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.

The Association of Center Performance Evaluations and Kidney Transplant Volume in the United States

“…This type of patient selection has been illustrated in other healthcare contexts associated with implementation of report cards (7)(8)(9). In a similar fashion, there may be legitimate concerns that transplant centers become more conservative with respect to selecting donor organs as a consequence of public reporting of performance (10). In this sense, report cards may unintentionally lead to greater rates of organ discard, longer cold ischemia times or disincentivize procurement of hard to place organs.…”

Potential Implications of Recent and Proposed Changes in the Regulatory Oversight of Solid Organ Transplantation in the United States

“…A recent analysis demonstrated that transplant programs do not come under regulatory scrutiny solely on the basis of underperformance on high-risk transplants (14). Nevertheless, the perception of many transplant programs is that risky transplants and innovations can cause program outcomes to appear worse and result in lost contracts and referrals (15). Thus, programs with worse outcomes reduce the numbers of transplants they perform and preferentially avoid accepting high-risk recipients and donors (16,17).…”

Association between Kidney Transplant Center Performance and the Survival Benefit of Transplantation Versus Dialysis

“…Despite the significant differences in patient outcomes between centers, there are concerns about quality oversight and the potential reduction in transplant rates among lowperforming centers (14,15,18,22). Concerns about performance evaluations generally derive from the fact that measures have inherent limitations (e.g., inability to account for disproportionate prevalence of underlying risk factors) that may unintentionally bias reports (22)(23)(24).…”

“…Since publication of the COP, centers with low-rated performance have had significant decline in transplant volume, whereas transplants have continued to increase among other centers (16). Although the specific mechanisms for this association have not been comprehensively evaluated, it is plausible that centers that receive low-performance evaluations have become increasingly risk averse (14,15,18). However, quality oversight may have substantial benefits for identification and improvement efforts for centers with suboptimal outcomes (14,19).…”