Changing Metrics of Organ Procurement Organization Performance in Order to Increase Organ Donation Rates in the United States.

The shortage of deceased-donor organs is compounded by donation metrics that fail to account for the total pool of possible donors, leading to ambiguous donor statistics. We sought to assess potential metrics of organ procurement organizations (OPOs) utilizing data from the Nationwide Inpatient Sample (NIS) from 2009-2012 and State Inpatient Databases (SIDs) from 2008-2014. A possible donor was defined as a ventilated inpatient death ≤75 years of age, without multi-organ system failure, sepsis, or cancer, whose cause of death was consistent with organ donation. These estimates were compared to patient-level data from chart review from two large OPOs. Among 2,907,658 inpatient deaths from 2009-2012, 96,028 (3.3%) were a "possible deceased-organ donor." The two proposed metrics of OPO performance were: (1) donation percentage (percentage of possible deceased-donors who become actual donors; range: 20.0-57.0%); and (2) organs transplanted per possible donor (range: 0.52-1.74). These metrics allow for comparisons of OPO performance and geographic-level donation rates, and identify areas in greatest need of interventions to improve donation rates. We demonstrate that administrative data can be used to identify possible deceased donors in the US and could be a data source for CMS to implement new OPO performance metrics in a standardized fashion.

Effect of insurance status on patients admitted for acute diverticulitis.

AIM: The study aimed to evaluate the relationship between insurance status and the management and outcome of acute diverticulitis in a nationally representative sample. METHOD: A retrospective cohort analysis of a nationally representative sample of 1 031 665 hospital discharges of patients admitted for acute diverticulitis in the 2006-2009 Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project data set. The main outcome measures included state at presentation (complicated/uncomplicated), management (medical/surgical), time to surgical intervention, type of operation and inpatient death. RESULTS: In total, 207 838 discharges were identified (including 37.0% with private insurance, 49.3% in Medicare, 5.6% in Medicaid and 5.8% uninsured) representing 1 031 665 total discharges nationally. Medicare patients were more likely to present with complicated diverticulitis compared with private insurance patients (23.8% vs 15.1%). Time to surgical intervention differed by insurance status. After adjusting for patient, hospital and treatment factors, Medicare patients were less likely than those with private insurance to undergo a procedure (Medicare OR = 0.86, 95% CI: 0.82-0.91), while the uninsured were more likely to undergo drainage (OR = 1.30, 95% CI: 1.16-1.46) or a colostomy only (OR = 1.70, 95% CI: 1.24-2.33). All patients without private insurance were more likely to die in hospital (Medicare OR = 1.29, 95% CI: 1.09-1.52; Medicaid OR = 1.55, 95% CI: 1.22-1.97; uninsured OR = 1.41, 95% CI: 1.07-1.87). CONCLUSION: In a nationally representative sample of patients with acute diverticulitis, patient management and outcome varied significantly by insurance status, despite adjustment for potential confounders. Providers might need to heighten surveillance for complications when treating patients without private insurance to improve outcome.

Non-fatal and fatal crash injury risk for children in minivans compared with children in sport utility vehicles.

OBJECTIVE: To compare the fatal and non-fatal crash injury risk for children in minivans compared with midsize and large sport utility vehicles (SUVs). DESIGN: Three large population-based sources of US crash data were used--a nationwide cohort of sampled police-reported crashes (NASS-CDS) along with a census of fatal crashes (FARS), plus a large child crash surveillance system, Partners for Child Passenger Safety (PCPS)--collected in 16 states via insurance claim records and validated telephone survey. Each included: 2000-2006 data, occupants aged 0-15 years, traveling in minivan or (midsize/large) SUV, model year 1998-2007. Outcome of interest was parent/driver report of non-fatal injury (Abbreviated Injury Scale scores of 2 or higher) in PCPS and fatal injury in NASS-CDS/FARS. RESULTS: Compared with children riding in SUVs, those in minivans experienced a similar crude reduction in the relative risk of non-fatal injury (PCPS: unadjusted odds ratio (OR) = 0.55) and fatality (NASS-CDS/FARS cohort: unadjusted OR = 0.58). In PCPS, this reduction in injury risk changed little after adjustment for child, driver, and vehicle factors (adjusted OR = 0.56, 95% CI 0.38 to 0.82). Lower fatality risk in the NASS-CDS/FARS cohort was partially explained by the same factors (adjusted OR = 0.76, 95% CI 0.51 to 1.13). CONCLUSIONS: There may be important safety differences in vehicles during a crash that lead to fewer non-fatal injuries to child occupants of minivans compared with SUVs.

Trip characteristics of vehicle crashes involving child passengers.

OBJECTIVES: To describe the trip characteristics of vehicle crashes involving children, and to examine the effect of situational factors on front row seating or inappropriate restraint for young children. METHODS: A cross sectional study was conducted on children <16 years in crashes of insured vehicles in 15 US states, with data collected using insurance claims records and a telephone interview. A descriptive analysis of the characteristics of vehicle crashes involving children was performed. Multivariate Poisson regression was used to identify situational factors associated with inappropriate restraint or front row seating. RESULTS: These data suggest that children were traveling in vehicles involved in crashes that occurred under usual driving circumstances-that is, closer to home (60%), on a local road (56%), during normal daytime hours (71%), within areas with relatively lower posted speed limits (76%). Compared with children involved in morning crashes, those in daytime crashes (RR = 1.65, 95% CI 1.13 to 2.49) or in night-time crashes (RR = 1.63, 95% CI 1.09 to 2.67) were more likely to be sitting in the front seat. Children involved in night-time crashes were more likely to be inappropriately restrained (RR = 1.12, 95% CI 1.01 to 1.22) than those in daytime crashes. Children riding with two or more additional passengers were more likely to be inappropriately restrained (RR = 1.12, 95% CI 1.02 to 1.27) than those with no other passengers. CONCLUSIONS: Educational initiatives should aim to increase the perception that parents have about the potential crash risk of everyday trips. Some situational characteristics of trips were associated with inappropriate restraint and front row seating behaviors for young children.

Trends in booster seat use among young children in crashes.

INTRODUCTION: Booster seat use in the United States is extremely low among 4- to 8-year-old children, the group targeted for their use. However, more recent attention has been paid to the role of booster seats for children who have outgrown their forward-facing child safety seat. In particular, several states are currently considering upgrades to their child restraint laws to include the use of booster seats for children over 4 years of age. OBJECTIVE: To examine recent trends in booster seat use among children involved in automobile crashes in 3 large regions of the United States. DESIGN: This study was performed as part of the Partners for Child Passenger Safety project, an ongoing, child-specific crash surveillance system that links insurance claims data to telephone survey and crash investigation data. All crashes occurring between December 1, 1998, and November 30, 2000, involving a child occupant between 2 to 8 years of age riding in a model year 1990 or newer vehicle reported to State Farm Insurance Companies from 15 states and Washington, DC, were eligible for this study. A probability sample of eligible crashes was selected for a telephone survey with the driver of the vehicle using a previously validated instrument. The study sample was weighted according to each subject's probability of selection, with analyses conducted on the weighted sample. RESULTS: The weighted study sample consisted of 53 834 children between 2 to 8 years old, 11.5% of whom were using a booster seat at the time of the crash. Booster seat use peaked at age 3 and dropped dramatically after age 4. Over the period of study, booster seat use among 4- to 8-year-olds increased from 4% to 13%. Among 4-year-olds specifically, booster use increased from 14% to 34%. Among children using booster seats, approximately half used shield boosters and half used belt-positioning boosters. CONCLUSIONS: Although overall booster seat use among the targeted population of 4- to 8-year-old children remains low, significant increases have been noted among specific age groups of children over the past 2 years. These data may be useful to pediatricians, legislators, and educators in efforts to target interventions designed to increase appropriate booster seat use in these children.

Cognitive and psychomotor effects of paroxetine and sertraline on healthy elderly volunteers.

The authors evaluated the cognitive and psychomotor effects of serotonin reuptake inhibitors in healthy elderly volunteers. Paroxetine, sertraline, and placebo were compared for 3 weeks of testing in a double-blind study with behavioral testing at baseline and at the end of each week. MANOVA models demonstrated no between-group differences; however, mixed-model random regression analyses revealed that Day 14 plasma paroxetine levels correlated negatively with delayed verbal recall and paired-associate learning scores. In contrast, plasma sertraline levels correlated positively with Day 7 immediate verbal recall, Day 14 tapping, and Day 21 delayed verbal recall scores, and negatively with divided-attention task scores on Day 21. Plasma paroxetine levels were associated with mild behavioral impairment at Day 14, with no other significant adverse effects. Plasma sertraline levels were associated with mild and transient behavioral changes, as well as early termination in several subjects.

Validating the diagnosis of delirium and evaluating its association with deterioration over a one-year period.

The authors probed the associations between clinical diagnoses and independent research measures of cognitive, behavioral, and electroencephalographic (EEG) changes in hospitalized older patients and investigated the contribution of medical illness to deterioration. Patients (N=96; 47 of whom were hospitalized during the course of 1 year; 12 diagnosed with delirium) received tests of cognitive and physical functioning and the Cumulative Illness Rating Scale, specific neuropsychological tests, and a two-channel EEG. Delirium was associated with independent measures of cognitive decline and EEG slowing. Hospitalization was associated with deterioration in functional status during the year, whether or not patients showed delirium. Results suggest that medical illness leading to hospitalization can contribute significantly to deterioration in self-care, and, when it is associated with delirium, to deterioration in cognitive performance and cerebral activity over a period of 1 year.

Rear seating and risk of injury to child occupants by vehicle type.

The safety of rear-seated child passengers was evaluated across vehicle types. 113,887 children under age 16 in crashes were enrolled as part of an on-going crash surveillance system which links insurance claims data to telephone survey and crash investigation data. Children in the second row suffered less significant injuries than those in the front in all vehicle types except compact extended cab pickup trucks in which the risk for children in the rear was 13% as compared to 2.8% for front-seated occupants. Further research is needed to identify the child and vehicle characteristics which might explain this increased injury risk.

The danger of premature graduation to seat belts for young children.

OBJECTIVE: To determine the risk of significant injury associated with premature graduation of young (2- to 5-year-old) children to seat belts from child restraint systems (CRS). BACKGROUND: Advocates recommend use of child safety seats for children younger than age 4 and booster seats for children age 4 and older. Despite these recommendations, many children are prematurely taken out of these child restraints and placed in seat belts. Although data exist to support the use of child restraints over nonrestraint, no real-world data exist to evaluate the risk of significant injury associated with premature use of seat belts. DESIGN/METHODS: Partners for Child Passenger Safety includes a child-focused crash surveillance system based on a representative sample of children ages 0 to 15 years in crashes involving 1990 and newer vehicles reported to State Farm Insurance Companies in 15 states and the District of Columbia. Driver reports of crash circumstances and parent reports of child occupant injury were collected via telephone interview using validated surveys. Results were weighted based on sampling frequencies to represent the entire population. RESULTS: Between December 1, 1998, and November 30, 1999, 2077 children aged 2 to 5 years were included and were weighted to represent 13 853 children. Among these young children, 98% were restrained, but nearly 40% of these children were restrained in seat belts. Compared with children in CRS, children in seat belts were more likely to suffer a significant injury (relative risk: 3.5; 95% confidence interval: [2. 4, 5.2]). Children in seat belts were at particular risk of significant head injuries (relative risk: 4.2; 95% confidence interval: [2.6, 6.7]) when compared with children in CRS. CONCLUSIONS: Premature graduation of young children from CRS to seat belts puts them at greatly increased risk of injury in crashes. A major benefit of CRS is a reduction in head injuries, potentially attributable to a reduction in the amount of head excursion in a crash.