The Attenuation of National Kidney Volume is Strongly Associated with

Center Performance Evaluations

Jesse D. Schold, PhD, John Fung, MD, PhD, Laura Buccini, PhDTransplant Center

Cleveland Clinic, Cleveland, Ohio

Introduction

• In the United States, there has been an unprecedented attenuation of the growth of kidney transplantation

• The stagnation in national kidney transplant volume may have multiple etiologies but is of clear concern to prospective transplant recipients and caregivers

• One source of this limited growth in volume may be associated with increased emphases on regulatory oversight of center performance

• We hypothesized that centers with low performance evaluations may have become more conservative and limited transplant growth in the current era.

2007 Conditions of Participation

Methods

• We evaluated data directly from archived SRTR performance reports from 2007 through 2009

• We compared the change in transplant volume for each kidney transplant center in the US over the study period relative to the incidence of low performance evaluation

• In addition, we evaluated changes in recipient and donor characteristics between centers based on receipt of a low performance evaluation

• We then tested the association between changes in kidney transplant volume with incidence of low performance evaluations

1/2007 7/2007 1/2008 7/2008 1/2009 7/2009

Program-Specific Report (PSR) PeriodsSpecific Aims:

- Evaluate the difference in patient characteristics between centers that did or did not have at least one low performance evaluation between 2007 and 2009

- Test for changes in recipient characteristics from the baseline cohort to the end cohort within centers with and without at least one low performance evaluation between 2007 and 2009

- Test for changes in overall transplant volume from the baseline cohort to the end cohort between centers with and without at least one low performance evaluation between 2007 and 2009

- Test for changes in transplant volume from the baseline cohort to the end cohort by type of transplants (standard criteria, expanded criteria and living donor) between centers with and without at least one low performance evaluation between 2007 and 2009

Baseline Cohort

January, 2007 PSR (transplants 1/2004 – 6/2006)*

End Cohort

January, 2010 PSR (transplants 1/2007 – 6/2009)

* Study excludes centers with < 10 transplants in January, 2007 PSR

Study Design / Aims

Transplant Characteristics Centers with Low Performance Evaluation between 2007-2009

p-value

No (n=157)* Yes (n=46)*Recipient age >= 65 (%) 14% 13% 0.22

Donor age >= 60 (%) 7% 7% 0.54

Living donor recipient (%) 36% 33% 0.17

SCD transplant (%) 53% 56% 0.08

ECD transplant (%) 11% 10% 0.48

Caucasian recipient (%) 54% 55% 0.78

African American recipient (%) 24% 25% 0.73

Other race recipient (%) 22% 20% 0.57

Diabetes as primary diagnosis (%) 24% 23% 0.23

Re-transplant recipient (%) 11% 13% 0.01

PRA >= 10% (%) 32% 31% 0.74

CIT >= 24 hours (%) 21% 23% 0.46

Recipient pre-transplant dialysis time >= 36 months (%) 37% 35% 0.36

Recipient BMI >= 30 (%) 30% 30% 0.96

Recipient college education or more (%) 22% 21% 0.24

Donor race African American (%) 12% 13% 0.51

Recipient private primary insurance (%) 37% 35% 0.47

Recipient Medicare as primary insurance 55% 60% 0.05

Recipient Medicaid as primary insurance 6% 5% 0.41

Female recipient (%) 39% 39% 0.88

Study Population

Number of Program-Specific Reports with a One-Year Low Performance Evaluation (out of six consecutive cohorts)

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

0 1 2 3 4 5 6

N=203 Centersn=157

n=11n=13

n=10 n=5 n=2 n=5

Prop

ortio

n of

Adu

lt Ki

dney

Tra

nspl

ant C

ente

rs

12% of Centers with 1-2 Low Performance Evaluations between 2007-2009

11% of Centers with 3-6 Low Performance Evaluations between 2007-2009

Distribution of Flagged Centers

Center Volume for Jan, 2007 Program-Specific

Report (transplants performed 1/2004-

6/2006)

Number of Centers with Lower than Expected One-Year Survival during the Study PeriodNone Graft

Survival Only

Patient Survival Only

Both Graft and Patient Survival

Either Graft or Patient Survival

All Centers

10-79 35(74%)

4(9%)

3(6%)

5(11%)

12(26%)

47

80-139 35(71%)

8(16%)

0(0%)

6(12%)

14(29%)

49

140-226 47(91%)

5(9%)

1(2%)

0(0%)

6(11%)

53

227-709 40(74%)

3(6%)

3(6%)

8(15%)

14(26%)

54

All Centers n(%) 157 (77%)

20 (10%)

7 (3%)

19 (9%)

46 (23%)

203

Distribution of Flagging by Center Volume

-40

-30

-20

-10

0

10

20

Centers without Low Performance

(n=163)

Low Performance

Centers(n=39)

Chan

ge in

Vol

ume

bet

wee

n 1/

2007

and

1/

2010

PSR

Coh

orts

Overall Graft Survival Patient Survival

p=0.0002 p=0.002 p=0.001

Either Graft or Patient Survival

Low Performance

Centers(n=26)

Low Performance

Centers(n=46)

Centers without Low Performance

(n=176)

Centers without Low Performance

(n=157)

Change in Kidney Volume by Performance

Centers without Low Performance Evaluations

Centers with Low Performance Evaluations

-3.7

-14.7

+10.3

-3.1

+3.9

-4.7

-20

-15

-10

-5

0

5

10

15

Aver

age

Cent

er C

hang

e in

Tra

nspl

ant V

olum

e:

Janu

ary

2007

to Ja

nuar

y 20

10 C

ohor

ts

Living Donor TransplantsStandard Criteria Donor

TransplantsExpanded Criteria Donor

Transplants

Centers without Low Performance Evaluations

Centers with Low Performance Evaluations

p=0.01*

p=0.02*p=0.001*

Change in Kidney Volume by Performance by Transplant Type

Change in Transplant Characteristics by Center Performance

Summary and Conclusions

• There is a significant association between changes in transplant volume and receipt of low performance evaluations for US kidney transplant centers

• Results may suggest that centers that receive low performance evaluations react by reducing their transplant volume and changing selection criteria of donors and candidates

• This change may or may not improve measured performance but may be a significant source of the lack of transplant growth in the United States