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Brahmania M, Kuo A, Tapper EB, Volk ML, Vittorio JM, Ghabril M, Morgan TR, Kanwal F, Parikh ND, Martin P, Mehta S, Winder GS, Im GY, Goldberg D, Lai JC, Duarte-Rojo A, Paredes AH, Patel AA, Sahota A, McElroy LM, Thomas C, Wall AE, Malinis M, Aslam S, Simonetto DA, Ufere NN, Ramakrishnan S, Flynn MM, Ibrahim Y, Asrani SK, Serper M. Quality measures in pre-liver transplant care by the Practice Metrics Committee of the American Association for the Study of Liver Diseases. Hepatology 2024:01515467-990000000-00816. [PMID: 38536021 DOI: 10.1097/hep.0000000000000870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 05/19/2024]
Abstract
The liver transplantation (LT) evaluation and waitlisting process is subject to variations in care that can impede quality. The American Association for the Study of Liver Diseases (AASLD) Practice Metrics Committee (PMC) developed quality measures and patient-reported experience measures along the continuum of pre-LT care to reduce care variation and guide patient-centered care. Following a systematic literature review, candidate pre-LT measures were grouped into 4 phases of care: referral, evaluation and waitlisting, waitlist management, and organ acceptance. A modified Delphi panel with content expertise in hepatology, transplant surgery, psychiatry, transplant infectious disease, palliative care, and social work selected the final set. Candidate patient-reported experience measures spanned domains of cognitive health, emotional health, social well-being, and understanding the LT process. Of the 71 candidate measures, 41 were selected: 9 for referral; 20 for evaluation and waitlisting; 7 for waitlist management; and 5 for organ acceptance. A total of 14 were related to structure, 17 were process measures, and 10 were outcome measures that focused on elements not typically measured in routine care. Among the patient-reported experience measures, candidates of LT rated items from understanding the LT process domain as the most important. The proposed pre-LT measures provide a framework for quality improvement and care standardization among candidates of LT. Select measures apply to various stakeholders such as referring practitioners in the community and LT centers. Clinically meaningful measures that are distinct from those used for regulatory transplant reporting may facilitate local quality improvement initiatives to improve access and quality of care.
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Affiliation(s)
- Mayur Brahmania
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexander Kuo
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael L Volk
- Department of Medicine, Baylor Scott and White Health, Temple, Texas, USA
| | - Jennifer M Vittorio
- Division of Pediatric Gastroenterology, Department of Medicine, New York University (NYU) Langone Health, New York, New York, USA
| | - Marwan Ghabril
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Timothy R Morgan
- Division of Gastroenterology, Department of Medicine, University of California, Irvine, California, USA
- Medical Service, VA Long Beach Healthcare System, Long Beach, California, USA
| | - Fasiha Kanwal
- Division of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul Martin
- Division of Gastroenterology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Shivang Mehta
- Department of Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Gene Y Im
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David Goldberg
- Division of Gastroenterology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Jennifer C Lai
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Angelo H Paredes
- Division of Gastroenterology, Department of Medicine, University of San Antonio, San Antonio, Texas, USA
| | - Arpan A Patel
- Division of Gastroenterology, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Amandeep Sahota
- Department of Transplant Hepatology, Southern California Permanente Medical Group, Los Angeles, California, USA
| | - Lisa M McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Charlie Thomas
- Banner University Medical Center Phoenix Transplant Program, Phoenix, Arizona, USA
| | - Anji E Wall
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Maricar Malinis
- Section of Infectious Diseases, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nneka N Ufere
- Department of Medicine, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Mary Margaret Flynn
- Division of Gastroenterology, Department of Medicine, University of Massachusetts, Boston, Massachusetts, USA
| | | | - Sumeet K Asrani
- Department of Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Rose SW, Strackman BW, Gilbert ON, Lasser KE, Paasche‐Orlow MK, Lin M, Saylor G, Hanchate AD. Disparities by Sex, Race, and Ethnicity in Use of Left Ventricular Assist Devices and Heart Transplants Among Patients With Heart Failure With Reduced Ejection Fraction. J Am Heart Assoc 2024; 13:e031021. [PMID: 38166429 PMCID: PMC10926796 DOI: 10.1161/jaha.123.031021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/11/2023] [Indexed: 01/04/2024]
Abstract
BACKGROUND The extent to which sex, racial, and ethnic groups receive advanced heart therapies equitably is unclear. We estimated the population rate of left ventricular assist device (LVAD) and heart transplant (HT) use among (non-Hispanic) White, Hispanic, and (non-Hispanic) Black men and women who have heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS We used a retrospective cohort design combining counts of LVAD and HT procedures from 19 state inpatient discharge databases from 2010 to 2018 with counts of adults with HFrEF. Our primary outcome measures were the number of LVAD and HT procedures per 1000 adults with HFrEF. The main exposures were sex, race, ethnicity, and age. We used Poisson regression models to estimate procedure rates adjusted for differences in age, sex, race, and ethnicity. In 2018, the estimated population of adults aged 35 to 84 years with HFrEF was 69 736, of whom 44% were women. Among men, the LVAD rate was 45.6, and the HT rate was 26.9. Relative to men, LVAD and HT rates were 72% and 62% lower among women (P<0.001). Relative to White men, LVAD and HT rates were 25% and 46% lower (P<0.001) among Black men. Among Hispanic men and women and Black women, LVAD and HT rates were similar (P>0.05) or higher (P<0.01) than among their White counterparts. CONCLUSIONS Among adults with HFrEF, the use of LVAD and HT is lower among women and Black men. Health systems and policymakers should identify and ameliorate sources of sex and racial inequities.
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Affiliation(s)
- Scott W. Rose
- Section of Cardiology Medicine, Department of MedicineWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Braden W. Strackman
- Department of Social Sciences and Health Policy, Division of Public Health SciencesWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Olivia N. Gilbert
- Section of Cardiology Medicine, Department of MedicineWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Karen E. Lasser
- Section of General Internal MedicineBoston University School of MedicineBostonMAUSA
| | | | - Meng‐Yun Lin
- Department of Social Sciences and Health Policy, Division of Public Health SciencesWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Georgia Saylor
- Section of Cardiology Medicine, Department of MedicineWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Amresh D. Hanchate
- Department of Social Sciences and Health Policy, Division of Public Health SciencesWake Forest University School of MedicineWinston‐SalemNCUSA
- Section of General Internal MedicineBoston University School of MedicineBostonMAUSA
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Rizzolo K, Shen JI. Barriers to home dialysis and kidney transplantation for socially disadvantaged individuals. Curr Opin Nephrol Hypertens 2024; 33:26-33. [PMID: 38014998 DOI: 10.1097/mnh.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
PURPOSE OF REVIEW People with kidney disease facing social disadvantage have multiple barriers to quality kidney care. The aim of this review is to summarize the patient, clinician, and system wide factors that impact access to quality kidney care and discuss potential solutions to improve outcomes for socially disadvantaged people with kidney disease. RECENT FINDINGS Patient level factors such as poverty, insurance, and employment affect access to care, and low health literacy and kidney disease awareness can affect engagement with care. Clinician level factors include lack of early nephrology referral, limited education of clinicians in home dialysis and transplantation, and poor patient-physician communication. System-level factors such as lack of predialysis care and adequate health insurance can affect timely access to care. Neighborhood level socioeconomic factors, and lack of inclusion of these factors into public policy payment models, can affect ability to access care. Moreover, the effects of structural racism and discrimination nay negatively affect the kidney care experience for racially and ethnically minoritized individuals. SUMMARY Patient, clinician, and system level factors affect access to and engagement in quality kidney care. Multilevel solutions are critical to achieving equitable care for all affected by kidney disease.
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Affiliation(s)
- Katherine Rizzolo
- Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Section of Nephrology
| | - Jenny I Shen
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
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Kelty CE, Dickinson MG, Lyerla R, Chillag K, Fogarty KJ. Non-Medical Characteristics Affect Referral for Advanced Heart Failure Services: a Retrospective Review. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01879-w. [PMID: 38038903 PMCID: PMC11143079 DOI: 10.1007/s40615-023-01879-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Patients with advanced heart failure (AHF) are extensively evaluated before heart transplantation or left ventricular assist device (LVAD) eligibility. Patients are assessed for medical need and psychosocial or economic factors that may affect success post-treatment. For patients to be evaluated, however, they first must be referred. This study investigated social and economic factors affecting AHF referral, specialist visits, or treatment. METHODS Patients with heart failure (n = 24,258) were reviewed at one large hospital system over 4 years. Independent variables age, sex, marital status, race/ethnicity, preferred language, smoking, and insurance status were assessed for the outcomes of referral, clinic visit, and treatment by Chi-square and ANOVA. In-house and 1-year mortality were evaluated by logistic regression, and time-to-event was assessed by the Cox proportional hazards model. RESULTS Younger (HR 0.934, 95% CI 0.925-0.943), male (HR 2.216, 95% CI 1.544-3.181), and publicly insured (HR 1.298 [95% CI 1.038, 1.623]) patients were more likely to be referred, while unmarried (HR 0.665, 95% CI 0.488-0.905) and smoking (HR 0.549, 95% CI 0.389-0.776) patients had fewer referrals. Younger, married, and nonsmoking patients were more likely to have a clinic visit. Younger age, White race, and Hispanic/Latino ethnicity were associated with receiving a heart transplant, and LVAD recipients were more likely Hispanic/Latino ethnicity. Advanced age, Hispanic/Latino ethnicity, and smoking were associated with 1-year mortality after heart failure diagnosis. CONCLUSIONS Disparities in access exist before evaluation for AHF therapies. Improving access at the levels of referral and evaluation is a necessary step toward achieving equity in organ allocation.
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Affiliation(s)
- Catherine E Kelty
- Interdisciplinary Health Sciences PhD Program, Western Michigan University, Kalamazoo, MI, USA.
- Frederik Meijer Heart & Vascular Institute, Corewell Health, Grand Rapids, MI, USA.
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Michael G Dickinson
- Frederik Meijer Heart & Vascular Institute, Corewell Health, Grand Rapids, MI, USA
| | - Rob Lyerla
- Interdisciplinary Health Sciences PhD Program, Western Michigan University, Kalamazoo, MI, USA
| | - Kata Chillag
- Department of Public Health, Davidson College, Davidson, NC, USA
| | - Kieran J Fogarty
- Interdisciplinary Health Sciences PhD Program, Western Michigan University, Kalamazoo, MI, USA
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Deng LX, Sharma A, Gedallovich SM, Tandon P, Hansen L, Lai JC. Caregiver Burden in Adult Solid Organ Transplantation. Transplantation 2023; 107:1482-1491. [PMID: 36584379 PMCID: PMC10993866 DOI: 10.1097/tp.0000000000004477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The informal caregiver plays a critical role in supporting patients with various end-stage diseases throughout the solid organ transplantation journey. Caregiver responsibilities include assistance with activities of daily living, medication management, implementation of highly specialized treatments, transportation to appointments and treatments, and health care coordination and navigation. The demanding nature of these tasks has profound impacts across multiple domains of the caregiver's life: physical, psychological, financial, logistical, and social. Few interventions targeting caregiver burden have been empirically evaluated, with the majority focused on education or mindfulness-based stress reduction techniques. Further research is urgently needed to develop and evaluate interventions to improve caregiver burden and outcomes for the patient-caregiver dyad.
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Affiliation(s)
- Lisa X. Deng
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Arjun Sharma
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Seren M. Gedallovich
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Palo Alto, CA
| | - Puneeta Tandon
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, AB, Canada
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, OR
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
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Wadhwani SI, Kumar WM, Hsu EK. Towards equity in paediatric liver transplantation: improving access and long-term outcomes. Lancet Gastroenterol Hepatol 2023; 8:600-602. [PMID: 37301205 DOI: 10.1016/s2468-1253(23)00099-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/29/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Sharad I Wadhwani
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA 94143, USA.
| | - Wasan M Kumar
- Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Evelyn K Hsu
- University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
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Germani G, Mathurin P, Lucey MR, Trotter J. Early liver transplantation for severe acute alcohol-related hepatitis after more than a decade of experience. J Hepatol 2023; 78:1130-1136. [PMID: 37208100 DOI: 10.1016/j.jhep.2023.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 05/21/2023]
Abstract
In patients with severe acute alcohol-related hepatitis not responding to medical therapy, early liver transplantation (LT) represents the only effective therapy and, when performed within strict and well-defined protocols, it is associated with a clear survival benefit and acceptable rates of return to alcohol use after transplantation. However, there is still high variability in access to LT for patients with severe alcohol-related hepatitis, mainly due to a persistent overemphasis in the pre-LT evaluation on duration of pre-transplant abstinence and the stigma that patients with alcohol-related liver disease often experience, leading to marked inequity of access to this potentially lifesaving procedure and negative health outcomes. Therefore, there is an increasing need for prospective multicentre studies focusing on pre-transplant selection practices and on better interventions to treat alcohol use disorder after LT.
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Affiliation(s)
- Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy.
| | - Philippe Mathurin
- Service des Maladies de l'appareil Digestif, Hôpital Huriez, CHU Lille, France
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Affiliation(s)
- Ramon Bataller
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
| | - Juan Pablo Arab
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
| | - Vijay H Shah
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
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9
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Kumar WM. Medical Need and Transplant Accessibility. JAMA 2022; 328:678-679. [PMID: 35972492 DOI: 10.1001/jama.2022.10409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Wasan M Kumar
- Stanford University School of Medicine, Stanford, California
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Wadhwani SI, Lai JC, Gottlieb L. Medical Need and Transplant Accessibility-Reply. JAMA 2022; 328:679-680. [PMID: 35972489 DOI: 10.1001/jama.2022.10412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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