Racialized Risk in Clinical Care: Clinician Vigilance and Patient Responsibility

Racial/ethnic identity is contingent and arbitrary, yet it is commonly used to evaluate disease risk and treatment response. Drawing on open-ended interviews with patients and clinicians in two US clinics, we explore how racialized risk is conceptualized and how it impacts patient care and experience. We found that racial/ethnic risk was a common but poorly defined construct for both patients and clinicians, who intermingled concepts of genetics, biology, behavior, and culture, while disregarding historical or structural context. We argue that racializing risk embodies social power in marked and unmarked bodies, reinforcing inequality along racial lines and undermining equitable health care.     

Disease-Modifying Therapy Adherence and Associated Factors in a National Sample of Medicare Patients With Multiple Sclerosis

ObjectivesDisease-modifying therapies (DMTs) reduce relapse rates and disability progression for relapsing multiple sclerosis (MS). Although 25% to 30% of all US patients with MS are Medicare beneficiaries, limited information exists on this population. This is the first study using national Medicare data to (1) describe characteristics of patients with MS using DMTs, (2) estimate adherence to DMTs over a 1-year and 3-year follow-up, and (3) examine factors associated with DMT adherence.MethodsThis retrospective claims analysis used 2011-2014 100% Medicare files. Monthly adherence to MS DMTs was defined as the proportion of days covered ≥0.80 with any DMT in each month for 1-year (n = 36 593) and 3-year (n = 17 599) follow-up samples of MS DMT users. Generalized estimating equation logistic regressions were used to estimate factors associated with adherence to DMTs.ResultsOver 90% of patients were eligible for Medicare owing to disability, and about three-quarters qualified for low-income subsidies. A downward trend in DMT adherence was observed over time in both samples. Monthly adherence dropped significantly between December of the prior year to January of the following year (from 76% to 65% in the 1-year follow-up sample and similar drops seen across all years in the 3-year follow-up sample). Multivariable regressions indicated characteristics such as being low-income, having a disability, and having high patient out-of-pocket DMT costs associated with poor adherence to DMTs.ConclusionOur study provides important insights into the characteristics and DMT adherence of Medicare patients with MS and highlights the need for interventions and policies mitigating barriers to adherence in this population.     

Appropriateness of End-of-Life Care in People Dying With Dementia: Applying Quality Indicators on Linked Administrative Databases

ObjectivesDementia is a progressive incurable life-limiting illness. Previous research suggests end-of-life care for people with dementia should have a symptomatic focus with an effort to avoid burdensome interventions that would not improve quality of life. This study aims to assess the appropriateness of end-of-life care in people who died with dementia in Belgium and to establish relative performance standards by measuring validated population-level quality indicators.DesignWe conducted a retrospective observational study.Setting and ParticipantsWe included all persons deceased with dementia in 2015 in Belgium. Data from 8 administratively collected population-level databases was linked.MeasuresWe used a validated set of 28 quality indicators for end-of-life dementia care. We compared quality indicator scores across 14 healthcare regions to establish relative benchmarks.ResultsIn Belgium in 2015, 10,629 people died with dementia. For indicators of appropriate end-of-life care, people who died with dementia had on average 1.83 contacts with their family physician in the last week before death, whereas 68.4% died at home or in their nursing home of residence. For indicators of inappropriate end-of-life care, 32.4% were admitted to the hospital and 36.3% underwent diagnostic testing in the last 30 days before death, whereas 25.1% died in the hospital. In the last 30 days, emergency department admission varied between 19% and 31%, dispensing of gastric protectors between 18% and 42%, and antihypertensives between 40% and 53% between healthcare regions, with at least 25% of health regions below 46%.Conclusions and ImplicationsOur study found indications of appropriate as well as inappropriate end-of-life care in people with dementia, including high rates of family physician contact, as well as high percentages of diagnostic testing, and emergency department and hospital admissions. We also found high risk-adjusted variation for multiple quality indicators, indicating opportunity for quality improvement in end-of-life dementia care.     

Sentencing Offenders with Foetal Alcohol Spectrum Disorder (FASD): The Challenge of Effective Management

The criminal justice system in Australia is increasingly being required to deal with offenders exhibiting the symptomatology of Foetal Alcohol Spectrum Disorder (FASD). Disproportionately they are indigenous. Diagnosis of the disorder is challenging and too frequently still not being made accurately. More challenging still is responding to it in the forensic system so that options for provision of suitable support are availed of, and thereby the risk of ongoing offending which puts the community at risk is minimised. This paper reviews the creative and compassionate judgment of the Western Australian Court of Appeal in Churnside v The State of Western Australia [2016] WASCA 146. It argues that the decision constitutes a model for the efforts that can and should be made by sentencing judges and magistrates required to deal with recidivist offenders with FASD.     

Choice of ICD‐10 codes for the identification of acute coronary syndrome in the French hospitalization database

The objective of this study was to evaluate the performance of the ICD‐10 (International Classification of Diseases and Related Health Problems, 10^th Edition) coding in the French hospitalization database (PMSI) to identify acute coronary syndrome (ACS) occurrence. Eligible hospitalizations were those that occurred at the Bordeaux teaching hospitals between 1 January 2011 and 31 December 2011 and had one of the ICD‐10 codes related to ischaemic heart diseases (I20 to I25, excluding I23 and I25.2). Among these, 100 hospitalizations were randomly selected; for each case, the ACS diagnosis was confirmed/excluded after medical file examination by an independent events validation committee and the performance of codes, and combinations of codes, to identify ACS was evaluated by calculating the positive predictive value (PPV). Of the individual codes, I20.0, I21 and I24 had the highest PPV; 100.0% for I24 (95%CI [15.8–100.0]); 90.0% for I21 (95%CI [76.3–97.2]); and 66.7% for I20.0 (95%CI [38.4–88.2]). The combination of I20.0 or I24 codes was able to identify 12 of the 56 validated ACS cases with a PPV of 70.6% (95%CI [44.0–89.7]), the combination of I21 or I24 identified 38 cases with a PPV of 90.5% (95%CI [77.4–97.3]), the combination of I20.0 or I21 identified 46 cases with a PPV of 83.6% (95%CI [71.2–92.2]), and the combination of I20.0, I21 or I24 identified 48 cases with a PPV of 84.2% (95%CI [72.1–92.5]). The combination of I20.0, I21 or I24 codes had the best performance to identify occurrence of ACS in the French hospitalization database.     

Responsabilidad social corporativa en los centros de la red hospitalaria de utilización pública de Cataluña

The adoption of a management approach that integrates corporate social responsibility in organizations is an increasing trend that responds to the demands of society related to sustainability, ethics and transparency. Health organizations are adopting corporate social responsibility asymmetrically, which raises the analysis of the implementation models and the developed initiatives. Through qualitative research, with four in-depth case studies of the Catalan health sector, this article analyzes the need to address this new approach and to identify good practices and the challenges for its implementation.     

Du parricide rêvé à l’infanticide réel,ou l’expertise mentale dans tous ses états

The authors describe at length the case of a 33-year-old woman who shot and killed her 9-year-old daughter and attempted suicide immediately afterwards. The judicial inquiry revealed that this infanticidal mother originally intended to kill her own father, who she accused of having sexually abused her in her own childhood and now her daughter, but that unforeseen circumstances changed the mode of operation. She was the subject of seven more or less contradictory psychiatric experts opinions over a period of more than three years before finally being found criminally irresponsible by the court of assizes. She was suffering from delusional psychotic mental disorders at the time of the homicide-suicide. The authors discuss and criticize the conclusions of the experts opinions and instead recommend a multidisciplinary criminological analysis that takes all the objective ans subjective aspects on the case into account.