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To update current estimates of non–device-associated pneumonia (ND pneumonia) rates and their frequency relative to ventilator associated pneumonia (VAP), and identify risk factors for ND pneumonia.
Academic teaching hospital.
All adult hospitalizations between 2013 and 2017 were included. Pneumonia (device associated and non–device associated) were captured through comprehensive, hospital-wide active surveillance using CDC definitions and methodology.
From 2013 to 2017, there were 163,386 hospitalizations (97,485 unique patients) and 771 pneumonia cases (520 ND pneumonia and 191 VAP). The rate of ND pneumonia remained stable, with 4.15 and 4.54 ND pneumonia cases per 10,000 hospitalization days in 2013 and 2017 respectively (P = .65). In 2017, 74% of pneumonia cases were ND pneumonia. Male sex and increasing age we both associated with increased risk of ND pneumonia. Additionally, patients with chronic bronchitis or emphysema (hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.40–3.06), congestive heart failure (HR, 1.48; 95% CI, 1.07–2.05), or paralysis (HR, 1.72; 95% CI, 1.09–2.73) were also at increased risk, as were those who were immunosuppressed (HR, 1.54; 95% CI, 1.18–2.00) or in the ICU (HR, 1.49; 95% CI, 1.06–2.09). We did not detect a change in ND pneumonia risk with use of chlorhexidine mouthwash, total parenteral nutrition, all medications of interest, and prior ventilation.
The incidence rate of ND pneumonia did not change from 2013 to 2017, and 3 of 4 nosocomial pneumonia cases were non–device associated. Hospital infection prevention programs should consider expanding the scope of surveillance to include non-ventilated patients. Future research should continue to look for modifiable risk factors and should assess potential prevention strategies.
To update current estimates of non–device-associated urinary tract infection (ND-UTI) rates and their frequency relative to catheter-associated UTIs (CA-UTIs) and to identify risk factors for ND-UTIs.
Academic teaching hospital.
All adult hospitalizations between 2013 and 2017 were included. UTIs (device and non-device associated) were captured through comprehensive, hospital-wide active surveillance using Centers for Disease Control and Prevention case definitions and methodology.
From 2013 to 2017 there were 163,386 hospitalizations (97,485 unique patients) and 1,273 UTIs (715 ND-UTIs and 558 CA-UTIs). The rate of ND-UTIs remained stable, decreasing slightly from 6.14 to 5.57 ND-UTIs per 10,000 hospitalization days during the study period (P = .15). However, the proportion of UTIs that were non–device related increased from 52% to 72% (P < .0001). Female sex (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.50–2.50) and increasing age were associated with increased ND-UTI risk. Additionally, the following conditions were associated with increased risk: peptic ulcer disease (HR, 2.25; 95% CI, 1.04–4.86), immunosuppression (HR, 1.48; 95% CI, 1.15–1.91), trauma admissions (HR, 1.36; 95% CI, 1.02–1.81), total parenteral nutrition (HR, 1.99; 95% CI, 1.35–2.94) and opioid use (HR, 1.62; 95% CI, 1.10–2.32). Urinary retention (HR, 1.41; 95% CI, 0.96–2.07), suprapubic catheterization (HR, 2.28; 95% CI, 0.88–5.91), and nephrostomy tubes (HR, 2.02; 95% CI, 0.83–4.93) may also increase risk, but estimates were imprecise.
Greater than 70% of UTIs are now non–device associated. Current targeted surveillance practices should be reconsidered in light of this changing landscape. We identified several modifiable risk factors for ND-UTIs, and future research should explore the impact of prevention strategies that target these factors.
In the May 1997 general election ‘New Labour’ won a landslide victory. The roots of the New Labour project lay in four successive, traumatic election defeats experienced by the party over the period from May 1979 to April 1992. The gradual transformation of Old Labour during these years came to fruition in 1997 and it produced a spectacular electoral success under the leadership of Tony Blair. Two more victories followed in 2001 and 2005, making Blair the only Labour leader in history to win three successive general elections. In May 2010, the New Labour era ended. Although the 2010 general election produced a hung parliament, Labour's much reduced share of seats made it very difficult – virtually impossible – for the party to continue in power as part of a viable coalition government. After five days of intensive interparty negotiations, Gordon Brown resigned as prime minister and Conservative Leader, David Cameron, was invited to form a government. The result was the Conservative–Liberal Democrat Coalition, Britain's first such government in over half a century.
In previous books, Political Choice in Britain (Clarke et al., 2004b) and Performance Politics and the British Voter (Clarke et al., 2009b), we have investigated alternative explanations of voting behaviour that have been proposed to account for the fates of British political parties both in the ‘New Labour’ era and more generally. We have provided a theoretical account of electoral choice which applies not only to Britain but also to other contemporary mature democracies such as Canada, France, Germany and the United States (see e.g. Clarke et al., 2009a; Clarke and Whitten, 2013; Lewis-Beck et al., 2012). According to this account, electoral choice in these countries is best understood as the product of the process of ‘valence’ or ‘performance’ politics. In a world of valence politics – where stakes are frequently high and risk is often better described as uncertainty – voters make choices primarily on the basis of evaluations of rival parties’ perceived abilities to deliver policy outcomes on salient issues involving broad consensus about what government should do.
In Affluence, Austerity and Electoral Change in Britain we have investigated factors affecting electoral choice and change in modern Britain. Beginning with the landslide 1997 general election that brought Tony Blair's New Labour Party to power, analyses show that the valence politics model that emphasizes party performance judgments, party leader images and flexible partisan attachments does much to account for voting decisions and patterns of party support in inter-election periods. Spatial models of party competition that focus on distances between parties and voters on positional issues dividing the electorate are relevant, but their effects are secondary. Sociological models featuring social class or other sociodemographic characteristics have much weaker effects. As discussed in Chapters 2 and 3, the valence politics model dominated throughout the Blair years and its explanatory power continued unabated during Gordon's Brown's premiership.
Chapters 4 and 5 demonstrate that valence politics considerations also did much to shape the choices voters made in the 2010 general election – the contest that ended the New Labour era and set the stage for a Conservative–Liberal Democrat Coalition Government. The impact of leader images was dramatically illustrated by the first-ever leaders’ debate when voters’ highly favourable reactions to Nick Clegg's performance boosted the Liberal Democrats’ standing in the polls and reconfigured the election campaign. Analyses show that both the Air War – the national campaign in the media – and the Ground War – local campaigns across the country – were important for understanding voting behaviour in 2010.
This appendix describes key variables in several models analyzed in various chapters. For additional information, please contact Harold Clarke: email@example.com. BES data, questionnaires and technical information are available for free download at: http://bes2009–10.org.
Voting in the 2010 General Election: Respondents were asked: (a) ‘Talking to people about the General Election on May 6th, we have found that a lot people didn't manage to vote. How about you – did you manage to vote in the General Election?’ If a respondent indicated voting, they were asked: (b) ‘Which party did you vote for in the General Election?’ In the binomial logit analyses of Labour voting, Labour voters are scored 1 and voters for all other parties are scored 0. In the multinomial logit analyses of opposition party voting Conservative voters are scored 1, Liberal Democrat voters are scored 2, voters for all other parties except Labour are scored 3, and Labour voters are scored 4.
Partisanship: Partisan attachments are measured using the first question
in the standard BES party identification sequence: ‘Generally
speaking, do you think of yourself as Labour, Conservative, Liberal
Democrat or what?’ Party identification variables are a series of 0–
1 dummies with ‘no’ and ‘don’t know’ responses designated as the
Public reactions to policy delivery are central to the valence model of electoral choice. Governments that succeed in delivering cherished public goods such as economic prosperity, low crime rates, effective health care and efficient public services can anticipate electoral success. In contrast, governments that fail to deliver satisfactory quantities of these goods can expect negative reactions from disgruntled electorates. Mechanisms linking policy performance with party support are generally left implicit in the valence model, since the assumption is that good performance automatically generates positive reactions from performance-oriented voters. However, it is an interesting question why people should behave in this way. The aim of this chapter is to examine this linkage, advancing the argument that successful policy delivery increases happiness or subjective well-being and failed policies have the opposite effect.
At the outset, it bears emphasis that the importance of subjective well-being is not restricted to the valence model of voting; rather, it also highly relevant for Downsian spatial models of party competition. Like their valence rivals, spatial models assume that voters are motivated by a desire to maximize utility. However, in spatial models well-being will be enhanced by the government implementing policies on position issues that divide electorates. Position issues animate both elite and mass political behaviour, and governments aim to deliver policies that some voters favour and others oppose. If the division of preferences on a particular policy is very close, large minorities of voters will not experience an increase, and may well experience a decrease in subjective well-being. In a ‘spatial world’ of fixed voter preferences and strategic politicians, there is no guarantee that government policy implementation will yield aggregate increases in life satisfaction. Minorities with intense preferences may be sorely disappointed with government policies and suffer sizable decreases in their sense of well-being.
Tony Blair propelled New Labour to power in May 1997, campaigning with the slogan ‘New Labour – New Britain’. From the time he became party leader in July 1994, he took full advantage of the difficulties encountered by John Major's weak and divided Conservative government. Blair had two core objectives, both of which reflected reactions to his party's lack of success in four successive elections held since 1979. He aimed to position what he called ‘New Labour’ as a responsible, slightly-left-of-centre party that would strive to achieve Labour's traditional goal of protecting the vulnerable and enhancing the life chances of the disadvantaged. At the same time, however, New Labour would not threaten the interests of Britain's increasingly prosperous middle class. Mr Blair and his colleagues believed that they could achieve these ends by demonstrating that their party was capable of managing the economy effectively – indeed, more effectively than their Conservative rivals. The resulting prosperity would provide the revenue needed for greatly enhanced social policy investment. New Labour thereby would deliver a highly attractive confluence of compassion and competence to government policy. During much of its long sojourn in the political wilderness Labour had been widely regarded as too great a risk to be trusted with the reigns of power. The party might care deeply about increasing public welfare, but it was incompetent to do much, if anything, about it. Blair aimed to change that longstanding perception and keep it changed.
Basking in the glow of his 1997 landslide victory, Blair's government got off to a terrific start. Labour experienced an extended honeymoon, enjoying enormous opinion polls leads over the demoralized Conservatives. By sticking firmly to the Conservatives’ spending plans for the first two years, as it had promised to do during the 1997 election campaign, New Labour demonstrated fiscal responsibility and consolidated a reputation for managerial acumen that it had begun to acquire almost by default in the wake of the 1992 Exchange Rate Mechanism crisis. By handing control of interest rates to the Bank of England's Monetary Policy Committee, Blair displayed his determination to run monetary policy in the service of controlling inflation, rather than as a handmaiden of party interests and the exigencies of the electoral calendar. Political business cycles would give way to sound economic stewardship in the national interest.
Leadership succession is never easy in British party politics, particularly if the outgoing leader is an incumbent prime minister. When Anthony Eden succeeded Winston Churchill as prime minister in April 1955, he had been waiting in the wings as leader-designate for almost a decade. Within two years he was forced to resign because of his inept handling of the Suez crisis. Jim Callaghan, who unexpectedly succeeded Harold Wilson in 1976, managed to survive until 1979, but his premiership was plagued by successive economic crises and backbench rebellions that were especially difficult to manage, given Labour's small parliamentary majority. John Major took over from Margaret Thatcher in November 1990. Against almost all expectations given the grim state of the national economy, Major took his party to a narrow victory in the 1992 general election. However, his subsequent tenure as prime minister was a tortuous one, punctuated by a major economic crisis within months of his election victory (the Exchange Rate Mechanism fiasco of September 1992) and a series of backbench rebellions that sought to take advantage, as with Callaghan, of the prime minister's small Commons majority.
When Gordon Brown succeeded Tony Blair on 27 June 2007, he appeared to be in a very different position from those of his postwar counterparts. Like Eden, he had been waiting expectantly for over a decade for his predecessor to make way. However, unlike Eden, Brown was not faced with the sort of major challenge to Britain's global role that was occasioned by the demands for political independence that were sweeping through Britain's current and former colonies in the 1950s. And, unlike Callaghan and Major, Brown was not taking over in conditions of economic crisis. When he became prime minister, Britain had enjoyed a 15-year period of uninterrupted good times – since 1993 the annual GDP growth rate had not fallen below 2 per cent. Unlike Major, Brown was elected unopposed as party leader, and by implication as prime minister. As Chancellor of the Exchequer since New Labour's initial victory in 1997, he had overseen the extended period of prosperity that preceded his premiership and as a result had established a reputation for highly competent economic management. He had consolidated this reputation by his dour rhetorical claims, widely believed at the time, that his budgets were invariably models of fiscal prudence.
The timing of the 2010 British general election had a high degree of predictability. When Gordon Brown announced that he would not seek a new mandate in October 2007 following widespread speculation that there would be an early election call, this had two effects. First, it precipitated a rapid erosion of his personal popularity and an end to the public opinion honeymoon which he had enjoyed since taking residence in Number 10 in June 2007. These dynamics were discussed in Chapter 3. But the decision to postpone had a second effect – it informed everyone that the next general election would be delayed until spring 2009 at the earliest and quite likely even longer. In fact, by early 2009, some four years after the previous election, Labour was too far behind in the polls to win, so from that point on it was clear that the next election would be put off until the last possible date – the spring of 2010. This meant that although the official 2010 campaign was a month long as usual, the unofficial ‘long’ campaign which preceded it lasted the best part of a year. From late spring 2009 knowledge that the election would take place a year later permitted the parties to start campaigning early without fear that their efforts would be wasted. As a result, the run-up to the official ‘short’ campaign involved an unusually long unofficial campaign and this helped to shape the outcome.
With this point in mind, the present chapter is divided into four sections. In the first section we describe the official or ‘short’ campaign which lasted from the date the election writs were issued on 6 April to polling day on 6 May. The analysis begins by placing the official campaign in context by describing events earlier in the year which preceded it. Public opinion dynamics during the official campaign are examined using the daily ‘replicate’ surveys conducted in the BES Rolling Campaign Panel Study (RCPS) described in Chapter 1.
Understanding party choice is a central concern for students of voting and elections. In previous chapters of this book and in earlier studies (Clarke et al., 2004b; 2009b) we have estimated various models of voting with the aim of determining which one provides the best account of the electoral choices people make. These statistical comparisons favour a composite model since no single theoretical account captures all of the factors which influence party choice. However, it bears emphasis that the valence model exhibits the strongest explanatory power. The valence politics model proved itself in the 2001 and 2005 general elections in Britain as the best single model for explaining why people vote as they do (Clarke et al., 2004b, 2009b). The valence model also consistently performs very well in analyses of voting in national elections in Canada and the United States (Clarke et al., 2009a; Clarke et al., 2012) and there is evidence to suggest that it works well in other mature and emerging democracies (Clarke and Whitten, 2013; Ho et al., 2013; Lewis-Beck et al., 2012). In all these cases, statistical analyses indicate that the valence model dominates rival models of voting behaviour, although it does not formally encompass them in the sense of completely accounting for competitors’ contributions to explaining why individuals vote as they do (Charemza and Deadman, 1997). As a result, a composite specification generally provides marginally greater explanatory purchase than a pure valence model.
The design of surveys conducted in the 2010 British Election Study is displayed in Figure A.1. The figure shows there are three distinct components: the in-person pre-campaign and post-election panel survey, the multiwave rolling campaign panel study (RCPS) and the monthly Continuous Monitoring Surveys (CMS). The first of these surveys repeated the classic in-person probability sample which has been the staple of the BES since the first study was conducted by Butler and Stokes in 1963. Although the BES originally included inter-election panel components, this design was replaced in the 1980s by a single post-election survey with no pre-campaign component. The latter design was changed in 2001 when the Essex team assumed responsibility for the study. For the first time the in-person survey consisted of a pre-campaign and a post-election panel survey.
In 2010, fieldwork for the in-person survey was performed by BMRB, under supervision of Study Director, Nick Howat. As Figure A.1 shows, the 2010 pre-campaign survey consisted of slightly less than 2000 respondents. These respondents were approached again immediately after the election, and the post-election sample was increased by a top-up survey giving a total of 3075 respondents. The top-up component was included to increase the representative quality of the survey given that a panel design was employed.
The 2010 general election resulted in a hung parliament and a Conservative–Liberal Democrat Coalition government. Had the numbers added up differently it is likely that the Liberal Democrats would have made a deal with Labour rather than the Conservatives, but that was not to be. After five days of intense negotiations, the first formal coalition government in Britain since the Second World War was announced on 11 May 2010. The Conservative–Liberal Democrat duo was an unlikely match, composed of two parties with historically different ideologies, policy goals and bases of support.
The agreement between the Coalition parties provided a roadmap for their partnership and it constructed a narrative which argued that Britain needed a strong, stable and prudent government to deal with what had become a protracted economic crisis. This was a popular message at the time. The June 2010 BES Continuous Monitoring Survey revealed that 41 per cent of respondents stated that the Conservatives were the best party for handling the economy, and a further 11 per cent said that the Liberal Democrats could do the best job. In sharp contrast, only 23 per cent replied that Labour was best on the economy. Labour was clearly paying a heavy price for being in power during the financial meltdown and subsequent recession. The political-economic context thus did much to validate the terms of the Coalition Agreement and the new government it produced.