Long-Term survival after heart transplantation at centers stratified by short-Term performance

Abstract

Background: Center differences in short-Term survival after heart transplant (HT) are known. We sought to compare long-Term graft survival (freedom from death or retransplantation) at currently active United States HT centers stratified by performance for short-Term survival. Methods: We used the Organ Procurement and Transplant Network database to identify subjects ≥18 years old who received primary HT during 2000 to 2014 at US centers active during 2013 and 2014. Follow-up was available until March 2016. Center case-mix was assessed by computing expected 90-day mortality and short-Term performance by 90-day standardized mortality ratio (SMR; observed/expected mortality). Centers were stratified by case-mix as transplanting low-, intermediate-, and high-risk patients and by short-Term performance as SMR quintiles. Center-level differences in long-Term graft survival were assessed by risk-Adjusted, mixed-effects Weibull survival models with center as a random effect. Results: We analyzed 25 467 HT recipients at 96 centers. Those receiving HT at centers with superior (lower) 90-day SMR had longer graft survival (P for trend <0.001). Survival difference among SMR groups remained significant in 90-day conditional survivors (P for trend <0.001). There was significant center-level variation in risk-Adjusted graft survival censored at 5 years (P<0.001) and with all follow-up (P<0.001). Adjusting for 90-day SMR was associated with 62% reduction in center variation in 5-year graft survival and 56% reduction in center variation in overall graft survival. Conclusions: HT recipients at centers with superior short-Term outcomes have longer graft survival on long-Term follow-up. Allocating resources to improve patient care processes and transplant expertise at high-SMR centers may improve short-Term and overall survival after HT.