THE RELATIONSHIP OF CLINICAL OUTCOMES TO STATUS AS A MEDICARE-APPROVED HEART-TRANSPLANT CENTER

This study reports the evaluation of the validity and utility of the M edicare heart transplant center selection process, as outlined in its 1986 Heart Coverage Regulations. A total of 9401 heart transplants per formed in the U.S. between 1986 and 1991 mere analyzed. The outcomes a ssessed were mortality and the occurrence of infection during the hosp ital stay. Outcomes experienced by centers with and without Medicare a pproval were compared directly and following adjustment for patient ri sk factors. Patients at centers that satisfied the Medicare criteria e xperienced lower mortality. The risk-adjusted hazard ratio for death o ver the five years of observation was 0.874 (P=0.005). The probability of death following a transplant at a Medicare-approved center was 7.0 +/-0.4% at 30 days and 16.2+/-0.6% at one year, and 9.2+/-0.4% and 19. 2+/-0.6%, respectively, at centers without Medicare approval (P=0.001) The difference appeared to be principally associated with death within 30 days of admission due to nonspecific graft failure. The posttransp lant infection rate at Medicare-approved centers was 0.743 (P<0.001) b ut this result is strongly confounded with differences in reporting pa tterns of the two types of centers. Criteria used by HCFA identify med ical centers where outcomes of heart transplantation, as measured by m ortality, are superior. This difference is established early, persists over time, and is not attributable to the numerous risk factors consi dered in our models. Overall, the results of the present study suggest that ''centers of excellence'' can be identified through the evaluati on of center characteristics and outcomes, and that this approach chos en by HCFA may have broad health care systems applications.