title: Association of Candidate Removals From the Kidney Transplant Waiting List and Center Performance Oversight.
abstract: Approximately 59 000 kidney transplant candidates have been removed from the waiting list since 2000 for reasons other than transplantation, death, or transfers. Prior studies indicate that low-performance (LP) center evaluations by the Scientific Registry of Transplant Recipients (SRTR) are associated with reductions in transplant volume. There is limited information to determine whether performance oversight impacts waitlist management. We used national SRTR data to evaluate outcomes of 315 796 candidates on the kidney transplant waiting list (2007-2014). Compared to centers without LP, rates of waitlist removal (WLR) were higher at centers with LP evaluations (44.6/1000 follow-up years, 95% confidence interval [CI] 44.0, 45.1 versus 68.0/1000 follow-up years, 95% CI 66.6, 69.4), respectively, which was consistent after risk adjustment (adjusted hazard ratio [AHR] = 1.59, 95% CI 1.55, 1.63). Candidate mortality following waitlist removal was lower at LP centers (AHR = 0.90, 95% CI 0.87, 0.94). Analyses limited to LP centers indicated a significant increase in WLR (+28.6 removals/1000 follow-up years, p < 0.001), a decrease in transplant rates (-11.9/1000 follow-up years, p < 0.001) and a decrease in mortality after removal (-67.5 deaths/1000 follow-up years, p < 0.001) following LP evaluation. There is a significant association between LP evaluations and transplant center processes of care for waitlisted candidates. Further understanding is needed to determine the impact of performance oversight on transplant center quality of care and patient outcomes.
authors.affiliation: Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.|Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.
authors.forename: J D
authors.initials: JD
authors.lastname: Schold
authors.affiliation: Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.|Digestive Disease Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: L D
authors.initials: LD
authors.lastname: Buccini
authors.affiliation: Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.|Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: E D
authors.initials: ED
authors.lastname: Poggio
authors.affiliation: Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.|Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: S M
authors.initials: SM
authors.lastname: Flechner
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: D A
authors.initials: DA
authors.lastname: Goldfarb
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007676:Kidney Failure, Chronic / Q000601:surgery*; D016030:Kidney Transplantation / Q000592:standards* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000592:standards*; D018579:Patient Selection; D011379:Prognosis; D015397:Program Evaluation; D019984:Quality Indicators, Health Care / Q000592:standards*; D013531:Surgicenters / Q000592:standards* / Q000706:statistics & numerical data*; D066027:Transplant Recipients; D014850:Waiting Lists; D055815:Young Adult
keywords: ethics and public policy; health services and outcomes research