Research Spotlight

Little, A., K. Brower, D. Keller, B. Ramshaw and J. E. Janis (2019). “A Cost-Minimization Analysis Evaluating the Use of Liposomal Bupivacaine in Reconstructive Plastic Surgery Procedures.” Plast Reconstr Surg 143(4): 1269-1274.

Full text of this article.

BACKGROUND: Postsurgical pain management is critical to patient satisfaction and value. Several studies have evaluated liposomal bupivacaine in postoperative pain management protocols; however, its economic feasibility remains undefined. This study analyzes the economic impact of liposomal bupivacaine using a national claims database to assess postoperative clinical and financial outcomes in plastic and reconstructive procedures. METHODS: The Vizient Clinical Data Base/Resource Manager electronic database was reviewed for plastic surgery procedures (i.e., abdominoplasty, abdominal wall reconstruction, mastectomy with immediate tissue expander placement, mastectomy with direct-to-implant reconstruction, autologous breast reconstruction, and augmentation mammaplasty) at participating hospitals from July 1, 2016, to July 1, 2017. The main outcome measures were the length of stay; 7-, 14-, and 30-day readmission rates; and direct and total costs observed. RESULTS: During the study period, 958 total cases met inclusion criteria. Liposomal bupivacaine was used in 239 cases (25 percent). Compared with cases that did not use liposomal bupivacaine, liposomal bupivacaine cases had a decreased length of stay (9.2 days versus 5.8 days), decreased cost (total cost, $39,531 versus $28,021; direct cost, $23,960 versus $17,561), and lower 30-day readmission rates (4 percent versus 0 percent). The 14- and 7-day readmission rates were similar between the two groups. CONCLUSIONS: The use of liposomal bupivacaine may contribute to a reduction in length of stay, hospital costs, and 30-day readmission rates for abdominal and breast reconstructive procedures, which could contribute to a favorable economic profile from a system view. Focusing on the measurement and improvement of value in the context of whole, definable, patient processes will be important as we transition to value-based payments.

Kobashigawa, J., D. Dadhania, S. Bhorade, D. Adey, J. Berger, G. Bhat, M. Budev, A. Duarte-Rojo, M. Dunn, S. Hall, M. N. Harhay, K. L. Johansen, S. Joseph, C. C. Kennedy, E. Kransdorf, K. L. Lentine, R. J. Lynch, M. McAdams-DeMarco, S. Nagai, M. Olymbios, J. Patel, S. Pinney, J. Schaenman, D. L. Segev, P. Shah, L. G. Singer, J. P. Singer, C. Sonnenday, P. Tandon, E. Tapper, S. G. Tullius, M. Wilson, M. Zamora and J. C. Lai (2019). “Report from the American Society of Transplantation on frailty in solid organ transplantation.” Am J Transplant 19(4): 984-994.

Full text of this article.

A consensus conference on frailty in kidney, liver, heart, and lung transplantation sponsored by the American Society of Transplantation (AST) and endorsed by the American Society of Nephrology (ASN), the American Society of Transplant Surgeons (ASTS), and the Canadian Society of Transplantation (CST) took place on February 11, 2018 in Phoenix, Arizona. Input from the transplant community through scheduled conference calls enabled wide discussion of current concepts in frailty, exploration of best practices for frailty risk assessment of transplant candidates and for management after transplant, and development of ideas for future research. A current understanding of frailty was compiled by each of the solid organ groups and is presented in this paper. Frailty is a common entity in patients with end-stage organ disease who are awaiting organ transplantation, and affects mortality on the waitlist and in the posttransplant period. The optimal methods by which frailty should be measured in each organ group are yet to be determined, but studies are underway. Interventions to reverse frailty vary among organ groups and appear promising. This conference achieved its intent to highlight the importance of frailty in organ transplantation and to plant the seeds for further discussion and research in this field.

Kobashigawa, J., D. Dadhania, S. Bhorade, D. Adey, J. Berger, G. Bhat, M. Budev, A. Duarte-Rojo, M. Dunn, S. Hall, M. N. Harhay, K. L. Johansen, S. Joseph, C. C. Kennedy, E. Kransdorf, K. L. Lentine, R. J. Lynch, M. McAdams-DeMarco, S. Nagai, M. Olymbios, J. Patel, S. Pinney, J. Schaenman, D. L. Segev, P. Shah, L. G. Singer, J. P. Singer, C. Sonnenday, P. Tandon, E. Tapper, S. G. Tullius, M. Wilson, M. Zamora and J. C. Lai (2019). “Report from the American Society of Transplantation on frailty in solid organ transplantation.” Am J Transplant 19(4): 984-994.

Full text of this article.

A consensus conference on frailty in kidney, liver, heart, and lung transplantation sponsored by the American Society of Transplantation (AST) and endorsed by the American Society of Nephrology (ASN), the American Society of Transplant Surgeons (ASTS), and the Canadian Society of Transplantation (CST) took place on February 11, 2018 in Phoenix, Arizona. Input from the transplant community through scheduled conference calls enabled wide discussion of current concepts in frailty, exploration of best practices for frailty risk assessment of transplant candidates and for management after transplant, and development of ideas for future research. A current understanding of frailty was compiled by each of the solid organ groups and is presented in this paper. Frailty is a common entity in patients with end-stage organ disease who are awaiting organ transplantation, and affects mortality on the waitlist and in the posttransplant period. The optimal methods by which frailty should be measured in each organ group are yet to be determined, but studies are underway. Interventions to reverse frailty vary among organ groups and appear promising. This conference achieved its intent to highlight the importance of frailty in organ transplantation and to plant the seeds for further discussion and research in this field.

Klintmalm, G. B., B. Kaplan and A. D. Kirk (2019). “FDA jeopardizes the lives of lung transplant recipients and in the process severely increases the cost to develop new immunosuppression.” Am J Transplant 19(4): 971-972.

Full text of this article.

The current FDA rules that prohibit the use of mycophenolate or azathioprine in lung transplant recipients substantially increase the likelihood that these patients will develop allograft rejection and die. Triple‐drug immunosuppression is standard in all other organs transplanted and has time and again been shown to not only improve survival but also reduce drug toxicity by allowing lower doses of the other immunosuppressants (calcineurin inhibitors and steroids). Additionally, mandating exceptionally expensive phase 3 registration trials for each different organ contributes to the prohibitive costs of drug development in the United States—one major reason why drug manufacturers now avoid performing trials in this country. This is in a time when we are seeking to reduce the cost of healthcare. There is a critical need for the FDA and Medicare to rethink their position. (Excerpt from text, p. 971; no abstract available.)

Kanwal, F., E. B. Tapper, C. Ho, S. K. Asrani, N. Ovchinsky, J. Poterucha, A. Flores, V. Ankoma-Sey, B. Luxon and M. Volk (2019). “Development of Quality Measures in Cirrhosis by the Practice Metrics Committee of the American Association for the Study of Liver Diseases.” Hepatology 69(4): 1787-1797.

Full text of this article.

Health care delivery is increasingly evaluated according to quality measures, yet such measures are underdeveloped for cirrhosis. The Practice Metrics Committee of the American Association for the Study of Liver Diseases was charged with developing explicit process-based and outcome-based measures for adults with cirrhosis. We identified candidate measures from comprehensive reviews of the literature and input from expert clinicians and patient focus groups. We conducted an 11-member expert clinician panel and used a modified Delphi method to systematically identify a set of quality measures in cirrhosis. Among 119 candidate measures, 46 were identified as important measures to define the quality of cirrhosis care, including 26 process measures, 7 clinical outcome measures, and 13 patient-reported outcome measures. The final process measures captured care processes for ascites (n = 5), varices/bleeding (n = 7), hepatic encephalopathy (n = 4), hepatocellular cancer (HCC) screening (n = 1), liver transplantation evaluation (n = 2), and other care (n = 7). Clinical outcome measures included survival, variceal bleeding and rebleeding, early-stage HCC, liver-related hospitalization, and rehospitalization within 7 and 30 days. Patient-reported outcome measures covered physical symptoms, physical function, mental health, general function, cognition, social life, and satisfaction with care. The final list of patient-reported outcomes was validated in 79 patients with cirrhosis from nine institutions in the United States. Conclusion: We developed an explicit set of evidence-based quality measures for adult patients with cirrhosis. These measures are a tool for providers and institutions to evaluate their care quality, drive quality improvement, and deliver high-value cirrhosis care. The quality measures are intended to be applicable in any clinical care setting in which care for patients with cirrhosis is provided.