Improving Transplant Patient Safety Through Pharmacist Discharge Medication Reconciliation

Greater than 50% of medication errors are estimated to occur during transitions of care, and solid‐organ transplant recipients are at an increased risk for errors due to significant changes in their medication regimen following transplantation. This prospective, observational study with a historical control group was conducted to evaluate the discharge process for transplant recipients and determine if transplant pharmacist involvement would improve safety. During the prospective period, a total of 191 errors were made on discharge medication reconciliations (n = 64, mean rate 3.0 per patient); however, pharmacists prevented 119 of these errors (1.9 errors per patient). In the retrospective period, none of the 430 errors identified were prevented at the time of discharge (n = 128, p < 0.0001). The 72 errors not prevented at the time of discharge in the prospective cohort were identified by the pharmacist at the patient's first clinic visit (1.1 errors per patient). In the historical cohort, all 430 errors made at discharge persisted until at least the time of the first clinic visit (3.4 errors per patient, p < 0.0001). This study demonstrates that transplant recipients are at a high risk for medication errors and that transplant pharmacist involvement leads to improved safety through the significant reduction of medication errors.     

Major Variation across Local Transplant Centers in Probability of Kidney Transplant for Wait-Listed Patients

BackgroundGeographic disparities in access to deceased donor kidney transplantation persist in the United States under the Kidney Allocation System (KAS) introduced in 2014, and the effect of transplant center practices on the probability of transplantation for wait-listed patients remains unclear.MethodsTo compare probability of transplantation across centers nationally and within donation service areas (DSAs), we conducted a registry study that included all United States incident adult kidney transplant candidates wait listed in 2011 and 2015 (pre-KAS and post-KAS cohorts comprising 32,745 and 34,728 individuals, respectively). For each center, we calculated the probability of deceased donor kidney transplantation within 3 years of wait listing using competing risk regression, with living donor transplantation, death, and waiting list removal as competing events. We examined associations between center-level and DSA-level characteristics and the adjusted probability of transplant.ResultsCandidates received deceased donor kidney transplants within 3 years of wait listing more frequently post-KAS (22%) than pre-KAS (19%). Nationally, the probability of transplant varied 16-fold between centers, ranging from 4.0% to 64.2% in the post-KAS era. Within DSAs, we observed a median 2.3-fold variation between centers, with up to ten-fold and 57.4 percentage point differences. Probability of transplantation was correlated in the post-KAS cohort with center willingness to accept hard-to-place kidneys (r=0.55, P<0.001) and local organ supply (r=0.44, P<0.001).ConclusionsLarge differences in the adjusted probability of deceased donor kidney transplantation persist under KAS, even between centers working with the same local organ supply. Probability of transplantation is significantly associated with organ offer acceptance patterns at transplant centers, underscoring the need for greater understanding of how centers make decisions about organs offered to wait-listed patients and how they relate to disparities in access to transplantation.     

Renal Transplant in Patients with Polycystic Disease: The Italian Experience

We analyzed the results of kidney transplantation in autosomal dominent polycystic kidney disease (ADPKD) patients in Italy, including 14,305 transplantations performed from January 2002 to December 2010, including: 12,859 first single or double kidneys from cadaveric donors (13% polycystic), 172 combined liver-kidney cases (22% polycystic), and 1,303 living-donor organs (7% polycystic). Among the first transplantations (12,008 single, 851 double), with follow-ups ranging from 16 to 120 months, polycystic patients demonstrated better graft survival compared with other kidney diseases (86% vs 82% at 5 years; P < .01); mortality was not different (92% vs 79% at 1 year). A better trend was obtained also among combined liver-kidney transplantations in ADPKD. Regarding pretransplantation management of polycystic patients, we noticed a conservative attitude in 32/35 transplant centers. The main indication for nephrectomy was for the lack of abdominal space. Regarding instrumental studies, 86% of centers asked for second-level investigations computerized tomography for kidney dimensions. Radiologic investigations for vasculocerebral malformations were required in 97% of the centers: 74% as a routine and 23% in the presence of familial history of cerebral hemorrhage. Polycystic patients are good candidates for kidney transplantation with correct management before transplantation.     

The Abdominal Transplant Surgery Workforce: Current state and future trends

Transplant surgical workforce concerns have arisen in the last 5 years as reflected in challenges securing job opportunities for new fellows. The present survey was designed by the ASTS Membership and Workforce Committee to describe the current practice characteristics of transplant centers in order to estimate changes in the workforce. The survey questionnaire requested information about the transplant programs, the transplant surgeons involved in the program, and the estimated changes in the staffing of the program over the next 3 years. Seventy‐one transplant centers responded from a total of 235 identified and queried (30.2% response rate), with median responding centers per UNOS region of 7 (IQR 4.5‐8.5). The recruitment outlook for the next 3 years forecasts a positive inflow of surgeons at a 2:1 rate (incoming:leaving). The new female transplant workforce within the responding cohort has increased from 3.7% in 1980 to 18.4% in 2010. Currently, 13.1% of practicing US transplant surgeons in this survey are female which is higher than many other surgical specialties. This report represents the most up‐to‐date view into the abdominal transplant surgical workforce. The positive job recruitment outlook for transplant surgeons and the narrowing gender gap are new findings from this study.     

Disparities in Provision of Transplant Education by Profit Status of the Dialysis Center

Kidney transplant education is associated with higher transplantation rates; however national policies regarding optimal timing and content of transplant education are lacking. We aimed to characterize nephrologists’ attitudes regarding kidney transplant education, and to compare practices between nephrologists at for-profit and nonprofit centers. We surveyed 906 nephrologist practicing in the United States. Most respondents (81%) felt the ideal time to spend on transplant education was >20 min, but only 43% reported actually doing so. Spending >20 min was associated with covering more topics, having one-on-one and repeated conversations, involving families in discussions and initiating discussions at CKD-stage 4. Providers at for-profit centers were significantly less likely to spend >20 min (RR = 0.89, 95%CI: 0.80–0.99) or involve families (RR = 0.57, 95%CI: 0.38–0.87); they reported that fewer of their patients received transplant counseling (RR = 0.58, 95%CI: 0.37–0.96), initiated transplant discussions (RR = 0.58, 95%CI: 0.38–0.88), or were eligible for transplantation (RR = 0.45, 95%CI: 0.30–0.68). Of nephrologists who spent ≤20 min, those at for-profit centers more often cited lack of reimbursement as a reason (30.0% vs. 18.9%, p = 0.02). Disparities in quality of education at for-profit centers might partially explain previously documented disparities in access to transplantation for patients at these centers. National policies detailing the optimal timing and content of transplant education are needed to improve equity.     

儿童肺移植患儿术后监护治疗期的多学科团队护理

目的 总结9例儿童肺移植患儿术后监护治疗期的多学科团队护理经验。 方法 组建多学科团队，落实精准用药、精准容量管理、术后感染控制、营养护理、心理干预、气道管理、个性化镇痛镇静等护理措施。 结果 9例患儿ICU住院2～21 d，中位数4 d，均顺利转出ICU；病房住院13～149 d，中位数16 d。患儿均康复出院，随访期间无一例死亡。 结论 基于多学科团队的护理，可以提高肺移植患儿术后护理水平，提高肺移植患儿长期生存率。     

Kidney transplant candidate evaluation

The practicing nephrologist is an indispensable component in the evaluation of the candidate for kidney transplantation, from referral to the transplant center to eventual transplantation, which now may be years later. Early referral may lead to preemptive transplantation, the ideal that has been achieved in 25% of living donor transplant cases. Annually approximately 30% of U.S. deceased donor kidneys are now transplanted under the allocation policies for zero human leukocyte antigen (HLA) mismatch kidneys and expanded criteria donor kidneys. Under either of these programs, candidates may receive a kidney offer soon after entering the wait-list, so prompt and complete evaluation and preparation by the practicing nephrologist is necessary for successful early transplantation. The remaining candidates require periodic review while ascending the wait-list and thorough repeat evaluation when nearing the top, as years may have passed since initial evaluation. Wait-list management is a major challenge faced by transplant centers, aggravated by the inexorable growth of the list. Active communication between the practicing nephrologist and the transplant center is essential to maintain the candidate's preparation for transplantation.     

Association of Candidate Removals From the Kidney Transplant Waiting List and Center Performance Oversight

Approximately 59 000 kidney transplant candidates have been removed from the waiting list since 2000 for reasons other than transplantation, death, or transfers. Prior studies indicate that low‐performance (LP) center evaluations by the Scientific Registry of Transplant Recipients (SRTR) are associated with reductions in transplant volume. There is limited information to determine whether performance oversight impacts waitlist management. We used national SRTR data to evaluate outcomes of 315 796 candidates on the kidney transplant waiting list (2007–2014). Compared to centers without LP, rates of waitlist removal (WLR) were higher at centers with LP evaluations (44.6/1000 follow‐up years, 95% confidence interval [CI] 44.0, 45.1 versus 68.0/1000 follow‐up years, 95% CI 66.6, 69.4), respectively, which was consistent after risk adjustment (adjusted hazard ratio [AHR] = 1.59, 95% CI 1.55, 1.63). Candidate mortality following waitlist removal was lower at LP centers (AHR = 0.90, 95% CI 0.87, 0.94). Analyses limited to LP centers indicated a significant increase in WLR (+28.6 removals/1000 follow‐up years, p < 0.001), a decrease in transplant rates (?11.9/1000 follow‐up years, p < 0.001) and a decrease in mortality after removal (?67.5 deaths/1000 follow‐up years, p < 0.001) following LP evaluation. There is a significant association between LP evaluations and transplant center processes of care for waitlisted candidates. Further understanding is needed to determine the impact of performance oversight on transplant center quality of care and patient outcomes.

     

Case Mix, Quality and High-Cost Kidney Transplant Patients

A better understanding of high-cost kidney transplant patients would be useful for informing value-based purchasing strategies by payers. This retrospective cohort study was based on the Medicare Provider Analysis and Review (MEDPAR) files from 2003 to 2006. The focus of this analysis was high-cost kidney transplant patients (patients that qualified for Medicare outlier payments and 30-day readmission payments). Using regression techniques, we explored relationships between high-cost kidney transplant patients, center-specific case mix, and center quality. Among 43 393 kidney transplants in Medicare recipients, 35.2% were categorized as high-cost patients. These payments represented 20% of total Medicare payments for kidney transplantation and exceeded $200 million over the study period. Case mix was associated with these payments and was an important factor underlying variation in hospital payments high-cost patients. Hospital quality was also a strong determinant of future Medicare payments for high-cost patients. Compared to high-quality centers, low-quality centers cost Medicare an additional $1185 per kidney transplant. Payments for high-cost patients represent a significant proportion of the total costs of kidney transplant surgical care. Quality improvement may be an important strategy for reducing the costs of kidney transplantation.     

Development of an upper extremity transplant program

Starting a hand transplant program poses tremendous challenges. Solid organ transplantation and hand replantation are time-tested procedures and are now standard of care. Hand transplantation is the amalgamation of the scientific principles of reconstructive surgery and the concepts of organ transplantation. Thus, for any hand transplant program to be successful, there must be collaboration within a multidisciplinary team comprising a core group of hand and transplant surgeons. Such a joint effort can overcome the challenges that are inherent in a complex therapeutic option that integrates different disciplines and organizations during the planning, procedural, and posttransplant phases.     

Survival After Adult Liver Transplantation Does Not Correlate with Transplant Center Case Volume in the MELD Era

It has been demonstrated that low-volume orthotopic liver transplant centers have poorer outcomes compared to high-volume centers. In light of the recent significant changes in liver transplantation, we performed an analysis of transplant center procedure volume and mortality with data from the Model for End-stage Liver Disease (MELD) era. We analyzed 9909 adult liver transplants performed in the United States since the beginning of the MELD allocation system. Transplant centers were categorized by volume of transplants performed per year. Multivariate survival models were constructed with raw survival as the primary endpoint for both high- and low-volume centers. Thirty percent of centers were categorized as low volume (< or =20 liver transplants per year) and 8.2% of all transplants were performed at low-volume centers. The unadjusted raw mortality rate at 1-year post-transplant at high-volume centers (9.5%, 95% CI 9.4-9.5) was significantly lower than the rate at low-volume centers (10.9%, 95% CI 10.4-11.4), p < 0.001. However, after adjusting for disease severity and multiple donor and recipient factors, transplant center volume was no longer a significant predictor of post-transplant survival (HR 0.99, 95% CI 0.99-1.00, p = 0.22). We conclude that transplant center case volume is no longer a significant predictor of post-transplant survival in the MELD era and factors which are currently unaccounted for in present survival models should be investigated.     

HIV-Infected Liver and Kidney Transplant Recipients: 1- and 3-Year Outcomes

Improvements in human immunodeficiency virus (HIV)-associated mortality make it difficult to deny transplantation based upon futility. Outcomes in the current management era are unknown. This is a prospective series of liver or kidney transplant recipients with stable HIV disease. Eleven liver and 18 kidney transplant recipients were followed for a median of 3.4 years (IQR [interquartile range] 2.9–4.9). One- and 3-year liver recipients' survival was 91% and 64%, respectively; kidney recipients' survival was 94%. One- and 3-year liver graft survival was 82% and 64%, respectively; kidney graft survival was 83%. Kidney patient and graft survival were similar to the general transplant population, while liver survival was similar to the older population, based on 1999–2004 transplants in the national database. CD4+ T-cell counts and HIV RNA levels were stable; and there were two opportunistic infections (OI). The 1- and 3-year cumulative incidence (95% confidence intervals [CI]) of rejection episodes for kidney recipients was 52% (28–75%) and 70% (48–92%), respectively. Two-thirds of hepatitis C virus (HCV)-infected patients, but no patient with hepatitis B virus (HBV) infection, recurred. Good transplant and HIV-related outcomes among kidney transplant recipients, and reasonable outcomes among liver recipients suggest that transplantation is an option for selected HIV-infected patients cared for at centers with adequate expertise.     

The Quality of Health Insurance Service Delivery for Kidney Transplant Recipients: A Patient Perspective

Increased attention has been devoted to improving quality care in kidney transplantation. The discourse on quality care has focused on transplant center metrics and other clinical parameters. However, there has been little discussion on the quality of health insurance service delivery, which may be critical to kidney recipients’ access to transplantation and immunosuppression. This paper describes and provides a framework for characterizing kidney transplant recipients’ positive and negative interactions with their insurers. A consecutive cohort of kidney recipients (n = 87) participated in semistructured interviews on their interactions with insurance agencies. Patients reported negative (37%) and/or neutral or positive (79%) interactions with their insurer (a subset [16%] reported both). Perceived negative experiences included: poor service, logistical difficulties with confusing and time‐consuming paperwork, poor communication, rude behavior and concerns about adequate coverage. Positive experiences related to: having good coverage, a simple application process, straightforward transactions and helpful communication. Findings suggest that even when patients have insurance coverage, difficult interactions with insurers and limited skills in navigating insurance options may limit their access to needed medications and health services. Future research is needed to test this hypothesis in a larger population.     

Variation in Access to Kidney Transplantation Across Renal Programs in Ontario,Canada

In the United States, kidney transplant rates vary significantly across end‐stage renal disease (ESRD) networks. We conducted a population‐based cohort study to determine whether there was variability in kidney transplant rates across renal programs in a health care system distinct from the United States. We included incident chronic dialysis patients in Ontario, Canada, from 2003 to 2013 and determined the 1‐, 5‐, and 10‐year cumulative incidence of kidney transplantation in 27 regional renal programs (similar to U.S. ESRD networks). We also assessed the cumulative incidence of kidney transplant for “healthy” dialysis patients (aged 18–50 years without diabetes, coronary disease, or malignancy). We calculated standardized transplant ratios (STRs) using a Cox proportional hazards model, adjusting for patient characteristics (maximum possible follow‐up of 11 years). Among 23 022 chronic dialysis patients, the 10‐year cumulative incidence of kidney transplantation ranged from 7.4% (95% confidence interval [CI] 4.8–10.7%) to 31.4% (95% CI 16.5–47.5%) across renal programs. Similar variability was observed in our healthy cohort. STRs ranged from 0.3 (95% CI 0.2–0.5) to 1.5 (95% CI 1.4–1.7) across renal programs. There was significant variation in kidney transplant rates across Ontario renal programs despite patients having access to the same publicly funded health care system.     

The Time Is Now: Formation of True Transplant Centers

With the advances in the complexity of medical care there is a need to change the way we are organized in order to deliver that care in the most patient‐friendly, efficient manner. This need is perhaps most compellingly manifest in the field of whole organ transplantation. Yet we are trying to deliver medical care with an organizational structure that was developed over 100 years ago when medical practice was considerably different. We argue for the development of a vertically integrated organizational structure in academic health centers for certain disciplines like transplantation. While this new arrangement for medical practice could be applied to many areas of medicine, transplantation is one of the best fields to begin making these changes. True transplant centers would bring avoid fragmentation of care and resources, thus bringing together the medical school and hospital into an integrated organization that would be responsible for all aspects of transplantation such as patient care, research, education and fiscal issues.