Variation in in-hospital mortality and its association with percutaneous coronary intervention-related bleeding complications: A report from nationwide registry in Japan

Large-scale registries have demonstrated that in-hospital mortality after percutaneous coronary intervention (PCI) varies widely across institutions. However, whether this variation is related to major procedural complications (e.g., bleeding) is unclear. In this study, institutional variation in in-hospital mortality and its association with PCI-related bleeding complications were investigated. We analyzed 388,866 procedures at 718 hospitals performed from 2017 to 2018, using data from a nationwide PCI registry in Japan. Hospitals were stratified into quintiles according to risk-adjusted in-hospital mortality (very low, low, medium, high, and very high). Incidence of bleeding complications, defined as procedure-related bleeding events that required a blood transfusion, and in-hospital mortality in patients who developed bleeding complications were calculated for each quintile. Overall, 4,048 (1.04%) in-hospital deaths and 1,535 (0.39%) bleeding complications occurred. Among patients with bleeding complications, 270 (17.6%) died during hospitalization. In-hospital mortality ranged from 0.22% to 2.46% in very low to very high mortality hospitals. The rate of bleeding complications varied modestly from 0.27% to 0.57% (odds ratio, 1.95; 95% confidence interval, 1.58–2.39). However, mortality after bleeding complications markedly increased by quintile and was 6-fold higher in very high mortality hospitals than very low mortality hospitals (29.0% vs. 4.8%; odds ratio, 12.2; 95% confidence interval, 6.90–21.7). In conclusion, institutional variation in in-hospital mortality after PCI was associated with procedure-related bleeding complications, and this variation was largely driven by differences in mortality after bleeding complications rather than difference in their incidence. These findings underscore the importance of efforts toward reducing not only bleeding complications but also, even more importantly, subsequent mortality once they have occurred.

819 INSTITUTIONAL VARIATION IN THE ORGANIZATION OF CLINICAL PATHWAYS IN ESOPHAGOGASTRIC CANCER, A MIXED METHOD MULTIPLE CASE STUDY

The probability of undergoing treatment with curative intent according to the hospital of diagnosis has been shown to vary considerately for esophagogastric cancer and was related to survival. However, little is known which factors attribute to this variation. In this study we aimed to gain in-depth understanding of the organization of clinical pathways and in particular factors and processes determining the organization of healthcare for esophagogastric cancer patients. Methods A mixed method study design consisting of quantitative and qualitative data was conducted. Quantitative data was gathered by the Netherlands cancer registry (e.g., outpatient clinic consultations and performed diagnostics). A thematic content analyses of the current sub-study focused on clinician’s perspectives using semi-structured interviews (n = 30), and observations of outpatient clinic consults (n = 26) as well as multidisciplinary team meetings (n = 16) in eight hospitals. Results Quantitative analyses showed that surgeons were more often consulted in hospitals with a high probability whereas geriatricians were more often consulted in hospitals with a low probability of receiving treatment with curative intent. Qualitative analyses showed that the organization of clinical pathways were analyzed according to three levels: regional, local and patient level. Hospitals differed regarding triage, patients discussed during an multidisciplinary team meeting, the revision of radiological images, and restaging after neoadjuvant treatment. Furthermore, assessment of patients physical and cognitive condition by fitness tests, pre-habilitation and/or geriatric assessment differed significantly. Conclusion Specific parts of the clinical pathways differed significantly between hospitals such as the consultation of a geriatrician and pre-habilitation. These results might provide implications for further research in order to optimize clinical pathways.

State-Firm Coordination and Upgrading

Since the 1980s, Spain and South Korea have experienced a dramatic transformation from middle-income to advanced economies. How did Spain and South Korea upgrade? While market liberalization and globalization were important forces for change, and states continue to be central in the organization of the Spanish and Korean economies, the liberal and the developmental state perspectives do not provide an comprehensive explanation of these transformations. Building on a combination of historical institutionalism and international business literatures, this book argues that upgrading was underpinned by cooperative models based on interdependencies and quid pro quo exchanges between national governments and large firms. The negotiated nature of these arrangements opened the door to institutional variation and enabled Spain and Korea to pursue different strategies. Spain adopted an integrational approach based on foreign direct investment, technological outsourcing, and regional integration. Korea pursued a techno-industrial strategy that prioritized self-sufficiency and the development of local technological capacity. These strategies enabled Spanish and Korean firms across multiple complex sectors to reach the efficiency frontier, but resulted in different productive specializations in complex services and manufacturing respectively. Through this comparative study of transformation in Spain and Korea, this book shifts our perspective on the political economy of economic transformation from markets or states to state–firm coordination as a driver for economic transformation, from one to at least two different pathways to upgrading, and from a world divided into emerging economies and world leaders to a more nuanced perspective that recognizes the perspective of new advanced economies.

Swords and Plowshares: Property Rights, Collective Action, and Nonstate Governance in the Jewish Community of Palestine 1920–1948

Developing states lacking a monopoly over the use of force are commonly seen as having failed to live up to the ideal Weberian sovereign type. Yet rather than being a calling card of anarchy, the devolution of important state functions to subnational actors is a rational strategy for developing states to effectively provide important public goods. The case study of the Jewish Community of Palestine demonstrates one instance where subnational communities provided public goods. This study highlights the causal effect of property rights within institutions to drive behavior consistent with the provision of public and private goods. Analyzing temporal and institutional variation across two agricultural communities demonstrates a unique strategy of subnational governance and public goods provision in a developing state. Devolution of public goods provision to subnational actors may be an alternative strategy of governance for developing states that are not yet able to effectively provide important public goods.

Institutional variation in occupational licensing and its consequences for wages. A distributional analysis for the USA and Germany.

Licensing is a central institution in labor markets worldwide. Using the example of the USA and Germany, this study shows strong institutional differences between licensing systems that are of great importance for wage distribution but are not yet part of the debate about the economic consequences of licensing. The two countries differ significantly in terms of the rules of entry into occupational labor markets, the competencies of occupational boards, and the combination of licensing with price regulation. I claim that licensing systems change the bargaining power and bargaining scope for wages, which leads to different wage premiums across the distribution and different consequences for wage inequality. Using novel license data, I empirically show that licensing is associated with the largest relative wage premium for German low-wage and American middle-wage workers. In addition, the USA system leads to greater dispersion among licensed workers and to higher wage inequality overall. In contrast, the German system compresses wages for licensed workers, thereby reducing overall wage inequality.

Caregiver Perspectives of Pre-Transplant Evaluation in Children

Pre-transplant evaluation is mandated by Centers for Medicare and Medicaid Services, but there is wide institutional variation in implementation, and the family experience of the process is incompletely understood. Current literature largely focuses on adult transplant recipients. This qualitative study begins to fill the knowledge gap about family experience of the pre-transplant evaluation for children through interviews with caregivers at a large pediatric transplant center. Prominent themes heard from caregivers include (1) the pre-transplant evaluation is overwhelming and emotional, (2) prior experiences and background knowledge frame the evaluation experience, and (3) frustration with communication among teams is common. These findings are relevant to efforts by transplant centers to optimize information delivery, minimize concrete barriers, and address healthcare systems issues.

Institutional Variation, Professionalization, and State Implementation Choices: An Examination of Investment in Water Quality Across the 50 States

The question of the effect of administrative arrangements on program administration and program outcomes is a central question for those interested in policy implementation. In the implementation of federal programs, the specific state-level administrative arrangements can have a significant impact not only on resource distribution patterns, but also on the ability of involved agencies to secure adequate state resources for the program. This paper addresses this question through the lens of the Clean Water State Revolving Loan Fund program designed to fund water quality infrastructure. Employing a dataset covering nearly thirty years of state-level data, we find that measures of administrative structure and state capability are more powerful explanators of state resource decisions than are more standard explanations of politics, needs, and ideology.