Excluding patients from transplant due to social support: Results from a national survey of transplant providers.

Social support is used to determine transplant eligibility despite lack of an evidence base and vague regulatory guidance. It is unknown how many patients are disqualified from transplantation due to inadequate support, and whether providers feel confident using these subjective criteria to determine eligibility. Transplant providers (n = 551) from 202 centers estimated that, on average, 9.6% (standard deviation = 9.4) of patients evaluated in the prior year were excluded due to inadequate support. This varied significantly by United Network for Organ Sharing region (7.6%-12.2%), and by center (21.7% among top quartile). Significantly more providers used social support in listing decisions than believed it ought to be used (86.3% vs 67.6%). Nearly 25% believed that using social support in listing determinations was unfair or were unsure; 67.3% felt it disproportionately impacted patients of low socioeconomic status. Overall, 42.4% were only somewhat or not at all confident using social support to determine transplant suitability. Compared to surgical/medical transplant providers, psychosocial providers had 2.13 greater odds of supporting the criteria (P = .03). Furthermore, 69.2% supported revised guidelines for use of social support in listing decisions. Social support criteria should be reconsidered in light of the limited evidence, potential for disparities, practice variation, low provider confidence, and desire for revised guidelines.

AST/ASTS workshop on increasing organ donation in the United States: creating an "arc of change" from removing disincentives to testing incentives.

The American Society of Transplantation (AST) and American Society of Transplant Surgeons (ASTS) convened a workshop on June 2-3, 2014, to explore increasing both living and deceased organ donation in the United States. Recent articles in the lay press on illegal organ sales and transplant tourism highlight the impact of the current black market in kidneys that accompanies the growing global organ shortage. We believe it important not to conflate the illegal market for organs, which we reject in the strongest possible terms, with the potential in the United States for concerted action to remove all remaining financial disincentives for donors and critically consider testing the impact and acceptability of incentives to increase organ availability in the United States. However, we do not support any trials of direct payments or valuable considerations to donors or families based on a process of market-assigned values of organs. This White Paper represents a summary by the authors of the deliberations of the Incentives Workshop Group and has been approved by both AST and ASTS Boards.

The transplant center and business unit as a model for specialized care delivery.

Transplant centers are valuable assets to a transplantation hospital and essential to organize the delivery of patient care. A transplant center defined around physicians and activities of caring for patients with organ failure creates a team better equipped to manage care across the continuum of the diseases treated by transplantation. Through monitoring of clinical and financial outcomes, the transplant center can better respond to the changing regulatory and financial landscape of health care. This article seeks to explain the major organizational challenges facing the transplant center and how a transplant center can best serve its patients and parent organization.

Standardization of terminology for episodes of hematopoietic stem cell patient transplant care.

The nomenclature describing hematopoietic stem cell transplantation has evolved, adding precision and definition in research and regulation. The lack of coordination and standardization in terminology has left some gaps in the definition of episodes of clinical care. These voids have caused particular problems in contracting for payment and billing for services rendered. The purpose of this report is to propose definitions for cell products, cell infusions, and transplantation episodes.

Income of living kidney donors and the income difference between living kidney donors and their recipients in the United States.

Disincentives for living kidney donation are common but are poorly understood. We studied 54 483 living donor kidney transplants in the United States between 2000 and 2009, limiting to those with valid zip code data to allow determination of median household income by linkage to the 2000 U.S. Census. We then determined the income and income difference of donors and recipients. The median household income in donors and recipients was $46 334 ±$17 350 and $46 439 ±$17 743, respectively. Donation-related expenses consume ≥ 1 month's income in 76% of donors. The mean ± standard deviation income difference between recipients and donors in transplants involving a wealthier recipient was $22 760 ± 14 792 and in 90% of transplants the difference was <$40 000 dollars. The findings suggest that the capacity for donors to absorb the financial consequences of donation, or of recipients to reimburse allowable expenses, is limited. There were few transplants with a large difference in recipient and donor income, suggesting that the scope and value of any payment between donors and recipients is likely to be small. We conclude that most donors and recipients have similar modest incomes, suggesting that the costs of donation are a significant burden in the majority of living donor transplants.

Factors influencing the acceptance of toenail-to-fingernail transfer.

The aim of this study is to determine the factors influencing the acceptance of toenail-to-fingernail transfer. A total of 240 patients were divided into four groups according to severity of nail injury. Half (expensed informed [EI] group) were informed about the expenses (about $9,000) before the interview; the other half were not informed (the expense not-informed [ENI] group). The participants were asked to answer yes or no to the question "If you lose your fingernail and it can be reconstructed by transferring your toenail like this figure, will you undergo surgery? If you want it or not, please choose the reason for your choice." In the EI group, 68.3% accepted the surgery. In the ENI group, 85.0% accepted the surgery. There was a significant difference between the EI and ENI groups (p = 0.002). In the EI group, the age of the surgery acceptance group (36.9 ± 11.8) was significantly lower (p = 0.004) than that of the surgery rejection group (44.5 ± 15.5). The young age group wished to accept the surgery irrespective of the expenses, yet the old age group hesitated to have surgery when informed about the expenses. We think the risk acceptance for toenail-to-fingernail transfer mostly depends upon the expense.

Potential of a hand transplantation program in Colombia.

The protocols and published results on hand transplantation show acceptable results of this technology. None of the registered groups, however has a sufficient number of patients to allow continuity of the process. In Colombia the main problems are violence, drug traffic, and guerrillas. Thanks to the profitability of drug traffic, guerrillas, who initially were created based on ideologic differences, have become terrorist groups whose main source of income is drug traffic. From that interest comes the use of landmines to protect illicit crops. Colombia is the most mined country in the world, followed by Cambodia and Afghanistan, and the only country in Latin America where there are still landmines. The mines, violence, and trauma produce a large number of people with disabilities and amputations. From 1990 to 2006, the number of victims rose from 21 to 1,041 per year. In Colombia, amputations are more frequently due to trauma than to disease. The fact that 88% of the victims are children and people of working age, affects the political and economic development. These alarming numbers generate a challenge for government, which has led to the creation of policies and laws aimed at comprehensive action against mines. This program under the Presidency has among its objectives assistance to victims, including integrated treatment, prostheses, and other procedures, financed entirely by the government. The number, type of victims, and their motivation to be transplanted, along with government programs directed to their attention, are key factors that we think will enable the continuity of our hand transplantation program at the Fundación Santa Fe de Bogotá, giving Colombia the unfortunate privilege of having the largest number of potential patients for transplantation.

Exceptional circumstance drug dispensing: history and expenditures of the Brazilian Ministry of Health.

OBJECTIVE: To describe the technical aspects of the Exceptional Circumstance Drug Dispensing Program of the Brazilian Ministry of Health, especially with respect to the cost of dispensed medication. METHODS: Technical information was obtained from the ordinances that regulate the Program. Expenditure from 2000 to 2007 was obtained from the Sistema Único de Saúde's (Unified Healthcare System) Outpatient Information System. All drugs dispensed between 1993 and 2009 and the amount and cost of each procedure were evaluated, based on information from the high-complexity procedure authorization of each of the country's states. RESULTS: The Program changed with the increase in the number of pharmacological agents and presentations distributed by, and the number of diseases contemplated in the program. In 1993, the program distributed 15 pharmacological agents in 31 distinct presentations. This number increased to 109 agents in 243 presentations in 2009. Total Ministry of Health expenditure with medications was R$1,410,181,600.74 in 2007, almost twice the amount spent in 2000, R$684,975,404.43. Diseases whose expenditure increased in the period included chronic renal insufficiency, transplantation, and hepatitis C. CONCLUSIONS: The Exceptional Circumstance Drug Dispensing Program is in constant transformation, aimed at building instruments and strategies that can ensure and expand access to medication among the population. Alternatives should be sought to decrease the financial impact of the Program to a level that does not impact other sectors of the health care system, given the high cost associated with novel interventions.

Cost of paid transplantation abroad: possible donor-origin early multiple myeloma in a renal transplant recipient treated using bortezomib.

The incidence of cancer is greater in transplant recipients compared with the general population. Posttransplantation lymphoproliferative disorder (PTLD) is the second most common cancer in these patients. Non-Hodgkin lymphoma is most commonly observed, and multiple myeloma (PTLD-MM) accounts for less than 4% of PTLDs. Most reported PTLD-MM is of recipient origin, and to date, few cases of donor-origin PTLD-MM have been reported. Bortezomib is a protease inhibitor that has been used successfully to treat multiple myeloma. Herein, we describe the case of a patient in whom multiple myeloma developed shortly after paid living-unrelated renal transplantation performed abroad (in Egypt). The patient had no apparent risk factors for PTLD-MM. Thus, it was supposed that PTLD-MM was of donor origin, considering its early development, lack of recipient risk factors, and no available donor medical status. To our knowledge, this report is the first to describe the use of bortezomib in this setting. Although bortezomib plus dexamethasone therapy resulted in hematologic remission, the patient remained dialysis-dependent.

Using the pharmacoepidemiology approach to evaluate the first-year posttransplantation ambulatory health care cost from the Longitudinal Health Insurance Database (2001 to 2006) in Taiwan.

This research evaluated the total first-year posttransplantation ambulatory health care cost using a countrywide health claims database. We searched all health reimbursement claims of posttransplantation patients from 2001 to 2006 using the ICD-9-CM codes (V42.0, V42.1, V42.6, V42.7, V42.8) for kidney, heart, lung, liver, and other specified organ transplantations. We excluded patients undergoing transplantation surgery>12 months before 2001 or with <1 year of or irregular follow-up visits. All of the studied ambulatory care expenditures by visit files were based on the Taiwan Longitudinal Health Insurance Database (2005), which contained the claims of 1,000,000 beneficiaries who were randomly sampled from the Registry for Beneficiaries of the National Health Insurance Research Database. During this 6-year period we identified 336 transplant patients with 145 new cases having consecutive and >12 months of follow-up ambulatory visits to calculate the first-year posttransplantation cost. Among them, the first-year posttransplantation drug costs and total health care costs of the kidney, heart, lung, liver, and other organ transplantations were (m NTs) 346,396.6+/-170,806.9 and 404,241.9+/-182,499.1, 242,878.5+/-128,772.7 and 302,325+/-129,609.9, 345,792+/-185,940.8 and 387,840.5+/-184,244.5, 404,441.8+/-299,311.7 and 471,631.5+/-306,936.3 and 40,718.2+/-50,740.2 and 67,469.8+/-70,765.7, respectively. Drug expenditures were approximately 80% of the total health care cost except for the other specified organ transplant, i.e., bone marrow, wherein they were 60%. The mean differences between drug expenditures and total costs of various organ transplants were significant (P<.01; ANOVA). Despite the first-year health care cost a the posttransplantation patient being less than dialysis costs in Taiwan, most end-stage renal disease patients are still a waiting organ donation; therefore, some candidates are seeking a transplants outside Taiwan.

Influence of the psychological state of relatives on the quality of life of patients at 1 year after transplantation.

We analyzed the influence of the psychological state of relatives on the quality of life of patients at 1 year after transplantation. We selected 2 groups: 94 transplant patients (47.9% liver, 40.4% kidney, and 11.7% heart) of mean age 49.42 years (SD, 11.21 years) and their close relatives (n = 94). All participants were assessed at 1 year after transplantation, using a Psychological Survey (both groups); the Hospital Anxiety and Depression Scale and the Quality of Life Questionnaire (transplant patients); and the Leeds Scales for the Self-Assessment of Anxiety and Depression (relatives). The results revealed that transplant patients whose relatives had more symptoms of anxiety and depression at 1 year after transplantation showed a decreased quality of life.