Assuntos
Seguro , Falência Renal Crônica , Transplante de Rim , Idoso , Humanos , Estados Unidos , MedicareRESUMO
Among the causes of inequity in organ transplantation, geography is oft-cited but rarely defined with precision. Traditionally, geographic inequity has been characterized by variation in distance to transplant centers, availability of deceased organ donors, or the consequences of allocation systems that are inherently geographically based. Recent research has begun to explore the use of measures at various geographic levels to better understand how characteristics of a patient's geographic surroundings contribute to a broad range of transplant inequities. Within, we first explore the relationship between geography, inequities, and the social determinants of health. Next, we review methodologic considerations essential to geographic health research, and critically appraise how these techniques have been applied. Finally, we propose how to use geography to improve access to and outcomes of transplantation.
Assuntos
Obtenção de Tecidos e Órgãos , Humanos , Determinantes Sociais da Saúde , Doadores de Tecidos , Geografia , Fatores SociaisRESUMO
Transplant referral and evaluation are critical steps to waitlisting yet remain an elusive part of the transplant process. Despite calls for more data collection on pre-waitlisting steps, there are currently no national surveillance data to aid in understanding the causes and potential solutions for the extreme variation in access to transplantation. As population health scientists, epidemiologists, clinicians, and ethicists we submit that the transplant community has an obligation to better understand disparities in transplant access as a first necessary step to effectively mitigating these inequities. Our position is grounded in a population health approach, consistent with several new overarching national policy and quality initiatives. The purpose of this Perspective is to (1) provide an overview of how a population health approach should inform current multisystem policies impacting kidney transplantation and demonstrate how these efforts could be enhanced with national data collection on pre-waitlisting steps; (2) demonstrate the feasibility and concrete next steps for pre-waitlisting data collection; and (3) identify potential opportunities to use these data to implement effective population-level interventions, policies, and quality measures to improve equity in access to kidney transplantation.
Assuntos
Acessibilidade aos Serviços de Saúde , Transplante de Rim , Saúde da População , Humanos , Listas de EsperaRESUMO
Disparities are well-documented across the continuum of surgical care. Counteracting such disparities requires new multidisciplinary approaches that utilize the expertise of affected individuals, such as community-based participatory research (CBPR). CBPR is an approach to research that is anchored in equitable, sustainable community-academic partnerships, and has been shown to improve intervention implementation and outcomes. In this article, community stakeholders and researchers outline the principles and benefits of CBPR, examples of CBPR in trauma and transplant, and future directions for CBPR within surgery.
Assuntos
Pesquisa Participativa Baseada na Comunidade , Disparidades em Assistência à Saúde , Procedimentos Cirúrgicos Operatórios , Humanos , Estados UnidosRESUMO
RATIONALE & OBJECTIVE: The shortage of deceased donor kidneys identified for potential transplantation in the United States is exacerbated by a high proportion of deceased donor kidneys being discarded after procurement. We estimated the impact of a policy proposal aiming to increase organ utilization by extending eligibility for waiting time reinstatement for recipients experiencing early allograft failure after transplantation. STUDY DESIGN: Decision analysis informed by clinical registry data. SETTING & POPULATION: We used Organ Procurement and Transplantation Network data to identify 76,044 deceased-donor kidneys procured in the United States from 2013 to 2017, 80% of which were transplanted and 20% discarded. INTERVENTION: Extend waiting time reinstatement for recipients experiencing allograft failure from the current 90 days to 1 year after transplantation. OUTCOME: Net impact to the waitlist, defined as the estimated number of additional transplants minus estimated increase in waiting list reinstatements. MODEL, PERSPECTIVE, & TIMEFRAME: We estimated (1) the number of additional deceased donor kidneys that would be transplanted if there was a 5%-25% relative reduction in discards, and (2) the number of recipients who would regain waiting time under a 6-, 12-, 18-, and 24-month reinstatement policy. RESULTS: Reinstating a waiting time for recipients experiencing allograft failure up to 1 year after transplantation yielded more additional transplants than growth in additions to the waiting list for all model assumptions except the combination of a very low relative reduction in discards (5%) and a very high failure rate of transplanted kidneys that would previously have been discarded (≥5 times the rate of currently transplanted kidneys). LIMITATIONS: Lack of empirical evidence supporting the proposed impact of such a policy change. CONCLUSIONS: A policy change reinstating waiting time for deceased donor kidneys recipients with allograft failure up to 1 year after transplantation should explored as a decision science-based intervention to improve organ utilization.
Assuntos
Transplante de Rim , Obtenção de Tecidos e Órgãos , Aloenxertos , Técnicas de Apoio para a Decisão , Sobrevivência de Enxerto , Humanos , Doadores de Tecidos , Estados Unidos , Listas de EsperaRESUMO
Importance: Improving the quality of dialysis care and access to kidney transplantation for patients with end-stage kidney disease is a national clinical and policy priority. The role of dialysis facility quality in increasing access to kidney transplantation is not known. Objective: To determine whether patient, facility, and kidney transplant waitlisting characteristics are associated with variations in dialysis center quality. Design, Setting, and Participants: This population-based cohort study is an analysis of US Renal Data System data and Medicare Dialysis Facility Compare (DFC) data from 2013 to 2018. Participants included all adult (aged ≥18 years) patients in the US Renal Data System beginning long-term dialysis in the US from 2013 to 2017 with follow-up through the end of 2018. Patients with a prior kidney transplant and matched Medicare DFC star ratings to each annual cohort of recipients were excluded. Patients at facilities without a star rating in that year were also excluded. Data analysis was performed from January to April 2021. Exposures: Dialysis center quality, as defined by Medicare DFC star ratings. Main Outcomes and Measures: The primary outcome was the proportion of patients undergoing incident dialysis who were waitlisted within 1 year of dialysis initiation. Secondary outcomes were patient and facility characteristics. Results: Of 507â¯581 patients beginning long-term dialysis in the US from 2013 to 2017, 291â¯802 (57.4%) were male, 266â¯517 (52.5%) were White, and the median (interquartile range) age was 65 (55-75) years. Of 5869 dialysis facilities in 2017, 132 (2.2%) were 1-star, 436 (7.4%) were 2-star, 2047 (34.9%) were 3-star, 1660 (28.3%) were 4-star, and 1594 (27.2%) were 5-star. Higher-quality dialysis facilities were associated with 47% higher odds of transplant waitlisting (odds ratio [OR], 1.47; 95% CI, 1.39-1.57 for 5-star facilities vs 1-star facilities; P < .001). Black patients were less likely than White patients to be waitlisted for transplantation (OR, 0.74; 95% CI, 0.72-0.76). In addition, patients at for-profit (OR, 0.78; 95% CI, 0.74-0.81) and rural (OR, 0.63; 95%, CI 0.58-0.68) facilities were less likely to be waitlisted for transplantation compared with those at nonprofit and urban facilities, respectively. Conclusions and Relevance: In this cohort study, patients at higher-quality dialysis facilities had higher odds than patients at lower-quality facilities of being waitlisted for kidney transplantation within 1 year. Waitlisting rates for kidney transplantation should be considered for integration into the current Centers for Medicare & Medicaid Services DFC star ratings to incentivize dialysis facility referral to transplant centers, inform patient choice, and drive quality improvement by increasing transplant waitlisting rates.
Assuntos
Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Transplante de Rim/estatística & dados numéricos , Seleção de Pacientes , Determinantes Sociais da Saúde/estatística & dados numéricos , Listas de Espera , Idoso , Centers for Medicare and Medicaid Services, U.S. , Estudos de Coortes , Feminino , Humanos , Falência Renal Crônica , Masculino , Medicare , Pessoa de Meia-Idade , Qualidade da Assistência à Saúde , Diálise Renal , Estados UnidosRESUMO
BACKGROUND: There is no consensus regarding the optimal surgical treatment for transplantable hepatocellular carcinoma (HCC) patients with well-compensated cirrhosis. Our aim was to compare outcomes between Child-Pugh A (CPA) cirrhotics who underwent liver resection or transplantation for HCC. METHODS: Clinicopathologic data were retrospectively collected for all surgically treated HCC patients between 7/1992 and 12/2015. Disease-free survival (DFS) and overall survival (OS) were calculated from the time of operation or diagnosis (intention-to-treat analysis including patients removed from the transplant list). The average overall cost including pre-operative and post-operative procedures was calculated for each group. RESULTS: Of the 513 surgically treated HCC patients, 184 had CPA cirrhosis and fulfilled the Milan criteria (MC). Of those, 95 (52%) were resected and 89 (48%) were transplanted. Twenty-two patients were removed from the transplant list. Transplanted patients were younger (p < 0.001), had a higher MELD score (p < 0.001) and a higher frequency of hepatitis C (p < 0.001). Length of stay and postoperative complication rates were similar between groups. DFS was longer for transplanted patients (3-, 5-, and 10-year DFS rates 48, 44, 31% vs 96, 94, 94%, respectively, p < 0.001). OS was similar between groups (3-, 5-, and 10-year OS rates 76, 62, 41% vs 82, 77, 53%, respectively, p = 0.07). Only size of greatest lesion and T stage were independent predictors of OS. The cost was much higher for the transplant group, even when accounting for the treatment of recurrences ($37,391 vs $137,996). CONCLUSIONS: Since OS is similar between CPA cirrhotics within the MC undergoing resection or transplantation for HCC, but cost is significantly higher for transplantation. Resection should be considered for first-line treatment.
Assuntos
Carcinoma Hepatocelular/diagnóstico , Hepatectomia/métodos , Cirrose Hepática/cirurgia , Neoplasias Hepáticas/diagnóstico , Transplante de Fígado/efeitos adversos , Transplantados , Idoso , Carcinoma Hepatocelular/etiologia , Carcinoma Hepatocelular/cirurgia , Intervalo Livre de Doença , Feminino , Humanos , Neoplasias Hepáticas/etiologia , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Although residential segregation has been implicated in various negative health outcomes, its association with kidney transplantation has not been examined. METHODS: Age- and sex-standardized kidney transplantation rates were calculated from the Scientific Registry of Transplant Recipients, 2000-2013. Population characteristics including segregation indices were derived from the 2010 U.S. Census data and the U.S. Renal Data System. Separate multivariable Poisson regression models were constructed to identify factors independently associated with kidney transplantation among Blacks and Whites. RESULTS: Median age- and sex-standardized kidney transplantation rates were 114 per 100,000 for Blacks and 38 per 100,000 for Whites. 16.1% of the U.S. population lived in counties with high segregation. There was no difference in the kidney transplantation rates across the levels of segregation among Blacks and Whites. CONCLUSION: Factors other than residential segregation may play roles in kidney transplantation disparities. Continued efforts to identify these factors may be beneficial in reducing transplantation disparities across the U.S. SUMMARY: Using the Scientific Registry of Transplant Recipients and U.S. census data, we aimed to determine whether residential segregation was associated with kidney transplantation rates. We found that there was no association between residential segregation and kidney transplantation rates.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Transplante de Rim/estatística & dados numéricos , Características de Residência/estatística & dados numéricos , População Branca/estatística & dados numéricos , Censos , Humanos , Sistema de Registros , Estados Unidos/epidemiologiaAssuntos
Doença Hepática Terminal/cirurgia , Regulamentação Governamental , Legislação Hospitalar , Transplante de Fígado , Avaliação de Resultados em Cuidados de Saúde/métodos , Seleção de Pacientes , Disfunção Primária do Enxerto , Alocação de Recursos , Doadores de Tecidos , Listas de Espera , Doença Hepática Terminal/diagnóstico , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/mortalidade , Humanos , Legislação Hospitalar/tendências , Transplante de Fígado/ética , Transplante de Fígado/legislação & jurisprudência , Transplante de Fígado/mortalidade , Transplante de Fígado/normas , Transplante de Fígado/tendências , Medicare , Avaliação de Resultados em Cuidados de Saúde/normas , Avaliação de Resultados em Cuidados de Saúde/tendências , Seleção de Pacientes/ética , Disfunção Primária do Enxerto/etiologia , Disfunção Primária do Enxerto/mortalidade , Alocação de Recursos/ética , Alocação de Recursos/legislação & jurisprudência , Alocação de Recursos/métodos , Alocação de Recursos/normas , Alocação de Recursos/tendências , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Falha de Tratamento , Estados UnidosRESUMO
BACKGROUND: Kidney transplant centers are distributed unevenly throughout 58 donor service areas (DSAs) in the United States. Market competition and transplant center density may affect transplantation access and outcomes. We evaluated the role of spatial organization of transplant centers in conjunction with market competition in the conduct of kidney transplantation. METHODS: The Scientific Registry of Transplant Recipients was queried for market characteristics associated with kidney transplantation between 2003 and 2012. Market competition was calculated using the Herfindahl Hirschman Index. Kidney transplant centers were geocoded to measure spatial organization by the average nearest neighbor (ANN) method. Kidney quality was assessed by kidney donor risk index. A hierarchical negative binomial mixed effects model tested the relationship between market characteristics and annual kidney transplants by DSA. RESULTS: About 152,071 kidney transplants were performed at 229 adult kidney transplant centers in 58 DSAs. Greater market competition was associated with kidney transplant center spatial clustering (P < 0.001). In multivariable analysis, more kidney transplant centers (incidence rate ratio [IRR], 1.04; P = 0.005), 100 more new listings (IRR, 1.02; P = 0.003), 100 more deceased donors (IRR, 1.23; P < 0.001), 100 more new dialysis registrants (IRR, 1.01; P < 0.001), and higher kidney donor risk index (IRR, 1.98; P < 0.001) were associated with increased kidney transplants. CONCLUSIONS: After controlling for market characteristics, larger numbers of kidney transplant centers were associated with more kidney transplants and increased utilization of deceased donor kidneys. This underlines the importance of understanding geography as well as competition in improving access to kidney transplantation.
Assuntos
Comércio/tendências , Planos Médicos Alternativos/tendências , Competição Econômica/tendências , Setor de Assistência à Saúde/tendências , Acessibilidade aos Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Falência Renal Crônica/cirurgia , Transplante de Rim/tendências , Avaliação de Processos em Cuidados de Saúde/tendências , Aloenxertos , Distribuição de Qui-Quadrado , Comércio/economia , Planos Médicos Alternativos/economia , Competição Econômica/economia , Sobrevivência de Enxerto , Alocação de Recursos para a Atenção à Saúde/tendências , Setor de Assistência à Saúde/economia , Acessibilidade aos Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/economia , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/economia , Falência Renal Crônica/mortalidade , Transplante de Rim/efeitos adversos , Transplante de Rim/economia , Transplante de Rim/mortalidade , Análise Multivariada , Avaliação das Necessidades/tendências , Avaliação de Processos em Cuidados de Saúde/economia , Modelos de Riscos Proporcionais , Indicadores de Qualidade em Assistência à Saúde/tendências , Sistema de Registros , Características de Residência , Fatores de Tempo , Doadores de Tecidos/provisão & distribuição , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Liver transplantation centers are unevenly distributed within the Donor Service Areas (DSAs) of the United States. This study assessed how market competition and liver transplantation center density are associated with liver transplantation volume within individual DSAs. STUDY DESIGN: We conducted a retrospective cohort study of 53,156 adult liver transplants in 45 DSAs with 110 transplantation centers identified from the Scientific Registry of Transplant Recipients between 2003 and 2012. The following measures were derived annually for each DSA: market competition using the Herfindahl Hirschman Index, transplantation center density by the Average Nearest Neighbor method, liver quality by the Liver Donor Risk Index, and patient risk by the Model for End-Stage Liver Disease. A hierarchical mixed effects negative binomial regression model of the relationship between liver transplants and market factors was created annually. Patient and graft survival were investigated with a Cox proportional hazards model. RESULTS: Transplantation center density was associated with market competition (p < 0.0001), listings for organ transplantation (p < 0.0001), and Model for End-Stage Liver Disease at transplantation (p = 0.0005). More liver transplantation centers (incidence rate ratio [IRR] = 1.03; p = 0.04), greater market competition (IRR = 1.36; p = 0.02), increased listings (IRR = 1.14; p < 0.0001), more donors (IRR = 1.24; p < 0.0001), and higher Liver Donor Risk Index (IRR = 3.35; p < 0.0001) were associated with more transplants. No market variables were associated with increased mortality after transplantation. CONCLUSIONS: After controlling for demographic and market factors, a greater concentration of centers was associated with more liver transplants without impacting overall survival. These results warrant additional investigation into the relationship between geospatial factors and liver transplantation volume with consideration for the optimization of scarce resources.
Assuntos
Comércio/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/economia , Disparidades em Assistência à Saúde/economia , Transplante de Fígado/economia , Adulto , Estudos de Coortes , Sistemas de Informação Geográfica , Sobrevivência de Enxerto , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Transplante de Fígado/mortalidade , Transplante de Fígado/estatística & dados numéricos , Modelos Estatísticos , Modelos de Riscos Proporcionais , Sistema de Registros , Estudos Retrospectivos , Análise Espacial , Estados UnidosRESUMO
BACKGROUND: Failure-to-rescue (FTR or death after postoperative complication) is thought to explain surgical mortality excesses across hospitals, and FTR is an emerging performance measure and target for quality improvement. We compared the FTR population to preoperatively identifiable subpopulations for their potential to close the mortality gap between lowest- and highest-mortality hospitals. STUDY DESIGN: Patients undergoing small bowel resection, pancreatectomy, colorectal resection, open abdominal aortic aneurysm repair, lower extremity arterial bypass, and nephrectomy were identified in the 2007 to 2011 Nationwide Inpatient Sample. Lowest- and highest-mortality hospitals were defined using risk- and reliability-adjusted mortality quintiles. Five target subpopulations were established a priori: the FTR population, predicted high-mortality risk (predicted highest-risk quintile), emergency surgery, elderly (>75 years old), and diabetic patients. RESULTS: Across the lowest mortality quintile (n=282 hospitals, 56,893 patients) and highest-mortality quintile (282 hospitals, 45,784 patients), respectively, the size of target subpopulations varied only for the FTR population (20.2% vs 22.4%, p=0.002) but not for other subpopulations. Variation in mortality rates across lowest- and highest-mortality hospitals was greatest for the high-mortality risk (7.5% vs 20.2%, p<0.0001) and FTR subpopulations (7.8% vs 18.9%, p<0.0001). The FTR and high-risk populations had comparable sensitivity (81% and 75%) and positive predictive value (19% and 20%, respectively) for mortality. In Monte Carlo simulations, the mortality gap between the lowest- and highest-mortality hospitals was reduced by nearly 75% when targeting the FTR population or the high-risk population, 78% for the emergency surgery population, but less for elderly (51%) and diabetic (17%) populations. CONCLUSIONS: Preoperatively identifiable patients with high estimated mortality risk may be preferable to the FTR population as a target for surgical mortality reduction.
Assuntos
Benchmarking , Mortalidade Hospitalar , Complicações Pós-Operatórias/mortalidade , Melhoria de Qualidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Método de Monte Carlo , Período Pré-Operatório , Análise de Regressão , Reprodutibilidade dos Testes , Risco Ajustado , Sensibilidade e Especificidade , Falha de Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To evaluate the impact of market competition on patient mortality and graft failure after kidney transplantation. BACKGROUND: Kidneys are initially allocated within 58 donation service areas (DSAs), which have varying numbers of transplant centers. Market competition is generally considered beneficial. METHODS: The Scientific Registry of Transplant Recipients database was queried and the Herfindahl-Hirschman index (HHI), a measure of market competition, was calculated for each DSA from 2003 to 2012. Receipt of low-quality kidneys (Kidney Donor Profile Index ≥ 85) was modeled with multivariable logistic regression, and Cox proportional hazards models were created for graft failure and patient mortality. RESULTS: A total of 127,355 adult renal transplants were performed. DSAs were categorized as 7 no (HHI = 1), 17 low (HHI = 0.52-0.97), 17 medium (HHI = 0.33-0.51), or 17 high (HHI = 0.09-0.32) competition. For deceased donor kidney transplantation, increasing market competition was significantly associated with mortality [hazard ratio (HR): 1.11, P = 0.01], graft failure (HR: 1.18, P = 0.0001), and greater use of low-quality kidneys (odds ratio = 1.39, P < 0.0001). This was not true for living donor kidney transplantation (mortality HR: 0.94, P = 0.48; graft failure HR: 0.99, P = 0.89). Competition was associated with longer waitlists (P = 0.04) but not with the number of transplants per capita in a DSA (P = 0.21). CONCLUSIONS: Increasing market competition is associated with increased patient mortality and graft failure and the use of riskier kidneys. These results may represent more aggressive transplantation and tolerance of greater risk for patients who otherwise have poor alternatives. Market competition should be better studied to ensure optimal outcomes.