Feature: More transplant volume may pump up outcomes
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Each year more than 2,000 heart transplants are performed in the U.S. For patients with end-stage heart failure (HF) whose heart cannot pump blood sufficiently, when medical therapies fail, heart transplantation may be the last resort to restore quality of life. Yet, previously published data have shown that many transplant centers performed at volumes and survival rates that are less than optimal.

Do more, succeed more

Data from the Department of Health and Human Services (HHS) Office of Inspector General in 2004 found that 69 of the then 90 Medicare-approved heart transplant centers failed to meet initial approval criteria for volume and/or survival rates. Data were collected between 1987 and 2000.

HHS also reported that between 1992 and 2000, 15 percent of Medicare beneficiaries received a heart transplant at a Medicare-approved transplant center that fell below Medicare standards. Despite the fact that Medicare-approved transplant centers are required to submit outcomes and volumes data for heart transplants, data may still be lacking.

In 2000, the Centers for Medicare & Medicaid Services (CMS) lowered volume criteria for heart transplants from 36 procedures to 12. However, that number was then lowered to 10.

While the key to becoming a Medicare-approved center includes publicly reporting outcomes data to the Scientific Registry of Transplant Recipients, and meeting national requirements of transplants per year, Ernst R. Schwarz, MD, PhD, director of Multidisciplinary Heart Failure Research at the Cedars-Sinai Heart Institute in Los Angeles, told Cardiovascular Business some centers may be sluggish at meeting these goals. “Less than that and you are now under the radar of CMS for becoming a Medicare-approved transplant center,” Schwarz said.

A study presented at the 44th annual meeting of the Society of Thoracic Surgeons showed that higher-volume transplant centers had fewer complications and saw decreased mortality. During the study, Johns Hopkins researchers in Baltimore evaluated 14,401 patient records of heart transplants that took place between 1999 and 2006. The researchers recommended that the benchmark for a high-volume transplant hospital be raised from 10 heart transplants per year to 14 after they found hospitals that performed fewer than 14 transplants per year saw steadily increasing death rates one-month post-procedure.

In fact, patients had a 16 percent greater chance of dying in hospitals performing less than five transplants per year, compared with a less-than-1 percent 30-day mortality rate at centers performing more than 40 transplant procedures per year. It was noted that patients had an 80 percent greater risk of dying 30-days post-procedure at hospitals that performed less than 10 transplants per year.

CMS requires active transplant centers to achieve a 73 percent one-year survival rate for transplant recipients and a 65 percent two-year survival rate. However, Schwarz said that current nationwide survival rates are higher than that—an estimated 89 percent at one year.

Waiting is the hardest part

While many patients with end-stage heart failure could benefit from heart transplantation, often wait times hinder the procedure. These wait times may vary by region and by urgency, Schwarz said.

The transplant center at Cedars-Sinai performed more than 85 transplants last year, and saw an average wait time that was between three and four months. “Considerably short,” Schwarz said. But, he added that most of the patients on the transplant list are high urgency cases, “meaning they may be in the hospital, have a device or be on inotropic therapy, making them higher status.”

As of press time, the active heart transplant waiting list included 3,145 patients. Wait times for heart transplants varied, with 284 patients waiting five years or more and 218 patients waiting less than 30 days.

Advice for others

For others wishing to improve transplant outcomes and get certified as a Medicare-approved center, Schwarz offered the following advice:
  1. Increase your waiting list: You must provide an advance heart failure service that includes not only transplantation but also other services such as bridge-to-transplant devices (left ventricular assist devices), among other advanced therapies.
  2. Enhance accessibility: “I worked in a transplant program where patients were referred to the program or were tried to be referred and the waiting periods to see a patient were unacceptable,” Schwarz said. The center must have short wait times for patients to get a workup, evaluated and put on the transplant list.
  3. Ensure quality outcomes: An adequate team of post-transplant care givers will be necessary to ensure good outcomes. A structured team that includes transplant coordinators, psychologists, cardiologists and lab workers to measure levels of immunosuppression and ensure post-op care are required.

"If a patient is in his or her mid-70s, with heart transplant, that person can be granted another 10 years of life,” Schwarz concluded.