Appropriate One-Year Outcomes for Measuring Success in Organ Transplantation
The American Society of Transplantation would like to call your attention to an emerging needing in our country: determining appropriate one-year outcomes for measuring success in organ transplantation.
Why Is This a Problem?
The current metrics used for measuring transplant program performance are not appropriate in the modern era. There have been significant advances in the field over the past two decades such that the average one-year survival for solid organ transplant recipients exceeds 90%. As transplant centers are compared to each other on a normative reference, many centers are now identified as underperforming based on very modest differences (e.g. <2%) in patient survival. This occurs in a context in which transplantation is a life-saving intervention, with no alternative therapy for many patients and an approximate doubling of life expectancy for patients with kidney failure relative to maintenance dialysis.
Does This Impact the Number of People who Receive a Life Saving Organ Transplant?
Yes. The current metrics have been shown to influence listing practices at transplant hospitals and potentially inhibit innovation that will expand the field and promote scientific advancement. Transplant hospitals have become more risk averse based on these metrics with concerns about (1) treating patients who are considered relatively at higher risk for survival; or (2) accepting organs for transplantation that are noted as carrying increased risk for disease transmission[i] based on potential repercussions from regulatory bodies such as the Organ Procurement and Transplantation Network (OPTN) or Center for Medicare and Medicaid Services (CMS). Importantly, transplantation remains the optimal treatment even among transplant candidates at higher risk for death. There is significant concern that quality oversight is dis-incentivizing the use of life saving donor organs to facilitate transplantation. Many transplant centers are now placed in a difficult circumstance, where providing the optimal treatment option for patients with end-stage organ disease may place programs at higher risk for punitive regulatory consequences.
How Can We Solve This Problem?
Quality oversight is a necessary and important component of healthcare delivery. However, the metrics used to evaluate quality in the field of transplantation have significant impact on practice and must evolve to reflect advances in the field. These metrics should be applicable to assess performance of transplant centers in the current era and most importantly directly align with what is in the best interest of the patient population. There is compelling need to coordinate efforts among regulatory agencies that adjudicate the quality of transplant programs to modify current metrics and promote the life-saving treatment of transplantation.
Approved by the AST Executive Committee on April 4, 2017
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[i] U.S. Public Health Service Guideline for Reducing Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Transmission Through Organ Donation. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3675207/