Cramm Shannon L, Waits Seth A, Englesbe Michael J, Bucuvalas John C, Horslen Simon P, Mazariegos George V, Soltys Kyle A, Anand Ravinder, Magee John C
1 Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, MI. 2 Pediatric Liver Care Center, Cincinnati Children's Hospital, Cincinnati, OH. 3 Division of Gastroenterology, Seattle Children's Hospital, Seattle, WA. 4 Department of Surgery, University of Pittsburgh, Pittsburgh, PA. 5 The EMMES Corporation, Rockville, MD.
Transplantation. 2016 Apr;100(4):801-7. doi: 10.1097/TP.0000000000001121.
Significant intercenter variation exists in mortality and death-censored graft loss (DCGL) after transplantation. Failure to rescue (FTR, death after a major complication) is an emerging tool in quality improvement and may underlie this variation. This study is the first effort to investigate the relationship between FTR and outcomes in transplantation to assess its utility in care improvement.
Using the Studies of Pediatric Liver Transplantation database, we identified 2330 children undergoing primary liver transplants at 21 centers. Centers were ranked by risk-adjusted mortality and sorted into tertiles. We then compared mortality, complications, and FTR across tertiles.
Overall mortality was 4.9%, ranging from 1.4% to 8.1% in the low and high mortality tertiles (P < 0.01). The low mortality tertile had significantly lower rates of complications (30.9% vs 38.5% and 40.4%, P < 0.01) as well as FTR (4.6% vs 9.9% and 14.3%, P < 0.01). A similar trend was seen in the DCGL analysis.
Our results demonstrate that although centers with higher mortality and DCGL have more frequent major complications, they exhibit 3-fold the rate of FTR. Efforts to standardize perioperative care, and thus minimize FTR, will have value to pediatric liver transplantation recipients. This preliminary study indicates that FTR may provide a useful quality improvement tool for the field of transplantation and warrants further investigation.
移植后死亡率和死亡删失移植物丢失（DCGL）存在显著的中心间差异。抢救失败（FTR，重大并发症后死亡）是质量改进中一种新兴工具，可能是造成这种差异的原因。本研究首次探讨FTR与移植结局之间的关系，以评估其在改善护理方面的效用。
利用儿童肝移植研究数据库，我们确定了在21个中心接受初次肝移植的2330名儿童。根据风险调整后的死亡率对中心进行排名，并分为三分位数。然后我们比较了三分位数之间的死亡率、并发症和FTR。
总体死亡率为4.9%，低死亡率和高死亡率三分位数分别为1.4%至8.1%（P<0.01）。低死亡率三分位数的并发症发生率（30.9%对38.5%和40.4%，P<0.01）以及FTR（4.6%对9.9%和14.3%，P<0.01）显著更低。DCGL分析中也观察到类似趋势。
我们的结果表明，尽管死亡率和DCGL较高的中心有更频繁的重大并发症，但它们的FTR发生率是其三倍。标准化围手术期护理的努力，从而尽量减少FTR，对儿童肝移植受者将具有价值。这项初步研究表明，FTR可能为移植领域提供一种有用的质量改进工具，值得进一步研究。
