Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.
Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
JAMA Netw Open. 2020 Nov 2;3(11):e2023515. doi: 10.1001/jamanetworkopen.2020.23515.
Differences among pediatric transplant centers in long-term survival of pediatric recipients of heart transplants can be mostly explained by differences in 90-day mortality.
To understand characteristics associated with high-performing pediatric HT centers by comparing key outcomes among centers stratified by 90-day risk-adjusted mortality.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included recipients of HT aged younger than 18 years in the US. Analyses included 44 US centers during 2006 to 2015 using the Organ Procurement and Transplant Network database. A risk model for 90-day mortality was developed using data from all recipients to estimate expected 90-day mortality and 90-day standardized mortality ratio (SMR; calculated as observed mortality divided by expected mortality) for each center. Centers were stratified into tertiles by SMR and compared for key outcomes. Data were analyzed from January to March 2020.
High-, medium-, and low-performing centers (SMR tertile).
Posttransplant 90-day mortality across recipient risk spectrum and incidence of and mortality following early posttransplant complications.
Of 3211 children analyzed, 1016 (31.6%) were infants younger than 1 year and 1459 (45.4%) were girls. The median (interquartile range) age was 4 (0-12) years. Centers were stratified by SMR tertile, and SMR was 0 to 0.71 among 15 high-performing centers, 0.79 to 1.12 among 14 medium-performing centers, and 1.19 to 3.33 among 15 low-performing centers. High-performing centers had 90-day mortality of 0.8% (95% CI, 0.3%-1.8%) in children with low risk and expected mortality of 2.0%, 2.3% (95% CI, 0.6%-5.7%) in children with intermediate risk and expected mortality of 6.5%, and 16.7% (95% CI, 7.9%-29.3%) in children with high risk and expected mortality of 30.8%. Incidence of acute rejection during transplant hospitalization was 10.3% at high-performing centers, 10.3% at medium-performing centers, and 9.7% at low-performing centers (P for trend = .68), and incidence of post-HT kidney failure requiring dialysis was 4.1% at high-performing centers, 5.2% at medium-performing centers, and 8.5% at low-performing centers (P for trend = .001). Ninety-day mortality was significantly lower at high-performing centers among children treated for rejection (high-performing: 2.0%; medium-performing: 6.9%; low-performing: 11.7%; P for trend = .006) and among recipients receiving dialysis for post-HT kidney failure (high-performing: 17.5%; medium-performing: 39.4%; low-performing: 47.6%; P for trend < .001).
This cohort study found that high-performing pediatric HT centers had lower 90-day mortality across the recipient risk spectrum and lower mortality among recipients who develop rejection or post-HT kidney failure during transplant hospitalization. These findings suggest presence of superior processes and systems of care at high-performing pediatric HT centers.
重要性：儿科心脏移植受者的移植中心在长期生存率方面的差异主要可以用 90 天死亡率的差异来解释。
目的：通过比较按 90 天风险调整死亡率分层的中心之间的关键结果，了解与高表现儿科 HT 中心相关的特征。
设计、地点和参与者：本回顾性队列研究纳入了美国年龄在 18 岁以下接受 HT 的受者。使用器官获取和移植网络数据库，分析了 2006 年至 2015 年期间的 44 个美国中心。使用所有受者的数据开发了一个 90 天死亡率风险模型，以估计每个中心的 90 天预期死亡率和 90 天标准化死亡率比（SMR；计算为观察死亡率除以预期死亡率）。根据 SMR 将中心分层为三分位，并对关键结果进行比较。数据于 2020 年 1 月至 3 月进行分析。
暴露：高、中、低表现中心（SMR 三分位）。
主要结果和措施：在整个受者风险谱中移植后 90 天的死亡率，以及早期移植后并发症的发生率和死亡率。
结果：在分析的 3211 名儿童中，1016 名（31.6%）为年龄小于 1 岁的婴儿，1459 名（45.4%）为女孩。中位（四分位间距）年龄为 4（0-12）岁。根据 SMR 三分位分层，15 个高表现中心的 SMR 为 0 至 0.71，14 个中表现中心的 SMR 为 0.79 至 1.12，15 个低表现中心的 SMR 为 1.19 至 3.33。高表现中心中低风险且预期死亡率为 2.0%的患儿 90 天死亡率为 0.8%（95%CI，0.3%-1.8%），中风险且预期死亡率为 6.5%的患儿为 2.3%（95%CI，0.6%-5.7%），高风险且预期死亡率为 30.8%的患儿为 16.7%（95%CI，7.9%-29.3%）。高表现中心在移植住院期间急性排斥反应的发生率为 10.3%，中表现中心为 10.3%，低表现中心为 9.7%（趋势 P=0.68），HT 后需要透析的肾衰发生率为 4.1%，中表现中心为 5.2%，低表现中心为 8.5%（趋势 P=0.001）。在因排斥反应而接受治疗的儿童中，高表现中心的 90 天死亡率明显较低（高表现：2.0%；中表现：6.9%；低表现：11.7%；趋势 P=0.006），在因 HT 后肾衰而接受透析的受者中，高表现中心的死亡率也明显较低（高表现：17.5%；中表现：39.4%；低表现：47.6%；趋势 P<0.001）。
结论和相关性：本队列研究发现，高表现儿科 HT 中心在整个受者风险谱中 90 天死亡率较低，在移植住院期间发生排斥反应或 HT 后肾衰的受者死亡率较低。这些发现表明高表现儿科 HT 中心存在优越的护理流程和系统。
