A community hospital builds successful liver transplant program
By Melanie Padgett Powers Fall 2019
The Piedmont Transplant Institute in Atlanta performs about 135 liver transplants each year. It’s the highest-volume liver transplant center of any nonacademic, community hospital in the United States and is among the top 10% in the nation of all transplant centers.
Piedmont’s success was achieved primarily because of the collaboration between various interdisciplinary departments—especially IR and hepatology—and an extensive network of referrals.
“Our center comes up with a treatment plan that’s not fragmented, that has come about by consensus and that’s communicated to the patient and documented in the medical record as such. And then we carry it out,” says interventional radiologist Steve Citron, MD, FSIR. “IR is a necessary component of a successful transplant program. The fact that we have such success is a testament to how closely we work together.” Dr. Citron is a partner at Radiology Associates of Atlanta, the independent contractor that provides all radiology services to Piedmont Atlanta Hospital and Piedmont Henry Hospital.
Piedmont’s liver cancer program is based around a single-day consultation for every patient. Patients referred to Piedmont will see in one day a transplant hepatologist, a transplant surgeon and an IR. “Among community hospitals, it’s rare, to our knowledge, where you go in and talk to multiple different specialties on the same day under the same roof about your issues,” Dr. Citron says.
That streamlined process reduces patient anxiety caused by long waits for answers. And it helps patients traveling from throughout Georgia and the Southeastern United States, saving travel costs and time off work.
A multidisciplinary liver tumor board holds a meeting every Friday to discuss cases from patients who were seen within the past week. The meeting always includes an IR, transplant hepatologist, transplant surgeon, surgical oncologist, medical oncologist, radiation oncologist, and all other ancillary and research staff supporting the program. The six IRs who rotate through the meeting prepare by looking through the patient scans beforehand. At least 16 new or follow-up patients are presented, and the team creates a management plan. The patient is called that afternoon with the next steps.
“In a lot of these cases, it’s very complex to coordinate care unless you meet together as a group and then look at all the images, look at the clinical story. That was necessary,” says hepatologist Roshan Shrestha, MD, FAST, FAASLD, clinical professor of medicine at Mercer University School of Medicine and medical director of the liver transplant program at Piedmont Transplant Institute.
The transplant institute has really become a primary liver cancer program. “The hospital had planned on transplant. What they didn’t plan on was the 70% of people who come in for evaluation for transplant who have or will develop a primary liver cancer,” Dr. Citron says. “So what came out of this is we have a liver cancer program that is an orphan.” There was no other program in the hospital with the resources of the transplant team, nor covering a patient population with chronic liver disease, so the primary liver cancer program became part of the institute.
The majority of chronic liver disease and transplant patients are in some way treated by an IR. An IR may treat primary liver cancer, dissolve a clot in the portal vein to maintain a patient’s candidacy for liver transplant or create a TIPS. After transplant, an IR may drain fluid collections or dilate arteries, veins or bile ducts. Primary liver cancer patients may be treated with chemoembolization, radioembolization, microwave ablation or a combination thereof. Patients may also be treated by a combination of an IR, transplant surgeon and transplant hepatologist with therapeutic biliary endoscopy.
Creating the program and overcoming challenges
Find resources and other examples of collaborating with referring physicians at the Vision to Heal website, visiontoheal.org
The Piedmont Transplant Institute was conceived in 2002 and launched in 2005. Piedmont Atlanta Hospital was doing over 100 kidney transplants a year, and a transplant surgeon recommended the hospital pursue other transplant opportunities. The hospital hired Dr. Shrestha as a primary liver transplant physician certified by the United Network for Organ Sharing, as well as a surgeon, Mark W. Johnson, MD, and several supporting allied health specialists.
Dr. Citron jumped on board, shadowing the liver transplant team at the University of North Carolina (UNC) for a week to learn how to build a successful multidisciplinary program. “I came away with a template of what our program should look like.”
Drs. Citron, Shrestha and Johnson began meeting once a week at 6:30 a.m. for 5 years, before and after the institute was created. “We basically hammered out the program that we now have,” Dr. Citron says. “A lot of work went into it.”
Dr. Citron had been involved in the birth of the bone marrow transplant program at Northside Hospital in Atlanta. He saw how that program expanded his radiology practice, and he also enjoyed the challenges of building a new program. But not everyone was on board. Because Piedmont is a community hospital—not an academic setting—there were clinicians who were worried it would be too complex and make them too busy.
“There was a lot of resistance to change. And that was true amongst a lot of my partners as well,” he says. “It’s the clinical side of longitudinal patient management that was not part of our IR culture, and that requires increased personnel and cost. In a private practice that is concerned about maximizing income and minimizing costs, there was some resistance to the increase in work product required, the complexity of the work, and the costs that the work would entail."
Dr. Shrestha constantly encouraged Dr. Citron to change the culture and convince other clinicians of the huge potential of a liver transplant program. And then Piedmont Radiology Associates hired IR Aravind Arepally, MD, FSIR, from Johns Hopkins University, to support the program. “That was a seminal moment in the growth of our program because we now had increased stability to provide university-level care for these patients,” Dr. Citron says. “And then we added a third IR, and we were really off and running. It was difficult, but in the end we’ve created something really worthwhile and meaningful that we’re all proud of,” he says.
Developing a necessary referral network
A critical component of the liver program is the referral system. Without doctors—primarily gastroenterologists—knowing about the program and referring their patients to Piedmont, there would be few patients.
Dr. Shrestha oversees an extensive referral program across Georgia. There are five satellite clinics across the state, with a sixth in the works. Once a month, a hepatologist and physician assistant or nurse practitioner spend the day at one of the clinics in a local hospital to evaluate patients. The goal is to see all patients within one week of referral for evaluation.
To promote the liver program, Dr. Shrestha and other members of the liver cancer program travel the state regularly, holding presentations or stopping in gastroenterologist practices. A dedicated outreach coordinator maps out the plan, making sure clinicians reach out to specific practices in Georgia and the neighboring states about every six months to remind them about the program and answer any questions.
“It’s always multidisciplinary, and it takes the village,” Dr. Shrestha says. “You have to have your house in order before you go out and advertise yourself and your program, so that you can actually do what you tell them you’re going to do. That’s my message: Build the program, go out and talk to everybody and then provide the service. At the end of the day, action matters.”
As Dr. Citron explains, “We took a private practice customer-service concept and joined it with an academic multispecialty practice to create what we have now, which I think is exceptional.
“If I’m a patient coming in with a problem, I’m scared, I’m anxious, and I lack knowledge,” Dr. Citron continues. “And when patients with primary liver cancer leave that day—when they spend time with transplant hepatology, transplant surgery and interventional radiology—they know a lot and they feel more comfortable with their diagnosis, with the management plan, with what needs to happen. And we all become their doctors, and we try to act as one.”