Audrey E. Ertel

Variation by center and economic burden of readmissions after liver transplantation

The rate and causes of hospital readmissions after liver transplantation (LT) remain largely unknown in the United States. Adult patients (n = 11,937; 43.1% of all LT cases) undergoing LT from 2007 to 2011 were examined with a linkage of the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases to determine the incidence and risk factors for 30‐day readmissions and utilization metrics 90 days after LT. The overall 30‐day hospital readmission rate after LT was 37.9%, with half of patients admitted within 7 days after discharge. Readmitted patients had worse overall graft and patient survival with a 2‐year follow‐up. Multivariate analysis identified risk factors associated with 30‐day hospital readmission, including a higher Model for End‐Stage Liver Disease score, diabetes at LT, dialysis dependence, a high donor risk index allograft, and discharge to a rehabilitation facility. After adjustments for donor, recipient, and geographic factors in a hierarchical model, we found significant variation in readmission rates among hospitals ranging from 26.3% to 50.8% (odds ratio, 0.53‐1.90). In the 90‐day analysis after LT, readmissions accounted for

Does race affect management and survival in hepatocellular carcinoma in the United States

43,785 of added costs in comparison with patients who were not readmitted in the first 90 days. This is the first national report showing that more than one‐third of LT recipients are readmitted to their center within 30 days and that readmissions are associated with center variation and increased resource utilization. Liver Transpl 21:953‐960, 2015.

Using Telehealth to Enable Patient-Centered Care for Liver Transplantation

BACKGROUND Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death, and its incidence is increasing in the United States. This analysis describes the association between race, treatment decisions, operative outcomes, and survival for patients with HCC. METHODS The National Cancer Database was queried for all patients diagnosed with HCC from 1998 to 2011 (n = 143,692) who were white (76.9%), black (14.7%), or Asian (8.4%). Multivariate logistic regression was performed to determine factors that affected the likelihood of having surgery and postoperative mortality, and a Cox regression was performed to evaluate the effect of these factors on survival. RESULTS The proportion of black patients with HCC increased in the United States during the 13-year period. There were no substantial differences among races in tumor size, grade, or overall clinical stage at the time of presentation; however, black patients were less likely to have surgery (odds ratio 0.69, 95% confidence interval 0.67-0.72). Of patients who had surgery, there were no significant differences in pathologic stage, margin negative resection rate, or 30-day mortality; however, black patients had the longest interval between diagnosis and surgery, as well as the worst overall adjusted survival (hazard ratio 1.14, 95% confidence interval 1.05-1.25). These findings were independent of HCC stage, insurance provider, and socioeconomic status. CONCLUSION Despite similar clinical presentation of HCC, substantial racial differences exist with regard to management and outcomes. Black patients are less likely to receive surgery for HCC and have worse long-term survival, despite similar perioperative quality metrics. This difference in long-term survival may highlight neighborhood, cultural, or biological differences between races.

Addressing the High Costs of Pancreaticoduodenectomy at Safety-Net Hospitals

What Is the Innovation? Liver transplantation is a highly complex and resource-intense intervention. Patients are often significantly debilitated, have a poor nutritional state, and incur the comorbidities of chronic immunosuppression. These realities leave recipients at high risk for complicationsandsubsequent rehospitalization.Atour institution, the30day readmission rate following liver transplantation is 42% and increases to69%at 1 year.1 This rate is similar tonational 30-day readmission rates of 40%, andmore than 20%of these patients are readmittedmultiple times, with readmissions accounting formore than 10% of combined 90-day direct costs.2 Clearly, this is an area in which we as a community must improve. To address this issue, we are currently piloting a patientcentricmodelofacuteposttransplantationsurgical andmedical care. Throughatablet-basedmonitoringandfeedback infrastructure, telehealth will be used to support patients and caregivers and to improve their communication with health care professionals. Although use of telehealth has gained momentum in the medical community, it has not yet been well adopted in the surgical community. Duringthedevelopmental stage,asurveywasconductedamong transplantation candidates toassess technological literacy andwillingness to adopt a tablet monitoring system into their postoperative care. In total, 159 surveyswerecollected,withmostpatients reportinguseof the Internet (70.8%)andemail (73.8%),while almost half of the patients (45.6%) reported having used a smartphone or tablet computer. Almost 90%of patients reported being comfortableusingelectronicmonitoringandcommunicationduringtheposttransplantation period. In addition, 77.1% of patients thought that it would be helpful for postoperative care. Eligiblepatientsareenrolledat thetimeof transplantsurgeryadmission. On discharge, patients receive a tablet containing automatedtextmessagesspecifictotheirpostoperativestatus,dailyhealth questions, anda configuredvital sign trackingprogram fromremote devices to include temperature, bloodpressure, bloodglucose level, and weight measurements. The tablets are also equipped with videoconferencing ability to allow for patient and health care professional interface (Figure). Objectivemeasures, including alerts, timeliness of responses, and data inputs, are tracked by the transplant team.Thisprotocol isdesignedtoaddressacutepostoperativeneeds after transplantation, andpatientswill participate for90days.Using thesedata,thetransplantteamwillbeabletocloselymonitortheprogress of the recipients during their initial at-home days. In addition to reported patient data, health services utilization is tracked, including calls, clinic visits, and health care professional satisfaction.This informationwill beusedtoevaluate the impact that suchaprogramwillhaveonresourceutilizationandpatientandcaregiver satisfaction. Long-termendpoints of analysiswill include 30day and 90-day readmission rates, outpatient clinic visits, and recipient health metrics such as blood glucose level, blood pressure control,medicationadherence,weight lossorgain,andactivitygoals. The pilot study has successfully enrolled 20 of 23 eligible patients.Threepatientswerenotenrolleddue todeath, refusal, or lack of long-termevolution coverage at the place of residence. Because of theongoingnatureof thispilot study,preliminarydataarenotyet available but are expected by the fall of 2015.

Use of video-based education and tele-health home monitoring after liver transplantation: Results of a novel pilot study

Importance Safety-net hospitals care for vulnerable patients, providing complex surgery at increased costs. These hospitals are at risk due to changing health care reimbursement policies and demand for better value in surgical care. Objective To model different techniques for reducing the cost of complex surgery performed at safety-net hospitals. Design, Setting, and Participants Hospitals performing pancreaticoduodenectomy (PD) were queried from the University HealthSystem Consortium database (January 1, 2009, to December 31, 2013) and grouped according to safety-net burden. A decision analytic model was constructed and populated with clinical and cost data. Sensitivity analyses were then conducted to determine how changes in the management or redistribution of patients between hospital groups affected cost. Main Outcomes and Measures Overall cost per patient after PD. Results During the 5 years of the study, 15 090 patients underwent PD. Among safety-net hospitals, low-burden hospitals (LBHs), medium-burden hospitals (MBHs), and high-burden hospitals (HBHs) treated 4220 (28.0%), 9505 (63.0%), and 1365 (9.0%) patients, respectively. High-burden hospitals had higher rates of complications or comorbidities and more patients with increased severity of illness. Perioperative mortality was twice as high at HBHs (3.7%) than at LBHs (1.6%) and MBHs (1.7%) (P < .001). In the base case, when all clinical and cost data were considered, PD at HBHs cost

Organ quality metrics are a poor predictor of costs and resource utilization in deceased donor kidney transplantation

35 303 per patient, 30.1% and 36.2% higher than at MBHs (

Case mix–adjusted cost of colectomy at low-, middle-, and high-volume academic centers

27 130) and LBHs (

Improvement and persistent disparities in completion lymph node dissection: Lessons from the National Cancer Database

25 916), respectively. Reducing perioperative complications or comorbidities by 50% resulted in a cost reduction of up to

Cost-effectiveness of cervical spine clearance interventions with litigation and long-term care implications in obtunded adult patients following blunt injury.

4607 for HBH patients, while reducing mortality rates had a negligible effect. However, redistribution of HBH patients to LBHs and MBHs resulted in significantly more cost savings of

Surgical Approaches to Hepatocellular Carcinoma

9155 per HBH patient, or