1
|
Saben JL, Kaplan B, Burton JR, Cooper JE, Pomposelli JJ, Schold JD, Pomfret EA. Highlights From Controversies in Transplantation 2023 Conference. Transplantation 2024; 108:598-600. [PMID: 37314449 DOI: 10.1097/tp.0000000000004699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Jessica L Saben
- University of Colorado Anschutz Medical Campus, Department of Surgery, Aurora, CO
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
| | - Bruce Kaplan
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
- University of Colorado Anschutz Medical Campus, Department of Medicine, Aurora, CO
| | - James R Burton
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
- University of Colorado Anschutz Medical Campus, Department of Medicine, Aurora, CO
| | - James E Cooper
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
- University of Colorado Anschutz Medical Campus, Department of Medicine, Aurora, CO
| | - James J Pomposelli
- University of Colorado Anschutz Medical Campus, Department of Surgery, Aurora, CO
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
| | - Jesse D Schold
- University of Colorado Anschutz Medical Campus, Department of Surgery, Aurora, CO
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
| | - Elizabeth A Pomfret
- University of Colorado Anschutz Medical Campus, Department of Surgery, Aurora, CO
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
| |
Collapse
|
2
|
Wang C, Garg AX, Luo B, Kim SJ, Knoll G, Yohanna S, Treleaven D, McKenzie S, Ip J, Cooper R, Elliott L, Naylor KL. Defining pre-emptive living kidney donor transplantation as a quality indicator. Am J Transplant 2024:S1600-6135(24)00159-X. [PMID: 38395149 DOI: 10.1016/j.ajt.2024.02.017] [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: 10/03/2023] [Revised: 01/31/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024]
Abstract
Quality indicators in kidney transplants are needed to identify care gaps and improve access to transplants. We used linked administrative health care databases to examine multiple ways of defining pre-emptive living donor kidney transplants, including different patient cohorts and censoring definitions. We included adults from Ontario, Canada with advanced chronic kidney disease between January 1, 2013, to December 31, 2018. We created 4 unique incident patient cohorts, varying the eligibility by the risk of progression to kidney failure and whether individuals had a recorded contraindication to kidney transplant (eg, home oxygen use). We explored the effect of 4 censoring event definitions. Across the 4 cohorts, size varied substantially from 20 663 to 9598 patients, with the largest reduction (a 43% reduction) occurring when we excluded patients with ≥1 recorded contraindication to kidney transplantation. The incidence rate (per 100 person-years) of pre-emptive living donor kidney transplant varied across cohorts from 1.02 (95% CI: 0.91-1.14) for our most inclusive cohort to 2.21 (95% CI: 1.96-2.49) for the most restrictive cohort. Our methods can serve as a framework for developing other quality indicators in kidney transplantation and monitoring and improving access to pre-emptive living donor kidney transplants in health care systems.
Collapse
Affiliation(s)
- Carol Wang
- Division of Nephrology, Western University, London, Ontario, Canada.
| | - Amit X Garg
- Division of Nephrology, Western University, London, Ontario, Canada; ICES, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
| | - Bin Luo
- ICES, Ontario, Canada; Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
| | - S Joseph Kim
- Division of Nephrology and the Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Gregory Knoll
- University of Ottawa, Department of Medicine (Nephrology) and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Seychelle Yohanna
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | - Darin Treleaven
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | | | - Jane Ip
- Ontario Renal Network, Ontario Health, Ontario, Canada
| | - Rebecca Cooper
- Ontario Renal Network, Ontario Health, and Trillium Gift of Life Network, Ontario Health, Canada
| | - Lori Elliott
- Ontario Renal Network, Ontario Health, Ontario, Canada
| | - Kyla L Naylor
- ICES, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
| |
Collapse
|
3
|
Yu M, King KL, Husain SA, Huml AM, Patzer RE, Schold JD, Mohan S. Discrepant Outcomes between National Kidney Transplant Data Registries in the United States. J Am Soc Nephrol 2023; 34:1863-1874. [PMID: 37535362 PMCID: PMC10631598 DOI: 10.1681/asn.0000000000000194] [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] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 07/03/2023] [Indexed: 08/04/2023] Open
Abstract
SIGNIFICANCE STATEMENT Effects of reduced access to external data by transplant registries to improve accuracy and completeness of the collected data are compounded by different data management processes at three US organizations that maintain kidney transplant-related datasets. This analysis suggests that the datasets have large differences in reported outcomes that vary across different subsets of patients. These differences, along with recent disclosure of previously missing outcomes data, raise important questions about completeness of the outcome measures. Differences in recorded deaths seem to be increasing in recent years, reflecting the adverse effects of restricted access to external data sources. Although these registries are invaluable sources for the transplant community, discrepancies and incomplete reporting risk undermining their value for future analyses, particularly when used for developing national transplant policy or regulatory measures. BACKGROUND Central to a transplant registry's quality are accuracy and completeness of the clinical information being captured, especially for important outcomes, such as graft failure or death. Effects of more limited access to external sources of death data for transplant registries are compounded by different data management processes at the United Network for Organ Sharing (UNOS), the Scientific Registry of Transplant Recipients (SRTR), and the United States Renal Data System (USRDS). METHODS This cross-sectional registry study examined differences in reported deaths among kidney transplant candidates and recipients of kidneys from deceased and living donors in 2000 through 2019 in three transplant datasets on the basis of data current as of 2020. We assessed annual death rates and survival estimates to visualize trends in reported deaths between sources. RESULTS The UNOS dataset included 77,605 deaths among 315,346 recipients and 61,249 deaths among 275,000 nonpreemptively waitlisted candidates who were never transplanted. The SRTR dataset included 87,149 deaths among 315,152 recipients and 60,042 deaths among 259,584 waitlisted candidates. The USRDS dataset included 89,515 deaths among 311,955 candidates and 63,577 deaths among 238,167 waitlisted candidates. Annual death rates among the prevalent transplant population show accumulating differences across datasets-2.31%, 4.00%, and 4.03% by 2019 from UNOS, SRTR, and USRDS, respectively. Long-term survival outcomes were similar among nonpreemptively waitlisted candidates but showed more than 10% discordance between USRDS and UNOS among transplanted patients. CONCLUSIONS Large differences in reported patient outcomes across datasets seem to be increasing, raising questions about their completeness. Understanding the differences between these datasets is essential for accurate, reliable interpretation of analyses that use these data for policy development, regulatory oversight, and research. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_10_24_JASN0000000000000194.mp3.
Collapse
Affiliation(s)
- Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Kristen L. King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Anne M. Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
- Department of Transplantation, Cleveland Clinic, Cleveland, Ohio
| | - Rachel E. Patzer
- Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana
- Department of Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana
- Indiana University Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Jesse D. Schold
- Department of Surgery, University of Colorado – Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, School of Public Health, University of Colorado – Anschutz Medical Campus, Aurora, Colorado
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| |
Collapse
|
4
|
Abstract
BACKGROUND Quality in kidney transplantation is measured using 1-year patient and graft survival. Because 1-year patient and graft survival exceed 95%, this metric fails to measure a spectrum of quality. Textbook outcomes (TO) are a composite quality metric offering greater depth and resolution. We studied TO after living donor (LD) and deceased donor (DD) kidney transplantation. STUDY DESIGN United Network for Organ Sharing data for 69,165 transplant recipients between 2013 and 2017 were analyzed. TO was defined as patient and graft survival of 1 year or greater, 1-year glomerular filtration rate of greater than 40 mL/min, absence of delayed graft function, length of stay of 5 days or less, no readmissions during the first 6 months, and no episodes of rejection during the first year after transplantation. Bivariate analysis identified characteristics associated with TO, and covariates were incorporated into multivariable models. Five-year conditional survival was measured, and center TO rates were corrected for case complexity to allow center-level comparisons. RESULTS The national average TO rates were 54.1% and 31.7% for LD and DD transplant recipients. The hazard ratio for death at 5 years for recipients who did not experience TO was 1.92 (95% CI 1.68 to 2.18, p ≤ 0.0001) for LD transplant recipients and 2.08 (95% CI 1.93 to 2.24, p ≤ 0.0001) for DD transplant recipients. Center-level comparisons identify 18% and 24% of centers under-performing in LD and DD transplantation. High rates of TO do not correlate with transplantation center volume. CONCLUSION Kidney transplant recipients who experience TO have superior long-term survival. Textbook outcomes add value to the current standards of 1-year patient and graft survival.
Collapse
|
5
|
Patzer RE, Adler JT, Harding JL, Huml A, Kim I, Ladin K, Martins PN, Mohan S, Ross-Driscoll K, Pastan SO. A Population Health Approach to Transplant Access: Challenging the Status Quo. Am J Kidney Dis 2022; 80:406-415. [PMID: 35227824 DOI: 10.1053/j.ajkd.2022.01.422] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/09/2022] [Indexed: 01/27/2023]
Abstract
Transplant referral and evaluation are critical steps to waitlisting yet remain an elusive part of the transplant process. Despite calls for more data collection on pre-waitlisting steps, there are currently no national surveillance data to aid in understanding the causes and potential solutions for the extreme variation in access to transplantation. As population health scientists, epidemiologists, clinicians, and ethicists we submit that the transplant community has an obligation to better understand disparities in transplant access as a first necessary step to effectively mitigating these inequities. Our position is grounded in a population health approach, consistent with several new overarching national policy and quality initiatives. The purpose of this Perspective is to (1) provide an overview of how a population health approach should inform current multisystem policies impacting kidney transplantation and demonstrate how these efforts could be enhanced with national data collection on pre-waitlisting steps; (2) demonstrate the feasibility and concrete next steps for pre-waitlisting data collection; and (3) identify potential opportunities to use these data to implement effective population-level interventions, policies, and quality measures to improve equity in access to kidney transplantation.
Collapse
Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
| | - Joel T Adler
- Department of Surgery, Division of Organ Transplantation, University of Massachusetts, Worcester, Massachusetts; Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jessica L Harding
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Anne Huml
- Case Center for Reducing Health Disparities, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Irene Kim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts; Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, Massachusetts
| | - Paulo N Martins
- Department of Surgery, Division of Organ Transplantation, University of Massachusetts, Worcester, Massachusetts
| | - Sumit Mohan
- Departments of Medicine and Epidemiology, Columbia University, New York, New York
| | - Katie Ross-Driscoll
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stephen O Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
6
|
Josephson MA, Wiseman AC, Tucker JK, Segal MS, Schmidt RJ, Mujtaba MA, Gurley SB, Gaston RS, Doshi MD, Brennan DC, Moe SM. Existing Transplant Nephrology Compensation Models and Opportunities for Equitable Pay. Clin J Am Soc Nephrol 2022; 17:1407-1409. [PMID: 35914793 PMCID: PMC9625105 DOI: 10.2215/cjn.02010222] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
| | | | - J. Kevin Tucker
- Renal Medicine, Brigham and Women’s Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts
| | - Mark S. Segal
- Division of Nephrology, Hypertension & Transplantation, University of Florida, Gainesville, Florida
- Renal Section, North Florida/South Georgia Veteran Healthcare System, Gainesville, Florida
| | - Rebecca J. Schmidt
- Section of Nephrology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Muhammad A. Mujtaba
- Nephrology, Kidney and Pancreas Transplants, University of Texas Medical Branch School of Medicine, Galveston, Texas
| | - Susan B. Gurley
- Division of Nephrology and Hypertension, Oregon Health and Science University, Portland, Oregon
| | - Robert S. Gaston
- CTI Clinical Trial and Consulting, Inc., Covington, Kentucky
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Mona D. Doshi
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Daniel C. Brennan
- Nephrology, Comprehensive Transplant Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sharon M. Moe
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
7
|
Cacciola R, Cooper M, Favi E. Improving Clinical Governance of Kidney Transplantation: Review of a Ruling and of the Clinical Governance Process in the United Kingdom. Transplant Proc 2022; 54:1745-1749. [PMID: 35933236 DOI: 10.1016/j.transproceed.2022.03.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/26/2022] [Indexed: 11/16/2022]
Abstract
The presentation of adverse events and negative outcomes is uncommon in scientific publications, particularly in a highly regulated and scrutinized practice such as solid organ transplantation. A ruling of a regulatory body of the pharmaceutical industry in the United Kingdom generates several considerations, in particular, regarding the governance process of kidney transplantation, as the events reported in the ruling are linked with high rejection rates and negative patient outcomes. This analysis offered a review of the current governance processes, while recognizing the relevant limitations of the system regulating kidney transplantation outcomes in the United Kingdom. The article identified some of the potential interventions that may contribute to delivering an improved governance, harmonizing contemporary practice, modern health care system, and establishing scientific knowledge.
Collapse
Affiliation(s)
- Roberto Cacciola
- University of Tor Vergata, Department of Surgical Science, Rome, Italy; King Salman Armed Forces Hospital, Tabuk, Saudi Arabia.
| | - Matthew Cooper
- Georgetown University School of Medicine, Washington DC, USA
| | - Evaldo Favi
- Renal Transplantation, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
8
|
Wang C, Naylor KL, Luo B, Bota SE, Dixon SN, Yohanna S, Treleaven D, Elliott L, Garg AX. Using Administrative Health Care Databases to Identify Patients With End-Stage Kidney Disease With No Recorded Contraindication to Receiving a Kidney Transplant. Can J Kidney Health Dis 2022; 9:20543581221111712. [PMID: 35898578 PMCID: PMC9309776 DOI: 10.1177/20543581221111712] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/30/2022] [Indexed: 11/17/2022] Open
Abstract
Background Administrative health care databases can be efficiently analyzed to describe the degree to which patients with end-stage kidney disease (ESKD) have access to kidney transplantation. Measures of access to transplantation are better represented when restricting to only those patients eligible to receive a kidney transplant. The way administrative data can be used to assess kidney transplant eligibility in the absence of clinical data has not been well described. Objective To demonstrate a method that uses administrative health care databases to identify patients with ESKD who have no recorded contraindication to receiving a kidney transplant. Design and setting Population-based cohort study using linked administrative health care databases in Ontario, Canada. Patients Adult patients with ESKD approaching the need for dialysis (predialysis) or receiving maintenance dialysis between January 1, 2013 and March 31, 2015 in Ontario, Canada. Measurements Recipient of a kidney-only or kidney-pancreas transplant. Methods We assessed more than 80 baseline characteristics, including demographic information, comorbidities, kidney-specific characteristics, and referral and listing criteria for kidney transplantation. We compared these characteristics between patients who did and did not receive a kidney transplant. Results We included 23 642 patients with ESKD (11 195 who were predialysis and 12 447 receiving maintenance dialysis). Over a median follow-up of 3.2 years (25th, 75th percentile: 1.3, 5.6), 3215 (13.6%) received a kidney-only or kidney-pancreas transplant. Of the studied characteristics available in administrative databases, >97% of patients with one or more of these characteristics did not receive a kidney transplant during follow-up: ESKD-modified Charlson Comorbidity Index score ≥7 (a higher score represents greater comorbidity), home oxygen use, age above 75 years, dementia, living in a long-term care facility, receiving at least one physician house call in the past year, and a combination of select malignancies (ie, lung, lymphoma, cervical, colorectal, liver, active multiple myeloma, and bladder cancer). Using these combined criteria reduced the total number of patients from 23 642 to 12 539 with no recorded contraindications to transplant (a 47% reduction), while the proportion who received a kidney transplant changed from 13.6% (denominator of 23 642) to 24.9% (denominator of 12 539). Limitations Administrative databases are unable to capture all the complexities of determining transplant eligibility. Conclusion We identified several criteria available within administrative health care databases that can be used to identify patients with ESKD who have no recorded contraindications to kidney transplant. These criteria could be applied when reporting measures of access to kidney transplantation that require knowledge of transplant eligibility.
Collapse
Affiliation(s)
- Carol Wang
- Division of Nephrology, Western University, London, ON, Canada.,London Health Sciences Center, Victoria Hospital, London, ON, Canada
| | - Kyla L Naylor
- ICES, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | | | | | - Stephanie N Dixon
- ICES, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | | | - Darin Treleaven
- Division of Nephrology, McMaster University, Hamilton, ON, Canada
| | - Lori Elliott
- Ontario Renal Network, Ontario Health, Toronto, Canada
| | - Amit X Garg
- Division of Nephrology, Western University, London, ON, Canada.,ICES, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| |
Collapse
|
9
|
Abstract
Transplantation is a life-saving medical intervention that unfortunately is constrained by scarcity of available organs. An ideal system for allocating organs should seek to achieve the greatest good for the greatest number of people. It also must be fair and not disadvantage certain populations. However, policies aimed at reducing disparities also must be balanced with considerations of utility (graft outcomes), cost, efficiency, and any adverse effects on organ utilization. Here, we discuss the ethical challenges of creating a fair and equitable organ allocation system, focusing on the principles governing deceased donor kidney transplant waitlists around the world. The kidney organ allocation systems in the United States, Australia, and Hong Kong are used as illustrations.
Collapse
|
10
|
The Kidney Transplant Equity Index: Improving Racial and Ethnic Minority Access to Transplantation. Ann Surg 2022; 276:420-429. [PMID: 35762615 DOI: 10.1097/sla.0000000000005549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To develop a scalable metric which quantifies kidney transplant (KT) centers' performance providing equitable access to KT for minority patients, based on the individualized pre-listing prevalence of End-Stage Renal Disease (ESRD). SUMMARY BACKGROUND DATA Racial and ethnic disparities for access to transplant in patients with ESRD are well described; however, variation in care among KT centers remains unknown. Furthermore, no mechanism exists that quantifies how well a KT center provides equitable access to KT for minority patients with ESRD. METHODS From 2013-2018, custom datasets from the United States Renal Data System and United Network for Organ Sharing were merged to calculate the Kidney Transplant Equity Index (KTEI), defined as: the number of minority patients transplanted at a center relative to the prevalence of minority patients with ESRD in each center's health service area. Markers of socioeconomic status (SES) and recipient outcomes were compared between high and low KTEI centers. RESULTS 249 transplant centers performed 111,959 KTs relative to 475,914 non-transplanted patients with ESRD. High KTEI centers performed more KTs for Black (105.5 vs. 24, P<0.001), Hispanic (55.5 vs. 7, P<0.001), and American Indian (1.0 vs. 0.0, P<0.001) patients than low KTEI centers. In addition, high KTEI centers transplanted more patients with higher unemployment (52 vs. 44, P<0.001), worse social deprivation (53 vs. 46, P<0.001), and lower educational attainment (52 vs. 43, P<0.001). While providing increased access to transplant for minority and low SES populations, high KTEI centers had improved patient survival (HR: 0.86, 95% CI: 0.77-0.95). CONCLUSIONS The KTEI is the first metric to quantify minority access to KT incorporating the pre-listing ESRD prevalence individualized to transplant centers. KTEIs uncover significant national variation in transplant practices and identify highly equitable centers. This novel metric should be used to disseminate best practices for minority and low socioeconomic patients with ESRD.
Collapse
|
11
|
King KL, Husain SA, Cohen DJ, Schold JD, Mohan S. The role of bypass filters in deceased donor kidney allocation in the United States. Am J Transplant 2022; 22:1593-1602. [PMID: 35090080 DOI: 10.1111/ajt.16967] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/25/2023]
Abstract
Kidney transplant centers set organ offer filters enabling all candidates at their center to be bypassed during allocation of deceased donor kidneys from the UNOS Organ Center. These filters aim to increase allocation efficiency by preemptively screening out offers unlikely to be accepted. National data were used to compare filter settings of 175 centers in 2007 and in 2019. We examined characteristics of centers whose settings became increasingly restrictive over time, and associations between filter settings and organ offer acceptance. Overall, centers became more open to receiving offers over time, from a median 62% of filters open to receiving national offers in 2007 to 73% in 2019. Intravenous drug use filter settings changed most, from 63 to 153 willing centers. Centers with more open filter settings had higher transplant volume and offer acceptance ratios across all risk categories despite preemptively screening out fewer offers compared to centers with less open settings, but similar transplant rates. There was significant geographic heterogeneity in the distribution of centers with more open filter settings. Current center bypass filters may impact patients' access to transplantation without achieving their full potential for improving allocation efficiency.
Collapse
Affiliation(s)
- Kristen L King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - David J Cohen
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| |
Collapse
|
12
|
Textbook Outcome as a Quality Metric in Liver Transplantation. Transplant Direct 2022; 8:e1322. [PMID: 35464875 PMCID: PMC9018997 DOI: 10.1097/txd.0000000000001322] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/22/2022] [Accepted: 03/15/2022] [Indexed: 11/27/2022] Open
Abstract
Quality in liver transplantation (LT) is currently measured using 1-y patient and graft survival. Because patient and graft survival rates now exceed 90%, more informative metrics are needed. Textbook outcomes (TOs) describe ideal patient outcomes after surgery. This study critically evaluates TO as a quality metric in LT.
Collapse
|
13
|
Kshirsagar AV, Weiner DE, Mendu ML, Liu F, Lew SQ, O’Neil TJ, Bieber SD, White DL, Zimmerman J, Mohan S. Keys to Driving Implementation of the New Kidney Care Models. Clin J Am Soc Nephrol 2022; 17:1082-1091. [PMID: 35289764 PMCID: PMC9269631 DOI: 10.2215/cjn.10880821] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Contemporary nephrology practice is heavily weighted toward in-center hemodialysis, reflective of decisions on infrastructure and personnel in response to decades of policy. The Advancing American Kidney Health initiative seeks to transform care for patients and providers. Under the initiative’s framework, the Center for Medicare and Medicaid Innovation has launched two new care models that align patient choice with provider incentives. The mandatory ESRD Treatment Choices model requires participation by all nephrology practices in designated Hospital Referral Regions, randomly selecting 30% of all Hospital Referral Regions across the United States for participation, with the remaining Hospital Referral Regions serving as controls. The voluntary Kidney Care Choices model offers alternative payment programs open to nephrology practices throughout the country. To help organize implementation of the models, we developed Driver Diagrams that serve as blueprints to identify structures, processes, and norms, and generate intervention concepts. We focused on two goals that are directly applicable to nephrology practices and central to the incentive structure of the ESRD Treatment Choices and Kidney Care Choices: (1) increasing utilization of home dialysis, and (2) increasing the number of kidney transplants. Several recurring themes became apparent with implementation. Multiple stakeholders from assorted backgrounds are needed. Communication with primary care providers will facilitate timely referrals, education, and comanagement. Nephrology providers (nephrologists, nursing, dialysis organizations, others) must lead implementation. Patient engagement at nearly every step will help achieve the aims of the models. Advocacy with federal and state regulatory agencies will be crucial to expanding home dialysis and transplantation access. Although the models hold promise to improve choices and outcomes for many patients, we must be vigilant that they not do reinforce existing disparities in health care or widen known racial, socioeconomic, or geographic gaps. The Advancing American Kidney Health initiative has the potential to usher in a new era of value-based care for nephrology.
Collapse
Affiliation(s)
- Abhijit V. Kshirsagar
- University of North Carolina Kidney Center and Division of Nephrology & Hypertension, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Quality Committee, American Society of Nephrology, Washington, DC
| | - Daniel E. Weiner
- Quality Committee, American Society of Nephrology, Washington, DC
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Mallika L. Mendu
- Quality Committee, American Society of Nephrology, Washington, DC
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Frank Liu
- Quality Committee, American Society of Nephrology, Washington, DC
- Division of Nephrology and Hypertension, Weill Cornell Medicine, Rogosin Institute, New York, New York
| | - Susie Q. Lew
- Quality Committee, American Society of Nephrology, Washington, DC
- Division of Renal Diseases and Hypertension, George Washington University, Washington, DC
| | - Terrence J. O’Neil
- Quality Committee, American Society of Nephrology, Washington, DC
- James Quillen Veterans Administration Medical Center, Johnson City, Tennessee
| | - Scott D. Bieber
- Quality Committee, American Society of Nephrology, Washington, DC
- Kootenai Health, Coeur d’Alene, Idaho
| | - David L. White
- Quality Committee, American Society of Nephrology, Washington, DC
- Policy and Government Affairs, American Society of Nephrology, Washington, DC
| | - Jonathan Zimmerman
- Center for Health Innovation, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sumit Mohan
- Quality Committee, American Society of Nephrology, Washington, DC
- Division of Nephrology, Department of Medicine and Department of Epidemiology, Columbia University, New York, New York
| |
Collapse
|
14
|
Davis S, Mohan S. Managing Patients with Failing Kidney Allograft: Many Questions Remain. Clin J Am Soc Nephrol 2022; 17:444-451. [PMID: 33692118 PMCID: PMC8975040 DOI: 10.2215/cjn.14620920] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Patients who receive a kidney transplant commonly experience failure of their allograft. Transplant failure often comes with complex management decisions, such as when and how to wean immunosuppression and start the transition to a second transplant or to dialysis. These decisions are made in the context of important concerns about competing risks, including sensitization and infection. Unfortunately, the management of the failed allograft is, at present, guided by relatively poor-quality data and, as a result, practice patterns are variable and suboptimal given that patients with failed allografts experience excess morbidity and mortality compared with their transplant-naive counterparts. In this review, we summarize the management strategies through the often-precarious transition from transplant to dialysis, highlighting the paucity of data and the critical gaps in our knowledge that are necessary to inform the optimal care of the patient with a failing kidney transplant.
Collapse
Affiliation(s)
- Scott Davis
- Department of Medicine, University of Colorado, Aurora, Colorado,Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York, New York,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Sumit Mohan
- Department of Medicine, University of Colorado, Aurora, Colorado .,Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| |
Collapse
|
15
|
Schold JD, Mohan S, Huml A, Buccini LD, Sedor JR, Augustine JJ, Poggio ED. Failure to Advance Access to Kidney Transplantation over Two Decades in the United States. J Am Soc Nephrol 2021; 32:913-926. [PMID: 33574159 PMCID: PMC8017535 DOI: 10.1681/asn.2020060888] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 12/02/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Extensive research and policies have been developed to improve access to kidney transplantation among patients with ESKD. Despite this, wide variation in transplant referral rates exists between dialysis facilities. METHODS To evaluate the longitudinal pattern of access to kidney transplantation over the past two decades, we conducted a retrospective cohort study of adult patients with ESKD initiating ESKD or placed on a transplant waiting list from 1997 to 2016 in the United States Renal Data System. We used cumulative incidence models accounting for competing risks and multivariable Cox models to evaluate time to waiting list placement or transplantation (WLT) from ESKD onset. RESULTS Among the study population of 1,309,998 adult patients, cumulative 4-year WLT was 29.7%, which was unchanged over five eras. Preemptive WLT (prior to dialysis) increased by era (5.2% in 1997-2000 to 9.8% in 2013-2016), as did 4-year WLT incidence among patients aged 60-70 (13.4% in 1997-2000 to 19.8% in 2013-2016). Four-year WLT incidence diminished among patients aged 18-39 (55.8%-48.8%). Incidence of WLT was substantially lower among patients in lower-income communities, with no improvement over time. Likelihood of WLT after dialysis significantly declined over time (adjusted hazard ratio, 0.80; 95% confidence interval, 0.79 to 0.82) in 2013-2016 relative to 1997-2000. CONCLUSIONS Despite wide recognition, policy reforms, and extensive research, rates of WLT following ESKD onset did not seem to improve in more than two decades and were consistently reduced among vulnerable populations. Improving access to transplantation may require more substantial interventions.
Collapse
Affiliation(s)
- Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, New York,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Anne Huml
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Laura D. Buccini
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - John R. Sedor
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Emilio D. Poggio
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
16
|
Paul S, Melanson T, Mohan S, Ross-Driscoll K, McPherson L, Lynch R, Lo D, Pastan SO, Patzer RE. Kidney transplant program waitlisting rate as a metric to assess transplant access. Am J Transplant 2021; 21:314-321. [PMID: 32808730 PMCID: PMC7980228 DOI: 10.1111/ajt.16277] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 01/25/2023]
Abstract
Kidney transplant program performance in the United States is commonly measured by posttransplant outcomes. Inclusion of pretransplant measures could provide a more comprehensive assessment of transplant program performance and necessary information for patient decision-making. In this study, we propose a new metric, the waitlisting rate, defined as the ratio of patients who are waitlisted in a center relative to the person-years referred for evaluation to a program. Furthermore, we standardize the waitlisting rate relative to the state average in Georgia, North Carolina, and South Carolina. The new metric was used as a proof-of-concept to assess transplant-program access compared to the existing transplant rate metric. The study cohorts were defined by linking 2017 United States Renal Data System (USRDS) data with transplant-program referral data from the Southeastern United States between January 1, 2012 and December 31, 2016. Waitlisting rate varied across the 9 Southeastern transplant programs, ranging from 10 to 22 events per 100 patient-years, whereas the program-specific waitlisting rate ratio ranged between 0.76 and 1.33. Program-specific waitlisting rate ratio was uncorrelated with the transplant rate ratio (r = -.15, 95% CI, -0.83 to 0.57). Findings warrant collection of national data on early transplant steps, such as referral, for a more comprehensive assessment of transplant program performance and pretransplant access.
Collapse
Affiliation(s)
- Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Taylor Melanson
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
| | - Sumit Mohan
- Department of Medicine, Vagelos College of Physicians & Surgeons, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Katherine Ross-Driscoll
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Raymond Lynch
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
| | - Denise Lo
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen O. Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
17
|
Knoll GA, Fortin MC, Gill J, Grimshaw JM, Hartell DP, Karnabi P, Parsons CD, Vorster H, Kim SJ. Measuring quality in living donation and kidney transplantation: moving beyond survival metrics. Kidney Int 2020; 98:860-869. [PMID: 32791254 DOI: 10.1016/j.kint.2020.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/10/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Greg A Knoll
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Marie-Chantal Fortin
- Research Centre of the Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Québec, Canada; Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada; Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada
| | - Jagbir Gill
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, Canada; Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, Canada
| | - Jeremy M Grimshaw
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - David P Hartell
- Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada
| | - Priscilla Karnabi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Christina D Parsons
- Organ and Tissue Donation and Transplantation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Hans Vorster
- Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada; Patient Governance Council, Can-SOLVE CKD Network, Vancouver, British Columbia, Canada
| | - S Joseph Kim
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
18
|
Kim DW, Tsapepas D, King KL, Husain SA, Corvino FA, Dillon A, Wang W, Mayne TJ, Mohan S. Financial impact of delayed graft function in kidney transplantation. Clin Transplant 2020; 34:e14022. [PMID: 32573812 DOI: 10.1111/ctr.14022] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/09/2020] [Accepted: 06/16/2020] [Indexed: 11/28/2022]
Abstract
Increased utilization of suboptimal organs in response to organ shortage has resulted in increased incidence of delayed graft function (DGF) after transplantation. Although presumed increased costs associated with DGF are a deterrent to the utilization of these organs, the financial burden of DGF has not been established. We used the Premier Healthcare Database to conduct a retrospective analysis of healthcare resource utilization and costs in kidney transplant patients (n = 12 097) between 1/1/2014 and 12/31/2018. We compared cost and hospital resource utilization for transplants in high-volume (n = 8715) vs low-volume hospitals (n = 3382), DGF (n = 3087) vs non-DGF (n = 9010), and recipients receiving 1 dialysis (n = 1485) vs multiple dialysis (n = 1602). High-volume hospitals costs were lower than low-volume hospitals ($103 946 vs $123 571, P < .0001). DGF was associated with approximately $18 000 (10%) increase in mean costs ($130 492 vs $112 598, P < .0001), 6 additional days of hospitalization (14.7 vs 8.7, P < .0001), and 2 additional ICU days (4.3 vs 2.1, P < .0001). Multiple dialysis sessions were associated with an additional $10 000 compared to those with only 1. In conclusion, DGF is associated with increased costs and length of stay for index kidney transplant hospitalizations and payment schemes taking this into account may reduce clinicians' reluctance to utilize less-than-ideal kidneys.
Collapse
Affiliation(s)
- Daniel W Kim
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - Demetra Tsapepas
- Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA.,Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, NY, USA.,Department of Analytics, New York Presbyterian Hospital, New York, NY, USA
| | - Kristen L King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | | | | | | | | | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| |
Collapse
|
19
|
Huml AM, Sedor JR, Poggio E, Patzer RE, Schold JD. An opt-out model for kidney transplant referral: The time has come. Am J Transplant 2020; 21:32-36. [PMID: 32519382 PMCID: PMC7725926 DOI: 10.1111/ajt.16129] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 05/14/2020] [Accepted: 06/01/2020] [Indexed: 01/25/2023]
Abstract
Disparities that affect equity in access to kidney transplantation for patients with kidney failure have been well described. Many robust clinical trials have tested the effectiveness of interventions to reduce disparities and equilibrate access to kidney transplantation. Moreover, policy changes have been enacted to achieve the same aims. Despite these efforts, rates of kidney transplant waitlisting within the first year of end-stage kidney disease have remained unchanged over the past 2 decades, while incident rates of end-stage kidney disease have climbed. Because prior interventions have not durably increased transplant access, disruptive change is clearly needed. The Advancing American Kidney Health Executive Order sets bold goals to transform kidney care for patients and caregivers. In this spirit, we discuss an Opt-Out for Transplant Referral Model as a compelling solution to improve equity in access to kidney transplantation.
Collapse
Affiliation(s)
- Anne M. Huml
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic
| | - John R. Sedor
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic
| | - Emilio Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine,Department of Epidemiology, Emory University Rollins School of Public Health
| | - Jesse D Schold
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic,Department of Quantitative Health Sciences, Cleveland Clinic
| |
Collapse
|
20
|
Ibrahim M, Vece G, Mehew J, Johnson R, Forsythe J, Klassen D, Callaghan C, Stewart D. An international comparison of deceased donor kidney utilization: What can the United States and the United Kingdom learn from each other? Am J Transplant 2020; 20:1309-1322. [PMID: 31758833 DOI: 10.1111/ajt.15719] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/28/2019] [Accepted: 11/15/2019] [Indexed: 01/25/2023]
Abstract
In transplant, meaningful international comparisons in organ utilization are needed. This collaborative study between the United Kingdom (UK) and the United States (US) aimed to develop a kidney utilization metric allowing for legitimate intercountry comparisons. Data from the UK and US transplant registries, including all deceased donor kidneys recovered from 2006 to 2017, were analyzed. To identify a potentially comparable kidney utilization rate (UR), several denominators were assessed. We discovered that the proportion of transplanted kidneys from elderly donors in the UK (10.7%) was 18 times greater than that in the US (0.6%). Conversely, en bloc pediatric kidney transplant was more common in the US. Donation after circulatory death utilization has risen in both countries but is twice as prevalent in the UK (39% of transplants) vs the US (20%). In addition, US and UK URs are not directly comparable due to fundamental system differences. However, using a suite of URs revealed practice areas likely to yield the most benefit if improved, such as efforts to increase kidney offer acceptance in the US and to reduce postacceptance discard in the UK. Methods used in this study, including novel intracountry risk-adjusted UR trend logistic regression analyses, can be translated to other international transplant registries in pursuit of further global learning opportunities.
Collapse
Affiliation(s)
- Maria Ibrahim
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK.,National Health Service Blood and Transplant, Bristol, UK
| | - Gabe Vece
- United Network for Organ Sharing, Richmond, Virginia
| | - Jenny Mehew
- National Health Service Blood and Transplant, Bristol, UK
| | - Rachel Johnson
- National Health Service Blood and Transplant, Bristol, UK
| | - John Forsythe
- National Health Service Blood and Transplant, Bristol, UK
| | - David Klassen
- United Network for Organ Sharing, Richmond, Virginia
| | - Chris Callaghan
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK.,National Health Service Blood and Transplant, Bristol, UK
| | | |
Collapse
|
21
|
The evolving role of regulatory reporting on patient and donor selection in organ transplantation. Curr Opin Organ Transplant 2020; 25:158-162. [DOI: 10.1097/mot.0000000000000741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
22
|
Patzer RE, Pastan SO. Policies to promote timely referral for kidney transplantation. Semin Dial 2020; 33:58-67. [PMID: 31957930 DOI: 10.1111/sdi.12860] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/14/2019] [Indexed: 02/06/2023]
Abstract
There are numerous patient, provider, and health system barriers to accessing kidney transplantation. Patient barriers such as sociocultural and clinical characteristics and provider factors such as provider knowledge and awareness of transplantation play important roles in facilitating transplant. Health system factors like misaligned incentives and quality metrics for dialysis facilities and transplant centers also influence transplant access. While numerous studies have documented the impact of these barriers on wait-listing and transplant, few studies have examined referral from a dialysis facility to a transplant center and start of the transplant evaluation process. While the Centers for Medicare and Medicaid Services (CMS) require that dialysis facilities educate patients about transplant, there are no guidelines for the content and objectives for this education. In addition, policies to require timely referral for transplantation have been considered by CMS but are difficult to implement without national data on referral. Federal policies should be amended to mandate transplant center submission of referral data-while decreasing the unfunded mandate to collect other unusable data currently collected as part of regulatory monitoring of transplant centers-to promote timely access to transplant, increased transplant rates, and to better understand the multilevel barriers and facilitators to transplant referral.
Collapse
Affiliation(s)
- Rachel E Patzer
- Department of Medicine, Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA.,Department of Surgery, Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA.,Emory Transplant Center, Atlanta, GA, USA.,Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Stephen O Pastan
- Department of Medicine, Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA.,Department of Surgery, Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA.,Emory Transplant Center, Atlanta, GA, USA.,Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
23
|
Elfadawy N, Flechner SM. Retransplantation after nonadherence-related kidney allograft failure - forgive or forget? Transpl Int 2019; 32:1241-1243. [PMID: 31553095 DOI: 10.1111/tri.13531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/19/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Nissreen Elfadawy
- Division on Nephrology, Department of Medicine, University Hospitals Cleveland Medical Center and School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Stuart M Flechner
- Glickman Urology and Kidney Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| |
Collapse
|
24
|
Patzer RE, McPherson L. Variation in Kidney Transplant Referral: How Much More Evidence Do We Need To Justify Data Collection on Early Transplant Steps? J Am Soc Nephrol 2019; 30:1554-1556. [PMID: 31471500 DOI: 10.1681/asn.2019070674] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; .,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia; and.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Laura McPherson
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
25
|
Mohan S, Husain SA. Patient-Centered Outcomes with Second Kidney Transplant. Clin J Am Soc Nephrol 2019; 14:1131-1132. [PMID: 31337622 PMCID: PMC6682818 DOI: 10.2215/cjn.07400619] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York; .,The Columbia University Renal Epidemiology Group, New York, New York; and.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York; and
| |
Collapse
|