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Florissi I, Chidi AP, Liu Y, Ruck JM, Mauney C, McAdams-DeMarco M, Merlo CA, Shah P, Stewart DE, Segev DL, Bush EL. Racial Disparities in Waiting List Outcomes of Patients Listed for Lung Transplantation. Ann Thorac Surg 2024; 117:619-626. [PMID: 37673311 PMCID: PMC10924067 DOI: 10.1016/j.athoracsur.2023.07.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 07/08/2023] [Accepted: 07/31/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND The Lung Allocation Score, implemented in 2005, prioritized lung transplant candidates by medical urgency rather than waiting list time and was expected to improve racial disparities in transplant allocation. We evaluated whether racial disparities in lung transplant persisted after 2005. METHODS We identified all wait-listed adult lung transplant candidates in the United States from 2005 through 2021 using the Scientific Registry of Transplant Recipients. We evaluated the association between race and receipt of a transplant by using a multivariable competing risk regression model adjusted for demographics, socioeconomic status, Lung Allocation Score, clinical measures, and time. We evaluated interactions between race and age, sex, socioeconomic status, and Lung Allocation Score. RESULTS We identified 33,158 candidates on the lung transplant waiting list between 2005 and 2021: 27,074 White (82%), 3350 African American (10%), and 2734 Hispanic (8%). White candidates were older, had higher education levels, and had lower Lung Allocation Scores (P < .001). After multivariable adjustment, African American and Hispanic candidates were less likely to receive lung transplants than White candidates (African American: adjusted subhazard ratio, 0.86; 95% CI, 0.82-0.91; Hispanic: adjusted subhazard ratio, 0.82; 95% CI, 0.78-0.87). Lung transplant was significantly less common among Hispanic candidates aged >65 years (P = .003) and non-White candidates from higher-poverty communities (African-American: P = .013; Hispanic: P =.0036). CONCLUSIONS Despite implementation of the Lung Allocation Score, racial disparities persisted for wait-listed African American and Hispanic lung transplant candidates and differed by age and poverty status. Targeted interventions are needed to ensure equitable access to this life-saving intervention.
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Affiliation(s)
- Isabella Florissi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexis P Chidi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yi Liu
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carrinton Mauney
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Pali Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Darren E Stewart
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Errol L Bush
- Division of Thoracic Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
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Lepore G, Long J, Tade Y, Shah NR, Murimwa G, Montgomery K, Chidi AP. First-generation physicians: The pursuit of academic surgery. Am J Surg 2024; 228:297-298. [PMID: 37735008 PMCID: PMC10922584 DOI: 10.1016/j.amjsurg.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 09/05/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Gina Lepore
- American Journal of Surgery Student and Resident Scholars Publications Delegation, USA.
| | - Jane Long
- American Journal of Surgery Student and Resident Scholars Publications Delegation, USA
| | - Yanick Tade
- American Journal of Surgery Student and Resident Scholars Publications Delegation, USA
| | - Nikhil R Shah
- American Journal of Surgery Student and Resident Scholars Publications Delegation, USA
| | - Gilbert Murimwa
- American Journal of Surgery Student and Resident Scholars Publications Delegation, USA
| | - Kelsey Montgomery
- American Journal of Surgery Student and Resident Scholars Publications Delegation, USA
| | - Alexis P Chidi
- American Journal of Surgery Student and Resident Scholars Publications Delegation, USA
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Feldman HA, Bostock IC, Chidi AP, Antonoff MB. Letter re: Mentorship Is Necessary but Not Sufficient to Promote Diversity in Surgery. Am Surg 2023; 89:6446-6447. [PMID: 35006024 DOI: 10.1177/00031348211067997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Affiliation(s)
- Hope A Feldman
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ian C Bostock
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Alexis P Chidi
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Chen VW, Chidi AP, Rosen T, Dong Y, Richardson PA, Kramer J, Axelrod DA, Petersen LA, Massarweh NN. Case Sampling vs Universal Review for Evaluating Hospital Postoperative Mortality in US Surgical Quality Improvement Programs. JAMA Surg 2023; 158:1312-1319. [PMID: 37755869 PMCID: PMC10535011 DOI: 10.1001/jamasurg.2023.4532] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/04/2023] [Indexed: 09/28/2023]
Abstract
Importance Representative surgical case sampling, rather than universal review, is used by US Department of Veterans Affairs (VA) and private-sector national surgical quality improvement (QI) programs to assess program performance and to inform local QI and performance improvement efforts. However, it is unclear whether case sampling is robust for identifying hospitals with safety or quality concerns. Objective To evaluate whether the sampling strategy used by several national surgical QI programs provides hospitals with data that are representative of their overall quality and safety, as measured by 30-day mortality. Design, Setting, and Participants This comparative effectiveness study was a national, hospital-level analysis of data from adult patients (aged ≥18 years) who underwent noncardiac surgery at a VA hospital between January 1, 2016, and September 30, 2020. Data were obtained from the VA Surgical Quality Improvement Program (representative sample) and the VA Corporate Data Warehouse surgical domain (100% of surgical cases). Data analysis was performed from July 1 to December 21, 2022. Main Outcomes and Measures The primary outcome was postoperative 30-day mortality. Quarterly, risk-adjusted, 30-day mortality observed-to-expected (O-E) ratios were calculated separately for each hospital using the sample and universal review cohorts. Outlier hospitals (ie, those with higher-than-expected mortality) were identified using an O-E ratio significantly greater than 1.0. Results In this study of data from 113 US Department of Veterans Affairs hospitals, the sample cohort comprised 502 953 surgical cases and the universal review cohort comprised 1 703 140. The majority of patients in both the representative sample and the universal sample were men (90.2% vs 91.1%) and were White (74.7% vs 74.5%). Overall, 30-day mortality was 0.8% and 0.6% for the sample and universal review cohorts, respectively (P < .001). Over 2145 quarters of data, hospitals were identified as an outlier in 11.7% of quarters with sampling and in 13.2% with universal review. Average hospital quarterly 30-day mortality rates were 0.4%, 0.8%, and 0.9% for outlier hospitals identified using the sample only, universal review only, and concurrent identification in both data sources, respectively. For nonsampled cases, average hospital quarterly 30-day mortality rates were 1.0% at outlier hospitals and 0.5% at nonoutliers. Among outlier hospital quarters in the sample, 47.4% were concurrently identified with universal review. For those identified with universal review, 42.1% were concurrently identified using the sample. Conclusions and Relevance In this national, hospital-level study, sampling strategies employed by national surgical QI programs identified less than half of hospitals with higher-than-expected perioperative mortality. These findings suggest that sampling may not adequately represent overall surgical program performance or provide stakeholders with the data necessary to inform QI efforts.
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Affiliation(s)
- Vivi W. Chen
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Alexis P. Chidi
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tracey Rosen
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Yongquan Dong
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Peter A. Richardson
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer Kramer
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | | | - Laura A. Petersen
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Nader N. Massarweh
- Surgical and Perioperative Care, Atlanta Veterans Affairs Health Care System, Decatur, Georgia
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
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Chen VW, Chidi AP, Dong Y, Richardson PA, Axelrod DA, Petersen LA, Massarweh NN. Risk-Adjusted Cumulative Sum for Early Detection of Hospitals With Excess Perioperative Mortality. JAMA Surg 2023; 158:1176-1183. [PMID: 37610743 PMCID: PMC10448363 DOI: 10.1001/jamasurg.2023.3673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/03/2023] [Indexed: 08/24/2023]
Abstract
Importance National surgical quality improvement programs lack tools for early detection of quality or safety concerns, which risks patient safety because of delayed recognition of poor performance. Objective To compare the risk-adjusted cumulative sum (CUSUM) with episodic evaluation for early detection of hospitals with excess perioperative mortality. Design, Setting, and Participants National, observational, hospital-level, comparative effectiveness study of 697 566 patients. Identification of hospitals with excess, risk-adjusted, quarterly 30-day mortality using observed to expected ratios (ie, current criterion standard in the Veterans Affairs Surgical Quality Improvement Program) was compared with the risk-adjusted CUSUM. Patients included in the study underwent a noncardiac operation at a Veterans Affairs hospital, had a record in the Veterans Affairs Surgical Quality Improvement Program (January 1, 2011, through December 31, 2016), and were aged 18 years or older. Main Outcome and Measure Number of hospitals identified as having excess risk-adjusted 30-day mortality. Results The cohort included 697 566 patients treated at 104 hospitals across 24 quarters. The mean (SD) age was 60.9 (13.2) years, 91.4% were male, and 8.6% were female. For each hospital, the median number of quarters detected with observed to expected ratios, at least 1 CUSUM signal, and more than 1 CUSUM signal was 2 quarters (IQR, 1-4 quarters), 8 quarters (IQR, 4-11 quarters), and 3 quarters (IQR, 1-4 quarters), respectively. During 2496 total quarters of data, outlier hospitals were identified 33.3% of the time (830 quarters) with at least 1 CUSUM signal within a quarter, 12.5% (311 quarters) with more than 1 CUSUM signal, and 11.0% (274 quarters) with observed to expected ratios at the end of the quarter. The CUSUM detection occurred a median of 49 days (IQR, 25-63 days) before observed to expected ratio reporting (1 signal, 35 days [IQR, 17-54 days]; 2 signals, 49 days [IQR, 26-61 days]; 3 signals, 58 days [IQR, 44-69 days]; ≥4 signals, 49 days [IQR, 42-69 days]; trend test, P < .001). Of 274 hospital quarters detected with observed to expected ratios, 72.6% (199) were concurrently detected by at least 1 CUSUM signal vs 42.7% (117) by more than 1 CUSUM signal. There was a dose-response relationship between the number of CUSUM signals in a quarter and the median observed to expected ratio (0 signals, 0.63; 1 signal, 1.28; 2 signals, 1.58; 3 signals, 2.08; ≥4 signals, 2.49; trend test, P < .001). Conclusions This study found that with CUSUM, hospitals with excess perioperative mortality can be identified well in advance of standard end-of-quarter reporting, which suggests episodic evaluation strategies fail to detect out-of-control processes and place patients at risk. Continuous performance evaluation tools should be adopted in national quality improvement programs to prevent avoidable patient harm.
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Affiliation(s)
- Vivi W. Chen
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Alexis P. Chidi
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Yongquan Dong
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Peter A. Richardson
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - David A. Axelrod
- Division of Transplantation, Department of Surgery, University of Iowa, Iowa City
| | - Laura A. Petersen
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Nader N. Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
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Ruck JM, Zeiser LB, Zhou AL, Chidi AP, Winchester SL, Durand CM, Ha JS, Shah PD, Massie AB, Segev DL, Merlo CA, Bush EL. Trends in use and three-year outcomes of hepatitis C virus-viremic donor lung transplants for hepatitis C virus-seronegative recipients. J Thorac Cardiovasc Surg 2023; 165:1587-1595.e2. [PMID: 36207160 PMCID: PMC9989038 DOI: 10.1016/j.jtcvs.2022.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The feasibility and 6-month outcome safety of lung transplants (LTs) from hepatitis C virus (HCV)-viremic donors for HCV-seronegative recipients (R-) were established in 2019, but longer-term safety and uptake of this practice nationally remain unknown. METHODS We identified HCV-seronegative LT recipients (R-) 2015-2020 using the Scientific Registry of Transplant Recipients. We classified donors as seronegative (D-) or viremic (D+). We used χ2 testing, rank-sum testing, and Cox regression to compare posttransplant outcomes between HCV D+/R- and D-/R- LT recipients. RESULTS HCV D+/R- LT increased from 2 to 97/year; centers performing HCV D+/R- LT increased from 1 to 25. HCV D+/R- versus HCV D-/R- LT recipients had more obstructive disease (35.7% vs 23.3%, P < .001), lower lung allocation score (36.5 vs 41.1, P < .001), and longer waitlist time (P = .002). HCV D+/R- LT had similar risk of acute rejection (adjusted odds ratio [aOR], 0.87; P = .58), extracorporeal membranous oxygenation (aOR, 1.94; P = .10), and tracheostomy (aOR, 0.42; P = .16); similar median hospital stay (P = .07); and lower risk of ventilator > 48 hours (aOR, 0.68; P = .006). Adjusting for donor, recipient, and transplant characteristics, risk of all-cause graft failure and mortality were similar at 30 days, 1 year, and 3 years for HCV D+/R- versus HCV D-/R- LT (all P > .1), as well as for high- (≥20/year) versus low-volume LT centers and high- (≥5/year) versus low-volume HCV D+/R- LT centers (all P > .5). CONCLUSIONS HCV D+/R- and HCV D-/R- LT have similar outcomes at 3 years posttransplant. These results underscore the safety of HCV D+/R- LT and the potential benefit of expanding this practice further.
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Affiliation(s)
- Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Laura B Zeiser
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Alice L Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Alexis P Chidi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Christine M Durand
- Division of Infectious Disease, Deparment of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jinny S Ha
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Pali D Shah
- Division of Pulmonology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Allan B Massie
- Department of Surgery, NYU Langone School of Medicine, New York, NY
| | - Dorry L Segev
- Department of Surgery, NYU Langone School of Medicine, New York, NY; Scientific Registry of Transplant Recipients, Minneapolis, Minn
| | - Christian A Merlo
- Division of Pulmonology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Errol L Bush
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
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Chidi AP, Antonoff MB. Hybrid video-assisted thoracoscopic sleeve lobectomy: an elegant minimally invasive technique for locally advanced non-small cell lung cancer. J Thorac Dis 2023; 15:1533-1535. [PMID: 37197535 PMCID: PMC10183493 DOI: 10.21037/jtd-23-77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 01/30/2023] [Indexed: 03/28/2023]
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Carney PR, Ma M, Theiss LM, Chidi AP. Introducing the American Journal of Surgery Virtual Research Mentor: A primer for aspiring surgeon-scientists. Am J Surg 2021; 223:1015-1016. [PMID: 34785031 DOI: 10.1016/j.amjsurg.2021.10.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/11/2021] [Accepted: 10/19/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Patrick R Carney
- University of Wisconsin School of Medicine and Public Health, 750 Highland Ave., Madison, WI, 53705, USA.
| | - Meixi Ma
- Department of Surgery, University of Alabama at Birmingham School of Medicine, 1808 7th Ave. S., Birmingham, AL, 35233, USA.
| | - Lauren M Theiss
- Department of Surgery, University of Alabama at Birmingham School of Medicine, 1808 7th Ave. S., Birmingham, AL, 35233, USA.
| | - Alexis P Chidi
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, 21287, USA.
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Chidi AP, Broderick SR. Commentary: Defining HSR: Health services research or healthy skepticism remains. J Thorac Cardiovasc Surg 2020; 161:819-820. [PMID: 33234252 DOI: 10.1016/j.jtcvs.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Alexis P Chidi
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Stephen R Broderick
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
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Varley PR, Tohme ST, Chidi AP, Goswami J, van der Windt D, Geller DA, Tsung A. Dissemination of Minimally Invasive Liver Resection for Primary Malignancy: Reevaluating Effectiveness. Ann Surg Oncol 2018; 25:808-817. [PMID: 29302818 DOI: 10.1245/s10434-017-6308-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Experiences at specialized hepatobiliary centers have demonstrated efficacy of minimally invasive liver resection, but concerns exist regarding whether these procedures would remain effective once disseminated to a broad range of clinical practices. We sought to present the first comparison of MILR and open liver resection (OLR) for primary liver malignancy from a nationally representative cancer registry. METHODS Cases of liver and intrahepatic bile duct cancer were identified from the National Cancer Data Base Participant Use File. Mixed effects logistic regression and stratified Cox proportional hazards regression were used for analysis. A propensity score matched cohort was used as an alternative form of analysis to evaluate the robustness of results. RESULTS A total of 3236 cases were analyzed from 2010 to 2011 with 2581 OLR (80%) and 655 MILR (20%). Of the variation in patient selection for MILR 28.5% was related to treatment at a specific treatment center; however, the proportion of MILR was similar among low-, medium-, and high-volume centers. Overall 90-day mortality was lower at high-volume centers (odds ratio [OR] 0.58; 95% confidence interval [CI] 0.40-0.85) compared with low-volume centers. MILR was similar to OLR in both 90-day mortality and overall survival (OR 0.9; 95% CI 0.62-1.10) and hazard ratio [HR] 0.88 (95% CI 0.72-1.07), regardless of treatment center volume. CONCLUSIONS MILR for primary liver malignancy is used across a variety of practice settings, with similar outcomes to OLR. While volume is associated with short-term outcomes of liver resection as a whole, this relationship is not explained by adoption of MILR at low-volume centers.
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Affiliation(s)
- Patrick R Varley
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Samer T Tohme
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alexis P Chidi
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Julie Goswami
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dirk van der Windt
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David A Geller
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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Tohme S, Chidi AP, Sud V, Tsung A. Prognostic Nutritional Index Is Associated with Survival in Patients with Unresectable Hepatocellular Carcinoma Treated with Radioembolization. J Vasc Interv Radiol 2017; 28:470-472. [DOI: 10.1016/j.jvir.2016.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 10/23/2016] [Accepted: 10/23/2016] [Indexed: 10/20/2022] Open
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Chidi AP, Bryce CL, Donohue JM, Fine MJ, Landsittel DP, Myaskovsky L, Rogal SS, Switzer GE, Tsung A, Smith KJ. Economic and Public Health Impacts of Policies Restricting Access to Hepatitis C Treatment for Medicaid Patients. Value Health 2016; 19:326-34. [PMID: 27325324 PMCID: PMC4916393 DOI: 10.1016/j.jval.2016.01.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 01/24/2016] [Accepted: 01/27/2016] [Indexed: 05/27/2023]
Abstract
BACKGROUND Interferon-free hepatitis C treatment regimens are effective but very costly. The cost-effectiveness, budget, and public health impacts of current Medicaid treatment policies restricting treatment to patients with advanced disease remain unknown. OBJECTIVES To evaluate the cost-effectiveness of current Medicaid policies restricting hepatitis C treatment to patients with advanced disease compared with a strategy providing unrestricted access to hepatitis C treatment, assess the budget and public health impact of each strategy, and estimate the feasibility and long-term effects of increased access to treatment for patients with hepatitis C. METHODS Using a Markov model, we compared two strategies for 45- to 55-year-old Medicaid beneficiaries: 1) Current Practice-only advanced disease is treated before Medicare eligibility and 2) Full Access-both early-stage and advanced disease are treated before Medicare eligibility. Patients could develop progressive fibrosis, cirrhosis, or hepatocellular carcinoma, undergo transplantation, or die each year. Morbidity was reduced after successful treatment. We calculated the incremental cost-effectiveness ratio and compared the costs and public health effects of each strategy from the perspective of Medicare alone as well as the Centers for Medicare & Medicaid Services perspective. We varied model inputs in one-way and probabilistic sensitivity analyses. RESULTS Full Access was less costly and more effective than Current Practice for all cohorts and perspectives, with differences in cost ranging from $5,369 to $11,960 and in effectiveness from 0.82 to 3.01 quality-adjusted life-years. In a probabilistic sensitivity analysis, Full Access was cost saving in 93% of model iterations. Compared with Current Practice, Full Access averted 5,994 hepatocellular carcinoma cases and 121 liver transplants per 100,000 patients. CONCLUSIONS Current Medicaid policies restricting hepatitis C treatment to patients with advanced disease are more costly and less effective than unrestricted, full-access strategies. Collaboration between state and federal payers may be needed to realize the full public health impact of recent innovations in hepatitis C treatment.
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Affiliation(s)
- Alexis P Chidi
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA.
| | - Cindy L Bryce
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Julie M Donohue
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Michael J Fine
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA
| | | | - Larissa Myaskovsky
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA
| | - Shari S Rogal
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA
| | - Galen E Switzer
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA
| | - Allan Tsung
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA
| | - Kenneth J Smith
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Tohme S, Varley PR, Landsittel DP, Chidi AP, Tsung A. Preoperative anemia and postoperative outcomes after hepatectomy. HPB (Oxford) 2016; 18:255-61. [PMID: 27017165 PMCID: PMC4814609 DOI: 10.1016/j.hpb.2015.09.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 09/22/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative anaemia is associated with adverse outcomes after surgery but outcomes after liver surgery specifically are not well established. We aimed to analyze the incidence of and effects of preoperative anemia on morbidity and mortality in patients undergoing liver resection. METHODS All elective hepatectomies performed for the period 2005-2012 recorded in the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database were evaluated. We obtained anonymized data for 30-day mortality and major morbidity (one or more major complication), demographics, and preoperative and perioperative risk factors. We used multivariable logistic regression models to assess the adjusted effect of anemia, which was defined as (hematocrit <39% in men, <36% in women), on postoperative outcomes. RESULTS We obtained data for 12,987 patients, of whom 4260 (32.8%) had preoperative anemia. Patients with preoperative anemia experienced higher postoperative major morbidity and mortality rates compared to those without anemia. After adjustment for predefined variables, preoperative anemia was an independent risk factor for postoperative major morbidity (adjusted OR 1.21, 1.09-1.33). After adjustment, there was no significant difference in postoperative mortality for patients with or without preoperative anemia (adjusted OR 0.88, 0.66-1.16). CONCLUSION Preoperative anemia is independently associated with an increased risk of major morbidity in patients undergoing hepatectomy. Therefore, it is crucial to readdress preoperative blood management in anemic patients prior to hepatectomy.
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Affiliation(s)
- Samer Tohme
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick R. Varley
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Douglas P. Landsittel
- Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alexis P. Chidi
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,Correspondence Allan Tsung, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 300, Pittsburgh, PA 15213, USA. Tel: +1 412 692 2001. Fax: +1 412 692 2002.
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Chidi AP, Rogal S, Bryce CL, Fine MJ, Good CB, Myaskovsky L, Rustgi VK, Tsung A, Smith KJ. Cost-effectiveness of new antiviral regimens for treatment-naïve U.S. veterans with hepatitis C. Hepatology 2016; 63:428-36. [PMID: 26524695 PMCID: PMC4718749 DOI: 10.1002/hep.28327] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 10/30/2015] [Indexed: 12/17/2022]
Abstract
UNLABELLED Recently approved, interferon-free medication regimens for treating hepatitis C are highly effective, but extremely costly. We aimed to identify cost-effective strategies for managing treatment-naïve U.S. veterans with new hepatitis C medication regimens. We developed a Markov model with 1-year cycle length for a cohort of 60-year-old veterans with untreated genotype 1 hepatitis C seeking treatment in a typical year. We compared using sofosbuvir/ledipasvir or ombitasvir/ritonavir/paritaprevir/dasabuvir to treat: (1) any patient seeking treatment; (2) only patients with advanced fibrosis or cirrhosis; or (3) patients with advanced disease first and healthier patients 1 year later. The previous standard of care, sofosbuvir/simeprevir or sofosbuvir/pegylated interferon/ribavirin, was included for comparison. Patients could develop progressive fibrosis, cirrhosis, or hepatocellular carcinoma, undergo transplantation, or die. Complications were less likely after sustained virological response. We calculated the incremental cost per quality-adjusted life year (QALY) and varied model inputs in one-way and probabilistic sensitivity analyses. We used the Veterans Health Administration perspective with a lifetime time horizon and 3% annual discounting. Treating any patient with ombitasvir-based therapy was the preferred strategy ($35,560; 14.0 QALYs). All other strategies were dominated (greater costs/QALY gained than more effective strategies). Varying treatment efficacy, price, and/or duration changed the preferred strategy. In probabilistic sensitivity analysis, treating any patient with ombitasvir-based therapy was cost-effective in 70% of iterations at a $50,000/QALY threshold and 65% of iterations at a $100,000/QALY threshold. CONCLUSION Managing any treatment-naïve genotype 1 hepatitis C patient with ombitasvir-based therapy is the most economically efficient strategy, although price and efficacy can impact cost-effectiveness. It is economically unfavorable to restrict treatment to patients with advanced disease or use a staged treatment strategy. (Hepatology 2016;63:428-436).
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Affiliation(s)
- Alexis P. Chidi
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
| | - Shari Rogal
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
| | - Cindy L. Bryce
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Hines, IL
| | - Michael J. Fine
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
| | - Chester B. Good
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL,VA Center for Medication Safety, Department of Veterans Affairs, Hines, IL
| | - Larissa Myaskovsky
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
| | - Vinod K. Rustgi
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kenneth J. Smith
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
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15
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Tohme S, Yazdani HO, Al-Khafaji AB, Chidi AP, Loughran P, Mowen K, Wang Y, Simmons RL, Huang H, Tsung A. Neutrophil Extracellular Traps Promote the Development and Progression of Liver Metastases after Surgical Stress. Cancer Res 2016; 76:1367-80. [PMID: 26759232 DOI: 10.1158/0008-5472.can-15-1591] [Citation(s) in RCA: 430] [Impact Index Per Article: 53.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 12/19/2015] [Indexed: 12/13/2022]
Abstract
Risks of tumor recurrence after surgical resection have been known for decades, but the mechanisms underlying treatment failures remain poorly understood. Neutrophils, first-line responders after surgical stress, may play an important role in linking inflammation to cancer progression. In response to stress, neutrophils can expel their protein-studded chromatin to form local snares known as neutrophil extracellular traps (NET). In this study, we asked whether, as a result of its ability to ensnare moving cells, NET formation might promote metastasis after surgical stress. Consistent with this hypothesis, in a cohort of patients undergoing attempted curative liver resection for metastatic colorectal cancer, we observed that increased postoperative NET formation was associated with a >4-fold reduction in disease-free survival. In like manner, in a murine model of surgical stress employing liver ischemia-reperfusion, we observed an increase in NET formation that correlated with an accelerated development and progression of metastatic disease. These effects were abrogated by inhibiting NET formation in mice through either local treatment with DNAse or inhibition of the enzyme peptidylarginine deaminase, which is essential for NET formation. In growing metastatic tumors, we found that intratumoral hypoxia accentuated NET formation. Mechanistic investigations in vitro indicated that mouse neutrophil-derived NET triggered HMGB1 release and activated TLR9-dependent pathways in cancer cells to promote their adhesion, proliferation, migration, and invasion. Taken together, our findings implicate NET in the development of liver metastases after surgical stress, suggesting that their elimination may reduce risks of tumor relapse.
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Affiliation(s)
- Samer Tohme
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hamza O Yazdani
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ahmed B Al-Khafaji
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alexis P Chidi
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Patricia Loughran
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Center for Biologic Imaging, Department of Cell Biology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kerri Mowen
- Department of Pharmacology and Department of Chemical Physiology, Scripps Research Institute, La Jolla, California
| | - Yanming Wang
- Department of Biochemistry & Molecular Biology, The Pennsylvania State University, University Park, Pennsylvania
| | - Richard L Simmons
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hai Huang
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Department of Surgery, Union Hospital, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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16
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Dong ZM, Chidi AP, Goswami J, Han K, Simmons RL, Rosengart MR, Tsung A. Prior inpatient admission increases the risk of post-operative infection in hepatobiliary and pancreatic surgery. HPB (Oxford) 2015; 17:1105-12. [PMID: 26333471 PMCID: PMC4644362 DOI: 10.1111/hpb.12499] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 07/16/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatobiliary and pancreatic (HPB) operations have a high incidence of post-operative nosocomial infections. The aim of the present study was to determine whether hospitalization up to 1 year before HPB surgery is associated with an increased risk of post-operative infection, surgical-site infection (SSI) and infection resistant to surgical chemoprophylaxis. METHODS A retrospective cohort study of patients undergoing HPB surgeries between January 2008 and June 2013 was conducted. A multivariable logistic regression model was used for controlling for potential confounders to determine the association between pre-operative admission and post-operative infection. RESULTS Of the 1384 patients who met eligibility criteria, 127 (9.18%) experienced a post-operative infection. Pre-operative hospitalization was independently associated with an increased risk of a post-operative infection [adjusted odds ratio (aOR): 1.61, 95% confidence interval [CI]: 1.06-2.46] and SSI (aOR: 1.79, 95% CI: 1.07-2.97). Pre-operative hospitalization was also associated with an increased risk of post-operative infections resistant to standard pre-operative antibiotics (OR: 2.64, 95% CI: 1.06-6.59) and an increased risk of resistant SSIs (OR: 3.99, 95% CI: 1.25-12.73). DISCUSSION Pre-operative hospitalization is associated with an increased incidence of post-operative infections, often with organisms that are resistant to surgical chemoprophylaxis. Patients hospitalized up to 1 year before HPB surgery may benefit from extended spectrum chemoprophylaxis.
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Affiliation(s)
- Zachary M Dong
- Department of Surgery, University of Pittsburgh School of MedicinePittsburgh, PA, USA
| | - Alexis P Chidi
- Department of Surgery, University of Pittsburgh School of MedicinePittsburgh, PA, USA
| | - Julie Goswami
- Department of Surgery, University of Pittsburgh School of MedicinePittsburgh, PA, USA
| | - Katrina Han
- Department of Surgery, University of Pittsburgh School of MedicinePittsburgh, PA, USA
| | - Richard L Simmons
- Department of Surgery, University of Pittsburgh School of MedicinePittsburgh, PA, USA
| | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh School of MedicinePittsburgh, PA, USA
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh School of MedicinePittsburgh, PA, USA
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Tohme S, Goswami J, Han K, Chidi AP, Geller DA, Reddy S, Gleisner A, Tsung A. Minimally Invasive Resection of Colorectal Cancer Liver Metastases Leads to an Earlier Initiation of Chemotherapy Compared to Open Surgery. J Gastrointest Surg 2015; 19:2199-206. [PMID: 26438480 PMCID: PMC4892107 DOI: 10.1007/s11605-015-2962-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/17/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Previous studies have shown benefit not only from postoperative chemotherapy but also from a short interval to initiation of treatment after resection of primary colorectal cancer. The aim of this study was to determine difference in timing to postoperative chemotherapy for minimally invasive resection (MIR) vs. open resection (OR) of colorectal cancer liver metastases (CRCLM). METHODS This is a retrospective review of 1:1 matched patients undergoing MIR (n = 66) and OR (n = 66) for CRCLM at a single institution. RESULTS Patients undergoing MIR of CRCLM had significantly shorter length of hospital stay, fewer major complications, and shorter interval to postoperative chemotherapy (median 42 vs. 63 days, p < 0.001). Univariable analysis showed that surgical approach, postoperative complications, blood loss, number of lesions, and length of stay were associated with timing to chemotherapy. On multivariable analysis, surgical approach was still associated with timing to chemotherapy, and postoperative complications resulted in a delay of chemotherapy among patients who underwent OR but not among those who underwent MIR. In addition, worse disease-free survival was seen among patients who received postoperative chemotherapy more than 60 days after surgery. CONCLUSION By modifying the deleterious effects of postoperative complications on timing of postoperative chemotherapy, patients undergoing MIR for CRCLM are treated with chemotherapy sooner after surgery compared to those undergoing OR.
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Affiliation(s)
- Samer Tohme
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Liver Cancer Center, 3459 Fifth Ave., 7 South, Pittsburgh, PA 15213, USA
| | - Julie Goswami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Liver Cancer Center, 3459 Fifth Ave., 7 South, Pittsburgh, PA 15213, USA
| | - Katrina Han
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Liver Cancer Center, 3459 Fifth Ave., 7 South, Pittsburgh, PA 15213, USA
| | - Alexis P. Chidi
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Liver Cancer Center, 3459 Fifth Ave., 7 South, Pittsburgh, PA 15213, USA
| | - David A. Geller
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Liver Cancer Center, 3459 Fifth Ave., 7 South, Pittsburgh, PA 15213, USA
| | - Srinevas Reddy
- Hepatobiliary and Pancreatic Surgery, Virginia Piper Cancer Institute—Allina Health, 800 East 28th Street, Ste 602, Minneapolis, MN 55415, USA
| | - Ana Gleisner
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Liver Cancer Center, 3459 Fifth Ave., 7 South, Pittsburgh, PA 15213, USA
| | - Allan Tsung
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Liver Cancer Center, 3459 Fifth Ave., 7 South, Pittsburgh, PA 15213, USA
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Chidi AP, Chishimba S, Kobayashi T, Hamapumbu H, Mharakurwa S, Thuma PE, Moss WJ. Validation of oral fluid samples to monitor serological changes to Plasmodium falciparum: an observational study in southern Zambia. Malar J 2011; 10:162. [PMID: 21663660 PMCID: PMC3141589 DOI: 10.1186/1475-2875-10-162] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 06/10/2011] [Indexed: 11/21/2022] Open
Abstract
Background In formerly endemic areas where malaria transmission has declined, levels of population immunity to Plasmodium falciparum provide information on continued malaria transmission and potentially susceptible populations. Traditional techniques for measuring serological responses to P. falciparum antigens use plasma or dried blood spots (DBS). These invasive procedures pose a biohazard and may be unacceptable to communities if performed frequently. The use of oral fluid (OF) samples to detect antibodies to P. falciparum antigens may be a more acceptable strategy to monitor changes in population immunity. Methods An enzyme immunoassay was optimized to detect antibodies to whole, asexual stage P. falciparum antigens. Optical density (OD) values from paired DBS and OF samples collected as part of a community-based survey of malaria parasitaemia were compared. Results Oral fluid and dried blood spot samples were collected from 53 participants in Southern Province, Zambia. Their ages ranged from 1 to 80 years and 45% were female. A statistically significant correlation (r = 0.79; P < 0.01) was observed between OD values from OF and DBS samples. The OF assay identified all DBS-confirmed positive and negative samples, resulting in 100% sensitivity and specificity. Conclusions Oral fluid is a valid alternative specimen for monitoring changes in antibodies to P. falciparum antigens. As OF collection is often more acceptable to communities, poses less of a biohazard than blood samples and can be performed by community volunteers, serological surveys using OF samples provide a strategy for monitoring population immunity in regions of declining malaria transmission.
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Affiliation(s)
- Alexis P Chidi
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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