The effect of center volume on the incidence of postoperative complications and their impact on survival after lung transplantation
ABSTRACT OBJECTIVE: The aim of this study was to evaluate the effect of center volume on the incidence of postoperative complications and their impact on survival after lung transplantation (LTx). METHODS: United Network for Organ Sharing data were used to identify adult patients undergoing LTx between 1999 and 2009. Center volume was modeled as both a continuous and a categorical variable. Postoperative complications included infection, rejection, stroke, reoperation, and renal failure requiring dialysis. Multivariable Cox regression and Kaplan-Meier analyses were conducted after stratification on the basis of center volume and type of complication. RESULTS: A total of 12,565 LTx recipients were included in the study. Overall rates of postoperative complications were 5.4% for renal failure requiring dialysis, 1.9% for stroke, 19.9% for reoperation, 42.8% for infection, and 10.0% for rejection. High volume centers did not have significantly reduced rates of postoperative complications. Risk-adjusted multivariable Cox analysis demonstrated that in patients with a complication, low volume center was a significant risk factor for increased 90-day, 1-year, and 5-year mortality. Kaplan-Meier analyses similarly demonstrated reduced posttransplant survival in lower volume centers, a finding that persisted after stratification based on individual complication type except for stroke. CONCLUSIONS: Although high volume centers do not have significantly lower incidences of individual postoperative complications after LTx, they are best able to minimize the adverse effects of these complications on short- and long-term survival. These data suggest that identifying and implementing the institutional practices that lead to better management of postoperative complications after LTx in high volume centers may be prudent to improving outcomes in lower volume hospitals.
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ABSTRACT: Risk factors and outcomes of bronchial stricture after lung transplantation are not well defined. An association between acute rejection and development of stricture has been suggested in small case series. We evaluated this relationship using a large national registry. All lung transplantations between April 1994 and December 2008 per the United Network for Organ Sharing (UNOS) database were analyzed. Generalized linear models were used to determine the association between early rejection and development of stricture after adjusting for potential confounders. The association of stricture with postoperative lung function and overall survival was also evaluated. Nine thousand three hundred thirty-five patients were included for analysis. The incidence of stricture was 11.5% (1,077/9,335), with no significant change in incidence during the study period (P = 0.13). Early rejection was associated with a significantly greater incidence of stricture (adjusted odds ratio [AOR], 1.40; 95% confidence interval [CI], 1.22-1.61; p < 0.0001). Male sex, restrictive lung disease, and pretransplantation requirement for hospitalization were also associated with stricture. Those who experienced stricture had a lower postoperative peak percent predicted forced expiratory volume at 1 second (FEV1) (median 74% versus 86% for bilateral transplants only; p < 0.0001), shorter unadjusted survival (median 6.09 versus 6.82 years; p < 0.001) and increased risk of death after adjusting for potential confounders (adjusted hazard ratio 1.13; 95% CI, 1.03-1.23; p = 0.007). Early rejection is associated with an increased incidence of stricture. Recipients with stricture demonstrate worse postoperative lung function and survival. Prospective studies may be warranted to further assess causality and the potential for coordinated rejection and stricture surveillance strategies to improve postoperative outcomes.The Annals of thoracic surgery 07/2013; DOI:10.1016/j.athoracsur.2013.01.104 · 3.65 Impact Factor
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ABSTRACT: The aim of this study was to evaluate whether functional status is a predictor of outcomes after redo lung transplantation (LTx). Adults undergoing redo LTx after implementation of the Lung Allocation Score (May 2005 to December 2010) were identified in the United Network for Organ Sharing database. Patients were stratified into three groups based on functional status as measured before redo LTx by the Karnofsky scale: (1) no assistance required, (2) some assistance required, and (3) total assistance required. Outcomes after redo LTx were compared based on these preoperative functional cohorts. A total of 390 redo LTx were identified: 44 (11%) required no functional assistance, 176 (45%) required some assistance, and 170 (44%) required total assistance preoperatively. Overall survival at 1 year after redo LTx was significantly reduced in the total assistance group (56% versus 82% no assistance, versus 82% some assistance; p < 0.001). After risk adjustment, recipients requiring total assistance preoperatively were at significant risk for 1-year mortality (odds ratio 3.72, p = 0.02). Overall, the preoperative functional assessment outperformed the Lung Allocation Score in predicting 1-year survival after redo LTx (c-index: 0.68 versus 0.58). Transplant survivors who required total assistance before redo LTx were also at increased risk of requiring total assistance after redo LTx (26% versus 0% no assistance, versus 3% some assistance; p < 0.001). These data suggest that performing redo LTx in patients requiring total functional assistance is associated with significant risk of early mortality and continued functional limitation, findings that may have important implications in organ allocation.The Annals of thoracic surgery 08/2013; 96(5). DOI:10.1016/j.athoracsur.2013.05.080 · 3.65 Impact Factor
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ABSTRACT: The optimal healthcare model for follow-up of allogeneic hematopoietic stem cell transplant (HSCT) recipients after day-100 is not clear. We previously demonstrated that longitudinal follow-up at the transplant center using a multi-disciplinary approach is associated with superior survival. Recent data suggests that increased distance from the transplant center is associated with inferior survival. A dedicated long term transplant clinic (LTTC) was established in 2006 at our center. We hypothesized that geographic distance would not be associated with inferior outcome if patients are followed in LTTC. We studied 299 consecutive patients who underwent HSCT and established care in LTTC. The median distance from the transplant center was 118 miles (range, 1-1591). The 75th percentile (170 miles) was used as the cutoff to analyze the impact of distance from the center on outcome (219 patients ≤ 75th percentile; 80 patients > 75th percentile). The two groups were balanced for pre-transplant characteristics. In multivariate analyses, adjusted for donor type, CIBMTR risk, and transplant regimen intensity, distance from transplant center did not impact outcome. Our study suggests that geographic distance from the transplant center is not associated with inferior outcome when follow-up care is delivered via a dedicated long-term transplant clinic incorporating well-coordinated multidisciplinary care.Biology of blood and marrow transplantation: journal of the American Society for Blood and Marrow Transplantation 10/2013; 20(1). DOI:10.1016/j.bbmt.2013.10.004 · 3.35 Impact Factor