A novel patient-centered “intention-to-treat” metric of U.S. lung transplant center performance

Abstract

Despite the importance of pretransplantation outcomes, 1-year posttransplantation survival is typically considered the primary metric of lung transplant center performance in the United States. We designed a novel lung transplant center performance metric that incorporates both pre- and posttransplantation survival time. We performed an ecologic study of 12 187 lung transplant candidates listed at 56 U.S. lung transplant centers between 2006 and 2012. We calculated an "intention-to-treat" survival (ITTS) metric as the percentage of waiting list candidates surviving at least 1 year after transplantation. The median center-level 1-year posttransplantation survival rate was 84.1%, and the median center-level ITTS was 66.9% (mean absolute difference 19.6%, 95% limits of agreement 4.3 to 35.1%). All but 10 centers had ITTS values that were significantly lower than 1-year posttransplantation survival rates. Observed ITTS was significantly lower than expected ITTS for 7 centers. These data show that one third of lung transplant candidates do not survive 1 year after transplantation, and that 12% of centers have lower than expected ITTS. An "intention-to-treat" survival metric may provide a more realistic expectation of patient outcomes at transplant centers and may be of value to transplant centers and policymakers.

Heart and lung organ offer acceptance practices of transplant programs are associated with waitlist mortality and organ yield

“…Approaches to reducing variability in offer acceptance have potential limitations. For example, a recently proposed metric considered survival among lung candidates who underwent transplant,22 although Although transplant rates are not associated with posttransplant outcomes, 21 a metric that integrates pretransplant and posttransplant outcomes may better describe the overall patient experience at a program.…”

“…metric that integrates pretransplant and posttransplant outcomes may better describe the overall patient experience at a program. For example, a recently proposed metric considered survival among lung candidates who underwent transplant,22 although survival from listing could also provide a straightforward alternative approach for integrating the pretransplant and posttransplant experience at a program. Alternatively, clinical support tools may help characterize scenarios in which accepting an offer of a heart or lung may confer a survival benefit relative to declining and remaining on the waiting list for a better offer.…”

Defining Success in Lung Transplantation: From Survival to Quality of Life

“…In their article, the authors suggested moving to an "intention to treat 1-year survival" analysis. 48 In this model, patients were observed from the time of listing through 1 year after LT. A successful transplant was defined as listing for transplant and surviving the first year after LT. Failure was defined as removal from the waiting list for illness, death on the waiting list, or death within 1 year after transplant. This novel metric did not correlate with the center-specific 1-year survival.…”

Procedure Preference and Intention-to-Treat Outcomes after Listing for Lung Transplantation among U.S. Adults. A Cohort Study

“…To date, few studies have examined "intention-to-treat" outcomes in lung transplantation (i.e., the inclusion of survival time and events that occur both before and after transplantation) (18). Because intention-to-treat outcome measures capture the entirety of the patient experience after placement on the waiting list, examination of these outcomes can capture unique center performance metrics (18) and may yield important clinical insights above and beyond those provided by studies restricted to either pre-or posttransplant outcomes.…”