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Tsapepas DS, King K, Husain SA, Yu ME, Hippen BE, Schold JD, Mohan S. UNOS Decisions Impact Data Integrity of the OPTN Data Registry. Transplantation 2023; 107:e348-e354. [PMID: 37726879 DOI: 10.1097/tp.0000000000004792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND The Organ Procurement Transplant Network (OPTN)/United Network for Organ Sharing (UNOS) registry is an important national registry in the field of solid organ transplantation. Data collected are mission critical, given its role in organ allocation prioritization, program performance monitoring by both the OPTN and the Centers for Medicare & Medicaid Services, and countless observational analyses that helped to move the field forward. Despite the multifaceted importance of the OPTN/UNOS database, there are clear indications that investments in the database to ensure the quality and reliability of the data have been lacking. METHODS This analysis outlines 2 examples: (1) primary diagnosis for patients who are receiving a second transplant and (2) reporting peripheral vascular disease in kidney transplantation to illustrate the extensive challenges facing the veracity and integrity of the OPTN/UNOS database today. RESULTS Despite guidance that repeat kidney transplant patients should be coded as "retransplant/graft failure" rather than their native kidney disease, only 59% of new incident patients are coded in this manner. Peripheral vascular disease prevalence more than doubled in a 20-y span when the variable became associated with risk adjustment. CONCLUSIONS This article summarizes critical gaps in the OPTN/UNOS database, and we bring forward ideas and proposals for consideration as a path toward improvement.
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Affiliation(s)
- Demetra S Tsapepas
- Department of Transplant Analytics, New York Presbyterian Hospital, New York, NY
- Department of Transplant Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Kristen King
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Syed Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Miko E Yu
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | | | - Jesse D Schold
- Departments of Surgery and Epidemiology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Yu M, King KL, Husain SA, Huml AM, Patzer RE, Schold JD, Mohan S. Discrepant Outcomes between National Kidney Transplant Data Registries in the United States. J Am Soc Nephrol 2023; 34:1863-1874. [PMID: 37535362 PMCID: PMC10631598 DOI: 10.1681/asn.0000000000000194] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 07/03/2023] [Indexed: 08/04/2023] Open
Abstract
SIGNIFICANCE STATEMENT Effects of reduced access to external data by transplant registries to improve accuracy and completeness of the collected data are compounded by different data management processes at three US organizations that maintain kidney transplant-related datasets. This analysis suggests that the datasets have large differences in reported outcomes that vary across different subsets of patients. These differences, along with recent disclosure of previously missing outcomes data, raise important questions about completeness of the outcome measures. Differences in recorded deaths seem to be increasing in recent years, reflecting the adverse effects of restricted access to external data sources. Although these registries are invaluable sources for the transplant community, discrepancies and incomplete reporting risk undermining their value for future analyses, particularly when used for developing national transplant policy or regulatory measures. BACKGROUND Central to a transplant registry's quality are accuracy and completeness of the clinical information being captured, especially for important outcomes, such as graft failure or death. Effects of more limited access to external sources of death data for transplant registries are compounded by different data management processes at the United Network for Organ Sharing (UNOS), the Scientific Registry of Transplant Recipients (SRTR), and the United States Renal Data System (USRDS). METHODS This cross-sectional registry study examined differences in reported deaths among kidney transplant candidates and recipients of kidneys from deceased and living donors in 2000 through 2019 in three transplant datasets on the basis of data current as of 2020. We assessed annual death rates and survival estimates to visualize trends in reported deaths between sources. RESULTS The UNOS dataset included 77,605 deaths among 315,346 recipients and 61,249 deaths among 275,000 nonpreemptively waitlisted candidates who were never transplanted. The SRTR dataset included 87,149 deaths among 315,152 recipients and 60,042 deaths among 259,584 waitlisted candidates. The USRDS dataset included 89,515 deaths among 311,955 candidates and 63,577 deaths among 238,167 waitlisted candidates. Annual death rates among the prevalent transplant population show accumulating differences across datasets-2.31%, 4.00%, and 4.03% by 2019 from UNOS, SRTR, and USRDS, respectively. Long-term survival outcomes were similar among nonpreemptively waitlisted candidates but showed more than 10% discordance between USRDS and UNOS among transplanted patients. CONCLUSIONS Large differences in reported patient outcomes across datasets seem to be increasing, raising questions about their completeness. Understanding the differences between these datasets is essential for accurate, reliable interpretation of analyses that use these data for policy development, regulatory oversight, and research. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_10_24_JASN0000000000000194.mp3.
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Affiliation(s)
- Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Kristen L. King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Anne M. Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
- Department of Transplantation, Cleveland Clinic, Cleveland, Ohio
| | - Rachel E. Patzer
- Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana
- Department of Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana
- Indiana University Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Jesse D. Schold
- Department of Surgery, University of Colorado – Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, School of Public Health, University of Colorado – Anschutz Medical Campus, Aurora, Colorado
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Boster JM, Superina R, Mazariegos GV, Tiao GM, Roach JP, Lovell MA, Greffe BS, Yanni G, Leung DH, Elisofon SA, McDiarmid SV, Gupta NA, Lobritto SJ, Lemoine C, Stoll JM, Vitola BE, Daniel JF, Sayed BA, Desai DM, Martin AE, Amin A, Anand R, Anderson SG, Sundaram SS. Predictors of survival following liver transplantation for pediatric hepatoblastoma and hepatocellular carcinoma: Experience from the Society of Pediatric Liver Transplantation (SPLIT). Am J Transplant 2022; 22:1396-1408. [PMID: 34990053 DOI: 10.1111/ajt.16945] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/28/2021] [Accepted: 12/28/2021] [Indexed: 01/25/2023]
Abstract
Management of unresectable pediatric hepatoblastoma (HB) and hepatocellular carcinoma (HCC) remains challenging. The Society of Pediatric Liver Transplantation (SPLIT) database was used to study survival predictors in pediatric liver transplantation (LT) for HB and HCC. Event-free survival (EFS), associated risk factors, and postoperative complications were studied in children requiring LT for HB/HCC at 16 SPLIT centers. Three-year EFS was 81% for HB (n = 157) and 62% for HCC (n = 18) transplants. Of HB transplants, 6.9% were PRETEXT II and 15.3% were POST-TEXT I/II. Tumor extent did not impact survival (p = NS). Salvage (n = 13) and primary HB transplants had similar 3-year EFS (62% versus 78%, p = NS). Among HCC transplants, 3-year EFS was poorer in older patients (38% in ≥8-year-olds vs 86% <8-year-olds) and those with larger tumors (48% for those beyond versus 83% within Milan criteria, p = NS). Risk of infection (HR 1.5, 95% CI 1.1-2.2, p = .02) and renal injury (HR 2.4, 95% CI 1.7-3.3, p < .001) were higher in malignant versus nonmalignant LT. Survival is favorable for pediatric HB and HCC LT, including outcomes after salvage transplant. Unexpected numbers of LTs occurred in PRE/POST-TEXT I/II tumors. Judicious patient selection is critical to distinguish tumors that are potentially resectable; simultaneously, we must advocate for patients with unresectable malignancies to receive organs.
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Affiliation(s)
- Julia M Boster
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado, Aurora, Colorado, USA
| | - Riccardo Superina
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - George V Mazariegos
- Department of Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gregory M Tiao
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jonathan P Roach
- Department of Surgery, Children's Hospital Colorado and University of Colorado, Aurora, Colorado, USA
| | - Mark A Lovell
- Department of Pathology, Children's Hospital Colorado and University of Colorado, Aurora, Colorado, USA
| | - Brian S Greffe
- Department of Pediatric Oncology, Children's Hospital Colorado and University of Colorado, Aurora, Colorado, USA
| | - George Yanni
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Daniel H Leung
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Scott A Elisofon
- Department of Pediatrics, Boston Children's Hospital, Massachusetts, USA
| | - Suzanne V McDiarmid
- Department of Pediatrics, University of California and Los Angeles Mattel Children's Hospital, Los Angeles, California, USA
| | - Nitika A Gupta
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Steven J Lobritto
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Caroline Lemoine
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Janis M Stoll
- Department of Pediatrics, St. Louis Children's Hospital and Washington University School of Medicine, St. Louis, Missouri, USA
| | - Bernadette E Vitola
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - James F Daniel
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Blayne A Sayed
- Department of Surgery, University Health Network and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dev M Desai
- Department of Surgery, University of Texas Southwestern Medical Center and Children's Medical Center, Dallas, Texas, USA
| | - Abigail E Martin
- Department of Surgery, Nemours Children's Hospital Delaware and Sidney Kimmel Medical College of Thomas Jefferson University, Wilmington, Delaware, USA
| | - Arpit Amin
- Department of Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | - Shikha S Sundaram
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado, Aurora, Colorado, USA
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Amdani S, Boyle G, Rossano J, Scheel J, Richmond M, Arrigain S, Schold JD. Association of low center performance evaluations and pediatric heart transplant center behavior in the United States. J Heart Lung Transplant 2021; 40:831-840. [PMID: 34078559 DOI: 10.1016/j.healun.2021.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/09/2021] [Accepted: 04/16/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To date, no study has evaluated the effects of low center performance evaluations (CPE) on pediatric heart transplant center behavior. We sought to assess the impact of low CPE flags on pediatric heart transplant center listing and transplant volumes and center recipient and donor characteristics. METHODS We included centers performing at least 10 pediatric (age <18 years) transplants during the Scientific Registry of Transplant Recipients reporting period January 2009-June 2011 and evaluated consecutive biannual program specific reports until the last reporting period January 2016-June 2018. We evaluated changes in center behavior at following time points: a year before flagging, a year and two years after the flag; and at last reporting period. RESULTS During our study period, 24 pediatric centers were non-flagged and 6 were flagged. Compared to non-flagged centers, there was a decline in candidate listings in flagged centers at the last reporting period (mean increase of 5.5 ± 12.4 listings vs"?> mean decrease of 14.0 ± 14.9 listings; p = .003). Similarly, the number of transplants declined in flagged centers (mean increase of 2.6 ± 9.6 transplants vs"?> mean decrease of 10.0 ± 12.8 transplants; p = .012). Flagged centers had declines in listings for patients with restrictive cardiomyopathy, re-transplant, renal dysfunction, those on mechanical ventilation and extracorporeal membrane oxygenation. There was no significant change in donor characteristics between flagged and non-flagged centers. CONCLUSIONS Low CPE may have unintended negative consequences on center behavior leading to declines in listing and transplant volumes and potentially leading to decreased listing for higher risk recipients.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio.
| | - Gerard Boyle
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Joseph Rossano
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Janet Scheel
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Marc Richmond
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Susana Arrigain
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Jesse D Schold
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
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Wesselman H, Ford CG, Leyva Y, Li X, Chang CCH, Dew MA, Kendall K, Croswell E, Pleis JR, Ng YH, Unruh ML, Shapiro R, Myaskovsky L. Social Determinants of Health and Race Disparities in Kidney Transplant. Clin J Am Soc Nephrol 2021; 16:262-274. [PMID: 33509963 PMCID: PMC7863655 DOI: 10.2215/cjn.04860420] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 11/16/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Black patients have a higher incidence of kidney failure but lower rate of deceased- and living-donor kidney transplantation compared with White patients, even after taking differences in comorbidities into account. We assessed whether social determinants of health (e.g., demographics, cultural, psychosocial, knowledge factors) could account for race differences in receiving deceased- and living-donor kidney transplantation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Via medical record review, we prospectively followed 1056 patients referred for kidney transplant (2010-2012), who completed an interview soon after kidney transplant evaluation, until their kidney transplant. We used multivariable competing risk models to estimate the cumulative incidence of receipt of any kidney transplant, deceased-donor transplant, or living-donor transplant, and the factors associated with each outcome. RESULTS Even after accounting for social determinants of health, Black patients had a lower likelihood of kidney transplant (subdistribution hazard ratio, 0.74; 95% confidence interval, 0.55 to 0.99) and living-donor transplant (subdistribution hazard ratio, 0.49; 95% confidence interval, 0.26 to 0.95), but not deceased-donor transplant (subdistribution hazard ratio, 0.92; 95% confidence interval, 0.67 to 1.26). Black race, older age, lower income, public insurance, more comorbidities, being transplanted before changes to the Kidney Allocation System, greater religiosity, less social support, less transplant knowledge, and fewer learning activities were each associated with a lower probability of any kidney transplant. Older age, more comorbidities, being transplanted before changes to the Kidney Allocation System, greater religiosity, less social support, and fewer learning activities were each associated with a lower probability of deceased-donor transplant. Black race, older age, lower income, public insurance, higher body mass index, dialysis before kidney transplant, not presenting with a potential living donor, religious objection to living-donor transplant, and less transplant knowledge were each associated with a lower probability of living-donor transplant. CONCLUSIONS Race and social determinants of health are associated with the likelihood of undergoing kidney transplant.
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Affiliation(s)
- Hannah Wesselman
- Department of Biological Sciences, University of Notre Dame, Notre Dame, Indiana
| | - Christopher Graham Ford
- Center for Healthcare Equity in Kidney Disease, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Yuridia Leyva
- Center for Healthcare Equity in Kidney Disease, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Xingyuan Li
- Eli Lilly and Company, Indianapolis, Indiana
| | - Chung-Chou H. Chang
- Department of Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania,Department of Biostatistics, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Kellee Kendall
- Department of Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Emilee Croswell
- Department of Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - John R. Pleis
- Division of Research and Methodology, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - Yue Harn Ng
- Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico
| | - Mark L. Unruh
- Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico
| | - Ron Shapiro
- Mount Sinai Recanati/Miller Transplantation Institute, Icahn School of Medicine, New York, New York
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease, University of New Mexico Health Sciences Center, Albuquerque, New Mexico,Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico
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Nolley E, Fleck J, Kavalieratos D, Dew MA, Dilling D, Colman R, Crespo MM, Goldberg H, Hays S, Hachem R, Lease E, Lee J, Reynolds J, Morrell M, Schenker Y. Lung Transplant Pulmonologists' Views of Specialty Palliative Care for Lung Transplant Recipients. J Palliat Med 2020; 23:619-626. [PMID: 31895634 PMCID: PMC7232634 DOI: 10.1089/jpm.2019.0222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Lung transplant recipients with serious illness may benefit from but rarely receive specialty palliative care (SPC) services. Transplant pulmonologists' views of SPC may be key to understanding SPC utilization but have not been well characterized. Objectives: (1) To understand how transplant pulmonologists view SPC and decide to refer transplant recipients and (2) to identify unique aspects of lung transplantation that may influence referral decisions. Design: We conducted semistructured interviews with transplant pulmonologists at nine geographically diverse high-volume North American transplant centers with SPC services. A multidisciplinary team analyzed interview transcripts using constant comparative methods to inductively develop and refine a coding framework related to SPC views and referral decisions. Results: We interviewed 38 transplant pulmonologists; most (36/38) had referred lung transplant recipients to SPC. Participants described SPC as a medical specialty that aims to improve quality of life and distinguished SPC from hospice care, which was considered end-of-life care. Participants who viewed transplant as a temporary solution (n = 17/38, 45%) described earlier utilization of SPC alongside disease-directed therapies, whereas those who viewed transplant as survival-focused (n = 21/38, 55%) described utilization of SPC after disease-directed therapies were exhausted. Concerns about one-year survival metrics and use of addicting medications for symptom palliation were barriers to referral. Conclusions: Transplant pulmonologists' SPC referral practices may be related to their views of lung transplantation. Optimizing use of SPC in lung transplantation will require improving communication between transplant pulmonology and SPC to ensure a collaborative effort toward patient-centered goals while addressing unique barriers to SPC referral.
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Affiliation(s)
- Eric Nolley
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica Fleck
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mary Amanda Dew
- Departments of Psychiatry, Psychology, Epidemiology, Biostatistics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel Dilling
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Loyola, Chicago, Illinois, USA
| | - Rebecca Colman
- Division of Respirology and Division of Palliative Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Maria M. Crespo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hiliary Goldberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Steven Hays
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ramsey Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis, St. Louis, Missouri, USA
| | - Erika Lease
- Department of Medicine, Division of Pulmonary Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - James Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Reynolds
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Matthew Morrell
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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7
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The evolving role of regulatory reporting on patient and donor selection in organ transplantation. Curr Opin Organ Transplant 2020; 25:158-162. [DOI: 10.1097/mot.0000000000000741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Rana A, Price MB, Barrett SC, Lai J, Bakhtiyar SS, Kanwal F, Vierling J, Wu M, Galvan NT, Goss J. Aggressive utilization of liver allografts: Improved outcomes over time. Clin Transplant 2020; 34:e13860. [PMID: 32198898 DOI: 10.1111/ctr.13860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/18/2020] [Accepted: 03/15/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Aggressive acceptance of liver allografts has driven utilization of marginal allografts. Our aim was to assess the impact of the aggressive phenotype on transplant center outcomes over time. METHODS We used a cohort of 148 361 candidates from the Organ Procurement and Transplantation Network for liver transplantation between 2002 and 2016 in 134 centers. Using the Discard Risk Index, we designated high probability discard allografts by the top 10th percentile for likelihood of discard. Aggressive phenotype was defined by usage of high probability discard (HPD) allografts (top 10th percentile). Our analysis of survival on waitlist and graft survival after transplantation included a comprehensive list of center level covariates across three equal time periods (2002-2006, 2007-2011, and 2012-2016). RESULTS After adjusting for recipient and center-level factors, aggressive centers had improving graft survival over time. Aggressive vs non-aggressive centers: 2002-2006 HR 1.12 (1.05-1.19), 2007-2011 HR 1.13 (1.05-1.22), 2012-2016 HR 0.99 (0.89-1.10). Aggressive centers had improved waitlist survival compared with non-aggressive centers after adjusting for allograft disparity. CONCLUSIONS Aggressive phenotype had a positive impact on waitlist survival, and graft survival in aggressive centers have improved to benchmark levels over time. These findings serve as justification for aggressive utilization of allografts.
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Affiliation(s)
- Abbas Rana
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Matthew Brent Price
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Spencer C Barrett
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer Lai
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Syed Shahyan Bakhtiyar
- Division of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Fasiha Kanwal
- Division of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - John Vierling
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Mengfen Wu
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Nhu Thao Galvan
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - John Goss
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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9
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Schold JD, Patzer RE, Pruett TL, Mohan S. Quality Metrics in Kidney Transplantation: Current Landscape, Trials and Tribulations, Lessons Learned, and a Call for Reform. Am J Kidney Dis 2019; 74:382-389. [DOI: 10.1053/j.ajkd.2019.02.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/15/2019] [Indexed: 12/12/2022]
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10
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Risk Stratification of Patients With Current Generation Continuous-Flow Left Ventricular Assist Devices Being Bridged to Heart Transplantation. ASAIO J 2019; 64:196-202. [PMID: 28885379 DOI: 10.1097/mat.0000000000000635] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Patients bridged to transplant (BTT) with continuous-flow left ventricular assist devices (CF-LVADs) have increased in the past decade. Decision support tools for these patients are limited. We developed a risk score to estimate prognosis and guide decision-making. We included heart transplant recipients bridged with CF-LVADs from the United Network for Organ Sharing (UNOS) database and divided them into development (2,522 patients) and validation cohorts (1,681 patients). Univariate and multivariate Cox proportional hazards models were performed. Variables that independently predicted outcomes (age, African American race, recipient body mass index [BMI], intravenous [IV] antibiotic use, pretransplant dialysis, and total bilirubin) were assigned weight using linear transformation, and risk scores were derived. Patients were grouped by predicted posttransplant mortality: low risk (≤ 38 points), medium risk (38-41 points), and high risk (≥ 42 points). We performed Cox proportional hazards analysis on wait-listed CF-LVAD patients who were not transplanted. Score significantly discriminated survival among the groups in the development cohort (6.7, 12.9, 20.7; p = 0.001), validation cohort (6.4, 10.1, 13.6; p < 0.001), and ambulatory cohort (6.4, 11.5, 17.2; p < 0.001). We derived a left ventricular assist device (LVAD) BTT risk score that effectively identifies CF-LVAD patients who are at higher risk for worse outcomes after heart transplant. This score may help physicians weigh the risks of transplantation in patients with CF-LVAD.
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11
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Beller JP, Hawkins RB, Mehaffey JH, Chancellor WZ, Teaster R, Walters DM, Krupnick AS, Davis RD, Lau CL. Poor Performance Flagging Is Associated With Fewer Transplantations at Centers Flagged Multiple Times. Ann Thorac Surg 2019; 107:1678-1682. [PMID: 30629928 DOI: 10.1016/j.athoracsur.2018.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 11/30/2018] [Accepted: 12/04/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Lung transplantation outcomes are heavily scrutinized, given the high stakes of these operations, yet the Center for Medicare and Medicaid Services (CMS) method of using Scientific Registry of Transplant Recipients (SRTR) risk-adjusted outcomes to identify underperforming centers is controversial. We hypothesized that CMS flagging results in conservative behavior for recipient and organ selection, resulting in fewer patients added to the waitlist and fewer transplantations performed. METHODS SRTR reports from July 2012 through July 2017 were included. Center characteristics were compared, stratified by number of flagging events. The impact of flagging for underperformance on risk aversion outcomes was analyzed using a mixed-effects regression model. RESULTS A total of 72 centers had reported SRTR data during the study period. Of these, 21 centers (29%) met flagging criteria a median of 2 times (interquartile range, 1 to 4 times) for a total of 53 events. Flagging had no statistically significant impact on waitlist or transplantation volume and patient selection by mixed-effects modeling. Despite similar average expected 1-year survival (86.6% versus 87.7%, p = 0.27), centers that were flagged only once added more patients per year to the waitlist (16.3 patients versus 7.8 patients, p = 0.01) and performed more transplantations per year (28.4 transplantations versus 11.1 transplantations, p = 0.01). CONCLUSIONS This analysis defines center-level trends in lung transplantation after CMS flagging. Contrary to our primary hypothesis, flagging did not result in temporal center-level changes. However, programs on prolonged probation demonstrated reduced activity, which likely indicates a shift to higher performing centers.
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Affiliation(s)
- Jared P Beller
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - William Z Chancellor
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert Teaster
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Dustin M Walters
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Alexander S Krupnick
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - R Duane Davis
- Cardiovascular and Transplant Institutes, Florida Hospital Orlando, Orlando, Florida
| | - Christine L Lau
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
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12
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Scientific Registry of Transplant Recipients program-specific reports: where we have been and where we are going. Curr Opin Organ Transplant 2018; 24:58-63. [PMID: 30575617 DOI: 10.1097/mot.0000000000000597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Reporting provider data on quality to patients and the general public is increasingly common in healthcare. Reporting outcomes in solid organ transplantation has always been controversial and deserves careful consideration to ensure optimal results. RECENT FINDINGS As mandated by Federal law, the Scientific Registry of Transplant Recipients publishes program-specific reports on transplant candidates, recipients, donors, and transplant outcomes every 6 months. Recent changes designed to make the results more easily understood by patients and the general public have been well received by patients and controversial among providers. In particular, outcomes are now reported using a five-tier system that distinguishes program results better than the old three-tier system, in which almost all programs were reported "as expected." Metrics that reflect access to transplant are also reported, including transplant rate and survival on the waiting list. Possible measures of longer term outcomes and program rates of accepting organs for transplant are being explored. SUMMARY Providing detailed information regarding transplant program practices and outcomes in ways that patients and the general public can understand remains a major focus of the Scientific Registry of Transplant Recipients. Efforts to improve data collection and metrics reported are ongoing.
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13
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Van Pilsum Rasmussen SE, Thomas AG, Garonzik-Wang J, Henderson ML, Stith SS, Segev DL, Nicholas LH. Reported effects of the Scientific Registry of Transplant Recipients 5-tier rating system on US transplant centers: results of a national survey. Transpl Int 2018; 31:1135-1143. [PMID: 29802802 PMCID: PMC6219856 DOI: 10.1111/tri.13282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 03/17/2018] [Accepted: 05/17/2018] [Indexed: 11/30/2022]
Abstract
In the United States, the Scientific Registry of Transplant Recipients (SRTR) provides publicly available quality report cards. These reports have historically rated transplant programs using a 3-tier system. In 2016, the SRTR temporarily transitioned to a 5-tier system, which classified more programs as under-performing. As part of a larger survey about transplant quality metrics, we surveyed members of the American Society of Transplant Surgeons and American Society of Transplantation (N = 280 respondents) on transplant center experiences with patient and payer responses to the 5-tier SRTR ratings. Over half of respondents (n = 137, 52.1%) reported ≥1 negative effect of the new 5-tier ranking system, including losing patients, losing insurers, increased concern among patients, and increased concern among referring providers. Few respondents (n = 35, 13.7%) reported any positive effects of the 5-tier ranking system. Lower SRTR-reported scores on the 5-tier scale were associated with increased risk of reporting at least one negative effect in a logistic model (P < 0.01). The change to a more granular rating system provoked an immediate response in the transplant community that may have long-term implications for transplant hospital finances and patient options for transplantation.
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Affiliation(s)
| | - Alvin G. Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Macey L. Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sarah S. Stith
- Department of Economics, University of New Mexico, Albuquerque, NM
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Lauren Hersch Nicholas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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14
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Celik N, Stanley K, Rudolph J, Al-Issa F, Kosmach B, Ashokkumar C, Sun Q, Brown-Bakewell R, Zecca D, Soltys K, Khanna A, Bond G, Ganoza A, Mazariegos G, Sindhi R. Improvements in intestine transplantation. Semin Pediatr Surg 2018; 27:267-272. [PMID: 30342602 DOI: 10.1053/j.sempedsurg.2018.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Transplantation of the intestine in children has presented significant challenges even as it has become a standard to treat nutritional failure due to short gut syndrome. These challenges have been addressed in part by significant improvements in short and long-term care. Noteworthy enhancements include reduced need for intestine transplantation, drug-sparing immunosuppressive regimens, immune monitoring, and improved surveillance and management of PTLD and non-adherence.
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Affiliation(s)
- Neslihan Celik
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Kaitlin Stanley
- Division of Pediatric Hematology/Oncology, Children's Hospital of Pittsburgh of UPMC, USA
| | - Jeff Rudolph
- Intestinal Care and Rehabilitation Center, Children's Hospital of Pittsburgh of UPMC, USA
| | - Feras Al-Issa
- Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, USA
| | - Beverly Kosmach
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Chethan Ashokkumar
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Qing Sun
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Renee Brown-Bakewell
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Dale Zecca
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Kyle Soltys
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Ajai Khanna
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Geoffrey Bond
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Armando Ganoza
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - George Mazariegos
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Rakesh Sindhi
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA.
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15
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Schold JD, Flechner SM, Poggio ED, Augustine JJ, Goldfarb DA, Sedor JR, Buccini LD. Residential Area Life Expectancy: Association With Outcomes and Processes of Care for Patients With ESRD in the United States. Am J Kidney Dis 2018. [PMID: 29525324 DOI: 10.1053/j.ajkd.2017.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The effects of underlying noncodified risks are unclear on the prognosis of patients with end-stage renal disease (ESRD). We aimed to evaluate the association of residential area life expectancy with outcomes and processes of care for patients with ESRD in the United States. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Adult patients with incident ESRD between 2006 and 2013 recorded in the US Renal Data System (n=606,046). PREDICTOR The primary exposure was life expectancy in the patient's residential county estimated by the Institute for Health Metrics and Evaluation. OUTCOMES Death, placement on the kidney transplant wait list, living and deceased donor kidney transplantation, and posttransplantation graft loss. RESULTS Median life expectancies of patients' residences were 75.6 (males) and 80.4 years (females). Compared to the highest life expectancy quintile and adjusted for demographic factors, disease cause, and multiple comorbid conditions, the lowest quintile had adjusted HRs for mortality of 1.20 (95% CI, 1.18-1.22); placement onto the waiting list, 0.68 (95% CI, 0.67-0.70); living donor transplantation, 0.53 (95% CI, 0.51-0.56); posttransplantation graft loss, 1.35 (95% CI, 1.27-1.43); and posttransplantation mortality, 1.29 (95% CI, 1.19-1.39). Patients living in areas with lower life expectancy were less likely to be informed about transplantation, be under the care of a nephrologist, or receive an arteriovenous fistula as the initial dialysis access. Results remained consistent with additional adjustment for zip code-level median income, population size, and urban-rural locality. LIMITATIONS Potential residual confounding and attribution of effects to individuals based on residential area-level data. CONCLUSIONS Residential area life expectancy, a proxy for socioeconomic, environmental, genetic, and behavioral factors, was independently associated with mortality and process-of-care measures for patients with ESRD. These results emphasize the underlying effect on health outcomes of the environment in which patients live, independent of patient-level factors. These findings may have implications for provider assessments.
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Affiliation(s)
- Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH; Center for Populations Health Research, Lerner Research Institute, Cleveland, OH.
| | - Stuart M Flechner
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Emilio D Poggio
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Joshua J Augustine
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - David A Goldfarb
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - John R Sedor
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Laura D Buccini
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
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16
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van Berkel V. The dangers of oversimplification - quality metrics and lung transplantation. Am J Transplant 2018; 18:11-12. [PMID: 28925582 DOI: 10.1111/ajt.14505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 09/05/2017] [Accepted: 09/10/2017] [Indexed: 01/25/2023]
Affiliation(s)
- Victor van Berkel
- University of Louisville, Cardiovascular and Thoracic Surgery, Louisville, KY, USA
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17
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Vinayak R, Cruz RJ, Ranganathan S, Mohanka R, Mazariegos G, Soltys K, Bond G, Tadros S, Humar A, Marsh JW, Selby RR, Reyes J, Sun Q, Haberman K, Sindhi R. Pediatric liver transplantation for hepatocellular cancer and rare liver malignancies: US multicenter and single-center experience (1981-2015). Liver Transpl 2017; 23:1577-1588. [PMID: 28834194 PMCID: PMC5725660 DOI: 10.1002/lt.24847] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 07/14/2017] [Accepted: 08/03/2017] [Indexed: 02/06/2023]
Abstract
A tenth of all pediatric liver transplantations (LTs) are performed for unresectable liver malignancies, especially the more common hepatoblastoma (HBL). Less understood are outcomes after LT for the rare hepatocellular carcinoma, nonhepatoblastoma embryonal tumors (EMBs), and slow growing metastatic neuroendocrine tumors of childhood. Pediatric LT is increasingly performed for rare unresectable liver malignancies other than HBL. We performed a retrospective review of outcomes after LT for malignancy in the multicenter US Scientific Registry of Transplant Recipients (SRTR; n = 677; 1987-2015). We then reviewed the Children's Hospital of Pittsburgh (CHP; n = 74; 1981-2014) experience focusing on LT for unresectable hepatocellular cancer (HCC), EMBs, and metastatic liver tumors (METS). HBL was included to provide reference statistics. In the SRTR database, LT for HCC and HBL increased over time (P < 0.001). Compared with other malignancies, the 149 HCC cases received fewer segmental grafts (P < 0.001) and also experienced 10-year patient survival similar to 15,710 adult HCC LT recipients (51.6% versus 49.6%; P = 0.848, not significant [NS], log-rank test). For 22 of 149 cases with incidental HCC, 10-year patient survival was higher than 127 primary HCC cases (85% [95% confidence interval (CI), 70.6%-100%] versus 48.3% [95% CI, 38%-61%]; P = 0.168, NS) and similar to 3392 biliary atresia cases (89.9%; 95% CI, 88.7%-91%). Actuarial 10-year patient survival for 17 EMBs, 10 METS, and 6 leiomyosarcoma patients exceeded 60%. These survival outcomes were similar to those seen for HBL. At CHP, posttransplant recurrence-free and overall survival among 25 HCC, 17 (68%) of whom had preexisting liver disease, was 16/25 or 64%, and 9/25 or 36%, respectively. All 10 patients with incidental HCC and tumor-node-metastasis stage I and II HCC survived recurrence-free. Only vascular invasion predicted poor survival in multivariate analysis (P < 0.0001). A total of 4 of 5 EMB patients (80%) and all patients with METS (neuroendocrine-2, pseudopapillary pancreatic-1) also survived recurrence-free. Among children, LT can be curative for unresectable HCC confined to the liver and without vascular invasion, incidental HCC, embryonal tumors, and metastatic neuroendocrine tumors. Liver Transplantation 23 1577-1588 2017 AASLD.
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Affiliation(s)
- Rohan Vinayak
- Department of Surgery, College of MedicineMedical University of South CarolinaCharlestonSC
| | - Ruy J. Cruz
- Thomas E. Starzl Transplantation InstituteUniversity of Pittsburgh Medical CenterMontefiore, PittsburghPA
| | - Sarangarajan Ranganathan
- Thomas E. Starzl Transplantation Institute, Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Ravi Mohanka
- Liver Transplant and Hepatobiliary Surgery, Global HospitalsMumbaiIndia
| | - George Mazariegos
- Thomas E. Starzl Transplantation Institute, Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Kyle Soltys
- Thomas E. Starzl Transplantation Institute, Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Geoff Bond
- Thomas E. Starzl Transplantation Institute, Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Sameh Tadros
- Thomas E. Starzl Transplantation Institute, Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Abhinav Humar
- Thomas E. Starzl Transplantation InstituteUniversity of Pittsburgh Medical CenterMontefiore, PittsburghPA
| | - J. Wallis Marsh
- Thomas E. Starzl Transplantation InstituteUniversity of Pittsburgh Medical CenterMontefiore, PittsburghPA
| | - Robert R. Selby
- Department of Surgery, Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCA
| | - Jorge Reyes
- Kidney, Liver, Intestinal Care ServicesUniversity of Washington Medical CenterSeattleWA
| | - Qing Sun
- Thomas E. Starzl Transplantation Institute, Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Kimberly Haberman
- Thomas E. Starzl Transplantation InstituteUniversity of Pittsburgh Medical CenterMontefiore, PittsburghPA
| | - Rakesh Sindhi
- Thomas E. Starzl Transplantation Institute, Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPA
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18
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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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19
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Abstract
Background The association of HLA mismatching with kidney allograft survival has been well established. We examined whether amino acid (AA) mismatches (MMs) at the antigen recognition site of HLA molecules represent independent and incremental risk factors for kidney graft failure (GF) beyond those MMs assessed at the antigenic (2-digit) specificity. Methods Data on 240 024 kidney transplants performed between 1987 and 2009 were obtained from the Scientific Registry of Transplant Recipients. We imputed HLA-A, -B, and -DRB1 alleles and corresponding AA polymorphisms from antigenic specificity through the application of statistical and population genetics inferences. GF risk was evaluated using Cox proportional-hazards regression models adjusted for covariates including patient and donor risk factors and HLA antigen MMs. Results We show that estimated AA MMs at particular positions in the peptide-binding pockets of HLA-DRB1 molecule account for a significant incremental risk that was independent of the well-known association of HLA antigen MMs with graft survival. A statistically significant linear relationship between the estimated number of AA MMs and risk of GF was observed for HLA-DRB1 in deceased donor and living donor transplants. This relationship was strongest during the first 12 months after transplantation (hazard ratio, 1.30 per 15 DRB1 AA MM; P < 0.0001). Conclusions This study shows that independent of the well-known association of HLA antigen (2-digit specificity) MMs with kidney graft survival, estimated AA MMs at peptide-binding sites of the HLA-DRB1 molecule account for an important incremental risk of GF. In a population of 240 024 kidney transplant recipients using the data of the Scientific Registry of Transplant recipients, the authors demonstrate that, independently of HLA antigen mismatches, estimated amino-acid mismatches at peptide-binding sites of the HLA-DRB1 molecule, accounts for an increased graft failure risk. Supplemental digital content is available in the text.
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20
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Schold JD, Buccini LD, Phelan MP, Jay CL, Goldfarb DA, Poggio ED, Sedor JR. Building an Ideal Quality Metric for ESRD Health Care Delivery. Clin J Am Soc Nephrol 2017; 12:1351-1356. [PMID: 28515155 PMCID: PMC5544503 DOI: 10.2215/cjn.01020117] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | | | | | | | - David A. Goldfarb
- Glickman Urological and Kidney Institutes, Cleveland Clinic, Cleveland, Ohio
| | - Emilio D. Poggio
- Glickman Urological and Kidney Institutes, Cleveland Clinic, Cleveland, Ohio
| | - John R. Sedor
- Departments of Medicine, Physiology and Biophysics, Case Western Reserve University, Rammelkamp Center for Research and Education, MetroHealth System, Cleveland, Ohio
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21
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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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22
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The ethics of risk and innovation. J Heart Lung Transplant 2015; 35:24-25. [PMID: 26123952 DOI: 10.1016/j.healun.2015.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 05/28/2015] [Indexed: 11/23/2022] Open
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23
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24
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Schold JD, Nicholas LH. Considering potential benefits and consequences of hospital report cards: what are the next steps? Health Serv Res 2015; 50:321-9. [PMID: 25756733 DOI: 10.1111/1475-6773.12280] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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25
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Roberts JP. Does center-specific reporting limit innovation. Liver Transpl 2014; 20 Suppl 2:S42-4. [PMID: 25220793 DOI: 10.1002/lt.23998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 09/11/2014] [Indexed: 01/12/2023]
Affiliation(s)
- John Paul Roberts
- Liver Transplant Program, University of California, San Francisco, San Francisco, CA
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26
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Maxwell BG, Levitt JE, Goldstein BA, Mooney JJ, Nicolls MR, Zamora M, Valentine V, Weill D, Dhillon GS. Impact of the lung allocation score on survival beyond 1 year. Am J Transplant 2014; 14:2288-94. [PMID: 25208599 PMCID: PMC4428280 DOI: 10.1111/ajt.12903] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/23/2014] [Accepted: 05/11/2014] [Indexed: 01/25/2023]
Abstract
Implementation of the lung allocation score (LAS) in 2005 led to transplantation of older and sicker patients without altering 1-year survival. However, long-term survival has not been assessed and emphasizing the 1-year survival metric may actually sustain 1-year survival while not reflecting worsening longer-term survival. Therefore, we assessed overall and conditional 1-year survival; and the effect of crossing the 1-year threshold on hazard of death in three temporal cohorts: historical (1995-2000), pre-LAS (2001-2005) and post-LAS (2005-2010). One-year survival post-LAS remained similar to pre-LAS (83.1% vs. 82.1%) and better than historical controls (75%). Overall survival in the pre- and post-LAS cohorts was also similar. However, long-term survival among patients surviving beyond 1 year was worse than pre-LAS and similar to historical controls. Also, the hazard of death increased significantly in months 13 (1.44, 95% CI 1.10-1.87) and 14 (1.43, 95% CI 1.09-1.87) post-LAS but not in the other cohorts. While implementation of the LAS has not reduced overall survival, decreased survival among patients surviving beyond 1 year in the post-LAS cohort and the increased mortality occurring immediately after 1 year suggest a potential negative long-term effect of the LAS and an unintended consequence of increased emphasis on the 1-year survival metric.
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Affiliation(s)
- B. G. Maxwell
- Department of Anesthesiology and Medicine, Stanford University School of Medicine, Stanford, CA
| | - J. E. Levitt
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA
| | - B. A. Goldstein
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA
| | - J. J. Mooney
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA
| | - M. R. Nicolls
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA
| | - M. Zamora
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, Aurora, CO
| | - V. Valentine
- University of Texas Medical Branch, Galveston, TX
| | - D. Weill
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA
| | - G. S. Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA,Corresponding author: Gundeep S. Dhillon,
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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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28
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Massie AB, Kucirka L, Segev DL, Segev DL. Big data in organ transplantation: registries and administrative claims. Am J Transplant 2014; 14:1723-30. [PMID: 25040084 PMCID: PMC4387865 DOI: 10.1111/ajt.12777] [Citation(s) in RCA: 258] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 03/06/2014] [Accepted: 03/25/2014] [Indexed: 01/25/2023]
Abstract
The field of organ transplantation benefits from large, comprehensive, transplant-specific national data sets available to researchers. In addition to the widely used Organ Procurement and Transplantation Network (OPTN)-based registries (the United Network for Organ Sharing and Scientific Registry of Transplant Recipients data sets) and United States Renal Data System (USRDS) data sets, there are other publicly available national data sets, not specific to transplantation, which have historically been underutilized in the field of transplantation. Of particular interest are the Nationwide Inpatient Sample and State Inpatient Databases, produced by the Agency for Healthcare Research and Quality. The USRDS database provides extensive data relevant to studies of kidney transplantation. Linkage of publicly available data sets to external data sources such as private claims or pharmacy data provides further resources for registry-based research. Although these resources can transcend some limitations of OPTN-based registry data, they come with their own limitations, which must be understood to avoid biased inference. This review discusses different registry-based data sources available in the United States, as well as the proper design and conduct of registry-based research.
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Affiliation(s)
- Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Lauren Kucirka
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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29
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Salkowski N, Snyder JJ, Zaun DA, Leighton T, Israni AK, Kasiske BL. Bayesian methods for assessing transplant program performance. Am J Transplant 2014; 14:1271-6. [PMID: 24787026 DOI: 10.1111/ajt.12707] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 01/09/2014] [Accepted: 01/19/2014] [Indexed: 01/25/2023]
Abstract
Based on recommendations from a recent consensus conference and a report commissioned by the Centers for Medicare & Medicaid Services to the Committee of Presidents of Statistical Societies, the Scientific Registry of Transplant Recipients (SRTR) plans to adopt Bayesian methods for assessing transplant program performance. Current methods for calculating program-specific reports (PSRs) often generate implausible point estimates of program performance, wide confidence intervals and underpowered conventional statistical tests. Although technically correct, these methods produce statistical summaries that are prone to misinterpretation. The Bayesian approach assumes that performance of most programs is about average and few programs perform much better or much worse than average; thus, strong evidence is required to conclude that performance is extremely good or poor. In Bayesian statistics, inference is performed via a posterior probability distribution, which reflects both the available data and prior beliefs about what model parameter values are most likely. In the PSRs, the posterior distribution of a program-specific hazard ratio will show whether a program is likely to be performing better or worse than average. Bayesian-derived PSRs will be available for preview by programs on the private SRTR website in mid-2014 and will likely replace current methods for public reporting in early 2015.
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Affiliation(s)
- N Salkowski
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
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30
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Salkowski N, Snyder JJ, Zaun DA, Leighton T, Edwards EB, Israni AK, Kasiske BL. A scientific registry of transplant recipients bayesian method for identifying underperforming transplant programs. Am J Transplant 2014; 14:1310-7. [PMID: 24786673 DOI: 10.1111/ajt.12702] [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: 08/07/2013] [Revised: 12/09/2013] [Accepted: 12/30/2013] [Indexed: 01/25/2023]
Abstract
In response to recommendations from a recent consensus conference and from the Committee of Presidents of Statistical Societies, the Scientific Registry of Transplant Recipients explored the use of Bayesian hierarchical, mixed-effects models in assessing transplant program performance in the United States. Identification of underperforming centers based on 1-year patient and graft survival using a Bayesian approach was compared with current observed-to-expected methods. Fewer small-volume programs (<10 transplants per 2.5-year period) were identified as underperforming with the Bayesian method than with the current method, and more mid-volume programs (10-249 transplants per 2.5-year period) were identified. Simulation studies identified optimal Bayesian-based flagging thresholds that maximize true positives while holding false positive flagging rates to approximately 5% regardless of program volume. Compared against previous program surveillance actions from the Organ Procurement and Transplantation Network Membership and Professional Standards Committee, the Bayesian method would have reduced the number of false positive program identifications by 50% for kidney, 35% for liver, 43% for heart and 57% for lung programs, while preserving true positives for, respectively, 96%, 71%, 58% and 83% of programs identified by the current method. We conclude that Bayesian methods to identify underperformance improve identification of programs that need review while minimizing false flags.
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Affiliation(s)
- N Salkowski
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
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31
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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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32
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Massie AB, Segev DL. Rates of false flagging due to statistical artifact in CMS evaluations of transplant programs: results of a stochastic simulation. Am J Transplant 2013; 13:2044-51. [PMID: 23890285 DOI: 10.1111/ajt.12325] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/12/2013] [Accepted: 03/18/2013] [Indexed: 01/25/2023]
Abstract
The recent CMS conditions of participation are based on risk-adjusted models produced by the Scientific Registry for Transplant Recipients (SRTR). The accuracy of these models in identifying poor-performing centers is unknown. In this stochastic simulation study, 1-year mortality outcomes were simulated in virtual transplant centers, and used to flag centers according to the methods used by CMS, evaluating nine overlapping 2.5-year periods of simulated data. In a simulation where all centers had the same underlying risk, 10.2% were falsely flagged at least once during the 4.5 years of simulated evaluations. The probability of false-positive flagging was lowest in low-volume centers (2.5%) and highest in high-volume centers (16.2%). In another simulation where 5% of centers were assigned twofold risk ("poor-performing centers"), only 32% of poor-performing centers were correctly flagged. In a final simulation where each center was assigned a unique mortality risk, 94% of flagged centers had greater-than-median risk, but only 32% of flagged centers were among the 5% with highest risk. Even after disregarding known covariate limitations to the risk adjustment models, statistical noise alone leads to spurious flagging of many adequately-performing transplant centers, yet the methods used by CMS fail to flag most centers with true elevated risk.
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Affiliation(s)
- A B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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33
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Kettelhut VV, Nayar P. Liver Transplant Center Performance Profiling: 2005–2011 Reports of the Scientific Registry for Transplant Recipients. Prog Transplant 2013; 23:165-72. [DOI: 10.7182/pit2013118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Context Transplant center performance profiling provides important information for various concerned parties. Comparing a transplant center's performance against the performance of the best-in-class centers may help in understanding the performance thresholds for the underperforming centers. Objectives (1) To identify and describe “Centers for Medicare and Medicaid Services (CMS)-red-flag” performers and the “best-in-class” performers and (2) to examine the relationships between a center's performance profile and outcomes such as 1-year observed mortality, 1-month observed mortality, 1-year risk-adjusted mortality, and volume. Methods The data for analysis was obtained from the published reports on the Scientific Registry for Transplant Recipients (SRTR) website for adult liver transplant programs compiled for the rolling 2½-year cohorts of patients and included 7 cohorts of liver transplant recipients in the study from January through July 1, 2002, through December 31, 2010. We defined 4 performance profiles: CMS-red-flag, lower-than-expected, higher-than-expected, and best-in-class performers. Results The current SRTR methods classify approximately 7% of the adult liver centers as CMS-red-flag performers and 6% of the centers as best-in-class performers in every reported period. Neither of the low-volume centers (<30 liver transplants per 2½-year cohort) was profiled as CMS-red-flag until the 2010 reporting period. The transplant center's profile was significantly associated with the 1-year and 1-month observed mortality rates in every reported cohort ( P < .001). Conclusion The CMS-red-flag profile can be characterized with the following: (1) the highest observed 1-year mortality, (2) the highest observed 1-month mortality, (3) a very large difference between the observed and adjusted mortality rates, and (4) the center volume greater than 30 liver transplants per 2½-year cohort. The SRTR methods are not sensitive for performance profiling in the centers that perform fewer than 30 orthotopic liver transplants per 2½-year cohort.
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34
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Abstract
PURPOSE OF REVIEW Measuring and monitoring transplant center performance is vital to ongoing quality assessment and performance improvement initiatives geared toward ensuring optimal care for patients with end-stage organ failure. The impact of regulatory oversight on transplant center behavior and programmatic decision-making is complex. RECENT FINDINGS Program-specific reports (PSRs) are published by the Scientific Registry for Transplant Recipients (SRTR) and are publically available for use by a variety of stakeholders, including patients, regulators, insurers, and care providers. PSRs have been both groundbreaking and controversial. The principal areas of concern relate to potential unintended consequences of PSRs, limitations in both the data collected by the registry and the currently used statistical methodology employed by the SRTR for risk adjustment, and the subsequent impact on transplant program behavior. SUMMARY PSRs, which serve the purposes of fueling ongoing performance improvement initiatives and informing consumers and payers by fostering transparency in the communication of risk, also involve trade-offs because of their unintended use for regulatory oversight and subsequent impact on transplant center behavior. Future research is necessary to improve data integrity and risk-adjustment methodologies which will enhance regulation and preserve access to transplantation among vulnerable patient populations.
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Affiliation(s)
- Lisa B VanWagner
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
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35
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Schnier KE, Cox JC, McIntyre C, Ruhil R, Sadiraj V, Turgeon N. Transplantation at the nexus of behavioral economics and health care delivery. Am J Transplant 2013; 13:31-5. [PMID: 23279680 DOI: 10.1111/j.1600-6143.2012.04343.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 08/03/2012] [Accepted: 08/23/2012] [Indexed: 01/25/2023]
Abstract
The transplant surgeon's decision to accept and utilize an organ typically is made within a constrained time window, explicitly cognizant of numerous health-related risks and under the potential influence of considerable regulatory and institutional pressures. This decision affects the health of two distinct populations, those patients receiving organ transplants and those waiting to receive a transplant; it also influences the physician's life and their institute's productivity. The numerous, at times nonaligned, incentives established by the complex clinical and regulatory environment, have been derived specifically to influence physicians' behaviors, and though well intended, may lead to responses that are nonoptimal when considering the myriad stakeholders being influenced. This may compromise the quality of care provided to the population at risk, and has potential to influence the physician-patient relationship. A synergistic collaboration between transplant physicians and economists that is focused on this decision environment may help to alleviate these strains. This viewpoint discusses behavioral economic principles and how they might be applied to transplantation. Specifically, the previous medical decision-making literature on transplantation will be reviewed and a discussion on how a behavioral model of physician decision making can be utilized will be explored. To date this approach has not been integrated into transplantation decision making.
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Affiliation(s)
- K E Schnier
- Department of Economics and Experimental Economics Center, Andrew Young School of Policy Studies, Georgia State University, USA
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36
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Roberts JP. Impact of outcomes monitoring on innovation and risk in liver transplantation. Liver Transpl 2012; 18 Suppl 2:S59-63. [PMID: 22903931 DOI: 10.1002/lt.23539] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
1. The reporting of liver transplant center outcomes is required by the final rule of the Department of Health and Human Services. The reported patient and graft survival outcomes are risk-adjusted for specific donor and recipient factors, and the observed survival is compared to the expected survival. Both the Centers for Medicare and Medicaid Services and the Organ Procurement and Transplantation Network flag programs for corrective action when the observed survival is significantly less than the expected survival. Both agencies can take action up to the closure of a center. In the last 5 years, the Organ Procurement and Transplantation Network has not taken an adverse action that required the closure of a liver transplant center because of outcomes. 2. Center survey data suggest that centers may try to select donors and recipients to minimize poor outcomes. This strategy may not be effective if centers stop accepting donors or recipients according to factors that are included in the risk adjustment model. For example, limiting recipients to those less than 65 years old may improve the observed outcomes, but the expected outcomes will also improve because a recipient 65 years or older is included in the model's risk adjustment. 3. For factors such as cardiovascular risk that are not included in the model, it may be reasonable to exclude patients in an attempt to improve the observed outcomes without affecting the expected outcomes. Other examples of these types of factors are smoking, nutritional status, and donor liver biopsy findings. 4. Currently, there is no exemption for patients undergoing experimental protocols. Down-staging for hepatocellular carcinoma, transplantation for human immunodeficiency virus-positive recipients, and the use of left lobe grafts with inflow modification are relatively recent areas of innovation in liver transplantation. Because innovation is frequently associated with a learning curve and, therefore, poor outcomes, the inclusion of patients in innovative protocols potentially could lead to centers being subjected to an adverse action by the Organ Procurement and Transplantation Network or the Centers for Medicare and Medicaid Services. Active consideration is being given to the exclusion of patients in innovative protocols from center-specific outcomes.
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Affiliation(s)
- John Paul Roberts
- Division of Transplantation, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA.
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37
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Kasiske BL, McBride MA, Cornell DL, Gaston RS, Henry ML, Irwin FD, Israni AK, Metzler NW, Murphy KW, Reed AI, Roberts JP, Salkowski N, Snyder JJ, Sweet SC. Report of a consensus conference on transplant program quality and surveillance. Am J Transplant 2012; 12:1988-96. [PMID: 22682114 DOI: 10.1111/j.1600-6143.2012.04130.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Public reports of organ transplant program outcomes by the US Scientific Registry of Transplant Recipients have been both groundbreaking and controversial. The reports are used by regulatory agencies, private insurance providers, transplant centers and patients. Failure to adequately adjust outcomes for risk may cause programs to avoid performing transplants involving suitable but high-risk candidates and donors. At a consensus conference of stakeholders held February 13-15, 2012, the participants recommended that program-specific reports be better designed to address the needs of all users. Additional comorbidity variables should be collected, but innovation should also be protected by excluding patients who are in approved protocols from statistical models that identify underperforming centers. The potential benefits of hierarchical and mixed-effects statistical methods should be studied. Transplant centers should be provided with tools to facilitate quality assessment and performance improvement. Additional statistical methods to assess outcomes at small-volume transplant programs should be developed. More data on waiting list risk and outcomes should be provided. Monitoring and reporting of short-term living donor outcomes should be enhanced. Overall, there was broad consensus that substantial improvement in reporting outcomes of transplant programs in the United States could and should be made in a cost-effective manner.
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Affiliation(s)
- B L Kasiske
- Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota, USA.
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38
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Johnson SR, Karp SJ, Curry MP, Barugel M, Rodrigue JR, Mandelbrot DA, Rogers CP, Hanto DW. Liver transplant center risk tolerance. Clin Transplant 2012; 26:E269-76. [DOI: 10.1111/j.1399-0012.2012.01658.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Scott R. Johnson
- The Transplant Center; Beth Israel Deaconess Medical Center (BIDMC); Harvard Medical School; Boston; MA; USA
| | - Seth J. Karp
- Vanderbilt Transplant Center; Vanderbilt University; Memphis; TN
| | - Michael P. Curry
- The Transplant Center; Beth Israel Deaconess Medical Center (BIDMC); Harvard Medical School; Boston; MA; USA
| | | | - James R. Rodrigue
- The Transplant Center; Beth Israel Deaconess Medical Center (BIDMC); Harvard Medical School; Boston; MA; USA
| | - Didier A. Mandelbrot
- The Transplant Center; Beth Israel Deaconess Medical Center (BIDMC); Harvard Medical School; Boston; MA; USA
| | - Christin P. Rogers
- The Transplant Center; Beth Israel Deaconess Medical Center (BIDMC); Harvard Medical School; Boston; MA; USA
| | - Douglas W. Hanto
- The Transplant Center; Beth Israel Deaconess Medical Center (BIDMC); Harvard Medical School; Boston; MA; USA
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39
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Abstract
Measurements of health care spending and outcomes in a geographic area and comparisons of one area to another have been used to make observations about health delivery systems and guide health care policy. Medicare claims files are a ready source of data about health care utilization and have served as the basis for a large number of studies in the United States. If ecologic studies are to accurately reflect local practices, potential variables must be accounted for. In the United States, differences in disease burden and socioeconomic factors are important variables affecting health care spending and outcomes. The assertion that regional variation in Medicare spending in the last two years of life is indicative of widespread waste in the U.S. health care system became a controversial part of the health care reform debate in 2009-2010.
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Affiliation(s)
- Tom Rosenthal
- David Geffen School of Medicine, University of California, Los Angeles, California 90095-7400, USA.
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40
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Abstract
BACKGROUND A pretransplant positive crossmatch in combined liver kidney transplants (CLK) is not considered a contraindication based on the reported immunoprotection conferred by the liver allograft. However, antibody-mediated rejection of the kidney in CLK has been reported recently. This prompted our study to investigate the impact of presensitization on CLK recipient outcomes. METHODS We examined kidney allograft and patient survival by indication of sensitization using Scientific Registry of Transplant Recipients data on CLK performed from 1995 to 2008. We defined sensitization as panel reactive antibody (PRA) more than 10% or a positive T-cell crossmatch (TXM). RESULTS Among 2484 CLK recipients with available PRA or TXM information, 30% had positive TXM or PRA more than 10%. Among those with TXM information, 12% had a positive crossmatch (n=234). In univariate analyses, patient (P=0.002) and overall kidney graft survival (P=0.015) were significantly diminished among sensitized patients. Differences in patient survival translated to estimated half-lives of 10.3 years among nonsensitized recipients versus 7.8 years among sensitized recipients, In multivariable Cox models, allosensitization was independently associated with patient death (adjusted hazard ratio=1.22, 95% CI, 1.04-1.43) and overall kidney graft loss (adjusted hazard ratio=1.16, 95% CI, 1.00-1.36). CONCLUSIONS These results suggest a negative impact of presensitization on patient and overall renal allograft survival in CLK. Accordingly, presensitization may need to be considered in risk stratification and clinical management of CLK.
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Hidden selection bias deriving from donor organ characteristics does not affect performance evaluations of kidney transplant centers. Med Care 2010; 48:907-14. [PMID: 20733532 DOI: 10.1097/mlr.0b013e3181e57a4d] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transplant center performance evaluations have garnered substantial attention in recent years. Among sources of bias that may affect measured performance are underlying characteristics of donor organs. An unresolved question is whether centers accepting higher-risk donations are placed in jeopardy for lower evaluations independent of actual quality of care. OBJECTIVE The primary aim was to assess whether unmeasured characteristics of donor organs impact risk-adjusted outcomes used for center performance evaluations. SUBJECTS The study included adult kidney transplant recipients (n = 53,791) from 1994 to 2008 from a national registry. RESEARCH DESIGN We compared adjusted graft survival with use of paired-donor kidneys (allocated to high- and low-performing centers) and unpaired donor kidneys to investigate whether measured center performance was consistent with organs derived from the same donor (minimizing the influence of noncodified risk factors). RESULTS The primary finding was that differences between centers were unaffected by use of paired or unpaired donations (hazard ratio for patients transplanted at high performing centers with paired kidneys = 0.63 [95% CI, 0.53-0.74] and with unpaired kidneys = 0.66 [95% CI, 0.62-0.70], P value for interaction = 0.52). This finding was consistent over 5 consecutive cohorts, based on either concurrent or prospective outcomes and by altering the threshold criteria for identification of performance outliers. CONCLUSIONS Results indicate that underlying selection bias from donor characteristics does not impact transplant center evaluations. This is important evidence that donor selection is not a primary driver for evaluated quality of care among transplant centers and acceptance of higher-risk kidneys should not be perceived as a primary threat to measured performance.
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42
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Schold JD, Arrington CJ, Levine G. Significant Alterations in Reported Clinical Practice Associated with Increased Oversight of Organ Transplant Center Performance. Prog Transplant 2010; 20:279-87. [DOI: 10.1177/152692481002000313] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the past several years, emphasis on quality metrics in the field of organ transplantation has increased significantly, largely because of the new conditions of participation issued by the Centers for Medicare and Medicaid Services. These regulations directly associate patients' outcomes and measured performance of centers with the distribution of public funding to institutions. Moreover, insurers and marketing ventures have used publicly available outcomes data from transplant centers for business decision making and advertisement purposes. We gave a 10-question survey to attendees of the Transplant Management Forum at the 2009 meeting of the United Network for Organ Sharing to ascertain how centers have responded to the increased oversight of performance. Of 63 responses, 55% indicated a low or near low performance rating at their center in the past 3 years. Respondents from low-performing centers were significantly more likely to indicate increased selection criteria for candidates (81% vs 38%, P= .001) and donors (77% vs 31%, P< .001) as well as alterations in clinical protocols (84% vs 52%, P=.007). Among respondents indicating lost insurance contracts (31%), these differences were also highly significant. Based on respondents' perceptions, outcomes of performance evaluations are associated with significant changes in clinical practice at transplant centers. The transplant community and policy makers should practice vigilance that performance evaluations and regulatory oversight do not inadvertently lead to diminished access to care among viable candidates or decreased transplant volume.
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Affiliation(s)
- Jesse D. Schold
- Cleveland Clinic Foundation, Cleveland, Ohio (JDS), Arbor Research Collaborative for Health, Ann Arbor, Michigan (CJA), University of Michigan, Ann Arbor (GL)
| | - Charlotte J. Arrington
- Cleveland Clinic Foundation, Cleveland, Ohio (JDS), Arbor Research Collaborative for Health, Ann Arbor, Michigan (CJA), University of Michigan, Ann Arbor (GL)
| | - Greg Levine
- Cleveland Clinic Foundation, Cleveland, Ohio (JDS), Arbor Research Collaborative for Health, Ann Arbor, Michigan (CJA), University of Michigan, Ann Arbor (GL)
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Schold J, Arrington C, Levine G. Significant alterations in reported clinical practice associated with increased oversight of organ transplant center performance. Prog Transplant 2010. [DOI: 10.7182/prtr.20.3.bj6mh237p6912251] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Using past performance to guide referrals for heart transplantation. J Heart Lung Transplant 2010; 29:908-9. [PMID: 20510629 DOI: 10.1016/j.healun.2010.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 04/09/2010] [Accepted: 04/13/2010] [Indexed: 11/22/2022] Open
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Tracy ET, Bennett KM, Danko ME, Diesen DL, Westmoreland TJ, Kuo PC, Pappas TN, Rice HE, Scarborough JE. Low volume is associated with worse patient outcomes for pediatric liver transplant centers. J Pediatr Surg 2010; 45:108-13. [PMID: 20105589 DOI: 10.1016/j.jpedsurg.2009.10.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Accepted: 10/06/2009] [Indexed: 11/17/2022]
Abstract
BACKGROUND An inverse association between hospital procedure volume and postoperative mortality has been demonstrated for a variety of pediatric surgical procedures. The objective of our study was to determine whether such an association exists for pediatric liver transplantation. METHODS We performed a retrospective analysis of pediatric liver transplant procedures included in the Scientific Registry of Transplant Recipients over a 7.5-year time period from July 1, 2000, through December 31, 2007. Pediatric liver transplant centers were divided into three volume categories (high, middle, low) based on absolute annual volume. Mean 1-year patient survival rates and aggregate 1-year observed-to-expected (O:E) patient death ratios were calculated for each hospital volume category and then compared using ordered logistic regression and chi square analyses. RESULTS High-volume pediatric liver transplant centers achieved significantly lower aggregate 1-year O:E patient death ratios than low-volume centers. When freestanding children's hospitals (FCH), children's hospitals within adult hospitals (CAH), and other centers (OC) were considered separately, we found that a significant volume-outcomes association existed among OC centers but not among FCH or CAH centers. Low-volume OC centers, which represent 41.6% of all pediatric liver transplant centers and perform 10% of all pediatric liver transplantation, had the least favorable aggregate 1-year O:E patient death ratio of all groups. CONCLUSIONS We demonstrate that a significant center volume-outcomes relationship exists among OC pediatric liver transplant centers but not among FCH or CAH centers. These findings support the possible institution of minimum annual procedure volume requirements for OC pediatric liver transplant centers.
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Affiliation(s)
- Elisabeth T Tracy
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Tracy ET, Bennett KM, Aviki EM, Pappas TN, Collins BH, Tuttle-Newhall JE, Marroquin CE, Kuo PC, Scarborough JE. Temporal trends in liver transplant centre volume in the USA. HPB (Oxford) 2009; 11:414-21. [PMID: 19768146 PMCID: PMC2742611 DOI: 10.1111/j.1477-2574.2009.00075.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2009] [Accepted: 05/04/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although prior studies have suggested an inverse association between liver transplant centre volume and postoperative patient mortality, more recent analyses have failed to confirm this association. To date, all studies of the relationship between centre volume and outcomes in liver transplantation have been cross-sectional in design. OBJECTIVE The objective of our study was to examine temporal trends in the volume-outcomes relationship for liver transplantation. METHODS We used information obtained from the Scientific Registry of Transplant Recipients (SRTR) programme-specific data reports to examine the outcomes of adult liver transplant recipients stratified by annual centre volume. This relationship between centre volume and patient outcomes was assessed over three consecutive time periods from 2000 through 2007. RESULTS The overall 25% increase in adult liver transplant volume in the USA from 2000 to 2007 appeared to be distributed fairly equally among existing transplant centres. In the earliest time period of our analysis, high-volume centres achieved superior risk-adjusted 1-year patient outcomes compared with low-volume centres. By the third and most recent time period of the analysis, this discrepancy between the outcomes of high- and low-volume centres was no longer statistically apparent. CONCLUSIONS The relationship between centre volume and patient outcomes for liver transplantation in the USA has become less pronounced over time, suggesting that the use of procedure volume as a marker of liver transplant centre quality cannot be justified. The performance-based review process currently utilized in the USA may have contributed to this diminishing influence of centre volume on liver transplant recipient outcomes. This type of review process should be considered as a potential alternative to the volume-based referral initiatives that have been developed for other non-transplant, complex surgical procedures.
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Affiliation(s)
- Elisabeth T Tracy
- Department of Surgery, Duke University Medical Centre, Durham, NC 27710, USA
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Weinhandl ED, Snyder JJ, Israni AK, Kasiske BL. Effect of comorbidity adjustment on CMS criteria for kidney transplant center performance. Am J Transplant 2009; 9:506-16. [PMID: 19191763 PMCID: PMC2670063 DOI: 10.1111/j.1600-6143.2008.02527.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The Centers for Medicare & Medicaid Services (CMS) uses kidney transplant outcomes, unadjusted for standard comorbidity, to identify centers with sufficiently higher than expected rates of graft failure or patient death (underperforming centers) that they may be denied Medicare participation. To examine whether comorbidity adjustment would affect this determination, we identified centers that would have failed to meet 1-year graft survival criteria, 1992-2005, with and without adjustment using the Elixhauser Comorbidity Index. Adjustment was performed for each U.S. center for 24 consecutive (overlapping) 30-month intervals, including 102 176 adult deceased-donor and living-donor kidney transplant patients with Medicare as primary payer 6 months pretransplant. For each interval, we determined percent positive agreement (PPA) (number of centers underperforming both before and after adjustment, divided by number underperforming either before or after adjustment). Overall PPA was 80.8%, with no evidence of a trend over time. Among deceased-donor recipients, 10 of 31 comorbid conditions were predictors of graft failure in at least half of the intervals, as were six conditions among living-donor recipients. Lack of comorbidity adjustment may disadvantage centers willing to accept higher risk patients. Risk of jeopardizing Medicare funding may give centers incentive to deny transplantation to higher risk patients.
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Affiliation(s)
- E. D. Weinhandl
- United States Renal Data System, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - J. J. Snyder
- United States Renal Data System, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - A. K. Israni
- Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - B. L. Kasiske
- United States Renal Data System, Minneapolis Medical Research Foundation, Minneapolis, Minnesota,Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Abecassis MM, Burke R, Cosimi AB, Matas AJ, Merion RM, Millman D, Roberts JP, Klintmalm GB. Transplant center regulations--a mixed blessing? An ASTS Council viewpoint. Am J Transplant 2008; 8:2496-502. [PMID: 19032221 DOI: 10.1111/j.1600-6143.2008.02434.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The Centers for Medicare and Medicaid Services (CMS) has developed a set of regulations that spell out the Conditions of Participation (CoPs) for provider hospitals that wish to be certified (and thus eligible for reimbursement) by Medicare for transplant services. The American Society of Transplant Surgeons (ASTS) Council has played a major role in providing CMS with advice and guidance in the development and ongoing implementation of these conditions through a process of fruitful dialogue. In this report, we highlight the events that led to the development of the regulations and describe the process to date in implementing the CoPs. We have raised some important questions regarding the effectiveness of the regulations for improving safety, and we have highlighted the cost associated with their implementation. This report has been vetted by and represents the opinions of the Council of the ASTS.
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Port FK, Merion RM, Roys EC, Wolfe RA. Trends in organ donation and transplantation in the United States, 1997-2006. Am J Transplant 2008; 8:911-21. [PMID: 18336695 DOI: 10.1111/j.1600-6143.2008.02170.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- F K Port
- Scientific Registry of Transplant Recipients, Arbor Research Collaborative for Health, Ann Arbor, MI, USA.
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