Susan L. Smith, MN, PhD

Disclosures

March 31, 2003

Introduction

During the indemnity era of healthcare reimbursement when the financial risk was on the payer, outcomes assessment was not a highly valued endeavor to anyone other than a handful of academic researchers. In an increasingly cost-conscious healthcare environment, the healthcare industry is challenged to preserve the aspects of patient care associated with desirable patient outcomes. With the advent of prospective payment systems and the shift of financial risk to the provider, outcomes began to be factored into the equation use to determine what services are covered and who has access to those services. Healthcare providers, in turn, responded by more carefully and comprehensively measuring the outcomes of their products and services. Although cost is the historic driver in the purchase of healthcare, quality has emerged as a competitive factor and hospital organizations are challenged more than ever to document cost-effective outcomes.

The Changing Landscape of Transplantation

Solid organ transplantation has a brief history in the greater context of medicine and surgery, spanning little more than a half-century. Yet, in this relatively short period of time, organ transplantation has become the preferred treatment option for thousands of patients suffering from end-stage failure of vital organs. In response to the ever-escalating demand for transplantation, both the number of transplant centers and patients waiting for organs have increased sharply. In 2002, 24,833 solid organ transplants were performed at more than 250 transplant centers in the United States.

The evolution of outcomes assessment in transplantation is illustrated in the Figure. The initial clinical research focus in organ transplantation was the demonstration of technical (surgical) and survival outcomes. Clinical success was equated to the simple binary variable, survival. Next came the need to better understand the immune responses to successful transplantation and to test drugs for their efficacy in holding those responses at bay. With the advent of expensive new immunosuppressive agents, resource utilization became important. Today, complex patient-reported measures of quality of life and complex economic indicators have been added to the outcomes checklist to augment objective biologic measures. As clinicians mastered the learning curve of transplantation and as the length of patient survival increased, the focus of care changed from acute care to the full continuum of care, and success was no longer measured one patient at a time.

Figure.

Evolution of outcomes assessment in transplantation.

As the demand for donor organs continues to outstrip the supply, organ transplantation has become a victim of its own success. The major hurdle is no longer the immune response to foreign tissue. Now, the preeminent challenge is decreasing mortality on the ever-expanding waiting list that will soon reach 100,000 in number. Furthermore, managing the health and health outcomes of long-term survivors and the aging transplant recipient population is a new challenge in transplantation. The health problems of long-term survivors of transplantation are the same problems that confront other individuals as they age -- heart, bone, and cerebrovascular diseases -- only at a younger age and at an accelerated rate. An increasing number of patients are living 10, 20, and 30 years after transplantation. In the next decade, this new population of transplant recipients is likely to significantly increase in number. Transplant professionals must be prepared to deal with the emerging "epidemiology" of transplantation.

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