Patient Selection and Volume in the Era Surrounding Implementation of Medicare Conditions of Participation for Transplant Programs

White, Sarah L.; Zinsser, D.; Paul, Matthew A.; Levine, G. N.; Shearon, Tempie H.; Ashby, Valarie B.; Magee, John C.; Li, Yang; Leichtman, Alan B.

doi:10.1111/1475-6773.12188

Cited by 36 publications

(39 citation statements)

References 21 publications

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“…Centers flagged according to CMS conditions of participation decreased their overall transplant rates and to an even greater degree acceptance of ECD kidneys during a period of overall transplant growth at remaining centers. 20,21 While, these survival metrics are risk-adjusted by the SRTR according to recipient age and donor KDPI, concerns regarding the adequacy of this risk adjustment have been ongoing and pervasive. As such, proposals to exclude KDPI >85% transplants from transplant center regulatory metrics or to measure these graft outcomes separately have been suggested to encourage utilization of the organs nationally.…”

Section: Discussionmentioning

confidence: 99%

Survival Benefit in Older Patients Associated With Earlier Transplant With High KDPI Kidneys

et al. 2017

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Background Given high dialysis mortality rates for patients >60 years old, accepting a kidney with a high kidney donor profile index (KDPI) score could enable earlier and potentially preemptive transplantation (preKT). However, evidence regarding the risks of high KDPI allografts in older patients is limited. Our objective was to determine the relative benefit for older patients of KDPI>85% transplant either preemptively or not compared with remaining on the waitlist. Methods UNOS data from 2003–2012 for adult deceased donor kidney transplant candidates was analyzed to evaluate patient survival in patients >60 years old for preKT and non-preKT KDPI>85% transplants compared to candidates remaining on the waitlist including patients who received KDPI 0–85% transplants according to multivariate Cox regression models. Results In the first year posttransplant for KDPI>85% recipients >60 years old, preKT had a reduced mortality hazard (HR=0.61, 95%CI=0.41–0.90) and non-preKT an increased mortality hazard (HR= 1.15, 95%CI=1.03–1.27) compared with the waitlist including KDPI 0–85% transplant recipients. At 1–2 years and after 2 years, both KDPI >85% groups had significant reductions in mortality (1–2 yrs: preKT HR= 0.38, 95%CI=0.23–0.60 and non-preKT HR= 0.52, 95%CI=0.45–0.61; and 2+ yrs: preKT HR= 0.50, 95%CI=0.38–0.66 and non-preKT HR= 0.64, 95%CI=0.58–0.70, respectively). Conclusions PreKT and non-preKT KDPI>85% transplant was associated with lower mortality hazard after the first year compared with the waitlist including KDPI 0–85% transplants in patients >60 years old. Further consideration should be given to increased utilization of high KDPI grafts in older patients with the goal of avoiding or limiting time on dialysis.

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Section: Discussionmentioning

confidence: 99%

Survival Benefit in Older Patients Associated With Earlier Transplant With High KDPI Kidneys

et al. 2017

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“…White et al demonstrated that transplant volume declined 38% among programs with ongoing non-compliance with CMS CoP compared with a 6% increase in those programs remaining in compliance. [13] Schold et al identified a mean decline of 22.4 transplants annually in centers with a of LP PSR compared with an average 7.8 transplant increase annually for other centers during the same time period. [14] Of concern, almost a quarter of kidney transplant centers had LP report during this period.…”

Section: Unitended Consequences and Disincentivesmentioning

confidence: 99%

“…White et al showed evidence that programs with ongoing LP had a higher burden of risk due to recipient factors. [13] It is not surprising then, that one strategy employed by transplant centers fearful of regulatory trouble is more restrictive listing and transplant practices. In a survey of individuals in transplant administrative roles, 81% of centers with LP evaluations in the past 3 years had increased candidate selection criteria, and 94% of centers with LP evaluations and lost contracts had increased their criteria.…”

Section: Unitended Consequences and Disincentivesmentioning

confidence: 99%

“…[15] White et al demonstrated a 55% decrease in ECD volume (compared with the overall 38% in center transplant volume) for centers with ongoing non-compliance with CoP. [13] Similarly, Schold et al showed a 4.7 ECD transplant decline for centers with LP evaluations compared with a 3.9 increase in centers without LP evaluations. [14] Similar trends have been demonstrated for liver transplant centers.…”

Section: Unitended Consequences and Disincentivesmentioning

confidence: 99%

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

Jay

Schold

2017

Curr Transpl Rep

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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.

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“…Prior studies have found a decrease in transplant volume among centers “flagged” for low performance after the CMS Conditions of Participation were introduced, reducing access to transplantation for patients in the area . Furthermore, concern about post‐transplant outcome metrics included in report cards has been cited as a deterrent to providers’ willingness to accept organs from higher risk donors . Although receiving a transplant, even from an organ at increased risk of disease transmission (IRD), has survival benefit compared to remaining on dialysis, IRD organs are more likely to be discarded than non‐IRD organs .…”

Section: Introductionmentioning

confidence: 99%

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

Rasmussen

Zhou

Thomas

et al. 2019

Clinical Transplantation

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Background There is concern that the metrics currently used to regulate transplant centers, one‐year patient and graft survival, may have adverse consequences including decreasing higher risk donor organ acceptance and transplant volume. This raises questions about whether alternative measures would be more appropriate. Methods We surveyed American Society of Transplant Surgeons (ASTS) and American Society of Transplantation (AST) members (n = 270) to characterize perceptions of several metrics that are used for regulation, are publicly reported, or have been suggested elsewhere, regarding their effectiveness, amenability to risk adjustment, and predicted effects on volume, mortality, and waitlist size. Results Respondents rated one‐year patient and graft survival the most effective measure of quality of care (mean scores = 7.44, 7.31, respectively, out of 10) and most amenable to risk adjustment (mean scores = 6.26, 6.13, respectively). Most respondents believed alternative metrics would not impact their center's volume, waitlist size, or one‐year transplant mortality. However, some did predict unintended consequences; for example, some believed using one‐year waitlist mortality, one‐year mortality of patients listed, or one‐year mortality of patients referred for transplant would decrease the number of transplants performed (48.6%, 46.7%, and 48.3% of respondents, respectively). Discussion Despite previously published concerns with existing regulatory metrics, most participants did not believe any metrics would outperform one‐year patient and graft survival.

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Patient Selection and Volume in the Era Surrounding Implementation of Medicare Conditions of Participation for Transplant Programs

Cited by 36 publications

References 21 publications

Survival Benefit in Older Patients Associated With Earlier Transplant With High KDPI Kidneys

Survival Benefit in Older Patients Associated With Earlier Transplant With High KDPI Kidneys

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

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

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