A Learning Health System for Pediatric Liver Transplant: The Starzl Network for Excellence in Pediatric Transplantation

Patient-centered research in pediatric transplant: Engaging families and recipients

Pediatric liver transplant (LT) recipients navigate a lifelong journey that includes constant monitoring and challenges. Research priorities and questions in LT have traditionally been provider-driven. This project was a novel partnership between a learning health system dedicated to pediatric LT (Starzl Network for Excellence in Pediatric Transplantation) and a parent-led advocacy group (Transplant Families) that aimed to prepare families and providers for collaborative patient-centered outcomes research (PCOR). We developed 5 virtual modules to (1) teach participants about PCOR, and (2) elicit ideas for PCOR priorities and processes in pediatric LT. Parents and providers participated via self-guided online modules or focus groups. Participants included 240 patient partners and 133 pediatric LT providers from 16 centers over 2 years. We held 20 focus groups, including 5 to amplify underrepresented voices: young adults, Spanish speakers, and African Americans. Feedback was summarized to create a PCOR Roadmap, a guide for future PCOR in the Starzl Network, which was disseminated back to participants online and via webinars. Feedback from a diverse group of stakeholders allowed us to develop PCOR priorities and processes for the pediatric LT community. Our engagement strategies could be adapted by other transplant communities to facilitate patient and provider research partnerships.

Impact of early immunosuppression on pediatric liver transplant outcomes within 1 year

OBJECTIVES

The Starzl Network for Excellence in Pediatric Transplantation identified optimizing immunosuppression (IS) as a priority practice improvement area for patients, families, and providers. We aimed to evaluate associations between clinical characteristics, early IS, and outcomes.

METHODS

We analyzed pediatric liver transplant (LT) data from 2013 to 2018 in the United Network for Organ Sharing (UNOS) and the Society of Pediatric Liver Transplantation (SPLIT) registries.

RESULTS

We included 2542 LT recipients in UNOS and 1590 in SPLIT. IS choice varied between centers with steroid induction and mycophenolate mofetil (MMF) use each ranging from 0% to 100% across centers. Clinical characteristics associated with early IS choice were inconsistent between the two data sets. T-cell depleting antibody use was associated with improved 1-year graft (hazard ratio [HR] 0.50, 95% confidence interval [CI] 0.34-0.76) and patient (HR 0.40, 95% CI 0.20-0.79) survival in UNOS but decreased 1-year patient survival (HR 4.12, 95% CI 1.31-12.93) and increased acute rejection (HR 1.58, 95% CI 1.07-2.34) in SPLIT. Non-T-cell depleting antibody use was not associated with differential risk of survival nor rejection. MMF use was associated with improved 1-year graft survival (HR 0.73, 95% CI 0.54-0.99) in UNOS only.

CONCLUSIONS

Variation exists in center choice of early IS regimen. UNOS and SPLIT data provide conflicting associations between IS and outcomes in multivariable analysis. These results highlight the need for future multicenter collaborative work to identify evidence-based IS best practices.

A Scoping Review on Learning Health Networks Available in Pediatric Surgical Specialties

BACKGROUND

Learning health networks (LHN) are consortia of institutions that collaborate and embrace the elements of the learning health system (LHS), including quality improvement, education, research, and stakeholder involvement. Their ultimate goal is rapid information dissemination in clinical care. Pediatric surgical specialties perform unique yet high-impact procedures that could benefit from LHN, thereby improving surgical outcomes and care through LHS approaches. Consequently, health system leaders should be aware of LHN and their importance in enhancing surgical care and improving outcomes. This scoping review aims to map and characterize the existing LHN applied in pediatric surgical specialties.

METHODS

A systematic literature search was performed on Medline, EMBASE, and Scopus up to June 2022, with an update search conducted in May 2023. Additionally, Google Scholar, ProQuest and inquiry from topic experts were used for cross-referencing relevant review articles to identify grey literature. This scoping review was conducted and reported according to the PRISMA-scoping review extension.

RESULTS

A total of 56 publications for 19 LHN were identified and included in this scoping review. Out of 19 identified LHN in pediatric surgical specialties, 18 were organized in North America. Eight of the networks are related to pediatric general surgery and another eight were related to pediatric transplantation. The 16 out of 19 LHN were initiated after 2001. To date, only eight of the LHNs generated reports of comparative improved outcomes.

CONCLUSION

This scoping review provides an overview of the available LHNs in pediatric surgical specialties. Over the past decade, several pediatric surgical specialties have embraced the principles of learning health systems, forming inter-institutional collaborations that utilize information technology to generate big data on patient-level clinical information, engage in quality improvement cycles, adopt evidence-based practices, and actively involve patients and stakeholders.

LEVEL OF EVIDENCE

IV.

Implementation strategies and outcome measures for advancing learning health systems: a mixed methods systematic review

BACKGROUND

Learning health systems strive to continuously integrate data and evidence into practice to improve patient outcomes and ensure value-based healthcare. While the LHS concept is gaining traction, the operationalization of LHSs is underexplored.

OBJECTIVE

To identify and synthesize the existing evidence on the implementation and evaluation of advancing learning health systems across international health care settings.

METHODS

A mixed methods systematic review was conducted. Six databases (CINAHL, Embase, Medline, PAIS, Scopus and Nursing at Allied Health Database) were searched up to July 2022 for terms related to learning health systems, implementation, and evaluation measures. Any study design, health care setting and population were considered for inclusion. No limitations were placed on language or date of publication. Two reviewers independently screened the titles, abstracts, and full texts of identified articles. Data were extracted and synthesized using a convergent integrated approach. Studies were critically appraised using relevant JBI critical appraisal checklists.

RESULTS

Thirty-five studies were included in the review. Most studies were conducted in the United States (n = 21) and published between 2019 and 2022 (n = 24). Digital data capture was the most common LHS characteristic reported across studies, while patient engagement, aligned governance and a culture of rapid learning and improvement were reported least often. We identified 33 unique strategies for implementing LHSs including: change record systems, conduct local consensus discussions and audit & provide feedback. A triangulation of quantitative and qualitative data revealed three integrated findings related to the implementation of LHSs: (1) The digital infrastructure of LHSs optimizes health service delivery; (2) LHSs have a positive impact on patient care and health outcomes; and (3) LHSs can influence health care providers and the health system.

CONCLUSION

This paper provides a comprehensive overview of the implementation of LHSs in various healthcare settings. While this review identified key implementation strategies, potential outcome measures, and components of functioning LHSs, further research is needed to better understand the impact of LHSs on patient, provider and population outcomes, and health system costs. Health systems researchers should continue to apply the LHS concept in practice, with a stronger focus on evaluation.

The First Collective Examination of Immunosuppressive Practices Among American Intestinal Transplant Centers

Background

Unlike other solid organs, no standardized treatment algorithms exist for intestinal transplantation (ITx). We established a consortium of American ITx centers to evaluate current practices.

Methods

All American centers performing ITx during the past 3 y were invited to participate. As a consortium, we generated questions to evaluate and collect data from each institution. The data were compiled and analyzed.

Results

Ten centers participated, performing 211 ITx during the past 3 y (range, 3-46; mean 21.1). Induction regimens varied widely. Thymoglobulin was the most common, used in the plurality of patients (85/211; 40.3%), but there was no consensus regimen. Similarly, regimens for the treatment of acute cellular rejection, antibody-mediated rejection, and graft-versus-host disease varied significantly between centers. We also evaluated differences in maintenance immunosuppression protocols, desensitization regimens, mammalian target of rapamycin use, antimetabolite use, and posttransplantation surveillance practices. Maintenance tacrolimus levels, stoma presence, and scoping frequency were not associated with differences in rejection events. Definitive association between treatments and outcomes, including graft and patient survival, was not the intention of this initial collaboration and is prevented by the lack of patient-level data and the presence of confounders. However, we identified trends regarding rejection episodes after various induction strategies that require further investigation in our subsequent collaborations.

Conclusions

This initial collaboration reveals the extreme heterogeneity of practices among American ITx centers. Future collaboration will explore patient-level data, stratified by age and transplant type (isolated intestine versus multivisceral), to explore the association between treatment regimens and outcomes.

Center use of technical variant grafts varies widely and impacts pediatric liver transplant waitlist and recipient outcomes in the United States

To assess the impact of technical variant grafts (TVGs) [including living donor (LD) and deceased donor split/partial grafts] on waitlist (WL) and transplant outcomes for pediatric liver transplant (LT) candidates, we performed a retrospective analysis of Organ Procurement and Transplantation Network (OPTN) data on first-time LT or liver-kidney pediatric candidates listed at centers that performed >10 LTs during the study period, 2004-2020. Center variance was plotted for LT volume, TVG usage, and survival. A composite center metric of TVG usage and WL mortality was developed to demonstrate the existing variation and potential for improvement. Sixty-four centers performed 7842 LTs; 657 children died on the WL. Proportions of WL mortality by center ranged from 0% to 31% and those of TVG usage from 0% to 76%. Higher TVG usage, from deceased donor or LD, independently or in combination, significantly correlated with lower WL mortality. In multivariable analyses, death from listing was significantly lower with increased center TVG usage (HR = 0.611, CI: 0.40-0.92) and LT volume (HR = 0.995, CI: 0.99-1.0). Recipients of LD transplants (HR = 0.637, CI: 0.51-0.79) had significantly increased survival from transplant compared with other graft types, and recipients of deceased donor TVGs (HR = 1.066, CI: 0.93-1.22) had statistically similar outcomes compared with whole graft recipients. Increased TVG utilization may decrease WL mortality in the US. Hence, policy and training to increase TVG usage, availability, and expertise are critical.

Anti-thymocyte globulin induction with delayed introduction of tacrolimus preserves renal function in pediatric liver transplant recipients

BACKGROUND

Tacrolimus (TAC)-mediated renal disease occurs in up to 70% of pediatric liver transplant (LT) recipients. The safety and efficacy of renal-sparing immunosuppression using anti-thymocyte globulin (ATG) induction and delayed TAC administration has not been studied in children. We evaluated the safety and efficacy of ATG induction on preserving renal function in children within the first year (Y1) post-LT in a single-center retrospective cohort study.

METHODS

Children under age 18 years of who received isolated LT from 2008 to 2020 with a GFR < 70 received renal-sparing (RS) protocol consisting of ATG with methylprednisolone (MP), delayed TAC administration, lower initial TAC trough goals, and mycophenolate mofetil (MMF). The RS group was matched 1:2 by age and LT indication with standard immunosuppression (SI) group. Changes in renal function as well as adverse events within Y1 post-LT were compared.

RESULTS

Forty-four pediatric patients were included in the analysis, of which 13 received RS. As expected, the RS group had significantly lower mean TAC trough levels at 30 days (10.3 vs. 13.2, p = .001) post-LT. Renal function was significantly preserved at 6 (-0.26 vs. 0.21, p = .004) and 12 months (-0.33 vs. 0.11, p = .003) post-LT in the RS versus SI group as measured by mean change in serum creatinine, with similar trends observed in eGFR and cystatin C. ACR, sepsis, viremia, graft loss and mortality occurred at similar rates in both RS and SI groups.

CONCLUSION

Induction immunosuppression with ATG and delayed TAC administration in children with renal impairment is safe and effectively preserves renal function during Y1 post-LT.

Systematic review on the involvement and engagement of patients as advisers for the organisation of organ transplantation services

OBJECTIVES

This systematic review aims to derive practical lessons from publications on patient involvement and engagement in the organisation of organ transplantation services.

DESIGN

This systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Inclusion criteria for the analysis of publications in English cited in the databases PubMed and Web of Science until 6 December 2022 required that patients participated as advisers in the organisation of organ transplantation services. Quality assessment was performed using the Guidance for Reporting Involvement of Patients and the Public (GRIPP) 2 small form and the Critical Appraisal Skills Programme (CASP) tool for the assessment of the risks of bias.

RESULTS

Deployed search strings identified 2263 records resulting in a total of 11 articles. The aims and strategies, deployed methods, observed effects, observed barriers and proposed improvements for the future varied vastly. All reported that well-developed programmes involving and engaging patients at an organisational level provide additional benefits for patients and foster patient-centred care. Lessons learnt include: (1) to empower patients, the information provided to them should be individualised to prioritise their needs; (2) financial as well as organisational resources are important to successfully implement patient involvement and engagement; (3) systematic feedback from patients in organisational structures to health providers is required to improve clinical workflows and (4) the consideration of ethical issues and the relationship between investigators and participating patients should be clarified and reported.

CONCLUSIONS

Actionable management recommendations could be derived. The quantitative impact on clinical outcome and economic clinical process improvements remains to be investigated. Study quality can be improved using the GRIPP 2 guidance and the CASP tool.

PROSPERO REGISTRATION NUMBER

CRD42022186467.

Stroke Learning Health Systems: A Topical Narrative Review With Case Examples

To our knowledge, the adoption of Learning Health System (LHS) concepts or approaches for improving stroke care, patient outcomes, and value have not previously been summarized. This topical review provides a summary of the published evidence about LHSs applied to stroke, and case examples applied to different aspects of stroke care from high and low-to-middle income countries. Our attempt to systematically identify the relevant literature and obtain real-world examples demonstrated the dissemination gaps, the lack of learning and action for many of the related LHS concepts across the continuum of care but also elucidated the opportunity for continued dialogue on how to study and scale LHS advances. In the field of stroke, we found only a few published examples of LHSs and health systems globally implementing some selected LHS concepts, but the term is not common. A major barrier to identifying relevant LHS examples in stroke may be the lack of an agreed taxonomy or terminology for classification. We acknowledge that health service delivery settings that leverage many of the LHS concepts do so operationally and the lessons learned are not shared in peer-reviewed literature. It is likely that this topical review will further stimulate the stroke community to disseminate related activities and use keywords such as learning health system so that the evidence base can be more readily identified.

Feasibility of using a patient-reported outcome measure into clinical practice following pediatric liver transplantation: The Starzl Network experience

BACKGROUND

Patient-reported outcome measures (PROMs) are not routinely used in clinical care by pediatric liver transplant (LT) teams. The Starzl Network for Excellence in Pediatric Transplantation (SNEPT) assessed feasibility of using a disease-specific Quality of Life (QoL) questionnaire in the ambulatory setting at 10 SNEPT sites.

METHODS

A mixed methods feasibility project assessing administration processes, barriers, and user experiences with the Pediatric Liver Transplant Quality of Life (PeLTQL) tool. Iterative processes sought stakeholder feedback across four phases (Pilot, Extended Pilot, Development of a Mobile App PeLTQL version, and Pilot App use).

RESULTS

A total of 149 patient-parent dyads completed the PeLTQL during LT clinic follow-up. Clinicians, parents, and patients evaluated and reported on feasibility of operationalization. Only two of 10 SNEPT sites continued PeLTQL administration after the initial two pilot phases. Reasons include limited clinical time and available personnel aggravated by the COVID-19 pandemic. In response, a mobile application version of the PeLTQL was initiated. Providing PeLTQL responses electronically was "very easy" or "easy" as reported by 96% (22/23) parents.

CONCLUSIONS

Administration of a PROM into post-pediatric LT clinical care was feasible, but ongoing utilization stalled. Use of a mobile app towards facilitating completion of the PeLTQL outside of clinic hours may address the time and work-flow barriers identified.

Health Care Transition for Adolescents and Young Adults With Pediatric-Onset Liver Disease and Transplantation: A Position Paper by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition

Advances in medical therapies and liver transplantation have resulted in a greater number of pediatric patients reaching young adulthood. However, there is an increased risk for medical complications and morbidity surrounding transfer from pediatric to adult hepatology and transplant services. Health care transition (HCT) is the process of moving from a child/family-centered model of care to an adult or patient-centered model of health care. Successful HCT requires a partnership between pediatric and adult providers across all disciplines resulting in a transition process that does not end at the time of transfer but continues throughout early adulthood. Joint consensus guidelines in collaboration with the American Society of Transplantation are presented to facilitate the adoption of a structured, multidisciplinary approach to transition planning utilizing The Six Core Elements of Health Care Transition TM for use by both pediatric and adult specialists. This paper provides guidance and seeks support for the implementation of an HCT program which spans across both pediatric and adult hepatology and transplant centers.