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Membership & Professional Standards Committee Fall 2014

Implementing pre-transplant performance review by the Membership and Professional Standards Committee. Membership & Professional Standards Committee Fall 2014. The Problem. Performance review includes only post-transplant performance and functional inactivity

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Membership & Professional Standards Committee Fall 2014

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  1. Implementing pre-transplant performance review by the Membership and Professional Standards Committee Membership & Professional Standards Committee Fall 2014

  2. The Problem • Performance review includes only post-transplant performance and functional inactivity • Unbalanced review of transplant programs • Previous high profile incidences of waiting list mismanagement

  3. Goal of the Proposal • 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

  4. How the Proposal will Achieve its Goal • 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

  5. Long Term Effort • 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

  6. Composite Metric? • 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

  7. Alternative Approaches Considered • 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

  8. Other Key Decision Points • 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”

  9. Thresholds for Identification • 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

  10. Supporting Evidence Based on 2011 data, 6 (5%) liver programs had CPM above 1.5.

  11. Supporting Evidence (cont’d) Based on 2011 data, 16 (7%) kidney programs had CPM above 1.5.

  12. Supporting Evidence (cont’d) “Safety net”: 3 kidney and 2 liver programs had statistically significant waitlist mortality O/E > 2.0.

  13. Supporting Evidence (cont’d) Program 2 Program 1 The two high profile cases of waitlist mismanagement from the mid-2000’s had outlying CPM values.

  14. What Members will Need to Do • 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

  15. Liver Acceptance Rate Model Donor factors Candidate factors • 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 • SGP/ALT • HTLV • EBV • Lab MELD • Match MELD & status • Serum sodium • Albumin • Dialysis past week • HCC exception • Previous malignancy • Height • Time on waitlist • other factors…

  16. Questions? • 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

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