IMPORTANCE Low-income older adults who are dually eligible (DE) for Medicare and Medicaid often experience worse outcomes following hospitalization. Among other federal policies aimed at improving health for DE patients, Medicare has recently begun reporting disparities in withinhospital readmissions. The degree to which disparities for DE patients are owing to differences in community-level factors or, conversely, are amenable to hospital quality improvement, remains heavily debated. OBJECTIVE To examine the extent to which within-hospital disparities in 30-day readmission rates for DE patients are ameliorated by state-and community-level factors. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, Centers for Medicare & Medicaid Services (CMS) Disparity Methods were used to calculate within-hospital disparities in 30-day risk-adjusted readmission rates for DE vs non-DE patients in US hospitals participating in Medicare. All analyses were performed in February and March 2019. The study included Medicare patients (aged Ն65 years) hospitalized for acute myocardial infarction (AMI), heart failure (HF), or pneumonia in 2014 to 2017. MAIN OUTCOMES AND MEASURES Within-hospital disparities, as measured by the rate difference (RD) in 30-day readmission between DE vs non-DE patients following admission for AMI, HF, or pneumonia; variance across hospitals; and correlation of hospital RDs with and without adjustment for state Medicaid eligibility policies and community-level factors. RESULTSThe final sample included 475 444 patients admitted for AMI, 898 395 for HF, and 1 214 282 for pneumonia, of whom 13.2%, 17.4%, and 23.0% were DE patients, respectively. Dually eligible patients had higher 30-day readmission rates relative to non-DE patients (RD >0) in 99.0% (AMI), 99.4% (HF), and 97.5% (pneumonia) of US hospitals. Across hospitals, the mean (IQR) RD between DE vs non-DE was 1.00% (0.87%-1.10%) for AMI, 0.82% (0.73%-0.96%) for HF, and 0.53% (0.37%-0.71%) for pneumonia. The mean (IQR) RD after adjustment for community-level factors was 0.87% (0.73%-0.97%) for AMI, 0.67% (0.57%-0.80%) for HF, and 0.42% (0.29%-0.57%) for pneumonia. Relative hospital rankings of corresponding within-hospital disparities before and after community-level adjustment were highly correlated (Pearson coefficient, 0.98). CONCLUSIONS AND RELEVANCEIn this cohort study, within-hospital disparities in 30-day readmission for DE patients were modestly associated with differences in state Medicaid policies and community-level factors. This suggests that remaining variation in these disparities should be the focus of hospital efforts to improve the quality of care transitions at discharge for DE patients in efforts to advance equity.

A recognised imbalance of power exists between athletes and sporting institutions. Recent cases of systemic athlete abuse demonstrate the relationship between power disparities and harassment and abuse in sport. Embedding human rights principles into sporting institutions is a critical step towards preventing harassment and abuse in sport. In 2017, the World Players Association (WPA) launched the Universal Declaration of Player Rights. A year later, the International Olympic Committee (IOC) developed their Athletes’ Rights and Responsibilities Declaration. These two documents codify benchmarks ‘for international sporting organisations to meet their obligations to protect, respect and guarantee the fundamental rights of players’. This paper is the first project exploring athletes’ knowledge, understanding and awareness of rights in the sports context. This study presents the development and validation of a survey investigating athletes’ knowledge of these declarations, associated attitudes/beliefs and understanding of how these rights can be enacted in practice. The survey includes 10 statements of athlete rights based on the WPA and IOC declarations. Face validation was assessed by distributing the survey to 10 athletes and conducting qualitative interviews with a subgroup of four athletes. The survey was reworked into 13 statements, and the tool was validated with 611 responses through confirmatory factor analysis. Key findings include a weak correlation between athletes’ knowledge and their attitudes/beliefs, and challenges with the interpretation of words such as ‘pressure,’ ‘violence,’ ‘harassment’ and ‘intimidation.’ This validation puts forward the first survey instrument to directly test athletes’ knowledge, attitudes and beliefs about rights in sport.

ObjectivesModern sport safeguarding strategies include published global rights declarations that enshrine athletes’ entitlements at the policy level. It is unclear how these documents translate to athletes’ lived experiences. The study aimed to determine athletes’ knowledge, attitudes and beliefs about their human rights in sports settings.SettingWeb-based survey.Participants1159 athletes from 70 countries completed a validated web-based survey. Over half of participants (60.1%) were between 18 and 29 years, currently competing (67.1%), not members of players’ unions (54.6%), elite (60.0%) and participating in individual (55.8%) non-contact (75.6%) Olympic (77.9%) sports. Gender distribution was equal.Primary and secondary outcome measuresParticipant demographics (eg, gender, age) and athletes’ knowledge, attitudes and beliefs about their human rights in sports settings.ResultsMost (78.5%) were unaware of any athletes’ rights declarations. Gender influenced participants’ confidence in acting on their rights in sport significantly. Males were more likely to accept pressure from coaches and teammates than females, but age affected how likely males were to accept this pressure. Paralympic athletes were less likely to agree that violence is acceptable in sports, compared with Olympic. Player union membership increased confidence in freely expressing one’s opinion in sports settings. Athletes’ rights-related awareness, knowledge and beliefs were disconnected.ConclusionsAwareness raising is not enough to prevent human rights violations in sports. The cultural climate of the entire ecosystem must be targeted, using systems-level strategies to shift stakeholders’ biases, beliefs and behaviours. This approach takes the onus of addressing abuse off athletes’ shoulders and places accountability on sports organisations.

Objective: To propose and evaluate a novel approach for measuring hospital-level disparities according to the effect of a continuous, polysocial risk factor on those outcomes.Study Setting: Our cohort consisted of Medicare Fee-for-Service (FFS) patients 65 years and older admitted to acute care hospitals for one of six common conditions or procedures. Medicare administrative claims data for six hospital readmission measures including hospitalizations from July 2015 to June 2018 were used.Study Design: We adapted existing methodologies that were developed to report hospital-level disparities using dichotomous social risk factors (SRFs). The existing methods report disparities within and across hospitals; we developed and tested modified approaches for both methods using the Agency for Healthcare Research and Quality Socioeconomic Status Index. We applied the adapted methodologies to six 30-day hospital readmission measures included in the Centers for Medicare & Medicaid Services Hospital Readmissions Reduction Program measures. We compared the within-and across-hospital results for each to those obtained from using the original methods and dichotomizing the AHRQ SES Index into "low" and "high" scores.Data Collection: We used Medicare FFS administrative claims data linked to U.S. Census data.Principal Findings: For all six readmission measures we find that, when compared with the existing methods, the methods for continuous SRFs provide disparity results for more facilities though across a narrower range of values. Measures of disparity based on this approach are moderately to highly correlated with those based on a dichotomous version of the same risk factor, while reflecting a fuller spectrum of risk. This approach represents an opportunity for detection of provider-level results that more closely align with underlying social risk. Conclusion:We have demonstrated the feasibility and utility of estimating hospital disparities of care using a continuous, polysocial risk factor. This approach expands the potential for reporting hospital-level disparities while better accounting for the multifactorial nature of social risk on hospital outcomes.