Variation in Patient-Sharing Networks of Physicians Across the United States

Sociolog

Governance and Susceptibility in Conflict Resolution: Possibilities Beyond Control

Governmentality analysis offers a nuanced critique of informal Western conflict resolution by arguing that recently emerged alternatives to adversarial court processes both govern subjects and help to constitute rather than challenge formal regulation. However, this analysis neglects possibilities for transforming governance from within conflict resolution that are suggested by Foucault's contention that there are no relations of power without resistances. To explore this lacuna, I theorise and explore the affective and interpersonal nature of governance in mediation through autoethnographic reflection upon mediation practice, and Levina's insights about the relatedness of selves. The paper argues that two qualitatively different mediator capacities - technical ability and susceptibility - operate in concert to effect liberal governance. Occasionally though, difficulties and failures in mediation practice bring these capacities into tension and reveal the limits of governance. By considering these limits in mediation with Aboriginal Australian people, I argue that the susceptibility of mediator selves contains prospects for mitigating and transforming the very operations of power occurring through conflict resolution. This suggests options for expanded critical thinking about power relations operating through informal processes, and for cultivating a susceptible sensibility to mitigate liberal governance and more ethically respond to difference through conflict resolution

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Assessing the impact of colonoscopy complications on use of colonoscopy among primary care physicians and other connected physicians: an observational study of older Americans

Objectives: Psychological biases can distort treatment decision-making. The availability heuristic is one such bias, wherein events that are recent, vivid or easily imagined are readily ‘available’ to memory and are therefore judged more likely to occur than expected based on epidemiological data. We assessed if the occurrence of a serious colonoscopy complication for a primary care physician’s patient influenced colonoscopy rates for the physician’s other patients. Design: Longitudinal study with time-varying exposure variables. Setting/participants Individuals living in 51 hospital referral regions across the USA identified based on enrolment in fee-for-service Medicare during 2005–2010. We assigned patients to a primary care physician based on office visits during the prior 2 years. Exposures For each physician in each month, we calculated the proportion of patients assigned to them who had a colonoscopy. We identified two serious complications of which the primary care provider would very likely be aware: gastrointestinal bleed or perforation leading to hospitalisation or death within 14 days of colonoscopy. Main outcome measures We employed Poisson regression models including physician fixed effects to assess the change in number of colonoscopies in the four quarters following an adverse colonoscopy event. Results: We identified 5 360 191 patients assigned to 30 704 physicians. 4864 physicians (16%) had at least one patient with an adverse event. The estimated change in the quarterly number of colonoscopies among physicians’ patients was significantly lower in quarter 2 following an adverse colonoscopy event (change=−2.1% (95% CI −3.4 to −0.8%)), before returning to the rate expected in the absence of an adverse event. Conclusions: Having a patient experience a serious adverse colonoscopy event was associated with a small and temporary decline in colonoscopy rates among a physician’s other patients. This finding provides empirical evidence for the influence of notable adverse events on care, possibly due to the availability heuristic

Comparison of physician networks constructed from thresholded ties versus shared clinical episodes

Abstract Objective To compare standard methods for constructing physician networks from patient-physician encounter data with a new method based on clinical episodes of care. Data source We used data on 100% of traditional Medicare beneficiaries from 51 nationally representative geographical regions for the years 2005–2010. Study design We constructed networks of physicians based on their shared patients. In the fixed-threshold networks and adaptive-threshold networks, we included data on all patient-physician encounters to form the physician-physician ties, and then subsequently thresholded some proportion of the strongest ties. In contrast, in the episode-based approach, only those patient-physician encounters that occurred within shared clinical episodes treating specific conditions contributed towards physician-physician ties. Data collection/extraction methods We extracted clinical episodes in the Medicare data and investigated structural properties of the patient-sharing networks of physicians, temporal dynamics of their ties, and temporal stability of network communities across the two approaches. Principal findings The episode-based networks accentuated ties between primary care physicians (PCPs) and medical specialists, had ties that were more likely to reappear in the future, and appeared to have more fluid community structure. Conclusions Constructing physician networks around shared episodes of care is a clinically sound alternative to previous approaches to network construction that does not require arbitrary decisions about thresholding. The resulting networks capture somewhat different aspects of patient-physician encounters