Paula Buchanan

Liver transplantation cost in the model for end‐stage liver disease era: Looking beyond the transplant admission

We examined the relationship between the total cost incurred by liver transplantation (LT) recipients and their Model for End‐Stage Liver Disease (MELD) score at the time of transplant. We used a novel database linking billing claims from a large private payer with the Organ Procurement and Transplantation Network registry. Included were adults who underwent LT from March 2002 through August 2007 (n = 990). Claims within the year preceding and following transplantation were analyzed according to the recipients calculated MELD score. Cost was the primary endpoint and was assessed by the length of stay and charges. Transplant admission charges represented approximately 50% of the total cost of LT. MELD was a significant cost driver for pretransplant, transplant, and total charges. A MELD score of 28 to 40 was associated with additional charges of

A prospective, randomized, double-blinded comparison of thymoglobulin versus Atgam for induction immunosuppressive therapy: 10-year results.

349,213 (P < 0.05) in comparison with a score of 15 to 20. Pretransplant and transplant admission charges were higher by

Quality of Care in Patients With Chronic Hepatitis C Virus Infection: A Cohort Study

152,819 (P < 0.05) and

Association of Lower Costs of Pulsatile Machine Perfusion in Renal Transplantation from Expanded Criteria Donors

64,286 (P < 0.05), respectively, in this higher MELD group. No differences by MELD score were found for posttransplant charges. Those in the highest MELD group also experienced longer hospital stays both in the pretransplant period and at the time of LT but did not have higher rates of re‐admissions. In conclusion, high‐MELD patients incur significantly higher costs prior to and at the time of LT. Following LT, the MELD score is not a significant predictor of cost or re‐admission. Liver Transpl 15:1270–1277, 2009.

Delivery patterns of recommended chronic kidney disease care in clinical practice: administrative claims-based analysis and systematic literature review.

Background. Use of induction for renal transplantation is controversial because of the concerns about long-term safety and efficacy. Methods. We compared the safety and efficacy at 10 years among patients randomized to thymoglobulin or Atgam induction in a single center, randomized, double-blinded trial. Quality-adjusted life years (QALYs) were calculated using utility weights. Results. The primary composite endpoint of freedom from death, graft loss, or rejection, “event-free survival,” was higher with thymoglobulin compared with Atgam (48% vs. 29%; P=0.011). At 10 years, patient survival (75% vs. 67%) and graft survival (48% vs. 50%) were similar, whereas acute rejection remained lower (11% vs. 42%, P=0.004) in the thymoglobulin group. The incidence of all types of cancer was numerically lower with thymoglobulin compared with Atgam (8% vs. 21%, P=NS). There were no posttransplant lymphoproliferative disorder in the thymoglobulin group and there were two cases in the Atgam group. There were no new cases of cytomegalovirus disease in either group. Mean serum creatinine levels were higher (1.7±0.5 mg/dL vs. 1.2±0.3 mg/dL; P=0.003) and estimated glomerular filtration rates tended to be lower (49±22 mL/min vs. 65±19 mL/min; P=0.065) in the thymoglobulin group. There were 0.53 QALYs gained (3.68 thymoglobulin vs. 3.15 Atgam; 16.7% improvement) from thymoglobulin compared with Atgam. Conclusions. This long-term follow-up showed that thymoglobulin was associated with higher event-free survival and improved QALYs, without increased posttransplant lymphoproliferative disorder or cytomegalovirus disease, compared with Atgam at 10 years.

Predictive Ability of Pretransplant Comorbidities to Predict Long‐Term Graft Loss and Death

BACKGROUND Medicare has proposed quality-of-care indicators for chronic hepatitis C virus (HCV) infection. The extent to which these standards are met in practice is largely unknown. OBJECTIVE To evaluate the quality of health care that patients with HCV receive and the factors associated with receipt of quality care. DESIGN Retrospective cohort study. SETTING Nationwide U.S. health insurance company research database. PARTICIPANTS 10 385 patients with HCV enrolled in the database between 2003 and 2006. Patients were included if they were eligible for at least 1 quality indicator. MEASUREMENTS Quality of HCV care received by patients, as measured by 7 explicit quality indicators included in Medicares 2009 Physician Quality Reporting Initiative. RESULTS Proportions of patients meeting quality indicators varied, ranging from 21.5% for vaccination to 79% for the HCV genotype testing indicator. Overall, 18.5% of patients (95% CI, 18% to 19%) received all recommended care. Older age and presence of comorbid conditions were associated with lower quality, whereas elevated liver enzyme levels, cirrhosis, and HIV infection were associated with higher quality. Patients who saw both generalists and specialists received the best care (odds ratio of receiving care for which a patient is eligible: specialists alone, 0.79 [CI, 0.66 to 0.95]; primary care physician alone, 0.44 [CI, 0.40 to 0.48]). LIMITATIONS The study had an observational retrospective design, used a convenience sample, and had no information on patient ethnicity. It may be that the indicators or the reporting of the indicators of HCV care--and not the care itself--is suboptimum. CONCLUSION Health care quality, based on Medicare criteria, is suboptimum for HCV. Care that included both specialists and generalists is associated with the best quality. Our results support the development of specialist and primary care collaboration to improve the quality of HCV care. PRIMARY FUNDING SOURCE Saint Louis University Liver Center.

Early outcomes of thymoglobulin and basiliximab induction in kidney transplantation: Application of statistical approaches to reduce bias in observational comparisons

Pulsatile machine perfusion (PMP) has been shown to reduce delayed graft function (DGF) in expanded criteria donor (ECD) kidneys. Here, we investigate whether there is a cost benefit associated with PMP utilization in ECD kidney transplants. We analyzed United States Renal Data System (USRDS) data describing Medicare‐insured ECD kidney transplant recipients in 1995–2004 (N = 5840). We examined total Medicare payments for transplant hospitalization and annually for 3 years posttransplant according to PMP utilization. After adjusting for other recipient, donor and transplant factors, PMP utilization was associated with a

Lack of Association Between Hepatitis C Infection and Chronic Kidney Disease

2130 reduction (p = 0.007) in hospitalization costs. PMP utilization was also associated with lower DGF risk (p < 0.0001). PMP utilization did not predict differences in rejection, graft survival, patient survival, or costs at 1, 2 and 3 years posttransplant. PMP utilization is correlated with lower costs for the transplant hospitalization, which is likely due to the associated reduction in DGF among recipients of PMP kidneys. However, there is no difference in long‐term Medicare costs for ECD recipients by PMP utilization. A prospective trial is necessary as it will help determine if the associations seen here are due to PMP utilization and not differences in the population studied.

Sensitivity of Billing Claims for Cardiovascular Disease Events among Kidney Transplant Recipients

BackgroundClinical practice guidelines for management of chronic kidney disease (CKD) have been developed within the Kidney Disease Outcomes Quality Initiative (K/DOQI). Adherence patterns may identify focus areas for quality improvement.MethodsWe retrospectively studied contemporary CKD care patterns within a private health system in the United States, and systematically reviewed literature of reported practices internationally. Five hundred and nineteen patients with moderate CKD (estimated GFR 30–59 ml/min) using healthcare benefits in 2002–2005 were identified from administrative insurance records. Thirty-three relevant publications in 2000–2006 describing care in 77,588 CKD patients were reviewed. Baseline demographic traits and provider specialty were considered as correlates of delivered care. Testing consistent with K/DOQI guidelines and prevalence of angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB) medication prescriptions were ascertained from billing claims. Care descriptions in the literature sample were based on medical charts, electronic records and/or claims.ResultsKDOQI-consistent measurements of parathyroid hormone (7.1 vs. 0.6%, P = 0.0002), phosphorus (38.2 vs. 1.9%, P < 0.0001) and quantified urinary protein (23.8 vs. 9.4%, P = 0.008) were more common among CKD patients with versus without nephrology referral in the administrative data. Nephrology referral correlated with increased likelihood of testing for parathyroid hormone and phosphorus after adjustment for baseline patient factors. Use of ACEi/ARB medications was more common among patients with nephrology contact (50.0 vs. 30.0%; P = 0.008) but appeared largely driven by higher comorbidity burden. The literature review demonstrated similar practice patterns.ConclusionsDelivery of CKD care may be monitored by administrative data. There is opportunity for improvement in CKD guideline adherence in practice.

The quality of care provided to patients with varices in the department of Veterans Affairs.

Whether to include additional comorbidities beyond diabetes in future kidney allocation schemes is controversial. We investigated the predictive ability of multiple pretransplant comorbidities for graft and patient survival. We included first‐kidney transplant deceased donor recipients if Medicare was the primary payer for at least one year pretransplant. We extracted pretransplant comorbidities from Medicare claims with the Clinical Classifications Software (CCS), Charlson and Elixhauser comorbidities and used Cox regressions for graft loss, death with function (DWF) and death. Four models were compared: (1) Organ Procurement Transplant Network (OPTN) recipient and donor factors, (2) OPTN + CCS, (3) OPTN + Charlson and (4) OPTN + Elixhauser. Patients were censored at 9 years or loss to follow‐up. Predictive performance was evaluated with the c‐statistic.