Accurately assessing elderly fall deaths using hospital discharge and vital statistics data

Historically, fatal injury monitoring and surveillance have relied on mortality data derived from death certificates (DC). However, problems associated with utilizing DC have been well documented. Recently, access to and utilization of hospital discharge data (HDD) have offered a new and important secondary source of data regarding in-hospital deaths. However, studies have shown that discrepancies between the HDD and the corresponding DC often exist. This discrepancy was especially evident when comparing HDD to the vital statistics data (VSD) for deaths by falls among those aged 65 and over in 19 states.This was a retrospective forensic review of elderly (age 65 and over) fall-associated fatalities (E880-E888) identified from HDD and VSD in Allegheny County, Pennsylvania, between 1997 and 1998. Seventy-seven cases were identified, with the original manner of death listed as natural (34), suicide (1), and accidental (42) on the DC. Following a forensic review of the cases, the manner of the death on the DC should have been changed from natural to accidental in 28% (n = 12) of the cases, representing an undercount in the VSD. Undercounts were due to a failure of clinicians to account for the significance of a fall event that contributed to subsequent pathology and death. In addition, in that 22% (n = 17) of the HDD fall-associated deaths, the fall did not contribute directly or sequentially to the underlying cause of death, thereby representing an overcount in the HDD.Based on these findings we recommend (1) elderly fall surveillance systems should only count HDD E-coded falls that demonstrate a serious traumatic injury which directly or subsequently results in death, (2) all in-hospital fall-associated deaths should be reported to and reviewed by coroner/Medical Examiner offices for determination of the cause and manner of death, and (3) physicians should be better educated in properly completing death certificates.     

Policy Studies And Political Science

Studies of "policy" and l'policymakingll have proliferated recently. One reason is the serious policymaking difficulties of American and other Western governments. Earlier political science did not address these problems well because of its concentration on political input processes rather than outputs. Most policy studies either evaluate programs 0' explain cases of policymaking, The approach proposed here, called public policy, does both. Analyses of preferred options are played off against the limitations of process, and vice versa. This conception is illustrated and the problems posed by it are discussed.     

Returning to Delinquency: Factors Effecting the Survivorship of Juvenile Shoplifters

This article examines a program designed to provide a family court with a means of lessening the probability that youths on probation for shoplifting will return to criminal behavior. A single staff member within the family court screened possible participants, all of whom were defined as first-time shoplifting offenders and had been assigned to formal or informal probation. Each individual was invited to participate in a four-hour clinic, during which time the realities and possible consequences of shoplifting were explained. If they were able to successfully complete six months of supervised probation, then only the administrative record remained; the conviction itself was expunged. Over a period of nine months, a total of 154 juveniles were invited; however, only 100 actually took part in all facets of the program. A total of 30 clinic attendees and 14 nonparticipants were excluded from the present analysis, owing to missing data, or the fact that at the time of follow-up, they were legally classified as adults. The prior and subsequent court contacts of 110 subjects are reviewed. While less than 3% of either group had subsequent shoplifting arrests, nearly 26% of the program group and 35% of the nonparticipants were rearrested. Factors associated with long-term success and failure are examined. Possible reasons for these observations are discussed, with specific grounding in the shoplifting literature and the concepts of juvenile diversion and “net-widening.”     

Mediating science-intensive policy disputes

Public policy disputes involving complex scientific issues usually entail conflicts not only over those scientific issues, but also over the distribution of gains and losses. The presence of scientific or technical dimensions to a dispute should not be allowed to mask underlying distributional considerations. On the other hand, science-intensive disputes require special attention. Merely resolving distributional conflicts without incorporating the best scientific judgment will produce unwise and potentially dangerous results. The usual adversarial approach that characterizes the handling of such disputes by agencies and courts is less than ideal for creating an understanding of scientific evidence or the resolution of scientific differences. A process of mediation, already applied in a number of significant cases, offers strong promise as a superior approach.     

Labor market policy: A comparative view on the costs and benefits of labor market flexibility

I review theories and evidence on wage‐setting institutions and labor market policies in an international comparative context. These include collective bargaining, minimum wages, employment protection laws, unemployment insurance (UI), mandated parental leave, and active labor market policies (ALMPs). Since it is unlikely that an unregulated private sector would provide the income insurance these institutions do, these policies may enhance economic efficiency. However, to the extent that unemployment or resource misallocation results from such measures, these efficiency gains may be offset. Overall, Scandinavia and Central Europe follow distinctively more interventionist policies than the English‐speaking countries in the Northern Hemisphere. Possible explanations for such differences include vulnerability to external market forces and ethnic homogeneity. I then review evidence on the impacts of these policies and institutions. While the interventionist model appears to cause lower levels of wage inequality and high levels of job security to incumbent workers, it also in some cases leads to the relegation of new entrants (disproportionately women, youth, and immigrants) as well as the less skilled to temporary jobs or unemployment. Making labor markets more flexible could bring these groups into the regular labor market to a greater extent, at the expense of higher levels of economic insecurity for incumbents and higher levels of wage inequality. © 2011 by the Association for Public Policy Analysis and Management.     

Random assignment without tears: how to stop worrying and love the Cambridge randomizer

Objectives  

This note describes a low-cost online portal called “the Cambridge Randomizer”, which enables treatment providers to conduct random assignment themselves, while the researcher still maintains control over the entire process and the integrity of the allocation process.     

The fox and the grapes: is real reform beyond reach in the United States?

As the challenges of maintaining (or, in the US case, attaining) affordable universal coverage multiply, the debate about what constitutes "real" reform intensifies in Western health care systems. The reality of reform, however, lies in the eyes of myriad beholders who variously enshrine consumer responsibility, changes in payment systems, reorganization, and other strategies -- or some encompassing combination of all of the above -- as the essential ingredient(s). This debate, increasingly informed by the agendas of health services researchers and health policy analysts, arguably serves as much or more to becloud as to clarify the practical options policy makers face and remains severely imbalanced with respect to the institutional sectors on which it concentrates, the fields of knowledge on which it draws, and the roles it envisions for markets and the state.