We previously identified JACIE accreditation as a center

We previously identified JACIE accreditation as a center-specific factor after allogeneic HSCT and found indications for an effect of patient volume (Gratwohl et al. 2014). We used this aa-dutp well-defined large cohort of patients to investigate the multifaceted relationship between potential center- and country-specific economic factors and long-term outcome after the less complex autologous or the more complex allogeneic HSCT.
Methods
Discussion These differences between allogeneic and autologous HSCT warrant some explanations, as the systematic pattern of the effects renders a simple chance finding unlikely. They help as well to understand the findings. Allogeneic HSCT is a highly complex procedure with non-relapse mortality as the main cause of failure, autologous HSCT is less complex but with a high risk of relapse (Copelan 2006; Gratwohl et al. 2009). HSCT is not an isolated procedure; outcome depends on the pre-transplant history, the patient and donor selection and includes long-term post-transplant follow-up. Only half of the mortality occurs within the first year after HSCT. Success requires expertise in disease and complication management and the close collaboration of multiple individuals at various levels and over a long time period. Longer program duration and a higher patient volume can improve expertise in disease management, as shown by the reduced relapse rate and improved survival for all patients. Longer program duration, a higher patient volume and standardized patient management (indicated by the JACIE accreditation) can improve expertise in complication management as shown by the reduced non-relapse mortality after the more complex allogeneic HSCT with its inherently higher non-relapse mortality. These microeconomic center effect findings fit with the macroeconomic country observations. The impact of more resources for the health care system in a given country (indicated by the proportion of HCE/cap of the respective GNI/cap) and of the network infrastructure (as indicated by the HDI) became visible only after the more complex allogeneic HSCT with its higher non-relapse mortality over a long time period. More resources are required to achieve sufficient expertise for the team, and to maintain the pre- and post-transplant networks for individual patients (Majhail et al. 2012). This is probably best reflected by the lower long-term survival of patients transplanted in the years 1999 to 2006 in a center that failed to strive for accreditation at least in 2012. The present findings fit into ongoing general discussions on quality assurance, safety issues, center comparisons and minimum numbers of patients required for specific complex treatments (Horowitz et al. 1992; Taylor et al. 2013; Hunsicker et al. 1993; Ozhathil et al. 2011; Guba 2014; Birkmeyer et al. 2003; Lüchtenborg et al. 2013). Our data indicate that there is no threshold, rather a systematic impact of both, experience in years and experience in numbers. “Center effects” therefore should not be reduced to just one aspect, such as patient volume, learning curve or surgical skills (Guba 2014; Birkmeyer et al. 2003). Microeconomic center-specific effects comprise program duration, patient volume, center accreditation as well as training programs, standardization and individual skills; gonorrhea are complemented by the respective country-specific factors. Data show as well that team expertise in disease and complication management is required for optimal outcome (Majhail et al. 2012).Measuring day 30 or day 100 mortality alone is an insufficient measure of quality assurance when long-term disease free survival presents the most valid endpoint. As evidenced by this study, individual center- or country-specific economic factors may impact variably according to and depending on the complexity of the procedure (Greenfield et al. 2014; Apperley et al. 2000). Our results potentially apply to solid organ transplantation and other fields of complex medical care as well.