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.

Methods

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.

Results

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).

Conclusions

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.

Objective

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.

Conclusions

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.

OBJECTIVE

To determine if there is an association between self-reported and biologic measures of stress in low-income, reproductive age women.

STUDY DESIGN

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.

RESULTS

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).

CONCLUSION

Measures of self-reported psychosocial stress are associated with elevated levels EBV antibody in a low-income population of reproductive age women.

Innovation

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.

Results

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.

Objectives

We examined the relationship between material hardship reported by low-income caregivers and caregivers' assessments of their children's overall health.

Methods

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.

Results

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.

Conclusions

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.

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Objective

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.

Conclusions

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.