Reported effects of the Scientific Registry of Transplant Recipients 5-tier rating system on US transplant centers: results of a national survey

Health Care Provider Clustering Using Fusion Penalty in Quasi-Likelihood

There has been growing research interest in developing methodology to evaluate the health care providers' performance with respect to a patient outcome. Random and fixed effects models are traditionally used for such a purpose. We propose a new method, using a fusion penalty to cluster health care providers based on quasi-likelihood. Without any priori knowledge of grouping information, our method provides a desirable data-driven approach for automatically clustering health care providers into different groups based on their performance. Further, the quasi-likelihood is more flexible and robust than the regular likelihood in that no distributional assumption is needed. An efficient alternating direction method of multipliers algorithm is developed to implement the proposed method. We show that the proposed method enjoys the oracle properties; namely, it performs as well as if the true group structure were known in advance. The consistency and asymptotic normality of the estimators are established. Simulation studies and analysis of the national kidney transplant registry data demonstrate the utility and validity of our method.

Public Reporting of Heart Transplant Center Performance: Promoting Clarity or Causing Confusion?

BACKGROUND

Transplant center report cards are publicly available and used by regulators, insurance payers, and importantly patients and families.

OBJECTIVES

In this study, the authors sought to evaluate the variability in reported public performance ratings of pediatric and adult heart transplant centers.

METHODS

Program-specific reports from the Scientific Registry of Transplant Recipients from 2017-2021 were used to evaluate stability, volatility, and reliability of 3 publicly reported ratings: waitlist survival (WS), getting to a faster transplant (FT), and post-transplantation graft failure (GF).

RESULTS

There were 112 adult and 55 pediatric centers. Over the study period, nearly all centers (98%) had at least 1 change in rating in at least 1 of the tiers. The average time to the first rating change of any magnitude was 12-18 months for all tiers and centers. For adult centers, the most volatile rating was WS (SD: 0.77), followed by GF (SD: 0.76) and then FT (SD: 0.57). For pediatric centers, the most volatile rating was WS (SD: 0.79), followed by both GF (SD: 0.66) and FT (SD: 0.68), which were equally volatile. All tiers except adult FT had an estimated Fleiss's kappa <0.20, indicating poor agreement/consistency across the study period. In addition, the intraclass correlation coefficient for all tiers was <0.50, indicating poor reliability.

CONCLUSIONS

The current 5-tier reporting of transplant center performance is highly volatile and has poor reliability and consistency. Given the unintended and significant negative consequences these reports can have, critical revision of these ratings is warranted.

Association of Neighborhood Deprivation and Transplant Center Quality with Liver Transplantation Outcomes

BACKGROUND

Social determinants of health can impact the quality of liver transplantation (LT) care. We sought to assess whether the association between neighborhood deprivation and transplant outcomes can be mitigated by receiving care at high-quality transplant centers.

STUDY DESIGN

In this population-based cohort study, patients who underwent LT between 2004 and 2019 were identified in the Scientific Registry of Transplant Recipients. LT-recipient neighborhoods were identified at the county level and stratified into quintiles relative to Area Deprivation Index (ADI). Transplant center quality was based on the Scientific Registry of Transplant Recipients 5-tier ranking using standardized transplant rate ratios. Multivariable Cox regression was used to assess the relationship between ADI, hospital quality, and posttransplant survival.

RESULTS

A total of 41,333 recipients (median age, 57.0 [50.0 to 63.0] years; 27,112 [65.4%] male) met inclusion criteria. Patients residing in the most deprived areas were more likely to have nonalcoholic steatohepatitis, be Black, and travel further distances to reach a transplant center. On multivariable analysis, post-LT long-term mortality was associated with low- vs high-quality transplant centers (hazard ratio [HR] 1.19, 95% CI 1.07 to 1.32), as well as among patients residing in high- vs low-ADI neighborhoods (HR 1.25, 95% CI 1.16 to 1.34; both p ≤ 0.001). Of note, individuals residing in high- vs low-ADI neighborhoods had a higher risk of long-term mortality after treatment at a low-quality (HR 1.31, 95% CI 1.06 to 1.62, p = 0.011) vs high-quality (HR 1.12, 95% CI 0.83 to 1.52, p = 0.471) LT center.

CONCLUSIONS

LT at high-quality centers may be able to mitigate the association between posttransplant survival and neighborhood deprivation. Investments and initiatives that increase access to referrals to high-quality centers for patients residing in higher deprivation may lead to better outcomes and help mitigate disparities in LT.

Healthcare center clustering for Cox's proportional hazards model by fusion penalty

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.

Impact of Public Reporting of Center-Specific Survival Analysis Scores on Patient Volumes at Hematopoietic Cell Transplant Centers

BACKGROUND

The Center for International Blood and Marrow Transplant Research (CIBMTR) reports the outcomes of allogeneic hematopoietic cell transplantation (alloHCT) at United States transplant centers (TC) annually through its Center-Specific Survival Analysis (CSA). The CSA compares the actual 1-year overall survival (OS) and predicted 1-year OS rate after alloHCT at each TC, which is then reported as 0 (OS as expected), -1 (OS worse than expected), or +1 (OS better than expected).

OBJECTIVE

We evaluated the impact of public reporting of TC performance on their alloHCT patient volumes.

STUDY DESIGN

Ninety-one TCs that serve adult or combined adult and pediatric populations and had CSA scores reported for 2012-2018 were included. We analyzed prior-calendar year TC volume, prior-calendar year CSA score, whether the CSA score had changed in the prior year from two years earlier, calendar year, TC type (adult only vs. combined adult and pediatric), and years of alloHCT experience for their impact on patient volumes.

RESULTS

A CSA score of -1, as compared with 0 or +1, was associated with an 8%-9% reduction in the mean TC volume (P < 0.001) in the subsequent year, adjusting for the prior year center volume. Additionally, being a TC neighboring an index TC with a -1 CSA score, was associated with a 3.5% increase in mean TC volume (P = 0.04).

CONCLUSION

Our data show that public reporting of CSA scores is associated with changes in alloHCT volumes at TCs. Additional investigation into the causes of this shift in patient volume and the impact on outcomes is ongoing.