Assessing Consensus Between UK Renal Clinicians on Listing for Kidney Transplantation: A Modified Delphi Study.

BACKGROUND: It is well recognized that there is significant variation between centers in access to kidney transplantation. In the absence of high-grade evidence, it is unclear whether variation is due to patient case mix, other center factors, or individual clinician decisions. This study sought consensus between UK clinicians on factors that should influence access to kidney transplantation. METHODS: As part of the Access to Transplantation and Transplant Outcome Measures project, consultant nephrologists and transplant surgeons in 71 centers were invited to participate in a Delphi study involving 2 rounds. During rounds 1 and 2, participants rated their agreement to 29 statements covering 8 topics regarding kidney transplantation. A stakeholder meeting was used to discuss statements of interest after the 2 rounds. RESULTS: In total, 122 nephrologists and 16 transplant surgeons from 45 units participated in rounds 1 and 2. After 2 rounds, 12 of 29 statements reached consensus. Fifty people participated in the stakeholder meeting. After the stakeholder meeting, a further 4 statements reached agreement. Of the 8 topics covered, consensus was reached in 6: use of a transplant protocol, patient age, body mass index, patient compliance with treatment, cardiac workup, and use of multidisciplinary meetings. Consensus was not reached on screening for malignancy and use of peripheral Doppler studies. CONCLUSIONS: The Delphi process identified factors upon which clinicians agreed and areas where consensus could not be achieved. The findings should inform national guidelines to support decision making in the absence of high quality evidence and to guide areas that warrant future research

Variation in practice patterns for listing patients for renal transplantation in the United Kingdom: a national survey

Introduction: Despite the availability of guidelines for the evaluation of candidates for renal transplantation, variation in access to transplantation exists. This national survey investigates whether centre variation exists in the assessment of patients for renal transplantation in the UK. Methods: An online survey, informed by qualitative interviews, was distributed to all UK renal centres. This survey examined centre approaches to chronic kidney disease service provision, transplant recipient assessment, education provision and wait-listing decision making processes. Centre re-evaluation policies for patients already listed and priorities for future development were also examined. Results: All 71 renal centres responded. Of these, 83% reviewed pre-dialysis patients in a low clearance clinic. In 26% of centres transplantation was not discussed as a treatment option with all patients. Fourteen centres reported having a dedicated transplant assessment clinic whilst 28% did not have a formal assessment protocol. Age was an exclusion criterion for listing in three centres, all of which had a cut off at 75 years. 83% of centres excluded patients with a high BMI. Cardiac investigations were risk-stratified in 90% of centres. Surgical involvement varied with 11% of centres listing patients without formal surgical review. There was no formal protocol in place to re-evaluate listed patients in 62% of centres. Conclusions: There is wide variation in UK practice patterns for listing patients for renal transplantation, though its impact on access to transplantation is unclear. The extent to which centre-specific and patient-specific factors affect access to transplantation requires further analysis in a prospective cohort of patients.</p

Multimedia for international operations: a case study

Geographically-dispersed, global service organizations must find cost-effective ways of delivering consistent service quality while recognizing local differences in service culture. For such organizations, the management of operations cannot be separated from issues of training, corporate culture, and organizational identity. This paper presents an analysis of the experience of Avis Europe, a leading car rental firm, in developing a multimedia system for training frontline staff. The case illustrates how multimedia technologies enable a new sort of organizational text that has implications for the way in which operations may be documented and enacted. In particular, multimedia allows texts that are complex enough to address issues of what Hochschild describes as emotional labor in service operations. These developments have great significance for both practice and research in operations management.

Variation in practice patterns for listing patients for renal transplantation in the United Kingdom : a national survey

Background.Despite the availability of guidelines for the evaluation of candidates for renal transplantation, variation in access to transplantation exists. This national survey investigates whether center variation exists in the assessment of patients for renal transplantation in the United Kingdom. Methods. An online survey, informed by qualitative interviews, was distributed to all UK renal centers. This survey examined center approaches to chronic kidney disease service provision, transplant recipient assessment, education provision, and waitlisting decision making processes. Center reevaluation policies for patients already listed and priorities for future development were also examined. Results. All 71 renal centers responded. Of these, 83% reviewed pre-dialysis patients in a low clearance clinic. In 26% of the centers, transplantation was not discussed as a treatment option with all patients. Fourteen centers reported having a dedicated transplant assessment clinic, whereas 28% did not have a formal assessment protocol. Age was an exclusion criterion for listing in 3 centers, all of which had a cutoff at 75 years. Eighty-three percent of the centers excluded patients with a high body mass index. Cardiac investigations were risk-stratified in 90%of centers. Surgical involvement varied with 11%of centers listing patients without formal surgical review. There was no formal protocol in place to reevaluate listed patients in 62% of centers. Conclusions. There is wide variation in UK practice patterns for listing patients for renal transplantation, though its impact on access to transplantation is unclear. The extent to which center-specific and patient-specific factors affect access to transplantation requires further analysis in a prospective cohort of patients