Comparison of listing strategies for allosensitized heart transplant candidates requiring transplant at high urgency: a decision model analysis.

Allosensitized children who require a negative prospective crossmatch have a high risk of death awaiting heart transplantation. Accepting the first suitable organ offer, regardless of the possibility of a positive crossmatch, would improve waitlist outcomes but it is unclear whether it would result in improved survival at all times after listing, including posttransplant. We created a Markov decision model to compare survival after listing with a requirement for a negative prospective donor cell crossmatch (WAIT) versus acceptance of the first suitable offer (TAKE). Model parameters were derived from registry data on status 1A (highest urgency) pediatric heart transplant listings. We assumed no possibility of a positive crossmatch in the WAIT strategy and a base-case probability of a positive crossmatch in the TAKE strategy of 47%, as estimated from cohort data. Under base-case assumptions, TAKE showed an incremental survival benefit of 1.4 years over WAIT. In multiple sensitivity analyses, including variation of the probability of a positive crossmatch from 10% to 100%, TAKE was consistently favored. While model input data were less well suited to comparing survival when awaiting transplantation across a negative virtual crossmatch, our analysis suggests that taking the first suitable organ offer under these circumstances is also favored.

Patient race and ethnicity in primary care management of child behavior problems: a report from PROS and ASPN. Pediatric Research in Office Settings. Ambulatory Sentinel Practice Network.

BACKGROUND: Minority persons have less access to many specialty treatments and services, possibly because of clinician biases. It is not clear whether any such biases exist in primary care settings, especially for children with psychosocial problems. OBJECTIVES: The objective was to compare primary care recognition and treatment of pediatric psychosocial problems among African American, Hispanic American and European American patients. DESIGN: A survey was made of parents and respective clinicians in primary care offices in two large practice-based research networks (PROS and ASPN) from 44 states, Canada, and Puerto Rico. Mixed regression analyses were employed to control for patient, clinician, and practice effects. SUBJECTS: The subjects were 14,910 children aged 4 to 15 years seen consecutively for non-emergent care by 286 primary care clinicians in office-based practice. MEASURES: Measures were parents' report for sociodemographics and behavioral symptoms using the Pediatric Symptom Checklist, and clinicians' report of psychosocial problems, type, management, and severity. RESULTS: Of the sample, 8.0% were African American youth, 9.5% were Hispanic American youth, and 82.5% were European American youth. After controlling for other factors, race and ethnicity were not associated with any differences in psychotropic drug prescribing, counseling, referral, or recognition of psychosocial problems. Clinicians reported spending slightly more time with minority patients. CONCLUSION: Race and ethnic status were not related to receipt of mental health services for children in primary care offices, suggesting that clinician biases may not be the primary cause of the racial differences in services noted earlier research. Improving services for minority youth may require increasing access to office-based primary care.