Quality control of transplant centers, and the choice of who to transplant (and which organs to accept)

Transplant centers are regulated by measures such as their one-year graft-survival rate, so they feel pressure not to transplant patients, or organs, that have too high a risk to meet the required measure of success.

Here's a recent paper from the Journal of the American College of Surgeons that discusses some of the consequences:

Decade-Long Trends in Liver Transplant Waitlist Removal Due to Illness Severity: The Impact of Centers for Medicare and Medicaid Services Policy

Presented at the 96th Annual Meeting of the New England Surgical Society, Newport, RI, September 2015.

Natasha H. Dolgin, PhDPress enter key for correspondence informationPress enter key to Email the author

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Babak Movahedi, MD, PhD

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Paulo N.A. Martins, MD, PhD

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Robert Goldberg, PhD

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Kate L. Lapane, PhD, MS

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Frederick A. Anderson, PhD

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Adel Bozorgzadeh, MD, FACS

DOI: http://dx.doi.org/10.1016/j.jamcollsurg.2016.03.021

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Article Info

• Abstract

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Background

The central tenet of liver transplant organ allocation is to prioritize the sickest patients first. However, a 2007 Centers for Medicare and Medicaid Services regulatory policy, Conditions of Participation (COP), which mandates publically reported transplant center performance assessment and outcomes-based auditing, critically altered waitlist management and clinical decision making. We examine the extent to which COP implementation is associated with increased removal of the “sickest” patients from the liver transplant waitlist.

Study Design

This study included 90,765 adult (aged 18 years and older) deceased donor liver transplant candidates listed at 102 transplant centers from April 2002 through December 2012 (Scientific Registry of Transplant Recipients). We quantified the effect of COP implementation on trends in waitlist removal due to illness severity and 1-year post-transplant mortality using interrupted time series segmented Poisson regression analysis.

Results

We observed increasing trends in delisting due to illness severity in the setting of comparable demographic and clinical characteristics. Delisting abruptly increased by 16% at the time of COP implementation, and likelihood of being delisted continued to increase by 3% per quarter thereafter, without attenuation (p < 0.001). Results remained consistent after stratifying on key variables (ie, Model for End-Stage Liver Disease and age). The COP did not significantly impact 1-year post-transplant mortality (p = 0.38).

Conclusions

Although the 2007 Centers for Medicare and Medicaid Services COP policy was a quality initiative designed to improve patient outcomes, in reality, it failed to show beneficial effects in the liver transplant population. Patients who could potentially benefit from transplantation are increasingly being denied this lifesaving procedure while transplant mortality rates remain unaffected. Policy makers and clinicians should strive to balance candidate and recipient needs from a population-benefit perspective when designing performance metrics and during clinical decision making for patients on the waitlist.

It drew this headline in the news:
Hospitals are throwing out organs and denying transplants to meet federal standards