JAMA Network Open最新文献

{"title":"Early-Life Exposure to Acid-Suppressive Therapy and the Development of Celiac Disease Autoimmunity.","authors":"Tomer Achler, Tal Patalon, Sivan Gazit, Shlomi Cohen, Ron Shaoul, Amir Ben-Tov","doi":"10.1001/jamanetworkopen.2025.3376","DOIUrl":"10.1001/jamanetworkopen.2025.3376","url":null,"abstract":"<p><strong>Importance: </strong>Early-life use of acid-suppressive therapy has increased over the past 2 decades. Although these medications are widely used, recent studies showed an association between early-life use of acid-suppressive therapy and various long-term outcomes, including celiac disease.</p><p><strong>Objective: </strong>To assess the association between early-life use of acid-suppressive therapy and the risk of celiac disease autoimmunity using 2 observational approaches on a large population-based database.</p><p><strong>Design, setting, and participants: </strong>The cohort study took place in Israel using Maccabi Healthcare Services data. The data were collected on December 8, 2023, and were initially analyzed from January to May 2024. Analysis of the data continued during the revision rounds that took place from October 2024 to February 2025. Children born between January 1, 2005, and December 31, 2020, were included, grouped based on their exposure to acid-suppressive therapy within the first 6 months after birth and subsequently followed up for outcome development until the age of 10 years or December 8, 2023. A retrospective matched cohort design (N = 79 820) and retrospective matched test-negative case-control design (n = 24 684), including only the population tested for celiac disease autoimmunity, were used separately and compared.</p><p><strong>Exposure: </strong>Prescription purchase of acid-suppressive therapy, either proton-pump inhibitors or histamine-2 receptor antagonists, during the first 6 months of life.</p><p><strong>Main outcomes and measures: </strong>Celiac disease autoimmunity was defined as a positive anti-transglutaminase 2 enzyme-linked immunosorbent assay test result according to the thresholds of the commercial kits used. Time to first positive result for celiac disease autoimmunity was defined as the outcome in the cohort design, and acid-suppressive therapy use was defined as the outcome in the test-negative design.</p><p><strong>Results: </strong>The cohort design included 79 820 children (41 319 boys with no acid-suppressive therapy use [51.8%]; median birth year, 2015 [IQR, 2011-2018]), of whom 19 955 (25.0%) used acid-suppressive therapy. The rate of celiac disease autoimmunity was significantly higher among children using acid-suppressive therapy than among those not using acid-suppressive therapy (1.6% [310 of 19 955] vs 1.0% [610 of 59 865]; P < .001). The adjusted hazard ratio of acid-suppressive therapy use for development of celiac disease autoimmunity was 1.52 (95% CI, 1.33-1.74). In the test-negative case-control design, a total of 24 684 children were included (62.2% girls; median birth year, 2012 [IQR, 2009-2016]), of whom 6176 (25.0%) were celiac disease autoimmunity positive. The rate of acid-suppressive therapy users among those who tested positive for celiac disease autoimmunity was not significant compared with those who tested negative (5.0% [309 of 6176] vs 4.6% [858 of 18 508];","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 4","pages":"e253376"},"PeriodicalIF":10.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11971667/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143780019","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Gender Inequity in Institutional Leadership Roles in US Academic Medical Centers: A Systematic Scoping Review.","authors":"Morgan S Levy, Kelby N Hunt, Kara A Lindsay, Vikasni Mohan, Alyssa Mercadel, Eileen Malecki, Radhika Desai, Barbara M Sorondo, Asha Pillai, Marilyn Huang","doi":"10.1001/jamanetworkopen.2025.2829","DOIUrl":"10.1001/jamanetworkopen.2025.2829","url":null,"abstract":"<p><strong>Importance: </strong>Academic medical centers have focused their efforts on promoting gender equity in recent years, but the positive outcomes associated with those efforts remain to be seen in recruiting and retaining diverse institutional leadership.</p><p><strong>Objective: </strong>To evaluate the current state of gender inequity in institutional leadership roles, such as deans, department chairs, and residency and fellowship program directors, at US academic medical centers.</p><p><strong>Evidence review: </strong>A search for articles published from January 1, 2019, to August 5, 2022, on gender inequity in institutional leadership roles at academic medical centers was performed using the PubMed, CINAHL, and ERIC databases. Studies were screened for inclusion by sets of 2 independent reviewers (with disagreements resolved by a third reviewer) and evaluated for risk of bias. The Methodological Expectations of Cochrane Intervention Reviews Standards were followed for conducting the review, and the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) reporting guideline was followed for reporting results.</p><p><strong>Findings: </strong>A total of 8120 articles were retrieved, of which 6368 were screened by title and abstract, 6166 were excluded, and 202 underwent full-text review. Ultimately, 94 studies reported on institutional leadership roles, including deans (5 studies [5.3%]), department chairs (39 studies [41.5%]), division chiefs (25 studies [26.6%]), and program directors (67 studies [71.3%]), with some overlap. A total of 678 participants were deans (564 men [80.5%] and 132 women [19.5%]), 8518 were department chairs (7160 men [84.1%] and 1358 women [15.9%]), 3734 division chiefs (2997 men [80.3%] and 737 women [19.7%]), and 9548 program directors (7455 men [78.1%] and 2093 women [21.9%]). Even in specialties with 50% or more female faculty, none had equal representation of women as department chairs and division chiefs. Gender inequities were particularly pronounced in surgical specialties.</p><p><strong>Conclusions and relevance: </strong>This systematic scoping review suggests that even though emphasis has been placed on addressing gender inequities in academic medicine, considerable disparities remain at the leadership level. While certain positions and specialties have been observed to have more female leaders, niches of academic medicine almost or completely exclude women from their leadership ranks. Importantly, even female-dominated specialties, such as obstetrics and gynecology, have substantial inequity in leadership roles. It is past time for organizational and systems-level changes to ensure equitable gender representation in academic leadership.</p>","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 4","pages":"e252829"},"PeriodicalIF":10.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11971677/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143780101","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Accuracy of Medicare Information Provided by State Health Insurance Assistance Programs.","authors":"Kacey Dugan, Ilse Peterson, Allison Dorneo, Melissa M Garrido","doi":"10.1001/jamanetworkopen.2025.2834","DOIUrl":"10.1001/jamanetworkopen.2025.2834","url":null,"abstract":"<p><strong>Importance: </strong>Medicare beneficiaries, particularly those dually eligible for Medicaid, must navigate complex coverage options. The State Health Insurance Assistance Program (SHIP) provides counseling on Medicare options, but little is known about the quality of counseling sessions.</p><p><strong>Objective: </strong>To characterize experiences connecting to SHIP counselors, and to characterize the accuracy and completeness of information provided by counselors in response to questions about Medicare coverage options.</p><p><strong>Design, setting, and participants: </strong>In this cross-sectional study of 131 SHIP sites across the US, mystery shoppers posed as individuals newly eligible for Medicare. Shops occurred via telephone, in-person, and videoconference encounters from September 2023 to August 2024. Statistical analysis was performed from August to September 2024.</p><p><strong>Exposure: </strong>Mystery shoppers followed scripts with questions about coverage decisions corresponding to general Medicare eligibility and dual eligibility for Medicare and Medicaid.</p><p><strong>Main outcomes and measures: </strong>Responses were categorized as (1) accurate and complete, (2) accurate but incomplete, (3) not substantive, and (4) incorrect. This was a descriptive study without hypotheses.</p><p><strong>Results: </strong>Shoppers attempted 306 encounters. Of these, 122 (39.9%) could not be completed, most often because shoppers did not receive return calls. Within the 184 completed shops, the mean (SD) percentage of accurate and complete answers was 40.0% (25.7%). The percentage of responses with accurate answers (whether complete or incomplete) ranged from 26.1% (when asked whether a specific clinician was in network for a specific plan) to 94.3% (when asked about differences between traditional Medicare [TM] and Medicare Advantage [MA]). Responses were unlikely to be inaccurate (mean [SD], 6.7% [5.4%]). Fewer than half of counselors (44.8% [43 of 96]) mentioned Dual-Eligible Special Needs Plans (D-SNPs) as an option for mystery shoppers posing as dual eligibles.</p><p><strong>Conclusions and relevance: </strong>In this study of the accuracy of Medicare information provided by SHIP counselors, shoppers encountered challenges in reaching SHIP sites, indicating possible capacity constraints; responses varied in accuracy and completeness, with better performance on questions about TM vs MA comparisons, and weaker performance on questions about integrated care plans and specific MA plan details. Given recent growth in MA and federal efforts to counter deceptive marketing practices from agents or brokers-in part by directing beneficiaries to SHIPs-policymakers should consider providing SHIP with additional resources for training and capacity improvements.</p>","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 4","pages":"e252834"},"PeriodicalIF":10.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11962663/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143752748","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Overtime and Agency Nurse Staffing and Impacts on Patient Safety.","authors":"Sean P Clarke, Christopher D DePesa","doi":"10.1001/jamanetworkopen.2025.2880","DOIUrl":"https://doi.org/10.1001/jamanetworkopen.2025.2880","url":null,"abstract":"","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 4","pages":"e252880"},"PeriodicalIF":10.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143763942","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Resident Physician Intentions Regarding Unionization.","authors":"Laura K Barger, Matthew D Weaver, Christopher P Landrigan, Jason P Sullivan, Rebecca Robbins, Ariel S Winn, Charles A Czeisler","doi":"10.1001/jamanetworkopen.2025.3106","DOIUrl":"10.1001/jamanetworkopen.2025.3106","url":null,"abstract":"<p><strong>Importance: </strong>Resident physicians provide frontline care to approximately 70% of hospitalized patients. After decades of relative stability with a small minority of resident physicians unionized, unionization movements have succeeded in recent years at multiple major academic medical centers.</p><p><strong>Objective: </strong>To evaluate resident physicians' unionization intention and the factors informing their unionization consideration at their institution.</p><p><strong>Design, setting, and participants: </strong>This nationwide survey study was conducted in May 2023 among a cohort of resident physicians, which was established over the course of 3 academic years (2020-2023). Resident physicians were invited to participate in an end-of-study survey on contemporary topics, which included questions on unionization.</p><p><strong>Exposure: </strong>Consideration of unionization by resident physicians.</p><p><strong>Main outcomes and measures: </strong>The main outcomes were the presence of a union at the institution for physicians in training, the presence of a movement to unionize, whether the resident physician would vote to unionize, and the factors most important in considering unionization. All measures were self-reported.</p><p><strong>Results: </strong>A total of 1235 participants (mean [SD] age, 28.8 [3.6] years; 737 of 1224 females [60%]; 791 of 1086 (73%) in their first postgraduate year) responded to survey questions regarding unionization. Twenty percent of participants (n = 249) reported that physicians in training belonged to a union at their institution. Among the 986 nonunionized resident physicians, 63% (625) reported they would vote to unionize, whereas less than 10% (96) would not vote to unionize. Pay and work hours were the most commonly cited factors in considering unionization (88% [1081 of 1235 participants] and 76% [941 of 1235 participants], respectively).</p><p><strong>Conclusions and relevance: </strong>In this survey study, most resident physicians (>70%) reported either being in a union or supporting unionization at their institution, citing pay and financial security as critical factors in their consideration of unionization. Future research should investigate other factors and whether unionization achieves its goals of increased pay and benefits, work hours, and well-being.</p>","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 4","pages":"e253106"},"PeriodicalIF":10.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11969282/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143772430","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Environmental and Health Care Personnel Sampling and Unobserved Clostridium difficile Transmission in ICU.","authors":"Lindsay T Keegan, Windy Tanner, Brian Orleans, Rachel B Slayton, John A Jernigan, L Clifford McDonald, Judith Noble-Wang, Molly Leecaster, Candace Haroldsen, Karim Khader, Damon J A Toth, Tierney O'Sullivan, Matthew H Samore, William Brazelton, Michael Rubin","doi":"10.1001/jamanetworkopen.2025.2787","DOIUrl":"10.1001/jamanetworkopen.2025.2787","url":null,"abstract":"<p><strong>Importance: </strong>Clostridioides difficile is among the most prevalent health care-associated pathogens worldwide. Controlling it remains a critical challenge, due in part to spore viability on surfaces.</p><p><strong>Objective: </strong>To quantify transmission of C difficile within health care facilities and evaluate the roles of environmental surfaces and health care personnel (HCP) hands in C difficile movement.</p><p><strong>Design, setting, and participants: </strong>In 2018, a 13-week longitudinal, observational study was conducted in 2 intensive care units (ICUs) in Utah with daily culture-based sampling of patient body sites, room environmental surfaces, HCP hands, and shared environmental surfaces. Both toxigenic and nontoxigenic C difficile strains were selected for whole genome sequencing and included in the analysis. Data were analyzed from September 2021 to September 2024.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was the identification of transmission clusters based on genomic relatedness between isolates from patients, environmental surfaces, and HCP hands. Clusters were defined as isolates with 2 or fewer single nucleotide variants between them.</p><p><strong>Results: </strong>Of the 278 unique ICU admissions, 177 patients consented to body site sampling and were sampled. Along with these, environment surfaces and HCP hands were sampled daily for all occupied rooms, leading to 7000 total samples. Sampling patients, their environment, and HCP hands revealed that nearly 8% of all patients had C difficile linked to other admissions and 57% of transmission clusters bridged nonoverlapping patient-stays. Including environmental surfaces and HCP hands, a 3.6-fold higher C difficile movement was identified than with patient sampling alone, highlighting environmental surfaces as reservoirs.</p><p><strong>Conclusions and relevance: </strong>These results challenge the idea that nosocomial transmission is not a primary source of acquisition and underscore the importance of hand hygiene and environmental decontamination. This study reinforces the need to include environmental surfaces and HCP hands in future work characterizing the burden of nosocomial transmission. Understanding the transmission pathways of C difficile within health care facilities, particularly the roles of environmental surfaces and HCP hands, is critical to improving infection control measures.</p>","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 4","pages":"e252787"},"PeriodicalIF":10.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11971673/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143780021","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Valuing Clinical Strategies Immediately After FDA Approval.","authors":"Charles L Bennett, Kevin B Knopf","doi":"10.1001/jamanetworkopen.2025.0043","DOIUrl":"https://doi.org/10.1001/jamanetworkopen.2025.0043","url":null,"abstract":"","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e250043"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143542169","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prior Authorization, Quantity Limits, and Costs for Varenicline in Medicare.","authors":"Changchuan Jiang, Ryan D Nipp, Arthur S Hong, Ya-Chen Tina Shih, Jiazhang Xing, Megan A Mullins, K Robin Yabroff, Joshua M Liao","doi":"10.1001/jamanetworkopen.2025.0008","DOIUrl":"10.1001/jamanetworkopen.2025.0008","url":null,"abstract":"","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e250008"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11877188/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143542068","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patient Complexity and Bile Duct Injury After Robotic-Assisted vs Laparoscopic Cholecystectomy.","authors":"Cody Lendon Mullens, Sarah Sheskey, Jyothi R Thumma, Justin B Dimick, Edward C Norton, Kyle H Sheetz","doi":"10.1001/jamanetworkopen.2025.1705","DOIUrl":"10.1001/jamanetworkopen.2025.1705","url":null,"abstract":"<p><strong>Importance: </strong>Recent evidence suggests higher bile duct injury rates for patients undergoing robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy. Proponents of the robotic-assisted approach contend that this may be due to selection of higher-risk and more complex patients being offered robotic-assisted cholecystectomy.</p><p><strong>Objective: </strong>To evaluate the comparative safety of robotic-assisted cholecystectomy and laparoscopic cholecystectomy among patients with varying levels of risk for adverse postoperative outcomes.</p><p><strong>Design, setting, and participants: </strong>This retrospective cohort study assessed fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent cholecystectomy between January 1, 2010, and December 31, 2021. Data analysis was performed between June and August 2024. Medicare beneficiaries were separated into model training and experimental cohorts (60% and 40%, respectively). Random forest modeling and least absolute shrinkage and selection operator techniques were then used in a risk model training cohort to stratify beneficiaries based on their risk of a composite outcome of postoperative adverse events consisting of 90-day postoperative complications, serious complications, reoperations, and rehospitalization in an independent experimental cohort.</p><p><strong>Exposures: </strong>Robotic-assisted vs laparoscopic cholecystectomy.</p><p><strong>Main outcomes and measures: </strong>The primary outcome of interest was bile duct injury requiring operative intervention after cholecystectomy. Secondary outcomes were composite outcomes from cholecystectomy composed of any complications, serious complications, reoperations, and readmissions.</p><p><strong>Results: </strong>A total of 737 908 individuals (mean [SD] age, 74.7 [9.9] years; 387 563 [52.5%] female) were included, with 295 807 in an experimental cohort and 442 101 in a training cohort. Bile duct injury was higher among patients undergoing robotic-assisted compared with laparoscopic cholecystectomy in each subgroup (low-risk group: relative risk [RR], 3.14; 95% CI, 2.35-3.94; medium-risk group: RR, 3.13; 95% CI, 2.35-3.92; and high-risk group: RR, 3.11; 95% CI, 2.34-3.88). Overall, composite outcomes between the 2 groups were similar for robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy (RR, 1.09; 95% CI, 1.07-1.12), aside from reoperation, which was overall higher in the robotic-assisted group compared with the laparoscopic group (RR, 1.47; 95% CI, 1.35-1.59).</p><p><strong>Conclusions and relevance: </strong>In this cohort study of Medicare beneficiaries, bile duct injury rates were higher among low-, medium-, and high-risk surgical candidates after robotic-assisted cholecystectomy. These findings suggest that patient selection may not be the cause of differences in bile duct injury rates among patients undergoing robotic-assisted vs laparoscopic cholecystectomy.</p>","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e251705"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11937934/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143700423","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"US Population Size and Outcomes of Adults on Liver Transplant Waiting Lists.","authors":"Tomohiro Tanaka, George Wehby, Mark Vander Weg, Keith Mueller, David Axelrod","doi":"10.1001/jamanetworkopen.2025.1759","DOIUrl":"10.1001/jamanetworkopen.2025.1759","url":null,"abstract":"<p><strong>Importance: </strong>Disparities in organ supply and demand led to geographic inequities in the score-based liver transplant (LT) allocation system, prompting a change to allocation based on acuity circles (AC) defined by fixed distances. However, fixed distances do not ensure equivalent population size, potentially creating new sources of disparity.</p><p><strong>Objective: </strong>To estimate the association between population size around LT centers and waiting list outcomes for critically ill patients with chronic end-stage liver disease and high Model for End-stage Liver Disease (MELD) scores or acute liver failure (ALF).</p><p><strong>Design, setting, and participants: </strong>This US nationwide retrospective cohort study included adult (aged ≥18 years) candidates for deceased donor LT wait-listed between June 18, 2013, and May 31, 2023. Follow-up was completed June 30, 2023. Participants were divided into pre-AC and post-AC groups.</p><p><strong>Exposure: </strong>Population size within defined radii around each LT center (150 nautical miles [nm] for participants with high MELD scores and 500 nm for those with ALF) based on AC allocation policy.</p><p><strong>Main outcomes and measures: </strong>LT candidate waiting list mortality and dropout rate were analyzed using generalized linear mixed-effect models with random intercepts for center and listing date before and after AC implementation. Fine-Gray competing risk regression, accounting for clustering, was used as a secondary model.</p><p><strong>Results: </strong>The study analyzed 6142 LT candidates (1581 with ALF and 4561 with high MELD scores) during the pre-AC era and 4344 candidates (749 with ALF and 3595 with high- MELD scores) in the post-AC era, for a total of 10 486 participants (6331 male [60.5%]; mean [SD] age, 48.5 [7.1] years). In the high-MELD cohort, being listed at a center in the lowest tertile of population size was associated with increased waiting list mortality in the AC era (adjusted odds ratio [AOR], 1.68; 95% CI, 1.14-2.46). Doubling of the population size was associated with a 34% reduction in the odds of mortality or dropout (AOR, 0.66; 95% CI, 0.49-0.90). These results were consistent with those of the extended Fine-Gray models and were also corroborated by multiple sensitivity analyses. However, there were no significant population density-associated disparities in the ALF cohort.</p><p><strong>Conclusions and relevance: </strong>In this retrospective nationwide cohort study, being wait-listed in less populated regions was associated with greater mortality among critically ill LT candidates with high MELD scores, underscoring the limitations of allocation systems based purely on fixed distances.</p>","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e251759"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11937946/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143700442","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}