Characteristics Associated With High-Performing Pediatric Heart Transplant Centers in the United States From 2006 to 2015
Authors: Tajinder P. Singh, Mandeep R. Mehra, Kimberlee Gauvreau
Journal: JAMA Network Open (2020)

<h3>Importance</h3> 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. <h3>Objective</h3> To understand characteristics associated with high-performing pediatric HT centers by comparing key outcomes among centers stratified by 90-day risk-adjusted mortality. <h3>Design, Setting, and Participants</h3> 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. <h3>Exposures</h3> High-, medium-, and low-performing centers (SMR tertile). <h3>Main Outcomes and Measures</h3> Posttransplant 90-day mortality across recipient risk spectrum and incidence of and mortality following early posttransplant complications. <h3>Results</h3> 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 (<i>P</i>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 (<i>P</i>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%;<i>P</i>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%;<i>P</i>for trend &lt; .001). <h3>Conclusions and Relevance</h3> 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.