The association between clinical integration of care and transfer of veterans with acute coronary syndromes from primary care VHA hospitals

BACKGROUND: Few studies report on the effect of organizational factors facilitating transfer between primary and tertiary care hospitals either within an integrated health care system or outside it. In this paper, we report on the relationship between degree of clinical integration of cardiology services and transfer rates of acute coronary syndrome (ACS) patients from primary to tertiary hospitals within and outside the Veterans Health Administration (VHA) system. METHODS: Prospective cohort study. Transfer rates were obtained for all patients with ACS diagnoses admitted to 12 primary VHA hospitals between 1998 and 1999. Binary variables measuring clinical integration were constructed for each primary VHA hospital reflecting: presence of on-site VHA cardiologist; referral coordinator at the associated tertiary VHA hospital; and/or referral coordinator at the primary VHA hospital. We assessed the association between the integration variables and overall transfer from primary to tertiary hospitals, using random effects logistic regression, controlling for clustering at two levels and adjusting for patient characteristics. RESULTS: Three of twelve hospitals had a VHA cardiologist on site, six had a referral coordinator at the tertiary VHA hospital, and four had a referral coordinator at the primary hospital. Presence of a VHA staff cardiologist on site and a referral coordinator at the tertiary VHA hospital decreased the likelihood of any transfer (OR 0.45, 95% CI 0.27–0.77, and 0.46, p = 0.002, CI 0.27–0.78). Conversely, having a referral coordinator at the primary VHA hospital increased the likelihood of transfer (OR 6.28, CI 2.92–13.48). CONCLUSIONS: Elements of clinical integration are associated with transfer, an important process in the care of ACS patients. In promoting optimal patient care, clinical integration factors should be considered in addition to patient characteristics

Parallels, prescience and the past: analogical reasoning and contemporary international politics

Analogical reasoning has held a perpetual appeal to policymakers who have often drafted in historical metaphor as a mode of informing decision-making. However, this article contends that since the beginning of the ‘War on Terror’ we have arguably seen the rise of a more potent form of analogy, namely ones that are selected because they fulfil an ideological function. Analogical reasoning as a tool of rational decision-making has increasingly become replaced by analogical reasoning as a tool of trenchant ideologically-informed policy justification. This article addresses three key areas which map out the importance of analogical reasoning to an understanding of developments in contemporary international politics: the relationship between history and politics, in intellectual and policy terms; a critical assessment of the appeal that analogical reasoning holds for policymakers; and the development of a rationale for a more effective use of history in international public policymaking

Democracy transfigured:The dawn of the ‘umpire state’

In the previous chapter, I focussed on the state. However, answering the question on how modern security technology impacts on our liberal democracies requires a look at actors other than the state as well – actors that are per definition non-state actors but who, in some regard, act like quasi-state actors. In this chapter, I assess these private actors in a critical perspective to see how they influence our daily lives. My main argument, following James Madison, is that ‘the state’ as such is running the risk of being reduced to an ‘umpire state’ in the shape of a political actor who, as a primus inter pares (first among equals) mediates conflicts between private actors in the shape of powerful corporations but is no longer able to control their ‘quasi-feudal’ domains. But, since our ability to predict the future arguably is quite limited, I end this chapter with a couple of thought-provoking questions: could it be that this fear of many ‘Big Brothers’ instead of just one is as overblown as the fear of terrorism?</p

Surveillance and observation:The all-seeing eyes of big brother

As the marauding attacks of Mumbai and Paris or the various recent vehicle attacks in Nice, Berlin, London and Barcelona demonstrate, many terrorists select ‘soft targets’ in the shape of unprotected locations where a crowd usually can be expected. But even if they are bound for hard targets, terrorists are likely to move through public space. In order to heighten the security of such public spaces as well, and in order to prevent an impending attack from taking place, surveillance and observation devices could serve as an early-warning system enabling us to initiate counter-measures. Currently, CCTV systems as well as ‘Smart’ CCTV systems offer us this opportunity – which is why in this chapter, I discuss the advantages and disadvantages of such systems, to then take a critical look at Augmented Reality (Mixed Reality) as an up-and-coming tool in the fight against terrorism (and criminality in general). Some Chinese police forces for example already make use of ‘smart glasses’ in order to identify suspects just by looking at them. I conclude this chapter with some critical remarks on this ‘Minority Report’-style policing of the (near) future.</p

The quest for silver bullets:Implications for our construction of citizenship

In this first chapter of the book’s third part, I set the scene by discussing our conception and construction of citizenship. My core argument here is that new technologies, especially security-related technologies, change our view of what it means to be a citizen. In particular, I draw on the ‘Agency of Things’ as well as the ‘Internet of Things’ to highlight the relevance of technology in that regard. Since it is not only about technology per se but also the willingness to make use of it without too many critical questions asked, I also discuss some controversial views of politicians who seem to be willing to trade civil liberties for more security. I conclude this chapter by pointing out that we are already on a slippery slope in that regard, sleepwalking away from being citizens of liberal democracies towards being citizens of less liberal states driven by an ‘us versus them’ dichotomy much more pronounced than it is right now.</p