Innovations in the Assessment of Transplant Center Performance: Implications for Quality Improvement

Axelrod, David A.; Kalbfleisch, John D.; Sun, Rena Jie; Guidinger, Mary K.; Biswas, Pinaki; Levine, G. N.; Arrington, Charlotte J.; Merion, Robert M.

doi:10.1111/j.1600-6143.2009.02570.x

Cited by 50 publications

(50 citation statements)

References 23 publications

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“…Because lowvolume centers are expected to have a large variation in annual mortality rates, simply through sampling variation, statistical process control techniques such as cumulative sum charts are required to monitor performance. 25,26 There are no international guidelines regarding acceptable volumes for heart transplant centers. In the United States, Centers for Medicare and Medicaid Services require heart transplant centers to perform at least 10 transplants per year and centers are defined as functionally inactive if no transplants are performed for 3 months.…”

Section: Can Low-volume Transplant Centers Have Satisfactory Outcomes?mentioning

confidence: 99%

How Small Is Too Small? A Systematic Review of Center Volume and Outcome After Cardiac Transplantation

Pettit

Jhund²,

Hawkins³

et al. 2012

Circ: Cardiovascular Quality and Outcomes

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Background-The aim of this study was to assess the relationship between the volume of cardiac transplantation procedures performed in a center and the outcome after cardiac transplantation. Methods and Results-PubMed, Embase, and the Cochrane library were searched for articles on the volume-outcome relationship in cardiac transplantation. Ten studies were identified, and all adopted a different approach to data analysis and varied in adjustment for baseline characteristics. The number of patients in each study ranged from 798 to 14 401, and observed 1-year mortality ranged from 12.6% to 34%. There was no association between the continuous variables of center volume and observed mortality. There was a weak association between the continuous variables of center volume and adjusted mortality up to 1 year and a stronger association at 5 years. When centers were grouped in volume categories, low-volume centers had the highest adjusted mortality, intermediate-volume centers had lower adjusted mortality, and high-volume centers had the lowest adjusted mortality but were not significantly better than intermediate-volume centers. Category limits were arbitrary and varied between studies. Conclusions-There is a relationship between center volume and mortality in heart transplantation. The existence of a minimum acceptable center volume or threshold is unproven. However, a level of 10 to 12 heart transplants per year corresponds to the upper limit of low-volume categories that may have relatively higher mortality. It is not known whether outcomes for patients treated in low-volume transplant centers would be improved by reorganizing centers to ensure volumes in excess of 10 to 12 heart transplants per year. (Circ Cardiovasc Qual Outcomes. 2012;5:783-790.)

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Section: Can Low-volume Transplant Centers Have Satisfactory Outcomes?mentioning

confidence: 99%

How Small Is Too Small? A Systematic Review of Center Volume and Outcome After Cardiac Transplantation

Pettit

Jhund²,

Hawkins³

et al. 2012

Circ: Cardiovascular Quality and Outcomes

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“…Employing this decision model assumes that the transplant surgeon is a risk neutral individual. Although the medical literature has hypothesized that surgeons are risk-averse (1,18), for the most part and remarkably, the medical decision-making literature has not developed a behavioral theory that accounts for a physician's risk preferences. Despite this, expected value theory continues to be applied to research on medical decision-making (4,6,8,10).…”

Section: Economic Decision Theory and Transplantationmentioning

confidence: 99%

“…Alternative references points may be the output from center-specific data that tracks their real time performance such as a cumulative sum (CUMSUM) chart (18), or the CER practices recommended for organ utilization (i.e. use of ECD kidneys).…”

Section: Benefits Of Synergymentioning

confidence: 99%

Transplantation at the Nexus of Behavioral Economics and Health Care Delivery

Schnier

Cox

McIntyre

et al. 2013

American Journal of Transplantation

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The transplant surgeon's decision to accept and utilize an organ typically is made within a constrained time window, explicitly cognizant of numerous healthrelated 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 physicianpatient 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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“…Others have failed to demonstrate an effect of volume. 196,197 The variation in conclusions as to the impact of volume on outcomes could relate, at least in part, to the impact of small numbers, the relative bluntness of risk adjustment, the fact that some small-volume centers may be led by very experienced surgeons trained elsewhere, and the experience with related surgical interventions. 198 These figures, however, do not take into account other activities, such as living or deceased donors, liver resection and other solid organ transplants.…”

Section: Provision Of Transplant Unitsmentioning

confidence: 99%