Journal of Gastrointestinal Surgery

, Volume 12, Issue 9, pp 1527–1533 | Cite as

Relationship Between Provider Volume and Outcomes For Orthotopic Liver Transplantation

  • John E. Scarborough
  • Ricardo Pietrobon
  • Janet E. Tuttle-Newhall
  • Carlos E. Marroquin
  • Bradley H. Collins
  • Dev M. Desai
  • Paul C. Kuo
  • Theodore N. Pappas
original article



Recent data suggests that the previously demonstrable relationship between hospital volume and outcomes for liver transplant procedures may no longer exist. Furthermore, to our knowledge, no study has been published examining whether individual surgeon volume is associated with outcomes in liver transplantation.

Materials and methods

The Nationwide Inpatient Sample database was used to obtain early clinical outcome and resource utilization data for liver transplant procedures performed in the USA from 1988 through 2003. The relationship between surgeon and hospital volume and early clinical outcomes was analyzed with and without adjustment for certain confounding variables such as patient age and presence of co-morbid disease.


The in-hospital mortality rate, major postoperative complication rate, and length of hospital stay after liver transplantation did not differ significantly based on hospital procedural volume. These outcome variables did, however, exhibit a statistically significant inverse relationship with individual surgeon volume of liver transplant procedures. A significant relationship between procedure volume and outcomes for liver transplantation cannot be demonstrated at the level of transplant center, but does appear to exist at the level of the individual transplant center.


Minimal volume requirements for individual liver transplant surgeons may be justified, pending validation of this volume–outcomes relationship using a clinical data source.


Liver transplantation Outcomes assessment Resource utilization Provider volume 


  1. 1.
    Dimick JB. Measuring surgical quality: what’s the role of provider volume? World J Surg 2005;29(10):1217–1221. doi:10.1007/s00268-005-7989-4.PubMedCrossRefGoogle Scholar
  2. 2.
    Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med 2002;137:511–520.PubMedGoogle Scholar
  3. 3.
    Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128–1137. doi:10.1056/NEJMsa012337.PubMedCrossRefGoogle Scholar
  4. 4.
    Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117–2127. doi:10.1056/NEJMsa035205.PubMedCrossRefGoogle Scholar
  5. 5.
    Birkmeyer JD, Dimick JB. Potential benefits of the new Leapfrog standards: effect of process and outcome measures. Surgery 2004;135(6):569–575. doi:10.1016/j.surg.2004.03.004.PubMedCrossRefGoogle Scholar
  6. 6.
    Dudley RA, Johansen KL, Brand R, et al. Selective referral to high-volume hospitals: estimating potentially avoidable deaths. JAMA 2000;283:1159–1166. doi:10.1001/jama.283.9.1159.PubMedCrossRefGoogle Scholar
  7. 7.
    Adam R, Cailliez V, Majno P, Karam V, McMaster P, Calne RY, et al. Normalized intrinsic mortality risk in liver transplantation: European Liver Transplant Registry study. Lancet 2000;356:621–627. doi:10.1016/S0140-6736(00)02603-9.PubMedCrossRefGoogle Scholar
  8. 8.
    Lin HM, Kauffman HM, McBride MA, Davies DB, Rosendale JD, Smith CM, et al. Center-specific graft and patient survival rates: 1997 United Network for Organ Sharing report. JAMA 1998;280:1153–1160. doi:10.1001/jama.280.13.1153.PubMedCrossRefGoogle Scholar
  9. 9.
    Edwards EB, Roberts JP, McBride MA, Schulack MA, Hunsicker LG. The effect of the volume of procedures at transplantation centers on mortality after liver transplantation. N Engl J Med 1999;341:2049–2053. doi:10.1056/NEJM199912303412703.PubMedCrossRefGoogle Scholar
  10. 10.
    Axelrod DA, Guidinger MK, McCullough KP, Leichtman AB, Ponch JD, Merion RM. Association of center volume with outcome after liver and kidney transplantation. Am J Transplant 2004;4:920–927. doi:10.1111/j.1600-6143.2004.00462.x.PubMedCrossRefGoogle Scholar
  11. 11.
    NIS Technical Documentation. Agency for Healthcare Research and Quality, Rockville, MD. Available from: URL: Accessed September 2005.
  12. 12.
    Overview of the HCUP Nationwide Inpatient Sample (NIS). Agency for Healthcare Research and Quality, Rockville, MD. Available from: URL: Accessed September 2005.
  13. 13.
    International Classification of Diseases, Ninth Revision, Clinical Modification. Los Angeles: Practice Management Information Corporation; 2002.Google Scholar
  14. 14.
    HCUP quality control procedures. Agency for Healthcare Research and Quality, Rockville, MD. Available from: URL: Accessed September 2005.
  15. 15.
    Comparative Analysis of HCUP and NHDS Inpatient Discharge Data. Technical Supplement 13, NIS Release 5. Rockville, MD: Agency for Health Care Policy and Research. Available from: URL: Accessed September 2005.
  16. 16.
    Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128–1137. doi:10.1056/NEJMsa012337.PubMedCrossRefGoogle Scholar
  17. 17.
    Jain N, Pietrobon R, Hocker S, et al. The relationship between surgeon and hospital volume and outcomes for shoulder arthroplasty. J Bone Joint Surg Am 2004;86:496–505. doi:10.1302/0301-620X.86B7.14546.PubMedCrossRefGoogle Scholar
  18. 18.
    Kreder HJ, Deyo RA, Koepsell T, Swiontkowski MF, Kreuter W. Relationship between the volume of total hip replacements performed by providers and the rates of postoperative complications in the state of Washington. J Bone Joint Surg Am 1997;79:485–494.PubMedGoogle Scholar
  19. 19.
    Schrag D, Cramer LD, Back PB, et al. Influence of hospital procedure volume on outcomes following surgery for colon cancer. JAMA 2000;284:3028–3035. doi:10.1001/jama.284.23.3028.PubMedCrossRefGoogle Scholar
  20. 20.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383. doi:10.1016/0021-9681(87)90171-8.PubMedCrossRefGoogle Scholar
  21. 21.
    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45:613–619. doi:10.1016/0895-4356(92)90133-8.PubMedCrossRefGoogle Scholar
  22. 22.
    Roberts JP. An eye to quality. Am J Transplant 2004;4:844–845. doi:10.1111/j.1600-6143.2004.00491.x.PubMedCrossRefGoogle Scholar
  23. 23.
    Belle SH, Detre KM, Beringer KC. The relationship between outcome of liver transplantation and experience in new centers. Liver Transpl Surg 1995;1:347–353. doi:10.1002/lt.500010602.PubMedCrossRefGoogle Scholar
  24. 24.
    Filipponi F, Pisati R, Cavicchini G, Ulivieri MI, Ferrara R, Mosca F. Cost and outcome analysis and cost determinants of liver transplantation in a European National Health Service hospital. Transplantation 2003;75(10):1731–1736. doi:10.1097/01.TP.0000063828.20960.35.PubMedCrossRefGoogle Scholar
  25. 25.
    Northup PG, Pruett TL, Stukenborg GJ, Berg CL. Survival after adult liver transplantation does not correlate with transplant center case volume in the MELD era. Am J Transplant 2006;6:2455–2462. doi:10.1111/j.1600-6143.2006.01501.x.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2008

Authors and Affiliations

  • John E. Scarborough
    • 1
  • Ricardo Pietrobon
    • 2
    • 3
  • Janet E. Tuttle-Newhall
    • 1
  • Carlos E. Marroquin
    • 1
  • Bradley H. Collins
    • 1
  • Dev M. Desai
    • 1
  • Paul C. Kuo
    • 1
  • Theodore N. Pappas
    • 1
  1. 1.Department of Surgery, Division of General SurgeryDuke University Medical CenterDurhamUSA
  2. 2.Department of Surgery, Division of Orthopaedic SurgeryDuke University Medical CenterDurhamUSA
  3. 3.Center for Excellence in Surgical OutcomesDuke University Medical CenterDurhamUSA

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