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

INTRODUCTION: Pediatric liver transplantation provides substantial survival benefit. An emphasis on value-based practices has become a central theme in many surgical fields, but value-based practices have not been well studied in pediatric transplantation. Given an increasing focus on optimizing outcomes with containing costs, defining value in pediatric liver transplantation warrants investigation. METHODS: Pediatric End-stage Liver Disease (PELD) era pediatric liver transplant recipients from February 2002 to February 2019 were identified using United Network for Organ Sharing (UNOS) STAR file data (n = 5,770). Liver centers were divided into volume tertiles (small, medium, large) and recipients were stratified by age (0 to 4, 5 to 11, 12 to 18 years). Value for the index transplant episode was defined as % graft survival ≥1 year divided by mean post-transplant length-of-stay (LOS). Nearest-neighbor Mahalanobis metric matching was used to account for confounding when assessing the impact of center volume on value. RESULTS: Compared with 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 to 4 age group, but not in older recipients (Table). The 0 to 4 age group comprised the largest proportion of status 1B patients (20.8%, 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 very young (0 to 4 years) pediatric patients. Given improved survival of these patients in higher-volume centers, regionalization of care may benefit this specific population of recipients. Table. - Matched Comparison of Length of Stay and 1-Year Graft Survival after Liver Transplant 1-year graft survival Small (%) Large (%) p Value Pediatric 0–4 y 87.1% 94.7% 0.011 Pediatric 5–11 y 92.0% 95.9% 0.252 Pediatric 12–18 y 92.4% 90.8% 0.704 Length of stay, days Small, mean (SD) Large, mean (SD) Pediatric 0–4 y 28.29 (22.8) 22.40 (14.8) 0.003 Pediatric 5–11 y 16.05 (12.6) 18.57 (13.8) 0.182 Pediatric 12–18 y 13.67 (12.3) 19.87 (15.0) 0.003