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Is liver transplantation ‘out-of-hours’ non-inferior to ‘in-hours’ transplantation? A retrospective analysis of the UK Transplant Registry
  1. Neil Halliday1,2,
  2. Kate Martin3,
  3. David Collett3,
  4. Elisa Allen3,
  5. Douglas Thorburn1
  1. 1 Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute for Liver and Digestive Health, London, UK
  2. 2 Institute of Immunity and Transplantation, University College London, London, UK
  3. 3 Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
  1. Correspondence to Dr Neil Halliday; neilhalliday{at}doctors.org.uk

Abstract

Objectives Increased morbidity and mortality have been associated with weekend and night-time clinical activity. We sought to compare the outcomes of liver transplantation (LT) between weekdays and weekends or night-time and day-time to determine if ‘out-of-hours’ LT has acceptable results compared with ‘in-hours’.

Design, setting and participants We conducted a retrospective analysis of patient outcomes for all 8816 adult, liver-only transplants (2000–2014) from the UK Transplant Registry.

Outcome measures Outcome measures were graft failure (loss of the graft with or without death) and transplant failure (either graft failure or death with a functioning graft) at 30 days, 1 year and 3 years post-transplantation. The association of these outcomes with weekend versus weekday and day versus night transplantation were explored, following the construction of a risk-adjusted Cox regression model.

Results Similar patient and donor characteristics were observed between weekend and weekday transplantation. Unadjusted graft failure estimates were 5.7% at 30 days, 10.4% at 1 year and 14.6% at 3 years; transplant failure estimates were 7.9%, 15.3% and 21.3% respectively.

A risk-adjusted Cox regression model demonstrated a significantly lower adjusted HR (95% CI) of transplant failure for weekend transplant of 0.77 (0.66 to 0.91) within 30 days, 0.86 (0.77 to 0.97) within 1 year, 0.89 (0.81 to 0.99) within 3 years and for graft failure of 0.81 (0.67 to 0.97) within 30 days. For patients without transplant failure within 30 days, there was no weekend effect on transplant failure. Neither night-time procurement nor transplantation were associated with an increased hazard of transplant or graft failure.

Conclusions Weekend and night-time LT outcomes were non-inferior to weekday or day-time transplantation, and we observed a possible small beneficial effect of weekend transplantation. The structure of LT services in the UK delivers acceptable outcomes ‘out-of-hours’ and may offer wider lessons for weekend working structures.

  • transplant medicine
  • transplant surgery
  • hepatology
  • quality in health care

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

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Footnotes

  • Patient consent for publication Not required.

  • Contributors NH designed the study concept and strategy, undertook data analysis and drafted and revised the manuscript. KM proposed statistical methods, undertook data analysis and drafted the manuscript. DC proposed statistical methods, reviewed data analysis and drafted the manuscript. EA proposed statistical methods, undertook data analysis and drafted the manuscript. DT designed the study concept and strategy, undertook data analysis and drafted and revised the manuscript.

  • Funding NH is supported by a Wellcome Trust PhD Studentship.

  • Competing interests None declared.

  • Ethics approval Ethical approval was not required as this study relied solely on retrospective analysis of pseudanonymised patient data collected for the purposes of clinical care and programme outcome evaluation.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data and statistical code may be made available on request by enquiry via the corresponding author, following approval by NHS Blood and Transplant.

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