Development, Implementation, and Evaluation of a Telemedicine Preoperative Evaluation Initiative at a Major Academic Medical Center.

BACKGROUND: With health care practice consolidation, the increasing geographic scope of health care systems, and the advancement of mobile telecommunications, there is increasing interest in telemedicine-based health care consultations. Anesthesiology has had experience with telemedicine consultation for preoperative evaluation since 2004, but the majority of studies have been conducted in rural settings. There is a paucity of literature of use in metropolitan areas. In this article, we describe the implementation of a telemedicine-based anesthesia preoperative evaluation and report the program's patient satisfaction, clinical case cancellation rate outcomes, and cost savings in a large metropolitan area (Los Angeles, CA). METHODS: This is a descriptive study of a telemedicine-based preoperative anesthesia evaluation process in an academic medical center within a large metropolitan area. In a 2-year period, we evaluated 419 patients scheduled for surgery by telemedicine and 1785 patients who were evaluated in-person. RESULTS: Day-of-surgery case cancellations were 2.95% and 3.23% in the telemedicine and the in-person cohort, respectively. Telemedicine patients avoided a median round trip driving distance of 63 miles (Q1 24; Q3 119) and a median time saved of 137 (Q1 95; Q3 195) and 130 (Q1 91; Q3 237) minutes during morning and afternoon traffic conditions, respectively. Patients experienced time-based savings, particularly from traveling across a metropolitan area, which amounted to $67 of direct and opportunity cost savings. From patient satisfaction surveys, 98% (129 patients out of 131 completed surveys) of patients who were consulted via telemedicine were satisfied with their experience. CONCLUSIONS: This study demonstrates the implementation of a telemedicine-based preoperative anesthesia evaluation from an academic medical center in a metropolitan area with high patient satisfaction, cost savings, and without increase in day-of-procedure case cancellations.

Inferior allograft outcomes in adolescent recipients of renal transplants from ideal deceased donors.

OBJECTIVE: To measure the impact of the Share-35 policy on the allocation of ideal deceased donor kidneys and to examine the impact of age on outcomes after kidney transplantation using ideal donor kidneys. BACKGROUND: In the United States, through Share-35, transplant candidates aged 18 years or younger receive priority for the highest-quality deceased donor kidneys. Adolescent (15-18 years) kidney transplant recipients (KTRs), however, may be more susceptible to allograft loss due to elevated rates of acute rejection and a possible increased risk of primary renal disease recurrence. METHODS: We used registry data to perform a retrospective cohort study of 39,136 KTRs from January 1, 1994, to December 31, 2008. Ideal donors were defined as 2 to 34 years old with creatinine <1.5 mg/dL and absence of hypertension, diabetes, and hepatitis C. RESULTS: After Share-35, the percentage of ideal donor kidneys allocated to pediatric recipients increased from 7% to 16%. In multivariable Cox regression, compared with adolescent KTRs, all age strata except recipients older than 70 years had a lower risk of allograft failure (P < 0.01 for each comparison); results were similar after excluding KTRs with diseases at high risk of recurrence. Adolescent recipients had higher mortality rates than KTRs younger than 14 years, similar mortality compared with that of KTRs older than 18 and younger than 40 years, and lower mortality than KTRs older than 40 years. CONCLUSIONS: The allocation of "ideal donors" to adolescent recipients may not maximize graft utility. Reevaluation of pediatric allocation priority may offer opportunities to optimize ideal renal allograft survival.

Changes in vitamin D binding protein and vitamin D concentrations associated with liver transplantation.

BACKGROUND: Vitamin D deficiency is associated with fractures, infections and death. Liver disease impairs vitamin D and vitamin D binding protein (DBP) metabolism. AIMS: We aimed to determine the impact of liver transplantation on vitamin D, particularly on DBP and free vitamin D concentrations. METHODS: Serum 25(OH)D, 1,25(OH)(2) D and DBP concentrations were measured in 202 adults before liver transplantation and 3 months later in 155. Free vitamin D concentrations were estimated from these values. Risk factors for 25(OH)D deficiency (<20 ng/ml) and low 1,25(OH)(2) D (<20 pg/ml) were examined with logistic regression, and changes in concentrations following transplantation with linear regression. RESULTS: Pretransplant, 84% were 25(OH)D deficient, 13% had 25(OH)D concentrations <2.5 ng/ml, and 77% had low 1,25(OH)(2) D. Model for end-stage liver disease score ≥ 20 (P < 0.005) and hypoalbuminemia (P < 0.005) were associated with low 25(OH)D and 1,25(OH)(2) D concentrations. Following transplantation, 25(OH)D concentrations increased a median of 17.8 ng/ml (P < 0.001). Albumin increased from a median of 2.7 to 3.8 g/dl (P < 0.001) and DBP from 8.6 to 23.8 mg/dl (P < 0.001). Changes in total 25(OH)D were positively and independently associated with changes in DBP (P < 0.05) and albumin (P < 0.001). Free 25(OH)D concentrations rose from 6.0 to 9.7 pg/ml (P < 0.001). In contrast, total 1,25(OH)(2)D concentrations rose only by 4.3 pg/ml (P < 0.001) and free 1,25(OH)(2D concentrations declined (P < 0.001). CONCLUSIONS: Serum total and free 25(OH)D and DBP concentrations rose substantially following transplantation, while 1,25(OH)(2) D concentrations showed modest changes and free 1,25(OH)(2) D decreased. Studies of the effects of vitamin D status on diverse transplant complications are needed.

Age, exclusion criteria, and generalizability of randomized trials enrolling kidney transplant recipients.

BACKGROUND: The proportion of elderly (≥65 years) kidney transplant recipients (KTRs) doubled in the United States from 1999 to 2008. Given higher mortality, more medication side effects, and less rejection among elderly KTRs, optimal care of these patients may require tailored decisions about transplant therapeutics. It is unknown whether participants in transplant clinical trials-which generate the best evidence for patient care-are representative of the aging population of KTRs. METHODS: Using PubMed, we identified randomized trials involving KTRs from 1999 to 2008 and determined age-exclusion criteria and the mean age of participants. The mean age of these trial participants was compared with the mean age of the overall population of incident KTRs in the United States. RESULTS: The 87,222 participants in 573 trials were significantly younger than the US KTR population (P<0.05). This age discrepancy worsened over the study period (during the years 2006 to 2008, the mean age was 45 years for trial participants versus 50 years for US KTRs, P<0.05). Thirty percent of trials had an exclusion criterion based on older age, and 16% excluded recipients aged 65 years or older. In multivariable regression, immunosuppression trials (P<0.01) and trials in higher impact journals (P=0.03) were more likely to exclude the elderly, but there was no significant difference in exclusion of elderly patients based on a trial's geographic location. CONCLUSIONS: Trial participants are younger than KTRs in the United States and many trials exclude older patients. Transplant investigators should make strong efforts to recruit patients across the total age spectrum.