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Truncus arteriosus is a congenital heart defect with high resource use, cost, and mortality. Value assessment (outcome relative to cost) can improve quality of care and decrease cost. This study hypothesized that truncus arteriosus repair at a high-volume center would result in better outcomes at lower cost (higher value) compared with a low-volume center.This study retrospectively analyzed a multicenter cohort of neonates undergoing truncus arteriosus repair (2004 to 2015) by using the Pediatric Health Information Systems database. Multivariate quantile, logistic, and negative binomial regression models were used to evaluate total hospital cost, in-hospital mortality, ventilation days, intensive care unit length of stay (LOS), hospital LOS, and days of inotropic agent use by center volume (high-volume3/year) and age at repair while adjusting for sex, ethnicity, race, genetic abnormality, prematurity, low birth weight, concurrent interrupted arch repair, and truncal valve repair.Of 1024 neonates with truncus arteriosus, 495 (48%) were treated at high-volume centers. Costs at the 75th percentile were lower at high-volume vs low-volume centers by $28,456 (P = .02) at all ages at repair. Patients at high-volume centers had lower median postoperative ventilation days (5 days vs 6 days; P.001), intensive care unit LOS (13 days vs 19 days; P.001), hospital LOS (23 days vs 28 days; P = .02), and inotropic agent use (3 days vs 4 days; P = .004). In-hospital mortality did not differ by center volume.In neonates undergoing truncus arteriosus repair, costs are lower and outcomes are better at high-volume centers, thus resulting in higher value at all ages of repair. Value-based interventions should be considered to improve outcomes and decrease cost in truncus arteriosus care.

Millions of people worldwide live in extreme poverty, which has an adverse effect on global food security. Research shows that growth in the agricultural labor sector has twice the impact on poverty compared to growth in other labor sectors. To that end, we examine some of the enabling factors of private sector investment to increase food security and reduce poverty: innovative output, intellectual property rights innovation, gender-sensitive land tenure, creation of new businesses, openness to trade, government institutional flexibility, access to credit, inclusion of new sectors, income diversification, public-private partnerships, infrastructure improvements, payments for eco-system services, and climate-smart innovation. Developing policies that improve food security will help to reduce poverty.

This cross-sectional study investigates the prevalence of alcohol in unintentional opioid overdose deaths in Illinois from 2017 through 2020.

Purpose Agriculture must transform as climate change progresses. The international community has promoted climate-smart agriculture (CSA) as a set of solutions. Previous analyses of opportunities for scaling up CSA have not looked closely at building political and social support for policies, practices and programs. The purpose of this paper is to fill that gap in the case study country of Senegal. Design/methodology/approach The study applies the conceptual definitions, operationalizations and assessment targets from the political will and public will (PPW) approach to social change. Semi-structured interviews and documents constitute the sources of data and information. Findings The analysis identifies opportunities to generate political will for supplying an enabling environment for the widespread adoption of CSA. On the public will side, the analysis identifies opportunities to generate and channel demand for CSA. Research limitations/implications Researchers investigated some definitional components more completely than others due to resource and access constraints. Further, the context specificity of the components limits generalizability of certain findings. Social implications Social structures may need to change for successful adoption of certain CSA innovations, but improved agricultural outcomes are likely to result. Originality/value This examination of crucial elements for scaling up CSA efforts constitutes the most extensive application of the PPW approach to date, thus providing an example of this generalizable method.

The international community has advocated the adoption of climate-smart agriculture (CSA) as lower-income countries deal with the negative consequences of climate change. Scaling up such policies, practices, and programs successfully will require support from a variety of local stakeholders. Such support requires alignment between CSA solutions and the problem understandings of stakeholders. However, problem understandings can differ across individuals, stakeholder groups, and geographic areas. Consequently, we examine understandings of climate problems and socioeconomic and infrastructure problems related to agriculture among different stakeholder groups in Uganda and Senegal. We operationalized and measured these problem understandings following the detailed guidance of the political will and public will approach for analyzing social change. Semi-structured interviews elicited stakeholder-generated lists of problems for each group. Limited quantification of problem understandings and their relative importance or “ripeness” demonstrates how contexts might shape opportunities for CSA.

Decision makers face difficult choices when tasked with identifying and implementing appropriate mechanisms for protecting the elderly and other vulnerable adults from abuse. A pilot project involving fingerprint-based criminal history background checks for personal care workers in Michigan has supplied an opportunity to examine one such mechanism. In conjunction with the pilot project, we have conducted a stakeholder analysis with the aim of informing decision makers about stakeholder perceptions of standard policy criteria like effectiveness, efficiency, and equity. We employed focus groups and a Web-based survey to collect data from stakeholders. While stakeholders generally see fingerprint-based background checks for personal care workers as potentially effective and as a net benefit, they also point to a variety of contingencies. They also recognize difficulties and constraints for government involvement. This preliminary analysis provides solid foundational information for decision makers and for more extensive benefit-cost analysis.

Introduction Promoting emergency medicine (EM) clinical trials research remains a priority. To characterize the status of clinical EM research, this study assessed trial quality, funding source, and publication of EM clinical trials and compared EM and non-EM trials on these key metrics. We also examined the volume of EM trials and their subspecialty areas. Methods We abstracted data from ClinicalTrials.gov (February 2000 - September 2013) and used individual study National Clinical Trial numbers to identify published trials (January 2007 - September 2016). We used descriptive statistics and chi-square tests to examine study characteristics by EM and non-EM status, and Kaplan-Meier curves and log-rank tests to compare time to publication of completed EM and non-EM studies. Results We found 638 interventional EM trials and 59,512 non-EM interventional trials conducted in the United States between February 2000 and September 2013, registered on ClinicalTrials.gov. EM studies were significantly less likely than non-EM studies to be National Institutes of Health-funded or to evaluate a drug or biologic. However, EM studies had significantly larger sample sizes, and were significantly more likely to use randomization and blinding. Overall, 34.3% of EM and 26.0% of non-EM studies were published in peer-reviewed journals. By subspecialty, more EM trials concerned medical/surgical and psychiatric/neurological conditions than trauma. Conclusion Although EM studies were less likely to have received federal or industry funding, and the EM portfolio consisted of only 638 trials over the 14-year study period, the quality of EM trials surpassed that of non-EM trials, based on indices such as randomization and blinding. This novel finding bodes well for the future of clinical EM research, as does the higher proportion of published EM than non-EM trials. Our study also revealed that trauma studies were under-represented among EM studies. Periodic assessment of EM trials with the metrics used here could provide an informative and valuable longitudinal view of progress in clinical EM research.

Immigrant/refugee children sometimes have substantially higher blood lead levels (BLLs) than US-born children in similar environments. We try to understand why, by exploring the relationship between immigration status of mother and the BLLs of US-born children. We compared BLLs of children born in Michigan to immigrant and non-immigrant parents, using the Michigan database of BLL tests for 2002-2005, which includes the child's race, Medicaid eligibility and address. We added census data on socio-demographic/housing characteristics of the child's block group, and information about parents. Low parental education, single parent households, mothers' smoking and drinking, all increase the child's BLL. However, immigrant parents had fewer characteristics associated with high BLL than US born parents, and their children had lower BLLs than children of US-born mothers. Our findings suggest that prior findings of higher BLLs among immigrant/refugee children probably result from them starting life in high-lead environments.

Background and objectives Older adults (age 65 and older) use the emergency department (ED) at a rate of nearly 50 ED visits per 100 older adults, accounting for over 23 million ED visits in the US annually, up to 20% of all ED visits. These ED visits are sentinel health events as discharged patients often return to the ED, experience declines in health-related quality of life (HRQoL) and disability, or are later hospitalized. Those who are admitted incur increased costs and greater risk for poor outcomes including infections, delirium, and falls. The objective of this randomized controlled trial (RCT) is to evaluate the efficacy of the Geriatric Emergency Department Innovations (GEDI) program, an ED nurse-led geriatric assessment and care coordination program, in decreasing unnecessary health services use and improving Health-Related Quality-of-Life (HRQoL) for older adults in the ED. Methods Community dwelling older adults aged 65 and older who are vulnerable or frail according to the Clinical Frailty Scale (CFS) during an ED visit will be randomized to either GEDI (n = 420) or to usual ED care (n = 420). Outcome variables will be assessed during the ED visit and at 7–11 days and 28–32 days post ED visit. Projected outcomes The primary outcome is hospitalization or death within 30 days of the ED visit. Secondary outcomes include health service use outcomes (ED visits and hospitalizations), healthcare costs, and HRQoL outcomes [Patient-Reported Outcomes Measurement Information System (PROMIS) scores: PROMIS-Preference, Physical Function, Ability to Participate in Social Roles and Activities, Anxiety, and Depression]. Trial registration Clinicaltrials.Gov identifier NCT04115371

Background Overuse of computed tomography (CT) for minor head injury continues despite developed and rigorously validated clinical decision rules like the Canadian CT Head Rule (CCHR). Adherence to this sensitive and specific rule could decrease the number of CT scans performed in minor head injury by 35%. But in practice, the CCHR has failed to reduce testing, despite its accurate performance. Objectives The objective was to identify nonclinical, human factors that promote or inhibit the appropriate use of CT in patients presenting to the emergency department (ED) with minor head injury. Methods This was a qualitative study in three phases, each with interview guides developed by a multidisciplinary team. Subjects were recruited from patients treated and released with minor head injuries and providers in an urban academic ED and a satellite community ED. Focus groups of patients (four groups, 22 subjects total) and providers (three groups, 22 subjects total) were conducted until thematic saturation was reached. The findings from the focus groups were triangulated with a cognitive task analysis, including direct observation in the ED (>150 hours), and individual semistructured interviews using the critical decision method with four senior physician subject matter experts. These experts are recognized by their peers for their skill in safely minimizing testing while maintaining patient safety and engagement. Focus groups and interviews were audio recorded and notes were taken by two independent note takers. Notes were entered into ATLAS.ti and analyzed using the constant comparative method of grounded theory, an iterative coding process to determine themes. Data were double-coded and examined for discrepancies to establish consensus. Results Five core domains emerged from the analysis: establishing trust, anxiety (patient and provider), constraints related to ED practice, the influence of others, and patient expectations. Key themes within these domains included patient engagement, provider confidence and experience, ability to identify and manage patient anxiety, time constraints, concussion knowledge gap, influence of health care providers, and patient expectations to get a CT. Conclusions Despite high-quality evidence informing use of CT in minor head injury, multiple factors influence the decision to obtain CT in practice. Identifying and disseminating approaches and designing systems that help clinicians establish trust and manage uncertainty within the ED context could optimize CT use in minor head injury.

Scientific elaboration of “public will” would enhance the concept's analytical usefulness and contribute to improved understanding in various fields, including political science and public policy. Previous work has utilized the term but has jumped the crucial stage of formally defining public will as a conceptual variable. This project constructs a definitional system that breaks the concept into components and offers operationalizations and assessment targets. Analysis begins with consideration of social systems and their direct ties with other definitional components like shared recognition of the problem and of proposed means of addressing the problem. Resolve to address the situation and to sustain collective action are also essential components. The project then applies the definitional system through a brief case study of firearm control and considers various scholarly implications. The definitional system emphasizes the simultaneous existence of multiple “publics” and argues against using public will synonymously with majority public opinion.

Our objective was to characterize the tasks of emergency radiologists and emergency physicians and quantify the proportion of time spent on these tasks to assess their roles in patient evaluation. Our study involved emergency radiologists and emergency physicians at an urban academic level I trauma medical center. Participants were observed for continuous 2-h periods during which all of their activities were timed and categorized into the following tasks: patient history, patient physical findings, assessment/plan, procedures, technical/administration, paperwork, and personal time. We performed multivariate analyses to compare the proportion of time spent on task categories between specialties. Twenty physicians (10 emergency medicine and 10 radiology) were observed for a total of 146,802 s (2,446.7 min). Radiologists spent a significantly larger combined proportion of time on determining physical findings and paperwork than emergency physicians (61.9 vs. 28.3 %, p

Although research on domestic elder abuse and neglect has grown over the past 20 years, there is limited research on elder neglect in nursing homes. The purpose of this study is to estimate the incidence of elder neglect in nursing homes and identify the individual and contextual risks associated with elder neglect. Data came from a 2005 random digit dial survey of individuals in Michigan who had relatives in long term care. Our analytic sample included 414 family members who had a relative aged 65 or older in nursing homes. Results showed that about 21% of nursing home residents were neglected on one or more occasion in the last 12 months. Two nursing home residents' characteristics reported by family members appear to significantly increase the odds of neglect: functional impairments in activities of daily living and previous resident-to-resident victimization. Behavior problems also are associated with higher odds of neglect (p = 0.078). Policy implications of these results are discussed.

Although frequently invoked as a rhetorical tool in political discussions, “political will” remains ambiguous as a concept. Acknowledging the centrality of political will to policy outcomes, the authors propose a pragmatic and systematic approach to definition. This approach facilitates analysis by identifying particular shortcomings in political will. This identification in turn permits the application of appropriate theoretical frameworks from various disciplines and the effective construction and use of ameliorative measures. The authors also address fundamental issues like the specification of contexts. The analytical approach includes a conceptual definition dissected into essential components, along with corresponding means of operationalization and targets for assessment. Among the major definitional components are requirements that a sufficient set of decision makers intends to support a particular initiative and that such support is committed. The latter condition is difficult to ascertain, but various signals, influences, and constraints on action are observable. Aunque frecuentemente invocado como una herramienta retorica en las discusiones politicas, “la voluntad politica” se mantiene como unconcepto ambiguo. Reconociendo la importancia de la voluntad politica en los resultados politicos, los autores proponen una aproximacion pragmatica y sistematica para su definicion. Esta aproximacion facilita el analisis al identificar faltas particulares en el concepto de voluntad politica. Dicha identificacion permite a su vez la aplicacion del marco teorico apropiado de varias disciplinas y la construccion efectiva y utilizacion de medidas de mejoramiento. Los autores abordan tambien topicos fundamentales como la importancia del contexto. La aproximacion analitica incluye una definicion conceptual diseccionada en componentes esenciales, junto con medios correspondientes de operacionalizacion y los objetivos a evaluar. Entre los componentes mas importantes de la definicion estan los requerimientos que una serie de hacedores de politicas intente apoyar una iniciativa particular y que dicho apoyo sea real. La ultima condicion es dificil de determinar, pero varias senales, influencias, y limitaciones son observables.

The authors investigated types and patterns of elder abuse by paid caregivers in long-term care and assessed the role of several risk factors for different abuses and for multiple abuse types. The results are based on a 2005 random-digit-dial survey of relatives of persons in long-term care. We computed occurrence rates and conditional occurrence rates for each of six abuse types: physical, caretaking, verbal, emotional, neglect, and material. Among older adults who have experienced at least one type of abuse, more than half (51.4%) have experienced another type of abuse. Physical functioning problems, activities of daily living limitations, and behavioral problems are significant risk factors for at least three types of abuse and are significant for multiple abuse types. The findings have implications for those monitoring the well-being of older adults in long-term care as well as those responsible for developing public health interventions.

Objective.We determined which children should be tested for elevated blood lead levels (BLLs) in the face of financial and practical barriers to universal screening efforts and within 2009 Centers for Disease Control and Prevention recommendations allowing health departments to develop BLL screening strategies.Methods.We used the Michigan database of BLL tests from 1998 through 2005, which contains address, Medicaid eligibility, and race data. Linking addresses to U.S. Census 2000 data by block group provided neighborhood sociodemographic and housing characteristics. To derive an equation predicting BLL, we treated BLL as a continuous variable and used Hierarchical Linear Modeling to estimate the prediction equation.Results.Census block groups explained more variance in BLL than tracts and much more than dichotomized zip code risk (which is current pediatric practice). Housing built before 1940, socioeconomic status and racial/ethnic characteristics of the block group, child characteristics, and empirical Bayesian residuals explained more than 41% of the variance in BLL during 1998–2001. By contrast, zip code risk and Medicaid status only explained 15% of the BLL variance. An equation using 1998–2001 BLL data predicted well for BLL tests performed in 2002–2005. While those who received BLL tests had above-average risk, this method produced minimal bias in using the prediction equation for all children.Conclusions.Our equation offers better specificity and sensitivity than using dichotomized zip codes and Medicaid status, thereby identifying more high-risk children while also offering substantial cost savings. Our prediction equation can be used with a simple Internet-based program that allows health-care providers to enter minimal information and determine whether a BLL test is recommended.

This article describes media coverage of elder abuse from 2003 to 2005. Guided by media typification and framing literatures, eight newspapers' elder abuse coverage was content analyzed. The newspapers' coverage usually typified and framed elder abuse in a criminal justice context. The stories covered most often featured episodic frames, 57.1%, while a majority, 65.2%, of the coverage framed elder abuse as an individual- as opposed to a societal-level problem. Most elder abuse occurs in domestic settings, yet the newspapers' coverage most often focused on elder abuse in long-term care settings.

Objectives. Articles describing the epidemiology of intimate partner homicide (IPH) have often been positioned as one-time research projects utilizing a single data source for case identification. However, researchers without access to centralized repositories for data pertinent to IPH can ascertain cases by using multiple extant data sources. The authors describe a surveillance system that can serve as a model for state health departments and others seeking to quantify and characterize violent deaths related to intimate partner relationships on an ongoing basis. Methods. Retrospective surveillance was conducted to identify and characterize deaths related to intimate partnerships by linking the following data sources: death certificates, newspaper articles, law enforcement reports, and medical examiners' records. Results. The authors identified at least 34% more IPHs using multiple data sources than would have been recognized solely using Supplementary Homicide Reports—the most frequently cited data source for IPH case ascertainment—and 22% more cases than newspaper data alone would have allowed for. Conclusions. While it was discovered that at least 181 IPHs—and at least 128 other deaths related to intimate partnerships—occurred in Michigan from 1999–2001, this frequency of occurrences is probably conservative. This limitation is due, in part, to the researchers not having access to information from all possible data source contributors. However, in the absence of statewide data systems, the authors demonstrate the utility of using multiple data sources for violent death surveillance to address incomplete case ascertainment.

Fear of violence appears to be widespread among women, and many feminist scholars attribute such fear to gender inequality at a societal level. The present article uses qualitative interviews with 32 women older than the age of 50 to determine the context in which women perceive violence in their neighborhoods and communities and how their present experience with fear and violence differs from childhood experience. The authors also assess the various mechanisms women employ to keep themselves safe from harm and how daily routines are altered to avoid violence. Using feminist theory as a foundation for analysis, an ecological system of violence is constructed, which incorporates the individual, neighborhood, and societal environments

This study describes the risk factors associated with experiencing and committing sexual aggression among a sample of male and female adolescents. High school students completed a questionnaire containing a revised form of the Sexual Experiences Survey to assess sexual victimization and offending experiences. Ordinal regression equations were estimated separately for male and female students, regressing background characteristics, dating behaviors, and attitudinal scales on sexual victimization (for females) or offending (for males). Nearly half (48%) of the females report experiencing sexual aggression, and one-third (34%) of males admit committing this type of offending. Regression analyses show that the likelihood of reporting victimization/offending increases among females who report dating more frequently during the past month, among both males and females who report dating more different people during the past 6 months, and among older males. Females who report their religious affiliation as Protestants compared to those with no religious affiliation, and those planning to attend college are less likely to report victimization. Among the males, rejecting rape stereotypes and having more accurate legal knowledge regarding rape are related to reduced likelihoods of reporting sexual offending. Implications for improving sexual assault educational programs for adolescents are discussed.

This study assessed whether sexual assault offenders were differently adjudicated from other violent felons and to what extent any differences in adjudication decisions were explained by the defendant's race. Five court decisions were analyzed using a weighted sample of 41,151 cases adjudicated between 1990 and 1996 that were representative of cases in the seventy-five most populous United States counties. The results did not support the hypothesis that sexual assault cases were given, on average, more leniency than less serious violent offenses, however, various adjudication decisions for the four violent offenses were moderated by the defendant's race. Interaction models showed minorities were treated more punitively compared to Whites when they were charged with an assault, robbery, or murder, but they were treated more leniently when they were charged with a sexual assault. Explanatory models that accounted for the differential processing of minorities that were disproportionately lenient or punitive, depending on the crime, are discussed.

This study examines the relationship between age, physical violence and non‐physical abuse within the context of intimate partner violence (IPV). It tests the hypothesis that while the prevalence of physical violence is lower among older women, other forms of intimate partner violence are not related to age. The study uses data from the Michigan Violence Against Women Survey to measure physical violence and two forms of non‐physical abuse: psychological vulnerability and autonomy‐limiting behavior. Findings support the hypothesis that the rate of physical abuse is negatively related to age but the rate of nonphysical abuse is not. By expanding the definition of IPV to include other forms of abusive behavior, the study finds that older women have IPV prevalence rates similar to younger women. This raises the question of whether batterers alter their means of power and control by emphasizing non‐physical abuse rather than continuing to use physical violence that exposes them to formal and informal social controls and sanctions.

This study examines the justice system's decision that sexual violence, particularly rape, is not an economic crime. The authors estimate the tangible and intangible financial costs of sexual violence in Michigan. In 1996, rape and sexual assault cost Michigan more than $6.5 billion, most of which came in the form of intangible costs. Sex-offense homicide cost more than $18 million, two thirds of which was intangible costs. If divided equallyas a “rape tax,” each resident of Michigan would have paid nearly $700 in 1996 to cover the cost of sexual violence. The implication is that prevention is the best way to reduce the high cost of sexual violence. Furthermore, rape and sexual assault need to be identified as a public health issue to raise awareness about sexual violence. Finally, courts and prosecutors need to think about sexual violence as an economic crime to better protect victims and survivors of sexual violence.

Objectives. We compared the likelihood that a tobacco user would receive treatment with the likelihood that an adult with another common chronic condition would receive treatment for that condition at an office visit. Methods. We analyzed data from the 2005–2007 National Ambulatory Medical Care Survey to compare the proportion of US office visits at which tobacco users and individuals with hypertension, hyperlipidemia, diabetes, asthma, or depression received condition-specific treatment. We calculated the odds that a visit for a comparison condition would result in treatment relative to a visit for tobacco dependence. Results. From 2005 to 2007, 38 004 patient visits involved at least 1 study condition. Tobacco users received medication at fewer visits (4.4%) than individuals with hypertension (57.4%), diabetes (46.2%), hyperlipidemia (47.1%), asthma (42.6%), and depression (53.3%). In multivariate analyses, the odds for pharmacological treatment of these disorders relative to tobacco use were, for hypertension, 32.8; diabetes, 20.9; hyperlipidemia, 16.5; asthma, 22.1; and depression, 24.0 (all Ps Conclusions. Alternate models of engagement may be needed to enhance use of effective treatments for tobacco use.

This study compares abuse rates for elders age 60 and older in three care settings: nursing home, paid home care, and assisted living. The results are based on a 2005 random-digit dial survey of relatives of or those responsible for, a person in long-term care. Nursing homes have the highest rates of all types of abuse, although paid home care has a relatively high rate of verbal abuse and assisted living has an unexpected high rate of neglect. Even when adjusting for health conditions, care setting is a significant factor in both caretaking and neglect abuses. Moving from paid home care to nursing homes is shown to more than triple the odds of neglect. Furthermore, when computing abuse rates by care setting for persons with specified health conditions, nursing homes no longer have the highest abuse rates.

There is a scarcity of theoretical frameworks capable of describing precursors and dynamics associated with elder abuse and neglect in Latino families. The present manuscript seeks to address this gap in the literature by presenting an integrative theoretical framework that fosters an ecological and cultural understanding of elder abuse and neglect among Latinos. The proposed model rests on the premise that Latino families caring for elder adults have the ability to adapt to the demands of aging only if they are supported by nurturing environments. The usefulness of the model is threefold. First, the proposed model describes elder abuse and neglect as multifactorial phenomena and identifies specific risk factors associated with the etiology and maintenance of elder abuse and neglect in Latino families. Second, the model provides clinical applications, including reflections about the therapists' need to extend their scope of practice beyond traditional family therapy interventions. A brief case study is presented that illustrates the clinical application of the model with a Latino family. Implications for future research are discussed.