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In the U.S., older adults hospitalized with acute episodes of chronic conditions often are rehospitalized within 30 days of discharge. Numerous studies reveal that poor management of the complex needs of this population remains the norm. METHODS: This prospective, intent-to-treat, randomized controlled trial (RCT) will assess the effects of replicating the rigorously studied Transitional Care Model (TCM) in four U.S. healthcare systems. The TCM is an advanced practice registered nurse led, team-based, care management intervention that supports older adults throughout vulnerable care episodes that span hospital to home. This RCT will compare health and economic outcomes demonstrated by at-risk older adults hospitalized with heart failure, chronic obstructive pulmonary disease or pneumonia randomized to receive usual discharge planning (control group, N = 800) to those observed by a similar group of older adults randomized to receive the TCM protocol (N = 800). The primary outcome is number of rehospitalizations at 12 months post-discharge, with secondary resource use outcomes measured at multiple intervals. Patient experience with care, health and quality of life outcomes will be assessed at 90 days post-discharge. DISCUSSION: Based on health and economic benefits demonstrated in multiple NIH funded RCTs, the study team hypothesizes that the intervention group, both within and across participating health systems, will have decreased acute care resource use and costs at 12 months and better ratings of the care experience and health and quality of life through 90 days post-discharge compared to the control group. The impact of COVID-19 on implementation of this study also is discussed.

Aim: The aim of the current study was to investigate the relationship between escalating higher doses of psilocybin and the potential psilocybin occasioned positive subjective effects. Methods: Healthy participants ( n=12) were given three escalating doses of oral psilocybin (0.3 mg/kg; 0.45 mg/kg; 0.6 mg/kg) or (18.8–36.6 mg; 27.1–54.0 mg; 36.3–59.2 mg) a minimum of four weeks apart in a supervised setting. Blood and urine samples, vital signs, and electrocardiograms were obtained. Subjective effects were assessed using the Mystical Experience Questionnaire and Persisting Effects Questionnaire. Results: There was a significant linear dose-related response in Mystical Experience Questionnaire total score and the transcendence of time and space subscale, but not in the rate of a complete mystical experience. There was also a significant difference between dose 3 compared to dose 1 on the transcendence of time and space subscale, while no dose-related differences were found for Mystical Experience Questionnaire total scores or rate of a mystical experience. Persisting Effects Questionnaire positive composite scores 30 days after completion of the last dose were significantly higher than negative composite scores. Persisting Effects Questionnaire results revealed a moderate increase in sense of well-being or life satisfaction on average that was associated with the maximum Mystical Experience Questionnaire total score. Pharmacokinetic measures were associated with dose but not with Mystical Experience Questionnaire total scores or rate of a mystical experience. Conclusions: High doses of psilocybin elicited subjective effects at least as strong as the lower doses and resulted in positive persisting subjective effects 30 days after, indicating that a complete mystical experience was not a prerequisite for positive outcomes.

The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative's effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care.

Background This paper reports on the feasibility, acceptability, and effectiveness of an innovative implementation strategy named “systems consultation” aimed at improving adherence to clinical guidelines for opioid prescribing in primary care. While clinical guidelines for opioid prescribing have been developed, they have not been widely implemented, even as opioid abuse reaches epidemic levels. Methods We tested a blended implementation strategy consisting of several discrete implementation strategies, including audit and feedback, academic detailing, and external facilitation. The study compares four intervention clinics to four control clinics in a randomized matched-pairs design. Each systems consultant aided clinics on implementing the guidelines during a 6-month intervention consisting of monthly site visits and teleconferences/videoconferences. The mixed-methods evaluation employs the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Quantitative outcomes are compared using time series analysis. Qualitative methods included focus groups, structured interviews, and ethnographic field techniques. Results Seven clinics were randomly approached to recruit four intervention clinics. Each clinic designated a project team consisting of six to eight staff members, each with at least one prescriber. Attendance at intervention meetings was 83%. More than 80% of staff respondents agreed or strongly agreed with the statements: “I am more familiar with guidelines for safe opioid prescribing” and “My clinic’s workflow for opioid prescribing is easier.” At 6 months, statistically significant improvements were noted in intervention clinics in the percentage of patients with mental health screens, treatment agreements, urine drug tests, and opioid-benzodiazepine co-prescribing. At 12 months, morphine-equivalent daily dose was significantly reduced in intervention clinics compared to controls. The cost to deliver the strategy was $7345 per clinic. Adaptations were required to make the strategy more acceptable for primary care. Qualitatively, intervention clinics reported that chronic pain was now treated using approaches similar to those employed for other chronic conditions, such as hypertension and diabetes. Conclusions The systems consultation implementation strategy demonstrated feasibility, acceptability, and effectiveness in a study involving eight primary care clinics. This multi-disciplinary strategy holds potential to mitigate the prevalence of opioid addiction and ultimately may help to improve implementation of clinical guidelines across healthcare. Trial registration ClinicalTrials.gov (NCT02433496). https://clinicaltrials.gov/ct2/show/NCT02433496 Registered May 5, 2015 Electronic supplementary material The online version of this article (10.1186/s13012-018-0713-1) contains supplementary material, which is available to authorized users.

Over 16 million Americans meet diagnostic criteria for alcohol use disorder (AUD), but only 7.8% of them receive formal treatment each year. Safe and effective pharmacological treatments for AUD exist; however, they are rarely prescribed. Therefore, we developed and pilot tested a multifaceted implementation intervention to improve consideration and receipt of effective pharmacologic treatments for AUD, focusing on primary care settings where patients have the most frequent contact with healthcare systems. The intervention included training of local providers to serve as champions and a website for primary care providers that included educational materials, a case-finding dashboard, and contact information for local and national clinical experts. We also mailed patients educational material about treatment options. The intervention was implemented at three large facilities of the Veterans Health Administration (VHA). An interrupted time series design, analyzed with segmented logistic regression, was used to evaluate the intervention's effects. The odds of a patient with AUD receiving one of the AUD medications was increasing throughout the pre-implementation period, and the rate of change (slope) increased significantly in the implementation period. Translating these numbers into percentages, at baseline 2.9% of patients filled a prescription for an AUD medication within 30days of a primary care visit. This increased to 3.8% by the end of the pre-implementation period (increasing 0.037% per month), and increased to 5.2% by the end of the implementation period (increasing 0.142% per month). However, the intervention effect was not significant when control sites were added, suggesting that improvement may have been driven by secular trends rather than solely by this intervention. Although the intervention was feasible, it was not effective. Continued analysis of process and implementation data including qualitative interviews with key stakeholders, may elucidate the reasons this intervention was not successful and ways to strengthen its effects.

BACKGROUND Injectable naltrexone for alcohol use disorders (AUDs) has been efficacious in several studies. It has not been (i) compared head-to-head with oral naltrexone or (ii) examined in the hospital setting as an intervention that might facilitate treatment attendance after hospital discharge. METHODS Fifty-four hospitalized veterans identified as having DSM-IV-TR alcohol dependence were randomized to receive (i) a 50 mg oral naltrexone plus a 30-day prescription or (ii) a 380 mg intramuscular naltrexone injection prior to discharge. Of 113 veteran inpatients deemed eligible based on screening criteria, 54 met final eligibility criteria and were enrolled and randomized. Baseline data included demographics, alcohol consumption, and comorbidity. Measures of treatment initiation and engagement and alcohol consumption were reassessed at 14- and 45-day follow-ups. RESULTS Thirty-five participants (64.8%) completed the entire study protocol (received a study medication and completed 14- and 45-day follow-ups). Among those who received a study medication (n = 45), 77.8% completed all follow-up interviews. This pilot study was not designed to have sufficient statistical power for hypothesis testing, and thus, as expected, there were no significant differences between groups in medication adherence (self-report of >80% of daily doses taken in oral group; receipt of second injection in the injection group), treatment engagement (at least treatment 3 visits in the 30 days postdischarge, and 2 or more visits per month in each of the 3 months following discharge) or alcohol consumption at 14 or at 45 days (p > 0.05). The median number of drinks among the entire cohort in the 2 weeks prior to hospitalization (128 drinks) was significantly higher than at day 14 (0 drinks, p

Background Exercise has been examined as an adjunctive treatment for substance use disorders (SUDs), yet few exercise interventions have been conducted among patients undergoing intensive outpatient (IOP) treatment, who may be the most vulnerable to relapse and for whom exercise could provide the most benefits. This study examined the effects of aerobic exercise, in addition to IOP treatment, on psychological variables and endocannabinoids in individuals with SUDs. Methods: Twenty-one SUD patients (mean age 35 years) were recruited from local IOPs. Participants were randomized to either treatment-as-usual (TAU, at their outpatient clinic) or TAU plus aerobic exercise training (EX). EX participants engaged in supervised, moderate-intensity exercise for 30 min, 3 times/week for 6 weeks. TAU participants came into the laboratory once per week for assessments and a 30-min quiet rest session. Participants provided blood samples and completed questionnaires evaluating substance use, mood states, depression, anxiety, perceived stress, self-efficacy to abstain from substance use, and craving. Data were analyzed with Mann–Whitney U tests or mixed model ANOVAs to determine group differences in outcomes acutely and over 6 weeks. Results Over 6 weeks, there were reductions in perceived stress ( p 0.05). Acutely, both exercise and quiet rest sessions led to reductions in craving, tension, depression, anger, confusion, and total mood disturbance (all ps Conclusions An adjunctive aerobic exercise program during SUD treatment was associated with similar reductions in perceived stress and drug craving as standard care. Thirty minutes of exercise or quiet rest led to acute improvements in mood, but exercise produced the additional benefit of increases in vigor and circulating anandamide.

BACKGROUND The United States spends more than US $100 billion annually on the impact of medication misuse. Serious games are effective and innovative digital tools for educating patients about positive health behaviors. There are limited systematic reviews that examine the prevalence of serious games that incorporate medication use. OBJECTIVE This systematic review aimed to identify (1) serious games intended to educate patients about medication adherence, education, and safety; (2) types of theoretical frameworks used to develop serious games for medication use; and (3) sampling frames for evaluating serious games on medication use. METHODS PubMed, Scopus, and Web of Science databases were searched for literature about medication-based serious games for patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for article selection. RESULTS Using PRISMA guidelines, 953 publications and 749 unique titles were identified from PubMed, Scopus, and Web of Science. A total of 16 studies featuring 12 unique serious games were included with components of medication adherence, education, and safety, published from 2003 to 2019. Of the 12 games included, eight serious games were tested in adolescents, three games were tested in young adults, and one game was tested in adults. Most studies (n=11) used small sample sizes to test the usability of serious games. Theoretical frameworks identified in the 12 serious games included information, motivation, and behavior theory; social cognitive theory; precede-proceed model; middle-range theory of chronic illness; adult learning theory; experiential learning theory; and the theory of reasoned action. Existing reviews explore serious games focused on the management of specific disease states, such as HIV, diabetes, and asthma, and on the positive impact of serious game education in each respective disease state. Although other reviews target broad topics such as health care gamification and serious games to educate health care workers, no reviews focus solely on medication use. Serious games were mainly focused on improving adherence, whereas medication safety was not widely explored. Little is known about the efficacy and usability of medication-focused serious games often because of small and nonrepresentative sample sizes, which limit the generalizability of existing studies. CONCLUSIONS Limited studies exist on serious games for health that incorporate medication use. The findings from these studies focus on developing and testing serious games that teach patients about medication use and safety. Many of these studies do not apply a theoretical framework in the design and assessment of these games. In the future, serious game effectiveness could be improved by increasing study sample size and diversity of study participants, so that the results are generalizable to broader populations. Serious games should describe the extent of theoretical framework incorporated into game design and evaluate success by testing the player’s retention of learning objectives.

Moderate-to-severe pain normally warranting consideration of opioid analgesics may occur in patients with substance use disorder (SUD) or an SUD history. If opioid analgesics are considered, consideration should also be given to enhanced monitoring practices during the course of pain management. Additionally, care should be coordinated with providers of SUD-related care, such as therapists and other mental health consultants, and prescribers of medication-assisted therapies (e.g. naltrexone, buprenorphine, methadone).

Screening and brief intervention should be a standard procedure for physicians to identify, reduce, and prevent unhealthy substance use and addiction. This chapter provides an overview of standardized screening measures and guidelines on implementing screening and brief intervention in the pain clinic setting.

Background Despite the high prevalence of alcohol use disorders (AUDs), in 2016, only 7.8% of individuals meeting diagnostic criteria received any type of AUD treatment. Developing options for treatment within primary care settings is imperative to increase treatment access. As part of a trial to implement AUD pharmacotherapy in primary care settings, this qualitative study analyzed pre-implementation provider interviews using the Consolidated Framework for Implementation Research (CFIR) to identify implementation barriers. Methods Three large Veterans Health Administration facilities participated in the implementation intervention. Local providers were trained to serve as implementation/clinical champions and received external facilitation from the project team. Primary care providers received a dashboard of patients with AUD for case identification, educational materials, and access to consultation from clinical champions. Veterans with AUD diagnoses received educational information in the mail. Prior to the start of implementation activities, 24 primary care providers (5–10 per site) participated in semi-structured interviews. Transcripts were analyzed using common coding techniques for qualitative data using the CFIR codebook Innovation/Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals domains. Number and type of barriers identified were compared to quantitative changes in AUD pharmacotherapy prescribing rates. Results Four major barriers emerged across all three sites: complexity of providing AUD pharmacotherapy in primary care, the limited compatibility of AUD treatment with existing primary care processes, providers’ limited knowledge and negative beliefs about AUD pharmacotherapy and providers’ negative attitudes toward patients with AUD. Site specific barriers included lack of relative advantage of providing AUD pharmacotherapy in primary care over current practice, complaints about the design quality and packaging of implementation intervention materials, limited priority of addressing AUD in primary care and limited available resources to implement AUD pharmacotherapy in primary care. Conclusions CFIR constructs were useful for identifying pre-implementation barriers that informed refinements to the implementation intervention. The number and type of pre-implementation barriers identified did not demonstrate a clear relationship to the degree to which sites were able to improve AUD pharmacotherapy prescribing rate. Site-level implementation process factors such as leadership support and provider turn-over likely also interacted with pre-implementation barriers to drive implementation outcomes.

Addiction, or “substance use disorder (SUD),” is characterized by maladaptive substance use that is associated with adverse consequences in term of mental, physical, and social functioning. The state of addiction is associated with predictable alterations of central nervous system (CNS) function and neurobiology that, in turn, are predictive of behavioral patterns and functional declines. As such, SUDs are accurately characterized as a chronic relapsing disease of the brain.

Objectives To test whether a care management program could replicate its success in an earlier trial and determine likely explanations for why it did not. Data Sources/Setting Medicare claims and nurse contact data for Medicare fee-for-service beneficiaries with chronic illnesses enrolled in the trial in eastern Pennsylvania (N = 483). Study Design A randomized trial with half of enrollees receiving intensive care management services and half receiving usual care. We developed and tested hypotheses for why impacts declined. Data Extraction All outcomes and covariates were derived from claims and the nurse contact data. Principal Findings From 2010 to 2014, the program did not reduce hospitalizations or generate Medicare savings to offset program fees that averaged $260 per beneficiary per month. These estimates are statistically different (p

Family-focused prevention programs have been shown to effectively reduce a range of negative behavioral health outcomes but have had limited reach. Three key barriers must be overcome to expand the reach of family-focused prevention programs and thereby achieve a significant public health impact. These barriers are (1) current social norms and perceptions of parenting programs; (2) concerns about the expertise and legitimacy of sponsoring organizations to offer parenting advice; and (3) a paucity of stable, sustainable funding mechanisms. Primary healthcare settings are well positioned to overcome these barriers. Recent changes within health care make primary care settings an increasingly favorable home for family-focused prevention and suggest possibilities for sustainable funding of family-focused prevention programs. This paper discusses the existing advantages of primary care settings and lays out a plan to move toward realizing the potential public health impact of family-focused prevention through widespread implementation in primary healthcare settings.

The 4-year, multipayer Comprehensive Primary Care Initiative was started in October 2012 to determine whether several forms of support would produce changes in care delivery that would improve the quality and reduce the costs of care at 497 primary care practices in seven regions across the United States. Support included the provision of care-management fees, the opportunity to earn shared savings, and the provision of data feedback and learning support.We tracked changes in the delivery of care by practices participating in the initiative and used difference-in-differences regressions to compare changes over the first 2 years of the initiative in Medicare expenditures, health care utilization, claims-based measures of quality, and patient experience for Medicare fee-for-service beneficiaries attributed to initiative practices and a group of matched comparison practices.During the first 2 years, initiative practices received a median of $115,000 per clinician in care-management fees. The practices reported improvements in approaches to the delivery of primary care in areas such as management of the care of high-risk patients and enhanced access to care. Changes in average monthly Medicare expenditures per beneficiary did not differ significantly between initiative and comparison practices when care-management fees were not taken into account (-$11; 95% confidence interval [CI], -$23 to $1; P=0.07; negative values indicate less growth in spending at initiative practices) or when these fees were taken into account ($7; 95% CI, -$5 to $19; P=0.27). The only significant differences in other measures were a 3% reduction in primary care visits for initiative practices relative to comparison practices (P0.001) and changes in two of the six domains of patient experience--discussion of decisions regarding medication with patients and the provision of support for patients taking care of their own health--both of which showed a small improvement in initiative practices relative to comparison practices (P=0.006 and P0.001, respectively).Midway through this 4-year intervention, practices participating in the initiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after accounting for care-management fees, nor have they shown an appreciable improvement in the quality of care or patient experience. (Funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services; ClinicalTrials.gov number, NCT02320591.).

Background Asthma exacerbation risk increases with worsening asthma control. Prevailing numerical control tools evaluate only current symptom impairment despite the importance of also assessing risk based on exacerbation history. An easy-to-use questionnaire addressing impairment and risk domains of control is needed. Objective To validate a composite asthma control tool that includes impairment and risk assessments (Asthma Impairment and Risk Questionnaire [AIRQ]). Methods Four-hundred forty-two patients aged ≥12 years with physician-diagnosed asthma who were followed in specialty practices completed 15 impairment and risk questions with dichotomized yes/no responses. Patients spanned all Global Initiative for Asthma severities and were classified as well-controlled, not well-controlled, or very poorly controlled according to a standard of Asthma Control Test (ACT) score plus prior-year exacerbations. Logistic regression analyses identified questions with the greatest predictive validity to discriminate among patients and determine cut points for these 3 classifications. Results The final AIRQ comprises 10 equally weighted yes/no impairment and risk questions. The final 10-item models yielded receiver operating characteristic curves of 0.94 to identify well-controlled versus not well-/very poorly controlled and 0.93 to identify well-/not well-controlled versus very poorly controlled asthma, as reflected by the ACT plus prior-year exacerbations standard. Cut points of 0-1, 2-4, and 5-10 best represented well-, not well-, and very poorly controlled asthma. Conclusions AIRQ is a rigorously validated composite measure designed to identify adults and adolescents with varying degrees of asthma control. Ongoing investigations will determine test-retest reliability, responsiveness to change, and predictive ability for future exacerbations.

Objective: To examine associations between Pain Catastrophizing Scale (PCS) scores and daily opioid dosage in traumatic injury patients. Design: This was a prospective cohort study with patient assessments at baseline and 1-month following discharge. Setting: Study visits were conducted at a Regional Level I Trauma Center and by phone at follow-up. Patients: Forty-nine injured inpatients completed baseline PCS. A subsample of 23 patients continued to take prescribed opioid medication at 1-month postdischarge and were included in the current analyses. Main Outcome measured: Associations between baseline PCS and morphine equivalent daily dose (MEDD) at 1-month follow-up. Results: Controlling for baseline MEDD, baseline PCS score was positively associated with MEDD at 1-month postdischarge ( β = 0.577 [0.399, 1.535]; p = 0.002; R 2 of PCS = 0.395). Conclusions : In the current sample of traumatic injury inpatients, findings indicated that a baseline measure of pain catastrophizing predicts ongoing opioid medication use and dosage at 1-month postdischarge from an inpatient trauma unit.

There is a national opioid misuse and overdose crisis. Consensus guidelines seek to inform practice and reduce risk; however, effect on clinician attitudes and knowledge remains unclear.We surveyed 228 medical students and physicians in Wisconsin to assess their knowledge regarding at-risk patients, alternatives to opioids, and best treatment practices for opioid addiction. We also assessed attitudes about prescribing naloxone, relapse likelihood, and responsibility for the crisis.Enhancement of opioid-related education is both necessary to address knowledge gaps and desired by students and physicians.

Background: Despite the near ubiquity of mobile phones, little research has been conducted on the implementation of mobile health (mHealth) apps to treat patients in primary care. Although primary care clinicians routinely treat chronic conditions such as asthma and diabetes, they rarely treat addiction, a common chronic condition. Instead, addiction is most often treated in the US health care system, if it is treated at all, in a separate behavioral health system. mHealth could help integrate addiction treatment in primary care. Objective: The objective of this paper was to report the effects of implementing an mHealth system for addiction in primary care on both patients and clinicians. Methods: In this implementation research trial, an evidence-based mHealth system named Seva was introduced sequentially over 36 months to a maximum of 100 patients with substance use disorders (SUDs) in each of three federally qualified health centers (FQHCs; primary care clinics that serve patients regardless of their ability to pay). This paper reports on patient and clinician outcomes organized according to the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Results: The outcomes according to the RE-AIM framework are as follows: Reach—Seva reached 8.31% (268/3226) of appropriate patients. Reach was limited by our ability to pay for phones and data plans for a maximum of 100 patients per clinic. Effectiveness—Patients who were given Seva had significant improvements in their risky drinking days (44% reduction, (0.7-1.25)/1.25, P=.04), illicit drug-use days (34% reduction, (2.14-3.22)/3.22, P=.01), quality of life, human immunodeficiency virus screening rates, and number of hospitalizations. Through Seva, patients also provided peer support to one another in ways that are novel in primary care settings. Adoption—Patients sustained high levels of Seva use—between 53% and 60% of the patients at the 3 sites accessed Seva during the last week of the 12-month implementation period. Among clinicians, use of the technology was less robust than use by patients, with only a handful of clinicians using Seva in each clinic and behavioral health providers making most referrals to Seva in 2 of the 3 clinics. Implementation—At 2 sites, implementation plans were realized successfully; they were delayed in the third. Maintenance—Use of Seva dropped when grant funding stopped paying for the mobile phones and data plans. Two of the 3 clinics wanted to maintain the use of Seva, but they struggled to find funding to support this. Conclusions: Implementing an mHealth system can improve care among primary care patients with SUDs, and patients using the system can support one another in their recovery. Among clinicians, however, implementation requires figuring out how information from the mHealth system will be used and making mHealth data available in the electronic health (eHealth) record. In addition, paying for an mHealth system remains a challenge.

The third paper in a series on how learning health systems can use routinely collected electronic health data (EHD) to advance knowledge and support continuous learning, this review describes how analytical methods for individual-level electronic health data EHD, including regression approaches, interrupted time series (ITS) analyses, instrumental variables, and propensity score methods, can also be used to address the question of whether the intervention “works.”The two major potential sources of bias in non-experimental studies of health care interventions are that the treatment groups compared do not have the same probability of treatment or exposure and the potential for confounding by unmeasured covariates. Although very different, the approaches presented in this chapter are all based on assumptions about data, causal relationships, and biases. For instance, regression approaches assume that the relationship between the treatment, outcome, and other variables is properly specified, all of the variables are available for analysis (i.e., no unobserved confounders) and measured without error, and that the error term is independent and identically distributed. The instrumental variables approach requires identifying an instrument that is related to the assignment of treatment but otherwise has no direct on the outcome. Propensity score methods approaches, on the other hand, assume that there are no unobserved confounders. The epidemiological designs discussed also make assumptions, for instance that individuals can serve as their own control.To properly address these assumptions, analysts should conduct sensitivity analyses within the assumptions of each method to assess the potential impact of what cannot be observed. Researchers also should analyze the same data with different analytical approaches that make alternative assumptions, and to apply the same methods to different data sets. Finally, different analytical methods, each subject to different biases, should be used in combination and together with different designs, to limit the potential for bias in the final results.

BACKGROUND Performance feedback is central to data-driven models of quality improvement, but the use of claims-based data for feedback has received little attention. PURPOSE To examine the challenges, uses, and limitations of quarterly Medicare claims-based performance feedback reports generated for practices participating in the Comprehensive Primary Care (CPC) initiative from 2012 to 2015. METHODS Mixed methods study of nearly 500 CPC practices in seven regions, combining pilot testing; systematic monitoring; surveys; in-depth interviews; user feedback; and input from data feedback team. RESULTS Designing reports required addressing issues about timing, data completeness and reliability, variations in patient risk across practices, and use of benchmarks and metrics understandable to users. Practices' ability to use reports constructively depended on their experience, analytic resources, expectations, and perceptions about the role of primary care in improving reported outcomes. CONCLUSIONS Generating claims-based feedback reports that support practices' quality improvement efforts requires a significant investment of analytic expertise, time, resources, continuous improvement, and technical assistance. IMPLICATIONS Claims-based performance feedback can provide insight into patterns of patients' care across provider settings and opportunities for improvement, but practices need data from other sources to manage patients in real time or assess the short-term effects of specific changes in care delivery.

Background Opioid addiction and overdose are epidemic in the U.S. Victims of traumatic injury are at greater than average risk for opioid misuse and related complications. Potential risk screens and preventive interventions in this clinical population remain under-investigated. The current project seeks to develop and pilot the implementation of a screening tool for opioid risk at American College of Surgeons (ACS) Level I and Level II trauma centers. Methods The project began with an online survey, which was sent to Wisconsin trauma center medical directors and trauma coordinators for the purpose of gathering information on current substance use screening practices. Next, a focus group of trauma center staff was convened to discuss barriers and facilitators to screening, resources available and needed to support trauma patients with opioid use disorders, and measurable clinical observations that could indicate a patient’s potential risk for opioid misuse. Data from the surveys and focus group were combined to inform the data collection instruments that are currently being administered to patients recruited from the University of Wisconsin Hospital Trauma Inpatient and Orthopedic Surgery Services. Eligible and consenting patients complete standardized measures of socio-demographics, substance use history, opioid misuse risk, mental health, medical history, and injury and pain severity. Follow up visits at weeks 4, 12, and 24 after hospital discharge assess hypothesized risk factors for opioid addiction and opioid use disorder diagnosis. At the completion of patient data collection, a forward stepwise regression will identify factors of most significant risk of the development of opioid use disorder after traumatic injury. This modeling will inform the development of a novel opioid risk screening tool, which will undergo pilot implementation at 4 Wisconsin ACS Level I and Level II trauma centers, using an evidence-based implementation strategy with roots in systems engineering. Discussion Positive findings from the proposed work would lead to improved, standardized opioid risk screening practices among victims of traumatic injury. The ultimate goal of this and future work is to reduce the likelihood of opioid misuse, addiction, and related complications, such as overdose and death. Trial registration Clinicaltrials.gov registration number: NCT02861976. Date of registration: Feb 9, 2016

Psilocybin is a psychedelic tryptamine that has shown promise in recent clinical trials for the treatment of depression and substance use disorders. This open-label study of the pharmacokinetics of psilocybin was performed to describe the pharmacokinetics and safety profile of psilocybin in sequential, escalating oral doses of 0.3, 0.45, and 0.6 mg/kg in 12 healthy adults. Eligible healthy adults received 6–8 h of preparatory counseling in anticipation of the first dose of psilocybin. The escalating oral psilocybin doses were administered at approximately monthly intervals in a controlled setting and subjects were monitored for 24 h. Blood and urine samples were collected over 24 h and assayed by a validated liquid chromatography-tandem mass spectrometry (LC–MS/MS) assay for psilocybin and psilocin, the active metabolite. The pharmacokinetics of psilocin were determined using both compartmental (NONMEM) and noncompartmental (WinNonlin) methods. No psilocybin was found in plasma or urine, and renal clearance of intact psilocin accounted for less than 2% of the total clearance. The pharmacokinetics of psilocin were linear within the twofold range of doses, and the elimination half-life of psilocin was 3 h (standard deviation 1.1). An extended elimination phase in some subjects suggests hydrolysis of the psilocin glucuronide metabolite. Variation in psilocin clearance was not predicted by body weight, and no serious adverse events occurred in the subjects studied. The small amount of psilocin renally excreted suggests that no dose reduction is needed for subjects with mild–moderate renal impairment. Simulation of fixed doses using the pharmacokinetic parameters suggest that an oral dose of 25 mg should approximate the drug exposure of a 0.3 mg/kg oral dose of psilocybin. Although doses of 0.6 mg/kg are in excess of likely therapeutic doses, no serious physical or psychological events occurred during or within 30 days of any dose. NCT02163707.

Objective To identify the most robust methods for evaluating alternative payment models (APMs) in the emerging health care delivery system environment. Study Design (Approach) We assess the impact of widespread testing of alternative payment models on the ability to find credible comparison groups. We consider the applicability of factorial research designs for assessing the effects of these models. Principal Findings The widespread adoption of alternative payment models could effectively eliminate the possibility of comparing APM results with a “pure” control or comparison group unaffected by other interventions. In this new environment, factorial experiments have distinct advantages over the single-model experimental or quasi-experimental designs that have been the mainstay of recent tests of Medicare payment and delivery models. Conclusions The best prospects for producing definitive evidence of the effects of payment incentives for APMs include fractional factorial experiments that systematically vary requirements and payment provisions within a payment model.

Objective To describe the modified Patient-Centered Medical Home Assessment (M-PCMH-A) survey module developed to track primary care practices' care delivery approaches over time, assess whether its underlying factor structure is reliable, and produce factor scores that provide a more reliable summary measure of the practice's care delivery than would a simple average of question responses. Data sources/study setting Survey data collected from diverse practices participating in the Comprehensive Primary Care (CPC) initiative in 2012 (n = 497) and 2014 (n = 493) and matched comparison practices in 2014 (n = 423). Study design Confirmatory factor analysis. Data collection Thirty-eight questions organized in six domains: Access and Continuity of Care, Planned Care for Chronic Conditions and Preventive Care, Risk-Stratified Care Management, Patient and Caregiver Engagement, Coordination of Care across the Medical Neighborhood, and Continuous Data-Driven Improvement. Principal findings Confirmatory factor analysis suggested using seven factors (splitting one domain into two), reassigning two questions to different domain factors, and removing one question, resulting in high reliability, construct validity, and stability in all but one factor. The seven factors together formed a single higher-order factor summary measure. Factor scores guard against potential biases from equal weighting. Conclusions The M-PCMH-A can validly and reliably track primary care delivery across practices and over time using factors representing seven key components of care as well as an overall score. Researchers should calculate factor loadings for their specific data if possible, but average scores may be suitable if they cannot use factor analysis due to resource or sample constraints.

Background Peripheral blood stem cell (PBSC) mobilization is routinely undertaken prior to autologous stem cell transplantation (ASCT) in patients with multiple myeloma (MM). A number of studies have identified risk factors for poor PBSC mobilization, however, little data exists to correlate mobilization with disease-specific outcomes in this patient population. Prospective work in MM has demonstrated similar outcomes in a homogenous patient population. Methods In this single institution analysis, we retrospectively studied the impact of poor PBSC mobilization on progression free survival (PFS) and OS in MM patients undergoing PBSC mobilization. Poor mobilizers are defined as patients that collected 10 mcg/kg/day) and/or plerixafor can significantly improve mobilization and ASCT chances in this population. Discussion These data indicate that poor mobilization can be predictable and is associated with more aggressive disease biology and worse outcomes, warranting intensive post-ASCT management.

This first issue in the Hot Topics in COPD and Asthma Management series (issue 1) with Dr. Brown focuses on unmet needs in COPD symptom assessment and management and discusses practical approaches for addressing these unmet needs.

With the growing popularity of self-service technologies (SST), businesses have to determine how to combine traditional human service with SST technologies. These mix problems have not received adequate attention in the research literature. This paper offers a decision model for solving mix problems between human service channels and SSTs. The decision problem cannot be determined as a traditional max or min problem and it is fuzzy. In fuzzy problems, the decision maker (DM) is considered as the focal point with the relevant knowledge and preferences and therefore, the objective is to maximize the DM's preferences. This paper develops a decision support system for eliciting a DM's value function when the service channels are considered to be substitutes, but when the rate of substitution may change and then uses a linear-fractional model to fit the DM's data and optimize the DM's preferences. A service mix problem for a grocery store with human service providers and SSTs is used to demonstrate how the decision model can be employed to analyze and solve service mix decision making problems. Copyright © 2014 John Wiley & Sons, Ltd.

Previous papers developed a method to easily elicit a decision maker's (DM) preferences and account for changes in the DM's preference structure. Those preferences are modeled by piecewise linear indifference curves with varying slopes producing a piecewise linear-fractional value function. Compared with traditional optimization problems which traditionally use cost minimization or revenue maximization, this model is DM-specific, it generates a knowledge set (KS) and allows the DM to find an optimal solution based on his/her expertise and preferences. When combined with real world constraints, maximizing the DM's preferences generates a decision support system (DSS) for solving specific organizational problems. This paper develops an efficient algorithm to solve a mathematical programming problem with a linear fractional objective function that models changing DM preferences and linear constraints. A DSS is developed and its algorithm is illustrated by constructing a specific example of the DSS for scheduling a police force when the objective is to maximize the police chief's expertise and preferences regarding law enforcement.

Millions of Americans need but don’t receive treatment for substance use, and evidence suggests that addiction-focused interventions on smart phones could support their recovery. There is little research on implementation of addiction-related interventions in primary care, particularly in Federally Qualified Health Centers (FQHCs) that provide primary care to underserved populations. We used mixed methods to examine three FQHCs’ implementation of Seva, a smart-phone app that offers patients online support/discussion, health-tracking, and tools for coping with cravings, and offers clinicians information about patients’ health tracking and relapses. We examined (a) clinicians’ initial perspectives about implementing Seva, and (b) the first year of implementation at Site 1. Prior to staggered implementation at three FQHCs (Midwest city in WI vs. rural town in MT vs. metropolitan NY), interviews, meetings, and focus groups were conducted with 53 clinicians to identify core themes of initial expectations about implementation. One year into implementation at Site 1, clinicians there were re-interviewed. Their reports were supplemented by quantitative data on clinician and patient use of Seva. Clinicians anticipated that Seva could help patients and make behavioral health appointments more efficient, but they were skeptical that physicians would engage with Seva (given high caseloads), and they were uncertain whether patients would use Seva. They were concerned about legal obligations for monitoring patients’ interactions online, including possible “cries for help” or inappropriate interactions. One year later at Site 1, behavioral health care providers, rather than physicians, had incorporated Seva into patient care, primarily by discussing it during appointments. Given workflow/load concerns, only a few key clinicians monitored health tracking/relapses and prompted outreach when needed; two researchers monitored the discussion board and alerted the clinic as needed. Clinician turnover/leave complicated this approach. Contrary to clinicians’ initial concerns, patients showed sustained, mutually supportive use of Seva, with few instances of misuse. Results suggest the value of (a) focusing implementation on behavioral health care providers rather than physicians, (b) assigning a few individuals (not necessarily clinicians) to monitor health tracking, relapses, and the discussion board, (c) anticipating turnover/leave and having designated replacements. Patients showed sustained, positive use of Seva. ClinicalTrials.gov ( NCT01963234 ).

Background Adoption of evidence-based practices takes place at a glacial place in healthcare. This research will pilot test an innovative implementation strategy – systems consultation –intended to speed the adoption of evidence-based practice in primary care. The strategy is based on tenets of systems engineering and has been extensively tested in addiction treatment. Three innovations have been included in the strategy – translation of a clinical practice guideline into a checklist-based implementation guide, the use of physician peer coaches (‘systems consultants’) to help clinics implement the guide, and a focus on reducing variation in practices across prescribers and clinics. The implementation strategy will be applied to improving opioid prescribing practices in primary care, which may help ultimately mitigate the increasing prevalence of opioid abuse and addiction. Methods/Design The pilot test will compare four intervention clinics to four control clinics in a matched-pairs design. A leading clinical guideline for opioid prescribing has been translated into a checklist-based implementation guide in a systematic process that involved experts who wrote the guideline in consultation with implementation experts and primary care physicians. Two physicians with expertise in family and addiction medicine are serving as the systems consultants. Each systems consultant will guide two intervention clinics, using two site visits and follow-up communication by phone and email, to implement the translated guideline. Mixed methods will be used to test the feasibility, acceptability, and preliminary effectiveness of the implementation strategy in an evaluation that meets standards for ‘fully developed use’ of the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance). The clinic will be the primary unit of analysis. Discussion The systems consultation implementation strategy is intended to generalize to the adoption of other clinical guidelines. This pilot test is intended to prepare for a large randomized clinical trial that will test the strategy against other implementation strategies, such as audit/feedback and academic detailing, used to close the gap between knowledge and practice. The systems consultation approach has the potential to shorten the famously long time it takes to implement evidence-based practices and clinical guidelines in healthcare.

As one of the initial fifteen participants in the Medicare Coordinated Care Demonstration, the Washington University School of Medicine in St. Louis was not able to demonstrate any reduction in hospitalizations or Medicare spending for the patients it served. In fact, the Washington University program increased total Medicare spending by 12 percent. But after a redesign, the results changed. The program stopped conducting care management of most of its patients via telephone from a remote site in California and, instead, served all patients through frequent phone and occasional in-person contact from local care managers in St. Louis. Care management efforts were focused especially on patients deemed at greatest risk of hospitalization, and stronger hospital transition planning and medication reconciliation were provided, among other changes. After that point, the program reduced hospitalizations by 12 percent and monthly Medicare spending by $217 per enrollee-more than offsetting the program's monthly $151 care management fee. The results underscore findings from the overall Medicare Coordinated Care Demonstration that suggest that programs with more in-person contacts were more likely than others to build trusting relationships with patients and providers, improve patient adherence to care plans, and address additional needs and barriers that entirely telephonic contacts had been unable to identify. The results also indicate that programs can be more effective by focusing on the highest-risk patients, for whom the largest savings resulted.

Family-focused prevention programs have been shown to effectively reduce a range of negative behavioral health outcomes but have had limited reach. Three key barriers must be overcome to expand the reach of family-focused prevention programs and thereby achieve a significant public health impact. These barriers are: (1) current social norms and perceptions of parenting programs; (2) concerns about the expertise and legitimacy of sponsoring organizations to offer parenting advice; and (3) a paucity of stable, sustainable funding mechanisms. Primary healthcare settings are well positioned to overcome these barriers. Recent changes within health care make primary care settings an increasingly favorable home for family-focused prevention and suggest possibilities for sustainable funding of family-focused prevention programs. This paper discusses the existing advantages of primary care settings and lays out a plan to move toward realizing the potential public health impact of family-focused prevention through widespread implementation in primary healthcare settings.

Background Only 7.8 % of individuals meeting diagnostic criteria for alcohol use disorder (AUD) receive treatment in a given year. Most individuals with AUDs are identified in primary care (PC) settings and referred to substance use disorders (SUD) clinics; however, only a minority of those referred attend treatment services. Safe and effective pharmacological treatments for AUD exist, but they are rarely prescribed by PC providers. The objective of this study is to refine, implement, and evaluate an intervention to integrate pharmacological AUD treatment options into PC settings. This paper provides a detailed description of the intervention design and the evaluation components. Methods/design Three large Veterans Health Administration (VHA) facilities are participating in the intervention. The intervention targets stakeholder groups with tailored strategies based on implementation theory and prior research identifying barriers to implementation of AUD pharmacotherapy. Local SUD providers and primary care mental health integration (PCMHI) providers are trained to serve as local implementation/clinical champions and receive external facilitation. PC providers receive access to consultation from local and national clinical champions, educational materials, and a dashboard of patients with AUD on their caseloads for case identification. Veterans with AUD diagnoses receive educational information in the mail just prior to a scheduled PC visit. Effectiveness of the intervention will be evaluated through an interrupted time series with matched controls to monitor change in facility level AUD pharmacotherapy prescribing rates. Following Stetler’s four-phase formative evaluation (FE) strategy, FE methods include (1) developmental FE (pre-implementation interviews with champions, PC providers, and Veterans), (2) implementation-focused FE (tracking attendance at facilitation meetings, academic detailing efforts by local champions, and patient dashboard utilization), (3) progress-focused FE (tracking rates of AUD pharmacotherapy prescribing and rates of referral to PCMHI and SUD specialty care), and (4) interpretive FE (post-implementation interviews with champions and PC providers). Analysis of FE data will be guided by the Consolidated Framework for Implementation Research (CFIR). Discussion If demonstrated to be successful, this implementation strategy will provide a replicable, feasible, and relative low-cost method for integrating AUD treatment services into PC settings, thereby increasing access to AUD treatment.

Drug treatment courts (DTCs) are widely viewed as effective diversion programs for drug-involved offenders; however, previous studies frequently used flawed comparison groups. In the current study, the author compared rates of recidivism for drug court participants to rates for a traditionally adjudicated comparison group matched on potentially important characteristics. The Wisconsin Circuit Court database was searched for individuals with drug-related charges during the period from 2004–2006. Of the resulting data set, 137 DTC participants were identified. These DTC participants were then matched on age, gender, ethnicity, and criminal history to traditionally adjudicated individuals (non-DTC, n = 274). Kaplan-Meier curves of time to new crime were compared for the two main study groups and for potentially important subgroups. The DTC group demonstrated longer time to new crime (p = 0.028). Reductions in recidivism for DTC versus non-DTC were enhanced for women, older individuals, minorities, and those ...

The classical traveling-salesman problem involves the establishment of a tour around a set of points in a plane such that each point is intersected only once and the circuit is of minimal total length. When the length of a salesman's tour cannot exceed a specified constant, the problem becomes that of finding the fewest number of salesmen such that every city is visited by a salesman and the length of each salesman's tour does not exceed a specified constant. This is the chromatic traveling-salesmen problem. An algorithm for this problem is developed and is used to create periodic markets in parts of Sierra Leone. Fifteen rural areas were examined from Sierra Leone, and weekly market places were identified in each area. Salesmen were to be assigned to an area so that each market place was visited and each tour (or periodic ring) did not exceed forty hours. The chromatic traveling-salesmen algorithm was used to minimize the number of periodic rings needed for each area and provide the specific tour for each ring.

It was no coincidence that the first notable baseball club of young ladies took the field in the upstate New York village of Peterboro. The sponsors were well known political figures, committed to the cause of equal rights for women. Gerrit Smith was as radical as he was wealthy, an old friend of Frederick Douglass and John Brown. In the spring of 1851, Smith's daughter, Elizabeth Miller, disgusted with the difficulty of working in the long skirts of the period, had designed a more comfortable outfit, consisting of Turkish trousers beneath a short dress. Her idea was soon adopted by other feminists, including her cousin, Elizabeth Cady Stanton, and their friend Amelia Bloomer, who popularized the costume in her magazine, The Lily.1Conservative commentators of both sexes dismissed the notion of sharing the nation's diamonds with women. A columnist for the Ladies' Repository listed a number of suitable outdoor activities for girls, but stated flatly that "Base Ball would seem so far out of the line of feminine pursuits that nothing need be said of it."2 Mr. Hooper of Appleton's Magazine argued that the National Pastime's "moral influence" was shown by its exclusion of the opposite sex, noting proudly that "while women are soliciting office and demanding the franchise, base ball clubs are only accessible to men."3The new organization was there to give them the lie. Word of their innovation spread quickly, thanks to Mrs. Cady Stanton, who shared the news with her many contacts in the press. On August 13, 1868, the Buffalo Courier and Republic summarized her report, noting that "Nannie Miller, a granddaughter of Gerrit Smith's, is captain, and handles the bat with a grace and strength worthy of note. It was a pretty sight to see the girls with their white dresses and blue ribbons flying, in full possession of the public square last Saturday afternoon, while the boys were quiet spectators of the scene." An engraved illustration, showing the club at play, helped reinforce the message.4Others soon adopted the notion. The following season, Cincinnati, home of the undefeated Red Stockings, also hosted a club "composed entirely of young ladies, who play very well."5 In Evansville, Illinois, the students of a female seminary followed suit. "They call themselves the Dianas," noted Oliver Optic's Magazine, "and they lately received a challenge from the Baltic club of Chicago, Juniors."6 The movement spread as far south as Columbus, Georgia, and in 1872, Appleton's reported that "the swiftest 'pitch' in the country is a young woman, aged 23, belonging to a Minnesota female base ball club."7In the early 1870s, the focus of organized baseball shifted from clubs of gentlemen amateurs (more or less) to lineups composed of the best available professional players. In the fall of 1875, readers of the New York Clipper, which featured sports and theater, learned thatthe latest commotion in the base ball line is the formation of a club composed of young ladies-9 blondes and 9 brunettes-at Springfield, Ill. The originators of the idea, Frank Myers, S. B. Brock, and Thomas Halligan, under the impression that there is money in it, propose to give exhibitions in the principal cities, depending on the novelty of the thing to render it a success.8The "first game of baseball ever played in public for gate money between feminine ball-tossers" took place in the Illinois capital on September 11. The press was advised that the players were "a selected troupe of girls of reputable character who have shown some degree of aptitude in ball playing." The Clipper's correspondent noted thatboth clubs wear a handsome new uniform, which does not differ materially from those worn by ordinary clubs. The Brunettes wear white suits trimmed with blue. The Blondes wear blue suits trimmed with white. They also have light leather gloves, and use a lighter ball than that required by the rules. The bases and field are a trifle over half the ordinary field, the bases being only 50 feet apart. …

It is true that the obituaries of Abner Doubleday, the former general who had fired "the first shot for the Union" from Fort Sumter, did not connect his name with baseball. They also failed to mention that he had served as a commander of a unit of "Buffalo Soldiers" and-to "add to the happiness of the men" as they patrolled the Texas frontier in 1871-had decided "to purchase baseball implements" and "a Magic Lantern."1As plans progressed for the opening of Baseball's Hall of Fame in Cooperstown in 1939, the underlying premise that young Doubleday had invented the game there was called into question. The most reasonable argument was that baseball was not the product of one mind, but had evolved over a number of decades.When some cited the lack of evidence that Doubleday had even played the sport, a letter was received from Robert S. Doubleday, of Tacoma, Washington, stating: "The last time the General was at our house in New York, I was just a young boy, but I very well remember his telling me the story of the beginnings of baseball." This testimony was scoffed at by critics, but young Robert, whose father was a cousin of Abner, lived in Brooklyn in 1880, at a time when the retired soldier had settled in the New York City area.The harshest criticism was reserved for the man whose 1905 letters to the Mills Commission, appointed to determine the origin of the National Pastime, had provided enough evidence to justify its conclusion that the future general had invented baseball. As it happened, "Colonel" Mills was a friend of Doubleday, and in 1893 had led the honor guard at his funeral. Veteran sportswriter Will Rankin had answered the report of the commission with the following blast, reprinted in Alfred Spink's The National Game, in 1911:"The latest of all the fakes was the one with the Cooperstown flavor in which one Abner Graves of Denver, Colo., declared that the late General Doubleday was its designer and christener. He said he was a kidlet and was on the ground when General Doubleday turned the trick in 1839."2Rankin's argument was based on the idea that attendance at West Point would have prevented the cadet from appearing on a ball field in Cooperstown. "What a pity for him, he did not select some other year so that his air bubble could not have been pricked so easily. The records at West Point and the war Department at Washington, D. C. were the means of exposing his fake." Conveniently overlooked was the fact that the Military Academy routinely granted furloughs to students upon the completion of their second year, and that graduates often returned home to await their regular army assignments.The testimony of Abner Graves was gradually dismissed on the grounds that he was too old and eccentric to remember events clearly and that, having been born in 1834, he had been too young to be involved in baseball in 1839. Without a reputable witness, the case for Doubleday's "invention" fell apart and a substitute creator was apparently found in the person of Alexander Cartwright. In recent years, however, it has become clear that baseball had many "fathers" and that early versions of the modern game were played in New York City and Rochester in the 1820s and 1830s.Once the assumption that baseball was invented by one man is disposed of, it becomes possible to take a fresh look at the stories told by Abner Graves and Abner Doubleday's actual contribution to the national pastime.As might be expected, dates were not significant to a young boy, and when urged to "positively name the year of Doubleday's invention," Graves stated that "it was either 1839, 1840, of '41, and in the spring of the year."3 What followed this remark was clearer:I remember well Abner Doubleday explaining base ball to a lot of us that were playing marbles in the street, in front of Cooper's tailor shop, and drawing a diagram in the dirt with a stick. We smaller boys didn't like it as it shut us out of playing while Town Ball let in everyone who could run and catch flies. …

Before the Civil War, the most popular outdoor activity in New York City may have been fighting. The prize ring was popular, but rioting in streets and public squares attracted more participants. In fact, there was little distinction between professional pugilists and gang brawlers. Heavyweights like John Morrissey were also employed as "shoulder-hitters" by political gangs like the Empire Club, run by Captain Isaiah Rynders, a leading Democrat, or the Short Boys of Bill "the Butcher" Poole, hero of the Know-Nothings.Rynders and his crew delighted in attacking abolitionist gatherings. In May 1850 they showed up in force at an antislavery convention at the Broadway Tabernacle. Speaker Frederick Douglass defused the attack by inviting a racist orator to share the platform. To the argument that Negroes were a kind of ape, Douglass, whose father was probably a slave-owner, responded:"Captain Rynders, do you think I am a monkey?""Oh no," replied Rynders, "you are half a white man.""Then I am half man and half monkey?""Yes.""And half brother to Captain Rynders?"With the audience "united in laughter and applause," Douglass spoke his piece. It was a short-lived triumph, however. Threats of mayhem truncated the conference and, several days later, while walking with two white women in Battery Park, Douglass was assaulted.1A year later, on May 27, 1851, the Elysian Fields in Hoboken was the scene of what the Brooklyn Eagle described as... one of the most earnest and angry promiscuous fights that has ever occurred in this country. The Germans of this city, with their families, assembled in large numbers in Hoboken, for the celebration of their Maifest. Scarcely two hours had elapsed when they were set upon by a party of rascals called "Short Boys."At first the Germans were disposed to avoid a conflict, but finding it impossible to do so, they sallied out against them, and drove them to the Elysian Fields. The Short Boys took refuge in a house kept by one McCarthy, which was attacked by the Germans, and greatly injured. McCarthy, in defense of himself and his house, shot two of the Germans with a double barreled gun, killing them, it is said.2Fortunately, this incident did not disrupt the plans of the tenants of the Club Room at McCarty's Colonnade House. The Knickerbocker Base Ball Club had been challenged to play a home-and-home series by the recently formed Washington Club. After a promising start, the Knickerbockers had been, in the words of D. L. Adams, in "pursuit of pleasure under difficulties." "There was then no rivalry," he recalled, "as no other club was formed until 1850, and during these five years baseball had a desperate struggle for existence."3It happened that the first match, on June 3, was an away game at the Red House Grounds in Harlem. Down 7-3 after two innings, the Knickerbockers rallied to win 21-11. Two weeks later, the clubs met for a thrilling return match at the Elysian Fields, with the home club managing a 22-20 victory. As usual, "an entertainment was given after play at McCarty's Hotel."Since 1844, the waiters at the Colonnade House had been privy to the world of the New York and Knickerbocker Base Ball clubs, had watched their game develop in the neighboring fields, and were a fixture at the convivial dinners when plays and points were reviewed. The Stevens family, which owned the Hoboken grounds, like many upperclass New Yorkers employed colored help. Michael McCarty, born in Ireland, employed his countrymen as barkeepers but conformed to the expectations of his gentlemen patrons by hiring black servants (including live-in waiter Jeremiah Jackson).This link between early baseball and black New Yorkers was soon severed, however. On March 7, 1852, the Brooklyn Eagle reported that "Mr. McCarty of the Elysian Fields Hotel, was accidentally shot and killed by his own act yesterday." Sarah McCarty, 27 years old with four children under the age of nine, was leftin charge. …

The Sacramento-San Joaquin Delta, the landward reach of the San Francisco Estuary, provides habitat for threatened delta smelt, endangered winter-run Chinook salmon, and other species of concern. It is also the location of huge freshwater diversion facilities that entrain large numbers of fish. Reducing the entrainment of listed fishes into these facilities has required curtailment of pumping, reducing the reliability of water deliveries. We reviewed the first 5 years (2001-2005) of the Environmental Water Account (EWA), a program instituted to resolve conflicts between protecting listed fishes and providing a reliable water supply. The EWA provided fishery agencies with control over 0.2-0.4 km(3) of water to be used for fish protection at no cost to users of exported water, and fish agencies guaranteed no disruption of water supply for fish protection. The EWA was successful in reducing uncertainty in water supply; however, its contribution to the recovery of listed fishes was unclear. We estimated the effectiveness of the EWA to be modest, increasing the survival of winter-run Chinook salmon by 0-6% (dependent on prescreen mortality), adult delta smelt by 0-1%, and juvenile delta smelt by 2-4%. Allocating EWA water for a single life stage of one species could provide larger gains in survival. An optimally allocated EWA of equal size to the median of the first 5 years could increase abundance of juvenile delta smelt up to 7% in the springs of dry years. If the EWA is to become a long-term program, estimates of efficacy should be refined. If the program is to be held accountable for quantitative increases in fish populations, it will be necessary to integrate scientific, possibly experimental, approaches.

The Cash and Counseling Demonstration and Evaluation was designed to assess whether a new, consumer-directed manner of obtaining personal care services (PCS) or home and community based services (HCBS) could improve the outcomes of beneficiaries and their caregivers without increasing the Medicaid cost per recipient for such services. Under Cash and Counseling, Medicaid beneficiaries could receive a monthly allowance to be used in lieu of PCS (in Arkansas and New Jersey) or HCBS waiver services (in Florida) they were authorized to receive. This allowance was supposed to be set so that per-person costs for care recipients under Cash and Counseling would be approximately equal to the amount that would have been expected had consumers received care under the traditional agency-based program. The program could still affect Medicaid costs, however, if the program increased the proportion of beneficiaries receiving care or the amount that they received. Furthermore, the program could affect Medicaid costs for services other than personal care in either direction. These costs could decrease if Cash and Counseling was more effective than the traditional PCS or waiver program in providing Medicaid beneficiaries with the assistance they need to remain at home instead of in nursing facilities. Costs could increase if beneficiaries were more likely to be injured or experience adverse events related to caregiving under consumer direction. While Cash and Counseling only intended to change the manner of service provision to eligible beneficiaries, it had the potential to expand the number of recipients and the amount of services they used for two reasons. First, Cash and Counseling could improve access to care by expanding the supply of home-care workers as Cash and Counseling participants could hire family and friends who would not have been interested in working for an agency during a time of agency worker shortages. Additionally, individuals who found traditional PCS or waiver services unacceptable might find a flexible allowance appealing, and therefore be more likely to seek services under Cash and Counseling. In fact, results from the Channeling demonstration suggested that offering such services did not reduce long-term care costs because many who used the more attractive home-care alternatives would not have entered a nursing home under any circumstances (Kemper, Applebaum, and Harrigan 1987; Weissert, Cready, and Pawelak 1988). The potential for cost increases due to enrollment in the program by people who would not have sought agency services was greatest in Arkansas, as it was the only state that allowed “new” PCS applicants to enroll in Cash and Counseling. Individuals had to have been previously assessed to receive personal care (in New Jersey) or already receiving HCBS waiver services (in Florida) in order to enroll in the program. The goals of this paper are to examine Cash and Counseling's (1) effects on the costs and use of PCS/waiver services, (2) spillover effects on other Medicaid costs,1 and (3) net effects on total Medicaid costs. We also seek to explain why Cash and Counseling might have affected costs for PCS/waiver services. In short, we find that Medicaid costs for PCS/waiver services were higher for the treatment group than for the control group during the 2 years after enrollment for every state and age group except among the elderly in Florida (where less than half of treatment group members actually received the intervention). Medicaid costs for PCS/waiver services were higher both because the program increased the number of people receiving paid care (particularly in Arkansas, but also in New Jersey) and because costs per recipient were greater for the treatment group than for the control group (in all three states). Costs per recipient were higher for the treatment group primarily because (1) the control group received less care than authorized at baseline (in Arkansas and New Jersey), and (2) the treatment group received more care than authorized at baseline (among children and the nonelderly in Florida). While the participants' higher personal care/waiver costs were partially offset by lower costs for other long-term care services, total annual Medicaid costs were higher for the treatment group than for the control group for every state and age group, with treatment–control cost differences ranging from 1 percent (and statistically insignificant) for the elderly in Florida, to 17 percent for the elderly in Arkansas in year 1.