Abstract
US liver transplant programs have traditionally been evaluated on 1-year patient and graft survival. However, there is concern that a narrow focus on recipient outcomes may not incentivize programs to improve in other ways that would benefit patients with end-stage liver disease. To determine the correlation among different potential domains of quality for adult liver transplant programs. This retrospective cohort study was conducted from 2014 to 2019 among adult liver transplant programs included in the United Network for Organ Sharing and Scientific Registry of Transplant Recipients program-specific reports. Liver transplant programs in the United States completing at least 10 liver transplants per year were included. Data were analyzed from March 2 to August 13, 2020. The potential domains of quality examined included recipient outcomes (1-year graft and patient survival), aggressiveness (ie, marginal graft use, defined as the rate of use of donors with body mass index [calculated as weight in kilograms divided by height in meters squared] greater than 40, age older than 65 years, or deceased by cardiac death), and waiting list management (ie, waiting list mortality). The correlation among measures, aggregated at the center level, was evaluated using linear regression to control for mean Model for End Stage Liver Disease-Sodium score at organ allocation. The extent to which programs were able to achieve high quality across multiple domains was also evaluated. Among 114 transplant programs that performed a total of 44 554 transplants, the mean (SD) 1-year graft and patient survival was 90.3% (3.0%) with a total range of 75.9% to 96.6%. The mean (SD) waiting list mortality rate was 16.7 (6.1) deaths per 100 person-years, with a total range of 6.3 to 53.0 deaths per 100 person years. The mean (SD) marginal graft use rate was 15.8 (8.8) donors per 100 transplants, with a total range of 0 to 49.3 donors. There was no correlation between 1-year graft and patient survival and waiting list mortality (β = -0.053; P = .19) or marginal graft use (β = -0.007; P = .84) after correcting for mean allocation Model for End Stage Liver Disease-Sodium scores. There were 2 transplant programs (1.8%) that performed in the top quartile on all 3 measures, while 4 transplant programs (3.6%) performed in the bottom quartile on all 3 measures. This cohort study found that among US liver transplant programs, there were no correlations among 1-year recipient outcomes, measures of program aggressiveness, or waiting list management. These findings suggest that a program's performance in one domain may be independent and unrelated to its performance on others and that the understanding of factors contributing to these domains is incomplete.
Highlights
Since 1991 the United Network for Organ Sharing (UNOS) and the Scientific Registry of Transplant Recipients (SRTR) have been required to publish regular reports on program-specific survival rates for all solid organ transplants performed in the United States.1 While this has increased the regulatory pressure on transplant programs, it has been associated with improvements in outcomes
There was no correlation between 1-year graft and patient survival and waiting list mortality (β = −0.053; P = .19) or marginal graft use (β = −0.007; P = .84) after correcting for mean allocation Model for End Stage Liver Disease–Sodium scores
There were 2 transplant programs (1.8%) that performed in the top quartile on all 3 measures, while 4 transplant programs (3.6%) performed in the bottom quartile on all 3 measures. This cohort study found that among US liver transplant programs, there were no correlations among 1-year recipient outcomes, measures of program aggressiveness, or waiting list management
Summary
Since 1991 the United Network for Organ Sharing (UNOS) and the Scientific Registry of Transplant Recipients (SRTR) have been required to publish regular reports on program-specific survival rates for all solid organ transplants performed in the United States. While this has increased the regulatory pressure on transplant programs, it has been associated with improvements in outcomes. Since 1991 the United Network for Organ Sharing (UNOS) and the Scientific Registry of Transplant Recipients (SRTR) have been required to publish regular reports on program-specific survival rates for all solid organ transplants performed in the United States.. Since 1991 the United Network for Organ Sharing (UNOS) and the Scientific Registry of Transplant Recipients (SRTR) have been required to publish regular reports on program-specific survival rates for all solid organ transplants performed in the United States.1 While this has increased the regulatory pressure on transplant programs, it has been associated with improvements in outcomes. 1-year graft and patient survival rates do not vary much, with 95% of programs rating within 7% of the mean in 2020, a statistic that has not changed substantially over the last 30 years.2 This may make it difficult to identify the best and worst performing programs and limit how much can be learned from each for the purpose of quality improvement. Little is known about the correlation between potential domains of quality among liver transplant programs
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