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 jonathan.chen@seattlechildrens.org

Regional representative name (RA will complete) Region X Representative email address

Sharon Shepherd Committee Liaisonsharon.shepherd@unos.org

Questions?