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Butler CR, Reese PP, Cheng XS. Referral and Beyond: Restructuring the Kidney Transplant Process to Support Greater Access in the United States. Am J Kidney Dis 2024:S0272-6386(24)00743-1. [PMID: 38670253 DOI: 10.1053/j.ajkd.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/28/2024]
Abstract
Advocates for improved equity in kidney transplant in the US have recently focused efforts on initiatives to increase referral for transplant evaluation. However, because donor kidneys remain scarce, increased referrals are likely to result in an increasing number of patients proceeding through the evaluation process without ultimately receiving a kidney. Unfortunately, the process of referral and evaluation can be highly resource-intensive for patients, families, transplant programs, and payers. Patients and families may incur out-of-pocket expenses and be required to complete testing and treatments that they might not have chosen in the course of routine clinical care. Kidney transplant programs may struggle with insufficient capacity, inefficient workflow, and challenging programmatic finances and payers will need to absorb the increased expenses of upfront pretransplant costs. Increased referral in isolation may risk simply transmitting system stress and resulting disparities to downstream processes in this complex system. We argue that success in efforts to improve access through increased referrals hinges on adaptations to the pretransplant process more broadly. We call for an urgent reevaluation and redesign at multiple levels of the pretransplant system in order to achieve the aim of equitable access to kidney transplantation for all patients with kidney failure.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, WA; Veteran Affairs Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA; Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University, Palo Alto, CA.
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2
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Johansen KL, Gilbertson DT, Li S, Li S, Liu J, Roetker NS, Ku E, Schulman IH, Greer RC, Chan K, Abbott KC, Butler CR, O'Hare AM, Powe NR, Reddy YNV, Snyder J, St Peter W, Taylor JS, Weinhandl ED, Wetmore JB. US Renal Data System 2023 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2024; 83:A8-A13. [PMID: 38519262 DOI: 10.1053/j.ajkd.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
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3
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Morenz A, Ng YH, Butler CR. Learning From the Experiences of Undocumented Immigrant Kidney Transplant Recipients-From Exceptional Individuals to Equitable Systems. JAMA Netw Open 2024; 7:e2354548. [PMID: 38421654 DOI: 10.1001/jamanetworkopen.2023.54548] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Affiliation(s)
- Anna Morenz
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle
| | - Yue-Harn Ng
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - Catherine R Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
- VA Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, Washington
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Watnick S, Blake PG, Mehrotra R, Mendu M, Roberts G, Tummalapalli SL, Weiner DE, Butler CR. System-Level Strategies to Improve Home Dialysis: Policy Levers and Quality Initiatives. Clin J Am Soc Nephrol 2023; 18:1616-1625. [PMID: 37678234 PMCID: PMC10723911 DOI: 10.2215/cjn.0000000000000299] [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] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/18/2023] [Indexed: 09/09/2023]
Abstract
Advocacy and policy change are powerful levers to improve quality of care and better support patients on home dialysis. While the kidney community increasingly recognizes the value of home dialysis as an option for patients who prioritize independence and flexibility, only a minority of patients dialyze at home in the United States. Complex system-level factors have restricted further growth in home dialysis modalities, including limited infrastructure, insufficient staff for patient education and training, patient-specific barriers, and suboptimal physician expertise. In this article, we outline trends in home dialysis use, review our evolving understanding of what constitutes high-quality care for the home dialysis population (as well as how this can be measured), and discuss policy and advocacy efforts that continue to shape the care of US patients and compare them with experiences in other countries. We conclude by discussing future directions for quality and advocacy efforts.
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Affiliation(s)
- Suzanne Watnick
- Northwest Kidney Centers, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
- VA Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, Washington
| | - Peter G. Blake
- Division of Nephrology, Western University, London, Ontario, Canada
- Ontario Renal Network, Toronto, Ontario, Canada
| | - Rajnish Mehrotra
- Department of Medicine, University of Washington, Seattle, Washington
| | - Mallika Mendu
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Glenda Roberts
- Department of Medicine, University of Washington, Seattle, Washington
| | - Sri Lekha Tummalapalli
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
- The Rogosin Institute, New York, New York
| | - Daniel E. Weiner
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Catherine R. Butler
- Department of Medicine, University of Washington, Seattle, Washington
- VA Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, Washington
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Butler CR, Wightman AG. Beyond Autonomy: Ethics of Decision Making About Treatments for Kidney Failure at the Extremes of Age. Am J Kidney Dis 2023; 82:360-367. [PMID: 37028637 PMCID: PMC10524142 DOI: 10.1053/j.ajkd.2023.01.451] [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] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/18/2023] [Indexed: 04/08/2023]
Abstract
Decisions around initiating and forgoing treatments for kidney failure are complex, and contemporary approaches to medical decision making are designed to uphold patients' own preferences and values when there are multiple clinically reasonable treatment options. When patients do not have cognitive capacity to make their own decisions, these models can be adapted to support the previously expressed preferences of older adults and to promote open futures as autonomous persons for young children. Nonetheless, an autonomy-focused approach to decision making may not align with other overlapping values and needs of these groups. Dialysis profoundly shapes life experience. Values framing decisions about this treatment extend beyond independence and self-determination and vary between life stages. Patients at the extremes of age may place a strong emphasis on dignity, caring, nurturing, and joy. Models of decision making tailored to support an autonomous individual may also discount the role of family as not only surrogate decision makers but stakeholders whose lives and experience are interwoven with a patient's and will be shaped by their treatment decisions. These considerations underline a need to more flexibly incorporate a diversity of ethical frameworks to support medical decisions, especially for the very young and old, when facing complex medical decisions such as initiating or forgoing treatments for kidney failure.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, and the Kidney Research Institute, School of Medicine, University of Washington, Seattle; Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle.
| | - Aaron G Wightman
- Department of Pediatrics, School of Medicine, University of Washington, Seattle; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington
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Butler CR, Wightman AG, Taylor JS, Hick JL, O’Hare AM. Experiences of US Clinicians Contending With Health Care Resource Scarcity During the COVID-19 Pandemic, December 2020 to December 2021. JAMA Netw Open 2023; 6:e2318810. [PMID: 37326986 PMCID: PMC10276299 DOI: 10.1001/jamanetworkopen.2023.18810] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
Importance The second year of the COVID-19 pandemic saw periods of dire health care resource limitations in the US, sometimes prompting official declarations of crisis, but little is known about how these conditions were experienced by frontline clinicians. Objective To describe the experiences of US clinicians practicing under conditions of extreme resource limitation during the second year of the pandemic. Design, Setting, and Participants This qualitative inductive thematic analysis was based on interviews with physicians and nurses providing direct patient care at US health care institutions during the COVID-19 pandemic. Interviews were conducted between December 28, 2020, and December 9, 2021. Exposure Crisis conditions as reflected by official state declarations and/or media reports. Main Outcomes and Measures Clinicians' experiences as obtained through interviews. Results Interviews with 23 clinicians (21 physicians and 2 nurses) who were practicing in California, Idaho, Minnesota, or Texas were included. Of the 23 total participants, 21 responded to a background survey to assess participant demographics; among these individuals, the mean (SD) age was 49 (7.3) years, 12 (57.1%) were men, and 18 (85.7%) self-identified as White. Three themes emerged in qualitative analysis. The first theme describes isolation. Clinicians had a limited view on what was happening outside their immediate practice setting and perceived a disconnect between official messaging about crisis conditions and their own experience. In the absence of overarching system-level support, responsibility for making challenging decisions about how to adapt practices and allocate resources often fell to frontline clinicians. The second theme describes in-the-moment decision-making. Formal crisis declarations did little to guide how resources were allocated in clinical practice. Clinicians adapted practice by drawing on their clinical judgment but described feeling ill equipped to handle some of the operationally and ethically complex situations that fell to them. The third theme describes waning motivation. As the pandemic persisted, the strong sense of mission, duty, and purpose that had fueled extraordinary efforts earlier in the pandemic was eroded by unsatisfying clinical roles, misalignment between clinicians' own values and institutional goals, more distant relationships with patients, and moral distress. Conclusions and Relevance The findings of this qualitative study suggest that institutional plans to protect frontline clinicians from the responsibility for allocating scarce resources may be unworkable, especially in a state of chronic crisis. Efforts are needed to directly integrate frontline clinicians into institutional emergency responses and support them in ways that reflect the complex and dynamic realities of health care resource limitation.
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Affiliation(s)
- Catherine R. Butler
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle
- Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Aaron G. Wightman
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Hospital, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Janelle S. Taylor
- Department of Anthropology, University of Toronto, Toronto, Ontario, Canada
| | - John L. Hick
- Hennepin Healthcare, University of Minnesota, Minneapolis
| | - Ann M. O’Hare
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle
- Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Wong SPY, Prince DK, Kurella Tamura M, Hall YN, Butler CR, Engelberg RA, Vig EK, Curtis JR, O’Hare AM. Value Placed on Comfort vs Life Prolongation Among Patients Treated With Maintenance Dialysis. JAMA Intern Med 2023; 183:462-469. [PMID: 36972031 PMCID: PMC10043804 DOI: 10.1001/jamainternmed.2023.0265] [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: 11/26/2022] [Accepted: 01/29/2023] [Indexed: 03/29/2023]
Abstract
Importance Patients receiving maintenance dialysis experience intensive patterns of end-of-life care that might not be consistent with their values. Objective To evaluate the association of patients' health care values with engagement in advance care planning and end-of-life care. Design, Setting, and Participants Survey study of patients who received maintenance dialysis between 2015 and 2018 at dialysis centers in the greater metropolitan areas of Seattle, Washington, and Nashville, Tennessee, with longitudinal follow-up of decedents. Logistic regression models were used to estimate probabilities. Data analysis was conducted between May and October 2022. Exposures A survey question about the value that the participant would place on longevity-focused vs comfort-focused care if they were to become seriously ill. Main Outcomes and Measures Self-reported engagement in advance care planning and care received near the end of life through 2020 using linked kidney registry data and Medicare claims. Results Of 933 patients (mean [SD] age, 62.6 [14.0] years; 525 male patients [56.3%]; 254 [27.2%] identified as Black) who responded to the question about values and could be linked to registry data (65.2% response rate [933 of 1431 eligible patients]), 452 (48.4%) indicated that they would value comfort-focused care, 179 (19.2%) that they would value longevity-focused care, and 302 (32.4%) that they were unsure about the intensity of care they would value. Many had not completed an advance directive (estimated probability, 47.5% [95% CI, 42.9%-52.1%] of those who would value comfort-focused care vs 28.1% [95% CI, 24.0%-32.3%] of those who would value longevity-focused care or were unsure; P < .001), had not discussed hospice (estimated probability, 28.6% [95% CI, 24.6%-32.9%] comfort focused vs 18.2% [95% CI, 14.7%-21.7%] longevity focused or unsure; P < .001), or had not discussed stopping dialysis (estimated probability, 33.3% [95% CI, 29.0%-37.7%] comfort focused vs 21.9% [95% CI, 18.2%-25.8%] longevity focused or unsure; P < .001). Most respondents wanted to receive cardiopulmonary resuscitation (estimated probability, 78.0% [95% CI, 74.2%-81.7%] comfort focused vs 93.9% [95% CI, 91.4%-96.1%] longevity focused or unsure; P < .001) and mechanical ventilation (estimated probability, 52.0% [95% CI, 47.4%-56.6%] comfort focused vs 77.9% [95% CI, 74.0%-81.7%] longevity focused or unsure; P < .001). Among decedents, the percentages of participants who received an intensive procedure during the final month of life (estimated probability, 23.5% [95% CI, 16.5%-31.0%] comfort focused vs 26.1% [95% CI, 18.0%-34.5%] longevity focused or unsure; P = .64), discontinued dialysis (estimated probability, 38.3% [95% CI, 32.0%-44.8%] comfort focused vs 30.2% [95% CI, 23.0%-37.8%] longevity focused or unsure; P = .09), and enrolled in hospice (estimated probability, 32.2% [95% CI, 25.7%-38.7%] comfort focused vs 23.3% [95% CI, 16.4%-30.5%] longevity focused or unsure; P = .07) were not statistically different. Conclusions and Relevance This survey study found that there appeared to be a disconnect between patients' expressed values, which were largely comfort focused, and their engagement in advance care planning and end-of-life care, which reflected a focus on longevity. These findings suggest important opportunities to improve the quality of care for patients receiving dialysis.
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Affiliation(s)
| | | | | | - Yoshio N. Hall
- Department of Medicine, University of Washington, Seattle
| | | | | | | | - J. Randall Curtis
- Department of Medicine, Stanford University, Palo Alto, California
- Cambia Palliative Care Center of Excellence, Department of Medicine, University of Washington, Seattle
| | - Ann M. O’Hare
- Department of Medicine, University of Washington, Seattle
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Kattah AG, Butler CR. The Nephrologist's Role in Supporting People with CKD and Unplanned Pregnancy Post-Dobbs. J Am Soc Nephrol 2023; 34:530-532. [PMID: 36749205 PMCID: PMC10103197 DOI: 10.1681/asn.0000000000000081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/04/2023] [Indexed: 01/21/2023] Open
Affiliation(s)
- Andrea G Kattah
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Catherine R Butler
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington
- Veterans Affairs Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
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9
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Butler CR. Understanding Public Perspectives on Opt-Out Deceased Donor Transplant Policy: Ethically Obligatory and Practically Necessary. Clin J Am Soc Nephrol 2022; 17:1577-1579. [PMID: 36288932 PMCID: PMC9718040 DOI: 10.2215/cjn.11230922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Catherine R Butler
- Department of Medicine, Division of Nephrology, University of Washington, Seattle, Washington
- Department of Hospital and Specialty Medicine and Veterans Affairs Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
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10
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O’Hare AM, Vig EK, Iwashyna TJ, Fox A, Taylor JS, Viglianti EM, Butler CR, Vranas KC, Helfand M, Tuepker A, Nugent SM, Winchell KA, Laundry RJ, Bowling CB, Hynes DM, Maciejewski ML, Bohnert ASB, Locke ER, Boyko EJ, Ioannou GN. Complexity and Challenges of the Clinical Diagnosis and Management of Long COVID. JAMA Netw Open 2022; 5:e2240332. [PMID: 36326761 PMCID: PMC9634500 DOI: 10.1001/jamanetworkopen.2022.40332] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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] [Indexed: 11/06/2022] Open
Abstract
IMPORTANCE There is increasing recognition of the long-term health effects of SARS-CoV-2 infection (sometimes called long COVID). However, little is yet known about the clinical diagnosis and management of long COVID within health systems. OBJECTIVE To describe dominant themes pertaining to the clinical diagnosis and management of long COVID in the electronic health records (EHRs) of patients with a diagnostic code for this condition (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] code U09.9). DESIGN, SETTING, AND PARTICIPANTS This qualitative analysis used data from EHRs of a national random sample of 200 patients receiving care in the Department of Veterans Affairs (VA) with documentation of a positive result on a polymerase chain reaction (PCR) test for SARS-CoV-2 between February 27, 2020, and December 31, 2021, and an ICD-10 diagnostic code for long COVID between October 1, 2021, when the code was implemented, and March 1, 2022. Data were analyzed from February 5 to May 31, 2022. MAIN OUTCOMES AND MEASURES A text word search and qualitative analysis of patients' VA-wide EHRs was performed to identify dominant themes pertaining to the clinical diagnosis and management of long COVID. RESULTS In this qualitative analysis of documentation in the VA-wide EHR, the mean (SD) age of the 200 sampled patients at the time of their first positive PCR test result for SARS-CoV-2 in VA records was 60 (14.5) years. The sample included 173 (86.5%) men; 45 individuals (22.5%) were identified as Black and 136 individuals (68.0%) were identified as White. In qualitative analysis of documentation pertaining to long COVID in patients' EHRs 2 dominant themes were identified: (1) clinical uncertainty, in that it was often unclear whether particular symptoms could be attributed to long COVID, given the medical complexity and functional limitations of many patients and absence of specific markers for this condition, which could lead to ongoing monitoring, diagnostic testing, and specialist referral; and (2) care fragmentation, describing how post-COVID-19 care processes were often siloed from and poorly coordinated with other aspects of care and could be burdensome to patients. CONCLUSIONS AND RELEVANCE This qualitative study of documentation in the VA EHR highlights the complexity of diagnosing long COVID in clinical settings and the challenges of caring for patients who have or are suspected of having this condition.
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Affiliation(s)
- Ann M. O’Hare
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Elizabeth K. Vig
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Theodore J. Iwashyna
- Pulmonary and Critical Care Medicine, Department of Health Policy & Management, School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Alexandra Fox
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
| | | | - Elizabeth M. Viglianti
- Department of Internal Medicine Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor
| | - Catherine R. Butler
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Mark Helfand
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Anaïs Tuepker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Shannon M. Nugent
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Kara A. Winchell
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Ryan J. Laundry
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - C. Barrett Bowling
- Geriatric Research Education and Clinical Center, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Denise M. Hynes
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
- College of Public Health and Human Sciences and Center for Quantitative Life Sciences, Oregon State University, Corvallis
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Amy S. B. Bohnert
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Departments of Anesthesiology and Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Emily R. Locke
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
| | - Edward J. Boyko
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
| | - George N. Ioannou
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
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Butler CR, Wachterman MW, O’Hare AM. Concurrent Hospice and Dialysis: Proof of Concept. J Am Soc Nephrol 2022; 33:1808-1810. [PMID: 36096635 PMCID: PMC9528330 DOI: 10.1681/asn.2022080919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Catherine R. Butler
- Kidney Research Institute and Department of Medicine, Division of Nephrology, University of Washington, Seattle, Washington
- Hospital and Specialty Medicine Service and Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Melissa W. Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts
- Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ann M. O’Hare
- Kidney Research Institute and Department of Medicine, Division of Nephrology, University of Washington, Seattle, Washington
- Hospital and Specialty Medicine Service and Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
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12
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Struthers SA, Kribs Z, Butler CR. Policy and Kidney Community Engagement to Advance toward Greener Kidney Care. J Am Soc Nephrol 2022; 33:1811-1813. [PMID: 35981765 PMCID: PMC9528340 DOI: 10.1681/asn.2022070741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Sarah A Struthers
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | | | - Catherine R Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
- Department of Hospital and Specialty Medicine and VA Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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13
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Butler CR, Sharma RK, Eneanya ND, Bernacki GM, Ghuman JK, Curtis JR, O'Hare AM. Differences Among Racial and Ethnic Minority Groups in the Unmet Existential and Supportive Care Needs of People Receiving Dialysis. JAMA Intern Med 2022; 182:992-995. [PMID: 35816354 PMCID: PMC9274444 DOI: 10.1001/jamainternmed.2022.1677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This cohort study examines differences regarding existential and supportive care needs for patients with kidney disease between individuals of racial and ethnic minority groups compared with White individuals.
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Affiliation(s)
- Catherine R Butler
- Kidney Research Institute and Department of Medicine, Division of Nephrology, University of Washington, Seattle.,Veterans Affairs Health Services Research & Development Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Rashmi K Sharma
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Nwamaka D Eneanya
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Gwen M Bernacki
- Department of Medicine, Division of Cardiology, University of Washington and Veterans Administration Puget Sound Geriatric Research Education and Clinical Center, Seattle
| | - Jasleen K Ghuman
- Kidney Research Institute and Department of Medicine, Division of Nephrology, University of Washington, Seattle
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle.,Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
| | - Ann M O'Hare
- Kidney Research Institute and Department of Medicine, Division of Nephrology, University of Washington, Seattle.,Veterans Affairs Health Services Research & Development Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
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14
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Butler CR, Webster LB, Diekema DS. Staffing crisis capacity: a different approach to healthcare resource allocation for a different type of scarce resource. J Med Ethics 2022:medethics-2022-108262. [PMID: 35777960 PMCID: PMC9844994 DOI: 10.1136/jme-2022-108262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/24/2022] [Indexed: 06/15/2023]
Abstract
Severe staffing shortages have emerged as a prominent threat to maintaining usual standards of care during the COVID-2019 pandemic. In dire settings of crisis capacity, healthcare systems assume the ethical duty to maximise aggregate population-level benefit of existing resources. To this end, existing plans for rationing mechanical ventilators and intensive care unit beds in crisis capacity focus on selecting individual patients who are most likely to survive and prioritising these patients to receive scarce resources. However, staffing capacity is conceptually different from availability of these types of discrete resources, and the existing strategy of identifying and prioritising patients with the best prognosis cannot be readily adapted to fit this real-world scenario. We propose that two alternative approaches to staffing resource allocation offer a better conceptual fit: (1) prioritise the worst off: restrict access to acute care services and hospital admission for patients at relatively low clinical risk and (2) prioritise staff interventions with high near-term value: universally restrict selected interventions and treatments that require substantial staff time and/or energy but offer minimal near-term patient benefit. These strategies-while potentially resulting in care that deviates from usual standards-support the goal of maximising the aggregate benefit of scarce resources in crisis capacity settings triggered by staffing shortages. This ethical framework offers a foundation to support institutional leaders in developing operationalisable crisis capacity policies that promote fairness and support healthcare workers.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Hospital and Speciality Medicine, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Laura B Webster
- Bioethics Progam, Virginia Mason Medical Center, Seattle, Washington, USA
- Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Douglas S Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Trueman Katz Center for Pediatric Bioethics, Seattle Children's Research Institure, Seattle, Washington, USA
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15
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O'Hare AM, Butler CR, Laundry RJ, Showalter W, Todd-Stenberg J, Green P, Hebert PL, Wang V, Taylor JS, Van Eijk M, Matthews KL, Crowley ST, Carey E. Implications of Cross-System Use Among US Veterans With Advanced Kidney Disease in the Era of the MISSION Act: A Qualitative Study of Health Care Records. JAMA Intern Med 2022; 182:710-719. [PMID: 35576068 PMCID: PMC9112136 DOI: 10.1001/jamainternmed.2022.1379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
IMPORTANCE Since 2014, when Congress passed the Veterans Access Choice and Accountability (Choice) Act (replaced in 2018 with the more comprehensive Maintaining Internal Systems and Strengthening Integrated Outside Networks [MISSION] Act), the Department of Veterans Affairs (VA) has been paying for US veterans to receive increasing amounts of care in the private sector (non-VA care or VA community care). However, little is known about the implications of these legislative changes for the VA system. OBJECTIVE To describe the implications for the VA system of recent increases in VA-financed non-VA care. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was a thematic analysis of documentation in the electronic health records (EHRs) of a random sample of US veterans with advanced kidney disease between June 6, 2019, and February 5, 2021. EXPOSURES Mentions of community care in participant EHRs. MAIN OUTCOMES AND MEASURES Dominant themes pertaining to VA-financed non-VA care. RESULTS Among 1000 study participants, the mean (SD) age was 73.8 (11.4) years, and 957 participants (95.7%) were male. Three interrelated themes pertaining to VA-financed non-VA care emerged from qualitative analysis of documentation in cohort member EHRs: (1) VA as mothership, which describes extensive care coordination by VA staff members and clinicians to facilitate care outside the VA and the tendency of veterans and their non-VA clinicians to rely on the VA to fill gaps in this care; (2) hidden work of veterans, which describes the efforts of veterans and their family members to navigate the referral process, and to serve as intermediaries between VA and non-VA clinicians; and (3) strain on the VA system, which describes a challenging referral process and the ways in which cross-system care has stretched the traditional roles of VA staff and clinicians and interfered with VA care processes. CONCLUSIONS AND RELEVANCE The findings of this qualitative study describing VA-financed non-VA care for veterans with advanced kidney disease spotlight the substantial challenges of cross-system use and the strain placed on the VA system, VA staff and clinicians, and veterans and their families in recent years. These difficult-to-measure consequences of cross-system care should be considered when budgeting, evaluating, and planning the provision of VA-financed non-VA care in the private sector.
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Affiliation(s)
- Ann M O'Hare
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Washington.,VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington.,Department of Medicine and Kidney Research Institute, University of Washington, Seattle
| | - Catherine R Butler
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Washington.,VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington.,Department of Medicine and Kidney Research Institute, University of Washington, Seattle
| | - Ryan J Laundry
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington
| | - Whitney Showalter
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington
| | - Jeffrey Todd-Stenberg
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington
| | - Pam Green
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington
| | - Paul L Hebert
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle
| | - Virginia Wang
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine Durham, North Carolina.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Janelle S Taylor
- Department of Anthropology, University of Toronto, Ontario, Canada
| | | | | | - Susan T Crowley
- Department of Medicine, Yale University, New Haven, Connecticut.,VA Connecticut Health Care System, West Haven, Connecticut
| | - Evan Carey
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Denver
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16
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Butler CR, Appelbaum PS, Ascani H, Aulisio M, Campbell CE, de Boer IH, Dighe AL, Hall DE, Himmelfarb J, Knight R, Mehl K, Murugan R, Rosas SE, Sedor JR, O'Toole JF, Tuttle KR, Waikar SS, Freeman M. A Participant-Centered Approach to Understanding Risks and Benefits of Participation in Research Informed by the Kidney Precision Medicine Project. Am J Kidney Dis 2022; 80:132-138. [PMID: 34871700 PMCID: PMC9166631 DOI: 10.1053/j.ajkd.2021.10.006] [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] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/12/2021] [Indexed: 11/11/2022]
Abstract
An understanding of the ethical underpinnings of human subjects research that involves some risk to participants without anticipated direct clinical benefit-such as the kidney biopsy procedure as part of the Kidney Precision Medicine Project (KPMP)-requires a critical examination of the risks as well as the diverse set of countervailing potential benefits to participants. This kind of deliberation has been foundational to the development and conduct of the KPMP. Herein, we use illustrative features of this research paradigm to develop a more comprehensive conceptualization of the types of benefits that may be important to research participants, including respecting pluralistic values, supporting the opportunity to act altruistically, and enhancing benefits to a participant's community. This approach may serve as a model to help researchers, ethicists, and regulators to identify opportunities to better respect and support participants in future research that entails some risk to these participants as well as to improve the quality of research for people with kidney disease.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington; Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.
| | - Paul S Appelbaum
- Department of Psychiatry, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York; New York State Psychiatric Institute, New York, New York
| | - Heather Ascani
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Mark Aulisio
- Department of Bioethics, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Center for Biomedical Ethics, MetroHealth System, Cleveland, Ohio
| | - Catherine E Campbell
- Kidney Precision Medicine Project Patient Partner, American Association of Kidney Patients, Tampa, Florida; Sigma Theta Tau International Honor Society, Case Management Society of America, AARP Volunteer Nursing Leadership Board
| | - Ian H de Boer
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Ashveena L Dighe
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Daniel E Hall
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Wolff Center at UPMC, Pittsburgh, Pennsylvania; Center for Health Equity Research and Promotion and Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Jonathan Himmelfarb
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Richard Knight
- Kidney Precision Medicine Project Patient Partner, American Association of Kidney Patients, Tampa, Florida; American Association of Kidney Patients, Pittsburgh, Pennsylvania
| | - Karla Mehl
- Division of Nephrology, Irving Medical Center, Columbia University, New York, New York
| | - Raghavan Murugan
- Center for Critical Care Nephrology, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sylvia E Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - John R Sedor
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Department of Nephrology and Hypertension, Glickman Urological and Kidney and Lerner Research Institutes, Cleveland Clinic Foundation, Cleveland, Ohio
| | - John F O'Toole
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Department of Nephrology and Hypertension, Glickman Urological and Kidney and Lerner Research Institutes, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Katherine R Tuttle
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Sushrut S Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts; Renal Division, Brigham & Women's Hospital, Boston, Massachusetts
| | - Michael Freeman
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics and Humanities, Penn State College of Medicine, Hershey, Pennsylvania
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Butler CR, O'Hare AM, Wong SPY. Supporting scholarship in palliative care across the medical specialties. J Pain Symptom Manage 2022; 63:e665-e666. [PMID: 35595386 DOI: 10.1016/j.jpainsymman.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/09/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Catherine R Butler
- Division of Nephrology (C.R.B.,A.M.H., S.P.Y.W.), VA Puget Sound Health Care System, University of Washington, Seattle WA
| | - Ann M O'Hare
- Division of Nephrology (C.R.B.,A.M.H., S.P.Y.W.), VA Puget Sound Health Care System, University of Washington, Seattle WA
| | - Susan P Y Wong
- Division of Nephrology (C.R.B.,A.M.H., S.P.Y.W.), VA Puget Sound Health Care System, University of Washington, Seattle WA.
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18
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Butler CR, Watnick S. The Role of Dialysis Organizations in Promoting and Facilitating Access to Non-Dialytic Treatment Options. Kidney Med 2022; 4:100480. [PMID: 35637926 PMCID: PMC9142681 DOI: 10.1016/j.xkme.2022.100480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Butler CR, Webster LB, Diekema DS, Gray MM, Sakata VL, Tonelli MR, Vranas KC. Perspectives of Triage Team Members Participating in Statewide Triage Simulations for Scarce Resource Allocation During the COVID-19 Pandemic in Washington State. JAMA Netw Open 2022; 5:e227639. [PMID: 35435971 PMCID: PMC9016492 DOI: 10.1001/jamanetworkopen.2022.7639] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE The COVID-19 pandemic prompted health care institutions worldwide to develop plans for allocation of scarce resources in crisis capacity settings. These plans frequently rely on rapid deployment of institutional triage teams that would be responsible for prioritizing patients to receive scarce resources; however, little is known about how these teams function or how to support team members participating in this unique task. OBJECTIVE To identify themes illuminating triage team members' perspectives and experiences pertaining to the triage process. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was conducted using inductive thematic analysis of observations of Washington state triage team simulations and semistructured interviews with participants during the COVID-19 pandemic from December 2020 to February 2021. Participants included clinician and ethicist triage team members. Data were analyzed from December 2020 through November 2021. MAIN OUTCOMES AND MEASURES Emergent themes describing the triage process and experience of triage team members. RESULTS Among 41 triage team members (mean [SD] age, 50.3 [11.4] years; 21 [51.2%] women) who participated in 12 simulations and 21 follow-up interviews, there were 5 Asian individuals (12.2%) and 35 White individuals (85.4%); most participants worked in urban hospital settings (32 individuals [78.0%]). Three interrelated themes emerged from qualitative analysis: (1) understanding the broader approach to resource allocation: participants strove to understand operational and ethical foundations of the triage process, which was necessary to appreciate their team's specific role; (2) contending with uncertainty: team members could find it difficult or feel irresponsible making consequential decisions based on limited clinical and contextual patient information, and they grappled with ethically ambiguous features of individual cases and of the triage process as a whole; and (3) transforming mindset: participants struggled to disentangle narrow determinations about patients' likelihood of survival to discharge from implicit biases and other ethically relevant factors, such as quality of life. They cited the team's open deliberative process, as well as practice and personal experience with triage as important in helping to reshape their usual cognitive approach to align with this unique task. CONCLUSIONS AND RELEVANCE This study found that there were challenges in adapting clinical intuition and training to a distinctive role in the process of scarce resource allocation. These findings suggest that clinical experience, education in ethical and operational foundations of triage, and experiential training, such as triage simulations, may help prepare clinicians for this difficult role.
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Affiliation(s)
- Catherine R. Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
- Veterans Affairs Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Laura B. Webster
- Bioethics Program, Virginia Mason Medical Center, Seattle, Washington
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle
| | - Douglas S. Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Trueman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington
| | - Megan M. Gray
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Vicki L. Sakata
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Northwest Healthcare Response Network, Seattle, Washington
| | - Mark R. Tonelli
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland
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20
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Butler CR. A Critical Role for Shared Decision-Making about Referral and Evaluation for Kidney Transplant. Kidney360 2022; 3:14-16. [PMID: 35368579 PMCID: PMC8967623 DOI: 10.34067/kid.0007642021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/14/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Catherine R. Butler
- Division of Nephrology, Department of Medicine, University of Washington; Veterans Affairs Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
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21
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Butler CR, Webster LB, Sakata VL, Tonelli MR, Diekema DS, Gray MM. Functionality of Scarce Healthcare Resource Triage Teams During the COVID-19 Pandemic: A Multi-Institutional Simulation Study. Crit Care Explor 2022; 4:e0627. [PMID: 35083438 PMCID: PMC8785932 DOI: 10.1097/cce.0000000000000627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Plans for allocating scarce healthcare resources during the COVID-19 pandemic commonly involve the activation of institutional triage teams. These teams would be responsible for selecting patients who are most likely to survive to be prioritized to receive scarce resources. However, there is little empirical support for this approach. DESIGN High-fidelity triage-team simulation study. SETTING Healthcare institutions in Washington state. SUBJECTS Triage teams, consisting of at least two senior clinicians and a bioethicist. INTERVENTIONS Participants reviewed a limited amount of deidentified information for a diverse sample of critically ill patients. Teams then assigned each patient to one of five prioritization categories defined by likelihood of survival to hospital discharge. The process was refined based on observation and participant feedback after which a second phase of simulations was conducted. MEASUREMENTS AND MAIN RESULTS Feasibility was assessed by the time required for teams to perform their task. Prognostic accuracy was assessed by comparing teams' prediction about likelihood of survival to hospital discharge with real-world discharge outcomes. Agreement between the teams on prognostic categorization was evaluated using kappa statistics. Eleven triage team simulations (eight in phase 1 and three in phase 2) were conducted from December 2020 to February 2021. Overall, teams reviewed a median of 23 patient cases in each session (interquartile range [IQR], 17-29) and spent a median of 102 seconds (IQR, 50-268) per case. The concordance between expected survival and real-world survival to discharge was 71% (IQR, 64-76%). The overall agreement between teams for placement of patients into prognostic categories was moderate (weighted kappa = 0.53). CONCLUSIONS These findings support the potential feasibility, accuracy, and effectiveness of institutional triage teams informed by a limited set of patient information items as part of a strategy for allocating scarce resources in healthcare emergencies. Additional work is needed to refine the process and adapt it to local contexts.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle WA
- Veterans Affairs Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle WA
| | - Laura B Webster
- Virginia Mason Medical Center, Seattle, WA
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA
| | - Vicki L Sakata
- Northwest Healthcare Response Network, Seattle, WA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Mark R Tonelli
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Douglas S Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
- Trueman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle WA
| | - Megan M Gray
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
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Saeed F, Butler CR, Clark C, O’Loughlin K, Engelberg RA, Hebert PL, Lavallee DC, Vig EK, Tamura MK, Curtis JR, O’Hare AM. Family Members' Understanding of the End-of-Life Wishes of People Undergoing Maintenance Dialysis. Clin J Am Soc Nephrol 2021; 16:1630-1638. [PMID: 34507967 PMCID: PMC8729422 DOI: 10.2215/cjn.04860421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 08/25/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES People receiving maintenance dialysis must often rely on family members and other close persons to make critical treatment decisions toward the end of life. Contemporary data on family members' understanding of the end-of-life wishes of members of this population are lacking. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Among 172 family members of people undergoing maintenance dialysis, we ascertained their level of involvement in the patient's care and prior discussions about care preferences. We also compared patient and family member responses to questions about end-of-life care using percentage agreement and the κ-statistic. RESULTS The mean (SD) age of the 172 enrolled family members was 55 (±17) years, 136 (79%) were women, and 43 (25%) were Black individuals. Sixty-seven (39%) family members were spouses or partners of enrolled patients. A total of 137 (80%) family members had spoken with the patient about whom they would want to make medical decisions, 108 (63%) had spoken with the patient about their treatment preferences, 47 (27%) had spoken with the patient about stopping dialysis, and 56 (33%) had spoken with the patient about hospice. Agreement between patient and family member responses was highest for the question about whether the patient would want cardiopulmonary resuscitation (percentage agreement 83%, κ=0.31), and was substantially lower for questions about a range of other aspects of end-of-life care, including preference for mechanical ventilation (62%, 0.21), values around life prolongation versus comfort (45%, 0.13), preferred place of death (58%, 0.07), preferred decisional role (54%, 0.15), and prognostic expectations (38%, 0.15). CONCLUSIONS Most surveyed family members reported they had spoken with the patient about their end-of-life preferences but not about stopping dialysis or hospice. Although family members had a fair understanding of patients' cardiopulmonary resuscitation preferences, most lacked a detailed understanding of their perspectives on other aspects of end-of-life care.
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Affiliation(s)
- Fahad Saeed
- Department of Medicine and Public Health, Divisions of Nephrology and Palliative Care, University of Rochester Medical Center, Rochester, New York
| | - Catherine R. Butler
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, Washington
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Health Services Research and Development and Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Carlyn Clark
- Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, Washington
| | - Kristen O’Loughlin
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia
| | - Ruth A. Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
| | - Paul L. Hebert
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Health Services Research and Development and Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington
| | - Danielle C. Lavallee
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington
- British Columbia Academic Health Science Network, Vancouver, British Columbia, Canada
| | - Elizabeth K. Vig
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Health Services Research and Development and Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Geriatrics and Extended Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Manjula Kurella Tamura
- Stanford University School of Medicine, Palo Alto, California
- Geriatric Research and Education Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California
| | - J. Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
| | - Ann M. O’Hare
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, Washington
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Health Services Research and Development and Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Butler CR, Wightman AG. Scarce Health Care Resources and Equity during COVID-19: Lessons from the History of Kidney Failure Treatment. Kidney360 2021; 2:2024-2026. [PMID: 35419528 PMCID: PMC8986052 DOI: 10.34067/kid.0005292021] [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] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/22/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Catherine R. Butler
- Division of Nephrology, University of Washington, Seattle, Washington,Veterans Affairs Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Aaron G. Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington,Treuman Katz Center for Pediatric Bioethics, Seattle, Washington
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Butler CR, Johansen KL. Beyond exercise: supporting a range of physical activity for people receiving dialysis. Nephrol Dial Transplant 2021; 37:405-406. [PMID: 34610134 DOI: 10.1093/ndt/gfab288] [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: 09/22/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Catherine R Butler
- Division of Nephrology, University of Washington and VA Health Services Research & Development Seattle-Denver Center of Innovation, Seattle, WA, USA
| | - Kirsten L Johansen
- Hennepin County Medical Center, Division of Nephrology and Division of Nephrology, University of Minnesota, Minneapolis, MN, USA
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25
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Affiliation(s)
- Catherine R Butler
- University of Washington
- Veterans Affairs Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care
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26
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Affiliation(s)
- John S. Gill
- Division of Nephrology, St. Paul’s Hospital, Vancouver, Canada
| | - Catherine R. Butler
- Division of Nephrology, University of Washington, the Kidney Research Institute, Seattle, Washington,Veterans Affairs Health Services Research & Development, Seattle, Washington
| | - Neil R. Powe
- Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco
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Butler CR, O’Hare AM, Kestenbaum BR, Sayre GG, Wong SP. An Introduction to Qualitative Inquiry. J Am Soc Nephrol 2021; 32:1275-1278. [PMID: 34039668 PMCID: PMC8259646 DOI: 10.1681/asn.2021040473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/10/2021] [Accepted: 04/12/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Catherine R. Butler
- Division of Nephrology and Kidney Research InstituteUniversity of WashingtonSeattle, Washington,Veterans Affairs Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven CareVA Puget Sound Health Care SystemSeattle, Washington
| | - Ann M. O’Hare
- Division of Nephrology and Kidney Research InstituteUniversity of WashingtonSeattle, Washington,Veterans Affairs Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven CareVA Puget Sound Health Care SystemSeattle, Washington
| | - Bryan R. Kestenbaum
- Division of Nephrology and Kidney Research InstituteUniversity of WashingtonSeattle, Washington
| | - George G. Sayre
- Veterans Affairs Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven CareVA Puget Sound Health Care SystemSeattle, Washington
| | - Susan P.Y. Wong
- Division of Nephrology and Kidney Research InstituteUniversity of WashingtonSeattle, Washington,Veterans Affairs Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven CareVA Puget Sound Health Care SystemSeattle, Washington
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Butler CR, Wong SPY, Vig EK, Neely CS, O'Hare AM. Professional roles and relationships during the COVID-19 pandemic: a qualitative study among US clinicians. BMJ Open 2021; 11:e047782. [PMID: 33766845 PMCID: PMC7995668 DOI: 10.1136/bmjopen-2020-047782] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The COVID-19 pandemic has transformed healthcare delivery in the USA, but there has been little empirical work describing the impact of these changes on clinicians. We conducted a study to address the following question: how has the pandemic impacted US clinicians' professional roles and relationships? DESIGN Inductive thematic analysis of semi-structured interviews. SETTING Clinical settings across the USA in April and May of 2020. PARTICIPANTS Clinicians with leadership and/or clinical roles during the COVID-19 pandemic. MEASURES Emergent themes related to professional roles and relationships. RESULTS Sixty-one clinicians participated in semi-structured interviews. Study participants were practising in 15 states across the USA, and the majority were White physicians from large academic centres. Three overlapping and inter-related themes emerged from qualitative analysis of interview transcripts: (1) disruption: boundaries between work and home life became blurred and professional identity and usual clinical roles were upended; (2) constructive adaptation: some clinicians were able to find new meaning in their work and described a spirit of collaboration, shared goals, open communication and mutual respect among colleagues; and (3) discord and estrangement: other clinicians felt alienated from their clinical roles and experienced demoralising work environments marked by division, value conflicts and mistrust. CONCLUSIONS Clinicians encountered marked disruption of their professional roles, identities and relationships during the pandemic to which they and their colleagues responded in a range of different ways. Some described a spirit of collaboration and camaraderie, while others felt alienated by their new roles and experienced work environments marked by division, value conflicts and mistrust. Our findings highlight the importance of effective teamwork and efforts to support clinician well-being during the COVID-19 pandemic.
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Affiliation(s)
- Catherine R Butler
- Department of Medicine, Division of Nephrology and the Kidney Research Institute, University of Washington, Seattle, Washington, USA
- Department of Hospital and Specialty Medicine, Nephrology Section and Health Services Research & Development, Seattle-Denver Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Susan P Y Wong
- Department of Medicine, Division of Nephrology and the Kidney Research Institute, University of Washington, Seattle, Washington, USA
- Department of Hospital and Specialty Medicine, Nephrology Section and Health Services Research & Development, Seattle-Denver Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Elizabeth K Vig
- Department of Hospital and Specialty Medicine, Geriatrics and Extended Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Claire S Neely
- Institute for Clinical Systems Improvement, Bloomington, Minnesota, USA
| | - Ann M O'Hare
- Department of Medicine, Division of Nephrology and the Kidney Research Institute, University of Washington, Seattle, Washington, USA
- Department of Hospital and Specialty Medicine, Nephrology Section and Health Services Research & Development, Seattle-Denver Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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Butler CR, Wightman A, Richards CA, Laundry RS, Taylor JS, Hebert PL, Liu CF, O'Hare AM. Thematic Analysis of the Health Records of a National Sample of US Veterans With Advanced Kidney Disease Evaluated for Transplant. JAMA Intern Med 2021; 181:212-219. [PMID: 33226419 PMCID: PMC7684522 DOI: 10.1001/jamainternmed.2020.6388] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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] [Indexed: 01/13/2023]
Abstract
IMPORTANCE To be considered for a kidney transplant, patients with advanced kidney disease must participate in a formal evaluation and selection process. Little is known about how this process proceeds in real-world clinical settings. OBJECTIVE To characterize the transplant evaluation process among a representative national sample of US veterans with advanced kidney disease who were referred to a kidney transplant center. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was a thematic analysis of clinician notes in the electronic health records of US veterans referred for kidney transplant evaluation. In a random sample of 4000 patients with advanced kidney disease between January 1, 2004, and December 31, 2014, cared for in the US Department of Veterans Affairs (VA) health care system, there were 211 patients who were referred to a transplant center during the follow-up period. This group was included in the qualitative analysis and was followed up until their date of death or the end of the follow-up period on October 8, 2019. MAIN OUTCOMES AND MEASURES Dominant themes pertaining to the kidney transplant evaluation and selection process identified through thematic analysis. RESULTS Among 211 study patients, the mean (SD) age was 57.9 (9.5) years, and 202 patients (95.7%) were male. The following 4 dominant themes regarding the transplant evaluation process emerged: (1) far-reaching and inflexible medical evaluation, in which patients were expected to complete an extensive evaluation that could have substantial physical and emotional consequences, made little accommodation for their personal values and needs, and impacted other aspects of their care; (2) psychosocial valuation, in which the psychosocial component of the transplant assessment could be subjective and intrusive and could place substantial demands on patients' family members; (3) surveillance over compliance, in which the patients' ability and willingness to follow medical recommendations was an important criterion for transplant candidacy and their adherence to a wide range of recommendations and treatments was closely monitored; and (4) disempowerment and lack of transparency, in which patients and their local clinicians were often unsure about what to expect during the evaluation process or about the rationale for selection decisions. For the evaluation process to proceed, local clinicians had to follow transplant center requirements even when they believed the requirements did not align with best practices or the patients' needs. CONCLUSIONS AND RELEVANCE In this qualitative study of US veterans with advanced kidney disease evaluated for transplant, clinician documentation in the medical record indicated that, to be considered for a kidney transplant, patients were required to participate in a rigid, demanding, and opaque evaluation and selection process over which they and their local clinicians had little control. These findings highlight the need for a more evidence-based, individualized, and collaborative approach to kidney transplant evaluation.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington
| | - Aaron Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington
| | - Claire A Richards
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington.,School of Nursing, University of Washington, Seattle
| | - Ryan S Laundry
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington
| | - Janelle S Taylor
- Department of Anthropology, University of Toronto, Toronto, Ontario, Canada
| | - Paul L Hebert
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington.,Department of Health Services Research, University of Washington, Seattle
| | - Chuan-Fen Liu
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington.,Department of Health Services Research, University of Washington, Seattle
| | - Ann M O'Hare
- Division of Nephrology, Department of Medicine, University of Washington, Seattle.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington
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Ortiz-Soriano V, Butler CR, Levy M, Huen SC, Castaneda JL, Sakhuja A, Basu RK, Liu KD, Cerda J, Neyra JA. Survey of Current Practices of Outpatient Hemodialysis for AKI Patients. Kidney Int Rep 2021; 6:1156-1160. [PMID: 33912764 PMCID: PMC8071612 DOI: 10.1016/j.ekir.2021.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/01/2020] [Accepted: 01/04/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Victor Ortiz-Soriano
- Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Catherine R Butler
- Department of Medicine, Division of Nephrology, University of Washington and Veterans Affairs Health Services Research & Development, Seattle-Denver Center of Innovation, Seattle, Washington, USA
| | - Marla Levy
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California, USA
| | - Sarah C Huen
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jorge L Castaneda
- Department of Emergency Medicine, Division of Toxicology, Banner University Medical Center, Phoenix, Arizona, USA
| | - Ankit Sakhuja
- Department of Cardiovascular and Thoracic Surgery, Division of Cardiovascular Critical Care, West Virginia University, Morgantown, West Virginia, USA
| | - Rajit K Basu
- Department of Pediatrics, Division of Critical Care Medicine, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kathleen D Liu
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California, USA
| | - Jorge Cerda
- Department of Medicine, St Peter's Hospital Healthcare Partners, Albany, New York, USA
| | - Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky Medical Center, Lexington, Kentucky, USA
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Abstract
IMPORTANCE Little is known about how US clinicians have responded to resource limitation during the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE To describe the perspectives and experiences of clinicians involved in institutional planning for resource limitation and/or patient care during the pandemic. DESIGN, SETTING, AND PARTICIPANTS This qualitative study used inductive thematic analysis of semistructured interviews conducted in April and May 2020 with a national group of clinicians (eg, intensivists, nephrologists, nurses) involved in institutional planning and/or clinical care during the COVID-19 pandemic across the United States. MAIN OUTCOMES AND MEASURES Emergent themes describing clinicians' experience providing care in settings of resource limitation. RESULTS The 61 participants (mean [SD] age, 46 [11] years; 38 [63%] women) included in this study were practicing in 15 US states and were more heavily sampled from areas with the highest rates of COVID-19 infection at the time of interviews (ie, Seattle, New York City, New Orleans). Most participants were White individuals (39 [65%]), were attending physicians (45 [75%]), and were practicing in large academic centers (≥300 beds, 51 [85%]; academic centers, 46 [77%]). Three overlapping and interrelated themes emerged from qualitative analysis, as follows: (1) planning for crisis capacity, (2) adapting to resource limitation, and (3) multiple unprecedented barriers to care delivery. Clinician leaders worked within their institutions to plan a systematic approach for fair allocation of limited resources in crisis settings so that frontline clinicians would not have to make rationing decisions at the bedside. However, even before a declaration of crisis capacity, clinicians encountered varied and sometimes unanticipated forms of resource limitation that could compromise care, require that they make difficult allocation decisions, and contribute to moral distress. Furthermore, unprecedented challenges to caring for patients during the pandemic, including the need to limit in-person interactions, the rapid pace of change, and the dearth of scientific evidence, added to the challenges of caring for patients and communicating with families. CONCLUSIONS AND RELEVANCE The findings of this qualitative study highlighted the complexity of providing high-quality care for patients during the COVID-19 pandemic. Expanding the scope of institutional planning to address resource limitation challenges that can arise long before declarations of crisis capacity may help to support frontline clinicians, promote equity, and optimize care as the pandemic evolves.
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Affiliation(s)
- Catherine R. Butler
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle
- Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Susan P. Y. Wong
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle
- Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Aaron G. Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Hospital, Seattle, Washington
| | - Ann M. O’Hare
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle
- Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Butler CR, Reese PP, Perkins JD, Hall YN, Curtis JR, Kurella Tamura M, O'Hare AM. End-of-Life Care among US Adults with ESKD Who Were Waitlisted or Received a Kidney Transplant, 2005-2014. J Am Soc Nephrol 2020; 31:2424-2433. [PMID: 32908000 DOI: 10.1681/asn.2020030342] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/22/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The care of patients in the United States who have ESKD is often shaped by their hopes and prognostic expectations related to kidney transplant. Little is known about how patients' engagement in the transplant process might relate to patterns of end-of-life care. METHODS We compared six measures of intensity of end-of-life care among adults in the United States with ESKD who died between 2005 and 2014 after experiencing differing exposure to the kidney transplant process. RESULTS Of 567,832 decedents with ESKD, 27,633 (5%) had a functioning kidney transplant at the time of death, 14,653 (3%) had a failed transplant, 16,490 (3%) had been removed from the deceased donor waitlist, 17,010 (3%) were inactive on the waitlist, 11,529 (2%) were active on the waitlist, and 480,517 (85%) had never been waitlisted for or received a transplant (reference group). In adjusted analyses, compared with the reference group, patients exposed to the transplant process were significantly more likely to have been admitted to an intensive care unit and to have received an intensive procedure in the last 30 days of life; they were also significantly more likely to have died in the hospital. Those who died on the transplant waitlist were also less likely than those in the reference group to have been enrolled in hospice and to have discontinued dialysis before death. CONCLUSIONS Patients who had engaged in the kidney transplant process received more intensive patterns of end-of-life care than other patients with ESKD. These findings support the relevance of advance care planning, even for this relatively healthy segment of the ESKD population.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine and Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington
| | - Yoshio N Hall
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and the Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
| | - Manjula Kurella Tamura
- Division of Nephrology, Geriatric Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Ann M O'Hare
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington.,Division of Nephrology, Department of Medicine, Veterans Affairs Puget Sound Heath Care System, Seattle, Washington
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O'Hare AM, Butler CR, Taylor JS, Wong SPY, Vig EK, Laundry RS, Wachterman MW, Hebert PL, Liu CF, Rios-Burrows N, Richards CA. Thematic Analysis of Hospice Mentions in the Health Records of Veterans with Advanced Kidney Disease. J Am Soc Nephrol 2020; 31:2667-2677. [PMID: 32764141 DOI: 10.1681/asn.2020040473] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 06/29/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Patients with advanced kidney disease are less likely than many patients with other types of serious illness to enroll in hospice. Little is known about real-world clinical decision-making related to hospice for members of this population. METHODS We used a text search tool to conduct a thematic analysis of documentation pertaining to hospice in the electronic medical record system of the Department of Veterans Affairs, for a national sample of 1000 patients with advanced kidney disease between 2004 and 2014 who were followed until October 8, 2019. RESULTS Three dominant themes emerged from our qualitative analysis of the electronic medical records of 340 cohort members with notes containing hospice mentions: (1) hospice and usual care as antithetical care models: clinicians appeared to perceive a sharp demarcation between services that could be provided under hospice versus usual care and were often uncertain about hospice eligibility criteria. This could shape decision-making about hospice and dialysis and made it hard to individualize care; (2) hospice as a last resort: patients often were referred to hospice late in the course of illness and did not so much choose hospice as accept these services after all treatment options had been exhausted; and (3) care complexity: patients' complex care needs at the time of hospice referral could complicate transitions to hospice, stretch the limits of home hospice, and promote continued reliance on the acute care system. CONCLUSIONS Our findings underscore the need to improve transitions to hospice for patients with advanced kidney disease as they approach the end of life.
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Affiliation(s)
- Ann M O'Hare
- Department of Medicine, University of Washington, Seattle, Washington .,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | | | - Janelle S Taylor
- Department of Anthropology, University of Toronto, Toronto, Ontario, Canada
| | - Susan P Y Wong
- Department of Medicine, University of Washington, Seattle, Washington.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Elizabeth K Vig
- Department of Medicine, University of Washington, Seattle, Washington.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ryan S Laundry
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Melissa W Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Paul L Hebert
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Chuan-Fen Liu
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Nilka Rios-Burrows
- Chronic Kidney Disease Initiative, Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Claire A Richards
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,School of Nursing, University of Washington, Seattle, Washington
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Butler CR, Taylor JS, Reese PP, O'Hare AM. Thematic analysis of the medical records of patients evaluated for kidney transplant who did not receive a kidney. BMC Nephrol 2020; 21:300. [PMID: 32711468 PMCID: PMC7382039 DOI: 10.1186/s12882-020-01951-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 07/15/2020] [Indexed: 01/11/2023] Open
Abstract
Background A potential pitfall of policies intended to promote referral for kidney transplant is that greater numbers of patients may be evaluated for transplant without experiencing the intended benefit of receiving a kidney. Little is known about the potential implications of this experience for patients. Methods We performed a thematic analysis of clinician documentation in the electronic medical records of all adults at a single medical center with advanced kidney disease who were referred to the local transplant coordinator for evaluation between 2008 and 2018 but did not receive a kidney. Results 148 of 209 patients referred to the local kidney transplant coordinator at our center (71%) had not received a kidney by the end of follow-up. Three dominant themes emerged from qualitative analysis of documentation in the medical records of these patients: 1) Forward momentum: patients found themselves engaged in an iterative process of testing and treatment that tended to move forward unless an absolute contraindication to transplant was identified or patients disengaged; 2) Potential for transplant shapes other medical decisions: engagement in the transplant evaluation process could impact many other aspects of patients’ care; and 3) Personal responsibility and psychological burden for patients and families: clinician documentation suggested that patients felt personally responsible for the course of their evaluation and that the process could take an emotional toll on them and their family members. Conclusions Engagement in the kidney transplant evaluation process can be a significant undertaking for patients and families and may impact many other aspects of their care. Policies to promote referral for kidney transplant should be coupled with efforts to strengthen shared decision-making to ensure that the decision to undergo transplant evaluation is framed as an explicit choice with benefits, risks, and alternatives and patients have an opportunity to shape their involvement in this process.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, 1959 NE Pacific St, Campus Box 356521, Seattle, WA, 98195, USA.
| | - Janelle S Taylor
- Department of Anthropology, University of Toronto, Toronto, Canada
| | - Peter P Reese
- Renal-Electrolyte & Hypertension Division and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ann M O'Hare
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, 1959 NE Pacific St, Campus Box 356521, Seattle, WA, 98195, USA.,Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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Butler CR, Perkins JD, Johnson CK, Blosser CD, De Castro I, Leca N, Sibulesky L. Contemporary patterns in kidney graft survival from donors after circulatory death in the United States. PLoS One 2020; 15:e0233610. [PMID: 32469937 PMCID: PMC7259576 DOI: 10.1371/journal.pone.0233610] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 05/08/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Kidney transplants from donors after circulatory death (DCD) make up an increasing proportion of all deceased donor kidney transplants in the United States (US). However, DCD grafts are considered to be of lower quality than kidneys from donors after brain death (DBD). It is unclear whether graft survival is different for these two types of donor kidneys. MATERIALS AND METHODS We conducted a retrospective cohort study of US deceased donor kidney recipients using data from the United Network of Organ Sharing from 12/4/2014 to 6/30/2018. We employed a Cox proportional hazard model with mixed effects to compare all-cause graft loss and death-censored graft loss for DCD versus DBD deceased donor kidney transplant recipients. We used transplant center as the random effects term to account for cluster-specific random effects. In the multivariable analysis, we adjusted for recipient characteristics, donor factors, and transplant logistics. RESULTS Our cohort included 27,494 DBD and 7,770 DCD graft recipients transplanted from 2014 to 2018 who were followed over a median of 1.92 years (IQR 1.08-2.83). For DCD compared with DBD recipients, we did not find a significant difference in all-cause graft loss (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.87-1.05 in univariable and HR 1.03 [95% CI 0.95-1.13] in multivariable analysis) or for death-censored graft loss (HR 0.97 (95% CI 0.91-1.06) in univariable and 1.05 (95% CI 0.99-1.11) in multivariable analysis). CONCLUSIONS For a contemporary cohort of deceased donor kidney transplant recipients, we did not find a difference in the likelihood of graft loss for DCD compared with DBD grafts. These findings signal a need for additional investigation into whether DCD status independently contributes to other important outcomes for current kidney transplant recipients and indices of graft quality.
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Affiliation(s)
- Catherine R. Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - James D. Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, United States of America
| | - Christopher K. Johnson
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine, Peoria, IL, United States of America
| | - Christopher D. Blosser
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Iris De Castro
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, United States of America
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Butler CR, Vig EK, O'Hare AM, Liu CF, Hebert PL, Wong SPY. Ethical Concerns in the Care of Patients with Advanced Kidney Disease: a National Retrospective Study, 2000-2011. J Gen Intern Med 2020; 35:1035-1043. [PMID: 31654358 PMCID: PMC7174459 DOI: 10.1007/s11606-019-05466-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 03/18/2019] [Revised: 07/26/2019] [Accepted: 09/19/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Understanding ethical concerns that arise in the care of patients with advanced kidney disease may help identify opportunities to support medical decision-making. OBJECTIVE To describe the clinical contexts and types of ethical concerns that arise in the care of patients with advanced kidney disease. DESIGN Retrospective cohort study. PARTICIPANTS A total of 28,568 Veterans with advanced kidney disease between 2000 and 2009 followed through death or 2011. EXPOSURE Clinical scenarios that prompted clinicians to consider an ethics consultation as documented in the medical record. MAIN MEASURES Dialysis initiation, dialysis discontinuation, receipt of an intensive procedure during the final month of life, and hospice enrollment. KEY RESULTS Patients had a mean age of 67.1 years, and the majority were male (98.5%) and white (59.0%). Clinicians considered an ethics consultation for 794 patients (2.5%) over a median follow-up period of 2.7 years. Ethical concerns involved code status (37.8%), dialysis (54.5%), other invasive treatments (40.6%), and noninvasive treatments (61.1%) and were related to conflicts between patients, their surrogates, and/or clinicians about treatment preferences (79.3%), who had authority to make healthcare decisions (65.9%), and meeting the care needs of patients versus obligations to others (10.6%). Among the 20,583 patients who died during follow-up, those for whom clinicians had considered an ethics consultation were less likely to have been treated with dialysis (47.6% versus 62.0%, adjusted odds ratio [aOR] 0.63, 95% CI 0.53-0.74), more likely to have discontinued dialysis (32.5% versus 20.9%, aOR 2.07, CI 1.61-2.66), and less likely to have received an intensive procedure in the last month of life (8.9% versus 18.9%, aOR 0.41, CI 0.32-0.54) compared with patients without documentation of clinicians having considered consultation. CONCLUSIONS Clinicians considered an ethics consultation for patients with advanced kidney disease in situations of conflicting preferences regarding dialysis and other intensive treatments, especially when these treatments were not pursued.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Elizabeth K Vig
- Geriatrics and Extended Care, VA Puget Sound Healthcare System, Seattle, WA, USA.,Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ann M O'Hare
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA.,Health Service Research and Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Chuan-Fen Liu
- Health Service Research and Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Paul L Hebert
- Health Service Research and Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Susan P Y Wong
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA.,Health Service Research and Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, WA, USA
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Mole JA, Baker IW, Ottley Munoz JM, Danby M, Warren JD, Butler CR. Avian agnosia: A window into auditory semantics. Neuropsychologia 2019; 134:107219. [PMID: 31593713 PMCID: PMC6891886 DOI: 10.1016/j.neuropsychologia.2019.107219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 09/25/2019] [Accepted: 09/27/2019] [Indexed: 02/03/2023]
Abstract
The functional and neural organisation of auditory knowledge is relatively poorly understood. The breakdown of conceptual knowledge in semantic dementia has revealed that pre-morbid expertise influences the extent to which knowledge is differentiated. Whether this principle applies to a similar extent in the auditory domain is not yet known. Previous reports of patients with impaired auditory vs. intact visual expert knowledge suggest that expertise may have differential effects upon the organisation of auditory and visual knowledge. An equally plausible alternative, however, is that auditory knowledge is simply more vulnerable to deterioration. Thus, expertise effects in the auditory domain may not yet have been observed because knowledge of auditory expert vs. non-expert knowledge has yet to be compared. We had the opportunity to address this issue by studying SA, a patient with semantic dementia and extensive pre-morbid knowledge of birds. We undertook a systematic investigation of SA's auditory vs. visual knowledge from matched expert vs. non-expert categories. Relative to a group of 10 age, education and IQ matched bird experts, SA showed impaired auditory vs. intact visual avian knowledge, despite intact basic auditory perceptual abilities. This was explained by independent effects of modality and expertise. Thus, he was also disproportionately impaired for auditory vs. visual knowledge of items from non-expert categories. In both auditory and visual modalities, his performance was relatively more impaired on tests of non-expert vs. expert knowledge. These findings suggest that, while auditory knowledge may be more vulnerable to deterioration, expertise modulates visual and auditory knowledge to a similar extent.
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Affiliation(s)
- J A Mole
- Russell Cairns Unit, John Radcliffe Hospital, Oxford, UK; Department of Neuropsychology, National Hospital for Neurology and Neurosurgery, London, UK.
| | - I W Baker
- Russell Cairns Unit, John Radcliffe Hospital, Oxford, UK
| | | | - M Danby
- Russell Cairns Unit, John Radcliffe Hospital, Oxford, UK
| | - J D Warren
- Dementia Research Centre, UCL Institute of Neurology, University College London, London, UK
| | - C R Butler
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
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O'Hare AM, Murphy E, Butler CR, Richards CA. Achieving a person-centered approach to dialysis discontinuation: An historical perspective. Semin Dial 2019; 32:396-401. [PMID: 30968459 DOI: 10.1111/sdi.12808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In this essay, we describe the evolution of attitudes toward dialysis discontinuation in historical context, beginning with the birth of outpatient dialysis in the 1960s and continuing through the present. From the start, attitudes toward dialysis discontinuation have reflected the clinical context in which dialysis is initiated. In the 1960s and 1970s, dialysis was only available to select patients and concerns about distributive justice weighed heavily. Because there was strong enthusiasm for new technology and dialysis was regarded as a precious resource not to be wasted, stopping treatment had negative moral connotations and was generally viewed as something to be discouraged. More recently, dialysis has become the default treatment for advanced kidney disease in the United States, leading to concerns about overtreatment and whether patients' values, goals, and preferences are sufficiently integrated into treatment decisions. Despite the developments in palliative nephrology over the past 20 years, dialysis discontinuation remains a conundrum for patients, families, and professionals. While contemporary clinical practice guidelines support a person-centered approach toward stopping dialysis treatments, this often occurs in a crisis when all treatment options have been exhausted. Relatively little is known about the impact of dialysis discontinuation on the experiences of patients and families and there is a paucity of high-quality person-centered evidence to guide practice in this area. Clinicians need better insights into decision-making, symptom burden, and other palliative outcomes that patients might expect when they discontinue dialysis treatments to better support decision-making in this area.
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Affiliation(s)
- Ann M O'Hare
- University of Washington, Seattle, Washington.,VA Puget Sound Health Care System, Seattle, Washington
| | | | - Catherine R Butler
- University of Washington, Seattle, Washington.,VA Puget Sound Health Care System, Seattle, Washington
| | - Claire A Richards
- University of Washington, Seattle, Washington.,VA Puget Sound Health Care System, Seattle, Washington
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Affiliation(s)
- Catherine R Butler
- Department of Medicine and Kidney Research Institute, University of Washington and Hospital and Specialty Medicine and Seattle Denver Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ann M O'Hare
- Department of Medicine and Kidney Research Institute, University of Washington and Hospital and Specialty Medicine and Seattle Denver Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Butler CR, Schwarze ML, Katz R, Hailpern SM, Kreuter W, Hall YN, Montez Rath ME, O'Hare AM. Lower Extremity Amputation and Health Care Utilization in the Last Year of Life among Medicare Beneficiaries with ESRD. J Am Soc Nephrol 2019; 30:481-491. [PMID: 30782596 PMCID: PMC6405144 DOI: 10.1681/asn.2018101002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/10/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Lower extremity amputation is common among patients with ESRD, and often portends a poor prognosis. However, little is known about end-of-life care among patients with ESRD who undergo amputation. METHODS We conducted a mortality follow-back study of Medicare beneficiaries with ESRD who died in 2002 through 2014 to analyze patterns of lower extremity amputation in the last year of life compared with a parallel cohort of beneficiaries without ESRD. We also examined the relationship between amputation and end-of-life care among the patients with ESRD. RESULTS Overall, 8% of 754,777 beneficiaries with ESRD underwent at least one lower extremity amputation in their last year of life compared with 1% of 958,412 beneficiaries without ESRD. Adjusted analyses of patients with ESRD showed that those who had undergone lower extremity amputation were substantially more likely than those who had not to have been admitted to-and to have had prolonged stays in-acute and subacute care settings during their final year of life. Amputation was also associated with a greater likelihood of dying in the hospital, dialysis discontinuation before death, and less time receiving hospice services. CONCLUSIONS Nearly one in ten patients with ESRD undergoes lower extremity amputation in their last year of life. These patients have prolonged stays in acute and subacute health care settings and appear to have limited access to hospice services. These findings likely signal unmet palliative care needs among seriously ill patients with ESRD who undergo amputation as well as opportunities to improve their care.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington;
| | - Margaret L Schwarze
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, University of Wisconsin, Madison, Wisconsin
| | - Ronit Katz
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Susan M Hailpern
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - William Kreuter
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Yoshio N Hall
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Maria E Montez Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
- Department of Medicine, Stanford University, Stanford, California; and
| | - Ann M O'Hare
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
- Division of Nephrology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
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Butler CR, Perkins JD, Johnson CK, Blosser CD, Bakthavatsalam R, Leca N, Sibulesky L. Burden of excess mortality after implementation of the new kidney allocation system may be borne disproportionately by middle-aged recipients. PLoS One 2019; 14:e0210589. [PMID: 30677058 PMCID: PMC6345464 DOI: 10.1371/journal.pone.0210589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 12/25/2018] [Indexed: 11/19/2022] Open
Abstract
Under the new kidney allocation system (KAS), implemented in 2014, the distribution of the best quality donor kidney grafts shifted between age groups, but it is unclear whether this change translates to meaningful differences in post-transplant outcomes. We conducted a retrospective cohort study of 20,345 deceased donor kidney transplant recipients before and 4,605 recipients after implementation of the KAS using data from the United Network of Organ Sharing. Overall, two-year mortality was greater among recipients in the post-KAS era compared with the pre-KAS era (6.31% vs 5.91% respectively, [p = 0.01]), and two-year graft loss was not significantly different between eras (9.95% and 9.65%, respectively [p = 0.13]). In analysis stratified by age group (18-45, 46-55, 56-65, and ≥66 years), relative risk of mortality was 1.48 (95% confidence interval [CI] 1.09-1.98) among recipients 46-55 years old and 1.47 (95% CI 1.18-1.81) among recipients 56-65 years old. Relative risk of all-cause graft loss was 1.43 (95% CI 1.20-1.70) among recipients 56-65 years old. There were no significant differences in relative risk of mortality or graft loss associated with the KAS era among other age groups. After adjustment for recipient characteristics and characteristics of the changing donor pool, relative risk of two-year mortality and graft loss associated with the post-KAS era was attenuated for recipients aged 46-55 and 56-65 years, but remained statistically significant. In this early analysis after implementation of the KAS, there is suggestion that increased risk of mortality and graft loss may be disproportionately borne by middle-aged recipients, which is only partially accounted for by changes in recipient and donor characteristics. These findings signal a need to continue to monitor the effects of the KAS to ensure that allocation practices both maximize utility of the kidney graft pool and respect fairness between age groups.
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Affiliation(s)
- Catherine R. Butler
- Department of Medicine, Division of Nephrology, University of Washington Medical Center, Seattle, WA, United States America
| | - James D. Perkins
- Department of Surgery, Division of Transplant Surgery, University of Washington Medical Center, Seattle, WA, United States America
| | - Christopher K. Johnson
- Department of Medicine, Division of Nephrology, University of Washington Medical Center, Seattle, WA, United States America
| | - Christopher D. Blosser
- Department of Medicine, Division of Nephrology, University of Washington Medical Center, Seattle, WA, United States America
| | - Ramasamy Bakthavatsalam
- Department of Surgery, Division of Transplant Surgery, University of Washington Medical Center, Seattle, WA, United States America
| | - Nicolae Leca
- Department of Medicine, Division of Nephrology, University of Washington Medical Center, Seattle, WA, United States America
| | - Lena Sibulesky
- Department of Surgery, Division of Transplant Surgery, University of Washington Medical Center, Seattle, WA, United States America
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Den Hondt M, Vanaudenaerde BM, Maughan EF, Butler CR, Crowley C, Verbeken EK, Verleden SE, Vranckx JJ. An optimized non-destructive protocol for testing mechanical properties in decellularized rabbit trachea. Acta Biomater 2017; 60:291-301. [PMID: 28739545 DOI: 10.1016/j.actbio.2017.07.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/16/2017] [Accepted: 07/20/2017] [Indexed: 11/18/2022]
Abstract
Successful tissue-engineered tracheal transplantation relies on the use of non-immunogenic constructs, which can vascularize rapidly, support epithelial growth, and retain mechanical properties to that of native trachea. Current strategies to assess mechanical properties fail to evaluate the trachea to its physiological limits, and lead to irreversible destruction of the construct. Our aim was to develop and evaluate a novel non-destructive method for biomechanical testing of tracheae in a rabbit decellularization model. To validate the performance of this method, we simultaneously analyzed quantitative and qualitative graft changes in response to decellularization, as well as in vivo biocompatibility of implanted scaffolds. Rabbit tracheae underwent two, four and eight cycles of detergent-enzymatic decellularization. Biomechanical properties were analyzed by calculating luminal volume of progressively inflated and deflated tracheae with microCT. DNA, glycosaminoglycan and collagen contents were compared to native trachea. Scaffolds were prelaminated in vivo. Native, two- and four-cycle tracheae showed equal mechanical properties. Collapsibility of eight-cycle tracheae was significantly increased from -40cm H2O (-3.9kPa). Implantation of two- and four-cycle decellularized scaffolds resulted in favorable flap-ingrowth; eight-cycle tracheae showed inadequate integration. We showed a more limited detergent-enzymatic decellularization successfully removing non-cartilaginous immunogenic matter without compromising extracellular matrix content or mechanical stability. With progressive cycles of decellularization, important loss of functional integrity was detected upon mechanical testing and in vivo implantation. This instability was not revealed by conventional quantitative nor qualitative architectural analyses. These experiments suggest that non-destructive, functional evaluation, e.g. by microCT, may serve as an important tool for mechanical screening of scaffolds before clinical implementation. STATEMENT OF SIGNIFICANCE Decellularization is a front-running strategy to generate scaffolds for tracheal tissue-engineering. Preservation of biomechanical properties of the trachea during this process is paramount to successful clinical transplantation. In this paper, we evaluated a novel method for biomechanical testing of decellularized trachea. We detected important loss of functional integrity with progressive cycles of decellularization. This instability was not revealed by our quantitative nor qualitative analyses. These experiments suggest that the technique might serve as a performant, non-destructive tool for mechanical screening of scaffolds before clinical implementation.
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Affiliation(s)
- M Den Hondt
- Department of Plastic & Reconstructive Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - B M Vanaudenaerde
- Lung Transplant Unit, Laboratory of Pulmonology, Department of Clinical and Experimental Medicine, KU Leuven - University of Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - E F Maughan
- Department of Academic Surgery, Institute of Child Health, University College London, 30 Guilford Street, London, United Kingdom.
| | - C R Butler
- Department of Academic Surgery, Institute of Child Health, University College London, 30 Guilford Street, London, United Kingdom.
| | - C Crowley
- Department of Academic Surgery, Institute of Child Health, University College London, 30 Guilford Street, London, United Kingdom.
| | - E K Verbeken
- Department of Pathology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - S E Verleden
- Lung Transplant Unit, Laboratory of Pulmonology, Department of Clinical and Experimental Medicine, KU Leuven - University of Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - J J Vranckx
- Department of Plastic & Reconstructive Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Nouraei SAR, Makmur E, Dias A, Butler CR, Nandi R, Elliott MJ, Hewitt R. Validation of the Airway-Dyspnoea-Voice-Swallow (ADVS) scale and Patient-Reported Outcome Measure (PROM) as disease-specific instruments in paediatric laryngotracheal stenosis. Clin Otolaryngol 2017; 42:283-294. [PMID: 27542317 DOI: 10.1111/coa.12729] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To validate the Airway-Dyspnoea-Voice-Swallow (ADVS) instrument as a disease-specific Patient-Reported Outcome Measure in paediatric laryngotracheal stenosis. DESIGN Prospective observational study. SETTING A quaternary referral centre for complex airway disease. PARTICIPANTS Forty-eight patients (30 males) with a mean age of 49 ± 49 months who underwent laryngotracheal surgery or microlaryngoscopy and bronchoscopy (MLB) following laryngotracheal surgery. MAIN OUTCOME MEASURES Airway-Dyspnoea-Voice-Swallow summary scale and Patient-Reported Outcome Measure (PROM), Paediatric Quality of Life (PedsQL) scale, Paediatric Voice Handicap Index (pVHI) and Lansky performance scale were administered to patients before and 6-8 weeks following airway examination/surgery. RESULTS Most patients (73%) had intubation-related subglottic stenosis, and 60% of patients had prior airway treatments. The majority of patients (77%) had more than one major chronic morbidity, and the commonest procedures were diagnostic MLB (49%), followed by airway dilation (29%). Cronbach-α value for the ADVS PROM was 0.71 overall and 0.85, 0.86 and 0.64 for the dyspnoea, voice and swallow domains, respectively. Rank correlations between Dyspnoea, Voice and Swallow summary scale and PROM scores were 0.83, 0.71 and 0.81, respectively (P < 0.0001). For those patients undergoing diagnostic MLB, pre- and post-examination scores were highly correlated (intraclass correlations >0.75). There was a significant rank correlation between ADVS PROM score and Lansky performance score (r = -0.68; P < 0.0001). There were significant correlations between PROM score and PedsQL (r = -0.57; P < 0.0001) and between voice domain of the PROM and pVHI (r = 0.78; P < 0.0001). There were strong correlations between Myer-Cotton stenosis severity and dyspnoea scale and PROM score (r = 0.68; P < 0.0001). There were significant differences in voice and swallow ADVS scales and PROM scores between patients with and without concomitant laryngeal/oesophageal pathology. Patient age and presence of high dyspnoea and swallowing PROM scores were independently associated with poorer quality of life and performance status. CONCLUSIONS These series of observations validate the ADVS instrument as a disease-specific outcome measure for paediatric laryngotracheal stenosis. Dyspnoea and swallowing dysfunction appear to have the greatest impact on quality of life. More widespread adoption of the ADVS instrument could help create a shared language for outcomes communication and benchmarking for children with this complex condition.
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Affiliation(s)
- S A R Nouraei
- Department of Otolaryngology - Head and Neck Surgery, Great Ormond Street Hospital, London, UK
- Department of Ear Nose and Throat Surgery, Auckland City Hospital, Auckland, New Zealand
- Academic Department of Surgery, University of Auckland, Auckland, New Zealand
| | - E Makmur
- The Medical School, University College London, London, UK
| | - A Dias
- Department of Ear Nose and Throat Surgery, Auckland City Hospital, Auckland, New Zealand
| | - C R Butler
- Academic Department of Surgery, University of Auckland, Auckland, New Zealand
| | - R Nandi
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - M J Elliott
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - R Hewitt
- Department of Otolaryngology - Head and Neck Surgery, Great Ormond Street Hospital, London, UK
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Hamilton NJ, Kanani M, Roebuck DJ, Hewitt RJ, Cetto R, McLaren CA, Butler CR, Crowley C, Janes SM, O'Callaghan C, Culme-Seymour EJ, Mason C, De Coppi P, Lowdell MW, Elliott MJ, Birchall MA. Reply to: "Recent Advances in Circumferential Tracheal Replacement and Transplantation". Am J Transplant 2016; 16:1336-7. [PMID: 26813777 DOI: 10.1111/ajt.13736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- N J Hamilton
- University College London Ear Institute, Royal National Throat Nose and Ear Hospital, London, UK
| | - M Kanani
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - D J Roebuck
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - R J Hewitt
- Department of Otorhinolaryngology, Great Ormond Street Hospital, London, UK
| | - R Cetto
- Department of Aeronautics, Imperial College London, London, UK
| | - C A McLaren
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - C R Butler
- Lungs for Living Research Centre, Rayne Institute, London, UK
| | - C Crowley
- University College London Centre for Nanotechnology and Regenerative Medicine, Royal Free Hospital, London, UK
| | - S M Janes
- Lungs for Living Research Centre, Rayne Institute, London, UK
| | - C O'Callaghan
- Department of Respiratory Medicine, Great Ormond Street Hospital, London, UK
| | | | - C Mason
- London Regenerative Medicine Network, London, UK
| | - P De Coppi
- Department of Surgery, Great Ormond Street Hospital, London, UK
| | - M W Lowdell
- Department of Haematology, Royal Free Hospital, University College London Paul O'Gorman Laboratory of Cellular Therapeutics, London, UK
| | - M J Elliott
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - M A Birchall
- University College London Ear Institute, Royal National Throat Nose and Ear Hospital, London, UK
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Abstract
Throughout the history of dialysis, four bioethical principles - beneficence, nonmaleficence, autonomy and justice - have been weighted differently based upon changing forces of technologic innovation, resource limitation, and societal values. In the 1960s, a committee of lay people in Seattle attempted to fairly distribute a limited number of maintenance hemodialysis stations guided by considerations of justice. As technology advanced and dialysis was funded under an amendment to the Social Security Act in 1972, focus shifted to providing dialysis for all in need while balancing the burdens of treatment and quality of life, supported by the concepts of beneficence and nonmaleficence. At the end of the last century, the importance of patient preferences and personal values became paramount in medical decisions, reflecting a focus on the principle of autonomy. More recently, greater recognition that health care financial resources are limited makes fair allocation more pressing, again highlighting the importance of distributive justice. The varying application and prioritization of these four principles to both policy and clinical decisions in the United States over the last 50 years makes the history of hemodialysis an instructive platform for understanding principlist bioethics. As medical technology evolves in a landscape of changing personal and societal values, a comprehensive understanding of an ethical framework for evaluating appropriate use of medical interventions enables the clinician to systematically negotiate and optimize difficult ethical situations.
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Affiliation(s)
| | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington; and
| | - Mark R Tonelli
- Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, Washington
| | - Daniel Y Lam
- Division of Nephrology, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
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Butler CR, O'Hare AM. Considerations in Applying the Results of Randomized Controlled Clinical Trials to the Care of Older Adults With Kidney Disease in the Clinical Setting: The SHARP Trial. Adv Chronic Kidney Dis 2016; 23:29-35. [PMID: 26709060 DOI: 10.1053/j.ackd.2015.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The Study of Heart and Renal Protection (SHARP) found that treatment with ezetemibe and low-dose simvastatin reduced the incidence of major atherosclerotic events in patients with kidney disease. Due to the paucity of evidence-based interventions that lower cardiovascular morbidity in this high-risk population, the SHARP trial will likely have a large impact on clinical practice. However, applying the results of clinical trials conducted in select populations to the care of individual patients in real-world settings can be fraught with difficulty. This is especially true when caring for older adults with complex comorbidity and limited life expectancy. These patients are often excluded from clinical trials, frequently have competing health priorities, and may be less likely to benefit and more likely to be harmed by medications. We discuss key considerations in applying the results of the SHARP trial to the care of older adults with CKD in real-world clinical settings using guiding principles set forth by the American Geriatrics Society's Expert Panel on the Care of Older Adults with Multimorbidity. Using this schema, we emphasize the importance of evaluating trial results in the unique context of each patient's goals, values, priorities, and circumstances.
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Hamilton NJ, Kanani M, Roebuck DJ, Hewitt RJ, Cetto R, Culme-Seymour EJ, Toll E, Bates AJ, Comerford AP, McLaren CA, Butler CR, Crowley C, McIntyre D, Sebire NJ, Janes SM, O'Callaghan C, Mason C, De Coppi P, Lowdell MW, Elliott MJ, Birchall MA. Tissue-Engineered Tracheal Replacement in a Child: A 4-Year Follow-Up Study. Am J Transplant 2015. [PMID: 26037782 DOI: 10.1111/ajt.13318.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In 2010, a tissue-engineered trachea was transplanted into a 10-year-old child using a decellularized deceased donor trachea repopulated with the recipient's respiratory epithelium and mesenchymal stromal cells. We report the child's clinical progress, tracheal epithelialization and costs over the 4 years. A chronology of events was derived from clinical notes and costs determined using reference costs per procedure. Serial tracheoscopy images, lung function tests and anti-HLA blood samples were compared. Epithelial morphology and T cell, Ki67 and cleaved caspase 3 activity were examined. Computational fluid dynamic simulations determined flow, velocity and airway pressure drops. After the first year following transplantation, the number of interventions fell and the child is currently clinically well and continues in education. Endoscopy demonstrated a complete mucosal lining at 15 months, despite retention of a stent. Histocytology indicates a differentiated respiratory layer and no abnormal immune activity. Computational fluid dynamic analysis demonstrated increased velocity and pressure drops around a distal tracheal narrowing. Cross-sectional area analysis showed restriction of growth within an area of in-stent stenosis. This report demonstrates the long-term viability of a decellularized tissue-engineered trachea within a child. Further research is needed to develop bioengineered pediatric tracheal replacements with lower morbidity, better biomechanics and lower costs.
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Affiliation(s)
- N J Hamilton
- University College London Ear Institute, Royal National Throat Nose and Ear Hospital, London, UK
| | - M Kanani
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - D J Roebuck
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - R J Hewitt
- Department of Otorhinolaryngology, Great Ormond Street Hospital, London, UK
| | - R Cetto
- Imperial College London, Department of Aeronautics, London, UK
| | | | - E Toll
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - A J Bates
- Imperial College London, Department of Aeronautics, London, UK
| | - A P Comerford
- Imperial College London, Department of Aeronautics, London, UK
| | - C A McLaren
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - C R Butler
- Lungs for Living Research Centre, Rayne Institute, London, UK
| | - C Crowley
- University College London Centre for Nanotechnology and Regenerative Medicine, Royal Free Hospital, London, UK
| | - D McIntyre
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - N J Sebire
- Department of Histopathology, Great Ormond Street Hospital, London, UK
| | - S M Janes
- Lungs for Living Research Centre, Rayne Institute, London, UK
| | - C O'Callaghan
- Department of Respiratory Medicine, Great Ormond Street Hospital, London, UK
| | - C Mason
- London Regenerative Medicine Network, London, UK
| | - P De Coppi
- Department of Surgery, Great Ormond Street Hospital, London, UK
| | - M W Lowdell
- Department of Haematology, Royal Free Hospital, University College London Paul O'Gorman Laboratory of Cellular Therapeutics, London, UK
| | - M J Elliott
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - M A Birchall
- University College London Ear Institute, Royal National Throat Nose and Ear Hospital, London, UK
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Butler CR, Kim DH, Chow K, Toma M, Thompson R, Mengel M, Haykowsky M, Pearson GJ, Paterson I. Cardiovascular MRI predicts 5-year adverse clinical outcome in heart transplant recipients. Am J Transplant 2014; 14:2055-61. [PMID: 25100504 DOI: 10.1111/ajt.12811] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 04/21/2014] [Accepted: 04/27/2014] [Indexed: 01/25/2023]
Abstract
Imaging recommendations for the follow-up of heart transplant recipients (HTRs) lack evidence justifying their prognostic value. Cardiovascular magnetic resonance imaging (CMRI) can characterize heart structure and function and has prognostic value in many myocardial diseases. We hypothesized that CMRI evaluation of cardiac allografts would predict adverse events. We performed CMRI on 60 HTRs evaluating biventricular size, function and myocardial scar. We performed survival analysis to identify independent predictors of cardiovascular (CV) death or hospitalization. Participants had a mean age of 51 ± 14 years, mean graft age of 3.5 years (±4) and 75% are male. Median follow-up time was 4.9 years with 22 CV hospitalizations and 7 CV deaths. A multivariable survival analysis of imaging and clinical variables identified myocardial scar (hazard ratio [HR] of 10.7, p = 0.005), right ventricular end- diastolic volume index (RVEDVI; 1.1/mL/m(2) , p = 0.001), graft age (HR = 1.2/year, p = 0.004) and previous allograft rejection (HR = 4.4, p = 0.006) as predictive of time to CV death or hospitalization. CMRI-derived myocardial scar and RVEDVI are independently associated with CV outcomes in HTRs.
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Affiliation(s)
- C R Butler
- Division of Cardiology, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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Milton F, Butler CR, Benattayallah A, Zeman A. MP 2 An fMRI study of autobiographical memory deficits in transient epileptic amnesia. J Neurol Neurosurg Psychiatry 2012. [DOI: 10.1136/jnnp-2012-303538.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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