Balancing Accountable Care With Risk Aversion: Transplantation as a Model

Axelrod, David A.

doi:10.1111/j.1600-6143.2012.04346.x

Cited by 41 publications

(37 citation statements)

References 8 publications

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“…Despite the significant differences in patient outcomes between centers, there are concerns about quality oversight and the potential reduction in transplant rates among lowperforming centers (14,15,18,22). Concerns about performance evaluations generally derive from the fact that measures have inherent limitations (e.g., inability to account for disproportionate prevalence of underlying risk factors) that may unintentionally bias reports (22)(23)(24).…”

Section: Discussionmentioning

confidence: 99%

“…Since publication of the COP, centers with low-rated performance have had significant decline in transplant volume, whereas transplants have continued to increase among other centers (16). Although the specific mechanisms for this association have not been comprehensively evaluated, it is plausible that centers that receive low-performance evaluations have become increasingly risk averse (14,15,18). However, quality oversight may have substantial benefits for identification and improvement efforts for centers with suboptimal outcomes (14,19).…”

Section: Introductionmentioning

confidence: 99%

“…Although the specific mechanisms for this association have not been comprehensively evaluated, it is plausible that centers that receive low-performance evaluations have become increasingly risk averse (14,15,18). However, quality oversight may have substantial benefits for identification and improvement efforts for centers with suboptimal outcomes (14,19). An important unresolved issue relates to understanding what the potential tradeoff is for candidate outcomes if performance oversight leads to reduced transplant volume.…”

Section: Introductionmentioning

confidence: 99%

“…This trend is particularly notable given that transplant volume had increased in each consecutive year between 1989 and 2006 (13). Although there are likely multiple causes explaining this stagnation, one potential contributing factor relates to increased oversight of transplant centers (14)(15)(16). In 2007, the Centers for Medicare and Medicaid Services (CMS) issued a Conditions of Participation (COP), which explicitly linked performance of transplant centers, as measured by risk-adjusted post-transplant outcomes, with access to reimbursement (17).…”

Section: Introductionmentioning

confidence: 99%

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Association between Kidney Transplant Center Performance and the Survival Benefit of Transplantation Versus Dialysis

Schold

Buccini²,

Goldfarb

et al. 2014

Clinical Journal of the American Society of Nephrology

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Background and objectives Despite the benefits of kidney transplantation, the total number of transplants performed in the United States has stagnated since 2006. Transplant center quality metrics have been associated with a decline in transplant volume among low-performing centers. There are concerns that regulatory oversight may lead to risk aversion and lack of transplantation growth.Design, setting, participants, & measurements A retrospective cohort study of adults (age$18 years) wait-listed for kidney transplantation in the United States from 2003 to 2010 using the Scientific Registry of Transplant Recipients was conducted. The primary aim was to investigate whether measured center performance modifies the survival benefit of transplantation versus dialysis. Center performance was on the basis of the most recent Scientific Registry of Transplant Recipients evaluation at the time that patients were placed on the waiting list. The primary outcome was the time-dependent adjusted hazard ratio of death compared with remaining on the transplant waiting list.Results Among 223,808 waitlisted patients, 59,199 and 32,764 patients received a deceased or living donor transplant, respectively. Median follow-up from listing was 43 months (25th percentile=25 months, 75th percentile=67 months), and there were 43,951 total patient deaths. Deceased donor transplantation was independently associated with lower mortality at each center performance level compared with remaining on the waiting list; adjusted hazard ratio was 0.24 (95% confidence interval, 0.21 to 0.27) among 11,972 patients listed at high-performing centers, adjusted hazard ratio was 0.32 (95% confidence interval, 0.31 to 0.33) among 203,797 patients listed at centers performing as expected, and adjusted hazard ratio was 0.40 (95% confidence interval, 0.35 to 0.45) among 8039 patients listed at low-performing centers. The survival benefit was significantly different by center performance (P value for interaction ,0.001).Conclusions Findings indicate that measured center performance modifies the survival benefit of kidney transplantation, but the benefit of transplantation remains highly significant even at centers with low measured quality. Policies that concurrently emphasize improved center performance with access to transplantation should be prioritized to improve ESRD population outcomes.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Association between Kidney Transplant Center Performance and the Survival Benefit of Transplantation Versus Dialysis

Schold

Buccini²,

Goldfarb

et al. 2014

Clinical Journal of the American Society of Nephrology

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“…Our findings may also reflect active risk aversion by transplant centers. That is, it is possible that centers with LP evaluations are reluctant to accept donor organs or list patients that are perceived to be higher risk and considered a threat to a center's measured performance (25,26).…”

Section: Discussionmentioning

confidence: 99%

Association Between Liver Transplant Center Performance Evaluations and Transplant Volume

Buccini

Segev

Fung

et al. 2014

American Journal of Transplantation

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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 ¼ 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 ¼ 0.002, p ¼ 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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Regulations' Impact on Donor and Recipient Selection for Liver Transplantation: How Should Outcomes be Measured and MELD Exception Scores be Considered?

Adler¹,

Axelrod²

2016

AMA Journal of Ethics

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Balancing Accountable Care With Risk Aversion: Transplantation as a Model

Cited by 41 publications

References 8 publications

Association between Kidney Transplant Center Performance and the Survival Benefit of Transplantation Versus Dialysis

Association between Kidney Transplant Center Performance and the Survival Benefit of Transplantation Versus Dialysis

Association Between Liver Transplant Center Performance Evaluations and Transplant Volume

Regulations' Impact on Donor and Recipient Selection for Liver Transplantation: How Should Outcomes be Measured and MELD Exception Scores be Considered?

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