Research Spotlight

Wall, A. E., B. da Graca, S. K. Asrani, R. Ruiz, H. Fernandez, A. Gupta, E. Martinez, J. Bayer, G. J. McKenna, R. Goldstein, N. Onaca, J. F. Trotter and G. Testa (2021). “Cost Analysis of Liver Acquisition Fees Before and After Acuity Circle Policy Implementation.” JAMA Surg.

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IMPORTANCE: Acuity circles (AC) liver allocation policy was implemented to eliminate donor service area geographic boundaries from liver allocation and to decrease variability in median Model of End-stage Liver Disease (MELD) score at transplant and wait list mortality. However, the broader sharing of organs was also associated with more flights for organ procurements and higher costs associated with the increase in flights. OBJECTIVE: To determine whether the costs associated with liver acquisition changed after the implementation of AC allocation. DESIGN, SETTING, AND PARTICIPANTS: This single-center cost comparison study analyzed fees associated with organ acquisition before and after AC allocation implementation. The cost data were collected from a single transplant institute with 2 liver transplant centers, located 30 miles apart, in different donation service areas. Cost, recipient, and transportation data for all cases that included fees associated with liver acquisition from July 1, 2019, to October 31, 2020, were collected. EXPOSURES: Primary liver offer acceptance with associated organ procurement organization or charter flight fees. MAIN OUTCOMES AND MEASURES: Specific fees (organ acquisition, surgeon, import, and charter flight fees) and total fees per donor were collected for all accepted liver donors with at least 1 associated fee during the study period. RESULTS: Of 213 included donors, 171 were used for transplant; 90 of 171 (52.6%) were male, and the median (interquartile range) age of donors was 41.0 (30.0-52.8) years in the pre-AC period and 36.9 (24.0-48.8) years in the post-AC period. There was no significant difference in the post-AC compared with pre-AC period in median (range) MELD score (24 [8-40] vs 25 [6-40]; P = .27) or median (range) match run sequence (15 [1-3951] vs 10 [1-1138]; P = .31), nor in mean (SD) distance traveled (155.83 [157.00] vs 140.54 [144.33] nautical miles; P = .32) or percentage of donors requiring flights (58.5% [69 of 118] vs 56.8% [54 of 95]; P = .82). However, costs increased significantly in the post-AC period: total cost increased 16% per accepted donor (mean [SD] of $52 966 [13 278] vs $45 725 [9300]; P < .001) and 55% per declined donor (mean [SD] of $15 865 [3942] vs $10 217 [4853]; P < .001). Contributing factors included more than 2-fold increases in the proportions of donors incurring import fees (31.4% [37 of 118] vs 12.6% [12 of 95]; P = .002) and surgeon fees (19.5% [23 of 118] vs 9.5% [9 of 95]; P = .05), increased acquisition fees (10% increase; mean [SD] of $43 860 [3266] vs $39 980 [2236]; P < .001), and increased flight expenses (43% increase; mean [SD] of $12 904 [6066] vs $9049 [5140]; P = .002). CONCLUSIONS AND RELEVANCE: The unintended consequences of implementing broader sharing without addressing organ acquisition fees to account for increased importation between organ procurement organizations must be remedied to contain costs and ensure viability of transplant programs.

Waddimba, A. C., P. Newman, J. K. Shelley, E. E. McShan, Z. O. Cheung, J. N. Gibson, M. M. Bennett and L. B. Petrey (2021). “Pain management after laparoscopic appendectomy: Comparative effectiveness of innovative pre-emptive analgesia using liposomal bupivacaine.” Am J Surg.

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BACKGROUND: Laparoscopic appendectomy is standard of care for appendicitis in the US. Pain control that limits opioids is an important area of research given the opioid epidemic. This study examined post-appendectomy inpatient opioid use and pain scores following intraoperative use of liposomal bupivacaine (LB) versus non-liposomal bupivacaine. METHODS: This was a retrospective cohort study of 155 adults who underwent laparoscopic appendectomy for acute appendicitis. Patients were divided into four cohorts based on the analgesia administered: (i) bupivacaine hydrochloride (BH)± epinephrine; (ii) undiluted LB; (iii) LB diluted with normal saline; and (iv) LB diluted with BH. RESULTS: Baseline demographic/clinical attributes, intra-operative findings, and post-operative pain scores were equivalent across cohorts. Post-operative pre-discharge opioid use was higher in the BH vs. LB cohorts (mean 60.4 vs. 46.0, 35.5, and 30.4 morphine milligram equivalents, respectively; p < 0.001). CONCLUSIONS: Pre-emptive analgesia with LB during laparoscopic appendectomy can reduce inpatient opioid use without significantly increasing post-operative pain scores.

Waddimba, A. C., M. M. Bennett, M. Fresnedo, T. G. Ledbetter and A. M. Warren (2021). “Resilience, Well-being, and Empathy Among Private Practice Physicians and Advanced Practice Providers in Texas: A Structural Equation Model Study.” Mayo Clin Proc Innov Qual Outcomes 5(5): 928-945.

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OBJECTIVE: To investigate structural relationships of latent constructs such as occupational wellbeing, resilience, work meaningfulness, and psychological empowerment with affective and cognitive clinical empathy among a community of physicians and advanced practice providers. METHODS: We conducted a cross-sectional observational study. We gathered data by an anonymous self-administered multidimensional questionnaire disseminated electronically between March and May 2016. Participants were physicians and advanced practice providers belonging to the Health Texas Provider Network, a group private practice affiliated with the Baylor Scott and White Health system. We excluded allied health care staff (eg, nurses) and trainees (eg, residents, medical students). We pursued a 3-step strategy: (1) confirmatory factor analysis of a theory-driven measurement model, (2) a modified structural equation model from which pathways with nonsignificant path coefficients were deleted, and (3) multigroup analyses of the modified model. RESULTS: Cognitive empathy was the strongest predictor of affective empathy. We observed modest positive associations of resilience with cognitive and affective empathy and of well-being and meaning with affective but not with cognitive empathy. Resilience, meaning, and psychological empowerment were surprisingly negatively associated with well-being, suggesting diminished self-care among practitioners. Effects of psychological empowerment on empathy and well-being were mediated by resilience and meaning. CONCLUSION: Cognitive empathy directly influenced affective empathy; well-being and meaningfulness exerted direct positive effects on affective but not on cognitive empathy, whereas resilience had direct positive associations with both empathy dimensions. Resilience and meaning manifested direct, negative associations with well-being, revealing clinicians’ disproportionate focus on patient care at the expense of self-care.

Gupta, A. and G. Testa (2021). “Pure Laparoscopic Donor Right Posterior Sectionectomy for Living Donor Liver Transplantation: Finding the Balance.” Liver Transpl. Sep 30. Epub ahead of print].

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Live donor liver transplant (LDLT) continues to be an important tool to mitigate the substantial organ shortage worldwide, and in many Eastern countries it remains the only viable option for liver transplantation (1). As donor safety remains an important pillar of LDLT, many potential donors are excluded due to inadequate remnant liver size or anatomical variations. As interest in minimally invasive donor hepatectomy grows this emphasis on patient safety must remain in the forefront.

Squiers, J. J. and J. M. DiMaio (2021). “SYNTAX Score II 2020: A Remake Worth the Price of Admission?” J Am Coll Cardiol 78(12): 1239-1241.

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The SYNTAX score has been widely applied in clinical trial design and clinical practice to objectively measure and stratify the anatomical complexity of coronary artery disease (CAD) (1). Calculation of the SYNTAX score to inform heart team decision-making for patients with multivessel CAD has also been recommended in the 2014 American guidelines and 2018 European guidelines. Defining the complexity of CAD by the SYNTAX score has proven useful as an independent predictor of long-term survival and major adverse cardiovascular events (MACE) in patients undergoing percutaneous coronary intervention (PCI) but not those undergoing coronary artery bypass grafting (CABG). Thus, the value of the SYNTAX score for treatment selection between CABG and PCI by the heart team is uncertain. [No abstract; excerpt from article].