Quality-based ratings in Medicare and trends in kidney transplantation.

OBJECTIVE: To assess the relationship between the 2007 Medicare regulation enforcing quality standards for transplant centers and trends in kidney transplantation. DATA SOURCES: Transplant centers' biannual reports and the national registry for kidney transplantation from 2003 to 2010. STUDY
DESIGN: Non-compliant (low-performing) centers were compared with centers in compliance with quality standards according to: number of transplants, waiting-list registrations, and rates of graft failures, transfers, and deaths. Multivariate regressions were estimated to evaluate the association between the regulation and transplantation outcomes. DATA EXTRACTION
METHODS: Patient characteristics and outcomes were aggregated to six-month periods and linked to centers' reports. PRINCIPAL
FINDINGS: Relative to average-performing centers, 12 percent of transplants shifted away from low-performing centers and high-performing centers captured 6 percent of this decline. Low-performing centers experienced a 2-percentage point per period decline in 1-year graft failure rates and a 15-percent decrease in registrations post-regulation, whereas high-performing centers incurred a 5-percent decrease in registrations relative to average-performing centers.
CONCLUSIONS: Government oversight in kidney transplantation was associated with a small downward shift in overall kidney transplants. Reductions in graft failure rates at low-performing centers may imply an increase in quality or a decline in transplantation of either marginal organs or riskier patients; whereas reductions in registrations may indicate risk aversion toward high-risk patients. Policy makers should consider making less punitive requirements for programs, which employ new transplantation techniques to expand access. © Health Research and Educational Trust.