title: Renal transplantation: relationship between hospital/surgeon volume and postoperative severe sepsis/graft-failure. a nationwide population-based study.
abstract: BACKGROUND AND OBJECTS: We explored the relationship between hospital/surgeon volume and postoperative severe sepsis/graft-failure (including death).
  
  
  METHODS
  The Taiwan National Health Insurance Research Database claims data for all patients with end-stage renal disease patients who underwent kidney transplantation between January 1, 1999, and December 31, 2007, were reviewed. Surgeons and hospitals were categorized into two groups based on their patient volume. The two primary outcomes were severe sepsis and graft failure (including death). The logistical regressions were done to compute the Odds ratios (OR) of outcomes after adjusting for possible confounding factors. Kaplan-Meier analysis was used to calculate the cumulative survival rates of graft failure after kidney transplantation during follow-up (1999-2008).
  
  
  RESULTS
  The risk of developing severe sepsis in a hospital in which surgeons do little renal transplantation was significant (odds ratio [OR]; p = 0.0115): 1.65 times (95% CI: 1.12-2.42) higher than for a hospital in which surgeons do many. The same trend was true for hospitals with a low volume of renal transplantations (OR = 2.39; 95% CI: 1.62-3.52; p < 0.0001). The likelihood of a graft failure (including death) within one year for the low-volume surgeon group was 3.1 times higher than for the high-volume surgeon group (p < 0.0001); the trend was similar for hospital volume. Female patients had a lower risk than did male patients, and patients ≥ 55 years old and those with a higher Charlson comorbidity index score, had a higher risk of severe sepsis.
  
  
  CONCLUSIONS
  We conclude that the risk of severe sepsis and graft failure (including death) is higher for patients treated in hospitals and by surgeons with a low volume of renal transplantations. Therefore, the health authorities should consider exporting best practices through educational outreach and regulation and then providing transparent information for public best interest.
authors.affiliation: 1. Departments of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan. ; 4. Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan.
authors.forename: Shih-Feng
authors.initials: SF
authors.lastname: Weng
authors.affiliation: 2. Departments of Anesthesiology, Chi-Mei Medical Center, Tainan, Taiwan.
authors.forename: Chin-Chen
authors.initials: CC
authors.lastname: Chu
authors.affiliation: 3. Departments of Nephrology, Chi-Mei Medical Center, Tainan, Taiwan. ; 5. Department of Food Nutrition, Chung Hwa University of Medical Technology, Tainan, Taiwan.
authors.forename: Chih-Chiang
authors.initials: CC
authors.lastname: Chien
authors.affiliation: 1. Departments of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan.
authors.forename: Jhi-Joung
authors.initials: JJ
authors.lastname: Wang
authors.affiliation: 1. Departments of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan.
authors.forename: Yi-Chen
authors.initials: YC
authors.lastname: Chen
authors.affiliation: 6. Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taiwan.
authors.forename: Shang-Jyh
authors.initials: SJ
authors.lastname: Chiou
mesh_terms: D000328:Adult; D016208:Databases, Factual; D005260:Female; D006084:Graft Rejection / Q000453:epidemiology; D006761:Hospitals; D006801:Humans; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000150:complications / Q000453:epidemiology* / Q000601:surgery; D016030:Kidney Transplantation / Q000009:adverse effects*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology*; D018805:Sepsis / Q000453:epidemiology* / Q000209:etiology / Q000473:pathology; D066231:Surgeons; D013624:Taiwan; D000078329:Workforce
keywords: graft failure; population-based; renal transplantation; sepsis; volume-outcome relationship.