The association of candidate mortality rates with kidney transplant outcomes and center performance evaluations

Timely access to transplantation for eligible patients with end-stage renal disease (ESRD) is critical. However, pressures exist to improve efficiencies in transplantation and to achieve high center performance ratings, including the recently submitted "Final Rule" by Center for Medicare and Medicaid Services. This policy may affect the availability of public funding for as many as 10% of kidney transplant centers in the United States. This study examined adult solitary kidney transplant candidates from 1995 to 2005 using a national database. Mortality rates were calculated for candidates at individual centers prior to transplantation. Posttransplant survival and center's standardized mortality ratios were then calculated and compared to rates of candidate mortality. Candidate mortality rates varied substantially across centers (highest quartile with almost 2-fold elevated mortality). Recipients at centers with the highest candidate mortality rates had approximately 1.9 years reduced median graft survival for deceased donor transplants and decreased patient survival even after risk adjustment (adjusted hazard ratio=1.33, 95% confidence interval 1.25-1.41). This association was greater among living transplants (adjusted hazard ratio=1.49, 95% confidence interval 1.31-1.70). For 1-year outcomes, 19% (43/224) of centers met criteria for low performance for either graft loss or patient death in living or deceased donor transplants. Of these, 51% were among centers with the highest candidate mortality as compared to 7% of centers with the lowest candidate mortality. The health status of centers' transplant candidate pool is a significant determinant of outcomes and performance ratings. Centers with a higher risk candidate pool are significantly more likely to be identified for poor performance and could potentially lose public funding. Pressures to enhance outcomes may lead centers to exclude high-risk but otherwise viable transplant candidates.