Insights from High-Performing Heart Transplant Centers across the Recipient Risk-Spectrum

Abstract

Purpose Heart transplant (HT) centers with superior short-term (90 day) survival of recipients maintain performance advantage over other centers for long-term survival. However, signature characteristics of high-performing centers have not been adequately analyzed. We stratified US centers by 90-day performance and compared them for mortality across recipient risk-spectrum, ability to rescue from early renal failure and cause-specific mortality during the first 90 post-HT days. Methods We analyzed 25467 HT recipients >18 yrs. old at 96 US centers during 2000-2014 (UNOS data). We developed and validated a risk-model for 90-day mortality using baseline characteristics of all recipients and yr. of HT. We used the model to estimate the risk of 90-day mortality for each recipient, expected 90-day mortality for each center and 90-day standardized mortality ratio (SMR, observed divided by expected mortality, lower SMR in high-performing centers) for each center, stratifying centers into SMR quintiles. Results SMR was 0.23 to 0.69, 0.70 to 0.91, 0.92 to 1.13, 1.14 to 1.42 and 1.43 to 2.66, respectively among SMR 1-5 centers. The difference between observed vs. expected mortality at low vs. high SMR centers increased progressively in higher risk recipients (Figure). Post-HT dialysis was required in 7.8, 8.1, 8.3, 9.0 and 13.4 % recipients, respectively among SMR 1-5 centers (P for trend Conclusion High performing HT centers have superior outcomes in higher risk recipients, lower incidence of early post-HT renal failure, higher renal rescue rate and lower cause-specific mortality from all causes. These findings suggest superior systems of care and/or expertise in managing higher risk recipients at such centers