• Natasha H Dolgin, Babak Movahedi, Paulo N A Martins, Robert Goldberg, Kate L Lapane, Frederick A Anderson, and Adel Bozorgzadeh.
• Department of Surgery, Division of Organ Transplantation, UMass Memorial Medical Center, University of Massachusetts, Worcester, MA; Department of Quantitative Health Sciences, Clinical and Population Health Research, University of Massachusetts Medical School, Worcester, MA; Department of Surgery, Center for Outcomes Research, University of Massachusetts Medical School, University of Massachusetts, Worcester, MA. Electronic address: natasha.dolgin@umassmemorial.org.
• J. Am. Coll. Surg. 2016 Jun 1; 222 (6): 1054-65.

BackgroundThe central tenet of liver transplant organ allocation is to prioritize the sickest patients first. However, a 2007 Centers for Medicare and Medicaid Services regulatory policy, Conditions of Participation (COP), which mandates publically reported transplant center performance assessment and outcomes-based auditing, critically altered waitlist management and clinical decision making. We examine the extent to which COP implementation is associated with increased removal of the "sickest" patients from the liver transplant waitlist.Study DesignThis study included 90,765 adult (aged 18 years and older) deceased donor liver transplant candidates listed at 102 transplant centers from April 2002 through December 2012 (Scientific Registry of Transplant Recipients). We quantified the effect of COP implementation on trends in waitlist removal due to illness severity and 1-year post-transplant mortality using interrupted time series segmented Poisson regression analysis.ResultsWe observed increasing trends in delisting due to illness severity in the setting of comparable demographic and clinical characteristics. Delisting abruptly increased by 16% at the time of COP implementation, and likelihood of being delisted continued to increase by 3% per quarter thereafter, without attenuation (p < 0.001). Results remained consistent after stratifying on key variables (ie, Model for End-Stage Liver Disease and age). The COP did not significantly impact 1-year post-transplant mortality (p = 0.38).ConclusionsAlthough the 2007 Centers for Medicare and Medicaid Services COP policy was a quality initiative designed to improve patient outcomes, in reality, it failed to show beneficial effects in the liver transplant population. Patients who could potentially benefit from transplantation are increasingly being denied this lifesaving procedure while transplant mortality rates remain unaffected. Policy makers and clinicians should strive to balance candidate and recipient needs from a population-benefit perspective when designing performance metrics and during clinical decision making for patients on the waitlist.Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

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