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Davenport M, Superina R. Primary Liver Transplant in Biliary Atresia: The Case for and Against. J Pediatr Surg 2024:S0022-3468(24)00156-8. [PMID: 38565475 DOI: 10.1016/j.jpedsurg.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/27/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024]
Abstract
The role of liver transplantation as a primary procedure in biliary atresia has been argued over for at least 40 years, indeed since the coming of age of safe liver transplantation during the 1980s. Yet, it is not a common option in most series (usually ≤5%) and typically reserved for those with late presentations (arguably >100 days) with established cirrhosis. This review presents the pros and cons of primary liver transplant. The pros are based upon the observation that at best a Kasai portoenterostomy (KPE) is simply palliative in most, and at worse has no effect whatsoever on restoration of bile flow and is therefore pointless. Set against this are the cons: there is a dearth of prognostic tests (clinical, biochemical, or histological) at the time of presentation which may predict inevitable failure; the possibility of long-term native liver survival to adulthood in a proportion (albeit a minority); and the implied increased need for donor organs suitable for infants - a stressor for an already overstressed system. Improving results from KPE in terms of increasing the proportions clearing their jaundice and minimizing the effects of chronic liver fibrosis and cirrhosis would surely limit the siren calls for primary transplants but the key must be better discrimination at presentation with the use of biomarkers (circulatory or histological, individually or together) to enable better decision making.
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Affiliation(s)
- Mark Davenport
- Department of Pediatric Surgery, Kings College Hospital, London, SE5 9RS, UK.
| | - Riccardo Superina
- Department of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA.
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2
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Pustavoitau A, Qin CX, Navarrete SB, Rao S, Almazan E, Ariyo P, Frank SM, Merritt WT, Rizkalla NA, Villamayor AJ, Cameron AM, Garonzik-Wang JM, Ottman SE, Philosophe B, Gurakar AO, Gottschalk A. Comprehensive quality initiative leads to immediate postoperative extubation following liver transplant. J Clin Anesth 2023; 85:111040. [PMID: 36549035 DOI: 10.1016/j.jclinane.2022.111040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/03/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Immediate postoperative extubation (IPE) can reduce perioperative complications and length of stay (LOS), however it is performed variably after liver transplant across institutions and has historically excluded high-risk recipients from consideration. In late 2012, we planned and implemented a single academic institution structured quality improvement (QI) initiative to standardize perioperative care of liver transplant recipients without exceptions. We hypothesized that such an approach would lead to a sustained increase in IPE after primary (PAC) and delayed abdominal closure (DAC). METHODS We retrospectively studied 591 patients from 2013 to 2018 who underwent liver transplant after initiative implementation. We evaluated trends in incidence of IPE versus delayed extubation (DE), and reintubation, LOS, and mortality. RESULTS Overall, 476/591 (80.5%) recipients underwent PAC (278 IPE, 198 DE) and 115/591 (19.5%) experienced DAC (39 IPE, 76 DE). When comparing data from 2013 to data from 2018, the incidence of IPE increased from 9/67 (13.4%) to 78/90 (86.7%) after PAC and from 1/12 (8.3%) to 16/23 (69.6%) after DAC. For the same years, the incidence of IPE after PAC for recipients with MELD scores ≥30 increased from 0/19 (0%) to 12/17 (70.6%), for recipients who underwent simultaneous liver-kidney transplant increased from 1/8 (12.5%) to 4/5 (80.0%), and for recipients who received massive transfusion (>10 units of packed red blood cells) increased from 0/17 (0%) to 10/13 (76.9%). Reintubation for respiratory considerations <48 h after IPE occurred in 3/278 (1.1%) after PAC and 1/39 (2.6%) after DAC. IPE was associated with decreased intensive care unit (HR of discharge: 1.92; 95% CI: 1.58, 2.33; P < 0.001) and hospital LOS (HR of discharge: 1.45; 95% CI: 1.20, 1.76; P < 0.001) but demonstrated no association with mortality. CONCLUSION A structured QI initiative led to sustained high rates of IPE and reduced LOS in all liver transplant recipients, including those classified as high risk.
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Affiliation(s)
- Aliaksei Pustavoitau
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Caroline X Qin
- The Johns Hopkins University School of Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Sergio B Navarrete
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Sneha Rao
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Erik Almazan
- The Johns Hopkins University School of Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Promise Ariyo
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - William T Merritt
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Nicole A Rizkalla
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - April J Villamayor
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Andrew M Cameron
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Shane E Ottman
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Benjamin Philosophe
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ahmet O Gurakar
- Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Allan Gottschalk
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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3
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Filip AB, Mullins ME. Fomepizole should be used more liberally in paracetamol overdose. Br J Clin Pharmacol 2023; 89:594-598. [PMID: 36471569 DOI: 10.1111/bcp.15594] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 12/12/2022] Open
Abstract
Growing clinical and basic science data support the use of fomepizole as an adjunct to N-acetylcysteine in paracetamol poisoning. This safe antidote may be helpful in severely poisoned patients.
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Affiliation(s)
- Ari B Filip
- Arkansas Poison and Drug Information Center, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas, USA
| | - Michael E Mullins
- Department of Emergency Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
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4
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Anti-hepatitis B virus activity of food nutrients and potential mechanisms of action. Ann Hepatol 2022:100766. [PMID: 36179798 DOI: 10.1016/j.aohep.2022.100766] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/21/2022] [Indexed: 02/04/2023]
Abstract
Hepatitis B virus (HBV) is endemic in many parts of the world and is a significant cause of chronic liver damage and hepatocellular carcinoma. HBV therapeutics vary according to the disease stage. The best therapeutic option for patients with end-stage liver disease is liver transplantation, while for chronic patients, HBV infection is commonly managed using antivirals (nucleos(t)ides analogs or interferons). However, due to the accessibility issues and the high cost of antivirals, most HBV patients do not have access to treatment. These complications have led researchers to reconsider treatment approaches, such as nutritional therapy. This review summarizes the nutrients reported to have antiviral activity against HBV and their possible mechanism of action. Recent studies suggest resveratrol, vitamin E, lactoferrin, selenium, curcumin, luteolin-7-O-glucoside, moringa extracts, chlorogenic acid, and epigallocatechin-3-gallate may be beneficial for patients with hepatitis B. The anti-HBV effect of most of these nutrients has been analyzed in vitro and in animal models. Different antiviral and hepatoprotective mechanisms have been proposed for these nutrients, such as the activation of antioxidant and anti-inflammatory pathways, regulation of metabolic homeostasis, epigenetic control, activation of the p53 gene, inhibition of oncogenes, inhibition of virus entry, and induction of autophagosomes. In conclusion, scientific evidence indicates that HBV replication, transcription, and expression of viral antigens can be affected directly by nutrients. In the future, these nutrients may be considered to develop appropriate nutritional management for patients with hepatitis B.
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Filip AB, Berg SE, Mullins ME, Schwarz ES. Fomepizole as an adjunctive therapy for acetaminophen poisoning: cases reported to the toxicology investigators consortium (ToxIC) database 2015-2020. Clin Toxicol (Phila) 2022; 60:1006-1011. [PMID: 35510880 DOI: 10.1080/15563650.2022.2070071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Fomepizole inhibits formation of toxic acetaminophen (APAP) metabolites and may prevent or reverse mitochondrial toxicity. Given these mechanisms, it may be beneficial in patients with severe APAP toxicity. Current patterns of use for this indication are not well-studied. METHODS This is a secondary analysis of patients enrolled in the Toxicology Investigators Consortium (ToxIC) database from January 2015 to July 2020. We queried cases in which APAP was listed as an ingested agent and fomepizole was also administered. We excluded cases in which APAP was not the primary agent, N-acetylcysteine (NAC) was not administered, or fomepizole was explicitly administered for another indication. Additionally, we sent a survey to each ToxIC site that administered fomepizole for APAP toxicity to better understand when, why, and how they were using it for this indication. RESULTS Twenty-five cases of fomepizole administration following an APAP ingestion met our inclusion criteria. There were one to four cases per year between 2015 and 2019 and eight cases in 2020. Seventeen of 25 (68%) cases were for a known acute ingestion. Eighteen of 25 (72%) patients developed hepatotoxicity (AST or ALT > 1000 IU/L) and 10 of 25 (40%) developed coagulopathy (PT > 15s). This was an ill patient population, with 18 of 25 (72%) developing metabolic acidosis (pH <7.20), 12 of 25 (48%) were intubated, 9 of 25 (36%) receiving vasopressors, and 6 of 25 (24%) receiving continuous renal replacement therapy. Overall, mortality was 24%. CONCLUSION The use of fomepizole is increasing in frequency in a small subset of critically ill and acutely APAP-poisoned patients.
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Affiliation(s)
- Ari B Filip
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sarah E Berg
- The Toxikon Consortium, Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael E Mullins
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Evan S Schwarz
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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- American College of Medical Toxicology, Phoenix, AZ, USA
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Trends in the Economic Burden of Chronic Liver Diseases and Cirrhosis in the United States: 1996-2016. Am J Gastroenterol 2021; 116:2060-2067. [PMID: 33998785 DOI: 10.14309/ajg.0000000000001292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/29/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The management of chronic liver diseases (CLDs) and cirrhosis is associated with substantial healthcare costs. We aimed to estimate trends in national healthcare spending for patients with CLDs or cirrhosis between 1996 and 2016 in the United States. METHODS National-level healthcare expenditure data developed by the Institute for Health Metrics and Evaluations for the Disease Expenditure Project and prevalence of CLDs and cirrhosis derived from the Global Burden of Diseases Study were used to estimate temporal trends in inflation-adjusted US healthcare spending, stratified by setting of care (ambulatory, inpatient, emergency department, and nursing care). Joinpoint regression was used to evaluate temporal trends, expressed as annual percent change (APC) with 95% confidence intervals (CIs). Drivers of change in spending for ambulatory and inpatient services were also evaluated. RESULTS Total expenditures in 2016 were $32.5 billion (95% CI, $27.0-$40.4 billion). Over 65% of spending was for inpatient or emergency department care. From 1996 to 2016, there was a 4.3%/year (95% CI, 2.8%-5.8%) increase in overall healthcare spending for patients with CLDs or cirrhosis, driven by a 17.8%/year (95% CI, 14.5%-21.6%) increase in price and intensity of hospital-based services. Total healthcare spending per patient with CLDs or cirrhosis began decreasing after 2008 (APC -1.7% [95% CI, -2.1% to -1.2%]), primarily because of reductions in ambulatory care spending (APC -9.1% [95% CI, -10.7% to -7.5%] after 2011). DISCUSSION Healthcare expenditures for CLDs or cirrhosis are substantial in the United States, driven disproportionately by acute care in-hospital spending.
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Dennis BB, Naji L, Jajarmi Y, Ahmed A, Kim D. New hope for hepatitis C virus: Summary of global epidemiologic changes and novel innovations over 20 years. World J Gastroenterol 2021; 27:4818-4830. [PMID: 34447228 PMCID: PMC8371499 DOI: 10.3748/wjg.v27.i29.4818] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/20/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C virus (HCV) is a global health concern associated with significant morbidity and mortality. Before the approval of second-generation direct-acting antiviral agents (DAAs), interferon therapy and liver transplantation constituted the mainstay of treatment. The introduction of well-tolerated oral DAAs in late 2013 has revolutionized HCV management with over 95% cure rates. The predominance of HCV-related liver transplantations has declined following the widespread approval of DAAs. Despite the unparallel efficacy observed among these novel therapies, pharmaceutical costs continue to limit equitable access to healthcare and likely contribute to the differential HCV infection rates observed globally. To reduce the burden of disease worldwide, essential agenda items for all countries must include the prioritization of integrated care models and access to DAAs therapies. Through transparent negotiations with the pharmaceutical industry, the consideration for compassionate release of medications to promote equitable division of care is paramount. Here we provide a literature review of HCV, changes in epidemiologic trends, access issues for current therapies, and global inequities in disease burden.
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Affiliation(s)
- Brittany B Dennis
- Department of Medicine, McMaster University, Hamilton L8S 4L8, ON, Canada
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94304, United States
| | - Leen Naji
- Department of Family Medicine, McMaster University, Hamilton L8P 1H6, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton L8S 4K1, ON, Canada
| | - Yasmin Jajarmi
- Department of Medicine, McMaster University, Hamilton L8S 4L8, ON, Canada
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94304, United States
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94304, United States
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Costs Associated With Early Vascular and Biliary Complications in Liver-Transplanted Patients in a Hospital in Antioquia, Colombia 2019: A Case Series. Value Health Reg Issues 2020; 23:131-136. [PMID: 33221679 DOI: 10.1016/j.vhri.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 05/19/2020] [Accepted: 06/01/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Vascular and biliary complications associated with liver transplants involve high morbidity and mortality as well as cost overrun for health systems. Efforts to prioritize their prevention require not only clinical information but also information on costs that reflect the economic burden on health systems. The objective of this study was to describe cost overrun incurred from early vascular and biliary complications after liver transplant. METHODS This cases series included liver transplant patients treated at the San Vicente Foundation University Hospital, Rionegro, Antioquia, from January 1, 2013, to December 31, 2018. All liver transplant patients treated during the above period were included; the absence of clinical records on the variables of interest was considered the exclusion criterion. A probabilistic analysis of patient cost was performed. Monte Carlo simulations as well as a 1-way sensitivity analysis per transplant cost component were performed. RESULTS Records from 154 patients were assessed. The average patient age was 56.9 (SD 10.9) years; 42.9% of patients were women. Of all, 36.4% patients were classified as Child C, and the average Model for End-Stage Liver Disease score was 19.6. The average cost for patients without complications was $27 834.82, whereas that for patients with early vascular complications was $36 747.83 and for those with early biliary complications was $38 523.74. CONCLUSION Early vascular and biliary complications after liver transplant increase healthcare costs, with the increase being significant in patients with biliary complications.
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Oliveira RA, Poveda VDB, Tanner J. Perioperative intensive glycemic control for liver transplant recipients to prevent surgical site infection: A systematic review and meta-analysis. Transpl Infect Dis 2020; 22:e13390. [PMID: 32589805 DOI: 10.1111/tid.13390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/15/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Surgical Site Infections (SSIs) are common among liver transplant recipients and result in adverse patient outcomes. Standard glycemic control is effective in reducing SSIs. Some studies suggest intensive glycemic control reduces the risk of SSI further. METHODS For this systematic review, were searched for studies comparing perioperative intensive and standard glycemic control in liver transplant recipients. Clinical trials registries and reference lists of included studies were also searched. No date or language restrictions were applied. Randomized controlled trials (RCTs) were assessed using Cochrane risk of bias tool and GRADE method. Cohort studies were assessed using the Newcastle-Ottawa Scale. RESULTS Two RCTs and three cohort studies met the inclusion criteria. Low-quality evidence from the two RCTs in a meta-analysis with 264 recipients found it was uncertain whether the risk of SSI was reduced by having intensive glycemic control (Risk Ratio [RR] 1.52, 95% CI 0.66-3.51). However, there was an increased risk of hypoglycemia among recipients having intensive glycemic control (RR 2.34, 95% CI 1.40-3.92) n = 264. Meta-analyses found it uncertain whether secondary outcomes, allograft rejection and death, were reduced among recipients having intensive glycemic control; (RR 0.85, 95% CI 0.48-1.50) and (RR 0.92, 95% CI 0.44-1.95), respectively. The two cohort studies were poor quality and presented conflicting outcomes on the effects of intensive blood glucose control on SSI. CONCLUSION There is insufficient evidence to recommend the use of intensive glycemic control among liver transplant recipients to reduce SSIs.
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Affiliation(s)
| | | | - Judith Tanner
- Faculty of Medicine and Health Sciences, The Queen's Medical Centre, The University of Nottingham, Nottingham, UK
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The Psychological and Financial Impact of Long-distance Travel for Liver Transplantation. Transplant Direct 2020; 6:e558. [PMID: 32607424 PMCID: PMC7266360 DOI: 10.1097/txd.0000000000001005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/02/2020] [Accepted: 04/20/2020] [Indexed: 11/26/2022] Open
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Lebovitz EE, Nguyen AVT, Sakai T. Economic considerations in abdominal transplantation. Best Pract Res Clin Anaesthesiol 2020; 34:15-23. [DOI: 10.1016/j.bpa.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/26/2019] [Accepted: 01/08/2020] [Indexed: 12/16/2022]
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Abstract
AIMS Major depressive disorders are highly prevalent in the world population, contribute substantially to the global disease burden and cause high health care expenditures. Information on the economic impact of depression, as provided by cost-of-illness (COI) studies, can support policymakers in the decision-making regarding resource allocation. Although the literature on COI studies of depression has already been reviewed, there is no quantitative estimation of depression excess costs across studies yet. Our aims were to systematically review COI studies of depression with comparison group worldwide and to assess the excess costs of depression in adolescents, adults, elderly, and depression as a comorbidity of a primary somatic disease quantitatively in a meta-analysis. METHODS We followed the PRISMA reporting guidelines. PubMed, PsycINFO, NHS EED, and EconLit were searched without limitations until 27/04/2018. English or German full-text peer-reviewed articles that compared mean costs of depressed and non-depressed study participants from a bottom-up approach were included. We only included studies reporting costs for major depressive disorders. Data were pooled using a random-effects model and heterogeneity was assessed with I2 statistic. The primary outcome was ratio of means (RoM) of costs of depressed v. non-depressed study participants, interpretable as the percentage change in mean costs between the groups. RESULTS We screened 12 760 articles by title/abstract, assessed 393 articles in full-text and included 48 articles. The included studies encompassed in total 55 898 depressed and 674 414 non-depressed study participants. Meta-analysis showed that depression was associated with higher direct costs in adolescents (RoM = 2.79 [1.69-4.59], p < 0.0001, I2 = 87%), in adults (RoM = 2.58 [2.01-3.31], p < 0.0001, I2 = 99%), in elderly (RoM = 1.73 [1.47-2.03], p < 0.0001, I2 = 73%) and in participants with comorbid depression (RoM = 1.39 [1.24-1.55], p < 0.0001, I2 = 42%). In addition, we conducted meta-analyses for inpatient, outpatient, medication and emergency costs and a cost category including all other direct cost categories. Meta-analysis of indirect costs showed that depression was associated with higher costs in adults (RoM = 2.28 [1.75-2.98], p < 0.0001, I2 = 74%). CONCLUSIONS This work is the first to provide a meta-analysis in a global systematic review of COI studies for depression. Depression was associated with higher costs in all age groups and as comorbidity. Pooled RoM was highest in adolescence and decreased with age. In the subgroup with depression as a comorbidity of a primary somatic disease, pooled RoM was lower as compared to the age subgroups. More evidence in COI studies for depression in adolescence and for indirect costs would be desirable.
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Harries L, Gwiasda J, Qu Z, Schrem H, Krauth C, Amelung VE. Potential savings in the treatment pathway of liver transplantation: an inter-sectorial analysis of cost-rising factors. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:281-301. [PMID: 30051153 DOI: 10.1007/s10198-018-0994-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 07/13/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Identification of cost-driving factors in patients undergoing liver transplantation is essential to target reallocation of resources and potential savings. AIM The aim of this study is to identify main cost-driving factors in liver transplantation from the perspective of the Statutory Health Insurance. METHODS Variables were analyzed with multivariable logistic regression to determine their influence on high cost cases (fourth quartile) in the outpatient, inpatient and rehabilitative healthcare sectors as well as for medications. RESULTS Significant cost-driving factors for the inpatient sector of care were a high labMELD-score (OR 1.042), subsequent re-transplantations (OR 7.159) and patient mortality (OR 3.555). Expenditures for rehabilitative care were significantly higher in patients with a lower adjusted Charlson comorbidity index (OR 0.601). The indication of viral cirrhosis and hepatocellular carcinoma resulted in significantly higher costs for medications (OR 21.618 and 7.429). For all sectors of care and medications each waiting day had a significant impact on high treatment costs (OR 1.001). Overall, cost-driving factors resulted in higher median treatment costs of 211,435 €. CONCLUSIONS Treatment costs in liver transplantation were significantly influenced by identified factors. Long pre-transplant waiting times that increase overall treatment costs need to be alleviated by a substantial increase in donor organs to enable transplantation with lower labMELD-scores. Disease management programs, the implementation of a case management for vulnerable patients, medication plans and patient tracking in a transplant registry may enable cost savings, e.g., by the avoidance of otherwise necessary re-transplants or incorrect medication.
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Affiliation(s)
- Lena Harries
- Department of Health Economics and Health Policy, Institute of Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Jill Gwiasda
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Zhi Qu
- Department of Health Economics and Health Policy, Institute of Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Harald Schrem
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Department of General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Krauth
- Department of Health Economics and Health Policy, Institute of Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Volker Eric Amelung
- Department of Health Economics and Health Policy, Institute of Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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14
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Bjørnelv GMW, Dueland S, Line PD, Joranger P, Fretland ÅA, Edwin B, Sørbye H, Aas E. Cost-effectiveness of liver transplantation in patients with colorectal metastases confined to the liver. Br J Surg 2018; 106:132-141. [PMID: 30325494 DOI: 10.1002/bjs.10962] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/28/2018] [Accepted: 06/28/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with non-resectable colorectal metastases are currently treated with chemotherapy. However, liver transplantation can increase the 5-year survival rate from 9 to 56 per cent if the cancer is confined to the liver. The aim of this study was to estimate the cost-effectiveness of liver transplantation for colorectal liver metastases. METHODS A Markov model with a lifetime perspective was developed to estimate the life-years, quality-adjusted life-years (QALYs), direct healthcare costs and cost-effectiveness for patients with non-resectable colorectal liver metastases who received liver transplantation or chemotherapy alone. RESULTS In non-selected cohorts, liver transplantation increased patients' life expectancy by 3·12 life-years (2·47 QALYs), at an additional cost of €209 143, giving an incremental cost-effectiveness ratio (ICER) of €67 140 per life-year (€84 667 per QALY) gained. In selected cohorts (selection based on tumour diameter, time since primary cancer, carcinoembryonic antigen levels and response to chemotherapy), the effect of liver transplantation increased to 4·23 life-years (3·41 QALYs), at a higher additional cost (€230 282), and the ICER decreased to €54 467 per life-year (€67 509 per QALY) gained. Given a willingness to pay of €70 500, the likelihood of transplantation being cost-effective was 0·66 and 0·94 (0·23 and 0·67 QALYs) for non-selected and selected cohorts respectively. CONCLUSION Liver transplantation was cost-effective but only for highly selected patients. This might be possible in countries with good access to grafts and low waiting list mortality.
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Affiliation(s)
- G M W Bjørnelv
- The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Institute of Health and Society, University of Oslo, Oslo, Norway
| | - S Dueland
- Department of Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - P-D Line
- Section for Transplantation Surgery, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - P Joranger
- Department of Nursing and Health Promotion, OsloMet-Oslo Metropolitan University, Oslo, Norway
| | - Å A Fretland
- The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - B Edwin
- The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - H Sørbye
- Department of Oncology and Clinical Science, Haukeland University Hospital, Bergen, Norway
| | - E Aas
- Institute of Health and Society, University of Oslo, Oslo, Norway
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15
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Bhutiani N, Jones CM, Cannon RM, Wei D, Goldstein L, Roy S, Philips P, Scoggins CR, McMasters KM, Martin RCG. Assessing relative cost of complications following orthotopic liver transplant. Clin Transplant 2018; 32:e13209. [PMID: 29364553 DOI: 10.1111/ctr.13209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2018] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Perioperative complications impose both a clinical and financial burden on patients and the healthcare system. This study sought to identify the frequency and economic impact of complications following orthotopic liver transplantation (OLT). METHODS The Premier Perspective® Hospital Database was queried for patients undergoing OLT between 2008 and 2015. Complications were identified by ICD-9 code and grouped by complication type. Complication frequency as well as impact on clinical and economic outcomes was calculated. Complication frequency and effect on cost were combined to determine the annual impact of each complication type on perioperative OLT cost. RESULTS Among 2747 OLT patients, the most common groups of complications following OLT were pulmonary, bleeding, and infectious. The complications with the greatest average effect on treatment-related costs were infectious, neurologic, deep vein thrombosis/pulmonary embolus, and hepatic arterial thrombosis. Infectious, pulmonary, and bleeding complications had the greatest annual effect on perioperative OLT cost. CONCLUSIONS Efforts focused on preventing coagulopathic bleeding, improving post-operative pulmonary toilet, and minimizing sources of infection can help improve the cost-effectiveness of OLT. Additionally, the combination of these cost data and systematized protocols can help insurers construct bundled payments for OLT that more accurately reflect the cost of perioperative transplant care.
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Affiliation(s)
- Neal Bhutiani
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | | | - Robert M Cannon
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - David Wei
- Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, NJ, USA
| | - Laura Goldstein
- Health Economics and Market Access, Ethicon, Somerville, NJ, USA
| | - Sanjoy Roy
- Health Economics and Market Access, Ethicon, Somerville, NJ, USA
| | - Prejesh Philips
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | | | - Kelly M McMasters
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Robert C G Martin
- Department of Surgery, University of Louisville, Louisville, KY, USA
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16
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Lee DH, Lee HW, Ahn YJ, Kim H, Yi NJ, Lee KW, Suh KS. Initiating Liver Transplantation at a Public Hospital in Korea. KOREAN JOURNAL OF TRANSPLANTATION 2017. [DOI: 10.4285/jkstn.2017.31.4.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Doo-ho Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Young Joon Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeyoung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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17
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Zhang SX, Shoptaw S, Reback CJ, Yadav K, Nyamathi AM. Cost-effective way to reduce stimulant-abuse among gay/bisexual men and transgender women: a randomized clinical trial with a cost comparison. Public Health 2017; 154:151-160. [PMID: 29245022 DOI: 10.1016/j.puhe.2017.10.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/13/2017] [Accepted: 10/25/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVES A randomized controlled study was conducted with 422 homeless, stimulant-using gay/bisexual (G/B) men and 29 transgender women (n = 451) to assess two community-based interventions to reduce substance abuse and improve health: (a) a nurse case-managed program combined with contingency management (NCM + CM) versus (b) standard education plus contingency management (SE + CM). STUDY DESIGN Hypotheses tested included: a) completion of hepatitis A/B vaccination series; b) reduction in stimulant use; and c) reduction in number of sexual partners. METHODS A deconstructive cost analysis approach was utilized to capture direct costs associated with the delivery of both interventions. Based on an analysis of activity logs and staff interviews, specific activities and the time required to complete each were analyzed as follows: a) NCM + CM only; b) SE + CM only; c) time to administer/record vaccines; and d) time to receive and record CM visits. Cost comparison of the interventions included only staffing costs and direct cash expenditures. RESULTS The study outcomes showed significant over time reductions in all measures of drug use and multiple sex partners, compared to baseline, although no significant between-group differences were detected. Cost analysis favored the simpler SE + CM intervention over the more labor-intensive NCM + CM approach. Because of the high levels of staffing required for the NCM relative to SE, costs associated with it were significantly higher. CONCLUSIONS Findings suggest that while both intervention strategies were equally effective in achieving desired health outcomes, the brief SE + CM appeared less expensive to deliver.
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Affiliation(s)
- S X Zhang
- San Diego State University, Department of Sociology, San Diego, CA, USA.
| | - S Shoptaw
- University of California at Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA.
| | - C J Reback
- Friends Research Institute, Inc., University of California at Los Angeles, Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA.
| | - K Yadav
- University of California at Irvine, Sue & Bill Gross School of Nursing, Irvine, CA, USA
| | - A M Nyamathi
- University of California at Irvine, Sue & Bill Gross School of Nursing, Irvine, CA, USA.
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18
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19
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de Paiva Haddad LB, Ducatti L, Mendes LRBC, Andraus W, D’Albuquerque LAC. Predictors of micro-costing components in liver transplantation. Clinics (Sao Paulo) 2017; 72:333-342. [PMID: 28658432 PMCID: PMC5463250 DOI: 10.6061/clinics/2017(06)02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 02/14/2017] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES: Although liver transplantation procedures are common and highly expensive, their cost structure is still poorly understood. This study aimed to develop models of micro-costs among patients undergoing liver transplantation procedures while comparing the role of individual clinical predictors using tree regression models. METHODS: We prospectively collected micro-cost data from patients undergoing liver transplantation in a tertiary academic center. Data collection was conducted using an Intranet registry integrated into the institution's database for the storing of financial and clinical data for transplantation cases. RESULTS: A total of 278 patients were included and accounted for 300 procedures. When evaluating specific costs for the operating room, intensive care unit and ward, we found that in all of the sectors but the ward, human resources were responsible for the highest costs. High cost supplies were important drivers for the operating room, whereas drugs were among the top four drivers for all sectors. When evaluating the predictors of total cost, a MELD score greater than 30 was the most important predictor of high cost, followed by a Donor Risk Index greater than 1.8. CONCLUSION: By focusing on the highest cost drivers and predictors, hospitals can initiate programs to reduce cost while maintaining high quality care standards.
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Affiliation(s)
- Luciana Bertocco de Paiva Haddad
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Liliana Ducatti
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, BR
| | - Luana Regina Baratelli Carelli Mendes
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, BR
| | - Wellington Andraus
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, BR
| | - Luiz Augusto Carneiro D’Albuquerque
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, BR
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20
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Harries L, Schrem H, Stahmeyer JT, Krauth C, Amelung VE. High resource utilization in liver transplantation-how strongly differ costs between the care sectors and what are the main cost drivers?: a retrospective study. Transpl Int 2017; 30:621-637. [DOI: 10.1111/tri.12950] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 09/05/2016] [Accepted: 03/07/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Lena Harries
- Institute for Epidemiology, Social Medicine and Health Systems Research; Hannover Medical School; Hannover Germany
- Core Facility Quality Management & Health Technology Assessment in Transplantation; Integrated Research and Treatment Center Transplantation; Hannover Medical School; Hannover Germany
| | - Harald Schrem
- Core Facility Quality Management & Health Technology Assessment in Transplantation; Integrated Research and Treatment Center Transplantation; Hannover Medical School; Hannover Germany
- Department of General, Visceral and Transplantation Surgery; Hannover Medical School; Hannover Germany
| | - Jona T. Stahmeyer
- Institute for Epidemiology, Social Medicine and Health Systems Research; Hannover Medical School; Hannover Germany
| | - Christian Krauth
- Institute for Epidemiology, Social Medicine and Health Systems Research; Hannover Medical School; Hannover Germany
- Core Facility Quality Management & Health Technology Assessment in Transplantation; Integrated Research and Treatment Center Transplantation; Hannover Medical School; Hannover Germany
| | - Volker E. Amelung
- Institute for Epidemiology, Social Medicine and Health Systems Research; Hannover Medical School; Hannover Germany
- Core Facility Quality Management & Health Technology Assessment in Transplantation; Integrated Research and Treatment Center Transplantation; Hannover Medical School; Hannover Germany
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21
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Nyamathi AM, Zhang S, Salem BE, Farabee D, Hall B, Marlow E, Faucette M, Bond D, Yadav K. A randomized clinical trial of tailored interventions for health promotion and recidivism reduction among homeless parolees: outcomes and cost analysis. JOURNAL OF EXPERIMENTAL CRIMINOLOGY 2016; 12:49-74. [PMID: 27217822 PMCID: PMC4874341 DOI: 10.1007/s11292-015-9236-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVES This study conducted a randomized controlled trial with 600 recently released homeless men exiting California jails and prisons. METHODS The purpose of this study was to primarily ascertain how different levels of intensity in peer coaching and nurse-partnered intervention programs may impact reentry outcomes; specifically: (a) an intensive peer coach and nurse case managed (PC-NCM) program; (b) an intermediate peer coaching (PC) program with brief nurse counseling; and (c) the usual care (UC) program involving limited peer coaching and brief nurse counseling. Secondary outcomes evaluated the operational cost of each program. RESULTS When compared to baseline, all three groups made progress on key health-related outcomes during the 12-month intervention period; further, 84.5 % of all participants eligible for hepatitis A/B vaccination completed their vaccine series. The results of the detailed operational cost analysis suggest the least costly approach (i.e., UC), which accounted for only 2.11 % of the total project expenditure, was as effective in achieving comparable outcomes for this parolee population as the PC-NCM and PC approaches, which accounted for 53.98 % and 43.91 %, respectively, of the project budget. CONCLUSIONS In this study, all three intervention strategies were found to be comparable in achieving a high rate of vaccine completion, which over time will likely produce tremendous savings to the public health system.
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Affiliation(s)
- Adeline M. Nyamathi
- University of California at Los Angeles, School of Nursing, Room 2-250, Factor Building, Los Angeles, CA 90095-1702, USA
| | | | - Benissa E. Salem
- University of California at Los Angeles, School of Nursing, Room 2-250, Factor Building, Los Angeles, CA 90095-1702, USA
| | - David Farabee
- University of California Los Angeles, Integrated Substance Abuse Programs, San Diego, CA, USA
| | - Betsy Hall
- University of California Los Angeles, Integrated Substance Abuse Programs, San Diego, CA, USA
| | - Elizabeth Marlow
- University of California, San Francisco, School of Nursing, San Diego, CA, USA
| | | | - Doug Bond
- Amity Foundation, Los Angeles, CA, USA
| | - Kartik Yadav
- University of California at Los Angeles, School of Nursing, Room 2-250, Factor Building, Los Angeles, CA 90095-1702, USA
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22
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Li M, Dick A, Montenovo M, Horslen S, Hansen R. Cost-effectiveness of liver transplantation in methylmalonic and propionic acidemias. Liver Transpl 2015; 21:1208-18. [PMID: 25990417 DOI: 10.1002/lt.24173] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/14/2015] [Accepted: 05/06/2015] [Indexed: 12/21/2022]
Abstract
Propionic acidemia (PA) and classical methylmalonic acidemia (MMA) are rare inborn errors of metabolism that can cause early mortality and significant morbidity. The mainstay of disease management is lifelong protein restriction. As an alternative, liver transplantation (LT) may improve survival, quality of life, and prevent further neurological deterioration. The aim of our study was to estimate the incremental costs and outcomes of LT versus nutritional support in patients with early-onset MMA or PA. We constructed a Markov model to simulate and compare life expectancies, quality-adjusted life years (QALYs), and lifetime direct and indirect costs for a cohort of newborns with MMA or PA who could either receive LT or be maintained on conventional nutritional support. We conducted a series of 1-way and probabilistic sensitivity analyses. In the base case, LT on average resulted in 1.5 more life years lived, 7.9 more QALYs, and a savings of $582,369 for lifetime societal cost per individual compared to nutritional support. LT remained more effective and less costly in all 1-way sensitivity analyses. In the probabilistic sensitivity analysis, LT was cost-effective at the $100,000/QALY threshold in more than 90% of the simulations and cost-saving in over half of the simulations. LT is likely a dominant treatment strategy compared to nutritional support in newborns with classical MMA or PA.
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Affiliation(s)
- Meng Li
- Pharmaceutical Outcomes Research and Policy Program, School of Pharmacy, University of Washington, Seattle, WA
| | - Andre Dick
- Department of Surgery, University of Washington, Seattle, WA.,Division of Transplant Surgery, Seattle Children's Hospital, Seattle, WA
| | | | - Simon Horslen
- Department of Pediatrics, University of Washington, Seattle, WA.,Department of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, WA.,Department of Transplantation, Seattle Children's Hospital, Seattle, WA
| | - Ryan Hansen
- Pharmaceutical Outcomes Research and Policy Program, School of Pharmacy, University of Washington, Seattle, WA
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23
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de Soárez PC, Lara AN, Sartori AMC, Abdala E, Haddad LBDP, D’Albuquerque LAC, Novaes HMD. Healthcare resource utilization and costs of outpatient follow-up after liver transplantation in a university hospital in São Paulo, Brazil: cost description study. SAO PAULO MED J 2015; 133:171-8. [PMID: 26039536 PMCID: PMC10876370 DOI: 10.1590/1516-3180.2013.7000011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 04/09/2013] [Accepted: 03/07/2014] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE Data on the costs of outpatient follow-up after liver transplantation are scarce in Brazil. The purpose of the present study was to estimate the direct medical costs of the outpatient follow-up after liver transplantation, from the first outpatient visit after transplantation to five years after transplantation. DESIGN AND SETTING Cost description study conducted in a university hospital in São Paulo, Brazil. METHODS Cost data were available for 20 adults who underwent liver transplantation due to acute liver failure (ALF) from 2005 to 2009. The data were retrospectively retrieved from medical records and the hospital accounting information system from December 2010 to January 2011. RESULTS Mean cost per patient/year was R$ 13,569 (US$ 5,824). The first year of follow-up was the most expensive (R$ 32,546 or US$ 13,968), and medication was the main driver of total costs, accounting for 85% of the total costs over the five-year period and 71.9% of the first-year total costs. In the second year after transplantation, the mean total costs were about half of the amount of the first-year costs (R$ 15,165 or US$ 6,509). Medication was the largest contributor to the costs followed by hospitalization, over the five-year period. In the fourth year, the costs of diagnostic tests exceeded the hospitalization costs. CONCLUSION This analysis provides significant insight into the costs of outpatient follow-up after liver transplantation due to ALF and the participation of each cost component in the Brazilian setting.
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Affiliation(s)
- Patricia Coelho de Soárez
- DDS, MPH, PhD. Adjunct Professor, Department of Preventive Medicine, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | - Amanda Nazareth Lara
- MD. Attending Physician, Infectious and Parasitic Diseases Clinic, Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | - Ana Marli Christovam Sartori
- MD, MSc, PhD. Attending Physician, Infectious and Parasitic Diseases Clinic, Hospital das Clínicas (HC) Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | - Edson Abdala
- MD, MSc, PhD. Attending Physician, Digestive Organ Transplantation Service, Department of Gastroenterology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | - Luciana Bertocco de Paiva Haddad
- MD, MSc. Attending Physician, Digestive Organ Transplantation Service, Department of Gastroenterology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | - Luiz Augusto Carneiro D’Albuquerque
- MD, MSc, PhD. Titular Professor, Digestive Organ Transplantation Service, Department of Gastroenterology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | - Hillegonda Maria Dutilh Novaes
- MD, MSc, PhD. Associate Professor, Department of Preventive Medicine, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
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24
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Lim KC, Wang VW, Siddiqui FJ, Shi L, Chan ESY, Oh HC, Tan SB, Chow PKH. Cost-effectiveness analysis of liver resection versus transplantation for early hepatocellular carcinoma within the Milan criteria. Hepatology 2015; 61:227-37. [PMID: 24638991 DOI: 10.1002/hep.27135] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 03/13/2014] [Indexed: 12/13/2022]
Abstract
UNLABELLED Both liver resection (LR) and cadaveric liver transplantation (CLT) are potentially curative treatments for patients with hepatocellular carcinoma (HCC) within the Milan criteria and with adequate liver function. Adopting either as a first-line therapy carries major cost and resource implications. The objective of this study was to estimate the relative cost-effectiveness of LR against CLT for patients with HCC within the Milan criteria using a decision analytic model. A Markov cohort model was developed to simulate a cohort of patients aged 55 years with HCC within the Milan criteria and Child-Pugh A/B cirrhosis, undergoing LR or CLT, and followed up over their remaining life expectancy. Analysis was performed in different geographical cost settings: the USA, Switzerland and Singapore. Transition probabilities were obtained from systematic literature reviews, supplemented by databases from Singapore and the Organ Procurement and Transplantation Network (USA). Utility and cost data were obtained from open sources. LR produced 3.9 quality-adjusted life years (QALYs) while CLT had an additional 1.4 QALYs. The incremental cost-effectiveness ratio (ICER) of CLT versus LR ranged from $111,821/QALY in Singapore to $156,300/QALY in Switzerland, and was above thresholds for cost-effectiveness in all three countries. Sensitivity analysis revealed that CLT-related 5-year cumulative survival, one-time cost of CLT, and post-LR 5-year cumulative recurrence rates were the most sensitive parameters in all cost scenarios. ICERs were reduced below threshold when CLT-related 5-year cumulative survival exceeded 84.9% and 87.6% in Singapore and the USA, respectively. For Switzerland, the ICER remained above the cost-effectiveness threshold regardless of the variations. CONCLUSION In patients with HCC within the Milan criteria and Child-Pugh A/B cirrhosis, LR is more cost-effective than CLT across three different costing scenarios: the USA, Switzerland, Singapore.
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Affiliation(s)
- Kheng Choon Lim
- Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore; Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
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25
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Apica BS, Ocama P, Seremba E, Opio KC, Kagimu MM. Decompensated cirrhosis-related admissions in a large urban hospital in Uganda: prevalence, clinical and laboratory features and implications for planning patient management. Afr Health Sci 2013; 13:927-32. [PMID: 24940314 PMCID: PMC4056489 DOI: 10.4314/ahs.v13i4.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Cirrhosis-related complications are a major cause of morbidity and mortality in areas where its risk factors are endemic. OBJECTIVE We determined the prevalence of decompensated cirrhosis among patients on the gastroenterology service of Mulago Hospital and described the clinical and laboratory features of these patients. METHODS All patients admitted to the unit were assessed and their diagnosis documented. Patients with cirrhosis had clinical features of decompensation recorded. History of alcohol consumption was taken and testing for hepatitis B surface antigen (HBsAg) and hepatitis C antibody (anti-HCV) performed. RESULTS Between September 2010 and January 2011, we enrolled 482 patients. The majority (53.7%) were male, overall median age 38 years. Decompensated cirrhosis was diagnosed in 85 (17.6%) patients. Of the 85 patients, 47 (55.3%) gave a history of alcohol intake, HBsAg was positive in 23 (27.1%) and anti-HCV in 3 (3.5%). Decompensation was defined by ascites among 81 (95.3%) patients, variceal bleeding in 31 (36.5%), encephalopathy in 20 (23.5%). CONCLUSION Cirrhosis is common in Mulago hospital presenting mainly with ascites and variceal bleeding. Aside from controlling causes of liver diseases, especially alcohol and hepatitis B virus infection, in the interim it is necessary to manage complications in patients who already have cirrhosis.
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Affiliation(s)
- B S Apica
- Department of Medicine, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda
| | - P Ocama
- Department of Medicine, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda
| | - E Seremba
- Department of Medicine, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda
| | - K C Opio
- Department of Medicine, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda
| | - M M Kagimu
- Department of Medicine, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda
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26
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Impact of consideration of transplantation on end-of-life care for patients during a terminal hospitalization. Transplantation 2013. [PMID: 23197177 DOI: 10.1097/tp.0b013e318277f238] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Many patients considered for transplantation die before receiving the organ, underlining the importance of providing high-quality symptomatic relief and communication for all transplant patients. METHODS To study how consideration of transplantation affects the end-of-life care received by patients, care was evaluated by abstracting medical records for 496 adults who died in one high-volume transplant medical center between April 2005 and April 2006. Sixteen quality indicators from the Assessing Care of Vulnerable Elders set that focused on communication and symptom management were measured to calculate an overall patient-level quality score. We evaluated the predictors of quality of end-of-life care, with the main independent variable being whether the patient was being considered for transplantation. Restricting to patients who died an "expected death," we also evaluated the end-of-life treatments received. RESULTS Twenty-five percent of decedent patients were considered for transplantation. In adjusted models, patients considered for transplantation received lower-quality end-of-life care, had longer hospital stays before death, and were more likely to receive aggressive life-sustaining treatments. CONCLUSIONS Care models should incorporate an emphasis on symptom relief and communication along with transplant preparation.
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van der Hilst CS, IJtsma AJ, Bottema JT, van Hoek B, Dubbeld J, Metselaar HJ, Kazemier G, van den Berg AP, Porte RJ, Slooff MJ. The price of donation after cardiac death in liver transplantation: a prospective cost-effectiveness study. Transpl Int 2013; 26:411-8. [DOI: 10.1111/tri.12059] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 02/13/2013] [Accepted: 12/23/2012] [Indexed: 12/14/2022]
Affiliation(s)
- Christian S. van der Hilst
- Department of Surgery; University Medical Center Groningen; University of Groningen; Groningen; The Netherlands
| | - Alexander J.C. IJtsma
- Department of Surgery; University Medical Center Groningen; University of Groningen; Groningen; The Netherlands
| | - Jan T. Bottema
- Department of Surgery; University Medical Center Groningen; University of Groningen; Groningen; The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology; Leiden University Medical Center; Leiden; The Netherlands
| | - Jeroen Dubbeld
- Department of Surgery; Leiden University Medical Center; Leiden; The Netherlands
| | - Herold J. Metselaar
- Department of Gastroenterology; Erasmus Medical Center; Rotterdam; The Netherlands
| | - Geert Kazemier
- Department of Surgery; Erasmus Medical Center; Rotterdam; The Netherlands
| | - Aad P. van den Berg
- Department of Gastroenterology; University Medical Center Groningen; University of Groningen; Groningen; The Netherlands
| | - Robert J. Porte
- Department of Surgery; University Medical Center Groningen; University of Groningen; Groningen; The Netherlands
| | - Maarten J.H. Slooff
- Department of Surgery; University Medical Center Groningen; University of Groningen; Groningen; The Netherlands
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Lankarani KB, Mahmoodi M, Gholami S, Mehravar S, Malekhosseini SA, Heydari ST, Zarei E, Salahi H, Nikeghbalian S, Taghavi SA, Janghorban P, Ghaffarpasand F. Reducing Social Disparity in Liver Transplantation Utilization through Governmental Financial Support. HEPATITIS MONTHLY 2012; 12:e6463. [PMID: 23300495 PMCID: PMC3539062 DOI: 10.5812/hepatmon.6463] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 05/25/2012] [Accepted: 06/15/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND A high proportion of patients suffering from end stage liver disease are from low socioeconomic classes , which limits their access to liver transplantation as the most effctive treatment of this condition because of cost barrier. OBJECTIVES one of the most challenging aspects of liver transplantation is its affordability and utilization by those who need it the most. PATIENTS AND METHODS Since November 2005, Iran Ministry of Health had covered 100% of the costs of in-patient liver transplantation care. To determine the effects of this policy, patterns of utilization of liver transplantation were compared before and after implementation of the policy. Group one included 112 and group two included 120 individuals who received transplantation before (from early January 2003 to November 2005) and after (from November 2005 to the end of December 2007) the legislation entered into the effect, respectively. Socioeconomic characteristics of these patients were evaluated by data collected about house and car ownership, education level, employment status, and place of residence. RESULTS Coverage of the costs allowed more illiterate and semiliterate people (P = 0.032) as well as more unemployed or unskilled workers to receive transplantation (P = 0.021). The number of transplantations also increased in children and geriatric age group. This legislation also led to greater countrywide regional coverage of indigent patients. CONCLUSIONS This survey provides evidence that coverage of the costs by Ministry of Health was effective in reducing social discrimination in utilization of liver transplantation, and narrowed the gap between low and high socioeconomic classes in Iranian society.
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Affiliation(s)
- Kamran B. Lankarani
- Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding author: Kamran B. Lankarani, Health Policy Research Center, Building No 2, Eighth Floor, School of Medicine, Zand Blvd., Shiraz University of Medical Sciences, Shiraz, IR Iran. Tel.: +98-7112309615, Fax: +98-7112309615, E-mail:
| | - Mojtaba Mahmoodi
- Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Siavash Gholami
- Shiraz Organ Transplantation Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Soheila Mehravar
- Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | | | - Sayed Taghi Heydari
- Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Elham Zarei
- Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Heshmatollah Salahi
- Shiraz Organ Transplantation Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Saman Nikeghbalian
- Shiraz Organ Transplantation Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | | | - Parisa Janghorban
- Shiraz Organ Transplantation Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
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Mak CM, Lam CW, Chim S, Siu TS, Ng KF, Tam S. Biochemical and molecular diagnosis of tyrosinemia type I with two novel FAH mutations in a Hong Kong chinese patient: recommendation for expanded newborn screening in Hong Kong. Clin Biochem 2012; 46:155-9. [PMID: 23000314 DOI: 10.1016/j.clinbiochem.2012.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 08/02/2012] [Accepted: 09/07/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Tyrosinemia type I is an autosomal recessive disorder in tyrosine metabolism. In areas without expanded newborn screening, patients present with acute hepatorenal failure in early infancy. Diagnosis can be elusive when clinical presentation is non-specific and biochemical abnormalities are masked by secondary changes. This is the first Hong Kong Chinese report. DESIGN AND METHODS A two-month-old Chinese male infant with unremarkable antenatal and postnatal history presented with progressive abdominal distension for three days. He suffered from end-stage liver failure, hypoglycemia and hepatic encephalopathy. Diagnostic work-up was complicated starting from rule-out sepsis, intestinal obstruction, volvulus, peritonitis, septic ileus, poisoning to metabolic diseases. Clinical, biochemical and genetic data was described. RESULTS The patient showed increases in multiple plasma amino acids including tyrosine, phenylalanine and methionine, and hyper-excretions of 4-hydroxyphenyl-acetate, -pyruvate, and -lactate, as well as N-acetyltyrosine which could be seen in liver failure due to both tyrosinemia type I and non-metabolic conditions. Because of the volatile nature, succinylacetone was almost undetectable. The diagnosis was confirmed by genetic analysis of FAH with two novel mutations, viz. NM_000137.2:c.1063-1G>A and NM_000137.2:c.1035_1037del. Living-related liver transplantation was done. However, the patient still suffered many complications after the severe metabolic insult with hypoxic ischemic encephalopathy, cerebral atrophy, global developmental delay and cortical visual impairment. CONCLUSIONS Because of the lack of expanded newborn screening in Hong Kong, this child unfortunately presented in the most severe form of tyrosinemia type I. Expanded newborn screening can save life and reduce the burden of diagnostic complexity. This illustrates the need for expanded newborn screening in Hong Kong.
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Affiliation(s)
- Chloe Miu Mak
- Kowloon West Cluster Laboratory Genetic Service, Department of Pathology, Princess Margaret Hospital, Hong Kong, China.
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El Khoury AC, Klimack WK, Wallace C, Razavi H. Economic burden of hepatitis C-associated diseases in the United States. J Viral Hepat 2012; 19:153-60. [PMID: 22329369 DOI: 10.1111/j.1365-2893.2011.01563.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
There are approximately 100 drugs in development to treat hepatitis C. Over the next decade, a number of new therapies will become available. A good understanding of the cost of hepatitis C sequelae is important for assessing the value of new treatments. The objective of this study was to assess the economic burden data sources for hepatitis C in the United States. A systematic literature search was conducted to identify studies reporting the costs of hepatitis C sequelae in the United States. Over 400 references were identified, of which 50 were pertinent. The costs were compiled and adjusted to 2010 constant US dollars using the medical component of the consumer price index (CPI). The cost of liver transplants was estimated at $201 110 ($178 760-$223 460), hepatocellular carcinoma (HCC) at $23 755-$44 200, variceal haemorrhage at $25 595, compensated cirrhosis at $585-$1110, refractory ascites at $24 755, hepatic encephalopathy at $16 430, sensitive ascites at $2450, moderate chronic hepatitis C at $155, and mild chronic hepatitis C at $145 per year per person. All studies were traced back to a handful of publications in the 1990s, which have provided the basis for all sequelae-based cost estimates to date. Hepatitis C imposes a high economic burden. Most cost analysis is more than 10 years old, and more research is required to update the sequelae costs associated with HCV infection.
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Affiliation(s)
- A C El Khoury
- Global Health Outcomes, Merck & Co. Inc., West Point, PA, USA.
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El Khoury AC, Wallace C, Klimack WK, Razavi H. Economic burden of hepatitis C-associated diseases: Europe, Asia Pacific, and the Americas. J Med Econ 2012; 15:887-96. [PMID: 22458755 DOI: 10.3111/13696998.2012.681332] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Globally, hepatitis C virus (HCV) infects ∼3% of the population. The objective of this study was to review published work and determine the direct medical costs for diseases associated with HCV infection globally, with the exception of the US. METHODS A systematic literature search was conducted to identify studies reporting the costs of hepatitis C sequelae between January 1990 and January 2011. Over 400 references were identified, of which 45 were pertinent. The costs were compiled, converted to US dollars, and adjusted to 2010 costs using the medical component of the consumer price index. RESULTS The median cost of liver transplants was estimated at $139,070 ($15,430-$443,700), refractory ascites at $16,740 ($8990-$35,940), hepatocellular carcinoma (HCC) at $15,310 ($3370-$84,710), decompensated cirrhosis at $14,660 ($3810-$48,360), variceal hemorrhage at $12,190 ($3550-$46,120), hepatic encephalopathy at $9180 ($5370-$50,120), diuretic sensitive ascites at $3400 ($1320-$7470), compensated cirrhosis at $820 ($50-$2890), and chronic hepatitis C at $280 ($90-$1860). The variation among studies was mainly due to the methodology used to assess cost, local cost and government reimbursement, and country-specific treatment protocols. LIMITATIONS All costs were adjusted to 2010 US dollars using the US medical component of the consumer price index (CPI) which may not reflect the change in medical costs in other countries. In addition, the costs, in the local currency were converted to US dollars in the year of the study. However, medical expenses may not vary with exchange rate, leading to artificial variations. Finally, there was no assessment of the quality of individual studies, which resulted in the same weighting to all studies. CONCLUSIONS Hepatitis C imposes a high economic burden globally. Knowing the burden of HCV sequelae is useful for policy decisions as well as serving as a basis for determining the value of HCV screening and treatment.
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Akarsu M, Matur M, Karademir S, Unek T, Astarcioglu I. Cost Analysis of Liver Transplantation in Turkey. Transplant Proc 2011; 43:3783-8. [DOI: 10.1016/j.transproceed.2011.09.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 09/08/2011] [Indexed: 01/10/2023]
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Åberg F, Mäklin S, Räsänen P, Roine RP, Sintonen H, Koivusalo AM, Höckerstedt K, Isoniemi H. Cost of a quality-adjusted life year in liver transplantation: the influence of the indication and the model for end-stage liver disease score. Liver Transpl 2011; 17:1333-43. [PMID: 21770017 DOI: 10.1002/lt.22388] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cost issues in liver transplantation (LT) have received increasing attention, but the cost-utility is rarely calculated. We compared costs per quality-adjusted life year (QALY) from the time of placement on the LT waiting list to 1 year after transplantation for 252 LT patients and to 5 years after transplantation for 81 patients. We performed separate calculations for chronic liver disease (CLD), acute liver failure (ALF), and different Model for End-Stage Liver Disease (MELD) scores. For the estimation of QALYs, the health-related quality of life was measured with the 15D instrument. The median costs and QALYs after LT were €141,768 and 0.895 for 1 year and €177,618 and 3.960 for 5 years, respectively. The costs of the first year were 80% of the 5-year costs. The main cost during years 2 to 5 was immunosuppression drugs (59% of the annual costs). The cost/QALY ratio improved from €158,400/QALY at 1 year to €44,854/QALY at 5 years, and the ratio was more beneficial for CLD patients (€42,500/QALY) versus ALF patients (€63,957/QALY) and for patients with low MELD scores versus patients with high MELD scores. Although patients with CLD and MELD scores > 25 demonstrated markedly higher 5-year costs (€228,434) than patients with MELD scores < 15 (€169,541), the cost/QALY difference was less pronounced (€59,894/QALY and €41,769/QALY, respectively). The cost/QALY ratio for LT appears favorable, but it is dependent on the assessed time period and the severity of the liver disease.
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Affiliation(s)
- Fredrik Åberg
- Transplantation and Liver Surgery Clinic, Helsinki University Hospital, Helsinki, Finland.
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Foss A, Adam R, Dueland S. Liver transplantation for colorectal liver metastases: revisiting the concept. Transpl Int 2010; 23:679-85. [PMID: 20477993 DOI: 10.1111/j.1432-2277.2010.01097.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Liver transplantation (Lt) for colorectal cancer (CRC) liver metastases is no more considered due to the poor outcome observed up to the 1990s. According to the European Liver Transplant Registry (ELTR), 1- and 5-year patient survival following Lt for CRC liver metastases performed prior to 1995 was 62% and 18%, respectively. However, 44% of graft loss or patient deaths were not related to tumor recurrence. Over the last 20 years there has been dramatic progress in patient survival after Lt, thus it could be anticipated that survival after Lt for CRC secondaries today would exceed from far, the outcome of the past experience. By utilizing new imaging techniques for proper patient selection, modern chemotherapy and aggressive multimodal treatment against metastases, long term survivors and even cure could be expected. Preliminary data from a pilot study show an overall survival rate of 94% after a median follow up of 25 months. While long term survival after the first Lt is 80% all indications confounded, 5-year survival after repeat Lt is no more than 50% to 55%. If patients transplanted for CRC secondaries can reach the latter survival rate, it could be difficult to discriminate them in the liver allocation system and live donation could be an option.
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Affiliation(s)
- Aksel Foss
- Department of Transplantation, Oslo University Hospital - Rikshospitalet, Oslo, Norway
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