Liver transplantation and chronic disease management: Moving beyond patient and graft survival

Serper, Marina; Asrani, Sumeet K.

doi:10.1111/ajt.15749

Cited by 7 publications

(8 citation statements)

References 3 publications

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“…Although not unique to CVD care, this system-level failure points to the need for a redesign of the systems and processes of CVD care and potentially of other chronic disease management in LTRs. (19)…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, the capacity to provide longterm care for LTRs is an issue due to the number of LTRs increasing in the United States with prolonged patient and graft survival, and aging of the LTR population who now more closely resemble a general chronic disease population. (18,19) LT providers indicated that they are no longer able to provide adequate CVD care to all LTRs because of time constraints and competing health priorities (ie, immunosuppression management). Personalized care planning, used often with medically complex patients, may be a potential system-based solution to improving CVD outcomes in LTRs.…”

Section: Discussionmentioning

confidence: 99%

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Liver Transplant Recipient, Caregiver, and Provider Perceptions of Cardiovascular Disease and Related Risk Factors After Transplant

et al. 2021

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Liver transplant recipients (LTRs) are at high risk for cardiovascular disease (CVD). We sought to characterize LTR, informal caregiver, and health care provider perceptions about CVD care after liver transplantation (LT) to inform the design of solutions to improve care. Participants included adult LTRs, their caregivers, and multispecialty health care providers recruited from an urban tertiary care network who participated in 90-minute focus groups and completed a brief survey. Focus group transcripts were analyzed using thematic analysis, and survey data were analyzed using descriptive statistics. A total of 17 LTRs, 9 caregivers, and 22 providers participated in 7 separate focus groups. Most (93.3%) LTRs and caregivers were unaware of the risk of CVD after LT. Although 54.5% of providers were confident discussing CVD risk factors with LTRs, only 36.3% were confident managing CVD risk factors in LTRs, and only 13.6% felt that CVD risk factors in their LTR patients were well controlled. Barriers to CVD care for LTRs included (1) lack of awareness of CVD risk after LT, (2) lack of confidence in an ability to provide proper CVD care to LTRs, (3) reluctance to provide CVD care without transplant provider review, and (4) complexity of communication with the multidisciplinary LTR care team about CVD care. Participant recommendations included improved education for LTRs and caregivers about CVD risk factors, electronic health record alerts for providers, clearly defined CVD care provider roles, increased use of the transplant pharmacist, and multidisciplinary provider meetings to discuss care plans for LTRs. Multiple barriers to CVD care after LT were identified, and targeted recommendations were proposed by participants. Transplant centers should integrate participants' recommendations when designing interventions to optimize CVD care for LTRs.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Liver Transplant Recipient, Caregiver, and Provider Perceptions of Cardiovascular Disease and Related Risk Factors After Transplant

et al. 2021

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“…29 Admittedly, designing a CIM intervention will require adapted methods beyond the traditional clinical research methods to achieve successful implementation, adoption, and sustainability of an innovative model of care for follow-up of transplant patients. 30 Implementation science could offer a way forward to achieve success in this regard. 31 We are currently investing in developing, implementing, and testing this CIM-based eHealth-powered integrated care modelconsisting of a human-component (i.e.…”

Section: Discussionmentioning

confidence: 99%

Is degree of chronic illness management in heart transplant centers associated with better patient survival? Findings from the intercontinental BRIGHT study

et al. 2021

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Purpose To explore the association between the degree of Chronic illness management and survival rates at 1-, 3-, 5-years post heart transplantation. Methods Exploratory secondary analysis of a cross-sectional, international study (Building Research Initiative Group study). Latent profile analysis was performed to classify 36 heart transplant centers according to the degree of chronic illness management. Results The analysis resulted in 2 classes with 29 centers classified as “low-degree chronic illness management” and 7 centers as “high-degree chronic illness management”. After 1-year posttransplantation, the high-degree chronic illness management class had a significantly greater mean survival rate compared to the low-degree chronic illness management class (88.4% vs 84.2%, p = 0.045) and the difference had a medium effect size (η2 = .06). No difference in survival for the other time points was observed. Patients in high-degree chronic illness management centers had 52% lower odds of moderate to severe drinking (95% confidence interval .30–.78, p = 0.003). No significant associations between degree of chronic illness management and the other recommended health behaviors were observed. Conclusions The findings from this exploratory study offer preliminary insight into a system-level pathway (chronic illness management) for improving outcomes for heart transplant recipients. The signals observed in our data support further investigation into the effectiveness of chronic illness management-based interventions in heart transplant follow-up care.

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“…There is a growing consensus in the transplant community that quality metrics and quality improvement should also consider longer‐term survival and patient‐centered and clinically relevant outcomes. ( 29,30 ) Patients who pursue LT inherently expect improvements in quality of life without significant comorbid disease, but this is not always the case. ( 1,8 ) Understanding center‐specific variation with regard to health care utilization and relevant comorbidities may allow for internal assessment of referral processes, patient selection, WL management, and posttransplant care.…”

Section: Discussionmentioning

confidence: 99%

Center Variation in Intention‐to‐Treat Survival Among Patients Listed for Liver Transplant

et al. 2020

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In the United States, centers performing liver transplant (LT) are primarily evaluated by patient survival within 1 year after LT, but tight clustering of outcomes allows only a narrow window for evaluation of center variation for quality improvement. Alternate measures more relevant to patients and the transplant community are needed. We examined adults listed for LT in the United States, using data submitted to the Scientific Registry of Transplant Recipients. Intention-to-treat (ITT) survival was defined as survival within 1 year from listing, regardless of transplant. Mixed effects/frailty models were used to assess center variation in ITT survival. Between January 2010 and December 2016, there were 66,428 new listings at 113 centers. Overall, median 1-year ITT survival was 79.8% (interquartile range [IQR], 76.1%-83.4%), whereas 1-year waiting-list (WL) survival was 75.8% (IQR, 71.2%-79.4%), and 1-year post-LT survival was 90.0% (IQR, 87.9%-91.8%). Higher rates of ITT mortality were correlated with increased WL mortality (correlation, r = 0.76), increased post-LT mortality (r = 0.31), lower volume centers (r = −0.34), and lower transplant rate ratio (r = −0.25). Similar patterns were observed in the subgroup of WL candidates listed with Model for End-Stage Liver Disease (MELD) ≥25: median 1-year ITT survival was 65.2% (IQR, 60.2%-72.6%), whereas 1-year post-LT survival was 87.5% (IQR, 84.0%-90.9%), and 1-year WL survival was 36.6% (IQR, 27.9%-47.0%). In mixed effects modeling, the transplant center was an independent predictor of ITT survival even after adjustment for age, sex, MELD, and sociodemographic variables. Center variation for ITT survival was larger compared with post-LT survival. The measurement of ITT outcome offers a complementary method to assess center performance. This is a first step toward understanding differences in program quality beyond patient and graft survival after LT.

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Liver transplantation and chronic disease management: Moving beyond patient and graft survival

Abstract: A paradigm shift is needed, whereby care provided by liver transplant centers needs to focus not only on survival but also on optimizing long‐term management and overall health of liver transplant recipients. VanWagner et al’s article is on page 797.

Cited by 7 publications

References 3 publications

Liver Transplant Recipient, Caregiver, and Provider Perceptions of Cardiovascular Disease and Related Risk Factors After Transplant

Liver Transplant Recipient, Caregiver, and Provider Perceptions of Cardiovascular Disease and Related Risk Factors After Transplant

Is degree of chronic illness management in heart transplant centers associated with better patient survival? Findings from the intercontinental BRIGHT study

Center Variation in Intention‐to‐Treat Survival Among Patients Listed for Liver Transplant

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