A novel patient‐centered “intention‐to‐treat” metric of U.S. lung transplant center performance

Despite the importance of pretransplantation outcomes, 1‐year posttransplantation survival is typically considered the primary metric of lung transplant center performance in the United States. We designed a novel lung transplant center performance metric that incorporates both pre‐ and posttransplantation survival time. We performed an ecologic study of 12 187 lung transplant candidates listed at 56 U.S. lung transplant centers between 2006 and 2012. We calculated an “intention‐to‐treat” survival (ITTS) metric as the percentage of waiting list candidates surviving at least 1 year after transplantation. The median center‐level 1‐year posttransplantation survival rate was 84.1%, and the median center‐level ITTSwas 66.9% (mean absolute difference 19.6%, 95% limits of agreement 4.3 to 35.1%). All but 10 centers had ITTSvalues that were significantly lower than 1‐year posttransplantation survival rates. Observed ITTSwas significantly lower than expected ITTSfor 7 centers. These data show that one third of lung transplant candidates do not survive 1 year after transplantation, and that 12% of centers have lower than expected ITTS. An “intention‐to‐treat” survival metric may provide a more realistic expectation of patient outcomes at transplant centers and may be of value to transplant centers and policymakers. Incorporation of pretransplant survival time into a novel lung transplant center performance metric provides a realistic expectation of patient outcomes that may be of value to transplant centers and policymakers. Van Berkel provides words of caution in his editorial on page 11.