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Amdani S, Dewey EN, Schold JD. Public Reporting of Heart Transplant Center Performance: Promoting Clarity or Causing Confusion? JACC. HEART FAILURE 2024; 12:1274-1283. [PMID: 38613559 DOI: 10.1016/j.jchf.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/07/2023] [Accepted: 01/22/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Transplant center report cards are publicly available and used by regulators, insurance payers, and importantly patients and families. OBJECTIVES In this study, the authors sought to evaluate the variability in reported public performance ratings of pediatric and adult heart transplant centers. METHODS Program-specific reports from the Scientific Registry of Transplant Recipients from 2017-2021 were used to evaluate stability, volatility, and reliability of 3 publicly reported ratings: waitlist survival (WS), getting to a faster transplant (FT), and post-transplantation graft failure (GF). RESULTS There were 112 adult and 55 pediatric centers. Over the study period, nearly all centers (98%) had at least 1 change in rating in at least 1 of the tiers. The average time to the first rating change of any magnitude was 12-18 months for all tiers and centers. For adult centers, the most volatile rating was WS (SD: 0.77), followed by GF (SD: 0.76) and then FT (SD: 0.57). For pediatric centers, the most volatile rating was WS (SD: 0.79), followed by both GF (SD: 0.66) and FT (SD: 0.68), which were equally volatile. All tiers except adult FT had an estimated Fleiss's kappa <0.20, indicating poor agreement/consistency across the study period. In addition, the intraclass correlation coefficient for all tiers was <0.50, indicating poor reliability. CONCLUSIONS The current 5-tier reporting of transplant center performance is highly volatile and has poor reliability and consistency. Given the unintended and significant negative consequences these reports can have, critical revision of these ratings is warranted.
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Affiliation(s)
- Shahnawaz Amdani
- Children's Institute Department of Heart, Vascular and Thoracic, Division of Cardiology and Cardiovascular Medicine, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA.
| | - Elizabeth N Dewey
- Center for Populations Health Research, Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Pinney SP, Walsh MN. The Path Toward a More Equitable Transplant System: There Can Be No Improvement Without Measurement. JACC. HEART FAILURE 2024; 12:1288-1292. [PMID: 38960522 DOI: 10.1016/j.jchf.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 06/03/2024] [Indexed: 07/05/2024]
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Amdani S, Gossett JG, Chepp V, Urschel S, Asante-Korang A, Dalton JE. Review on clinician bias and its impact on racial and socioeconomic disparities in pediatric heart transplantation. Pediatr Transplant 2024; 28:e14704. [PMID: 38419391 DOI: 10.1111/petr.14704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/18/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024]
Abstract
This expert review seeks to highlight implicit bias in health care, transplant medicine, and pediatric heart transplantation to focus attention on the role these biases may play in the racial/ethnic and socioeconomic disparities noted in pediatric heart transplantation. This review breaks down the transplant decision making process to highlight points at which implicit bias may affect outcomes and discuss how the science of human decision making may help understand these complex processes.
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Affiliation(s)
- Shahnawaz Amdani
- Children's Institute Department of Heart, Vascular & Thoracic, Division of Cardiology & Cardiovascular Medicine, Cleveland, Ohio, USA
| | - Jeffrey G Gossett
- Northwell, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Valerie Chepp
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Simon Urschel
- Division of Pediatric Cardiology at the University of Alberta, Edmonton, Alberta, Canada
| | - Alfred Asante-Korang
- Division of Pediatric Cardiology, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Jarrod E Dalton
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
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McCulloch MA, Alonzi LP, White SC, Haregu F, Porter MD. Pediatric donor heart acceptance practices in the United States: What is really being considered? Pediatr Transplant 2024; 28:e14649. [PMID: 38013204 PMCID: PMC10872937 DOI: 10.1111/petr.14649] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/23/2023] [Accepted: 11/06/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Recent studies demonstrate high offer decline and organ non-utilization rates are associated with increased pediatric heart transplant waitlist mortality. We sought to determine which donor, candidate, and offer specific variables most importantly influenced these decisions using only data available at the time of each offer. METHODS Retrospective review of pediatric (<18 years) heart donor offers made to pediatric candidates in the United States between 2010 and 2020. In addition to standard donor, candidate, and offer data available in UNOS, we extracted objective and qualitative valvar and myocardial function data from all available donor echocardiogram reports. RESULTS During the study period, 5625 pediatric donor hearts produced 30 156 offers to 4905 unique candidates, of which 88.7% of all offers were declined and 39.2% of organs were not utilized by pediatric waitlisted candidates. Of the 60.8% utilized hearts, 89.7% had a 'cumulatively' normal echocardiogram at the time of offer acceptance; 62.9% of hearts not utilized for a pediatric candidate also had a cumulatively normal final echocardiogram. Random forest and logistic regression modeling demonstrated good predictive performance (AUROC ≥0.83) of likelihood to accept when utilizing donor, candidate, and offer specific variables. SHAP variable importance scores demonstrated number of prior offer declines and candidate institution's prior year acceptance rates as the two most important variables influencing offer decisions. CONCLUSIONS Behavioral economics appear to play a significant role in pediatric heart transplant candidate institutions' acceptance practices, even when considering the arguably healthier pediatric donor population. Removal of prior institution's decisions from DonorNet may help increase donor utilization.
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Affiliation(s)
- M A McCulloch
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia, USA
| | - L P Alonzi
- School of Data Science, University of Virginia, Charlottesville, Virginia, USA
| | - S C White
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia, USA
| | - F Haregu
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia, USA
| | - M D Porter
- School of Data Science, University of Virginia, Charlottesville, Virginia, USA
- Department of Systems and Information Engineering, University of Virginia, Charlottesville, Virginia, USA
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Sharma A, Logan B, Estrada-Merly N, Lehmann LE, Rangarajan HG, Preussler JM, Troy JD, Akard LP, Bhatt NS, Truong TH, Wood WA, Strouse C, Juckett M, Khera N, Rizzo D, Saber W. Impact of Public Reporting of Center-Specific Survival Analysis Scores on Patient Volumes at Hematopoietic Cell Transplant Centers. Transplant Cell Ther 2023:S2666-6367(23)01296-4. [PMID: 37220838 DOI: 10.1016/j.jtct.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND The Center for International Blood and Marrow Transplant Research (CIBMTR) reports the outcomes of allogeneic hematopoietic cell transplantation (alloHCT) at United States transplant centers (TC) annually through its Center-Specific Survival Analysis (CSA). The CSA compares the actual 1-year overall survival (OS) and predicted 1-year OS rate after alloHCT at each TC, which is then reported as 0 (OS as expected), -1 (OS worse than expected), or +1 (OS better than expected). OBJECTIVE We evaluated the impact of public reporting of TC performance on their alloHCT patient volumes. STUDY DESIGN Ninety-one TCs that serve adult or combined adult and pediatric populations and had CSA scores reported for 2012-2018 were included. We analyzed prior-calendar year TC volume, prior-calendar year CSA score, whether the CSA score had changed in the prior year from two years earlier, calendar year, TC type (adult only vs. combined adult and pediatric), and years of alloHCT experience for their impact on patient volumes. RESULTS A CSA score of -1, as compared with 0 or +1, was associated with an 8%-9% reduction in the mean TC volume (P < 0.001) in the subsequent year, adjusting for the prior year center volume. Additionally, being a TC neighboring an index TC with a -1 CSA score, was associated with a 3.5% increase in mean TC volume (P = 0.04). CONCLUSION Our data show that public reporting of CSA scores is associated with changes in alloHCT volumes at TCs. Additional investigation into the causes of this shift in patient volume and the impact on outcomes is ongoing.
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Affiliation(s)
- Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN.
| | - Brent Logan
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI; CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Noel Estrada-Merly
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Leslie E Lehmann
- Dana Farber Cancer Institute/Boston Children's Hospital, Boston, MA
| | - Hemalatha G Rangarajan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, OH
| | - Jaime M Preussler
- National Marrow Donor Program®/Be The Match®, CIBMTR® (Center for International Blood and Marrow Transplant Research), Minneapolis, MN
| | - Jesse D Troy
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Luke P Akard
- Indiana Blood and Marrow Transplantation, Franciscan Health, Indianapolis, IN
| | - Neel S Bhatt
- University of Washington School of Medicine, Department of Pediatrics, Division of Hematology/Oncology and Bone Marrow Transplant, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Tony H Truong
- Division of Pediatric Oncology, Blood and Marrow Transplant, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - William A Wood
- Division of Hematology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Christopher Strouse
- Division of Hematology, Oncology, and Bone Marrow Transplantation, University of Iowa, Iowa City, IA
| | - Mark Juckett
- Department of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Nandita Khera
- Department of Hematology/Oncology, Mayo Clinic, Phoenix, AZ
| | - Douglas Rizzo
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Wael Saber
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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Schold JD, Hoffman J, Cleveland J. Developing a System for Best Performance for Cardiac Transplantation. JACC. HEART FAILURE 2023; 11:520-522. [PMID: 37137659 DOI: 10.1016/j.jchf.2023.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/04/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
| | - Jordan Hoffman
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joseph Cleveland
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Amdani S, Korang AA, Law Y, Cantor R, Koehl D, Kirklin JK, Ybarra M, Rusconi P, Azeka E, Ruiz ACP, Schowengerdt K, Bostdorff H, Joong A. Waitlist and post-transplant outcomes for children with myocarditis listed for heart transplantation over 3 decades. J Heart Lung Transplant 2023; 42:89-99. [PMID: 36038480 DOI: 10.1016/j.healun.2022.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/09/2022] [Accepted: 07/12/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND There is limited and conflicting information on waitlist and transplant outcomes for children with myocarditis. METHODS Retrospective review included children with myocarditis and dilated cardiomyopathy (DCM) listed for HT from January 01, 1993 to December 31, 2019 in the Pediatric Heart Transplant Society database. Clinical characteristics, waitlist and post-HT outcomes (graft loss, rejection, cardiac allograft vasculopathy, infection and malignancy) for children listed from early (1993-2008) and current era (2009-2019) with myocarditis were evaluated and compared to those with DCM. RESULTS Of 9755 children listed, 322 (3.3%) had myocarditis and 3178 (32.6%) DCM. Compared to DCM, children with myocarditis in the early and the current era were significantly more likely to be listed at higher urgency; be in intensive care unit; on mechanical ventilation; extracorporeal membrane oxygenation and ventricular assist device (p < 0.05 for all). While unadjusted analysis revealed lower transplant rates and higher waitlist mortality for children with myocarditis, in multivariable analysis, myocarditis was not a risk factor for waitlist mortality. Myocarditis, however, was a significant risk factor for early phase post-HT graft loss (HR 2.46; p = 0.003). Waitlist and post-HT survival for children with myocarditis were similar for those listed and transplanted in the early era to those listed and transplanted in the current era (p > 0.05 for both). CONCLUSIONS Children with myocarditis have a higher acuity of illness at listing and at HT and have inferior post-HT survival compared to children with DCM. Outcomes for children with myocarditis have not improved over the 3 decades and efforts are needed to improve outcomes for this cohort.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Ohio.
| | | | - Yuk Law
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Ryan Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Marion Ybarra
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Paolo Rusconi
- Department of Pediatrics, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Estela Azeka
- Heart Institute (InCor) University of Sao Paulo Medical School, Brazil
| | | | - Kenneth Schowengerdt
- Division of Pediatric Cardiology, Cardinal Glennon Children's Hospital, St. Louis University School of Medicine, St. Louis, Missouri
| | - Hannah Bostdorff
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Ohio
| | - Anna Joong
- Division of Pediatric Cardiology, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Waitlist Outcomes for Children With Congenital Heart Disease: Lessons Learned From Over 5000 Heart Transplant Listings in the United States. J Card Fail 2022; 28:982-990. [PMID: 35301110 DOI: 10.1016/j.cardfail.2022.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND We evaluated the impact of pediatric heart-allocation policy changes over time and the approval of the Berlin ventricular assist device (VAD) on waitlist (WL) outcomes for children with congenital heart disease (CHD). METHODS The Scientific Registry of Transplant Recipients database was evaluated to include all children (age < 18) with CHD and cardiomyopathy (CMP) on the WL between 1999 and 2019, divided into 4 eras: Era 1 (1999-2008); Era 2 (2009-2011); Era 3 (2012-2016); and Era 4 (2016-2019). WL characteristics and survival outcomes were evaluated for patients with CHD over time and were compared to those with CMP listed currently (Era 4). RESULTS We included 5185 children with CHD on the WL during the study period; 1999 (39%) were listed in Era 1; 693 (13%) in Era 2; 1196 (23%) in Era 3; and 1297 (25%) in Era 4. Compared to the CHD WL in eras 1 and 2, those in Era 4 were less likely to be infants (48% vs 49% vs 43%), on mechanical ventilation (30% vs 26% vs 19%), on extracorporeal membrane oxygenation (15% vs 9.7% vs 6.2%), and were more likely to be on a VAD (2.4% vs 2.2% vs 6.0%) (P < .05 for all). WL survival improved in children with CHD from Era 1 to Era 4 (P < .001). However, in Era 4, children with CHD had lower WL survival than those with CMP (P < .001). CONCLUSION Children with CHD are increasingly being listed with less advanced heart failure, and they have had improved WL survival over time; however, WL outcomes remain inferior to those with CMP. Advances in pediatric medical and VAD therapy may improve future WL outcomes.
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Woods RK, Kirklin JK, Maeda K, Adachi I. We Need Better Pediatric Cardiac Transplantation Risk Modeling. J Thorac Cardiovasc Surg 2022; 164:2036-2039.e1. [DOI: 10.1016/j.jtcvs.2021.12.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/15/2021] [Accepted: 12/20/2021] [Indexed: 11/16/2022]
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