1. David Taber, Charles Bratton, Angello Lin, John McGillicuddy, Kenneth Chavin and Prabhakar Baliga

2. Define Health Care Value Health Care Value in Kidney Transplant Current and future challenges Study Design Study Results Discussion and Conclusions OUTLINE

3. RESULTS OF CARE ÷ COST NEJM 2010; 363:2477-81. (TRUE OUTCOMES per care cycle) (TOTAL OF ALL SERVICES to provide care during this cycle)

4. Measuring Health Care Value in Kidney Txp OUTCOMES COSTS Patient and Graft Survival 1, 3, 5, 10 year Graft Function (GFR) 1, 3, 5, 10 year Acute Rejection 3, 6, 12 month Infections 6, 12, >12 month Peri-Operative Urine leak, wound infection, hernia, NODAT, HTN, acute MI, etc… Indicators: LOS & Readmissions Organ Acquisition Surgery Medication Accommodations Imaging Laboratory PT/OT Clinic Visits Outpatient Procedures Additional Ancillary

5. Increased use of marginal donors

6. Higher risk donors (KDRI) KDRI 0.8 = 80% GS at 5 years KDRI 1.45 = 60% GS at 5 years

7. Older Recipients

8. More Comorbidities

9. AJT 2008;8(3):586-92.

10. Use of marginal donors and high-risk recipients has led to more complex post- operative management Stagnate or shrinking reimbursement rates Shrinking or negative net margins Future risks associated with lack of payment for readmissions

11. Retrospective cross-sectional analysis Utilized both UHC and SRTR data Compare outcomes at our center, benchmarked to national data Before, during and after quality initiatives implemented Outcomes measured LOS, readmissions, in-hospital complications, costs

12. STRUCTUREPROCESS Daily Rounds with Nephrologist Early dialysis for anuric/rising SrCr POD 2 – review need for dialysis, reserve chair for 7 AM Coordinate with need for medications with long infusions (rATG, IVIG) Daily clinic visits with nephrologist Revised DGF Protocols Discharge on POD 3 with daily clinic follow up by nephrologist Early referral back to home dialysis chair Protocol biopsies

13. Baseline Demographics MUSC Transplant Center National Transplant Centers P-value Age 18-34 35-49 50-64 65 15.3% 27.8% 38.4% 18.5% 14.0% 28.4% 41.2% 16.3% 0.317 Gender Male Female 58.5% 41.5% 60.8% 39.2% 0.258 Race/Ethnicity White Black Hispanic Asian Other 46.0% 50.8% 1.7% 0.9% 0.6% 53.6% 25.3% 14.2% 5.6% 1.4% <0.001 Primary Diagnosis Diabetes Hypertension Glomerulonephritis PKD Other 27.2% 35.4% 9.4% 8.7% 19.3% 24.8% 24.6% 19.2% 12.7% 18.7% <0.001 Insurance Private Medicare Other 24.7% 70.5% 4.8% 39.3% 54.7% 6.0% <0.001

14. Transplant Characteristics MUSC Txp Centers National Txp Centers p-value Donor Type Standard Deceased Donor Cardiac Death Donor Extended Criteria Donor Living Donor 72.2% 0.5% 9.8% 17.5% 51.0% 8.3% 10.5% 30.0% <0.001 Panel Reactive Antibody (PRA) 0-9% 10-79% 80% 42.0% 40.8% 17.2% 53.7% 27.0% 19.2% <0.001 HLA Mismatches 0 1-2 3+ 4.6% 2.9% 92.5% 7.9% 11.0% 80.2% <0.001 Cold Ischemic Time 0-11 hours 12-21 hours 22-31 hours 32-41 hours >41 hours 30.0% 44.3% 20.7% 1.7% 0.0% 29.9% 42.7% 17.5% 4.7% 1.5% <0.001 Re-Transplant 9.2%12.1%0.037 Induction Therapy IL2-RA T-cell Depleting 54.5% 44.7% 21.2% 61.6% <0.001 De novo Immunosuppression Tac & MMF 98.1% 81.2% <0.001

15. Transplant Outcomes MUSC Transplant Center National Transplant Centers p-Value Delayed Graft Function 12.1%23.9%<0.001 Graft Survival 6-month 1-year 97.7% 94.6% 95.3% 93.3% 0.190 1-Year Acute Rejection Rate 12.3%11.1%0.341

16. MUSC All Other Txp Centers

17. ALL PATIENTS DGF PATIENTS MUSC All Other Txp Centers MUSC All Other Txp Centers

18. ALL PATIENTS DGF PATIENTS MUSC All Other Txp Centers MUSC All Other Txp Centers

19. ALL PATIENTS DGF PATIENTS MUSC All Other Txp Centers MUSC

20. ALL PATIENTS DGF PATIENTS MUSC All Other Txp Centers MUSC All Other Txp Centers

21. Healthcare value can be significantly improved in kidney transplant recipients by implementing initiatives aimed at improving both the process and structure of how care is provided

22. Partner with other surgery types to demonstrate applicability and scalability Develop and submit prospective study in other organ transplant types Develop initiatives to reduce long-term readmissions