Codesign of health technology interventions to support best-practice perioperative care and surgical waitlist management.

OBJECTIVES: This project aimed to determine where health technology can support best-practice perioperative care for patients waiting for surgery. METHODS: An exploratory codesign process used personas and journey mapping in three interprofessional workshops to identify key challenges in perioperative care across four health districts in Sydney, Australia. Through participatory methodology, the research inquiry directly involved perioperative clinicians. In three facilitated workshops, clinician and patient participants codesigned potential digital interventions to support perioperative pathways. Workshop output was coded and thematically analysed, using design principles. RESULTS: Codesign workshops, involving 51 participants, were conducted October to November 2022. Participants designed seven patient personas, with consumer representatives confirming acceptability and diversity. Interprofessional team members and consumers mapped key clinical moments, feelings and barriers for each persona during a hypothetical perioperative journey. Six key themes were identified: 'preventative care', 'personalised care', 'integrated communication', 'shared decision-making', 'care transitions' and 'partnership'. Twenty potential solutions were proposed, with top priorities a digital dashboard and virtual care coordination. DISCUSSION: Our findings emphasise the importance of interprofessional collaboration, patient and family engagement and supporting health technology infrastructure. Through user-based codesign, participants identified potential opportunities where health technology could improve system efficiencies and enhance care quality for patients waiting for surgical procedures. The codesign approach embedded users in the development of locally-driven, contextually oriented policies to address current perioperative service challenges, such as prolonged waiting times and care fragmentation. CONCLUSION: Health technology innovation provides opportunities to improve perioperative care and integrate clinical information. Future research will prototype priority solutions for further implementation and evaluation.

OPTN/SRTR 2022 Annual Data Report: Introduction.

The OPTN/SRTR 2022 Annual Data Report presents the status of the solid organ transplant system in the United States from 2011 through 2022. Organ-specific chapters are presented for kidney, pancreas, liver, intestine, heart, and lung transplant. Each organ-specific chapter is organized to present waitlist information, donor information (both deceased and living, as appropriate), transplant information, and patient outcomes. Data pertaining to pediatric patients are generally presented separately from the adult data. In addition to the organ-specific chapters, the reader will find chapters dedicated to deceased organ donation, vascularized composite allografts, and the COVID-19 pandemic. The data presented in the Annual Data Report are descriptive in nature. In other words, most tables and figures present raw data without statistical adjustment for possible confounding or changes over time. Therefore, the reader should keep in mind the observational nature of the data when attempting to draw inferences before trying to ascribe a cause to any observed patterns or trends. This introduction provides a brief overview of trends in waitlist and transplant activity from 2012 through 2022. More detailed descriptions can be found in the respective organ-specific chapters.

Reducing wait times and avoiding unnecessary use of high-cost mental health services through a Rapid Access and Stabilization Program: protocol for a program evaluation study.

BACKGROUND: Emergency psychiatric care, unplanned hospital admissions, and inpatient health care are the costliest forms of mental health care. According to Statistics Canada (2018), almost 18% (5.3 million) of Canadians reported needing mental health support. However, just above half of this figure (56.2%) have reported their needs were fully met. In light of this evidence there is a pressing need to provide accessible mental health services in flexible yet cost-effective ways. To further expand capacity and access to mental health care in the province, Nova Scotia Health has launched a novel mental health initiative for people in need of mental health care without requiring emergency department visits or hospitalization. This new service is referred to as the Rapid Access and Stabilization Program (RASP). This study evaluates the effectiveness and impact of the RASP on high-cost health services utilization (e.g. ED visits, mobile crisis visits, and inpatient treatments) and related costs. It also assesses healthcare partners' (e.g. healthcare providers, policymakers, community leaders) perceptions and patient experiences and satisfaction with the program and identifies sociodemographic characteristics, psychological conditions, recovery, well-being, and risk measures in the assisted population. METHOD: This is a hypothesis-driven program evaluation study that employs a mixed methods approach. A within-subject comparison (pre- and post-evaluation study) will examine health services utilization data from patients attending RASP, one year before and one year after their psychiatry assessment at the program. A controlled between-subject comparison (cohort study) will use historical data from a control population will examine whether possible changes in high-cost health services utilization are associated with the intervention (RASP). The primary analysis involves extracting secondary data from provincial information systems, electronic medical records, and regular self-reported clinical assessments. Additionally, a qualitative sub-study will examine patient experience and satisfaction, and health care partners' impressions. DISCUSSION: We expect that RASP evaluation findings will demonstrate a minimum 10% reduction in high-cost health services utilization and corresponding 10% cost savings, and also a reduction in the wait times for patient consultations with psychiatrists to less than 30 calendar days, in both within-subject and between-subject comparisons. In addition, we anticipate that patients, healthcare providers and healthcare partners would express high levels of satisfaction with the new service. CONCLUSION: This study will demonstrate the results of the Mental Health and Addictions Program (MHAP) efforts to provide stepped-care, particularly community-based support, to individuals with mental illnesses. Results will provide new insights into a novel community-based approach to mental health service delivery and contribute to knowledge on how to implement mental health programs across varying contexts.

Socioeconomic factors influence surgical wait times for non-emergent gynecologic surgical procedures: a retrospective analysis.

BACKGROUND: In various disciplines, an association between surgical wait times and patient outcomes has been identified. This study is among the first to investigate whether practice setting influences wait times for elective surgeries in benign gynecology. METHODS: This retrospective study of patients at three New York hospitals from 10/2019-2/2020 compared surgical wait times among patients seen in federally-qualified health centers (FQHC's) and private practice settings. Emergent surgeries, oncology cases, abortions, urogynecology procedures, and cases concurrently booked with another specialty were excluded. Surgical wait time was defined as the time (days) from the decision to operate to the day of the procedure. A multivariable mixed model was used to model surgical wait time by setting of care, adjusting for age, BMI, race, ethnicity, insurance, need for medical clearance, and scheduled block time. A univariable analysis was then utilized to assess surgical wait times by clinical setting for each insurance type. RESULTS: Five hundred forty patients were identified with a median age of 45.6 years (range 16-87). Average surgical wait time was 27 days (range 1-288 days). In multivariable analysis, longer surgical wait times were associated with being seen preoperatively in a FQHC compared to the private practice setting (102% longer, 59.5 days vs. 22 days, p < 0.0001), and with needing medical clearance (56.4% longer, 45 days vs. 22 days. p = 0.0001). CONCLUSIONS: These results suggest that in benign gynecology, surgical wait times are significantly influenced by the practice setting in which a patient gets care, with notable delays in care among patients who are seen in a federally qualified health center preoperatively.

Discrete Event Simulation to Incorporate Infusion Wait-Time When Assessing Cost-Effectiveness of a Chimeric-Antigen Receptor T Cell Therapy.

OBJECTIVES: The main objective was to use discrete event simulation to model the impact of wait-time, defined as the time between leukapheresis and chimeric antigen receptor (CAR-T) infusion, when assessing the cost-effectiveness of tisagenlecleucel in young patients with relapsed/refractory acute lymphoblastic leukemia. METHODS: The movement of patients through the model was determined by parametric time-to-event distributions, with the competing risk of an event determining the costs and quality-adjusted life-years (QALYs) assigned. Cost-effectiveness was expressed using the incremental cost-effectiveness ratio (ICER) for tisagenlecleucel compared with chemotherapy over the lifetime. RESULTS: The base case generated a total of 5.79 QALYs and $622 872 for tisagenlecleucel and 1.19 QALYs and $181 219 for blinatumomab, resulting in an ICER of $96 074 per QALY. An increase in mean CAR-T wait-time to 6.20 months reduced the benefit and costs of tisagenlecleucel to 2.78 QALYs and $294 478 because of fewer patients proceeding to infusion, reducing the ICER to $71 112 per QALY. Alternatively, when the cost of tisagenlecleucel was assigned pre-infusion in sensitivity analysis, the ICER increased with increasing wait-time. CONCLUSIONS: Under a payment arrangement where CAR-T cost is incurred post-infusion, the loss of benefit to patients is not reflected in the ICER. This may be misguiding to decision makers, where cost-effectiveness ratios are used to guide resource allocation. discrete event simulation is an important tool for economic modeling of CAR-T as it is amenable to capturing the impact of wait-time, facilitating better understanding of factors affecting service delivery and consequently informed decision making to deliver faster access to CAR-T for patients.

Adolescent Residential Addiction Treatment In The US: Uneven Access, Waitlists, And High Costs.

Drug overdose deaths among adolescents are increasing in the United States. Residential treatment facilities are one treatment option for adolescents with substance use disorders, yet little is known about their accessibility or cost. Using the Substance Abuse and Mental Health Services Administration's treatment locator and search engine advertising data, we identified 160 residential addiction treatment facilities that treated adolescents with opioid use disorder as of December 2022. We called facilities while role-playing as the aunt or uncle of a sixteen-year-old child with a recent nonfatal overdose, to inquire about policies and costs. Eighty-seven facilities (54.4 percent) had a bed immediately available. Among sites with a waitlist, the mean wait time for a bed was 28.4 days. Of facilities providing cost information, the mean cost of treatment per day was $878. Daily costs among for-profit facilities were triple those of nonprofit facilities. Half of facilities required up-front payment by self-pay patients. The mean up-front cost was $28,731. We were unable to identify any facilities for adolescents in ten states or Washington, D.C. Access to adolescent residential addiction treatment centers in the United States is limited and costly.

Social Risk and Dialysis Facility Performance in the First Year of the ESRD Treatment Choices Model.

Importance: The End-Stage Renal Disease Treatment Choices (ETC) model randomly selected 30% of US dialysis facilities to receive financial incentives based on their use of home dialysis, kidney transplant waitlisting, or transplant receipt. Facilities that disproportionately serve populations with high social risk have a lower use of home dialysis and kidney transplant raising concerns that these sites may fare poorly in the payment model. Objective: To examine first-year ETC model performance scores and financial penalties across dialysis facilities, stratified by their incident patients' social risk. Design, Setting, and Participants: A cross-sectional study of 2191 US dialysis facilities that participated in the ETC model from January 1 through December 31, 2021. Exposure: Composition of incident patient population, characterized by the proportion of patients who were non-Hispanic Black, Hispanic, living in a highly disadvantaged neighborhood, uninsured, or covered by Medicaid at dialysis initiation. A facility-level composite social risk score assessed whether each facility was in the highest quintile of having 0, 1, or at least 2 of these characteristics. Main Outcomes and Measures: Use of home dialysis, waitlisting, or transplant; model performance score; and financial penalization. Results: Using data from 125 984 incident patients (median age, 65 years [IQR, 54-74]; 41.8% female; 28.6% Black; 11.7% Hispanic), 1071 dialysis facilities (48.9%) had no social risk features, and 491 (22.4%) had 2 or more. In the first year of the ETC model, compared with those with no social risk features, dialysis facilities with 2 or more had lower mean performance scores (3.4 vs 3.6, P = .002) and lower use of home dialysis (14.1% vs 16.0%, P < .001). These facilities had higher receipt of financial penalties (18.5% vs 11.5%, P < .001), more frequently had the highest payment cut of 5% (2.4% vs 0.7%; P = .003), and were less likely to achieve the highest bonus of 4% (0% vs 2.7%; P < .001). Compared with all other facilities, those in the highest quintile of treating uninsured patients or those covered by Medicaid experienced more financial penalties (17.4% vs 12.9%, P = .01) as did those in the highest quintile in the proportion of patients who were Black (18.5% vs 12.6%, P = .001). Conclusions: In the first year of the Centers for Medicare & Medicaid Services' ETC model, dialysis facilities serving higher proportions of patients with social risk features had lower performance scores and experienced markedly higher receipt of financial penalties.

Racial Disparities in Waiting List Outcomes of Patients Listed for Lung Transplantation.

BACKGROUND: The Lung Allocation Score, implemented in 2005, prioritized lung transplant candidates by medical urgency rather than waiting list time and was expected to improve racial disparities in transplant allocation. We evaluated whether racial disparities in lung transplant persisted after 2005. METHODS: We identified all wait-listed adult lung transplant candidates in the United States from 2005 through 2021 using the Scientific Registry of Transplant Recipients. We evaluated the association between race and receipt of a transplant by using a multivariable competing risk regression model adjusted for demographics, socioeconomic status, Lung Allocation Score, clinical measures, and time. We evaluated interactions between race and age, sex, socioeconomic status, and Lung Allocation Score. RESULTS: We identified 33,158 candidates on the lung transplant waiting list between 2005 and 2021: 27,074 White (82%), 3350 African American (10%), and 2734 Hispanic (8%). White candidates were older, had higher education levels, and had lower Lung Allocation Scores (P < .001). After multivariable adjustment, African American and Hispanic candidates were less likely to receive lung transplants than White candidates (African American: adjusted subhazard ratio, 0.86; 95% CI, 0.82-0.91; Hispanic: adjusted subhazard ratio, 0.82; 95% CI, 0.78-0.87). Lung transplant was significantly less common among Hispanic candidates aged >65 years (P = .003) and non-White candidates from higher-poverty communities (African-American: P = .013; Hispanic: P =.0036). CONCLUSIONS: Despite implementation of the Lung Allocation Score, racial disparities persisted for wait-listed African American and Hispanic lung transplant candidates and differed by age and poverty status. Targeted interventions are needed to ensure equitable access to this life-saving intervention.

Increased disparities in waitlist and post-heart transplantation outcomes according to socioeconomic status with the new heart transplant allocation system.

BACKGROUND: The study objective was to assess disparities in outcomes in the waitlist and post-heart transplantation (HT) according to socioeconomic status (SES) in the old and new U.S. HT allocation systems. METHODS: Adult HT candidates in the United Network for Organ Sharing database from 2014 through 2021 were included. Old or new system classification was according to listing before or after October 18, 2018. SES was stratified by patient ZIP code and median household income via U.S. Census Bureau and classified into terciles. Competing waitlist outcomes and post-transplantation survival were compared between systems. RESULTS: In total, 26,450 patients were included. Waitlisted candidates with low SES were more frequently younger, female, African American, and with higher body mass index. Reduced cumulative incidence (CI) of HT in the old system occurred in low SES (53.5%) compared to middle (55.7%, p = 0.046), and high (57.9%, p < 0.001). In the new system, the CI of HT was 65.3% in the low SES vs middle (67.6%, p = 0.002) and high (70.2%, p < 0.001), and SES remained significant in the adjusted analysis. In the old system, CI of death/delisting was similar across SES. In the new system, low SES had increased CI of death/delisting (7.4%) vs middle (6%, p = 0.012) and high (5.4%, p = 0.002). The old system showed similar 1-year survival across SES. In the new system, recipients with low SES had decreased 1-year survival (p = 0.041). CONCLUSIONS: SES affects waitlist and post-transplant outcomes. In the new system, all SES had increased access to HT; however, low SES had increased death/delisting due to worsening clinical status and decreased post-transplant survival.

Superiority of the new sex-adjusted models to remove the female disadvantage restoring equity in liver transplant allocation.

BACKGROUND AND AIMS: Model for End-stage Liver Disease (MELD) and MELDNa are used worldwide to guide graft allocation in liver transplantation (LT). Evidence exists that females are penalized in the present allocation systems. Recently, new sex-adjusted scores have been proposed with improved performance respect to MELD and MELDNa. GEMA-Na, MELD 3.0, and sex-adjusted MELDNa were developed to improve the 90-day dropout prediction from the list. The present study aimed at evaluating the accuracy and calibration of these scores in an Italian setting. METHODS: The primary outcome of the present study was the dropout from the list up to 90 days because of death or clinical deterioration. We retrospectively analysed data from 855 adults enlisted for liver transplantation in the Lazio region (Italy) (2012-2018). Ninety-day prediction of GEMA-Na, MELD 3.0 and sex-adjusted MELDNa with respect to MELD and MELDNa was analysed. Brier score and Brier Skill score were used for accuracy, and the Greenwood-Nam-D'Agostino test was used to evaluate the calibration of the models. RESULTS: GEMA-Na (concordance = .82, 95% CI = .75-.89), MELD 3.0 (concordance = .81, 95% CI = .74-.87) and sex-adjusted MELDNa (concordance = .81, 95% CI = .74-.88) showed the best 90-day dropout prediction. GEMA-Na showed a higher increase in accuracy with respect to MELD (p = .03). No superiority was shown with respect to MELDNa. All the tested scores showed a good calibration of the models. Using GEMA-Na instead of MELD would potentially save one in nine dropouts and could save one dropout per 285 patients listed. CONCLUSIONS: Validation and reclassification of the sex-adjusted score GEMA-Na confirm its superiority in predicting short-term dropout also in an Italian setting when compared with MELD.

Tailoring allocation policies and improving access to paediatric liver transplantation over a 16-year period.

BACKGROUND & AIMS: Mortality on the paediatric liver transplantation (pLT) waiting list (WL) is still an issue. We analysed the Italian pLT WL to evaluate the intention-to-treat (ITT) success rate and to identify factors influencing success. METHODS: All children (<18 years) listed for pLT in Italy between 2002-2018 were included (Era 1 [2002-2007]: centre-based allocation; Era 2 [2008-2014]: national allocation; Era 3 [2015-2018]: national allocation+mandatory-split policy). RESULTS: A total of 1,424 patients (median age: 2.0 [IQR 1.0-9.0] years; median weight: 12.0 kg [IQR 7-27]) were listed for pLT. Median WL time was 2 days (IQR 1-5) for Status 1 and 44 days (IQR 15-120) for non-Status 1 patients; 1,302 children (91.4%) were transplanted (67.3% with split grafts), while 50 children (3.5%) dropped off the WL (2.5% death, 1.0% clinical deterioration). Predictive factors for receiving LT included Status 1 (hazard ratio [HR] 1.66, p = 0.001), Status 1B (HR 1.96, p = 0.016), Status 2A (HR 2.15, p = 0.024) and each 1-point increase in PELD/MELD score. Children with recipient's weight >25 kg, blood group O or awaiting pLT combined with other organs had less chance of being transplanted. ITT patient survival rates were 90.5% at 1 year and 87.5% at 5 years, remaining stable across eras. Risk factors for ITT survival were re-transplantation (HR 5.83, p <0.001), Status 1 (HR 2.28, p = 0.006), Status 1B (HR 2.90, p = 0.014), Status 2A (HR 9.12, p <0.001), recipient weight <6 kg (HR 4.53, p <0.001) and low-volume activity (HR 4.38, p = 0.001). CONCLUSIONS: In Italy, continuous adaption of paediatric organ allocation policies via the introduction of national allocation, paediatric prioritisation rules and a mandatory-split policy have helped maximise the use of donors for paediatric candidates and to minimise WL mortality without compromising outcomes. IMPACT AND IMPLICATIONS: Globally, paediatric liver transplant candidates still suffer from high mortality. Over recent decades, the continuous adaption of organ allocation policies in Italy has led to excellent outcomes for children awaiting liver transplantation. The mortality rate of paediatric liver transplant candidates has been minimised to almost zero, mainly using grafts from deceased donors. Paediatric prioritisation rules, national organ exchange organisation and a mandatory-split liver policy have resulted in a unique allocation model for paediatric liver transplant candidates and represent a landmark for the paediatric transplant community.

Equity matrix for kidney transplant allocation.

There is a general agreement that the distribution of kidneys for transplantation should balance utility criteria with justice. Moreover, a kidney allocation system must be based on transparent policies and seen as an ongoing process. This study aims to present an allocation system grounded on an equity matrix that balances the criteria of utility and justice. Synthetic data for a waiting list with 2000 transplant candidates and a pool of 280 donors were generated. A color priority system, the Eurotransplant (ET) kidney allocation system, and the proposed Equity Matrix (EQM) allocation system were compared after 1000 iterations of kidney allocations. Distributions of variables like the age difference, Human Leukocyte Antigens (HLA) mismatches (mmHLA), recipients' time on dialysis, cPRA, and a transplant score obtained by different allocation models were compared graphically and with Cohen's d effect size. For the analyzed variables, when we compare only the selected recipients from ET with the selected recipients from the EQM neutral model, we can conclude that the former model selects more hypersensitized recipients, a higher number of 65+ years' old recipients with 65+ years' old donors and higher number of recipients with 0 mmHLA. While recipients from EQM neutral are slightly older, have a lower age difference with their donors, have a lower number of mmHLA, are less likely to have 6 mmHLA with their donors, and have more time on dialysis. The proposed EQM model attempts to provide a simple, transparent, and equitable response to a complex question with results that outperform established practices.

Evidências de validade de umsoftware para gestão da fila cirúrgica eletiva / Evidence of validity of software for managing the elective surgical queue

Objetivo: Desenvolver um software para gestão da fila cirúrgica eletiva. Métodos: Estudo metodológico, conduzido para desenvolver e validar um protótipo computacional na forma de software. Para validar o conteúdo, participaram 55 juízes selecionados intencionalmente. Empregou-se o Índice de Validação de Conteúdo para medir o grau e a porcentagem de concordância entre os juízes. O estudo foi aprovado pelo Comitê de Ética em Pesquisa da Universidade Federal do Piauí, com Nº de Parecer 5.306.171. Resultados: As evidências de validade do conteúdo foram consideradas satisfatórias, indicando clareza, adequação aos objetivos propostos, coerência, atualização, organização lógica, precisão e objetividade, além de apresentar potencialidades para que os pacientes possam acompanhar o seu posicionamento na fila. Conclusão: O desenvolvimento do software reúne evidências válidas e favoráveis para a organização e gestão da lista de espera cirúrgica, permitindo a priorização de casos com base na gravidade clínica e no senso de urgência.(AU)

Objective: To develop a software for elective surgery queue management. Methods: Methodological study, conducted to develop and validate a computational prototype in the form of software. To validate the content, 55 intentionally selected judges participated. The Content Validation Index was used to measure the degree and percentage of agreement between the judges. The study was approved by the Research Ethics Committee of the Federal University of Piauí, with Opinion No. 5.306.171. Results: The evidence of content validity was considered satisfactory, indicating clarity, adequacy to the proposed objectives, coherence, updating, logical organization, precision and objectivity, in addition to presenting potentialities for patients to monitor their position in the queue. Conclusion: The development of the software brings together valid and favorable evidence for the organization and management of the surgical waiting list, allowing the prioritization of cases based on clinical severity and sense of urgency.(AU)

Objetivo: Desarrollar un software para la gestión de colas de cirugía electiva. Métodos: Estudio metodológico, realizado para desarrollar y validar un prototipo computacional en forma de software. Para validar el contenido, participaron 55 jueces seleccionados intencionadamente. Se utilizó el Índice de Validación de Contenido para medir el grado y el porcentaje de acuerdo entre los jueces. El estudio fue aprobado por el Comité de Ética en Investigación de la Universidad Federal de Piauí, con el Dictamen nº 5.306.171. Resultados: Las evidencias de validez de contenido fueron consideradas satisfactorias, indicando claridad, adecuación a los objetivos propuestos, coherencia, actualización, organización lógica, precisión y objetividad, además de presentar potencial para que los pacientes monitoreen su posición en la fila. Conclusión: El desarrollo del software reúne evidencias válidas y favorables para la organización y gestión de la lista de espera quirúrgica, permitiendo la priorización de los casos en función de la gravedad clínica y del sentido de urgencia.(AU)

Information and support to patients when the waiting time guarantee cannot be fulfilled: a qualitative study.

BACKGROUND: Long waiting times for health care services are a prominent health policy issue. Waiting time guarantees may limit time to assessment and treatment. METHODS: This study aims to investigate the information and support given to patients when the waiting time guarantee cannot be fulfilled from a care provider and administrative management perspective. Semi-structured interviews (N = 28) were conducted with administrative management and care providers (clinic staff and clinic line managers) in specialized clinics in the Stockholm Region, Sweden. Clinics were purposefully sampled for maximum variation in ownership (private, public), complexity of care, geographical location, volume of production, and waiting times. Thematic analysis was applied. RESULTS: Care providers reported that patients received inconsistent information and support with regard to the waiting time guarantee and that information was not adapted to health literacy or individual patient needs. Contrary to local law, they made some patients responsible for finding a new care provider or arranging a new referral. Furthermore, financial interests affected whether patients were referred to other providers. Administrative management steered care providers' informing practices at specific time points (upon establishment of a new unit and after six months of operation). A specific regional support function, Region Stockholm's Care Guarantee Office, helped patients change care providers when long waiting times occurred. However, administrative management perceived that there was no established routine to assist care providers in informing patients. CONCLUSIONS: Care providers did not consider patients' health literacy when informing them about the waiting time guarantee. Administrative management's attempts to provide information and support to care providers are not producing the results they expect. Soft-law regulations and care contracts seem insufficient, and economic mechanisms undermine care providers' willingness to inform patients. The described actions are unable to mitigate the inequality in health care that arises from differences in care-seeking behavior.