One-year Mortality after Lung Transplant is Not a Reliable Indicator of Lung Transplant Center Performance

Abstract

<h3>Purpose</h3> Measuring performance in lung transplantation (LTx) is complex, but in the United States the most common performance indicator is one-year mortality. This indicator is shared with centers in quarterly reports and is used by the United Network for Organ Sharing (UNOS) to identify programs for review and trigger penalties including loss of accreditation. Reliability adjustment, a novel technique for quantifying and removing statistical "noise" from quality rankings, is becoming more widely used outside surgery. We sought to evaluate the reliability of 1-year mortality outcomes in LTx. <h3>Methods</h3> We used the Standard Transplant Analysis and Research (STAR) files form UNOS to identify LTx recipients from 2013-2018 in the United States. We first used standard risk adjustment methods to estimate expected 1-year mortality rates at the hospital level. We then examined the effect of adjusting for reliability using empirical Bayes techniques. <h3>Results</h3> We identified 12,769 recipients in 69 centers over the study period. Reliability adjustment greatly diminished apparent variation in hospital outcomes. For risk-adjusted 1-year mortality, there was a large range (range 0 to 89%), which decreased to a 2.5-fold difference (6 to 15%) after reliability adjustment. Reliability adjustment had a large impact on hospital mortality rankings. For example, with rankings based on mortality, 22% (4 hospitals) of the "best" hospitals (top 25%) were reclassified after reliability adjustment . Similarly, 18% (3 hospitals) of the "worst" hospitals (bottom 25%) were reclassified after reliability adjustment. The overall reliability of 1-year mortality was 0.42. <h3>Conclusion</h3> Conclusions: The reliability of 1-year mortality benchmarking in lung transplantation is low. Accounting for reliability yields more accurate measures of LTx center performance.