Renee R. Anspach

Decision Making in Liver Transplant Selection Committees: A Multicenter Study

BACKGROUND To receive a liver transplant, patients must first be placed on a waiting list-a decision made at most transplant centers by a multidisciplinary committee. The function of these committees has never been studied. OBJECTIVE To describe decision making in liver transplant committees and identify opportunities for process improvement. DESIGN Observational multicenter study. SETTING 4 liver transplant centers in the United States. PARTICIPANTS 68 members of liver transplant committees across the 4 centers. MEASUREMENTS 63 meetings were observed, and 50 committee members were interviewed. Recorded transcripts and field notes were analyzed by using standard qualitative sociologic methods. RESULTS Although the structure of the meetings varied by center, the process was uniform and primarily involved inductive reasoning to review possible reasons for patient exclusion. Patients were excluded if they were too well, too sick (in the setting of advanced liver disease), or too old or had nonhepatic comorbid conditions, substance abuse problems, or other psychosocial barriers. Dominant themes in the discussions included member angst over deciding who lived or died, a high correlation between psychosocial barriers to transplantation and the patients socioeconomic status, and the influence of external forces on decision making. Unwritten center policies and confusion regarding advocacy versus stewardship roles were consistently identified as barriers to effective group decision making. LIMITATIONS The use of qualitative methods provides broad understanding but limits specific inferences. The 4 centers may not reflect the practices of every transplant center nationwide. CONCLUSION The difficult decisions made by liver transplant committees are reasonably consistent and well-intentioned, but the process might be improved by having more explicit written policies and clarifying roles. This may inform resource allocation in other areas of medicine. PRIMARY FUNDING SOURCE The Greenwall Foundation and the National Institutes of Health.

Everyday Methods for Assessing Organizational Effectiveness

Consistent with a growing interest among organizational sociologists and evaluation researchers, this paper examines effectiveness as a socially constructed phenomenon in a study of how providers and consumers in social programs decide that their programs are working. Through analysis of data collected as part of an evaluation of a program to integrate former mental patients into their local communities, five everyday evaluation methods are identified: (1) measuring “success” against personal trajectories, (2) interpreting acts in the context of relationships, (3) using the dramatic incident, (4) relying on appearances of involvement, and (5) scaling goals to meet shifting constraints. Analysis shows that participants use devices for maintaining and sustaining beliefs in effectiveness despite evidence to the contrary. The understanding of everyday evaluation methods suggests the need for new models and research strategies in the study of effectiveness. As organizational survival strategies designed to instill commitment to the labor process, everyday evaluation methods, no less than the more “scientific” ones, are significant forms of organizational behavior that merit further study.

Gender and Health Care

The health care system often affects men and women differently. Health care occupations and professions are sex segregated, with men constituting a majority of physicians and women predominating in occupations that are less prestigious and poorly paid. Gender also affects medical encounters. There is evidence that male and female patients are treated differently and that there are tensions in physician–patient relationships. Women patients are less likely than men to be treated aggressively for heart disease, kidney disease, and AIDS. Women physicians are more likely to order preventive screening and to adopt more collaborative styles of communication with patients. Treatment of womens medical problems has varied historically and cross-culturally. In Europe and America, the reproductive phases in the female life course—childbirth, menstruation, and menopause—have been medicalized, a trend typically accompanied by the growth of medical technologies, some of which have adversely affected womens health. Recent research on gender and health care has moved away from an exclusive focus on gender and toward a focus on the intersection of gender with race, class, and other forms of inequality.

The Study of Medical Institutions Eliot Freidson's Legacy

During more than three decades of scholarship on American medicine, Eliot Freidson has both contributed to and advocated a distinctive variety of medical sociology: one that applies structural perspectives to medical institutions and remains detached from medicines own viewpoints and assumptions. This article reviews Freidsons legacy to six substantive arenas in the study of medical institutions. It then examines the evolving status of the type of scholarship Freidson championed. Conventional wisdom holds that medical sociology is in the doldrums because applied work has supplanted discipline-grounded research. This article suggests a counterhypothesis: Institutionally oriented medical sociology is no less prevalent than in the past; rather, the perceived salience of this type of work has declined because of trends within sociology at large.

Decision Making in Liver Transplant Selection Committees

To better understand how liver transplant centers make decisions to list patients for liver transplantation, researchers observed selection committee meetings at 4 centers in the United States and ...

Interhospital transfer of children in respiratory failure: a clinician interview qualitative study.

Purpose: To investigate the decision making underlying transfer of children with respiratory failure from level II to level I pediatric intensive care unit care. Methods: Interviews with 19 eligible level II pediatric intensive care unit physicians about a hypothetical scenario of a 2‐year‐old girl in respiratory failure:Baseline: Ventilator settings: rate 25, peak inspiratory pressure 28, positive end‐expiratory pressure 8, fraction of inspired oxygen (Fio2) 100%Escalation Point (EP) 1: after 8 hours. Higher ventilator settings; oxygenation index (OI) 32EP 2: 3 hours later. OI 40 Results: At baseline, indices critical to management were as follows: OI (53%), partial pressure of oxygen in arterial blood (Pao2)/Fio2 (32%), and inflation pressure (16%). Poor clinical response was signified by high OI, inflation pressure, and Fio2, and low Pao2/Fio2. At EP 1, 18 of 19 respondents would initiate high‐frequency oscillatory ventilation, and 1 would transfer. At EP 2, 15 of 18 respondents would maintain high‐frequency oscillatory ventilation, 9 of them calling to discuss transfer. All respondents would transfer if escalated therapies failed to reverse the patients clinical deterioration. Conclusion: Interhospital transfer of children in respiratory failure is triggered by poor response to escalation of locally available care modalities. This finding provides new insight into decision making underlying interhospital transfer of children with respiratory failure.

Interhospital Transfer of Children in Septic Shock: A Clinician Interview Qualitative Study

Objective: To determine the factors that influence the decision to transfer children in septic shock from level II to level I pediatric intensive care unit (PICU) care. Design: Interviews with level II PICU physicians in Michigan and Northwest Ohio. A hypothetical scenario of a 14-year-old boy in septic shock was presented. Baseline: 40 mL/kg fluid resuscitation, central venous and peripheral arterial access, and high-dose vasopressor infusions were provided. Escalation Point: After 2 hours. When the patient is in catecholamine-resistant shock and oliguric, invasive mechanical ventilation is initiated. Measurements and Main Results: All 19 eligible physicians participated. At baseline, respondents would assess measures of perfusion and hemodynamics: blood pressure (BP; 15 [79%]), lactate (12 [63%]), and central venous oxygen saturation (ScvO2; 10 [53%]). Poor clinical response was signified by low BP (11 [58%]), elevated lactate (9 [47%]), low urine output (8 [42%]), and low ScvO2 (6 [32%]). At the escalation point, 13 of 18 respondents felt there was <50% probability of clinical turnaround without escalating treatment, though only 3 (16%) would call to discuss transfer. Seven (37%) respondents would give more fluid, whereas 8 (42%) would use central venous pressure to guide fluid resuscitation. Ultimately, 15 (79%) respondents would transfer for extracorporeal membrane oxygenation (ECMO) or renal replacement therapy if there was no response to escalated care. Four (21%) respondents would not transfer the patient: 1 felt appropriate care could be provided in the level II PICU, 2 felt transfer was unconventional, and 1 was unaware ECMO could be provided in refractory septic shock. Conclusions: Level II to level I PICU transfer of children with septic shock is triggered by perceived nonresponse to locally available therapies. Few referring physicians do not transfer children in refractory septic shock. This study provides new insight into decision-making that influences the interhospital transfer of children with septic shock.