Objective: Previous research on inpatient care for children and adolescents with emotional or behavioral problems indicates that patient-level factors predict length of stay (LOS) poorly. This analysis examines whether patient-level factors are poor predictors of LOS, because LOS is primarily determined by facilities rather patients. Study Design: This study uses Tennessee Medicaid claims data from 1996 to 2001. The data include information on 14,162 observations related to 8400 patients (age 12–21) from 163 hospitals. We estimate log LOS using a cross-classified model. Covariates include admission-level characteristics (age, diagnosis, qualification for Medicaid, year), patient-level characteristics (gender, race), and facility characteristics (facility type). Principle Findings: Our results suggest that variation in LOS is attributable to facility-level factors (51%), time-invariance patient-level factors (5%), factors that vary across admissions (42%), and a correlation between patient-level and facility-level factors (5%). Conclusions: About half of the variation in LOS is explained by facility-level factors. Given the vulnerable nature of youth who are in need of inpatient psychiatric care, it may be particularly important to monitor provider-level processes and outcomes. Measuring facility or provider level quality is complicated because of difficulties in adjusting for case-mix severity across providers. The methodology presented here represents a general framework that can be widely used in health services research. Potential applications include broadening models of utilization to simultaneously include patient, provider, geographic and community level variations, as well as provider profiling.

BACKGROUND Child maltreatment is underreported in the United States and in North Carolina. In North Carolina and other states, mandatory reporting laws require various professionals to make reports, thereby helping to reduce underreporting of child maltreatment. This study aims to understand why emergency medical services (EMS) professionals may fail to report suspicions of maltreatment despite mandatory reporting policies.

Gulf War Illness (GWI), a chronic multisymptom illness with a complex and uncertain etiology and pathophysiology, is highly prevalent among veterans deployed to the 1990–1991 GW. We examined how GWI phenotypes varied by demographic and military characteristics among GW-era veterans. Data were from the VA’s Cooperative Studies Program 2006/Million Veteran Program (MVP) 029 cohort, Genomics of GWI. From June 2018 to March 2019, 109,976 MVP enrollees (out of a total of over 676,000) were contacted to participate in the 1990–1991 GW-era Survey. Of 109,976 eligible participants, 45,169 (41.1%) responded to the 2018–2019 survey, 35,902 respondents met study inclusion criteria, 13,107 deployed to the GW theater. GWI phenotypes were derived from Kansas (KS) and Centers for Disease Control and Prevention (CDC) GWI definitions: (a) KS Symptoms (KS Sym+), (b) KS GWI (met symptom criteria and without exclusionary health conditions) [KS GWI: Sym+/Dx−], (c) CDC GWI and (d) CDC GWI Severe. The prevalence of each phenotype was 67.1% KS Sym+, 21.5% KS Sym+/Dx−, 81.1% CDC GWI, and 18.6% CDC GWI severe. These findings affirm the persistent presence of GWI among GW veterans providing a foundation for further exploration of biological and environmental underpinnings of this condition.

Veterans with difficult-to-diagnose conditions who receive care in the Department of Veterans Affairs (VA) healthcare system can be referred for evaluation at one of three specialty VA War-Related Illness and Injury Study Centers (WRIISC). Veterans of the 1990–1991 Gulf War have long experienced excess rates of chronic symptoms associated with the condition known as Gulf War Illness (GWI), with hundreds evaluated at the WRIISC. Here we provide the first report from a cohort of 608 Gulf War Veterans seen at the WRIISC who completed questionnaires on chronic symptoms (>6 months) consistent with GWI as well as prominent exposures during Gulf War deployment. These included veterans’ reports of hearing chemical alarms/donning Military-Ordered Protective Posture Level 4 (MOPP4) gear, pesticide use, and use of pyridostigmine bromide (PB) pills as prophylaxis against the effects of nerve agents. Overall, veterans in the cohort were highly symptomatic and reported a high degree of exposures. In multivariable models, these exposures were significantly associated with moderate-to-severe chronic symptoms in neurocognitive/mood, fatigue/sleep, and pain domains. Specifically, exposure to pesticides was associated with problems with concentration and memory, problems sleeping, unrefreshing sleep, and joint pain. Use of MOPP4 was associated with light sensitivity and unrefreshing sleep and use of PB was associated with depression. We also evaluated the association of exposures with symptom summary scores based on veterans’ severity of symptoms in four domains and overall. In multivariable modeling, the pain symptom severity score was significantly associated with pesticide use (Odds ratio (OR): 4.13, 95% confidence intervals (CI): 1.78–9.57) and taking PB pills (OR: 2.28, 95% CI: 1.02–5.09), and overall symptom severity was significantly associated with use of PB pills (OR: 2.41, 95% CI: 1.01–5.75). Conclusion: Decades after deployment, Gulf War veterans referred to a VA tertiary evaluation center report a high burden of chronic symptoms, many of which were associated with reported neurotoxicant exposures during the war.