Assessing the Performance of Organ Transplant Programs: Liver and Heart Transplantation

08/01/1999

Assessing the Performance of Organ Transplant Programs: Liver and Heart Transplantation

Henry Krakauer Office of Health Policy, Office of the Assistant Secretary for Planning and EvaluationAugust, 1999

Overview

In its role under the National Organ Transplant Act as the responsible steward of the program of solid organ transplantation in the United States, the Department of Health and Human Services has carried out analyses of the three critical issues in transplantation. These are: (1) What is the likelihood that, having been declared a transplant patient by being placed on a waiting list, the patient will actually receive an organ within a reasonable amount of time, say one year? (2) What is the likelihood that the patient will, instead, die while awaiting transplantation? (3) And what is the probability that the patient will still be alive one year after having been placed on the list, whether or not he or she received a transplant?

The need for such analyses is highlighted by Figures A (for liver transplantation) and B (for heart transplantation). These figures present the fraction of centers (vertical axis) with actual transplant or waiting-list mortality rates (horizontal axes) and demonstrate the very wide variation among the centers in the rates of transplantation achieved for the patients within one year of being placed on the waiting list. In contrast, the variation in waiting-list mortality rates is much narrower and more clearly centered around an average or peak rate. This indicates that, unlike the probability of death, which is primarily but not solely determined by the clinical condition of the patient, many other considerations determine the probability of being transplanted.

This point is brought out more clearly in Figures C (liver) and D (heart) and in more detail in Tables A (liver) and B (heart). These tables and figures present center-specific risk-adjusted rates of transplantation or of death on the waiting list and the probability of still being alive overall one year after being placed on the waiting list. The risk-adjustment corrects, as best the currently available data permit, for the disparities in the clinical conditions at the time of listing of the patients accepted as candidates by the various centers.

Despite the risk-adjustment, a wide variation in center-specific outcomes is observed. In the case of liver transplantation, 10% of the centers have a standardized risk-adjusted rate of transplantation within one year of listing of 24.9% or less, and 10% have a rate of 71.2% or more. For the probability of dying within a year of listing while awaiting a liver transplant, the corresponding range is 7.7-22.3%, and for the probability of surviving one year as a candidate and/or recipient of the liver transplant the range is 65.3-85.9%. The ranges of standardized risk-adjusted probabilities for heart transplantation are: 35.8-71.8% (transplantation), 9.4-23.1% (death while awaiting a transplant), and 67.0-84.0% (one year survival).

In both liver and heart transplantation, about two-thirds of the deaths within a year of listing occur while awaiting the transplant. The two measures of mortality are strongly correlated, with about 50% of the variation among centers in risk-adjusted survival accounted for by risk-adjusted mortality on the waiting list.

In contrast, there is little correlation between the risk-adjusted rate of transplantation and risk-adjusted survival, none in the case of the liver. In other words, a more aggressive transplant policy does not necessarily achieve better ultimate results. This reinforces the point that the early performance of a transplant is not necessarily the best care that can be provided to a patient. The best care consists of a broad constellation of practices of the listing center and of other hospitals and care-givers to which the patient is subjected while awaiting transplantation, as well as during and after the transplantation itself.

In carrying out these analyses, the Department identified gaps in the currently available data collected by the Scientific Registry. Some additional clinical details about the condition of the patient at the time of listing will be helpful in improving risk-adjustment. Moreover, death is not the sole outcome that must be addressed in the evaluation of transplantation because it is not the sole factor that drives the care of the patient. A clear understanding of the morbidity (clinical complications) and of the impairment of the patient’s ability to function before and after transplantation is also indispensable. For this, the data are currently not available.

The Department, to fulfill its responsibility for review and oversight of transplantation in the United States, is currently reevaluating the objectives and functions of the Scientific Registry. Its goal is to assure that the Registry carries out on an ongoing and timely basis the assessments of the effectiveness of the transplant program in sustaining the life, health and functional capacities of transplant patients, and of the burdens associated with their care, needed

by the Department and by the transplantation community.

How to Read the Tables

The objective of the accompanying tables is to inform persons concerned with liver or heart transplantation, most particularly the patients, of the likelihood of three critical outcomes: (a) receiving a transplant within one year of being placed on the waiting list, (b) dying before receiving a transplant, and

(c) most importantly, still being alive at least one year after being placed on the waiting list. This information, which applies to an average candidate, is contained in the columns labeled Survival, subheaded Alive (at one year), and Experience on the Waiting List with subheadings Transplanted or Died (within 1 year). The outcomes are presented in two forms, Actual and Adjusted. The term Adjusted refers to a method for correcting for the differences in the severity of the illness of the patients taken care of by the different centers by projecting the center’s result, corrected for the severity of illness of its patients, on a standard population. If all patients received equally effective care, the centers’ adjusted rates would be identical. The differences among the centers in the adjusted rates, therefore, reflect the differences in how well the patients were cared for by the listing center as well as by other hospitals and care givers who participated in the management of the patients’ conditions.

The first column in each Table identifies by a code number the Center at which the patients were registered as candidates for transplantation. The column labeled Patients gives number of persons listed and provides an indication of how active that center is. The next two columns report on the probability of surviving one year after listing, whether or not a transplant was received - the “bottom line”. The remaining numerical columns provide information on the two principal alternative events that the patient may experience while awaiting a transplant – receipt of the transplant or death. A third alternative, which affects a very small proportion, removal from the waiting list, was also considered in the analyses. All the patients for whom data are displayed in these last columns were followed for at least a full year, hence the cutoff date of December 31, 1997 to permit follow up through 1998. Because of delays in reporting in the post-transplant period, an earlier cutoff date, December 31, 1996, was needed in the analysis of survival.

The ranges listed beneath the US averages cover the middle 80% of the centers. Thus, 10% of the centers had rates below the lower end of the range and 10% had rates above the upper end of the range. In the evaluation of performance, attention should principally focus on the magnitude of the difference between the center=s result and the US average. The ranges are provided to help the reader assess how much the experience of the patients of that center differs from the average.

An additional indication of the differences among the centers is given by the + and - signs to the right of the numbers that signify the rate. This indication addresses the statistical uncertainty about how precisely those differences can be measured. The uncertainty is greatest when few cases or patients are involved and smallest in the case of the high-volume centers. A single symbol indicates that the center=s outcome differs from what would be expected with reasonable certainty (less than 1 chance in 20 that the difference is due to chance only) and two symbols indicate considerable certainty (less than one chance in 100). A + sign indicates that the difference is in a favorable direction (higher probability of transplantation and of surviving at least one year, and lower probability of dying while awaiting a transplant), and a - sign indicates an unfavorable direction (lower than expected probability of transplantation, etc.). The difference between the result obtained at a center and the national average, taken together with this measure of uncertainty, is, therefore, an indication of how distinctively different the experience of the center’s patients is from the national average. (Please note that the measures of uncertainty apply to a pattern rather than specifically to the data provided in the Tables. For example, in the case of Survival, the analyses addressed the pattern of survival for a period of up to three years, and that is what is reported by the measure of the level of uncertainty, not just the result at one year given in the Table.)

How to Use the Tables

We have produced the accompanying Tables to draw on recent experience in liver and heart transplantation to help clinicians to provide and patients to obtain the best care possible. By describing what happened to patients following their acceptance as candidates for transplantation by the more than 100 transplant centers in the US, we hope to enable (1) patients and their physicians to make more informed choices, and (2) the transplantation community to more effectively examine its practices and identify those that offer the greatest benefits to the patients.

To compare the experiences of the patients of the various centers, attention should principally be given to the columns that contain the standardized, risk-adjusted data. The data for a particular center should be compared to the national average, given in the first line of each column, and to the range, given in the second line in each column. The range provides reference marks to calibrate the degree of concern with which a center’s difference from the national average should be viewed by giving the results obtained by the middle 80% of the centers, with 10% of the centers having results below the low end of the range and 10% above the high end of the range. The columns with the pluses and minuses give an indication of how (un)likely it is that the deviation from the national norm could have been due purely to chance. The pluses and minuses are not measures of how “good” or “bad” the centers are. A single plus or minus indicates a chance of less than one in 20 and two pluses or minus a chance of less than one in 100. But keep in mind that over 100 centers are listed in the Tables. That means that for 6 or 7 of them, the observed deviations could in fact be the result of statistical uncertainty at the 1 in 20 level, and for 1 or 2 at the 1 in 100 level.

Therefore, although the data given in the Tables are suggestive, they do not provide definitive proof of superior or inferior performance. What the data do clearly demonstrate is that there is, for the very effective life-saving treatments of heart and liver transplantation, wide variation in the results achieved at different centers, even after variations in the severity of illness of the patients of these centers are corrected for.

We began this note with the statement that the purpose of the Tables is to help us learn from experience. We must end with a word of caution. Whether we draw lessons correctly from experience depends entirely on how completely and accurately the patients, their severity of illness and what happened to them are known to us and on how good the analytic methods that we used are. We are confident about the methods because they have been well tested over the years. However, because the collection of the data about the patients and the clinical events they experience is a complex and arduous task, gaps do exist. In one extreme example, data on either the height or the weight of 80% of the patients of one center were unavailable, preventing the calculation in those cases of the body mass index, an important predictor in several analyses. Depending on how the missing data were handled in the analyses, the results at that center appeared either very good or just average. Therefore, the gaps in the data limit the accuracy of the assessments of performance that we can produce. We are confident about the pattern of variation that we observed, but less so about the position of any given center within that variation. We are currently working with the Scientific Transplant Registry to fill the gaps in the data and to further improve the analytic methods so that we may better determine what works best for patients.

Table A. The Risk-Adjusted Experience of Patients Registered for Liver Transplantation Within One Year of Being Placed on the Waiting List

                   Survival                     Experience on the Waiting List            (Listings, 4/94-112/96)               (Listings, 4/94-12/97)         Patients     Alive             Patients   Transplanted           Died                   (at 1 Year)                             (within 1 year)       Center         Actual  Adjusted                Actual  Adjusted    Actual  Adjusted  					      US  16,406    79.6%    79.6%        23,326    46.8%    46.8%      14.1%    14.1%  (Range[10-90%] 67.3-87.7 65.3-85.9            22.5-75.0 24.9-71.2  7.4-20.9  7.7-22.3)     12    108     76.2     77.7           175     17.7     20.8 --    20.0     21.3     13     42     83.1     75.0            44     54.5     61.7 ++    13.6     18.3  -     14    108     80.2     78.3           157     48.4     46.5       10.8     10.6     15    118     59.9     63.5 --        171     64.3     61.2 ++    22.8     24.7 --     16    280     78.6     82.8           355     44.5     51.3       16.6     14.1     17    340     79.2     76.6  -        469     19.4     23.3 --    16.4     19.8     18    190     79.3     76.7           258     50.8     50.5       13.2     14.6     19    186     78.7     79.1           226     55.3     52.1       11.1     10.7     20    235     70.6     71.1 --        296     75.3     73.7 ++    18.2     18.7 --     21     18     77.6     76.7            27     40.7     45.7       18.5     22.7     22     21     85.2     84.4            28     75.0     66.0  +     7.1     11.9     23    108     81.0     82.9           148     62.2     58.3 ++    12.2     12.7     25    377     71.5     73.1 --        524     46.6     43.2       20.4     22.1 --     26    202     82.9     82.5           268     58.2     55.0 ++    15.3     15.3  -     28    490     79.3     83.8  +        655     58.5     54.1 ++    15.9     13.8     29    100     75.2     73.5           150     21.3     22.9 --    17.3     19.3     30    556     73.7     77.1           837     69.2     67.4 ++    14.1     13.6 ++     31    268     83.2     78.3           364     34.9     37.9 --    14.0     19.3     32    717     78.3     81.6  +        989     50.3     49.8       14.7     12.6     33     96     76.8     79.5           150     20.7     30.0 --    18.7     18.3     34     26     61.5     60.8  -         37     59.5     52.8       24.3     25.5  -     35    149     83.0     85.6           206     72.3     67.6 ++    10.7     10.7     36    156     80.0     73.4           220     53.2     57.2 ++    11.4     14.7  -     37    151     79.4     78.3           225     34.2     37.4 --    16.4     17.3     38    178     81.4     78.3           267     54.7     58.3 ++    10.9     13.1     39    249     85.8     79.6  +        375     74.4     71.9 ++    11.2     12.1 ++     41     87     79.1     82.5           104     63.5     62.9 ++    10.6     11.2     42     93     79.4     79.8           153     75.8     72.9 ++    15.7     17.0 --     43     92     75.8     73.1           117     40.2     39.7  -    14.5     13.6     44     87     87.7     84.7           121     90.1     89.0 ++     7.4      7.7 ++     45     83     67.3     69.0  -        121     75.2     74.8 ++    14.0     13.8 ++     46    348     76.7     78.9 --        470     24.3     24.3 --    20.0     17.5 --     47    356     87.7     83.6 ++        493     22.5     24.2 --    11.2     14.6 --     48     94     79.6     77.3           130     63.8     63.1 ++    13.8     14.4  -     49     97     77.8     78.5           161     51.6     54.1       13.0     12.4     50     82     69.5     67.6 --        111     36.0     40.4       18.9     24.5  -     51    118     76.8     76.9           147     77.6     76.4 ++    11.6     11.6 ++       52    291     86.1     82.3  +        415     70.4     67.7 ++     9.4     12.2 ++     53    160     82.8     83.1  +        269     40.5     39.0 --    11.9     10.8 ++     54    145     83.8     81.0           199     52.8     51.7       12.1     12.1     55     94     73.4     72.0  -        136     40.4     42.4       18.4     22.3  -     56     49     72.7     75.2            91     57.1     57.7 ++    24.2     24.5 --     57    136     76.4     75.3           206     59.7     57.2 ++    17.0     18.9 --        58    164     84.4     79.8           213     25.8     29.3 --    15.5     18.1     59     97     72.9     68.9  -        168     57.7     54.9 ++    11.9     14.8     61    457     77.2     77.1           646     37.9     39.8 --    13.6     14.0  +     63    225     80.7     82.1           308     68.8     65.2 ++    10.1     10.8     64    112     76.3     77.9           174     52.9     55.9  +    11.5     10.7     65     69     77.8     76.2            88     59.1     55.2       14.8     15.7     66    247     72.9     79.2           409     36.4     37.6 --    18.3     15.4     67    262     80.3     80.4           392     65.8     66.1 ++    11.2     12.1 ++     68     55     90.9     89.1  +         90     56.7     54.9       12.2     12.7     69    259     80.2     76.7           366     23.0     28.2 --    13.4     17.0     70    177     62.4     63.9 --        208     35.1     34.7       32.2     33.1 --     71    338     75.6     78.5           433     32.3     32.6 --    18.5     14.9     72    113     83.7     84.3           173     81.5     79.7 ++     8.7      8.5 ++     73      8     62.5     67.2            46     65.2     62.2  +    21.7     18.8  -     74    128     71.5     77.2           158     34.2     30.3 --    20.9     16.4     75    112     79.8     80.0           148     52.0     46.0        8.8      8.3  +     76    154     78.1     78.4           261     34.9     44.8       10.3      9.6  +     77    128     77.0     77.2           231     20.3     23.1 --    16.5     16.5  -     78    673     80.1     79.3           854     48.0     47.0       12.5     11.7  +     79    101     60.6     66.3 --        150     66.0     70.8 ++    18.7     15.1 --     80    196     75.2     77.3           250     33.6     27.8 --    20.0     16.0  -     81     68     70.4     71.9  -        100     84.0     82.9 ++    14.0     15.5 --     82    232     77.5     75.8           324     44.4     42.6       20.1     21.4 --     83     32     75.0     71.4            45     68.9     65.6 ++    20.0     21.4 --     84      7     84.6     83.8            32     65.6     63.8 ++    12.5     15.3  -     85    120     83.0     81.2           211     46.4     53.0  +    14.7     14.8     86    266     86.7     85.6 ++        391     33.5     40.5 --     8.4     10.4 ++     87     41     73.2     65.3            68     20.6     21.7 --    17.6     21.4     88    720     79.3     82.9 ++       1042     62.9     56.3 ++    13.0     10.8     90    127     83.9     81.0           202     34.2     37.6 --    10.9     11.6  +     91    126     84.6     81.1           189     47.1     52.6       10.6     10.3     92      .        .        .            29     48.3     36.1       13.8     12.1     93     12    100.0     79.0            13     76.9     73.6        0.0      0.0 ++     94     45     72.6     79.4            66     68.2     58.5  +    15.2     14.8     95     16     86.2     85.7            29     37.9     35.5       13.8     12.1     96     11    100.0     91.3            16     75.0     60.9        0.0      0.0 ++     97     32     93.7     95.0  +         39     56.4     41.1        7.7      8.9     98     25     87.8     83.8            31     41.9     32.5        9.7     11.8     99     51     82.7     89.2  +         73     46.6     37.1        9.6      7.3  +    100     10     50.0     55.9  -         11     54.5     48.1 ++    45.5     51.9    102     32     87.0     85.2            35     28.6     17.3 --    14.3     16.4    103    156     74.3     73.6           208     37.0     27.2 --    21.6     21.8    104     41     85.3     89.6            53     84.9     72.8  +     5.7      6.4    105     33     84.1     86.2            51     62.7     50.9        5.9      6.7    106     33     84.8     85.3            41     65.9     51.6        7.3      9.3    108    112     87.3     86.7           143     39.9     41.2  -    10.5      9.9  +    109     58     78.0     79.7           102     47.1     43.8        9.8      7.2 ++    110    128     85.7     85.9  +        171     43.9     41.9  -     9.9     10.9    111    374     87.3     81.9  +        547     26.0     28.8 --    10.8     13.6 ++    112    777     89.8     88.1 ++       1024     21.2     25.1 --     9.7     11.2 ++    113     28     70.8     76.8            56     26.8     31.0  -    19.6     19.3    114     41     65.4     55.9  -         58     70.7     71.2 ++    15.5     17.0 --    115    177     78.6     85.2           250     65.6     65.6 ++     9.2      7.6    117     47     58.3     63.9 --         93     17.2     24.9 --    20.4     16.5    119      7     71.4     69.8            16     56.2     55.0       12.5     15.8    121     17     94.1     65.1            17     23.5     27.8  -     5.9      9.8    122     12     82.5     60.8            25     32.0     36.3       24.0     29.4    123    101     99.0     82.2 ++        214      0.9      2.6 --     1.9      4.7 ++    124      6     83.3     86.4            14     78.6     67.5        0.0      0.0 ++    125     47     68.5     58.1 --         65     43.1     44.9  -    26.2     28.1 --    126      6     50.0     74.6            20     40.0     54.3       15.0     12.3    127     24     31.7     51.2 --         30     60.0     57.6  +    26.7     24.6 --    128      5    100.0    100.0            10     20.0     23.9  -     0.0      0.0 ++    129     12     83.3     72.0            70     32.9     42.1       11.4     11.4

Table B. The Risk-Adjusted Experience of Patients Registered for Heart Transplantation Within One Year of Being Placed on the Waiting List

                  Survival                     Experience on the Waiting List            (Listings, 4/94-112/96)               (Listings, 4/94-12/97)         Patients     Alive             Patients   Transplanted           Died                   (at 1 Year)                             (within 1 year)  					     Center          Actual  Adjusted                Actual  Adjusted    Actual  Adjusted        US  10,034    75.8%    75.8%        13,448    53.7%    53.7%      16.5%    16.5%  (Range[10-90%] 64.4-83.5 67.0-84.0            35.0-72.7  35.8-71.8 10.0-24.7 9.4-23.1)                               1     38     77.6     71.3            58     60.3     62.6  +    19.0     18.0      6     43     70.5     76.0            52     42.3     46.9       23.1     20.7      7     66     70.5     69.2            82     74.4     71.4 ++    18.3     19.3 --      8     92     74.9     69.7           119     56.3     56.0       14.3     16.4      9     52     80.6     74.6            64     48.4     48.8       17.2     17.9     12     61     80.0     81.8            88     72.7     76.0 ++    13.6     13.0  +     15     54     65.1     53.3 --         65     24.6     30.5  -    20.0     28.7     16     63     74.5     75.1            86     65.1     65.7  +    17.4     15.2     17     75     89.2     79.6           116     63.8     70.7 ++     6.0      7.5     18    110     71.3     68.5 --        133     39.1     44.2  -    21.1     20.2     19     86     83.2     75.2           113     44.2     50.6        9.7     13.5     20     51     81.1     77.3            71     64.8     67.2  +     8.5     10.2     21     78     73.8     70.8            91     67.0     62.4  +    17.6     20.2  -     22     92     80.3     74.8           125     34.4     39.0 --    17.6     23.1     23     32     84.4     84.7            46     71.7     66.0        8.7     10.9     24     29     93.1     87.9            34     35.3     38.9 --     8.8      9.2  +     25    146     89.4     87.4  +        195     40.0     45.5 --    10.8     14.6  +     27     55     68.2     65.4            72     58.3     56.0       15.3     19.6     28    342     74.4     73.3           479     48.6     44.7 --    19.0     17.3 --     29     23     73.9     75.9            32     68.8     69.3        9.4      6.9     30    109     80.5     76.0           137     47.4     49.4  -    13.1     12.9  +     33     40     79.9     70.9            49     44.9     50.6       12.2     17.3     34     47     82.8     87.3            58     60.3     64.1        8.6     10.0     35     42     73.7     72.9            52     55.8     55.7       17.3     18.8     36     54     65.6     59.1  -         88     43.2     44.8       19.3     23.9     37    112     70.2     72.8           166     60.2     58.6       16.9     15.0     38     54     72.0     68.7            83     50.6     48.3       19.3     19.5     40    196     76.4     73.1           249     31.3     35.0 --    18.1     21.0     41     69     78.1     76.8            92     68.5     64.9 ++    16.3     18.1     42     43     82.0     82.0            66     65.2     63.2       13.6     12.1     43     64     65.5     70.3            79     63.3     62.6  +    20.3     18.4     44    247     80.0     78.8           327     74.6     71.1 ++    10.1     10.1     45    106     79.1     78.5           134     43.3     45.7  -    18.7     19.4     47     91     74.3     76.5           119     68.1     67.1 ++    16.8     17.5  -     48     41     69.9     73.8            55     67.3     64.7  +    18.2     16.4     49     34     70.4     67.7            40     32.5     33.5 --    22.5     19.8     50    148     74.9     74.1           203     71.4     71.8 ++    17.7     18.8 --     51     34     69.2     68.5            38     57.9     59.7       18.4     18.6     52    255     72.0     73.5  -        314     47.8     47.7 --    15.0     14.7 ++     53    129     64.4     67.1  -        162     56.2     56.6  +    24.1     22.7 --     54    117     74.3     70.4           141     41.1     41.2 --    18.4     22.8     57     62     79.0     79.1           101     62.4     60.3       14.9     15.1     58    116     66.0     69.0           155     51.6     51.8       21.9     21.4        59     44     75.9     73.8            59     49.2     51.8       25.4     23.5     60     80     80.7     75.3           113     43.4     45.8       16.8     19.6     61     42     80.9     80.5            54     51.9     51.9       11.1     11.4     62     66     60.6     67.5            97     49.5     46.6       32.0     31.1 --     63     99     84.4     78.3           123     28.5     31.9 --    12.2     16.2 ++     65     77     71.4     74.6            95     25.3     27.5 --    22.1     22.5     66    155     76.0     76.7           198     56.6     55.3       19.7     19.0  -     67     23     73.8     84.3 ++         26     42.3     39.1  -    15.4      8.8  +     68     59     74.4     71.4            78     67.9     68.4 ++    11.5     14.0     70     40     95.0     93.9 ++         50     62.0     64.8        4.0      6.5     71     60     73.3     73.0            93     54.8     53.6       16.1     19.9     72     49     73.4     74.3  -         68     73.5     73.1 ++    17.6     19.2 --     73     56     81.9     78.5            68     38.2     47.0  -    11.8     12.9     74     73     75.1     78.9            98     44.9     41.9       17.3     17.0     75     74     67.5     64.2            97     39.2     42.1       23.7     28.0     76    153     89.4     82.7  +        223     43.0     43.9 --    11.2     15.6  +     77     49     74.6     62.0            70     55.7     60.5       12.9     13.8     78     68     79.4     82.4            93     45.2     45.6 --    14.0     11.2 ++     79     55     87.1     86.4            83     67.5     67.1  +     6.0      5.3     80    100     80.9     74.5           126     47.6     56.2       14.3     16.2     81     70     75.7     68.3            88     51.1     51.1       18.2     22.8     82     18     69.1     81.2            25     48.0     50.7       16.0     12.3     83     70     76.6     73.0            97     42.3     42.7 --    15.5     14.8  +     84     46     83.5     83.1            60     43.3     43.5       16.7     19.4     85     24     66.7     68.4            37     48.6     48.2       27.0     23.7     87     62     75.8     73.9            80     41.2     41.2 --    18.8     18.7     88    171     83.1     84.0  +        225     68.9     71.0 ++    12.0     12.3     90     60     85.0     81.8            83     42.2     43.0  -    19.3     21.5     91     89     76.3     79.5  +        112     51.8     52.6       14.3     18.4     92     10     69.3     67.2            18     61.1     63.3       16.7     20.0     94     41     78.0     75.7            51     29.4     35.7 --    13.7     17.7     95     89     80.2     83.6           120     78.3     72.1 ++    10.0     11.0     96    119     80.3     77.0           180     58.3     56.6       16.1     16.0     97    157     72.0     64.8 --        206     33.0     38.8 --    20.9     26.9     98    138     81.0     80.3           192     68.8     69.6 ++     9.4      9.4     99     72     75.5     69.5           101     58.4     56.6       13.9     16.1    100     35     74.3     75.5            48     70.8     74.4 ++    18.8     18.6 --    101     32     65.6     63.9            46     65.2     65.3       10.9     10.2    102     21     68.1     84.6            40     62.5     72.4 ++    25.0     20.2 --    103     55     64.5     72.8            71     45.1     39.0  -    31.0     23.3    104    141     76.7     79.1           162     50.6     51.1       14.2     12.9    105     96     81.1     71.2           123     29.3     38.2 --    13.0     21.0    106    121     79.5     75.6           169     60.4     59.8       12.4     13.0    108     28     69.9     59.7            31     32.3     34.3       22.6     29.4    109     34     57.7     58.8  -         45     57.8     54.9       22.2     23.0    111     71     83.0     75.4            88     64.8     67.4 ++    10.2     13.7    112    146     77.9     76.0           198     40.9     41.3 --    15.7     20.0    113     33     74.9     74.5            42     71.4     70.0  +    14.3     16.2    114     21     60.5     62.6            24     37.5     35.2  -    20.8     16.9    115    204     72.8     73.4           260     35.8     35.8 --    20.8     21.4    118     38     49.7     57.2 --         40     50.0     50.8       30.0     24.0    119     18     82.5     77.1            40     40.0     39.9       17.5     21.3    120    317     79.3     81.4 ++        449     56.1     53.3       14.9     14.2    121    172     72.5     76.7           228     53.1     51.7       18.0     16.3    122     46     74.1     81.6            62     74.2     65.6       12.9      9.1    123     31     74.1     69.2            32     71.9     76.9 ++    21.9     18.3  -    124     97     70.1     75.7           136     54.4     49.5       24.3     19.8    125    338     76.7     78.3           509     55.8     57.8       14.9     14.2    126    111     75.0     73.5           146     56.2     53.3       15.1     16.7    128     19     78.6     85.4            28     57.1     47.3       25.0     15.6    129     11     81.8     87.4            19     84.2     89.7 ++    15.8     10.3    130      9     55.6     71.7            15     66.7     50.0       26.7     16.6    131     13     76.9     75.0            15     66.7     55.3       20.0     14.4    132     13     53.9     69.3            15     26.7     17.4 --    33.3     20.6    133     13     32.6     73.0            15     40.0        .       33.3        .    137     70     63.9     72.1            89     67.4     62.9       24.7     18.5    138     59     75.8     80.0            80     85.0     83.3  +    12.5     11.2    139     18     55.6     70.8            22     72.7     69.9       18.2     16.7    143     29     68.3     79.8            43     81.4     74.9        9.3      6.8    144     15     66.7     79.7            22     72.7     66.3       13.6      7.4    145     57     80.2     84.2  +         78     39.7     33.8 --    17.9     12.0 ++    146     31     62.9     80.2            40     35.0     26.6 --    32.5     15.6  +    147     39     55.8     77.7            62     48.4     37.0 --    30.6     14.4  +    148    105     71.5     80.6 ++        146     66.4     67.9 ++    17.8     14.8 ++    150     76     74.9     75.8           115     64.3     62.7 ++    18.3     17.0    151    139     78.0     77.5           190     61.6     60.5  +    15.3     14.8    152     46     84.7     80.5            68     52.9     58.1       10.3     11.1    154     41     79.7     78.2            60     71.7     73.8  +    13.3      8.1    156     86     87.2     83.0           110     77.3     75.8 ++    10.0     10.8    157     54     63.7     63.3            59     62.7     60.1  +    22.0     23.5  -    158     58     93.1     92.1 ++         94     89.4     84.8 ++     3.2      3.6    159     35     81.5     81.3            51     45.1     44.5  -    15.7     14.0    160     14     71.4     69.4            18     66.7     61.6       22.2     23.5    161     64     78.1     73.9            91     23.1     25.3 --    19.8     18.5  -    162     23     69.2     80.0  +         30     76.7     68.4       13.3      9.3  

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