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1.
Clin J Am Soc Nephrol ; 16(11): 1695-1703, 2021 11.
Article in English | MEDLINE | ID: covidwho-1596096

ABSTRACT

BACKGROUND AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has had a profound effect on transplantation activity in the United States and globally. Several single-center reports suggest higher morbidity and mortality among candidates waitlisted for a kidney transplant and recipients of a kidney transplant. We aim to describe 2020 mortality patterns during the COVID-19 pandemic in the United States among kidney transplant candidates and recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using national registry data for waitlisted candidates and kidney transplant recipients collected through April 23, 2021, we report demographic and clinical factors associated with COVID-19-related mortality in 2020, other deaths in 2020, and deaths in 2019 among waitlisted candidates and transplant recipients. We quantify excess all-cause deaths among candidate and recipient populations in 2020 and deaths directly attributed to COVID-19 in relation to prepandemic mortality patterns in 2019 and 2018. RESULTS: Among deaths of patients who were waitlisted in 2020, 11% were attributed to COVID-19, and these candidates were more likely to be male, obese, and belong to a racial/ethnic minority group. Nearly one in six deaths (16%) among active transplant recipients in the United States in 2020 was attributed to COVID-19. Recipients who died of COVID-19 were younger, more likely to be obese, had lower educational attainment, and were more likely to belong to racial/ethnic minority groups than those who died of other causes in 2020 or 2019. We found higher overall mortality in 2020 among waitlisted candidates (24%) than among kidney transplant recipients (20%) compared with 2019. CONCLUSIONS: Our analysis demonstrates higher rates of mortality associated with COVID-19 among waitlisted candidates and kidney transplant recipients in the United States in 2020.


Subject(s)
COVID-19/mortality , Kidney Transplantation/mortality , Transplant Recipients , Waiting Lists/mortality , Aged , COVID-19/diagnosis , Cause of Death , Female , Humans , Kidney Transplantation/adverse effects , Male , Middle Aged , Registries , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome , United States/epidemiology
5.
J Am Soc Nephrol ; 32(3): 677-685, 2021 03.
Article in English | MEDLINE | ID: covidwho-1496676

ABSTRACT

BACKGROUND: Patients may accrue wait time for kidney transplantation when their eGFR is ≤20 ml/min. However, Black patients have faster progression of their kidney disease compared with White patients, which may lead to disparities in accruable time on the kidney transplant waitlist before dialysis initiation. METHODS: We compared differences in accruable wait time and transplant preparation by CKD-EPI estimating equations in Chronic Renal Insufficiency Cohort participants, on the basis of estimates of kidney function by creatinine (eGFRcr), cystatin C (eGFRcys), or both (eGFRcr-cys). We used Weibull accelerated failure time models to determine the association between race (non-Hispanic Black or non-Hispanic White) and time to ESKD from an eGFR of ≤20 ml/min per 1.73 m2. We then estimated how much higher the eGFR threshold for waitlisting would be required to achieve equity in accruable preemptive wait time for the two groups. RESULTS: By eGFRcr, 444 CRIC participants were eligible for waitlist registration, but the potential time between eGFR ≤20 ml/min per 1.73 m2 and ESKD was 32% shorter for Blacks versus Whites. By eGFRcys, 435 participants were eligible, and Blacks had 35% shorter potential wait time compared with Whites. By the eGFRcr-cys equation, 461 participants were eligible, and Blacks had a 31% shorter potential wait time than Whites. We estimated that registering Blacks on the waitlist as early as an eGFR of 24-25 ml/min per 1.73 m2 might improve racial equity in accruable wait time before ESKD onset. CONCLUSIONS: Policies allowing for waitlist registration at higher GFR levels for Black patients compared with White patients could theoretically attenuate disparities in accruable wait time and improve racial equity in transplant access.


Subject(s)
Glomerular Filtration Rate , Healthcare Disparities , Kidney Transplantation , Racism , Renal Insufficiency, Chronic/physiopathology , Renal Insufficiency, Chronic/surgery , Waiting Lists , African Americans , Aged , Cohort Studies , Disease Progression , Female , Health Policy , Healthcare Disparities/statistics & numerical data , Humans , Kidney Failure, Chronic/physiopathology , Kidney Failure, Chronic/surgery , Male , Middle Aged , Models, Statistical , Racism/statistics & numerical data , Time Factors , United States
8.
BMC Health Serv Res ; 21(1): 1076, 2021 Oct 11.
Article in English | MEDLINE | ID: covidwho-1463251

ABSTRACT

BACKGROUND: International healthcare systems face the challenge that waiting times may create barriers to accessing medical care, and that those barriers are unequally distributed between different patient groups. The disruption of healthcare systems caused by the COVID-19 pandemic could exacerbate this already strained demand situation. Using the German healthcare system as an example, this study aims to analyze potential effects of the COVID-19 pandemic on waiting times for outpatient specialist care and to evaluate differences between individual patient groups based on their respective insurance status and the level of supply. METHODS: We conducted an experiment in which we requested appointments by telephone for different insurance statuses in regions with varying levels of supply from 908 outpatient specialist practices in Germany before and during the COVID-19 pandemic. Data from 589 collected appointments were analyzed using a linear mixed effect model. RESULTS: The data analysis revealed two main counteracting effects. First, the average waiting time has decreased for both patients with statutory (mandatory public health insurance) and private health insurance. Inequalities in access to healthcare, however, remained and were based on patients' insurance status and the regional level of supply. Second, the probability of not receiving an appointment at all significantly increased during the pandemic. CONCLUSIONS: Patient uncertainty due to the fear of a potential COVID-19 infection may have freed up capacities in physicians' practices, resulting in a reduction of waiting times. At the same time, the exceptional situation caused by the pandemic may have led to uncertainty among physicians, who might thus have allocated appointments less frequently. To avoid worse health outcomes in the long term due to a lack of physician visits, policymakers and healthcare providers should focus more on regular care in the current COVID-19 pandemic.


Subject(s)
COVID-19 , Waiting Lists , Germany/epidemiology , Humans , Outpatients , Pandemics , SARS-CoV-2
9.
Clin J Am Soc Nephrol ; 16(11): 1695-1703, 2021 11.
Article in English | MEDLINE | ID: covidwho-1444002

ABSTRACT

BACKGROUND AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has had a profound effect on transplantation activity in the United States and globally. Several single-center reports suggest higher morbidity and mortality among candidates waitlisted for a kidney transplant and recipients of a kidney transplant. We aim to describe 2020 mortality patterns during the COVID-19 pandemic in the United States among kidney transplant candidates and recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using national registry data for waitlisted candidates and kidney transplant recipients collected through April 23, 2021, we report demographic and clinical factors associated with COVID-19-related mortality in 2020, other deaths in 2020, and deaths in 2019 among waitlisted candidates and transplant recipients. We quantify excess all-cause deaths among candidate and recipient populations in 2020 and deaths directly attributed to COVID-19 in relation to prepandemic mortality patterns in 2019 and 2018. RESULTS: Among deaths of patients who were waitlisted in 2020, 11% were attributed to COVID-19, and these candidates were more likely to be male, obese, and belong to a racial/ethnic minority group. Nearly one in six deaths (16%) among active transplant recipients in the United States in 2020 was attributed to COVID-19. Recipients who died of COVID-19 were younger, more likely to be obese, had lower educational attainment, and were more likely to belong to racial/ethnic minority groups than those who died of other causes in 2020 or 2019. We found higher overall mortality in 2020 among waitlisted candidates (24%) than among kidney transplant recipients (20%) compared with 2019. CONCLUSIONS: Our analysis demonstrates higher rates of mortality associated with COVID-19 among waitlisted candidates and kidney transplant recipients in the United States in 2020.


Subject(s)
COVID-19/mortality , Kidney Transplantation/mortality , Transplant Recipients , Waiting Lists/mortality , Aged , COVID-19/diagnosis , Cause of Death , Female , Humans , Kidney Transplantation/adverse effects , Male , Middle Aged , Registries , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome , United States/epidemiology
11.
PLoS One ; 16(8): e0256578, 2021.
Article in English | MEDLINE | ID: covidwho-1378137

ABSTRACT

BACKGROUND: Concern about long waiting times for elective surgeries is not a recent phenomenon, but it has been heightened by the impact of the COVID-19 pandemic and its associated measures. One way to alleviate the problem might be to use prioritisation methods for patients on the waiting list and a wide range of research is available on such methods. However, significant variations and inconsistencies have been reported in prioritisation protocols from various specialties, institutions, and health systems. To bridge the evidence gap in existing literature, this comprehensive systematic review will synthesise global evidence on policy strategies with a unique insight to patient prioritisation methods to reduce waiting times for elective surgeries. This will provide evidence that might help with the tremendous burden of surgical disease that is now apparent in many countries because of operations that were delayed or cancelled due to the COVID-19 pandemic and inform policy for sustainable healthcare management systems. METHODS: We searched PubMed, EMBASE, SCOPUS, Web of Science, and the Cochrane Library, with our most recent searches in January 2020. Articles published after 2013 on major elective surgery lists of adult patients were eligible, but cancer and cancer-related surgeries were excluded. Both randomised and non-randomised studies were eligible and the quality of studies was assessed with ROBINS-I and CASP tools. We registered the review in PROSPERO (CRD42019158455) and reported it in accordance with the PRISMA statement. RESULTS: The electronic search in five bibliographic databases yielded 7543 records (PubMed, EMBASE, SCOPUS, Web of Science, and Cochrane) and 17 eligible articles were identified in the screening. There were four quasi-experimental studies, 11 observational studies and two systematic reviews. These demonstrated moderate to low risk of bias in their research methods. Three studies tested generic approaches using common prioritisation systems for all elective surgeries in common. The other studies assessed specific prioritisation approaches for re-ordering the waiting list for a particular surgical specialty. CONCLUSIONS: Explicit prioritisation tools with a standardised scoring system based on clear evidence-based criteria are likely to reduce waiting times and improve equitable access to health care. Multiple attributes need to be considered in defining a fair prioritisation system to overcome limitations with local variations and discriminations. Collating evidence from a diverse body of research provides a single framework to improve the quality and efficiency of elective surgical care provision in a variety of health settings. Universal prioritisation tools with vertical and horizontal equity would help with re-ordering patients on waiting lists for elective surgery and reduce waiting times.


Subject(s)
Elective Surgical Procedures/statistics & numerical data , COVID-19/epidemiology , COVID-19/virology , Databases, Factual , Humans , Pandemics , Patients/psychology , SARS-CoV-2/isolation & purification , Waiting Lists
13.
Lancet Oncol ; 22(7): 970-976, 2021 07.
Article in English | MEDLINE | ID: covidwho-1331315

ABSTRACT

BACKGROUND: The COVID-19 pandemic has disrupted health-care systems, leading to concerns about its subsequent impact on non-COVID disease conditions. The diagnosis and management of cancer is time sensitive and is likely to be substantially affected by these disruptions. We aimed to assess the impact of the COVID-19 pandemic on cancer care in India. METHODS: We did an ambidirectional cohort study at 41 cancer centres across India that were members of the National Cancer Grid of India to compare provision of oncology services between March 1 and May 31, 2020, with the same time period in 2019. We collected data on new patient registrations, number of patients visiting outpatient clinics, hospital admissions, day care admissions for chemotherapy, minor and major surgeries, patients accessing radiotherapy, diagnostic tests done (pathology reports, CT scans, MRI scans), and palliative care referrals. We also obtained estimates from participating centres on cancer screening, research, and educational activities (teaching of postgraduate students and trainees). We calculated proportional reductions in the provision of oncology services in 2020, compared with 2019. FINDINGS: Between March 1 and May 31, 2020, the number of new patients registered decreased from 112 270 to 51 760 (54% reduction), patients who had follow-up visits decreased from 634 745 to 340 984 (46% reduction), hospital admissions decreased from 88 801 to 56 885 (36% reduction), outpatient chemotherapy decreased from 173634 to 109 107 (37% reduction), the number of major surgeries decreased from 17 120 to 8677 (49% reduction), minor surgeries from 18 004 to 8630 (52% reduction), patients accessing radiotherapy from 51 142 to 39 365 (23% reduction), pathological diagnostic tests from 398 373 to 246 616 (38% reduction), number of radiological diagnostic tests from 93 449 to 53 560 (43% reduction), and palliative care referrals from 19 474 to 13 890 (29% reduction). These reductions were even more marked between April and May, 2020. Cancer screening was stopped completely or was functioning at less than 25% of usual capacity at more than 70% of centres during these months. Reductions in the provision of oncology services were higher for centres in tier 1 cities (larger cities) than tier 2 and 3 cities (smaller cities). INTERPRETATION: The COVID-19 pandemic has had considerable impact on the delivery of oncology services in India. The long-term impact of cessation of cancer screening and delayed hospital visits on cancer stage migration and outcomes are likely to be substantial. FUNDING: None. TRANSLATION: For the Hindi translation of the abstract see Supplementary Materials section.


Subject(s)
COVID-19/therapy , Delivery of Health Care, Integrated/trends , Health Services Accessibility/trends , Medical Oncology/trends , Neoplasms/therapy , Ambulatory Care/trends , COVID-19/diagnosis , Delayed Diagnosis , Early Detection of Cancer/trends , Hospitalization/trends , Hospitals, High-Volume/trends , Humans , India/epidemiology , Neoplasms/diagnosis , Neoplasms/epidemiology , Patient Acceptance of Health Care , Time Factors , Time-to-Treatment , Waiting Lists
16.
Crit Care Med ; 49(7): 1192-1193, 2021 07 01.
Article in English | MEDLINE | ID: covidwho-1327407
17.
Arch Argent Pediatr ; 119(4): 266-269, 2021 08.
Article in English, Spanish | MEDLINE | ID: covidwho-1325944

ABSTRACT

OBJECTIVE: To describe the impact of the COVID-19 pandemic on a pediatric cardiovascular surgery program and estimate the necessary time to reduce the surgery waiting list. METHODS: Retrospective, descriptive study. Surgical outcomes from the pre-COVID-19 period and COVID-19 period were compared. A mathematical model was used to estimate the time necessary to reduce the waiting list. RESULTS: Between March 23rd and August 31st, 2020, 83 patients underwent surgery, accounting for a 60 % reduction compared to the pre-COVID-19 period. Their median age was 6 months (interquartile range [IQR]: 25-75, 1.8 months to 2.9 years; p = 0.0023). The time necessary to eliminate the waiting list ranges from 10 to 19 months. CONCLUSIONS: There was a 60 % reduction in the program. The time required to clear the backlog of cases may range from, at least, 10 to 19 months.


Objetivo. Describir el impacto de la pandemia por COVID-19 en el programa de cirugía cardiovascular pediátrica y estimar el tiempo para reducir la lista de espera quirúrgica. Métodos. Estudio descriptivo y retrospectivo. Se compararon resultados quirúrgicos del período preCOVID versus el período COVID. Se utilizó un modelo matemático para estimar el tiempo para reducir la lista de espera. Resultados. Entre el 23 de marzo y el 31 de agosto de 2020 se operaron 83 pacientes, que representan una reducción del 60 %, respecto al período preCOVID. La mediana de edad fue de 6 meses (rango intercuartílico [RIC]: 25-75, 1,8 meses a 2,9 años; p = 0,0023. El tiempo para eliminar la lista de espera varía entre 10 y 19 meses. Conclusiones. El programa tuvo una reducción del 60 %. El tiempo de resolución de la lista de espera puede ser al menos 10 a 19 meses.


Subject(s)
COVID-19 , Cardiovascular Surgical Procedures/trends , Health Services Accessibility/trends , Hospitals, Public/trends , Time-to-Treatment/trends , Waiting Lists , Argentina/epidemiology , COVID-19/epidemiology , COVID-19/prevention & control , Child , Child, Preschool , Humans , Infant , Models, Theoretical , Pandemics , Retrospective Studies
18.
JAMA Netw Open ; 4(7): e2118223, 2021 07 01.
Article in English | MEDLINE | ID: covidwho-1321668

ABSTRACT

Importance: Methadone access may be uniquely vulnerable to disruption during COVID-19, and even short delays in access are associated with decreased medication initiation and increased illicit opioid use and overdose death. Relative to Canada, US methadone provision is more restricted and limited to specialized opioid treatment programs. Objective: To compare timely access to methadone initiation in the US and Canada during COVID-19. Design, Setting, and Participants: This cross-sectional study was conducted from May to June 2020. Participating clinics provided methadone for opioid use disorder in 14 US states and territories and 3 Canadian provinces with the highest opioid overdose death rates. Statistical analysis was performed from July 2020 to January 2021. Exposures: Nation and type of health insurance (US Medicaid and US self-pay vs Canadian provincial). Main Outcomes and Measures: Proportion of clinics accepting new patients and days to first appointment. Results: Among 268 of 298 US clinics contacted as a patient with Medicaid (90%), 271 of 301 US clinics contacted as a self-pay patient (90%), and 237 of 288 Canadian clinics contacted as a patient with provincial insurance (82%), new patients were accepted for methadone at 231 clinics (86%) during US Medicaid contacts, 230 clinics (85%) during US self-pay contacts, and at 210 clinics (89%) during Canadian contacts. Among clinics not accepting new patients, at least 44% of 27 clinics reported that the COVID-19 pandemic was the reason. The mean wait for first appointment was greater among US Medicaid contacts (3.5 days [95% CI, 2.9-4.2 days]) and US self-pay contacts (4.1 days [95% CI, 3.4-4.8 days]) than Canadian contacts (1.9 days [95% CI, 1.7-2.1 days]) (P < .001). Open-access model (walk-in hours for new patients without an appointment) utilization was reported by 57 Medicaid (30%), 57 self-pay (30%), and 115 Canadian (59%) contacts offering an appointment. Conclusions and Relevance: In this cross-sectional study of 2 nations, more than 1 in 10 methadone clinics were not accepting new patients. Canadian clinics offered more timely methadone access than US opioid treatment programs. These results suggest that the methadone access shortage was exacerbated by COVID-19 and that changes to the US opioid treatment program model are needed to improve the timeliness of access. Increased open-access model adoption may increase timely access.


Subject(s)
COVID-19 , Health Services Accessibility , Methadone/therapeutic use , Opiate Substitution Treatment , Opioid-Related Disorders/therapy , Pandemics , Waiting Lists , Ambulatory Care Facilities , Analgesics, Opioid , Canada , Cross-Sectional Studies , Financing, Personal , Health Services , Insurance, Health , Medicaid , United States
19.
Nat Rev Nephrol ; 17(8): 554-568, 2021 08.
Article in English | MEDLINE | ID: covidwho-1319029

ABSTRACT

Although overall donation and transplantation activity is higher in Europe than on other continents, differences between European countries in almost every aspect of transplantation activity (for example, in the number of transplantations, the number of people with a functioning graft, in rates of living versus deceased donation, and in the use of expanded criteria donors) suggest that there is ample room for improvement. Herein we review the policy and clinical measures that should be considered to increase access to transplantation and improve post-transplantation outcomes. This Roadmap, generated by a group of major European stakeholders collaborating within a Thematic Network, presents an outline of the challenges to increasing transplantation rates and proposes 12 key areas along with specific measures that should be considered to promote transplantation. This framework can be adopted by countries and institutions that are interested in advancing transplantation, both within and outside the European Union. Within this framework, a priority ranking of initiatives is suggested that could serve as the basis for a new European Union Action Plan on Organ Donation and Transplantation.


Subject(s)
Organ Transplantation , Tissue and Organ Procurement , Europe/epidemiology , European Union , Humans , Kidney Transplantation/statistics & numerical data , Organ Transplantation/statistics & numerical data , Stakeholder Participation , Tissue and Organ Procurement/organization & administration , Tissue and Organ Procurement/statistics & numerical data , Waiting Lists/mortality
20.
Gut ; 70(10): 1914-1924, 2021 10.
Article in English | MEDLINE | ID: covidwho-1318040

ABSTRACT

OBJECTIVE: Explore the impact of COVID-19 on patients on the waiting list for liver transplantation (LT) and on their post-LT course. DESIGN: Data from consecutive adult LT candidates with COVID-19 were collected across Europe in a dedicated registry and were analysed. RESULTS: From 21 February to 20 November 2020, 136 adult cases with laboratory-confirmed SARS-CoV-2 infection from 33 centres in 11 European countries were collected, with 113 having COVID-19. Thirty-seven (37/113, 32.7%) patients died after a median of 18 (10-30) days, with respiratory failure being the major cause (33/37, 89.2%). The 60-day mortality risk did not significantly change between first (35.3%, 95% CI 23.9% to 50.0%) and second (26.0%, 95% CI 16.2% to 40.2%) waves. Multivariable Cox regression analysis showed Laboratory Model for End-stage Liver Disease (Lab-MELD) score of ≥15 (Model for End-stage Liver Disease (MELD) score 15-19, HR 5.46, 95% CI 1.81 to 16.50; MELD score≥20, HR 5.24, 95% CI 1.77 to 15.55) and dyspnoea on presentation (HR 3.89, 95% CI 2.02 to 7.51) being the two negative independent factors for mortality. Twenty-six patients underwent an LT after a median time of 78.5 (IQR 44-102) days, and 25 (96%) were alive after a median follow-up of 118 days (IQR 31-170). CONCLUSIONS: Increased mortality in LT candidates with COVID-19 (32.7%), reaching 45% in those with decompensated cirrhosis (DC) and Lab-MELD score of ≥15, was observed, with no significant difference between first and second waves of the pandemic. Respiratory failure was the major cause of death. The dismal prognosis of patients with DC supports the adoption of strict preventative measures and the urgent testing of vaccination efficacy in this population. Prior SARS-CoV-2 symptomatic infection did not affect early post-transplant survival (96%).


Subject(s)
COVID-19/mortality , Liver Transplantation , Pneumonia, Viral/mortality , Transplant Recipients , Cause of Death , Europe/epidemiology , Female , Humans , Male , Middle Aged , Pneumonia, Viral/virology , Registries , Risk Factors , SARS-CoV-2 , Waiting Lists
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