Improving Kidney Transplant Outcomes and Reducing Costs of Care through Better Pretransplant Operations - PROJECT ABSTRACT Kidney transplantation is the best treatment for end-stage renal disease (ESRD), but most patients with ESRD have no access. In 2023, 88,763 patients were on the deceased donor kidney transplant waitlist, yet only 27,332 transplants were performed. Over 200 kidney transplant programs In the United-States (US) deliver most of the nation’s transplant-related services. Transplant programs evaluate and select individuals to be added to the waitlist, maintain the waitlist, and manage both living donor work-up and deceased donor offers from organ procurement organizations. Collective, these activities are called pretransplant operations. Much of these pretransplant operations are not well-described, and the implications of operational differences are not understood. In addition to being opaque, current pretransplant operations leave gaping holes: 15-20% kidney offers between 2008-2015 were made to dead candidates; the most common reported reason for kidney discard is “no recipient located”; 26% of patients are added to the waitlist as “status inactive” (during which they are unable to receive kidney offers), and Hispanic and black patients are less likely to have this status inactivity resolved to regain transplant access. The specific practices leading to these undesirable outcomes need to be understood in order to increase transplant access to patients with ESRD. We will comprehensively characterize all US adult kidney transplant programs in terms of their pretransplant operation strategies and local conditions. Our central hypothesis is that some pretransplant strategies arise in response to local conditions, but transplant programs in similar locations can use different pretransplant operation strategies, resulting in differences in patient outcomes and cost of care. We will define the local conditions of transplant programs in terms of: 1) descriptive characteristics of patients with ESRD serviced and 2) deceased donor organ supply (based on geospatial and match run data). For the transplant program characteristics analysis, we will use program-level and patient-level outcomes from the Scientific Registry of Transplant Recipient and US Renal Data System; we will approximate costs from our pre-created organ acquisition cost center database and Medicare claims data collected in US Renal Data System. We hope to identify pretransplant operations which are associated with better program-level and patient-level outcomes, even after accounting for local conditions. We aim to provide the evidence base for concrete, actionable recommendations to transplant programs and their governing bodies to 1) improve programmatic and population outcomes within their community and 2) reduce the programmatic and population costs of care.
