Is there value in volume? An assessment of liver transplant practices in the United States since the inception of MELD

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 1/4 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 similar to 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 thorn17% vs small thorn7.0%, 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.

Automated summary

This study evaluates the value of liver transplantation and finds that all centers have increased in value over time, with large centers showing the most significant changes. Despite providing more complex care, large centers are able to deliver higher value. Learning from the practices of large centers can help optimize healthcare delivery for liver transplantation.