key: cord-0016247-l7010fzq
authors: Gaber, A Osama
title: Invited Commentary
date: 2021-03-23
journal: J Am Coll Surg
DOI: 10.1016/j.jamcollsurg.2020.12.036
sha: 26c9be3e446b5618f23047d2b34be00f6392a370
doc_id: 16247
cord_uid: l7010fzq

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A Osama Gaber, MD, FACS Houston, TX The appearance of severe acute respiratory syndrome coronavirus 2 infection in the US in early 2020 placed significant stress on the healthcare system and altered the established pattern of care delivery throughout the country. These disruptions were particularly hard on minorities, the elderly, and the economically disadvantaged. Reported disruptions in transplantation access and organ distribution seen in other countries 1,2 threatened the lives of more than 110,000 patients on transplant waiting lists and dictated that transplantation programs quickly adopt new processes and technology to maintain patient access to life-saving transplantations.

In their report to be presented at the 2020 Southern Surgical meeting, the group from the Medical University of South Carolina demonstrate how the successful implementation of a virtual kidney transplantation evaluation targeted maintaining equity and access for their rural, mostly minority and aging population. 3 They detail the planning and organization of a new patient evaluation system in a virtual platform that capitalizes on the broadening of Medicare coverage for telehealth. They also developed a new patient stratification system that identifies patients less likely to progress through the workup and expedites patients who are predicted to get listed quickly or receive living donations. In addition, their report introduces secondary visits by advanced practice providers to complete patient education and ascertain completion of required testing.

The success of this system at Medical University of South Carolina resulted in the provision of access to their population of rural and African-American patients and in increased completion of patient evaluations despite a decline in referral rates. Similar systems have been implemented across the country and have resulted in a projected increase in the number of deceased donor transplants in 2020 compared with 2019, even though 2019 was a record year for deceased organ donation. 4 Continued adoption of virtual platforms and remote visits in transplantation will require resolution of several outstanding issues that threaten this new model of transplantation care delivery. Most transplantation programs are regional or national in their scope and serve patients from multiple states. This is supported by the United Network for Organ Sharing rule that allows patients to become listed in multiple geographic areas. The future of virtual transplantation access will depend on establishing a regulatory framework that allows transplantation providers to offer remote care and be reimbursed across state lines. Additional guidelines that regulate issues of liability and jurisdiction for such claims in remote care will also be necessary. Medically, additional enhancements to the technology platforms beyond the simple conference room format available today and their full integration into medical records as recorded videos or through recording and automatic transcription will be required. Future enhancement of the platforms that allow measurement of vital signs, obtaining electrocardiograms, measuring cardiac output, and obtaining Doppler evaluations, all attainable within short times, will enrich virtual visits and enhance important data acquisitions that could strengthen the stratification scheme posed by the Medical University of South Carolina. Most importantly, virtual platforms must be adaptable to allow enhanced patient and family education and ensure their access to information that is sensitive to age, race, language, and culture. Finally, transplantation centers will need to restructure more fundamentally around the new technology-based care by devising pathways of care, education, and follow-up, and by initiating novel roles that facilitate these new realities. It is sobering to think, however, that despite these amazing virtual advances, we will still need to grapple with the problem of availability of electronic access by minorities and the poor for a long time, as the pandemic has revealed the serious lack of access to technology in our underserved populations.

Rohan and colleagues 3 clearly launch the build-up to the future in transplantation laying the solid foundation. It is now up to the whole transplantation field to continue the forward progression.

Organ procurement and transplantation during the COVID-19 pandemic

Donation and transplantation activity in the UK during the COVID-19 lockdown

Maintaining equity and access: successful implementation of a virtual kidney transplant evaluation

Organ Procurement and Transplantation Network. National data