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Impact of Competition on Health Care Quality

Crespin, D., Christianson, J., McCullough, J., & Finch, M. (2019). Do Health Systems Respond to the Quality of Their Competitors? The American Journal of Managed Care, 25(4). https://www.ajmc.com/view/do-health-systems-respond-to-the-quality-of-their-competitors.

This article seeks to determine whether health systems increased the quality of diabetes care provided by their clinics based on performance relative to competitors using publicly available performance measures. Although diabetes care performance improved during our study, health systems did not differentially improve the diabetes care performance of their clinics performing worse than clinics in competing systems. This result indicates divergence between high-performing and low-performing clinics. This result does not appear to be due to risk selection. Publicly reporting quality information did not incentivize health systems to increase the performance of their clinics with lower performance than competitors, as would be expected under retail competition. Our results do not support strategies that rely on competition on publicly reported performance measures to improve quality in diabetes care management.

Misalignment of OPOs and Transplant Centers

Reese, P. P., Aubert, O., Naesens, M., Huang, E., Potluri, V., Kuypers, D., Bouquegneau, A., Divard, G., Raynaud, M., Bouatou, Y., Vo, A., Glotz, D., Legendre, C., Lefaucheur, C., Jordan, S., Empana, J.-P., Jouven, X., & Loupy, A. (2020). Assessment of the Utility of Kidney Histology as a Basis for Discarding Organs in the United States: A Comparison of International Transplant Practices and Outcomes. Journal of the American Society of Nephrology, 32(2), 397–409. https://doi.org/10.1681/asn.2020040464

Many kidneys donated for transplantation are discarded because of abnormal histology, but it is unknown whether preimplantation kidney biopsies that are routinely performed in the United States add incremental value beyond usual donor attributes in predicting allograft survival. They also studied donor kidneys from deceased United States donors—specifically, organs discarded because of abnormal histology—and matched them with similar kidneys transplanted in Europe. About 45% of 1103 United States kidneys discarded because of histologic findings could be accurately matched to very similar kidneys that had been transplanted in France; these discarded kidneys would be expected to have allograft survival of 93.1% at 1 year, 80.7% at 5 years, and 68.9% at 10 years.

Husain, S. A., King, K. L., Pastan, S., Patzer, R. E., Cohen, D. J., Radhakrishnan, J., & Mohan, S. (2019). Association Between Declined Offers of Deceased Donor Kidney Allograft and Outcomes in Kidney Transplant Candidates. The Journal of the American Medical Association Open Network, 2(8). https://doi.org/10.1001/jamanetworkopen.2019.10312

This cohort study seeks to determine the outcome of wait-listed transplant candidates after a transplant center’s refusal to accept a deceased donor kidney offer on the candidates behalf. The study found that approximately 30% of these candidates eventually died or were removed from the waiting list before receiving an allograft. This study suggests that a large number of deceased donor kidney offers are received by candidates but are declined on their behalf, resulting in what appears to be many missed opportunities for a transplant before death or removal from the waiting list. Transplant centers have the authority to decline organs on behalf of the patient, unlike Organ Procurement Organizations.

Recommendations

Ojo, A. O., Pietroski, R. E., O'Connor, K., McGowan, J. J., & Dickinson, D. M. (2005). Quantifying Organ Donation Rates by Donation Service Area. American Journal of Transplantation, 5(4p2), 958–966. https://doi.org/10.1111/j.1600-6135.2005.00838.x

This article explains recent developments in OPO performance evaluation methodology, including those developed by the SRTR. As a replacement for the previously established measure of OPO performance- donors per million population--using eligible deaths as a national metric has yielded promising results for understanding variations in donation rates among the donation service areas assigned to each OPO. A major improvement uses "notifiable deaths" as a denominator describing a standardized maximal pool of potential donors. Notifiable deaths are defined as in-hospital deaths among ages 70 years and under, excluding certain diagnosis codes related to infections, cancers, etc. A most proximal denominator for determining donation rates is "eligible deaths," which includes only those deaths meeting the criteria for organ donation upon initial assessment. Neither measure is based on the population of a geographic unit, but on restricted upper limits of deaths that could be potential donors in any one locale (e.g., hospital or OPO). The inherent strengths and weaknesses of metrics such as donors per eligible deaths, donors per notifiable deaths, and number of organs per donor are discussed in detail.

Hamory, B., Javanmardian, M., & Shellenbarger, D. (2021). (rep.). Opportunity to Increase Deceased Donor Organ Donation and Transplantation 2021 - 2026: Summary Findings. Oliver Wyman. Retrieved from https://www.oliverwyman.com/content/dam/oliver-wyman/v2/publications/2021/feb/Organ%20donation_Feb9%20(003).pdf

Oliver Wyman conducted a study in partnership with Hogan Lovells, and its client, a work group of Organ Procurement Organizations (OPOs), to assess deceased donor organ donation and transplantation in the United States. The goal of the study was to evaluate historical data on deceased donor organ donation and transplantation, and then produce a data-driven model to estimate the potential for improvement in deceased donor organ recovery and subsequent organ transplantation at a national level in the next six years. This analysis, stratifying different segments of organ donors by age, then enables the quantification of impact that different shifts in performance of each component of the system can have (1) on organ recovery, and (2) on subsequent organ transplantation. While this assessment considered all organ donors, it focused primarily on kidney donation and transplantation given the prevalence and need in this area. Additionally, this study considered the interdependence of the system components involved in the process, and the manners in which they interact to drive transplantation rates. By stratifying these impacts, the report provides a summary of how performance improvement in components of the system results in performance of the system as a whole in increasing the number of patients transplanted.