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The American Academy of Pediatrics recommends pre-discharge Car Seat Tolerance Screening (CSTS) for all neonates born37 weeks estimated gestational age (EGA), or otherwise at risk for cardiorespiratory compromise. Screening is burdensome and there remains tremendous variation in testing criteria and methodology.We conducted a retrospective chart review of 1,072 infants who underwent CSTS between 11/2013 and 7/2016 at a single academic health center. CSTS outcomes (failure and, separately, significant cardiorespiratory instability (CRI)), including those not meeting failure thresholds) were analyzed for all infants screened, and for preterm infants by screening location (Neonatal Intensive Care Unit (NICU) and Mother/Baby Unit (MBU)). Logistic regression was used to estimate associations between infant characteristics and CSTS outcomes.Overall incidence of CSTS failure was 9.2%. Among all infants, hemodynamically significant congenital heart disease, apnea, chronic lung disease, and being small for EGA were associated with failure. Additionally, those born ≤28 weeks EGA had 2.4 times greater likelihood of failure than those 34-36 weeks EGA. Among preterm infants in the NICU and MBU, those of earlier EGA were also more likely to fail. Almost half (47.5%) of all preterm infants demonstrated CRI during CSTS.We found high CSTS failure rates, and identified key infant characteristics that were associated with increased likelihood of failure. Significant CRI events were remarkably common. Larger, prospective studies are needed to elucidate risk factors for instability and failure and define practical criteria for CSTS recommendations.

Objective Many post-9/11 Veterans have received Department of Veterans Affairs (VA) healthcare for traumatic brain injury (TBI). Pain conditions are prevalent among these patients and are often managed with opioid analgesics. Opioids may impose unique risks to Veterans with a history of TBI, especially when combined with other psychotropic medications. We examined receipt of opioid and sedative-hypnotic prescriptions among post-9/11 Veterans with TBI who received VA care nationally between 2012 and 2020. Setting Nationwide VA outpatient care. Participants Veterans with, versus without, clinician-confirmed TBI based on the VA's Comprehensive TBI Evaluation (CTBIE) were followed up for subsequent years in which they received VA care. Design A historical cohort study. Main measures Proportions of Veterans who received opioid, benzodiazepine, and nonbenzodiazepine sedative-hypnotic prescriptions were compared by CTBIE outcome (TBI yes/no) and by year; overlaps between medication classes, long-term opioid therapy, and high-dose opioid therapy were also examined. Among those with confirmed TBI, logistic regression was used to examine associations between veteran characteristics and likelihood of these potentially high-risk opioid use outcomes. Results Among 69 752 Veterans with clinician-confirmed TBI, 26.9% subsequently received opioids. The prevalence receiving opioids each year increased from 2012 (16.7%) to 2014 (17.7%), and then decreased each of the following years through 2020 (5.8%). Among Veterans with TBI who received opioids, large proportions also received benzodiazepine (30.1%) and nonbenzodiazepine (36.0%) sedative-hypnotic prescriptions; these proportions also decreased in recent years. In both bivariable and multivariable regression models, Veterans' demographic, TBI, and clinical characteristics were associated with likelihood of potentially high-risk opioid use. Conclusions VA opioid prescribing to Veterans with TBI has decreased in recent years but remains an important source of risk, particularly when considering coprescriptions of sedative-hypnotic medication. Understanding patterns of psychotropic prescription use among Veterans with TBI can highlight important healthcare and rehabilitation needs in this large patient cohort.

Objective Receipt of concurrent psychotropic prescription medications from both US Department of Veterans Affairs (VA) and non-VA healthcare providers may increase risk of adverse opioid-related outcomes among veterans with traumatic brain injury (TBI). Little is known about patterns of dual-system opioid or sedative-hypnotic prescription receipt in this population. We estimated the prevalence and patterns of, and risk factors for, VA/non-VA prescription overlap among post-9/11 veterans with TBI receiving opioids from VA providers in Oregon. Setting Oregon VA and non-VA outpatient care. Participants Post-9/11 veterans in Oregon with TBI who received an opioid prescription from VA providers between the years of 2014 and 2019. Design Historical cohort study. Main measures Prescription overlap of VA opioids and non-VA opioids or sedative-hypnotics; proportions of veterans who received VA or non-VA opioid, benzodiazepine, and nonbenzodiazepine sedative-hypnotic prescriptions were also examined by year and by veteran characteristics. Results Among 1036 veterans with TBI receiving opioids from the VA, 210 (20.3%) received an overlapping opioid prescription from a non-VA provider; 5.3% received overlapping benzodiazepines; and none received overlapping nonbenzodiazepine sedative-hypnotics. Proportions of veterans with prescription overlap tended to decrease over time. Veterans with other than urban versus urban addresses (OR = 1.4; 95% CI, 1.0-1.8), high versus medium average annual VA visits (OR = 1.7; 95% CI, 1.1-2.6), and VA service connection of 50% or more versus none/0% to 40% (OR = 4.3; 95% CI, 1.3-14.0) were more likely to have concurrent VA/non-VA prescriptions in bivariable analyses; other than urban remained associated with overlap in multivariable models. Similarly, veterans with comorbid posttraumatic stress disorder diagnoses were more likely to have concurrent VA/non-VA prescriptions in both bivariable and multivariable (OR = 2.1; 95% CI, 1.0-4.1) models. Conclusion Among post-9/11 veterans with TBI receiving VA opioids, a considerable proportion had overlapping non-VA prescription medications. Providers and healthcare systems should consider all sources of psychotropic prescriptions, and risk factors for overlapping medications, to help mitigate potentially unsafe medication use among veterans with TBI.

Statement of purpose International Classification of Diseases, Tenth Revision (ICD-10), Clinical Modification codes are used to identify Veterans with traumatic brain injury (TBI) for surveillance and research. We examined the validity of using ICD-10 codes in Veterans Health Administration (VA) administrative data to identify Veterans with TBI. Methods/Approach Clinician-confirmed TBI cases and non-cases after October 1, 2016 were extracted from the VA Comprehensive TBI Evaluation (CTBIE) database, a standardized TBI evaluation tool, and used as the criterion standard. Accessing VA administrative healthcare data, we compared three series of TBI-related ICD-10 codes recommended by the Centers for Disease Control and Prevention (CDC), the Defense and Veterans Brain Injury Center (DVBIC), and the VA TBI Program Office (VA) to clinician- confirmed TBI diagnoses. Sensitivity, specificity, and concordance were calculated. The validity of distinguishing TBI severity (mild versus moderate/severe), using DVBIC-recommended codes, was also examined. Results Among 29,767 Veterans who received a CTBIE between 2016 and 2019, 20,670 (69.4%) received a clinician-confirmed TBI diagnosis and 20,760 (69.7%) had at least one TBI-related ICD-10 code assigned from any series. The CDC series had low sensitivity (40.8%) but high specificity (80.7%; 53.0% concordance). The DVBIC series had moderate sensitivity and specificity (71.7% and 63.9%, respectively; 69.3% concordance). The VA series had high sensitivity (81.8%), but moderate specificity (58.8%; 74.7% concordance). The sensitivity of DVBIC-recommended codes to distinguish TBI severity was high (83.4%), but specificity was low (21.5%; 76.4% concordance). Conclusion We found that all three series of ICD-10 codes for TBI resulted in considerable misclassification of clinician-confirmed TBI cases and non-cases. The potential misclassification in studies using ICD-10 codes to examine TBI prevalence and outcomes among Veterans should inform surveillance and research efforts. Significance Examining the validity of methods used for enumerating TBI cases allows researchers to interpret and translate their findings in the context of potential error.

Objective State prescription drug monitoring programs (PDMPs) identify controlled medications dispensed across providers and systems. Department of Veterans Affairs (VA) policy requires electronic health record documentation of PDMP queries at least annually for VA patients receiving controlled medications; however, queries are not uniformly conducted. We examined factors associated with PDMP queries for veterans receiving long-term opioid therapy. Methods Veterans with a VA provider who received long-term opioid therapy between August 2015 and August 2016 within a four-state region were identified; 9,879 were due for a PDMP query between August 2016 and February 2017. Likelihood of veterans’ PDMP queries during this follow-up period was modeled as a function of patient, provider, and facility characteristics of interest in mixed-effects modified Poisson models estimating relative risk and 95% confidence intervals. Multivariable models controlled for potential confounders identified through the use of directed acyclic graphs. Results PDMP queries were documented for 62.1% of veterans that were due for a PDMP query. Veterans were more likely to be queried if they were Hispanic or if they received methadone, had average daily milligram morphine equivalents >20, or received urine drug screening during the studied period. Veterans were less likely to be queried if they had a rural address, mail order medication, or cancer diagnosis. Likelihood of PDMP queries was also lower for veterans whose opioid-prescribing provider was an oncologist or working in a low-complexity facility. Conclusions Adherence to PDMP query policy within the VA varied by patient, clinician, and facility factors. Mechanisms to standardize the conduct of PDMP queries may be needed.

Purpose Although injury is the third leading cause of death in the United States (US), and the leading cause of death for ages 1–44, injury-related curricula are often unavailable to students of public health. The purpose of this project was to assess the availability of injury- and violence-related curricula in public health education. Methods We surveyed websites of all Council on Education for Public Health (CEPH)-accredited schools and programs of public health (both graduate and undergraduate) in the US. Degree program catalogs and class syllabi were searched to identify the presence and types of injury- and violence-related curricula offered at each school/program. School/program characteristics were also recorded, including type (schools versus programs), size and region, public health degrees offered, and presence of Injury Control Research Centers (ICRCs). Using descriptive statistics and mapping approaches, we examined the availability and types of injury- and violence-related curricula by school/program characteristics. Results Out of 178 CEPH-accredited schools/programs of public health, only 43 (24%) offered injury- or violence-related curricula. Of these, most (72%) were schools of public health. Some curricula covered both injury and violence topics (35%), while others focused exclusively on violence (30%). Regionally, the northeast had the most schools/programs with injury- and violence-related curricula (6.1 schools per 100,000 miles) and the western region had the least (0.5 schools per 100,000 miles). Schools/programs with ICRCs were more likely to offer injury or violence curriculum. Conclusion Results of this project suggest that access to injury- and violence-related curricula continues to be limited across schools and programs of public health. Significance/Contribution Training efforts led by the Society for Advancement of Violence and Injury Prevention (SAVIR) or other professional organizations might fill this gap by providing distance-learning opportunities that are accessible across regions. Future research should survey school/program leaders to identify additional facilitators to increasing curricula availability.

Introduction Tinnitus is prevalent among Service members and Veterans and is often comorbid with mental health disorders. Associations between the severity of individuals’ tinnitus and mental health symptoms are not well described. Materials and Methods We conducted a population-based survey of a stratified random sample of 1,800 Veterans diagnosed with tinnitus. We used the Tinnitus Functional Index to measure tinnitus severity and the Primary Care-Posttraumatic Stress Disorder (PTSD) screen and the Hospital Anxiety and Depression Scale to assess PTSD, depression, and anxiety. Descriptive statistics and bivariable and multivariable regression models were used to estimate associations between Veterans’ tinnitus severity and mental health symptoms. Inverse probability weights were used to account for sample stratification and survey non-response. Multivariable odds ratios (ORs) and 95% confidence intervals (CIs) controlled for Veterans’ demographics, military history, and health diagnoses. Results A total of 891 Veterans completed surveys (adjusted response rate = 53%). Large proportions rated their tinnitus as severe (29.4%; 95% CI: 27.2-31.6) or very severe (18.7%; 95% CI: 16.8-20.5). In multivariable regression models, and compared with Veterans with none/mild tinnitus, the likelihood of screening positive for PTSD was increased for those who reported moderate (OR = 4.0; 95% CI: 1.6-10.3), severe (OR = 7.5; 95% CI: 3.1-18.5), or very severe (OR = 17.5; 95% CI: 4.4-70.0) tinnitus. Similarly, Veterans’ likelihood of positive depression screens were elevated for those with moderate (OR = 2.6; 95% CI: 1.1-5.9), severe (OR = 3.0; 95% CI: 1.4-6.5), or very severe (OR = 15.5; 95% CI: 4.3-55.5) tinnitus, as was the likelihood of positive anxiety screens for those with severe (OR = 2.6; 95% CI: 1.1-6.3) or very severe (OR = 13.4; 95% CI: 4.0-44.3) tinnitus. Conclusions Mental health symptoms are strongly associated with Veterans’ tinnitus severity. A better understanding of the interplay between these conditions may help improve the provision of interdisciplinary (Audiology and Mental Health) care for Service members and Veterans.

Objective To examine the prevalence of concurrent Veterans Health Administration (VA) and non-VA prescriptions for opioids and sedative-hypnotic medications among post-9/11 veterans in Oregon. Data sources VA health care and prescription data were probabilistically linked with Oregon Prescription Drug Monitoring Program (PDMP) data. Study design This retrospective cohort study examined concurrent prescriptions among n = 19,959 post-9/11 veterans, by year (2014-2016) and by patient demographic and clinical characteristics. Veterans were included in the cohort for years in which they received VA outpatient care; those receiving hospice or palliative care were excluded. Concurrent prescriptions were defined as ≥1 days of overlap between outpatient prescriptions for opioids and/or sedative-hypnotics (categorized as benzodiazepines vs. non-benzodiazepines). Principal findings Among 5,882 veterans who filled opioid or sedative-hypnotic prescriptions at VA pharmacies, 1,036 (17.6 percent) filled concurrent prescriptions from non-VA pharmacies. Within drug class, 15.1, 8.8, and 4.6 percent received concurrent VA and non-VA opioids, benzodiazepines, and non-benzodiazepines, respectively. Veteran demographics and clinical diagnoses were associated with the likelihood of concurrent prescriptions, as was enrollment in the Veterans Choice Program. Conclusions A considerable proportion of post-9/11 veterans receiving VA care in Oregon filled concurrent prescriptions for opioids and sedative-hypnotics. Fragmentation of care may contribute to prescription drug overdose risk among veterans.

Purpose Tinnitus is prevalent among military Veterans and may frequently co-occur with mental health disorders. This study examined health care utilization and mental health diagnoses among Veterans with and without tinnitus who receive Department of Veterans Affairs (VA) health care. Method We randomly sampled 10% of VA health care users for a 5-year period between 2011 and 2016. Tinnitus and other diagnoses were identified using International Classification of Diseases diagnosis codes; Veterans assigned 1 or more inpatient codes or 2 or more outpatient codes were considered to have the respective diagnosis. We examined demographics, military service, clinical characteristics, and health care utilization of Veterans with and without tinnitus diagnoses. Bivariable and multivariable logistic regression was used to estimate associations between tinnitus and mental health diagnoses of interest. Results Among 617,534 eligible Veterans, 3.8% met criteria for tinnitus diagnosis. Prevalence of tinnitus was associated with sex, age, race, marital status, and VA service connection status; additionally, hearing loss and traumatic brain injury were frequently codiagnosed with tinnitus. Veterans with tinnitus had higher annual health care utilization than those without. While controlling for potential confounders, tinnitus diagnoses were associated with mental health diagnoses, including anxiety, depression, and substance use disorders. Conclusion Findings suggest that Veterans who are diagnosed with tinnitus have more health care utilization and are more frequently diagnosed with mental health disorders than Veterans who are not diagnosed with tinnitus. This suggests a need for coordinated tinnitus and mental health care services for Veterans in the VA system of care.

Evidence suggests that Iraq and Afghanistan war veterans with polytrauma/traumatic brain injury (TBI) history and neurobehavioral symptoms may face difficulties returning to work, yet also encounter barriers to accessing, navigating, and engaging in Department of Veterans Affairs (VA) vocational rehabilitation programs. This study utilized qualitative interviews and focus groups with veterans with documented polytrauma/TBI history to explore veterans' perceived barriers to employment and vocational rehabilitation program participation, as well as to solicit thoughts regarding interest in an evidence-based vocational rehabilitation program, the Individual Placement and Support model of Supported Employment (IPS-SE). Veterans identified physical, emotional, cognitive, and interpersonal barriers to finding and maintaining work that they described as linked with their polytrauma/TBI symptoms and sequelae. Communication and logistical issues were described as the primary barriers to vocational rehabilitation program access, while barriers to program utilization included eligibility characteristics, fear of losing financial benefits, and a military-cultural belief of self-sufficiency that made help-seeking difficult. Finally, veterans endorsed key aspects of IPS-SE, such as staff serving as translators, advocates, and navigators of the job search and maintenance process. Policy recommendations are addressed. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Purpose: Motor vehicle crashes (MVCs) are the leading cause of death for children ages 1-14 years in the United States. Car safety seats are effective in decreasing the risk of injury and death, and rear-facing car safety seats (RFCSSs) are significantly more effective than forward-facing seats in protecting children less than 24 months of age. While the American Academy of Pediatrics (AAP) recommends that children remain in a RFCSS until at least 2 years of age, …

Purpose Veterans using Veterans Affairs (VA) healthcare have twice the risk of fatal prescription drug overdose (PDO) than non-Veterans. This elevated risk may be related to Veteran receipt of opioid prescriptions from both inside and outside the VA system. State prescription drug monitoring programs (PDMPs) can help reduce PDO by providing data on patients prescriptions across healthcare systems; however, to date, little research has leveraged PDMP data to understand Veterans PDO risk. Methods We conducted two analyses using VA and PDMP data. First, VA data for 23,052 VA users in a single state were probabilistically linked to PDMP data to examine incidence and patterns of dual VA/non-VA use of opioid prescribers. Second, using VA data from a four-state region, we examined prevalence and correlates of VA prescribers documentation of PDMP queries for 25,809 Veterans receiving long-term opioid therapy from 2015–2016. Results Results of the first analysis showed that, from 2011–2016, 53% of Veterans with VA opioid prescriptions also received non-VA opioid prescriptions in the same year; age, race, marital status, and health diagnoses such as depression and substance use disorder (SUD) were associated with dual use. Results of the second analysis showed that, among Veterans on opioid therapy, 64% had a documented PDMP query. Veterans were more likely to have a PDMP query if prescribed higher morphine-equivalent doses or if diagnosed with a substance use disorder. Conclusion While the prevalence of dual VA/non-VA use of opioid prescribers in a single state was high, more than 1/3 of Veterans receiving opioids in the VA did not have a documented PDMP query. Significance PDO is a leading cause of fatal injury and is especially important among Veterans who use VA healthcare. Increased use of PDMP data for research and healthcare may help ameliorate PDO in this population.

To quantify the need for, and interest in, supported employment (SE) among recent military veterans with traumatic brain injury (TBI); and to examine characteristics associated with veterans' interest in SE.Stratified random sample of Iraq and Afghanistan War veterans confirmed to have TBI through the Veterans Health Administration (VHA) screening and evaluation system.Community-based via mailed survey.We recruited 1800 veterans with clinician-confirmed TBI (mild TBI: n=1080; moderate/severe TBI: n=720) through multiple mailings. Among 1451 surveys that were not returned undeliverable, N=616 (42%) responded.Not applicable.Veterans rated their interest in SE after reading a script describing the program. Additional measures assessed mental health and pain-related comorbidities, employment, financial/housing difficulties, demographics, and military service characteristics. Estimates were weighted to represent the population of veterans with VHA clinician-confirmed TBI.Unemployment was reported by 45% (95% confidence interval [CI], 43-47) of veterans with TBI. Although 42% (95% CI, 40-44) reported they would be interested in using SE if it were offered to them, only 12% had heard of SE (95% CI, 11-14) and1% had used it. TBI severity and comorbidities were not associated with veterans' interest in SE. However, those who were unemployed, looking for work, experiencing financial strain, or at risk for homelessness were more likely to be interested in SE.Our research highlights an important gap between veterans' vocational needs and interests and their use of SE. Systematically identifying and referring those with employment and financial/housing difficulties may help close this gap.

Objective To examine the prevalence and potential determinants of rear-facing car safety seat use among children approximately 18 months of age born at a university hospital. Study design We administered a telephone survey to caregivers of children 17-19 months of age who were born between November 2013 and May 2014. The survey was designed to assess the prevalence of rear-facing car safety seat use and estimate the likelihood of rear-facing car safety seat use, compared with forward-facing car seat use, in reference to hypothesized determinants. aORs and 95% CIs were calculated using multivariable logistic regression. Results In total, 56% of potentially eligible caregivers (491/877) completed the survey; 62% of these reported rear-facing car safety seat use. Race, education, rurality, and household income were associated with rear-facing car safety seat use after controlling for potential confounders. Additionally, caregivers who reported having discussed car seats with their child's provider (aOR 1.7; 95% CI 1.1-2.6); receiving their child's primary care in pediatrics compared with family practice clinics (aOR 2.4; 95% CI 1.1-2.6); and being aware of the American Academy of Pediatrics rear-facing recommendation (aOR 2.8; 95% CI 1.8-4.1) were significantly more likely to report rear-facing car safety seat use. Conversely, caregivers who previously used a car seat with another child were less likely to have their child rear facing at 18 months of age (aOR 0.6; 95% CI 0.4-0.9). Conclusions A large proportion of children were forward facing at 18 months of age. Future efforts focused on encouraging providers to discuss car seats during patient visits, increasing awareness of the American Academy of Pediatrics' rear-facing recommendation, and targeting high-risk populations may improve the prevalence of children who remain rear facing until 2 years of age.