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Current and future regulatory and financial challenges in vascularized composite allotransplantation. Curr Opin Organ Transplant 2020; 25:615-619. [PMID: 33060543 DOI: 10.1097/mot.0000000000000813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To discuss current and future regulatory and financial issues affecting the field of vascularized composite allotransplantation (VCA). RECENT FINDINGS Vascularized composite allografts are regulated by the US Department of Health and Human Services Organ Procurement and Transplantation Network Final Rule (42 CFR part 121) in the United States and Directive 2010/53/EU of the European Parliament and the Council of 7 July 2010 in the European Union (EU). However, in the United States and most of the EU, VCA is not yet paid for by insurance or third-party payers and many centers depend upon grant funding, philanthropic gifts, and/or supplemental hospital/institutional funding strategies to pay for the transplants and postoperative care. SUMMARY In the absence of randomized clinical trial data, which is infeasible for studying VCA outcomes, consensus data sets are needed to document these procedures' value proposition and have them accepted as part of the standard of care. Procedure and immunosuppression protocol variability applied to a small patient cohort necessitates collaborative efforts by field experts to devise creative approaches, such as determining return-on-investment for anatomical subunits, to better understand these transplants' value and impact on patient quality-of-life.
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Rose J, Cooney CM, Kaufman C, Talbot SG, Caplan A, Kahn J, Sugarman J, Shores JT, Levin LS, Brandacher G, McDiarmid SV, Lee WPA, Dean W. Evolving ethics, policy and reimbursement issues of vascularized composite allotransplantation: Symposium summary. SAGE Open Med 2019. [PMID: 31384465 PMCID: PMC6661784 DOI: 10.1177/2050312119866944] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
In this article, we present a report from a national meeting titled, “Evolving Issues of Vascularized Composite Allotransplantation—A Symposium on Ethics, Policy, and Reimbursement Issues,” which convened in September 2017. We discuss the maturation of vascularized composite allotransplantation from an emerging technology to becoming an extension of clinical practice for select patients with complex reconstructive needs. Viewpoints and action items were presented by and discussed among the 70+ clinicians, researchers, policymakers, ethicists, healthcare administrators, and third-party payers who attended the symposium with the goals of implementing a collaborative roadmap for vascularized composite allotransplantation growth, evaluation, and sustainability by establishing a unified plan to help address concerns of the public, policymakers, and healthcare finance. We review the current status of vascularized composite allotransplantation in clinical practice and summarize symposium discussions regarding ethical considerations, reimbursement, payer strategies, and standardization of data collection.
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Affiliation(s)
- John Rose
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christina Kaufman
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Simon G Talbot
- Division of Plastic and Reconstructive Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Arthur Caplan
- Division of Medical Ethics, New York University School of Medicine, New York City, NY, USA
| | - Jeffrey Kahn
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Jaimie T Shores
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - L Scott Levin
- Department of Orthopaedic Surgery, Division of Plastic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sue V McDiarmid
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics and Surgery. David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - WP Andrew Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wendy Dean
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
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Bonavina L, Attwood S. Laparoscopic alternatives to fundoplication for gastroesophageal reflux: the role of magnetic augmentation and electrical stimulation of the lower esophageal sphincter. Dis Esophagus 2016; 29:996-1001. [PMID: 26676715 DOI: 10.1111/dote.12425] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Reflux symptoms are very common, and despite modern medication they are a major cause of disease burden and loss of quality of life worldwide. Laparoscopic anti-reflux surgery is the only current effective alternative but suffers from the risks of long-term side effects. Surgery also suffers variation in standards and outcomes. Magnetic augmentation and electrical stimulation of the lower esophageal sphincter represent promising innovative procedures in the field.
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Affiliation(s)
- L Bonavina
- Department of Surgery, University of Milano Medical School, Milan, Italy
| | - S Attwood
- Department of Health Services Research, Durham University Medical School, Durham, UK
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Murthy SS, Eyal N, Norheim OF, Ruan DT, Ntakiyiruta G, Robert R. Standard of care versus second-best: Ethical dilemmas in surgery for high risk papillary thyroid cancer in low and middle-income countries. J Cancer Policy 2015. [DOI: 10.1016/j.jcpo.2015.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Hand and upper extremity transplantation: an update of outcomes in the worldwide experience. Plast Reconstr Surg 2015; 135:351e-360e. [PMID: 25401735 DOI: 10.1097/prs.0000000000000892] [Citation(s) in RCA: 169] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hand/upper extremity transplantation is the most common form of vascularized composite allotransplantation performed to date. An Update of worldwide outcomes is reported. METHODS The authors summarize the international experience with 107 known transplanted hand/upper extremities in 72 patients. Data from published medical literature, national and international meetings, lay press reports, and personal communications were utilized to provide the most up-to-date summary. RESULTS Although 24 losses (including four mortalities) are known, three of the four reported mortalities and eight of 24 limb losses were caused by multiple type vascularized composite allotransplantations (combined upper and lower limb or upper limb and face). Seven more losses were attributable to 15 patients in the early experience in China. In the United States and Western Europe, only three other non-acute graft losses have been reported, resulting in a patient survival rate for unilateral or bilateral hand transplantation in isolation of 98.5 percent and an overall graft survival rate of 83.1 percent. CONCLUSIONS Published functional outcomes continue to demonstrate improvement in function and quality of life. The international experience supports the idea that, for properly selected individuals, hand and upper extremity transplantation should be considered an important treatment option.
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