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Kodali S, Mobley CM, Brombosz EW, Lopez A, Graves R, Ontiveros J, Velazquez M, Saharia A, Cheah YL, Simon CJ, Valverde C, Brown A, Corkrean J, Moore LW, Graviss EA, Victor DW, Maresh K, Hobeika MJ, Egwim C, Ghobrial RM. Effect of a Hispanic outreach program on referral and liver transplantation volume at a single center. Transpl Immunol 2024; 84:102034. [PMID: 38499048 DOI: 10.1016/j.trim.2024.102034] [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: 09/20/2023] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Although Hispanic patients have high rates of end-stage liver disease and liver cancer, for which liver transplantation (LT) offers the best long-term outcomes, they are less likely to receive LT. Studies of end-stage renal disease patients and kidney transplant candidates have shown that targeted, culturally relevant interventions can increase the likelihood of Hispanic patients receiving kidney transplant. However, similar interventions remain largely unstudied in potential LT candidates. METHODS Referrals to a single center in Texas with a large Hispanic patient population were compared before (01/2018-12/2019) and after (7/2021-6/2023) the implementation of a targeted outreach program. Patient progress toward LT, reasons for ineligibility, and differences in insurance were examined between the two eras. RESULTS A greater proportion of Hispanic patients were referred for LT after the implementation of the outreach program (23.2% vs 26.2%, p = 0.004). Comparing the pre-outreach era to the post-outreach era, more Hispanic patients achieved waitlisting status (61 vs 78, respectively) and received a LT (971 vs 82, respectively). However, the proportion of Hispanic patients undergoing LT dropped from 30.2% to 20.3%. In the post-outreach era, half of the Hispanic patients were unable to get LT for financial reasons (112, 50.5%). CONCLUSIONS A targeted outreach program for Hispanic patients with end-stage liver disease effectively increased the total number of Hispanic LT referrals and recipients. However, many of the patients who were referred were ineligible for LT, most frequently for financial reasons. These results highlight the need for additional research into the most effective ways to ameliorate financial barriers to LT in this high-need community.
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Affiliation(s)
- Sudha Kodali
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA; JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Constance M Mobley
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | | | - Analisa Lopez
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Riki Graves
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - John Ontiveros
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Marcela Velazquez
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Ashish Saharia
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Yee Lee Cheah
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Caroline J Simon
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Christian Valverde
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Alphonse Brown
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Julie Corkrean
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Linda W Moore
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Edward A Graviss
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA; Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - David W Victor
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA; JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Kelly Maresh
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Mark J Hobeika
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | | | - R Mark Ghobrial
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA.
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Holland AM, Mead BS, Lorenz WR, Scarola GT, Augenstein VA. Racial and Socioeconomic Disparities in Complex Abdominal Wall Reconstruction Referrals. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2024; 3:12946. [PMID: 38873344 PMCID: PMC11169567 DOI: 10.3389/jaws.2024.12946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/20/2024] [Indexed: 06/15/2024]
Abstract
Background: Health disparities are pervasive in surgical care. Particularly racial and socioeconomic inequalities have been demonstrated in emergency general surgery outcomes, but less so in elective abdominal wall reconstruction (AWR). The goal of this study was to evaluate the disparities in referrals to a tertiary hernia center. Methods: A prospectively maintained hernia database was queried for patients who underwent open ventral hernia (OVHR) or minimally invasive surgical (MISR) repair from 2011 to 2022 with complete insurance and address information. Patients were divided by home address into in-state (IS) and out-of-state (OOS) referrals as well as by operative technique. Demographic data and outcomes were compared. Standard and inferential statistical analyses were performed. Results: Of 554 patients, most were IS (59.0%); 334 underwent OVHR, and 220 underwent MISR. IS patients were more likely to undergo MISR (OVHR: 45.6% vs. 81.5%, laparoscopic: 38.2% vs. 14.1%, robotic: 16.2% vs. 4.4%; p < 0.001) when compared to OOS referrals. Of OVHR patients, 44.6% were IS and 55.4% were OOS. Patients' average age and BMI, sex, ASA score, and insurance payer were similar between IS and OOS groups. IS patients were more often Black (White: 77.9% vs. 93.5%, Black: 16.8% vs. 4.3%; p < 0.001). IS patients had more smokers (12.1% vs. 3.2%; p = 0.001), fewer recurrent hernias (45.0% vs. 69.7%; p < 0.001), and smaller defects (155.7 ± 142.2 vs. 256.4 ± 202.9 cm2; p < 0.001). Wound class, mesh type, and rate of fascial closure were similar, but IS patients underwent fewer panniculectomies (13.4% vs. 34.1%; p < 0.001), component separations (26.2% vs. 51.4%; p < 0.001), received smaller mesh (744.2 ± 495.6 vs. 975.7 ± 442.3 cm2; p < 0.001), and had shorter length-of-stay (4.8 ± 2.0 vs. 7.0 ± 5.5 days; p < 0.001). There was no difference in wound breakdown, seroma requiring intervention, hematoma, mesh infection, or recurrence; however, IS patients had decreased wound infections (2.0% vs. 8.6%; p = 0.009), overall wound complications (11.4% vs. 21.1%; p = 0.016), readmissions (2.7% vs. 13.0%; p = 0.001), and reoperations (3.4% vs. 11.4%; p = 0.007). Of MISR patients, 80.9% were IS and 19.1% were OOS. In contrast to OVHR, MISR IS and OOS patients had similar demographics, preoperative characteristics, intraoperative details, and postoperative outcomes. Conclusion: Although there were no differences in referred patients for MISR, this study demonstrates the racial disparities that exist among our IS and OOS complex, open AWR patients. Awareness of these disparities can help clinicians work towards equitable access to care and equal referrals to tertiary hernia centers.
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Affiliation(s)
| | | | | | | | - Vedra A. Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, United States
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Hasjim BJ, Huang AA, Paukner M, Polineni P, Harris A, Mohammadi M, Kershaw KN, Banea T, VanWagner LB, Zhao L, Mehrotra S, Ladner DP. Where you live matters: Area deprivation predicts poor survival and liver transplant waitlisting. Am J Transplant 2024; 24:803-817. [PMID: 38346498 PMCID: PMC11070293 DOI: 10.1016/j.ajt.2024.02.009] [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: 09/25/2023] [Revised: 01/25/2024] [Accepted: 02/08/2024] [Indexed: 03/03/2024]
Abstract
Social determinants of health (SDOH) are important predictors of poor clinical outcomes in chronic diseases, but their associations among the general cirrhosis population and liver transplantation (LT) are limited. We conducted a retrospective, multiinstitutional analysis of adult (≥18-years-old) patients with cirrhosis in metropolitan Chicago to determine the associations of poor neighborhood-level SDOH on decompensation complications, mortality, and LT waitlisting. Area deprivation index and covariates extracted from the American Census Survey were aspects of SDOH that were investigated. Among 15 101 patients with cirrhosis, the mean age was 57.2 years; 6414 (42.5%) were women, 6589 (43.6%) were non-Hispanic White, 3652 (24.2%) were non-Hispanic Black, and 2662 (17.6%) were Hispanic. Each quintile increase in area deprivation was associated with poor outcomes in decompensation (sHR [subdistribution hazard ratio] 1.07; 95% CI 1.05-1.10; P < .001), waitlisting (sHR 0.72; 95% CI 0.67-0.76; P < .001), and all-cause mortality (sHR 1.09; 95% CI 1.06-1.12; P < .001). Domains of SDOH associated with a lower likelihood of waitlisting and survival included low income, low education, poor household conditions, and social support (P < .001). Overall, patients with cirrhosis residing in poor neighborhood-level SDOH had higher decompensation, and mortality, and were less likely to be waitlisted for LT. Further exploration of structural barriers toward LT or optimizing health outcomes is warranted.
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Affiliation(s)
- Bima J Hasjim
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA
| | - Alexander A Huang
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA
| | - Mitchell Paukner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Division of Biostatistics, Department of Preventive Medicine, Northwestern University, Chicago, Illinois, USA
| | - Praneet Polineni
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA
| | - Alexandra Harris
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Institute for Public Health and Medicine (IPHAM), Northwestern University, Chicago, Illinois, USA
| | - Mohsen Mohammadi
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Department of Industrial Engineering and Management Sciences, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
| | - Kiarri N Kershaw
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Division of Epidemiology, Department of Preventive Medicine, Northwestern University, Chicago, Illinois, USA
| | - Therese Banea
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA
| | - Lisa B VanWagner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Division of Digestive and Liver Diseases, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lihui Zhao
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Division of Biostatistics, Department of Preventive Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sanjay Mehrotra
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Department of Industrial Engineering and Management Sciences, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
| | - Daniela P Ladner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Division of Organ Transplantation, Department of Surgery, Northwestern University, Chicago, Illinois, USA.
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Kakish H, Suraju MO, Seth A, DiGioia ON, Pawar O, Kwon YK, Hemming AW, Aziz H. Liver transplant versus liver resection in patients with multifocal hepatocellular carcinoma. J Gastrointest Surg 2024:S1091-255X(24)00422-0. [PMID: 38653337 DOI: 10.1016/j.gassur.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/13/2024] [Accepted: 04/19/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND The optimal surgical option in patients with multifocal hepatocellular carcinoma (MHCC) is an area of active research. The preference varies based on geographic variations and institutional policies. We sought to determine long-term outcomes in patients with MHCC based on surgical treatment-liver transplant (LT) vs resection (LR). METHODS We performed a retrospective analysis of the National Cancer Database (2004-2015) and identified patients with MHCC within Milan criteria. Patients with α-fetoprotein ≥ 1000 ng/mL and those who underwent ablation were excluded. The primary outcome measure was long-term survival in patients undergoing LT vs LR. The secondary aim of our study was to determine clinicodemographic factors associated with the receipt of LT and LR. RESULTS A total of 1546 patients were included, of whom 1211 received LT and 335 underwent LR. Patients who were non-Hispanic White (70.8% vs 54.9%; P < .01), privately insured (53.7% vs 36.7%; P < .01), and treated at academic centers (85.4% vs 71.6%; P < .01) were more likely to receive an LT. Multivariable Cox analysis revealed LT was associated with improved survival compared with LR (hazard ratio, 0.34; 95% CI, 0.28-0.42). CONCLUSION We described clinical and sociodemographic differences in LT and LR patients and found LT to be associated with a decreased mortality risk compared with LR. The study's findings should be interpreted in the context of several limitations, including the selection of MHCC criteria within Milan criteria.
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Affiliation(s)
- Hanna Kakish
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Mohammed O Suraju
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Abhinav Seth
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Olivia N DiGioia
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Omkar Pawar
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Yong K Kwon
- Department of Surgery, University of Washington, Seattle, Washington, United States
| | - Alan W Hemming
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Hassan Aziz
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States.
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Endo Y, Sasaki K, Moazzam Z, Woldesenbet S, Lima HA, Alaimo L, Munir MM, Shaikh CF, Yang J, Azap L, Katayama E, Kitago M, Schenk A, Washburn K, Pawlik TM. Liver transplantation access and outcomes: Impact of variations in liver-specific specialty care. Surgery 2024; 175:868-876. [PMID: 37743104 DOI: 10.1016/j.surg.2023.06.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/08/2023] [Accepted: 06/28/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND We sought to characterize the impact access to gastroenterologists/hepatologists has on liver transplantation listing, as well as time on the liver transplantation waitlist and post-transplant outcomes. METHODS Liver transplantation registrants aged >18 years between January 1, 2004 and December 31, 2019 were identified from the Scientific Registry of Transplant Recipients Standard Analytic Files. The liver transplantation registration ratio was defined as the ratio of liver transplant waitlist registrations in a given county per 1,000 liver-related deaths. RESULTS A total of 150,679 liver transplantation registrants were included. Access to liver transplantation centers and liver-specific specialty physicians varied markedly throughout the United States. Of note, the liver transplantation registration ratio was lower in counties with poor access to liver-specific care versus counties with adequate access (poor access 137.2, interquartile range 117.8-163.2 vs adequate access 157.6, interquartile range 127.3-192.2, P < .001). Among patients referred for liver transplantation, the cumulative incidence of waitlist mortality and post-transplant graft survival was comparable among patients with poor versus adequate access to liver-specific care (both P > .05). Among liver transplantation recipients living in areas with poor access, after controlling for recipient and donor characteristics, cold ischemic time, and model for end-stage liver disease score, the area deprivation index predicted graft survival (referent, low area deprivation index; medium area deprivation index, hazard ratio 1.52, 95% confidence interval 1.03-12.23; high area deprivation index, 1.45, 95% confidence interval 1.01-12.09, both P < .05). CONCLUSION Poor access to liver-specific care was associated with a reduction in liver transplantation registration, and individuals residing in counties with high social deprivation had worse graft survival among patients living in counties with poor access to liver-specific care.
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Affiliation(s)
- Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | | | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Chanza F Shaikh
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Jason Yang
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Lovette Azap
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Minoru Kitago
- Department of Surgery, Keio University, Tokyo, Japan
| | - Austin Schenk
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Kenneth Washburn
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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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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Hendele JB, Nichols JT, Vutien P, Perkins JD, Reyes J, Dick AAS. A retrospective cohort study of socioeconomic deprivation and post-liver transplant survival in adults. Liver Transpl 2024:01445473-990000000-00321. [PMID: 38289266 DOI: 10.1097/lvt.0000000000000337] [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: 10/20/2023] [Accepted: 01/12/2024] [Indexed: 05/08/2024]
Abstract
The Area Deprivation Index is a granular measure of neighborhood socioeconomic deprivation. The relationship between neighborhood socioeconomic deprivation and recipient survival following liver transplantation (LT) is unclear. To investigate this, the authors performed a retrospective cohort study of adults who underwent LT at the University of Washington Medical Center from January 1, 2004, to December 31, 2020. The primary exposure was a degree of neighborhood socioeconomic deprivation as determined by the Area Deprivation Index score. The primary outcome was posttransplant recipient mortality. In a multivariable Cox proportional analysis, LT recipients from high-deprivation areas had a higher risk of mortality than those from low-deprivation areas (HR: 1.81; 95% CI: 1.03-3.18, p =0.04). Notably, the difference in mortality between area deprivation groups did not become statistically significant until 6 years after transplantation. In summary, LT recipients experiencing high socioeconomic deprivation tended to have worse posttransplant survival. Further research is needed to elucidate the extent to which neighborhood socioeconomic deprivation contributes to mortality risk and identify effective measures to improve survival in more socioeconomically disadvantaged LT recipients.
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Affiliation(s)
- James B Hendele
- Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington, USA
| | - Jordan T Nichols
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Philip Vutien
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington, USA
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - James D Perkins
- Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington, USA
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington, USA
| | - Jorge Reyes
- Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington, USA
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington, USA
| | - André A S Dick
- Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington, USA
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, Washington, USA
- Department of Surgery, Division of Transplant Surgery, University of Washington, Section of Pediatric Transplant Surgery, Seattle Children's Hospital, Seattle, Washington, USA
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Cullaro G, Ge J, Lee BP, Lai JC, Wadhwani SI. Association between neighborhood-based material deprivation and liver transplant waitlist registrants demographics and mortality. Clin Transplant 2024; 38:e15189. [PMID: 37937349 PMCID: PMC10842435 DOI: 10.1111/ctr.15189] [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: 04/24/2023] [Revised: 09/29/2023] [Accepted: 10/28/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND & AIMS Liver transplantation for alcohol-related liver disease (ARLD) has increased. We examined temporal trends in ARLD listing practices by neighborhood deprivation and evaluated the impact of neighborhood deprivation on waitlist mortality. METHODS We included all adults > 18 years listed 2008-2019 in the UNOS registry. Our primary exposure was the neighborhood socioeconomic deprivation index based on patients' listing zip codes. We determined temporal trends in an ARLD listing diagnosis. We modeled ARLD listing diagnosis using logistic regression and waitlist mortality using Cox proportional hazards models. RESULTS The waitlist contained an increasing proportion of patients listed with ARLD over the study period; however, this rate increased the least for patients from the most deprived tertile (p < .001). Patients from the most deprived tertile were the least likely to be listed with ARLD (OR: .97, 95CI: .95-.98). In our adjusted model, patients from the most deprived tertile had an increased hazard of waitlist mortality (OR: 1.10, 95CI: 1.06-1.14). CONCLUSION Neighborhood deprivation was associated with a decreased likelihood of being listed with ARLD, suggesting that transplant for ARLD is inequitably available. The increased mortality associated with neighborhood deprivation demands future work to uncover the underlying reasons for this disparity.
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Affiliation(s)
- Giuseppe Cullaro
- Division of Gastroenterology, University of California, San Francisco, CA, USA
| | - Jin Ge
- Division of Gastroenterology, University of California, San Francisco, CA, USA
| | - Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, CA, USA
| | - Jennifer C. Lai
- Division of Gastroenterology, University of California, San Francisco, CA, USA
| | - Sharad I Wadhwani
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, 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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10
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Saberi B, Gurakar A, Tamim H, Schneider CV, Sims OT, Bonder A, Fricker Z, Alqahtani SA. Racial Disparities in Candidates for Hepatocellular Carcinoma Liver Transplant After 6-Month Wait Policy Change. JAMA Netw Open 2023; 6:e2341096. [PMID: 37917059 PMCID: PMC10623194 DOI: 10.1001/jamanetworkopen.2023.41096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/21/2023] [Indexed: 11/03/2023] Open
Abstract
Importance Racial disparities in liver transplant (LT) for hepatocellular carcinoma (HCC) may be associated with unequal access to life-saving treatment. Objective To quantify racial disparities in LT for HCC and mortality after LT, adjusting for demographic, clinical, and socioeconomic factors. Design, Setting, and Participants This cohort study was a retrospective analysis of United Network Organ Sharing/Organ Procurement Transplant Network (OPTN) data from 2003 to 2021. Participants were adult patients with HCC on the LT waiting list and those who received LT. Data were analyzed from March 2022 to September 2023. Exposures Race and time before and after the 2015 OPTN policy change. Main Outcomes and Measures Proportion of LT from wait-listed candidates, the proportion of waiting list removals, and mortality after LT. Results Among 12 031 patients wait-listed for LT with HCC (mean [SD] age, 60.8 [7.4] years; 9054 [75.3%] male; 7234 [60.1%] White, 2590 [21.5%] Latinx/o/a, and 1172 [9.7%] Black or African American), this study found that after the 2015 model of end-stage liver disease (MELD) exception policy changes for HCC (era 2), the overall proportion of LT for HCC across all races decreased while the proportion of dropouts on the LT waiting list remained steady compared with patients who did not have HCC. In Kaplan-Meier analysis, Asian patients demonstrated the lowest dropout rates in both era 1 and era 2 (1-year dropout, 16% and 17%, respectively; P < .001). In contrast, Black or African American patients had the highest dropout rates in era 1 (1-year dropout, 24%), but comparable dropout rates (23%) with White patients (23%) and Latinx/o/a patients in era 2 (23%). In both eras, Asian patients had the highest survival after LT (5-year survival, 82% for era 1 and 86% for era 2), while Black or African American patients had the worst survival after LT (5-year survival, 71% for era 1 and 79% for era 2). In the multivariable analysis for HCC LT recipients, Black or African American race was associated with increased risk of mortality in both eras, compared with White race (HR for era 1, 1.17; 95% CI, 1.05-1.35; and HR for era 2, 1.31; 95% CI, 1.10-1.56). Conclusions and Relevance This cohort study of LT candidates in the US found that after the 2015 MELD exception policy change for HCC, the proportion of LT for HCC had decreased for all races. Black or African American patients had worse outcomes after LT than other races. Further research is needed to identify the underlying causes of this disparity and develop strategies to improve outcomes for HCC LT candidates.
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Affiliation(s)
- Behnam Saberi
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ahmet Gurakar
- Johns Hopkins University, Division of Gastroenterology and Hepatology, Baltimore, Maryland
| | - Hani Tamim
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Carolin V. Schneider
- Department of Internal Medicine III, Rheinisch Westfälisch Technische Hochschule Aachen University, Aachen, Germany
| | - Omar T. Sims
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Alan Bonder
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Zachary Fricker
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Saleh A. Alqahtani
- Johns Hopkins University, Division of Gastroenterology and Hepatology, Baltimore, Maryland
- Liver Transplant Center, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
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11
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Henson JB, Chan NW, Wilder JM, Muir AJ, McElroy LM. Characterization of social determinants of health of a liver transplant referral population. Liver Transpl 2023; 29:1161-1171. [PMID: 36929783 PMCID: PMC10509317 DOI: 10.1097/lvt.0000000000000127] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/07/2023] [Indexed: 03/18/2023]
Abstract
Disparities exist in referral and access to the liver transplant (LT) waitlist, and social determinants of health (SDOH) are increasingly recognized as important factors driving health inequities, including in LT. The SDOH of potential transplant candidates is therefore important to characterize when designing targeted interventions to promote equity in access to LT. Yet, it is uncertain how a transplant center should approach this issue, characterize SDOH, identify disparities, and use these data to inform interventions. We performed a retrospective study of referrals for first-time, single-organ LT to our center from 2016 to 2020. Addresses were geoprocessed and mapped to the corresponding county, census tract, and census block group to assess their geospatial distribution, identify potential disparities in referrals, and characterize their communities across multiple domains of SDOH to identify potential barriers to evaluation and selection. We identified variability in referral patterns and areas with disproportionately low referrals, including counties in the highest quartile of liver disease mortality (9%) and neighborhoods in the highest quintile of socioeconomic deprivation (17%) and quartile of poverty (21%). Black individuals were also under-represented compared with expected state demographics (12% vs. 18%). Among the referral population, several potential barriers to evaluation and selection for LT were identified, including poverty, educational attainment, access to healthy food, and access to technology. This approach to the characterization of a transplant center's referral population by geographic location and associated SDOH demonstrates a model for identifying disparities in a referral population and potential barriers to evaluation that can be used to inform targeted interventions for disparities in LT access.
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Affiliation(s)
- Jacqueline B Henson
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Norine W Chan
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Julius M Wilder
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Lisa M McElroy
- Division of Abdominal Transplant, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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12
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Endo Y, Sasaki K, Munir MM, Woldesenbet S, Resende V, Rawicz-Pruszyński K, Waqar U, Mavani P, Katayama E, Yang J, Khalil M, Khan MMM, Kitago M, Pawlik TM. Survival Benefit Relative to Treatment Modalities Among Patients with Very Early Intrahepatic Cholangiocarcinoma: an Analysis of the National Cancer Database. J Gastrointest Surg 2023; 27:2103-2113. [PMID: 37674099 DOI: 10.1007/s11605-023-05821-7] [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: 07/19/2023] [Accepted: 08/19/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Liver transplantation (LT) has been considered a potential curative treatment for patients with very early intrahepatic cholangiocarcinoma (ICC) and cirrhosis, yet the survival benefit of LT has not been well defined. This study aimed to compare the long-term survival outcomes of patients who underwent LT with that of individuals who received resection and non-curative intent treatment (non-CIT). METHODS Patients who underwent LT, hepatectomy, and non-CIT between 2004 and 2018 were included in the National Cancer Database. Survival benefits of LT over resection and non-CIT were analyzed relative to overall survival (OS). RESULTS Among 863 patients, 54 (6.3%) underwent LT, while 342 (39.6%) underwent surgical resection, and 467 (54.1%) received non-CIT, respectively. While the rates of non-CIT increased over time, the percentages of LT remained consistent during the study period. LT patients had similar 5-year OS to individuals who underwent resection (referent, resection: LT, HR 0.95, 95%CI 0.84-1.58, p=0.84). In contrast, 5-year OS was better among patients who underwent LT versus individuals who had non-CIT after controlling other variables using propensity score overlapping weighting (5-year OS, LT 57.1% vs. LR 25.8%, p<0.001). CONCLUSIONS The outcomes of very early ICC patients who underwent LT were similar to individuals who underwent hepatectomy, but better than patients treated with non-CIT. LT should be may be a consideration as a treatment option for patients with early stage ICC who are unsuitable candidates for resection.
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Affiliation(s)
- Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Kazunari Sasaki
- Department of Surgery, Stanford University, Palo Alto, CA, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Vivian Resende
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Karol Rawicz-Pruszyński
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland
| | - Usama Waqar
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Parit Mavani
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jason Yang
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Muntazir Mehdi Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Minoru Kitago
- Department of Surgery, Keio University, Tokyo, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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13
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Ross-Driscoll K, Gunasti J, Ayuk-Arrey AT, Adler JT, Axelrod D, McElroy L, Patzer RE, Lynch R. Identifying and understanding variation in population-based access to liver transplantation in the United States. Am J Transplant 2023; 23:1401-1410. [PMID: 37302576 PMCID: PMC10529375 DOI: 10.1016/j.ajt.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/04/2023] [Accepted: 06/02/2023] [Indexed: 06/13/2023]
Abstract
We aimed to identify variations in liver transplant access across transplant referral regions (TRRs), accounting for differences in population characteristics and practice environments. Adult end-stage liver disease (ESLD) deaths and liver waitlist additions from 2015 to 2019 were included. The primary outcome was listing-to-death ratio (LDR). We modeled the LDR as a continuous variable and obtained adjusted LDR estimates for each TRR, accounting for clinical and demographic characteristics of ESLD decedents, socioeconomic and health care environment within the TRR, and characteristics of the transplant environment. The overall mean LDR was 0.24 (range: 0.10-0.53). In the final model, proportion of patients living in poverty and concentrated poverty was negatively associated with LDR; organ donation rate was positively associated with LDR. The R2 was 0.60, indicating that 60% of the variability in LDR was explained by the model. Approximately 40% of this variation remained unexplained and may be due to transplant center behaviors amenable to intervention to improve access to care for patients with ESLD.
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Affiliation(s)
- Katie Ross-Driscoll
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Jonathan Gunasti
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arrey-Takor Ayuk-Arrey
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joel T Adler
- Division of Abdominal Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
| | - David Axelrod
- Solid Organ Transplant Center, Department of Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Lisa McElroy
- Division of Abdominal Transplantation, Department of Surgery and Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Raymond Lynch
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
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14
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Handzel RM, Huckaby LV, Dadashzadeh ER, Silver D, Rieser C, Sivagnanalingam U, Rosengart MR, van der Windt DJ. Sex, race, and socioeconomic distinctions in incisional hernia management. Am J Surg 2023; 226:202-206. [PMID: 37032236 DOI: 10.1016/j.amjsurg.2023.04.001] [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: 01/12/2023] [Revised: 03/16/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND We sought to explore the impact of sex, race, and insurance status on operative management of incisional hernias. METHODS A retrospective cohort study was conducted to explore adult patients diagnosed with an incisional hernia. Adjusted odds for non-operative versus operative management and time to repair were queried. RESULTS Of the 29,475 patients with an incisional hernia, 20,767 (70.5%) underwent non-operative management. In relation to private insurance, Medicaid (aOR 1.40, 95% CI 1.27-1.54), Medicare (aOR 1.53, 95% CI 1.42-1.65), and uninsured status (aOR 1.99, 95% CI 1.71-2.36) were independently associated with non-operative management. African American race (aOR 1.30, 95% CI 1.17-1.47) was associated with non-operative management while female sex (aOR 0.81, 95% CI 0.77-0.86) was predictive of elective repair. For patients who underwent elective repair, both Medicare (aOR 1.40, 95% CI 1.18-1.66) and Medicaid (aOR 1.49, 95% CI 1.29-1.71) insurance, but not race, were predictive of delayed repair (>90 days after diagnosis). CONCLUSIONS Sex, race, and insurance status influence incisional hernia management. Development of evidence-based management guidelines may help to ensure equitable care.
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Affiliation(s)
- Robert M Handzel
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Lauren V Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Esmaeel R Dadashzadeh
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - David Silver
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Caroline Rieser
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Pittsburgh Surgical Outcomes Research Center (PittSORCe), University of Pittsburgh, Pittsburgh, PA, USA
| | - Dirk J van der Windt
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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15
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Johnson WR, Rega SA, Feurer ID, Karp SJ. Associations between social determinants of health and abdominal solid organ transplant wait-lists in the United States. Clin Transplant 2022; 36:e14784. [PMID: 35894259 DOI: 10.1111/ctr.14784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 07/07/2022] [Accepted: 07/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Societal factors that influence wait-listing for transplantation are complex and poorly understood. Social determinants of health (SDOH) affect rates of and outcomes after transplantation. METHODS This cross-sectional study investigated the impact of SDOH on additions to state-level, 2017-2018 kidney and liver wait-lists. Principal components analysis, starting with 127 variables among 3142 counties, was used to derive novel, comprehensive state-level composites, designated (1) health/economics and (2) community capital/urbanicity. Stepwise multivariate linear regression with backwards elimination (n = 51; 50 states and DC) tested the effects of these composites, Medicaid expansion, and center density on adult disease burden-adjusted wait-list additions. RESULTS SDOH related to increased community capital/urbanicity were independently associated with wait-listing (starting models: B = .40, P = .010 Kidney; B = .36, P = .038 Liver) (final models: B = .31, P = .027 Kidney, B = .34, P = .015 Liver). In contrast and surprisingly, no other covariates were associated with wait-listing (P ≥ .122). CONCLUSIONS These results suggest that deficits in community resources are important contributors to disparities in wait-list access. Our composite SDOH metrics may help identify at-risk communities, which can be the focus of local and national policy initiatives to improve access to organ transplantation.
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Affiliation(s)
- Wali R Johnson
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott A Rega
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Irene D Feurer
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Seth J Karp
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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16
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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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17
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Schappe T, Peskoe S, Bhavsar N, Boulware LE, Pendergast J, McElroy LM. Geospatial Analysis of Organ Transplant Referral Regions. JAMA Netw Open 2022; 5:e2231863. [PMID: 36107423 PMCID: PMC9478781 DOI: 10.1001/jamanetworkopen.2022.31863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
IMPORTANCE System and center-level interventions to improve health equity in organ transplantation benefit from robust characterization of the referral population served by each transplant center. Transplant referral regions (TRRs) define geographic catchment areas for transplant centers in the US, but accurately characterizing the demographics of populations within TRRs using US Census data poses a challenge. OBJECTIVE To compare 2 methods of linking US Census data with TRRs-a geospatial intersection method and a zip code cross-reference method. DESIGN, SETTING, AND PARTICIPANTS This cohort study compared spatial congruence of spatial intersection and zip code cross-reference methods of characterizing TRRs at the census block level. Data included adults aged 18 years and older on the waiting list for kidney transplant from 2008 through 2018. EXPOSURES End-stage kidney disease. MAIN OUTCOMES AND MEASURES Multiple assignments, where a census tract or block group crossed the boundary between 2 hospital referral regions and was assigned to multiple different TRRs; misassigned area, the portion of census tracts or block groups assigned to a TRR using either method but fall outside of the TRR boundary. RESULTS In total, 102 TRRs were defined for 238 transplant centers. The zip code cross-reference method resulted in 4627 multiple-assigned census block groups (representing 18% of US land area assigned to TRRs), while the spatial intersection method eliminated this problem. Furthermore, the spatial method resulted in a mean and median reduction in misassigned area of 65% and 83% across all TRRs, respectively, compared with the zip code cross-reference method. CONCLUSIONS AND RELEVANCE In this study, characterizing populations within TRRs with census block groups provided high spatial resolution, complete coverage of the country, and balanced population counts. A spatial intersection approach avoided errors due to duplicative and incorrect assignments, and allowed more detailed and accurate characterization of the sociodemographics of populations within TRRs; this approach can enrich transplant center knowledge of local referral populations, assist researchers in understanding how social determinants of health may factor into access to transplant, and inform interventions to improve heath equity.
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Affiliation(s)
- Tyler Schappe
- Duke University, School of Medicine, Durham, North Carolina
| | - Sarah Peskoe
- Duke University, School of Medicine, Durham, North Carolina
| | - Nrupen Bhavsar
- Duke University, School of Medicine, Durham, North Carolina
| | | | | | - Lisa M McElroy
- Duke University, School of Medicine, Durham, North Carolina
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18
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Ending Disparities in Liver Transplantation: The Time to Act Is Now. Am J Gastroenterol 2022; 117:1181-1183. [PMID: 35926487 DOI: 10.14309/ajg.0000000000001827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/29/2022] [Indexed: 12/11/2022]
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19
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A scoping review of inequities in access to organ transplant in the United States. Int J Equity Health 2022; 21:22. [PMID: 35151327 PMCID: PMC8841123 DOI: 10.1186/s12939-021-01616-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/24/2021] [Indexed: 02/06/2023] Open
Abstract
Background Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research. Methods We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes. Results Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant. Conclusions This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01616-x.
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20
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Huang DC, Fricker ZP, Alqahtani S, Tamim H, Saberi B, Bonder A. The influence of equitable access policies and socioeconomic factors on post-liver transplant survival. EClinicalMedicine 2021; 41:101137. [PMID: 34585128 PMCID: PMC8452797 DOI: 10.1016/j.eclinm.2021.101137] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/27/2021] [Accepted: 09/03/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Survival following liver transplant (LT) is influenced by a variety of factors, including donor risk factors and recipient disease burden and co-morbidities. It is difficult to separate these effects from those of socioeconomic factors, such as income or insurance. The United Network for Organ Sharing (UNOS) created equitable access policies, such as Share 35, to ensure that organs are distributed to individuals with greatest medical need; however, the effect of Share 35 on disparities in post-LT survival is not clear. This study aimed to (1) characterize associations between post-transplant survival and race and ethnicity, income, insurance, and citizenship status, when adjusted for other clinical and demographic factors that may influence survival, and (2) determine if the direction of associations changed after Share 35. METHODS A retrospective, cohort study of adult LT recipients (n = 83,254) from the UNOS database from 2005 to 2019 was conducted. Kaplan-Meier survival graphs and stepwise multivariate cox-regression analyses were performed to characterize the effects of socioeconomic status on post-LT survival, adjusted for recipient and donor characteristics, across the time period and after Share 35. FINDINGS Male sex (HR: 0.93 (95% CI: 0.90-0.96)), private insurance (0.91 (0.88-0.94)), income (0.82 (0.79-0.85)), U.S. citizenship, and Asian (0.81 (0.75-0.88)) or Hispanic (0.82 (0.79-0.86)) race and ethnicity were associated with higher post-transplant survival, after adjustment for clinical and demographic factors (Table 3). These associations were found across the entire time period studied and many persisted after the implementation of Share 35 in 2013 (Table 3; male sex (0.84 (0.79-0.90)), private insurance (0.94 (0.89-1.00)), income (0.82 (0.77-0.89)), and Asian (0.87 (0.73-1.02)) or Hispanic (0.88 (0.81-0.96)) race and ethnicity). INTERPRETATION Recipients' socioeconomic factors at time of transplant may impact long-term post-transplant survival, and a single policy may not significantly alter these structural health inequalities. FUNDING None.
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Key Words
- DDLT, deceased donor living transplant
- DM, diabetes mellitus
- DRI, donor risk index
- HCC, hepatocellular carcinoma
- HCV, hepatitis c virus
- HE, hepatic encephalopathy
- Health disparities
- IQR, interquartile range
- IRB, institutional review board
- LT, liver transplant
- Liver transplant
- MELD, Model for End-Stage Liver Disease
- NAFLD, Non-alcoholic fatty liver disease
- OPTN, Organ Procurement and Transplantation Network
- STAR, Standard Transplant Analysis and Research
- Socioeconomic factors
- UNOS, United Network for Organ Sharing
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Affiliation(s)
- Dora C Huang
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States
| | - Zachary P Fricker
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Saleh Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Behnam Saberi
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Alan Bonder
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
- Corresponding author.
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21
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Niazi SK, Vargas E, Spaulding A, Crook J, Keaveny AP, Schneekloth T, Rummans T, Taner CB. Impact of County Health Rankings on Nationwide Liver Transplant Outcomes. Transplantation 2021; 105:2411-2419. [PMID: 33239542 DOI: 10.1097/tp.0000000000003557] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is limited information concerning whether social determinants of health affect postliver transplant (LT) outcomes. This study aims to understand to what extent the health of LT recipients' counties of residence influence long-term LT outcomes. METHODS We used the United Network for Organ Sharing data to identify adult LT recipients transplanted between January 2010 and June 2018. Patient-level data were matched to county-level County Health Ranking (CHR) data using transplant recipient zip code, and nationwide CHRs were created. Mixed-effects Cox proportional hazards models were used to examine associations between CHRs and graft and patient survival post-LT. RESULTS Health outcomes rank was significantly associated with posttransplant graft and patient survival, with worst tertile counties showing a 13% increased hazard of both graft failure and patient mortality compared to the best tertile counties. CONCLUSIONS Although county health is associated with LT outcomes, it also appears that LT recipient selection is effective at mitigating major disparities based on county of residence and helps yield equitable outcomes in this respect.
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Affiliation(s)
- Shehzad K Niazi
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL
| | - Emily Vargas
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Aaron Spaulding
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Julia Crook
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | | | | | - Teresa Rummans
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN
| | - C Burcin Taner
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
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22
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Feng Y, Jones MR, Ahn JB, Garonzik-Wang JM, Segev DL, McAdams-DeMarco M. Ambient air pollution and posttransplant outcomes among kidney transplant recipients. Am J Transplant 2021; 21:3333-3345. [PMID: 33870639 PMCID: PMC8500923 DOI: 10.1111/ajt.16605] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/16/2021] [Accepted: 04/03/2021] [Indexed: 01/25/2023]
Abstract
Fine particulate matter (PM2.5 ), a common form of air pollution which can induce systemic inflammatory response, is a risk factor for adverse health outcomes. Kidney transplant (KT) recipients are likely vulnerable to PM2.5 due to comorbidity and chronic immunosuppression. We sought to quantify the association between PM2.5 and post-KT outcomes. For adult KT recipients (1/1/2010-12/31/2016) in the Scientific Registry of Transplant Recipients, we estimated annual zip-code level PM2.5 concentrations at the time of KT using NASA's SEDAC Global PM2.5 Grids. We determined the associations between PM2.5 and delayed graft function (DGF) and 1-year acute rejection using logistic regression and death-censored graft failure (DCGF) and mortality using Cox proportional hazard models. All models were adjusted for sociodemographics, recipient, transplant, and ZIP code level confounders. Among 87 233 KT recipients, PM2.5 was associated with increased odds of DGF (OR = 1.59; 95% CI: 1.48-1.71) and 1-year acute rejection (OR = 1.31; 95% CI: 1.17-1.46) and increased risk of all-cause mortality (HR = 1.15; 95% CI: 1.07-1.23) but not DCGF (HR = 1.05; 95% CI: 0.97-1.51). In conclusion, PM2.5 was associated with higher odds of DGF and 1-year acute rejection and elevated risk of mortality among KT recipients. Our study highlights the importance of considering environmental exposure as risk factors for post-KT outcomes.
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Affiliation(s)
- Yijing Feng
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miranda R. Jones
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - JiYoon B. Ahn
- 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 Bloomberg School of Public Health, Baltimore, MD
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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23
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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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24
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Hung YC, Chen YW, Rickert CG, Hsu YT, Yeh H, Chang DC. Practitioner availability rather than surgical quality impacts the utilization of liver transplantation for hepatocellular carcinoma. HPB (Oxford) 2021; 23:861-867. [PMID: 33579641 DOI: 10.1016/j.hpb.2020.12.012] [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: 05/29/2020] [Revised: 12/05/2020] [Accepted: 12/27/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver transplantation (LT) provides better outcome than surgical resection (SR) although both are acceptable surgical options for hepatocellular carcinoma (HCC). It is unclear whether non-clinical factors drive treatment decisions. Our goal is to identify factors that may affect treatment decisions. METHODS Patients aged 18-74 with T2 HCC undergoing either LT or SR in Surveillance, Epidemiology, and End Results Database from 2004 to 2014 were included. Healthcare resources data were analyzed to assess factors that predict utilization of LT versus SR, adjusted for demographic, clinical outcomes, and socioeconomic factors. RESULTS 51% of patients (Total N = 2616) received LT, with a substantial state-level variation in LT rates (0.0%-66.9%). Higher LT center density [OR = 1.04 per 1% increment, P < 0.01], male gender (OR = 1.38, P = 0.02), and numbers of potential donors (OR = 1.19, P = 0.03) were positively associated with LT utilization. Conversely, higher incidence of chronic liver disease/cirrhosis (OR = 0.41 per one additional case per 100,000 populations, P = 0.001) and minority populations were negatively correlated with LT utilization. Notably, short-term surgical outcomes (in-hospital LT & SR mortality) were not associated with LT utilization. CONCLUSION Liver transplant center density and organ availability, but not surgical outcomes, affect utilization of LT. Future studies should focus on increasing availability of resources.
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Affiliation(s)
- Ya-Ching Hung
- Sinai Hospital of Baltimore, Baltimore, MD, USA; Department of Surgery, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA.
| | - Ya-Wen Chen
- Department of Surgery, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
| | - Charles G Rickert
- Department of Surgery, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
| | - Yu-Tien Hsu
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, USA
| | - Heidi Yeh
- Department of Surgery, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
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25
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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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26
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Nitski O, Azhie A, Qazi-Arisar FA, Wang X, Ma S, Lilly L, Watt KD, Levitsky J, Asrani SK, Lee DS, Rubin BB, Bhat M, Wang B. Long-term mortality risk stratification of liver transplant recipients: real-time application of deep learning algorithms on longitudinal data. LANCET DIGITAL HEALTH 2021; 3:e295-e305. [PMID: 33858815 DOI: 10.1016/s2589-7500(21)00040-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 02/06/2021] [Accepted: 02/17/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Survival of liver transplant recipients beyond 1 year since transplantation is compromised by an increased risk of cancer, cardiovascular events, infection, and graft failure. Few clinical tools are available to identify patients at risk of these complications, which would flag them for screening tests and potentially life-saving interventions. In this retrospective analysis, we aimed to assess the ability of deep learning algorithms of longitudinal data from two prospective cohorts to predict complications resulting in death after liver transplantation over multiple timeframes, compared with logistic regression models. METHODS In this machine learning analysis, model development was done on a set of 42 146 liver transplant recipients (mean age 48·6 years [SD 17·3]; 17 196 [40·8%] women) from the Scientific Registry of Transplant Recipients (SRTR) in the USA. Transferability of the model was further evaluated by fine-tuning on a dataset from the University Health Network (UHN) in Canada (n=3269; mean age 52·5 years [11·1]; 1079 [33·0%] women). The primary outcome was cause of death, as recorded in the databases, due to cardiovascular causes, infection, graft failure, or cancer, within 1 year and 5 years of each follow-up examination after transplantation. We compared the performance of four deep learning models against logistic regression, assessing performance using the area under the receiver operating characteristic curve (AUROC). FINDINGS In both datasets, deep learning models outperformed logistic regression, with the Transformer model achieving the highest AUROCs in both datasets (p<0·0001). The AUROC for the Transformer model across all outcomes in the SRTR dataset was 0·804 (99% CI 0·795-0·854) for 1-year predictions and 0·733 (0·729-0·769) for 5-year predictions. In the UHN dataset, the AUROC for the top-performing deep learning model was 0·807 (0·795-0·842) for 1-year predictions and 0·722 (0·705-0·764) for 5-year predictions. AUROCs ranged from 0·695 (0·680-0·713) for prediction of death from infection within 5 years to 0·859 (0·847-0·871) for prediction of death by graft failure within 1 year. INTERPRETATION Deep learning algorithms can incorporate longitudinal information to continuously predict long-term outcomes after liver transplantation, outperforming logistic regression models. Physicians could use these algorithms at routine follow-up visits to identify liver transplant recipients at risk for adverse outcomes and prevent these complications by modifying management based on ranked features. FUNDING Canadian Donation and Transplant Research Program, CIFAR AI Chairs Program.
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Affiliation(s)
- Osvald Nitski
- Faculty of Applied Science and Engineering, University of Toronto, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Amirhossein Azhie
- Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Fakhar Ali Qazi-Arisar
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada; Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Xueqi Wang
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Shihao Ma
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
| | - Leslie Lilly
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Kymberly D Watt
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Josh Levitsky
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Douglas S Lee
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada; Ted Rogers Centre for Heart Research, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Barry B Rubin
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Mamatha Bhat
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Division of Gastroenterology & Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada; Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Bo Wang
- Department of Computer Science, University of Toronto, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada; Vector Institute, Toronto, ON, Canada.
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27
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Ross-Driscoll K, Kramer M, Lynch R, Plantinga L, Wedd J, Patzer R. Variation in Racial Disparities in Liver Transplant Outcomes Across Transplant Centers in the United States. Liver Transpl 2021; 27:558-567. [PMID: 37160041 PMCID: PMC8201428 DOI: 10.1002/lt.25918] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
Little is known about the role that transplant centers may play in perpetuating racial disparities after liver transplantation, which are unexplained by patient-level factors. We examined variation in between-center and within-center disparities among 34,114 Black and White liver transplant recipients in the United States from 2010 to 2017 using Scientific Registry of Transplant Recipient (SRTR) data. We used Cox proportional hazards models to calculate transplant center-specific Black-White hazard ratios and hierarchical survival analysis to examine potential effect modification of the race-survival association by transplant center characteristics, including transplant volume, proportion of Black patients, SRTR quality rating, and region. Models were sequentially adjusted for clinical, socioeconomic, and center characteristics. After adjustment, Black patients experienced 1.11 excess deaths after liver transplant per 100 person-years compared with White patients (95% confidence interval [CI], 0.65-1.56), corresponding to a 21% increased mortality risk (95% CI, 1.12-1.31). Although there was substantial variation in this disparity across transplant centers, there was no evidence of effect modification by transplant center volume, proportion of minority patients seen, quality rating, or region. We found significant racial disparities in survival after transplant, with substantial variation in this disparity across transplant centers that was not explained by selected center characteristics. This is the first study to directly evaluate the role transplant centers play in racial disparities in transplant outcomes. Further assessment of the qualitative factors that may drive disparities, such as selection processes and follow-up care, is needed to create effective center-level interventions to address health inequity.
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Affiliation(s)
- Katherine Ross-Driscoll
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Center for Health Services Research, Emory University School of Medicine, Atlanta, GA
| | - Michael Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Raymond Lynch
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Laura Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Joel Wedd
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Rachel Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Center for Health Services Research, Emory University School of Medicine, Atlanta, GA,Department of Surgery, Emory University School of Medicine, Atlanta, GA,Department of Medicine, Emory University School of Medicine, Atlanta, GA
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28
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Rieser CJ, Hoehn RS, Zenati M, Hall LB, Kang E, Zureikat AH, Lee A, Ongchin M, Holtzman MP, Pingpank JF, Bartlett DL, Choudry MHA. Impact of Socioeconomic Status on Presentation and Outcomes in Colorectal Peritoneal Metastases Following Cytoreduction and Chemoperfusion: Persistent Inequalities in Outcomes at a High-Volume Center. Ann Surg Oncol 2021; 28:3522-3531. [PMID: 33687614 PMCID: PMC8184539 DOI: 10.1245/s10434-021-09627-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS HIPEC) can offer significant survival advantage for select patients with colorectal peritoneal metastases (CRPM). Low socioeconomic status (SES) is implicated in disparities in access to care. We analyze the impact of SES on postoperative outcomes and survival at a high-volume tertiary CRS HIPEC center. PATIENTS AND METHODS We conducted a retrospective cohort study examining patients who underwent CRS HIPEC for CRPM from 2000 to 2018. Patients were grouped according to SES. Baseline characteristics, perioperative outcomes, and survival were examined between groups. RESULTS A total of 226 patients were analyzed, 107 (47%) low-SES and 119 (53%) high-SES patients. High-SES patients were younger (52 vs. 58 years, p = 0.01) and more likely to be White (95.0% vs. 91.6%, p = 0.06) and privately insured (83% vs. 57%, p < 0.001). They traveled significantly further for treatment and had lower burden of comorbidities and frailty (p = 0.01). Low-SES patients more often presented with synchronous peritoneal metastases (48% vs. 35%, p = 0.05). Following CRS HIPEC, low-SES patients had longer length of stay and higher burden of postoperative complications, 90-day readmission, and 30-day mortality. Median overall survival following CRS HIPEC was worse for low-SES patients (17.8 vs. 32.4 months, p = 0.02). This disparity persisted on multivariate survival analysis (low SES: HR = 1.46, p = 0.03). CONCLUSIONS Despite improving therapies for CRPM, low-SES patients remain at a significant disadvantage. Even patients who overcome barriers to care experience worse short- and long-term outcomes. Improving access and addressing these disparities is crucial to ensure equitable outcomes and improve patient care.
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Affiliation(s)
- Caroline J Rieser
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA.
| | - Richard S Hoehn
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Mazen Zenati
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Lauren B Hall
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Eliza Kang
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Andrew Lee
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Melanie Ongchin
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Matthew P Holtzman
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - James F Pingpank
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - David L Bartlett
- AHN Cancer Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - M Haroon A Choudry
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
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Hoehn RS, Rieser CJ, Winters S, Stitt L, Hogg ME, Bartlett DL, Lee KK, Paniccia A, Ohr JP, Gorantla VC, Krishnamurthy A, Rhee JC, Bahary N, Olson AC, Burton S, Ellsworth SG, Slivka A, McGrath K, Khalid A, Fasanella K, Chennat J, Brand RE, Das R, Sarkaria R, Singhi AD, Zeh HJ, Zureikat AH. A Pancreatic Cancer Multidisciplinary Clinic Eliminates Socioeconomic Disparities in Treatment and Improves Survival. Ann Surg Oncol 2021; 28:2438-2446. [PMID: 33523364 DOI: 10.1245/s10434-021-09594-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/31/2020] [Indexed: 11/18/2022]
Abstract
AIMS National studies have demonstrated disparities in the treatment and survival of pancreatic cancer patients based on socioeconomic status (SES). This study aimed to identify specific differences in perioperative management and outcomes based on patient SES and to study the role of a multidisciplinary clinic (MDC) in mitigating any variations. METHODS The study analyzed patients undergoing pancreaticoduodenectomy for pancreatic ductal adenocarcinoma in a large hospital system. The patients were categorized into groups of high and low SES and whether they were managed by the authors' pancreatic cancer MDC or not. The study compared differences in disease characteristics, receipt of multimodality therapy, perioperative outcomes, and recurrence-free and overall survival. RESULTS Of the 162 low-SES patients and 119 high-SES patients, 54% were managed in the MDC. Outside the MDC, low-SES patients were less likely to receive neoadjuvant chemotherapy and had less minimally invasive surgery, a longer OR time, less enhanced recovery participation, and more major complications (p < 0.05). No SES disparities were observed among the MDC patients. Despite similar tumor characteristics, the low-SES patients had inferior median overall survival (21 vs 32 months; p = 0.005), but the MDC appeared to eliminate this disparity. Low SES correlated with inferior survival for the non-MDC patients (17 vs 32 months; p < 0.001), but not for the MDC patients (24 vs 25 months; p = 0.33). These findings persisted in the multivariable analysis. CONCLUSION A pancreatic cancer MDC standardizes treatment decisions, eliminates disparities in surgical outcomes, and improves survival for low-SES patients.
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Affiliation(s)
- Richard S Hoehn
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Caroline J Rieser
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sharon Winters
- Cancer Registries, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Lauren Stitt
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore Hospital, Chicago, IL, USA
| | - David L Bartlett
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth K Lee
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alessandro Paniccia
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James P Ohr
- Division of Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vikram C Gorantla
- Division of Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anuradha Krishnamurthy
- Division of Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John C Rhee
- Division of Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nathan Bahary
- Division of Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Adam C Olson
- Division of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Steve Burton
- Division of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Susannah G Ellsworth
- Division of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Adam Slivka
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin McGrath
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Asif Khalid
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth Fasanella
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jennifer Chennat
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Randal E Brand
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rohit Das
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ritu Sarkaria
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Kassam AF, Kim Y, Cortez AR, Dhar VK, Wima K, Shah SA. The impact of opioid use on human and health care costs in surgical patients. Surg Open Sci 2020; 2:92-95. [PMID: 32754712 PMCID: PMC7391897 DOI: 10.1016/j.sopen.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 12/02/2022] Open
Abstract
Background Preoperative narcotic use impacts hospital cost and outcomes in surgical patients, but the underlying reasons are unclear. Methods A single-center retrospective analysis was performed on surgical patients admitted with intestinal obstruction (2010–2014). Patients were grouped into active opioid and nonopioid user cohorts. Active opioid use was defined as having an opioid prescription overlapping the date of admission. Chronic opioid use was defined by duration of use ≥ 90 days. Admission or intervention due to opioid-related illness was determined through consensus decision of 2 independent, blinded clinicians. Primary end point was the effect of active opioid use on hospital resource utilization. Results During the study period, 296 patients were admitted with a primary diagnosis of intestinal obstruction. Active opioid users accounted for 55 (18.6%) of these patients, with a median length of opioid use of 164 days (interquartile range 54–344 days). Average length of use was 164 days, with the majority of active users (n = 42, 76.4%) meeting criteria for chronic use. A subgroup analysis of active users demonstrated that opioid-related conditions were responsible for 10 admissions (18.2%) and 2 readmissions (3.6%). Among active users requiring surgical intervention, 3 procedures (21.4%) were due to opioid-related illnesses. Median hospital length of stay was 2 days longer (8 vs 6 days) and hospital costs were greater ($12,241 vs $8489) among active users (P < .05 each). Conclusion Active opioid users are predisposed to avoidable admissions and interventions for opioid-related illnesses. Efforts to address opioid use in the surgical population may improve patient outcomes and health care spending.
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Affiliation(s)
- Al-Faraaz Kassam
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Young Kim
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alexander R Cortez
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Vikrom K Dhar
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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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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County Rankings Have Limited Utility When Predicting Liver Transplant Outcomes. Dig Dis Sci 2020; 65:104-110. [PMID: 31332626 PMCID: PMC6946869 DOI: 10.1007/s10620-019-05734-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 07/10/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Evidence of geographical differences in liver transplantation (LT) outcomes has been proposed as a reason to include community characteristics in risk adjustment of transplant quality metrics. However, consistency and utility of rankings in LT outcomes for counties have not been demonstrated. AIMS We sought to evaluate the utility of county rankings (county socioeconomic status (SES) or county health scores (CHS)) on outcomes after LT. METHODS Using the United Network for Organ Sharing Registry, adults ≥ 18 years of age undergoing LT between 2002 and 2014 were identified. County-specific 1-year survival was calculated using the Kaplan-Meier method for counties with ≥ 5 LT performed during this period. Agreement between high-risk designation by 1-year mortality rate and county ranking was calculated using the Spearman correlation coefficient. RESULTS The analysis included 47,769 LT recipients in 1092 counties. County 1-year mortality rates were not correlated with county CHS (Spearman ρ = 0.01, p = 0.694) or county SES (Spearman ρ = - 0.01, p = 0.734). After controlling for individual-level covariates, a statistically significant variability in mortality hazards across counties (p < 0.001) persisted. Although both CHS and SES measures improved the model fit (p = 0.004 and p = 0.048, respectively), an unexplained residual variation in mortality hazard across counties continued. CONCLUSIONS There is poor agreement between county rankings on various socioeconomic indicators and LT outcomes. Although there is variability in outcomes across counties, this appears not to be due to county-level socioeconomic indices.
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Liver transplantation at safety net hospitals: Potentially vulnerable patients with noninferior outcomes. Surgery 2019; 166:1135-1141. [DOI: 10.1016/j.surg.2019.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 05/28/2019] [Accepted: 06/10/2019] [Indexed: 12/29/2022]
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34
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Liu CC, Lu CL, Notobroto HB, Tsai CC, Wen PH, Li CY. Individual and neighborhood socioeconomic status in the prediction of liver transplantation among patients with liver disease: A population-based cohort study in Taiwan. Medicine (Baltimore) 2019; 98:e14849. [PMID: 30882681 PMCID: PMC6426624 DOI: 10.1097/md.0000000000014849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Given the fact that >80% of liver transplantations (LTs) were living donor liver transplantation (LDLT) in Taiwan, we conducted this study to assess whether patients with lower socioeconomic status are subject to a lower chance of receiving hepatic transplantation.This was a cohort study including 197,082 liver disease patients admitted in 1997 to 2013, who were at higher risk of LT. Personal monthly income and median family income of living areas were used to indicate individual and neighborhood socioeconomic status, respectively. Cox proportional hazard model that considered death as a competing risk event was used to estimate subdistribution hazard ratio (sHR) of LT in association with socioeconomic status.Totally 2204 patients received LT during follow-up, representing a cumulative incidence of 1.12% and an incidence rate of 20.54 per 10 person-years. After adjusting for potential confounders, including age, sex, co-morbidity, location/urbanization level of residential areas, we found that patients with < median monthly income experienced significantly lower incidence of LT (aHR = 0.802, 95% confidence interval (CI) = 0.717-0.898), but those with >- median monthly income had significantly elevated incidence of LT (aHR = 1.679, 95% CI = 1.482-1.903), as compared to those who were not actively employed. Additionally, compared to areas with the lowest quartile of median family income, the highest quartile of median family income was also associated with significantly higher incidence rate of LT (aHR = 1.248, 95% CI = 1.055-1.478).Higher individual and neighborhood socioeconomic status were significantly associated with higher incidence of LT among patients with higher risk of LT.
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Affiliation(s)
- Chi-Chu Liu
- Department of Anesthesiology, Tainan Sin-Lau Hospital, Tainan
- Department of Health Care Administration, Chang Jung Christian University, Tainan
| | - Chin-Li Lu
- Graduate Institute of Food Safety, College of Agriculture and Natural Resources, National Chung Hsing University, Taichung, Taiwan
| | - Hari Basuki Notobroto
- Department of Biostatistics and Population Studies, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia
| | - Chiang-Chin Tsai
- Department of Health Care Administration, Chang Jung Christian University, Tainan
- Department of Surgery, Tainan Sin-Lau Hospital, Tainan, Taiwan
| | - Pei-Hung Wen
- Department of Public Health, College of Medicine, National Cheng Kung University
- Department of Surgery, E-DA Cancer Hospital, I-Shou University
- Department of Surgery, E-DA Hospital, I-Shou University, Kaohsiung
| | - Chung-Yi Li
- Department of Biostatistics and Population Studies, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia
- Department of Public Health, College of Medicine, National Cheng Kung University
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
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Dhar VK, Kim Y, Wima K, Hoehn RS, Shah SA. The Importance of Safety-Net Hospitals in Emergency General Surgery. J Gastrointest Surg 2018; 22:2064-2071. [PMID: 30039448 DOI: 10.1007/s11605-018-3885-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 07/12/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Safety-net hospitals provide care to an inherently underprivileged patient population. These hospitals have previously been shown to have inferior surgical outcomes after complex, elective procedures, but little is known about how hospital payer-mix correlates with outcomes after more common, emergent operations. METHODS The University HealthSystem Consortium database was queried for all emergency general surgery procedures performed from 2009 to 2015. Emergency general surgery was defined as the seven operative procedures recently identified as contributing most to the national burden. Only urgent and emergent admissions were included (n = 653,305). Procedure-specific cohorts were created and hospitals were grouped according to safety-net burden. Multivariate analyses were done to study the effect of safety-net burden on hospital outcomes. RESULTS For all seven emergency procedures, patients at hospitals with a high safety-net burden were more likely to be young and black (p < 0.01 each). Patients at high-burden hospitals had similar severity of illness scores to those at other hospitals. Compared with lower burden hospitals, in-hospital mortality rates at high-burden hospitals were similar or lower in five of seven procedures (p = NS or < 0.01, respectively). After adjusting for patient factors, high-burden hospitals had similar or lower odds of readmission in six of seven procedures, hospital length of stay in four of seven procedures, and cost of care in three of seven procedures (p = NS or < 0.01, respectively). CONCLUSION Safety-net hospitals provide emergency general surgery services without compromising patient outcomes or incurring greater healthcare resources. These data may help inform the vital role these institutions play in the healthcare of vulnerable patients in the USA.
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Affiliation(s)
- Vikrom K Dhar
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Young Kim
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard S Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Division of Transplantation, University of Cincinnati School of Medicine, 231 Albert Sabin Way, ML 0558, MSB 2006C, Cincinnati, OH, 45267-0558, USA.
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Dave S, Dodge JL, Terrault NA, Sarkar M. Racial and Ethnic Differences in Graft Loss Among Female Liver Transplant Recipients. Transplant Proc 2018; 50:1413-1423. [PMID: 29880364 DOI: 10.1016/j.transproceed.2018.02.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 01/29/2018] [Accepted: 02/17/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Racial differences in post-liver transplantation (LT) outcomes are identified in predominantly male cohorts. Despite known sex differences in a spectrum of liver-related outcomes, it is not known how race influences graft outcomes in women. METHODS Using the Scientific Registry of Transplant Recipients, we examined race and ethnicity and graft loss (death or retransplant) in women transplanted from 2002 to 2012. Covariates included recipient and donor characteristics, socioeconomics, and medical comorbidities. RESULTS The eligible cohort (n = 15,860) included 11,051 Caucasians, 2171 Hispanics, 1876 African Americans (AAs), and 762 Asian women with median follow-up of 3.1 years. Five-year graft survival was lower in AA women (60%) compared with Caucasians (71%), Hispanics (70%), and Asians (73%) (P < .001). Graft loss was 45% higher among AA women <40 years at transplant compared with AA women aged 50 to 59 (hazard ratio 1.45, 95% confidence interval 1.17-1.81) and aged 60 to 69 years (hazard ratio 1.33, 95% confidence interval 1.03-1.71), and risk increased after age 60 among Caucasians (P < .001 for race-age interactions). Increased graft loss among young AA women was limited to the first 2 years post-LT (P = .002). CONCLUSION Younger AA women are at particularly high risk for graft loss, which predominates in the first 2 years post-LT. Prospective studies of immunosuppression adherence and pharmacokinetics, particularly in relation to patient age, may help to explain the mechanisms underlying the higher rates of graft loss in younger AA women.
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Affiliation(s)
- S Dave
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - J L Dodge
- Department of Surgery, Division of Transplant, University of California-San Francisco, San Francisco, California, USA
| | - N A Terrault
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA; Department of Surgery, Division of Transplant, University of California-San Francisco, San Francisco, California, USA
| | - M Sarkar
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA.
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Miller R, Akateh C, Thompson N, Tumin D, Hayes D, Black SM, Tobias JD. County socioeconomic characteristics and pediatric renal transplantation outcomes. Pediatr Nephrol 2018. [PMID: 29532229 PMCID: PMC6425941 DOI: 10.1007/s00467-018-3928-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Existing risk adjustment models for solid organ transplantation omit socioeconomic status (SES). With limited data available on transplant candidates' SES, linkage of transplant outcomes data to geographic SES measures has been proposed. We investigate the utility of county SES for understanding differences in pediatric kidney transplantation (KTx) outcomes. METHODS We identified patients < 18 years of age receiving first-time KTx using United Network for Organ Sharing registry data in two eras: 2006-2010 and 2011-2015, corresponding to periods of county SES data collection. In each era, counties were ranked by 1-year rates of survival with intact graft, and by county SES score. We used Spearman correlation (ρ) to evaluate the association between county rankings on SES and transplant outcomes in each era and consistency between these measures across eras. We also evaluated the utility of county SES for improving prediction of individual KTx outcomes. RESULTS The analysis included 2972 children and 108 counties. County SES and transplant outcomes were not correlated in either 2006-2010 (ρ = 0.06; p = 0.525) or 2011-2015 (ρ = 0.162, p = 0.093). County SES rankings were strongly correlated between eras (ρ = 0.99, p < 0.001), whereas county rankings of transplant outcomes were not correlated between eras (ρ = 0.16, p = 0.097). Including county SES quintile in individual-level models of transplant outcomes did not improve model predictive utility. CONCLUSIONS Pediatric kidney transplant outcomes are unstable from period to period at the county level and are not correlated with county-level SES. Appropriate adjustment for SES disparities in transplant outcomes could require further collection of detailed individual SES data.
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Affiliation(s)
- Rebecca Miller
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Clifford Akateh
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Noelle Thompson
- Center for Innovation in Pediatric Practice, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Don Hayes
- Section of Pulmonary Medicine, Nationwide Children’s Hospital, Columbus, OH, USA,Department of Pulmonary and Critical Care, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sylvester M. Black
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Dhar VK, Wima K, Kim Y, Hoehn RS, Jung AD, Ertel AE, Diwan TS, Paterno F, Shah SA. Cost of achieving equivalent outcomes in sicker patients after liver transplant. HPB (Oxford) 2018; 20:268-276. [PMID: 28988703 DOI: 10.1016/j.hpb.2017.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/10/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND We aimed to characterize variability in cost after straightforward orthotopic liver transplant (OLT). METHODS Using the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified patients who underwent OLT between 2011 and 2014. Patients meeting criteria for straightforward OLT, defined as length of stay < 14 days with discharge to home, were selected (n = 5763) and grouped into tertiles (low, medium, high) according to cost of perioperative stay. RESULTS Patients undergoing straightforward OLT were of similar demographics regardless of cost. High cost patients were more likely to require preoperative hemodialysis, had higher severity of illness, and higher model for end-stage liver disease (MELD) (p < 0.01). High cost patients required greater utilization of resources including lab tests, blood transfusions, and opioids (p < 0.01). Despite having higher burden of disease and requiring increased resource utilization, high cost OLT patients with a straightforward perioperative course were shown to have identical 2-year graft and overall survival compared to lower cost patients (p = 0.82 and p = 0.63), respectively. CONCLUSION Providing adequate perioperative care for OLT patients with higher severity of illness and disease burden requires increased cost and resource utilization; however, doing so provides these patients with long term survival equivalent to more routine patients.
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Affiliation(s)
- Vikrom K Dhar
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Young Kim
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard S Hoehn
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew D Jung
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Audrey E Ertel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tayyab S Diwan
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Flavio Paterno
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Wayda B, Clemons A, Givens RC, Takeda K, Takayama H, Latif F, Restaino S, Naka Y, Farr MA, Colombo PC, Topkara VK. Socioeconomic Disparities in Adherence and Outcomes After Heart Transplant: A UNOS (United Network for Organ Sharing) Registry Analysis. Circ Heart Fail 2018; 11:e004173. [PMID: 29664403 DOI: 10.1161/circheartfailure.117.004173] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 01/26/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is mixed evidence of racial and socioeconomic disparities in heart transplant outcomes. Their underlying cause-and whether individual- or community-level traits are most influential-remains unclear. The current study aimed to characterize socioeconomic disparities in outcomes and identify time trends and mediators of these disparities. METHODS AND RESULTS We used United Network for Organ Sharing registry data and included 33 893 adult heart transplant recipients between 1994 and 2014. Socioeconomic status (SES) indicators included insurance, education, and neighborhood SES measured using a composite index. Black race and multiple indicators of low SES were associated with the primary outcome of death or retransplant, independent of baseline clinical characteristics. Blacks had lower HLA and race matching, but further adjustment for these and other graft characteristics only slightly attenuated the association with black race (HR, 1.25 after adjustment). This and the associations with neighborhood SES (HR, 1.19 for lowest versus highest decile), Medicare (HR, 1.17), Medicaid (HR, 1.29), and college education (HR, 0.90) remained significant after full adjustment. When comparing early (1994-2000) and late (2001-2014) cohorts, the disparities associated with the middle (second and third) quartiles significantly decreased over time, but those associated with lowest SES quartile and black race persisted. Low neighborhood SES was also associated with higher risks of noncompliance (HR, 1.76), rejection (HR, 1.28), hospitalization (HR, 1.13), and infection (HR, 1.10). CONCLUSIONS Racial and socioeconomic disparities exist in heart transplant outcomes, but the latter may be narrowing over time. These disparities are not explained by differences in clinical or graft characteristics.
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Affiliation(s)
- Brian Wayda
- From the Division of Cardiology, Department of Medicine (B.W., A.C., R.C.G., F.L., S.R., M.A.F., P.C.C., V.K.T.) and Division of Cardiothoracic Surgery, Department of Surgery (K.T., H.T., Y.N.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Autumn Clemons
- From the Division of Cardiology, Department of Medicine (B.W., A.C., R.C.G., F.L., S.R., M.A.F., P.C.C., V.K.T.) and Division of Cardiothoracic Surgery, Department of Surgery (K.T., H.T., Y.N.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Raymond C Givens
- From the Division of Cardiology, Department of Medicine (B.W., A.C., R.C.G., F.L., S.R., M.A.F., P.C.C., V.K.T.) and Division of Cardiothoracic Surgery, Department of Surgery (K.T., H.T., Y.N.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Koji Takeda
- From the Division of Cardiology, Department of Medicine (B.W., A.C., R.C.G., F.L., S.R., M.A.F., P.C.C., V.K.T.) and Division of Cardiothoracic Surgery, Department of Surgery (K.T., H.T., Y.N.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Hiroo Takayama
- From the Division of Cardiology, Department of Medicine (B.W., A.C., R.C.G., F.L., S.R., M.A.F., P.C.C., V.K.T.) and Division of Cardiothoracic Surgery, Department of Surgery (K.T., H.T., Y.N.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Farhana Latif
- From the Division of Cardiology, Department of Medicine (B.W., A.C., R.C.G., F.L., S.R., M.A.F., P.C.C., V.K.T.) and Division of Cardiothoracic Surgery, Department of Surgery (K.T., H.T., Y.N.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Susan Restaino
- From the Division of Cardiology, Department of Medicine (B.W., A.C., R.C.G., F.L., S.R., M.A.F., P.C.C., V.K.T.) and Division of Cardiothoracic Surgery, Department of Surgery (K.T., H.T., Y.N.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Yoshifumi Naka
- From the Division of Cardiology, Department of Medicine (B.W., A.C., R.C.G., F.L., S.R., M.A.F., P.C.C., V.K.T.) and Division of Cardiothoracic Surgery, Department of Surgery (K.T., H.T., Y.N.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Maryjane A Farr
- From the Division of Cardiology, Department of Medicine (B.W., A.C., R.C.G., F.L., S.R., M.A.F., P.C.C., V.K.T.) and Division of Cardiothoracic Surgery, Department of Surgery (K.T., H.T., Y.N.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Paolo C Colombo
- From the Division of Cardiology, Department of Medicine (B.W., A.C., R.C.G., F.L., S.R., M.A.F., P.C.C., V.K.T.) and Division of Cardiothoracic Surgery, Department of Surgery (K.T., H.T., Y.N.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Veli K Topkara
- From the Division of Cardiology, Department of Medicine (B.W., A.C., R.C.G., F.L., S.R., M.A.F., P.C.C., V.K.T.) and Division of Cardiothoracic Surgery, Department of Surgery (K.T., H.T., Y.N.), Columbia University College of Physicians and Surgeons, New York, NY.
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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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Equivalent Treatment and Survival after Resection of Pancreatic Cancer at Safety-Net Hospitals. J Gastrointest Surg 2018; 22:98-106. [PMID: 28849353 DOI: 10.1007/s11605-017-3549-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/15/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Due to disparities in access to care, patients with Medicaid or no health insurance are at risk of not receiving appropriate adjuvant treatment following resection of pancreatic cancer. We have previously shown inferior short-term outcomes following surgery at safety-net hospitals. Subsequently, we hypothesized that safety-net hospitals caring for these vulnerable populations utilize less adjuvant chemoradiation, resulting in inferior long-term outcomes. METHODS The American College of Surgeons National Cancer Data Base was queried for patients diagnosed with pancreatic adenocarcinoma (n = 32,296) from 1998 to 2010. Hospitals were grouped according to safety-net burden, defined as the proportion of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared to lower-burden hospitals with regard to patient demographics, disease characteristics, surgical management, delivery of multimodal systemic therapy, and survival. RESULTS Patients at safety-net hospitals were less often white, had lower income, and were less educated. Safety-net hospital patients were just as likely to undergo surgical resection (OR 1.03, p = 0.73), achieving similar rates of negative surgical margins when compared to patients at medium and low burden hospitals (70% vs. 73% vs. 66%). Thirty-day mortality rates were 5.6% for high burden hospitals, 5.2% for medium burden hospitals, and 4.3% for low burden hospitals. No clinically significant differences were noted in the proportion of surgical patients receiving either chemotherapy (48% vs. 52% vs. 52%) or radiation therapy (26% vs. 30% vs. 29%) or the time between diagnosis and start of systemic therapy (58 days vs. 61 days vs. 53 days). Across safety-net burden groups, no difference was noted in stage-specific median survival (all p > 0.05) or receipt of adjuvant as opposed to neoadjuvant systemic therapy (82% vs. 85% vs. 85%). Multivariate analysis adjusting for cancer stage revealed no difference in survival for safety-net hospital patients who had surgery and survived > 30 days (HR 1.02, p = 0.63). CONCLUSION For patients surviving the perioperative setting following pancreatic cancer surgery, safety-net hospitals achieve equivalent long-term survival outcomes potentially due to equivalent delivery of multimodal therapy at non-safety-net hospitals. Safety-net hospitals are a crucial resource that provides quality long-term cancer treatment for vulnerable populations.
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Ross K, Patzer RE, Goldberg DS, Lynch RJ. Sociodemographic Determinants of Waitlist and Posttransplant Survival Among End-Stage Liver Disease Patients. Am J Transplant 2017; 17:2879-2889. [PMID: 28695615 DOI: 10.1111/ajt.14421] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 06/02/2017] [Accepted: 07/01/2017] [Indexed: 01/25/2023]
Abstract
While regional organ availability dominates discussions of distribution policy, community-level disparities remain poorly understood. We studied micro-geographic determinants of survival risk and their distribution across Donor Service Areas (DSAs). Scientific Registry of Transplant Recipients records for all adults waitlisted for liver transplantation 2002-2014 were reviewed. The primary exposure variables were county-level sociodemographic risk, as measured by the Community Health Score (CHS), a previously-validated composite index local health conditions, and distance to listing transplant center. Among 114 347 patients, the median CHS was 19.4 (range: 0-40). Compared the lowest risk counties (CHS 1-10), highest-risk counties (CHS 31-40) had more black (14.6% vs. 5.4%), publicly insured (44.9% vs. 33.0), and remote candidates (34.0% vs. 15.1% living >100 miles away). Higher-CHS candidates had greater waitlist mortality in Cox multivariable (HR 1.16 for CHS 31-40, 95% CI 1.11-1.21) and competing risks analysis (sHR 1.07, 95% CI 0.99-1.14). Post-transplant survival was similar across CHS quartiles. Living >25 miles from the transplant center conferred excess mortality risk (sHR 1.08, 95% CI 1.03-1.12). Proposed distribution changes would disproportionately impact DSAs with more high-CHS or distant candidates. Low-income, rural and minority patients experience excess mortality while awaiting transplant, and risk disproportionately worse outcomes with reduced organ availability under current proposals.
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Affiliation(s)
- K Ross
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - R E Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - D S Goldberg
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - R J Lynch
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Factors associated with hospital readmission following diverting ileostomy creation. Tech Coloproctol 2017; 21:641-648. [DOI: 10.1007/s10151-017-1667-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 07/08/2017] [Indexed: 12/24/2022]
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Tumin D, Horan J, Shrider EA, Smith SA, Tobias JD, Hayes D, Foraker RE. County socioeconomic characteristics and heart transplant outcomes in the United States. Am Heart J 2017; 190:104-112. [PMID: 28760203 DOI: 10.1016/j.ahj.2017.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/27/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Geographic disparities in survival after heart transplantation have received mixed support in prior studies, and specific geographic characteristics that might be responsible for these differences are unclear. We tested for differences in heart transplant outcomes across United States (US) counties after adjustment for individual-level covariates. Our secondary aim was to evaluate whether specific county-level socioeconomic characteristics explained geographic disparities in survival. METHODS Data on patients aged ≥18 years undergoing a first-time heart transplant between July 2006 and December 2014 were obtained from the United Network for Organ Sharing. Residents of counties represented by <5 patients were excluded. Patient survival (censored in March 2016) was analyzed using multivariable Cox regression. Shared frailty models were used to test for residual differences in overall all-cause mortality across counties after adjusting for recipient and donor characteristics. Measures of county economic disadvantage, inequality, and racial segregation were obtained from US Census data and coded into quintiles. A likelihood ratio test determined whether adjusting for each county measure improved the fit of the Cox model. RESULTS Multivariable analysis of 10,879 heart transplant recipients found that, adjusting for individual-level characteristics, there remained statistically significant variation in mortality hazard across US counties (P=.004). Adjusting for quintiles of community disadvantage, economic inequality, or racial segregation did not significantly improve model fit (likelihood ratio test P=.092, P=.273, and P=.107, respectively) and did not explain residual differences in patient survival across counties. CONCLUSIONS Heart transplantation outcomes vary by county, but this difference is not attributable to county-level socioeconomic disadvantage.
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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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The center volume-outcome effect in pancreas transplantation: a national analysis. J Surg Res 2017; 213:25-31. [PMID: 28601322 DOI: 10.1016/j.jss.2017.02.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 12/27/2016] [Accepted: 02/17/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although increased hospital volume has been correlated with improved outcomes in certain surgical procedures, the effect of center volume on pancreas transplantation (PT) is less understood. Our study aims to establish whether a volume-outcome effect exists for PT. METHODS Through an established linkage between the University HealthSystem Consortium and the Scientific Registry of Transplant Recipients (SRTR) databases, we performed a retrospective cohort analysis of adult PT recipients between 2009 and 2012. Surgical volume was divided equally into low volume (LV), middle volume (MV), and high volume (HV) tertiles for each year that was studied. Hospital outcomes were measured through University HealthSystem Consortium, and long-term outcomes were measured through Scientific Registry of Transplant Recipients. Statistical analysis was performed using regression analyses and the Kaplan-Meier method. Median follow-up period was 2 y. RESULTS Among the 2309 PT recipients included, 815 (35.3%) were performed at LV centers, 755 (32.7%) at MV centers, and 739 (32.0%) at HV centers. Compared with MV and LV centers, organs transplanted at HV centers were more frequently donation after cardiac death (5.1% versus 2.4% versus 3.3%, P = 0.01) and from older donors (2.8% [>50 y] versus 0.8% versus 0.1%, P < 0.001). In addition, HV recipients were older (31.5% [>50 y] versus 20.9% versus 19.7%, P < 0.001) and had worse functional status (39.5% dependent versus 9.7% versus 9.9%, P < 0.001). Patient and graft survival were similar across hospital volume tertiles. Center volume was not predictive of readmission rates, total length of stay, intensive care unit length of stay, or total direct cost on multivariate analysis (all P > 0.05). CONCLUSIONS Short- and long-term outcomes after PT are not affected by hospital volume. Although LV centers confine their cases to low-risk patients, HV centers transplant a higher percentage of high-risk donor and recipient combinations with equivalent outcomes.
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Hoehn RS, Hanseman DJ, Chang AL, Daly MC, Ertel AE, Abbott DE, Shah SA, Paquette IM. Surgeon Characteristics Supersede Hospital Characteristics in Mortality After Urgent Colectomy. J Gastrointest Surg 2017; 21:23-32. [PMID: 27586190 DOI: 10.1007/s11605-016-3254-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/11/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Urgent colectomy is a common procedure with a high mortality rate that is performed by a variety of surgeons and hospitals. We investigated patient, surgeon, and hospital characteristics that predicted mortality after urgent colectomy. METHODS The University HealthSystem Consortium was queried for adults undergoing urgent or emergent colectomy between 2009 and 2013 (n = 50,707). Hospitals were grouped into quartiles according to risk-adjusted observed-to-expected (O/E) mortality ratios and compared using the 2013 American Hospital Association Annual Survey. Multiple logistic regression was used to determine patient and provider characteristics associated with in-hospital mortality. RESULTS The overall mortality rate after urgent colectomy was 9 %. Mortality rates were higher for patients with extreme severity of illness (27.6 %), lowest socioeconomic status (10.6 %), weekend admissions (10.7 %), and open (10.5 %) and total (15.8 %) colectomies. Hospitals with the lowest O/E ratios were smaller and had lower volume and less teaching intensity, but there were no significant trends with regard to financial (expenses, payroll, capital expenditures per bed) or personnel characteristics (physicians, nurses, technicians per bed). On multivariate analysis, mortality was associated with patient age (10 years: OR 1.31, p < 0.01), severity of illness (extreme: OR 34.68, p < 0.01), insurance status (Medicaid: OR 1.24, p < 0.01; uninsured: OR 1.40, p < 0.01), and weekend admission (OR 1.09, p = 0.04). Surgeon volume was associated with reduced mortality (per 10 cases: OR 0.99, p < 0.01), but hospital volume was not (per case: OR 1.00, p = 0.84). CONCLUSIONS Mortality is common after urgent colectomy and is associated with patient characteristics. Surgeon volume and practice patterns predicted differences in mortality, whereas hospital factors did not. These data suggest that policies focusing solely on hospital volume ignore other more important predictors of patient outcomes.
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Affiliation(s)
- Richard S Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dennis J Hanseman
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alex L Chang
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Megan C Daly
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Audrey E Ertel
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ian M Paquette
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA. .,Division of Colorectal Surgery, University of Cincinnati School of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA.
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Case mix-adjusted cost of colectomy at low-, middle-, and high-volume academic centers. Surgery 2016; 161:1405-1413. [PMID: 27919447 DOI: 10.1016/j.surg.2016.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 09/20/2016] [Accepted: 10/07/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Efforts to regionalize surgery based on thresholds in procedure volume may have consequences on the cost of health care delivery. This study aims to delineate the relationship between hospital volume, case mix, and variability in the cost of operative intervention using colectomy as the model. METHODS All patients undergoing colectomy (n = 90,583) at 183 academic hospitals from 2009-2012 in The University HealthSystems Consortium Database were studied. Patient and procedure details were used to generate a case mix-adjusted predictive model of total direct costs. Observed to expected costs for each center were evaluated between centers based on overall procedure volume. RESULTS Patient and procedure characteristics were significantly different between volume tertiles. Observed costs at high-volume centers were less than at middle- and low-volume centers. According to our predictive model, high-volume centers cared for a less expensive case mix than middle- and low-volume centers ($12,786 vs $13,236 and $14,497, P < .01). Our predictive model accounted for 44% of the variation in costs. Overall efficiency (standardized observed to expected costs) was greatest at high-volume centers compared to middle- and low-volume tertiles (z score -0.16 vs 0.02 and -0.07, P < .01). CONCLUSION Hospital costs and cost efficiency after an elective colectomy varies significantly between centers and may be attributed partially to the patient differences at those centers. These data demonstrate that a significant proportion of the cost variation is due to a distinct case mix at low-volume centers, which may lead to perceived poor performance at these centers.
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Beck KR, Kim N, Khalili M. Sofosbuvir-Containing Regimens for Chronic Hepatitis C Are Successful in the Safety-Net Population: A Real-World Experience. Dig Dis Sci 2016; 61:3602-3608. [PMID: 27743164 PMCID: PMC5106301 DOI: 10.1007/s10620-016-4340-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 10/03/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Vulnerable populations are disproportionately affected by hepatitis C virus (HCV) infection and experience high rates of health disparity. There are no data on real-world experience with highly efficacious direct-acting anti-HCV treatment in this population. AIMS We aimed to evaluate the real-world experience with sofosbuvir-based regimens among a vulnerable HCV-infected population. METHODS HCV treatment response was assessed among 204 patients who completed 12-24 weeks of sofosbuvir-based regimens (in combination with pegylated interferon and ribavirin, simeprevir, ledipasvir, or daclatasvir) at the San Francisco safety-net healthcare system liver specialty clinic between January 2014 and December 2015. Virologic response during therapy was assessed at weeks 4 and 8, end of therapy, and 12-week treatment discontinuation (SVR 12). RESULTS Patient characteristics were median age 58 years, 60 % male, 42 % Caucasian (21 % black, 19 % Hispanic), 72 % had genotype 1 (23 % genotype 2 or 3), and the median baseline log10 HCV viral load was 6.1 IU/ml and alanine transaminase 63 U/l. Cirrhosis was present in 36 % (of whom 40 % were decompensated), and 18 % were HCV treatment-experienced. Overall, SVR 12 was achieved in 97 % (99 % genotype 1, 100 % genotype 2, 84 % genotype 3). Five of six (83 %) patients who relapsed had decompensated cirrhosis, and 67 % were also non-adherent to therapy. On-treatment virologic response did not impact SVR. CONCLUSIONS High rates of sustained virologic response can be achieved in safety-net HCV-infected patients. Access to DAA-based regimens is critical to addressing HCV-related health disparity in this at-risk population.
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Affiliation(s)
- Kendall R Beck
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, NH 3-D, San Francisco, CA, 94110, USA
| | - Nicole Kim
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, NH 3-D, San Francisco, CA, 94110, USA
| | - Mandana Khalili
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, NH 3-D, San Francisco, CA, 94110, USA.
- Liver Center, University of California San Francisco, San Francisco, CA, USA.
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Ertel AE, Wima K, Hoehn RS, Chang AL, Hohmann SF, Ahmad SA, Sussman JJ, Shah SA, Abbott DE. Variability in postoperative resource utilization after pancreaticoduodenectomy: Who is responsible. Surgery 2016; 160:1477-1484. [PMID: 27712874 DOI: 10.1016/j.surg.2016.08.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/14/2016] [Accepted: 08/18/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND We aimed to quantify and predict variability that exists in resource utilization after pancreaticoduodenectomy and determine how such variability impacts postoperative outcomes. METHODS The University HealthSystems Consortium database was queried for all pancreaticoduodenectomies performed between 2011-2013 (n = 9,737). A composite resource utilization score was created using z-scores of 8 clinically significant postoperative care delivery variables including number of laboratory tests, imaging tests, computed tomographic scans, days on antibiotics, anticoagulation, antiemetics, promotility agents, and total number of blood products transfused per patient. Logistic, Poisson, and gamma regression models were used to determine predictors of increased variability in care between patients. RESULTS Having a high (versus low) resource utilization score after pancreaticoduodenectomy correlated with increased duration of stay; (odds ratio 2.28), cost (odds ratio 1.89), readmission rate (odds ratio 1.46), and mortality (odds ratio 7.54). Patient-specific factors were the strongest predictors and included extreme severity of illness (odds ratio 114), major comorbidities/complications (odds ratio 5.99), and admission prior to procedure (odds ratio 2.72; all P < .01). Surgeon and center volume were not associated with resource utilization. CONCLUSION Public reporting of patient outcomes and resource utilization, invariably tied to reimbursement in the near future, should consider that much of the postoperative variability after complex pancreatic operation is related to patient-specific risk factors.
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Affiliation(s)
- Audrey E Ertel
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Koffi Wima
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Richard S Hoehn
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Alex L Chang
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | | | - Syed A Ahmad
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Jeffrey J Sussman
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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