14 Jan Transplant Rate – A new metric to worry about?
By: Koren Fay
For years now, the transplant world has been focused on early outcomes. We can all recite our center’s 1-year and 3-year graft and patient survival O/E by heart. This is important because CMS, UNOS and the insurance payors used it as an important metric for assessing how well we were caring for our patients. And not doing well on these metrics could result in the loss of payor contracts, site visits, SIA’s and even closure. Most importantly, it gave us valuable information about how our patients were doing after transplant.
Recently, payers and CMS have shifted their attention to pre-transplant metrics and specifically to Transplant Rate. While this metric has been reported on the PSRs for a long time, several things have changed. First, the SRTR has been developing revised (and more accurate) ways to calculate this rate. This alone has raised its profile. Second, and more importantly, CMS, UNOS, and the insurance payors have begun to include transplant rate on their assessment of center performance. Some payors are now weighing it heavily in their Centers of Excellence (COE) distinctions. Third, it is now very easy to compare center rates. The new SRTR website allows patients, providers, and payors to sort centers in their region by transplant rate. If you are a patient, you may choose to trade off a small reduction in post-transplant outcome for a center that doubles your likelihood of transplant. Therefore, like it or not, your center has to pay attention to it.
So, what can your center do to improve your transplant rate? The transplant rate is calculated by considering the number of patients on the program’s waiting list at any time during a one-year period. The number of days each patient was on the waiting list during that period is then totaled. Next, the number of patients who were removed from the list because they underwent transplant at the program are determined (transplants at a different program are not counted). The number of transplants performed at the program is then divided by the total number of days the patients were on the waiting list. Then this number is standardized to a rate per 100 patient-years. Two things are important here: first, this is the prior year, not the standard 2.5 year cohort, and second, all patients active or inactive on the list are included.
If I lost you in that explanation, here’s an example of the calculation:
- Number of patients on the waiting list: 340
- Number of days waiting on the list for these patients in that one year period: 93,500
- Number of patients transplanted at that center during the one year period: 31
- Rate per one patient day: 31/93,500 = .0003315
- Standardized to 100 patient years: 31 patients x (365.25 days/year) x (100 years)/(93,500 days)
- Transplant rate = 12.1
Reviewing the transplant rate calculation and factors, you can see you have two numbers you can affect. The first, and most obvious is the number of transplants. If the center in our example had done 35 transplants instead of 31, their transplant rate would be 13.7. And 4 more transplants in a year equates to 1 additional transplant every three months or a 13% increase. The problem is, we all know how hard that can be to achieve. With deceased donors in short supply and living donation decreasing, the ability to simply “do more transplants” is not always a viable option. Maybe if you became a little more aggressive in your acceptance of marginal organs, you could add a couple of transplants per year. You have to be careful that your team does not let post-transplant survival suffer in the name of volume. Unfortunately, the ability to do more transplants is also a function of organ supply, patient characteristics, and local competition. It is always important to try to transplant everyone you can, but this is not the only answer.
The other number that you can affect, and you do have direct control over, is number of patient-days on the waiting list. Again, this number is calculated using total number of days on the list – not active days. And you do have control over the number of inactive days a patient spends on the list. Let’s look at the example again. This time the center reduces the number of inactive patients on the waiting list from 50% to 40%, reducing the days on the list by 9,350…. and now their transplant rate is 13.5.
Every center has those patients who have been inactive more than they have been active, for varied reasons including medical, insurance, and compliance. Removing patients who will never be transplanted (the high BMI patients who have not lost weight, the cancer patients who are on dialysis but not yet 5 years out, the chronically inactive patient for infections and re-admissions) is vital. In this example, a 10% reduction in the list accomplished by removing these patients generates enough days to increase the transplant rate to 13.5. More importantly, this reduction of inactive patients helps every year, unlike the 4 additional transplants, which only helps in the year it occurs. And with this reduction in inactive patients, your coordinators can focus on the many patients in evaluation, move them through the process faster, and add these active patients to your waiting list.
We all know it is hard to remove a patient from the list. But remember, kidney patients won’t lose their waiting time if they are removed (as long as they were not added prior to starting dialysis). If they lose weight or complete the dental work, they can be added back to the list and their time will go back to the start of their dialysis. Some physicians worry that removing a patient will dishearten them or cause them to give up. Sometimes being removed from the list – or at least the threat of being removed – will motivate the non-compliant patient. And being upfront with the patient and their referring provider about what they need to do in order to be added back to the waiting list will help them in getting well enough to be transplanted. It is better to be honest with patients about their real chances of being transplanted, than to leave them status 7 with the false hope that they will one day get the call.
I am not arguing that this is an easy process, or that it will make the committee “feel good.” But transplant centers had to make tough decisions when their outcomes were starting to go in the wrong direction. Keeping patients on the list that your center will never realistically transplant is not fair either to the patient or to the center. These are the tough decisions that need to be made for the good of the patient and the program. Clearly, take all of the organs that your team can safely transplant, encourage patients to do what it takes to become active, and focus on the positive. However, for the patients that need to be removed, do it with compassion, transparency, with the interests of the patient in mind and as a team. This is important, because your Transplant Rate can become a metric to highlight and celebrate.