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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.

The Journal of Surgical Research

|January 24, 2025

Summary

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.

Keywords:

Liver Pediatric Transplantation Value Volume

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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.