Transplant Statistics: Annual Report : Appendix G

Appendix G

SRTR Center- and OPO-Specific Reports

As part of its SRTR contract, URREA conducts ongoing analyses of Center-Specific Reports (CSRs) and OPO-Specific Reports (OSRs). Analyses for the CSRs and OSRs are updated twice a year. The prepared reports are posted at www.ustransplant.org each January and July. Preparation for each release entails review of report contents, preparation of data, coordination with center staff regarding comment periods and report content, and private review and comment periods for center staff via a secure web site. A detailed schedule of this process is presented in Appendix Table G-1.

The CSRs and OSRs include ongoing analyses of pre- and posttransplant data, and are disseminated via the Internet. The effectiveness of organ procurement organizations (OPOs) and transplant programs is crucial to the health and well-being of transplant candidates and recipients. As these organizations operate with considerable administrative autonomy, it is valuable to document and evaluate their activities. Accurate and timely reporting of performance measures for these organizations is useful to the organizations themselves for quality improvement activities, to contracting agencies for quality assurance, to transplant candidates whose lives depend upon their activities, and to families of potential donors who seek assurance that their decisions will bear fruit.

OPO-specific report tables are also shown, which summarize OPO activities and compare them to national averages. In addition to demographic data, these reports include information on the number of deaths and number of organs recovered.

CENTER-SPECIFIC REPORTS

The statistics in Center-Specific Reports (CSRs) include descriptions of the patients served by a program and their transplants, as well as the outcomes of these patients and transplants. The reports summarize several program-specific characteristics, including waiting list and transplant operation data, in addition to other center-specific characteristics collected on standard data collection forms. These summaries help describe the patient mix, severity of illness, and other risk factors of patients treated in each program, providing a context for interpretation of the other outcome statistics for the center.

Outcome evaluation is useful for many objectives, including quality improvement and assurance mechanisms. Measures presented in the CSRs include both waiting list outcomes (percentiles of time to transplant and percentages of patients that have received a transplant at relevant time points) and posttransplant outcomes (risk-adjusted patient and graft survival).

These outcomes provide a basis for reviewing and evaluating a center's transplant practice. The usefulness of these statistics for such evaluation is shown by the wide interest among some users to receive these statistics in different formats. The SRTR currently produces reports of these statistics, specifically adapted for the OPTN/UNOS Transplant Administrators Committee, for submission to payers. Similar reports are also prepared for the Centers for Medicare and Medicaid Services (CMS) and for the OPTN/UNOS Membership and Professional Standards Committee (MPSC). See Appendix H for additional discussion, such as the research completed for the MPSC.

In order to help users interpret the reports by comparing a center's characteristics to regional and national averages, each CSR includes region-level (and sometimes nation-level) summaries, in addition to center-specific results. For some outcomes, such as transplant and mortality rates, an "observed versus expected" comparison is made. The "expected" is the rate that one would see in the entire country if the country had a patient mix similar to that of the facility. This allows the reader to compare the results for patients at this facility to other similar patients across the country. See Chapter IX of this report for a further discussion of adjusted models and observed versus expected outcomes.

Cohorts for each table are chosen with timeliness and completeness in mind, given the constraints of the pattern of data flowing through the OPTN to the SRTR for each type of analysis.

Tables 1 through 6 of the CSR show transplant candidate activity and outcomes. The information in each of these tables is presented both for the entire center and by relevant patient subgroups, with regional and national comparisons. By reporting these outcomes by patient subgroup, the user is provided with a simple method of risk adjustment, and can also evaluate the center's experience with a particular type of patient. Such subgroups include initial medical urgency status (e.g., for liver and heart transplant candidates) and sociodemographic factors. Specific tables are described below:

Table 1. Waiting list activity: additions to and reasons for removal from the waiting list.

Table 2. Characteristics of waiting list patients: description of new and prevalent waiting list patients, including both demographic and medical characteristics.

Table 3. Cadaveric transplant and mortality rates among waiting list patients: risk-adjusted analyses comparing observed to expected.

Table 4. Waiting list activity and patient vital status at 6, 12, and 18 months since wait-listing: outcomes from the waiting list and posttransplant at different time periods after wait-listing. Also reported separately by medical urgency status for liver and heart programs.

Table 5.Percentage transplanted at various times since wait-listing (cadaveric transplants only).

Table 6. Time to transplant for wait-listed patients: 5th , 10th, 25th, 50th, and 75th percentiles listed.

Tables 7 through 9 show transplant recipient analyses based on the most current data available from the OPTN. This information includes tabulations of the number of patients receiving transplants of each organ during the time period by transplant center, by OPTN/UNOS region, and nationally. As shown in the tables, we stratify most results for demographic and clinical factors.

The center-specific results include summaries of the characteristics of the transplanted organs, transplant recipients, and transplant donors. These characteristics are reported separately for living donor and deceased donor transplants where appropriate. Living donor tables are only produced for kidney and liver transplants. The individual tables are listed below:

Table 7C. Cadaveric transplant recipient characteristics

Table 7L. Living donor transplant recipient characteristics

Table 8C. Cadaveric transplant donor characteristics

Table 8L. Living transplant donor characteristics

Table 9C. Characteristics of cadaveric transplant operations

Table 9L. Characteristics of living donor transplant operations

The final two tables of the CSR provide risk-adjusted posttransplant outcomes. Additionally, for kidney and liver programs a breakdown of outcomes for deceased donor transplant is also shown separately from outcomes for living donor transplants.

Table 10. Graft survival rates (cadaveric and living combined)

Table 10CL. Graft survival rates by donor type (cadaveric and living separately)

Table 11. Patient survival rates (cadaveric and living combined)

Table 11CL. Patient survival rates by donor type (cadaveric and living separately)

SSDMF in Public Release

Because of concerns regarding the completeness of follow-up information filed with the OPTN for posttransplant outcomes, starting with the July 2002 reports, data from the OPTN used to calculate posttransplant survival has been augmented with data from the Social Security Death Master File (SSDMF). We use the SSDMF to provide more complete ascertainment of a patient's outcomes.

Centers were alerted to this change during the review process for the January 2002 reports. In these reports, centers were provided a version of the posttransplant survival table (Table 11) that used these supplemental data. At the aggregate level, there was little change in survival for most centers. However, there was a substantial change for some centers. By providing more complete ascertainment of patient outcomes, we hope to address criticisms that some centers may not fairly report outcomes for all patients, and to provide users with a more accurate picture of each center's experience. Results are compared further in Chapter IX of this report.

OPO-SPECIFIC REPORTS

OPO Tables 1 through 7 show donor and transplant recipient analyses based on the most current data available from the OPTN. This information includes tabulations for each organ of the number of donors, organs recovered, and transplant recipients within each OPTN/UNOS region during the time period. The donor and recipients were stratified by demographic factors. The mapping between OPO and counties is also reported.

The individual tables are listed below:

Table 1. Number of donors and organs recovered and transplanted by organ combination and time interval (of one year in length)

Table 2. Number and location of organs transplanted, of those organs recovered within this OPO, by organ

Table 3. Measures of donor procurement efficiency (not currently reported)

Table 4. Characteristics of recovered donors by time interval (of one year in length)

Table 5. Characteristics of recovered donors by organ type (for kidney, liver, and heart)

Table 6. Characteristics of cadaveric organ recipients and organ type - separate table for each organ

Table 7. Counties assigned to this OPO by CMS by year

The SRTR is currently investigating methods for measuring donor procurement efficiency for Table 3. Historically, such efficiency may have been assessed using a donors-per-million of general population measure. The SRTR is investigating using other sources of data that provide a more accurate count of the number of deaths within each OPO's service area that may be suitable for recovery. This count would be used as a denominator in a calculated donor procurement rate. Other planned additions include an OPO-level measure of waiting list activity.

REPORT DISTRIBUTION

The reports are available on the SRTR web site, www.ustransplant.org. The reports for each center may be separately selected and viewed as an HTML page for each table, and they are also available in PDF format for easy downloading. The interface for selecting a transplant program allows the user to choose from a list which can be dynamically narrowed by choosing an organ or a state. These useful "filters" reduce the list of available reports to a manageable size, while also allowing the user to easily find the geographically relevant comparisons.

A single HTML page (or PDF document) presents an individual table or the entire report for that institution. The tables in each report provide comparisons with relevant regional and national statistics. Each page provides links to documents detailing analysis methods and report descriptions in both HTML and PDF. Tables that have a summary available provide a link to the summary at the bottom of the page.

COMMENT PUBLISHING

Each institution has a three-week period to review its own report before it is posted for public use. During the review period, representatives of each institution may provide comments that will be published with the report (in both HTML and in the PDF files). Each institution has access to a password-protected area of the web site, where representatives from that institution may view their own (and only their own) report, and enter any comments for publishing with their report.

Comments entered for publication are reviewed for appropriateness by SRTR staff before posting on the web. In many cases, comments pointing out discrepancies may be the result of misunderstandings of the data, or poor comparison of records by the facility; in such cases, SRTR staff usually contact the facility staff directly to resolve these issues and discuss comments. It is not unusual for centers to request that specific comments be withdrawn as a result of these conversations.

CENTER COMMUNICATION

In preparation for the review period and subsequent release, the SRTR coordinates a substantial effort to contact facilities and OPOs. Three months before the release of the reports, OPO and center staff are contacted via a faxed letter from the SRTR. This letter notifies staff (usually the program director and transplant administrator) of the cohorts to be used in the reports, and the date on which all forms need to be turned in to the OPTN for these patients, donors, and transplants. The letter also reviews the logistics of the comment period, specifying which designated staff members will be contacted with password information (and when), log-in instructions, and dates for the review period. Centers are given a chance to change the designated contact for the review period. Because of the confidential nature of the passwords themselves, the actual password notification is sent to the designated staff person by United States mail.