Measuring Transplant Center Performance: the Goals Are Not Controversial but the Methods and Consequences Can Be

Abstract

Purpose of Review Risks of regulatory scrutiny has generated widespread concern about increasingly risk averse transplant center behaviors regarding both donor and candidate acceptance patterns. To address potential unintended consequences threatening access to care, we discuss recent changes in regulatory metrics and potential improvements in quality oversight of transplant centers. Recent Findings Despite many recent changes to one-year patient and graft survival regulatory criteria, the capacity to accurately identify true underperforming centers and avoiding false positive flagging remains an area of great concern. Numerous studies have demonstrated restrictions in transplant volume and access following transplant center flagging. Summary Current regulatory criteria are limited in their capacity to accurately identify poorly performing centers and potentially encourage risk-averse behavior by transplant centers. Efforts to address these concerns should focus on (1) improving risk-adjustment models with better data which captures the acuity of candidate and donor risk, (2) reconsidering primary outcomes measured to assess comprehensive transplant center performance, (3) improving education to address rational or perceived disincentives, and (4) using data more effectively to share best practices.

An international comparison of deceased donor kidney utilization: What can the United States and the United Kingdom learn from each other?

“…The sharply higher utilization of older and high‐KDRI kidney donors in the UK compared with the US is one of the most salient observations from this study, which echo key messages from a recent comparison of kidney utilization in the US and France . Potential explanations for these US–UK differences include the following: Kidney allocation policy differences ◦Donor–recipient age‐matching points (UK) ◦Fast track offering scheme (UK) ◦High‐KDPI consent requirement (US) Differential reliance on biopsies for ruling in and ruling out transplantable kidneys Broader (US) vs narrower (UK) geography Variations in transplant finances Differences in dialysis practices Transplant center regulatory oversight differences Cultural differences influencing patient treatment expectations …”

How Should Physicians Respond to Requests for LVAD Removal?

“…Advanced heart failure programs that perform LVADs and transplants are graded on their outcomes, including short-term mortality, such that patient decisions not to "make the most" of their LVAD or transplant can put patients and clinicians at odds with each other. 12 Thus, creating opportunities to reasonably ensure patient and caregiver commitment prior to durable LVAD implantation might avoid downstream disappointment and conflict.…”

Transplant community perceptions of the benefits and drawbacks of alternative quality metrics for regulation

“…For example, tying payer participation to post‐transplant outcomes may incentivize centers to avoid transplanting patients perceived as higher risk for adverse outcomes. Various alternative metrics have been proposed, such as patient or graft survival under longer time‐frames, or pre‐transplant factors such as organ acceptance rates . The SRTR publishes additional metrics including transplant rate and transplant volume to inform patient and payer choice of center, but these metrics are not used for regulation.…”