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Beck KR, Kim N, Khalili M. Sofosbuvir-Containing Regimens for Chronic Hepatitis C Are Successful in the Safety-Net Population: A Real-World Experience. Dig Dis Sci 2016; 61:3602-3608. [PMID: 27743164 PMCID: PMC5106301 DOI: 10.1007/s10620-016-4340-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 10/03/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Vulnerable populations are disproportionately affected by hepatitis C virus (HCV) infection and experience high rates of health disparity. There are no data on real-world experience with highly efficacious direct-acting anti-HCV treatment in this population. AIMS We aimed to evaluate the real-world experience with sofosbuvir-based regimens among a vulnerable HCV-infected population. METHODS HCV treatment response was assessed among 204 patients who completed 12-24 weeks of sofosbuvir-based regimens (in combination with pegylated interferon and ribavirin, simeprevir, ledipasvir, or daclatasvir) at the San Francisco safety-net healthcare system liver specialty clinic between January 2014 and December 2015. Virologic response during therapy was assessed at weeks 4 and 8, end of therapy, and 12-week treatment discontinuation (SVR 12). RESULTS Patient characteristics were median age 58 years, 60 % male, 42 % Caucasian (21 % black, 19 % Hispanic), 72 % had genotype 1 (23 % genotype 2 or 3), and the median baseline log10 HCV viral load was 6.1 IU/ml and alanine transaminase 63 U/l. Cirrhosis was present in 36 % (of whom 40 % were decompensated), and 18 % were HCV treatment-experienced. Overall, SVR 12 was achieved in 97 % (99 % genotype 1, 100 % genotype 2, 84 % genotype 3). Five of six (83 %) patients who relapsed had decompensated cirrhosis, and 67 % were also non-adherent to therapy. On-treatment virologic response did not impact SVR. CONCLUSIONS High rates of sustained virologic response can be achieved in safety-net HCV-infected patients. Access to DAA-based regimens is critical to addressing HCV-related health disparity in this at-risk population.
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Affiliation(s)
- Kendall R Beck
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, NH 3-D, San Francisco, CA, 94110, USA
| | - Nicole Kim
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, NH 3-D, San Francisco, CA, 94110, USA
| | - Mandana Khalili
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, NH 3-D, San Francisco, CA, 94110, USA.
- Liver Center, University of California San Francisco, San Francisco, CA, USA.
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Ertel AE, Wima K, Hoehn RS, Chang AL, Hohmann SF, Ahmad SA, Sussman JJ, Shah SA, Abbott DE. Variability in postoperative resource utilization after pancreaticoduodenectomy: Who is responsible. Surgery 2016; 160:1477-1484. [PMID: 27712874 DOI: 10.1016/j.surg.2016.08.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/14/2016] [Accepted: 08/18/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND We aimed to quantify and predict variability that exists in resource utilization after pancreaticoduodenectomy and determine how such variability impacts postoperative outcomes. METHODS The University HealthSystems Consortium database was queried for all pancreaticoduodenectomies performed between 2011-2013 (n = 9,737). A composite resource utilization score was created using z-scores of 8 clinically significant postoperative care delivery variables including number of laboratory tests, imaging tests, computed tomographic scans, days on antibiotics, anticoagulation, antiemetics, promotility agents, and total number of blood products transfused per patient. Logistic, Poisson, and gamma regression models were used to determine predictors of increased variability in care between patients. RESULTS Having a high (versus low) resource utilization score after pancreaticoduodenectomy correlated with increased duration of stay; (odds ratio 2.28), cost (odds ratio 1.89), readmission rate (odds ratio 1.46), and mortality (odds ratio 7.54). Patient-specific factors were the strongest predictors and included extreme severity of illness (odds ratio 114), major comorbidities/complications (odds ratio 5.99), and admission prior to procedure (odds ratio 2.72; all P < .01). Surgeon and center volume were not associated with resource utilization. CONCLUSION Public reporting of patient outcomes and resource utilization, invariably tied to reimbursement in the near future, should consider that much of the postoperative variability after complex pancreatic operation is related to patient-specific risk factors.
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Affiliation(s)
- Audrey E Ertel
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Koffi Wima
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Richard S Hoehn
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Alex L Chang
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | | | - Syed A Ahmad
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Jeffrey J Sussman
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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Kim Y, Chang AL, Wima K, Ertel AE, Diwan TS, Abbott DE, Shah SA. The impact of morbid obesity on resource utilization after renal transplantation. Surgery 2016; 160:1544-1550. [PMID: 27574775 DOI: 10.1016/j.surg.2016.07.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 07/15/2016] [Accepted: 07/27/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND A growing number of renal transplant recipients have a body mass index ≥40. While previous studies have shown that patient and graft survival are significantly decreased in renal transplant recipients with body mass indexes ≥40, less is known about perioperative outcomes and resource utilization in morbidly obese patients. We aimed to analyze the effects of morbid obesity on these parameters in renal transplant. METHODS Using a linkage between the Scientific Registry of Transplant Recipients and the databases of the University HealthSystem Consortium, we identified 29,728 adult renal transplant recipients and divided them into 2 cohorts based on body mass index (<40 vs ≥40 kg/m2). The body mass index ≥40 group comprised 2.5% (n = 747) of renal transplant recipients studied. RESULTS Body mass index ≥40 recipients incurred greater direct costs ($84,075 vs $79,580, P < .01), index admission costs ($91,169 vs $86,141, P < .01), readmission costs ($5,306 vs $4,596, P = .01), and combined costs ($99,590 vs $93,939, P < .001). Thirty-day readmission rates were also greater among body mass index ≥40 recipients (33.92% vs 26.9%, P < .01). Morbid obesity was not predictive of stay (odds ratio 1.01, P = .75). CONCLUSION Morbidly obese renal transplant recipients incur greater costs and readmission rates compared with nonobese patients. Recognition of increased resource utilization should be accompanied by appropriate, risk-adjustment reimbursement.
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Affiliation(s)
- Young Kim
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alex L Chang
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Audrey E Ertel
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Tayyab S Diwan
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.
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Tumin D, Hayes D, Washburn WK, Tobias JD, Black SM. Medicaid enrollment after liver transplantation: Effects of medicaid expansion. Liver Transpl 2016; 22:1075-84. [PMID: 27152888 DOI: 10.1002/lt.24480] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 04/17/2016] [Accepted: 04/24/2016] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) recipients in the United States have low rates of paid employment, making some eligible for Medicaid public health insurance after transplant. We test whether recent expansions of Medicaid eligibility increased Medicaid enrollment and insurance coverage in this population. Patients of ages 18-59 years receiving first-time LTs in 2009-2013 were identified in the United Network for Organ Sharing registry and stratified according to insurance at transplantation (private versus Medicaid/Medicare). Posttransplant insurance status was assessed through June 2015. Difference-in-difference multivariate competing-risks models stratified on state of residence estimated effects of Medicaid expansion on Medicaid enrollment or use of uninsured care after LT. Of 12,837 patients meeting inclusion criteria, 6554 (51%) lived in a state that expanded Medicaid eligibility. Medicaid participation after LT was more common in Medicaid-expansion states (25%) compared to nonexpansion states (19%; P < 0.001). Multivariate analysis of 7279 patients with private insurance at transplantation demonstrated that after the effective date of Medicaid expansion (January 1, 2014), the hazard of posttransplant Medicaid enrollment increased in states participating in Medicaid expansion (hazard ratio [HR] = 1.5; 95% confidence interval [CI] = 1.1-2.0; P = 0.01), but not in states opting out of Medicaid expansion (HR = 0.8; 95% CI = 0.5-1.3; P = 0.37), controlling for individual characteristics and time-invariant state-level factors. No effects of Medicaid expansion on the use of posttransplant uninsured care were found, regardless of private or government insurance status at transplantation. Medicaid expansion increased posttransplant Medicaid enrollment among patients who had private insurance at transplantation, but it did not improve overall access to health insurance among LT recipients. Liver Transplantation 22 1075-1084 2016 AASLD.
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Affiliation(s)
- Dmitry Tumin
- Department of Pediatrics, Wexner Medical Center, The Ohio State University, Columbus, OH.,Department of Comprehensive Transplant Center, Wexner Medical Center, The Ohio State University, Columbus, OH.,Center for Epidemiology of Organ Failure and Transplantation, Nationwide Children's Hospital, Columbus, OH.,Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Don Hayes
- Department of Pediatrics, Wexner Medical Center, The Ohio State University, Columbus, OH.,Department of Internal Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH.,Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH.,Center for Epidemiology of Organ Failure and Transplantation, Nationwide Children's Hospital, Columbus, OH.,Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH.,Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - W Kenneth Washburn
- Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH.,Department of Comprehensive Transplant Center, Wexner Medical Center, The Ohio State University, Columbus, OH.,Center for Epidemiology of Organ Failure and Transplantation, Nationwide Children's Hospital, Columbus, OH.,Division of Transplantation, Nationwide Children's Hospital, Columbus, OH
| | - Joseph D Tobias
- Department of Anesthesiology, College of Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH.,Center for Epidemiology of Organ Failure and Transplantation, Nationwide Children's Hospital, Columbus, OH.,Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Sylvester M Black
- Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH.,Department of Comprehensive Transplant Center, Wexner Medical Center, The Ohio State University, Columbus, OH.,Center for Epidemiology of Organ Failure and Transplantation, Nationwide Children's Hospital, Columbus, OH.,Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH
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Jones P, Kanwal F. Communication and trust: Critically important to eliminate disparities in liver transplantation. Liver Transpl 2016; 22:881-3. [PMID: 27149083 DOI: 10.1002/lt.24475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 05/02/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Patricia Jones
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL.,Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | - Fasiha Kanwal
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.,Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX.,Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
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56
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Adler JT, Yeh H. Social determinants in liver transplantation. Clin Liver Dis (Hoboken) 2016; 7:15-17. [PMID: 31041019 PMCID: PMC6490244 DOI: 10.1002/cld.525] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/11/2015] [Accepted: 12/13/2015] [Indexed: 02/04/2023] Open
Affiliation(s)
- Joel T. Adler
- Division of Transplant Surgery, Department of SurgeryMassachusetts General HospitalBostonMA
| | - Heidi Yeh
- Division of Transplant Surgery, Department of SurgeryMassachusetts General HospitalBostonMA
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57
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Ertel AE, Wima K, Chang AL, Hoehn RS, Hohmann SF, Edwards MJ, Abbott DE, Shah SA. Risk of Reoperation Within 90 Days of Liver Transplantation: A Necessary Evil? J Am Coll Surg 2016; 222:419-28. [PMID: 26905185 DOI: 10.1016/j.jamcollsurg.2016.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 01/07/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The rate and consequences of reoperation after liver transplantation (LT) are unknown in the United States. STUDY DESIGN Adult patients (n = 10,295; 45% of all LT) undergoing LT from 2009 through 2012 were examined using a linkage of the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases providing recipient, donor, center, hospitalization, and survival details. Median follow-up was 2 years. Reoperations were identified within 90 days after LT. RESULTS Overall 90-day reoperation rate after LT was 29.3%. Risk factors for 90-day reoperation included recipients with a history of hemodialysis, severely ill functional status, government insurance, increasing Model for End-Stage Liver Disease score, and increasing donor risk index. Reoperation within 90 days was found to be an independent predictor of adjusted 1-year mortality (odds ratio = 1.8; 95% CI, 1.5-2.1), as was government-provided insurance and increasing donor risk index. Additionally, patients undergoing delayed reoperative intervention (after 30 days) were found to have increased risk of 1-year mortality compared with those undergoing early reoperative intervention (odds ratio = 1.96; 95% CI, 1.4-2.7; p < 0.01). CONCLUSIONS This is the first national study reporting that nearly one-third of transplant recipients undergo reoperation within 90 days of LT. Although necessary at times, reoperation is associated with increased risk of death at 1 year; however, it appears that the timing of these interventions can be critical, due to the type of intervention required. Early reoperative intervention does not appear to influence long-term outcomes, and delayed intervention (after 30 days) is strongly associated with decreased survival.
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Affiliation(s)
- Audrey E Ertel
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Alex L Chang
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Richard S Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Samual F Hohmann
- University Health Consortium, Chicago, IL; Department of Health Systems Management, Rush University, Chicago, IL
| | - Michael J Edwards
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
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58
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59
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Ertel AE, Wima K, Hoehn RS, Abbott DE, Shah SA. Hospital Utilization of Nationally Shared Liver Allografts from 2007 to 2012. World J Surg 2015; 40:958-66. [DOI: 10.1007/s00268-015-3357-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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60
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Singhal A, Wilson GC, Wima K, Quillin RC, Cuffy M, Anwar N, Kaiser TE, Paterno F, Diwan TS, Woodle ES, Abbott DE, Shah SA. Impact of recipient morbid obesity on outcomes after liver transplantation. Transpl Int 2015; 28:148-55. [PMID: 25363625 DOI: 10.1111/tri.12483] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 09/25/2014] [Accepted: 10/24/2014] [Indexed: 12/28/2022]
Abstract
The aim of this study was to analyze the impact of morbid obesity in recipients on peritransplant resource utilization and survival outcomes. Using a linkage between the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified 12 445 patients who underwent liver transplantation (LT) between 2007 and 2011 and divided them into two cohorts based on recipient body mass index (BMI; <40 vs. ≥40 kg/m²). Recipients with BMI ≥40 comprised 3.3% (n = 416) of all LTs in the studied population. There were no significant differences in donor characteristics between two groups. Recipients with BMI ≥40 were significant for being female, diabetic, and with NASH cirrhosis. Patients with a BMI ≥40 had a higher median MELD score, limited physical capacity, and were more likely to be hospitalized at LT. BMI ≥40 recipients had higher post-LT length of stay and were less often discharged to home. With a median follow-up of 2 years, patient and graft survival were equivalent between the two groups. In conclusion, morbidly obese LT recipients appear sicker at time of LT with an increase in resource utilization but have similar short-term outcomes.
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Affiliation(s)
- Ashish Singhal
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
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61
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Hoehn RS, Singhal A, Wima K, Sutton JM, Paterno F, Steve Woodle E, Hohmann S, Abbott DE, Shah SA. Effect of pretransplant diabetes on short-term outcomes after liver transplantation: a national cohort study. Liver Int 2015; 35:1902-9. [PMID: 25533420 DOI: 10.1111/liv.12770] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 12/15/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS We sought to analyse the effect of pretransplant diabetes on post-operative outcomes and resource utilization following liver transplantation. METHODS A retrospective cohort study was designed using a linkage between the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases. We identified 12 442 patients who underwent liver transplantation at 63 centres from 2007-2011 and separated cohorts of patients with diabetes (n = 2971; 24%) and without (n = 9471; 76%) at the time of transplant. We analysed transplant related outcomes and short-term survival. RESULTS Diabetic recipients were more likely to be male (70% vs 67%), non-white (32% vs 26%), older (age ≥60; 41% vs 28%), and have a higher BMI (29 vs 27; P < 0.001). More diabetic patients were on haemodialysis (10% vs 7%), had cirrhosis caused by NASH (24% vs 9%; P < 0.001), and received liver allografts from older donors (≥ 60 years; 19% vs 15%) with a higher donor risk index (>1.49; 46% vs 42%; P < 0.001). Post-transplant, diabetic recipients had longer hospital length of stay (10 vs 9 days), higher peri-transplant mortality (5% vs 4%) and 30-day readmission rates (41% vs 37%), were less often discharged to home (83% vs 87%; P < 0.05), and had inferior graft and patient survival. Liver transplant was more expensive for type 1 vs type 2 diabetics ($105 078 vs $100 624, P < 0.001). Poorly controlled diabetic recipients were less likely discharged home following transplant (75% vs 82%, P < 0.01). CONCLUSIONS This national study indicates that pretransplant diabetes is associated with inferior post-operative outcomes and increased resource utilization after liver transplantation.
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Affiliation(s)
- Richard S Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Ashish Singhal
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Jeffrey M Sutton
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Flavio Paterno
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - E Steve Woodle
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Sam Hohmann
- University Health Consortium and Department Health Systems Management, Rush University, Chicago, IL, USA
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
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Wilson GC, Hoehn RS, Ertel AE, Wima K, Quillin RC, Hohmann S, Paterno F, Abbott DE, Shah SA. Variation by center and economic burden of readmissions after liver transplantation. Liver Transpl 2015; 21:953-60. [PMID: 25772696 DOI: 10.1002/lt.24112] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 02/14/2015] [Accepted: 03/08/2015] [Indexed: 12/13/2022]
Abstract
The rate and causes of hospital readmissions after liver transplantation (LT) remain largely unknown in the United States. Adult patients (n = 11,937; 43.1% of all LT cases) undergoing LT from 2007 to 2011 were examined with a linkage of the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases to determine the incidence and risk factors for 30-day readmissions and utilization metrics 90 days after LT. The overall 30-day hospital readmission rate after LT was 37.9%, with half of patients admitted within 7 days after discharge. Readmitted patients had worse overall graft and patient survival with a 2-year follow-up. Multivariate analysis identified risk factors associated with 30-day hospital readmission, including a higher Model for End-Stage Liver Disease score, diabetes at LT, dialysis dependence, a high donor risk index allograft, and discharge to a rehabilitation facility. After adjustments for donor, recipient, and geographic factors in a hierarchical model, we found significant variation in readmission rates among hospitals ranging from 26.3% to 50.8% (odds ratio, 0.53-1.90). In the 90-day analysis after LT, readmissions accounted for $43,785 of added costs in comparison with patients who were not readmitted in the first 90 days. This is the first national report showing that more than one-third of LT recipients are readmitted to their center within 30 days and that readmissions are associated with center variation and increased resource utilization.
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Affiliation(s)
- Gregory C Wilson
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard S Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Audrey E Ertel
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - R Cutler Quillin
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Sam Hohmann
- Department of Health Systems Management, University Health Consortium, Rush University, Chicago, IL
| | - Flavio Paterno
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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63
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Abstract
PURPOSE OF REVIEW To review and highlight recent literature regarding the medical management of adult patients undergoing liver transplantation. RECENT FINDINGS The addition of serum sodium concentration to the model for end-stage liver disease (MELD) score more accurately predicts 90-day waitlist mortality. Predictors of waitlist mortality and posttransplant survival include lower albumin and the presence of ascites, varices, and encephalopathy, as well as more nontraditional predictors such as older age, obesity, frailty, and sarcopenia. Indications for liver transplantation are evolving with the advent of effective therapy for hepatitis C and the increased prevalence of nonalcoholic steatohepatitis. Disparities persist in the current allocation system, including geographic variation and MELD inflation for hepatocellular carcinoma. Share 35 allows for broader regional sharing of organs for patients with the highest need, without detrimental effects on waitlist mortality or survival. Everolimus is a recently approved option for posttransplant immunosuppression that spares renal function. SUMMARY The MELD score has enabled the liver transplant community to equitably allocate organs. Recent literature has focused on the limitations of the MELD score and the disparities inherent in the current system. The next steps for liver transplantation will be to develop strategies to further optimize waitlist prioritization and organ allocation.
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64
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Singhal A, Wima K, Hoehn RS, Quillin RC, Woodle ES, Paquette IM, Paterno F, Abbott DE, Shah SA. Hospital Resource Use with Donation after Cardiac Death Allografts in Liver Transplantation: A Matched Controlled Analysis from 2007 to 2011. J Am Coll Surg 2015; 220:951-8. [DOI: 10.1016/j.jamcollsurg.2015.01.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/30/2015] [Accepted: 01/31/2015] [Indexed: 01/28/2023]
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65
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Ward FL, O'Kelly P, Donohue F, ÓhAiseadha C, Haase T, Pratschke J, deFreitas DG, Johnson H, Conlon PJ, O'Seaghdha CM. Influence of socioeconomic status on allograft and patient survival following kidney transplantation. Nephrology (Carlton) 2015; 20:426-33. [DOI: 10.1111/nep.12410] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Frank L Ward
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
| | - Patrick O'Kelly
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
| | - Fionnuala Donohue
- Health Intelligence Unit; Health & Wellbeing Directorate; Health Service Executive; Dublin Ireland
| | - Coilin ÓhAiseadha
- Health Intelligence Unit; Health & Wellbeing Directorate; Health Service Executive; Dublin Ireland
| | - Trutz Haase
- Social and Economic Consultant; Health Service Executive; Dublin Ireland
| | - Jonathan Pratschke
- Social and Economic Consultant; Health Service Executive; Dublin Ireland
| | - Declan G deFreitas
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
| | - Howard Johnson
- Health Intelligence Unit; Health & Wellbeing Directorate; Health Service Executive; Dublin Ireland
| | - Peter J Conlon
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
| | - Conall M O'Seaghdha
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
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