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The authors examined the impact of COVID-19-related policies reducing barriers to telehealth delivery of buprenorphine treatment for opioid use disorder (OUD) on buprenorphine treatment across different modalities (telephone, video, and in-person visits).This was a national retrospective cohort study with interrupted time-series analyses to examine the impact of policy changes in March 2020 on buprenorphine treatment for OUD in the Veterans Health Administration, during the year before the start of the COVID-19 pandemic (March 2019 to February 2020) and during the first year of the pandemic (March 2020 to February 2021). The authors also examined trends in the use of telephone, video, and in-person visits for buprenorphine treatment and compared patient demographic characteristics and retention in buprenorphine treatment across the two periods.The number of patients receiving buprenorphine increased from 13,415 in March 2019 to 15,339 in February 2021. By February 2021, telephone visits were used by the most patients (50.2%; 4,456 visits), followed by video visits (32.4%; 2,870 visits) and in-person visits (17.4%; 1,544 visits). During the pre-pandemic period, the number of patients receiving buprenorphine increased significantly by 103 patients per month. After the COVID-19 policy changes, there was an immediate increase of 265 patients in the first month, and the number continued to increase significantly, at a rate of 47 patients per month. The demographic characteristics of patients receiving buprenorphine during the pandemic period were similar to those during the pre-pandemic period, but the proportion of patients reaching 90-day retention on buprenorphine treatment decreased significantly from 49.6% to 47.7%, while days on buprenorphine increased significantly from 203.8 to 208.7.The number of patients receiving buprenorphine continued to increase after the COVID-19 policy changes, but the delivery of care shifted to telehealth visits, suggesting that any reversal of COVID-19 policies must be carefully considered.

This study examined if lithium's association with suicide risk varies by diagnosis. We performed separate 1:1 high-dimensional propensity score (hdPS)-matching in US Veterans with and without bipolar disorder starting lithium or valproate. Among individuals with bipolar disorder, actively receiving lithium (compared to valproate) was not associated with suicide risk. However, in intent-to-treat analyses (following all individuals with bipolar disorder starting lithium or valproate for all 365 days, regardless of whether they stopped the medication), starting lithium was significantly associated with higher one-year risks of suicide (HR = 1.50, 95% CI: 1.05-2.15, p = 0.03). These intent-to-treat risks were attributable entirely to transiently elevated suicide risks observed among individuals no longer receiving lithium (significant at 180 days [HR = 6.10, CI: 1.37-27.3, p = 0.02] but not 365 days [HR = 2.05, CI: 0.88-4.79, p = 0.10]). Among individuals without bipolar disorder, depending on the analysis, actively receiving lithium was associated with nonsignificantly (HR = 0.43, CI: 0.15-1.20, p = 0.11) or significantly (HR = 0.28, CI: 0.08-0.98, p = 0.047) decreased one-year suicide risks. Study limitations included limited power, brief follow-up, and potential residual confounding. Residual confounding is suggested by the observation that more individuals diagnosed with suicidal ideation started lithium than valproate (with this difference being statistically significant for individuals with bipolar disorder, p = 0.0012). If it were possible to correct for this potential confounding, then the suicide-related risks associated with among individuals discontinuing lithium would be expected to be less, and the suicide-related benefits associated with actively receiving lithium (already statistically significant in some analyses among individuals without bipolar disorder) would be expected to increase. Further research is needed.

ObjectivesFibromyalgia is characterized by chronic widespread pain, mood, and sleep disturbance. Pharmacological treatments have modest efficacy and are associated with negative side effects, and alternative approaches are needed. Morning bright light treatment may assist in the management of fibromyalgia as it can reduce depressive symptoms, improve sleep, and advance circadian timing.MethodsSixty people with fibromyalgia (58 women, mean age 41.8 ± 13.3 years) were enrolled in a study comparing 4 weeks of a 1-hour daily morning bright light treatment (active treatment) to a morning dim light treatment (comparison treatment). Both light treatments included behavioral procedures to stabilize sleep timing. The morning bright light treatment was expected to produce larger improvements in pain and function than the dim light treatment and larger improvements in potential mediators (mood, sleep, and circadian timing).ResultsBoth the bright and dim light treatment groups achieved significant but similar levels of improvement in pain intensity, pain interference, physical function, depressive symptoms, and sleep disturbance. Overall, the sample on average displayed a clinically meaningful improvement in the Fibromyalgia Impact Questionnaire-Revised score (mean reduction of 11.2 points), comparable to that reported following physical exercise treatments. Minimal side effects were observed.ConclusionsFindings indicate that the effects of a morning bright light treatment did not exceed those of a comparison dim light treatment; yet the changes on average in both conditions revealed clinically meaningful improvements. Future research is warranted to identify what elements of this trial may have contributed to the observed effects.

Introduction While initiation rates of tobacco cessation pharmacotherapy have improved both inside and outside the Department of Veteran Affairs (VA), prescribing rates remain low. The objective of this study was to examine correlation of the characteristics of providers, clinics, and facilities with initiation of tobacco cessation pharmacotherapy. Methods This retrospective, observational study used VA outpatient electronic medical record data from federal fiscal year 2011. Logistic regression models estimated the adjusted odds ratio associated with provider characteristics for pharmacotherapy initiation. Results For the 639507 veterans who used tobacco, there were 30388 providers caring for them. Younger (p

Quantitative diffuse reflectance spectroscopy (DRS) was developed for label-free, noninvasive, and real-time assessment of implanted tissue-engineered devices manufactured from primary human oral keratinocytes (six batches in two 5-patient cohorts). Constructs were implanted in a murine model for 1 and 3 weeks. DRS evaluated construct success in situ using optical absorption (hemoglobin concentration and oxygenation, attributed to revascularization) and optical scattering (attributed to cellular density and layer thickness). Destructive pre- and postimplantation histology distinguished experimental control from stressed constructs, whereas noninvasive preimplantation measures of keratinocyte glucose consumption and residual glucose in spent culture media did not. In constructs implanted for 1 week, DRS distinguished control due to stressed and compromised from healthy constructs. In constructs implanted for 3 weeks, DRS identified constructs with higher postimplantation success. These results suggest that quantitative DRS is a promising, clinically compatible technology for rapid, noninvasive, and localized tissue assessment to characterize tissue-engineered construct success in vivo. IMPACT STATEMENT: Despite the recent advance in tissue engineering and regenerative medicine, there is still a lack of nondestructive tools to longitudinally monitor the implanted tissue-engineered devices. In this study, we demonstrate the potential of quantitative diffuse reflectance spectroscopy as a clinically viable technique for noninvasive, label-free, and rapid characterization of graft success in situ.

BACKGROUND/OBJECTIVES Psychotropic and opioid medications are routinely prescribed for symptom management in hospice, but national estimates of prescribing are lacking. Changes in Medicare hospice payment in 2014 provide the first opportunity to examine psychotropic and opioid prescribing among hospice beneficiaries, and the factors associated with use of specific medication classes. DESIGN Cross-sectional analysis of a 20% sample of traditional and managed Medicare with Part D enrolled in hospice, 2014-2016. SETTING Beneficiaries enrolled in the Medicare hospice benefit. PARTICIPANTS Medicare beneficiaries ≥65 newly enrolled in hospice between July 1, 2014 and December 31, 2016 (N = 554,022). MAIN OUTCOME Prevalence of psychotropic and opioid medication prescribing by class and factors associated with prescribing. RESULTS 70.3% of hospice beneficiaries were prescribed a psychotropic and 63.3% were prescribed an opioid. The most common psychotropic classes prescribed were: benzodiazepines (60.6%), antipsychotics (38.3%), antidepressants (18.4%), and antiepileptics (10.2%). Lorazepam (56.4%), morphine (52.8%), and haloperidol (28.6%) were received by the most beneficiaries. Prevalence of any psychotropic and opioid prescription was highest among beneficiaries who were female (76.7%), non-Hispanic white (76.6%), and those with cancer (78.9%). Compared to white beneficiaries, non-Hispanic black beneficiaries were less likely to receive nearly every class of medication, with significantly lower odds of receiving opioids (64.1% vs 57.9%; AOR 0.75, 95% CI 0.72-0.77) and benzodiazepines (61.6% vs 52.2%; AOR 0.66, 95% CI 0.64-0.68). Differences were seen across hospice diagnosis; those with cancer were more likely to receive opioids, benzodiazepines, and antipsychotics but less likely to receive antidepressants and antiepileptics. CONCLUSIONS Psychotropic and opioid medications are frequently prescribed in hospice. Observed variations in prescribing across race and ethnicity may reflect disparities in prescribing as well as patient preferences for care. Further work is important to understand factors driving prescribing given limited studies surrounding medication prescribing in hospice.

Background: Patients undergoing ablation of premature ventricular complexes (PVCs) can have cardiac scar. Risk factors for the presence of scar are not well defined. Objectives: To determine the prevalence of scarring detected by delayed enhancement cardiac magnetic resonance imaging (DE-CMR) in patients undergoing ablation of PVCs, to create a risk score predictive of scar, and to explore correlations between the scoring system and long-term outcomes. Methods: DE-CMR imaging was performed in consecutive patients with frequent PVCs referred for ablation. The full sample was used to develop a prediction model for cardiac scar based on demographic and clinical characteristics, and internal validation of the prediction model was done using bootstrap samples. Results: The study consisted of 333 patients (52% male, aged 53.2 ± 14.5 years, preablation ejection fraction 50.9% ± 12.2%, PVC burden 20.7 ± 13.14), of whom 112 (34%) had DE-CMR scarring. Multiple logistic regression analysis showed age (odds ratio [OR] 1.02 [1.01–1.04]/year, P = .019) and preablation ejection fraction (OR 0.92 [0.89–0.94]/%, P < .001) to be predictive of scar. A weighted risk score incorporating age and ejection fraction was used to stratify patients into low-, medium-, and high-risk groups. Scar prevalence was around 86% in the high-risk group and 12% in the low-risk group; high-risk patients had worse survival free of arrhythmia. Conclusions: Cardiac scar was present in one-third of patients referred for PVC ablation. A weighted risk score based simply on patient age and preprocedural ejection fraction can help discriminate between patients at high and low risk for the presence of cardiac scar and worse arrhythmia outcomes.

Summary Background Although acellular dermal matrix (ADM) is widely used in expander-implant-based breast reconstructions, previous analyses have been unable to demonstrate improvements in patient-reported outcomes (PROs) with this approach over non-ADM procedures. This study aims to develop a more selective, evidence-based approach to the use of ADM in expander-implant-based breast reconstruction by identifying patient subgroups in which ADM improved clinical outcomes and PROs. Study design The Mastectomy Reconstruction Outcomes Consortium Study prospectively evaluated immediate expander-implant reconstructions at 11 centers from 2012 to 2015. Complications (any/overall and major), and PROs (satisfaction, physical, psychosocial, and sexual well-being) were assessed two years postoperatively using medical records and the BREAST-Q, respectively. Using mixed-models accounting for centers and with interaction terms, we analyzed for differential ADM effects across various clinical subgroups, including age, body mass index, radiation timing, and chemotherapy. Results Expander-implant-based breast reconstruction was performed in 1451 patients, 738 with and 713 without ADM. Major complication risk was higher in ADM users vs. nonusers (22.9% vs. 16.4% and p = 0.04). Major complication risk with ADM increased with higher BMI (BMI=30, OR=1.70; BMI=35, OR=2.29, interaction p = 0.02). No significant ADM effects were observed for breast satisfaction, psychosocial, sexual, and physical well-being within any subgroups. Conclusion In immediate expander-implant-based breast reconstruction, ADM was associated with a greater risk of major complications, particularly in high-BMI patients. We were unable to identify patient subgroups where ADM was associated with significant improvements in PROs. Given these findings and the financial costs of ADM, a more critical approach to the use of ADM in expander-implant reconstruction may be warranted.

BACKGROUND: Clinical services provided by pharmacists embedded in practices can improve patient outcomes within the primary care setting. Little is known about whether physician organizations (POs) will retain the services of clinical pharmacists after outside funding for a statewide implementation program is ended. OBJECTIVE: To evaluate a statewide program, Michigan Pharmacists Transforming Care and Quality (MPTCQ), that incorporated pharmacists within 17 POs. METHODS: A descriptive study was conducted using data collected from June 2016 to September 2018 from primary care clinical pharmacist encounters in POs participating in MPTCQ. Process outcomes included the number of participating POs, patient encounters, and average visits per patient. Analyses at the encounter level were stratified by 2 encounter types: disease state management (DSM) or comprehensive medication review (CMR). Separately by encounter type, pharmacist effect was described by the number, type, and reasons for medication changes, as well as medication adherence and cost barriers found and addressed. Clinical outcomes included hemoglobin A1c and blood pressure change. Sustainability and patient satisfaction of pharmacists providing clinical services are reported. RESULTS: Across 17 POs, 27 pharmacists participated in the MPTCQ program. Pharmacists completed 24,523 patient encounters for DSM with 5,942 patients, with an average of 5 visits per patient with diabetes and 2 visits for hypertension. Pharmacists made 15,153 therapeutic medication changes during visits for diabetes and hypertension, with approximately 70% related to efficacy. Pharmacists completed 4,203 CMR visits for 3,092 patients. During CMR visits, 1,296 therapeutic medication changes were recommended. Problems with medication cost were identified in 13% of CMR visits. Blood pressure and A1c levels decreased in patients managed by pharmacists. In 157 patients surveyed, 87% rated their pharmacists' care as excellent. Sixteen POs retained their pharmacists at the end of funding. CONCLUSIONS: A statewide provider-payer partnership successfully integrated and retained primary care pharmacists within POs. Pharmacists in the MPTCQ program contributed to improvements in disease control by changing medications to improve patient clinical outcomes. DISCLOSURES: Support for MPTCQ was provided by Blue Cross and Blue Shield of Michigan (BCBSM) as part of the BCBSM Value Partnerships program. Coe was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR002241. Although BCBSM and MPTCQ work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors have no conflicts of interest to report.

Objective While single-use and detachable-tip duodenoscopes have been recently developed to overcome risks of infection transmission, there are no reliable tools to objectively assess their technical performance. We evaluated the reliability and validity of a newly developed tool to assess the technical performance of reusable duodenoscopes. Methods An assessment tool was developed to measure duodenoscope performance based on three distinct criteria: maneuverability, mechanical/imaging characteristics and ability to perform requisite interventions. The assessment tool was tested prospectively on duodenoscopes used in endoscopic retrograde cholangiopancreatography (ERCP) procedures at nine academic medical centers over a 6-month period. The main outcome was reliability of the duodenoscope assessment tool, which was estimated using Cronbach's coefficient alpha (α). The secondary outcome was validity of the assessment tool. Results The assessment tool evaluated technical performance of reusable duodenoscopes in 1080 ERCP procedures. Indications were biliary in 92.8% and pancreatic in 7.2% procedures. The overall Cronbach's coefficient α for maneuverability was 0.81, assessment of mechanical/imaging characteristics was 0.92, and ability to perform requisite interventions was 0.87. On multiple linear regression analysis, prolonged procedure duration, older patient age and pancreatic interventions were significantly positively associated with higher (worse) scores. Conclusions The newly developed assessment tool appears reliable and valid for evaluating the technical performance of duodenoscopes. Registration: ClinicalTrials.gov Identifier: NCT04004533.

Complex and invasive postoperative pain regimens for microtia reconstruction with costal cartilage are often utilized. These generate added costs and invasiveness. We evaluated the effectiveness of a de-escalated pain regimen without use of invasive interventions.Case series of patients who underwent stage 1 microtia reconstruction with a modified Nagata/Firmin technique from 2017 to 2020 at a pediatric tertiary care hospital. Patients received intraoperative bupivacaine intercostal blocks and scheduled acetaminophen. Adjunct medications administered and pain scores (Wong-Baker FACES and FLACC-Face, Legs, Activity, Cry, Consolability) at intervals 2-72 h postoperatively were recorded. Narcotic use, peak and median pain scores, and length of stay were compared with published values.Twenty patients were included. Mean age of 12 and length of stay of 2.8 days. Average postoperative FACES scores between 0 and 72 h ranged between 0.7 and 4.0. The average peak pain score was 6.1 (±2.0). FLACC scores were low. Narcotics (0.59 ±0 .35 Morphine Milligram Equivalents/kg) were given to 17 patients. Compared to Shaffer et al. (paravertebral catheter-based infusion), total narcotics use (p = 0.03), peak pain (p = 0.0001), and length of stay (p = 0.001) were less. Compared to Woo et al. (intercostal catheter-based infusion), median pain scores at identical time intervals were lower (p = 0.04).Intraoperative intercostal nerve blocks followed by scheduled, weight-based acetaminophen, adjunctive medications (ibuprofen and lidocaine patches), and rescue narcotics are effective in managing pain following microtia repair with autologous costal cartilage. It results in decreased narcotic usage, shorter length of stay, and lower pain scores compared to more complex regimens.

Objective: To assess mental health symptoms, suicidal ideation/behaviors, and treatment among a nationally representative probability sample of student veterans. Participants: Student veterans enro...

BACKGROUND The objective of this study was to determine whether women with a history of radiation therapy before mastectomy experience a risk for postoperative complications and patient-reported outcomes similar to those of women undergoing postmastectomy radiation therapy in the setting of immediate implant reconstruction. METHODS The cohort included patients undergoing immediate implant reconstruction at 11 centers across North America. Women were categorized into three groups: prior breast conservation therapy, postmastectomy radiation therapy, and no radiation therapy. Mixed effect logistic regressions were used to analyze the effects of radiation therapy status on complication rates and patient-reported outcomes. RESULTS ONE THOUSAND FIVE HUNDRED NINETY-FOUR: patients were analyzed, including 84 women with prior breast conservation therapy, 329 women who underwent postmastectomy radiation therapy, and 1181 women with no history of radiation therapy. Compared with postmastectomy radiation therapy, breast conservation was associated with lower rates of all complications and major complications (OR, 0.65; 95 percent CI, 0.37 to 1.14; p = 0.13; and OR, 0.61; 95 percent CI, 0.33 to 1.13; p = 0.12). These differences were not statistically significant. Rates of reconstructive failure between the two cohorts were comparable. Before reconstruction, satisfaction with breasts was lowest for women with prior breast conservation therapy (p < 0.001). At 2 years postoperatively, satisfaction with breasts was lower for women with postmastectomy radiation therapy compared with breast conservation patients (p = 0.007). CONCLUSIONS Higher postoperative complication rates were observed in women exposed to radiation therapy regardless of timing. Although women with prior breast conservation experienced greater satisfaction with their breasts and fewer complications when compared to women undergoing postmastectomy radiation therapy, there was a similar risk for reconstruction failure. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.

Objectives The goal of this study was to assess the value of a stepwise, image-guided ablation approach in patients with cardiomyopathy and predominantly intramural scar. Background Few reports have focused on catheter-based ventricular tachycardia (VT) ablation strategies in patients with predominantly intramural scar. Methods The study included patients with predominantly intramural scar undergoing VT ablation. A stepwise strategy was performed consisting of a localized ablation guided by conventional mapping criteria followed by a more extensive ablation if VT remained inducible. The extensive ablation was guided by the location and extent of intramural scarring on delayed enhanced–cardiac magnetic resonance imaging. A historical cohort who did not undergo additional extensive ablation was identified for comparison. A novel measurement, the scar depth index (SDI), indicating the percent area of the scar at a given depth, was correlated with outcomes. Results Forty-two patients who underwent stepwise ablation (median age 61 years [interquartile range: 55 to 69 years], 35 male patients, median left ventricular ejection fraction 36.0% [25.0% to 55.0%], ischemic [n = 4] or nonischemic cardiomyopathy [n = 38]) were followed up for a median of 17 months (8 to 36 months). A stepwise approach resulted in a 1-year freedom from VT, death, or cardiac transplantation of 76% (32 of 42). Patients who underwent additional extensive ablation had a lower risk of events than a clinically similar historical cohort (N = 19) (hazard ratio: 0.30; 95% CI: 0.13 to 0.68; p 5mm was associated with worse long-term outcomes (hazard ratio: 1.03; 95% CI: 1.01 to 1.06%; p = 0.03), SDI>5mm >16.5% was associated with failed ablation (area under the curve: 0.84; 95% CI: 0.71 to 0.97). Conclusions Stepwise ablation using delayed enhanced–cardiac magnetic resonance guidance is a novel approach to VT ablation in patients with predominantly intramural scarring. The SDI correlates with immediate procedural and long-term outcomes.

OBJECTIVE: We sought to evaluate national trends in incident varenicline and nicotine replacement therapy (NRT) prescribing among Veterans Affairs (VA) beneficiaries before and after U.S. Food and Drug Administration (FDA) warnings regarding neuropsychiatric side effects with varenicline use. METHODS: We determined all adult VA patients identified as smokers from 2007–2019 (N=3,600,947) and calculated monthly counts of new varenicline and NRT users. An interrupted times series analysis estimated the effect of the FDA warnings on varenicline and NRT prescribing overall and among Veterans with and without mental health disorders. RESULTS: The incident use rate of varenicline decreased from a peak of 6.2 per 1,000 Veteran smokers in 10/2007 to 1.0 by 6/2009 following the first FDA warning (pre-warning monthly slope = −0.27; p=0.03). New NRT use increased from 10.7 per 1,000 Veteran smokers in 10/2007 to a peak of 12.6 in 7/2009 (slope change = 0.71, p=0.01) suggesting potential substitution. Following removal of the FDA boxed warning in 12/2016, varenicline prescribing increased but did not return to pre-warning levels by 12/2019. Among Veterans with and without mental health disorders, varenicline use decreased 90% and 88%, following the first FDA warning—both groups had comparable rates of new NRT use. CONCLUSIONS: Following the first FDA warning, incident use of varenicline declined significantly both among Veterans with and without mental health disorders. Despite removal of the FDA boxed warning in 12/2016, new use of varenicline had not returned to pre-warning levels 3 years following the removal.

IMPORTANCE: Ventricular tachycardia (VT) is associated with high mortality in patients with cardiac sarcoidosis (CS), and medical management of CS-associated VT is limited by high failure rates. The role of catheter ablation has been investigated in small, single-center studies. OBJECTIVE: To investigate outcomes associated with VT ablation in patients with CS. DESIGN, SETTING, AND PARTICIPANTS: This cohort study from the Cardiac Sarcoidosis Consortium registry (2003-2019) included 16 tertiary referral centers in the US, Europe, and Asia. A total of 158 consecutive patients with CS and VT were included (33% female; mean [SD] age, 52 [11] years; 53% with ejection fraction [EF]

BACKGROUND/OBJECTIVES Hypertension treatment reduces cardiovascular events. However, uncertainty remains about benefits and harms of deintensification or further intensification of antihypertensive medication when systolic blood pressure (SBP) is tightly controlled in older multimorbid patients, because of their frequent exclusion in trials. We assessed the association of hypertension treatment deintensification or intensification with clinical outcomes in older adults with tightly controlled SBP. DESIGN Longitudinal cohort study (2011-2013) with 9-month follow-up. SETTING U.S.-nationwide primary care Veterans Health Administration healthcare system. PARTICIPANTS Veterans aged 65 and older with baseline SBP

Background Previous investigators demonstrated that female patients often prefer female providers. However, these studies have not determined whether there are gender preferences for breast reconstruction surgeons or whether the effects of surgeon gender impacts patient-reported outcomes. Methods Adult women were crowdsourced using Amazon Mechanical Turk to characterize societal preferences for the gender of breast and plastic surgeons in a hypothetical scenario. The authors also used data from the Mastectomy Reconstruction Outcomes Consortium to determine the association between surgeon gender and patient satisfaction after breast reconstruction. The BREAST-Q questionnaire was used to assess patient-reported outcomes at 3 months and 2 years following reconstruction. Regression analyses were performed to investigate the effects of surgeon gender on patient-reported outcomes. Results In total, 1413 surveys were collected. Forty-two percent preferred female plastic surgeons, 5 percent preferred male surgeons, and 53 percent reported no preference. The Mastectomy Reconstruction Outcomes Consortium analysis included 2236 patients of 55 male and nine female plastic surgeons. In this cohort, 1921 patients (82.2 percent) had male surgeons, whereas 415 patients (17.8 percent) had female surgeons. Regression analysis at 2 years revealed no differences in satisfaction with surgeon, outcome, or psychosocial well-being. Only satisfaction with information differed, as patients of female surgeons reported greater satisfaction in this category, with an adjusted mean difference of 2.82 (p = 0.018). Conclusions Although nonpatient women hypothetically prefer female providers, surgeon gender makes little difference in actual patient satisfaction with breast reconstruction. More investigation is needed to determine whether the difference in information delivery is clinically significant and whether it reflects variations in practices between male and female surgeons. Clinical question/level of evidence Therapeutic, III.

Benzodiazepines and antipsychotics are routinely prescribed for symptom management in hospice. There is minimal evidence to guide prescribing in this population, and little is known about how prescribing varies across hospice agencies.Examine patient- and hospice agency-level characteristics associated with incident prescribing of benzodiazepines and antipsychotics in hospice.Retrospective cohort study of a 20% sample of Medicare beneficiaries newly enrolled in hospice.Medicare hospice beneficiaries ≥ 65 years old between 2014 and 2016, restricted to those without benzodiazepine (N = 169,688) or antipsychotic (N = 190,441) prescription fills in the 6 months before hospice enrollment.The primary outcome was incident (i.e., new) prescribing of a benzodiazepine or antipsychotic. A series of multilevel Cox regression models with random intercepts for hospice agency were fit to examine the association of incident benzodiazepine and antipsychotic prescribing with patient and hospice agency characteristics.A total of 91,728 (54.1%) and 58,175 (30.5%) hospice beneficiaries were newly prescribed an incident benzodiazepine or antipsychotic. The prescribing rate of the hospice agency was the strongest predictor of incident prescribing: Compared to patients in bottom-quartile benzodiazepine-prescribing agencies, those in top-quartile agencies were 10.7 times more likely to be prescribed an incident benzodiazepine (adjusted hazard ratio [AHR] 10.7, 95% CI 10.1-11.3). For incident antipsychotic prescribing, patients in top-quartile agencies were 51.7 times more likely to receive an antipsychotic (AHR 51.7, 95% CI 44.3-60.4) compared to those in the bottom quartile. Results remained consistent accounting for comfort kit prescribing.The pattern of benzodiazepine or antipsychotic prescribing of a hospice agency strongly predicts whether a hospice enrollee is prescribed these medications, exceeding every other patient-level factor. While the appropriate level of prescribing in hospice is unclear, this variation may reflect a strong local prescribing culture across individual hospice agencies.

Importance Distal radius fractures (DRFs) are common injuries among older adults and can result in substantial disability. Current evidence regarding long-term outcomes in older adults is scarce. Objective To compare outcomes across treatment groups at 24 months among adults with DRFs who participated in the WRIST trial. Design, Setting, and Participants The Wrist and Radius Injury Surgical Trial (WRIST) randomized, international, multicenter trial was conducted from April 1, 2012, through December 31, 2016. Participants were adults aged 60 years or older with isolated, unstable DRFs at 24 health systems in the US, Canada, and Singapore. Data analysis was performed from March 2019 to March 2021. Interventions Participants were randomized to open reduction and volar locking plate system (VLPS), external fixation with or without supplementary pinning (EFP), and percutaneous pinning (CRPP). The remaining participants chose closed reduction and casting. Main Outcomes and Measures The primary outcome was the 24-month Michigan Hand Outcomes Questionnaire (MHQ) summary score. Secondary outcomes were scores on the MHQ subdomains hand strength and wrist motion. Results A total of 304 adults were recruited for the study, and 187 were randomized to undergo surgery, 65 to VLPS, 64 to EFP, and 58 to CRPP; 117 participants opted for closed reduction and casting. Assessments were completed at 24 months for 182 participants (160 women [87.9%]; mean [SD] age, 70.1 [8.5] years). Mean MHQ summary scores at 24 months were 88 (95% CI, 83-92) for VLPS, 83 (95% CI, 78-88) for EFP, 85 (95% CI, 79-90) for CRPP, and 85 (95% CI, 79-90) for casting, with no clinically meaningful difference across groups after adjusting for covariates (χ23 = 1.44; P = .70). Pain scores also did not differ across groups at 24 months (χ23 = 2.64; P = .45). MHQ summary scores changed from 82 (95% CI, 80-85) to 85 (95% CI, 83-88) (P = .12) between 12 and 24 months across groups. The rate of malunion was higher in the casting group (26 participants [59.1%]) than in the other groups (4 participants [8.0%] for VLPS, 8 participants [17.0%] for EFP, and 4 participants [9.8%] for CRPP; χ23 = 43.6; P

Background Whether to irradiate the tissue expander before implant exchange or to defer irradiation until after exchange in immediate, two-stage expander/implant reconstruction remains uncertain. The authors evaluated the effects of irradiation timing on complication rates and patient-reported outcomes in patients undergoing immediate expander/implant reconstruction. Methods Immediate expander/implant reconstruction patients undergoing postmastectomy radiation therapy at 11 Mastectomy Reconstruction Outcomes Consortium sites with demographic, clinical, and complication data were analyzed. Patient-reported outcomes were assessed with BREAST-Q, Patient-Reported Outcomes Measurement Information System, and European Organisation for Research and Treatment of Cancer Breast Cancer-Specific Quality-of-Life Questionnaire surveys preoperatively and 2 years postoperatively. Survey scores and complication rates were analyzed using bivariate comparison and multivariable regressions. Results Of 317 patients who met inclusion criteria, 237 underwent postmastectomy radiation therapy before expander/implant exchange (before-exchange cohort), and 80 did so after exchange (after-exchange cohort). Timing of radiation had no significant effect on risks of overall complications (OR, 1.25; p = 0.46), major complications (OR, 1.18; p = 0.62), or reconstructive failure (OR, 0.72; p = 0.49). Similarly, radiation timing had no significant effect on 2-year patient-reported outcomes measured by the BREAST-Q or the European Organisation for Research and Treatment of Cancer survey. Outcomes measured by the Patient-Reported Outcomes Measurement Information System showed less anxiety, fatigue, and depression in the after-exchange group. Compared with preoperative assessments, 2-year patient-reported outcomes significantly declined in both cohorts for Satisfaction with Breasts, Physical Well-Being, and Sexual Well-Being, but improved for anxiety and depression. Conclusions Radiation timing (before or after exchange) had no significant effect on complication risks or on most patient-reported outcomes in immediate expander/implant reconstruction. Although lower levels of anxiety, depression, and fatigue were observed in the after-exchange group, these differences may not be clinically significant. Clinical question/level of evidence Therapeutic, II.

Objective The primary aim of this study was to compare patient-reported outcomes (PROs) of women who underwent immediate implant-based breast reconstruction (IBBR) after receiving either: (1) nipple-sparing mastectomy (NSM) or (2) simple mastectomy with subsequent nipple reconstruction (SNR). Background The goal of post-mastectomy breast reconstruction is to restore body image and quality-of-life after mastectomy, but removal of the nipple-areolar complex may have its own negative psychosocial consequences. NSM may have increased in popularity due to its perceived oncologic safety in many women and to reports of superior aesthetic results with this technique. Despite the increased utilization of NSM, few studies have evaluated the impact of NSM on PROs and complications in women undergoing immediate IBBR. Methods We performed a secondary analysis of the Mastectomy Reconstruction Outcomes Consortium study, a multicenter, prospective cohort study that recruited patients between February 2012 and July 2015. The primary aim of this study was to compare PROs as measured by BREAST-Q scores between women who underwent IBBR after NSM versus SNR. The secondary aim was to compare complication rates. Mixed-effects regression models controlled for demographic and clinical covariates. Results Of the 600 women in the study, 286 (47.7%) underwent NSM. After controlling for baseline patient characteristics, we found no significant differences in satisfaction with breast, psychosocial well-being, physical well-being or sexual well-being between women undergoing NSM versus SNR. Mastectomy type was not a significant predictor of complications or reconstructive failure. Conclusions Despite reports of superior aesthetics for NSM over simple mastectomy with nipple reconstruction in immediate IBBR, we found no significant differences at 2 years after reconstruction in patient satisfaction, quality-of-life, or complication rates.

Context Engaging underrepresented communities in health research priority setting could make the scientific agenda more equitable and more responsive to their needs. Objective Evaluate democratic deliberations engaging minority and underserved communities in setting health research priorities. Methods Participants from underrepresented communities throughout Michigan (47 groups, n = 519) engaged in structured deliberations about health research priorities in professionally facilitated groups. We evaluated some aspects of the structure, process, and outcomes of deliberations, including representation, equality of participation, participants’ views of deliberations, and the impact of group deliberations on individual participants’ knowledge, attitudes, and points of view. Follow‐up interviews elicited richer descriptions of these and also explored later effects on deliberators. Results Deliberators (age 18‐88 years) overrepresented minority groups. Participation in discussions was well distributed. Deliberators improved their knowledge about disparities, but not about health research. Participants, on average, supported using their group's decision to inform decision makers and would trust a process like this to inform funding decisions. Views of deliberations were the strongest predictor of these outcomes. Follow‐up interviews revealed deliberators were particularly struck by their experience hearing and understanding other points of view, sometimes surprised at the group's ability to reach agreement, and occasionally activated to volunteer or advocate. Conclusions Deliberations using a structured group exercise to engage minority and underserved community members in setting health research priorities met some important criteria for a fair, credible process that could inform policy. Deliberations appeared to change some opinions, improved some knowledge, and were judged by participants worth using to inform policymakers.

BACKGROUND: Guidelines recommend most benzodiazepine (BZD) treatment be short-term, though chronic BZD use is increasing. OBJECTIVE: Determine the rate of BZD discontinuation among chronic users and identify patient- and provider-level factors associated with discontinuation. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study using nationwide insurance claims data from 2014 to 2016 of US adults ≥ 18 years old with chronic BZD use (i.e., > 120 days) during the baseline year. MAIN OUTCOMES AND MEASURES: The primary outcome was BZD discontinuation among chronic users after 1 year of follow-up. A series of multilevel logistic regression models examined the association of BZD discontinuation with patient and provider characteristics. Covariates included patient sociodemographics, medical and psychiatric comorbidity, co-prescribed opioids and other psychotropics, and characteristics of the prescribed BZD. KEY RESULTS: Of 141,008 chronic BZD users, 13.4% discontinued use after 1 year. Females had lower odds of discontinuation (AOR 0.83, 99% CI 0.79–0.87), while African-American patients had higher odds (AOR 1.12, 99% CI 1.03–1.22). Those prescribed a high-potency BZD had lower odds of discontinuation (AOR 0.51, 99% CI 0.47–0.54), as did those prescribed an opioid (AOR 0.94, 99% CI 0.89–0.99). After adjusting for patient- and provider-level factors, differences between providers accounted for 5.8% of variation in BZD discontinuation (p

Background and aims Cost-effectiveness studies in randomized clinical trials have shown that tobacco cessation pharmacotherapy is among the most cost-effective of health-care interventions. Clinical trial eligibility criteria and treatment protocols may not be followed in actual practice. This study aimed to determine whether tobacco cessation pharmacotherapy is cost-effective in real-world settings. Design A retrospective analysis of costs and outcomes. Setting Hospitals and clinics of the US Veterans Health Administration, USA. Participants A total of 589 862 US veterans who screened positive for tobacco use in 2011. Intervention and comparator Tobacco users who initiated smoking cessation pharmacotherapy in the 6 months after screening were compared with those who did not use pharmacotherapy in this period. Pharmacotherapy included nicotine replacement therapy, bupropion (if prescribed at 300 mg per day or specifically for tobacco cessation) or varenicline. Measures Effectiveness was determined from responses to a subsequent tobacco screening conducted between 7 and 18 months after the treatment observation period. Cost of medications and prescribing health-care encounters was determined for the period between initial and follow-up tobacco use screening. Multivariate fixed-effects regression was used to assess the effect of initial treatment status on cost and outcome while controlling for differences in case-mix with propensity weighting to adjust for confounding by indication. Findings Thirteen per cent of participants received tobacco cessation pharmacotherapy within 6 months of initial screening. After an average of an additional 218.1 days' follow-up, those who initially received pharmacotherapy incurred $143.79 in additional treatment cost and had a 3.1% absolute increase in tobacco quit rates compared with those who were not initially treated. This represents an incremental cost-effectiveness ratio of $4705 per quit. The upper limit of the 99.9% confidence region was $5600 per quit. Without propensity adjustment, the cost-effectiveness ratio was $7144 per quit, with the upper limit of the 99.9% confidence region $9500/quit. Conclusions Tobacco cessation pharmacotherapy provided by the US Veterans Health Administration in 2011/12 was cost-effective in this real-world setting, with an incremental cost-effectiveness ratio of $4705 per quit.

PURPOSE This randomized clinical trial compared a personally tailored, automated telephone symptom management intervention to improve self-management among long-term survivors of prostate cancer with usual care enhanced with a nontailored newsletter about symptom management. We hypothesized that intervention-group participants would have more confident symptom self-management and reduced symptom burden. METHODS A total of 556 prostate cancer survivors who, more than 1 year after treatment, were experiencing symptom burden were recruited from April 2015 to February 2017 across four Veterans Affairs sites. Participants were randomly assigned to intervention (n = 278) or usual care (n = 278) groups. We compared differences in the primary (symptom burden according to Expanded Prostate Cancer Index Composite-26 [EPIC], confidence in self-management) and secondary outcomes between groups using intent-to-treat analyses. We compared domain-specific changes in symptom burden from baseline to 5 and 12 months among the intervention group according to the primary symptom focus area (urinary, bowel, sexual, general) of participants. RESULTS Most of the prostate cancer survivors in this study were married (54.3%), were white (69.2%), were retired (62.4%), and underwent radiation therapy (56.7% v 46.2% who underwent surgery), and the mean age was 67 years. There were no baseline differences in urinary, bowel, sexual, or hormonal domain EPIC scores across groups. We observed higher EPIC scores in the intervention arm in all domain areas at 5 months, though differences were not statistically significant. No differences were found in secondary outcomes; however, coping appraisal was higher (2.8 v 2.6; P = .02) in intervention-arm patients at 5 months. In subgroup analyses, intervention participants reported improvement from baseline at 5 and 12 months in their symptom focus area domains. CONCLUSION This intervention was well received among veterans who were long-term survivors of prostate cancer. Although overall outcome differences were not observed across groups, the intervention tailored to symptom area of choice may hold promise to improve associated burden.

Objective Our objectives were to investigate case-mix adjusted hospital variations in 2-year clinical and patient-reported outcomes following immediate breast reconstruction. Background Over the past few decades, variations in medical practice have been viewed as opportunities to promote best practices and high-value care. Methods The Mastectomy Reconstruction Outcomes Consortium Study is an National Cancer Institute-funded longitudinal, prospective cohort study assessing clinical and patient-reported outcomes of immediate breast reconstruction after mastectomy at 11 leading medical centers. Case-mix adjusted comparisons were performed using generalized linear mixed-effects models to assess variation across the centers in any complication, major complications, satisfaction with outcome, and satisfaction with breast. Results Among 2252 women in the analytic cohort, 1605 (71.3%) underwent implant-based and 647 (28.7%) underwent autologous breast reconstruction. There were significant differences in the sociodemographic and clinical characteristics, and distribution of procedure types at the different Mastectomy Reconstruction Outcomes Consortium Study centers. After case-mix adjustments, hospital variations in the rates of any and major postoperative complications were observed. Medical center odds ratios for major complication ranged from 0.58 to 2.13, compared with the average major complication rate across centers. There were also meaningful differences in satisfaction with outcome (from the lowest to highest of -2.79-2.62) and in satisfaction with breast (-2.82-2.07) compared with the average values. Conclusions Two-year postoperative complications varied widely between hospitals following post-mastectomy breast reconstruction. These variations represent an important opportunity to improve care through dissemination of best practices and highlight the limitations of extrapolating single-institution level data and the ongoing challenges of studying hospital-based outcomes for this patient population.

Many conventional methods to assess engineered tissue morphology and viability are destructive techniques with limited utility for tissue constructs intended for implantation in patients. Sterile label-free optical molecular imaging methods analyzed tissue endogenous fluorophores without staining, noninvasively and quantitatively assessing engineered tissue, in lieu of destructive assessment methods. The objective of this study is to further investigate label-free optical metrics and their correlation with destructive methods. Tissue-engineered constructs (n = 33 constructs) fabricated with primary human oral keratinocytes (n = 10 patients) under control, thermal stress, and rapamycin treatment manufacturing conditions exhibited a range of tissue viability states, as evaluated by quantitative histology scoring, WST-1 assay, Ki-67 immunostaining imaging, and label-free optical molecular imaging methods. Both histology sections of fixed tissues and cross-sectioned label-free optical images of living tissues provided quantitative spatially selective information on local tissue morphology, but optical methods noninvasively characterized both local tissue morphology and cellular viability at the same living tissue site. Furthermore, optical metrics noninvasively assessed living tissue viability with a statistical significance consistent with the destructive tissue assays WST-1 and histology. Over the range of cell viability states created experimentally, optical metrics noninvasively and quantitatively characterized living tissue viability and correlated with the destructive WST-1 tissue assay. By providing, under sterile conditions, noninvasive metrics that were comparable with conventional destructive tissue assays, label-free optical molecular imaging has the potential to monitor and assess engineered tissue construct viability before surgical implantation. IMPACT STATEMENT: The U.S. Food and Drug Administration has identified the lack of noninvasive evaluation method as an essential missing experimental release criterion strongly desired for clinical translation of tissue-engineered constructs. This study addresses the need by investigating label-free optical metrics for monitoring engineered tissues with a range of viability states. The noninvasive optical method was compared with multiple traditional assays and was found to correlate with a destructive tissue assay. The study would draw interest from many fields, including academics and professionals working in biomedical optics, tissue engineering, regenerative medicine, and the broader medical audience due to its potential applications to any cell-based construct.

OBJECTIVE: Mood disorders lead to significant functional impairment and are the costliest conditions for health plans. Few individuals with mood disorders have access to evidence-based Collaborative Chronic Care Models (CCMs) because most are seen in small-group practices (

Background Previous findings regarding the association between benzodiazepine exposure and dementia have conflicted, though many have not accounted for anticholinergic exposure. The goal of this study was to evaluate the association of benzodiazepine exposure with the risk of developing dementia, accounting for the anticholinergic burden. Methods Using a retrospective cohort design, we identified veterans 65 or older without dementia during a 10-year baseline period and then followed participants for 5 years to evaluate the risk of dementia diagnosis. The primary exposure was cumulative benzodiazepine exposure. Cox proportional hazards survival model was used to examine the association between benzodiazepine exposure and dementia, adjusting for anticholinergic burden and other demographic and clinical characteristics associated with increased dementia risk. Results Of the 528 006 veterans in the study cohort, 28.5% had at least one fill for a benzodiazepine. Overall, 7.9% developed a diagnosis of dementia during the observation period. Compared to veterans with no exposure to benzodiazepines, the adjusted hazard ratios for dementia risk were 1.06 (95% confidence interval [CI] 1.02–1.10) for low benzodiazepine exposure, 1.05 (95% CI 1.01–1.09) for medium benzodiazepine exposure, and 1.05 (95% CI 1.02–1.09) for high benzodiazepine exposure. Conclusions Cumulative benzodiazepine exposure was minimally associated with increased dementia risk when compared with nonuse but did not increase in a dose-dependent fashion with higher exposure. Veterans with low benzodiazepine exposure had essentially the equivalent risk of developing dementia as veterans with high exposure. While benzodiazepines are associated with many side effects for older adults, higher cumulative use does not appear to increase dementia risk.

Key Points Question Can the intensity of hypertension treatment by total dose burden for older patients be accurately quantified using only health system administrative pharmacy fill data? Findings In this cross-sectional study, dose intensity measured using pharmacy data in a national health care system was highly correlated with dose intensity documented in clinical notes by using a new algorithm that can be applied to an individual patient on any given day. Meaning This study suggests that intensity of hypertension treatment can be measured using pharmacy data at a more detailed level than using medication counts or blood pressure alone for quality comparison or as a research tool., Importance Simple measures of hypertension treatment, such as achievement of blood pressure (BP) targets, ignore the intensity of treatment once the BP target is met. High-intensity treatment involves increased treatment burden and can be associated with potential adverse effects in older adults. A method was previously developed to identify older patients receiving intense hypertension treatment by low BP and number of BP medications using national Veterans Health Administration and Medicare Part D administrative pharmacy data to evaluate which BP medications a patient is likely taking on any given day. Objective To further develop and validate a method to more precisely quantify dose intensity of hypertension treatment using only health system administrative pharmacy fill data. Design, Setting, and Participants Observational, cross-sectional study of 319 randomly selected older veterans in the national Veterans Health Administration health care system who were taking multiple BP-lowering medications and had a total of 3625 ambulatory care visits from July 1, 2011, to June 30, 2013. Measure development and medical record review occurred January 1, 2017, through November 30, 2018, and data analysis was conducted from December 1, 2019, to August 31, 2020. Main Outcomes and Measures For each BP-lowering medication, a moderate hypertension daily dose (HDD) was defined as half the maximum dose above which no further clinical benefit has been demonstrated by that medication in hypertension trials. Patients’ total HDD was calculated using pharmacy data (pharmacy HDDs), accounting for substantial delays in refills (>30 days) when a patient’s pill supply was stretched (eg, cutting existing pills in half). As an external comparison, the pharmacy HDDs were correlated with doses manually extracted from clinicians’ visit notes (clinically noted HDDs). How well the pharmacy HDDs correlated with clinically noted HDDs was calculated (using C statistics). To facilitate interpretation, HDDs were described in association with the number of medications. Results A total of 316 patients (99.1%) were male; the mean (SD) age was 75.6 (7.2) years. Pharmacy HDDs were highly correlated (r = 0.92) with clinically noted HDDs, with a mean (SD) of 2.7 (1.8) for pharmacy HDDs and 2.8 (1.8) for clinically noted HDDs. Pharmacy HDDs correlated with high-intensity, clinically noted HDDs ranging from a C statistic of 92.8% (95% CI, 92.0%-93.7%) for 2 or more clinically noted HDDs to 88.1% (95% CI, 85.5%-90.6%) for 6 or more clinically noted HDDs. Conclusions and Relevance This study suggests that health system pharmacy data may be used to accurately quantify hypertension regimen dose intensity. Together with clinic-measured BP, this tool can be used in future health system–based research or quality improvement efforts to fine-tune, manage, and optimize hypertension treatment in older adults., This cross-sectional study develops and validates a method to more precisely quantify dose intensity of hypertension treatment using only health system administrative pharmacy fill data.

Aims Catheter ablation is an effective treatment for post-infarction ventricular tachycardia (VT). However, some patients may experience a worsened arrhythmia phenotype after ablation. We aimed to determine the prevalence and prognostic impact of arrhythmia exacerbation (AE) after post-infarction VT ablation. Methods and results A total of 1187 consecutive patients (93% men, median age 68 years, median ejection fraction 30%) who underwent post-infarction VT ablation at six centres were included. Arrhythmia exacerbation was defined as post-ablation VT storm or incessant VT in patients without prior similar events. During follow-up (median 717 days), 426 (36%) patients experienced VT recurrence. Events qualifying as AE occurred in 67 patients (6%). Median times to VT recurrence with and without AE were 238 [interquartile range (IQR) 35–640] days and 135 (IQR 22–521) days, respectively (P = 0.25). Almost half of the patients (46%) who experienced AE experienced it within 6 months of the index procedure. Patients with AE had had longer ablation times during the ablation procedures compared to the rest of the patients (median 42 vs. 34 min, P = 0.02). Among patients with VT recurrence, the risk of death or heart transplantation was significantly higher in patients with than without AE (hazard ratio 1.99, 95% CI 1.28–3.10; P = 0.002) after adjusting for age, gender, ejection fraction, cardiac resynchronization therapy, post-ablation non-inducibility, and post-ablation amiodarone use. Conclusion Arrhythmia exacerbation after ablation of infarct-related VT is infrequent but is independently associated with an adverse long-term outcome among patients who experience a VT recurrence. The mechanisms and mitigation strategies of AE after catheter ablation require further investigation.

About a third of college students struggle with anxiety, depression, or an eating disorder, and only 20–40% of college students with mental disorders receive treatment. Inadequacies in mental health care delivery result in prolonged illness, disease progression, poorer prognosis, and greater likelihood of relapse, highlighting the need for a new approach to detect mental health problems and engage college students in services. We have developed a transdiagnostic, low-cost mobile mental health targeted prevention and intervention platform that uses population-level screening to engage college students in tailored services that address common mental health problems. We will test the impact of this mobile mental health platform for service delivery in a large-scale trial across 20+ colleges. Students who screen positive or at high-risk for clinical anxiety, depression, or an eating disorder and who are not currently engaged in mental health services (N = 7884) will be randomly assigned to: 1) intervention via the mobile mental health platform; or 2) referral to usual care (i.e., campus health or counseling center). We will test whether the mobile mental health platform, compared to referral, is associated with improved uptake, reduced clinical cases, disorder-specific symptoms, and improved quality of life and functioning. We will also test mediators, predictors, and moderators of improved mental health outcomes, as well as stakeholder-relevant outcomes, including cost-effectiveness and academic performance. This population-level approach to service engagement has the potential to improve mental health outcomes for the millions of students enrolled in U.S. colleges and universities.