Waitlist Placement Research Articles

#189 Aortic stenosis is an independent risk factor for mortality in end-stage kidney disease patients on the transplant waitlist

Abstract Background and Aims Valvular heart disease (VHD) is a risk factor for adverse outcomes in end-stage kidney disease (ESKD) patients. However, the impact of individual valvular heart lesions on outcomes in patients on the kidney transplant waitlist is unclear. This study aims to analyse the relationship between different VHD and all-cause mortality, and to determine the characteristics of patients on the transplant waitlist stratified by the different types of VHD. Method This was a single-center retrospective cohort study of ESKD patients who were referred for kidney transplant waitlist placement from May 2008 to February 2021 and had undergone baseline transthoracic echocardiogram (TTE). Significant VHD was defined as VHD of at least moderate severity based on TTE findings. Patients were followed up until death or kidney transplantation. Results Of the 512 patients included, 89 (17.4%) had significant VHD. Mean follow-up duration was 6.6 ± 3.3 years. Significant VHD included 46 (9.0%) tricuspid regurgitation (TR), 44 (8.6%) mitral regurgitation (MR), 11 (2.2%) aortic regurgitation (AR), 7 (1.4%) aortic stenosis (AS) and 2 (0.4%) mitral stenosis (MS). Of the different VHD (Table 1), only AS was associated with all-cause mortality (hazard ratio (HR) 2.41, 95% CI 1.53-3.78, p < 0.0001, Fig. 1) and remained significant after adjusting for age, diabetes mellitus (DM) and other cardiovascular diseases (CVD) (adjusted HR 1.71, 95% CI 1.07-2.73, p = 0.02). Risk factors associated with AS included older age (odds ratio (OR) 1.12, 95% CI 1.03-1.23, p = 0.01), history of CVD (OR 7.31, 95% CI 1.59-33.6, p = 0.01), longer dialysis vintage (OR 1.01, 95% CI 1.00-1.02, p = 0.02), previous parathyroidectomy (OR 15.1, 95% CI 2.68-85.4, p = 0.002) and higher corrected calcium (OR 43.9, 95% CI 1.56-1240, p = 0.03). Age (adjusted OR 1.12, 95% CI 1.02-1.24, p = 0.02), history of CVD (aOR 7.70, 95% CI 1.50-39.5, p = 0.02) and previous parathyroidectomy (aOR 11.8, 95% CI 1.83-76.7, p = 0.01) remained significant in the multivariable model. No specific risk factors were identified for the other valvular lesions. Conclusion AS appears to be an independent risk factor for all-cause mortality in ESKD patients on the transplant waitlist. Differences in mortality and risk factors associated with different types of VHD may suggest differing underlying pathophysiological mechanisms.

Quantifying the Effect of Consent for High-Kidney Donor Profile Index Deceased Donor Transplants in the United States.

Despite known benefits of kidney transplantation, including transplantation from donors with increased risk factors, many waitlisted candidates die prior to transplantation. Consent to receive donor kidneys with lower expected survival (e.g. kidney donor profile index [KDPI]>85%) is typically obtained at waitlist placement. The presumed benefit of consent to receive high-KDPI donor kidneys is increased likelihood and timeliness of donor offers for transplantation. However, the specific impact of consent on access to transplantation is unclear. Our aims were to evaluate the characteristics of candidates consenting to high-KDPI donor kidneys and the likelihood of receiving a deceased donor transplant (DDTX) over time based on consent. We used national Scientific Registry of Transplant Recipients data between 2015 and 2022(n=213,364). We evaluated the likelihood of consent using multivariable logistic models and time to DDTX with cumulative incidence plots accounting for competing risks and multivariable Cox models. Overall, high-KDPI consent was 41%, which was higher among candidates who were older, Black or Hispanic, had higher BMI, were diabetic, had vascular disease, and 12-48 months pre-listing dialysis time, with significant center-level variation. High-KDPI consent was associated with higher rates of DDTX(Adjusted Hazard Ratio=1.15,95% Confidence Interval=1.13,1.17) with no difference in likelihood of DDTX from donors with KDPI<85%. The effect of high-KDPI consent on higher rates of DDTx was higher among candidates ages >60 years and diabetic candidates and variable based on center characteristics. There is significant variation of consent for high-KDPI donor kidneys and higher likelihood of transplantation associated with consent.

Cardiac evaluation for end-stage kidney disease patients on the transplant waitlist: a single-center cohort study.

BackgroundCardiac evaluation before deceased donor kidney transplant (DDKT) remains a matter of debate. Data on Asian countries and countries with prolonged waiting times are lacking. This study aimed to assess the outcomes of patients referred for DDKT after a cardiac evaluation at an Asian tertiary transplant center.MethodsThis single-center retrospective review analyzed patients who were referred for waitlist placement and underwent cardiac stress testing between January 2009 and December 2015. Patients with cardiac symptoms were excluded. The primary outcome was three-point major adverse cardiovascular events (MACE), a composite of non-fatal myocardial infarction, non-fatal stroke, and cardiovascular death.ResultsOf 468 patients referred for DDKT, 198 who underwent cardiac stress testing (myocardial perfusion studies in 159 patients and stress echocardiography in 39 patients) were analyzed. MACE occurred in 20.7% of the patients over a median follow-up of 4.6 years. Cardiac stress tests were positive for ischemia in 19.7% of the patients. Coronary angiography was performed in 63 patients, including 29 patients with diabetic kidney disease and negative cardiac stress tests. Significant coronary artery disease (CAD) was detected in 27 patients (42.8%), of whom 18 underwent revascularization. MACE was associated with significant CAD on coronary angiography in the multivariable analysis. Cardiac stress test results were not associated with MACE. Amongst diabetic patients who had negative cardiac stress tests, 37.9% had significant CAD on coronary angiography.ConclusionsThe cardiovascular disease burden is significant amongst DDKT waitlist candidates. Pretransplant cardiac screening may identify patients with significant CAD at higher risk of MACE.

Geographic hot spots of kidney transplant candidates wait-listed post-dialysis.

Preemptive wait-listing of deceased donor kidney transplant (DDKT) candidates before maintenance dialysis increases the likelihood of transplantation and improves outcomes among transplant patients. Previous studies have identified substantial disparities in rates of preemptive listing, but a gap exists in examining geographic sources of disparities, particularly for sub-regional units. Identifying small area hot spots where delayed listing is particularly prevalent may more effectively inform both health policy and regionally appropriate interventions. We conducted a retrospective cohort study utilizing 2010-2020 Scientific Registry of Transplant Recipients (SRTR) data for all DDKT candidates to examine overall and race-stratified geospatial hot spots of post-dialysis wait-listing in U.S. zip code tabulation areas (ZCTA). Three geographic clustering methods were utilized to identify robust statistically significant hot spots of post-dialysis wait-listing. Novel sub-regional hot spots were identified in the southeast, southwest, Appalachia, and California, with a majority existing in the southeast. Race-stratified results were more nuanced, but broadly reflected similar patterns. Comparing transplant candidates in hot spots to candidates in non-clusters indicated a strong association between residence in hot spots and high area deprivation (OR: 6.76, 95%CI: 6.52-7.02), indicating that improving access healthcare in these areas may be particularly beneficial. Our study identified overall and race-stratified hot spots with low rates of preemptive wait list placement in the U.S., which may be useful for prospective healthcare policy and interventions via targeting of these narrowly defined geographical areas.

A tool for decision-making in kidney transplant candidates with poor prognosis to receive deceased donor transplantation in the United States

The primary outcomes for kidney transplant candidates are receipt of deceased or living donor transplant, death or removal from the waiting list. Here, we conducted a retrospective analysis of national Scientific Registry of Transplant Recipients data to evaluate outcomes for 208,717 adult kidney transplant candidates following the 2014 Kidney Allocation System in the United States. Competing risks models were utilized to evaluate Time to Equivalent Risk (TiTER) of deceased donor transplantation (DDTX) and death versus waitlist removal. We also evaluated TiTER based on kidney donor profile index (KDPI) and donor age. For all groups, the cumulative incidence of DDTX was initially higher from time of listing than death or waitlist removal. However, following accrued time on the waiting list, the cumulative incidence of death or waitlist removal exceeded DDTX for certain patient groups, particularly older, diabetic, blood type B and O and shorter pre-listing dialysis time. TiTER for all candidates aged 65-69 averaged 41 months and for 70 and older patients 28 months. Overall, 39.6% of candidates were in risk groups with TiTER under 72 months and 18.5% in groups with TiTER under 24 months. Particularly for older candidates, TiTER for kidneys was substantially shorter for younger donors or lower KDPI. Thus, our findings reveal that a large proportion of wait-listed patients in the United States have poor prognoses to ever undergo DDTX and our data may improve shared decision-making for candidates at time of waitlist placement. Hence, for specific patient groups, TiTER may be a useful tool to disseminate and quantify benefits of accepting relatively high risk donor organs.

Black Patients Have Unequal Access to Listing for Liver Transplantation in the United States.

The Model for End-Stage Liver Disease score may have eliminated racial disparities on the waitlist for liver transplantation (LT), but disparities prior to waitlist placement have not been adequately quantified. We aimed to analyze differences in patients who are listed for LT, undergo transplantation, and die from end-stage liver disease (ESLD), stratified by state and race/ethnicity. We analyzed two databases retrospectively, the Center for Disease Control Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) and the United Network for Organ Sharing (UNOS) databases, from 2014 to 2018. We included patients aged 25-64years who had a primary cause of death of ESLD and were listed for transplant in the CDC WONDER or UNOS database. Our primary outcome was the ratio of listing for LT to death from ESLD-listing to death ratio (LDR). Our secondary outcome was the transplant to listing and transplant to death ratios. Chi-squared and multivariable linear regression evaluated for differences between races/ethnicities. There were 135,367 patients who died of ESLD, 54,734 patients who were listed for transplant, and 26,571 who underwent transplant. Patients were mostly male and White. The national LDR was 0.40, significantly lowest in Black patients (0.30), P<0.001. The national transplant to listing ratio was 0.48, highest in Black patients (0.53), P<0.01. The national transplant to death ratio was 0.20, lowest in Black patients (0.16), P<0.001. States that had an above-mean LDR had a lower transplant to listing ratio but a higher transplant to death ratio. Multivariable analysis confirmed that Black race is significantly associated with a lower LDR and transplant to death ratio. Black patients face a disparity in access to LT due to low listing rates for transplant relative to deaths from ESLD.

Patients with High Priority for Kidney Transplant Who Are Not Given Expedited Placement on the Transplant Waiting List Represent Lost Opportunities.

Kidney transplantation is associated with the best outcomes for most patients with ESKD. The national Kidney Allocation System prioritizes patients with Estimated Post-Transplant Survival (EPTS) scores in the top 20% for expedited access to optimal deceased donor kidneys. We studied adults aged ≥18 years in the United States Renal Data System with top 20% EPTS scores who had been preemptively waitlisted or initiated dialysis in 2015-2017. We evaluated time to waitlist placement, transplantation, and mortality with unadjusted and multivariable survival models. Of 42,445 patients with top 20% EPTS scores (mean age, 38.0 years; 57% male; 59% White patients, and 31% Black patients), 7922 were preemptively waitlisted. Among 34,523 patients initiating dialysis, the 3-year cumulative waitlist placement incidence was 37%. Numerous factors independently associated with waitlisting included race, income, and having noncommercial insurance. For example, waitlisting was less likely for Black versus White patients, and for patients in the lowest-income neighborhoods versus those in the highest-income neighborhoods. Among patients initiating dialysis, 61% lost their top 20% EPTS status within 30 months versus 18% of patients who were preemptively listed. The 3-year incidence of deceased and living donor transplantation was 5% and 6%, respectively, for patients who initiated dialysis and 26% and 44%, respectively, for patients who were preemptively listed. Many patients with ESKDqualifying with top 20% EPTS status are not placed on the transplant waiting list in a timely manner, with significant variation on the basis of demographic and social factors. Patients who are preemptively listed are more likely to receive benefits of top 20% EPTS status. Efforts to expedite care for qualifying candidates are needed, and automated transplant referral for patients with the best prognoses should be considered. This article contains a podcast athttps://www.asn-online.org/media/podcast/JASN/2021_07_30_JASN2020081146.mp3.

Cumulative Deficits Frailty Index Predicts Outcomes for Solid Organ Transplant Candidates.

In this retrospective cohort study of solid organ transplant candidates from Toronto General Hospital, cumulative deficits FI and SVI were created from data collected during candidacy evaluations for consecutive kidney, heart, liver, and lung transplant candidates. Regression modeling measured associations between the FI and transplant listing, death or removal from the transplant waitlist, and survival after waitlist placement. For 794 patients, 40 variable FI and 10 variable SVI were created (258 lung, 222 kidney, 201 liver, and 113 heart transplant candidates). The FI correlated with assessment outcomes; patients with medical contraindications (mean FI 0.35 ± 0.10) had higher FI scores than those listed (0.29 ± 0.09), P < 0.001. For listed patients, adjusted for age, sex, transplant type, and SVI, higher FI was associated with an increased risk of death (pretransplant or posttransplant) or delisting (hazard ratio 1.03 per 0.01 FI score, 95% confidence interval, 1.01-1.05, P = 0.01). A cumulative deficits FI can be derived from routine organ transplant candidacy evaluations and may identify candidates at higher risk of adverse outcomes.

Kidney Transplant Evaluation and Listing: Development and Preliminary Evaluation of Multimedia Education for Patients.

BackgroundPatient knowledge gaps about the evaluation and waitlisting process for kidney transplantation lead to delayed and incomplete testing, which compromise transplant access. We aimed to develop and evaluate a novel video education approach to empower patients to proceed with the transplant evaluation and listing process and to increase their knowledge and motivation.Material/MethodsWe developed 2 theory-informed educational animations about the kidney transplantation evaluation and listing process with input from experts in transplantation and communication, 20 candidates/recipients, 5 caregivers, 1 anthropologist, 3 community advocates, and 36 dialysis or transplant providers. We then conducted an online pre-post study with 28 kidney transplantation candidates to measure the acceptability and feasibility of the 2 videos to improve patients’ evaluation and listing knowledge, understanding, and concerns.ResultsCompared with before intervention, the mean knowledge score increased after intervention by 38% (5.7 to 7.9; P<0.001). Increases in knowledge effect size were large across age group, health literacy, education, technology access, and duration of pretransplant dialysis. The proportion of positive responses increased from before to after animation viewing for understanding the evaluation process (25% to 61%; P=0.002) and waitlist placement (32% to 86%; P<0.001). Concerns about list placement decreased (32% to 7%; P=0.039). After viewing the animations, >90% of responses indicated positive ratings on trusting the information, comfort level with learning, and engagement.ConclusionsIn partnership with stakeholders, we developed 2 educational animations about kidney transplant evaluation and listing that were positively received by patients and have the potential to improve patient knowledge and understanding and reduce patient concerns.

Maintaining Equity and Access: Successful Implementation of a Virtual Kidney Transplantation Evaluation

Maintaining access to kidney transplantation during a pandemic is a challenge, particularly for centers that serve a large rural and minority patient population with an additional burden of travel. The aim of this article was to describe our experience with the rollout and use of a virtual pretransplantation evaluation platform to facilitate ongoing transplant waitlisting during the early peak of the COVID-19 pandemic. This is a retrospective analysis of the process improvement project implemented to continue the evaluation of potential kidney transplantation candidates and ensure waitlist placement during the COVID-19 pandemic. Operational metrics include transplantation volume per month, referral volume per month, pretransplantation patients halted before completing an evaluation per month, evaluations completed per month, and patients waitlisted per month. Between April and September 2020, a total of 1,258 patients completed an evaluation. Two hundred and forty-seven patients were halted during this time period before completing a full evaluation. One hundred and fifty-two patients were presented at selection and 113 were placed on the waitlist. In addition, the number of patients in the active referral phase was able to be reduced by 46%. More evaluations were completed within the virtual platform (n=930 vs n= 880), yielding similar additions to the waitlist in 2020 (n= 282) vs 2019 (n= 308) despite the COVID-19 pandemic. The virtual platform allowed continued maintenance of a large kidney transplantation program despite the inability to have in-person visits. The value of this platform will likely transform our approach to the pretransplantation process and provides an additional valuable method to improve patient equity and access to transplantation.

Consequences of Extended Spectrum Beta-Lactamase-Producing Enterobacteriaceae and Methicillin-Resistant Staphylococcus aureus Carriage in Awaiting Liver Transplant Patients.

Infections in patients with cirrhosis are associated with liver-related complications (LRCs), especially in patients awaiting liver transplantation (LT). The aim of this study was to evaluate the impact of methicillin-resistant Staphylococcus aureus (MRSA) and extended spectrum beta-lactamase colonization on infections and LRCs for patients on the wait list and on infections after LT. We retrospectively included 250 of 483 patients with cirrhosis who were placed on the wait list for LT from December 2015 to January 2018. These patients were screened for MRSA or extended spectrum beta-lactamase-producing Enterobacteriaceae (ESBLE) at the time of wait-list placement and after LT. Of the patients, 76% were male with a mean age of 57.5±10 years, and the most frequent cause of liver disease was alcohol (39%). Median Model for End-Stage Liver Disease (MELD) score was 19 (12-28). Only 1 patient was positive for MRSA; 19% of patients (n=47) had ESBLE fecal carriage at the time of wait-list placement and 15% (n=37) had it after LT. Infection-free survival on the wait list and after LT, according to fecal carriage status, was not statistically different between 2 groups. LRC-free survival at 6 and 12months was significantly lower in ESBLE fecal carriage (HR, 1.6; P =0.04). MELD score >19 (HR, 3.0; P=0.01) and occurrence of infection during the first 3months on the wait list (HR, 4.13; P<0.001) were independent risk factors for LRC occurrence in the multivariate analysis. Our study is the first showing that in a cohort of patients with cirrhosis waiting for LT LRC-free survival was lower in patients with ESBLE fecal carriage but that infection-free survival was not different between the 2 groups.

Bariatric Surgery for Congestive Heart Failure Patients Improves Access to Transplantation and Long-term Survival

IntroductionObese patients with congestive heart failure (CHF) are often denied access to heart transplantation until they obtain significant weight loss to achieve a certain BMI threshold, often less than 35 kg/m2. It is unknown whether the rapid weight loss associated with bariatric surgery leads to improved waitlist placement, and as such improved survival for morbidly obese patients with CHF. MethodsA decision analytic Markov state transition model was created to simulate the life of morbidly obese patients with CHF who were deemed ineligible to be waitlisted for heart transplantation unless they achieved a BMI less than 35 kg/m2. Life expectancy following medical weight management (MWM), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) was estimated. Base case patients were defined as having a pre-intervention BMI of 45 kg/m2. Sensitivity analysis of initial BMI was performed. Markov parameters were extracted from literature review. ResultsRYGB improved survival compared with both SG and MWM. RYGB patients had higher rates of transplantation, leading to improved mean long-term survival. Base case patients who underwent RYGB gained 2.1 additional years of life compared with patient’s who underwent SG and 7.4 additional years of life compared with MWM. SG patients gained 5.3 years of life compared with MWM. ConclusionsWhen strict waitlist criteria were applied, bariatric surgery improved access to heart transplantation and thereby increased long-term survival compared with MWM. Morbidly obese CHF patients who anticipate need for heart transplantation should be encouraged to pursue surgical weight management strategies, necessitating discussion between bariatric surgeons, cardiologists, and cardiac surgeons for appropriate perioperative risk management.

Rates and reasons for emergency department presentations of patients wait-listed for public bariatric surgery in Tasmania, Australia

BackgroundDemand for bariatric surgery in the public hospital setting in Australia is high with prolonged wait-list times. Policy-makers need to consider the consequences of expanding public bariatric surgery including on emergency department (ED) presentations. AimsTo describe and evaluate public ED presentation rates and reasons for presenting in a cohort of patients wait-listed for public surgery. MethodsAll Tasmanians placed on the public wait-list for primary bariatric surgery in 2008–2013 were identified using administrative datasets along with their ED presentations in 2000–2014. The presentations were assigned to one of three periods: before wait-list placement, whilst on the wait-list, and after wait-list removal for publicly-funded surgery or drop-out. A negative binomial mixed-effects regression model was used to derive ED presentation incidence rate ratios (IRR) to compare observation periods and patient groups. Results652 wait-listed patients had 5149 public ED presentations. 178 patients had publicly-funded bariatric surgery — all as laparoscopically adjustable gastric banding (LAGB). Overall, ED presentation rates did not change significantly post-surgery compared with the waiting period (IRR 1.19, 95%CI 0.90–1.56). Presentation rates significantly increased for digestive system (IRR 2.02, 95%CI 1.19–3.45) and psychiatric diseases (IRR 4.85, 95%CI 1.06–22.26) after surgery. The likelihood of being admitted from the ED significantly increased after surgery (31.7%–38.9%, p<0.05). ConclusionED presentations were common for patients wait-listed for public bariatric surgery and rates did not decrease over an average of three years post-LAGB. The likelihood of being admitted to the hospital from the ED increased after surgery.

Socioeconomic Inequalities in the Kidney Transplantation Process: A Registry-Based Study in Sweden.

Few studies have examined the association between individual-level socioeconomic status and access to kidney transplantation. This study aims to investigate the association between predialysis income and education, and access to (i) the kidney waitlist (first listing), and (ii) kidney transplantation conditional on waitlist placement. Adjustment will be made for a number of medical and nonmedical factors. The Swedish Renal Register was linked to national registers for adult patients in Sweden who started dialysis during 1995 to 2013. We employed Cox proportional hazards models. Nineteen per cent of patients were placed on the waitlist. Once on the waitlist, 80% received kidney transplantation. After adjusting for covariates, patients in the highest income quintile were found to have higher access to both the waitlist (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.53-1.96) and kidney transplantation (HR, 1.33; 95% CI, 1.16-1.53) compared with patients in the lowest income quintile. Patients with higher education also had better access to the waitlist and kidney transplantation (HR, 2.16; 95% CI, 1.94-2.40; and HR, 1.16; 95% CI, 1.03-1.30, respectively) compared with patients with mandatory education. Socioeconomic status-related inequalities exist with regard to both access to the waitlist, and kidney transplantation conditional on listing. However, the former inequality is substantially larger and is therefore expected to contribute more to societal inequalities. Further studies are needed to explore the potential mechanisms and strategies to reduce these inequalities.

Twenty-Year Comparative Analysis of Patients With Autoimmune Liver Diseases on Transplant Waitlists

The rarity of autoimmune liver disease poses challenges to epidemiology studies. However, waitlists for liver transplantation can be used to study patients with end-stage liver diseases. We used these waitlists to assess trends in numbers and demographics of patients awaiting liver transplant for primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), or autoimmune hepatitis (AIH). We collected data from UK and US national registries for all adults on liver transplant waitlists, from January 1, 1995, through December 31, 2014. We analyzed data from patients with PBC (n= 1434 in the United Kingdom and n= 5598 in the United States), PSC (n= 1093 in the United Kingdom and n= 6820 in the United States), and AIH (n= 538 in the United Kingdom and n= 4949 in the United States). Numbers of listings per year were adjusted to the estimated populations during each year. Regression analyses were used to examine trends and comparative statistics were used to evaluate differences in individual characteristics among groups. Over the total study period, listings for PBC were 1.2 and 1.0 per million population per year in the United Kingdom and United States, respectively; for PSC, 0.9 and 1.2 per million population per year; and for AIH, 0.5 and 0.8 per million population per year. Over the period studied, numbers of listings for PBC decreased by 50% in both countries; changes in numbers of listings for PSC and AIH were smaller and not consistent between countries. By 2014, PSC had become the leading indication for liver transplantation among patients with autoimmune liver diseases in both countries. Median patient ages at time of listing were lower than those reported as median age of diagnosis for AIH and PBC. The ratio of women:men with PBC decreased by almost 50% from 1995 through 2014. Men with PSC were placed on the waitlist with higher disease severity scores than women in both countries. Among patients with PBC, those of black race were under-represented on waitlists from both countries. Among patients with PSC, Hispanics were under-represented on waitlists in the United States. Patients of non-white races were placed on waitlists at younger ages for all diseases; age differences in waitlist placement varied by up to 10 years, depending on race, among patients with PBC. In an analysis of data collected from UK and US national liver transplant registries over 20 years, we found that PSC has become the leading indication for liver transplantation among patients with autoimmune liver diseases. Numbers of patients with PBC placed on waitlists, and the ratio of women:men with PBC, each decreased by almost 50%, possibly due to increased treatment with ursodeoxycholic acid. Within groups of patients on the transplant waitlist for PBC, PSC, or AIH, we found differences in age, sex, disease severity scores, and ethnicity between diseases and countries that require further study.

Factors Associated with Residential Long-Term Care Wait-List Placement in North West Ontario.

This article is based on a study that investigated factors associated with long-term care wait list placement in Ontario, Canada. We based the study's analysis on Resident Assessment Instrument for Home Care (RAI-HC) data for 2014 in the North West Local Health Integration Network (LHIN). Our analysis quantified the contribution of three factors on the likelihood of wait list placement: (1) care recipient, (2) informal caregiver, and (3) formal system. We find that all three factors are significantly related to wait list placement. The results of this analysis could have implications for policies aimed at reducing the number of wait-listed individuals in the community.

Why wait? The effect of wait-times on subsequent help-seeking among families looking for children's mental health services.

Placement on a wait-list may increase families' help-seeking efforts, leading them to contact more than one children's mental health (MH) agency/professional. Two issues were examined in the current study: 1) Does time on a wait-list for families impact the time to contact a new agency for children's MH services? 2) What are the effects of predisposing (e.g., child age), need (e.g., child psychopathology), and enabling/system-level factors (e.g., parent treatment history) on the length of time parents wait before they contact a new agency for help with their child's MH problems? A total of 273 families seeking help for their child (64% boys, M = 10.7 years old, SD = 3.3) were asked about their contact with MH agencies/professionals during the previous year. Survival analyses, modeling time from initial wait-list placement to when a new agency was contacted, were conducted separately for families who did (n = 114), and those who did not (n = 159), receive help prior to contacting a new agency. Almost half of wait-listed families contacted a new agency by the end of the study period. Longer wait-time was associated with a greater likelihood of seeking help at a second agency with 25% of families contacting a new agency within the first month of being wait-listed. Parents with previous treatment experience and families living in areas with more agencies contacted a new agency sooner. Subsequent help-seeking behaviour suggests parents' intolerance for lengthy treatment delays may result in disorganized pathways to care. These findings suggest a highly fragmented service delivery system.

Association of Distance From a Transplant Center With Access to Waitlist Placement, Receipt of Liver Transplantation, and Survival Among US Veterans

Centralization of specialized health care services such as organ transplantation and bariatric surgery is advocated to improve quality, increase efficiency, and reduce cost. The effect of increased travel on access and outcomes from these services is not fully understood. To evaluate the association between distance from a Veterans Affairs (VA) transplant center (VATC) and access to being waitlisted for liver transplantation, actually having a liver transplant, and mortality. Retrospective study of veterans meeting liver transplantation eligibility criteria from January 1, 2003, until December 31, 2010, using data from the Veterans Health Administration's integrated, national, electronic medical record linked to Organ Procurement and Transplantation Network data. The primary outcome was being waitlisted for transplantation at a VATC. Secondary outcomes included being waitlisted at any transplant center, undergoing a transplantation, and survival. From 2003-2010, 50,637 veterans were classified as potentially eligible for transplant; 2895 (6%) were waitlisted and 1418 of those were waitlisted (49%) at 1 of the 5 VATCs. Of 3417 veterans receiving care at a VA hospital located within 100 miles from a VATC, 244 (7.1%) were waitlisted at a VATC and 372 (10.9%) at any transplant center (VATC and non-VATCs). Of 47,219 veterans receiving care at a VA hospital located more than 100 miles from a VATC, 1174 (2.5%) were waitlisted at a VATC and 2523 (5.3%) at any transplant center (VATC and non-VATCs). In multivariable models, increasing distance to closest VATC was associated with significantly lower odds of being waitlisted at a VATC (odds ratio [OR], 0.91 [95% CI, 0.89-0.93] for each doubling in distance) or any transplant center (OR, 0.94 [95% CI, 0.92-0.96] for each doubling in distance). For example, a veteran living 25 miles from a VATC would have a 7.4% (95% CI, 6.6%-8.1%) adjusted probability of being waitlisted, whereas a veteran 100 miles from a VATC would have a 6.2% (95% CI, 5.7%-6.6%) adjusted probability. In adjusted models, increasing distance from a VATC was associated with significantly lower transplantation rates (subhazard ratio, 0.97; 95% CI, 0.95-0.98 for each doubling in distance). There was significantly increased mortality among waitlisted veterans from the time of first hepatic decompensation event in multivariable survival models (hazard ratio, 1.03; 95% CI, 1.01-1.04 for each doubling in distance). For example, a waitlisted veteran living 25 miles from a VATC would have a 62.9% (95% CI, 59.1%-66.1%) 5-year adjusted probability of survival from first hepatic decompensation event compared with a 59.8% (95% CI, 56.3%-63.1%) 5-year adjusted probability of survival for a veteran living 100 miles from a VATC. Among VA patients meeting eligibility criteria for liver transplantation, greater distance from a VATC or any transplant center was associated with lower likelihood of being waitlisted, receiving a liver transplant, and greater likelihood of death. The relationship between these findings and centralizing specialized care deserves further investigation.

Printed quit-pack sent to surgical patients at time of waiting list placement improved perioperative quitting

This study aimed to measure the effects of sending a smoking cessation 'quit-pack' to all patients placed on the elective surgical waiting list. Questionnaire-based study before intervention (mid-2011, 177 patients) and after (2012/13, 170 patients) conducted on day of surgery. All were identified as adult smokers at time of waiting list placement at an outer metropolitan Melbourne public hospital. The intervention was a quit-pack consisting of educational brochure containing cessation advice and focused on perioperative risks of smoking, together with Quitline referral form and reply-paid envelope. The primary outcome measure was proportion of smokers who quit on waiting list for ≥1 month before surgery, considered a clinically meaningful duration to reduce surgical complications. An 8.6% improvement in waiting list smokers achieving the target ≥1 month abstinence at day of surgery (P = 0.03). The number needed to treat of 12 (95% confidence interval 6-240) meant 12 smokers receiving intervention would create one additional episode of clinically meaningful quitting on wait list. Smoking cessation outcomes before elective surgery are significantly improved by systematic application of a printed intervention delivered at time of wait list placement that encourages and supports perioperative quitting.

Smokers know little of their increased surgical risks and may quit on surgical advice

Smoking cessation before surgery improves perioperative outcomes and some smokers may quit if undergoing surgery. Quitting smoking in community settings is influenced by physician quit advice and knowledge of smoking hazards, but there are few data on whether this applies in perioperative settings. Survey on day of surgery of elective patients who reported being a smoker at the time of wait-list placement. Duration of smoking abstinence before surgery (if any) and length timing of failed quit attempts was determined. Sources of any quit advice before surgery, including from physicians, and patient knowledge on hazards of smoking and surgery were questioned. While on the waiting list, 44/177 smokers reported quitting (>24 h) before surgery and 42/177 others made an attempt. Quitting was usually brief. Fewer than 40% of smokers answered yes (correct answer) to questions on whether smoking increased wound infection rates, worsened wound healing, increased anaesthetic complications or increased post-operative pain. Incorrect answers (no) were less likely in quitters than those smoking until surgery (OR 0.41, 95% CI 0.25-0.68). Patients still smoking by admission recalled quit advice from a surgeon in 22.6% of cases, while wait-list quitters recalled surgical quit advice in 43.2% of cases (OR 2.6 95% CI 1.2-5.4 P = 0.01). Effects of general practitioner quit advice were significant (OR 3.2 95% CI 1.5-6.8 P = 0.004) while anaesthetists, nurse and hospital brochure advice were not. Improving patient knowledge of the perioperative risks of smoking and increased physician advice to quit may improve smoking abstinence at surgery.