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HomeNewsLittle Variation in Outcomes Across US Liver Transplant Programs

Little Variation in Outcomes Across US Liver Transplant Programs

NEW YORK (Reuters Health) – An analysis of data from U.S. adult liver-transplant programs found little variation in graft and patient survival rates but significantly more variation in two other domains of quality: waiting list mortality and use of marginal grafts.

Only two programs (1.8%) were in the top quartile for all three measures while four programs (3.6%) were in the bottom quartile on all three measures.

“The small number of centers identified in this study as high performers across all three domains represent an opportunity for the field of transplantation to learn from their outcomes, identify best practices, and eventually disseminate new strategies for quality improvement throughout the country and world,” write Dr. Craig S. Brown and colleagues of the University of Michigan, in Ann Arbor, in JAMA Network Open.

Their retrospective study included 114 U.S. liver-transplant programs that performed more than 44,000 transplants (minimum 10 per year) between 2014 and 2019, with data analyzed from March 2 to August 13, 2020.

The study team measured recipient outcomes using patient and graft survival at one-year and generated proxy measures for waiting-list management quality and program aggressiveness.

For waiting list management, they used one-year waiting list death rates for each individual program. For program aggressiveness, they calculated the rate of marginal-graft use per 100 transplant episodes, which included the use of any graft from a donor older than 65 years, with BMI greater than 40, or who died from a cardiac cause.

The average one-year graft and patient survival for the programs was 90% and ranged from 76% to 97%. The average wait list death rate was 16.7 per 100 person-years and ranged from 6.3 to 53.0 deaths per 100 person-years. The average rate of marginal-graft use was 15.8 donors per 100 transplants (range, 0 to 49.3).

There was no correlation between one-year graft and patient survival and wait list mortality or marginal-graft use after correcting for average allocation Model for End Stage Liver Disease-Sodium scores.

The researchers note that discussions of transplant-program quality often focus on recipient outcomes, namely one-year graft and patient survival. Yet, they found that this measure does not substantially vary across programs, suggesting that this measure is “unable to meaningfully discriminate low-performing from high-performing programs.”

The other two measures (wait list mortality rate and marginal-graft-use rate) were “significantly more variable across programs and allowed for a greater ability to distinguish performance levels between institutions.” Data for these two measures are already collected and would be easy to implement broadly, they point out.

The authors of an editorial say this study is “notable and impactful” for several reasons.

The finding that one-year survival rates across programs are high with little variation will be reassuring to patients and physicians, write Dr. Shimul A. Shah of the University of Cincinnati College of Medicine, in Ohio, and coauthors.

The lack of association between a programs’ marginal-graft-use rate and their one-year survival outcomes “implies that we may be able to continue to encourage marginal graft utilization without experiencing a decrease in patient survival,” they point out.

They say the authors should be congratulated “for providing transplant professionals with a deeper understanding of the multiple domains of quality in liver transplantation, how they interact, and their lack of association with one-year patient and/or graft survival rates.”

“Their work can be used as a springboard to further the development of pretransplant, and even prelisting, quality metrics for patients with end-stage liver disease. In addition, this study highlights the need for further research into the underlying mechanisms that affect center-level listing practices, waiting list dynamics, and the decision-making process surrounding the usability of marginal grafts,” Dr. Shah and colleagues conclude.

SOURCE: https://bit.ly/2VHLgwp and https://bit.ly/3yG1Xac JAMA Network Open, online August 9, 2021.

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