Serial sexual murder by juveniles and the role of sexual sadism: An international study.

This is a descriptive study of 21 cases of serial sexual murder by children and adolescents spanning nearly the past century and a half. No earlier cases worldwide were identified. Each of these youth committed two or more sexual homicides prior to age 18. Their psychopathological, psychosocial, crime scene behaviors, and offender-victim relationship characteristics are presented. Additionally, the role of sexual sadism and its measurement using the SADSEX-SH rating scale is addressed. Nearly all of the sample had conduct disorder, a paraphilic disorder, and sadistic fantasies, and two-thirds had sexual sadism disorder. Family dysfunction, serious school problems, and average or above IQ levels were typical. Their modus operandi generally reflected predatory behavior and direct contact methods of killing were most common. Two case reports are provided to illustrate the breadth and complexity of these offenders. Juvenile Serial Sexual Homicide is an extremely rare but persistent phenomenon. Prognostic implications and future research directions are discussed.

Trajectories of Frailty in the 5 Years Prior to Death Among U.S. Veterans Born 1927-1934.

BACKGROUND: Electronic frailty indices (eFIs) are increasingly used to identify patients at risk for morbidity and mortality. Whether eFIs capture the spectrum of frailty change, including decline, stability, and improvement, is unknown. METHODS: In a nationwide retrospective birth cohort of U.S. Veterans, a validated eFI, including 31 health deficits, was calculated annually using medical record and insurance claims data (2002-2012). K-means clustering was used to assign patients into frailty trajectories measured 5 years prior to death. RESULTS: There were 214 250 veterans born between 1927 and 1934 (mean [SD] age at death = 79.4 [2.8] years, 99.2% male, 90.3% White) with an annual eFI in the 5 years before death. Nine frailty trajectories were identified. Those starting at nonfrail or prefrail had 2 stable trajectories (nonfrail to prefrail, n = 29 786 and stable prefrail, n = 28 499) and 2 rapidly increasing trajectories (prefrail to moderately frail, n = 28 244 and prefrail to severely frail, n = 22 596). Those who were mildly frail at baseline included 1 gradually increasing trajectory (mildly to moderately frail, n = 33 806) and 1 rapidly increasing trajectory (mildly to severely frail, n = 15 253). Trajectories that started at moderately or severely frail included 2 gradually increasing trajectories (moderately to severely frail, n = 27 662 and progressing severely frail, n = 14 478) and 1 recovering trajectory (moderately frail to mildly frail, n = 13 926). CONCLUSIONS: Nine frailty trajectories, including 1 recovering trajectory, were identified in this cohort of older U.S. Veterans. Future work is needed to understand whether prevention and treatment strategies can improve frailty trajectories and contribute to compression of morbidity toward the end of life.

A heuristic study of the similarities and differences in offender characteristics across potential and successful serial sexual homicide offenders.

This heuristic study examined potential serial sexual homicide offenders (SSHOs), an unacknowledged offender group comprised of aspiring and probable SSHOs, and compared them with successful SSHOs. Data were collected on six aspiring SSHOs who each failed a single homicide attempt, 16 probable SSHOs who committed 17 homicides in separate events, and 13 successful SSHOs who killed 90 victims in separate events. The study results indicate that while potential SSHOs share more in common with successful SSHOs than they do with single-victim nonsexual homicide offenders, and that there is an overlap between potential SSHOs and successful SSHOs, there is currently insufficient evidence to suggest that there are discreet transitions among categories. While few potential SSHOs strive to become successful SSHOs, this may be due to weak or nonexistent emotional triggers. Being a potential SSHO does not appear to be a predictable first step on a pathway towards becoming a successful SSHO, as potential SSHOs cannot reliably be thought of as prospective SSHOs if all things were equal. The present study could not foresee all potential SSHOs becoming successful ones. An as yet unidentified number of factors still appear to separate potential SSHOs from successful SSHOs.

Updating and Validating the U.S. Veterans Affairs Frailty Index: Transitioning From ICD-9 to ICD-10.

BACKGROUND: The Veterans Affairs Frailty Index (VA-FI) is an electronic frailty index developed to measure frailty using administrative claims and electronic health records data in Veterans. An update to ICD-10 coding is needed to enable contemporary measurement of frailty. METHOD: International Classification of Diseases, ninth revision (ICD-9) codes from the original VA-FI were mapped to ICD-10 first using the Centers for Medicaid and Medicare Services (CMS) General Equivalence Mappings. The resulting ICD-10 codes were reviewed by 2 geriatricians. Using a national cohort of Veterans aged 65 years and older, the prevalence of deficits contributing to the VA-FI and associations between the VA-FI and mortality over years 2012-2018 were examined. RESULTS: The updated VA-FI-10 includes 6422 codes representing 31 health deficits. Annual cohorts defined on October 1 of each year included 2 266 191 to 2 428 115 Veterans, for which the mean age was 76 years, 97%-98% were male, 78%-79% were White, and the mean VA-FI was 0.20-0.22. The VA-FI-10 deficits showed stability before and after the transition to ICD-10 in 2015, and maintained strong associations with mortality. Patients classified as frail (VA-FI > 0.2) consistently had a hazard of death more than 2 times higher than nonfrail patients (VA-FI ≤ 0.1). Distributions of frailty and associations with mortality varied with and without linkage to CMS data and with different assessment periods for capturing deficits. CONCLUSIONS: The updated VA-FI-10 maintains content validity, stability, and predictive validity for mortality in a contemporary cohort of Veterans aged 65 years and older, and may be applied to ICD-9 and ICD-10 claims data to measure frailty.

Using Behavior Sequence Analysis to Map Serial Killers' Life Histories.

The aim of the current research was to provide a novel method for mapping the developmental sequences of serial killers' life histories. An in-depth biographical account of serial killers' lives, from birth through to conviction, was gained and analyzed using Behavior Sequence Analysis. The analyses highlight similarities in behavioral events across the serial killers' lives, indicating not only which risk factors occur, but the temporal order of these factors. Results focused on early childhood environment, indicating the role of parental abuse; behaviors and events surrounding criminal histories of serial killers, showing that many had previous convictions and were known to police for other crimes; behaviors surrounding their murders, highlighting differences in victim choice and modus operandi; and, finally, trial pleas and convictions. The present research, therefore, provides a novel approach to synthesizing large volumes of data on criminals and presenting results in accessible, understandable outcomes.

A Behaviour Sequence Analysis of Serial Killers' Lives: From Childhood Abuse to Methods of Murder.

The aim of the current research was to provide a new method for mapping the developmental sequences of serial killers' life histories. The role of early childhood abuse, leading to types of serial murder and behaviours involved in the murders, was analysed using Behaviour Sequence Analysis. A large database (n = 233) of male serial killers with known childhood abuse (physical, sexual, or psychological) was analysed according to typologies and crime scene behaviours. Behaviour Sequence Analysis was used to show significant links between behaviours and events across their lifetime. Sexual, physical, and psychological abuse often led to distinct crime scene behaviours. The results provide individual accounts of abuse types and behaviours. The present research highlights the importance of childhood abuse as a risk factor for serial killers' behaviours, and provides a novel and important advance in profiling serial killers and understanding the sequential progression of their life histories.

The Burden of Frailty Among U.S. Veterans and Its Association With Mortality, 2002-2012.

BACKGROUND: Frailty is a key determinant of clinical outcomes. We sought to describe frailty among U.S. Veterans and its association with mortality. METHODS: Nationwide retrospective cohort study of regular Veterans Affairs (VA) users, aged at least 65 years in 2002-2012, followed through 2014, using national VA administrative and Medicare and Medicaid data. A frailty index (FI) for VA (VA-FI) was calculated using the cumulative deficit method. Thirty-one age-related deficits in health from diagnostic and procedure codes were included and were updated biennially. Survival analysis assessed associations between VA-FI and mortality. RESULTS: A VA-FI was calculated for 2,837,152 Veterans over 10 years. In 2002, 35.5% were non-frail (FI = 0-0.10), 32.6% were pre-frail (FI = 0.11-0.20), 18.9% were mildly frail (FI = 0.21-0.30), 8.7% were moderately frail (FI = 0.31-0.40), and 4.3% were severely frail (FI > 0.40). From 2002 to 2012, the prevalence of moderate frailty increased to 12.7%and severe frailty to 14.1%. Frailty was strongly associated with survival and was independent of age, sex, race, and smoking; the VA-FI better predicted mortality than age alone. Although prevalence of frailty rose over time, compared to non-frail Veterans, 2 years' hazard ratios (95% confidence intervals) for mortality declined from a peak in 2004 of 2.01 (1.97-2.04), 3.49 (3.44-3.55), 5.88 (5.79-5.97), and 10.39 (10.23-10.56) for pre-frail, mildly, moderately, and severely frail, respectively, to 1.51 (1.49-1.53), 2.36 (2.33-2.39), 3.68 (3.63-3.73), 6.62 (6.53-6.71) in 2012. At every frailty level, risk of mortality was lower for women versus men and higher for blacks versus whites. CONCLUSIONS: Frailty affects at least 3 of every 10 U.S. Veterans aged 65 years and older, and is strongly associated with mortality. The VA-FI could be used to more accurately estimate life expectancy and individualize care for Veterans.

Geriatric Patient-Aligned Care Teams in Department of Veterans Affairs: How Are They Structured?

Geriatric Patient-Aligned Care Teams (GeriPACT) were implemented in the Department of Veterans Affairs (VA) (i.e., Patient-Centered Medical Homes for older adults) to provide high quality coordinated care to older adults with more risk of negative health and psychosocial outcomes. The objectives of this paper are: (1) to present data on GeriPACT structural characteristics; and (2) to examine a composite measure of GeriPACT model consistency. We utilized a web survey targeting 71 physician leads resulting in a 62% response rate. We found GeriPACTs employed a range of staffing, empanelment, clinic space, and patient assignment practices. The mean value of the GeriPACT consistency measure was 2.03 (range: 1-4) and 6.3% of facilities were considered consistent to the GeriPACT model. We observed large variation in GeriPACT structure and in model consistency. More research is needed to understand how these variations are related to processes and outcomes of care.

Evaluating the Implementation of Project Re-Engineered Discharge (RED) in Five Veterans Health Administration (VHA) Hospitals.

BACKGROUND: Improving the process of hospital discharge is a critical priority. Interventions to improve care transitions have been shown to reduce the rate of early unplanned readmissions, and consequently, there is growing interest in improving transitions of care between hospital and home through appropriate interventions. Project Re-Engineered Discharge (RED) has shown promise in strengthening the discharge process. Although studies have analyzed the implementation of RED among private-sector hospitals, little is known about how hospitals in the Veterans Health Administration (VHA) have implemented RED. The RED implementation process was evaluated in five VHA hospitals, and contextual factors that may impede or facilitate the undertaking of RED were identified. METHODS: A qualitative evaluation of VHA hospitals' implementation of RED was conducted through semistructured telephone interviews with personnel involved in RED implementation. Qualitative data from these interviews were coded and used to compare implementation activities across the five sites. In addition guided by the Practical, Robust Implementation and Sustainability Model (PRISM), cross-site analyses of the contextual factors were conducted using a consensus process. RESULTS: Progress and adherence to the RED toolkit implementation steps and intervention components varied across study sites. A majority of contextual factors identified were positive influences on sites' implementation. CONCLUSION: Although the study sites were able to tailor and implement RED because of its adaptability, redesigning discharge processes is a significant undertaking, requiring additional support/resources to incorporate into an organization's existing practices. Lessons learned from the study should be useful to both VHA and private-sector hospitals interested in implementing RED and undertaking a care transition intervention.

Tailoring an educational program on the AHRQ Patient Safety Indicators to meet stakeholder needs: lessons learned in the VA.

BACKGROUND: Given that patient safety measures are increasingly used for public reporting and pay-for performance, it is important for stakeholders to understand how to use these measures for improvement. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are one particularly visible set of measures that are now used primarily for public reporting and pay-for-performance among both private sector and Veterans Health Administration (VA) hospitals. This trend generates a strong need for stakeholders to understand how to interpret and use the PSIs for quality improvement (QI). The goal of this study was to develop an educational program and tailor it to stakeholders' needs. In this paper, we share what we learned from this program development process. METHODS: Our study population included key VA stakeholders involved in reviewing performance reports and prioritizing and initiating quality/safety initiatives. A pre-program formative evaluation through telephone interviews and web-based surveys assessed stakeholders' educational needs/interests. Findings from the formative evaluation led to development and implementation of a cyberseminar-based program, which we tailored to stakeholders' needs/interests. A post-program survey evaluated program participants' perceptions about the PSI educational program. RESULTS: Interview data confirmed that the concepts we had developed for the interviews could be used for the survey. Survey results informed us on what program delivery mode and content topics were of high interest. Six cyberseminars were developed-three of which focused on two content areas that were noted of greatest interest: learning how to use PSIs for monitoring trends and understanding how to interpret PSIs. We also used snapshots of VA PSI reports so that participants could directly apply learnings. Although initial interest in the program was high, actual attendance was low. However, post-program survey results indicated that perceptions about the program were positive. CONCLUSIONS: Conducting a formative evaluation was a highly important process in program development. The useful information that we collected through the interviews and surveys allowed us to tailor the program to stakeholders' needs and interests. Our experiences, particularly with the formative evaluation process, yielded valuable lessons that can guide others when developing and implementing similar educational programs.

A Systematic Review of Patient Safety Measures in Adult Primary Care.

Safety measure development has focused on inpatient care despite outpatient visits far outnumbering inpatient admissions. Some measures are clearly identified as outpatient safety measures when published, yet outcomes from quality improvement studies also may be useful measures. The authors conducted a systematic review of the literature to identify published articles detailing safety measures applicable to adult primary care. A total of 21 articles were identified, providing specifications for 182 safety measures. Each measure was classified into one of 6 outpatient safety dimensions: medication management, sentinel events, care coordination, procedures and treatment, laboratory testing and monitoring, and facility structures/resources. Compared to the multitude of available inpatient safety measures, the number of existing adult primary care measures is low. The measures identified by this systematic review may yield further insight into the breadth of safety events causing harm in primary care, while also identifying areas of patient safety in primary care that may be understudied.