Abstract and Introduction
Previous economic analyses of liver transplantation have focused on the cost of the transplant and subsequent care. Accurate characterization of the pretransplant costs, indexed to severity of illness, is needed to assess the economic burden of liver disease. A novel data set linking Medicare claims with transplant registry data for 15 710 liver transplant recipients was used to determine average monthly waitlist spending (N = 249 434 waitlist months) using multivariable linear regression models to adjust for recipient characteristics including Model for End-Stage Liver Disease (MELD) score. Characteristics associated with higher spending included older age, female gender, hepatocellular carcinoma, diabetes, hypertension and increasing MELD score (p < 0.05 for all). Spending increased exponentially with severity of illness: expected monthly spending at a MELD score of 30 was 10 times higher than at MELD of 20 ($22 685 vs. $2030). Monthly spending within MELD strata also varied geographically. For candidates with a MELD score of 35, spending varied from $19 548 (region 10) to $36 099 (region 7). Regional variation in waitlist costs may reflect the impact of longer waiting times on greater pretransplant hospitalization rates among high MELD score patients. Reducing the number of high MELD waitlist patients through improved medical management and novel organ allocation systems could decrease total spending for end-stage liver care.
The prevalence of end-stage liver disease (ESLD) has risen significantly over the past several decades, fueled initially by the epidemic in hepatitis C infection and more recently by the rise in obesity-related steatohepatitis. Over the current decade, the cost of care for US patients with ESLD related to hepatitis C alone is estimated to be greater than $10 billion in direct medical expenses and up to $50 billion if the loss of productive life-years is included. Treatment of complications of ESLD including encephalopathy, variceal bleeding and the development of hepatocellular carcinoma (HCC) have all increased in frequency and expense over the past decade. Liver transplantation (LT) remains the only curative option for patients with ESLD. Unfortunately, access to LT is limited by the ongoing shortage of donated allografts. Consequently, prolonged medical management of waitlisted patients is vital to reduce the incidence of life-threatening complications that may prevent transplantation.
In an effort to reduce waiting list mortality, LT allocation policy was changed in 2002 to prioritize patients with the greatest severity of liver failure as assessed by the Model for End-Stage Liver Disease (MELD) score. Increasing MELD score has been associated with higher mortality rates at 90 days, higher cost of LT and a greater benefit of receiving a transplant. Unfortunately, as a result of ongoing disparities between the supply and demand for allografts, LT candidates living in different locations receive transplants at significantly different average MELD scores. In regions with higher MELD scores at transplant, LT candidates must wait longer and have a greater severity of illness to receive an organ. This disparity results in higher waiting list mortality rates and higher costs at the time of transplantation.
The cost of medical care for patients waiting for LT has been poorly characterized as large, integrated clinical registry and administrative data sources are not readily available. Integrated data are needed to appropriately adjust costs for differences in severity of illness, diagnosis and clinical characteristics. While a prior study using solely administrative data reported the cost of caring for patients with advanced, decompensated liver disease was 2.4 times that of patients with compensated cirrhosis, this analysis could not further discriminate costs on the basis clinical measures such as MELD score. The present study uses a novel data source linking Medicare claims data and registry data from the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) to characterize differences in the monthly costs of pretransplant care, defined using Medicare spending, as a function of severity of illness, geography and diagnoses. These data could be utilized to guide decisions on future organ allocation strategies as well as designing reimbursement models aimed at the most cost-effective strategies to maximize survival benefit.