Demographic and Clinical Variation in Veterans Health Administration Provision of Assistive Technology Devices to Veterans Poststroke

Objectives: To examine variation in provision of assistive technology (AT) devices and the extent to which such variation may be explained by patient characteristics or Veterans Health Administration (VHA) administrative region. Design: Retrospective population-based study. Setting: VHA. Participants: Veterans poststroke in fiscal years 2001 and 2002 (N=12,046). Interventions: Not applicable. Main Outcome Measure: Provision of 8 categories of AT devices. Results: There was considerable regional variation in provision of AT. For example, differences across administrative regions in the VHA ranged from 5.1 to 28.1 standard manual wheelchairs per 100 veterans poststroke. Using logistic regression, with only demographic variables as predictors of standard manual wheelchair provision, the c statistic was .62, and the pseudo R2 was 2.5%. Adding disease severity increased the c statistic to .67 and the pseudo R2 to 6.2%, and adding Veteran Integrated Network System further increased the c statistic to .72 and pseudo R2 to 9.8%. Conclusions: Our research showed significant variation in the provision of AT devices to veterans poststroke, and it showed that patient characteristics accounted for only 6.2% of the variation. VHA administrative region and disability severity accounted for equivalent amounts of the variation

Coastal adaptation with ecological engineering

The use of combined approaches to coastal adaptation in lieu of a single strategy, such as sea-wall construction, allows for better preparation for a highly uncertain and dynamic coastal environment. Although general principles such as mainstreaming and no- or low-regret options exist to guide coastal adaptation and provide the framework in which combined approaches operate, few have examined the interactions, synergistic effects and benefits of combined approaches to adaptation. This Perspective provides three examples of ecological engineering — marshes, mangroves and oyster reefs — and illustrates how the combination of ecology and engineering works.So-Min Cheong, Brian Silliman, Poh Poh Wong, Bregje van Wesenbeeck, Choong-Ki Kim, and Greg Guanne