Chronic limb-threatening ischemia (CLTI) is the most severe form of peripheral artery disease. It is estimated that 60% of all nontraumatic lower-extremity amputations performed annually in the United States are in patients with diabetes and CLTI. The consequences of this condition are extraordinary, with substantial patient morbidity and mortality and high socioeconomic costs. Strategies that optimize the success of arterial revascularization in this unique patient population can have a substantial public health impact and improve patient outcomes. This article provides an up-to-date comprehensive assessment of management strategies for patients afflicted by both diabetes and CLTI.
Background and Aims With more transplant centers in the United States are accepting hepatitis C virus infected (HCV+) deceased donor kidneys (dHCV+), the trend of non-utilization and decline of these organs have not been re-examined. Method We used data from the national Organ Procurement and Transplantation Network on deceased donor kidneys between Jan 2000 and Dec 2018 in the United States. Kidney non-utilization for HCV+ was defined as a positive donor HCV status and positive hepatitis as the reason for non-utilization. dHCV+ kidney decline was defined as a donor HCV+ status among kidneys recovered for transplantation but not transplanted. We assessed associations of a dHCV+ status with kidney non-utilization or decline, adjusted for donor characteristics (age, race, sex, body mass index, diabetes, hypertension, kidney donor profile index), using multivariable logistic regression. Results A total of 274,570 deceased donor kidneys procured for transplantation between 2000 and 2018 were identified. Among these kidneys, 4.1% were from dHCV+. Proportion of dHCV+ non-utilization among all non-utilized kidneys increased from 2000-2005 (3.9%) and then subsequently declined. This proportion increased slightly to 1.1% in 2014 and decreased to 0.5, 0.8, 0.4, 0.6% in 2015-2018, respectively. Multivariable-adjusted odds ratios for dHCV+ non-utilization and decline by year demonstrate consistently an increasing trend from 2000-2006 followed by a decreasing trend from 2006-2011 (Fig A-B). Multivariable-adjusted odds ratios for dHCV+ (compared to dHCV-) non-utilization and decline increased to 6.56 (95% CI 5.30-8.12) and 6.66 (95% CI 5.39-8.24), respectively, in 2012, and decreased to 2.32 (95% CI 2.01-2.69) and 2.28 (95% CI 1.98-2.64), respectively, in 2018. Conclusion dHCV+ non-utilization and decline have decreased in the last few years, particularly after 2014. 2018 had a historic lowest odds ratio for non-utilization and decline of dHCV+ organs, which reflects the increased acceptability of transplant centers to these kidneys. Overall, since 2014, the odds ratios for dHCV+ non-utilization and decline decreased by half. Yet, there is more room for decreasing the non-utilization and decline for these potentially life-saving organs.
Methods: A large statewide retrospective quality improvement database was reviewed for years 2013 to 2019. Hospitals participating in the quality collaborative were required to submit adherence and outcome data and met semiannually, incentivized by a pay-for-participation model. Aggregate adherence rates among all hospitals were calculated and compared.Results: Thirty-nine hospitals participated in the collaborative, with attendance of surgeon champions at face-to-face meetings of >85%. Statewide, hospital systems improved every year of participation in the collaborative across most best practice domains, including adherence to preoperative skin preparation recommendations (odds ratio [OR], 1.83; confidence interval [CI], 1.76-1.79; P < .001), intraoperative antibiotic redosing (OR, 1.09; CI, 1.02-1.17; P ¼0.018), statin use at discharge among appropriate patients (OR, 1.18; CI, 1.16-1.2; P < .001), and reducing transfusion for asymptomatic patients with hemoglobin level >8 mg/dL (OR, 0.66; CI, 0.66-0.66; P < .001). Antiplatelet therapy at discharge remained high and did not change significantly during the study period. Teaching hospital and urban or rural status did not have an impact on adherence. Adherence rates exceeded professional society mean rates for guideline adherence.Conclusions: The use of a statewide hospital collaborative with incentivized semiannual meetings resulted in significant improvements in adherence to best practice guidelines across a large, heterogeneous group of hospitals.
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