Indigenous people make up approximately 3% of the total Australian population and score poorer on all health indices, including back pain. Chiropractors are well placed to alleviate back pain, yet there is no research that considers chiropractors’ readiness to treat Indigenous patients. This study explores chiropractors` experience working with Indigenous Australians, describes perceived barriers and facilitators to chiropractors’ participation in Indigenous Healthcare and their willingness to engage in cultural competency training.This study used a non-representative cross-sectional design and a convenience sample. Participants were recruited via email invitation to complete an online survey and encouraged to send the invitation on to colleagues. A 17-item online-survey measured demographic data, perceived barriers and facilitators related to caring for Indigenous Australians, participants` level of comfort when working in Indigenous health, and their willingness to participate in cultural competency programs to enhance their skills, knowledge and cultural capacity when engaging with Indigenous Australians. Analysis of the data included descriptive statistics as well as thematic analysis of qualitative free text.n = 108) were employed in private practice. 62% of respondents were members of the Chiropractors' Association of Australia, 41% were Chiropractic and Osteopathic College of Australasia members. 60% of chiropractors considered that they had, or do treat Indigenous patients yet only 4% of respondents asked their patients if they identified as Indigenous. A majority of participants expressed a high level of ‘comfort’ or confidence in working with Indigenous people while only 17% of respondents had undertaken some form of cultural proficiency training. A majority of respondents  expressed an interest in working with Indigenous Australians and a majority  were willing to participate in training to develop Indigenous cultural competency.One hundred and twenty-five chiropractors participated in the survey. The majority of participants  contains supplementary material, which is available to authorized users. The gap in all health and quality of life outcomes for Indigenous Australians continues to be of great concern  and thisThe explanations given for the ongoing gap in health status between Indigenous and non-Indigenous people have been well described in the published literature e.g. , 6). The. The6]).Given the poorer overall health status of Indigenous people, it might be expected that the use of primary health services would be higher for Indigenous than non-Indigenous peoples, but this is not the case , 9. SomeConsidering the population distribution of Indigenous Australian people and the spread of chiropractic clinics in urban, rural and remote Australia, there is an expectation that a lack of geographically accessible health services should not be a barrier to chiropractic care.There are approximately 5000 registered chiropractors in Australia . Of the Another important and possibly overlooked barrier accounting for the continued gap in health status is the reluctance of Indigenous people to access health care  often beIn addition previous experiences of institutionalised racism have been reported by Indigenous Australians as a deterrent to seeking treatment, particularly for conditions that might be stigmatised, such as back pain . To helpImportantly, as cultural competency training for health professionals has more generally been shown to improve patient outcomes  it is imFurthermore, beyond the perceived potential for chiropractors to provide effective management of musculoskeletal conditions for Indigenous Australians, there is a need to understand the extent to which Victorian chiropractors may already provide treatment for Indigenous people, the issues they may face and the opportunities for increasing the reach and impact of chiropractic care for Indigenous Australian people. Anecdotal evidence suggests that there is an under-representation of chiropractors caring for Indigenous Australians. Though the majority of chiropractors work in private practice, the extent to which they care for Indigenous people is unknown.The main purpose of this study is to inform the development of cultural proficiency programs. It explores the extent to which chiropractors routinely collect data that identify Aboriginal and/or Torres Strait Islander patients, chiropractors’ clinical experience and participation in Indigenous healthcare, their preparedness and perceived barriers and facilitators to caring for Indigenous patients and their interest in participating in cultural competency programs to enable them to acquire the necessary knowledge, skills and attitudes to achieve best practice in promoting Indigenous health.The Human Research Ethics Committee of the Royal Melbourne Institute of Technology (RMIT) University (BSEHAPP 06–15) approved the project, including its design and recruitment methods. The aims were met using a non-representative, cross-sectional design.While predominantly quantitative, this survey used a mixed method approach, by asking participants to consider the barriers and facilitators of Indigenous people accessing chiropractic care, and included an opportunity for participants to add comments. Quantitative data were subjected to descriptive analysis only, with qualitative data subjected to thematic analysis .Chiropractors who were members of the CAA (Victoria branch) were recruited by an email inviting them to participate in the online survey. In order to increase recruitment, participants were encouraged to contact their Chiropractic and Osteopathic College of Australasia (COCA) colleagues to participate in the online survey via a ‘snowballing’ technique . The incTo meet the aims of the research, a17-item online-questionnaire was created using the Qualtrics platform  together with a short email invitation from the C.I. and a participant information sheet explaining the study. The CAAV sent the email invitation, survey link and information sheet to all CAAV active members, who then chose to participate or not. Participants were also invited to forward the link to other chiropractors, using a snowballing method. The survey was ‘live’ for six months. Participation in the survey was limited to one attempt per participant only by the survey software .The bulk of the questionnaire was analysed using descriptive statistics to answer the research questions. The open ended qualitative responses from participants focussed on participants’ perception of barriers and facilitators to Indigenous people accessing chiropractic services, and their willingness to undertake cultural competency training for health professionals. This approach was informed by a previous study conducted in a large, rural Indigenous Community exploring the prevalence of musculoskeletal conditions which also identified a range of barriers and facilitators for Community members accessing allied healthcare. The barriers and facilitators included geographical accessibility, financial and socio-cultural considerations . Though The responses of the current study were subjected to thematic analysis . Using tn = 108) were employed in private practice, and the remaining 14% (n = 17) were employed elsewhere. Only 3.2% (n = 4) had below a Bachelor degree , with an average age of 42.7 years, . The majority of participants . ThOnly 5 participants did not belong to a chiropractic organisation  of participants reported they had previously treated Indigenous patients, leaving 24% (n = 30) reporting they had not treated Indigenous patients, while 9% (n = 11) were unsure. Only 3.4% (n = 4) asked patients if they identified as Aboriginal and/or Torres Strait Islanders and the remaining 96.6% (n = 114) did not ask their patients if they did or did not identify as Indigenous.To meet the aims of this research, participants were asked about their experience working with Indigenous patients. Overall, 60% (n = 72), reported their level of comfort in working with Indigenous people as 10/10 on a Likert scale (where 1 corresponded to no comfort and 10 to completely comfortable) and 83% scored 8/10 and above (n = 97%). Of the practitioner respondents (n = 118), 17% (n = 21) had attended training to work with Indigenous patients, and 91% (n = 104) would be likely or very likely to attend training if made available.Over half of the participants working in a clinical setting  replied they would, while 30% (n = 36) replied maybe, and 6.8% (n = 8) reported they would not be interested. Thirteen (10%) participants did not answer this question. Participants’ comments regarding their interest and readiness in working with Indigenous patients underwent a thematic analysis. Four themes emerged that shaped their interest in working with Indigenous patients: the chiropractor`s ‘personal situation’ such as travelling time to certain Indigenous organisations; their ‘reluctance to participate due to financial considerations including negotiating Medicare payments and remuneration; ‘circumvention’ such as wanting to become familiarised with cultural practices and having a “good clinical supervisor” in the case of students; and ‘positivity’ as expressed through respondents` appreciation for the “privilege of treating Indigenous people”. These themes, in turn, reinforced the perceived facilitators and barriers to the provision of a chiropractic service from the perspective of the chiropractor that the thematic analysis revealed as evidenced in Tables Participants were asked should opportunities exist for them to provide chiropractic care in established Indigenous settings would they be interested in working there. Sixty-two percent (62.7%) n = 7 replied Participants were asked to consider barriers for Indigenous people seeking chiropractic care. There were 112 responses (90%) and these also underwent thematic analysis resulting in the identification of four broad thematic areas (see Table Participants were asked to consider the facilitators for Indigenous people seeking chiropractic care. There were 112 responses (90%) and these also underwent thematic analysis grouping into 4 themes  people. The majority of respondents reported that they felt confident to treat Indigenous people. In this context it is interesting to note that chiropractors felt that one of the barriers and facilitators for Indigenous patients to access a chiropractor was geographical accessibility  scored 8–10 out of 10 in levels of ‘comfort’ or confidence in working with Indigenous people. While this seems to be a positive data point, it is important to consider the level of ‘comfort’ an Indigenous person might feel attending a chiropractor who claims to be completely at ease with an Indigenous person. Other studies demonstrate that to say ‘I treat all the people the same’ is never appropriate , 26 – a An important question that arises from this finding is whether the experience of members of Indigenous Communities reflects the chiropractors’ self-appraisal of a high level of comfort in treating (‘working with’) Indigenous people. A previously conducted study involving one of this papers' co-authors  reportedCultural competence is the awareness, knowledge, understanding and sensitivity to other cultures combined with a proficiency to interact appropriately with people from those cultures in a way that is congruent with the behaviour and expectations that members of a distinctive culture recognise as appropriate among themselves. Cultural competence includes having an awareness of one's own culture in order to understand its cultural limitations as well as being open to cultural differences, cultural integrity and the ability to use cultural resources. It can be viewed as a non-linear and dynamic process which integrates and interlinks individuals with the organisation and its systems. (Indigenous Higher Education Advisory Council (IHEAC), 2007, p.5 and pp.34-38, and amended in 2011, IHEAC meeting and endorsed by the IHEAC Chair and Deputy Chair) [.y Chair) .Cultural competence, as a term, has been described and defined by Indigenous peoples. The definition of cultural competence recommended by Universities Australia  is:CultDespite the World Health Organisation’s ‘Closing the Gap in a Generation’  program Having a strong skill set in working with Indigenous people, including respectful communication and trust will enable the development of therapeutic relationships between practitioner and Indigenous patients . For thiThis study had several limitations. Although we invited participation in our project from all members of the CAA (Victoria) and used snowballing to include chiropractors of other associations and non-affiliated practitioners, our respondents may have only included those with an interest in this topic leading to a selection bias and limiting the generalisability of the results to other chiropractors. This, in turn, may have led to a bias in our results – particularly regarding chiropractors’ experience in treating Indigenous patients as well as their level of comfort in treating Indigenous people. These preliminary findings have nonetheless established a base upon which to refine and deliver a more representative study that surveys chiropractors nationally and provided the researchers with data supporting the potential benefit of developing and making available a cultural proficiency program for chiropractors.Given the geographical location of chiropractors throughout Australia, it may have been instructive to record the postcode of participating chiropractors that completed the survey. Such a request would not preclude the anonymity associated with this study and would have provided the study team with an understanding of whether those practitioners having experience with treating Indigenous patients was associated with their geographical location.Another limitation of this study is that it collected self-perception data from chiropractors. Though conclusions drawn from these data are necessarily limited, the study does provide preliminary information which may be used to inform on-going education of chiropractors and other health professionals. Future studies could compare whether the experience of members of the Indigenous Community match the chiropractors` self-appraisal. That is, do the chiropractors` perceptions of barriers and the thematic evaluation match the perceptions of the Indigenous Community? If not, what biases might be at play for chiropractors? If they do match, is this different to other health professions? Even if chiropractors are equipped with cultural competence, does the Indigenous Community want access to chiropractic services?Although outside the scope of this article, future studies could explore whether chiropractors who were interested in working in Indigenous settings have different "interests" related to working with Indigenous patients compared to those who were not interested in this work, or were they the same?Finally, a comparison of thematic evaluation between the results provided by chiropractors and an Indigenous response sampling is an important subsequent step. An analysis of these questions would create a worthwhile template by which other groups could challenge their preparedness to communicate with diverse cultural groups and their needs.The gap between Indigenous and non-Indigenous health equalities is a persistent problem in Australia. This inequality includes the enormous burden of illness presented by musculoskeletal conditions and perceived barriers to providing musculoskeletal healthcare to Indigenous Australians. A lack of formal cultural competency training of health professionals is thought to contribute to the lack of progress in closing the gap, including in musculoskeletal conditions.Given the substantial burden of musculoskeletal illness experienced by Indigenous Australians, there may be an opportunity for chiropractors to become more culturally proficient in managing these conditions by participating in Indigenous cultural competency programs that enable them to engage respectfully, confidently and more capably with Aboriginal Australians. However, what has also become evident from this preliminary study are the potential questions that arise such as ‘How do chiropractors know if their patients are Indigenous or non-Indigenous if the majority of practitioners do not ask their patients to identify their indigeneity? Do they simply ‘guess’ their ethnicity based on outward appearances? Also why do chiropractors feel equipped to care for Indigenous patients when 83% have had no special training? Does the experience of members of the Indigenous community match ‘chiropractors’ self-appraisal of their ability to be culturally competent? Finally, to avoid potential bias, future studies should incorporate a larger, more representative sample that is generalisable. Incorporating measures that will address these questions may be used as steps to exploring cross-cultural pathways in caring for Indigenous Australians and aid in the development and implementation of cultural proficiency training programs for chiropractors.


Background: The risk-adjusted mortality rate (RAMR) is used widely by healthcare agencies to evaluate hospital performance. The RAMR is insensitive to case volume and requires a confidence interval for proper interpretation, which results in a hypothesis testing framework. Unfamiliarity with hypothesis testing can lead to erroneous interpretations by the public and other stakeholders. We argue that screening, rather than hypothesis testing, is more defensible. We propose an alternative to the RAMR that is based on sound statistical methodology, easier to understand and can be used in large-scale screening with no additional data requirements.Methods: We use an upper-tail probability to screen for hospitals performing poorly and a lower-tail probability to screen for hospitals performing well. Confidence intervals and hypothesis tests are not needed to compute or interpret our measures. Moreover, unlike the RAMR, our measures are sensitive to the number of cases treated.Results: To demonstrate our proposed methodology, we obtained data from the New York State Department of Health for 10 Inpatient Quality Indicators (IQIs) for the years 2009-2013. We find strong agreement between the upper tail probability (UTP) and the RAMR, supporting our contention that the UTP is a viable alternative to the RAMR.Conclusion: We show that our method is simpler to implement than the RAMR and, with no need for a confidence interval, it is easier to interpret. Moreover, it will be available for all hospitals and all diseases/conditions regardless of patient volume. Hospitals may look for ways to reduce cost by reducing the number of treatments, using less expensive interventions, or reducing length of stay, thereby risking quality degradation. Thus, the need to monitor provider performance has perhaps never been greater.Healthcare costs in the United States rose 5.3% in 2014 to $3.0 trillion, or over $9500 per capita, reaching 17.5% of gross domestic product (GDP),2 release these reports to the public. The Leapfrog Group3 and the Agency for Healthcare Research and Quality (AHRQ)4 contribute to these reports. The public as well as healthcare agencies look to these reports, which may be difficult to interpret, to find quality healthcare providers.Comparing hospitals based on their outcome measures is a relatively common practice. Healthcare agencies often use hospital mortality rates within specific disease or condition categories to measure performance. Often state health departments and the Center for Medicare and MedicaidA proper comparison of mortality rates must include an adjustment for risk variation that “levels the playing field” so that a hospital’s evaluation is independent of the risk profile of its patients. Risk factors commonly include age, comorbidities, illness severity, and other patient and case characteristics. The most commonly used adjustment method is the risk-adjusted mortality rate (RAMR) defined later.5 found that hospitals whose RAMRs were made public were more likely to engage in quality improvements efforts than those who had a confidential quality report or no quality report at all. Baker6 showed that the 30-day mortality rate in New York State (NYS) after coronary artery bypass graft declined 41% between 1989 and 1992 after public reporting, and that published mortality rates impacted referral rates among cardiologists in NYS, thereby affecting provider market share and patient choice of healthcare provider. Schneider and Lieberman7 report that, when choosing health plans, employers use these “report cards” to identify high quality health plans at reasonable costs. Similarly, employees may select plans, doctors and hospitals using report card information about providers, quality score, price and accessibility. Moreover, a poorly rated provider may cease operations leaving the local area with a diminished supply of a critical healthcare service.Hibbard et al8 shows that different methods can provide varying judgments. Thomas and Hofer9 questioned the accuracy of the RAMR as a valid indicator of a hospital’s quality performance, and conclude that “reports that measure quality using RAMRs misinform the public about hospital performance.” Dimick et al10 show that the RAMR may not be appropriate for all procedures, particularly when the sample size is small. Scott11 discusses the statistical difficulties associated with a rare outcome (death), the omission or difficulty of proper measurement of patient-related prognostic factors, and the weak and inconsistent correlation between hospital-wide RAMR and explicit quality indicators. He concludes the RAMR is a poor indicator of unsafe hospital care.However, previous studies have questioned the use of the RAMR for this adjustment. Iezzoni12 modeled risk-adjusted assessments utilizing Bayesian and frequentist indirect standardization methods, which they compared to the RAMR for “provider profiling.” These methodologies produced very similar results although they found markedly fewer outlying hospitals when the random-effects assumption was applied to the hospitals. The Leapfrog Group3 provides a hospital safety score that is generally a grading system that shows how safe a hospital is for patients. The purpose of the score is to provide a mechanism to consumers in which they can educate themselves about the safety of a facility they may be considering. The scores are publically reported and are available online. In addition, the Joint Commission’s ORYX program13 integrates performance measurement into their accreditation and quality improvement processes. The Center for Medicare and Medicaid Services (CMS)2 publicly reports process performance measures based on data collected by the Hospital Quality Alliance (HQA).14There are a number of ways a hospital’s performance is measured. Racz and SedranskIn this paper, we will demonstrate that the RAMR is intrinsically a highly flawed performance measure and that, moreover, it is applied improperly. We will then propose an alternative to the RAMR, along with statistically appropriate implementation methods, that avoids all the problems listed above without requiring additional data. Our alternative measure has a clear and practical interpretation, is based on standard statistical theory and methods and, unlike the RAMR, can be applied regardless of the number of cases.15 We chose to test our model using NYS data for several reasons. NYS was among the first states to use the RAMR, applying it to cardiac surgeons and the hospitals in which they performed cardiac surgery starting in 1989. Kasprak16 cites the NYS DOH program as “the first program in the country to produce public data on outcomes for cardiac surgery and is the nation’s longest running program of its kind.” During the intervening 28 years, the NYS DOH has dramatically expanded its use of the RAMR to 24 inpatient quality indicators (IQIs). It also applies the methodology to complications and readmissions. NYS DOH makes its raw data readily available to the public through its web site.15 We believe that, if we can effect improvements in NYS, then other states are likely to follow.We demonstrate our methodology using data from the NYS Department of Health (NYS DOH).The RAMR attempts to account for the differing risk profiles of patients. It is standard practice to use a logistic regression model for a given procedure or illness to estimate each patient’s probability of death based on their patient and case characteristics. The mean and standard deviation of the number of deaths, and therefore the expected mortality rate (EMR) for a procedure or illness at a given hospital, is then estimated from these probabilities. The ratio of the observed mortality rate (OMR), which equals the number of deaths divided by the number of cases, to the EMR is then multiplied by the statewide observed mortality rate (SOMR) or national mortality rate (NMR) to obtain the RAMR.n patients with a particular diagnosis and that X of these patients die. Then theOMR = X/n. Define a variable called Death, which equals 1 if the patient died, or equals to 0 if the patient survived. Next, consider a logistic regression model that has Death as its dependent variable and a set of established mortality risk factors for that diagnosis as its independent variables. Suppose that this model estimates probabilities of death of p1, p2, …, pn, for the n patients. Then the hospital’s Suppose that a hospital treats 17 the hospital standardized mortality ratio . This is a very wide confidence interval primarily because the sample size is small. Also, since the CI for the RAMR contains the SOMR (4.60%), the NYS DOH reports that the difference between Ellenville Regional Hospital’s RAMR and the SOMR was not statistically significant.The NYS DOHGiven that this information is made public, and given the public’s general lack of understanding of the proper interpretation of confidence intervals and statistical significance, Ellenville Regional Hospital runs the very real risk that people, including the media, will focus only on the RAMR since it is the performance measure that the State uses. The mysterious confidence interval and the reference to “not statistically significant” is likely to be ignored.The interpretation of the RAMR is obscure: The NYS DOH web site that provides the data to the public includes the formula given above for computing the RAMR but we could find no explanation regarding its interpretation. One interpretation is that, if every patient in NYS with the given condition had been treated at the given hospital, then the RAMR represents the estimated proportion that would have died. We seriously doubt that many people would have come to this interpretation without guidance.Moreover, even if they had, it is unlikely that they would have recognized the amount of sampling error in the RAMR, especially when the sample size is small. We can only wonder how many pneumonia (and other) patients might have boycotted Ellenville Regional Hospital because of its high RAMR, even though it was not statistically significantly different from the statewide rate.The normal distribution is not statistically justified in many cases: The computations performed for NYS DOH by The Leapfrog Group3 analyze only situations in which the number of cases equals 30 or more. They state “This minimum reporting requirement was identified from the literature, which suggests that 30 cases is generally the point at which a non-normal distribution begins to approximate a normal distribution, which is important given the Safety Score’s use of z-scores for standardizing data across disparate data sets.”3mean. A mortality rate is a proportion, not a mean. The commonly used rule for using the normal approximation to the sampling distribution of the proportion is that both nπ ≥ 10 and n(1-π) ≥ 10, where π is the hospital’s EMR. For pneumonia in 2013, these requirements were not met in 110 of the 181 hospitals (60.8%) of the hospitals with 30 or more cases.This is a misuse of the normal approximation. The rule cited refers to using the normal approximation to the sampling distribution of the CIs are often misunderstood: The importance of avoiding confidence intervals should not be minimized. Several authors including Hoekstra et al,18 Belia et al,19 Gigerenzer,20 and Lecoutre et al21 have demonstrated the widespread inability of undergraduate and master’s degree students, researchers, and even statisticians to properly interpret confidence intervals and the associated null hypothesis significance tests. More relevant to the current application, Wulff et al22 showed the difficulty that physicians have in properly interpreting a wide range of statistical results, and Scheutz et al23 replicated those results for dentists. Given that professionals who use statistical inference regularly have problems with the proper interpretation of confidence intervals, we question the wisdom of using confidence intervals in a context in which the public is expected to use them in making critical healthcare decisions. Clearly the difficulty in the interpretation of statistical methods makes the interpretation of the quality reports confusing. In addition, Porter et al24 states “sensitivity to physicians’ concerns about being judged unfairly results in a tendency to exclude patients from outcomes comparisons instead of incorporating accepted risk-adjustment methods.”There is no adjustment for multiple comparisons: NYS constructs confidence intervals for each RAMR and uses them to test the null hypothesis that the hospital’s performance does not differ from the statewide performance. We believe that the state should instead view this exercise as a screening process, not as a hypothesis testing process. There are two reasons why we advocate screening rather than hypothesis testing.25 or Benjamini and Hochberg,26 which would be unlikely to serve the desired purposes in these circumstances. Second, there is no a priori theoretical reason to believe that any given hospital is either better or worse than average.First, the state examines hundreds, if not thousands, of such analyses each year . This means that the state would need to use a multiple comparisons procedure, such as Bonferronin be the number of patients treated, d be the number of observed deaths, and π be the EMR. Then the UTP = P and the LTP = P. It should be noted that both the UTP and the LTP include the number of deaths, d, so they do not sum to one.Our methodology uses two measures: the upper tail probability (UTP) to screen for hospitals performing poorly and the lower tail probability (LTP) to screen for hospitals performing well. Let The UTP computes the probability that the hospital would have had as many deaths as they did, or more, given their number of cases and their EMR. A small UTP indicates that the hospital’s number of deaths is unusually high. The LTP computes the probability that the hospital would have had as few deaths as they did, or fewer, given their number of cases and their EMR. A small LTP indicates that the hospital’s number of deaths is unusually low. Therefore, with either the UTP or the LTP, a small value represents either unusually poor performance or unusually good performance.27 drew on the work of four previous studies to construct the list of verbal interpretations of probabilities shown in HammWe approximate the UTP and the LTP using the binomial distribution function. We recognize that the use of the binomial distribution in this application technically requires that each patient in each hospital with a given condition must have the same probability of death, which is not the case since patients are known to have different patient and case characteristics. The calculation of the exact values of the UTP and the LTP would require the individual patient probabilities of death, which are not publicly available. If they were, the resulting probability distribution would be the so-called Poisson binomial distribution.28 and Boland29). Thus, the UTP and LTP values reported herein are conservatively large in the sense that any UTP or LTP that we report is greater than the values computed using the individual patient probabilities of death.Under the Poisson binomial distribution, the expected number of deaths would equal the expected number under the traditional binomial distribution but the variance of the number of deaths would be smaller. Thus, the tail areas computed using the binomial are larger than those computed using the Poisson binomial , which equals 0.214. Thus, there is a 21.4% chance that Ellenville Regional Hospital would have experienced 2 or more pneumonia deaths given that the EMR of its 42 pneumonia patients was 2.06%. This is between “Not very probable” and “Fairly unlikely” on Hamm’s scale. It is clear that Ellenville Regional Hospital’s performance in pneumonia in 2013 did not approach the level of requiring greater scrutiny even though its RAMR was 2.31 times the SOMR. All that needs to be reported is that its UTP is 21.4% and its interpretation is clear: If Ellenville Regional Hospital treated 42 pneumonia patients with the same EMR every year, then it would experience two or more deaths in 21.4% of the years. There is no need for a confidence interval.Next consider an imaginary Hospital A that treated 420 pneumonia cases and experienced 20 deaths. Suppose also that its EMR was 2.06%. Then its OMR would equal 20/420 = 4.76%, and its RAMR would be 10.65, all equal to Ellenville’s values. However, its UTP would be P = 0.00057. This is two orders of magnitude below “Rarely” and is very close to “Absolutely impossible.”P = .00057 has an expected value of 1/0.00057 = 1754, meaning that, if Hospital A treated 420 pneumonia patients with the same EMR every year, then it would experience 20 or more deaths on average once every 1754 years. The observed number of deaths at Hospital A should therefore be considered highly unusual while Ellenville’s is not unusual at all. This demonstrates that the RAMR is insensitive to case volume, which is incorporated naturally into the UTP in a statistically sound manner.How often does an event with probability 0.00057 occur? The geometric distribution with Note that the normal approximation is not needed to compute the UTP and the LTP. Therefore, we can analyze hospitals regardless of the number of cases they treated and their EMRs. Thus, by switching to the UTP/LTP methodology, no such methodological restrictions exist; NYS could assess situations with any number of cases.15 The database contains the number of cases treated, the number of deaths, and the EMRs for each of 10 IQIs for the years 2009-2013. The risk adjustments for the IQIs studied are explained in the AHRQ quality indicators, IQI parameter estimates.24 NYS reports this data only for hospitals that had 30 or more cases in the given IQI in the given year.We demonstrate our methodology using data from the NYS DOH web site.P < .00005), demonstrating strong agreement between the two measures. This supports our contention that the UTP is a viable alternative to the RAMR.We computed the 5-year overall RAMR and UTP across all IQIs for 196 hospitals. The Spearman rank correlation is −0.8559  suggesting that hospitals with fewer than 30 cases in an IQI are unlikely to have patients that are, on average, at higher risk of dying.It is possible that the adjustment for EMR, for which the data are unavailable, would explain this difference. This might happen if those situations involving fewer than 30 cases also had higher EMRs relative to patients treated in situations involving 30 or more cases. To check this possibility, we fit a linear regression model using EMR  as the dependent variable and the number of cases  as the independent variable. The resulting model, with n = 196 hospitals, yields a highly statistically significant positive slope  repair, 23.6% for pancreatic resection and 13.3% for carotid endarterectomy.The State does not evaluate these situations, apparently due to its reliance on the normal approximation to the binomial for the purpose of computing a confidence interval for the RAMR. By switching to the UTP/LTP methodology, no such methodological restrictions exist; the State could assess situations with any number of cases.P values commonly used in hypothesis testing. There are no hypotheses here to test. We do not, for example, create a null hypothesis that the hospital’s mortality rate is greater (less) than or equal to its EMR and then use the UTP (LTP) to reject or not reject this null hypothesis. To do so would require solution of the massive multiple comparisons problem26 resulting from the very large number of hypothesis tests being performed across all hospitals, all diseases and conditions, and all years. Rather, the purpose of the analysis is to screen for circumstances in which there may have been more (fewer) deaths than might be expected based on their number of cases and EMR.The UTP and the LTP are not to be confused with upper-tail and lower-tail Rather than classify a hospital’s performance as average, below average, or above average, which would imply a hypothesis testing framework, we propose using the UTP as a screening measure to identify situations in which there are likely to be opportunities for improvement. For example, In this paper, we make two essential points. First, measuring hospital performance is essential for quality improvement but hypothesis testing is not the appropriate approach. Rather, agencies should take a screening approach that seeks to identify both where attention may be needed to improve performance, and where superior performance is occurring that might be emulated elsewhere. Second, the current RAMR methodology should be replaced. Our proposed alternative method, using the UTP and the LTP, should be considered as a replacement.Briefly, we have shown that:The RAMR does not provide the information necessary to determine whether a hospital’s performance is especially bad or especially good, in part because it is insensitive to sample size;The interpretation of the RAMR is obscure to many people;The use of the normal distribution to construct a confidence interval for the RAMR is not statistically justified in many cases;While a proper confidence interval for the RAMR can be constructed without reference to the normal distribution, there is considerable evidence that large portions of the population, including physicians, other healthcare professionals, and the public, do not have a sufficiently fundamental understanding of confidence intervals to use them as a basis for healthcare decision-making; andThe RAMR and its confidence interval are portrayed as if a two-tailed hypothesis test were being performed without any attempt to adjust for the multiple comparisons that are being made.The current implementation of the RAMR in NYS does not examine situations in which a hospital has treated fewer than 30 cases in a given IQI. We have found that such situations may account for as much as half of all such cases statewide. This failure is particularly troubling in light of the suggestive evidence that higher volume providers tend to perform better. This shortcoming disappears when using the UTP/LTP approach.For the purposes of our study, we were unable to apply our methodology to situations with fewer than 30 cases since NYS DOH does not publish the necessary data. However, there is no reason to suspect that there would be any problems computing the UTP since the binomial distribution is readily available for any number of trials.Our planned future research involves comparing the UTP/LTP results with the quality report cards prepared for each hospital. To the degree to which they agree, we will know that the UTP/LTP and the report cards are sensing similar phenomena. To the extent that they disagree, we will have an opportunity to learn more about the hospital’s quality performance.In summary, our proposed method is simpler to implement than the RAMR – no need for a confidence interval – and it is easy to interpret. It is statistically sound and is applicable to all situations regardless of the number of cases treated, therefore providing a more comprehensive assessment of performance.Not applicable.Authors declare that they have no competing interests.CP’s contributions come from her expertise and experience in hospital management. TRS’s contributions arise from his education and experience in statistics and mathematical modeling. Policy-makers can benefit from the results of our study in the following ways:We frame the evaluation of hospitals in terms of screening rather than hypothesis testing.Unlike the risk-adjusted mortality rate (RAMR) , our method can be applied to all situations, regardless of the number of cases, thereby providing a more comprehensive evaluation of each hospital.Our alternative measure has a clear and practical interpretation.In choosing a hospital for treatment of a serious disease or condition, you will want to consider many factors, perhaps the most important being your likelihood of surviving the hospitalization. You may find the risk-adjusted mortality rate (RAMR) difficult to interpret since that will require that you have a benchmark value for comparison and an understanding of confidence intervals. Our proposed method will provide you with a measure that:has a clear and practical interpretation,does not rely on a benchmark or an understanding of confidence intervals, andis available regardless of the number of cases were treated by the hospital last year.Therefore, you will be sure to have information on all hospitals under consideration, and that the information will be readily understood without confusion.


Despite bacterial culture of platelets, transfusion-associated bacteremia/sepsis (TABS) may occur with a frequency of approximately 1/60,000 platelet transfusions, while an emerging transfusion-transmitted infection (TTI) could reproduce the epidemic of transfusion-transmitted human immunodeficiency virus (HIV) in the future. As platelet pathogen-reduction (PR) systems licensed in Europe may eventually become licensed in the U.S., three alternative strategies for reducing the residual risks of TTIs and TABS may become available in the U.S. in the future: (1) transfusion of  non–pathogen-reduced single-donor (as opposed to pooled whole-blood-derived [PWBD]) platelets, (2) transfusion of pathogen-reduced single-donor platelets, or (3) transfusion of pathogen-reduced PWBD platelets . PR of platelets will increase the risk of mild and moderate  bleeding complications and it cannot protect from all pathogens. Compared to PWBD platelets, single-donor platelets can reduce, by at least twofold, the risk of all known and emerging TTIs, as well as the risk of TABS, without incurring any risk. The fewer donor exposures secured by the use of single-donor platelets – especially if combined with collection of red blood cells and/or plasma from the same donation for transfusion to the same recipient through the use of multicomponent apheresis – may also reduce the risk of transfusion-related acute lung injury. To choose between pathogen-reduced and non–pathogen-reduced single-donor platelets, the increased risks of bleeding complications as well as other possible adverse events secondary to PR need to be quantified precisely and weighed against the competing risks of TABS and emerging TTIs.


Pathological abnormalities were observed in testicles exposed to sperm retrieval (≥11 of 14) compared to 0 of 4 control testicles. Testicular damage was found independently of the kind of intervention used. Therefore, cryopreservation of excess sperm should be considered while retrieving sperm.The aim of this study was to evaluate the possible development of histological abnormalities such as fibrosis and microcalcifications after sperm retrieval in a ram model. Fourteen testicles in nine rams were exposed to open biopsy, multiple TESAs, or TESE, and the remaining four testicles were left unoperated on as controls. Three months after sperm retrieval, the testicles were removed, fixed, and cut into 1/2 cm thick slices and systematically put onto a glass plate exposing macroscopic abnormalities. Tissue from abnormal areas was cut into 3  Since the early nineties, large and increasing numbers of infertile couples have had Intracytoplasmic Sperm Injection (ICSI) using sperm retrieved from the testis or epididymis. In many azoospermic men, particularly men with obstructive azoospermia (OA), testicular sperm retrieval is performed as a randomly located open biopsy using a scalpel , 2; testSeveral studies have shown that children born after ICSI using testicular or epididymal sperm are healthy and the risk of malformations, except from hypospadias and cryptorchidism, is not increased , 11. In An association between testicular fibrosis and reduced semen quality has been found in cattle . StudiesHematomas and scar tissue are also found in human testicles after biopsy . Using uPain does not necessarily reflect the magnitude of scar formation. Nevertheless, it is worth mentioning the study of Westlander et al.  who repoWith this study, we wanted to investigate whether sperm retrieval leads to chronic testicular changes and which sperm retrieval technique is the better choice. Since it is not possible to examine the human testicles histologically after operation, we have looked for an animal model. Compared to humans, most animals have a larger testis weight/body weight ratio , and notThe experiments were done on Shropshire rams, 6–8 months of age, originating from Tyrevoldsdal, Skanderborg, Denmark. Each testicle was exposed to a given surgical procedure  or left μm sections and stained with hematoxylin-eosin and Masson trichrome for histological evaluation.Three months later, the animals were sacrificed, and the testicles and epididymides adhering to the testicles were removed for histological examination. Immediately after removal, each testis was cut longitudinally from upper to lower pole 2/3 of the diameter from the side opposite to the epididymis. This allows the formaldehyde (4%) to penetrate the testis tissue. The formalin fixed tissue was afterwards completely cut into slices of about 1/2 cm thickness and systematically put on a glass plate, making it possible to identify and localize macroscopic abnormalities, for example, areas with extensive fibrosis . Tissue Three rams underwent sperm retrieval performed as TESE with TruCut needle ) in two testicles or as multiple biopsies (TESA) with a 19G needle in another two testicles. The remaining two testicles were left unoperated on as control. Each procedure was performed in one right and one left testicle. Thus, the two testicles in each animal were in every case treated in two different ways. tunica albuginea was cut using small scissors. The tunica albuginea and tunica vaginalis were closed with running Vicryl suture, while the skin was sutured with three Vicryl knots. TruCut biopsies (14G) were performed in seven testicles, while the remaining two testicles served as control. In four of the seven testicles undergoing TruCut biopsy in Experiment 2, the needle was inserted centrally near the rete testis. In the other three cases, the needle was inserted in the testicular periphery (distant from the rete testis). Identical procedures were never performed on each side of a given ram, and we always avoided hitting the mediastinum testis since it contains vessels. Damage to these might cause bleeding and intratesticular hematoma.In three of six rams, one testicle underwent traditional open biopsy, where a small testis sample quelling out through a small incision in theThe study was approved in 2012 as method testing by the Animal Experiments Inspectorate .Most testicles exposed to any sperm retrieval procedures showed areas with microcalcifications (11 of 14) and fibrosis (9 of 14) surrounded by areas with dilated seminiferous tubules Figures . In comp rete testis caused larger damage than TruCut biopsies located in the testicular periphery. Therefore, we compared the morphological damage seen after peripheral testicular TruCut biopsies and central TruCut biopsies located near the rete testis.The first experiment left the impression that TruCut biopsies located near the rete testis. Independently of biopsy location, areas with fibrosis and calcifications were seen. The size of the affected area varied, and the extent could not be associated with the location of the biopsy. In biopsies taken near the rete testis, the fibrotic process did not expand in the peripheral direction of the seminiferous tubules. In no case was the rete testis damaged. If the affected tissue has a length of 30 mm and a radius of 4 mm as shown in 2 × π/6).In the second experiment, three rams had TruCut biopsies taken in the testicular periphery and four near theSince the caput of the epididymis in rams prolonged around the upper pole of the testis, the epididymis was in a few cases hit during sperm retrieval from peripheral or central areas of the testis using the TruCut needle. This caused development of a sperm granuloma in a couple of cases. rete testis as well as in the testicular periphery far away from the rete testis. Fibrosis and microcalcifications were not seen in control testicles not exposed to sperm retrieval or other operative procedures. Such pathological changes in the testicles may impede sperm production and testicular function relatively more in small testicles or testicles with sperm production in only small foci.This experimental ram study shows that pathological, testicular abnormalities, such as scar tissue and microcalcifications, were found very often after conventional testicular sperm retrieval, whether traditional open biopsy, multiple needle biopsy (TESA), or TruCut biopsy (TESE) was performed. The pathological testicular abnormalities were observed when TruCut biopsies were taken near theThe strength of using an animal model is that it is possible to remove and systematically evaluate the whole testis by, for example, histological examination at systematically chosen time intervals following the operative procedure. Furthermore, the strength of using a ruminant species such as the sheep is that the testicles are permanently present in a scrotum outside the body similar to humans. However, a weakness using an animal model is that almost all animal species have much higher testis weight/body weight ratio compared to humans . A damagSeveral techniques have been used for testicular sperm sampling. For testicular fine needle aspirations , needles or butterfly needles with sizes 19G , 21G 1,, 23, or TruCut biopsies with 14G , 6, 26 aVanderzwalmen et al.  found spThe risks of impairment of the blood supply and of postsurgical fibrosis seem to be increased by multiple testicular tissue sampling, and testicular abnormalities detected by ultrasonography remain up to 6 months after surgery . In patiFrom these data, it is suggested that OA and NOA should be treated in different ways, and omission of diagnostic TESE should be considered in NOA. An alternative to diagnostic TESE in men with NOA might be an examination for the presence of ejaculated spermatids. If spermatids—but no mature sperm—are detected in the ejaculate, the diagnosis is NOA. However, when spermatids are not ejaculated, it is not possible to distinguish between lack of production of testicular germ cells  and OA , 29. vas deferens (CBAVD) in the other 2 men [The possible risk of development of anti-sperm antibodies (ASA) after sperm retrieval procedures is not fully clarified. Steele et al.  detecteder 2 men . Howeverer 2 men .In some men with very impaired spermatogenesis, a few sperm are present in the ejaculates now and then. This condition is termed cryptozoospermia . In pracThe risk of postsurgical fibrosis found in humans  was confStudies in humans have shown that testosterone levels decrease after TESE , 33 as wIn conclusion, testicular damage can be found independently of the kind of intervention used. For patients with OA, we therefore recommend considering retrieval of epididymal spermatozoa, given that epididymal reconstructive surgery is excluded as an option. In any case, we recommend cryopreservation of excess sperm obtained by testicular sperm retrieval to minimize the risk of further sperm retrieval.Further research is needed focusing on additive effects of repeated sperm retrieval procedures, including the length of the intervals between repeated procedures. Since the acute changes seen at ultrasonography in retrospective studies have been found to be reduced after mTESE compared to conventional TESE , 37, it


T2 mapping can potentially be used to investigate CSF composition. A previously proposed CSF T2–mapping method reported a T2 difference between peripheral and ventricular CSF, and suggested that this reflected different CSF compositions. We studied the performance of this method at 7 T and evaluated the influence of partial volume and B1 and B0 inhomogeneity.Cerebrospinal fluid (CSF) T2-preparation-based CSF T2-mapping was performed in seven healthy volunteers at 7 and 3 T, and was compared with a single echo spin-echo sequence with various echo times. The influence of partial volume was assessed by our analyzing the longest echo times only. B1 and B0 maps were acquired. B1 and B0 dependency of the sequences was tested with a phantom.T2,CSF was shorter at 7 T compared with 3 T. At 3 T, but not at 7 T, peripheral T2,CSF was significantly shorter than ventricular T2,CSF. Partial volume contributed to this T2 difference, but could not fully explain it. B1 and B0 inhomogeneity had only a very limited effect. T2,CSF did not depend on the voxel size, probably because of the used method to select of the regions of interest.T2 mapping is feasible at 7 T. The shorter peripheral T2,CSF is likely a combined effect of partial volume and CSF composition.CSF The online version of this article (doi:10.1007/s10334-017-0659-3) contains supplementary material, which is available to authorized users. T2 of cerebrospinal fluid (CSF) in the brain. A striking finding with this method was the observation of a shorter T2 in the peripheral CSF compared with the T2 of the CSF in the lateral ventricles. Qin suggested that this T2 difference is caused by differences in CSF composition between both areas, implying that CSF T2  can be used as a noninvasive biomarker for CSF composition. This would be highly relevant in the light of the recent attention to the clearance of brain waste products, in which CSF is involved , and sF  participated in this study. Informed consent was given by all volunteers in accordance with the requirements of the Institutional Review Board of the University Medical Center Utrecht . All volunteers were scanned with both a 3-T Philips Achieva scanner with an eight-channel head coil  and the 7-T scanner that was also used for the phantom study. The CSF T2 mapping scans were acquired in a single coronal slice, planned through both the lateral ventricles and the fourth ventricle  remained well within the specific absorption rate limits, also at 7 T. No additional methods were used to correct the scans for eddy currents. The low bandwidth of the scan may cause distortions in areas with poor shimming, such as the nasal cavities. However, shimming was good in the selected coronal slice. Also B0 and B1 maps were acquired. In vivo experiments were performed at both 7 and 3 T to test the feasibility of CSF T2 estimates were analyzed as a function of B1 and B0. B1 sensitivity was assessed with use of the scans with the highest B0 gradient strength (0.5 mT/m), where no FID artifacts were present. The B1 range present in the scan was used. On the basis of B1 in each voxel, the voxels were sorted over eight bins of 5% B1, leading to B1 bins ranging from (85 ± 2.5)% to (120 ± 2.5)%. The signal was averaged over each B1 bin, and T2 values were fitted over this averaged signal. B0 sensitivity was assessed with the various applied B0 gradient strengths . In each scan, only voxels with B1 between 97.5% and 102.5% were included. An additional intensity threshold was applied on the scan with the longest TET2-prep to minimize the influence of artifacts in the lower B0 gradient scans. This threshold was set at 75% of the maximum intensity for the longest TE. The signal of all voxels included was averaged over each scan, and T2 values were fitted over this averaged signal.The resulting T2-prep = 0.6 s). The intensity threshold was set at 25% of the maximum intensity in the image. Figure T2 mapping scan at 7 T with a resolution of 1 × 1 × 4 mm3 at all TEs for one volunteer, and the ROIs used. Conservative ROIs were used in the ventricles by our eroding the intensity-based ROIs with one voxel to minimize both partial volume and motion sensitivity. Erosion of the peripheral ROIs was not feasible.Three regions of interest (ROIs) were defined on the acquired in vivo scans: the lateral ventricles, the fourth ventricle, and peripheral CSF. The ROI masks were made by our applying an intensity threshold to the first TE  were taken into account in the analysis. Thereby, maximal nulling of, for example, tissue signal was achieved, since the T2 values of tissue are below 100 ms , and higher B1 values were observed in the lateral ventricles [median 111% (range 109–116)]. Similar B0 gradients were observed in the three ROIs .At 7 T significantly shorter T2 times, with a significant increase of 118 ms at both 3 and 7 T. At 7 T the corrected peripheral CSF T2 was quite similar to the ventricular T2 (1.01 s vs 1.05 s), while at 3 T the mean peripheral T2 was still approximately 200 ms shorter than the ventricular T2 times . The results for this analysis of the phantom data are shown in Fig. T2 values, indicating no systematic errors in the additional analysis with only the longest TEs.Figure T2 mapping at 7 T with a dedicated CSF T2 mapping sequence based on T2 preparation, which was initially developed at 3 T. We investigated the sensitivity of this sequence for the influence of B1, diffusion (B0 gradient), and partial volume effects. The sequence appeared to be relatively insensitive to B1 and B0 inhomogeneity. Partial volume effects tend to lower the observed T2 values at the periphery. T2,CSF was considerably shorter at 7 T than at 3 T in all three ROIs. The peripheral T2,CSF was significantly shorter than the ventricular T2,CSF at 3 T (but not at 7 T).In this research we have shown the feasibility of CSF T2,CSF increased considerably on partial volume correction, as obtained from analysis of long TEs (more than ten times the tissue T2). The partial volume correction for the SE-EPI sequence, which was used as a relatively B1-insensitive reference , did not significantly increase T2 values, although the SE-EPI sequence showed an even larger T2 difference between the periphery and ventricles. The ventricular T2 values measured with the CSF T2 mapping sequence at 3 T match with T2 values found in literature [T2 difference between the ventricular and peripheral CSF could be partly due to physiological differences. However, the different results for different sequences and field strengths and the confounding influence of partial volume effects will make it challenging to accurately isolate and quantify any true physiological effect from confounders. This will hamper applications in research focusing on in vivo evaluation of the  composition of CSF.The peripheral terature , 19, 20.B1 dependency was found for the CSF T2 mapping sequence, as shown in Fig. B0 gradient showed only limited B0 gradient dependency, except for the highest B0 gradient (0.5 mT/m), as shown in Fig. B0 gradient was similar between the periphery and the ventricles at 7 T, and differed by a maximum of 0.38 mT/m (median B0 gradient was 0.13 mT/m) at 3 T , although there is a trend of longer measured ventricular T2 times for smaller voxel sizes at 3 T, similarly to what was found by to De Vis et al. [The different resolutions used at both field strengths did not yield considerably different s et al. . As the s et al. , partialT2,CSF was investigated by use of the longest TEs only , the signal of arterial blood has decayed to 2%. However, in the case of small partial volume fractions of CSF in the periphery, this could still have a considerable influence on the measured T2. The outer layer of the cerebral cortex (layer I) may have a long T2 because it contains almost no neuronal cell bodies, and many glial cells instead, similarly to gliotic lesions, which also have a long T2 [The role of partial volume effects regarding the measured peripheral nly Fig.  to maxims at 3 T , 22 and s at 3 T , 23, whis at 3 T , 25) or , at 7 T ). At thelong T2 .T2 difference of 609 ± 133 ms between the periphery and the ventricles at 3 T, and Qin found a T2 difference of 420 ± 155 ms at 3 T. Also in this work a shorter T2,CSF was measured in the periphery compared with the ventricles, as shown in Fig. T2 difference is larger at 3 T than at 7 T: the T2 difference is 365 ms at 3 T and 161 ms at 7 T, which corresponds to differences of 18% and 15% relative to the T2 in the lateral ventricles for 3 and 7 T, respectively. Partial volume correction, which led to a peripheral CSF T2 increase of 118 ms at both field strengths .De Vis et al.  found a T2 difference between peripheral and ventricular CSF. A potential physiological explanation for this observed T2 difference could be sought in differences in, for example, in the levels of O2, protein, and/or glucose, since these substrates are known to decrease T2 [T2,CSF. So although differences in CSF composition may partly cause the observed T2 difference, it seems unlikely that these are the only contributor.These results indicate a true ease T2 , 27–29. T2 at 7 T than at 3 T  were used  be explained by (a combination of) physiological differences. The possibility that the shorter peripheral T2 is entirely caused by an artifact, like B0 gradients caused by imperfect shimming and/or partial volume effects between tissue, blood, and CSF, seems unlikely.Before CSF T2 measurements of CSF, and more work is necessary to find the true explanations for the T2 differences between 3 and 7 T and between the peripheral and ventricular CSF at 3 T.Care should be taken when one is interpreting T2,CSF is due to different CSF compositions.The major limitation of this work is that it is an observational study, which limits the extent to which underlying mechanisms causing the observations can be identified. Despite our efforts to separate the effects of partial volume and true physiological differences, it remains uncertain to what extent the observed shorter peripheral R2 criterion, which resulted in a relatively large dropout of ROIs.Furthermore, the statistical power of this study was limited by the low number of volunteers combined with the stringent B0 gradients could be determined in the in vivo scans, and the magnitude of microscopic, subvoxel B0 gradients remains unknown.Moreover, only macroscopic 2 content, compared with in vivo CSF, which may induce T2 differences between in vitro and in vivo CSF.Finally, no in vitro CSF sample was used to validate the in vivo measurements. In vitro CSF is prone to changes in, for example, OT2 mapping with a dedicated sequence is feasible at both 3 and 7 T, and yields shorter CSF T2 times at 7 T compared with 3 T. At 3 T, shorter T2 times were found for peripheral CSF compared with ventricular CSF; at 7 T this effect was much smaller. Partial volume effects can partly explain this T2 difference, but a physiological contribution to the difference in T2 between ventricular and peripheral CSF is possible. The different results for different sequences and field strengths, and the confounding influence of partial volume, will make it challenging to accurately isolate and quantify any true physiological effect for applications in research focusing on in vivo evaluation of the  composition of CSF.CSF Supplementary material 1 (PDF 321 kb)Below is the link to the electronic supplementary material.


This study interviewed adolescents conceived using sperm donation to examine their experiences of contacting and meeting ‘same‐donor offspring’ (i.e. donor‐conceived offspring raised in different families who share the same donor), their motivations for this contact, and how they make meaning of these relationships. This in‐depth qualitative study involved semi‐structured interviews with 23 young people aged 12–19 years (mean = 14 years). Interviewees were motivated by curiosity about their biological relations and by wanting to extend their family. Contact with same‐donor offspring was described as being either normal/neutral or as a unique experience that was integrated into their identity. This study highlights the importance of contact between same donor offspring, particularly during adolescence, a developmental stage associated with identity formation. The findings have important policy implications as they suggest that donor‐conceived individuals may benefit from contact with others conceived using the same donor prior to the age of 18 years. Advances in assisted reproductive technologies have helped many individuals to conceive children through the use of donated sperm and eggs. As more families begin to utilise gamete donation as a means to achieve parenthood, the possibility of connecting to other ‘same‐donor offspring’ . Other mechanisms for facilitating donor connections are available in other countries and these operate in different ways . In Sweden and parts of Australia, New Zealand and throughout Europe, policies have been implemented that require sperm donors to disclose their identity . A total of 25 participants whose parents had consented to being interviewed were invited to take part in this study. Of these, 23 agreed to be interviewed (92 per cent) and 2 declined.Semi‐structured interviews lasting approximately 60–90 min were conducted in participants’ homes. The interview inquired about participants’ sense of what it meant to be donor conceived and explored the terminology used to describe same‐donor offspring and donors. The interview also examined adolescents’ experiences of learning about their conception, motivations for searching for same‐donor offspring, experiences of contacting and meeting families sharing the same donor, information known about their donor, and feelings about not knowing their donor. This paper reports on sections of the interview relating to the experiences of meeting and contacting same‐donor offspring as well as feelings regarding donor conception.Interviews were recorded and transcribed verbatim and analysed using thematic analysis  participants had one sibling (mean age = 11.1 years) residing with them; of these eight siblings, five were conceived with the same donor sperm as the participant, one was adopted and two were conceived using a different donor. With regards to the age at which they had found out about their donor conception, four (18 per cent) participants reported having ‘always known’, nine (39 per cent) ‘could not recall’, nine (39 per cent) found out before the age of 7 and one (4 per cent) found out after the age of 10. Twenty‐two (96 per cent) participants were identified as White and one (4 per cent) as ‘Other, unspecified'. There were two sets of siblings who were raised in the same family who participated in the study.Two main themes were identified as motivations for contact with same‐donor offspring: ‘Curiosity about donor and genetic origins’ and ‘forming relationships to extend family’.n = 19). Some participants said that they had not been aware of the existence of other same‐donor offspring (n = 7) and that they felt excited to learn about the possibility of meeting them:I didn't know that more people used the sperm from the gu‐same guy… I didn't know that anyone else would buy the sperm from the same guy as us and that I didn't, I didn't even know half‐families existed so when I first met them it was pretty cool. (Anthony)The most common motivating factor for contacting and meeting same‐donor offspring was a sense of curiosity (n = 10) were driven to contact same‐donor offspring as a means of obtaining more information about their donor. By comparing themselves to their donor siblings, participants were able to identify characteristics that they thought could originate from the donor and provide them with a better understanding of him:If it's something we, we both have like in common it's like ‘oh well it's probably from like our donor’ or like once um we were like talking, I was talking about like how I'm good at English and we're both good at math, she's not good at English though, I and um it was just kind of like ‘well he was an English teacher and he had a perfect score on his SAT's for math and stuff’ like so like we probably got that from him and um and like he's also really ugly so sometimes we're like ‘I don't know where we came from because we're so beautiful (said in playful tone) but he's like disgusting.’ (Veronica)Most participants (n = 14) indicated that they were curious to meet same‐donor offspring to better understand their origins, not all expressed a desire to contact or meet their donor. For some (n = 6), meeting same donor offspring was seen as transformative, as it provided insight into themselves. One participant described how meeting same‐donor offspring had provided him with the opportunity to explore aspects of himself:It's been great it was an awesome opportunity. There's nothing, I would do it all the same way again. It's yeah it's been great, I mean it's been awesome to meet them, hang out with them, have this new kind of relative, explore like I mean through meeting them I've gotten to know more about myself you know and uh you know who I am, what the donor's like… I mean it's helped me learn about you know how these uh relationships were gonna work like how it would work if I met my father or how um you know about, taught me about you know brother relationships it's, it's cultivated, given me more inspiration in music and stuff… and that's gonna be three new really good friends and brothers (Gregory)Although most participants (n = 13) stated that knowing others who share half their genetic makeup was important to them because it provided them with a more nuanced sense of identity. For some (n = 4), simply the fact of knowing about same‐donor offspring provided this enhanced sense of self and they did not necessarily need to meet their donor siblings to achieve this. For others (n = 3), the concept of sharing genes with same‐donor offspring motivated them to make contact, even if they did not feel that the experience was overtly significant:It's been I wouldn't say life changing but it's definitely something that I will remember ‘cause I know that I now have sisters who also are donor conceived and we have the same DNA and stuff like that, well half the same DNA. (Joanna)Indeed, most participants (n = 15). For some (n = 4), this relationship was portrayed as multifaceted in that the donor sibling was experienced as in between a friend and a family member. For three other participants who had no siblings residing with them, finding same‐donor offspring provided them with someone who could fulfil a perceived ‘missing’ role in their family. Participants described how their bond to a particular same‐donor offspring helped to serve such a role:I'm really just like happy with like just her cause she real–she kind of like filled the place of needing to find like another sister or like someone who's really like me and so I still really, so I do still like see like other siblings but for the most part I really just like spending time with [Donor Sibling Sister] cause I just, I love seeing her. (Veronica)I thought it was cool, it wasn't like I was kind of envious of not having a dad, um I was more I mean if I was ever envious of any family relationship I kind of wanted a brother or something, which I now have. (Gregory)Another motivation given by most participants for contacting and meeting same‐donor offspring was to form a relationship with them (n = 4). In these cases, connecting with same‐donor offspring was uniformly viewed as enhancing their sense of family, whether the experience was found to be positive, neutral or awkward. Of those participants who were aware of multiple same‐donor offspring, most (n = 5) participants developed a close familial relationship with a few and felt relatively distant to others:I'm best friends with my brother. Like I have two other ones that are girls that like me, um my brother and my two sisters. Like they, we get together sometimes just us ‘cause we're the oldest ones. And we have like a lot of fun together and so we're just like kind of the group. And yeah, the other ones I don't really feel close to. Like they're, I'm aware they're there but I don't like love them like I love those three. (Chelsea)For Veronica, being close to just one of her same‐donor offspring gave her a sense of having a sister which was enough for her. Similarly, Gregory describes how knowing about a same‐donor offspring had given him a brother, which he found fulfilling. These donor relations were often described as complex; sometimes experienced as awkward at first but then developing into a closer relationship (n = 7) expressed that it would be interesting to know about more donor siblings but that it may be difficult to connect with all of them, particularly once a connection had been made to at least one other same‐donor offspring. Unlike siblings who live and grow up together, most participants were introduced to their donor siblings later in life and special trips were required to visit them. Although participants often described their relationship with same‐donor offspring as familial, the relationship was complex as there was an expectation to feel close to their donor siblings despite possible feelings of awkwardness or distance.A third of participants . All but two participants articulated that their parent(s) had integrated their donor conception into their lives in such a way that it became a normal part of their identity growing up. This sense of normalcy about their donor conception translated into how they perceived contacting and meeting same‐donor offspring as it provided a foundation from which participants could understand this relationship. While most participants described being excited about the possibility of meeting same‐donor offspring (n = 16), some felt indifferent (n = 4). In either case, it appeared that adolescents’ feelings of normalcy or indifference about their donor conception was related to them perceiving connecting with same‐donor offspring as being normal.Most participants described having a sense of knowing about their donor conception from an early age, such that it felt like they had always known (n = 16) described subjectively feeling neutral about the idea of same‐donor offspring; it is when their differences from others are accentuated that they felt a discrepancy.In one case, a participant said that although she perceived connecting with same‐donor offspring to be normal for her, she was aware of the fact that this might not be perceived as normal to others. Most participants (n = 13) described feeling that their donor conception was a part of who they were and that fundamentally they did not differ from other families. The majority of participants (n = 19) felt comfortable telling others that they had contacted or met same‐donor offspring. While participants could recognise that others may find it ‘different’ to be in contact with donor siblings, most adopted terminology to describe same‐donor offspring in a normative manner. Some participants referred to same‐donor offspring as a ‘half sibling’ (n = 9) or ‘donor sibling’ (n = 5), whereas others reserved the term ‘brother’ or ‘sister’ for same‐donor offspring to whom they felt particularly close (n = 5).Most participants (n = 9) reported that being donor conceived and knowing same‐donor offspring provided them with a special experience that set them aside from others. Sharing this experience with other same‐donor offspring provided some participants with an understanding of their own donor‐conceived identity, as they were able to make meaning of this in the context of a shared experience:I was so happy about it…, I thought it made me so interesting like I was the most interesting person. I thought it was so cool, like I would tell everyone about it… like I am always open to telling people I think, people are always so interested and I think it really makes people like ‘Oh wow, she's a really interesting person’. And it is really interesting especially now that I have all my donor siblings in the mix ‘cause it doesn't feel as confusing. It doesn't feel like as much of a mystery. (Chelsea)Most participants (n = 4) felt that the experience of contacting and meeting same‐donor offspring gave them a unique part of their narrative of who they are. This contributed to their experience of finding it valuable to connect with same‐donor offspring. Participants expressed an appreciation of the fact that they were able to connect with same‐donor offspring and that they were able to form a relationship that was unlike others. Most noted that it provided them with a ‘quirky story’ that they were pleased to integrate into their lives.Other participants Although being donor‐conceived and seeking same‐donor offspring provided an unusual experience that most participants liked about their life story, being brought up in a single mother or lesbian couple family sometimes produced ambivalent feelings related to not having a father:Whilst elsewhere in the interview Gina described feeling that she did not need ‘that extra person’ when referring to her donor, here she suggested that a part of her longs for a father. This difficulty appeared to be contextual for Gina in situations in which she was reminded of her status as socially different from others (e.g. during holidays such as Father's Day). Gina concluded that she ultimately liked being different. However, she qualified this statement with ‘I guess’, indicating that there was perhaps some underlying uncertainty about this.This study highlights the importance of understanding the motivations, experiences and sense of meaning that young people make of contacting and meeting same‐donor offspring. Participants in this study delineated motivations of curiosity and wanting to build familial relationships, and described the experience of meeting same‐donor offspring as a unique one that they had integrated into their sense of normality. In line with other research exploring the experiences and motivations of connecting with same‐donor offspring  led to feelings of being different to others; however, these differences were not about their donor conception In line with the relevance of identity formation during adolescence, participants described their experience of contacting same‐donor offspring as a unique one that provided them with a sense of being special. Particularly during adolescence, there is a pressure to differentiate the self from others in important and personally meaningful ways .