Finding Value in Pediatric Liver Transplantation: When Does Volume Matter?

Abstract

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.