The who, what, and why of risk adjustment: a technology on the cusp of adoption

Risk adjustment (RA) consists of a series of techniques that account for the health status of patients when predicting or explaining costs of health care for defined populations or for evaluating retrospectively the performance of providers who care for them. Although the federal government seems to have settled on an approach to RA for Medicare Advantage programs, adoption and implementation of RA techniques elsewhere have proceeded much more slowly than was anticipated. This article examines factors affecting the adoption and use of RA outside the Medicare program using case studies in six U.S. health care markets (Baltimore, Seattle, Denver, Cleveland, Phoenix, and Atlanta) as of 2001. We found that for purchasing decisions, RA was used exclusively by public agencies. In the private sector, use of risk adjustment was uncommon and scattered and assumed informal and unexpected forms. The most common private sector use of RA was by health plans, which occasionally employed RA in negotiations with purchasers or to allocate resources internally among providers. The article uses classic technology diffusion theory to explain the adoption and use of RA in these six markets and derives lessons for health policy generally and for the future of RA in particular. For health policy generally, the differing experiences of public and private actors with RA serve as markers of the divergent paths that public and private health care sectors are pursuing with respect to managed care and risk sharing. For the future of RA in particular, its history suggests the need for health service researchers to consider barriers to use adoption and new analytic technologies as they develop them.     

Multifactorial analysis of firearm wounds to the head with attention to anatomic location.

Firearm wounds to the head are often fatal and are routinely encountered in the practice of forensic pathology in the United States. Often, the anatomic site of the entrance wound is used to support or refute the manner of death indicated by the scene investigation and/or circumstances of the case. The present retrospective study of 120 fatalities resulting from 140 firearm wounds to the head correlates the anatomic region of the entrance wound and range of fire with the manner of death. Other demographic data analyzed include age, race, and gender of the decedents, as well as evidence of drug and/or ethanol use. It is hoped that this study will provide concrete data to support the largely anecdotal associations between the specific site of entry of firearm injuries to the head and the manner of death.     

A decade of pediatric homicide: a retrospective study at the Medical University of South Carolina.

More than 3 million children are abused and/or neglected each year in the United States. Unfortunately, a significant percentage of these cases result in homicide by child abuse or child neglect. Causes of death range from blunt force trauma and shaking to asphyxia to immolation. We retrospectively reviewed all pediatric forensic cases referred to the Medical University of South Carolina Forensic Pathology Section over the past 10 years, from January 1986 to December 1995. Of these, we looked only at children < or =5 years of age. The majority (342 cases, 69%) of these deaths were classified as natural, 96 (19%) as accident, and 60 (12%) as homicide. Of the homicides, we examined the cause of death; age, gender, and race of the victim; relationship to the perpetrator; time interval between injury and death; and the initial history given as to the cause of the injury. The cause of death fell into nine categories, the number one category being head trauma. Forty-five percent of the homicides were by head trauma, 12% by abdominal or body trauma, 25% by asphyxia (with half of these due to drowning), 10% by carbon monoxide poisoning or thermal injury, and the remaining 8% involving cases of neglect, stabbing, and poisoning. The majority of the homicide victims were male (67%) and black (67%). Forty-six percent were < or =1 year of age. Approximately 25% of the homicide cases were designated as shaken baby syndrome (SBS). In 97% of the cases, the assailant was known to the victim and was a family relative in 77%. Sixty-three percent of the assailants were female and 45% of the assailants were male; in 12%, the assailants were both parents, and in 1 case, the assailant remains unknown. Of the asphyxia deaths, 87% of the assailants were female. The time interval between injury and death ranged from minutes to hours in most cases to months in cases of repeated abuse and chronic injury and sequelae. The time interval between injury and the onset of symptoms remains unknown in most cases due to inconsistencies in the history and lack of credibility of the caretaker. The most common initial history given was "a fall" (20%). We report our findings of a decade of pediatric homicides to increase awareness of the common scenarios and case histories, demographics of the victims, causes of death, and perpetrators of pediatric homicide.     

Competence to Stand Trial: A Neuropsychological Inquiry

Law and Human Behavior - How might the deconstruction of the legal theory of competence be related to modern neuropsychological models of cognition? To address this question, we examined...