J.F Whiting

The influence of clinical variables on hospital costs after orthotopic liver transplantation

BACKGROUNDnThe burgeoning influence of managed care in transplantation, coupled with a shrinking health-care dollar, has placed most transplant programs under intense pressure to cut costs. We undertook a retrospective cost-identification analysis to determine what clinical variables influenced financial outcomes after orthotopic cadaver liver transplants (OLTx).nnnMETHODSnFifty patients receiving 53 transplants between April 1995 and November 1996 were reviewed. Clinical data were obtained from our institutions transplant database, and total costs (not charges) for the transplant admission and the 6 months after transplant were obtained with use of an activity-based cost accounting system (HBOC Trendstar, Atlanta, Ga).nnnRESULTSnThe average total cost of second transplants (n = 5) was

The cost-effectiveness of transplantation with expanded donor kidneys

97,262 greater than for first transplants (n = 48, P < .05). Patients transplanted initially as United Network for Organ Sharing (UNOS) status 2 (n = 20) incurred average costs that were

The economic impact of preservation time in cadaveric liver transplantation.

51,762 higher than for patients transplanted as UNOS status 3 (n = 28, P = .008). Patients with a major bacterial or fungal infection (n = 28) incurred average costs

Clinical and Economic Outcomes of the Use of Expanded Criteria Donors in Renal Transplantation

46,282 higher than recipients who were infection free (n = 22, P = .02). Multivariate analysis demonstrated that only length of stay, retransplantation, and postoperative dialysis were significantly and independently correlated with costs (r2 = .605). When the model was repeated with preoperative variables alone, only UNOS status was significantly correlated with 6-month total costs (P = .006, r2 = .16).nnnCONCLUSIONSnLength of stay is the most important determinant of costs after OLTx. Rational strategies to design cost-effective protocols after OLTx will require further studies to truly define the cost of various morbidities and outcomes after OLTx.

The Cost of Rejection in Liver Allograft Recipients

Transplantation with EDKs is a cost-effective therapy for ESRD as compared to hemodialysis across a variety of clinical and financial scenarios. In many cases the costs of pursuing transplantation with these donors will exceed hospital reimbursement for the procedure, providing a financial disincentive to pursuing a clearly cost-effective therapy.

Clinical and economic outcomes of expanded criteria donors in renal transplantation

There has been considerable recent debate concerning the reconfiguration of the cadaveric liver allocation system with the intent to allocate livers to more severely ill patients over greater distances. We sought to assess the economic implications of longer preservation times in cadaveric liver transplantation that may be seen in a restructured allocation system. A total of 683 patients with nonfulminant liver disease, aged 16u2003years or older, receiving a cadaveric donor liver as their only transplant, were drawn from a prospective cohort of patients who received transplants between January 1991 and July 1994 at the University of California, San Francisco, the Mayo Clinic, Rochester, Minnesota, or the University of Nebraska, Omaha. The primary outcome measure was standardized hospitalization resource utilization from the day of transplantation through discharge. Secondary outcome measures included 2‐year patient survival, and 2‐year retransplantation rates. Results indicated that each 1‐h increase in preservation time was associated with a 1.4% increase in standardized hospital resource utilization (p =u200a0.014). The effects on 2‐year patient survival and retransplantation rates were not measurably affected by an increase in preservation time. We conclude that policies that increase preservation time may be expected to increase the cost of liver transplantation.

THE COST-EFFECTIVENESS OF TRANSPLANTATION WITH EXPANDED DONOR KIDNEYS(EDKs)- A MARKOV MODEL

Renal transplantation is the therapy of choice for endstage renal disease (ESRD). Compared to dialysis, it provides improved survival, superior quality of life, and is, over time, less expensive. The willingness of payers, such as Medicare, to invest in the favorable financial and clinical outcomes of renal transplantation largely explains its success in this country. The United States comprises approximately 5% of the world’s population, yet accounts for nearly 50% of the kidney transplants performed each year worldwide (1). Currently this remarkable success story is threatened by a shortage of organ donors. As of February 10, 2000, 44,117 ESRD patients were on the waiting list for renal transplants in this country, and it is expected that fewer than 13,000 renal transplants will be performed this year (2). One proposed solution has been to direct efforts at increasing organ donation, but such attempts have met with equivocal results (3–5). Xenotransplantation has been advanced as a solution to the organ shortage (6), but widespread clinical use would appear to be years away, as serious technical, ethical, and biologic hurdles remain (6–8). Virtually all of the growth in organ supply over the past 10 years has come from the increased use of living donors and the increased use of expanded criteria donors (ECDs) (2,9). ECDs are those donors who, because of extremes of age or other clinical characteristics, might be expected to produce allografts at risk for diminished posttransplant function (Table 1) (10). The use of ECDs has increased fivefold in the last decade, and in 1997 comprised more than 30% of the total donor pool. The population demographics of the United States virtually insures that this proportion will continue to grow as the first of the “baby boom” generation is now turning 55. Despite this growth, the use of ECDs in renal transplantation has not been universally embraced in the transplant community. Several centers avoid their use entirely, while in other centers they make up more than 50% of the donor pool (2). In addition, approximately 12% of all donor kidneys in the United States are discarded because a suitable recipient cannot be identified, and the overwhelming majority of these are ECD kidneys (2,9). An unknown number of ECD kidneys are never procured because of doubts about their ability to be allocated and transplanted. There is considerable controversy concerning the appropriate use of ECD kidneys, the likely outcomes associated with their use, the most appropriate recipients for them, and their costeffectiveness. The purpose of this article is to review the available data concerning the clinical and economic outcomes associated with the use of kidneys obtained from ECDs.

ABO-incompatible liver transplantation with no immunological graft losses using total plasma exchange, splenectomy, and quadruple immunosuppression: Evidence for accommodation

THE growing cost of health care has heightened the pressure to decrease costs while maintaining or improving clinical outcome. One area of transplantation that is frequently referred to as “costly” is rejection. Immunosuppressive drug regimens may be differentiated primarily on the basis of whether or not polyclonal or monoclonal antibodies are used for induction in the early transplant therapy. Proponents of induction therapy have argued that the incidence of rejection is less and that overall costs are reduced when induction is utilized. However, no attempt has been previously reported to specifically analyze the cost (not charges) associated with rejection following liver transplantation. Consequently, we retrospectively examined episodes of acute rejection in liver transplant patients to determine the costs associated with the diagnosis, management, and complications of organ rejection.

Aggressive venous neointimal hyperplasia in a pig model of arteriovenous graft stenosis

Although graft and patient survival rates were similar between recipients of kidneys from ECDs and non-ECDs, transplantation with organs from ECDs was significantly more expensive. Multivariate analysis using stepwise linear regression demonstrated length of stay to be a strong proxy for total hospital costs. Inherent tensions between the overall good clinical outcomes associated with the use of ECDs in terms of graft survival and the markedly increased costs seen with these organs are evident.

Long-term outcome of kidney transplantation from expanded criteria donors: a single center experience.

Transplantation with EDKs is a cost-effective therapy for ESRD as compared to hemodialysis across a variety of clinical and financial scenarios. In many cases the costs of pursuing transplantation with these donors will exceed hospital reimbursement for the procedure, providing a financial disincentive to pursuing a clearly cost-effective therapy.