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Center variation in intention to treat survival among patients listed for liver transplant.

Center variation in intention to treat survival among patients listed for liver transplant. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society Kwong, A. J., Flores, A., Saracino, G., Boutte, J., McKenna, G., Giuliano, T., Bahirwani, R., Wall, A., Kim, W. R., Klintmalm, G., Trotter, J. F., Asrani, S. K. 2020

Abstract

BACKGROUND & AIMS: Currently liver transplant (LT) centers are evaluated by patient survival within 1 year after LT, but tight clustering of outcomes allow only a narrow window for evaluation of center variation for quality improvement. Alternate measures more relevant to patients and the transplant community are needed.APPROACH & RESULTS: We examined adults listed for LT in the United States, using data submitted to Scientific Registry of Transplant Recipients. Intention to treat (ITT) survival was defined as survival within 1 year from listing, regardless of transplant. Mixed effects/frailty models were used to assess center variation in ITT survival. Between 1/2010 and 12/2016, there were 66,428 new listings at 113 centers. Overall, median 1-year ITT survival was 79.8% (IQR 76.1-83.4), while 1-year WL survival was 75.8% (IQR 71.2-79.4), and 1-year post-LT survival was 90.0% (IQR 87.9-91.8). Higher rates of ITT mortality were correlated with increased WL mortality (correlation, r=0.76), increased post-LT mortality (r=0.31), lower volume centers (r=-0.34), and lower transplant rate ratio (r=-0.25). Similar patterns were observed in the subgroup of WL candidates listed with MELD =25: median 1-year ITT survival was 65.2% (IQR 60.2-72.6), while 1-year post-LT survival was 87.5% (IQR 84.0-90.9), and 1-year WL survival was 36.6% (IQR 27.9-47.0). In mixed effects modeling, center was an independent predictor of ITT survival even after adjustment for age, sex, MELD, and sociodemographic variables. Center variation for ITT survival was larger compared to post-LT survival.CONCLUSIONS: Measurement of ITT outcome offers a complementary method to assess center performance. This is a first step toward understanding differences in program quality beyond patient and graft survival after LT.

View details for DOI 10.1002/lt.25852

View details for PubMedID 32725923