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. 2013 Jan;19(1):96-104.
doi: 10.1002/lt.23561.

Center competition and outcomes following liver transplantation

Jeffrey B Halldorson  1 , Harry J Paarsch, Jennifer L Dodge, Alberto M Segre, Jennifer Lai, John Paul Roberts
Affiliations

Center competition and outcomes following liver transplantation

Jeffrey B Halldorson et al. Liver Transpl. 2013 Jan.

Abstract

In the United States, livers for transplantation are distributed within donation service areas (DSAs). In DSAs with multiple transplant centers, competition among centers for organs and recipients may affect recipient selection and outcomes in comparison with DSAs with only 1 center. The objective of this study was to determine whether competition within a DSA is associated with posttransplant outcomes and variations in patients wait-listed within the DSA. United Network for Organ Sharing data for 38,385 adult cadaveric liver transplant recipients undergoing transplantation between January 1, 2003 and December 31, 2009 were analyzed to assess differences in liver recipients and donors and in posttransplant survival by competition among centers. The main outcome measures that were studied were patient characteristics, actual and risk-adjusted graft and patient survival rates after transplantation, organ quality as quantified by the donor risk index (DRI), wait-listed patients per million population by DSA, and competition as quantified by the Hirschman-Herfindahl index (HHI). Centers were stratified by HHI levels as no competition or as low, medium (or mid), or high competition. In comparison with DSAs without competition, the low-, mid-, and high-competition DSAs (1) performed transplantation for patients with a higher risk of graft failure [hazard ratio (HR) = 1.24, HR = 1.26, and HR = 1.34 (P < 0.001 for each)] and a higher risk of death [HR = 1.21, HR = 1.23, and HR = 1.34 (P < 0.001 for each)] and for a higher proportion of sicker patients as quantified by the Model for End-Stage Liver Disease (MELD) score [10.0% versus 14.8%, 20.1%, and 28.2% with a match MELD score of 31-40 (P < 0.001 for each comparison)], (2) were more likely to use organs in the highest risk quartile as quantified by the DRI [18.3% versus 27.6%, 20.4%, and 31.7% (P ≤ 0.001 for each)], and (3) listed more patients per million population [18 (median) versus 34 (P = not significant), 37 (P = 0.005), and 45 (P = 0.0075)]. Significant variability in patient selection for transplantation is associated with market variables characterizing competition among centers. These findings suggest both positive and negative effects of competition among health care providers.

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Conflict of interest statement

No authors of this research have any potential conflicts of interest such as relevant financial interests, activities, relationships, or affiliations.

Figures

Figure 1
Figure 1
HHI distribution by DSAs and competitive groupings. The HHI (scaled) was calculated for each DSA. Competitive groups were designated as no competition or as low, mid, or high competition (by HHI tertile) for comparison.
Figure 2
Figure 2
Comparison of (A) observed graft survival and (B) observed patient survival after liver transplantation by the HHI level.
See this image and copyright information in PMC

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