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Resource Utilization in Liver Transplantation
Effects of Patient Characteristics and Clinical Practice
Jonathan Showstack, PhD, MPH;
Patricia P. Katz, PhD;
John R. Lake, MD;
Robert S. Brown, Jr, MD, MPH;
R. Adams Dudley, MD, MBA;
Steven Belle, PhD;
Russell H. Wiesner, MD;
Rowen K. Zetterman, MD;
James Everhart, MD, MPH;
for the NIDDK Liver Transplantation Database Group
JAMA. 1999;281:1381-1386.
Context Liver transplantation is among the most costly of medical services, yet few studies have addressed the relationship between the resources utilized for this procedure and specific patient characteristics and clinical practices.
Objective To assess the association of pretransplant patient characteristics and clinical practices with hospital resource utilization.
Design Prospective cohort of patients who received liver transplants between January 1991 and July 1994.
Setting University of California, San Francisco; Mayo Clinic, Rochester, Minn; and the University of Nebraska, Omaha.
Patients Seven hundred eleven patients who received single-organ liver transplants, were at least 16 years old, and had nonfulminant liver disease.
Main Outcome Measure Standardized resource utilization derived from a database created by matching all services to a single price list.
Results Higher adjusted resource utilization was associated with donor age of 60 years or older (28% [$53,813] greater mean resource utilization; P=.005); recipient age of 60 years or older (17% [$32,795]; P=.01); alcoholic liver disease (26% [$49,596]; P=.002); Child-Pugh class C (41% [$67,658]; P<.001); care from the intensive care unit at time of transplant (42% [$77,833]; P<.001); death in the hospital (35% [$67,076]; P<.001); and having multiple liver transplants during the index hospitalization (154% increase [$474,740 vs $186,726 for 1 transplant]; P<.001). Adjusted length of stay and resource utilization also differed significantly among transplant centers.
Conclusions Clinical, economic, and ethical dilemmas in liver transplantation are highlighted by these findings. Recipients who were older, had alcoholic liver disease, or were severely ill were the most expensive to treat; this suggests that organ allocation criteria may affect transplant costs. Clinical practices and resource utilization varied considerably among transplant centers; methods to reduce variation in practice patterns, such as clinical guidelines, might lower costs while maintaining quality of care.
Author Affiliations: Department of Medicine (Drs Showstack, Katz, and Dudley) and Liver Transplant Program (Drs Lake and Brown), University of California, San Francisco; Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pa (Dr Belle); Department of Medicine, Mayo Clinic, Rochester, Minn (Dr Wiesner); Department of Medicine, University of Nebraska, Omaha (Dr Zetterman); and Branch of Epidemiology and Clinical Trials, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md (Dr Everhart). Dr Lake is now with the Liver Transplant Program, University of Minnesota, Minneapolis, and Dr Brown is with the Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, New York, NY.
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