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Woelfel I, Faulkner D, Wong S, Washburn K, Schenk A. A “Return to Normalcy” or Establishing a “New Normal”: The Patient Experience of Liver Transplantation. JOURNAL OF LIVER TRANSPLANTATION 2023. [DOI: 10.1016/j.liver.2023.100149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
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2
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Butler AE, Chapman GB. Don't Throw Your Heart Away: Increased Transparency of Donor Utilization Practices in Transplant Center Report Cards Alters How Center Performance Is Evaluated. Med Decis Making 2021; 42:341-351. [PMID: 34605713 DOI: 10.1177/0272989x211038941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Publicly available report cards for transplant centers emphasize posttransplant survival and obscure the fact that some centers reject many of the donor organs they are offered (reflecting a conservative donor acceptance strategy), while others accept a broader range of donor offers (reflecting an open donor acceptance strategy). OBJECTIVE We assessed how the provision of salient information about donor acceptance practices and waitlist survival rates affected evaluation judgments of hospital report cards given by laypeople and medical trainees. METHODS We tested 5 different report card formats across 4 online randomized experiments (n1 = 1,003, n2 = 105, n3 = 123, n4 = 807) in the same hypothetical decision. The primary outcome variable was a binary choice between transplant hospitals (one with an open donor acceptance strategy and the other with a conservative donor acceptance strategy). RESULTS Report cards featuring salient information about donor organ utilization rates (transplant outcomes categorized by quality of donor offers accepted) or overall survival rates (outcomes from both waitlist and transplanted patients) led lay participants (studies 1, 3, and 4) and medical trainees (study 2) to evaluate transplant centers with open donor acceptance strategies more favorably than centers with conservative strategies. LIMITATIONS Due to the nature of the decision, a hypothetical scenario was necessary for both ethical and practical reasons. Results may not generalize to transplant clinicians or patients faced with the decision of where to join the transplant waitlist. CONCLUSIONS These findings suggest that performance evaluations for transplant centers may vary significantly based not only on what outcome information is presented in report cards but also how the information is displayed.
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Affiliation(s)
- Alison E Butler
- Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA, USA.,Medical Scientist Training Program, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Gretchen B Chapman
- Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA, USA
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3
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Ross-Driscoll K, Patzer RE, Axelrod DA. Ecological factors and posttransplant outcomes: Causation or correlation? Am J Transplant 2021; 21:3219-3220. [PMID: 34117719 PMCID: PMC9051979 DOI: 10.1111/ajt.16716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/20/2021] [Accepted: 05/20/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Katherine Ross-Driscoll
- Division of Transplant, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Division of Transplant, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia
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4
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Does Liver Transplant Center Size Matter? Center Size Disparities and the Unintended Consequences of Transplant Regulation- A Commentary. Transplantation 2021; 106:911-912. [PMID: 34366387 DOI: 10.1097/tp.0000000000003916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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5
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Ross-Driscoll K, Kramer M, Lynch R, Plantinga L, Wedd J, Patzer R. Variation in Racial Disparities in Liver Transplant Outcomes Across Transplant Centers in the United States. Liver Transpl 2021; 27:558-567. [PMID: 37160041 PMCID: PMC8201428 DOI: 10.1002/lt.25918] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
Little is known about the role that transplant centers may play in perpetuating racial disparities after liver transplantation, which are unexplained by patient-level factors. We examined variation in between-center and within-center disparities among 34,114 Black and White liver transplant recipients in the United States from 2010 to 2017 using Scientific Registry of Transplant Recipient (SRTR) data. We used Cox proportional hazards models to calculate transplant center-specific Black-White hazard ratios and hierarchical survival analysis to examine potential effect modification of the race-survival association by transplant center characteristics, including transplant volume, proportion of Black patients, SRTR quality rating, and region. Models were sequentially adjusted for clinical, socioeconomic, and center characteristics. After adjustment, Black patients experienced 1.11 excess deaths after liver transplant per 100 person-years compared with White patients (95% confidence interval [CI], 0.65-1.56), corresponding to a 21% increased mortality risk (95% CI, 1.12-1.31). Although there was substantial variation in this disparity across transplant centers, there was no evidence of effect modification by transplant center volume, proportion of minority patients seen, quality rating, or region. We found significant racial disparities in survival after transplant, with substantial variation in this disparity across transplant centers that was not explained by selected center characteristics. This is the first study to directly evaluate the role transplant centers play in racial disparities in transplant outcomes. Further assessment of the qualitative factors that may drive disparities, such as selection processes and follow-up care, is needed to create effective center-level interventions to address health inequity.
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Affiliation(s)
- Katherine Ross-Driscoll
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Center for Health Services Research, Emory University School of Medicine, Atlanta, GA
| | - Michael Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Raymond Lynch
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Laura Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Joel Wedd
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Rachel Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Center for Health Services Research, Emory University School of Medicine, Atlanta, GA,Department of Surgery, Emory University School of Medicine, Atlanta, GA,Department of Medicine, Emory University School of Medicine, Atlanta, GA
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6
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Using Geographic Catchment Areas to Measure Population-based Access to Kidney Transplant in the United States. Transplantation 2020; 104:e342-e350. [PMID: 33215901 DOI: 10.1097/tp.0000000000003369] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Monitoring efforts to improve access to transplantation requires a definition of the population attributable to a transplant center. Previously, assessment of variation in transplant care has focused on differences between administrative units-such as states-rather than units derived from observed care patterns. We defined catchment areas (transplant referral regions [TRRs]) from transplant center care patterns for population-based assessment of transplant access. METHODS We used US adult transplant listings (2006-2016) and Dartmouth Atlas catchment areas to assess the optimal method of defining TRRs. We used US Renal Data System and Scientific Registry of Transplant Recipient data to compare waitlist- and population-based kidney transplant rates. RESULTS We identified 110 kidney, 67 liver, 85 pancreas, 68 heart, and 43 lung TRRs. Most patients were listed in their assigned TRR (kidney: 76%; liver: 75%; pancreas: 75%; heart: 74%; lung: 72%), although the proportion varied by organ (interquartile range for kidney, 65.7%-82.5%; liver, 58.2%-78.8%; pancreas, 58.4%-81.1%; heart, 63.1%-80.9%; lung, 61.6%-76.3%). Patterns of population- and waitlist-based kidney transplant rates differed, most notably in the Northeast and Midwest. CONCLUSIONS Patterns of TRR-based kidney transplant rates differ from waitlist-based rates, indicating that current metrics may not reflect transplant access in the broader population. TRRs define populations served by transplant centers and could enable future studies of how transplant centers can improve access for patients in their communities.
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7
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Baez Hernandez N, Kirk R, Davies R, Bano M, Sutcliffe D, Pirolli T, Jaquiss R, Daneman S, Butts RJ. A comprehensive strategy in donor acceptance: Impact on pediatric waitlist and heart transplant outcomes. Pediatr Transplant 2020; 24:e13764. [PMID: 32536034 DOI: 10.1111/petr.13764] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 12/12/2022]
Abstract
Significant inter- and intra-center practice variability is present in pediatric donor heart acceptability. This may contribute to variation in the donor refusal rate and may impact waitlist time, morbidity, mortality, and transplant rates. In order to reduce practice variability, our center developed and implemented a comprehensive strategy regarding donor acceptance in September 2017. The aim of this study was to assess the impact of this strategy on waitlist time and outcomes as well as early post-transplant outcomes. We performed a single-center, retrospective analysis of all pediatric (<18 years) patients listed for single-organ heart transplant at our center from September 2015 to September 2018. Patients were divided into those listed before (Group 1) and after implementation of the comprehensive strategy (Group 2). The primary end-point was waitlist time. Secondary end-points included waitlist removal due to death or clinical deterioration, donor refusals per listed patient, early post-transplant outcomes (graft failure, mechanical ventilation time, inotropic support, length of hospital stay) and 1-year post-transplant survival. Of 78 listed patients, 54 were transplanted (29 in Group 1), 9 were removed due to death or clinical deterioration (7 in Group 1) and 15 were removed due to clinical improvement (12 in Group 1). The waitlist time was significantly shorter in Group 2 (17 days, IQR 7-53) vs Group 1 (90 days, IQR 14-162); P = .006. The number of donor refusals was lower in Group 2 (1, IQR 0-2.2) vs Group 1 (4, IQR 2-19); P < .001. The percentage of refused donors with normal function (Left ventricular ejection fraction > 50%) was lower in Group 2 vs Group 1 (53% vs 84%; P < .001). Difference in removal from the waitlist for death or deterioration in Group 2 vs Group 1 (n = 2, 7% vs n = 7, 20%, P = .18) did not reach statistical significance. There was no difference in post-transplant outcomes between groups. The waitlist time and donor refusals significantly decreased after implementation of a comprehensive donor acceptance strategy without impacting transplant outcomes. This analysis supports the need for a comprehensive approach to donor organ acceptance within a pediatric transplant center.
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Affiliation(s)
| | - Richard Kirk
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ryan Davies
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Maria Bano
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David Sutcliffe
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Timothy Pirolli
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Jaquiss
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Susan Daneman
- Children's Health, Children's Medical Center, Dallas, TX, USA
| | - Ryan J Butts
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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8
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Deceased Brain Dead Donor Liver Transplantation and Utilization in the United States: Nighttime and Weekend Effects. Transplantation 2020; 103:1392-1404. [PMID: 30444802 DOI: 10.1097/tp.0000000000002533] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Understanding factors that contribute to liver discards and nonusage is urgently needed to improve organ utilization. METHODS Using Scientific Registry of Transplant Recipient data, we studied a national cohort of all US adult, deceased brain dead donor, isolated livers available for transplantation from 2003 to 2016, including organ-specific and system-wide factors that may affect organ procurement and discard rates. RESULTS Of 73 686 available livers, 65 316 (88.64%) were recovered for transplant, of which 6454 (9.88%) were ultimately discarded. Livers that were not procured or, on recovery, discarded were more frequently from older, heavier, hepatitis B virus (HCV)+, and more comorbid donors (P < 0.001). However, even after adjustment for organ quality, the odds of liver nonusage were 11% higher on the weekend (defined as donor procurements with cross-clamping occurring from 5:00 PM Friday until 11:59 AM Sunday) compared with weekdays (P < 0.001). Nonuse rates were also higher at night (P < 0.001), defined as donor procurements with cross-clamping occurring from 5:00 PM to 5:00 AM; however, weekend nights had significantly higher nonuse rates compared with weekday nights (P = 0.005). After Share 35, weekend nonusage rates decreased from 21.77% to 19.51% but were still higher than weekday nonusage rates (P = 0.065). Weekend liver nonusage was higher in all 11 United Network of Organ Sharing regions, with an absolute average of 2.00% fewer available livers being used on the weekend compared with weekdays. CONCLUSIONS Although unused livers frequently have unfavorable donor characteristics, there are also systemic and operational factors, including time of day and day of the week a liver becomes available, that impact the chance of liver nonprocurement and discard.
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9
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Butler A, Chapman G, Johnson JN, Amodeo A, Böhmer J, Camino M, Davies RR, Dipchand AI, Godown J, Miera O, Pérez-Blanco A, Rosenthal DN, Zangwill S, Kirk R. Behavioral economics-A framework for donor organ decision-making in pediatric heart transplantation. Pediatr Transplant 2020; 24:e13655. [PMID: 31985140 DOI: 10.1111/petr.13655] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 12/09/2019] [Indexed: 12/18/2022]
Abstract
The high discard rate of pediatric donor hearts presents a major challenge for children awaiting heart transplantation. Recent literature identifies several factors that contribute to the disparities in pediatric donor heart usage, including regulatory oversight, the absence of guidelines on pediatric donor heart acceptance, and variation among transplant programs. However, a likely additional contributor to this issue are the behavioral factors influencing transplant team decisions in donor offer scenarios, a topic that has not yet been studied in detail. Behavioral economics and decision psychology provide an excellent foundation for investigating decision-making in the pediatric transplant setting, offering key insights into the behavior of transplant professionals. We conducted a systematic review of published literature in pediatric heart transplant related to behavioral economics and the psychology of decision-making. In this review, we draw on paradigms from these two domains in order to examine how existing aspects of the transplant environment, including regulatory oversight, programmatic variation, and allocation systems, may precipitate potential biases surrounding donor offer decisions. Recognizing how human decision behavior influences donor acceptance is a first step toward improving utilization of potentially viable pediatric donor hearts.
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Affiliation(s)
| | | | | | | | - Jens Böhmer
- The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Ryan R Davies
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA
| | - Anne I Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Justin Godown
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oliver Miera
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum, Berlin, Germany
| | | | | | | | - Richard Kirk
- Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA
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10
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Kirk R, Dipchand AI, Davies RR, Miera O, Chapman G, Conway J, Denfield S, Gossett JG, Johnson J, McCulloch M, Schweiger M, Zimpfer D, Ablonczy L, Adachi I, Albert D, Alexander P, Amdani S, Amodeo A, Azeka E, Ballweg J, Beasley G, Böhmer J, Butler A, Camino M, Castro J, Chen S, Chrisant M, Christen U, Danziger-Isakov L, Das B, Everitt M, Feingold B, Fenton M, Garcia-Guereta L, Godown J, Gupta D, Irving C, Joong A, Kemna M, Khulbey SK, Kindel S, Knecht K, Lal AK, Lin K, Lord K, Möller T, Nandi D, Niesse O, Peng DM, Pérez-Blanco A, Punnoose A, Reinhardt Z, Rosenthal D, Scales A, Scheel J, Shih R, Smith J, Smits J, Thul J, Weintraub R, Zangwill S, Zuckerman WA. ISHLT consensus statement on donor organ acceptability and management in pediatric heart transplantation. J Heart Lung Transplant 2020; 39:331-341. [PMID: 32088108 DOI: 10.1016/j.healun.2020.01.1345] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 01/24/2020] [Indexed: 12/14/2022] Open
Abstract
The number of potential pediatric heart transplant recipients continues to exceed the number of donors, and consequently the waitlist mortality remains significant. Despite this, around 40% of all donated organs are not used and are discarded. This document (62 authors from 53 institutions in 17 countries) evaluates factors responsible for discarding donor hearts and makes recommendations regarding donor heart acceptance. The aim of this statement is to ensure that no usable donor heart is discarded, waitlist mortality is reduced, and post-transplant survival is not adversely impacted.
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Affiliation(s)
- Richard Kirk
- Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, Texas.
| | - Anne I Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ryan R Davies
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, Texas
| | - Oliver Miera
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | | | - Jennifer Conway
- Department of Pediatrics, Division of Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Susan Denfield
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jeffrey G Gossett
- University of California Benioff Children's Hospitals, San Francisco, California
| | - Jonathan Johnson
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Michael McCulloch
- University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Martin Schweiger
- Division of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Vienna and Pediatric Heart Center Vienna, Vienna, Austria
| | - László Ablonczy
- Pediatric Cardiac Center, Hungarian Institute of Cardiology, Budapest, Hungary
| | - Iki Adachi
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Dimpna Albert
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Peta Alexander
- Department of Cardiology, Boston Children's Hospital Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | | | - Estela Azeka
- Heart Institute (InCor) University of São Paulo, São Paulo, Brazil
| | - Jean Ballweg
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital and Medical Center University of Nebraska Medical Center, Omaha, Nebraska
| | - Gary Beasley
- Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Jens Böhmer
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alison Butler
- Carnegie Mellon University, Pittsburgh, Pennsylvania
| | | | - Javier Castro
- Fundacion Cardiovascular de Colombia, Santander, Bucaramanga City, Colombia
| | | | - Maryanne Chrisant
- Heart Institute, Joe Dimaggio Children's Hospital, Hollywood, Florida
| | - Urs Christen
- Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Lara Danziger-Isakov
- Pediatric Infectious Diseases, Cincinnati Children's Hospital Medical Center & University of Cincinnati, Cincinnati, Ohio
| | - Bibhuti Das
- Heart Institute, Joe Dimaggio Children's Hospital, Hollywood, Florida
| | | | - Brian Feingold
- Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew Fenton
- Great Ormond Street Hospital for Children Foundation Trust, London, United Kingdom
| | | | - Justin Godown
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dipankar Gupta
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Claire Irving
- Children's Hospital Westmead, Sydney, New South Wales, Australia
| | - Anna Joong
- Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois
| | | | | | - Steven Kindel
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | | | | | - Kimberly Lin
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Karen Lord
- New England Organ Bank, Boston, Massachusetts
| | - Thomas Möller
- Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Deipanjan Nandi
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Oliver Niesse
- Division of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland
| | | | | | - Ann Punnoose
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | | | | | - Angie Scales
- Pediatric and Neonatal Donation and Transplantation, Organ Donation and Transplantation, NHS Blood and Transplant, London, United Kingdom
| | - Janet Scheel
- Washington University School of Medicine, St. Louis, Missouri
| | - Renata Shih
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | | | | | - Josef Thul
- Children's Heart Center, University of Giessen, Giessen, Germany
| | | | | | - Warren A Zuckerman
- Columbia University Medical Center, Morgan Stanley Children's Hospital of New York, New York, New York
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Chandraker A, Andreoni KA, Gaston RS, Gill J, Locke JE, Mathur AK, Norman DJ, Patzer RE, Rana A, Ratner LE, Schold JD, Pruett TL. Time for reform in transplant program-specific reporting: AST/ASTS transplant metrics taskforce. Am J Transplant 2019; 19:1888-1895. [PMID: 31012525 DOI: 10.1111/ajt.15394] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 02/26/2019] [Accepted: 03/31/2019] [Indexed: 01/25/2023]
Abstract
In accordance with the National Organ Transplant Act and Department of Health and Human Services' Final Rule, the Scientific Registry of Transplant Recipients (SRTR) publicly releases biannual program-specific reports that include analyses of transplant centers' risk-adjusted waitlist mortality, organ acceptance ratios, transplant rates, and graft and patient survival. Since the inception of these center metrics, 1-year posttransplant graft and patient survival have improved, and center variation has decreased, casting uncertainty on their clinical relevance. The SRTR has recently modified center evaluations by ranking centers into 5 tiers rather than 3 tiers in an attempt to discriminate between programs performing within a tight range, further exacerbating this uncertainty. The American Society of Transplantation/American Society of Transplant Surgeons convened an expert taskforce to examine both the utility and unintended consequences of transplant center metrics. Estimates of center variation in outcomes in adjacent tiers are imprecise and fleeting, but can result in consequential changes in clinician and center behavior. The taskforce has concerns that current metrics, based principally on 1-year graft and patient survival, provide minimal if any benefit in informing patient choice and access to transplantation, with the untoward effect of decreased utilization of organs and restriction of research and innovation.
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Affiliation(s)
- Anil Chandraker
- Transplantation Research Center, Renal Division, Brigham& Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kenneth A Andreoni
- Division of Abdominal Transplantation, University of Florida, Gainesville, Florida
| | | | - John Gill
- Nephrology, Providence Health Care Research Institute, Vancouver, BC, Canada
| | - Jayme E Locke
- Surgery, UAB School of Medicine, Birmingham, Alabama
| | - Amit K Mathur
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona
| | | | - Rachel E Patzer
- Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Abbas Rana
- Division of Abdominal Transplantation and Liver Disease, Baylor College of Medicine, Houston, Texas
| | | | - Jesse D Schold
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Timothy L Pruett
- Division of Transplantation, University of Minnesota, Minneapolis, Minnesota
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12
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Maximizing Utilization in Pancreas Transplantation: Phenotypic Characteristics Differentiating Aggressive From Nonaggressive Transplant Centers. Transplantation 2019; 102:2108-2119. [PMID: 29944617 DOI: 10.1097/tp.0000000000002334] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Maximizing pancreas utilization requires a balance between judicious donor selection and transplant center aggressiveness. We sought to determine how such aggressiveness affects transplant outcomes. METHODS Using the Scientific Registry of Transplant Recipients, we studied 28 487 deceased-donor adult pancreas transplants. Donor and recipient demographic factors indicative of aggressiveness were used to score center aggressiveness. We compared outcomes of low (> 1 SD below mean), medium (± 1 SD from mean), and high (> 1 SD above mean) aggressiveness centers using bivariate and multivariable regressions. RESULTS Donor and recipient aggressiveness demonstrated a roughly linear relationship (R = 0.20). Center volume correlated moderately with donor (rs = 0.433) and recipient (rs = 0.270) aggressiveness. In bivariate analysis, there was little impact of donor selection aggressiveness on graft survival. Further, for simultaneous pancreas and kidney transplants, centers with greater recipient aggressiveness selection had better graft survival. High-volume centers had better graft survival than low-volume centers. In multivariable analysis, donor aggressiveness did not have an effect on graft survival, whereas graft survival for medium (hazard ratio [HR], 0.66, 95% confidence interval [95% CI], 0.53-0.83) and high (HR, 0.67; CI, 0.51-0.86) recipient aggressiveness performed better than low-aggressiveness centers. There was a clear volume effect, with high-volume centers (>20 transplants/year; HR, 0.69; CI, 0.61-0.79) performing better than low-volume centers. CONCLUSIONS Center practice patterns using higher-risk donors and recipients did not negatively affect outcomes. This effect is likely mediated through efficiencies gained with the increased transplant volumes at these centers.
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Cooper M, Formica R, Friedewald J, Hirose R, O’Connor K, Mohan S, Schold J, Axelrod D, Pastan S. Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards. Clin Transplant 2018; 33:e13419. [DOI: 10.1111/ctr.13419] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 09/29/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew Cooper
- Medstar Georgetown Transplant Institute; Georgetown University; Washington District of Columbia
| | - Richard Formica
- Department of Medicine, Section of Nephrology; Yale School of Medicine; New Haven Connecticut
| | - John Friedewald
- Northwestern University Comprehensive Transplant Center; Chicago Illinois
| | - Ryutaro Hirose
- Department of Surgery; University of California San Francisco; San Francisco California
| | | | - Sumit Mohan
- Division of Nephrology, Department of Medicine; Vagelos College of Physicians & Surgeons, Columbia University; New York New York
- Department of Epidemiology, Mailman School of Public Health; Columbia University; New York New York
| | - Jesse Schold
- Department of Quantitative Health Sciences; Cleveland Clinic; Cleveland Ohio
| | - David Axelrod
- Department of Surgery; Lahey Hospital and Medical Center; Burlington Massachusetts
| | - Stephen Pastan
- Renal Division, Department of Medicine; Emory University School of Medicine; Atlanta Georgia
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14
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Taber DJ, Su Z, Fleming JN, Pilch NA, Morinelli T, Mauldin P, Dubay D. The impact of time-varying clinical surrogates on disparities in African-American kidney transplant recipients - a retrospective longitudinal cohort study. Transpl Int 2018; 32:84-94. [PMID: 30176087 DOI: 10.1111/tri.13338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/22/2018] [Accepted: 08/20/2018] [Indexed: 01/06/2023]
Abstract
An improved understanding of the impact of clinical surrogates on disparities in African-American (AA) kidney transplantation (KTX) is needed. We conducted a 10-year retrospective longitudinal cohort study of electronically abstracted clinical data assessing the impact of surrogates on disparities in KTX. Clinical surrogates were assessed by posttransplant year (1, 2, 3 or 4) and defined as acute rejection (Banff ≥1A), mean SBP >140 mmHg, tacrolimus variability (CV) >40%, mean glucose >160 mg/dl and mean hemoglobin <10 g/dl. We utilized landmark methodology to minimize immortal time bias and logistic and survival regression to assess outcomes; 1610 KTX were assessed (54.2% AAs), with 1000, 468, 368 and 303 included in the year 1, 2, 3 and 4 complete case analyses, respectively. AAs had significantly higher odds of developing a clinical surrogate, which increased in posttransplant years three and four [OR year 1 1.99 (1.38-2.88), year 2 1.77 (1.20-2.62), year 3 2.35 (1.49-3.71), year 4 2.85 (1.72-4.70)]. Adjusting for the five clinical surrogates in survival models explained a significant portion of the higher risks of graft loss in AAs in post-transplant years three and four. Results suggest focusing efforts on improving late clinical surrogate management within AAs may help mitigate racial disparities in KTX.
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Affiliation(s)
- David J Taber
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.,Department of Pharmacy Services, Ralph H Johnson VAMC, Charleston, SC, USA
| | - Zemin Su
- Division of General Internal Medicine & Geriatrics, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - James N Fleming
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.,Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA
| | - Nicole A Pilch
- Transplant Center, Medical University of South Carolina, Charleston, SC, USA
| | - Thomas Morinelli
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Patrick Mauldin
- Division of General Internal Medicine & Geriatrics, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Derek Dubay
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
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15
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Incerti D, Summers N, Ton TGN, Boscoe A, Chandraker A, Stevens W. The Lifetime Health Burden of Delayed Graft Function in Kidney Transplant Recipients in the United States. MDM Policy Pract 2018; 3:2381468318781811. [PMID: 30288451 PMCID: PMC6124921 DOI: 10.1177/2381468318781811] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 05/12/2018] [Indexed: 11/20/2022] Open
Abstract
Background. Although delayed graft function (DGF) is associated with
an increased risk of acute rejection and decreased graft survival, there are no
estimates of the long-term or lifetime health burden of DGF.
Objectives. To estimate the long-term and lifetime health
burden of DGF, defined as the need for at least one dialysis session within the
first week after transplantation, for a cohort representative of patients who
had their first kidney transplant in 2014. Methods. Data from the
United States Renal Data System (USRDS; 2001–2014) were used to estimate a
semi-Markov parametric multi-state model with three disease states. Maximum
length of follow-up was 13.7 years, and a microsimulation model was used to
extrapolate results over a lifetime. The impact of DGF was assessed by
simulating the model for each patient in the cohort with and without DGF.
Results. At the end of 13.7 years of follow-up, DGF reduces the
probability of having a functioning graft from 52% to 32%, increases the
probability of being on dialysis from 10% to 19%, and increases the probability
of death from 38% to 50% relative to transplant recipients who do not experience
DGF. A typical transplant recipient with DGF (median age = 53) is observed to
lose 0.87 quality-adjusted life-years (QALYs). Extrapolated over a lifetime, the
same 53-year-old DGF patient is projected to lose 3.01 (95% confidence interval:
2.33, 3.70) QALYs relative to a transplant recipient with the same
characteristics who does not experience DGF. Conclusions. The
lifetime health burden of DGF is substantial. Understanding these consequences
will help health care providers weigh kidney transplant decisions and inform
policies for patients in the context of varying risks of DGF.
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Affiliation(s)
| | | | | | - Audra Boscoe
- Alexion Pharmaceuticals Inc., New Haven, Connecticut
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16
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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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17
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Mohan S, Chiles MC. Achieving Equity through Reducing Variability in Accepting Deceased Donor Kidney Offers. Clin J Am Soc Nephrol 2017; 12:1212-1214. [PMID: 28751578 PMCID: PMC5544510 DOI: 10.2215/cjn.06220617] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York; and
- Department of Epidemiology, Mailman School of Public Health and
- The Columbia University Renal Epidemiology Group, New York, New York
| | - Mariana C. Chiles
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York; and
- The Columbia University Renal Epidemiology Group, New York, New York
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18
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Survival Benefit in Older Patients Associated With Earlier Transplant With High KDPI Kidneys. Transplantation 2017; 101:867-872. [PMID: 27495758 DOI: 10.1097/tp.0000000000001405] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Given high dialysis mortality rates for patients older than 60 years, accepting a kidney with a high Kidney Donor Profile Index (KDPI) score could enable earlier and potentially preemptive transplantation (preKT). However, evidence regarding the risks of high KDPI allografts in older patients is limited. Our objective was to determine the relative benefit for older patients of KDPI greater than 85% transplant either preemptively or not compared with remaining on the waitlist. METHODS United Network of Organ Sharing data from 2003 to 2012 for adult deceased donor kidney transplant candidates was analyzed to evaluate patient survival in patients older than 60 years for preKT and non-preKT KDPI greater than 85% transplants compared with candidates remaining on the waitlist including patients who received KDPI 0% to 85% transplants according to multivariate Cox regression models. RESULTS In the first year posttransplant for KDPI greater than 85% of transplants in recipients older than 60 years, preKT had a reduced mortality hazard (hazards ratio [HR], 0.61; 95% confidence interval [95% CI], 0.41-0.90) and non-preKT an increased mortality hazard (HR, 1.15; 95% CI, 1.03-1.27) compared with the waitlist including KDPI 0% to 85% transplant recipients. At 1 to 2 years and after 2 years, both KDPI greater than 85% groups had significant reductions in mortality (1-2 years: preKT HR, 0.38; 95% CI, [0.23-0.60] and non-preKT HR, 0.52; 95% CI, 0.45-0.61; and 2+ years: preKT HR, 0.50; 95% CI, 0.38-0.66 and non-preKT HR, 0.64; 95% CI, 0.58-0.70, respectively). CONCLUSIONS PreKT and non-preKT KDPI greater than 85% transplant was associated with lower mortality hazard after the first year compared with the waitlist including KDPI 0% to 85% transplants in patients older than 60 years. Further consideration should be given to increased utilization of high KDPI grafts in older patients with the goal of avoiding or limiting time on dialysis.
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19
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Klassen DK, McBride MA, Tosoc-Haskell H. A Look into a New Approach to Transplant Program Evaluation—the COIIN Project. CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0140-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Rege A, Irish B, Castleberry A, Vikraman D, Sanoff S, Ravindra K, Collins B, Sudan D. Trends in Usage and Outcomes for Expanded Criteria Donor Kidney Transplantation in the United States Characterized by Kidney Donor Profile Index. Cureus 2016; 8:e887. [PMID: 28018757 PMCID: PMC5179248 DOI: 10.7759/cureus.887] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
There has been increasing concern in the kidney transplant community about the declining use of expanded criteria donors (ECD) despite improvement in survival and quality of life. The recent introduction of the Kidney Donor Profile Index (KDPI), which provides a more granular characterization of donor quality, was expected to increase utilization of marginal kidneys and decrease the discard rates. However, trends and practice patterns of ECD kidney utilization on a national level based on donor organ quality as per KDPI are not well known. We, therefore, performed a trend analysis of all ECD recipients in the United Network for Organ Sharing (UNOS) registry between 2002 and 2012, after calculating the corresponding KDPI, to enable understanding the trends of usage and outcomes based on the KDPI characterization. High-risk recipient characteristics (diabetes, body mass index ≥30 kg/m2, hypertension, and age ≥60 years) increased over the period of the study (trend test p<0.001 for all). The proportion of ECD transplants increased from 18% in 2003 to a peak of 20.4% in 2008 and then declined thereafter to 17.3% in 2012. Using the KDPI >85% definition, the proportion increased from 9.4% in 2003 to a peak of 12.1% in 2008 and declined to 9.7% in 2012. Overall, although this represents a significant utilization of kidneys with KDPI >85% over time (p<0.001), recent years have seen a decline in usage, probably related to regulations imposed by Centers for Medicare & Medicaid Services (CMS). When comparing the hazards of graft failure by KDPI, ECD kidneys with KDPI >85% have a slightly lower risk of graft failure compared to standard criteria donor (SCD) kidneys with KDPI >85%, with a hazard ratio (HR) of 0.95, a confidence interval (CI) of 0.94-0.96, and statistical significance of p<0.001. This indicates that some SCD kidneys may actually have a lower estimated quality, with a higher Kidney Donor Risk Index (KDRI), than some ECDs. The incidence of delayed graft function (DGF) in ECD recipients has significantly decreased over time from 35.2% in 2003 to 29.6% in 2011 (p=0.007), probably related to better understanding of the donor risk profile along with increased use of hypothermic machine perfusion and pretransplant biopsy to aid in optimal allograft selection. The recent decline in transplantation of KDPI >85% kidneys probably reflects risk-averse transplant center behavior. Whether discard of discordant SCD kidneys with KDPI >85% has contributed to this decline remains to be studied.
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Affiliation(s)
| | - Bill Irish
- Health Outcomes Research & Biostatistics, CTI Clinical Trial and Consulting
| | | | - Deepak Vikraman
- Surgery, Duke University Medical Center ; Division of Abdominal Transplantation, Duke University Medical Center
| | - Scott Sanoff
- Transplant Nephrology, Duke University Medical Center
| | - Kadiyala Ravindra
- Surgery, Duke University Medical Center ; Division of Abdominal Transplantation, Duke University Medical Center
| | | | - Debra Sudan
- Surgery, Duke University Medical Center ; Division of Abdominal Transplantation, Duke University Medical Center
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21
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Nephrologists' Perspectives on Recipient Eligibility and Access to Living Kidney Donor Transplantation. Transplantation 2016; 100:943-53. [PMID: 26425873 DOI: 10.1097/tp.0000000000000921] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Wide variations in access to living kidney donation are apparent across transplant centers. Such disparities may be in part explained by nephrologists' beliefs and decisions about recipient eligibility. This study aims to describe nephrologists' attitudes towards recipient eligibility and access to living kidney donor transplantation. METHODS Face-to-face semistructured interviews were conducted from June to October 2013 with 41 nephrologists from Australia and New Zealand. Transcripts were analyzed thematically. RESULTS We identified five major themes: championing optimal recipient outcomes (maximizing recipient survival, increasing opportunity, accepting justified risks, needing control and certainty of outcomes, safeguarding psychological wellbeing), justifying donor sacrifice (confidence in reasonable utility, sparing the donor, ensuring reciprocal donor benefit), advocating for patients (being proactive and encouraging, addressing ambivalence, depending on supportive infrastructure, avoiding selective recommendations), maintaining professional boundaries (minimizing conflict of interest, respecting shared decision-making, emphasizing patient accountability, restricted decisional power, protecting unit interests), and entrenched inequities (exclusivity of living donors, inherently advantaging self-advocates, navigating language barriers, increasing center transparency, inevitable geographical disadvantage, understanding cultural barriers). CONCLUSIONS Nephrologists' decisions about recipient suitability for living donor transplantation aimed to achieve optimal recipient outcomes, but were constrained by competing priorities to ensure reasonable utility derived from the donor kidney and protect the integrity of the transplant program. Comprehensive guidelines that provide explicit recommendations for complex medical and psychosocial risk factors might promote more equitable and transparent decision-making. Psychosocial support and culturally sensitive educational resources are needed to help nephrologists advocate for disadvantaged patients and address disparities in access to living kidney donor transplantation.
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22
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Jarral OA, Baig K, Pettengell C, Uppal R, Taggart DP, Darzi A, Westaby S, Athanasiou T. National Survey of UK Consultant Surgeons’ Opinions on Surgeon-Specific Mortality Data in Cardiothoracic Surgery. Circ Cardiovasc Qual Outcomes 2016; 9:414-23. [DOI: 10.1161/circoutcomes.116.002749] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 05/18/2016] [Indexed: 11/16/2022]
Abstract
Background—
In the United Kingdom, cardiothoracic surgeons have led the outcome reporting revolution seen over the last 20 years. The objective of this survey was to assess cardiothoracic surgeons’ opinions on the topic, with the aim of guiding future debate and policy making for all subspecialties.
Methods and Results—
A questionnaire was developed using interviews with experts in the field. In January 2015, the survey was sent out to all consultant cardiothoracic surgeons in the United Kingdom (n=361). Logistic regression, bivariate correlation, and the χ
2
test were used to assess whether there was a relationship between answers and demographic variables. Free-text responses were analyzed using the grounded theory approach. The response rate was 73% (n=264). The majority of respondents (58.1% oppose, 34.1% favor, and 7.8% neither) oppose the public release of surgeon-specific mortality data and associate it with several adverse consequences. These include risk-averse behavior, gaming of data, and misinterpretation of data by the public. Despite this, the majority overwhelmingly supports publication of team-based measures of outcome. The free-text responses suggest that this is because most believe that quality of care is multifactorial and not represented by an individual’s mortality rate.
Conclusions—
There is evident opposition to surgeon-specific mortality data among UK cardiothoracic surgeons who associate this with several unintended consequences. Policy makers should refine their strategy behind publication of surgeon-specific mortality data and possibly consider shift toward team-based results for which there will be the required support. Stakeholder feedback and inclusive strategy should be completed before introducing major initiatives to avoid unforeseen consequences and disagreements.
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Affiliation(s)
- Omar A. Jarral
- From the Department of Surgery and Cancer, Imperial College London, London, United Kingdom (O.A.J., C.P., A.D., T.A.); Department of Cardiothoracic Surgery, St. Thomas’ Hospital, London, United Kingdom (K.B.); Department of Cardiothoracic Surgery, St Bartholomew’s Hospital, London, United Kingdom (R.U.); and Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, United Kingdom (D.P.T., S.W.)
| | - Kamran Baig
- From the Department of Surgery and Cancer, Imperial College London, London, United Kingdom (O.A.J., C.P., A.D., T.A.); Department of Cardiothoracic Surgery, St. Thomas’ Hospital, London, United Kingdom (K.B.); Department of Cardiothoracic Surgery, St Bartholomew’s Hospital, London, United Kingdom (R.U.); and Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, United Kingdom (D.P.T., S.W.)
| | - Christopher Pettengell
- From the Department of Surgery and Cancer, Imperial College London, London, United Kingdom (O.A.J., C.P., A.D., T.A.); Department of Cardiothoracic Surgery, St. Thomas’ Hospital, London, United Kingdom (K.B.); Department of Cardiothoracic Surgery, St Bartholomew’s Hospital, London, United Kingdom (R.U.); and Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, United Kingdom (D.P.T., S.W.)
| | - Rakesh Uppal
- From the Department of Surgery and Cancer, Imperial College London, London, United Kingdom (O.A.J., C.P., A.D., T.A.); Department of Cardiothoracic Surgery, St. Thomas’ Hospital, London, United Kingdom (K.B.); Department of Cardiothoracic Surgery, St Bartholomew’s Hospital, London, United Kingdom (R.U.); and Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, United Kingdom (D.P.T., S.W.)
| | - David P. Taggart
- From the Department of Surgery and Cancer, Imperial College London, London, United Kingdom (O.A.J., C.P., A.D., T.A.); Department of Cardiothoracic Surgery, St. Thomas’ Hospital, London, United Kingdom (K.B.); Department of Cardiothoracic Surgery, St Bartholomew’s Hospital, London, United Kingdom (R.U.); and Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, United Kingdom (D.P.T., S.W.)
| | - Ara Darzi
- From the Department of Surgery and Cancer, Imperial College London, London, United Kingdom (O.A.J., C.P., A.D., T.A.); Department of Cardiothoracic Surgery, St. Thomas’ Hospital, London, United Kingdom (K.B.); Department of Cardiothoracic Surgery, St Bartholomew’s Hospital, London, United Kingdom (R.U.); and Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, United Kingdom (D.P.T., S.W.)
| | - Stephen Westaby
- From the Department of Surgery and Cancer, Imperial College London, London, United Kingdom (O.A.J., C.P., A.D., T.A.); Department of Cardiothoracic Surgery, St. Thomas’ Hospital, London, United Kingdom (K.B.); Department of Cardiothoracic Surgery, St Bartholomew’s Hospital, London, United Kingdom (R.U.); and Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, United Kingdom (D.P.T., S.W.)
| | - Thanos Athanasiou
- From the Department of Surgery and Cancer, Imperial College London, London, United Kingdom (O.A.J., C.P., A.D., T.A.); Department of Cardiothoracic Surgery, St. Thomas’ Hospital, London, United Kingdom (K.B.); Department of Cardiothoracic Surgery, St Bartholomew’s Hospital, London, United Kingdom (R.U.); and Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, United Kingdom (D.P.T., S.W.)
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23
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Decade-Long Trends in Liver Transplant Waitlist Removal Due to Illness Severity: The Impact of Centers for Medicare and Medicaid Services Policy. J Am Coll Surg 2016; 222:1054-65. [PMID: 27178368 DOI: 10.1016/j.jamcollsurg.2016.03.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 03/02/2016] [Accepted: 03/02/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The central tenet of liver transplant organ allocation is to prioritize the sickest patients first. However, a 2007 Centers for Medicare and Medicaid Services regulatory policy, Conditions of Participation (COP), which mandates publically reported transplant center performance assessment and outcomes-based auditing, critically altered waitlist management and clinical decision making. We examine the extent to which COP implementation is associated with increased removal of the "sickest" patients from the liver transplant waitlist. STUDY DESIGN This study included 90,765 adult (aged 18 years and older) deceased donor liver transplant candidates listed at 102 transplant centers from April 2002 through December 2012 (Scientific Registry of Transplant Recipients). We quantified the effect of COP implementation on trends in waitlist removal due to illness severity and 1-year post-transplant mortality using interrupted time series segmented Poisson regression analysis. RESULTS We observed increasing trends in delisting due to illness severity in the setting of comparable demographic and clinical characteristics. Delisting abruptly increased by 16% at the time of COP implementation, and likelihood of being delisted continued to increase by 3% per quarter thereafter, without attenuation (p < 0.001). Results remained consistent after stratifying on key variables (ie, Model for End-Stage Liver Disease and age). The COP did not significantly impact 1-year post-transplant mortality (p = 0.38). CONCLUSIONS Although the 2007 Centers for Medicare and Medicaid Services COP policy was a quality initiative designed to improve patient outcomes, in reality, it failed to show beneficial effects in the liver transplant population. Patients who could potentially benefit from transplantation are increasingly being denied this lifesaving procedure while transplant mortality rates remain unaffected. Policy makers and clinicians should strive to balance candidate and recipient needs from a population-benefit perspective when designing performance metrics and during clinical decision making for patients on the waitlist.
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24
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Schold JD, Buccini LD, Poggio ED, Flechner SM, Goldfarb DA. Association of Candidate Removals From the Kidney Transplant Waiting List and Center Performance Oversight. Am J Transplant 2016; 16:1276-84. [PMID: 26762606 DOI: 10.1111/ajt.13594] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 10/21/2015] [Accepted: 10/25/2015] [Indexed: 01/25/2023]
Abstract
Approximately 59 000 kidney transplant candidates have been removed from the waiting list since 2000 for reasons other than transplantation, death, or transfers. Prior studies indicate that low-performance (LP) center evaluations by the Scientific Registry of Transplant Recipients (SRTR) are associated with reductions in transplant volume. There is limited information to determine whether performance oversight impacts waitlist management. We used national SRTR data to evaluate outcomes of 315 796 candidates on the kidney transplant waiting list (2007-2014). Compared to centers without LP, rates of waitlist removal (WLR) were higher at centers with LP evaluations (44.6/1000 follow-up years, 95% confidence interval [CI] 44.0, 45.1 versus 68.0/1000 follow-up years, 95% CI 66.6, 69.4), respectively, which was consistent after risk adjustment (adjusted hazard ratio [AHR] = 1.59, 95% CI 1.55, 1.63). Candidate mortality following waitlist removal was lower at LP centers (AHR = 0.90, 95% CI 0.87, 0.94). Analyses limited to LP centers indicated a significant increase in WLR (+28.6 removals/1000 follow-up years, p < 0.001), a decrease in transplant rates (-11.9/1000 follow-up years, p < 0.001) and a decrease in mortality after removal (-67.5 deaths/1000 follow-up years, p < 0.001) following LP evaluation. There is a significant association between LP evaluations and transplant center processes of care for waitlisted candidates. Further understanding is needed to determine the impact of performance oversight on transplant center quality of care and patient outcomes.
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Affiliation(s)
- J D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
| | - L D Buccini
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.,Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - E D Poggio
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - S M Flechner
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - D A Goldfarb
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
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25
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Emond JC. Measuring access to liver transplantation: An overdue metric for center quality and performance. J Hepatol 2016; 64:766-7. [PMID: 26827790 DOI: 10.1016/j.jhep.2016.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 01/25/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Jean C Emond
- Columbia University, New York, United States; The New York Presbyterian Hospital, New York, United States.
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26
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Schold JD, Buccini LD, Rodrigue JR, Mandelbrot D, Goldfarb DA, Flechner SM, Kayler LK, Poggio ED. Critical Factors Associated With Missing Follow-Up Data for Living Kidney Donors in the United States. Am J Transplant 2015; 15:2394-403. [PMID: 25902877 DOI: 10.1111/ajt.13282] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/25/2015] [Accepted: 02/11/2015] [Indexed: 01/25/2023]
Abstract
Follow-up care for living kidney donors is an important responsibility of the transplant community. Prior reports indicate incomplete donor follow-up information, which may reflect both donor and transplant center factors. New UNOS regulations require reporting of donor follow-up information by centers for 2 years. We utilized national SRTR data to evaluate donor and center-level factors associated with completed follow-up for donors 2008-2012 (n = 30 026) using multivariable hierarchical logistic models. We compared center follow-up compliance based on current UNOS standards using adjusted and unadjusted models. Complete follow-up at 6, 12, and 24 months was 67%, 60%, and 50% for clinical and 51%, 40%, and 30% for laboratory data, respectively, but have improved over time. Donor risk factors for missing laboratory data included younger age 18-34 (adjusted odds ratio [AOR] = 2.03, 1.58-2.60), black race (AOR = 1.17, 1.05-1.30), lack of insurance (AOR = 1.25, 1.15-1.36), lower educational attainment (AOR = 1.19, 1.06-1.34), >500 miles to center (AOR = 1.78, 1.60-1.98), and centers performing >40 living donor transplants/year (AOR = 2.20, 1.21-3.98). Risk-adjustment moderately shifted classification of center compliance with UNOS standards. There is substantial missing donor follow-up with marked variation by donor characteristics and centers. Although follow-up has improved over time, targeted efforts are needed for donors with selected characteristics and at centers with higher living donor volume. Adding adjustment for donor factors to policies regulating follow-up may function to provide more balanced evaluation of center efforts.
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Affiliation(s)
- J D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
| | - L D Buccini
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.,Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - J R Rodrigue
- Beth Israel Deaconess Medical Center, Boston, MA
| | | | - D A Goldfarb
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - S M Flechner
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | | | - E D Poggio
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
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Berney T, Kandaswamy R. Who needs a pancreas donor risk index? Transpl Int 2015; 28:1025-7. [DOI: 10.1111/tri.12599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 04/24/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Thierry Berney
- Divisions of Transplantation and Visceral Surgery; University of Geneva Hospitals and School of Medicine; Geneva Switzerland
| | - Raja Kandaswamy
- Division of Transplantation; Department of Surgery; University of Minnesota; Minneapolis MN USA
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Parikh ND, Hutton D, Marrero W, Sanghani K, Xu Y, Lavieri M. Projections in donor organs available for liver transplantation in the United States: 2014-2025. Liver Transpl 2015; 21:855-63. [PMID: 25845830 DOI: 10.1002/lt.24136] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 02/26/2015] [Accepted: 03/22/2015] [Indexed: 12/19/2022]
Abstract
With the aging US population, demographic shifts, and obesity epidemic, there is potential for further exacerbation of the current liver donor shortage. We aimed to project the availability of liver grafts in the United States. We performed a secondary analysis of the Organ Procurement and Transplantation Network database of all adult donors from 2000 to 2012 and calculated the total number of donors available and transplanted donor livers stratified by age, race, and body mass index (BMI) group per year. We used National Health and Nutrition Examination Survey and Centers for Disease Control and Prevention historical data to stratify the general population by age, sex, race, and BMI. We then used US population age and race projections provided by the US Census Bureau and the Weldon Cooper Center for Public Service and made national and regional projections of available donors and donor liver utilization from 2014 to 2025. We performed sensitivity analyses and varied the rate of the rise in obesity, proportion of Hispanics, population growth, liver utilization rate, and donation after cardiac death (DCD) utilization. The projected adult population growth in the United States from 2014 to 2025 will be 7.1%. However, we project that there will be a 6.1% increase in the number of used liver grafts. There is marked regional heterogeneity in liver donor growth. Projections were significantly affected by changes in BMI, DCD utilization, and liver utilization rates but not by changes in the Hispanic proportion of the US population or changes in the overall population growth. Overall population growth will outpace the growth of available donor organs and thus potentially exacerbate the existing liver graft shortage. The projected growth in organs is highly heterogeneous across different United Network for Organ Sharing regions. Focused strategies to increase the liver donor pool are warranted.
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Affiliation(s)
- Neehar D Parikh
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI
| | - David Hutton
- School of Public Health, University of Michigan Ann Arbor, MI
| | - Wesley Marrero
- Industrial and Operational Engineering, University of Michigan, Ann Arbor, MI
| | - Kunal Sanghani
- Industrial and Operational Engineering, University of Michigan, Ann Arbor, MI
| | - Yongcai Xu
- Industrial and Operational Engineering, University of Michigan, Ann Arbor, MI
| | - Mariel Lavieri
- Industrial and Operational Engineering, University of Michigan, Ann Arbor, MI
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Affiliation(s)
- Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
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Schold JD, Buccini LD, Goldfarb DA, Flechner SM, Poggio ED, Sehgal AR. Association between kidney transplant center performance and the survival benefit of transplantation versus dialysis. Clin J Am Soc Nephrol 2014; 9:1773-80. [PMID: 25237071 DOI: 10.2215/cjn.02380314] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite the benefits of kidney transplantation, the total number of transplants performed in the United States has stagnated since 2006. Transplant center quality metrics have been associated with a decline in transplant volume among low-performing centers. There are concerns that regulatory oversight may lead to risk aversion and lack of transplantation growth. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A retrospective cohort study of adults (age≥18 years) wait-listed for kidney transplantation in the United States from 2003 to 2010 using the Scientific Registry of Transplant Recipients was conducted. The primary aim was to investigate whether measured center performance modifies the survival benefit of transplantation versus dialysis. Center performance was on the basis of the most recent Scientific Registry of Transplant Recipients evaluation at the time that patients were placed on the waiting list. The primary outcome was the time-dependent adjusted hazard ratio of death compared with remaining on the transplant waiting list. RESULTS Among 223,808 waitlisted patients, 59,199 and 32,764 patients received a deceased or living donor transplant, respectively. Median follow-up from listing was 43 months (25th percentile=25 months, 75th percentile=67 months), and there were 43,951 total patient deaths. Deceased donor transplantation was independently associated with lower mortality at each center performance level compared with remaining on the waiting list; adjusted hazard ratio was 0.24 (95% confidence interval, 0.21 to 0.27) among 11,972 patients listed at high-performing centers, adjusted hazard ratio was 0.32 (95% confidence interval, 0.31 to 0.33) among 203,797 patients listed at centers performing as expected, and adjusted hazard ratio was 0.40 (95% confidence interval, 0.35 to 0.45) among 8039 patients listed at low-performing centers. The survival benefit was significantly different by center performance (P value for interaction <0.001). CONCLUSIONS Findings indicate that measured center performance modifies the survival benefit of kidney transplantation, but the benefit of transplantation remains highly significant even at centers with low measured quality. Policies that concurrently emphasize improved center performance with access to transplantation should be prioritized to improve ESRD population outcomes.
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Affiliation(s)
- Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; and Center for Reducing Health Disparities, MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Laura D Buccini
- Department of Quantitative Health Sciences, Digestive Disease Institute, and
| | - David A Goldfarb
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Stuart M Flechner
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emilio D Poggio
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ashwini R Sehgal
- Center for Reducing Health Disparities, MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
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Buccini LD, Segev DL, Fung J, Miller C, Kelly D, Quintini C, Schold JD. Association between liver transplant center performance evaluations and transplant volume. Am J Transplant 2014; 14:2097-105. [PMID: 25307038 DOI: 10.1111/ajt.12826] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 05/07/2014] [Accepted: 05/07/2014] [Indexed: 01/25/2023]
Abstract
There has been increased oversight of transplant centers and stagnation in liver transplantation nationally in recent years. We hypothesized that centers that received low performance (LP) evaluations were more likely to alter protocols, resulting in reduced rates of transplants and patients placed on the waiting list. We evaluated the association of LP evaluations and transplant activity among liver transplant centers in the United States using national Scientific Registry of Transplant Recipients data (January 2007 to July 2012). We compared the average change in recipient and candidate volume and donor and patient characteristics based on whether the centers received LP evaluations. Of 92 eligible centers, 27 (29%) received at least one LP evaluation. Centers without an LP evaluation (n = 65) had an average increase of 9.3 transplants and 14.9 candidates while LP centers had an average decrease of 39.9 transplants (p < 0.01) and 67.3 candidates (p < 0.01). LP centers reduced the use of older donors, donations with longer cold ischemia, and donations after cardiac death (p-values < 0.01). There was no association between the change in transplant volume and measured performance (R(2) = 0.002, p = 0.91). Findings indicate a strong association between performance evaluations and changes in candidate listings and transplants among liver transplant centers, with no measurable improvement in outcomes associated with reduction in transplant volume.
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Affiliation(s)
- L D Buccini
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
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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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White SL, Zinsser DM, Paul M, Levine GN, Shearon T, Ashby VB, Magee JC, Li Y, Leichtman AB. Patient selection and volume in the era surrounding implementation of Medicare conditions of participation for transplant programs. Health Serv Res 2014; 50:330-50. [PMID: 24838079 DOI: 10.1111/1475-6773.12188] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate evidence of practice changes affecting kidney transplant program volumes, and donor, recipient and candidate selection in the era surrounding the introduction of Centers for Medicare and Medicaid Services (CMS) conditions of participation (CoPs) for organ transplant programs. DATA Scientific Registry of Transplant Recipients; CMS ESRD and Medicare claims databases. DESIGN Retrospective analysis of national registry data. METHODS A Cox proportional hazards model of 1-year graft survival was used to derive risks associated with deceased-donor kidney transplants performed from 2001 to 2010. FINDINGS Among programs with ongoing noncompliance with the CoPs, kidney transplant volumes declined by 38 percent (n = 766) from 2006 to 2011, including a 55 percent drop in expanded criteria donor transplants. Volume increased by 6 percent (n = 638) among programs remaining in compliance. Aggregate risk of 1-year graft failure increased over time due to increasing recipient age and obesity, and longer ESRD duration. CONCLUSIONS Although trends in aggregate risk of 1-year kidney graft loss do not indicate that the introduction of the CoPs has systematically reduced opportunities for marginal candidates or that there has been a systematic shift away from utilization of higher risk deceased donor kidneys, total volume and expanded criteria donor utilization decreased overall among programs with ongoing noncompliance.
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Affiliation(s)
- Sarah L White
- Department of Internal Medicine, Division of Nephrology, Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; The George Institute for International Health, University of Sydney, Camperdown, NSW
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Kruel CRP, Chedid A. Balancing accountable care with risk aversion: transplantation as a model--we cannot forget the outcomes. Am J Transplant 2013; 13:1937-8. [PMID: 23659795 DOI: 10.1111/ajt.12261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Mange KC. Time for demonstrating quality and accountable care: renal transplantation model. Am J Transplant 2013; 13:1369. [PMID: 23590579 DOI: 10.1111/ajt.12213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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