Socio-demographic and clinical characteristics of re-presentation to an Australian inner-city emergency department: implications for service delivery

BACKGROUND: People who have complex health care needs frequently access emergency departments for treatment of acute illness and injury. In particular, evidence suggests that those who are homeless, or suffer mental illness, or have a history of substance misuse, are often repeat users of emergency departments. The aim of this study was to describe the socio-demographic and clinical characteristics of emergency department re-presentations. Re-presentation was defined as a return visit to the same emergency department within 28 days of discharge from hospital. METHODS: A retrospective cohort study was conducted of emergency department presentations occurring over a 24-month period to an Australian inner-city hospital. Characteristics were examined for their influence on the binary outcome of re-presentation within 28 days of discharge using logistic regression with the variable patient fitted as a random effect. RESULTS: From 64,147 presentations to the emergency department the re-presentation rate was 18.0% (n = 11,559) of visits and 14.4% (5,894/40,942) of all patients. Median time to re-presentation was 6 days, with more than half occurring within one week of discharge (60.8%; n = 6,873), and more than three-quarters within two weeks (80.9%; n = 9,151). The odds of re-presentation increased three-fold for people who were homeless compared to those living in stable accommodation (adjusted OR 3.09; 95% CI, 2.83 to 3.36). Similarly, the odds of re-presentation were significantly higher for patients receiving a government pension compared to those who did not (adjusted OR 1.73; 95% CI, 1.63 to 1.84), patients who left part-way through treatment compared to those who completed treatment and were discharged home (adjusted OR 1.64; 95% CI, 1.36 to 1.99), and those discharged to a residential-care facility compared to those who were discharged home (adjusted OR 1.46: 95% CI, 1.03 to 2.06). CONCLUSION: Emergency department re-presentation rates cluster around one week after discharge and rapidly decrease thereafter. Housing status and being a recipient of a government pension are the most significant risk factors. Early identification and appropriate referrals for those patients who are at risk of emergency department re-presentation will assist in the development of targeted strategies to improve health service delivery to this vulnerable group

Ideologies and crime:Political ideas and the dynamics of crime control

This paper assembles some theoretical resources for a project that investigates the ways in which thinking about politics has since the 1970s been bound up with thinking and action around crime. Such investigation is hampered by a dominant (neo-liberal) narrative of governance that tends to reduce crime policy to a ‘contest’ between tactics and technique. In contrast, we establish a political framework for theorizing crime and its control. This framework calls for close interpretive analysis of the ways in which disputes about the crime question are always in part contests between different political ideologies and the meaning and significance of their defining concepts. By revisiting penal developments of recent several decades with these questions in mind, one can get closer to the heart of what is at stake when crime is being discussed and acquire a better sense of why crime and its control are legitimately the subject of politics

Patient-Centered Research: A Novel Method of Screening for Alcohol Use Disorders in a Primary Care Clinic

PURPOSE: Alcohol use disorders are common and poorly detected in most primary care settings. We implemented a new method of screening for alcohol use disorders among primary care patients. METHODS: A health screening Interactive Voice Response (IVR) interviewing system (respondents answer pre-recorded questions via touch tone telephones) that includes the Alcohol Use Disorders Identification Test (AUDIT) was developed and administered in an urban primary care practice housed in a county hospital. Patients were contacted for screening approximately two weeks prior to their next scheduled visit. At the conclusion of the interview, patients heard on-line feedback advising them on safe-drinking behaviors (appropriate to their AUDIT score). Each patient's primary care physician was faxed a report of the screening results, clinical management recommendations, and referral resources. RESULTS: Of 6035 eligible patients contacted, 86% (5174) agreed to begin the interview, resulting in 2997 interviews in which all necessary alcohol-related questions were answered (58% completion rate). Seventy-one percent of respondents were female; 58% white, 32% black, and 6% Hispanic; the mean age was 49 ± 14.8; insurance status was: 26% uninsured, 24% private, 17% managed care, 17% Medicaid, 16% Medicare. Screening results for 7.9% of respondents were within the hazardous range (AUDIT = 8–10) and 14.1% screened in the harmful range (AUDIT = *11). As expected, increased AUDIT scores (*8) were more prevalent among men (29.3% of men and 10.8% for women). After controlling for gender, the Cochran-Mantel-Haenszel test was used to compare AUDIT level across age groups (p = 0.001) and racial groups (p = 0.018). Hazardous drinking rates were similar across age groups (range: 4.9–7%) and racial groups (range; 4.1–7.9%). A larger proportion of respondents with AUDIT scores indicating harmful use of alcohol were between the ages of 26–55 (range: 14.4–19.8%), with the highest proportion falling within the 36–45 age group. Hispanic and Black respondents were most likely to report harmful drinking/dependence—16.6% and 16.4%, respectively. However, when rates of hazardous and harmful drinking behaviors are considered together, there was little difference among races (18.5 to 22.9%). CONCLUSION: Using a computerized interview allowed us to screen many more patients for alcohol use disorders than would normally be screened in most primary care settings. The finding that 20% of our patients reported hazardous or harmful drinking behaviors alerts us to how common this stigmatized problem is. IVR systems should be considered as effective tools to screen patients for a prevalent, sensitive issue such as alcohol misuse. We are in the process of examining the effects of novel treatment approaches for alcohol use disorders in primary care

Role-Taking and Recidivism: A Test of Differential Social Control Theory

To assess the generality of differential social control (DSC) theory, this study examines whether the core propositions of DSC could explain recidivism among a sample of adult offenders. Overall, the results do not lend support for DSC\u27s ability to account for offenders\u27 persistence in crime. Specifically, the results reveal that only two of the five measures of role-taking, antisocial attitudes and number of prior arrests, are consistent significant predictors of recidivism. The results also indicate that measures of role-commitment are not generally related to recidivism and as a consequence, the hypothesized mediating effects of role-taking on the relationship between role-commitment and recidivism by DSC are not supported. The results also show that with the exception of age, social location measures generally are not related to recidivism and thus, definite statements on the mediating effects of DSC\u27s central concepts on this relationship could not be drawn