title: Association between kidney transplant center performance and the survival benefit of transplantation versus dialysis.
abstract: OBJECTIVE
  Despite the benefits of kidney transplantation, the total number of transplants performed in the United States has stagnated since 2006. Transplant center quality metrics have been associated with a decline in transplant volume among low-performing centers. There are concerns that regulatory oversight may lead to risk aversion and lack of transplantation growth.
  
  
  METHODS
  A retrospective cohort study of adults (age≥18 years) wait-listed for kidney transplantation in the United States from 2003 to 2010 using the Scientific Registry of Transplant Recipients was conducted. The primary aim was to investigate whether measured center performance modifies the survival benefit of transplantation versus dialysis. Center performance was on the basis of the most recent Scientific Registry of Transplant Recipients evaluation at the time that patients were placed on the waiting list. The primary outcome was the time-dependent adjusted hazard ratio of death compared with remaining on the transplant waiting list.
  
  
  RESULTS
  Among 223,808 waitlisted patients, 59,199 and 32,764 patients received a deceased or living donor transplant, respectively. Median follow-up from listing was 43 months (25th percentile=25 months, 75th percentile=67 months), and there were 43,951 total patient deaths. Deceased donor transplantation was independently associated with lower mortality at each center performance level compared with remaining on the waiting list; adjusted hazard ratio was 0.24 (95% confidence interval, 0.21 to 0.27) among 11,972 patients listed at high-performing centers, adjusted hazard ratio was 0.32 (95% confidence interval, 0.31 to 0.33) among 203,797 patients listed at centers performing as expected, and adjusted hazard ratio was 0.40 (95% confidence interval, 0.35 to 0.45) among 8039 patients listed at low-performing centers. The survival benefit was significantly different by center performance (P value for interaction <0.001).
  
  
  CONCLUSIONS
  Findings indicate that measured center performance modifies the survival benefit of kidney transplantation, but the benefit of transplantation remains highly significant even at centers with low measured quality. Policies that concurrently emphasize improved center performance with access to transplantation should be prioritized to improve ESRD population outcomes.
authors.affiliation: Department of Quantitative Health Sciences, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; and Center for Reducing Health Disparities, MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio scholdj@ccf.org.
authors.forename: Jesse D
authors.initials: JD
authors.lastname: Schold
authors.affiliation: Department of Quantitative Health Sciences, Digestive Disease Institute, and.
authors.forename: Laura D
authors.initials: LD
authors.lastname: Buccini
authors.affiliation: Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio;
authors.forename: David A
authors.initials: DA
authors.lastname: Goldfarb
authors.affiliation: Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio;
authors.forename: Stuart M
authors.initials: SM
authors.lastname: Flechner
authors.affiliation: Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio;
authors.forename: Emilio D
authors.initials: ED
authors.lastname: Poggio
authors.affiliation: Center for Reducing Health Disparities, MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio.
authors.forename: Ashwini R
authors.initials: AR
authors.lastname: Sehgal
mesh_terms: D000328:Adult; D005260:Female; D054625:Healthcare Disparities / Q000592:standards; D061847:Hospitals, High-Volume / Q000592:standards; D061846:Hospitals, Low-Volume / Q000592:standards; D006801:Humans; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D016030:Kidney Transplantation / Q000009:adverse effects / Q000401:mortality / Q000592:standards; D019520:Living Donors / Q000600:supply & distribution; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000592:standards; D016016:Proportional Hazards Models; D019984:Quality Indicators, Health Care / Q000592:standards; D012042:Registries; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality / Q000592:standards; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014850:Waiting Lists / Q000401:mortality
keywords: ESRD; outcomes; renal transplantation; survival