RESUMO
Liver allocation policies are evaluated by how they impact waitlisted patients, without considering broader outcomes for all patients with end-stage liver disease (ESLD) not on the waitlist. We conducted a retrospective cohort study using two nationally representative databases: HealthCore (2006-2014) and five-state Medicaid (California, Florida, New York, Ohio and Pennsylvania; 2002-2009). United Network for Organ Sharing (UNOS) linkages enabled ascertainment of waitlist- and transplant-related outcomes. We included patients aged 18-75 with ESLD (decompensated cirrhosis or hepatocellular carcinoma) using validated International Classification of Diseases, Ninth Revision (ICD-9)-based algorithms. Among 16 824 ESLD HealthCore patients, 3-year incidences of waitlisting and transplantation were 15.8% (95% confidence interval [CI] : 15.0-16.6%) and 8.1% (7.5-8.8%), respectively. Among 67 706 ESLD Medicaid patients, 3-year incidences of waitlisting and transplantation were 10.0% (9.7-10.4%) and 6.7% (6.5-7.0%), respectively. In HealthCore, the absolute ranges in states' waitlist mortality and transplant rates were larger than corresponding ranges among all ESLD patients (waitlist mortality: 13.6-38.5%, ESLD 3-year mortality: 48.9-62.0%; waitlist transplant rates: 36.3-72.7%, ESLD transplant rates: 4.8-13.4%). States' waitlist mortality and ESLD population mortality were not positively correlated: ρ = -0.06, p-value = 0.83 (HealthCore); ρ = -0.87, p-value = 0.05 (Medicaid). Waitlist and ESLD transplant rates were weakly positively correlated in Medicaid (ρ = 0.36, p-value = 0.55) but were positively correlated in HealthCore (ρ = 0.73, p-value = 0.001). Compared to population-based metrics, waitlist-based metrics overestimate geographic disparities in access to liver transplantation.
Assuntos
Doença Hepática Terminal/cirurgia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Transplante de Fígado , Obtenção de Tecidos e Órgãos , Listas de Espera , Conjuntos de Dados como Assunto , Doença Hepática Terminal/epidemiologia , Feminino , Seguimentos , Geografia , Humanos , Classificação Internacional de Doenças , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
The authors describe the development of a preventive program focused on intravenous drug users at risk of HIV infection, using the Social Network Approach as the intervention model. The authors describe the project's steps in a large university hospital in southern Brazil, emphasizing the unique methods and techniques developed by the treatment staff. Problems encountered during the project development are discussed, aimed at identifying the reasons why the program only achieved partial success. The authors identify critical issues, such as the use of a new technique not previously tried in Brazil, difficulties in maintaining IV drug users in treatment, lack of infrastructure for walk-in treatment, and the challenge of motivating staff and patients to continue treatment. The authors conclude by listing suggestions aimed at facilitating the development of new projects based on the same conceptual model.