Institutional volume affects long-term survival following lung transplantation in the USA

Abstract

Objectives: The aim of this study was to evaluate the impact of institutional volume on long-term outcomes following lung transplantation (LTx) in the USA. Methods: Adults undergoing LTx were identified in the United Network for Organ Sharing registry. Patients were divided into equal size tertiles according to the institutional volume. All-cause mortality following LTx was evaluated using the risk-adjusted multivariable Cox regression and the Kaplan-Meier analyses, and compared between these volume cohorts at 3 points: 90 days, 1 year (excluding 90-day deaths) and 10 years (excluding 1-year deaths). Lowess smoothing plots and receiver-operating characteristic analyses were performed to identify optimal volume thresholds associated with long-term survival. Results: A total of 13 370 adult LTx recipients were identified. The mean annual centre volume was 33.6 ± 20.1. After risk adjustment, low-volume centres were found to be at increased risk for 90-day mortality, [hazard ratio (HR) 1.56, P < 0.001], 1-year mortality excluding 90-day deaths (HR 1.46, P < 0.001) and 10-year mortality excluding 1-year deaths (HR 1.22, P < 0.001). These findings persisted when the centre volume was modelled as a continuous variable. The Kaplan-Meier analysis also demonstrated significant reductions in survival at each of these time points for low-volume centres (each P < 0.001). The 10-year survival conditional on 1-year survival was 37.4% in high-volume centres vs 28.0% in low-volume centres (P < 0.001). The optimal annual volume threshold for long-term survival was 26 LTx/year. Conclusions: The institutional volume impacts long-term survival following LTx, even after excluding deaths within the first post-transplant year. Identifying the processes of care that lead to longer survival in high-volume centres is prudent.