Annals of internal medicine
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Most physicians and hospitals are paid the same regardless of the quality of the health care they provide. This produces no financial incentives and, in some cases, produces disincentives for quality. Increasing numbers of programs link payment to performance. ⋯ Ongoing monitoring of incentive programs is critical to determine the effectiveness of financial incentives and their possible unintended effects on quality of care. Further research is needed to guide implementation of financial incentives and to assess their cost-effectiveness.
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Multicenter Study
Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate.
Glomerular filtration rate (GFR) estimates facilitate detection of chronic kidney disease but require calibration of the serum creatinine assay to the laboratory that developed the equation. The 4-variable equation from the Modification of Diet in Renal Disease (MDRD) Study has been reexpressed for use with a standardized assay. ⋯ The 4-variable MDRD Study equation provides reasonably accurate GFR estimates in patients with chronic kidney disease and a measured GFR of less than 90 mL/min per 1.73 m2. By using the reexpressed MDRD Study equation with the standardized serum creatinine assay, clinical laboratories can report more accurate GFR estimates.
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Cystatin C is an alternative measure of kidney function that may have prognostic importance among elderly persons who do not meet standard criteria for chronic kidney disease (estimated glomerular filtration rate [GFR] > or =60 mL/min per 1.73 m2). ⋯ Among elderly persons without chronic kidney disease, cystatin C is a prognostic biomarker of risk for death, cardiovascular disease, and chronic kidney disease. In this setting, cystatin C seems to identify a "preclinical" state of kidney dysfunction that is not detected with serum creatinine or estimated GFR.
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Comparative Study
Victims of cardiac arrest occurring outside the hospital: a source of transplantable kidneys.
The use of non-heart-beating donors could help shorten the list of patients who are waiting for a kidney transplant. Several reports describe acceptable results of transplantations from non-heart-beating donors who had in-hospital cardiac arrest, but few reports describe results of transplantations from non-heart-beating donors who had cardiac arrest that occurred outside of the hospital (Maastricht type I and type II donors). ⋯ Outcomes of transplants from non-heart-beating donors and younger heart-beating donors are similar, and results for transplants from non-heart-beating donors improved compared with those from older heart-beating donors. On the basis of these results, the authors encourage other transplant units to adopt the use of type I and type II non-heart-beating donors.
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In many transplant centers, organ retrieval from altruistic strangers is accepted practice; patients use Internet Web sites and other public media to locate strangers willing to give them an organ. It is argued that altruistic strangers should be permitted to select the recipients of their organs because 1) personal relationships are morally important; 2) it increases the number of available organs; and 3) no one is hurt by the process. ⋯ A publicly chartered organization should be established to coordinate live organ donation, including donation by altruistic strangers. Altruistic strangers should be educated to allocate their donated organs according to a prudent balance of equity and utility rather than their emotional response to a particular patient's plight, identity, or circumstances.