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Time for Demonstrating Quality and Accountable Care: Renal Transplantation Model

2013; Elsevier BV; Volume: 13; Issue: 5 Linguagem: Inglês

10.1111/ajt.12213

1600-6143

Kevin C. Mange,

Organ Donation and Transplantation

To the Editor: Dr. Axelrod (1Axelrod DA. Balancing accountable care with risk aversion: Transplantation as a model.Am J Transplant. 2013; 13: 7-8Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar) in his editorial, along with Schnier et al. (2Schnier KE Cox JC McIntyre C Ruhil R Sadiraj V Turgeon N. Transplantation at the nexus of behavioral economics and health care delivery.Am J Transplant. 2013; 13: 31-35Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar) and Schold et al. (3Schold JD Buccini LD Srinivas TR et al.The association of center performance evaluations and kidney transplant volume in the United States.Am J Transplant. 2013; 13: 67-75Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar), raise important points regarding factors that influence the practice of transplantation in the United States that could form the basis of a broader discussion leading to actionable proposals around enhancing the health of renal transplant recipients. The renal transplant community is an example in the US of a specialty summarizing mortality data at a center level, but with limited collection and reporting of data on morbidities. Incrementally, the dialysis community regularly summarizes measures, for example, hemoglobin, urea reduction ratios, to modify care towards favorably impacting outcomes. Schnier et al. describe that reporting mortality rates unintentionally has heightened risk adverse behavior of centers, which influences selection of patients eligible for listing based on potential impact on center performance. Dr. Axelrod correctly expands that presently the incomplete collection of and the absence of appropriate adjustment for significant confounders leads to incomplete understanding of the quality of care using metrics that are inadequate. This inadvertently intensifies risk aversion denying care to patients who may potentially derive the most relative benefit from transplantation compared to remaining on chronic dialysis, if not preemptively transplanted. Although Schold et al. support the possibility that centers have become more conservative in acceptance rates, they could not demonstrate that this is the case, perhaps reflective of the incomplete collection of relevant data, among other reasons. Dr. Axelrod alludes to that the time has emerged where we discuss accountable care within transplantation. Importantly, this discussion should not be in a punitive context, but rather in the context of how health care professionals, in collaboration with the patients themselves, can provide quality health. Arguably, this may not begin with the time of the transplant, but instead begins at time of listing. Ideally, this should commence at the time when chronic renal disease develops so that other concomitant chronic diseases that carry risks into the posttransplant period that are preventable or modifiable could still be impacted. Dr. Axelrod correctly refers to topics that require discussion—What is the population? Who is responsible? What and how do we measure? and the focus should be on the patient. I would supplement this last important point in how do we provide a coordinated level of care that achieves outcomes that are meaningful to the patient and that operates with quality, efficiency and costs centered on the patient. It is time that the transplantation community designs and affirms within a collaborative project how to provide coordinated quality care; perhaps leveraging applicable learning from the Physician Group Practice Demonstration project organized by the Center for Medicare and Medicaid Services (4Wilensky GR. Lessons from the Physician Group Practice Demonstration—A sobering reflection.New Engl J Med. 2011; 365: 1659-1660Crossref PubMed Scopus (37) Google Scholar). The renal transplant community is in advance of other medical specialties, having decades-long experience working in an environment centered around Medicare, bundled payments for services in some cases and experience in utilizing electronic medical systems, and is well suited to study this further. Perhaps transplantation can serve as a model, if not as a whole, at least in part, to other practices of medicine. The author of this manuscript has no conflicts of interest to disclose as described by the American Journal of Transplantation.