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To develop and implement antibiotic stewardship activities in urgent care targeting non–antibiotic-appropriate acute respiratory tract infections (ARIs) that also reduces overall antibiotic prescribing and maintains patient satisfaction.
Patients and setting:
Patients and clinicians at the urgent care clinics of an integrated academic health system.
Intervention and methods:
The stewardship activities started in fiscal 2020 and included measure development, comparative feedback, and clinician and patient education. We measured antibiotic prescribing in fiscal years 2019, 2020, and 2021 for the stewardship targets, potential diagnosis-shifting visits, and overall. We also collected patient satisfaction data for ARI visits.
Results:
From FY19 to FY21, 576,609 patients made 1,358,816 visits to 17 urgent care clinics, including 105,781 visits for which stewardship measures were applied and 149,691 visits for which diagnosis shifting measures were applied. The antibiotic prescribing rate decreased for stewardship-measure visits from 34% in FY19 to 12% in FY21 (absolute change, −22%; 95% confidence interval [CI], −23% to −22%). The antibiotic prescribing rate decreased for diagnosis-shifting visits from 63% to 35% (−28%; 95% CI, −28% to −27%), and the antibiotic prescribing rate decreased overall from 30% to 10% (−20%; 95% CI, −20% to −20%). The patient satisfaction rate increased from 83% in FY19 to 89% in FY20 and FY21. There was no significant association between antibiotic prescribing rates of individual clinicians and ARI visit patient satisfaction.
Conclusions:
Although it was affected by the COVID-19 pandemic, an ambulatory antimicrobial stewardship program that focused on improving non–antibiotic-appropriate ARI prescribing was associated with decreased prescribing for (1) the stewardship target, (2) a diagnosis shifting measure, and (3) overall antibiotic prescribing. Patient satisfaction at ARI visits increased over time and was not associated with clinicians’ antibiotic prescribing rates.
Background: A clear understanding of the neuropathological causes of RPD is needed to inform the diagnosis and treatment of patients with rapidly progressive dementia (RPD). Methods: Patients with <4.0 years from symptom onset to death were identified within the Mayo Clinic Neurodegenerative Brain Bank (1998-2020). Relevant clinical details were extracted from available records. Neuropathological diagnoses were assigned following standard protocols. Results: 310/8586 (3.6%) cases met RPD criteria. Relative to typically progressive cases, prion disease most commonly presented as RPD (74%, 32/43), followed by progressive supranuclear palsy/corticobasal degeneration (PSP/CBD: 7.5%, 142/1894), other frontotemporal lobar degeneration (FTLD: 5.7%, 32/561), Lewy body disease (LBD: 4.1%, 49/1202), and Alzheimer disease (AD: 1.8%, 48/2687). Average age-at-symptom onset was 69.5±10.4 years. Average disease duration was 2.9±1.0 years. Prion diseases had the most rapid disease course (1.6±1.3 years). Comorbid cerebrovascular disease (25.5%), and clinically symptomatic depression (41.3%), psychoses (37.1%), and sleep disturbances (39.4%) were common across groups. Only psychosis was associated with shorter disease duration (β=-0.31 years, CI95% -0.53, -0.082, controlling for age-at-symptomatic onset). Conclusions: Although prion disease commonly presented as RPD, atypical presentations of more prevalent neurodegenerative diseases accounted for most cases of RPD. Rapidly progressive variants of typical neurodegenerative diseases warrant consideration in clinical practice.
INTRODUCTION: DEVELOPMENT ENTAILS EQUALIZING OPP ORTUNITIES
A society – even one that has achieved a high level of average income, education and public health outcomes – cannot be considered developed if its ordinary citizens do not believe that life is fair. But what exactly is fairness? However varied, most answers have their root in some notion of equality – equality before the law, equality of representation in politics, and so on. Building upon the work of one of the present authors (Roemer, 1996, 1998) we propose that fairness means that citizens have equal opportunities to achieve their goals. We will define the roles played by choices and circumstances in the origins of inequality and go on to propose metrics for measuring, and policies for achieving, equality of opportunity. We will conclude with a set of recommendations for policymakers.
We consider the goals of citizens as those that prior work in development has identified as important and influential in policy: Individuals seek to achieve a high income, good health, the empowerment afforded by education and other such objectives as measured and reported in past United Nations Development Programme (UNDP) Human Development Reports. We will refer to these goals as the objectives of individuals.
What does it mean for individuals to have equal opportunities to achieve these objectives? We postulate three categories of inputs that determine their success in achieving these objectives. The first set of factors are the individual's choices, which includes the effort she puts in, the decision of which sector to work in, and so on. The second set includes those that we call the individual's circumstances, which are outside her control. This includes all individual-specific factors relevant for success but which the individual did not choose. For example, individuals do not choose the ethnic group to which they belong, the socioeconomic status of their families of origin, their rural or urban background, or their gender. But it is evident that these things will matter at least to a degree in determining their lot in life. Individuals ought to be held responsible for their choices, but not their circumstances. The final category is public policy which shapes the economic and social environment in which individuals live, the benefits they receive and, importantly, the relative importance of their circumstances versus their choices.
The neo-Lockean justification of the highly unequal distribution of income in capitalist societies is based upon two key premises: that people are the rightful owners of their labor and talents, and that the external world was, in the state of nature, unowned, and therefore up for grabs by people, who could rightfully appropriate parts of it subject to a ‘Lockean proviso.’ The argument is presented by Nozick. Counter-proposals to Nozick’s, for the most part, have either denied the premise that people should morally be viewed as the owners of their talents, or have challenged Nozick’s Lockean proviso.
Rawls, and to a more limited extent Ronald Dworkin, deny self-ownership. As Rawls writes: ‘…the difference principle represents, in effect, an agreement to regard the distribution of natural talents as a common asset … The naturally advantaged are not to gain merely because they are more gifted, but only to cover the costs of training and education and for using their endowments in ways that help the less fortunate as well. No one deserves his greater natural capacity nor merits a more favorable starting place in society.’ Behind the Rawlsian veil of ignorance, those who deliberate about justice are deprived of knowledge about characteristics whose distribution is morally arbitrary. In Dworkin’s proposal for resource egalitarianism, agents calculate the insurance policy they would hypothetically ask for, were they denied knowledge of what talents they will draw in the birth lottery. Compensation for unequal talents is, according to Dworkin, properly made by taxing and transferring income according to the way it would have been distributed as a consequence of such insurance. Dworkin’s veil of ignorance is thin, because agents in the appropriate posture for deliberating about income distribution know their preferences and attitudes toward risk, but not their talents. For both Rawls and Dworkin, the self-ownership premise is challenged by constructing a veil of ignorance in which people are deprived of knowledge of certain personal characteristics, knowledge of which would bias their opinions, from a moral viewpoint.
We study how rich shareholders use their political influence to deregulate firms that they own, thus skewing the income distribution towards themselves. Individuals differ in productivity and choose how much labor to supply. High productivity individuals also own shares in the productive sector and thus earn capital income. All individuals vote over a linear tax rate on (labor and capital) income whose proceeds are redistributed lump sum. Shareholders also lobby in order to ease the price cap imposed on the private firm. We first solve analytically for the Kantian equilibrium of this lobbying game together with the majority voting equilibrium over the tax rate. We then proceed to a comparative statics analysis of the model with the help of numerical simulations. We obtain that, as the capital income distribution becomes more concentrated among the top productivity individuals, increased lobbying effort generates efficiency as well as equity costs, with lower labor supply and lower average utility levels in society.
Many believe that equality of opportunity will be achieved when the prospects of children no longer depend upon the wealth and education of their parents. The institution through which the link between child and parental prospects may be weakened is public education. Many also believe that democracy is the political institution that will bring about justice. This study, first published in 2006, asks whether democracy, modeled as competition between political parties that represent different interests in the polity, will result in educational funding policies that will, at least eventually, produce citizens who have equal capacities (human capital), thus breaking the link between family background and child prospects. In other words, will democracy engender, through the educational finance policies it produces, a state of equal opportunity in the long run?
The formal theory of equality of opportunity emerged as a response – a friendly amendment – to Ronald Dworkin's (1981) characterization of resource egalitarianism, as defined by the allocation that would emerge from insurance contracts arrived at behind a thin veil of ignorance. This article compares several of the prominent versions of this response, put forth in the period 1993–2008. I argue that a generalization of Roemer's (1998) proposal is the most satisfactory approach. Inherent in that generalization is an indeterminism, which reflects a philosophical problem: that we do not know what comprise the ethically correct rewards to effort. The indeterminism should be resolved, I propose, by an ancillary theory which limits the degree of inequality which is acceptable.
In this volume a diverse group of economists, philosophers, political scientists, and psychologists address the problems, principles, and practices involved in comparing the well-being of different individuals. A series of questions lie at the heart of this investigation: What is the relevant concept of well-being for the purposes of comparison? How could the comparisons be carried out for policy purposes? How are such comparisons made now? How do the difficulties involved in these comparisons affect the status of utilitarian theories? This collection constitutes the most advanced and comprehensive treatment of one of the cardinal issues in social theory.
As earlier, the main activity of the Commission was performed by the Central Bureau for Astronomical Telegrams (CBAT), effectively directed by Dan Green. These three years were a difficult period for the Bureau and thus for the Commission because the Bureau unexpectedly had to move from the Smithsonian Astrophysical Observatory, its home since 1965, to the Harvard University's Department of Earth and Planetary Sciences. This move caused many serious administrative and logistical problems, effectively solved by the CBAT Director, Dan Green, and CBAT Director Emeritus, Brian Marsden. A great shock, not only for our commission but for the whole astronomical community, was Brian's death on November 18, 2010.
The President verbally reported that the only scientific matter that he dealt with during the triennium as an appeal over the withholding of a supernova designation from an object observed only in the infra-red with no supporting spectrum.
How can a political party whose economic policies are in the interests of only a small fraction of the richest citizens maintain a sizable vote share in a democracy with full enfranchisement? The prime example of this puzzle today occurs in the United States. My aim in this chapter is to outline the possible answers to the question and then to present in some detail a study of one of the possibilities. I cannot claim, however, to know the answer.
One might, first of all, challenge my presumption that the economic policies advanced by the US Republican Party are indeed only in the interests of a small fraction of citizens at the top of the wealth distribution. Indeed, by the standards of one hundred years ago, the US has a progressive economic policy. About 31 percent of the national product is collected in taxes (at the federal, state, and local levels), and these taxes are used predominantly for transfer payments and expenditure on public goods. There is universal public education through age seventeen, and many states provide publicly financed tertiary education with modest private co-payments. Although the United States remains unique in the degree of private financing of its health services, nevertheless approximately 50 percent of health expenditures are public. There is a universal publicly financed pension system which is redistributive.
This book presents fifteen essays, written over the past dozen years, on egalitarianism. The essays explore contemporary philosophical debates on this subject, using the tools of modern economic theory, general equilibrium theory, game theory, and the theory of mechanism design. Egalitarian Perspectives is divided into four parts: the theory of exploitation; equality of resources; bargaining theory and distributive justice; and market socialism and public ownership. The first part presents Roemer's influential reconceptualisation of the Marxian theory of exploitation as a theory of distributive justice. The second part offers a critique of Ronald Dworkin's equality-of-resources theory, and puts forward a new egalitarian proposal based upon a specific method of measuring individual responsibility. The third part introduces a novel application of the theory of mechanism design to the study of political philosophy, and raises new concerns about the limitations of that application. The fourth part presents the author's views on market socialism and public ownership, and demonstrates that Professor Roemer is at the forefront of refining new theories and conceptions of market socialism.
Professor Roemer's goal in this book is to give a rigorous view of classical Marxian economic theory by presenting specific analytic models. The theory is not extended to deal with new problems, but it is deepened: Marxian theory is given micro-foundations and upon those foundations the author begins to rebuild a tightly constructed Marxian economics. The book begins, after a methodological introduction, with an examination of the Marxian notion of equilibrium and the theory of exploitation, and goes on to deal with the theory of the falling rate of profit. The next section explores one of the points made in the first section of the book, that the Marxian theory of exploitation can be constructed completely independently of the labor theory of value as a theory of exchange. Technical study of this problem allows comment on various issues, such as the relative importance of 'marginal utilities' and 'class struggle' in determining relative prices. The final part examines models of various Marxian concepts.
If one is an egalitarian, what should one want to equalize? Opportunities or outcomes? Resources or welfare? These positions are usually conceived to be very different. I argue in this paper that the distinction is misconceived: the only coherent conception of resource equality implies welfare equality, in an appropriately abstract description of the problem. In this section, I motivate the program which the rest of the paper carries out.
Radical and liberal theories of egalitarianism are distinguished, in large part, by the differing degrees to which they hold people responsible for their own well-being. The most liberal or individualistic theory calls for equality of opportunity. Once such “starting gate equality,” as Dworkin (1981a) calls it, is guaranteed, then any final outcome is justified, provided certain rules, such as voluntary trading, are observed. At the other pole, the most radical egalitarianism calls for equality of welfare (assuming that interpersonal welfare comparisons can be made, so that such equality makes sense). In between these two extremes are egalitarian proposals that equalize more than conventional opportunities, yet less than full welfare. Sen (1980) speaks of equality of basic capabilities as a goal; implementing that requires more than starting gate equality, because some will require more resources than others to attain the same capabilities. Meeting basic needs is another objective. Equality of needs fulfillment is perhaps less radical than equality of basic capabilities and more radical than equality of opportunity. Rawls (1971) takes equality of primary goods as a benchmark; he distinguishes primary goods from welfare, but includes among them goods that are more complicated than conventional resources and opportunities, all of which are supposed inputs into any conception of welfare. One could imagine proposing an egalitarianism that equalized some quite measurable outcome across populations, such as infant mortality. That would be an outcome-equalizing theory where the rate of infant mortality is a proxy, presumably, for some more complicated maximand, such as the degree of wellbeing of a population.
From Director Dan Green's report, following this report, it is obvious that the Central Bureau for Astronomical Telegrams (CBAT) continues its excellent work. The Electronic Telegrams (CBETs), established in the previous triennium, have become the regular means for fast communication, with the Circulars providing the official and archival record of discoveries and designations. It is regretted that subscriptions to the printed Circulars continue to decline, but inevitable in this age of electronic communication.
The veil of ignorance has been used often as a tool for recommending what justice requires with respect to the distribution of wealth. We complete Harsanyi's model of the veil of ignorance by appending information permitting objective comparisons among persons. In order to do so, we introduce the concept of objective empathy. We show that the veil-of-ignorance conception of John Harsanyi, so completed, and Ronald Dworkin's, when modelled formally, recommend wealth allocations in conflict with the prominently espoused view that priority should be given to the less able in wealth allocation. We finally argue that the veil of ignorance should be rejected as a tool for discovering what justice requires.