Center volume, competition, and outcome in German liver transplant centers

Abstract

In recent years, a growing body of literature has suggestedthat patients who undergo surgery at high-volume centersfare better than those treated in low-volume hospitals.In the study by Nijboer et al. (unpublished work) in thismonth’s Transplant Research issue, liver transplantationoutcomes were investigated in relation to center case vol-ume in 24 German transplant centers. High-volume centershad higher 1-year survival rates, but no difference in in-hospital mortality. The overall outcomes of all Germantransplant centers were poor with in hospital mortality rateof 18% and a 1-year patient survival of 73%. The ROC ana-lysis did not reveal a clinical meaningful cutoff value forlow- versus high-volume center. Looking at the center datain Nijboer’s study, one gets the impression that the volumeoutcome relationship is not linear but a bell-shaped curvewith inferior outcomes in small centers ( 80-100). Centers with a volumebelow 20 cases per year show very heterogeneous results,suggesting that some centers in that group may not havethe personal and infrastructural resources to run the pro-gram. On the other hand, very high-volume centers may bepressured to keep their high market share by acceptingmarginal transplant candidates and a poor donor organ/re-cipient match. A recently published article by Macomberet al. has analyzed for the same purpose the UHC databasewhich included 63 US liver transplant centers [1]. Whatthey found was that high-volume centers, defined as thoseperforming more than 75 liver transplants per year hadlower morbidity and mortality rates than lower-volumecenters and were also more cost-efficient. To provide easyadequate access for patients in some German regions theestablishment of small-volume centers may be necessary,but in those where such issues are not so pressing it maybecome difficult to justify having higher-cost and worse-performing small centers, as a high-performing lower-costcenter. In Germany such decisions usually lie in the handsof the federal states, but in close-by centers patients maywell vote with their feet if the data are made public. Besidesvolume another important factor, hospital competition,may negatively interfere with outcome. Although more hos-pital competition is associated with improved access tocare, it also can be linked to poorer outcomes, according toa recent study by Halldorson et al. [2]. The authors foundthat low, mid, and high levels of competition significantlyincreased the risk of graft failure and patient death. Withincreased competition among medical centers that per-form liver transplants, higher-risk patients received lower-quality donor organs. Transplantation for sicker patientsand the use of higher-risk organs also meant higher costs.The findings question whether competition for the sameorgans decreased the ability to match donor and recipientcharacteristics. Competition may incentivize medical cen-ters to perform enough transplants to meet fixed costs,boost profits, and maintain market share, which can in-hibit them from best matching organs with recipients.Competition has been advocated as important for better-ing market performance, but there may be limits to thevalue of competition in the healthcare setting. The debateabout volume, competition, and transparent outcomereporting continues. Liver transplantation is often lookedon as a ‘prestige programme’ and healthcare providers arereluctant to give up their (small and not cost-effective)liver transplant program. In the light of unacceptable pooroutcomes in liver transplantation in Germany, the studyby Nijboer et al. will contribute to an ongoing discussionon the size and organization of transplant centers.