The interaction among donor characteristics, severity of liver disease, and the cost of liver transplantation

Abstract

Introduction Accurate assessment of the impact of donor quality on liver transplant (LT) costs has been limited by the lack of a large, multicenter study of detailed clinical and economic data. Methods A novel, retrospective database linking information from the University HealthSystem Consortium and the OPTN registry was analyzed using multivariate regression to determine the relationship between donor quality (assessed through the Donor Risk Index (DRI)), recipient illness severity, and total inpatient costs (transplant and all readmissions) for 1 year following LT. Results Cost data were available for 9,059 LT recipients. Increasing MELD score, higher DRI, simultaneous liver kidney transplant, female gender and prior liver transplant were associated with increasing cost of LT (P<0.05). MELD and DRI interact to synergistically increase the cost of LT (P<0.05). Donors in the highest DRI quartile added close to $12,000 to the cost of transplantation and nearly $22,000 to post-transplant costs in comparison to the lowest risk donors. Among the individual components of the DRI, donation after cardiac death (increased $20,769 vs. brain dead donors) had the greatest impact on transplant costs. Overall one year costs were increased in older donors, minority donors, nationally shared organs, and those with cold ischemic times 7–13 hours (p<0.05 for all) Conclusion Donor quality, as measured by the DRI, is an independent predictor of LT costs in the perioperative and post-operative periods. Centers in highly competitive regions who transplant higher MELD patients with high DRI livers may be particularly affected by the synergistic impact of these factors.

The Economic Implications of Broader Sharing of Liver Allografts

“…This may reflect our emphasis on inpatient cost or a learning curve associated with the use of marginal donors (22). MELD and DRI do interact to increase costs of care in both the inpatient stay and over the life of the transplant, with variation according to MELD score dominating the cost during the initial transplant hospitalization and DRI predominantly affecting long-term costs (10). Other analyses have demonstrated that using organs from Donors following Cardiac Death (DCD), dramatically increases the cost of transplant within the first posttransplant year while decrease graft and patient survival (23)(24)(25).…”

“…Thus, physician fees and posttransplant costs are not captured in this database. This limitation is mitigated by the fact that the vast majority of the costs of liver transplant are the hospital costs incurred during the initial hospitalization (10). In addition, MELD score prior to transplant has a limited impact on posttransplant costs (30).…”

“…Given the geographic variation in access to liver transplant, areas with a relative donor shortage are forced to transplant patients with higher MELD scores using more marginal organs. Consequently, these transplant centers face disproportionate financial and clinical risk (9,10). Broader organ-sharing proposals have been considered by the United Network for Organ Sharing (UNOS) Liver and Intestine Transplant Committee.…”

Association Between Liver Transplant Center Performance Evaluations and Transplant Volume

“…Low performing centers may be more likely to consolidate resources by decreasing services and staffing perceived as detracting from their core operations such as high risk transplantations (e.g. multi-organ and/or HIV transplants), community outreach, innovative programs or participation in clinical trials (23). Moreover, private insurance companies may sever contracts with low performing centers, resulting in reduced patient referrals (24).…”

Barriers to Care at High Volume Centers in Hepatic Surgery

“…The University Health Consortium (UHC) Clinical Database/Resource Manager (CDB/RM) is an administrative database that has found recent utilization in health services research [10][11][12]. This administrative database has been demonstrated to capture accurate clinical data in the setting of complex surgical care [13].…”