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Quality and Value in Lung Transplant

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Joshua Mooney, MD
Stanford University
Stanford, CA, USA

During the 2016 ISHLT Annual Meetings President's Report a call was made to the society to "embrace the role of improving quality and value in the treatment of heart and lung failure." These terms, quality and value, have permeated healthcare discussions, news, and policy over recent years becoming widely accepted and emphasized metrics for healthcare performance. This development provokes questions for those in the field of thoracic transplant about how we should respond to the evolving focus of quality and value in healthcare delivery.

The lung transplant community has responded to date by acknowledging the resources associated with lung transplant and has worked to understand high resource events, such as the index transplant hospitalization and readmissions. In 2016 alone, the number of publications on resource utilization and readmissions in lung transplant grew exponentially from prior years [1-8]. These recent publications highlight the resources expended in lung transplant and identify factors contributing to high resource use, particularly readmissions. While the identified resource burden is significant so are the life-saving benefits that lung transplant provides to our patients. To ensure that cost saving measures do not adversely influence patient outcomes or inhibit innovation in our field it is imperative that the lung transplant community engages in the charge of measuring and improving quality and value in lung transplant.

A key question is how we should measure quality and value in lung transplant. Individual transplant centers are involved in quality monitoring but are transplant centers monitoring and seeking to improve patient-centered metrics or rather those centered on insurers and governing bodies. Quality metrics such as length of stay and readmissions are used across healthcare but how well do they translate to measuring quality and value in lung transplant. For instance, it remains unclear how preventable readmissions are in lung transplant. Some readmissions may be unavoidable and necessary for ensuring longer-term patient survival or quality. Other readmissions may result from initial surgical complications or breakdowns in transitions from inpatient to outpatient care. Whether we believe they are relevant or not, insurers and governing bodies are embracing these metrics and centers must focus on how to improve these metrics while ensuring the focus remains on the patient not on the number.

One way we can improve quality and value in lung transplant is to embrace the other call from the 2016 ISHLT president's report to "facilitate knowledge transfer from the high performers." Lung transplant centers around the world uniformly strive towards the goal of improving the lives of patients with advanced lung disease. Although this fundamental aim is broadly shared, there remains significant variation in how well individual transplant centers achieve it. This variation in care delivery is evident by differences in risk-adjusted survival between transplant centers with similar differences also seen in adjusted readmission rates and transplant admission cost. In short, there are centers that are providing higher value care, by achieving greater patient survival at lower cost. As we seek to improve value in lung transplant, we need to learn from these high value centers.

Learning from each other may entail positive outlier research where high value centers are identified and their care processes are reviewed. This approach has the potential to understand best center practices or care processes in lung transplant that could be translated to other programs. For example, ambulatory extracorporeal membrane oxygenation (compared to non-ambulatory) has shown to be a cost-savings way to bridge patients to lung transplant [2]. Identification of similar care practices has the potential to improve patient outcomes, quality, and value. Whether identified high value center practices could be generalizable and transferable to other centers is uncertain, and therefore testing of transplant care processes across multiple centers may be necessary.

Notably, the busyness of a transplant center is associated with value, as higher center volume is generally associated with better survival, lower readmissions, and lower cost [6]. This speaks to the importance of directly learned experience in lung transplant outcomes, quality, and value. Some countries already only provide care at regionalized transplant centers, however this approach may not be applicable to all countries and healthcare systems. Therefore, we are faced with the arduous task of improving quality and value in lung transplant through working together and facilitating knowledge transfer and education of high value care process that improve patient outcomes and lower cost. The value of lung transplant will ultimately be determined by how lung transplant is practiced which is something we are responsible for. Therefore, let us lead the way in improving lung transplant quality and value. ■

Disclosure Statement: The author has no conflicts of interest to disclose.


  1. Alrawashdeh M, Zomak R, Dew MA, Sereika S, Song MK, Pilewski JM, et al. Pattern and Predictors of Hospital Readmission During the First Year After Lung Transplantation. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2016.
  2. Bain JC, Turner DA, Rehder KJ, Eisenstein EL, Davis RD, Cheifetz IM, et al. Economic Outcomes of Extracorporeal Membrane Oxygenation With and Without Ambulation as a Bridge to Lung Transplantation. Respiratory care. 2016;61(1):1-7.
  3. Courtwright AM, Salomon S, Fuhlbrigge A, Divo M, Rosas IO, Camp PC, et al. Predictors and outcomes of unplanned early rehospitalization in the first year following lung transplantation. Clinical transplantation. 2016;30(9):1053-8.
  4. Lushaj E, Julliard W, Akhter S, Leverson G, Maloney J, Cornwell RD, et al. Timing and Frequency of Unplanned Readmissions After Lung Transplantation Impact Long-Term Survival. The Annals of thoracic surgery. 2016;102(2):378-84.
  5. Mollberg NM, Howell E, Vanderhoff DI, Cheng A, Mulligan MS. Health care utilization and consequences of readmission in the first year after lung transplantation. The Journal of Heart and Lung Transplantation.
  6. Mooney JJ, Weill D, Boyd JH, Nicolls MR, Bhattacharya J, Dhillon GS. Effect of Transplant Center Volume on Cost and Readmissions in Medicare Lung Transplant Recipients. Annals of the American Thoracic Society. 2016;13(7):1034-41.
  7. Schnitzler MA, Valapour M, Skeans MA, Axelrod DA, Lentine KL, Randall HB, et al. Economics. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2016;16 Suppl 2:169-94.
  8. Vogl M, Warnecke G, Haverich A, Gottlieb J, Welte T, Hatz R, et al. Lung transplantation in the spotlight: Reasons for high-cost procedures. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation. 2016.

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