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Trasplante de Pulmón , China , Trasplante de Pulmón/economía , Humanos , Fundaciones/economíaRESUMEN
INTRODUCTION: Fungal infection after lung transplantation can lead to poor clinical outcome, for which lung transplant recipients require prophylaxis. One of the antifungal agents used after lung transplantation is nebulized amphotericin B (AMB). Nebulized AMB causes adverse events such as dyspnea and airway irritation, and long-term use leads to high economic costs. So far, prophylactic regimens employing AMB deoxycholate (AMB-d) and liposomal AMB (L-AMB) have been developed. This study compared the efficacy, safety, and cost of AMB-d and L-AMB. PATIENTS AND METHODS: Patients who underwent lung transplantation at Kyoto University Hospital from January 2021 to May 2023 were included in this study. Thirty-three patients received nebulized AMB-d, whereas 29 received nebulized L-AMB. RESULTS: Both regimens maintained comparable prophylactic efficacy regarding the development of fungal infection in the AMB-d and L-AMB groups (3.0% vs. 3.4%, P = 0.877). Patients treated with nebulized L-AMB experienced fewer respiratory-related adverse reactions than those treated with nebulized AMB-d (6.9% vs. 30.3%, P < 0.05), leading to a longer treatment duration with L-AMB than with AMB-d. Additionally, the daily cost of administering L-AMB was lower than that of administering AMB-d (3609 Japanese yen vs. 1792.3 Japanese yen, P < 0.05). DISCUSSION: These results suggest that nebulized L-AMB is safer and more cost-effective than nebulized AMB-d, with comparable efficacy.
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Anfotericina B , Antifúngicos , Análisis Costo-Beneficio , Ácido Desoxicólico , Combinación de Medicamentos , Trasplante de Pulmón , Micosis , Nebulizadores y Vaporizadores , Humanos , Anfotericina B/administración & dosificación , Anfotericina B/economía , Anfotericina B/efectos adversos , Anfotericina B/uso terapéutico , Antifúngicos/economía , Antifúngicos/administración & dosificación , Antifúngicos/uso terapéutico , Antifúngicos/efectos adversos , Masculino , Femenino , Trasplante de Pulmón/efectos adversos , Trasplante de Pulmón/economía , Persona de Mediana Edad , Ácido Desoxicólico/administración & dosificación , Ácido Desoxicólico/efectos adversos , Ácido Desoxicólico/economía , Ácido Desoxicólico/uso terapéutico , Micosis/prevención & control , Micosis/economía , Anciano , Adulto , Administración por Inhalación , Estudios Retrospectivos , JapónRESUMEN
BACKGROUND: Lung transplantation is a lifesaving intervention for people with advanced lung disease, but it is costly and resource-intensive. To investigate the cost-effectiveness of lung transplantation as a treatment option in pulmonary disease, we must understand costs attributable to end-of-life hospitalizations for end-stage lung disease. RESEARCH QUESTION: What are the costs associated with end-of-life hospitalizations for people with pulmonary disease, and how have these trends changed over time? STUDY DESIGN AND METHODS: Adults aged 18 to 74 years with hospitalization data in the Cost and Utilization Project National Inpatient Sample data from 2009 to 2019 with a pulmonary disease admission were included in this analysis. Those with a history of lung transplantation were excluded. International Classification of Diseases codes were used to identify pulmonary disease admissions, complications, and procedures and interventions. Total charges were calculated for hospitalizations and stratified by patient status at time of discharge. Trends in charges over time were assessed by demographic and hospital factors. RESULTS: One hundred nine thousand nine hundred twenty-four (4.1%) hospital admissions for pulmonary disease resulted in in-hospital mortality. Those with obstructive lung disease accounted for 94.1% of hospitalizations and 88.1% cases of in-hospital mortality. Estimated costs for end-of-life hospitalizations were $29,981 on average with wide variation in cost by diagnosis and procedure utilization. Inpatient costs were highest for younger people who received more procedures. Among the most expensive admissions, mechanical ventilation accounted for the greatest proportion of interventions. Significant increases in the use of mechanical ventilation, extracorporeal membrane oxygenation, and dialysis occurred over the time period. The rate of hospital transfers increased with a proportionately greater increase across admissions resulting in in-hospital mortality. INTERPRETATION: Costs accrued during end-of-life hospitalizations vary across people but represent a significant health care cost that can be averted for selected people who undergo lung transplantation. These costs should be considered in studies of cost-effectiveness in lung transplantation.
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Hospitalización , Humanos , Persona de Mediana Edad , Estados Unidos/epidemiología , Masculino , Femenino , Adulto , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Anciano , Adolescente , Cuidado Terminal/economía , Cuidado Terminal/tendencias , Enfermedades Pulmonares/economía , Enfermedades Pulmonares/terapia , Enfermedades Pulmonares/epidemiología , Mortalidad Hospitalaria/tendencias , Adulto Joven , Trasplante de Pulmón/economía , Trasplante de Pulmón/tendencias , Trasplante de Pulmón/estadística & datos numéricos , Costos de Hospital/tendencias , Costos de Hospital/estadística & datos numéricosRESUMEN
BACKGROUND: Evaluation of the joint clinical and economic impacts of lung transplant and associated technologies is crucial for evidence-informed decision-making and wise allocation of scarce healthcare resources. We performed a scoping review to summarize and categorize the available evidence of the costs and cost-effectiveness of lung transplantation. METHODS: A systematic search of MEDLINE, EMBASE, NHS EED, and EconLit was performed to identify studies involving lung transplantation for adults that measured costs, cost-effectiveness, or which described themselves as economic evaluations. A scoping review was performed in adherence to the framework described by Arksey & O'Malley. Risk of bias was assessed in included studies using the ECOBIAS and CHEC-list tools. RESULTS: In total, 324 studies were identified, of which 28 met inclusion criteria. Cost-utility estimates of lung transplant versus waitlist, from the healthcare payer perspective and a time-horizon of at least 10-years ranged between $42,459 and $154,051 per quality-adjusted life year. Common topics of study included lung transplant versus waitlist care, immunosuppression, organ retrieval and allocation, and mechanical life support. CONCLUSIONS: Sources of variation in costs-assessments and economic evaluations included differences in the type of study performed, payer perspective adopted, study time horizon, and variation in clinical practice. The best available cost-utility estimates for lung transplant versus waitlist may represent cost-effectiveness under some circumstances, but high-quality evidence is lacking. Further cost-utility analyses, with sufficient methodologic rigour, are required to overcome the observed variation in results and confirm cost-effectiveness of the current standard of care in lung transplantation.
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Trasplante de Pulmón/economía , Obtención de Tejidos y Órganos/economía , Costos y Análisis de Costo , HumanosRESUMEN
BACKGROUND: Previous studies in the field of organ transplantation have shown a possible association between nighttime surgery and adverse outcomes. We aim to determine the impact of nighttime lung transplantation on postoperative outcomes, long-term survival, and overall cost. METHODS: We performed a single-center retrospective cohort analysis of adult lung transplant recipients who underwent transplantation between January 2006 and December 2017. Data were extracted from our institutional Lung Transplant Registry and Mid-America Transplant services database. Patients were classified into 2 strata, daytime (5 AM to 6 PM) and nighttime (6 PM to 5 AM), based on time of incision. Major postoperative adverse events, 5-year overall survival, and 5-year bronchiolitis obliterans syndrome-free survival were examined after propensity score matching. Additionally we compared overall cost of transplantation between nighttime and daytime groups. RESULTS: Of the 740 patients included in this study, 549 (74.2%) underwent daytime transplantation and 191 (25.8%) underwent nighttime transplantation (NT). Propensity score matching yielded 187 matched pairs. NT was associated with a higher risk of having any major postoperative adverse event (adjusted odds ratio, 1.731; 95% confidence interval, 1.093-2.741; P = .019), decreased 5-year overall survival (adjusted hazard ratio, 1.798; 95% confidence interval, 1.079-2.995; P = .024), and decreased 5-year bronchiolitis obliterans syndrome-free survival (adjusted hazard ratio, 1.556; 95% confidence interval, 1.098-2.205; P = .013) in doubly robust multivariable analyses after propensity score matching. Overall cost for NT and daytime transplantation was similar. CONCLUSIONS: NT was associated with a higher risk of major postoperative adverse events, decreased 5-year overall survival, and decreased 5-year bronchiolitis obliterans syndrome-free survival. Our findings suggest potential benefits of delaying NT to daytime transplantation.
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Trasplante de Pulmón , Adulto , Análisis de Varianza , Bronquiolitis Obliterante/etiología , Femenino , Costos de Hospital , Humanos , Modelos Logísticos , Trasplante de Pulmón/efectos adversos , Trasplante de Pulmón/economía , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
Lung transplantation has become an accepted therapeutic option for a select group of children with end-stage lung disease. We evaluated the impact of early extubation in a pediatric lung transplant population and its post-operative outcomes. Single-center retrospective study. PICU within a tertiary academic pediatric hospital. Patients <22 years after pulmonary transplant between January 2011 and December 2016. A total of 74 patients underwent lung transplantation. The primary pretransplantation diagnoses included cystic fibrosis (58%), pulmonary fibrosis (9%), and surfactant dysfunction disorders (10%). Of 60 patients, 36 (60%) were extubated within 24 hours and 24 patients after 24 hours (40%). A total of seven patients (11.6%) required reintubation within 24 hours. Median length of stay for the early extubation group was shorter at 3 days ([(IQR) 2.2-4.7]) compared to 5 days (IQR, 3-7) (P = .02) in the late extubation group. Median costs were lower for the early extubation group with 13,833 US dollars (IQR, 9980-22,822) vs 23 671 US dollars (IQR, 16 673-39 267) (P = .043). Fourteen patients were in the PICU prior to their transplantation; this did not affect their early extubation success. Neither did the fact of requiring invasive or non-invasive mechanical ventilation before transplantation. Early extubation appears to be safe in a pediatric population after lung transplantation and is associated with a shorter LOS and decreased hospital costs. It may prevent known complications associated with mechanical ventilation.
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Extubación Traqueal/métodos , Trasplante de Pulmón , Cuidados Posoperatorios/métodos , Adolescente , Extubación Traqueal/economía , Niño , Preescolar , Femenino , Costos de Hospital/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Trasplante de Pulmón/economía , Masculino , Evaluación de Resultado en la Atención de Salud , Cuidados Posoperatorios/economía , Estudios Retrospectivos , Texas , Adulto JovenRESUMEN
OBJECTIVE: The purpose of this study was to recognize clinically meaningful differences in lung transplant outcomes based on local or distant lung procurement. This could identify if the lung allocation policy change would influence patient outcomes. METHODS: This single-center retrospective cohort study analyzed adult patients who underwent lung transplant from 2006 to 2017. Donor and recipient data were abstracted from a collaborative, prospective registry shared by our local organ procurement organization, and tertiary medical center. Short-term outcomes, 1-year survival, and hospitalization costs were compared between local and distant lung transplants defined by donor service area. RESULTS: Of the 722 lung transplants performed, 392 (54%) had local donors and 330 (46%) had distant donors. Donors were similar in age and cause of death. Recipients were significantly different in diagnosis and local recipients had lower median lung allocation scores (local, 37.3 and distant, 44.9; P < .01). Distant lung transplants had longer total ischemic times (local, 231 ± 52 minutes and distant, 313 ± 48 minutes; P < .01). The rate of major complications, length of hospital stay, and 1-year survival were similar between groups. Distant lung transplants were associated with higher median overall cost (local, $183,542 and distant, $229,871; P < .01). Local lung transplants were more likely to be performed during daytime (local, 333 out of 392 [85%] and distant, 291 out of 330 [61%]; P < .01). CONCLUSIONS: Local lung transplants are associated with shorter ischemic times, lower cost, and greater likelihood of daytime surgery. Short- and intermediate-term outcomes are similar for lung transplants from local and distant donors. The new lung allocation policy, with higher proportion of distant lung transplants, is likely to incur greater costs but provide similar outcomes.
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Supervivencia de Injerto , Trasplante de Pulmón , Complicaciones Posoperatorias , Asignación de Recursos , Obtención de Tejidos y Órganos , Trasplantes/provisión & distribución , Adulto , Isquemia Fría/estadística & datos numéricos , Femenino , Humanos , Pulmón/irrigación sanguínea , Trasplante de Pulmón/efectos adversos , Trasplante de Pulmón/economía , Trasplante de Pulmón/métodos , Trasplante de Pulmón/estadística & datos numéricos , Masculino , Evaluación de Resultado en la Atención de Salud , Formulación de Políticas , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Sistema de Registros/estadística & datos numéricos , Asignación de Recursos/economía , Asignación de Recursos/métodos , Estudios Retrospectivos , Centros de Atención Terciaria/estadística & datos numéricos , Donantes de Tejidos/clasificación , Donantes de Tejidos/estadística & datos numéricos , Obtención de Tejidos y Órganos/métodos , Obtención de Tejidos y Órganos/organización & administración , Obtención de Tejidos y Órganos/provisión & distribución , Topografía Médica , Estados UnidosRESUMEN
Challenges and special aspects related to the management and prognosis of pulmonary hypertension (PH) in middle- to low-income regions (MLIRs) range from late presentation to comorbidities, lack of resources and expertise, cost, and rare options of lung transplantation. Expert consensus recommendations addressing the specific challenges for prevention and therapy of PH in MLIRs with limited resources have been lacking. To date, 6 MLIR-PH registries containing mostly adult patients with PH exist. Importantly, the global prevalence of PH is much higher in MLIRs compared with high-income regions: group 2 PH (left heart disease), pulmonary arterial hypertension associated with unrepaired congenital heart disease, human immunodeficiency virus, or schistosomiasis are highly prevalent. This consensus statement provides selective, tailored modifications to the current PH guidelines to address the specific challenges faced in MLIRs, resulting in the first pragmatic and cost-effective consensus recommendations for PH care providers, patients, and their families.
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Hipertensión Pulmonar/economía , Hipertensión Pulmonar/terapia , Pobreza/economía , Pobreza/tendencias , Cardiología/economía , Cardiología/tendencias , Cardiopatías Congénitas/economía , Cardiopatías Congénitas/epidemiología , Cardiopatías Congénitas/terapia , Humanos , Hipertensión Pulmonar/epidemiología , Trasplante de Pulmón/economía , Trasplante de Pulmón/tendencias , Sistema de Registros , Literatura de Revisión como AsuntoRESUMEN
Organ transplant guidelines in many settings recommend that people with potential hepatitis C virus (HCV) exposure or infection are deemed ineligible to donate. The recent availability of highly-effective treatments for HCV means that this may no longer be necessary. We used a mathematical model to estimate the expected difference in healthcare costs, difference in disability-adjusted life years (DALYs) and cost-effectiveness of removing HCV restrictions for lung and kidney donations in Australia. Our model suggests that allowing organ donations from people who inject drugs, people with a history of incarceration and people who are HCV antibody-positive could lead to an estimated 10% increase in organ supply, population-level improvements in health (reduction in DALYs), and on average save AU$2,399 (95%CI AU$1,155-3,352) and AU$2,611 (95%CI AU$1,835-3,869) per person requiring a lung and kidney transplant respectively. These findings are likely to hold for international settings, since this policy change remained cost saving with positive health gains regardless of HCV prevalence, HCV treatment cost and waiting list survival probabilities. This study suggests that guidelines on organ donation should be revisited in light of recent changes to clinical outcomes for people with HCV.
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Rechazo de Injerto/inmunología , Hepacivirus/fisiología , Hepatitis C/inmunología , Trasplante de Riñón/economía , Trasplante de Pulmón/economía , Australia/epidemiología , Estudios de Cohortes , Análisis Costo-Beneficio , Rechazo de Injerto/epidemiología , Costos de la Atención en Salud , Hepatitis C/epidemiología , Humanos , Modelos Teóricos , Políticas , Riesgo , Donantes de Tejidos , Obtención de Tejidos y ÓrganosRESUMEN
In heart transplantation, pulmonary hypertension and increased pulmonary vascular resistance followed by donor right ventricular dysfunction remain a major cause of perioperative morbidity and mortality. In lung transplantation, primary graft dysfunction remains a major obstacle because it can cause bronchiolitis obliterans and mortality. Pulmonary vasodilators have been used as an adjunct therapy for heart or lung transplantation, mainly to treat pulmonary hypertension, right ventricular failure, and associated refractory hypoxemia. Among pulmonary vasodilators, inhaled nitric oxide is unique in that it is selective in pulmonary circulation and causes fewer systemic complications such as hypotension, flushing, or coagulopathy. Nitric oxide is expected to prevent or attenuate primary graft dysfunction by decreasing ischemia-reperfusion injury in lung transplantation. However, when considering the long-term benefit of these medications, little evidence supports their use in heart or lung transplantation. Current guidelines endorse inhaled vasodilators for managing immediate postoperative right ventricular failure in lung or heart transplantation, but no guidance is offered regarding agent selection, dosing, or administration. This review presents the current evidence of inhaled nitric oxide in lung or heart transplantation as well as comparisons with other pulmonary vasodilators including cost differences in consideration of economic pressures to contain rising pharmacy costs.
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Trasplante de Corazón/métodos , Trasplante de Pulmón/métodos , Vasodilatadores/administración & dosificación , Administración por Inhalación , Análisis Costo-Beneficio , Trasplante de Corazón/economía , Humanos , Hipertensión Pulmonar/tratamiento farmacológico , Hipertensión Pulmonar/etiología , Trasplante de Pulmón/economía , Óxido Nítrico/administración & dosificación , Óxido Nítrico/economía , Disfunción Primaria del Injerto/prevención & control , Circulación Pulmonar/efectos de los fármacos , Vasodilatadores/economía , Disfunción Ventricular Derecha/tratamiento farmacológico , Disfunción Ventricular Derecha/etiologíaAsunto(s)
Adenocarcinoma Bronquioloalveolar/cirugía , Neoplasias Pulmonares/cirugía , Trasplante de Pulmón , Adulto , Toma de Decisiones Clínicas , Femenino , Humanos , Trasplante de Pulmón/economía , Trasplante de Pulmón/ética , Recurrencia Local de Neoplasia , Años de Vida Ajustados por Calidad de VidaAsunto(s)
Oxigenación por Membrana Extracorpórea/economía , Oxigenación por Membrana Extracorpórea/métodos , Trasplante de Pulmón/economía , Trasplante de Pulmón/métodos , Medicaid/economía , Patient Protection and Affordable Care Act , Adolescente , Adulto , Costos de la Atención en Salud , Accesibilidad a los Servicios de Salud , Humanos , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: An estimated 20-30% of end-stage lung disease patients awaiting lung transplant die whilst on the waiting list due to a shortage of suitable donor lungs. Ex-Vivo Lung Perfusion is a technique that reconditions donor lungs initially not deemed usable in order to make them suitable for transplantation, thereby increasing the donor pool. In this study, an economic evaluation was conducted as part of DEVELOP-UK, a multi-centre study assessing the clinical and cost-effectiveness of the Ex-Vivo Lung Perfusion technique in the United Kingdom. METHODS: We estimated the cost-effectiveness of a UK adult lung transplant service combining both standard and Ex-Vivo Lung Perfusion transplants compared to a service including only standard lung transplants. A Markov model was developed and populated with a combination of DEVELOP-UK, published and clinical routine data, and extrapolated to a lifetime horizon. Probabilistic sensitivity and scenario analyses were used to explore uncertainty in the final outcomes. RESULTS: Base-case model results estimated life years gained of 0.040, quality-adjusted life-years (QALYs) gained of 0.045 and an incremental cost per QALY of £90,000 for Ex-Vivo Lung Perfusion. Scenario analyses carried out suggest that an improved rate of converting unusable donor lungs using Ex-Vivo Lung Perfusion, similar resource use post-transplant for both standard and EVLP lung transplant and applying increased waiting list costs would reduce ICERs to approximately £30,000 or below. CONCLUSION: DEVELOP-UK base-case results suggest that incorporating Ex-Vivo Lung Perfusion into the UK adult lung transplant service is more effective, increasing the number of donor lungs available for transplant, but would not currently be considered cost-effective in the UK using the present NICE threshold. However, results were sensitive to change in some model parameters and in several plausible scenario analyses results indicate that a service incorporating Ex-vivo lung perfusion would be considered cost-effective . TRIAL REGISTRATION: ISRCTN registry number: ISRCTN44922411 . Date of registration: 06/02/2012. Retrospectively registered.
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Trasplante de Pulmón/métodos , Recolección de Tejidos y Órganos/métodos , Adolescente , Adulto , Anciano , Análisis Costo-Beneficio , Humanos , Trasplante de Pulmón/economía , Masculino , Persona de Mediana Edad , Años de Vida Ajustados por Calidad de Vida , Estudios Retrospectivos , Donantes de Tejidos , Recolección de Tejidos y Órganos/economía , Reino Unido , Listas de Espera , Adulto JovenRESUMEN
This study evaluated the impact of Medicaid eligibility expansion (ME) on lung transplant (LT) listings and Medicaid coverage. Data on LT candidates aged 18-64 were obtained from the Scientific Registry of Transplant Recipients (N = 9153). The impact of ME was evaluated by comparing LT listings in 2011-2013 with listings in 2014-2016, as well as comparing states that had and had not adopted ME in 2014. LT listings increased by 7.7% nationally post-ME. In ME states, LT listings increased by 15.2%, whereas nonexpansion states decreased by 1.5%. LT candidates with Medicaid increased after ME nationally (8.3% vs. 9.9%, P = 0.006) and in ME states (9.7% vs. 11.5%, P = 0.036), but not in nonexpansion states (6.6% vs. 7.7%, P = 0.170). Following multivariable adjustment, LT listings in ME states had 58% greater odds for Medicaid compared to nonexpansion states (P < 0.001). Expansion of Medicaid provided greater healthcare access and increased LT listings, but only within states that adopted eligibility expansion.
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Accesibilidad a los Servicios de Salud , Enfermedades Pulmonares/cirugía , Trasplante de Pulmón/economía , Trasplante de Pulmón/métodos , Medicaid , Patient Protection and Affordable Care Act , Adolescente , Adulto , Femenino , Reforma de la Atención de Salud , Humanos , Trasplante de Riñón , Enfermedades Pulmonares/economía , Enfermedades Pulmonares/epidemiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Obtención de Tejidos y Órganos/economía , Obtención de Tejidos y Órganos/normas , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: Lungs are allocated in the United States using the lung allocation score (LAS). We investigated the effect of LAS trends on lung transplant-related costs, healthcare utilization, and mortality. METHODS: Utilization data from Mayo Clinic (Florida and Minnesota) from 2005 to 2015 were obtained from the electronic health records (N = 465). Costs were categorized as 1-year posttransplant or transplant episode and standardized using 2015 Medicare reimbursement and cost-to-charge ratios. Regression analysis was used to assess the relationship of LAS to length of stay (LOS), mortality, and cost of transplant. RESULTS: The mean LAS at transplant increased from 45.7 to 58.3 during the study period, whereas the 1-year survival improved from 88.1% to 92.5% (P < 0.0001). The proportion of patients transplanted with LAS of 60 or greater increased from 16.9% to 33.3%. Posttransplant, overall, and intensive care unit LOS increased with increasing LAS. Patients with higher LAS had substantially higher transplant episode costs. An increase of LAS at transplant by 10 points increased inflation-adjusted costs by 12.0% (95% confidence interval, 9.3%-14.5%). CONCLUSIONS: The mean LAS at transplant has significantly increased over time associated with increases in LOS, resource utilization and cost. Lung allocation score has not jeopardized overall survival, but a high LAS (>60) at transplant is associated with increased mortality.
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Enfermedades Pulmonares/economía , Enfermedades Pulmonares/cirugía , Trasplante de Pulmón/economía , Trasplante de Pulmón/estadística & datos numéricos , Puntuaciones en la Disfunción de Órganos , Anciano , Registros Electrónicos de Salud , Femenino , Florida , Costos de la Atención en Salud , Asignación de Recursos para la Atención de Salud , Humanos , Tiempo de Internación , Enfermedades Pulmonares/mortalidad , Masculino , Medicare , Persona de Mediana Edad , Minnesota , Selección de Paciente , Donantes de Tejidos , Obtención de Tejidos y Órganos , Resultado del Tratamiento , Estados Unidos , Listas de EsperaRESUMEN
Employment status may capture elements of patients' physical strength, mental resilience, and socioeconomic status to better prognosticate transplant outcomes. This study characterized the effect of working status on thoracic transplant outcomes by evaluating the United Network for Organ Sharing registry for adult lung or heart transplants from 2005 to 2016. Kaplan-Meier estimates illustrated 5-year and 10-year survival by working status at transplant, while multivariable Cox proportional hazards regressions controlled for baseline differences, including functional and socioeconomic status. Of 17 778 lung transplant recipients, 1700 (9.6%) worked at transplant and experienced significantly lower 5-year mortality than nonworking recipients (38.6% vs 45.5%, P < 0.001). Of 21 394 heart transplant recipients, 1289 (6.0%) were employed and experienced significantly lower 10-year mortality than nonworking recipients (34.1% vs 40.2%, P < 0.001). Adjusted Cox regressions demonstrated that employment significantly reduced mortality independent of functional status for both lung (HR: 0.86 [0.78-0.95], P = 0.003) and heart (HR: 0.84 [0.72-0.97], P = 0.023) recipients. After accounting for insurance status, the effect of working status persisted only in lung transplantation (HR: 0.89 [0.81-0.98], P = 0.023). Since heart and lung transplant candidates employed at transplant face lower long-term mortality, working status must encompass a broad set of physical, psychological, and socioeconomic variables that may prognosticate post-transplant outcomes.
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Empleo , Trasplante de Corazón/mortalidad , Trasplante de Pulmón/mortalidad , Sistema de Registros/estadística & datos numéricos , Receptores de Trasplantes/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Trasplante de Corazón/economía , Humanos , Trasplante de Pulmón/economía , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
BACKGROUND: Idiopathic pulmonary fibrosis is a disease with high morbidity and mortality. Care for these patients, including lung transplantation, may provide significant benefits, but is resource-intensive and expensive. Disadvantaged patients with IPF may hence be at risk for receiving inferior care. METHODS: We analyzed data from the Nationwide Inpatient Sample, a database consisting of all hospitalizations from a 20% sample of US hospitals. We identified adults hospitalized with IPF between 1998 and 2011 using ICD-9 codes. We assessed the effect of insurance coverage and socioeconomic status (SES) on lung transplantation, a treatment that may improve survival. We also examined the effect of coverage and SES on mortality, as well as discharge to inpatient rehabilitation and receipt of a lung biopsy, two markers of the intensity of care delivered. We used multiple logistic regression to adjust for patient and hospital characteristics. RESULTS: We identified 148,877 hospitalizations that met our definition of pulmonary fibrosis. In the main adjusted analyses, hospitalizations of patients with Medicaid (OR 0.30, 95% CI 0.16-0.57) or no insurance (OR 0.22, 95% CI 0.07-0.72) were less likely to result in a lung transplantation compared to hospitalizations of those with non-Medicaid insurance. Those of lower SES were also less likely to undergo transplantation, while hospitalized patients with Medicaid and the uninsured were less likely to be discharged to inpatient rehabilitation or to receive a lung biopsy. CONCLUSIONS: Among hospitalized patients with IPF, those with lower SES, Medicaid coverage and without insurance were less likely to receive several clinical interventions.
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Disparidades en Atención de Salud/estadística & datos numéricos , Trasplante de Pulmón/estadística & datos numéricos , Fibrosis Pulmonar/terapia , Anciano , Bases de Datos Factuales , Femenino , Disparidades en Atención de Salud/economía , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Hospitales/estadística & datos numéricos , Humanos , Pacientes Internos/estadística & datos numéricos , Cobertura del Seguro/estadística & datos numéricos , Clasificación Internacional de Enfermedades , Modelos Logísticos , Trasplante de Pulmón/economía , Masculino , Medicaid/economía , Medicaid/estadística & datos numéricos , Pacientes no Asegurados/estadística & datos numéricos , Persona de Mediana Edad , Alta del Paciente/economía , Alta del Paciente/estadística & datos numéricos , Fibrosis Pulmonar/economía , Fibrosis Pulmonar/epidemiología , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Severe coal workers' pneumoconiosis (CWP) is increasingly common, and sometimes requires lung transplantation. METHODS: Using Organ Procurement and Transplantation Network data, we updated the trend for CWP-related lung transplants, described CWP patients who have been waitlisted but not transplanted, and characterized the primary payer of medical costs for CWP-related and other occupational lung disease transplants. RESULTS: There have been at least 62 CWP-related lung transplants; 49 (79%) occurred in the last decade. The rate of these procedures has also increased. Twenty-seven patients were waitlisted but did not receive a transplant. Compared to other occupational lung diseases, transplants for CWP were more likely to be paid for by public insurance. CONCLUSIONS: The increase in the frequency and rate of lung transplantation for CWP is consistent with the rising prevalence of severe CWP among U.S. coal miners. Effective exposure controls and identification of early stage CWP remain essential for protecting these workers.
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Antracosis/cirugía , Trasplante de Pulmón/tendencias , Enfermedades Profesionales/cirugía , Adulto , Anciano , Humanos , Seguro de Salud , Trasplante de Pulmón/economía , Masculino , Medicaid , Medicare , Medicare Part C , Persona de Mediana Edad , Estados Unidos , United States Department of Veterans Affairs , Listas de EsperaRESUMEN
BACKGROUND: Unplanned rehospitalizations (UR) within 30 days of discharge are common after lung transplantation. It is unknown whether UR represents preventable gaps in care or necessary interventions for complex patients. The objective of this study was to assess the incidence, causes, risk factors, and preventability of UR after initial discharge after lung transplantation. METHODS: This was a single-center prospective cohort study. Subjects completed a modified short physical performance battery to assess frailty at listing and at initial hospital discharge after transplantation and the State-Trait Anxiety Inventory at discharge. For each UR, a study staff member and the patient's admitting or attending clinician used an ordinal scale (0, not; 1, possibly; 2, definitely preventable) to rate readmission preventability. A total sum score of 2 or higher defined a preventable UR. RESULTS: Of the 90 enrolled patients, 30 (33.3%) had an UR. The single most common reasons were infection (7 [23.3%]) and atrial tachyarrhythmia (5 [16.7%]). Among the 30 URs, 9 (30.0%) were deemed preventable. Unplanned rehospitalization that happened before day 30 were more likely to be considered preventable than those between days 30 and 90 (30.0% versus 6.2%, P = 0.04). Discharge frailty, defined as short physical performance battery less than 6, was the only variable associated with UR on multivariable analysis (odds ratio, 3.4; 95% confidence interval, 1.1-11.8; P = 0.04). CONCLUSIONS: Although clinicians do not rate the majority of UR after lung transplant as preventable, discharge frailty is associated with UR. Further research should identify whether modification of discharge frailty can reduce UR.