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Institutional Variability in Outcomes of Cardiac Transplantation
Arman Kilic*1, David D Yuh*2, Ashish S Shah*1, Duke E Cameron1, William A Baumgartner1, John V Conte*1
1Johns Hopkins Hospital, Baltimore, MD;2Yale University School of Medicine, New Haven, CT

OBJECTIVE(S): To evaluate the contribution of institutional volume to the between-center variability in outcomes following orthotopic heart transplantation(OHT).
METHODS: The UNOS database was used to identify OHTs between 2000-2010. Separate mixed-effect logistic regression models were constructed, with the primary endpoint being post-OHT mortality. Model A included only individual centers, model B added validated recipient and donor risk indices, and model C added average annual OHT volume as a continuous variable to model B. The reduction in between-center variance in mortality between models B and C was used to define the contribution of institutional volume. Kaplan-Meier survival curves were also compared after stratifying patients into equal size tertiles based on center volume.
RESULTS: A total of 119 centers performed OHT in 19,156 patients. After adjusting for differences in recipient and donor risk, decreasing center volume was associated with an increased risk of 1-year mortality(p<0.001). However, procedural volume only accounted for 15.6% of the variance in mortality between centers, and significant between-center variance persisted after adjusting for institutional volume(p<0.001). In Kaplan-Meier analysis, there was significant variability in 1-year survival within each center volume category: low-volume(1-13 OHTs/year:65.2%-95.7%), intermediate-volume(14-25 OHTs/year:79.9%-96.6%), and high-volume(26-73 OHTs/year:83.1%-93.6%). These trends were also observed with 5-year mortality, where procedural volume accounted for 16.2% of the between-center variability, and significant variance in mortality persisted after adjusting for volume(p<0.001).
CONCLUSIONS: This large-cohort analysis demonstrates that procedural volume should not be the sole indicator of “center quality” in OHT as other institutional factors contribute significantly to the varying mortality rates observed between centers.

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