Archive
The Evolving Role of Emergency Departments in the United States
The Evolving Role of Emergency Departments in the United States
Source: RAND Corporation
From press release:
Hospital emergency departments play a growing role in the U.S. health care system, accounting for a rising proportion of hospital admissions and serving increasingly as an advanced diagnostic center for primary care physicians, according to a new RAND Corporation study.
While often targeted as the most expensive place to get medical care, emergency rooms remain an important safety net for Americans who cannot get care elsewhere and may play a role in slowing the growth of health care costs, according to the study.
Emergency departments are now responsible for about half of all hospital admissions in the United States, accounting for nearly all of the growth in hospital admissions experienced between 2003 and 2009.
Despite evidence that people with chronic conditions such as asthma and heart failure are visiting emergency departments more frequently, the number of hospital admissions for these conditions has remained flat. Researchers say that suggests that emergency rooms may help to prevent some avoidable hospital admissions.
"Use of hospital emergency departments is growing faster than the use of other parts of the American medical system," said Dr. Art Kellermann, the study’s senior author and a senior researcher at RAND, a nonprofit research organization. "While more can be done to reduce the number of unnecessary visits to emergency rooms, our research suggests emergency rooms can play a key role in limiting growth of preventable hospital admissions."
Overseas Basing of U.S. Military Forces: An Assessment of Relative Costs and Strategic Benefits
Overseas Basing of U.S. Military Forces: An Assessment of Relative Costs and Strategic Benefits
Source: RAND Corporation
Section 347 of the 2012 National Defense Authorization Act called on the Department of Defense to commission an independent assessment of the overseas basing presence of U.S. military forces. As the recipient of that commission, RAND’s National Defense Research Institute conducted an independent assessment of the advisability of changes in the overseas basing presence of U.S. forces based on an evaluation of strategic benefits, risks, and costs. The report characterizes how overseas presence contributes to assurance of allies, deterrence, contingency responsiveness, and security cooperation, along with the risks involved with investing in facilities overseas. It breaks new ground in the understanding of the costs associated with overseas presence, including how permanent and rotational presence costs compare, and provides cost models for policymakers to weigh alternative posture options. To support this understanding of costs the report also lays out the conditions of U.S. installations and levels of host nation support.
The report concludes that there are certain minimum requirements necessary to carry out the current national security strategy, but it is prudent, based upon the net value produced, to maintain an overseas posture that goes beyond these minimums. Additionally, it combines benefit, cost, and risk considerations to distill a number of strategic judgments that have implications for the advisability of considering identified posture changes.
Providing for the Casualties of War: The American Experience Through World War II
Providing for the Casualties of War: The American Experience Through World War II
Source: RAND Corporation
War has always been a dangerous business, bringing injury, wounds, and death, and — until recently — often disease. What has changed over time, most dramatically in the last 150 or so years, is the care these casualties receive and who provides it. Medical services have become highly organized and are state sponsored. Diseases are now prevented through vaccination and good sanitation. Sedation now ameliorates pain, and antibiotics combat infection. Wounds that once meant amputation or death no longer do so. Transfers from the field to more-capable hospitals are now as swift as aircraft can make them. The mental consequences of war are now seen as genuine illnesses and treated accordingly, rather than punished to the extreme. Likewise, treatment of those disabled by war and of veterans generally has changed markedly — along with who supplies these and other benefits. This book looks at the history of how humanity has cared for its war casualties, from ancient times through the aftermath of World War II. For each historical period, the author examines the care the sick and wounded received in the field and in hospitals, the care given to the disabled veteran and his dependents, and who provided that care and how. He shows how the lessons of history have informed the American experience over time. Finally, the author sums up this history thematically, focusing on changes in the nature and treatment of injuries, organization of services on and off the battlefield, the role of the state in providing care, and the invisible wounds of war.
Why the Rich Drink More but Smoke Less: The Impact of Wealth on Health Behaviors
Why the Rich Drink More but Smoke Less: The Impact of Wealth on Health Behaviors
Source: RAND Corporation
Wealthier individuals engage in healthier behavior. This paper seeks to explain this phenomenon by developing a theory of health behavior, and exploiting both lottery winnings and inheritances to test the theory. It distinguishes between the direct monetary cost and the indirect health cost (value of health lost) of unhealthy consumption. The health cost increases with wealth and the degree of unhealthiness, leading wealthier individuals to consume more healthy and moderately unhealthy, but fewer severely unhealthy goods. The empirical evidence presented suggests that differences in health costs may indeed provide an explanation for behavioral differences, and ultimately health outcomes, between wealth groups.
When Armies Divide: The Security of Nuclear Arsenals During Revolts, Coups, and Civil Wars
When Armies Divide: The Security of Nuclear Arsenals During Revolts, Coups, and Civil Wars
Source: RAND Corporation
This work examines what happened in April of 1961, when the French government was about to conduct the fourth of a series of nuclear tests in the Sahara. Four French Army generals, unhappy that de Gaulle was willing to support Algerian independence, staged a coup to keep Algeria as a French colony. The nuclear test was conducted a few days ahead of schedule — it was not successful — and speculation ever since has been that the test was moved up to keep the weapon out of the rebel generals’ hands.
While there is evidence that one of the generals contacted the officer who was in charge of the tests to try to delay them, Jenkins concludes that the generals really never had a plan in place to seize the weapon and that the French government didn’t want to delay the test. At the time it happened, the world viewed it as an internal, French problem.
The second, shorter part of the book compares the 1961 events to what might happen today if the military in Pakistan or North Korea splintered, and a rebel group got their hands on those countries’ nuclear materials. Jenkins contends that such a scenario today would clearly be an international incident, that neither Pakistan nor North Korea would want any foreign intervention, and that the United States "might not be the only first responder."
Two additional short essays by Dr. Stephen J. Lukasik and Constantin Melnik, a security assistant to the French prime minister in 1961, also review what happened in 1961.
Three Essays on Entrepreneurship in India and the U.S.: Policies, Social Ties and Mobility
Three Essays on Entrepreneurship in India and the U.S.: Policies, Social Ties and Mobility
Source: RAND Corporation
Across the globe, policymakers view entrepreneurship as a potential route out of poverty, even for the most disadvantaged. Many countries have developed policies to encourage business creation within this group. These dissertation papers explore the role entrepreneurship plays in the lives of the economically disadvantaged in both India and the US. The first paper examines how India’s Micro, Small and Medium-sized Enterprise (MSME) policies affect low-income and female entrepreneurship. In addition to important policy effects, a key finding highlights that entrepreneurial social ties significantly correlate with early-stage entrepreneurship, regardless of income level. The second paper explores this result by instrumenting for the endogeneity of entrepreneurship and social ties using past vernacular newspaper circulation and population density. Instrumental variables regression substantiates the non-instrumented finding indicating social ties play a non-trivial role in increasing early-stage entrepreneurship in India. Finally, analysis of data from the US Panel Study of Income Dynamics in the third paper finds no evidence that self-employment provides any particular advantage in achieving upward mobility, or in reducing downward mobility. In contrast, family business ownership associates with more upward mobility and less downward mobility. We instrument for the endogeneity of family business ownership and mobility using tax schedule progressivity. Instrumental variables regression results substantiate the non-instrumented findings but should be interpreted with some caution.
Voting Patterns in Post-Mubarak Egypt
Voting Patterns in Post-Mubarak Egypt
Source: RAND Corporation
While much has been written on the electoral strength of Islamists in Egypt, most analysis has been done at the national level, ignoring regional divides within the country. As a means of helping U.S. policymakers and Middle East watchers better understand voting patterns in Egypt since the 2011 revolution, RAND researchers identified the areas where Islamist parties run strongest and the areas where non-Islamists are most competitive. They found that while Islamists perform well across the whole of the country, they draw their strongest electoral support in Upper Egypt, North Sinai, and sparsely populated governorates in the west, while non-Islamist parties fare best in Cairo and its immediate environs, Port Said, South Sinai, and the sparsely populated governorates abutting the Red Sea. Tracking electoral performance over time reveals a narrowing of the gap between Islamist parties and their non-Islamist rivals. Islamists thoroughly dominated the initial parliamentary elections held in late 2011 and early 2012, just as their position prevailed overwhelmingly in the March 2011 referendum on the interim constitution. However, the MB candidate eked out a victory in the June 2012 presidential contest, and the December 2012 referendum on the permanent constitution passed more narrowly than the interim charter. Egypt appears headed toward a much more competitive political environment in which Islamists will be increasingly challenged to maintain their electoral edge.
Syria as an Arena of Strategic Competition
Syria as an Arena of Strategic Competition
Source: RAND Corporation
Less than two years since the beginning of the uprising in Syria, localized protests have morphed into full-blown civil conflict. Along with internal escalation, the conflict has drawn in external actors, including Syria’s neighbors and extra-regional powers. With the regional balance of power hinging on the conflict’s outcome, Middle Eastern and extra-regional states have taken sides — some in support of the Assad regime, others in support of the opposition. RAND convened a group of 26 experts who cover Syria and the various external players to participate in an analytic exercise on November 16, 2012, to generate a greater understanding of the parties and issues in play. The report begins by analyzing what is driving both regional (e.g., Iran and Saudi Arabia) and extra-regional (e.g., Russia) players to intervene in the Syrian conflict. It then proceeds to look at the internal actors (e.g., the Free Syrian Army and Alawite community) that may operate as conduits of external influence. The report concludes with an examination of the relationships between external and internal actors and possible effects of these groups’ actions.
Capabilities-Based Planning for Energy Security at Department of Defense Installations
Capabilities-Based Planning for Energy Security at Department of Defense Installations
Source: RAND Corporation
Department of Defense (DoD) installations rely on the commercial electricity grid for 99 percent of their electricity needs, but extensive energy delivery outages in 2012 have reinforced that the U.S. electricity grid is vulnerable to disruptions from natural hazards and actor-induced outages, such as physical or cyber attacks. In the event of a catastrophic disaster — such as a severe hurricane, massive earthquake, or large-scale terrorist attack — DoD installations would also serve as a base for emergency services. To enhance energy security, DoD has identified diversifying energy sources and increasing efficiency in DoD operations as critical goals. But how to enhance energy security across the portfolio of installations is not clear and several questions remain unanswered: Energy security for how long? Under what conditions? At what cost? The underlying analytical questions are, what critical capabilities do U.S. installations provide, and how can DoD maintain these capabilities during an energy services disruption in the most cost-effective manner? Answering these questions requires a systems approach that incorporates technological, economic, and operational uncertainties. Using portfolio analysis methods for assessing capability options, this paper presents a framework to evaluate choices among energy security strategies for DoD installations. This framework evaluates whether existing or proposed installation energy security strategies enhance DoD capabilities and evaluates strategy cost-effectiveness.
Reducing the Cost and Risk of Major Acquisitions at the Department of Homeland Security
Reducing the Cost and Risk of Major Acquisitions at the Department of Homeland Security
Source: RAND Corporation
Widespread cost, schedule, and performance shortfalls point to ongoing and expensive problems in the Department of Homeland Security (DHS) acquisition process. This paper is intended to help improve DHS acquisition management and oversight by providing a common problem definition, conceptual framework, and recommendations that DHS headquarters and component acquisition officials, as well as interested parties in Congress and related agencies, can use to improve the efficiency and effectiveness of DHS acquisition organizations. The authors recommend that DHS place greater emphasis on improved acquisition planning, including requiring rigorous planning and analysis as an inviolable condition of proceeding with each major acquisition. They also recommend that DHS senior officials take the following actions to improve the quality and use of acquisition planning: (1) Strengthen and rationalize DHS headquarters oversight to better enforce discipline in acquisition planning. (2) Better utilize objective analysis to improve planning, particularly analyses performed independently of the program or agency seeking the acquisition. (3) Broaden dissemination and improve transparency of analysis and planning to ensure that senior decisionmakers have access to a full range of appropriate information and perspectives.
Increasing Organizational Diversity in 21st-Century Policing: Lessons from the U.S. Military
Increasing Organizational Diversity in 21st-Century Policing: Lessons from the U.S. Military
Source: RAND Corporation
Both the military and police departments are concerned about recruiting and promoting a racially/ethnically diverse workforce. This paper discusses three broad lessons from the Military Leadership Diversity Commission (MLDC) that can be used to inform police department hiring and personnel management: qualified minority candidates are available, career paths impact diversity, and departments should leverage organizational commitment to diversity. Additionally, specific suggestions are given as to how law enforcement agencies can incorporate each of these lessons.
Selected RAND Abstracts: A Guide to RAND Publications, Volume 50, January – December 2012
Selected RAND Abstracts: A Guide to RAND Publications, Volume 50, January – December 2012
Source: RAND Corporation
Selected RAND Abstracts (SRA) is a complete guide to all unclassified RAND publications for a given calendar year. Each volume contains author, subject, and title indexes covering all the material abstracted in that volume. The abstracts are arranged by type of publication and publication number. In addition, the SRA contains information about ordering RAND documents and obtaining annual subscriptions to RAND unclassified publications.
Military Caregivers Aid Injured Warriors, but Little Is Known About Their Needs
Military Caregivers Aid Injured Warriors, but Little Is Known About Their Needs
Source: RAND Corporation
Spouses, family members and others who provide informal care to U.S. military members after they return home from conflict often toil long hours with little support, putting them at risk for physical, emotional and financial harm, according to a new RAND Corporation report.
Researchers estimate there are between 275,000 and 1 million women and men who are providing care or have provided care for military members or veterans who served in Iraq or Afghanistan. Caregivers include spouses, children and parents of military members and veterans.
Despite the serious challenges faced by this group, there is no national strategy for supporting military caregivers, even as the nation prepares to end more than a decade of war fighting.
…
Military caregivers tend to differ from civilian informal caregivers in several ways. Military caregivers are younger and tend to live with the individual they care for, relative to civilian caregivers who tend to be older adults caring for elderly parents, often with age-associated illnesses like Alzheimer’s disease. Military caregivers must navigate multiple systems of health care and benefit providers for individuals who often face complex injuries and illnesses. The typical military caregiver is a younger woman with dependent-age children.Caregivers help provide a broad assortment of aid, assisting with the normal activities of daily life such as bathing, dressing and eating, serving as mental health counselors, advocating for better treatment, and even overseeing a family’s legal and financial needs.
In addition to general physical strain, caregivers may experience a greater incidence of disease and other health problems than the general population. Prior research on the general caregiver population found that they are at greater risk for coronary heart disease, hypertension, compromised immune function and reduced sleep. It also found that they suffer disproportionately from mental health problems and experience emotional distress associated with caregiving. However, studies on how these conditions compare in the military caregiver population are lacking.
Physical and Psychological Health Following Military Sexual Assault
Physical and Psychological Health Following Military Sexual Assault
Source: RAND Corporation
Awareness of military sexual assault — sexual assault of a servicemember — has been increasing within the Department of Defense (DoD). The DoD is striving to improve this situation, but unique conditions of life in the military may make response to these events more difficult than within the civilian sector. This paper reviews the prevalence of sexual assault among servicemembers, victim responses in the immediate aftermath of a sexual assault, barriers to disclosure, victim needs, and DoD efforts to provide necessary resources to victims. The authors review civilian guidelines for the care of physical injuries, response to STI/HIV and pregnancy risk, forensic services, advocacy and support services, and formal mental health care. They then review DoD directives, forms, and guidelines for sexual assault victim care, revealing that these generally are consistent with civilian guidelines. However, little is known about the fidelity with which these DoD recommendations are implemented. The authors close with recommendations for future research to support the DoD’s commitment to a culture free of sexual assault, including a comprehensive, longitudinal epidemiological study of military sexual assault, a needs assessment of disclosed and undisclosed military victims, an evaluation of the training enterprise, and an evaluation to document the extent to which DoD directives requiring immediate, evidence-based care for military victims are being implemented with fidelity.
Measuring Army Deployments to Iraq and Afghanistan
Measuring Army Deployments to Iraq and Afghanistan
Source: RAND Corporation
The Demands Placed Upon the Army by Operations in Iraq and Afghanistan
- The Army has provided the bulk of U.S. troops to Iraq and Afghanistan: over 1.5 million troop-years as of December 2011, and 54 percent of all active component troop-year deployments within the area of operations.
- Since 2008, the cumulative amount of time that a soldier has spent deployed has increased (on average) by 28 percent. In contrast, the percentage "not yet deployed" and the Army’s unutilized capacity to deploy have both decreased.
- As of December 2011, roughly 73 percent of active component soldiers had deployed to Iraq and Afghanistan, an increase of 6 percentage points since December 2008. Most of these soldiers were working on their second, third, or fourth year of cumulative deployed duty.
- Most of the remaining 27 percent are not yet deployed, since they are recent recruits, are forward-stationed in other overseas locations, or have contributed to Operation Enduring Freedom and/or Operation Iraqi Freedom/Operation New Dawn without deploying.
- The Army retains very little unutilized capacity to deploy additional active component soldiers without increasing the burden on those who have already deployed.
RAND Review: Vol. 36, No. 3, Winter 2012-2013
RAND Review: Vol. 36, No. 3, Winter 2012-2013
Source: RAND Corporation
Feature stories discuss the promotion of tolerance and critical thinking in the Arab world through children’s media, the challenges faced by the United States in an era of fiscal austerity, and promising models for measuring teacher performance. Two other stories highlight the National Science Foundation’s role in promoting research in the United States and how RAND is helping several countries to foster technological innovation.
Hepatitis C: A projection of the healthcare and economic burden in the UK
Hepatitis C: A projection of the healthcare and economic burden in the UK
Source: RAND Corporation
Work presented in this report sought to assess the healthcare and economic burden of the hepatitis C virus (HCV) infection in the United Kingdom. It used a cohort simulation model to estimate the prevalence of HCV infection in the UK, including the number of persons who live with HCV infection at different disease stages, and the number of deaths that can be attributed to HCV infection through to 2035. It further assessed the healthcare and societal costs that are associated with HCV infection under different scenarios of diagnosis and treatment rates.
Exploring the Association Between Military Base Neighborhood Characteristics and Soldiers’ and Airmen’s Outcomes
Exploring the Association Between Military Base Neighborhood Characteristics and Soldiers’ and Airmen’s Outcomes
Source: RAND Corporation
Current extended military engagements in foreign nations have taken their toll on U.S. service members and their families. As a result, the services have made renewed commitments to support the needs of these families of military personnel. Quality-of-life and family programs across the services continue to grow. But no service has applied neighborhood theory and methods to better understand these military issues. Installations, and the communities where they are located, vary in terms of the quality of life they provide inhabitants. Similarly, the families who live in these communities and who are assigned to these installations vary in terms of their needs. A one-size-fits-all approach to base resource allocation and the provision of services may not be the most effective in fostering health and well-being among service members and their families. Thus, the services may want to use this approach as part of their efforts to identify gaps in support to service members and families so that they can make the necessary adjustments and better compensate where communities are lacking. This report explores the applicability of neighborhood theory and social indicators research to understanding the quality of life in and around military bases. It also highlights gaps in neighborhood study methodology that need to be addressed in future research. Finally, it outlines how a more in-depth neighborhood analysis of military installations could be conducted.
Choosing a New Organization for Management and Disposition of Commercial and Defense High-Level Radioactive Materials
Source: RAND Corporation
Finding ways to safely store and ultimately dispose of nuclear waste has been on the national policy agenda for decades and remains a matter of considerable debate. This volume considers the creation of a new, single-purpose organization to manage and dispose of commercial and defense high-level radioactive materials. The authors first examine three organizational models — federal government corporation, federally chartered private corporation, and independent government agency — and evaluate how well they could perform the goals and responsibilities needed in a new management and disposition organization (MDO). The authors find that a federally chartered private corporation, with its commitment to stockholders and making a profit, would be weak in public accountability and political credibility. For the other two models (a federal government corporation and independent government agency), they describe the critical steps to designing an MDO, focusing on the critical relationship of the organization to the President and Congress, its source of funding, and other organizational attributes, such as how it will engage stakeholders and be treated by federal and state regulatory agencies. The authors emphasize that the key challenge in designing a new MDO is the need to strike a balance between political accountability and flexibility.
U.S. Global Defense Posture, 1783–2011
U.S. Global Defense Posture, 1783–2011
Source: RAND Corporation
Debates over the U.S. global defense posture are not new. As policymakers today evaluate the U.S. forward military presence, it is important that they understand how and why the U.S. global posture has changed in the past. Today’s posture is under increasing pressure from a number of sources, including budgetary constraints, precision-guided weapons that reduce the survivability of forward bases, and host-nation opposition to a U.S. military presence. This monograph aims to describe the evolution of the U.S. global defense posture from 1783 to the present and to explain how the United States has grown from a relatively weak and insular regional power that was primarily concerned with territorial defense into the preeminent global power, with an expansive system of overseas bases and forward-deployed forces that enable it to conduct expeditionary operations around the globe. This historical overview has important implications for current policy and future efforts to develop an American military strategy, in particular the scope, size, and type of military presence overseas. As new and unpredictable threats emerge, alliance relationships are revised, and resources decline, past efforts at dealing with similar problems yield important lessons for future decisions. The author draws recommendations out of these lessons that touch on the importance of strategic planning; the need to think globally; the desirability of a lighter, more agile footprint overseas; and more.
