Donation after circulatory death (DCD) liver transplantation (LT) has increased slowly over the past decade. Given that transplant surgeons generally determine liver offer acceptance, understanding surgeon incentives and disincentives is paramount. The purpose of this study was to assess aggregate travel distance per successful DCD versus deceased after brain death (DBD) liver procurement as a surrogate for surgeon time expenditure and opportunity cost. All consecutive liver offers made to Michigan Medicine from 2006 to 2017 were analyzed. Primary outcome was the summative travel distance (spent on all attempted procurements) per successful liver procurement that resulted in LT. Donation after circulatory death liver offer acceptance was lower than DBD liver offers, as was proportion of successful procurements among accepted offers. Overall, 10 275 miles were travelled for accepted DCD liver offers, resulting in 23 successful procurements (mean 447 miles per successful DCD liver procurement). For accepted DBD liver offers, 197 299 miles were travelled, resulting in 863 successful procurements (mean 229 miles per successful DBD liver procurement). On average, each successful DCD liver procurement required 218 more miles of travel than each successful DBD liver procurement. Current reimbursement policies poorly reflect increased surgeon travel (and time) expenditures between DCD and DBD liver offers.

Background Horizontal care, in which clinicians assume roles outside of their usual responsibilities, is an important health care systems response to emergency situations. Allocating residents and fellows into skill-concordant clinical roles, however, is challenging. The most efficient method to accomplish graduate medical education (GME) assessment and deployment for horizontal care is not known. Objective We designed a categorization schema that can efficiently facilitate clinical and educational horizontal care delivery for trainees within a given institution. Methods In September 2019, as part of a general emergency response preparation, a 4-tiered system of trainee categorization was developed at one academic medical center. All residents and fellows were mapped to this system. This single institution model was disseminated to other institutions in 2020 as the COVID-19 pandemic began to affect hospitals nationally. In March 2020, a multi-institution collaborative launched the Trainee Pandemic Role Allocation Tool (TPRAT), which allows institutions to map institutional programs to COVID-19 roles within minutes. This was disseminated to other GME programs for use and refinement. Results The emergency response preparation plan was disseminated and selectively implemented with a positive response from the emergency preparedness team, program directors, and trainees. The TPRAT website was visited more than 100 times in the 2 weeks after its launch. Institutions suggested rapid refinements via webinars and e-mails, and we developed an online user's manual. Conclusions This tool to assess and deploy trainees horizontally during emergency situations appears feasible and scalable to other GME institutions.

Pediatric tuberculosis (TB) represents a major barrier to reducing global TB mortality, especially in countries confronting dual TB and human immunodeficiency virus (HIV) epidemics. Our study aimed to characterize pediatric TB epidemiology in the high-burden setting of Harare, Zimbabwe, both to fill the current knowledge gap around the epidemiology of pediatric TB and to indicate areas for future research and interventions. We analyzed de-identified data of 1,051 pediatric TB cases (0-14 years) found among a total of 11,607 TB cases reported in Harare, Zimbabwe, during 2011-2012. We performed Pearson's χ test and multivariate logistic regression analysis to characterize pediatric TB and to assess predictors of HIV coinfection. Pediatric TB cases accounted for 9.1% of all TB cases reported during 2011-2012. Approximately 50% of pediatric TB cases were children younger than 5 years. Almost 60% of the under-5 age group were male, whereas almost 60% of the 10-14 age group were female. The overall HIV coinfection rate was 58.3%. Odds for HIV coinfection was higher for the 5-9 age group (adjusted odds ratio [AOR]: 2.77, 95% confidence interval [CI]: 1.97-3.94), the 10-14 group (AOR: 3.57, 95% CI: 2.52-5.11), retreatment cases (AOR: 6.17, 95% CI: 2.13, 26.16), and pulmonary TB cases (AOR: 2.39, 95% CI: 1.52, 3.75). In conclusion, our study generated evidence that pediatric TB, compounded by HIV coinfection, significantly impacts children in high-burden settings. The findings of our study indicate a critical need for targeted interventions.

invoked sweeping expansions to the nation's telehealth capacity, authorizing providers to bill for telehealth visits with Medicare beneficiaries at cost parity to in-person visits, eliminating deductibles, and waiving penalties for non-HIPAA compliant communication platforms. 1 While issued on a temporary and emergency basis, this policy provides an opportunity for the transplant community to explore permanent telehealth infrastructure.Before the COVID-19 pandemic, our center's long-term goal was to increase utilization of telehealth to 20% of patient visits over 5 years. COVID-19 has forced us to adapt rapidly. In 2019, we performed 5 telehealth visits per month-in March 2020 alone we performed 184, and have had over 475 telehealth visits in April. We moved the majority of our low-acuity patient visits to video or phone and are working on transitioning required transplant education classes to an interactive, virtual format. During the rapid expansion, we have been stressed by network traffic, availability of compatible technology, and billing concerns, yet we are overcoming these barriers and have made lasting progress through a team-based approach to patient and provider education and technical support.Long-term transplant telehealth plans at our institution were motivated by evidence that transplant telehealth programs may reduce costs, shorten time to initial evaluation and waitlist placement, improve quality of life, and decrease readmissions following transplant. 2,3 While these long-term goals still exist, the rapid roll-out has demonstrated additional benefits. Our video care teams are able to frequently check-in on patients with acute medical and surgical issues and reinforce education on challenges like polypharmacy or low health literacy. Anecdotally, patients have been enthusiastic participants and have experienced no known adverse events. We are learning and honing best practices each day but will need to be rigorous in our interpretation of data and mindful of barriers.As with any change in care delivery, telehealth services must not create or further disparities for the most vulnerable populations. Utilization of telehealth requires at a minimum access to a smartphone and/or Internet. Demographic factors including education, age, language, and culture may all impact telehealth accessibility. At the same time, some of the greatest disparities in the transplantation process occur with waitlist access. Distance from a transplant center has been associated with increased mortality. 4 If implemented carefully, telehealth may increase access to our rural patients and reduce travel-related time and financial costs. There is also evidence that implementing telehealth measures focused on patients of lower socioeconomic status, creating tools accessible across broad ranges of literacy, and aiming for universal access to technology may allow telehealth expansion to be a solution rather than a barrier to access. 5As we move past COVID-19, our department is committed to advancing our infrastructure for telemedi...

Objective: To perform a cost-effectiveness analysis of staple-line reinforcement in laparoscopic sleeve gastrectomy. Summary of Background Data: Exponential increases in surgical costs have underscored the critical need for evidence-based methods to determine the relative value of surgical devices. One such device is stapleline reinforcement, thought to decrease bleeding rates in laparoscopic sleeve gastrectomy. Methods: Two intervention arms were modeled, staple-line reinforcement and standard nonreinforced stapling. Bleed and leak rates and 30-day treatment costs were obtained from national and state registries. Qualityadjusted life-year (QALY) values were drawn from previous literature. Device prices were drawn from institutional data. A final incremental cost-effectiveness ratio was calculated, and one-way and probabilistic sensitivity analyses were performed.Results: A total of 346,530 patient records from 2012 to 2018 were included. Complication rates for the reinforced and standard cohorts were 0.05% for major bleed in both cohorts (P = 0.8841); 0.45% compared with 0.59% for minor bleed (P < 0.0001); and 0.24% compared with 0.26% for leak (P = 0.4812