A_Guide_to_the_SRTR_OPO_Reports_update

Document Sample
A_Guide_to_the_SRTR_OPO_Reports_update Powered By Docstoc
					A Guide to the
Scientific Registry of
Transplant Recipients
Organ Procurement
Organization Reports
www.srtr.org
Conceptual Framework for OPO Measures
• OPOs can be assessed for performance at several points
  during the organ procurement process.

• Steps are discussed in the following slides, including the
  current state of development of each metric and data
  limitations.
Step 1: Identify Eligible Deaths
• Metric:
    Eligible deaths per notifiable death.
• Development:
    Historically available on the SRTR website with
     comparisons to expected rates before January 2008.
• Limitations:
    Eligible deaths historically self-reported aggregate counts.
Step 2: Convert Eligible Deaths to Donors
• Metric:
    Donors per eligible death.
• Development:
    Historically available on the SRTR website with comparison to
      expected rates (not in January 2008).
• Limitations
    Eligible deaths are currently self-reported aggregate counts.
    Does not include DCD or donors aged > 70 years.
    Current models for “expected” donation rates are limited to
      information about the hospitals where the deaths occurred, which is
      not much better than crude rates.
    Models will likely be improved by accounting for the characteristics of
      individual eligible deaths (data to be collected by the OPTN beginning
      January 9, 2008).
    Specific underlying adjustment data from AHA cannot be shared.
      Alternative sources are being explored.
Step 3: Recovered and Transplanted Organs
• Metric:
    Organs recovered and transplanted per donor.
• Development:
    Crude rates available on the SRTR website, stratified by donor
     type.
    Methods for modeling an expected yield per donor are under
     consideration.
• Limitations:
    Statistical test is not straightforward for the combined observed
     vs. expected yield because recovery of different organs from the
     same donor are not independent events.
    Multiple factors, including factors external to the OPO, influence
     this outcome.
www.srtr.org
Table    Description
1        Organs recovered and transplanted per donor
2        Centers transplanting organs/exports
3        Adjusted measures of donation rates, DSA
3A       Adjusted measures of donation rates, hospital
4        Donor characteristics
5        Donor characteristics by organ
6        Percent undergoing transplant, waitlisted patients
7        Time to transplant, waitlisted patients
8        Recipient characteristics
9        Coverage area: Counties assigned to DSA
Table 1: Organs Recovered/Transplanted per
Deceased Donor
• N and % of recovered (and transplanted) organs or donors per
  donor type.
    includes organs exported to other DSAs.
    segmented organs may count for more than one transplant
     (n transplants may be > n recovered).
• National averages.
• Separate reporting by donor type (instead of adjustment).
• “Donors”: at least one organ recovered for transplant.
        793 organs recovered
          from 239 donors

                                            This DSA                                           US

                     Donors                            Organs                                 Organs

                                      Recovered                 Transplanted          Rec.      Transplanted

              Count        Per   Count        Per      Count         Per       % TX     Per     Per      % TX
                         Donor              Donor                  Donor              Donor   Donor
                          type               type                   Type               Type    Type
All Donors     239/239=100.0     793         3.32       664        2.78        83.7   3.52     3.09      87.7

Intestine       6         0.03    6          0.03        6         0.03        100    0.02     0.02      89.8

Kidney         204        0.85   408         1.71       333        1.39        81.6   1.77     1.49      84.1

Pancreas        43        0.18    43         0.18       35         0.15        81.4   0.27     0.21      77.1

Liver          208        0.87   208         0.87       175        0.73        84.1   0.88     0.82      93.1

Lung            29        0.12    55         0.23       48          0.2        87.3   0.27     0.26      95.9

Heart           73        0.31    73         0.31       69         0.29        94.5    0.3     0.3       98.4
             = 3.32 organs recovered
                    per donor

                                             This DSA                                           US

                    Donors                              Organs                                 Organs

                                       Recovered                 Transplanted          Rec.      Transplanted

             Count        Per   Count          Per      Count         Per       % TX     Per     Per      % TX
                        Donor                Donor                  Donor              Donor   Donor
                         type                 type                   Type               Type    Type
All Donors     239/239=100.0     793          3.32       664        2.78        83.7   3.52     3.09      87.7

Intestine      6         0.03     6           0.03        6         0.03        100    0.02     0.02      89.8

Kidney        204        0.85    408          1.71       333        1.39        81.6   1.77     1.49      84.1

Pancreas       43        0.18     43          0.18       35         0.15        81.4   0.27     0.21      77.1

Liver         208        0.87    208          0.87       175        0.73        84.1   0.88     0.82      93.1

Lung           29        0.12     55          0.23       48          0.2        87.3   0.27     0.26      95.9

Heart          73        0.31     73          0.31       69         0.29        94.5    0.3     0.3       98.4
                                                                         664 organs transplanted
                                                                            from 239 donors

                                          This DSA                                                 US

                   Donors                            Organs                                    Organs

                                    Recovered                 Transplanted            Rec.          Transplanted

             Count       Per   Count        Per      Count         Per       % TX      Per       per         % TX
                       Donor              Donor                  Donor               Donor     Donor
                        type               type                   Type                Type      Type
All Donors    239/239=100.0    793         3.32       664        2.78        83.7     3.52         3.09      87.7

Intestine     6         0.03    6          0.03        6         0.03        100      0.02         0.02      89.8

Kidney       204        0.85   408         1.71       333        1.39        81.6     1.77         1.49      84.1

Pancreas      43        0.18    43         0.18       35         0.15        81.4     0.27         0.21      77.1

Liver        208        0.87   208         0.87       175        0.73        84.1     0.88         0.82      93.1

Lung          29        0.12    55         0.23       48          0.2        87.3     0.27         0.26      95.9

Heart         73        0.31    73         0.31       69         0.29        94.5     0.3          0.3       98.4
                                                                               = 2.78 transplanted
                                                                                organs per donor

                                          This DSA                                               US

                   Donors                            Organs                                    Organs

                                    Recovered                 Transplanted            Rec.           Transplanted

             Count       Per   Count        Per      Count         Per       % TX      Per       Per          % TX
                       Donor              Donor                  Donor               Donor     Donor
                        type               type                   Type                Type      Type
All Donors    239/239=100.0    793         3.32       664        2.78        83.7     3.52      3.09          87.7

Intestine     6         0.03    6          0.03        6         0.03        100      0.02      0.02          89.8

Kidney       204        0.85   408         1.71       333        1.39        81.6     1.77      1.49          84.1

Pancreas      43        0.18    43         0.18       35         0.15        81.4     0.27      0.21          77.1

Liver        208        0.87   208         0.87       175        0.73        84.1     0.88      0.82          93.1

Lung          29        0.12    55         0.23       48          0.2        87.3     0.27      0.26          95.9

Heart         73        0.31    73         0.31       69         0.29        94.5      0.3       0.3          98.4
                                        664/793 (83.7%) of organs
                                       recovered were transplanted

                                          This DSA                                           U.S.

                   Donors                            Organs                                 Organs

                                    Recovered                 Transplanted          Rec.      Transplanted

             Count       Per   Count        Per      Count         Per       % TX     Per     Per      % TX
                       Donor              Donor                  Donor              Donor   Donor
                        type               type                   Type               Type    Type
All Donors    239/239=100.0    793         3.32       664        2.78        83.7   3.52     3.09      87.7

Intestine     6         0.03    6          0.03        6         0.03        100    0.02     0.02      89.8

Kidney       204        0.85   408         1.71       333        1.39        81.6   1.77     1.49      84.1

Pancreas      43        0.18    43         0.18       35         0.15        81.4   0.27     0.21      77.1

Liver        208        0.87   208         0.87       175        0.73        84.1   0.88     0.82      93.1

Lung          29        0.12    55         0.23       48          0.2        87.3   0.27     0.26      95.9

Heart         73        0.31    73         0.31       69         0.29        94.5    0.3     0.3       98.4
                               All of the statistics from this DSA were
                                     lower than the US averages

                                             This DSA                                           US

                   Donors                               Organs                                 Organs

                                       Recovered                 Transplanted          Rec.      Transplanted

             Count       Per     Count         Per      Count         Per       % TX     Per     Per      % TX
                       Donor                 Donor                  Donor              Donor   Donor
                        type                  type                   Type               Type    Type
All Donors    239/239=100.0       793         3.32       664        2.78        83.7   3.52     3.09      87.7

Intestine     6         0.03       6          0.03        6         0.03        100    0.02     0.02      89.8

Kidney       204        0.85      408         1.71       333        1.39        81.6   1.77     1.49      84.1

Pancreas      43        0.18       43         0.18       35         0.15        81.4   0.27     0.21      77.1

Liver        208        0.87      208         0.87       175        0.73        84.1   0.88     0.82      93.1

Lung          29        0.12       55         0.23       48          0.2        87.3   0.27     0.26      95.9

Heart         73        0.31       73         0.31       69         0.29        94.5    0.3     0.3       98.4
Reporting by Donor Types
• Heart-beating.
    SCD: standard criteria donor.
        • Aged younger than 60 years and not DCD or ECD.
      ECD: expanded criteria donor (KI-donor type).
        • Heart-beating donors aged older than 60 years and aged between
          50 and 59 years meeting 2 of the following 3 conditions: died of
          stroke, history of hypertension, serum creatinine > 1.5 mg/dL.
• Non-heart beating.
    DCD: donation after cardiac death.
Table 3: Measures of Donation Rates: Two
Processes
                   Donation Rate:                       Notification Rate:
                                           and
                  Deceased Donors                       Eligible Deaths*
                   Eligible Deaths*                  Notifiable Deaths, DSA

• Notifiable deaths: DSA-wide in-hospital deaths of patients
  aged 0-70 years with no exclusionary medical diagnosis for
  possible donation,† mean 5.4 (eligible deaths per 100
  notifiable deaths).
• Eligible deaths*: OPO-reported aggregate eligible deaths from
  hospitals (excludes cardiac deaths).
• Deceased donors: at least 1 organ recovered.
  *Eligible:
           Aged 0-70 years, death by neurological criteria, no exclusionary medical conditions.
  †Ojo AO, et al. A practical approach to evaluate the potential donor pool and trends in
     cadaveric kidney donation. Transplantation 1999; 67:548-566.
Crude (Observed) Donation Rate
• Eligible deaths.
    OPTN definition (heart-beating, aged < 71 years,
      acceptable cause of death).
• Eligible donors (subset of eligible deaths).
    Aged < 71 years and not DCD becoming donors.
• Crude donation rate.
    100 * eligible donors/eligible deaths.
• Additional donors.
    Not eligible deaths.
    Aged > 70 years plus DCD.
                  135 eligible donors/232 eligible
                   deaths = 58% donation rate.


                                                                This DSA/OPO   Average
Observed donation measures
Deceased donors (all)                                               162         138
Deceased donors meeting eligibility criteria                        135         121
Additional donors (aged > 70 years, DCD)                            27           17
Eligible deaths                                                     232         190
Crude donation rate1 (donors per 100 eligible deaths)               58.2        63.7

Crude organ-specific rates 2 (organs per 100 eligible deaths)

  Kidney                                                            53.0        57.5
  Liver                                                             54.7        57.0
  Heart                                                             17.7        20.6
  Lung                                                              7.8         11.9
  Pancreas                                                          19.0        17.7
             27 additional donors not included in
                the donation rate calculations.


                                                               This DSA/OPO   Average
Observed donation measures
Deceased donors (all)                                              162         138
Deceased donors meeting eligibility criteria                       135         121
Additional donors (aged > 70 eyars, DCD)                           27           17
Eligible deaths                                                    232         190
Crude donation rate1 (donors per 100 eligible deaths)              58.2        63.7

Crude organ specific rates2 (organs per 100 eligible deaths)

  Kidney                                                           53.0        57.5
  Liver                                                            54.7        57.0
  Heart                                                            17.7        20.6
  Lung                                                             7.8         11.9
  Pancreas                                                         19.0        17.7
Percentage of Additional Donors* Among All
Deceased Donors by OPO




 *Donors aged >70 years and donors after cardiac death not currently included in
 SRTR conversion calculations.
Average Conversion and Discard Rates for All
OPOs 2002-2006




HRSA collaboratives began in April 2003.
Source: SRTR analysis, August 2007.
Adjustments Used for Expected Rates
• Notification rate: age, sex, race, and cause of death. Source:
  NCHS Population Death Record

• Donation rate 1: trauma center, MSA size, CMS case mix index,
  total bed size, ICU beds, children’s hospital, resident training
  program, neurological services, hospital control/ownership.
  Source: AHA Survey.

• Donation rate 2: as above, plus notification rate.
Standardized Donation Rate Model
• “What donation rate would we expect for this DSA, given the
  characteristics of the hospitals in its service area?”
      Trauma center, MSA size, CMS case mix index, total bed size, ICU beds,
       neurological service, resident training program, children’s hospital, hospital
       control/ownership. Source: AHA Survey
• ASDR = SDR with an adjustment for notifiable deaths.
• Standardized ratio: observed rate/expected rate.
• Statistical comparisons:
    Compare observed to expected counts, 2-sided p-value.
    95% confidence limits for standardized ratio.
How to Compare Crude Rates to Expected Rates
                    Almost 8 fewer organs were recovered than
                expected. Given the characteristics of the hospitals
                  in this DSA, this difference is significantly lower
                                    than expected.

Measure of Donation                            Observed           Expected5,6,7   p-value8
Notification rate (eligible deaths per 100
                                                   5.3                  4.6        0.339
notifiable deaths)


Donation rate (hospital characteristics)6          58.2                 65.9       0.043
  Kidney-specific rate                             53.0                 59.5       0.102
  Liver-specific rate                              54.7                 58.7       0.316
  Heart-specific rate                              17.7                 19.5       0.514
  Lung-specific rate                               7.8                  10.5       0.161
  Pancreas-specific rate                           19.0                 17.6       0.592
  The observed donation rate is 12% lower than
          the expected donation rate.


                                                                                 95% Confidence
                               This DSA/OPO                      Standardized
                                                                                   Interval10
Measure of Donation        Observed   Expected5,6,7   P-value8      Ratio9      Lower     Upper
Notification rate            5.3          4.6          0.339         1.15       1.16       0.86


Donation rate (hospital)     58.2         65.9         0.043         0.88       0.88       0.78

  Kidney-specific rate       53.0         59.5         0.102         0.89       0.89       0.78

  Liver-specific rate        54.7         58.7         0.316         0.93       0.93       0.82

  Heart-specific rate        17.7         19.5         0.514         0.91       0.91       0.67

  Lung-specific rate         7.8          10.5         0.161         0.74       0.74       0.44

  Pancreas-specific rate     19.0         17.6         0.592         1.08       1.08       0.80
                                       Donation rates adjusted for hospital
                                       characteristics AND notification rate.
                                                                   This DSA/OPO
Measure of donation                                       Observed            Expected5,6,7   P-value8
Notification rate (eligible deaths per 100 notifiable
                                                            5.3                   4.6          0.339
deaths)


Donation rate (hospital characteristics)6                   58.2                  65.9         0.043

   Kidney-specific rate                                     53.0                  59.5         0.102
   Liver-specific rate                                      54.7                  58.7         0.316
   Heart-specific rate                                      17.7                  19.5         0.514
   Lung-specific rate                                       7.8                   10.5         0.161
  Pancreas-specific rate                                    19.0                  17.6         0.592


Donation rate

(hospital characteristics, notification rate)7              58.2                  64.3         0.062

   Kidney-specific rate                                     53.0                  58.4         0.113
   Liver-specific rate                                      54.7                  57.1         0.510
   Heart-specific rate                                      17.7                  21.1         0.232
   Lung-specific rate                                       7.8                   12.2         0.042
  Pancreas-specific rate                                    19.0                  18.4         0.877
Why Suppress Expected Rates Now?
• Statistics intended for quality improvement purposes.

• Lack of data for individual eligible deaths does not allow for
  substantive statistical adjustment.

• Data currently available for use in the models cannot currently
  be released to OPOs or the public.

• Important to assess the sources of variation in donation rates
  among the OPOs before finalizing the methods for assigning
  statistical significance to the comparisons.
Future Changes
• Donation rates will be adjusted when eligible death
  characteristics are collected:
    Age
    Race
    Sex
    Cause of death
Pilot Study of Individual Eligible Death Data
• 11 OPOs were selected as a representative sample.

• A multivariate model with age, race, sex, US citizenship, cause
  of death was highly significant (chi-square = 130, P < 0.0001),
  indicating that the factors were useful predictors of donation.
OPTN Collection of Individual Eligible Death Data
• Began January 9, 2008.

• Includes data on age, sex, race/ethnicity, and cause of death
  for each eligible death.

• Improves the modeling of expected conversion rates.

• Expect to begin using models after 1 year of data collection.
Additional Measures: Access to Transplant
• Components of variation: OPO and transplant center.

• OPO Table 6: percent transplanted by point in time.

• OPO Table 7: median waiting time.

• CSR Table 3: adjusted transplant rate.
Contact the SRTR
• www.srtr.org

• (877) 970-SRTR

• srtr@srtr.org

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:0
posted:2/18/2012
language:
pages:31