Volume and outcome relation in German liver transplant centers: what lessons can be learned?

Abstract

BackgroundThe volume and outcome relationship for transplant procedures has become one of the major topics during discussions about consequences following the organ transplantation scandal of wait-list manipulations in Germany during the past year. Proponents of reducing the number of centers argue in favor of increasing quality at highly specialized transplant centers while disregarding the wish of patients for regionally available medical service.MethodsThe homepage of the German Organ Procurement Organization (DSO) was screened for the annual reports of transplant programs for the years 2007 to 2010. Results were extracted from these reports. Additionally, an analysis of volume per million people per number of transplant centers for each German federal state was made to give an overview of the density of transplant programs for the years 2009 to 2011.ResultsIn-house mortality (R2 = 0.005, P = 0.518), 3-year survival (R2 = 0.068, P = 0.085), and a ROC analysis for in-house mortality (AUC 0.55, CI: 0.41; 0.68, P = 0.53), did not show volume-outcome relation. Definition of a threshold for good centers was impossible. One-year survival indicated better outcome in high volume centers. R2 = 0.106, P = 0.009. Outcome data in Germany, as provided by Institute für angewandte Qualitätsförderung und Forschung im Gesundheitswesen (AQUA) or the DSO, are not risk adapted for the investigated time period. The factor of transplants per year per million people per transplant centers is 0.6 for Germany. Some Federal States (for example, Bavaria and Northrhine Westfalia) have an oversupply of transplant centers, which means that the average number transplanted per center and year is very low.Discussion and conclusionWe propose a risk-adapted prospective analysis of outcome and definition of a quality catalogue for liver transplant centers. Volume and outcome relation is not conclusive for liver transplantation in Germany. Data should be collected, for example, for a time period of 3 to 5 years, and decisions influencing the regulation of numbers of transplant centers should be based upon the findings, weighing federal state sovereignty and regional medical requirements against an optimal patient supply while respecting a plausible risk adaption for each center.

The center effect in liver transplantation in the Eurotransplant region: a retrospective database analysis

“…The improved outcomes for high‐volume centers in Germany, one of the Eurotransplant countries, were recently addressed in a study by Nijboer et al . , and an editorial related to this study also suggested that there was no linear relation between outcome and center size , which was also seen in the present study. One explanation for this effect could be that when a center grows beyond the 50 transplants, there will first be a transition period from being an intermediate‐volume to a high‐volume center.…”

Mindestmengen und Krankenhaussterblichkeit – Beobachtungsstudie mit deutschlandweiten Krankenhausabrechnungsdaten von 2006 bis 2013

“…Hinsichtlich der Organvergabe wäre denkbar, dass gerade Kliniken mit kleinerer Fallzahl angesichts des Mangels an Spenderorganen vor allem bei den dringlichen Indikationen berücksichtigt werden. Eine weitere Studie aus Deutschland konnte eine Mengen-Ergebnis-Beziehung bei Lebertransplantationen ebenfalls nicht überzeugend nachweisen [20], obwohl es aus der internationalen Literatur Hinweise auf bessere Behandlungsergebnisse bei höherer Leistungsmenge gibt [21,22].…”

Advancing Transplantation

“…An analysis of nearly 35000 liver transplant recipients in the ELTR showed patients transplanted in centers performing 70 or more transplants/year had significantly better early outcomes compared with patients transplanted in centers performing less than 70 transplants/year. 192 Another earlier study found that outcomes were better in patients transplanted in centers performing more than 20 transplants/year versus less than 20 transplants/year, whereas, a study by Nijboer et al 193,194 did not find a clear correlation between center activity and outcomes in 24 liver transplant units in Germany. In a similar US-based study, Macomber et al 195 found lower mortality rates in higher-volume centers, with lower median length of hospital and intensive care unit stay and lower direct costs.…”