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Becker EC, Siddique O, O'Sullivan DM, Dar W, Einstein M, Morgan G, Emmanuel B, Sotil EU, Richardson E, Serrano OK. Disparities in Liver Transplantation for Nonalcoholic Steatohepatitis in Women. Transplantation 2024; 108:e181-e186. [PMID: 38419160 DOI: 10.1097/tp.0000000000004964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Nonalcoholic steatohepatitis (NASH) is the fastest-growing indication for liver transplantation (LT). Sex disparities among patients with cirrhosis on the LT waitlist are well known. We wanted to understand these disparities further in women with end-stage liver disease patients listed for NASH cirrhosis in a contemporary cohort. METHODS We used data from the Scientific Registry of Transplant Recipients to assess sex racial, and ethnic differences in NASH patients listed for LT. Adults transplanted from August 1997 to June 2021 were included. Inferential statistics were used to evaluate differences with univariate and multivariate comparisons, including competitive risk analysis. RESULTS During the study time period, we evaluated 12 844 LT for NASH cirrhosis. Women were transplanted at a lower rate (46.5% versus 53.5%; P < 0.001) and higher model for end-stage liver disease (MELD) (23.8 versus 22.6; P < 0.001) than men. Non-White women were transplanted at a higher MELD (26.1 versus 23.1; P < 0.001) than White women and non-White male patients (26.1 versus 24.8; P < 0.001). Graft and patient survivals were significantly different ( P < 0.001) between non-White women and White women and men (White and non-White). CONCLUSIONS Evaluation of LT candidates in the United States demonstrates women with NASH cirrhosis have a higher MELD than men at LT. Additional disparities exist among non-White women with NASH as they have higher MELD and creatinine at LT compared with White women. After LT, non-White women have worse graft and patient survival compared with men or White women. These data indicate that non-White women with NASH are the most vulnerable on the LT waitlist.
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Affiliation(s)
- Erica C Becker
- Department of Internal Medicine, University of Connecticut Health, Farmington, CT
| | - Osama Siddique
- Department of Gastroenterology, Hartford Hospital, Hartford, CT
| | - David M O'Sullivan
- Department of Research Administration, Hartford HealthCare, Hartford, CT
| | - Wasim Dar
- Transplant Program, Hartford Hospital, Hartford, CT
- Department of Surgery, University of Connecticut Health, Farmington, CT
| | - Michael Einstein
- Department of Internal Medicine, University of Connecticut Health, Farmington, CT
- Transplant Program, Hartford Hospital, Hartford, CT
| | - Glyn Morgan
- Transplant Program, Hartford Hospital, Hartford, CT
- Department of Surgery, University of Connecticut Health, Farmington, CT
| | - Bishoy Emmanuel
- Transplant Program, Hartford Hospital, Hartford, CT
- Department of Surgery, University of Connecticut Health, Farmington, CT
| | - Eva U Sotil
- Department of Internal Medicine, University of Connecticut Health, Farmington, CT
- Transplant Program, Hartford Hospital, Hartford, CT
| | - Elizabeth Richardson
- Department of Internal Medicine, University of Connecticut Health, Farmington, CT
- Transplant Program, Hartford Hospital, Hartford, CT
| | - Oscar K Serrano
- Transplant Program, Hartford Hospital, Hartford, CT
- Department of Surgery, University of Connecticut Health, Farmington, CT
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Forman LM, Jackson WE, Arrigain S, Lopez R, Schold JD. Socioeconomic deprivation is associated with worse patient and graft survival following adult liver transplantation. Liver Transpl 2024:01445473-990000000-00380. [PMID: 38767448 DOI: 10.1097/lvt.0000000000000400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/05/2024] [Indexed: 05/22/2024]
Abstract
The impact of social determinants of health on adult liver transplant recipient outcomes is not clear at a national level. Further understanding of the impact of social determinants of health on patient outcomes can inform effective, equitable health care delivery. Unadjusted and multivariable models were used to analyze the Scientific Registry of Transplant Recipients to evaluate the association between the Social Deprivation Index (SDI) based on the liver transplant recipient's residential location and patient and graft survival. We included adult recipients between January 1, 2008 and December 1, 2021. Patient and graft survival were lower in adults living in areas with deprivation scores above the median. Five-year patient and graft survival were 78.7% and 76.5%, respectively, in the cohort above median SDI compared to 80.5% and 78.3% below median SDI. Compared to the recipients in low-deprivation residential areas, recipients residing in the highest deprivation (SDI quintile = 5) cohort had 6% higher adjusted risk of mortality (adjusted hazard ratio = 1.06, 95% CI: 1.01-1.13) and 6% higher risk of graft failure (adjusted hazard ratio = 1.06, 95% CI: 1.001-1.11). The increased risks for recipients residing in more vulnerable residential areas were higher (adjusted hazard ratio = 1.11, 95% CI: 1.03-1.20 for both death and graft loss) following the first year after transplantation. Importantly, the overall risk for graft loss associated with SDI was not linear but instead accelerated above the median level of deprivation. In the United States, social determinants of health, as reflected by residential distress, significantly impacts 5-year patient and graft survival. The overall effect of residential deprivation modest, and importantly, results illustrate they are more strongly associated with longer-term follow-up and accelerate at higher deprivation levels. Further research is needed to evaluate effective interventions and policies to attenuate disparities in outcomes among recipients in highly disadvantaged areas.
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Affiliation(s)
- Lisa M Forman
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Surgery, Division of Transplantation, Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | - Whitney E Jackson
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Surgery, Division of Transplantation, Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | - Susana Arrigain
- Department of Surgery, Division of Transplantation, Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
- Department of Surgery, Division of Transplant Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rocio Lopez
- Department of Surgery, Division of Transplantation, Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
- Department of Surgery, Division of Transplant Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jesse D Schold
- Department of Surgery, Division of Transplantation, Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
- Department of Surgery, Division of Transplant Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Ross-Driscoll K, Adams A, Caicedo J, Gordon EJ, Kirk AD, McElroy LM, Taber D, Patzer R. Health Disparity Metrics for Transplant Centers: Theoretical and Practical Considerations. Transplantation 2024:00007890-990000000-00708. [PMID: 38548712 DOI: 10.1097/tp.0000000000004973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Affiliation(s)
- Katie Ross-Driscoll
- Division of Transplantation, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN
| | - Andrew Adams
- Division of Transplantation, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN
| | - Juan Caicedo
- Division of Transplantation, Department of Surgery, Northwestern University School of Medicine, Chicago, IL
| | - Elisa J Gordon
- Department of Surgery and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN
| | - Alan D Kirk
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Lisa M McElroy
- Division of Transplantation, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - David Taber
- Division of Transplantation, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Rachel Patzer
- Regenstrief Institute, Indianapolis, IN
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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Kim DK, Ascherman JA. Impact of Sociodemographic and Hospital Factors on Inpatient Bilateral Reduction Mammaplasty: A National Inpatient Sample Analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5682. [PMID: 38525492 PMCID: PMC10959567 DOI: 10.1097/gox.0000000000005682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/22/2024] [Indexed: 03/26/2024]
Abstract
Background Although reduction mammaplasty remains a common procedure in plastic surgery, its interaction with sociodemographic and economic disparities has remained relatively uncharacterized on a nationwide scale. Methods Patients who underwent reduction mammaplasty were identified within the 2016-2018 National Inpatient Sample databases. In addition to clinical comorbidities, sociodemographic characteristics, hospital-level variables, and postoperative outcomes of each patient were collected for analysis. Statistical analyses, including univariate comparison and multivariate logistic regression, were applied to the cohort to determine significant predictors of adverse outcomes, described as extended length of stay, higher financial cost, and postoperative complications. Results The final patient cohort included 414 patients who underwent inpatient reduction mammaplasty. The average age was 45.2 ± 14.5 years. The average length of stay was 1.6 ± 1.5 days, and the average hospital charge was $53,873.81 ± $36,014.50. Sixty (14.5%) patients experienced at least one postoperative complication. Black race and treatment within a nonmetropolitan or rural county predicted postoperative complications (P < 0.01). Black race, lower relative income, and concurrent abdominal contouring procedures also predicted occurrence of extended length of stay (P < 0.01). Hospital factors, including larger bed capacity and for-profit ownership, predicted high hospital charges (P < 0.05). Severity of comorbidities, measured by a clinical index, also predicted all three outcomes (P < 0.001). Conclusion In addition to well-described clinical variables, multiple sociodemographic and economic disparities affect outcomes in inpatient reduction mammaplasty.
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Affiliation(s)
- Dylan K. Kim
- From the Division of Plastic Surgery, Columbia University Irving Medical Center, New York, N.Y
| | - Jeffrey A. Ascherman
- From the Division of Plastic Surgery, Columbia University Irving Medical Center, New York, N.Y
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5
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Munir MM, Endo Y, Mehdi Khan MM, Woldesenbet S, Yang J, Washburn K, Limkemann A, Schenk A, Pawlik TM. Association of Neighborhood Deprivation and Transplant Center Quality with Liver Transplantation Outcomes. J Am Coll Surg 2024; 238:291-302. [PMID: 38050968 DOI: 10.1097/xcs.0000000000000905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Social determinants of health can impact the quality of liver transplantation (LT) care. We sought to assess whether the association between neighborhood deprivation and transplant outcomes can be mitigated by receiving care at high-quality transplant centers. STUDY DESIGN In this population-based cohort study, patients who underwent LT between 2004 and 2019 were identified in the Scientific Registry of Transplant Recipients. LT-recipient neighborhoods were identified at the county level and stratified into quintiles relative to Area Deprivation Index (ADI). Transplant center quality was based on the Scientific Registry of Transplant Recipients 5-tier ranking using standardized transplant rate ratios. Multivariable Cox regression was used to assess the relationship between ADI, hospital quality, and posttransplant survival. RESULTS A total of 41,333 recipients (median age, 57.0 [50.0 to 63.0] years; 27,112 [65.4%] male) met inclusion criteria. Patients residing in the most deprived areas were more likely to have nonalcoholic steatohepatitis, be Black, and travel further distances to reach a transplant center. On multivariable analysis, post-LT long-term mortality was associated with low- vs high-quality transplant centers (hazard ratio [HR] 1.19, 95% CI 1.07 to 1.32), as well as among patients residing in high- vs low-ADI neighborhoods (HR 1.25, 95% CI 1.16 to 1.34; both p ≤ 0.001). Of note, individuals residing in high- vs low-ADI neighborhoods had a higher risk of long-term mortality after treatment at a low-quality (HR 1.31, 95% CI 1.06 to 1.62, p = 0.011) vs high-quality (HR 1.12, 95% CI 0.83 to 1.52, p = 0.471) LT center. CONCLUSIONS LT at high-quality centers may be able to mitigate the association between posttransplant survival and neighborhood deprivation. Investments and initiatives that increase access to referrals to high-quality centers for patients residing in higher deprivation may lead to better outcomes and help mitigate disparities in LT.
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Affiliation(s)
- Muhammad Musaab Munir
- From the Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
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De Simone P, Germani G, Lai Q, Ducci J, Russo FP, Gitto S, Burra P. The impact of socioeconomic deprivation on liver transplantation. FRONTIERS IN TRANSPLANTATION 2024; 3:1352220. [PMID: 38993752 PMCID: PMC11235234 DOI: 10.3389/frtra.2024.1352220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/13/2024] [Indexed: 07/13/2024]
Abstract
Despite global expansion, social disparities impact all phases of liver transplantation, from patient referral to post-transplant care. In pediatric populations, socioeconomic deprivation is associated with delayed referral, higher waitlist mortality, and reduced access to living donor transplantation. Children from socially deprived communities are twice as much less adherent to immunosuppression and have up to a 32% increased incidence of graft failure. Similarly, adult patients from deprived areas and racial minorities have a higher risk of not initiating the transplant evaluation, lower rates of waitlisting, and a 6% higher risk of not being transplanted. Social deprivation is racially segregated, and Black recipients have an increased risk of post-transplant mortality by up to 21%. The mechanisms linking social deprivation to inferior outcomes are not entirely elucidated, and powered studies are still lacking. We offer a review of the most recent evidence linking social deprivation and post-liver transplant outcomes in pediatric and adult populations, as well as a literature-derived theoretical background model for future research on this topic.
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Affiliation(s)
- Paolo De Simone
- Liver Transplant Program, University of Pisa Medical School Hospital, Pisa, Italy
- Department of Surgical, Medical, Molecular Pathology and Intensive Care, University of Pisa, Pisa, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, La Sapienza University of Rome, Rome, Italy
| | - Juri Ducci
- Liver Transplant Program, University of Pisa Medical School Hospital, Pisa, Italy
| | - Francesco Paolo Russo
- Department of Surgery, Gastroenterology, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Stefano Gitto
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, University Hospital Careggi, University of Florence, Florence, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
- Department of Surgery, Gastroenterology, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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7
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West E, Jackson L, Greene H, Lucas DJ, Gadbois KD, Choi PM. Race Does Not Affect Rates of Surgical Complications at Military Treatment Facility. Mil Med 2024:usad502. [PMID: 38241780 DOI: 10.1093/milmed/usad502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/02/2023] [Accepted: 12/19/2023] [Indexed: 01/21/2024] Open
Abstract
INTRODUCTION Racial minorities have been found to have worse health care outcomes, including perioperative adverse events. We hypothesized that these racial disparities may be mitigated in a military treatment facility, where all patients have a military service connection and are universally insured. MATERIALS AND METHODS This is a single institution retrospective review of American College of Surgeons National Surgical Quality Improvement Program data for all procedures collected from 2017 to 2020. The primary outcome analyzed was risk-adjusted 30-day postoperative complications compared by race. RESULTS There were 6,941 patients included. The overall surgical complication rate was 6.9%. The complication rate was 7.3% for White patients, 6.5% for Black patients, 12.6% for Asian patients, and 3.4% for other races. However, after performing patient and procedure level risk adjustment using multivariable logistic regression, race was not independently associated with surgical complications. CONCLUSIONS Risk-adjusted surgical complication rates do not vary by race at this military treatment facility. This suggests that postoperative racial disparities may be mitigated within a universal health care system.
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Affiliation(s)
- Erin West
- Department of General Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Laurinda Jackson
- Department of General Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Howard Greene
- Clinical Investigation Department, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Donald J Lucas
- Division of Pediatric Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Kyle D Gadbois
- Department of General Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Pamela M Choi
- Division of Pediatric Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
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Okumura K, Dhand A, Misawa R, Sogawa H, Veillette G, Nishida S. The effects of acuity circle policy on racial disparity in liver transplantation. Surgery 2023; 174:1436-1444. [PMID: 37827898 DOI: 10.1016/j.surg.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 08/03/2023] [Accepted: 09/05/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND A new deceased donor liver allocation policy using an acuity circle-based model was implemented with the goal of providing equitable access to liver transplantation. We assessed the effect of the acuity circle policy on racial disparities in liver transplantation by analyzing waitlist mortality, transplant probability, and post-transplant outcomes. METHODS We conducted a retrospective analysis of 23,717 adult liver transplantation candidates listed during the pre-acuity circle period and 21,051 during the post-acuity circle period (N = 44,768) in the United Network for Organ Sharing database from February 2020 to December 2021. RESULTS Acuity circle-policy implementation was not associated with any significant difference in 90-day waitlist mortality but increased the 90-day probability of all candidates. Implementation did not decrease 90-day waitlist mortality but increased the 90-day transplant probability for all patients. One-year patient and liver graft survival were comparable between the study periods for all recipients, but Black recipients had higher rates of 1-year post-liver transplantation mortality and liver graft failure in both periods. CONCLUSION Although the implementation of the acuity circle policy is associated with an increase in transplant probability in White, Black, and Hispanic liver transplantation candidates, it did not change their waitlist mortality, nor did it lead to any improvement in the preexistent worse post-transplant outcomes in Black liver transplantation recipients.
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Affiliation(s)
- Kenji Okumura
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York. https://twitter.com/KenjiOkumura_MD
| | - Abhay Dhand
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York. https://twitter.com/DhandAbhay
| | - Ryosuke Misawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Hiroshi Sogawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York. https://twitter.com/HiroNewYork
| | - Gregory Veillette
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Seigo Nishida
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York.
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Atiemo K, Baudier R, Craig-Schapiro R, Guo K, Mazumder N, Anderson A, Zhao L, Ladner D. Factors Underlying Racial Disparity in Utilization of Hepatitis C-Viremic Kidneys in the United States. J Racial Ethn Health Disparities 2023; 10:2185-2194. [PMID: 35997960 PMCID: PMC10348076 DOI: 10.1007/s40615-022-01398-0] [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: 06/16/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022]
Abstract
Utilization of hepatitis C (HCV) viremic kidneys is increasing in the United States. We examined racial disparity in this utilization using UNOS/OPTN data (2014-2020) and mixed effects models adjusting for donor/recipient/center factors. Included in the study were 58,786 adults receiving a deceased donor kidney transplant from 191 centers. Two thousand six hundred thirteen (4%) received kidneys from HCV-viremic donors. Of these, 1598 (61%) were HCV seronegative and 1015 (49%) were HCV seropositive. Among seronegative recipients, before adjusting for waiting time and education, Blacks (OR 0.69, 95%CI (0.60, 0.80)), Hispanics (OR 0.63, 95%CI (0.51, 0.79)), and Asians (OR 0.69, 95%CI (0.53, 0.90)) were less likely than Whites to receive HCV-viremic kidneys. In final models, effect of race was attenuated. Notably, shorter waiting time (OR 0.65, 95%CI (0.63, 0.67)) and increasing educational level (grade school less likely compared to high school OR 0.67, 95% CI (0.49, 0.92) and college more likely than high school (OR 1.16 95% CI (1.02, 1.31)) were associated with receipt of HCV-viremic kidneys. Among HCV-seropositive recipients, recipient race was not independently associated with receipt of HCV-viremic kidneys; however, centers with larger populations of Black waitlisted patients were more likely to utilize HCV-viremic kidneys (OR 1.71, 95%CI (1.20, 2.45)) compared to other centers. Our results suggest recipient race does not independently determine who receives HCV-viremic kidneys; however, other underlying factors including waiting time, education (among seronegative), and center racial mix (among seropositive) contribute to the current differential distribution of HCV-viremic kidneys among races.
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Affiliation(s)
- Kofi Atiemo
- Division of Transplant Surgery, Weill Cornell Medical Center, 525 East 68 thStreet, Box 98, New York, NY, 10065, USA.
| | - Robin Baudier
- Epidemiology Department, Tulane School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Rebecca Craig-Schapiro
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
| | - Kexin Guo
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
| | - Nikhilesh Mazumder
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
| | - Amanda Anderson
- Epidemiology Department, Tulane School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Lihui Zhao
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern Medicine, Chicago, IL, USA
| | - Daniela Ladner
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
- Division of Transplantation, Department of Surgery, Northwestern Medicine, Chicago, IL, USA
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern Medicine, Chicago, IL, USA
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Clark JD, Albers EL, Albert JE, Berkman ER, Englund JA, Farris RWD, Johnson BA, Lewis‐Newby M, McGuire J, Rogers M, Thompson HM, Wagner TA, Wells C, Yanay O, Zerr DM, Limaye AP. SARS-CoV-2 RNA positive pediatric organ donors: A case report. Pediatr Transplant 2023; 27:e14452. [PMID: 36518025 PMCID: PMC9878170 DOI: 10.1111/petr.14452] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/23/2022] [Accepted: 10/24/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Preliminary evidence suggests that non-lung organ donation from resolved, asymptomatic or mildly symptomatic SARS-CoV-2 infected adults may be safe. However, several biological aspects of SARS-CoV-2 infection differ in children and the risk for transmission and outcomes of recipients from pediatric donors with SARS-CoV-2 infection are not well described. METHODS We report two unvaccinated asymptomatic pediatric non-lung organ deceased donors who tested positive for SARS-CoV-2 RNA by RT-PCR. Donor One unexpectedly had SARS-CoV-2 RNA detected in nasopharyngeal swab and plasma specimens at autopsy despite several negative tests (upper and lower respiratory tract) in the days prior to organ recovery. Donor Two had SARS-CoV- 2 RNA detected in multiple nasopharyngeal swabs but not lower respiratory tract specimens (endotracheal aspirate and bronchoalveolar lavage) during routine surveillance prior to organ recovery and was managed with remdesivir and monoclonal antibodies prior to organ recovery. RESULTS Two hearts, two livers and four kidneys were successfully transplanted into seven recipients. No donor to recipient transmission of SARS-CoV-2 was observed and graft function of all organs has remained excellent for up to 7 months of followup. CONCLUSIONS Due to the persistent gap between organ availability and the number of children waiting for transplants, deceased pediatric patients with non-disseminated SARS-CoV-2 infection, isolated to upper and/or lower respiratory tract, should be considered as potential non-lung organ donors.
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Affiliation(s)
- Jonna D. Clark
- Division of Bioethics and Palliative Care, Department of PediatricsUniversity of Washington School of MedicineSeattleWashingtonUSA
- Treuman Katz Center for Pediatric BioethicsSeattle Children's Hospital and Research InstituteSeattleWashingtonUSA
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Erin L. Albers
- Division of Pediatric CardiologyUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Jesselle E. Albert
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Emily R. Berkman
- Division of Bioethics and Palliative Care, Department of PediatricsUniversity of Washington School of MedicineSeattleWashingtonUSA
- Treuman Katz Center for Pediatric BioethicsSeattle Children's Hospital and Research InstituteSeattleWashingtonUSA
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Janet A. Englund
- Division of Pediatric Infectious DiseasesUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Reid W. D. Farris
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | | | - Mithya Lewis‐Newby
- Division of Bioethics and Palliative Care, Department of PediatricsUniversity of Washington School of MedicineSeattleWashingtonUSA
- Treuman Katz Center for Pediatric BioethicsSeattle Children's Hospital and Research InstituteSeattleWashingtonUSA
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - John McGuire
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | | | | | - Thor A. Wagner
- Division of Pediatric Infectious DiseasesUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | | | - Ofer Yanay
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Danielle M. Zerr
- Division of Pediatric Infectious DiseasesUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Ajit P. Limaye
- Department of Medicine, Division of Allergy and Infectious DiseasesUniversity of WashingtonSeattleWashingtonUSA
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11
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Bonner SN, Thumma JR, Valbuena VSM, Stewart JW, Combs M, Lyu D, Chang A, Lin J, Wakeam E. The intersection of race and ethnicity, gender, and primary diagnosis on lung transplantation outcomes. J Heart Lung Transplant 2023; 42:985-992. [PMID: 36967318 PMCID: PMC11258797 DOI: 10.1016/j.healun.2023.02.1496] [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: 05/11/2022] [Revised: 01/10/2023] [Accepted: 02/18/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Reducing racial disparities in lung transplant outcomes is a current priority of providers, policymakers, and lung transplant centers. It is unknown how the combined effect of race and ethnicity, gender, and diagnosis group is associated with differences in 1-year mortality and 5-year survival. METHODS This is a longitudinal cohort study using Standard Transplant Analysis Research files from the United Network for organ sharing. A total of 25,444 patients undergoing first time lung transplantation between 2006 and 2019 in the United States. The primary exposures were lung transplant recipient race and ethnicity, gender, and primary diagnosis group at listing. Multivariable regression models and cox-proportional hazards models were used to determine adjusted 1-year mortality and 5-year survival. RESULTS Overall, 25,444 lung transplant patients were included in the cohort including 15,160 (59.6%) men, 21,345 (83.9%) White, 2,318 (9.1%), Black and Hispanic/Latino (7.0%). Overall, men had a significant higher 1-year mortality than women (11.87%; 95% CI 11.07-12.67 vs 12.82%; 95% CI 12.20%-13.44%). Black women had the highest mortality of all race and gender combinations (14.51%; 95% CI 12.15%-16.87%). Black patients with pulmonary vascular disease had the highest 1-year mortality (19.77%; 95% CI 12.46%-27.08%) while Hispanic/Latino patients with obstructive lung disease had the lowest (7.42%; 95% CI 2.8%-12.05%). 5-year adjusted survival was highest among Hispanic/Latino patients (62.32%) compared to Black (57.59%) and White patients (57.82%). CONCLUSIONS There are significant differences in 1-year and 5-year mortality between and within racial and ethnic groups depending on gender and primary diagnosis. This demonstrates the impact of social and clinical factors on lung transplant outcomes.
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Affiliation(s)
- Sidra N Bonner
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan.
| | - Jyothi R Thumma
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Valeria S M Valbuena
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan
| | - James W Stewart
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Yale University, New Haven, Connecticut
| | - Michael Combs
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Dennis Lyu
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Andrew Chang
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jules Lin
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Elliot Wakeam
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
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12
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Abu S, Chen PH, Harris CM. Comparisons between White and Black Patients Hospitalized with Postliver Transplant Complications/Failure. South Med J 2023; 116:524-529. [PMID: 37400095 DOI: 10.14423/smj.0000000000001578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
OBJECTIVES The impact of race on patients presenting to North American hospitals with postliver transplant complications/failure (PLTCF) has not been studied fully. We compared in-hospital mortality and resource utilization outcomes between White and Black patients hospitalized with PLTCF. METHODS This was a retrospective cohort study that evaluated the years 2016 and 2017 from the National Inpatient Sample. Regression analysis was used to determine in-hospital mortality and resource utilization. RESULTS There were 10,805 hospitalizations for adults with liver transplants who presented with PLTCF. White and Black patients with PLTCF made up 7925 (73.3%) hospitalizations from this population. Among this group, 6480 were White (81.7%) and 1445 were Black (18.2%). Blacks were younger than Whites (mean age ± standard error of the mean: 46.8 ± 1.1 vs 53.6 ± 0.39 years, P < 0.01). Blacks were more likely to be female (53.9% vs 37.4%, P < 0.01). Charlson Comorbidity Index scores were not significantly different (scores ≥3: 46.7% vs 44.2%, P = 0.83). Blacks had significantly higher odds for in-hospital mortality (adjusted odds ratio 2.9, confidence interval [CI] 1.4-6.1; P < 0.01). Hospital charges were higher for Blacks compared with Whites (adjusted mean difference $48,432; 95% CI $2708-$94,157, P = 0.03). Blacks had significantly longer lengths of hospital stays (adjusted mean difference 3.1 days, 95% CI 1.1-5.1, P < 0.01). CONCLUSIONS Compared with White patients hospitalized for PLTCF, Black patients had higher in-hospital mortality and resource use. Investigation into causes leading to this health disparity is needed to improve in-hospital outcomes.
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Orozco G, Shah MB, Gupta M, Marti F, Mei X, Ancheta A, Desai S, Cavnar M, Evers BM, Zwischenberger J, Gedaly R. Liver transplantation for biliary cysts: perioperative and long-term outcomes. HPB (Oxford) 2023:S1365-182X(23)00130-2. [PMID: 37149484 DOI: 10.1016/j.hpb.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 04/12/2023] [Accepted: 04/18/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Biliary cysts (BC) is a rare indication for orthotopic liver transplantation (OLT). METHODS We queried the UNOS dataset to identify patients who underwent OLT for Caroli's disease (CD) and choledochal cysts (CC). All patients with BC (CD + CC) were compared to a cohort of patients transplanted for other indications. Patients with CC were also compared to those with CD. Cox proportional hazard model was performed to assess predictors of graft and patient survival. RESULTS 261 patients underwent OLT for BC. Patients with BC had better pre-operative liver function compared to those transplanted for other indications. 5-year graft and patient survival were 72% and 81%, respectively, similar to those transplanted for other indications after matching. Patients with CC were younger and had increased preoperative cholestasis compared to those with CD. Donor age, race, and gender were predictors of poor graft and patient survival in patients transplanted for CC. CONCLUSIONS Patients with BC have similar outcomes to those transplanted for other indications and more frequently require MELD score exception. In patients transplanted for choledochal cysts, female gender, donor age, and African-American race were independent predictors of poor survival. Pediatric patients transplanted for Caroli's disease had better survival compared to adults.
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Affiliation(s)
- Gabriel Orozco
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA; University of Kentucky Department of Surgery, Lexington, KY, USA
| | - Malay B Shah
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA; University of Kentucky Department of Surgery, Lexington, KY, USA
| | - Meera Gupta
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA; University of Kentucky Department of Surgery, Lexington, KY, USA
| | - Francesc Marti
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA; University of Kentucky Department of Surgery, Lexington, KY, USA
| | - Xiaonan Mei
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA; University of Kentucky Department of Surgery, Lexington, KY, USA
| | - Alexandre Ancheta
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA; University of Kentucky Department of Surgery, Lexington, KY, USA
| | - Siddharth Desai
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA; University of Kentucky Department of Surgery, Lexington, KY, USA
| | - Michael Cavnar
- Markey Cancer Center, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA; University of Kentucky Department of Surgery, Lexington, KY, USA
| | - B Mark Evers
- Markey Cancer Center, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA; University of Kentucky Department of Surgery, Lexington, KY, USA
| | - Joseph Zwischenberger
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA; Markey Cancer Center, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA; University of Kentucky Department of Surgery, Lexington, KY, USA
| | - Roberto Gedaly
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA; Markey Cancer Center, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA; University of Kentucky Department of Surgery, Lexington, KY, USA.
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14
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Outcomes of endoscopic retrograde cholangio-pancreatography in patients with liver transplant. Clin Exp Hepatol 2022; 8:226-232. [PMID: 36685268 PMCID: PMC9850314 DOI: 10.5114/ceh.2022.119246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/13/2022] [Indexed: 02/01/2023] Open
Abstract
Aim of the study Biliary complications are the leading causes of morbidity and mortality after liver transplant (LT). However, national data on endoscopic retrograde cholangiopancreatography (ERCP) usage and outcomes in LT patients are lacking. Our study aims to identify the trends, outcomes, and predictors of ERCP and related complications in this patient subgroup. Material and methods We derived our study cohort from the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) between 2007 and 2017. LT patients were identified using ICD-9/10CM diagnosis codes and patients who underwent ERCP were identified by ICD-9/10-CM procedure codes. We utilized the Cochrane-Armitage trend test and multivariate logistic regression to analyze temporal trends, outcomes, and predictors. Results A total of 372,814 hospitalizations occurred in LT patients between 2007 and 2017. ERCP was performed in 2.05% (n = 7632) of all hospitalizations. There was a rise in ERCP procedures from 1.96% (n = 477) in 2007 to 2.05% (n = 845) in 2017. Among LT patients who underwent ERCP, the in-hospital mortality rate was 1% (n = 73) and 8% (n = 607) were discharged to facilities. Mean length of hospital stay was 7 ±0.3 days. Septicemia was the most common periprocedural complication (18.3%, n = 1399) followed by post-ERCP pancreatitis (8.8%, n = 674). Conclusions There has been an increase in ERCP procedures over the past decade among LT patients. Our study highlights the periprocedural complications and outcomes of ERCP in LT patients from a nationally representative dataset.
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Lehman LL, Mostofsky E, Salia S, Gupta S, Barrera FJ, Liou L, Mittleman MA. Racial and Ethnic Disparities in Incidence and Prognosis of Perioperative Stroke Among Pediatric Cardiac Transplant Recipients. J Am Heart Assoc 2022; 11:e025149. [PMID: 35861816 PMCID: PMC9707814 DOI: 10.1161/jaha.121.025149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
In the general population, Black children have a higher incidence of stroke and all‐cause mortality after stroke than White children. Beginning 6 months following cardiac transplantation, Black children have higher mortality than White children. However, whether there are racial and ethnic disparities in incidence and all‐cause mortality following perioperative stroke among pediatric cardiac transplant recipients is unknown.
Methods and Results
Using the Scientific Registry of Transplant Recipients, we studied children who underwent their first heart transplant in the United States between January 1994 and September 2019. Using multivariable logistic regression, we assessed the association between race and ethnicity and perioperative stroke. We used multivariable piecewise Cox regression to examine the association between race and ethnicity and mortality among survivors of perioperative stroke. Among 8224 children who had a first cardiac transplant, 255 (3%) had a perioperative stroke. Black children had 32% lower odds of perioperative stroke compared with White children (adjusted odds ratio, 0.68 [95% CI, 0.46–0.996]). Following perioperative stroke, mortality rates were similar for Black and White children in the first 6 months (adjusted hazard ratio [HR], 0.99 [95% CI, 0.44–2.26]). However, Black children had a higher mortality rate than White children beyond 6 months (adjusted HR, 3.36 [95% CI, 1.22–9.22]).
Conclusions
Among pediatric cardiac transplant recipients, Black children have a lower incidence of perioperative stroke than White children. Among survivors of perioperative stroke, mortality is initially similar by race and ethnicity, but beyond 6 months, Black children have over a 3‐fold higher mortality rate than White children. Identifying and intervening on potential differences in care is essential to addressing these disparities.
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Affiliation(s)
- Laura L. Lehman
- Department of Neurology Boston Children’s Hospital Boston MA
- Harvard Medical School Boston MA
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
| | - Elizabeth Mostofsky
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
| | - Soziema Salia
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
- Department of Internal Medicine Cape Coast Teaching Hospital Cape Coast Ghana
| | - Suruchi Gupta
- Harvard Medical School Boston MA
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine Beth Israel Deaconess Medical Center Boston MA
- Harvard Vanguard Medical Associates Boston Boston MA
| | | | - Lathan Liou
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
- Merck & Co., Merck Research Laboratories Boston MA
| | - Murray A. Mittleman
- Harvard Medical School Boston MA
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
- Division of Cardiovascular Medicine, Department of Medicine Beth Israel Deaconess Medical Center Boston MA
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16
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Mansour MM, Fard D, Basida SD, Obeidat AE, Darweesh M, Mahfouz R, Ahmad A. Disparities in Social Determinants of Health Among Patients Receiving Liver Transplant: Analysis of the National Inpatient Sample From 2016 to 2019. Cureus 2022; 14:e26567. [PMID: 35936191 PMCID: PMC9350951 DOI: 10.7759/cureus.26567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 11/05/2022] Open
Abstract
Background Liver transplantation is the life-saving standard of care for those with end-stage liver disease. Unfortunately, many patients on the liver transplant list die waiting. Several studies have demonstrated significant differences based on disparities in race, gender, and multiple socioeconomic factors. We sought to evaluate recent disparities among patients receiving liver transplants using the latest available data from the National Inpatient Sample (NIS), the largest publicly available inpatient care database in the United States. Methods We performed an analysis of discharge data from the NIS between 2016 and 2019. We identified adult patients with chronic liver disease who underwent a liver transplant using the International Classification of Diseases, 10th revision (ICD-10) codes. Multivariate logistic regression was used to adjust for differences in race, gender, socioeconomic status, and comorbidities among those who received a liver transplant. Results A total of 24,595 liver transplants were performed over the study period. Female gender was independently associated with decreased transplant rates (adjusted odds ratio (AOR) 0.83, 95% confidence interval (CI), 0.78-0.89, P < 0.001). Compared to White patients, Black patients had decreased transplant rates (AOR 0.86, 95% CI, 0.75-0.99, P = 0.034), as did Native Americans (AOR 0.64; 95% CI, 0.42-0.97, P = 0.035). Hispanics and Asian Americans had increased rates of liver transplantation (AOR 1.16, 95% CI 1.02-1.32, P = 0.022, and 1.36, 95% CI 1.11-1.67, P = 0.003; respectively). The increase in income quartile was associated with an incremental increase in transplant rates. Additionally, patients with private insurance had much higher transplant rates compared to those with Medicare (AOR 2.50, 95% CI 2.31-2.70, P < 0.001) while patients without insurance had the lowest rates of transplantation (AOR 0.18, 95% CI 0.12-0.28, P < 0.001). Conclusions Our analysis demonstrates that race, gender, and other social determinants of health have significant impacts on the likelihood of receiving a liver transplant. Our study, on a national level, confirms previously described disparities in receiving liver transplantation. Patient-level studies are needed to better understand how these variables translate into differing liver transplantation rates.
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17
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Gray C, Arney J, Clark JA, Walling AM, Kanwal F, Naik AD. The chosen and the unchosen: How eligibility for liver transplant influences the lived experiences of patients with advanced liver disease. Soc Sci Med 2022; 305:115113. [PMID: 35690034 DOI: 10.1016/j.socscimed.2022.115113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 02/07/2023]
Abstract
Advanced liver disease is often uncurable and fatal. Liver transplant is the only curative option for patients with advanced, irreversible liver disease, but the need for new livers far exceeds the supply. Patients with the greatest need as well as the greatest likelihood of benefit, based on a complex array of biomedical and psychosocial considerations, are prioritized for transplant. The opportunity to receive a life-saving surgery no doubt has enormous consequences for patients and their healthcare providers, as does the absence of that opportunity. But these consequences are poorly characterized, especially for patients deemed poor candidates for liver transplant. Through in-depth interviews with patients living with advanced liver disease and the providers who care for them, we explore how eligibility status affects illness experiences, including patients' interactions with clinicians, knowledge about their disease, expectations for the future, and efforts to come to terms with a life-limiting illness. We describe how the clinical and social requirements needed to secure eligibility for liver transplant lend themselves to a clinical and cultural logic that delineates "worthy" and "unworthy" patients. We describe how providers and candidates discuss the possibility of moral redemption for such patients through transplant surgeries, a discourse notably absent among patients not eligible for transplant.
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Affiliation(s)
- Caroline Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA.
| | - Jennifer Arney
- Department of Sociology, University of Houston-Clear Lake, 2700 Bay Area Boulevard, Houston, TX, 77058, USA; VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA.
| | - Jack A Clark
- Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA.
| | - Anne M Walling
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA; Department of Medicine, Division of General Internal Medicine and Health Services Research University of California at Los Angeles, 1100 Glendon Ave STE 850, Los Angeles, CA, 90024, USA.
| | - Fasiha Kanwal
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA; Department of Medicine, Health Services Research and Gastroenterology and Hepatology, Baylor College of Medicine, 7200 Cambridge St., Houston, TX, 77030, USA.
| | - Aanand D Naik
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA; Department of Medicine, Department of Health Services Research, Geriatrics and Palliative Medicine, Baylor College of Medicine, Houston, TX 7200 Cambridge St., Houston, TX, 77030, USA.
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18
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Keeling SS, McDonald MF, Anand A, Handing GE, Prather LL, Christmann CR, Jalal PK, Kanwal F, Cholankeril G, Goss JA, Rana A. Significant improvements, but consistent disparities in survival for African Americans after liver transplantation. Clin Transplant 2022; 36:e14646. [PMID: 35304775 PMCID: PMC9310351 DOI: 10.1111/ctr.14646] [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: 08/21/2021] [Revised: 02/20/2022] [Accepted: 03/06/2022] [Indexed: 11/28/2022]
Abstract
Despite improvements in survival across races in the past 20 years, African Americans have worse liver transplant outcomes after orthotopic liver transplantation (OLT). This study aims at quantifying the change in disparities between African Americans and other races in survival after OLT. We retrospectively analyzed the United Network for Organ Sharing (UNOS) database for patient data for candidates who received a liver transplant between January 1, 2007 and December 31, 2017. Multivariate Cox proportional hazards regression indicated similar decreases in mortality over time for each race with a decrease in mortality for African Americans: 2010-2012 (HR = .930), 2012-2015 (HR = .882), and 2015-2017 (HR = .883) when compared to 2007-2010. Risk of mortality for African Americans compared to Caucasians varied across the 4 eras: 2007-2010 (HR = 1.083), 2010-2012 (HR = 1.090), 2012-2015 (HR = 1.070), and 2015-2017 (HR = 1.125). While African Americans have seen increases in survival in the past decade, a similar increase in survival for other races leaves a significant survival disparity in African Americans.
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Affiliation(s)
| | - Malcolm F. McDonald
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Adrish Anand
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Greta E. Handing
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Lyndsey L. Prather
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | | | - Prasun K. Jalal
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Fasiha Kanwal
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - George Cholankeril
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - John A. Goss
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Abbas Rana
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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Textbook Outcome as a Quality Metric in Liver Transplantation. Transplant Direct 2022; 8:e1322. [PMID: 35464875 PMCID: PMC9018997 DOI: 10.1097/txd.0000000000001322] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/22/2022] [Accepted: 03/15/2022] [Indexed: 11/27/2022] Open
Abstract
Quality in liver transplantation (LT) is currently measured using 1-y patient and graft survival. Because patient and graft survival rates now exceed 90%, more informative metrics are needed. Textbook outcomes (TOs) describe ideal patient outcomes after surgery. This study critically evaluates TO as a quality metric in LT.
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Choubey AP, Bullock B, Choubey AS, Pai K, Ortiz AC, Khan SA, Mishra A, James R, Koizumi N, Pearson T, Ortiz J. Transplant surgery departmental leaders do not represent workforce demographics especially among women and underrepresented minorities - A retrospective analysis. Am J Surg 2021; 224:153-159. [PMID: 34802691 DOI: 10.1016/j.amjsurg.2021.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/20/2021] [Accepted: 11/04/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The diversity among surgical directors for liver, kidney, and pancreas transplant departments has not been previously evaluated. We aim to quantify the sex and racial demographics of transplant department leaders and assess the impact on patient outcomes. METHODS Demographics were collected for 116 liver, 192 kidney, and 113 pancreas transplant directors using Organ Procurement and Transplantation Network (OPTN) directory and program websites. Scientific Registry of Transplant Recipients (SRTR) 5-tier program outcomes rankings were obtained for each program and matched to leader demographics. A retrospective analysis of transplant recipients from 2010 to 2019 was performed using the United Network for Organ Sharing (UNOS) database. RESULTS 91.5% of transplant surgical directors were male. 55% of departments had a Non-Hispanic White leader. Asian, Hispanic and Black transplant chiefs were at the helm of 23.3%, 9%, and 5% of divisions respectively. Multivariate cox regression analysis did not identify any differences in patient outcomes by transplant director demographics. CONCLUSION There is a paucity of female and URM leaders in transplant surgery. Initiatives to promote research, mentorship, and career advancement opportunities for women and URM are necessary to address the current leadership disparity.
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Affiliation(s)
- Ankur P Choubey
- Department of Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ, USA.
| | - Brenna Bullock
- Department of Surgery, University of Toledo Medical Center, OH, USA
| | - Apurva S Choubey
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kavya Pai
- Department of Surgery, University of Toledo Medical Center, OH, USA
| | | | - Samar A Khan
- Department of Surgery, University of Toledo Medical Center, OH, USA
| | - Anil Mishra
- Department of Surgery, University of Toledo Medical Center, OH, USA
| | - Rosy James
- Schar School of Policy and Government, George Mason University, Fairfax, VA, USA
| | - Naoru Koizumi
- Schar School of Policy and Government, George Mason University, Fairfax, VA, USA
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21
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Transplant Outcomes: Just One Part of the Equity Story. Transplantation 2021; 105:2340-2341. [PMID: 33239540 DOI: 10.1097/tp.0000000000003558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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McClinton A, Gullo J, Martins PN, Serrano OK. Access to liver transplantation for minority populations in the United States. Curr Opin Organ Transplant 2021; 26:508-512. [PMID: 34354000 DOI: 10.1097/mot.0000000000000904] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Racial disparities in access to liver transplantation have been known since the National Transplant Act of 1980. Since the inception of the Final Rule in 2000, the United Network of Organ Sharing has sought to ensure the equitable distribution of donor livers. Despite several measures aimed to improve access for vulnerable populations, disparities in outcomes are still prevalent throughout the liver transplant (LT) evaluation, while on the waitlist, and after liver transplantation. RECENT FINDINGS Blacks and Hispanics are underrepresented on the LT list and have an increased waitlist mortality rate compared to Whites. Additionally, Blacks have a significantly higher risk of posttransplant mortality. SUMMARY Ongoing efforts are necessary to eliminate inequities in transplant access. Strategies such as policy implementation and increasing diversity in the healthcare workforce may prove efficacious in creating change.
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Affiliation(s)
| | - Joy Gullo
- University of Connecticut School of Medicine, Farmington, Connecticut
| | - Paulo N Martins
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Oscar K Serrano
- Department of Surgery, University of Connecticut School of Medicine
- Hartford Hospital Transplant & Comprehensive Liver Center, Hartford, Connecticut, USA
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Chiodo Ortiz A, Choubey AP, Pai K, Khan S, Mishra A, Bullock B, Sureddi S, James R, Siddique AB, Koizumi N, Ortiz J. Kidney transplant surgical director training: Urologists represent a functional alternative to general surgeons. Clin Transplant 2021; 35:e14385. [PMID: 34132442 DOI: 10.1111/ctr.14385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/18/2021] [Accepted: 06/02/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Kidney transplant (KT) directors are general surgeons or urologists. All KT centers must meet established performance standards. However, it has not been established if general surgery and urology led programs have disparate outcomes. METHODS Transplant outcomes and donor-recipient characteristics by director training were investigated. Organ Procurement and Transplantation Network (OPTN) directory, program websites were analyzed for surgical director demographics. Scientific Registry of Transplant Recipients (SRTR) 1-year kidney survival and deceased donor (DD) wait-time rankings were evaluated. A retrospective analysis of 142 157 KT recipients from 2010 to 2019 was performed using the United Network for Organ Sharing (UNOS) database. RESULTS One hunderd and seventy three (90.6%) KT programs were led by general surgeons. There were no significant differences in gender, ethnicity, region, credentials, or fellowship completion. Recipients undergoing KT with urology led programs were older (P = .002) and had longer wait-times (P < .001). These centers used higher KDPI (.47 vs. .45, P < .001) and higher HLA mismatch (3.92 vs. 3.89, P = .02) kidneys. Urology led centers utilized living donors less frequently (32.1% vs. 35.8%, P < .001) and had longer CIT (15.44 vs. 12.21, P < .001). Both had similar SRTR ranking of 1-year survival and DD wait-time. CONCLUSION Most directors were general surgeon. Patient outcomes did not differ by transplant director training. Urologists represent a viable option for KT leadership and recruitment should be encouraged.
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Affiliation(s)
- A Chiodo Ortiz
- Department of Surgery, Albany Medical Center, Albany, New York, USA
| | - Ankur P Choubey
- Department of Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - K Pai
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - S Khan
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - A Mishra
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - B Bullock
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - S Sureddi
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - R James
- Schar School of Policy and Government, George Mason University, Fairfax, Virginia, USA
| | - A B Siddique
- Schar School of Policy and Government, George Mason University, Fairfax, Virginia, USA
| | - N Koizumi
- Schar School of Policy and Government, George Mason University, Fairfax, Virginia, USA
| | - J Ortiz
- Department of Surgery, Albany Medical Center, Albany, New York, USA
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