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Is the Cost of Adult Living Donor Liver Transplantation Higher Than Deceased Donor Liver Transplantation?
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Liver Transplantation Worldwide
Volume 10, Issue 3, March 2004
Mark W. Russo, MD, MPH 1, Robert S. Brown Jr., MD, MPH 21Department of Medicine University of North Carolina Chapel Hill, NC2Center for Liver Diseases and Transplantation Columbia College of Physicians and Surgeons New York, NY
Abstract
An important long-term consideration for living-donor liver transplantation (LDLT) is the expense compared with cadaveric-liver transplantation. LDLT is a more complex procedure than cadaveric transplantation and the cost of donor evaluation, donor surgery, and postoperative donor care must be included in a cost analysis for LDLT. In this study, we compare the comprehensive cost of LDLT with that of cadaveric-liver transplantation.
All costs for medical services provided at our institution were recorded for 24 LDLT and 43 cadaveric recipients with greater than 1 year follow-up transplanted between August 1997 and April 2000. The donor costs include donors evaluated and rejected, donors evaluated and accepted, donor right hepatectomy costs, and donor follow-up costs (365 days postdonation). LDLT and cadaveric recipient costs include medical care 90 days pre-LDLT, recipient transplant costs, and recipient follow-up costs (365 days posttransplant) including retransplantation. Cost is expressed as an arbitrary cost unit (CU) that is a value between $500 to $1,500.
Total LDLT costs (evaluations of rejected donors + evaluations of accepted donors + donor hepatectomy + donor follow-up care for 1 year + pretransplant recipient care [90 days pretransplant] + recipient transplantation + recipient 1-year posttransplant care)= 162.7 CU. Total mean cadaveric transplant costs (pretransplant recipient care [90 days pretransplant] + recipient transplantation [including organ acquisition cost] + recipient 1-year posttransplant care)=134.5 CU, (P = ns)
The total comprehensive cost of LDLT is 21% higher than cadaveric transplantation, although this difference is not significant.
Review
Comprehensive Cost Comparison of Adult-Adult Right Hepatic Lobe Living-Donor Liver Transplantation With Cadaveric Transplantation. Trotter JF, MacKenzie S, Wachs M, Bak T, Steinberg T, Polsky P, Kam I, Everson T. Transplantation 2003; 75: 473-476.
Comments
Studies have compared patient and graft survival between adult living donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT), but few studies have compared costs between the 2 procedures. After the introduction of a new technique, initial studies traditionally evaluate efficacy and safety with later studies focusing on costs. Now with multiple studies demonstrating acceptable patient and graft survival rates with LDLT, initial studies of the costs of LDLT are emerging. Cost and cost-effectiveness are important outcomes in an era of increasing financial pressures in Medicine. Thus, the economic consequences of LDLT on society and patients require study.
In their manuscript, Trotter et al. from the University of Colorado compared pre- and posttransplant costs in LDLT and DDLT recipients. In contrast to a prior study on the cost-effectiveness of LDLT that used economic modeling, actual patients undergoing both types of transplants were compared in this study. Costs were captured from 90 days before transplantation to 1 year posttransplantation. Costs associated with evaluating potential living donors, including volunteers who underwent evaluation but were rejected, were captured, and applied to the LDLT group. In the DDLT group, organ acquisition costs were captured during the transplant admission. Results were reported as cost units since the authors' institution prohibits the publication of actual cost. Professional fees as well as any admissions or other costs accrued outside of the transplant center were not included.
The authors report that the total comprehensive cost of LDLT was 21% higher than DDLT. The difference was not statistically significant. This may have been due to a small sample size; only 24 LDLT recipients and 43 DDLT recipients transplanted over a 3-year period were compared, which may have inadequate power to distinguish differences in total comprehensive costs or costs in specific areas. In the LDLT group, costs were higher for pretransplant care and the transplant admission, but not for posttransplant care. The mean length of stay was 6 days longer in the LDLT group, although median length of stay was similar. For the living donors, most of the costs were associated with the hepatectomy operation itself, which is not surprising.
Trotter et al. provide a compelling cost analysis comparing LDLT to DDLT. They highlight the costs associated with the donor evaluation and the donor hepatectomy, which need to be offset by either increased compensation or increased benefit. However, there are several limitations to their study. Professional fees and cost for care outside of their institution were not included in their analysis. The exclusion of these fees would underestimate the total costs of transplantation, but is likely to be similar in the 2 groups and not affect the cost differences between LDLT and DDLT. In addition, there were baseline differences between the LDLT and DDLT groups. An important difference between the LDLT and DDLT group was the younger age of LDLT recipients. The difference in costs between the 2 groups may be even greater than reported after adjusting for age. Multivariate analysis was not performed by the authors to control for factors associated with costs.
The largest difficulty with this and most studies comparing LDLT to DDLT is the difficulty in identifying an appropriate control group. The resultant biases introduced are inherently against LDLT. First, the early experience with LDLT is compared to established results with DDLT in the analysis. The authors demonstrate the impact of that bias against LDLT in their analysis when they state in the discussion that all 4 of the LDLT recipients who were retransplanted occurred during their first 10 cases. In addition, they state that their LDLT selection process has improved over time and they are selecting transplant candidates for LDLT who have a better chance at a favorable outcome. Ideally, if their sample size was large enough the authors could have stratified costs by year of transplantation or controlled for year of transplant in multivariate analysis to assess the impact of the learning curve for the procedure. As is the case with most single center studies of LDLT, their sample size was too small to conduct meaningful subgroup analyses. Finally, a large component of pretransplant costs in the DDLT group may have occurred more than 90 days pretransplant. By only capturing costs close to the time of transplant, Trotter et al. minimize the potential cost savings of LDLT, which would accrue by shortening waiting time and decreasing the rate of costly pretransplant complications. The manuscript also lacked any effectiveness data, thus a cost-effectiveness ratio for LDLT could not be determined. The impact of increased transplant number and reduced waiting list mortality of LDLT needs to be accounted for in cost comparisons of LDLT and DDLT.
Studies comparing costs of LDLT and DDLT will continue to emerge. Thus far, studies have been small, single center reports that include the early experience of the center. A study comparing 19 patients who underwent LDLT to a DDLT control group reported that total costs were significantly higher in the LDLT group as was pretransplant and posttransplant length of stay. However, 2 patients with very long length of stays skewed the data in the LDLT group. In addition, similar to the study by Trotter et al. most of the patients in the latter study were transplanted before model for end-stage liver disease (MELD)-based allocation. This data needs to be verified in the post-MELD era when differences in ICU usage and severity of illness pretransplant may be systematically different, particularly in the DDLT group.
Futures studies comparing the cost of LDLT to DDLT should account for the early experience with LDLT and stratify or adjust for costs by year of transplantation. This will most likely require multicenter studies since few, if any, single U.S. liver transplant centers have adequate volume to stratify costs by year of transplant. Other studies on cost of LDLT could analyze the impact of factors known to be associated with DDLT, such as pretransplant severity of illness or cytomegalo-virus (CMV) infection. In addition, the effect of other factors that are specific to LDLT on costs of LDLT can be studied, such as the biliary anatomy of the donor or size of the donor graft. Finally, the appropriate control group needs to be identified so that the benefits of reduced waiting time and increased likelihood of transplantation in LDLT is appropriately analyzed. This will be a part of the National Institutes of Health-sponsored study of LDLT, A2ALL. Appropriate study of the resource utilization and benefits of LDLT may help identify areas where improvement in management and care of these patients is needed as well as inform payers and patients of the relative costs and benefits of these 2 life-saving procedures. In the interim, this important study of Trotter et al. provides us with the first look at economic differences between living and deceased donor transplantation.
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