Health care has shifted to placing priority on quality and value instead of volume. Liver transplantation uses substantial resources and is associated with high readmission rates. Our goal was to determine if a protocol designed to reduce readmission after liver transplant was effective. We conducted a prospective study of a protocol designed to reduce readmission rates after liver transplantation by expanding outpatient services and alternatives to readmission. The 30-day readmission rate 1 year after implementing the protocol was compared to the 30-day rate for 2 years prior to implementation. Multivariate analysis was used to control for potential confounding factors. Over the study period, 167 adult primary liver transplants were performed with a mean biological Model for End-Stage Liver Disease score of 21 6 8. Fifty-seven (34%) patients were readmitted. The most common reason for readmission was biliary complications (n 5 13). The 30-day readmission rate decreased from 40% before implementing the protocol to 20% after implementation (P 5 0.02). In multivariate analysis, the protocol remained associated with readmission (odds ratio, 0.39; 95% confidence interval, 0.16-0.92; P 5 0.03). The mean length of stay after transplant was 13 6 12 days preprotocol and 9 6 5 days postprotocol (P 5 0.09). Alternatives to readmission, including hospital lodging and observation status, were main factors in reducing readmission rates. If the most recent definitions of inpatient admission and observation status were applied over the entire study period, then the readmission rates preprotocol and postprotocol were 31% and 20% indicating that the revised definition of observation status accounted for 45% of the reduction in the readmission rate. Readmission after liver transplantation can be reduced without increasing length of stay by implementing a specifically designed protocol that expands outpatient services and alternatives to inpatient admission.Liver Transplantation 22 765-772 2016 AASLD.
Liver transplantation (LT) is hospital-resource intensive and associated with high rates of readmission. We have previously shown a reduction in 30-day readmission rates by implementing a specifically designed protocol to increase access to outpatient care. The aim of this work is to determine if the strategies that reduce 30-day readmission after LT were effective in also reducing 90-day readmission rates and costs. A protocol was developed to reduce inpatient readmissions after LT that expanded outpatient services and provided alternatives to readmission. The 90-day readmission rates and costs were compared before and after implementing strategies outlined in the protocol. Multivariable analysis was used to control for potential confounding factors. Over the study period, 304 adult primary LTs were performed on patients with a median biological Model for End-Stage Liver Disease of 22. There were 112 (37%) patients who were readmitted within 90 days of transplant. The readmission rates before and after implementation of the protocol were 53% and 26%, respectively (P < 0.001). The most common reason for readmission was elevated liver tests/rejection (24%). In multivariable analysis, the protocol remained associated with avoiding readmission (odds ratio, 0.33; 95% confidence interval, 0.20-0.55; P < 0.001). The median length of stay after transplant before and after protocol implementation was 8 days and 7 days, respectively. A greater proportion of patients were discharged to hospital lodging after protocol implementation (10% versus 19%; P = 0.03). The 90-day readmission costs were reduced by 55%, but the total 90-day costs were reduced by only 2.7% because of higher outpatient costs and index admission costs. In conclusion, 90-day readmission rates and readmission costs can be reduced by improving access to outpatient services and hospital-local lodging. Total 90-day costs were similar between the 2 groups because of higher outpatient costs after the protocol was introduced.
Introduction: Anal cancers are rare, accounting for 2% of gastrointestinal malignancies. Their incidence is increasing, particularly in women. The current standard of care is concurrent RCT. Overall 5-year survival rates reach 75%, colostomy free survival rate is 65-70% and complete pathological response rates reach 90%. While treatment outcomes are excellent, associated toxicities are high. Clinician-reported acute grade 3/4 toxicities can be as high as 80% (1). Methods: The files of patients diagnosed with non-metastatic anal cancer managed with radical RCT were retrospectively reviewed in respect to effectiveness and toxicity. All patients underwent staging MRI prior and post RCT. CT scans were performed prior to RCT onset, 6 monthly up to 2 years and yearly up to 5 years. Patients were clinically evaluated 3 monthly for the first 2 years and 6 monthly thereafter. Toxicity was recorded by using CTCAEv4 criteria. Statistical analysis of time-to-event data was done using Kaplan-Meier plots. Results: From 2003 to 2017 sixty-nine patients (38 females, 31 males) received RCT with 2 cycles of MMC-5FU. Radiotherapy dose ranged between 5220-5940cGy. Median age was 63 years. Two patients had stage I disease, 22 stage II, 9 stage IIIA and 36 stage IIIB. IMRT technique was used in 56% of patients and conformal RT (CRT) in 44% of patients. Median follow up (FU) was 31 months. Complete clinical response rate at 3 months was 84%. Three-year overall survival (OS), Disease free survival (DFS), Locoregional disease free survival (LDFS), metastasis free survival (MFS) and colostomy free survival (CFS) rates were 85%, 82%, 87%, 89% and 82% respectively. 3 year OS was 100% for stage I, 89.5% for stage II, 83.3% for stage IIIA and 75.2% for stage IIIB patients. Rates remained unchanged after 3y FU. No significant differences in survivals were noted between patients managed with IMRT vs CRT, apart from OS that favoured those managed with IMRT (p < 0.023). Acute grade 3/4 toxicity rates were: skin dermatitis 43.5%, diarrhoea 10.1%, proctitis 39.1%, cystitis-urinary frequency 2.8%, neutropenic fever 7.2%, thrombocytopenia 2.9%, and Leukopenia 13%. Late grade 3/4 toxicity rates were minimal with 2 patients developing a fistula (2.8%) and 3 anal stenosis (3.3%). One patient developed a secondary malignancy (sarcoma) at 4 years of FU. Acute grade 3 dermatitis was more frequent in patients managed with CRT (53.3% vs 35.9%) whereas no differences were noted in acute grade 3 diarrhoea (10% each). Grade III leukopenia was more frequent in CRT patients. Conclusion:We herein report the results of a single institutional study involving patients with anal carcinoma. Survival rates are comparable to those of published literature data. An interesting characteristic of this study is the possibility to compare the results between patients managed with CRT vs IMRT. Interestingly OS was statistically significantly higher in patients treated with IMRT. Moreover, grade 3/4 acute toxicity rates were higher in CRT patients.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.