Association Between Dialysis Facility Ownership and Access to the Waiting List and Transplant in Pediatric Patients With End-stage Kidney Disease in the US

Importance: Care of adults at profit vs nonprofit dialysis facilities has been associated with lower access to transplant. Whether profit status is associated with transplant access for pediatric patients with end-stage kidney disease is unknown. Objective: To determine whether profit status of dialysis facilities is associated with placement on the kidney transplant waiting list or receipt of kidney transplant among pediatric patients receiving maintenance dialysis. Design, Setting, and Participants: This retrospective cohort study reviewed the US Renal Data System records of 13 333 patients younger than 18 years who started dialysis from 2000 through 2018 in US dialysis facilities (followed up through June 30, 2019). Exposures: Time-updated profit status of dialysis facilities. Main Outcomes and Measures: Cox models, adjusted for clinical and demographic factors, were used to examine time to wait-listing and receipt of kidney transplant by profit status of dialysis facilities. Results: A total of 13 333 pediatric patients who started receiving maintenance dialysis were included in the analysis (median age, 12 years [IQR, 3-15 years]; 6054 females [45%]; 3321 non-Hispanic Black patients [25%]; 3695 Hispanic patients [28%]). During a median follow-up of 0.87 years (IQR, 0.39-1.85 years), the incidence of wait-listing was lower at profit facilities than at nonprofit facilities, 36.2 vs 49.8 per 100 person-years, respectively (absolute risk difference, -13.6 (95% CI, -15.4 to -11.8 per 100 person-years; adjusted hazard ratio [HR] for wait-listing at profit vs nonprofit facilities, 0.79; 95% CI, 0.75-0.83). During a median follow-up of 1.52 years (IQR, 0.75-2.87 years), the incidence of kidney transplant (living or deceased donor) was also lower at profit facilities than at nonprofit facilities, 21.5 vs 31.3 per 100 person-years, respectively; absolute risk difference, -9.8 (95% CI, -10.9 to -8.6 per 100 person-years) adjusted HR for kidney transplant at profit vs nonprofit facilities, 0.71 (95% CI, 0.67-0.74). Conclusions and Relevance: Among a cohort of pediatric patients receiving dialysis in the US from 2000 through 2018, profit facility status was associated with longer time to wait-listing and longer time to kidney transplant

Embedded ethics: Discourse and power in the New South Wales police service

In this paper we report an ethnographic research study conducted in one of the world's largest police organizations, the New South Wales Police Service. Our research question was, 'How do forms of power shape organizational members' ethical practices?' We look at existing theories that propose the deployment of two interrelated arguments: that ethics are embedded in organizational practices and discourse at a micro-level of everyday organizational life, which is contrasted with a focus on the macro-organizational, institutional forces that are seen to have an impact on ethics. Resisting this distinction between the 'micro' and the 'macro', we build on these two bodies of knowledge to explain ethical change as deeply embedded in power relations that traverse the scale of social action. copyright © 2009 SAGE Publications

Adapting California's Ecosystems to a Changing Climate

Significant efforts are underway to translate improved understanding of how climate change is altering ecosystems into practical actions for sustaining ecosystem functions and benefits. We explore this transition in California, where adaptation and mitigation are advancing relatively rapidly, through four case studies that span large spatial domains and encompass diverse ecological systems, institutions, ownerships, and policies. The case studies demonstrate the context specificity of societal efforts to adapt ecosystems to climate change and involve applications of diverse scientific tools (e.g., scenario analyses, downscaled climate projections, ecological and connectivity models) tailored to specific planning and management situations (alternative energy siting, wetland management, rangeland management, open space planning). They illustrate how existing institutional and policy frameworks provide numerous opportunities to advance adaptation related to ecosystems and suggest that progress is likely to be greatest when scientific knowledge is integrated into collective planning and when supportive policies and financing enable action