Potential to Mitigate Disparities in Access to Kidney Transplant in the Hispanic/Latino Population With a Specialized Clinic: Single Center Study Representing Single State Data.

BACKGROUND: We sought to evaluate potential disparities in kidney transplant rates in a single state in the United States. We studied the potential to mitigate disparities with a specialized clinic using it as a model presentation. METHODS: Based on data from the United States Renal Data System and Organ Procurement and Transplantation Network, we estimated the yearly end-stage renal disease and waitlist addition, stratified by race/ethnicity from 2000 to 2018. Institution rates were analyzed similarly, and the implementation of a focused Latino clinic was evaluated. RESULTS: The number of patients added to the national transplant waitlist has increased by 40% in non-Latino whites and by 160% in Latinos from 2000 to 2017. Comparing the period from 2000 to 2004 to 2015 to 2018 in North Carolina, the waitlist increased for Latino patients by 482% and non-Latino whites by 23%. One year after a designated Latino transplant clinic at our institution, there was a 125% increase in the number of Latino referrals for kidney transplant evaluation, a 142% increase in the number of waitlisted Latino patients, and an increase in kidney transplants of 145%. CONCLUSION: With the increasing number of patients in the Latino community who are diagnosed with end-stage renal disease, there is a direct benefit for a culturally competent program that addresses access to transplants.

Center-level Variation in HLA-incompatible Living Donor Kidney Transplantation Outcomes.

BACKGROUND: Desensitization protocols for HLA-incompatible living donor kidney transplantation (ILDKT) vary across centers. The impact of these, as well as other practice variations, on ILDKT outcomes remains unknown. METHODS: We sought to quantify center-level variation in mortality and graft loss following ILDKT using a 25-center cohort of 1358 ILDKT recipients with linkage to Scientific Registry of Transplant Recipients for accurate outcome ascertainment. We used multilevel Cox regression with shared frailty to determine the variation in post-ILDKT outcomes attributable to between-center differences and to identify any center-level characteristics associated with improved post-ILDKT outcomes. RESULTS: After adjusting for patient-level characteristics, only 6 centers (24%) had lower mortality and 1 (4%) had higher mortality than average. Similarly, only 5 centers (20%) had higher graft loss and 2 had lower graft loss than average. Only 4.7% of the differences in mortality (P < 0.01) and 4.4% of the differences in graft loss (P < 0.01) were attributable to between-center variation. These translated to a median hazard ratio of 1.36 for mortality and 1.34 of graft loss for similar candidates at different centers. Post-ILDKT outcomes were not associated with the following center-level characteristics: ILDKT volume and transplanting a higher proportion of highly sensitized, prior transplant, preemptive, or minority candidates. CONCLUSIONS: Unlike most aspects of transplantation in which center-level variation and volume impact outcomes, we did not find substantial evidence for this in ILDKT. Our findings support the continued practice of ILDKT across these diverse centers.

Reducing liver transplant length of stay: a Lean Six Sigma approach.

CONTEXT: Organ transplant centers are under increasing scrutiny to maintain outcomes while controlling cost in a challenging population of patients. Throughout health care and transplant specifically, length of stay is used as a benchmark for both quality and resource utilization. OBJECTIVE: To decrease our length of stay for liver transplant by using Lean Six Sigma methods. DESIGN: The Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) method was used to systematically analyze our process from transplant listing to hospital discharge after transplant, identifying many factors affecting length of stay. PATIENTS OR OTHER PARTICIPANTS: Adult, single-organ, primary liver transplant recipients between July 2008 and June 2012 were included in the study. Recipients with living donors or fulminant liver failure were excluded. INTERVENTION(S): Multiple interventions, including a clinical pathway and enhanced communication, were implemented. MAIN OUTCOME MEASURE(S): Length of stay after liver transplant and readmission after liver transplant.R ESULTS: Median length of stay decreased significantly from 11 days before the intervention to 8 days after the intervention. Readmission rate did not change throughout the study. The improved length of stay was maintained for 24 months after the study. CONCLUSION: Using a Lean Six Sigma approach, we were able to significantly decrease the length of stay of liver transplant patients. These results brought our center's outcomes in accordance with our goal and industry benchmark of 8 days. Clear expectations, improved teamwork, and a multidisciplinary clinical pathway were key elements in achieving and maintaining these gains.

Local access to subspecialty care influences the chance of receiving a liver transplant.

Prior studies have examined the impact of demographic factors on liver transplant outcomes. These factors may be surrogate markers for access to medical care. We investigated physician density in referred patients' hospital service areas (HSAs) as a factor in patients' probability of receiving a liver transplant. We performed a retrospective review of patients referred for liver transplantation from 2002 through 2010. Data on physician density were obtained from the Dartmouth Atlas of Health Care. The primary outcome was the receipt of a liver transplant. A Cox hazard analysis was used to control for various demographic and medical covariates. Over the time period, 1485 adult patients were considered for liver transplantation. Factors that influenced the hazard of receiving a liver transplant were the Model for End-Stage Disease (MELD) score at referral {Hazard ratios (HR) per point = 1.11 [95% confidence interval (CI) = 1.09-1.14]}, a secondary diagnosis of hepatocellular carcinoma [HR = 2.72 (95% CI = 1.76-4.20)], blood group AB [HR = 2.98 (95% CI = 1.52-5.87) with blood group A as the referent], the type of insurance [HR for Medicare = 0.36 (95% CI = 0.14-0.89) with commercial insurance as the referent], and the number of gastroenterologists in an HSA [odds ratio with each additional gastroenterologist per 100,000 population = 1.12 (95% CI = 1.01-1.25)]. Age, race, sex, distance to the transplant center, and residence in a rural community did not influence the chance of receiving a liver transplant. In conclusion, the hazard of receiving a liver transplant are influenced by the diagnosis, MELD score, and insurance status; in addition, patients were 12% more likely to receive a transplant with each additional gastroenterologist per 100,000 population in their local HSA. Local access to gastroenterology subspecialty care is an important factor in receiving a liver transplant.

Posttransplant diabetes mellitus in kidney allograft recipients: incidence, risk factors, and management.

BACKGROUND: Posttransplant diabetes mellitus (PTDM), associated with the use of immunosuppressants, occurs at varying rates in kidney transplant recipients. METHODS: Five transplant centers conducted a retrospective review of 435 kidney recipients completing at least 6 months of follow-up to determine risk factors, incidence, and management strategies for posttransplant glucose intolerance. A distinction was made between hyperglycemia and diabetes. RESULTS: The incidence of PTDM was found to be 4.9%. Among tacrolimus-treated patients it was 5.7%, compared with 3.3% among cyclosporine-treated patients (P=0.453). Mean daily maintenance doses of prednisone and mycophenolate mofetil (MMF) were significantly lower in tacrolimus-treated patients. Significantly more tacrolimus-treated patients were prednisone-free (9.0%/0%; P<0.001). Logistic regression analysis revealed that the absence of an antiproliferative agent correlated with the development of PTDM (odds ratio=3.56; P=0.01). CONCLUSIONS: Based on this study, we propose management guidelines specifically for glucose intolerance developing after renal transplantation. Maintenance of blood glucose levels within strict limits is recommended, and the contribution of immunosuppressive agents to the development of PTDM is accounted for. Gradual tapering of prednisone and tacrolimus is proposed for patients who develop PTDM but also bear minimal risk of rejection. Tapering and eventual withdrawal of insulin should be attempted once blood glucose levels normalize. Switching to the alternative calcineurin inhibitor should only be considered as a late intervention. Tacrolimus therapy should be considered even in patients at high risk for diabetes, because the benefit of reduced acute rejection incidence and severity, as demonstrated in other studies, outweighs the risk of PTDM.