Thomas E. Burroughs

Transplant Outcomes and Economic Costs Associated with Patient Noncompliance to Immunosuppression

We describe factors associated with immunosuppression compliance after kidney transplantation and examine relationships between compliance with allograft outcomes and costs. Medicare claims for immunosuppression in 15 525 renal transplant recipients with at least 1 year of graft function were used to calculate compliance as medication possession ratio. Compliance was categorized by quartiles as poor, fair, good and excellent. We modeled adjusted associations of clinical factors with the likelihood of persistent compliance by multiple logistic regressions (aOR), and estimated associations of compliance with subsequent graft and patient survival with Cox proportional hazards (aHR). Adolescent recipients aged 19–24 years were more likely to be persistently noncompliant compared to patients aged 24–44 years (aOR 1.49 [1.06–2.10]). Poor (aHR 1.80 [1.52–2.13]) and fair (aHR 1.63[1.37–1.93]) compliant recipients were associated with increased risks of allograft loss compared to the excellent compliant recipients. Persistent low compliance was associated with a

Mycophenolate mofetil dose reductions and discontinuations after gastrointestinal complications are associated with renal transplant graft failure.

12 840 increase in individual 3‐year medical costs. Immunosuppression medication possession ratios indicative of less than the highest quartile of compliance predicted increased risk of graft loss and elevated costs. These findings suggest that interventions to improve medication compliance among kidney transplant recipients should emphasize the benefits of maximal compliance, rather than discourage low compliance.

A Retrospective Analysis of Immunosuppression Compliance, Dose Reduction and Discontinuation in Kidney Transplant Recipients

Background. Mycophenolate mofetil (MMF) use in renal transplantation has steadily increased since 1995 because of its ability to lower the risks of rejection and chronic allograft nephropathy. However, significant gastrointestinal (GI) complications may lead to MMF dose reductions and discontinuations. Little is known of the association between MMF dose reductions and discontinuations following GI complications and graft survival. Methods. Using the United States Renal Data System, we identified 3,675 adult recipients (age ≥18) with a diagnosed GI complication who were prescribed MMF at the time of first GI diagnosis and had Medicare as their primary insurer. MMF doses were ascertained from Medicare payment records. We estimated risk of graft loss associated with MMF dose adjustments after GI diagnosis: dosage unchanged (reference), reduced <50%, reduced ≥50%, and MMF discontinued. Patients were followed until graft loss, death, last recorded immunosuppression prescription, or 3 years posttransplant. Results. Compared to those with no MMF dose reductions or discontinuations, the risk of graft failure increased with MMF doses reduction ≥50% (HR=2.36, 95% CI 1.23–4.54) and those with MMF discontinuation (2.72, CI 1.60–4.64). Conclusion. Renal transplant recipients who underwent MMF dose reduction or withdrawal following GI diagnosis are associated with increased risk of graft failure.

BRIEF REPORT: Hospitalized Patients' Attitudes About and Participation in Error Prevention

We describe factors associated with poor compliance and dose reductions and examine the relative impact of compliance, dose reduction and discontinuation on graft outcome.

Diabetic Complications Associated With New-onset Diabetes Mellitus in Renal Transplant Recipients

BACKGROUND AND OBJECTIVE: Although many patient safety organizations and hospital leaders wish to involve patients in error prevention, it is unknown whether patients will take the recommended actions or whether error prevention involvement affects hospitalization satisfaction.DESIGN AND PARTICIPANTS: Telephone interviews with 2,078 patients discharged from 11 Midwest hospitals.RESULTS: Ninety-one percent agreed that patients could help prevent errors. Patients were very comfortable asking a medication’s purpose (91%), general medical questions (89%), and confirming their identity (84%), but were uncomfortable asking medical providers whether they had washed their hands (46% very comfortable). While hospitalized, many asked questions about their care (85%) and a medication’s purpose (75%), but fewer confirmed they were the correct patient (38%), helped mark their incision site (17%), or asked about handwashing (5%). Multivariate logistic regression revealed that patients who felt very comfortable with error prevention were significantly more likely to take 6 of the 7 error-prevention actions compared with uncomfortable patients.CONCLUSIONS: While patients were generally comfortable with error prevention, their participation varied by specific action. Since patients who were very comfortable were most likely to take action, educational interventions to increase comfort with error prevention may be necessary to help patients become more engaged.

Implantable Cardiac Device Procedures in Older Patients: Use and In-Hospital Outcomes

Background. Data are scarce regarding the incidence and risk factors for complications of new-onset diabetes mellitus (NODM) in renal transplant patients. Methods. United States Renal Data System (USRDS) data from primary renal transplant recipients during 1995–2001 who developed NODM was used to examine diabetic complications over the first three years posttransplant. Prognostic models were used to evaluate patient characteristics and treatment choices associated with risk of each class of complications. Propensity scores for choice of calcineurin inhibitor were included in multivariate analyses. Results. The analysis included 21,489 patients, of whom 4,105 developed NODM by 3 years posttransplant. One or more NODM complications developed in 2,393 patients (58.3% of all patients with NODM), comprising ketoacidosis (334, 8.1%), hyperosmolarity (131, 3.2%), renal complications (1,286, 31.3%), ophthalmic complications (340, 8.3%), neurological complications (665, 16.2%), peripheral circulatory disorders (170, 4.1%) and hypoglycemia/shock (301, 7.3%). Complications developed within a mean of 500 to 600 days from diagnosis of NODM. Multivariate analysis showed that increased recipient age, higher body mass index, African-American race, hepatitis C infection, hypertension as cause of end-stage renal disease, cold ischemia ≥30 hours, and use of tacrolimus each increased risk of complications. Conclusion. NODM is associated with similar complications to those seen in the general population, but these appear to develop at an accelerated rate. Obesity and use of tacrolimus are the only modifiable factors that appear to affect risk of NODM or its complications.

Incidence and risk factors for diarrhea following kidney transplantation and association with graft loss and mortality.

BACKGROUND Although the effectiveness of implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) alone or in combination is well established, limited data are available on device use and short-term outcomes in older patients. We sought to characterize age-specific practices and outcomes among patients with heart failure undergoing device implantation using a large nationally representative administrative database. METHODS The cohort comprised patients older than 18 years with a diagnosis of heart failure who underwent implantation of an ICD or CRT between January 1, 2004, and December 31, 2005. Data included patient demographics, comorbidities, type of device, procedural complications, length of stay, total cost of hospitalization, and hospital characteristics. Multivariate stepwise logistic regression analysis was used to identify risk factors for in-hospital mortality. RESULTS We identified 26 887 patients who received an implantable device. The median age was 70.0 years (17.5% were > or =80 years), 72.6% were male, and 31.3% were of nonwhite race/ethnicity. Compared with younger patients, those 80 years or older were more likely to receive CRT alone. In-hospital mortality increased from 0.7% among patients younger than 80 years to 1.2% among those aged 80 to 85 years and 2.2% among those older than 85 years (P < .001). Independent predictors of in-hospital mortality included age 80 years or older, elevated comorbidity score, inotrope use, and procedure-related complications. CONCLUSIONS Despite the fact that most device trials have excluded patients 80 years or older, more than one-fifth of ICD and CRT devices are implanted in this age group. Advanced age is an independent predictor of in-hospital mortality following device implantation, suggesting that additional study is needed to define criteria for appropriate device use in older patients.

Patient satisfaction: focusing on "excellent".

BACKGROUND Gastrointestinal complications after kidney transplantation are associated with inferior graft outcomes. We examined the incidence, risk factors, and outcomes of posttransplantation diarrhea. STUDY DESIGN Historic cohort study. SETTING & PARTICIPANTS We examined first kidney transplant recipients in the United States from 1995 to 2002, with follow-up through December 2002. Recipients of multiple organs were excluded. We limited our study population to Medicare beneficiaries. PREDICTORS Recipient, donor, and transplant characteristics were ascertained by means of US Renal Data System database inquiry. OUTCOMES Incidence of diarrhea, graft loss, and death after transplantation. First episodes of diarrhea after transplantation were ascertained by using International Classification of Disease, Ninth Revision, Clinical Modification codes using Medicare billing data. Cause of diarrhea was classified as infectious or not and according to specific cause. Graft loss and death were ascertained from the date of the first diarrhea episode. RESULTS We enrolled 41,442 patients. Mean follow-up was 758 +/- 399 days. We observed 7,103 diarrhea cases and 8,104 graft losses (4,201 deaths). The 3-year cumulative incidence of diarrhea was 22%, with 18% diagnosed as noninfectious diarrhea with an unspecified cause. Using multivariate Cox proportional hazards analysis, factors associated with increased risk of unspecified noninfectious diarrhea were female sex (hazard ratio [HR], 1.40; 95% confidence interval, 1.33 to 1.48), type 1 diabetes (HR, 1.20; 95% confidence interval, 1.06 to 1.37), and regimens containing tacrolimus and mycophenolate mofetil (HR, 1.37; 95% confidence interval, 1.28 to 1.46). Unspecified noninfectious diarrhea was associated with increased risk of graft failure (HR, 2.13; 95% confidence interval, 1.98 to 2.28) and patient death (HR, 2.04; 95% confidence interval, 1.85 to 2.24). LIMITATIONS Use of claims data to ascertain patient characteristics and events; inability to make causal inference based on retrospective designs. CONCLUSIONS Regimens containing tacrolimus and mycophenolate mofetil were associated with increased risk of noninfectious diarrhea. Episodes of noninfectious diarrhea doubled the hazard of graft loss and patient death.

Association of Lower Costs of Pulsatile Machine Perfusion in Renal Transplantation from Expanded Criteria Donors

&NA; In an emerging competitive market such as healthcare, managers should focus on achieving excellent ratings to distinguish their organization from others. When it comes to customer loyalty, “excellent” has a different meaning. Customers who are merely satisfied often do not come back. The purpose of this study was to find out what influences adult patients to rate their overall experience as “excellent.” The study used patient satisfaction data collected from one major academic hospital and four community hospitals. After conducting a multiple logistic regression analysis, certain attributes were shown to be more likely than others to influence patients to rate their experiences as excellent. The study revealed that staff care is the most influential attribute, followed by nursing care. These two attributes are distinctively stronger drivers of overall satisfaction than are the other attributes studied (i.e., physician care, admission process, room, and food). Staff care and nursing care are under the control of healthcare managers. If improvements are needed, they can be accomplished through training programs such as total quality management or continuous quality improvement, through which staff employees and nurses learn to be sensitive to patients’ needs. Satisfying patients’ needs is the first step toward having loyal patients, so hospitals that strive to ensure their patients are completely satisfied are more likely to prosper.

Delivery patterns of recommended chronic kidney disease care in clinical practice: administrative claims-based analysis and systematic literature review.

Pulsatile machine perfusion (PMP) has been shown to reduce delayed graft function (DGF) in expanded criteria donor (ECD) kidneys. Here, we investigate whether there is a cost benefit associated with PMP utilization in ECD kidney transplants. We analyzed United States Renal Data System (USRDS) data describing Medicare‐insured ECD kidney transplant recipients in 1995–2004 (N = 5840). We examined total Medicare payments for transplant hospitalization and annually for 3 years posttransplant according to PMP utilization. After adjusting for other recipient, donor and transplant factors, PMP utilization was associated with a