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1.  The impact of health literacy in the care of surgical patients: a qualitative systematic review 
BMC Surgery  2015;15:86.
Inadequate health literacy affects more than 90 million Americans and it has been associated with adverse outcomes in the medicine field including increased hospitalization rates and greater mortality. Since surgical patients are often required to make complex decisions and adhere to complex instructions, health literacy may have a profound impact in the surgical practice. The main objective of the current study was to systematically evaluate the role of health literacy in surgical patients.
A systematic search was performed to identify studies that evaluated the role of health literacy in the perioperative setting following the PRISMA guidelines. Only studies that examined health literacy using a validated instrument in the perioperative setting were included.
Ten studies including data on 1147 patients were included. The median (IQR) number of patients in the included studies was 101 (30 to 152). The majority of studies used the Short Test of Functional Literacy in adults (STOFHLA) to evaluate patients’ health literacy. Five studies evaluated the patients preoperatively, four studies evaluated patients in the postoperative period and in one study the time of evaluation in relation to the surgical procedure was not defined. The lowest prevalence of inadequate health literacy was detected in kidney transplant patients, 6 out of 124 (5 %), while the highest prevalence of inadequate health literacy was detected in orthopedic patients having total joint replacement, 86 out of 126 (60 %). Inadequate health literacy in the preoperative period was associated with poor medical information comprehension and it may adversely affect adherence to preoperative medications and even modulate surgical disparities. Inadequate health literacy in the postoperative period was associated with poor comprehension of discharge instructions and worse kidney function in transplant recipients.
Health literacy seems to have a very significant impact in the care of surgical patients. More studies to establish the impact of poor health literacy on perioperative outcomes are needed.
PMCID: PMC4504415  PMID: 26182987
2.  Evaluation of Initial Participation in Public Reporting of ACS NSQIP Surgical Outcomes on Medicare’s Hospital Compare Website 
In October 2012, The Centers for Medicare and Medicaid Services (CMS) began publicly reporting American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical outcomes on its public reporting website, Hospital Compare. Participation in this CMS-NSQIP initiative is voluntary. Our objective was to compare CMS-NSQIP participating hospitals to ACS NSQIP hospitals that elected not to participate.
Study Design
Hospital Compare and American Hospital Association Annual Survey data were merged to compare CMS-NSQIP participants to non-participants. Regression models were developed to assess predictors of participation and to assess if hospitals differed on 32 process, 10 patient experience (HCAHPS), and 16 outcome (Hospital Compare & AHRQ) measures. Additionally, performance on two waves of publicly reported ACS NSQIP surgical outcome measures was compared.
Of the 452 ACS NSQIP hospitals, 80 (18%) participated in CMS-NSQIP public reporting. Participating hospitals had more beds, admissions, operations, and were more often accredited (Commission on Cancer and the Council of Teaching Hospitals (COTH) (P<0.05). Only COTH membership remained significant in adjusted analyses (OR 2.45, 95% CI 1.12–5.35). Hospital performance on process, HCAHPS, and outcome measures were not associated with CMS-NSQIP participation for 54 of 58 measures examined. Hospitals with “better-than-average” performance were more likely to publicly report the Elderly Surgery measure (P<0.05). In wave two, an increased proportion of new participants reported “worse-than-average” outcomes.
There were few measurable differences between CMS-NSQIP participating and non-participating hospitals. The decision to voluntarily publicly report may be related to the hospital’s culture of quality improvement and transparency.
PMCID: PMC4324751  PMID: 24468223
3.  Welfare, Work, and Health Care Access Predictors of Low-Income Children’s Physical Health Outcomes 
This analysis examines whether young children’s (N= 494) general physical health is associated with parental employment, welfare receipt, and health care access within a low-income population transitioning from welfare to work. A latent physical health measure derived from survey and medical chart data is used to capture children’s poor health, and parental ratings of child health are used to identify excellent health. Controlling for a host of factors associated with children’s health outcomes, results show that children of caregivers who are unemployed and off welfare have better health than children of caregivers who are working and off welfare. Children whose caregivers are unemployed and on welfare, or combining work and welfare, have health outcomes similar to children of caregivers who are working and off welfare. Health care access characteristics, such as gaps in health insurance coverage, source of primary care setting, and type of health insurance are associated with children’s general physical health. Implications of these results for state TANF programs are discussed.
PMCID: PMC4260331  PMID: 25505809
4.  Activities of Daily Living (ADL) Trajectories Surrounding Acute Hospitalization of Long-stay Nursing Home Residents 
Journal of the American Geriatrics Society  2013;61(11):10.1111/jgs.12511.
To explore patterns of change in nursing home residents’ activities of daily living (ADLs), particularly surrounding acute hospital stays.
Longitudinal study using Medicare and Minimum Data Set (MDS) assessments
National sample of long-stay nursing home residents
We identified 40,128 residents who were hospitalized for the seven most common inpatient diagnoses. Each hospital admission was at least 90 days after any prior hospitalization and had at least two preceding MDS assessments.
We represented residents’ ADL function with the MDS ADL-Long form score, a simple sum of seven self-care variables coded from 0 (independent) to 4 (totally dependent). Scores ranged from 0 to 28; higher scores indicated greater impairment. We jointly estimated a linear mixed model describing ADL trajectories with mortality and hospital readmission.
Before hospitalization, the most common trajectory represented stability (53.7%), with 27.5% of residents worsening and 18.8% improving. ADL function after hospital discharge was most often characterized by stability (43.1%) or worsening (39.2%). Mortality (20.3%) was higher for those with worsening pre-hospital ADL function (28.9%) compared to those with stable (19.1%) or improving (11.3%) trajectories. Hospital diagnosis was associated with both the amount of ADL worsening and the rate of subsequent ADL change. Most residents with the best initial function continued to worsen after hospital discharge. Cognitive impairment was associated with poorer ADL function and accelerated worsening of ADLs.
For many long-stay nursing home residents acute hospitalization is accompanied by substantial and sustained ADL worsening. Thus, acute hospitalization presents an opportunity to revisit care goals; our results can help inform decision-making.
PMCID: PMC3831170  PMID: 24219192
nursing homes; activities of daily living; hospitalization; Minimum Data Set
Health care management review  2013;38(4):295-305.
Culture Change initiatives propose to improve care by addressing the lack of managerial supports and prevalent stressful work environments in the industry; however, little is known about how Culture Change facilities differ from facilities in the industry that have not chosen to affiliate with the resident-centered care movements.
To evaluate representation of organizational culture values within a random sample of U.S. nursing home facilities using the Competing Values Framework (CVF) and to determine whether organizational values are related to membership in resident-centered Culture Change initiatives.
Design and Methods
We collected reports of cultural values using a well-established CVF instrument in a random survey of facility administrators and directors of nursing within all states. We received responses from 57% of the facilities that were mailed the survey. Directors of nursing and administrators did not vary significantly in their reports of culture and facility measures combine their responses.
Nursing facilities favored market-focused cultural values on average and developmental values, key to innovation, were the least common across all nursing homes. Approximately 17% of facilities reported all cultural values were strong within their facilities. Only high developmental cultural values were linked to participation in culture change initiatives. Culture Change facilities were not different from non-Culture Change facilities in the promotion of employee focus as organizational culture, as is emphasized in group culture values. Likewise, Culture Change facilities were also not any more likely to have hierarchical or market foci than non-Culture Change facilities.
Practice Implications
Our results counter the argument that Culture Change facilities have a stronger internal employee focus than facilities more generally but does show that Culture Change facilities report stronger developmental cultures than non-Culture Change facilities, which indicates a potential to be innovative in their strategies. Facilities are culturally ready to become resident-centered and may face other barriers to adopting these practices.
PMCID: PMC3567244  PMID: 22936002
Long-term care; managerial values; culture change
6.  Application of a Proactive Risk Analysis to Emergency Department Sickle Cell Care 
Patients with sickle cell disease (SCD) often seek care in emergency departments (EDs) for severe pain. However, there is evidence that they experience inaccurate assessment, suboptimal care, and inadequate follow-up referrals. The aim of this project was to 1) explore the feasibility of applying a failure modes, effects and criticality analysis (FMECA) in two EDs examining four processes of care (triage, analgesic management, high risk/high users, and referrals made) for patients with SCD, and 2) report the failures of these care processes in each ED.
A FMECA was conducted of ED SCD patient care at two hospitals. A multidisciplinary group examined each step of four processes. Providers identified failures in each step, and then characterized the frequency, impact, and safeguards, resulting in risk categorization.
Many “high risk” failures existed in both institutions, including a lack of recognition of high-risk or high-user patients and a lack of emphasis on psychosocial referrals. Specific to SCD analgesic management, one setting inconsistently used existing analgesic policies, while the other setting did not have such policies.
FMECA facilitated the identification of failures of ED SCD care and has guided quality improvement activities. Interventions can focus on improvements in these specific areas targeting improvements in the delivery and organization of ED SCD care. Improvements should correspond with the forthcoming National Heart, Lung and Blood-sponsored guidelines for treatment of patients with sickle cell disease.
PMCID: PMC4100851  PMID: 25035751
7.  NUTORC—a transdisciplinary health services and outcomes research team in transplantation 
The field of solid organ transplantation has historically concentrated research efforts on basic science and translational studies. However, there has been increasing interest in health services and outcomes research. The aim was to build an effective and sustainable, inter- and transdisciplinary health services and outcomes research team (NUTORC), that leveraged institutional strengths in social science, engineering, and management disciplines, coupled with an international recognized transplant program. In 2008, leading methodological experts across the university were identified and intramural funding was obtained for the NUTORC initiative. Inter- and transdisciplinary collaborative teams were created across departments and schools within the university. Within 3 years, NUTORC became fiscally sustainable, yielding more than tenfold return of the initial investment. Academic productivity included funding for 39 grants, publication of 60 manuscripts, and 166 national presentations. Sustainable educational opportunities for students were created. Inter- and transdisciplinary health services and outcomes research in transplant can be innovative and sustainable.
PMCID: PMC3647618  PMID: 23667403
Transdisciplinary research teams; Health Services and Outcomes Research; Educational opportunities; Academic productivity; Sustainable research efforts
8.  Preventable Errors in Organ Transplantation: An Emerging Patient Safety Issue? 
Several widely publicized errors in transplantation including a death due ABO incompatibility, two HIV transmissions and two HCV transmissions have raised concerns about medical errors in organ transplantation. The root cause analysis of each of these events revealed preventable failures in the systems and processes of care as the underlying causes. In each event, no standardized system or redundant process was in place to mitigate the failures that led to the error. Additional system and process vulnerabilities such as poor clinician communication, erroneous data transcription and transmission were also identified. Organ transplantation, because it is highly complex, often stresses the systems and processes of care and, therefore, offers a unique opportunity to proactively identify vulnerabilities and potential failures. Initial steps have been taken to understand such issues through the OPTN/UNOS Operations and Safety Committee, the Disease Transmission Advisory Committee (DTAC), and the current A2ALL ancillary Safety Study. However, to effectively improve patient safety in organ transplantation, the development of a process for reporting of preventable errors that affords protection and the support of empiric research are critical. Further, the transplant community needs to embrace the implementation of evidence-based system and process improvements that will mitigate existing safety vulnerabilities.
PMCID: PMC3429784  PMID: 22703471
Medical Error; Preventable Errors; Organ Donation; Disease Transmission; Patient Safety; ABO incompatibility
9.  The Comparative Effectiveness of Donation after Cardiac Death versus Donation after Brain Death Liver Transplantation: Recognizing Who Can Benefit 
Liver Transplantation  2012;18(6):630-640.
Due to organ scarcity and wait-list mortality, transplantation of donation after cardiac death (DCD) livers has increased. However, the group of patients benefiting from DCD liver transplantation is unknown. We studied the comparative effectiveness of DCD versus donation after brain death (DBD) liver transplantation.
A Markov model was constructed to compare undergoing DCD transplantation with remaining on the wait-list until death or DBD liver transplantation. Differences in life years, quality-adjusted life years (QALYs), and costs according to candidate Model for End-Stage Liver Disease (MELD) score were considered. A separate model for hepatocellular carcinoma (HCC) patients with and without MELD exception points was constructed.
For patients with a MELD score <15, DCD transplantation resulted in greater costs and reduced effectiveness. Patients with a MELD score of 15 to 20 experienced an improvement in effectiveness (0.07 QALYs) with DCD liver transplantation, but the incremental cost-effectiveness ratio (ICER) was >$2,000,000/QALY. Patients with MELD scores of 21 to 30 (0.25 QALYs) and >30 (0.83 QALYs) also benefited from DCD transplantation with ICERs of $478,222/QALY and $120,144/QALY, respectively. Sensitivity analyses demonstrated stable results for MELD scores <15 and >20, but the preferred strategy for the MELD 15 to 20 category was uncertain. DCD transplantation was associated with increased costs and reduced survival for HCC patients with exception points but led to improved survival (0.26 QALYs) at a cost of $392,067/QALY for patients without exception points.
In conclusion, DCD liver transplantation results in inferior survival for patients with a MELD score <15 and HCC patients receiving MELD exception points, but provides a survival benefit to patients with a MELD score >20 and to HCC patients without MELD exception points.
PMCID: PMC3365831  PMID: 22645057
cost-effectiveness; quality-adjusted life-years; regional variation; biliary complications
10.  NUTORC—a transdisciplinary health services and outcomes research team in transplantation 
The field of solid organ transplantation has historically concentrated research efforts on basic science and translational studies. However, there has been increasing interest in health services and outcomes research. The aim was to build an effective and sustainable, inter- and transdisciplinary health services and outcomes research team (NUTORC), that leveraged institutional strengths in social science, engineering, and management disciplines, coupled with an international recognized transplant program. In 2008, leading methodological experts across the university were identified and intramural funding was obtained for the NUTORC initiative. Inter- and transdisciplinary collaborative teams were created across departments and schools within the university. Within 3 years, NUTORC became fiscally sustainable, yielding more than tenfold return of the initial investment. Academic productivity included funding for 39 grants, publication of 60 manuscripts, and 166 national presentations. Sustainable educational opportunities for students were created. Inter- and transdisciplinary health services and outcomes research in transplant can be innovative and sustainable.
PMCID: PMC3647618  PMID: 23667403
Transdisciplinary research teams; Health Services and Outcomes Research; Educational opportunities; Academic productivity; Sustainable research efforts
11.  A Comprehensive Risk Assessment of Mortality Following Donation after Cardiac Death Liver Transplant – An Analysis of the National Registry 
Journal of hepatology  2011;55(4):808-813.
Background and Aims
Organ scarcity has resulted in increased utilization of donation after cardiac death (DCD) donors. Prior analysis of patient survival following DCD liver transplantation has been restricted to single institution cohorts and a limited national experience. We compared the current national experience with DCD and DBD livers to better understand survival after transplantation.
We compared 1,113 DCD and 42,254 DBD recipients from the Scientific Registry of Transplant Recipients database between 1996 and 2007. Patient survival was analyzed using Kaplan-Meier methodology and Cox regression.
DCD recipients experienced worse patient survival compared to DBD recipients (p<0.001). One and three year survival was 82% and 71% for DCD compared to 86% and 77% for DBD recipients. Moreover, DCD recipients required re-transplantation more frequently (DCD 14.7% versus DBD 6.8%, p<0.001), and re-transplantation survival was markedly inferior to survival after primary transplant irrespective of graft type. Amplification of mortality risk was observed when DCD was combined with cold ischemia time > 12hours (HR=1.81), shared organs (HR=1.69), recipient hepatocellular carcinoma (HR=1.80), recipient age >60 years (HR=1.92), and recipient renal insufficiency (HR=1.82).
DCD recipients experience signficantly worse patient survival after transplantation. This increased risk of mortality is comparable in magnitude to, but often exacerbated by other well-established risk predictors. Utilization decisions should carefully consider DCD graft risks in combination with these other factors.
PMCID: PMC3177011  PMID: 21338639
12.  Predictors of Chain Acquisition among Independent Dialysis Facilities 
Health Services Research  2010;45(2):476-496.
To determine the predictors of chain acquisition among independent dialysis providers.
Data Sources
Retrospective facility-level data combined from CMS Cost Reports, Medical Evidence Forms, Annual Facility Surveys, and claims for 1996–2003.
Study Design
Independent dialysis facilities' probability of acquisition by a dialysis chain (overall and by chain size) was estimated using a discrete time hazard rate model, controlling for financial and clinical performance, practice patterns, market factors, and other facility characteristics.
Data Collection
The sample includes all U.S. freestanding dialysis facilities that report not being chain affiliated for at least 1 year between 1997 and 2003.
Principal Findings
Above-average costs and better quality outcomes are significant determinants of dialysis chain acquisition. Facilities in larger markets were more likely to be acquired by a chain. Furthermore, small dialysis chains have different acquisition strategies than large chains.
Dialysis chains appear to employ a mix of turn-around and cream-skimming strategies. Poor financial health is a predictor of chain acquisition as in other health care sectors, but the increased likelihood of chain acquisition among higher quality facilities is unique to the dialysis industry. Significant differences among predictors of acquisition by small and large chains reinforce the importance of using a richer classification for chain status.
PMCID: PMC2838156  PMID: 20148985
Chain acquisition; end-stage renal disease; dialysis; Medicare
13.  The relationship between self-report and biomarkers of stress in low-income, reproductive age women 
To determine if there is an association between self-reported and biologic measures of stress in low-income, reproductive age women.
Between 1999 and 2005, randomly selected reproductive age women from the 1998 welfare rolls in Chicago were interviewed yearly to assess psychosocial, socioeconomic, and health characteristics. The association of two stress sensitive biomarkers (Epstein-Barr virus antibody titer (EBV) and C-reactive protein (CRP) level) with self-reported stress was assessed.
Of the 206 women interviewed, 205 (99%) agreed to provide a blood sample. There was no difference in mean EBV or CRP levels based on age, race, parity, employment, marital status, or education. Women who reported a higher degree of perceived stress or reported experiences of discrimination had significantly higher levels of EBV (p < .05).
Measures of self-reported psychosocial stress are associated with elevated levels EBV antibody in a low-income population of reproductive age women.
PMCID: PMC3000746  PMID: 20870203
biomarkers; C-reactive protein; Epstein-Barr virus; low-income women; stress
14.  Computer-Enhanced Visual Learning Method: A Paradigm to Teach and Document Surgical Skills 
Changes in health care are stimulating residency training programs to develop new methods for teaching surgical skills. We developed Computer-Enhanced Visual Learning (CEVL) as an innovative Internet-based learning and assessment tool. The CEVL method uses the educational procedures of deliberate practice and performance to teach and learn surgery in a stylized manner.
Aim of Innovation
CEVL is a learning and assessment tool that can provide students and educators with quantitative feedback on learning a specific surgical procedure. Methods involved examine quantitative data of improvement in surgical skills. Herein, we qualitatively describe the method and show how program directors (PDs) may implement this technique in their residencies.
CEVL allows an operation to be broken down into teachable components. The process relies on feedback and remediation to improve performance, with a focus on learning that is applicable to the next case being performed. CEVL has been shown to be effective for teaching pediatric orchiopexy and is being adapted to additional adult and pediatric procedures and to office examination skills. The CEVL method is available to other residency training programs.
PMCID: PMC2931197  PMID: 21975716
15.  Material Hardship and the Physical Health of School-Aged Children in Low-Income Households 
American journal of public health  2008;99(5):829-836.
We examined the relationship between material hardship reported by low-income caregivers and caregivers' assessments of their children's overall health.
We used logistic regression techniques to analyze data from 1073 children aged 5 through 11 years whose caregivers participated in multiple waves of the Illinois Families Study.
Caregivers' reports of food hardship were strongly associated with their assessments of their children's health. Other sources of self-reported material hardship were also associated with caregivers' assessments of their children's health, but the effects disappeared when we controlled for caregiver physical health status and mental health status. Proximal measures of material hardship better explained low-income children's health than traditional socioeconomic measures. There were no statistically significant cumulative effects of material hardships above and beyond individual hardship effects.
Our findings highlight the importance of developing and supporting programs and policies that ensure access to better-quality food, higher quantities of food, and better living conditions for low-income children, as well as health promotion and prevention efforts targeted toward their primary caregivers as ways to reduce health disparities for this population.
PMCID: PMC2667853  PMID: 18703452
16.  Ambulatory care adverse events and preventable adverse events leading to a hospital admission 
Quality & Safety in Health Care  2007;16(2):127-131.
Most healthcare in the US is delivered in the ambulatory care setting, but the epidemiology of errors and adverse events in ambulatory care is understudied.
Using the population‐based data from the Colorado and Utah Medical Practices Study, we identified adverse events that occurred in an ambulatory care setting and led to hospital admission. Proportions with 95% CIs are reported.
We reviewed 14 700‐hospital discharge records and found 587 adverse events of which 70 were ambulatory care adverse events (AAEs) and 31 were ambulatory care preventable adverse events (APAEs). When weighted to the general population, there were 2608 AAEs and 1296 (44.3%) APAEs in Colorado and Utah, USA, in 1992. APAEs occurred most commonly in physicians' offices (43.1%, range 46.8–27.8), the emergency department (32.3%, 46.1–18.5) and at home (13.1%, 23.1–3.1). APAEs in day surgery were less common (7.1%, 13.6–0.6) but caused the greatest harm to patients. The types of APAEs were broadly distributed among missed or delayed diagnoses (36%, 50.2–21.8), surgery (24.1%, 36.7–11.5), non‐surgical procedures (14.6%, 25.0–4.2), medication (13.1%, 23.1–3.1) and therapeutic events (12.3%, 22.0–2.6). Overall, 10% of the APAEs resulted in serious permanent injury or death. The proportion of APAEs that resulted in death was 31.8% for general internal medicine, 22.5% for family practice and 16.7% for emergency medicine.
An estimated 75 000 hospitalisations per year are due to preventable adverse events that occur in outpatient settings in the US, resulting in 4839 serious permanent injuries and 2587 deaths.
PMCID: PMC2653165  PMID: 17403759
17.  Development of the Chicago Food Allergy Research Surveys: assessing knowledge, attitudes, and beliefs of parents, physicians, and the general public 
Parents of children with food allergy, primary care physicians, and members of the general public play a critical role in the health and well-being of food-allergic children, though little is known about their knowledge and perceptions of food allergy. The purpose of this paper is to detail the development of the Chicago Food Allergy Research Surveys to assess food allergy knowledge, attitudes, and beliefs among these three populations.
From 2006–2008, parents of food-allergic children, pediatricians, family physicians, and adult members of the general public were recruited to assist in survey development. Preliminary analysis included literature review, creation of initial content domains, expert panel review, and focus groups. Survey validation included creation of initial survey items, expert panel ratings, cognitive interviews, reliability testing, item reduction, and final validation. National administration of the surveys is ongoing.
Nine experts were assembled to oversee survey development. Six focus groups were held: 2/survey population, 4–9 participants/group; transcripts were reviewed via constant comparative methods to identify emerging themes and inform item creation. At least 220 participants per population were recruited to assess the relevance, reliability, and utility of each survey item as follows: cognitive interviews, 10 participants; reliability testing ≥ 10; item reduction ≥ 50; and final validation, 150 respondents.
The Chicago Food Allergy Research surveys offer validated tools to assess food allergy knowledge and perceptions among three distinct populations: a 42 item parent tool, a 50 item physician tool, and a 35 item general public tool. No such tools were previously available.
PMCID: PMC2736935  PMID: 19664230
18.  Food allergy knowledge, attitudes and beliefs: Focus groups of parents, physicians and the general public 
BMC Pediatrics  2008;8:36.
Food allergy prevalence is increasing in US children. Presently, the primary means of preventing potentially fatal reactions are avoidance of allergens, prompt recognition of food allergy reactions, and knowledge about food allergy reaction treatments. Focus groups were held as a preliminary step in the development of validated survey instruments to assess food allergy knowledge, attitudes, and beliefs of parents, physicians, and the general public.
Eight focus groups were conducted between January and July of 2006 in the Chicago area with parents of children with food allergy (3 groups), physicians (3 groups), and the general public (2 groups). A constant comparative method was used to identify the emerging themes which were then grouped into key domains of food allergy knowledge, attitudes, and beliefs.
Parents of children with food allergy had solid fundamental knowledge but had concerns about primary care physicians' knowledge of food allergy, diagnostic approaches, and treatment practices. The considerable impact of children's food allergies on familial quality of life was articulated. Physicians had good basic knowledge of food allergy but differed in their approach to diagnosis and advice about starting solids and breastfeeding. The general public had wide variation in knowledge about food allergy with many misconceptions of key concepts related to prevalence, definition, and triggers of food allergy.
Appreciable food allergy knowledge gaps exist, especially among physicians and the general public. The quality of life for children with food allergy and their families is significantly affected.
PMCID: PMC2564918  PMID: 18803842
19.  Using a Standardized Donor Ratio to Assess Organ Procurement Organizations 
Health Services Research  2002;37(5):1329-1344.
To develop a Standardized Donor Ratio (SDR) as an outcome measure for evaluating the effectiveness of organ procurement organizations (OPOs).
Data Sources/Study Setting
All deaths by cause in the United States during 1993–1994 as reported in the Vital Mortality Statistics, Multiple Cause of Death files. The OPO-specific data were provided by the United Network for Organ Sharing (UNOS).
Study Design
Each OPO's expected number of donors was calculated by applying national donation rates to deaths with potential for donation in 24 age, sex, and race cells. The SDR was calculated by dividing the observed number of donors by the expected number. The X2 tests of the hypothesis that the OPO's performance differed from the national norm of 1.0 were performed. The SDR was compared to the existing performance standard based on the unadjusted number of donors per million live population in the OPO's service area. An ordinary least squares (OLS) regression assessed predictors of the SDR.
Principal Findings
The SDRs ranged from 0.41 to 1.99. Twenty-nine of 64 OPOs had SDRs significantly different than 1.0. The SDRs were positively associated with the percent of white living population and the number of organ types transplanted per transplant center served by the OPO.
The SDRs can be used by Centers for Medicare and Medicaid Services (CMS), UNOS, and OPOs to target quality improvement initiatives, present more accurate comparisons of OPO performance, and develop public policy on the evaluation of the effectiveness of organ procurement efforts.
PMCID: PMC1464027  PMID: 12479499
Organ donation; organ procurement organization; effectiveness

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