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Bigger Isn’t Necessarily Better: Increased Rates of Surgical Site Infection and Total Hospital Charges for Liver Transplantation at Higher Volume Centers
*James E Tooley, *Daniel D Bohl, *Bryce A Basques, *Manuel I Rodriguez-Davalos, *Sanjay Kulkarni, *Sukru Emre, *David C Mulligan, *Peter S Yoo
Yale School of Medicine, New Haven, CT

Objective. To determine the differences in infectious complications and resource utilization between high- and low-volume centers performing liver transplantation (LTx). Design. Retrospective cohort study of the 2004-2011 Nationwide Inpatient Sample (NIS). The median annual liver transplant volume for centers in the NIS is 40 cases. This was defined as the threshold dividing high- and low-volume centers. Setting. The NIS is the largest all-payer inpatient database in the United States and contains data from about 8 million hospitalizations each year. Patients or other participants. Patients undergoing liver transplant procedures at high (n=4,784) and low (n=1,286) volume centers were identified by ICD-9 procedure codes for liver transplant. Main outcome measures. Main outcome measures included: surgical site infection, sepsis, pneumonia, clostridium difficile infection, central line infection, death during hospitalization, pre- and postoperative length of stay, and total hospital charges. Results. Demographics were similar for liver transplants at high and low volume centers. Low-volume centers had a lower rate of surgical site infection after LTx than high volume centers (3.3% low volume, 4.9% high volume, p<0.01). Other infectious complications following LTx did not differ based on center volume. No differences were observed regarding in-hospital mortality or length of stay, however total hospital charges for LTx were $35,618 greater at high volume centers (95% CI 17,328-53,907, p<0.001). Conclusions. Surgical site infections are more common at centers performing 40 or more LTx cases per year. High volume centers have an increased cost associated with liver transplant procedures.

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