Center Variation in Intention‐to‐Treat Survival Among Patients Listed for Liver Transplant

Abstract

In the United States, centers performing liver transplant (LT) are primarily evaluated by patient survival within 1 year after LT, but tight clustering of outcomes allows only a narrow window for evaluation of center variation for quality improvement. Alternate measures more relevant to patients and the transplant community are needed. We examined adults listed for LT in the United States, using data submitted to the Scientific Registry of Transplant Recipients. Intention-to-treat (ITT) survival was defined as survival within 1 year from listing, regardless of transplant. Mixed effects/frailty models were used to assess center variation in ITT survival. Between January 2010 and December 2016, there were 66,428 new listings at 113 centers. Overall, median 1-year ITT survival was 79.8% (interquartile range [IQR], 76.1%-83.4%), whereas 1-year waiting-list (WL) survival was 75.8% (IQR, 71.2%-79.4%), and 1-year post-LT survival was 90.0% (IQR, 87.9%-91.8%). Higher rates of ITT mortality were correlated with increased WL mortality (correlation, r = 0.76), increased post-LT mortality (r = 0.31), lower volume centers (r = −0.34), and lower transplant rate ratio (r = −0.25). Similar patterns were observed in the subgroup of WL candidates listed with Model for End-Stage Liver Disease (MELD) ≥25: median 1-year ITT survival was 65.2% (IQR, 60.2%-72.6%), whereas 1-year post-LT survival was 87.5% (IQR, 84.0%-90.9%), and 1-year WL survival was 36.6% (IQR, 27.9%-47.0%). In mixed effects modeling, the transplant center was an independent predictor of ITT survival even after adjustment for age, sex, MELD, and sociodemographic variables. Center variation for ITT survival was larger compared with post-LT survival. The measurement of ITT outcome offers a complementary method to assess center performance. This is a first step toward understanding differences in program quality beyond patient and graft survival after LT.

MELD is MELD is MELD? Transplant center–level variation in waitlist mortality for candidates with the same biological MELD

“…Similar to prior studies, we found that the greatest variation in bMELD‐predicted mortality risk was observed among candidates with MELD 26–30. In an analysis that followed transplant recipients from the time of listing, the variation in 1‐year waitlist mortality across transplant centers was 20.6%–28.8%, greater than post‐transplant mortality variation, and more varied (53%–72.1%) among candidates with MELD ≥ 25 27 . The rare transplant centers and circumstances that have a relatively higher‐than‐average waitlist mortality risk likely warrants targeted investigation rather than radical changes to MELD‐based allocation.…”

“…among candidates with MELD ≥ 25. 27 The rare transplant centers and circumstances that have a relatively higher-than-average waitlist mortality risk likely warrants targeted investigation rather than radical changes to MELD-based allocation.…”

Center variations in patient selection for simultaneous heart‐kidney transplantation

“…This policy void sets the stage for potential wide variability in center‐level patient selection for SHK. Indeed, center level differences pertaining to patient selection in solid‐organ transplantation are well‐described, 1–11 including in simultaneous liverkidney (SLK) transplantation 12 prior to the implementation of standardized SLK criteria in 2017 13 . To our knowledge, differences in center level practice of SHK transplantation have not yet been described.…”

“…This policy void sets the stage for potential wide variability in center-level patient selection for SHK. Indeed, center level differences pertaining to patient selection in solid-organ transplantation are well-described, [1][2][3][4][5][6][7][8][9][10][11] including in simultaneous liverkidney (SLK) transplantation 12 prior to the implementation of standard-…”

Rethinking Transplant Quality: New Performance Measures and Wait‐List Prioritization

“…Kwong et al address a key metric to compare transplant centers: 1‐year posttransplant survival. ( 2 ) Although this undoubtedly is an important individual patient outcome, it does not provide a complete picture of a center’s ability to guide wait‐listed patients to transplant. Furthermore, tight clustering of 1‐year posttransplant survival data makes it difficult to ascertain individual center quality.…”