Poor Performance Flagging Is Associated With Fewer Transplantations at Centers Flagged Multiple Times

Area of Science:

• Transplantation Medicine
• Health Services Research
• Quality Improvement in Healthcare

Background:

• The Center for Medicare and Medicaid Services (CMS) uses Scientific Registry of Transplant Recipients (SRTR) risk-adjusted outcomes to identify underperforming lung transplant centers.
• This methodology is controversial due to the high stakes of lung transplantation and potential impacts on center behavior.

Purpose of the Study:

• To investigate the hypothesis that CMS flagging leads to conservative recipient and organ selection, reducing waitlist additions and transplantations.
• To analyze center-level trends in lung transplantation following CMS performance flagging.

Main Methods:

• Analysis of SRTR data from July 2012 to July 2017 for 72 lung transplant centers.
• Comparison of center characteristics stratified by the number of flagging events.
• Mixed-effects regression modeling to assess the impact of flagging on risk aversion outcomes.

Main Results:

• 21 out of 72 centers (29%) met flagging criteria a median of 2 times.
• Flagging did not significantly impact waitlist or transplantation volume or patient selection.
• Centers flagged once added more patients to the waitlist and performed more transplants than unflagged centers, despite similar expected survival rates.

Conclusions:

• CMS flagging did not lead to significant temporal changes in center-level lung transplantation activity.
• Programs under prolonged probation showed reduced activity, potentially indicating a migration of patients to higher-performing centers.
• The study's primary hypothesis regarding conservative behavior post-flagging was not supported by the data.