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The relation between experience and outcome in heart transplantation
G L Laffel1, A I Barnett, S Finkelstein
1Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115.
Insights
Heart transplant center experience significantly impacts patient survival. Early transplants at a center had higher mortality, but experienced teams, particularly cardiologists, improved outcomes.
Area of Science:
- Cardiology
- Transplantation Medicine
- Health Policy
Background:
- Current organ transplantation policies in the US prioritize experienced centers and physicians.
- These policies may inadvertently restrict patient access to transplantation services.
- Validating these policies is crucial for equitable healthcare access.
Purpose of the Study:
- To investigate the relationship between heart transplantation experience and patient mortality.
- To assess the impact of institutional and team experience on heart transplant outcomes.
Main Methods:
- Data from 1123 heart transplant recipients at 56 US hospitals (1984-1986) were analyzed.
- Merged data from the International Society for Heart and Lung Transplantation registry and a supplemental survey.
- Statistical analyses included univariate, bivariate, and logistic regression techniques.
Main Results:
- A significant learning curve was observed: the first five transplants at a center had higher mortality (20%) than later ones (12%, P=0.002).
- New centers with cardiologists previously trained in heart transplantation showed lower mortality (7%) compared to those without (16%, P=0.001).
- Surgeon experience did not correlate with transplant mortality rates.
Conclusions:
- Heart transplantation experience is directly associated with improved patient outcomes.
- Transplantation policies can be refined based on center and team experience.
- Similar experience-based policies may benefit other organ transplantation programs.
Background:
Current policies related to organ transplantation in the United States are designed to ensure that centers and physicians with experience in transplantation perform these procedures. It is essential to confirm the validity of such policies, since they may limit access to transplantation services.
Methods:
To determine the relation between experience with heart transplantation and mortality after the procedure, we merged data from the registry of the International Society for Heart and Lung Transplantation with data from a survey that provided additional information about patients and transplantation centers. Our study included 1123 patients who received a heart transplant at one of 56 hospitals in the United States from 1984 through 1986. We used univariate and bivariate techniques, as well as logistic regression, to analyze our data.
Results:
We observed an institutional learning curve for heart transplantation. Patients who received one of a center's first five transplants had higher mortality rates than patients who received a subsequent transplant (20 percent vs. 12 percent; P = 0.002; relative risk = 2.2; 95 percent confidence interval, 1.6 to 3.4). In addition, we found a correlation between the training of key personnel on the transplantation team and mortality at new transplantation centers. For example, new centers staffed by cardiologists with previous training in heart transplantation had lower mortality rates among heart-transplant recipients than centers without experienced cardiologists (7 percent vs. 16 percent; P = 0.001; relative risk = 2.7; 95 percent confidence interval, 1.3 to 5.9). By contrast, the previous training of the surgeons who performed transplantations was not related to the mortality rate associated with the procedure.
Conclusions:
Experience with heart transplantation is associated with a better outcome for patients after that procedure. Opportunities exist to refine transplantation policies on the basis of the experience of a center and its transplantation team and to develop similar policies for other forms of organ transplantation.