1
|
Catalano MA, Pupovac S, Jhaveri KD, Stevens GR, Hartman AR, Yu PJ. Simultaneous Heart-Kidney Transplant-Does Hospital Experience With Heart Transplant or Kidney Transplant Have a Greater Impact on Patient Outcomes? Transpl Int 2023; 36:10854. [PMID: 37091962 PMCID: PMC10116866 DOI: 10.3389/ti.2023.10854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 03/14/2023] [Indexed: 04/25/2023]
Abstract
High institutional transplant volume is associated with improved outcomes in isolated heart and kidney transplant. The aim of this study was to assess trends and outcomes of simultaneous heart-kidney transplant (SHKT) nationally, as well as the impact of institutional heart and kidney transplant volume on survival. All adult patients who underwent SHKT between 2005-2019 were identified using the United Network for Organ Sharing (UNOS) database. Annual institutional volumes in single organ transplant were determined. Univariate and multivariable analyses were conducted to assess the impact of demographics, comorbidities, and institutional transplant volumes on 1-year survival. 1564 SHKT were identified, increasing from 54 in 2005 to 221 in 2019. In centers performing SHKT, median annual heart transplant volume was 35.0 (IQR 24.0-56.0) and median annual kidney transplant volume was 166.0 (IQR 89.5-224.0). One-year survival was 88.4%. In multivariable analysis, increasing heart transplant volume, but not kidney transplant volume, was associated with improved 1-year survival. Increasing donor age, dialysis requirement, ischemic times, and bilirubin were also independently associated with reduced 1-year survival. Based on this data, high-volume heart transplant centers may be better equipped with managing SHKT patients than high-volume kidney transplant centers.
Collapse
Affiliation(s)
- Michael A. Catalano
- Division of Cardiac Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Stevan Pupovac
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Gerin R. Stevens
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Alan R. Hartman
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Pey-Jen Yu
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- *Correspondence: Pey-Jen Yu,
| |
Collapse
|
2
|
Saeg F, Chiccarelli EN, Hilaire HS, Lau FH. Regenerative Limb Salvage: A Novel Technique for Soft Tissue Reconstruction of Pediatric Extremities. JOURNAL OF RECONSTRUCTIVE MICROSURGERY OPEN 2020. [DOI: 10.1055/s-0040-1718420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Background In complex extremity wounds, free flap-based limb salvage (fLS) is the standard of care. However, fLS is resource- and cost-intensive, and the limited availability of pediatric microsurgical expertise exacerbates these challenges. Regenerative LS (rLS) addresses these barriers to care. The aim of this study was to quantify the efficacy, safety, and cost-effectiveness of rLS in complex pediatric extremity wounds.
Methods We conducted a retrospective cohort study of pediatric LS at a single hospital. Subjects were treated with fLS or rLS based on surgeon preference. Primary outcome measures were: definitive wound closure rates and time, rates of return to ambulation, number and length of procedures to achieve definitive closure, and rates of perioperative complications. Statistical analyses were performed utilizing the Wilcoxon Mann–Whitney U test with statistical significance set at p < 0.05.
Results Over a 2-year period, nine consecutive patients presented with complex extremity wounds requiring fLS (n = 4) or rLS (n = 5). Demographics and wound characteristics were similar between groups. Compared with fLS, the rLS group achieved definitive wound closure 85.8% more quickly (13.8 vs. 97.5 days, p < 0.02), required 64.5% less operative time (132.6 vs. 373.0 minutes, p < 0.02), had fewer perioperative complications (0 vs. 5), and required fewer intensive care unit stays (0 vs. 1.3 days).
Conclusion These data indicate that rLS is a safe and efficacious option in pediatric patients requiring soft tissue reconstruction for LS. Use of this novel technique can restore the reconstructive ladder, thereby expand patient access to pediatric LS while minimizing morbidity and reducing LS-related resource utilization.
Collapse
Affiliation(s)
- Fouad Saeg
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Elvira N. Chiccarelli
- Department of Pediatrics, Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana
| | - Hugo St. Hilaire
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana
| | - Frank H. Lau
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana
| |
Collapse
|
3
|
Regionalization of Isolated Pediatric Femur Fracture Treatment: Recent Trends Observed Using the Kids' Inpatient Database. J Pediatr Orthop 2020; 40:277-282. [PMID: 32501908 DOI: 10.1097/bpo.0000000000001452] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Isolated pediatric femur fractures have historically been treated at local hospitals. Pediatric referral patterns have changed in recent years, diverting patients to high volume centers. The purpose of this investigation was to assess the treatment location of isolated pediatric femur fractures and concomitant trends in length of stay and cost of treatment. METHODS A cross-sectional analysis of surgical admissions for femoral shaft fracture was performed using the 2000 to 2012 Kids' Inpatient Database. The primary outcome was hospital location and teaching status. Secondary outcomes included the length of stay and mean hospital charges. Polytrauma patients were excluded. Data were weighted within each study year to produce national estimates. RESULTS A total of 35,205 pediatric femoral fracture cases met the inclusion criteria. There was a significant shift in the treatment location over time. In 2000, 60.1% of fractures were treated at urban, teaching hospitals increasing to 81.8% in 2012 (P<0.001). Mean length of stay for all hospitals decreased from 2.59 to 1.91 days (P<0.001). Inflation-adjusted total charges increased during the study from $9499 in 2000 to $25,499 in 2012 per episode of treatment (P<0.001). Total charges per hospitalization were ∼$8000 greater at urban, teaching hospitals in 2012. CONCLUSIONS Treatment of isolated pediatric femoral fractures is regionalizing to urban, teaching hospitals. Length of stay has decreased across all institutions. However, the cost of treatment is significantly greater at urban institutions relative to rural hospitals. This trend does not consider patient outcomes but the observed pattern appears to have financial implications. LEVEL OF EVIDENCE Level III-case series, database study.
Collapse
|
4
|
Suarez‐Pierre A, Lui C, Zhou X, Fraser CD, Crawford TC, Choi CW, Whitman GJ, Higgins RS, Kilic A. Discrepancies in access and institutional risk tolerance in heart transplantation: A national open cohort study. J Card Surg 2019; 34:994-1003. [DOI: 10.1111/jocs.14179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Alejandro Suarez‐Pierre
- Department of Surgery, Division of Cardiac SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| | - Cecillia Lui
- Department of Surgery, Division of Cardiac SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| | - Xun Zhou
- Department of Surgery, Division of Cardiac SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| | - Charles D. Fraser
- Department of Surgery, Division of Cardiac SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| | - Todd C. Crawford
- Department of Surgery, Division of Cardiac SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| | - Chun W. Choi
- Department of Surgery, Division of Cardiac SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| | - Glenn J. Whitman
- Department of Surgery, Division of Cardiac SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| | - Robert S. Higgins
- Department of Surgery, Division of Cardiac SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| | - Ahmet Kilic
- Department of Surgery, Division of Cardiac SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| |
Collapse
|
5
|
Getz KD, He C, Li Y, Huang YSV, Burstein DS, Rossano J, Aplenc R. Successful merging of data from the United Network for Organ Sharing and the Pediatric Health Information System databases. Pediatr Transplant 2018; 22:e13168. [PMID: 29635813 PMCID: PMC6047917 DOI: 10.1111/petr.13168] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2018] [Indexed: 12/24/2022]
Abstract
Data routinely collected through United Network for Organ Sharing (UNOS) lack the detailed information on medical resource utilization and treatment costs required to accomplish for center-level comparisons of quality of care and cost for pediatric heart transplantation. We aimed to overcome this limitation by merging UNOS with the Pediatric Health Information System (PHIS) database, an administrative database containing inpatient, emergency department, ambulatory surgery, and observation unit information from over 40 not-for-profit, tertiary care pediatric hospitals. Utilizing a probabilistic match based on center, date of birth, recipient gender, and transplant date within ±2 days, more than 90% of eligible UNOS patients (N = 2264) were successfully merged to their corresponding PHIS records. Thirty-day and 1-year mortality rates observed for the merged cohort (3.2% and 9.0%, respectively) were compared with those previously reported for pediatric heart transplants, as were the significant predictors of increased mortality. These results demonstrate that the established UNOS-PHIS cohort will provide a valid platform for subsequent research aimed at identifying center-level differences that could be exploited to optimize quality of care while minimizing cost across institutions.
Collapse
Affiliation(s)
- Kelly D. Getz
- The Children’s Hospital of Philadelphia, Division of Oncology, 2716 South Street, Office 10291, Philadelphia, PA 19146, USA, Telephone: (267) 426-9719, Fax: (267)425-5839,
| | - Christy He
- Drexel University College of Medicine, 2900 W Queen Lane, Philadelphia, PA 19129, USA, Telephone: (610) 308-1788,
| | - Yimei Li
- The Children’s Hospital of Philadelphia, Division of Oncology, 3501 Civic Center Blvd, Philadelphia, PA 19104, USA, Telephone: (267) 425-3084,
| | - Yuan-Shung V. Huang
- The Children’s Hospital of Philadelphia, Healthcare Analytics Unit, Philadelphia, PA, USA, 2716 South Street, Philadelphia, PA 19146, USA, Telephone: (267) 426-7748,
| | - Danielle S. Burstein
- The Children’s Hospital of Philadelphia, Division of Cardiology, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA, Telephone: (215) 590-3548,
| | - Joseph Rossano
- The Children’s Hospital of Philadelphia, Division of Cardiology, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA, Telephone: (215) 590-4040,
| | - Richard Aplenc
- The Children’s Hospital of Philadelphia, Division of Oncology, 3501 Civic Center Blvd, Philadelphia, PA 19104, USA, Telephone: (267) 426-7252,
| |
Collapse
|
6
|
Influence of Transplant Center Procedural Volume on Survival Outcomes of Heart Transplantation for Children Bridged with Mechanical Circulatory Support. Pediatr Cardiol 2017; 38:280-288. [PMID: 27882424 DOI: 10.1007/s00246-016-1510-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 11/08/2016] [Indexed: 10/20/2022]
Abstract
Transplant center expertise improves survival after heart transplant (HTx) but it is unknown whether center expertise ameliorates risk associated with mechanical circulatory support (MCS) bridge to transplantation. This study investigated whether center HTx volume reduced survival disparities among pediatric HTx patients bridged with extracorporeal membrane oxygenation (ECMO), left ventricular assist device (LVAD), or no MCS. Patients ≤18 years of age receiving first-time HTx between 2005 and 2015 were identified in the United Network of Organ Sharing registry. Center volume was the total number of HTx during the study period, classified into tertiles. The primary outcome was 1 year post-transplant survival, and MCS type was interacted with center volume in Cox proportional hazards regression. The study cohort included 4131 patients, of whom 719 were supported with LVAD and 230 with ECMO. In small centers (≤133 HTx over study period), patients bridged with ECMO had increased post-transplant mortality hazard compared to patients bridged with LVAD (HR 0.29, 95% CI 0.12, 0.71; p = 0.006) and patients with no MCS (HR 0.33, 95% CI 0.19, 0.57; p < 0.001). Interactions of MCS type with medium or large center volume were not statistically significant, and the same differences in survival by MCS type were observed in medium- or large-volume centers (136-208 or ≥214 HTx over the study period). Post-HTx survival disadvantage of pediatric patients bridged with ECMO persisted regardless of transplant program volume. The role of institutional ECMO expertise outside the transplant setting for improving outcomes of ECMO bridge to HTx should be explored.
Collapse
|
7
|
|
8
|
|
9
|
McCarthy FH, McDermott KM, Spragan D, Hoedt A, Kini V, Atluri P, Gaffey A, Szeto WY, Acker MA, Desai ND. Unconventional Volume-Outcome Associations in Adult Extracorporeal Membrane Oxygenation in the United States. Ann Thorac Surg 2016; 102:489-95. [PMID: 27130248 DOI: 10.1016/j.athoracsur.2016.02.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/21/2016] [Accepted: 02/01/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND The aim of this study was to evaluate institutional volume-outcome relationships in extracorporeal membrane oxygenation (ECMO) with subanalyses of ECMO in patients with a primary diagnosis of respiratory failure. METHODS All institutions with adult ECMO discharges in the Nationwide Inpatient Sample from 2002 to 2011 were evaluated. International Classification of Diseases (ninth revision) codes were used to identify ECMO-treated patients, indications, and concurrent procedures. Patients who were treated with ECMO after cardiotomy were excluded. Annual institutional and national volume of ECMO hospitalizations varied widely, hence the number of ECMO cases performed at an institution was calculated for each year independently. Institutions were grouped into high-, medium-, and low-volume terciles by year. Statistical analysis included hierarchical, multivariable logistic regression. RESULTS The in-hospital mortality rates for ECMO admissions at low-, medium-, and high-volume ECMO centers were 48% (n = 467), 60% (n = 285), and 57% (n = 445), respectively (p = 0.001). In post hoc pairwise comparisons, patients in low-volume hospitals were more likely to survive to discharge compared with patients in medium-volume (p = 0.001) and high-volume (p = 0.005) hospitals. There was no significant difference in survival between medium-volume and high-volume hospitals (p = 0.81). In a subanalysis of patients with respiratory failure, low-volume ECMO centers maintained the lowest rates of in-hospital mortality (47%), versus 61% in medium-volume institutions (p = 0.045) and 56% in high-volume institutions (p = 0.15). Multivariable logistical regression produced similar results in the entire study sample and in patients with respiratory failure. CONCLUSIONS ECMO outcomes in the Nationwide Inpatient Sample do not follow a traditional volume-outcome relationship, and these results suggest that, in properly selected patients, ECMO can be performed with acceptable results in U.S. centers that do not perform a high volume of ECMO.
Collapse
Affiliation(s)
- Fenton H McCarthy
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
| | - Katherine M McDermott
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Danielle Spragan
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Ashley Hoedt
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Vinay Kini
- Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Ann Gaffey
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Michael A Acker
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| |
Collapse
|
10
|
Chen JM. Invited Commentary. Ann Thorac Surg 2015; 100:1431. [PMID: 26434437 DOI: 10.1016/j.athoracsur.2015.06.056] [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: 06/16/2015] [Revised: 06/16/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Jonathan M Chen
- Cardiothoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Ste 2820, Seattle, WA 98105.
| |
Collapse
|