Regulatory oversight in transplantation

The Collaborative Innovation and Improvement Network (COIIN): Effect on donor yield, waitlist mortality, transplant rates, and offer acceptance

The Organ Procurement and Transplantation Network implemented the Collaborative Improvement and Innovation Network (COIIN) to improve the use of donors with kidney donor profile index >50%. COIIN recruited 2 separate cohorts of kidney transplant programs. Cohort A included 19 programs of 44 applicants (January 1, 2017, to September 30, 2017), and cohort B included 39 programs of 47 applicants (October 1, 2017, to June 30, 2018). We investigated the effect of COIIN on kidney yield (number of kidneys transplanted from donors from whom any organ was recovered), offer acceptance, deceased donor transplant rates, and waitlist mortality rates for January 1, 2016, to March 31, 2019. COIIN did not notably affect kidney yield or waitlist mortality rates. Cohort A, but not cohort B, had significantly higher deceased donor transplant and offer acceptance rates during its intervention period than programs not in COIIN (adjusted transplant rate ratio: cohort A, _1.08 1.17_1.27 , cohort B, _0.94 1.01_1.08 ; adjusted offer acceptance ratio: cohort A, _1.08 1.18_1.29 , cohort B, _0.93 1.00_1.08 ). Thus, COIIN improved the use of kidneys at programs in cohort A but not at those in cohort B. Further research is necessary to understand the different effects for cohorts A and B, and further monitoring of posttransplant outcomes is required.

Patients and their family members prioritize post-transplant survival over waitlist survival when considering donor hearts for transplantation

Heart transplant providers often focus on post-transplant outcomes when making donor decisions, potentially at the expense of higher waitlist mortality. This study aimed to assess public opinion regarding the selection of donor hearts and the balance between pre- and post-transplant risk. The authors generated a survey to investigate public opinion regarding donor acceptance. The survey was shared freely online across social media platforms in April-May 2019. A total of 718 individuals responded to the survey, with an equal distribution between patients and family members. Respondents consistently favored post-transplant outcomes over waitlist outcomes. About 83.9% of respondents favored a hospital with longer waitlist times, worse waitlist outcomes, but excellent post-transplant survival over a hospital with short waitlist times, a high waitlist survival, and inferior post-transplant survival. This preference was no different between pediatric and adult populations (P = .7), patient and family members (P = .935), or those with a pre- vs post-transplant perspective (P = .985). Patients and their family members consistently favor improved post-transplant survival over waitlist survival when considering the risks of accepting a donor organ. These findings suggest that current practice patterns of donor selection align with the opinions of patients and family members with heart failure or who have undergone heart transplantation.

Comparing Scientific Registry of Transplant Recipients posttransplant program-specific outcome ratings at listing with subsequent recipient outcomes after transplant

To improve accessibility of program-specific reports to patients, the Scientific Registry of Transplant Recipients released a 5-tier system for categorizing 1-year posttransplant program evaluations. Whether this system predicts subsequent posttransplant outcomes at the time patients are waitlisted has been questioned. We investigated the association of tier at listing and the corresponding continuous score used for tier assignment, which ranges from 0 (poor outcomes) to 1 (good outcomes), with eventual 1-year posttransplant graft survival for candidates listed between July 12, 2011, and June 16, 2014, who underwent transplant before December 31, 2016. One additional tier at listing was associated with better 1-year posttransplant outcomes in liver (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.89-0.97) and lung transplant (HR, 0.90; 95% CI, 0.84-0.97) but not kidney (HR, 0.96; 95% CI, 0.92-1.01) or heart transplant (HR, 1.02; 95% CI, 0.93-1.10). In liver and lung transplant, longer time between listing and transplant was associated with stronger protective effects for high-tier programs. In kidney, liver, and lung transplant, posttransplant evaluations at listing had nonlinear associations with eventual posttransplant outcomes: relatively flat for 5-tier scores <0.5 and decreasing for scores >0.5. After adjustment for measured recipient and donor risk factors, posttransplant evaluations at listing predicted differences in eventual outcomes in liver and lung transplant, providing useful information to patients.

Association of pretransplant and posttransplant program ratings with candidate mortality after listing

The Scientific Registry of Transplant Recipients (SRTR) is responsible for understandable reporting of program metrics, including transplant rate, waitlist mortality, and posttransplant outcomes. SRTR developed five-tier systems for each metric to improve accessibility for the public. We investigated the associations of the five-tier assignments at listing with all-cause candidate mortality after listing, for candidates listed July 12, 2011-June 16, 2014. Transplant rate evaluations with one additional tier were associated with lower mortality after listing in kidney (hazard ratio [HR], _0.93 0.95_0.97 ), liver (HR, _0.87 0.90_0.92 ), and heart (HR, _0.92 0.96_1.00 ) transplantation. For lung transplant patients, mortality after listing was highest at programs with above- and below-average transplant rates and lowest at programs with average transplant rates, suggesting that aggressive acceptance behavior may not always provide a survival benefit. Waitlist mortality evaluations with one additional tier were associated with lower mortality after listing in kidney (HR, _0.94 0.96_0.99 ) transplantation, and posttransplant graft survival evaluations with one additional tier were associated with lower mortality after listing in lung (HR, _0.90 0.94_0.98 ) transplantation. Transplant rate typically had the strongest association with mortality after listing, but the strength of associations differed by organ.

Poor Performance Flagging Is Associated With Fewer Transplantations at Centers Flagged Multiple Times

BACKGROUND

Lung transplantation outcomes are heavily scrutinized, given the high stakes of these operations, yet the Center for Medicare and Medicaid Services (CMS) method of using Scientific Registry of Transplant Recipients (SRTR) risk-adjusted outcomes to identify underperforming centers is controversial. We hypothesized that CMS flagging results in conservative behavior for recipient and organ selection, resulting in fewer patients added to the waitlist and fewer transplantations performed.

METHODS

SRTR reports from July 2012 through July 2017 were included. Center characteristics were compared, stratified by number of flagging events. The impact of flagging for underperformance on risk aversion outcomes was analyzed using a mixed-effects regression model.

RESULTS

A total of 72 centers had reported SRTR data during the study period. Of these, 21 centers (29%) met flagging criteria a median of 2 times (interquartile range, 1 to 4 times) for a total of 53 events. Flagging had no statistically significant impact on waitlist or transplantation volume and patient selection by mixed-effects modeling. Despite similar average expected 1-year survival (86.6% versus 87.7%, p = 0.27), centers that were flagged only once added more patients per year to the waitlist (16.3 patients versus 7.8 patients, p = 0.01) and performed more transplantations per year (28.4 transplantations versus 11.1 transplantations, p = 0.01).

CONCLUSIONS

This analysis defines center-level trends in lung transplantation after CMS flagging. Contrary to our primary hypothesis, flagging did not result in temporal center-level changes. However, programs on prolonged probation demonstrated reduced activity, which likely indicates a shift to higher performing centers.

Quality measurement and improvement in liver transplantation

There is growing interest in the quality of health care delivery in liver transplantation. Multiple stakeholders, including patients, transplant providers and their hospitals, payers, and regulatory bodies have an interest in measuring and monitoring quality in the liver transplant process, and understanding differences in quality across centres. This article aims to provide an overview of quality measurement and regulatory issues in liver transplantation performed within the United States. We review how broader definitions of health care quality should be applied to liver transplant care models. We outline the status quo including the current regulatory agencies, public reporting mechanisms, and requirements around quality assurance and performance improvement (QAPI) activities. Additionally, we further discuss unintended consequences and opportunities for growth in quality measurement. Quality measurement and the integration of quality improvement strategies into liver transplant programmes hold significant promise, but multiple challenges to successful implementation must be addressed to optimise value.

Transplant Center Variability in Disparities for African-American Kidney Transplant Recipients

Background

Disparities research has traditionally focused on patient-level variables to ascertain predominant risk factors driving differences in outcomes for African-American (AA) kidney transplant recipients. Our objectives were to determine the magnitude and impact of transplant center variability for graft outcome disparities.

Material/Methods

This was a retrospective cohort study analyzing 25 years of U.S. national transplant registry data at both the patient and center levels using univariate descriptive statistics and multivariable modeling.

Results

A total of 257,024 recipients from 191 centers were analyzed; AAs represented 31.1% of recipients. After adjusting for baseline characteristics, AAs had 42% higher risk of graft loss (aHR 1.42, 95% CI 1.39 to 1.45; p<0.001). Center variability for graft outcome disparities in AAs was significant (race*center interaction term p<0.05), with the aHRs ranging from 0.5 to 4.9; 46% of centers demonstrated a non-statistically significant disparity (aHR p>0.05) and 25% of centers had a large AA disparity (aHR >1.75). In a more recent transplant time period (2000–14), overall racial disparities decreased but center-level disparities increased in variability. Center-level factors significantly associated with increasing disparity included higher acute rejection rates, fewer transplants per year, longer length of stay, lower use of calcineurin inhibitors (CNI), and lower living donor rates.

Conclusions

There is evidence of significant center-level variability in graft outcome disparities for AA kidney recipients. Further, there appears to be a number of center-level factors associated with this variability, including acute rejection rates, CNI use, number of transplants per year, and, in recent years, low living donor rates.

Influence of kidney offer acceptance behavior on metrics of allocation efficiency

We investigated associations of deceased donor kidney offer acceptance with likelihood of the kidney being discarded, cold ischemia time at transplant (CIT), and likelihood of the kidney being exported outside the donation service area (DSA). We used kidney offers from donors in the Scientific Registry of Transplant Recipients July 1, 2015-June 30, 2016, and a stratified logistic regression to estimate odds ratios of acceptance for candidates wait-listed in a DSA. We estimated associations between these ratios and likelihood of discard or export and CIT at transplant. Approximately 0.50 kidneys were discarded per donor; lower DSA-specific offer acceptance ratios were associated with more discards (R=-0.20; P=0.006). For a median donor, the DSA with the highest acceptance ratio would place 0.12 more kidneys per donor than the DSA with the lowest ratio. Low acceptance ratios were associated with higher CIT (R=-0.23; P<0.001). For the median donor, CIT was 2.9 hours shorter for the DSA with the highest versus lowest acceptance ratio. Low acceptance ratios were associated with more exports (R=-0.43; P<0.001); the probability was 15% higher for a median donor in the DSA with the lowest versus highest acceptance ratio. Improving lower-than-expected offer acceptance would likely reduce discards, CIT, and exports.

A Five-Tier System for Improving the Categorization of Transplant Program Performance

OBJECTIVE

To better inform health care consumers by better identifying differences in transplant program performance.

DATA SOURCE

Adult kidney transplants performed in the United States, January 1, 2012-June 30, 2014.

STUDY DESIGN

In December 2016, the Scientific Registry of Transplant Recipients instituted a five-tier system for reporting transplant program performance. We compare the differentiation of program performance and the simulated misclassification rate of the five-tier system with the previous three-tier system based on the 95 percent credible interval.

DATA COLLECTION

Scientific Registry of Transplant Recipients database.

PRINCIPAL FINDINGS

The five-tier system improved differentiation and maintained a low misclassification rate of less than 22 percent for programs differing by two tiers.

CONCLUSION

The five-tier system will better inform health care consumers of transplant program performance.

Decade-Long Trends in Liver Transplant Waitlist Removal Due to Illness Severity: The Impact of Centers for Medicare and Medicaid Services Policy

BACKGROUND

The central tenet of liver transplant organ allocation is to prioritize the sickest patients first. However, a 2007 Centers for Medicare and Medicaid Services regulatory policy, Conditions of Participation (COP), which mandates publically reported transplant center performance assessment and outcomes-based auditing, critically altered waitlist management and clinical decision making. We examine the extent to which COP implementation is associated with increased removal of the "sickest" patients from the liver transplant waitlist.

STUDY DESIGN

This study included 90,765 adult (aged 18 years and older) deceased donor liver transplant candidates listed at 102 transplant centers from April 2002 through December 2012 (Scientific Registry of Transplant Recipients). We quantified the effect of COP implementation on trends in waitlist removal due to illness severity and 1-year post-transplant mortality using interrupted time series segmented Poisson regression analysis.

RESULTS

We observed increasing trends in delisting due to illness severity in the setting of comparable demographic and clinical characteristics. Delisting abruptly increased by 16% at the time of COP implementation, and likelihood of being delisted continued to increase by 3% per quarter thereafter, without attenuation (p < 0.001). Results remained consistent after stratifying on key variables (ie, Model for End-Stage Liver Disease and age). The COP did not significantly impact 1-year post-transplant mortality (p = 0.38).

CONCLUSIONS

Although the 2007 Centers for Medicare and Medicaid Services COP policy was a quality initiative designed to improve patient outcomes, in reality, it failed to show beneficial effects in the liver transplant population. Patients who could potentially benefit from transplantation are increasingly being denied this lifesaving procedure while transplant mortality rates remain unaffected. Policy makers and clinicians should strive to balance candidate and recipient needs from a population-benefit perspective when designing performance metrics and during clinical decision making for patients on the waitlist.

Patient selection and volume in the era surrounding implementation of Medicare conditions of participation for transplant programs

OBJECTIVE

To evaluate evidence of practice changes affecting kidney transplant program volumes, and donor, recipient and candidate selection in the era surrounding the introduction of Centers for Medicare and Medicaid Services (CMS) conditions of participation (CoPs) for organ transplant programs.

DATA

Scientific Registry of Transplant Recipients; CMS ESRD and Medicare claims databases.

DESIGN

Retrospective analysis of national registry data.

METHODS

A Cox proportional hazards model of 1-year graft survival was used to derive risks associated with deceased-donor kidney transplants performed from 2001 to 2010.

FINDINGS

Among programs with ongoing noncompliance with the CoPs, kidney transplant volumes declined by 38 percent (n = 766) from 2006 to 2011, including a 55 percent drop in expanded criteria donor transplants. Volume increased by 6 percent (n = 638) among programs remaining in compliance. Aggregate risk of 1-year graft failure increased over time due to increasing recipient age and obesity, and longer ESRD duration.

CONCLUSIONS

Although trends in aggregate risk of 1-year kidney graft loss do not indicate that the introduction of the CoPs has systematically reduced opportunities for marginal candidates or that there has been a systematic shift away from utilization of higher risk deceased donor kidneys, total volume and expanded criteria donor utilization decreased overall among programs with ongoing noncompliance.

Infrastructure, logistics and regulation of transplantation: UNOS

Organ transplantation has evolved into the standard of care for patients with end-stage organ failure. Despite considering increasingly complex transplant recipients for organs recovered from donors with increasing comorbid conditions, 1-year patient survival following kidney transplantation is 97% in the United States, whereas liver transplant recipient 1-year survival is 90%. There were 16,485 kidney recipients in the United States in 2012, and 6256 patients who underwent liver transplantation. The intent of this review is to highlight the logistics required for transplantation as well as reviewing the current oversight of transplantation.