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- Title
Selection Bias in Reporting of Median Waiting Times in Organ Transplantation.
- Authors
Schwab, Simon; Elmer, Andreas; Sidler, Daniel; Straumann, Lisa; Stürzinger, Ueli; Immer, Franz
- Abstract
Key Points: Question: What is the best way to estimate how long candidates wait to receive an organ transplant in Switzerland? Findings: In a national cohort study of 3643 participants, the median time to transplant was 0.9 years for heart, 3.1 years for kidney, 1.3 years for liver, 0.8 years for lungs, and 1.6 years for pancreas and/or islet. Competing-risk multistate models were more appropriate than median waiting time among recipients, which underestimated waiting times and had selection bias; the Kaplan-Meier estimator also slightly underestimated waiting times. Meaning: These findings suggest that transplant organizations should adopt appropriate competing-risk methods to address censoring and competing events when reporting waiting times in organ transplantation. Importance: Median organ waiting times published by transplant organizations may be biased when not appropriately accounting for censoring, death, and competing events. This can lead to overly optimistic waiting times for all transplant programs and, consequently, may deceive patients on the waiting list, transplant physicians, and health care policymakers. Objective: To apply competing-risk multistate models to calculate probabilities for transplantation and adverse outcomes on the Swiss national transplant waiting list. Design, Setting, and Participants: The WAIT (Waitlist Analysis in Transplantation) study was a retrospective cohort study of all transplant candidates in Switzerland listed from January 1, 2018, or later and observed until December 31, 2023. Transplant candidates were listed in 1 of the 6 transplant centers (Basel, Bern, Geneva, Lausanne, St Gallen, and Zurich) for heart, liver, lungs, kidney, or pancreas and/or islet transplant. A total of 4352 candidates were listed during the study period, of whom 709 (16.3%) were excluded due to living-donor transplant (691 in the kidney program and 18 in the liver program). Exposure: Waiting for organ transplant. Main Outcomes and Measures: Time to transplantation, death, or delisting. Competing-risk multistate models were used to analyze time-to-event data from the national organ waiting list with the Aalen-Johansen estimator to compute probabilities for both transplant and adverse outcomes. Results were compared with the sample median among only those undergoing transplant and the Kaplan-Meier method with censoring of competing events. Results: Data from 3643 transplant candidates (2428 [66.6%] male; median age, 56 [range, 0-79] years) were included in the analysis. The median time to transplantation (MTT) was 0.91 (95% CI, 0.83-1.07) years for heart, 3.10 (95% CI, 2.57-3.77) years for kidney, 1.32 (95% CI, 0.76-1.55) years for liver, 0.80 (95% CI, 0.37-1.12) years for lung, and 1.62 (95% CI, 0.91-2.17) years for pancreas and/or islet programs. Alternative estimation methods introduced bias to varying degrees: the sample median among only persons undergoing transplantation underestimated the waiting time by 38% to 61% and the Kaplan-Meier method by 2% to 12% compared with the MTT. Conclusions and Relevance: In this cohort study of transplant candidates in Switzerland, the MTT, the duration at which the transplant probability is 0.50, was used as a measure of average waiting time. Suboptimal methods led to biased and overly optimistic waiting time estimations; thus, applying appropriate competing-risk methods to address censoring and competing events is crucial. This cohort study applies a competing-risk multistate model to compute probabilities for both transplant and adverse outcomes among individuals on the Swiss national transplant waiting list.
- Subjects
SWITZERLAND; KIDNEY transplantation; TRANSPLANTATION of organs, tissues, etc.; PATIENTS; ACADEMIC medical centers; LUNG transplantation; DEATH; PROBABILITY theory; RETROSPECTIVE studies; DESCRIPTIVE statistics; RESEARCH bias; LONGITUDINAL method; KAPLAN-Meier estimator; HEART transplantation; PANCREAS transplantation; MEDICAL records; ACQUISITION of data; QUALITY assurance; SURVIVAL analysis (Biometry); DATA analysis software; CONFIDENCE intervals; TIME; DISEASE incidence; LIVER transplantation
- Publication
JAMA Network Open, 2024, Vol 7, Issue 9, pe2432415
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2024.32415