title: Pediatric Liver Transplant Center Volume and the Likelihood of Transplantation.
abstract: BACKGROUND
  Low case volume has been associated with poorer surgical outcomes in a multitude of surgical procedures. We studied the association among low case volume, outcomes, and the likelihood of pediatric liver transplantation.
  
  
  METHODS
  We studied a cohort of 6628 candidates listed in the Organ Procurement and Transplantation Network for primary pediatric liver transplantation between 2002 and 2012; 4532 of the candidates went on to transplantation. Candidates were divided into groups according to the average volume of yearly transplants performed in the listing center over 10 years: >15, 10 to 15, 5 to 9, and <5. We used univariate and multivariate Cox regression analyses with bootstrapping on transplant recipient data and identified independent recipient and donor risk factors for wait-list and posttransplant mortality.
  
  
  RESULTS
  38.5% of the candidates were listed in low-volume centers, those in which <5 transplants were performed annually. These candidates had severely reduced likelihood of transplantation with only 41% receiving a transplant. For the remaining candidates, listed at higher volume centers, the transplant rate was 85% (P < .001). Being listed at a low-volume center was a significant risk factor in multivariate Cox regression analysis for both wait-list mortality (hazard ratio, 3.27; confidence interval, 2.53-4.23) and posttransplant mortality (hazard ratio, 2.21; confidence interval, 1.43-3.40).
  
  
  CONCLUSIONS
  38.5% of pediatric transplant candidates are listed in low-volume transplant centers and have lower likelihood of transplantation and poorer outcomes. If further studies substantiated these findings, we would advocate consolidating pediatric liver transplantation in higher volume centers.
authors.affiliation: Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas; Department of Surgery, Texas Children's Hospital, Houston, Texas; abbas.rana@bcm.edu.
authors.forename: Abbas
authors.initials: A
authors.lastname: Rana
authors.affiliation: Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas;
authors.forename: Zachary
authors.initials: Z
authors.lastname: Pallister
authors.affiliation: Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia; and.
authors.forename: Karim
authors.initials: K
authors.lastname: Halazun
authors.affiliation: Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas;
authors.forename: Ronald
authors.initials: R
authors.lastname: Cotton
authors.affiliation: Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas;
authors.forename: Jacfranz
authors.initials: J
authors.lastname: Guiteau
authors.affiliation: Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas; Department of Biostatistics, Baylor College of Medicine, Houston, Texas.
authors.forename: Courtney C
authors.initials: CC
authors.lastname: Nalty
authors.affiliation: Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas; Department of Surgery, Texas Children's Hospital, Houston, Texas;
authors.forename: Christine A
authors.initials: CA
authors.lastname: O'Mahony
authors.affiliation: Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas; Department of Surgery, Texas Children's Hospital, Houston, Texas;
authors.forename: John A
authors.initials: JA
authors.lastname: Goss
mesh_terms: D002675:Child, Preschool; D005260:Female; D006801:Humans; D016031:Liver Transplantation; D008297:Male; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D014019:Tissue Donors / Q000600:supply & distribution*; D009927:Tissue and Organ Procurement / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology; D014850:Waiting Lists / Q000401:mortality*