Addressing Critiques of the Proposed CMS Metric of Organ Procurement Organ Performance: More Data Isn't Better

Direct Measurement of DCD Donor Potential

BACKGROUND

Existing methods of comparing organ procurement organization (OPO) performance use administrative data to indirectly measure donation after circulatory death (DCD). The purpose of this study was to categorize and quantify reasons that potential DCD donors do not progress to donation to facilitate the direct measurement of OPO donor potential.

METHODS

Records of all 18 685 potential organ donors referred to the organ procurement agency OneLegacy in 2021 and 2022 were reviewed, and reasons that cases did not proceed to donation were categorized and quantified. All hospital deaths were reviewed through tissue referrals and chart audits to assess whether potential organ donors were not referred.

RESULTS

There were 8349 potential DCD donors. Of these, 5640 cases were ruled out for clinical reasons, and 1458 cases were ruled out for factors unique to DCD, such as ventilation, which was never withdrawn. Of the 1251 ruled in for the family approach to donation consent, there were ultimately 191 donors with organs transplanted.

CONCLUSIONS

OPO donor potential calculated from referral and hospital death record reviews is substantially lower than donor potential determined by administrative data, validating the need for direct measurement for regulatory purposes and performance improvement. For a usable direct measure of donor potential, DCD donor criteria must be codified, electronic donor records optimized, and audit processes developed.

Opportunity to increase deceased donation for United States veterans

Recent changes to organ procurement organization (OPO) performance metrics have highlighted the need to identify opportunities to increase organ donation in the United States. Using data from the Organ Procurement and Transplantation Network (OPTN), Scientific Registry of Transplant Recipients (SRTR), and Veteran Health Administration Informatics and Computing Infrastructure Clinical Data Warehouse (VINCI CDW), we sought to describe historical donation performance at Veteran Administration Medical Centers (VAMCs). We found that over the period 2010-2019, there were only 33 donors recovered from the 115 VAMCs with donor potential nationwide. VA donors had similar age-matched organ transplant yields to non-VA donors. Review of VAMC records showed a total of 8474 decedents with causes of death compatible with donation, of whom 5281 had no infectious or neoplastic comorbidities preclusive to donation. Relative to a single state comparison of adult non-VA inpatient deaths, VAMC deaths were 20 times less likely to be characterized as an eligible death by SRTR. The rate of conversion of inpatient donation-consistent deaths without preclusive comorbidities to actual donors at VAMCs was 5.9% that of adult inpatients at non-VA hospitals. Overall, these findings suggest significant opportunities for growth in donation at VAMCs.

Results of a data-driven performance improvement initiative in organ donation

New metrics for organ procurement organization (OPO) performance utilize National Center for Health Statistics data to measure cause, age, and location consistent (CALC) deaths. We used this denominator to identify opportunities for improved donor conversion at one OPO, Indiana Donor Network (INOP). We sought to determine whether such analyses are immediately actionable for quality improvement (QI) initiatives directed at increased donor conversion. CALC-based assessment of INOP's performance revealed an opportunity to improve conversion of older donors. Following the QI initiative, INOP donor yield rose by 44%, while organs transplanted rose by 29%. These changes tolerated temporary disruption around the COVID-19 pandemic. Improved donor yield was primarily seen in older groups identified by CALC-based methods. Process changes in resource allocation and monitoring were associated with a 57% increase in the number of potential donors approached in the QI period and a subsequent rise in the number of potential donor referrals, suggesting positive feedback at area hospitals. Post-intervention, INOP's projected donation performance rose from 51st to 18th among all OPOs. OPOs can use CALC death data to accurately assess donor conversion by categories including age and race/ethnicity. These data can be used in real time to inform OPO-level processes to maximize donor recovery.

Rapid improvement in organ procurement organization performance: Potential for change and impact of new leadership

Recently proposed rulemaking from Centers for Medicare and Medicaid Services would change how organ procurement organizations (OPOs) are evaluated. The proposals include using national inpatient death data to define a standardized denominator to calculate comparable donation rates among OPOs. Based on these objective metrics, OPOs not performing at a prespecified threshold will be required to rapidly improve performance to avoid decertification. We sought to determine whether rapid OPO improvement was possible based on objective donation metrics, and whether leadership change was associated with rapid improvement. We evaluated United Network for Organ Sharing and Centers for Disease Control and Prevention (CDC) data from 2011 to 2018, and measured donation rates using CDC data on inpatient deaths from causes consistent with donation, based on the location of deaths. During the two 4-year cycles, we found that an OPO's ranking relative to other OPOs was fairly static, with more than 90% of the OPOs at risk of flagging at the end of each 4-year cycle (2014, 2018) being in the bottom 75% of OPOs in the preceding 3 years. In multivariable logistic regression models, leadership changes were only statistically significantly associated with an improvement in OPO rankings during the 2011-2014 cycle. These data demonstrate that rapid improvements in OPO performance are uncommon, and while leadership changes increase the odds of rapid improvement, they do not guarantee improvement.