Mark Schlesinger

Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care.

Delirium, or acute confusional state, which often results from hospital-related complications or inadequate hospital care for older patients, can serve as a marker of the quality of hospital care. By reviewing five pathways that can lead to a greater incidence of delirium--iatrogenesis, failure to recognize delirium in its early stages, attitudes toward the care of the elderly, the rapid pace and technological focus of health care, and the reduction in skilled nursing staff--we identify how future trends and cost-containment practices may exacerbate the problem. Examining delirium also provides an opportunity to improve the quality of hospital care for older persons. Interventions to reduce delirium would need to occur at the local and national levels. Local strategies would include routine cognitive assessment and the creation of systems to enhance geriatric care, such as incentives to change practice patterns, geriatric expertise, case management, and clinical pathways. National strategies might include providing education for physicians and nurses to improve the recognition of delirium and the awareness of its clinical implications, improving quality monitoring systems for delirium, and creating environments to facilitate the provision of high-quality geriatric care.

Management of mental health and substance abuse services: state of the art and early results

Managed care (MC) refers to capitated practice (HMOs), utilization management (UM), and programs of case management for persons with mental illness and problems of substance abuse. These approaches differ substantially, and within each type are variations. Management of mental health and substance abuse services is increasingly prevalent, often sharply reducing costs. Savings result from reducing inpatient hospitalization and, sometimes, by substituting less expensive services for more costly ones. Most studies of managed care, however, measure costs narrowly, neglecting shifts in costs to patients, professionals, families, and the larger community. Strategies typical of HMOs and UM may result in lower-quality care for persons with serious mental illness and problems of substance abuse. Studies on this topic are reviewed, an analytic frame of reference is presented, and research needs are defined.

Insecure Alliances: Risk, inequality, and support for the Welfare State

Popular support for the welfare state varies greatly across nations and policy domains. We argue that these variations—vital to understanding the politics of the welfare state—reflect in part the degree to which economic disadvantage (low income) and economic insecurity (high risk) are correlated. When the disadvantaged and insecure are mostly one and the same, the base of popular support for the welfare state is narrow. When the disadvantaged and insecure represent two distinct groups, popular support is broader and opinion less polarized. We test these predictions both across nations within a single policy area (unemployment insurance) and across policy domains within a single polity (the United States, using a new survey). Results are consistent with our predictions and are robust to myriad controls and specifications. When disadvantage and insecurity are more correlated, the welfare state is more contested.

On the Limits of Expanding Health Care Reform: Chronic Care in Prepaid Settings

Health Maintenance Organizations have become a favored vehicle for reform of the American health care system, while controlling costs and assuring quality. But for populations with a high prevalence of chronic disease--the elderly or the mentally ill--HMOs may fall short of meeting needs. Three stages of reform are proposed for adapting the principle of prepayment to better serve enrollees with chronic illness.

Gender Gap or Gender Gaps? New Perspectives on Support for Government Action and Policies

This paper clarifies the theoretical bases for expecting women to be more supportive of government programs than are men. We identify several factors not developed in past literature: (1) differences in emotional responses to social problems, (2) gendered differences in the awareness of those problems among ones own kin, (3) differences in the perceived fairness of existing social institutions, (4) differences in the perceived efficacy of government programs, and (5) variations in the preferred form that those programs should take. Testing hypotheses using data from a 1995 survey of public opinion covering five policy domains, we find that the gender gap in these domains is substantial, comparable to that associated with race and partisanship. These differences are attributable in part to factors identified previously in the literature-such as gendered differences in perceived opportunity-but are also affected by differences between men and women in the perceived efficacy of government programs (e.g., the extent of fraud and abuse) and differences in the preferred form those programs should take.

Racial and ethnic differences in the use of high-volume hospitals and surgeons.

OBJECTIVE To examine racial/ethnic differences in the use of high-volume hospitals and surgeons for 10 surgical procedures with documented associations between volume and mortality. DESIGN Cross-sectional regression analysis. SETTING New York City area hospital discharge data, 2001-2004. PATIENTS Adults from 4 racial/ethnic categories (white, black, Asian, and Hispanic) who underwent surgery for cancer (breast, colorectal, gastric, lung, or pancreatic resection), cardiovascular disease (coronary artery bypass graft, coronary angioplasty, abdominal aortic aneurysm repair, or carotid endarterectomy), or orthopedic conditions (total hip replacement). MAIN OUTCOME MEASURE Treatment by a high-volume surgeon at a high-volume hospital. RESULTS There were 133 821 patients who underwent 1 of the 10 procedures. For 9 of the 10 procedures, black patients were significantly (P < .05) less likely (after adjustment for sociodemographic characteristics, insurance type, proximity to high-volume providers, and comorbidities) to be operated on by a high-volume surgeon at a high-volume hospital and more likely to be operated on by a low-volume surgeon at a low-volume hospital. Asian and Hispanic patients, respectively, were significantly less likely to use high-volume surgeons at high-volume hospitals for 5 and 4 of the 10 procedures and more likely to use low-volume surgeons at low-volume hospitals for 3 and 5 of the 10 procedures. CONCLUSIONS Minority patients in New York City are doubly disadvantaged in their surgical care; they are substantially less likely to use both high-volume hospitals and surgeons for procedures with an established volume-mortality association. Better information is needed about which providers minority patients have access to and how they select them.

Trust, repute and the role of non-profit enterprise

This article examines the trust hypothesis: the claim that asymmetric information can explain the existence of non-profit enterprise in certain markets. We argue that this hypothesis, in order to be viable, has to meet three challenges: ‘reputational ubiquity’, ‘incentive compatibility’ and ‘adulteration’. Drawing on modern agency theory, we conclude that the trust hypothesis stands on shaky ground. It can be sustained only under particular conditions that have been neither carefully described in theory nor subject to empirical assessment. The available evidence, patchy and inadequate as it is, seems to suggests that there are some ownership-related differences in aspects of organisational performance connected with asymmetric information. However, there is little evidence that this relates to trustper se or provides a rationale for the existence of non-profit ownership in these industries. We conclude with a plea for substantial research on consumer expectations and provider motivations.

Translating Research into Clinical Practice: Making Change Happen

To describe the process of adoption of an evidence‐based, multifaceted, innovative program into the hospital setting, with particular attention to issues that promoted or impeded its implementation. This study examined common challenges faced by hospitals implementing the Hospital Elder Life Program (HELP) and strategies used to address these challenges.

The Meaning and Measure of Policy Metaphors

The apparent ability of the American public to form coherent assessments of policy options—while being largely ignorant of political institutions, actors, and ideology—remains a persistent puzzle for political science. We develop a theory of political decision making that helps resolve this puzzle. We postulate that both the public and political elites comprehend complex policies in part through “reasoning by policy metaphor,” which involves comparisons between proposed alternative policies and more readily understood social institutions. Using data from 169 intensive interviews, we test claims about metaphorical reasoning for a particularly complex policy domain: health care reform. We demonstrate that our hypothesized policy metaphors are coherent to both elites and the general public, including the least sophisticated members of the public. We further show that elites and the public share a common understanding of the relevant policy metaphors, that metaphorical reasoning differs from other forms of analogic reasoning, and that metaphorical cognition is distinct from ideological orientation.

The flip-side of social capital: The distinctive influences of trust and mistrust on health in rural China

Despite increasing evidence that social capital is positively associated with health, the pathways that link social capital to health are not definitive and invite further investigation. This paper uses household survey data from 22 villages in China in 2002 to test the relationship between social capital and the self-reported health status of the rural population. Focusing on the cognitive dimension of social capital, this paper complements current social capital research by introducing an overlooked distinction between trust and mistrust. Trust and mistrust are measured at the individual and aggregate levels, and the distinct ways in which they affect general and mental health are explored. We adopt an ordered logistic regression using survey procedures in SAS version 9.1 to account for the stratified and clustered data structure. The results suggest that: (1) individual-level trust and mistrust are both associated with self-reported health in rural China--trust is positively associated with both general health and mental health, while mistrust is more powerfully associated with worse mental health; and (2) the effects of individual-level trust and mistrust are dependent on village context--village-level trust substitutes for individual-level trust, while individual-level mistrust interacts positively with village-level mistrust to affect health. However, an unexpected protective health effect of mistrust is found in certain types of villages, and this unique result has yet to be examined. Overall, this study suggests the conceptual difference between trust and mistrust and the differential mechanisms by which trust and mistrust affect health in rural China. It also suggests that effective policies should aim at enhancing trust collectively or reducing mistrust at the personal level to improve health status in rural areas of China.