Meaningful Choices? Understanding and Participation in Direct Democracy in the American States

What role does political knowledge play in campaigning for and participation in direct democracy? A foundational principle of democracy is citizen participation in decision-making. This foundation assumes that citizens are at least somewhat knowledgeable about government and able to make informed choices. This analysis examines the role that meaningful decisions play in direct democracy, because “for voters to make meaningful decisions, they must understand the options on which they are deciding” (Dalton 1988: 13). This analysis uses three different methodologies to investigate this relationship. First, through qualitative analysis and a mail survey of petitioners, this study explores how petitioners view and approach the public. This study finds that expectations of political knowledge affects how petitioners approach the public and how much time they spend educating the public about their initiative. Second, through statistical (multi-level regression) analysis, this study investigates the impact of the ballot language on participation in individual ballot propositions. This study finds that ballot language is a significant barrier to participation. Third, through experimental analysis, this study connects measures of political knowledge and participation on ballot propositions written by petitioners across the country. This study finds that when confronted with more difficult ballot language voters are less likely to participate. However, when controlling for political knowledge this effect is truncated. The findings of this analysis argue the elite bias of direct democracy in ballot language, accessibility, and motives of petitioners. The study of participation in direct democracy and political knowledge across American states advances the theoretical understanding of democratic participation, and furthers our understanding of the role citizen political knowledge plays in policymaking

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570