L. H. Nicholas1,2, D. Segev1,2 1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2Johns Hopkins School Of Public Health,Baltimore, MD, USA
Introduction: Since 2007, the Centers for Medicare and Medicaid Services (CMS) requires organ transplantation programs that perform poorly on two biannual report cards within a 30-month period to enter a Systems Improvement Agreement (SIA) to continue receiving CMS reimbursement. Each SIA prescribes a number of steps that transplant centers must take to improve their performance. Centers are also required to notify all patients on their waitlist of the quality problems and pay all costs associated with the patient joining the waiting list at an additional center. While this regulatory program is designed to save lives by targeting programs with low 1-year patient and graft survival rates, the impact of the SIAs on waitlist candidates is unknown.
Methods: We obtained details of all Systems Improvement Agreements between 2008 and 2014 through a Freedom of Information Act. We compared waitlist outcomes for patients on the waitlist before and after their centers entered SIAs using patient-level data from the Scientific Registry of Transplant Recipients. We also compared SIA centers before and after the SIA to other poor-performing but non-sanctioned centers before and after their second instance of poor performance. All analyses estimated multivariate regressions adjusting for patient and center characteristics with standard errors clustered at the center level.
Results: 26 centers entered SIAs for kidney, liver, and lung transplantation during the study period. 8,506 patients were on the waiting list at SIA centers, 41% were female, 64% were non-White, and 38% had private insurance. On average, only 3% listed at an additional center during any 6 month period and 8% left the list due to transplant. Following an SIA, patients were 4 percentage points less likely to leave the list due to transplant (p < 0.01). There was no change in multi-listing behavior in response to the notification letters.
Conclusion: A CMS quality improvement initiative designed to improve transplant center quality was associated with a reduction in the probability of transplant receipt among patients waiting for transplant at the targeted centers. Letters describing quality problems and offering to pay the costs associated with moving to another center were insufficient tools to motivate patients to list at higher performing centers.