Division of Cardiovascular and Thoracic Surgery, Duke University, Durham, North Carolina.
Surgical Center for Outcomes Research, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina.
J Heart Lung Transplant. 2020 Apr;39(4):353-362. doi: 10.1016/j.healun.2019.12.010. Epub 2020 Jan 21.
Lung transplantation offers a survival benefit for patients with end-stage lung disease. When suitable donors are identified, centers must accept or decline the offer for a matched candidate on their waitlist. The degree to which variability in per-center offer acceptance practices impacts candidate survival is not established. The purpose of this study was to determine the degree of variability in per-center rates of lung transplantation offer acceptance and to ascertain the associated contribution to observed differences in per-center waitlist mortality.
We performed a retrospective cohort study of candidates waitlisted for lung transplantation in the US using registry data. Logistic regression was fit to assess the relationship of offer acceptance with donor, candidate, and geographic factors. Listing center was evaluated as a fixed effect to determine the adjusted per-center acceptance rate. Competing risks analysis employing the Fine-Gray model was undertaken to establish the relationship between adjusted per-center acceptance and waitlist mortality.
Of 15,847 unique organ offers, 4,735 (29.9%) were accepted for first-ranked candidates. After adjustment for important covariates, transplant centers varied markedly in acceptance rate (9%-67%). Higher cumulative incidence of 1-year waitlist mortality was associated with lower acceptance rate. For every 10% increase in adjusted center acceptance rate, the risk of waitlist mortality decreased by 36.3% (sub-distribution hazard ratio 0.637; 95% confidence interval 0.592-0.685).
Variability in center-level behavior represents a modifiable risk factor for waitlist mortality in lung transplantation. Further intervention is needed to standardize center-level offer acceptance practices and minimize waitlist mortality.
肺移植为终末期肺病患者提供了生存获益。当合适的供体被识别出来后，中心必须在他们的候补名单上接受或拒绝匹配的候选人。中心之间接受或拒绝供体的差异程度如何影响候选者的生存尚未确定。本研究的目的是确定每个中心接受肺移植的接受率的差异程度，并确定其对每个中心等待名单死亡率差异的相关影响。
我们使用注册数据对美国等待肺移植的候选者进行了回顾性队列研究。逻辑回归用于评估接受与供体、候选者和地理因素的关系。将列出的中心作为固定效应进行评估，以确定调整后的每个中心接受率。采用 Fine-Gray 模型进行竞争风险分析，以确定调整后的每个中心接受率与等待名单死亡率之间的关系。
在 15847 个独特的器官供体中，有 4735 个（29.9%）被第一顺位候选人接受。在调整了重要的协变量后，移植中心的接受率差异显著（9%-67%）。调整后的中心接受率较高与 1 年等待名单死亡率较低相关。调整后的中心接受率每增加 10%，等待名单死亡率的风险降低 36.3%（亚分布风险比 0.637；95%置信区间 0.592-0.685）。
中心层面行为的差异是肺移植等待名单死亡率的一个可改变的危险因素。需要进一步干预来规范中心层面的接受率，以最小化等待名单死亡率。
