title: Inferior Outcomes on the Waiting List in Low-Volume Pediatric Heart Transplant Centers.
abstract: Low case volume has been associated with poor outcomes in a wide spectrum of procedures. Our objective was to study the association of low case volume and worse outcomes in pediatric heart transplant centers, taking the novel approach of including waitlist outcomes in the analysis. We studied a cohort of 6482 candidates listed in the Organ Procurement and Transplantation Network for pediatric heart transplantation between 2002 and 2014; 4665 (72%) of the candidates underwent transplantation. Candidates were divided into groups according to the average annual transplantation volume of the listing center during the study period: more than 10, six to 10, three to five, or fewer than three transplantations. We used multivariate Cox regression analysis to identify independent risk factors for waitlist and posttransplantation mortality. Of the 6482 candidates, 24% were listed in low-volume centers (fewer than three annual transplantations). Of these listed candidates in low-volume centers, only 36% received a transplant versus 89% in high-volume centers (more than 10 annual transplantations) (p < 0.001). Listing at a low-volume center was the most significant risk factor for waitlist death (hazard ratio [HR] 4.5, 95% confidence interval [CI] 3.5-5.7 in multivariate Cox regression and HR 5.6, CI 4.4-7.3 in multivariate competing risk regression) and was significant for posttransplantation death (HR 1.27, 95% CI 1.0-1.6 in multivariate Cox regression). During the study period, one-fourth of pediatric transplant candidates were listed in low-volume transplant centers. These children had a limited transplantation rate and a much greater risk of dying while on the waitlist.
authors.affiliation: Division of Abdominal Transplantation, Department of Surgery, Texas Children's Hospital, Houston, TX.
authors.forename: A
authors.initials: A
authors.lastname: Rana
authors.affiliation: Division of Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX.
authors.forename: C D
authors.initials: CD
authors.lastname: Fraser
authors.affiliation: Division of Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX.
authors.forename: B B
authors.initials: BB
authors.lastname: Scully
authors.affiliation: Division of Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX.
authors.forename: J S
authors.initials: JS
authors.lastname: Heinle
authors.affiliation: Division of Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX.
authors.forename: E D
authors.initials: ED
authors.lastname: McKenzie
authors.affiliation: Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Houston, TX.
authors.forename: W J
authors.initials: WJ
authors.lastname: Dreyer
authors.affiliation: Division of Abdominal Transplantation, Department of Surgery, Texas Children's Hospital, Houston, TX.
authors.forename: M
authors.initials: M
authors.lastname: Kueht
authors.affiliation: Dan L. Duncan Cancer Center, Department of Biostatistics, Baylor College of Medicine, Houston, TX.
authors.forename: H
authors.initials: H
authors.lastname: Liu
authors.affiliation: Division of Pediatric Nephrology, Department of Nephrology, Texas Children's Hospital, Houston, TX.
authors.forename: E D
authors.initials: ED
authors.lastname: Brewer
authors.affiliation: Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: T K
authors.initials: TK
authors.lastname: Rosengart
authors.affiliation: Division of Abdominal Transplantation, Department of Surgery, Texas Children's Hospital, Houston, TX.
authors.forename: C A
authors.initials: CA
authors.lastname: O'Mahony
authors.affiliation: Division of Abdominal Transplantation, Department of Surgery, Texas Children's Hospital, Houston, TX.
authors.forename: J A
authors.initials: JA
authors.lastname: Goss
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000401:mortality*; D006085:Graft Survival; D016027:Heart Transplantation / Q000401:mortality*; D061846:Hospitals, Low-Volume / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011183:Postoperative Complications; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D009927:Tissue and Organ Procurement; D014850:Waiting Lists
keywords: clinical research/practice; heart transplantation/cardiology; patient survival; pediatrics; waitlist management