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Measures of intimate partner violence (IPV) have largely been developed and validated in heterosexual, cisgender samples, with little attention to whether these measures are culturally appropriate for sexual and gender minority (SGM) populations. However, rates of IPV are two to three times higher among SGM than heterosexual populations, highlighting the importance of culturally appropriate measures of IPV for SGM populations. In this article, after reviewing key problems with the use of existing IPV measures with SGM samples, we describe the development of a toolkit of new and adapted measures of IPV for use with SGM assigned female at birth (SGM-AFAB) populations, including an adapted version of the Conflict Tactics Scale–Revised, an adapted measure of coercive control, and the newly developed SGM-Specific IPV Tactics Measure. Using data from a sample of 352 SGM-AFAB individuals, we then test the psychometric properties of these three measures, including their factor structures, internal reliability, and convergent/divergent validity. Results provide initial evidence of the reliability and validity of each measure. Together, these three measures comprise a culturally appropriate and psychometrically validated measurement toolkit for studying a broad range of IPV tactics among SGM-AFAB that will help build a foundation for more in-depth research into IPV in SGM populations.

Although intimate partner violence (IPV) is highly prevalent among lesbian, gay, bisexual, and transgender (LGBT) youth, little is known regarding its developmental patterns, risk factors, or health-related consequences. We examined IPV victimization in an ethnically diverse community-based convenience sample of 248 LGBT youth (aged 16-20 at study outset) who provided six waves of data across a 5-year period. Results from multilevel models indicated high, stable rates of IPV victimization across this developmental period (ages 16-25 years) that differed between demographic groups. Overall, 45.2% of LGBT youth were physically abused and 16.9% were sexually victimized by a dating partner during the study. Odds of physical victimization were 76% higher for female than for male LGBT youth, 2.46 times higher for transgender than for cisgender youth, and 2 to 4 times higher for racial-ethnic minorities than for White youth. The prevalence of physical IPV declined with age for White youth but remained stable for racial-ethnic minorities. Odds of sexual victimization were 3.42 times higher for transgender than for cisgender youth, 75% higher for bisexual or questioning than for gay or lesbian youth, and increased more with age for male than female participants. Within-person analyses indicated that odds of physical IPV were higher at times when youth reported more sexual partners, more marijuana use, and lower social support; odds of sexual IPV were higher at times when youth reported more sexual partners and more LGBT-related victimization. In prospective analyses, sexual IPV predicted increased psychological distress; both IPV types marginally predicted increased marijuana use.

Researchers have long observed that problem behaviors tend to cluster together, particularly among adolescents. Epidemiological studies have suggested that this covariation is due, in part, to common genetic influences, and a number of plausible candidates have emerged as targets for investigation. To date, however, genetic association studies of these behaviors have focused mostly on unidimensional models of individual phenotypes within European American samples. Herein, we compared a series of confirmatory factor models to best characterize the structure of problem behavior (alcohol and marijuana use, sexual behavior, and disruptive behavior) within a representative community-based sample of 592 low-income African American adolescents (50.3% female), ages 13 to 18. We further explored the extent to which 3 genes previously implicated for their role in similar behavioral dimensions (CHRM2, GABRA2, and OPRM1) independently accounted for variance within factors specified in the best-fitting model. Supplementary analyses were conducted to derive comparative estimates for the predictive utility of these genes in more traditional unidimensional models. Findings provide initial evidence for a bifactor structure of problem behavior among African American adolescents and highlight novel genetic correlates of specific behavioral dimensions otherwise undetected in an orthogonal syndromal factor. Implications of this approach include increased precision in the assessment of problem behavior, with corresponding increases in the reliability and validity of identified genetic associations. As a corollary, the comparison of primary and supplementary association analyses illustrates the potential for overlooking and/or overinterpreting meaningful genetic effects when failing to adequately account for phenotypic complexity.

Suicide is prevalent among youth, especially those involved in the juvenile justice system. Although many studies have examined suicidal ideation and behavior in delinquent youth, prevalence rates vary widely. This article reviews studies of suicidal ideation and behavior in youth in the juvenile justice system, focusing on the point of contact: incarceration status and stage of judicial processing. Suicidal ideation and behavior are prevalent and increase with greater involvement in the juvenile justice system. Depression, sexual abuse, and trauma were the most commonly identified predictors of suicidal ideation and behavior. Prevalence rates of suicidal ideation and behavior vary by gender and race/ethnicity, indicating the need for gender-specific and culturally relevant interventions.

BACKGROUND: This study examined whether relocating from a high-poverty neighborhood to a lower poverty neighborhood as part of a federal housing relocation program (HOPE VI; Housing Opportunities for People Everywhere) had effects on adolescent mental and behavioral health compared to adolescents consistently living in lower poverty neighborhoods. METHODS: Sociodemographic, risk behavior, and neighborhood data were collected from 592 low-income, primarily African-American adolescents and their primary caregivers. Structured psychiatric interviews were conducted with adolescents. Prerelocation neighborhood, demographic, and risk behavior data were also included. Hierarchical Linear Modeling (HLM) was used to test associations between neighborhood variables and risk outcomes. HLM was used to test whether the effect of neighborhood relocation and neighborhood characteristics might explain differences in sexual risk taking, substance use, and mental health outcomes. RESULTS: Adolescents who relocated of HOPE VI neighborhoods (n = 158) fared worse than control group participants (n = 429) on most self-reported mental health outcomes. The addition of subjective neighborhood measures generally did not substantively change these results. CONCLUSIONS: Our findings suggest that moving from a high-poverty neighborhood to a somewhat lower poverty neighborhood is not associated with better mental health and risk behavior outcomes in adolescents. The continued effects of having grown up in a high-poverty neighborhood, the small improvements in their new neighborhoods, the comparatively short length of time they lived in their new neighborhood, and/or the stress of moving appears to worsen most of the mental health outcomes of HOPE VI compared to control group participants who consistently lived in the lower poverty neighborhoods. Language: en

Purpose African-American youth, particularly those from low-income backgrounds, evidence high rates of negative outcomes associated with three problem behaviors, conduct problems, risky sexual behavior, and substance use. This study used a contextually tailored version of problem behavior theory (PBT) to examine predictors of the simultaneous development of problem behaviors in this specific cultural group. Methods Sociocontextual and individual variables representing four PBT predictor categories, controls protection, support protection, models risk, and vulnerability risk, were examined as predictors of co-occurring problem behaviors among economically disadvantaged African-American adolescents (n = 949). Specifically, the likelihood of following three classes of multiple problem behavior trajectories spanning ages 12–18, labeled the "early experimenters," "increasing high risk-takers," and "adolescent-limited" classes, as opposed to a "normative" class, was examined. Results Among other findings, controls protection in the form of a more stringent household curfew at age 12 was related to a lower likelihood of being in the "early experimenters" and "increasing high risk-takers" classes. Conversely, vulnerability risk manifested as stronger attitudes of violence inevitability was associated with a higher likelihood of being in the "early experimenters" class. However, the PBT category of support protection was not associated with risk trajectory class. More distal neighborhood-level manifestations of PBT categories also did not predict co-occurring behavior problems. Conclusion Guided by an incorporation of contextually salient processes into PBT, prevention programs aiming to decrease co-occurring problem behaviors among low-income African-American adolescents would do well to target both proximal systems and psychological constructs related to perceived security throughout adolescence.

There is limited literature on the relationship between sensation seeking and adolescent risk behaviors, particularly among African Americans. We tested the association between psychometrically-derived subscales of the Zuckerman Sensation Seeking Scale and the intercepts and slopes of individual growth curves of conduct problems, sexual risk taking, and substance use from ages 13 to 18 years by sex. Boys and girls had different associations between sensation seeking and baseline levels and growth of risk behaviors. The Pleasure Seeking scale was associated with baseline levels of conduct problems in boys and girls, baseline substance use in boys, and growth in sexual risk taking and substance use by girls. Girls had the same pattern of associations with the Danger/Novelty scale as the Pleasure Seeking scale. Knowledge about the relationships between adolescent risk taking and sensation seeking can help in the targeted design of prevention and intervention programs for the understudied population of very low-income, African American adolescents.

In a community sample of low-income African American adolescents, we tested the interactive effects of variation in the mu 1 opioid receptor (OPRM1) gene and the occurrence of stressful life events on symptoms of depression.Interactive effects of 24 OPRM1 simple nucleotide polymorphisms (SNP) and adolescent report of stressful life events on depression were tested using multilevel regressions. SNPs were dummy coded to test both additive and dominate forms of coding.Five OPRM1 SNPs showed significant evidence of interaction with stressful life events to alter depression risk (or symptoms) after adjusting for multiple testing and the correlated nature of the SNPs. Follow-up analyses showed significant differences based on OPRM1 genotype at both lower and higher frequencies of stressful life events, suggesting that participants with a copy of the minor allele on OPRM1 SNPs rs524731, rs9478503, rs3778157, rs10485057, and rs511420 have fewer symptoms in low stress conditions but more symptoms in high stress conditions compared to major allele homozygotes.The genetic variants associated with depression in African American adolescents may not translate to other ethnic groups. This study is also limited in that only one gene that functions within a complex biological system is addressed.This current study is the first to find an interaction between OPRM1 and life stress that is associated with depression. It also addressed an understudied population within the behavioral genetics literature. Further research should test additional genes involved in the opioid system and expand the current findings to more diverse samples.

This study examined interdependent trajectories of sexual risk, substance use, and conduct problems among 12- to 18-year-old African American youths who were followed annually as part of the Mobile Youth Study. We used growth mixture modeling to model the development of these three outcomes in the 1,406 participants who met the inclusion criteria. Results indicate that there were four distinct classes: normative, low risk (74.3% of sample); increasing high-risk takers (11.9%); adolescent-limited conduct problems and drug risk with high risky sex (8.0%); and early experimenters (5.8%) The higher risk classes had higher rates of pregnancy and sexually transmitted infections diagnoses than the normative sample at each of the ages we examined. Differing somewhat from our hypothesis, all of the nonnormative classes exhibited high sexual risk behavior. Although prevention efforts should be focused on addressing all three risk behaviors, the high rate of risky sexual behavior in the 25% of the sample that fall into the three nonnormative classes underscores an urgent need for improved sex education, including teen pregnancy and HIV/sexually transmitted infections prevention, in this community.

Data on the prevalence of mental health disorders for low-income, urban African American adolescents are scarce. This study presents data about the burden of mental disorders for this understudied population.Mental disorders were assessed using the Diagnostic Interview Schedule for Children (C-DISC), Youth Self-Report (YSR), and Child Behavior Checklist (CBCL) among a sample of adolescents and their caregivers from very impoverished neighborhoods in a Southern city.Based on the C-DISC, 3.8, 5.1 and 7.7% of adolescents met diagnostic criteria for major depression, post-traumatic stress disorder, and conduct disorder, respectively. There were significant differences among some of the mental health disorders based on adolescent and caregiver characteristics such as sex, school status, caregiver work status, and income level. We found a low prevalence of alcohol, marijuana, and substance abuse and dependence disorders.Information about the prevalence of mental health disorders in specific communities and populations can assist in addressing unmet needs, planning for services and treatment, and reducing health disparities.

Federally qualified health centers play a major role in providing health care to the underserved, and will remain an important part of the health care safety net even under reforms that will increase the number of Americans with health insurance. We show that the investments made in federally qualified health centers during 1996-2006 clearly translated into an increase in services available to patients, including mental health and substance abuse treatment and counseling and staffing. One particularly notable finding is that an additional $500,000 in federal grants translates into 540 more uninsured patients treated.

Objective To identify trajectories of substance use disorders (SUDs) in youth during the 12 years after detention and how gender, race/ethnicity, and age at baseline predict trajectories. Method As part of the Northwestern Juvenile Project, a longitudinal study of 1,829 youth randomly sampled from detention in Chicago, Illinois from 1995 through 1998, participants were reinterviewed in the community or correctional facilities up to 9 times over 12 years. Independent interviewers assessed SUDs using the Diagnostic Interview Schedule for Children 2.3 (baseline) and the Diagnostic Interview Schedule IV (follow-ups). Primary outcome was a mutually exclusive 5-category typology of disorder: no SUD, alcohol alone, marijuana alone, comorbid alcohol and marijuana, or "other" illicit ("hard") drug. Trajectories were estimated using growth mixture models with a 3-category ordinal variable derived from the typology. Results During the 12-year follow-up, 19.6% of youth did not have an SUD. The remaining 81.4% were in 3 trajectory classes. Class 1 (24.5%), a bell-shaped trajectory, peaked 5 years after baseline when 42.7% had an SUD and 12.5% had comorbid or "other" illicit drug disorders. Class 2 (41.3%) had a higher prevalence of SUD at baseline, 73.8%. Although prevalence decreased over time, 23.5% had an SUD 12 years later. Class 3 (14.6%), the most serious and persistent trajectory, had the highest prevalence of comorbid or "other" illicit drug disorders—52.1% at baseline and 17.4% 12 years later. Males, Hispanics, non-Hispanic whites, and youth who were older at baseline (detention) had the worst outcomes. Conclusion Gender, race/ethnicity, and age at detention predict trajectories of SUDs in delinquent youth. Findings provide an empirical basis for child psychiatry to address health disparities and improve prevention.

Background: Genetic and environmental factors influence substance use behaviors in youth. One of the known environmental risk factors is exposure to life stressors. The aim of this project is to study the interaction between NR3C1 and CRHBP, genes thought to be involved in stress pathways, exposure to stressful life events, and adolescent alcohol use/misuse. Methods: The sample included 541 African American individuals (ages 13–18) from the Genes, Environment, and Neighborhood Initiative, a subset of the Mobile Youth Survey sample from whom DNA and more extensive phenotypic data were collected. Participants were selected from high-poverty neighborhoods in Mobile, Alabama, with potential exposure to a variety of extreme life stressors. Results: A measure of stressful life events was significantly predictive of alcohol use/misuse. In addition, this association was significantly dependent upon the number of putative risk variants at rs1715749, a single-nucleotide polymorphism (SNP) in CRHBP ( P ≤ .006). There was no significant interaction between NR3C1 and stressful life events with respect to alcohol use/misuse, after taking into account multiple testing. Conclusions: These findings suggest that CRHBP variants are potentially relevant for adolescent alcohol use/misuse among African American youth populations being reared within the context of stressful life events and warrant replication.

The purpose of this study is to provide descriptive data on the presence of dental schools, dental school graduates, instate enrollment, and interstate dental education agreements for U.S. states, districts, and regions. This information may be helpful in deciding to open or maintain a dental school. Data from the American Dental Association (ADA), American Dental Education Association (ADEA), and U.S. Census Bureau were used to conduct cross-sectional comparisons for states, census divisions, and regions for 2000. In 2000, there were fifty-four dental schools in thirty-two states and the District of Columbia. Total graduation across 1990–2000 was 43,289 dentists. Over half (56 percent) of the graduates were from public schools. The distribution of schools and graduates differed by geographic region. Alaska, Utah, Hawaii, and Nebraska were outliers with respect to high and low numbers of dental schools in states, in-state enrollment, and dentists to population. U.S. states, districts, and regions vary widely on the number of dental schools, dentists to population, first-year dental school enrollees, and dental school graduates. Further assessment on additional factors such as dental health provider shortage areas, state oral health status, and attractiveness of locations to dentists is needed to more fully understand the impact of these factors.

Background Federal policy supports and funds community-based clinics to provide health care to low-income and under-served groups. This study examines the role of community dental safety-net clinics in providing dental care for these populations. Methods The authors administered a cross-sectional survey of all identified safety-net dental clinics in Illinois. Seventy-one of 94 clinics responded (response rate, 76 percent), describing their history, operations, patients, staffing and dentist relationships. An in-depth analysis of 57 clinics presents comparisons of three categories of clinics, sponsored by community health centers (23), local health departments (21) and private service agencies (13). Results Clinics were distributed across the state; 80 percent were located in facilities with other health care providers, and all provided dental care to low-income and other underserved groups. Clinics provided more than 3,100 annual dental visits, operated with limited staffing and budgets, and had referral relationships with local dentists. Clinics with full-time dentists or any dental hygienists had higher annual numbers of dental visits. Conclusions These clinics provide dental care to groups with traditional access barriers. Although they represent a small portion of all dental care, their mission and role make them a key component of strategies to address the dental access problem. Practice Implications Local and state dental practitioners and coalitions seeking to expand dental access should consider their community dental safety-net clinics as partners. Efforts to expand these clinics should include considering optimizing staffing for better dental productivity.

Background Women are increasingly entering the dental work force. This study examines the impact of sex, age and other demographic characteristics on dentists' work force participation and on hours worked from 1979 through 1999. Methods The study drew on cross-sectional data on dentists (4,209 men and 354 women) from national population surveys conducted by the U.S. Bureau of Labor Statistics from 1979 through 1999. The authors used descriptive statistics and regression analyses to examine sex differences in work force participation and in hours worked across age, as well as other factors. Results Work force participation was high for both men and women. Men worked more hours and worked part time less frequently; they worked more than 42 hours per week more frequently. Older dentists worked fewer hours, with a larger impact of age seen among men. Having children had a significantly greater effect on the number of hours worked per week among female dentists than among male dentists. Conclusions There were significant differences in dentists' hours worked by sex and by age. The consistency of the results with past studies suggests these differences will hold in the near future. Practice Implications Women's entry into the dental work force has been significant and has helped maintain the supply of dentists. Sex differences in the work force should be considered in evaluating the supply of dentists and related work force policy.

Poor oral health status and limited access to dental care have been recognized as problems for children from Medicaid and low-income families. However, little is known about dental access for Medicaid-enrolled children in rural areas. This study examines differences between rural and urban counties in dental utilization rates of Illinois children enrolled in either Medicaid or the Children's Health Insurance Program. How the overall dentist supply, the dentist Medicaid participation rate, and county level sociodemographic factors relate to Medicaid dental utilization are examined. Illinois counties were aggregated into four urban/rural categories. Descriptive analysis showed lower utilization rates in the rural categories (25 and 27%) compared with the metropolitan categories (35 and 31%). Rural areas had a substantially lower supply of dentists, and consequently a lower supply of dentists participating in Medicaid, despite the substantially higher Medicaid participation rate of dentists in the rural categories (45 and 51%) than in the metropolitan categories (22 and 32%). However, regression results indicated no significant relationship between the rate of utilization of Medicaid-enrolled children and rural status after controlling for several dental supply and population factors. The most important factors relating to Medicaid-enrolled children's dental utilization, regardless of urban or rural status, were the proportion of children enrolled in Medicaid and the participating dentist to population ratio. Without the high participation rate of dentists in rural areas, access to oral health care for rural children enrolled in Medicaid would have been worse. Policy makers should focus on maintaining high rural dentist participation rates as well as addressing future supply problems that may exacerbate difficulties with access in rural areas.

Objectives.To describe the sociodemographic and health status characteristics of the national uninsured, State Children's Health Insurance Program (SCHIP)-eligible population, and to compare this population with Medicaid-enrolled children, privately insured children, and privately insured children who have family income in the SCHIP eligibility range.Procedures.Data were analyzed for 50 950 children 0 to 18 years of age included in the 1993 and 1994 National Health Interview Surveys. The survey obtained information on insurance coverage and sociodemographic and health status measures. Bivariate analyses were conducted to identify the relationships between SCHIP eligibility and sociodemographic and health status characteristics. Multivariate analyses were conducted to assess the independent association of the sociodemographic and health status variables with the likelihood of being uninsured, SCHIP-eligible.Primary Findings.Results indicate that SCHIP children exhibit markedly different socioeconomic and health status characteristics than do both Medicaid- enrolled and privately insured children, although these differences are less significant in privately insured children. SCHIP children more often live with college- educated (39.4%) and employed adults (91.2%) than do Medicaid-enrolled children (23.0% and 53.9%, respectively). However, SCHIP children live with college-educated and employed adults less than do all privately insured children (66.7% and 96.9%, respectively) and privately insured/same-income children (57.8% and 97.0%, respectively). Parents of SCHIP-eligible children are also disproportionately self-employed or employed in industries (eg, retail trade) and occupations in which health insurance coverage is less available or affordable. SCHIP-eligible children are also 2 times more likely to be adolescents and 1½ times more likely to be in excellent health than Medicaid-eligible children. Compared with privately insured children, SCHIP-eligible children are nearly 3 times more likely to be Hispanic and nearly 2 times more likely to be rated in fair or poor health.Conclusions.The results demonstrate that uninsured, SCHIP-eligible children are substantially different from children in these groups, particularly compared with Medicaid-enrolled children. These differences need to be taken into account when setting policies and implementing programs intended to increase health insurance coverage and access to health care.

The literature on continuous quality improvement (CQI) has produced some evidence, based on nonrandomized studies, that its clinical application can improve outcomes of care while reducing costs. Its effectiveness is enhanced by a nucleus of physician involvement, individual practitioner feedback, and a supportive organizational culture. The few randomized studies, however, suggest no impact of CQI on clinical outcomes and no evidence to date of organization-wide improvement in clinical performance. Further, most studies address misuse issues and avoid examining overuse or underuse of services. The clinical application of CQI is more likely to have a pervasive impact when it takes place within a supportive regulatory and competitive environment, when it is aligned with financial incentives, and when it is under the direction of an organizational leadership that is committed to integrating all aspects of the work.

Subacute care is a transitional level of care for medically stable patients who no longer require daily diagnostic/invasive care but require more intensive care than is typical in a skilled care facility. A Congressionally mandated study was undertaken to determine the number of VA patients with subacute needs being cared for in acute care. InterQual, Inc. subacute care criteria were retrospectively applied to 858 medical and surgical admissions from 43 VA hospitals. Over one-third contained at least one subacute days with an average length of stay (LOS) of 12.7 days (SD e 12.4)s of which 6.8 days were subacute. Patients with these admissions had significantly longer LOSs, were older, and were more likely to die or to be discharged to a nursing home. Diagnoses with subacute days included COPD, pneumonia, joint replacement, and cellulitis. Future studies should develop clinical pathways to prospectively manage admissions with subacute needs and then evaluate their effectiveness.

The HIV/AIDS epidemic is disproportionately impacting young African Americans. Efforts to understand and address risk factors for unprotected sex in this population are critical in improving prevention efforts. Situational risk factors, such as relationship type and substance use before sex, are in need of further study. This study explored how established cognitive predictors of risky sexual behavior moderated the association between situational factors and unprotected sex among low-income, African American adolescents. The largest main effect on the number of unprotected sex acts was classifying the relationship as serious (event rate ratio=10.18); other significant main effects were alcohol use before sex, participant age, behavioral skills, and level of motivation. HIV information moderated the effect of partner age difference, motivation moderated the effects of partner age difference and drug use before sex, and behavioral skills moderated the effects of alcohol and drug use before sex. This novel, partnership-level approach provides insight into the complex interactions of situational and cognitive factors in sexual risk taking.

The purpose of this study is to provide descriptive data on the presence of dental schools, dental school graduates, instate enrollment, and interstate dental education agreements for U.S. states, districts, and regions. This information may be helpful in deciding to open or maintain a dental school. Data from the American Dental Association (ADA), American Dental Education Association (ADEA), and U.S. Census Bureau were used to conduct cross-sectional comparisons for states, census divisions, and regions for 2000. In 2000, there were fifty-four dental schools in thirty-two states and the District of Columbia. Total graduation across 1990-2000 was 43,289 dentists. Over half (56 percent) of the graduates were from public schools. The distribution of schools and graduates differed by geographic region. Alaska, Utah, Hawaii, and Nebraska were outliers with respect to high and low numbers of dental schools in states, in-state enrollment, and dentists to population. U.S. states, districts, and regions vary widely on the number of dental schools, dentists to population, first-year dental school enrollees, and dental school graduates. Further assessment on additional factors such as dental health provider shortage areas, state oral health status, and attractiveness of locations to dentists is needed to more fully understand the impact of these factors.

Women are increasingly entering the dental work force. This study examines the impact of sex, age and other demographic characteristics on dentists' work force participation and on hours worked from 1979 through 1999.The study drew on cross-sectional data on dentists (4,209 men and 354 women) from national population surveys conducted by the U.S. Bureau of Labor Statistics from 1979 through 1999. The authors used descriptive statistics and regression analyses to examine sex differences in work force participation and in hours worked across age, as well as other factors.Work force participation was high for both men and women. Men worked more hours and worked part time less frequently; they worked more than 42 hours per week more frequently. Older dentists worked fewer hours, with a larger impact of age seen among men. Having children had a significantly greater effect on the number of hours worked per week among female dentists than among male dentists.There were significant differences in dentists' hours worked by sex and by age. The consistency of the results with past studies suggests these differences will hold in the near future.Women's entry into the dental work force has been significant and has helped maintain the supply of dentists. Sex differences in the work force should be considered in evaluating the supply of dentists and related work force policy.

An evaluation of a pilot program for community nursing home care reimbursement by Department of Veterans Affairs Medical Centers (VAMCs) was undertaken. Eight VAMCs began using the Enhanced Prospective Payment System (EPPS) in 1992. These sites were compared to eight customary payment sites in a pretest/posttest quasi-experimental design. Outcomes included access to care, administrative workload, quality of care, and cost. As expected, per diem costs were significantly higher for EPPS than customary reimbursement patients ($106 vs. $87). However, EPPS sites placed veterans more quickly (81 days vs. 113 days; p < .01) than comparison sites and reduced administrative workload associated with placement. EPPS sites also increased the number of Medicare-certified homes under contract (76% vs. 54%) and placed significantly more veterans who received therapy (20% vs. < 1%). Savings in hospital days more than offset the increased cost of nursing home placement. Because the findings were attributed largely to a few veterans with long lengths of hospital stay, the early success of EPPS may diminish as the backlog of these long-stay patients decreases.