Program-specific transplant rate ratios: Association with allocation priority at listing and posttransplant outcomes.

The Scientific Registry of Transplant Recipients (SRTR) is considering more prominent reporting of program-specific adjusted transplant rate ratios (TRRs). To enable more useful reporting of TRRs, SRTR updated the transplant rate models to adjust explicitly for components of allocation priority. We evaluated potential associations between TRRs and components of allocation priority that could indicate programs' ability to manipulate TRRs by denying or delaying access to low-priority candidates. Despite a strong association with unadjusted TRRs, we found no candidate-level association between the components of allocation priority and adjusted TRRs. We found a strong program-level association between median laboratory Model for End-stage Liver Disease (MELD) score at listing and program-specific adjusted TRRs (r = .37; P < .001). The program-level association was likely confounded by regional differences in donor supply/demand and listing practices. In kidney transplantation, higher program-specific adjusted TRRs were weakly associated with better adjusted posttransplant outcomes (r = -.14; P = .035) and lower adjusted waitlist mortality rate ratios (r = -.15; P = .022), but these associations were absent in liver, lung, and heart transplantation. Program-specific adjusted TRRs were unlikely to be improved by listing candidates with high allocation priority and can provide useful information for transplant candidates and programs.

The Impact of Redistricting Proposals on Health Care Expenditures for Liver Transplant Candidates and Recipients.

Redistricting, which means sharing organs in novel districts developed through mathematical optimization, has been proposed to reduce pervasive geographic disparities in access to liver transplantation. The economic impact of redistricting was evaluated with two distinct data sources, Medicare claims and the University HealthSystem Consortium (UHC). We estimated total Medicare payments under (i) the current allocation system (Share 35), (ii) full regional sharing, (iii) an eight-district plan, and (iv) a four-district plan for a simulated population of patients listed for liver transplant over 5 years, using the liver simulated allocation model. The model predicted 5-year transplant volumes (Share 35, 29,267; regional sharing, 29,005; eight districts, 29,034; four districts, 28,265) and a reduction in overall mortality, including listed and posttransplant patients, of up to 676 lives. Compared with current allocation, the eight-district plan was estimated to reduce payments for pretransplant care ($1638 million to $1506 million, p < 0.001), transplant episode ($5607 million to $5569 million, p < 0.03) and posttransplant care ($479 million to $488 million, p < 0.001). The eight-district plan was estimated to increase per-patient transportation costs for organs ($8988 to $11,874 per patient, p < 0.001) and UHC estimated hospital costs ($4699 per case). In summary, redistricting appears to be potentially cost saving for the health care system but will increase the cost of performing liver transplants for some transplant centers.

Broader Geographic Sharing of Pediatric Donor Lungs Improves Pediatric Access to Transplant.

US pediatric transplant candidates have limited access to lung transplant due to the small number of donors within current geographic boundaries, leading to assertions that the current lung allocation system does not adequately serve pediatric patients. We hypothesized that broader geographic sharing of pediatric (adolescent, 12-17 years; child, <12 years) donor lungs would increase pediatric candidate access to transplant. We used the thoracic simulated allocation model to simulate broader geographic sharing. Simulation 1 used current allocation rules. Simulation 2 offered adolescent donor lungs across a wider geographic area to adolescents. Simulation 3 offered child donor lungs across a wider geographic area to adolescents. Simulation 4 combined simulations 2 and 3. Simulation 5 prioritized adolescent donor lungs to children across a wider geographic area. Simulation 4 resulted in 461 adolescent transplants per 100 patient-years on the waiting list (range 417-542), compared with 206 (range 180-228) under current rules. Simulation 5 resulted in 388 adolescent transplants per 100 patient-years on the waiting list (range 348-418) and likely increased transplant rates for children. Adult transplant rates, waitlist mortality, and 1-year posttransplant mortality were not adversely affected. Broader geographic sharing of pediatric donor lungs may increase pediatric candidate access to lung transplant.

A workshop for receptionists in mental health settings.

This article addresses an area which has received little attention in the mental health field--the education and training needs of receptionists. Factors that can assist or impede the contribution of this important position are identified. The authors describe the process used to design and deliver a one-day workshop to enhance receptionists' interpersonal skills, and to increase their understanding of mental health issues. The benefits of this experience for the individual and for mental health organizations are described.

Improving accessibility: the experience of a Canadian Mental Health Agency.

This article describes the process undertaken by a community mental health organization in Toronto, whose staff are predominantly white and unilingual, to be more accessible and responsive to Toronto's diverse ethnic communities. Board, staff, and consumer input provided guidance for the development of antidiscrimination and antiracism policies, and subsequently for expectations that each program find ways to implement these policies. The article focuses on events and opportunities of one of the programs that led to connections being established between the organization and the Somali community.

[The Community Resources Consultants of Toronto (CRCT): Two Case Management Programs.]. / Le Community Resources Consultants de Toronto : deux programmes de case management.

This article describes two well established case management services which were developed in response to clearly identified gaps in the mental health system in Toronto. The significance of case management and its place in the mental health system are addressed. CRCT's service philosophy and how that philosophy is put into operation at an organizational level and in the delivery of case management service is described. Client vignettes illustrate the day-to-day work of the case managers and the importance of a strong working alliance.

Evaluating a case management service: a family perspective.

This article describes how a long-standing community-based case management service conducted a survey of clients and their family members. The overall objectives of the survey were twofold: to learn how best to undertake such a survey and to get feedback from service users about the strengths and limitations of the service with suggestions for improvement. A steering committee was established, comprising key stakeholders of the service: consumers, family members, case managers, and other service providers. Steering Committee members were actively involved in shaping the questions, designing the instruments, conducting parts of the survey, and preparing the report and recommendations for the board of directors. This article reports on the process of the survey, the findings of the survey of family members, and service modifications that were introduced as a result of family members' feedback. The benefits and significance of actively involving family members throughout the survey are discussed.

Suicide in a community based case management service.

Over a 9 year period, 532 people with a long term mental illness received the services of a community based case management program. Of the 532 clients, 13 committed suicide (2%). This group was compared to a control group matched for age, sex and length of stay in the program. No differences were found with regard to most socio-demographic and clinical variables investigated. However, statistically significant differences were found with regard to chronicity and number of post-admittance hospitalizations. Difficulties in establishing a working relationship were noted more often for clients who committed suicide. Some of the implications for case management programs are discussed.

The management of hypertension in Queensland general practice.

This survey indicates that hypertension in Queensland is primarily treated by general practitioners. It suggests a real need for a professionally endorsed information package for general practitioners and overwhelmingly points to the need for lifestyle information for patient use. It also identifies the elderly as a special treatment group.

Social support and married agoraphobic women.

This study was conducted to determine if a relationship exists between social support and agoraphobia. Married agoraphobic women from a support group for phobics were compared with married, non-agoraphobic women from Family Practice clinics, and social support factors were examined. The agoraphobic women were found to perceive their husbands as less supportive. As well, there were important reductions in network size and network support in these agoraphobic women.

Efficacy of prostaglandin E1 in the treatment of lower extremity ischemic ulcers secondary to peripheral vascular occlusive disease. Results of a prospective randomized, double-blind, multicenter clinical trial.

Most previous reports suggesting beneficial effects of prostaglandin E1 (PGE1) have been retrospective and uncontrolled. Therefore, this study was undertaken to assess the efficacy of PGE1 in the treatment of ischemic ulcers in patients with peripheral vascular occlusive disease (PVOD). One hundred twenty patients with one to three ischemic ulcers not healing for 3 weeks with standard care were randomized to receive either PGE1 (20 ng/kg/min) or a placebo for 72 hours through a central venous catheter. Ulcers were measured and photographed, and the rest pain was evaluated before and after infusion and at 1- and 2-month follow-up intervals. Fifty-seven patients with 95 ulcers received PGE1. Seventeen ulcers healed (18%); 22 ulcers decreased in size (23%); 37 ulcers remained unchanged or increased in size (39%); five new ulcers developed during the study (5%); and 14 ulcers had inadequate follow-up (15%). Sixty-three patients with 115 ulcers received a placebo. Nineteen ulcers healed (16%); 38 ulcers decreased in size (33%); 45 ulcers remained unchanged or increased in size (39%); three new ulcers developed during the study (3%); and 10 ulcers had inadequate follow-up (9%). None of the above differences between the drug-treated group and the placebo-treated group was statistically significant. This study did not demonstrate efficacy for intravenously administered PGE1 in the healing of ischemic ulcers in patients with PVOD.

A psychiatric clinic for the deaf.

From the increasing number of requests being received by the Deafness Clinic (as many in the first three months of 1981 as in the whole of 1980), it would appear there is a sizable minority in Canada for whom psychiatric and mental health services are not easily accessible in their present form. Not only does hearing impairment significantly affect language, communication and social skills acquisition, it also separates persons so affected from services that other Canadians take for granted.

Co-therapy in a clinic for schizophrenia.

In the outpatient treatment of schizophrenia, the routine practice of providing each patient with two co-therapists results in several benefits: reduced dependency, increased expertise, objective monitoring, added support and morale for the therapists, more obvious and therefore more reversible countertransference, more obvious and therefore more treatable "splitting" and "projecting." Despite these benefits, problems arise in the two-therapist arrangement. They are discussed under the following headings: loyalty conflicts; limit setting; crisis management; family work. The authors report on techniques of co-therapy problem prevention and problem resolution. Though not always successful, co-therapy continues to be a useful model of service delivery to schizophrenic outpatients.