John Marshall

Parties, Brokers, and Voter Mobilization: How Turnout Buying Depends Upon the Party’s Capacity to Monitor Brokers

Despite its prevalence, little is known about when parties buy turnout. We emphasize the problem of parties monitoring local brokers with incentives to shirk. Our model suggests that parties extract greater turnout buying effort from their brokers where they can better monitor broker performance and where favorable voters would not otherwise turn out. Exploiting exogenous variation in the number of polling stations—and thus electoral information about broker performance—in Mexican electoral precincts, we find that greater monitoring capacity increases turnout and votes for the National Action Party (PAN) and the Institutional Revolutionary Party (PRI). Consistent with our theoretical predictions, the effect of monitoring capacity on PRI votes varies nonlinearly with the distance of voters to the polling station: it first increases because rural voters—facing larger costs of voting—generally favor the PRI, before declining as the cost of incentivizing brokers increases. This nonlinearity is not present for the PAN, who stand to gain less from mobilizing rural voters.

Leveraging a critical care database: selective serotonin reuptake inhibitor use prior to ICU admission is associated with increased hospital mortality.

BACKGROUNDnObservational studies have found an increased risk of adverse effects such as hemorrhage, stroke, and increased mortality in patients taking selective serotonin reuptake inhibitors (SSRIs). The impact of prior use of these medications on outcomes in critically ill patients has not been previously examined. We performed a retrospective study to determine if preadmission use of SSRIs or serotonin norepinephrine reuptake inhibitors (SNRIs) is associated with mortality differences in patients admitted to the ICU.nnnMETHODSnThe retrospective study used a modifiable data mining technique applied to the publicly available Multiparameter Intelligent Monitoring in Intensive Care (MIMIC) 2.6 database. A total of 14,709 patient records, consisting of 2,471 in the SSRI/SNRI group and 12,238 control subjects, were analyzed. The study outcome was in-hospital mortality.nnnRESULTSnAfter adjustment for age, Simplified Acute Physiology Score, vasopressor use, ventilator use, and combined Elixhauser score, SSRI/SNRI use was associated with significantly increased in-hospital mortality (OR, 1.19; 95% CI, 1.02-1.40; P=.026). Among patient subgroups, risk was highest in patients with acute coronary syndrome (OR, 1.95; 95% CI, 1.21-3.13; P=.006) and patients admitted to the cardiac surgery recovery unit (OR, 1.51; 95% CI, 1.11-2.04; P=.008). Mortality appeared to vary by specific SSRI, with higher mortalities associated with higher levels of serotonin inhibition.nnnCONCLUSIONSnWe found significant increases in hospital stay mortality among those patients in the ICU taking SSRI/SNRIs prior to admission as compared with control subjects. Mortality was higher in patients receiving SSRI/SNRI agents that produce greater degrees of serotonin reuptake inhibition. The study serves to demonstrate the potential for the future application of advanced data examination techniques upon detailed (and growing) clinical databases being made available by the digitization of medicine.

Antipsychotic Use in Hospitalized Adults: Rates, Indications, and Predictors

To investigate patterns and predictors of use of antipsychotics in hospitalized adults.

Credible Sources and Sophisticated Voters: When Does New Information Induce Economic Voting?

When does new economic information cause voters to reevaluate the government’s competence and ultimately vote economically? Since politically relevant information is often conveyed by actors with incentives to influence voter perceptions, the credibility of information sources can vary significantly. This article randomly varies whether voters receive an aggregate unemployment forecast from the central bank, government or main opposition party using a survey experiment in Denmark linked to detailed panel data. We find that politically sophisticated voters discern differences in institutional credibility and the political cost of the signal and update their unemployment expectations accordingly. Despite failing to differentiate political costs, unsophisticated voters still substantially update their expectations. However, while sophisticated voters intend to engage in substantial prospective economic voting, unsophisticated voters do not relate their new unemployment expectations to their vote intention. These findings suggest that economic information supports economic voting most when it is credible and reaches sophisticated voters.

Antipsychotic utilization in the intensive care unit and in transitions of care.

PURPOSEnThe objective of this study was to quantify the rate at which newly initiated antipsychotic therapy is continued on discharge from the intensive care unit (ICU) and describe risk factors for continuation post-ICU discharge.nnnMATERIALS AND METHODSnThis is a retrospective cohort study of all patients receiving an antipsychotic in the ICUs of a large academic medical center from January 1, 2005, to October 31, 2011. Medical record review was conducted to ascertain whether a patient was newly started on antipsychotic therapy and whether therapy was continued post-ICU discharge.nnnRESULTSnA total of 39,248 ICU admissions over the 7-year period were evaluated. Of these, 4468 (11%) were exposed to antipsychotic therapy, of which 3119 (8%) were newly initiated. In the newly initiated cohort, 642 (21%) were continued on therapy on discharge from the hospital. Type of drug (use of quetiapine vs no use of quetiapine: odds ratio, 3.2; 95% confidence interval, 2.5-4.0; P < .0001 and use of olanzapine: odds ratio, 2.4, 95% confidence interval, 2.0-3.1; P ≤ .0001) was a significant risk factor for continuing antipsychotics on discharge despite adjustment for clinical factors.nnnCONCLUSIONSnAntipsychotic use is common in the ICU setting, and a significant number of newly initiated patients have therapy continued upon discharge from the hospital.

Pharmacovigilance: An Active Surveillance System to Proactively Identify Risks for Adverse Events

Postmarketing drug safety surveillance is a challenging and vital component of contemporary medical practice. Obtaining new information about the benefits and risks of a medication should not stop after market authorization, and it has become increasingly clear that the risk profile cannot be fully elucidated via the current approval process. Highly publicized postmarketing crises, including the increased cardiovascular risk with COX-2 inhibitors, heart failure with rosiglitazone, increased risk of suicide in children and adolescents taking selective serotonin reuptake inhibitors (SSRIs), and most recently, increased cardiovascular death with azithromycin, have raised awareness of the shortcomings of the the Food and Drug Administration’s (FDA’s) Adverse Event Reporting System (AERS), a database for storing and analyzing safety reports. Mining clinical databases for health outcomes provides an effective tool for mitigating these various risks, for discovering patient subpopulations that experience increased efficacy or unanticipated delayed adverse effects, and for uncovering drug interactions that typically are not examined in traditional randomized controlled trials. In this commentary, we highlight the challenges of identifying risk in the current approval process and offer steps the FDA can take to realize continuous learning and improvement as described in the Institute of Medicine’s recent report on achieving best care at lower cost. We believe the FDA can foster new cross-disciplinary partnerships that leverage the growing amount of electronic clinical data to design an early-warning system that targets risks associated with the areas generating the most costs. A new active surveillance system can be used not simply to identify contraindications but to educate the medical community on real risks and to target subpopulations of patients for whom certain drugs are more beneficial or more harmful. Examination of a drug’s postapproval risk profile began in 1952 when the FDA instituted voluntary reporting of adverse events pursuant to bone marrow suppression seen with chloramphenicol. Little changed with the process until 1993, when the FDA instituted MedWatch, a program for both health care professionals and the public to report adverse effects of drugs and medical devices. AERS, a database used to compile and analyze adverse events and medication error reports, was introduced in 1998. To this point, many of the methods to evaluate postapproval drug safety surveillance were dependent on the voluntary reporting of adverse events by health care practitioners, patients, and companies. This changed in September 2007 with the Food and Drug Administration Amendments Act, which gave the FDA the authority to compel manufacturers to conduct postapproval safety studies, and formalized the Risk Evaluation and Mitigation Strategies program. The most recent initiative undertaken by the FDA, Sentinel, seeks to identify safety concerns more proactively through the use of administrative claims and pharmacy dispensing data, expanding in the future to include inpatient electronic health records and registries. A medication that is studied in 5–10 thousand patients in a controlled environment may not identify rare adverse reactions, and is likely to underrepresent the myriad variables (age, comorbidities, other medications, clinical context) that the larger population who may be exposed to the drug will have, potentially interacting with the drug and with each other. Many times, these unaccounted variables play a considerable role in the side effect profile of a given medication, and thus may alter the risk-benefit of a given pharmaceutical. Additionally, it is increasingly difficult to determine causality in patients who have multiple chronic disease states, as clinicians may ascribe the adverse drug reaction to the patient’s other conditions when that is not necessarily the case. Lastly, the risk rate of adverse drug reactions often changes with increased exposure. An adverse reaction that is seen rarely during a 6-month clinical trial may, in fact, be drastically increased when patients are exposed for a more extended period of time. All of these examples represent areas in which a more informed and systematic approach to postapproval drug evaluation may yield earlier identification of medication risk and subsequent intervention to ensure the balance of risks and benefits to using the medication is maintained. In the Sentinel initiative, the FDA is making strides in achieving a nationwide rapid-response electronic surveillance system. The FDA announced in June 2012 that the Mini-Sentinel pilot program had exceeded expectations by providing secure access to data of approximately 126 million patients across 17 data partners. Signals detected through AERS prompt the FDA to formulate safety questions for investigation by the data partners. The resulting data

Compensation or Constraint? How Different Dimensions of Economic Globalization Affect Government Spending and Electoral Turnout

This paper extends theoretical arguments regarding the impact of economic globalization on policy-making to electoral turnout and considers how distinct dimensions of globalization may produce different effects. We theorize that constraints on government policy that reduce incentives to vote are more likely to be induced by foreign ownership of capital, while compensation through increased government spending is more likely—if at all—to be the product of structural shifts in production associated with international trade. Using data from twenty-three OECD countries, 1970-2007, we find strong support for the ownership-constraint hypothesis where foreign ownership reduces turnout, both directly and—in strict opposition to the compensation hypothesis—indirectly by reducing government spending (and thus the importance of politics). Our estimates suggest that increased foreign ownership, especially the most mobile capital flows, can explain up to two-thirds of the large declines in turnout over recent decades.

Extension for Community Healthcare Outcomes—Care Transitions: Enhancing Geriatric Care Transitions Through a Multidisciplinary Videoconference

To examine whether a novel videoconference that connects an interdisciplinary hospital‐based team with clinicians at postacute care sites improves interprofessional communication and reduces medication errors.

Education and Voting Conservative: Evidence from a Major Schooling Reform in Great Britain

High school education is central to adolescent socialization and has important downstream consequences for adult life. However, scholars examining schooling’s political effects have struggled to reconcile education’s correlation with both more liberal social attitudes and greater income. To disentangle this relationship, I exploit a major school leaving age reform in Great Britain that caused almost half the population to remain at high school for at least an additional year. Using a fuzzy regression discontinuity design, I find that each additional year of late high school increases the probability of voting Conservative in later life by 12 percentage points. A similar relationship holds when pooling all cohorts, suggesting that high school education is a key determinant of voting behavior and that the reform could have significantly altered electoral outcomes. I provide evidence suggesting that, by increasing an individual’s income, education increases support for right-wing economic policies and, ultimately, the Conservative Party.