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The Psychosocial Assessment of Organ Transplant Candidates: A Report on SIPAT's Prediction of Medical & Psychosocial Outcomes
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The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
Purpose: The aim was to evaluate the impact of implanting center left ventricular assist device (LVAD) surgical volumes on patient outcomes. Methods: VAD center volume was provided for 2,665 INTERMACS patients undergoing LVAD or BiVAD implant in 2014. Center VAD volume was categorized as very low (≤ 10 implants/yr, n= 215 patients), low (11-30 implants/ yr, n= 878), medium (31-50 implants/yr, n= 782), high volume (> 50 implants/ yr, n= 790). The main outcome of interest was Kaplan-Meier survival estimates based on center VAD volume compared between groups. Cox adjusted mortality hazard ratios (HR, with 95% confidence interval) were derived. Results: Low volume centers implanted older patients and fewer bridge to transplants. High volume centers had more INTERMACS profile 1-2 patients and more preoperative vasopressors. Operative deaths occurred in 10.7% (OR 1.3 [0.8-2.1]), 8.8% (OR 1.1 [0.79-1.6]), 8.4% (reference), and 11.9% (OR 1.6 [1.2, 2.2]) of very low, low, medium and high volume centers. Survival at 1 year was associated with center volume (p< 0.001): 78±2.9% (very low volume), 83±1.4% (low volume), 85±1.4% (medium volume), and 78±1.6% (high volume). Overall survival was worse in the high vs medium (p= 0.001) volume; high vs low volume (p= 0.011); and very low vs medium volume (p= 0.046) centers. Compared with medium volume centers, the adjusted HR for mortality was 1.5 [1.01-2.1] (p= 0.04), 1.2 [0.92-1.6], and 1.5 [1.11.9] (p= 0.003) for very low, low, and high volume centers, respectively. In Profiles 1-2 (n= 1337) alone, mortality was 40% higher (HR 1.4 [1.1-1.9]) in high vs medium volume centers (p= 0.020). Conclusion: Center volume correlates with postVAD survival. After adjusting for 11 preoperative markers of risk, VAD survival was worse in high volume and very low volume centers. High center volume also correlated with worse outcome in patients restricted to Profiles 1-2. 5( 33) WITHDRAWN
5( 34) Depressive Symptoms and Post-Transplant Mortality: Examining the Influence of Perioperative Outcomes P.J. Smith , S.M. Palmer, L.D. Snyder, B.M. Hoffman, K.K. Ingle, G.L. Stonerock, C. Saulino, J.A. Blumenthal. Duke University Medical Center, Durham, NC. Purpose: Depression is common among lung transplant recipients but its association with clinical outcomes is uncertain. We therefore examined the association between pre-transplant depressive symptoms and mortality in a large, single-center cohort of lung transplant recipients, adjusting for relevant medical and background risk factors. Methods: Participants included lung transplant recipients evaluated at Duke University Medical Center following the implementation of the Lung Allocation System (May, 2005, to July, 2015). Depressive symptoms were evaluated using the Beck Depression Inventory (BDI-II). Medical risk factors included the forced expiratory volume (FEV1), transplant graft time, six-minute walk distance (6MWD), transplant type (bilateral vs. unilateral), and donor age. We also controlled for demographic factors, including age, gender, and native disease. Length of stay (LOS) was examined as a marker of perioperative clinical outcomes. Results: Participants included 367 lung recipients (183 IPF, 101 COPD, 37 CF). Depressive symptoms were common, with 74 participants (21%) exhibiting clinically elevated levels (BDI-II > 14). Depressive symptoms were not associated with mortality as a main effect (HR = 1.02 [0.82, 1.26], P = .864). However, in follow-up analyses, the association between depressive symptoms and mortality appeared to be moderated by LOS (P = .006), such that depression was associated with mortality only among individuals with poorer perioperative outcomes. For individuals with < 3-week LOS depressive symptoms were unrelated to mortality (HR = 0.74 [0.40, 1.35], P = .324), whereas depression (BDI-II > 14) was associated with nearly a 90% increased risk of mortality among individuals with > 3-week LOS (HR = 1.86 [1.04, 3.32], P= .037). Conclusion: Depressive symptoms are common and associated with greater mortality among individuals with worse perioperative outcomes.
5( 35) Social Desirability Response Bias in Transplant Candidates' SelfReport of Psychosocial Variables G.L. Stonerock , P.J. Smith, B.M. Hoffman, K.K. Ingle, C.K. Saulino, J.A. Blumenthal. Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC. Purpose: Transplant candidates exhibit elevated levels of psychological distress compared to the general population. Although psychometric instruments are often used to assess emotional adjustment as part of the pre-transplant evaluation process, the extent to which response bias may affect self-reported psychological functioning has not been investigated. Methods: Between January, 2001, and July, 2015, 1563 transplant candidates were enrolled (1348 lung [86%], 215 heart [14%]). We examined the relationships between social desirability (Marlowe-Crowne Social Desirability Scale [MCSDS]) and patient-reported psychosocial variables, including depression (Beck Depression Inventory-II [BDI-II]), anxiety (Spielberger State Anxiety Inventory [STAI]), social support (Perceived Social Support Scale [PSSS]), and medication adherence. We also compared the level of social desirability to previously published cohorts of normative controls, as well as patients undergoing forensic assessment, in which demand characteristics of the testing situation are known to contribute to elevated scores. Results: Social desirability was significantly elevated among transplant candidates (mean MCSDS 9.5 [SD = 2.7]) and substantially greater compared to published norms for healthy controls (d = 1.35, t = 40.0, P < .001) and forensic patients (d = 0.63, t = 16.2, P < .001). Greater levels of social desirability were associated with lower self-report of depression (b = -2.6, P < .001, Fig. 1) and anxiety (b = -2.9, P < .001), as well as higher self-reported levels of perceived social support (b = 2.1, P < .001) and medication adherence (b = 1.04, P < .001). Conclusion: Socially desirable responding is common among pre-transplant candidates and likely contributes to an under-estimate of emotional distress. Psychosocial evaluations of pre-transplant candidates must take into account patients’ tendency to minimize or under-report emotional distress and to present themselves in an overly positive light.
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
Purpose: The aim was to evaluate the impact of implanting center left ventricular assist device (LVAD) surgical volumes on patient outcomes. Methods: VAD center volume was provided for 2,665 INTERMACS patients undergoing LVAD or BiVAD implant in 2014. Center VAD volume was categorized as very low (≤ 10 implants/yr, n= 215 patients), low (11-30 implants/ yr, n= 878), medium (31-50 implants/yr, n= 782), high volume (> 50 implants/ yr, n= 790). The main outcome of interest was Kaplan-Meier survival estimates based on center VAD volume compared between groups. Cox adjusted mortality hazard ratios (HR, with 95% confidence interval) were derived. Results: Low volume centers implanted older patients and fewer bridge to transplants. High volume centers had more INTERMACS profile 1-2 patients and more preoperative vasopressors. Operative deaths occurred in 10.7% (OR 1.3 [0.8-2.1]), 8.8% (OR 1.1 [0.79-1.6]), 8.4% (reference), and 11.9% (OR 1.6 [1.2, 2.2]) of very low, low, medium and high volume centers. Survival at 1 year was associated with center volume (p< 0.001): 78±2.9% (very low volume), 83±1.4% (low volume), 85±1.4% (medium volume), and 78±1.6% (high volume). Overall survival was worse in the high vs medium (p= 0.001) volume; high vs low volume (p= 0.011); and very low vs medium volume (p= 0.046) centers. Compared with medium volume centers, the adjusted HR for mortality was 1.5 [1.01-2.1] (p= 0.04), 1.2 [0.92-1.6], and 1.5 [1.11.9] (p= 0.003) for very low, low, and high volume centers, respectively. In Profiles 1-2 (n= 1337) alone, mortality was 40% higher (HR 1.4 [1.1-1.9]) in high vs medium volume centers (p= 0.020). Conclusion: Center volume correlates with postVAD survival. After adjusting for 11 preoperative markers of risk, VAD survival was worse in high volume and very low volume centers. High center volume also correlated with worse outcome in patients restricted to Profiles 1-2. 5( 33) WITHDRAWN
5( 34) Depressive Symptoms and Post-Transplant Mortality: Examining the Influence of Perioperative Outcomes P.J. Smith , S.M. Palmer, L.D. Snyder, B.M. Hoffman, K.K. Ingle, G.L. Stonerock, C. Saulino, J.A. Blumenthal. Duke University Medical Center, Durham, NC. Purpose: Depression is common among lung transplant recipients but its association with clinical outcomes is uncertain. We therefore examined the association between pre-transplant depressive symptoms and mortality in a large, single-center cohort of lung transplant recipients, adjusting for relevant medical and background risk factors. Methods: Participants included lung transplant recipients evaluated at Duke University Medical Center following the implementation of the Lung Allocation System (May, 2005, to July, 2015). Depressive symptoms were evaluated using the Beck Depression Inventory (BDI-II). Medical risk factors included the forced expiratory volume (FEV1), transplant graft time, six-minute walk distance (6MWD), transplant type (bilateral vs. unilateral), and donor age. We also controlled for demographic factors, including age, gender, and native disease. Length of stay (LOS) was examined as a marker of perioperative clinical outcomes. Results: Participants included 367 lung recipients (183 IPF, 101 COPD, 37 CF). Depressive symptoms were common, with 74 participants (21%) exhibiting clinically elevated levels (BDI-II > 14). Depressive symptoms were not associated with mortality as a main effect (HR = 1.02 [0.82, 1.26], P = .864). However, in follow-up analyses, the association between depressive symptoms and mortality appeared to be moderated by LOS (P = .006), such that depression was associated with mortality only among individuals with poorer perioperative outcomes. For individuals with < 3-week LOS depressive symptoms were unrelated to mortality (HR = 0.74 [0.40, 1.35], P = .324), whereas depression (BDI-II > 14) was associated with nearly a 90% increased risk of mortality among individuals with > 3-week LOS (HR = 1.86 [1.04, 3.32], P= .037). Conclusion: Depressive symptoms are common and associated with greater mortality among individuals with worse perioperative outcomes.
5( 35) Social Desirability Response Bias in Transplant Candidates' SelfReport of Psychosocial Variables G.L. Stonerock , P.J. Smith, B.M. Hoffman, K.K. Ingle, C.K. Saulino, J.A. Blumenthal. Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC. Purpose: Transplant candidates exhibit elevated levels of psychological distress compared to the general population. Although psychometric instruments are often used to assess emotional adjustment as part of the pre-transplant evaluation process, the extent to which response bias may affect self-reported psychological functioning has not been investigated. Methods: Between January, 2001, and July, 2015, 1563 transplant candidates were enrolled (1348 lung [86%], 215 heart [14%]). We examined the relationships between social desirability (Marlowe-Crowne Social Desirability Scale [MCSDS]) and patient-reported psychosocial variables, including depression (Beck Depression Inventory-II [BDI-II]), anxiety (Spielberger State Anxiety Inventory [STAI]), social support (Perceived Social Support Scale [PSSS]), and medication adherence. We also compared the level of social desirability to previously published cohorts of normative controls, as well as patients undergoing forensic assessment, in which demand characteristics of the testing situation are known to contribute to elevated scores. Results: Social desirability was significantly elevated among transplant candidates (mean MCSDS 9.5 [SD = 2.7]) and substantially greater compared to published norms for healthy controls (d = 1.35, t = 40.0, P < .001) and forensic patients (d = 0.63, t = 16.2, P < .001). Greater levels of social desirability were associated with lower self-report of depression (b = -2.6, P < .001, Fig. 1) and anxiety (b = -2.9, P < .001), as well as higher self-reported levels of perceived social support (b = 2.1, P < .001) and medication adherence (b = 1.04, P < .001). Conclusion: Socially desirable responding is common among pre-transplant candidates and likely contributes to an under-estimate of emotional distress. Psychosocial evaluations of pre-transplant candidates must take into account patients’ tendency to minimize or under-report emotional distress and to present themselves in an overly positive light.