1 research outputs found
Value Based Care in Transplantation: Is There Value in Volume? An Assessment of Liver Transplant Practices in the United States
No full textThe general metadata -- e.g., title, author, abstract, subject headings, etc. -- is publicly available, but access to the submitted files is restricted to UT Southwestern campus access and/or authorized UT Southwestern users.BACKGROUND: Liver transplantation has increased in volume and provides substantial survival benefit. Value-based practice has become a central theme in many surgical fields but has not been well studied in liver transplantation. Given an increasing focus on optimizing outcomes with containing costs, defining value in liver transplantation warrants investigation.
OBJECTIVE: We hypothesize value in liver transplantation has improved over time, and centers that perform more transplants (i.e. high volume centers), deliver more value.
METHODS: MELD era adult (n=75,988) and pediatric (n=5,770) liver transplant recipients were identified using UNOS STARfile data and compared across time periods (Period A: 2/2002-1/2007, B: 2/2007-1/2013, C: 2/2013-1/2019). Status 1, multiorgan, living donor, lost to follow-up, retransplants, and recipients dying during index post-transplant hospitalization were excluded. Liver centers were divided into volume tertiles for each period (small, medium, large) based upon the cumulative number of transplants completed at each center during each analysis period, and pediatric recipients were further stratified by age (0-4, 5-11, 12-18 years). Value for the index transplant episode was defined as % graft survival ≥ 1 year divided by mean post-transplant length-of-stay (LOS). The statistical analyses were performed using Stata 16/MP4 (StataCorp LP, College Station, TX), and p values < 0.05 (2-tailed) were considered statistically significant. Nearest-neighbor Mahalanobis metric matching was used to account for confounding when assessing the impact of center volume on value.
RESULTS: Adult 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<0.001) due to a -8.5% reduction in large centers LOS from Period A to C, while small centers LOS 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<0.001), fewer MELD exceptions (34.0% vs 38.2%, p<0.001), higher rates of candidate portal vein thrombosis (10.1% vs 8.5%, p<0.001) and prior abdominal surgery (43.4% vs 37.4%, p<0.001), and more marginal donor utilization (DRI 1.45±0.38 vs 1.36±0.33, p<0.001). Mahalanobis matching demonstrated that compared to small centers, large centers progressively shortened recipient LOS per transplant in each Period (A: -0.36 days, p=0.437) (B: -2.14 days, p<0.001) (C: -2.49 days, p<0.001). In pediatric transplantation, compared to small centers, large centers delivered better outcomes (1-year graft survival 93.7% vs 89.4%, p=0.017) without increased resource utilization (LOS 20.8±15.6 days vs 19.6±17.0, p=0.281) during the 17-year 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).
CONCLUSION: There is value in liver transplant volume. In the adult population, value was observed with volume, driven by lower resource utilization. In the pediatric population, value was observed with volume specifically in very young (0 - 4 y/o) patients, driven by better outcomes. High volume centers scale more rapidly to deliver value and drive resource utilization reduction without compromising graft survival, and adoption of value-based practices from large centers may allow optimization of health care delivery for this costly procedure. Further detailed study of the factors at large volume centers that enable greater healthcare value delivery is warranted
