TY - JOUR
T1 - Is there value in volume? An assessment of liver transplant practices in the United States since the inception of MELD
AU - Patel, Madhukar S.
AU - Wang, Benjamin K.
AU - MacConmara, Malcolm P
AU - Hwang, Christine
AU - Shah, Jigesh A.
AU - De Gregorio, Lucia
AU - Hanish, Steven I.
AU - Desai, Dev M.
AU - Zhang, Song
AU - Zeh, Herbert J.
AU - Vagefi, Parsia A.
N1 - Publisher Copyright:
© 2022 Elsevier Inc.
PY - 2022/10
Y1 - 2022/10
N2 - Background: Liver transplantation has increased in volume and provides substantial survival benefit. However, there remains a need for value-based assessment of this costly procedure. Methods: Model for end stage liver disease era adult recipients were identified using United Network for Organ Sharing Standard Transplant Analysis file data (n = 75,988) and compared across time periods (period A: February 2002 to January 2007; B: February 2007 to January 2013; C: February 2013 to January 2019). Liver centers were divided into volume tertiles for each period (small, medium, large). Value for the index transplant episode was defined as percentage graft survival ≥1 year divided by mean posttransplant duration of stay. Results: All centers increased value over time due to ubiquitous improvement in 1-year graft survival. However, large centers demonstrated the most significant value change (large +17% vs small +7.0%, P < .001) due to a –8.5% reduction in large centers duration of stay from period A to C, while small centers duration of stay remained unchanged (–0.1%). Large centers delivered higher value despite more complex care: older recipients (54.8 ± 10.3 vs 53.0 ± 11.4 years P < .001), fewer model for end stage liver disease exceptions (34.0% vs 38.2%, P < .001), higher rates of candidate portal vein thrombosis (10.1% vs 8.5%, P < .001) and prior abdominal surgery (43.4% vs 37.4%, P < .001), and more marginal donor utilization (donor risk index 1.45 ± 0.38 vs 1.36 ± 0.33, P < .001). Mahalanobis metric matching demonstrated that compared with small centers, large centers progressively shortened recipient duration of stay per transplant in each period (A: –0.36 days, P =. 437; B: –2.14 days, P < .001; C: –2.49 days, P < .001). Conclusion: There is value in liver transplant volume. Adoption of value-based practices from large centers may allow optimization of health care delivery for this costly procedure.
AB - Background: Liver transplantation has increased in volume and provides substantial survival benefit. However, there remains a need for value-based assessment of this costly procedure. Methods: Model for end stage liver disease era adult recipients were identified using United Network for Organ Sharing Standard Transplant Analysis file data (n = 75,988) and compared across time periods (period A: February 2002 to January 2007; B: February 2007 to January 2013; C: February 2013 to January 2019). Liver centers were divided into volume tertiles for each period (small, medium, large). Value for the index transplant episode was defined as percentage graft survival ≥1 year divided by mean posttransplant duration of stay. Results: All centers increased value over time due to ubiquitous improvement in 1-year graft survival. However, large centers demonstrated the most significant value change (large +17% vs small +7.0%, P < .001) due to a –8.5% reduction in large centers duration of stay from period A to C, while small centers duration of stay remained unchanged (–0.1%). Large centers delivered higher value despite more complex care: older recipients (54.8 ± 10.3 vs 53.0 ± 11.4 years P < .001), fewer model for end stage liver disease exceptions (34.0% vs 38.2%, P < .001), higher rates of candidate portal vein thrombosis (10.1% vs 8.5%, P < .001) and prior abdominal surgery (43.4% vs 37.4%, P < .001), and more marginal donor utilization (donor risk index 1.45 ± 0.38 vs 1.36 ± 0.33, P < .001). Mahalanobis metric matching demonstrated that compared with small centers, large centers progressively shortened recipient duration of stay per transplant in each period (A: –0.36 days, P =. 437; B: –2.14 days, P < .001; C: –2.49 days, P < .001). Conclusion: There is value in liver transplant volume. Adoption of value-based practices from large centers may allow optimization of health care delivery for this costly procedure.
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U2 - 10.1016/j.surg.2022.05.001
DO - 10.1016/j.surg.2022.05.001
M3 - Article
C2 - 35871852
AN - SCOPUS:85134777177
SN - 0039-6060
VL - 172
SP - 1257
EP - 1262
JO - Surgery (United States)
JF - Surgery (United States)
IS - 4
ER -