Background and Aims:Cirrhosis prevalence is increasing, yet costs associated with its chronic, complex care are poorly understood. The aim was to characterize the costs of care for patients with cirrhosis and compare them to other chronic diseases such as heart failure (HF) and chronic obstructive pulmonary disease (COPD), for which the public health burden is better recognized.Approach and Results:Patients enrolled in Medicare Advantage plans from a large national insurer between 2011 and 2020 with cirrhosis, HF, and COPD were identified by ICD-9/-10 codes. Costs (USD) of care were calculated per patient-month and included inpatient medical, emergency medical, pharmacy, and other costs. In all, 93,308 patients with cirrhosis, 355,520 patients with HF, and 318,949 patients with COPD were analyzed. Patients with cirrhosis, HF, and COPD had a mean (SD) age of 69.6 (9.5), 75.9 (9.7), and 72.9 (9.8) years, respectively. The most frequent etiologies were metabolic dysfunction-associated steatohepatitis (37.7%) and alcohol-associated cirrhosis (22.1%). The total monthly cost of care for patients with cirrhosis, HF, and COPD was $3032.00, $2491.60, and $1955.60 respectively. The cost for patients with cirrhosis exceeded that for HF by $540.40 (21.7% higher) and COPD by $1076.30 (55.0% higher). The monthly cost of care for decompensated cirrhosis was $3969.30, which was 59.3% ($1477.70) higher than for HF and 103.0% ($1,955.60) higher than for COPD.Conclusions:The cost of care for cirrhosis is high, significantly higher than HF and COPD. Interventions directed at optimizing care to prevent progression to cirrhosis and decompensation are likely to alleviate this public health burden.

PurposeAfrica bears 25% of the world's burden of surgical disease with only 3% of the global health workforce. Laparoscopy is now the standard approach for many surgical conditions and yet laparoscopic training remains mostly inaccessible to practicing surgeons in low- and middle-income African countries (LMICs). The goal of this study is to assess the efficacy of a low-cost, locally accessible laparoscopic skills course designed to meet the critical need in this region.MethodsALL-SAFE is a global surgical collaborative that designed a low-cost laparoscopy training system with modules simulating laparoscopic salpingostomy for ectopic pregnancy and laparoscopic appendectomy for appendicitis using locally accessible materials. A laparoscopic skills course was conducted by ALL-SAFE in a large tertiary-care hospital in Abuja, Nigeria, in October 2023. During the 2-day course, participants engaged in didactic lectures on the physiology and mechanics of laparoscopic surgery, practiced basic laparoscopic skills, observed two live laparoscopic cases, and completed the ALL-SAFE ectopic pregnancy and appendectomy simulated procedures on individual box trainers. Participants completed pre- and post-course surveys to assess their confidence in the knowledge and skills required for laparoscopic surgery.Results100% (n = 32) of the participants completed the pre-course survey and 71.9% (n = 23) completed the post-course survey. Course participants were mostly male (81.3%, n = 26), while 46.9% (n = 15) were general surgeons, 25% (n = 8) were urologists, and the remaining represented other surgical subspecialties. While most participants reported that they had access to a laparoscopic tower at their hospital (93.8%) and they had previously observed laparoscopic cases (62.5%), 50% (n = 16) said that this ALL-SAFE course was their first exposure to laparoscopic simulation. Prior to the course, 46.9% of participants felt "not at all confident" and 37.5% felt "slightly confident" in performing a laparoscopic appendectomy. Following the course, 39.1% of participants felt "very confident" and 34.8% felt "moderately confident". All participants felt that they were successful in achieving their educational goals for the course (17.4% moderately successful, 56.5% very successful, 26.1% extremely successful).ConclusionA short laparoscopy training course using a low-cost platform was successful at improving confidence in performing laparoscopic surgery and achieving the educational goals of a diverse group of Nigerian surgeons. Hosting similar courses in other African LMICs may improve dissemination of laparoscopic surgical skills in this region.

Purpose This narrative review examines the current state of Diversity, Equity, and Inclusion (DEI) in the transplant surgery workforce, with the goal of highlighting the impact that diversity in the workforce has on equity in the transplant system in the United States(US). Summary A diverse healthcare workforce is associated with improved care for disenfranchised patient populations. However, the United States transplant surgery workforce does not currently reflect the patient population in need of transplantation. Despite modest gains in gender diversity, a lack of racial and ethnic diversity in the transplant surgical workforce persists. Prior work has identified lack of diversity in the workforce as a contributor to inequities across the system, though there is limited data specific to transplant surgeons. There are, however, notable examples of the positive impact that a diverse transplant workforce has achieved through community engagement, culturally sensitive transplant access clinics, advocacy, and policy. Societies such as the American Society of Transplant Surgery and others have recognized the importance of DEI in the workforce and have created a mechanism to support improving DEI in the workforce. National policy changes currently underway to modernize the national transplantation system and provide a channel for existing efforts to improve workforce diversity towards the goal of equity in the transplant system.

Background:Health system websites are important resources to guide health care decisions and may be useful tools to improve racial equity in access to living donor kidney transplant (LDKT). Methods:We performed a cross-sectional study of adult LDKT programs in the United States. We created an assessment tool for website quality across three domains: accessibility (access to LDKT specific information from the transplant center website), readability (ease of reading and clarity), and educational content (appropriateness and presentation of information, LDKT-specific content, program-specific characteristics, and adherence to equity-centered principles of web design). Results:Among the 185 transplant center websites reviewed, only 14.6% of LDKT sites could be accessed directly from the transplant center webpage. The median suitability assessment of materials (SAM)-a validated measure of website content for chronic kidney disease (CKD)-was 45 out of 86 (IQR 4) and the median Flesch-Kincaid grade level and ease score were 9.1 (IQR 0.8) on a scale of 0-18 and 51.2 (IQR 5) on a scale of 0-100, respectively. Conclusion:These results indicate that LDKT websites are currently not available, accessible, and understandable for many potential transplant candidates and donors. Optimizing the content and design of transplant center websites may be a promising and effective strategy for improving equity in access to LDKT.

Black Americans experience end-stage kidney disease (ESKD) at a disproportionately higher rate than other racial and ethnic groups in the United States. Kidney transplantation provides the best outcomes for patients with ESKD. However, Black patients frequently have decreased access to kidney transplantation. This article summarizes the robust literature on disparities in transplantation for Black patients and presents a practical solution to this complex issue by redesigning the transplant access process for Black patients challenged by structural and institutional barriers. The authors provide a detailed overview of a novel African American Transplant Access Program (AATAP) with its pillars of cultural congruency, trust, health literacy, and psychosocial support. This overview includes a thorough description of the program's conceptualization, the process of creating the program, the preliminary results, and guidance to establish similarly culturally congruent transplant access programs.

IntroductionThere is a critical need for comprehensive surgical training in African countries given the unmet surgical burden of disease in this region. Collaborative and progressive initiatives in global surgical education will have the greatest impact on trainees. Little is known about surgical education needs from the perspective of practicing surgeons and trainees in low-middle-income countries (LMICs). Even less is known about the potential role for simulation to augment training.MethodsA modified Delphi methodology with 2 rounds of responses was employed to survey program directors (PD) and associate program directors (APD) of Pan-African Association of Christian Surgeons (PAACS) general surgery residency programs across eight low-middle-income countries in Africa. 3 PD/APDs and 2 surgical residents participated in semi-structured interviews centered around the role of simulation in training. Descriptive analysis was performed to elicit key themes and illustrative examples.ResultsThe survey of program directors revealed that teaching residents the psychomotor skills need to perform intracorporeal suturing was both high priority and desired in multiple training sites. Other high priority skills were laparoscopic camera driving and medial visceral rotation. The interviews revealed a specific desire to perform laparoscopic surgery and a need for a simulation curriculum to familiarize staff and trainees with laparoscopic techniques. Several barriers to laparoscopic surgery exist, such as lack of staff familiarity with the equipment, lack of public buy in, and lack of generalizable and adaptable educational modules. Trainees saw utility in the use of simulation to optimize time in the operating room and sought opportunities to improve their laparoscopic skills.ConclusionFaculty and surgical trainees in LMICs have interest in learning advanced surgical techniques, such as laparoscopy. Developing a simulation curriculum tailored to the trainees' local context has the potential to fill this need.

INTRODUCTION:Social determinants of health (SDOH) may impact chronic liver disease (CLD) outcomes but are not clearly understood. We conducted a systematic review to describe the associations of SDOH with mortality, hospitalizations, and readmissions among patients with CLD. METHODS:This review was registered (PROSPERO ID: CRD42022346654) and identified articles through MEDLINE, Embase, Cochrane Library, and Scopus databases. The review included studies that reported SDOH characteristics within the domains of economic stability, healthcare access, education, social and community context, and the neighborhood-built environment. Associated outcomes of interest were mortality, hospitalizations, or readmissions. The Cochrane Risk of Bias in Nonrandomized Studies for Exposure was used to assess study quality and risk of bias. RESULTS:A total of 5,205 abstracts were screened, 60 articles underwent full-text review, and 27 articles were included in the final review. Poor economic stability, healthcare access, social support, and household/environmental conditions were associated with higher mortality and hospital readmissions among patients with CLD. Increasing distance (≥25 miles away) from a liver transplantation center was associated with higher mortality, despite increasing access to the liver transplantation waitlist. When assessing the overall risk of bias among included studies, most had "some concern" (N = 13, 48.1%) or "high risk" (N = 11, 40.7%), whereas a minority had "very high risk" (N = 3, 11.1%). No studies were categorized as "low risk." DISCUSSION:Unfavorable SDOH were associated with increased mortality and hospital readmissions among patients with CLD. Rigorous empirical research is needed to identify evidence-based strategies that aim to mitigate disparities among vulnerable populations.

The advent of more affordable genomic analytical pipelines has facilitated the expansion of genetic studies in kidney transplantation. Advances in genetic sequencing have allowed for a greater understanding of the genetic basis of chronic kidney disease, which has helped to guide transplant management and address issues related to living donation in specific disease settings. Recent efforts have shown significant effects of genetic ancestry and donor APOL1 risk genotypes in determining worse allograft outcomes and increased donation risks. Genetic studies in kidney transplantation outcomes have started to assess the effects of donor and recipient genetics in primary disease recurrence and transplant-related comorbidities, while genome-wide donor-recipient genetic incompatibilities have been shown to represent an important determinant of alloimmunity. Future large-scale comprehensive studies will shed light on the clinical utility of integrative genomics in the kidney transplantation setting.

Tacrolimus metabolism is heavily influenced by the CYP3A5 genotype, which varies widely among African Americans (AA). We aimed to assess the performance of a published genotype-informed tacrolimus dosing model in an independent set of adult AA kidney transplant (KTx) recipients. CYP3A5 genotypes were obtained for all AA KTx recipients (n = 232) from 2010 to 2019 who met inclusion criteria at a single transplant center in Philadelphia, Pennsylvania, USA. Medical record data were used to calculate predicted tacrolimus clearance using the published AA KTx dosing equation and two modified iterations. Observed and model-predicted trough levels were compared at 3 days, 3 months, and 6 months post-transplant. The mean prediction error at day 3 post-transplant was 3.05 ng/mL, indicating that the model tended to overpredict the tacrolimus trough. This bias improved over time to 1.36 and 0.78 ng/mL at 3 and 6 months post-transplant, respectively. Mean absolute prediction error-a marker of model precision-improved with time to 2.33 ng/mL at 6 months. Limiting genotype data in the model decreased bias and improved precision. The bias and precision of the published model improved over time and were comparable to studies in previous cohorts. The overprediction observed by the published model may represent overfitting to the initial cohort, possibly limiting generalizability.

PURPOSE OF REVIEW:This review summarizes the different instruments for evaluating the psychosocial health of transplant candidates, the evidence demonstrating how these instruments relate to probability of transplant waitlisting and transplant outcomes, and the critical knowledge gaps that exist in the causal pathway between psychosocial health and clinical transplant trajectory. RECENT FINDINGS:The current literature reveals that psychosocial assessments are a common reason for racial and ethnic minorities to be denied access to the transplant list. Given evidence that a lack of clinician consensus exists regarding the definition of, importance of, and reproducibility of psychosocial support evaluations, this facet of the holistic evaluation process may create a unique challenge for already vulnerable patient populations. Though recent evidence shows that psychosocial evaluation scores predict select transplant outcomes, these findings remain inconsistent. SUMMARY:Multiple instruments for psychosocial transplant evaluation exist, though the utility of these instruments remains uncertain. As equity becomes an increasingly urgent priority for the transplant system, rigorous interrogation of the causal pathway between psychosocial health and transplant longevity is still needed.

African American (AA) kidney recipients have a higher risk of allograft rejection and failure compared to non-AAs, but to what extent these outcomes are due to genetic versus environmental effects is currently unknown. Herein, we tested the effects of recipient self-reported race versus genetic proportion of African ancestry (pAFR), and neighborhood socioeconomic status (SES) on kidney allograft outcomes in multiethnic kidney transplant recipients from Columbia University (N = 1083) and the University of Pennsylvania (N = 738). All participants were genotyped with SNP arrays to estimate genetic admixture proportions. US census tract variables were used to analyze the effect of neighborhood factors. In both cohorts, self-reported recipient AA race and pAFR were individually associated with increased risk of rejection and failure after adjustment for known clinical risk factors and neighborhood SES factors. Joint analysis confirmed that self-reported recipient AA race and pAFR were both associated with a higher risk of allograft rejection (AA: HR 1.61 (1.31-1.96), P = 4.05E-06; pAFR: HR 1.90 (1.46-2.48), P = 2.40E-06) and allograft failure (AA: HR 1.52 (1.18-1.97), P = .001; pAFR: HR 1.70 (1.22-2.35), P = .002). Further research is needed to disentangle the role of genetics versus environmental, social, and structural factors contributing to poor transplantation outcomes in kidney recipients of African ancestry.

The choice to participate in cancer screening is more complex than it may seem and often reflects a multifactorial decision made by patients in an individual social context. While screening remains a vital means of detecting early-stage malignancy, facilitating appropriate treatment, and improving cancer-related survival, it requires that a clinically well and asymptomatic individual voluntarily engage with the healthcare system. As Dr. Fayanju and her colleagues adeptly highlight in their study, large swaths of the population – often patients from low socioeconomic backgrounds, immigrants, and ethnic minorities – have low rates of cancer screening participation. 1 Fayanju O.M. et al. Modifiable patient-reported factors associated with cancer-screening knowledge and participation in a Community-based Health Assessment. Am J Surg. 2023; https://doi.org/10.1016/j.amjsurg.2022.10.059 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar , 2 Adams L.B. et al. Medical mistrust and colorectal cancer screening among african Americans. J Community Health. 2017; 42: 1044-1061 Crossref PubMed Scopus (81) Google Scholar , 3 Hall I.J. et al. Patterns and trends in cancer screening in the United States. Prev Chronic Dis. 2018; 15: E97 Crossref PubMed Scopus (173) Google Scholar Due to historical mistreatment and exploitation of these communities by the American healthcare system, these groups often have generations of trauma and justified mistrust of clinicians that can result in hesitancy to engage in cancer screening and may perpetuate disparities in cancer detection and outcomes. The authors of this study attempt to identify modifiable system and patient factors that could provide opportunities for intervention and improvements in screening habits, especially among these key populations.

Introduction: Case-based learning (CBL) utilizes authentic clinical cases that connect theory to practice. CBL has been shown to result in deeper learning and high engagement of adult learners. An open-source, web-based CBL module was created to help learners develop the cognitive foundation of ectopic pregnancy management in the low-resource setting. We present psychometric evidence that supports the use of this web-based CBL in the low resource setting. Methods: The case scenario comprising 20 topics in ectopic pregnancy management was created by an Ethiopian team member and hosted on an interactive web-based platform. The module was reviewed by Ethiopian, Cameroonian, and US surgeons and OB/GYN team members for content, relevance, and clarity, followed by a psychometrician for clarity, bias, relevance, and alignment. Twenty participants (3-Mbingo Baptist Hospital Cameroon, 6-Soddo Christian Hospital-Ethiopia, 3-Southern Illinois University (SIU), and 8-University of Michigan (UM)) then completed the module. Four attending surgeons (2 OB/GYN, 2 general surgery) were designated experts while 10 medical students and 6 residents were designated novices. The module included a 10-item dichotomously scored pre-test, the CBL content, and the same, but shuffled, post-test. Pre-and post-test summed scores were compared using paired Student's t-tests, while differences in scores across participants' experience levels and sites were analyzed using a many-facet Rasch model. Results: Findings indicated a statistically significant improvement in participants' mean summed scores from pretest (M = 6.7, SD = 2.2) to post-test (M = 9.0, SD = 1.5), t(20) = - 4.76, P < 0.0001 and confirmed by Rasch analysis, P < 0.001. An adequate distribution of difficulty was demonstrated and 80% of questions had high discrimination value between experts and novices, d = | 0.87, 1.40 |. There was no difference in scores across specialties. Following the module, expert scores (M = 9.7) were higher than novice scores (M = 9.0), but the difference was not statistically significant. Conclusion: Our findings suggest that using a web-based CBL module could be used to effectively improve understanding of the management of ectopic pregnancy in the low-resource setting, especially for nascent surgeons. The concept of a web-based CBL module has special attraction in the low-resource setting as it may target the adult surgical learner in remote regions where established technologies and existing experts are unavailable.

Abstract Background Musculoskeletal injury contributes significantly to the burden of disease in Tanzania and other LMICs. For hospitals to cope financially with this burden, they often mandate that patients pay their entire hospital bill before leaving the hospital. This creates a phenomenon of patients who remain hospitalized solely due to financial hardship. This study aims to characterize the impact of this policy on patients and hospital systems in resource-limited settings. Methods A mixed-methods study using retrospective medical record review and semi-structured interviews was conducted at a tertiary hospital in Moshi, Tanzania. Information regarding patient demographics, injury type, days spent in the ward after medical clearance for discharge, and hospital invoices were collected and analyzed for orthopaedic patients treated from November 2016 to June 2017. Results 346 of the 867 orthopaedic patients (39.9%) treated during this time period were found to have spent additional days in the hospital due to their inability to pay their hospital bill. Of these patients, 72 patient charts were analyzed. These 72 patients spent an average of 9 additional days in the hospital due to financial hardship (range: 1–64 days; interquartile range: 2–10.5 days). They spent an average of 112,958 Tanzanian Shillings (TSH) to pay for services received following medical clearance for discharge, representing 12.3% of the average total bill (916,840 TSH). 646 hospital bed-days were spent on these 72 patients when they no longer clinically required hospitalization. 7 (9.7%) patients eloped from the hospital without paying and 24 (33.3%) received financial assistance from the hospital’s social welfare office. Conclusions Many patients do not have the financial capacity to pay hospital fees prior to discharge. This reality has added significantly to these patients’ overall financial hardship and has taken hundreds of bed-days from other critically ill patients. This single-institution, cross-sectional study provides a deeper understanding of this phenomenon and highlights the need for changes in the healthcare payment structure in Tanzania and other comparable settings.

Background. Pharmacogenetic profiling of transplant recipients demonstrates that the marked variation in the metabolism of immunosuppressive medications, particularly tacrolimus, is related to genetic variants. Patients of African ancestry are less likely to carry loss-of-function (LoF) variants in the CYP3A5 gene and therefore retain a rapid metabolism phenotype and higher clearance of tacrolimus. Patients with this rapid metabolism typically require higher dosing to achieve therapeutic trough concentrations. This study aims to further characterize the impact of CYP3A5 genotype on clinical outcomes and financial expenditure. Methods. The CYP3A5 phenotype status was identified in 438 adult kidney transplant (KTx) recipients (96% were African American) using 3 LoF alleles (CYP3A5*3, *6 or *7). Individuals were categorized as rapid metabolism phenotype without LoF alleles‚ intermediate phenotype for 1 LoF allele‚ and slow phenotype for 2 LoF alleles. KTx outcomes (patient/kidney survival and Medicare spending) were determined using linked transplant registry and claims data. Results. Among the cohort, 23% had a rapid, 47% intermediate, and 30% a slow metabolism phenotype based on genotype. At 3 y, the rate of death censored graft failure and all cause graft failure was highest in the rapid metabolism phenotype and lowest in the intermediate metabolism phenotype group. First-year Medicare reimbursement differed significantly by genotype (rapid: $79 535, intermediate: $72 796, slow: $79 346, P = 0.03). After adjustment for donor and recipient characteristics, care for patients with intermediate metabolism was $4790 less expensive (P = 0.003). Conclusions. Pharmacogenomic assessment of African American KTx recipients may be useful to guide therapy when as CYP3A5 functional variants appear to be associated with differential outcome and spending after transplant.