Realizing the Promise of Equity in the Organ Transplantation System (2022) / Chapter Skim
Currently Skimming:
7 Measuring and Improving System Performance
7 Measuring and Improving System Performance
Pages 199-224
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 199... ...
website is an extraordinary national resource with extensive, publicly available data collected from transplant centers, organ procurement organizations (OPOs) , and immunology laboratories on current and past organ donors, transplant candidates, transplant recipients, and transplant outcomes.1 1 Scientific Registry of Transplant Recipients website: www.srtr.org (accessed November 2, 2021)
|
From page 200... ...
. Out of all the organs, kidney transplantation has the most measures, and many of the metrics focus specifically on single organ transplant.
|
From page 201... ...
Dashboard of Standardized Performance Metrics for the U.S. Organ Transplantation System As described earlier in this report, there is an opportunity to move away from the current focus on a single metric, such as 1-year-graft survival for transplant centers or donation rates for OPOs, and move toward an interrelated and integrated approach to measurement and performance.
|
From page 202... ...
The committee's recommended dashboard should also minimize measurement burden by drawing on existing work, such as the OPTN metrics dashboard and access to transplant dashboard.3 The OPTN Membership and Professional Standards Committee has proposed four new metrics for evaluating transplant center performance. Two pretransplant measures for transplant centers are the rate of pretransplant deaths and the ratio of organ offers made to and accepted for candidates, as well as two posttransplant metrics of 90-day graft survival and 1-year graft survival conditional to the 90-day period.
|
From page 203... ...
Figure 7-1 contains the committee's suggestions for the elements of the proposed standardized performance metrics for transplant centers to be included in the dashboard. FIGURE 7-1 Recommended measurement elements for referring organizations, transplant centers, donor hospitals, and OPOs.
|
From page 204... ...
The committee envisioned that the standardized performance metrics could be used first as quality improvement tools and, if successful, in quality improvement efforts, then the metrics can be used as standards of performance with regulatory implications. Audiences and users of the dashboard include individual organizations (e.g., donor hospitals, OPOs, referring organizations, and transplant centers)
|
From page 205... ...
There is a need to reduce variations in the performance of donor hospitals, OPOs, and transplant centers in order to increase equity, efficiency, usefulness, reliability, pre dictability, and trustworthiness of the transplantation system. Creating standardized, consensus-based metrics to compare performance of donor hospitals, OPOs, and transplant centers needs to be a priority for HHS and the OPTN.
|
From page 206... ...
• Create a publicly available dashboard of standardized metrics to provide a com plete human-centered picture of the patient experience -- from patient referral for transplant evaluation, time on the waiting list, to posttransplant quality of life -- managed by the SRTR or a similar entity. QUALITY IMPROVEMENT IN ORGAN DONATION AND TRANSPLANTATION Over the last 30 years principles of quality improvement (QI)
|
From page 207... ...
Fortunately, strategies to support active dissemination and use of complex changes have been well documented in health care settings. The strategies combine principles from quality improvement, network management, social psychology, and logistics, and apply them to large-scale change efforts.
|
From page 208... ...
However, building on the success of OPO improvement initiatives, the participation of transplant centers in similar initiatives could lead to comparable improvement in the U.S. organ transplantation system.
|
From page 209... ...
A campaign could be used effectively in the organ transplantation system if, for instance, high leverage and well-understood interventions from the Organ Donation Breakthrough Collaborative can be distilled with an aim to spread their use further or increase uptake of their use. Similarly, a campaign could take straightforward practices that result in successful organ transplant waiting list management in some regions and spread them to regions that
|
From page 210... ...
When planned and timed well, mandates, policies, and regulations can have a significant effect. Conclusion 7-3: The committee concludes widespread variation in practices and performance among donor hospitals, OPOs, referring organizations, and transplant centers shows there is a need to support and expand the use of proven systemwide quality improvement methods used in other areas of health care and that have suc cessfully been used in the past to improve organ donation.
|
From page 211... ...
• Explore additional tools and approaches for promoting innovation in the organ transplantation system, including the following: ° Launch a nationwide learning process improvement collaborative to address deceased organ donors, waiting list management, the acceptance of offered organs, transplant rate, and automated organ referrals. ° Encourage preapproved controlled experiments by OPOs and transplant centers to allow experimentation with innovation and the development of evidence to support widespread adoption of best practices.
|
From page 212... ...
As discussed in previous chapters, CMS also sets conditions for coverage for OPOs and conditions of participation for transplant programs and donor hospitals -- setting requirements that must be met for OPOs, transplant programs, and donor hospitals to receive Medicare and Medicaid payment. CMS requests that dialysis centers inform new patients of their transplant options, which can potentially lead to referral for transplant evaluation before dialysis even begins (Waterman et al., 2015)
|
From page 213... ...
The learning system includes model participants and other stakeholders such as transplant centers, OPOs, and large donor hospitals, and uses learning and QI techniques to systematically spread the best practices of the highest performers (CMS, 2019b)
|
From page 214... ...
Opportunities to Align Reimbursement Incentives In considering opportunities to improve alignment of reimbursement incentives for stakeholders in the organ transplantation system, the committee explored the following areas: • Referrals for transplant evaluation; • Reimbursement to transplant centers for transplanting medically complex organs and caring for patients who receive these transplants; • Intensive waiting list management; • Enhanced communication and education with patients on the waiting list; • Medical care and support for waiting list patients, including those with complex needs; and • Innovative technology to maximize organ use. The remainder of this chapter discusses these opportunities for improved alignment, reflects on differing viewpoints within the committee regarding the appropriate role of financial incentives in changing behaviors, and ends with the committee's recommendations for aligning reimbursement and programs with desired outcomes and behaviors (Recommendation 14)
|
From page 215... ...
. Intensive Waiting List Management Optimizing transplant waiting list management is critical for maintaining candidacy of kidney transplant recipients and effectively managing the waiting list as organs become available.
|
From page 216... ...
. Improving waiting list management requires more clarity about waiting list inactivity prior to kidney transplantation, which is known to affect clinical outcomes.
|
From page 217... ...
. A study evaluating the association between comorbidity and waiting list mortality among frail and nonfrail kidney transplantation candidates found that nonfrail candidates with high comorbidity burdens at kidney transplant evaluation have increased risk of waiting list mortality (Fernández et al., 2019)
|
From page 218... ...
Under this reasoning, quality improvement efforts and the sharing of best practices across transplant centers, rather than increased payments, are the right way to increase the number of organs used and the diversity of patients successfully transplanted. In the end, the committee agreed on the following conclusions and recommendation: Conclusion 7-6: This report presents a number of conclusions and recommenda tions that aim to provide more transplants more fairly, such as by making better use of donated organs; by increasing the number of organs obtained and the propor tion treated to improve their suitability for transplantation; by broadening the pool of patients who are referred, evaluated, and listed for a transplant; and by better management of patients on the waiting list.
|
From page 219... ...
• Sustain and expand current work in the End-Stage Renal Disease program to ° refer more eligible patients for transplant, ° help referred patients to get both evaluated and listed by transplant centers, ° assist patients in fully understanding and engaging with transplant centers when organs that are offered are declined on their behalf, and ° work with Congress to update and increase the existing and outdated dialy sis withholding payment to fund ESRD quality improvement activities. • Sustain and expand model tests and other payment policies to increase reimburse ment for nephrologists and dialysis centers to educate and refer patients for trans plant evaluation.
|
From page 220... ...
• Incentivize OPOs and transplant centers to learn from the organizations and cen ters that already make extensive use of medically complex organs, and actively work to spread the practices for obtaining and transplanting these organs have proven to be most successful and cost effective. • Within the next 2 years, the CMS Innovation Center should design and implement one or more model tests to assess the effects of additional increased payments to address the added costs of rehabilitating and using more organs that are medically complex and increasing equitable access to a broader pool of patients.
|
From page 221... ...
2012. Disparities in provision of transplant information affect access to kidney transplantation.
|
From page 222... ...
2014. Mak ing house calls increases living donor inquiries and evaluations for blacks on the kidney transplant waiting list.
|
From page 223... ...
2011. The effects of two health education models on psychological and nutritional profile of patients waiting for kidney transplantation.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.