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author:("toll, Jane L")
1.  Ambulatory care adverse events and preventable adverse events leading to a hospital admission 
Quality & Safety in Health Care  2007;16(2):127-131.
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.
doi:10.1136/qshc.2006.021147
PMCID: PMC2653165  PMID: 17403759
2.  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.
doi:10.1111/j.1600-6143.2012.04139.x
PMCID: PMC3429784  PMID: 22703471
Medical Error; Preventable Errors; Organ Donation; Disease Transmission; Patient Safety; ABO incompatibility
3.  Material Hardship and the Physical Health of School-Aged Children in Low-Income Households 
American journal of public health  2008;99(5):829-836.
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.
doi:10.2105/AJPH.2007.119776)
PMCID: PMC2667853  PMID: 18703452
4.  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.
Introduction
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1002/lt.23418
PMCID: PMC3365831  PMID: 22645057
cost-effectiveness; quality-adjusted life-years; regional variation; biliary complications
5.  NUTORC—a transdisciplinary health services and outcomes research team in transplantation 
ABSTRACT
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.
doi:10.1007/s13142-012-0176-x
PMCID: PMC3647618  PMID: 23667403
Transdisciplinary research teams; Health Services and Outcomes Research; Educational opportunities; Academic productivity; Sustainable research efforts
6.  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.
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.
doi:10.1016/j.jhep.2011.01.040
PMCID: PMC3177011  PMID: 21338639
7.  The relationship between self-report and biomarkers of stress in low-income, reproductive age women 
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.
doi:10.1016/j.ajog.2010.08.002
PMCID: PMC3000746  PMID: 20870203
biomarkers; C-reactive protein; Epstein-Barr virus; low-income women; stress
8.  Food allergy knowledge, attitudes and beliefs: Focus groups of parents, physicians and the general public 
BMC Pediatrics  2008;8:36.
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.
doi:10.1186/1471-2431-8-36
PMCID: PMC2564918  PMID: 18803842
9.  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.
doi:10.1007/s13142-012-0176-x
PMCID: PMC3647618  PMID: 23667403
Transdisciplinary research teams; Health Services and Outcomes Research; Educational opportunities; Academic productivity; Sustainable research efforts

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