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

Report cards evaluating transplant center performance have received significant attention in recent years corresponding with the Centers for Medicare and Medicaid Services issue of the 2007 Conditions of Participation. Our primary aim was to evaluate the association of report card evaluations with transplant center volume. We utilized data from the Scientific Registry of Transplant Recipients (SRTR) along with six consecutive program‐specific reports from January 2007 to July 2009 for adult kidney transplant centers. Among 203 centers, 46 (23%) were low performing (LP) with statistically significantly lower than expected 1‐year graft or patient survival at least once during the study period. Among LP centers, there was a mean decline in transplant volume of 22.4 cases compared to a mean increase of 7.8 transplants among other centers (p = 0.001). Changes in volume between LP and other centers were significant for living, standard and expanded criteria deceased donor (ECD) transplants. LPs had a reduction in use of donors with extended cold ischemia time (p = 0.04) and private pay recipients (p = 0.03). Centers without low performance evaluations were more likely to increase the proportion of overall transplants that were ECDs relative to other centers (p = 0.04). Findings indicate a significant association between reduced kidney transplant volume and low performance report card evaluations.     

Dramatic secular changes in prognosis for kidney transplant candidates in the United States

Over recent decades, numerous clinical advances and policy changes have affected outcomes for candidates of kidney transplantation in the United States. We examined the national Scientific Registry for Transplant Recipients for adult (18+) solitary kidney transplant candidates placed on the waiting list for primary listing from 2001 to 2015. We evaluated rates of mortality, transplantation, and waitlist removal. Among 340 115 candidates there were significant declines in mortality (52 deaths/1000 patient years in 2001‐04 vs 38 deaths/1000 patient years in 2012‐15) and transplant rates (304 transplants/1000 patient years in 2001‐04 vs 212 transplants/1000 patient years in 2012‐15) and increases in waitlist removals (15 removals/1000 patient years in 2001‐04 vs 25/1000 patient years in 2012‐15) within the first year after listing. At 5 years an estimated 37% of candidates listed in 2012‐15 were alive without transplant as compared to 22% in 2001‐04. Declines in mortality over time were significantly more pronounced among African Americans, candidates with longer dialysis duration, and those with diabetes (P < .001). Cumulatively, results indicate dramatic changes in prognoses for adult kidney transplant candidates, likely impacted by selection criteria, donor availability, regulatory oversight, and clinical care. These trends are important considerations for prospective policy development and research, clinical and patient decision‐making, and evaluating the impact on access to care.     

Time for reform in transplant program–specific reporting: AST/ASTS transplant metrics taskforce

In accordance with the National Organ Transplant Act and Department of Health and Human Services’ Final Rule, the Scientific Registry of Transplant Recipients (SRTR) publicly releases biannual program‐specific reports that include analyses of transplant centers’ risk‐adjusted waitlist mortality, organ acceptance ratios, transplant rates, and graft and patient survival . Since the inception of these center metrics, 1‐year posttransplant graft and patient survival have improved, and center variation has decreased, casting uncertainty on their clinical relevance. The SRTR has recently modified center evaluations by ranking centers into 5 tiers rather than 3 tiers in an attempt to discriminate between programs performing within a tight range, further exacerbating this uncertainty. The American Society of Transplantation/American Society of Transplant Surgeons convened an expert taskforce to examine both the utility and unintended consequences of transplant center metrics. Estimates of center variation in outcomes in adjacent tiers are imprecise and fleeting, but can result in consequential changes in clinician and center behavior. The taskforce has concerns that current metrics, based principally on 1‐year graft and patient survival, provide minimal if any benefit in informing patient choice and access to transplantation, with the untoward effect of decreased utilization of organs and restriction of research and innovation.     

The Prognostic Value of Kidney Transplant Center Report Cards

SRTR report cards provide the basis for quality measurement of US transplant centers. There is limited data evaluating the prognostic value of report cards, informing whether they are predictive of prospective patient outcomes. Using national SRTR data, we simulated report cards and calculated standardized mortality ratios (SMR) for kidney transplant centers over five distinct eras. We ranked centers based on SMR and evaluated outcomes for patients transplanted the year following reports. Recipients transplanted at the 50th, 100th and 200th ranked centers had 18% (AHR = 1.18, 1.13?1.22), 38% (AHR = 1.38, 1.28?1.49) and 91% (AHR = 1.91, 1.64?2.21) increased hazard for 1‐year mortality relative to recipients at the top‐ranked center. Risks were attenuated but remained significant for long‐term outcomes. Patients transplanted at centers meeting low‐performance criteria in the prior period had 40% (AHR = 1.40, 1.22?1.68) elevated hazard for 1‐year mortality in the prospective period. Centers' SMR from the report card was highly predictive (c‐statistics > 0.77) for prospective center SMRs and there was significant correlation between centers' SMR from the report card period and the year following (ρ = 0.57, p < 0.001). Although results do not mitigate potential biases of report cards for measuring quality, they do indicate strong prognostic value for future outcomes. Findings also highlight that outcomes are associated with center ranking across a continuum rather than solely at performance margins.

     

Expanding clarity or confusion? Volatility of the 5‐tier ratings assessing quality of transplant centers in the United States

Outcomes of patients receiving solid organ transplants in the United States are systematically aggregated into bi‐annual Program‐Specific Reports (PSRs) detailing risk‐adjusted survival by transplant center. Recently, the Scientific Registry of Transplant Recipients (SRTR) issued 5‐tier ratings evaluating centers based on risk‐adjusted 1‐year graft survival. Our primary aim was to examine the reliability of 5‐tier ratings over time. Using 10 consecutive PSRs for adult kidney transplant centers from June 2012 to December 2016 (n = 208), we applied 5‐tier ratings to center outcomes and evaluated ratings over time. From the baseline period (June 2012), 47% of centers had at least a 1‐unit tier change within 6 months, 66% by 1 year, and 94% by 3 years. Similarly, 46% of centers had at least a 2‐unit tier change by 3 years. In comparison, 15% of centers had a change in the traditional 3‐tier rating at 3 years. The 5‐tier ratings at 4 years had minimal association with baseline rating (Kappa 0.07, 95% confidence interval [CI] ‐0.002 to 0.158). Centers had a median of 3 different 5‐tier ratings over the period (q1 = 2, q3 = 4). Findings were consistent for center volume, transplant rate, and baseline 5‐tier rating. Cumulatively, results suggest that 5‐tier ratings are highly volatile, limiting their utility for informing potential stakeholders, particularly transplant candidates given expected waiting times between wait listing and transplantation.     

Inferior Outcomes on the Waiting List in Low‐Volume Pediatric Heart Transplant Centers

Low case volume has been associated with poor outcomes in a wide spectrum of procedures. Our objective was to study the association of low case volume and worse outcomes in pediatric heart transplant centers, taking the novel approach of including waitlist outcomes in the analysis. We studied a cohort of 6482 candidates listed in the Organ Procurement and Transplantation Network for pediatric heart transplantation between 2002 and 2014; 4665 (72%) of the candidates underwent transplantation. Candidates were divided into groups according to the average annual transplantation volume of the listing center during the study period: more than 10, six to 10, three to five, or fewer than three transplantations. We used multivariate Cox regression analysis to identify independent risk factors for waitlist and posttransplantation mortality. Of the 6482 candidates, 24% were listed in low‐volume centers (fewer than three annual transplantations). Of these listed candidates in low‐volume centers, only 36% received a transplant versus 89% in high‐volume centers (more than 10 annual transplantations) (p < 0.001). Listing at a low‐volume center was the most significant risk factor for waitlist death (hazard ratio [HR] 4.5, 95% confidence interval [CI] 3.5–5.7 in multivariate Cox regression and HR 5.6, CI 4.4–7.3 in multivariate competing risk regression) and was significant for posttransplantation death (HR 1.27, 95% CI 1.0–1.6 in multivariate Cox regression). During the study period, one‐fourth of pediatric transplant candidates were listed in low‐volume transplant centers. These children had a limited transplantation rate and a much greater risk of dying while on the waitlist.     

Prominent Impact of Community Risk Factors on Kidney Transplant Candidate Processes and Outcomes

Numerous factors impact patients' health beyond traditional clinical characteristics. We evaluated the association of risk factors in kidney transplant patients' communities with outcomes prior to transplantation. The primary exposure variable was a community risk score (range 0–40) derived from multiple databases and defined by factors including prevalence of comorbidities, access and quality of healthcare, self‐reported physical and mental health and socioeconomic status for each U.S. county. We merged data with the Scientific Registry of Transplant Recipients (SRTR) and utilized risk‐adjusted models to evaluate effects of community risk for adult candidates listed 2004–2010 (n = 209 198). Patients in highest risk communities were associated with increased mortality (adjusted hazard ratio [AHR] = 1.22, 1.16–1.28), decreased likelihood of living donor transplantation (adjusted odds ratio [AOR] = 0.90, 0.85–0.94), increased waitlist removal for health deterioration (AHR = 1.36, 1.22–1.51), decreased likelihood of preemptive listing (AOR = 0.85, 0.81–0.88), increased likelihood of inactive listing (AOR = 1.49, 1.43–1.55) and increased likelihood of listing for expanded criteria donor kidneys (AHR = 1.19, 1.15–1.24). Associations persisted with adjustment for rural–urban location; furthermore the independent effects of rural–urban location were largely eliminated with adjustment for community risk. Average community risk varied widely by region and transplant center (median = 21, range 5–37). Community risks are powerful factors associated with processes of care and outcomes for transplant candidates and may be important considerations for developing effective interventions and measuring quality of care of transplant centers.     

Evaluating the Impact of Performance Improvement Initiatives on Transplant Center Reporting Compliance and Patient Follow‐Up After Living Kidney Donation

With the changing demographics of the living donor population and increased regulatory oversight, it is important that transplant centers report outcomes accurately. The aim of our retrospective cohort study of 312 living donors who underwent nephrectomy between 2008 and 2013 was to evaluate the impact of living donor program performance improvement initiatives on: (i) transplant center program reporting compliance; (ii) patient compliance with postdonation follow‐up and its associated factors; and (iii) overall financial costs to the transplant center. The effect of the initiatives (donation eras 2008–2010 and 2011–2013) on compliance at key reporting points (6 months, 1 year, 2 years) was analyzed using correlation coefficients, χ² and Fisher's exact tests. Multivariable logistic regression models tested the initiatives' effect on the likelihood of patient follow‐up. The initiatives were associated with significant improvement in form reporting compliance (r ≥ 0.862, p ≤ 0.027; 1 and 2 year Fisher's Exact p ≤ 0.002) and patient follow‐up (χ² p ≤ 0.009) with acceptable transplant center costs. Multivariable analyses demonstrated that donation era was consistently and significantly (p < 0.001) associated with increased likelihood of postdonation patient follow‐up. Institution of performance improvement initiatives with dedicated program resources is financially feasible and leads to more accurate and complete form reporting and improved patient follow‐up after nephrectomy.     

Critical Factors Associated With Missing Follow‐Up Data for Living Kidney Donors in the United States

Follow‐up care for living kidney donors is an important responsibility of the transplant community. Prior reports indicate incomplete donor follow‐up information, which may reflect both donor and transplant center factors. New UNOS regulations require reporting of donor follow‐up information by centers for 2 years. We utilized national SRTR data to evaluate donor and center‐level factors associated with completed follow‐up for donors 2008–2012 (n = 30 026) using multivariable hierarchical logistic models. We compared center follow‐up compliance based on current UNOS standards using adjusted and unadjusted models. Complete follow‐up at 6, 12, and 24 months was 67%, 60%, and 50% for clinical and 51%, 40%, and 30% for laboratory data, respectively, but have improved over time. Donor risk factors for missing laboratory data included younger age 18–34 (adjusted odds ratio [AOR] = 2.03, 1.58–2.60), black race (AOR = 1.17, 1.05–1.30), lack of insurance (AOR = 1.25, 1.15–1.36), lower educational attainment (AOR = 1.19, 1.06–1.34), >500 miles to center (AOR = 1.78, 1.60–1.98), and centers performing >40 living donor transplants/year (AOR = 2.20, 1.21–3.98). Risk‐adjustment moderately shifted classification of center compliance with UNOS standards. There is substantial missing donor follow‐up with marked variation by donor characteristics and centers. Although follow‐up has improved over time, targeted efforts are needed for donors with selected characteristics and at centers with higher living donor volume. Adding adjustment for donor factors to policies regulating follow‐up may function to provide more balanced evaluation of center efforts.     

Nonstandard Exception Requests Impact Outcomes for Pediatric Liver Transplant Candidates

Nonstandard exceptions requests (NSERs), in which transplant centers appeal on a case‐by‐case basis for Pediatric End‐Stage Liver Disease/Mayo End‐Stage Liver Disease points, have been highly utilized for pediatric liver transplant candidates. We evaluated whether NSE outcomes are associated with waitlist and posttransplant mortality. United Network for Organ Sharing (UNOS) Scientific Registry of Transplant Recipients data on pediatric liver transplant candidates listed in 2009–2014 were analyzed after excluding those granted automatic UNOS exceptions. Of 2581 pediatric waitlist candidates, 44% had an NSE request. Of the 1134 children with NSERs, 93% were approved and 7% were denied. For children 2–18 years at listing, NSER denial increased the risk of waitlist mortality or removal for being too sick (subhazard ratio 2.99, 95% confidence interval [CI] 1.26–7.07, p = 0.01 in multivariate analysis). For children younger than 2 years, NSER denial did not impact waitlist mortality/removal. Children with NSER approved had reduced risk of graft loss 3 years posttransplant in univariate but not multivariable analysis (odds ratio 0.73, 95% CI 0.53–1.01, p = 06). Those with NSER denial had a higher risk of posttransplant death than those with no NSER (hazard ratio 2.43, 95% CI 0.99–5.95, p = 0.05, multivariable analysis), but NSER approval did not impact posttransplant death. Further research on NSER utilization in pediatric liver transplant is needed to optimize organ allocation and outcomes for children.     

The relative risk of overall graft loss and acute rejection among African American renal transplant recipients is attenuated with advancing age

Schold JD, Srinivas TR, Braun WE, Shoskes DA, Nurko S, Poggio ED. The relative risk of overall graft loss and acute rejection among African American renal transplant recipients is attenuated with advancing age.
Clin Transplant 2011: 25: 721–730. © 2010 John Wiley & Sons A/S. Abstract: Background: Graft loss rates are elevated among African American (AA) kidney transplant recipients. This may be attributable to immunological responses, socioeconomic disparities, comorbid conditions and access to care, but it is unclear whether risks are uniform in the AA population. Methods: We utilized multivariable models with the national SRTR database for adult recipients transplanted from 2000 to 2009 (n = 112 120) to investigate whether risks of graft loss, death and acute rejection between AAs and Caucasians vary with age. Results: Relative to Caucasians, AA recipients had significantly higher risk of overall graft loss among patients aged 18–49 (AHR = 1.37, 95% CI 1.30–1.43) but comparable risk among patients aged >65 (AHR = 1.04, 95% CI 0.96–1.13). Among recipients aged 18–34, AAs had higher risk of acute rejection (AOR = 1.33, 95% CI 1.12–1.57) but similar likelihood among recipients aged >65 (AOR = 0.94, 95% CI 0.75–1.17). Differences between race groups, as well as the relatively higher risks among younger AAs, were most pronounced following one yr post‐transplantation and diminished with presence of other risk factors. Conclusions: Elevated risks of overall graft loss and acute rejection are present among younger but not older AA kidney transplant recipients. These findings may have important implications for treatment decisions, follow‐up protocols and designation of “high‐risk” patients.     

Impact of Cytomegalovirus Disease in D+/R– Kidney Transplant Patients Receiving 6 Months Low‐Dose Valganciclovir Prophylaxis

Late‐onset cytomegalovirus (CMV) disease remains common in CMV serology naïve kidney transplant patients of CMV serology positive organs (D+/R–) despite the use of antiviral prophylaxis. We studied clinical efficacy of 6‐month low‐dose valganciclovir (VGCV) prophylaxis, risk factors for late‐onset CMV disease and its impact on kidney transplant outcomes. Between October 2005 and December 2009, 166 consecutive D+/R– kidney alone and simultaneous pancreas and kidney transplant patients received VGCV 450 mg daily for 6 months after transplantation. After a median follow‐up of 3.2 years, 30 cases of CMV disease occurred within the first 2 years after transplantation with a cumulative incidence of 11.5 and 18.1% at 1 and 2 years, respectively. The use of an induction agent with rabbit antithymocyte globulin and older donor age were factors associated with the risk of late‐onset CMV disease (AHR 2.91, 95% CI 1.18–7.20, p = 0.021 and AHR 1.03, 95% CI 1.01–1.06, p = 0.016, respectively). Late‐onset CMV disease was associated with increased risk for death‐uncensored graft loss (AHR 2.95, 95% CI 1.15–7.61, p = 0.025). In conclusion, late‐onset CMV disease continues to negatively impact kidney transplant outcome despite 6‐month low‐dose VGCV prophylaxis. Investigations focusing on novel preventive approaches should be emphasized.     

The aggressive phenotype: center-level patterns in the utilization of suboptimal kidneys

Despite the fact that suboptimal kidneys have worse outcomes, differences in waiting times and wait-list mortality have led to variations in the use of these kidneys. It is unknown whether aggressive center-level use of one type of suboptimal graft clusters with aggressive use of other types of suboptimal grafts, and what center characteristics are associated with an overall aggressive phenotype. United Network for Organ Sharing (UNOS) data from 2005 to 2009 for adult kidney transplant recipients was aggregated to the center level. An aggressiveness score was assigned to each center based on usage of suboptimal grafts. Deceased-donor transplant volume correlated with aggressiveness in lower volume, but not higher volume centers. Aggressive centers were mostly found in regions 2 and 9. Aggressiveness was associated with wait-list size (RR 1.69, 95% CI 1.20-2.34, p = 0.002), organ shortage (RR 2.30, 95% CI 1.57-3.37, p < 0.001) and waiting times (RR 1.75, 95% CI 1.20-2.57, p = 0.004). No centers in single-center OPOs were classified as aggressive. In cluster analysis, the most aggressive centers were aggressive in all metrics and vice versa; however, centers with intermediate aggressiveness had phenotypic patterns in their usage of suboptimal kidneys. In conclusion, wait-list size, waiting times, geographic region and OPO competition seem to be driving factors in center-level aggressiveness.     

Association of pretransplant and posttransplant program ratings with candidate mortality after listing

The Scientific Registry of Transplant Recipients (SRTR) is responsible for understandable reporting of program metrics, including transplant rate, waitlist mortality, and posttransplant outcomes. SRTR developed five‐tier systems for each metric to improve accessibility for the public. We investigated the associations of the five‐tier assignments at listing with all‐cause candidate mortality after listing, for candidates listed July 12, 2011‐June 16, 2014. Transplant rate evaluations with one additional tier were associated with lower mortality after listing in kidney (hazard ratio [HR], _0.930.95_0.97), liver (HR, _0.870.90_0.92), and heart (HR, _0.920.96_1.00) transplantation. For lung transplant patients, mortality after listing was highest at programs with above‐ and below‐average transplant rates and lowest at programs with average transplant rates, suggesting that aggressive acceptance behavior may not always provide a survival benefit. Waitlist mortality evaluations with one additional tier were associated with lower mortality after listing in kidney (HR, _0.940.96_0.99) transplantation, and posttransplant graft survival evaluations with one additional tier were associated with lower mortality after listing in lung (HR, _0.900.94_0.98) transplantation. Transplant rate typically had the strongest association with mortality after listing, but the strength of associations differed by organ.     

Geographic disparities in donor lung supply and lung transplant waitlist outcomes: A cohort study

Despite the Final Rule mandate for equitable organ allocation in the United States, geographic disparities exist in donor lung allocation, with the majority of donor lungs being allocated locally to lower‐priority candidates. We conducted a retrospective cohort study of 19 622 lung transplant candidates waitlisted between 2006 and 2015. We used multivariable adjusted competing risk survival models to examine the relationship between local lung availability and waitlist outcomes. The primary outcome was a composite of death and removal from the waitlist for clinical deterioration. Waitlist candidates in the lowest quartile of local lung availability had an 84% increased risk of death or removal compared with candidates in the highest (subdistribution hazard ratio [SHR]: 1.84, 95% confidence interval [CI]: 1.51‐2.24, P < .001). The transplantation rate was 57% lower in the lowest quartile compared with the highest (SHR: 0.43, 95% CI: 0.39‐0.47). The adjusted death or removal rate decreased by 11% with a 50% increase in local lung availability (SHR: 0.89, 95% CI: 0.85‐0.93, P < .001) and the adjusted transplantation rate increased by 19% (SHR: 1.19, 95% CI: 1.17‐1.22, P < .001). There are geographically disparate waitlist outcomes in the current lung allocation system. Candidates listed in areas of low local lung availability have worse waitlist outcomes.     

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

Every 6 months, the Scientific Registry of Transplant Recipients (SRTR) publishes evaluations of every solid organ transplant program in the United States, including evaluations of 1‐year patient and graft survival. The Centers for Medicare & Medicaid Services (CMS) and the Organ Procurement and Transplantation Network (OPTN) Membership and Professional Standards Committee (MPSC) use SRTR's 1‐year evaluations for regulatory review of transplant programs. Concern has been growing that the regulatory scrutiny of transplant programs with lower‐than‐expected outcomes is harmful, causing programs to undertake fewer high‐risk transplants and leading to unnecessary organ discards. As a result, CMS raised its threshold for a “Condition‐Level Deficiency” designation of observed relative to expected 1‐year graft or patient survival from 1.50 to 1.85. Exceeding this threshold in the current SRTR outcomes report and in one of the four previous reports leads to scrutiny that may result in loss of Medicare funding. For its part, OPTN is reviewing a proposal from the MPSC to also change its performance criteria thresholds for program review, to review programs with “substantive clinical differences.” We review the details and implications of these changes in transplant program oversight.     

Center‐Level Experience and Kidney Transplant Outcomes in HIV‐Infected Recipients

Excellent outcomes among HIV+ kidney transplant (KT) recipients have been reported by the NIH consortium, but it is unclear if experience with HIV+ KT is required to achieve these outcomes. We studied associations between experience measures and outcomes in 499 HIV+ recipients (SRTR data 2004–2011). Experience measures examined included: (1) center‐level participation in the NIH consortium; (2) KT experiential learning curve; and (3) transplant era (2004–2007 vs. 2008–2011). There was no difference in outcomes among centers early in their experience (first 5 HIV+ KT) compared to centers having performed > 6 HIV+ KT (GS adjusted hazard ratio [aHR]: 1.05, 95% CI: 0.68–1.61, p = 0.82; PS aHR: 0.93; 95% CI: 0.56–1.53, p = 0.76), and participation in the NIH‐study was not associated with any better outcomes (GS aHR: 1.08, 95% CI: 0.71–1.65, p = 0.71; PS aHR: 1.13; 95% CI: 0.68–1.89, p = 0.63). Transplant era was strongly associated with outcomes; HIV+ KTs performed in 2008–2011 had 38% lower risk of graft loss (aHR: 0.62; 95% CI: 0.42–0.92, p = 0.02) and 41% lower risk of death (aHR: 0.59; 95% CI: 0.39–0.90, p = 0.01) than that in 2004–2007. Outcomes after HIV+ KT have improved over time, but center‐level experience or consortium participation is not necessary to achieve excellent outcomes, supporting continued expansion of HIV+ KT in the US.     

Hospital readmissions following HLA‐incompatible live donor kidney transplantation: A multi‐center study

Thirty percent of kidney transplant recipients are readmitted in the first month posttransplantation. Those with donor‐specific antibody requiring desensitization and incompatible live donor kidney transplantation (ILDKT) constitute a unique subpopulation that might be at higher readmission risk. Drawing on a 22‐center cohort, 379 ILDKTs with Medicare primary insurance were matched to compatible transplant‐matched controls and to waitlist‐only matched controls on panel reactive antibody, age, blood group, renal replacement time, prior kidney transplantation, race, gender, diabetes, and transplant date/waitlisting date. Readmission risk was determined using multilevel, mixed‐effects Poisson regression. In the first month, ILDKTs had a 1.28‐fold higher readmission risk than compatible controls (95% confidence interval [CI] 1.13‐1.46; P < .001). Risk peaked at 6‐12 months (relative risk [RR] 1.67, 95% CI 1.49‐1.87; P < .001), attenuating by 24‐36 months (RR 1.24, 95% CI 1.10‐1.40; P < .001). ILDKTs had a 5.86‐fold higher readmission risk (95% CI 4.96‐6.92; P < .001) in the first month compared to waitlist‐only controls. At 12‐24 (RR 0.85, 95% CI 0.77‐0.95; P = .002) and 24‐36 months (RR 0.74, 95% CI 0.66‐0.84; P < .001), ILDKTs had a lower risk than waitlist‐only controls. These findings of ILDKTs having a higher readmission risk than compatible controls, but a lower readmission risk after the first year than waitlist‐only controls should be considered in regulatory/payment schemas and planning clinical care.     

Regional Variation in Survival Before and After Pediatric Heart Transplantation—An Analysis of The UNOS Database

Geographic variation occurs in a variety of health outcomes. Regional influences on outcomes before and after listing for pediatric heart transplantation have not been assessed. Review of the UNOS dataset identified 5398 pediatric (≤18 years) patients listed for heart transplantation 2000–2011. Patients were stratified based on the region of listing. Regional‐level variables were correlated with individual risk‐adjusted outcomes. Mean time spent on the waitlist varied from 91.0 ± 163 days (Region 6 [R6]) to 248.1 ± 493 days (R4, p < 0.0001). Regions with more transplant centers (p < 0.0001) and fewer transplants (p = 0.0015) had higher waitlist mortality. Risk‐adjusted individual waitlist mortality varied from 6.9% (R1, CI 6.2–7.8) to 19.2% (R5, CI 18.0–20.6). Waitlist mortality was higher for individuals awaiting transplant in regions with more listings per center (OR 1.04, CI 1.01–1.08) and lower in regions with more donors per center (OR 0.95, CI 0.90–0.99 per donor). Posttransplant risk‐adjusted survival varied across regions (R4: 5.4%, CI 4.2–7.4; R7: 18.0%, CI 12.4–32.5), but regional variables were not correlated with outcomes. Outcomes among children undergoing heart transplantation vary by region. Factors leading to increased competition for donor allografts are associated with poorer waitlist survival. Equitable allocation of cardiac allografts requires further investigation of these findings.     

Kidney offer acceptance at programs undergoing a Systems Improvement Agreement

In the United States, the Centers for Medicare and Medicaid Services (CMS) use Systems Improvement Agreements (SIAs) to require transplant programs repeatedly flagged for poor‐performance to improve performance or lose CMS funding for transplants. We identified 14 kidney transplant (KT) programs with SIAs and 28 KT programs without SIAs matched on waitlist volume and characterized kidney acceptance using SRTR data from 12/2006‐3/2015. We used difference‐in‐differences linear regression models to identify changes in acceptance associated with an SIA independent of program variation and trends prior to the SIA. SIA programs accepted 26.9% and 22.1% of offers pre‐ and post‐SIA, while non‐SIA programs accepted 33.9% and 44.4% of offers in matched time periods. After adjustment for donor characteristics, time‐varying waitlist volume, and secular trends, SIAs were associated with a 5.9 percentage‐point (22%) decrease in kidney acceptance (95% CI: ?10.9 to ?0.8, P = .03). The decrease in acceptance post‐SIA was more pronounced for KDPI 0‐40 kidneys (12.3 percentage‐point decrease, P = .007); reductions in acceptance of higher KDPI kidneys occurred pre‐SIA. Programs undergoing SIAs substantially reduced acceptance of kidney offers for waitlisted candidates. Attempts to improve posttransplant outcomes might have the unintended consequence of reducing access to transplantation as programs adopt more restrictive organ selection practices.