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Lee MS, Batiste C, Onwuzurike J, Elkoustaf R, Wu YL, Chen W, Kahwaji J, Sahota A, Lee RL. Pretransplant cardiac stress testing and transplant wait time in kidney transplantation candidates. Open Heart 2024; 11:e002738. [PMID: 39277185 PMCID: PMC11404252 DOI: 10.1136/openhrt-2024-002738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 09/04/2024] [Indexed: 09/17/2024] Open
Abstract
OBJECTIVE Routine screening for cardiovascular disease before kidney transplantation remains controversial. This study aims to compare cardiac testing rates in patients with end-stage renal disease, referred and not referred for transplantation, and assess the impact of testing on transplant wait times. METHODS This is a retrospective cohort study of 22 687 end-stage renal disease patients from 2011 to 2022, within an integrated health system. Cardiac testing patterns, and the association between cardiac testing and transplant wait times and post-transplant mortality were evaluated. RESULTS Of 22 687 patients (median age 66 years, 41.1% female), 6.9% received kidney transplants, and 21.0% underwent evaluation. Compared with dialysis patients, transplant patients had a 5.6 times higher rate of stress nuclear myocardial perfusion imaging with single-photon emission (rate ratio (RR) 5.64, 95% CI 5.37 to 5.92), a 6.5 times higher rate of stress echocardiogram (RR 6.51, 95% CI 5.65 to 7.51) and 16% higher cardiac catheterisation (RR 1.16, 95% CI 1.06 to 1.27). In contrast, revascularisation rates were significantly lower in transplant patients (RR 0.46, 95% CI 0.36 to 0.58). Transplant wait times were longer for patients who underwent stress testing (median 474 days with no testing vs 1053 days with testing) and revascularisation (1796 days for percutaneous intervention and 2164 days for coronary artery bypass surgery). No significant association was observed with 1-year post-transplant mortality (adjusted OR 1.99, 95% CI 0.46 to 8.56). CONCLUSIONS This study found a higher rate of cardiac testing in dialysis patients evaluated for kidney transplants. Cardiac testing was associated with longer transplant wait time, but no association was observed between testing and post-transplant mortality.
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Affiliation(s)
- Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Columbus Batiste
- Department of Cardiology, Kaiser Permanente Riverside Medical Center, Riverside, California, USA
| | - James Onwuzurike
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Rachid Elkoustaf
- Department of Cardiology, Kaiser Permanente Riverside Medical Center, Riverside, California, USA
| | - Yi-Lin Wu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Wansu Chen
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Joseph Kahwaji
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Amandeep Sahota
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Roland L Lee
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
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Lu Y, Arowojolu O, Qiu X, Liu Y, Curry LA, Krumholz HM. Barriers to Optimal Clinician Guideline Adherence in Management of Markedly Elevated Blood Pressure: A Qualitative Study. JAMA Netw Open 2024; 7:e2426135. [PMID: 39106065 PMCID: PMC11304113 DOI: 10.1001/jamanetworkopen.2024.26135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 06/09/2024] [Indexed: 08/07/2024] Open
Abstract
IMPORTANCE Hypertension poses a substantial public health challenge. Despite clinical practice guidelines for hypertension management, clinician adherence to these guidelines remains suboptimal. OBJECTIVE To develop a taxonomy of suboptimal adherence scenarios for severe hypertension and identify barriers to guideline adherence. DESIGN, SETTING, and PARTICIPANTS This qualitative content analysis using electronic health records (EHRs) of Yale New Haven Health System included participants who had at least 2 consecutive visits with markedly elevated blood pressure (BP; defined as at least 2 consecutive readings of systolic BP ≥160 mm Hg and diastolic BP ≥100 mm Hg) between January 1, 2013, and December 31, 2021, and no prescription for antihypertensive medication within a 90 days of the second BP measurement. Data analysis was conducted from January to December 2023. MAIN OUTCOMES AND MEASURES The primary outcome was scenarios and influencing factors contributing to clinician nonadherence to the guidelines for hypertension management. A thematic analysis of EHR data was conducted to generate a pragmatic taxonomy of scenarios of suboptimal clinician guideline adherence in the management of severe hypertension. RESULTS Of the 20 654 patients who met criteria, 200 were randomly selected and thematic saturation was reached after analyzing 100 patients (mean [SD] age at index visit, 66.5 [12.8] years; 50 female [50%]; 8 Black [8%]; 5 Hispanic or Latino [5%]; 85 White [85%]). Three content domains emerged: (1) clinician-related scenarios (defined as noninitiation or nonintensification of treatment due to issues relating to clinician intention, capability, or scope), which included 2 subcategories (did not address and diffusion of responsibility); (2) patient-related scenarios (defined as noninitiation or nonintensification of treatment due to patient behavioral considerations), which included 2 subcategories (patient nonadherence and patient preference); and (3) clinical complexity-related scenarios (defined as noninitiation or nonintensification of treatment due to clinical situational complexities), which included 3 subcategories (diagnostic uncertainty, maintenance of current intervention, and competing medical priorities). CONCLUSIONS AND RELEVANCE In this qualitative study of EHR data, a taxonomy of suboptimal adherence scenarios for severe hypertension was developed and barriers to guideline adherence were identified. This pragmatic taxonomy lays the foundation for developing targeted interventions to improve clinician adherence to guidelines and patient outcomes.
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Affiliation(s)
- Yuan Lu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Oreoluwa Arowojolu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Xiaoliang Qiu
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Yuntian Liu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Leslie A. Curry
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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Reese PP, Powe NR, Lo B. Engineering Equity Into the Promise of Xenotransplantation. Am J Kidney Dis 2024; 83:677-683. [PMID: 37992981 DOI: 10.1053/j.ajkd.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 11/24/2023]
Abstract
Two of the greatest challenges facing kidney transplantation are the lack of donated organs and inequities in who receives a transplant. Xenotransplantation holds promise as a treatment approach that could solve the supply problem. Major advances in gene-editing procedures have enabled several companies to raise genetically engineered pigs for organ donation. These porcine organs lack antigens and have other modifications that should reduce the probability of immunological rejection when transplanted into humans. The US Food and Drug Administration and transplantation leaders are starting to chart a path to test xenotransplants in clinical trials and later integrate them into routine clinical care. Here we provide a framework that industry, regulatory authorities, payers, transplantation professionals, and patient groups can implement to promote equity during every stage in this process. We also call for immediate action. Companies developing xenotransplant technology should assemble patient advocacy boards to bring the concerns of individuals with end-stage kidney disease to the forefront. For trials, xenotransplantation companies should partner with transplant programs with substantial patient populations of racial and ethnic minority groups and that have reciprocal relationships with those communities. Those companies and transplant programs should reach out now to those communities to inform them about xenotransplantation and try to address their concerns. These actions have the potential to make these communities full partners in the promise of xenotransplantation.
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Affiliation(s)
- Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Neil R Powe
- Department of Medicine, University of California San Francisco at the Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA; Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Bernard Lo
- Department of Medicine, University of California San Francisco, San Francisco, CA
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4
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Butler CR, Reese PP, Cheng XS. Referral and Beyond: Restructuring the Kidney Transplant Process to Support Greater Access in the United States. Am J Kidney Dis 2024:S0272-6386(24)00743-1. [PMID: 38670253 DOI: 10.1053/j.ajkd.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/28/2024]
Abstract
Advocates for improved equity in kidney transplants in the United States have recently focused their efforts on initiatives to increase referral for transplant evaluation. However, because donor kidneys remain scarce, increased referrals are likely to result in an increasing number of patients proceeding through the evaluation process without ultimately receiving a kidney. Unfortunately, the process of referral and evaluation can be highly resource-intensive for patients, families, transplant programs, and payers. Patients and families may incur out-of-pocket expenses and be required to complete testing and treatments that they might not have chosen in the course of routine clinical care. Kidney transplant programs may struggle with insufficient capacity, inefficient workflow, and challenging programmatic finances, and payers will need to absorb the increased expenses of upfront pretransplant costs. Increased referral in isolation may risk simply transmitting system stress and resulting disparities to downstream processes in this complex system. We argue that success in efforts to improve access through increased referrals hinges on adaptations to the pretransplant process more broadly. We call for an urgent re-evaluation and redesign at multiple levels of the pretransplant system in order to achieve the aim of equitable access to kidney transplantation for all patients with kidney failure.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; Veteran Affairs Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University, Palo Alto, California.
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5
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Lu Y, Arowojolu O, Qiu X, Liu Y, Curry L, Krumholz HM. Barriers to Optimal Clinician Guideline Adherence in the Management of Markedly Elevated Blood Pressure: A Qualitative Content Analysis of Electronic Health Records. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.12.24301223. [PMID: 38260693 PMCID: PMC10802744 DOI: 10.1101/2024.01.12.24301223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
IMPORTANCE Hypertension poses a significant public health challenge. Despite clinical practice guidelines for hypertension management, clinician adherence to these guidelines remains suboptimal. OBJECTIVE This study aims to develop a taxonomy of suboptimal adherence scenarios for severe hypertension and identify barriers to guideline adherence. DESIGN We conducted a qualitative content analysis using electronic health records (EHRs) of Yale New Haven Health System who had at least two consecutive visits between January 1, 2013, and October 31, 2018. SETTING This was a thematic analysis of EHR data to generate a real-world taxonomy of scenarios of suboptimal clinician guideline adherence in the management of severe hypertension. PARTICIPANTS We identified patients with markedly elevated blood pressure ([BP]; defined as at least 2 consecutive readings of BP ≥160/100 mmHg) and no prescription for antihypertensive medication within a 90-day of the 2nd BP elevation (n=4,828). We randomly selected 100 records from the group of all eligible patients for qualitative analysis. MAIN OUTCOMES AND MEASURES The scenarios and influencing factors contributing to clinician non-adherence to the guidelines for hypertension management. RESULTS Thematic saturation was reached after analyzing 100 patient records. Three content domains emerged: clinician-related scenarios (neglect and diffusion of responsibility), patient-related scenarios (patient non-adherence and patient preference), and clinical complexity-related scenarios (diagnostic uncertainty, maintenance of current intervention and competing medical priorities). Through a metareview of literature, we identified several plausible influencing factors, including a lack of protocols and processes that clearly define the roles within the institution to implement guidelines, infrastructure limitations, and clinicians' lack of autonomy and authority, excessive workload, time constraints, clinician belief that intervention was not part of their role, or perception that guidelines restrict clinical judgment. CONCLUSIONS AND RELEVANCE This study illuminates reasons for suboptimal adherence to guidelines for managing markedly elevated BP. The taxonomy of suboptimal adherence scenarios, derived from real-world EHR data, is pragmatic and provides a basis for developing targeted interventions to improve clinician guideline adherence and patient outcomes.
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Affiliation(s)
- Yuan Lu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Oreoluwa Arowojolu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Xiaoliang Qiu
- Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Yuntian Liu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Leslie Curry
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
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6
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Pullen LC. Rethinking coronary heart disease tests in pretransplant evaluation: Cardiologists no longer screen asymptomatic patients for coronary artery disease-so why are transplant centers still doing it? Am J Transplant 2023; 23:1087-1089. [PMID: 37419453 DOI: 10.1016/j.ajt.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
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7
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Cheng XS. Preoperative Evaluations Before Transplantation-Essential Tools, Not Obstacles-Reply. JAMA Intern Med 2023; 183:745-746. [PMID: 37184870 DOI: 10.1001/jamainternmed.2023.1242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
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8
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Shapiro LN, Gray MF, Freitag C, Taneja P, Kariya H, Crane PK, O'Hare AM, Vig EK, Taylor JS. Expanding the ethnographic toolkit: Using medical documents to include kinless older adults living with dementia in qualitative research. J Aging Stud 2023; 65:101140. [PMID: 37268383 DOI: 10.1016/j.jaging.2023.101140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 06/04/2023]
Abstract
Ethnographic research with cognitively impaired older adults can be challenging, in part because cognitive impairment raises questions about the ability to provide informed consent. Relying on proxy consent is a commonly used strategy, but often excludes people with dementia who lack close kin (de Medeiros, Girling, & Berlinger, 2022). In this paper, we describe how we have analyzed existing research data from a well-established and ongoing prospective cohort study, the Adult Changes in Thought Study, along with unstructured text from the medical records of participants who had no living spouse or adult children when they developed dementia, as a way of studying the circumstances, life trajectories, caregiving resources, and care needs of this vulnerable and difficult-to-research group. In this article, we detail this methodology, exploring what can and cannot be gleaned from it, what the ethical implications may be, and how and whether this type of research can be considered ethnographic. In conclusion, we argue that collaborative interdisciplinary research using existing, longitudinal research data and text from medical records deserves to be considered as a potentially useful addition to the ethnographic toolkit. We anticipate that this is a methodology that could be applied more broadly, and paired with more traditional ethnographic methods, might be one way to make research with this population more inclusive.
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Affiliation(s)
- Lily N Shapiro
- Kaiser Permanente Washington Health Research Institute, USA.
| | | | | | | | | | | | - Ann M O'Hare
- University of Washington and VA Puget Sound Health Care System, USA
| | - Elizabeth K Vig
- University of Washington and VA Puget Sound Health Care System, USA
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Lu Y, Xinxin Du C, Khidir H, Caraballo C, Mahajan S, Spatz ES, Curry LA, Krumholz HM. Developing an Actionable Taxonomy of Persistent Hypertension Using Electronic Health Records. Circ Cardiovasc Qual Outcomes 2023; 16:e009453. [PMID: 36727515 DOI: 10.1161/circoutcomes.122.009453] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The digital transformation of medical data presents opportunities for novel approaches to manage patients with persistent hypertension. We sought to develop an actionable taxonomy of patients with persistent hypertension (defined as 5 or more consecutive measurements of blood pressure ≥160/100 mmHg over time) based on data from the electronic health records. METHODS This qualitative study was a content analysis of clinician notes in the electronic health records of patients in the Yale New Haven Health System. Eligible patients were 18 to 85 years and had blood pressure ≥160/100 mmHg at 5 or more consecutive outpatient visits between January 1, 2013 and October 31, 2018. A total of 1664 patients met criteria, of which 200 records were randomly selected for chart review. Through a systematic, inductive approach, we developed a rubric to abstract data from the electronic health records and then analyzed the abstracted data qualitatively using conventional content analysis until saturation was reached. RESULTS We reached saturation with 115 patients, who had a mean age of 66.0 (SD, 11.6) years; 54.8% were female; 52.2%, 30.4%, and 13.9% were White, Black, and Hispanic patients. We identified 3 content domains related to persistence of hypertension: (1) non-intensification of pharmacological treatment, defined as absence of antihypertensive treatment intensification in response to persistent severely elevated blood pressure; (2) non-implementation of prescribed treatment, defined as a documentation of provider recommending a specified treatment plan to address hypertension but treatment plan not being implemented; and (3) non-response to prescribed treatment, defined as clinician-acknowledged persistent hypertension despite documented effort to escalate existing pharmacologic agents and addition of additional pharmacologic agents with presumption of adherence. CONCLUSIONS This study presents a novel actionable taxonomy for classifying patients with persistent hypertension by their contributing causes based on electronic health record data. These categories can be automated and linked to specific types of actions to address them.
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Affiliation(s)
- Yuan Lu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (Y.L., C.C., S.M., E.S.S., H.M.K.)
- Section of Cardiovascular Medicine, Department of Internal Medicine (Y.L., C.X.D., C.C., S.M., E.S.S., H.M.K.), Yale School of Medicine, New Haven, CT
| | - Cindy Xinxin Du
- Section of Cardiovascular Medicine, Department of Internal Medicine (Y.L., C.X.D., C.C., S.M., E.S.S., H.M.K.), Yale School of Medicine, New Haven, CT
| | - Hazar Khidir
- Department of Emergency Medicine (H.K.), Yale School of Medicine, New Haven, CT
| | - César Caraballo
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (Y.L., C.C., S.M., E.S.S., H.M.K.)
- Section of Cardiovascular Medicine, Department of Internal Medicine (Y.L., C.X.D., C.C., S.M., E.S.S., H.M.K.), Yale School of Medicine, New Haven, CT
| | - Shiwani Mahajan
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (Y.L., C.C., S.M., E.S.S., H.M.K.)
- Section of Cardiovascular Medicine, Department of Internal Medicine (Y.L., C.X.D., C.C., S.M., E.S.S., H.M.K.), Yale School of Medicine, New Haven, CT
| | - Erica S Spatz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (Y.L., C.C., S.M., E.S.S., H.M.K.)
- Section of Cardiovascular Medicine, Department of Internal Medicine (Y.L., C.X.D., C.C., S.M., E.S.S., H.M.K.), Yale School of Medicine, New Haven, CT
| | - Leslie A Curry
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (L.C., H.M.K.)
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (Y.L., C.C., S.M., E.S.S., H.M.K.)
- Section of Cardiovascular Medicine, Department of Internal Medicine (Y.L., C.X.D., C.C., S.M., E.S.S., H.M.K.), Yale School of Medicine, New Haven, CT
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (L.C., H.M.K.)
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Berkman ER, Richardson KL, Clark JD, Dick AAS, Lewis-Newby M, Diekema DS, Wightman AG. An ethical analysis of obesity as a contraindication of pediatric kidney transplant candidacy. Pediatr Nephrol 2023; 38:345-356. [PMID: 35488137 DOI: 10.1007/s00467-022-05572-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 01/10/2023]
Abstract
The inclusion of body mass index (BMI) as a criterion for determining kidney transplant candidacy in children raises clinical and ethical challenges. Childhood obesity is on the rise and common among children with kidney failure. In addition, obesity is reported as an independent risk factor for the development of CKD and kidney failure. Resultantly, more children with obesity are anticipated to need kidney transplants. Most transplant centers around the world use high BMI as a relative or absolute contraindication for kidney transplant. However, use of obesity as a relative or absolute contraindication for pediatric kidney transplant is controversial. Empirical data demonstrating poorer outcomes following kidney transplant in obese pediatric patients are limited. In addition, pediatric obesity is distributed inequitably among groups. Unlike adults, most children lack independent agency to choose their food sources and exercise opportunities; they are dependent on their families for these choices. In this paper, we define childhood obesity and review (1) the association and impact of obesity on kidney disease and kidney transplant, (2) existing adult guidelines and rationale for using high BMI as a criterion for kidney transplant, (3) the prevalence of childhood obesity among children with kidney failure, and (4) the existing literature on obesity and pediatric kidney transplant outcomes. We then discuss ethical considerations related to the use of obesity as a criterion for kidney transplant.
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Affiliation(s)
- Emily R Berkman
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA.
- Division of Bioethics and Palliative Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA.
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA.
| | - Kelsey L Richardson
- Division of Pediatric Nephrology, Oregon Health Sciences University, Portland, OR, USA
| | - Jonna D Clark
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
- Division of Bioethics and Palliative Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
| | - André A S Dick
- Division of Transplantation, Section of Pediatric Transplantation, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Mithya Lewis-Newby
- Division of Bioethics and Palliative Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
- Division of Cardiac Critical Care, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Douglas S Diekema
- Division of Bioethics and Palliative Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
- Division of Pediatric Emergency Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Aaron G Wightman
- Division of Bioethics and Palliative Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
- Division of Pediatric Nephrology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
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11
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Wang J, Zhang X, Li M, Li R, Zhao M. Shifts in Intestinal Metabolic Profile Among Kidney Transplantation Recipients with Antibody-Mediated Rejection. Ther Clin Risk Manag 2023; 19:207-217. [PMID: 36896026 PMCID: PMC9990454 DOI: 10.2147/tcrm.s401414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/26/2023] [Indexed: 03/06/2023] Open
Abstract
Background Antibody-mediated rejection (AMR) is emerging as the main cause of graft loss after kidney transplantation. Our previous study revealed the gut microbiota alternation associated with AMR in kidney transplant recipients, which was predicted to affect the metabolism-related pathways. Methods To further investigate the shifts in intestinal metabolic profile among kidney transplantation recipients with AMR, fecal samples from kidney transplant recipients and patients with end-stage renal disease (ESRD) were subjected to untargeted LC-MS-based metabolomics. Results A total of 86 individuals were enrolled in this study, including 30 kidney transplantation recipients with AMR, 35 kidney transplant recipients with stable renal function (KT-SRF), and 21 participants with ESRD. Fecal metabolome in patients with ESRD and kidney transplantation recipients with KT-SRF were parallelly detected as controls. Our results demonstrated that intestinal metabolic profile of patients with AMR differed significantly from those with ESRD. A total of 172 and 25 differential metabolites were identified in the KT-AMR group, when compared with the ESRD group and the KT-SRF group, respectively, and 14 were common to the pairwise comparisons, some of which had good discriminative ability for AMR. KEGG pathway enrichment analysis demonstrated that the different metabolites between the KT-AMR and ESRD groups or between KT-AMR and KT-SRF groups were significantly enriched in 33 or 36 signaling pathways, respectively. Conclusion From the metabolic point of view, our findings may provide key clues for developing effective diagnostic biomarkers and therapeutic targets for AMR after kidney transplantation.
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Affiliation(s)
- Junpeng Wang
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, People's Republic of China.,Department of Urology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, People's Republic of China
| | - Xiaofan Zhang
- Medical Research Center, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Mengjun Li
- Department of Pathophysiology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, People's Republic of China
| | - Ruoying Li
- Department of Pathophysiology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, People's Republic of China
| | - Ming Zhao
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, People's Republic of China
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12
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O’Hare AM, Vig EK, Iwashyna TJ, Fox A, Taylor JS, Viglianti EM, Butler CR, Vranas KC, Helfand M, Tuepker A, Nugent SM, Winchell KA, Laundry RJ, Bowling CB, Hynes DM, Maciejewski ML, Bohnert ASB, Locke ER, Boyko EJ, Ioannou GN. Complexity and Challenges of the Clinical Diagnosis and Management of Long COVID. JAMA Netw Open 2022; 5:e2240332. [PMID: 36326761 PMCID: PMC9634500 DOI: 10.1001/jamanetworkopen.2022.40332] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022] Open
Abstract
Importance There is increasing recognition of the long-term health effects of SARS-CoV-2 infection (sometimes called long COVID). However, little is yet known about the clinical diagnosis and management of long COVID within health systems. Objective To describe dominant themes pertaining to the clinical diagnosis and management of long COVID in the electronic health records (EHRs) of patients with a diagnostic code for this condition (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] code U09.9). Design, Setting, and Participants This qualitative analysis used data from EHRs of a national random sample of 200 patients receiving care in the Department of Veterans Affairs (VA) with documentation of a positive result on a polymerase chain reaction (PCR) test for SARS-CoV-2 between February 27, 2020, and December 31, 2021, and an ICD-10 diagnostic code for long COVID between October 1, 2021, when the code was implemented, and March 1, 2022. Data were analyzed from February 5 to May 31, 2022. Main Outcomes and Measures A text word search and qualitative analysis of patients' VA-wide EHRs was performed to identify dominant themes pertaining to the clinical diagnosis and management of long COVID. Results In this qualitative analysis of documentation in the VA-wide EHR, the mean (SD) age of the 200 sampled patients at the time of their first positive PCR test result for SARS-CoV-2 in VA records was 60 (14.5) years. The sample included 173 (86.5%) men; 45 individuals (22.5%) were identified as Black and 136 individuals (68.0%) were identified as White. In qualitative analysis of documentation pertaining to long COVID in patients' EHRs 2 dominant themes were identified: (1) clinical uncertainty, in that it was often unclear whether particular symptoms could be attributed to long COVID, given the medical complexity and functional limitations of many patients and absence of specific markers for this condition, which could lead to ongoing monitoring, diagnostic testing, and specialist referral; and (2) care fragmentation, describing how post-COVID-19 care processes were often siloed from and poorly coordinated with other aspects of care and could be burdensome to patients. Conclusions and Relevance This qualitative study of documentation in the VA EHR highlights the complexity of diagnosing long COVID in clinical settings and the challenges of caring for patients who have or are suspected of having this condition.
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Affiliation(s)
- Ann M. O’Hare
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Elizabeth K. Vig
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Theodore J. Iwashyna
- Pulmonary and Critical Care Medicine, Department of Health Policy & Management, School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Alexandra Fox
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
| | | | - Elizabeth M. Viglianti
- Department of Internal Medicine Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor
| | - Catherine R. Butler
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Mark Helfand
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Anaïs Tuepker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Shannon M. Nugent
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Kara A. Winchell
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Ryan J. Laundry
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - C. Barrett Bowling
- Geriatric Research Education and Clinical Center, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Denise M. Hynes
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
- College of Public Health and Human Sciences and Center for Quantitative Life Sciences, Oregon State University, Corvallis
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Amy S. B. Bohnert
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Departments of Anesthesiology and Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Emily R. Locke
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
| | - Edward J. Boyko
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
| | - George N. Ioannou
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
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Wong SPY, Foglia MB, Cohen J, Oestreich T, O'Hare AM. The VA Life-Sustaining Treatment Decisions Initiative: A qualitative analysis of veterans with advanced kidney disease. J Am Geriatr Soc 2022; 70:2517-2529. [PMID: 35435246 PMCID: PMC9790645 DOI: 10.1111/jgs.17807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Documentation of patients' goals of care is integral to promoting goal-concordant care. In 2017, the Department of Veterans Affairs (VA) launched a system-wide initiative to standardize documentation of patients' preferences for life-sustaining treatments (LST) and related goals-of-care conversations (GoCC) that included using a note template in its national electronic medical record system. We describe implementation of the LST note based on documentation in the medical records of patients with advanced kidney disease, a group that has traditionally experienced highly intensive patterns of care. METHODS We performed a qualitative analysis of documentation in the VA electronic medical record for a national random sample of 500 adults with advanced kidney disease for whom at least one LST note was completed between July 2018 and March 2019 to identify prominent themes pertaining to the content and context of LST notes. RESULTS During the observation period, a total of 723 (mean 1.5, range 1-6) LST notes were completed for this cohort. Two themes emerged from the analysis: (1) Reactive approach: LST notes were largely completed in response to medical crises, in which they focused on short-term goals and preferences rather than patients' broader health and goals, or certain clinical encounters designated by the initiative as "triggering events" for LST note completion; (2) Practitioner-driven: Documentation suggested that practitioners would attempt to engage patients/surrogates in GoCC to lay out treatment options in order to move care forward, but patients/surrogates sometimes appeared reluctant to engage in GoCC and had difficulty communicating in ways that practitioners could understand. CONCLUSIONS Standardized documentation of patients' treatment preferences and related GoCC was used to inform in-the-moment decision-making during acute illness and certain junctures in care. There is opportunity to expand standardized documentation practices and related GoCC to address patients'/surrogates' broader health concerns and goals and to enhance their engagement in these processes.
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Affiliation(s)
- Susan P. Y. Wong
- Division of NephrologyVA Puget Sound Health Care SystemSeattleWashingtonUSA
| | - Mary Beth Foglia
- VA National Center for Ethics in Health CareSeattleWashingtonUSA
| | - Jennifer Cohen
- VA National Center for Ethics in Health CareSeattleWashingtonUSA
| | - Taryn Oestreich
- Division of NephrologyVA Puget Sound Health Care SystemSeattleWashingtonUSA
| | - Ann M. O'Hare
- Division of NephrologyVA Puget Sound Health Care SystemSeattleWashingtonUSA
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Decision-making Among Hepatitis C Virus-negative Transplant Candidates Offered Organs from Donors with HCV Infection. Transplant Direct 2022; 8:e1341. [PMID: 35923812 PMCID: PMC9298473 DOI: 10.1097/txd.0000000000001341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/16/2022] [Indexed: 11/26/2022] Open
Abstract
Background Historically, many organs from deceased donors with hepatitis C virus (HCV) were discarded. The advent of highly curative direct-acting antiviral (DAA) therapies motivated transplant centers to conduct trials of transplanting HCV-viremic organs (nucleic acid amplification test positive) into HCV-negative recipients, followed by DAA treatment. However, the factors that influence candidates' decisions regarding acceptance of transplant with HCV-viremic organs are not well understood. Methods To explore patient-level perceptions, influences, and experiences that inform candidate decision-making regarding transplant with organs from HCV-viremic donors, we conducted a qualitative semistructured interview study embedded within 3 clinical trials investigating the safety and efficacy of transplanting lungs and kidneys from HCV-viremic donors into HCV-negative recipients. The study was conducted from June 2019 to March 2021. Results Among 44 HCV-negative patients listed for organ transplant who were approached for enrollment in the applicable clinical trial, 3 approaches to decision-making emerged: positivist, risk analyses, and instinctual response. Perceptions of risk contributed to conceptualizations of factors influencing decisions. Moreover, most participants relied on multiple decision-making approaches, either simultaneously or sequentially. Conclusions Understanding how different decisional models influence patients' choices regarding transplant with organs from HCV-viremic donors may promote shared decision-making among transplant patients and providers.
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O'Hare AM, Butler CR, Laundry RJ, Showalter W, Todd-Stenberg J, Green P, Hebert PL, Wang V, Taylor JS, Van Eijk M, Matthews KL, Crowley ST, Carey E. Implications of Cross-System Use Among US Veterans With Advanced Kidney Disease in the Era of the MISSION Act: A Qualitative Study of Health Care Records. JAMA Intern Med 2022; 182:710-719. [PMID: 35576068 PMCID: PMC9112136 DOI: 10.1001/jamainternmed.2022.1379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
IMPORTANCE Since 2014, when Congress passed the Veterans Access Choice and Accountability (Choice) Act (replaced in 2018 with the more comprehensive Maintaining Internal Systems and Strengthening Integrated Outside Networks [MISSION] Act), the Department of Veterans Affairs (VA) has been paying for US veterans to receive increasing amounts of care in the private sector (non-VA care or VA community care). However, little is known about the implications of these legislative changes for the VA system. OBJECTIVE To describe the implications for the VA system of recent increases in VA-financed non-VA care. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was a thematic analysis of documentation in the electronic health records (EHRs) of a random sample of US veterans with advanced kidney disease between June 6, 2019, and February 5, 2021. EXPOSURES Mentions of community care in participant EHRs. MAIN OUTCOMES AND MEASURES Dominant themes pertaining to VA-financed non-VA care. RESULTS Among 1000 study participants, the mean (SD) age was 73.8 (11.4) years, and 957 participants (95.7%) were male. Three interrelated themes pertaining to VA-financed non-VA care emerged from qualitative analysis of documentation in cohort member EHRs: (1) VA as mothership, which describes extensive care coordination by VA staff members and clinicians to facilitate care outside the VA and the tendency of veterans and their non-VA clinicians to rely on the VA to fill gaps in this care; (2) hidden work of veterans, which describes the efforts of veterans and their family members to navigate the referral process, and to serve as intermediaries between VA and non-VA clinicians; and (3) strain on the VA system, which describes a challenging referral process and the ways in which cross-system care has stretched the traditional roles of VA staff and clinicians and interfered with VA care processes. CONCLUSIONS AND RELEVANCE The findings of this qualitative study describing VA-financed non-VA care for veterans with advanced kidney disease spotlight the substantial challenges of cross-system use and the strain placed on the VA system, VA staff and clinicians, and veterans and their families in recent years. These difficult-to-measure consequences of cross-system care should be considered when budgeting, evaluating, and planning the provision of VA-financed non-VA care in the private sector.
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Affiliation(s)
- Ann M O'Hare
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Washington.,VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington.,Department of Medicine and Kidney Research Institute, University of Washington, Seattle
| | - Catherine R Butler
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Washington.,VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington.,Department of Medicine and Kidney Research Institute, University of Washington, Seattle
| | - Ryan J Laundry
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington
| | - Whitney Showalter
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington
| | - Jeffrey Todd-Stenberg
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington
| | - Pam Green
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington
| | - Paul L Hebert
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle
| | - Virginia Wang
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine Durham, North Carolina.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Janelle S Taylor
- Department of Anthropology, University of Toronto, Ontario, Canada
| | | | | | - Susan T Crowley
- Department of Medicine, Yale University, New Haven, Connecticut.,VA Connecticut Health Care System, West Haven, Connecticut
| | - Evan Carey
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Denver
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16
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Butler CR. A Critical Role for Shared Decision-Making about Referral and Evaluation for Kidney Transplant. KIDNEY360 2022; 3:14-16. [PMID: 35368579 PMCID: PMC8967623 DOI: 10.34067/kid.0007642021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/14/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Catherine R. Butler
- Division of Nephrology, Department of Medicine, University of Washington; Veterans Affairs Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
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17
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Butler CR, Wightman AG. Scarce Health Care Resources and Equity during COVID-19: Lessons from the History of Kidney Failure Treatment. KIDNEY360 2021; 2:2024-2026. [PMID: 35419528 PMCID: PMC8986052 DOI: 10.34067/kid.0005292021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/22/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Catherine R. Butler
- Division of Nephrology, University of Washington, Seattle, Washington,Veterans Affairs Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Aaron G. Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington,Treuman Katz Center for Pediatric Bioethics, Seattle, Washington
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Greysen SR, Auerbach AD, Mitchell MD, Goldstein JN, Weiss R, Esmaili A, Kuye I, Manjarrez E, Bann M, Schnipper JL. Discharge Practices for COVID-19 Patients: Rapid Review of Published Guidance and Synthesis of Documents and Practices at 22 US Academic Medical Centers. J Gen Intern Med 2021; 36:1715-1721. [PMID: 33835314 PMCID: PMC8034037 DOI: 10.1007/s11606-021-06711-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/09/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND There are currently no evidence-based guidelines that provide standardized criteria for the discharge of COVID-19 patients from the hospital. OBJECTIVE To address this gap in practice guidance, we reviewed published guidance and collected discharge protocols and procedures to identify and synthesize common practices. DESIGN Rapid review of existing guidance from US and non-US public health organizations and professional societies and qualitative review using content analysis of discharge documents collected from a national sample of US academic medical centers with follow-up survey of hospital leaders SETTING AND PARTICIPANTS: We reviewed 65 websites for major professional societies and public health organizations and collected documents from 22 Academic Medical Centers (AMCs) in the US participating in the HOspital MEdicine Reengineering Network (HOMERuN). RESULTS We synthesized data regarding common practices around 5 major domains: (1) isolation and transmission mitigation; (2) criteria for discharge to non-home settings including skilled nursing, assisted living, or homeless; (3) clinical criteria for discharge including oxygenation levels, fever, and symptom improvement; (4) social support and ability to perform activities of daily living; (5) post-discharge instructions, monitoring, and follow-up. LIMITATIONS We used streamlined methods for rapid review of published guidance and collected discharge documents only in a focused sample of US academic medical centers. CONCLUSION AMCs studied showed strong consensus on discharge practices for COVID-19 patients related to post-discharge isolation and transmission mitigation for home and non-home settings. There was high concordance among AMCs that discharge practices should address COVID-19-specific factors in clinical, functional, and post-discharge monitoring domains although definitions and details varied.
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Affiliation(s)
- S Ryan Greysen
- Penn Medicine Center for Evidence-based Practice, Section of Hospital Medicine, Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, USA.
| | - Andrew D Auerbach
- Division of Hospital Medicine, University of California San Francisco, San Francisco, USA
| | - Matthew D Mitchell
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, USA
| | | | - Rachel Weiss
- Division of Hospital Medicine, University of California San Francisco, San Francisco, USA
- University of Virginia, Charlottesville, VA, USA
| | - Armond Esmaili
- Division of Hospital Medicine, University of California San Francisco, San Francisco, USA
| | - Ifedayo Kuye
- Division of Hospital Medicine, University of California San Francisco, San Francisco, USA
- Johns Hopkins University, Baltimore, MD, USA
| | | | - Maralyssa Bann
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Jeffrey L Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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19
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CC-BY Open Access Added. JAMA Intern Med 2021; 181:296. [PMID: 33394008 PMCID: PMC7783588 DOI: 10.1001/jamainternmed.2020.8392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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