Every six months, the SRTR releases a publicly available assessment of each transplant center in the country, using one-year post-transplant survival rates as a key metric. A poor evaluation means a center gets “flagged,” triggering an investigation into why its one-year survival rates aren’t what they should be. Consultants come in. Medicare and Medicaid may refuse to pay for their patients to be transplanted at these centers. It can cost the centers thousands or even millions of dollars. On rare occasions, they may even be shut down.
But one-year survival may not be the most useful metric for judging a transplant center’s quality. “It’s hard to argue against patient survival as an important measure,” Klassen said, but he also explained that because liver-transplant outcomes have improved so much in recent years, many surgeons and organ-procurement organizations wonder if the difference between top-performing centers and flagged centers is really clinically significant. The differences can be extremely small, often just percentage point or two.
The current system “puts pressure on people to try to make sure that they’re using the best organs that they can,” said John Roberts, the chief of transplant surgery at the University of California, San Francisco. This comes with its own drawbacks: “Not listing patients who may otherwise benefit from transplants because they’re too old or too sick ... It’s a problem that no one has a great solution to.”
In 2014, three larges transplant centers were flagged for having unacceptable one-year survival rates. The following year, all three transplant centers became more conservative, conducting about 30 percent fewer transplants. The centers may have increased post-transplant survival rates and thus stayed in business, but cutting down on the number of surgeries means they also likely denied potentially lifesaving transplants to patients that they would have treated a year before. “You’re only accountable for the patients that you transplant,” said Kevin Cmunt, the president and CEO of the organ-procurement organization Gift of Life. “So if you don’t transplant somebody, you can’t get in trouble.”
UNOS is currently working on a pilot program to identify alternative measures for assessing transplant centers, like program structure and access to resources. Next year, it hopes to test the measures in a small group of hospitals; in 2017, the organization hopes to apply the measures nationally, for a system that more accurately reflects a transplant center’s success and allows more leeway for high-risk procedures.
In the meantime, Goldberg is hoping for a smaller step: that transplant centers’ organ-acceptance rates will become publicly available information. “Patients, providers, and insurers really don’t know anything about this stuff,” he said. “This is an area that needs to have some more transparency.”