Does screening or routine enquiry for adverse childhood experiences (ACEs) meet criteria for a screening programme? A rapid evidence summary.

BACKGROUND: Adverse childhood experiences (ACEs) are traumatic events in childhood that can have impacts throughout life. It has been suggested that ACEs should be 'screened' for, or routinely enquired about, in childhood or adulthood. The aim of this work is to review evidence for this against the United Kingdom National Screening Committee (UKNSC) programme criteria. METHODS: A rapid review of evidence on ACEs screening was conducted using the approach of the UKNSC. RESULTS: Good quality evidence was identified from meta-analyses for associations between ACEs and a wide range of adverse outcomes. There was no consistent evidence on the most suitable screening tool, setting of administration, and time or frequency of use. Routine enquiry among adults was feasible and acceptable to service users and professionals in various settings. A wide range of potentially effective interventions was identified. Limited evidence was available on the potential for screening or routine enquiry to reduce morbidity and mortality or possible harms of screening. CONCLUSIONS: Based on the application of available evidence to UKNSC screening criteria, there is currently insufficient evidence to recommend the implementation of a screening programme for ACEs. Further research is needed to determine whether routine enquiry can improve morbidity, mortality, health and wellbeing.

How can we achieve impact from public health research? A meta-ethnography of case studies.

BACKGROUND: Generation of public health impact from research is challenging. Research of similar quality often has differential uptake and there is considerable lag time between initiation and uptake of research. Improving understanding of how research impact can be achieved may identify areas stakeholders could target. METHODS: This work uses meta-ethnography to synthesize 21 case studies exploring how researchers have generated public health policy impact. RESULTS: Eight constructs were identified: expertise; motivation; practical solutions to important problems; support structure and funding; collaboration; wide dissemination and use of media to contribute ideas to the wider narrative; understanding the policy realm; and models of impact. The constructs were combined in a lines-of-argument synthesis, producing a model that seeks to illustrate the diffuse, complex and dynamic nature of the process of generating impact from research. CONCLUSION: Achieving research impact involves seeking to shape wider debates, building relationships with policy makers, becoming a trusted collaborator and being available to provide relevant and practical solutions to questions of concern to policy makers at the appropriate time.

Why is translating research into policy so hard? How theory can help public health researchers achieve impact?

OBJECTIVE: To describe how overly simple conceptualisations of how research is translated into public health policy impact impair effective translation. To suggest how alternative approaches to conceptualising impact, which incorporate recent developments in social and political sciences, can help stakeholders improve translation of high-quality public health research into policy impact. STUDY DESIGN: Researchers often describe generating impact in terms of linear or cyclical models, in which the production of scientific findings alone compels action and leads to impact. However, such conceptualisations do not appear to have supported improved translation of research into policy and practice. Improving understanding of how research impact is achieved may identify areas stakeholders seeking to achieve impact could target. METHODS: Overview of theoretical and practical approaches to achieving public health policy impact from research. RESULTS: Despite much evidence that translating research into public health policy is more complex than linear and cyclical models suggest, stakeholders often revert to these heuristics, that is shorthand ways of thinking that allow simple but inaccurate answers to complex problems. This leads to potentially missing opportunities for impact, such as conducting research in collaboration with local policy makers and contributing ideas to the wider narrative through the media and public engagement. CONCLUSION: The process of translating research into impact appears more complex than that suggested by linear and cyclical models. Success involves a planned approach targeting multiple routes to impact, sustained over time.

Effectiveness of a voluntary family befriending service: a mixed methods evaluation using the Donabedian model.

OBJECTIVES: Voluntary befriending schemes operate in many countries, promoting public health by supporting vulnerable individuals and families. Use of third sector and voluntary services to complement health and social care provision is increasingly important globally in the context of economic and demographic challenges, but the evidence base around such collaborations is limited. This article reports the results of operational evaluation research seeking to use robust routine work to generate transferable findings for use by those commissioning and providing services. The subject of our evaluation research is 'Home-Start Suffolk' (HSS) in Suffolk County, UK, an example of a third sector organisation commissioned to support the public health offer to local families. STUDY DESIGN: This evaluation research used the Donabedian framework, which assesses the structure, process and outcome in delivery of health services. METHODS: Methods included a cross-sectional stakeholder survey with qualitative and quantitative elements (n = 96), qualitative interviews (n = 41) and quantitative analysis of the service's routine data (5740 visits) for the period from 01 July 2014 to 01 July 2016. RESULTS: Triangulation of data from each component revealed that HSS was perceived by diverse stakeholders to successfully support families in need of additional help. HSS service users perceived the service to offer greater flexibility, to be tailored to their needs and to be more trustworthy and supportive than statutory services. Volunteering with HSS enabled people to feel productive in their community and gain new skills. Managers of social care services perceived that HSS activity decreased burden on their staff. These benefits were facilitated through a long-standing organisational HSS structure and relationships between HSS and social care. Challenges posed by service provision by a third sector organisation included the need for volunteers to negotiate the boundary between being a friend and a professional outside of a professional framework. Quantitative analysis of impact was limited by the poor quality of routinely collected administrative data, highlighting the importance of planning processes for data collection with evaluation in mind. CONCLUSION: We believe that the results of this evaluation research provide transferrable lessons. They demonstrate how a third sector organisation with a long-standing structure and relationships with statutory services was able to reduce perceived service burden while also offering support in a more flexible and tailored way greatly valued by service users.

Waitlist Outcomes of Liver Transplant Candidates Who Were Reprioritized Under Share 35.

Under Share 35, deceased donor (DD) livers are offered regionally to candidates with Model for End-Stage Liver Disease (MELD) scores ≥35 before being offered locally to candidates with MELD scores <35. Using Scientific Registry of Transplant Recipients data from June 2013 to June 2015, we identified 1768 DD livers exported to regional candidates with MELD scores ≥35 who were transplanted at a median MELD score of 39 (interquartile range [IQR] 37-40) with 30-day posttransplant survival of 96%. In total, 1764 (99.8%) exports had an ABO-compatible candidate in the recovering organ procurement organization (OPO), representing 1219 unique reprioritized candidates who would have had priority over the regional candidate under pre-Share 35 allocation. Reprioritized candidates had a median waitlist MELD score of 31 (IQR 27-34) when the liver was exported. Overall, 291 (24%) reprioritized candidates had a comparable MELD score (within 3 points of the regional recipient), and 209 (72%) were eventually transplanted in 11 days (IQR 3-38 days) using a local (50%), regional (50%) or national (<1%) liver; 60 (21%) died, 13 (4.5%) remained on the waitlist and nine (3.1%) were removed for other reasons. Of those eventually transplanted, MELD score did not increase in 57%; it increased by 1-3 points in 37% and by ≥4 points in 5.7% after the export. In three cases, OPOs exchanged regional exports within a 24-h window. The majority of comparable reprioritized candidates were not disadvantaged; however, 21% died after an export.

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.

Early changes in liver distribution following implementation of Share 35.

In June 2013, a change to the liver waitlist priority algorithm was implemented. Under Share 35, regional candidates with MELD ≥ 35 receive higher priority than local candidates with MELD < 35. We compared liver distribution and mortality in the first 12 months of Share 35 to an equivalent time period before. Under Share 35, new listings with MELD ≥ 35 increased slightly from 752 (9.2% of listings) to 820 (9.7%, p = 0.3), but the proportion of deceased-donor liver transplants (DDLTs) allocated to recipients with MELD ≥ 35 increased from 23.1% to 30.1% (p < 0.001). The proportion of regional shares increased from 18.9% to 30.4% (p < 0.001). Sharing of exports was less clustered among a handful of centers (Gini coefficient decreased from 0.49 to 0.34), but there was no evidence of change in CIT (p = 0.8). Total adult DDLT volume increased from 4133 to 4369, and adjusted odds of discard decreased by 14% (p = 0.03). Waitlist mortality decreased by 30% among patients with baseline MELD > 30 (SHR = 0.70, p < 0.001) with no change for patients with lower baseline MELD (p = 0.9). Posttransplant length-of-stay (p = 0.2) and posttransplant mortality (p = 0.9) remained unchanged. In the first 12 months, Share 35 was associated with more transplants, fewer discards, and lower waitlist mortality, but not at the expense of CIT or early posttransplant outcomes.

Center-level utilization of kidney paired donation.

With many multicenter consortia and a United Network for Organ Sharing program, participation in kidney paired donation (KPD) has become mainstream in the United States and should be feasible for any center that performs live donor kidney transplantation (LDKT). Lack of participation in KPD may significantly disadvantage patients with incompatible donors. To explore utilization of this modality, we analyzed adjusted center-specific KPD rates based on casemix of adult LDKT-eligible patients at 207 centers between 2006 and 2011 using SRTR data. From 2006 to 2008, KPD transplants became more evenly distributed across centers, but from 2008 to 2011 the distribution remained unchanged (Gini coefficient = 0.91 for 2006, 0.76 for 2008 and 0.77 for 2011), showing an unfortunate stall in dissemination. At the 10% of centers with the highest KPD rates, 9.9-38.5% of LDKTs occurred through KPD during 2009-2011; if all centers adopted KPD at rates observed in the very high-KPD centers, the number of KPD transplants per year would increase by a factor of 3.2 (from 494 to 1593). Broader implementation of KPD across a wide number of centers is crucial to properly serve transplant candidates with healthy but incompatible live donors.

Addressing geographic disparities in liver transplantation through redistricting.

Severe geographic disparities exist in liver transplantation; for patients with comparable disease severity, 90-day transplant rates range from 18% to 86% and death rates range from 14% to 82% across donation service areas (DSAs). Broader sharing has been proposed to resolve geographic inequity; however, we hypothesized that the efficacy of broader sharing depends on the geographic partitions used. To determine the potential impact of redistricting on geographic disparity in disease severity at transplantation, we combined existing DSAs into novel regions using mathematical redistricting optimization. Optimized maps and current maps were evaluated using the Liver Simulated Allocation Model. Primary analysis was based on 6700 deceased donors, 28 063 liver transplant candidates, and 242 727 Model of End-Stage Liver Disease (MELD) changes in 2010. Fully regional sharing within the current regional map would paradoxically worsen geographic disparity (variance in MELD at transplantation increases from 11.2 to 13.5, p = 0.021), although it would decrease waitlist deaths (from 1368 to 1329, p = 0.002). In contrast, regional sharing within an optimized map would significantly reduce geographic disparity (to 7.0, p = 0.002) while achieving a larger decrease in waitlist deaths (to 1307, p = 0.002). Redistricting optimization, but not broader sharing alone, would reduce geographic disparity in allocation of livers for transplant across the United States.

Dynamic challenges inhibiting optimal adoption of kidney paired donation: findings of a consensus conference.

While kidney paired donation (KPD) enables the utilization of living donor kidneys from healthy and willing donors incompatible with their intended recipients, the strategy poses complex challenges that have limited its adoption in United States and Canada. A consensus conference was convened March 29-30, 2012 to address the dynamic challenges and complexities of KPD that inhibit optimal implementation. Stakeholders considered donor evaluation and care, histocompatibility testing, allocation algorithms, financing, geographic challenges and implementation strategies with the goal to safely maximize KPD at every transplant center. Best practices, knowledge gaps and research goals were identified and summarized in this document.

Equal Opportunity Supplemented by Fair Innings: equity and efficiency in allocating deceased donor kidneys.

For 7 years, the Kidney Transplantation Committee of the United Network for Organ Sharing/Organ Procurement Transplantation Network has attempted to revise the kidney allocation algorithm for adults (≥18 years) in end-stage renal disease awaiting deceased donor kidney transplants. Changes to the kidney allocation system must conform to the 1984 National Organ Transplant Act (NOTA) which clearly states that allocation must take into account both efficiency (graft and person survival) and equity (fair distribution). In this article, we evaluate three allocation models: the current system, age-matching and a two-step model that we call "Equal Opportunity Supplemented by Fair Innings (EOFI)". We discuss the different conceptions of efficiency and equity employed by each model and evaluate whether EOFI could actually achieve the NOTA criteria of balancing equity and efficiency given current conditions of growing scarcity and donor-candidate age mismatch.

The economic implications of broader sharing of liver allografts.

Liver transplantation has evolved over the past four decades into the most effective method to treat end-stage liver failure and one of the most expensive medical technologies available. Accurate understanding of the financial implication of recipient severity of illness is crucial to assessing the economic impact of allocation policies. A novel database of linked clinical data from the Organ Procurement and Transplantation Network with cost accounting data from the University HealthSystem Consortium was used to analyze liver transplant costs for 15,813 liver transplants. This data was then utilized to consider the economic impact of alternative allocation systems designed to increase sharing of liver allografts using simulation results. Transplant costs were strongly associated with recipient severity of illness as assessed by the MELD score (p < 0.0001); however, this relationship was not linear. Simulation analysis of the reallocation of livers from low MELD patients to high MELD using a two-tiered regional sharing approach (MELD 15/25) resulted in 88 fewer deaths annually at estimated cost of $17,056 per quality-adjusted life-year saved. The results suggest that broader sharing of liver allografts offers a cost-effective strategy to reduce the mortality from end stage liver disease.

MELD Exceptions and Rates of Waiting List Outcomes.

Model for End-stage Liver Disease (MELD)-based allocation of deceased donor livers allows exceptions for patients whose score may not reflect their true mortality risk. We hypothesized that organ procurement organizations (OPOs) may differ in exception practices, use of exceptions may be increasing over time, and exception patients may be advantaged relative to other patients. We analyzed longitudinal MELD score, exception and outcome in 88 981 adult liver candidates as reported to the United Network for Organ Sharing from 2002 to 2010. Proportion of patients receiving an HCC exception was 0-21.4% at the OPO-level and 11.9-18.8% at the region level; proportion receiving an exception for other conditions was 0.0%-13.1% (OPO-level) and 3.7-9.5 (region-level). Hepatocellular carcinoma (HCC) exceptions rose over time (10.5% in 2002 vs. 15.5% in 2008, HR = 1.09 per year, p<0.001) as did other exceptions (7.0% in 2002 vs. 13.5% in 2008, HR = 1.11, p<0.001). In the most recent era of HCC point assignment (since April 2005), both HCC and other exceptions were associated with decreased risk of waitlist mortality compared to nonexception patients with equivalent listing priority (multinomial logistic regression odds ratio [OR] = 0.47 for HCC, OR = 0.43 for other, p<0.001) and increased odds of transplant (OR = 1.65 for HCC, OR = 1.33 for other, p<0.001). Policy advantages patients with MELD exceptions; differing rates of exceptions by OPO may create, or reflect, geographic inequity.

The roles of dominos and nonsimultaneous chains in kidney paired donation.

Efforts to expand kidney paired donation have included matching nondirected donors (NDDs) to incompatible pairs. In domino paired donation (DPD), an NDD gives to the recipient of an incompatible pair, beginning a string of simultaneous transplants that ends with a living donor giving to a recipient on the deceased donor waitlist. Recently, nonsimultaneous extended altruistic donor (NEAD) chains were introduced. In a NEAD chain, the last donor of the string of transplants initiated by an NDD is reserved to donate at a later time. Our aim was to project the impact of each of these strategies over 2 years of operation for paired donation programs that also allocate a given number of NDDs. Each NDD facilitated an average of 1.99 transplants using DPD versus 1.90 transplants using NEAD chains (p = 0.3), or 1.0 transplants donating directly to the waitlist (p < 0.001). NEAD chains did not yield more transplants compared with simultaneous DPD. Both DPD and NEAD chains relax reciprocality requirements and rebalance the blood-type distribution of donors. Because traditional paired donation will leave many incompatible pairs unmatched, novel approaches like DPD and NEAD chains must be explored if paired donation programs are to help a greater number of people.

Influenza B virus infection in pediatric solid organ transplant recipients.

OBJECTIVE: Influenza B virus causes epidemic infection in normal children, but only one case of infection in an immunocompromised solid organ transplant (SOT) recipient has been reported. Characterization of the clinical course of influenza B virus infection in pediatric SOT recipients may increase the utilization of preventive and therapeutic interventions by pediatricians caring for these immunocompromised children. DESIGN: Retrospective chart review of patients whose respiratory viral cultures yielded influenza B from January 1989 through March 1992. PATIENTS: Twelve pediatric SOT recipients with influenza B virus infection were identified. These included five renal, four hepatic, and three cardiac allograft recipients, ranging from 19 months to 17 years 9 months of age (median 6 years 2 months). The posttransplant interval ranged from 6 weeks to 4 years 6 months (average 26.7 months). No patient had been immunized against influenza. Exposure histories were documented for eight children; five of these occurred in the hospital. RESULTS: Clinical symptoms included fever (12/12), respiratory (11/12), or gastrointestinal complaints (8/12). Five patients had neurologic involvement; one died of uncal herniation. Ten children were hospitalized (median duration, 3 days; range, 2 to 79 days). Two patients (post-transplant interval, 3 to 8 months) required mechanical ventilation, and one of these received aerosolized ribavirin. Three children had concurrent allograft rejection. CONCLUSIONS: Influenza B infection is potentially life-threatening in pediatric SOT recipients. We recommend annual immunization of pediatric SOT recipients, their household contacts, and health care workers. Prospective studies are needed to evaluate the efficacy of influenza vaccination in pediatric SOT recipients.

Comparison of cardiovascular responses and left ventricular work during exercise before and after artificial heart implantation.

Cardiovascular dynamics and left ventricular work were evaluated in 15 resting, standing, and treadmill-exercised calves before and at periodic intervals after their natural hearts (NH) were replaced with an artificial heart (AH). Standing produced increases in heart rate, cardiac output, oxygen uptake, and left ventricular work and decreases in mean aortic pressure and systemic vascular resistance in NH calves which were more marked with exercise. AH calves had higher aortic pressures, cardiac output, systemic vascular resistance, oxygen uptake, and left ventricular work during resting conditions in the first 2 postoperative weeks than did NH calves, which gradually returned to values similar to the latter by the fifth week after operation. Exercise was not tolerated early after AH implantation, but was after 5 to 6 weeks. Our results indicate that AH calves increase cardiac output with exercise by reducing systemic vascular resistance, whereas NH animals respond similarly, but also increase heart rate. The data suggest that a marked elevation in systemic vascular resistance early after AH implantation increases left ventricular work and prevents adequate rises in cardiac output to all but minor increases in metabolic requirements.