1
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Brahmania M, Rogal S, Serper M, Patel A, Goldberg D, Mathur A, Wilder J, Vittorio J, Yeoman A, Rich NE, Lazo M, Kardashian A, Asrani S, Spann A, Ufere N, Verma M, Verna E, Simpson D, Schold JD, Rosenblatt R, McElroy L, Wadwhani SI, Lee TH, Strauss AT, Chung RT, Aiza I, Carr R, Yang JM, Brady C, Fortune BE. Pragmatic strategies to address health disparities along the continuum of care in chronic liver disease. Hepatol Commun 2024; 8:e0413. [PMID: 38696374 PMCID: PMC11068141 DOI: 10.1097/hc9.0000000000000413] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 01/05/2024] [Indexed: 05/04/2024] Open
Abstract
Racial, ethnic, and socioeconomic disparities exist in the prevalence and natural history of chronic liver disease, access to care, and clinical outcomes. Solutions to improve health equity range widely, from digital health tools to policy changes. The current review outlines the disparities along the chronic liver disease health care continuum from screening and diagnosis to the management of cirrhosis and considerations of pre-liver and post-liver transplantation. Using a health equity research and implementation science framework, we offer pragmatic strategies to address barriers to implementing high-quality equitable care for patients with chronic liver disease.
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Affiliation(s)
- Mayur Brahmania
- Department of Medicine, Division of Gastroenterology and Transplant Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shari Rogal
- Department of Medicine, Division of Gastroenterology, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Marina Serper
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arpan Patel
- Department of Medicine, Division of Gastroenterology, University of California Los Angeles, Los Angeles, California, USA
| | - David Goldberg
- Department of Medicine, Division of Gastroenterology, University of Miami, Miami, Florida, USA
| | - Amit Mathur
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Julius Wilder
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer Vittorio
- Department of Pediatrics, Division of Pediatric Gastroenterology, NYU Langone Health, New York, New York, USA
| | - Andrew Yeoman
- Department of Medicine, Gwent Liver Unit, Aneurin Bevan University Health Board, Newport, Wales, UK
| | - Nicole E. Rich
- Department of Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Mariana Lazo
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ani Kardashian
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Sumeet Asrani
- Department of Medicine, Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas, USA
| | - Ashley Spann
- Department of Medicine, Division of Gastroenterology, Vanderbilt University, Nashville, Tennessee, USA
| | - Nneka Ufere
- Department of Medicine, Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Elizabeth Verna
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Dinee Simpson
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - Jesse D. Schold
- Department of Surgery and Epidemiology, University of Colorado, Aurora, Colorado, USA
| | - Russell Rosenblatt
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Lisa McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sharad I. Wadwhani
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Tzu-Hao Lee
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Alexandra T. Strauss
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Raymond T. Chung
- Department of Medicine, Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ignacio Aiza
- Department of Medicine, Liver Unit, Hospital Ángeles Lomas, Mexico City, Mexico
| | - Rotonya Carr
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Jin Mo Yang
- Department of Medicine, Division of Gastroenterology, Catholic University of Korea, Seoul, Korea
| | - Carla Brady
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brett E. Fortune
- Department of Medicine, Division of Hepatology, Montefiore Einstein Medical Center, Bronx, New York, USA
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2
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Strauss AT, Sidoti CN, Sung HC, Jain VS, Lehmann H, Purnell TS, Jackson JW, Malinsky D, Hamilton JP, Garonzik-Wang J, Gray SH, Levan ML, Hinson JS, Gurses AP, Gurakar A, Segev DL, Levin S. Artificial intelligence-based clinical decision support for liver transplant evaluation and considerations about fairness: A qualitative study. Hepatol Commun 2023; 7:e0239. [PMID: 37695082 PMCID: PMC10497243 DOI: 10.1097/hc9.0000000000000239] [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: 03/01/2023] [Accepted: 06/28/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND The use of large-scale data and artificial intelligence (AI) to support complex transplantation decisions is in its infancy. Transplant candidate decision-making, which relies heavily on subjective assessment (ie, high variability), provides a ripe opportunity for AI-based clinical decision support (CDS). However, AI-CDS for transplant applications must consider important concerns regarding fairness (ie, health equity). The objective of this study was to use human-centered design methods to elicit providers' perceptions of AI-CDS for liver transplant listing decisions. METHODS In this multicenter qualitative study conducted from December 2020 to July 2021, we performed semistructured interviews with 53 multidisciplinary liver transplant providers from 2 transplant centers. We used inductive coding and constant comparison analysis of interview data. RESULTS Analysis yielded 6 themes important for the design of fair AI-CDS for liver transplant listing decisions: (1) transparency in the creators behind the AI-CDS and their motivations; (2) understanding how the AI-CDS uses data to support recommendations (ie, interpretability); (3) acknowledgment that AI-CDS could mitigate emotions and biases; (4) AI-CDS as a member of the transplant team, not a replacement; (5) identifying patient resource needs; and (6) including the patient's role in the AI-CDS. CONCLUSIONS Overall, providers interviewed were cautiously optimistic about the potential for AI-CDS to improve clinical and equitable outcomes for patients. These findings can guide multidisciplinary developers in the design and implementation of AI-CDS that deliberately considers health equity.
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Affiliation(s)
- Alexandra T. Strauss
- Department of Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Carolyn N. Sidoti
- Department of Surgery, New York University, Grossman School of Medicine, New York, New York, USA
| | - Hannah C. Sung
- Department of Surgery, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Vedant S. Jain
- Department of Surgery, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Harold Lehmann
- Department of Medicine, Division of Biomedical Informatics & Data Science, School of Medicine, Baltimore, Maryland, USA
| | - Tanjala S. Purnell
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John W. Jackson
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniel Malinsky
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York, USA
| | - James P. Hamilton
- Department of Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Jacqueline Garonzik-Wang
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Stephen H. Gray
- Department of Surgery, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Macey L. Levan
- Department of Surgery, New York University, Grossman School of Medicine, New York, New York, USA
| | - Jeremiah S. Hinson
- Department of Emergency Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Ayse P. Gurses
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ahmet Gurakar
- Department of Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Dorry L. Segev
- Department of Surgery, New York University, Grossman School of Medicine, New York, New York, USA
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
- Beckman Coulter, Brea, California, USA
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3
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Liang PS, Andres SF, Perumpail RB, Shah R, Strauss AT, Pointer S. The Importance of Professional Societies as Academic Homes. Clin Gastroenterol Hepatol 2023; 21:2450-2456. [PMID: 37301221 DOI: 10.1016/j.cgh.2023.05.005] [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] [Received: 01/09/2023] [Revised: 04/23/2023] [Accepted: 05/02/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Peter S Liang
- Department of Medicine, NYU Grossman School of Medicine, New York, New York; Department of Medicine, Veterans Affairs New York, Harbor Health Care System, New York, New York
| | - Sarah F Andres
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | | | - Raj Shah
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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4
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Strauss AT, Moughames E, Jackson JW, Malinsky D, Segev DL, Hamilton JP, Garonzik-Wang J, Gurakar A, Cameron A, Dean L, Klein E, Levin S, Purnell TS. Critical interactions between race and the highly granular area deprivation index in liver transplant evaluation. Clin Transplant 2023; 37:e14938. [PMID: 36786505 PMCID: PMC10175104 DOI: 10.1111/ctr.14938] [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: 09/14/2022] [Revised: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023]
Abstract
Neighborhood socioeconomic deprivation may have important implications on disparities in liver transplant (LT) evaluation. In this retrospective cohort study, we constructed a novel dataset by linking individual patient-level data with the highly granular Area Deprivation Index (ADI), which is advantageous over other neighborhood measures due to: specificity of Census Block-Group (versus Census Tract, Zip code), scoring, and robust variables. Our cohort included 1377 adults referred to our center for LT evaluation 8/1/2016-12/31/2019. Using modified Poisson regression, we tested for effect measure modification of the association between neighborhood socioeconomic status (nSES) and LT evaluation outcomes (listing, initiating evaluation, and death) by race and ethnicity. Compared to patients with high nSES, those with low nSES were at higher risk of not being listed (aRR = 1.14; 95%CI 1.05-1.22; p < .001), of not initiating evaluation post-referral (aRR = 1.20; 95%CI 1.01-1.42; p = .03) and of dying without initiating evaluation (aRR = 1.55; 95%CI 1.09-2.2; p = .01). While White patients with low nSES had similar rates of listing compared to White patients with high nSES (aRR = 1.06; 95%CI .96-1.17; p = .25), Underrepresented patients from neighborhoods with low nSES incurred 31% higher risk of not being listed compared to Underrepresented patients from neighborhoods with high nSES (aRR = 1.31; 95%CI 1.12-1.5; p < .001). Interventions addressing neighborhood deprivation may not only benefit patients with low nSES but may address racial and ethnic inequities.
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Affiliation(s)
- Alexandra T. Strauss
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric Moughames
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John W. Jackson
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Daniel Malinsky
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY
| | - Dorry L. Segev
- Department of Surgery, New York University, Grossman School of Medicine, New York, NY
| | - James P. Hamilton
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jacqueline Garonzik-Wang
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Ahmet Gurakar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Cameron
- Department of Surgery, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Lorraine Dean
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Eili Klein
- Department of Emergency Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Tanjala S. Purnell
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
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5
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Strauss AT, Sidoti CN, Purnell TS, Sung HC, Jackson JW, Levin S, Jain VS, Malinsky D, Segev DL, Hamilton JP, Garonzik‐Wang J, Gray SH, Levan ML, Scalea JR, Cameron AM, Gurakar A, Gurses AP. Multicenter study of racial and ethnic inequities in liver transplantation evaluation: Understanding mechanisms and identifying solutions. Liver Transpl 2022; 28:1841-1856. [PMID: 35726679 PMCID: PMC9796377 DOI: 10.1002/lt.26532] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/15/2022] [Accepted: 06/06/2022] [Indexed: 01/02/2023]
Abstract
Racial and ethnic disparities persist in access to the liver transplantation (LT) waiting list; however, there is limited knowledge about underlying system-level factors that may be responsible for these disparities. Given the complex nature of LT candidate evaluation, a human factors and systems engineering approach may provide insights. We recruited participants from the LT teams (coordinators, advanced practice providers, physicians, social workers, dieticians, pharmacists, leadership) at two major LT centers. From December 2020 to July 2021, we performed ethnographic observations (participant-patient appointments, committee meetings) and semistructured interviews (N = 54 interviews, 49 observation hours). Based on findings from this multicenter, multimethod qualitative study combined with the Systems Engineering Initiative for Patient Safety 2.0 (a human factors and systems engineering model for health care), we created a conceptual framework describing how transplant work system characteristics and other external factors may improve equity in the LT evaluation process. Participant perceptions about listing disparities described external factors (e.g., structural racism, ambiguous national guidelines, national quality metrics) that permeate the LT evaluation process. Mechanisms identified included minimal transplant team diversity, implicit bias, and interpersonal racism. A lack of resources was a common theme, such as social workers, transportation assistance, non-English-language materials, and time (e.g., more time for education for patients with health literacy concerns). Because of the minimal data collection or center feedback about disparities, participants felt uncomfortable with and unadaptable to unwanted outcomes, which perpetuate disparities. We proposed transplant center-level solutions (i.e., including but not limited to training of staff on health equity) to modifiable barriers in the clinical work system that could help patient navigation, reduce disparities, and improve access to care. Our findings call for an urgent need for transplant centers, national societies, and policy makers to focus efforts on improving equity (tailored, patient-centered resources) using the science of human factors and systems engineering.
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Affiliation(s)
- Alexandra T. Strauss
- Department of MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Malone Center for Engineering in HealthcareWhiting School of Engineering, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Carolyn N. Sidoti
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Tanjala S. Purnell
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Department of EpidemiologyBloomberg School of Public, Health Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Hannah C. Sung
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - John W. Jackson
- Department of EpidemiologyBloomberg School of Public, Health Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Scott Levin
- Malone Center for Engineering in HealthcareWhiting School of Engineering, Johns Hopkins UniversityBaltimoreMarylandUSA,Department of Emergency MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Vedant S. Jain
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Daniel Malinsky
- Department of BiostatisticsColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Dorry L. Segev
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Department of EpidemiologyBloomberg School of Public, Health Johns Hopkins UniversityBaltimoreMarylandUSA
| | - James P. Hamilton
- Department of MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Stephen H. Gray
- Department of SurgerySchool of Medicine, University of MarylandBaltimoreMarylandUSA
| | - Macey L. Levan
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Joseph R. Scalea
- Department of SurgerySchool of Medicine, University of MarylandBaltimoreMarylandUSA
| | - Andrew M. Cameron
- Department of SurgerySchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Ahmet Gurakar
- Department of MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Ayse P. Gurses
- Department of Emergency MedicineSchool of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Center for Health Care Human FactorsArmstrong Institute for Patient Safety and Quality, Johns Hopkins MedicineBaltimoreMarylandUSA,Anesthesiology and Critical Care Medicine, Biomedical Informatics and Data Science (General Internal Medicine)School of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA,Department of Health Policy and ManagementBloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMarylandUSA
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6
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Strauss AT, Chang A, Alejo JL, Chiang TP, Hernandez NF, Zeiser LB, Boyarsky BJ, Avery RK, Tobian AAR, Levan ML, Warren DS, Massie AB, Garonzik‐Wang JM, Segev DL, Werbel WA. Severe acute respiratory syndrome coronavirus 2 antibody response to a third dose of homologous messenger RNA vaccination in liver transplantation recipients. Liver Transpl 2022; 28:1393-1396. [PMID: 35389558 PMCID: PMC9088577 DOI: 10.1002/lt.26472] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/11/2022] [Accepted: 03/17/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Alexandra T. Strauss
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Amy Chang
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Jennifer L. Alejo
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Teresa P.‐Y. Chiang
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Nicole F. Hernandez
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Laura B. Zeiser
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Brian J. Boyarsky
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Robin K. Avery
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Aaron A. R. Tobian
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Macey L. Levan
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of Acute and Chronic CareJohns Hopkins University School of NursingBaltimoreMarylandUSA
| | - Daniel S. Warren
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Allan B. Massie
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUSA
| | | | - Dorry L. Segev
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - William A. Werbel
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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7
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Hinson JS, Klein E, Smith A, Toerper M, Dungarani T, Hager D, Hill P, Kelen G, Niforatos JD, Stephens RS, Strauss AT, Levin S. Multisite implementation of a workflow-integrated machine learning system to optimize COVID-19 hospital admission decisions. NPJ Digit Med 2022; 5:94. [PMID: 35842519 PMCID: PMC9287691 DOI: 10.1038/s41746-022-00646-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 06/24/2022] [Indexed: 11/09/2022] Open
Abstract
Demand has outstripped healthcare supply during the coronavirus disease 2019 (COVID-19) pandemic. Emergency departments (EDs) are tasked with distinguishing patients who require hospital resources from those who may be safely discharged to the community. The novelty and high variability of COVID-19 have made these determinations challenging. In this study, we developed, implemented and evaluated an electronic health record (EHR) embedded clinical decision support (CDS) system that leverages machine learning (ML) to estimate short-term risk for clinical deterioration in patients with or under investigation for COVID-19. The system translates model-generated risk for critical care needs within 24 h and inpatient care needs within 72 h into rapidly interpretable COVID-19 Deterioration Risk Levels made viewable within ED clinician workflow. ML models were derived in a retrospective cohort of 21,452 ED patients who visited one of five ED study sites and were prospectively validated in 15,670 ED visits that occurred before (n = 4322) or after (n = 11,348) CDS implementation; model performance and numerous patient-oriented outcomes including in-hospital mortality were measured across study periods. Incidence of critical care needs within 24 h and inpatient care needs within 72 h were 10.7% and 22.5%, respectively and were similar across study periods. ML model performance was excellent under all conditions, with AUC ranging from 0.85 to 0.91 for prediction of critical care needs and 0.80–0.90 for inpatient care needs. Total mortality was unchanged across study periods but was reduced among high-risk patients after CDS implementation.
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Affiliation(s)
- Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Malone Center for Engineering in Healthcare, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA.
| | - Eili Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | - Aria Smith
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Malone Center for Engineering in Healthcare, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
| | - Matthew Toerper
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Trushar Dungarani
- Department of Medicine, Howard County General Hospital, Columbia, MD, USA
| | - David Hager
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter Hill
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gabor Kelen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joshua D Niforatos
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - R Scott Stephens
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexandra T Strauss
- Malone Center for Engineering in Healthcare, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Malone Center for Engineering in Healthcare, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
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8
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Chang A, Strauss AT, Alejo JL, Chiang TP, Hernandez NF, Zeiser LB, Boyarsky BJ, Avery RK, Tobian AAR, Levan ML, Warren DS, Garonzik‐Wang JM, Massie AB, Werbel WA, Segev DL. Letter to the editor: Six‐month antibody kinetics and durability in liver transplant recipients after two doses of
SARS‐CoV
‐2
mRNA
vaccination. Hepatol Commun 2022; 6:2990-2992. [PMID: 35791054 PMCID: PMC9350026 DOI: 10.1002/hep4.2027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/09/2022] [Accepted: 05/30/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Amy Chang
- Department of Surgery Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Alexandra T. Strauss
- Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Jennifer L. Alejo
- Department of Surgery Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Teresa P.‐Y. Chiang
- Department of Surgery Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Nicole F. Hernandez
- Department of Surgery Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Laura B. Zeiser
- Department of Surgery Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Brian J. Boyarsky
- Department of Surgery Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Robin K. Avery
- Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Aaron A. R. Tobian
- Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Macey L. Levan
- Department of Surgery Johns Hopkins University School of Medicine Baltimore Maryland USA
- Department of Surgery New York University Grossman School of Medicine New York New York USA
- Department of Population of Health New York University Grossman School of Medicine New York New York USA
| | - Daniel S. Warren
- Department of Surgery Johns Hopkins University School of Medicine Baltimore Maryland USA
| | | | - Allan B. Massie
- Department of Surgery Johns Hopkins University School of Medicine Baltimore Maryland USA
- Department of Surgery New York University Grossman School of Medicine New York New York USA
- Department of Population of Health New York University Grossman School of Medicine New York New York USA
| | - William A. Werbel
- Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Dorry L. Segev
- Department of Surgery Johns Hopkins University School of Medicine Baltimore Maryland USA
- Department of Surgery New York University Grossman School of Medicine New York New York USA
- Department of Population of Health New York University Grossman School of Medicine New York New York USA
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9
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Strauss AT, Segev DL, Werbel WA. Shared and Data-Driven Decision-Making with Transplant Recipients About COVID-19 Vaccination Is Crucial. Liver Transpl 2022; 28:900-901. [PMID: 35094484 PMCID: PMC9015359 DOI: 10.1002/lt.26418] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 01/18/2022] [Indexed: 01/13/2023]
Affiliation(s)
| | - Dorry L. Segev
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
- Department of EpidemiologyJohns Hopkins University Bloomberg School of Public HealthBaltimoreMD
| | - William A. Werbel
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMD
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10
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Strauss AT, Morgan C, El Khuri C, Slogeris B, Smith AG, Klein E, Toerper M, DeAngelo A, Debraine A, Peterson S, Gurses AP, Levin S, Hinson J. A Patient Outcomes-Driven Feedback Platform for Emergency Medicine Clinicians: Human-Centered Design and Usability Evaluation of Linking Outcomes Of Patients (LOOP). JMIR Hum Factors 2022; 9:e30130. [PMID: 35319469 PMCID: PMC8987968 DOI: 10.2196/30130] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/11/2021] [Accepted: 11/11/2021] [Indexed: 02/05/2023] Open
Abstract
Background The availability of patient outcomes–based feedback is limited in episodic care environments such as the emergency department. Emergency medicine (EM) clinicians set care trajectories for a majority of hospitalized patients and provide definitive care to an even larger number of those discharged into the community. EM clinicians are often unaware of the short- and long-term health outcomes of patients and how their actions may have contributed. Despite large volumes of patients and data, outcomes-driven learning that targets individual clinician experiences is meager. Integrated electronic health record (EHR) systems provide opportunity, but they do not have readily available functionality intended for outcomes-based learning. Objective This study sought to unlock insights from routinely collected EHR data through the development of an individualizable patient outcomes feedback platform for EM clinicians. Here, we describe the iterative development of this platform, Linking Outcomes Of Patients (LOOP), under a human-centered design framework, including structured feedback obtained from its use. Methods This multimodal study consisting of human-centered design studios, surveys (24 physicians), interviews (11 physicians), and a LOOP application usability evaluation (12 EM physicians for ≥30 minutes each) was performed between August 2019 and February 2021. The study spanned 3 phases: (1) conceptual development under a human-centered design framework, (2) LOOP technical platform development, and (3) usability evaluation comparing pre- and post-LOOP feedback gathering practices in the EHR. Results An initial human-centered design studio and EM clinician surveys revealed common themes of disconnect between EM clinicians and their patients after the encounter. Fundamental postencounter outcomes of death (15/24, 63% respondents identified as useful), escalation of care (20/24, 83%), and return to ED (16/24, 67%) were determined high yield for demonstrating proof-of-concept in our LOOP application. The studio aided the design and development of LOOP, which integrated physicians throughout the design and content iteration. A final LOOP prototype enabled usability evaluation and iterative refinement prior to launch. Usability evaluation compared to status quo (ie, pre-LOOP) feedback gathering practices demonstrated a shift across all outcomes from “not easy” to “very easy” to obtain and from “not confident” to “very confident” in estimating outcomes after using LOOP. On a scale from 0 (unlikely) to 10 (most likely), the users were very likely (9.5) to recommend LOOP to a colleague. Conclusions This study demonstrates the potential for human-centered design of a patient outcomes–driven feedback platform for individual EM providers. We have outlined a framework for working alongside clinicians with a multidisciplined team to develop and test a tool that augments their clinical experience and enables closed-loop learning.
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Affiliation(s)
- Alexandra T Strauss
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Cameron Morgan
- Center for Social Design, Maryland Institute College of Art, Baltimore, MD, United States
| | - Christopher El Khuri
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Becky Slogeris
- Center for Social Design, Maryland Institute College of Art, Baltimore, MD, United States
| | - Aria G Smith
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Eili Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Matt Toerper
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,StoCastic, Towson, MD, United States
| | | | | | - Susan Peterson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ayse P Gurses
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Armstrong Institute Center for Health Care Human Factors, Johns Hopkins Medicine, Baltimore, MD, United States.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,StoCastic, Towson, MD, United States
| | - Jeremiah Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,StoCastic, Towson, MD, United States
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11
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Krishnan A, Prichett L, Tao X, Alqahtani SA, Hamilton JP, Mezey E, Strauss AT, Kim A, Potter JJ, Chen PH, Woreta TA. Abnormal liver chemistries as a predictor of COVID-19 severity and clinical outcomes in hospitalized patients. World J Gastroenterol 2022; 28:570-587. [PMID: 35316959 PMCID: PMC8905016 DOI: 10.3748/wjg.v28.i5.570] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/21/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Abnormal liver chemistries are common findings in patients with Coronavirus Disease 2019 (COVID-19). However, the association of these abnormalities with the severity of COVID-19 and clinical outcomes is poorly understood
AIM We aimed to assess the prevalence of elevated liver chemistries in hospitalized patients with COVID-19 and compare the serum liver chemistries to predict the severity and in-hospital mortality.
METHODS This retrospective, observational study included 3380 patients with COVID-19 who were hospitalized in the Johns Hopkins Health System (Baltimore, MD, United States). Demographic data, clinical characteristics, laboratory findings, treatment measures, and outcome data were collected. Cox regression modeling was used to explore variables associated with abnormal liver chemistries on admission with disease severity and prognosis
RESULTS A total of 2698 (70.4%) had abnormal alanine aminotransferase (ALT) at the time of admission. Other more prevalent abnormal liver chemistries were aspartate aminotransferase (AST) (44.4%), alkaline phosphatase (ALP) (16.1%), and total bilirubin (T-Bil) (5.9%). Factors associated with liver injury were older age, Asian ethnicity, other race, being overweight, and obesity. Higher ALT, AST, T-Bil, and ALP levels were more commonly associated with disease severity. Multivariable adjusted Cox regression analysis revealed that abnormal AST and T-Bil were associated with the highest mortality risk than other liver injury indicators during hospitalization. Abnormal AST, T-Bil, and ALP were associated with a need for vasopressor drugs, whereas higher levels of AST, T-Bil, and a decreased albumin levels were associated with mechanical ventilation
CONCLUSION Abnormal liver chemistries are common at the time of hospital admission in COVID-19 patients and can be closely related to the patient’s severity and prognosis. Elevated liver chemistries, specifically ALT, AST, ALP, and T-Bil levels, can be used to stratify risk and predict the need for advanced therapies in these patients.
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Affiliation(s)
- Arunkumar Krishnan
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Laura Prichett
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Xueting Tao
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Saleh A Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
- Liver Transplant Center, King Faisal Specialist Hospital & Research Center, Riyadh 12713, Saudi Arabia
| | - James P Hamilton
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Esteban Mezey
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Alexandra T Strauss
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Ahyoung Kim
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - James J Potter
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Po-Hung Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Tinsay A Woreta
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
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12
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Strauss AT, Hallett AM, Boyarsky BJ, Ou MT, Werbel WA, Avery RK, Tobian AAR, Massie AB, Hamilton JPA, Garonzik‐Wang JM, Segev DL. Antibody Response to Severe Acute Respiratory Syndrome-Coronavirus-2 Messenger RNA Vaccines in Liver Transplant Recipients. Liver Transpl 2021; 27:1852-1856. [PMID: 34407309 PMCID: PMC8441851 DOI: 10.1002/lt.26273] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/14/2021] [Accepted: 08/06/2021] [Indexed: 12/23/2022]
Affiliation(s)
| | - Andrew M. Hallett
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| | - Brian J. Boyarsky
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| | - Michael T. Ou
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| | - William A. Werbel
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Robin K. Avery
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Aaron A. R. Tobian
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMD
- Department of EpidemiologyJohns Hopkins University School of MedicineBaltimoreMD
| | - Allan B. Massie
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| | | | | | - Dorry L. Segev
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
- Department of EpidemiologyJohns Hopkins University School of MedicineBaltimoreMD
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13
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Herrick-Reynolds KM, Punchhi G, Greenberg RS, Strauss AT, Boyarsky BJ, Weeks-Groh SR, Krach MR, Anders RA, Gurakar A, Chen PH, Segev DL, King EA, Philosophe B, Ottman SE, Wesson RN, Garonzik-Wang JM, Cameron AM. Evaluation of Early vs Standard Liver Transplant for Alcohol-Associated Liver Disease. JAMA Surg 2021; 156:1026-1034. [PMID: 34379106 DOI: 10.1001/jamasurg.2021.3748] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Traditionally, liver transplant (LT) for alcohol-associated liver disease (ALD) requires 6 months of abstinence. Although early LT before 6 months of abstinence has been associated with decreased mortality for decompensated ALD, this practice remains controversial and concentrated at a few centers. Objective To define patient, allograft, and relapse-free survival in early LT for ALD, and to investigate the association between these survival outcomes and early vs standard LT. Design, Setting, and Participants This cohort study analyzed all patients with ALD who underwent their first LT at a single academic referral center between October 1, 2012, and November 13, 2020. Patients with known pretransplant hepatocellular carcinoma, hepatitis B or C, or an alternative cause of liver failure were excluded. Follow-up period was defined as the time from LT to the most recent encounter with a transplant center or death. Exposures The exposure of interest was early LT, which was defined as less than 180 days of pre-LT abstinence. Standard LT was defined as 180 days or more of pre-LT abstinence. Patients were separated into early LT and standard LT by time from abstinence to LT. Main Outcomes and Measures The outcomes were patient, allograft, relapse-free, and hazardous relapse-free survival for patients who underwent early LT or standard LT. These groups were compared by log-rank testing of Kaplan-Meier estimates. Hazardous relapse was defined as binge, at-risk, or frequent drinking. Abstinence was reassessed at the most recent follow-up visit for all patients. Results Of the 163 patients with ALD included in this study, 88 (54%) underwent early LT and 75 (46%) underwent standard LT. This cohort had a mean (SD) age at transplant of 52 (10) years and was predominantly composed of 108 male patients (66%). Recipients of early LT vs standard LT were younger (median [interquartile range (IQR)] age, 49.7 [39.0-54.2] years vs 54.6 [48.7-60.0] years; P < .001) and had a higher median (IQR) Model for End-stage Liver Disease score at listing (35.0 [29.0-39.0] vs 20.0 [13.0-26.0]; P < .001). Both recipients of early LT and standard LT had similar 1-year patient survival (94.1% [95% CI, 86.3%-97.5%] vs 95.9% [95% CI, 87.8%-98.7%]; P = .60), allograft survival (92.7% [95% CI, 84.4%-96.7%] vs 90.5% [95% CI, 81.0%-95.3%]; P = .42), relapse-free survival (80.4% [95% CI, 69.1%-88.0%] vs 83.5% [95% CI, 72.2%-90.6%]; P = .41), and hazardous relapse-free survival (85.8% [95% CI, 75.1%-92.2%] vs 89.6% [95% CI, 79.5%-94.9%]; P = .41). Conclusions and Relevance Adherence to the 6-month rule was not associated with superior patient survival, allograft survival, or relapse-free survival among selected patients. This finding suggests that patients with ALD should not be categorically excluded from LT solely on the basis of 6 months of abstinence, but rather alternative selection criteria should be identified that are based on need and posttransplant outcomes.
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Affiliation(s)
- Kayleigh M Herrick-Reynolds
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Gopika Punchhi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ross S Greenberg
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexandra T Strauss
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian J Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sharon R Weeks-Groh
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michelle R Krach
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert A Anders
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmet Gurakar
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Po-Hung Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Elizabeth A King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Benjamin Philosophe
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shane E Ottman
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Russell N Wesson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Andrew M Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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14
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Strauss AT, Boyarsky BJ, Garonzik-Wang JM, Werbel W, Durand CM, Avery RK, Jackson KR, Kernodle AB, Baker T, Snyder J, Segev DL, Massie AB. Liver transplantation in the United States during the COVID-19 pandemic: National and center-level responses. Am J Transplant 2021; 21:1838-1847. [PMID: 33107180 PMCID: PMC9800484 DOI: 10.1111/ajt.16373] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [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: 06/08/2020] [Revised: 10/02/2020] [Accepted: 10/15/2020] [Indexed: 01/25/2023]
Abstract
COVID-19 has profoundly affected the American health care system; its effect on the liver transplant (LT) waitlist based on COVID-19 incidence has not been characterized. Using SRTR data, we compared observed LT waitlist registrations, waitlist mortality, deceased donor LTs (DDLT), and living donor LTs (LDLT) 3/15/2020-8/31/2020 to expected values based on historical trends 1/2016-1/2020, stratified by statewide COVID-19 incidence. Overall, from 3/15 to 4/30, new listings were 11% fewer than expected (IRR = 0.84 0.890.93 ), LDLTs were 49% fewer (IRR = 0.37 0.510.72 ), and DDLTs were 9% fewer (IRR = 0.85 0.910.97 ). In May, new listings were 21% fewer (IRR = 0.74 0.790.84 ), LDLTs were 42% fewer (IRR = 0.39 0.580.85 ) and DDLTs were 13% more (IRR = 1.07 1.151.23 ). Centers in states with the highest incidence 3/15-4/30 had 59% more waitlist deaths (IRR = 1.09 1.592.32 ) and 34% fewer DDLTs (IRR = 0.50 0.660.86 ). By August, waitlist outcomes were occurring at expected rates, except for DDLT (13% more across all incidences). While the early COVID-affected states endured major transplant practice changes, later in the pandemic the newly COVID-affected areas were not impacted to the same extent. These results speak to the adaptability of the transplant community in addressing the pandemic and applying new knowledge to patient care.
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Affiliation(s)
- Alexandra T. Strauss
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brian J. Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - William Werbel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robin K. Avery
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kyle R. Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amber B. Kernodle
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Talia Baker
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jon Snyder
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
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15
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Strauss AT, Yeh J, Martinez DA, Yenokyan G, Yoder J, Nehra R, Feller T, Bull-Henry K, Stein E, Hsu LCH, Al-Grain H, Zabko C, Fain C. A patient-centered framework for health systems engineering in gastroenterology: improving inpatient colonoscopy bowel preparation. BMC Gastroenterol 2021; 21:89. [PMID: 33639850 PMCID: PMC7912514 DOI: 10.1186/s12876-021-01661-4] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 02/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background Inpatient colonoscopy bowel preparation (ICBP) is frequently inadequate and can lead to adverse events, delayed or repeated procedures, and negative patient outcomes. Guidelines to overcome the complex factors in this setting are not well established. Our aims were to use health systems engineering principles to comprehensively evaluate the ICBP process, create an ICBP protocol, increase adequate ICBP, and decrease length of stay. Our goal was to provide adaptable tools for other institutions and procedural specialties. Methods Patients admitted to our tertiary care academic hospital that underwent inpatient colonoscopy between July 3, 2017 to June 8, 2018 were included. Our multi-disciplinary team created a protocol employing health systems engineering techniques (i.e., process mapping, cause-effect diagrams, and plan-do-study-act cycles). We collected demographic and colonoscopy data. Our outcome measures were adequate preparation and length of stay. We compared pre-intervention (120 ICBP) vs. post-intervention (129 ICBP) outcomes using generalized linear regression models. Our new ICBP protocol included: split-dose 6-L polyethylene glycol-electrolyte solution, a gastroenterology electronic note template, and an education plan for patients, nurses, and physicians. Results The percent of adequate ICBPs significantly increased with the intervention from 61% pre-intervention to 74% post-intervention (adjusted odds ratio of 1.87, p value = 0.023). The median length of stay decreased by approximately 25%, from 4 days pre-intervention to 3 days post-intervention (p value = 0.11). Conclusions By addressing issues at patient, provider, and system levels with health systems engineering principles, we addressed patient safety and quality of care provided by improving rates of adequate ICBP. Supplementary information The online version contains supplementary material available at 10.1186/s12876-021-01661-4.
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Affiliation(s)
- Alexandra T Strauss
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 600 N Wolfe St. Blalock 465, Baltimore, MD, 21205, USA.
| | - Jennifer Yeh
- Department of Internal Medicine, Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21287, USA
| | - Diego A Martinez
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21287, USA
| | - Gayane Yenokyan
- Johns Hopkins Biostatistics Center, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Janet Yoder
- Department of Medical Nursing, Johns Hopkins University, 601 N Caroline St, Baltimore, MD, 21287, USA
| | - Ravi Nehra
- Department of Pharmacy, Johns Hopkins Hospital, 601 N Caroline St, Baltimore, MD, 21287, USA
| | - Tara Feller
- Department of Pharmacy, Johns Hopkins Hospital, 601 N Caroline St, Baltimore, MD, 21287, USA
| | - Kathy Bull-Henry
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 600 N Wolfe St. Blalock 465, Baltimore, MD, 21205, USA
| | - Ellen Stein
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 600 N Wolfe St. Blalock 465, Baltimore, MD, 21205, USA
| | - Lawrence C H Hsu
- Operations Integration, Johns Hopkins Health System, 601 N Caroline St, Baltimore, MD, 21287, USA
| | - Haitham Al-Grain
- Department of Anesthesiology, Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21287, USA
| | - Candice Zabko
- Department of Medical Nursing, Johns Hopkins University, 601 N Caroline St, Baltimore, MD, 21287, USA
| | - Christopher Fain
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 600 N Wolfe St. Blalock 465, Baltimore, MD, 21205, USA
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16
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Abstract
A wide gap between the increasing demand for organs and the limited supply leads to immeasurable loss of life each year. The organ shortage could be attenuated by donors with human immunodeficiency virus (HIV) or hepatitis C virus (HCV). The transplantation of organs from HIV+ deceased donors into HIV+ individuals (HIV D+ /R+) was initiated in South Africa in 2010; however, this practice was forbidden in the USA until the HIV Organ Policy Equity (HOPE) Act in 2013. HIV D+/R+ transplantation is now practiced in the USA as part of ongoing research studies, helping to reduce waiting times for all patients on the waitlist. The introduction of direct acting antivirals for HCV has revolutionized the utilization of donors with HCV for HCV-uninfected (HCV-) recipients. This is particularly relevant as the HCV donor pool has increased substantially in the context of the rise in deaths related to drug overdose from injection drug use. This article serves to review the current literature on using organs from donors with HIV or HCV.
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Affiliation(s)
- Brian J Boyarsky
- Department of Surgery, Epidemiology Research Group in Organ Transplantation, Johns Hopkins University School of Medicine, 2000 E Monument St, Baltimore, MD, 21205, USA
| | - Alexandra T Strauss
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Epidemiology Research Group in Organ Transplantation, Johns Hopkins University School of Medicine, 2000 E Monument St, Baltimore, MD, 21205, USA. .,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA.
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17
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Strauss AT, Cartier D, Gunning BA, Boyarsky BJ, Snyder J, Segev DL, Roush M, Massie AB. Impact of the COVID-19 pandemic on commercial airlines in the United States and implications for the kidney transplant community. Am J Transplant 2020; 20:3123-3130. [PMID: 32860307 PMCID: PMC9800715 DOI: 10.1111/ajt.16284] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/12/2020] [Accepted: 08/19/2020] [Indexed: 01/25/2023]
Abstract
Many deceased-donor and living-donor kidney transplants (KTs) rely on commercial airlines for transport. However, the coronavirus-19 pandemic has drastically impacted the commercial airline industry. To understand potential pandemic-related disruptions in the transportation network of kidneys across the United States, we used national flight data to compare scheduled flights during the pandemic vs 1-year earlier, focusing on Organ Procurement Organization (OPO) pairs between which kidneys historically most likely traveled by direct flight (High Volume by direct Air transport OPO Pairs, HVA-OPs). Across the United States, there were 39% fewer flights in April 2020 vs April 2019. Specific to the kidney transportation network, there were 65.1% fewer flights between HVA-OPs, with considerable OPO-level variation (interquartile range [IQR] 54.7%-75.3%; range 0%-100%). This translated to a drop in median number of flights between HVA-OPs from 112 flights/wk in April 2019 to 34 in April 2020 (P < .001), and a rise in wait time between scheduled flights from 1.5 hours in April 2019 (IQR 0.76-3.3) to 4.9 hours in April 2020 (IQR 2.6-11.2; P < .001). Fewer flights and longer wait times can impact logistics as well as cold ischemia time; our findings motivate an exploration of creative approaches to KT transport as the impact of this pandemic on the airline industry evolves.
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Affiliation(s)
- Alexandra T. Strauss
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Brian J. Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jon Snyder
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA,Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA,Correspondence Dorry L. Segev
| | | | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
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18
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Boyarsky BJ, Ruck JM, Chiang TPY, Werbel WA, Strauss AT, Getsin SN, Jackson KR, Kernodle AB, Van Pilsum Rasmussen SE, Baker TB, Al Ammary F, Durand CM, Avery RK, Massie AB, Segev DL, Garonzik-Wang JM. Evolving Impact of COVID-19 on Transplant Center Practices and Policies in the United States. Clin Transplant 2020; 34:e14086. [PMID: 32918766 DOI: 10.1111/ctr.14086] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 07/02/2020] [Revised: 08/26/2020] [Accepted: 09/04/2020] [Indexed: 12/20/2022]
Abstract
In our first survey of transplant centers in March 2020, >75% of kidney and liver programs were either suspended or operating under restrictions. To safely resume transplantation, we must understand the evolving impact of COVID-19 on transplant recipients and center-level practices. We therefore conducted a six-week follow-up survey May 7-15, 2020, and linked responses to the COVID-19 incidence map, with a response rate of 84%. Suspension of live donor transplantation decreased from 72% in March to 30% in May for kidneys and from 68% to 52% for livers. Restrictions/suspension of deceased donor transplantation decreased from 84% to 58% for kidneys and from 73% to 42% for livers. Resuming transplantation at normal capacity was envisioned by 83% of programs by August 2020. Exclusively using local recovery teams for deceased donor procurement was reported by 28%. Respondents reported caring for a total of 1166 COVID-19-positive transplant recipients; 25% were critically ill. Telemedicine challenges were reported by 81%. There was a lack of consensus regarding management of potential living donors or candidates with SARS-CoV-2. Our findings demonstrate persistent heterogeneity in center-level response to COVID-19 even as transplant activity resumes, making ongoing national data collection and real-time analysis critical to inform best practices.
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Affiliation(s)
- Brian J Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Teresa Po-Yu Chiang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William A Werbel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexandra T Strauss
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Samantha N Getsin
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kyle R Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amber B Kernodle
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Talia B Baker
- Department of Surgery, University of Chicago School of Medicine, Chicago, IL, USA
| | - Fawaz Al Ammary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robin K Avery
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
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19
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Strauss AT, James TW, Mathews SC. Fellow Education Improved Through Mobile Clinical Decision Support Application: A Multi-Center Approach Involving Peri-Procedural Antithrombotic Use. Gastroenterology 2018; 155:2014-2015. [PMID: 30165048 DOI: 10.1053/j.gastro.2018.08.034] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 08/14/2018] [Indexed: 12/02/2022]
Affiliation(s)
- Alexandra T Strauss
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Theodore W James
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Baltimore, Maryland
| | - Simon C Mathews
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland.
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20
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Saco TV, Strauss AT, Ledford DK. Hepatitis B vaccine nonresponders: Possible mechanisms and solutions. Ann Allergy Asthma Immunol 2018; 121:320-327. [PMID: 29567355 DOI: 10.1016/j.anai.2018.03.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 03/12/2018] [Accepted: 03/13/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Hepatitis B (HBV) is a viral illness that chronically infects 240 million people worldwide, leads to liver disease, and increases risk of hepatocellular carcinoma. The HBV vaccine has decreased HBV infection, and it and the human papilloma virus vaccine are the only vaccines that prevent cancer. Despite the effectiveness of the HBV vaccine, some populations do not develop protective responses. The risk groups for poor response include those with immunosuppression or dialysis-dependent, end-stage renal disease. Five percent of normal people do not have a response. These subjects are deemed HBV "nonresponders." Multiple strategies to improve the immunogenicity of the HBV vaccine are currently being pursued, including vaccine adjuvants, recombinant vaccines, and immune enhancement via up-regulation of dendritic cells. DATA SOURCES PubMed was searched for peer-reviewed publications published from January 1980 to September 2017. STUDY SELECTIONS Studies retrieved for inclusion summarized potential mechanisms behind HBV vaccine nonresponsiveness and potential solutions. RESULTS The mechanisms behind HBV vaccine nonresponsiveness vary between each subject population. Many current and future strategies may provide protective immunity against HBV in each of these populations. CONCLUSION This review provides a background on the immunology of HBV infection, the possible immunologic mechanisms to explain HBV vaccine nonresponsiveness, current research aimed at improving vaccine effectiveness, and possible future approaches for providing nonresponders protection from HBV.
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Affiliation(s)
- Tara Vinyette Saco
- University of South Florida Morsani College of Medicine, and James A. Haley Veterans Hospital, Department of Internal Medicine and Division of Allergy and Immunology, Tampa, Florida.
| | - Alexandra T Strauss
- University of South Florida Morsani College of Medicine, and James A. Haley Veterans Hospital, Department of Internal Medicine and Division of Allergy and Immunology, Tampa, Florida
| | - Dennis K Ledford
- University of South Florida Morsani College of Medicine, and James A. Haley Veterans Hospital, Department of Internal Medicine and Division of Allergy and Immunology, Tampa, Florida
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21
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Strauss AT, Martinez DA, Garcia-Arce A, Taylor S, Mateja C, Fabri PJ, Zayas-Castro JL. A user needs assessment to inform health information exchange design and implementation. BMC Med Inform Decis Mak 2015; 15:81. [PMID: 26459258 PMCID: PMC4603345 DOI: 10.1186/s12911-015-0207-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 10/05/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Important barriers for widespread use of health information exchange (HIE) are usability and interface issues. However, most HIEs are implemented without performing a needs assessment with the end users, healthcare providers. We performed a user needs assessment for the process of obtaining clinical information from other health care organizations about a hospitalized patient and identified the types of information most valued for medical decision-making. METHODS Quantitative and qualitative analysis were used to evaluate the process to obtain and use outside clinical information (OI) using semi-structured interviews (16 internists), direct observation (750 h), and operational data from the electronic medical records (30,461 hospitalizations) of an internal medicine department in a public, teaching hospital in Tampa, Florida. RESULTS 13.7 % of hospitalizations generate at least one request for OI. On average, the process comprised 13 steps, 6 decisions points, and 4 different participants. Physicians estimate that the average time to receive OI is 18 h. Physicians perceived that OI received is not useful 33-66 % of the time because information received is irrelevant or not timely. Technical barriers to OI use included poor accessibility and ineffective information visualization. Common problems with the process were receiving extraneous notes and the need to re-request the information. Drivers for OI use were to trend lab or imaging abnormalities, understand medical history of critically ill or hospital-to-hospital transferred patients, and assess previous echocardiograms and bacterial cultures. About 85 % of the physicians believe HIE would have a positive effect on improving healthcare delivery. CONCLUSIONS Although hospitalists are challenged by a complex process to obtain OI, they recognize the value of specific information for enhancing medical decision-making. HIE systems are likely to have increased utilization and effectiveness if specific patient-level clinical information is delivered at the right time to the right users.
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Affiliation(s)
- Alexandra T Strauss
- Department of Internal Medicine, College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Diego A Martinez
- Johns Hopkins Department of Emergency Medicine, Baltimore, MD, USA
| | - Andres Garcia-Arce
- Department of Industrial and Management Systems Engineering, College of Engineering, University of South Florida, Tampa, FL, USA
| | - Stephanie Taylor
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Candice Mateja
- Department of Internal Medicine, College of Medicine, University of South Florida, Tampa, FL, USA
| | - Peter J Fabri
- Department of Surgery, College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jose L Zayas-Castro
- Department of Industrial and Management Systems Engineering, College of Engineering, University of South Florida, Tampa, FL, USA
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