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PARTICIPANTS: D. Stevenson (Harvard University Ph.D. Program in Health Policy, Watertown, MA), D. Studdert (Harvard School of Public Health, Boston, MA). The Rise of Nursing Home Litigation: Findings From a National Survey of Attorneys. C. Johnson (University of Florida, Gainesville, FL). Florida's Nursing Home Litigation Experience--1991-2000. J. Salmon (Florida Policy Exchange Center on Aging, Tampa, FL). Nursing Home Tort Reform Legislation: Policy Development and Implementation in Florida. DISCUSSANTS: M. Kapp (Office of Geriatric Medicine and Gerontology, Dayton, OH). Lawsuits against nursing homes are a relatively recent phenomenon. Despite a growing sense of concern among some policy-makers, little is known about their scale, dynamics, or outcomes. In addition to presenting national data on this topic, the symposium will explore the predictors of these claims and potential policy responses. For instance, what might be the impact of care quality and other facility characteristics on nursing home litigation? Finally, potential reforms, the tradeoffs involved, and the stakeholders in the process will be discussed. In particular, early lessons from the recently passed reforms in Florida will be shared.

Leading patient safety proposals promote the design and implementation of error prevention strategies that target systems used to deliver care and eschew individual blame. They also call for candor among practitioners about the causes and consequences of medical injury. Both goals collide with fundamental tenets of the medical malpractice system. Thus, the challenge of addressing error in medicine demands a thorough reconsideration of the legal mechanisms currently used to deal with harms in health care. In this article, we describe an alternative to litigation that does not predicate compensation on proof of practitioner fault, suggest how it might be operationalized, and argue that there is a pressing need to test its promise. We tackle traditional criticisms of "no-fault" compensation systems for medical injury-specifically, concerns about their cost and the presumption that eliminating liability will dilute incentives to deliver high-quality care. Our recent empirical work suggests that a model designed around avoidable or preventable injuries, as opposed to negligent ones, would not exceed the costs of current malpractice systems in the United States. Implementation of such a model promises to promote quality by harmonizing injury compensation with patient safety objectives, especially if it is linked to reforms that make institutions, rather than individuals, primarily answerable for injuries. [ABSTRACT FROM AUTHOR]

Abstracts are presented of articles in the Archives of Surgery, Pediatrics, Ophthalmology, General Psychiatry, Neurology, Internal Medicine, and Dermatology. They include "Incidence, Patterns, and Prevention of Wrong-Site Surgery," "Does Children's Screen Time Predict Requests for Advertised Products? Cross-sectional and Prospective Analyses," "Temporary Eyelid Closure Appliqué," "Gender Disadvantage and Reproductive Health Risk Factors for Common Mental Disorders in Women: A Community Survey in India," "Effects of Anticonvulsant Drugs on Life Span," "Effects of Etanercept in Patients With the Metabolic Syndrome," and "UV Tanning Advertisements in High School Newspapers."

Abstract Background The Australian state of Victoria, with 5.2 million residents, enforced home quarantine during a H1N1 pandemic in 2009. The strategy was targeted at school children. The objective of this study was to investigate the extent to which parents’ access to paid sick leave or paid carer’s leave was associated with (a) time taken off work to care for quarantined children, (b) household finances, and (c) compliance with quarantine recommendations. Methods We conducted an online and telephone survey of households recruited through 33 schools (85% of eligible schools), received 314 responses (27%), and analysed the subsample of 133 households in which all resident parents were employed. Results In 52% of households, parents took time off work to care for quarantined children. Households in which no resident parent had access to leave appeared to be less likely to take time off work (42% vs 58%, p=0.08) although this difference had only borderline significance. Among parents who did take time off work, those in households without access to leave were more likely to lose pay (73% vs 21%, p Conclusions Future pandemic plans should consider the economic costs borne by households and options for compensating quarantined families for income losses.

Abstract Background Localized reactive school and classroom closures were implemented as part of a suite of pandemic containment measures during the initial response to influenza A (H1N1) 2009 in Melbourne, Australia. Infected individuals, and those who had been in close contact with a case, were asked to stay in voluntary home quarantine and refrain from contact with visitors for seven days from the date of symptom onset or exposure to an infected person. Oseltamivir (Tamiflu®) was available for treatment or prophylaxis. Methods We surveyed affected families through schools involved in the closures. Analyses of responses were descriptive. We characterized recommendations made to case and contact households and quantified adherence to guidelines and antiviral therapy. Results Of the 314 respondent households, 51 contained a confirmed case. The prescribed quarantine period ranged from 1-14 days, reflecting logistic difficulties in reactive implementation relative to the stated guidelines. Household-level compliance with the requirement to stay at home was high (84.5%, 95% CI 79.3,88.5) and contact with children outside the immediate family infrequent. Conclusions Levels of compliance with recommendations in our sample were high compared with other studies, likely due to heightened public awareness of a newly introduced virus of uncertain severity. The variability of reported recommendations highlighted the difficulties inherent in implementing a targeted reactive strategy, such as that employed in Melbourne, on a large scale during a public health emergency. This study emphasizes the need to understand how public health measures are implemented when seeking to evaluate their effectiveness.

Abstract Background Voluntary home quarantine of cases and close contacts was the main non-pharmaceutical intervention used to limit transmission of pandemic (H1N1) 2009 influenza (pH1N1) in the initial response to the outbreak of the disease in Australia. The effectiveness of voluntary quarantine logically depends on affected families having a clear understanding of what they are being asked to do. Information may come from many sources, including the media, health officials, family and friends, schools, and health professionals. We report the extent to which families who entered home quarantine received and used information on what they were supposed to do. Specifically, we outline their sources of information; the perceived usefulness of each source; and associations between understanding of recommendations and compliance. Methods Cross-sectional survey administered via the internet and computer assisted telephone interview to families whose school children were recommended to go into home quarantine because they were diagnosed with H1N1 or were a close contact of a case. The sample included 314 of 1157 potentially eligible households (27% response rate) from 33 schools in metropolitan Melbourne. Adjusting for clustering within schools, we describe self-reported 'understanding of what they were meant to do during the quarantine period'; source of information (e.g. health department) and usefulness of information. Using logistic regression we examine whether compliance with quarantine recommendations was associated with understanding and the type of information source used. Results Ninety per cent understood what they were meant to do during the quarantine period with levels of understanding higher in households with cases (98%, 95% CI 93%-99% vs 88%, 95% CI 84%-91%, P = 0.006). Over 87% of parents received information about quarantine from the school, 63% from the health department and 44% from the media. 53% of households were fully compliant and there was increased compliance in households that reported that they understood what they were meant to do (Odds Ratio 2.27, 95% CI 1.35-3.80). Conclusions It is critical that public health officials work closely with other government departments and media to provide clear, consistent and simple information about what to do during quarantine as high levels of understanding will maximise compliance in the quarantined population.

Background: Too little is known about the effectiveness of efforts to prevent firearm violence. We evaluated California's Armed and Prohibited Persons System (APPS), which identifies legal purchasers of firearms who have become prohibited persons and seeks to recover all firearms and ammunition to which they have access., Design and Methods: This cluster-randomised pragmatic trial was made possible by APPS's expansion from a small pilot to a continuing statewide programme. We included 363 California cities, allocated to early (n=187) or later (n=176) intervention in blocks stratified by region within the state, and within region by population and violent crime rate. The study period began 1 February 2015; region-specific end dates ranged from 1 May 2015 to 1 February 2016. Analysis was on an intention-to-treat, difference-in-difference basis using generalised linear mixed models and generalised estimating equations with robust SEs. The population-level primary outcome measures were monthly city-level counts of firearm-related homicides, robberies and aggravated assaults. The primary model was adjusted for stratification variables; city-level population, population density, socioeconomic status and firearm purchasing; year; and month., Findings: Allocation groups were well balanced on baseline characteristics and implementation measures. In adjusted models, allocation to early intervention was not associated with statistically significant differences in any primary outcome measure; these findings were robust to multiple sensitivity analyses. There was some heterogeneity across regions., Conclusions: The APPS intervention directly affects a very small percentage of the population, limiting its potential for population-level effects. Individual-level analyses may provide a better estimate of the intervention's effectiveness., Trial Registration Number: NCT02318732., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The aim of the study was to describe the sources of notifications of concern ("notifications") regarding the health, performance, and conduct of health practitioners from 14 registered professions in Australia., Methods: This retrospective cohort study analyzed 43,256 notifications lodged with the Australian Health Practitioner Regulation Agency and the Health Professional Councils Authority between 2011 and 2016. We used descriptive statistical analysis to describe the characteristics of these notifications, including their source, issue and domain, and subject., Results: Patients and their relatives lodged more than three-quarters (78%) of notifications regarding clinical performance, including diagnosis, treatment, and communication. Fellow practitioners were a common source of notifications about advertising and titles. Self-reports commonly related to health impairments, such as mental illness or substance use. Other agencies played a role in reporting concerns about prescribing or supply of medicines., Conclusions: Various actors in the healthcare system play different roles in sketching the picture of healthcare quality and safety that notifications present to regulators. Improved understanding of which sources are most likely to raise which concerns may enhance regulators' ability to identify and respond to patient safety risks., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objective: Too little is known about the effectiveness of efforts to prevent firearm violence. Our objective is to evaluate California's Armed and Prohibited Persons System (APPS), a law enforcement intervention that seeks to recover firearms from individuals who purchased them legally but subsequently became prohibited from having access to firearms. Prohibitions usually arise from events suggesting an increased risk for future violence., Design and Study Population: This group-randomised trial involves approximately 20 000 APPS-eligible individuals in 1041 communities. Randomisation was performed at the community level, to early or later intervention (Group 1 and Group 2, respectively) with stratification by region, population and violent crime rate., Methods: APPS is being implemented by the California Department of Justice. The principal outcome measure is the incidence of arrest for a firearm-related or violent crime. Primary analysis will be on an intention-to-treat basis, comparing individuals in Group 1 and Group 2 communities. Analyses will focus on time to event, using proportional hazards regression with adjustment for the clustered nature of the data and incorporating individual- and community-level characteristics. Secondary analyses will examine the effect of the intervention on an as treated basis, effects on subgroups, and effects on community-wide measures such as crime rates., Discussion: APPS may have a significant impact on risk for future violence among members of its target population. The findings of this study will likely be generalisable and have clear implications for violence prevention policy and practice., Trial Registration Number: NCT02318732., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Internationally, men with disabilities have higher rates of social and economic disadvantage and poorer health and wellbeing than men without disabilities. No single study has provided comprehensive, population-level information about the magnitude of such differences among adult men using a well-validated instrument to measure disability., Methods: We analysed baseline data from Ten to Men - an Australian longitudinal study of male health. Ten to Men used a stratified multi-stage cluster random sample design to recruit a national sample of males aged 10 to 55 years residing in private dwellings. Data were collected between October 2013 and July 2014 from 15,988 males. This analysis was restricted to 18-55 year old participants with data available on age and disability (n = 13,569). We compared the demographic, socio-economic characteristics and health and wellbeing of men with and without disabilities using chi squared tests for proportions and t tests for continuous variables. Linear regression adjusted for age was used to assess the association between disability status and health and wellbeing, which were measured using the SF-12 mental and physical health component scores and the Personal Wellbeing Index., Results: Men with disabilities were older and more likely to be born in Australia, speak English at home, be Aboriginal and Torres Strait Islander and were less likely to be married or de facto, or to live in urban areas. They were less likely to have completed secondary school, be employed and live in affordable housing, and were more likely to live on low incomes, in more socio-economically disadvantaged areas, and in rental accommodation and to experience shortages of money. Among employed men, those with disabilities were less likely to be in high skilled jobs, worked less hours on average, and were more likely to report that they would prefer to work more. Men with disabilities had lower levels of social support and community participation and poorer mental and physical health and overall wellbeing., Conclusion: Adult men with disabilities experience marked social and economic disadvantage and poorer health and wellbeing. Improving the health and wellbeing of disabled men should be a priority for public health researchers and policy-makers.

Background: Certain sites have gained notoriety as 'hotspots' for suicide by jumping. Structural interventions (e.g. barriers and safety nets) have been installed at some of these sites. Individual studies examining the effectiveness of these interventions have been underpowered., Method: We conducted a meta-analysis, pooling data from nine studies., Results: Following the interventions, there was an 86% reduction in jumping suicides per year at the sites in question (95% CI 79% to 91%). There was a 44% increase in jumping suicides per year at nearby sites (95% CI 15% to 81%), but the net gain was a 28% reduction in all jumping suicides per year in the study cities (95% CI 13% to 40%)., Conclusions: Structural interventions at 'hotspots' avert suicide at these sites. Some increases in suicide are evident at neighbouring sites, but there is an overall gain in terms of a reduction in all suicides by jumping.

There are worldwide concerns that pro-suicide web sites may trigger suicidal behaviors among vulnerable individuals. In 2006, Australia became the first country to criminalize such sites, sparking heated debate. Concerns were expressed that the law casts the criminal net too widely; inappropriately interferes with the autonomy of those who wish to die; and has jurisdictional limitations, with off-shore web sites remaining largely immune. Conversely, proponents point out that the law may limit access to domestic pro-suicide web sites, raise awareness of Internet-related suicide, mobilize community efforts to combat it, and serve as a powerful expression of societal norms about the promotion of suicidal behavior.

Background: Unlike Canada's medical malpractice system, patients in New Zealand who are dissatisfied with the quality of their care may choose between 2 well-established medicolegal paths: one leads to monetary compensation and the other to nonmonetary forms of accountability. We compared the forms of accountability sought by patients and families in New Zealand who took different types of legal action following a medical injury. This study offers insights into the forms of accountability sought by injured patients and may help to inform tort-reform initiatives., Methods: We reviewed compensation claims submitted to the Accident Compensation Corporation (ACC), New Zealand's national no-fault insurer, following injuries associated with admission to a public hospital in 1998 (n = 582). We also reviewed complaint letters (n = 254) submitted to the national Health and Disability Commissioner (HDC) that same year to determine the forms of accountability sought by injured patients. We used univariable and multivariable analyses to compare sociodemographic and socioeconomic characteristics of patients who sought nonmonetary forms of accountability with those of patients who claimed compensation., Results: Of 154 injured patients whose complaints were sufficiently detailed to allow coding, 50% sought corrective action to prevent similar harm to future patients (45% system change, 6% review of involved clinician's competence) and 40% wanted more satisfying communication (34% explanation, 10% apology). The odds that patients would seek compensation were significantly increased if they were in their prime working years (aged between 30 and 64 years) (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.14-2.41) or had a permanent disability as a result of their injury (OR 1.75, 95% CI 1.14-2.70). When injuries resulted in death, the odds of a compensation claim to the ACC were about one-eighth those of a complaint to the HDC (OR 0.13, 95% CI 0.08-0.23)., Interpretation: Injured patients who pursue medicolegal action seek various forms of accountability. Compensation is important to some, especially when economic losses are substantial (e.g., with injury during prime working years or severe nonfatal injuries). However, others have purely nonmonetary goals, and ensuring alternative options for redress would be an efficient and effective response to their needs.

Florida's Birth-Related Neurological Injury Compensation Plan (NICA) is the most significant experiment with compensation for medical injury yet undertaken in the United States. As NICA enters its second decade of operation, maintaining the scheme's jurisdictional integrity has emerged as a key challenge for policy makers in Florida. We explore the relationship that has emerged between NICA and the tort system as competing avenues for families to obtain compensation for severe birth-related neurological injury. By linking NICA claims data with data on malpractice claims filed in Florida, we found a lively persistence of "bad baby" litigation despite NICA's implementation. Many families pursued claims in both fora. An explanation for these results can be traced to key features of the plan's design--primarily, the way in which "exclusive" jurisdiction over injuries is determined and the restrictive nature of the compensation criteria used. Our findings may help efforts to consolidate NICA's role in injury compensation and inform future design of alternative compensation systems.

Policymakers are considering legislative changes that would increase managed care organizations' exposure to civil liability for withholding coverage or failing to deliver needed care. Using a combination of empirical information and theoretical analysis, we assess the likely responses of health plans and Employee Retirement Income Security Act (ERISA) plan sponsors to an expansion of liability, and we evaluate the policy impact of those moves. We conclude that the direct costs of liability are uncertain but that the prospect of litigation may have other important effects on coverage decision making, information exchange, risk contracting, and the extent of employers' involvement in health coverage.