Is the hub-and-spoke model of care delivery a possible answer to geographical variation in liver transplant outcomes?

Abstract

We read with interest the United Kingdom (UK) transplant registry analysis article by Webb et al on the proximity to transplant center and outcome among liver transplant (LT) patients. 1 The negative correlation between travel time to the LT center and subsequent access to organs and mortality is of great concern. We highlight recent advances in the delivery of LT care via a "hub-and-spoke" mechanism that may have in part already addressed this inequity. 2The Royal Free Hospital (RFH) has delivered LT care via a "huband-spoke" network model since 2011 and has 8 dedicated spoke centers. 2 In addition, Kings College Hospital has similar networks based in South West England and Northern Ireland. 3 Spoke centers are chosen by need based on patient population, geographical remoteness, and in conjunction with local and central enthusiasm and receive outreach services from the hub (Figure 1). Webb et al report from a registry dating as far back as 1995, and given the recent incorporation of this model of LT care delivery within the United Kingdom, the impact of such network collaborations may well have been overlooked in the study.Since setting up formal hub-and-spoke networks, data from the UK National Health Service blood and transplant report a 54% increase in LT activity at the RFH hub centers, whereas numbers assessed and transplanted from geographies local to the RFH have remained static, indicating that this model has improved LT access to patients distant from our center. 2 Moreover, no differences in mortality on the waiting list, waiting time to LT, access to donation after brain death (DBD) organs, 1-and 3-year graft, and patient survival were noted between hub-and-spoke centers. If travel time between patient and transplant center exceed 60 minutes, Webb et al suggest that waiting list mortality could increase by as much as a third, with a reduced likelihood of transplantation and suggest Bristol as a location for an additional LT center. 1 Our data describe outcomes of network arrangements for patients referred to Bristol Royal Infirmary. All 40 patients (23 listed) assessed from Bristol were managed as spoke patients with a median travel time of 151 minutes (interquartile range 150-156) from the RFH. Waitlist mortality, waiting time to LT, access to DBD organs, and graft and patient survival were equivalent to those for patients local to the RFH hub. 2 This suggests that inferior geographical outcomes reported by Webb et al may in fact be due to less accessed and specialized pretransplant care as opposed to geographical remoteness.It is therefore our opinion that before considering an additional LT center, a more detailed and less historic review of service delivery within each LT hub to its geographically remote areas should be undertaken. Development of strategically placed "spoke" centers with transplant outreach expertise may help to deliver LT care equitably while avoiding the need for additional new transplant centers.

Disparities in travel time to liver transplantation centers in the United States

“…For example, in the United Kingdom, transplant centers have adopted a "hub and spoke" network model, where bilateral arrangements were made between LTCs and regional hospitals and clinics to reduce geographic disparities. [5] Lastly, novel liver preservation techniques, such as the use of portable normothermic machine perfusion, have been shown to reduce ischemia and increase the number of viable livers for transplantation. [6] These initiatives have been shown to significantly increase geographic access to LT and patient satisfaction without negatively impacting outcomes after transplantation.…”

“…Additionally, it is crucial to strengthen partnerships between LTCs and local primary care specialist providers. For example, in the United Kingdom, transplant centers have adopted a “hub and spoke” network model, where bilateral arrangements were made between LTCs and regional hospitals and clinics to reduce geographic disparities 5 . Lastly, novel liver preservation techniques, such as the use of portable normothermic machine perfusion, have been shown to reduce ischemia and increase the number of viable livers for transplantation 6 .…”

Long-term outcomes of liver transplant recipients followed up in non-transplant centres: Care closer to home

“…All of this would help to remove some of the patient care burden from transplant centres and allow transplant services to grow beyond their geographical limits. 29 Further, this may improve organ donation rates from regions away from transplant centres as people see more visible 'benefit' to the local population, and thereby overcome the societal behaviours and beliefs that currently create barriers to donation. 30 Cost analysis, based on NHS reimbursement tariff per transplant, shows financial sustainability of providing post-transplant service in nontransplant centres such as Nottingham (personal communication to Martin W James).…”

Toward social-health integration in Sicily: description of the first hub and spoke model to improve the diagnostic therapeutic care paths for neurorehabilitation

“…Indeed, the Sicilian government expressed its intention to requalify the rehabilitation facilities through the creation of a hub and spoke (HS) model, with the purpose of developing new guidelines, assistance protocols and recommendations on the rehabilitation pathway. A HS model includes a vertical organization with rules extending from the hub to the spokes in order to maximize efficiencies and effectiveness (2), and in the last years, many integrated models designed as HS networks emerged in several health areas, including the organization and delivery of novel rehabilitation services (3)(4)(5)(6)(7).…”