1
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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.
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2
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Kayler LK, Nie J, Noyes K. Hardest-to-place kidney transplant outcomes in the United States. Am J Transplant 2021; 21:3663-3672. [PMID: 34212471 DOI: 10.1111/ajt.16739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/22/2021] [Accepted: 06/27/2021] [Indexed: 01/25/2023]
Abstract
The outcomes of hardest-to-place kidney transplants-accepted last in the entire match run after being refused by previous centers-are unclear, potentially translating to risk aversion and unnecessary organ discard. We aimed to determine the outcomes of hardest-to-place kidney transplants and whether the organ acceptance position on the match run sufficiently captures the risk. This is a cohort study of the United Network for Organ Sharing data of all adult kidney-only transplant recipients from deceased donors between 2007 and 2018. Multiple regression models assessed delayed graft function, graft survival, and patient survival stratified by share type: local versus shared kidney acceptance position scaled by tertile. Among 127 028 kidney transplant recipients, 92 855 received local kidneys. The remaining received shared kidneys at sequence number 1-4 (n = 12 322), 5-164 (n = 10 485) and >164 (n = 11 366). Hardest-to-place kidneys, defined as the latest acceptance group in the match-run, were associated with delayed graft function (adjusted odds ratio 1.83, 95% confidence interval [CI] 1.74-1.92) and all-cause allograft failure (adjusted hazard ratio [aHR] 1.11, 95% CI 1.04-1.17). Results of this IRB-approved study were robust to the exclusion of operational allocation bypass and mandatory shares. The hardest-to-place kidneys accepted later in the match run were associated with higher graft failure and delayed graft function.
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Affiliation(s)
- Liise K Kayler
- Department of Surgery, University at Buffalo, Buffalo, New York, USA.,Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA
| | - Jing Nie
- Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, New York, USA
| | - Katia Noyes
- Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, New York, USA
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3
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Does Liver Transplant Center Size Matter? Center Size Disparities and the Unintended Consequences of Transplant Regulation- A Commentary. Transplantation 2021; 106:911-912. [PMID: 34366387 DOI: 10.1097/tp.0000000000003916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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4
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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.
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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
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5
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Batra RK, Mulligan DC. Current status: meeting the regulatory goals of your liver transplant program. Curr Opin Organ Transplant 2021; 26:146-151. [PMID: 33650996 DOI: 10.1097/mot.0000000000000869] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The regulatory framework set by the Organ Procurement and Transplantation Network (OPTN) and Center for Medicare and Medicaid Services (CMS) for practice of liver transplantation in US is periodically updated and risk adjusted. Therefore, it is prudent for transplant centers to know the rules of engagement as it pertains to their practice. RECENT FINDINGS OPTN besides providing the regulatory oversight for safe and continued practice of transplant centers, provides necessary tools like: advanced statistical models and technological platforms to aid, and guide transplant centers including the necessary safeguards for high-quality transplant care.CMS regulations although had different thresholds to flag underperformance, often covered common grounds similar to the OPTN, therefore considered duplicative and unnecessary. But with much deliberation and consideration CMS undertook a major overhaul to the final rule for re-approval applications, a giant leap in the positive direction for transplant innovation and growth. SUMMARY The duplicative regulatory framework of OPTN and CMS has although achieved the goal of improving 1-year patient outcomes, it has proven costly in terms of slowing innovation, increasing organ discard and stunting growth of transplant volume. But the new updates in effect and also in the pipeline are a long-awaited opportunity for waiting transplant patients.
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Affiliation(s)
- Ramesh K Batra
- Yale University School of Medicine, Director, Liver Transplant Program
| | - David C Mulligan
- Yale University School of Medicine, Chair, Division of Transplantation and Immunology, Yale New Haven Hospital, New Haven, Connecticut, USA
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6
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Ouayogodé MH, Schnier KE. Patient selection in the presence of regulatory oversight based on healthcare report cards of providers: the case of organ transplantation. Health Care Manag Sci 2021; 24:160-184. [PMID: 33417173 PMCID: PMC7791538 DOI: 10.1007/s10729-020-09530-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 10/27/2020] [Indexed: 11/13/2022]
Abstract
Many healthcare report cards provide information to consumers but do not represent a constraint on the behavior of healthcare providers. This is not the case with the report cards utilized in kidney transplantation. These report cards became more salient and binding, with additional oversight, in 2007 under the Centers for Medicare and Medicaid Services Conditions of Participation. This research investigates whether the additional oversight based on report card outcomes influences patient selection via waiting-list registrations at transplant centers that meet regulatory standards. Using data from a national registry of kidney transplant candidates from 2003 through 2010, we apply a before-and-after estimation strategy that isolates the impact of a binding report card. A sorting equilibrium model is employed to account for center-level heterogeneity and the presence of congestion/agglomeration effects and the results are compared to a conditional logit specification. Our results indicate that patient waiting-list registrations change in response to the quality information similarly on average if there is additional regulation or not. We also find evidence of congestion effects when spatial choice sets are smaller: new patient registrations are less likely to occur at a center with a long waiting list when fewer options are available.
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Affiliation(s)
- Mariétou H. Ouayogodé
- School of Medicine and Public Health, Department of Population Health Sciences, University of Wisconsin-Madison, 610 Walnut St, Madison, WI 53726 USA
| | - Kurt E. Schnier
- School of Social Sciences, Humanities and Arts, University of California, Merced, 5200 North Lake Road, Merced, CA 95343 USA
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7
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Andreoni KA. Now is the time for the Organ Procurement and Transplantation Network to change regulatory policy to effectively increase transplantation in the United States; Carpe Diem. Am J Transplant 2020; 20:2026-2029. [PMID: 31883214 DOI: 10.1111/ajt.15759] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/09/2019] [Accepted: 12/17/2019] [Indexed: 01/25/2023]
Abstract
With the Centers for Medicare and Medicaid Services proposing to remove outcome measures from the transplant centers' renewal for Conditions of Participation an exciting opportunity surfaces for the Organ Procurement and Transplantation Network to make an equally bold change and allow for increased transplantation options for patients in the United States.
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Affiliation(s)
- Kenneth A Andreoni
- Division of Abdominal Transplantation, Department of Surgery, University of Florida, Gainesville, Florida
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8
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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]
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9
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Lehner LJ, Kleinsteuber A, Halleck F, Khadzhynov D, Schrezenmeier E, Duerr M, Eckardt KU, Budde K, Staeck O. Assessment of the Kidney Donor Profile Index in a European cohort. Nephrol Dial Transplant 2019; 33:1465-1472. [PMID: 29617898 DOI: 10.1093/ndt/gfy030] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/23/2018] [Indexed: 12/26/2022] Open
Abstract
Background Recently, transplant societies have had to change their allocation policies to counter global organ shortages. However, strategies differ significantly and long-term outcomes and cross-regional applicability remain to be evaluated. Methods Therefore, we retrospectively analysed the Kidney Donor Profile Index (KDPI) of 987 adult kidney transplants at our centre using data from the Organ Procurement and Transplantation Network (OPTN) as a reference. Results In our cohort, the median KDPI was 66%, with a higher proportion of >85% KDPI kidneys compared with the US cohort (32.3% versus 9.2%). Among elderly patients (≥65 years of age), 62% received >95% KDPI kidneys, which were primarily allocated within the Eurotransplant Senior Program (ESP). After 10 years, the rate of death-censored graft survival was 70.5%. Recipients of >85% KDPI kidneys were significantly older, demonstrating higher mortality, poorer graft survival and lower estimated glomerular filtration rate. Patients receiving ≥99% KDPI kidneys had a satisfactory 5-year death-censored graft survival (72.9%). The 5-year survival rate of patients living with a functioning graft exceeded the matched OPTN data in the whole KDPI range, despite a higher proportion of elderly recipients. Multivariate analysis revealed KDPI as an independent risk factor for graft loss (hazard ratio 1.14/10%, P < 0.001), although C-statistics of 0.62 indicated limited discriminative ability for individuals. Conclusion The analysis demonstrated KDPI as a potentially useful tool for donor quality assessment in a European cohort. Most importantly, our analysis revealed acceptable outcomes even for very high KDPI kidneys.
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Affiliation(s)
- Lukas Johannes Lehner
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Kleinsteuber
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Dmytro Khadzhynov
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Eva Schrezenmeier
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Duerr
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Staeck
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
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10
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Schold JD, Patzer RE, Pruett TL, Mohan S. Quality Metrics in Kidney Transplantation: Current Landscape, Trials and Tribulations, Lessons Learned, and a Call for Reform. Am J Kidney Dis 2019; 74:382-389. [DOI: 10.1053/j.ajkd.2019.02.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/15/2019] [Indexed: 12/12/2022]
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11
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Van Pilsum Rasmussen SE, Zhou S, Thomas AG, Segev DL, Nicholas LH. Transplant community perceptions of the benefits and drawbacks of alternative quality metrics for regulation. Clin Transplant 2019; 33:e13500. [PMID: 30773685 PMCID: PMC6465095 DOI: 10.1111/ctr.13500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/01/2019] [Accepted: 02/11/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is concern that the metrics currently used to regulate transplant centers, one-year patient and graft survival, may have adverse consequences including decreasing higher risk donor organ acceptance and transplant volume. This raises questions about whether alternative measures would be more appropriate. METHODS We surveyed American Society of Transplant Surgeons (ASTS) and American Society of Transplantation (AST) members (n = 270) to characterize perceptions of several metrics that are used for regulation, are publicly reported, or have been suggested elsewhere, regarding their effectiveness, amenability to risk adjustment, and predicted effects on volume, mortality, and waitlist size. RESULTS Respondents rated one-year patient and graft survival the most effective measure of quality of care (mean scores = 7.44, 7.31, respectively, out of 10) and most amenable to risk adjustment (mean scores = 6.26, 6.13, respectively). Most respondents believed alternative metrics would not impact their center's volume, waitlist size, or one-year transplant mortality. However, some did predict unintended consequences; for example, some believed using one-year waitlist mortality, one-year mortality of patients listed, or one-year mortality of patients referred for transplant would decrease the number of transplants performed (48.6%, 46.7%, and 48.3% of respondents, respectively). DISCUSSION Despite previously published concerns with existing regulatory metrics, most participants did not believe any metrics would outperform one-year patient and graft survival.
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Affiliation(s)
| | - Sheng Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD., , ,
| | - Alvin G. Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD., , ,
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD., , ,
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.,
| | - Lauren Hersch Nicholas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD., , ,
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD
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12
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Abstract
End-stage renal disease patients who have impaired physical function are denied for transplantation by clinicians concerned about graft/survival outcomes. The purpose of this study was to determine the impact of physical function on graft/survival outcomes at 1-year post-kidney transplantation. Data were analyzed from the Scientific Registry of Transplant Recipients regarding kidney transplantation patients (N = 218,657) between January 1, 2000 and September 2, 2014. The hazard ratio of 1-year graft failure for deceased donor transplantation recipients needing total assistance was 1.60 (95% confidence interval [CI] = [1.303, 1.965], p < .01). Patients needing none or some assistance did not demonstrate a significant difference in 1-year graft failure in either deceased or living donor transplantation. The hazard ratio of 1-year death for those needing total assistance was 2.52 (95% CI = [2.087, 3.045], p < .001) in deceased donor kidney transplantation.
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Affiliation(s)
- Jongwon Yoo
- Loyola University Medical Center, Maywood, IL, USA.,The University of Illinois at Chicago, IL, USA
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13
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Beller JP, Hawkins RB, Mehaffey JH, Chancellor WZ, Teaster R, Walters DM, Krupnick AS, Davis RD, Lau CL. Poor Performance Flagging Is Associated With Fewer Transplantations at Centers Flagged Multiple Times. Ann Thorac Surg 2019; 107:1678-1682. [PMID: 30629928 DOI: 10.1016/j.athoracsur.2018.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 11/30/2018] [Accepted: 12/04/2018] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Jared P Beller
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - William Z Chancellor
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert Teaster
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Dustin M Walters
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Alexander S Krupnick
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - R Duane Davis
- Cardiovascular and Transplant Institutes, Florida Hospital Orlando, Orlando, Florida
| | - Christine L Lau
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
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14
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Ouayogodé MH. Quality-based ratings in Medicare and trends in kidney transplantation. Health Serv Res 2018; 54:106-116. [PMID: 30520027 DOI: 10.1111/1475-6773.13098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess the relationship between the 2007 Medicare regulation enforcing quality standards for transplant centers and trends in kidney transplantation. DATA SOURCES Transplant centers' biannual reports and the national registry for kidney transplantation from 2003 to 2010. STUDY DESIGN Non-compliant (low-performing) centers were compared with centers in compliance with quality standards according to: number of transplants, waiting-list registrations, and rates of graft failures, transfers, and deaths. Multivariate regressions were estimated to evaluate the association between the regulation and transplantation outcomes. DATA EXTRACTION METHODS Patient characteristics and outcomes were aggregated to six-month periods and linked to centers' reports. PRINCIPAL FINDINGS Relative to average-performing centers, 12 percent of transplants shifted away from low-performing centers and high-performing centers captured 6 percent of this decline. Low-performing centers experienced a 2-percentage point per period decline in 1-year graft failure rates and a 15-percent decrease in registrations post-regulation, whereas high-performing centers incurred a 5-percent decrease in registrations relative to average-performing centers. CONCLUSIONS Government oversight in kidney transplantation was associated with a small downward shift in overall kidney transplants. Reductions in graft failure rates at low-performing centers may imply an increase in quality or a decline in transplantation of either marginal organs or riskier patients; whereas reductions in registrations may indicate risk aversion toward high-risk patients. Policy makers should consider making less punitive requirements for programs, which employ new transplantation techniques to expand access.
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Affiliation(s)
- Mariétou H Ouayogodé
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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15
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Van Pilsum Rasmussen SE, Thomas AG, Garonzik-Wang J, Henderson ML, Stith SS, Segev DL, Nicholas LH. Reported effects of the Scientific Registry of Transplant Recipients 5-tier rating system on US transplant centers: results of a national survey. Transpl Int 2018; 31:1135-1143. [PMID: 29802802 PMCID: PMC6219856 DOI: 10.1111/tri.13282] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 03/17/2018] [Accepted: 05/17/2018] [Indexed: 11/30/2022]
Abstract
In the United States, the Scientific Registry of Transplant Recipients (SRTR) provides publicly available quality report cards. These reports have historically rated transplant programs using a 3-tier system. In 2016, the SRTR temporarily transitioned to a 5-tier system, which classified more programs as under-performing. As part of a larger survey about transplant quality metrics, we surveyed members of the American Society of Transplant Surgeons and American Society of Transplantation (N = 280 respondents) on transplant center experiences with patient and payer responses to the 5-tier SRTR ratings. Over half of respondents (n = 137, 52.1%) reported ≥1 negative effect of the new 5-tier ranking system, including losing patients, losing insurers, increased concern among patients, and increased concern among referring providers. Few respondents (n = 35, 13.7%) reported any positive effects of the 5-tier ranking system. Lower SRTR-reported scores on the 5-tier scale were associated with increased risk of reporting at least one negative effect in a logistic model (P < 0.01). The change to a more granular rating system provoked an immediate response in the transplant community that may have long-term implications for transplant hospital finances and patient options for transplantation.
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Affiliation(s)
| | - Alvin G. Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Macey L. Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sarah S. Stith
- Department of Economics, University of New Mexico, Albuquerque, NM
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Lauren Hersch Nicholas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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16
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Bowring MG, Massie AB, Craig-Schapiro R, Segev DL, Nicholas LH. Kidney offer acceptance at programs undergoing a Systems Improvement Agreement. Am J Transplant 2018; 18:2182-2188. [PMID: 29718565 PMCID: PMC6117205 DOI: 10.1111/ajt.14907] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 04/05/2018] [Accepted: 04/23/2018] [Indexed: 01/25/2023]
Abstract
In the United States, the Centers for Medicare and Medicaid Services (CMS) use Systems Improvement Agreements (SIAs) to require transplant programs repeatedly flagged for poor-performance to improve performance or lose CMS funding for transplants. We identified 14 kidney transplant (KT) programs with SIAs and 28 KT programs without SIAs matched on waitlist volume and characterized kidney acceptance using SRTR data from 12/2006-3/2015. We used difference-in-differences linear regression models to identify changes in acceptance associated with an SIA independent of program variation and trends prior to the SIA. SIA programs accepted 26.9% and 22.1% of offers pre- and post-SIA, while non-SIA programs accepted 33.9% and 44.4% of offers in matched time periods. After adjustment for donor characteristics, time-varying waitlist volume, and secular trends, SIAs were associated with a 5.9 percentage-point (22%) decrease in kidney acceptance (95% CI: -10.9 to -0.8, P = .03). The decrease in acceptance post-SIA was more pronounced for KDPI 0-40 kidneys (12.3 percentage-point decrease, P = .007); reductions in acceptance of higher KDPI kidneys occurred pre-SIA. Programs undergoing SIAs substantially reduced acceptance of kidney offers for waitlisted candidates. Attempts to improve posttransplant outcomes might have the unintended consequence of reducing access to transplantation as programs adopt more restrictive organ selection practices.
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Affiliation(s)
- Mary G. Bowring
- Johns Hopkins University School of Medicine; Department of Surgery, Baltimore MD
| | - Allan B. Massie
- Johns Hopkins University School of Medicine; Department of Surgery, Baltimore MD,Johns Hopkins University Bloomberg School of Public Health; Department of Epidemiology, Baltimore MD
| | | | - Dorry L. Segev
- Johns Hopkins University School of Medicine; Department of Surgery, Baltimore MD,Johns Hopkins University Bloomberg School of Public Health; Department of Epidemiology, Baltimore MD,Scientific Registry of Transplant Recipients, Minneapolis MN
| | - Lauren Hersch Nicholas
- Johns Hopkins University School of Medicine; Department of Surgery, Baltimore MD,Johns Hopkins University Bloomberg School of Public Health; Department of Health Policy and Management, Baltimore MD
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17
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Sheetz KH, Englesbe MJ. Rethinking performance benchmarks in kidney transplantation. Am J Transplant 2018; 18:2109-2110. [PMID: 29791069 DOI: 10.1111/ajt.14947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 05/17/2018] [Accepted: 05/17/2018] [Indexed: 01/25/2023]
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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18
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Schold JD, Andreoni KA, Chandraker AK, Gaston RS, Locke JE, Mathur AK, Pruett TL, Rana A, Ratner LE, Buccini LD. Expanding clarity or confusion? Volatility of the 5-tier ratings assessing quality of transplant centers in the United States. Am J Transplant 2018; 18:1494-1501. [PMID: 29316241 DOI: 10.1111/ajt.14659] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/06/2017] [Accepted: 12/22/2017] [Indexed: 01/25/2023]
Abstract
Outcomes of patients receiving solid organ transplants in the United States are systematically aggregated into bi-annual Program-Specific Reports (PSRs) detailing risk-adjusted survival by transplant center. Recently, the Scientific Registry of Transplant Recipients (SRTR) issued 5-tier ratings evaluating centers based on risk-adjusted 1-year graft survival. Our primary aim was to examine the reliability of 5-tier ratings over time. Using 10 consecutive PSRs for adult kidney transplant centers from June 2012 to December 2016 (n = 208), we applied 5-tier ratings to center outcomes and evaluated ratings over time. From the baseline period (June 2012), 47% of centers had at least a 1-unit tier change within 6 months, 66% by 1 year, and 94% by 3 years. Similarly, 46% of centers had at least a 2-unit tier change by 3 years. In comparison, 15% of centers had a change in the traditional 3-tier rating at 3 years. The 5-tier ratings at 4 years had minimal association with baseline rating (Kappa 0.07, 95% confidence interval [CI] -0.002 to 0.158). Centers had a median of 3 different 5-tier ratings over the period (q1 = 2, q3 = 4). Findings were consistent for center volume, transplant rate, and baseline 5-tier rating. Cumulatively, results suggest that 5-tier ratings are highly volatile, limiting their utility for informing potential stakeholders, particularly transplant candidates given expected waiting times between wait listing and transplantation.
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Affiliation(s)
- Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Robert S Gaston
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jayme E Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Timothy L Pruett
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Abbas Rana
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Lloyd E Ratner
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Laura D Buccini
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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19
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Schold JD, Poggio ED, Augustine JJ. Gathering Clues to Explain the Stagnation in Living Donor Kidney Transplantation in the United States. Am J Kidney Dis 2018; 71:608-610. [PMID: 29685212 DOI: 10.1053/j.ajkd.2018.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/14/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.
| | - Emilio D Poggio
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Joshua J Augustine
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Louis Stokes Veterans Administration Hospital, Cleveland, OH
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20
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Evaluation of Flagging Criteria of United States Kidney Transplant Center Performance: How to Best Define Outliers? Transplantation 2017; 101:1373-1380. [PMID: 27482960 DOI: 10.1097/tp.0000000000001373] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Scientific Registry of Transplant Recipients report cards of US organ transplant center performance are publicly available and used for quality oversight. Low center performance (LP) evaluations are associated with changes in practice including reduced transplant rates and increased waitlist removals. In 2014, Scientific Registry of Transplant Recipients implemented new Bayesian methodology to evaluate performance which was not adopted by Center for Medicare and Medicaid Services (CMS). In May 2016, CMS altered their performance criteria, reducing the likelihood of LP evaluations. METHODS Our aims were to evaluate incidence, survival rates, and volume of LP centers with Bayesian, historical (old-CMS) and new-CMS criteria using 6 consecutive program-specific reports (PSR), January 2013 to July 2015 among adult kidney transplant centers. RESULTS Bayesian, old-CMS and new-CMS criteria identified 13.4%, 8.3%, and 6.1% LP PSRs, respectively. Over the 3-year period, 31.9% (Bayesian), 23.4% (old-CMS), and 19.8% (new-CMS) of centers had 1 or more LP evaluation. For small centers (<83 transplants/PSR), there were 4-fold additional LP evaluations (52 vs 13 PSRs) for 1-year mortality with Bayesian versus new-CMS criteria. For large centers (>183 transplants/PSR), there were 3-fold additional LP evaluations for 1-year mortality with Bayesian versus new-CMS criteria with median differences in observed and expected patient survival of -1.6% and -2.2%, respectively. CONCLUSIONS A significant proportion of kidney transplant centers are identified as low performing with relatively small survival differences compared with expected. Bayesian criteria have significantly higher flagging rates and new-CMS criteria modestly reduce flagging. Critical appraisal of performance criteria is needed to assess whether quality oversight is meeting intended goals and whether further modifications could reduce risk aversion, more efficiently allocate resources, and increase transplant opportunities.
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21
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Schold JD, Buccini LD, Phelan MP, Jay CL, Goldfarb DA, Poggio ED, Sedor JR. Building an Ideal Quality Metric for ESRD Health Care Delivery. Clin J Am Soc Nephrol 2017; 12:1351-1356. [PMID: 28515155 PMCID: PMC5544503 DOI: 10.2215/cjn.01020117] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | | | | | | | - David A. Goldfarb
- Glickman Urological and Kidney Institutes, Cleveland Clinic, Cleveland, Ohio
| | - Emilio D. Poggio
- Glickman Urological and Kidney Institutes, Cleveland Clinic, Cleveland, Ohio
| | - John R. Sedor
- Departments of Medicine, Physiology and Biophysics, Case Western Reserve University, Rammelkamp Center for Research and Education, MetroHealth System, Cleveland, Ohio
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22
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Survival Benefit in Older Patients Associated With Earlier Transplant With High KDPI Kidneys. Transplantation 2017; 101:867-872. [PMID: 27495758 DOI: 10.1097/tp.0000000000001405] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Given high dialysis mortality rates for patients older than 60 years, accepting a kidney with a high Kidney Donor Profile Index (KDPI) score could enable earlier and potentially preemptive transplantation (preKT). However, evidence regarding the risks of high KDPI allografts in older patients is limited. Our objective was to determine the relative benefit for older patients of KDPI greater than 85% transplant either preemptively or not compared with remaining on the waitlist. METHODS United Network of Organ Sharing data from 2003 to 2012 for adult deceased donor kidney transplant candidates was analyzed to evaluate patient survival in patients older than 60 years for preKT and non-preKT KDPI greater than 85% transplants compared with candidates remaining on the waitlist including patients who received KDPI 0% to 85% transplants according to multivariate Cox regression models. RESULTS In the first year posttransplant for KDPI greater than 85% of transplants in recipients older than 60 years, preKT had a reduced mortality hazard (hazards ratio [HR], 0.61; 95% confidence interval [95% CI], 0.41-0.90) and non-preKT an increased mortality hazard (HR, 1.15; 95% CI, 1.03-1.27) compared with the waitlist including KDPI 0% to 85% transplant recipients. At 1 to 2 years and after 2 years, both KDPI greater than 85% groups had significant reductions in mortality (1-2 years: preKT HR, 0.38; 95% CI, [0.23-0.60] and non-preKT HR, 0.52; 95% CI, 0.45-0.61; and 2+ years: preKT HR, 0.50; 95% CI, 0.38-0.66 and non-preKT HR, 0.64; 95% CI, 0.58-0.70, respectively). CONCLUSIONS PreKT and non-preKT KDPI greater than 85% transplant was associated with lower mortality hazard after the first year compared with the waitlist including KDPI 0% to 85% transplants in patients older than 60 years. Further consideration should be given to increased utilization of high KDPI grafts in older patients with the goal of avoiding or limiting time on dialysis.
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23
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Schold JD, Phelan MP, Buccini LD. Utility of Ecological Risk Factors for Evaluation of Transplant Center Performance. Am J Transplant 2017; 17:617-621. [PMID: 27696682 DOI: 10.1111/ajt.14074] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/20/2016] [Accepted: 09/22/2016] [Indexed: 01/25/2023]
Abstract
There is substantial evidence across different healthcare contexts that social determinants of health are strongly associated with morbidity and mortality in the United States. These factors, including socioeconomic status, behavior and environmental risks, education, social support, healthy food, and access to healthcare also vary widely by region and individual communities. One of the implications of heterogeneity in these risks is the potential impact on measured quality of healthcare providers. In particular, there is concern that providers treating disproportionally vulnerable communities may be disadvantaged by lack of risk adjustment for these factors that affect health but not indicators of quality of care. Recently, the National Quality Forum has endorsed risk adjustment for sociodemographic characteristics based on these concerns. These issues are salient to transplant programs since social determinants of health impact transplant patient outcomes and vary by region. In this viewpoint, we argue that integration of ecological (area-level) factors in risk adjustment models used to assess transplant center quality should be strongly considered. We believe this reform could be accomplished rapidly, would attenuate disparities in access to care by reducing disincentives to treat patients from vulnerable communities, and improve risk adjustment and calibration of models used for center evaluations.
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Affiliation(s)
- J D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
| | - M P Phelan
- Department of Emergency Medicine, Cleveland Clinic, Cleveland, OH
| | - L D Buccini
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.,Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
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24
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Jay C, Schold JD. Measuring transplant center performance: The goals are not controversial but the methods and consequences can be. CURRENT TRANSPLANTATION REPORTS 2017; 4:52-58. [PMID: 28966901 DOI: 10.1007/s40472-017-0138-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Risks of regulatory scrutiny has generated widespread concern about increasingly risk averse transplant center behaviors regarding both donor and candidate acceptance patterns. To address potential unintended consequences threatening access to care, we discuss recent changes in regulatory metrics and potential improvements in quality oversight of transplant centers. RECENT FINDINGS Despite many recent changes to one-year patient and graft survival regulatory criteria, the capacity to accurately identify true underperforming centers and avoiding false positive flagging remains an area of great concern. Numerous studies have demonstrated restrictions in transplant volume and access following transplant center flagging. SUMMARY Current regulatory criteria are limited in their capacity to accurately identify poorly performing centers and potentially encourage risk-averse behavior by transplant centers. Efforts to address these concerns should focus on (1) improving risk-adjustment models with better data which captures the acuity of candidate and donor risk, (2) reconsidering primary outcomes measured to assess comprehensive transplant center performance, (3) improving education to address rational or perceived disincentives, and (4) using data more effectively to share best practices.
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Affiliation(s)
- Colleen Jay
- University Transplant Center, University of Texas Health Science Center, San Antonio
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
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25
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Klassen DK, McBride MA, Tosoc-Haskell H. A Look into a New Approach to Transplant Program Evaluation—the COIIN Project. CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0140-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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26
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Decade-Long Trends in Liver Transplant Waitlist Removal Due to Illness Severity: The Impact of Centers for Medicare and Medicaid Services Policy. J Am Coll Surg 2016; 222:1054-65. [PMID: 27178368 DOI: 10.1016/j.jamcollsurg.2016.03.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 03/02/2016] [Accepted: 03/02/2016] [Indexed: 02/06/2023]
Abstract
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.
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27
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Schold JD, Buccini LD, Poggio ED, Flechner SM, Goldfarb DA. Association of Candidate Removals From the Kidney Transplant Waiting List and Center Performance Oversight. Am J Transplant 2016; 16:1276-84. [PMID: 26762606 DOI: 10.1111/ajt.13594] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 10/21/2015] [Accepted: 10/25/2015] [Indexed: 01/25/2023]
Abstract
Approximately 59 000 kidney transplant candidates have been removed from the waiting list since 2000 for reasons other than transplantation, death, or transfers. Prior studies indicate that low-performance (LP) center evaluations by the Scientific Registry of Transplant Recipients (SRTR) are associated with reductions in transplant volume. There is limited information to determine whether performance oversight impacts waitlist management. We used national SRTR data to evaluate outcomes of 315 796 candidates on the kidney transplant waiting list (2007-2014). Compared to centers without LP, rates of waitlist removal (WLR) were higher at centers with LP evaluations (44.6/1000 follow-up years, 95% confidence interval [CI] 44.0, 45.1 versus 68.0/1000 follow-up years, 95% CI 66.6, 69.4), respectively, which was consistent after risk adjustment (adjusted hazard ratio [AHR] = 1.59, 95% CI 1.55, 1.63). Candidate mortality following waitlist removal was lower at LP centers (AHR = 0.90, 95% CI 0.87, 0.94). Analyses limited to LP centers indicated a significant increase in WLR (+28.6 removals/1000 follow-up years, p < 0.001), a decrease in transplant rates (-11.9/1000 follow-up years, p < 0.001) and a decrease in mortality after removal (-67.5 deaths/1000 follow-up years, p < 0.001) following LP evaluation. There is a significant association between LP evaluations and transplant center processes of care for waitlisted candidates. Further understanding is needed to determine the impact of performance oversight on transplant center quality of care and patient outcomes.
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Affiliation(s)
- J D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
| | - L D Buccini
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.,Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - E D Poggio
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - S M Flechner
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - D A Goldfarb
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
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28
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Schold JD, Nicholas LH. Considering potential benefits and consequences of hospital report cards: what are the next steps? Health Serv Res 2015; 50:321-9. [PMID: 25756733 DOI: 10.1111/1475-6773.12280] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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