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What are PSRs doing for your center?

A challenge of serving as your President is the constant whir of changing responsibilities. Last week, the NEJM article and “immuno” legislation. This week, I will be representing AST as workgroup chair in a Consensus Conference on Transplant Program Quality and Surveillance, sponsored by SRTR. This is being held in Washington, DC, with a primary focus on addressing the Program Specific Reports (PSRs). Basically, since creation a few years ago by SRTR, with availability to the public at www.srtr.org, PSRs have become very controversial. If their purpose is primarily to facilitate transplant center quality improvement, how else are they to be utilized? By whom? Are the proper metrics applied? The consensus conference promises some very heated discussions that hopefully can impact what the entire country will see over the next 6-12 months.

Are the PSRs serving their original purpose? How could they be made better for centers? For patients?

Any other thoughts?

Robert S. Gaston


Insurance companies appear to be using the PSR's for contracting purposes and decisions about Centers of Excellence. This was not the intent of the reports and they should not be used in this fashion. The transplant rate is a problem for kidney transplant because this is very dependent on how the waitlist is managed.

Again, you are correct, and some data indicate that good waiting list management is linked to good posttransplant outcomes. The PSRs are indeed used by industry to categorize and monitor centers; however, third party payers are a major stakeholder in the transplant process. Any interest in having them support the data collection and analysis? Any way that could be done without compromising the integrity of the data?

I agree that PSR's are great for what they are intended to be- a tool to allow programs to compare themselves to national norms. Unfortunately they are being used to judge "quality". It is so intuitive that if program A gets better adjusted survival than program B then they are "better." This ignores a major threat to our patients, namely death on the waiting list. From a patient point of view it does not matter if they die waiting or at the time of the transplant. An intent to treat analysis from the time of listing would provide more relevant information, from a patient point of view. However, even this isn't necessarily a perfect measure of "quality" since it can also reflect organ availability given that allocation is still primarily local, and recipient selection. The Transplant community should work to develop more appropriate quality standards.

Obviously, I am more familiar with kidney, and outcomes on the waiting list, as you note, are very important, and underappreciated as a metric. I get the feeling that is about to change. At least 2 papers by Jesse Schold and colleagues emphasize the importance of looking not just at graft and patient survival after transplantation, but before as well, and that the two are linked. This issue (outcomes from referral and listing) should get some attention at this conference.

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