Impact of Share 35 liver transplantation allocation in Australia and New Zealand.

Patients with high model for end-stage liver disease (MELD) scores waiting for liver transplantation in Australia and New Zealand (ANZ) have had limited access to deceased donor livers and therefore binational sharing of livers, for patients with a MELD score ≥35 was introduced in February 2016. Waiting list mortality, post-transplant outcomes and intention-to-treat survival were compared between patients whose MELD score reached 35 on the waiting list between October 2013 and April 2015 (Pre-Share 35 group, n = 23) and patients who were Share 35 listed between February 2016 and May 2022 (Share 35 group, n = 112). There was significantly reduced waiting list mortality in share 35 listed patients in comparison to the pre-Share 35 group (11.7% vs. 52.2%, OR .120 95% CI .044-.328, P < .001). Post-transplant patient and graft survival were not significantly different between the groups (5-year patient survival 82% vs. 84%, P = .991, 5-year graft survival 82% vs. 76%, P = .543). Intention-to-treat survival was superior in the Share 35 group (HR .302, 95% CI .149-.614, P < .001). Introduction of Share 35 in ANZ resulted in a 78% risk reduction in waiting list mortality, equivalent post-transplant survival and an improvement in intention-to-treat survival.

Individual variation of follicular phase changes in endothelial function across two menstrual cycles.

NEW FINDINGS: What is the central question of this study? The purpose of this study was to determine intra-individual reproducibility of follicular phase changes in endothelial function (flow-mediated dilatation) over two menstrual cycles in healthy, premenopausal women. What is the main finding and its importance? Phase changes in endothelial function were not consistent at the individual level across two menstrual cycles, which challenges the utility of interpreting individual responses over one cycle. ABSTRACT: Evidence regarding the impact of menstrual phase on endothelial function is conflicting, and studies to date have examined responses only over a single cycle. It is unknown whether the observed inter-individual variability of phase changes in endothelial function reflects stable, inter-individual differences in responses to oestrogen (E2 ; a primary female sex hormone). The purpose of this study was to examine changes in endothelial function from the early follicular (EF; low-E2 ) phase to the late follicular (LF; high-E2 ) phase over two consecutive cycles. Fourteen healthy, regularly menstruating women [22 ± 3 years of age (mean ± SD)] participated in four visits (EFVisit 1 , LFVisit 2 , EFVisit 3 and LFVisit 4 ) over two cycles. Ovulation testing was used to determine the time between the LF visit and ovulation. During each visit, endothelial function [brachial artery flow-mediated dilatation (FMD)], E2 and progesterone were assessed. At the group level, there was no impact of phase or cycle on FMD (P = 0.48 and P = 0.65, respectively). The phase change in FMD in cycle 1 did not predict the phase change in cycle 2 (r = 0.03, P = 0.92). Using threshold-based classification (2 × typical error threshold), four of 14 participants (29%) exhibited directionally consistent phase changes in FMD across cycles. Oestrogen was not correlated between cycles, and this might have contributed to variability in the FMD response. The intra-individual variability in follicular fluctuation in FMD between menstrual cycles challenges the utility of interpreting individual responses to phase over a single menstrual cycle.

Exploring disparities in receipt of adjuvant chemotherapy in culturally and linguistically diverse groups: an Australian centre's experience.

BACKGROUND: Globally, racial and ethnic disparities exist in treatments and outcomes for cancer patients. In Australia, there are few published data related to cancer patients from culturally and linguistically diverse (CALD) backgrounds. AIM: To explore disparities in adjuvant chemotherapy utilisation in cancer patients from CALD groups. METHODS: Retrospective analysis of patients who were recommended adjuvant chemotherapy for early stage breast cancer or early stage colorectal cancer between July 2011 and October 2014 was performed. Rates of adjuvant chemotherapy uptake were analysed between those who identified English as their first-preferred language, versus those who did not, as well as between patients who were born in a country where English is the main language (non-CALD), versus those born in a country where English is not the main language (CALD). RESULTS: Two hundred and eleven patients were identified. One hundred and forty-three (67.7%) patients had early stage breast cancer and 68 (32.2%) patients had early stage colorectal cancer. No difference was detected in the acceptance of adjuvant chemotherapy between non-CALD (80.9%) and CALD patients (81.3%, P = 0.984) or between patients who identified English as their first-preferred language (80.8%) and those who did not (81.8%, P = 0.870). There was no difference in the rate of chemotherapy completion, with 75.6% completion in the non-English-speaking group and 81.1% in the English-speaking group (P = 0.426). CONCLUSION: No difference was observed in adjuvant chemotherapy utilisation in patients who identified English as their first-preferred language compared to those who did not, as well as between non-CALD and CALD groups. This is the first study to assess these differences in Australia.

Factors associated with referral offer and acceptance following supportive care problem identification in a comprehensive cancer service.

To improve understanding of the triage process following distress and problem identification and the factors associated with offer and acceptance of supportive care referrals. Review of patient records/charts at a metropolitan hospital in Melbourne, Australia. Data were collected on problem identifications from 1/1/13 to 30/6/14, including patient demographics, disease and treatment information, responses to the NCCN Distress Thermometer (DT) and Problem Checklist (PC), whether referrals to supportive care services were offered and accepted/declined. Logistic regressions examined factors associated with referral offer and acceptance. Of patients completing the DT/PC, 50.1% reported a high level of distress. Overall, 61% of patients were offered referral(s), with the majority (71%) being accepted. Referrals were more likely to be offered to patients with a greater number of problems (Odds Ratio[OR] = 1.18, 95%CI = 1.12-1.25) and higher distress (OR = 1.68, 95%CI = 1.07-2.64). Referrals were more likely to be accepted by patients with a greater number of problems (OR = 1.12, 95%CI = 1.06-1.19) and lower distress (OR = 0.58, 95%CI = 0.34-1.00). The type of problem experienced by the patient was strongly related to the type of referral they were offered. At a large metropolitan hospital with in-house supportive care services, simple problem identification with the DT/PC enabled triage to services that reflected patients' needs. The findings suggest that clear referral pathways and an organisational emphasis on supportive care may facilitate service use.

The state of TRUS biopsy sepsis: readmissions to Victorian hospitals with TRUS biopsy-related infection over 5 years.

OBJECTIVES: To describe the incidence, morbidity and mortality of men who developed infectious complications requiring hospital admission following TRUS prostate biopsy in Victoria, Australia. Further it aimed to report the financial cost of these admissions. SUBJECTS & METHODS: The Department of Health's Victorian Admitted Episodes Data Set was used to identify those patients who underwent TRUS biopsy in Victoria who were subsequently readmitted within 7 days to any Victorian hospital with infective complications from July 2007 to June 2012. All Victorian public and private hospitals were included. Patients were excluded if their biopsy was performed during a multi-day admission. Financial costing data was obtained where available from the Department Of Health and Human Services for readmissions with post-TRUS infection where available and adjusted to 2012 prices. Institutional ethics committee approval was granted for this study. RESULTS: Thirty-four thousand eight hundred and sixty-five TRUS biopsies were performed in the 5-year period. 1276 (3.66%) were readmitted to a Victorian hospital within 7 days. 604 (1.73%) of these were readmitted with a biopsy-related infection. No significant trend in sepsis rates was seen in 5 years. The median readmission LOS was 4 days. The total burden of readmissions was 3 686 days over 5 years. One patient readmitted with a biopsy related infection died during that episode of care. 20 051 (57.51%) of biopsies resulted in a diagnosis of prostate cancer. Financial costing data was available for 218 (36%) of infectious readmissions with a mean cost per readmission were $7 362 AUD (£4137 or $6844 USD, 95% CI $6219-8505 AUD) or $1 256 AUD per day. CONCLUSION: Infection following TRUS biopsy was associated with a readmission rate for infection of 1 in 57 biopsies, an excess of 3 686 bed days required over 5 years with a cost of $1 256 AUD per day. The rate of infection remained stable for the period examined.

PET changes management and improves prognostic stratification in patients with recurrent colorectal cancer: results of a multicenter prospective study.

UNLABELLED: The aims of our study were to examine the impact of PET in changing management in patients with proven or suspected colorectal cancer recurrence and to assess the impact of management change on disease-free survival. METHODS: Symptomatic patients with a residual structural lesion suggestive of recurrent tumor (group A) or patients with pulmonary or hepatic metastases considered to be potentially resectable (group B) underwent PET scans. Pre-PET management plans were documented by referring clinicians unaware of the PET results, and follow-up to 12 mo was performed to determine actual management and clinical outcomes. RESULTS: A total of 191 patients (118 men and 73 women; mean age, 66 y) were studied. PET detected additional sites of disease in 48.4% of patients in group A and in 43.9% of patients in group B. A change in planned management was documented in 65.6% of group A and in 49.0% of group B patients. These management plans were implemented in 96% of patients. Follow-up data in group A showed progressive disease in 60.5% of patients with additional lesions detected by PET, compared with conventional imaging, and in 36.2% of patients with no additional lesions detected by PET (P=0.04). In group B, progressive disease was identified in 65.9% of patients with additional lesions detected by PET and in 39.2% of patients with no additional lesions detected by PET (P=0.01). PET also provided valuable prognostic information on patients stratified into curative- or palliative-intent groups. CONCLUSION: These data demonstrate the significant impact of PET on management and outcomes in patients with suspected recurrent colorectal cancer.

Avoidable Technical and Clinical Denial Write-Off Management in Hospitals, Physician Offices, and Clinics.

PURPOSE/OBJECTIVES: This article reviews the various types of technical and clinical denials that are usually "written off" and proposes strategies to prevent this loss. For purposes of this writing, avoidable technical and clinical denial write-offs are defined as revenue lost from "first-pass" denials rejections. For example, a procedure that requires an authorization is performed without having had an authorization obtained. After appeals and attempts to recoup the revenue, often unsuccessful, the organization ultimately "writes off" the revenue as not collectable. The question to ask is: Are these claims really not collectable or can actionable steps be taken to conserve these dollars and improve the bottom line? PRIMARY PRACTICE SETTING: Acute care hospitals, physician offices, and clinics. FINDINGS AND CONCLUSIONS: In today's environment, the need to manage costs is ubiquitous. Cost management is on the priority list of all savvy health care executives, even if margins are healthy, revenue is under pressure, and the magnitude of cost reduction needed is greater than what past efforts have achieved. As hospitals and physician clinics prioritize areas for improvement, reduction in lost revenue-especially avoidable lost revenue-should be at the top of the list. Attentively managing claim denial write-offs will significantly reduce lost revenue. IMPLICATIONS FOR CASE MANAGEMENT: There is significant interface between case management and the revenue cycle. Developing core competencies for reducing clinical and technical denials should be a critical imperative in overall cost management strategy. Case managers are well placed to prevent these unnecessary losses through accurate status determination and clinical documentation review. These clinical professionals can also provide insight into work flow and other processes inherent in the preauthorization process.

In vivo imaging of cellular proliferation in renal cell carcinoma using 18F-fluorothymidine PET.

OBJECTIVES: The ability to measure cellular proliferation non-invasively in renal cell carcinoma may allow prediction of tumour aggressiveness and response to therapy. The aim of this study was to evaluate the uptake of 18F-fluorothymidine (FLT) PET in renal cell carcinoma (RCC), and to compare this to 18F-fluorodeoxyglucose (FDG), and to an immunohistochemical measure of cellular proliferation (Ki-67). METHODS: Twenty seven patients (16 male, 11 females; age 42-77) with newly diagnosed renal cell carcinoma suitable for resection were prospectively enrolled. All patients had preoperative FLT and FDG PET scans. Visual identification of tumour using FLT PET compared to normal kidney was facilitated by the use of a pre-operative contrast enhanced CT scan. After surgery tumour was taken for histologic analysis and immunohistochemical staining by Ki-67. RESULTS: The SUVmax (maximum standardized uptake value) mean±SD for FLT in tumour was 2.59±1.27, compared to normal kidney (2.47±0.34). The mean SUVmax for FDG in tumour was similar to FLT (2.60±1.08). There was a significant correlation between FLT uptake and the immunohistochemical marker Ki-67 (r=0.72, P<0.0001) in RCC. Ki-67 proliferative index was mean ± SD of 13.3%±9.2 (range 2.2% - 36.3%). CONCLUSION: There is detectable uptake of FLT in primary renal cell carcinoma, which correlates with cellular proliferation as assessed by Ki-67 labelling index. This finding has relevance to the use of FLT PET in molecular imaging studies of renal cell carcinoma biology.

Impact of ¹8F-FDG-PET in decision making for liver metastectomy of colorectal cancer.

BACKGROUND: The ability of (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) to impact on management of patients with recurrent colorectal cancer is high. However, direct impact of FDG-PET on surgical management of patients with potentially resectable hepatic metastases is limited. METHODS: FDG-PET scans of patients with colorectal cancer at Austin Hospital in a 2-year period were retrospectively evaluated. Data were collected on patient demographics, scan indication and sites of disease pre- and post-PET. Results of standard imaging tests and FDG-PET scans were analysed. The potential impact of FDG-PET on proposed surgical management plans was assessed by an experienced surgeon. RESULTS: There were 585 FDG-PET scans performed on 470 patients (309M : 161F, mean age 61.9 years) with colorectal cancer. Hepatic metastases were identified on standard imaging in 232 (39.7%) patients, and FDG-PET confirmed hepatic metastasis in 203 cases, including 22 cases with new lesions, and clarified presence of disease in 34/37 (92%) cases with equivocal standard imaging. In 54 patients, FDG-PET was performed for disease assessment before hepatic resection. FDG-PET had substantial management plan impact in 36/54 (66.7%) patients. CONCLUSIONS: FDG-PET can profoundly impact on the management plan of patients with colorectal cancer who may be suitable for hepatic metastectomy.

Assessment of the role of FDG PET in the diagnosis and management of children with refractory epilepsy.

PURPOSE: We performed a retrospective analysis of the results of FDG PET scans in children with refractory epilepsy referred to our centre over an 8-year period, with a view to ascertaining the impact of FDG PET on subsequent patient management. METHODS: A questionnaire was used to assess the impact of FDG PET scan on diagnosis, management and clinical decision-making processes for epilepsy surgery from the managing clinician's perspective. FDG PET scan results were also compared with MRI, EEG and SPECT results and coded according to whether the FDG PET scan provided independent information and localisation of epileptogenic regions. RESULTS: A total of 118 eligible patients under the age of 14 years were identified, with questionnaires being completed on 113 evaluable patients (96%). The pre-PET management plan consisted of consideration for surgery in 92 patients (81%) and medical therapy for the remaining 21 patients (19%). Managing physicians rated FDG PET as providing information additional to that obtained with other investigations regarding epileptogenic sites in 88 patients (77%). FDG PET had either a minor or a major impact on clinical management in 58 patients (51%), principally with regard to surgical candidacy. CONCLUSION: FDG PET has a definite role in the assessment of paediatric patients with refractory epilepsy who are being considered for surgery. In the future, analysis of FDG PET data in specific subpopulations of children with refractory epilepsy may lead to novel insights regarding aetiology.

Positron emission tomography with selected mediastinoscopy compared to routine mediastinoscopy offers cost and clinical outcome benefits for pre-operative staging of non-small cell lung cancer.

PURPOSE: (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging is an important staging procedure in patients with non-small cell lung cancer (NSCLC). We aimed to demonstrate, through a decision tree model and the incorporation of real costs of each component, that routine FDG-PET imaging as a prelude to curative surgery will reduce requirements for routine mediastinoscopy and overall hospital costs. METHODS: A decision tree model comparing routine whole-body FDG-PET imaging to routine staging mediastinoscopy was used, with baseline variables of sensitivity, specificity and prevalence of non-operable and metastatic disease obtained from institutional data and a literature review. Costings for hospital admissions for mediastinoscopy and thoracotomy of actual patients with NSCLC were determined. The overall and average cost of managing patients was then calculated over a range of FDG-PET costs to derive projected cost savings to the community. RESULTS: The prevalence of histologically proven mediastinal involvement in patients with NSCLC presenting for surgical assessment at our institution is 20%, and the prevalence of distant metastatic disease is 6%. Based on literature review, the pooled sensitivity and specificity of FDG-PET for detection of mediastinal spread are 84% and 89% respectively, and for mediastinoscopy, 81% and 100%. The average cost of mediastinoscopy for NSCLC in our institution is 4,160 AUD, while that of thoracotomy is 15,642 AUD. The cost of an FDG-PET scan is estimated to be 1,500 AUD. Using these figures and the decision tree model, the average cost saving is 2,128 AUDper patient. CONCLUSION: Routine FDG-PET scanning with selective mediastinoscopy will save 2,128 AUD per patient and will potentially reduce inappropriate surgery. These cost savings remain robust over a wide range of disease prevalence and FDG-PET costs.