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Ross-Driscoll K, Adams A, Caicedo J, Gordon EJ, Kirk AD, McElroy LM, Taber D, Patzer R. Health Disparity Metrics for Transplant Centers: Theoretical and Practical Considerations. Transplantation 2024; 108:1823-1825. [PMID: 38548712 DOI: 10.1097/tp.0000000000004973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Affiliation(s)
- Katie Ross-Driscoll
- Division of Transplantation, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN
| | - Andrew Adams
- Division of Transplantation, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN
| | - Juan Caicedo
- Division of Transplantation, Department of Surgery, Northwestern University School of Medicine, Chicago, IL
| | - Elisa J Gordon
- Department of Surgery and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN
| | - Alan D Kirk
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Lisa M McElroy
- Division of Transplantation, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - David Taber
- Division of Transplantation, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Rachel Patzer
- Regenstrief Institute, Indianapolis, IN
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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2
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McDonald WE, Shorbaji K, Kilcoyne M, Few W, Welch B, Hashmi Z, Kilic A. Impact of institutional variables on centre performance in long-term survival after heart transplant. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae111. [PMID: 38870536 PMCID: PMC11196378 DOI: 10.1093/icvts/ivae111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/23/2024] [Accepted: 06/12/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVES The gold standard metric for centre-level performance in orthotopic heart transplantation (OHT) is 1-year post-OHT survival. However, it is unclear whether centre performance at 1 year is predictive of longer-term outcomes. This study evaluated factors impacting longer-term centre-level performance in OHT. METHODS Patients who underwent OHT in the USA between 2010 and 2021 were identified using the United Network of Organ Sharing data registry. The primary outcome was 5-year survival conditional on 1-year survival following OHT. Multivariable Cox proportional hazard models assessed the impact of centre-level 1-year survival rates on 5-year survival rates. Mixed-effect models were used to evaluate between-centre variability in outcomes. RESULTS Centre-level risk-adjusted 5-year mortality conditional on 1-year survival was not associated with centre-level 1-year survival rates [hazard ratio: 0.99 (0.97-1.01, P = 0.198)]. Predictors of 5-year mortality conditional on 1-year survival included black recipient race, pre-OHT serum creatinine, diabetes and donor age. In mixed-effect modelling, there was substantial variability between centres in 5-year mortality rates conditional on 1-year survival, a finding that persisted after controlling for recipient, donor and institutional factors (P < 0.001). In a crude analysis using Kaplan-Meier, the 5-year survival conditional on 1-year survival was: low volume: 86.5%, intermediate volume: 87.5%, high volume: 86.7% (log-rank P = 0.52). These measured variables only accounted for 21.4% of the between-centre variability in 5-year mortality conditional on 1-year survival. CONCLUSIONS Centre-level risk-adjusted 1-year outcomes do not correlate with outcomes in the 1- to 5-year period following OHT. Further research is needed to determine what unmeasured centre-level factors contribute to longer-term outcomes in OHT.
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Affiliation(s)
- Weston E McDonald
- Department of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Khaled Shorbaji
- Division of Biology and Biomedical Sciences, Washington University in St. Louis, St. Louis, MO, 63130, USA
| | - Maxwell Kilcoyne
- Department of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - William Few
- Department of Orthopaedic Surgery, Ochsner Clinical School, Jefferson, LA, 70121, USA
| | - Brett Welch
- Department of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Zubair Hashmi
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Arman Kilic
- Department of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, 29425, USA
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3
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Liu L, He K, Wang D, Ma S, Qu A, Lin L, Miller JP, Liu L. Healthcare center clustering for Cox's proportional hazards model by fusion penalty. Stat Med 2023; 42:3685-3698. [PMID: 37315935 PMCID: PMC10530598 DOI: 10.1002/sim.9825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 03/31/2023] [Accepted: 06/01/2023] [Indexed: 06/16/2023]
Abstract
There has been growing research interest in developing methodology to evaluate healthcare centers' performance with respect to patient outcomes. Conventional assessments can be conducted using fixed or random effects models, as seen in provider profiling. We propose a new method, using fusion penalty to cluster healthcare centers with respect to a survival outcome. Without any prior knowledge of the grouping information, the new method provides a desirable data-driven approach for automatically clustering healthcare centers into distinct groups based on their performance. An efficient alternating direction method of multipliers algorithm is developed to implement the proposed method. The validity of our approach is demonstrated through simulation studies, and its practical application is illustrated by analyzing data from the national kidney transplant registry.
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Affiliation(s)
- Lili Liu
- Division of Biostatistics, Washington University in St. Louis, St. Louis, U.S.A
- Research Center for Mathematics and Interdisciplinary Sciences, Shandong, University, Qingdao, China
| | - Kevin He
- Department of Biostatistics, University of Michigan, Ann Arbor, U.S.A
| | - Di Wang
- Department of Biostatistics, University of Michigan, Ann Arbor, U.S.A
| | - Shujie Ma
- Department of Statistics, University of California, Riverside, California, U.S.A
| | - Annie Qu
- Department of Statistics, University of California, Irvine, California, U.S.A
| | - Lu Lin
- Zhongtai Securities Institute for Financial Studies, Shandong University, Jinan, China
| | - J. Philip Miller
- Division of Biostatistics, Washington University in St. Louis, St. Louis, U.S.A
| | - Lei Liu
- Division of Biostatistics, Washington University in St. Louis, St. Louis, U.S.A
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4
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Malamon JS, Ho B, Jackson WE, Saben JL, Schold JD, Pomposelli JJ, Pomfret EA, Kaplan B. An evaluation of the organ procurement and transplantation network's expanded post-transplant performance metrics. FRONTIERS IN TRANSPLANTATION 2023; 2:1237112. [PMID: 38993926 PMCID: PMC11235232 DOI: 10.3389/frtra.2023.1237112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/03/2023] [Indexed: 07/13/2024]
Abstract
On July 14, 2022, the Organ Procurement and Transplantation Network's (OPTN) Membership and Professional Standards Committee (MPSC) approved bylaws including two new post-transplant performance evaluation metrics, the 90-day (90D) and 1-year conditional on the 90-day (1YC90D) graft survival hazard ratio (HR). These metrics have replaced the previous 1-year (1Y) unconditional, post-transplant graft survival HR and are used to nationally rank and identify programs for MPSC review. The MPSC's policies have major implications for all transplant programs, providers, and patients across the United States. Herein we show two significant limitations with the new evaluation criteria, arbitrary censoring periods and interdependence in the new performance metrics. We have demonstrated a strong and consistent inverse correlation between the new evaluation metrics, thus proving a lack of independence. Moreover, these two evaluation criteria are interdependent even at nominal HRs. Thus, the 90D cohort can be used to accurately predict whether the 1YC90D is above or below a given HR threshold. This could alter practice behaviors and the timing of patient event reporting, which may result in many unintended consequences related to clinical practice. Here we provide the first evidence that this new evaluation system will lead to a significant increase in the number of programs flagged for MPSC review. When this occurs, the cost of operating a transplant program will increase without a clear demonstration of an increased accuracy in identifying problematic programs.
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Affiliation(s)
- John S. Malamon
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Research and Education (CCTCARE), Colorado Center for Transplantation Care, Aurora, CO, United States
| | - Bing Ho
- Feinberg School of Medicine, Department of Medicine and Surgery, Northwestern University, Chicago, IL, United States
| | - Whitney E. Jackson
- Research and Education (CCTCARE), Colorado Center for Transplantation Care, Aurora, CO, United States
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jessica L. Saben
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Research and Education (CCTCARE), Colorado Center for Transplantation Care, Aurora, CO, United States
| | - Jesse D. Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Research and Education (CCTCARE), Colorado Center for Transplantation Care, Aurora, CO, United States
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - James J. Pomposelli
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Research and Education (CCTCARE), Colorado Center for Transplantation Care, Aurora, CO, United States
| | - Elizabeth A. Pomfret
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Research and Education (CCTCARE), Colorado Center for Transplantation Care, Aurora, CO, United States
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Research and Education (CCTCARE), Colorado Center for Transplantation Care, Aurora, CO, United States
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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5
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Snyder JJ, Schaffhausen CR, Hart A, Axelrod DA, Dils D, Formica RN, Gaber AO, Hunt HF, Jones J, Mohan S, Patzer RE, Pinney SP, Ratner LE, Slaker D, Stewart D, Stewart ZA, Van Slyck S, Kasiske BL, Hirose R, Israni AK. Stakeholders' Perspectives on Transplant Metrics: The 2022 Scientific Registry of Transplant Recipients' Consensus Conference. Am J Transplant 2023:S1600-6135(23)00355-6. [PMID: 36958628 DOI: 10.1016/j.ajt.2023.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 03/25/2023]
Abstract
In July 2022, the Scientific Registry of Transplant Recipients (SRTR) hosted an innovative, multistakeholder consensus conference to identify information and metrics desired by stakeholders in the transplantation system, including patients, living donors, caregivers, deceased donor family members, transplant professionals, organ procurement organization professionals, payers, and regulators. Crucially, patients, caregivers, living donors, and deceased donor family members were included in all aspects of this conference, including serving on the planning committee, participating in preconference focus groups and learning sessions, speaking at the conference, moderating conference sessions and breakout groups, and shaping the conclusions. Patients constituted 24% of the meeting participants. In this report, we document the proceedings and enumerate 160 recommendations, 10 of which have been highly prioritized. SRTR will use the recommendations to develop new presentations of information and metrics requested by stakeholders to support informed decision-making.
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Affiliation(s)
- Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.
| | - Cory R Schaffhausen
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Allyson Hart
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - David A Axelrod
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; University of Iowa Transplant Institute, Iowa City, Iowa, USA
| | - Dorrie Dils
- Gift of Life Michigan, Ann Arbor, Michigan, USA
| | | | - A Osama Gaber
- Department of Surgery, Houston Methodist Hospital, J.C. Walter Jr. Transplant Center, Houston, Texas, USA
| | | | - Jennifer Jones
- American Association of Kidney Patients, Kidney Transplant Recipient
| | - Sumit Mohan
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sean P Pinney
- Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Lloyd E Ratner
- Department of Surgery, Columbia University, New York, New York
| | - Dirk Slaker
- Optum Health Solutions, Eden Prairie, Minnesota, USA
| | - Darren Stewart
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Zoe A Stewart
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | | | - Bertram L Kasiske
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ryutaro Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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6
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Kwong AJ, Kim WR, Lake J, Stock PG, Wang CJ, Wetmore JB, Melcher ML, Wey A, Salkowski N, Snyder JJ, Israni AK. Impact of Donor Liver Macrovesicular Steatosis on Deceased Donor Yield and Posttransplant Outcome. Transplantation 2023; 107:405-409. [PMID: 36042548 PMCID: PMC9877102 DOI: 10.1097/tp.0000000000004291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The Scientific Registry of Transplant Recipients (SRTR) had not traditionally considered biopsy results in risk-adjustment models, yet biopsy results may influence outcomes and thus decisions regarding organ acceptance. METHODS Using SRTR data, which includes data on all donors, waitlisted candidates, and transplant recipients in the United States, we assessed (1) the impact of macrovesicular steatosis on deceased donor yield (defined as number of livers transplanted per donor) and 1-y posttransplant graft failure and (2) the effect of incorporating this variable into existing SRTR risk-adjustment models. RESULTS There were 21 559 donors with any recovered organ and 17 801 liver transplant recipients included for analysis. Increasing levels of macrovesicular steatosis on donor liver biopsy predicted lower organ yield: ≥31% macrovesicular steatosis on liver biopsy was associated with 87% to 95% lower odds of utilization, with 55% of these livers being discarded. The hazard ratio for graft failure with these livers was 1.53, compared with those with no pretransplant liver biopsy and 0% to 10% steatosis. There was minimal change on organ procurement organization-specific deceased donor yield or program-specific posttransplant outcome assessments when macrovesicular steatosis was added to the risk-adjustment models. CONCLUSIONS Donor livers with macrovesicular steatosis are disproportionately not transplanted relative to their risk for graft failure. To avoid undue risk aversion, SRTR now accounts for macrovesicular steatosis in the SRTR risk-adjustment models to help facilitate use of these higher-risk organs. Increased recognition of this variable may also encourage further efforts to standardize the reporting of liver biopsy results.
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Affiliation(s)
- Allison J. Kwong
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - W. Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - John Lake
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Peter G. Stock
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Division of Transplantation, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Connie J. Wang
- Division of Nephrology, Hennepin County Medical Center, and University of Minnesota, Minneapolis, MN, USA
| | - James B. Wetmore
- Division of Nephrology, Hennepin County Medical Center, and University of Minnesota, Minneapolis, MN, USA
| | - Marc L. Melcher
- Department of Surgery, Stanford University, Palo Alto, CA, USA
| | - Andrew Wey
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Nicholas Salkowski
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Jon J. Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Ajay K. Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Division of Nephrology, Hennepin County Medical Center, and University of Minnesota, Minneapolis, MN, USA
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
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7
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Miller J, Lyden GR, Zaun D, Kasiske BL, Hirose R, Israni AK, Snyder JJ. Transplant program evaluations in the middle of the COVID-19 pandemic. Am J Transplant 2022; 22:2616-2626. [PMID: 35727854 PMCID: PMC9350340 DOI: 10.1111/ajt.17123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/26/2022] [Accepted: 06/19/2022] [Indexed: 01/25/2023]
Abstract
Potential regional variations in effects of COVID-19 on federally mandated, program-specific evaluations by the Scientific Registry of Transplant Recipients (SRTR) have been controversial. SRTR January 2022 program evaluations ended transplant follow-up on March 12, 2020, and excluded transplants performed from March 13, 2020 to June 12, 2020 (the "carve-out"). This study examined the carve-out's impact, and the effect of additionally censoring COVID-19 deaths, on first-year posttransplant outcomes for transplants from July 2018 through December 2020. Program-specific hazard ratios (HRs) for graft failure and death estimated under two alternative scenarios were compared with published HRs: (1) the carve-out was removed; (2) the carve-out was retained, but deaths due to COVID-19 were additionally censored. The HRs estimated by censoring COVID-19 deaths were highly correlated with those estimated with the carve-out alone (r2 = .96). Removal of the carve-out resulted in greater variation in HRs while remaining highly correlated (r2 = .82); however, little geographic impact of the carve-out was observed. The carve-out increased average HR in the Northwest by 0.049; carve-out plus censoring reduced average HR in the Midwest by 0.009. Other regions of the country were not significantly affected. Thus, the current COVID-19 carve-out does not appear to impart substantial bias based on the region of the country.
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Affiliation(s)
- Jonathan Miller
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
| | - Grace R. Lyden
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
| | - David Zaun
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
| | - Bertram L. Kasiske
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
| | - Ryutaro Hirose
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
- Department of Surgery University of California San Francisco San Francisco, California USA
| | - Ajay K. Israni
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
- Department of Medicine, Hennepin Healthcare University of Minnesota Minneapolis, Minnesota USA
- Department of Epidemiology and Community Health University of Minnesota Minneapolis, Minnesota USA
| | - Jon J. Snyder
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
- Department of Medicine, Hennepin Healthcare University of Minnesota Minneapolis, Minnesota USA
- Department of Epidemiology and Community Health University of Minnesota Minneapolis, Minnesota USA
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8
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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.
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9
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Wang K, Deng Y, Stewart D, Formica RN. A Composite End Point of Graft Status and eGFR at 1 Year to Improve the Scientific Registry of Transplant Recipients' Five-Tier Rating System. J Am Soc Nephrol 2022; 33:1613-1624. [PMID: 35537779 PMCID: PMC9342646 DOI: 10.1681/asn.2022010078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/12/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Performance of kidney transplant programs in the United States is monitored and publicly reported by the Scientific Registry of Transplant Recipients (SRTR). With relatively few allograft failure events per program and increasing homogeneity in program performance, quantifying meaningful differences in program competency based only on 1-year survival rates is challenging. METHODS We explored whether the traditional end point of allograft failure at 1 year can be improved by incorporating a measure of allograft function (i.e., eGFR) into a composite end point. We divided SRTR data from 2008 through 2018 into a training and validation set and recreated SRTR tiers, using the traditional and composite end points. The conditional 5-year deceased donor allograft survival and 5-year eGFR were then assessed using each approach. RESULTS Compared with the traditional end point, the composite end point of graft failure or eGFR <30 ml/min per 1.73 m2 at 1-year post-transplant performed better in stratifying transplant programs based on long-term deceased donor graft survival. For tiers 1 through 5 respectively, the 5-year conditional graft survival was 72.9%, 74.8%, 75.4%, 77.0%, and 79.7% using the traditional end point and 71.1%, 74.4%, 76.9%, 77.0%, and 78.4% with the composite end point. Additionally, with the five-tier system derived from the composite end point, programs in tier 3, tier 4, and tier 5 had significantly higher mean eGFRs at 5 years compared with programs in tier 1. There were no significant eGFR differences among tiers derived from the traditional end point alone. CONCLUSIONS This proof-of-concept study suggests that a composite end point incorporating allograft function may improve the post-transplant component of the five-tier system by better differentiating between transplant programs with respect to long-term graft outcomes.
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Affiliation(s)
- Kaicheng Wang
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Yanhong Deng
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
| | | | - Richard N. Formica
- Departments of Medicine and Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
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10
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Wakeam E, Thumma JR, Bonner SN, Chang AC, Reddy RM, Lagisetty K, Lynch W, Grenda T, Chan K, Lyu D, Lin J. One-year Mortality Is Not a Reliable Indicator of Lung Transplant Center Performance. Ann Thorac Surg 2022; 114:225-232. [PMID: 35247344 DOI: 10.1016/j.athoracsur.2022.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/25/2022] [Accepted: 02/09/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND In the United States, the Organ Procurement and Transplant Network uses one-year mortality as the primary measure of transplant center quality. We sought to evaluate the reliability of mortality outcomes in lung transplant and compare statistical methods of program performance evaluation. METHODS We used the Standard Transplant Analysis and Research files from the United Network for Organ Sharing to identify lung transplant recipients from 2013-2018 in the United States. We stratified hospitals based on 30-day, 1-year and 5-year survival using risk adjustment, reliability adjustment using empirical Bayes technique, and hierarchical Bayesian mixed-effects models currently used by the OPTN. We measured variation in mortality rates and identification of performance outliers between techniques. RESULTS We identified 12,769 recipients in 69 centers. Reliability adjustment reduced variation in hospital outcomes and had a large impact on hospital mortality rankings. For example, with 1-year mortality, 28% (5 hospitals) of the "best" hospitals (top 25%) and 18% (3 hospitals) of the "worst" hospitals (bottom 25%) were reclassified after reliability adjustment. The overall reliability of 1-year mortality was low at 0.42. Compared to the Bayesian method used by the OPTN, reliability adjustment identified fewer outliers. 5-year survival reached a higher reliability plateau with a lower volume of cases required. CONCLUSIONS The reliability of 1-year mortality in lung transplantation is low, while 5-year survival estimates may be more reliable at lower case volumes. Reliability adjustment yielded more conservative measures of center performance and fewer outliers compared to current Bayesian methods.
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Affiliation(s)
- Elliot Wakeam
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI.
| | - Jyothi R Thumma
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Sidra N Bonner
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI; Section of General Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Andrew C Chang
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Rishindra M Reddy
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Kiran Lagisetty
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - William Lynch
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Tyler Grenda
- Division of Thoracic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Kevin Chan
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Dennis Lyu
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Jules Lin
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
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11
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Andreoni KA. Kidney transplant program specific reporting and transplant metrics. Curr Opin Organ Transplant 2022; 27:70-74. [PMID: 34939966 DOI: 10.1097/mot.0000000000000947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Kidney transplantation is a heavily regulated medical procedure with the Secretary of HHS ultimately responsible for oversight and authority derived from the NOTA and the Final Rule. Transplant Programs undergo publicly reported evaluations every 6 months based on outcomes from a 2-and-a-half-year period. The current Bayesian metrics for kidney transplant programs were created such that over ten percentage of programs are deemed underperformers, or 'flag', every 6 months. Newly suggested transplant metrics have been released for public comment in Summer 2021. In addition to graft outcomes, waiting list mortality and organ acceptance rate ratios are proposed. RECENT FINDINGS Under the newly proposed kidney transplant metrics, over 10% of programs are expected to be deemed underperformers or 'flagged'. Transplant Center flagging is well correlated with decreased transplantation due to the transplant centres move to more conservative organ and patient acceptance. Death on the waiting list is a proposed metric over which transplant centres have little influence. SUMMARY In the USA, the harsh regulation continued by Health Resources and Services Administration (HRSA) through the national organ procurement and transplant network (OPTN) and Scientific Registry for Transplant Recipients (SRTR) leads directly to high organ discard rates and limitations to transplanting patients with perceived unadjusted risks. Instead of loosening regulation in a highly functioning industry that achieves remarkable outcomes in end stage kidney patients, the OPTN with the SRTR persist in increasing potential penalties through more proposed metrics that continue to deem 10% of US kidney transplant programs as underperformers. HRSA must establish a reasonable regulatory environment that allows for innovation and increased transplant opportunities for US end-stage renal disease patients.
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Affiliation(s)
- Kenneth A Andreoni
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Department of Surgery, Division of Transplantation and Hepatobiliary Surgery, Cleveland, Ohio, USA
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12
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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.
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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
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13
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Wey A, Hart A, Salkowski N, Skeans M, Kasiske BL, Israni AK, Snyder JJ. Posttransplant outcome assessments at listing: Long-term outcomes are more important than short-term outcomes. Am J Transplant 2020; 20:2813-2821. [PMID: 32282985 DOI: 10.1111/ajt.15911] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/05/2020] [Accepted: 03/29/2020] [Indexed: 01/25/2023]
Abstract
Posttransplant outcome assessments are publicly reported for patient and regulatory use. However, the currently reported 1-year posttransplant graft survival assessments are commonly criticized for not identifying clinically meaningful differences between programs, and not providing information about longer-term posttransplant outcomes. We investigated the association of different posttransplant outcome assessments available to patients at the time of listing with subsequent posttransplant graft survival. The posttransplant assessments were from period prevalent, rather than incident, cohorts with more timely 1-, 3-, and 5-year follow-up and 6-, 12-, 18-, 24-, and 30-month cohort windows. The association of these assessments at listing with subsequent posttransplant graft survival included candidates listed between July 12, 2011, and December 15, 2015, who subsequently underwent transplant before December 31, 2018. The assessments with 1-year follow-up had uniformly weaker associations than the assessments with 3- and 5-year follow-up. The assessments with 5-year follow-up had the strongest association in kidney and liver transplantation. For kidney, liver, and lung transplantation, assessment windows of at least 18 months typically had the strongest associations with subsequent graft survival. Posttransplant assessments with 5-year follow-up and 18-30-month cohort windows are better than the current posttransplant assessment with 1-year follow-up, particularly at the time of listing.
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Affiliation(s)
- Andrew Wey
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Allyson Hart
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas Salkowski
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Melissa Skeans
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Bertram L Kasiske
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
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14
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Wey A, Salkowski N, Carrico RJ, Shepherd S, Kasiske BL, Thompson B, Israni AK, Snyder JJ. Association between changes in Membership and Professional Standards Committee review criteria and use of higher-risk kidneys for transplant. Clin Transplant 2020; 34:e13872. [PMID: 32271964 DOI: 10.1111/ctr.13872] [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: 07/16/2019] [Revised: 03/16/2020] [Accepted: 03/31/2020] [Indexed: 11/29/2022]
Abstract
The Organ Procurement and Transplantation Network's Membership and Professional Standards Committee implemented an operational rule on March 1, 2017, intended to increase the number of kidneys transplanted from donors with kidney donor profile index (KDPI) ≥ 85% into recipients with poor estimated posttransplant survival (≥ 80%). Using data from the Scientific Registry of Transplant Recipients, ordinal and logistic regressions estimated, respectively, differences in kidney yield (number of transplanted kidneys per recovered donor) and offer acceptance practices before and after implementation. We included donors recovered January 1, 2016-February 28, 2018. The odds of higher kidney yield for donors with KDPI ≥ 85% were 27% higher after implementation (odds ratio, 1.06 1.271.53 ), but odds were also 20% higher for donors with KDPI < 85% (1.04 1.201.38 ). Thus, kidney yield was higher for all donors, with a slightly larger difference for donors with KDPI ≥ 85%. Additionally, the difference in offer acceptance before and after implementation was similar regardless of KDPI (KDPI < 85%, 0.97 1.021.07 ; KDPI ≥ 85%, 0.95 1.041.14 ). In the first year after implementation, kidney yield increased for donors with KDPI < and ≥ 85%. Thus, kidney yield from higher KDPI donors may have increased without the operational rule.
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Affiliation(s)
- Andrew Wey
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Nicholas Salkowski
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Robert J Carrico
- Organ Procurement and Transplantation Network, Richmond, Virginia.,United Network for Organ Sharing, Richmond, Virginia
| | - Sharon Shepherd
- Organ Procurement and Transplantation Network, Richmond, Virginia.,United Network for Organ Sharing, Richmond, Virginia
| | - Bertram L Kasiske
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota
| | - Bryn Thompson
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
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15
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Wey A, Salkowski N, Kremers W, Ahn YS, Snyder J. Piecewise exponential models with time‐varying effects: Estimating mortality after listing for solid organ transplant. Stat (Int Stat Inst) 2020. [DOI: 10.1002/sta4.264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Andrew Wey
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis MN USA
| | - Nicholas Salkowski
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis MN USA
| | - Walter Kremers
- Division of Biomedical Statistics and Informatics Mayo Clinic Rochester MN USA
| | - Yoon Son Ahn
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis MN USA
| | - Jon Snyder
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis MN USA
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16
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Wey A, Salkowski N, Kasiske BL, Skeans M, Schaffhausen CR, Gustafson SK, Israni AK, Snyder JJ. Comparing Scientific Registry of Transplant Recipients posttransplant program-specific outcome ratings at listing with subsequent recipient outcomes after transplant. Am J Transplant 2019; 19:391-398. [PMID: 30053337 PMCID: PMC6836690 DOI: 10.1111/ajt.15038] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/28/2018] [Accepted: 07/22/2018] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Andrew Wey
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Nicholas Salkowski
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Bertram L. Kasiske
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
- Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
| | - Melissa Skeans
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Cory R. Schaffhausen
- Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
| | - Sally K. Gustafson
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Ajay K. Israni
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
- Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Jon J. Snyder
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
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17
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Wey A, Gustafson SK, Salkowski N, Kasiske BL, Skeans M, Schaffhausen CR, Israni AK, Snyder JJ. Association of pretransplant and posttransplant program ratings with candidate mortality after listing. Am J Transplant 2019; 19:399-406. [PMID: 30040191 PMCID: PMC6837730 DOI: 10.1111/ajt.15032] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/28/2018] [Accepted: 07/18/2018] [Indexed: 01/25/2023]
Abstract
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 0.950.97 ), liver (HR, 0.87 0.900.92 ), and heart (HR, 0.92 0.961.00 ) 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 0.960.99 ) transplantation, and posttransplant graft survival evaluations with one additional tier were associated with lower mortality after listing in lung (HR, 0.90 0.940.98 ) transplantation. Transplant rate typically had the strongest association with mortality after listing, but the strength of associations differed by organ.
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Affiliation(s)
- Andrew Wey
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Sally K. Gustafson
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Nicholas Salkowski
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Bertram L. Kasiske
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota,Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
| | - Melissa Skeans
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Cory R. Schaffhausen
- Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
| | - Ajay K. Israni
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota,Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Jon J. Snyder
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
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18
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Wey A, Salkowski N, Kasiske BL, Skeans MA, Gustafson SK, Israni AK, Snyder JJ. The relationship between the C-statistic and the accuracy of program-specific evaluations. Am J Transplant 2019; 19:407-413. [PMID: 30282119 PMCID: PMC6836685 DOI: 10.1111/ajt.15132] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/24/2018] [Accepted: 09/27/2018] [Indexed: 01/25/2023]
Abstract
The C-statistic of the risk-adjustment model is often used to judge the accuracy of program evaluations. However, the C-statistic depends on the variability in risk for individual transplants and may be inappropriate for determining the accuracy of program evaluations. A simulation study investigated the association of the C-statistic with several metrics of program evaluation accuracy, including categorizing programs into the 5-tier system and identifying programs for regulatory review. The simulation study used data from deceased donor kidney-alone transplants for adult recipients in the program-specific reports released January 2018. A range of C-statistics was generated by changing the variability in risk for individual transplants. The C-statistic had no association with any metric of program evaluation accuracy. Instead, the number of expected events at a program was the most important factor. For example, Spearman's rho, which is the correlation of ranks, was -0.27 and -0.72 between the true program-specific hazard ratios and assigned tiers for programs with, respectively, <3 and >10 expected events. Presence of unadjusted risk factors did not modify the associations, although the accuracy of program evaluations was systematically lower. Therefore, the C-statistic provides no information on the accuracy of program evaluations.
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Affiliation(s)
- Andrew Wey
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Nicholas Salkowski
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Bertram L. Kasiske
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota,Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
| | - Melissa A. Skeans
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Sally K. Gustafson
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Ajay K. Israni
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota,Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Jon J. Snyder
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
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19
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Kasza J, Polkinghorne KR, Wolfe R, McDonald SP, Marshall MR. Comparing dialysis centre mortality outcomes across Australia and New Zealand: identifying unusually performing centres 2008-2013. BMC Health Serv Res 2018; 18:1007. [PMID: 30594187 PMCID: PMC6311072 DOI: 10.1186/s12913-018-3832-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Comparing the mortality profiles of dialysis centres is important to ensure that high standards of care are maintained. We compare the performance of dialysis centres in Australia and New Zealand in their treatment of haemodialysis patients, accounting for the competing risks of kidney transplantation and transfer to peritoneal dialysis. METHODS Observational cohort study. We included data from all adult patients (5574 patients) commencing haemodialysis at home or in a facility between 2008 and 2010 across 62 dialysis centres, from the Australia and New Zealand Dialysis and Transplant Registry. Standardised mortality ratios were calculated by estimating mortality probabilities from a pooled random effects logistic regression model, accounting for the competing risk of transplantation using an inverse probability weighting approach. Models were adjusted for patient comorbidities, sex, height, weight, late referral to a nephrologist, age, race, primary kidney disease, smoking status, and serum creatinine (μmol/l). RESULTS Two dialysis centres were found to have relatively higher levels of risk-adjusted mortality lying outside the prediction intervals for "usual" performance. Risk adjusted mortality rates were not associated with centres' compliance with guidelines for vascular access and biochemical and haematological targets. CONCLUSIONS We demonstrate that standardised mortality ratios are useful to identify facilities that have statistically outlying mortality risk. Our criterion for determining whether a centre has better or worse performance than expected is statistical, and thus analyses such as ours can serve only as a screening tool, and are only one aspect of assessment of "quality" of performance.
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Affiliation(s)
- Jessica Kasza
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, 3004, Australia.
| | - Kevan R Polkinghorne
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, 3004, Australia.,Departments of Nephrology and Medicine, Monash Medical Centre, Monash University, Melbourne, Victoria, 3168, Australia
| | - Rory Wolfe
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, 3004, Australia
| | - Stephen P McDonald
- ANZDATA Registry, SA Health and Medical Research Institute, Adelaide, South Australia, 5000, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia, 5005, Australia
| | - Mark R Marshall
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.,Baxter Healthcare (Asia) Pte Ltd, 150 Beach Road. #30-01/08 Gateway West, Singapore, 189720, Singapore.,Department of Renal Medicine, Counties Manukau Health, Private Bag 93311, Auckland, 1640, New Zealand
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20
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Scientific Registry of Transplant Recipients program-specific reports: where we have been and where we are going. Curr Opin Organ Transplant 2018; 24:58-63. [PMID: 30575617 DOI: 10.1097/mot.0000000000000597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Reporting provider data on quality to patients and the general public is increasingly common in healthcare. Reporting outcomes in solid organ transplantation has always been controversial and deserves careful consideration to ensure optimal results. RECENT FINDINGS As mandated by Federal law, the Scientific Registry of Transplant Recipients publishes program-specific reports on transplant candidates, recipients, donors, and transplant outcomes every 6 months. Recent changes designed to make the results more easily understood by patients and the general public have been well received by patients and controversial among providers. In particular, outcomes are now reported using a five-tier system that distinguishes program results better than the old three-tier system, in which almost all programs were reported "as expected." Metrics that reflect access to transplant are also reported, including transplant rate and survival on the waiting list. Possible measures of longer term outcomes and program rates of accepting organs for transplant are being explored. SUMMARY Providing detailed information regarding transplant program practices and outcomes in ways that patients and the general public can understand remains a major focus of the Scientific Registry of Transplant Recipients. Efforts to improve data collection and metrics reported are ongoing.
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21
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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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22
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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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23
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Quality measurement and improvement in liver transplantation. J Hepatol 2018; 68:1300-1310. [PMID: 29559346 DOI: 10.1016/j.jhep.2018.02.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 02/21/2018] [Accepted: 02/27/2018] [Indexed: 02/07/2023]
Abstract
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.
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24
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Wey A, Gustafson SK, Salkowski N, Pyke J, Kasiske BL, Israni AK, Snyder JJ. Program-specific transplant rate ratios: Association with allocation priority at listing and posttransplant outcomes. Am J Transplant 2018; 18:1360-1369. [PMID: 29397038 DOI: 10.1111/ajt.14684] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 01/25/2018] [Accepted: 01/28/2018] [Indexed: 01/25/2023]
Abstract
The Scientific Registry of Transplant Recipients (SRTR) is considering more prominent reporting of program-specific adjusted transplant rate ratios (TRRs). To enable more useful reporting of TRRs, SRTR updated the transplant rate models to adjust explicitly for components of allocation priority. We evaluated potential associations between TRRs and components of allocation priority that could indicate programs' ability to manipulate TRRs by denying or delaying access to low-priority candidates. Despite a strong association with unadjusted TRRs, we found no candidate-level association between the components of allocation priority and adjusted TRRs. We found a strong program-level association between median laboratory Model for End-stage Liver Disease (MELD) score at listing and program-specific adjusted TRRs (r = .37; P < .001). The program-level association was likely confounded by regional differences in donor supply/demand and listing practices. In kidney transplantation, higher program-specific adjusted TRRs were weakly associated with better adjusted posttransplant outcomes (r = -.14; P = .035) and lower adjusted waitlist mortality rate ratios (r = -.15; P = .022), but these associations were absent in liver, lung, and heart transplantation. Program-specific adjusted TRRs were unlikely to be improved by listing candidates with high allocation priority and can provide useful information for transplant candidates and programs.
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Affiliation(s)
- A Wey
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - S K Gustafson
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - N Salkowski
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - J Pyke
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - B L Kasiske
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN, USA.,Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - A K Israni
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN, USA.,Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - J J Snyder
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN, USA.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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25
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Sypek MP, Jose MD, McDonald SP. Clinical quality registries for clinician-level reporting: strengths and limitations. Med J Aust 2018; 208:322-323. [PMID: 29642821 DOI: 10.5694/mja17.00581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 07/04/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Matthew P Sypek
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA
| | | | - Stephen P McDonald
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA
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26
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Maldonado DA, RoyChoudhury A, Lederer DJ. A novel patient-centered "intention-to-treat" metric of U.S. lung transplant center performance. Am J Transplant 2018; 18:226-231. [PMID: 28862792 PMCID: PMC5739968 DOI: 10.1111/ajt.14486] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/31/2017] [Accepted: 08/22/2017] [Indexed: 01/25/2023]
Abstract
Despite the importance of pretransplantation outcomes, 1-year posttransplantation survival is typically considered the primary metric of lung transplant center performance in the United States. We designed a novel lung transplant center performance metric that incorporates both pre- and posttransplantation survival time. We performed an ecologic study of 12 187 lung transplant candidates listed at 56 U.S. lung transplant centers between 2006 and 2012. We calculated an "intention-to-treat" survival (ITTS) metric as the percentage of waiting list candidates surviving at least 1 year after transplantation. The median center-level 1-year posttransplantation survival rate was 84.1%, and the median center-level ITTS was 66.9% (mean absolute difference 19.6%, 95% limits of agreement 4.3 to 35.1%). All but 10 centers had ITTS values that were significantly lower than 1-year posttransplantation survival rates. Observed ITTS was significantly lower than expected ITTS for 7 centers. These data show that one third of lung transplant candidates do not survive 1 year after transplantation, and that 12% of centers have lower than expected ITTS. An "intention-to-treat" survival metric may provide a more realistic expectation of patient outcomes at transplant centers and may be of value to transplant centers and policymakers.
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Affiliation(s)
- Dawn A. Maldonado
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York
| | - Arindam RoyChoudhury
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - David J. Lederer
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York,Department of Biostatistics Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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27
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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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28
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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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29
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Wey A, Salkowski N, Kasiske BL, Israni AK, Snyder JJ. A Five-Tier System for Improving the Categorization of Transplant Program Performance. Health Serv Res 2017; 53:1979-1991. [PMID: 28608369 DOI: 10.1111/1475-6773.12726] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew Wey
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Nicholas Salkowski
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Bertram L Kasiske
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN.,Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN.,Department of Medicine, Hennepin County Medical Center, Minneapolis, MN.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
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30
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Kasiske BL, Salkowski N, Wey A, Israni AK, Snyder JJ. Potential Implications of Recent and Proposed Changes in the Regulatory Oversight of Solid Organ Transplantation in the United States. Am J Transplant 2016; 16:3371-3377. [PMID: 27401597 PMCID: PMC5233595 DOI: 10.1111/ajt.13955] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 01/25/2023]
Abstract
Every 6 months, the Scientific Registry of Transplant Recipients (SRTR) publishes evaluations of every solid organ transplant program in the United States, including evaluations of 1-year patient and graft survival. The Centers for Medicare & Medicaid Services (CMS) and the Organ Procurement and Transplantation Network (OPTN) Membership and Professional Standards Committee (MPSC) use SRTR's 1-year evaluations for regulatory review of transplant programs. Concern has been growing that the regulatory scrutiny of transplant programs with lower-than-expected outcomes is harmful, causing programs to undertake fewer high-risk transplants and leading to unnecessary organ discards. As a result, CMS raised its threshold for a "Condition-Level Deficiency" designation of observed relative to expected 1-year graft or patient survival from 1.50 to 1.85. Exceeding this threshold in the current SRTR outcomes report and in one of the four previous reports leads to scrutiny that may result in loss of Medicare funding. For its part, OPTN is reviewing a proposal from the MPSC to also change its performance criteria thresholds for program review, to review programs with "substantive clinical differences." We review the details and implications of these changes in transplant program oversight.
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Affiliation(s)
- BL Kasiske
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
,Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
| | - N Salkowski
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - A Wey
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - AK Israni
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
,Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - JJ Snyder
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
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31
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Abstract
Anesthesiologists are obligated to demonstrate the value of the care they provide. The Centers for Medicare and Medicaid Services has multiple performance-based payment programs to drive high-value care and motivate integrated care for surgical patients and hospitalized patients. These programs rely on diverse arrays of performance measures and complex reporting rules. Among all specialties, anesthesiology has tremendous potential to effect wide-ranging change on diverse measures. Performance measures deserve scrutiny by anesthesiologists as tools to improve care, the means by which payment is determined, and as a means to demonstrate the value of care to surgeons, hospitals, and patients.
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Affiliation(s)
- Joseph A Hyder
- Division of Critical Care Medicine, Department of Anesthesiology, Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
| | - James R Hebl
- Department of Anesthesiology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
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32
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Snyder JJ, Salkowski N, Wey A, Israni AK, Schold JD, Segev DL, Kasiske BL. Effects of High-Risk Kidneys on Scientific Registry of Transplant Recipients Program Quality Reports. Am J Transplant 2016; 16:2646-53. [PMID: 26954720 DOI: 10.1111/ajt.13783] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/16/2016] [Accepted: 03/03/2016] [Indexed: 01/25/2023]
Abstract
There is a perception that transplanting high-risk kidneys causes programs to be identified as underperforming, thereby increasing the frequency of discards and diminishing access to transplant. Thus, the Organ Procurement and Transplantation Network (OPTN) has considered excluding transplants using kidneys from donors with high Kidney Donor Profile Index (KDPI) scores (≥0.85) when assessing program performance. We examined whether accepting high-risk kidneys (KDPI ≥0.85) for transplant yields worse outcome evaluations. Despite a clear relationship between KDPI and graft failure and mortality, there was no relationship between a program's use of high-KDPI kidneys and poor performance evaluations after risk adjustment. Excluding high-KDPI donor transplants from the June 2015 evaluations did not alter the programs identified as underperforming, because in every case underperforming programs also had worse-than-expected outcomes among lower-risk donor transplants. Finally, we found that hypothetically accepting and transplanting additional kidneys with KDPI similar to that of kidneys currently discarded would not adversely affect program evaluations. Based on the study findings, there is no evidence that programs that accept higher-KDPI kidneys are at greater risk for low performance evaluations, and risk aversion may limit access to transplant for candidates while providing no measurable benefit to program evaluations.
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Affiliation(s)
- J J Snyder
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - N Salkowski
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - A Wey
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - A K Israni
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN.,Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - J D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - D L Segev
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - B L Kasiske
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
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33
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Salkowski N, Wey A, Snyder JJ, Orlowski JP, Israni AK, Kasiske BL. The clinical relevance of Organ Procurement and Transplantation Network screening criteria for program performance review in the United States. Clin Transplant 2016; 30:1066-73. [PMID: 27313143 DOI: 10.1111/ctr.12789] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2016] [Indexed: 11/29/2022]
Abstract
The Organ Procurement and Transplantation Network is charged with overseeing the quality of transplant programs in the United States. However, there has been controversy over whether too many programs are being identified as underperforming. It has also been suggested that dramatic improvements in outcomes throughout the United States have made the thresholds for determining which deceased donor transplant programs are underperforming no longer clinically relevant. The Scientific Registry of Transplant Recipients compared actual and expected 1-y graft survival for transplant programs identified as underperforming in the most recent cohort (transplants from July 1, 2012 to December 31, 2014). For most organs, actual 1-y graft survival was substantially lower for programs identified as underperforming than for programs identified as performing as expected. Differences were smallest for kidney programs: median 1-y graft survival 89.2% vs 95.4% in large-volume programs identified and not identified for Membership and Professional Standards Committee review, respectively. Median expected graft survival was only slightly lower (94.8% vs 95.1%, respectively), suggesting that identified and not identified programs tend to have similar risk tolerances. An excess of 143 grafts were lost from kidney programs identified as underperforming. Transplant programs identified as underperforming generally have reduced 1-y graft survival that stakeholders may consider clinically relevant.
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Affiliation(s)
- Nicholas Salkowski
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - Andrew Wey
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN, USA.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN, USA.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA.,Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - Bertram L Kasiske
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN, USA. .,Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN, USA.
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34
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Irwin FD, Wu C, Bannister WM, Bonagura AF, Laihinen B, Axelrod DA, Schnitzler MA. A commercial transplant network's perspective of value in solid organ transplantation: Strategizing for value in transplant care. Transplant Rev (Orlando) 2016; 30:71-6. [DOI: 10.1016/j.trre.2015.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 11/10/2015] [Indexed: 10/22/2022]
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35
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Hernández D, Muriel A, Abraira V. Current state of clinical end-points assessment in transplant: Key points. Transplant Rev (Orlando) 2016; 30:92-9. [PMID: 26948088 DOI: 10.1016/j.trre.2016.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 02/03/2016] [Indexed: 12/20/2022]
Abstract
Solid organ transplantation is the treatment of choice for patients with end-stage organ disease. However, organ transplantation can stress the cardiovascular system and decrease immune surveillance, leading to early mortality and graft loss due to multiple underlying comorbidities. Clinical end-points in transplant include death and graft failure. Thus, generating accurate predictive models through regression models is crucial to test for definitive clinical post-transplantation end-points. Survival predictive models should assemble efficient surrogate markers or prognostic factors to generate a minimal set of variables derived from a proper modeling strategy through regression models. However, a few critical points should be considered when reporting survival analyses and regression models to achieve proper discrimination and calibration of the predictive models. Additionally, population-based risk scores may underestimate risk prediction in transplant. The application of predictive models in these patients should therefore incorporate both classical and non-classical risk factors, as well as community-based health indicators and transplant-specific factors to quantify the outcomes in terms of survival properly. This review focuses on assessment of clinical end-points in transplant through regression models by combining predictive and surrogate variables, and considering key points in these analyses to accurately predict definitive end-points, which could aid clinicians in decision making.
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Affiliation(s)
- Domingo Hernández
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD12/0021/0015). Avda. Carlos Haya s/n., 29010, Málaga, Spain.
| | - Alfonso Muriel
- Clinical Biostatistic Unit, Hospital Ramón y Cajal, IRYCIS, CIBERESP, Crta. Colmenar km 9.1, 28034, Madrid, Spain
| | - Víctor Abraira
- Clinical Biostatistic Unit, Hospital Ramón y Cajal, IRYCIS, CIBERESP, Crta. Colmenar km 9.1, 28034, Madrid, Spain
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36
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Kalbfleisch JD, Schaubel DE. A Perspective on the Scientific Registry of Transplant Recipients' Migration to Bayesian Methods. Am J Transplant 2015; 15:2271-2. [PMID: 26096593 DOI: 10.1111/ajt.13354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 03/08/2015] [Accepted: 03/13/2015] [Indexed: 01/25/2023]
Affiliation(s)
- J D Kalbfleisch
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, 48109
| | - D E Schaubel
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, 48109
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37
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Salkowski N, Snyder JJ, Kasiske BL. Response to Kalbfleish and Schaubel: "A Perspective on the Scientific Registry of Transplant Recipients Migration to Bayesian Methods". Am J Transplant 2015; 15:2273-4. [PMID: 26096466 DOI: 10.1111/ajt.13353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 04/15/2015] [Indexed: 01/25/2023]
Affiliation(s)
- N Salkowski
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - J J Snyder
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - B L Kasiske
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota.,Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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38
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39
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Kremers WK. Impact of the Scientific Registry of Transplant Recipients' new Bayesian method on estimating center effects and flagging of centers as worse than expected. Am J Transplant 2014; 14:1703-4. [PMID: 24909450 DOI: 10.1111/ajt.12813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- W K Kremers
- Department of Health Sciences Research and The William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
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40
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Schold JD, Axelrod DA. Changing our prior assumptions: adapting to new bayesian transplant center report cards. Am J Transplant 2014; 14:1231-3. [PMID: 24786835 DOI: 10.1111/ajt.12704] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 02/10/2014] [Accepted: 02/10/2014] [Indexed: 01/25/2023]
Affiliation(s)
- J D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
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