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Objective. To understand how health care providers and social services providers coordinate their work in communities that achieve relatively low health care utilization and costs for older adults. Study Setting. Sixteen Hospital Service Areas (HSAs) in the United States. Study Design. We conducted a qualitative study of HSAs with performance in the top or bottom quartiles nationally across three key outcomes: ambulatory care sensitive hospitalizations, all-cause risk-standardized readmission rates, and average reimbursements per Medicare beneficiary. We selected 10 higher performing HSAs and six lower performing HSAs for inclusion in the study. Data Collection. To understand patterns of collaboration in each community, we conducted site visits and in-depth interviews with a total of 245 representatives of health care organizations, social service agencies, and local government bodies. Principal Findings. Organizations in higher performing communities regularly worked together to identify challenges faced by older adults in their areas and responded through collective action--in some cases, through relatively unstructured coalitions, and in other cases, through more hierarchical configurations. Further, hospitals in higher performing communities routinely matched patients with needed social services. Conclusions. The collaborative approaches used by higher performing communities, if spread, may be able to improve outcomes elsewhere. Key Words. Social determinants of health, coordination, older adults, Social determinants of health are critical for older adults with complex health needs, often described by policy makers as high-need, high-cost patients, a group estimated to constitute 5 percent of [...]

BACKGROUND The evolution of global health (Bunyavanich and Walkup 2001; Koplan et al. 2009; Fried et al. 2010) from its roots in international health to its current focus on health [...]

Objective. To identify key characteristics of a national quality campaign that participants viewed as effective, to understand mechanisms by which the campaign influenced hospital practices, and to elucidate contextual factors that modified the perceived influence of the campaign on hospital improvements. Data Sources. In-depth interviews, hospital surveys, and Health Quality Alliance data. Study Design. We conducted a qualitative study using in-depth interviews with clinical and administrative staff (N=99) at hospitals reporting strong influence (n = 6) as well as hospitals reporting limited influence (n = 6) of the Door-to-Balloon (D2B) Alliance, a national quality campaign to improve heart attack care. We analyzed these qualitative data as well as changes in hospital use of recommended strategies reported through a hospital survey and changes in treatment times using Health Quality Alliance data. Data Collection Methods. In-depth, open-ended interviews; hospital survey. Principal Findings. Key characteristics of the national quality campaign viewed as enhancing its effectiveness were as follows: credibility of the recommendations, perceived simplicity of the recommendations, alignment with hospitals' strategic goals, practical implementation tools, and breadth of the network of peer hospitals in the D2B Alliance. Perceived mechanisms of the campaign's influence included raising awareness and influencing goals, fostering strategy adoption, and influencing aspects of organizational culture. Modifying contextual factors included perceptions about current performance and internal championship for the recommended changes. Conclusions. The impact of national quality campaigns may depend on both campaign design features and on the internal environment of participating hospitals. Key Words. Quality improvement, campaigns, hospitals, acute myocardial infarction, Amid persistent evidence that many patients do not receive guideline-based care, national quality campaigns have developed to motivate widespread adoption of evidence-based practices to improve quality of care. Recent examples [...]

Objective. To characterize the types of hospices with higher rates of patient disenrollment from the Medicare Hospice Benefit and the markets in which these hospices operate. Data Source. Secondary analyses of Surveillance, Epidemiology and End Results-Medicare data. Analyses included patients who died of cancer from 1998 to 2002 and who used hospice (n = 90,826). Study Design. We used generahzed estimating equations to estimate the association of patient disenrollment with hospice size, years since Medicare certification, ownership, staff mix, competition, urban/rural status, region, and fiscal intermediary. Other covariates included patient demographic and clinical characteristics. Principal Findings. Patients were more likely to disenroll from hospice if they were served by newer hospices (OR = 1.14; 95 percent CI 1.03, 1.26), by smaller hospices (OR = 1.11; 95 percent CI 1.02, 1.20), or by hospices in more competitive markets (OR = 1.17, 95 percent CI 1.03, 1.35). There was an independent effect of the hospice's fiscal intermediary on disenrollment, particularly disenrollment after 6 months with hospice (Wald [[chi square] = 21.2, p = .007). Conclusions. The reasons for higher disenrollment rates for newer hospices, for smaller hospices, and for hospices in highly competitive markets are likely complex; however, results suggest that there are organizational-level barriers to keeping patients with cancer enrolled with hospice. Variation across fiscal intermediaries may indicate that regulatory oversight, particularly of long-stay patients, influences hospice disenrollment. Key Words. Health care organization, hospice, Medicare hospice benefit, Approximately 10-15 percent of individuals with serious illness who enroll in the Medicare Hospice Benefit (MHB) subsequently disenroll from hospice before death (Casarett, Marenberg, and Karlawish 2001; Carlson et al. [...]

EXECUTIVE SUMMARY Despite substantial improvement in recent years in hospital performance in many quality measures for acute myocardial infarction (AMI), national performance lags in a key publicly reported quality indicator [...]

Objective. To provide practical strategies for conducting and evaluating analyses of qualitative data applicable for health services researchers. Data Sources and Design. We draw on extant qualitative methodological literature to describe practical approaches to qualitative data analysis. Approaches to data analysis vary by discipline and analytic tradition; however, we focus on qualitative data analysis that has as a goal the generation of taxonomy, themes, and theory germane to health services research. Principle Findings. We describe an approach to qualitative data analysis that applies the principles of inductive reasoning while also employing predetermined code types to guide data analysis and interpretation. These code types (conceptual, relationship, perspective, participant characteristics, and setting codes) define a structure that is appropriate for generation of taxonomy, themes, and theory. Conceptual codes and subcodes facilitate the development of taxonomies. Relationship and perspective codes facilitate the development of themes and theory. Intersectional analyses with data coded for participant characteristics and setting codes can facilitate comparative analyses. Conclusions. Qualitative inquiry can improve the description and explanation of complex, real-world phenomena pertinent to health services research. Greater understanding of the processes of qualitative data analysis can be helpful for health services researchers as they use these methods themselves or collaborate with qualitative researchers from a wide range of disciplines. Key Words. Qualitative methods, taxonomy, theme development, theory generation., Qualitative research is increasingly common in health services research (Shortell 1999; Sofaer 1999). Qualitative studies have been used, for example, to study culture change (Marshall et al. 2003; Craigie and [...]

Objective. To determine the degree to which patients and families enrolled with hospice received services across key categories of palliative care, the extent of hospice-level variability in services delivered, and changes over time in services delivered. Data Source. Nationally representative sample of 9,409 discharged patients from 2,066 hospices in the National Home and Hospice Care Survey. Study Design. Observational, cross-sectional study conducted from 1992 to 2000. The primary outcome is the receipt of services across five key categories of palliative care: nursing care, physician care, medication management, psychosocial care, and caregiver support. Data Collection. Data were obtained via interview with the hospice staff member most familiar with the patient's care, in conjunction with medical record review. Principle Findings. In 2000, 22 percent of patients enrolled with hospice received services across five key categories of palliative care. There was marked variation across hospices in service delivery. One-third of hospices provided patients and families services in one or two of the five key categories of palliative care, whereas 14 percent of hospices provided services across five key categories of palliative care. In multivariable analysis, the odds of receiving any additional hospice service was significantly greater in later compared with earlier years (odds ratio = 1.10, 95 percent confidence interval 1.01-1.20). Nevertheless, the percentages of patients in 2000 receiving medication management (59 percent), respite care (7 percent), and physician services (30 percent) remained low. Conclusions. Hospice care for patients and families varies substantially across hospices. Whereas some hospices provide services across the key categories of palliative care, other hospices do not provide this breadth of services. Greater understanding of the causes of variation in service delivery as well as its impact on patient and family outcomes and satisfaction with end-of-life care is a critical subject for future research. Changes in Medicare's reimbursement policies may help hospices increase the range of services provided to patients and families. Key Words. Hospice, palliative care, Medicare Hospice Benefit, Three-quarters of individuals who die in the United States do so from chronic illnesses (Minino et al. 2002), often after suffering both physically and psychologically for months or years (The [...]

Background: Increasing the racial and ethnic diversity of the physician workforce is a national priority. However, insight into the professional experiences of minority physicians is limited. This knowledge is fundamental to developing effective strategies to recruit, retain, and support a diverse physician workforce. Objective: To characterize how physicians of African descent experience race in the workplace. Design: Qualitative study based on in-person and in-depth racially concordant interviews using a standard discussion guide. Setting: The 6 New England states in the United States. Participants: 25 practicing physicians of African descent representing a diverse range of primary practice settings, specialties, and ages. Measurements: Professional experiences of physicians of African descent. Results: 1) Awareness of race permeates the experience of physicians of African descent in the health care workplace; 2) race-related experiences shape interpersonal interactions and define the institutional climate; 3) responses to perceived racism at work vary along a spectrum from minimization to confrontation; 4) the health care workplace is often silent on issues of race; and 5) collective race-related experiences can result in 'racial fatigue,' with personal and professional consequences for physicians. Limitations: The study was restricted to New England and may not reflect the experiences of physicians in other geographic regions. The findings are meant to be hypothesis-generating and require additional follow-up studies. Conclusions: The issue of race remains a pervasive influence in the work lives of physicians of African descent. Without sufficient attention to the specific ways in which race shapes physicians' work experiences, health care organizations are unlikely to create environments that successfully foster and sustain a diverse physician workforce.

EXECUTIVE SUMMARY With the aging of the population, healthcare executives are paying increased attention to fostering safe and high-quality care for older adults who become hospitalized. The Hospital Elder Life [...]

Objective. To describe the perceived impact of the Centers for Medicare and Medicaid Services Quality Improvement Organizations (QIOs) on quality of care for patients hospitalized with acute myocardial infarction, in the context of new efforts to work more collaboratively with hospitals in the pursuit of quality improvement. Data Source. Primary data collected from a national random sample of 105 hospital quality management directors interviewed between January and July 2002. Study Design. We interviewed quality management directors concerning their interactions with the QIO interventions, the helpfulness of QIO interventions and the degree to which they helped or hindered their hospital quality efforts, and their recommendations for improving QIO effectiveness. Principle Findings. More than 90% of hospitals reported that their QIO had initiated specific interventions, the most common being the provision of educational materials, benchmark data, and hospital performance data. Many respondents (60%) rated most QIO interventions as helpful or very helpful, although only one quarter of respondents believed quality of care would have been worse without the QIO interventions. To increase QIO efficacy, respondents recommended that QIOs appeal more directly to senior administration, target physicians (not just hospital employees), and enhance the perceived validity and timeliness of data used in quality indicators. Conclusions. Our study demonstrates that the QIOs have overcome, to some degree, the previously adversarial and punitive roles of Peer Review Organizations with hospitals. The generally positive view among most hospital quality improvement directors concerning the QIO interventions suggests that QIOs are potentially poised to take a leading role in promoting quality of care. However, the full potential of QIOs will likely not be realized until QIOs are able to engender greater engagement from senior hospital administration and physicians. Key Words. quality, quality improvement organizations, peer review organizations, acute myocardial infarction, Quality Improvement Organizations (QIOs), formerly called Peer Review Organizations (PROs), are the primary means by which the Centers for Medicare and Medicaid Services (CMS) promote quality of care for Medicare's [...]

Objective: Many terminally ill patients enroll in a hospice late in their illness, and recent data indicate decreasing lengths of hospice enrollment, yet we know little about the impact of hospice enrollment length on surviving caregivers. This is the first study the authors know of that examines the association between hospice enrollment length and subsequent major depressive disorder among surviving caregivers. Method: The authors conducted a prospective cohort study with 174 primary family caregivers of consecutively enrolled hospice patients with cancer between October 1999 and September 2001. Using data from in-person interviews at the time of enrollment and 6-8 months after the patient's death, they estimated with logistic regression the adjusted risk of major depressive disorder with the Structured Clinical Interview for the DSM-IV axis I modules based on the number of days of hospice care before death. Results: Caregivers of patients enrolled with hospice for 3 or fewer days were significantly more likely to have major depressive disorder at the follow-up interview than caregivers of those with longer hospice enrollment (24.1% versus 9.0%, respectively), adjusted for baseline major depressive disorder and other potential confounders. Conclusions: The findings identify a target group for whom bereavement services might be most needed. The authors also suggest that earlier hospice enrollment may help reduce the risk of major depressive disorder during the first 6-8 months of bereavement, which raises concerns about recent trends toward decreasing lengths of hospice enrollment before death.

The process of adoption of an evidence-based, multifaceted, innovative program into the hospital setting, with particular attention to issues that promoted or impeded its implementation, is described. The study examined common challenges faced by hospitals implementing the Hospital Elder Life Program (HELP) and strategies used to address these challenges.

EXECUTIVE SUMMARY With increasing attention directed at quality problems and medical errors in healthcare organizations, the ability of senior management to promote and sustain effective quality improvement efforts is paramount [...]

Objective. To examine a prevailing conceptual model of health services use (Andersen 1995) and to suggest modifications that may enhance its explanatory power when applied to empirical studies of race/ethnicity and long-term care. Study Setting. Twelve focus groups of African-American (five groups) and white (seven groups) individuals, aged 65 and older, residing in Connecticut during 2000. Study Design. Using qualitative analysis, data were coded and analyzed in NUD-IST 4 software to facilitate the reporting of recurrent themes, supporting quotations, and links among the themes for developing the conceptual framework. Specific analysis was conducted to assess distinctions in common themes between African-American and white focus groups. Data Collection. Data were collected using a standardized discussion guide, augmented by prompts for clarification. Audio taped sessions were transcribed and independently coded by investigators and crosschecked to enhance coding validity. An audit trail was maintained to document analytic decisions during data analysis and interpretation. Principal Findings. Psychosocial factors (e.g., attitudes and knowledge, social norms, and perceived control) are identified as determinants of service use, thereby expanding the Andersen model (1995). African-American and white focus group members differed in their reported accessibility of information about long-term care, social norms concerning caregiving expectations and burden, and concerns of privacy and self-determination. Conclusions. More comprehensive identification of psychosocial factors may enhance our understanding of the complex role of race/ethnicity in long-term care use as well as the effectiveness of policies and programs designed to address disparities in long-term care service use among minority and nonminority groups. Key Words. Race/ethnicity, long-term care, health service use, Use of long-term care services among minority elders is an important topic of research in light of the changing age and ethnic composition of the U.S. population. By 2030, the [...]

Background: Self-reported functional status is a commonly used health measure in clinical settings, yet the optimal approach for assessing function is often debated. Objective: To examine the agreement between a self-reported and a performance-based measure of function and the relative ability of each measure to predict long-term health outcomes. Design Prospective cohort study. Setting: 20 hospitals in Connecticut and Massachusetts. Participants: 620 postmenopausal women (46 to 91 years of age) who had experienced a stroke or transient ischemic attack. Measurements: A self-reported and a performance-based measure of function were assessed at baseline (before intervention) by using the Barthel index and the Physical performance Test. Results: Disagreement between the self-reported and performance-based measure of function was common (slight disagreement, 55.0%; substantial disagreement, 19.3%). Most women (95.4%) overreported their level of function. Women who were more clinically impaired (risk ratio [RR] for more comorbid conditions, 1.52 [95% CT, 1.17 to 1.97]; RR for recent stroke, 2.33 [CI, 1.45 to 3.73]; and RR for cognitive impairment, 1.76 [CI, 1.34 to 2.32]); who were less educated (RR=1.30 [CI, 1.02 to 1.67]); and who were of nonwhite ethnicity (RR 1.43 [CI, 10.7 to 1.91]) were more likely to overreport their level of function. An impaired performance-based measure of function predicted subsequent stroke or death (hazard ratio, 1.50, [CI, 1.06 to 2.11]); however, an impaired self-reported measure of function was not likely to predict these outcomes. Conclusions: Clinicians should be aware that results of self-reported and performance-based measures of function can differ in women who have experienced a recent cerebrovascular event. Although more difficult to collect, results of a performance-based measure may provide information about long-term health outcomes that is not available from a self-reported measure.

Background: The rapidly expanding proportion of the US population 65 years and older is anticipated to have a profound effect on health care expenditures. Whether the changing health status of older Americans will modulate this effect is not well understood. This study sought to determine the relationship between functional status and government-reimbursed health care services in older persons. Methods: Longitudinal cohort study of a representative sample of community-dwelling persons 72 years or older. Clinical data were linked with data on 2-year expenditures for Medicare-reimbursed hospital, outpatient, and home care services and Medicare- and Medicaid-reimbursed nursing home services. Per capita expenditures associated with different functional status transitions were calculated, as were excess expenditures associated with functional disability adjusted for demographic, health, and psychosocial variables. Results: The 19.6% of older persons who had stable functional dependence or who declined to dependence accounted for almost half (46.3%) of total expenditures. Persons in these groups had an excess of approximately $10 000 in expenditures in 2 years compared with those who remained independent. The 9.6% of patients who were dependent at baseline accounted for more than 40.0% of home health and nursing home expenditures; the 10.0% who declined accounted for more than 20.0% of hospital, outpatient, and nursing home expenditures. Conclusions: Functional dependence places a large burden on government-funded health care services. Whereas functional decline places this burden on short-and long-term care services, stable functional dependence places the burden predominantly on long-term care services. Declining rates of functional disability and interventions to prevent disability hold promise for ameliorating this burden. Arch Intern Med. 2001;161:2602-2607

A study of all cancer related deaths in Connecticut in 1994 show that 42% of patients died in the hospital, 29% died at home and 28% died in a nursing home or hospice facility. Statistical evidence also shows that some demographic groups are more likely to die in institutions.

Studies show that communication regarding future treatment preferences within nursing homes has not been significantly affected by the passage of the Patient Self Determination Act. Despite expectations that the Act would increase discussions about future care, these conversations were either undocumented or occurred infrequently and were of limited scope.

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.

A study on implementation and diffusion of hospital elder life program with relation to delirium prevention is presented.

Challenges that occur in the initial stage of adopting Hospital Elder Life Program (HELP) are discussed. Procedures for collecting required data and drawing the results to find out the capability of hospitals to continuing the adopted HELP are discussed. A longitudinal and qualitative study made on 13 hospitals between November 2000 and November 2003 revealed that 10 hospitals out of 13 are sustaining the HELP program. Good leadership, resources and funding, are stated as the main reasons of this sustainability.

Caregivers undergo mental and emotional agony as they look after the elderly persons. Communication plays an important role in between the caregiver and the seriously ill older person. Inability to communicate on the part of the seriously ill patient and inability to comprehend on the part of caregivers is examined and its effect on the caregivers' burden is analyzed.

A study conducted to determine predictors of recommendation adherence and goal attainment of family caregivers of patients at a geriatric assessment center is presented. A broad range of treatment recommendation in geriatric assessment is revealed.

The agreement between patients, caregivers and clinicians regarding prognosis communication and their desire for prognostic information are examined. Findings indicate that many ill older persons and caregivers are not ready or able to receive prognostic information.

EXECUTIVE SUMMARY Despite the many graduate programs that specialize in health administration, healthcare leaders and practitioners have expressed concern about the quality of preparation of health administration graduates. The purpose [...]

Nursing homes have complied with the procedural standards of the Patient Self-Determination Act (PSDA), but their measures to enhance patient autonomy and advanced care planning remain problematic. Using advanced care planning forms to meet the pragmatic needs of nursing home staff and to incorporate patient or surrogate needs into future medical treatment have begun, but more work remains to be done. Such forms could enhance patient autonomy if they lead to more complete discussions on end-of-life treatment wishes.

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.

Outcomes-based quality improvement using administrative data can reduce the time and cost of collecting data from patients. A 1998 study found that administrative data could predict functional decline and hospitalization among elderly patients as well as self-reported data collected from patients. If high-risk patients could be identified sooner, interventions could be created to prevent hospitalization and functional decline.

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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?