title: Biliary atresia in Canada: the effect of centre caseload experience on outcome.
abstract: OBJECTIVE
  : Biliary atresia (BA) is a leading cause of end-stage paediatric liver disease. Standard BA treatment is sequential surgery with an initial Kasai procedure (KP) followed by liver transplant (LT) for patients who progress to liver failure. A key determinant for the post-KP patient survival with their native liver is patient age at KP (older age, poorer outcome). Recently, European studies have reported that caseload experience influences prognosis with centres managing <5 cases per year (UK) or <2 cases per year (France) having worse survival. Our study investigates the effect of caseload experience on outcomes of Canadian patients with BA.
  
  
  METHODS
  : A national database of cases with BA, born from 1992 to 2002, was examined. Patients were grouped according to treatment centre size (A: on average <1 case per year; B: 1 to 3 cases per year; and C: >3 cases per year). Overall patient, post-KP native liver, and LT survivals were compared between centres. Outcome parameters were reevaluated for patients grouped by the largest Canadian centre (>5 cases per year) and all other centres (<5 cases per year).
  
  
  RESULTS
  : Two-hundred thirty patients were identified among 6 group A, 4 group B, and 2 group C centres. The overall median age at KP was 64 days. There were no significant differences in patient, post-KP native liver, or LT survivals between the sized centres and even the largest centre, with the overall 4-year post-KP native liver survival being 39%.
  
  
  CONCLUSIONS
  : Caseload experience does not importantly affect the outcomes for Canadian children with BA. Although outcomes in Canada are comparable to those elsewhere, national policies directed towards timely referral and earlier age at KP rather than centralisation of care are needed.
authors.affiliation: Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC. rschreiber@cw.bc.ca
authors.forename: Richard A
authors.initials: RA
authors.lastname: Schreiber
authors.forename: Collin C
authors.initials: CC
authors.lastname: Barker
authors.forename: Eve A
authors.initials: EA
authors.lastname: Roberts
authors.forename: Steven R
authors.initials: SR
authors.lastname: Martin
mesh_terms: D000293:Adolescent; D001656:Biliary Atresia / Q000401:mortality* / Q000601:surgery; D002170:Canada / Q000453:epidemiology; D019090:Case Management / Q000592:standards*; D002648:Child; D003695:Delivery of Health Care / Q000592:standards*; D005260:Female; D006761:Hospitals / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D017093:Liver Failure / Q000401:mortality* / Q000601:surgery; D016031:Liver Transplantation / Q000401:mortality*; D008297:Male; D010030:Ostomy / Q000379:methods / Q000401:mortality; D011379:Prognosis; D011787:Quality of Health Care; D016019:Survival Analysis; D016896:Treatment Outcome