted for federal spending and estimated adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs). States' total spending was inversely associated with all maltreatment outcomes. For each additional $1000 states spent on benefit programs per person living in poverty, there was an associated -4.3% (adjusted IRR: 0.9573 [95% CI: 0.9486 to 0.9661]) difference in reporting, -4.0% (adjusted IRR: 0.903 [95% CI: 0.9534 to 0.9672]) difference in substantiations, -2.1% (adjusted IRR: 0.9795 [95% CI: 0.9759 to 0.9832]) difference in foster care placements, and -7.7% (adjusted IRR: 0.9229 [95% CI: 0.9128 to 0.9330]) difference in fatalities. In 2017, extrapolating $1000 of additional spending for each person living in poverty ($46.5 billion nationally, or 13.3% increase) might have resulted in 181 850 fewer reports, 28 575 fewer substantiations, 4168 fewer foster care placements, and 130 fewer fatalities. State spending on benefit programs was associated with reductions in child maltreatment, which might offset some benefit program costs.

Using social network analysis to evaluate relationships among community nutrition education partners

Abstract Background The Supplemental Nutrition Assistance Program - Education (SNAP-Ed) program is an evidence-based program funded by the United States Department of Agriculture (USDA) that provides direct education and multi-level interventions for low-income families about nutrition, physical activity, and making healthy choices on a limited budget. Each U.S. state is funded to administer the program. SNAP-Ed works by building partnerships with community organizations. The purpose of this study was to identify characteristics of Minnesota's community partnership network involved in the SNAP-Ed program from the federal fiscal years 2016 (FY16) to 2020 (FY20). Analysis aims include 1) mapping the growth of SNAP-Ed community partners each year, 2) identifying essential network patterns and thereby highlight potential network gaps, 3) gauging the current level of partner involvement, and 4) enabling a data-driven approach for future collaborative network improvements. Methods Social network theory and analysis (SNA) was used to examine changes in partnerships over time. The data was retrieved from Minnesota's SNAP Education Evaluation and Database System (SEEDS) where maintained program and evaluation data; SNA metrics such as size, breadth, density, degree centralization, clusters, and modularity were calculated for each network. Results Partners of SNAP-Ed programs expanded from 869 in FY16 to 1032 in FY19. Due to COVID-19, in FY20, the number of partners decreased to 804. The network density decreased over time due to expansion of the number of partners between FY16(.0263) and FY19(.021). In FY20, the network density significantly decreased to .001 since partners were not able to be connected to each other. Network centrality will also be reported. Conclusions Our study presents a novel use of social network analysis methods to evaluate the community partnerships involved in the SNAP-Ed program. Key messages Using social network analysis to analyze the quantity and quality of the relationship among community nutrition education program partners gives practical policy recommendations. A novel use of social network analysis methods to evaluate the community partnerships involved in the SNAP-Ed program.

Adolescent Mother Maltreatment Perpetrators’ Past Experiences with Child Protective Services

The experience of childhood maltreatment is associated with pregnancy during adolescence and increased risk for maltreating one’s own child or children. However, adolescent mothers who have been identified by child protective services (CPS) both as perpetrators and alleged victims carry a unique burden of trauma and are seldom the focus of retrospective studies. This study examines the extent to which adolescent mother perpetrators have prior experience with CPS as alleged victims and how their current perpetrator characteristics are associated with their prior CPS experience. We constructed a study sample of adolescent mother perpetrators reported to the National Child Abuse and Neglect Data System (NCANDS) by 27 states for federal fiscal years (FFYs) 2016–2018 (N = 8205) and determined whether they had any prior CPS experience as alleged victims since 2005. Characteristics of the participants as both perpetrators and alleged victims were examined, and associations between these were analyzed using odds ratios. Nearly two-thirds (62%) of adolescent mother perpetrators had prior experience with CPS. Analyses revealed significant associations of prior CPS experiences and perpetrator age, race, and connection with additional perpetrators. The types of maltreatment allegations that adolescent mothers experienced as children were significantly associated with the type of maltreatment they perpetrated. Key conclusions highlight the importance in understanding the link between childhood CPS experience and later maltreatment perpetration by adolescent mothers which will in turn help target prevention services to break the cycle of intergenerational maltreatment. Limitations and future research directions are discussed.

Rates of Diagnoses Indicating Opioid Dependence After Hospice Live Discharge: A National Study (SCI929)

1.Enumerate the rate of hospice live discharges associated with subsequent opioid dependence.2.Identify patient and provider trends in the rate of opioid dependence incidents after hospice live discharge. Medicare beneficiaries that elect the Medicare Hospice benefit often receive opioids as a standard medication to treat pain. Little is known about the prevalence of opioid dependence following live discharge from hospice. The Centers for Medicare & Medicaid Services Chronic Care Policy Group seeks to examine live discharges associated with subsequent opioid dependence and identify patient and provider characteristics of such discharges. Retrospective cohort analysis of Medicare hospice discharges during Federal Fiscal Years 2017-18 (FY2017-2018). Using 100% Medicare inpatient and Part B claims, we identified ICD-10 codes indicating opioid dependence indicated by a crosswalk maintained by the Agency for Healthcare Research and Quality. There were 2,673,218 hospice discharges FY2017-FY2018, of which 468,204 (17.5%) were live discharges. Among these, 9,282 discharges (2.0%) were associated with 28,962 opioid-related diagnoses after discharge. Approximately one quarter (26.4%) of these diagnoses appeared on inpatient claims. The states with the highest rates of opioid-related post-discharge incidents per 10,000 hospice live discharges were Kentucky (435.2), Wyoming (386.0), Tennessee (359.3), Washington (345.6), and Idaho (342.9). Post-hospice opioid diagnoses were more likely if the beneficiary was younger (for ages <65 relative to 85-89, AOR=6.23, 95% CI 5.73-6.77); dual-eligible (AOR=1.40, 95% CI 1.34-1.47); and relative to cancer, being diagnosed at admission with COPD (AOR=1.83, 95% CI 1.72-1.95), heart diseases (CHF: AOR=1.23, 95% CI 1.14-1.34; Other Heart Disease: AOR=1.23, 95% CI 1.14-1.33), or liver disease (AOR=1.25, 95% CI 1.10-1.42). There were no discernable patterns among hospice characteristics. Opioid dependence after hospice was more frequent among beneficiaries who were younger, dual-eligible, diagnosed with COPD, heart, or liver diseases, or residing in the lower Appalachian and Northwestern states.

Suicide rates of migrants in United States immigration detention (2010-2020).

ObjectiveWe determined the annual suicide rate of migrants detained by U.S. Immigration and Customs Enforcement (ICE) in the past decade.MethodsWe performed a retrospective cohort analysis of the annual suicide rates for ICE detainees from federal fiscal years (FY) 2010–2020. Death date and cause of death were directly extracted from publicly available ICE Freedom of Information Act (FOIA) Library, ICE death reports, and ICE press releases. Annual suicide rates were calculated as suicides per 100,000 person-years and suicides per 100,000 admissions.ResultsFrom 2010–2019, the mean number of suicides per 100,000 person-years was 3.3 (standard deviation (SD): 2.6). In 2020, the suicide rate increased 5.3 times the prior 10-year average to 17.4 suicides per 100,000 person-years. When calculating suicide rate based on admissions per FY, the mean number of suicides from 2010–2019 per 100,000 admissions was 0.3 (SD: 0.3). In 2020, the suicide rate increased 11.0 times the prior 10-year average to 3.4 suicides per 100,000 admissions.ConclusionIn 2020, the detainee suicide rate increased substantially compared to the past decade. This may point to a worsening mental health crisis in ICE detention.

Rates of Diagnoses Indicating Opioid Dependence After Hospice Live Discharge: A National Study

Opioids are an important tool for managing Medicare Hospice beneficiaries’ pain and symptoms. Little is known about the prevalence of opioid dependence among patients discharged alive from hospice. Using 100% Medicare hospice, acute inpatient, and Part B claims from Federal Fiscal Years (FY) 2017-2018, we identified hospice beneficiaries that were discharged alive during FY2017-2018 and associated with diagnosis codes in subsequent health care incidents indicating opioid dependence. We used a crosswalk from the Agency for Healthcare Research and Quality to determine which codes represented opioid dependence. We characterized beneficiaries and their hospice providers using information from the Medicare Enrollment Database and Provider of Services file. There were 468,204 live hospice discharges during FY2017-2018, among which 9,282 (2.0%) were associated with subsequent health care events including a diagnosis code signifying opioid dependence. Post-hospice opioid diagnoses were more frequent among beneficiaries who were younger (for ages <65 relative to 85-89; Adjusted Odds Ratio [AOR]=6.23, 95% Confidence Intervals [CI] 5.73-6.77); dual-eligible (AOR=1.40, 95% CI 1.34-1.47); and relative to cancer, diagnosed with lung (AOR=1.83, 95% CI 1.72-1.95), heart (AOR=1.23, 95% CI 1.14-1.34), or liver diseases (AOR=1.25, 95% CI 1.10-1.42). Beneficiaries with opioid incidents tended to have survived much longer after hospice (150.9 days with opioid incidents vs. 13.6 days no opioid-related incidents). The states with the highest rates of post-hospice opioid-incidents per 10,000 live discharges were Kentucky (435.2), Wyoming (386.0), Tennessee (359.3), Washington (345.6), and Idaho (342.9). Further monitoring can ensure that hospice beneficiaries receive appropriate care during and after hospice enrollment.

Brief Report: Participation Among Transition-Aged Youth With Traumatic Brain Injury in the State/Federal Vocational Rehabilitation System

This study aimed to understand the level of participation among transition-aged youth with traumatic brain injury (TBI) in the state/federal Vocational Rehabilitation (VR) system in the context of the Workforce Innovation and Opportunity Act (WIOA). Case closures, case duration, and case expenditures in federal fiscal years (FYs) 2014, 2015, and 2016 were examined among transition-aged youth (i.e., state VR clients under the age of 22 years at application) with TBI, autism spectrum disorder (ASD), and intellectual disability (ID), using a nonexperimental and descriptive design. A disproportionate number of transition-aged youth with ASD and ID had closed state VR cases compared with transition-aged youth with TBI. Alternatively, there were greater state VR case duration levels and case service expenditures for persons with TBI compared with those with ASD or ID. The disproportionate participation with state VR was consistent among these three groups via eligibility for services under the Individuals with Disabilities Education Act. This article highlights areas of attention concerning transition-aged youth with TBI and will hopefully stimulate future dialogue, research, and policy development concerning participation with State VR for this population.

Asking for Identification and Retail Tobacco Sales to Minors

A previous single-county study found that retail stores usually asked young-looking tobacco customers to show proof-of-age identification, but a large proportion of illegal tobacco sales to minors occurred after the customers had shown identification proving they were too young to purchase tobacco. We sought to investigate these findings on a larger scale. We obtained state reports for federal fiscal years 2017 and 2018 from a federal agency that tracks tobacco sales to supervised minors conducting compliance checks in retail stores. We used descriptive and multivariable logistic regression methods to determine (1) how often stores in 17 states requested identifications, (2) what proportion of violations occurred after identification requests, and (3) if violation rates differed when minors were required versus forbidden to carry identification. Stores asked minors for identification in 79.6% (95% confidence interval: 79.3%-80.8%) of compliance checks (N = 17 276). Violations after identification requests constituted 22.8% (95% confidence interval: 20.0%-25.6%; interstate range, 1.7%-66.2%) of all violations and were nearly 3 times as likely when minors were required to carry identification in compliance checks. Violations were 42% more likely when minors asked for a vaping product versus cigarettes. Stores that sell tobacco to underage customers are more likely to be detected and penalized when youth inspectors carry identification during undercover tobacco sales compliance checks. The new age-21 tobacco sales requirement presents an opportunity to require identifications be carried and address other long-standing weaknesses in compliance-check protocols to help combat the current adolescent vaping epidemic.