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Finding Value in Pediatric Liver Transplantation: When Does Volume Matter?
Benjamin K Wang1, Madhukar S Patel1, Christine Hwang1
1Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
Insights
Higher volume pediatric liver transplant centers improve outcomes for very young recipients (0-4 years). This suggests regionalizing care for these patients may enhance graft survival and value-based outcomes.
Area of Science:
- Pediatric Surgery
- Transplantation Medicine
- Health Services Research
Background:
- Pediatric liver transplantation significantly improves survival rates.
- Value-based healthcare models are increasingly important but understudied in pediatric transplantation.
- Defining value in pediatric liver transplantation is crucial for optimizing outcomes and managing costs.
Purpose of the Study:
- To investigate the relationship between pediatric liver transplant center volume and value of care.
- To assess how center volume impacts graft survival and resource utilization in pediatric liver transplant recipients.
- To determine if a volume-value relationship exists across different pediatric age groups.
Main Methods:
- Analysis of deceased donor pediatric liver transplant recipients (n=5770) from 2002-2019 using UNOS data.
- Centers categorized into volume tertiles (small, medium, large); recipients stratified by age (0-4, 5-11, 12-18 years).
- Value defined as % 1-year graft survival / mean post-transplant length of stay; Mahalanobis matching used to control for confounders.
Main Results:
- Large centers showed better 1-year graft survival (93.7%) than small centers (89.4%) without increased length of stay.
- A volume-value relationship (better outcomes, less resource use) was observed in the 0-4 age group.
- The 0-4 age group had the highest proportion of status 1B patients and partial allograft use.
Conclusions:
- Liver transplant center volume is associated with value in very young (0-4 years) pediatric recipients.
- Higher volume centers provide improved survival for this young population.
- Regionalization of care may be beneficial for improving outcomes in very young pediatric liver transplant recipients.
Introduction:
Pediatric liver transplantation provides substantial survival benefit. An emphasis on value-based practices has become a central theme in many surgical fields, but have not been well-studied in pediatric transplantation. Given an increasing focus on optimizing outcomes while containing costs, defining value in pediatric liver transplantation warrants investigation.
Methods:
Pediatric end-stage liver disease -era deceased donor pediatric liver transplant recipients from 2/2002 to 2/2019 were identified using the United Network for Organ Sharing Standard Transplant Analysis file data (n = 5770). Liver centers were divided into volume tertiles (small, medium, and large), and recipients were stratified by age (0-4, 5-11, and 12-18 y). The value for the index transplant episode was defined as % graft survival ≥1 y divided by mean post-transplant length of stay. Nearest-neighbor Mahalanobis metric matching was used to account for confounding when assessing the impact of center volume on value.
Results:
Compared to small centers, large centers delivered better outcomes (1-y graft survival 93.7% versus 89.4%, P = 0.017) without increased resource utilization (length of stay 20.8 ± 15.6 d versus 19.6 ± 17.0, P = 0.281) during the 17-y study period. Mahalanobois-matched cohorts demonstrated a volume-value relationship (higher value care with better outcomes and decreased resource utilization) in the 0-4 age group, but not in older recipients. The 0-4 age group comprised the largest proportion of status 1B patients (21.8%, P < 0.001) and the highest utilization rate of partial liver allografts (40.9%, P < 0.001).
Conclusions:
There is value in liver transplant volume in very young (0-4 y) deceased donor pediatric patients. Given improved survival of these patients in higher volume centers, regionalization of care may benefit this specific population of recipients.
