Cost of a quality-adjusted life year in liver transplantation: The influence of the indication and the model for end-stage liver disease score

Abstract

Cost issues in liver transplantation (LT) have received increasing attention, but the cost-utility is rarely calculated. We compared costs per quality-adjusted life year (QALY) from the time of placement on the LT waiting list to 1 year after transplantation for 252 LT patients and to 5 years after transplantation for 81 patients. We performed separate calculations for chronic liver disease (CLD), acute liver failure (ALF), and different Model for End-Stage Liver Disease (MELD) scores. For the estimation of QALYs, the health-related quality of life was measured with the 15D instrument. The median costs and QALYs after LT were €141,768 and 0.895 for 1 year and €177,618 and 3.960 for 5 years, respectively. The costs of the first year were 80% of the 5-year costs. The main cost during years 2 to 5 was immunosuppression drugs (59% of the annual costs). The cost/QALY ratio improved from €158,400/QALY at 1 year to €44,854/QALY at 5 years, and the ratio was more beneficial for CLD patients (€42,500/QALY) versus ALF patients (€63,957/QALY) and for patients with low MELD scores versus patients with high MELD scores. Although patients with CLD and MELD scores > 25 demonstrated markedly higher 5-year costs (€228,434) than patients with MELD scores < 15 (€169,541), the cost/QALY difference was less pronounced (€59,894/QALY and €41,769/QALY, respectively). The cost/QALY ratio for LT appears favorable, but it is dependent on the assessed time period and the severity of the liver disease. Liver Transpl 17:1333-1343, 2011. V C 2011 AASLD.Received April 26, 2011; accepted July 11, 2011.The increasing pressure to improve the cost-effectiveness of medicine has not spared the field of liver transplantation (LT). 1-7 A cost-effective intervention is generally defined as either (1) an intervention that achieves a benefit similar to that achieved by its alternative but at a lower cost or (2) an intervention that achieves a considerably greater benefit than that achieved by its alternative, even at a higher cost, as long as the additional cost is worthwhile.The absence of an effective alternative to LT has restricted controlled studies; with no comparable therapy, cost-effectiveness analyses are considerably more complicated and must depend on numerous assumptions and estimations. 2,5 Therefore, 2 issues of health economics here are the actual costs of LT with respect to the achieved health benefits [preferably measured as quality-adjusted life years (QALYs)] and the justification of these costs. 2,7,8 LT is known to be very costly, but studies that quantify the cost with respect to QALYs are scarce. 9-11 Similarly, although factors have been identified that can predict the high consumption of economic resources, 3,6,[12][13][14][15][16][17][18][19] the effects of these factors on the costeffectiveness ratio are largely unknown. For instance,

Quality of life after liver transplantation: State of the art

“…However, rejection and re-transplantation affect QoL, and should be avoided by proper immunosuppressive therapy [8,12,13] . We can conclude that the maximal reduction of side effects has a beneficial effect on QoL [12,33,34] .…”

“…Poppe et al [32] Improving quality of life in patients Åberg et al [33] Cost of a quality-adjusted life year in liver transplantation: The influence of the indication and the model for endstage liver disease score…”

Model for End-stage Liver Disease

“…31 However, there is also significant improvement in quality of life resulting in dynamic improvement in the cost to quality adjusted life years (QALY) ratio especially after 3-5 years of follow up amongst patients with high MELD scores prior to transplantation. 32 …”

Access to new direct‐acting antiviral agents against HCV infection: A view from Spain

“…7 Recently, it has been estimated that QALY liver transplantation is 158,000. 8 The vast majority of liver specialists in Spain believe that we are missing the opportunity for the near eradication of HCV infection. The need for specific funding to fight HCV similar to the national and global initiatives of the past to eradicate malaria, human immunodeficiency virus (HIV), and tuberculosis seems undeniable, 9 especially when we now know that the mortality rate is similar to that generated by HIV and higher than that estimated for malaria or tuberculosis.…”