Beyond survival: Creation of a novel composite index to assess value-based care in liver transplantation

Value-based care is becoming increasingly integrated within health care, yet standardized measures of "value" in liver transplantation have not been established. We aim to define a novel composite index to assess value-based care across the spectrum of liver transplantation care.

We analyzed the Scientific Registry of Transplant Recipients (SRTR) Program Specific Reports published from 2018 to 2025. For each center, pretransplant value was defined as the transplant rate ratio divided by median time to transplant whereas post-transplant value was defined as risk-adjusted graft survival over median hospital length of stay. A Value Composite Index was constructed by summing normalized pre- and post-transplant components.

There was little correlation between each center's pre- and post-transplant value (Pearson r = 0.28). Among the top 10 composite value centers, concordance of pre- and post-transplant value rankings varied widely. Top-quartile composite value centers had higher annual transplant volumes (113 [interquartile range 65-149] vs 34.5 [17.3-65.5], P < .001) and greater overall offer-acceptance ratios (1.2 vs 0.7, P < .001) compared with their bottom quartile counterparts. Centers demonstrating high pretransplant value had no compromise in survival metrics, despite greater use of older and extended-criteria donors.

Composite value metrics can provide a more holistic assessment of liver transplant center performance. Efficiency and outcomes may coexist. Broader adoption of value-based metrics will be essential to advance equitable access, optimize resource use, and ensure the sustainability of liver transplantation as a curative therapy. Strategies that promote high value across the transplant continuum should be endorsed versus reliance on isolated metrics.