title: High-surgical-volume hospitals associated with better quality and lower cost of kidney transplantation in Taiwan.
abstract: BACKGROUND
  Only a small proportion of patients with end-stage renal disease can receive kidney transplants because of insufficiency of kidney donors in Taiwan. Hospitals compete with each other for kidney transplant surgeries. This study examined the association between hospital surgical volume of kidney transplants and patients' outcomes and utilizations.
  
  
  METHODS
  Claims data of all kidney transplants between 1996 and 2003 were retrieved from the National Health Insurance Research Database for analysis. Every kidney recipient was followed up for 3 years until the end of 2006. Hospitals were classified as high-surgical-volume hospitals (HSVHs) if their total number of kidney transplants was 72 or more between 1996 and 2003; otherwise, they were grouped into the low-surgical-volume hospitals (LSVHs). The differences in quality (infection rate, graft rejection rate, readmission rate, mortality, and survival rates of patients and transplanted grafts at 1, 2, and 3 years after surgery) and cost (length of stay, total transplant cost, and annual medical cost for 3 years) of kidney transplants were examined between the two groups.
  
  
  RESULTS
  Totally, 1,060 kidney transplants were analyzed, 77% of which were conducted at 6 of 29 qualified hospitals. Compared with those performed at LSVHs, transplant surgeries at HSVHs were associated with lower bacteria (35.1% vs. 48.8%, p<0.001), fungus (0.2% vs. 1.3%, p=0.008), and cytomegalovirus (1.2% vs. 4.6%, p=0.003) infection; lower mortality (1.1% vs. 5.0%, p<0.001); and higher 1-, 2-, and 3-year survival rates for patients (96.3%, 94.1%, 93.5% vs. 91.2%, 87.1%, 85.4%, respectively, p<0.01) and for transplanted grafts (89.5%, 81.0%, 80.5% vs. 85.8%, 74.6%, 73.3%, respectively, p<0.015). The transplant cost was lower for HSVHs than for LSVHs (New Taiwan $221,977 vs. New Taiwan $257,992, p=0.018).
  
  
  CONCLUSIONS
  Seventy-seven percent of kidney transplant surgeries were concentrated at six hospitals in Taiwan. There were significant differences in quality and cost between HSVHs and LSVHs. We suggest adopting volume-based strategies for nonurgent kidney transplants.
authors.affiliation: Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.
authors.forename: Shu-Yun
authors.initials: SY
authors.lastname: Tsao
authors.forename: Wui-Chiang
authors.initials: WC
authors.lastname: Lee
authors.forename: Che-Chuan
authors.initials: CC
authors.lastname: Loong
authors.forename: Tzeng-Ji
authors.initials: TJ
authors.lastname: Chen
authors.forename: Jen-Hwey
authors.initials: JH
authors.lastname: Chiu
authors.forename: Ling-Chen
authors.initials: LC
authors.lastname: Tai
mesh_terms: D000328:Adult; D015897:Comorbidity; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000601:surgery; D016030:Kidney Transplantation / Q000009:adverse effects / Q000191:economics* / Q000401:mortality / Q000592:standards*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013624:Taiwan