Kidney Graft Survival according to the Teaching Status of a Transplant Hospital Open Access

Maroney, Kieran (Spring 2020)

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Introduction: Graft survival is an important metric in which transplant hospitals are graded, yet disparities in kidney graft survival still exist even after accounting for patient and donor characteristics. Some research shows the teaching status of a hospital has impacts on patient outcomes, however this has not been assessed in kidney transplant patients. We aim to assess how the teaching status of a transplant hospital is associated with three-year graft failure. 

Methods: We examined first-time single organ kidney transplant recipients from the Scientific Registry of Transplant Recipients from January 2008 to January 2019, and linked data to the American Hospital Association Annual Survey to obtain information on teaching status of each transplant hospital determined as membership in the Council of Teaching Hospital of the Association of American Medical Colleges. Characteristics of transplant patients in teaching vs. non- teaching hospitals were compared using t-tests and chi-squared tests as appropriate. Differences in death censored three-year graft survival by teaching status were measured using the log-rank test. Using inverse probability weighting, the cause-specific association between teaching status and the cumulative incidence of three-year graft failure was assessed separately for both living and deceased donor transplants and accounted for patient clustering by transplant hospital.

Results: Of 152,603 patients, 83% were transplanted at hospitals classified as teaching hospitals. Teaching hospitals demonstrated lower three-year graft survival than non-teaching hospitals among deceased donor transplant recipients (log-rank p<0.001), but not living donors. The three-year rate of graft loss among deceased and living donor transplants in teaching hospitals was no different than non-teaching hospitals after adjusting for clustering, donor, recipient and hospital-level characteristics [Deceased Donor: Hazard Ratio: 1.07, 95% Confidence Interval (0.97-1.18); Living Donor: Hazard Ratio: 0.92, 95% Confidence Interval: (0.75-1.12)].

Conclusion: Transplant hospitals classified as teaching hospitals have an increased rate of graft loss among deceased donor kidney transplants compared to patients transplanted in non-teaching hospitals under specific definitions of teaching status. Future studies should examine the importance of various measurements of teaching status and processes of care that differ between teaching and non-teaching hospitals to reduce disparities in graft survival.

Table of Contents

Introduction 1

Methods 2

Study Design and Data Sources 2

Study Population 2

Definition of Teaching Status 3

Outcomes 3

Confounders/Missing Data 3

Statistical Methods 4

Results 5

Participant Characteristics 5

Kidney Graft Survival and Patient Mortality 6

Teaching Status and Graft Loss by Donor Type 7

Sensitivity Analysis for Teaching Status 7

Discussion 8

References 11

Tables 15

Table 1 Characteristics of First Time Single Organ Kidney Transplant Recipients (Jan. 2008 – Jan. 16th, 2019) 15

Table 2 Absolute Rates of 3 Year Graft Loss and Death among transplant patients, by Selected Characteristics (Jan. 2008 – Jan. 16th,2019) 17

Table 3 Results of Multivariable Analysis of Transplant Center Teaching Status with Three-Year Graft Loss for First Time Single Organ Kidney Transplant Recipients by Donor Type (Jan. 2008 – Jan. 16th, 2019) 18

Table 4 Sensitivity Analysis of Teaching Status Ascertainment and Three-Year Graft Loss for First Time Single Organ Kidney Transplant Recipients by Donor Type (Jan. 2008 – Jan. 16th, 2019)                                                                                 19

Figures 20

Figure 1 Study Flow Chart Describing Inclusion, Exclusion, and Data Linkage 20

Figure 2 Three-Year Death Censored Graft Loss by Teaching Status for First Time Deceased Donor Kidney Transplant Recipients (2008-2019) 21

Figure 3 Three-Year Death Censored Graft Loss by Teaching Status for First Time Living Donor Kidney Transplant Recipients (2008-2019) 22

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