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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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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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Bodek DD, Everwine MM, Lunsford KE, Okoronkwo N, Patel PA, Pyrsopoulos N. Racial Disparities in Liver Transplantation for Hepatocellular Carcinoma: Analysis of the National Inpatient Sample From 2007 to 2014. J Clin Gastroenterol 2023; 57:311-316. [PMID: 35180149 DOI: 10.1097/mcg.0000000000001675] [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: 05/03/2021] [Accepted: 01/05/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) remains a deadly disease, with patients' best hope for a cure being liver transplantation; however, access to health care resources, such as donor organs, between ethnic groups has historically been unbalanced. Ensuring equitable access to donor livers is crucial to minimize disparities in HCC outcomes. As a result, we sought to better elucidate the differences in transplantation rates among various ethnic groups. MATERIALS AND METHODS The National Inpatient Sample (NIS) was utilized to evaluate for disparities in liver transplantation in patients whose primary or secondary diagnosis was recorded as HCC or hepatoma. The study included admissions between 2007 and 2014 to centers with at least 1 documented liver transplant. RESULTS A total of 7244 transplants were performed over 70,406 weighted admissions. Black race was associated with lower transplantation rates, with an adjusted odds ratio of 0.46 (95% confidence interval: 0.42-0.51, P <0.01) when accounting for a number of possible confounders including socioeconomic and geographic factors. CONCLUSIONS Our study observed decreased rates of liver transplant in blacks compared with whites for HCC. Furthermore, improved economic status and private insurance had a significantly higher odds ratio for transplantation. Hospital-level studies are needed to clarify confounding factors not apparent in large administrative datasets and help better investigate factors that lead to less optimal transplant rates among blacks. Interventions may include more optimal screening policies and procedures, improved interdisciplinary management, and earlier referrals.
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Affiliation(s)
| | | | - Keri E Lunsford
- Division of Liver Transplant and HPB Surgery, Department of Surgery and Center for Immunity and Inflammation
| | - Nneoma Okoronkwo
- Department of Gastroenterology, Rutgers New Jersey Medical School, Newark, NJ
| | - Pavan A Patel
- Department of Gastroenterology, Rutgers New Jersey Medical School, Newark, NJ
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Perceptions and Early Outcomes of the Acuity Circles Allocation Policy Among Liver Transplant Centers in the United States. Transplant Direct 2022; 9:e1427. [PMID: 36582673 PMCID: PMC9750633 DOI: 10.1097/txd.0000000000001427] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/25/2022] [Accepted: 10/12/2022] [Indexed: 12/27/2022] Open
Abstract
Recently, a new liver allocation policy called the acuity circles (AC) framework was implemented to decrease geographic disparities in transplant metrics across donor service areas. Early analyses have examined the changes in outcomes because of the AC policy. However, perceptions among transplant surgeons and staff regarding the new policy remain unknown. Methods A 28-item survey was sent to division chiefs and surgical directors of liver transplantation across the United States. Questions assessed the respondents' perceptions regarding center-level metrics and staff satisfaction. We used Organ Procurement and Transplantation Network data to study differences in allocation between the pre-AC implementation period (2019) and the post-AC implementation period (2020-2021). Results A total of 40 participants completed this ongoing survey study. Most responses were from region 8 (13%), region 10 (15%), and region 11 (13%). Sixty-three percent of respondents stated that the wait time for a suitable offer for recipients with model of end-stage liver disease score <30 has decreased, whereas 50% stated that wait time for a suitable offer for recipients with model of end-stage liver disease score >30 has increased. However, most respondents (75%) felt that the average cost per transplant had increased and that the rate of surgical complications and 1-y graft survival had remained the same. In most states, an observable decrease in in-state liver transplantations occurred each year between 2019 and 2021. In addition, most allocation regions reported an increase in donations after circulatory deaths between 2019 and 2021. Conclusions Perceptions of the new AC policy among liver transplant surgeons in the United States remain mixed, highlighting the potential strengths and concerns regarding its future impact. Further studies should assess the effects of the AC policy on clinical outcomes and liver transplantation access.
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Abstract
PURPOSE OF REVIEW The Final Rule clearly states that geography should not be a determinant of a chance of a potential candidate being transplanted. There have been multiple concerns about geographic disparities in patients in need of solid organ transplantation. Allocation policy adjustments have been designed to address these concerns, but there is little evidence that the disparities have been solved. The purpose of this review is to describe the main drivers of geographic disparities in solid organ transplantation and how allocation policy changes and other potential actions could impact these inequalities. RECENT FINDINGS Geographical disparities have been reported in kidney, pancreas, liver, and lung transplantation. Organ Procurement and Transplant Network has modified organ allocation rules to underplay geography as a key determinant of a candidates' chance of receiving an organ. Thus, heart, lung, and more recently liver and Kidney Allocation Systems have incorporated broader organ sharing to reduce geographical disparities. Whether these policy adjustments will indeed eliminate geographical disparities are still unclear. SUMMARY Modern allocation policy focus in patients need, regardless of geography. Innovative actions to further reduce geographical disparities are needed.
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Liver Transplant Center Size and The Impact on the Clinical Outcomes and Resource Utilization. Transplantation 2021; 106:988-996. [PMID: 34366386 DOI: 10.1097/tp.0000000000003915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prior studies suggest that transplant center volume is associated with liver transplantation (LT) outcomes. We compared patient characteristics and waitlist outcomes among transplant centers in the U.S. with different volumes. METHODS Data for adult waitlisted candidates and LT recipients in the U.S. between 2008 and 2017 were extracted from the Scientific Registry of Transplant Recipients database. Transplant centers were categorized by transplants/year into tertiles:low-volume centers (LVCs; <20 transplantations per year)medium-volume centers (MVCs; 20-55 transplantations per year)high-volume centers (HVCs; >55 transplantations per year)Patient characteristics, waitlist outcomes, and factors associated with post-transplantation mortality were compared. RESULTS From 141 centers, 112,110 patients were waitlisted for LT: 6% at LVCs, 26% at MVCs, and 68% at HVCs. Patients listed in LVCs were less likely to have private insurance but had higher Medicaid and Veterans Affairs healthcare rates. Patients at LVCs were less likely to receive LT (47% vs. 53% in MVC vs. 61% in HVC), had higher transfer rates to other centers, and were more likely to be removed from the waitlist. In competing risk survival analysis, adjusted for center location, MELD score, and clinico-demographic factors, patients listed at an HVC were more likely to receive LT (aHR:1.30; 95%CI= 1.27-1.33; P<0.001). Among LT-recipients (n=62,131), receiving a transplant at an LVC was associated with higher post-LT mortality (aHR:1.16; 95%CI=1.05-1.28; P=0.003). CONCLUSION Patients in LVCs were less likely to receive a LT and a higher risk of post-LT death.Supplemental Visual Abstract; http://links.lww.com/TP/C274.
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7
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Da BL, Ezaz G, Kushner T, Crismale J, Kakked G, Gurakar A, Dieterich D, Schiano TD, Saberi B. Donor Characteristics and Regional Differences in the Utilization of HCV-Positive Donors in Liver Transplantation. JAMA Netw Open 2020; 3:e2027551. [PMID: 33275155 PMCID: PMC7718602 DOI: 10.1001/jamanetworkopen.2020.27551] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Increased utilization of hepatitis C virus (HCV)-positive liver allografts for liver transplant (LT) has been endorsed as one of several ways to combat national organ shortages. However, HCV-positive donors remain poorly characterized, and Organ Procurement and Transplantation Network regional differences in the utilization of HCV-positive liver allografts are unclear. OBJECTIVE To characterize HCV-positive donors and the allografts that come from them. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, the Scientific Registry of Transplant Recipients database was queried for all donors who underwent HCV testing from June 2015 to December 2018. Clinical and allograft characteristics were evaluated, and utilization across the United States was studied. Patients with positive or negative results for HCV antibody (Ab) and HCV nucleic acid amplification testing (NAT) were included in this study. Donors utilized for living donor transplant and pediatric (age <18 years) recipients were excluded. MAIN OUTCOMES AND MEASURES The primary comparison was between donors who were HCV Ab positive and those who were HCV Ab negative. Regional variations in the utilization of HCV-positive and HCV-negative donors were analyzed. RESULTS Of 24 500 donors utilized for LT, 1887 (7.7%) were HCV Ab positive; 64.4% of HCV Ab-positive donors were HCV NAT positive. HCV Ab-positive donors were younger (median [interquartile range] age, 35 [29-46] years vs 40 [27-54] years) and had fewer comorbidities, such as diabetes (8.3% vs 12.0%) and hypertension (25.9% vs 35.2%), compared with HCV Ab-negative donors. These findings were even more pronounced in HCV Ab-positive /NAT-positive compared with HCV Ab-positive/NAT-negative donors. Organ Procurement and Transplantation Network regions 2, 3, 10, and 11 had the highest absolute utilization of HCV Ab-positive donors, accounting for 64.4% of all HCV Ab-positive donors used in the United States. Region 1 had the highest relative utilization of HCV Ab-positive donors (18.7%). The use of HCV Ab-positive donors in some regions was associated with the rate of drug overdose, but this was not always the case. Similar utilization results were found with HCV NAT-positive donors. CONCLUSIONS AND RELEVANCE In this cross-sectional study, HCV-positive donors were younger and healthier than utilized HCV-negative donors. Significant differences exist in the utilization of HCV-positive donors across the 11 Organ Procurement and Transplantation Network regions, which is not entirely explained by organ demand or by higher availability of HCV-positive livers as per the distribution of the opioid epidemic. Initiatives to increase the use of HCV-positive donors, particularly in regions of high organ demand, should be implemented.
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Affiliation(s)
- Ben L. Da
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
- Sandra Atlas Bass Center for Liver Diseases & Transplantation, Division of Hepatology, Department of Internal Medicine, Donald and Barbara Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York
| | - Ghideon Ezaz
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - James Crismale
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gaurav Kakked
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ahmet Gurakar
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Douglas Dieterich
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Thomas D. Schiano
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Behnam Saberi
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Benhammou JN, Aby ES, Shirvanian G, Manansala K, Hussain SK, Tong MJ. Improved survival after treatments of patients with nonalcoholic fatty liver disease associated hepatocellular carcinoma. Sci Rep 2020; 10:9902. [PMID: 32555268 PMCID: PMC7303220 DOI: 10.1038/s41598-020-66507-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/22/2020] [Indexed: 02/07/2023] Open
Abstract
Worldwide, nonalcoholic fatty liver disease (NAFLD) has reached epidemic proportions and in parallel, hepatocellular carcinoma (HCC) has become one of the fastest growing cancers. Despite the rise in these disease entities, detailed long-term outcomes of large NAFLD-associated HCC cohorts are lacking. In this report, we compared the overall and recurrence-free survival rates of NAFLD HCC cases to patients with HBV and HCV-associated HCC cases. Distinguishing features of NAFLD-associated HCC patients in the cirrhosis and non-cirrhosis setting were also identified. We conducted a retrospective study of 125 NAFLD, 170 HBV and 159 HCV HCC patients, utilizing clinical, pathological and radiographic data. Multivariate regression models were used to study the overall and recurrence-free survival. The overall survival rates were significantly higher in the NAFLD-HCC cases compared to HBV-HCC (HR = 0.35, 95% CI 0.15-0.80) and HCV-HCC (HR = 0.37, 95% CI 0.17-0.77) cases. The NAFLD-HCC patients had a trend for higher recurrence-free survival rates compared to HBV and HCV-HCC cases. Within the NAFLD group, 18% did not have cirrhosis or advanced fibrosis; Hispanic ethnicity (OR = 12.34, 95% CI 2.59-58.82) and high BMI (OR = 1.19, 95% CI 1.07-1.33) were significantly associated with having cirrhosis. NAFLD-HCC cases were less likely to exhibit elevated serum AFP (p < 0.0001). After treatments, NAFLD-related HCC patients had longer overall but not recurrence-free survival rates compared to patients with viral-associated HCC. Non-Hispanic ethnicity and normal BMI differentiated non-cirrhosis versus cirrhosis NAFLD HCC. Further studies are warranted to identify additional biomarkers to stratify NAFLD patients without cirrhosis who are at risk for HCC.
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Affiliation(s)
- Jihane N Benhammou
- Pfleger Liver Institute, University of California Los Angeles, Los Angeles, CA, USA.
| | - Elizabeth S Aby
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Gayaneh Shirvanian
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Kohlett Manansala
- Pfleger Liver Institute, University of California Los Angeles, Los Angeles, CA, USA
| | - Shehnaz K Hussain
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
- Department of Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Myron J Tong
- Pfleger Liver Institute, University of California Los Angeles, Los Angeles, CA, USA
- Liver Center, Huntington Medical Research Institutes, Pasadena, CA, USA
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Schenk AD, Washburn WK. Disentangling Candidate Priority and Candidate Geography in Patients With Hepatocellular Carcinoma. Liver Transpl 2020; 26:624-625. [PMID: 32167670 DOI: 10.1002/lt.25749] [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: 03/10/2020] [Accepted: 03/10/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Austin D Schenk
- The Comprehensive Transplant Center, The Ohio State Wexner Medical Center, Columbus, OH
| | - W Kenneth Washburn
- The Comprehensive Transplant Center, The Ohio State Wexner Medical Center, Columbus, OH
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10
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Geographic Disparities in Liver Allocation and Distribution in the United States: Where Are We Now? Transplant Proc 2019; 51:3205-3212. [PMID: 31732201 DOI: 10.1016/j.transproceed.2019.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/24/2019] [Accepted: 07/09/2019] [Indexed: 12/13/2022]
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Bowring MG, Zhou S, Chow EK, Massie AB, Segev DL, Gentry SE. Geographic Disparity in Deceased Donor Liver Transplant Rates Following Share 35. Transplantation 2019; 103:2113-2120. [PMID: 30801545 PMCID: PMC6699938 DOI: 10.1097/tp.0000000000002643] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The Organ Procurement and Transplantation Network implemented Share 35 on June 18, 2013, to broaden deceased donor liver sharing within regional boundaries. We investigated whether increased sharing under Share 35 impacted geographic disparity in deceased donor liver transplantation (DDLT) across donation service areas (DSAs). METHODS Using Scientific Registry of Transplant Recipients June 2009 to June 2017, we identified 86 083 adult liver transplant candidates and retrospectively estimated Model for End-Stage Liver Disease (MELD)-adjusted DDLT rates using nested multilevel Poisson regression with random intercepts for DSA and transplant program. From the variance in DDLT rates across 49 DSAs and 102 programs, we derived the DSA-level median incidence rate ratio (MIRR) of DDLT rates. MIRR is a robust metric of heterogeneity across each hierarchical level; larger MIRR indicates greater disparity. RESULTS MIRR was 2.18 pre-Share 35 and 2.16 post-Share 35. Thus, 2 candidates with the same MELD in 2 different DSAs were expected to have a 2.2-fold difference in DDLT rate driven by geography alone. After accounting for program-level heterogeneity, MIRR was attenuated to 2.10 pre-Share 35 and 1.96 post-Share 35. For candidates with MELD 15-34, MIRR decreased from 2.51 pre- to 2.27 post-Share 35, and for candidates with MELD 35-40, MIRR increased from 1.46 pre- to 1.51 post-Share 35, independent of program-level heterogeneity in DDLT. DSA-level heterogeneity in DDLT rates was greater than program-level heterogeneity pre- and post-Share 35. CONCLUSIONS Geographic disparity substantially impacted DDLT rates before and after Share 35, independent of program-level heterogeneity and particularly for candidates with MELD 35-40. Despite broader sharing, geography remains a major determinant of access to DDLT.
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Affiliation(s)
- Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sheng Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eric K.H. Chow
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
- Scientific Registry of Transplant Recipients, Minneapolis, MN, USA
| | - Sommer E. Gentry
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Mathematics, United States Naval Academy, Baltimore, MD, USA
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12
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Samstein B, McElroy LM. Agree on much, except it is time for change. Am J Transplant 2019; 19:1912-1916. [PMID: 30884119 DOI: 10.1111/ajt.15362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 02/11/2019] [Accepted: 03/10/2019] [Indexed: 01/25/2023]
Abstract
The imbalance between supply and demand of organs for transplant will not be fully solved by changes to the allocation system. Improved organ donation and utilization must be accomplished through critical reassessment of organ procurement organization (OPO) performance as a partnership between transplant centers, OPOs, and community hospitals. The continued discussion on changes to the organ distribution system should be based on patient-centeredness, enhanced transparency, improved models, and metrics. Focusing too heavily on geography without consideration for the other factors at play risks oversimplification of this complex issue.
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13
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Haugen CE, Ishaque T, Sapirstein A, Cauneac A, Segev DL, Gentry S. Geographic disparities in liver supply/demand ratio within fixed-distance and fixed-population circles. Am J Transplant 2019; 19:2044-2052. [PMID: 30748095 PMCID: PMC6591030 DOI: 10.1111/ajt.15297] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 01/25/2023]
Abstract
Recent OPTN proposals to address geographic disparity in liver allocation have involved circular boundaries: the policy selected 12/17 allocated to 150-mile circles in addition to DSAs/regions, and the policy selected 12/18 allocated to 150-mile circles eliminating DSA/region boundaries. However, methods to reduce geographic disparity remain controversial, within the OPTN and the transplant community. To inform ongoing discussions, we studied center-level supply/demand ratios using SRTR data (07/2013-06/2017) for 27 334 transplanted deceased donor livers and 44 652 incident waitlist candidates. Supply was the number of donors from an allocation unit (DSA or circle), allocated proportionally (by waitlist size) to the centers drawing on these donors. We measured geographic disparity as variance in log-transformed supply/demand ratio, comparing allocation based on DSAs, fixed-distance circles (150- or 400-mile radius), and fixed-population (12- or 50-million) circles. The recently proposed 150-mile radius circles (variance = 0.11, P = .9) or 12-million-population circles (variance = 0.08, P = .1) did not reduce the geographic disparity compared to DSA-based allocation (variance = 0.11). However, geographic disparity decreased substantially to 0.02 in both larger fixed-distance (400-mile, P < .001) and larger fixed-population (50-million, P < .001) circles (P = .9 comparing fixed distance and fixed population). For allocation circles to reduce geographic disparities, they must be larger than a 150-mile radius; additionally, fixed-population circles are not superior to fixed-distance circles.
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Affiliation(s)
- Christine E. Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tanveen Ishaque
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Abel Sapirstein
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander Cauneac
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota
| | - Sommer Gentry
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Mathematics, United States Naval Academy, Annapolis, Maryland
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14
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Abstract
PURPOSE OF REVIEW Scarcity is a defining feature of the modern transplant landscape, and in light of chronic shortages in donor organs, there is cause for concern about geographic inequities in patients' access to lifesaving resources. Recent policy changes designed to ameliorate unequal donor supply and demand have brought new interest to measuring and addressing disparities at all stages of transplant care. The purpose of this review is to describe an overview of recent literature on geographic inequities in transplant access, focusing on kidney, liver, and lung transplantation and the impact of policy changes on organ allocation. RECENT FINDINGS Despite a major change to the kidney allocation policy in 2014, geographic inequity in kidney transplant access remains. In liver transplantation, the debate has centered on the median acuity score at transplantation; however, a more thorough examination of disparities in access and survival has emerged. SUMMARY Geographic differences in access and quality of transplant care are undeniable, but existing disparity metrics reflect disparities only among candidates who are waitlisted. Future research should address major gaps in our understanding of geographic inequity in transplant access, including patients who may be transplant-eligible but experience a wide variety of barriers in accessing the transplant waiting list.
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15
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MacKay D, Fitz S. Geographic Location and Moral Arbitrariness in the Allocation of Donated Livers. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2019; 47:308-319. [PMID: 31298097 DOI: 10.1177/1073110519857287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The federal system for allocating donated livers in the United States is often criticized for allowing geographic disparities in access to livers. Critics argue that such disparities are unfair on the grounds that where one lives is morally arbitrary and so should not influence one's access to donated livers. They argue instead that livers should be allocated in accordance with the equal opportunity principle, according to which US residents who are equally sick should have the same opportunity to receive a liver, regardless of where they live. In this paper, we examine a central premise of the argument for the equal opportunity principle, namely, that geographic location is a morally arbitrary basis for allocating livers. We raise some serious doubts regarding the truth of this premise, arguing that under certain conditions, factors closely associated with geographic location are relevant to the allocation of livers, and so that candidates' geographic location is sometimes a morally non-arbitrary basis for allocating livers. Geographic location is morally non-arbitrary, we suggest, since by taking it into account, the UNOS may better fulfill its central goals of facilitating the effective and efficient placement of organs for transplantation and increasing organ donation.
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Affiliation(s)
- Douglas MacKay
- Douglas MacKay, Ph.D., is an Assistant Professor in the Department of Public Policy at the University of North Carolina at Chapel Hill. He is also a Core Faculty Member of the UNC Center for Bioethics and the UNC Philosophy, Politics, & Economics Program. He is currently working on projects concerning the ethics of public policy research, the ethics of immigration policy, and the ethics of welfare policy. Samuel Fitz currently works in New York City as a research analyst for Benenson Strategy Group. He recently graduated from the University of North Carolina at Chapel Hill's Honors College with a degree in Public Policy and Economics
| | - Samuel Fitz
- Douglas MacKay, Ph.D., is an Assistant Professor in the Department of Public Policy at the University of North Carolina at Chapel Hill. He is also a Core Faculty Member of the UNC Center for Bioethics and the UNC Philosophy, Politics, & Economics Program. He is currently working on projects concerning the ethics of public policy research, the ethics of immigration policy, and the ethics of welfare policy. Samuel Fitz currently works in New York City as a research analyst for Benenson Strategy Group. He recently graduated from the University of North Carolina at Chapel Hill's Honors College with a degree in Public Policy and Economics
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16
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Abstract
PURPOSE OF REVIEW Organ allocation is a highly complex process with significant impact on outcomes of donor organs and end-stage organ disease patients. Policies governing allocation must incorporate numerous factors to meet stated objective. There have been significant alterations and ongoing discussion about changes in allocation policy for all solid organs in the United States. As with any policy change, rigorous evaluation of the impact of changes is important. RECENT FINDINGS This manuscript discusses metrics to consider to evaluate the impact of organ allocation policy that may be monitored on an ongoing basis including examples of research evaluating current policies. Potential metrics to evaluate allocation policy include the effectiveness, efficiency, equity, costs, donor rates, and transparency associated with the system. SUMMARY Ultimately, policies will often need to adapt to secular changes in donor and patient characteristics, clinical and technological advances, and overarching healthcare polices. Providing objective empirical evaluation of the impact of policies is a critical component for assessing quality of the allocation system and informing the effect of changes. The foundation of organ transplantation is built upon public trust and the dependence on the gift of donor organs, as such the importance of the most appropriate organ allocation policies cannot be overstated.
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17
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Lynch RJ, Ye F, Sheng Q, Zhao Z, Karp SJ. State-Based Liver Distribution: Broad Sharing With Less Harm to Vulnerable and Underserved Communities Compared With Concentric Circles. Liver Transpl 2019; 25:588-597. [PMID: 30873761 DOI: 10.1002/lt.25425] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/20/2019] [Indexed: 12/31/2022]
Abstract
Allocation of livers for transplantation faces regulatory pressure to move toward broader sharing. A current proposal supported by the United Network for Organ Sharing Board of Directors relies on concentric circles, but its effect on socioeconomic inequities in access to transplant services is poorly understood. In this article, we offer a proposal that uses the state of donation as a unit of distribution, given that the state is a recognized unit of legal jurisdiction and socioeconomic health in many contexts. The Scientific Registry of Transplant Recipients liver simulated allocation model algorithm was used to generate comparative estimates of regional transplant volume and the impact of these considered changes with regard to vulnerable and high-risk patients on the waiting list and to disparities in wait-list access. State-based liver distribution outperforms the concentric circle models in overall system efficiency, reduced discards, and minimized flights for organs. Furthermore, the efflux of organs from areas of greater sociodemographic vulnerability and lesser wait-list access is more than 2-fold lower in a state-based model than in concentric circle alternatives. In summary, we propose that a state-based system offers a legally defensible, practical, and ethically sound alternative to geometric zones of organ distribution.
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Affiliation(s)
- Raymond J Lynch
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Fei Ye
- Center for Quantitative Sciences, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Quanhu Sheng
- Center for Quantitative Sciences, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Zhiguo Zhao
- Center for Quantitative Sciences, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Seth J Karp
- Transplant Center, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
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18
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Hanto DW, Ladin K. Travel time disparities in access to liver transplantation in the United Kingdom: An argument for adding another center. Am J Transplant 2019; 19:13-14. [PMID: 30086208 DOI: 10.1111/ajt.15060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/31/2018] [Indexed: 01/25/2023]
Affiliation(s)
- Douglas W Hanto
- Veterans Administration St. Louis Health Care System, St. Louis, MO, USA
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA, USA
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19
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Ye F, Sheng Q, Feurer ID, Zhao Z, Fan R, Teng J, Ping J, Rega SA, Hanto DW, Shyr Y, Karp SJ. Directed solutions to address differences in access to liver transplantation. Am J Transplant 2018; 18:2670-2678. [PMID: 29689125 DOI: 10.1111/ajt.14889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 03/20/2018] [Accepted: 04/15/2018] [Indexed: 01/25/2023]
Abstract
The United Network for Organ Sharing recently altered current liver allocation with the goal of decreasing Model for End-Stage Liver Disease (MELD) variance at transplant. Concerns over these and further planned revisions to policy include predicted decrease in total transplants, increased flying and logistical complexity, adverse impact on areas with poor quality health care, and minimal effect on high MELD donor service areas. To address these issues, we describe general approaches to equalize critical transplant metrics among regions and determine how they alter MELD variance at transplant and organ supply to underserved communities. We show an allocation system that increases minimum MELD for local allocation or preferentially directs organs into areas of need decreases MELD variance. Both models have minimal adverse effects on flying and total transplants, and do not disproportionately disadvantage already underserved communities. When combined together, these approaches decrease MELD variance by 28%, more than the recently adopted proposal. These models can be adapted for any measure of variance, can be combined with other proposals, and can be configured to automatically adjust to changes in disease incidence as is occurring with hepatitis C and nonalcoholic fatty liver disease.
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Affiliation(s)
- Fei Ye
- Center for Quantitative Sciences and Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Quanhu Sheng
- Center for Quantitative Sciences and Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Irene D Feurer
- Center for Quantitative Sciences and Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Surgery and the Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Zhiguo Zhao
- Center for Quantitative Sciences and Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Run Fan
- Center for Quantitative Sciences and Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jing Teng
- Center for Quantitative Sciences and Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jie Ping
- Center for Quantitative Sciences and Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott A Rega
- Department of Surgery and the Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Douglas W Hanto
- Department of Surgery, Veterans Affairs St. Louis Health Care System, Saint Louis, MO, USA
| | - Yu Shyr
- Center for Quantitative Sciences and Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Seth J Karp
- Department of Surgery and the Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
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20
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Bodzin AS, Baker TB. Liver Transplantation Today: Where We Are Now and Where We Are Going. Liver Transpl 2018; 24:1470-1475. [PMID: 30080954 DOI: 10.1002/lt.25320] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/10/2018] [Accepted: 07/24/2018] [Indexed: 12/12/2022]
Abstract
Liver transplantation was made a reality through the bravery, innovation, and persistence of Dr. Thomas Starzl. His death in 2017, at the age of 90, makes us pause to consider how far the field has come since its inception by this remarkable pioneer. It also is an opportunity to evaluate the continued novel innovations which contribute to the growth and potential for liver transplantation in the future. The liver transplant community in 2017 continued to be most significantly challenged by an overwhelming disparity between the need for liver transplant and the shortage of donor organs. The many ways in which this critical shortage are being addressed are examined in this article. The continued debate about equitable and efficacious organ allocation, "the liver wars," has dominated much of the recent past, while efforts to optimize current organ availability have also been aggressively pursued. Efforts to optimize the use of marginal and expanded criteria organs have escalated in recent years and have been accompanied by rigorous scientific evaluation. The ongoing opioid epidemic, combined with the approval and availability of highly effective hepatitis C treatment options, has allowed the increased use of HCV positive organs in HCV positive and negative recipients. Machine perfusion, both cold and warm, has moved solidly into the liver transplant world potentiating optimization of marginal donors and also offering potential modulation of liver grafts (ie, gene therapy, stem cell therapy, and defatting). Finally, pharmacological and mechanical interventions in DCD procurement techniques have contributed to improved outcomes in DCD transplants. All of these are explored in this article as a tribute to innovative spirit of Dr. Starzl and his continued impact on liver transplant today.
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Affiliation(s)
- Adam S Bodzin
- Transplantation Institute, University of Chicago Medicine, Chicago, IL
| | - Talia B Baker
- Transplantation Institute, University of Chicago Medicine, Chicago, IL
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21
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Beal EW, Tumin D, Sobotka L, Tobias JD, Hayes D, Pawlik TM, Washburn K, Mumtaz K, Conteh L, Black SM. Patients From Appalachia Have Reduced Access to Liver Transplantation After Wait-Listing. Prog Transplant 2018; 28:305-313. [PMID: 30205758 DOI: 10.1177/1526924818800037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Appalachian region is medically underserved and characterized by high morbidity and mortality. We investigated disparities among patients listed for liver transplantation (LT) in wait-list outcomes, according to residence in the Appalachian region. METHODS Data on adult patients listed for LT were obtained from the United Network for Organ Sharing for July 2013 to December 2015. Wait-list outcomes were compared using cause-specific hazard models by region of residence (Appalachian vs non-Appalachian) among patients listed at centers serving Appalachia. Posttransplant patient and graft survival were also compared. The study included 1835 LT candidates from Appalachia and 5200 from non-Appalachian regions, of whom 1016 patients experienced wait-list mortality or were delisted; 3505 received liver transplants. RESULTS In multivariable analyses, patients from Appalachia were less likely to receive LT (hazard ratio [HR] = 0.86; 95% confidence interval [CI]: 0.79-0.93; P < .001), but Appalachian residence was not associated with wait-list mortality or delisting (HR = 1.03; 95% CI: 0.89-1.18; P = .696). Among liver transplant recipients, patient and graft survival did not differ by Appalachian versus non-Appalachian residence. CONCLUSION Appalachian residence was associated with lower access to transplantation after listing for LT. This geographic disparity should be addressed in the current debate over reforming donor liver allocation and patient priority for LT.
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Affiliation(s)
- Eliza W Beal
- 1 Division of Transplantation, Department of General Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Dmitry Tumin
- 2 Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Lindsay Sobotka
- 3 Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joseph D Tobias
- 2 Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Don Hayes
- 4 Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- 5 Division of Surgical Oncology, Department of General Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kenneth Washburn
- 1 Division of Transplantation, Department of General Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Khalid Mumtaz
- 3 Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lanla Conteh
- 3 Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sylvester M Black
- 1 Division of Transplantation, Department of General Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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22
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Ladin K, Hanto DW. Equitable Access Is Not a Secondary Goal of Organ Allocation. Am J Transplant 2017; 17:3258. [PMID: 28597548 DOI: 10.1111/ajt.14387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- K Ladin
- Tufts University, Medford, MA
| | - D W Hanto
- St. Louis Veteran's Administration Hospital, St. Louis, MO
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23
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Glazier AK. It Is Bad Policy and Contrary to Federal Law to Prioritize Local Allocation of Livers to Address Geographically Based Social Inequities. Am J Transplant 2017; 17:3257. [PMID: 28556433 DOI: 10.1111/ajt.14384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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24
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Cantrelle C, Dorent R, Savoye E, Tuppin P, Lebreton G, Legeai C, Bastien O. Between-center disparities in access to heart transplantation in France: contribution of candidate and center factors - A comprehensive cohort study. Transpl Int 2017; 31:386-397. [PMID: 29130535 DOI: 10.1111/tri.13093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 09/20/2017] [Accepted: 11/08/2017] [Indexed: 11/29/2022]
Abstract
Transplantation represents the last option for patients with advanced heart failure. We assessed between-center disparities in access to heart transplantation in France 1 year after registration and evaluated the contribution of factors to these disparities. Adults (n = 2347) registered on the French national waiting list between January 1, 2010, and December 31, 2014, in the 23 transplant centers were included. Associations between candidate and transplant center characteristics and access to transplantation were assessed by proportional hazards frailty models. Candidate blood groups O and A, sensitization, and body mass index ≥30 kg/m2 were independently associated with lower access to transplantation, while female gender, severity of heart failure, and high serum bilirubin levels were independently associated with greater access to transplantation. Center factors significantly associated with access to transplantation were heart donation rate in the donation service area, proportion of high-urgency candidates among listed patients, and donor heart offer decline rate. Between-center variability in access to transplantation increased by 5% after adjustment for candidate factors and decreased by 57% after adjustment for center factors. After adjustment for candidate and center factors, five centers were still outside of normal variability. These findings will be taken into account in the future French heart allocation system.
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Affiliation(s)
| | | | | | - Philippe Tuppin
- Caisse Nationale d'Assurance Maladie des Travailleurs Salariés, Paris, France
| | - Guillaume Lebreton
- Service de Chirurgie Cardio-Vasculaire, Assistance Publique Hôpitaux de Paris, Hôpital de la Pitié Salpêtrière, Paris, France
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