The Organ Procurement and Transplantation Network monitors progress toward strategic goals such as increasing the number of transplants and improving waitlisted patient, living donor, and transplant recipient outcomes. However, a methodology for assessing system performance in providing equity in access to transplants was lacking. We present a novel approach for quantifying the degree of disparity in access to deceased donor kidney transplants among waitlisted patients and determine which factors are most associated with disparities. A Poisson rate regression model was built for each of 29 quarterly, period-prevalent cohorts (January 1, 2010-March 31, 2017; 5 years pre-kidney allocation system [KAS], 2 years post-KAS) of active kidney waiting list registrations. Inequity was quantified as the outlier-robust standard deviation (SD ) of predicted transplant rates (log scale) among registrations, after "discounting" for intentional, policy-induced disparities (eg, pediatric priority) by holding such factors constant. The overall SD declined by 40% after KAS implementation, suggesting substantially increased equity. Risk-adjusted, factor-specific disparities were measured with the SD after holding all other factors constant. Disparities associated with calculated panel-reactive antibodies decreased sharply. Donor service area was the factor most associated with access disparities post-KAS. This methodology will help the transplant community evaluate tradeoffs between equity and utility-centric goals when considering new policies and help monitor equity in access as policies change.

BackgroundIn May 2009, the New Zealand government announced a new policy aimed at improving the quality of Emergency Department care and whole hospital performance. Governments have increasingly looked to time targets as a mechanism for improving hospital performance and from a whole system perspective, using the Emergency Department waiting time as a performance measure has the potential to see improvements in the wider health system. However, the imposition of targets may have significant adverse consequences. There is little empirical work examining how the performance of the wider hospital system is affected by such a target. This project aims to answer the following questions: How has the introduction of the target affected broader hospital performance over time, and what accounts for these changes? Which initiatives and strategies have been successful in moving hospitals towards the target without compromising the quality of other care processes and patient outcomes? Is there a difference in outcomes between different ethnic and age groups? Which initiatives and strategies have the greatest potential to be transferred across organisational contexts?Methods/designThe study design is mixed methods; combining qualitative research into the behaviour and practices of specific case study hospitals with quantitative data on clinical outcomes and process measures of performance over the period 2006-2012. All research activity is guided by a Kaupapa Māori Research methodological approach. A dynamic systems model of acute patient flows was created to frame the study. Consequences of the target (positive and negative) will be explored by integrating analyses and insights gained from the quantitative and qualitative streams of the study.DiscussionAt the time of submission of this protocol, the project has been underway for 12 months. This time was necessary to finalise both the case study sites and the secondary outcomes through key stakeholder consultation. We believe that this is an appropriate juncture to publish the protocol, now that the sites and final outcomes to be measured have been determined.

Objective: The present study aims to inform the use of discharge summaries as a marker of the quality of communication between ED and primary care; this systematic review aims to identify a consensus on the key components of a high-quality discharge summary. Method: A systematic search of the major medical and allied health databases and Google Scholar was conducted, using predetermined criteria for inclusion. Two authors independently reviewed the full texts of potentially relevant studies to determine eligibility for inclusion. Data were extracted using a standard form, and the level of evidence was assessed using a predetermined scale. Results: We screened 827 articles, and 84 articles underwent full-text review. Thirty-two studies were included, and 15 studies were level A or B studies. The agreement between authors for level of evidence was good: k = 0.62 (95% confidence interval [CI] 0.4-0.84) and for which components were included was 1011/1056, 95.7% (95% CI 94.3-96.8%). Thirty-four components were identified; however, only four were ranked as important by ≥80% of respondents or scored ≥80% on a scale of importance. These were: discharge diagnosis, treatment received, investigation results and followup plan. The quality of information contained in summaries was incompletely assessed in most studies. Conclusion:The key components to include in a discharge summary are the discharge diagnosis, treatment received, results of investigations and the follow up required. The limited evidence pertaining to ED discharges was consistent with this. The adequacy of the components rather than just their presence or absence should also be considered when assessing the quality of discharge summaries.

Objective: Despite the spread of time targets for ED lengths of stay around the world, there have been few studies exploring the effects of such policies on quality of ED care. The Shorter Stays in Emergency Departments (SSED) National Research Project seeks to address this. The purpose of this paper was to describe how the indicators for the SSED study in New Zealand were selected and validated. Methods: A literature review was used to identify potential indicators. A reference group of 25 key stakeholders from across the health system was convened, with the aims of validating the suggested indicators and to ensure that other candidate indicators were not overlooked. A thematic analysis using a general inductive approach was used to analyse focus group discussions. Results: The major themes were communication, access, timeliness, appropriateness and satisfaction. The 12 indicators selected after literature review were confirmed and two further indicators added after the thematic analysis. The indicators are: hospital and ED length of stay; re‐presentation within 48 h; mortality; times to reperfusion, antibiotics, asthma treatment, analgesia, CT for head injury and to theatre (appendicitis and fractured neck of femur); triage time compliance; proportion who left without being seen; quality of discharge information; and ED overcrowding/access block. Conclusion: Through literature review and consultation with stakeholders, an evidence‐based and clinically relevant set of indicators was compiled with which to measure the effect of the SSED target. This indicator set is consistent with recent international recommendations for measuring quality of care in EDs.

Introduction of the target was not associated with a change in times to steroids in ED, although more patients received steroids in ED indicating closer adherence to recommended practice.