Search

Higher education has been touted as critical to social mobility, even greater longevity; however, these benefits accrue with degree completion, and many students who begin college never earn a degree. Using the most recent Integrated Postsecondary Education Data System (IPEDS), we sought to understand variation in college completion rates and test hypotheses related to a set of institutional factors potentially associated with higher completion rates. Our findings suggest that greater attention to low-resource institutions is paramount if higher education is to fulfill the aspiration of promoting social mobility and equity. Several policy interventions could be used to combat ongoing disparities.

Wolf (Canis lupus) depredations of livestock are a ubiquitous source of conflict in every country where wolves and livestock overlap. We studied the spatial and temporal variation of wolf depredations of livestock in Montana during 2005–2015, including evaluations of targeted control efforts and public harvest as potential means to reduce depredations. During this time we collected spatial data for all confirmed wolf‐livestock depredations, tallied the annual number of depredation events within hunting districts, and collected data for variables potentially predictive of depredation events. We decomposed variation in depredation data into 2 distinct components: the binary presence or absence of depredation events in each district‐year, and the count of depredation events in district‐years with ≥1 event. We found that presence‐absence of depredations increased with wolf presence and wolf density, increased with livestock density, were highest at intermediate proportionate areas of agricultural land, and were a recurrent phenomenon such that districts with depredations the previous year were more likely to continue having them. Targeted removal, but not public harvest, significantly reduced the recurrent presence of depredations. The number of conflicts in district‐years with ≥1 depredation event was positively correlated with wolf density, cattle density, intermediate proportionate areas of forested land, and the number of events during the previous year. Public harvest reduced the counts of depredation events in areas where conflict reoccurred, though with a modest predicted effect size of 0.22 fewer depredations/district‐year, or 5.7 fewer depredation events statewide/year (8% of the annual average). Minimizing livestock losses is a top priority for wolf management. These results shed light on the broad‐scale patterns behind chronic problems and the effectiveness of wolf management practices in addressing them. © 2018 The Wildlife Society. Wolf‐livestock conflicts are a chronic phenomenon in certain local areas of Montana, USA. Targeted lethal control of wolves can reduce the likelihood of recurring conflicts. Public harvest of wolves did not effectively stop the occurrence of conflicts but may reduce their frequency to a modest degree in problem areas.

Gray wolves (Canis lupus) were extirpated from the northern Rocky Mountains (NRM) of the United States by the 1930s. Dispersing wolves from Canada naturally recolonized Montana and first denned there in 1986. In 1995 and 1996, the United States Fish and Wildlife Service reintroduced 66 wolves into central Idaho and Yellowstone National Park. By 2008, there were ≥1,655 wolves in ≥217 packs, including 95 breeding pairs in the NRM. From 1993–2008, we captured and radio‐collared 1,681 wolves and documented 297 radio‐collared wolves dispersing as lone individuals. We monitored dispersing wolves to determine their pack characteristics (i.e., pack size and surrounding pack density) before and after dispersal, their reproductive success, and eventual fate. We calculated summary statistics for characteristics of wolf dispersal (i.e., straight‐line distance, age, time of year, sex ratio, reproduction, and survival), and we tested these characteristics for differences between sexes and age groups. Approximately, 10% of the known wolf population dispersed annually. The sex ratio of dispersals favored males (169 M, 128 F), but fewer dispersed males reproduced (28%, n = 47) than females (42%, n = 54). Fifty‐nine percent of all dispersers of known age were adults (n = 156), 37% were yearlings (n = 99), and 4% were pups (n = 10). Mean age at dispersal for males (32.8 months) was not significantly different (P = 0.88) than for females (32.1 months). Yellowstone National Park had a significant positive effect on dispersal rate. Pack density in a wolf's natal population had a negative effect on dispersal rate when the entire NRM population was considered. The mean NRM pack size (6.9) from 1993 to 2008 was smaller than the mean size of packs (10.0) from which wolves dispersed during that time period (P<0.001); however, pack size was not in our most supported model. Dispersals occurred throughout the year but generally increased in the fall and peaked in January. The mean duration of all dispersals was 5.5 months. Radio‐collared wolves dispersed between Montana, Idaho, and Wyoming to other adjacent states, and between the United States and Canada throughout the study. Mean straight‐line distance between starting and ending points for dispersing males (98.1 km) was not significantly different than females (87.7 km; P = 0.11). Ten wolves (3.4%) dispersed distances >300 km. On average, dispersal distance decreased later in the study (P = 0.006). Sex, survival rate in the natal population, start date, dispersal distance, and direction were not significant predictors of dispersal rate or successful dispersal. Wolves that formed new packs were >11 times more likely to reproduce than those that joined packs and surrounding pack density had a negative effect on successful dispersal. Dispersal behavior seems to be innate in sexually mature wolves and thereby assures that genetic diversity will remain high and help conserve the NRM wolf population. © 2017 The Wildlife Society. We analyzed dispersal characteristics and determined which variables were predictors of annual dispersal rate and success for gray wolves in the northern Rocky Mountains from 1993 to 2008. Dispersal behavior seems to be innate in sexually mature wolves and thereby assures genetic diversity will remain high and help conserve the northern Rocky Mountain wolf population.

Supplemental Digital Content is available in the text.

Wolf (Canis lupus) predation on livestock and management methods used to mitigate conflicts are highly controversial and scrutinized especially where wolf populations are recovering. Wolves are commonly removed from a local area in attempts to reduce further depredations, but the effectiveness of such management actions is poorly understood. We compared the effects of 3 management responses to livestock depredation by wolf packs in Montana, Idaho, and Wyoming: no removal, partial pack removal, and full pack removal. We examined the effectiveness of each management response in reducing further depredations using a conditional recurrent event model. From 1989 to 2008, we documented 967 depredations by 156 packs: 228 on sheep and 739 on cattle and other stock. Median time between recurrent depredations was 19 days following no removal (n?=?593), 64 days following partial pack removal (n?=?326), and 730 days following full pack removal (n?=?48; recurring depredations were made by the next pack to occupy the territory). Compared to no removal, full pack removal reduced the occurrence of subsequent depredations by 79% (hazard ratio [HR]?=?0.21, P?

Recent reductions in average door-to-balloon (D2B) times have not been associated with decreases in mortality at the population level. We investigated this seemingly paradoxical finding by assessing components of this association at the individual and population levels simultaneously. We postulated that the changing population of patients undergoing primary percutaneous coronary intervention (pPCI) contributed to secular trends toward an increasing mortality risk, despite consistently decreased mortality in individual patients with shorter D2B times.

Hospice use has increased substantially during the past decade by an increasingly diverse patient population; however, little is known about patterns of hospice use and how these patterns have changed during the past decade.

IMPORTANCE The impact of the substantial growth in for-profit hospices in the United States on quality and hospice access has been intensely debated, yet little is known about how for-profit and nonprofit hospices differ in activities beyond service delivery. OBJECTIVE To determine the association between hospice ownership and (1) provision of community benefits, (2) setting and timing of the hospice population served, and (3) community outreach. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey (the National Hospice Survey), conducted from September 2008 through November 2009, of a national random sample of 591 Medicare-certified hospices operating throughout the United States. EXPOSURES For-profit or nonprofit hospice ownership. MAIN OUTCOMES AND MEASURES Provision of community benefits; setting and timing of the hospice population served; and community outreach. RESULTS A total of 591 hospices completed our survey (84% response rate). For-profit hospices were less likely than nonprofit hospices to provide community benefits including serving as training sites (55% vs 82%; adjusted relative risk [ARR], 0.67 [95% CI, 0.59-0.76]), conducting research (18% vs 23%; ARR, 0.67 [95% CI, 0.46-0.99]), and providing charity care (80% vs 82%; ARR, 0.88 [95% CI, 0.80-0.96]). For-profit compared with nonprofit hospices cared for a larger proportion of patients with longer expected hospice stays including those in nursing homes (30% vs 25%; P = .009). For-profit hospices were more likely to exceed Medicare’s aggregate annual cap (22% vs 4%; ARR, 3.66 [95% CI, 2.02-6.63]) and had a higher patient disenrollment rate (10% vs 6%; P &lt; .001). For-profit were more likely than nonprofit hospices to engage in outreach to low-income communities (61% vs 46%; ARR, 1.23 [95% CI, 1.05-1.44]) and minority communities (59% vs 48%; ARR, 1.18 [95% CI, 1.02-1.38]) and less likely to partner with oncology centers (25% vs 33%; ARR, 0.59 [95% CI, 0.44-0.80]). CONCLUSIONS AND RELEVANCE Ownership-related differences are apparent among hospices in community benefits, population served, and community outreach. Although Medicare’s aggregate annual cap may curb the incentive to focus on long-stay hospice patients, additional regulatory measures such as public reporting of hospice disenrollment rates should be considered as the share of for-profit hospices in the United States continues to increase.

Reducing readmissions is a national priority, but many hospitals lack practical tools to identify patients at increased risk of unplanned readmission.

Reducing hospital readmission rates is a national priority; however, evidence about hospital strategies that are associated with lower readmission rates is limited. We sought to identify hospital strategies that were associated with lower readmission rates for patients with heart failure.

A founding principle of hospice is that the patient and family is the unit of care; however, we lack national information on services to family members. Although Medicare certification requires bereavement services be provided, reimbursement rates are not tied to the level or quality of care; therefore, limited financial incentives exist for hospice to provide more than a minimal benefit.

The National Quality Forum (NQF) identified hospice services as a national priority area for health care quality improvement and endorsed a set of preferred practices for quality palliative and hospice care. This study reports the first national data regarding hospices' self-reported implementation of the NQF preferred practices and identifies hospice characteristics associated with more comprehensive implementation.

AbstractPurpose To characterize attitudes of residents toward racial/ethnic disparities in health care and to explore the effect of a simple intervention to improve awareness of these disparities.Methods The authors surveyed residents in internal and emergency medicine rotating through the Coronary Care Unit of a major teaching hospital about their attitudes toward disparities in cardiovascular care before and after an intervention that fostered discussion of evidence for the existence of disparities, possible causes of disparities, and clinically focused approaches to quality improvement tailored to the residents' practice environment.Results Before the intervention, 35 of residents agreed that racial/ethnic disparities might occur for patients within the US health care system in general, and only 7 agreed that patients they personally treated might experience racial/ethnic disparities in healthcare. These proportions increased significantly after the intervention: 85 agreement at level of US health care system and 32 at the level of individual practice (P < .001). Changes in awareness did not differ by sex, postgraduate year of training, race/ethnicity, reported prior diversity training, or plans to subspecialize.Conclusion Awareness of racial/ethnic disparities in care among residents remains low, particularly at the level of individual practice, but is amenable to intervention.

To examine the association between physician race/ethnicity, workplace discrimination, and physician job turnover.

AbstractManagers of recovering wolf (Canis lupus) populations require knowledge regarding the potential impacts caused by the loss of territorial, breeding wolves when devising plans that aim to balance population goals with human concerns. Although ecologists have studied wolves extensively, we lack an understanding of this phenomenon as published records are sparse. Therefore, we pooled data (n= 134 cases) on 148 territorial breeding wolves (75 M and 73 F) from our research and published accounts to assess the impacts of breeder loss on wolf pup survival, reproduction, and territorial social groups. In 58 of 71 cases (84%), =1 pup survived, and the number or sex of remaining breeders (including multiple breeders) did not influence pup survival. Pups survived more frequently in groups of =6 wolves (90%) compared with smaller groups (68%). Auxiliary nonbreeders benefited pup survival, with pups surviving in 92% of cases where auxiliaries were present and 64% where they were absent. Logistic regression analysis indicated that the number of adult-sized wolves remaining after breeder loss, along with pup age, had the greatest influence on pup survival. Territorial wolves reproduced the following season in 47% of cases, and a greater proportion reproduced where one breeder had to be replaced (56%) versus cases where both breeders had to be replaced (9%). Group size was greater for wolves that reproduced the following season compared with those that did not reproduce. Large recolonizing (>75 wolves) and saturated wolf populations had similar times to breeder replacement and next reproduction, which was about half that for small recolonizing (=75 wolves) populations. We found inverse relationships between recolonizing population size and time to breeder replacement (r= —0.37) and time to next reproduction (r= —0.36). Time to breeder replacement correlated strongly with time to next reproduction (r=0.97). Wolf social groups dissolved and abandoned their territories subsequent to breeder loss in 38% of cases. Where groups dissolved, wolves reestablished territories in 53% of cases, and neighboring wolves usurped territories in an additional 21% of cases. Fewer groups dissolved where breeders remained (26%) versus cases where breeders were absent (85%). Group size after breeder loss was smaller where groups dissolved versus cases where groups did not dissolve. To minimize negative impacts, we recommend that managers of recolonizing wolf populations limit lethal control to solitary individuals or territorial pairs where possible, because selective removal of pack members can be difficult. When reproductive packs are to be managed, we recommend that managers only remove wolves from reproductive packs when pups are =6 months old and packs contain =6 members (including =3 ad-sized wolves). Ideally, such packs should be close to neighboring packs and occur within larger (=75 wolves) recolonizing populations.

Despite the clinical importance of prompt percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction, many hospitals do not routinely achieve the guideline-recommended 90-minute door-to-balloon times. In this review, we evaluate existing evidence that identifies effective hospital strategies for reducing door-to-balloon time.

The article describes how a diverse school community in Lewiston, Maine, employed a two-pronged strategy to assist the students in overcoming issues of racial conflict. The Lewiston High School community asked for help from the Center for Prevention of Hate Violence in dealing with sociocultural issues. This resulted into the creation of the Unity Project with its Student Leadership Project and Controversial Dialogue subprograms.

In this article, the author presents her views on the U.S. policy decisions that prioritize medical care for individuals at the expense of public health. Topics discussed include health care preparation of the U.S. for emergencies and other measures for the common goods; stories about the potential of rationing the use of incentive care units beds and ventilators; and ethical issues during pandemic.

Objective To examine the association between a multi-item measure of religiousness and major depressive disorder (MDD) in bereaved family caregivers of patients with cancer.Design A prospective longitudinal study of primary caregivers of consecutive patients (n=175) with cancer enrolled in the largest hospice in Connecticut.Results Caregivers with a high religiousness summary score were significantly less likely to have MDD at the 13–month follow-up interview (OR=0.79, 95% CI: 0.68–0.91). This finding remained significant (OR=0.74, 95% CI: 0.59–0.91) after adjustment for caregiver MDD at baseline, caregiver age, caregiver burden, and number of activities restricted due to caregiving roles.Conclusions Family caregivers who reported greater religiousness at baseline had lower rates of depression in the 13–month follow up after their loss. Collaboration with religious support groups or community groups during bereavement could offer an effective mechanism for speeding the process of recovery for some caregivers.

Hospitals are under increasing pressure to measure and improve quality of care, and substantial resources are being directed at a variety of quality improvement strategies; however, the evidence base supporting these strategies is limited.

National surveys indicate improvement in beta-blocker use after acute myocardial infarction (AMI) over time; however, these data could obscure important variation in improvement at individual hospitals. Our objective was to characterize the hospital-level variation in the improvements in beta-blocker prescription rates after AMI and to identify hospital characteristics that were associated with hospital improvement rates after adjustment for patient demographic and clinical characteristics.

The number of for-profit hospices increased nearly 4-fold over the past decade, more than 6 times the growth of nonprofit hospices. Despite this growth, the impact of ownership on hospice care is largely unknown. We sought to assess differences in the provision of services to patients of for-profit and nonprofit hospices.

The role of stress in the development of cardiovascular disease is well established. Previous research has demonstrated that involuntary job loss in the years immediately preceding retirement can be a stressful life event shown to produce adverse changes in physical and affective health. The objective of this study was to estimate the risk of myocardial infarction (MI) and stroke associated with involuntary job loss among workers nearing retirement in the United States. We used multivariable survival analysis to analyze data from the first four waves of the Health and Retirement Survey (HRS), a nationally representative sample of older individuals in the US. The analytic sample includes 457 workers who experienced job loss and a comparison group of 3,763 employed individuals. The results indicate that involuntary job loss is not associated with subsequent risk of MI (adjusted HR = 1.89; 95% CI = 0.91, 3.93); the risk of subsequent stroke associated with involuntary job loss is more than double (adjusted HR = 2.64; 95% CI = 1.01, 6.94). Our findings present new data to suggest that involuntary job loss should be considered as a plausible risk factor for subsequent cardiovascular and cerebrovascular illness among older workers. Am. J. Ind. Med. 45:408–416, 2004. © 2004 Wiley-Liss, Inc.

Objective To identify factors associated with caregiver burden among those caring for terminally ill patients with cancer.Design Cross-sectional study of interviews with primary caregivers (n=206) of consecutive patients with cancer enrolled in the largest hospice in Connecticut.Methods Data were collected on the caregivers’ sociodemographic characteristics, social network index, and number of restrictions in their own activities due to their caregiving role. The outcome was a nine-item questionnaire adapted from the Zarit Burden Inventory.Results The highest burden was reported among caregivers with more limited social networks (OR 1.38, CI 1.02–1.87), more restrictions in their daily activities (OR 1.35, CI 1.13–1.61), and who were younger (OR 1.46, CI 1.10–1.93).Conclusions Variations exist in the intensity of caregiver burden based on subjective experiences and social support, rather than on the amount of assistance provided. Clinicians should consider factors such as these when targeting caregivers for interventions to alleviate burden.

While much attention has been directed at improving the quality of care at the end of life, few studies have examined what determines a good death in different individuals. We sought to identify common domains that characterize a good death in a diverse range of community-dwelling individuals, and to describe differences that might exist between minority and non-minority community-dwelling individuals’ views. Using data from 13 focus groups, we identified 10 domains that characterize the quality of the death experience: 1) physical comfort, 2) burdens on family, 3) location and environment, 4) presence of others, 5) concerns regarding prolongation of life, 6) communication, 7) completion and emotional health, 8) spiritual care, 9) cultural concerns, 10) individualization. Differences in minority compared to non-minority views were apparent within the domains of spiritual concerns, cultural concerns, and individualization. The findings may help in efforts to encourage more culturally sensitive and humane end-of-life care for both minority and non-minority individuals.

AbstractUsing data from the 1994–1996 waves of the German Socio-Economic Panel (GSOEP), this prospective longitudinal study investigates the association between job displacement and subsequent self-assessed health (SAH). The sample consists of 253 displaced workers and a comparison group of 6,934 continuously-employed workers. Controlling for baseline SAH and standard demographic characteristics, we find no statistical association between job displacement and subsequent SAH. Our findings are consistent with those of earlier studies of the relationship between unemployment and subsequent health.

Background Despite the central role of hospice in end-of-life care, little is known about the proportion of terminally ill patients referred for hospice and the physician factors associated with hospice referral.Methods Cross-sectional data from a self-administered survey of 231 physicians were used to estimate the proportion of terminally ill patients who were referred for hospice and to assess the independent effects of physician factors on hospice referral.Results On average, physicians reported referring about 55% of their terminally ill patients for hospice; 26.7% of the physicians referred less than one quarter of their terminally ill patients. Physician specialty, board certification, and physicians’ knowledge level about hospice were independently associated with the proportions of terminally ill patients referred for hospice.Conclusion Many terminally ill patients are not referred for hospice care and physician factors influence the use of hospice significantly. The study suggests effective factors and groups to target with interventions to enhance the appropriate use of hospice.

Several initiatives to improve care at the end of life involve educational programs to influence clinicians’ attitudes about care for patients with terminal illnesses. The objective of this research was to develop and test a short and easily administered instrument for measuring physicians’ and nurses’ attitudes towards care at the end of life. The instrument was tested using a cross-sectional study of 50 clinicians (25 physicians and 25 nurses) from general medicine, cardiology, oncology, and geriatric medicine. Both reliability and validity were assessed, and the instrument was found to have acceptable test-retest reliability and construct validity. Such an assessment instrument may be useful in evaluating the impact of initiatives to modify attitudes towards terminal care and in improving the quality of care at the end of life.

OBJECTIVE: To measure the frequency with which nursing home residents and their surrogates discuss with clinicians the resident's wishes concerning future treatment and to assess the influence of the Patient Self Determination Act (PSDA) on the frequency and nature of such discussions.