It only took a review of the list of uncompleted transplant evaluations for Sanjay Kulkarni, MD, Associate Professor of Surgery and Medicine at Yale University School of Medicine, and his colleagues to know it was time to change the procedure.
“We had an enormous amount of patients who were pending activation,” Dr. Kulkarni said. “The numbers were mind-boggling. We thought, we have to make this system more effective going forward so we can reduce the number of pending patients and get them on a list quicker.”
Yale–New Haven Transplantation Center initiated a one-day in-center pretransplant evaluation that decreased the median time to listing by 180 days, according to a retrospective study published in the American Journal of Kidney Diseases (2012;60:288–294). Dr. Kulkarni was the senior author, and Richard N. Formica Jr., MD, and Fidel Barrantes, MD, also of Yale, were the lead authors.
“Most importantly, it doesn't decrease the amount of tests required to get someone listed,” Dr. Kulkarni said.
“The simplest way to get somebody listed quickly is to do a shoddy job, and that will ultimately translate to bad outcomes for the transplant center. When we looked at our evaluation after and before it, we added more tests to the evaluation.”
The one-day workup was undertaken for all patients referred to the transplant center between July 1, 2007, and Jan. 31, 2010. This group of 527 patients was compared with the cohort of 378 patients who had a conventional pretransplant workup at the center between July 1, 2004, and June 30, 2007.
The median time to listing decreased from 226 days in the conventional group to 46 days in the one-day group. After controlling for age, sex, and education level in multivariable analysis, those in the one-day workup group were three times more likely to be placed on the waiting list.
The move to a shorter evaluation period also eliminated disparities across race/ethnicity and educational level.
“Having a patient ultimately be required to complete this workup negates the fact that these patients often have many financial and logistic issues,” Dr. Kulkarni said.
“When you get them in the transplant center and you basically get it done immediately, you are treating people essentially equally. They are all in the same system, and they are all going through the exact same thing.”
In terms of the economics of the new approach, the one-day process led to more per-patient encounters and revenue.
During the evaluation day, patients receive education and a marathon of tests.
“When they come in, they get an hour of different presentations by me, pharmacists, or dietitians, and then the controlled chaos starts going,” Dr. Kulkarni said.
“We have coordinators who bring patients to different areas. They get their blood drawn, ultrasounds and EKG [electrocardiogram] done, and then they go see a surgeon, social worker. The patient goes from one test and one evaluation to another.
“Then, we make a determination of whether or not we need subspecialty evaluations, and we offer them an appointment in the next couple of days with a subspecialist.”
Accomplishing all these steps in an expedited way can be a lot for patients to take.
“The only negative is that it tends to be overwhelming at times for the patient, and I don't know how to fix that,” Dr. Kulkarni said.
“You need to get through a certain amount of educational information. You also need to get through a certain amount of informed consent, and you need to do that with requirements from regulatory agencies, so sometimes there is a little bit of information overload.”
Nationally, it takes more than 300 days for 75% of patients to complete pretransplant evaluation, according to statistics highlighted in the study.
“The patient population is struggling through trying to maintain dialysis three times a week, maintain jobs, family issues, and then you throw a large list of things at them,” Dr. Kulkarni said.
“Our system has failed to recognize that this stumbling block causes discontent in the community, and some patients may give up.”
Also driving longer waits for transplant listing are the complicated medical histories of these individuals.
“Patients frequently arrive to kidney transplantation with multiple comorbidities,” said Gabriel Danovitch, MD, Medical Director of the Kidney and Pancreas Transplant Program at UCLA.
“Transplant programs are often seeing these patients for the first time, and they need to know them inside out and to have a good understanding of their comorbidities and the potential impact of them on their outcomes.”
While diligent pretransplant workups are critical for an excellent prognosis, transplant listing delays can be dangerous.
“We know the longer you wait for a transplant, the worse it is for the patient's outcome,” Dr. Danovitch said.
“Early referral to transplant programs is important, particularly because of the opportunity to look for a potential living donor candidate, which in most programs is the best way to get a kidney transplant quickly with the best outcome.”
A Large Playground
While the one-day workup provided positive results in this study, its applicability at other institutions is an open question.
“In a busy hospital, it would be a little bit difficult,” said Bruce Kaplan, MD, the Kathy and Harry Jentsch Professor of Medicine, Professor of Surgery and Pharmacology, Chief of the Section of Nephrology, and Medical Director of Transplantation at the University of Arizona College of Medicine.
“I don't think anyone who is responsible for a transplant program wouldn't love to have an institution be flexible enough to have a patient worked up that day, but we do live in a large playground, and we are not necessarily the center of everyone else's universe.”
It may be difficult to set up the expedited evaluation, but it's possible, Dr. Kulkarni said.
“It takes a lot of infrastructure. You need to have personnel. We have three dedicated coordinators running things and guiding patients, and we are fortunate to have the testing immediately available. We have that all compartmentalized.”
While it's clear that the one-day workup meant faster transplant listing in this study, further research is needed to determine the implications of that nimbleness.
“You can argue that all we are doing is listing patients more, and there are now more people competing for the same lot of deceased donors,” Dr. Kulkarni said. “We would like to look at: are you able to provide more transplants through living donations in this group that could have been lost, and what is the mortality and the outcomes of doing that intervention?
“Secondly, does getting them listed quicker result in less dialysis exposure prior to transplant, and how does this relate to their outcomes after transplant?”
As of now, the study represents one step being taken by an institution to make life easier for the patient, and for that, Dr. Danovitch commends the authors.
“I congratulate any program, including this one, that makes an effort to put its head together and think, what can we do to make this process more user-friendly for patients? Every program needs to look at the realities of its own waiting time to come up with the best solution.”
Listen In Online
Tune into the Nephrology Times website at http://bit.ly/NTPodcasts to hear Sanjay Kulkarni, MD, discuss the one-day pretransplant evaluation that shaved 180 days off time to listing.