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Chacon MA, Cook CA, Flynn-O'Brien K, Zagory JA, Choi PM, Wilson NA. Assessing the Impact of Neighborhood and Built Environment on Pediatric Perioperative Care: A Systematic Review of the Literature. J Pediatr Surg 2024; 59:1378-1387. [PMID: 38631997 PMCID: PMC11164636 DOI: 10.1016/j.jpedsurg.2024.03.033] [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: 02/16/2024] [Accepted: 03/04/2024] [Indexed: 04/19/2024]
Abstract
CONTEXT Neighborhood and built environment encompass one key area of the Social Determinants of Health (SDOH) and is frequently assessed using area-level indices. OBJECTIVE We sought to systematically review the pediatric surgery literature for use of commonly applied area-level indices and to compare their utility for prediction of outcomes. DATA SOURCES A literature search was conducted using PubMed, Ovid MEDLINE, Ovid MEDLINE Epub Ahead of Print, PsycInfo, and an artificial intelligence search tool (1/2013-2/2023). STUDY SELECTION Inclusion required pediatric surgical patients in the US, surgical intervention performed, and use of an area-level metric. DATA EXTRACTION Extraction domains included study, patient, and procedure characteristics. RESULTS Area Deprivation Index is the most consistent and commonly accepted index. It is also the most granular, as it uses Census Block Groups. Child Opportunity Index is less granular (Census Tract), but incorporates pediatric-specific predictors of risk. Results with Social Vulnerability Index, Neighborhood Deprivation Index, and Neighborhood Socioeconomic Status were less consistent. LIMITATIONS All studies were retrospective and quality varied from good to fair. CONCLUSIONS While each index has strengths and limitations, standardization on ideal metric(s) for the pediatric surgical population will help build the inferential power needed to move from understanding the role of SDOH to building meaningful interventions towards equity in care. TYPE OF STUDY Systematic Review. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Miranda A Chacon
- Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave, Box SURG, Rochester, NY 14642, USA
| | - Caitlin A Cook
- Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave, Box SURG, Rochester, NY 14642, USA
| | - Katherine Flynn-O'Brien
- Division of Pediatric Surgery, Children's Wisconsin and Medical College of Wisconsin, 8915 W. Connell Ct., Milwaukee, WI 53226, USA
| | - Jessica A Zagory
- Division of Pediatric Surgery, Department of Surgery, Louisiana State University Health Sciences Center - New Orleans, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Pamela M Choi
- Department of Surgery, Naval Medical Center, 34800 Bob Wilson Dr, San Diego, CA 92134, USA
| | - Nicole A Wilson
- Division of Pediatric Surgery, Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave, Box SURG, Rochester, NY 14642, USA; Department of Biomedical Engineering, University of Rochester, 601 Elmwood Ave, Box SURG, Rochester, NY 14642, USA.
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Andrist E, Clarke RG, Phelps KB, Dews AL, Rodenbough A, Rose JA, Zurca AD, Lawal N, Maratta C, Slain KN. Understanding Disparities in the Pediatric ICU: A Scoping Review. Pediatrics 2024; 153:e2023063415. [PMID: 38639640 DOI: 10.1542/peds.2023-063415] [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] [Accepted: 02/06/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Health disparities are pervasive in pediatrics. We aimed to describe disparities among patients who are likely to be cared for in the PICU and delineate how sociodemographic data are collected and categorized. METHODS Using MEDLINE as a data source, we identified studies which included an objective to assess sociodemographic disparities among PICU patients in the United States. We created a review rubric, which included methods of sociodemographic data collection and analysis, outcome and exposure variables assessed, and study findings. Two authors reviewed every study. We used the National Institute on Minority Health and Health Disparities Research Framework to organize outcome and exposure variables. RESULTS The 136 studies included used variable methods of sociodemographic data collection and analysis. A total of 30 of 124 studies (24%) assessing racial disparities used self- or parent-identified race. More than half of the studies (52%) dichotomized race as white and "nonwhite" or "other" in some analyses. Socioeconomic status (SES) indicators also varied; only insurance status was used in a majority of studies (72%) evaluating SES. Consistent, although not uniform, disadvantages existed for racial minority populations and patients with indicators of lower SES. The authors of only 1 study evaluated an intervention intended to mitigate health disparities. Requiring a stated objective to evaluate disparities aimed to increase the methodologic rigor of included studies but excluded some available literature. CONCLUSIONS Variable, flawed methodologies diminish our understanding of disparities in the PICU. Meaningfully understanding and addressing health inequity requires refining how we collect, analyze, and interpret relevant data.
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Affiliation(s)
- Erica Andrist
- Division of Pediatric Critical Care Medicine
- Departments of Pediatrics
| | - Rachel G Clarke
- Division of Pediatric Critical Care Medicine, Upstate University Hospital, Syracuse, New York
- Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, New York
| | - Kayla B Phelps
- Division of Pediatric Critical Care Medicine, Louisiana State University Health Sciences Center, Children's Hospital of New Orleans, New Orleans, Louisiana
| | - Alyssa L Dews
- Human Genetics, University of Michigan Medical School, Ann Arbor, Michigan
- Susan B. Meister Child Health and Adolescent Research Center, University of Michigan, Ann Arbor, Michigan
| | - Anna Rodenbough
- Division of Pediatric Critical Care Medicine, Children's Hospital of Atlanta, Atlanta, Georgia
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jerri A Rose
- Pediatric Emergency Medicine
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Adrian D Zurca
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nurah Lawal
- Stepping Stones Pediatric Palliative Care Program, C.S. Mott Children's Hospital, Ann Arbor, Michigan
- Departments of Pediatrics
| | - Christina Maratta
- Department of Critical Care, The Hospital for Sick Children, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Katherine N Slain
- Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Isa HM, Alkharsi FA, Khamis JK, Hasan SA, Naser ZA, Mohamed ZN, Mohamed AM, Altamimi SA. Pediatric and adult liver transplantation in Bahrain: The experiences in a country with no available liver transplant facilities. World J Transplant 2024; 14:87752. [PMID: 38576753 PMCID: PMC10989476 DOI: 10.5500/wjt.v14.i1.87752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/29/2023] [Accepted: 12/19/2023] [Indexed: 03/15/2024] Open
Abstract
BACKGROUND Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease and has become the standard and most effective treatment method for these patients. There are many indications for LT that vary between countries and settings. The outcome of LT depends on the available facilities and surgical expertise, as well as the types of liver graft donors available. AIM To assess the clinical characteristics of patients from Bahrain who underwent LT overseas, and analyze factors affecting their survival. METHODS In this retrospective cohort study, we reviewed the medical records and overseas committee registry information of all pediatric and adult patients who were sent overseas to undergo LT by the Pediatric and Medical Departments of Salmaniya Medical Complex and Bahrain Defence Force Hospital via the Overseas Treatment Office, Ministry of Health, Kingdom of Bahrain, between 1997 and 2023. Demo graphic data, LT indication, donor-recipient relationship, overseas LT center, graft type, post-LT medications, and LT complications, were collected. Outcomes measured included the overall and 5-year LT survival rate. Fisher's exact, Pearson χ2, and Mann-Whitney U tests were used to compare the pediatric and the adults' group in terms of clinical characteristics, donor-recipient relationship, medication, complications, and outcome. Survival analysis was estimated via the Kaplan-Meier's method. Univariate and multivariate analyses were used to detect predictors of survival. RESULTS Of the 208 eligible patients, 170 (81.7%) were sent overseas to undergo LT while 38 (18.3%) remained on the waiting list. Of the 170 patients, 167 (80.3%) underwent LT and were included in the study. The majority of the patients were Bahraini (91.0%), and most were males (57.5%). One-hundred-and-twenty (71.8%) were adults and 47 (28.3%) were children. The median age at transplant was 50.0 [interquartile range (IQR): 14.9-58.4] years. The main indication for pediatric LT was biliary atresia (31.9%), while that of adult LT was hepatitis C-related cirrhosis (35.0%). Six (3.6%) patients required re-transplantation. Most patients received a living-related liver graft (82%). Pediatric patients received more living and related grafts than adults (P = 0.038 and P = 0.041, respectively), while adult patients received more cadaveric and unrelated grafts. Most patients required long-term immunosuppressive therapy after LT (94.7%), of which tacrolimus was the most prescribed (84.0%), followed by prednisolone (50.7%), which was prescribed more frequently for pediatric patients (P = 0.001). Most patients developed complications (62.4%) with infectious episodes being the most common (38.9%), followed by biliary stricture (19.5%). Tonsilitis and sepsis (n = 12, 8.1% for each) were the most frequent infections. Pediatric patients experienced higher rates of infection, rejection, and early poor graft function than adult patients (P < 0.001, P = 0.003, and P = 0.025, respectively). The median follow-up time was 6.5 (IQR: 2.6-10.6) years. The overall survival rate was 84.4%, the 5-year survival rate, 86.2%, and the mortality rate, 15.6%. Younger patients had significantly better odds of survival (P = 0.019) and patients who survived had significantly longer follow-up periods (P < 0.001). CONCLUSION Patients with end-stage liver disease in Bahrain shared characteristics with those from other countries. Since LT facilities are not available, an overseas LT has offered them great hope.
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Affiliation(s)
- Hasan M Isa
- Department of Pediatrics, Salmaniya Medical Complex, Manama 26671, Bahrain
- Department of Pediatrics, Arabian Gulf University, Manama 26671, Bahrain
| | - Fatema A Alkharsi
- Department of Pediatrics, Salmaniya Medical Complex, Manama 26671, Bahrain
| | - Jawad K Khamis
- Department of Medicine, Salmaniya Medical Complex, Manama 26671, Bahrain
| | - Sawsan A Hasan
- Department of Pediatrics, Salmaniya Medical Complex, Manama 26671, Bahrain
| | - Zainab A Naser
- Department of Pediatrics, Salmaniya Medical Complex, Manama 26671, Bahrain
| | - Zainab N Mohamed
- Department of Pediatrics, Salmaniya Medical Complex, Manama 26671, Bahrain
| | - Afaf M Mohamed
- Public Health Directorate, Ministry of Health, Manama 26671, Bahrain
| | - Shaikha A Altamimi
- The Overseas Office, Supreme Committee for Treatment Abroad, Ministry of Health, Manama 26671, Bahrain
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Armstrong A, Liang JW, Char D, Hollander SA, Pyke-Grimm KA. The effect of socioeconomic status on pediatric heart transplant outcomes at a single institution between 2013 and 2022. Pediatr Transplant 2024; 28:e14695. [PMID: 38433565 DOI: 10.1111/petr.14695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/06/2023] [Accepted: 01/05/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Disparities in pediatric heart transplant outcomes based on socioeconomic status (SES) have been previously observed. However, there is a need to reevaluate these associations in contemporary settings with advancements in transplant therapies and increased awareness of health disparities. This retrospective study aims to investigate the relationship between SES and outcomes for pediatric heart transplant patients. METHODS Data were collected through a chart review of 176 pediatric patients who underwent first orthotopic heart transplantation (OHT) at a single center from 2013 to 2021. The Area Deprivation Index (ADI), a composite score based on U.S. census data, was used to quantify SES. Cox proportional hazards models and generalized linear models were employed to analyze the association between SES and graft failure, rejection rates, and hospitalization rates. RESULTS The analysis revealed no statistically significant differences in graft failure rates, rejection rates, or hospitalization rates between low-SES and high-SES pediatric heart transplant patients for our single-center study. CONCLUSION There may be patient education, policies, and social resources that can help mitigate SES-based healthcare disparities. Additional multi-center research is needed to identify post-transplant care that promotes patient equity.
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Affiliation(s)
- Allison Armstrong
- Department of Cardiology, Lucile Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Jane W Liang
- Quantitative Sciences Unit, Stanford University of Medicine, Palo Alto, California, USA
| | - Danton Char
- Department of Cardiology, Lucile Packard Children's Hospital/Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Department of Cardiology, Lucile Packard Children's Hospital/Stanford University School of Medicine, Palo Alto, California, USA
| | - Kimberly A Pyke-Grimm
- Center for Nursing Excellence, Bass Center for Childhood Cancer and Blood Diseases, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
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Shifman HP, Huang CY, Beck AF, Bucuvalas J, Perito ER, Hsu EK, Ebel NH, Lai JC, Wadhwani SI. Association of state Medicaid expansion policies with pediatric liver transplant outcomes. Am J Transplant 2024; 24:239-249. [PMID: 37776976 PMCID: PMC10843745 DOI: 10.1016/j.ajt.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 08/22/2023] [Accepted: 09/14/2023] [Indexed: 10/02/2023]
Abstract
Children from minoritized/socioeconomically deprived backgrounds suffer disproportionately high rates of uninsurance and graft failure/death after liver transplant. Medicaid expansion was developed to expand access to public insurance. Our objective was to characterize the impact of Medicaid expansion policies on long-term graft/patient survival after pediatric liver transplantation. All pediatric patients (<19 years) who received a liver transplant between January 1, 2005, and December 31, 2020 in the US were identified in the Scientific Registry of Transplant Recipients (N = 8489). Medicaid expansion was modeled as a time-varying exposure based on transplant and expansion dates. We used Cox proportional hazards models to evaluate the impact of Medicaid expansion on a composite outcome of graft failure/death over 10 years. As a sensitivity analysis, we conducted an intention-to-treat analysis from time of waitlisting to death (N = 1 1901). In multivariable analysis, Medicaid expansion was associated with a 30% decreased hazard of graft failure/death (hazard ratio, 0.70; 95% confidence interval, 0.62, 0.79; P < .001) after adjusting for Black race, public insurance, neighborhood deprivation, and living in a primary care shortage area. In intention-to-treat analyses, Medicaid expansion was associated with a 72% decreased hazard of patient death (hazard ratio, 0.28; 95% confidence interval, 0.23-0.35; P < .001). Policies that enable broader health insurance access may help improve outcomes and reduce disparities for children undergoing liver transplantation.
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Affiliation(s)
- Holly Payton Shifman
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Andrew F Beck
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - John Bucuvalas
- Division of Pediatric Hepatology, Department of Pediatrics Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Hepatology, Department of Pediatrics, Kravis Children's Hospital, New York, New York, USA
| | - Emily R Perito
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Evelyn K Hsu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Noelle H Ebel
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California, USA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sharad I Wadhwani
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA.
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Ascher Bartlett J, Barhouma S, Bangerth S, Mejia V, Weaver C, Kohli R, Emamaullee J. Finance, race, ethnicity, and spoken language impact clinical outcomes for children with acute liver failure. Pediatr Transplant 2024; 28:e14686. [PMID: 38317347 PMCID: PMC10857738 DOI: 10.1111/petr.14686] [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: 06/21/2023] [Revised: 11/29/2023] [Accepted: 12/18/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Pediatric acute liver failure (PALF) is an emergency, necessitating prompt referral and management at an experienced liver transplant center. Social determinants of health (SDOH) drive healthcare disparities and can affect many aspects of disease presentation, access to care, and ultimately clinical outcomes. Potential associations between SDOH and PALF outcomes, including spontaneous recovery (SR), liver transplant (LT) or death, are unknown. This study aims to investigate how SDOH may affect PALF and therefore identify areas for intervention to mitigate unrecognized disparities. METHODS A retrospective, single-center cohort was analyzed and then compared and validated with data from the multicenter National Institutes of Health PALF Study Group. The single-center review included 145 patients admitted with PALF using diagnostic codes. Medical records were reviewed to extract patient demographics, family structure, inpatient social worker assessments, and clinical outcomes. Data were stratified by outcome. RESULTS This analysis determined that level of family support (p = .02), caretaker employment (p = .02), patient age, race, and language (p = .01) may impact clinical outcomes. Specifically, the cohort of children that died had the largest proportion of non-English speaking patients with limited support systems and parents who worked full-time. Conversely, patients who underwent LT more often belonged to English-speaking families with a homemaker and extensive support systems. CONCLUSION This study suggests that SDOH impact PALF outcomes and highlights patient populations facing additional challenges during an already complex healthcare emergency. These associations may indicate unconscious biases held by transplant teams when evaluating waitlist candidacy, as well as barriers to healthcare access. Strategies to better understand the broader applicability of our findings and, if confirmed, efforts to mitigate social disparities, may improve clinical outcomes in PALF.
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Sauer CG, Barnard JA, Vinci RJ, Strople JA. Child Health Needs and the Pediatric Gastroenterology Workforce: 2020-2040. Pediatrics 2024; 153:e2023063678K. [PMID: 38300013 DOI: 10.1542/peds.2023-063678k] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 02/02/2024] Open
Abstract
This article is part of an American Board of Pediatrics Foundation-sponsored effort to analyze and forecast the pediatric subspecialty workforce between 2020 and 2040. Herein, an overview of the current pediatric gastroenterology workforce is provided, including demographics, work characteristics, and geographic distribution of practitioners. Brief context is provided on the changing nature of current practice models and the increasing prevalence of some commonly seen disorders. On the basis of a rigorous microsimulation workforce projection model, projected changes from 2020 to 2040 in the number of pediatric gastroenterologists and clinical workforce equivalents in the United States are presented. The article closes with a brief discussion of training, clinical practice, policy, and future workforce research implications of the data presented. This data-driven analysis suggests that the field of pediatric gastroenterology will continue to grow in scope and complexity, propelled by scientific advances and the increasing prevalence of many disorders relevant to the discipline. The workforce is projected to double by 2040, a growth rate faster than most other pediatric subspecialties. Disparities in care related to geography, race, and ethnicity are among the most significant challenges for the years ahead. Changes to training and education, incentives to meet the needs of underserved populations, and new multidisciplinary models for health care delivery will be necessary to optimally meet the volume, diversity, and complexity of children with gastroenterological diseases in the years ahead.
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Affiliation(s)
- Cary G Sauer
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - John A Barnard
- Department of Pediatrics, Ohio State University College of Medicine, Columbus, Ohio
| | - Robert J Vinci
- Department of Pediatrics, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Jennifer A Strople
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, Illinois
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Carbone M, Neuberger J, Rowe I, Polak WG, Forsberg A, Fondevila C, Mantovani L, Nardi A, Colli A, Rockell K, Schick L, Cristoferi L, Oniscu GC, Strazzabosco M, Cillo U. European Society for Organ Transplantation (ESOT) Consensus Statement on Outcome Measures in Liver Transplantation According to Value-Based Health Care. Transpl Int 2024; 36:12190. [PMID: 38332850 PMCID: PMC10850237 DOI: 10.3389/ti.2023.12190] [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: 10/05/2023] [Accepted: 12/14/2023] [Indexed: 02/10/2024]
Abstract
Liver transplantation is a highly complex, life-saving, treatment for many patients with advanced liver disease. Liver transplantation requires multidisciplinary teams, system-wide adaptations and significant investment, as well as being an expensive treatment. Several metrics have been proposed to monitor processes and outcomes, however these lack patient focus and do not capture all aspects of the process. Most of the reported outcomes do not capture those outcomes that matter to the patients. Adopting the principles of Value-Based Health Care (VBHC), may provide an opportunity to develop those metrics that matter to patients. In this article, we present a Consensus Statement on Outcome Measures in Liver Transplantation following the principles of VBHC, developed by a dedicated panel of experts under the auspices of the European Society of Organ Transplantation (ESOT) Guidelines' Taskforce. The overarching goal is to provide a framework to facilitate the development of outcome measures as an initial step to apply the VMC paradigm to liver transplantation.
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Affiliation(s)
- Marco Carbone
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Liver Unit, ASST Grande Ospedale Metropolitano (GOM) Niguarda, Milan, Italy
| | - James Neuberger
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Ian Rowe
- School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Wojciech G. Polak
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Anna Forsberg
- Institute of Health Sciences, Lund University, Lund, Sweden
| | | | - Lorenzo Mantovani
- Center for Study and Research on Public Health, University of Milan-Bicocca, Milan, Italy
| | - Alessandra Nardi
- Department of Mathematics, University of Rome Tor Vergata, Rome, Italy
| | - Agostino Colli
- Istituto di Ricovero e Cura a Carattere Scientifico, Ca’ Granda Foundation Maggiore Policlinico Hospital, Milan, Italy
| | | | - Liz Schick
- World Transplant Games Federation, Winchester, United Kingdom
| | - Laura Cristoferi
- Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Gabriel C. Oniscu
- Division of Transplantation Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Mario Strazzabosco
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, United States
| | - Umberto Cillo
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine and Surgery, University of Padua, Padua, Italy
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9
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Brugha R, Wu D, Spencer H, Marson L. Disparities in lung transplantation in children. Pediatr Pulmonol 2023. [PMID: 38131456 DOI: 10.1002/ppul.26813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 11/17/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
Lung transplantation is a recognized therapy for end-stage respiratory failure in children and young people. It is only available in selected countries and is limited by access to suitable organs. Data on disparities in access and outcomes for children undergoing lung transplantation are limited. It is clear from data from studies in adults, and from studies in other solid organ transplants in children, that systemic inequities exist in this field. While data relating specifically to pediatric lung transplantation are relatively sparse, professionals should be aware of the risk that healthcare systems may result in disparities in access and outcomes following lung transplantation in children.
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Affiliation(s)
- Rossa Brugha
- Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK
- Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Diana Wu
- General Surgery, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Helen Spencer
- Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK
| | - Lorna Marson
- Transplant Unit, Royal Infirmary Edinburgh, Edinburgh, UK
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10
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Rea KE, West KB, Dorste A, Christofferson ES, Lefkowitz D, Mudd E, Schneider L, Smith C, Triplett KN, McKenna K. A systematic review of social determinants of health in pediatric organ transplant outcomes. Pediatr Transplant 2023; 27:e14418. [PMID: 36321186 DOI: 10.1111/petr.14418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/27/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Equitable access to pediatric organ transplantation is critical, although risk factors negatively impacting pre- and post-transplant outcomes remain. No synthesis of the literature on SDoH within the pediatric organ transplant population has been conducted; thus, the current systematic review summarizes findings to date assessing SDoH in the evaluation, listing, and post-transplant periods. METHODS Literature searches were conducted in Web of Science, Embase, PubMed, and Cumulative Index to Nursing and Allied Health Literature databases. RESULTS Ninety-three studies were included based on pre-established criteria and were reviewed for main findings and study quality. Findings consistently demonstrated disparities in key transplant outcomes based on racial or ethnic identity, including timing and likelihood of transplant, and rates of rejection, graft failure, and mortality. Although less frequently assessed, variations in outcomes based on geography were also noted, while findings related to insurance or SES were inconsistent. CONCLUSION This review underscores the persistence of SDoH and disparity in equitable transplant outcomes and discusses the importance of individual and systems-level change to reduce such disparities.
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Affiliation(s)
- Kelly E Rea
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Kara B West
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anna Dorste
- Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Debra Lefkowitz
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Mudd
- Cleveland Clinic Children's, Center for Pediatric Behavioral Health, Wilmington, North Carolina, USA
| | - Lauren Schneider
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Courtney Smith
- Norton Children's, University of Louisville, Louisville, Kentucky, USA
| | - Kelli N Triplett
- Children's Health, Children's Medical Center Dallas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Wadhwani SI, Barrera AG, Shifman HP, Baker E, Bucuvalas J, Gottlieb LM, Kotagal U, Rhee SJ, Lai JC, Lyles CR. Caregiver perspectives on the everyday medical and social needs of long-term pediatric liver transplant patients. Liver Transpl 2022; 28:1735-1746. [PMID: 35524767 PMCID: PMC9949888 DOI: 10.1002/lt.26498] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 02/05/2023]
Abstract
Using in-depth interviews, we sought to characterize the everyday medical and social needs of pediatric liver transplant caregivers to inform the future design of solutions to improve care processes. Participants (parents/caregivers of pediatric liver transplant recipients) completed a survey (assessing socioeconomic status, economic hardship, health literacy, and social isolation). We then asked participants to undergo a 60-min virtual, semistructured qualitative interview to understand the everyday medical and social needs of the caregiver and their household. We intentionally oversampled caregivers who reported a social or economic hardship on the survey. Transcripts were analyzed using thematic analysis and organized around the Capability, Opportunity, Motivation-Behavior model. A total of 18 caregivers participated. Of the participants, 50% reported some form of financial strain, and about half had less than 4 years of college education. Caregivers had high motivation and capability in executing transplant-related tasks but identified several opportunities for improving care. Caregivers perceived the health system to lack capability in identifying and intervening on specific family social needs. Caregiver interviews revealed multiple areas in which family supports could be strengthened, including (1) managing indirect costs of prolonged hospitalizations (e.g., food, parking), (2) communicating with employers to support families' needs, (3) coordinating care across hospital departments, and (4) clarifying care team roles in helping families reduce both medical and social barriers. This study highlights the caregiver perspective on barriers and facilitators to posttransplant care. Future work should identify whether these themes are present across transplant centers. Caregiver perspectives should help inform future interventions aimed at improving long-term outcomes for children after liver transplantation.
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Affiliation(s)
| | | | - Holly P. Shifman
- Oakland University William Beaumont School of Medicine, Rochester, MI
| | - Ethel Baker
- University of California, San Francisco, San Francisco, CA
| | - John Bucuvalas
- Icahn School of Medicine at Mount Sinai, New York, NY
- Kravis Children’s Hospital, New York, NY
| | | | - Uma Kotagal
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Sue J. Rhee
- University of California, San Francisco, San Francisco, CA
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12
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Perez A, Ovchinsky N. Caring for a child after a liver transplant: Challenges beyond medical complexity. Liver Transpl 2022; 28:1707-1708. [PMID: 35779249 DOI: 10.1002/lt.26540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Adriana Perez
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital at Montefiore-Albert Einstein College of Medicine, Bronx, New York, USA
| | - Nadia Ovchinsky
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital at Montefiore-Albert Einstein College of Medicine, Bronx, New York, USA
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13
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Sayegh CS, Im D, Moss IK, Urquiza R, Patel S, Thomas D. Randomized pilot trial of praise text messages to improve medication adherence among adolescents and young adults with liver transplants. Pediatr Transplant 2022; 26:e14361. [PMID: 35854423 PMCID: PMC9560958 DOI: 10.1111/petr.14361] [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: 12/01/2021] [Revised: 04/27/2022] [Accepted: 06/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AYA who have undergone liver transplantations often struggle to adhere to their post-transplant immunosuppressant medications, which can lead to serious health complications. The objective of this pilot study is to examine the acceptability and feasibility of a brief mobile health (mHealth) intervention and its impact on medication adherence among AYA liver transplant recipients. METHODS Thirty-five AYAs (13-21 years old) were randomized to either (1) receive praise text messages whenever laboratory results indicated immunosuppressant medications within the expected range or (2) usual care. Motivation for adherence and adherence were assessed via self-report, and a MLVI was calculated based on values abstracted from the electronic health record. RESULTS Multilevel, multivariate models showed significant associations between group assignment and some self-reported motivation and adherence outcomes but not MLVI. Specifically, AYA receiving the praise text messages were significantly more likely to report taking their prescribed doses (OR = 2.49, p = .03), taking their medicine according to the directions (OR = 2.39, p = .04), and being highly confident in taking their medication (OR = 2.46, p = .04), compared with the usual services group. Qualitative responses indicated praise texts were mostly helpful but could be improved. CONCLUSIONS The results suggest texting patients about positive health indicators was acceptable and, with refinement, might promote AYA illness self-management.
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Affiliation(s)
- Caitlin S. Sayegh
- Children’s Hospital Los Angeles, Division of Adolescent and Young Adult Medicine
- Children’s Hospital Los Angeles, USC University Center for Excellence in Developmental Disabilities
- University of Southern California Keck School of Medicine
| | - Deborah Im
- University of Southern California Keck School of Medicine
| | - Ilana K. Moss
- Children’s Hospital Los Angeles, Division of Gastroenterology, Hepatology, and Nutrition
| | - Ruby Urquiza
- Children’s Hospital Los Angeles, Division of Gastroenterology, Hepatology, and Nutrition
| | - Shreena Patel
- University of Southern California Keck School of Medicine
- Children’s Hospital Los Angeles, Division of Gastroenterology, Hepatology, and Nutrition
| | - Daniel Thomas
- University of Southern California Keck School of Medicine
- Children’s Hospital Los Angeles, Division of Gastroenterology, Hepatology, and Nutrition
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14
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Education and Psychosocial Factors Predict Odds of Death After Transfer to Adult health Care in Pediatric Liver Transplant Patients. J Pediatr Gastroenterol Nutr 2022; 75:623-628. [PMID: 35767565 DOI: 10.1097/mpg.0000000000003549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To analyze demographic, psychosocial, and clinical factors in pediatric liver transplant recipients for their association with death or loss to follow up in adulthood. We aimed to better understand known health disparities in transplant outcomes and identify potentially modifiable risk factors prior to transfer. METHODS A retrospective cohort study of children who underwent liver transplantation at a large tertiary transplant center and were transferred to adult care between 2000 and 2015. RESULTS During the study period, 101 qualifying patients were transferred. Ninety-three individuals followed with an adult provider, while 8 were lost to follow up. In total 23 of 93 patients died after transfer (24.7%). Several childhood factors were associated with adult death: Black race [odds ratio (OR) 6.59, P < 0.001]; psychiatric illness or substance use (OR 2.81, P = 0.04); failure to graduate high school before transfer (OR 9.59, P < 0.001); posttransplant tacrolimus medication-level variability index >2.5 (OR 5.36, P = 0.04); provider documentation of medication nonadherence (OR 4.72, P = 0.02); acute cellular rejection (OR 4.44, P = 0.03); the presence of diabetes mellitus (OR 5.71, P = 0.001), and chronic kidney disease (OR 2.82, P = 0.04). Failure to graduate HS was associated with loss to follow up ( P < 0.001). On multivariate analysis, Black race, substance use, diabetes, and failure to graduate HS retained association with adult death (each P < 0.05). CONCLUSIONS Complex, intertwined patient characteristics are associated with increased odds of death in pediatric liver transplant recipients transferred to adult care. Early recognition of high-risk patients and intervention for modifiable factors, such as improved HS graduation and substance use prevention, may improve long-term outcomes.
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15
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Reine PK, Feier F, da Fonseca EA, Hernandes RG, Seda-Neto J. Quality of life, depression and anxiety in potential living liver donors for pediatric recipients: A retrospective single center experience. World J Hepatol 2022; 14:1899-1906. [PMID: 36340749 PMCID: PMC9627440 DOI: 10.4254/wjh.v14.i10.1899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/21/2022] [Accepted: 09/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Living donor liver transplantation is a safe alternative for patients on a liver transplant list. Donor evaluation goes beyond physical variables to include social, emotional, and ethical aspects. The role of pre-donation sociopsychological evaluation of the donor candidate is as important to the success of the procedure as is the medical assessment. Success implies recovery from the operation and prompt engagement in pre-transplant professional and social activities, without leading to psychological or physical distress. Psychological profiling of potential living liver donors (PLLD) and evaluation of quality of life (QOL) can influence outcomes.
AIM To evaluate the socio-demographics and psychological aspects (QOL, depression, and anxiety) of PLLD for pediatric liver transplantation in a cohort of 250 patients.
METHODS This was a retrospective cohort study of 250 PLLD who underwent psychological pre-donation evaluation between 2015 and 2019. All the recipients were children. The Beck anxiety inventory, Beck depression inventory, and 36-item short-form health survey (SF-36) scores were used to evaluate anxiety (Beck anxiety inventory), depression (Beck depression inventory), and QOL, respectively.
RESULTS A total of 250 PLLD were evaluated. Most of them were women (54.4%), and the mean age was 29.2 ± 7.2 years. A total of 120 (48.8%) PLLD were employed at the time of evaluation for donation; however, most had low income (57% earned < 2 times the minimum wage). A total of 110 patients (44%) did not finish the donation process, and 247 PLLD answered a questionnaire to evaluate depression, anxiety, and QOL (SF-36). Prevalence of depression was of 5.2% and anxiety 3.6%. Although most of the PLLD were optimistic regarding the donation process and never had doubts about becoming a donor, some traces of ambivalence were observed: 46% of the respondents said they would feel relieved if a deceased donor became available.
CONCLUSION PLLD had a low prevalence of anxiety and depression. The foundation for effective and satisfactory results can be found in the pre-transplantation process, during which evaluations must follow rigorous criteria to mitigate potential harm in the future. Pre-donation psychological evaluation plays a predictive role in post-donation emotional responses and mental health issues. The impact of such findings on the donation process and outcomes needs to be further investigated.
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Affiliation(s)
- Paula K Reine
- Department of Psychology, Hospital Sírio-Libanês, São Paulo 01308901, Brazil
| | - Flavia Feier
- Department ofLiver Transplantation, Santa Casa de Porto Alegre, Porto Alegre 90020090, Brazil
| | | | - Rosely G Hernandes
- Department of Psychology, Hospital Sírio-Libanês, São Paulo 01308901, Brazil
| | - Joao Seda-Neto
- Department of Liver Transplantation, Hospital Sírio-Libanês, São Paulo 01308901, Brazil
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16
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Ebel NH, Lai JC, Bucuvalas JC, Wadhwani SI. A review of racial, socioeconomic, and geographic disparities in pediatric liver transplantation. Liver Transpl 2022; 28:1520-1528. [PMID: 35188708 PMCID: PMC9949889 DOI: 10.1002/lt.26437] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/21/2022] [Accepted: 02/15/2022] [Indexed: 02/07/2023]
Abstract
Equity is a core principle in both pediatrics and solid organ transplantation. Health inequities, specifically across race, socioeconomic position, or geography, reflect a moral failure. Ethical principles of prudential life span, maximin principle, and fair innings argue for allocation priority to children related to the number of life years gained, equal access to transplant, and equal opportunity for ideal posttransplant outcomes. Iterative policy changes have aimed to narrow these disparities to achieve pediatric transplant equity. These policy changes have focused on modifying pediatric priority for organ allocation to eliminate mortality on the pediatric transplant waiting list. Yet disparities remain in pediatric liver transplantation at all time points: from access to referral for transplantation, likelihood of living donor transplantation, use of exception narratives, waitlist mortality, and inequitable posttransplant outcomes. Black children are less likely to be petitioned for exception scores, have higher waitlist mortality, are less likely to be the recipient of a living donor transplant, and have worse posttransplant outcomes compared with White children. Children living in the most socioeconomically deprived neighborhoods have worse posttransplant outcomes. Children living farther from a transplant center have higher waitlist mortality. Herein we review the current knowledge of these racial and ethnic, socioeconomic, and geographic disparities for these children. To achieve equity, stakeholder engagement is required at all levels from providers and health delivery systems, learning networks, institutions, and society. Future initiatives must be swift, bold, and effective with the tripartite mission to inform policy changes, improve health care delivery, and optimize resource allocation to provide equitable transplant access, waitlist survival, and posttransplant outcomes for all children.
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Affiliation(s)
- Noelle H Ebel
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics Stanford University Stanford California USA Division of Gastroenterology, Hepatology & NutritionDepartment of Medicine University of California San Francisco California USA Division of Pediatric HepatologyDepartment of Pediatrics Icahn School of Medicine at Mount Sinai New York New York USA Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of PediatricsUniversity of CaliforniaSan Francisco California USA
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17
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Shifman HP, Rasnick E, Huang CY, Beck AF, Bucuvalas J, Lai JC, Wadhwani SI. Association of Primary Care Shortage Areas with Adverse Outcomes after Pediatric Liver Transplant. J Pediatr 2022; 246:103-109.e2. [PMID: 35301019 PMCID: PMC9987637 DOI: 10.1016/j.jpeds.2022.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To characterize associations between living in primary care shortage areas and graft failure/death for children after liver transplantation. STUDY DESIGN This was an observational study of all pediatric patients (aged <19 years) who received a liver transplant between January 1, 2005, and December 31, 2015 in the US, with follow-up through January 2019 (N = 5964). One hundred ninety-five patients whose home ZIP code could not be matched to primary care shortage area status were excluded. The primary outcome was a composite endpoint of graft failure or death. We used Cox proportional hazards to model the associations between health professional shortage area (HPSA) and graft failure/death. RESULTS Children living in HPSAs had lower estimated graft survival rates at 10 years compared with those not in HPSAs (76% vs 80%; P < .001). In univariable analysis, residence in an HPSA was associated with a 22% higher hazard of graft failure/death than non-residence in an HPSA (hazard ratio [HR], 1.22; 95% CI, 1.09-1.36; P < .001). Black children from HPSAs had a 67% higher hazard of graft failure/death compared with those not in HPSAs (HR, 1.67; 95% CI, 1.29 to 2.16; P = .006); the effect of HPSA status was less pronounced for White children (HR, 1.11; 95% CI, 0.98-1.27; P = .10). CONCLUSIONS Children living in primary care shortage areas are at increased risk of graft failure and death after liver transplant, and this risk is particularly salient for Black children. Future work to understand how living in these regions contributes to adverse outcomes may enable teams to mitigate this risk for all children with chronic illness.
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Affiliation(s)
- Holly P Shifman
- School of Medicine, Oakland University William Beaumont, Rochester, MI
| | - Erika Rasnick
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Chiung-Yu Huang
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA
| | - Andrew F Beck
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH
| | - John Bucuvalas
- Division of Hepatology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY; Division of Hepatology, Department of Pediatrics, Kravis Children's Hospital, New York, NY
| | - Jennifer C Lai
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Sharad I Wadhwani
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, University of California San Francisco, San Francisco, CA.
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18
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An Assessment of Ineligible Donor Use in Solid Organ Transplant. Transplantation 2022; 106:1629-1637. [DOI: 10.1097/tp.0000000000004084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Wadhwani SI, Ge J, Gottlieb L, Lyles C, Beck AF, Bucuvalas J, Neuhaus J, Kotagal U, Lai JC. Racial/ethnic disparities in wait-list outcomes are only partly explained by socioeconomic deprivation among children awaiting liver transplantation. Hepatology 2022; 75:115-124. [PMID: 34387881 PMCID: PMC8934136 DOI: 10.1002/hep.32106] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/20/2021] [Accepted: 07/31/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS Racial/ethnic minority children have worse liver transplant (LT) outcomes. We evaluated whether neighborhood socioeconomic deprivation affected associations between race/ethnicity and wait-list mortality. APPROACH AND RESULTS We included children (age <18) listed 2005-2015 in the Scientific Registry of Transplant Recipients. We categorized patients as non-Hispanic White, Black, Hispanic, and other. We matched patient ZIP codes to a neighborhood socioeconomic deprivation index (range, 0-1; higher values indicate worse deprivation). Primary outcomes were wait-list mortality, defined as death/delisting for too sick, and receipt of living donor liver transplant (LDLT). Competing risk analyses modeled the association between race/ethnicity and wait-list mortality, with deceased donor liver transplant (DDLT) and LDLT as competing risks, and race/ethnicity and LDLT, with wait-list mortality and DDLT as competing risks. Of 7716 children, 17% and 24% identified as Black and Hispanic, respectively. Compared to White children, Black and Hispanic children had increased unadjusted hazard of wait-list mortality (subhazard ratio [sHR], 1.44; 95% CI, 1.18, 1.75 and sHR, 1.48; 95% CI, 1.25, 1.76, respectively). After adjusting for neighborhood deprivation, insurance, and listing laboratory Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease, Black and Hispanic children did not have increased hazard of wait-list mortality (sHR, 1.12; 95% CI, 0.91, 1.39 and sHR, 1.21; 95% CI, 1.00, 1.47, respectively). Similarly, Black and Hispanic children had a decreased likelihood of LDLT (sHR, 0.58; 95% CI, 0.45, 0.75 and sHR, 0.61; 95% CI, 0.49, 0.75, respectively). Adjustment attenuated the effect of Black and Hispanic race/ethnicity on likelihood of LDLT (sHR, 0.79; 95% CI, 0.60, 1.02 and sHR, 0.89; 95% CI, 0.70, 1.11, respectively). CONCLUSIONS Household and neighborhood socioeconomic factors and disease severity at wait-list entry help explain racial/ethnic disparities for children awaiting transplant. A nuanced understanding of how social adversity contributes to wait-list outcomes may inform strategies to improve outcomes.
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Affiliation(s)
| | - Jin Ge
- University of California, San Francisco, San Francisco, CA
| | - Laura Gottlieb
- University of California, San Francisco, San Francisco, CA
| | - Courtney Lyles
- University of California, San Francisco, San Francisco, CA
| | - Andrew F. Beck
- University of Cincinnati College of Medicine, Cincinnati, OH,Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - John Bucuvalas
- Icahn School of Medicine at Mount Sinai, New York, NY,Kravis Children’s Hospital at Mount Sinai, New York, NY
| | - John Neuhaus
- University of California, San Francisco, San Francisco, CA
| | - Uma Kotagal
- University of Cincinnati College of Medicine, Cincinnati, OH,Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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20
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Wadhwani SI, Huang CY, Gottlieb L, Beck AF, Bucuvalas J, Kotagal U, Lyles C, Lai JC. Center variation in long-term outcomes for socioeconomically deprived children. Am J Transplant 2021; 21:3123-3132. [PMID: 33565227 PMCID: PMC8353008 DOI: 10.1111/ajt.16529] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 01/25/2023]
Abstract
Neighborhood socioeconomic deprivation is associated with adverse outcomes after pediatric liver transplant. We sought to determine if this relationship varies by transplant center. Using SRTR, we included patients <18 years transplanted 2008-2013 (N = 2804). We matched patient ZIP codes to a deprivation index (range [0,1]; higher values indicate increased socioeconomic deprivation). A center-level patient-mix deprivation index was defined by the distribution of patient-level deprivation. Centers (n = 66) were classified as high or low deprivation if their patient-mix deprivation index was above or below the median across centers. Center quality was classified as low or high graft failure if graft survival rates were better or worse than the overall 10-year graft survival rate. Primary outcome was patient-level graft survival. We used random-effect Cox models to evaluate center-level covariates on graft failure. We modeled center quality using stratified Cox models. In multivariate analysis, each 0.1 increase in the patient-mix deprivation index was associated with increased hazard of graft failure (HR 1.32; 95%CI: 1.05, 1.66). When stratified by center quality, patient-mix deprivation was no longer significant (HR 1.07, 95%CI: 0.89, 1.28). Some transplant centers care for predominantly high deprivation children and maintain excellent outcomes. Revealing and replicating these centers' practice patterns should enable more equitable outcomes.
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Affiliation(s)
| | | | - Laura Gottlieb
- University of California San Francisco, San Francisco, CA
| | - Andrew F. Beck
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,University of Cincinnati School of Medicine, Cincinnati, OH
| | - John Bucuvalas
- Icahn School of Medicine at Mount Sinai, New York, NY,Kravis Children’s Hospital, New York, NY
| | - Uma Kotagal
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,University of Cincinnati School of Medicine, Cincinnati, OH
| | - Courtney Lyles
- University of California San Francisco, San Francisco, CA
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21
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Katz M, Gillespie S, Stevens JP, Hall L, Kolachala V, Ford R, Levin K, Gupta NA. African American Pediatric Liver Transplant Recipients Have an Increased Risk of Death After Transferring to Adult Healthcare. J Pediatr 2021; 233:119-125.e1. [PMID: 33667506 DOI: 10.1016/j.jpeds.2021.02.069] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/10/2021] [Accepted: 02/25/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To analyze the long-term outcomes in pediatric liver transplant recipients after they have transferred to an adult provider and assess for racial disparities in health outcomes. STUDY DESIGN This is a single-center, retrospective review of pediatric patients who underwent liver transplantation between July 1990 and August 2015 at a tertiary healthcare system with a large transplant center. Patient mortality and retransplantation were assessed after transfer to adult care. RESULTS There were 120 patients who were transferred, of whom 19 did not meet the inclusion criteria. Of the remaining 101 patients, 64 (63%) transferred care to a nearby affiliated tertiary adult facility, 29 (29%) were followed by other healthcare systems, and 8 (8%) were lost to follow-up. Of the patients followed at our affiliated adult center, 18 of the 64 (28%) died. Of those 18 deaths, 4 (22%) occurred within the first 2 years after transfer, and 10 (55%) within 5 years of transfer. Four patients were retransplanted by an adult provider, of whom 2 eventually received a third transplant. African Americans had higher rates of death after transfer than patients of other races (44% mortality vs 16%, representing 67% of all cases of death; P = .032), with nearly 50% mortality at 20 years from time of transplantation. CONCLUSIONS Death is common in pediatric liver transplant recipients after transfer to adult care, with African Americans having disproportionately higher mortality. This period of transition of care is a vulnerable time, and measures must be taken to ensure the safe transfer of young adults with chronic health care needs.
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Affiliation(s)
- Mikaela Katz
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Scott Gillespie
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - James P Stevens
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Transplant services, Children's Healthcare of Atlanta, Atlanta, GA
| | - Lori Hall
- Transplant services, Children's Healthcare of Atlanta, Atlanta, GA
| | - Vasantha Kolachala
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Ryan Ford
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Keri Levin
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Nitika A Gupta
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Transplant services, Children's Healthcare of Atlanta, Atlanta, GA.
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22
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Menahem B, Dejardin O, Alves A, Launay L, Lubrano J, Duvoux C, Laurent A, Launoy AG. Socioeconomic Deprivation Does Not Impact Liver Transplantation Outcome for HCC: A Survival Analysis From a National Database. Transplantation 2021; 105:1061-1068. [PMID: 32541559 DOI: 10.1097/tp.0000000000003340] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND To investigate the value of European deprivation index (EDI) and hepatocellular carcinoma (HCC) characteristics and their relationships with outcome after liver transplantation (LT). METHODS Patients undergoing LT for HCC were included from a national database (from "Agence de la Biomédecine" between 2006 and 2016. Characteristics of the patients were blindly extracted from the database. Thus, EDI was calculated in 5 quintiles and prognosis factors of survival were determined according to a Cox model. RESULTS Among the 3865 included patients, 33.9% were in the fifth quintile (quintile 1, N = 562 [14.5%]; quintile 2, N = 647 [16.7%]; quintile 3, N = 654 [16.9%]; quintile 4, N = 688 [17.8%]). Patients in each quintile were comparable regarding HCC history, especially median size of HCC, number of nodules of HCC and alpha-fetoprotein score. In the univariate analysis of the crude survival, having >2 nodules of HCC before LT and time on waiting list were associated with a higher risk of death (P < 0.0001 and P = 0.03, respectively). EDI, size of HCC, model for end-stage liver disease score, Child-Pugh score were not statistically significant in the crude and net survival. In both survival, time on waiting list and number of HCC ≥2 were independent factor of mortality after LT for HCC (P = 0.009 and 0.001, respectively, and P = 0.03 and 0.02, respectively). CONCLUSIONS EDI does not impact overall survival after LT for HCC. Number of HCC and time on waiting list are independent prognostic factors of survival after LT for HCC.
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Affiliation(s)
- Benjamin Menahem
- Department of Digestive Surgery, CHU de Caen, Caen cedex, France
- Anticipe, INSERM U1086, Pôle de Recherche du CHU de Caen, Centre François Baclesse, Caen cedex, France
| | - Olivier Dejardin
- Anticipe, INSERM U1086, Pôle de Recherche du CHU de Caen, Centre François Baclesse, Caen cedex, France
- Department of Research, CHU de Caen, Caen cedex, France
| | - Arnaud Alves
- Department of Digestive Surgery, CHU de Caen, Caen cedex, France
- Anticipe, INSERM U1086, Pôle de Recherche du CHU de Caen, Centre François Baclesse, Caen cedex, France
| | - Ludivine Launay
- Anticipe, INSERM U1086, Pôle de Recherche du CHU de Caen, Centre François Baclesse, Caen cedex, France
| | - Jean Lubrano
- Department of Digestive Surgery, CHU de Caen, Caen cedex, France
- Anticipe, INSERM U1086, Pôle de Recherche du CHU de Caen, Centre François Baclesse, Caen cedex, France
| | - Christophe Duvoux
- Department of Hepatology, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Alexis Laurent
- Department of Hepatobiliary, Pancreatic Surgery and Liver Transplantation, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
- INSERM, UMR 955, Créteil, France
| | - And Guy Launoy
- Anticipe, INSERM U1086, Pôle de Recherche du CHU de Caen, Centre François Baclesse, Caen cedex, France
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Molleston JP, Bennett WE. Mortality, Risk Factors and Disparities Associated with Esophageal Variceal Bleeding in Children's Hospitals in the US. J Pediatr 2021; 232:176-182. [PMID: 33450222 DOI: 10.1016/j.jpeds.2020.12.082] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/30/2020] [Accepted: 12/31/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To use a large administrative database to determine the mortality, risk factors, and comorbidities of esophageal variceal bleeding in children. STUDY DESIGN Retrospective cohort study using Pediatric Health Information System data from 50 tertiary children's hospitals in the US. International Classification of Diseases (ICD) codes (FY 2020 ICD-10 update and revision 10 of ICD-9) from 2004 through 2019 identified children 18 years and younger with variceal bleeding and complications. Univariate analyses used the Student t -test for continuous variables (age) and the χ2 test for categorical variables (all others). A mixed-effects linear regression was performed for multiple variables. RESULTS There were 1902 patients who had 3399 encounters for esophageal variceal bleeding. The mortality rate for variceal bleeding was 7.3%, increasing to 8.8% by 6 weeks; any mortality during the study was 20.1%. Transfusion was required in 54.7% of encounters, and 42.6% were admitted to the intensive care unit. Variceal bleeding encounters were complicated by peptic ulcer disease (6.9%), bacteremia (11.4%), acute renal failure (5.1%), mechanical ventilation (18%), ascites (21.3%), and peritonitis (3.3%). Multivariable mixed-effects logistic regression showed that Black race (OR, 2.59; P < .001) or Hispanic ethnicity (OR, 2.31; P = .001), but not sex, household income, or insurance type, were associated with increased mortality. Bacteremia, peritonitis, mechanical ventilation, acute renal failure, and transfusion were associated with higher mortality (ORs of 2.29, 2.18, 1.93, 6.33, and 1.81, respectively; P < .001, .005, .011, <.001, and .005, respectively). CONCLUSIONS The 6-week mortality rate for variceal bleeding in children is 8.8%. Black or Hispanic children are at higher risk of dying. Serious morbidities associated with variceal hemorrhage impact mortality. These data can inform consideration of prophylactic or therapeutic interventions for children at risk.
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Affiliation(s)
- Jean P Molleston
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, IN.
| | - William E Bennett
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, IN; Department of Pediatrics, Division of Pediatric and Adolescent Comparative Effectiveness Research, Indiana University School of Medicine, Indianapolis, IN
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Hager A, Mager D, Robert C, Nicholas D, Gilmour S. Health-Related Quality of Life 10 Years after Liver Transplantation: A Longitudinal Retrospective Review. Diagnostics (Basel) 2021; 11:diagnostics11010111. [PMID: 33445652 PMCID: PMC7827867 DOI: 10.3390/diagnostics11010111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 02/07/2023] Open
Abstract
As survival post-liver transplantation (LTx) improves, it becomes increasingly important to understand how long-term health-related quality of life (HRQOL) is impacted. This was a longitudinal review examining HRQOL measured by Pediatric Liver Transplant Quality of Life (PeLTQL) in children between 8-17 years who underwent LTx (1.4 [0.8–3.3] years) at least one year prior to assessment. Demographic, medical, anthropometric, and HRQOL data (self-reported and parent proxy) were retrospectively collected over four years (2014–2017) at annual LTx clinic visits. The study included 35 patients (18M, 17F) and their parents/guardians. Parent-proxy and child PeLTQL scores (total, subdomain) showed good to excellent agreement (p > 0.05) and did not change over four years (p > 0.05). Younger age (<12 years) and Caucasian ancestry were associated with higher parental and self-reported perceptions of HRQOL, respectively (future health, coping and adjustment, total scores). Parent perceived lower HRQOL in social–emotional sub-domain (p = 0.03) and the child reported lower sub-domain scores related to coping and adjustment (p = 0.04) when the child was noted to have co-morbid conditions related to mental health and neurocognitive development (25.7%). While child–parent perceptions of HRQOL in a multi-ethnic population of pediatric LTx recipients remain unchanged 10 years post-LTx, adolescents of non-Caucasian ancestry remain a population at risk for lower HRQOL.
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Affiliation(s)
- Amber Hager
- Department of Agricultural, Food & Nutritional Sciences, University of Alberta, Edmonton, AB T6G 2E1, Canada; (A.H.); (D.M.)
| | - Diana Mager
- Department of Agricultural, Food & Nutritional Sciences, University of Alberta, Edmonton, AB T6G 2E1, Canada; (A.H.); (D.M.)
- Department of Pediatrics, University of Alberta, Edmonton, AB T6G 1C9, Canada;
| | - Cheri Robert
- Department of Pediatrics, University of Alberta, Edmonton, AB T6G 1C9, Canada;
| | - David Nicholas
- Department of Social Work, University of Calgary, Calgary, AB T5J 4P6, Canada;
| | - Susan Gilmour
- Department of Pediatrics, University of Alberta, Edmonton, AB T6G 1C9, Canada;
- Division of Pediatric Gastroenterology & Nutrition/Transplant Services, The Stollery Children’s Hospital, Alberta Health Services, Edmonton, AB T6G 1C9, Canada
- Correspondence: ; Tel.: +1-780-248-5410
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Thuluvath PJ, Amjad W, Zhang T. Liver transplant waitlist removal, transplantation rates and post-transplant survival in Hispanics. PLoS One 2020; 15:e0244744. [PMID: 33382811 PMCID: PMC7774861 DOI: 10.1371/journal.pone.0244744] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/15/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hispanics are the fastest growing population in the USA, and our objective was to determine their waitlist mortality rates, liver transplantation (LT) rates and post-LT outcomes. METHODS All adults listed for LT with the UNOS from 2002 to 2018 were included. Competing risk analysis was performed to assess the association between ethnic group with waitlist removal due to death/deterioration and transplantation. For sensitivity analysis, Hispanics were matched 1:1 to Non-Hispanics using propensity scores, and outcomes of interest were compared in matched cohort. RESULTS During this period, total of 154,818 patients who listed for liver transplant were involved in this study, of them 23,223 (15%) were Hispanics, 109,653 (71%) were Whites, 13,020 (8%) were Blacks, 6,980 (5%) were Asians and 1,942 (1%) were others. After adjusting for differences in clinical characteristics, compared to Whites, Hispanics had higher waitlist removal due to death or deterioration (adjusted cause-specific Hazard Ratio: 1.034, p = 0.01) and lower transplantation rates (adjusted cause-specific Hazard Ratio: 0.90, p<0.001). If Hispanics received liver transplant, they had better patient and graft survival than Non-Hispanics (p<0.001). Compared to Whites, adjusted hazard ratio for Hispanics were 0.88 (95% CI 0.84, 0.92, p<0.001) for patient survival and 0.90 (95% CI 0.86, 0.94, p<0.001) for graft survival. Our analysis in matched cohort showed the consistent results. CONCLUSIONS This study showed that Hispanics had higher probability to be removed from the waitlist due to death, and lower probability to be transplanted, however they had better post-LT outcomes when compared to whites.
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Affiliation(s)
- Paul J. Thuluvath
- Institute for Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Waseem Amjad
- Institute for Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, United States of America
| | - Talan Zhang
- Institute for Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, United States of America
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Harney SM, Kahn JM, Jin Z, Wong P, McKetta S, Satwani P. Race and socioeconomic status in pediatric allogeneic hematopoietic cell transplantation for nonmalignant conditions. Pediatr Blood Cancer 2020; 67:e28367. [PMID: 32497418 DOI: 10.1002/pbc.28367] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Survival disparities by race/ethnicity and socioeconomic status (SES) are observed in a wide range of pediatric treatment settings including oncology and solid organ transplantation. To date, few studies have examined the effects of race and SES on outcomes in pediatric allogeneic hematopoietic cell transplantation (HCT). We explored whether survival differed by race/ethnicity or SES in children receiving HCT for nonmalignant conditions at a single institution serving a diverse patient population. PROCEDURES The Kaplan-Meier method was used to estimate overall survival (OS) with the log-rank test for between-group comparisons. Cox proportional hazards models were used to identify risk factors for OS, adjusting for treatment- and disease-related factors. RESULTS Of 133 subjects, 0 to 21 years, 19% were non-Hispanic (NH) white, 34% were NH black, 40% were Hispanic, and 7% were Asian. Sixty-seven percent of the subjects had public insurance; 49% lived in neighborhoods with poverty rate ≥20%. Primary diagnoses included hemoglobinopathies (56%), bone marrow failure (22%), and other conditions (22%). Median follow-up was 5.8 years (range 0.1-14.5). Analysis revealed no difference in OS by race, insurance type, or neighborhood SES. CONCLUSIONS Findings from this single-institution study suggest that in pediatric patients undergoing HCT for nonmalignant conditions, treatment at a tertiary care center with a multidisciplinary approach may mitigate drivers of disparities observed in other settings. Additional studies are now needed to further elucidate the complex interrelationships among race, SES, and clinical outcomes for children undergoing HCT.
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Affiliation(s)
- Sarah M Harney
- Department of Pediatrics, Hasbro Children's Hospital, Brown University, Providence, Rhode Island
| | - Justine M Kahn
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Priscilla Wong
- Compliance Department, New York City Housing Authority, New York, New York
| | - Sarah McKetta
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, New York
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Wadhwani SI, Beck AF, Bucuvalas J, Gottlieb L, Kotagal U, Lai JC. Neighborhood socioeconomic deprivation is associated with worse patient and graft survival following pediatric liver transplantation. Am J Transplant 2020; 20:1597-1605. [PMID: 31958208 PMCID: PMC7261648 DOI: 10.1111/ajt.15786] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/10/2019] [Accepted: 01/08/2020] [Indexed: 01/25/2023]
Abstract
Long-term outcomes remain suboptimal following pediatric liver transplantation; only one third of children have normal biochemical liver function without immunosuppressant comorbidities 10 years posttransplant. We examined the association between an index of neighborhood socioeconomic deprivation with graft and patient survival using the Scientific Registry of Transplant Recipients. We included children <19 years who underwent liver transplantation between January 1, 2008 to December 31, 2013 (n = 2868). Primary exposure was a neighborhood socioeconomic deprivation index-linked via patient home ZIP code-with a range of 0-1 (values nearing 1 indicate neighborhoods with greater socioeconomic deprivation). Primary outcome measures were graft failure and death, censored at 10 years posttransplant. We modeled survival using Cox proportional hazards. In univariable analysis, each 0.1 increase in the deprivation index was associated with a 14.3% (95% confidence interval [CI]): 3.8%-25.8%) increased hazard of graft failure and a 12.5% (95% CI: 2.5%-23.6%) increased hazard of death. In multivariable analysis adjusted for race, each 0.1 increase in the deprivation index was associated with a 11.5% (95% CI: 1.6%-23.9%) increased hazard of graft failure and a 9.6% (95% CI: -0.04% to 20.7%) increased hazard of death. Children from high deprivation neighborhoods have diminished graft and patient survival following liver transplantation. Greater attention to neighborhood context may result in improved outcomes for children following liver transplantation.
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Affiliation(s)
| | - Andrew F. Beck
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,University of Cincinnati College of Medicine, Cincinnati, OH
| | - John Bucuvalas
- Icahn School of Medicine at Mount Sinai, New York, NY,Mount Sinai Kravis Children’s Hospital, New York, NY
| | - Laura Gottlieb
- University of California San Francisco, San Francisco, CA
| | - Uma Kotagal
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,University of Cincinnati College of Medicine, Cincinnati, OH
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Covarrubias K, Luo X, Massie A, Schwarz KB, Garonzik-Wang J, Segev DL, Mogul DB. Determinants of length of stay after pediatric liver transplantation. Pediatr Transplant 2020; 24:e13702. [PMID: 32212292 PMCID: PMC7260078 DOI: 10.1111/petr.13702] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/07/2020] [Accepted: 03/04/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND We sought to identify factors that are associated with LOS following pediatric (<18 years) liver transplantation in order to provide personalized counseling and discharge planning for recipients and their families. METHODS We identified 2726 infants (≤24 months) and 3210 children (>24 months) who underwent pediatric liver-only transplantation from 2002-2017 using the Scientific Registry of Transplant Recipients. We used multilevel multivariable negative binomial regression to analyze associations between LOS and recipient and donor characteristics and calculated the MLOSR to quantify heterogeneity in LOS across centers. RESULTS In infants, the median LOS (IQR) was 19 (13-32) days. Hospitalization prior to transplant (ICU ratio:1.46 1.591.70 ; non-ICU ratio:1.08 1.161.23 ), public insurance (ratio:1.03 1.091.15 ), and a segmental graft (ratio:1.08 1.151.22 ) were associated with a longer LOS; thus, we would expect a 1.59-fold longer LOS in an infant admitted to the ICU compared to a non-hospitalized infant with similar characteristics. In children, the median LOS (IQR) was 13 (9-21) days. Hospitalization prior to transplant (ICU ratio:1.49 1.621.77 ; non-ICU ratio:1.34 1.441.56 ), public insurance (ratio:1.02 1.071.13 ), a segmental graft (ratio:1.20 1.271.35 ), a living donor graft (ratio:1.27 1.381.51 ), and obesity (ratio:1.03 1.101.17 ) were associated with a longer LOS. The MLOSR was 1.25 in infants and 1.26 in children, meaning if an infant received a transplant at another center with a longer LOS, we would expect a 1.25-fold difference in LOS driven by center practices alone. CONCLUSIONS While center-level practices account for substantial variation in LOS, consideration of donor and recipient factors can help clinicians provide more personalized counseling for families of pediatric liver transplant candidates.
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Affiliation(s)
- Karina Covarrubias
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD
| | - Kathleen B. Schwarz
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD
| | - Douglas B. Mogul
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Indur Wadhwani S, Hsu EK, Shaffer ML, Anand R, Lee Ng V, Bucuvalas JC. Predicting ideal outcome after pediatric liver transplantation: An exploratory study using machine learning analyses to leverage Studies of Pediatric Liver Transplantation Data. Pediatr Transplant 2019; 23:e13554. [PMID: 31328849 PMCID: PMC7980252 DOI: 10.1111/petr.13554] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/21/2019] [Accepted: 06/27/2019] [Indexed: 12/15/2022]
Abstract
Machine learning analyses allow for the consideration of numerous variables in order to accommodate complex relationships that would not otherwise be apparent in traditional statistical methods to better classify patient risk. The SPLIT registry data were analyzed to determine whether baseline demographic factors and clinical/biochemical factors in the first-year post-transplant could predict ideal outcome at 3 years (IO-3) after LT. Participants who received their first, isolated LT between 2002 and 2006 and had follow-up data 3 years post-LT were included. IO-3 was defined as alive at 3 years, normal ALT (<50) or GGT (<50), normal GFR, no non-liver transplants, no cytopenias, and no PTLD. Heat map analysis and RFA were used to characterize the impact of baseline and 1-year factors on IO-3. 887/1482 SPLIT participants met inclusion criteria; 334 had IO-3. Demographic, biochemical, and clinical variables did not elucidate a visual signal on heat map analysis. RFA identified non-white race (vs white race), increased length of operation, vascular and biliary complications within 30 days, and duct-to-duct biliary anastomosis to be negatively associated with IO-3. UNOS regions 2 and 5 were also identified as important factors. RFA had an accuracy rate of 0.71 (95% CI: 0.68-0.74), PPV = 0.83, and NPV = 0.70. RFA identified participant variables that predicted IO-3. These findings may allow for better risk stratification and personalization of care following pediatric liver transplantation.
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Affiliation(s)
| | - Evelyn K. Hsu
- University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, WA
| | | | | | - Vicky Lee Ng
- Hospital for Sick Children, Transplant and Regenerative Medicine Center, University of Toronto, Toronto, Canada
| | - John C. Bucuvalas
- Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital New York, NY
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30
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Gender Affirmation Surgery: A Synopsis Using American College of Surgeons National Surgery Quality Improvement Program and National Inpatient Sample Databases. Ann Plast Surg 2019; 80:S229-S235. [PMID: 29401127 DOI: 10.1097/sap.0000000000001350] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Gender affirmation surgery (GAS) is a heterogeneous group of body transformational procedures to match one's gender identity. There is a paucity of literature on the outcomes and safety profile of GAS. This study aims to examine trends and outcomes of GAS from 2010 to 2015 using the American College of Surgeons National Surgery Quality Improvement Program and National Inpatient Sample databases. METHODS Patients with a primary diagnosis of gender dysphoria at the time of surgery were identified in both databases. Thirty-day complication rates were determined using the National Surgery Quality Improvement Program database. Patient socioeconomic status and hospital characteristics were examined using the National Inpatient Sample database. RESULTS The number of cases per year increased from 5 in 2010 to 231 in 2015. The overall 30-day complication rate was 5.5%. Younger age was an independent risk factor for overall complications and reoperation. Total operating time was an independent risk factor for overall complications and infection. Black/African American race was associated with an increased risk of reoperation and readmission. Most patients (80%) had income at or above the national median income level; most were self-pay or had private insurance (90%). The typical hospitals providing GAS were large, urban, nonteaching, private nonprofit institutions in the US West Coast and Northeast. CONCLUSIONS Gender affirmation surgery has an acceptable safety profile. The marked increase in case numbers likely reflects recent improvements in social climate and access to care. However, there are socioeconomic disparities in utilization and surgical outcomes among this already vulnerable patient population.
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31
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Mogul DB, Lee J, Purnell TS, Massie AB, Ishaque T, Segev DL, Bridges JF. Barriers to access in pediatric living-donor liver transplantation. Pediatr Transplant 2019; 23:e13513. [PMID: 31215155 PMCID: PMC9421564 DOI: 10.1111/petr.13513] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 05/09/2019] [Accepted: 05/12/2019] [Indexed: 12/13/2022]
Abstract
Children receiving a LDLT have superior post-transplant outcomes, but this procedure is only used for 10% of transplant recipients. Better understanding about barriers toward LDLT and the sociodemographic characteristics that influence these underlying mechanisms would help to inform strategies to increase its use. We conducted an online, anonymous survey of parents/caregivers for children awaiting, or have received, a liver transplant regarding their knowledge and attitudes about LDLT. The survey was completed by 217 respondents. While 97% of respondents understood an individual could donate a portion of their liver, only 72% knew the steps in evaluation, and 69% understood the donor surgery was covered by the recipient's insurance. Individuals with public insurance were less likely than those with private insurance to know the steps for LDLT evaluation (44% vs 82%; P < 0.001). Respondents with public insurance were less likely to know someone that had been a living donor (44% vs 56%; P = 0.005) as were individuals without a college degree (64% vs 85%; P = 0.007). Nearly all respondents generally trusted their healthcare team. Among respondents, 82% believed they were well-informed about LDLT but individuals with public insurance were significantly less likely to feel well-informed (67% vs 87%; P = 0.03) and to understand how donor surgery might impact donor work/time off (44% vs 81%; P = 0.001). Substantial gaps exist in parental understanding about LDLT, including its evaluation, potential benefits, and complications. Greater emphasis on addressing these barriers, especially to individuals with fewer resources, will be helpful to expand the use of LDLT.
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Affiliation(s)
- Douglas B. Mogul
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joy Lee
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN
| | - Tanjala S. Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Tanveen Ishaque
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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32
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Triggs ND, Beer S, Mokha S, Hosek K, Guffey D, Minard CG, Munoz FM, Himes RW. Central line-associated bloodstream infection among children with biliary atresia listed for liver transplantation. World J Hepatol 2019; 11:208-216. [PMID: 30820270 PMCID: PMC6393719 DOI: 10.4254/wjh.v11.i2.208] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/15/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pre-transplant nutrition is a key driver of outcomes following liver transplantation in children. Patients with biliary atresia (BA) may have difficulty achieving satisfactory weight gain with enteral nutrition alone, and parenteral nutrition (PN) may be indicated. While PN has been shown to improve anthropometric parameters of children with BA listed for liver transplantation, less is known about the risks, particularly infectious, associated with this therapy among this specific group of patients.
AIM To describe the incidence, microbiology, and risk factors of central line-associated bloodstream infection (CLABSI) among children with BA listed for liver transplantation.
METHODS Retrospective review of children aged ≤ 2-years of age with BA who were listed for primary liver transplantation at Texas Children’s Hospital from 2008 through 2015 (n = 96). Patients with a central line for administration of PN (n = 63) were identified and details of each CLABSI event were abstracted. We compared the group of patients who experienced CLABSI to the group who did not, to determine whether demographic, clinical, or laboratory factors correlated with development of CLABSI.
RESULTS Nineteen of 63 patients (30%, 95%CI: 19, 43) experienced 29 episodes of CLABSI during 4800 line days (6.04 CLABSI per 1000 line days). CLABSI was predominantly associated with Gram-negative organisms (14/29 episodes, 48%) including Klebsiella spp., Enterobacter spp., and Escherichia coli. The sole polymicrobial infection grew Enterobacter cloacae and Klebsiella pneumoniae. Gram-positive organisms (all Staphylococcus spp.) and fungus (all Candida spp.) comprised 9/29 (31%) and 6/29 (21%) episodes, respectively. No demographic, clinical, or laboratory factors were significantly associated with an increased risk for the first CLABSI event in Cox proportional hazards regression analysis
CONCLUSION There is substantial risk for CLABSI among children with BA listed for liver transplantation. No clinical, demographic, or laboratory factor we tested emerged as an independent predictor of CLABSI. While our data did not show an impact of CLABSI on the short-term clinical outcome, it would seem prudent to implement CLABSI reduction strategies in this population to the extent that each CLABSI event represents potentially preventable hospitalization, unnecessary healthcare dollar expenditures, and may exact an opportunity cost, in terms of missed allograft offers.
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Affiliation(s)
- Nicole D Triggs
- Department of Pediatrics, Section of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, TX 77030, United States
| | - Stacey Beer
- Department of Pediatrics, Section of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, TX 77030, United States
| | - Sonam Mokha
- College of Arts and Sciences, Washington University in St. Louis, St. Louis, MO 63130, United States
| | - Kat Hosek
- Outcomes and Impact Service, Texas Children’s Hospital, Houston, TX 77030, United States
| | - Danielle Guffey
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX 77030, United States
| | - Charles G Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX 77030, United States
| | - Flor M Munoz
- Department of Pediatrics, Section of Infectious Disease, Baylor College of Medicine, Houston, TX 77030, United States
| | - Ryan W Himes
- Department of Pediatrics, Section of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, TX 77030, United States
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Cho SS, Ju YS, Park H, Kim YK, Hwang S, Choi SS. Impact of educational levels on survival rate: A cohort study of 2007 living donor liver transplant recipients at a single large center. Medicine (Baltimore) 2019; 98:e13979. [PMID: 30702556 PMCID: PMC6380783 DOI: 10.1097/md.0000000000013979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Among living donor liver transplantation recipients, the impact of educational levels on survival has rarely explored. Thus, the purpose of study is to analyze the survival rate differences across educational levels among recipients who underwent living donor liver transplantation.We retrospectively analyzed 2007 adult recipients who underwent living donor liver transplantation in a single large center. The educational level was divided into three categories: middle school or lower, high school, and college or higher. The primary outcome was all-cause mortality after living donor liver transplantation. Stratified log-rank test and Cox proportional hazard model were employed for statistical analysis.The incidence rates of all-cause mortality were 23.85, 20.19, and 18.75 per 1000 person-year in recipients with middle school or lower, high school, and college or higher education groups, respectively. However, the gender-stratified log-rank test has not shown a statistically significant difference (P = .3107). In the unadjusted model, hazard ratio (HR) was 1.02 [95% confidence interval (CI) = 0.79-1.33] in high school and 1.23 (95% CI = 0.93-1.64) and in middle school or lower educational level, respectively; In the full adjusted model, the HR of high school was 0.98 (95% CI = 0.75-1.28) and the HR of middle school or lower was 1.01 (95% CI = 0.74-1.37).Although study population of this study is large, we could not find significant survival rate differences by the levels of education. Social selection and high compliance rate might contribute to this result.
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Affiliation(s)
- Seong-Sik Cho
- Department of Occupational and Environmental Medicine, Hallym University Sacred Heart Hospital, Anyang
| | - Young-Su Ju
- Department of Occupational and Environmental Medicine, Hallym University Sacred Heart Hospital, Anyang
| | - Hanwool Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center
| | - Shin Hwang
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center
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Zhang Y, Boktour MR. The Impact of Share 35 Policy on Patient Survival in Patients Undergoing Liver Transplantation With Gender- and Race-Mismatched Donors: An Analysis of the United Network for Organ Sharing Registry. Prog Transplant 2018; 28:151-156. [PMID: 29558873 DOI: 10.1177/1526924818765802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The United Network for Organ Sharing (UNOS) instituted the Share 35 policy in June 2013 in order to reduce death on liver transplant waitlist. The effect of this policy on patient survival among patients with gender- and race-mismatched donors has not been examined. RESEARCH QUESTION To assess the impact of Share 35 policy on posttransplantation patient survival among patients with end-stage liver disease (ESLD) transplanted with gender- and race-mismatched donors. DESIGN A total of 16 467 adult patients with ESLD who underwent liver transplantation between 2012 and 2015 were identified from UNOS. An overall Cox proportional hazards model adjusting for demographic, clinical, and geographic factors and separate models with a dummy variable of pre- and post-Share 35 periods as well as its interaction with other factors were performed to model the effect of gender and race mismatch on posttransplantation patient survival and to compare the patient survival differences between the first 18 months of Share 35 policy to an equivalent time period before. RESULTS Comparison of the pre- and post-Share 35 periods did not show significant changes in the numbers of gender- and race-mismatched transplants, or the risk of death for gender-mismatched recipients. However, black recipients with Hispanic donors (hazard ratio: 0.51, 95% confidence interval, 0.29-0.90) had significantly increased patient survival after Share 35 policy took effect. CONCLUSION The Share 35 policy had a moderate impact on posttransplantation patient survival among recipients with racially mismatched donors according to the first 18-month experience. Future research is recommended to explore long-term transplantation.
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Affiliation(s)
- Yefei Zhang
- 1 Department of Biostatistics, School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Maha R Boktour
- 2 Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
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Racial and regional disparity in liver transplant allocation. Surgery 2018; 163:612-616. [DOI: 10.1016/j.surg.2017.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 10/05/2017] [Accepted: 10/10/2017] [Indexed: 11/17/2022]
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Demographic and Urbanization Disparities of Liver Transplantation in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15020177. [PMID: 29360736 PMCID: PMC5857045 DOI: 10.3390/ijerph15020177] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/10/2018] [Accepted: 01/18/2018] [Indexed: 12/26/2022]
Abstract
Limited access to or receipt of liver transplantation (LT) may jeopardize survival of patients with end-stage liver diseases. Taiwan launched its National Health Insurance (NHI) program in 1995, which essentially removes financial barriers to health care. This study aims to investigate where there are still demographic and urbanization disparities of LT after 15 years of NHI program implementation. Data analyzed in this study were retrieved from Taiwan’s NHI inpatient claims. A total of 3020 people aged ≥18 years received LT between 2000 and 2013. We calculated crude and adjusted prevalence rate of LT according to secular year, age, sex, and urbanization. The multiple Poisson regression model was further employed to assess the independent effects of demographics and urbanization on prevalence of LT. The biennial number of people receiving LT substantially increased from 56 in 2000–2001 to 880 in 2012–2013, representing a prevalence rate of 1.63 and 18.58 per 106, respectively. Such increasing secular trend was independent of sex. The prevalence was consistently higher in men than in women. The prevalence also increased with age in people <65 years, but dropped sharply in the elderly (≥65 years) people. We noted a significant disparity of LT in areas with different levels of urbanization. Compared to urban areas, satellite (prevalence rate ratio (PRR), 0.63, 95% confidence interval (CI), 0.57–0.69) and rural (PRR, 0.76, 95% CI, 0.69–0.83) areas were both associated with a significantly lower prevalence of LT. There are still significant demographic and urbanization disparities in LT after 15 years of NHI program implementation. Given the predominance of living donor liver transplantation in Taiwan, further studies should be conducted to investigate factors associated with having a potential living donor for LT.
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Zhang Y. Access to Liver Transplantation and Patient Survival among Asian Populations: Pre-Share 35 vs Post-Share 35. Int J Organ Transplant Med 2017; 8:173-179. [PMID: 29321832 PMCID: PMC5756898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Studies addressing ethnic disparities and trends in liver transplantation for Asian population are scant. Objective: To examine the impact of Share 35 policy on Asian patients' access to liver transplantation and outcomes since its implementation in June 2013. METHODS A total of 11,910 adult white and Asian patients who were registered for deceased donor liver transplantation between 2012 and 2015, was identified from the United Network for Organ Sharing database. Logistic regression and proportional hazard models with adjustment for demographic, clinical and geographic factors were used to model the access to liver transplantation and patient survival. Stratification on pre- and post-Share 35 periods was performed to compare the first 18 months of Share 35 policy to an equivalent period. RESULTS Comparison of the pre- and post-Share 35 periods showed a significant decrease in time on waiting list and higher proportions of patients receiving liver transplantation for Asian patients. Asians shared similar transplant rates as whites (OR: 1.15, 95% CI: 0.80-1.67) but experienced significantly longer waiting time (HR: 0.56, 95% CI: 0.34-0.92) before they received liver transplantation after Share 35 policy took effect. No significant post-transplantation survival difference was observed between Asians and whites at the 18-month outcome. CONCLUSION Although benefited from the Share 35 policy, Asian patients are still at greater risk of disparities in access to liver transplantation.
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Affiliation(s)
- Y Zhang
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center, Houston, TX, USA
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Green DJ, Brooks MM, Burckart GJ, Chinnock RE, Canter C, Addonizio LJ, Bernstein D, Kirklin JK, Naftel DC, Girnita DM, Zeevi A, Webber SA. The Influence of Race and Common Genetic Variations on Outcomes After Pediatric Heart Transplantation. Am J Transplant 2017; 17:1525-1539. [PMID: 27931092 DOI: 10.1111/ajt.14153] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 11/16/2016] [Accepted: 11/25/2016] [Indexed: 01/25/2023]
Abstract
Significant racial disparity remains in the incidence of unfavorable outcomes following heart transplantation. We sought to determine which pediatric posttransplantation outcomes differ by race and whether these can be explained by recipient demographic, clinical, and genetic attributes. Data were collected for 80 black and 450 nonblack pediatric recipients transplanted at 1 of 6 centers between 1993 and 2008. Genotyping was performed for 20 candidate genes. Average follow-up was 6.25 years. Unadjusted 5-year rates for death (p = 0.001), graft loss (p = 0.015), acute rejection with severe hemodynamic compromise (p = 0.001), late rejection (p = 0.005), and late rejection with hemodynamic compromise (p = 0.004) were significantly higher among blacks compared with nonblacks. Black recipients were more likely to be older at the time of transplantation (p < 0.001), suffer from cardiomyopathy (p = 0.004), and have public insurance (p < 0.001), and were less likely to undergo induction therapy (p = 0.0039). In multivariate regression models adjusting for age, sex, cardiac diagnosis, insurance status, and genetic variations, black race remained a significant risk factor for all the above outcomes. These clinical and genetic variables explained only 8-19% of the excess risk observed for black recipients. We have confirmed racial differences in survival, graft loss, and several rejection outcomes following heart transplantation in children, which could not be fully explained by differences in recipient attributes.
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Affiliation(s)
- D J Green
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - M M Brooks
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - G J Burckart
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - R E Chinnock
- Department of Pediatrics, Loma Linda University, Loma Linda, CA
| | - C Canter
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO
| | - L J Addonizio
- Division of Cardiology, Department of Pediatrics, Columbia University, New York, NY
| | - D Bernstein
- Division of Cardiology, Department of Pediatrics, Stanford University, Lucile Packard Children's Hospital, Palo Alto, CA
| | - J K Kirklin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - D C Naftel
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - D M Girnita
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA
| | - A Zeevi
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA
| | - S A Webber
- Department of Pediatrics, Vanderbilt University, Nashville, TN
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Zhang Y. The Impact of the Share 35 Policy on Racial and Ethnic Disparities in Access to Liver Transplantation for Patients with End Stage Liver Disease in the United States: An Analysis from UNOS Database. Int J Equity Health 2017; 16:55. [PMID: 28340592 PMCID: PMC5366147 DOI: 10.1186/s12939-017-0552-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/20/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The Share 35 policy was instituted in June 2013 by the United Network for Organ Sharing (UNOS) in order to reduce death on liver transplant waiting list. The effect of this policy on racial and ethnic disparities in access to liver transplantation has not been examined. METHODS A total of 14,585 adult patients registered for liver transplantation between 2012 and 2015 were identified from UNOS database. Logistic and proportional hazards models were used to model the effects of race and ethnicity on access to liver transplantation. Stratification on pre- and post-Share 35 periods was performed to compare the first 18 months of Share 35 policy to an equivalent time period before. RESULTS Comparison of the pre- and post-Share 35 periods showed significantly decreased time on waiting list and increased numbers of minorities having access to liver transplantation. Hispanic recipients still experienced significantly longer waiting time (HR: 0.69, 95% CI: 0.53-0.88) before they received liver transplantation after Share 35 policy took effect. CONCLUSION The Share 35 policy did not lead to improved access to liver transplantation among minorities but eliminated the previously observed racial and ethnic disparities in transplant rates as well as shortened the waiting time.
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Affiliation(s)
- Yefei Zhang
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, 1200 Pressler Street, RAS-E803f, Houston, TX, 77030, USA.
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Nieman CL, Tunkel DE, Boss EF. Do race/ethnicity or socioeconomic status affect why we place ear tubes in children? Int J Pediatr Otorhinolaryngol 2016; 88:98-103. [PMID: 27497394 PMCID: PMC4988399 DOI: 10.1016/j.ijporl.2016.06.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 06/04/2016] [Accepted: 06/08/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Despite recent concerns about potential overuse of tympanostomy tube (TT) placement to treat otitis media in children, utilization of this common procedure in the U.S. has been shown to be relatively less common among minority children. It is not known if the indications for TT differ by child race/ethnicity and/or socioeconomic status (SES). Our objective is to analyze the association of patient- and neighborhood-level demographics and SES with clinical indications for TT. METHODS We conducted a retrospective chart review of children who underwent TT at single urban academic tertiary pediatric care center in a 6-month period (8/2013-3/2014). Children with congenital anomalies or syndromic diagnoses were excluded (50/137 children, 36.5%). Children were grouped by primary TT indication, recurrent acute otitis media (RAOM) or chronic otitis media with effusion (OME). Group characteristics were compared using t-tests and chi-square analyses, and logistic regression was performed to assess the association between demographics and TT indication. RESULTS 87 children were included in this analysis (mean age = 2.8 years, 1-6 years). The most common indication for TT was RAOM (53%), and these children had a mean of 6 AOM episodes/year. Indications for TT varied significantly by the patient's neighborhood SES (median neighborhood income $70,969.09-RAOM vs $58, 844.95-OME, p-value = 0.009). Those undergoing TT for RAOM were less likely to live in a high-poverty neighborhood (OR = 0.36,p-value = 0.02), whereas children who underwent TT for OME were more likely to live in a high-poverty neighborhood. There was no significant difference in indication by race/ethnicity or insurance type. CONCLUSIONS In this population, TT indications differed by SES. Among children receiving tubes, those from high poverty areas were more likely than those from low poverty neighborhoods to receive tubes for the indication of OME as opposed to RAOM. This finding suggests that concerns for appropriate use of TT in the setting of RAOM may be specific to a more affluent population. Future prospective patient-centered research will evaluate cultural and economic influences for families pursuing TT placement, as well as factors considered by physicians who make surgical recommendations.
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Affiliation(s)
- Carrie L Nieman
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 N. Caroline St., 6th Floor, Baltimore, MD 21287, USA.
| | - David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 N. Caroline St., 6th Floor, Baltimore, MD 21287, USA; Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, Johns Hopkins University School of Medicine, 601 N. Caroline St., 6th Floor, Baltimore, MD 21287, USA.
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 N. Caroline St., 6th Floor, Baltimore, MD 21287, USA; Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, Johns Hopkins University School of Medicine, 601 N. Caroline St., 6th Floor, Baltimore, MD 21287, USA; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, 750 E Pratt St, 15th Floor, Baltimore, MD 21202, USA.
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Cholankeril G, Perumpail RB, Tulu Z, Jayasekera CR, Harrison SA, Hu M, Esquivel CO, Ahmed A. Trends in Liver Transplantation Multiple Listing Practices Associated With Disparities in Donor Availability: An Endless Pursuit to Implement the Final Rule. Gastroenterology 2016; 151:382-386.e2. [PMID: 27456386 DOI: 10.1053/j.gastro.2016.07.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
| | | | - Zeynep Tulu
- Stanford University School of Medicine, Stanford, California
| | | | | | - Menghan Hu
- Brown University School of Public Health, Providence, Rhode Island
| | | | - Aijaz Ahmed
- Stanford University School of Medicine, Stanford, California.
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Wagenaar AE, Tashiro J, Sola JE, Ekwenna O, Tekin A, Perez EA. Pediatric liver transplantation: predictors of survival and resource utilization. Pediatr Surg Int 2016; 32:439-49. [PMID: 27001031 DOI: 10.1007/s00383-016-3881-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE We sought to identify factors associated with increased resource utilization and in-hospital mortality for pediatric liver transplantation (LT). METHODS Kids' Inpatient Database (1997-2009) was used to identify cases of LT in patients <20 years old. RESULTS Overall, 2905 cases were identified, with an in-hospital survival of 91 %. LT was performed most frequently in < 5 year olds (61 %), females (51 %), and Caucasians (56 %). LT was performed at urban teaching hospitals (97 %) and facilities with children's units (51 %). Indications included pathologic conditions of the biliary tract (44 %) and inborn errors of metabolism (34 %), though unspecified end stage liver disease was the most common (75 %). Logistic regression found higher mortality in children undergoing LT for malignant conditions (odds ratio: 4.8) and acute hepatic failure (OR 3.4). Cases complicated by renal failure (OR 7.7) and complications of LT (OR 2.7) had higher mortality rates. Resource utilization increased for children with renal failure and those with hemorrhage as a complication of LT, p < 0.05. CONCLUSION Hospital survival is predicted by indication and complications associated with LT. Resource utilization increased with renal failure and complications related to LT. Admission length was sensitive to payer status, hospital characteristics, and UNOS region, whereas total costs were unaffected by payer status or hospital type.
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Affiliation(s)
- Amy E Wagenaar
- Division of Pediatric Surgery, DeWitt-Daughtry Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Suite 450, Miami, FL, 33136, USA
| | - Jun Tashiro
- Division of Pediatric Surgery, DeWitt-Daughtry Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Suite 450, Miami, FL, 33136, USA
| | - Juan E Sola
- Division of Pediatric Surgery, DeWitt-Daughtry Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Suite 450, Miami, FL, 33136, USA
| | - Obi Ekwenna
- Miami Transplant Institute, Jackson Memorial Hospital, Miami, FL, USA
| | - Akin Tekin
- Miami Transplant Institute, Jackson Memorial Hospital, Miami, FL, USA
| | - Eduardo A Perez
- Division of Pediatric Surgery, DeWitt-Daughtry Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Suite 450, Miami, FL, 33136, USA.
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De Oliveira GS, McCarthy RJ, Wolf MS, Holl J. The impact of health literacy in the care of surgical patients: a qualitative systematic review. BMC Surg 2015; 15:86. [PMID: 26182987 PMCID: PMC4504415 DOI: 10.1186/s12893-015-0073-6] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 07/09/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Inadequate health literacy affects more than 90 million Americans and it has been associated with adverse outcomes in the medicine field including increased hospitalization rates and greater mortality. Since surgical patients are often required to make complex decisions and adhere to complex instructions, health literacy may have a profound impact in the surgical practice. The main objective of the current study was to systematically evaluate the role of health literacy in surgical patients. METHODS A systematic search was performed to identify studies that evaluated the role of health literacy in the perioperative setting following the PRISMA guidelines. Only studies that examined health literacy using a validated instrument in the perioperative setting were included. RESULTS Ten studies including data on 1147 patients were included. The median (IQR) number of patients in the included studies was 101 (30 to 152). The majority of studies used the Short Test of Functional Literacy in adults (STOFHLA) to evaluate patients' health literacy. Five studies evaluated the patients preoperatively, four studies evaluated patients in the postoperative period and in one study the time of evaluation in relation to the surgical procedure was not defined. The lowest prevalence of inadequate health literacy was detected in kidney transplant patients, 6 out of 124 (5 %), while the highest prevalence of inadequate health literacy was detected in orthopedic patients having total joint replacement, 86 out of 126 (60 %). Inadequate health literacy in the preoperative period was associated with poor medical information comprehension and it may adversely affect adherence to preoperative medications and even modulate surgical disparities. Inadequate health literacy in the postoperative period was associated with poor comprehension of discharge instructions and worse kidney function in transplant recipients. CONCLUSIONS Health literacy seems to have a very significant impact in the care of surgical patients. More studies to establish the impact of poor health literacy on perioperative outcomes are needed.
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Affiliation(s)
- Gildasio S De Oliveira
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, 241 East Huron St, F5-704, Chicago, IL, USA.
| | - Robert J McCarthy
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, 241 East Huron St, F5-704, Chicago, IL, USA
| | - Michael S Wolf
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Jane Holl
- Center for Health Care studies, Northwestern University, Chicago, USA
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Dead wrong: the growing list of racial/ethnic disparities in childhood mortality. J Pediatr 2015; 166:790-3. [PMID: 25819908 PMCID: PMC4523121 DOI: 10.1016/j.jpeds.2015.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 02/03/2015] [Indexed: 01/21/2023]
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Hsu EK, Shaffer M, Bradford M, Mayer-Hamblett N, Horslen S. Heterogeneity and disparities in the use of exception scores in pediatric liver allocation. Am J Transplant 2015; 15:436-44. [PMID: 25612496 DOI: 10.1111/ajt.13089] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 08/20/2014] [Accepted: 09/07/2014] [Indexed: 01/25/2023]
Abstract
Physicians apply for Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease exception points on a case-by-case basis to improve an individual patient's chances of receiving a liver transplant. This retrospective cohort study describes trends in the use of exceptions among the pediatric liver waitlist population with chronic liver disease. The cohort (n = 3728) included all children with a diagnosis of chronic liver disease listed in the United Network for Organ Sharing transplant database for first isolated liver transplant between February 27, 2002 and March 31, 2013. Exception score requests were common (34%); 90% of requests were approved. The rate of exception score requests in 2013 was five times that of 2002 (incident rate ratios [IRR] 5.25, 95% confidence interval [CI] 3.19-8.63, p < 0.01). Patients of non-White race had exception score request rates 13% lower than patients of White race (IRR 0.87, 95% CI 0.77-0.98, p = 0.02). Older patients had lower rates of exception score requests than younger patients (p = 0.03). Request rates varied by region. Time spent at an active exception status nearly tripled the hazard rate for transplantation (hazard ratio = 2.90, 95% CI 2.62-3.21, p < 0.01). There is disparity in use of exceptions by race that is not explained by clinical disease severity, diagnosis, geography or other demographic factors.
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Affiliation(s)
- E K Hsu
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
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Quillin RC, Wilson GC, Wima K, Hohmann SF, Sutton JM, Shaw JJ, Paquette IM, Woodle ES, Abbott DE, Shah SA. Neighborhood level effects of socioeconomic status on liver transplant selection and recipient survival. Clin Gastroenterol Hepatol 2014; 12:1934-41. [PMID: 24907503 DOI: 10.1016/j.cgh.2014.05.020] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 05/21/2014] [Accepted: 05/21/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Previous studies have reported that patients of higher socioeconomic status (SES) have increased access to liver transplantation and reduced waitlist mortality than patients of lower SES. However, little is known about the association between SES and outcomes after liver transplantation. METHODS By using a link between the University HealthSystem Consortium and the Scientific Registry of Transplant Recipients databases, we identified 12,445 patients who underwent liver transplantation from 2007 through 2011. We used a proportional hazards model to assess the effect of SES on patient survival, controlling for characteristics of recipients, donors, geography, and center. RESULTS Compared with liver recipients in the lowest SES quintile, those in the highest quintile were more likely to be male, Caucasian, have private insurance, and undergo transplantation when they had lower Model for End-Stage Liver Disease scores. In proportional hazards model analysis, liver recipients of the lowest SES were at an increased risk for death within a median of 2 years after transplantation (hazard ratio, 1.17; 95% confidence interval, 1.02-1.35). CONCLUSIONS Patients of lower SES appear to face barriers to liver transplantation, but perioperative outcomes (length of stay, in-hospital mortality, or 30-day readmission) do not differ significantly from those of patients of higher SES. However, fewer patients of low SES survive for 2 years after transplantation, independent of features of the recipient, donor, surgery center, or location.
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Affiliation(s)
- R Cutler Quillin
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Gregory C Wilson
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Samuel F Hohmann
- University Health Consortium and Department Health Systems Management, Rush University, Chicago, Illinois
| | - Jeffrey M Sutton
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Joshua J Shaw
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Ian M Paquette
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - E Steve Woodle
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio.
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Lefkowitz DS, Fitzgerald CJ, Zelikovsky N, Barlow K, Wray J. Best practices in the pediatric pretransplant psychosocial evaluation. Pediatr Transplant 2014; 18:327-35. [PMID: 24802341 DOI: 10.1111/petr.12260] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2014] [Indexed: 01/27/2023]
Abstract
Assessment of psychosocial functioning is an often-included component of the pretransplant evaluation process. This study reviews several domains of assessment that have been related to post-transplant outcomes across solid organ transplant populations. These include evaluation of patient and family past adherence, knowledge about the transplantation process, and their neurocognitive, psychological, and family functioning. To date, few comprehensive pretransplant evaluation measures have been standardized for use with children; however, several assessment measures used to evaluate the aforementioned domains are reviewed throughout the study. Additionally, this article discusses some developmental, illness-specific, and cultural considerations in conducting the psychosocial evaluation. We also discuss ethical issues specific to the pediatric psychosocial evaluation. Recommendations are advanced to promote a comprehensive evaluation that identifies family strengths and risk factors as they begin the transplant journey.
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Shemesh E, Kleinman LC, Howell EA, Annunziato R. Racial and economic disparities in transplant outcomes: the not-so-hidden morbidities. Liver Transpl 2014; 20:4-6. [PMID: 24288361 PMCID: PMC3895939 DOI: 10.1002/lt.23801] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 11/21/2013] [Indexed: 12/29/2022]
Affiliation(s)
- Eyal Shemesh
- Department of Pediatrics and Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, NY
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