Research Spotlight

Sheehy, A. M., A. L. Masica and S. S. Shah (2020). “Next Steps for Next Steps: The Intersection of Health Policy with Clinical Decision-Making.” J Hosp Med 15(1): 5.

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The Journal of Hospital Medicine introduced the Choosing Wisely: Next Steps in Improving Healthcare Value series in 2015 as a companion to the popular Choosing Wisely: Things We Do for No Reason series that was introduced in October in the same year. Both series were created in partnership with the American Board of Internal Medicine Foundation and were designed in the spirit of the Choosing Wisely campaign’s mission to “promote conversations between clinicians and patients” in choosing care supported by evidence that minimizes harm, including avoidance of unnecessary treatments and tests. The Choosing Wisely: Next Steps in Improving Healthcare Value series extends these principles as a forum for manuscripts that focus on translating value-based concepts into daily operations, including systems-level care delivery redesign initiatives, payment model innovations, and analyses of relevant policies or practice trends. Since its inception, Choosing Wisely: Next Steps in Improving Healthcare Value manuscripts have been published, encompassing a wide range of topics such as post-acute care transitions,4 the role of hospital medicine practice within accountable care organizations (ACOs),5 and quality and value at end-of-life. Few physicians receive health policy training. Hospital medicine practitioners are a core component of the workforce, driving change and value-based improvements at almost every inpatient facility across the country. Regardless of their background or experience, hospital medicine practitioners must interface with legislation, regulation, and other policies every day while providing patient care. Intentional, value-based improvements are more likely to succeed if those providing direct patient care understand health policies, particularly the effects of those policies on transactional, point-of-care decisions. We are pleased to expand the Choosing Wisely: Next Steps in Improving Healthcare Value series to include articles exploring health policy implications at the bedside. (Excerpt from text, p. 5; no abstract available.)

Shahbazov, R., B. Naziruddin, O. Salam, G. Saracino, M. F. Levy, E. Beecherl and N. Onaca (2020). “The impact of surgical complications on the outcome of total pancreatectomy with islet autotransplantation.” Am J Surg 219(1): 99-105.

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Total pancreatectomy with islet autotransplantation is a promising treatment for refractory chronic pancreatitis. We analyzed postoperative complications in 83 TPIAT patients and their impact on islet graft function. We examined patient demographics, preoperative risk factors, intraoperative variables, and 30- and 90-day postoperative morbidity and mortality. Daily insulin requirement, HbA1c, C-peptide levels, and narcotic requirements were analyzed before and after surgery. Adverse events were recorded, with postoperative complications graded according to the Clavien-Dindo classification. There was no mortality in this patient group. Postoperative complications occurred in 38 patients (45.7%). Patients with postoperative complications were readmitted significantly more often within 30 days (p=0.01) and 90 days posttransplant (p<0.0003) and had a significantly longer hospital stay (p=0.004) and intensive care unit stay (p=0.001). Insulin dependence and graft function assessed by HbA1c, C-Peptide and insulin requirements did not differ significantly by these complications. Postoperative complications after TPIAT are associated with longer hospital and intensive care unit stay and with readmission; however, the surgical complications do not affect islet graft function.

Shadman, M., D. G. Maloney, B. Storer, B. M. Sandmaier, T. R. Chauncey, N. Smedegaard Andersen, D. Niederwieser, J. Shizuru, B. Bruno, M. A. Pulsipher, R. T. Maziarz, E. D. Agura, P. Hari, A. A. Langston, M. B. Maris, P. A. McSweeney, R. Storb and M. L. Sorror (2020). “Rituximab-based allogeneic transplant for chronic lymphocytic leukemia with comparison to historical experience.” Bone Marrow Transplant 55(1): 172-181.

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Relapse of chronic lymphocytic leukemia (CLL) after allogeneic hematopoietic cell transplantation (HCT) remains a clinical challenge. We studied in a phase II trial whether the addition of peri-transplant rituximab would reduce the relapse risk compared with historical controls (n = 157). Patients (n = 55) received fludarabine and low-dose total body irradiation combined with rituximab on days -3, + 10, + 24, + 36. Relapse rate at 3 years was significantly lower among rituximab-treated patients versus controls (17% versus 31%; P = 0.04). Overall survival (OS), progression-free survival (PFS) and nonrelapse mortality (NRM) were statistically similar: (53% versus 50%; P = 0.8), (44% versus 42%; P = 0.63), and (38% versus 28%; P = 0.2), respectively. In multivariate analysis, rituximab treatment was associated with lower relapse rates both in the overall cohort [hazard ratio (HR): 0.34, P = 0.006] and in patients with high-risk cytogenetics (HR: 0.21, P = 0.0003). Patients with no comorbidities who received rituximab conditioning had an OS rate of 100% and 75% at 1 and 3 years, respectively, with no NRM. Peri-transplant rituximab reduced relapse rates regardless of high-risk cytogenetics. HCT is associated with minimal NRM in patients without comorbidities and is a viable option for patients with high-risk CLL. Clinical trial information: NCT00867529.

Serper, M. and S. K. Asrani (2019). “Liver transplantation and chronic disease management: Moving beyond patient and graft survival.” Am J Transplant Dec 17. [Epub ahead of print].

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With advances in surgical techniques, multidisciplinary care and immunosuppression, patient and graft survival continue to improve in liver transplantation (LT). Excellent patient and graft survival have translated into an aging liver transplant recipient (LTRs) cohort that resembles a general chronic disease population. LTRs are becoming more medically complex related to LT indication (e.g. non-alcoholic fatty liver disease) and with increased prevalence of relevant chronic conditions such as chronic kidney disease.(Excerpt from text of this editorial.)

Sengupta, A., S. Zaid, N. Kamioka, J. Terre, M. Miyasaka, S. A. Hirji, M. Hensey, N. Geloo, G. Petrossian, N. Robinson, E. Sarin, L. Ryan, S. H. Yoon, C. W. Tan, O. K. Khalique, S. K. Kodali, T. Kaneko, P. B. Shah, S. C. Wong, A. Salemi, K. Sharma, J. A. Kozina, M. A. Szerlip, C. W. Don, S. Gafoor, M. Zhang, Z. Newhart, S. R. Kapadia, S. L. Mick, A. Krishnaswamy, A. Kini, H. Ahmad, S. L. Lansman, M. J. Mack, J. G. Webb, V. Babaliaros, V. H. Thourani, R. R. Makkar, M. B. Leon, I. George and G. H. L. Tang (2019). “Mid-Term Outcomes of Transcatheter Aortic Valve Replacement in Extremely Large Annuli With Edwards SAPIEN 3 Valve.” JACC Cardiovasc Interv Dec 18. [Epub ahead of print].

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OBJECTIVES: The aim of this study was to report the 1-year results of transcatheter aortic valve replacement (TAVR) with the Edwards SAPIEN 3 (S3) valve in extremely large annuli. BACKGROUND: Favorable 30-day outcomes of S3 TAVR in annuli >683 mm(2) have previously been reported. Pacemaker implantation rates were acceptable, and a larger left ventricular outflow tract and more eccentric annular anatomy were associated with increasing paravalvular leak. METHODS: From December 2013 to December 2018, 105 patients across 15 centers with mean area 721.3 +/- 36.1 mm(2) (range: 683.5 to 852.0 mm(2)) underwent TAVR using an S3 device. Clinical, anatomic, and procedural characteristics were analyzed. One-year survival and echocardiographic follow-up were reached in 94.3% and 82.1% of patients, respectively. Valve Academic Research Consortium-2 30-day and 1-year outcomes were reported. RESULTS: The mean age was 76.9 +/- 10.4 years, and Society of Thoracic Surgeons predicted risk score averaged 5.2 +/- 3.4%. One-year overall mortality and stroke rates were 18.2% and 2.4%, respectively. Quality-of-life index improved from baseline to 30 days and at 1 year (p < 0.001 for both). Mild paravalvular aortic regurgitation occurred in 21.7% of patients, while moderate or greater paravalvular aortic regurgitation occurred in 4.3%. Mild and moderate or severe transvalvular aortic regurgitation occurred in 11.6% and 0%, respectively. Valve gradients remained stable at 1 year. CONCLUSIONS: S3 TAVR in annular areas >683 mm(2) is feasible, with favorable mid-term outcomes.