Tuesday, January 27, 2009

Too many transplant programs

Long-term readers will recall that one of my pet peeves is the proliferation of solid organ transplant programs in New England. In simple terms, there are too many such programs given the small size of the region and the limited number of organs made available from living and deceased donors. This surfeit results in unreasonable expenditures for the region, and it also results in less than optimum care for those patients served, especially the ones seen by smaller programs.

The Health Resources and Services Administration (HRSA) Best Practices Evaluation, conducted in 2007, states that transplant programs should meet the following six criteria:

①Institutional vision and commitment
-- “Fundamental”.
-- “Hospitals cannot dabble in organ transplantation. They must commit to it fully and provide the resources and support necessary.”

②Dedicated transplant team
-- Attracting & retaining dynamic, dedicated and skilled specialists who consistently function as a team.
-- Collegial and nonhierarchical team provides the best care.

③Aggressive clinical style
-- For the care of patients before, during & after transplant is central to making best use of organs that are chronically in short supply.

④Patient- and family-centered care
-- Organize care around needs of patients and families, instead of around the needs of the institution.
-- Streamlining processes to reduce paperwork burden on patients; increasing educational opportunities for patients and families about lifelong care of the transplant; creating comfortable spaces in the hospital that do not isolate the patient from his/her family.

⑤Financial intelligence
-- Rigorously detailed accounting of program finances, sound financial management, and excellent payer relations.

⑥Protocol-driven results
-- Leading centers consistently conduct improvement-oriented performance reviews based on protocols, data-driven quality control methods, innovation, and research.

The chart above shows the number of adult abdominal organ transplants for all the centers in New England through October of 2008. I am going to go out on a limb here and assert that a substantial number of these programs would not meet the HRSA criteria. I do not say this to insult anybody, but objective observers throughout the country would surely reach the same conclusion.

We hear over and over again from state officials and insurance company executives that they want to rationalize health care in the state, increase efficiency, reduce costs, and make it more patient-centered. Question: When are the state regulators and/or insurance companies going to step in and shut down some of these programs?

10 comments:

Anonymous said...

Paul,

"Abdominal organs" would seem to cover a variety of types of transplants. Does a program need to do a certain number of transplants of a particular organ to be high quality or is there value in doing an aggregate number regardless of which organ? If doing a specific number of a specific organ is important, it would be useful to see the statistics by organ. For example, a hospital might have a small number of transplants in aggregate but expertise in a particular organ. And another hospital might do a lot in aggregage but scattered among many different organs.

Zelda

Anonymous said...

Paul-

Looking down the list, the bottom two are BMC and CH (I assume Cambridge). I assume that BI will graciously provide the charity care/transplant at a loss that these institutions provide?

The fact of the matter is that if you're from a certain socio-economic stratum in the region and need a transplant, you aren't going to MGH, BWH or Lahey. Maybe Tufts will take you sans insurance or on one of the crummy connector plans, but otherwise its BMC or bust.

I actually agree with you on the need to consolidate, esp. on surgical procedures where volume is king, but you need to do something about the access problem at the same time.

Paul Levy said...

CH is actually Children's Hospital. We do indeed provide charity care, as do others beside BMC. Your characterization on that front is incorrect.

Doug Hanto said...

Dear Zelda,
Your question is a good one. “Abdominal organs” refer to kidney, liver, pancreas, and intestinal transplants. The vast majority of abdominal transplants are kidney and liver transplants. There are many aspects of caring for abdominal organ transplant donors and recipients that are similar or require similar expertise e.g. management of the drugs that prevent rejection (immunosuppressive drugs), the diagnosis and treatment of “opportunistic infections” that occur in immunocompromised patients, management of surgical complications, management of organ failure prior to transplant, etc. It is necessary to have trained and experienced specialists in many different areas to provide the best care for these patients while waiting for a transplant and after the transplant, and they can be more easily attracted to and retained in programs where there are more patients to care for. It also requires dedicated inpatient and outpatient units with trained staff to care for these patients. In order to maintain proficiency and efficiency it is necessary to care regularly for these patients. There is some data that shows that programs with very low volumes and those with very high volumes have worse outcomes. Programs with low volumes obviously may be unable to provide enough resources to provide the quality of care required and when programs get too big patient care can suffer because the infrastructure cannot keep up with the volume. I think Paul has appropriately quoted the HRSA best practices evaluation and you can see that supporting and running a transplant program requires significant dedication of staff and resources in order to provide the kind of care you and I would want for a loved one. This simply does not make sense from a patient care or financial standpoint to have small programs in every hospital; this kind of duplication dilutes quality, reduces efficiency, and increases costs. The question we all have to ask is when will we have the will to make the obvious choices and limit the number of transplant programs.
Doug Hanto

Doug Hanto said...

Dear Anonymous,
The Transplant Institute at BIDMC is very committed to caring for all patients regardless of socioeconomic status. In fact a major focus of our Center for Transplant Outcomes and Quality Improvement within the Transplant Institute is to identify and eliminate disparities in access to transplant and in outcomes. Dr. Jim Rodrigue who heads our Behavioral Care Program in the Transplant Institute has an NIH grant to try to improve the rate of living kidney donation in underrepresented minorities and is having a phenomenal impact.
Doug Hanto

Anonymous said...

Doug,

Many thanks for your reply to my question. I appreciate that we don't want lots of small programs, for many reasons, including quality and cost. I just didn't know if the data on total transplant volume that Paul provided was the best or most appropriate metric to use to gauge which hospitals were sufficiently big. Now I know. Zelda

Anonymous said...

So the point your trying to make is that state officials and insurance regulators have to save us from those greedy not for profit hospitals who implement sub standard programs that are complicated and reduce efficiencies. Wow, since when did insurance companies become the good guys and not for profit hospitals (including their boards) becomes Wall Street Investment Banks?

Anonymous said...

You also overlooked Hartford Hospital because it has its' own agency(?). That agency should be consolidated into NE at the minimum.

Anonymous said...

Without meaning to be a complete ass ... What's your point? That the little tiny programs should voluntarily fold up, or that we need someone who can put them out of business? Or is this a precusor to your announcement that you're folding the BIDMC program into MGH's or Brigham & Womens'?

I understand the rationale for Centers of Excellence, and I wouldn't want to get a pancreas or intestinal xplnt at a place that does 20 or 30 a year ... but it's always the Other Guy's program that should close ...

And do you really think that closing programs is a function that payors should perform?? Don't they get enough heat for being the only rational voice in health care delivery?

Paul Levy said...

Yes, I think the payers should exercise some authority in this arena. Setting minimum standards, for example.