Significant Alterations in Reported Clinical Practice Associated with Increased Oversight of Organ Transplant Center Performance

Abstract

In the past several years, emphasis on quality metrics in the field of organ transplantation has increased significantly, largely because of the new conditions of participation issued by the Centers for Medicare and Medicaid Services. These regulations directly associate patients' outcomes and measured performance of centers with the distribution of public funding to institutions. Moreover, insurers and marketing ventures have used publicly available outcomes data from transplant centers for business decision making and advertisement purposes. We gave a 10-question survey to attendees of the Transplant Management Forum at the 2009 meeting of the United Network for Organ Sharing to ascertain how centers have responded to the increased oversight of performance. Of 63 responses, 55% indicated a low or near low performance rating at their center in the past 3 years. Respondents from low-performing centers were significantly more likely to indicate increased selection criteria for candidates (81% vs 38%, P = .001) and donors (77% vs 31%, P < .001) as well as alterations in clinical protocols (84% vs 52%, P = .007). Among respondents indicating lost insurance contracts (31%), these differences were also highly significant. Based on respondents' perceptions, outcomes of performance evaluations are associated with significant changes in clinical practice at transplant centers. The transplant community and policy makers should practice vigilance that performance evaluations and regulatory oversight do not inadvertently lead to diminished access to care among viable candidates or decreased transplant volume.

Making House Calls Increases Living Donor Inquiries and Evaluations for Blacks on the Kidney Transplant Waiting List

“…In contrast, the current study recruited more diverse black patients from an urban region and who had more shallow roots and more dispersion of extended family members throughout the United States and other countries. Also noteworthy is that the current study was conducted in an era of increased regulatory oversight of LD and transplant center performance,[18-20] more complex histocompatibility testing, a more protracted evaluation process, more restrictive selection criteria for black donors due to less favorable long-term outcomes,[21-23] and a national decline in LDKT, particularly among blacks. [15] All of these factors may have contributed to lower LDKT rates in the current study, although we did not evaluate in either study the reasons why potential donors did not progress to donation.…”

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

“…Most alarming is that in the two years following the publication of the 2007 CoP, there was a decline in national kidney transplant volumes. [15] LP evaluations do not impact CMS participation alone, but can impact private insurance contracts even more. Studies have demonstrated a significant decline in the proportion of patients who had private primary insurance in centers with a LP evaluation.…”

“…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. [15] Older patients with end-stage renal disease have received much of the attention with respect to more restrictive eligibility criteria related to the inherent higher mortality risks and potentially heavier burden of cardiovascular disease in older patients. This restricted access to relatively high risk candidates creates a conflict between the interests of the patient and perceived benefits to the transplant center.…”

“…Surveyed transplant center administrators also reported on increased selection criteria for donors more often in LP centers (77% of LP centers vs 31% of others, p<0.001). [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.…”

“…[15, 30] Centers have added personnel to comply with the needed documentation and monitoring related to CMS regulations and/or have had to improve existing electronic medical record infrastructures and support, all frequently very costly endeavors. [30]…”