Using a standardized donor ratio to assess the performance of organ procurement organizations

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 chi2 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.     

Potential organ-donor supply and efficiency of organ procurement organizations

The authors estimated the supply of organ donors in the U.S. and also according to organ procurement organizations (OPOs). They estimated the number of donors in the U.S. to be 16,796. Estimates of the number of potential donors for each OPO were used to calculate the level of donor efficiency (actual donors as a percent of potential donors). Overall, donor efficiency for OPOs was 35 percent; the majority was between 30- and 40-percent efficient. Although there is room to improve donor efficiency in the U.S., even a substantial improvement will not meet the Nation's demand for organs.     

A methodological framework for optimally reorganizing liver transplant regions.

BACKGROUND: The United States is divided currently into 11 transplant regions, which vary in area and number of organ procurement organizations (OPOs). Region size affects organ travel time and organ viability at transplant. PURPOSE: To develop a methodologic framework for determining optimal configurations of regions maximizing transplant allocation efficiency and geographic parity. METHODS: An integer program was designed to maximize a weighted combination of 2 objectives: 1) intraregional transplants, 2) geographic parity-maximizing the lowest intraregional transplant rate across all OPOs. Two classes of functions relating liver travel time to liver viability were also examined as part of the sensitivity analyses. RESULTS: Preliminary results indicate that reorganizing regions, while constraining their number to 11, resulted in up to 17 additional transplants/year depending on the travel-viability function; when not constrained, it resulted in up to 18/year of increase. CONCLUSION: Our analysis indicates that liver transplantation may benefit through region reorganization. The analytic method developed here should be applicable to other organs and sets of organs.     

Difficult Communication: Compliance-Gaining Strategies of Organ Procurement Coordinators

Organ procurement coordinators (OPCs) face a formidable communication task when making familial requests for consent to organ donation, because they must provide social support for grieving family members while seeking compliance to the donation request. Structured interviews were conducted with 102 OPCs, representing 16 organ procurement organizations (OPOs) (27.6% of national organizations) across the United States. Responses were transcribed and content-analyzed along four domain areas: (a) establishing credibility, (b) message strategies, (c) timing/setting of requests, and (d) adaptation of messages to diverse families. OPO conversion rates were used as a criterion factor for OPCs' persuasive communication success and regressed onto self-reported strategy use. Results indicate message strategies varied at the OPC level of analysis and 7 techniques significantly predicted 32% of the variance in conversion rates. Two strategies (i.e., gaining early intervention, approaching with additional support) positively influenced conversion rates, whereas 5 strategies (e.g., discussing benefits as a persuasive strategy, emphasizing the need for donation in particular racial/ethnic groups) negatively influenced conversion rates. Future research is recommended to validate the study findings toward the goal of improving OPCs' communication strategies.     

Difficult communication: compliance-gaining strategies of organ procurement coordinators

Organ procurement coordinators (OPCs) face a formidable communication task when making familial requests for consent to organ donation, because they must provide social support for grieving family members while seeking compliance to the donation request. Structured interviews were conducted with 102 OPCs, representing 16 organ procurement organizations (OPOs) (27.6% of national organizations) across the United States. Responses were transcribed and content-analyzed along four domain areas: (a) establishing credibility, (b) message strategies, (c) timing/setting of requests, and (d) adaptation of messages to diverse families. OPO conversion rates were used as a criterion factor for OPCs' persuasive communication success and regressed onto self-reported strategy use. Results indicate message strategies varied at the OPC level of analysis and 7 techniques significantly predicted 32% of the variance in conversion rates. Two strategies (i.e., gaining early intervention, approaching with additional support) positively influenced conversion rates, whereas 5 strategies (e.g., discussing benefits as a persuasive strategy, emphasizing the need for donation in particular racial/ethnic groups) negatively influenced conversion rates. Future research is recommended to validate the study findings toward the goal of improving OPCs' communication strategies.     

Transplantation-transmitted tuberculosis--Oklahoma and Texas, 2007

Approximately 28,000 organ transplants were performed in the United States in 2007. When infections are transmitted from donors, the implications can be serious for multiple recipients. Tuberculosis (TB), a known infectious disease complication associated with organ transplantation, occurs in an estimated 0.35%-6.5% of organ recipients in the United States and Europe posttransplantation. In 2007, the Oklahoma State Department of Health identified Mycobacterium tuberculosis in an organ donor 3 weeks after the donor's death. This report summarizes results of the subsequent investigation, which determined that disseminated TB occurred in two of three transplant recipients from this donor, and one recipient died. Genotypes of the donor and recipient TB isolates were identical, consistent with transmission of TB by organ transplantation. To reduce the risk for TB transmission associated with organ transplantation, organ recovery personnel should consider risk factors for TB when assessing all potential donors. In addition, clinicians should recognize that transplant recipients with TB might have unusual signs or symptoms. When transmission is suspected, investigation of potential donor-transmitted TB requires rapid communication among physicians, transplant centers, organ procurement organizations (OPOs), and public health authorities.     

Assessing emerging technologies--the case of organ replacement technologies: volume, durability, cost

OBJECTIVES: The aim of this study was to estimate thresholds for production volume, durability, and cost of care for the cost-effective adoption of liver organ replacement technologies (ORTs). METHODS: We constructed a discrete-event simulation model of the liver allocation system in the United States. The model was calibrated against UNOS data (1994-2000). Into this model, we introduced ORTs with varying durability (time to failure), cost of care, and production volume. Primary outputs of interest were time to 5 percent reduction in the waiting list and time to 5 percent increase in expected transplant volume. RESULTS: Model output for both calibration and validation phases closely matched published data: waiting list length (+/-2 percent), number of transplants (+/-2 percent), deaths while waiting (+/-5 percent), and time to transplant (+/-11 percent). Reducing the waiting list was dependent on both ORT durability and production volume. The longer the durability, the less production volume needed to reduce the waiting list and vice versa. However, below 250 ORT/year, durability needed to be >2 years for any significant change to be seen in the waiting list. For base-case costs, all ORT production volume and durability scenarios result in more transplants per year at less total cost of care/patient than the current system. ORTs remain cost saving until manufacturing costs are >5 times base-case costs, production is less 500 ORT/year, and durability <6 months. CONCLUSIONS: Although there remain many technical challenges to overcome, as long as ORTs can meet these threshold criteria, they have the potential of transforming the world of end-stage liver disease.     

The impact of graduate medical education on teaching hospital efficiency

This quantitative research study assesses the efficiency of university teaching hospitals in providing hospital services and graduate medical education, identifying areas in which inefficient teaching hospitals differed from their efficient counterparts. The study analyzed American Hospital Association (AHA) data from 2002 in order to examine the efficiency of Council of Teaching Hospital (COTH) hospitals. An efficiency frontier was determined using Data Envelopment Analysis, an effective method of measuring efficiency widely accepted within the health care management literature. The study found that the performance of teaching hospitals increased approximately 6.6 percent when graduate medical education (GME) was included as a key measure of output. Additionally, average excess operating expenses per hospital went from $29,447,581 without residents to $8,321,407 with residents. The average excess full-time employees decreased by 24 percent from 187 without residents to 143 with residents. Conversely, the shortage of outpatient visits increased from an average of 29,461 per hospital without residents to 36,155 with residents. This study clearly documents the need to include GME when benchmarking teaching hospitals. It also shows inefficient COTH hospitals could save approximately $1.6 billion in excess overhead expenses if they emulate the practices of the most efficient members.     

A national study of the efficiency of hospitals in urban markets.

Using a sample of 3,000 urban hospitals, this article examines the contributions of selected hospital characteristics to variations in hospital technical efficiencies, while it accounts for multiple products and inputs, and controls for local environmental variations. Four hospital characteristics are examined: hospital size, membership in a multihospital system, ownership, and payer mix (managed care contracts, percent Medicare, and percent Medicaid). Ownership and percent Medicare are consistently found to be related significantly to hospital efficiency. Within the ownership variable, government hospitals tend to be more efficient and for-profit hospitals less efficient than other hospitals. Higher percentages of Medicare payment are negatively related to efficiency. While not consistently significant across all five of the MSA size categories in which the analyses are conducted, possession of managed care contracts, membership in a multihospital system, and size all are consistently related positively to hospital technical efficiency. These variables are also all significant when the hospitals are examined in a combined analysis. Percent Medicaid was not significant in any of the analyses. Implications for policy and the need for methodological work are discussed.     

The efficiency of the delivery of neonatal care in the UK

BACKGROUND: A recent paper in Journal of Public Health Medicine (O'Neill et al., 2000; 22(1): 108-115) used regression modelling to determine the average costs of neonatal care services for a sample of 49 units in the United Kingdom in 1990-1991, and concluded that economies of scale were present in the sample as a whole. Although this form of modelling is useful, analysis of the efficiency of production for individual units is also important. METHODS: Data envelopment analysis (DEA) was used to analyse the data set published by O'Neil et al., to determine technical efficiency of neonatal units, measuring efficiency compared with a benchmark efficient frontier, and estimating economies of scale for each unit. Potential cost savings if units were to operate efficiently are estimated. RESULTS: There is evidence of substantial levels of technical inefficiency. Economies of scale varied between units, with increasing returns in the 36 inefficient units, and mainly constant returns in the 13 efficient units. This suggests that the presence of technical inefficiency was as important as scale inefficiencies. Total cost savings, if all units were operating efficiently, are estimated at ?10.4 million, equivalent to 10 extra units producing 57,000 additional days of care. CONCLUSIONS: DEA is a technique of great potential value in analysing the efficiency of health care production. As well as inefficiencies in the production of neonatal care in the United Kingdom due to differences in the scale of production, there appears to have been considerable technical inefficiency, which was not due to differences in case mix. The potential cost savings from efficiency gains are large.     

Managing urgent surgery as a process: Case study of a trauma center

OBJECTIVES: Industrial management principles could be used to improve the quality and efficiency of health care. In this study, we have evaluated the effects of a process management approach to trauma patient care. The major objective was to reduce the waiting times and increase the efficiency of the hospital. METHODS: Urgent surgery care was analyzed as an overall process. The process development followed the Plan-Do-Check-Act (PDCA) cycle and was based on statistical analysis of certain performance metrics. Data were collected from hospital databases and by personnel interviews. To develop the process, the anesthesia induction was performed outside the operating room, better process guidance was developed, and patient flow was reorganized. The transition time for these changes was 1 year (2002 to 2003). RESULTS: Waiting times decreased by 20.5 percent (p < .05), nonoperative times in the operating room were reduced by 23.1 percent (p < .001), and efficiency was increased by 9.7 percent (p < .001) after reengineering of the care process. Overtime hours decreased by 30.9 percent. CONCLUSIONS: Managing urgent surgical care as a process can improve the productivity and quality of care without a need to increase personnel resources. The focus should be on reducing waiting times and waste times.     

Efficiency of Health Care System in India: An Inter-State Analysis using DEA Approach

Since independence a massive personnel and public health infrastructure has been created in India. However, there is no competition and hardly any choice to the poor patients resulting in poor quality services leading to allocative and technical inefficiencies. This study uses the data envelopment analysis model to assess and compare the efficiency of health system within various states of India. It shows the inadequacy of health infrastructure and manpower in the inefficient states where poor people are concentrated. Among the determinants of efficiency female literacy, poverty level, institutional delivery, and full immunization of children are proved to be important factors in explaining efficiency of health system in India.     

National Hospital Ambulatory Medical Care Survey: 2004 outpatient department summary

OBJECTIVES: This report describes ambulatory care visits to hospital OPDs in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. Selected trends in OPD utilization from 1994 through 2004 are also presented. METHODS: The data presented in this report were collected in the 2004 NHAMCS, a national probability sample survey of visits to emergency and outpatient departments of nonfederal, short-stay, and general hospitals in the United States. Selected comparisons are also made with data from the 2004 National Ambulatory Medical Care Survey (NAMCS), a national probability sample survey of visits to office-based physicians in the United States. Sample data are weighted to produce annual national estimates. RESULTS: During 2004, an estimated 85.0 million visits were made to hospital OPDs in the United States, about 29.5 visits per 100 persons. Females (35.1 per 100 persons) had higher OPD visit rates than males (23.6 per 100 persons), and black or African American persons (50.3 per 100 persons) had higher OPD visit rates than white persons (27.0 visits per 100 persons). The overwhelming majority of visits to hospital OPDs were made by established patients (85.4 percent). Females made 75.5 percent of preventive care visits. The preventive care visit rate by Hispanic or Latino patients was twice the rate of non-Hispanic patients. Diagnostic and screening services were ordered at 90.3 percent of visits, therapeutic and preventive services were ordered at 50.0 percent of visits, and medications were ordered at 67.4 percent of visits. The proportion of visits involving only midlevel providers increased from 5.9 in 1993-94 to 11.4 percent of visits in 2003-04.     

National Hospital Ambulatory Medical Care Survey: 2000 outpatient department summary

OBJECTIVES: This report describes ambulatory care visits to hospital outpatient departments (OPDs) in the United States. Statistics are presented on selected hospital, clinic, patient, and visit characteristics. Highlights of trends in OPD utilization from 1997 through 2000 are also presented. METHODS: The data presented in this report were collected from the 2000 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability sample survey of visits to emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. Trends are based on NHAMCS data from 1997 through 2000. RESULTS: During 2000, an estimated 83.3 million visits were made to hospital OPDs in the United States, about 30.4 visits per 100 persons. Females had higher OPD visit rates than males (35.3 versus 25.2 visits per 100 persons). The OPD utilization rate for black persons was higher than for white persons (48.3 versus 28.0 visits per 100 persons). Of all visits made to hospital OPDs in 2000, private insurance (38.5 percent), Medicaid (22.1 percent), and Medicare (16.9 percent) were listed as the leading primary expected source of payment. Approximately 21 percent of OPD visits reported that patients belonged to an HMO. There were an estimated 9.5 million injury-related OPD visits in 2000. Since 1997, the percent of OPD visits that were for injuries increased by 24% (from 9.2 percent to 1.4 percent). Most of these visits were for unintentional injuries (57.6 percent), including those caused by falls (12.9 percent). Medications were prescribed at 64.0 percent of visits. On average, 1.6 medications were ordered at each OPD visit. In 2000, patients saw one or more physicians (i.e., staff physician, resident/intern, or other physician) at approximately 79 percent of visits. Most patients were given an appointment to return to the clinic (57.2 percent).     

Randomized trial of a brief physiotherapy intervention compared with usual physiotherapy for neck pain patients: cost-effectiveness analysis

OBJECTIVES: To assess the cost-effectiveness of brief physiotherapy intervention versus usual physiotherapy management in patients with neck pain of musculoskeletal origin in the community setting. METHODS: A cost-effectiveness analysis was conducted alongside a multicenter pragmatic randomized controlled clinical trial. Individuals 18 years of age and older with neck pain of more than 2 weeks were recruited from physiotherapy departments with referrals from general practitioners (GPs) in the East Yorkshire and North Lincolnshire regions in the United Kingdom. A total of 139 patients were allocated to the brief intervention, and 129 to the usual physiotherapy. Resource use data were prospectively collected on the number of physiotherapy sessions, hospital stay, specialist, and GP visits. Quality-adjusted life years (QALYs) were estimated using EQ-5D data collected at baseline, 3 and 12 months from the start of the treatment. The economic evaluation was conducted from the U.K. National Health System perspective. RESULTS: On average, brief intervention produced lower costs (pounds--68; 95 percent confidence interval [CI], pounds--103 to pounds--35) and marginally lower QALYs (-0.001; 95 percent CI, -0.030 to 0.028) compared with usual physiotherapy, resulting in an incremental cost per QALY of pounds 68,000 for usual physiotherapy. These results are sensitive to patients' treatment preferences. CONCLUSIONS: Usual physiotherapy may not be good value for money for the average individual in this trial but could be a cost-effective strategy for those who are indifferent toward which treatment they receive.     

National Hospital Ambulatory Medical Care Survey: 2005 outpatient department summary

OBJECTIVES: This report describes ambulatory care visits to hospital outpatient departments (OPDs) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. Selected trends in OPD utilization from 1995 to 2005 are also presented. METHODS: The data presented in this report were collected in the 2005 National Hospital Ambulatory Medical Care Survey (NHAMCS), a national probability sample survey of visits to emergency and OPDs of nonfederal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. RESULTS: During 2005, an estimated 90.4 million visits were made to hospital OPDs in the United States, about 31.0 visits per 100 persons. Females (37.2 per 100 persons) had higher OPD visit rates than males (24.7 visits per 100 persons), and black or African-American persons (56.8 visits per 100 persons) had higher OPD visit rates than white persons (28.3 visits per 100 persons). Visit rates to OPD clinics for preventive care were highest for children under 1 year of age (43.1 per 100 persons). Almost one-half of OPD visits (46.1 percent) were made by patients with one or more chronic conditions. Hypertension was the most frequent chronic condition listed (19.7 percent). Visits with asthma declined with increasing age. From 1995 to 2005, the following visit characteristics changed: The visit rate for children under 15 years of age increased by 38%, the percentage of visits made by adults 18 years and over with depression indicated on the medical record increased by 48%; visits by adults with obesity, diabetes, and hypertension increased by 24%, 34%, and 43%, respectively; visits with counseling for tobacco use increased from 2.7 to 3.8 percent; visits with counseling for diet and nutrition increased from 9.4 to 15.7 percent; and visits with 6 or more medications prescribed or provided more than doubled, from 4.9 to 11.2 percent.     

The Decomposition of Cost Efficiency: An Empirical Application of the Shadow Cost Function Model to Dutch General Hospitals

This paper investigates the performance of the Dutch general hospital industry by a parametric method. In general, the parametric approaches find more difficulties in distinguishing between technical and allocative efficiencies than DEA. Only recently a class of models is developed based on shadow prices which have possibilities to distinguish between technical and allocative efficiency. However, these models cause some serious computational problems. This paper recommends an approach to overcome these problems by using an iterative two-stage estimation procedure. The estimation is conducted on a panel data set of Dutch general hospitals. Estimation shows that this method is effective. The parameter estimates are plausible, reliable and satisfy all theoretical requirements. In particular we find some reliable estimates for the individual hospitals' shadow prices. According to these shadow prices hospitals should reallocate their resources in favor of material supplies at the cost of other personnel and nursing personnel. The mean technical efficiency is about 86%, whereas the allocative efficiency is about 92%. The outcomes also show that technical progress is very small. Economies of scale are present only for small hospitals.     

U.S. hospital workforce-to-population ratios by service area

Traditionally, hospital productivity has been measured in terms of episodic patient services such as days or admissions. However, the delivery of health care is shifting toward a greater focus on the health of a covered population. Thus, population-based indicators of hospital productivity are needed. This work analyzes hospital FTEs per 10,000 served population across the United States as a function of regional demographic, socioeconomic, and geographic factors. For managers of integrated service networks, it provides benchmarks for hospital FTEs per service population for several personnel categories. Important findings for public policy include an 11 percent increase in FTEs per 1 percent increase in interns and residents and a 2 percent increase in FTEs per 1 percent increase in the elderly.     

National Hospital Ambulatory Medical Care Survey: 2001 outpatient department summary

OBJECTIVES: This report describes ambulatory care visits to hospital outpatient departments (OPDs) in the United States. Statistics are presented on selected hospital, clinic, patient, and visit characteristics. The report highlights new items on continuity of care of OPD visits, including: whether the visit was the first or a followup for a problem, number of visits to the clinic during the past 12 months for established patients, and whether other physicians shared care for the patient's problem. The report also highlights variation in utilization across the major types of OPD clinics surveyed. METHODS: The data presented in this report were collected from the 2001 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability sample survey of visits to emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. RESULTS: During 2001, about 83.7 million visits were made to hospital OPDs in the United States. The 2001 rate (29.9 per 100 persons) represents a 33 percent increase since 1992. Females had higher OPD visit rates than males (35.2 versus 24.3 visits per 100 persons) and black or African-American persons had higher OPD visit rates than white persons (48.8 versus 27.9 visits per 100 persons). The majority of visits to hospital OPDs were made by patients with previous visits to the clinic (84.2 percent); 70.0 percent had visited the clinic one or more times during the past 12 months. Preventive care visits comprised 15.5 percent of all OPD visits; nearly three out of four preventive care visits were made by females (72.8 percent). Diagnostic and screening services were ordered or provided at 85.0 percent of visits, therapeutic and preventive services were ordered or provided at 45.6 percent of visits, and medications were prescribed at 64.6 percent of visits. Most patients were given an appointment to return to the clinic (60.1 percent).     

Effects of wearing the wrong glove size on shoulder and forearm muscle activities during simulated assembly work

This study was performed to determine the changes in electromyographic activities in the shoulder and forearm muscles when using the bare hands, well-fitting gloves, and gloves that are one size smaller or one size larger for simulated assembly operations. Sixteen asymptomatic seated workers with normal hands and no obvious deformities, skin diseases, or allergies were recruited. The subjects were asked to simulate assembly operations using their bare hands, well-fitting gloves, and one size smaller or one size larger. This study showed that wearing the wrong glove size led to a decrease in forceful activation of the forearm muscle and a compensatory increase in shoulder movement. In contrast, use of the bare hands or wearing well-fitting gloves led to effective forearm muscle activation, which decreased inefficient shoulder movement. These data indicate that wearing the wrong glove size will lead to continuous inefficient use of the forearm and shoulder muscles, and result in overuse of the shoulder.