Association between Kidney Transplant Center Performance and the Survival Benefit of Transplantation Versus Dialysis

Abstract

Background and objectives Despite the benefits of kidney transplantation, the total number of transplants performed in the United States has stagnated since 2006. Transplant center quality metrics have been associated with a decline in transplant volume among low-performing centers. There are concerns that regulatory oversight may lead to risk aversion and lack of transplantation growth.Design, setting, participants, & measurements A retrospective cohort study of adults (age$18 years) wait-listed for kidney transplantation in the United States from 2003 to 2010 using the Scientific Registry of Transplant Recipients was conducted. The primary aim was to investigate whether measured center performance modifies the survival benefit of transplantation versus dialysis. Center performance was on the basis of the most recent Scientific Registry of Transplant Recipients evaluation at the time that patients were placed on the waiting list. The primary outcome was the time-dependent adjusted hazard ratio of death compared with remaining on the transplant waiting list.Results Among 223,808 waitlisted patients, 59,199 and 32,764 patients received a deceased or living donor transplant, respectively. Median follow-up from listing was 43 months (25th percentile=25 months, 75th percentile=67 months), and there were 43,951 total patient deaths. Deceased donor transplantation was independently associated with lower mortality at each center performance level compared with remaining on the waiting list; adjusted hazard ratio was 0.24 (95% confidence interval, 0.21 to 0.27) among 11,972 patients listed at high-performing centers, adjusted hazard ratio was 0.32 (95% confidence interval, 0.31 to 0.33) among 203,797 patients listed at centers performing as expected, and adjusted hazard ratio was 0.40 (95% confidence interval, 0.35 to 0.45) among 8039 patients listed at low-performing centers. The survival benefit was significantly different by center performance (P value for interaction ,0.001).Conclusions Findings indicate that measured center performance modifies the survival benefit of kidney transplantation, but the benefit of transplantation remains highly significant even at centers with low measured quality. Policies that concurrently emphasize improved center performance with access to transplantation should be prioritized to improve ESRD population outcomes.

Dialysis vintage and outcomes in renal transplantation

“…X X X " " " " SB, LTB, IB USA Schold [15] X X X " SB, LTB, IB USA Abramowicz et al [8] X X " but <12 months versus pre-emptive-no effects…”

Might the Current Gauge of Transplant Center Quality Result in Reducing Patient Access via Diminished Organ Utilization?

“…It is our opinion that Schold et al have actually substantiated the contentions of the CMS that lowerperforming centers produce inferior graft survival outcomes (6). One could argue that shifting volume to high-performing centers may actually lead to an overall reduction in organ need because retransplantation rates might decrease.…”

“…As a result, we have become victims of our own success, leading to an increased disparity between donor organ supply and demand. In this issue of CJASN, Schold et al make the argument that the aforementioned disparity was a driving force to increase organ utilization (6). Increasingly challenged, marginal, or so-called extended criteria donor organs were being utilized in an attempt to increase organ access to those active on the national deceased-donor wait list.…”

“…This was intended to provide a framework to improve quality outcomes of transplant centers by identifying potential deficiencies, which has led to improvement efforts (8). Schold et al argue that government attempts to rate transplant centers are the reason for declining organ utilization especially among the "lower performers" because centers that have been put on alert will radically change their protocols and become risk averse in an attempt to survive even at the compromise of reducing volume (6). The authors make a cogent argument that even the lowest performing centers still save lives versus persistent dialysis and the focus of government efforts should be to improve overall transplant access and not attempt to cull transplant centers in a punitive fashion.…”

“…Concomitant changes in public safety measures such as implementation and enforcement of helmet laws, speed/traffic/seat belt laws, lowering legal alcohol levels, and so forth have consequently lowered traumatically derived organ availability. The article by Schold et al (6) does not provide a "denominator" to prove that actual available organ utilization has been reduced versus an absolute reduction in available organs for the aforementioned reasons.…”