Implementing pre-transplant performance review by the
Membership and Professional Standards Committee
Membership & Professional Standards CommitteeFall 2014
Performance review includes only post-transplant performance and functional inactivity
Unbalanced review of transplant programs
Previous high profile incidences of waiting list mismanagement
The Problem
Need tool to identify and review programs that need pre-transplant performance improvement
Areas to monitor: Acceptance of deceased donor organ offers Transplantation of patients on the waiting list Mitigation of waiting list mortality
Goal of the Proposal
Use composite pre-transplant metric (CPM) that includes: Waiting list mortality rates (liver programs) Geography-adjusted transplant rates Organ offer acceptance rates
Safety net metric based on waiting list mortality
Identify outlier programs that may need pre-transplant performance review
Balanced program performance review
How the Proposal will Achieve its Goal
July 2009 - CPM concept initially presented to MPSC
CPM work group
December 2011 - pilot and survey
Presentations/Discussions American Transplant Congress Transplant Management Forum PSR Consensus Conference
Long Term Effort
Incorporate acceptance rates but temper impact
No single metric fully represents pre-transplant performance
Mitigates effect of geography
Identifies programs needing improvement that would not be identified by single metric
Summary statistic to prioritize MPSC resources
Composite Metric?
Using acceptance rates alone
Using transplant rates alone
Using independent acceptance, transplant, and mortality rate thresholds
Life Years from Listing (LYFL)
CUSUM –potential complementary tool to CPM in the future
Alternative Approaches Considered
Weighting the CPM sub-components
Accounting for varying sample sizes among programs
Adjusting for geography (supply-to-demand)
Including both living and deceased donor transplants
Including both active and inactive patients
Choosing a threshold for identifying programs
Use of a “safety net”
Other Key Decision Points
Review transplant program based on pre-transplant performance if the program meets either of the following criteria over a 1-year period: CPM >1.5 waiting list mortality rate O/E ratio > 2.0 and one-sided p-
value < 0.05
At first, only liver and kidney programs
In an example analysis, 14 programs were newly identified for review
Thresholds for Identification
Supporting Evidence
Based on 2011 data, 6 (5%) liver programs had CPM above 1.5.
Supporting Evidence (cont’d)
Based on 2011 data, 16 (7%) kidney programs had CPM above 1.5.
Supporting Evidence (cont’d)
“Safety net”: 3 kidney and 2 liver programs had statistically significant waitlist mortality O/E > 2.0.
Supporting Evidence (cont’d)
The two high profile cases of waitlist mismanagement from the mid-2000’s had outlying CPM values.
Program 1 Program 2
No additional data submission for CPM analysis
Respond to inquiry from MPSC if identified for review. Will request information on: waiting list management process any unique clinical aspects (i.e., potential mitigating
factors) that may influence ability to meet the thresholds
What Members will Need to Do
Age Blood type History of cancer BUN Death circum. Insulin administered Antihypertensive admin. Liver biopsy & % macro fat PHS increased risk Proteinuria SGP/ALT Location & distance
Liver Acceptance Rate Model
Lab MELD Match MELD & status Serum sodium Albumin Dialysis past week HCC exception Previous malignancy Height Time on waitlist other factors…
Candidate factors Donor factors SGP/ALT HTLV EBV
Jonathan Chen, M.D. Committee Chair [email protected]
Regional representative name (RA will complete) Region X Representative email address
Sharon Shepherd Committee [email protected]
Questions?