This article attempts to consolidate theorizing about the radicalization of Western homegrown jihadists. Five major models of radicalization are reviewed. The commonalities and discrepancies among ...these models are identified and analyzed in the context of empirical evidence in the field of terrorism research and social psychology. Three psychological factors emerge as contributors to radicalization: group relative deprivation, identity conflicts, and personality characteristics. Avenues for future research concerning the radicalization of homegrown jihadists are suggested, focusing on research that may not only be practical for counter-terrorism, but also feasible given the challenges of research with radicalized individuals.
Our study estimates the sensitivity and specificity of Medicare claims to identify clinically-diagnosed dementia, and documents how errors in dementia assessment affect dementia cost estimates. We ...compared Medicare claims from 1993-2005 to clinical dementia assessments carried out in 2001-2003 for the Aging Demographics and Memory Study (ADAMS) cohort (n = 758) of the Health and Retirement Study. The sensitivity and specificity of Medicare claims was 0.85 and 0.89 for dementia (0.64 and 0.95 for AD). Persons with dementia cost the Medicare program (in 2003) $7,135 more than controls (P < 0.001) when using claims to identify dementia, compared to $5,684 more when using ADAMS (P < 0.001). Using Medicare claims to identify dementia results in a 110% increase in costs for those with dementia as compared to a 68% increase when using ADAMS to identify disease, net of other variables. Persons with false positive Medicare claims notations of dementia were the most expensive group of subjects ($11,294 versus $4,065, for true negatives P < 0.001). Medicare claims overcount the true prevalence of dementia, but there are both false positive and negative assessments of disease. The use of Medicare claims to identify dementia results in an overstatement of the increase in Medicare costs that are due to dementia.
Advanced heart failure (HF) is characterized by high morbidity and mortality. Conventional therapy may not sufficiently reduce patient suffering and maximize quality of life.
The authors investigated ...whether an interdisciplinary palliative care intervention in addition to evidence-based HF care improves certain outcomes.
The authors randomized 150 patients with advanced HF between August 15, 2012, and June 25, 2015, to usual care (UC) (n = 75) or UC plus a palliative care intervention (UC + PAL) (n = 75) at a single center. Primary endpoints were 2 quality-of-life measurements, the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary and the Functional Assessment of Chronic Illness Therapy-Palliative Care scale (FACIT-Pal), assessed at 6 months. Secondary endpoints included assessments of depression and anxiety (measured via the Hospital Anxiety and Depression Scale HADS), spiritual well-being (measured via the FACIT-Spiritual Well-Being scale FACIT-Sp), hospitalizations, and mortality.
Patients randomized to UC + PAL versus UC alone had clinically significant incremental improvement in KCCQ and FACIT-Pal scores from randomization to 6 months (KCCQ difference = 9.49 points, 95% confidence interval CI: 0.94 to 18.05, p = 0.030; FACIT-Pal difference = 11.77 points, 95% CI: 0.84 to 22.71, p = 0.035). Depression improved in UC + PAL patients (HADS-depression difference = -1.94 points; p = 0.020) versus UC-alone patients, with similar findings for anxiety (HADS-anxiety difference = -1.83 points; p = 0.048). Spiritual well-being was improved in UC + PAL versus UC-alone patients (FACIT-Sp difference = 3.98 points; p = 0.027). Randomization to UC + PAL did not affect rehospitalization or mortality.
An interdisciplinary palliative care intervention in advanced HF patients showed consistently greater benefits in quality of life, anxiety, depression, and spiritual well-being compared with UC alone. (Palliative Care in Heart Failure PAL-HF; NCT01589601).
Learning Objectives
Describe the experiences of insured cancer patients requesting copayment assistance in order to better understand the challenges of underinsurance.
Describe the impact of costs on ...the well being of insured cancer patients.
Evaluate the impact of costs on the treatment received by insured cancer patients.
Purpose.
Cancer patients carry rising burdens of health care‐related out‐of‐pocket expenses, and a growing number of patients are considered “underinsured.” Our objective was to describe experiences of insured cancer patients requesting copayment assistance and to describe the impact of health care expenses on well‐being and treatment.
Methods.
We conducted baseline and follow‐up surveys regarding the impact of health care costs on well‐being and treatment among cancer patients who contacted a national copayment assistance foundation along with a comparison sample of patients treated at an academic medical center.
Results.
Among 254 participants, 75% applied for drug copayment assistance. Forty‐two percent of participants reported a significant or catastrophic subjective financial burden; 68% cut back on leisure activities, 46% reduced spending on food and clothing, and 46% used savings to defray out‐of‐pocket expenses. To save money, 20% took less than the prescribed amount of medication, 19% partially filled prescriptions, and 24% avoided filling prescriptions altogether. Copayment assistance applicants were more likely than nonapplicants to employ at least one of these strategies to defray costs (98% vs. 78%). In an adjusted analysis, younger age, larger household size, applying for copayment assistance, and communicating with physicians about costs were associated with greater subjective financial burden.
Conclusion.
Insured patients undergoing cancer treatment and seeking copayment assistance experience considerable subjective financial burden, and they may alter their care to defray out‐of‐pocket expenses. Health insurance does not eliminate financial distress or health disparities among cancer patients. Future research should investigate coverage thresholds that minimize adverse financial outcomes and identify cancer patients at greatest risk for financial toxicity.
The experiences of insured cancer patients requesting copayment assistance and the impact of health care expenses on well‐being and treatment are examined. Insured patients undergoing cancer treatment and seeking copayment assistance were found to experience considerable subjective financial burden and were found to alter care to defray out‐of‐pocket expenses.
Knowing oneself and experiencing oneself as clearly defined has been linked to positive self-esteem and psychological well-being; however, this association has been tested only at the level of ...personal identity. The authors propose that a clear cultural identity provides the individual with a clear prototype with which to engage the processes necessary to construct a clear personal identity and, by extension, to achieve self-esteem and well-being. For samples of undergraduate students, Anglophone Quebecers, Francophone Québécois, Chinese North Americans, and Aboriginal Canadians, cultural identity clarity was positively related to self-concept clarity, self-esteem, and markers of subjective well-being. The relationship between cultural identity clarity and both self-esteem and well-being was consistently mediated by self-concept clarity. Interventions designed to clarify cultural identity might have psychological benefits for individuals facing cultural identity challenges.
Abstract Background Historically, palliative care has been focused on those with cancer. While these ties persist, palliative care is rapidly integrating into the care of patients with common, ...non-cancer serious illnesses. Despite this, the bulk of literature informing palliative care practices stems from the care of cancer patients. Objectives We compared functionality, advanced care planning, hospital admissions, prognosis, quality of life, pain, dyspnea, fatigue, and depression between patients with cancer and three non-cancer diagnoses--end stage renal disease (ESRD), heart failure (HF), and chronic obstructive pulmonary disease (COPD). Methods We conducted a cross-sectional, retrospective analysis of the characteristics and symptoms of patient’s with ESRD, HF, COPD and cancer at time of first specialty palliative care referral. Using a web based point of care quality assessment and reporting tool, Quality Data and Collection Tool-Palliative care (QDACT-PC), this analysis evaluated all eligible patients who received a palliative care consultation between October 1, 2012 and November 25, 2014. Data was obtained from 13 participating sites. The primary outcome for the study was functionality using the palliative performance scale. Hospital admission in the last 30 days, prognosis, patient’s understanding of prognosis, advanced care planning including code status and appointed decision maker, pain, fatigue, depression and dyspnea were also evaluated as secondary outcomes. We tested for an association between our outcomes with disease type (cancer vs. non-cancer) fitting multivariable logistic regression models. Results We found that the patients with primary diagnoses other than cancer were less functional at time of referral (OR: 1.6; 95%CI: 1.1, 2.3; p<0.05). Conclusion Patients with COPD, ESRD and HF were less functional and more likely to be hospitalized at time of referral to palliative care than cancer patients. These findings may be reflective of the slower and more varied trajectory of non-cancer serious illness. One aim of palliative care for those with non-cancer severe illness should be directed towards improving and assisting with functionality and decreasing frequency of hospital admissions. These interventions could take place in the palliative care office, but could also be integrated into hospital discharge plans.
For patients with limited prognosis, some medication risks may outweigh the benefits, particularly when benefits take years to accrue; statins are one example. Data are lacking regarding the risks ...and benefits of discontinuing statin therapy for patients with limited life expectancy.
To evaluate the safety, clinical, and cost impact of discontinuing statin medications for patients in the palliative care setting.
This was a multicenter, parallel-group, unblinded, pragmatic clinical trial. Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease. Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year. The study was conducted from June 3, 2011, to May 2, 2013. All analyses were performed using an intent-to-treat approach.
Statin therapy was withdrawn from eligible patients who were randomized to the discontinuation group. Patients in the continuation group continued to receive statins.
Outcomes included death within 60 days (primary outcome), survival, cardiovascular events, performance status, quality of life (QOL), symptoms, number of nonstatin medications, and cost savings.
A total of 381 patients were enrolled; 189 of these were randomized to discontinue statins, and 192 were randomized to continue therapy. Mean (SD) age was 74.1 (11.6) years, 22.0% of the participants were cognitively impaired, and 48.8% had cancer. The proportion of participants in the discontinuation vs continuation groups who died within 60 days was not significantly different (23.8% vs 20.3%; 90% CI, -3.5% to 10.5%; P=.36) and did not meet the noninferiority end point. Total QOL was better for the group discontinuing statin therapy (mean McGill QOL score, 7.11 vs 6.85; P=.04). Few participants experienced cardiovascular events (13 in the discontinuation group vs 11 in the continuation group). Mean cost savings were $3.37 per day and $716 per patient.
This pragmatic trial suggests that stopping statin medication therapy is safe and may be associated with benefits including improved QOL, use of fewer nonstatin medications, and a corresponding reduction in medication costs. Thoughtful patient-provider discussions regarding the uncertain benefit and potential decrement in QOL associated with statin continuation in this setting are warranted.
clinicaltrials.gov Identifier: NCT01415934.
OBJECTIVES
To assess trends and factors associated with place of death among individuals with Alzheimer's disease‐related dementias (ADRD).
DESIGN
Cross‐sectional analysis.
SETTING
Centers for ...Disease Control and Prevention Wide‐ranging OnLine Data for Epidemiologic Research, 2003‐2017.
PARTICIPANTS
Natural deaths occurring between 2003 and 2017 for which ADRD was determined to be the underlying cause.
MEASUREMENTS
Place of death was categorized as hospital, home, nursing facility, hospice facility, and other. Aggregate data included age, race, Hispanic ethnicity, sex, urbanization, and census division. Individual‐level predictors included age, race, Hispanic ethnicity, sex, marital status, and education.
RESULTS
From 2003 to 2017, nursing facility and hospital deaths declined from 65.7% and 12.7% to 55.0% and 8.0% while home and hospice facility deaths increased from 13.6% and .2% to 21.9% and 6.2%, respectively. Odds of hospital and hospice facility deaths declined with age while odds of nursing facility deaths increased with age. Male sex was associated with higher odds of hospital or hospice facility death and lower odds of home or nursing facility death. Nonwhite race, Hispanic ethnicity, and being married were associated with increased odds of hospital or home death and reduced odds of nursing facility death. More education was associated with higher odds of home or in a hospice facility death and reduced odds of death in a nursing facility or hospital. Significant disparities in place of death by urban‐rural status were also noted.
CONCLUSION
As ADRD deaths at home increase, the need for caregiver support and home‐based palliative care may become more critical. Further research should examine the care preferences and experiences of ADRD patients and caregivers, the financial impact of home death on families and insurers, and explore factors that may contribute to differences in actual and preferred place of death. J Am Geriatr Soc 68:250–255, 2020
See related editorial by Oh et al.
This panel paper is the third installment in a six-part Nursing Outlook special edition based on the 2022 Emory Business Case for Nursing Summit. The 2022 summit was led by Emory School of Nursing in ...partnership with Emory School of Business. It convened national nursing, health care, and business leaders to explore possible solutions to nursing workforce crises, including the nursing shortage. Each of the summit’s four panels authored a paper in this special edition on their respective topic(s). This panel paper focuses on strategies to optimally distribute nursing talent in rural and underserved areas. It discusses the role of nursing talent distribution in ensuring equity in access to care for U.S. populations. Topics covered include the need for expanded and standardized advanced practice registered nurse (APRN) scope of practice, an expanded nurse licensure compact, reimbursement reforms, and competitive nursing salaries.
•Written by panelists from the 2022 Emory Business Case for Nursing Summit.•Discusses factors undermining effective national distribution of nursing talent.•Proposes strategies for improving nursing distribution nationally.•Establish standardized APRN practice authority and national licensure compacts.•Implement measures to increase equity in nursing reimbursement and pay.
Hospices have been expected to reduce health expenditures since their addition to the US Medicare benefit package in the early-1980s, but the literature on their ability to do so is mixed. The ...contradictory findings noted in previous studies may be due to selection bias and the period of cost comparison used. Accounting for these, this study focuses on the length of hospice use that maximizes reductions in medical expenditures near death. We used a retrospective, case/control study of Medicare decedents (1993–2003, National Long Term Care Survey screening sample) to compare 1819 hospice decedents, with 3638 controls matched via their predicted likelihood of dying while using a hospice. Variables used to create matches were demographic, primary medical condition, cost of Medicare financed care prior to the last year of life, nursing home residence and Medicaid eligibility.
Hospice use reduced Medicare program expenditures during the last year of life by an average of $2309 per hospice user; expenditures after initiation of hospice were $7318 for hospice users compared to $9627 for controls (
P<0.001). On average, hospice use reduced Medicare expenditures during all but 2 of hospice users’ last 72 days of life; about $10 on the 72nd day prior to death, with savings increasing to more than $750 on the day of death. Maximum cumulative expenditure reductions differed by primary condition. The maximum reduction in Medicare expenditures per user was about $7000, which occurred when a decedent had a primary condition of cancer and used a hospice for their last 58–103 days of life. For other primary conditions, the maximum savings of around $3500 occurred when a hospice was used for the last 50–108 days of life. Given the length of hospice use observed in the Medicare program, increasing the length of hospice use for 7 in 10 Medicare hospice users would increase savings.
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