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This paper begins with the lived accounts of emergency and critical care medical interventions in which an unhoused person is brought to the emergency department in cardiac arrest. The case is a dramatised representation of the extent to which biopolitical forces via reduction to bare life through biopolitical and necropolitical operations are prominent influences in nursing and medical care. This paper draws on the scholarship of Michel Foucault, Giorgio Agamben, and Achille Mbembe to offer a theoretical analysis of the power dynamics that influence the health care and death care of patients who are caught in the auspices of a neoliberal capitalist healthcare apparatus. This paper offers analysis of the overt displays of biopower over those individuals cast aside as generally unworthy of access to healthcare in a postcolonial capitalist system, in addition to the ways in which humans are reduced to 'bare life' in their dying days. We analyse this case study through Agamben's description of thanatopolitics, a 'regime of death', and the technologies that accompany the dying process, particularly in that of the homo sacer. Additionally, this paper illustrates the ways in which necropolitics and biopower are integral to understanding how the most advanced and expensive medical interventions make visible the political values of the healthcare system and how nurses and healthcare functions in these deathworlds. The purpose of this paper is to develop a greater understanding of biopolitical and necropolitical operations in acute and critical care environments, and to offer guidance to nurses in these spaces as they work to uphold ethical duties in a system that increasingly dehumanises. [ABSTRACT FROM AUTHOR]

Policy PointsThe predominantly fee‐for‐service reimbursement architecture of the US health care system contributes to waste and excess spending.While the past decade of payment reforms has galvanized the adoption of alternative payment models and generated moderate savings, uptake of truly population‐based payment systems continues to lag, and interventions to date have had limited impact on care quality, outcomes, and health equity.To realize the promise of payment reforms as instruments for delivery system transformation, future policies for health care financing must focus on accelerating the diffusion of value‐based payment, leveraging payments to redress inequities, and incentivizing partnerships with cross‐sector entities to invest in the upstream drivers of health. [ABSTRACT FROM AUTHOR]

Purpose: Children with hypoplastic left heart syndrome (HLHS) experience numerous vulnerabilities during transitions from hospital to home during their first year of life. This paper examines the parents' responses to the situations they experience during the initial interstage transition as described through illness blogs. Design and methods: A qualitative descriptive design through inductive theme development using thematic analysis was performed for this study. Text data were used from publically available blogs written by parents of HLHS children on their feelings and experiences during transitions between hospital‐ and home‐care during the interstage period. Results: Six blogs were analyzed. Overall, the lack of difference in normalcy for these parents and their families was apparent. Major themes included: thoughts and feelings when discharged from the hospital, difficulties with hospital readmissions, protecting their child from infection, and developing a support system. Conclusions: Parents looked forward to going home and learned all they could about properly caring for their child before going home. They were disappointed and frustrated when returning to the hospital for either emergency or scheduled admissions and were not prepared to see their child in the intensive care unit environment again. Many parents isolated themselves and avoided the hospital as much as possible to avoid their child developing an infection. All parents had support systems through family and/or friends and found an unexpected sense of support through their blog families. [ABSTRACT FROM AUTHOR]

Objective: To determine between-hospital variation in interventions provided to patients with do not resuscitate (DNR) orders.Data Sources/setting: United States Agency of Healthcare Research and Quality, Healthcare Cost and Utilization Project, California State Inpatient Database.Study Design: Retrospective cohort study including hospitalized patients aged 40 and older with potential indications for invasive treatments: in-hospital cardiac arrest (indication for CPR), acute respiratory failure (mechanical ventilation), acute renal failure (hemodialysis), septic shock (central venous catheterization), and palliative care. Hierarchical logistic regression to determine associations of hospital "early" DNR rates (DNR order placed within 24 hours of admission) with utilization of invasive interventions.Data Collection/extraction Methods: California State Inpatient Database, year 2011.Principal Findings: Patients with DNR orders at high-DNR-rate hospitals were less likely to receive invasive mechanical ventilation for acute respiratory failure or hemodialysis for acute renal failure, but more likely to receive palliative care than DNR patients at low-DNR-rate hospitals. Patients without DNR orders experienced similar rates of invasive interventions regardless of hospital DNR rates.Conclusions: Hospitals vary widely in the scope of invasive or organ-supporting treatments provided to patients with DNR orders. [ABSTRACT FROM AUTHOR]

Objectives: To test whether a care management program could replicate its success in an earlier trial and determine likely explanations for why it did not.Data Sources/setting: Medicare claims and nurse contact data for Medicare fee-for-service beneficiaries with chronic illnesses enrolled in the trial in eastern Pennsylvania (N = 483).Study Design: A randomized trial with half of enrollees receiving intensive care management services and half receiving usual care. We developed and tested hypotheses for why impacts declined.Data Extraction: All outcomes and covariates were derived from claims and the nurse contact data.Principal Findings: From 2010 to 2014, the program did not reduce hospitalizations or generate Medicare savings to offset program fees that averaged $260 per beneficiary per month. These estimates are statistically different (p < .05) from the large reductions in hospitalizations and spending in the first trial (2002-2010). The treatment-control differences in the second trial disappeared because the control group's risk-adjusted hospitalization rate improved, not because the treatment group's outcomes worsened.Conclusion: Even if demonstrated in a randomized trial, successful results from one test may not replicate in other settings or time periods. Assessing whether gaps in care that the original program filled exist in other settings can help identify where earlier success is likely to replicate. [ABSTRACT FROM AUTHOR]