Advancing patient-centered metrics for heart transplantation: The role of days alive and outside the hospital.

Background: Heart transplantation (HT) survival and waitlist times are established outcome metrics. Patient-centered HT outcomes are insufficiently characterized. This study evaluates the role of days alive and outside the hospital (DAOH) as a candidate patient-centered HT performance measure.

Methods: The study cohort included Medicare beneficiaries undergoing HT (July 2008-December 2017). The percent of days outside of hospital (%DOH) 6 months before (%DOH-BF) and percent of days alive outside of hospital 12 months after HT (%DAOH-AF) were evaluated along with adverse events (AEs, early: ≤3 months; late: 4-12 months). Patients were stratified by patient %DAOH-AF terciles. Risk-adjusted %DAOH was evaluated across hospitals.

Results: A total of 5,104 beneficiaries underwent HT across 108 hospitals. Median [interquartile range (IQR)] age was 62 [53-67] years, 23.9% were female, and 21.4% were African-American. The overall median %DOAH-AF was 92.9% [83.8%, 95.9%], varying by tercile: low 71.8% [4.9%, 83.6%], intermediate 92.9% [91%, 94%]; high 96.4% [95.9%, 97.3%]. The lowest (vs highest) tercile %DAOH-AF had a lower median %DOH-BF (88% [73%-97%] vs 92% [81%-98%]) and longer post-HT inpatient stay (54 [36-81] vs 13 [10-15] days). After HT, the lowest versus highest tercile had greater AEs burden in the early (allograft failure [16.1% vs 1.6%], stroke [12.1% vs 2.3%]) and late (stroke [5.1% vs 1.9%], sternal wound infection [5.0% vs 0.8%]) phases post-HT. The mean hospital %DAOH was 80.5% (min:max 57.7%-96.7%).

Conclusions: Post-HT %DAOH varies across beneficiaries and hospitals and is associated with AEs. Further research is warranted to assess the role and validity of %DAOH as an HT quality metric.