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Invited Commentary
August 9, 2021

The Opportunity for Impactful Policy Change in Liver Transplantation—Expanding Our Definition of Quality

Author Affiliations
  • 1Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
  • 2Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
JAMA Netw Open. 2021;4(8):e2119336. doi:10.1001/jamanetworkopen.2021.19336

The Department of Health and Human Services Final Rule mandates the public release of biannual program-specific reports on waiting list mortality, waiting list dynamics, organ acceptance ratios, transplant rates, and risk-adjusted 1-year graft and patient survival.1,2 These reports are a pillar of transparency for a community that relies on public donation, trust, and fairness in allocation. However, concerns regarding the validity of the publicly reported short-term outcome metrics and their association with quality have come to the forefront.3,4 Furthermore, the sole reliance on 1-year survival outcomes for transplant center oversight and punitive measures has been associated with the unintended consequence of decreasing access to transplantation.5

Brown and colleagues, in their novel analysis “Associations Among Different Domains of Quality Among US Liver Transplant Programs,”6 describe the association, or lack thereof, between program specific rates of 1-year patient and graft survival, waiting list mortality, and marginal graft utilization in liver transplantation.6 This investigation merged program-identified donor and recipient characteristics from the United Network for Organ Sharing (UNOS) database with the Scientific Registry of Transplant Recipients (SRTR) survival and waiting list data. They were able to identify 114 liver transplant programs that met inclusion criteria and evaluated high- and low-performing programs by stratifying each quality domain into quartiles.

Contrary to their hypothesis, they found no association at the program level between 1-year survival rates, waiting list mortality, or center aggressiveness. These findings suggest that a program’s performance in one domain may be unrelated to its performance in others. Furthermore, they found that most programs achieved higher quality in 1 or 2 domains but rarely in all 3 domains concurrently. These findings continue to call into question the validity of our sole reliance on 1-year survival outcomes for punitive measures, which may not truly identify low-quality programs with any specificity.

Their study is notable and impactful for 4 specific implications. First, Brown et al6 found that nationwide 1-year patient and graft survival rates are not only high (mean [SD], 90.3% [3.0%]) but variation is quite low. Liver transplant surgeons, physicians, and patients should be reassured that high-quality survival outcomes can be achieved across the country with minimal variability. Second, the lack of association between a programs’ marginal graft utilization rate and their 1-year survival outcomes implies that we may be able to continue to encourage marginal graft utilization without experiencing a decrease in patient survival. Third, as Brown et al6 suggest, policy interventions to improve program performance in waiting list management or center-level aggressiveness may not have deleterious associations with a center’s performance in 1-year survival. Lastly, they provide further evidence that the transplant community should continue to search for targeted, regionally based, flexible metrics that focus on rewarding and disseminating best practices rather than punishing poor performance.

We congratulate Brown and colleagues6 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 1-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. In summary, Brown et al6 describe a highly reliable transplant system that provides transplant practitioners with the opportunity to focus on improving our understanding of waiting list management, center aggressiveness, and the development of targeted metrics for quality improvement and dissemination of best practices.

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Article Information

Published: August 9, 2021. doi:10.1001/jamanetworkopen.2021.19336

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Delman AM et al. JAMA Network Open.

Corresponding Author: Shimul A. Shah, MD, MHCM, Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Solid Organ Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Medical Science Building, 231 Albert Sabin Way, PO Box 670558, Cincinnati, OH 45267-0558 (shahsu@ucmail.uc.edu).

Conflict of Interest Disclosures: None reported.

Centers for Medicare & Medicaid Services (CMS).  Medicare program; hospital conditions of participation: requirements for approval and re-approval of transplant centers to perform organ transplants: final rule.   Fed Regist. 2007;72(61):15197-15280.PubMedGoogle Scholar
Chandraker  A, Andreoni  KA, Gaston  RS,  et al; AST/ASTS Transplant Metrics Taskforce.  Time for reform in transplant program-specific reporting: AST/ASTS transplant metrics taskforce.   Am J Transplant. 2019;19(7):1888-1895. doi:10.1111/ajt.15394PubMedGoogle Scholar
Buccini  LD, Schold  JD.  Considerations of reliability and validity of transplant center report cards.   Am J Transplant. 2014;14(1):239-240. doi:10.1111/ajt.12548PubMedGoogle ScholarCrossref
Jay  C, Schold  JD.  Measuring transplant center performance: the goals are not controversial but the methods and consequences can be.   Curr Transplant Rep. 2017;4(1):52-58. doi:10.1007/s40472-017-0138-9PubMedGoogle ScholarCrossref
Roberts  JP.  Impact of outcomes monitoring on innovation and risk in liver transplantation.   Liver Transpl. 2012;18(suppl 2):S59-S63. doi:10.1002/lt.23539PubMedGoogle ScholarCrossref
Brown  CS, Waits  SA, Englesbe  MJ, Sonnenday  CJ, Sheetz  KH.  Associations among different domains of quality among US liver transplant programs.   JAMA Netw Open. 2021;4(8):e2118502. doi:10.1001/jamanetworkopen.2021.18502Google Scholar
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