title: Utility of Ecological Risk Factors for Evaluation of Transplant Center Performance.
abstract: There is substantial evidence across different healthcare contexts that social determinants of health are strongly associated with morbidity and mortality in the United States. These factors, including socioeconomic status, behavior and environmental risks, education, social support, healthy food, and access to healthcare also vary widely by region and individual communities. One of the implications of heterogeneity in these risks is the potential impact on measured quality of healthcare providers. In particular, there is concern that providers treating disproportionally vulnerable communities may be disadvantaged by lack of risk adjustment for these factors that affect health but not indicators of quality of care. Recently, the National Quality Forum has endorsed risk adjustment for sociodemographic characteristics based on these concerns. These issues are salient to transplant programs since social determinants of health impact transplant patient outcomes and vary by region. In this viewpoint, we argue that integration of ecological (area-level) factors in risk adjustment models used to assess transplant center quality should be strongly considered. We believe this reform could be accomplished rapidly, would attenuate disparities in access to care by reducing disincentives to treat patients from vulnerable communities, and improve risk adjustment and calibration of models used for center evaluations.
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: Department of Emergency Medicine, Cleveland Clinic, Cleveland, OH.
authors.forename: M P
authors.initials: MP
authors.lastname: Phelan
authors.affiliation: Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.|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
mesh_terms: D006801:Humans; D016377:Organ Transplantation / Q000706:statistics & numerical data*; D010043:Outcome and Process Assessment, Health Care; D011379:Prognosis; D015397:Program Evaluation; D012042:Registries; D018570:Risk Assessment; D012923:Social Class; D009927:Tissue and Organ Procurement; D014481:United States
keywords: Scientific Registry for Transplant Recipients (SRTR); disparities; editorial/personal viewpoint; health services and outcomes research; income; organ transplantation in general; risk assessment/risk stratification; social sciences; statistics