A Tale of Two Centers: Access to Private Care Improves Outcomes in Allogeneic Transplant Recipients

Introduction Allogeneic bone marrow transplantation (BMT) is a potentially curative treatment for many hematological diseases. However, lack of availability of specialized centers and high costs limit access to the procedure in low and middle income countries. Previous research has shown that Latin-American patients with hematological malignancies have worse outcomes when treated in public health systems compared to patients treated in the private setting. Healthcare in Mexico is provided by three systems: the private sector (financed by a private insurance or out of pocket), social security (government-run health systems) and a public system (partially funded by the government), where the most vulnerable population is treated. To date, disparities in outcomes of BMT between patients in public and private health systems have not been widely studied. Objectives Primary: to determine the impact of access to private healthcare in BMT recipients by comparing the outcomes of patients treated in two centers that are led by a single team. Secondary objectives were to determine differences in the overall treatment population and transplantation strategies in each context. Patients and Methods We performed a retrospective analysis of consecutive patients aged 15 and older who underwent BMT regardless of diagnosis form 2015-2021 in two Institutions: 1) A private hematology practice treating insured patients in conventional BMT units similar to those in high-income countries (Private) and 2) A public academic institution where an outpatient transplant strategy is common in the context of significant limitations in access to quality supportive care and high-cost medications (Public). Both programs are led by the same team of hematologists following similar transplant strategies with the salient features being the frequent use of peripheral blood stem cells, chemotherapy-based conditioning regimens, and the preferred use of haploidentical donors vs. matched unrelated donors. We excluded second transplants from this analysis and patients who received them were censored at the time of infusion. We compared baseline characteristics, overall survival (OS), event free survival (EFS), non-relapse mortality (NRM), and the incidence of GVHD in the two different treatment systems. Results A total of 219 patients underwent BMT from January 2015 to June 2021, n=166 (76%) were performed in the Public setting, and n=53 (24%) in the Private setting. Patients in the Private group were older, with a higher proportion of high/very high disease risk index (DRI), hematopoietic cell comorbidity index (HCT-CI) and more frequent use of myeloablative conditioning (Table 1). A similar proportion haploidentical donor grafts were performed (61 vs 57%) with a single matched unrelated donor transplant in the Private center. Median follow-up was 9.7 (0.2-71), and 10.3 (0.7-67.6) months, for Public and Private centers respectively (p=0.38). Median time to neutrophil and platelet engraftment were similar. Seventy patients (42%) in Public, and 15 patients (28%) in Private groups relapsed (p=0.049), with a median time to relapse of 17.5 vs. 47.6 months (p<0.017); there were no significant differences in non-relapse mortality at 2 years (27 vs. 18%) (Fig.1) and primary failure (9% vs 2%). Grade 2-4 aGVHD occurred in 31% patients in the Public setting vs. 19% in Private (p=0.08), without differences in grade 3-4 aGVHD (12% vs 8%). Moderate/severe cGVHD incidence was similar for both groups with (19 vs. 18%). Estimated 2-year EFS was 34% in Public vs. and 54% in Private (Fig. 2), with a median EFS of 8.8 vs 25.7 months (p= 0.024). There were no statistically significant differences in OS (p=0.65), with estimated 2-year OS of 51% for Public and 68% for Privately treated patients, and a median OS of 21.1 months vs. not reached (Fig. 3). When stratified by DRI, patients with Public BMT and a high/very high DRI had a median OS of only 9.7 months vs. not reached for the Private group (Fig. 4). Patients with high/very high DRI in the Private setting had similar outcomes to those with low/intermediate disease in the Public group with the best outcomes achieved by patients with low/intermediate disease treated privately. Conclusion Patients who undergo BMT in the public health system are at risk for significantly worse outcomes when compared to patients cared for in private systems even if a similar strategy is followed and are led by the same team. Figure 1 Figure 1. Disclosures González López: AMGEN: Honoraria; JANSSEN: Honoraria. Gomez-Almaguer: Janssen: Honoraria, Speakers Bureau; Takeda: Honoraria, Speakers Bureau; Bristol-Myers-Squibb: Honoraria, Speakers Bureau; Roche: Honoraria, Speakers Bureau. Gomez-De Leon: ASH: Research Funding; Abbvie: Honoraria; Sanofi: Honoraria; Novartis: Honoraria.

Examples from practice

I want to draw on the experiences of two practitioners. Jodie, who is an experienced room leader at a family owned and managed, private setting in the West Midlands. And Thandi, who is in her second year of teaching a reception class in Yorkshire. Prior to moving into teaching, Thandi began as a nursery nurse before managing a charity ran nursery.

Haematological Correlates of Helicobacter pylori Infection Amongst Children Receiving Care in a Private Setting in Port Harcourt, Rivers State

Helicobacter pylori is a spiral-shaped, gram-negative bacterium that basically colonizes the digestive tract of humans. It is an established cause of anaemia, leucopenia and thrombocytopenia and affects 70-95% of children in developing countries. We carried out a retrospective study of 140 children, presenting with abdominal discomfort and/or vomiting in a private hospital in Port Harcourt, South-South, Nigeria. Positive serology for H.pylori was established using IgG test kit and Full blood counts were done with an autoanalyzer. Sixty-four (45.7%) of the children studied were serologically positive for H.pylori infection, while 54.3%(76) were negative. H.pylori has been detected in virtually all age groups of children studied. Ten (15.6%) of the children with H.pylori positive serology had anaemia, 3.1%(2) had leucopenia and 12.5%(8) had leucocytosis. None of these was statistically significant. The overall seroprevalence of H.pylori in the children studied was high. Similarly, there was a high prevalence of haematologic derangements in the children with positive H.pylori assay compared to those children with negative serology for H.pylori. This was however not statistically significant. Routine screening of children with symptoms of abdominal discomfort for H.pylori and commencement of treatment for those with positive serology results is not recommended without a confirmatory test.

Are You Happy for Me? How Sharing Positive Tourism Experiences through Social Media Affects Posttrip Evaluations

Social media has changed travelers’ behavior in many aspects, including tourism experience sharing. This study examines the influence of tourism experience sharing on travelers’ posttrip evaluations, by considering three facets of experience sharing on social media: expressive writing, sharing on social media, and audience response on social media. Through an experimental design, this study reveals that (1) travelers’ posttrip evaluations increase when they write expressively about their positive travel experiences in a private setting; (2) travelers’ posttrip evaluations also increase when they share their positive travel experiences on social media, although the increase shows no significant difference between sharing and expressively writing about their experiences; and (3) constructive responses from online viewers increase travelers’ positive moods when they share positive travel experiences, thereby enhancing their posttrip evaluations.

SARS-CoV-2 seroprevalence survey among health care providers in a Belgian public multiple-site hospital

Although the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is lasting for more than 1 year, the exposition risks of health-care providers are still unclear. Available evidence is conflicting. We investigated the prevalence of antibodies against SARS-CoV-2 in the staff of a large public hospital with multiple sites in the Antwerp region of Belgium. Risk factors for infection were identified by means of a questionnaire and human resource data. We performed hospital-wide serology tests in the weeks following the first epidemic wave (16 March to the end of May 2020) and combined the results with the answers from an individual questionnaire. Overall seroprevalence was 7.6%. We found higher seroprevalences in nurses [10.0%; 95% confidence interval (CI) 8.9–11.2] than in physicians 6.4% (95% CI 4.6–8.7), paramedical 6.0% (95% CI 4.3–8.0) and administrative staff (2.9%; 95% CI 1.8–4.5). Staff who indicated contact with a confirmed coronavirus disease 2019 (COVID-19) colleague had a higher seroprevalence (12.0%; 95% CI 10.7–13.4) than staff who did not (4.2%; 95% CI 3.5–5.0). The same findings were present for contacts in the private setting. Working in general COVID-19 wards, but not in emergency departments or intensive care units, was also a significant risk factor. Since our analysis points in the direction of active SARS-CoV-2 transmission within hospitals, we argue for implementing a stringent hospital-wide testing and contact-tracing policy with special attention to the health care workers employed in general COVID-19 departments. Additional studies are needed to establish the transmission dynamics.

Contextual culpability: How drinking and social context impact sentencing of violence

The controversial effect of intoxication on sentencing outcomes has received renewed attention with a series of new empirical studies. However, these studies have relied on survey data that conflate alcohol and drug intoxication and miss pertinent contextual features of the offence. This article explores how alcohol intoxication, and its social context, impact sentence outcomes for violent offences. To do so, the probability of custodial sentence severity is modelled using multilevel Cox regression using data from online sentence transcripts. Findings contribute insights into how punishment is shaped by not only the presence of alcohol intoxication in offending but also in which contexts by highlighting the significant punitive effects of reference to concomitant drug use, the defendant drinking together with the victim and if the offence occurred in a private setting. This helps clarify complex considerations taken into account by sentencers when processing cases and the need for clearer guidance.

The effectiveness of leadership: meta-analysis of trial, cross-sectional, and before after studies

Background The clinical and surgical procedures are often based on scientifical evidence but 30-40% of patients do not receive treatment according to evidence based medicine. The main aim of this review and meta-analysis is to assess the effectiveness of leadership in healthcare setting. Methods It was conducted a literature research on MEDLINE, Pubmed and Scopus with publication year between 2015 and 2019. The inclusion criteria were studies involving healthcare workers that evaluated effectiveness of opinion leaders in improving behaviour of healthcare workers, according to clinical or patient related outcomes. The quality of studies were assesed with the NHLBI for before after studies and the NOS for other study designs. The effect of leadership was assessed as risk difference for all studies with the exception of cross sectional studies. For the last it was evaluated correlation between leadership level and outcome measurment. Results A total of 3,155 articles were screened and 284 were fully assessed including 22 of them in the final database: 1 randomized trial, 9 cross sectional and 12 before after studies. For the cross-sectional studies there was a correlation of 0.22 (95% CI 0.15-0.28) between leadership level and outcome measurment. In the metaregression analysis the only factor that increased the correlation was private setting (meta regression coefficent =0.52, p = 0.022). The pooled efficacy was 24% (95% CI 10%-17%) for before after studies. Furthermore, a higher effectiveness was revealed in studies conducted on multi professional (24%) than single professional (9%) healthcare workers. Conclusions According to results, the guidelines adherence and task performance increased in a setting with leadership implementation. The leadership effectiveness appears comparable to other strategies as audit and feedback used to implement evidence-based practice in worldwide healthcare. Key messages The translation of evidence into clinical practice is often difficult but this study suggests that leaderhip can had higher effectiveness in multiprofessional healthcare workers and private setting. The effectiveness of leadership in this review suggests that it can be of help in order to make aware healthcare professionals about effectiveness of comply with evidence-based practice.